Derm

In psoriasis: Neutrophils may form spongiotic clusters in the superficial dermis and the parakeratotic stratum
corneum (munro microabscesses)
Melanoma commonly mets to the brain, GI tract, bone, liver and lungs.
The most common metastatic tumors to the brain are lung cancer, renal cancer, and melanoma.
Disinfectants:
Agent
Alcohols (isopropanol,
ethanol)
Chlorhexidine
Hydrogen peroxide
Iodine

Mechanism
Disruption of cell membranes;
denaturation of proteins
Disruption of cell membranes;
coagulation of cytoplasm
Produces destructive free
radicals that oxidize cellular
components
Halogenation of proteins and
nucleic acids

Sporicidal
No
N
Yes
Yes

Xeroderma pigmentosum is AR. It is DNA excision repair cant repair DNA following UV light damage.
An IgE independent urticarial can develop after exposure to substances that directly stimulate mast cell
degranulation (opiates, ABX, radiographic contrast media).
Erythema migrans is the classic skin lesion of lyme disease.
Mycobacterium scrofulaceum is commonly found in and around environmental water sources. It is the
etiologic agents of scrofula, a disease characterized by lymphadenitis (cervical) that occurs most often in
children.
Rocky mountain spotted fever risk factors include frequent contact with dogs and exposure to wooded areas or
grassy fields.
Most common organisms that cause otitis media are: strep pneumo, h. influenza, and moraxella. Recurrent
infections with these organisms suggests humoral immunodeficiency. Pneumocystitis and chronic candidiasis
suggests T-cell deficiency.
The key cells involved in cell mediated immunity are macrophages, CD4+ helper T cells, CD8 cytotoxic t cells
and NK cells.
Failure to generate a response to a skin test testing for type IV HS is called anergy.
Post-herpetic neuralgia (MC complication of VZV) is described as stabbing pain.
RPR for syphilis (rapid plasma reagin). The patients serum is mixed with a solution of cardiolipin, cholesterol,
and lecithin. Aggregation or flocculation of the sample demonstrates the presence of cardiolipin antibodies int
eh pts serum. This test detects antibodies to human cellular lipids released into the bloodstream after cell
destruction by T. pallidum. RPR is positive in all illnesses caused by T. pallidum and subspecies (syphilis, yaws,
pinta, bejel).
Common medical conditions influenced by multiple genes:
Androgenetic alopecia, epilepsy, ischemic heart disease, schizophrenia, glaucoma, HTN, malignancy,
type II DM
Koplik spots are grains of sand on an erythematous base next to the 2 nd molar.
Tuberculoid leprosy spots are hypopigmented and anesthetized due to superifical nerve involvement.
Skin test for tuberculoid leprosy is the lepromin skin test. It will be positive because of the strong CD4 Th1
cell-mediated immune response. Lepromatous leprosy is is characterized by a weak cell mediated response.
The lepromin skin test is usually nonreactive in these pts. Remember: tuberculosis itself involves a strong cellmediated response (resulting in caseating necrosis). This should help remember it.

Plane xanthomas are linear lesions in skin folds that are strongly associated with primary biliary cirrhosis.
Xanthelasma is a cutaneous lesion (commonly found on th eyelid) that contains lipid-laden histiocytes (foam
cells). Classically, these are associated with primary or secondary hyperlipidemia. Chronic cholestatic
processes including obstructive biliary lesions and primary biliary cirrhosis result in subsequent
hypercholesterolemia, leading to the formation of xanthelasmas.
VZV mainfests with a burning sensation and/or pain unilaterally in a dermatomal distribution. In 2-3 days, an
erythematous maculopapular rash develops in the affected dermatome. The papules transform into the
vesicles that later coalesce. Rupture of the vesicles produces ulcers that crust in a few weeks. The pt is
contagious until the lesions are dry.
Tzanck intranuclear invlsuions in keratinocytes and multinucleated giant cells are seen
In bacterial vaginosis, alterations in the normal vaginal flora (specifically loss of lactobacilli and overgrowth of
mixed anaerobic organisms) produce a gray discharge and a fishy odor that becomes more prominent with
addition of KOH (the whiff test).
Class
Anti-pseudomonal pencillins
Cephalosporins
Aminoglycosides
Flouroquinolones
Monobactams
Carbapenems

Drugs
Ticarcillin, piperacillin
Ceftazidime (3rd generation), cefepime (4th
generation)
Amikacin, gentamycin, tobramycin
Ciprofloxacin, levofloxacin
Azteronam
Imipenem, meropenem

Lymphangiosarcoma (pg. 295) is also called Stewart-Treves syndrome.

