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Microbiology

ABX
Demeclocycline (tx lyme, acne bronchitis) causes diabetes insipidus
Aminoglycosidesactivity via acetylation, phosphorylation, adenylation;
given paraenterally; combined w/ beta lactams for cidal activity
Aztreonam is gram negative drug like pseudomonas (esp penc allergy)
Vanco like beta lactam inhibit cell wall synthesis; main SE is
myelosuppression & nephrotoxicity (RED mad syndrome-tx antihistamine)
Cephalosporins inhibit transpeptidases (aka PBP via D-alaDala);
cefazolin/lexin 1st gen cover PEcK, cefoxitin 2nd gen cover HENS, 3rd gen
good for brain, ceftazadime only 3rd gen that cover pseudomoans4th gen
effective against G-rods & psuedomons) dont cover LAME listeria,
atypicals, MRSA (except 5th ceftaroline) & enterococcus. SE HYPN, vitK,
nephrotox of aminoglycosides
Macrolides block TRANSLOCATION & transpeptidation by binding 23s
RNA (tx atypical pneumonia; ileus); SE:MACRO: GI Motility, arrhythmia
QT, cholestatic hepatitis (erythromycin&clarithro only b/c eliminated in bile
so no dose adjustment for renal failure pt), rash, eOsinophilia; inhibits P-450
(except azithromycin) bleeding diathesis in heart valve pt.
Chloroamphenicol (most lipophilic) blocks peptidyl transferase (peptide bond
formation like clindamycin); activity by bacterial acetylation; tx lyme dz
in early pregnancy but switched to doxy near term SE aplastic anemia
Linezolid: SE: HOT high risk of serotonin syndrome (flushing, diarrhea,
sweating, hyperthermia, agitation), optic neuritis, thrombocytopenia
(suppression)
Pyrimethamine for tx todo is same as trimethoprim
Sulfonamide: use for simple UTIs; unlike aminoglycosides (ATN) cause
TINephritis; also cause hemolysis in G6PD deficiency (IS PAIN: Isoniazid,
Sulfonamide, Primaquine, Aspirin, Ibuprofen, Nitrofurantoin) & kernicterus
(displaces compounds off albumin)
TMP-SMX- Tx pneumocystis jiroveci pneumonia, salmonella, shigella; SE: 35-1
penia incld megaloblastic anemia (reversed w/ leucoverin/folinic acid)
Fluroquinolones : Resistance to is from CHROMOSOMAL-mediated
mutation of DNA gyrase (II); can tx shigella; DOC for UTIs w/ sulfa allergy
Unit 35
(use nitrfurantoin
if GERDDISCUSSION:
& present too);
Has GREAT oral
SMALL GROUP
ANTIMICROBIALS
bioavailability; gatofloxacin causes dysglycemias & moxi heart problems;
Key
Concepts:
Cipro
does not cover G+ & anaerobes but covers Pseudomonas; while moxi
covers
anaerobes but not pseudomonas
Upon completion of this lesson, students will understand the class, mechanism of action,
spectrum of action, and main adverse reactions of prototypical antimicrobials, as well as apply
this knowledge to common clinical scenarios.

Learning Objective before small group session:

Beta lactamase inhibitors are useful for anaerobes (not for strep)
Metronidazole: toxic metabolites damage DNA; cause peripheral
neuropathy; GET GAP Giardia, Entamoeba, Trichomonas, Gardnerella
vaginalis, Anaerobes, H. pylori, C.DIFF (toxin B & cytotoxin disrupt
cytoskeleton; exotoxin A attracts granulocytes);
Use metronidazole CREAM as Tx for acne rosacea. But
erythromycin CREAM is Tx for acne vulgaris.
Polymyxins: cationic, basic w/ long hydrophobic tale that act as
detergent (disrupt osmotic properties of cell membrane); SE: neur0- &
nephrotoxicity; the polymixin clostin is used in VPN (remove G-)
Daptomycin (cyclic lipopeptide)- contraindicated w/ statins due to
myopathy w/ CPK SE; blocked by pulmonary surfactant (avoid in
pneumonia)
INH: syn of mycolic acids; needs KatG (catalase peroxidase; carries
out acyl-carrier and ketoacyl-carrier protein synthesis) to become
active metabolite; causes lupus-like syndrome (joint pain), vit B6
deficiency (paresthesias, seizures due to GABA) because inhibits
pyridoxal kinase; used over rifampin for TB prophylaxis b/c rifampin
is hepatotoxic (fever, anorexia, nausea); response varies w/ acetylation
Pyrazinamide: blocks fatty acid synthase I (effective in acid pH; best
for killing INTRACELLULAR TB); has hepatotox, gout Sx
Ethambutol: carbohydrate polymerization by blocking arabinosyl
transferase; cause optic neuropathy (central scotoma optic neuritis)
or red green colorblindness), gout, ; not as hepatotoxic as others;
[sidenafil causes blue-green color blindness]
Ethambutol knocks out carbohydrate synthesis but that pyrazinamide
knocks out fatty acid synthesis. Isoniazid hits mycolic acid synthesis
directly, and rifampin inhibits nucleic acid synthesis.
Rifampin inhibits -subunit of DNA dep RNA polymerase; orange
tears- rust lenses; never use it alone for tx; prophylax for N. men (b/c
penetrates reap tract and prevents pharyngeal colonization) & H influx
35-2 pt, give rifabutin instead)
B; revs up p450 (so avoid in HIV+
cycloserine & streptomycin also treat TB
continued,
Table
Sodium
stibogluconate tx visceral leshmaniasis
Specific Antibiotic

Category (i.e.
aminoglycoside, Betalactam, quinolone,
etc.)

Mechanism of action (i.e.


cell wall inhibition,
nucleic acid inhibition,
etc.)

Main Spectrum of
Action

Main Adverse Reaction(s)

Meropenem

Carbapenem

Cell wall inhibition

Hypersensitivity

Vancomycin

Glycopeptide

Cell wall inhibition

Staph, strep, Gram


aerobes
including
Pseudomonas,
anaerobes
Staph, strep

Doxycycline

Tetracycline

Protein synthesis
inhibition

Tobramycin

Aminoglycoside

Protein synthesis
inhibition

TMP-SMX

Anti-folate

Anti-metabolite
(nucleic acid
inhibition)

Identify the bold print items in the following table upon request.
This table is not meant to be complete, but one to build upon.
Specific
Antibiotic

Category (i.e.
aminoglycoside,
Beta-lactam,
quinolone, etc.)
Beta-lactam

Mechanism of
action (i.e. cell wall
inhibition, nucleic
acid inhibition, etc.)
Cell wall inhibition

Semi-synthetic
penicillin (betalactam)
Semi-synthetic
penicillin (betalactam)
1st generation
cephalosporin
(beta-lactam)
2nd generation
cephalosporin
(beta-lactam)
3rd generation
cephalosporin
(beta-lactam)

Cefepime

4th generation
cephalosporin
(beta-lactam)

Cell wall inhibition

Piperacillintazobactam

Beta-lactam plus
beta-lactamase
inhibitor

Cell wall inhibition

Penicillin
Oxacillin (IV)
Dicloxacillin
(oral)
Cephalexin
Cefoxitin
Ceftriaxone

G+

Main Spectrum of
Action

Main Adverse
Reaction(s)
Hypersensitivity

Cell wall inhibition

Strep, syphilis,
most enterococci
Staph, strep

Hypersensitivity

Cell wall inhibition

Staph, strep

Hypersensitivity

Ciprofloxacin

Quinolone

Nucleic acid
inhibition

Cell wall inhibition

Staph, strep,
E. coli, Proteus

Hypersensitivity

Moxifloxacin

Quinolone

Nucleic acid
inhibition

Cell wall inhibition

Anaerobes
Gram aerobes
(not Pseudomonas)
Gram aerobes
(not
Pseudomonas),
streptococci
Staph, strep,
Gram aerobes
including
Pseudomonas
Staph, strep, Gram
aerobes
including
Pseudomonas,
anaerobes

Hypersensitivity

Erythromycin

Macrolide

Protein synthesis
inhibition

Azithromycin

Macrolide

Protein synthesis
inhibition

Clindamycin

Lincosamine

Metronidazole

Nitroimidazole

Linezolid

Oxazolidinone

Protein synthesis
inhibition
Nucleic acid
synthesis inhibition
Protein synthesis
inhibition

Cell wall inhibition

Hypersensitivity,
biliary sludge
Hypersensitivity

Hypersensitivity,
GI

S. Aureus: colonize nares; causes pneumonia after pt had a cold; secretes


DNAse; have protein A to bind Fc region of IgG to prevent opsonization and

Staph, Lyme,
Rickettsia,
Anaplasma
Gram aerobes
including
Pseudomonas
Staph, Gram
aerobes,
Nocardia,
Pneumocystis
Gram aerobes
including
Pseudomonas

Nephrotoxicity,
ototoxicity, marrow
toxicity, infusion
related histamine
release
Teeth and bones, GI,
photosensitivity
Nephrotoxicity,
otovestibular
toxicity
Folate deficiency
Skin rashes,
cytopenia

Phototoxicity;
cartilage,
tendonopathy,
neuropathy
Staph, strep,
cartilage,
Gram- aerobes (not tendonopathy
Pseudomonas),
neuropathy
anaerobes
Strep,
GI, drug-drug
mycoplasma,
interactions,
legionella,
ototoxicity
chlamydia,
pertussis
Strep,
GI
mycoplasma,
legionella,
chlamydia,
pertussis
Staph, strep,
Pseudo-membranous
Anaerobes
colitis
Anaerobes
Peripheral neuritis,
metallic taste
Staph, strep
GI,
thrombocytopenia,
anemia, neuropathy

Enterococcus: If you get a vignette of a pt with BPH UTI


Enterococcus endocarditis; Tx, ampicillin; if resistant

phagocytosis; coagulase binds fibrinogen; causes SSS w/ + nikolsky sign


(removal w/ friction); SSS in baby is called Ritter syndrome; desmosomal
disruption is granulosal; TSST-1 SUPERANTIGEN toxin (heat resistant),
which causes TSS, causes desquamation of the hands/soles after ~2wks. It is
a superantigen (bridges MHC-II to V- region of TCR); cause BULLOUS
impetigo; NB: endotoxins bind CD14 on macrophages
S. saprophiticus: 3rd common cause of UTI; urease + struvite (ammonium,
magnesium phosphate NOT calcium; tx by acidifying urine (unlike other
cysteine stones which give citrate for tx) struvite stone also w/ proteus
H. influx can be grown alongside S.aureus (provide NAD)
MSSA - MRSA via altered PBP2a (transpeptidase)
All - hemolytic bact have pore forming ability (group A/B strep & staph)
-hemolysis (partial) shows a greenish zone on blood agar
S. pneumonia is optician sensitive: lacer shaped diplococci; pneumolysin
cause -hemolysin; causes rusty sputum; NB: vaccines against capsule only
produces IgM, so major opinion is C3b not IgG; Quelln rxn= capsule
swelling; macrocodes are treatment of choice
S. epidermis is novobiocin sensitive; tx is immediate vanco
S. pyogenes is bacitracin sensitive; beefy red oropharynx (scarlet fever); M
protein (type II Hypersensitivity); + ASO titer
S. bovis and enterococcus grows well in bile, but only enterococcus (hemolytic) survive in high NaCl which S. bovis can't; endocarditis in colon
cancer pt
S. viridans causes SUBacute endocarditid; binds fibrin; produces dextran
biofilm
S. agalactiae- CAMP factor (incomplete hemolysis; enlarges area of
hemolysis by S. aureus); causes premature rupture of membrane still
birth) screen at 35wks, INTRAPARTUM (i.e. during birth) penicillin
prophylaxis
Strep pneumo is optichin sensitive; lancet shaped; most common cause of
meningitis in adults
Haemophilus is a G neg cocobacilus while neiserria is a bean shaped gram
neg cocci in pairs
Only the tail of pancreas is intrperitoneal (rest is retro)
Vit B1 deficiency Dry (symmetrical peripheral neuropathy) or wet beriberi
w/ DCM, peripheral edema
Inhibition of viral RNA pol prevents Rota virus from replicatin
Trep pyogenes is bacitracin sensitive
Sporothrix Shenkii cigar shaped budding yeast
Necrotizing enterocolitis: see gangrene of ileum+ascending colon + abdm
distension and NEU w/ fever or hypothermia (ie sepsis)

G G- cocci
Thayer Martin (chocolate) VPN grows Neiserria only menigititis ferments Matose;
both ferment glucose); N Men has lipoligosaccharide NOT lipopolysacharide which
causes rash & WF syndrome; N gon has a pious for antigenic variation & causes
septic arthritis, PID, Fitz Hugh Curtis syndrome; cants w/ cipro or ceft + Azithro (for
Chlamydia)
Klebsiella (indole-) and E.coli (Indole+; pink on McConkey agar, but green on EMB)
are FAST lactose fermenters
Kleb (causes empyema & cavitations tx w/ ceftriaxone) & Bacteroides (fould
smelling sputum w/ CXR w/ air fluid levels cause aspiration pneumonia in
alcoholics
Vitamin K = phytonadione
Oxidase -: Salmonella is motile but Shigella is not; Proteus oxidase- urease+ cause
stag horn calculi
Aerobic GNR Oxidase +: Psuedomonas (grows in alkaline media; causes diabetic
osteomyeolitis & ecthyma gangrenosum if bacteremia) & Vibrio (not)
Campy(urease-) grows well at 42C; like Hp it's oxidase +
Cocobacilli: H. flu req factors V (NAD+) & X (haematin); Legionella (aerobic GNR,
grows on charcoal yeast agar with iron + cysteine; tx macrolide or quinolone;
hyponatremia, acute pyrexia w/ NEU); Bordetella can also grow on Regan-Lowe
medium, and that it is swabbed using a calcium alginate swab; tularemia req cysteine
for growth; Pasturella is oxidase a& catalase +
ETEC: grows on lettuce; HL (like cholera; cAMP Cl secretion) & HS (like
yersinia entercolitica, cGMP NaCl absorption) toxin both cause WATERY
diarrhea
Leprosy- Tuberculoid (Th1, reactive PPD), Lepromatous (Th2)
Young person develops shingle - look for hodgkins or HIV
Halo or crescent sign on CT lung indicates Aspergillus

vancomycin; if resistant streptogramin ((dalfopristin /


quinupristin); daptomycin works too
Spore forming: B. cereus is motile but B. anthracis
(aerobic)(only bacterium w/ protein poly-D glutamate capsule,
painLESS black eshcar- lethal factor, edema- edema factor
(cAMP via AC); widened mediastinum on CXR; produces
long chains that have serpentine medusa head on culture) is
non-motile; C. apoptosisle (do AB toxin (causes actin
depolymerization) test; toxic megacolon is complication of
pseudo membranous colitis), tetani (ENTERS wounds and
ascend MOTOR neurons of spinal cord; causes TRISMUS
which is locked jaw; causes opisthotonos (arching of back) via
entry thru umbilicus) and botulinum (constipation prior to
floppy baby syndrome) are all motile but C. perfringens
(phospholipase, watery diarrhea, gas)is non-motile.
Non spore forming: listeria (hemolytic, tumbling motility, like
yersinia entercolitica (G-) grows well at 4C (motile at 25 instead
of 37C); ONLY G+ organism w/ ENDOtoxin; intracellular
organism; causes pyogenic granulomas in babies and listeriosis
in women; tx w/ ampicillin) & cornybacterium diptheria (
protein syn via toxin (AB5 which binds to cardiac(B)and neural
cells and ribosylates(A)); club-shaped rods; metachromatic
blue red granules; K antigen (capsule); Tx is antitoxin;
cardiomyopathy is leading cause of death; grey oropharygeal
exudate; lysogenic phage- ABCDE: shiga, botulinum, cholera,
diphtheria, erythrogenic toxin of S. progenies)(nonmotile)
Dyptheria use ELEK test
Tx C. perferinges (alpha lecthinase toxin) with clina & penn w/
debridement
Nocardia is G+ w/ long branching filaments aerobic bacteria
and weakly acid fast and caseating;pul infections like TB in
immunocomp; can cause osteomyelitis) vs actinomyces
(filamentous rod; anaerobic; draing facial abscess)
Salmonella is swarming
Candida krusei and glabrata are fluzanozle resistant
Mycoplasma pneumonia: fried egg appearance w/ domed shape
colonies
Amp B: renal tox, phlebitis, anemia, shaking cills fever
Cenral squzmmous cell lung carcinoma is aw PTH-related
peptide hypercalcemia (constipation & polyuria)

Yersinia entercolitica toxin though can cause bloody diarrhea


Shiga toxin & verotoxin inactivate 60S ribosomal subunit by
cleaving rRNA; Verotoxin causes swelling of renal vascular
endothelium thrombocytopenia & subsequent mechanical
hemolysis (HUS= MAHA + acute renal failure ); EHEC cannot
ferment sorbitol; e. coli has numerous flagella
HUS: EHEC; Guillian barre: Campy
Sigella sonnei once invaded spreads via actin polymerization
UropathogenicEC- UTIs via P1-pilus; tx w/ rifaximin
EPEC- destroys villi-> malabsorption; EAEC- biofilm (diarrhea
w/mucus)
Pseudomonas commonly infect diabetics (pulmonary or
osteomyelitis); like diptheria inhibits EF2 (protein syn); tx amino
glycosides, pip/tazo, tic/tazo, cetazadime, cefepime; virulence:
alginate exopolysaccharidic capsule; causes botryomyosis and
ecthyma gangrenosum.
See black necrotic skin lesions= P. aeruginosa, B. anthracis, F.
tularensis and Y. pestis (painful; farmer w/ pneumonia)
Any cholera question unless pt is in shock need ORAL fluids
Antigenic variation is used by Salmonella (cause osteomyelitis in
SC dz), N. bon & B. recurrentis
Y. enter colitis: mesenteric adenines for kids & arthritis for adults
w/ diarrhea; transmitted by contaminated milk/pork/puppies;
infectivity via Yop plasmid
H. pylori is oxidase, catalase & urease +
Biliverdin is green, bilirubin yellow
Shigella is non lactose lon oxidase that can cleave host rRNA
HUS (renal failure, micro angipathic hemolytic anemia,

thrombocytopenia)
Viruses
Polio infects anterior horns, superior gluteal nerve (trendelenburg gait);
ingested
CoxsakieA herpangina, hand foot mouth dz,
CoxB myocarditis via DIRECT damage not HYSN DCM
echovirus- non-enveloped ssRNA virus that causes meningitis in kids
Rhinovirus- ifects thrug ICAM-1 (CD54)
Rotavirus: highly segmented; #1 cause of viral enteritis in kids; BOAReo:
bunyavirus, Orhmyovirs, arenavirus, reo
Coltivirus(reovirus) causes colorado tick fever
Togaviridae are alpha virus (equine encephalitides) and rubivirus (rubella)

Flaviviridae are HepC, West Nile, Yellow/Dengue fevers, Japanese


encephalitis

Rubella: causes post-auricular or sub-occipital lymph node tenderness w/ 3day rash


HepC (transmitted by blood not sex; tx pegylated interferon-alpha (SE flu,
depression) and ribavirin) will cause a nodular or clumpy appearance;
HepB (transmit by sex; tx Regulater interferon-alpha ), in contrast, will
cause a ground-glass appearance
Tx Hep B w/ lamivudine (cytidine analog that inhibits reverse
transcription) + interferon alpha
A liver with MANY neoplastic lesions is likely colon cancer (CEA marker)
not HCC
West nile virus: pt is jaundice w/ zone 2 necrosis of the liver; transmitted
by Culex mosquito w/ reservoir in birds

Dengue fever: pt has high fever, facial flushing, mottling of skin,


thrombocytopenia, severe back pain, and severe retro-ocular headache;
transmitted by Aedes mosquito
In Sezarys, youve got Pautrier microabscesses (T-cell collections). Dont
confuse with the Munro microabscesses of psoriasis (neutrophils in the
skin).
Hanta virus causes pulmonary syndrome and is transmitted by mice
Parainfluenza- croup; RSV (F- protein spread cell to cell)- bronchiolitis (tx
w// ribavirinl pavilizumab targets F protein); need strong CD 8 to kill RSV
PARAMYXOviridae: Rubulavirus = mumps (MOP meningitis, orchitis,
parotitis); Morbillivirus = measles = ruBeola (don't confuse w/ Rubulavirus
or roSeola infantum = HHV-6), measles is a/w subacute sclerosing panencephalitis (SSPE- latent measles infection) myalgia poor concentration
seen in immigrants (no MMR vaccine)) and rash starts at face and spreads
downward; WARTHIN-FINKELDEY cells, caused by MEASLES, are
VERY SIMILAR histologically to cells w/ herpes-induced Cowdry A
bodies.
Rbies has long incubation period
Entamoba histolytica: immigrant, gradual onset while shigella is rapid
onset w/ tenesmus

Neurology
NF1: chrom 17 (ras): CANN OT FAI L2 B 1st : OpTic gliomas, Lisch
nodules (pig iris); bone abnrml (kyphoscoliosis, owing tibia, sphenoid
dysplasia); a/w Wilm, pheo, juvenile CMV
Facial nerve paralysis will develop dry eye (eyes up), hyperacusis in affected
ear; caused by AIDS, Lyme, sacoidosis, or idiopathic
Guillian barr syndrome (ascending muscle weakness)occurs after Campy
EBV, CMV; T cell Atb target myelin; tx w/ plasmapheresis, steroids
Thiamine deficiency can manifest in the form of Wernicke's encephalopathy,
which presents with ataxia, lateral gaze palsy, and confusion; or Korsakoff's
psychosis, which results in anterograde and retrograde amnesia, often with
confabulation
Notochord (D18) stimulate neuroectoderm
Maternal folate must be adequate BEFORE pregnancy to avoid neural tube
defects
Alar- is dorsal sensory; basal -s ventral motor
Cerebral aquaduct in 3rd ventricle
Microglia originate from mesoderm

When PML (JC) appears, the USMLE wants you to know that its always
because its always because of REACTIVATION OF LATENT VIRUS;
see MANY NON-CONTRASTING LESIONS on MRI; often seen in AIDS
BK affects the kidneys (BK = kidney) .
HPV-6/11 cause condyloma acuminata (warts)

HPV, just know that is causes koilocytes (large, irregular cells with perinuclear halos on Pap-smear) and cervical cancer
Adenovirus: CONJUNCTIVITIS and HAEMORRHAGIC CYSTITIS
(hematuria)
lymphocytic choriomeningitis virus (arenavirus) is rodent trasmitted
Ebola/marburg, just know that primates can transmit the virus and its
rapidly fatal
Parvo B19 causes Aplastic anaemia in children and ARTHRITIS IN
ADULTS; one rash formed the virus has been cleared & no Tx needed;
PB19 binds to P-antigen, aka globoside, on the RBC surface.

