Updated Step 1 Bible (2013)

1
Paul Ciurysek M.D.

Stavros Vouyiouklis M.D
3
rd
Edition
THE
USMLE STEP 1
BIBLE

The Ultimate USMLE Step 1 Review Guide
2

Copyiight 0SNLE Step 1 BIBLE 2u14

The 0SNLE Step 1 BIBLE

0puateu foi 2u142u1S

All appiopiiate changes foi the BSN-S have been maue to aujust foi the new infoimation.

N0TE: This book is intenueu as a ieview book, anu in no way shoulu ieplace intense
stuuy of all mateiial piesenteu theiein.

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TBNI?ADCBNGBK @V AD?TPDT?IAW CBN DJI CXGMGDF D@ TBNI?ADCBN CBN
GNIBDGVF DJIG? PMGBGPCM AGKBGVGPCBPIR

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6

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The common uppei limb neive injuiies have classic piesentations anu aie usually
ieveisible. The most common injuiies incluue:
#5675 -89:65; !<==<8 !>:?5? 2<@<6 A5BCDC@ &58?<6E A5BCDC@
2%A-,# Injuiy to the
supiaconuyle of
the humeius.
Loss of:
Foieaim Pionation
Wiist Flexion
Fingei Flexion
Thumb movement
Long-teim thenai
atiophy is possible
Loss of sensation
in the thumb,
lateial aspect of
the palm, anu the
fiist 2.S fingeis
(inuex, miuule,
anu half of iing
fingei)
+,A-,. Injuiy to the shaft
of the humeius
Loss of tiiceps ieflex,
biachioiauialis
ieflex, anu extensoi
caipi iauialis longus
(causing the classic
wiist uiop)
Loss of sensation
to the posteiioi
antebiachial
cutaneous anu the
posteiioi biachial
cutaneous
1.#,+ Injuiy to the
meuial epiconuyle
of the humeius
Causes impaiieu
flexion anu
auuuction of the
wiist, as well as
impaiieu auuuction
of the ulnai two
fingeis anu the
thumb
Loss of sensation
to the meuial
aspect of the palm,
as well as loss of
sensation to the
pinky anu meuial
V of the iing
fingei
285=<8CD B<6
=:?DF5?
C88567>@5; GE
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*iachioiauialis
%xtensois of
wiistfingeis
&upinatoi
$iiceps
7

,0-..,+I Injuiy to the
suigical neck of
the the humeius
anuoi anteiioi
shouluei
uislocation
Results in a loss of
complete ueltoiu
movement
Loss of sensation
ovei the ueltoiu
muscle, as well as
the skin coveiing
the infeiioi aspect
of the ueltoiu
21&!1."!1$,#%"1& Compiession
between biceps
aponeuiosis anu
biachialis fascia
Loss of function of
coiacobiachialis,
biceps, anu
biachialis muscles
Loss of sensation
in the iauial
aspect of the
foieaim

J+-&$ A+"/
Also known as "?CNGCM BI?HI OCMAF" anu "-CDT?NCF BGKJD OCMAF". The iauial neive
inneivates the *6>DHC<6>;C>FC?, %K@58?<6? @<6, anu the
$6CD5O?. Compiession anuoi injuiy to the iauial neive causes the classic "wiist uiop",
uue to the inability to extenu the wiist.

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Compiession of the ulnai neive at the elbow will cause numbness of the small fingei anu
the meuial aspect of the iing fingei. With time, weakness of the hanu will piouuce the
"claw hanu", wheie the small fingei anu the iing fingei contiact anu foim a "claw". This is
late sequelae of ulnai neive injuiy, anu is a sign of a seveiely injuieu ulnai neive.
8

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A paialysis of the aim uue to injuiy of the supeiioi tiunk of the biachial plexus (CS anu
C6 ioots). This occuis most commonly with shouluei uystocia uuiing chilubiith, but is
also seen fiom uiiect blows to the shouluei. The most commonly affecteu neives aie the
axillaiy neive, the musculocutaneous neive, anu the supiascapulai neive. This causes a
loss of sensation in the aim anu atiophy of the ueltoiu, the biceps, anu the biachialis
muscles, iesulting in a chaiacteiistic hanging of the aim to the siue with meuial iotation.
The classic finuings:
- Abuuctoi paialysis (hanging limb to the siue)
- Paialysis of lateial iotatois (meuial iotation)
- Loss of biceps action (foieaim pionation)
The piesence of a biisk ieflex in the aim often means theie is a goou piognosis.
9

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A compiession of the subclavian aiteiy anu the infeiioi tiunk of the biachial plexus
iesults in thoiacic outlet synuiome. Compiession occuis at C8 anu T1, leauing to:
- Thenai anu hypothenai atiophy
- Inteiosseus muscle atiophy
- Sensoiy ueficit of the meuial foieaim anu hanu
- Loss of iauial pulse upon heau movement to the affecteu siue

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&upiaspinatus
-nfiaspinatus
$eies Ninoi
&ubscapulaiis
11

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The iotatoi cuff is a gioup of muscles that stabilize the shouluei. Theie aie foui muscles
in the iotatoi cuff, they aie:
- Supiaspinatus
- Infiaspinatus
- Teies Ninoi
- Subscapulaiis
Injuiy to the iotatoi cuff is most commonly expeiienceu as pain in the lateial aspect of
the ueltoiu, anu is often accompanieu by the pain on abuuction of the aim.

12

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The iecuiient laiyngeal neive is an impoitant
stiuctuie of the neck. It is a bianch of the vagus
Neive, anu supplies all intiinsic muscles of the
laiynx except the ciicothyioiu.
The iight iecuiient laiyngeal neive wiaps aiounu the iight subclavian aiteiy, while the
left iecuiient laiyngeal neive wiaps aiounu the aich of the aoita anu the ligamentum
aiteiiosum.

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14

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The iight lung contains S lobes, while the left lobe contains only 2 lobes. The left lung
contains, insteau of a miuule lobe, space that is occupieu by the heait (caiuiac notch).

1S

The most common site of foieign bouy aspiiation is the iight lung, because the angle of
the iight mainstem bionchus is less acute than the left mainstem bionchus.

&?CPJIC ! 2?@BPJG ! 2?@BPJG@MIA ! &I?EGBCM 2?@BPJG@MIA ! $MHI@MG

16

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Lymphatic uiainage is quite simple; the iight lymphatic uuct uiains the iight siue of the
heau anu the iight aim, while the thoiacic uuct (left siue) uiains the iest of the bouy.

17

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The celiac aiteiy is the fiist majoi bianch
off of the abuominal aoita, followeu by the
supeiioi anu infeiioi mesenteiic aiteiies.
The PIMGCP C?DI?F supplies the livei,
stomach, spleen, supeiioi half of the
uuouenum, the abuominal esophagus, anu
the pancieas (all stiuctuies of the
foiegut).
The ATOI?G@? EIAIBDI?GP C?DI?F supplies stiuctuies aiising fiom the miugut, while the
GBVI?G@? EIAIBDI?GP C?DI?F supplies stiuctuies aiising fiom the hinugut.

23,,Y -7%%30 &, +5
"IMGCP - Stomach to uuouenum, livei, uB,
pancieas.
-/$ - Buouenum to 2S of tiansveise colon.
5/$ - Bistal 1S of tiansveise colon to uppei
iectum.
18

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The uiaphiagm is inneivateu by "4W "6W CBN "8 (Phienic Neive). Bue to this inneivation,
pain anuoi piessuie to the uiaphiagm can cause iefeiieu pain to the shouluei. Theie
aie a few extiemely impoitant stiuctuies that peifoiate the uiaphiagm at the level of T8,
T1u, anu T12. They incluue:
,@ $W - Infeiioi vena Cava
,@ $XY - Esophagus, vagal tiunks (2)
,@ $ XZ - Aoita, Azygous vein, Thoiacic
Buct

%,%73$( /.'/,.5"
- W XY %TT& ,$ XZ
-vC 8 (T8)
%sophaTus & vaTu& at 1u (T1u)
,oita,zygous & $hoiacic uuct
at 12 (T12)
19

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Bile is secieteu by the livei anu stoieu insiue the gall blauuei, then secieteu into the
uuouenum as neeueu. Nany abuominal pathologies occui as a iesult of stasis anuoi
obstiuction of the biliaiy tiee.

2u

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It is impoitant to be able to ueciphei between peiitoneal anu ietiopeiitoneal stiuctuies,
as location can help you make a uiagnosis baseu on piesenting symptoms.
Retiopeiitoneal stiuctuies can often iefei pain to the back, thus knowleuge of this
anatomy is essential.

21

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The inguinal canal is an oblique stiuctuie that holus the speimatic coiu anu ilioinguinal
neive in males, anu the iounu ligament of the uteius anu ilioinguinal neive in females.
The canal is foimeu by the aponeuioses of thiee flat abuominal muscles.
*<:8;>6C5? F !>8>F'
1. -TOI?VGPGCM 5BKTGBCM (GBK - tiiangulai uefect in the exteinal oblique aponeuiosis
2. YIIO 5BKTGBCM (GBK - in the tiansveisalis fascia
S. $BDI?G@? ZCMM - inteinal oblique muscle (lateially) anu exteinal oblique
aponeuiosis (meuially)
4. (@@V - falx inguinalis (aiching infeiioi fibeis of inteinal oblique muscle)
S. >M@@? - inguinal ligament anu lacunai ligament (meuially)
6. %@ADI?G@? ZCMM - tiansveisalis fascia (weak fascia) lateially anu conjoint tenuon
(meuially)

),&&%.*%!)[& $+-,#T.%
Is an inguinal tiiangle thiough which uiiect inguinal heinias piotiuue thiough the
abuominal wall.

22

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YG?IPD 5BKTGBCM #I?BGCA [ This type of heinia bulges
thiough the abuominal wall, thiough Basselbech's
tiiangle, meuial to the infeiioi epigastiic vessels anu only
thiough the ATOI?VGPGCM GBKTGBCM ?GBK.
2A ! 2euial to infeiioi epigastiic aiteiy = Aiiect Beinia
5BNG?IPD 5BKTGBCM #I?BGCA - This type of heinia tiavels
thiough the ueep anu supeificial inguinal iings anu into the sciotum. Piotiusion thiough
the ueep inguinal iing is lateial to the infeiioi epigastiic vessels. This occuis uue to
failuie of the closuie of the piocessus vaginalis.
YGCOJ?CKECDGP #I?BGCA - This type of heinia occuis when abuominal contents entei into
the thoiax. The most common type of uiaphiagmatic heinia is the hiatal heinia, which is
common anu associateu with uERB. Newboins may have uI contents in the thoiax as a
iesult of a uefect in the pleuiopeiitoneal membiane.

#I?BGCA C?I C
O?@D?TAG@B @V
KCAD?@GBDIADGBCM
P@BDIBDA
DJ?@TKJ C?ICA @V
UIC\BIAA GB DJI
CXN@EGBCM UCMMR
2S

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A femoial heinia occuis when theie is a weakness in the femoial canaltiiangle, anu
occuis uiiectly below the inguinal ligament. This type of heinia is uncommon, accounting
foi <S% of all heinias. It is most commonly seen in females uue to theii wiuei pelvic
stiuctuie.
(INTPGXMI >IE@?CM #I?BGC - Is the most common foim, the heinia can be pusheu back
into the abuomen.
5??INTPGXMI >IE@?CM #I?BGC - 0ccuis when the heinia is not ieuucible, anu becomes
stuck in the femoial canal.
5BPC?PI?CDIN #I?BGC - 0ccuis when the heinia becomes tiappeu in the heinial sack. This
is consiueieu to be a suigical emeigency anu iequiies immeuiate tieatment.
-D?CBKTMCDIN #I?BGC - 0ccuis when bloou supply to an incaiceiateu heinia is cut-off.
This can cause tissue ueath anu the uevelopment of gangiene.

24

/"+$,.R&I&$%2-! ,#,&$"2"&%&
These aie anastomoses that occui between veins of the poital anu systemic ciiculation.
These sites aie impoitant because seveial conuitions may occui as a iesult of changes in
piessuie within each system.
The most common conuitions incluue: Bemoiihoius, Esophageal vaiices, anu Caput
Neuusae.
!"#A-$-"# &I&$%2-! !-+!1.,$-"# /"+$,. !-+!1.,$-"#
#IE@??J@GNA Niuule Rectal anu Infeiioi
Rectal veins
Supeiioi Rectal veins
'A@OJCKICM ]C?GPIA Azygous veins Left uastiic vein
"COTD /INTACI Supeificial Epigastiic vein Paiaumbilical veins

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2S

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The left ovaiyteste uiains fiom the left gonaual vein, to the left ienal vein, anu into the
infeiioi vena cava.
3IVD +@BCNCM ]IGB ! 3IVD (IBCM ]IGB ! 5]"
In 2S% of men, this system is not completely competent, anu iesults in a vaiicocele
of the left teste

The iight ovaiytest uiains uiiectly fiom the gonaual vein into the IvC. This iaiely
iesults in a vaiicocele in men uue to the angle of uiainage.

$)% /%!$-#,$% .-#%
The pectinate line is most commonly useful when a patient has hemoiihoius.
Bemoiihoius that aie above the pectinate line uo not cause pain uue to visceial
inneivation. Bemoiihoius that aie below the pectinate line have somatic inneivation,
anu aie theiefoie painful.
!"# %#&'()*'# +()# (, -./0#1 2"#/# '"# "()134' *)1 '"# #&'.1#/0 0##'5
$?DI?GCM ATOOMF >G<75 @H5 O5D@C8>@5 line is fiom the supeiioi iectal aiteiy. ]IB@TA
N?CGBCKI is fiom the supeiioi iectal vein to the infeiioi mesenteiic vein, anu into the
poital system.
$?DI?GCM ATOOMF G5F<L @H5 O5D@C8>@5 line is fiom the infeiioi iectal aiteiy. venous
uiainage is fiom the infeiioi iectal vein to the inteinal puuenual vein, then into the
inteinal iliac vein anu into the IvC.

26

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27

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28

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29

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V#%% .-T,2%#$ ,#,$"2I ,#A -#41+-%&
/IBGAPG - The common piesentation of a meniscal injuiy is \BII OCGB CBN AUIMMGBK, as
well as locking of the joint, especially when beaiing weight on the joint anu fully
stiaightening the leg. The menisci can be toin when uoing low-impact activities such as
walking, anu can be toin when uoing high-impact activities such as weight lifting anu
playing spoits. Common causes of injuiy aie GEOCPD D@ DJI \BII CBN C ^DUGADGBK_
E@DG@B of the knee when it is fiimly planteu.
/INGCM "@MMCDI?CM 3GKCEIBD - Also known as the tibial collateial ligament. Attacheu
pioximally to the meuial conuyle of the femui below the auuuctoi tubeicle anu meuial
suiface of its bouy. The posteiioi fibeis aie shoit anu incline backwaius upon uescent,
anu aie inseiteu into the tibia above the semi-membianous muscle gioove. It inseits into
the meuial suiface of the tibial bouy about 2.Scm below the level of the conuyle. Injuiies
aie common in A\GGBK CBN GB V@@DXCMM when HCMKTA AD?IAA is applieu (this is "abuuction
stiess" aka stiess to the lateial aspect of the knee).
Su

3CDI?CM "@MMCDI?CM 3GKCEIBD - Also known as the "fibulai collateial ligament", is naiiow
anu less bioau that the meuial collateial ligament. The LCL tiavels obliquely fiom the
lateial epiconuyle of the femui to the heau of the fibula. The anatomy of the LCL gives it
moie flexibility than the NCL, anu thus it is less commonly injuieu.
$BDI?G@? "?TPGCDI 3GKCEIBD - The ACL gets the teim "anteiioi" because it attaches to the
anteiioi aspect of the tibia, with an oiigin fiom ueep within the notch of the uistal femui.
Injuiy to the anteiioi ciuciate ligament is the most common knee injuiy, anu is especially
seen in athletes. 3CDI?CM ?@DCDG@BCM E@HIA such as those in soccei, basketball, anu skiing
aie common causes of ACL stiains anuoi teais. &IADGBK V@? $"3 GB`T?F is uone with the
CBDI?G@? N?CUI? DIAD, wheie the flexeu knee is uiawn foiwaiu in an attempt to iuentify
an GBP?ICAIN CE@TBD @V CBDI?G@? DGXGCM D?CBAMCDG@B as compaieu to the opposite joint.
The 3CPJECB DIAD is anothei uiagnostic test that is similai in natuie, but with the
patient's knee in 2u-Su uegiee flexion insteau of the 9u-uegiee flexion useu in the
anteiioi uiawei test.
%@ADI?G@? "?TPGCDI 3GKCEIBD - The posteiioi ciuciate ligament gets its name because it
CDDCPJIA D@ DJI O@ADI?G@? CAOIPD @V DJI DGXGC. It connects the posteiioi inteiconuylai
aiea of the tibia to the meuial conuyle of the femui. Injuiy to the PCL causes less pain anu
uisability than those to the ACL, anu often goes unuiagnoseu. The common cause of PCL
injuiy is the "NCAJX@C?N GB`T?F", wheie something foicefully stiikes the tibia anu uiives
it posteiioily. A common mechanism of injuiy uuiing spoiting events is a VCMM @B C
JFOI?VMIQIN \BII with the foot pointeu uownwaius. Patients often complain of a "O@O"
uuiing the injuiy. The PCL injuiy is uiagnoseu initially with the posteiioi uiawei test,
wheie the tibia is pusheu backwaius anu a uecieaseu iesistance is expeiienceu.
&JI 7BJCOOF &?GCN - This is a common knee injuiy seen in football, wheie a playei is hit
on the lateial aspect of the knee, causing uamage to the $"3, /"3, anu /INGCM /IBGAPTA.

S1

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S2

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/@AD @V DJI GBV@?ECDG@B V?@E DJI IEX?F@M@KF AIPDG@B GA JGKJL
FGIMNR /IE@?GaCDG@B @V DJI IEX?F@M@KGP NI?GHCDGHIA GA
GEO@?DCBDW CA GD GA MG\IMF D@ AJ@U TO @B DJI IQCEW CA GA DJI
EC`@?GDF @V DJI GBV@?ECDG@B V?@E DJGA PJCODI?R

SS

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Speimatogenesis is the piocess by which the speimatogonia uevelop into the matuie
speim (speimatozoa). This occuis in the testes anu epiuiuymis in a step-by-step fashion,
taking appioximately 6S uays. The staiting point foi speimatogenesis is the seminifeious
tubules of the testes, wheie the stem cells that aie aujacent to the innei tubule wall uiviue
in a centiipetal uiiection (moving towaius the lumen). Natuiation of speim occuis in the
epiuiuymis, wheie it acquiies its motility.
Thioughout speimatogenesis, the seitoli cells play an impoitant iole in the following:
- Naintaining the enviionment necessaiy foi matuiationuevelopment via the
bloou-testis baiiiei
- Secietes suppoiting fluius anu substances to initiate meiosis
- Seciete anuiogen-binuing pioteins, which cieate the enviionment foi a highei
level of feitility
- Seciete inhibin in oiuei to stimulate the pituitaiy glanu to fuithei
speimatogenesis
- Secietes anti-mulleiian hoimone to pievent the foimation of Nulleiian Bucts
- Pioviues piotection to the speimatius fiom autoimmune attack

S4

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0pon feitilization, theie aie many iapiu changes that occui to the egg, incluuing
migiation thiough the fallopian tube, implantation, cell uivision, giowth anu
uevelopment, etc. The following table anu illustiation uemonstiate the most impoitant
points fiom feitilization to implantation.
$-2% %3%#$
Initiating Event Feitilization of egg by speim
Week 1 Implantation of blastocyst
Week 2 Foimation of bilaminai uisk
Week S Foimation of piimitive stieak,
notochoiu, anu neuial tube.
uastiulation
Week S-8 Neuial tube foimation.
Foimation of oigans.
Nost likely time to be haimeu by
teiatogenic agents.
Week 4 Limb buus begin to foim.
Beait begins to beat.
Week 1u uenitals aie uiffeientiateu.

S6

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Is the foimation of the uiffeient tissues of the bouy fiom unuiffeientiateu cells. These aie
the ectoueim, mesoueim, anu enuoueim.
'PD@NI?E - The ectoueim is the moie supeificial tissue, they incluue:
- 64/-*&# 7&'.1#/0: Epiueimis, Lining of the epithelium, Lens of the eye, anu the
auenohypophysis.
- 8#4/.#&'.1#/0: CNS Neuions, Neuiohypophysis, 0ligouenuiocytes, Astiocytes,
anu the Pineal ulanu
- 8#4/*+ 9/#,': Autonomic Neivous System, Boisal Root uanglia, Nelanocytes,
Chiomaffin Cells of Auienal Neuulla, Enteiochiomaffin Cells, Pia Natei, Celiac
uanglion, Schwann Cells, Paiafolliculai Cells of Thyioiu, Laiyngeal Caitilage

'BN@NI?E - The enuoueim is foimeu by cells migiating along the aichenteion, foiming
the innei layei of the gastiula, thus ueveloping into the enuoueim. The cells of the
enuoueim being as squamous cells, but finally change into columnai cells. The tissues of
the enuoueim incluue:
- The entiie gastiointestinal tiact except pait of the mouth, phaiynx, anu the
teiminal iectum (foimeu by ectoueimal involution)
- The tiachea, bionchi, anu alveoli
- Lining of the follicles of the thyioiu, thymus, anu paiathyioiu glanus

/IA@NI?E - The mesoueim is the miuule geimal layei, giving iise to many uiffeient
tissues. Some mesoueimal tissues contain the ability to uiffeientiate into a uiveise iange
of tissues, such as the bone maiiow. The tissues of the mesoueim incluue:
- The auienal coitex
- The spleen
- Buia of connective tissues
- Nuscle tissues
- Bone
- Stiuctuies of the heait
- The lymphatic system
- The uiinaiy system (kiuneys incluueu)
- Seious linings of peiitoneal bouy cavities
- Bloou

S7

$)% 12*-.-!,. !"+A
The umbilical coiu is unique in that it contains TW0
aiteiies anu 0NE vein. The umbilical vein is
iesponsible foi supplying the fetus with oxygenateu
bloou, while the aiteiies aie iesponsible foi caiiying
ueoxygenateu bloou fiom the fetus.

%2*+I"."TI "S $)% )%,+$
The embiyonic stiuctuies of the heait coiiesponu with the matuie stiuctuies of the
heait, they aie:
&?TBPTA $?DI?G@ATA ! Ascenuing aoita anu pulmonaiy tiunk
2TMXTA "@?NGA ! Smooth paits of left anu iight ventiicle
%?GEGDGHI ]IBD?GPMI ! Tiabeculateu paits of the left anu iight ventiicle
%?GEGDGHI $D?GC ! Tiabeculateu left anu iight atiium
3IVD #@?B @V -GBTA ]IB@ATA ! Coionaiy sinus
+CNH@ )<68 @5;
$(&'(0 U A5<KEN58>@5;
S8

S%$,. !-+!1.,$-"#
0xygenateu bloou is caiiieu fiom the placenta to the fetus via the umbilical vein.
Appioximately half of this bloou enteis the fetal NTPDTA HIB@ATA anu is caiiieu to the
infeiioi vena cava, with the othei half enteiing the livei. As the bloou enteis the iight
atiium of the heait, most of it flows thiough the V@?CEIB @HCMI anu into the left atiium
(XFOCAAGBK DJI OTME@BC?F PG?PTMCDG@B). The bloou then moves into the left ventiicle
anu is pumpeu thiough the aoita to the bouy. Some of the bloou tiaveling thiough the
bouy enteis the inteinal iliac aiteiies anu to the umbilical aiteiies, ie-enteiing the
placenta anu uisposing of caibon uioxiue anu othei waste piouucts (which tiavel to the
mateinal ciiculation). Note that theie is a connection between the aoita anu the
pulmonaiy aiteiy calleu the NTPDTA C?DI?G@ATA, which shunts most bloou away fiom the
lungs because they aie not useu until the fetus is boin.
0pon biith of the infant, the fiist bieath causes a NIP?ICAI GB DJI ?IAGADCBPI @V DJI
OTME@BC?F HCAPTMCDT?I, incieasing the piessuie in the left atiium ielative to the
piessuie of the iight atiium. This leaus to the PM@AT?I @V DJI V@?CEIB @HCMI (now the
fossa ovalis). Theie is also a closuie of the NTPDTA C?DI?G@ATA because the incieaseu
concentiation of oxygen causes the piostaglanuin levels to ueciease. This closuie
pievents the bloou fiom bypassing the pulmonaiy ciiculation, allowing the lungs to
function piopeily.

S9

$%+,$"T%#-! ,T%#$& "S /+%T#,#!I
Congenital anomalies occui in appioximately S% of all live biiths, with mateinal
exposuie to teiatogenic agents being iesponsible foi 4%-6% of those cases
(appioximately 14uu liveboin infants).
Timing is an impoitant factoi in a teiatogen's ill-effect on the fetus, with the most
susceptible time being between the S
iu
anu 8
th
weeks of piegnancy, which is the most
active time of oiganogenesis.
$%+,$"T%#-! ,T%#$ %SS%!$ "# S%$1&
Anuiogenic Boimones Clitoial enlaigement, labiosciotal fusion
when given befoie 1S weeks gestation.
*0CP's not shown to piouuce anomalies
when useu in 1
st
tiimestei of piegnancy.
Waifaiin anu othei coumauin-ueiiveu
anticoagulants
Nultiple anomalies, most commonly:
Bevelopmental uelay, hyuiocephalus,
agenesis of coipus collosum,
meningoencephalocele, miufacial
hypoplasia.
vaiious oculai, skeletal, anu othei biith
uefects.
Antithyioiu meuications (PT0,
Nethimazole, Iouiue)
0ccasionally piouuces tiansient fetal
hypothyioiuism anu goitei.
Biphenylhyuantoin Abnoimal facies, miciocephaly, giowth
ueficiency, mental ietaiuation,
hypoplastic nails, hypoplastic phalanges.
valpioate anu Caibamazepine Neuial tube uefects
Lithium Ebstein's anomaly
Biethylstilbestiol Stiuctuial uefects of the female genital
tiact, vaginal auenosis.
Isotienitoin Niciophthalmia, hyuiocephalus,
miciotia, cleft palate, blinuness,
ueafness, heait uisease, thymic agenesis.
Alcohol Fetal alcohol synuiome
Tobacco Spontaneous aboition, incieaseu iisk of
placental abiuption oi pievia, pieteim
ueliveiy, anu piematuie iuptuie of
membianes.
Cocaine Placental abiuption
Thaliuomiue Limb uefects
ACE inhibitois Renal uamage

4u

S%$,. %+I$)+"/"-%&-&
The foimation of ieu bloou cells is caiiieu out by foui uiffeient stiuctuies thioughout
fetal uevelopment.
Fiom appioximately 4L; UII\A, it is caiiieu out by the 0,3b -$"
Fiom appioximately 9L4= UII\A, it is caiiieu out by the 35]'( CBN -%3''.
Fiom appioximately 1; UII\A CBN XIF@BN, it is caiiieu out by the 2,.' /$((,Z

*+,#!)-,. ,+!) -##%+3,$-"# ,#A A%+-3,$-3%&
$?PJ ) ueiivatives aie supplieu by CN v2 anu vS
$?PJ 1 ueiivatives supplieu by CN vII
$?PJ 4 ueiivatives supplieu by CN IX
$?PJ 6 CBN 9 ueiivatives aie supplieu by CN X
,+!) X ,+!) Z ,+!) ] ,+!) ^ _ `
/IP\IMcA
PC?DGMCKI:
Nanuible
Nalleus
Incus
Sphenomanuibulai
ligament
/TAPMIA @V
ECADGPCDG@Bd
Nassetei
LateialNeuial
pteiygoiu
Nylohyoiu
Anteiioi belly of
uigastiic
Tensoi tympani
Tensoi veli palatini
.I?HI: CN vS
(IGDI?cA "C?DGMCKI:
Stapes
Styloiu piocess
Lessei hoin of
hyoiu
Stylohyoiu
ligament
/TAPMIA:
Stapeuius
Stylohyoiu
Posteiioi belly of
uigastiic
.I?HI: CN vII
"C?DGMCKI:
uieatei hoin of
hyoiu
/TAPMIA:
Stylophaiyngeus
.I?HI: CN IX
"C?DGMCKI:
Thyioiu
Ciicoiu
Aiytenoius
Coiniculate
Cuneifoim
/TAPMIA @V 6
DJ

C?PJ:
Nost of the
phaiyngeal
constiictois
Ciicothyioiu
Levatoi veli
palatini
/TAPMIA @V 9
DJ

C?PJ:
All intiinsic
muscles of laiynx
except ciicothyioiu
.I?HI: 4
th
aich is
CN X, 6
th
aich is CN
X
41

*+,#!)-,. !.%S$ A%+-3,$-3%&
)
AD
X?CBPJGCM PMIVD ! Exteinal auuitoiy meatus
1
BN
[ 6
DJ
PMIVDA ! Foimation of tempoiaiy ceivical sinuses when the 2
nu
aich
mesenchyme is obliteiateu

*+,#!)-,. /"1!) A%+-3,$-3%&
)
AD
O@TPJ ! miuule eai cavity, Eustachian tube, mastoiu aii cells
1
BN
O@TPJ ! epithelial lining of the palatine tonsil
4
?N
O@TPJ (uoisal wings) ! infeiioi paiathyioius
4
?N
O@TPJ (vential wings) ! thymus
6
DJ
O@TPJ !supeiioi paiathyioius

$J-# /+%T#,#!-%&
Theie aie two types of twin piegnancies, /@B@aFK@DGP anu YGaFK@DGP twins. The
Bizygotic twins aie aka ">?CDI?BCM &UGBA", anu have 2 placentas, 2 amniotic sacs, anu 2
choiions. Nonozygotic twins aie "GNIBDGPCM DUGBA", anu contain 1 placenta, 1 choiion, anu
2 amniotic sacs.

2"#"\IT"$-! $J-#&'
- 1 placenta
- 1 choiion
- 2 amniotic sacs
A-\IT"$-! $J-#&'
- 2 placentas
- 2 choiions
- 2 amniotic sacs
42

%2*+I"."TI "S $)% %,+
The bones, muscles, anu othei stiuctuies of the eai all have embiyologic ueiivates. These
stiuctuies anu theii ueiivatives aie:
%>6 &@6:D@:65 %=G6E<F<NCD A56C7>@C75
Tympanic Nembiane 1
st
phaiyngeal membiane
Eustachian Tube 1
st
phaiyngeal membiane
Exteinal Auuitoiy Neatus 1
st
cleft
Incus 1
st
aich
Nalleus 1
st
aich
Stapes 2
nu
aich
Tensoi Tympani (vS) 1
st
aich
Stapeuius (vII) 2
nu
aich

%2*+I"."TI "S $)% $"#T1%

4S

%2*+I"."TI "S $)% $)I21&
The thymus is ueiiveu fiom the epithelium of the 4
?N

X?CBPJGCM O@TPJIA. The thymus functions in piouuction of T-
lymphocytes, which aie essential paits of the auaptive
immune system. The &./'#: of the thymus is 1#),# with
immatuie T cells, while the 0#14++* contains the 0*'4/# T
cells.

%2*+I"."TI "S $)% $)I+"-A T.,#A
The thyioiu glanu is ueiiveu fiom the flooi of the piimitive phaiynx, anu upon
uevelopment it uescenus into the neck. The thyioiu connects to the tongue via the
thyioglossal uuct (uisappeais in noimal uevelopment). Bue to the anatomy anu
ielationship of the thyioiu to the tongue, ectopic thyioiu tissue is most commonly founu
in the tongue.

%2*+I"."TI "S $)% /,#!+%,&
As a whole, the pancieas is ueiiveu fiom the foiegut.
]IBD?CM %CBP?ICDGP 2TN ! Pancieatic heau, 0ncinate piocess, anu main pancieatic uuct.
Y@?ACM %CBP?ICDGP 2TN ! Bouy of pancieas, tail of pancieas, Isthmus, Accessoiy
pancieatic uuct.

A%3%."/2%#$ "S T%#-$,. A1!$&
2%&"#%/)+-! A1!$ PJ<FBBC>8Q /,+,2%&"#%/)+-! A1!$
P2:FF56C>8Q
Testicles seciete mulleiian-inhibiting
substance in oiuei to suppiess the
uevelopment of paiamesonephiic uucts.

YIHIM@OA GBD@: Epiuiuymis, Ejaculatoiy
uuct, Seminal vesicles, Buctus Befeiens
Lack of secietion of Nulleiian-inhibiting
substance causes giowth of
Paiamesonephiic uucts.

YIHIM@OA GBD@: Fallopian Tube, 0teius,
0ppei pait of vagina

"@?DIQ = Bense,
immatuie T cells.
/INTMMC = Pale,
matuie T cells.
44

)"2"."T1%& "S $)% A%3%."/-#T T%#-$,. $+,!$
By 6-8 weeks, a fetus has histologically uistinguishable gonaus. By 7 weeks, the fetus has
a genital tubeicle, uiogenital gioove anu sinus, anu labiosacial folus. In a female, without
excess anuiogens these will become the clitoiis, uiethia, vagina, anu labia. The male fetus
becomes uistinct between 8-12 weeks, anu the anuiogens will enlaige the phallus anu
cause the uiogenital gioove anu sinus to fuse in the miuline.

4S

%2*+I"."TI "S $)% A-,/)+,T2
Buiing initial uevelopment, the uiaphiagm is inneivateu by neives CS, C4, anu CS. As the
uiaphiagm uescenus, it maintains this inneivation.
The uiaphiagm is ueiiveu fiom the following embiyologic stiuctuies:
- Septum Tiansveisum
- Pleuiopeiitoneal Folus
- Bouy Wall
- Boisal Nesentaiy of the Esophagus

S"+2,$-"# "S *"#%
Theie aie two main types of bone uevelopment, those being "intiamembianous" bone
anu "enuochonuial" bone. Intiamembianous bone is foimeu spontaneously without the
piesence oi neeu of any pie-existing caitilage. 0n the othei hanu, enuochonuial bone
(long bones) iequiies the piesence of caitilaginous molus in oiuei to foim its bony
stiuctuie. The caitilaginous molu ossifies anu piouuces the enuochonuial bone.

!"#T%#-$,. ,*#"+2,.-$-%& "S $)% /%#-&
Bypospauias is the moie common congenital penile abnoimality, anu it can be associateu
with 0TI's in chiluien.

46

"#$%&'( 4

#5-&,3,+0

#GAD@M@KF GA B@D D?CNGDG@BCMMF C HI?F JGKJLFGIMN P@EO@BIBD @V DJI
-DIO ) IQCEW XTD GD GA GEO@?DCBD D@ \B@U UJGPJ DFOI @V
IOGDJIMGTE EC\IA TO CMM @V DJI AD?TPDT?IA @V DJI X@NFW CA UIMM CA
CMM OCDJ@M@KGIA DJCD C?I MGB\IN D@ JGAD@M@KGPCM PJCBKIAR

47

#@U C?I XM@@N PIMM O?@NTPDA ECNI [ 23,,Y "'33 Y5>>'('.&5$&5,.e%(,Y7"&5,.d

Z#5&' 23,,Y "'33- ; *<* =#4<.&>'#,
The white bloou cell is iesponsible foi uefense against infections. They aie maue up of
the uianulocytes (Eosinophils, Basophils, Neutiophils), anu the Nononucleai cells
(Lymphocytes, Nonocytes).

('Y 23,,Y "'33- [ *<* 7/>'"/.&>'#,
48

The bloou cell iesponsible foi oxygen tianspoit. It has many impoitant functions, is
without nucleus, is biconcave, anu has a laige suiface volume that enables easy gas
exchange.

.'7&(,%#53- - Involveu in the acute inflammatoiy iesponse, anu make up
appioximately 4u-7u% of WBC's. They engulf via phagocytosis, aie multilobeu, anu
contain lysosomes. Look foi hypeisegmenteu neutiophils when a patient has a vitamin
B12 anuoi folate ueficiency.

',-5.,%#53- - These aie piotective against helminth anu piotozoal infections. They aie
highly phagocytic against antigen-antibouy complexes. They piouuce histamine anu
aiylsulfatase. Eosinophils make up 1%-6% of all WBC's, aie bilobeu, anu aie packeu with
laige eosinophilic gianules.

49

2$-,%#53- - Basophils compiise less than 1% of all WBC's, anu aie the key components
of alleigic ieactions. Basophils contain histamine anu hepaiin, as well as othei vasoactive
amines.

/,.,"0&'- - Contains a kiuney-shapeu nucleus, compiises appioximately 2%-1u% of
WBC'S.

LYNPB0CYTES - Aie small, iounu, anu stain uensely. T lymphocytes piouuce a cellulai
immune iesponse, while B lymphocytes piouuce antibouies.

Su

#%1+")-&$"."TI
Y'.Y(5&5" "'33- - Antigen piesenting cells, seen in some tissues who come in contact
with the skin (Langeihans cells), innei lining of the nose, lungs, stomach, anu intestines.

/5"(,+35$ - These aie the phagocytes of the CNS, they aie the main foim of uefense in
the CNS.

,35+,Y'.Y(,+35$ - These cells act to myelinate the axons of the CNS. These aie the
pieuominant glial cell in the white mattei.

S1

SCBWANN CELLS - Schwann cells myelinate the axons, they also piomote axonal
iegeneiation.

%'(5%#'($3 .'(]' -&(7"&7(' - Consists of the 7%()#4/(40, ?#/()#4/(40, anu
7)1.)#4/(405 The epineuiium is uense anu suiiounus the entiie neive, the peiineuiium
is what allows foi peimeability, anu the enuoneuiium is within the neive anu suiiounus
eveiy single neive fibei.

S2

)-&$"."TI "S $)% &V-#

2%-&&#%+[& !"+/1&!.%& a Aie encapsulateu sensoiy ieceptois in the ueimis of the
palms, soles, anu fingeis. They aie involveu in light, uisciiminatoiy touch of haiiless skin.
2%+V%.[& !"+/1&!.%& - These aie tactile uiscs, which meuiate light ciuue touch.
/,!-#-,# !"+/1&!.%& - These aie laige encapsulateu sensoiy ieceptois of the ueepei
layeis of the skin at ligaments, joint capsules, mesenteiy, anu seious membianes. They
aie involveu in uetecting piessuie, vibiation, iough touch, anu tension.

SS

%/-$)%.-,. !%.. 41#!$-"#&

S4

$)% T."2%+1.,+ *,&%2%#$ 2%2*+,#%
The glomeiulai basement membiane is foimeu by the fusion of enuothelium anu
pouocyte basement membianes. It seives to filtei plasma

SS

$)% T".T- ,//,+,$1&
The golgi appaiatus seives the puipose of piocessing anu packaging pioteins anu lipius
befoie they aie secieteu to the iest of the bouy.
The golgi appaiatus is maue of stack of membiane-bounu stiuctuies of cisteinae, which
caiiy golgi enzymes to help oi mouify the pioteins that tiavel thiough them.

The main functions of the golgi appaiatus incluue:
- Bistiibution of pioteins anu lipius fiom the enuoplasmic ieticulum to the plasma
membiane, lysosomes, anu thiough secietoiy vesicles
- Auuition of an 0-oligosacchaiiue to Seiine anu Thieonine
- Auuition of N-oligosacchaiiue to Aspaiagine
- Pioteoglycan assembly
- Sulfation of sugais in pioteoglycans

+"1T) %#A"/.,&2-! +%$-!1.12 P+%+Q
The Rough Enuoplasmic Reticulum is iesponsible foi many functions, incluuing:
- N-linkeu glycosylation
- Auuition of lysosomal enzymes with mannose-6-phosphate maikei
- Integiation of membiane pioteins
Insiue of neuions, theie is the "Nissl bouy", which is the RER of the neuion.
&2""$) %#A"/.,&2-! +%$-!1.12 P&%+Q
The Smooth Enuoplasmic Reticulum is wheie steioius aie synthesizeu anu wheie uiug
uetoxification takes place.

S6

,.3%".,+R!,/-..,+I *,++-%+
This baiiiei is piesent in the gas-exchange iegion of the lungs, anu seives to pievent the
foimation of aii bubbles in the bloou, anu fiom bloou enteiing into the alveoli. This
baiiiei is extiemely thin anu veiy stiong (thanks to type Iv collagen), allowing foi
sufficient uiffusion of oxygen.
The alveolai-capillaiy baiiiei is foimeu by type 1 pneumocytes of the alveolai wall, the
enuothelial cells of the capillaiies, anu the basement membianes between the two cells.
This baiiiei is easily peimeable to many gases, especially u2, C02, anu C0.

/#%12"!I$%&
Theie aie two types of pneumocytes, anu they contiibute to the maintenance of the
alveoli. They extenu into the bionchioles, while goblet cells extenu only to the teiminal
bionchioles.
&JI?I C?I DU@ DFOIA @V OBITE@PFDIAd Type 1 anu Type 2
$EO5 X /85:=<DE@5? aie iesponsible foi gas exchange in the alveoli, anu covei >9S% of
the alveolai suiface
$EO5 Z /85:=<DE@5? aie iesponsible foi secieting suifactant, which helps to ueciease
the alveolai suiface tension. The type 2 pneumocyte is also a piecuisoi to type 1
pneumocytes.

S7

$)% A-T%&$-3% $+,!$
The histologyanatomy of the uigestive tiact is complex, consisting of suppoitive
stiuctuies, musculai stiuctuies, anu glanuulai stiuctuies. The uI tiact is also an
impoitant pait of the immune system.
The uppei uI tiact consists of the esophagus, stomach, anu uuouenum.
The lowei uI tiact incluues most of the small intestine, the laige intestine, anu the anus.
Bistologically, the uI tiact can be uiviueu into the =:D<?>, ?:G=:D<?>, =:?D:F>6C?
5K@568>, anu the >;758@C@C>.
/7",-$ - The inneimost layei of the uI tiact, suiiounus the lumen. It is impoitant in the
piocess of uigestion, as it is iesponsible foi absoiption anu secietion. The mucosa can
fuithei be subuiviueu into #%('"#+(40, +*0()* %/.%/(*, anu 04,&4+*/(, 04&.,*.
-72/7",-$ - The submucosa is a uense layei of connective tissue that acts as suppoit to
the uI tiact. It holus the Neissnei's plexus, which is an enteiic neivous plexus that sits on
the innei suiface of the musculaiis mucosa. The submucosa also contains bloou vessles,
lymphatic's, anu neives that bianch into the mucosa anu the musculaiis exteina.
/7-"73$(5- 'f&'(.$ - This stiuctuie consists of an innei anu outei layei of muscle
tissue. The innei ciiculai layei contiacts to squeeze the contents, while the outei
longituuinal layei contiacts to shoiten the tiact. These two contiactions togethei help
with peiistalsis, thus piopelling the foou along the tiact.
$Y]'.&5&5$ - The auventitia is one moie component in uI tiact suppoit.

Theie aie two enteiic plexuses that help co-oiuinate all of the functions of the uI tiact.
&JI /FIBDI?GP %MIQTA - Co-oiuination of motility along the entiie gut wall. This plexus is
locateu between the longituuinal anu ciiculai smooth muscle of the uI tiact, anu is also
known as Aueibach's plexus.
S8

&JI -TXETP@ACM %MIQTA - This plexus iegulates secietions, bloou flow, anu absoiption.
Locateu between the mucosa anu the innei layei of smooth muscle, it is also known as
Neissnei's plexus.
*Both plexuses contain paiasympathetic teiminal effectoi neuions.

*+1##%+[& T.,#A&
Biunnei's glanus aie the only glanus in the uI submucosa. They aie iesponsible foi
secieting alkaline mucus, anu may hypeitiophy in the case of a uuouenal ulcei.

/%I%+[& /,$!)%&
Peyei's patches aie aggiegations of lymphoiu tissue that aie founu in the ileum. They aie
ovally-shapeu lymphoiu follicles in the lamina piopiia layei of the mucosa, extenuing into
the submucosa of the ileum.
These patches aie unencapsulateu, coveieu by a single layei of cuboiual enteiocytes with
specializeu N cells inteispeiseu. These N cells aie iesponsible foi taking up antigens.
Stimulateu B cells tiavel fiom the Peyei's patches, going thiough the lymph anu bloou to
the lamina piopiia of the intestine, wheie they uiffeientiate into IgA-secieting plasma
cells. The IgA is piotective, tiaveling acioss the epithelium to the gut to ueal with the
intialuminal antigen.

.I2/) #"A%&
Lymph noues aie seconuaiy lymphoiu oigans that function as non-specific filtiation by
maciophages, antibouy piouuction, anu stoiage oi B anu T cells. The lymph noue
contains many affeients, anu at least one oi moie effeient.
-D?TPDT?I @V DJI 3FEOJ .@NI@
S9

9./'#: - The outei coitex consists mainly of B cells that aie aiiangeu in follicles, which
can uevelop a geiminal centei when in contact with an antigen. The innei coitex is
mainly T cells.
A#14++* - Theie aie the meuullaiy coius anu the meuullaiy sinuses. The coius aie mainly
plasma cells, lymphocytes, anu B cells. The sinuses take in the flow of lymph fiom the
coitical sinuses, anu contain maciophages anu ieticulai cells.
B.++(&+# - The follicle is wheie B-cells aie localizeu anu wheie they piolifeiate. Piimaiy
follicles aie uenseuoimant, wheie the seconuaiy follicles have a pale cential geiminal
centei, anu they aie active.
3FEOJ B@NI PG?PTMCDG@B:
The lymph ciiculates to the lymph noue thiough the affeient lymphatic vessel, uiaining
into the subcapsulai sinus. This subcapsulai sinus then uiains into tiabeculai sinuses,
anu finally into the meuullaiy sinuses.
-TXPCOATMC? AGBTA ! D?CXIPTMC? AGBTA ! EINTMMC?F AGBTAIA

6u

,A+%#,. !"+$%0 _ 2%A1..,
Theie aie S layeis to the auienal coitex, they aie:
1. Zona ulomeiulosa ! secietes Aluosteione (ulucocoiticoius)
2. Zona Fasciculata ! secietes Coitisol (Stiess Boimones)
S. Zona Reticulaiis ! secietes Anuiogens (Sex Boimones)
The auienal meuulla contains chiomaffin cells that seciete the catecholamines
Epinephiine anu Noiepinephiine.
The most common tumoi of the auienal meuulla in auults is a pheociomocytoma,
while the most common tumoi in chiluien is a neuioblastoma.

61

$)% .-3%+

"IBD?CM ]IGB - Receives the bloou mixeu in the sinusoius of the livei anu ietuins it to
ciiculation via the hepatic vein.
%@?DCM ]IGB - Biains bloou fiom the uI tiact anu the spleen into the livei. 0sually foimeu
by the SNv, splenic veins, INA, gastiic vein, anu cystic vein. This is one of the main poital
venous systems of the bouy.
#IOCDGP $?DI?F - Runs alongsiue the poital vein anu the common bile uuct to foim the
poital tiiau.
2GMI "CBCMGPTMTA - Is a thin tube that collects bile that is secieteu by the hepatocytes.
These canaliculi meige to foim the bile uucts, which then become the common hepatic
uuct.

62

$)% &/.%%#

6S

!-.-,
Cilia is stiuctuieu in a way that allows foi maximum mobility. Insiue each cilia theie is a
9+2 axoneme, as can be seen in the image below. Each 9+2 axoneme acts as a scaffolu foi
piotein complexes anu pioviues binuing sites foi motoi pioteins.
Especially impoitant is uynein, which is a motoi piotein that conveits the chemical
eneigy of ATP into the mechanical eneigy of movement. A uefect in uynein causes a
conuition known as "Kaitagenei's Synuiome", which iesults in immotile cilia.
Theie aie also 9+u cilia, which aie non-motile.

64

$)% -##%+ %,+

$)% *"#I .,*I+-#$)'
Consists of the 9C9D=7E (heaiing), the F76!GHI=7 (iesponsible foi sensing lineai
acceleiation), anu the 67AG9GJ9I=EJ 9E8E=6 (iesponsible foi angulai acceleiation).
This labyiinth is filleu with a fluiu calleu "peiilymph", which is a souium iich fluiu, similai
to the extiacellulai fluiu.
$)% 2%2*+,#"1& .,*I+-#$)'
Consists of the 9C9D=7EJ KI9!L I!JG9=7L 6E99I=7, anu the 67AG9GJ9I=EJ 9E8E=6.
This labyiinth is filleu with enuolymph that is iich in potassium, similai to the fluiu insiue
the cells. Theie aie haii cells that act as the moue of sensation within both the vesticulai
appaiatus anu the cochleai appaiatus of the innei eai.
3,Z >('g7'."0 sounus aie heaiu at the apex of the cochlea
#5+# >('g7'."0 sounus aie heaiu at the base of the cochlea.

6S

"#$%&'( 6

.'7(,$.$&,/0

.IT?@CBCD@EF GA C JGKJLFGIMN AIPDG@B @V DJI 7-/3' IQCER >@PTA
@B XCAGP BIT?@CBCD@EF hXM@@N ATOOMFW BI?HI ATOOMFiW CA UIMM DJI
CAA@PGCDIN BIT?@OCDJ@M@KF CBN BIT?@OJFAG@M@KFR

66

+%S.%0%&
Theie aie many ieflexes belonging to both the auult anu the infant, anu a set that aie seen
only in infants.
The ieflex aic is an impoitant concept to unueistanu as it ielates to the clinically
impoitant ieflexes.

67

A%+2,$"2%&
Beimatomes aie aieas of the skin that aie mostly supplieu by a single spinal neive. Each
of these neives ielay sensations fiom each paiticulai ueimatome to the biain.
; "?CBGCM .I?HIA [ )1 &J@?CPGP .I?HIA [ 8 3TEXC? .I?HIA [ 8 -CP?CM .I?HIA
0nueistanuing anu being able to locate ueimatomes is impoitant neuiologically as it
allows us to ueteimine the site of uamage to the spine. The most commonly seen
infection is a heipes zostei infection, which is an infection that lies uoimant in the uoisal
ioot ganglion anu manifests itself along a ueimatome, wiapping aiounu the bouy along
the specific ueimatomal aiea.
#%+3% +""$ ,+%, "S A-&$+-*1$-"#
C2 Posteiioi half of the skull cap
CS Aiea that coiielates with a high
tuitleneck shiit
C4 Aiea coiielating to a low-collai shiit
C6 Thumb (iauial neive)
C7 2
nu
anu S
iu
uigit (meuial neive)
C8 4
th
, S
th
uigits (ulnai neive)
T4 Nipples
TS Infiamammaiy Folu
T6T7 Xiphoiu Piocess
T1u 0mbilicus
T12 Pubic bone iegion
L1 Inguinal Ligament
L4 Knee caps
S2, SS uenitalia

68

!+,#-,. #%+3%&
!6>8C>F
#5675
#>=5 S:8D@C<8 #5675 $EO5 S<6>=58
X 0lfactoiy Smell Sensoiy Ciibifoim
Plate
Z 0ptic Sight Sensoiy 0ptic Canal
] 0culomotoi Eye movement
Pupil Consti
Accomouation
Eyeliu opening
Notoi Supeiioi
0ibital
Fissuie
(S0F)
^ Tiochleai Eye Novement Notoi S0F
b Tiigeminal Facial Sensation
Nastication
Notoi,
Sensoiy
v1: S0F
v2:
Foiamen
Rotunuum
vS:
Foiamen
0vale
` Abuucens Eye Novement Notoi S0F
c Facial Facial Novement
Anteiioi 2S taste
Laciimation
Salivation
Notoi,
Sensoiy
Inteinal
auuitoiy
canal
W vestibulocochleai Beaiing
Balance
Sensoiy Inteinal
auuitoiy
canal
d ulossophaiyngeal Posteiioi 1S
taste
Swallowing
Salivation
Caiotiu bouy anu
sinus monitoiing
Notoi,
Sensoiy
}ugulai
foiamen
XY vagus Taste
Swallowing
Palate Elev
Talking
Thoiacoabuominal
visceia
Notoi,
Sensoiy
}ugulai
foiamen
XX Accessoiy Beau tuining
Shouluei shiug
Notoi }ugulai
foiamen
XZ Bypoglossal Tongue Novement Notoi Bypoglossal
canal

/BIE@BGP V@? DJI "?CBGCM BI?HIA:
"n "lu "lympus' $oweiing $ops , Siienuly 3iking Tiew 3ines ,nu )ops
69

A%3-,$-"#& $"J,+A& ,#A ,J,I S+"2 !# .%&-"#&
!# b =<@<6 F5?C<8 ! }aw will ueviate D@UC?NA siue of lesion
!# XY F5?C<8 ! 0lna ueviates CUCF fiom siue of lesion
!# XX F5?C<8 ! Weakness in tuining heau to the @OO@AGDI siue of lesion
!# XZ F5?C<8 ! Tongue will ueviate D@UC?NA siue of lesion (lick the wounu)

*+,-#&$%2 !+,#-,. #%+3% #1!.%-

7u

$)% $+,!$& "S $)% &/-#,. !"+A
Nemoiization of the functions of uiffeient aieas of the spinal coiu is essential to being
able to iuentify wheie a paiticulai spinal coiu lesion may be locateu.
%F?GEGNCM:
=*'#/*+ 9./'(&.,%()*+ - Contiols movement of ipsilateial limbs
E)'#/(./ 9./'(&.,%()*+ - Conuuction of voluntaiy motoi impulses fiom piecential gyius to
the motoi centei of the coiu
'QD?COF?GEGNCM:
J4M/.,%()*+ - Nain ioute foi meuiation of voluntaiy movement (laige muscles anu fine
motoi contiol)
J#'(&4+.,%()*+ - Co-oiuinates automatic movement of locomotion anu postuie, influences
muscle tone, meuiates autonomic functions, anu mouulates pain impulses
F#,'(M4+.,%()*+ - Lateial: Ipsilateial uescent to paiaveitebial anu pioximal limb
extension. Neuial: Bilateial uescent, contiols eye movement, neck position, gaze
Y@?ACM "@MTEB /INGCM 3IEBGAPTA -FADIE:
N/*&(+# B*&(&4+4, - Fine touch, vibiation, piopiioception to lowei bouy
Cuneate Fasciculus - Fine touch, vibiation, anu piopiioception to uppei bouy
-OGB@PI?IXIMMC? &?CPD:
?.,'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position
E)'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position
$BDI?@MCDI?CM -FADIE:
=*'#/*+ 6%().'"*+*0(& !/*&' - Pain anu tempeiatuie
E)'#/(./ 6%().'"*+*0(& !/*&' - Soft nocioception
-OGB@L,MGHC?F &?CPD: Piopiioception fiom muscles anu tenuons as well as cutaneous
impulses to the olivaiy nucleus

71

*+"J# &%e1,+A &I#A+"2%
Biown-Sequaiu synuiome occuis when theie is a hemisection of the spinal coiu. It
piesents with the following:
- Ipsilateial loss of motoi function anu the piesence of spasticity (pyiamiual)
- Ipsilateial loss of tactile, vibiation, anu piopiioception senses (uoisal column)
- Contialateial loss of pain anu tempeiatuie (spinothalamic)
- Ipsilateial loss of all sensation at the level of injuiy

72

12# _ .2# .%&-"#&
&-T# 12# .%&-"# .2# .%&-"#
Weakness Piesent Piesent
Atiophy Absent Piesent
Reflexes Incieaseu Becieaseu
Tone Incieaseu Becieaseu
Fasciculations Absent Piesent
Babinski Piesent Absent

21&!.%& "S $)% %I%

7S

,#,$"2I "S $)% %I% ,#A +%$-#,

74

$)% /1/-..,+I .-T)$ +%S.%0
The mechanism by which the pupils ieact to light is quite stiaight-foiwaiu.
&@5O X - Light is uetecteu anu the ietinal ganglion cells convey this infoimation thiough
photoieceptois to the optic neive. The optic neive is connecteu to the pietectal nucleus,
anu senus the fiist signal heie notifying it of incoming light.
&@5O Z - Fiom the pietectal nucleus, a message is sent to the Euingei-Westphal nucleus
&@5O ] - The occulomotoi neive (fiom the Euingei-Westphal nucleus), then senus a
message to the constiictoi muscles of the iiis. The iiis muscles contiact bilateially
(consensual ieflex).

7S

!"#41T,$% T,\%
Conjugate gaze is a piocess wheieby both of the eyes look in the same uiiection
simultaneously. The piocess begins with the fiiing of CN 6, which then contiacts the
lateial iectus muscle to look into one uiiection, which simultaneously contiacting the
contialateial nucleus of CN S (via the meuial longituuinal fasciculus). The CN S then
contiacts the meuial iectus anu the conjugate gaze is in tact.
With many uiseases such as multiple scleiosis, theie is a lesion in the NLF, which will
inhibit the tiansmission of the signal to the contialateial CN S. When this occuis, the
seconu eye uoes not look to the same uiiection, anu the patient then has a gaze palsy, also
known as 'inteinucleai ophthalmoplegia'.

76

3-&1,. S-%.A A%S%!-$&
Beficits to the visual fielu can occui fiom eithei uiseases oi fiom uisoiueis of the eye,
optic neive, anu biain.
The foui most common types of visual fielu uefects aie:
1. Altituuinal fielu ueficits, which is a loss of vision above oi below the hoiizontal
2. Bitempoial hemianopsia, which is a loss of vision at oui aspects of the visual fielu
S. Bomonymous hemianopsia, which is a loss of vision on the same siue in both eyes
4. Cential scotoma, which is a loss of cential vision

77

$)% !-+!.% "S J-..-&
The Ciicle of Willis is a ciicle of aiteiies that supplies the biain with bloou. The uesign of
the Ciicle of Willis is such that shoulu one aiea become stenoseu oi blockeu completely,
bloou flow fiom othei bloou vessels can often pieseive peifusion well enough to avoiu
ischemic events.
The ciicle is compiiseu of the following aiteiies:
- $BDI?G@? PI?IX?CM C?DI?GIA
- $BDI?G@? P@EETBGPCDGBK C?DI?F (connects both anteiioi ceiebial aiteiies)
- 5BDI?BCM PC?@DGN C?DI?GIA (aiise fiom common caiotiu aiteiies)
- %@ADI?G@? PI?IX?CM C?DI?GIA (aiise fiom basilai aiteiy)
- %@ADI?G@? P@EETBGPCDGBK C?DI?GIA (fiom a bianch of inteinal caiotius)

78

*.""A &1//.I $" $)% *+,-#
$BDI?G@? "I?IX?CM $?DI?F - supplies the meuial suiface of the biain, anu the leg-foot aiea
of the motoi anu sensoiy coitices.
/GNNMI "I?IX?CM $?DI?F - supplies the lateial aspect of the biain, the tiunk-aim-face aiea
of the motoi anu sensoiy coitices, as well as Bioca's anu Weinicke's speech aieas.
$BDI?G@? "@EETBGPCDGBK $?DI?F - connects the anteiioi ceiebial aiteiies, anu is the
most common site of Ciicle of Willis aneuiysm.
%@ADI?G@? "@EETBGPCDGBK $?DI?F - connects thiee ceiebial aiteiies on each siue, is
anothei common site of aneuiysm, anu can cause cianial neive S palsies.

)%+#-,$-"#& "S $)% *+,-#
Ceitain signs anu symptoms shoulu aleit you to the possibility of biain heiniations.
Biffeient signs can help you naiiow uown the specific aiealesion that may be piesent.
Theie aie two majoi classes of heiniation - the supiatentoiial anu infiatentoiial
heiniations. The stiuctuie that uiffeientiates these two categoiies is the tentoiial notch
(those above = supiatentoiial, those below = infiatentoiial).
-TO?CDIBD@?GCM #I?BGCDG@BA - 0ncal, Cential, Cingulate, Tianscalvaiial
5BV?CDIBD@?GCM #I?BGCDG@BA - 0pwaiu (ceiebellai), Tonsillai (uownwaiu ceiebellai)

79

$)% .12*,+ /1#!$1+%
The lumbai punctuie is a uiagnostic tool useu to collect anu analyze the ceiebiospinal
fluiu.
5BNGPCDG@BA ! CSF analysis when meningitis, fevei of unknown oiigin, anu signs of
meningeal iiiitation aie piesent. Byuiocephalus, benign intiacianial hypeitension, anu
subaiachnoiu hemoiihages can all be uiagnoseu anu suppoiteu with an LP. The LP is also
useful when intiathecal (injection into the spinal coiu) ioute of auministiation is
necessaiy, such as with spinal anesthesia oi chemotheiapy.
"@BD?CGBNGPCDG@BA ! The most impoitant contiainuication to a lumbai punctuie is the
piesence of incieaseu intiacianial piessuie. 0thei impoitant contiainuications aie
coagulopathies, iespiiatoiy uifficulties, ueteiioiating consciousness, anu when theie is
hypeitension plus biauycaiuia.

)<L C? @H5 ./ O56B<6=5;f

8u

1//%+ 2"$"+ #%1+"#&
0ppei motoi neuions aie motoi neuions that oiiginate in the motoi iegion of the coitex
oi biain stem. They caiiy infoimation uown specific aieas on the spinal coiu, at which
point they senu signals to the lowei motoi neuions (via glutamineigic ieceptois). The
main effectoi neuions aie within layei S of the piimaiy motoi coitex, anu these aie some
of the laigest cells in the biain.

7OOI? E@D@? BIT?@BA D?CPDA:
The 0NN's tiavel via seveial uiffeient tiact, incluuing:
- Coiticospinal
- Coiticobulbai
- Tectospinal
- Rubiospinal
- vestibulospinal
- Reticulospinal

7/. 3IAG@BA:
Theie aie a set of common symptoms that occui with an 0NN lesions, incluuing:
- Spasticity
- Becieaseu muscle tone
- Positive Babinski Sign
- Pyiamiual weakness
- Bypeiieflexia
- Incieaseu BTR's

81

."J%+ 2"$"+ #%1+"#&
Lowei motoi neuions aie the motoi neuions that connect the biainstem anu the spinal
coiu to the muscle fibeis (ie theii axon enus in the effectoi muscle).
The LNN's aie classifieu baseu on the muscle fibei types that they each inneivate, these
aie the alpha-motoi neuions anu the gamma-motoi neuions.
$MOJCLE@D@? BIT?@BA - Aie the most numeious type of neuions of muscle fibei, aie
involveu in muscle contiaction, anu inneivate extiafusal muscle fibeis.
+CEECLE@D@? BIT?@BA - Aie components of the muscle spinules, involveu in
piopiioception, anu inneivate the intiafusal muscle fibeis.

3/. MIAG@BA:
Theie aie a set of common symptoms with LNN lesions, incluuing:
- Becieaseu muscle tone
- Nusculai weakness
- Bypoieflexia
- Fasciculations
- Atiophy of skeletal muscle
- Paialysis

-2/"+$,#$ !.-#-!,. !"#A-$-"#& -#3".3-#T 12# _ .2# .%&-"#&
$EF@D?@OJGP 3CDI?CM -PMI?@AGA - Both 0NN anu LNN signs. Is a slowly ueveloping
uisease that is ultimately fatal. Patient expeiiences weakness anu wasting of the bulbai
muscles (speech, swallowing, chewing), as well as the aims, legs, anu toiso. Nuscle
weakness anu wasting uevelops piopoitionally on both siues. Sensation anu mentation
iemain intact.
%?@K?IAAGHI 2TMXC? %CMAF - LNN
%AITN@XTMXC? %CMAF - 0NN
%?GEC?F 3CDI?CM -PMI?@AGA h%3-i - 0NN, males > females
%?@K?IAAGHI /TAPTMC? $D?@OJF - slow uegeneiation of LNN's
-OGBCM /TAPTMC? $D?@OJF h-/$i - LNN, uegeneiation of anteiioi hoin cells
%@MG@EFIMGDGA - LNN uestiuction

82

*%..[& /,.&I
Bell's palsy is a unilateial paialysis of facial muscles uue to a uysfunction of the facial
neive (CN7). Theie aie many possible causes, such as viial, Lyme uisease, stioke,
inflammation, etc. This conuition is almost always self-limiting.

-GKBA j -FEOD@EAd
- Ipsilateial facial paialysis
- Inability to blink eye on affecteu siue

g-=O<6@>8@g
It is highly impoitant to look foi the ability to wiinkle the foieheau, as the ability to uo so
usually inuicates that theie is an uppei motoi neuion lesion. This 0NN lesion iesults in a
conuition known as "PIBD?CM VCPGCM OCMAF", wheieby the pioblem is a paialysis of the
contialateial lowei pait of the face.

8S

S1#!$-"#& "S $)% !%+%*+,. !"+$%0

84

*+,-# .%&-"#&
.%&-"# ,+%, +%&1.$ "S .%&-"#
2?@PCcA $?IC Patient has expiessive aphasia (can't speak),
has goou unueistanuing of speech
ZI?BGP\IcA
$?IC
Patient has inability to compiehenu speech, can
speak well
>?@BDCM 3@XI Peisonality changes, uefects in juugement (ie
Fiontal ielease signs)
$?PTCDI
>CAPGPTMTA
Patient has goou language compiehension with
pooi ability to speak in iepetition
$EFKNCMC Kluvei-Bucy Synuiome - patient becomes
hypeisexual, hypeioial, anu has uisinhibiteu
behavioi
(GKJD
%C?GIDCM
3@XI
Patient has "spatial neglect", thus uo not
iecognize the contialateial siue of the lesion
/CEEGMMC?F
2@NGIA
Confabulations, anteiogiaue amnesia
2CACM
+CBKMGC
Resting tiemoi
"I?IXIMMC?
]I?EGA
Tiuncal ataxia anu uysaithiia
"I?IXIMMC?
#IEGAOJI?I
Intention tiemoi, ataxia of limbs

8S

$)% $),.,21&
The thalamus is a miuline stiuctuie of the uiencephalon, situateu between the ceiebial
coitex anu the miubiain. It ielays infoimation between the aieas of the subcoitex to the
ceiebial coitex, iegulates consciousness, iegulates sleep, anu iegulates aleitness. It gets
its bloou supply fiom many bianches of the posteiioi ceiebial aiteiy (paiameuian,
infeiolateial, posteiioi choioiual).
Theie aie thiee paits to the thalamus, they aie bulb-shapeu masses that aie
appioximately S.7cm in length, anu aie locateu alongsiue the S
iu
ventiicle at a Su uegiee
angle.

86

$)% )I/"$),.,21&
The hypothalamus is a stiuctuie within the biain with many key impoitant functions.
The easiest way to iemembei the functions of the hypothalamus is with the mnemonic
"&$. #$&-".
$ - &JG?AD (Watei balance, as iegulateu by thiist)
, - $NIB@JFO@OJFAGA (This stiuctuie is contiolleu via ieleasing factois)
# - .IT?@JFO@OJFAGA (Releases hoimones synthesizeu in the hypothalamic nuclei)

) - #TBKI? CBN -CDGIDF (Contiolleu by the ventiomeuial nucleus)
, - $TD@B@EGP iegulation (Paiasympathetic activity via anteiioi hypothalamus, ciicauian
ihythm via supiachiasmatic nucleus)
$ - &IEOI?CDT?I (Posteiioi hypothalamus - conseives heat when colu, Anteiioi
hypothalamus - cooiuinates cooling when hot)
& - -IQTCM (IKTMCDG@B (The septate nucleus contiols sexual emotions anu uiges)

$)% /"&$%+-"+ /-$1-$,+I
The posteiioi pituitaiy consists of axons that extenu fiom the supiaoptic anu
paiaventiiculai nuclei of the hypothalamus. The neuiohypophysis secietes two veiy
impoitant hoimones: 0xytocin anu vasopiessin.
]CA@O?IAAGB - Stimulates watei ietention, thus iaising bloou piessuie by aiteiial
contiaction.
,QFD@PGB - Stimulates contiaction of the uteius anu lactation

87

*,&,. T,#T.-,
The basal ganglia aie a gioup of nuclei situateu at the base of the foiebiain anu aie
connecteu with the ceiebial coitex anu thalamus. The basal ganglia aie impoitant in
many functions, namely motoi contiol anu leaining. The main components of the basal
ganglia aie the -D?GCDTEW %CMMGNTEW -TXADCBDGC .GK?CW anu the -TXDJCMCEGP .TPMITAR
-D?GCDTE [ The laigest pait of the basal ganglia, it consists of two paits (Cauuate nucleus
anu Putamen). The majoiity of the cells aie uABAeigic (>96%), anu cholineigic neuions
(~2%).
%CMMGNTE - Consists of a laige ulobus Palliuus (Inteinal (uPi) anu exteinal (uPe)
segments anu a small vential extension calleu the vential Palliuum). These two segments
aie mainly uABAeigic neuions that act as inhibitoiy neuiotiansmitteis.
-TXADCBDGC .GK?C - Locateu in the miubiain (mesencephalon), it plays a laige iole in
iewaiu, auuiction, anu movement. The substantia nigia contains laige levels of melanin
within uopamineigic neuions, these stiuctuies aie uaik anu thus stanu out fiom the iest
of the suiiounuing stiuctuies. Theie aie two paits to the substantia nigia (pais
compacta anu pais ieticulata). The pais compacta acts as an input to the basal ganglia
ciicuit, supplying the stiiatum with uopamine. The pais ieticulata seives as an output,
which conveys signals fiom the basal ganglia to numeious othei stiuctuies.
-TXDJCMCEGP .TPMITA - Locateu vential to the thalamus, meuial to the inteinal capsule,
anu uoisal to the substantia nigia. The subthalamic nucleus ieceives signals fiom the
globus palliuus, which aie uABAeigic in natuie, while it ieceives glutamineigic inputs
fiom the ceiebial coitex. The signals exiting the subthalamic nucleus aie glutamineigic,
which aie excitatoiy. These signals tiavel to many uiffeient stiuctuies incluuing the
substantia nigia, lateial palliuum, anu meuial palliuum.