In breast carcinoma, nipple inversion is observed when the tumor invades the central region of the breast, and
skin retraction is identified when the cancer infiltrates the suspensory Cooper ligaments.
Granulomas associated with TB develop a central zone of necrosis due to hypoxia and free-radical injury. This
appears grossly as a granular and cheesy material.
Bacillary angiomatosis is from bartonella henselae (cat scratch disease, which can also cause culture-negative
endocarditis). Cat scratch disease is characterized by low fever, lymphadenopathy, and self limited course. BA
can be fatal if left untreated though.
PABA esters are sunscreens for UVB only (290-320). UVA is 320-400.
A number of topical and systemic therapies are available for treating psoriasis. Topical vitamin D analogs are
frequently used and include calcipotriene, calcitriol, tacalcitol. These medications bind to and activate the vit
D receptor, a nuclear transcription factor that causes inhibition of keratinocyte proliferation and stimulation of
keratinocyte differentiation. Treatment with vit D analogs has also been shown to inhibit T cell proliferation
and other inflammatory mediators.
Nafcillin is often used to treat skin and soft tissue infectinos for which S. aureus is a common cause (folliculitis,
abscess).
Acyclovir, its prodrug valacyclovir, famiciclovir, and ganciclovir are all nucleoside analogues that require both
herpes viral and cellular kinases for conversion to their active nucleoside triphosphate form. Cidofovir is a
nucleoside monophosphate that requires only cellular kinases for activation.
Local cutaneous adverse effects of chronic topical corticosteroid administration including atrophy/thinning of
the dermis that is assoacited with loss of dermal collagen, drying, cracking, and/or tightening of the skin,
telangiectasias, and ecchymoses.
Musculoskeletal
Caudal regression syndrome is a rare condition. Patients are born with agenesis of the sacrum and
occasionally lumbar spine and experience resultant flaccid paralysis of the legs, dorsiflexed contractures of the
feet, and urinary incontinence. Caudal regression syndrome can range in severity from isolated anal atresia to
sirenomelia. It is frequently related to poorly controlled maternal diabetes, though this is certainly not the only
etiologic factor considering the frequency of diabetes and the relative rarity of caudal regression syndrome.

Glenohumeral joint is the most commonly dislocated joint int eh body owing to the shallow articulation
between the humeral head and the glenoid fossa of the scapula.
In rotator cuff syndrome, the most commonly injured tendon is the supraspinatous because this tendon is
prone to repeated impingement trauma between the humeral head and the acromion.
Female athlete triad: eating disorder, amenorrhea, osteoporosis.
All injections into the gluteal region should target the superloateral quadrant, to avoid damage to the gluteal
nerves and sciatic nerve. This pt is exhibiting the classic gluteus medius gait hip dips downwards when the
ipsilateral foot is lefted off of the ground. This is observed when there is injury to the superior gluteal nerve or
to the gluteus medius muscle itself. The superior gluteal nerve leaves the pelvis through the greater sciatic
foramen above the level of the piriformis. Injection in the superomedial quandrant of the buttock is liekyl to
injure this nerve.
Sciatic nerve is in the inferomedial quadrant of the buttock.
Large fluid collection in the retroperitoneum laying anterior to the psoas muscle with isodense fluid is
consistent with a spontaneous retroperitoneal hematoma, likely secondary to warfarin use. The femoral nerve
descends through the fibers of the psoas muscle, and then runs beneath the inguinal ligament into the thigh.
Femoral nerve mononeuropathy can occur due to pelvic fracture, compression from a hematoma or abscess,
stretch injury, or ischemia.
Femoral nerve injury knee buckles, patellar reflex is diminished, sensory loss over the anterior thigh.
Several muscles insert of the clavicle including the pectoralis major on the inferior medial aspect, the deltoid
on the inferior lateral aspect, the subclavius on the interior lateral aspect, the trapezius on the superior lateral
aspect, and the SCM on the superior medial aspect.
SCM is innervated by CN XI.
Radial head subluxation (nursemaids elbow) is the MC elbow injury in children. It occurs most frequently
between the ages of 1-4 yo. The injury often results from a sarp pull on the hand while the forarm is pronated
and the elbow is extended. This traction causes the annular ligament to tear form its periosteal attachement
at the neck of the radius. It then becomes trapped in the radiohumeral joint. Kids with this injury present with
the injured arm held close to the body with the elbow extended (or slightly flexed) and the forearm pronated.
The child is typically in little distress until attempts are made to move the elbow.
The inferior gluteal nerve exits the pelvis through the greater sciatic foramen below the piriformis.
Housemaids knee prepatellar bursitis chornic trauma from repeated kneeling. Also common in roofers,
plumbers,a nd carpet layers.
Dysthymic disorder is a chronic, low-intensity mood disorder (at least 2 years) that responds well to
antidepressant medications.
Major depression is diagnosed when at least 5 of the following symptoms are present for at least 2 weeks:
depressed mood, sleep disorder, anhedonia, guilt (worthless, hopelessness, regret), energy deficit,
concentration deficit, appetite disorder, psychomotor retardation or agitation, suicidality (SAGECAP).
The median nerve courses with the brachial artery in the groove bewteween the biceps brachii and the
brachialis muscles. It gains access to the forearm in the medial aspect of the antecubital fossa and
immediately courses between the humeral and ulnar heads of the pronator teres muscle. It then courses
between the flexor digitorum superficialis and the flexor digitorum profundus muscles before netering the wrist
and hand within the flexor retinaculum.
The musculocutaneous nerve courses directly between the biceps brachii and the coracobrachialis muscles.
Injury to this nerve leads to paralysis of the biceps and the brachialis, which results in an inability to flex the
forearm.
Treatment for paroxysmal supraventricular tachycardia can be with vagal stimulation, such as carotid sinus
massage or the valsalva maneuver. Maneuvers that increase vagal tone increase the refractory period in the
AV node and help prevent a reentrant circuit from conducting. If valsalva fails, the IV adenosine is used.
Serum sickness is a type III HS reaction which generally produces fever, urticarial, arthralgias,
glomerulonephritis, and lymphadenopathy 5-10 days after exposure to an antigen. It can have vasculitis with
vessel wall fibrinoid necrosis and neutrophil infiltration can be features of systemic despotition of circulating