For herpes, they like intranuclear inclusions for Cowdry bodies.


Punched out ulcers is herpes. Linear ulcers is CMV.

HHV8 causes Kaposis sarcoma in HIV pts (abnormal endothelial/vascular


proliferations histologically), body-fluid lymphoma, and Castlemans
disease
herpesviridae GET envelope FROM THE NUCLEAR MEMBRANE.

dsDNA and SS(+)RNA viruses are infective VIA PURIFIED NUCLEIC


ACID ALONE
Fat products like vit A initially drain into lymphatics
Ribavirin inhibits IMP dehydrogenase & causes hemolytic anemia
FAMcyclovir is for shingles
SE of gamcyclovir is NEUTROPENIA
Foscarnet just know this is for ganciclovir-refractory SE.
NEPHROTOXICITY and HYPOCALCAEMIA, HypOKALAEMIA,
hyPOMAGNAESEMIA
Toxo causes chorioretinitis, hydrocephalus, intracranial calcifications
Wuchereria bancrofti causes lymphedema / elephantiasis (only adult worms
pathogenic); tx diethylcarbamazapine
Reo/Rota & Colorado tick fever virus: dsRNA nonenveloped
Toxins encoded by lysogenic phage: ABCDE= shigA-like toxin, Botulinum
toxin (certains strains), Cholera toxin, Diphtheria toxin and Erythrogenic
toxin of streptococcus pyogenes
Corona virus: + sigle stranded helical causes ARDs
Verapamil is a p-glycoprotein inhibitor while loperamide is g-glycoprotein
inhibitor both prevent loperamide (opiod) from being pulled out of CSF
Gastric cancer rates are highest in Asians NOT AA
The antrum of stomach is a/w H pylori, nitrosamines, male, tobacco use

ACh is parkinsons, in alzheimers & Huntingtons


Locus ceruleus- NE; Nucleus accumbens & septal nucleus (reward center);
raphe nucleus- 5HT, basal nucleus of Meynert- ACh
Area postremavomiting after chemo, OVLTosmotic sensing
Hypothalamus- lateral (hunger); ventromedial (satiety); anterior(cooling);
posterior(heating); suprachiasmatic(circadian- release NE to pineal gland
melatonin)
eta wave- awake eyes open
Neurohypophysis: supraoptic (ADH) and paraventricular (oxytocin) nuclei.
Thalamus: LGN- vision (calcimine nucleus); MGN- hearing Lateral=light;
medial=music; VL- basal ganglia moto cortex
Cerebellum: Deep nuclei (lateral -> medial)Dentate, Emboliform,
Globose, Fastigial (Dont Eat Greasy Foods).
Basal Ganglia: Striatum = putamen (motor) + caudate (cognitive). Lentiform
= putamen + globus pallidus
Parkinsons- TRAPS your bodyTremor (at rest), cogwheel Rigidity,
Akinesia (or bradykinesia), Postural instability and Shuffling gait.

Neural tube defect: AFP & AChE in amniotic fluid


Anencephaly- no forebrain or skull; frog like;plyhydram;a/w matertal DM 1
holoprosencephaly- failure of L/R hemisphere to separate; mutation in sonic
hedgehog aw alcohol use
WNT7 is a/w dorsal ventral axis so feet and nose point in same direction;
FGF is a/w limb lengthening
Wk4 limb buds and heart forms 4 chambers
Statin, MTX, warfarin, DES, are teratogens a/w valproate&carbamazapine
Lithium is a/w Ebstein anomaly (hypoplastic RV and large RA)
Danny Walker: Agenesis of cerebellar vermis with cystic enlargement of 4th
ventricle; a/w hydrocephalus, spin bifid a
Wallerian degeneration (if axon injured)degeneration distal to the injury
and axonal retraction proximally; allows for potential regeneration of axon
(if in PNS).
Astrocyte marker GFAP
Perineurium must be rejoined in microsurgery
Dopamine (ventral tegmntum) is in hutingtons and in depression &
parkinsons
GABA is in anxiety & Huntingtons (CAG: Caudate loses ACh and GABA,
Dopamine- ACDC; HD gene chrom 4)
Poliomyelitis & Werdig Hoffmann dz (floppy baby; death in few yrs)- both
have degeneration of anterior motor horn of LMN signs
Amyotropic Lateral Sclerosis (Lougerig): UMN (lateral horn) and LMN
(anterior horn) degeneration (1st intrinsic muscle of hand); no pain or temp
loss; most are sporadic but some Zn-Cu superoxide dismutase mutation; tx
w/ glutamate antag riluzole
Friedreich Ataxia: AR GAA repeat in frataxin gene (reg Fe in
mitochondria); degenerate cerebellum (ataxia) &, DRG, vibratory sense, LE
muscle weakness & loss of DTR a/w hypertrophic cardiomyopathy DM1
Epidural hematoma- lens shape; lucid interval then coma, unlike subdural
cannot cross suture lines, but can cross falx, tentorium.
Demeyelinating disorders: Leukoystrophy: arylsulfatase (myelin cannot be
degraded-> ataxia & dementia; Krabbe dz: galactocerebroside betagalactosidase accumulation in MAC; Adenoleukodystrophy: impaired
addition of CoA to long chain FA accumulatin in adrenal gland & white
matter; Carcot Marie tooth: polyneuropathy in child, stork leg w/ high arch
(demylination & remylination -> onion bulb)
Myopathy= diffuse skeletal muscles- proximal muscle weakness;
radiculopathy= shooting pain; Spondylosis= compression
Genetic imprinting prevents human species from parthenogensis
MG- Atb to Ach_RW>M, dysfunction of NMJ, (thymic hyperplasia); weak
in eye lid
Multiple sclerosis: autoimmune distruction of central (not peripheral) CNS
myelin & oligodendrocytes; a/w HLADR2 A3, B7 DW2; seen in regions
away from equator; px blurry vision, vertigo, drunk speech, internuclear
opthalmoplegia (MLF), hemiparesis, incontinence; dx by MRI plaques
(greying of white matter)&LP LYM, oligoclonal IgG bands & myelin
basic protein; tx steroids IFN-beta
Subacute sclerosisng panencephalitis: measles virus; infected early presents
late, progressive debilitating (see inclusion in grey & white matter
PML- JC virus; immunosuppression leads to reactivation
Cluster headache- periorbital pain, rhinorrhea, congestion, lacrimation;
tension headache is bilateral while migraine and cluster are unilateral
General tonic clonic seizures -> hippocampal sclerosing; absences seizuresstaring spells in kids
Digoxin
Transient global ischemia: anterograde amnesia w/ radpid resolution; ask
same questions
31 spinal nerves; C3 exits above the 3rd cervical vertebra; L2 exits below
the 2nd lumbar vertebra)
Degenerative neurons- cortex (dementia), basal ganglia (movement
problems)
Therapeutic hyperventilation (PCO2) helps intracranial pressure in cases
of acute cerebral edema (stroke, trauma)
CJD: startle myoclonus, spike wave complexes on EEG, death in 1 yr, very
early dementia; vCJD- mad cow meat; familial fatal insomnia- inherited
form, exaggerated startle response
C6-thumb, elbow extension; C7 middle, elbow flexion; C8 pinky; L3 knee;
L5 big toe
Frontal lobe syndrome: disorganized behavior (poor memory), disinhibited,
apathetic

Hemiballismus- flailing, ballistic, undesired movements of the limbs


Athetosis- lesion in BG writhing movement
Paramedian pontine reticular formation- eyes look away from lesion; frontal
eye fields- eye look toward lesion
Central pontine myelinosis )overly rapid correction of hyponatremia)
locked in syndrome; From low to high, your pons will die(CPM); From
high to low, your brain will blow(cerebral edema/herniation)
Locked in syndrome also seen in basilar a. thrombosis affecting
corticobulbar tract of ventral pons
Leptomeningeses (Pia + arachnoid)
Meningitis cause: neonate (GBS, List, E.coli), teen/child (N. men),
nonvacinated infant (H flu), imunompromised (fungal- see LYMP w/ Glu),
Cosakie virus; px with fever, neck stiffness, L4/L5 get LP; if severe hearing
loss, hydrocephalus, seizures
Global ischemia- caused by hypOglucemia, atherosclerosis,blood
moderate global ischemia: damage to layers 3,5,6 (corticolaminar necrosis),
pyramidal neurons of hypothalamus, perking layer of cerebellum (ataxia)
Stroke- ischemic (most; regional; Red neuron is 1st sign of ischemic stroke
and by 1 month have gliotoc cyst) or hemorrhagic (thromboembolism)
Lacunar stroke- hyaline arteriolosclerosis close lumen of MCA lenticustriate
Lenticulostriate art undergo hyaline arteriolosclerosis weak wall
charcot- couchard microaneurysm which rupture (due to HTN)
hemorrhage; basal ganglia is most common (NV, headache, coma)
Subarachnoid hemorrhage- rupture berry aneurysm, sudden onset oheadache
(worst headache) yellow tinge in CS fluid; a/w marfan (chrom15) APCKD
Anterior cerebral artery (ACA) infarcts: upper motor-neuron weakness and
cortical-type sensory loss in the contralateral leg, gait apraxia, and urinary
incontinence
Posterior cerebral artery (PCA) infarcts: contralateral homonymous
hemianopia. PCA infarcts can also affect the thalamus or posterior limbs of
the internal capsule, resulting in contralateral hemiparesis or sensory loss.
Middle cerebral artery (MCA) infarcts: aphasia (Brocas or motor aphasia),
hemineglect, hemianopia, and contralateral face-arm sensorimotor loss.
There is sometimes gaze preference toward the same side as the lesion.
MCA infarcts are common.
Amaurosis fugax; temporary loss of vision; embolic matcriai trapped al
bifurcation of retinal vessels
Alzheimers risk by ApoE 4 allele ( risk w/ ApoE2); presenilin 1
mutation or DS (3 copies of APP on chrom21) early onset Alzheimer; see
diffuse cerebral atrophy (narrowing of gyri) hydrocephalus exvacuo;see NFt
w/ tau; Amyloid plaques is always extra cellular; see Hirano bodies
(eosinophillic inclusions of actin)
Tx for alzhemers- donepezil, alpha-tocopherol (vit E), memantine (NMDA
antag)
DubinJohnson syndrome is a/w w/ cMOAT transporter deficiency
Technicium concentrates in gastric mucosa; useful for dx meckels
diverticulum (vitilline duct)
Babies can become lactose intolerant after viral gastroenteritis= deficient in
beta-galactosidase that breaks down lactose into galactose+glucose
IN HIV, only env gene of the (gag, pol env struc genes) is glucosylated to
become gp160gp 120 & 41
Neonate meningitis: GB Strep, ecli, listeria, klebsiel, H flu in nonimmunized
Vascular dementia- consequence of moderate globa cerebral ischemia (cause
HTN, vasculitis, atherosclerosis)
Pick- frontal (behavior) & temporal cortex (language), round aggregates of
tau
T1/2= (Vdx0.7)/CL; takes 2 half lifes to eliminate 75% drug
Portal vein thrombosis causes portal HTN, splenomegaly, varicosities but
NOT ascites as it is presinusoidal and liver parenchyma is normal
Aspergillus have septated hyphaeaffect immunocompromised
Ureter travels b/w internal & external iliac arteries
AFP &AchE in placenta are indicativw of neural tube defets
MPTP can led to parkinsons; see Lewy bodies of alpha synuclein; AR
mutation oin DJ1, pink1, prin?
Lewy body dementia- lewy body in cortex, early onset
Huntingtons: lose GABA neurons of caudate of BG overactive cortex
(chorea)
Leukotirene B4 & its precursor 5HETE stimulate NEU chemotaxis
Neuroborreliosis (Lyme) bilat facial neuropathy (also seen in acute
inflammatory demyelinating dz w/ prior Campy infection)
Thiamine deficiency (B1): ataxia, opthalmoplegia, confusion

thalamic syndrome (Dejerine-Roussy syndrome)- pain onset after


contralateral sensory loss
Epithlamus= pineal gland
Moro reflex- extend limbs when startled and draw together
Galant reflex: Stroking along one side of the spine while newborn is in
ventral suspension (face down) causes lateral flexion of lower body toward
stimulated side
Parinaud syndromeparalysis of conjugate vertical gaze due to lesion in
superior colliculi (e.g., pinealoma).
Uvula deviates away from lesion
Wegners granulomatis (granulomatosis w/ polyangitis): dz with shallow
ulcers & perforation of nasal septum, inflammation of Uupper resp tract &
kidneys (red cell casts); c-anca; large nodular densiites on Xray
Acromegaly in adults- serum IGF-1; failure to suppress serum GH
following oral glucose tolerance test; pituitary mass seen on brain MRI, tx
w/ octreotide or pegvisomant; gigantism in children
Urine vanillilmandellic acid in heochromocytoma
Tenesmus is feeling of needing to empty bowels while trismus is locked jaw
Hashimoto thyroiditis: most common cause of hypothyroidism in US; LYM
infiltrate, Hurthle cells (epithelial cells w/ eosinophillic cytoplasm w/
germinal center formation
Neuropblastomas occur in adrenal medulla or sym chain-> pheo
Biotin deficiency alopecia. Causes : consumption of raw egg whites,
prolonged oral ABX, & anticonvulsant (phenytoin, primidone, and
carbamazepine- has SJS SE); cofactor in carboxylation rxn; req 1 ATP for
activation
Porphyria cutanea tarda: autosomal dominant defect of UROD
(uroporphyrinogen decarboxylase)get skin blisters
3Ds of pellagra- demen, dear, dermatitis
AREAS- compile of SC
folatedeficiency- phenytoin use
PIG- JaK Stat
S2 splitting A<P w/ inspiration
S3- normal inpreg and child, adult: filling pressure
S4- nl in young: filling ventricle with compliance
cannon a waves : 3rd degree heart block
absent x- tri regur; rapid x: constrict (rapid y), tamponade(no y)
large cv waves- tri regurg
rapid y: tri regurg, constr, severe RHF
tx lyme with doxy/ceftri
hypercalcem: bones, moans groans stones, card
treat secondary hypocalcemia w/ bit D and phis binders (alum hydros or ca
carbonate)
Chlopromazine & thioridazine are low potency; Haloperidol bind D2
strongly with minimal anticholinergic, effects EPS (akathsia- fidgetiness;
akinesia- lack voluntary movement with pin rolling tremor); tx
neuromalignant syndrome (FEVER) with Na dantrolene and DA agonist
Myosin heavy chain most commonly mutated in HCM, 1st degree scree w/
echo
Graft vs host- dermatitis, hepatitis, gastroenteritis (5wks)
Berkson bias is a seletion bias
Dj1, parkin pink1 are recessive mutations in alzeimers
Leukotriene b4 and 5hete stimulate NEU chemotaxis
Appetite suppressing meds >3 mo pul HTN & RVH
Isosorbide DInitrate has 100% bioavailability
Traction diverticulum is a true diverticulum
MHC2 when antigen bound is endocytosed and taken to acidic endosome
While MHC1 is produced (w/ B2 microglobulin) and attached to antigen
before being expressed

Cardiology
Sequelae of ASD (fixed splitting) is infective endocarditis, paradoxical
emboli & CHF
Give aspirin & IVIG in child only if Kawasaki dz (child w/ hand foot rash,

EtOH- confusion, dysarthria, ataxia, polyneuropathy


B12 deficiency (like HIV) causes polyneuropathy, w/ dysfunction of
posterior & lateral corticospinal tract
Heliotrope is a macular rash with periorbital edema, is considered a
characteristic finding of autoimmune dermatomyositis
Presyncope: vasovagal, orthostatic, cardiogenic,(no presyncope or trigger)
Anterior spinothalamic tract (crude touch, pressure)
Tabes dorsal is: 3 syphilis, impaired sensation proprioception and
progressive sensory ataxia, a/w Charcot joints, shooting pain, Argyll
Robertson pupils (small bilateral pupils that further constrict to
accommodation and convergence, not to light)
S1, 2buckle my shoe (Achilles reflex) L3, 4kick the door (patellar
reflex) C5, 6pick up sticks (biceps reflex) C7, 8lay them straight
(triceps reflex)
Additional reflexes: L1, L2testicles move (cremaster reflex) S3, S4
winks galore (anal wink reflex)
Mesencephalon= midbrain
Vasospasm often follows from subarachnoid hemorrhage
Low frequency sound is bes heard at apex of cochlea near helicotrema while
high frequency sound is detected at base of cochlea near oval & round
window
medial striate arteries are the largest branch of the ACA and supplies the
head of caudate, anterior portion of the lentiform nucleus and anterior limb
of the internal capsule.
The anterior choroidal artery is a branch of the internal carotid. It
contributes blood supply to the lateral geniculate body, globus pallidus, and
posterior limb of the internal capsule.
Peripheral neuropathy has been associated with didanosine (ddI), zalcitabine
(ddC), and stavudine (d4T). In addition to retroviral reverse transcriptase,
these drugs also inhibit an enzyme that mitochondria use to reproduce,
resulting in the production of fewer mitochondria and an increase in
mitochondrial mutations.
B2 deficiency (riboflavin)angular cheilitis (cracked angles of the mouth),
glossitis
Hartnup disease: autosomal-recessive defect in intestinal and renal
transporters for neutral amino acid causes tryptophan excretion in urine
leads to pellagra
PCA (supplies hypo&vental thalamus) 3rd most common aneyrysm site
3rd nerve palsy
Small saphenous vein is lateral lower leg; the great saphenous vein courses
anterior to medial malleolus and travels on medial leg harvested from
inferior lateral of pubic tubercle
1st gen H1 antagonist also block M1 (both are activated in motion sickness);
scopolamine has only antimuscarinic effects
Chediak higashi dz- partial albinism, pyogenic infections,
neurodegeneration; mx impaired microtubules impaired phagocytosis
1 hydroxyls makes active vit D in kidneys
histamine- vasodilator, bronchoconstrictor
levetiracetam- seizure
Wechsler- 6 verbal 5 performance
cluster headaches- verapamil. ergo li, predni
prostate metastasizes to bone
CHF- ABDS
ToRCHeS cross placenta HSV 1 2
multiple sclerosis- SIIIN
renal papillary necrosis- SO sAAD
Gartner's duct- mesonephric duct
Hombox gene - head neck & limb development;
The IVC can be compressed greatly in pregnancy dizziness
Amantadine dopamine release and influenza prophylaxis SE: ataxia
Dhole bodies are found in NEU of people w/ infections, trauma, pregnancy
Pappenheimer bodies are in RBC of sideroblastic anemia
Wiedle Palafe bodies in endothelial cells vWF, p selectin

Amiodarone tox: pul fibr, heaptotox, hyperthyroid (hyperrefles, weight


loss, hest palpitations), photo dermatitis
Diarrhea w/ VOMITING- norovirus /staph aureus

red eyes, fever, painful LAD); med-small arteres


Phosphbalmin: block L Ca channel on sarcolemma (ryanodine receptor)
Digoxin toxicity: yellow hallows, ST depression, T inversion, Tx CHF
Clonidine is alpha-2 agonist
Erythema multiform (SSS)
Erythema migrans (Lyme)
Erythema marginatum- rheumatic fever (FEVERS- fever, erythema
marginatum, valvular damage MS, ESR, red hot joints, subQ nodules,
Syndenhym chorea
Adenosine is drug of choice for paroxysmal SVT, Mx: hyperpolarizes the
pacemaker-> AV block, SE hypotension, chest burning (bronchospasm),
flushing
Verapamil: constipation; lidocaine cause neurologix Sx, ProcainamideLupus-like, Digoxin- NVD, delirium, blurry vision
preload, afterload, and contractility will increase LVOT obstruction in
hypertrophic cardiomyopathy
Aspirin toxicity: anion gap metabolic acidosis, respiratory alkalosis,
tinnitus; tx w/ bicarb & dialysis
Defect in AV node case 1st degree block or mobitz 1 (Wenkebach)while
purkinje abnml mobitz II
Excessive beta blockade can cause bradycardia, hyperkalemia, confusion
and hypoglycemia. The treatment is to provide glucagon
Nitroprusside is #1 for malignant HTN, dialates arteries & veins; SE: reflex
tachy & cyanide toxicity (esp in liver dz pts)
Alpha- hepatitis, Kaposi, RCC, melanoma;
gamma-IFN= CGD; beta-IFN= MS
Azathioprine- rheumatoid arthritis, & kidney transplant
Testosterone is reduced by 5 alpha reductase to DTH which is responsible
for BPH and secondary sex characteristics in men and women. Finasteride
treats BPH by blocking 5alpha reductase
GNRH analogue is leuprolide tx prostatic cancer by LH; flutamide is
testosterone_R antagonist; tx prostate cancer
Sildenafil inhibits cGMP-phosphodiesterase 5; tx erectile dysfunction
Cyclin D is overexpressed in breast, lung, esophageal cancers;
BRACA-1 is an oncogene
Dilated Cardiiomyopathy Causes: ABCCCD: Alcohol abuse, Beriberi,
Coxsackie B myocarditis, chronic Cocaine use, Chagas' disease, and
Doxorubicin toxicity.
Pulmonology
Pancoast tumor/superior sulcus tumor: apex squamous cell tumor invading
sympathetic ganglion
Indirect hernia are lateral to epigastric aa while direct are medial
Polymyositis: LYM in muscles, proximal muscle weakness