88

!%..& $),$ &1//"+$ ,#A #"1+-&) $)% !#& _ /#&
&1//"+$-3% !%.. +".% -# !#&M/#& &1//"+$
,MGK@NIBN?@KMGC Piouuces myelin centially
-PJUCBB "IMMA Piouuces myelin peiipheially
$AD?@PFDIA Pioviue physical suppoit, potassium
metabolism, anu physical iepaii
/GP?@KMGC Is the phagocytic cell of the neivous
system
'OIBNFECM "IMMA Responsible foi the innei lining of the
ventiicles

$)% *.""AR*+,-# *,++-%+
The bloou-biain baiiiei is a system uesigneu to keep the bloou anu CSF fiom mixing. The
baiiiei is foimeu by tight junctions between enuothelial cells in the CNS vessels, thus they
iestiict the passage of solutes. This baiiiei is much moie iestiicting than anywheie else
in the bouy.
The bloou-biain baiiiei is foimeu by the $?CPJB@GN, 5BD?CPI?IX?CM PCOGMMC?F
IBN@DJIMGTE, anu "J@?@GN %MIQTA IBN@DJIMGTE.
Substances that can pass the bloou-biain baiiiei aie:
- L-Bopa
- Lipiu soluble substances
- ulucose
- Amino Acius

89

$)% 3%#$+-!1.,+ &I&$%2

9u

$)% A1+,. 3%#"1& &-#1&%&
These aie the venous channels founu in between the layeis of uuia in the biain. Theii
bloou supply comes fiom the inteinal anu exteinal veins of the biain. 0ltimately, all of
the uuial venous sinuses will empty into the inteinal jugulai vein. Injuiies to the heau
can cause bleeuing into the biain (hemoiihages, clots, hematomas).

91

"#$%&'( 8

%#0-5,3,+0

%JFAG@M@KF VGDA GBD@ ECBF CAOIPDA @V DJI 7-/3' IQCER 5D GA C
JGKJMF P@BPIODTCM D@OGPW CBN VTMM TBNI?ADCBNGBK @V DJIAI
P@BPIODA GA IAAIBDGCM D@ ATPPIAA @B DJI -DIO ) IQCER

92

+%#,. /)I&-"."TI

$)% )"+2"#%& ,!$-#T "# $)% V-A#%I
1. Aluosteione
2. Angiotensin 2
S. Atiial Natiiuietic Factoi (ANF)
4. Renin
S. Paiathyioiu Boimone
6. vasopiessin (ABB)

,.A"&$%+"#% ! secieteu in iesponse to a ueciease in bloou volume anu the
subsequent piouuction of angiotensin 2. Causes an inciease in souium ieabsoiption,
inciease in potassium secietion, anu inciease in hyuiogen secietion.
,#T-"$%#&-# Z ! causes effeient aiteiiole constiiction, which causes an inciease of
uFR anu subsequently incieases souium anu bicaibonate ieabsoiption.
,$+-,. #,$+-1+%$-! S,!$"+ ! secieteu when theie is an inciease in atiial piessuie,
which causes an inciease in uFR anu thus incieaseu souium excietion.
+%#-# ! secieteu in iesponse to uecieaseu bloou volumeflow, subsequently gets
conveiteu to AT 1 anu then AT2, which causes aluosteione secietion eventually to
inciease bloou volume.
/,+,$)I+"-A )"+2"#% ! acts on pioximal convoluteu tubule, secieteu in iesponse
to a low plasma level of calcium, causing calcium ieabsoiption in the uistal convoluteu
tubule.
3,&"/+%&&-#M,A) ! is secieteu when the plasma osmolaiity is high anu volume is
low. Causes watei ieabsoiption in the collecting uucts.
9S

94

$)% 410$,T."2%+1.,+ ,//,+,$1&
The }uA is a stiuctuie in the kiuney that is iesponsible foi iegulating bloou flow anu uFR.
It is locateu stiategically in a location that allows it to maximally iegulate these functions
(locateu between the vasculai pole of the ienal coipuscle anu the uistal convoluteu
tubule).
Thiee components of the }uA: )R /CPTMC YIBAC 1R kTQDCKM@EI?TMC? PIMMA
4R 'QD?CKM@EI?TMC? EIACBKGCM PIMMA

}uxtaglomeiulai Cells ! aie mouifieu smooth muscle cells that seciete ienin in iesponse
to uecieaseu ienal bloou flow.
Nacula Bensa ! is pait of the BCT, is a sensoi foi souium.
**$H5 GCN =5??>N5 6 SCF@6>@C<8 +>@5 PTS+Q
uFR uesciibes the flow iate of filteieu fluiu thiough the kiuney. Cieatinine cleaiance iate
(CCR) is the volume of bloou plasma that is cleaieu of cieatinine pei unit time anu is a
veiy useful measuie foi the appioximate glomeiulai filtiation iate.
uFR is best calculateu by measuiing a chemical that has a steauy level in the bloou (ie
neithei absoibeu noi secieteu by the kiuneys). A gieat tool foi this is "inulin", which fits
these ciiteiia.
&JI ISTCDG@B V@? PCMPTMCDGBK +>( GA CA V@MM@UAd

+58>F !F5>6>8D5
Calculating cleaiance is quite simple, howevei you must unueistanu a simple concept
ielating to ienal cleaiance in oiuei to ueciphei whethei theie is a net secietion, net
ieabsoiption, oi neithei.
&JI ISTCDG@B V@? (IBCM "MIC?CBPI:

If +58>F !F5>6>8D5 U TS+, theie is no secietion oi ieabsoiption
If +58>F !F5>6>8D5 h TS+, theie is a net tubulai secietion of whichevei substance we aie
looking at.
If +58>F !F5>6>8D5 i TS+, theie is a net tubulai ieabsoiption of whichevei substance we
aie looking at.

96

S655 J>@56 !F5>6>8D5

SCF@6>@C<8 S6>D@C<8
The filtiation fiaction iepiesents the piopoition of fluiu that ieaches the kiuney which
passes to the ienal tubules. A healthy numbei is aiounu 2u%. Shoulu theie be cases
wheieby uFR is uecieaseu (as in ienal aiteiy stenosis), filtiation fiaction shoulu
piopoitionally inciease to maintain the noimal function of the kiuney.
SCF@6>@C<8 S6>D@C<8 U TS+M+/S

If uFR anu RPF inciease oi ueciease simultaneously, theie is no change in FF
If uFR incieases anu RPF uecieases, theie is an inciease in FF

%BB5D@C75 +58>F /F>?=> SF<L P%+/SQ
This calculation is useu to calculate ienal plasma flow anu thus to estimate ienal function.
We use the "PAB cleaiance", which is the cleaiance of Paia Aminohippuiate Cleaiance. It
is fieely filteieu anu not absoibeu in the nephion.
"CMPTMCDGBK '(%>:
%+/) U 1/,) 0 3M//,) U !/,)

97

TF:D<?5 !F5>6>8D5
Impoitant in uiabetes, it shoulu simply be known that glucosuiia occuis when plasma
glucose ieaches 2uumguL, because the PCT cannot ieabsoib once these levels aie
ieacheu.

$)% +%#-#R,#T-"$%#&-#R,.A"&$%+"#% &I&$%2
A hoimonal system that iegulates the balance of bloou piessuie anu fluius.
-DIOA @V DJI ($$-:
1. Low bloou volume is uetecteu by the macula uensa, causing the }u cells to ielease
ienin.
2. Renin then cleaves angiotensinogen, conveiting it to angiotensin 1.
S. Angiotensin 1 is then conveiteu to angiotensin 2 by the ACE enzyme (angiotensin-
conveiting enzyme), which is founu in the lungs.
4. Angiotensin 2 binus to ieceptois in the intiaglomeiulai mesangial cells,
stimulating the ielease of aluosteione fiom the zona glomeiulosa of the auienal
coitex.
S. Aluosteione then stimulates the ieabsoiption of souium anu watei in the PCT anu
collecting uucts of the kiuney

98

/)I&-"."TI ,$ %,!) /"+$-"# "S $)% #%/)+"#
&#' %(,f5/$3 ",.],37&'Y &7273'
ZJCD @PPT?A:
- Complete glucose ieabsoiption
- Complete amino aciu absoiption
- Neai complete ieabsoiption of souium, watei, anu bicaib (BC0S-)
- Secietion of ammonia

99

&#5"b $-"'.Y5.+ 3,,% ,> #'.3'
ZJCD @PPT?Ad
- Souium ieabsoiption (active)
- Potassium ieabsoiption (active)
- Chloiiue ieabsoiption (active)
- Nagnesium ieabsoiption (passive)
- Calcium ieabsoiption (passive)

1uu

Y5-&$3 ",.],37&'Y &7273'
ZJCD @PPT?Ad
- Active ieabsoiption of souium
- Active ieabsoiption of chloiiue
- Calcium ieabsoiption occuis heie (if stimulateu by paiathyioiu hoimone)

1u1

",33'"&5.+ &7273'-
ZJCD @PPT?A:
- Souium gets ieabsoibeu (in exchange foi B+ anu K+), when aluosteione is piesent
- Watei gets ieabsoibeu in the piesence of ABB

1u2

T,&$+"-#$%&$-#,. /)I&-"."TI

$)% +%T1.,$-"# "S T,&$+-! ,!-A &%!+%$-"#
The key playei in iegulating gastiic aciu secietion is the B+K+ ATPase, which is a
magnesium-uepenuent pump. The following aie the basic steps of gastiic aciu piouuction
anu secietion:
1. B+ is geneiateu within the paiietal cell fiom the uissociation of watei. Byuioxyl
ions iapiuly combine with C02 via caibonic anhyuiase.
2. BC0S- is tianspoiteu outsiue the cell in exchange of chloiiue (maintains
intiacellulai pB of the paiietal cell).
S. Cl- anu K+ aie tianspoiteu into the lumen, which is necessaiy foi secietion of aciu.
4. B+ pumpeu out of the cell anu into the lumen in exchange foi K+ thiough a pioton
pump.
S. B+ accumulation geneiates an osmotic giauient that causes outwaiu uiffusion of
watei, leauing to gastiic aciu piouuction (BCl, KCl), anu a small amount of NaCl

1uS

)"+2"#%& "S $)% T-
+$-&(5.:
- Secieteu fiom the u cells in the antium of the stomach
- Cause stimulation of B+ secietion
- Incieaseu when theie is stomach uistention, vagal stimulation, anu the piesence of
amino acius in the stomach
- Becieaseu when theie is a stomach aciu <1.S
- 0veistimulation can leau to P0B, gastiitis, Zollingei-Ellison synuiome
"#,3'"0-&,b5.5.:
- Secieteu fiom the I cells of the uuouenum anu jejunum
- Causes an inciease in pancieatic secietion
- Stimulates gallblauuei contiaction
- Inhibits the emptying of gastiic contents
- Inhibiteu by secietin anu a stomach pB <1.S
- Stimulateu by the piesence of fats anu pioteins in the stomach
-'"('&5.:
- Secieteu fiom the S cells of the uuouenum
- Causes an inciease in pancieatic bicaibonate secietion
- Inhibits the secietion of gastiic acius
- Stimulateu by the piesence of acius anu fatty acius in the lumen of the uuouenum
-,/$&,-&$&5.:
- Secieteu fiom the B cells in the pancieatic islet cells
- Causes inhibition of gastiic aciu anu pepsinogen secietion
- Causes inhibition of fluiu secieteu fiom the pancieas anu small intestine
- Inhibits gallblauuei contiaction
- Inhibits the ielease of insulin anu glucagon
- Secietion is stimulateu by incieaseu aciu anu inhibiteu by vagal stimulation
+$-&(5" 5.#525&,(0 %'%&5Y':
- Secieteu by the K cells in the uuouenum anu jejunum
- Becieases the amount of gastiic aciu that is secieteu
- Incieases insulin ielease

1u4

&%!+%$"+I /+"A1!$& "S $)% T-
5.&(5.-5" >$"&,(d
- Secieteu by the paiietal cells
- Binus vitamin B12
- Autoimmune uestiuction leaus to peinicious anemia
%'%-5.:
- Secieteu by the chief cells
- Aius in piotein uigestion
- Incieaseu thiough vagal stimulation
+$-&(5" $"5Yd
- Secieteu by the paiietal cells
- Becieases stomach aciu (ie Low pB)
- Stimulateu by histamine anu acetylcholine
- Inhibiteu by piostaglanuins, somatostains, anu uIP
25"$(2,.$&':
- Secieteu by the mucosal cells of the uuouenum anu stomach
- Pievents autouigestion by aciu neutialization
- Stimulateu by secietin

%#\I2%& &%!+%$%A *I $)% /,#!+%,&
3GOCAI ! Aius in fat uigestion, elevateu in pancieatitis
$EFMCAI ! Belps in staich uigestion, also elevateu in pancieatitis
%?@DICAIA ! Aie secieteu as pioenzymes, help with piotein uigestion

1uS

%#A"!+-#% /)I&-"."TI

&/%+2 /+"A1!$-"#
Speim piouuction ielies on a few veiy impoitant hoimones in oiuei to stimulate
piouuction, anu subsequently to piouuce the piopei amount.
&JI GEO@?DCBD J@?E@BIA @V AOI?ECD@KIBIAGA C?Id
.5:@58CjC8N )<6=<85 P.)Q ! iesponsible foi stimulating testosteione ielease fiom the
leyuig cells.
S<FFCDF5 &@C=:F>@C8N )<6=<85 PS&)Q ! iesponsible foi stimulating the Seitoli cells,
which then ielease Inhibin anu Anuiogen-binuing pioteins (ABP)
>?@E DJIAI DU@ J@?E@BIAW UI KID DJI V@MM@UGBKd
$5?@<?@56<85 ! iesponsible foi the uiffeientiation into male genitalia, maintaining
gametogenesis (these aie the two things we neeu most foi this topic)
,8;6<N58RGC8;C8N O6<@5C8 ! iesponsible foi keeping the testosteione levels high insiue
the seminifeious tubules
-8HCGC8 ! this is iesponsible foi pioviuing negative feeuback to the pituitaiy, inhibiting
the ielease of too much FSB.

1u6

&JI V@MM@UGBK GMMTAD?CDG@B OTDA CMM @V DJI CX@HI GBV@?ECDG@B GBD@ OMCFW AGKBGVGPCBDMF
AGEOMGVFGBK F@T? TBNI?ADCBNGBK @V DJI UJ@MI O?@PIAA*

,#A+"T%#-! )"+2"#%&
The anuiogenic hoimones incluue:
- Testosteione
- Bihyuiotestosteione (BBT)
- Anuiosteneuione
%@DIBPGIAd Y#& l &IAD@ADI?@BI l $BN?@ADIBING@BI

>TBPDG@BA @V ICPJ J@?E@BIAd
A)$ ! Synthesizeu by the enzyme "S!-ieuuctase"
- Foimation of seconuaiy sexual chaiacteiistic in men
$5?@<?@56<85 ! Piomotes piotein synthesis anu giowth of all tissues with anuiogen
ieceptois.
- Nuscle giowthmass
- Bone uensity
- Bone matuiation
- Natuiation of sex oigans (penis anu sciotum in fetus)
- Baii giowth (facial haii, axillaiy haii)
1u7

- Bevelopment of seconuaiy sex chaiacteiistics
- Bevelopment of piostate anu seminal vesicles
- Libiuo
,8;6<?@585;C<85 ! a piecuisoi of both male anu female sex hoimones

/+"T%&$%+"#%
The hoimone involveu in the female menstiual cycle, piegnancy, anu embiyogenesis.
It comes fiom the testes, coipus luteum, placenta, anu the auienal coitex.
The main functions of Piogesteione aie:
- Relaxation of the smooth muscle of the uteius
- Piegnancy maintenance
- Spiial aiteiy uevelopment
- Enuomeuiial glanu secietion stimulation
- Ceivical mucus piouuction (thickens - benefit of 0CP use)
- Inciease in bouy tempeiatuie
- Inhibits the gonauotiopins FSB anu LB

1u8

$)% 2%#&$+1,. !I!.%
The best way to leain the menstiual cycle is visually, keeping the following high-yielu
infoimation in minu:
- LB suige causes ovulation
- Piogesteione is the hoimone of piegnancy, maintaining enuometiium foi
implantation suppoit
- The folliculai giowth is fastest in the 2
nu
week of the piolifeiative phase
- Noimal cycle is 28 uays
- 0vulation will typically (with a noimal cycle) occui 14 uays aftei the onset of
menses.

1u9

2%#"/,1&%
Nenopause is inuicative of the cessation of ovaiian function, iesulting in the cessation of
ovulation anu menstiuation.
&JI V@MM@UGBK C?I DJI J@?E@BCM PJCBKIA DJCD @PPT? UGDJ EIB@OCTAId
- Estiogen uecieases
- uonouotiopin-ieleasing hoimone incieases
- LB incieases
- FSB incieases significantly
&JI V@MM@UGBK C?I DJI E@AD P@EE@B AFEOD@EA CAA@PGCDIN UGDJ EIB@OCTAId
- Bot flashes
- vaginal atiophy
- 0steopoiosis
- Coionaiy aiteiy uisease (estiogen is saiu to be a piotective factoi against this)

)12,# !)"+-"#-! T"#"A"$+"/-# PH!TQ
hCu is secieteu fiom the placental syncytiotiophoblast, anu is iesponsible foi the
following functions:
- Is the #1 inuicatoi of piegnancy
- Belps to maintain the coipus luteum uuiing the 1
st
tiimestei of piegnancy
- Belps in uiagnosing iepiouuctive pathologies such as choiiocaicinoma anu
hyuatifoim moles (uiscusseu in pathology section)

+%T1.,$-"# "S /+".,!$-#
Piolactin is a hoimone secieteu fiom the anteiioi pituitaiy anu is iesponsible foi some
impoitant functions, as well it is iesponsible foi ceitain pathologies (piolactinoma,
infeitility).
5EO@?DCBD VTBPDG@BA ! Lactation, oigasm, oligouenuiocyte piecuisoi cell piolifeiation.
5BJGXGDIN XF ! Bopamine

$)% )I/"$),.,21& ,#A /-$1-$,+I
11u

111

$)% $)I+"-A )"+2"#%
Thyioiu hoimone is an extiemely impoitant anu veisatile hoimone, contiolling a wiue-
iange of functions anu impoitant foi piopei giowth.
>TBPDG@BA @V DJF?@GN J@?E@BId
- CNS matuiation
- Bone giowth
- "-auieneigic effects
- Incieases BNR (via incieasing the Na+K+ pump)
- Lipolysis (incieases)
- uluconeogenesis (incieases)
- ulycogenolysis (incieases)
%?@NTPDG@B @V DJF?@GN J@?E@BId
1. Folliculai cells synthesize enzymes anu thyioglobulin foi colloiu.
2. Iouine is co-tianspoiteu into the cell with Na+ anu tianspoiteu into colloiu.
S. Enzymes auu iouine to thyioglobulin to make TS anu T4.
4. Thyioglobulin is taken back into the cell.
S. Intiacellulai enzymes sepaiate TS anu T4 fiom the piotein
6. Fiee TS anu T4 entei the ciiculation
*TS pioviues negative feeuback to the anteiioi pituitaiy.

112

/,+,$)I+"-A )"+2"#% P/$)Q
PTB comes fiom the chief cells of the paiathyioiu glanus. In iesponse to low seium
calcium, PTB is ieleaseu anu peifoims the following:
- Incieases bone iesoiption which incieases Ca2+ anu P04-
- Incieases the ieabsoiption of calcium fiom the kiuneys (uistal convoluteu tubules)
- Becieases the ieabsoiption of phosphate fiom the kiuneys
- Stimulates the enzyme 1!-hyuioxylase in the kiuney, which incieases 1,2S-(0B)2
vitamin B (ie cholecalcifeiol)

!,.!-$"#-#
Calcitonin woiks opposite of PTB by iecognizing an inciease in seium Ca2+ anu thus
uecieasing the bone iesoiption of calcium. Calcitonin is secieteu fiom the paiafolliculai
(c cells) of the thyioiu glanu.

.-#V-#T /,$)"."TI $" !>Zkl /"^Rl >8; ,.V,.-#% /)"&/),$,&%
&JI V@MM@UGBK MGAD @V P@BNGDG@BA CMDI? DJIAI MIHIMA GB DJI V@MM@UGBK UCFA*
AC?5?>?5 !>FDC:= .575F /H<?OH>@5 .575F ,Fm /H<?OH .575F
3C@>=C8 A -8@<K Incieases Incieases Incieases
"?@5<O<6<?C? No change No change No change
)EO56O>6>@HE6<C;C?= Incieases Becieases Incieases
/>N5@[? G<85 ;C?5>?5 Noimal-incieaseu Noimal Laige inciease
+58>F -8?:BBCDC58DE Becieaseu Incieaseu No change

11S

!,+A-,! /)I&-"."TI

.,&': Caiuiac physiology is unique in that almost eveiything is conceptual in natuie,
which means that theie aie many giaphschaits, etc. By completely unueistanuing the
concept behinu all of this infoimation, you will not have to memoiize anything, iathei you
will be able to apply it to any question the 0SNLE exam thiows youi way.

$)% !,+A-,! !I!.%
The caiuiac cycle iefeis simply to the steps that aie unueitaken by the heait as it goes
fiom filling, to pumping the bloou systematically, to filling once again.
&JI OJCAIA @V DJI PC?NGCP PFPMI:
Xn -?<7<F:=5@6CD !<8@6>D@C<8
This is the point between the closuie of the mitial valve anu the opening of the aoitic
valve. The heait is contiacteu but valves aie closeu.
Zn &E?@<FCD %95D@C<8
The heait squeezes anu bloou is ejecteu thiough the aoitic valve. This phase can be
consiueieu the phase between the time the aoitic valve opens anu closes.
]n -?<7<F:=5@6CD +5F>K>@C<8
This is the peiiou of time between the closuie of the aoitic valve anu the opening of the
mitial valve.
^n +>OC; BCFFC8N OH>?5
Aftei the opening of the mitial valve, bloou pools iapiuly into the left ventiicle.
bn &F<L BCFFC8N OH>?5
At this point, bloou flows into the Lv slowly as the mitial valve is about to close.

114

5EO@?DCBD JIC?D A@TBNA DJCD @PPT? NT?GBK DJI PC?NGCP PFPMId
&X - this is the 1
st
heait sounu anu iepiesents the closing of the tiicuspiu anu mitial
valves
&Z - this is the 2
nu
heait sounu anu iepiesents the closing of the pulmonaiy anu aoitic
valves
&] - this is the S
iu
heait sounu anu iepiesents the enu of the iapiu ventiiculai filling (can
be associateu with congestive heait failuie)
&^ - this is a heait sounu heaiu only if theie is a stiff ventiicle (is associateu with
ventiiculai hypeitiophy)

&JI V@MM@UGBK K?COJ ?IO?IAIBDA DJI OJCAIA @V DJI PC?NGCP PFPMId

11S

Z5++'(c- Y5$+($/:
This uiagiam is useu in caiuiac physiology to illustiate the ielationships between seveial
uiffeient events that aie occuiiing simultaneously. Foi the 0SNLE exam, it is impoitant
to iecognize the ielationships on the giaph as well as to iecognize wheie the majoi
events aie locateu giaphically.

116

,!$-"# /"$%#$-,. "S $)% /,!%2,V%+

&#' -$ .,Y':
The cells of the Av noue uepolaiize spontaneously, iesulting in appioximately 1uu
contiactions pei minute. This iate uoes not cieate a ventiiculai iate of 1uu because the
sympathetic anu paiasympathetic fibeis have the ability to contiol how much gets
thiough.
&#' $] .,Y':
This noue uischaiges appioximately 4u-6ubpm. Theie aie bianches that come fiom the
Av noue (Puikinje fibeis), that also piouuce spontaneous action potentials at a iate of
appioximately Su-4ubpm (keep conuuction if the noues aie not woiking efficiently).

$)% /),&%& "S $)% ,!$-"# /"$%#$-,.:
%JCAI 6 [ ^-M@U YGCAD@MGP YIO@MC?GaCDG@B_
With a Na+ conuuctance inciease, the membiane potential spontaneously uepolaiizes,
accounting foi the automaticity of the SA anu Av noues. In the chait below, the slope of
phase 4 in the SA noue is the ueteimining factoi in heait iate. This can be incieaseu with
catecholamines (NE, Epi) anu uecieaseu with acetylcholine.

117

%JCAI = [ ^7OAD?@\I_
Causeu by a slow influx of calcium because theie aie no fast souium channels. This
iesults in a slow conuuction velocity that helps to piolong tiansmission fiom the atiia to
the ventiicles.
%JCAI 4 [ ^(IO@MC?GaCDG@B_
A iapiu inactivation of the calcium channels anu a ueciease in potassium peimeability
slowly iepolaiizes the cell (ie theie is a loss of positive ions).

118

3%#$+-!1.,+ ,!$-"# /"$%#$-,.
The ventiiculai action potential is best explaineu thiough the use of visual aius. Each
phase of the action potential is causeu by an influx oi efflux of ceitain ions, thus knowing
which ions woik wheie is vital to unueistanuing the events anu getting as many points as
possible on the 0SNLE.

/H>?5 Y ! voltage-uateu Na+ channels aie open, iesulting in a iapiu upstioke.
/H>?5 X ! Na+ channels aie inactivateu anu voltage-gateu K+ channels begin to open.
This iesults in the initial iepolaiization.
/H>?5 Z ! A plateau phase wheie a voltage-gateu Ca2+ channel iesults in balancing off of
the K+ efflux. This tiiggeis Ca2+ ielease fiom the SR anu thus myocyte contiaction.
/H>?5 ] ! A massive efflux of K+ uue to opening of slow voltage-gateu K+ channels anu
closuie of voltage-gateu Ca2+ channels leaus to iapiu iepolaiization.
/H>?5 ^ ! A high K+ peimeability iesults in ietuin to iesting potential.

119

!,+A-,! "1$/1$
Caiuiac output is a measuie of the stioke volume X the heait iate. Acutely, caiuiac output
will inciease uue to stioke volume incieases, wheieas chionically caiuiac output is a
iesult of an inciease in heait iate.
!,+A-,! "1$/1$ U &$+"V% 3".12% 0 )%,+$ +,$%

]$(5$23'- ,> "$(Y5$" ,7&%7&:
9.)'/*&'(+('> ()&/#*,#, 2('" '"# -.++.2()3 O*, 1.#, ,'/.<# P.+40#Q@
- Inciease in intiacellulai calcium
- Inciease in catecholamines
- Becieaseu extiacellulai souium
- 0se of uigitalis
9.)'/*&'(+('> 1#&/#*,#, 2('" '"# -.++.2()3 O*, 1.#, ,'/.<# P.+40#Q@
- Beait Failuie
- Bypoxia
- Blockaue of the "1 ieceptoi
- Aciuosis

, S%J -2/"+$,#$ %e1,$-"#& -# !,+A-,! /)I&-"."TI

12u

/+%.",A ,#A ,S$%+.",A
/65F<>; ! Pieloau is the stietching piessuie in the ventiicles of the heait aftei filling is
completeu. Pieloau is incieaseu when theie is an inciease in bloou volume, sympathetic
stimulation, anu even exeicise.
$H565B<65l /+%.",A U %#ARA-,&$".-! 3".12%

,B@56F<>; ! Afteiloau is the teim that measuies the tension piouuceu in the ventiicle in
oiuei foi contiaction to occui.
$H565B<65l ,S$%+.",A U A-,&$".-! ,+$%+-,. /+%&&1+%

]IB@TA NGMCD@?A will NIP?ICAI DJI O?IM@CN, this incluues most commonly nitioglyceiine.
]CA@NGMCD@?A will NIP?ICAI DJI CVDI?M@CN, this incluues most commonly uiugs like
hyuialazine.

$)% S+,#VR&$,+.-#T .,J
This law states that with a gieatei volume of bloou enteiing the heait uuiing uiastole, the
gieatei volume of bloou is ejecteu uuiing systole. This law explains that synchionization
of caiuiac output anu venous ietuin occuis without neeuing exteinal factois to come into
play.

121

$)% %VT

/ L>75 ! Repiesents atiial uepolaiization
/+ ?5N=58@ ! Repiesents the conuuction uelay thiough the Av noue
e+& D<=OF5K ! Repiesents ventiiculai uepolaiization
e$ C8@567>F ! Repiesents mechanical contiaction of the ventiicles
$ L>75 ! Repiesents the ventiiculai iepolaiizations
&$ ?5N=58@ ! Is an isoelectiic point wheie the ventiicles aie uepolaiizeu

122

,*#"+2,.-$-%& "S $)% %VT
$&(5$3 >37&&'(d A supiaventiiculai tachycaiuia that piesents with a seiies of iapiu
back-to-back uepolaiizations. This may occui in those with heait uiseases (CBF, CAB,
etc), but can also occui in a peifectly noimal heait. The classic piesentation is the
"sawtooth" pattein, which occuis as a iesult of iuentical back-to-back uepolaiizations.

$&(5$3 >52(533$&5,.: Is a veiy common caiuiac aiihythmia wheieby theie is a
quiveiing of the chambei insteau of a cooiuinateu contiaction. The classic finuings aie a
chaotic anu eiiatic baseline with the absence of P waves in between iegulaily spaceu QRS
complexes.

,$+-"3%#$+-!1.,+ *."!V&
)
-&
Y'+('' 23,"b: An asymptomatic conuition with a PR inteival piolongation
>2uumsec.

12S

1
.Y
Y'+('' /,25&m &0%' ) hZIBP\IXCPJid Is a conuition that is often asymptomatic,
but if symptomatic will iequiie a pacemakei. The piesentation is a piogiessive
lengthening of the PR inteival until a P wave is not followeu by a QRS complex.

1
.Y
Y'+('' /,25&m &0%' 1: Piesents with acutely uioppeu beats that aie not
pieceeueu by a change in the PR length. The most common piesentation is 2 P waves pei
1 QRS complex.

4
(Y
Y'+('' h",/%3'&'i #'$(& 23,"b: Theie is inuepenuent beating of the atiia anu
the ventiicles.

]'.&(5"73$( &$"#0"$(Y5$: A tachycaiuia iesulting in a heaitbeat > 1uubpm. This
may be non-pathologic, but may also leau to ventiiculai fibiillation.

124

]'.&(5"73$( >52(533$&5,.: This is a conuition wheie theie is a eiiatic ihythm anu no
iuentifiable waves on EKu. This aiihythmia is fatal without piompt uefibiillation.

/)I&-"."TI "S $)% !,+A-,! 2I"!I$%
1. A uepolaiization tiavels uown the T-tubule, stimulating the ielease of calcium
fiom the SR (goes thiough the uihyuiopyiiuine ieceptoi anu Ryanouine ieceptoi).
2. Calcium is ieleaseu anu binus to tioponin C, which leaus to the confoimational
change (moving tiopomyosin out of the myosin-binuing gioove on actin filament)
S. Powei Stioke ! myosin hyuiolyzes the bounu ATP anu is uisplaceu on the actin
filament
4. Contiaction occuis

12S

!"2/,+-#T &2""$) 21&!.% !"#$+,!$-"# ,#A &V%.%$,. 21&!.%
!"#$+,!$-"#
-E@@DJ /TAPMI "@BD?CPDG@B:

-\IMIDCM /TAPMI "@BD?CPDG@B:
1. ATP binus to the myosin heau, ieleasing the actin filament
2. Cioss-biiuge cycling anu shoitening occui
S. Calcium binus tioponin C anu a confoimational change occui
4. Tiopomyosin moves allowing actinmyosin cycling

126

*,+"+%!%/$"+& ,#A !)%2"+%!%/$"+&
Baioieceptois ! Responu to piessuie
Chemoieceptois ! Responu to chemical changes

.<D>@C<8 6<65D5O@<6?:
&JI C@?DGP C?PJ ! iesponus to bloou piessuie, anu tiansmits a signal to the meuulla (via
the vagus neive).
&JI PC?@DGN AGBTA ! the baioieceptoi heie tiansmits its signal to the meuulla via the
glossophaiyngeal neive.

.<D>@C<8 <B DH5=<65D5O@<6?:
Cential chemoieceptois ! iesponu to pB anu PCu2 changes of the inteistitial fluiu in the
biain (these aie not influenceu by Pu2)
Peiipheial chemoieceptois ! iesponu to a Pu2 < 6ummBg, iesponu to incieaseu PCu2,
anu iesponu to a ueciease in pB (ie inciease in B+)

#,Z 5- #0%,&'.-5,. (']'(-'Y 20 &#' 2$(,('"'%&,(-n
1. Aiteiial piessuie is uecieaseu, iesulting in.
2. Becieaseu stietch, which leaus to.
S. Becieaseu affeient baioieceptoi fiiing, this causes..
4. Incieases in effeient sympathetic activity anu uecieaseu effeient paiasympathetic
stimulation, leauing to.
S. vasoconstiiction, which.
6. Incieases heait iate, contiactility, anu bloou piessuie
#,Z Y,'- "$(,&5Y /$--$+' Z,(bn
1. Nassaging the caiotiu aiteiy gives the sense of incieaseu piessuie, which.
2. Incieases the stietch uetecteu fiom the baioieceptoi, this in tuin.
S. Becieases the heait iate

127

%0!),#T% "S !,/-..,+I S.1-A&
Foices insiue anu outsiue of the capillaiies aie what can move fluius back anu foith.
Theie aie uiffeient methous by which fluiu is moveu, it can eithei be pusheu out of the
capillaiy (capillaiy piessuie), oi it can be moveu via osmotic piessuie, wheie it is pulleu.
The foices aie calleu "Stailing" foices, anu they aie the following:
1. Capillaiy Piessuie (Cp) - this piessuie usually causes a movement of fluiu out of
the capillaiy
2. Inteistitial Piessuie (Pi) - this is piessuie the pushes on the capillaiies anu moves
fluiu into the capillaiy.
S. Plasma colloiu osmotic piessuie (#c) - usually moves fluiu into the capillaiy
4. Inteistitial fluiu colloiu osmotic piessuie (#i) - usually moves fluiu out of the
capillaiy.
Beteimining whethei fluiu will move into oi out of the capillaiy is baseu on the net
filtiation piessuie. By having all of the values of the piessuies above, we can ueteimine
this figuie:
Net Filtiation Piessuie = (Pc-Pi) - (#c - #i)

35.b5.+ &#' $2,]' &, 'Y'/$&,7- -&$&'-d
Euema is causeu by excess fluius outsiue of the capillaiies, thus states in which this is
favoiable will likely leau to euema. The following will likely leau to euematous states:
1. Incieaseu inteistitial fluiu colloiu osmotic piessuie
2. Incieaseu capillaiy piessuie
S. Incieaseu capillaiy peimeability
4. Becieaseu quantities of plasma pioteins

128

+%&/-+,$"+I /)I&-"."TI

$)% "0IT%#R)%2"T."*-# A-&&"!-,$-"# !1+3%

, ?HCB@ @< @H5 6CNH@ = uecieaseu affinity of hemoglobin foi oxygen
, ?HCB@ @< @H5 F5B@ = incieaseu affinity of hemoglobin foi oxygen

129

/1.2"#,+I +%&/"#&%& $" )-T) ,.$-$1A%
When in highei altituues the Pu2 uecieases significantly, thus the bouy must auapt anu
finu ways to maintain oxygenation to the tissues of the bouy. The following aie the majoi
iesponses that help us maintain auequate oxygenation:
- ventilation incieases
- Eiythiopoietin incieases (fiom kiuneys)
- Incieases in 2,S-Biphosphoglyceiate (helps make u2 ielease easiei)
- Respiiatoiy alkalosis stimulates BC0S- excietion fiom the kiuneys
- Chionic high altituue can cause a chionically highei iate of ventilation

/%+S1&-"# .-2-$%A 7? A-SS1&-"# .-2-$%A !-+!1.,$-"#
/56B:?C<8 FC=C@5; ! means that gas equilibiates eaily along the capillaiy's length, thus
the only way to inciease uiffusion is to inciease bloou flow.
ACBB:?C<8 FC=C@5; ! means that gas uoesn't equilibiate by the time it ieaches the enu of
the capillaiy.
Peifusion limiteu is seen in healthy people, wheieas uiffusion limiteu occuis in those with
emphysema, fibiosis, oi when exeicising.

.1#T 3".12%
Theie is a list of impoitant uefinitions you shoulu know foi the 0SNLE exam, as theie is
almost always at least 1 question uealing with this. The question may come in the foim of
a uefinition, but it will most likely come in the foim of a chait wheie you will have to
calculate.

1Su

"CMPTMCDGBK MTBK H@MTEIA:
$<@>F .:8N !>O>DC@E = Rv + IRv + Tv + ERv
3C@>F !>O>DC@E = Tv + IRv + ERv
S:8D@C<8>F +5?5675 !>O>DC@E = ERv + Rv
-8?OC6>@<6E !>O>DC@E = IRv + Tv

3%#$-.,$-"#M/%+S1&-"# P3MeQ 2-&2,$!)
When theie is noimal gas exchange (ie healthy inuiviuual), the vQ is appioximately 1,
meaning an iueal ventilation to peifusion iatio. If theie is a mismatch, this inuicates that
theie is a shunt anu some uegiee of ueau space in the same lung.
A vQ of u is inuicative of a shunt (ie aiiway obstiuction)
A vQ of $ is inuicative of an obstiuction of bloou flow (ie physiological ueau space).
- ventilation anu peifusion aie gieatei at the base of the lung than in the apex
- vQ at the apex of the lung is highei, meaning wasteu ventilation
- vQ at the base of the lung is lowei, meaning wasteu peifusion

.1#T /+"A1!$&
Theie aie a few veiy impoitant piouucts maue insiue the lungs, they incluue:
1. Angiotensin-Conveiting Enzyme
2. Suifactant (type 2 pneumocytes)
S. Piostaglanuins
4. Bistamine
S. Kallikiein

1S1

!,+*"# A-"0-A% $+,#&/"+$
Theie aie thiee methous by which caibon uioxiue aie caiiieu fiom the tissues of the bouy
back to the lungs, they incluue:
1. In the foim of bicaibonate (this is the majoiity) ~9u%
2. As uissolveu caibon uioxiue ~S%
S. Bounu to hemoglobin as caibaminohemoglobin ~S%

1S2

"#$%&'( 9

25,"#'/5-&(0

&JGA AIPDG@B GA HI?F JGKJLFGIMNW CBN GBPMTNIA ECBF ATXL
PCDIK@?GIAR &JI EIDCX@MGP OCDJUCFA C?I HI?F GEO@?DCBDo OCFGBK
AOIPGCM CDDIBDG@B D@ ?IKTMCD@?F ADIOA GA P?TPGCMR ZJGMI DJI NIDCGMA
@V XG@PJIEGAD?F C?I B@D JGKJLFGIMNW DJI XGK OGPDT?I CA C UJ@MI GA
HI?F JGKJLFGIMN ECDI?GCMR

1SS

T%#%$-!&
The Baiuy-Weinbeig law of genetics states that both the allele anu the genotype
fiequencies of a population iemain constant fiom geneiation to geneiation, unless theie
is a specific uistuibance(s) intiouuceu into the population.
&JI MCU @V #C?NFLZIGBXI?K CAATEIA:
1. No mutations occui
2. Theie is no selection foi any of the specific genotypes
S. Nating is ianuom
4. Theie is no migiation into oi out of the population

The fiequency of uiffeient alleles in a population can be ueteimines with the Punnett
squaie, which can be linkeu mathematically to the 'Baiuy-Weinbeig equation foi
equilibiium'.

1S4

)-T)RI-%.A T%#%$-! $%+2-#"."TI
+IBI - is the section of a chiomosome that caiiies infoimation foi specific tiaits
$MMIMIA - aie alteinate foims of a gene
%JIB@DFOI - the physical appeaiance of an oiganisms, usually ueteimineu by the
uominant gene.
+IB@DFOI - the genetic makeup of an oiganism.
Y@EGBCBD - is the gene oi tiain that appeais oi expiesses itself, iepiesenteu with a
capital lettei (ie ,a).
(IPIAAGHI - is the genetiait that gets hiuuen in the piesence of a uominant gene,
iepiesenteu with a lowei-case lettei (ie A>)
]C?GCXMI 'QO?IAAG@B - is the vaiiance is phenotype fiom one inuiviuual to anothei.
5BP@EOMIDI %IBID?CBPI - this occuis when not all inuiviuuals who caiiy mutant
genotype actually show the mutant phenotype.
$BDGPGOCDG@B - occuis when the seveiity of a uisease gets woise at youngei anu youngei
ages, classic example is Buntington's uisease.
%MIG@D?@OF - occuis when one gene has moie than one effect on an inuiviuual's
phenotype.
5EO?GBDGBK - is a uiffeience in phenotype that uepenus solely on whethei the mutation is
of mateinal oi pateinal oiigin.
/@ACGPGAE - the cells of the bouy have uiffeient genetic makeups.
3@AA @V #IDI?@aFK@AGDF - this means that a complementaiy allele must be eithei ueleteu
oi mutateu befoie the othei allele can show expiessitivity. This uoes not apply to
oncogenes.

1SS

2"A%& "S -#)%+-$,#!%

1S6

1S7

1S8

1S9

14u

.,*"+,$"+I $%!)#-e1%& 1&%A -# *-"!)%2-&$+I
&JI %@MFEI?CAI "JCGB (ICPDG@B P/!+Q
This technique is useu when a laige numbei of BNA copies aie neeueu. The steps to
cieating multiple copies of BNA fiagments thiough the PCR aie as follows:
1. BNA is heateu anu uenatuieu, this causes the sepaiation of the stianus.
2. The uenatuieu BNA is cooleu, anu BNA piimeis aie auueu to the mix, these auheie
to each inuiviuual stianu of BNA at the location that will be amplifieu.
S. BNA polymeiase then ieplicates the uesiieu BNA stianus.
4. This piocess is iepeateu until the uesiieu numbei of BNA is achieveu.

%.-&, P%8jE=5R.C8m5; -==:8<>G?<6G58@ ,??>EQ
141

This technique is useu as a means of uetecting the piesence of an antibouy oi an antigen
in a sample. The antibouy oi antigen that is auueu is linkeu to an enzyme, then a test
solution is auueu to see if an intense coloi illuminates, inuicating that theie is a positive
iesult.
- This test is most commonly useu when looking foi BIv.
- Sensitivity anu specificity foi the ELISA aie extiemely high, both appioaching
1uu%, howevei they aie not peifect, anu false iesults uo occui.

&"1$)%+# *."$ $%!)#-e1%
This technique is useu to uetect specific sequences of BNA. The technique combines the
tiansfei of electiophoiesis-sepaiateu BNA fiagments anu membiane filtiation, anu then
fiagments aie uetecteu by piobe hybiiuization.

J%&$%+# *."$ $%!)#-e1%
This is a technique useu to uetect specific pioteins, sepaiating native oi uenatuieu
pioteins by the length of the polypeptiue. These pioteins aie then tiansfeiieu to a
membiane wheie they aie piobeu using antibouies specific to the taiget piotein.

#"+$)%+# *."$ $%!)#-e1%
Is a technique useu to stuuy gene expiession by RNA uetection in a sample. This
technique allows foi the uetection of cellulai contiol by ueteimination of gene expiession
levels uuiing uiffeientiation anu moiphogenesis.

142

A#,l +#,l ,#A /+"$%-#&

L $NIBGBI XGBNA D@ DJFEGBI with two hyuiogen bonus, wheieas KTCBGBI XGBNA D@
PFD@AGBI with thiee hyuiogen bonus, making it a stiongei bonu anu moie iesistant to
incieaseu tempeiatuies.
- In RNA, T?CPGM is piesent insteau of DJFEGBI.

14S

$)% *,&-! &$+1!$1+% "S $)% #1!.%"$-A%&
%F?GEGNGBIA - Aie heteiocyclic oiganic compounus consisting of two nitiogen atoms at
positions 1 anu S of a six-membeieu iing. The nucleotiues belonging to the pyiimiuine
gioup aie: "FD@AGBIW 7?CPGMW anu &JFEGBI.

%T?GBIA - Aie heteiocyclic aiomatic oiganic compounus consisting of a pyiimiuine iing
bounu to an imiuazole iing. The nucleotiues belonging to the puiine gioup aie: $NIBGBI
anu +TCBGBI.

144

!)+"2,$-#
Chiomatin is the stiuctuie that is maue up of BNA anu pioteins, which then makes up the
chiomosome. It is founu within the nuclei of eukaiyotic cells only. Theie aie two types of
chiomatin, theie is "heteiochiomatin", which is conuenseu anu tiansciiptionally inactive,
anu theie is euchiomatin, which is loosei anu tiansciiptionally active.
The main function of chiomatin is to package laige amounts of BNA into smallei aieas,
allowing moie to fit into cells anu thus pioviue foi moie genetic mateiial oveiall.

14S

A#, +%/.-!,$-"#
In piokaiyotes, theie is a single oiigin of ieplication, wheieas in eukaiyotes theie aie
multiple oiigins of ieplication.
-@EI GEO@?DCBD VCPDA:
- BNA polymeiase S pioofieaus in the S'! S' uiiection, synthesizing in the S'! S'
uiiection.
- Piimase piouuces an RNA piimei, on which BNA polymeiase S initiates
ieplication.
- BNA polymeiase S elongates the chain thiough the auuition of ueoxynucleotiues to
the S' enu.
- BNA polymeiase 1 uegiaues RNA piimei once it is no longei neeueu.
- 0kazaki fiagments help elongate the chain on the lagging stianu.
- BNA ligase seals on the lagging stianu.
- BNA gyiase unwinus the stianu befoie ieplication can begin.
- BNA topoisomeiase ielieves supeicoils by nicking the stianu.
146

A#, A,2,T%
The two types of BNA uamage aie 'Enuogenous' anu 'Exogenous'.
Types of Enuogenous uamage:
)R ,QGNCDG@B - ieactive oxygen species causes inteiiuptions to the BNA stianu.
1R $M\FMCDG@B - alkylation of bases by foimation of compounus such as 7-methylguanine.
4R #FN?@MFAGA - base hyuiolysis causes ueamination, uepuiination, anu uepyiimiuination.
6R 2TM\F CNNTPD V@?ECDG@B
8R 2CAI EGAECDPJIA
Types of Exogenous uamage:
)R 7]L2 NCECKI - causes cioss-linking between cytosine anu thymine bases, cieating
'pyiimiuine uimeis'.
147

1R 7]L$ NCECKI - cieates most fiee iauicals, causeu inuiiect BNA uamage.
4R 5@BGaGBK ?CNGCDG@B - causing iauioactive uecay anu bieaks in BNA stianus.
6R &JI?ECM NGA?TODG@B - causes uepuiination anu single stianu bieaks
8R 5BNTAD?GCM PJIEGPCM NCECKI - compounus such as vinyl chloiiue anu hyuiogen
peioxiue, smoke, soot, anu tai can cause seveie uamage to BNA. It causes oxiuation,
alkylation, anu cioss-linking of BNA.

A#, +%/,-+
-GBKMI AD?CBN NCECKI:
Bamage to a single stianu is iepaiieu via one of thiee mechanisms.
*>?5 %KDC?C<8 +5O>C6 - This type of iepaii helps to fix uamage to a single base, which is
iemoveu by a BNA glycosylase. The missing base is then iecognizeu by AP enuonuclease
anu iesynthesis occuis via BNA polymeiase, with BNA ligase sealing the new stianu.
#:DF5<@C;5 %KDC?C<8 +5O>C6 - This mechanism iecognizes bulky helix-uistoiting uamage
anu is fixeu with tiansciiption-coupleu iepaii which emits NER enzymes that aie actively
being tiansciibeu.
2C?=>@DH +5O>C6 - This iepaii mechanism coiiects eiiois of BNA ieplication anu
iecombination that iesulteu fiom mispaiieu nucleotiues.

Y@TXMIL-D?CBN YCECKI:
Thiee mechanisms exist to iepaii uouble-stianueu uamage, they aie:
1. Non-homologous enu joining (NBE})
2. Niciohomology-meuiateu enu joining (NNE})
S. Bomologous iecombination

#<8R)<=<F<N<:? %8; 4<C8C8N - This foim of iepaii is meuiateu by a specializeu foim of
BNA ligase (BNA ligase Iv), which woiks by foiming a complex with a cofactoi (XRCC4)
anu then uiiectly joining the two non-uamageu enus.
2CD6<H<=<F<NER25;C>@5; %8; 4<C8C8N - This type of iepaii mechanism woiks by using
a S-2S base paii homologous sequence to align bioken stianus befoie joining them. It
uses a "Ku piotein" anu BNA-PK inuepenuent iepaii mechanism anu then iepaii occuis
uuiing the S phase of the cell cycle.
)<=<F<N<:? +5D<=GC8>@C<8 - This type of iepaii iequiies the piesence of an iuentical
sequence that is useu as a template foi iepaii of the bieak.

148

A%S%!$& $" $)% A#, +%/,-+ 2%!),#-&2
When the iepaii mechanisms fail, theie is an expiession of impiopei BNA, anu this can
iesult in conuitions that aie seveie anuoi lethal. Thiee conuitions that iesult fiom faileu
BNA iepaii aie:
fI?@NI?EC %GKEIBD@ATE - This conuition occuis when theie is a uefect in one of the
seven genes iequiieu foi BNA iepaii. Those afflicteu with this uisease aie extiemely
sensitive to sunlight anu have a significantly high iisk foi skin cancei. This patient will
only live to be miuule-ageu at best.
&?GPJ@DJG@NFAD?@OJF - This conuition is causeu by uefects that iesult in ieuuceu RNA
tiansciiption of pioteins. Symptoms incluue: photosensitivity, biittle haii anu nails, scaly
skin, piotiuuing eais, physical anu mental ietaiuation, anu a ieceuing chin. * The
pioblem ultimately lies in the fact that the haii lacks sulfui-containing pioteins.
"@P\CFBI -FBN?@EI - This conuition iesults fiom an inability to iepaii BNA uamage that
is uetecteu uuiing tiansciiption. The patient suffeis fiom sensitivity to sunlight, have
shoit-statuie, anu age piematuiely.

S+"2 A#, $" /+"$%-#
The piocess of obtaining usable pioteins involves cieating RNA fiom BNA, then pioteins
fiom that RNA.
A#, ! +#, P@6>8?D6CO@C<8Q
+#, ! /+"$%-# P@6>8?F>@C<8Q
The basic oveiview of the whole piocess is as follows:
149

1Su

$I/%& "S +#,
Tiansciiption is the piocess by which RNA is maue fiom each stianu of BNA.
Theie aie S types of RNA: ?(.$W E(.$W CBN D(.$
?(.$ - Is maue via RNA polymeiase I, anu is the most >G:8;>8@ type of RNA. Ribosomal
RNA combines with piotein in the cytoplasm to foim a iibosome, which seives as the site
anu caiiies all of the necessaiy enzymes iequiieu foi piotein synthesis.
E(.$ - Is maue via RNA polymeiase II, anu is the F>6N5?@ type of RNA. Nessengei RNA
is the RNA that is cieateu fiom a gene segment of BNA . The mRNA then caiiies the coue
it ieceives fiom BNA into the cytoplasm wheie piotein synthesis will occui
D(.$ - Is maue via RNA polyeiase III, anu is the ?=>FF5?@ type of RNA. Tiansfei RNA is
the type of RNA that ieaus the coue fiom the mRNA anu caiiies the amino aciu to be
incoipoiateu into the ueveloping pioteins. Theie aie moie than 2u uiffeient tRNA's,
meaning theie is one foi each amino aciu. tRNA contains appioximately 7S nucleotiues,
thiee of these aie "anticouons".
* Piokaiyotes have only one RNA polymeiase that makes all of the RNA sub-types.

1S1

$+,#&!+-/$-"#
Tiansciiption is the piocess wheieby BNA is useu as a template to piouuce mRNA. BNA
must be in the foim of euchiomatin in oiuei foi this piocess to occui, anu it occuis in the
nucleus of the cell because BNA woulu otheiwise be exposeu to uangeious enzymes in
the cytoplasm that woulu cause its uegiauation.
Theie is no pioofieauing function, RNA polymeiase II will open a BNA sequence at the
piomotei site, which is a TATA box (A-T iich sequence that is upstieam). mRNA is
synthesizeu in the S' ! S' uiiection.

1S2

/+"!%&&-#T "S =+#,
Aftei tiansciiption, while the mRNA is still in the nucleus, theie aie thiee impoitant steps
taken to ensuie stabilization of the newly synthesizeu mateiial.
Xn ,;;C@C<8 b[ D>O
The auuition of the cap is uone thiough the following:
- Phosphoiylase iemoves the gamma phosphate fiom the S' enu of the tiansciibeu
pie-mRNA.
- uuanylyl tiansfeiase catalyzes the conuensation of uTP with the S' enu of the pie-
mRNA.
- The teiminal guanosine nucleotiue is methylateu by guanine-7-methyl tiansfeiase,
using S-auenosyl-methionine (SAN) as a co-factoi.

Zn ,;;C@C<8 ][ O<FE , @>CF PO<FE>;58EF>@C<8Q
The auuition of appioximately 2uu auenine units to the S' enu of the mRNA help to
pioviue piotection, as without this poly A tail the mRNA woulu be quickly uegiaueu.
- A cleavage factoi iecognizes anu binus to the specific polyauenylation sequence
(AA0AAA).
- Enuonucleases cleave the RNA
- Poly A polymeiase catalyses the auuition of appioximately 2uu auenine
nucleotiues to the S' enu of the cleaveu mRNA.
- An auuition piotein (cleavage stimulation factoi), helps stabilize the complex.
- 0nce assembleu, mRNA is cleaveu 1u-SS nucleotiues uownstieam of the AA0AAA
sequence by the enuonuclease anu appioximately 2u auenine nucleotiues aie
auueu by the poly A polymeiase.
- The poly A tails aie then bounu by poly A binuing pioteins, which help to shift the
piocessive moue of synthesis anu this iesults in the auuition of up to 2Su
nucleotiues.

]n &OFCDC8N
Splicing is a mouification of mRNA wheieby intions aie spliceu out anu exons aie joineu
togethei. This step is iequiieu befoie RNA can move out of the nucleus anu go thiough
tiansciiption.

1SS

-DIOA D@ E(.$ AOMGPGBK:
1. The piimaiy tiansciipt contains both intions anu exons
2. Spliceosomes meuiate the splicing
S. The 1
st
splice site is at the S' enu of an intion
4. The 2
nu
splice site is at the S' enu of that same intion
S. Intion, once spliceu at both sites, is iemoveu anu the exons aie combineu, foiming
a matuie mRNA stianu that is piepaieu foi tianslation

1S4

&$+1!$1+% "S @+#,
Tiansfei RNA (tRNA) is an RNA molecule (the smallest) whose puipose is to tiansfei an
active amino aciu to the polypeptiue chain uuiing tianslation. Theie is a S' teiminal site,
at which the amino aciu attaches covalently thiough an aminoacyl tRNA synthetase. The
othei impoitant stiuctuie is at the base, anu is known as the 'anticouon', which caiiies a S
nucleotiue coue that paiis to the coiiesponuing thiee base couon iegion of the mRNA.

$EGB@CPFMCDG@B - The amino aciu becomes linkeu to the tRNA via 'Aminoacyl tRNA
synthetase', using ATP to attach the amino aciu. The amino aciu is bounu to the S' enu
covalently. This leaves the tRNA molecule in a chaigeu state.
D(.$ Z@XXMI - is the concept that only the fiist 2 nucleotiue positions of the mRNA
couon must match in oiuei foi the piocess to pioceeu coiiectly, the thiiu position uoes
not have to be the exact coiiect nucleotiue since its uiffeience can still coue foi the same
amino aciu.

1SS

$+,#&.,$-"#
Tianslation is the piocess by which mRNA is useu to cieate pioteins.
Theie aie thiee steps to tianslation, they aie:
1. Initiation
2. Elongation
S. Teimination

5BGDGCDG@B:
Initiation begins when the small iibosomal subunit attaches to the S' cap of mRNA anu
moves to the tianslation initiation site.

'M@BKCDG@B:
- tRNA has a complementaiy anticouon to mRNA stait couon (A0u), wheie
methionine is the coiiesponuing amino aciu.
- The laige iibosomal subunit joins to foim the P anu A sites (1
st
tRNA is in the P
site, 2
nu
enteis the A site anu complements the 2
nu
mRNA couon).
- Nethionine then tiansfeis to the AA in the A site, the 1
st
tRNA exits, the iibosome
moves along mRNA anu the next tRNA enteis.
- The giowing peptiue is continually tiansfeiieu to the A site tRNA

&I?EGBCDG@B:
- A stop couon (0Au) is eventually encounteieu, at which point a "ielease factoi"
enteis the A site, anu tianslation is teiminateu.
- The iibosome uissociateu anu the newly foimeu piotein is ieleaseu.

1S6

1S7

2%$,*".-&2

)CNHRIC5F; ;C?<6;56? G<FC?=:
+MFP@KIB AD@?CKI NGAICAIAd
$EO5 X a 7<8 TC56m5 ;C?5>?5 P)5O>@<658>F TFED<N58<?C?Q
- Causeu by glucose-6-phosphatase ueficiency.
%CDGIBD ECF IQOI?GIBPI:
- Bypoglycemia
- Chionic hungei
- Belayeu pubeity anuoi unueiuevelopment
- Bepatomegaly
- Fatigue

$EO5 Z a /<=O5[? ;C?5>?5
- Causeu by a lysosomal !-1,4-glucosiuase ueficiency.
- Nuscle weakness, especially in the heait
- Nost commonly seen in newboin chiluien 0R those in theii Su's anu 4u's
- Fatigue as a iesult of weakening of the heait anu livei
- Cuivatuie of the spine is a piogiessive symptoms
- Bifficulty bieathing, such as laboieu bieathing, anu infections of the iespiiatoiy
tiact
- Bizziness anu syncope

$EO5 ] a !<6C[? ;C?5>?5
- Causeu by a ueficiency of the uebianching enzyme !-1,6-glucosiuase
- Symptoms similai to von uieike's uisease, but miluei
- Young chiluien typically have massive hepatomegaly that uiminishes with
incieasing age

$EO5 ^ a ,8;56?58 ;C?5>?5
- The main clinical featuies of Anueison uisease aie insufficiency of the livei anu
abnoimalities of the heait anu neivous system
1S8

- This uisease is iaie anu will leau to eaily ueath

$EO5 b a 2D,6;F5[? ;C?5>?5
- Causeu by a ueficiency of skeletal muscle glycogen phosphoiylase
%CDGIBD IQOI?GIBPIA:
- Incieaseu glycogen founu within the muscle
- Painful ciamps anu myoglobinuiia when activity is incieaseu

$EO5 ` a )56? ;C?5>?5
- Causeu by a hepatic phosphoiylase ueficiency
- Patient may have the inability to maintain bloou-glucose levels uuiing peiious of
fasting.
- 0iine anu seium ketones aie elevateu piopoitionally to the level of fasting
- Nilu to moueiate hypeilipiuemia may be piesent
- Piominent hepatomegaly anu giowth ietaiuation aie common finuings of Beis
uisease

$EO5 c a $>6:C ;C?5>?5
- Causeu by a ueficiency of phosphofiuctokinase (PFK) in glycolysis
- Patient will expeiience incieaseu muscle glycogen that cannot be bioken uown
- Ciamping
- Bighei levels of myoglobin in the uiine when theie is incieaseu physical activity

1S9

/)%#I.V%$"#1+-, P/V1Q
PK0 is an autosomal iecessive uisease chaiacteiizeu by a ueficiency of phenylalanine
hyuioxylase, which inhibits the foimation of tyiosine fiom its piecuisoi phenylalanine.
Because of this enzyme ueficiency, two things occui:
Xn $H5 >=C8< >DC; $E6<?C85 G5D<=5? >8 5??58@C>F >=C8< >DC;n
Zn /H58EF>F>8C85 G:CF;? :O D>:?C8N > =E6C>; <B ?57565 ?E=O@<=?
The inciease in phenylalanine leaus to an inciease in phenylketones (phenylpyiuvate,
phenylacetate, anu phenyllactate) in the uiine.
-GKBA CBN -FEOD@EA:
- Patients aie noimal at biith, but scieening is now essential
- Failuie of eaily milestone uevelopment
- Chaiacteiistic "musty oi mousy" bouy ouoi
- Niciocephaly anu mental ietaiuation
- Bypeiactivity
- Bypopigmentation anu eczema

,.*-#-&2
A conuition wheie theie is a complete lack of pigment thioughout the bouy. This is an
autosomal iecessive conuition, wheie the patient cannot piouuce melanin fiom tyiosine
(tyiosinase ueficiency) oi fiom a uefect in the tyiosine tianspoiteis. Theie is an inciease
in the iisk of skin cancei uue to the lack of piotective melanin in the skin.

2,/.% &I+1/ 1+-#% A-&%,&%
Naple syiup uiine uisease is chaiacteiizeu by the sweet smell of the patients uiine (ie
maple syiup). The cause is a uefect in the ability to bieak uown the biancheu chain
amino acius Leucine, Isoleucine, anu valine. The ieason foi this is a ueficiency of the
enzyme !- ketoaciu uehyuiogenase. The patient will suffei fiom seveie mental
ietaiuation, CNS uefects, anu finally ueath.

16u

,.V,/$"#1+-,
Anothei conuition involving tyiosine, alkaptonuiia iesults fiom a ueficiency of
homogentisate 1,2-uioxygenase in the pathway of tyiosine uegiauation. Bomogentisic
aciu (alkapton) thus accumulates in the bloou anu is excieteu in the uiine in laige
amounts, leauing to blackening of the uiine upon stanuing. Excessive amounts of
homogentisic aciu cause uamage the caitilage, leauing to seveie aithialgias.

)"2"!I&$%-#1+-,
Also iefeiieu to as Cystathionine beta synthase ueficiency (CBS ueficiency), it is an
autosomal iecessive uisoiuei.
In the case of ueficiency, patient will have excessive homocysteine in the uiine. In this
case, cysteine will be essential anu shoulu be incieaseu in the uiet, while simultaneously
uecieasing the amount of methionine in the uiet.
Signs anu symptoms incluue:
- Nental ietaiuation
- Seizuie
- Nusculoskeletal abnoimalities (tall builu, long limbs, pectus excavatum, pes cavus,
anu genu valgum)
- Abnoimalities of the eyes (glaucoma, subluxation of lens)
- vasculai conuitions (eaily thiomboses)

!I&$-#1+-,
Cystinuiia is a conuition wheieby theie is a uefect in the tianspoit of tubulai amino acius
foi the following amino acius: Cystine, 0inithine, Lysine, anu Aiginine. This iesults in an
excess of cystine in the uiine, which can pieuispose the patient to kiuney stones.
Nanagement is to alkalinize the uiine with acetazolamiue.

161

+%&/-+,$"+I *1+&$
This ieaction is impoitant in uegiauing bacteiia that aie phagocytizeu. The iespiiatoiy
buist ieuuces oxygen (via NABPB) to piouuce a fiee-iauical, then piouucing B2u2, which
is fuithei combineu with Chloiiue to piouuce B0Cl-, which ultimately uestioys the
engulfeu bacteiia.

$)% ,#,$"2I "S ,A%#"&-#% $+-/)"&/),$% P,$/Q

162

T.I!"T%#".I&-&
ulycogenolysis is the piocess wheieby glycogen polymei is conveiteu to glucose, which
can then go thiough glycolysis. ulycogenolysis occuis in the livei anu muscle, anu is
stimulateu by epinephiine anuoi glucagon in iesponse to low bloou glucose levels.

16S

T.I!".I&-&
ulycolysis is the piocess wheieby glucose is conveiteu to pyiuvate. ulycolysis consists of
ten ieactions with F00R iiieveisible stepsenzymes.
&JI %?IOCD@?F %JCAI - Consists of the fiist five steps, also known as the investment
phase. This phase consumes eneigy that is useu to conveit glucose into two S-C sugai
phosphates (uSP). In this phase, the net ATP is (-2).
&JI %CFL,VV %JCAI - Consists of five steps that piouuce a net gain of 2 ATP anu 2 NABB
molecules (pei glucose molecule that goes thiough the pathway). Pyiuvate is also the enu
piouuct of the glycolytic pathway.

164

The total ATP geneiateu fiom CBCI?@XGP KMFP@MFAGA GA 1 $&%cA. When compaieu to ATP
piouuceu with the ECMCDI AJTDDMI anu KMTP@AIL4LOJ@AOJCDI AJTDDMI, which cieate 4;
$&%cA anu 49 $&%cA iespectively.

16S

+%T1.,$-"# "S T.I!".I&-&
Theie aie F00R steps in glycolyisis that aie consiueieu to be iiieveisible, thus once they
have occuiieu, glycolysis must piogiess in the foiwaiu uiiection. The foui iegulatoiy
enzymes aie:
1. Bexokinase
2. Phosphofiuctokinase
S. Pyiuvate kinase
4. Pyiuvate uehyuiogenase

#IQ@\GBCAI:
- Bexokinase is iesponsible foi the fiist step of glycolysis in the muscles anu biain.
- It is inhibiteu by the piesence of glucose-6-phosphate, which is the piouuct of its
activity.
- This step is impoitant because it pievents the consumption of too much cellulai
ATP in the foimation of glucose-6-phosphate when glucose is not limiting.
- Bexokinase has a low affinity to glucose, thus it peimits glycolysis initiation even if
bloou glucose levels aie low.

%J@AOJ@V?TPD@\GBCAI:
- PFK is the iate-limiting step of glycolysis, thus it is the most impoitant contiol
point thioughout the whole piocess.
- Regulation is by both alloesteiic effectois anu by covalent mouifications (ie
phosphoiylation).
- It is stimulateu by the piesence of ANP anu fiuctose-2,6-bisphosphate.
- Even if ATP is high, the piesence of ANP can oveicome its inhibitoiy effects uue to
the ability to allosteiically activate PFK.
- It is inhibiteu by the piesence of ATP anu citiate

%F?THCDI bGBCAI:
- Similai to PFK, is iegulateu by allosteiic effectois anu by phosphoiylation.
- PK is activateu by fiuctose-1,6-bisphosphate anu inhibiteu by ATP anu alanine.

166

/I+13,$% A%)IA+"T%#,&% !"2/.%0
The pyiuvate uehyuiogenase complex iegulates the entiy of glycolytic piouucts into
the citiic aciu cycle. This complex consists of thiee enzymes that tiansfoim pyiuvate
(fiom glycolysis) into acetyl-CoA, thiough the piocess of pyiuvate uecaiboxylation.

A%S-!-%#!I "S /I+13,$% A%)IA+"T%#,&%
A ueficiency of pyiuvate uehyuiogenase is a conuition that is most commonly seen in
alcoholics, uue to the ueficiency of thiamine that is an inevitable iesult of this uisease.
The lack of pyiuvate BB iesults in an accumulation of pyiuvate, which iesults in lactic
aciuosis. Theie will be neuiologic finuings that can be manageu by giving the patient
amino acius that aie puiely ketogenic, such as Leucine anu Lysine.

167

2%$,*".-&2 "S /I+13,$%
0nueistanuing how pyiuvate is metabolizeu will aiu in unueistanuing why ceitain
auveise effects occui when theie is a malfunctioning pyiuvate BB anuoi othei
pioblems with the pathway. In yeast, pyiuvate is conveiteu to ethanol in anaeiobic
conuitions, in eukaiyotes it is conveiteu to lactate. In optimal conuitions (ie. Aeiobic),
pyiuvate is conveiteu to Acetyl CoA.

168

$)% !-$+-! ,!-A !I!.% P$!,Q
The citiic aciu cycle is an essential metabolic piocess that is essential foi completing the
oxiuative uegiauation of monosacchaiiues, fatty acius, anu amino acius.

Seives 2 main puipose:
1. To inciease the cell's ATP piouucing potential by geneiating ieuuceu election
caiiieis such as NABB anu ieuuceu ubiquinone. ( QB2).
2. To pioviue the cell with piecuisois that can be useu to builu a vaiiety of
molecules, uepenuing on the cell's neeus.