GI
gynecomastia, spider angiomata & palma erythema are signs of estrogen
Carcinoid syndrome: chronic diarrhea, facial flusing, murmur (tricuspid);
ligament of treitz; serotonin; cells llok all the same shape &size
Chrons: uvetis, migratory polyarthritis, erythema nodosum, renal calculi;
affects terminal ileum most often
Metoclopramide: promotility drug; D2 agonist with extrapyramidal SE; tx
gastroschisis; only affects SB not colon (cannot treat constipation)
IBS: diarrhea, fever, arthralgia, weight loss along w/ arthrtitis, erythema
nodosum
Get cataracts not glaucoma from steroid therapy
DEAD PEEL- surface ectoderm- lens, enamel, parotid, inner ear

Review toxin summary card


Parafollicular C cells are neuro crest
Beta2 glucagon hypoglycemia in DM, vasopasm (acerbate PAD),
bronchoconstriction
Beta 1- heart only HR, contractility, CO, AV node(effective in atrial
arrhythmias
Benzos SE is sedation therefore should not be combined with other drugs
causing sedation like chlorpheniramine (1st gen antihistamine)
Know the AP plots of antiarrhythmic drugs
Review the FK brain tumor cards (meduloblastoma & astrocytoma affect
young children see undifferentiation in first and Rosenthal corkscrew fibers
in latter)
In atherosclerosis, intimal fibrosis and hyperplasia is 1 due to SM cells
Fastest-> slowest purkinje, atria, ventricular, AV node (Park at Ventura
Ave)
Bosentan blocks endothelin; tx pulmonary HTN
Clopidogrel is used to prevent acute stent thrombosis, & atherosclerotic
ischemic dz\ACEI- tx CHF, HTN, Diabetic neuropathy
Indomethacin COX 1 & 2 inhibitor, anti-inflammatory agent & pain
reliever; indo or NSAID help close PDA
Verly Long chain fatty acids and FA with branch points at odd numbered
carbons (phytanic acid) are metabolized in peroxisomes NOT mitochondria
Alpha oxidation branch chain FA on odd # carbon like phytanic acid
Zellweger is a peoxismole dz where infants cant properly form myelin
Refsum dz is from defect in peroxisome alpha oxidation; tx by avoiding
chlorophyll in diet
Alport- hematuria, sensorineural deafness & anterior bulging of ocular lens
Rb is inherited in an autosomal dominant fasion
Bipolar 1- maj depressive + manic while 2 is depression + hypomanic; tx
with lithium whose common SE is polyuria
While the LYM protect against localized cutaneous candidiasis, the NEU
protect againsts systemic candidiasis
Acute hepatitis B starts out as a serum-like sickness (malaise skin rash,
pruritis, joint pain, LAD)
Psuedo pancreatic cysts are lined by granulation fibrous tissue while true
cysts are lined by epithlium (glycogen rich cuboid cells in serous neoplasm
Carnatine is involved in transporting medium chain FA across
mitochondria to form ketones like acetoacetate

Upper lobe preference: sarcoidosis & silicosis, Langerhans cell


histiocytosis, CF, 2 TB
Lower lobe preference: idiopathic pul fibrosis, asbestosis, cryptogenic
organizing pneumonia, ILD mimic of HF
Asthma Differential: COPD, vocal cord dysfunction (wheezing from upper
airway, younger age monophonic wheezing), mechanical obstruct, CF
(clubbing of digits), HF (lower edema & bilateral ins crackles),
bronchiectasis, ABPA
Paget dz (osteitis deformans)
: lytic (osteoclasts), sclerotic (osteoblasts) ALK phos, nrml Ca, PTH, PO4;
caused by paramyovirus

P450 inhibitors: A cute gentaleman cipped iced grapefruit juice quickly and
kept munching on soft cinnamon rolls [acute alcohol, cipro, INH,
grapefruit, quinidine, amiodarone, ketoconazole, macrolide, sulfonamides,
cimetidine, rintonavir
P450 inducers: chronic alcoholic Mona steals phen phen and never refuses
greasy carbs [modafinil, st. john wart, phenytonin, phenobarbital, rifampin,
griseofulvin, carbamezapine]
P450 Substrates: always, always, always, always think when starting others
[antipsychotics, anisthetics, antidepressants, antiepileptics, heophylline,
warfarin, statin, OCP],
Hep B causes hepatotoxicity vid CD8 cells, the virus itself is not toxic

Heme
Multiple myeloma: elderly with back pain, interstial nephritist, fatigue; IgG light
chains; CRAB: hyperCalcemia , Renal insufficiency, Anemia , Bone lytic
lesions/Back pain; a/w Rouleaux phenomemnon
Waldenstrom macroglobulinemia- IgM

Myelodisplastic syndrome- Pelger Huet (bilobed NEU); can


become AML
9:22-CML (bcr-abl, blast crisis,tx imatinib); 8:14-Burkitt (c-myc);
11:14-Mantle (cyclin D1); 14:18-Follicullar (bcl2); 15:17-M3 AML

RBC have a HCO3- & Cl- antiporter


Platelets have alpha granules (vWF, fibrinogen), dense granules (ADP, calcium)
Leukocytes = granulocytes (neutrophil, eosinophil, basophil) and mononuclear
cells (monocytes, lymphocytes).
Neutrophil: azurophilic granules (lysosomes) contain proteinases, acid
phosphatase, myeloperoxidase, and -glucuronidase.
Monocyte- frosted glass cytoplasm (limits mast degranulation)
MAC: activated by IF-gamma; CD14 receptor
See EOS in NAACP- neoplasia, asthma, allergy, CT dz, parasite; EOS have
histaminases & arylsulfataase
Basophil- contains heparin, histamine, leukotriene; in CML
Mast cell release heparin; Cromylyn sulfate limits mast cell degranulation
AB blood type: universal donor of plasma; O is universal recipient of plasma
Bradykinin- permabilit, pain & vasodilates; activated by kallikrein (NEU
chemotactic), blocked by ACE
ondansetron is a 5ht3_R antagonist; tx nausea from chemo, better than
metoclopromide. Adverse effects of ondansetron are headache and constipation.
Plasmin changes C3 to C3a
if vWF F8 ; glanzmann (GpIIb/IIIa); bernard soulier (Gp1b; platelets)
Antithrombin inhibits 2, 7, 9, 10,11, 12; thrombomodulin coat on endo cells
Ticlopidine and clopidogrel inhibit ADP- induced expression of
GpIIb/IIIa;Abciximab inhibits GpIIb/IIIa directly. Ristocetin activates vWF to bind
to GpIb.
ESRinfections, autoimmune diseases (e.g., SLE, rheumatoid arthritis, temporal
arteritis), malignant neoplasms, GI disease (ulcerative colitis), pregnancy.
ESRpolycythemia, sickle cell anemia, CHF, microcytosis, hypofibrinogenemia.
Basophillic stippling (rRNA aggregates): Anemia of Chronic Disease, alcohol
abuse, Lead poisoning (inhibits ferrochetalse&ALA dehydrates), Thalassemias.
Target cell: HbC disease, Asplenia, Liver disease, Thalassemia. (HALT)
barts Hb = 4 (4 allele delition); HbH dz (3 allel deletion)
Methotrexate/phenytoin is folate antagonist while NO blocks B12; defect in
transcobalminB12 (best test for dx is methymalonic acid levels NOT b12);
methotrexate toxicity is tx w/ leucovorin
Ineffective erythropoiesis: b12 (cobalmin), thalassemia, myelodisplastic syndrome
LEAD: Purple Lines on gingivae (Burton lines) and on metaphyses of long bones,
Encephalopathy & Erythrocyte basophilic stippling, microcytic anemia, ataxia,
Abdominal colic and sideroblastic Anemia. Dropswrist and foot drop.
Dimercaprol and EDTA for tx (Succimer for kids).
-thal major: extramedullary- crew cut face, splenomegaly; chrom 11;
HbA2>3.5%, target cells
Sideroblastic: EtOH, lead, B6 or Cu, INH- defect in ALA synthase; iron, normal
TIBC,ferritin; tx w/ B6
Orotic acid: defect in UMP synthase; megaloblastic anemia w/ not recover from
B12 or folate; No hyperammonemia (vs. ornithine transcarbamylase deficiency
orotic acid with hyperammonemia). Tx with UMP
Nonmegaloblastic macrocytic anemias: liver disease; alcoholism; reticulocytosis
MCV; drugs (5-FU, zidovudine, hydroxyurea).
Zidovudine cause BM suppression while gancyclovir causes neutropenia, anemia,
thrombocytopenia, & impaired renal function
Foscarnet is a/w electrolyte abnml: HYPO- calcemia, kalemia, magnesemia,
phosphatemia
Pancreatitis is SE of didanosine (HIV NART)
Gancyclovir is a/w impaired renal function
SJS is a/w efavirenz & nevirapine (antiretroviral meds)
Aplastic anemia: caused by radiation, falcon, B19, EBV, HIV, chloroamphenicol,
alkylating agents
Hereditary elliptocytosis (HE) is the second most common autosomal dominant
defect in the RBC membrane. It is suggested that this mutation confers resistance
to malaria.
Eosin-5- maleimide binding test useful for screening hereditary spherocytosis
(defect in ankyrin, band 3 spectrin
CYP inhibitors: isoniazid, sulfonamides, cimetidine, ketoconazole, and grapefruit
juice; remember the mnemonic "Inhibitors Stop Cyber-Kids from Eating
Grapefruit.
Tuberous sclerosis: AD- cutaneous angiofibromas (adenoma sebaceum, seizures,
MR
Kussumals sign: paradoxical JVP w/ inspiration- restrictive cardiomyopathy,
severe RHF, TS, tamponade; pulsus paradoxsicus- in systolic pressure of >10 w/
inspiration, tamponade, corpulmonale
Mucor species are molds with irregular nonseptate hyphae that branch at wide

(responsive to retinoid; RF: alkylating chemo, Downs, px w/ DIC,


auer rods)
Hairy cell leukemia- EBV mature B cell tumor w/ filamentous
projections; stain is TRAP; causes marrow fibrosis; tx w/ cladribine
(2-CDA), an adenosine analog (inhibits adenosine deaminase).
ALL presents <15 yr as mediastinal mass, a/w downs; 12:21 has
good prognosis
Langerhans cell histiocytosis- child w/ lytic bone lesions, skin rash
or as recurrent otitis media with Birbeck granules on EM; mass
involving the mastoid bone
HIIT- IgG against heparin + PF4Cilostazol, dipyridamolephosphodiesterase III inhibitor used for angina prophylaxis,
coronary vasodilation
Antimetabolites: Cytarabine- is a pyramiding analog that block
DNA pol, SE cytopenia; 5FU-pyrimadine analog inhibit thymidine
synthase & MTX dTMP; Azathioprine/6MP- purine analog
activated by HGPRT, metal by xathine oxidase, fox w/ allopurinol
Dactinomycin- intercalates DNA; tx child tumors
Doxorubicine- & bleomycin induce free radicals
Alkylating agents: cyclophosphamide- covalently X-link DNA, SE
cystitis prevented w/ mensa; Nitrosoureas (carmustine, lstrptozocin,
semustine)- tx brain tumors cross BBB; busulfan cross links DNA,
tx CML
Vincristine (areflexia, peripheral neuritis)/vinblastine (BM)
(prevent polymerization of tubulin); paclitaxil (taxing stay
polymerized; myelosression w/ alopecia, HYSN)
Etoside- block topi II(SE alopecia & myelosuppression);
(nephrotox prevented w/ mannitol)tin- cross link DNA; irinotecanblock topo I; Hydroxyurea- block robonucleotide reductase;
prednisone- prodrug of prednisolone (11-beta-hydroxysteroid); used
for CLL/non-Hodgkins (SE: incweight, muscle breakdown,
cataracts, acne, osteoporosis, ulcer, hyperglycemia, psychosis);
21-Hydroxylase deficiency CAH, hypotension, hyperkalemia,
hyponatremia
17 hydroxylase deficieny hypertension, hypernatremia, sexual
infanilism
Tamoxifen ( endometrial cancer)/raloxiffene (no cancer)- estrogen
blocker in breast and agonist at bone
Traztuzumab- Heartceptin toxicicty; Imatinib- tx CML & c-kit
stromal tumors
Rituximab- tx nonhodgkins & arthritis; risk of PML
Vemurafenib- small molecule inhibitor of B-raf kinase; tx
metastatic melanoma
Bevacizumab- ATb against VEGF; SE hemorrhage
Aspirin toxicity: tinnitus, bleeding
Tx thrombolytic toxicity (altepase, -plase) w/ aminocaproic acid
(inhibits fibrinolysis)
Ticlodipine (ADP-R antag) causes neutropeni and TTP/HUS
Apixaban, rivaroxaban (direct F10a antag); prophylaxis for DVT or
PE
Argatroban, bivalirudin- direct thrombin inhibitors (leeches)
Spleen: medullary cords- plasma; medullary sinus: reticular& MAC
Aspirin- for MI; Warfarin for PE
Uteropelvic junction obstruction is common-> neonal hydronephsis
Effect modification is about stratification.
Ricketsia and chlamydia use host ATP to survive (intrcellular)
Means that there's difference among the different subgroups of the
population under study.For example; Drug X worked on children
but did not work on older adults. This is effect modification.
FoxP3 gene on X protein codes for Forkhead box protein P3immune tolerace; implicated in autoimmunity
Spooning of nails is a/w fe deficiency
Corpus spngiosum of males= vestibular bulbs of women;
Cowpers bulbourethal= bartholin/greater vestibular glands
Prostate= skenes glands (urethral & paraurethral glands
Confounding bias on the other hand, is for the entire population
under study. Means you cannot say drug X worked or not because
age was a confounding factor in the example above.
The Kozak consensus sequence lies upstream to AUG that regulates
mRNA bnding to ribosome
Insulin blood AA, glucose, K, formation of FAA, NA

angles (more than 90 degrees). worrisome in patients with diabetic ketoacidosis,


who may initially present with allergy-like symptoms.
Zone 3 of acinus: lipogenesis, glycolysis, detox, alcoholi hepatitis; Zone 1gluconeogen, chol syn
L4-bifourcation, L3-IMA, L1 SMA & renal. T12-celiac
Inferior phrenic supplies diaphragm and adrenal from superior suprarenal aa.
marginal artery of Drummond is the anastomoses of all the aa of colon
Nutcracker- left renal vein compressed b/w aorta & SMA
SMA syndrome- 3rd portion of duodenum compressed b/w aorta & SMA
inguinal(Hesselbachs) triangle(medial: rectus muscle)- site of direct inguinal
hernias ie thru superficial inguinal ring; indirect- thru
The basolatera surface of hepatocytes faces the sinusoids
The ventral bud of pancreas forms only uncinate process while tail forms rest
Retroperitoneal: pancreas head, duodenum 2-4, lower 2/3 esophagus
Lac operon: when glucose is present cAMP goes down (via inhibition of adenylate
cyclase) causing poor binding of Cap protein to CAP-DNA area expression
Lac operon expresses z gene (beta-gal), y for permease & a Beta-galactocide
tranacetylase

Renal
Post strep glomerulonephritis- Type III HYSN
Potter sequence (seen in ARPKD): bilateral ageneises, low ears, extremity
defects lung hypoplasia, oligohydramnios- incompatible w/ life
ARPKD- cyst in liver Portal HTN
Dysplastic kidney- not inherited, characterized by cyst with cartilage, when
bilateral must be distinguished from PKD
PKD- inherited defect, large kidneys, bilateral w/ cysts in cortex & medulla
ADPKD- HTN, hematuria, renal failure, berry aneurysm (chrom16 or 2)
Cause of nephrotoxic tubular necrosis: Amniglycossides, heavy meals,
Stmyoglobinuria, ethylene glycol, radiocontrast dye, urate (tumor lysis
syndrome)
Renal papillary necrosis caused by analgesic abuse (phenacetin, aspirin),
DM, SC, acute pyelonephritis
Tubular cells are stable cells so will take 2-3 wks for oliguria to heal
AIN is caused by NSAID, PCN, diuretics
MCD- a/w hodgkins or idiopathic; neg IF; loss of albumin but not
immunoglobulin
FSGS: heroin, HIC, SC;
Aspirin toxicity- tinnitus nausea vomiting; tx w/ charcoal, NaHCO3,
Mebranous: subepithelial deposits, spike & dome, hep B/C, SLE, NSAIDs,
penicllamine, solid tumors, most common in Caucasians; granular IF
Mebranoproliferate GN= tram track; type 1 = subendothelial aw hep B/C
(more a/w tram track); type 2 BM deposition, has C3 nephritic factor
Wegners- c-ANCA; if debating b/w good pasture & webners and pt has
sinus problems choose wegners
P-ANC: churg straus (granulomas, eosinophilia, asthma) vs microscopic
polyancitis (above sx not seen)
Histo of chronic nephritis = atrophic tubules w/ EOSinophilic proteinacious
material= thyroidization of kidneys
ACEI cause efferent arteriole dilation & kidney failure if pt was
dependent on efferent artery constriction to maintain glomerular pressure;
first dose hypotension occurs esp if pt on another diuretic, hyponatremic, ,
HF, renin/aldosterone, low baselin BB
Staghorn caliculus in adult=AMP stone but in kid = cysteine stone;
Ca oxylate stone in Chrons tx w/ THZ diuretic
Uric acid stone is radiolucent, seen in gout, myeloproliferatice disorders; tx
w/ alkalinization & hydration, allopurinol
Renal peritubual interstial cells secrete EPO
End stage renal failure (top 3 causes DM, HTN, glomerular dz); px: uremia
(asterixis, nausea, pericarditis, platlet aggregation), hyperkalemia w/ met
acid, anemia, salt & H2O retention, hypocalcemia, osteitis fibrosa cystica
(hypocalcemia PTH resorbption of bone fibrosis & cyst
formation), osteomalacia (cannot mineralize (w/Ca, PO4) the osteoid from
osteoblast), osteoporosis (leech Ca from bone slowly over time due to

retention
Glycine aspartate & glutamine are necessary for purine synthesis
BNP is released from stretched out ventricles
PPD test also called antoux or Pirquet test
Dieulafoy's lesion U GI bleed from large tortuous arteriole in
the stomach in submucosa
Inherited Osteoporosis is due to defect in osteoclasts bone
spongiose tissue in BM
Inguinal ligament from external abdm oblique
Conjoint tendon: transversus + internal oblique
Vertical diploplia- defect in trochlear nerve (look at nose or going
downstairs); horizontal diplopia abducens. CNIII cause both
Friedreich ataxia: hypertrophic cardiomyopathy, DM,
kyphoscoliosis, pes cavus, hammertoes AR; degeneration of dorsal
columns
Too much citrate form blood transfusions hypocalcemia
Oxalate stones are a/w chrons dz
Hemoglobin C is caused by missense mutation (Glulys);
Gel electrophoresis:(anode)Hgb A> S>C(closest to cathode - end)
Some non-small cell lung cancer have EML4-ALK fusion gene
constitutively active tyrosine kinase receptor
D-xylose can be used to differentiate malabsorption of pancreatic or
gastrointestinal origin
The esophagus is located b/w the trachea and vertebral bodies in
superior thorax

RCC: hematuria, palpable mass, flank pain; paraneoplastic syndrome (


EPO-reactive polycythemia, renin-HTN, PTHrP-hypercalcemia, ACTHcushing); rarely cause left side varicocele; does not occur on right side b/c
righ vein drains directly into IVC; pathogenesis: loss of VHL, IGF1, HIFTF VEGF & PDGF; smoking is key RF of sporadic syndrome
Von Hippel Lindo (chrom3) syndrome- AD, risk of hemangioblatoma of
cerebellum, retinal & medullar hemangiomas & bilateral RCC
Wilms tumor- most common tumor in child of 3yrs; blastema that forms
stroma along tubules; px w/ unilateral flank mass w/ HTN (renin); WAGR
syndrome; also seen in Beckwith Wiedmaan syndrome (as well as neonatal
hypoglycemia, muscular hemihypertrophy, organomegaly)
RF for Urothelial carcinoma is smoking, napthylamine, azo dyes
(hairdressers), long term cyclophosphamide or phenacetin; px as painless
hematuria; has 2 pathways (flat which starts out high grade; a/w w/ early
p53 lesions) & (papillary which starts low grade and progresses to high
grade)
Painless jaundice + weight loss is likely +/- migratory thrombophlebitis tic
cancer a/w painless enlargement of the gallbladder, known as Courvoisier's
sign& Trousseau's syndrome (migratory thombephlebitis /venous
thrombosis like PE; always indicative of visceral cancer)
Biliary atresia: see bile duct chlestas & prolif
Base repair: endonuclease cleaves 5 end whie lyase cleaves 3
Syryngomyelia damages the spinothalamic tract that crosses the anterior
white commissure
IL-7 stimulate bone erosion in rheumatoid arthritis
Adenocarcinoma- malignant proliferation of glands; arises from urachal
remnant (present at dome of bladder), cystitis glandularis (starts out as
columnar metaplasia), bladder exstrophy (failure to form the caudal portion
of bladder)
Acidosis is a/w hyperkalemia
Mensa counteracts hemorrhagic cystitis caused by alkylating agents
(cyclophosphamide, ifsofamide)
Ginigival hyperplasia seen in phenytoin, CCB, cyclosporine
Papillary carcinoma: most common; orphie annie & psammoma bodies
5-hydroxyindoleacetic acid is in carcinoid syndrome
Type IV RTA- impaired ability to secrete acid into urine due to
hypOaldosteronism; The alkalotic environment in the renal tubule cells,
however, inhibits ammonia and hydrogen production and secretion,
reducing the kidney's ability to excrete the generated acid; urine pH<5.5;
a/w otassium sparing diuretics, NSAIDs, ACEI, cyclosporine
Type I RTA is distal tubular acidosis w/ H+ ion secretion & lack of new
bicarb with urine pH & a/w nephrolithiasis, while type II is proximal
RTA w/ proximal bicarb reabsorption & a/w osteomalecia Both a/w
acetazolamide, topiramate, amphotericin B
Infusion rate = Steady state concentration Clearance; Maintenance dose

acidosis)
When inserting IV (Nor)Epi give alpha 1 agonist to prevent extravasation
Pt on chronic dialysis will have a shrinken kidney w/ cyts risk of RCC
Rash of palms & soles: Cosackie A, Ricketsia, Syphyliss, Staph aureus,
Strep pyogenes, Neiserria meningitides, kawasaki, hand & foot, tinea,
measles (rubeola), 1 HIV
Amiloride and triamterene K sparing diuretic function by blocking the
ENaC channels on apical surface of principal cells
Limited Scleroderma/CREST (calcinosis, Raynaud phenomenon,
esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome; antcentromere atb
Scleroderma would have thickened skin as well + invol kidney, heart, lungs
Respiratory
Angiofibroma- benign tumor of nasal mucosa composed of BV & fibrous
tissue; only seen in adolescent males w/ profuse epistaxis
Asopharyngeal Carcinoma- classically seen in African children and chinese
adults; a/w EBV; pleomorphic keratin positive epithelial cells (HPV 6 and
11); present w/ hoarseness
Laryngeal carcinoma= squamous carcinoma of epithelium lining vocal
cords; px w/ cough and stridor
H flu B causes epiglottitis
Laryngeal papilloma is single in adults and multiple in children
Mycoplasma pneumonia: no cell wall no G stain; IgM hemolytic anemia
erythema multiforme
COPD: risk of H flu, Moraxella, Legionella (silver stain atypical
pneumonia + hyponatremia) pneumonia
Chlamydia pneumonia: 2nd most common cause of atypical pneumonia in
young adults
Coxiella brunette causes atypical pneumonia in famers & vets (Q fever)
Aspiration pneumonia (alcoholics or comatose) Bacteroides,
Fusobacterium & Peptococcus (all cause right lower lobe abscess)
Primary TB (lower lobe) develops focal caseating ghon complex but no
systemic Sx, secondary TB (in AIDS) occurs at apex of lung (see caseous
necrosis or military TB)- fevers night sweats (acid fast stain)- can spread to
meninges (granulomas at base of brain), bone (Pott dz), kidney (#1; sterile
pyuria)
Aspirin induced asthma a/w nasal polyp in adults (if nasal polyp in child =
CF)
Bronchiectasis is due to necrotizing inflammation: CF, Kartagener
syndrome(situs inversus-heart on right, sinus infec, infertile), tumor/foreign
body, infection, allergic bronchopulmonary aspergillosis; px as cough
dyspnea, foul smelling sputum, cor pulmonale, 2 amyloidosis
Interstial fibrosis: bleomycin, radiation, amiodarone, idiopathic; honey
comb lung if all over transplant if severe
Pneomoconioses- chronic exposure to small particles interstaial fibrosis;
silicosis (nodes in upper lobe of lung) risk of TB; Berylliosis (looks
exactly like sarcoidosis; work for NASA)
Sarcoid noncaseating granuloma; can involve skin (erythema nodosun),
mimic sjogrens; px w/ hypercacemia (granulomas have alpha-1
hydroxylase vitD), ACE,
Hypersensitivity pneumonitis: Granulomas w/ EOS
Pulmonary HTN if >25mmHG; characterized by atherosclerosis of
pulmonary artery see plexiform lesions (group of tufts); young woman w/
exertional dyspnea; BMPR2 mutation prolif of SM; major complication
of sickle cell dz
Neonatal resp distress syn: granularity to xray
Phosphatidylcholine/mecithine is major component of surfactant; insulin
inhibits lecithin (aka phosphotidyl choline)
Bronchopulmonary dysplasia: giving premature lungs excess O2 free
radical damage
Psuedostratified columnar cells extend all the way through
+ Bronchial challenge: use inhaled mannitol/methacholine/histamine FEV1
by 20%; Suggests asthma, URI, bronchitis, CF, smoker. FN in long
acting bronchodilator; done when normal spirometry
Collapsing pressure== 2(ST)/r
exhaled NO = airway inflammation, less likely its asthma
inspiratory stridor- vocal cord dysfunction
Lypmatic pleural effusion, chylothorax TGs
Pneumothorax: unilateral chest expansion, tactile fremitus,

= Plasma concentration (Clearance/Bioavailability).


SJS is a/w penecillins, sulfonamides, ethosuxamids (blocks L Ca channel),
lamotrigene (tx bipolar 1 disorder block Na channel)
Hydralazine cause angina in setting of cardiac dz
Restore fluids to tx cryptosporidium
Migraine headache a/w photophobia, NV; tx w/ ergotamine or sumatriptan
Homeobox genes code for Transcription regulators
Complement binds the upper part of Fc receptor (not Fc itself)
CO binds to heme NOT iron

Club cells = clara cells secrete surfactant, degrade toxins


Surfactant levels begins wk 26 and mature levels begin wk 35
RALS- position of pulmonary artery relative to to bronchus
T10- esophagus vagus
FRC: bottom of TV to end of RV, at FRC the inward pull of lung is
balanced by outward pull of chest wall w/ atm system pressure; airway and
alveolar pressures are 0, and intrapleural pressure is negative (prevents
pneumothorax). PVR is at minimum.
Insp Capacity= bottom of TV to top IRV
Long acting beta agonist is never used alone need steroids
Physiologic dead space Vd= Vt x [(PaCO2 PECO2)/PaCO2]; includes
functional dead space
Minute vent Ve= Vt x RR= total vol of gas entering lungs
Alveolar vent= Va= (Vt-Vd) x RR= vol of gas per unit time that reaches
alveoli
PCO2 should rise by 0.7 mm Hg for every 1-mEq/L increase in bicarbonate
level.
Cl- gives a rightward shift
Methemoglobin-> cyanosis & chocolate blood; by nitrites; tc methylene
Tx cyanide poisoning w/ nitrites & use thiosulfate to renally excrete
O2 binding capacity 20.1 mL O2/dL. O2 content of arterial blood as Hb
falls, but O2 saturation and arterial PO2 do not.
Cyanosis results when deoxygenated Hb > 5 g/dL.
Perfusion limited circulation is normal but diffusion limited circulation
indicates emphysema, fibrosis
PVR = (pulmo arter pul Left atrium)/ CO; Resistance is inverse to r^4
A-a gradient: V/Q mismatch, diffusion limit, R/L shunt
Both vent & perf are greater In base but V/Q is > in apex; V/Q = 0 (shunt),
infinity (physiologic dead space); sup O2 improves latter but not former
Zone 1 PA>Pa>Pv
Rhinosinusitis- caused by S. pneumo, H. influ, M. catarralis
DVT- human sign (dorsiflex foot calf pain); tx short term w/ heparin
Pulmonary embolus: Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor;
lines of Zahn found in emboli before death
Fat emboliassociated with long bone fractures and liposuction; classic
triad of hypoxemia, neurologic abnormalities, and petechial rash.
Amniotic fluid embolican lead to DIC, especially postpartum.
Gas embolinitrogen bubbles precipitate in ascending divers; treat with
hyperbaric oxygen.
Omalizumab- antiIgE: most severe asthma w/ allergies
Obstructive lung dz: RV, TLV, FEV1/FVC (<70%)
Chronic bronchitis: reid index >50%; wheezes, crackles cyanosis (>3mo
/yr for 2 yr
Asthma has I/E
Restrictive dz: FEV1/FVC >80%
Coal workers pneumoconiosis (upper lobe): risk of Caplan syndrome
(rheumatoid arthritis and pneumoconioses with intrapulmonary nodules).
Asbestos affect lower lobe
ARDS caused by caused by trauma, sepsis, shock, gastric aspiration,
uremia, acute pancreatitis, or amniotic fluid embolis
Exercise induced asthma sx are worse 10 mins after exercise
Atelectasis: deviation towards bad side
All lung cancers except carcinoid have smoking RF;
Carcinoid: chromogranin +; 5-HT secretion flushing, diarrhea, wheezing
Adenocarcinoma: most common in nonsmokers; kras, EGFR, ALK

hyperresonance, diminished breath sounds, all on the affected side.


H1 blocker- diphenhydramine, -mine, dymenhydrinate; 2nd gen loratodine
fexofenadine, certrezine SE of 1st gen is sedation; use is allergies, motion
sickness (1st gen)
Expectorants: Guanefesin, nacetyl cysteine (loosen mucus in CF),
dextrmetophan (codeine analog, NMDA antag)
Psuedophedrine, phenylephrine: alpha agonist (nasal decongestant)
Theophelline- cAMP (block adenosine pathway & PDE)->
bronchodilation; beta-agonist AC -> CAMP -> bronchodilation
P450 monoxygenase metabolizes drugs
Glucuronide transferase makes soluble bili; GlutathioneST involed In detox
Vitiligo- hypopigmentation patch is due to apoptosis of melanocytes
Lentigo is a benign linear melanocytic hyperplasia
Triazolam is a benzo that can tx insomnia and its short life minimizes
daytime SE (daytime fatigue, impaired judgment)
Beta_R are Gs; M1,3-Gq, M2-Gi, Nic- Na channel,
DNA pol 1 replaces the RNA primer and fills in prokaryotes
Clinda is ABX of choice for lung abscesses
Pt undergoing total gastrectomy need lifelong B12 not pancreatic enz
NNRTIs (navripine, efavirenz, delavirdine) directly block rev pol (no
phosphorylation needed) while NRTI req phosphorylation
Transferance rxn often arise from parent child interactions
CCBs help relieve vasospasm (like berry aneurysm in APCKD)
Fever is temp > 38.3C via I IL1, 6 and PGE2; hyperpyrexia causes brain
damage; acetaminophen is antipyretic of choice in children; cold blankets
>43C is incompatible with life
Serotonin syndrome: flushing diarrhea, hyperthermia, myoclonus (tx w/
ciproheptadine(5HT2 agonist
MAO- tranylcypromine, selegline(MAO-B) (block reuptake of 5ht, NE,
Dopamine; tx atypical depression, hypochondriasis, anxiety; causes
hypertensive crisis w/ ingestion of tyramine foods
Campy: from undercooked poultry, unpasteurized milk and sick puppies
Urease converts urea to CO2 and ammonia
Sublingual gland is more mucinous; thick mucus ins by sym stim
Stenson dunct is duct of parotid gland; sour stuff secretions

(clubbing)
Squammous: Central, cigarettes, hyperCalcemia (constipation and polyuria
due to PTH-related peptide)
Small (oat) cell carcinoma: Kulchitsky cells; ACTH, ADH, or Antibodies
against presynaptic Ca2+ channels (Lambert-Eaton myasthenic syndrome,
Amplification of myc oncogenes common.
Pancoast tumor: apex; Px as horner, SVC syndrome (An obstruction of the
SVC that impairs blood drainage from the head (facial plethora), neck
(jugular venous distention), and upper extremities (edema), sensorimotor
deficits, and hoarseness
Mesothelioma: Psammomma bodies
Bosentan- tx pulmonary arterial HTN, block andothelin-1 receptors->PVR
Opiods via mu receptors cause constipation and miosis as well as
contraction of SM in sphincter of oddi
Sumatriptan tx migraines and is a 5HT agonist
Buptopion is a dopamine & NE reuptake inhibitor
Venlafaxine & TCA (amyitriptiline) block reuptake of 5HT & NE; TCAs
are known for their anticholinergic adverse effects (urinary retention, dry
mouth, tachycardia, constipation, and blurry vision) & arrythmias. Primary
TCAs like amitriptyline tend to have more anticholinergic effects than
secondary TCAs like nortriptyline.; all iptyline or pramine
exceptdoxepin, amoxapine; tx depression OCD (clomipramine),
fibromyalgia; SE convulsions, cardiotoxicity (tx NaHCO3), coma, antichol
(1st gen)
VEGF & FGF promote angiogenesis
IGF-1 is also called somatomedin C
Lissencephalopathy= (agyria) congenital abscense og gyri (smooth brain)
severe MR
If LN lacks germinal centers following live vaccine, give gamma-globulin
Histrionic personality is excess attension seeking & emotionality
Foramen ovale: V3; spinosum= V2; jugular- 9, 10, 11;
Trimethoprim, MTX, pyrimethamine bock formation of tetra hydrate folate
A +VDRL and WBC is characteristic of neurosyphillis (3 syp therefore
has gummas NOT chancre (which is 1 syphilis)
Need HbAg to coat the HDV for it to enter hepatocytes & cause dz

Acral Lentiguous: type of melanoma in palms & soles of black people


Fibroadenomas: do not risk of breask cancer; fibrous and galdular tissue
Gllomangioma appears as a tender red-blue lesion under nail bed and
originates from specialized SM cells responsible for thermoregulation
Ecoli need 10^8 innoculation while vibrio needs 10^6

AIN caused by 2-3wks of methicillin, sulfonamides, rifampin, & THZ or


months of MSAIDs
Direct sympathomimetics: Epi beta >alpha; NE alpha1>alpha2>beta
Indirect amphetamine (narcolepsy), ephedrine(congestion), cocaine
(never give bea blocker if cocaine tox suspected-> alpha1

Intestinal atresia diatal to duodenus is due to vascularaccidents in utero. If


SMA is blocked in utero apple peel atresia (distal ileum curls)
Internal pudendal artery gives rise to internal rectal artery supplying the
external hemorrhoids
MERF, MELAS, LHON- ragged red fibers mitochondrial inheritance
MERRF - muscle spasms, myopathy, ataxia, generalized seizures,
intellectual deterioration, and hearing loss in childhood or early adulthood.
MELAS- mitochondrial myopathy, encephalomyopathy, lactic acidoses,
and strokelike symptoms. Leber's hereditary optic neuropathy (LHON),
which presents with visual loss and a multiple sclerosis-like symptoms.
X-linked dom= hypOphasphatemia rickets
CheyneStokes breathing: central sleep apnea; HF
Lateral pterygoid opens jaw
Lumbricals extend at PIPJ, and flex at MCP

Hodgkins dz tx: MOPP cancer chemotherapy regimen: Mechlorethamine,


vincristine (Oncovin), Procarbazine, and Prednisone.
Smooth muscles dont have troponins; myosin is activated by Myosin
kinase
Superficial arch of hand is continuation of ular artery while deep arch is
continuation of radial artery
Coccidiodes: px similar to TB night sweats, weight loss, lung cavitations)
as well as erythema nodosum or multiforme, arthralgias/arthritis, and hilar/
mediastinal lymphadenopathy.
Acute pancreatitis is caused by gallstones ( TGs) or EtOH

Leflunomide inhibits dihydroorotate dehydrogenase;


Mycophenolate and ribavirin inhibit IMP dehydrogenase
Hydroxyurea inhibits ribonucleotide reductase
(6-MP) and its prodrug azathioprine inhibit de novo purine synthesis
(5-FU) inhibits thymidylate synthase ( [dTMP])
(MTX), trimethoprim (TMP), and pyrimethamine inhibit dihydrofolate
reductase (dTMP) in humans, bacteria, and protozoa, respectively
Lesch Nyan syndrome:HGPRT: Px: Hyperuricemia Gout Pissed off
(aggression, self-mutilation) Retardation (intellectual disability) DysTon

Glutathione peroxidase req Selenium to function


MTX toxicity mimic hypersensitiveity pneumonitis w/ eosinophils
16S RNA is part of 30S Ribosomal subunit that contains the Shine
Dealgarno sequence to bind mRNA
23S rRNA is responsible for peptidyltransferase function (peptide bond
formation)
each aminoacyltRNA synthetases is specifc for a particular AA
HCC is a well differentiated tumor of liver that can cause a bruit by
compressing hepatic artery & is a/w AFP

ia choreoathetosis (involuntary movements).


Methionine and tryptophan encoded by only 1 codon (AUG and UGG)
DNA pol 1 prokaryotic only, excises RNA primer
Mistmatch repair defect HNPCC; nucleotide excision defect- XP
Nonhomologous end joining defect- ataxia telangiectasia
TATA box is promoter
alpha-amanitin, found in Amanita phalloides (death cap mushrooms),
inhibits RNA polymerase II.
tRNA T-arm: contains the TC (thymine, pseudouridine, cytosine)
sequence necessary for tRNA- ribosome binding; D-arm: contains
dihydrouracil residues necessary for tRNA recognition by the correct
aminoacyl- tRNA synthetase.

Subarrachnoid may occur in acute hypernatremia


Low Ca (bones stones graons) or Mg (lethargy, bradycardia) tetany
Stable/quiescent (G0-G1)- liver or lymphocytes
Microtubule: Mebendazole (anti-helminthic) Griseofulvin (anti-fungal)
Colchicine (anti-gout) Vincristine/Vinblastine (anti-cancer) Paclitaxel (anticancer)
Desmin- marker for muscle
Collagen 1 (bone, skin, dentin, tendon, fascia, cornea), 2(cartilage,
nucleosus pulposus), 3(BV, fetal or granulation tissue) 4 (BM, lens)
Allelic heterogeneity- different mutations in same gene-> similar dz
D3 is formed from sun, D3 is changed to 25OHD3 by hepatic 25
hydroxylase, which is changed to 1, 25 OH D3 by 1 alpha hydroxylase in
kidney
PVT. TIM HALL: Phe (tyrosine-req for thyroglobulin, Epi, dopamine,
melanin), Val, Thr, Trp (serotonin, B3, melatonin), Ile, Met, His, Arg
(creatine, urea, NO), Leu, Lys

Hepatic hemangioma is a noncancerous tumor of liver that appears in


women 30-50yr
Diethylesbestelol (DES) exposure in utero reproductive system
disorders, including cervical hood, T-shaped uterus, hypoplastic uterus,
ovulatory disorders, infertility, premature labor and cervical incompetence.
& risk of clear cell adenocarcinoma of the vagina
Excess Vit A during preganancy is a/w ceft palate and heart defect
Thalidomidde risk of Down syndrome and limb hypoplasia
Potassium Iodide is found in cough medicines and X-ray cocktails for
organ visualization. It results in fetal thyroid enlargement and goiter and
mental retardation (cretinism).
Nicotine & cigarette smoke (hydrogen cyanide and CO) causes intrauterine
growth retardation, premature delivery, low birth weight, and attention
deficit hyperactive disorder.
Lipoprotein lipase is found on endothelial cells; metabolizes VLDL, chylo
Isotrentinoin external ear abnormalities, eye abnormalities, facial
dysmorphia, and cleft palate
Warfarin: stippled epiphyses, mental retardation, microcephaly, seizures,
fetal hemorrhage, nasal bridge hypoplasia, and optic atrophy in the fetus
Anticonvulsants- cleft lip & palate
Cocaine in utero still birth or fetal addiction
glycine is inhibitory in the spinal cord and brainstem, while excitatory in
cortex
Normal grief can have Sx of depression includeing mild
hallucinations/illusions. Thoughts of suicide esp w/ plan is always
pathologic, >2mo is bad
Azathioprine is a immunosuppressive agent that is used for autoimmune
disorders (incld glomerular nephritis & hemolytic anemia); toxic to prolif
LYM
Ras protooncogene is part of MAP kinase pathway

GI
Bloody vomiting: Mallory weis (mucosal tear) or boerhave (transmural
tear; fever dyspnea septic shock)
In the normal liver, type I and III collagen are localized around portal
tracts and type IV collagen is present in the space of Disse; In cirrhosis,
type I and III collagen are deposited in the space of Disse,
Magnesium hydroxide overuse: diarrhea, reflexes, hypotension, cardiac
arrest while Aluminum OH constipation
VIPoma: Watery Diarrhea Hypokalemia Achlorhydria; VIP helps relax
smooth muscle & sphincters ( by distention & vagus)
Epiblast forms epi, endo, meso while hypoblast forms endo only
Cohort studies: RR; Case studies OR
Olestra is a food additive that mimics taste & texture of TGs that is too big
to be absorbed

Parietal cells are located in the neck of the gastric fundus (middle portion)
Chief cells are located in the deep crypts of gastric mucosa
Hernias: impaired blood flow= striangulaton (fever) vs small space=
incarceration )femoral- NV abdominal pain)
CRC from colitis (IBD) is more likely to have: flat nonpolypoid dysplasia,
have eary p53 mutation & late APC mutation, polypoid, higher grade
dysplasia, when compared to sporadic CRC
Aflatoxin from aspergillus is a/w liver cancer
Misoprostol is a PGE agonist that is contraindicated in pregnancy
Pertussis toxin: inactivates Gi to cAMP
If you think cholestatsis is cause of problems think vitamin deficicency sx
Nuclear localization signals are rich in lysine arginine and proline