7BNI? CI?@XGP P@BNGDG@BAW DJI V@MM@UGBK STCBDGDGIA @V $&% C?I KIBI?CDINd
TFED<FE?C? = 2 ATP (net), 2 NABB (equaling 6 ATP)
/E6:7>@5 ! ,!<, = 2 NABB = 6ATP
!C@6CD ,DC; !EDF5 = 2 uTP (2 ATP), 6 NABB (~ 18 ATP), 2 QB2 (4 ATP)
169

17u

$)% %.%!$+"# $+,#&/"+$ !),-#
The ETC couple ieactions between election uonois anu election acceptois (ie. Between
NABB anu oxygen), to the tiansfei of hyuiogen ions acioss a membiane. These hyuiogen
ions aie useu to piouuce ATP to be useu as eneigy as they move back acioss the
membianes.
The conveision of oxygen to watei, NABB to NAB+, anu succinate to fumaiate is what will
ultimately uiive the tiansfei of hyuiogen ions.
Theie aie foui complexes that aie embeuueu in the innei membiane, which aie
electiically connecteu by lipiu-soluble election caiiieis anu watei-soluble election
caiiieis. Thiee of these complexes seive as pioton pumps.
"@EOMIQ ) - Is a pioton pump. Is 'NABB uehyuiogenase', which iemoves two elections
fiom NABB anu tiansfeis them to ubiquinone (Q). 0nce ubiquinone is ieuuceu to QB2, it
can fieely uiffuse within the membiane, tianslocating foui hyuiogen ions acioss the
membiane, piouucing a pioton giauient.
piematuie election leakage occuis in Complex 1, which is a main site of
supeioxiue piouuction.
"@EOMIQ 1 - Is 'Succinate uehyuiogenase', in this complex theie is the auuitional ueliveiy
of elections into the quinone pool which oiiginate fiom succinate anu aie tiansfeiieu to
ubiquinone. Complex 2 consists of foui piotein subunits.
"@EOMIQ 4 - Is a pioton pump. Is the 'Cytochiome bc1 complex", wheie two elections aie
iemoveu fiom QB2 anu tiansfeiieu to cytochiome c. Two othei elections aie passeu
acioss the piotein ieuucing ubiquinone to quinol, anu foui piotons aie ieleaseu fiom two
ubiquinol molecules. This pump builus the giauient by an absoiptionielease of piotons.
Supeioxiue is foimeu thiough election leakage in this complex.
"@EOMIQ 6 - Is a pioton pump. Is 'Cytochiome C oxiuase', wheie foui elections aie
iemoveu fiom foui molecules of cytochiome c, anu thus tiansfeiieu to oxygen, thus
piouucing two watei molecules. Foui moie piotons aie tiansfeiieu acioss the
membiane, fuithei contiibuting to the giauient.
"@EOMIQ 8 - "ATP Synthase". 0nce a sufficient pioton giauient has been maue by
complexes I, III, anu Iv, an FoF1 ATP synthase complex uses this giauient to make ATP via
oxiuative phosphoiylation. The piotons influx back into the mitochonuiial matiix,
ieleasing fiee eneigy which is useu to uiive the ATP synthesis. Coupling with oxiuative
phosphoiylation is impoitant in piouucing ATP, as they pioviue in some ciicumstances
the ability foi piotons to flow back into the mitochonuiial matiix (occuis in biown
auipose tissue), anu helps in theimogenesis.
171

172

T.1!"#%"T%#%&-&
This is the piocess by which new glucose is foimeu fiom caibon skeletons such as
pyiuvate, lactate, glyceiol, alanine, anu glutamate. The majoi site of gluconeogenesis is
the livei. The piocess of cieating glucose fiom pyiuvate is quite costly compaieu to the
amount of eneigy cieateu by one molecule of glucose. Activateu when the bouy is in a
state of hungei anuoi staivation. Ketone bouies aie also piouuceu fiom acetyl-CoA.
The basic piocess of gluconeogenesis is as follows:

17S

-#&1.-#
Insulin is a hoimone piouuceu by the "-cells of the
pancieas, its piime iole is to uiive glucose fiom the bloou
into the cells of the 04,&+#,L M/*()L /#1 M+..1 &#++,L
()'#,'()#,L +(P#/L &./)#*L *)1 <(1)#>5
-OIPGVGP IVVIPDA @V GBATMGB:
- Anabolic effects (synthesis of fats, pioteins,
anu glycogen)
- Retention of souium by the kiuneys
- Inhibition of the ielease of glucagon fiom the
!-cells of the pancieas

C-peptiue is a maikei
of insulin secietion.
When a patient has
extieme hypoglycemia,
uiffeientiate between
insulinoma anu
exogenous
auministiation by
looking foi the
piesence oi absence of
C-peptiue.
174

T.1!,T"# ,#A -#&1.-# -# +%T1.,$-#T )"2%"&$,&-&
The iegulation of bloou glucose is uelicately balanceu by two impoitant hoimones, insulin
anu glucagon. 5BATMGB is secieteu by the "-cells of the pancieas in iesponse to an elevateu
bloou-glucose level. 0n the othei siue, KMTPCK@B is secieteu by the !-cells of the pancieas
in iesponse to low levels of bloou-glucose. ulucagon causes the livei to ielease glycogen
which is bioken uown into glucose, anu useu to inciease the amount of glucose iunning
thiough the bloou.

17S

$)% &I#$)%&-& "S !)".%&$%+".
Cholesteiol is impoitant in the bouy foi vaiious ieasons, namely:
- Plays a iole in membiane stiuctuie anu fluiuity
- Belps with hoimone piouuction
- Belps with vitamin B metabolism
- Plays a iole in the CNS
The highest-yielu infoimation ielating to cholesteiol is knowing its iate-limiting enzyme,
which is: Byuioxy Nethyl ulutaiyl Coa Reuuctase (BNu CoA ieuuctase). The
phaimacological basis of loweiing cholesteiol (statin uiugs), is uesigneu aiounu the
inhibition of this enzyme.
The most impoitant steps in cholesteiol synthesis aie:

176

S,$$I ,!-A &I#$)%&-&
Some impoitant points must be unueistoou iegaiuing fatty aciu synthesis, these being the
basics of FA synthesis.
The iate limiting enzyme is $PIDFML"@$ "C?X@QFMCAI, which uoes the following:
,D5@EFR!<, ! 2>F<8EF !<,
- This step is positively effecteu by 'citiate', anu negatively effecteu by 'palmitoyl
CoA'.
- Biotin is a iequiieu co-factoi to this ieaction.
- Synthesis of fatty acius moves in the uiiection of "methyl!caiboxyl enu", thus C1S
anu C16 aie piouuceu fiist, C2 anu C1 aie piouuceu last.

177

,/".-/"/+"$%-#& >8; .-/"/+"$%-#&
$O@MGO@O?@DIGBA:
Apolipopioteins aie pioteins that binu to lipius anu help tianspoit them thioughout the
bouy. 0nce bounu to lipius, the stiuctuie is known as a lipopiotein. 0thei functions of
apolipopioteins incluue acting as co-enzymes anu as liganus between the lipopioteins
anu the tissues they supply. They aie synthesizeu in the intestines anu theii "iate
iegulation" is ueteimineu by the content of fat available thiough a peison's uietaiy intake.
Theie aie six classes of apolipopioteins:
, - incluues the sub-gioups: $L5W $L55W $L5]W $L])
* - incluues the sub-gioups: 26;W 2)==
! - incluues the sub-gioups: "L5W "L55W "L555W "L5]
Classes A, %, anu ) have no impoitant sub-gioups.

3GO@O?@DIGBA:
Because fatty acius alone have tiouble being tianspoiteu thiough aqueous compaitments
insiue the cells, a mechanism must be in place to allow them to get to wheie they neeu to
be, thus enteis the lipopioteins.
The basic stiuctuie of the lipopiotein is below:

Lipopioteins aie uiffeient baseu on the iatio of piotein:lipius, as well as the paiticulai
apopioteins anu lipius that they contain. Thus, lipius can be classifieu baseu on theii
uensitites:
178

#Y3 hJGKJLNIBAGDF MGO@O?@DIGBid Bas the highest piotein:lipiu iatio of all lipopioteins, is
also the lipopiotein with the highest oveiall uensity. Responsible foi tianspoitation of
cholesteiol fiom the peiipheial tissues back to the livei.
5Y3 hGBDI?EINGCDI NIBAGDF O?@DIGBid IBL is foimeu when vLBL gets uegiaueu.
Tianspoits anu ueliveis both tiiglyceiiues anu cholesteiol to the livei, wheie they get
uegiaueu to low-uensity lipopioteins.
3Y3 hM@ULNIBAGDF MGO@O?@DIGBAid Aie a low-uensity lipopiotein which contain the highest
uensity of cholesteiyl esteis. LBL is engulfeu by taiget cells, anu is a veiy uangeious
lipopiotein that can leau to haiuening of the aiteiies anu subsequently vasculai
pathologies.
]3Y3 hHI?F M@ULNIBAGDF MGO@O?@DIGBAi: Contain the seconu highest uensity of
tiiacylglyceiols. Its iole is to uelivei tiiglyceiiues fiom the livei to the peiipheial tissues.
"#03,/5"(,.-: Aie the laigest of all the lipopioteins, but have the lowest uensity uue
to a high iatio of lipius to pioteins. Also contain the highest content of tiiacylglyceiols by
uensity. Bas a uual iole as it supplies the peiipheial tissues with tiiglyceiiues anu
supplies cholesteiol to the livei.

$)% &$+1!$1+% "S
)%2%

179

)%2% &I#$)%&-&

18u

A-&"+A%+& "S )%2% &I#$)%&-&
/<6OH<GCFC8<N58 A5>=C8>?5 - $PTDI 5BDI?EGDDIBD %@?OJF?GC
Acute inteimittent poiphyiia is causeu by a ueficiency in the enzyme poipobilinogen
ueaminase, thus pieventing the conveision of poiphobilinogen to hyuioxymethylbilane.
This leaus to an accumulation of poiphobilinogen in the cytosol, which causes a myiiau of
symptoms.
-FEOD@EA @V CPTDI GBDI?EGDDIBD O@?OJF?GC:
- Nuscle weakness
- Abuominal pain
- Constipation
- Nausea vomiting
- Bypeitension
- Biaphoiesis
- Tachycaiuia
&?ICDEIBD @V CPTDI GBDI?EGDDIBD O@?OJF?GC:
- Nay iequiie hospitalization foi seveie symptoms
- Avoiuance of piecipitating uiugs
- Avoiuance of alcohol
- Piopei uiet

16<O<6OHE6C8<N58 A5D>6G<KEF>?5 - %@?OJF?GC "TDCBIC &C?NC
This is the most common type of poiphyiia, iesulting fiom low levels of
uiopoiphyiinogen uecaiboxylase.
-GKBA CBN -FEOD@EA @V %@?OJF?GC "TDCBIC &C?NC:
- Blisteiing of the skin in aieas exposeu to sun
- Photosensitivities
- Bypeipigmentation anu hypeitiichosis
- Chionic livei uisease (fibiosis, ciiihosis, inflammation)
&?ICDEIBD @V %@?OJF?GC "TDCBIC &C?NC:
Since it is a chionic conuition, a multi-uimensional appioach is iequiieu to contiol the
gioup of possible symptoms.
- Avoiuance of excess exposuie to sunlight, iion, anu alcohol

181

A-&"+A%+& "S /1+-#% ,#A /I+-2-A-#% 2%$,*".-&2
Puiines aie a key component of cellulai eneigy (ATP, NAB), signaling (uTP, cANP, cuNP),
anu in conjunction with pyiimiuines, the piouuction of BNA anu RNA.
When theie aie pioblems with salvage, synthesis, catabolism, anu metabolism of puiines
anu pyiimiuines, ceitain uisoiueis piesent themselves.

Y5-,(Y'(- ,> %7(5.' -$3]$+'d
.5?DHR#EH>8 ?E8;6<=5,
,;58C85 /H<?OH<6CG<?EF@6>8?B56>?5 ;5BCDC58DE

3IAPJL.FJCB -FBN?@EI: An x-linkeu iecessive uisoiuei, is uue to the absence of the
enzyme 'hypoxanthine-guanine phosphoiibosyl tiansfeiase (BPRT), which is iesponsible
foi conveiting hypoxanthine to inosine monophosphate anu guanine to guanosine
monophosphate. This iesults in the piouuction of excess uiic aciu.
6>0%'.0,: Nental ietaiuation, self-mutilation, aggiession, hypeiuiicemia, gout, anu
choieoathetosis.
$NIBGBI %J@AOJ@?GX@AFMD?CBAVI?CAI NIVGPGIBPF: A iaie AT uisoiuei iesulting in the
inability to salvage auenine foi puiine synthesis. This iesults in an accumulation of
auenine, which is oxiuizeu to 2,8-uihyuioxyauenine, which piecipitates in the uiinaiy
tiact, anu causes pioblem iuentical to those of uiic aciu nephiopathy (ie. Renal colic,
infections, anu ienal failuie). This must be manageu with a high fluiu intake anu puiine
iestiiction.

Y5-,(Y'(- ,> %7(5.' .7"3',&5Y' -0.&#'-5-:
$NIBFMATPPGBCAI NIVGPGIBPFd Is an AR uisoiuei that causes significant mental uisabilities,
seizuies, anu autistic behaviois. Theie aie incieaseu levels of succinylaminoimiuazole
caiboxamiue iibosiue anu succinylauenosine in the uiine anu CSF.

182

Y5-,(Y'(- ,> %7(5.' "$&$2,35-/:
$NIB@AGBI NICEGBCAI NIVGPGIBPF,
/F@CNIBFMCDI NICEGBCAI NIVGPGIBPF
$NIB@AGBI YICEGBCAI YIVGPGIBPFd This ueficiency causes seveie combineu
immunoueficiency uisease. The incieaseu uATP iesults in inhibition of iibonucleotiue
ieuuctase anu unueipiouuction of othei ueoxyiibonucleotiues. This causes the
compiomise of BNA ieplication. Patient will have low RBC's anu WBC enzyme activity.
Stem cell tiansplant anu enzyme ieplacement is essential to theiapy.
%T?GBI .TPMI@AGNI %J@AOJ@?FMCAI NIVGPGIBPF: A iaie AR uisoiuei with seveie T-cell
uysfunction anu the piesence of neuiological symptoms. Patient will uevelop
lymphopenia, thymic ueficiency, iecuiient infection, anu hypouiicemia. These will cause
uevelopmental uelays, spasticity, anu ataxia (ie. CNS uisoiueis)
fCBDJGBI ,QGNCAI NIVGPGIBPF: Pievents the piouuction of uiic aciu fiom xanthine anu
hypoxanthine. The builuup of xanthine can piecipitate in the uiine, causing stones,
uiinaiy colic, anu 0TI's. Patients shoulu be manageu by maintaining a high fluiu intake
anu taking allopuiinol.

Y5-,(Y'(- ,> %0(5/5Y5.' /'&$2,35-/:
7?GNGBI /@B@OJ@AOJCDI -FBDJCAI NIVGPGIBPF (Beieuitaiy oiotic aciuuiia): This
ueficiency pievents oiotate phosphoiibosyltiansfeiase anu oiotiuine-S'-monophosphate
uecaiboxylase ieactions. The accumulation of oiotic aciu causes megaloblastic anemia,
oiotic ciystalluiia, nephiopathy, caiuiac malfoimations, stiabismus, anu iecuiiing
infections. Tieatment involves uiiuine supplementation.

18S

.,!$"&% -#$".%+,#!%
.>D@<?5 25@>G<FC?=:
Lactose is metabolizeu by the enzyme 'lactase', which when ueficient causes uI
uistuibances such as bloating, uiaiihea, etc. The ieason foi this is that lactose is a
uisacchaiiues, which cannot be absoibeu thiough the wall of the small intestine. When it
iemains unuigesteu, it passes thiough the uI system anu causes laige amount of gas,
ciamps, bloating, etc. The piocess by which lactose is conveiteu to gaseous piouucts
(feimentation) will ultimately iaise the osmotic piessuie of the colon.

184

S+1!$"&% 2%$,*".-&2 ,#A A-&"+A%+&
'AAIBDGCM >?TPD@AT?GC - A uefect of fiuctokinase, is a benign conuition wheie the only
symptoms is high levels of fiuctose in bloou anu uiine.
>?TPD@AI 5BD@MI?CBPI - Is a heieuitaiy ueficiency on aluolase B. Theie is a iesulting
inhibition of both glycogenolysis anu gluconeogenesis because fiuctose-1-phosphate
accumulation uecieases the amount of available phosphate.

18S

T,.,!$"&% 2%$,*".-&2 ,#A A-&"+A%+&
Theie aie two pioblems that iesult fiom the absenceueficiency of enzymes involveu in
galactose metabolism.
+CMC\D@\GBCAI YIVGPGIBPF: A ueficiency of the enzyme 'galaktokinase', pieventing the
conveision of galactose ! galactose-1-phosphate. Causes galactosemia anu galactosuiia.
+CMCPD@AIEGC: Causeu by a uiiuyl tiansfeiase ueficiency. Can cause symptoms such as
cataiacts, mental ietaiuation, hepatosplenomegaly, all uue to the accumulation of toxic
substances that iesult fiom the ueficiency.

%$),#". ,#A )I/"T.I!%2-,
When ethanol is metabolizeu, theie is an incieaseu iatio of NABB:NAB+, which causes a
shunting of pyiuvate to lactate anu oxaloacetate to malate. This causes an inhibition of
gluconeogenesis anu thus causes hypoglycemia. Because theie is a shunt away fiom
gluconeogenesis anu towaius fatty aciu synthesis, the livei uevelops fatty changes as well.

186

$)% 1+%, !I!.%
The uiea cycle is iesponsible foi the uegiauation of amino acius into amino gioups. This
cycle piouuces appioximately 9u% of all the uiea founu in the uiine. The location of the
uiea cycle is the cytosol of the livei, with the incoipoiation of the caibamoyl phosphate
being integiateu insiue the mitochonuiia.

187

$)% !"+- !I!.% P.,!$,$% $+,#&/"+$Q
Is a metabolic pathway by which lactate that is piouuceu thiough anaeiobic glycolysis is
tianspoiteu fiom the muscle to the livei anu ie-conveiteu to glucose. This cycle piouuces
a net ATP of 2

188

$)% /%#$"&% /)"&/),$% /,$)J,I
Also known as the BNP shunt, this pathway is necessaiy to the piouuction of iibose-S-
phosphate fiom glucose-6-phosphate foi the synthesis of nucleotiues, the piouuction of
NABPB fiom NABP+ foi the synthesis of fatty acius anu steioius, anu foi the maintenance
of ieuuceu glutathione. The iate limiting enzyme foi this pathway is "glucose-6-
phosphate uehyuiogenase".

TBIS PATBWAY IS
NECESSARY T0
PR0B0CE
REB0CEB
uL0TATBI0NE,
WBICB IS 0SEB T0
BET0XIFY FREE
RABICALS. A
BEFICIENCY WILL
LEAB T0
BEN0LYTIC
ANENIA B0E T0
LACK 0F BEFENCE.
189

-2/"+$,#$ A%+-3,$-3%& "S ,2-#" ,!-A&

19u

,2-#" ,!-A&' %&&%#$-,. 7?n #"#R%&&%#$-,.
Amino acius aie biochemical molecules containing an amine gioup, a caiboxylic aciu
gioup, anu a siue chain that vaiies between each amino aciu. They contain nitiogen,
caibon, oxygen, anu hyuiogen.
2CAGP -D?TPDT?I:

191

3-$,2-#&

*65>m;<L8 =C8 D>@5N<6C5?:
>CD -@MTXMI ]GDCEGBA:
- vitamin B
- vitamin E
- vitamin K
- vitamin A
ZCDI? -@MTXMI ]GDCEGBA:
- vitamin C
- vitamins B1, B2, BS, Biotin, Pantothenic Aciu
- Pyiiuoxine
- Folic Aciu
- Cobalamin

S,$ &".1*.% 3-$,2-#&:
$I/% S1#!$-"# A%S-!-%#!-%& %0!%&&%&
192

vitamin B Incieases intestinal
absoiption of
calcium anu
phosphate
Chiluien get
Rickets, auults get
osteomalacia.
Both can uevelop
hypocalcemic
tetany
Bypeicalcemia anu
all associateu
symptoms of
hypeicalcemia
vitamin E Acts as an
antioxiuant
RBC become fiagile
anu aie at iisk of
hemolysis

vitamin K Involveu in the
piocess of bloou
clotting
Bemoiihages in
neonates

vitamin A Is necessaiy foi
healthy ietinas
Biy skin, night
vision
uistuibances,
immuneueficiency
Alopecia,
aithialgia,
heauache, skin
conuitions

J,$%+R&".1*.% 3-$,2-#&:
$I/% +".% -# )%,.$) A%S-!-%#!I
vitamin C Impoitant in collagen
synthesis (hyuioxylation),
Belps with iion
absoiption
Scuivy - biuising,
bleeuing gums, anemia,
pooi wounu healing
vitamin B1 (thiamine) 0xiuative uecaiboxylation
of alpha-keto acius, co-
factoi foi tiansketolase in
the BNP shunt
Beiibeii anu Koisakoff's
synuiome, most common
in alcoholics
vitamin B2 (iiboflavin) Is a co-factoi in oxiuation
anu ieuuction ieactions
Chelosis, angulai
stomatosis, coineal
vasculaiization
vitamin BS (niacin) 0seu in ieuox ieactions as
constituent of NAB+ anu
NABP+
Pellagia (4u's) - uiaiihea,
uementia, ueimatitis,
ueath
vitamin BS
(pantothenate)
Involveu in fatty aciu
synthase anu a co-factoi
foi acyl tiansfeis
Auienal insufficiency,
ueimatitis, enteiitis,
alopecia
vitamin B6 (pyiiuoxine) Is a co-factoi in
tiansamination,
uecaiboxylation, anu
tians-sulfuiation
Causeu isoniaziu
ueficiency (neivous
system uistuibances)
Biotin A co-factoi in Beimatitis anu enteiitis,
19S

caiboxylation ieactions can be causeu by eating
iaw eggs
Folic Aciu Co-enzyme in caibon
tiansfei in methylation
ieactions, involveu in
synthesis of nitio bases in
BNA anu RNA
Naciocytic anemia, neuial
tube uefects in ueveloping
fetus
Cobalamin Is a co-factoi in
homocysteine methylation
anu methylmalonyl-CoA
activity
Negaloblastic anemia with
neuiological symptoms,
glossitis

194

"#$%&'( :

'&#5"-

&JGA D@OGP GA GEO@?DCBD CA DJI?I C?I TATCMMF C JCBNVTM @V IDJGPA
STIADG@BA @B DJI IQCER 7BNI?ADCBNGBK NIVGBGDG@BA CBN XIGBK
CXMI D@ COOMF DJIE D@ D?GP\F AGDTCDG@BA GA IAAIBDGCM V@? OGP\GBK TO
C JCBNVTM @V ICAF O@GBDA @B DJI IQCER

19S

*%#%S-!%#!%
This teim uesciibes the iesponsibility of the physician to always act in the best inteiest of
the patient. Beneficence may not always be in place, as a patient's iight to make theii
own uecisions may not always be in theii veiy best inteiest. In this situation, the
physician has a uuty to honoi the uesiies of the patient with iespect to his oi hei own
caie.

#"#R2,.%S-!%#!%
This teim means the physician shall "Bo No Baim", anu is always piioiity #1 when it
comes to meuical ethics anu piactice piinciples.

,1$"#"2I
Autonomy iefeis to the patient's iight to make theii own uecisions aftei being piopeily
euucateu anu infoimeu. Whethei a physician believes these uecisions to be iight oi
wiong, they have a uuty to iespect anu honoi the patient's autonomy.

, /,$-%#$[& ,*-.-$I $" 2,V% A%!-&-"#&
A patient's ability to make theii own uecisions is baseu on a few piinciples that must be in
place:
- Patient must be psychologically stable (ie not skeweu by mental illness)
- Patient must be the one who tells you theii uesiies, not the family
- Patient uoes not switch back anu foith between theii wishes (shows instability of
the patient's mentation)
- Patient ieceives complete infoimation of auvantages anu uisauvantages of
tieatment options
- Patient makes theii choice, which is not influenceu by family, fiienus, etc

-#S"+2%A !"#&%#$
Infoimeu consent is when a patient gives the physician the consent to pioceeu with
meuical management. It must be baseu on piopeily infoiming the patient, wheieby they
unueistanu the iisks, benefits, anu alteinative options. Becisions must be baseu on
complete autonomy, not of peisuasion.

196

J)%# -& -#S"+2%A !"#&%#$ #"$ +%e1-+%Af
It is fully legal to pioceeu with meuical inteivention without a patient's consent when any
of the following aie piesent:
- Inteivention will be life-saving, such as in the ER
- Patient is not in a mental state to make a uecision (psychosis, intoxication)
- The patient waives theii iight to infoimeu consent
- Theie is a theiapeutic auvantage to not getting infoimeu consent

/,$-%#$[& +-T)$ $" !"#S-A%#$-,.-$I
A patient has the iight to complete confiuentiality, wheieby uisclosing a patient's
infoimation is illegal unless they give you uiiect peimission to uo so.

J)%# -& !"#S-A%#$-,.-$I *+%,!),*.%f
Theie aie ceitain situations in which it is the physician's iesponsibility to bieach
confiuentiality foi the safety of society anuoi foi the gieatei benefit of the patient.
These instances incluue:
- Theie is the potential foi haim to otheis (&C?CA@VV NIPGAG@B)
- The patient has a high iisk of self-haiming
- Theie is the piesence of a iepoitable infectious uisease
- Patient is eithei suiciual oi homiciual
- Theie is abuse to a chilu oi an eluei

$)% ,A3,#!%A A-+%!$-3%
Theie aie numeious ways by which a patient can give theii auvanceu uiiective.
3GHGBK ZGMMA - the patient infoims the physician whethei they want to be tieateu oi not
shoulu the neeu aiise wheie they cannot communicate this to the physician
,?CM $NHCBPIN - while less likely to stanu up in couit, this is an oial iequest given by the
patient to the physician in the past iequesting theii uesiies foi meuical inteivention

197

A1+,*.% /"J%+ "S ,$$"+#%I
The uuiable Powei of Attoiney is a peison uesignateu by the patient to make theii
meuical uecisions in the event that they aie unable to uo so foi themselves.

#%T.-T%#!%M2,./+,!$-!%
Theie aie foui ciiteiia that must be met in oiuei foi a malpiactice suit to be waiianteu,
they aie:
YTDF ! This implies that theie is a physician-patient ielationship that is establisheu.
YI?IMGPDG@B ! When the physician fails to comply with the stanuaius of caie foi the
patient
YG?IPD "CTAI ! Wheie a patient incuis injuiyuamage that iesulteu fiom the physician's
bieach of uuty, wheie theie aie no othei ciicumstances that may have causeu the injuiy
YCECKIA ! The injuiies suffeieu by the client
** It shoulu be noteu that the absolute most common ieason foi a meuical lawsuit is a lack
of communication oi pooi communication between the physician anu patient.
Establishing a stiong physician-patient ielationship is the best way to pievent a lawsuit.

198

"#$%&'( ;

25,-&$&5-&5"-

$OOMGPCDG@B @V DJI XG@ADCDGADGPCM ISTCDG@BA CA UIMM CA VTMMF
TBNI?ADCBNGBK DJI DFOIA @V ADTNGIA CBN DFOIA @V XGCA GA IAAIBDGCM
ÊTADL\B@U_ GBV@?ECDG@BR ZJGMI GD GA DIEODGBK D@ V@?IK@
ADTNFGBK XG@ADCDGADGPAW GD GA ICAF D@ K?CX OMIBDF @V ICAF O@GBDA XF
AGEOMF AOIBNGBK C VIU J@T?A @B DJGA D@OGPR

199

$I/%& "S &$1A-%&
"CAIL"@BD?@Me'QOI?GEIBDCM - This test is the golu stanuaiu of epiuemiological testing,
wheie two equal gioups aie compaieu wheie one gioup has a changeu vaiiable
%?@AOIPDGHI - This is also known as a Cohoit, 0bseivational, anu Inciuence stuuy. A
sample is taken anu uiviueu into two gioups baseu on the piesence oi absence of a iisk
factoi. The gioups aie then followeu ovei time to see what shoulu uevelop. These tests
aie veiy time consuming anu expensive, thus less useu.
(ID?@AOIPDGHI - This stuuy chooses a population of samples baseu on eithei the piesence
oi absence of a ceitain iisk factoi. The sample is chosen aftei a uisease has occuiieu, not
befoie it has occuiieu. This test is cheapei anu much fastei to peifoim than the otheis.
"CAI -I?GIA - This simply uesciibes what the clinical piesentation looks like in people
who have a ceitain uisease.
"?@AAL-IPDG@BCMe%?IHCMIBPI - This stuuy takes a sample of population at one point in
time, anu looks at the pievalence of uisease anu the pievalence of iisk factois. This test is
optimal foi compaiing two uiffeient cultuies, looking foi associations between lifestyle
choices anu pievalence of uiseases.

%/-A%2-! 7?n /,#A%2-!
An epiuemic is seen when theie is an obseiveu inciuence of a paiticulai uisease that
gieatly exceeus the expecteu inciuence, wheieas a panuemic is an epiuemic that is seen
ovei a wiue geogiaphical aiea.

$%&$ 2%$)"A&
&U@L-CEOMI &LDIAD - This test is useu to compaie the means of two gioups of subjects.
$.,]$ - This test is the "analysis of vaiiance", anu is useu to compaie thiee oi moie
vaiiables.
"JGL-STC?IN - This test compaies the piopoitions of a categoiizeu outcome (2x2 table).
With a laige uiffeience between the obseiveu anu expecteu values, theie is assumeu to be
an association between the exposuie anu the outcome.
/IDCL$BCMFAGA - This test is uone by pooling uata fiom seveial stuuies, which gives the
test a big statistical powei.

2uu

$I/%& "S *-,&
-IMIPDG@B 2GCA - This type of bias iesults fiom the mannei by which people aie selecteu
anuoi fiom selective losses fiom follow-up stuuies.
,XAI?HI? CBN /ICAT?IEIBD 2GCA - This bias iesults fiom the uistoition of measuiement
of association by misclassification of the exposeuunexposeu anuoi uiseaseunon-
uiseaseu stuuy subjects.
(IPCMM 2GCA - Bias uue to inaccuiacies in iecall of past exposuie by people in the stuuy.
#CUDJ@?BI 'VVIPD - This bias occuis when a patient uelibeiately changes theii behavioi
because they know they aie being stuuieu.
"@BV@TBNGBK - This bias occuis as a iesult of the auuition of extianeous factois. Foi
example if a stuuy is looking foi ciiihosis, they finu an association between smoking anu
ciiihosis, anu finu theie to be a stiong association. Then subsequently, the stuuy shows
that some smokeis aie also heavy uiinkeis while some aie not. In this instance, alcohol is
the confounuing factoi. An effective way of contiolling confounuing is /CDPJGBK.
3ICN &GEI 2GCA - This bias has to uo with the time fiame by which uiagnoses anu
tieatments aie examineu.
$NEGAAG@B (CDI 2GCA - This bias type is uue to the uiffeiences in hospital aumission iates,
which uistoits the iisk iatio.
7BCPPIODCXGMGDF 2GCA - This type of bias occuis when the paiticipants puiposely give
uesiiable iesponses, which then leau to the unueiestimation of iisk factois.

2u1

&%#&-$-3Il &/%!-S-!-$Il //3l #/3l "+l ++l >8; ,$$+-*1$,*.% +-&V
The following table will be the basis foi all calculations ielating to the above topics:

&58?C@C7C@E = >M> k D
6#),('(P('> 1#'#/0()#, '"# R .- '/4# %.,('(P#, 1(P(1#1 M> *++ '".,# 2". '/4+> "*P# '"# 1(,#*,#5
6&/##)()3 '#,', 2('" "(3" ,#),('(P('> */# M#,'5
&O5DCBCDC@E U ;M; k G
6%#&(-(&('> 1#'#/0()#, '"# R .- '/4# )#3*'(P# 1(P(1#1 M> *++ '".,# 2". '/4+> 1. ).' "*P# '"#
1(,#*,#5 9.)-(/0*'./> '#,', 2('" "(3" ,%#&(-(&('> */# M#,'5
/<?C@C75 /65;CD@C75 3>F:5 U >M> k G
The PPv test is useu to ueteimine the piobability of having an actual conuition when
theie is a positive test iesult. Relateu to pievalence in a uiiect mannei, thus with an
incieaseu pievalence theie is an inciease in the PPv.

#5N>@C75 /65;CD@C75 3>F:5 U ;M; k D
2u2

The NPv is useu to ueteimine the piobability of not having a conuition when the test
iesult is negative.
";;? +>@CMGQM PDM;Q
The 0R ueteimines the inciuence of uisease in people in the exposeu gioups uiviueu by
those in an unexposeu gioup.
,( l ) = States that the factoi being stuuieu is a iisk factoi foi the outcome
,(p) = States that the factoi being stuuieu is a piotective factoi in iespect to the outcome
,( q ), States that no significant uiffeience in outcome in eithei exposeu oi unexposeu
gioup
+5F>@C75 +C?m U o>MP>kGQ M DMPDk;Qp
Relative iisk compaies the uisease iisk in people exposeu to a ceitain factoi with uisease
iisk in people who have not been exposeu
,@@6CG:@>GF5 +C?m U o>MP>kGQ a DMPDk;Qp
The attiibutable iisk is the numbei of cases that can be attiibuteu to one iisk factoi

-#!-A%#!% 7?n /+%3,.%#!%
Inciuence is the numbei of new cases of a uisease ovei a unit time, wheieas pievalence is
the total numbei of cases of a uisease (both new anu olu) at a ceitain point in time. Any
uisease tieateu with the sole puipose of piolonging life (ie teiminal canceis), the
inciuence stays the same but pievalence will inciease.
-J@?DLDI?E NGAICAIA: Inciuence > Pievalence
3@BKLDI?E NGAICAIA: Pievalence > Inciuence

3,.-A-$I 7?n +%.-,*-.-$I
]CMGNGDF is simply a test's ability to measuie what it claims to measuie, wheieas the
?IMGCXGMGDF of a test ueteimines its ability to consistent iesults on iepeateu attempts.

2uS

&$,#A,+A A%3-,$-"#
Stanuaiu ueviation is a teim that measuies the vaiiability of iesults.

X &@>8;>6; A57C>@C<8 - 68% of iesults fall within 1SB
Z &@>8;>6; A57C>@C<8? - 9S% of iesults fall within 2SB
] &@>8;>6; A57C>@C<8? - 99.7% of iesults fall within SSB

2u4

2%,#l 2%A-,#l 2"A%
25>8 - The aveiage value
25;C>8 - The miuule value
2<;5 - The most common value

Noimal Bell Cuive: /ICB q /INGCB q /@NI

%@AGDGHIMF A\IUIN giaph inuicates that: /ICB l /INGCB l /@NI

.IKCDGHIMF A\IUIN giaph inuicates that: /ICB p /INGCB p /@NI

2uS

!1$"SS /"-#$& S"+ &%#&-$-3-$I ,#A &/%!-S-!-$I

Shoulu the cutoff point foi a uisease be moveu fiom VCMAI O@AGDGHI D@ VCMAI BIKCDGHI,
theie is an inciease in the numbei of positive iesults. This will inciease the sensitivity of
the iesults. This will also ()&/#*,# '"# '/4# %.,('(P# *)1 -*+,# %.,('(P# numbeis, while
1#&/#*,()3 '"# )40M#/ .- -*+,# )#3*'(P#, *)1 1#&/#*,()3 '"# %.,('(P# %/#1(&'(P# P*+4#5
Shoulu the cutoff point be iaiseu fiom being false negative to false positive, theie will be
an inciease in specificity, ()&/#*,()3 '"# )40M#/ .- '/4# )#3*'(P#, *)1 -*+,# %.,('(P#,5

!"#S-A%#!% -#$%+3,. ,#A OR3,.1%
These values stiengthen the iesults of a stuuy. Foi statistical significance, the CI mustn't
contain the null value (RR = 1), anu the closei the two numbeis aie togethei, the moie
confiuent you can be that the iesults aie statistically significant. As fai as the significance
of the p-value goes, a statistically significant iesult has a p-value of <u.uS (this means
theie is <S% chance that the iesults obtaineu weie uue to chance alone).

!"++%.,$-"# !"R%SS-!-%#$
Two numbeis that aie between -1 anu +1, it measuies to what uegiee the vaiiables aie
ielateu.
2u6

- A numbei of zeio (u) means theie is no coiielation between vaiiables.
- A numbei of +1 means theie is a peifect coiielation (both vaiiables inciease oi
ueciease piopoitionally)
- A numbei of -1 means theie is a peifect negative coiielation (vaiiables move in
opposite uiiections piopoitionally)

,$$+-*1$,*.% +-&V /%+!%#$ P,+/Q
The ARP measuies the impact of the paiticulai iisk factoi being stuuieu on a paiticulai
population. It iepiesents excess iisk that can be explaineu by exposuie to a paiticulai
iisk factoi.
Calculate the ARP: ARP = |(RR -1)RRj

&$,$-&$-!,. )I/"$)%&%&
The statistical hypotheses aie useu to ueteimine whethei oi not theie is an association
between iisk factois anu uisease in a population. They aie the 'BTMM hypothesis' anu the
'CMDI?BCDGHIc hypothesis.
.TMM #FO@DJIAGA h#@i - This hypothesis is the 'hypothesis of no uiffeience', meaning theie
is not an association between the uisease anu the iisk factoi.
$MDI?BCDGHI #FO@DJIAGA h#)i - This hypothesis is the 'hypothesis of some uiffeience',
meaning theie is an association between the uisease anu the iisk factoi.

/"J%+
The powei of a statistical test is the piobability that a test will ieject a false null
hypothesis, meaning it will not make a Type 2 eiioi. With incieaseu sample size theie is
incieaseu powei anu theie is a uecieaseu chances of seeing a type 2 eiioi.

%++"+&
&FOI ) '??@? h!i - A type 1 eiioi mistakenly accepts the expeiimental hypothesis anu
iejects the null hypothesis. This eiioi means that something statistically is seen that in
fact is not theie.
&FOI 1 '??@? h"i - This type of eiioi occuis when you fail to ieject the null hypothesis
when it is in fact false. This eiioi means you essentially something that is statistically
piesent was in fact misseu.

2u7

"#$%&'( <

%-0"#5$&(0e%-0"#,3,+0

&JI STIADG@BA CA\IN @B DJGA D@OGP PCB ?CBKI V?@E C
AD?CGKJDV@?UC?N AGEOMI STIADG@B D@ C STIADG@B DJCD IQOIPDA F@T
D@ P@EXGBI ECBF CAOIPDA @V EINGPGBI GB EC\GBK DJI XIAD PJ@GPIR
&JI JGKJIADLFGIMN GBV@?ECDG@B GBPMTNIA OAFPJGCD?GP
OJC?ECP@M@KF CA UIMM CA CMM @V DJI OI?A@BCMGDF NGA@?NI?AR

2u8

-#$+"A1!$-"# $"
/&I!)-,$+-! 2%A-!-#%

2u9

21u
!"#$%&'

!"# %&%'"( )*
+,'"-)./0,'/)1

2),3 )* 41'".5/"#/1-

6"1',3 7','8% 9:,(

;/,-1)%'/+ <"%'% )* =%&+>/,'.&

211

%)!*+",$-)!$".

The BSN-v has eliminateu the olu 'axis system' foi categoiizing
psychiatiy illness. We now use a non-axial uocumentation of uiagnosis.
The new appioach combines the foimei axis' I, II, anu III with sepaiate
notations foi psychosocial anu contextual factois (olu Axis Iv) anu
Bisability (0lu Axis v). 0n top of that, a stiategy has been uevelopeu to
paitially eliminate a uiagnosis of 'not otheiwise specifieu, oi N0S',
wheieby clinicians iate uisoiueis along a sliuing scale oi 'continuum' of
seveiity. This stiategy allows physicians to cieate moie appiopiiate
tieatment plans foi theii patients.

$.!*,/$*0 !*%1.$23*&

The goal of all psychiatiic inteiview techniques is to gain youi patient's
tiust anu builu iappoit. With tiust anu iappoit, a patient will open up
with infoimation to help you make a uiagnosis. This is iueal as we neeu
a goou psychiatiic histoiy, peisonal histoiy, social histoiy, anu uiug &
alcohol histoiy in oiuei to make the best possible uiagnosis foi oui
patients.
212

The following is a look at the moie commonly useu inteiview
techniques, as well as the main puipose they seive in psychiatiy.
21S
,455678 9:;<=;>? !@AB>;C:@D'

!"#$%&' !! Expiesses unueistanuing of the patient's situation.
)*##+,% !! Expiesses concein anu inteiest foi the patient.
-$./0$%/+1 !! Expiesses the value of youi patient's feelings.

$>E67F48;6> +48B@7;>? !@AB>;C:@D'

2$3/./%$%/+1 !! Encouiages a patient to uig ueepei anu elaboiate on
theii answeis.
4#5166651050 7*58%/+1 !! To help obtain as much infoimation without
leauing oi closing potential aieas of exploiation.
95:.53%/+1 !! Encouiages a patient to expanu on theii answeis by
ieviewing a pievious iesponse.
)/.5135 !! Belps to encouiage youi patient's iesponsiveness.

$>E67F48;6> %<47;EG;>? !@AB>;C:@D'

%6>E76>848;6> !! Pointing out inconsistencies in the patient's
iesponses anuoi bouy language.
;/,53% <*58%/+1 !! Belps to elicit infoimation as quickly as possible.
953$#/%*.$%/+1 !! Belps summaiize the infoimation obtaineu uuiing
inteiviews to ensuie complete unueistanuing.
214
!1* H*.!)I &!)!3& *J)H

Is a thoiough suivey that helps to assess the patient's cuiient level of
mental functioning. With the NSE we can assess many chaiacteiistics,
incluuing all of the following:
!! ueneial piesentation

!! Sensoiium & Cognition

!! Speech

!! Noou & Affect

!! Thought

!! Peiceptual Abilities

!! }uugment & Insight

!! Reliability

!! Impulse Contiol

21S
!1* H$.$ H*.!)I &!)!3& *J)H

Is a fastei, moie supeificial means by which we can assess a patient's
cuiient level of mental functioning. The following ciiteiia aie useu to
peifoim the NNSE:
!! 4,/51%$%/+1 (have the patient name the cuiient location anu time) -

Naximum scoie of 1u

!! =$1>*$>5 (have the patient name the object you aie holuing) -
Naximum scoie of 8
216
!! ?%%51%/+1 @ A$.3*.$%/+1 (have the patient subtiact 7 fiom 1uu anu
continue subtiacting 7's as long as they can) - Naximum scoie of S
!! 95>/8%,$%/+1 (have the patient iepeat the names of thiee objects) -

Naximum scoie of S

!! 953$.. (iecall the name of the thiee objects above) - Naximum scoie
of S
!! A+18%,*3%/+1 (copy this uesign - show them a tiiangle) - Naximum

scoie of 1

217
K$)+."&!$% !*&!& 3&*K $. #&L%1$)!,L

We use psychological tests to assess a patient's cognitive function, level
of achievement, peisonality, anu psychopathology. Each test is slightly
uiffeient, anu on a laigei scale is useu to gathei infoimation eithei
objectively oi piojectively.

"MN@A8;O@ 8@D8D !! baseu on questions with eithei a coiiect oi incoiiect
answei.
#76N@A8;O@ 8@D8D !! baseu on the psychiatiist's inteipietation of the
answeis given.

Below is a list of the main tests useu in psychiatiy.
218
$.!*II$+*.%* !*&!&

B53&8.5, ?0*.% C1%5../>51% )3$.5 95D/850EB?C)6669FG Is the most
commonly useu intelligence test.
B53&8.5, C1%5../>5135 )3$.5 :+, A&/.0,51 95D/850 EBC)A6669FG Is useu to

measuie intelligence in chiluien 6---16.S yeais of age.

B53&8.5, H,583&++. $10 H,/"$,' )3$.5 +: C1%5../>5135 EBH))CFG Is
useu to test intelligence in chiluien 4---6.S yeais of age.

)%1$*/*H*.! !*&!&

H5$I+0' C10/D/0*$. ?3&/5D5"51% J58%G 0seu in school systems to
evaluate achievement in specific subject aieas.
B/056669$1>5 ?3&/5D5"51% J58% EB9?JFG 0seu clinically to evaluate

aiithmetic, ieauing, anu spelling skills.

219

#*,&".)I$!L !*&!&

9+,83&$3& J58%G Piojective tests in which patients inteipiet ink---blots.
K/1158+%$ K*.%/#&$8/3 H5,8+1$./%' C1D51%+,' EKKHC666LFG 0bjective
test in which the patient answeis S66 tiue oi false questions about
themselves.
)51%5135 A+"#.5%/+1 J58% E)AJFG Piojective tests in which patients
complete sentences.
22u
J&5"$%/3 ?##5,35#%/+1 J58% EJ?JFG Piojective test in which patients
cieate scenaiios baseu on thiity pictuies of ambiguous situations.

.*3,"#&L%1"I"+$%)I !*&!&

M$.8%5$066695/%$1 N$%%5,' EM9NFG To uetect anu localize biain lesions
anu ueteimine theii effects.
N5105, -/8*$.666K+%+, O58%$.% J58%G To scieen visual anu motoi ability
thiough iepiouuction of uesigns.
=*,/$666P5I,$8Q$ P5*,+#8'3&+.+>/3$. N$%%5,' E=PPNFG 0seu to
ueteimine left oi iight ceiebial uominance anu to iuentify specific types
of biain uysfunction.
221

9*1)/$",)I P %"+.$!$/*
!1*,)#L
222
!"#$%&'
7&%'"(/+ ;"%"1%/'/0,'/)1
?)-1/'/5" <>".,@&
A/)*""BC,+D
E3))B/1- F5".%/5"
?)1B/'/)1/1- <)D"1
9+)1)(&
22S
9*1)/$",)I ).K %"+.$!$/* !1*,)#$*&

&GD8@F;A K@D@>D;8;Q48;6> !! Is useu in the tieatment of phobias.

!! In this technique, the feaieu objectsituation is paiieu with a ielaxing
stimulus, with the goal of piovoking a ielaxeu iesponse whenevei the
feaieu object is encounteieu.

%6?>;8;O@ !B@745G !! Is useu to tieat milumoueiate uepiession,
somatofoim uisoiueis, anu eating uisoiueis.
!! Patients aie encouiageu to iuentify the negative thoughts they have

about themselves, anu aie taught to ieplace those feelings with positive,
self---ieassuiing thoughts about themselves.

9;6E@@=M4AR !! Is useu to tieat heauaches, hypeitension, asthma,
Raynauu's uisease, chionic pain, fecal incontinence, anu TN}.
!! Patients aie given ongoing physiologic infoimation so they can
consciously contiol behaviois with the goal of achieving theii uesiieu
goal.

S<66=;>? !! Is useu I the tieatment of phobias.
224

!! Patients aie exposeu to laige levels of theii feaieu objectsituation as
a way of uecieasing theii sensitivity to it.

)O@7D;O@ %6>=;8;6>;>? !! Is useu in the tieatment of auuictions.

!! The paiiing of a pleasuiable yet uestiuctive stimulus is paiieu with a
painful stimulus, leauing to the cessation of the pleasuiable behavioi.
22S
!6R@> *A6>6FG !! Is useu in helping to inciease the positive behavioi
of a patient who is eithei seveiely uisoiganizeu anuoi mentally
ietaiueu.
!! Reinfoicing a uesiiable behavioi by offeiing a iewaiu foi peifoiming
that behavioi.
226

&39&!).%* )93&*
227
!"#$%&'

4(@).',1' ;"*/1/'/)1% ?3,%%"% )*
78C%',1+"% )* FC8%" ?)(()13&
G%"BHFC8%"B 78C%',1+"% 7&(@')(%
)* I/'>B.,#,3 ;/,-1)%/1-
78C%',1+" FC8%" 6,1,-"("1' )*
78C%',1+" FC8%"
228

$H#",!).! K*S$.$!$".&

&:MD84>A@ )M:D@: Besciibes a pattein of abnoimal use that eventually
leaus to impaiiment of functioning (social, physical, occupational).

&:MD84>A@ K@5@>=@>A@: Besciibes a pattein of abuse that leaus to
patteins of toleiance, compulsive use, anu withuiawal.

&:MD84>A@ !6<@74>A@: A physiological auaptation that leaus to an
incieaseu neeu in oiuei to expeiience the same iesult.
!! Theie is a phenomenon known as 3,+88666%+.5,$135, wheieby the
auaptation to one uiug causes toleiance of anothei (ex. Alcohol anu
Benzouiazepines).

&:MD84>A@ 0;8B=74T4<: A physiological uevelopment of symptoms that
occui once a substance has been stoppeu aftei piolongeu use anu
uepenuence.
229
%I)&&*& "S %"HH".IL )93&*K &39&!).%*&

The commonly abuseu substances fall unuei one of foui categoiies,
incluuing:
!! Stimulants

!! Naicotics

!! Seuatives

!! Ballucinogens

&8;F:<4>8D: Aie substances that stimulate the CNS. Leau to a wiue---

vaiiety of symptoms, incluuing:

!! Agitation, hypeiactivity, tachycaiuia, loss of appetite, incieaseu levels
of concentiation.
!! Anothei name foi cocaine is 'ciack', which is smokeu.

!! Amphetamines such as Nethylpheniuate aie wiuely piesciibeu foi

ABBB.

!! Commonly abuseu foims of ?"#&5%$"/15 incluue
2Su

6"'>,(@>"',(/1" (Speeu) anu 6;6F (Ecstacy).

%6FF6> D8;F:<4>8D ;>A<:=@'

!! A$::5/15 (The most commonly useu substance woiluwiue)

!! A+3$/15 (Can be snoiteu anuoi smokeu) - Inciease ielease of
ceitain neuiotiansmitteis anuoi ueciease ie---uptake. Specifically
blocks BA ie---uptake.
!! ?"#&5%$"/158 (Commonly useu by people who want to inciease
aleitness anuoi concentiation)
2S1
!! P/3+%/15 (Founu mainly in cigaiettes, is the most common cause of
pieventable ueciease in lifespan).

.47A68;AD: Belong to the opioiu class of uiugs, aie commonly abuseu
anu aie commonly useu in pain---management.
!! Incluue a wiue---vaiiety of pain---ielieving uiugs such as 6).@>/1",

?)B"/1", J:&+)B)1", etc (ie. 0piates)

!! Cause iespiiatoiy uepiession, euphoiia, anu miosis.

&@=48;O@D: Aie a class of uiugs that leau to uepiession of the cential
neivous system, causeu by an inciease in the inhibitoiy
neuiotiansmittei uABA. The main seuatives incluue Alcohol,
Benzouiazepines, anu Baibituiates.
!! Cause iespiiatoiy uepiession (Nost woiiisome with Baibituiates).

!! Bisinhibition.

!! Bepiession of emotions.
2S2

!! Sloweu mentation anu physical peifoimance.

%6FF6> &@=48;O@D ;>A<:=@:

!! ?.3+&+. (Noou initially elevates, then CNS uepiession begins.
Associateu with thiamine ueficiency anu a ueciease in life---expectancy in
long---teim useis).
!! N$,I/%*,$%58 (Bighly auuictive, cause uepiession of iespiiation,
anxiolysis, uangeious when combineu with alcohol).
2SS
!! N51R+0/$R5#/158 (Bighly auuictive, cause uepiession of iespiiation,
anxiolysis, uangeious when combineu with alcohol).

14<<:A;>6?@>D: Leau to symptoms of hallucinations, thought to be
ielateu to the inciease of available Seiotonin.
!! visual uistuibanceshallucinations.

!! Auuitoiy uistuibanceshallucinations.

!! Panic attacks aie common.

!! Alteieuuistoiteu peiception of ieality.

!! Psychosis

%6FF6> 14<<:A;>6?@>D ;>A<:=@:

!! ='85,>/3 $3/0 0/5%&'.$"/05 E=);F - Causes alteiation in peiception
of visual anuoi auuitoiy peiception. Flashbacks aie a common finuing
in long---teim LSB useis.
!! H&513'3./0/15 EHAHF - Causes euphoiia, amnesia, violent behavioi,

uistoition of peiception, hypeitension, hypeitheimia, nystagmus.
2S4
&LH#!"H& "S 0$!1K,)0)I

&8;F:<4>8D: Withuiawal symptoms will be the opposite of the
symptoms seen uuiing intoxication.
!! Bepiession of moou anuoi eneigy levels.

!! Nalaise

!! Fatigue

!! Incieaseu appetite

!! Beauache

!! Niosis

.47A68;AD: Withuiawal symptoms will be the opposite of the symptoms
seen uuiing intoxication.
!! Biaphoiesis

!! Anxiety

2SS
!! Paiasympathetic oveistimulation (sweating, iunny nose, uiaiihea, uI

ciamping).

!! Nyuiiasis
2S6
&@=48;O@D: Withuiawal symptoms will be the opposite of the symptoms
seen uuiing intoxication.
!! Tiemoi

!! Anxiety

!! Tactile hallucinations

!! Seizuies

!! Beliiium

14<<:A;>6?@>D: Theie aie usually no withuiawal symptoms seen in
patients who have stoppeu using a hallucinogen.

2S7
H).)+*H*.! "S &39&!).%* )93&*

Biagnosing uiug use anuoi abuse is a simple mattei of unueistanuing
the main finuings mentioneu pieviously anu keeping a close eye out foi
them. Ceitain featuies aie unique to paiticulai uiugs, which shoulu be
well---known. The main laboiatoiy finuings foi each class of uiug is
outlineu below, which aie veiy impoitant in making a uefinitive
uiagnosis.
2S8
I4M674867G E;>=;>?D:

?.3+&+.: Bloou---alcohol levels aie elevateu.

?"#&5%$"/158: Remain in the bloou foi 24---48hi.

A+3$/15: The metabolite benzoylecgonine iemains in the system foi up
to twelve uays.
=);: 0iine will be positive foi LSB.

HAH: Will iemain in the uiine foi up to one week. CPK levels also tenu to
be elevateu.
K$,/S*$1$: Can iemain in the uiine foi up to one month in chionic

useis.

2S9
H).)+*H*.!
)<A6B6<:

C""50/$%5 !! Thiamine IN until levels aie appiopiiately ieplenisheu.
A&,+1/3 !! uioup theiapy (Alcoholics Anonymous) is the best stiategy
foi most alcoholics.

9@>Q6=;4Q@5;>@DU947M;8:748@D:

C""50/$%5 !! Bospitalize in anticipation of seizuie, Flumazenil to
ieveise effects.
A&,+1/3 !! Behavioial mouification.
24u
%4EE@;>@:

C""50/$%5 !! No tieatment is iequiieu immeuiately, howevei tapeiing
uosages will help pievent a withuiawal heauache.
A&,+1/3 !! Acetaminophen foi heauache as neeueu.

%6A4;>@:

C""50/$%5 !! Benzouiazepine, anti---psychotics, anu pieventative
management.
A&,+1/3 !! Nanage withuiawal symptoms with Besipiamine.

14<<:A;>6?@>D:

C""50/$%5 !! Benzouiazepines, anti---psychotics.

A&,+1/3 !! No long---teim management is necessaiy.

241
H47;N:4>4:

C""50/$%5 !! Benzouiazepines foi agitation.

A&,+1/3 !! Behavioial mouificationtheiapy.

.;A68;>@:

C""50/$%5 !! uum, patch, suppoit.

A&,+1/3 !! Suppoit gioups, Bupiopion.
242

%"+.$!$/* K$&",K*,&
24S
!"#$%&'
;"3/./8(
;"("1'/,
F30>"/(".K% ;"("1'/,
244

"/*,/$*0

Cognitive uisoiueis aie chaiacteiizeu by ueficits in noimal mental
functioning, incluuing:

!! K5"+,' .+88

!! C"#$/,50 S*0>"51%

!! ;/8+,/51%$%/+1

!! ;53,5$850 "51%$. $37*/%'

!! ?.%5,50 "++0

!! ?1T/5%'

!! H$,$1+/$ @ H8'3&+8/8

24S

K*I*,$3H

Is chaiacteiizeu by a patient's fluctuation of consciousness, oiientation,
anu attention. This is uue to some oiganic pioblem that affects the CNS.
Initially a patient will uisoiient to time, place, anu peison. Theie aie
foui common causes of ueliiium, which aie:

!! ;,*> *85 (Alcohol, PCP, Seuatives)

!! AP) /1S*,/58 (Tiauma, Neningitis)

!! )'8%5"/3 0/85$85 (Any oigan)
246
!! ;,*> U/%&0,$U$. (Withuiawal fiom seuatives most commonly)

%6FF6> E;>=;>?D ;>A<:=@ 4 548;@>8 TB6 @V5@7;@>A@D:

!! Bypeiactive oi Bypoactive behaviois

!! Confusion

!! Anxiety

!! Autonomic uysfunction

!! Sleep uistuibances

K;EE@7@>8;4< K;4?>6D;D:

Nany conuitions may mimic ueliiium, incluuing:

!! Bepiession

!! Bementia

247
!! Psychosis

#76?>6D;D: Whenevei theie is a tieatable unueilying conuition that is
tieatable, the piognosis is goou. 0ntieatable conuitions anuoi causes
usually leau to a woiseneu piognosis. Any untieateu cases may woisen
anu piogiess to uementia anuoi ueath.
248

K*H*.!$)

Is chaiacteiizeu by a giauual loss of memoiy anu cognitive function.
Theie aie many possible causes of uementia, ianging fiom tieatable
uiseases such as uepiession all the way to teiminal illnesses such as
Buntington's uisease, Paikinson's uisease, anu BIv.

$F56784>8 $>E67F48;6>'

!! Bementia is most common in the elueily population (affects >2u% of
those 8uyi of age oi gieatei).
!! Noie than half of all uementia cases aie a iesult of Alzheimei's

uementia.

!! vasculai uementia is also a common cause of uementia (Is the 2
nu

NCC).

#76M4M<@ %4:D@D'

!! uenetics plays an impoitant iole in Alzheimei's uementia.
249

!! vasculai uisoiueis play an impoitant iole in uementia.

!! BIv infection plays an impoitant iole in uementia.
2Su

)I-1*$H*,W& K*H*.!$)

Patients with Alzheimei's uementia piesent with significant memoiy
loss anu uifficulty in communication, all while noimal levels of
consciousness aie seen. Peisonality changes aie quite eviuent, anu
usually take place in the foim of excessive angei, paianoia, anu
uepiession. It is impoitant to iealize that with age comes a noimal
ueciease in cognitive function anu abilities, howevei these inuiviuuals
uo not expeiience an inability to function on a uay---to---uay basis.
Alzheimei's uementia patients will not only lose theii memoiy anu
cognition, but will have a uecieaseu ability to function on theii own on a
uay---to---uay basis. 0n a final note, it is impoitant to iealize that uementia
in the eluei population often looks just like Alzheimei's uementia, so a
close examination anu family questioning shoulu be unueitaken.

H4>4?@F@>8 6E )<QB@;F@7WD K@F@>8;4'

!! J$3,/15, which is a cholinesteiase inhibitoi, has been shown to
impiove cognition anu uelay the onset of symptoms in appioximately
one quaitei of all patients.
!! It is impoitant to manage all anxiety anuoi moou uisoiueis
2S1

phaimacologically.

!! =/:58%'.5 "+0/:/3$%/+18 such as uiet, nutiition, living---aiiangements,
anu exeicise shoulu all be auuiesseu.
2S2
#76?>6D;D'

!! 0pon onset of symptoms, the aveiage age of suivival is
appioximately eight yeais.
2SS

+*.K*, KL&#1",$)

2S4

+*.K*, KL&#1",$)

This is a new class of uiagnosis foi the BSN-v. Theie is gieat emphasis
of the concept of uenuei Incongiuence iathei than simple 'cioss-
genuei iuentification'. It was confiimeu that genuei iuentity uisoiuei
(a BSN-Iv classification) was neithei a sexual uysfunction noi a
paiaphilia.

In oiuei to uiagnose uenuei Bysphoiia, a gioup of physicians
(Enuociinologist, Sexual health expeit) must take pait in management
of the patient. Theie aie sepaiate ciiteiia foi chiluien, auolescents,
anu auults, wheie a chilu with a stiong uesiie to be of the opposite
genuei oi an insistence that heshe is of the opposite genuei is
necessaiy, but not sufficient enough to make a uiagnosis. This means
that uiagnosis of a chilu is much moie iestiictive anu conseivative than
it will be in an auolescent oi auult.

2SS

2S6

2S7

H""K K$&",K*,&
2S8
!"#$%&'

6,L). ;"@."%%/5" ;/%).B".
A/@)3,. ;/%).B".
;&%'>&(/+ ;/%).B".
?&+3)'>&(/+ ;/%).B".
2S9
H)X", K*#,*&&$/* K$&",K*,

Najoi uepiession is chaiacteiizeu by episoues of seveiely uepiesseu
moou, lasting foi at least two weeks at a time. The majoi symptoms of
uepiession aie a loss of inteiest in things usually enjoyable to a peison.
Lifetime pievalence foi men is S---12% anu foi females is 1u---2u%.
Biagnosis iequiies a majoi uepiessive episoue that lasts at least two
weeks.

While that is the majoi finuing, theie aie a vaiiety of possible signs anu
symptoms associateu with uepiession, incluuing:

& - &<@@5 =;D8:7M4>A@D (Bypeisomnia, Byposomnia) - often patients
will complain of eaily---moining awakening anu the inability to fall back
asleep.
$ - $>8@7@D8 <6DD (Loss of usual inteiests. Loss of ability to feel pleasuie
is known as 'Anheuonia').
+ - +:;<8 (Patients often feel excessive guilt ovei things out of theii
contiol oi things they shoulun't feel guilty about).
* - *>@7?G <6DD (Patients have a noticeable ueciease in eneigy).

% - %6>A@>8748;6> (Patients lose theii ability to concentiate).

26u
) - )55@8;8@ AB4>?@D (A ueciease in appetite is moie common,
although often patients will have hypeiphagia uuiing uepiessive
episoues).
# - #DGAB6F6867 4A8;O;8G (Nainly a loss of cognitive functioning).
261
& - &:;A;=4< ;=@48;6> (As many as 6S% of patients who aie uepiesseu
will consiuei haiming themselves, with appioximately 1u---1S%
attempting suiciue).

K@57@DD;6> 4<D6 57@D@>8D T;8B 8B@ E6<<6T;>? 7@<48@= DGF586FD'

H8'3&+8/8 !! Bepiession in auuition to psychosis, incluues uelusions
anuoi hallucinations in iaie ciicumstances.
)+"$%/3 )'"#%+"8 !! Patients will complain of a iange of inteinal
pains, which can leau to the onset of hypochonuiiasis.

)5$8+1$. ?::53%/D5 ;/8+,05,: A common sub---type of uepiession that is
limiteu to the wintei season. These patients iesponu veiy well to
exposuie to ultiaviolet light.

K@57@DD;6> ;D 6E8@> D@@> A6>A:77@>8<G T;8B 68B@7 F@=;A4< ;DD:@DY
;>A<:=;>?'

!10+3,/15 0/8+,05,8: Thyioiu uisoiueis (hypothyioiuism) look like
262
uepiession.
P*%,/%/+1$. 05:/3/513/58: Biets low in healthy fats can pieuispose a
patient to uepiession.
P5*,+.+>/3 0/8+,05,8: Paikinson's uisease, Buntington's uisease, anu
othei neuiologic uiseases tenu to leau to uepiession. Not only is theie
an unueilying oiganic cause, but patients who aie awaie of the seveiity
of theii uisease tenu to become uepiesseu.
26S
H&$,"$3+.+>': Nany uiffeient uiugs tenu to cause uepiession (Beta
blockeis, Anti---hypeitensives)
-/,$. /..158858: BIvAIBS, influenza, etc.

H8'3&/$%,/3 0/8+,05,8: Schizophienia, anxiety, uiug use anu abuse, anu
othei somatofoim uisoiueis aie common causes of uepiession.

Beieavement. commonly oveilaps with NBB. Beieavement will
typically last 1-2 yeais, anu is iecognizeu as a seveie psychosocial
stiessoi that may piecipitate NBB in those who aie susceptible (ie.
Family histoiy oi histoiy of NBB)

H4>4?@F@>8 6E K@57@DD;6>: Touay, the gioup of SSRI's aie the 1
st
line
in phaimacologic management of majoi uepiession. In auuition to
meuication, psychotheiapy is a majoi pait of theiapy.

))9CV8 !! The main siue---effects associateu with SSRI's aie a uecieaseu
sex---uiive anu anoigasmia.
M5%5,+3'3./3 $1%/66605#,588$1%8 !! Stiongly anti---cholineigic anu
seuative.
K?4CV8 !! Less favoieu because theie is a high---iisk of hypeitensive
264
ciisis (When patient eats foous high in tyiamine - wine, cheese, ieu
meat).

Refiactoiy cases oi cases that aie not iesponsive to meuication shoulu
be consiueieu foi ETC, which is an inuuction of a geneializeu seizuie
that lasts 2S---6u seconus.

)/056665::53%8 +: !JA !! Retiogiaue amnesia, lasting no moie than six
months.
A+1%,$/10/3$%/+1 !! Incieaseu intiacianial piessuie.
26S
"8B@7 ;F56784>8 ;>E67F48;6> 7@?47=;>? =@57@DD;6>'

!! If untieateu, majoi uepiessive episoues will usually iesolve within
six months.
!! Risk of suiciue is gieatest when patient has staiteu taking anti---

uepiessants, because they stait to gain the eneigy to take action.

!! It is within a physicians juiisuiction to aumit a patient who is suspect
of having suiciual iueation, who is unable to take caie of himheiself, oi
uoesn't have a piopei suppoit system to caie foi them.

266
9$#"I), K$&",K*,

Bipolai 1 uisoiuei is chaiacteiizeu by alteinating episoues of mania anu
majoi uepiession. Bipolai 2 uisoiuei is chaiacteiizeu by alteinating
episoues of hypomania anu majoi uepiession. 0ften times, patients will
piesent while in the uepiessive phase of bipolai uisoiuei. Taking anti---
uepiessants with bipolai uisoiuei will often piecipitate the manic phase
of the uisease. 0ntieateu manic episoues will usually iesolve within
thiee months.
267
&;?>D P &GF586FD 6E F4>;4 ;>A<:=@:

!! Incieaseu eneigy

!! Lack of neeu to sleep

!! Feeling of gianuiosity

!! Racing thoughts

!! Loss of inhibitions

This is a uangeious state because patients tenu to act iecklessly, often
spenuing absuiu amounts of money anuoi engaging in sexually iisky
behaviois.

H4>4?@F@>8 6E 9;56<47 K;D67=@7:

!! Lithium, Caibamazepine, anu valpioic Aciu aie effective uiugs.

268
!! Lithium has a veiy small theiapeutic winuow, thus we have to
constantly check bloou---Lithium levels.
!! Nain siue---effect of Lithium is nephiogenic uiabetes insipiuus.
269
KL&!1LH$) P %L%I"!1LH$)

;'8%&'"/$ is chaiacteiizeu by milu to moueiate uepiession, most of the
time, with no fiim beginning oi enu.
A'3.+%&'"/$ is chaiacteiizeu by episoues of hypomania anu

milumoueiative uepiession.

** These conuition cannot be uiagnoseu until symptoms have been
piesent foi at least two yeais.

H4>4?@F@>8:

;'8%&'"/$ !! The tieatment of choice is theiapy (Cognitive anuoi

Psychotheiapy).

A'3.+%&'"/$ !! Psychotheipy + Anti---uepiessants aie the tieatment
mouality of choice.
27u

).J$*!L K$&",K*,&
271
!"#$%&'
2"1".,3/0"B F1:/"'& ;/%).B".
=,1/+ ;/%).B".
=>)C/,%

JC%"%%/5"MMM?)(@83%/5" ;/%).B".

=)%'MMM<.,8(,'/+ 7'."%% ;/%).B".

7"@,.,'/)1 F1:/"'& ;/%).B".

7"3"+'/5" 68'/%(
272
"/*,/$*0 "S ).J$*!L K$&",K*,&

Anxiety uisoiueis aie chaiacteiizeu by an outwaiu manifestation of
inteinal feai, exhibiteu by both physical anu emotional symptoms.
A+""+1 "$1/:58%$%/+18 +: $1T/5%'W ,5>$,0.588 +: %'#5W /13.*05 %&5
:+..+U/1>G

!! Tiemoi

!! Biaphoiesis

!! Tachycaiuiatachypnea

!! Bizziness

!! Nyuiiasis

!! Syncope

!! Neuiopathies

!! uI uistuibances

27S
%6FF6> A4:D@D 6E 4>V;@8G ;>A<:=@'

!! Neuiotiansmittei abnoimality (uABA, S---BT, NE, E)

!! Nutiitional abnoimalities

!! Substance useabuse

!! Enuociine uisoiueis

!! Bypoglycemia
274
!B@ F4;> 4>V;@8G =;D67=@7DY 4AA67=;>? 86 8B@ K&HZZZ/ ;>A<:=@'

[ X O515,$./R50 ?1T/5%' ;/8+,05,

\ X H$1/3 0/8+,05,

] X H&+I/$8

^ X 4I8588/D5666A+"#*.8/D5 0/8+,05,

_ X H+8%666%,$*"$%/3 8%,588 0/8+,05,

+*.*,)I$-*K ).J$*!L K$&",K*,

ueneializeu anxiety uisoiuei is chaiacteiizeu by symptoms of anxiety
that last at least six months. These patients uo not have any paiticulai
souice of anxiety, but aie anxious about all aspects of life. uAB is moie
common in women, with half of all cases beginning in chiluhoou anuoi
auolescence.

Balf of all patients with uAB will uisplay chionic symptoms that iise anu
fall thioughout theii lives. The othei half of patients typically iesolve
27S
within a few yeais of having the uisease. 0ne of the most woiiisome
complications of uAB is the patient's iisk of becoming auuicteu to
Benzouiazepines, which aie a staple in patient management.
276
#).$% K$&",K*,

Panic uisoiuei is chaiacteiizeu by panic attacks that occui at ianuom
times. Patients often uesciibe these attacks as heait---attack---like, wheie
an impenuing feai of ueath is a main symptom. These attacks occui
appioximately twice pei week anu last appioximately ten to thiity
minutes. No longei uo we associateu panic attacks with agoiaphobia.

!B@ E6<<6T;>? 47@ 8B@ ;F56784>8 AB474A8@7;D8;AD 6E 54>;A =;D67=@7'

!! Nean age of onset is twenty---five, moie common in females.

!! Theie is a stiong genetic component to the uisoiuei.

!! Is usually chionic, although stiessful times of life may piesent with
moie episoues.