Anticholinesterase and Organophosphates Symptoms: DUMBBELSS:


diarrhea, urination, miosis, bronchospasm, bradycardia, excitation of
skeletal muscle and CNS, lacrimation, sweating, and salivation
Antidote: Atropine and Pralidoxime

Alkali agents: dysphagia, drooling, metabolic alkalosis; tx milk water NPO


Bleomycin: Lymphomas (Hodgkins and non-Hodgkins), testicular cancer,
melanoma, squamous cell carcinoma
ABCDES of eton toxicity
Aplastic anemia: Chloramphenicol, NSAIDS, Benzene, Propylthiouracil
and Methimazole
Muscaranic antag: Antipsychotics, TCAs, Quinidine, Amantadine,
Meperidine, Antihistamines
Trichomonas vaginalis - only as a trophozoite (no cyst form) b/c
intracellular
Babesia: fever, hemolytic anemia, hemoglobinuria
PAINS.
Primaquine
Aspirin and NSAIDs
Isoniazid
Nitrofurantoin
Sulfonamides
Signs of liver dysfunction: fatigue, mailaise, anorexia)

Tx of HOCM- blockers, CCB; tx of diastolic HF- diuretics


Oligodendrogliomas have fried egg appearance (found in frontal lobe); slow
growing
2 agonist: clonidine, methyldopa, dexmedetomidine, guanfacine
Strabismus- tyrosinase deficient
Rhodamine + granules= Cu accumulation
Retroperitoneal organs: ascending & descending colon, most pancreas &
duodenum (except 1st 2 segments)
meconium ileus is a/e CF
Thyroid hormone is needed gor GH to function: Cretinism: protuberant
abdomen, dwarfism, dry skin, delayed closure of epiphyseal closure,
DNA pol III polymerizes the lagging & leading strand, while DNA pol 1
replaces RNA primer
Reyes sndrome: hepatomegaly (microscopic steatosis), cerebral edema
(coma), pernicious vomiting
ANP- blood volume by constricine efferent arteriole & Na reabsorptionn
Phenylalanine hydroxylase (PAH): enzyme that converts Phenylalanine to
Tyrosine (BH4 BH2 in process)
pulses paradoxes has systolic pressured ue to deviation of IV septum to
left SV
Epi has 2 activity while NE does not (both affect 1 & 2)
Type III HY SN: SLE (systemic lupus erythematosus), PAN (polyarteritis
nodosum), PSGN (poststreptococcal glomerulonephritis), serum sickness,
Arthus reaction, and hypersensitivity pneumonitis

Give flumanezil for benzo toxicity & thiamine+glucose for EtOH overdose
PBS
- Skin pigmentation
- Steatorrhea, light colored stool
- Inflammatory arthropathy
- Osteomalacia/osteoporosis
- Portal hypertension, varices, splenomegaly

strawberry cervixp T vaginalis

Hydroxyures- ribonucleotide reductase; MTX DHF reductase


5FU thymidylate synthase

Celiac sprue
methyldopa: combs positive
Mycophenolic acid is a reversible inhibitor of IMP dehydrogenase

Estrone (weakest) is synthesized from peripheral adipocytes


Griseofulvin is p450 inducer
pul fibrosis: Busulfan (SE hyperpigmentation) Nitrofurantoin

Cyclophosphamide metabolite acrolein causes hemorhagic cystitis

The decarboxylation of histidine produces histamine


MS cause urge incontinence by autonomic dysfunction
Ammonium magnesium sulfate stones- proteus or klebsiella

Metoclopramide: D2 receptor antagonist, 5HT3 antagonist, and 5HT4


agonist; used for gastroschesis not constipation; antiemetic in chemo
Exemestane- aromatase inhibitor

Extrapyramidal SE of antipsychotis: 4hr dystonia/akinesia (sustained


contractions of facial muscles esp; tx benztropine/diphenhydramine), , 4 d
akathsia (fidgetiness , tx propranolol), 4wk bradykinesia parkinson like
symptoms (impaired voluntary muscles; dopa agonist)4 mo tardive
dyskinesia (writhing involuntary movement of tongue& mouth; tx
dopamine agonist; benzodiazepine or baclofen)
Acute dystonia: 4 hours --> 4 days
Parkinsonism: 4 days --> 4 months
TD: 4 months --> 4 years
Akathisia: Any time
NMS: Any time
Hepatic necrosis:
Acetaminophen
Valproic Acid
Halothane
Amanita phalloides (mushroom)

Chrom 11 Wilms tumor


CN poisoning;
- almond scent breath

- trismus

- apnea, seizures, coma, cardiac arrest


Doxorubicine & danorubicin= dilated cardiomyopathy
MS Sx worse w/ heat b/c of slowed conduction
Phencyclidine: inhibiting activation of NMDA receptors
PAS stains oxidize C-C bonds which are good fro fungal cell walls, BM,
mucosubstances of epithelia. Diastase+PAS = stain glycogen
Most of the GI proplems of gall bladder or appendix START out with
blockage; PGs further worsen the gallbladder inflammation
Arsenic (garlic breath, seizures, mees lines- white horizontal lines on
finger nails), Gold, Mercury, and Copper -Dimercaprol (think American
GMC cars = Caprol). Iron and Lead require deferoxamine and EDTA,
respectively.

corticosteroids -2 receptor transcription in airways

UNCOMPETITIVE INHIBITORS Km & Vmax (parallel line);


NONcompetive Vmax only, Km is same

PARvo B19= erythema infectious = slapped cheek dz =5th dz


Charcoal is used as a safe and inexpensive way to induce vomiting in
patients who have taken excessive phenobarbiturate pills.
Coccidiodes: San Jouquinfever, arthralgial, erythema nodosum

Renal clearance: PAH > K > inulin > urea > Na > glucose, amino acids, and
HCO3 metformin, rosiglitazone, and pioglitazone wont cause hypoglycemic Sx
(flushing, tremors, MS changes)

CYP450 inhibitors
VICKS FACE All Over GQ stops ladies in their tracks.
Carbapenem- no activity against MRSA & E. faecium (DOC for
enterobacter)

Foster Kennedy Syndrome: Meningioma of olfactory groove


compression of olfactory tract and optic nerve ipsilateral anosmia and
optic atrophy.

Huntingtons: Characteristics: AC/DC


Autosomal dominant
Choreiform (dance-like) movements
Dementia, Depression, and other mental Disturbance (e.g., psychosis)
Caudate atrophy is prominent on imaging and postmortem exam; atrophy of
the putamen

Excess atropine/imilar: tachicarda, dry mouthconvulsions, Coma,


Cardiotoxicity (increase HR arrhythmias)

Rheumatic fever: - Erythema marginatummacular rash starting on


trunk/arms JONES
bronchiectasis: CF, Kartagner (hearing loss, infertile, situs inverts), A1TA,
SLE, TB, aspiration
Ecoli sepsis in neonate think galactosemia deficiency

Common precipitating conditions- DIC include: Mnemonic: ATTOMS


-Acute pancreatitis
-Trauma
-Transfusion reaction
-Obstetric causes such as abruptio placentae and amniotic fluid embolism
-Malignancy
-Sepsis

PaO2 is NOT affected in CO poisoning


review arbovirus
tyrosinase deficiency - albinism
PRalidoxime- inhibits acetylcholineesterase
Cinchonism = headache + tinnitus
Procainamide is a/w lupus like syndrome
glucokinase (liver) has greater Km than hexokinase
Ritodrine is a pure 2 agonist with no 1 activity. It is used to treat preterm
labor contractions. Terbutaline is also used for the same indication, but it
has mild 1 activity.

Flaviviruses:
- Dengue fever
- Yellow fever
- hepatitis C
- St. Louis encephalitis
- West Nile
Viral myocarditis w/ inflammation: Coxackie, rypanosome cruzi, Borrelia
burgoferri, ptheria; S. aureus has no inflammatory infiltrate/necrosis (px w/
janeway lesions,fever, chills, new murmur
Mesocortal pathway is responsible for neg Sx (flat affect social withdrawl,
ack of motivation) of Schizophrenia while meso limbic mediated pos Sx of
schizophrenia (delusions, halucinations, disorganized thought for >6mo)


Actions of Testosterone include:
1. Causes prenatal differentiation of the wolffian ducts
Recall that male internal genitalia development also requires antiMullerian hormone from the Sertoli cells.
2. Causes pubertal growth spurt including deepening of the voice
(laryngeal enlargement).
3. Maintain spermatogenesis in the Sertoli cells (paracrine effect)
4. libido
5. erythropoeisis
6. Helps fuse epiphyseal growth plates, though this effect is indirect:
Mulleran duct differentiate into fallopian tube, uterus, cervix and upper
vagina while
5-reductase inhibitors (finasteride) used to treat benign prostatic
hyperplasia because they block conversion of testosterone to
dihydrotestosterone.

Ragged red fiber myopathy: caused by a deletion in mitochondrial DNA.


The typical symptoms are ophthalmoplegia, dysphagia, proximal muscle
weakness, sensorineural hearing loss, cerebellar ataxia, and cardiac
conduction defects. Mitochondrial inheritience(all kids of affected females)
Tinnitus and a high anion gap metabolic acidosis are clinical hallmarks of
aspirin overdose. Tx bicarb
vinka alkaloids Toxicity: paralytic ileus ie neuropathy (vincristine),
myelosuppression (vinblastine) leukopenia, granulocytopenia. Intrathecal
administration of vinca alkaloids is fatal.
Tox of paclitaxel is myelosuppression
Recurrent laryngeal nerve intervates all the intrinsic laryngeal muscles
except cricothyroid (inntervated by external laryngeal nerve)
Aminocaproic acid is a derivative of the amino acid lysine, which makes it
an effective inhibitor for enzymes which bind to that residue.
Meckels is a true diverticulum (mucosa, submucosa, muscularis) while
zenkers is false diverticulum (only mucosa &submucosa)
Gatifloxacin is linked to dysglycemia
Kawasaki: Asian boy with erythema, red eyes, edema of hands & feet,
strawberry tongue, cervical LAD
Aplastic anemia: chloroamphenicol, NSAIDS Benzene, Prylthiouracil
Isoproterenol is beta adrenergic agonist (beta 1& 2)
Contraindications for tPa therapy in acute stroke are: head trauma w/i 3 mo,
HTN sys>185 and dias>110, Platlets<100000, INR>1.7
Downs causes in AFP while neural tube defects cause AFP
Amobarbital (known as amytal) and rotenONE bind to NADH
dehydrogenase (complex 1) directly inhibit electron transport
Antimycin A binds to cytochrome c reductase (complex III) directly
inhibits electron transport
Carbon monoxide and Cyanide bind to Cytochrome C oxidase (complex
IV) directly inhibit electron transport
Hem cysts: adenovirus.Radiation cystitis post radiation therapy. Treat with
TMP-SMX for susceptible bacterial infection can also use a muscarinic
antagonist (oxybutynin) to reduce urgency.
Lipofuscin- is product of lipid peroxidation; yellow brown pigment
PAS stain in liver A1AT
IFN-gamma is produced by T cells in granuloma formation
Malignant hyperthermia causes muscle rigidity (rhambomyolysis renal
failure); SE of anesthetics like halothane; dantrolene sodium is the
treatment; It acts by blocking the release of Ca2+ from the sarcoplasmic
reticulum,
HIT are 2 type: typ1 is by activation of platlets (resolves in 2 days); type 2
mediated by atb, platlets <100000, hypercoagulable state, tx w/
fondaperinea (Xa inhibitor), agatroban (direct thrombin inhibitor)
Bullimea: calluses on hand, parotid swelling
Congenital diaphragmatic hernia: due to pleuroperitoneal membrane fails
Trisomy 18: Edwards syndrome) prominent occiput, micrognathia, small
mouth, low set ears, rocker bottom feet, congenital heart dz
Treatment of H. pylori involves therapy consisting of bismuth,
metronidazole, omeprazole, and either tetracycline or amoxicillin; or
metronidazole in combination with omeprazole and clarithromycin.
Trisomy 13 (Patau syndrome): cleft lip palate, polydactyly, microcephaly,
holoprosencephaly, rocker bottom feet umbilical hernia, cardiac & renal
defects, cutis aplasia (punched out lesions in scalp)

The nigrostrial pathway is a/w parkinsons & tardive dyskinesia


The tubuloinfundibular tract dirsruptoion by D2 antag antipsychotics
prolactinoma & amenorrhea
Locus ceruleus- NE; role in depression & anxiety

5 toxicities of sulfonamides:
1) porphyria (sulfonamides are contraindicated in these disorders)
2) toxic epidermal necrolysis (Stevens Johnson syndrome)
3) kernicterus
4) hemolysis in G6PD pts
5) nephrotoxicity

uncompetitive Km & Vmax


Under Hardy-Weinberg conditions, for X-linked recessive conditions, the
frequency of the allele = the disease incidence in males,
Tumors of kidney and Lung metastasize to brain & bone more often
PML- rapidly progressive (w/i mo) demyliniating dz in
immunocompromised
HCTLV- T cell leukemia; paresis from demylination of spinal corned and
periventricular areas
PKU children need BH4
Lactate production NAD+
sex pilus mediate conjugation
Rhematic heart dz- mitral stenosis (S pyogenes)
Oligomycin (a macrolide) inhibits ATP synthase (complex V) by blocking
its proton channel
Gustation and olfaction are ipsilateral (via DORSAL trigeminal tract)
2,4-Dinitrophenol and doses of aspirin increase the permeability of the
inner mitochondrial membrane
IL4 + IL13 promote IgE differentiation
Drugs commonly associated with drug-induced lupus (use the mnemonic Q
CHIMPPP pronounced Cute Chimp):
Quinidine,Chlorpromazine,Hydralazine,Isoniazid,Methyldopa,Penicillamine
Phenytoin,Procainamide
Ampicillin: HELPSS: H flu, ecoli, listeria, proteus, shigella, salmonella
Takayasu arteritis: no UE pulse, diff of >10mmHg in UE pressuer, visual
defects, arthralgia
Long thoracici nerve (C5-7) is often cut in axillary node dissection ->
winging of scapula due to serratus anterior weakness
Libman sacks in SLE causes vegetations on both surfaces of valve regurg
Non-bacterial thrombotic endocarditis may also be secondary to
adenocarcinoma or hypercoagulative state and may result in vegetations
along the lines of closure of the mitral valve and in mitral valve
regurgitation.
atelectasis is avoided w/ incentive spirometers
Sickle cell anemia affects different AREAS of the body:
Autosplenectomy, acute pain crisis
Renal papillary necrosis
Catalase + org: SPANS KEC: S. aureus, pseudomonas, aspergillus,
nocardia, serratia, klebsiella, ecoli, candida
Encapsulated organism infection (S. pneumo, Haemophilus, etc)
Aplastic anemia from Parvovirus B19, benzene, radiation, chlorpromazine,
gold salts
Salmonella osteomyelitis, Splenic sequestration
Gaussian distribution: 68, 95, 99.7
Juxtaglomerular cell hyperplasia is diagnostic for barter syndrome
Gitelman syndrome: hypochloremic, hypokalemic, hypercalcemia,
metabolic alkalosis
Yellow fever is a flavi virus: muscle pain, headache, photophobia
MEN2- ret gene (Sipple dz)- parathyroid, pheo, medullary thyroid cancer
Zonula adherens= intermediate junction (cadeherins + actin); followed by
macula adherins (desmosome); hemidesmosome is made of integrins
Increasing the FN rate of study by specificity statistical power
Specificity rules IN a dz (SPIN); sensitivity rule OUT dz (SNOUT)
WINT tumor gene is 11q13; NF! Gene 17q11
Power= 1-beta(typeII error)
SSRI SE diaphoresis & dizziness, HTN (venlafaxine)
TCA: block 5ht & NE reuptake, Muscarinc_R, alpha1 H1 receptors
2nd portion of duodenum and kidneys are retoperitoneal
elastin, is composed of proline, glycine, valine, and alanine.

47XXY (Klinefelter syndrome) 47XXX & 47XYY do not cause fetal


death; phenotypically normal; hypogonadism due to inhibin from
damage to seminefrous tubulesand lehdig cells
For people taking steroids: LH, FSH, testosterone, sperm (need
high LOCAL not systemic concentrations to develop sperm)
Turner 45XO still born w/ edematous hands & feet, cystic hygroma of
neck, ovaries become fibrosed by age 2 (streak ovaries), coarctation of
aorta (narrowing near the ductus arteriosus; LE turns blue ie cyanosis while
UE & trunk are pink)
Coarctation of aorta (post ductal in adults, pre in kids) high UE
perfusion but low LE perfusion; may have notching of ribs on Xray due to
enlarged intercostal arteries, may have epistaxis
Patent ductus arteriosis takes mo to yr for cyanosis to develop; Central
cyanosis is a/w trucus arteriosis defect
MTX SE: myelosuppression, pulmonary toxicity, hepatotoxicity,
contraindicated in pregnancy
MR/TR- holosystolic high pitched blowing murmur vs VSD holosystolic
harsh sounding murmur vs MVP- mid systolic click with late crescendo
murmur vs PDA (rubella; continuous machine-like murmur); MS- opening
snap followed by diastolic rumble
N-myc neuroblastoma- adrenal medulla/symp chain
Eccrine glands secrete a watery solution (thermoregulation)and are
stimulated by direct sympathetic innervation. Apocrine glands, which
secrete oily, viscous fluid, are stimulated by catecholamines.
SVCS is a/w Hodgkins Lymphoma in young and SC lung cancer in old
Preeclampsia:>20wk w/ proteinuria + BP 140/90; eclampsia incld seizures
too; Sx of preeclamsia < 20 wks is likely molar pregnancy (trophoblast);
IV magnesium sulfate is given to preeclampsia to prevent seizure (toxicity=
hyporeflexia)
The left atrium of heart is positioned right next to aorta and esophagus
inferiorly while RV is right beneath the sternum; the descending aorta is
located posterior to mid esophagus
Meckels diverticulum is painless and px w/ bleeding while intercuseption
px w/ intermittent abdominal pain, current jelly stools. Intussusception can
be a complication of Henoch-Schnlein purpura, and, in these instances, the
obstruction is most likely ileoileal.
GIP insulin release
Nissel bodies are found in dendrite (NOT axons) and are RER organelles in
neurons
In acquired hemochromatosis, MAC cant phagocytose iron
Hemochromotosis: CHF, testicular atrophy, bronze DM; HLA-A3
Brown pigment stones are due to infection which causes relase of betaglucoronidase which cleaves conj bili to unconj bili
IgA protectsagainst giardia while EOS protect against heliminths
Gallstone ileus I s a cholesterol stones that enters the intestinve via a fistula
and air in the gallbladder is suggestive of this
Organisms that do not invade the intestinal wall are leukocyte negative; see
mucous and epithelial cells in stool. With EHEC see blood but no
leukocytes since it is toxin mediated but dos not directly invade
Pleomorphic adenoma is most common salivary gland tumor (benign; mix
well differentiated); followed by mucoepidermoid (malignant; poorly
differentiated) & warthin tumor (benign; lymphoid cells)
Hyperimmunoglobulin E syndrome job syndrome low IFN-gamma; see
coarse facial feature, eczema, abscesses
Thrombocytopenia purpura, nfections, eczema,: WAS
Dz of peroxisomes: xellwenger syndrome, refsum dz, hyperpipecoletemia
Serum gamma glutamyl transpeptidase sensitive indicator of EtOH abuse
Depressed people have REM sleep due to REM latency
Phencyclidine- angel dust dissociative anesthetic w/ motor SE
Children begin in cooperative play after age 4
DNA is in heterochromatin during mitosis
Regression: childlike patterns of behavior appear under stress. Associated
with dependent personality disorder. (For example, a 55-year-old male
after cardiac bypass surgery demands only to eat pizza and hot dogs.)
Repression: pushing unacceptable feelings into the unconscious mind.
Primary defense mechanism of the ego. (For example, a woman who has
no memory of having been raped.)
Splitting: believing people or events are either all bad or all good because
of intolerance of ambiguity. Associated with borderline personality
disorder. (For example, a woman believes her lawyer is the best in the

Cholesterol stones w/o calcium are radiolucent; a/w obesity, rapid weight
loss, multiparity, Crohns disease, and estrogens
Potassium citrate is prescribed to block Ca stone formation as citrate binds
free Ca; acidic pH is rew for formation of uric acid stones
Burr/helmet cells are seen in uremia, PK deficiency, microangipathic
hemolytic anemia, trauma
Promoters are 25-70 bases upstream
Chloesterol stones are a/w conj hyperbilirubinemia
Brunners gland present in submucosa of duodenum;hypertrophied in PUD
Dromotropic- conduction via AV node & inward Ca current;
chronotropic- HR (inward Na current); ionotropic- contractility (Ca in)
Mnire's disease- sensorineural hearing loss, tinnitus, vertigo in 30-60yr (
vol of endolymph)
Benign proxismal vertigo- crytals in semicircular canals
cranial nerve VIII lesions have hearing loss in the high-frequency range and
exhibit problems with speech discrimination.
The utricle & saccule are responsible for acceleration & deceleration (head
is tilted to affected side
key findings that suggest gallstone ileus: the multiple air-fluid levels in
small intestine and in the biliary tract due to the gallbladder and small bowel
fistula.
A volvulus only causes SBO
GI paracrine hormones histamine & somatostain ( insulin & glucagon)
Adverse effects of CAPTOPRIL include Cough, Angioedema, Proteinuria,
Taste changes, hypOtension, Pregnancy problems, Rash, Increased renin,
and Lower angiotensin II, and hyperkalemia.
Celecoxib is a COX2 inhibitor
Oral contraceptives are a/w hepatic adenomas which regress after stoping;
avoid OCPs in smokers >35 yr (CV events), stroke or thromboembolism
Cobalophilin is an R binder is a salivary protein that binds B12 initially
Saliva that is initially produced is rich in Na and low in K
FA metabolism: SYtrate- synthesis, CARNitine= carnage of FA; last step of
FA synthesis in cytosol while last step of FA degration in mitochondria
(forming ketone bodies)
The splenic flexure of the large bowel is most vulnerable to ischemia from
hypoperfusion because it is a watershed area.
Salmonella and EHEC are motile while Shigella is not
Bacillus antracsis produces edema factor which acts like adenylate cyc
The most common outcome of Hep B infection is complete resolution with
mild Sx
IN duodenal ulcer from Hp, Hp colonizes the antrum of stomach and blocks
the somatostatin which causes dysplasia of duodenum to gastric mucosa and
then infection
Gastric adenocarcinoma & lymphoma are a/w Hp infection
In Zollinger Ellison syndrome see rugal thickening
Necrosis (seen in ischemic colitis): nuclear pyknosis, karyohexsis,
karyolysis
If confidence interval includes 1 it is NOT significant
LESS MATURE
Acting out: unacceptable feelings are avoided by engaging in impulsive
behavior. It is associated with juvenile delinquency. (One example would be
a depressed teenager stealing a computer.)
Denial: disbelief of intolerable facts about reality (i.e.: serious illness or
addiction). Associated with substance abuse disorders
Displacement: transfer of emotions from an unacceptable to a tolerable
person or objectassociated with phobias. (For example, an abused child
who kicks his pet instead of yelling at his father.)
Dissociation: separation of function of mental processes. Associated with
dissociative identity disorder, or multiple personality disorder. (One
example would be a boy who was abused by a priest and who had two
distinct personalities in adulthood.)
Identification: a persons behavior is unconsciously patterned after that of
someone else. Associated with abuse of children
Intellectualization: overuse of the mind to explain away unwanted emotions.
Associated with obsessive compulsive personality disorder. (For example, a
urologist receives a diagnosis of metastatic prostate cancer and discusses the
intricacies of the various treatment options with his colleagues and family.)
Isolation of affect: emotions concerning stressful events are neither
experienced nor expressedassociated with obsessive-compulsive
personality disorder. (For example, a patient with metastatic bone cancer

world until he misses a meeting with herthen she insists that he is a


shows no emotion when discussing his diagnosis with family members.)
horrible lawyer.)
Projection: unacceptable impulses are attributable to others. Associated with
Fixation: partially remaining at a more childish level of development (vs.
paranoid symptoms. For example, a woman who has sexual feelings for her
regression). (For example, a man fixating on hockey games.)
neighbor accuses her own husband of cheating on her.
MATURE
Rationalization: seemingly reasonable explanations are given for
Altruism: unselfishly assisting others to avoid feeling bad about oneself.
unacceptable or irrational feelings. Associated with obsessive-compulsive
personality disorder. (For example, a student who fails Step 1 states it is not
(For example, many individuals who choose careers in the field of social
really an important part of medical school.)
services or a woman who travels on a mission trip to a Third World
country during her vacation.)
Reaction formation: unacceptable feelings are denied and opposite attitudes
and behavior adopted. Associated with obsessive compulsive disorder. (For
Humor: expression of feeling without causing discomforta good defense
example, a student who is really angry at her teacher states that she really
mechanism, if not used excessively. (For example, an Iraqi vet with an
amputation of his arm jokes about being a hand surgeon.)
likes his class.)
RE PRODUCTIVE
REPRODUCTIVEEMBRYOLOGY
SECTION III
553
S
Sublimation: an unacceptable
drive is rerouted
in a socially acceptable
way. (For example, an individual chooses a profession or activity in which PT & INR are the same thing
aggression is usefule.g., in the military, as a surgeon, or by joining a
Degeorge syndrome: lots of immune progenitors in BM; TBX1 mutation
Embryologicteam
derivatives
football
as a way of channeling his anger.)
Unfractionated heparin prolongs PTT and TT b/c binds thrombin and ATIII
Ectoderm
Suppression:
unwanted feelings are consciously put aside but not
while LMW heparin only prolong PTT
Surface ectoderm
lens of
Craniopharyngiomabenign Rathke pouch
represseda
goodAdenohypophysis
defense if(from
notRathke
usedpouch);
excessively.
(For example, a patient
eye; epithelial linings of oral cavity, sensory
tumor with cholesterol crystals, calcifications.

Aspirin has little effect on PTT, PT or TT


with stroke will only
worry
about
hisepithelium;
limitations for 1 hour a day.)
organs
of ear, and
olfactory

Slow twitch fibers (Type 1) have high myoglobin and low glycogen (aerobic
anal canal below
the pectinate
line;
Teratomas often pxepidermis;
as testicular
masses
and cause
hyperthyroidism b/c
parotid, sweat, and mammary glands.
metabolism) do low level sustained source- postural muscle
produce
hCG which is similar in shape to TSH, LH & FSH
Neuroectoderm
Brain (neurohypophysis, CNS neurons,
Neuroectodermthink CNS.

Type 2 fast twitch muscle fibers do anaerobic metabolism (glygenolysis,


Radiation induces damage
viaastrocytes,
doubleependymal
strandcells,
DNA breaks and O2 radicals;
oligodendrocytes,
glycolysis) and are fast moving muscle
pineal
gland),
retina
and
optic
nerve,
spinal
bowel and skin most affected b/c rapidly dividing
cord.

Flexion, extension, adduction are not done by any of the rotator cuff tendons
DNA
crosslinkingPNS
occurs
via alkylating agents Neural crestthink PNS and non-neural
Neural crest
(dorsal root ganglia, cranial nerves, celiac
Supraspinatus: abduction (most often injured); infraspinatu= medial rotation
ganglion,
Schwann
cells, ANS), melanocytes,
structures nearby.
Unlike Blasto, Histo
is found
WITHIN
macrophages
chromaffin cells of adrenal medulla,
Papillomas are benign epithelial tumors; intraductal papilloma have bloody
Aliskrin is a renin inhibitor
while
is an ARB
parafollicular (C)
cells oflosartan
thyroid, pia and
serosanguinous discharge of breast
arachnoid,
bones
of
the
skull,
odontoblasts,
Negative predictive value varies w/ the pretest probability of having dz ex.

Need GTP to phosphorylate oxaloacetate to PEP


aorticopulmonary septum.
A pt with high RF for dz will have a low NPV & vicer versa
Mesoderm
Muscle, bone, connective tissue, serous
Mesodermal defects = VACTERL:
Tibila injury causes dorsiflex, eversion and sensation on sole of foot
TSLS- is mediatedlinings
by superantigen
cell like MAC
of body cavities (e.g.,(APC
peritoneum),
Vertebral and
defectsCD4 Tcell)
Common peroneal nerve is the most commonly injured nerve of foot (lateral
spleen
(derived from
foregut mesentery),
Nitroglycerin causes
venous
pooling
reflex tachyAnal atresia
cardiovascular structures, lymphatics, blood,
Cardiac defects
trauma or neck of fibula) cause foot to be plantarflexed and everted; see foot
Dobutamine is Beta1>2
and
HRkidneys,
and adrenal
contractilityTracheo-Esophageal fistula
wall of gut
tube,
vagina,
drop due to inability to dorsiflex
cortex, dermis, testes, ovaries.
defects
Acne is caused byNotochord
follicular
epidermal hyperplasia,Renal
excess
sebum
Gout and pseudo gout are a/w synovial cell counts <20,000;
induces ectoderm to form
Limb defects (bone and muscle)
production, inflammation,
propionibacterium
acnes; androgens the first
neuroectoderm
(neural plate). Its only
>100,000=infection
postnatal
the nucleus
pulposusexcessiver
of
2 as well as inhibition
of derivative
EGFRis and
lithium;
perspiration

TNF-alpha inhibitors fungal or TB infections


the intervertebral disc.
acerbates but does not cause acne
Endoderm
Gut tube epithelium (including anal canal
Enoxoparin is a LMW heparin
Pregnancy, drugs, STDs,
birth control
can
tx minors w/o parents
above the pectinate
line), most of
urethra
The trigeminal nerve arises at the level of the middle cerebellar pedunclesat
(derived from urogenital sinus), luminal
Abciximab- gpIIb/IIIa
inhibitor (mimics glanzmann thrombosthenia)
epithelial derivatives (e.g., lungs, liver,
the lateral aspect of mid pons; CN7 arises from dorsolateral at
gallbladder,
pancreas,inhibitor;
eustachian tube,
Argatroban is a direct
thrombin
Cilostazol= PDiesteraseI
pontomedulary junction
thymus, parathyroid, thyroid follicular cells).
Formation of mature
thyroid occurs when thyroid follicles fuse w/
Digoxin causes Ca efflux not Ca influx
parafollicular cells
Hypothyroidism is a common cause of creatine kinase (other causes:
Types of errors in organ morphogenesis
statins, duchenne, autoimmune-polymyositis, dermatomyosistis)
Agenesis
Absent organ due to absent primordial tissue.
CK-MB highes in cardiac, CK-BB in brain, CK-MM skeletal muscle
Aplasia
Absent organ despite presence of primordial tissue.
Hypoplasia
Incomplete organ development; primordial tissue present.
The pituitary hormones have very little influence on secretion of
Deformation
Extrinsic disruption; occurs after the embryonic period.
catecholamined from adrenal medulla
Disruption
2 breakdown of a previously normal tissue or structure (e.g., amniotic band syndrome).
Behet syndrome: uveitis+recurrent apthous ulcers of mouth & genitalia
Malformation
Intrinsic disruption; occurs during the embryonic period (weeks 38).
Buerger disease (thromboangiitis obliterans) is a medium-sized vessel
Sequence
Abnormalities result from a single 1 embryological event (e.g., oligohydramnios Potter
vasculitis with digital vessel thrombosis; RF young male (jew, asians)
sequence).

smoker; px as resting pain on the forefoot, with possible ischemic ulcers


Sarcoidosis: hilar LAD, noncaseating granuloma, AA, uveitis, arthritis,
or gangrene of the foot and toes as wellas upper limb ischemia with
erethema nodosum, central&peripheral neuropathies, cardiomyopathy,
ulceration and gangrene and Raynaud phenomenon; Tx: stopsmoking,
hypERcalcemia
PG, alpha-blocker, CCB
Wegners: focal necrotizing vasculitisrhinitis, hemoptysis, renal failure
Long thoracic innervates the serratus anterior (wing of scapula if injured)
The axillary nerve can be damaged surgical neck. Mid-shaft fractures may The thoracodorsal- latissimus dorsi- extensor anf internal rotator of shoulder
damage the radial nerve. The median nerve damage in the supracondylar
Suprascapular innervates the supra (abduct) and infra spinatus(external rot)
area, and the ulnar nerve damage near the medial epicondyle
Chronic pancreatitis DM
Bowen dz is one form of penile sq carcinoma; another is bowenoid
papulosis
Peyronie dz is fibrosis of tunica albuginia, cuasing painful erections
curvature of penis
A chancre from syphyllis contains abundant plasma cells
DOCTORS IN TRAINIG
COPII is responsible for anterograde transport (RER to golgi)
RB on chrom 13 is a/w retinoblastoma and osteosarcoma
P21 (control by p53), p27, p57 bind and inactivate cyclin-cdk complexes &
INK4 (incld p15 & p16)

Omphalocele is worse than gastroschisis


Baby with projectile bilious vomiting after 1st couple feeding annular pancreas
squeezing duodenum
Traction diverticulum is in mid esophagus while

CyclinD-cdk4 phosphorylate Rb which releases it from E2F which then


synthesizes cyclin E which binds cdk2 to pass to S phase; then cyclinAcdk2 allow progression from G2 to M phase and cyclin B-cdk1 activate
cdc25 which allow breakdown of envelope and initiation of mitosis
Permanent cells: neurons, RBC, muscle; Stable: heptatocytes, PCT, LYM
Labile: skin hair follicles BM
Golgi modifies n-oligosaccharide on asparagine and o-oligosacharides to
serine and threonine; it also glycosolates proteins to form glycoproteins; it
adds sulfates to tyrosine & sugars; adds mannose-6phosphate to go to
lysosome (I-cell dz: phosphotransferasecorneal clouding, restricted
joint movement, coarse facial features; similar to hurler or hunter
syndorme)
Hsp60 and 90 help fold proteins; ubiquitin is also hsp
Peroxisomes function in long/branch chain FA metabolism and in synthesis
of plasmalogens (imp for myelin); metabolize EtOH w/ catalase+oxidase
Cell uses lysosomes, peroxisomes and Ca dep enz to break down proteins
CD14 is found on MAC and CD 16 on NK&MAC
Young Liver synthesizes Blood- yolk sac,liver, spleen, BM

IL4 and 5 promotes B cell differentiation


IFN-alpha and IFN-beta are released by virally infected cells
Antihistone Atb is seen in drug induced lupus
Anti SM atb seen in autoimmune hepatitis
Intracellular really lve cytoplasm: rickettsia, legionella, chalmydia
Gq Cutsies HAVe 1 M&M; G2: MAD 2s
Acute rejecteion: mediated by host T cells attacking foreign MHCs (wks)
Chroninc rejection is by Atb mediated vascular damage (mo to yrs)
Obligate anaerobes lack catalase and superoxide dismutase
Microbacterium scrofoloceum- causes cervical lymph adenitis in child
MAC in kidneys are called mesangial cells while in CT histiocytes, brain
microglia, bone osteoclasts
Obligate aerobic bacteria: nocardia, pseudomonas, mycobacterium, bacillus
(nagging pests mustbreathe)
Tx for glaucoma: alpha-agonist, beta blocker, cholinergic agonist, diuretics
(acetazolamide, mannitol), protoglandin F2-alpha
Dermatitis, enteritis, hepatitis after BM transplant= graft vs host dz
Rectum drains to internal iliac lymph nodes; external anus: superficial
inguinal; testes: para aortic; scrotum: superficial inguinal
RUQ US helps determine if there is extrahepatic obstruction
Nuclear lamins mutations- pregaria (rapid aging in kid) or muscular
dystrophy
Vincristine and vinblastine block microtubules polymerization while
paclitaxel and docetaxel stabilize microtubules; Mebendazoles act on MTs
of worms; griseofulvin on fungi MTs; colchicine block MAC MTs
Dyne-in (retrograde to ward nuclei) or taK(enisin)e Out
Cilia (9+2 w/ dynein connecting doublets) are found in trachea, bronchus,
paranasal sinuses, fallopian tubes; gap junctions in cilia motion
MTs are defective in Chediack higashi; 1 ciliary dyskinesia syn: defect in
dynein arms of cilia-> infertility, bronchiectasis, sinusitis, situs inversus
(dextro cardia-nrml heart on right, liver on left, spleen on right); last 3 are
called kartagner syndrome
HLA B27 subtype can be remembered with the mnemonic PAIR, and
include Psoriasis, Ankylosing spondylitis, Inflammatory bowel disease, and
Reiter's syndrome.
Graves and Celiac sprue are a/w HLA B8
MS, SLE, hay fever, good pasture a/w HLA DR2
Implanation of zygote occurs 6d after fertilization

Epiphrenic diverticulum is right above the LES


CMV esophagitis: clear perinuclear halo w/ inclusins
Candida esophagitis: PAS stain w/ hyphate organisms
HSV esophagitis: pink inclusions w/ host cell nuclei pushed to the edge
Plummer-vinson syndrome- dysphagia (webs- just mucosa), glossitis, Fe
deficiency
GERD smoking, obesity, nitrosamine is a/w esophageal adenocarcinoma; most
coomin in US (not a/w EtOH)
Most common esophageal carcinoma worlwides is squamous (EtOH + tobacco)
Chief cell of stomach secretes pepsin
Phenylanaline, tryptophan & Ca stimulate gastrin secretion
Zollinger syndrome can by a/w MEN1; tx PPI +/- octreotide
H2, CCKb, PG, M3, somatostain receptors on gastrin cells
Acute gastritis: Curling ulcer a/w burn injury; cushing ulcr a/w brain injury
Tertacyclin bismuth, metro is quadruple therapy for Hp ulcers
Cimetidine libido, causes gynecomastia, impotence, methhemoglobin & cyp
450; H2 blockers cause thrombocytopenia
Sucralafate like bismuth binds base of ulcer but needs acidic env
MisoPROSTol: avoid in pregnancy b/c uterine tone & causes diarrhea
Acathosis nigrans that px >40 thick visceral cancer; also a/w DM
Odansetron is a 5ht3 atang nausea drug for chemo SE headache, vasodilation,
constipation
Duble bubble sign- duodenal atresia, omega sign- sigmoid volvulus, thumb
printing- mesenteric ischemia; air fluid levels- Small Bowel Obstruction (tx:
replenish K and fluids, nasogastric tube to decompress stomach); intersucception
is a common SBO in children (often following viral illness)
Oral glucose is taken up more faster than IV glucose b/c GIP from K cells
insulin & acid
Brunner glands are found in submucosa of duodenum
Prokinetic agents Ach, 5ht or D2; metoclopramide 5ht4 and D2 Ach
and motility
The hepatoduodenal ligament contains the portal triad
Motilin SM contraction of sphincter, duodenum, & stomach
Defect in chylomicron exportation= abetalipoproteinemia
Whipples dz: weight loss, arthralgia, hyperpigmentation, LAD diarrhea
IBS is NOT a/w bleeding, nocturnal pain, electrolyte abnrml, inflammatory
markers
Intersceseption a/w currant jelly stool w/ bulls eye, coled spring appearance on
US
SBO causes: Adhesions, Bulge/hernia, cancer (ABC)
Intestinal ileus: lack of peristalsis a/w surgery; Meconium ileus a/w CF or
Hirsprung dz
Necrotizing enterocolitis is a/w early feeding pneumotosis internalis (air in the
small bowel wall)
Carcinoid Syndrome BFDR bronchospasm, flushing, diarrhea, Rhigh heart dz
Down syndrome GI- duodenal atresia, hirshprung, annular pancreas, celiac
Hyperplastic polyps are completely benign
Peutz Jegher Syndrome: hamartomas + hyperpigmentation around mouth, hands;
a/w visceral cancers
Turcot: meduloblastoma + FAP; Gardner: bone&soft tissue infections + FAP
Most common cancer of appendix is carcinoid
Apendicitis in id risk factor is viral infection lymphoid hyperplasia
Apple core syndrome = coloncancer
Tx for diverticulitis: Metro + TMP sulfa or luroquinolone
Contrast Xray: String sign = chrons; lead pipe= UC
UC complications: toxic megacolon, PSC, cholangiocarcinoma
PSC a/w young man and UC, pANCA+, HLA DR52wa, HLA DR4
Chorns complicatiosn: fistulas, fissures, perianal dz, strictures
Spleen is a mesodermal structure that arises from the dorsal mesentery of
stomach
Acute pancratitis: GET SMASHED: gallstones, ethanol, trauma, steroids,
mumps, autoimmune, scorpion bite, hyperCa/hyperTG, sulfa drugs ERCP
Pancreatic adenocarcinoma: weight loss, steatorrhea, trousseau, urination &
thirsty (atypical px of DM); a/w CA 19-9, CEA; a/w painless jaundice
Oligosaccharide hydrolases at brush border are rate limiting step of carb digeston
Crigler Najar syndrome: Type 2 respond to phenobarbital while type 1 doesnt
Tx for cirrhosis: diuretics, beta blocker, vit K , lactulose
Alk phos is in bone cancer, paget dz, children, pregnancy, gall stones
Pancreatic insufficiency is a/w CF (see patient with recuurent pulmonary
infections)

More cholesterol in plasma membrane fluidity and melting temp


PDGF are single pass receptors while insulin_R habe 2 alpha units(contain
disulfide bonds and bind ligand) and 2 beta untis (tyrosine kinase activity)
Phosphorylase enz adds inorganic phosphate w/o ATP
Dehydrogenase oxidizes compunds using NAD and NADP
COPI- golgi ER; COPII: ERgolgi; Clatherin: goli->lysosome, RME
Clatherin uses adaptin to coat and dynamin to pinch off vesicle; a/w
familial hypercholesteremia due to LDL_R not a/w clathrin
Peroxisome: catabolism of very long fatty acids

Apoptosis: cell shrinkage, pyknosis (condensation of chromatin),


membrane blebbing, karylysis (chromatin dissolution), karyorrhexsis (DNA
fragmentation), apoptotic bodies; med by caspase
Triggers: Bax is pro-apoptotic while Bcl-2 (+Apaf-1 bind free cyt c in
cytosol) is anti-apoptotic; p53, TNF_R and CD95 mediate extrinsic
pathway, Perforin+granzyme B from NK cells; end is caspases
Caseating granulomas are seen in fungal and TB;
sarcoidosis, , wegners & beryliosis, catscratch, syphyllis, lepreosy, PSC,