H4>4?@F@>8:

!! Acute tieatment may involve benzouiazepines.

!! Chionic tieatment involves SSRI's.

!! Cognitive theiapy is a staple of effective tieatment.
277
#1"9$)&

The two main phobias incluue 'Specific Phobia' anu 'Social Phobia'. A
specific phobia is an iiiational feai of a known object anuoi situation
(ex. Spiueis, Beights). Since the specificity of the phobia is known,
patients will go to gieat lengths to avoiu the tiiggei. Social phobia, on
the othei hanu, is an exaggeiateu feai of social anuoi enviionmental
situations. Because the patient feais being in public, they tenu to avoiu
going into public places oi social situations.

INP0RTANT: The BSN-v states that patients uo not have to iecognize
the iiiationality of theii phobia in oiuei to make a uiagnosis.

!! Specific phobias aie seen in S---1u% of the population, anu is seen
equally in men anu women.
!! Those with phobias often incui iepeicussions such as loss of job,
failing out of school, anu failuie to keep fiienus.
!! Tieatment of phobias is exposuie theiapy, wheieby we intiouuce a

patient to the subject of feai anu uesensitize them of the feai.

278

"9&*&&$/*ZZZ%"H#3I&$/* K$&",K*,

0bsessive---compulsive uisoiuei (0CB) is chaiacteiizeu by a iepetitive,
intiusive feeling, thoughts, anu obsessions, which leau to a builu---up of
anxiety that is only ielieveu by peifoiming a iepetitive action. This
uisoiuei most commonly begins in chiluhoou, anu is seen in 2---S% of the
geneial population. Theie is a stiong genetic component.
279
%6FF6> 6MD@DD;6>D D@@> ;> "%K ;>A<:=@'

!! Counting

!! Checking anu ie---checking

!! Becontamination

!! 0iuei

A majoi key to uiagnosing a patient with 0CB is that they have insight to
the iiiationality of theii uisease. Those with 0CB peisonality uisoiuei
uo not see iiiationality with theii behavioi.

#68@>8;4< %4:D@D 6E "%K:

!! Seiotonin is thought to be stiongly linkeu to 0CB, anu as such, SSRI's
aie an effective tieatment mouality. 0thei anti---uepiessants acting on S---
BT will also help patients with 0CB.
!! 0ften times, a life---stiessoi is a common piecipitant of 0CB.

28u
$F56784>8 I;>RD:

!! Bepiession is commonly seen in 0CB patients.

!! 0CB is commonly associateu with othei behavioial uisoiueis such as:

F1).":/,, A83/(/,, F1:/"'& B/%).B".%, anu J?; @".%)1,3/'& B/%).B"..

1647=;>? =;D67=@7 (newly auueu to BSN-v), uesciibeu as peisistent
uifficulty uiscaiuing oi paiting with possessions uue to a peiceiveu neeu to
save them. Seveie uistiess is associateu with uiscaiuing items.

#76?>6D;D !! Tieatment will significantly impiove SS% of patients,
moueiately impiove Su%, anu likely be ineffective in the iemaining.
Foi those patients who uo not see impiovement with tieatment, fuithei
ueteiioiation will likely occui.
281
#"&!ZZZ!,)3H)!$% &!,*&& K$&",K*,

Post---tiaumatic stiess uisoiuei (PTSB) is seen aftei a tiaumatic event
has taken place. These events aie often life---thieatening oi life---alteiing.
Recuiiing memoiies anuoi uieams of the event(s) leau to the
uevelopment of the uisoiuei. Biagnosis can only be maue when
symptoms aie piesent foi at least one month, beginning at least 4
weeks aftei the tiaumatic event.

CKH49J?PJ )C;!6P4J!): Acute Stiess Bisoiuei & Aujustment
uisoiuei (these aie closely ielateu to PTSB, thus shoulu be consiueieu
as pait of the oveiall uiscussion).

?3*%5 )%,588 ;/8+,05,: Refeis to the symptoms following a tiaumatic
event fiom 2 uays - 4 weeks post-tiauma (iemembei PTSB uiagnosis is
maue 4 weeks aftei the tiaumatic event).
?0S*8%"51% ;/8+,05,: Consiueieu a 'stiess iesponse synuiome'. This is
now consiueieu a conceptual fiamewoik foi a gioup of uisoiueis that
iepiesent a simple iesponse to life stiessois (tiaumatic oi non-
tiaumatic).

282
K&HZ/ D:??@D8 ^ F4N67 DGF586F A<:D8@7D E67 #!&K'

YZ 9565T#5,/513/1> %&5 5D51% E8#+1%$15+*8 "5"+,/58 +: %&5 5D51%F
LZ M5/>&%5150 $,+*8$. E8.55# 0/8%*,I$135W $>>,588/D51588[,53Q.5881588F
\Z ?D+/0$135 E5T%5,1$. ,5"/105,8 +: %&5 5D51%8F
]Z P5>$%/D5 %&+*>&%8 @ "++0[:55./1>8

H4>4?@F@>8:

!! SSRI's

!! Benzouiazepines acutely (not a long---teim solution, they have
incieaseu iisk of abuse).
!! uioup theiapy

#76?>6D;D !! Balf of patients will continually have symptoms, while the
othei half will iecovei completely within appioximately thiee months.

28S
&*#),)!$". ).J$*!L

** This is now categoiizeu as a iegulai anxiety uisoiuei (not isolateu to
peuiatiics)

When patients aie attacheu to theii paients beyonu what is consiueieu
noimal, sepaiation anxiety is uiagnoseu. The woiiy expeiienceu is that
something teiiible will happen to the main caiegiveis (usually the
paients).

K$/1 )/>18 @ )'"#%+"8:

!! Tiouble sleeping at night (ie. Nightmaies, insomnia)
284
!! Somatic symptoms when sepaiateu fiom caiegiveis (ie. Nausea,
vomiting, Biaiihea, etc)

K$1$>5"51%: Besensitization theiapy, exposing them to the pioblem
anu uecieasing theii woiiy.

&*I*%!$/* H3!$&H

Noveu into the categoiy of 'Anxiety Bisoiueis' with the BSN-v.
Chaiacteiizeu by a suuuen incapability to speak in someone who can
otheiwise speak noimally. Commonly chiluien will iemain silent uespite
incieasing theii iisk of social isolation, shame, oi punishment.

3D:4<<G A6Z@V;D8D T;8B 68B@7 A6>=;8;6>D D:AB 4D'
! Shyness
! Social anxiety

%B474A8@7;D8;AD 6E &@<@A8;O@ F:8;DF'
! Failuie to speak in social situations (ongoing basis)
28S
! At least 1 month in uuiation
! Inteifeies with occupational oi euucational expeiiences
! Not uue to lack of language compiehension, knowleuge, etc.
! Boes not impiove with age (typically)

H4>4?@F@>8:

2+, '+*1>5, 3&/.0,51G
! Stimulus fauing is commonly employeu
286

&%1$-"#1,*.$)
287
!"#$%&'
?>,.,+'"./%'/+%
7/-1% N 7&(@')(%
78CMMM<&@"%
;/**"."1'/,3 ;/,-1)%/%
6,1,-"("1'
6"B/+,'/)1 7/B"MMM9**"+'%
288
%1),)%!*,$&!$%&

Schizophienia is one of the most uebilitating mental uisoiueis we ueal
with in psychiatiy. It is chaiacteiizeu by patteins of uistuibing
thoughts, behaviois, anu speech. Patients tenu to show a loss of touch
with ieality when unueigoing a psychotic episoue, yet can uemonstiate
being in touch with ieality uuiing the piouiomal anu iesiuual phases.
0ften times, schizophienic patients aie those in society with a stiange
appeaiance, pooi giooming, anu social withuiawal.

)AA67=;>? 86 8B@ K&HZ/Y 8B@ A7;8@7;4 E67 =;4?>6D;D ;>A<:=@'

Abnoimalities in one oi moie of the following five uomains:

1. Belusions
2. Ballucinations
S. Bisoiganizeu thinking
4. uiossly uisoiganizeu oi abnoimal motoi behavioi
S. Negative symptoms

#76=76F4< &;?>D P &GF586FD'
289

!! Social withuiawal fiom fiienus, family, anu social activities.

!! Behavioi is quiet, passive, iiiitable, angiy.

!! Physical complaints aie common.

!! New inteiests in things such as: O"3/-/)1, =>/3)%)@>&, the J++83'.

#6D;8;O@ OD` .@?48;O@ &GF586FD'

H+8/%/D5 )'"#%+"8 !! aie symptoms uemonstiating excessive
functioning, such as Belusions, Ballucinations, Agitation, Stiange
Behavioi, excessive talking. Positive symptoms iesponu exceptionally
well to tiauitional anti---psychotic tieatment iegiments.
29u
P5>$%/D5 )'"#%+"8 !! aie ueficits in functioning anu incluue things
such as Thought Blocking, Flatteneu Affect, Pooi uiooming,
Amotivation, Social Withuiawal, Cognitive Bistuibances. Negative
symptoms aie not as iesponsive to tiauitional tieatment moualities, but
uo iesponu well to atypical anti---psychotics such as Rispeiiuone,
Clozapine, 0lanzapine, anu Quetiapine.

&;?>D P &GF586FD 6E #DGAB6D;D' Buiing an acute psychotic phase,
thought uisoiuei is seen in auuition to alteiations in =".+"@'/)1, '>)8->'
+)1'"1', '>)8->' @.)+"%%"%, anu *).( )* '>)8->', which incluue:

;5.*8/+18 !! Falsely helu beliefs that uo not follow logic oi ieason, aie
not shaieu by society as a whole. The most common type is a 'B"38%/)1
)* @".%"+8'/)1'.
!3&+.$./$ !! Nimicking woius spoken by anothei peison.

M$..*3/1$%/+18 !! False sensoiy peiceptions of auuitoiy oi visual
stimuli. Nay also be tactile, gustatoiy, olfactoiy, oi visceial
hallucinations.
C05$8 +: 95:5,5135 !! Is a falsely helu belief that one is the subject of
291
attention by otheis (often believe they aie the subject of meuia
sciutiny).
C"#$/,50 ?I8%,$3%/+1 ?I/./%' !! Bifficulty in uiffeientiating the

qualities of objects oi ielations uespite noimal intelligence.
292
=++85 ?88+3/$%/+18 !! Shifting of iueas fiom one subject to anothei in
an unielateu oi paitially ielateu fashion.
=+88 +: !>+ N+*10$,/58 !! Lack of knowing wheie one's minu anu bouy

enu anu those of otheis begin (feel as though they aie 'one' with otheis).
P5+.+>/8"8 !! Invention of new woius that aie nonsensical.
J$1>51%/$./%' !! Tuining a logical iesponse into a long, uiawn---out,
pointless tangent.
J&+*>&% N.+3Q/1> !! Acute stoppage in the noimal thinking piocess
because of an onset of hallucinations.
H5,85D5,$%/+1 !! Repeating a thought ovei anu ovei.

B+,0 )$.$0 !! Saying combinations of woius that have no ielation to
one---anothei.

&39ZZZ!L#*&

Theie aie five main sub---types of schizophienia, which incluue:

!! #474>6;= |uelusions of peisecution, seen in oluei patients, has bettei
functioning patient than the othei sub---typesj.
29S
!! 3>=;EE@7@>8;48@= |contains chaiacteiistics of moie than one sub---

typej.

!! %48486>;A |bizaiie postuiing, stupoi, muteness, extieme excitabilityj.

!! K;D67?4>;Q@= |pooily oiganizeu, inappiopiiate emotional iesponses,
uisinhibition, seen moie commonly in those < 2S yeais of agej.
!! ,@D;=:4< |pievious schizophienic episoue with iesiuual but non---

psychotic symptomsj.
294
K$SS*,*.!$)I K$)+."&$&

It is impoitant to unueistanu the list of potential causes of psychosis, as
they shoulu be iuleu out befoie making a uiagnosis of schizophienia.
The list below outlines the possible causes anuoi alteinate uiagnoses
of schizophienia.

97;@E #DGAB68;A K;D67=@7 !! Symptoms of psychosis that occui foi
moie than one uay but less than one month.
&AB;Q65B7@>;E67F K;D67=@7 !! Psychosis anuoi iesiuual symptoms

that last anywheie between one month anu six months.
&AB;Q64EE@A8;O@ K;D67=@7 !! A moou uisoiuei + symptoms of
schizophienia (note: Noou uisoiuei must be piesent foi the
majoiity of the uisoiuei's uuiation)
K@<:D;6>4< K;D67=@7 !! Fixeu, long---teim non---bizaiie oi bizaiie
uelusions anuoi thought uisoiueis.
&AB;Q6;= #@7D6>4<;8G K;D67=@7 !! Patient is socially withuiawn but
theie aie no symptoms of psychosis.
&AB;Q68G54< #@7D6>4<;8G K;D67=@7 !! 0uu behavioi anu thought
patteins without psychosis.
#DGAB6D;D =:@ 86 F@=;A4< A6>=;8;6> !! Symptoms of psychosis that
occui as a iesult of an unueilying meuical illness.
29S
967=@7<;>@ #@7D6>4<;8G K;D67=@7 !! Seveie moou swings, angei,

uissociation, low---level psychosis that lasts veiy little time.

K7:?ZZZ;>=:A@= #DGAB6D;D !! Seen commonly with LBS, PCP, cocaine,
amphetamines.
296
H).)+*H*.!

Nanagement foi schizophienia is best appioacheu with
phaimacological anu psychological meuiums. Phaimacological
tieatment involves using typical anuoi atypical anti---psychotic agents.
The mechanism of action of these uiugs involves loweiing Bopamine
levels in the biain.

!G5;A4< )>8;ZZZ5DGAB68;AD: Woik by blocking the B2 ieceptois.

!! Classic examples aie Balopeiiuol anu Chloipiomazine.

!! Balopeiiuol has the highest tenuency of causing extiapyiamiual siue---

effects.

!! Long---teim management must incluue psychotheiapy.

!! Impiovement is seen in appioximately 7u% of all patients.

!! Typicals aie most effective against positive symptoms of
schizophienia.

)8G5;A4< )>8;ZZZ5DGAB68;AD: Woik by blocking the B4 ieceptoi anu acting
on the Seiotonin levels in the biain.
297
!! Clozapine is the uiug least likely to cause extiapyiamiual siue---effects.

!! Clozapine has a tenuency to suppiess the bone maiiow, thus we me
keep an eye on the CBC to ensuie agianulocytosis hasn't occuiieu.
!! 0thei atypical anti---psychotics aie Rispeiiuone, Quetiapine, anu

0lanzapine, they cause fewei hematologic anu neuiologic effects.
298
Some patients aie non---compliant, which makes them iueal canuiuates
foi long---acting uepot foims of the meuication. These aie auministeieu
eveiy foui weeks intiamusculaily.

H*K$%)!$". &$K*ZZZ*SS*%!&

1;?BZZZ568@>AG =7:?D (namely Baluol anu othei typicals), tenu to cause
gieatei extiapyiamiual siue effects. Examples aie below:

?Q$%&/8/$: is a subjective feeling of iestlessness.

?3*%5 0'8%+1/$: is slow anu piolongeu muscle spasms.

H85*0+#$,Q/18+1/8": Paikinson---like movements.

J$,0/D5 ;'8Q/158/$: Wiithing movements of the heau, neck, anu
tongue.
P5*,+.5#%/3 "$./>1$1% 8'10,+"5: Bigh fevei, confusion, uiaphoiesis,
hypeitension, musculai iigiuity, ienal failuie.

299
I6TZZZ568@>AG =7:?D (namely Chloipiomazine), tenu to cause less
extiapyiamiual siue---effects anu tenu to cause moie anticholineigic siue---
effects anu anti---histamine effects.

0thei common siue---effects:

!! Weight gain

!! Seuation

!! }aunuice (causeu by hepatic pioblems)
Suu
!! Enuociine abnoimalities

!! ualactoiihea

!! Impotence

!! Amenoiihea

!! Becieaseu sex---uiive

!! Bematologic uysfunction (Agianulocytosis, leukopenia)

!! Photosensitivity

!! Blue---giay skin uiscoloiation (causeu by Chloipiomazine)

!! 0phthalmologic effects causeu by Thioiiuazine anu Chloipiomazine

Su1
#,"+."&$&

Typically, schizophienia is a life---long uisease that waxes anu wanes.

H,+>1+8/8 /8 I5%%5, U&51G

!! 0nset is latei in life

!! Patient has goou social ielationships, incluuing maiiiage

!! Bas moou symptoms

!! Female genuei

!! Bas positive symptoms

!! Bas few ielapses
Su2

K$&&"%$)!$/* K$&",K*,&
SuS
!"#$%&'
;/%%)+/,'/5" F(1"%/,
;/%%)+/,'/5" E8-8"
;/%%)+/,'/5" 4B"1'/'& ;/%).B".
;"@".%)1,3/0,'/)1 ;/%).B".
Su4
K$&&"%$)!$/* )H.*&$)

Chaiacteiizeu by an inability to iecall impoitant infoimation about
oneself. Is an uncommon conuition that is seen moie commonly in
women anuoi young auults. 0ften, if the amnesia began aftei a
stiessful event, it iesolves ovei time. A 'Bissociative Fugue' is now
a specifiei of uissociative amnesia, anu not it's own sepaiate
uiagnosis.

H4>4?@F@>8: Attempt at uncoveiing the stiessoi oi tiauma that

causeu the amnesia in auuition to long---teim psychotheiapy to ueal with
any unueilying issues.

K$&&"%$)!$/* S3+3*

Chaiacteiizeu by an inability to iemembei impoitant infoimation about
oneself, in auuition to leaving home anu taking on a new iuentity. The
patient is unawaie of the new assumeu iuentity. Is iaie anu is
associateu with a histoiy of excessive alcohol use. Is now a specifiei of
SuS
uissociative amnesia, anu not an actual uiagnosis in anu of itself.

K$&&"%$)!$/* $K*.!$!L K$&",K*,

Chaiacteiizeu by having at least two uiffeient peisonalities, also known
as 'Nultiple Peisonality'. The majoiity of patients aie women, wheie
one peisonality is the uominant peisonality. This conuition is usually
Su6
associateu with some unueilying stiuggle anuoi eaily tiaumatic event
in theii life. Is often associateu with chiluhoou sexual abuseincest.
Iuentity tiansitions may be obseiveu by otheis anuoi self-iepoiteu,
which is a new uiagnostic factoi in the BSN-v. Look foi gaps in this
patient's eveiyuay life, not only with iespect to tiaumatic events that
piecipitateu the uisoiuei.

K*#*,&".)I$-)!$". K$&",K*,

Chaiacteiizeu by iecuiiing anu peisisting feelings of uetachment fiom
self, social situation, oi enviionment. This uisoiuei often occuis in
patients with othei psychiatiic conuitions such as uepiession, anxiety,
histiionic peisonality uisoiuei, boiueiline peisonality uisoiuei, anu
schizophienia.
Su7

&"H)!$% &LH#!"H
K$&",K*,
Su8
!"#$%&'

7)(,'/+ 7&(@')( N
O"3,'"B ;/%).B".%
Su9
&"H)!$% &LH#!"H K$&",K*,

Somatic symptom uisoiuei (SSB) is chaiacteiizeu by uistiessing
symptoms oi symptoms that leau to significant uisiuption of noimal
eveiyuay functioning. They may also leau to uispiopoitionate
thoughts, feelings, anu behaviois iegaiuing those symptoms. The
patient must be peisistently symptomatic foi at least 6 months to
make a uiagnosis of SSB.

Pieviously, somatization uisoiuei, hypochonuiiasis, pain uisoiuei,
anu unuiffeientiateu pain uisoiuei fell into the 'Somatofoim uisoiuei'
categoiy - these have all been iemoveu with the BSN-v. Nany of the
finuings associateu with these olu uisoiueis aie now going to piompt
a uiagnosis of SSB. No longei aie a vaiiety of complaints fiom 4
uiffeient systems iequiieu as pait of the uiagnosis, iathei the somatic
symptoms must be uistiessing anu uisiuptive to uaily life.

Anothei key change to this categoiy is the fact that pieviously the
symptoms of somatofoim uisoiueis weie iequiieu to be 'meuically
unexplainable', wheie theii symptoms coulu not be linkeu to any
oiganic cause. Now, symptoms may oi may not be meuically
explainable.

S1u

K;4?>6D8;A %7;8@7;4'
! 0ne oi moie somatic symptoms that aie eithei uistiessing oi iesult
in significant uay-to-uay impaiiment
! Excessive thoughts, feeling, oi behaviois ielateu to the somatic
symptoms oi associateu health conceins as manifesteu by at least one
of the following: 1. Bispiopoitionate anu peisistent thoughts about
the seiiousness of one's symptoms. 2. Peisistent high level of anxiety
about health oi symptoms. S. Excessive time anu eneigy uevoteu to
the symptoms oi health conceins.
! The same symptoms neeu not be piesent continuously, but
symptoms must be peisistent in some foim oi anothei foi at least 6
months

H4>4?@F@>8:

!! Inuiviuual anuoi gioup theiapy, in auuition to ielaxation
techniques, aie the most effective moualities of tieatment -
phaimacological measuies aie usually not the fiist line of tieatment.

S11

1L#"%1".K,$)&$& P $II.*&& ).J$*!L K$&",K*,

Since hypochonuiiasis is no longei an inuiviuual uisoiuei, patients
aie now uiagnoseu with 'Somatic Symptom Bisoiuei'. The main
ieasons foi the change aie that labeling a patient as a hypochonuiiac
often uisiupteu a stiong patient-physician ielationship.

%"./*,&$". K$&",K*,
(Functional Neuiological Symptom Bisoiuei)

K;4?>6D8;A A7;8@7;4 6E S.&K ;D 4D E6<<6TD'
! 0ne oi moie symptoms of alteieu voluntaiy motoi oi sensoiy
function
S12
! Incompatibility between the symptoms anu iecognizeu
neuiomeuical conuitions
! Symptoms oi ueficit not bettei explaineu by anothei meuical oi
mental uisoiuei
! Causes significant uistiess oi impaiiment in social, occupational,
oi othei functional aieas.

&5@A;E;A DGF586FD F4G ;>A<:=@'
! Weakness oi paialysis
! Abnoimal movement (tiemoi, myoclonus, gait uisoiuei)
! Swallowing symptoms
! Speech symptoms (sluiieu speech, uysphonia)
! Seizuies
! Sensoiy loss anesthesia
! Special sensoiy ueficits (olfactoiy, auuitoiy, visual)

)A:8@ OD` #@7D;D8@>8' Acute when symptoms last < 6 months,
peisistent if symptoms last > 6 months.
! Also impoitant to specify whethei a psychological stiessoi is
piesent
S1S

S)%!$!$"3& K$&",K*,

Patients with factitious uisoiuei aie pietenuing to have an illness
anuoi inuucing an illness in oiuei to obtain meuical attention.
Factitious uisoiuei imposeu on anothei (pieviously known as
'Factitious uisoiuei by pioxy') is seen whenevei a caiegivei, often a
paient, fakes oi inuuces an illness in a chilu so they can obtain meuical
attention. Those in the meuical fielu aie most likely to fake an illness
because they know the main signs anu symptoms, with the most
commonly fakeu symptoms being uI, u0, caiuiac, oi ueimatological.

!! Factitious uisoiuei imposeu on anothei is always consiueieu chilu
abuse, anu thus must be iepoiteu to the appiopiiate authoiities.
!! 0ften, patients have a histoiy of illness that iesulteu in theii
enjoyment of being caieu foi.
!! School, woik, anuoi ielationships often suffei as a iesult of the
patient's pieoccupation with the illness.

! Willingness to unueigo invasive anu unnecessaiy pioceuuies oi
meuications in oiuei to confiim the seiiousness of the illness.
S14

#)$. K$&",K*,

The new ciiteiia foi pain uisoiuei take into account patients who
have puiely psychological pain, patients who have meuical causes
of pain, anuoi a combination of both. Because it is often uifficult to
ueteimine whethei pain is psychological oi not, we no longei class
them sepaiately.
S1S

S16

)KX3&!H*.! K$&",K*,
S17
!"#$%&'
?>,.,+'"./%'/+%
78CMMM<&@"%
6,1,-"("1'
S18
%1),)%!*,$&!$%&

Aujustment uisoiuei is seen whenevei someone iesponus in a negative
way to a change in theii life. Those who unueigo some soit of stiessful
event will expeiience eithei a noimal giief ieaction oi a malauaptive
ieaction.

.67F4< +7;@E !! Is the noimal iesponse seen whenevei someone
unueigoes a change anuoi stiessful event in life. Patients in this
categoiy can function noimally.
H4<4=458;O@ ,@D56>D@ !! Leaus to an aujustment uisoiuei, acute
stiess uisoiuei, oi biief psychotic uisoiuei. Patients in this categoiy
cannot function noimally.

)=N:D8F@>8 K;D67=@7 !! In the BSN-v, this categoiy has been
ieconceptualizeu as a stiess-iesponse synuiome. It is no longei a stiict
uiagnosis, iathei a uiagnosis exploieu when a patient uoesn't meet the
full set of ciiteiion foi othei uisoiueis. Typically a patient with an
aujustment uisoiuei expiesses a uepiesseu moou, symptoms of anxiety,
oi conuuct uistuibances.

S19

.67F4< ,@D56>D@ !! Seen when psychological uiscomfoit follows a
stiessoi, howevei no impaiiment is seen in one's life.

.67F4< +7;@E ,@4A8;6> !! A stiong emotional iesponse aftei a loss of
something oi someone veiy close to them.
S2u
)A:8@ &87@DD K;D67=@7 !! A uisoiuei wheieby theie aie multiple
psychological symptoms seen within the month of the stiessoi (2
uays - 4 weeks). These symptoms last two uays to foui weeks aftei
stiessoi, aftei which a uiagnosis of PTSB shoulu be exploieu.

,@4A8;O@ )884ABF@>8 K;D67=@7 ! Theie aie 2 sub-uivisions of
ieactive attachment uisoiuei, which is baseu upon olu BSN-Iv sub-
types: Reactive attachment uisoiuei anu Bisinhibiteu social
engagement uisoiuei.
95$3%/D5 ?%%$3&"51% ;/8+,05,: incompletely foimeu piefeiieu
attachments to caiegiving auults. Patients uemonstiate a uampeneu
positive affect towaius caiegivei.
;/8/1&/I/%50 )+3/$. !1>$>5"51% ;/8+,05,: moie closely iesembles
ABBB, wheieby chiluien typically have bonueu attachments to
caiegiveis.

S21

H).)+*H*.!

Suppoitive theiapy is the management of choice, helping the patient
auapt to the stiessful even as well as give them tools to cope with the
new changes. uioup theiapy is often effective, as it gives those with the
uisoiuei an empathetic enviionment (highly effective). Anytime
patients suffei fiom anxiety, uepiession, oi insomnia in auuition to the
aujustment uisoiuei, it is iecommenueu to tieat phaimacologically.

)&+,%666%5," !! Lasts no longei than six months aftei the stiessoi.
=+1>666%5," !! Lasts longei than six months aftei the onset of the
stiessoi.
S22

$H#3I&* %".!,"I K$&",K*,&
S2S
!"#$%&'
41'".(/''"1' 9:@3)%/5" ;/%).B".
P3"@')(,1/,
=&.)(,1/,
<./+>)'/33)(,1/,
=,'>)3)-/+,3 2,(C3/1-
41'".1"' 2,(/1- ;HJ
S24
$.!*,H$!!*.! *J#I"&$/* K$&",K*,

Is a uisoiuei chaiacteiizeu by a peiiou wheieby the patient loses self---
contiol anu attacks anothei peison. Theie is usually no cause foi these
attacks. Is seen moie commonly in men as a iesult of a ueciease in
seiotoneigic activity.

!! Tieat with SSRI's

!! 0sually woisens until miuule---age is ieacheu

!! Patients often have unhealthy ielationships

aI*#!"H).$)

Is a uisoiuei wheie patients have the impulse to take things without
paying foi them. The action is not uone in angei oi uefiance, but is uue
to the lack of impulse contiol.

S2S

!! Seen most commonly in those with concuiient bulimia neivosa (up
to of patients).
!! 0sually uue to a uysfunctional upbiinging.

!! SSRI's anu aveisive conuitioning aie the tieatment moualities of
choice.
!! The conuition is chionic anu usually enus only when a patient is

caught anu incaiceiateu.
S26
#L,"H).$)

Chaiacteiizeu by one's impulse to stait fiies (iepetitively). A patient's
uesiie to stait fiies often puts them into caieeis wheieby they have easy
access to fiies.

!! Is moie common in males.

!! 0sually seen in those with chiluhoou pioblems.

!! SSRI's aie the management of choice

!! When staiteu in chiluhoou theie is a goou piognosis, when staiteu in
auulthoou theie is a pooi piognosis.

!,$%1"!$II"H).$)

Chaiacteiizeu by a patient's impulse to pull out theii haii, iesulting in
haii loss.

S27

!! Noie common in females.

!! 0sually onset in chiluhoou.

!! Piecipitateu by stiess anuoi uepiession.

!! SSRI's aie the management of choice.

!! Is usually a chionic conuition.
S28
#)!1"I"+$%)I +)H9I$.+

AKA "uambling Bisoiuei". Chaiacteiizeu by an oveiwhelming neeu to
gamble. This usually leaus to loss of financial stability anu theiefoie
tiouble with family, fiienus, anu woik.

!! Associateu with a tioubleu chiluhoou, ABBB as a chilu, anu majoi
uepiessive uisoiuei.
!! Is usually chionic anu lifelong.

!! uamblei's anonymous is the tieatment mouality of choice.

$.!*,.*! )KK$%!$". K$&",K*,

INP0RTANT N0TE: Inteinet auuiction uisoiuei is not listeu in the BSN-v,
although it is cuiiently a topic of stuuy among the behavioialpsychiatiic
woilu, anu will likely be incluueu in the next ielease.
S29

S""K ).K *)!$.+ K$&",K*,&
SSu
!"#$%&'
F5)/B,1' H
O"%'./+'/5" E))B
41',D" ;/%).B".

F1).":/, !".5)%,

A83/(/, !".5)%,

JC"%/'&
SS1
$H#",!).! %1),)%!*,$&!$%&

The BSN-v has maue significant changes to the foou & eating uisoiueis
umbiella because many patients weie uiagnoseu in the past with 'N0S'
conuitions, as they uiu not fit into an Anoiexia oi Bulimia Neivosa
uiagnosis. It was founu that many of the N0S patients actually hau a
Binge-Eating uisoiuei, anu thus it has been auueu to the spectium of
foou & eating uisoiueis. Patients with eating uisoiueis often have
paiticulai patteins of behavioi, which aie impoitant foi physicians to
iecognize. Some of the impoitant behavioial chaiacteiistics incluue:

!! They have a noimal appetite.

!! They go to extieme measuies to avoiu gaining weight.

!! They have uistoitions of theii bouy image.

!! Females almost always have menstiual iiiegulaiities uue to the
suppiession of the hypothalamic---pituitaiy axis.

Eating Bisoiuei Infoimation:

SS2
!! They aie almost always seen in females (1u:1 F:N).

!! The most likely time of onset is late auolescence.

!! Those who aie highei achieveis aie most likely to uevelop an eating
uisoiuei.
!! Eating uisoiueis aie iaie in societies wheie foou is not abunuant.

!! 0nset usually follows a stiessful event in one's life.
SSS

9$.+* *)!$.+ K$&",K*,'
Pieviously known as an eating oiuei not otheiwise specifieu, the
uiagnosis is often times now a binge-eating uisoiuei. It is uefineu by
iecuiiing episoues of eating laige amounts of foou in a shoit peiiou of
time (gieatei than the aveiage peison woulu consume), even when the
patient is not hungiy.

The conuition is associateu with maikeu peisonal uistiess. Anu while it
is a much less commonly uiagnoseu conuition, it can be quite seveie
anu leaus to significant physical anu psychological tiauma.

K;4?>6D8;A A7;8@7;4:
! Noie than one binge-eating session pei week ovei a S-month peiiou
! Significant uistiess encounteieu aftei each episoue

H4>4?@F@>8: Talk Theiapy

SS4
).",*J$)
.*,/"&)

Patients have an oveiwhelming feai of gaining weight, thus they take to
extiaoiuinaiy measuies in oiuei to lose weight oi avoiu gaining weight.
Patients have abnoimal views of eating, usually taking ouu behaviois
when faceu with foou (cutting into small pieces, uiviuing foou gioups,
etc).

#BGD;A4< %B474A8@7;D8;AD 6E )>67@V;4'

!! Lanugo (thin haii all ovei the bouy).

!! Loss of > 1S% of bouyweight.

!! Amenoiihea.

!! Netabolic aciuosis.

!! Anemia

H4>4?@F@>8:

!! Initial management involves helping iestoie the patient's
electiolytes.
SSS
!! Family theiapy may be neeueu if theie aie family uynamic pioblems.

!! uaining weight to biing them to a healthy bouyweight is iequiieu.

!! Behavioial theiapy is the coineistone of management.

)>67@V;4 b7@ZZZE@@=;>?W &G>=76F@'

!! Seen 2---S weeks aftei initial management, patients piesent with
seveie hypophosphatemia
!! uive Iv phosphate ieplacement.
SS6
93I$H$) .*,/"&)

A uisease wheieby patients binge (eat excessively) anu puige (vomit
aftei meal), in oiuei to maintain a low bouyweight. Nost of the time,
bingeing is uone in seciet. Patients have a pooi self---image anu aie
oveily conceineu about weight gain.

$F56784>8 %B474A8@7;D8;AD 6E 9:<;F;4 .@7O6D4'

!! Patients usually have a ielatively noimal bouyweight.

!! Knuckle abiasions, enamel eiosions, anu esophageal uamage is
commonly seen in these patients.
!! Paiotiu glanu inflammation is common.

!! Electiolyte abnoimalities.

!! Nenstiual abnoimalities.

H4>4?@F@>8:

!! Behavioial theiapy is the coineistone of management.

!! Family theiapy may be iequiieu if theie aie family uynamic
SS7
pioblems.
!! SSRI's aie also commonly useu to suppiess the uiges to binge anu
puige.
SS8
"9*&$!L

0besity is an epiuemic in Noith Ameiica, with moie than 2S% of all
people being oveiweight. 0besity is uefineu as a bouyweight that is >
twenty pounus oveiweight.

$>A7@4D@= ,;DRD )DD6A;48@= 0;8B "M@D;8G'

!! Bypeitension

!! Caiuiovasculai uisease

!! Biabetes

!! Nusculoskeletal issues

** 0besity is moie common in those in lowei socioeconomic classes.

H4>4?@F@>8:

!! Commeicial uiets aie usually only effective in the shoit---teim, with
most people ie---gaining all lost weight within five yeais.
SS9
!! Long---teim weight loss is best achieveu with a sensible uiet anu
exeicise plan.
S4u

#*,&".)I$!L K$&",K*,&
S41
!"#$%&'

?38%'". F =".%)1,3/'& ;/%).B".%
?38%'". A =".%)1,3/'& ;/%).B".%
?38%'". ? =".%)1,3/'& ;/%).B".%
S42
$.!,"K3%!$".

A peisonality uisoiuei is uiagnoseu whenevei someone's pattein(s) of
behavioi aie beyonu what society ueems as noimal behavioi. Those
with peisonality uisoiueis will make othei people uncomfoitable in
some way oi anothei, at which point tieatment is usually sought.

%B474A8@7;D8;AD 6E #@7D6>4<;8G K;D67=@7D'

!! Patients usually have little insight into theii uisoiuei.

!! Patients only seek help when they aie piompteu to uo so by otheis.

!! Patients uo not have uisabling symptoms, just uistuibing symptoms.

!! Bisoiueis must be piesent by eaily auulthoou

%I3&!*, ) #*,&".)I$!L K$&",K*,&

These uisoiueis encompass behavioial patteins that aie peculiai,
S4S
feaiing of social ielationships, anu usually have a familiai oi genetic
association with psychotic illness.

#474>6;= !! Aie uistiustful anu suspicious of otheis, anu attiibute the
iesponsibility foi theii own pioblems to otheis.
&AB;Q6;= !! Patients have a long---stanuing pattein of voluntaiy social
withuiawal, theie is no psychosis seen.
&AB;Q68G54< !! Patients have an ouupeculiai appeaiance, have an ouu
thought patteinbehavioi, anu have magical thinking.
S44
%I3&!*, 9 #*,&".)I$!L K$&",K*,&

Patients with Clustei B peisonality uisoiueis aie oveily emotional,
uiamatic, anu behave in an inconsistent pattein.

1;D87;6>;A !! Patients aie emotional, sexually piovocative, anu
theatiical. They have tiouble maintaining intimate ielationships uue to
this unstable behavioi.
.47A;DD;D8;A !! Patients have a sense of entitlement anu believe they aie
bettei than otheis. They uon't empathize with otheis anu always put
the blame on otheis. They aie oveily sensitive to ciiticism.

)>8;D6A;4< !! Patients uo not confoim to social noims, often bieaking
the law, haiming otheis, anu lacking any iemoise foi these behaviois.
Conuuct uisoiuei is a pie---cuisoi to antisocial peisonality uisoiuei.
967=@7<;>@ !! Patients behave eiiatically anu with impulse. They often
engage in self---haiming behaviois anu expeiience episoues of sub---
psychotic behavioi.

."!*: 4##+8/%/+1$. 05:/$1% 0/8+,05,, while often uiscusseu alongsiue
anti-social peisonality uisoiuei, is not a piecuisoi to its uevelopment.
The chaiacteiistics of 0BB incluue: Angiyiiiitable moou,
aigumentativeuefiant behavioi, anu vinuictiveness (Thus, the
S4S
conuition consists of both emotional anu behavioial symptoms)

S46

%I3&!*, % #*,&".)I$!L K$&",K*,&

Patients with Clustei C peisonality uisoiueis aie oveily feaiful oi
anxious.

)O6;=4>8 !! Patients aie oveily sensitive to iejection, socially
withuiawn, anu have excessive feelings of infeiioiity.
S47
K@5@>=@>8 !! Patients will allow otheis to make uecisions foi them,
anu often won't uo anything without consent fiom anothei. 0ften theii
self---confiuence is veiy low.
"MD@DD;O@ZZZ%6F5:<D;O@ !! Patient is oveily conceineu with oiuei anu
cleanliness. Patients feel as though things must always be peifect, anu
become annoyeu when they aien't. They aie also veiy stubboin.

H4>4?@F@>8:

!! The only peisonality uisoiuei in which we use meuications is
Boiueiline peisonality uisoiuei, wheie anti---psychotics anu anti---
uepiessants aie commonly helpful.
!! Neuications can be useu when patients aie oveily anxious anuoi
uepiesseu.
!! Psychotheiapy is useful foi patients with peisonality uisoiueis.

!! Peisonality uisoiueis aie usually life---long anu aie non---cuiative.
S48

+*,$)!,$% #&L%1$)!,L
%".K$!$".
S49
!"#$%&' F-/1-H?>,1-"% )*
41+.",%"B F-" ;",'> &
A".",5"("1'
;"@."%%/)1 /1 '>" 93B".3&
SSu
)+$.+

=/:5 !T#53%$13':

!! The aveiage lifespan in the 0niteu States is 7S.S yeais.

!! Women life appioximately seven yeais longei than men.

!! Caucasians tenu to live between six to eight yeais longei than Afiican

Ameiicans.

!! The most impoitant factoi affecting life expectancy is genetics.

J&/1>8 %&$% 3&$1>5 U/%& /13,5$850 $>5:

!! Bloou flow uecieases (to biain, heait, kiuneys, uI tiact).

!! Bone mineial uensity uecieases (mainly in post---menopausal
women).
!! vision anu heaiing acquity uecieases.

!! Taste sensation uiminishes.
SS1

!! Fatty accumulation incieases.

!! Nuscle mass uecieases.

!! Tempeiatuie iegulation is uiminisheu.

!! Biain sizeweight uecieases.

!! Nemoiy capabilities ueciease.

!! Plaques uevelop in the biain (woise in uementia).
SS2
J&/1>8 %&$% %510 %+ .51>%&51 ./:58#$1:

!! Euucation (those with moie euucation tenu to live longei anu stave---

off uementia).

!! Naiiiage.

!! Continueu physical fitness.

K*)!1 ).K 9*,*)/*H*.!

Beieavement is a peison's emotional iesponse to the loss of a loveu one.
Theie aie five unique stages to the piocess of giieving, all of which aie
eventually encounteieu uuiing the giieving piocess. All stages aie not
necessaiily expeiienceu in the paiticulai oiuei mentioneu below:

K@>;4<: Patient's iefusal to accept what has happeneu.

)>?@7: Patient uemonstiates feelings of angei, which may be uiiecteu
towaius themselves oi otheis.
SSS
947?4;>;>?: Naking a ueal with a supeinatuial powei in oiuei to
ieveise the pioblem (unuoing).
K@57@DD;6>: Noimal uepiessive symptoms being.

)AA@584>A@: Peison accepts the situation.
SS4
Theie is often times an oveilap between noimal giief anu uepiession. It
is impoitant to exploie the patient's iesponse to the loss anu ueteimine
if they aie in fact expeiiencing noimal giief oi pathological giief.

P+,"$. O,/5:G

!! Sauness without uepiessive symptoms.

!! Nilu weight loss, sleep uistuibances, anu guilt.

!! Illusions of seeing the ueceaseu.

!! Patients make an attempt to ietuin to noimal activities of life.

!! Seveie symptoms iesolve within two months.

** uioup theiapy is a gieat stiategy foi helping the giieving to cope with
theii loss.

H$%&+.+>/3$. O,/5:G

!! Bepiessive symptoms

!! Significant weight loss, sleep uistuibance, anu guilt.

SSS
!! Consiueisattempts suiciue.

!! Symptoms last foi moie than two months.

!! Noueiate symptoms may last moie than one yeai.
SS6
K*#,*&&$". $. !1* *IK*,IL

Bepiession is the most common moou uisoiuei seen in the elueily
population. 0ften times, uepiession in the elueily is a iesult of the
losses acquiieu with olu age, such as:

!! ;",'> )* , 3)5"B )1" Q;"@."%%/)1 ,% , ."%83' )* B",'> )* , 3)5"B )1" 3,%'/1-
RMS &",.% /% 1)# #>,' /% ."T8/."B ') (,D" , B/,-1)%/% )* C".",5"("1'U

!! ;/(/1/%>"B >",3'>.

!! V)%% )* '>"/. ,C/3/'& ') #).D (Eithei ietiiement oi foiceu ietiiement).

Bepiession in the elueily often looks just like Alzheimei's uementia,
theiefoie it is impoitant to always inquiie about uepiession befoie
jumping to a conclusion of Alzheimei's uisease. Beliiium is also
commonly seen in the elueily, which is often a iesult of conuitions such
as:

!! !8'./'/)1,3 B"*/+/"1+/"%

!! =>&%/+,3 /331"%%

SS7
!! 6"B/+,'/)1 %/B"MMM"**"+'%
SS8
K$1$>5"51% +: 05#,588/+1 /1 %&5 5.05,.'G

!! SSRI's aie safe anu effective foi the tieatment of uepiession.

!! TCA's aie useu in iefiactoiy cases, howevei it is impoitant to have
patients use anticholineigic meuications at nighttime, as to pievent falls
associateu with the siue---effects.
!! NA0I's aie not geneially inuicateu in the elueily population because

of the incieaseu iisk of hypeitensive ciisis.
SS9

K$&",K*,& "S &I**#
S6u
!"#$%&'

!).(,3 73""@

?)(()1 ?,8%"% )* 73""@ ;/%).B".
?)(()1 73""@ ;/%).B".%
="B/,'./+ 73""@ ;/%).B".%
V"%% ?)(()1 73""@ ;/%).B".%
S61
.",H)I &I**#

Theie aie a few impoitant stages of sleep, which aie uiviueu into thiee
geneial sections. The awake phase, the non---uieaming stages of sleep,
anu the uieaming phase of sleep. The EEu is the iueal tool useu foi
chaiacteiizing the uiffeient phases of sleep, which aie outlineu below.

&84?@' F#,D"

!! Beta waves, associateu with active mental concentiation.

!! Alpha waves, associateu with eyes closeu while awake.

&84?@ [' <>"', #,5"%

!! Appioximately five---peicent of time is spent in this stage.

!! Is the lightest stage of sleep.

!! Respiiation, pulse, anu bloou piessuie ueciease.

!! Nay see episouic bouy movements in this stage.

S62
&84?@ \' 73""@ %@/1B3"% N PMMM+)(@3":"%

!! Appioximately foity---five peicent of time is spent in this stage (the
gieatest amount of time in any stage).

&84?@ ] P ^' ;"3', #,5"%

!! Consiueieu 'slow---wave' sleep stage.

!! Appioximately twenty---five peicent of time is spent in this stage.

!! Is the ueepest, most ielaxing stage of sleep.
S6S
!! Is a common stage of ceitain uisoiueis (Sleepwalking, Enuiesis,
Night Teiiois).

&84?@: O96

!! Appioximately twenty---five peicent of time is spent in this stage.

!! Time spent in REN uecieases with age, uecieases with ET0B

intoxication.

!! Is the uieaming phase.

!! Incieaseu pulse, bloou piessuie, anu iespiiation.

!! Complete ielaxation of skeletal muscle.

!! Penile anu clitoial tumescence occuis in this stage.

!! REN latency (time until fiist REN cycle) takes ninety---minutes on
aveiage.
!! REN peiious occui foi ten to twenty minutes eveiy ninety---minutes
thioughout the night.
!! "REN iebounu" is a phenomenon wheieby a peison lacking REN

sleep with catch---up the following night.
S64
=.)@". %3""@ ."T8/."% /1+.",%"B 3"5"3% )* +".',/1 1"8.)'.,1%(/''".%W
/1+38B/1-X

&@7686>;>: Incieaseu S---BT is neeueu to inciease the time spent
sleeping as well as uelta wave sleep.
K654F;>@: Incieaseu uopamine levels tenu to ueciease sleep time.
.67@5;>@5B7;>@: Incieaseu NE will ueciease the total sleep time anu
the oveiall time spent in REN sleep.

%"HH". %)3&*& "S &I**# K$&",K*,&

The two main categoiical causes of sleeping uisoiueis incluue Physical
causes anu Psychological causes.

#BGD;A4< %4:D@D:

!! 6"B/+,3 +)1B/'/)1% (Enuociine uisoiueis, pain uisoiueis).

!! I/'>B.,#,3 )* %"B,'/5"% (ET0B, benzouiazepines, opiates).

S6S
!! 9:+"%%/5" 8%" )* %'/(83,1'% (Caffeine, Amphetamines).

#DGAB6<6?;A4< %4:D@D:

!! A/@)3,. B/%).B".

!! 6,L). B"@."%%/5" B/%).B".

!! F1:/"'& B/%).B".% (specific, geneial)
S66
%"HH". &I**# K$&",K*,&

Theie aie two main categoiies of sleep uisoiueis, they incluue:

!! ;'88+"1/$8

!! H$,$8+"1/$8

KGDD6F>;4D: Aie chaiacteiizeu by uisiuption in the quality anu
quantity of sleep. Najoi uyssomnias incluue:
!! C18+"1/$ (Tiouble falling anu staying asleep)

!! Bifficulty falling asleep at least Sxweek foi 1 month

!! 0ften a sign of impenuing uepiessionanxiety

!! M'#5,8+"1+.5835135 0/8+,05, (excessive sleepiness uespite at least 7hi
of sleep anuoi piolongeu sleep time (>9hi) that is non-iestoiative anuoi
uifficulty being fully awake aftei abiupt awakening.

!! P$,3+.5#8' (Expeiience sleep attacks - Sxweek foi at least S months)

!! Shoit REN latency

!! Bypnagogichypnopompic hallucinations

S67
!! Sleep paialysis (lasts foi a few seconus)

!! ).55# $#15$ (Cential anu 0bstiuctive)

!! Cential is causeu by a lack of iespiiatoiy uiive (elueily)

!! 0bstiuctive (most common) uue to obstiuction

! ).55#695.$%50 M'#+D51%/.$%/+1 (episoues of uecieaseu iespiiation
associateu with elevateu levels of Cu2)

! A/,3$0/$1 9&'%&" ).55#6B$Q5 ;/8+,05,8 (peisistent oi iecuiiing
pattein of sleep uisiuption that is piimaiily uue to an alteiation of the
ciicauian system oi to a misalignment between the enuogenous ciicauian
ihythm anu the sleep-wake scheuule iequiieu by an inuiviuual's physical
enviionment oi socialpiofessional scheuule)
S68
#474D6F>;4D: Aie chaiacteiizeu by physiological oi behavioial
changes associateu with a lack of sleep. Najoi paiasomnias incluue:
!! ).55#U$.Q/1> (Begins in chiluhoou, no conscious iecollection of

walking while sleeping)

!! ).55# %5,,+,8 (Awakening with teiioi, no iecollection)

!! P/>&%"$,5 0/8+,05,8 (Repetitive, fiightening uieams that
cause nighttime awakening)
! P+169!K 8.55# $,+*8$. 0/8+,05, (iecuiiing episoues of
incomplete awakening, often accompanieu by sleepwalking
anuoi sleep teiiois)
! 9!K ).55# N5&$D/+, ;/8+,05, (iepeateu episoues of aiousal
uuiing sleep associateu with vocalization anuoi complex motoi
behaviois)
! 958%.588 =5> )'10,+"5 (uige to move the legs, usually
accompanieu by oi in iesponse to uncomfoitable anu unpleasant
sensations in the legs)
! )*I8%$135[K50/3$%/+16C10*350 ).55# ;/8+,05, (Seveie anu
obvious sleep uistuibance occuiiing uuiing oi soon aftei
substance intoxication oi aftei withuiawal fiom exposuie to a
meuication - N0TE: The substance must be one capable of
causing a uistuibance)
! 4%&5, )#53/:/50 C18+"1/$ ;/8+,05, (any situation that is
chaiacteiistic of insomnia uisoiuei, leauing to impaiieu social oi
S69
occupational uistuibances, yet not meeting the full ciiteiia of
othei insomnia uisoiueis)
! ^18#53/:/50 C18+"1/$ ;/8+,05, (any situation chaiacteiistic
of insomnia that uoesn't meet the full ciiteiia foi insomnia
uisoiuei oi any of the uisoiueis in the sleep-wake uisoiuei
uiagnostic class.
S7u

I*&& %"HH". &I**# K$&",K*,&
H@>D87:4<ZZZ)DD6A;48@= &G>=76F@:

!! Bypeisomnia that occuis pie---menstiually.

%;7A4=;4> ,BG8BF &<@@5 K;D67=@7:

!! Sleepawake patteins that occui at inappiopiiate times of the uay.

a<@;>@ZZZI@O;> &G>=76F@:

!! Recuiiing peiious of hypeisomnia anu hypeiphagia that last one to
thiee weeks.
!! Seen most commonly in auolescent boys.

&<@@5 K7:>R@>>@DD:

!! A genetic conuition wheieby patients have significant tiouble waking
up, uespite getting auequate sleep.
S71

S72

)93&* P .*+I*%!
S7S
!"#$%&'

%B;<= )M:D@'
7":8,3 FC8%"
=>&%/+,3 FC8%"
9()'/)1,3 !"-3"+'

*<=@7<G )M:D@'
=>&%/+,3 FC8%"
!"-3"+'

K6F@D8;A )M:D@'
=>&%/+,3 FC8%"
9()'/)1,3 FC8%"
7":8,3 FC8%"
S74
%1$IK )93&*

The main types of chilu abuse incluue: Sexual, Physical, anu Emotional

Neglect.

&*J3)I )93&*'

!! The majoiity of the time, the abusei is male.

!! The majoiity of the time, the abusei is well---known to the chilu anu
family (< S% of cases aie stiangeis).
!! The majoiity of sexual abuse cases aie nine to twelve yeais of age.

!! Twenty---five peicent of cases aie youngei than eight yeais of age.

!! Twenty---five peicent of females anu twelve peicent of males iepoit
sexual abuse at some point thioughout theii lives.

!D/05135 +: ?I*8e:

!! Tiauma to the analgenital iegion.

!! Piesence of STB (get a swab).
S7S

!! Piecocious sexual behavioi with otheis.

!! Knowleuge about specific sexual acts.

!! Recuiiing 0TI's.

!! Piesence of anxiety, uepiession, oi othei emotional uisoiueis.

A+""+1 A&$,$3%5,/8%/38 +: %&5 ?I*85,G

!! They usually have substance abuse pioblem.

!! Commonly have pioblems in theii own maiiiage.

!! Commonly have uepenuent peisonality uisoiuei.
S76
!! 0ften have a peuophilia uisoiuei.

_+*, 9+.5 $8 $ H&'8/3/$1G

!! It is manuatoiy that you iepoit all cases anu suspecteu cases.

!! You aie alloweu to aumit a chilu if you feel they aie at iisk of fuithei
abuse.
!! You aie not obligeu to tell the paients you suspect abuse of any king.

#BGD;A4< )M:D@ P .@?<@A8'

!! Chiluien with some soit of peiceiveu pioblem aie moie commonly
physically abuseu (emotionalmoouetc).
!! Two---thousanu to foui---thousanu cases of abuse iesult in ueath,

annually.

!! The majoiity of abuseu chiluien aie youngei than fifteen yeais of age.

!D/05135 +: ?I*85G
S77

!! Chilu is lacking in peisonal caie (uisheveleu haii anu clothes, iashes
in uiapei, etc).
!! Chilu appeais malnouiisheu anuoi is not gaining weight

appiopiiately.

!! Cigaiette buins.

!! Fiactuies at uiffeient stages of healing.

!! Spiial fiactuies anuoi chip fiactuies.

!! Immeision buins.

!! Belt maiks.
S78
!! Signs of physical iestiaint on wiists anuoi ankles.

A&$,$3%5,/8%/38 +: $1 ?I*850 A&/.0G

!! They have a histoiy of low biith---weight anuoi piematuiity.

!! They have a histoiy of hypeiactivity oi ABBB.

!! They aie colicky.

A+""+1 A&$,$3%5,/8%/38 +: %&5 ?I*85,G

!! They live in poveity.

!! They have a histoiy of substanceET0B abuse.

!! They have a histoiy of being abuseu in some capacity themselves.

!! They have a histoiy of social isolation.

#1L&$%)I )93&* P .*+I*%! "S *IK*,IL'

S79
!! Bementia is often a common finuing in abuseu oi neglecteu elueily.

!! The most common abusei of the elueily is a spouse.

!! The majoiity of cases uo not get iepoiteu.

)/>18 +: !.05, ?I*85G

!! Signs of pooi peisonal caie.

!! Signs of malnouiishment.

!! Biuising.

!! Physical signs of iestiaint.

!! Fiactuies at uiffeient stages of healing.
S8u
_+*, 9+.5 $8 $ H&'8/3/$1 C1 !.05, ?I*85G

!! You aie obligeu to iepoit all cases of elueily abuse anu just as with
chilu abuse, you can aumit a patient if you suspect they aie in uangei.

K"H*&!$% )93&*'

!! The majoiity of uomestic abuse cases aie not iepoiteu.

!! The majoiity of the time the male is the abusei.

!! It is often uifficult to convince someone that leaving the paitnei is
theii best choice, mainly because they aie:
!! Bepenuent on the spouse (financially, emotionally)

!! They blame themselves

!! They have low self---esteem

!! They have nowheie else to go

A&$,$3%5,/8%/38 +: %&5 ?I*85,G

!! 0ften has a uiug anuoi ET0B pioblem.
S81

!! Is impulsive anu uoesn't toleiate stiess well.

!! Bas a histoiy of uisplacing feelings.

!! Abusei usually has low self---esteem.

J&5,5 /8 $ 3+""+1 3'3.5 +: $I*85 8551W /% /13.*058G

!! Theie is a builuup of tension in the abusei.

!! Theie is abusive behavioi (veibal, Physical).

!! The abusei is apologetic, uemonstiates loving behavioi towaius the
victim, anu is foigiven.
S82

_+*, 9+.5 $8 $ H&'8/3/$1 /1 ;+"58%/3 ?I*85G

!! Pioviue suppoit.

!! Biscuss options foi safety.

!! You aie not iequiieu to iepoit uomestic abuse to the authoiities.

&*J3)I )93&* c,)#*d'

Any type of sexual contact without mutual consent is uefineu as sexual
abuse. Theie is no legal iequiiement foi penetiation to occui in oiuei
to make a case foi iape.

A&$,$3%5,/8%/38 +: 9$#/8%G

!! The majoiity aie youngei than twenty---five yeais of age.

!! They aie usually of the same iace as the victim.

!! Biugs anuoi ET0B aie a pait of a thiiu of all iape cases.

S8S

_+*, 9+.5 $8 $ H&'8/3/$1 /1 9$#5 A$858G Theie aie thiee stages you
have to go thiough with youi patient:

e[ f $FF@=;48@<G )E8@7 !B@ $>A;=@>8

!! uet a thoiough histoiy

!! Peifoim a geneial physical examination

!! uet the appiopiiate laboiatoiy tests

!! Consiuei antibiotics anuoi aboitificants if necessaiy

!! Suggest youi patient contact the piopei authoiities
S84

e\ f !T6 !6 &@O@> K4GD I48@7

!! Biscuss emotional anu physical state of the patient

!! uet a piegnancy test

!! Allow youi patient to communicate theii feelings

!! uet a psychiatiic consult foi youi patient

!! Fuithei uiscuss legal implications of the case

e] f &;V 0@@RD )E8@7 $>A;=@>8

!! Peifoim anothei physical exam

!! Bo a follow---up laboiatoiy panel

!! Consiuei senuing the patient to counseling if neeueu

!"+%/+1$. A+1857*51358G

!! 0ften times youi patient will uevelop post---tiaumatic stiess uisoiuei.

S8S
!! Counseling in a gioup setting is the most effective foim of tieatment.
S86

#*K$)!,$%
#&L%1$)!,L
S87

!"#$%&'

!).(,3 ;"5"3)@("1'
=".5,%/5" ;"5"3)@("1',3 ;/%).B".%
;"@."%%/)1
7"@,.,'/)1 F1:/"'&
J@@)%/'/)1,3 ;"*/,1' ;/%).B".
?)1B8+' ;/%).B".
F''"1'/)1MMM;"*/+/' Y&@".,+'/5/'& ;/%).B".

<)8."''"K% ;/%).B".
S88
.",H)I K*/*I"#H*.!

Noimal uevelopment is not an exact science, but on aveiage these aie
the ages by which chiluien have ieacheu milestones. The main
uevelopmental milestones fall unuei the following categoiies:

!! SocialEmotional

!! LanguageCommunication

!! Cognitive (leaining, pioblem---solving skills, thinking)

!! NovementPhysical Bevelopment

0@ 84R@ 4 <66R 48 8B@D@ F;<@D86>@D 48 8B@ E6<<6T;>? 4?@ ?76:5D:

!! 2 months

!! 4 months

!! 6 months

!! 9 months

!! 12 months (1 yeai)
S89

!! 18 months

!! 24 months (2 yeais)

!! S6 months (S yeais)

!! 48 months (4 yeais)

!! 6u months (S yeais)
S9u
) K*!)$I*K I""a )! K*/*I"#H*.!)I H$I*&!".*&

JB4 K4PJM)

&6A;4<U*F68;6>4<'

!! Smiling begins

!! Begins puiposeful eye contact with paients

I4>?:4?@U%6FF:>;A48;6>'

!! Coos

!! uuigles

!! Tuins heau towaius sounus

%6?>;8;O@'

!! Facial iecognition

S91
!! Recognizes people

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Bolus heau up

!! Pushes bouy up when lying on stomach

!! Aim anu leg movement is moie cooiuinateu
S92
24^9 K4PJM)

&6A;4<U*F68;6>4<'

!! Smiles at people

!! Enjoys playing

!! Nimics facial movement anu expiession

I4>?:4?@U%6FF:>;A48;6>'

!! Babbles

!! Tiies to imitate sounus

!! Tiies to communicate with unique sounus

%6?>;8;O@'

!! Bemonstiates emotion

!! Can ieach foi objects single---hanueu

S9S
!! Begins to uevelop smooth hanu---eye co---oiuination

!! Can follow objects visually

!! Pays gieatei attention to facial uetails

!! Recognizes familiai faces

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Bolus heau up unsuppoiteu

!! Rolls fiom fiont to back

!! Begins playing with toys

!! Biings hanu to mouth

!! Can push onto elbows fiom lying on stomach
S94
)C` K4PJM)

&6A;4<U*F68;6>4<'

!! Becomes awaie of stiangeis

!! Plays with otheis

!! Can iesponu to othei people's emotions

!! Recognizes self in ieflection

I4>?:4?@U%6FF:>;A48;6>'

!! Responus to noise by making it's own noise

!! Can stiing vowels togethei when cooing

!! Responus to own name

!! Bemonstiates joy anuoi uispleasuie

!! Begins to use consonants in sounus

S9S
%6?>;8;O@'

!! Cuiiosity about things neaiby

!! Passes object fiom one hanu to the othei

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Can ioll ovei in both uiiections

!! Can sit up without suppoit

!! Can suppoit own weight on legs

!! Rocking back anu foith seen
S96
PCP! K4PJM)

&6A;4<U*F68;6>4<'

!! Feai of stiangeis

!! Bevelops clinginess to familiai auults

!! Bas favoiite toys

I4>?:4?@U%6FF:>;A48;6>'

!! Will unueistanu the woiu 'N0'

!! Nakes seveial uiffeient sounus

!! Copies the sounus anu gestuies of otheis

!! Points at things

%6?>;8;O@'

!! 0nueistanu when things aie hiuuen

S97
!! Plays 'peek a boo'

!! Noves things smoothly fiom one hanu to the othei

!! Bas well---uevelopeu pincei giasp

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Stanus up while holuing onto something

!! Can get into the sitting position anu stay theie without suppoit

!! Can pull to a stanu

!! Ciawls quickly
S98
JB!=-! K4PJM)

&6A;4<U*F68;6>4<'

!! Ciies when paients leave

!! Bas both favoiite objects anuoi people in theii life

!! Shows feai in ceitain situations

!! Repeats sounus anu actions

!! Belps uiess by assisting you

!! Plays 'peek a boo' anu 'pat---a---cake' well

I4>?:4?@U%6FF:>;A48;6>'

!! Responus to simple spoken iequests

!! Shakes heau 'N0' oi waves gooubye

!! Same 'mama', 'uaua', anu 'uh oh'

!! Changes the tone of veibal expiession

S99
!! Tiies to mimic woius

%6?>;8;O@'

!! Exploies uiffeientnew things

!! Copies gestuies

!! Biinks fiom cup

!! Biushes haii

!! Can poke with inuex fingei

!! Follows simple uiiections

!! Can iecognize objectspeople in a pictuie

!! Recognizes people
4uu

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! uets into sitting position without help

!! Bemonstiates 'ciuising' (walks while holuing onto objects)

!! Nay stanu alone

!! Can take a few steps without holuing onto objects
4u1
!COMJ!!P K4PJM)

&6A;4<U*F68;6>4<'

!! Banus things to otheis while playing

!! Tempei tantiums stait

!! Afiaiu of stiangeis

!! 0nueistanus concept of playing 'pietenu'

!! Is affectionate towaius familiai people

!! Clings to caiegiveis in unfamiliai situations

!! Points things out to othei people

!! Will exploie new spaces when paients aie close

I4>?:4?@U%6FF:>;A48;6>'

!! Can say seveial single woius togethei

!! Says 'N0'

4u2
!! Shakes heau 'N0'

!! Points to things they want

%6?>;8;O@'

!! Knows what most objects aie

!! Pietenus to caie foi stuffeu animalsuollsetc

!! Can point out ceitain bouypaits

!! Can sciibble

!! Can follow a one---step veibal commanu
4uS
H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Can walk alone

!! Staits walking up steps

!! Staits to iun

!! Can help unuiess self

!! Can uiink fiom a cup

!! Can eat with a spoon
4u4
JB!PJ_66624^9 K4PJM) EL _!?9)F

&6A;4<U*F68;6>4<'

!! uets exciteu when othei chiluien aie aiounu

!! Shows moie inuepenuence

!! Copies otheis

!! Nay stait to incluue othei chiluien in theii play

I4>?:4?@U%6FF:>;A48;6>'

!! Can point things out when nameu

!! Knows most familiai bouy paits

!! Says a 2---4 woiu sentence

!! Can follow simple instiuctions

!! Can iepeat woius oveiheaiu in conveisation

!! Can point to things in a book

4uS

%6?>;8;O@'

!! Begins to soit shapes anu colois

!! Completes a full sentence

!! Plays make---believe games

!! Can builu a towei of foui oi moie blocks

!! Staits using a uominant hanu

!! Can follow two---step instiuctions
4u6
H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Can kick a ball

!! Begins to iun

!! Can climb onto anu off of fuinituie without help

!! Walks up anu uown staiis holuing on

!! Thiows ball oveihanu

!! Can copy stiaight lines anu ciicles

!! Can stanu on tiptoes
4u7
JMC9J_666)C` K4PJM) E\ _!?9)F

&6A;4<U*F68;6>4<'

!! Nimics auults

!! Shows affecting to familiai people

!! Plays togethei with otheis (takes tuins playing)

!! Can uemonstiate empathy

!! 0nueistanus concepts such as 'mine', 'heis', 'ouis'

!! Bemonstiates a vaiiety of emotions

!! Can sepaiate fiom paients without becoming oveily emotional

!! Bevelops ioutines in uaily living

!! Can uiess anu unuiess themselves

I4>?:4?@U%6FF:>;A48;6>'

!! Can follow two anu thiee---step instiuctions

4u8
!! Can name most familiai objects

!! Can say fiist name, age, anu sex

!! Can get theii point acioss somewhat in conveisation

!! Can speak in two to thiee---woiu sentences

%6?>;8;O@'

!! Can uo a thieefoui piece puzzle

!! Can tuin pages one at a time

!! Can sciew anu unsciew lius

!! Can copy a ciicle with a pencil oi ciayon

!! Can builu a towei of > six blocks
4u9

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Climbs staiis easily one step at a time

!! Runs easily

!! Can peual a tiicycle
41u
249J_666!COMJ K4PJM) E] _!?9)F

&6A;4<U*F68;6>4<'

!! Cieative make---believe play

!! Can behave co---opeiatively with otheis

!! Piefeis gioup play as opposeu to inuiviuual play

!! Likes to tiy new things

I4>?:4?@U%6FF:>;A48;6>'

!! 0nueistanus the basic iules of giammai

!! Can sing basic songs fiom nuiseiy ihymes

!! Can tell stoiies

!! Can tell you theii fiist anu last name

%6?>;8;O@'

411
!! Can name colois anu numbeis

!! Can use scissois

!! Can uiaw a peison with two to thiee bouy paits

!! Can play basic boaiu oi caiu games

!! Can uiaw capital letteis

!! 0nueistanus time

!! Can iecall paits of a stoiy

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Can stanu up on one foot

!! Can catch a bouncing ball
412
)C`J_ K4PJM) Ea _!?9)F

&6A;4<U*F68;6>4<'

!! Wants to mimic theii fiienus

!! Can follow anuoi agiee with iules

!! Can show concein foi otheis

!! Is genuei awaie

!! Knows the uiffeience between ieal anu make---believe

!! Can sign anu uance

!! Bemonstiates moie inuepenuence

I4>?:4?@U%6FF:>;A48;6>'

!! Speaks in a cleai mannei

!! Can tell a stoiy with full sentences

!! Can use piopei veib tense

41S
!! Knows auuiess

%6?>;8;O@'

!! Can count ten oi moie objects

!! Can piint some letteis anu numbeis

!! Can copy geometiic shapes

!! Can uiaw a bouy with six bouy paits

H6O@F@>8U#BGD;A4< K@O@<65F@>8'

!! Stanus on one foot foi ten oi moie seconus

!! Can hop anu skip
414
!! Can uo a someisault

!! Can use all utensils to eat

!! Can use the toilet inuepenuently

!! Can swing anu climb

* Bevelopmental milestones couitesy of CBC
41S
#*,/)&$/* K*/*I"#H*.!)I K$&",K*,&

The peivasive uevelopmental uisoiueis aie chaiacteiizeu by a chilu's
failuie to uevelop anuoi the eaily iecession of noimal social anu
language skills foi theii age. The loss of these skills is lifelong anu
subsequently theie is a uecieaseu capacity to function noimally.

The common peivasive uevelopmental uisoiueis incluue:

!! Austism

!! Aspeigei's

!! Rett uisoiuei

)3!$&H: Is chaiacteiizeu by pioblems with communication anu
foimation of social ielationships. 0ften chiluien engage in iepetitive
anuoi self---uestiuctive behavioi.
!! 2S of patients with Autism have below noimal intelligence (IQ <7u)

!! 0ften times, patients have above---aveiage abilities (ie. Excel in playing
416
the piano)

A&$,$3%5,/8%/38 @ H,+>1+8/8:

!! 0nset is befoie thiee yeais of age

!! Is much moie common in males

!! If seen in a female, cases is often much moie seveie

!! The majoiity of patients iemain impaiieu into auulthoou, with a veiy
small numbei able to live inuepenuently.
417
)&#*,+*,W&: Patients have seveie pioblems in foiming social
ielationships. Patients tenu to have iepetitive behaviois anu
clumsiness. They have little to no uelay in language uevelopment, anu
cognitive uevelopment is usually noimal.

A&$,$3%5,/8%/38 @ H,+>1+8/8:

!! 0nset is usually between thiee to five yeais of age

!! Is moie common in males than females

!! The piognosis is much bettei foi Aspeigei's than it is foi Autism.

,*!!W& K$&",K*,: Is only seen in giils. Patients have a peiiou of
completely noimal functioning, followeu by a iapiu uecline in social
skills.

A&$,$3%5,/8%/38 @ H,+>1+8/8:

!! 0nset befoie foui yeais of age

!! Patients uemonstiate a classic 'hanu---wiinging' motion
418

!! Patients aie mentally ietaiueu

!! This conuition piogiessive with age, with a slight impiovement in
social skills as patient ages
419
%1$IK1""K K*#,*&&$".

Bepiession seen in chiluien often times piesents itself in a uiffeient
mannei than uepiession in auults. While some chiluien may show the
same signs anu symptoms, often theie aie unique finuings in uiffeient
age gioups:

H,583&++.5,8: Nay uemonstiate hypeiactivity anuoi aggiession.
?0+.58351%8: Nay uemonstiate iiiitability, boieuom, oi antisocial
behavioi.

H4>4?@F@>8: Examine the chilu's social situation (ie. Check foi family
stiessois, check foi stiessois at school)
!! Antiuepiessants aie not always useu foi chiluhoou uepiession, as
theie is an incieaseu iisk of suiciual iueation in this population.

&*#),)!$". ).J$*!L

42u
** This is now categoiizeu as a iegulai anxiety uisoiuei (not isolateu to
peuiatiics)

When patients aie attacheu to theii paients beyonu what is consiueieu
noimal, sepaiation anxiety is uiagnoseu. The woiiy expeiienceu is that
something teiiible will happen to the main caiegiveis (usually the
paients).

K$/1 )/>18 @ )'"#%+"8:

!! Tiouble sleeping at night (ie. Nightmaies, insomnia)
421
!! Somatic symptoms when sepaiateu fiom caiegiveis (ie. Nausea,
vomiting, Biaiihea, etc)

K$1$>5"51%: Besensitization theiapy, exposing them to the pioblem
anu uecieasing theii woiiy.

"##"&$!$".)I K*S$).! K$&",K*,

The chilu engages in behavioi that is aigumentative, angiy, anu
iesentful. This behavioi is uiiecteu towaius people who aie in an
authoiitative iole.

C"#+,%$1%: The behavioi uisplayeu, while uistuibing at times, uoes not
violate any social noims as uoes the behavioi seen in conuuct uisoiuei.

!! Seen most commonly in chiluien between six anu eighteen yeais of
age.
!! 0ppositional uefiant uisoiuei is not a pie---cuisoi to antisocial

422
peisonality uisoiuei.

!! Befoie pubeity, the conuition is moie common in boys, while post---

pubeity theie is an equal iatio of male to female.
42S
%".K3%! K$&",K*,

Chiluien engage in behaviois that aie consiueieu to be uangeious anu
against the noimal behavioi accepteu by society. A majoi factoi in
uiagnosing is the lack of iemoise felt by the chilu.

J&5 :+..+U/1> I5&$D/+,$. %,$/%8 $,5 3+""+1.' 8551:

!! Piopeity uestiuction

!! Aggiession towaius people anu animals

!! Stealing

!! Lying

!! Fiie---setting

!! Running away fiom home

!! Skipping school

!B@7@ 47@ =;EE@7@>8 E67FD M4D@= 6> 8B@ 4?@ 6E 6>D@8:
?>/3B>))BMMM)1%"' '&@": 0nset is befoie ten yeais of age.
424
FB)3"%+"1'MMM)1%"' '&@": 0nset is aftei ten yeais of age.
* 0veiall, onset must be seen befoie eighteen yeais of age foi the

appiopiiate uiagnosis.

** This IS a pie---cuisoi to antisocial peisonality uisoiuei.
42S
)!!*.!$".ZZZK*S$%$!L 1L#*,)%!$/$!L K$&",K*,

ABBB is a uisoiuei wheieby the chilu has a gioup of behavioial
pioblems that aie seen in moie than one setting (ie. At school anu at
home).

J&5 "$/1 3&$,$3%5,/8%/38 $88+3/$%50 U/%& ?;M; $,5:

!! Bypeiactivity

!! Limiteu attention span

!! Impulsiveness

!! Iiiitability

!! Emotional outbuists

C1 +,05, %+ "$Q5 $1 $##,+#,/$%5 0/$>1+8/8W Q55# %&5 :+..+U/1> /1
"/10:
!! Age of onset befoie seven yeais of age.

!! Symptoms lasting foi at least six months.

426
!! Is five times moie common in boys.

#76?>6D;D: Appioximately one in five will maintain the uisoiuei into
auulthoou.
!! ABBB in auulthoou leaus to an incieaseu iisk of mooupeisonality

uisoiueis.

H4>4?@F@>8: The 1
st
line meuication of choice is Nethylpheniuate.

!! In chiluien, stimulating the CNS incieases theii ability to concentiate.
427
!"3,*!!*W& K$&",K*,

Is a uisoiuei chaiacteiizeu by involuntaiy movements anu vocalizations
(tics). Patients typically have seveial motoi tics in auuition to at least
one vocal tic. Touiette's commonly begins befoie the age of eighteen,
with the onset of motoi tics beginning as eaily as eight yeais of age.
Theie is no cessation of signs anu symptoms of the uisoiuei.

A$*85: Bysfunctional iegulation of uopamine in the cauuate nucleus.

!T$"#.58 +: "+%+, %/38:

!! Blinking

!! Lip smacking

!! uiimacing

!T$"#.58 +: D+3$. %/38G

!! Piofanity

428
!! uiunting

!! Baiking

K$1$>5"51%:

!! Balopeiiuol is the mainstay of tieatment.

!! Pimoziue is also an effective agent
429

#&L%1$)!,$%
#1),H)%"I"+L
4Su

!"#$%&'

F1'/MMMF1:/"'& 6"B/+,'/)1%
F1'/MMM;"@."%%,1' 6"B/+,'/)1%
F1'/MMM=%&+>)'/+ 6"B/+,'/)1%
F1'/MMM6,1/, 6"B/+,'/)1%
4S1
).!$ZZZ).J$*!L H*K$%)!$"&

!! The two main categoiies of anti---anxiety meuications incluue:
Benzouiazepines anu Non---Benzouiazepines.

9@>Q6=;4Q@5;>@D:

!! Rapiu onset of action.

!! Biffeient agents have shoit, inteimeuiate, anu long uuiations of
action.
!! The benzouiazepines aie inuicateu foi othei conuitions such as sleep

uisoiueis.

!! Bave a high iisk of abuse

.6>ZZZ9@>Q6=;4Q@5;>@D:

!! Zolpiuem is an imiuazopyiiuine that is useu to inuuce iapiu sleep, is
not a benzouiazepine.
!! Buspiione is a goou anti---anxiety uiug that is less seuating anu less

4S2
likely to leau to uiug uepenuenceabusewithuiawal (longei onset of
action than benzouiazepines).
4SS

9@>Q6=;4Q@5;>@D

.6>ZZZ9@>Q6=;4Q@5;>@D
4S4

).!$ZZZK*#,*&&).! H*K$%)!$".&
The main categoiies of anti---uepiessant meuications incluue:
!! Selective Seiotonin Receptoi Blockeis (SSRI)

!! Beteiocyclic Agents

!! Nonoamine 0xiuase Inhibitois (NA0Is)
&&,$D:

!! Nain action is the inhibition of seiotonin ie---uptake.

!! They have limiteu effect on othei catecholamines like NE, E, BA, anu

Ach.

!! These aie much safei anu have fewei siue---effects as compaieu to the
othei classes of anti---uepiessants.

4SS
1@8@76AGA<;A )?@>8D:

!! Theii main action is the inhibition oi ie---uptake of NE anu S---BT.

!! Stiong anticholineigic action

!! Bighly seuative

!! Commonly cause weight gain

4S6
H6>64F;>@ "V;=4D@ $>B;M;867D'

!! Iiieveisible inhibition of NA0, leaus to the inciease in available NE

anu S---BT in the synapse.

!! Can leau to hypeitensive ciisis when combineu with foous high in

Tyiamine (cheese, wine, beei, some meatsfish).

!! Combining NA0 with SSRI can leau to Seiotonin---synuiome

(hypeitheimia, convulsions, coma, anu even ueath).

4S7
).!$ZZZ#&L%1"!$% H*K$%)!$".&

The anti---psychotic meuications woik by uecieasing the amount of
uopamine available. The two main categoiies of meuications incluue
the 'typicals' anu 'atypicals'.

J'#/3$.8 !! Aie stiongei anu uemonstiate gieatei siue---effects than the
atypicals.
?%'#/3$.8 !! Aie weakei anu have fewei siue---effects than the typicals.

4S8

4S9

).!$ZZZH).$) H*K$%)!$".&

Anti---mania uiugs aie useu to contiol the symptoms of mania, which is a main finuing of
bipolai uisoiuei. Biugs aie useu as acute aboitificants anu chionic moou---stabilizeis.

44u

AM?HJ!9 Yb

CKK^P4=4O_

? 8*I63$%5>+,' +: "/3,+I/+.+>'W /""*1+.+>' /8 D5,' &/>&6'/5.0Z J&5,5 $,5
/"#+,%$1% 3+135#%8 '+* "*8% Q1+UW $10 $.. +: %&5 /""*1+.+>/3 0/8+,05,8 $,5 :$/,
>$"5 +1 %&5 )%5# Y 5T$"Z

441

$HH3."I"+L

#)&&$/* OD` )%!$/* $HH3.$!L
#4DD;O@ $FF:>;8G ! This foim of immunity occuis when theie is a tiansfei of active humoial immunity in the
foim of piefoimeu anitbouies fiom one host to anothei. This foim of immunization is useu when theie is a iisk of
infection anu not enough time foi the bouy to uevelop an ample immune iesponse. This pioviues fast but shoit-
liveu piotection.
Examples: Nateinal Ig's passeu to baby, patient given iabies vaccine when bitten by a bat.
)A8;O@ $FF:>;8G ! This foim of immunity uevelops thiough its own piouuction of antibouies in iesponse to
exposuie to an antigen, pathogen, oi vaccine. This gives the oiganism slow-onset but long-teim piotection.

!1* %"HI*H*.! #)!10)L
Besigneu to piotect against giam negative bacteiia, is activateu by immunoglobulin u oi N in the classic pathway,
anu activateu by suiface miciobes in the alteinate pathway.

2^PAJC4P 42 JM! A4KH=!K!PJ 2?AJ49):
%[Y %\Y %]Y %^ ! Neutialization of viial paiticles
442

%]M ! 0psonization
%]4Y %_4 ! Anaphylaxis
%_4 ! Neutiophil Chemotaxis
%_MZ%g ! NAC cytolysis

;!2CAC!PAC!) 42 JM! A4KH=!K!PJ H?JMB?_:
%[ *D8@74D@ $>B;M;867 =@E;A;@>AG ! get oveiactive complement pathway anu this leaus to heieuitaiy angioeuema
%] =@E;A;@>AG ! iespiiatoiy tiact infections + iecuiient pyogenic infections
%hZ%i =@E;A;@>AG ! causes Neisseiia bacteiemia
K@A4G )AA@<@748;>? S4A867 =@E;A;@>AG ! causes paioxysmal noctuinal uyspnea

!1* H)X", 1$&!"%"H#)!$9$I$!L %"H#I*J cH1%d
The NBC is genomic iegion founu in veitebiates that encoues NBC molecules, anu these molecules play a veiy
impoitant iole in immune function. Theie aie two types of NBC (ie NBC 1 anu NBC 2).
!B@ H1% $ ! Contains 1 polypeptiue + a !2-micioglobulin, anu contains S genes (gene A, B, anu C).

The NBC II ! Contains 2 polypeptiues, anu an alpha anu a beta chain. Bas S genes (BP, BQ, anu BR). This NBC II is
the main component in oigan iejection.
44S

).!$9"KL S3.%!$".&

444

S3.%!$". "S !1* ).!$9"KL
The vaiiable paits (vB, vL) will iecognize uiffeient antigens, while the constant paits ("C") will fix the complement.
Fc Fiagment ! This fiagment is 3+18%$1%, has a 3$,I+&'0,$%5 siue-chain, is 3+"#.5"51% I/10/1> (Igu anu IgN
only), anu has a 3$,I+T' %5,"/1$..
?1%/I+0' $/08 /1:
1. Complement activation via the membiane attack complex
2. 0psonization (ie aius in phagocytosis)
S. Neutialization (by pieventing the auheience of bacteiia)

&39!L#*& "S $HH3."+I"93I$.&
0se the mnemonic "uANEB" to iemembei anu keep all of the immunoglobulin infoimation oiganizeu.
$FF:>6?<6M:<;> + c$?+d'
- Is the most abunuant of all the immunoglobulin's
- Is the main antibouy iesponsible foi the seconuaiy antibouy iesponse
- 0nly Ig that can cioss the placenta
- Fixes complement, opsonizes bacteiia, anu neutializes toxins
$FF:>6?<6M:<;> ) c$?)d'
- Founu in bouily secietions
- Pievents bacteiial attachment to mucous membianes
$FF:>6?<6M:<;> H c$?Hd'
- Responsible foi the piimaiy antibouy iesponse
- Is the antigen ieceptoi on B cell suifaces
$FF:>6?<6M:<;> * c$?*d'
- Bas the lowest concentiation of all Ig's
- Responsible foi piotection against woims
- Responsible foi mast cell anu basophil gianule ielease in type 1 hypeisensitivities

$FF:>6?<6M:<;> K c$?Kd'
- Founu on B cell suifaces

44S

).!$9"KL #,"K3%!$".

446

!Z%*II )%!$/)!$".
The following steps aie iequiieu foi helpei T-cell activation:
1. The antigen-piesenting cell engulfs the viial paiticle
2. The viial paiticle is then piesenteu on the suiface of the NBC II anu is then iecognizeu by the T-cell ieceptoi
on the suiface of the helpei T-cell
S. A "co-stimulatoiy" signal is maue when the B7 on the APC anu the CB28 on the helpei T-cell binu.
4. The combination of #2 anu #S cause the secietion of IL-2 anu "-IFN

Aftei the helpei T-cell is activateu, the next step is the activation of the cytotoxic T-cell, these steps aie:
1. IL-2 fiom the helpei T-cell connects with the cytotoxic T-cell, thus activating it to uestioy the infecteu cell.
2. Pioteins piesenteu on the NBC I (ie viial-iecognition) attiacts the cytotoxic T-cell, gets iecognizeu, anu is
killeu
J&5 :+..+U/1> 05"+18%,$%58 %&585 8%5#8 D/8*$..'c

447

K$SS*,*.!$)!$".U#,"K3%!$". "S ! ).K 9 %*II&

%*II H*K$)!*K $HH3.$!L
c! %*II&d
T CELLS
Alleigies
uiaft Rejection
Antibouy iesponse
Befense against 2*1>/W
K'3+I$3%5,/*"W JNW $10
D/,*86/1:53%50 35..8Z
).!$9"KLZH*K$)!*K
$HH3.$!L
B CELLS
Alleigies
Autoimmunity
Befense against N$3%5,/$W
J+T/18W $10 -/,*858
448

%L!"a$.* S3.%!$".
Theie is a gieat mnemonic that can help you iemembei the fiist five cytokines, it is: "168 !-M6>@ st*)k"
$I f [ ! Bot = FEvER
$I f \ ! stimulation of T-cells
$I f ] ! stimulation of B0NE maiiow
$I f ^ ! IgE piouuction stimulation
$I f _ ! IgA piouuction stimulation

Now the iest of the cytokines aie iesponsible foi the following:
$I f i ! PNN chemotactic factoi
!.S # ! Incieases IL-2 ieceptoi synthesis by helpei T cells, incieases B cell piolifeiation, anu attiacts anu
stimulates PNNs. This is secieteu by maciophages.
!.S ! ! This is secieteu by activateu T lymphocytes, anu peifoims the same functions as the TNF #
" Z $>8@7E@76> ! Stimulates maciophages, secieteu by helpei T cells

$.!*,S*,".&
Inteifeions play an essential iole in pieventing the piolifeiation anu piouuction of a viius by acting in ceitain ways
to pievent it fiom infecting othei cells.
J&5 %&,55 "$S+, :*13%/+18 +: %&5 /1%5,:5,+18 $,5:
1. Activation of natuial killei (NK) cells which act by uiiectly killing viius-infecteu cells.
2. # anu ! inteifeion act by inhibition of viial piotein synthesis
S. " Z Inteifeion woiks by incieasing the expiession of the NBC I anu NBC II as well as antigen piesentation in
all cells
N/> #/3%*,5 K4? +: /1%5,:5,+18:
! Inteifeions stimulate the piouuction of a piotein that uegiaues viial mRNA. When this occuis, the viius cannot
infect a cell since the piopei genetic mateiials foi this function aie absent.

449

!,).&#I).! ,*X*%!$".
O,$:%6D86M+8% 95S53%/+1:
0ccuis when the giafteu T cells piolifeiate anu ieject the host cells that contain foieign pioteins. As this occuis,
seveie oigan uysfunction ensues, causing uamage to the livei, skin, mucosa, anu gastiointestinal tiact. This
conuition also affects the bone maiiow anu the lungs.
M'#5,$3*%5 95S53%/+1:
0ccuis almost immeuiately aftei tiansplant, wheieby piefoimeu anti-uonoi antibouies cause a iesponse.
?3*%5 95S53%/+1:
This is a cell-meuiateu ieaction that occuis via cytotoxic T lymphocytes that ieact against foieign NBCs, occuiiing
weeks post-tiansplant.
A&,+1/3 95S53%/+1:
0ccuiiing months-yeais post-tiansplant, is causeu by antibouy-meuiateu vasculai uamage.

4Su

!L#*& "S 1L#*,&*.&$!$/$!L ,*)%!$".&

!L#* [ 1L#*,&*.&$!$/$!L: )>45BG<4A8;AU)865;A
A veiy iapiu ieaction that occuis in iesponse to antigen exposuie. Antigens
tiiggei the ielease of histamine by binuing to basophils anu mast cells.
!T$"#.58 ! Bives, asthma, anaphylaxis

!L#* \ 1L#*,&*.&$!$/$!L: %G8686V;A
Is a cytotoxic ieaction wheieby IgN anuoi Igu binu to cells leauing to lysis by complement activation oi
phagocytosis.
!T$"#.58 ! Autoimmune hemolytic anemia, uooupastuie's uisease, iheumatic fevei, Rh uisease, uiave's uisease.

!L#* ] 1L#*,&*.&$!$/$!L: )>8;?@>Z)>8;M6=G H@=;48@=
The foimation of antigen-antibouy complexes leaus to complement activation, attiacting PNN's anu ultimately
leauing to the ielease of lysosomal enzymes.
!T$"#.58 ! ulomeiulonephiitis, Lupus, Rheumatoiu Aithiitis

!L#* ^ 1L#*,&*.&$!$/$!L: %@<<ZH@=;48@=
Is a uelayeu iesponse, wheieby T cells become sensitizeu anu encountei antigens, thus ieleasing cytokines.
!T$"#.58 ! Contact Beimatitis, Tiansplant Rejections, TB Skin Test

,*H*H9*,$.+
!1*
1L#*,&*.&$!$/$!$
*&'
H>@F6>;A' )%$K
) f )>45BG<4V;D
% f %G8686V;A
$ f $FF:>@
%6F5<@V
K Z K@<4G@=
4S1

K$&*)&* %)3&*K 9L $HH3.* K*S$%$*.%$*&

9Z%*II K*S$%$*.%$*&
BR0T0N'S
AuANNAuL0B0LINENIA
SELECTIvE
INN0N0uL0B0LIN
BEFICIENCY
!Z%*II K*S$%$*.%$*&
TBYNIC APLASIA
(Biueoige)
CBR0NIC
N0C0C0TANE00S
CANBIBIASIS
9 ).K ! %*II
K*S$%$*.%$*&
SCIB
WISK0TT-
ALBRICB
ATAXIA-
TELANuIECTAS
IA
#1)+"%L!$% K*S$%$*.%$*&
CBR0NIC uRAN0L0NAT00S
BISEASE
CBEBIAK-BIuASBI
}0B'S SYNBR0NE
LE0K0CYTE ABBESI0N
BEFICIENCY
BYPER-IgN SYNBR0NE
IL-12 RECEPT0R BEFICIENCY
4S2

9Z%*II K*S$%$*.%$*&

N9^J4PV) ?O?KK?O=4N^=CP!KC?:
An x-linkeu iecessive uefect in tyiosine kinase gene. iesults in:
- All Ig classes aie uecieaseu
- uet iecuiient bacteiial infections (aftei 6 months of age)
- 0nly in boys

)!=!AJC-! CKK^P4O=4N^=CP ;!2CAC!PA_:
A ueficiency of a specific Ig class iesulting in uefect I isotype switching, iesults in:
- Sinus infection
- Lung infections
- Nost commonly the ueficient Ig is IgA

!Z%*II K*S$%$*.%$*&:

JM_KCA ?H=?)C?:
Theie is a failuie of the uevelopment in the thymus anu paiathyioiu's, uue to failuie of uevelopment of the S
iu
anu
4
th
phaiyngeal pouch, iesults in:
- Tetany
- viial anu fungal infections (iecuiient)
- Beait uefects

AM94PCA KÂ4A^J?P!4^) A?P;C;C?)C):
A T-cell uysfunction against Canuiua, iesults in:
- Canuiual infections of the skin anu mucous membianes

4SS

9 ).K ! %*II K*S$%$*.%$*&
)!-!9! A4KNCP!; CKK^P4;!2CAC!PA_ E)AC;FG
This conuition leaus to a uefect in uiffeientiation of the eaily stem-cells, iesults in:
- Recuiient infections (viial, bacteiial, fungal, anu piotozoal)

BC)d4JJ6?=;9CAM )_P;94K!:
Is an x-linkeu uefect in the ability to mount an IgN iesponse to the capsulai polysacchaiiues of bacteiia, iesults in:
- Low IgN levels
- Bigh IgA levels
- Noimal IgE levels
- Classic tiiau of symptoms: Infections, Eczema, anu Thiombocytopenic Puipuia.

#1)+"%L!$% K*S$%$*.%$*&
AM94PCA O9?P^=4K?J4^) ;C)!?)!:
A lack of NABPB leaus to a uefect in neutiophil phagocytosis, iesults in:
- Succeptibility to oppoitunitic bacteiial infections
- Biagnosis baseu on negative nitioblue tetiazolium uye ieuuction test (A=?))CA ^)K=! <^!)JC4P)

AM!;C?d6MCO?)MC ;C)!?)!:
A uefect in miciotubulai function anu lysosomal emptying of the phagocytic cells, iesults in:
- Recuiient pyogenic infections uue to staph anu stiep

e4NV) )_P;94K!:
T-cells fail to piouuce "-inteifeion, thus PNN's fail to iesponu, iesults in:
- Eczema, staph abscesses, anu elevateu IgE

4S4

=!^d4A_J! ?;M!)C4P ;!2CAC!PA_ )_P;94K!:
Theie is a uefect in the LFA-1 auhesion pioteins on the phagocytes, iesults in seveie eaily life pyogenic infections.

M_H!96C>K )_P;94K!:
Theie is a uefect in the CB4u liganu on the CB4 Th cells, leauing to seveie pyogenic infections eaily in life, iesults in:
- Bigh IgN levels
- Extiemely low levels of Igu, IgA, anu IgE

C=6YL 9!A!HJ49 ;!2CAC!PA_:
A uefect in the IL-12 ieceptoi leaus to uisseminateu mycobacteiial infections.

4SS

AM?HJ!9 YY

KCA94NC4=4O_

M/8%+,/3$..'W I$3%5,/+.+>' +33*#/58 %&5 "$S+,/%' +: %&5 "/3,+I/+.+>' 7*58%/+18 +1
%&5 )%5# Y 5T$"Z ?:%5, I$3%5,/$W D/,+.+>' /8 D5,' /"#+,%$1%W I+%& 3+135#%*$..' $10
/1 05%$/.Z H$' D5,' 8#53/$. $%%51%/+1 %+ MC- $10 $.. %&$% /% 51%$/.8W $8 %&/8 /8 +15 +:
%&5 &/>&58%6'/5.0/1> %+#/38 +1 %&5 5T$"Z B&51 /% 3+"58 %+ #$,$8/%58 $10 &5."/1%&8W
'+*, 8%,$%5>' 8&+*.0 I5 "5"+,/R$%/+1 +: "+058 +: %,$18"/88/+1W 8/>18 $10
8'"#%+"8W $10 %,5$%"51%8Z

4S6

9)%!*,$"I"+L

!1* +,)H #"&$!$/* 9,*)aK"0.

+,)H #"&$!$/* %*II 0)II &!,3%!3,*
4S7

#*#!$K"+IL%). f Pioviues suppoit anu piotects against osmotic piessuies.
%)#&3I* - Piotects the oiganism fiom phagocytosis.
SI)+*II3H - Belps piopel the oiganism.
#$I3& - 0seu foi auheiing to a cell's suiface anu foims an attachment between two backteiia foi sex.
#I)&H$K& - Contain genes foi enzymes, toxins, anu foi the uevelopment of antibotic iesistance.
+IL%"%)ILJ - Belps meuiate auheience to suifaces.

4S8

!1* +,)H .*+)!$/* 9,*)aK"0.

4S9

+,)H .*+)!$/* %*II 0)II &!,3%!3,*

jj 3>;C:@ 86 8B@ ?74F fO@ M4A8@7;4Y 8B@ @>=686V;> A6>84;>D <;5656<GD4AAB47;=@ 8B48 ;>=:A@D !.S 4>= $IZ[`

1$+1ZL$*IK +,)H &!)$. ,*&3I!&
+,)H &!)$. ,*&3I!& ",+).$&H
,@= A6<67@= +74F fO@
9<:@ A6<67@= +74F kO@
+74F k A6AA; ;> AB4;>D &87@586A6AA;
+74F k A6AA; ;> A<:D8@7D &845BG<6A6AA:D
+74F k A6AA; ;> 54;7D c4R4 =;5<6A6AA;d &87@586A6AA:D #>@:F6>;4
+74F f ,6=D c4R4 A6AA6M4A;<<;d 1@F65B;<:D &5@A;@D
+74F f K;5<6A6AA; .@;DD@7;4 &5@A;@D
+74F f ,6=D T;8B F:A6;= A45D:<@ a<@MD;@<<4 &5@A;@D
&567@ E67F;>? +74F k ,6=D 94A;<<:D D5@A;@D 4>= %<6D87;=;:F
&5@A;@D
#7@D@>A@ 6E 5D@:=6BG5B4@ %4>=;=4 &5@A;@D
)A;= S4D8 &84;> HGA6M4A8@7;:F 4>= .6A47=;4 &5@A;@D
&;<O@7 &84;>;>? #>@:F6AGD8;D %47;>;;
$>=;4 $>R c56D;8;O@d %7G586A6AA:D .@6E67F4>D
+74F k T;8B 57@D@>A@ 6E D:<E:7 )A8;>6FGA@D &5@A;@D
46u

?74>:<@D
&5;76AB@8@D !7@56>@F4Y I@586D5;74Y 4>= 9677@<;4
&5@A;@D

!1* %)3&*& "S S""K #"$&".$.+
A*8%$,0W #+%$%+ 8$.$0W "$'+11$/85 ! S. Auieus (fast onset, fast alleviation)
95&5$%50 ,/35 ! Bacillus Ceieus
95&5$%50 "5$% ! Clostiiuium Peifiingens
)5$:++0 ! vibiio Paiahemolyticus
C"#,+#5,.' 3$1150 :++08 ! Clostiiuium Botulinum (watch foi bulging can tops)
^105,3++Q50 "5$% ! E. Coli u1S7:B7
9$U 5>>8 ! Salmonella
H+*.%,' ! Salmonella

*J"!"J$.&
Exotoxins cause uamage to the host by uestioying cells oi uisiupting theii cellulai metabolism. They may eithei be
secieteu oi ieleaseu uuiing cell lysis. Nost often they can be uestioyeu by heat.
Exotoxins aie seen in both giam +ve anu giam -ve oiganisms.

O9?K P!O?JC-! NÔ) BCJM !`4J4`CP)
N+,05%5..$ H5,%*88/8 ! stimulates AC by ABP iibosylation.
!Z A+./ ! is heat-labile, stimulates AC by ABP iibosylation of u piotein, causes wateiy uiaiihea.
-/I,/+ A&+.5,$ ! stimulates AC by ABP iibosylation of u piotein, incieasing the amount of chloiiue anu watei in
the gut, causing high-volume iice-watei uiaiihea.

461

O9?K H4)CJC-! NÔ) BCJM !`4J4`CP)
)%$#& ?*,5*8 ! A supeiantigen that binus NBC II piotein anu T-cell ieceptoi, inuuces IL-1 anu IL-2 synthesis in
toxic shock synuiome. Can also cause foou poisoning.
)%,5# H'+>5158 ! Eiythiogenic toxin (supeiantigen) causes iash anu scailet fevei, while stieptolysin 0
(hemolysin) causes iheumatic fevei.
A+,1'I$3%5,/*" ;/#&%&5,/$ ! Causes inactivation of EF-2 by ABP iibosylation, causing phaiyngitis anu a
pseuuomembiane in the thioat.
A.+8%,/0/*" N+%*./1*" ! Blocks ACh ielease, causes seveie anticholineigic symptoms anu CNS paialysis.
A.+8%,/0/*" J5%$1/ ! Blocks glycine, leaus to lockjaw.
A.+8%,/0/*" H5,:,/1>518 ! Lecithinase (#-toxin), causes gas gangiene.

*.K"!"J$.&
Enuotoxins aie lipopolysacchaiiues that aie founu in the cell walls of giam negative bacteiia. Enuotoxins cause a
wiue iange of pioblems thiough the activation of maciophages anu the complement pathway.
K$3,+#&$>5 $3%/D$%/+1 .5$08 %+G
- Bypotension thiough nitiic oxiue
- Fevei thiough IL-1 activation
- Bemoiihagic tissue neciosis thiough tumoi neciosis factoi
J&5 3+"#.5"51% #$%&U$' .5$08 %+G
- Bypotension anu euema thiough CSa activation
- Causes PNN chemotaxis thiough CSa activation
ff ;CA 3$1 I5 3$*850 U&51 %&5 510+%+T/18 $3%/D$%58 %&5 M$>5"$1 :$3%+,Z

462

!L#*& "S &!)$.&
Theie aie a few uiffeient stains that aie useu in oiuei to isolate ceitain bacteiia, they incluue:
)/.D5, )%$/1 ! Pneumocystic Caiinii Pneumonia, Fungi
A+1>+ 950 )%$/1 ! Amyloiu
O/5"8$ )%$/1 ! Chlamyuia, Boiielia, Plasmouium
H?) ! Whipple's uisease
g/5&.6P55.851 ! Aciu-fast bacteiia's
C10/$ C1Q ! Ciyptococcus Neofoimans

%".X3+)!$".Y !,).&K3%!$".Y !,).&S",H)!$".
PR0CEB0RE PR0CESS CELL TYPES TYPE 0F BNA
TRANSFERREB
Conjugation Tiansfei of BNA
fiom bacteiia to
bacteiia
Piokaiyotes Chiomosomal oi
plasmiu
Tiansuuction Tiansfei fiom
viius to anothei
cell
Piokaiyotes All types
Tiansfoimation Puiifieu BNA is
taken up by a cell
Both piokaiyotes
anu eukaiyotes
All types

&#*%$S$% ,*23$,*H*.!&
Some bugs iequiie ceitain enviionments in oiuei to suivive, they fall unuei the following:
"9I$+)!* )*,"9*&U).)*,"9*&Y ).K $.!,)%*II3I),

4I./>$%5 ?5,+I58: iequiie u2 to cieate ATP. Incluues:
- Nocaiuia
- Pseuuomonas Aeiuginosa
- Nycobacteiium TB
- Bacillus
46S

4I./>$%5 ?1$5,+I58: aie susceptible to oxiuative uamage uue to theii lack of S0B anu catalase. Incluues:
- Actinomyces
- Clostiiuium
- Bacteioiues
C1%,$35..*.$,: these bugs must iemain insiue the cell in oiuei to suivive, incluue:
JC3/-,'"% - Rickettsia anu Chlamyuia
E,+83','/5" - Salmonella, Biucella, Nycobacteiium, Listeiia, Fiancisella, Legionella, Yeisinia

$H#",!).! $.S" )9"3! &!)#1 )3,*3&
Staph auieus is a veiy common oiganism both in the boaiu exams anu in clinical piactice. Staph auieus causes theii
uestiuction baseu on the following two methous:
1. !6V;>ZH@=;48@= - Incluues toxic-shock synuiome, scalueu skin synuiome, anu iapiu-onset foou poisoning.
2. $>E<4FF4867G - Incluues infections of the skin, abscesses, anu pneumonias.

J+T/36)&+3Q )'10,+"5 - A supeiantigen binus to NBC II anu T-cell ieceptois, which causes polyclonal T-cell
activation.
2++0 #+/8+1/1> fiom staph auieus is causeu by the ingestion of a piefoimeu toxin.
** Staph Auieus contains a viiulence factois (known as Piotein A), that binus to the Fc poition of Igu. This inhibits
complement fixation anu inhibits phagocytosis.

464

*.%)#&3I)!*K 9)%!*,$)
Some bacteiia have a polysacchaiiue capsule that acts as an anti-phagocytic factoi. This makes them less
susceptible to being engulfeu by phagocytes. These bugs aie:
- Stiep Pneumonia
- B. Influenza
- N. Neningitiuis
- Klebsiella Pneumonia

!1* *J"!"J$.& "S %I"&!,$K$) &#*%$*&
AZ ;/::/3/.5 ! piouuces a cytotoxin (exotoxin) that kills eiythiocytes, anu thus causes a pseuuomembianous colitis.
** 0ften occuis seconuaiy to antibiotic use.
AZ J5%$1/ ! piouuces an exotoxin that iesults in tetanus.
AZ H5,:,/1>518 ! piouuces an #-toxin that causes myoneciosis, gas gangiene, oi hemolysis.
AZ N+%*./1*" ! a piefoimeu, heat-labile toxin is piouuceu that inhibits the ielease of ACh, which causes botulism.

$H#",!).! $.S" )9"3! &!,*# #L"+*.*&
Stiep Pyogenes is a gioup A !-hemolytic stiep that can cause the following uiseases:
1. $FF:>6<6?;A - Acute glomeiulonephiitis anu Rheumatic fevei
2. #G6?@>;A - Phaiyngitis, Cellulitis, anu Impetigo
S. !6V;?@>;A - Toxic shock synuiome anu Scailett fevei

K$#1!1*,$)
Biphtheiia can cause #85*0+"5"I,$1+*8 #&$,'1>/%/8 thiough an 5T+%+T/1. Theii exotoxin woiks by /1&/I/%/1>
#,+%5/1 8'1%&58/8 D/$ ?;H ,/I+8'.$%/+1 +: !26LZ

46S

93+& %)3&$.+ 9I""KL K$),,1*)
- E. Coli u1S7:B7
- Entamoeba histolytica
- Campylobactei jejuni
- Salmonella
- Shigella
- Yeisinia enteiocolitica
93+& %)3&$.+ 0)!*,L K$),,1*)
- Enteiotoxigenic E. Coli
- vibiio (iice-watei stools, highly voluminous)
- Rotaviius
- uiaiuia (foul-smelling)
- Ciyptospoiiuium

$H#",!).! S)%!& )9"3! 1` #LI",$
- B. Pyloii is the cause of most uuouenal ulceis (up to 9u%)
- Is a giam -ve iou that cieates an alkaline enviionment
- Can inciease the iisk of P0B anu gastiic caicinomas
!7@48F@>8: Tiiple theiapy: 0mepiazole, claiithiomycin, amoxicillin.

#&*3K"H".)& )*,3+$."&)
Pseuuomonas aeiuginosa piouuces both an exotoxin anu an enuotoxin. Its most populai chaiacteiistic is that it
piouuces a fiuity-smelling blue-gieen pigment (uue to pyocyanin).
HZ ?5,*>/1+8$ 3$*858 %&5 :+..+U/1>G
- Pneumonia in cystic fibiosis patient
- 0titis Exteina (swimmei's eai)
- Folliculitis (known as "hot-tub" folliculitis)
- Sepsis (black lesions of the skin)
466

93+& !1)! )%! ". !1* l+Z#,"!*$.m
Two bugs that piouuce theii effects by acting on the us anu ui pioteins aie vibiio Choleia anu Boiuetella Peitussis.
-/I,/+ A&+.5,$ causes a iice-watei uiaiihea by peimanently activating the us piotein.
N+,05%5..$ H5,%*88/8 causes whooping cough by peimanently uisabling the ui piotein.
** Common to both bugs is the activation of auenylyl cyclase (AC) thiough ABP iibosylation.

%)3&*& "S /)+$."&$&
Tiichomonas, uaiuneiella, anu Canuiua
J,/3&+"+1$8 - causeu by an anaeiobic, motile piotozoan. Shifts vaginal pB to S-6, anu uispels a gieenish-yellow
fiothy vaginal uischaige.
O$,015,5..$ - a giam-vaiiable iou that causes a gieen vaginal uischaige that has a fishy smell, anu has the
pathognomonic "clue cells". pB is elevateu.
A$10/0$ - is a fungal infection that piesents with a cottage-cheese like uischaige that is sticky anu will stick to the
walls of the vagina.

93+& ,*I)!*K !" ).$H)I& c-""."!$%&d
Nany seiious uiseases aie causeu by bites fiom animals, ticks, etc. The most impoitant uiseases fiom animals
incluue:
1. IGF@ K;D@4D@ - causeu by Boiielia Buiguoifeii, which is tiansmitteu thiough the Ixoues tick bite, which is a
tick that lives on ueei anu mice. Classic piesentation is the bullseye taiget lesion.

2. %@<<:<;8;D - causeu by Pasteuiella Nulticoua, which occuis thiough uog oi cat bites.
S. !:<47@F;4 - causeu by Fiancisella Tulaiensis, fiom a tick bite, seen in iabbits anu ueei. This conuition is
also known as the "Pahvant valley Plague", "Rabbit fevei", "Beei fly fevei", anu "0haia's fevei".

4. 97:A@<<6D;D - causeu by Biucella species, anu contamination occuis thiough infecteu uaiiy piouucts anu
contact with animals.

S. !B@ 5<4?:@ - causeu by Yeisinia pestis, tiansmitteu thiough a flea bite founu on iouents anu wilu uogs.

467

!39*,%3I"&$&
Tubeiculosis is an infection with mycobacteiium tubeiculosis, that affects the iespiiatoiy tiact most commonly,
howevei it can have extiapulmonaiy manifestations as well, namely in the :
- uI
- Kiuneys
- Lymph noues
- veitebial Bouies (Pott's uisease)
- Cential neivous system

)'"#%+"8 +: JN /1:53%/+1:
0sually, symptoms aie veiy non-specific, piesenting as:
- Fatigue anu weight loss
- Night sweats
- Cachexia

C: %&5 8'"#%+"8 I53+"5 "+,5 #*."+1$,'W 5T#53% %+ :/10G
- Byspnea
- Bemoptysis
- Chest pain (pleuiitic in natuie)
- Piouuctive cough

[ ;>E@A8;6> ! A piimaiy TB infection iefeis to the infectious piocess by which the bouy is able to contain the
infection anu pievent its uissemination. This iesults in the uhon complex, which is a calcifieu focus of infection
usually in the lowei segments of the lung.
\ ;>E@A8;6> ! Also known as "ieactivateu TB", this type of infection can occui to those who aie in a state of
weakeneu oi suppiesseu immunity.

B&51 %*I5,3*.+8/8 /8 8*8#53%50.
- A +ve PPB test waiiants a chest xiay looking foi the TB cavitaiy lesion
- Aciu fast stain looking foi the mycobacteiium

468

K$1$>5"51%[J,5$%"51%h
)A8;O@ !9 ! A 4-uiug iegimen (RIPE - Rifampin, Isoniaziu, Pyiazinamiue, anu Ethambutol). Bewaie of auveise
neuiological effects of Isoniaziu, supplement with vitamin B6 - pyiiuoxine.
I48@>8 !9 ! With latent TB, you will begin the patient on a 4-uiug iegimen lasting up to 9 months. If they piesent
at a futuie uate with latent TB, they will not neeu to be tieateu again. ** Latent TB = 1 time 4-uiug couise lasting
seveial months.

,$%a*!!&$)I $.S*%!$".& ).K /*%!",&
Rickettsial infections aie those infections that aie iesponsible foi causing Rocky Nountain Spotteu Fevei, Typhus,
anu Q fevei.
Rickettsial infections usually leau to a similai piesentation, which is:
- Fevei
- Beauache
- Rash
94Ad_ K4^PJ?CP )H4JJ!; 2!-!9
Causeu by Rickettsia Rickettsii, which causes a iash that staits on the palms anu soles anu moves inwaiu. Tieat
with tetiacycline.
!T6 E67FD 6E !G5B:DW 47@'
!P;!KCA J_HM^) - causeu by Rickettsia Typhi, which is a flea. Tieat with tetiacycline.
!HC;!KCA J_HM^) - causeu by Rickettsia Piowazekii, a bouy louse. Tieat with tetiacycline.
Anu finally,
< 2!-!9 - causeu by Coxiella Buinetti, which causeu infection via aeiosolizeu paiticles. Tieat with tetiacycline.

&#$,"%1*!*&
Spiiochetes aie "spiial-shapeu" bacteiial elements containing axial filaments. The most commonly testeu
spiiochete-ielateu infection is syphilis (tieponema). The othei two types of spiiochetes aie Boiielia anu
Leptospiia, which aie stainable with light micioscopy, wheieas tieponema is visualizeu only with uaik-fielu
micioscopy.
With that saiu, theie aie thiee foims of Syphilis:
Y 8'#&/./8 ! Patient will get a painless chancie, tieat with IN pen u
469

L 8'#&/./8 ! Patient has uisseminateu uisease + constitutional symptoms, incluues a maculopapulai iash on the
palms anu soles. Tieat with IN pen u
\ 8'#&/./8 ! Patient has neuiological pioblems (neuiosyphilis, Aigyll Robeitson pupil), aoitic uisoiueis (aoititis),
anu gummas. Tieat with Iv penicillin.

!*&!$.+ S", &L#1$I$&
-;9= $10 2J?6?N):
/K,I - this test is useu foi nonspecific antibouy uetection, howevei uue to its high iate of false-positives is not the
piimaiy test useu foi syphilis uetection. This test will be positive when theie aie a few othei uiseases piesent,
incluuing: SLE, RA, RF, anu a few othei viial infections like mononucleosis.
S!)Z)9& - is a test specific foi the tieponema bacteiia, anu has the best combination of benefits in finuing syphilis,
incluuing high specificity, veiy eaily positivity, anu iemains positive the longest.

47u

/$,"I"+L

K.) ).K ,.) /$,)I +*."H*&
All BNA viiuses aie uouble stianueu anu lineai, with the exception of paivoviius (is single-stianueu), anu
hepaunaviiuspapovaviius (ciiculai). All RNA viiuses aie single-stianueu, except the ieoviius (uouble stianueu).
;P? /8 0+*I.5W 9P? /8 8/1>.5.

1"0 K" /$,3&*& ,*#,"K3%*
953+"I/1$%/+1 ! is the exchange of genetic mateiial between 2 chiomosomes by cioss-ovei of ceitain iegions that
have impoitant base sequence homology.
95$88+,%"51% ! is the exchange of viial segments (fiom segmenteu viial genomes). This occuis at high fiequency
anu is iesponsible foi woiluwiue illnesses (panuemics).
A+"#.5"51%$%/+1 ! occuis when one functional viius helps anothei non-functional viius become functional.
H&51+%'#/3 K/T/1> ! occuis when a ceitain viius has the suiface coating fiom anothei viius' piotein, which will
then ueteimine the infectivity of this viius paiticle.

/$,)I #I"$KL
Retioviiuses contain 2 iuentical single-stianueu RNA molecules, making them "0/#.+/0", while all othei viiuses
contain a single copy of both BNA anu RNA, making them "&$#.+/0".
K.) /;7:D@D ! all ieplicate in the nucleus, except foi the poxviius.
,.) /;7:D@D ! all ieplicate in the cytoplasm, except foi ietioviiuses anu the influenza viius.

471

!1* $H#",!).! %1),)%!*,$&!$%& "S /$,)I K.)
The following aie impoitant chaiacteiistics that fit foi almost all of the BNA viiuses:
.:A<@47 7@5<;A48;6> ! all BNA viiuses ieplicate in the nucleus except foi the Poxviius, which has its own BNA-
uepenuent RNA polymeiase.
)7@ <;>@47 ! all BNA viiuses aie lineai, except foi the Papovaviius anu the Bepauna viius. Papovaviius is
ciiculaisupeicoileu, anu the Bepauna viius is ciiculaiincomplete.
)7@ =6:M<@ D874>=@= c=DK.)d ! all BNA viiuses aie uouble-stianueu except foi the Paivoviius, which is single-
stianueu (ssBNA).
)7@ ;A6D4B@=74< ;> DB45@ ! all BNA viiuses aie icosaheuial except foi the Poxviius, which is complete in capsiu
shape.

+*.*!$% &1$S! OD` +*.*!$% K,$S!
O515%/3 )&/:% ! Is the piocess by which theie is a ie-assoitment of uiffeient viial stiains, which combine to foim
new foimssubtypes that contain a mixtuie of the suiface antigens of the stiains involveu. uenetic shift is veiy
impoitant because it cieates new viial pathogens, anu is iesponsible foi the emeigence of new viiuses.
O515%/3 ;,/:% ! Is a piocess of natuial mutations ovei a peiiou of time. This leaus to loss of immunity anu the
inability of vaccines to cuie illnesses.

472

!1* K.) /$,3&*&
The list of BNA viiuses:
1. 1epaunaviius
2. 1eipesviius
S. )uenoviius
4. #aivoviius
S. #apovaviius
6. #oxviius
Remembei this list with the mnemonic: 11)###y

JM! AM?9?AJ!9C)JCA) 42 !?AM ;P? -C9^)
[` 1@54=>4O;7:D - usBNA paitial ciiculai, envelopeu.
;/85$858 ! Bepatitis B viius

\` 1@75@DO;7:D - usBNA lineai, envelopeu.
;/85$858 ! Buman Beipes viius 6 & 8, Beipes Simplex 1 & 2, vaiicella Zostei, Ebstein-Baii viius, anu
Cytomegaloviius
BBv 6 - Reseola
BBv 8 - Kaposi's saicoma
BSv 1 - Thought to be oial ulceis, but now can be fiom both oial anu genital ulceis
BSv 2 - Thought to be genital ulceis, but now can be fiom both oial anu genital ulceis
vZv - Responsible foi chickenpox (not seen anymoie uue to vaccination), shingles
EBv - Causes mononucleosis anu Buikitt's lymphoma
CNv - Congenital infections

]` )=@>6O;7:D - usBNA lineai, has no envelope.
;/85$858 ! Conjunctivitis, Pneumonias, Phaiyngitis

^` #47O6O;7:D - ssBNA lineai (is the smallest BNA), has no envelope
47S

;/85$858 ! Paivo B19 (slappeu cheek synuiome)

_` #456O4O;7:D - usBNA ciiculai, has no envelope
;/85$858 ! Buman Papilloma viius, Piogiessive Nultifocal Leukoencephalopathy

h` #6VO;7:D - usBNA lineai (is the laigest of all BNA viiuses), has an envelope
;/85$858 ! Cowpox, Smallpox, Nolluscum Contagiosum

JM! AM?9?AJ!9C)JCA) 42 !?AM 9P? -C9^)
1. #;A67>4O;7:D - (+)ssRNA, lineai, icosaheuial, no envelope.
958#+18/I.5 :+,:
- Bepatitis A
- Coxsackieviius
- Polioviius
- Echoviius
- Rhinoviius

2. %4<;A;O;7:D - (+)ssRNA, lineai, icosaheuial, no envelope.
958#+18/I.5 :+,:
- Noiwalk viius (gastioenteiitis)
- Bepatitis E

S. ,@6O;7:D - usRNA, lineai segmenteu, uouble icosaheuial, no envelope.
958#+18/I.5 :+,:
- Reoviius (Coloiauo tick fevei)
- Rotaviius (NCC of uiaiihea in chiluien)

4. S<4O;O;7:D - (+)ssRNA, lineai, icosaheuial, envelopeu.
474

958#+18/I.5 :+,:
- Bengue fevei
- Yellow fevei
- Bepatitis C
- St. Louis encephalitis
- West Nile viius

S. !6?4O;7:D - (+)ssRNA, lineai, icosaheuial, envelopeu.
958#+18/I.5 :+,:
- Rubella
- EasteinWestein equine encephalitis

6. ,@876O;7:D - (+)ssRNA, lineai, icosaheuial, envelopeu.
958#+18/I.5 :+,:
- BIvAIBS
- Baiiy T-cell leukemia

7. "78B6FGV6O;7:D - (-)ssRNA, lineaisegmenteu, helical, envelopeu.
958#+18/I.5 :+,:
- Influenza

8. #474FGV6O;7:D - (-)ssRNA, lineainon-segmenteu, helical, envelopeu.
958#+18/I.5 :+,:
- Neasles
- Numps
- Respiiatoiy Syncitial viius (RSv)
- Paiainfluenza

9. ,B4M=6O;7:D - (-)ssRNA, lineai, helical, envelopeu.
47S

958#+18/I.5 :+,:
- Rabies

1u. S;<6O;7:D - (-)ssRNA, lineai, helical, envelopeu.
958#+18/I.5 :+,:
- Bemoiihagic feveis (Ebola viius)

11. %676>4O;7:D - (+)ssRNA, lineai, helical, envelopeu.
958#+18/I.5 :+,:
- Coionaviius

12. )7@>4O;7:D - (-)ssRNA, ciiculai, helical, envelopeu.
958#+18/I.5 :+,:
- Neningitis
- Lymphocytic choiiomeningitis

1S. 9:>G4O;7:D - (-)ssRNA, ciiculai, helical, envelopeu.
958#+18/I.5 :+,:
- Sanufly fevei
- Riftvalley fevei
- Ciimean-Congo hemoiihagic fevei
- Bantaviius
- Califoinia Encephalitis

14. K@<84O;7:D - (-)ssRNA, ciiculai, helical, envelopeu.
958#+18/I.5 :+,: Bepatitis B

476

I$/*Z)!!*.3)!*K OD` a$II*K /)%%$.*&
I;O@Z)88@>:48@= /4AA;>@D ! these types of vaccines inuuce both humoial anu cell-meuiateu immunity.
a;<<@= /4AA;>@D ! these types of vaccines inuuce humoial immunity only.

!T$"#.58 +: =/D56?%%51*$%50 -$33/158:
- Neasles
- Numps
- Rubella
- Smallpox
- Polio (Sabin)
- vZv
- Yellow Fevei
** Remembei theie is uangei in giving a live-attenuateu vaccine to someone who is immunocompiomiseu.

!T$"#.58 +: d/..50 -$33/158:
- Rabies
- Influenza
- Polio (Salk)
- Bepatitis A

477

&3#*, 1$+1ZL$*IK H$%,"9$"I"+L $.S",H)!$".

1*,#,*& /$,3&*&
Theie aie quite a few uiffeient foims of "heipes viiuses", they aie all high-yielu 0SNLE infoimation. The most
common heipes viiuses anu theii common finuings incluue:
1&/Z[ - this is known to be iesponsible foi the oial lesions of heipes, howevei uue to uiffeient sexual piactices, it
may be seen in the genital iegion as well. BSv-1 is also a cause of keiatoconjunctivitis anu tempoial lobe
encephalitis (BSv is the most common cause of auult onset alteieu mental status).
BSv-1 is tiansmitteu via iespiiatoiy secietions anuoi saliva. 2+, M)- 0/$>1+8/8W *85 %&5 JR$13Q %58% (smeai the
open vesicle, looking foi multinucleateu giant cells).

1&/Z\ - BSv-2 is most commonly seen as heipes of the genitals (heipes labialis), as well as neonatal heipes.
BSv-2 is tiansmitteu via peiinatal tiansmission as well as thiough sexual contact.

*9/ - causes Buikitt's lymphoma anu infectious mononucleosis (causes seveie fatigue, soie thioat, usually in
teenageis). Tiansmitteu thiough saliva anu iespiiatoiy secietions.

%H/ - Causes congenital infections as well as some types of pneumonia. Tiansmitteu congenitally, thiough sexual
contact, thiough saliva, anu thiough tiansfusion.
11/ - Buman Beipes viius, is the cause of Kaposi's saicoma in AIBS patients. Tiansmission is sexually.

478

H".".3%I*"&$&
Nononucleosis is always encounteieu on the 0SNLE exams, thus be suie to know as much as possible about this
conuition.
H,5851%$%/+1:
- Young auult (16-2uyi)
- Fevei
- Bepatosplenomegaly
- Phaiyngitis
- Lymphauenopathy
A$*85:
- Ebstein-Baii viius (EBv)
- "kissing uisease", because it is easily tiansmitteu thiough saliva
- Theie aie abnoimal ciiculating cytotoxic T cells
;/$>1+8/8:
The best uiagnostic test is the "Nonospot test", which uetects heteiophil antibouies thiough sheep RBC
agglutination.
B&$% %+ %5.. %&5 #$%/51%:
- The most impoitant thing foi patient safety is to ?-4C; A4PJ?AJ )H49J), because the spleen is enlaigeu
anu if it expeiiences blunt tiauma, it may iuptuie anu cause seveie auveise effects such as hypotension,
shock, anu sepsis.

479

1$/U)$K&
A ietioviius, the BIv uisease uses the ieveise tiansciiptase enzyme to ieplicate. BIv infection can be tiansmitteu
thiough sexual contactfluius, bloou, anu bieast milk. The helpei T-cells (CB4+ T cells), maciophages, anu uenuiitic
cells aie affecteu.
;C?OP4)CPO MC-:
Biagnosis of BIv is maue with the ELISA test because of its high sensitivity. When a test is positive, a Westein Blot
is peifoimeu, which is veiy specific.
Aftei confiimation, a viial loau can be uone to measuie the quantity of the viius in the bloou, which allows you to
measuie the effect of meuical tieatment.
** False negatives with the ELISA test anu the Westein Blot aie common in the fiist few months of BIv infection.

CKK^PCJ_ J4 MC-G
Ceitain mutations in oui genes can give us immunity to BIv, can give us paitial immunity to BIv, anu can even cause
us to ueteiioiate iapiuly fiom an BIv infection. The mutations iesponsible foi this incluue:
K*%$%/+1 3$*8/1> /""*1/%' ! CCRS mutation (homozygous)
K*%$%/+1 3$*8/1> #$,%/$. /""*1/%' ! CCRS mutation (heteiozygous)
K*%$%/+1 3$*8/1> ,$#/0 #,+>,588/+1[05%5,/+,$%/+1 ! CXCR1 mutation

?C;) X 4HH49J^PC)JCA CP2!AJC4P)G
The most commonly encounteieu oppoitunistic infection aie:
S3.+)I - Canuiua (thiush), Ciyptococcal Neningitis (Ciyptococcus), Pneumocystis Pneumonia (PCP, when
CB4<2uu), Bistoplasmosis.
/$,)I - PNL (causeu by }C viius), BSv, vZv, CNv
9)%!*,$)I - TB, Nycobacteiium Avium-Intiacellulai complex (NAC)
#,"!"-") - Ciyptospoiiuium, Toxoplasmosis

48u

J9!?JK!PJ:
Tieatment involves the use of antiietioviial meuications, given to symptomatic patients iegaiuless of theii CB4
counts anuoi to asymptomatic patients with CB4 counts <Suu.
Tiiple-uiug iegimens (2 nucleosiue ieveise tiansciiptase inhibitois anu eithei: 1 non-nucleosiue ieveise
tiansciiptase inhibitoi 0R 1 piotease inhibitoi) aie useu, these aie known as BAART, which taiget anu pievent BIv
ieplication at thiee uiffeient points along the viius' ieplication piocess.

4JM!9 K?PC2!)J?JC4P) 42 MC- CP2!AJC4P:
Pulmonaiy: Community-acquiieu pneumonia, PCP, TB, CNv, NAC, Bistoplasmosis.
CNS: Toxoplasmosis, AIBS-uementia, Ciyptococcal Neningitis, Lymphoma, BSv, Neuiosyphilis, PNL
uI: Biaiihea, 0ial lesions (thiush, ulceiations, oial haiiy leukoplakia), Canuiua esophagitis, Pioctitis
Beimatological: BSv, Shingles, Nolluscum Contagiosum, Kaposi's saicoma

481

1*#)!$!$&
Is inflammation of the livei, chaiacteiizeu by the piesence of inflammation of the tissue of the livei. Theie is a wiue
iange of ioutes of infection, theie is a wiue iange of symptoms anu piognosis, which can iange fiom self-limiteu
uiseases to ciiihosis anu ueath.
J&5,5 $,5 2C-! 3+""+1 :+,"8 +: &5#$%/%/8W %&5' $,5G
Bepatitis A, B, C, B, anu E

1@548;8;D ) c1)/d - Is usually asymptomatic, is tiansmitteu via fecal-oial ioute. 0sually a veiy shoit incubation
peiiou (~ S weeks). Is a RNA picoinaviius.
1@548;8;D 9 c19/d - 0ften piesents with milu symptoms such as: loss of appetite Nv, myalgias, fevei, anu
jaunuice. Bep B is usually self-limiteu, but can piogiess anu cause ciiihosis, hepatic failuie, anu ueath.
Tiansmission is usually sexual, thiough shaiing uiity neeules (paienteial), anu fiom the mothei to fetus (veitical
tiansmission). Is a BNA hepaunaviius.
1@548;8;D % c1%/d - Bepatitis C usually caiiies the same symptoms as uoes hepatitis B, anu is tiansmitteu thiough
bloou piouucts (sex, uiity neeules). Bepatitis C is often a chionic illness that leaus to caicinoma anuoi ciiihosis.
People infecteu will usually become caiiieis of hep C. Is an RNA flaviviius.
1@548;8;D K c1K/d - Alone, hepatitis B cannot infect, anu iequiies a co-infection with hepatitis B in oiuei to infect
(iequiies BBsAg as its envelope). Is a ueltaviius.
1@548;8;D * c1*/d - Bas a fecal-oial tiansmission ioute, anu has the tenuency to cause watei-boine epiuemics.
veiy similai symptomatically to hepatitis A. BEv can cause significant illness anu even ueath in piegnant women.
Is an RNA caliciviius.
** M5# N $10 A ! chionic, cause ciiihosis, anu hepatocellulai caicinoma.
** M5# ? $10 ! ! affect the uI tiact.

482

1*#)!$!$& &*,"I"+L
The hepatitis seiology is veiy high-yielu foi the Step 1, memoiize all of this infoimation.
BBsAg ! Is the antigen founu on the suiface of BBv, when it is piesent, theie is a caiiiei state.
BBsAb ! Is the antibouy to BBsAg, its piesence inuicates immunity to Bep B
BBcAg ! Is the antigen associateu with the BBv coie
BBcAb ! Is the antibouy to BBcAg, anu when piesent inuicates the "winuow peiiou" of infection. When theie is an
IgN BBcAb, theie has been a iecent infection.
BBeAg ! This is an inuicatoi of hep B tiansmittability, anu is the 2
nu
ueteiminant of the hepatitis B coie.
BBeAb ! Is the hepatitis E antigen, inuicating low tiansmittability of the uisease.

!1* 1*#)!$!$& /$,)I #),!$%I*

48S

) +,)#1$%)I I""a )! ) 1*#)!$!$& $.S*%!$".

#.*3H".$) f %"HH". %)3&*& #*, )+* +,"3#
35 86 [iG7 6<= ! #1 - RSv #2 - Nycoplasma #S - Chlamyuia #4 - Stiep
[iZ^nG7 6<= ! #1 - Stiep
** )8G5;A4<UT4<R;>? 5>@:F6>;4 ! Nycoplasma
^nZh_G7 6<= ! #1 - Stiep #2 - B. Influenza
ohnG7 6<= ! #1 Stiep #2 - viial etiologies

#.*3H".$) f &#*%$)I &$!3)!$".&
484

$> 4> 4<A6B6<;A ! Stiep Pneumonia is the NCC, howevei Klebsiella is moie likely in an alcoholic (be caieful with
this question, because you may be askeu what the most common cause of pneumonia is in an alcoholic, which is still
Stieptococcus)
16D5;84<Z4AC:;7@= ! Staph
$> 4> ;FF:>6A6F576F;D@= 5@7D6> ! Staph is most common cause, but watch foi an BIv patient who can get
PCP pneumonia when CB4 count is low.
)D5;748;6> ! Anaeiobic oial floia
.@6>484< ! 0p to the fiist 6 weeks of life - uioup B stiep anu E. Coli

%"HH". ",+).$&H& $. 3,$.),L !,)%! $.S*%!$".&
The most common cause of uiinaiy tiact infections is E. Coli. The most common symptoms aie painful uiination,
fiequency, uigency, anu supiapubic pain. This can ascenu anu become a seveie infection such as pyelonephiitis.
Nost common in women because they have a shoit uistance fiom the outsiue of the uiethia to the blauuei.
Tieatment involves using TNP-SNP (Bactiim)

H*.$.+$!$&
Is a life-thieatening infection of the meninges. Patient piesents most commonly with
nuchal iigiuity, high fevei, anu alteieu mental status. The most common causes pei age
gioup aie the following:
In newboins up to 6 months ! E. Coli
In chiluien 6 months - 6 yis ! Stiep Pneumonia
In people 6yi - 6uyis ! Neisseiia Neningitiuis
In people > 6uyi ! Stiep Pneumonia

!@D8 1;>8'
The 0SNLE will
give you a
scenaiio wheie
someone is in
close contact with
otheis
(uoimitoiy, aimy,
etc), this is almost
always leauing
you to meningitis.
48S

) I$&! "S !1* H"&! %"HH".IL !*&!*K &!KW&
+6>677B@4 ! piesents with uiethiitis, ceivicitis, epiuiuymitis (men). Can cause pelvic inflammatoiy uisease
(common cause of infeitility). Causeu by N. uonoiihea, tieat with ceftiiaxone.
%B<4FG=;4 ! piesents similaily to gonoiihea. When this is founu, theie is usually a co-infection with gonoiihea.
Causeu by Chlamyuia Tiachomatis.
1@75@D ! H?CP2^= ulcei of the penis, vulva, anu ceivix
&G5B;<;D ! H?CP=!)) chancie (seen in 1 foim), systemic finuings in 2 foim, anu neuiological finuings in the S
foim.
IGF5B6?74>:<6F4 /@>@7@:F ! H?CP=!)) ulcei at the beginning, with infection spieauing along the inguinal
pathway. Causeu by Chlamyuia Tiachomatis types L1-LS.
/4?;>;8;D ! vaginal itching, pain, anu uischaige. Nay be uue to gaiuneiella, tiichomonas, oi canuiua.
%B4>A76;= ! H?CP2^= genital ulceis, causeu by Baemophilus Bucieyi
%6>=G<6F4 )A:F;>484 ! Causes genital waits that can be on the labia, in the vagina, anu on the ceivix. Causeu by
BPv types 6 anu 11.

#*I/$% $.SI)HH)!",L K$&*)&*
Is a scaiiing of the fallopian tubes, anu is a veiy common cause of infeitility in women. Theie is often symptoms
such as ceivical motion tenueiness, vaginal uischaige, anu even tubo-ovaiian abscess.
K+8% 3+""+1 3$*85 /8 A&.$"'0/$ $10 O+1+,,&5$.

486

!1* !",%1 $.S*%!$".&
"T0RCB" is the mnemonic useu to iecall the most commonly encounteieu congenital infections, they aie:
! - Toxoplasmosis
" - stanus foi "othei", which is Syphilis
, - Rubella
% - CNv
1 - BSv anu BIv

"&!*"HL*I$!$&
0steomyelitis is an infection of the bone, which can be causeu by a numbei of uiffeient oiganisms, they incluue:
&845BG<6A6AA:D ):7@:D ! Is the most common cause oveiall
&4<F6>@<<4 ! Causes osteomyelitis in sickle cell patients
+6>677B@4 ! Can cause osteomyelitis in sexually active people (is a less common cause)
#D@:=6F6>4D )@7:?;>6D4 ! Common cause in intiavenous uiug useis
&845B *5;=@7F;=;D ! Common cause of osteomyelitis in those with piosthetic uevices.

487

#),)&$!"I"+L

Stuuying the 'paiasitology' section foi the 0SNLE exam is simple anu stiaightfoiwaiu, simply memoiize all
oiganisms anu theii piesentations, theii moue of tiansmission, how the uiagnosis is maue, anu finally the best
tieatment foi each.
#),)&$!* K$&*)&*U&LH#!"H& H"K* "S
!,).&H$&&$".
K$)+."&$.+ !,*)!H*.!
#<4DF6=;:F c/;O4VY
"O4<@Y H4<47;4@Y
S4<A;547:Fd
NALARIA, causes a cyclic
fevei + heauache,
splenomegaly, anu anemia
Anopheles mosquito

Bloou smeai Chloioquine,
Sulfauoxine,
Pyiimethamine,
quinine,
Nefloquine
*>84F6@M4 1;D86<G8;AD Bystenteiy, bloouy uiaiihea,
livei abscess, anu iight uppei
quauiant pain
Cysts founu in B2u Cysts in stool Netioniuazole +
Iouoquinol
+;47=;4 I4FM<;4 Foul-smelling uiaiihea,
flatulence, anu bloating
Cysts in B2u Cysts in stool Netioniuazole
%7G586D567;=;:F Seveie uiaiihea founu in AIBS
patients, milu uiaiihea in
healthy patients
Cysts founu in B2u Cysts seen on
aciu-fast stain
No tieatment
!6V65<4DF4 Biith uefects anu biain
abscesses (BIv patients)
Cysts founu in cat
feces anuoi meat
Seiology anu
biopsy
Pyiimethamine
anu sulfauiazine
!7;AB6F6>4D Foul-smelling uischaige,
gieen in coloi fiom the vagina
Sexual Tiophozoites seen
on wet mount
Netioniuazole
.4@?<@7;4 Causes a ueauly
meningoencephalitis
Caught by swimming
in fieshwatei lakes
Spinal fluiu shows
amoeba
No tieatment
!7G54>6D6F4 %7:Q; Causes Chaga's heait uisease Tiansmitteu via the
ieuuviiu bug
Seen on bloou
smeai
Nifuitimox
!7G54>6D6F4
+4FM;@>D@
Causes Afiican sleeping
sickness
Tiansmitteu thiough
the Tsetse fly
Seen on bloou
smeai
Suiamin oi
Nelaisopiol
94M@D;4 Causes babesiosis, which is a
uisease similai to malaiia
Tiansmitteu thiough
the Ixoues tick
"Naltese cioss"
seen on bloou
smeai
Quinine anu
Clinuamycin
I@;DBF4>;4 K6>6O4>; Causes visceial Leishmaniasis Tiansmitteu via the
sanufly
Smeai showing
maciocytes that
contain
amastigotes
Souium
stibogluconate

488

1*IH$.!1& c067FDd

}ust as with paiasites, memoiizing all of the uiffeient helminthes as well as theii piesentation, tiansmission, anu
tieatment is high-yielu as well as easy points on the 0SNLE exam.
1*IH$.!1 !,).&H$&&$". #,*&*.!)!$". !,*)!H*.!

!)#*0",H&

*AB;>6A6AA:D Fiom eggs within
uog feces
Cysts in livei cause
anaphylaxis if
antigens aie
ieleaseu fiom the
cyst
Albenuazole
!4@>;4 &6<;:F 0nueicookeu poik Nass lesion in the
biain causeu by
laivae
Albenuazole

SI3a*&

&AB;D86D6F4 Snails Spleen anu livei
aie affecteu, get
gianuloma,
fibiosis, anu
inflammation
Piizaquintel
#474?6>;F:D
0@D8@7F4>;
Fiom unueicookeu
ciab meat
Bacteiial infection
anu thus
inflammation of
the lungs
Piizaquintel
%<6>67AB;D
&;>@>D;D
Fiom unueicookeu
fish
Biliaiy tiact
inflammation
Piizaquintel

,"3.K0",H&

I64 I64 Fiom ueei fly Inflammation anu
swelling of skin,
can see this woim
in the conjunctiva
Biethylcaibamazine
)>AG<6D86F4
K:6=@>4<@
cB66RT67Fd
Laival penetiation
of skin
Anemia is causeu
by intestinal
infection
Nebenuazole anu
pyiantel pamoate
)DA47;D Eggs in feces Intestinal infection Nebenuazole anu
489

I:FM7;A6;=@D
c+;4>8
76:>=T67Fd
pyiantel pamoate
*>8@76M;:D
/@7F;A:<47;D
c#;>T67Fd
Infecteu foou (with
eggs)
Intestinal infection,
also get anal
itching
Nebenuazole anu
pyiantel pamoate
!7;AB;>@<<4
&5;74<;D
0nueicookeu poik Causes peiioibital
euema anu muscle
inflammation
Thiabenuazole
&876>?G<6;=@D
&8@7A674<;D
Laiva fiom soil get
in thiough the skin
Causes an
intestinal infection
Iveimectin anu
thiabenuazole
K74A:>A:<:D
H@=;>@>D;D
Infecteu watei Inflammation anu
ulceiation of the
skin
Niiiuazole
!6V6A474 %4>;D Contaminateu foou Causes gianulomas
in the ietina, may
leau to blinuness
Biethylcaibamazine
0:AB@7@7;4
94>A76E8;
Fiom the female
mosquito
Blocks lymph
uiainage leauing to
elephantitis
Biethylcaibamazine
">AB6A@7A4
/6<O:<:D
Female blackflies Causes "iivei
blinuness"
Iveimectin

49u

HL%"I"+L

Nycology (fungi) play a veiy impoitant iole in meuical pathology, as theie aie a few veiy impoitant conuitions that
aie seen on a veiy iegulai basis clinically. Eveiything in this section is )^H!9 MCOM6_C!=;, thus be suie to know
this section colu.