GGT in in alcoholics, biliary dz, phenobarbital, phenytoin


No JVD distension in nutmeg liver distinguishes budd chiari from CHF; Budd
chiari syndrome is a/w pregnancy, polycythemia vera, HCC, hypercoagulable
Reye syndrome: child w/ viral illness; damage to mitochondria ( beta-Oxidation
hepatoencephalopathy (rash, confusion, hypoglycemia)
Serum bile acids are syn from cholesterol and conjugated w/ taurine or serine
Wilson: defect in ATP7B (P-ATPase in heaptocyetes golgi only depositing Cu in
bile) Cu deposited in descemet membrane, dx w/ slit lamp; Sx: Liver (LFTs,
cirrhosis, portal HTN, chronic hepatitis, Fanconi Sx of kidney & Brain (BG
dysfunction, ataxia, slurred speech, personality depression Parkinson sx)
Treat Wilson dz w/ Penicillamine (Cu chelator; pennies made of Cu)
Wilsons: think young man with ALF w/ AST/ALTs <1000
Both wilsons ( total Cu) and hemochromatosis (bronze Dm + cirrhosis) are AR
Tx hemochromotois w/ deferoximine or phlebotimies
Hepatic adenoma is tx w/ avoind OCP, resections, serial AFPs
Think budd chiari is PAINFUL hepatomegaly, abd pain, ascites; W>M; a/w OCP
PSC: men25-40, a/w cholangiocarcinoma, p-ANCA, UC; beads on a string
PBC: T cells attack bile ducts; W in 50-70s, + AMA, a/w sjogren, tx
UCDA/ursodiol
HIDA scan can be used for gall stone
Cardia right after the LES
Cholecystitis (inflammation of gall bladder- biliary colic with systemic sx but
NO jaundice), cholangitis (charcot triad, cholodocolethiasis+infection of bile
duct)
EtOH is not a RF for esophageal adeno, gastric adeno or pancreatic adeno
Zone 3 in liver is perivenular

VD= D/C WHERE D=vol of drug in IV form; C= serum concentration


CL= rate of elimination/plasma concentration = 0.7xVd/ t1/2
Loading dose = (Css x Vd )/F where Css is desired plasma concentration;
F=bioavailability; usual F=1 on Step 1
MD= (Css x CL)/F (note volume of distribution/body size does not determine
maintainence dose)
If inserting drug at steady state conc it will reach 94% of Css in 4 half lives
Efficacy has to do w/ max response while potency has to with dose; comp
inhibitor efficacy w/o changing potency while noncompetitive potency w/o
changing efficacy; partial agonist efficacy but can or potency
Therapeutic index = LD50 /ED50 (high TI means safer drug); low TI: seizure,
digoxin, warfarin, lithium

Chrons, CGD, foreign bodycause noncaseating granulomas


TNF-alpha is important for granuloma formation
Pyknosis, karylysis and karyhexis, Ca influx, dispersion of ribosomes
damage to plasma membrane or mitochondria are irreversible cell injury
Superoxide dismutase: O radical to H2O2; catalase: H2O2 to H2O
Vasodilation and vascular permeability is mediated by histamine serotonin,
D
Pancreatic cancer: painless jaundice w/ palpable gall bladder Couvoisier
sign

APGAR score- pinkness, pulse, resp, grimace


Hypersexuality- mania

bradykinin; Vit C and Zn are important for fibrosis


Selectins mediate LEU rolling while PECAM1 mediate diapedesis; PAF
enhances LEU diapedeis
ESR increases suspicion for osteomyelitis
L-selectin can also mediate rolling by binding to addressin, and GlyCam-1 on
endothelial cells
Osteogenesis imperfect type 1 (blue sclera, brittle bones, dental (due to dentin)
& hearing problems (abnrml ossicles)); Type 2 OI is deadly
Elastin unlike collagen is nonhydroxylated
Collage: strong slippery bloddy BM
Odontoblasts, bones and cartilage of pharyngeal arches+larynx, parafollicular C
cells, arachnoid+pia mater, middle ear bone arise from neuro crest cells
Uterine muscle/myometrial undergoes hypertrophy during pregnancy;
endometrium under goes hyperplasia

Neuro
Astrocytes form fibrosis in CNS (reactive gliosis); GFAP stain
Microglia: CNS phagocytes; form multinucleated giant cells in HIV
Cells w/ clear cytoplasm (fried egg) are seen in oligodendrocytes HPV
quillocytes, & vesicular sintomas (testicles); oligodendrocytes
myelinate multiple axons
Microglia are mesoderm while ependymal are neuroectoderm
Mannitol is a diuretic given to ICP short term;
Damage to BBB is seen in trauma infection stroke
Nigrostriatal (ventral tegmentum to cortex- Neg Sx);
Mesolimbic pathway (VT to limbic- + Sx)
Nigrostraiatal pathway (Substanci nigra to neostraitum- parkinsons if
blocked or extra pyramida SE if inc)
Tubuloinfundibula pathway (arcuate nucleus of hypothalamus to
pituitary prolactin secretion if blocked (amenorrhea, libido,
gynecomastia)tx bromocriptine
NE is made in locus ceruleus, solitary tract and reticular formation
5HT is in anxiety & depression; raphe nucleus
Ach in alzeimers, huntingtons, in parkinsons; basal nucleus of
meynert
GABA (need vit B6): in anxiety and huntingtons; nucleus
accumbens
GABA main inhibitor of CNS; glycine inhibitor of spinal cord,
glutamate excitatory oof CNS
Reticular activating system contains reticular formation, locus
ceruleus, parphe nucleus; mediates wakefulness
Anxiety: norepinephrine, GABA, serotonin
Depression: norepinephrine, serotonin, dopamine
Alzheimers dementia: acetylcholine
Huntingtons disease: dopamine, GABA, acetylcholine
Parkinsons disease: dopamine, serotonin, acetylcholine
Ehlers danlos is type 5 or 3 (vascular) collagen; OI is 1 only
Stage 1 sleep theta; (teeth grinding)m S2; beta is in rem; seep walking
S3
Kallman syndrome: GnRH and lack of smell due to abnrml
migration
Bells palsy affects muscles of forehead while stroke does not

Dorso medial nucleus stimulates GI savage eating behavior


Mamalory bodies- wernike encephalopathy
Melatonin when duration of darkness; does not directly affect suprachiasmatic
nucleus and suppresses LH FSH ( libido in winter months)
Lateral nuclei also regulates the sympathetic system
Horner syndrome seen in Pancoast tumor, Brown sequard syndrome, late stage
syringomyelemia
Prosencephalon
Hind brain-rhombencephalon divides- metencephalon and myelencephalon
Folate in normal pregnancy is 0.8mg; give 4mg if previous baby w/ neural tube
defect
AFP= ant abdominal or neural tube defect; AFP= down syndrome
Anencephaly: acidic amniotic fluid eats away at brain tissue
Holoprosencephaly (Cyclops): patau, sonic hedgehog, Fetal alcohol syndrome
Chiari 2: Significant herniation of cerebellar tonsils and vermis; posterior headache;

CN1-cribiform plate; CN7 stylomastoid foramen (parasym to


sublingual and submandibular gland)
CN8: internal acoustic meatus; 9,10,11: jugular foramen
CN9: sends parasym to parotid gland and stylopharyngeus muscle;
PICA infart
Pupillary reflex (CN2,3); Jaw jerk (CNV3), gag(9,10)
Pons (CN 5-8), Medulla (CN 9, 10, 12) Spinal cord (CN12)
Superior colliculi conjugate vertical gaze center; inferior colliculi:
auditory
Damage to: CN3/PCommA aneurysm = down and out eye; CN4=up,
CN6=adduct; ACommA aneurysm= bitemporal loss of vision
Pupillary light reflex does NOT go thru the LGN; pretectal-edingerciliary
PCA infarction can lead to macular sparing due to MCA collaterals
CN 3,4,6,V1,V2, ICA, sphenoid, pituitary gland are in cavernous
sinus
Wernicke Korsakoff (mammillary bodies a/w thiamine) problems
come in a CAN of beer: Confusion, Ataxia, Nystagmus, confabula
BG is implicated in parkinsons () +huntingtons ()
Cerebellar lesion intension tremor or ataxia
Subthalmic nucleus lesionhemibalismus (invol flailng of limbs)
Nucleus soltarius: taste, gut distension, baroreceptors
Nucleus ambiguous- motor of larynx, pharynx, & upper esophagus
Dorsal motor nucleus: autonomic fibers to heart lungs upper GI NOT
mototr
REM: high frequency, low amplitude waves
Narcolepsy is a/w hypnopompic hallucinations with sleep paralysis,
cataplexy (loss of muscle tension while awake)
Bells palsy seen in : lyme dz, herpes zoster, aids sarcoidosis, tumors,
DM (My Lovely Bella Had An STD)
Paramedian branches supply the medial brainstem while
circumferential brnaches cover lateral
Weber syndrome: CN3 palsy + contralateral hemiparesis=weakness;
medial midbrain infarct of the paramedian branches of PCA
AICA (anterior inferior cerebellar artery)

Sensitivity is used for screening while specificity is for confirming


CD15= NEU, CD16=NK
Hypoglycemia Sx: sweating, confusion, tremors, heart palpitations

a/w thoracolumbar myelomeningocele & hydrocephalus


Syringomyelia: fluid cavity in spine typically C8-T1 bilateral loss of pain and
temp with intact fine touch; a/w chiari 1; if expands affects anterior horn (LE
muscle weakness) & lateral horn (Horner syndrome); fibers crossing anterior
commissure affected first
Dandy Walker Malformatio: failure of cerebellar vermis to develop massive 4th
ventricle w/ absent cerebellum
Normal pressure hydrocephalus- MR, gait, incontinence -wacky, wobbly wet;
blockage of aqueduct of Sylvius- most common cause of hydrocephalus in new
borns
Branchial cleft cysts dont move when swallow and are lateral unlike thyroglossal
cyst
1st cleft external auditory meatus
Hippocampus is a common area where epilepsy takes place
Non-dominant aphasia: broca inability to express emotion or inflection in speech vs
wernike = inability to understand emotion or inflection in speech
Kluver-Bucy Syndrome: Bilateral destruction of amygdala in visual agnosia,
hyperphagia, docile disinhibited behavior, & hyper sexuality; a/w HSV1
Non-dominant parietal lobe lesionhemispatial neglect while dominant parietal
lobe lesion Gertsmann syndrome(visual association area defect);cant do
math/write/ RLdisorientation or distinguish fingers
PPRF lesion movement of eyes away from lesion
Sup Colliculi lesion paralyze of upward gaze (parinaud syndrome)
Medial medulla: fine touch, corticospinal, tongue
Lateral medulla: CN 9, 10 pain, ipsi face, contra body, muscles of pharynx except
stylopharyngeus
Medial pons: corticospinal, bulbar, ataxia, loss of vibration, ipsi eye abduction is
weak
Lateral pons: ipsi face weakness, mastication, hyperacusis,, ipsi ataxia, contra pain,
temp ipsi horner
Medial mid brain: ipsi CN3, vertical gaze, contra CN4, UMN prob of contra face &
body, contra ataxia
Lateral midbrain: Contra UMN face & body, loss of sensory of contra face, contra
ataxia
Ant Comm: CN3 eyes down & out; Post comm: visual fields defect
Fasiculations is a LMN sign
Kluver-Bucy syndrome. Mnemonic: HIP HIP:
- Hypermetamorphosis (old visual stimuli approached as if they are new)
- Increased oral exploratory behavior (putting everything in mouth)
- Placidity (no aggression)
- Hypersexuality and Hyperphagia
- Impaired memory (Anterograde Amnesia)
- Psychic Blindness (objects in visual field treated inappropriately)
Frontal eye field lesion: deviation of the eyes to the ipsilateral side (right way
eyes), in contrast to a lesion of the paramedian pontine reticular formation (PPRF)
The 4 medial structures and the associated deficits are:
1. Motor pathway (or corticospinal tract):contralateral weakness of the arm
and leg
2. Medial Lemniscus: contralateral loss of vibration and proprioception in
the arm and leg
3. Medial longitudinal fasciculus:ipsilateral inter-nuclear ophthalmoplegia
(failure of adduction of the ipsilateral eye towards the nose and nystagmus
in the opposite eye as it looks laterally)
4. Motor nucleus and nerve: ipsilateral loss of the cranial nerve that is
affected (3, 4, 6 or 12)
The 4 side (lateral) structures and the associated deficits are:
1. Spinocerebellar pathway:ipsilateral ataxia of the arm and leg
2. Spinothalamic pathway: contralateral alteration of pain and temperature
affecting the arm, leg and rarely the trunk
3. Sensory nucleus of the 5th cranial nerve:ipsilateral alteration of pain and
temperature on the face in the distribution of the 5th cranial nerve
(this nucleus is a long vertical structure that extends in the lateral aspect of
the pons down into the medulla)
4. Sympathetic pathway: ipsilateral Homers syndrome, that is partial ptosis
and a small pupil (miosis)
THE CORTEX (ie UMN) CONTROLS THE OPPOSITE SIDE OF FACE

Occlusion may result in lateral inferior pontine syndrome:


1. Ipsilateral facial paralysis
2. Ipsilateral hearing loss due to ipsilateral cochlear nucleus damage
3. Vestibular signs (e.g., vertigo, nystagmus) due to ipsilateral
vestibular nucleus damage
4. Ipsilateral loss of facial pain and temperature sensation
5. Ipsilateral ataxia
Medial Inferior pontine syndrome: contralateral hemiparesis & loss of
vibration, strabismus (eye adducted due to abducens lesion); pain and
temp is spared
PICA (posterior inferior cerebellar artery)
Occlusion may result in Wallenbergs syndrome (aka lateral
medullary syndrome):
1. Contralateral loss of body pain and temperature sensation
2. Ipsilateral loss of facial pain and temperature sensation
3. Ipsilateral dysphagia, hoarseness, decreased gag reflex; ambigus
4. Vertigo, nystagmus
5. Diplopia
6. Ipsilateral Horners syndrome (ptosis, miosis, anhidrosis)
7. Ipsilateral ataxia
Anterior spinal arteryOcclusion (at the level of the medulla) may result
in medial medullary syndrome:
1. Contralateral hemiparesis (lower extremities)
2. Decreased contralateral proprioception
3. Ipsilateral paralysis of hypoglossal nerve
Anterior communicating artery bitempooral emianopsia
MLF lesion works in convergence but not lateral gaze-> internuclear
opthalmoplegia (if<50=multiple sclerosis; >50=stroke)

Inferior collickculus is in caudal midbrain while superior is In rostral


In superior aspect of pons have trigeminal while in inferior aspect of pons have
facial nucleus
Ataxic hemiparesis: mid pons lesion
Prosencephaly is an example of malformation; sequence ex potter syndrome;
disruption- amniotic band syndrome (limb malformation); deforation=hip
dislocation/club foot/flat facies

Berry aneurysms: ADPKD, HTN smoking (tx clips, dihydroperidine


CCBs)
In hypoxic encephalopathy,the purkinje & & pyradimal cells affected
1st
Lake like cavitory lesion in BG= hypertensive arteriosclerosis;
Hyaline deposition leads to localized areas of ischemic necrosis
(lacunar infarcts), while Charcot-Bouchard microaneurysms rupture
and produce frank hemorrhage.
Intraparenchymal/HTN hemorrhage a/w charcot, vasculitis, amyloid,
tumors, anticoags, vascular malformations
Intraventricular hemorrhage occur< 72 hrs of life; germinal matrix

Lacunar infarcts in posterior limb (hemiparesis), VPL/VPM (sensory),


base of pons (ataxia hemiplegia syndrome), genu of internal capsule
(dysarthria/clumsy hand syndrome)
Xanthochromia: bilirubin in CSF(yellow)
Lumbar puncture: skin, facia, ligament (supraspinatus, interspinatus,
flavum), epidural space, dura, subarachnoid (spinal vs epidural
anesthesia); adult: L3-L5; children:L4-S1
Epidural hematoma: CN3 palsy, lucid interval
Besides aneurysm, AVMs are 2nd leading cause on non-traumatic
brain bleeds
Adult brain tumors (meningioma, glioblastoma, oligoderoglioma)
while kid brain tumors (astrocytoma, medulloblastoma, ependymoma)
are supratentorial while kids are inferotentorial
Schwannoma is a/w S-100 & palisading nuclei w/ spindle cells;
Meningioma: whorled body w/ psammoma bodies
Glioblastoma: psuedopalisading necrosis w/ VEGF; butterfly lesion
Oligodendroglioma: fired egg appearance frontal lobes slow growing
Kids: Pilocytic astrocytoma- Rosenthal fiberseosinophilic
corkscrew fiber ; Meduloblastoma (homer wright rosette- circle of
cells surrounding fibers; primitive NET; malignant but radiosensitive)
and ependymoma (perivascular rosette) compress 4th ventricle
VHL is a/w hemangioblastoma and RCC & polycythemia, foamy cells
Craniophryngioma from rathkes pouch (only childhood tumor that
is supratentorial), see bitemporal hemianopsia

Ischemic strokes are a/w thrombosis- give thrombolytics w/I 3hrs like streptokinase
(contraindications: recent surgery, severe HTN, active bleeding, intracranial
bleeding, bleeding diathesis, history og intracranial bleeding
Subdural hematoma are from rupture of bridging veins- old guy falling px w/ brain
sx days later
Normal pressure hydrocephalus: urinary incontinence, dementia, ataxia (wet,
wacky, wobbly)
Psuedotumor cerebri/ benign intracranial HTN: ICP but no hydrocephalus; px in
young obese women with headaches a/w N that worst in morning; comp-vision loss
from papilededema; tx stop tetracyclines & vitA, steroid withdrawl, weight loss,
acetazolamide
CSF is absorbed in the arachnoid granulations of superior saggital sinus
Hydrocephalus ex vacuo: alzeimers, advanced HIV, Picks dz
Parinaud syndromeparalysis of conjugate vertical gaze due to lesion in superior
colliculi (e.g., pinealoma).

Pituitary adenoma: prolactinoma, bitemporal hemianopsia


Herniation: Tonsillar (cerebellum CV arrest), subfalcine (cingulate
gyrus compress ACA), uncus (temporal lobe into cerebellum(CNIII
down & out w dilated fixed pupil, PCA compression, pull on
paramedian artery direct hemorrhage ) herniation
Duret hemorrhage= impinged BV of pons &mid brain
Tuberous sclerosis: triad (seizure, MR, angifibroma); a/w ash leaf
spots, retinal or cortical tubers, renal angimyolipoma, subependymal
giant cell astrocytoma, cardiac rhabdmyoma; TSC1/2 hemartin/tuberin
Sturge Weber syndrome: glaucoma, MR, seizure, hemiparesis, port
wine stain CNV1
Trigeminal neuralgia/tic doulereaux: light touch of faceextreme
pain; tx carbamazapine
Teratogenic: Valproic acid (spina bifida), carbamazepine, phenytoin
SJS: ethosuximide, phenytoin, phenobarbital lamotrige,
carbamazepine, sulfanimide, penicillins, allopurinol
Agranulocytosis: carbamazepine, clozapine, colchicine, PTU,
methimazole
Hpatotoxic: valproate + carbamazepine
Benzos are 1st line for status epilepticus (rev w/ flumanizil)
Phenytoin SE: gingival hyperplasia, hirsutism, fetal hydantoin
syndrome, drug induced lupus, SJS, induces CYP

Tension: usually around occipital or rontal; NOT a/w light, NV, vision change,
neuro sx
Cluster: partial horner miosis, anhidrosis, young male smoker, daily, ipsi eye
redness
Migraine: scintillating scotoma: migraine w/ aura;
headache + extra-occular palsies= cavernous sinus thrombosis.
CONSTANT headache= brain tumors (esp w/ focal neuro defecits +/- seizures
Headache before or after sex= postcoital cephalalgia
Tx: tension= NSAIDs, acetaminophen; migraines=-triptans(5ht 1d/b agonist; avoid
in pregnancy, CAD, prinzmetal angina); Cluster= -triptans, NSAIDs, 100% O2 for
15 mins

Parasympathetics will cause uterine contraction, penis erection, bronchospasm


Excess cholinergics will also cause sweating, & muscle excitation
Pralidoxime reactives inhibit AChE and tx organophosphate poisoning
Edrophonium-tensolin test dx. Myasthenia Graves while physostimine tx the dz
Donepezil, galantamin, rivastigmine is a cholinergic agonist that tx alzeimers
Tx urge incontinence: oxybutynin, tolteredine, Darifenecin, solfenesin,
trospium (On the darn stupid toilet)
Scopolamine muscarinic antag tx motion sickness and airway secretions
Tropicamide dilates the eye
Avoid atropine for BPH, ileus/GI obstruction, elderly (delirium), acute angle
glaucoma, hyperthermia
Drug w/ anticholinergics: neuroleptics, TCA, 1st gen H1 blockers, amantadine
Benztropine is a muscarinic antagonist tx parkinsons;
bethaneCOL: CHOlinergic agonist
rivastigmine is antiChE for alzeimers dz
Alpha 1- mydriasis & vasoconstriction, bladder sphincter tone
Beta 1 agonsit- release renin, lipolysis, contractility, tachycardia (HR+cntrct)
Beta 2: vasodilation, lipolysis HR (compensatory) & insulin, uterine tone,
bronchodilation
Epi has 2 activity while NE does not (both affect 1 & 2)
NE- septic or cardiogenic shock but renal and mesenteric perfusion;
Epi- anaphylaxisis, cardiac arrest, immediate bronchospasm
isoproterenol- beta1,2 ag

Alpha1 blocker (-zosin; tamsulosin=|only alpha1A,D_R) and finasteride tx


BPH
-zosin block alpha 1B (vascular) and alpha1AD (prostate)
Pnenoxybenzamine and phentolamine block alpha 1 and 2; tx pheochromo
Acebutolol and Pindolol (weak beta 1,2 ag)- tx pt w/ bradycardia and HTN
Carvedilol and labetolol: beta 1 and alpha 1 bockers
Timolol and Nandolol: tx glacoma
Beta blockers used for anxiety, migraine+varices prophylaxsis, hyperthyroid,
glaucoma (aqeus humor prod) aortic dissection, angina, MI, HTN, CHF ;
avoid in CHF exacerbations (AV block), DM , COPD, a
Beta blocker SE:glycogenolysis and glucagon release (DM pt risk of
hypoglycemia and masks Sx), HTN on cocaine (unopposed alpha1),
arrhythmia, bronchospasm (avoid in COPD, asthmatics)
2 agonist: clonidine (malignant HTN, sedative), methyldopa (pregnancy
HTN), dexmedetomidine, guanfacine
Note guafenesin- cough expectorant used w/ dextromethorphan (opiod)
Butorphenol is a partial piod agonist w/ minimal resp depression
COMT methylates NE while Mao oxidizes NE (NEanillylmandelic acid;
Dopaminehomovanllic acid; Epimetanephrine)

Dopamine: low dose (D1,2), medium (beta1,2), high (alpha1,2); HF, renal perf
Dobutamine: Beta 1 ag; phenylephrine: alpha 1ag;
tebutaline Beta2>1, subQ for asthma & to delay/stop premature
contractions/labor. Ritodrine (beat2 agonist only that tx premature labor)
Beta 2 ag SE: hypokalemia, remor, tachy
Amphetamines presyn release of store catecholamines (ADHD, narco, depr)
Ephedrine:mixed agonist; release stored catechol; tx urinary incontinence, colds
Cocaie inhibits reuptake of catecholamine; nasal decongestant, local anesthetic

D1- relax renal artery while D2 are found in brain


V1 vascular SM contraction; V2 H2O reabsorption

M1_R re found in ENS, while M3 gut peristalsis & bladder contraction


Gq activates phosphoLIPASE C PIP2 to DAG (activates PKC) + IP3

Tyrosine receptor also activates PKC or can Ras and activate PK1,2,3
Inhibit P450: CRACK AMIGOS= cimetidine, ritonavir, amiodarone, cipro,
ketoconazole, acute EtOH, macrolides, isoniazid, grapefruit juice, omeprazole,
sulfonamides
Induce CYPs: Guiness, Coronas & PBRs induce Chronic alcoholism:
carbamazepine, griseofulvin, phenytoin/phenobarb, rifampin, St. john wart
Fomeprazole blocks alcohol dehydrogenase (tx methanol and ethylene glycol
toxicity) while disulfuram blocks acetoaldehyde dehydrogenase
Ethanol metabolism yields NADH;
Ethylene glycol oxalic acid (acidosis, oxalate crystal kidney, neuro Sx,
cardiac/lung toxicity
Tx methanol poisoning w/ ethanol, fomeprazole to prevent formaldehyde
Disulfuram like rxn: metronidazole, procarbazine, 1stgen sulfonylureas, cipro

Phase 1 oxidation, reduction, hydrolysis (Methanol formic acid w/ phase


1; metabolites are slightly polar & can be active; lose this ability w/ aging
PhaseII: methylation, sulfation, glucoronidation, acetylation becime VERY
polar inactive metabolites
Zero order elimination: PEA phenytoin, ethanol. Aspirin
When pH<pKa you have more protonated form of drug b/c [H+]
When pH>pKa acidic drugs are in anion form and are trapped and excreted
Tx acidic ODs (salicylates/TCAs) w/ Nabicarb & basic ODs(amphetamine)
w/ NH4Cl

Sacral ilitis = ankylosing spondylitis ( spine mobility; a/w uveitis, aortic


regurs, conduction abnrml, CV dz; bamboo shaped spine)
Penci & cup deformities of hand= psoriatic arthritis
Reactive arthritis: cant see, pee, climb a tree

III CARDIOVASC U LAR

CARDIOVASCULAREMBRYOLOGY

REMBRYOLOGY
CARDIOLOGY

EMBRYONIC STRUCTURE

GIVES RISE TO

Truncus arteriosus (TA)

Ascending aorta and pulmonary trunk

Bulbus cordis

Smooth parts (outflow tract) of left and right


ventricles

Primitive atria

Trabeculated part of left and right atria

Primitive ventricle

Trabeculated part of left and right ventricles

Primitive pulmonary vein

Smooth part of left atrium

Left horn of sinus venosus (SV)

Coronary sinus

Right horn of SV

Smooth part of right atrium

Right common cardinal vein and right anterior


cardinal vein

SVC

First functional organ in vertebrate embryos; beats spontaneously by week 4 of development.


Primary heart tube loops to establish left-right
polarity; begins in week 4 of gestation.

Defect in left-right dynein (involved in L/R


asymmetry) can lead to dextrocardia, as seen
in Kartagener syndrome (primary ciliary
dyskinesia).

mbers

Septum primum grows toward endocardial


cushions, narrowing foramen primum.
Foramen secundum forms in septum
primum (foramen primum disappears).

Patent foramen ovalecaused by failure of

septum primum and septum secundum


to fuse after birth; most are left untreated.
Can lead to paradoxical emboli (venous
thromboemboli that enter systemic arterial

Methamphetamine OD tx: NH4Cl, benzos, antipsychotics, antihypertensives


Acetaminophen is toxic when have >12g in 24hr; tx N-acetylcyteline
Aspirin (NV, tinnitus, dizziness); tx Nabirb, dialysis
Physostigmine to tx atropine overdose
Lead OD (neuro and NS GI Sx): dimercaperol, succimer, EDTA, penicillam
Merguray, arsenic gold OD tx: dimercaperol, succimer
CN OD (fire, nitrprusside) tx: nitrites, hydroxocobalmin, thiosulfate
CO OD (kerosene lamp, heater, stove) tx: 100% O2
Beta-blocker or verapamil OD tx: glucagon, Ca, atropine
Heparin OD: protamine; Warfarin: vit K, FFP
tPa, streptokinase, urokinase OD tx: aminocaproic acid
Theophylline OD(tachy) tx: beta-blocker

Hox genes and retinoic acid are important for the early stages of head&neck
1st aortic arch- maxillary; 2- stapedial and hyoid, 3- CCA+ proximal ICA,
4- Left-arch of aorta, 4-right-proximal R subclavian, 6-proximal pul arteries+
ductus arteriosus
The left umbilical vein carries oxygenated blood from the placenta to the fetus
Ductus venosus, Foramen ovale & ductus arteriosus are the 3 shunts in fetal
circulation
Indomethacin (prostaglandin inhibitor), acetylcholine, histamine, and
catecholamines promote closure of the patent ductus arteriosus
Prostaglandin E, intrauterine asphyxia, and neonatal asphyxia keep patent
ductus arteriosus open
It is normal to hear a mumur in 1st 24hrs of life

STATUS
EPILEPTICUS

ABSENCE

GENERALIZED
TONIC-CLONIC

COMPLEX

SIMPLE

PARTIAL
(FOCAL)

Ethosuximide

Benzodiazepines
(diazepam,
lorazepam)
*

Phenytoin

CARDIOVASC U LAR

MECHANISM

SIDE EFFECTS

Blocks thalamic T-type


Ca2+ channels

GI, fatigue, headache, urticaria,


Steven-Johnson syndrome.
EFGHIJEthosuximide causes
Fatigue, GI distress, Headache,
Itching, and Stevens-Johnson
syndrome

**

GABA A action

***

Na+ channel inactivation;


zero-order kinetics

CARDIOVASCULARPHYSIOLOGY

Heart murmurs
Systolic
Mitral/tricuspid regurgitation
(MR/TR)
S1

S2

S1

S2

S2
S2
S2

S1
S1
VSD
S1
S1

MC

S2
S2
S2
S2

S1
S1
S1
S1

MC

S2
S2
S2
S2
S2

S1
S2
S1
S2 (MVP)
Mitral
valveMC
prolapse
S1
S2
S1
S1

MC

S2 OS
S2
S2

S1
S1
S1
S1

MC

S2
S2
S2
S2 OS
S2
S2

S1

MC

Diastolic

S2

S1
OS
Aortic
regurgitation S2
(AR)
S1
S1
S1
S1

S2
S2 OS
S2

MC

S2
S2

S1
S1
S2 OS
Mitral
stenosis (MS)S2
S1
S1

S2 OS
S2

S1

S2

S1
S1

S2
S2 OS

Continuous
PDA
S1

Nystagmus, diplopia, ataxia,


sedation, gingival hyperplasia,
SECTION III
hirsutism, peripheral neuropathy,
megaloblastic anemia,
teratogenesis (fetal hydantoin
syndrome) SLE-like syndrome,
induction of cytochrome P-450,
lymphadenopathy, StevensJohnson syndrome, osteopenia

Na+ channel inactivation

S2

273

Diplopia, ataxia, blood dyscrasias

Holosystolic, high-pitched blowing murmur.


(agranulocytosis, aplastic anemia),
liverthat
toxicity, teratogenesis,
Mitralloudest at apex and radiates toward axilla. Enhanced by maneuvers
induction
of cytochrome P-450,
TPR (e.g., squatting, hand grip). MR is often due to ischemic heart disease, MVP,
SIADH, Stevens-Johnson
or LV dilation.
syndrome
Tricuspidloudest
at
tricuspid
area
and
radiates
to
right
sternal
border.
Enhanced
+
*
Na
channel
inactivation,
GI,
distress, rare but fatal
Valproic acid
by maneuvers that RA return (e.g., inspiration).
TR
commonly causedhepatotoxicity
by RV
GABA
concentration
(measure LFTs),
by inhibiting
neural
tube defects in fetus (spina
dilation. Rheumatic fever and infective endocarditis
canGABA
cause either MR
or TR.
transaminase

Aortic stenosis (AS)


S1
S1
S1

Carbamazepine

Sedation, tolerance, dependence,


respiratory depression

bifida), tremor, weight gain,

Crescendo-decrescendo systolic ejection murmur. LV >> aortic pressure contraindicated


during
in pregnancy
systole.
Loudest
at
heart
base;
radiates
to
carotids.
Pulsus
parvus
et
tarduspulses
Sedation, ataxia
Primarily inhibits highGabapentin
2+
voltage-activated
Caand
are weak with a delayed peak. Can lead to Syncope,
Angina,
Dyspnea on
channels;
designed
as or bicuspid aortic
exertion (SAD). Often due to age-related calcific
aortic
stenosis
GABA analog
valve.
Holosystolic, harsh-sounding murmur. Loudest
at tricuspid
with
GABA
Sedation,
tolerance, dependence,
Phenobarbital
A action area, accentuated
induction
of cytochrome P-450,
hand grip maneuver due to afterload.
cardiorespiratory depression
Topiramate

Blocks Na+ channels,


GABA action

Sedation, mental dulling, kidney


stones, weight loss

Lamotrigine

Blocks voltage-gated Na+

Stevens-Johnson syndrome (must

Late systolic crescendo murmur with midsystolic


click (MC; due to sudden
tensing
channels
be titrated slowly)
of chordae tendineae). Most frequent valvular lesion. Best heard over apex. Loudest
Unknown; may modulate
Levetiracetam
just before S2. Usually benign. Can predispose
to and
infective
endocarditis. Can be
GABA
glutamate
releasefever, or chordae rupture. Occurs
caused by myxomatous degeneration, rheumatic
earlier with maneuvers that venous returnGABA
(e.g., standing
or Valsalva).
by inhibiting
Tiagabine
re-uptake

Vigabatrin

GABA by irreversibly

High-pitched blowing early diastolic decrescendo


murmur.
inhibiting
GABA Wide pulse pressure
transaminase
when chronic; can present with bounding pulses
and head bobbing. Often due
to aortic root dilation,
bicuspid
aortic and
valve,
endocarditis,
or rheumatic
fever.
Prodrome
of malaise
fever
followed by rapid
onset of erythematous/purpuric
macules (oral, o
Stevens-Johnson
lesions
progress
to epidermal
necrosisof
and
sloughing.
syndrome
murmur during hand
grip.
Vasodilators
intensity
murmur.

* = 1st line; ** = 1st line for acute; *** = 1st line for prophylaxis.

Follows opening snap (OS; due to abrupt halt in leaflet motion in diastole, after
rapid opening due to fusion at leaflet tips). Delayed rumbling late diastolic
murmur; interval between S2 and OS correlates with severity. LA >> LV
pressure during diastole. Often occurs 2 to rheumatic fever. Chronic MS can
result in LA dilation. Enhanced by maneuvers that LA return (e.g., expiration).
Continuous machine-like murmur. Loudest at S2. Often due to congenital rubella
or prematurity. Best heard at left infraclavicular area.

382

SECTION III

H E MATO LOGY AN D O N CO LOGY

H E MATOLOGY AN D ONCOLOGYPATHOLOGY

H E MATOLOGY AN D ONCOLOGY

HEMATOLOGY AND ONCOLOGYPHARMACOLOGY

SECTION III

407

Anemias
Bevacizumab

MCV (< 80 fL)


(Microcytic)

ANEMIAS

MECHANISM

Monoclonal antibody against VEGF. Inhibits angiogenesis.

CLINICAL USE
MCV (80100 fL)
TOXICITY
(Normocytic)

Solid tumors (colorectal cancer, renal cell carcinoma).

NONHEMOLYTIC
Common
(Reticulocyte count
normal or !) chemotoxicities

Hemorrhage and impaired wound healing.


HEMOLYTIC
(Reticulocyte count ")

ACDa

ACDa

Aplastic anemia

Thalassemias

Chronic kidney disease


Iron deficiency (early)

Lead poisoning

Autoimmune

Folate deficiency

Microangiopathic

B12 deficiency

Macroangiopathic

Orotic aciduria

RBC enzyme deficiency:


G6PD, pyruvate kinase

Infections

HbC defect

Sideroblastic anemiab

Cisplatin/Carboplatin
(and nephrotoxicity)

EXTRINSIC

RBC membrane defect:


hereditary spherocytosis

Paroxysmal nocturnal
hemoglobinuria

5-FU
6-MP

Sickle cell anemia


and iron deficiency anemia may first present as a normocytic anemia and then progress to a microcytic anemia.
bCopper deficiency can cause a microcytic sideroblastic anemia.

SECTION III

acoustic nerve damage

disease neuropathy
Vincristine Liver
peripheral
Bleomycin, Busulfan pulmonary fibrosis
Alcoholism
Doxorubicin cardiotoxicity
Trastuzumab
cardiotoxicity
Reticulocytosis
Cisplatin/Carboplatin nephrotoxic (and
acoustic nerve damage)

CYclophosphamide

aACD

300

NONMEGALOBLASTIC

MEGALOBLASTIC

CHEMO-TOX
MAN

INTRINSIC
Iron deficiency (late)

MCV (> 100 fL)


(Macrocytic)

hemorrhagic cystitis

myelosuppression
myelosuppression

Methotrexate

myelosuppression

Microcytic, hypochromic (MCV < 80 fL) anemia

CARDIOVASC U LAR DESCRIPTION


CARDIOVASCULARPHARMACOLOGY

Lipid-lowering agents

EFFECT ON LDL
EFFECT ON HDL
BAD CHOLESTEROL GOOD CHOLESTEROL

DRUG

FINDINGS

iron due to chronic bleeding (GI loss,


menorrhagia), malnutrition/absorption
disorders or demand (e.g., pregnancy)
final step in heme synthesis.

Iron deficiency

EFFECT ON
TRIGLYCERIDES

iron, TIBC, ferritin. Fatigue, conjunctival


pallor A .
Microcytosis and hypochromia B . May
manifest as Plummer-Vinson syndrome (triad
of iron deficiency anemia, esophageal webs,
and atrophic glossitis).
MECHANISMS OF ACTION
SIDE EFFECTS/PROBLEMS

Inhibit conversion
of HMG-CoA
to mevalonate,
a cholesterol
precursor

HMG-CoA reductase
inhibitors (lovastatin,
pravastatin,
simvastatin,
atorvastatin,
rosuvastatin)

Red, flushed face, which


is by aspirin or longterm
use
Iron deficiency.
Note microcytosis and hypochromia
(central pallor, arrows).
Hyperglycemia
(acanthosis
nigricans)
Defect: -globin gene deletions
-globin
4 allele
deletion: No
-globin. Excess -globin
Hyperuricemia
synthesis.
forms
4 (Hb Barts). Incompatible with life
(exacerbates
gout)
cis deletion prevalent in Asian populations; trans
(causes
hydrops fetalis).

Niacin (vitamin B3)

A
-thalassemia

Inhibits lipolysis
in adipose tissue;
Conjunctival pallor in anemia. reduces hepatic
VLDL synthesis

Hepatotoxicity ( LFTs),
rhabdomyolysis (esp.
when used with fibrates
and niacin)

Bile acid resins


(cholestyramine,
colestipol,
colesevelam)

populations.
deletion: HbH disease. Very little
Slightlydeletion prevalent
Slightlyin AfricanPrevent
intestinal 3 allele
Patients
hate ittastes
-globin. Excess -globin forms 4 (HbH).
reabsorption
bad and causes GI
12 allele deletion: no clinically significant anemia.
of bile acids;
discomfort, absorption
liver must use
of fat-soluble vitamins
cholesterol to
Cholesterol gallstones
make more

Cholesterol absorption
blockers (ezetimibe)

Prevent cholesterol
Rare LFTs, diarrhea
absorption at small
intestine brush
border
Upregulate LPL
TG clearance
Activates PPAR-
to induce HDL
synthesis

Fibrates (gemfibrozil,
clofibrate,
bezafibrate,
fenofibrate)

Endothelial
cells

Blood
Gut

Myositis ( risk with


concurrent statins),
hepatotoxicity ( LFTs),
cholesterol gallstones
(esp. with concurrent bile
acid resins)

Hepatocytes

Ezetimibe

Ac-CoA

LDL

HMG-CoA
reductase
inhibitors

HMG-CoA

LDL

Cholesterol

Bile acids

Gemfibrozil
R

LDL

IDL

Lipoprotein
lipase

Niacin
VLDL

VLDL

Early developmental
milestones

Milestone dates are ranges that have been approximated and vary by source. Children not meeting
milestones may need assessment for potential developmental delay.

AGE

MOTOR

SOCIAL

VERBAL/COGNITIVE

Infant

Parents

Start

Observing

Primitive reflexes disappear


Moro (by 3 mo), rooting (by
4 mo), palmar (by 6 mo),
Babinski (by 12 mo)
Posturelifts head up prone
(by 1 mo), rolls and sits
(by 6 mo), crawls (by 8 mo),
stands (by 10 mo), walks
(by 1218 mo)
Pickspasses toys hand to
hand (by 6 mo), Pincer grasp
(by 10 mo)
Points to objects (by 12 mo)

Social smile (by 2 mo)


Stranger anxiety (by 6 mo)
Separation anxiety (by 9 mo)

Orientsfirst to voice (by


4 mo), then to name and
gestures (by 9 mo)
Object permanence (by 9 mo)
Oratorysays mama and
dada (by 10 mo)

Child

Rearing

Climbs stairs (by 18 mo)


Cubes stackednumber
= age (yr) 3
Culturedfeeds self with fork
and spoon (by 20 mo)
Kicks ball (by 24 mo)

Recreationparallel play (by


Words200 words by age 2
12 mo)
(2 zeros), 2-word sentences
Ventricular system
Rapprochementmoves away
from and returns to mother
(by 24 mo)
Realizationcore gender
identity formed (by 36 mo)

Dont

Forget, theyre still

Learning!

Drivetricycle (3 wheels at
3 yr)
Drawingscopies line or
circle, stick figure (by 4 yr)
Dexterityhops on one foot
(by 4 yr), uses buttons or
zippers, grooms self (by 5 yr)

Freedomcomfortably spends
part of day away from mother
(by 3 yr)
Friendscooperative play, has
imaginary friends (by 4 yr)

Language1000 words by age


3 (3 zeroes), uses complete
sentences and prepositions
(by 4 yr)
Legendscan tell detailed
stories (by 4 yr)

012 mo

Toddler
1236 mo

Preschool
35 yr

464

SECTION III

N E U ROLOGY

NEUROLOGYANATOMY A

Working

Anterior
horn

Lateral ventricles

Foramen
of Monro
Third
ventricle
Foramen of Luschka

Foramen of Magendie

Posterior
horn

Cerebral
aqueduct
of Sylvius
Fourth
ventricle

CSF is made by ependymal cells of choroid plexu


then drains into dural venous sinuses.

Hydrocephalus
Communicating (nonobstructive)
Communicating
hydrocephalus
Normal pressure
hydrocephalus
A

Hydrocephalus ex
vacuo

CSF absorption by arachnoid granulations, whic


papilledema, and herniation (e.g., arachnoid sca

Does not result in increased subarachnoid space v


fibers of the corona radiata and leads to clinical
cognitive dysfunction (sometimes reversible).

Appearance of CSF in atrophy (e.g., Alzheimer


pressure is normal; triad is not seen.
Apparent increase in CSF observed on imaging is
atrophy.

Noncommunicating (obstructive)
Noncommunicating
hydrocephalus

Spinal nerves

Caused by a structural blockage of CSF circulatio


the aqueduct of Sylvius).

There are 31 spinal nerves in total: 8 cervical,


12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal.
Nerves C1C7 exit above the corresponding
vertebra. All other nerves exit below (e.g., C3
exits above the 3rd cervical vertebra; L2 exits
below the 2nd lumbar vertebra).

402

SECTION III

H E MATOLOGY AN D ONCOLOGY

HEMATOLOGY AND ONCOLOGYPHARMACOLOGY

Antineoplastics
Nucleotide synthesis

DNA

MTX, 5-FU:
thymidine synthesis

Alkylating agents, cisplatin:


cross-link DNA

6-MP:
purine synthesis

Dactinomycin, doxorubicin:
DNA intercalators
Etoposide:
inhibits topoisomerase II

RNA

Protein

Cellular division

Vinca alkaloids:
inhibit microtubule formation
Paclitaxel:
inhibits microtubule disassembly