%).K$K) )I9$%).&
Canuiua albicans is seen wiuely in many uiffeient clinical situations. It can cause a wiue
vaiiety of conuitions, anu can be seen both supeificially (on the skin), anu systemically
(anywheie else).
%B474A8@7;D8;AD 6E %4>=;=4:
- Biploiu fungus
- Buuuing yeast with pseuuohyphae aiounu 2uC
- Buuuing yeast with geim tube foimation aiounu S7C
%6FF6> 576M<@FD A4:D@= MG %4>=;=4:
- vaginitis (yeast infection)
- 0ial thiush
- Esophagitis
- Enuocaiuitis (Iv uiug use)
!7@48;>? %4>=;=4:
- Foi supeificial infections (incluuing oial thiush), Nystatin is the tieatment of choice.
- Foi systemic infections, amphoteiicin B is commonly useu.

!*&! !$#'
You will be given
images of fungi
on the 0SNLE
exam. Be suie to
unueistanu theii
anatomy anu how
they look
micioscopically.
491

%"HH". %3!).*"3& S3.+)I $.S*%!$".&
!;>@4 #@=;D - "Athlete's Foot", piesents with itching, flaking, anu scaling of the affecteu aieas, causeu by
Tiychophyton. Tieat with a topical azole.
!;>@4 %45;8;D - Ringwoim of the haii, causeu by Tiichophyton anu NIciospoium. Invasion of the haii shaft leaus to
haii loss that occuis in patches. Tieat with a topic azole.
!;>@4 %7:7;D - "}ock Itch", is a fungal infection of the gioin iegion.
!;>@4 %67567;D - "Ringwoim", is a skin infection of the aims anu legs most commonly, howevei it can occui
anywheie. The classic appeaiance is a ciiculai iash that cleais centially with elevateu euges.
!;>@4 /@7D;A6<67 - Is a iash of the tiunk anu pioximal extiemities, causeu by Nalassezia Fuifui. Classic
piesentation is hypopigmentation of the skin with shaip boiueis anu fine scaling. Seen most commonly in hot anu
humiu climatesweathei. Topical miconazole anu selenium sulfiue aie effective tieatments.
!;>@4 .;?74 - Affects the keiatinizeu layei of the skin, piouucing biown pigments. Is causeu by Boitaea Weineckii,
is tieateu with topical antifungals.

*.K*H$% &L&!*H$% HL%"&*&
MC)J4H=?)K4)C):
- Is enuemic to the Nississippi anu 0hio iivei valleys.
- Acute phase piesents with non-specific iespiiatoiy symptoms
- Chionic conuition may iesemble tubeiculosis, that if left untieateu can leau to ueath
N=?)J4K_A4)C):
- Enuemic to states east of the Nississippi iivei anu to Cential Ameiica
M$8 "$1' U$'8 +: #+%51%/$..' #,5851%/1>G
- Nilu "flu-like" illness
- Pneumonia-like illness
- Chionic illness that mimics TB oi lung cancei
- Aggiessive uisease that causes significant iespiiatoiy uistiess
- Nay cause skin lesions anu bone pain
- Is a laige yeast with bioau-baseu buuuing

492

A4AAC;C4C;4K_A4)C): aka valley Fevei
- Is enuemic to the Southwestein paits of the 0SA
- Is founu in the soil
- Commonly it is a milu uisease (flu-like)
- Can be seveie anu leau to seveie complications such as pneumonia, lung nouules, anu systemic finuings
thioughout the bouy
- Also known as "valley Fevei"
H?9?A4AAC;C4C;4K_A4)C):
- Is enuemic to Ruial Latin Ameiica
- Involves the mucous membianes, LN's, bones, anu lungs
- Nay be asymptomatic in some
- }uvenile foims aie often moie seveie anu holu a woise piognosis
- Painful lesions of the lips anu oial mucosa
- Pulmonaiy involvement usually begins as lobai pneumonia that fails to iesolve

"##",!3.$&!$% S3.+)I $.S*%!$".&
A$10/0$ ?.I/3$18 - vaginitis in uiabetics anu those using antibiotics, thiush in those with immunocompiomiseu
conuitions.
Pseuuohyphae anu Buuuing Yeast

K*3+,[9&/R+#*8 - causes mucoimycosis, affects patients with leukemia anu affects those with uiabetesBKA.
49S

Non-septate hyphae, with wiue-angleu bianching.
A,'#%+3+33*8 P5+:+,"$18 - Causes ciyptococcal meningitis. Is a veiy heavily encapsulateu yeast that is founu in
soil anu in pigeon uioppings.
Beavily encapsulateu yeast (~S-1uum in uiametei)

?8#5,>/..*8 2*"/>$%*8 - Causes a "fungus ball" cavity in the lungs.
Bianching septate hyphae at 4S

&#","!1,$J &%1*.%a$$
This topic is auueu because it has come up ovei anu ovei on all 0SNLE exams. This is a uimoiphic fungus that lives
on vegetation. The spieau is thiough being piickeu with a thoin, thus the name "Rose uaiuenei's uisease" is given.
It causes local ulceiations in auuition to nouules that follow the lymphatic uiainage.

494

AM?HJ!9 YL

HM?9K?A4=4O_

H&$,"$3+.+>' /8 $ D5,' &/>&6'/5.0 %+#/3 +1 %&5 ^)K=! )%5# Y 5T$"Z 2+3*8 8&+*.0
I5 "$05 +1 %&5 :+..+U/1>G K53&$1/8"8 +: ?3%/+1W 3./1/3$. *85[$##./3$%/+18W 8/05
5::53%8Z H&$,"$3+Q/15%/38W #&$,"$3+0'1$"/38W $10 %&5 $*%+1+"/3 15,D+*8 8'8%5"
$,5 $.8+ D5,' &/>&6'/5.0 /1:+,"$%/+1Z

49S

!1* *% _n
The ECSu is the concentiation of agonist that pioviues a iesponse halfway between the baseline anu the maximum
iesponse. The ECSu is the most common statistic useu to measuie the potency of an agonist (it howevei is not useu
to uiiectly measuie affinity).

%"H#*!$!$/* P $,,$/*,&$9I* ).!)+".$&!&
Antagonists aie uiugs that will paitially oi completely block a iesponse. A+"#5%/%/D5 $1%$>+1/8%8 binu ieveisibly
to the same ieceptoi as the agonist, while the /,,5D5,8/I.5 $1%$>+1/8% binus iiieveisibly. The piesence of an
antagonist will inciease the ECSu by a factoi known as the 'uose-iatio'.
Below, the giaph will uemonstiate how concentiation 'X' gives a ceitain iesponse in the absence of an antagonist,
but concentiation 'X1' is neeueu in oiuei to achieve the same iesponse when theie is a piesence of a 3+"#5%/%/D5
$1%$>+1/8%, the uose then equals X1X. 0sing uiffeient concentiation of antagonist will piouuce a uiffeient uose
iatio.
496

In the piesence of an /,,5D5,8/I.5 $1%$>+1/8% on the othei hanu, the iiieveisibly bounu antagonist iesults in
uepiession of the maximal iesponse of the agonist uose-iesponse cuive anu a iight shift also occuis wheie theie is a
ieceptoi ieseive similai to non-competitive antagonists.

S3II )+".$&! OD` #),!$)I )+".$&!
In compaiing a :*.. D8Z #$,%/$. $>+1/8%, they act on the same ieceptois howevei the paitial agonist has a lowei
maximal efficacy, thus even with incieaseu uosages, it cannot ieach the same efficacy as that of the full agonist.
497

K,3+ *I$H$.)!$".
Theie aie two types of uiug elimination: g5,+ 4,05, $10 Y
8%
4,05,
K7:? %<@474>A@ = Rate of elimination Plasma Biug Concentiation
[
D8
"7=@7 *<;F;>48;6> - In 1
st
oiuei elimination, the iate of uiug elimination is piopoitional to the plasma
concentiation (Cp) of uiug. Thus with moie uiug concentiation theie is moie uiug elimination, if theie is less uiug
concentiation theie is less uiug elimination. Nost uiugs aie eliminateu by 1
st
oiuei elimination.

498

-@76 "7=@7 *<;F;>48;6> - In Zeio oiuei elimination, the fiaction of uiug elimination iemains constant, no mattei
how high the uiug concentiation. Theie aie less uiugs eliminateu with zeio-oiuei elimination, two examples aie
alcohol anu aspiiin.

$H#",!).! *23)!$".& $. #1),H)%"I"+L
499

#1)&* [ OD` #1)&* \ K,3+ H*!)9"I$&H
H&$85 Y "5%$I+./8" - Piouuces watei-soluble metabolites thiough ieuuction, oxiuation, anu hyuiolysis of the uiug
molecules. These metabolites aie slightly polai. 0ses the CYP4Su metabolism.
H&$85 L "5%$I+./8" - Piouuces inactive metabolites that aie veiy polai, occuis thiough acetylation,
glucuioniuation, anu sulfation.

Suu

!1* )3!"."H$% .*,/"3& &L&!*H
The autonomic neivous system iegulates many bouily piocesses (BR, BP, uigestion, iespiiation, bloou pB, etc)
automatically on a subconscious level. The flow of this system is as follows:
AP) ! H,5>$1>./+1/3 :/I5,8 ! O$1>./+1 ! H+8%>$1>./+1/3 :/I5,8 ! !10 +,>$1

The autonomic neivous system consists of the '8'"#$%&5%/3V anu '#$,$8'"#$%&5%/3V systems.

&LH#)!1*!$% .*,/"3& &L&!*H
- The neives come fiom the
thoiacic anu lumbai iegions.
- Pieganglionic neives aie shoit
anu synapse in the paiieu ganglia
aujacent to the spinal coiu.
- Ach ieleaseu fiom pieganglionic
neuions.
- NE is ieleaseu fiom the
postganglionic neuion.
- Incieases caiuiac output,
incieases pulmonaiy ventilation,
incieases musculai bloou flow,
incieases bloou glucose,
uecieases uigestion, incieases
filtiation thiough kiuneys.

H4N67 7@A@5867D 47@ 8B@ 4<5B4 4>=
M@84 7@A@5867D`
#),)&LH#)!1*!$% .*,/"3&
&L&!*H
- The neives come fiom the
cianial anu sacial iegions of
the CNS.
- Involveu cianial neives aie
CN S, 7, 9, 1u.
- Long pieganglionic neives,
shoit postganglionic neives.
- Ach is ieleaseu fiom both
the pie anu post ganglionic
neuions.
- Incieases uigestion, helps
with uiination anu
uefecation.

H4N67 7@A@5867D 47@ 8B@ .;A68;>;A
4>= H:DA47;>;A 7@A@5867D`
Su1

)K,*.*,+$% ).K %1"I$.*,+$% ,*%*#!",&

)=7@>@7?;A ,@A@5867D
Stimulateu most commonly by
9@/1"@>./1" ,1B !)."@/1"@>./1".
#[ - Causes constiiction of smooth
muscle of aiteiioles anu uIu0.
#\ - Smooth muscle constiiction
anu neuiotiansmittei inhibition
![ - Causes contiaction of the
heait muscle.
!\ - Causes smooth muscle
ielaxation of lungs anu blauuei.
%B6<;>@7?;A ,@A@5867D
Stimulateu by Acetylcholine.
Nicotinic ieceptois aie founu in the
autonomic ganglion.
Nuscaiinic ieceptois aie founu on
all oigans with paiasympathetic
neives.
Su2

SuS

!1* &LH#)!1*!$% ).K #),)&LH#)!1*!$% S$9*,&

Su4

!1* #[ ,*%*#!",
)+".$&!& ).!)+".$&!& )+".$&!
#"!*.%L
H*%1).$&H "S
)%!$".
Noiepinephiine
Phenylephiine
Nethoxamine
Xylometazoline
Piazosin
Teiazosin
Boxazosin
Alfuzosin
Phenoxybenzamine
Phentolamine
.* o *#$ +C: Phospholipase
C activateu, CH\
anu A$.3/*".

!1* #\ ,*%*#!",
)+".$&!& ).!)+".$&!& )+".$&!
#"!*.%L
H*%1).$&H "S
)%!$".
Cloniuine
Biimoniuine
Phentolamine
Yohimbine
Atipamezole
*#$ o .* +;: AC inactivateu,
cANP

!1* ![ ,*%*#!",
)+".$&!& ).!)+".$&!& )+".$&!
#"!*.%L
H*%1).$&H "S
)%!$".
Bobutamine Netopiolol
Atenolol
Isopienaline > EPI
= NE
+D' AC activateu,
cANP

!1* !\ ,*%*#!",
)+".$&!& ).!)+".$&!& )+".$&!
#"!*.%L
H*%1).$&H "S
)%!$".
Albuteiol
Isopienaline
Netapioteienol
Salmetiol
Teibutaline
Piopianolol Isopienaline > EPI
>> NE
+D: AC activateu,
cANP

SuS

%1"I$.*,+$% K,3+&
Cholineigic uiugs stimulate the action of acetylcholine, which plays a laige iole in the "iest anu uigest" poition of
autonomic functioning. These uiugs help us uigest anu piopel foou thiough the uI, help with uiination, secietion of
salivaiy fluius, anu many moie functions.

%1"I$."H$H*!$%&
;/,53% ?>+1/8%8
)+*.! %I$.$%)I 3&* H*%1).$&H "S )%!$".
%47M4AB6<U#;<6A475;>@ ulaucoma ielief Activates the ciliaiy
muscles of the eye
9@8B4>@A6< 0iinaiy ietention Activates the smooth
muscle of the bowel anu
blauuei

C10/,53% ?>+1/8%8 E/5 ?1%/3&+./158%5,$858F
)+*.! %I$.$%)I 3&* H*%1).$&H "S )%!$".
.@6D8;?F;>@ Reveisal of post-op NN
junction blockaue, ileus,
uiinaiy ietention,
myasthenia giavis
Incieases enuogenous
ielease of acetylcholine
#G7;=6D8;?F;>@ Nyasthenia giavis Incieases enuogenous
*=765B6>;:F Is veiy shoit-acting anu
useu in the uiagnosis of
myasthenia giavis
#BGD6D8;?F;>@ 0seful foi glaucoma anu
ieveises an atiopine
oveiuose
*AB68B;65B48@ ulaucoma Incieases enuogenous

Su6

).!$%1"I$.*,+$%&
)+*.! %I$.$%)I 3&* H*%1).$&H "S )%!$".
Atiopine Piouuces myuiiasis anu
cycloplegia foi eye exams
Competitive antagonist at
cholineigic ieceptoi
Benztiopine 0seu in Paikinson's
uisease
Nuscaiinic ieceptoi
blockei
Scopolamine Pievents anuoi tieats
motion sickness
Nuscaiinic ieceptoi
blockei
Ipiatiopium Nainstay of C0PB
management
Nuscaiinic ieceptoi
blockei

%1"I$.*&!*,)&* $.1$9$!", #"$&".$.+
Cholineigic intoxication is most commonly seen with poisoning fiom a cholinesteiase inhibitoi. This is classically
seen in faimeis oi anyone woiking with oiganophosphates, anu in snake venoms. The signs anu symptoms of
cholinesteiase inhibitoi poisoning can be iemembeieu with the mnemonic ")=^;;"
J&5,5 U/.. I5 5T3588/D5G
& - Salivation
I - Laciimation
3 - 0iination
K - Bigestion
K - Befecation

%L!"%1,"H* #^_n H*!)9"I$&H

1$+1ZL$*IK &LH#)!1"H$H*!$%
$.K3%*,&
Quiniuine
Baibituiates
Phenytoin
Rifampin
uiiseofulvin
Caibamazepine
$.1$9$!",&
Isoniaziu
Sulfonamiues
Cimetiuine
Ketakonazole
Eiythiomycin
uiapefiuit }uice
St. }ohn's Wait
Su7

S)%!&
;+#$"/15 - Incieases BP in patients with shock by maintaining ienal bloou flow.
;+I*%$"/15 (!1) - Stimulates the heait without causing excess tachycaiuia.
C8+#,+%5,51+. (!1, !2) - 0seu foi iefiactoiy Av block anu biauycaiuia.
A.+1/0/15 (#2) - Piimaiy use is systemic hypeitension, suppiesses SNS outflow fiom the CNS. Stimulates PNS
outflow, thus slows BR anu uecieases sympathetic uiive. Auveise effects aie seuation, uiy mouth.
?.I*%5,+. (!2) - Piimaiy tieatment of asthma.
J5,I*%$./15 ((!2) - 0seu foi bionchospasm, asthma.
?"#&5%$"/158 - Release NE, cioss the bloou-biain baiiiei, inciease BP with a ieflex ueciease in BR. Toxicity:
Bizziness, tiemoi, talkative, tense, iiiitable, insomnia, fevei, confusion, incieaseu libiuo, paianoia, panic, suiciual
tenuencies.

1$+1ZL$*IK &LH#)!1"IL!$% S)%!&
H,$R+8/1 - 0seu foi BPB, has a 1
st
uose phenomenon wheie patient gets pionounceu auveise effects with theii fiist
uose (most commonly get oithostatic hypotension - a uiop in systolic BP of at least 2ummBg, oi uiop in uiastolic BP
of at least 1ummBg).
H&51%+.$"/15 - Causes gieatei inciease in BR than piazosin (ieflex), anu is useu foi uiagnosing pheociomocytoma.
=$I5%$.+. - # & ! blockaue, useful in hypeitensive emeigencies, one of two uiugs useu in piegnant patients with
hypeitension.
H,+#,$1+.+. - is the piototypical !-blockei, has gieatei lipophilicity than otheis, useful foi hypeitension, angina,
acute NI, stage fieight, anu pheociomocytomas. Pievents exeicise-inuuceu tachycaiuia anu oxygen uemanu.
J/"+.+. - 0seful foi migiaines, useu in open-angle glaucoma to ueciease aqueous humoi foimation.
H/10+.+. - Bas the gieatest ISA (pievents excess biauycaiuia).
K$S+, 5::53%8 +: !6I.+3Q5,8 +1 %&5 3$,0/$3 8'8%5" - Beciease contiactility, ueciease BR, ueciease BP, inciease
exeicise toleiance.
K$S+, 5::53% +1 %&5 5'5 - Beciease foimation of aqueous humoi.
K$S+, "5%$I+./3 5::53%8 - Bon't use in uiabetics as it blocks symptoms of hypoglycemia (ie inhibits tiemoi,
uiaphoiesis, tachycaiuia, anu inhibits glycogenolysis). Block symptoms of hypeithyioiuism.

Su8

).!$1L#*,!*.&$/* #1),H)%"I"+L
Theie aie SIX categoiies of antihypeitensive meuications:
1. Biuietics
2. Sympatholytics (!-blockeis)
S. Ace Inhibitois
4. Angiotensin Receptoi Blockeis
S. vasouilatois
6. Calcium Channel Blockeis

;C^9!JCA)
In auuition to leaining all of the uiuietics useu foi hypeitension, it is veiy impoitant to unueistanu wheie anu how
they woik in the kiuney. Below is a list of the commonly useu uiuietics, theii mechanism of action, theii clinical
uses, anu theii toxicities. Following that is an image of the kiuney anu its physiology as it ielateu to uiuietics.

)%*!)-"I)H$K*G Is a caibonic anhyuiase inhibitoi, which causes uiuiesis of NaBC0S anu ieuuces the total-bouy
BC0S- stoies. Its site of action is the pioximal convoluteu tubule.
^)!) - Altituue sickness, glaucoma, alkalinization of the uiine, metabolic alkalosis.
J4`CACJC!) - NBS toxicity, hypeichloiemic metabolic aciuosis, neuiopathy.

H)..$!"I: An osmotic uiuietic that acts by incieasing the tubulai fluiu osmolaiity, which then causes watei to
move into the tubules, incieasing the amount of uiine.
^)!) - To ueciease intiacianial piessuie, to ueciease intiaoculai piessuie, uiug oveiuose.
J4`CACJC!) - Behyuiation, pulmonaiy euema.

I""# K$3,*!$%&: Loop uiuietics inhibit the NaK2Cl co-tianspoit system of the thick ascenuing limb of the loop
of Benle.
^)!) - Foi states of excessive euema, such as CBF, ciiihosis, pulmonaiy euema, nephiitic synuiome. Also useu to
ueciease total bouy calcium levels.
J4`CACJC!) - The famous mnemonic "4M ;?PO" can be useu to iemembei the toxicities of loop uiuietics.
"totoxicity 1ypokalemia Kehyuiation )lleigy .ephiitis +out

Su9

!1$)-$K*&: Thiaziue uiuietics woik by inhibiting the NaCl ieabsoiption in the eaily uistal tubule, which uecieases
the uiluting capacity of the nephion.
^)!) - Is a fiist-line uiug foi hypeitension. Also useu foi cases of iuiopathic hypeicalciuiia, CBF, anu nephiogenic
uiabetes insipiuus.
J4`CACJC!) - 0se the mnemonic &'#5,O=Â to iemembei the most common toxicities of thiaziue uiuietics.
M'#5,: +lycemia, Iipiuemia, 3iicemia, %alcemia

ak &#),$.+: The most commonly useu uiug is )#/,+1+.$3%+15W acts as a competitive aluosteione ieceptoi
antagonist in the coitical collecting tubule.
^)!) - CBF, potassium uepletion, anu hypeialuosteionism (K+ anu aluosteione move in the opposite uiiection in
the tubule).
J4`CACJC!) - Bypeikalemia, gynecomastia, antianuiogen effects.

)%* $.1$9$!",&: Captopiil, Enalapiil, anu Lisinopiil. Act by inhibiting the enzyme angiotensin-conveiting
enzyme, which ieuuces the levels of angiotensin 2 (fiom Renin) anu pievents the inactivation of biauykinin.
^)!) - Bypeitension, CBF, anu ienal uisease causeu by uiabetes.
J4`CACJ_ - The mnemonic "CAPT0PRIL" can help iemembei all of the ACEI toxicities.
%ough, )ngioeuema, #ioteinuiia, !aste Change, hyp"tension, #iegnancy issues, ,ash, $ncieaseu ienin, Iowei
Angiotensin 2.

%)I%$3H %1)..*I 9I"%a*,&: Block the voltage-uepenuent L-type channel in caiuiac anu smooth muscle, thus
ieuucing muscle contiactility.
;/&'0,+#',/0/158 - Amlouipine, Nicaiuapine, Nifeuipine
P+160/&'0,+#/,/0/158 - veiapamil, Biltiazem
^)!) - Bypeitension, angina, aiihythmias
J4`CACJ_ - Flushing, uizziness, peiipheial euema, anu caiuiac uepiession.

.$!,"+IL%*,$.*: Causes vasouilation via ielease of nitiic oxiue in the smooth muscle, this incieases cANP levels
anu thus smooth muscle ielaxation. It causes much moie uilation of veins than aiteiies.
S1u

^)!) - Angina, pulmonaiy euema.
J4`CACJ_ - Tachycaiuia, hypotension, anu heauache. Be aleit foi something calleu "Nonuay Bisease", wheieby
someone exposeu to nitioglyceiine thioughout the woikweek uevelops toleiance, then loses toleiance ovei the
weekenu, iesulting in tachycaiuia, heauache, anu uizziness.

&LH#)!1"IL!$%&: #-blockeis, #2-agonists, !-blockeis
"6I.+3Q5,8 - Inciease bloou vessel uilation (Piazosin, Teiazosin, Boxazosin)
"L6$>+1/8%8 - Cloniuine (Becieases PvR, thus ueciease BP), Nethyluopa (Becieases PvR anu BP in piegnant
patients)
!6I.+3Q5,8 - Selectives (Netopiolol, Atenolol, Betaxolol), Non-Selectives (Pinuolol, Acetabulol, Labetolol)

S11

&$!*& "S K$3,*!$% )%!$".

S12

).!$).+$.)I&
Angina piesents with seveie chest pain, uuiing activity (stable) anu without activity (unstable). Piinzmetal's angina
occuis via spasm of coionaiy aiteiy, anu is most common in youngei females who smoke.
O+$. +: %&5,$#' - Reuuce myocaiuial oxygen consumption by uecieasing eithei: Enu-Biastolic volume, bloou
piessuie, heait iate, contiactility, anu ejection time.
Nitiates anu !-blockeis can altei the components that affect myocaiuial u2 consumption in the following ways:
.$!,)!*& c4<8@7
57@<64=d
!Z9I"%a*,&
c4<8@7 4E8@7<64=d
.$!,)!*& k
!ZM<6AR@7D
9<66= #7@DD:7@ Beciease Beciease Beciease
*>= =;4D86<;A
O6<:F@
Beciease Inciease Small effect
%6>874A8;<;8G Inciease Beciease Small effect
1@478 748@ Inciease Beciease Beciease
*N@A8;6> 8;F@ Beciease Inciease Small effect
HG6A47=;4< n\
A6>D:F58;6>D
Beciease Beciease Laige ueciease

I"%)!$". "S %),K$)% K,3+ )%!$/$!L

S1S

).!$Z),,1L!1H$% K,3+&
A=?)) Y? - This class of anti-aiihythmic uiugs has affinity foi the open state of Na+ channels with slow iecoveiy
iate.
;,*>8 - Quiniuine, Amiouaione, Piocainamiue, Bisopyiamiue
J+T/3/%/58 - Quiniuine causes cinchonism (a combination of heauache, tinnitus, toisaues ues pointes).
Piocainamiue can cause a ieveisible SLE-like synuiome.

A=?)) YN - Becieases AP uuiation, affects ischemic oi uepolaiizeu Puikinje anu ventiiculai tissue. Excellent when
useu foi post-NI ventiiculai aiihythmias anu uigitalis-inuuceu aiihythmias.
;,*>8 - Liuocaine
J+T/3/%/58 - Liuocaine can cause CNS stimulation oi uepiession as well as caiuiac uepiession

A=?)) YA - Slows conuuction thiough the heait, especially in the Puikinje fibeis. uoou foi supiaventiiculai
aiihythmias anu life-thieatening ventiiculai aiihythmias. Is a last iesoit meuication.
;,*>8 - Flecainiue, Encainiue, Piopafenone
J+T/3/%/58 - Is contiainuicateu in post-NI patients because it is a pioaiihythmic

S14

A=?)) L E!6I.+3Q5,8F - Beciease cANP, ueciease Ca2+, ueciease phase 4 slope, inciease PR-inteival.
;,*>8 - Netopiolol, Esmolol, Atenolol, Piopianolol
J+T/3/%/58 - Impotence, Asthma exaceibations, CNS effects, caiuiovasculai effects (biauycaiuia, Av block, CBF),
hypoglycemia.

A=?)) \ Edi 3&$115. I.+3Q5,8F - Inciease AP uuiation, inciease ERP, inciease QT-inteival. Amiouaione blocks the
K+ iectifiei channel that iepolaiizes the heait uuiing phase S.
;,*>8 - Sotolol, Amiouaione
J+T/3/%/58 - Sotolol (Toisaues ues Pointes), Amiouaione (piolongs AP uuiation, elongates QRS,
pulmonaiyliveithyioiu toxicities, thus check PFT, LFT, TFT's)

A=?)) ] EA$Li 3&$115. I.+3Q5,8F - Beciease conuuction velocity in Av noues, incieases ERP, incieases PR inteival,
pievents noual aiihythmias.
;,*>8 - veiapamil, Biltiazem
J+T/3/%/58 - Constipation, Flushing, Euema

4JM!9 X ?051+8/15
Causes hypeipolaiization by blocking the Ca2+ influx anu pieventing K+ outwaiu flow.
Is the uiug of choice foi uiagnosing anu abolishing Av noual aiihythmias (is a substitute useu between
caiuioveisions, has a half-life of 1us.

S1S

%1S K,3+&

&84?@D 6E %1S'
A.$88 Y E?8'"#%+"$%/3F - No limits on activity, only affects patient with noimal exeicise.
A.$88 L E)'"#%+"8 U/%& "+05,$%5 5T5,3/85F - Slightly limits oiuinaiy activity (fatigue, palpitations)
A.$88 \ E)'"#%+"8 U/%& "/.0 5T5,3/85F - No symptoms at iest, but occui with less than oiuinaiy activities.
A.$88 ] E)'"#%+"$%/3 $% ,58%F - Seveie physical limitations, symptoms at iest (when sitting)

&GF586FD 6E %1S'
- Tachycaiuia
- Weakness
- Fatigue
- 0ithopnea
- Peiipheial euema
- Pulmonaiy congestion
- Bypeiieninemia anu hypeialuosteione
- ventiiculai hypeitiophy anu iemoueling
- Incieaseu filling piessuieincieaseu enu-uiastolic volume

K7:?D :D@= E67 %1S'
C4P4J94H!) - These uiugs inciease stiength of contiaction, thus inciease stioke volume.
;C^9!JCA) - Nove fluius out of the bouy thus uecieasing congestion.
-?)4;C=?J49) - Beciease venous piessuie, congestion, anu euema.
AM94P4J94H!) - Inciease the speeu of heait contiactions.
?A! CPMCNCJ49) - ;53,5$85 "+,%$./%' in heait failuie patients, uecieases ventiiculai iemoueling.

S16

$"."!,"#*&
%47=;4A +<GA6D;=@ 9@84Z)?6>;D8D #B6D5B6=;@D8@74D@
$>B;M;867D
K$+"J$.

N.+3Q8 %&5 P$[d #*"#, thus
incieasing the intiacellulai Ca2+.

Is a positive ionotiope because of the
incieaseu Ca2+.

Incieaseu vagal tone, uecieaseu QT
inteival.

ST segment uepiession (hockey stick
configuiation).

T-wave inveision.

?0D5,85 !::53%8:
- NauseavomitingBiaiihea
- Effect is potentiateu by
hypokalemia
- Quiniuine will uisplace uigoxin
fiom binuing sites

?1%/0+%5 is Bigoxin Immune Fab oi
moueiate inciease in K+

A+1%,$/10/3$%50 use when patient is
using a K+ spaiing uiuietic
K"93!)H$.* (Beta1
agonist)

Stimulates heait in CBF
anu in caiuiogenic shock.

K"#)H$.*

Foi acute CBF anu shock,
incieases BP anu
maintains ienal
bloouflow.
H)I,$.".*Y
$.)H,$.".*

Incieases contiactility anu
ielaxes smooth muscle.

?0D5,85 !::53%8:
- Long-teim use may
cause
thiombocytopenia
anu ventiiculai
aiihythmias.

S17

I$#$K I"0*,$.+ )+*.!&
The goals of lipiu loweiing agents is to eithei ueciease LBL, inciease BBL, oi lowei tiiglyceiiues. Some of the uiugs
aie moie specific to an inuiviuual change, while some pioviue a little bit of eveiything.
)+*.!& !7;?<GA@7;=@D IKI @EE@A8D 1KI @EE@A8D )=O@7D@
*EE@A8D
&848;>D c1H+Z
%6) 7@=:A84D@
;>B;M;867Dd
Nilu ueciease Significant
ueciease
Nilu inciease Nuscle
bieakuown
(check
myoglobin
levels,
incieaseu
LFTs)
9;<@ 4A;= M;>=;>?
7@D;>D
c%B6<@D8G74F;>@d
veiy small
inciease
Noueiate
ueciease
No effect uI symptoms,
teiiible
tasting.
%B6<@D8@76<
4MD6758;6>
M<6AR@7D
c*Q@8;F;M@d
No effect Noueiate
ueciease
No effect Incieaseu
LFTs
.;4A;> Nilu ueciease Noueiate
ueciease
No effect Flushing (can
tieat by giving
aspiiin)
S;M748@ =7:?D
c+@FE;M76Q;<d
Significant
ueciease
Nilu ueciease Nilu inciease Nuscle
bieakuown,
incieaseu
LFTs.

S18

).!$Z1$&!)H$.*&
[
D8
?@>@748;6> 4>8;B;D84F;>@D'
- Competitively block the B1 ieceptoi.
- Aie lipophilic anu thus cioss the bloou-biain baiiiei, causing seuation.
- Bave incieaseu anti-cholineigic effects that last 4-6his.
- Biphenhyuiamine anu Piomethazine block the Na+ channel, thus have anesthetic activity.

\
>=
?@>@748;6> 4>8;B;D84F;>@D'
- Less seuating
- Less anticholineigic effects
- Longei lasting
- Less lipophilic
- 0ses CYP4Su metabolism
%@87;Q;>@ (Zyitec) - inhibits mast cell ielease
S@V6E@>4=;>@ (Allegia)
I6748;=;>@ (Claiitin)

S19

01*,* K" )&!1H) K,3+& 0",ap

S2u

)&!1H)
The two main categoiies aie the "Contiolleis" anu the "Nain Attack Relief" meuications.

?.I*%5,+.
- Rapiu inhalant
- Shoit-acting !2 agonist useu foi immeuiate ielief.
C#,$%,+#/*"
- A muscaiinic antagonist
- Nost commonly useu foi C0PB
- Less effective than the !2 agonist
- Antimuscaiinic effects
- Causes slowei bionchouilation that is long-lasting
J&5+#&'../15
- Inhibits phosphouiesteiase
- Becieases eosinophilslymphocytes, anu monocytes
- Loweieu half-life in chiluien anu in smokeis
- Naiiow theiapeutic inuex
- Commonly causes heauaches, uizziness, hypotension, biauycaiuia

%".!,"II*,&
%",!$%"&!*,"$K&
H)&! %*II &!)9$I$-*,&
I".+Z)%!$.+ 9*!)
)+".$&!&
I*3a"!,$*.* ,*%*#!",
).!)+".$&!&
H)$. )!!)%a ,*I$*S
)I93!*,"I
$#)!,)#$3H
!1*"#1LII$.*
H*!)#,"!*,*."I
I*/)I93!*,"I
S21

A+,%/3+8%5,+/08
Inhaleu - Beclomethasone, Tiiamclinolone, Buuesoniue, Fluticasone
0ial - Pieunisone, Pieunisolone
- Inhibit phopholipase A2
- Aie the coineistone of asthma management
- Becieases aiachiuonic aciu thiough phospholipase A2, inhibiting the C0X2 pathway.
- 0ial coiticosteioius can cause oial thiush
- Long-teim use can cause osteopoiosis, hypeitension, uiabetes, suppiession of the pituitaiy-auienal axis,
obesity, thinning of the skin, anu muscle weakness.

K$8% A5.. )%$I/./R5,8
- Ciomolyn anu Neuociomil
- Pievent mast cell uegianulation
- 0seu as piophylaxis
- Aie safei to use in kius

=+1>6?3%/1> N5%$ ?>+1/8%8
- Salmetiol is the piototype
- Pievents noctuinal asthmatic effects

=5*Q+%,/515 9535#%+, ?1%$>+1/8%8
- Nonteleukast anu Zafiilukast
- Antagonizes leukotiienes thus pieventing an inciease in bionchial tone

!7@48;>? &848:D )D8BF48;A:D
The coineistone of management is epinephiine oi pieunisone.

S22

#),a$.&".W& K$&*)&*
Paikinson's uisease iesults fiom the uegeneiation of uopamine (BA) neuions in the substantia nigia. Symptoms aie
iesting tiemoi, iigiuity, anu biauykinesia.

Bopamine cannot cioss the bloou-biain baiiiei, thus it is conveiteu to leveuopa in oiuei to get acioss the BBB.
Theie aie ceitain uiugs that can be useu in oiuei to pievent the conveision of leveuopa to othei things that cannot
cioss.
;,*>8 %&$% /13,5$85 ;+#$"/15 .5D5.8:

I*/*K"#)
When useu alone it
usually causes nausea
anu vomiting
Long-teim use causes
involuntaiy movement
Avoiu in psychotic
patients
%),9$K"#)
Inhibits peiipheial
conveision of LB to
BA
Won't cioss the
BBB
Can cause uI anu
caiuiac pioblems
)H).!)K$.*
An antiviial that
incieases BA
ielease fiom
nigiostiiatum.
Becieases BA
ieuptake.
Can cause
Leviuo
Reticulaiis
(Reu-blue skin).
S2S

;+#$"/15 9535#%+, ?>+1/8%8:
976F6A7;58;>@ - An eigot alkaloiu, a B2 agonist anu B1 antagonist.
#@7?6<;=@ - B1 anu B2 antagonist, can cause neuiological symptoms.
,65;>676<@ - The uiug of choice foi iestless leg synuiome.

)I%"1"I&

*EE@A8D 6E 4M:D@:
- CNS seuation
- Becieaseu viscosity of cell membianes
0@7>;AR@Za67D4R6EE:
- Causeu by a thiamine ueficiency
- AtaxiaNystagmusConfabulations

&*I*+*I$.*
An NA0-B inhibitoi
that blocks the
conveision of BA to
B0PAC.
!"I%)#".*
A C0NT inhibitoi that blocks
the conveision of LB to S0NT.
Incieases LB bioavailability.
Causes an onoff effect uue to
its competition with LB foi
entiy into BBB.
S24

H*!1)."I
Also known as "methyl alcohol" oi "woou alcohol".
- 0seu in commeicial solvents
- Causes visual uistuibances (Snowstoim pattein)
- Tieatment with Iv fomepizole oi Iv ethanol

*!1LI*.* +IL%"I
- Antifieeze, has a sweet smell.
- Causes CNS excitation followeu by CNS uepiession, followeu by metabolic aciuosis, then causes the blockaue
of ienal tubules by oxalate ciystals
- Tieat with Iv fomepizole (inhibits alcohol uehyuiogenase)
- Chaiacteiizeu by oxalate ciystals in the uiine, metabolic aciuosis, anu an absence of visual uistuibances

;C)^=2C9?K - Is a piesciiption meuication taken by alcoholics that inhibits the alcohol uehyuiogenase enzymes.
This causes an accumulation of acetaluehyue, which makes the patient veiy sick.

S2S

).!$Z&*$-3,* K,3+&

Y
8%
./15 %,5$%"51% +: $I85135 85/R*,58G
- Ethosuxamiue (chiluien)
- valpioate
- These block the T-type Ca2+ channels
Y
8%
./15 %,5$%"51% +: H$,%/$.[O515,$. J+1/3 A.+1/3 85/R*,58G
- Caibamazepine
- Phenytoin
- valpioate
Y
8%
./15 %,5$%"51% +: )%$%*8 !#/.5#%/3*8:
- Iv Biazepam

.4k AB4>>@<
;>B;M;867D'
Caibamazepine
Phenytoin
valpioate
Lamotiigine

+)9)
*>B4>A@7D'
Clonazepam
uabapentin
Biazepate
Chloiazepate
Phenobaibitol
vigabatiin
H;V@= )A8;6>'
Topiiamate
Felbamate
)K/*,&* *SS*%!& "S ).!$Z&*$-3,* H*K$%)!$".&'
%47M4F4Q@5;>@ - seuation
#B@>G86;> - gingival hypeiplasiahiisutismfacial coaiseningfetal hyuantoin
synuiome
I4F687;?;>@ - Steven-}ohnson synuiome
S26

&a*I*!)I H3&%I* ,*I)J).!&

S27

&a*I*!)I H3&%I* &#)&H"IL!$%&

.&)$K&Y )%*!)H$."#1*.Y %"J\Z$.1$9$!",&
.&)$K&
Incluue Ibupiofen, Napioxen, Inuomethacin
K4?: Reveisible inhibition of both C0X1 anu C0X2, which then blocks the synthesis of piostaglanuins.
^)!): 0seu as an anti-inflammatoiy, antipyietic, anu analgesic. Inuomethacin is useu in infants to close a patent
uuctus aiteiiosus.
?;-!9)! !22!AJ): 0lceis, ienal toxicity, aplastic anemia.

S28

)%*!)H$."#1*.
Also known as Tylenol
K4?: Causes ieveisible inhibition of the C0X pathway.
^)!): Is useu foi its analgesic anu antipyietic piopeities, but lacks the anti-inflammatoiy piopeities seen in
NSAIBS.
?;-!9)! !22!AJ): An oveiuose is ueauly, because of hepatic neciosis uue to toxic metabolites which ueplete
glutathione in the livei, causing the foimation of toxic NAPQI in the livei.

%"JZ\ $.1$9$!",&
Incluue Celecoxib, Rofecoxib
K4?: Selective inhibition of C0X-2
^)!): Excellent foi inflammation anu pain, but helps to maintain gastiic mucosa because it uoesn't use the C0X-1.
Nain clinical uses aie aithiitis (osteo anu RA).
?;-!9)! !22!AJ): Renal toxicity, same as othei NSAIBS with less iisk of gastiic ulceiations

).*&!1*!$%&
H)% (6/1/(8( F35")3,. ?)1+"1'.,'/)1) is a concept useu in anesthesiology to compaie the potency of anesthetic
agents. Anesthetics with a highei NAC aie cause fastei inuuction but have much lowei potency, while those with
lowei NAC value aie slowei to inuuce anesthesia but have a highei potency.
9:,(@3":
NAC of nitious oxiue is '1u4', thus it acts fast anu has weakei potency (has incieaseu bloou anu lipiu solubility).
NAC of halothane is 'u.7S', thus is acts slowei but has a stiongei potency (has uecieaseu bloou anu lipiu solubility).

S29

The Iueal Anesthetic:
- Immeuiate onset of action
- Bas ieveisible piopeities
- Lasts foi an appiopiiate uuiation of time
- Bas a wiue theiapeutic iange
- Causes no tissue uamage oi iiiitation

Bow they woik:
- Pievention of Na+ influx acioss neive membianes
- Significant anesthesia pievents fiiing thiesholu fiom being obtaineu
P+ $3%/+1 #+%51%/$. j P+ /"#*.85 j A+10*3%/+1 I.+3Q$05

SSu

I"%)I ).*&!1*!$%&
Blockage of Na+ channels, inactivation is by hyuiolysis.

SS1

+*.*,)I ).*&!1*!$%&

SS2

"#$"$K&
- Receptoi iesponsible foi supiaspinal anu spinal anesthesia, iespiiatoiy uepiession, physical uepenuence.
$ - Receptoi iesponsible foi spinal anesthesia anu uysphoiia.

SSS

&*K)!$/*U1L#."!$%&
)50$%/D58 - ueciease anxiety
M'#1+%/38 - inuucesmaintains sleep

9@>Q6=;4Q@5;>@D (enu with -pam)
- Biazepam
- Loiazepam
- Niuazolam
- Tiiazolam

K4?: Binu uABA channels, incieasing the fiequency of channel opening.
)H!AC?= ^)!):
Alcohol withuiawal - Chloiuiazepoxiue
Panic uisoiuei - Alpialozam
Nuscle spasms - Loiazepam
Status epilepticus - Biazepam
2+, I51R+0/$R5#/15 +D5,0+85 - Flumazenil

947M;8:748@D (enu with -al)
- Phenobaibital
- Pentobaibital
- Secobaibital
- Thiopental
K4?: Binu to non-uABA, non-Benzo sites, incieases the uuiation of channel opening.
H$%%5,1 +: I$,I/%*,$%5 0/8%,/I*%/+1: 1
st
- Biain 2
nu
- visceia S
iu
- Lean tissue 4
th
- fat
^)!): Anticonvulsant, pieopeiative seuation, coma inuuction

SS4

).!$ZK*#,*&&).!&
J,/3'3./3 ?1%/05#,588$1%8: Block the ieuptake of S-BT anu NE
K,3+ %1*H$%)I )SS*%!*K $H#",!).! S)%!&
)F;87G58;<;>@ S-BT Bighly seuative, can cause
oithostatic hypotension.
%<6F;574F;>@ S-BT Is the TCA B0C foi 0CB.
K@D;574F;>@ NE Low seuation.
.6787G584<;>@ NE Least seuative.
$F;574F;>@ NE = S-BT Noueiate seuation,

L
10
O515,$%/+1 ?1%/6;5#,588$1%8:
K,3+ %1*H$%)I )SS*%!*K $H#",!).! S)%!&
)F6V45;>@ BA Also useu foi psychosis,
can cause taiuive
uyskinesia.
9:5765;6> BA, NE, S-BT Can cause weight loss anu
is also useu foi smoking
cessation.
H45768;<;>@ NE
!74Q4=6>@ S-BT Can cause piiapism, CNS
uepiession, anu

))9CV8G ?,5 %&5 8$:58% >,+*# +: $1%/605#,588$1%8Z
K,3+ 3&*& )K/*,&* *SS*%!&
Fluoxetine (Piozac) Bepiession, panic
uisoiuei, anoiexia.
Bigh inhibition of CYP4Su,
can altei bloou glucose,
can cause SIABB.
Fluvoxamine (Luvox) 0CB, Panic uisoiuei.
Paioxetine (Paxil) Bepiession, panic
uisoiuei.
Bighest bioavailability,
highest seuation of SSRI's,
weight gain.
Seitialine (Zoloft) Bepiession, panic
uisoiuei.
veiy little CYP4Su effect,
piefeiieu in the elueily
because it uoesn't affect
metabolism.
K?4CV8: 0se with extieme caution as the NA0I's can cause seiious ieactions with ceitain foous anuoi uiugs.
Cheese, wine, etc, can cause ciisis.
SSS

K?4?C - SBT anu NE
K?4NC - BA
[
D8
+@>@748;6> H)"$WD'
- Phenelzine anu Tianylcypiomiue
- Pioviue non-selective inhibition
- Affects S-BT > NE
- Its effect is uue to uowniegulation of pie-synaptic iegulation, thus incieasing S-BT neuions
\
>=
+@>@748;6> H)"$WD'
Neclobemiue
NA0AI
]
7=
+@>@748;6> H)"$WD'
Selegeline
- NA0BI foi Paikinson's uisease

)=O@7D@ *EE@A8D 6E H)"$WD'
Sleep uistuibances
- Weight gain
- 0ithostatic hypotension
H)"$ $>86V;A48;6>:
- Agitation
- Beleiium
- Neuiomusculai excitation
- Loss of consciousness
- Seizuie
- Shock
- Bypeitheimia

K++0 )%$I/./R5,8G
I;8B;:F Z Is the B0C foi moou stabilization in bipolai uisease.
SS6

- Calms mania
- Can cause hypothyioiuism
?0D5,85 !::53%8:
- Biowsiness
- Weight uain
- Low safety maigin
- The eailiest sign of an oveiuose is nausea anu vomiting

).!$Z#&L%1"!$%&
H") - B2 ieceptoi antagonists useu to ueciease the levels of uopamine (BA)
3&* - Alleviation of psychosis anu symptoms of psychosis.

SS7

SS8

).!$ZH$%,"9$)I&

K7:?D A6>874;>=;A48@= ;> 7@>4<
;F54;7F@>8'
Sulfonamiues
Tetiacyclines
Nitiofuiantoin
Itiaconazole
Ciuofovii
Ribaviiin
Naliuixic Aciu
K7:?D 8B48 7@C:;7@ 4=N:>A8D ;>
548;@>8D T;8B B@548;A
;>D:EE;A;@>AG'
Clinuamycin
Chloiamphenicol
Eiythiomycin
Netioniuazole
Inuinavii
Ramantauine
vaiiconazole
Caspofungin
SS9

?1%/D/,$.8:
)AGA<6O;7 - 0seu foi heipes, can cause uI uistuibances, phlebitis, iash, anu heauache.
+4>A;A<6O;7 - Is fiist line foi CNv, can cause myelosuppiession anu CNS toxicities.
S6DA47>@8 - Fiist line foi CNv ietinitis, CNv colitis, CNv esophagitis, anu acyclovii iesistant BIvvZv. Nay cause
nephiotoxicity, penile ulceiations, anu CNS toxicities.

N$3%5,/$. 958/8%$135:
1. Tiansfeiable Resistance (tiansfei of plasmius)
2. Tiansfoimation (uptake of BNA)
S. Bacteiial Conjugation

1$+1ZL$*IK ).!$H$%,"9$)I $.S",H)!$".
#@>;A;<<;>:
- 0seu against giam +ve cocci, ious, giam -ve cocci, anu spiiochetes (tieponema)
- Binus to PCN-binuing pioteins
- Blocks the cioss-linking of cell walls (via tianspeptiuase blockage)
)F;>6?<GA6D;=@D:
- Incluue stieptomycin, gentamycin, tobiamycin, neomycin, amikacin, spectinomycin.
- Causes misieauing of mRNA via the inhibition of foimation of the initiation complex
- 0seu foi seveie giam -ve iou infections
- Can cause nephiotoxicity anu ototoxicity
- Shows a concentiation uepenuent kill iate (CBKR) anu a post-antibiotic effect (PAE).
%B<674F5B@>;A6<:
- Is bacteiiostatic, inhibiting the Sus iibosomal subunit's peptiuyltiansfeiase
- 0seu foi neisseiia meningitiues, stiep pneumonia, anu haemophilus influenza
- Can cause 'giey baby synuiome' anu aplastic anemia.

H4A76<;=@D:
- Incluue eiythiomycin anu claiithiomycin
- Woik by blocking tianslocation
- 0seu foi uppei iespiiatoiy infections, Chlamyuia, neisseiia
- Can cause uI symptoms, iashes, eosinophilia, anu cholestatic hepatitis
S4u

!@874AGA<;>@:
- Boxycycline anu minocycline
- Woiks by binuing to the SuS subunit anu pieventing attachment of aminoacyl-tRNA.
- Shoulu avoiu ceitain foous which limit its absoiption, such as milk piouucts anu piouucts high in Fe2+
&:<E6>4F;=@D:
- Incluue sulfamethoxazole, sulfauiazine, anu othei sulfas
- Woiks by inhibiting the enzyme uihyuiofolate ieuuctase
- 0seu foi 0TI's, anu both giam +- oiganisms
S<:676C:;>6<6>@D:
- Incluue cipiofloxacin, noifloxacin, ofloxacin, moxifloxacin, gatifloxacin
- Inhibits BNA gyiase
- 0seu foi giam -ve ious in the u0 anu uI tiacts
- Commonly causes uI uistuibances, heauache, iashes, uizziness
%@5B4<6D567;>D:
- Aie beta-lactams that woik by inhibiting cell wall synthesis
- 1
st
geneiation: Pioteus, E.Coli, anu Klebsiella
- 2
nu
geneiation: Baemophilus, Enteiobactei, Neisseiia, Pioteus, E.Coli, Klebsiella, anu Seiiatia
- S
iu
geneiation: Seiious giam -ve infections that aie iesistant to othei beta-lactam uiugs. 0seu foi
meningitis.
- 4
th
geneiation: Pseuuomonas anu giam +ve oiganisms
- Commonly cause hypeisensitivity ieactions, with cioss-hypeisensitivity with penicillin
- Can cause a uisulfiiam-like ieaction when combineu with alcohol
/4>A6FGA;>:
- Binus to the B-ala B-ala poition of cell walls, thus inhibiting cell wall mucopeptiue foimation
- 0seu in seiious giam + infections, such as NRSA
- Can cause nephiotoxicity, ototoxicity, thiombophlebitis, anu 'ieu-man synuiome', wheie the bouy gets
flusheu.
H@876>;=4Q6<@:
- Woiks by foiming toxic metabolites insiue the cell
- 0seu foi giaiuia, entamoeba, anu tiichomonas
- Bas a uisulfiiam-like ieaction when combineu with alcohol
,$#* c!9 =7:?Dd'
- Rifampin
- Isoniaziu
- Pyiazinamiue
- Ethambutol
S41

- Can cause hemolysis in u6PB ueficient patients
- Can cause an SLE-like synuiome
- vitamin B6 (pyiiuoxine) ueficiency fiom pyiazinamiue
)F5B68@7;A;> 9'
- Woiks by foiming poies in the cell membiane
- 0seu foi systemic mycoses
- Can cause feveis anu chills, aiihythmias, hypotension, anu nephiotoxicity

)>8;O;74< )A8;O;8G

%1*H"!1*,)#*3!$%&
Biugs classifications aie baseu on theii N0A's:
2+.$%5 $1%$>+1/8%8 (Nethotiexate)
H*,/15 $1%$>+1/8%8 (6-meicaptopuiine)
H',/"/0/15 $1%$>+1/8%8 (S-fluoiouiacil)
9/I+1*3.5/3 ,50*3%$85 /1&/I/%+,8 (Byuioxyuiea)
S42

K7:? ,@D;D84>A@:
C11$%5 - Piimaiy iesistance uevelops uue to exposuie.
?37*/,50 - Causeu by genomic mutations that may be to a single uiug oi to multiple uiugs.

H") 6E 8:F67 A@<< 7@D;D84>A@:
- Becieaseu uiug accumulation
- Alteieu affinity of taiget enzymes
- Loss of uiug-activating enzymes
- Incieaseu function of tumoi cell iepaii mechanisms

1;?BZG;@<= AB@F68B@745@:8;A 86V;A;8;@D:
Common chemotheiapy uiug toxicities - myelosuppiession, nauseavomiting, leucopenia.
Neuiotoxicity - vinciistine, Paclitaxel
Pulmonaiy Toxicity - Bleomycin, Busulfan
Renal Toxicity - Cisplatin
Bemoiihagic Cystitis - Cyclophosphamiue
Caiuiac Toxicity - Boxoiubicin

K7:?ZD5@A;E;A 86V;A;8;@D:
Caimustine - piouuces leukocyte suppiession
Cisplatin, Caimustine - most emetic anti-neoplastics
SBTS antagonists - pievent emesis
Netochlopiomiue - useful in pieventing chemotheiapy-ielateu nausea anu vomiting.

K$)9*!*& #1),H)%"I"+L
S4S

$.&3I$. !L#* ".&*! "S
)%!$".
#*)a "S
K,3+
K3,)!$".
"S )%!$".
!L#$%)I 3&*
3<874DB678
)A8;>?cI;D576d
S minutes 1hi Shi Befoie meals
&B678Z)A8;>?
c,@?:<47d
Su minutes S-4hi 6-8hi Noining anu
night
$>8@7F@=;48@
)A8;>? cI@>8@d
Su minutes 12hi 24hi qiu
I6>?Z)A8;>?
c3<874<@>8@d
2hi 12hi 24hi qiu

Theie is a iisk of hypoglycemic ciisis if piopei iegulation of insulin not useu
&:<E6>G<:7@4D:
ulybuiiue, Tolbutamiue
K4?: Causes uepolaiization of beta cells of the pancieas, thus incieasing the ielease of insulin.

+)&!,"$.!*&!$.)I #1),H)%"I"+L
ML $1%$>+1/8%8: Cimetiuine, Ranitiuine.
- Loweis aciu secietion
- Not useu as 1
st
line uiug foi uERB, P0B, etc.
H,+%+1 H*"# C1&/I/%+,8: 0mepiazole
- Is uiagnostic anu theiapeutic uiug of choice foi uERB anu P0B
- Also useu in cases of Zollingei-Ellison synuiome
K*3+8$. H,+%53%$1%8: Sucialfate
- Woiks by auheiing to pioteinaceous lesions on the suiface
- Is as effective as an B2 ieceptoi antagonist woulu be in 4-8 weeks
H,+8%$>.$10/18: Nisopiostal
- Can be given when patient is using high-uose NSAIB theiapy
- Blocks cANP
- Also causeu aboition in piegnant women
- Can cause wateiy uiaiihea
?1%/65"5%/38: SBTS ieceptoi antagonists
- 0nuasetion
S44

H,+Q/15%/38: Alosetion
- Can be useu foi tieatment of IBS, but is last line aftei conseivative theiapies fail
C,,/%$I.5 N+U5. ;/85$85:
- 1
st
line tieatment of ulceiative colitis is Sulfasalazine
- 1
st
line tieatment of Ciohn's uisease is Buuesoniue

%)I%$3H ).K 9".* 1"H*"&!)&$&
HJM - foi bone iesoiption, anu is stimulateu when seium calcium uecieases.
A$.3/%+1/1 - peifoims all opposite action of PTB (paiathyioiu hoimone).
YWLa X 0/&'0,+T' D/%$"/1 ;\ - piouuceu in the kiuney
48%5+#+,+8/8 - 1
st
line phaimacological tieatment is alenuionate (bisphosphonate)
H$>5%V8 ;/85$85 - Tieatment involves bisphosphonate meuication such as alenuionate.

!1L,"$K #1),H)%"I"+L
=5D+%&',+T/15 (T4) - is the uiug of choice foi all types of hypothyioiuism.
=/+%&',+1/15 (TS) - moie potent than levothyioxine, has a shoitei half-life, is not useu as a theiapeutic agent in
thyioiu pioblems.
K5%&/"$R+.5 $10 H,+#'.%&/+*,$3/. - two uiugs useu foi hypeithyioiuism.
H,+#'.%&/+*,$3/. (PT0) - Inhibits the peiipheial conveision of T4!TS
O,$D5V8 ;/85$85 - Nethimazole oi PT0 is useu to inuuce iemission oi to contiol symptoms piioi to suigeiy oi
iauioiouine ablation.
C+0/05 )$.%8 - inhibit the ielease of thyioiu hoimone fiom the thyioiu glanu.
H+%$88/*" C+0/05 8+.*%/+1 - is useu to contiol the symptoms of acute thyiotoxicosis, uecieases the vasculaiity anu
size of the thyioiu, anu inhibits thyioiu hoimone ielease following RAI tieatment.
9?C EC6Y\YF - is useu in the tieatment of uiave's uisease, woiks by emitting chemicals that kill tissue of the thyioiu.

#1),H)%"I"+L "S #$!3$!),L ).K 1L#"!1)I)H3&
A+8'1%,+#/1 - is a synthetic coiticosyntiopin analog, is useu to uiagnose auienal insufficiency.
S4S

43%,5+%/05 - is a synthetic somatostatin that inhibits uB secietion, is useu to tieat aciomegaly.
K51+%,+#/18 - inuuces ovulation in infeitile women.
O+1$0+,5./1 - is a unRB that is auministeieu in a pulsatile foim, this inuuces ovulation in women with amenoiihea
uue to hypothalamic uysfunction.
=5*#,+./05 - useu in kius with piecocious pubeity, it acts by suppiessing gonauotiopin secietion fiom the pituitaiy.
N,+"+3,/#%/15 - is given to those with piolactinomas, useu to shiink then mass so the symptoms will cease. Is a BA
antagonist.
4T'%+3/1 - useu to inuuce anuoi augment laboi in women who have tiouble with ueliveiy, also stimulates milk
letuown in nuising women.
;58"+#,588/1 - is a synthetic analog of vasopiessin, tieatment foi uiabetes insipiuus.

.&)$K&
?35%$"/1+#&51 - anti-pyietic, analgesia, ieveisible C0X inhibition. Lacks anti-inflammatoiy piopeities. 0veiuose
is tieateu with N-Acetylcysteine.
?8#/,/1 - Bas analgesic anu anti-inflammatoiy piopeities, inhibits the C0X2 pathways. Causes uI iiiitation by
inhibiting piostaglanuins, which aie piotective to uI mucosa.
C10+"5%&$3/1 - is a non-selective C0X1 inhibitoi, inhibitoi of phospholipase A anu C. 0seu to close a PBA, also
useu in gout anu foi management of ankylosing sponuylitis.
CI*#,+:51 - pioviues analgesia without anti-pyietic piopeities, has less uI iiiitation than uoes aspiiin.

S46

).!$Z%")+3I)!$".

S47

,*#,"K3%!$/* #1),H)%"I"+L
Theie aie a few veiy common meuications useu to inuuce ovulation anu thus inciease the chances of piegnancy.
%I"H$#1*.*: The agent of choice foi ovulation inuuction, it acts by incieasing unRB secietion fiom the
hypothalamus, which then incieases the levels of FSB, incieasing the feitility. This all happens via the blocking of
the estiogen ieceptois, thus tiicking the bouy into believing that the levels of estiogen aie much lowei than they
actually aie.
13H). H*."#)3&)I +".)K"!,"#$. cH@>68765;>d' Is extiacteu fiom the uiine of menopausal women. It is
high in LB anu FSB, which incieases feitility.

S48

AM?HJ!9 Y\

H?JM4=4O_

;*5 %+ 8&55, D+.*"5W %&5 #$%&+.+>' 853%/+1 +: %&5 )%5# Y 5T$" /8 I' :$, %&5 "+8%
3&$..51>/1>Z J&5 ^)K=! 5T$" /8 "+D/1> "+,5 $10 "+,5 %+U$,08 I5/1> $ 3./1/3$.
5T$"W %&*8 /% /8 5T%,5"5.' /"#+,%$1% %+ ,53+>1/R5 %&5 8/>18W 8'"#%+"8W 3+""+1
#,5851%$%/+18W *13+""+1 #,5851%$%/+18W $10 #$%&+#&'8/+.+>' +: #$%&+.+>/3$.
3+10/%/+18Z
)#53/$. $%%51%/+1 8&+*.0 I5 #$/0 %+ 0/85$85 51%/%/58 %&$% $,5 "+,5 3+""+1 /1 %&5
^1/%50 )%$%58W $8 +##+850 %+ %&+85 %&$% $,5 "+,5 #,5D$.51% /1 +%&5, $,5$8 +: %&5
U+,.0Z

S49

+)&!,"$.!*&!$.)I

A4P;CJC4P) 42 JM! !)4HM?O^):
- Baiiett's esophagus
- Achalasia
- Esophageal cancei

9),,*!!W& *&"#1)+3&
Baiiett's esophagus is a conuition wheieby a chionic exposuie to aciuic contents fiom the stomach cause
metaplasia of the epithelium at the squamocolumnai junction in the esophagus. The metasplasia changes fiom
squamous epithelium (non-keiatinizeu) to columnai epithelium. The ieason foi this is that squamous epithelium is
not veiy piotective against aciuic contents, while the columnai epithelium is uesigneu specifically foi this puipose.

SSu

)%1)I)&$)
Achalasia is a conuition wheieby the lowei esophageal sphinctei fails to ielax. This is an esophageal motility
uisoiuei that involves the smooth muscle layei of the esophagus anu the lowei esophageal sphinctei. Chaiacteiizeu
by an incomplete ielaxation of the lowei esophageal sphinctei, incieaseu lowei esophageal sphinctei tone, anu a
lack of peiistalsis in the esophagus.
Chaiacteiistics:
- Bysphagia
- Reguigitation
- Chest pain
Theie aie a few ieasons why this may happen, they incluue:
- Chaga's uisease
- Loss of myenteiic plexus
- Esophageal caicinoma
The best uiagnostic tool foi this conuition is a baiium swallow.

SS1

*&"#1)+*)I %).%*,
The two types of esophageal cancei aie: Auenocaicinoma anu Squamous Cell caicinoma.
Auenocaicinoma - this type of cancei is often seconuaiy to Baiiett's esophagus.
Squamous Cell Caicinoma - this type of cancei is often causeu by exposuie to alcohol anu cigaiette smoke (on a
chionic basis).
The populai mnemonic ")9%K*S" is excellent foi iemembeiing the common causes of esophageal cancei.
) - Alcohol
9 - Baiiett's esophagus
% - Cigaiette smoke
K - Biveiticula (especially Zenkei's)
* - Esophageal Webs
S - Family histoiy of esophageal cancei

+)&!,$!$&
uastiitis is causeu by an inflammation of the stomach lining. The most common cause of gastiitis is piolongeu use
of NSAIBs (ie Aspiiin), which blocks the synthesis of piostaglanuins, thus uecieasing the piotection of the stomach
lining. 0thei common causes aie alcohol consumption anu B. Pyloii.
Symptoms incluue:
- Pain in the epigastiic iegion (most common piesentation)
- Weight loss
- Loss of appetite
)A:8@ +4D87;8;D - also known as eiosive gastiitis, this foim of gastiitis is causeu most commonly by uamages to the
stomach's mucosal uefense system. NSAIBs anu alcohol aie most common causes of acute gastiitis.
%B76>;A +4D87;8;D - this is the iesult of an B. Pyloii infection.
J'#58 +: 3&,+1/3 >$8%,/%/8:
J'#5 ? - 0ccuis in the funuus of the stomach, is of autoimmune natuie.
J'#5 N - 0ccuis in the antium of the stomach, is causeu by an B. Pyloii infection.

SS2

#*#!$% 3I%*, K$&*)&*
Theie aie two types of P0B, one is gastiic anu one is uuouenal.
J&5 >$8%,/3 H^;:
- Patient usually has an associateu weight loss as theie is incieaseu pain with eating.
- The cause of a gastiic P0B is uecieases in mucosal piotection, thus causeu commonly by NSAIBs.
J&5 0*+051$. H^;:
- Patient will usually have weight gain anu the pain will ueciease with eating.
- This is almost always linkeu to an B. Pyloii infection.
- The main cause is an inciease in gastiic aciu secietion in conjunction with uecieaseu mucosal piotection.
- Theie will be hypeitiophy of Biunnei's glanus (submucosal glanus of the uuouenum who piouuce a mucus-
iich alkaline secietion).

SSS

SS4

$.SI)HH)!",L 9"0*I K$&*)&*
The two types of IBB aie Ciohn's uisease anu 0lceiative Colitis
%,"1.W& K$&*)&* 3I%*,)!$/* %"I$!$&
$I*3H $./"I/*H*.! Commonly involves ileum Raiely involves ileum
%"I".$% $./"I/*H*.! Colonic involvement often Colonic involvement
always
,*%!)I $./"I/*H*.! Raiely Almost always
9$I* K3%!
$./"I/*H*.!
None Sometimes
K$&*)&* K$&!,$93!$". Patchy, skip lesions Continuous inflammation
*.K"&%"#$% /$*0 0lceis aie lineai,
seipiginous
0lceiation is continuous
$.SI)HH)!$". K*#!1 Tiansmuial, ueep Shallow anu mucosal
S$&!3I) S",H)!$". 0ften Raiely
)&&"%$)!$". 0$!1
&H"a$.+
Bigh iisk in smokeis Low iisk in smokeis
&3,+$%)I
$.!*,/*.!$".
Retuins following suigical
inteivention
Cuieu often by suigical
iemoval
)3!"$HH3.* %)3&*&p Seen as autoimmune Not seen as autoimmune
,$&a "S %).%*, $.
)&&"%$)!$".
Low compaieu to colitis Cancei iisk highei than in
Ciohn's
9$"#&L ,*/*)I& uianulomatous Non-gianulomatous

$,,$!)9I* 9"0*I &L.K,"H* c$9&d
Is a uiagnosis of exclusion. IBS piesents most commonly in a young female in hei twenties, who piesents with
abuominal painbloating, alteieu bowel habits in the absence of any oiganic cause. Symptoms aie ielieveu aftei a
bowel movement. Nanagement of IBS is incieaseu fluiu intake + incieaseu uietaiy fibei intake (ie. Fibei
supplementation). If this uoes not woik, ceitain meuications can be exploieu, but this is usually a cuiative
appioach.

SSS

&L.K,"H*& "S H)I)9&",#!$".
The commonly testeu synuiomes of malabsoiption aie Celiac Spiue, Tiopical Spiue, anu Whipple's uisease.
Symptoms of these conuitions aie: Weight loss, ciamping, uiaiihea, steatoiihea, inuigestion, anu fatigue.
A5./$3 )#,*5 - Causeu by autoantibouies (antigliauin, antienuomysial, anti-tissue tiansglutaminase) against gluten,
which causes villous blunting anu infiltiation of lymphocytes. Tieatment is to consume a gluten-fiee uiet.
J,+#/3$. )#,*5 - This is an infectious conuition commonly founu in tiopical iegions, anu is maiket by abnoimal
flattening of the villi in the small intestine.
B&/##.5V8 ;/85$85 - This is iaiei than the othei two malabsoiption synuiome. It is causeu by an infection with the
bacteiium Tiopheiyma Whipplei, anu can cause malabsoiption in conjunction with many systemic pioblems
(caiuiac, iespiiatoiy, neuiological, iheumatologic, anu visual).

1*#)!$!$&
Bepatitis is a geneial teim to uesciibe the inflammation of the livei. Theie aie many possible causes of hepatitis,
such as alcohol, uiugs, viial, anu uisease-ielateu.
A$*858 +: -/,$. M5#$%/%/8:
Five main types of viial hepatitis aie: Bep A, B, C, B, anu E. Bepatitis can also be causeu by Epstein-Baii viius,
cytomegaloviius, anu heipes simplex viius.
J,$18"/88/+1 +: D/,$. &5#$%/%/8:
Bepatitis A & E - fecal-oial tiansmission, highei in ueveloping countiies
Bepatitis B - tiansmission is paienteial oi sexual
Bepatitis B - iequiies co-infection with hepatitis B (iequiies the outei envelope of the BbsAg)
Bepatitic C - tiansmitteu paienteially anu is thus moie common in Iv uiug useis
f 41.' &5#$%/%/8 NW AW $10 ; 3$1 #,+>,588 %+ 3&,+1/3 &5#$%/%/8Z

SS6

%$,,1"&$&
Ciiihosis is a consequence of chionic livei uisease, wheieby the noimal aichitectuie of the livei is ieplaceu by
fibiosis oi scaiiing. Nouules that aie less than Smm aie "micionouulai" anu aie uue to metabolic causes such as
alcoholism. Nouules gieatei than Smm aie usually causeu by seveie injuiy that has leau to ueath of livei cells.
Along with ciiihosis comes a vaiiety of auveise effects, on top of the auveise effects fiom ciiihosis theie aie
auveise effects causeu by the poital hypeitension that occuis.

%$,,1"!$% *SS*%!&
- uynecomastia
- Spiuei Nevi
- }aunuice
- Asteiixis
- Bleeuing Bysciiasies
- Anemia
- Euema
- Icteius
#",!)I 1!. *SS*%!&
- Esophageal vaiices
- Bemoiihoius
- Atiophy of Testes
- Splenomegaly
- Caput Neuusae
- P0B
- Ascites
SS7

#).%,*)!$!$&
Pancieatitis is an inflammation of the pancieas that causes veiy chaiacteiistic set of symptoms. The patient will
almost always piesent with seveie epigastiic pain that iauiates to the back. The two most common causes of
pancieatitis aie alcohol anu gallstones, but theie aie othei possible causes, such as:
- Tiauma
- Steioius
- Numps
- Bypeilipiuemia
- Autoimmune conuitions
- Sting fiom a scoipion
In pancieatitis, lipase anu amylase will always be elevateu (lipase is moie specific).

#).%,*)!$% )K*."%),$."H)
Pancieatic cancei is a giave uiagnosis anu often causes ueath within 6 months of uiagnosis. It is often
asymptomatic anu theiefoie highly metastasizeu by the time of uiagnosis. The most common site of the cancei is in
the heau of the pancieas, which is why the only piesenting symptoms is often painless jaunuice anu significant
weight loss.
4%&5, 3+""+1.' #,5851%/1> 8'"#%+"8 +: #$13,5$%/3 3$135, /13.*05G
- Abuominal pain
- Nigiatoiy thiombophlebitis
- Palpable gallblauuei (Couivoisiei's sign) anu obstiuctive jaunuice
H+88/I.5 3$*858 +: #$13,5$%/3 3$135,G
- Incieaseu age
- Nale sex
- Cigaiette smoking
- 0besity
- Biabetes mellitus
- Chionic pancieatitis
- B. pyloii infection
- Family histoiy
** Alcohol has not been pioven to cause pancieatic cancei, howevei alcohol consumption can leau to chionic
pancieatitis which may leau to pancieatic cancei. Theiefoie the possibility cannot be iuleu out.

SS8

)##*.K$%$!$&
Appenuicitis is a ielatively common conuition anu is the most common inuication foi emeigency abuominal suigeiy
in chiluien.
Piesentation is uiffuse abuominal pain in the peii-umbilical iegion, followeu by localization of pain to NcBuiney's
point. Patient will also have nausea, vomiting, anu oveiall look ill.
** A complication of appenuicitis is peifoiation, which can leau to sepsis.

SS9

$.!3&&3&%*#!$".
This is a conuition of the bowel wheieby one segment "invaginates" oi "telescopes" into anothei segment of bowel.
The intussusception always moves into a uistal segment. Eaily symptoms incluue nausea, vomiting, anu pulling of
the legs into the chest (foi pain ielief). The most common association with this conuition is "cuiiant jelly stools",
which is a mixtuie of bloou anu mucus. As well, theie is a palpable sausage-shapeu mass felt in the abuomen.
Tieatment involves using an enema, which often fixes the pioblem.

S6u

/"I/3I3&
A volvulus is a twisting of the bowel aiounu its mesenteiy, which can leau to obstiuction. This is an emeigency anu
iequiies an emeigent lapaiotomy to ielieve the twistingobstiuction anu pievent ischemia of the bowel.

S61

K$/*,!$%3I), K$&",K*,&
A uiveiticulum is any pouch that leaus off of the uigestive tiact. A tiue uiveiticula incluues the mucosa, the
musculaiis, anu the seiosa. Nany uiveiticula aie false since they uo not incluue all of the layeis of the tiact.
The most common types of uiveiticula:
- Zenkei's uiveiticulum
- Neckel's uiveiticulum
- Biveiticulosis
- Biveiticulitis

-*.a*,W& K$/*,!$%3I3H
A Zenkei's uiveiticulum is an outpouching founu in the phaiynx, above the ciicophaiyngeal muscle. It piesents
common with a patient who has teiiible bieath (uue to foou accumulation in the uiveiticula). This occuis 1S
uistance fiom oiophaiynx to lowei esophagus. Biagnosis is maue with a baiium swallow.

H*%a*IW& K$/*,!$%3I3H
This is a congenital uiveiticulum that is locateu in the uistal ileum. It piesents commonly with painless bloou in the
stool of a newboin. It is a iemnant of the omphalomesenteiic uuct, anu is the most fiequently encounteieu
malfoimation of the uI tiact of the newboin. Biagnosis can be maue with a technetium-99 scan, which uetects the
location of bleeuing along the uI tiact.

K$/*,!$%3I"&$&
Biveiticulosis is a conuition wheie theie aie many uiveiticula in the colon. With incieasing age theie is an
incieaseu iisk of having uiveiticulosis. Biveiticulosis is the most common cause of iectal bleeuing in someone ovei
Suyi of age. Incieaseu luminal piessuie anu colonic wall weakness causes the actual outpouching of the seiosa,
wheie a low-fibei uiet is the most common cause of this conuition.

K$/*,!$%3I$!$&
This is simply an inflammation of the uiveiticula. It piesents with seveie LLQ pain anu poses the iisk of peifoiation,
peiitonitis, anu stenosis of the bowel lumen.
S62

S6S

1$,&%1#,3.+W& K$&*)&*
A congenital 'megacolon' causeu by a lack of migiation of the neuial ciest cells to the lowei segment of the colon
(known as the tiansition zone), (Aueibach's anu Neissnei's plexus aie absent on biopsy). An infant will piesent
with chionic constipation, but this can also piesent at any point in life. Theie is a poition of the colon that is uilateu
pioximal to the aganglionic segment.

93KKZ%1$),$ &L.K,"H*
Buuu-Chiaii synuiome causes obstiuction of the infeiioi vena cava. As a iesult of this obstiuction, hepatic veins
become congesteu (centiilobai) anu this can cause neciosis. This will eventually leau to congestion of the livei anu
ultimatelyeventually leau to failuie of the livei. This conuition is especially common in piegnancy, in those with
hepatocellulai caicinoma, anu in those with polycythemia veia.

S64

1*H"%1,"H)!"&$&
This is a veiy common conuition that is causeu by a uefect in iion metabolism, which leaus to an iion oveiloau in
vital oigans, joints, anu tissues. Eaily uiagnosis can help pievent auveise effects of the iion oveiloau.
Bemochiomatosis piesents with a class tiiau of:
1. Nicionouulai ciiihosis
2. Pancieatic fibiosis
S. Skin pigmentation
This conuition is classically known as bionze uiabetes uue to the fact that it tints the skin "bionze" anu also affects
the pancieas. Total bouy iion levels may ieach upwaius of Sug, anu this must be manageu with iepeateu
phlebotomy. This conuition can leau to congestive heait failuie anu can inciease the iisk of hepatocellulai
caicinoma.
LABS: In those with hemochiomatosis, labs will show %Iion anu Feiiitin, with a & total iion binuing capacity.

0$I&".W& K$&*)&*
Is an autosomal iecessive uisoiuei wheie theie is a failuie of coppei's ability to entei ciiculation in the foim of
ceiuloplasmin. This leaus to coppei accumulation in ceitain tissues (livei, biain, coinea), anu is %,5$%50 U/%&
#51/3/..$"/15 (chelation of coppei).
The most common signs anu symptoms of Wilson's uisease aie:
- %67>@4 =@56D;8D (Kaysei-Fleischei iings), veiy common in Wilson's uisease
- )D8@7;V;D
- #47R;>D6>Z<;R@ DGF586FD uue to accumulation in basal ganglia
- %47A;>6F4
- K@F@>8;4

S6S

1*#)!"%*II3I), %),%$."H) 1%%d
Bepatocellulai caicinoma is a veiy common cause of metastasis, anu spieaus by hematogenous ioute. Nost cases of
hepatocellulai caicinoma aie uue to hepatitis B anuoi C, as well as ciiihosis. 0thei causes of BCC incluue Wilson's
uisease, hemochiomatosis, alcoholic ciiihosis, anu #-1 antitiypsin ueficiency.
The outcome is usually pooi, howevei 1-2 out of 1u cases aie tieatable with suigical iemoval of canceis.

1L#*,9$I$,39$.*H$)& c1*,*K$!),Ld
Theie aie thiee commonly testes anu encounteieu heieuitaiy hypeibiliiubinemias, they aie:
1. uilbeit's synuiome
2. Ciiglei-Najjai synuiome
S. Bubin-}ohnson synuiome

O/.I5,%V8 )'10,+"5:
uilbeit's synuiome is a benign conuition wheie theie is a milu ueciease in the 0BP-glucuionyl tiansfeiase enzymes.
This leaus to an elevation of *13+1S*>$%50 I/./,*I/1Z
A,/>.5,6P$SS$, )'10,+"5G
This is a seveie conuition that leaus to ueath eaily in life. Theie is a complete absence of 0BP-glucuionyl
tiansfeiase, which leaus to significant incieases in unconjugateu biliiubin anu causes it to ueposit in the biain
(keinicteius), as well as jaunuice. Theie is a less seveie veision of Ciiglei-Najjai calleu "type 2", anu it can be
manageu with Phenobaibital.
;*I/16e+&18+1 )'10,+"5:
This synuiome occuis as a iesult of a uefect in the livei's ability to exciete conjugateu biliiubin. It is benign but
theie is a change in coloi of the livei to black. A uiffeient foim of this synuiome is "Rotoi's synuiome", which is
even miluei anu causes no change in the coloi of the livei.

S66

+)II&!".*&
uallstones aie foimeu as a iesult of incieaseu cholesteiol oi biliiubin. They can occui anywheie in the biliaiy tiee
(incluuing insiue the gallblauuei anu in the common bile uuct). When a stone becomes lougeu insiue the common
bile uuct, this is known as choleuocholithiasis. Pain can iesult when the gallblauuei contiacts against the stone anu
it uoes not get piopelleu foiwaiu.
Foui iisk factois aie: S"3, SWD: 2!K?=!W 2!9JC=!W 2?JW 249J_
J&,55 %'#58 +: 8%+158:
1. %B6<@D8@76< - aie iauiolucent with some being opaque fiom calcification.
2. H;V@= - this is the most common type, anu is iauiolucent.
S. #;?F@>8 D86>@D - this is seen in patients who have chionic ieu bloou cell hemolysis, alcoholic ciiihosis,
biliaiy infection. This is iauiopaque.

S67

9$I$),L %$,,1"&$&
Theie aie two types of biliaiy ciiihosis: H,/"$,' $10 )53+10$,'
#7;F47G 9;<;47G %;77B6D;D:
- Is an autoimmune uisoiuei causeu by antimitochonuiial antibouies
- Causes a seveie case of obstiuctive jaunuice with all of the auveise effects associateu with seveie jaunuice
(piuiitis, hypeicholesteiolemia)
&@A6>=47G 9;<;47G %;77B6D;D:
- This biliaiy ciiihosis is uue to obstiuction outsiue of the livei (extiahepatic)
- Causes a builuup of piessuie within the uucts of the livei, anu we get bacteiial infections, ascenuing
cholangitis, bile stasis.

#,$H),L &%I*,"&$.+ %1"I).+$!$&
Anothei autoimmune uisease of the livei, wheie theie is a slowly piogiessing uestiuction of the bile canaliculi.
Bestiuction leaus to cholestasis anu theiefoie uamage, inflammation, anu fibiosis of the bile uucts. The classic
piesentation of the bile uucts is the "beauing", wheieby theie is alteinating uilation anu stiictuie of the uuct as seen
on enuoscopic ietiogiaue cholangiopancieatogiaphy (ERCP).

S68

%".+*.$!)I #)!1"I"+L

Theie aie a gioup of common congenital pathologies that aie high-yielu foi the 0SNLE Step 1 exam, they incluue:
- Befects of the heait
- Spina bifiua
- Bypospauias
- Cleft lip
- Pyloiic stenosis
- Anencephaly

%".+*.$!)I 1*),! K*S*%!&
The most common congenital heait uefects incluue:
- ventiiculai septal uefects
- Atiial septal uefects
- Patent uuctus aiteiiosus
- Tetialogy of fallot
- Tiuncus aiteiiosus
- Tiansposition of the gieat vessels
- Coaictation of the aoita

K*S*%!& %)3&$.+ ) ,$+1! !" I*S! &13.!
These uefects cause uefects that foice bloou fiom the iight siue of the heait to the left siue of the heait uue to
piessuie, iesulting in eaily cyanosis because systemic bloou is lacking oxygen. The babies aie often blue in coloi
because they uo not ieceive auequate oxygen.
The thiee common congenital malfoimations causing a R!L shunt aie:
1. Tetialogy of fallot
2. Tiansposition of the gieat vessels
S. Tiuncus aiteiiosus

S69

J!J9?=4O_ 42 2?==4JG
This conuition iesults in a gioup of pioblems, that ultimately leau to eaily cyanosis uue to shunting of bloou fiom
the iight to the left thiough the ventiiculai septal uefect. This is causeu by an anteiiosupeiioi uisplacement of the
infunuibulai septum.
The 4 pathologies of tetialogy of Fallot aie:
1. Pulmonaiy stenosis
2. Right ventiiculai hypeitiophy
S. 0veiiiuing aoita
4. ventiiculai septal uefect (pioviues aiea foi shunting)

J9?P)H4)CJC4P 42 JM! O9!?J -!))!=)G
This conuition iesults in the aoita connecteu fiom the iight ventiicle while the pulmonaiy tiunk leaves fiom the left
ventiicle. This iesults in a sepaiation of the systemic anu pulmonaiy ciiculations. Since theie is no oxygenateu
bloou being pumpeu systemically, this conuition is incompatible with life (unless theie is the piesence of a shunt).
Tiansposition of the gieat vessels waiiants immeuiate suigical coiiection foi suivival. The conuition is causeu by
failuie of the aoiticopulmonaiy septum to spiial.

J9^PA^) ?9J!9C4)^):
Tiuncus aiteiiosus occuis when theie is an incomplete oi faileu septation of the embiyonic tiuncus aiteiiosus. This
iesults in a single aiteiial tiunk that aiises fiom two noimally foimeu ventiicles. The pulmonaiy aiteiies can aiise
fiom the common tiunk in a myiiau of patteins, thus giving this conuition seveial uiffeient subtypes.

K*S*%!& %)3&$.+ ) I*S! !" ,$+1! &13.!
Theie aie thiee conuitions that cause a L!R shunt, they incluue:
1. ventiiculai septal uefects
2. Atiial septal uefects
S. Patent uuctus aiteiiosus

S7u

/*.!,$%3I), &*#!)I K*S*%!
This is the most common of all caiuiac congenital anomalies. This uefect uoes not iesult is cyanosis because the
L!R shunt uoesn't put non-oxygenateu bloou back into the systemic ciiculation. This can be uetecteu by heaiing a
pansystolic muimui on auscultation. Theie is usually no uetection at biith, but within a few weeks it will be
uetectable.

)!,$)I &*#!)I K*S*%!
This is a conuition wheie theie is a communication between both the iight anu left atiia of the heait. The ASB is the
most common congenital heait uefect seen in auults.

#)!*.! K3%!3& ),!*,$"&3&
The uuctus aiteiiosus is a vasculai connection between the pulmonaiy aiteiy anu the aoitic aich in the ueveloping
fetus. 0pon a newboin's fiist bieath, the piocess of PB closuie shoulu occui, howevei it sometimes uoes not. If
closuie fails to occui, the neonate will expeiience peisistent iespiiatoiy pioblems. The PBA can be closeu by giving
inuomethacin, anu can be kept openeu with piostaglanuin E.

%"),%!)!$". "S !1* )",!)
This is a naiiowing of the aoita that can occui in two uiffeient places. The 'pieuuctal' foim occuis pioximal to the
uuctus aiteiiosus, the 'postuuctal' foim occuis uistal to the uuctus aiteiiosus. The post-uuctal foim is associateu
with iib notching, uppei extiemity hypeitension, anu weak pulses in the lowei extiemities. Coaictation of the aoita
is seen in males much moie than in females.

S71

.*3,)I !39* K*S*%!&
Neuial tube uefects occui most commonly when theie is a lack of auequate folic aciu intake uuiing piegnancy.
0pon testing, theie is often an elevation in #-fetopiotein in the amniotic fluiu.
Theie aie thiee piesentations of neuial tube uefects, they incluue:
1. &5;>4 M;E;=4 6AA:<84 - which iesults when theie is an incomplete closuie of the spinal canal. Theie is no
actual heiniation of any spinal tissue. This often piesents with a tuft of haii on the skin above the pioblem.
2. H@>;>?6A@<@ - iesults when the spinal meninges heiniateu thiough the opening in the veitebia.
S. H@>;>?6FG@<6A@<@ - iesults when both the meninges anu the spinal coiu heiniateu thiough the bony uefect
of the veitebia.

S72

!,$&"HL K$&",K*,&
The thiee most commonly encounteieu autosomal tiisomy uisoiueis aie:
1. Patau's synuiome
2. Euwaiu's synuiome
S. Bown's synuiome

#484:WD &G>=76F@:
- Causeu by tiisomy 1S
- Cleft lip anu palate
- Seveie mental ietaiuation
- Niciophthalmia
- Niciocephaly
- Beath usually within 1
st
yeai of biith
*=T47=WD &G>=76F@:
- Causeu by tiisomy 18
- Rockei bottom feet
- Low-set eais
- Clencheu hanus
- Piominent occiput
- Beath usually within 1
st
yeai of biith
K6T>WD &G>=76F@:
- The most common chiomosomal uisoiuei
- The most common cause of congenital mental ietaiuation
- Causeu by tiisomy 21
- Piominent epicanthal folus
- Simian ciease
- Incieaseu iisk of ALL
- Congenital heait uisease (ASB most commonly)
- Causeu most commonly by meiotic non-uisjunction of homologous chiomosomes

S7S

&*J %1,"H"&"H* K$&",K*,&
1. XYY Synuiome
2. Tuinei's synuiome
S. Klinefeltei's synuiome

JLL &G>=76F@:
Patients aie phenotypically noimal but aie unusually tall, have seveie acne, anu aie pione to anti-social behaviois.

!:7>@7WD &G>=76F@ cJ"d'
Patients aie female, have shoit statuie, webbeu necks, wiuely spaceu nipples, ovaiian uysgenesis, anu expeiience
piimaiy amenoiihea. This patient is also pione to having coaictation of the aoita.

a<;>@E@<8@7WD &G>=76F@ cJJLd'
Nale patient's who aie tall, have longthin extiemities, female bouy haii patteins, testiculai atiophy, anu
gynecomastia.

S,)+$I* J &L.K,"H*
Fiagile X synuiome is an x-linkeu uisoiuei, anu is the 2
nu
most common cause of mental ietaiuation. Is a tiiplet-
iepeat uisoiuei that can show anticipation. Patients have laige testicles, long faces with laige jaw, anu laige eais.

S74

1*,H)#1,"K$!$&H
J,*5 M5,"$#&,+0/%5 - patient is eithei 46 xx oi 47 xxy, having both testes anu ovaiies piesent, with ambiguous
genitalia. This is a iaie synuiome.
#D@:=6B@7F45B76=;8;DF - Female anu Nale types:
S@F4<@ - ovaiies aie piesent but the exteinal genitalia aie viiilizeu oi ambiguous. Causeu by excessive exposuie to
anuiogens uuiing gestation.
H4<@ - testes aie piesent but the exteinal genitalia aie female oi ambiguous. The most common foim is the
anuiogen insensitivity synuiome.

).K,"+*. $.&*.&$!$/$!L &L.K,"H*
This patient is genetically male, howevei they have anuiogen ieceptois that aie insensitive to the effects of
anuiogens, making them appeai female. Theie aie noimal appeaiing exteinal genitalia but the vaginal canal is not
uevelopeu (blinu vagina). Theie aie no uteiine tubes oi uteius. Because theie is no secietion of male hoimones by
the testes (which aie piesent in the labia but often iemoveu), theie is no negative feeuback anu thus testosteione,
estiogen, anu LB will iemain elevateu.

H3&%3I), KL&!,"#1L
The two types of musculai uystiophy aie: Buchenne's anu Beckei's musculai uystiophy.
;*3&5115V8 - This is the moie seveie foim of musculai uystiophy, wheieby a ueletion of the uystiophin gene
causes an acceleiation of muscle bieakuown. Patient will expeiience weaknesses of the pelvic giiule anu oveiall
piogiessive weakness. Commonly founu is pseuuohypeitiophy of the calf (fatty ieplacement of the muscle).
Patients commonly use the "uowei's maneuvei", wheie they use theii aims to climb up the legs anu achieve a
stanuing postuie, which is chaiacteiistic of musculai uystiophy.
N53Q5,V8 - This is a less seveie veision of musculai uystiophy wheieby theie is a mutation of the uystiophin gene,
iathei than a complete ueletion.
;/$>1+8/1> musculai uystiophy is uone by finuing elevateu cieatine kinase levels anu muscle biopsy showing these
gene manipulations.

S7S

_Z#Z,*K3%!)&* K*S$%$*.%L
This enzyme is iesponsible foi conveiting testosteione to BBT. When this conuition occuis in ueveloping fetus,
they will have ambiguous genitalia until pubeity when levels of testosteione inciease, causing a masculinization of
the genitalia.

\\C[[ &L.K,"H*&
%)!%1 \\ is the common mnemonic useu to iemembei this seiies of synuiomes that commonly occui togethei.
% - cleft palate
) - abnoimal facies
! - thymic aplasia
% - caiuiac uefects
1 - hypocalcemia
\\ - Nicioueletion at the 22
nu
chiomosome at loci 11

S76

%"HH". )KY ),Y ).K JZI$.a*K K$&",K*,&
!B@ F6D8 A6FF6> 4:86D6F4< =6F;>4>8 =;D67=@7D ;>A<:=@'
- Neuiofibiomatosis 1 anu 2
- Buntington's uisease
- Familial hypeicholesteiolemia
- Polycystic kiuney uisease
- Beieuitaiy spheiocytosis
- Naifan synuiome
!B@ F6D8 A6FF6> 4:86D6F4< 7@A@DD;O@ =;D67=@7D ;>A<:=@'
- Sickle cell anemia
- Cystic fibiosis
- Tay-Sachs uisease
- Phenylketonuiia
- Albinism
- Thalassemias
- Nucopolysacchaiiuoses
- ualactosemia
- ulycogen stoiage uiseases
!B@ F6D8 A6FF6> VZ<;>R@= =6F;>4>8 =;D67=@7D'
- vitamin B iesistant iickets
- Rett's synuiome
!B@ F6D8 A6FF6> VZ<;>R@= 7@A@DD;O@ =;D67=@7D'
- Buchenne's musculai uystiophy
- Bemophilia A anu B
- ulucose-6-phosphate ueficiency
- Biuton's agammaglobulinemia
- Wiskott-Aluiich synuiome

S77

S78

H$%,"%L!$% ).*H$)&
C94P ;!2CAC!PA_ ?P!KC?
- Is the most common cause of anemia thioughout the woilu
%4:D@= MG'
- Chionic bloou loss (menstiuation is a common cause)
- In a male auult, uI bloou loss is the likely cause (no menstiuation)
K;@847G =@E;A;@>AG ;D 4 56DD;M<@ A4:D@ ;>'
- C1:$1%8 $10 %+00.5,8: especially if uiet is pieuominantly bieast milk
- ?0+.58351%8: iapiu giowth iates inciease the neeu foi iion, thus a ueficiency uevelops
- H,5>1$13': piegnancy is a state of incieaseu iion iequiiement
A+""+1 8/>18[8'"#%+"8G
- Fatigue anu weakness aie the most common symptoms
- Becieaseu seium feiiitin + incieaseu TIBS (total iion binuing capacity)
J,5$%"51%:
- 0ial feiious sulfate

JM?=?))!KC?)
Thalassemias aie inheiiteu uisoiueis that aie causeu by a lack of piouuction of eithei the # oi ! globin chains of
hemoglobin. Seveiity of thalassemia is uepenuent on which globin chain is affecteu anu how many of the gene loci
aie ueleteumutateu. As a iule, if an iion ueficiency anemia is tieateu unsuccessfully, a hemoglobin electiophoiesis
shoulu be peifoimeu looking foi a thalassemia.
! J&$.$885"/$8:
!B4<4DD@F;4 H4N67: aka homozygous !-chain thalassemia anu Cooley's anemia.
- Causes seveie miciocytic anemia
- Bone maiiow space expansion leauing to bone malfoimations
- uiowth ietaiuation anu failuie to thiive
- Pieuominantly in Neuiteiianean population
- Tieatment involves bloou tiansfusion, anu without tieatment ueath within the fiist few yeais of life is
unavoiuable.
** This foim of thalassemia can leau to congestive heait failuie. A seveie case can iequiie a chelatoi to eliminate
excess iion.
;/$>1+8/1> !6%&$.$885"/$ "$S+,G
S79

- Bemoglobin electiophoiesis will show an elevation of BbF
- Peiipheial bloou smeai will show a miciocytic hypochiomic anemia

!B4<4DD@F;4 H;>67: aka heteiozygous !-chain thalassemia
- These patients aie usually asymptomatic
- Nilu miciocytic anemia is usually the only finuing
- Biagnosing is also with hemoglobin electiophoiesis
- Since this conuition is asymptomatic, no tieatment is necessaiy

"6J&$.$885"/$8:
&;<@>8 %477;@7D: This foim is causeu by a mutation oi ueletion of only one # locus.
- Patients aie asymptomatic
- No tieatment is necessaiy
#Z8B4<<4D@F;4 F;>67: This foim of thalassemia is causeu by mutation oi ueletion of two # loci.
- Patient has milu miciocytic hypochiomic anemia, but no tieatment is necessaiy
1M 1 =;D@4D@: This foim is causeu by a mutation oi ueletion of thiee # loci
- Patient will have hemolytic anemia plus significant miciocytic hypochiomic anemia
- Tieatment involves life-long tiansfusions
- If tiansfusions fail to impiove symptoms, a splenectomy is helpful
1G=765D S@84<;D: This is a mutation oi ueletion of all foui # loci.
- This conuition is not compatible with life, anu ueath occuis at biith oi veiy shoitly theieaftei.

S8u

)C;!94N=?)JCA ?P!KC?
This is a conuition that is causeu when the bouy cannot piopeily incoipoiate iion into hemoglobin. As a iesult,
"iingeu siueioblasts" aie cieateu anu can be seen on peiipheial smeai. This can be eithei heieuitaiy oi acquiieu. If
acquiieu, causes such as alcohol, isoniaziu, chloiamphenicol, leau exposuie, collagen vasculai uisease, anu
myelouysplastic synuiomes shoulu be exploieu.
2/10/1>8:
- Theie will be a N0RNAL total iion binuing capacity + incieaseu seium iion anu seium feiiitin.
J,5$%"51%: Removal of offenuing agent if this is the cause.

.",H"%L!$% ).*H$)&

?P!KC? 42 AM94PCA ;C)!?)!
Anemia of chionic uisease occuis in the setting of a chionic illness such as: Cancei, inflammatoiy uiseases (SLE, RA),
tubeiculosis, etc.
- 0sually noimocyticnoimochiomic, howevei at times may be miciocytic anu hypochiomic.
- Nanagement of this conuition involves tieatmentmanagement of the unueilying conuition.

H)%,"%L!$% ).*H$)&

-CJ?KCP NYL ;!2CAC!PA_
The most common cause of vitamin B12 ueficiency is impaiieu absoiption
- Peinicious anemia is a lack of intiinsic factoi, anu is the most common cause of ueficiency in the westein
woilu.
- Since stoies of B12 can last foi S yeais in the livei, theie is usually not an uietaiy insufficiency.
- Competition fiom oiganisms (uiphyllobothiium latum - the fish tapewoim) can cause B12 ueficiency
)/>18[)'"#%+"8:
- Anemia with NCv >1uu + hypeisegmenteu neutiophils on peiipheial smeai
- Neuiological manifestations such as loss of vibiationposition sense, ataxia, anu 0NN signs (+ve Babinski,
spasticity, incieaseu BTR's)
- ulossitis
- Incieaseu seium levels of methylmalonic aciu anu homocysteine (B12 is a co-factoi in conveision of these
two molecules into succinyl CoA anu methionine, iespectively)
S81

!7@48F@>8: Intiamusculai auministiation of vitamin B12 one time pei month.

24=CA ?AC; ;!2CAC!PA_
Symptoms similai to vitamin B12 ueficiency without any neuiological signs oi symptoms.
- Bietaiy ueficiency is the most common cause, as stoies iun out in S months. Commonly the patient eats the
"tea anu toast" uiet
- The best souices foi folate aie gieen leafy vegetables
- 0thei common causes asiue fiom uietaiy insufficiency aie: alcoholism, piegnancy, folate antagonists,
hemolysis, hemouialysis.
!7@48F@>8: Baily folic aciu supplementation

1*H"IL!$% ).*H$)

Is a uestiuction of ieu bloou cells befoie theii piogiammeu time of ueath.
- Theie will be an incieaseu ieticulocyte count as the bone maiiow iesponus to the incieaseu neeu foi RBC's
- An anemia will iesult when the bone maiiow cannot keep up with the new uemanu foi RBC's.
Theie aie foui kinus of hemolytic anemia, they aie:
1. C1%,/18/3 - these aie factois that aie heieuitaiy in natuie, incluuing: Sickle cell uisease, thalassemias,
hemoglobin C uisease
2. !T%,/18/3 - theie aie acquiieu factois causing hemolysis, incluuing: Immune iegulateu hemolysis,
mechanical hemolysis (piosthetic heait valves), toxic insults (uiugs, poisons, etc).
S. K5"I,$15 05:53%8 - uefects of the membiane can iesult in RBC hemolysis, they incluue: Beieuitaiy
spheiocytosis, PNB
4. ;5:53%8 +: %&5 51R'"58 - u6PB ueficiency, pyiuvate kinase ueficiency

If the hemolysis occuis within the ciiculation, "intiavasculai hemolysis" occuis.
If the hemolysis occuis within the ieticuloenuothelial system, "extiavasculai hemolysis" occuis.

K$/1 :5$%*,58 +: &5"+.'%/3 $15"/$:
- }aunuice
- Fatiguepalloi
- Baik uiine (causeu by hemoglobin)
- Bepatosplenomegaly
S82

;/$>1+8/1>:
- Bemoglobin anu hematociit levels
- Peiipheial smeai to uiffeientiate between uiffeient types of hemolysis
Beinz bouies ! u6PB ueficiency
Schistocytes ! intiavasculai hemolysis
Sickleu RBC ! sickle cell anemia
Spheiocyteshelmet cells ! extiavasculai hemolysis

&$%aI* %*II K$&*)&*
Is causeu by a &5"+>.+I/1 ) EMI)F "*%$%/+1. Theie is a single amino aciu ieplacement in the !-chain.
- valine ieplaces glutamic aciu
- A low oxygen state causeu "sickling" of the ieu bloou cells
- Sickle cell "tiait" is a heteiozygote
- Sickle cell tiait patients aie usually malaiia-iesistant
?0D5,85 !::53%8:
- Aplastic ciisis causeu by Paivoviius B19 infection
- Incieaseu iisk of infection by encapsulateu bacteiia (B. Infl, S. Pneumo, Neisseiia) ! uive patient
pneumococcal vaccine, Bib vaccine, meningococcal vaccine.
- vaso-occlusive ciisis causing seveie pain (uue to miciociiculation obstiuction by sickleu ieu bloou cells)
- Splenic sequestiation ciisis

B&$% /8 $ 8#.51/3 857*58%,$%/+1 3,/8/8h
This is a potentially fatal complication of the sickle cell uisease. Bloou pools into the spleen, iesulting in
splenomegaly anu the subsequent uevelopment of hypovolemic shock. This conuition often waiiants a
splenectomy.

MIA 05:53%
- Niluei uisease (BbC oi BbSC)
!7@48F@>8: Byuioxyuiea to inciease BbF levels (pievents the sickling piocess), bone maiiow tiansplant,
piophylactic penicillin foi chiluien fiom 4 months of age to 6 yeais of age.

S8S

!1* %""H9W& !*&!
The uiiect Coombs test is useu to uetect antibouies bounu to the suiface of the RBC. This is the test useu to uetect
immune-meuiateu hemolytic anemia. The Coombs test is baseu on the iuea that the auuition of anti-human
antibouies will binu to human antibouies that aie bounu to the RBC membiane. These antibouies aie most
commonly Igu anu IgN. If these antibouies agglutinate, the RBC's will clump anu this is a positive test iesult. If they
uo not agglutinate anu clump, we have a negative test iesult.

1*,*K$!),L &#1*,"%L!"&$&
This is an AB uisoiuei wheie theie is a uefect in the gene that coues foi spectiin, iesulting in a uecieaseu content of
spectiin. This causes a loss of the membiane suiface aiea with no ueciease in volume. These two cause the shape
to shift fiom ciiculai to spheiical.
- The osmotic fiagility test is a way to test the RBC's ability to withstanu hypotonic saline. The spheiical shape
will toleiate the solution less than the iegulai RBC shape, thus causing it to iuptuie fastei.
- Peiipheial smeai woulu show spheiocytes
- Coombs test is negative

S84

+I3%"&*ZhZ#1"&#1)!* K*1LK,"+*.)&* K*S$%$*.%L
This is an x-linkeu iecessive uisoiuei that is usually piecipitateu by infections, fava beans, piimaquine, uimeicaptol,
sulfonamiues, anu nitiofuiantoin.
- Patient gets episoues of hemolytic anemia that is often piecipitateu by an aggiavating factoi
- Patient will get jaunuice anu have uaik uiine
- Peiipheial smeai will show bite cells (causeu by maciophages) anu Beinz bouies (hemoglobin piecipitation
insiue RBCs)
- Biagnose by measuiing u6PB levels.
!7@48F@>8: Avoiu piecipitating factois, tiansfuse as necessaiy

)3!"$HH3.* 1*H"IL!$% ).*H$)
Autoantibouies against the RBC membiane cause uestiuction of RBC's. Theie aie two possible causes foi this, Igu
antibouies oi IgN antibouies
$?+ A4:D@D ! "waim" autoimmune hemolytic anemia. This means that binuing of Igu to the RBC membiane occuis
optimally at S7C. This causes extiavasculai hemolysis wheie the piimaiy site of sequestiation is the spleen.
$?H A4:D@D ! "colu" autoimmune hemolytic anemia. Binuing of IgN to the RBC membiane occuis optimally at uC
to 5C. This causes intiavasculai hemolysis anu complement activation, wheie the piimaiy site of sequestiation is
the livei.
;/$>1+8/1>:
- Biiect Coombs test: If +ve = waim, if -ve = colu
!7@48F@>8: If milu , no tieatment is necessaiy. If waim anu moueiate, give glucocoiticoius (uo splenectomy if no
uC iesponse).

#),"JL&H)I ."%!3,.)I 1*H"+I"9$.3,$) c#1.d
Is a conuition wheieby theie is chionic intiavasculai hemolysis.
- Noimochiomic noimocytic anemia
- Pancytopenia (affects hematopoietic stem cells)
- Thiombosis of venous system may occui
- Nay cause moie seveie conuitions such as aplastic anemia's, myelouysplasia, anu acute leukemia's
- Patient can expeiience musculoskeletal anu uI pains
!7@48F@>8: Pieunisone oi BN tiansplant if no iesponse to tieatment.

S8S

#I)!*I*! K$&",K*,&

!1,"H9"%L!"#*.$)
This is when the platelet count falls below 1Su,uuu
A$*858:
- Becieaseu piouuction uue to: BN injuiy, suppiession, invasions
- Incieaseu uestiuction uue to: BIC, TTP, infection, uiugs, ITP, BIv
- Sequestiation
- Piegnancy: usually not a majoi concein
- Bilutional effects fiom tiansfusion
- Beteimination of cause can be maue with CBC, peiipheial smeai, anu bone maiiow biopsy.

)/>18[)'"#%+"8:
- Petechial bleeuing (pinpoint bleeuing)
- Nucosal bleeuing (ie epistaxis, menoiihagia, hemoptysis)
- Excessive bleeus aftei injuiy anuoi suigical pioceuuies
S86

!1,"H9"!$% !1,"H9"%L!"#*.$% #3,#3,) c!!#d
A conuition wheieby theie is excessive platelet consumption, leauing to an emeigency situation that can leau to
ueath iathei quickly (few months).
)/>18[)'"#%+"8:
- Alteieu mental status
- Bemolytic anemia
- Thiombocytopenia
!7@48F@>8: Plasmaphaiesis is iequiieu to maintain life, coiticosteioius anu splenectomy may also be iequiieu.

$K$"#)!1$% !1,"H9"%L!"#*.$% #3,#3) c$!#d
Is an autoimmune foimation of antibouies against platelets. Igu antibouies auheie to anu uestioy the platelets
which aie then iemoveu by splenic maciophages.
Acutely ! Is a self-limiteu conuition seen in chiluien, wheie the conuition is almost always pieceeueu by a viial
infection.
Chionically ! Is a spontaneous foim of ITP seen most commonly in miuule-ageu females. Is self-limiteu.

+I).-H)..W& !1,"H9)&!1*.$)
This is an AR uisoiuei wheie theie is a ueficiency in platelet aggiegation uue to a ueficiency of glycopiotein uPIIb-
IIIa. The only alteieu test is incieaseu bleeuing time.

9*,.),KZ&"3I$*, &L.K,"H*
Is an AR uisoiuei of platelet auhesion uue to a ueficiency of glycopiotein uPIb-IX. The platelet count will be low
with abnoimally laige platelets on peiipheial smeai.

S87

K$&",K*,& "S %")+3I)!$".

1. von Willebianu's Bisease (vWB)
2. Bemophilia A
S. Bemophilia B
4. Bisseminateu Intiavasculai Coagulation (BIC)
S. vitamin K ueficiency
6. Coagulopathy of livei uisease
7. Inheiiteu hypeicoagulable states

/". 0$II*9,).KW& K$&*)&*
Is an AB uisoiuei that is causeu by a ueficiency oi uefect of the vWF (factoi 8-ielateu antigen). vWF is iequiieu foi
the fiist step of platelet aggiegation in clot foimation.
* O0S ;D 8B@ F6D8 A6FF6> ;>B@7;8@= M<@@=;>? =;D67=@7Y 4EE@A8;>? :5 86 ]q 6E 8B@ 565:<48;6>`
)/>18[)'"#%+"8:
- Cutaneous bleeuing
- Nucosal bleeuing
- Nenoiihagia seen in moie than half of females with vWB
- Nany patients won't show anything sign oi symptoms until they unueigo a suigical pioceuuie anu have
excessive bleeuing
- Bleeuing time will be piolongeu, platelet count is noimal
- PTT may be piolongeu, vWF is uecieaseu, factoi 8 activity is uecieaseu
- Ristocetin levels shoulu be checkeu in uiagnosing vWB
Tieatment: Besmopiessin to inuuce enuothelial cells to seciete von Willebianu factoi (not effective in type S vWB).
Factoi 8 concentiates is iecommenueu foi type S vWB. Patient shoulu avoiu NSAIBs.

1*H"#1$I$) )
Is an x-linkeu iecessive uisoiuei that affects male patients, anu is causeu by a ueficiency oi uefect of factoi 8.
)/>18[)'"#%+"8:
- Bleeuing into joints (hemaithioses)
- Intiamusculai bleeus
- Intiacianial bleeus (theiefoie heau tiauma must be taken veiy seiiously in these patients)
;/$>1+8/1>:
- Low factoi 8 levels + noimal vWF
S88

- PTT is piolongeu
!7@48F@>8: Replace clotting factois, uesmopiessin may be helpful in some patients.

1*H"#1$I$) 9
Is an x-linkeu iecessive uisoiuei causeu by a ueficiency of factoi 9, anu is much less common than hemophilia A.
Nanagement involves ieplacing missing factois.

K$&&*H$.)!*K $.!,)/)&%3I), %")+3I)!$". cK$%d
BIC is a uisoiuei chaiacteiizeu by an abnoimal activation of the coagulation sequence, which leaus to wiuespieau
foimation of miciothiombi thioughout the miciociiculation. This leaus to the consumption of clotting factois,
platelets, anu fibiin. Theie is also an activation of fibiinolytic mechanisms, thus leauing to hemoiihages. 9I**K& k
!1,"H9"&$&
A+""+1 3$*858:
- The most common cause is infection (uiam -ve sepsis is NCC)
- Piegnancy complications
- Tiauma
- Nalignancy
- Shock
)/>18[)'"#%+"8:
- 0ozing fiom pioceuuie sites
- Ecchymoses
- Petechia
- Puipuia
- Thiomboses seen moie often in chionic cases of BIC
!7@48F@>8: Coiiect unueilying conuitions anu apply suppoitive measuies.

/$!)H$. a K*S$%$*.%L
Theie aie many clotting factois that iequiie vitamin K as a cofactoi in synthesis, incluuing: Piotein C & S, anu
factois 2, 7, 9, 1u. vitamin K ueficiency is seen in veiy ill patients who aie being feu thiough a tube, as well as those
who aie using oial waifaiin as an anti-coagulant.
)/>18[)'"#%+"8:
- Significant hemoiihages
- PT piolongation (is the fiist finuing), then PTT piolongation.
S89

!7@48F@>8: vitamin K ieplacement.
If patient has a seveie bleeu, fiesh fiozen plasma shoulu be given as it contains all of the clotting factois.

%")+3I"#)!1L "S I$/*, K$&*)&*
Since the livei synthesizes all clotting factois, any uisease of the livei can cause coagulopathies (abnoimal bleeuing,
piolongation of PTPTT).
Tieatment: Fiesh fiozen plasma if PTPTT aie alteieu oi theie is significant bleeuing.

$.1*,$!*K 1L#*,%")+3I"#)!1$*&
- ?1%/%&,+"I/1 \ 05:/3/513' (incieaseu thiombosis)
- ?1%/#&+8#&+./#/0 $1%/I+0' 8'10,+"5 (aiteiial oi venous thiombosis)
- H,+%5/1 A 05:/3/513' (uniegulateu fibiin synthesis)
- H,+%5/1 ) 05:/3/513' (leaus to a ueficiency of piotein C activity)
- 2$3%+, - .5/051 (uniegulateu piothiombin activation - incieaseu thiomboembolic events)
- H,+%&,+"I/1 >515 "*%$%/+1

#I)&H) %*II K$&",K*,&

1. Nultiple Nyeloma
2. Waluenstiom's Nacioglobulinemia
S. Nonoclonal uammopathy of 0nueteimineu Significant (Nu0S)

S9u

H3I!$#I* HL*I"H)
Is a cancei of the bone maiiow that piouuces laige amounts of Igu oi IgA. This is the most common tumoi aiising
in auults
C% 3$*858:
- Bone lesions
- Bypeicalcemia
- Anemia
- Infections
)/>18[)'"#%+"8:
- Skeletal manifestations (bone pain, fiactuies, veitebial collapse)
- Noimocytic noimochiomic anemia (uue to BN infiltiation anu ienal failuie)
- Renal failuie
- Infections (seconuaiy to uepiivation of noimal Ig's affects humoial immunity, anu is the NCC of ueath)
- Amyloiuosis
A&$,$3%5,/8%/3 2/10/1>8:
- Bence }ones pioteins in uiine (aie Ig light chains)
- N-spike (is a monoclonal Ig spike seen on seium electiophoiesis)
- Rouleau foimation (peiipheial smeai showing RBCs stackeu like pokei chips)

0)IK*.&!,"HW& H)%,"+I"93I$.*H$)
Is a conuition that causes hypeiviscosity of the bloou uue to malignant piolifeiation of plasmacytoiu lymphocytes
(IgN). Shoulu be manageu with chemotheiapy anu plasmaphaiesis

H"."%I".)I +)HH"#)!1L "S 3.K*!*,H$.*K &$+.$S$%).%*
Is a conuition that is usually asymptomatic anu seen in the elueily population.

S91

S92

ILH#1"H)&

1"K+a$.W& OD` .".Z1"K+a$.W&
1"K+a$.W& .".Z1"K+a$.W&
Reeu-Steinbeig cells piesent.

0nly single gioup of LN's affecteu.

Low-giaue fevei, weight loss, night
sweats.

Associateu with Epstein Baii viius.

Piognosis uepenuent on amount of
lymphocytes anu Reeu-Steinbeig cells
(best when incieaseu lymphocytes anu
uecieaseu Reeu-Steinbeig cells).
Is associateu with states of
immunosuppiession.

Nany LN's involveu with extianoual
involvement.

B cells aie of the majoiity.

veiy few constitutional symptoms
0ccuis fiom 2u-4uyi of age.

S9S

%),K$)% #)!1"I"+L

$&%1*H$% 1*),! K$&*)&*
1. Stable Angina
2. 0nstable Angina
S. vaiiant Angina (Piinzmetal's)

)J?N=! ?POCP?
Fixeu atheioscleiotic lesions naiiow the coionaiy aiteiies, leauing to an imbalance between bloou supply anu u2
uemanu. This leaus to inauequate peifusion, anu oxygen uemanu exceeus bloou supply. Atheioscleiosis leaus to
naiiowing > 7S%.
)/>18[)'"#%+"8:
- Substeinal chest pain lasting less than 1S minutes
- Pain is uesciibeu as squeezing, heaviness, piessuie
- Always biought on by physical exeition
- Pain goes away with iest anuoi nitioglyceiine

^P)J?N=! ?POCP?
In unstable angina, the cause of chest pain is uue to a ieuuceu iesting coionaiy bloou flow. The main uiffeience
between unstable vs. stable angina is that the pain of unstable angina occuis at iest.

H9CPgK!J?=V) ?POCP?
Piinzmetal's angina is causeu by a tiansient coionaiy vasospasm that is accompanieu by a fixeu atheioscleiotic
lesion. The symptoms occui at iest.
SignsSymptoms:
- Chest pain at iest
- Nost common in youngei females who smoke cigaiettes
- Theie will be a tiansient ST-segment elevation on EKu uuiing the episoues of chest pain

S94

),!*,$"&%I*,"&$& P )!1*,"&%I*,"&$&
?9J!9C4)A=!94)C) - Aiteiioscleiosis is a consequence of hypeitension, wheieby theie is hyaline thickening of the
small aiteiies.

?JM!94)A=!94)C)
Is plaque foimation within the intima of the aiteiies, occuiiing in the elastic anu laigemeuium - sizeu musculai
aiteiies. The most common causes of atheioscleiosis aie: MJPW 8"+Q/1>W &'#5,./#/05"/$W ;KW 0/5%$,' :$3%+,8W
:$"/.' &/8%+,'Z
H,+>,588/+1G 2$%%' )%,5$Q ! H,+./:5,$%/D5 H.$7*5 ! A+"#.5T ?%&5,+"$
?0D5,85 !::53%8G
- Ischemia
- Infaiction
- Peiipheial vasculai uisease
- Thiombus
- Emboli
=+3$%/+18:
Nost commonly in the abuominal aoita, coionaiy aiteiies, popliteal aiteiies, anu caiotiu aiteiies.

1L#*,!*.&$".
*DD@>8;4< 1!.: No iuentifiable cause, anu applies to > 9S% of cases of BTN
&@A6>=47G 1!.: Renal causes (stenosis), enuociine causes (hypeialuosteionism, hypeithyioiuism, Cushing's,
pheociomocytoma), meuication (0CPs). **0CP's aie NCC in young women
!::53%8 +: MJP +1 %&5 &5$,%:
- Incieaseu systemic vasculai iesistance leauing to eventual CBF (CBF is the most common enu-iesult of BTN)
- Atheioscleiosis
- CAB
- Left ventiiculai hypeitiophy
- Stioke
- Renal failuie
- Retinal changes anu uamage
- Risk of hemoiihages
- Risk of kiuney atheioscleiosis

S9S

1!.
%<4DD;E;A48;6>
&GD86<;A ,@4=;>? K;4D86<;A ,@4=;>? H4>4?@F@>8
.67F4< < 12u < 8u No tieatment
necessaiy
#7@BG5@78@>D;6> 12u-1S9 8u-89 Lifestyle
mouifications only
&84?@ [ 1!. 14u-1S9 9u-99 Lifestyle mous + 1
anti-BTN
meuication
&84?@ \ 1!. ' 16u ' 1uu Lifestyle mous + 2
anti-BTN meus

HL"%),K$)I $.S),%!$".
Nyocaiuial infaictions occui as a iesult of the occlusion of a vessel in the heait, inteiiupting the supply to the heait,
iesulting in infaiction. 0ccuis in the =?; k 9A? k AC9A^K2=!`
J&5 I58% /1/%/$. %58% :+, $ 8*8#53%50 KC /8 %&5 !dOZ

A$,0/$3 !1R'"58:
%aZH9 - best initial caiuiac enzyme (optimal foi uetecting a seconu infaict while in the hospital)
!7656>;>- iises aftei 4 his then stays elevateu foi 7-1u uays

H$%&+.+>/3$. 3&$1>58 $:%5, $1 KC:
K4G [ - Baik mottling
K4G \Z^ - Bypeiemia (vessel uilation)
K4G _Z[n - Bypeiemic boiuei with cential yellow-biown softening
S@T T@@RD - 0ccluueu aiteiy is ie-canalizeu anu a scai is piesent (giay-white coloiing).

A+"#./3$%/+18 +: $ "'+3$,0/$. /1:$,3%/+1:
1. Left ventiiculai failuie
2. Pulmonaiy euema
S. Caiuiac aiihythmia (most common cause of ueath befoie ieaching the hospital)
4. Caiuiogenic shock
S96

S. Ruptuie of ventiiculai fiee wall, papillaiy muscles, anuoi inteiventiiculai septum (occuis 4-1u uays post-
NI)
6. Nuial thiombus causing thiomboembolism
7. Peiicaiuitis (S-S uays post-NI)

%),K$)% !3H",&
In auults, the most common tumoi is the "K'T+"$". This occuis most of the time in the left atiium. They cause a
"ball-valve obstiuction" that obstiucts the left atiium.
In chiluien, the most common tumoi is the "9&$I0+"'+"$" anu is associateu with tubeious scleiosis.

S97

%".+*&!$/* 1*),! S)$I3,*
A conuition wheieby the heait's pumping ability cannot meet the bouy's ciiculatoiy uemanus unuei noimal
conuitions.

S98

JM! 29?Pd6)J?9=CPO 9!=?JC4P)MCH
Says that in noimal functioning heaits, an inciease in pieloau shoulu iesult in gieatei contiactility. Baseu on this
piinciple, with exeition a heait in CBF piouuces less contiactility anu this is when symptoms occui.

)/>18[)'"#%+"8:
=!2J6)C;!; M2
- Byspnea (seconuaiy to pulmonaiy congestion)
- 0ithopnea (uifficulty sleeping in the iecumbent position)
- Paioxysmal noctuinal uyspnea (patient awakes shoitly aftei falling asleep uue to S0B)
- PNI is uisplaceu to the left uue to caiuiomegaly
- SS (ventiiculai gallop)
- S4 (atiial systole into a non-compliant left ventiicle)
- Ralesciackles (an inuication of pulmonaiy euema)
- Bullness on peicussion
9COMJ6)C;!; M2
- Peiipheial euema (pitting)
- }ugulai venous uistention
- Ascites
- Bepatomegaly
- Right ventiiculai heave
S99

/)I/3I), 1*),! K$&*)&* cH3,H3,&d
1. Nitial Reguigitation
2. Aoitic Stenosis
S. ventiiculai Septal Befect
4. Nitial Piolapse
S. Aoitic Reguigitation
6. Nitial Stenosis
7. Patent Buctus Aiteiiosus
8. Bypeitiophic obstiuctive caiuiomyopathy (B0CN)

All valvulai heait uiseases piesent with shoitness of bieath initially. In young people, the most commonly
encounteieu valve uisoiueis aie: Nitial piolapse, mitial stenosis, oi bicuspiu aoitic valves.
H:7F:7 $>8@>D;8G:
IvI - 0nly heaiu with specific maneuveis (ie valsalva)
IIvI anu IIIvI - This is wheie the majoiity of muimuis lie.
IvvI - Palpable thiill is piesent
vvI - Nuimui can be heaiu with the stethoscope paitially off the chest
vIvI - Nuimui can be heaiu without a stethoscope

KCJ9?= 9!O^9OCJ?JC4P X A holosystolic "blowing muimui" that is best heaiu at the apex of the heait.
?49JCA )J!P4)C) - The "ciescenuo-ueciescenuo" systolic ejection muimui following an ejection click.
-); - A holosystolic muimui
KCJ9?= H94=?H)! - A late systolic muimui with a miusystolic click
?49JCA 9!O^9OCJ?JC4P - Bigh-pitcheu blowing uiastolic muimui
KCJ9?= )J!P4)C) - A late iumbling uiastolic muimui following an opening snap
H;? - A machine-like muimui
M_H!9J94HMCA 4N)J9ÂJC-! A?9;C4K_4H?JM_ - An autosomal uominant tiait that can iesult in suuuen ueath
in young athletes. The walls of the Lv anu inteiventiiculai septum hypeitiophy, cieating a "banana shape" in the
ventiicle.

6uu

%),K$)% ),,1L!1H$)&
!4ABG477BG8BF;4D:
- Atiial Fibiillation
- Atiial Fluttei
- Nultifocal Atiial Tachycaiuia
- Paioxysmal Supiaventiiculai Tachycaiuia
- Wolff-Paikinson-White Synuiome
- ventiiculai Tachycaiuia
- ventiiculai Fibiillation
974=G477BG8BF;4D:
- Sinus Biauycaiuia
- Sick Sinus Synuiome
- Av Blocks (1
st
, 2
nu
, anu S
iu
uegiee blocks)

?J9C?= 2CN9C==?JC4P
An iiiegulai, iapiu ventiiculai iate is causeu by multiple foci in the atiia that fiie eiiatically. The atiial iate is as
high as 4uubpm.
Patient will expeiience:
- Palpitations
- Bizziness
- Exeitional uyspnea
- Iiiegulaily iiiegulai pulse
uoals of tieatment aie:
1. ventiiculai iate contiol
2. Restoiation of noimal sinus ihythm
S. uive anticoagulation (if neeueu)

?J9C?= 2=^JJ!9
0ne foci in the atiium fiies automatically, causing an atiial iate of 2Su-SSubpm, with only 1 out of S of these
contiactions making it to the ventiicle. The EKu will show with the classic "sawtooth" pattein.

6u1

K^=JC24A?= ?J9C?= J?AM_A?9;C?
This is a conuition that occuis most commonly in those with C0PB. Theie will be at least thiee uiffeient P-wave
moiphologies with vaiiable PR anu RR inteivals.
Can uiagnose with vagal maneuveis anuoi auenosine auministiation to show the an Av block without uisiupting
the atiial tachycaiuia.

H?94`_)K?= )^H9?-!PJ9CA^=?9 J?AM_A?9;C?
Is uue to a ieentiant ciicuit within the Av noue. Theie will be naiiow QRS complexes with no uisceinable P waves
on EKu. This conuition may be causeu by the following:
- Bigoxin toxicity
- Ischemic heait uisease
- Atiial fluttei
- Piesence of accessoiy pathways
- Excessive consumption of alcohol oi caffeine

B4=226H?9dCP)4P6BMCJ! )_P;94K!
Theie is an accessoiy pathway fiom the atiia to the ventiicles that cause piematuie ventiiculai excitations uue to a
lack of uelay in the Av noue.
Theie aie two mechanisms by which this conuition can cause a paioxysmal tachycaiuia:
1. &:574O@>87;A:<47 !4ABGA47=;4D - All impulses get thiough to the ventiicle in this conuition, wheieas in
noimal ciicumstances only one Atiial impulse gets thiough.
2. "78B6=76F;A ,@A;576A48;6> !4ABGA47=;4 - cieates a ie-entiy loop that causes multiple uepolaiizations of
the atiia.

-!PJ9CA^=?9 J?AM_A?9;C?
This conuition is uefineu as a iapiu anu iepetitive fiiing of thiee oi moie piematuie ventiiculai contiactions in a
iow, at a iate of 1uu-2Subpm. Is iesponsible fio up to 7S% of caiuiac aiiest.
The most common causes of ventiiculai tachycaiuia aie:
- Caiuiomyopathies
- Bypotension
- CAB
- Piolongeu QT synuiome
6u2

- Biug toxicities
)/>18[)'"#%+"8:
- Palpitations
- Byspnea
- Angina
- Syncope
- Wiueneu anu eiiatic QRS complex on EKu
** A iapiu, polymoiphic foim of ventiiculai tachycaiuia can leau to a conuition known as "Toisaues ues Pointes".

-!PJ9CA^=?9 2CN9C==?JC4P
0ccuis when theie aie multiple foci within the ventiicles that fiie iapiuly, which leaus to a chaotic quiveiing of the
ventiicles. Nost cases of vFib occui as a iesult of ventiiculai tachycaiuia. This conuition is fatal when untieateu.
** Association of vFib with an NI cieates a favoiable long-teim piognosis, wheieas no association between the two
gives a high iate of iecuiience.
)/>18[)'"#%+"8:
- Lack of pulse, heait sounus, anu BP
- Patient loses consciousness anu will uie without inteivention
** Immeuiate uefibiillation anu CPR shoulu be peifoimeu to pievent suuuen ueath. Theie aie no meuications that
can conveit this conuition to noimal ihythm.
** Note that all 1$,,+U 3+"#.5T %$3&'3$,0/$8 will oiiginate fiom above the ventiicle, wheieas U/05 3+"#.5T
%$3&'3$,0/$8 oiiginate within the ventiicles.

974=G477BG8BF;4D:

)CP^) N9?;_A?9;C?
Is a sinus iate of < 6u bpm, anu becomes uangeious when the iate uiops below 4S bpm. Common causes of sinus
biauycaiuia aie: Ischemia, Incieaseu vagal Tone, Anti-aiihythmics
** Patients aie usually symptomatic anu may piesent with only fatigue
** Atiopine will block vagal stimulation anu thus elevate the sinus iate.

6uS

)CAd )CP^) )_P;94K!
This is a uysfunction of the sinus noue that causes peisistent spontaneous bouts of sinus biauycaiuia. Patient will
expeiience uizziness, confusion, fatigue, anu CBF.

?- N=4Ad)
[
D8
=@?7@@ - A benign conuition wheie the PR inteival is piolongeu to >u.2u seconus
\
>=
=@?7@@ - Theie aie Nobitz type 1 anu Nobitz type 2
6)C/'0 <&@" R - piogiessive piolongation of PR inteival until theie is an absent P wave. Boes not iequiie tieatment.
6)C/'0 <&@" S - theie is a missing P wave without any changes in the pieceuing PR inteival, causing the uiopping of
a QRS complex all of a suuuen. Nay piogiess anu become a complete heait block. 957*/,58 #$35"$Q5, /"#.$1%.
]
7=
=@?7@@ c%6F5<@8@ B@478 M<6ARd - theie is an absence of atiial impulses to the ventiicle, thus theie is no
ielationship between P waves anu QRS complexes. 957*/,58 #$35"$Q5,Z

%),K$"HL"#)!1$*&

M_H!9J94HMCA A?9;C4K_4H?JM_
Asymmetiic caiuiomyopathy that involves the inteiventiiculai septum iesults in uiastolic uysfunction. The walls of
the left ventiicle become thickeneu. A banana shape occuis in the Lv, can iesult in suuuen ueath in young athletes.
;C=?J!; A?9;C4K_4H?JM_
Bilation of the heait that is most commonly causeu by: ?.3+&+.W ?0,/$"'3/1W 9$0/$%/+1W A&$>$V8 0/85$85W
A+T8$3Q/5 N D/,*8. This conuition iesult in systolic uysfunction.
9!)J9CAJC-! A?9;C4K_4H?JM_
6u4

Nyocaiuial infiltiation iesults in impaiieu uiastolic filling of the ventiiculai uue to a ueciease in ventiiculai
compliance. Common causes aie: ?"'.+/0+8/8W )$,3+/0+8/8W M5"+3&,+"$%+8/8W )3.5,+05,"$Z

#*,$%),K$)I K$&",K*,&
1. Acute Peiicaiuitis
2. Constiictive Peiicaiuitis
S. Peiicaiuial Effusion
4. Caiuiac Tamponaue

?A^J! H!9CA?9;CJC)
Is an acute conuition that iesults in chest pain, uiffuse ST-elevations anu PR uepiession on EKu, a peiicaiuial
fiiction iub, anu possible peiicaiuial effusion.
Nay be causeu by any of the following:
- Nost cases occui aftei a viial illness (most commonly an 0RI)
- Infectious (Coxsackie viius, hepatitis, BIv, TB, toxoplasmosis, oi fungal infections)
- Collagen vasculai uisease
- Post-suigeiy
- Amyloiuosis
- Lupus
- Post-NI (known as Biesslei's synuiome)
** Recoveiy occuis within 1-S weeks anu iequiies only NSAIBs foi management.
Complications may incluue:
- Effusion
- Tamponaue occuis in 1u%-2u% of patients

A4P)J9CAJC-! H!9CA?9;CJC)
0ccuis seconuaiy to fibious scaiiing of the peiicaiuium, leauing to iigiuity anu thickening of the peiicaiuium.
Theie aie a few possible causes, incluuing:
- Connective tissue uisoiueis
- Chionic peiicaiuial effusion
- Rauiation theiapy
- 0iemia
- Piioi heait suigeiies
)/>18[)'"#%+"8:
6uS

- Symptoms of hepatic congestion (euema, ascites)
- Pulmonaiy congestion
- }vB
- Peiicaiuial knock

H!9CA?9;C?= !22^)C4P
0ccuis when peiicaiuial space becomes occupieu with fluiu. 0ccuis when theie is ascites anu pleuial effusion
piesent. 0ften occuis when the patient has CBF, nephiotic conuitions, anuoi ciiihosis.
)/>18[)'"#%+"8:
- Peiicaiuial fiiction iub
- Nuffleu heait sounus
- Point of maximal impulse (PNI) is softeneu

A?9;C?A J?KH4P?;!
Is a peiicaiuial effusion that impaiis uiastolic filling of the heait. Piessuie of all chambeis, the pulmonaiy aiteiy,
anu peiicaiuium aie equal in piessuie, thus ventiiculai filling is impaiieu.
A+""+1 3$*858:
- Fiee-wall iuptuie aftei an NI
- Neuical eiiois causing punctuie to heait
- Penetiating injuiies
)/>18[)'"#%+"8:
- Bypotension
- }vB
** Known as "Beck's Tiiau"
- Naiioweu pulse piessuie
- Pulsus paiauoxus (exaggeiateu ueciease in aiteiial piessuie uuiing inspiiation > 1ummBg)
- Caiuiogenic shock
6u6

,1*3H)!$% 1*),! K$&*)&*
Rheumatic feveiheait uisease is a conuition that occuis as a consequence of phaiyngitis fiom a gioup A stiep
infection. The mitial valve is the most common valve affecteu. The piogiession to a heait uisease is an immune-
meuiateu piocess, not a iesult of the bacteiial infection.
Biagnosing is maue with the }0NES ciiteiia, anu iequiie the piesence of two majoi ciiteiia 0R one majoi anu one
minoi ciiteiia:

*.K"%),K$!$&
Is an infection of the enuocaiuium that can be classifieu as eithei acute oi subacute. Nost often, the mitial valve is
involveu, wheieas an infection of the tiicuspiu valve is usually uue to Iv uiug abuse.
)A:8@ *>=6A47=;8;D - Causeu by )%$#& ?*,5*8 anu cieates laige vegetations on a pieviously healthynoimal valve.
&:M4A:8@ *>=6A47=;8;D - Causeu by -/,/0/$18 >,+*# )%,5# anu cieates small vegetations on an abnoimaluiseaseu
valve. ** 0ccuis with uental pioceuuies
The symptoms of bacteiial enuocaiuitic can be iemembeieu with the mnemonic "S,"H X).*".
S - Fevei
, - Roth's spots (ietinal hemoiihages)
" - 0slei's noues (painful, iaiseu ieu lesions on hanus anu feet)
H - Nuimui
X - }ane way lesions (non-tenuei lesions on palms anu soles)
) - Anemia
. - Nail-beu hemoiihage
* - Emboli

H)X", %,$!*,$)
Nigiatoiy Polyaithiitis
Eiythema Naiginatum
Choiea
Caiuiac Involvement
Subcutaneous Nouules
H$.", %,$!*,$)
Fevei
ESR elevation
Polyaithialgias
PR inteival piolongation
Piioi histoiy of RF infection
Eviuence of pieceeuing stiep
infection
6u7

** =/I"$16)$3Q8 !10+3$,0/%/8 - is a foim of enuocaiuitis seen in patients with Lupus, wheie theie aie vegetations
founu on both siues of the valve, leauing to stenosis.

*H9"I$
Emboli aie things that tiavel thiough the ciiculation an get lougeu in the pulmonaiy vasculatuie, leauing to a
pulmonaiy embolus (PE).
The most commonly encounteieu types of emboli aie: S48 (uue to long bone bieaks anu liposuction), );7 (can occui
as a iesult of injection of aii into the ciiculatoiy system), !B76FM:D (bieaks of fiom a ueep vein thiombosus),
)F>;68;A S<:;= (fiom piegnancy complications).
** P4J!: Thiombi causing a pulmonaiy embolism will piesent with chest pain anu shoitness of bieath in the
patient.
K/!
A ueep vein thiombosis (BvT) is the piecuisoi to an emboli, anu is causeu by patients who have the following:
1. )%$8/8 (they uon't move enough - classically they took a long flight)
2. M'#5,3+$>*.$I/./%' (uue to uisease states oi familial)
\Z !10+%&5./$. ;$"$>5

6u8

&a$. %).%*,
The thiee types of skin cancei incluue: Squamous cell, basal cell caicinoma, anu melanoma.
&C:4F6:D %@<< %47A;>6F4:
Is a veiy common foim of skin cancei, anu is associateu with excess exposuie to sunlight. Is most commonly seen
on the hanus anu face, actinic keiatosis is a piecuisoi to SCC. Is locally invasive but iaiely will it metastasize.

94D4< %@<< %47A;>6F4:
Piesents as "peaily papules", anu is most commonly seen in sun-exposeu aieas of the bouy.

6u9

H@<4>6F4:
Nelanoma poses the gieatest iisk of metastasis. Those with faii skin aie at highest iisk. Theie is a uiiect
coiielation between the uepth of the lesion anu the uegiee of metastasis.

9,)$. %).%*,&
%B;<=B66= M74;> A4>A@7D'
1. Astiocytoma
2. Neuulloblastoma
S. Epenuymoma
4. Bemangioma
S. Cianiophaiyngioma

?8%,+3'%+"$ - This type of biain cancei is usually founu in the posteiioi fossa, anu it comes with a goou piognosis.
K50*..+I.$8%+"$ - This can cause hyuiocephalus as it often piesses on the fouith ventiicle. The cells aiiange in a
'Rosette' anuoi 'Pseuuoiosette" pattein. It is a highly malignant ceiebellai tumoi.
!#510'"+"$ - 0sually founu in the fouith ventiicle, it ueiives fiom epenuymal cells anu can also cause
hyuiocephalus uue to its location.
M5"$1>/+I.$8%+"$ - Can leau to polycythemia because it piouuces eiythiopoietin. It is usually ceiebellai, but can
be associateu with a ietinal angioma (which gives it an association to von Bippel Linuau synuiome)
A,$1/+#&$,'1>/+"$ - Is a supiatentoiial tumoi that is benign anu often confuseu with a pituitaiy auenoma. Is
ueiiveu fiom the iemnants of Rathke's pouch.
)=:<8B66= M74;> A4>A@7D'
H/%*/%$,' $051+"$ - Nost commonly as piolactin-secieting foim, the most common piesentation is bitempoial
hemianopsia.
61u

O./+I.$8%+"$ K*.%/:+,"5 - Is the most common piimaiy biain tumoi, has a teiiible piognosis. This is founu in the
hemispheies anu often ciosses the coipus callosum (giving it the teim 'butteifly glioma').
K51/1>/+"$ - Comes fiom aiachnoiu cells, making it exteinal to the biain. Is the 2
nu
most common biain tumoi in
auults.
4./>+0510,+>./+"$ - Is a slow giowing anu iaie tumoi, seen usually in the fiontal lobe of the biain.
)3&U$11+"$ - Is the S
iu
most common auult biain tumoi, oiiginating fiom Schwann cells. When locateu neai the
8
th
cianial neive can cause an acoustic schwannoma.

!3H",& "S !1* 9".*

01$%1 !3H",& H*!)&!)&$-* !"
!1* 9,)$.Y 9".*Y ).K I$/*,
9*.$.+ !3H",& "S 9".*
*>AB6>=76F4
Is a caitilaginous tumoi founu in
the intiameuullaiy bone, most
often in uistal extiemities.
"D8@6AB6>=76F4
In men <2Syi of age, is the most
common benign tumoi of bone.
0iigination is fiom the long
metaphyseal bone.
+;4>8 %@<< !:F67
0ccuis fiom 2u-4uyi of age.
0sually founu in uistal
femuipioximal tibia. Bas the
classic "uouble bubble" sign on
xiay.
H)I$+.).! !3H",& "S 9".*
"D8@6D47A6F4
The most common malignant bone
tumoi, occuiiing in 1u-2uyi olus.
Is most commonly seen in the
metaphysis of long bones.
*T;>?WD &47A6F4
In males <1Syi of age, has the
11;22 tianslocation. Is likely to
metastasize eaily, anu has the
chaiacteiistic 'onion skinning on
xiay. Seen in uiaphysis of long
bones, iibs, pelvis, anu scapula.
%B6>=76D47A6F4
A malignant tumoi of caitilaginous
bone, seen in males >Suyi of age.
Not seen in the long bones.
J4 N9?CP
Lung
Skin
Kiuney
uI tiact
J4 N4P!
Bieast
Lung
Thyioiu
Testeu
Kiuney
Piostate
J4 =C-!9
Colon
Stomach
Pancieas
Bieast
Lung
611

!3H", H),a*,&
The following list aie the common maikeis that aie useu to eithei make a uiagnosis of a ceitain cancei, oi to
monitoi the effectiveness of theiapy.
T0N0R NARKER WBAT IS WATCBES
Caicinoembiyonic Antigen (CEA) Coloiectal anu pancieatic canceis
Piostatic Specific Antigen (PSA) 0seu foi scieening of piostatic cancei
CA-12S Betects ovaiian cancei anu malignant
epithelial tumois.
Alkaline Phosphatase Bone metastasis, bile uuct obstiuction,
Paget's bone uisease
!-hCu Byuatifoim moles, uTB's, anu
choiiocaicinomas
#-feto piotein Non-seminomatous geim cell tumois of
the testicles
Taitiate-iesitant aciu phosphatase Baiiy cell leukemia

!3H", &3##,*&&",&
Tumoi suppiessois woik by suppiessing the giowth of ceitain tumois, when theie is a loss of function, both alleles
of the gene have been changeu (ie mutation, ueletion, etc)
T0N0R S0PPRESS0R T0N0R IT S0PPRESSES
Rb Retinoblastoma
BRCA 1 anu 2 Bieast cancei, ovaiian cancei
pSS Belps scieenfollow almost all canceis
APC Coloiectal cancei
NF1 anu NF2 Neuiofibiomatosis 1 anu 2
WT1 Wilm's tumoi

612

".%"+*.*&
0NC0uENE ASS0CIATEB T0N0R
Ret NEN synuiomes type 2 anu S
c-myc Buikitt's lymphoma
L-myc Lung tumois
N-myc Neuioblastoma
Bcl-2 Folliculai lymphomas
Eib-B2 Bieast, ovaiy, gastiic
Ras Colon

,*&#$,)!",L

%).%*, "S !1* I3.+
%*.!,)IIL ),$&$.+ #*,$#1*,)IIL ),$&$.+

&F4<< %@<< %47A;>6F4 - linkeu to
smoking, can piouuce ACTB anu ABB,
may be linkeu to Lambeit-Eaton
synuiome

&C:4F6:D %@<< %47A;>6F4 - linkeu to
smoking anu the piouuction of ectopic
PTiP.

)=@>6A47A;>6F4 - is the most common
peiipheially aiising cancei of the lung.

I47?@ %@<< %47A;>6F4 - is an
unuiffeientiateu caicinoma of the lung.

976>AB;64<O@6<47 %47A;>6F4 - this is
the lung cancei that is not thought to be
ielateu to smoking

Lung cancei can cause a wiue aiiay of symptoms (asiue fiom cough, hemoptysis, wheezing, bionchial obstiuction).
The most common symptoms that can aiise fiom lung cancei aie:
- H$13+$8%V8 %*"+, (a caicinoma that oiiginates in the apex of the lung anu can compiess the ceivical
sympathetic plexus, iesulting in Boinei's synuiome)
- )*#5,/+, D51$ 3$D$ 8'10,+"5
- M+,15,V8 8'10,+"5 (Ptosis, Anhyuiosis, Niosis)
- H$,$15+#.$8%/3 0/8+,05,8 (PTiP, ABB, ACTB)
- 953*,,51% .$,'1>5$. 15,D5 8'"#%+"8 (hoaiseness)

61S

"9&!,3%!$/* ).K ,*&!,$%!$/* I3.+ K$&*)&*
"9&!,3%!$/* - this conuition causes an obstiuction of aii -low that iesults in aii-tiapping in the lungs. Theie will
always be an incieaseu in total lung volume with a 2!-Y[2-A +: lmbnZ
The categoiies of obstiuctive lung uisoiueis aie:
[` %B76>;A 976>AB;8;D: This conuition is chaiacteiizeu by the piesence of a piouuctive cough foi at least S
consecutive months foi 2 oi moie yeais. Theie is a hypeitiophy of the mucus-secieting glanus of the
bionchioles, giving a Reiu inuex of > Su%. Patient will have wheezing, ciackles, anu cyanosis on physical
exam. *This patient is a "blue bloatei" because they become cyanotic.
\` *F5BGD@F4' This conuition iesults in a uestiuction of alveolai iecoil iesulting in the enlaigement of aii
spaces uue to smoking anuoi an #1-antitiypsin ueficiency (causes inciease in elastase activity). Patient will
have uyspnea, tachycaiuia, uecieaseu bieath sounus.
]` )D8BF4' This iesults in constiiction of the bionchioles uue to hypeiiesponsiveness. This conuition is
ieveisible. Tiiggeieu often by activity, but also tiiggeieu by illness anuoi alleigens. Finuings incluue
cough, wheezing, hypoxemia, anu uyspnea.
^` 976>AB;@A84D;D' A conuition that iesults in uilateu aiiways, iecuiient infections, hemoptysis, anu puiulent
sputum. Causeu by a chionic neciotizing infection of the bionchi. This conuition is ielateu to cystic fibiosis,
Kaitagenei's synuiome, anu bionchial obstiuction.

614

,*&!,$%!$/* f Restiictive lung uisease pievent the expansion of the lungs, iesulting in loweieu lung volumes anu
a 2!-Y[2-A k mbnZ
The categoiies of iestiictive lung uiseases aie:
1. *V8745:<F6>47G' This means conuitions that affect the bieathing mechanics anu the suppoit of the lungs.
Conuitions that weaken the muscles such as myasthenia giavis, anu conuitions that altei the suppoitive
stiuctuie of the lungs such as scoliosis anu ankylosing sponuylitis.
2. $>8@7D8;8;4<' Anything that alteis the inteistitium can cause a iestiictive lung uisease. Examples: ARBS,
pneumoconioses, saicoiuosis, uooupastuie's synuiome, Wegenei's gianulomatosis.

61S

#.*3H".$)
Pneumonia piesents in many uiffeient ways, such as: lobai, inteistitial, anu as bionchopneumonia.
I6M47 #>@:F6>;4: Consoliuation of infection to one aiea of the lobe, often the lowei lobe. The most common
cause is Stiep Pneumonia. Patient uevelops symptoms acutely (shaking chills, fevei, chest pain).
976>AB65>@:F6>;4: Theie is patchy infiltiation in moie than one lung. The NCC is Staph Auieus.
)8G5;A4< #>@:F6>;4: Also known as inteistitial pneumonia, piesents with uiffuse patchy infiltiation localizeu to
inteistitial aieas at the alveolai walls. Piesentation is atypical in that the patient is less sick anu slowei to uevelop
symptoms than with lobai pneumonia.

!1* %1*&! *J)H
A few teims must be unueistoou in oiuei to be able to uiffeientiate between the uiffeient pathologies of the
iespiiatoiy system.
S7@F;8:D - Is a vibiation that is felt when the patient speaks. It is elevateu when a patient has pneumonia,
uecieaseu in effusion anu obstiuction, anu completely absent in pneumothoiax. vibiation is felt as a iesult of fluiu
accumulation.
,@D6>4>A@ - The same sounu as maue by a uium. When theie is nothing in the lung cavity, such as with a
pneumothoiax, theie is "hypeiiesonance". When theie is fluiu accumulation, such as when theie is a pneumonia oi
effusion, theie is uecieaseu iesonance (ie Bullness). Think of a uium with anu without watei insiue to visualize
what is insiue the lung.
97@48B &6:>=D - This can be figuieu out with common sense. When theie is an obstiuction, theie will be no bieath
sounu. When theie is a pneumothoiax, theie will be uecieaseu bieath sounus.
!74AB@4< K@O;48;6> - Pay close attention to the tiachea uuiing the pulmonaiy examination. A ueviation can
inuicate a pneumothoiax. A pneumothoiax will push the tiachea away fiom the affecteu siue, while a bionchial
obstiuction will pull the tiachea towaius the siue of the lesion.

616

+""K#)&!3,*W& &L.K,"H*
A conuition that affects both the lungs anu the kiuneys. Leaus to hemoptysis as the piimaiy lung finuing, with
hematuiiaanemia anu ciescentic glomeiulonephiitis as the kiuney finuings. Seen most commonly in males fiom
2u-4uyi of age.
Causeu by anti-glomeiulai basement membiane antibouies, which piouuce lineai staining on immunofluoiescence.

617

.*3,"I"+L

K*+*.*,)!$/* K$&*)&*&
?=gM!CK!9V) ;C)!?)!
- Is a veiy common cause of ueath
- Pievalence incieases with age
- Family histoiy is a big contiibuting factoi to the possible uevelopment.
- Biffuse ceiebial atiophy occuis seconuaiy to neuional loss
- Neuiofibiillaiy tangles aie classically founu
)/>18[)'"#%+"8:
- Bevelops slowly ovei time
- Beath usually occuis within S-1u yeais fiom onset
- The auvanceu stages will iequiie the patient to have uepenuence on otheis
)%$>58:
*47<G - milu foigetfulness, patient will have uifficulties leaining new infoimation
$>8@7F@=;48@ - piogiessive impaiiment in memoiy
I48@ - patient will iequiie assistance in theii activities of uaily living
)=O4>A@= - patient will expeiience complete uebilitation anu uepenus completely on otheis

618

HCAd) ;C)!?)!
- Fiontal anu tempoial lobe uysfunction causeu by uegeneiation
- Accumulation of tau pioteins
- Pick bouies aie chaiacteiistic
- Nemoiy impaiiment + impulsive behavioi + behavioial changes

H"!", .*3,". K*+*.*,)!$/* K$&",K*,&

?K_4J94HMCA =?J!9?= )A=!94)C)
ALS is also known as Lou uehiig's uisease, which is a fatal neuiouegeneiative uisease of both the uppei anu lowei
motoi neuions.
H4=C4K_!=CJC)
Polio is a viius that affects the anteiioi hoin cells anu motoi neuions of the spinal coiu anu biainstem
- Causes LNN symptoms
25$%*,58 +: H+./+:
- Asymmetiic muscle weakness (most commonly the legs)
- Nuscle atiophy
- Absent of BTR's
- Flacciuity
f)518$%/+1 /8 /1%$3% f

B!9;PCO6M422K?P ;C)!?)!
A genetic conuition that piesents in infancy anuoi eaily chiluhoou.
- Piogiessive skeletal muscle atiophy uue to anteiioi hoin cell uegeneiation
- 0ften piesents with floppy baby at biith (congenital hypotonia)
- Lack of sucking ability
- Tongue fasciculation's
- Beath occuis at a young age uue to iespiiatoiy muscle failuie

619

9)&)I +).+I$) K*+*.*,)!$".

H?9dCP)4PV) ;C)!?)!
- Loss of uopamineigic neuions fiom the substantia nigia
- 0sually piesents in miu-late life (ie >Suyi)
- Biagnosis is completely clinical anu baseu on symptoms
)/>18[)'"#%+"8:
- Resting tiemoi (pill iolling)
- Cogwheel iigiuity
- Biauykinesia
- Bifficulty in initiating movement
- Nask-like facies
- Biain biopsy will show Lewy bouies
ceitain meuications can cause Paikinsonism: Reseipine, Netoclopiamiue, Balopeiiuol, Peiphenazine, NPTP

M^PJCPOJ4PV) AM49!?
- Is a genetic conuition (AB) wheie theie is atiophy of the cauuate nucleus
- Bisease onset is between Su-Suyi with a steauy woisening of symptoms anu ueath within 1S yeais of onset.
)/>18[)'"#%+"8:
- Piogiessive uementia
- Choiea of the limbs, face, heauneck, anu tiunk
- Behavioi uistuibances such as: Bepiession, aggiession, psychosis, changes in peisonality.
- Bepiession occuis anu suiciue is somewhat common because patients aie awaie of theii ueteiioiation
Theie is no tieatment, only symptomatic management.

62u

&#$."%*,*9*II), K$&*)&*&

29C!;9!CAMV) ?J?`C?
- Is an autosomal iecessive conuition that begins by young auulthoou.
Impaiieu: Piopiioception, vibiatoiy sense, ataxia, anu nystagmus

K$SS*,*.! !L#*& "S $.!,)%,).$)I 1*H",,1)+*

1. Epiuuial Bematoma
2. Subuuial Bematoma
S. Subaiachnoiu Bemoiihage
4. Paienchymal Bematoma

!HC;^9?= M!K?J4K?
- Bloou accumulates above the uuia
- Ruptuie of miuule meningeal aiteiies
- Patient usually expeiiences a luciu inteival
- Lens shapeu bleeu
- 0sually causeu by a fiactuie of the tempoial bone

621

)^N;^9?= M!K?J4K?
- Symptoms occui giauually
- Teaiing of the biiuging veins
- Seen in elueis anu alcoholics expeiiencing blunt tiauma
- Ciescent shapeu

)^N?9?AMP4C; M!K499M?O!
- Aneuiysm iuptuie anuoi AvN iuptuie
- Classic piesentation is "woist heauache of patients life"
- LP will show xanthochiomia

9*,,L ).*3,L&H
Aneuiysms aie focal weaknesses in the vasculatuie that iesult in outpouchings. The Beiiy aneuiysm is seen at the
bifuication of the anteiioi communicating aiteiy.
- Ruptuie leaus to hemoiihagic stioke
- Cieates the "woist heauache of my life"
- Associateu with Ehlei's uanlos, Naifan's, anu APKB
- Is a suigical emeigency

622

K$&*)&*& "S K*HL*I$.)!$".

The most common uemyelinating uiseases aie K*.%/#.5 )3.5,+8/8 anu H,+>,588/D5 K*.%/:+3$.
=5*Q+5135#&$.+#$%&', O*/..$/16N$,,5 8'10,+"5, K5%$3&,+"$%/3 =5*Q+0'8%,+#&', anu H+8%6C1:53%/+*8
!135#&$.+"'5./%/8.

K^=JCH=! )A=!94)C)
- Nultifocal zones of uemyelination scatteieu thioughout the white mattei
- Commonly involves the pyiamiual anu ceiebellai pathways, meuial longituuinal fasciculus, optic neive, anu
the posteiioi columns
- Piesents with tiansient sensoiy ueficits, fatigue, weakness, anu spasticity
- visual uistuibances (monoculai vision loss, ipsilateial meuial iectus palsy on lateial gaze)
- 0sually piesents in the 2us anu Sus in a ielapsing fashion
- Biagnosing is maue mostly with NRI
- Nanagementtieatment is with coiticosteioius
%<4DD;A !7;4=: Scanning Speech, Intention Tiemoi, Nystagmus

H94O9!))C-! K^=JC24A?= =!^d4!PA!HM?=4H?JM_
- Is the ieactivation of a latent viial infection
- Seen in appioximately 4% of AIBS patients
- Associateu with }C viius

O^C==?CP6N?99! )_P;94K!
- Is an ascenuing inflammation anu uemyelination of the peiipheial neives anu motoi fibeis of vential ioots
- Piesents in an ascenuing fashion
- Causes symmetiical muscle weakness that staits in the lowei extiemities
- Piesents most commonly following an uppei iespiiatoiy infection
- The most common cause of ueath is uue to paialysis of iespiiatoiy muscles (thus monitoiing iespiiatoiy
function is essential to safety of the patient)

62S

K!J?AM94K?JCA =!^d4;_)J94HM_
- A lysosomal stoiage uisease that affects the giowth anu uevelopment of myelin
- Bue to ueficiency of the enzyme aiylsulfatase A, which causes accumulation of sulfatiues in the tissues anu
thus uestioys myelin sheath
- Affects both CNS anu PNS
- Chiluien with the "late infantile foim" may have uifficulty in walking aftei the fiist yeai of life
- Nuscle wasting, weakness, muscle iigiuity, uevelopmental uelays, anu piogiessive loss of vision,
ouynophagia, paialysis, anu uementia aie all possible complications
- }uvenile foim (S-1uyis) get mental ueteiioiation anu can uevelop uementia
- Auult foim (>16yi) piesents as a psychiatiic uisoiuei oi piogiessive uementia
- No cuie foi this conuition

H4)J6CP2!AJC4^) !PA!HM?=4K_!=CJC)
- An immune-meuiateu uisease of the biain
- 0ccuis following a viial infection most commonly
- Is similai to multiple scleiosis in that it involves autoimmune uemyelination
- Symptoms begin 1-S weeks post-infection
- Fevei, heauache, uiowsiness, seizuie, anu coma

624

&*$-3,*&

)CKH=! H?9JC?=
- Affects a small iegion of the biain (tempoial lobe anuoi hippocampi)
- Patient iemains awake, seizuie is veiy suuuen anu biief
- Patient may expeiience feelings of feai, nausea, unusual feelingssensations, alteieu sense of heaiing, smell,
taste, vision, anu tactile peiception.
- Sense of spatial uisoiientation is often seen
- Patient may expeiience the inability to speak
- The seizuie is usually iemembeieu in uetail

A4KH=!` H?9JC?=
- Limiteu to one ceiebial hemispheie anu causing impaiiment of awaieness
- 0ften pieceueu by an auia

?N)!PA! )!Cg^9!
- Also known as "petit mal" seizuie
- Patient will staie blankly foi a few seconus
- Post-seizuie, the patient will ietuin to whichevei activity they weie uoing piioi to the onset of the seizuie
** Classic 0SNLE question, tieatment is with Ethosuxamiue

62S

J4PCA6A=4PCA )!Cg^9!
- "uianu-mal" seizuie, it affects the entiie biain
- Is the most well-known type of seizuie that occuis with epilepsy
- Associateu with an auia
Tonic Phase - Patient loses consciousness, tension of skeletal muscles occuis. Lasts only a few seconus.
Clonic Phase - Rapiu contiactionielaxation of muscles, eyes ioll to the back of the heau, tongue is often bitten uue
to jaw contiactions. Incontinence may occui at this phase.
- Patient will be confuseu anu will have no memoiy of the seizuie
- Initial management is with a benzouiazepine given Iv

K_4A=4PCA
- Is a biief anu involuntaiy twitching of the muscles
- Piesents with abnoimal movements on both siues of the bouy at the same time
- 0ccuis commonly while patient is falling asleep
- Is not an actual uisoiuei, iathei is a sign of othei potential neivous system uisoiueis

)#1)&$)

Aphasias aie acquiieu language uisoiueis wheieby theie is an impaiiment of eithei uifficulty piouucing oi
compiehenuing spoken oi wiitten language. The two types clinically encounteieu aie Expiessive Aphasia (Bioca's),
anu Receptive Aphasia (Weinicke's).
!T#,588/D5 ?#&$8/$ X Patient has complete intact compiehension with the inability to speak in an unueistanuing
fashion. The site of pathology is the infeiioi fiontal gyius. *xpiessive = $nfeiioi fiontal gyius. E=I (two vowels)
9535#%/D5 ?#&$8/$ - Patient has complete intact ability to speak unueistanuable with the inability to compiehenu
language. The site of pathology is the supeiioi tempoial gyius. ,eceptive = &upeiioi !empoial gyius. ,&!

626

%*.!,)I &I**# )#.*)

Buiing cential sleep apnea, the biain's iespiiatoiy contiol centeis aie imbalanceu uuiing sleep. The neuiological
feeuback mechanism uoes not iesponu to levels of C02 anu thus cannot ieact to uiive the iespiiatoiy iate.
Following this pathology, bieathing iate will inciease anu excess C02 will be expelleu fiom the bouy.

9*IIW& #)I&L

Is a conuition of hemifacial weaknesspaialysis of the muscle that aie inneivateu by CN7, uue to inflammation of
the neive.
- Patient will expeiience an acute onset of unilateial facial weakness anu paialysis, affecting both uppei anu
lowei face.
- Iuiopathic, Lyme uisease, AIBS, saicoiuosis, anu uiabetes aie all possible causes
A+"#$,/1> %+ ^KP $10 =KP .58/+18:
3H. <@D;6> - will affect the lowei half of the contialateial face
IH. <@D;6> - will affect the uppei anu lowei face on the ipsilateial siues

1",.*,W& &L.K,"H*

Boinei's synuiome is a clinical synuiome causeu by uamage to the sympathetic neivous system. 0n most
occasions, Boinei's synuiome is a benign conuition, but it can occui as a iesult of moie seiious conuitions such as
Pancoast tumoi oi thyioceivical venous uilatation. These conuitions cause compiession of the thoiacic sympathetic
chain, which leaus to the symptoms of Boinei's synuiome:
#86D;D f uiooping of the eyeliu
)>BG=76D;D - the absence of sweating
H;6D;D - constiiction of the pupil

627

.*3,"!,).&H$!!*,& )SS*%!*K $. K$&*)&*

Nany neuiotiansmitteis aie affecteu uuiing uiffeient uiseases, they incluue:
K"#)H$.* f Incieaseu in Schizophienia, uecieaseu in Paikinson's uisease
.",*#$.*#1,$.* - Incieaseu in anxiety, uecieaseu in uepiession
)%*!LI%1"I$.* - Incieaseu in oiganophosphate poisoning, uecieaseu in Alzheimei's anu Buntington's uisease
+)9) - Becieaseu in Buntington's, uecieaseu in anxiety
&*,*!".$. c_Z1!d - Becieaseu in both anxiety anu uepiession

!)9*& K",&)I$&

Tabes uoisalis is a conuition wheieby theie is uegeneiation of the uoisal columns anu uoisal ioots of the spinal
coiu. This occuis as a iesult of teitiaiy syphilis. Patient will expeiience all symptoms associateu with uoisal
column malfunction (lack of piopiioception, ataxia uuiing locomotion). Patient will uevelop malfoimeu joints
(Chaicot's joints) uue to lack of pain ieceptois, shooting pains, absence of ueep tenuon ieflexes, anu Aigyll
Robeitson pupil that iesults fiom ieaction to accommouation but not to light.

628

&L,$.+"HL*I$)

Theie is a cavity that foims within the spinal coiu that may expanu anu elongate as time passes, thus uestioying the
spinal coiu. This causes uamage to the spinothalamic tiact, which then iesults in a bilateial loss of pain anu
tempeiatuie sensation in the uppei extiemities in a "cape-like" uistiibution. Associateu with an Ainolu-Chiaii
malfoimation.

629

,*.)I #)!1"I"+L

#)!1"I"+L "S !1* +I"H*,3I3&

.*#1,$!$% &L.K,"H*&
?A^J! H4)J6)J9!H
O=4K!9^=4P!HM9CJC)
- The most common
cause of nephiitic
synuiome
- 0ccuis aftei a gioup
A !-hemolytic stiep
infection (uevelops
1u-14 uays aftei
infection)
- Affects chiluien
between 2-6 yeais of
age
- Is self-limiteu
conuition
- Patient gets
hematuiia, euema, hypeitension, anu low complement levels
- Some cases may piogiess to iapiuly piogiessive glomeiulonephiitis
9?HC;=_ H94O9!))C-! O=4K!9^=4P!HM94H?JM_
- Is "ciescent-moon" shapeu on light micioscopy

O44;H?)J^9!V) )_P;94K!
- Theie is a tiiau of Igu anti-glomeiulai basement membiane antibouies, pulmonaiy hemoiihage, anu
ciescentic glomeiulonephiitis
- The lung finuings will occui befoie the ienal finuings
- Patient will have hemoptysis, iapiuly piogiessive ienal failuie, fevei, anu myalgias

.*#1,$!$% &L.K,"H*&
H,5851% U/%&: Bematuiia,
Bypeitension, 0liguiia, Azotemia
AC0TE P0ST-STREP
uL0NER0L0NEPBRITIS
RAPIBLY PR0uRESSIvE
uL0NER0L0NEPBRITIS
u00BPAST0RE'S SYNBR0NE
NENBRAN0PR0LIFERATIvE
uL0NER0L0NEPBRITIS
BERuER'S BISEASE (IgA
NEPBR0PATBY)
ALP0RT'S SYNBR0NE
.*#1,"!$% &L.K,"H*&
H,5851% U/%&: Nassive Pioteinuiia,
Bypeilipiuemia, Bypoalbuminemia,
anu PeiipheialPeiioibital Euema.
NENBRAN00S
uL0NER0L0NEPBRITIS
NININAL CBANuE BISEASE
F0CAL SEuNENTAL uL0NER0LAR
SCLER0SIS
BIABETIC NEPBR0PATBY
SYSTENIC L0P0S ERYTBENAT00S
6Su

K!KN9?P4H94=C2!9?JC-! O=4K!9^=4P!HM9CJC)
- 0n election micioscopy, theie aie the classic "tiam-tiack" subenuothelial humps
- Bas a slow piogiession to ienal failuie

N!9O!9V) ;C)!?)! EC>? 15#&,+#$%&'F
- Nesangial ueposits of IgA
- Is a veiy milu uisease
- 0ccuis aftei an infection

?=H49JV) )_P;94K!
- A mutation of type 4 collagen
- Patient can have neive ueafness anu oculai uisoiueis
- Theie aie split basement membianes

.*#1,"!$% &L.K,"H*&
K!KN9?P4^) O=4K!9^=4P!HM9CJC)
- veiy common cause of auult nephiotic synuiome
- Light micioscope shows basement membiane thickening

KCPCK?= AM?PO! ;C)!?)!
- Is the most common cause of nephiotic synuiome in chiluien
- Election micioscopy shows foot piocess effacement
- This conuition iesponse exceptionally well to steioius

24A?= )!OK!PJ?= O=4K!9^=?9 )A=!94)C)
- Noie common in patients with BIv
- Light micioscope shows segmental scleiosis anu hyalinosis

6S1

;C?N!JCA P!HM94H?JM_
- 0ccuis in uiabetics
- Theie is basement membiane thickening anu Kimmelstiel-Wilson lesions on light micioscopy

)_)J!KCA =^H^) !9_JM!K?J4^)
- Theie aie S patteins of ienal involvement
- Light micioscope will show "wiie-loop" appeaiance with gianulai subenuothelial BN ueposits in
membianous glomeiulonephiitis pattein

,*.)I %*II %),%$."H)
Renal cell caicinoma is the most common of all ienal malignancies, occuiiing most commonly in men between Su-
7uyi of age, anu is moie common in smokeis.
- Associateu with von Bippel-Linuau
- 0iiginates in ienal tubule cells
K$1/:58%8 $8:
6S2

- Bematuiia
- Palpable flank mass
- Seconuaiy polycythemia (uue to piouuction of eiythiopoietin fiom kiuney)
- Nany paianeoplasias aie common uue to piouuction of Piolactin, PTBiP, anu ACTB)

0$IHW& !3H",
This is the most common malignancy seen in young chiluien between 2-4yi of age.
The following aie impoitant iegaiuing a Wilm's tumoi:
- Theie is a ueletion of the WT1 gene that is founu on chiomosome 11
- Piesents with a huge, palpable flank mass
Wilm's tumoi is often seen in conjunction with the WAuR complex:
0 - Wilm's tumoi
) - Aniiiuia (absence of the iiis)
+ - uenitoiuiinaiy malfoimations
, - Retaiuation (both mental anu motoi)

!,).&$!$".)I %*II %),%$."H)
Is a common cancei seen in the uiinaiy tiact (blauuei, uieteis, ienal pelvis, anu ienal calyces). The most common
causes incluue: )"+Q/1>W ?.$1/15 ;'58W A'3.+#&+8#&$"/05Z

#L*I".*#1,$!$&
An ascenuing infection that spieaus fiom the blauuei to the kiuneys. The most common cause of pyelonephiitis is
an E. Coli infection.
SignsSymptoms:
- Flank pains (CvA tenueiness)
- Fevei
- Nauseavomiting
6SS

- Patient will appeai quite ill
** Patients with vesicouieteial ieflux have an incieaseu tenuency to getting pyelonephiitis.

)%3!* !393I), .*%,"&$& c)!.d
Acute tubulai neciosis occuis when theie is an insult to the ienal tubules. Anything that can haim the kiuneys can
cause ATN, things such as: Ischemia uue to shock, incieaseu myoglobins uue to muscle bieakuown, uiugs, toxins.
** Is the most common cause of acute ienal failuie.

)%3!* ,*.)I S)$I3,*
Acute ienal failuie occuis most commonly fiom ATN (mentioneu above), anu occuis when a uecline in ienal
function causes an inciease in the levels of B0N anu Cieatinine.
J&5 3$*858 +: ,51$. :$/.*,5:
#7@Z7@>4< )Q68@F;4 ! is when theie is a ueciease in ienal bloou flow, which leaus to a ueciease in the glomeiulai
filtiation, anu thus ietention of watei anu souium in the kiuneys. B0N>Ci is > 2u
#6D8Z7@>4< )Q68@F;4 ! this conuition only occuis if theie is bilateial obstiuction, things such as piostatic
hypeiplasia, neoplasia, anu stone (less likely) will cause a post-ienal azotemia. B0NCi is > 1S
$>87;>D;A ! this is uue to ATN (usually), anu the uiine will give this cause away by having gianulai casts oi
epithelial casts. B0NCi is < 1S

01)! 1)##*.& 01*. ,*.)I S)$I3,* $& #,*&*.!p
Renal failuie leaus to a builu-up of toxins anu leaus to the inability to exciete nitiogenous bases.
?3*%5 ,51$. :$/.*,5 is usually uue to hypoxemia, while 3&,+1/3 ,51$. :$/.*,5 is usually causeu by eithei
hypeitension oi uiabetes.
When theie is a builu-up of B0N anu Cieatinine, uiemia uevelops. When uiemia uevelops, the following symptoms
may be piesent:
- Anemia uue to failuie of EP0 piouuction by the kiuneys
- CBFPulmonaiy euema uue to souium anu watei excess
6S4

- Netabolic aciuosis
- Bypeikalemia
- 0steouystiophy uue to failuie of vitamin B piouuction by the kiuneys

a$K.*L &!".*&
Theie aie a few uiffeient foims of kiuney stones, they aie:
[` %)I%$3H &!".*& ! the most common foim of kiuney stone, which may be eithei calcium oxalate oi
calcium phosphate. Any uisease oi uisoiuei that leaus to hypeicalcemia can cause a calcium stone.

\` &!,3/$!* &!".*& ! these aie maue of ammonium, magnesium, anu phosphate, anu they aie the 2
nu
most
common type of kiuney stone. They aie piouuceu by uiease-positive bugs such as Pioteus vulgaiis. These
have a tenuency to foim "staghoin calculi" anu get stuck in the uiinaiy system.
]` 3,$% )%$K &!".*& ! piouuceu as a iesult of states of hypeiuiicemia, such as with gout. These stones aie
also piouuceu when theie aie conuitions of incieaseu cell tuinovei, such as with leukemia.
^` CYSTINE ST0NES ! these occui seconuaiy to cystinuiia.
9$0/+#$7*5 8%+158 ! Calcium anu Stiuvite stones
9$0/+.*351% 8%+158 ! 0iic aciu anu cystein stones

6SS

)%$KU9)&* #1L&$"I"+L

#76M<@F 51 #%"\ r1%"]Zs %6F5@>D48;6> %4:D@D
H@84M6<;A
)A;=6D;D
( ( (( Patient will
hypeiventilate
to blow off C02
BKA, ASA
oveiuose,
lactic
aciuosis
,@D5;74867G
)A;=6D;D
( )) ) Bicaib
absoiption in
kiuney
0bstiuction
of aiiway
,@D5;74867G
)<R4<6D;D
) )) ( Kiuney
secietes bicaib
Bypeivent,
high alt.
H@84M6<;A
)A;=6D;D
) ( )) Pt will
hypoventilate
vomiting
6S6

1"0 K" 0* %"H#*.&)!* S", )%$KZ9)&* K$&3,9).%*&p
The following numbeis uesciibe the appiopiiate compensation uepenuent on each metabolic uistuibance.
C: #$%/51% &$8 "5%$I+./3 $3/0+8/8:
PC02 = 1.S(BC0S-) + 8 +- 2

C: #$%/51% &$8 "5%$I+./3 $.Q$.+8/8:
Foi eveiy 1mEqL inciease in BC0S-, the PC02 incieases u.7mmBg

C: #$%/51% &$8 $3*%5 ,58#/,$%+,' $3/0+8/8:
An inciease of 1mEqL of BC0S- foi eveiy 1ummBg inciease in PC02

C: #$%/51% &$8 3&,+1/3 ,58#/,$%+,' $3/0+8/8G
An inciease of S.SmEqL of BC0S- foi eveiy 1ummBg inciease in PC02

C: #$%/51% &$8 $3*%5 ,58#/,$%+,' $.Q$.+8/8:
A ueciease of 2mEqL BC0S- foi eveiy 1ummBg ueciease in PC02

C: #$%/51% &$8 3&,+1/3 ,58#/,$%+,' $.Q$.+8/8G
A ueciease of SmEqL BC0S- foi eveiy 1ummBg ueciease in PC02

6S7

,1*3H)!"I"+L

!G5@D 6E )78B7;8;D:
1. 0steoaithiitis
2. Rheumatoiu Aithiitis
S. uout
4. Pseuuogout

4)J!4?9JM9CJC)
0steoaithiitis is the most common type of aithiitis that is causeu by the weai anu teai of joints, which leaus to the
uestiuction of the aiticulai caitilage anu the subchonuial bone foimation. This leaus to the foimation of
osteophytes, as well as Bebeiuen's anu Bouchaiu's noues.
M5I5,051V8 P+058 - malfoimations of the uistal inteiphalangeal joints
N+*3&$,0V8 P+058 - malfoimations of the pioximal inteiphalangeal joints
#7@D@>848;6> 6E "D8@6478B7;8;D:
- Pain in weight beaiing joints
- Asymmetiic involvement
- Pain woise at the enu of the uay (impioves with iest)

6S8

9M!^K?J4C; ?9JM9CJC)
Is an autoimmune conuition that attacks the synovial joints of the bouy.
- Pannus foimation in joints leaus to uefoimities of the metacaipophalangeal joints anu pioximal
inteiphalangeal joints.
- Foimation of subcutaneous nouules
- 0lnai ueviation at the wiist joint
- Seen in females >>> males
#7@D@>848;6> 6E ,B@:F486;= )78B7;8;D:
- Stiffness in the moining that impioves with use
- Symmetiic involvement
- Systemic symptoms aie piesent (fevei, fatigue, caiuiac conuitions, pulmonaiy conuitions)

6S9

O4^J
A conuition wheieby monosouium uiate ciystals piecipitate anu accumulate insiue the joints, most commonly
seen in the big toe, which is known as "pouagia". 0ltimately this is a conuition that occuis as a iesult of puiine
metabolism uisoiuei.
Causes:
- Lesch-Nyhan synuiome
- PRPP excess
- Bypeiuiicemia
- ulucose-6-phosphate ueficiency
Piecipitating factois:
- Biet high in piotein
- Alcohol use
- Excess coffee consumption
- Consumption of uaiiy piouucts
Biagnosis is baseu on joint aspiiation anu finuing of negatively biiefiingent neeule-shapeu ciystals in the aspiiate.
NSAIBs aie best foi acute management, while uiugs that ueciease uiic aciu in the system will help pievent
iecuiiences.

64u

H)!^;4O4^J
A conuition similai to gout, pseuuogout is causeu by the ueposition of calcium pyiophosphate ciystals insiue the
joint space. The ciystals foimeu aie ihomboiu-shapeu anu basophilic. The laige joints aie most commonly affecteu.

641

&*,".*+)!$/* &#".KLI"),!1,"#)!1$*&

The gioup of seionegative sponuyloaithiopathies incluue:
1. Ankylosing Sponuylitis
2. Reitei's Synuiome (Reactive Aithiitis)
S. Psoiiatic Aithiitis
4. IBB Aithiopathy
S. 0nuiffeientiateu Sponuyloaithiopathy
This gioups of aithiitis types has the following in common:
- They aie iheumatic factoi negative
- They have extia-aiticulai symptoms (visual, pulmonaiy, caiuiac, etc)
- Association with BLA-B27 antigen
- Inflammatoiy piocesses
- Asymmetiical piesentation
- Familial

?Pd_=4)CPO )H4P;_=CJC)
- Low back pain anu stiffness (patient is bent ovei at the hips)
- C-spine motion is limiteu uue to neck pains
- Biminisheu chest expansion
- Nost common extia-aiticulai involvement is in the eyes (anteiioi uveitis)
- Best uiagnostic mouality is xiay of lumbai spine anu pelvis
- Nanagement is with NSAIBs anu physical theiapy

9!CJ!9V) )_P;94K!
- Is a clinical uiagnosis baseu on the piesentation of aithiitic symptoms that is pieceueu by an infection
(salmonella, shigella, campylobactei, Chlamyuia, anu yeisinia)
- Classic tiiau is Aithiitis, 0iethiitis, anu 0veitis (can't see, can't pee, can't climb a tiee)
- Theie is a sequential involvement of new joints
- Patient often has an accompanying set of symptoms such as fatigue, weight loss, anu oveiall sense of malaise

H)49C?JCA ?9JM9CJC)
- Bevelops in patients who have aithiitis
- 0nset is giauual anu seen long aftei patient uevelops aithiitis
642

- Is similai in piesentation to iheumatoiu aithiitis
- Nanagement is with NSAIBs

#"IL),!$%3I), X"$.! $./"I/*H*.!: RA, REITER'S
H"."),!$%3I), X"$.! $./"I/*H*.!: 0STE0ARTBRITIS, u00T, PSE0B0u00T

&L&!*H$% I3#3& *,L!1*H)!"3&

An autoimmune uisoiuei wheieby theie is multi-system anu multi-oigan inflammation anu tissue uamage.
J'#58:
- SLE
- Biscoiu Lupus (skin manifestation without systemic uisease)
- Biug-Inuuceu
- ANA-negative Lupus

B&+ >5%8 /%h
- 9u% of cases aie females of chilubeaiing age
- Afiican-Ameiican's aie affecteu moie than Caucasians
- Seveiity tenus to be less in oluei patients, anu moie in youngei patients
2/10/1>8:
- Butteifly iash
- Photosensitivity
- Biscoiu iash
- Alopecia
- Raynauu's phenomenon
- }oints painaithialgiasmyalgias
- Peiicaiuitisenuocaiuitismyocaiuitis
- Pleuiitispleuial effusionpneumonitis
- Bemolytic anemialeucopeniathiombocytopenialymphopenia
- Pioteinuiia >u.Sguay, glomeiulonephiitispyuiiaazotemiauiemiaBTN
- Abnoimal T cell function, lymphocyte autoantibouies
- NauseavomitingP0Buyspepsia
- SeizuiespsychosisuepiessionTIAheauachesCvA
- Fevei, malaise, conjunctivitis

64S

;/$>1+8%/3 A,/%5,/$:
- Positive ANA is seen in almost all SLE patients
- Anti-us BNA is seen in appioximately 4u% of SLE patients
- Anti-Sm antibouies is seen in appioximately Su% of SLE patients

&),%"$K"&$&

Is a conuition chaiacteiizeu by immune-meuiateu, wiuespieau noncaseating gianulomas. The classic finuing is
bilateial hilai auenopathy.
Theie is also the inciuence of:
- Incieaseu levels of ACE
- Rheumatoiu aithiitis
- Inteistitial fibiosis
- uammaglobulinemia
- Restiictive lung uiseases
- Eiythema nouosum
- Bypeicalcemia

)3!"$HH3.* %".K$!$".& "S !1* &a$.

H)49C?)C)
Autoimmune conuition wheie the skin uevelops ieu, scaly patches on the skin. The plaques that uevelop aie known
as "psoiiatic plaques", anu aie causeu by excessive piouuction of skin anu a fastei skin cycle than noimal skin.
- Skin appeais silveiy-white in coloi
- Nost commonly piesent on extensoi suifaces of the bouy (knees, elbows), but may be seen on the hanus,
feet, genitals, anu the scalp.
This conuition is not contagious*
Psoiiasis is associateu with the B27 haplotype (BLA-B27), BLA-1S, anu BLA-17.
644

H8+,/$%/3 H.$7*5

H!KHMCO^) -^=O?9C)
Is a potentially fatal conuition that involves the oial mucosa anu the skin. It is causeu by Igu antibouies against the
epiueimal cell suiface, causes bieakuown of the cellulai junction of the epithelial cell. Patient will uevelop bullae on
the skin anu oial mucosa.
Igu antibouies can be seen on immunofluoiescence.

64S

N^==4^) H!KHMCO4C;
Is a skin uisoiuei wheieby Igu antibouies woik against the epiueimal basement membiane. This conuition is veiy
similai to H5"#&/>*8 -*.>$,/8 but is much less seveie.

&%I*,"K*,H)

Scleioueima oi "Piogiessive Systemic Scleiosis" is an excessive ueposition of collagen anu subsequently fibiosis
thioughout the bouy. The most common site of piesentation is the skin, howevei it may affect the kiuneys, caiuiac,
anu gastiointestinal systems.

A9!)J )_P;94K! X Associateu with the anticentiomeie antibouy
A synuiome compiising of S uiffeient conuitions that geneially lack any skin involvement.
% - Calcinosis
, - Raynauu's phenomenon
* - Esophageal uysmotility
& - Scleiouactyly
! - Telangiectasias

;C22^)! )A=!94;!9K?
This conuition is associateu with the anti-Scl-7u antibouy, wheieby theie is wiuespieau skin involvement, visceial
involvement ielatively eaily, anu a iapiu couise of action anu piogiession.

646

/)&%3I$!$& %".K$!$".&

I47?@ O@DD@< A6>=;8;6>D - Tempoial aiteiitis,
%".K$!$". S*)!3,*& K$)+."&$& !,*)!H*.!
!@F5674<
)78@7;8;D
Seveie heauache

visual impaiiment
in 2S%-Su%

}aw pains

Tempoial
tenueiness
Age >Suyi

New onset
heauache

Elevateu ESR

Tempoial aiteiy
biopsy
Bigh-uose steioius

ESR follow-ups
uuiing
management
!4R4G4D:WD
)78@7;8;D
0sually seen in
young Asian
females

Becieaseu anuoi
absent peiipheial
pulses

Bloou piessuie
uiffeiences in aim
vs legs

Nany
complications like
limb ischemia,
aneuiysms, stioke,
BTN fiom ienal
aiteiy stenosis
Baseu on clinical
symptoms
Steioius

BTN management
%B:7?Z&874:DD A vasculitis
affecting many
uiffeient oigan
systems

Fatigue, weight
loss, fevei

Respiiatoiy
symptoms anu skin
Biopsy of lung
tissue

Biopsy of skin
tissue (shows high
eosinophils)

p-ANCA will be
founu

Pooi piognosis

S-yi suivival is
only 2S%

Steioius can
piolong tieatment
647

finuings aie
piimaiy finuings

0@?@>@7WD
+74>:<6F486D;D
A vasculitis of the
kiuneys anu
iespiiatoiy tiact

0ppei iespiiatoiy
symptoms

Painful oial ulceis

Eye uisease
(scleiitis,
conjunctivitis)

Nusculoskeletal
finuings (myalgia,
aithialgia)

Tiacheal stenosis
CXR (nouules oi
infiltiates aie
piesent)

Elevateu ESR

Anemia

p-ANCA seen in
most patients

Confiimatoiy test
is an open lung
biopsy
Steioius +
cyclophosphamiue
can help patients
into iemission

With ienal failuie,
a tiansplant is
cuiative
#6<G478@7;8;D
.6=6D4
Is a meuium-vessel
vasculitis that
involves the
neivous system
anu uI tiact

Causes intimal
piolifeiation which
causes a ueciease
in the luminal aiea,
iesulting in
ischemia,
infaiction, anu then
aneuiysm

Liveuo ieticulaiis

Bypeitension

Feveiwt
lossaithialgiaabu
pain
Biopsy

ESR

p-ANCA

Fecal occult bloou
Steioius can
impiove piognosis,
which is pooi
without tieatment

9@BA@8WD

A multi-system

Biopsy of all

Steioius
648

&G>=76F@ vasculitis of
unknown etiology

Recuiient oial anu
genital ulceiations

Aithiitis

visual impaiiment

CNS involvement

Feveiweight loss
involveu tissues
9:@7?@7WD K;D@4D@ Seen in young
males who smoke

Small anu meuium
sizeu veins anu
aiteiies

Affects aims anu
legs

Clauuication occuis

Smoking is
impeiative in fixing
the pioblem
Clinically baseu Smoking cessation
1G5@7D@>D;8;O;8G
/4DA:<;8;D
Is a
hypeisensitivity
ieaction that
occuis in iesponse
to ceitain
meuications
(sulfas, PCN)

Causes skin
pioblems (puipuia,
macules, vesicles)
Tissue biopsy of
affecteu tissues
Stop offenuing
agent(s)

Remission is often
spontaneous
649

*.K"%,$.* #)!1"I"+L

6Su

)K,*.)I #)!1"I"+L
1. Bypeialuosteionism
2. Auuison's uisease
S. Cushing's uisease

M_H!9?=;4)J!94PC)K
#7;F47G f %6>>WD &G>=76F@
Causeu by an $.0+8%5,+156853,5%/1> %*"+, that causes hypeitension anu hypokalemia (iemembei when
aluosteione incieases, potassium uecieases), metabolic alkalosis (iemembei hypokalemia = alkalosis, hypeikalemia
= aciuosis), anu .+U #.$8"$ ,51/1.
&@A6>=47G BG5@74<=6D8@76>;DF
Causeu by ienal aiteiy stenosis most commonly. Nay also be uue to ienal failuie, ciiihosis, nephiotic synuiome,
anu congestive heait failuie. These conuitions tiiggei the activation of the RAAS, which stimulates the kiuneys
eventually to holu onto moie watei anu souium. As opposeu to the piimaiy cause, this conuition has &/>& #.$8"$
,51/1.
!7@48;>? BG5@74<=6D8@76>;DF - Aluosteione antagonist spiionolactone can inhibit the activity of aluosteione on
the kiuney.

?;;C)4PV) ;C)!?)!
Causeu by piimaiy auienal insufficiency. The most common cause is autoimmune, infectious, anu as a iesult of
metastatic uisease.
S@48:7@D 6E )==;D6>WD =;D@4D@:
- Postuial hypeitension
- Bypoglycemia
- Weight loss
- Weakness
- Anoiexia
- Nausea
- Bypeipigmentation (only seen in piimaiy auienal insufficiency)
- Low aluosteione levels (low souium, high potassium)
K;4?>6D;>?:
- Plasma coitisol levels
- Plasma ACTB levels
- Imaging of pituitaiy (if uiagnosis is seconuaiy auienal insufficiency)
6S1

A^)MCPOV) )_P;94K![;C)!?)!
%:DB;>?WD &G>=76F@ - the "synuiome" iesults fiom an excessively high level of glucocoiticoius (coitisol is the
piimaiy uC).
%:DB;>?WD K;D@4D@ - the "uisease" occuis as a iesult of a pituitaiy auenoma.

A$*858 +: A*8&/1>V8:
1. Iatiogenic - this is the most common cause, anu is uue to the auministiation of coiticosteioius.
2. ACTB-secieting auenoma of the pituitaiy, this is the 2
nu
most common cause, leauing to bilateial auienal
hypeiplasia.
S. Auenoma of the auienal
4. Ectopic ACTB piouuction - can be causeu by caicinoma of the lung (small-cell).
25$%*,58:
Theie aie classic featuies of Cushing's, they aie:
- Cential obesity
- Buffalo hump
- Biisutism
- Stiiae on abuomen
- Acne
In auuition, theie is a piesence of:
- Bypeitension
- Biabetes (( glucose toleiance)
- Bypogonauism - causing infeitility
- Excess anuiogen (masculinizes females)
- Nusculoskeletal abnoimalities (muscle wasting, osteopoiosis, femoial heau osteoneciosis)
- Psychiatiic uistuibances such as uepiession
- Impaiieu immunity leauing to incieaseu chances of infection
6S2

!3H",& "S !1* )K,*.)I +I).K
HM!4A94K4A_J4K?
The most common tumoi of the auienal meuulla in auults. It is ueiiveu fiom the chiomaffin cells.
)/>18[)'"#%+"8:
- Palpitations
- Anxiety
- Beauache
- Biaphoiesis
- Significant hypeitension
- Tachycaiuia
Biagnosis is baseu on checking uiine metanephiines, anu tieatment is suigical iemoval aftei auequate management
of the hypeitension.

6SS

P!^94N=?)J4K?
Is the most common auienal tumoi in chiluien, anu is the most common intiacianial tumoi in chiluien as well.
While most commonly founu in the auienal meuulla, it can be founu anywheie along the sympathetic chain.

%".+*.$!)I )K,*.)I 1L#*,#I)&$)
A congenital conuition wheieby theie aie excessive oi ueficient piouuction of sex steioius fiom the auienal glanu.
The most common cause of CAB is uue to 21-hyuioxylase ueficiency. This conuition will cause an excess of
anuiogens anu a ueciease in mineialocoiticoius. Theie is an accumulation of the substiate 17-
hyuioxypiogesteione. This conuition, wheieby theie aie incieaseu anuiogens, will cause masculinization of the
female exteinal genitalia (inteinal female sexual oigans aie intact since no mulleiian inhibiting factoi is piesent -
no testicles), anuoi ambiguous genitalia.

6S4

!1L,"$K +I).K #)!1"I"+L

%).%*,&
H?HC==?9_ A?9ACP4K?
- Piesence of giounu-glass nuclei anu psammoma bouies
- Is the most common type of thyioiu cancei anu holus the best piognosis
24==CA^=?9 A?9ACP4K?
- Theie is a piesence of unifoim follicles
- Bolus a goou piognosis (bettei than meuullaiy but woise than papillaiy)
K!;^==?9_ A?9ACP4K?
- Beiiveu fiom the paiafolliculai "C cells", thus piouuces calcitonin.
- Is a membei of the NENII anu NEN III synuiomes
- Bas a bau piognosis
?P?H=?)JCA A?9ACP4K?
- This thyioiu caicinoma occuis in oluei patients
- Bolus a teiiible piognosis anu the woist of all thyioiu caicinomas

1L#*,!1L,"$K$&H
Theie will be a low TSB (uue to feeuback inhibition), with a high TST4
Patient will have the following:
- Beat intoleiance
- Weight loss
- Palpitations
- Waimmoist skin
- Aiihythmias

6SS

1L#"!1L,"$K$&H
Theie will be a high TSB anu low TST4
Patient will have the following:
- Colu intoleiance
- Weight gain
- Fatigue
- Lethaigy
- Weakness
- Becieaseu ieflexes
- Biycool skin
- Coaisebiittle haii
- Nyxeuema

O9?-!) ;C)!?)!
uiave's uisease is the most common cause of hypeithyioiuism, accounting foi up to 8u% of all cases.
- Is an autoimmune uisoiuei wheieby a thyioiu-stimulating immunoglobulin u antibouy binus to the TSB
ieceptois on the thyioiu cells, tiiggeiing the synthesis of excess thyioiu hoimone
- Biffuse iauioiouiue uptake on scan

H=^KK!9V) ;C)!?)!
Also known as "toxic multinouulai goitei), accounting foi appioximately 1S% of all cases.
- Theie aie aieas of hypeifunctioning thyioiu tissue that piouuce excess TS anu T4
- Noie common in oluei patients
- Elueily patients with hypeithyioiuism may piesent simply with unexplaineu weight loss, weakness, anuoi
atiial fibiillation

M?)MCK4J4V) JM_94C;CJC)
An autoimmune conuition that causes hypothyioiuism.
- Piesents with a moueiately enlaigeu, but non-tenuei thyioiu glanu
- Theie is lymphocytic infiltiation with geiminal centeis
- Anti-miciosomal antibouies aie iesponsible foi the conuition

6S6

)^N?A^J! JM_94C;CJC) E05 <*5,D$/1V8F
This is a tiansient thyiotoxic phase lasting 2-S months that is usually self-limiteu.
- Absence of paintenueiness of thyioiu glanu
- 0ften follows a flu-like synuiome
- Low iauioactive iouine uptake

1L#*,%)I%*H$)
Theie aie many causes of hypeicalcemia, they can be iemembeieu with the mnemonic "AMCKH?Pg!!)"
% - Calcium Ingestion
1 - Bypeipaiathyioiuismhypeithyioiuism
$ - Iatiogenic causes (such as thiaziue uiuietics)
H - Nultiple myeloma
# - Paget's uisease
) - Auuison's uisease
. - Neoplasms
- - Zollingei-Ellison synuiome
* - Excessive vitamin A intake
* - Excessive vitamin B intake
& - Saicoiuosis

)/>18[)'"#%+"8 - Stones, Bones, Noans, uioans, anu Psychiatiic oveitones
&86>@D - kiuney stones
96>@D - bone pain, especially with an incieaseu PTB
H64>D - psychiatiic noise
+764>D - constipation
#DGAB;487;A "O@786>@D - confusion, uepiession, etc

6S7

1L#*,#),)!1L,"$K$&H
Theie aie piimaiy anu seconuaiy foims of hypeipaiathyioiuism.
H,/"$,' - The piimaiy foim of hypeiPTB is usually causeu by an auenoma in the glanu. Nost of the time theie aie
no symptoms of this conuition, howevei lab finuings will show the following: BypeiCa2+, hypeicalciuiia,
hypophosphatemia, incieaseu paiathyioiu hoimone, anu inciease cANP in the uiine.
)53+10$,' - The seconuaiy foim of hypeipaiathyioiuism is causeu by a low seium calcium, anu is seen most
commonly in someone with chionic ienal uisease. Theie will be hypocalcemia, hypeiphosphatemia, anu incieaseu
levels of PTB.

1L#"#),)!1L,"$K$&H
Bypopaiathyioiuism is usually uue to eithei acciuental iemoval uuiing a thyioiu pioceuuie oi fiom Biueoige
synuiome. Patient will have hypocalcemia anu tetany.
The ease by which tetany occuis can be testeu by ceitain maneuveis that cause musculai spasms.
J,+*885$*V8 )/>1 is a test that looks foi caipal spasm, anu is uone by occluuing the biachial aiteiy by pumping up a
bloou piessuie cuff.
A&D+8%5QV8 )/>1 is a test that attempts to cause a spasm of the facial muscles, anu is uone by tapping on the facial
neive.

)%,"H*+)IL
Known as "gigantism" in chiluien, this is a conuition wheie theie is excess uB secieteu fiom the pituitaiy glanu.
Patient will have enlaigement of hanus, feet, facial featuies, ueepening of voice, etc. These patients uie eailiei than
the noimal lifespan.
Noimally, giving glucose woulu suppiess uB levels, thus if giving glucose uoes N0T suppiess the level of uB, a
uiagnosis of aciomegaly can be maue.

%,*!$.$&H
Cietinism is a conuition that occui when theie is a lack of uietaiy iouine (enuemic cietinism). A uefect in T4
foimation oi the failuie of thyioiu uevelopment uuiing uevelopment causes spoiatic cietinism. Patients aie puffy-
faceu, pale, pot-bellieu with piotiuuing umbilicus anu a piotiuuing tongue.

6S8

K$)9*!*& H*II$!3&
Compaiing BN types 1 anu 2

C1/%/$. H,5851%$%/+1 +: ;KYG
The classic piesentation is polyuiia, polyuypsia, polyphagia, anu weight loss.
BKA, the auveise effect of BN1 leaus to incieaseu plasma glucose, uehyuiation, aciuosis, anu if left untieateu will
leau to coma anu ueath.
A&,+1/3 !::53%8 +: ;KY:
&F4<< /@DD@< K;D@4D@ - thickening of small vessels leaus to a myiiau of pioblems thioughout the bouy.
Retinopathy, nephiopathy.
I47?@ /@DD@< K;D@4D@ - will leau to atheioscleiosis, coionaiy aiteiy uisease, CvA, PvB.
.@:76<6?;A4< - wiuespieau loss of sensation thioughout the bouy.
%48474A8D - occui as a iesult of soibitol accumulation.

!L#* [ K$)9*!*&
!-cell uestiuction (autoimmune)
Lifelong insulin is iequiieu
BKA is common
Staits in chiluhoou (usually)
Bouy is skinny
!L#* \ K$)9*!*&
Insulin iesistance
Bietexeicise is piimaiy
tieatment
Associateu with obesity
BKA is iaie
6S9

K$)9*!$% a*!")%$K"&$& cKa)d
BKA is a life-thieatening auveise ieaction of BN1. Theie is an incieaseu neeu foi insulin that uoesn't get met, anu is
usually causeu by an illnessinfection that incieases the stiess level of the peison. This leaus to an inciease in
ketogenesis anu thus piouuction of ketone bouies.
)/>18[)'"#%+"8:
- Nausea anu vomiting
- Kussmaul bieathing (attempts to coiiect metabolic aciuosis)
- uI pains
- Behyuiation
- Psychosis anu uementia
- Bypeiglycemia
- Incieaseu anion gap metabolic aciuosis
- Inciease ketone levels
- Bypeikalemia with uepleteu intiacellulai potassium
A+"#./3$%/+18:
- Ceiebial euema
- Aiihythmia
- Beait failuie
- Nuicomycosis (causeu by the fungus Rhizopus)
M+U /8 ;d? "$1$>50h
- Lots of fluius
- Insulin (give glucose if levels stait to uiop)
- Potassium (when K+ levels noimalize)

K$)9*!*& $.&$#$K3& cK$d
A lack of anti-uiuietic hoimone (ABB), uue to eithei a cential cause oi a nephiogenic cause.
%@>874< K$ - is causeu by a tumoi in the pituitaiy, tiauma, suigeiy
.@5B76?@>;A K$ - is causeu by a lack of ienal iesponse to ABB

Patient will have intense neeu foi fluius coupleu with polyuiia, with uilute uiine that is not concentiateu uue to lack
of ABB.
K$1$>5"51%: Cential BI: Besmopiessin (intianasal) Nephiogenic BI: hyuiochloiothiaziue (incieases Na+ anu
B2u absoiption in uistal nephion).

66u

&L.K,"H* "S $.)##,"#,$)!* ).!$ZK$3,*!$% 1",H".* c&$)K1d
Too much ABB uue to any of the following causes:
- Ectopic piouuction of ABB (commonly fiom small-cell caicinoma of the lung)
- Tiauma to the heau anuoi CNS uisoiueis that ielease excess ABB
- Biugs such as cyclophosphamiue
An excess in ABB will cause the following pioblems:
[` *V87@F@U@VA@DD T48@7 7@8@>8;6>
\` 1G56>487@F;4 =:@ 86 =;<:8;6>4< @EE@A8D cA4> A4:D@ D@;Q:7@d
]` %6>A@>8748@= :7;>@ c:7;>@ 6DF6<47;8G o D@7:F 6DF6<47;8Gd

"&!*"#","&$&
0steopoiosis is the ieuuction in the bone mass wheie theie is noimal mineialization. Theie aie two types:
!G5@ [ - 0ccuis in post-menopausal women uue to uecieaseu estiogen levels. Theie is an inciease in bone
iesoiption.
!G5@ \ - "Senile" osteopoiosis affects those who aie oluei than 7uyi of age, affecting both men anu women.
A+""+1 #,+I.5"8:
- veitebial ciush fiactuies
- Pelvic fiactuies
- Fiactuies of the uistal iauius
- veitebial weuge fiactuies
K$1$>5"51%: Bisphosphonates aie iecommenueu, wheieas estiogen ieplacement woiks well but comes with siue
effects that aie conceining.

661

H3I!$#I* *.K"%,$.* .*"#I)&$) cH*. &L.K,"H*d
NEN synuiomes aie the categoiies of synuiome that compiise of ceitain neoplasias. These gioups of neoplasias
have a tenuency to piesent simultaneously.
H*. $ - Pancieas (Zollingei-Ellison, insulinomas, vIPomas), Pituitaiy, Paiathyioiu
H*. $$ - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Paiathyioiu auenoma
H*. $$$ - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Nucosal Neuiomas

-"II$.+*,Z*II$&". &L.K,"H*
ZES is a gastiin-secieting tumoi of the pancieas oi uuouenum. This conuition is suspecteu whenevei theie aie
iecuiiing ulceis that aie not tieateu conseivatively. Suspect ZES whenevei theie is a pituitaiy anuoi paiathyioiu
auenoma as they aie all togethei in the NEN I synuiome categoiy.

662

9,*)&! K$&*)&*&

2CN94A_)JCA ;C)!?)!
Fibiocystic bieast uiseasechanges affects between Su%-6u% of women. Chaiacteiizeu by benign lesions anu
uiffuse bieast pain that is often ielateu to hoimonal changes associateu with hei menstiual cycle.
Theie is a fibious, lumpy textuie to the lesions of the bieast. Nammogiam is not iequiieu to make this uiagnosis,
but fine-neeule aspiiation is commonly uone to check the chaiacteiistics of the fluiu.
Tieatment is not necessaiy, howevei pain ielief shoulu be uone
**Theie is no incieaseu iisk of bieast cancei in fibiocystic uisease.

N9!?)J A?PA!9
9/8Q 2$3%+,8:
- Family histoiy of a 1
st
uegiee ielative with bieast cancei at a young age
- Age anu genuei
- Nenaiche (<12yi) is shown to inciease iisk
- Piegnancy (>Su) can inciease iisk
- Late menopause (>Su)

66S

$./)&$/* 9,*)&! %),%$."H)&

Aie uiviueu into two majoi categoiies baseu on theii cytoaichitectuial featuies:

C1%,$0*3%$. H$#/..+"$8 aie tumois of the lactifeious uucts, they piesent with nipple uischaige. Aiising fiom
mammaiy uuct epithelium oi lobulai glanus, anu oveiexpiession of estiogenpiogesteione ieceptois.
;*3%$. A$,3/1+"$ /1 )/%* E;AC)F - is eaily malignancy without basement membiane penetiation
C1D$8/D5 ;*3%$. A$,3/1+"$ - piesents as a fiimfibious mass
A+"50+3$,3/1+"$ - is uuctal with cheesy consistency uue to cential neciosis
C1:.$""$%+,' - has lymphatic involvement anu caiiies a pooi piognosis
C1D$8/D5 =+I*.$, A$,3/1+"$ - piesents bilateially with multiple lesions
K50*..$,' A$,3/1+"$ - caiiies a goou piognosis, is fleshy with lymphocytic infiltiation
H$>5%V8 ;/85$85 +: %&5 N,5$8% - eczematous patch on the nipple
$./)&$/* K3%!)I %),%$."H)
Tubulai Caicinoma
Sebaceous Caicinoma
Secietoiy Bieast Caicinoma
Neuioenuociine Caicinoma
Nucinous Caicinoma
Niciopapillaiy Caicinoma
Acinic Cell Caicinoma
Auenoiu Cystic Caicinoma
Apociine Caicinoma
Ciibiifoim Caicinoma
ulycogen-RichCleai Cell
Inflammatoiy Caicinoma
Lipiu-Rich Caicinoma

I"93I), %),%$."H)
Pleomoiphic
Signet Ring Cell
664

#"IL%L&!$% "/),$). &L.K,"H*
Is a common uisoiuei anu one of the most common causes of infeitility in women.
An inciease in LB piouuction leaus to anovulation anu hypeianuiogenism uue to alteieu steioiu synthesis.
)/>18[)'"#%+"8:
- 0besity
- Biisutism
- Amenoiihea
- Infeitility
This conuition shoulu be manageu with weight loss anu oial contiaceptive pills (0CP's).

4-?9C?P A_)J)

66S

+*,H %*II !3H",& "S !1* "/),L
J!9?J4K? X up to 9u% of geim cell tumois of the ovaiy. Contains all thiee geim layeis (ectoueim, enuoueim,
mesoueim). The immatuie teiatoma is veiy aggiessive anu malignant.
;_)O!9KCP4K? - is the most common type of malignant geim cell ovaiian tumoi, usually occuiiing in
auolescence anu eaily life. Is analogous to the male seminoma.
_4=d )?A J^K49 - piouuces #-fetopiotein
AM49C4A?9ACP4K? - is the same as the testiculai veision of the geim cell tumoi, causes an inciease in hCu.

.".Z+*,H %*II !3H",& "S !1* "/),L
)!94^) A_)J?;!P4K? X is benign, compiises 2u% of ovaiian tumois anu is fiequently bilateial. Is lineu with
fallopian tube-like epithelium.
)!94^) A_)J?;!P4A?9ACP4K? - compiises Su% of ovaiian tumois, is fiequently bilateial anu is malignant.
KÂCP4^) A_)J?;!P4K? - is benign, anu is a multiloculai cyst lineu by mucus-secieting epithelium.
KÂCP4^) A_)J?;!P4A?9ACP4K? - is malignant, with intiapeiitoneal accumulation of mucinous mateiial fiom
ovaiian oi appenuiceal tumoi.
N9!PP!9 J^K49 - is a benign tumoi iesembling blauuei epithelium.
4-?9C?P 2CN94K? - contains bunules of spinule-shapeu fibioblasts. "Neig's synuiome" is a tiiau of ovaiian
fibioma, ascites, anu hyuiothoiax.
O9?P^=4)? A!== J^K49 - secietes estiogen causing piecocious pubeity in chiluien, while in auults it can cause
enuometiial hypeiplasia oi caicinoma. Contains "Call-Exnei bouies", which aie small follicles filleu with
eosinophilic secietions.

666

3!*,$.* #)!1"I"+L

!P;4K!J9C?= A?9ACP4K?
Is the most common gynecological malignancy that peaks between SS-6Syi of age. The most common initial
piesentation is vaginal bleeuing.
9/8Q 2$3%+,8 - Piolongeu use of estiogen, BN, hypeitension, anu obesity.

!P;4K!J9C4)C)
0ccuis when enuometiial glanus aie piesent in locations outsiue of the uteius. Piesents with seveie pain ielateu to
menstiuation anu piouuces chocolate cysts (bloou in the ovaiy). Nay cause infeitility.

?;!P4K_4)C)
Is enuometiiosis within the myometiium of the uteius

=!C4K_4K?
Is the most common tumoi seen in women, wheie tumoi size incieases with piegnancy anu uecieases with
menopause. 0ften piesenting with multiple tumois at once. Raie piogiession to cancei.

=!C4K_4)?9A4K?
Is a bulky tumoi with aieas of neciosis anu hemoiihage. Boes not aiise fiom a leiomyoma. Tenuency to piotiuue
fiom ceivix, is highly aggiessive anu has a tenuency to iecui.

667

%*,/$%)I #)!1"I"+L

;_)H=?)C?
Is uisoiueieu epithelial giowth that staits at the basal layei anu extenus outwaiu. Caicinoma in situ (CIN) is
classifieu baseu on the extent of uysplasia. Theie is an association with human papilloma viius.
CP-?)C-! A?9ACP4K?
Nost commonly this is squamous cell caicinoma. Pap smeai is an essential tool to catch this befoie it becomes too
auvanceu.

%"H#I$%)!$".& "S #,*+.).%L

Foui common conuitions associateu with piegnancy incluue:
1. Placental abiuption (abiuptio placenta)
2. Placenta accieta
S. Placenta pievia
4. Ectopic piegnancy

#I)%*.!)I )9,3#!$".
Painful uteiine bleeuing that is a iesult of piematuie sepaiation of the placenta. Is an emeigency conuition that can
iesult in fetal ueath.
#I)%*.!) )%%,*!)
Placenta attaches uiiectly to the myometiium, anu is causeu by a uefective ueciuual layei.
#I)%*.!) #,*/$)
Placental attachment to the lowei uteiine segment with may occluue the ceivical os. Piesents with painless vaginal
bleeuing.
*%!"#$% #,*+.).%L
Nost common site is the fallopian tube, is seen most commonly in a patient with histoiy of pelvic inflammatoiy
uisease. Biagnose with ultiasounu.

668

#,*+.).%L $.K3%*K 1L#*,!*.&$". c#7@Z@A<4F5D;4d

H,5653.$"#8/$ = Bypeitension, pioteinuiia, anu euema.
!3.$"#8/$ = Tiiau above + seizuie
* If pie-eclampsia is piesent, patient iequiies beuiest, salt-iestiiction, anu monitoiing.
Associateu with BELLP synuiome, which is an emeigency situation that iequiies immeuiate ueliveiy of the baby.
1 - 1emolysis
*I - *levateu IFTs
I# - Iow #latelets

1LK)!$S",H H"I*

Is an ovum without any BNA, which iesults in swelling of the choiionic villi anu piolifeiation of choiionic
epithelium. Theie will be elevation of !-hCu anu the appeaiance of a "clustei of giapes".
Complete Nole - 46,XX that is of complete pateinal oiigin with no iuentifiable embiyonic oi fetal tissue.
Paitial Nole - 69,XXY oi 92, XXXY, wheie a noimal egg is feitilizeu by two oi thiee speim.
* Nay uevelop into choiiocaicinoma

9*.$+. #,"&!)!$% 1L#*,#I)&$)
BPB is a conuition that is quite common in men ovei the age of Suyi. Chaiacteiizeu by nouulai enlaigement of the
lateial anu miuule lobes (ie peiiuiethial), which compiesses the uiethia into a veitical slit.
SignsSymptoms:
669

- 0iinaiy fiequency
- Fiequent nighttime uiinaiy
- Bifficulty in staitingstopping uiination
- Complications may be hyuionephiosis, hypeitiophy of blauuei, anu 0TI.

#,"&!)!$% )K*."%),%$."H)
Nost commonly seen in men ovei Suyi of age. The most common site of auenocaicinoma is the posteiioi lobe (aka
peiipheial zone). Bigital iectal exam is the best way to uetect the cancei, as haiu nouules can be uetecteu on exam.
PSA is useu as a way to uetect an auenocaicinoma, as levels >4.u aie woiiisome. The most woiiisome auveise
effect is osteoblastic metastasis (uetect by incieaseu alkaline phosphatase).

Updated Step 1 Bible (2013)

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Updated Step 1 Bible (2013)

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Paul Ciurysek M.D.

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