immune complexes in arteries and arterioles. Sulfonamides can provoke this condition. There is often
hypocomplimentemia, including a decreased serum C3 level.
Serum sickness is a type III HS reaction characterized by desposition of circulating, complement fixing immune
complexes and resulting vasculitis. Associated findings include fever, urticarial, arthralgias,
glomerulonephritis, lymphadenopathy, and a low serum C3 level 5-10 days after intravascular exposure to
antigen.
Neuromuslcular lesions, ragged red skeletal muscle fibers, and lactic acidosis suggest mitochondrial
encephalomyopathy.
Mitochondria make ATP via oxidative phsophorylation, which is why mitochondrial problems often lead to lactic
acidosis and primarily affect tissues with the highest metabolic rates (neural tissue, muscular tissue).
Heteroplasmy describes the condition of having different organellar genomes (mutated and wild type) within a
single cell. For mitochondrial diseases, pts with more severe disease are those with a higher proportion of
defective mitochondrial genomes within their cells.
Homocysteinuria is characterized by ectopic lentis, mental retardation, marfanoid habitus, and osteoporosis in
addition to vascular problems.
Congenital hypothyroid: also associated with muscle hypotonia, hoarse cry, prolonged jaundice, poor feeding,
and congenital heart defects.
Strep pneumo, H. influenza, Neisseria, and salmonella are encapsulated (increased risk in asplenics and SS
pts). Give pneumovax for S. pneumo, hib for h. influenza type B, and the meningitis polysaccharide capsular
vaccine for N. meningitidis. Salmonella possesses a special capsule called the vi antigen (Vi stands for
virulence) which protects the bacterium from opsonization and phagocytosis.
E. coli is second MCC of osteomyelitis after salmonella in SS>
Sacroiliitis occurs in 20% of reactive arthritis cases. Also assoacited is synovitis, enthesitis, conjunctivitis,
mouth ulcerations, balanitis circinata, and keratoderma blennorrhagicum.
Tetanospasmin is a protein toxin produces by C. tetani that can travel by retrograde axonal transport into the
CNS. The tetanospasmin heavy chain binds ganlioside receptors on the neuronal membranes and the light
chain inhibits release of glycine and GABA from inhibitor interneurons. Absence of these inhibitor NTs causes
sutained muscle contraction, or tetanus. Prominent signs and symptoms include: masseter muscle spasm
(lockjaw), opisthotonos, dysphagia, and facial muscle spasm (risus sardonicus).
Tetanus is inhibited by tetanus toxoid (inactived tetanus toxin) vaccination. This vasccination elecitis
humoral immunity for tetanus toxin (antitoxin antibodies active immunity).
In goodpastures, autoantibodies are formed against the noncollagenous domain of the alpha-3 chain of
collagen IV (anti-GBM antibodies).
Osteocytes in bone communicate via gap junctions to send signals and exchange nutreints and waste
products. Osteocytes can stress mechanical stresses and send signals to modulate the activity of surface
osteoblasts, thereby helping to regulate bony remodeling.
Myeloperoxidase deficiency is an immune deficiency not unlike the caused by CGD. In CGD the absence of
NADPH oxidase causes an inability to form hydrogen peroxide, and therefore the enzyme MPO has no susbtrate
(hydrogen peroxide) to metabolize into reactive oxygen species (oxygen free radicals) used to kill
microorganisms. The difference between these 2 illnesses lies in the fact that in CGD some phagocytosed
organisms can be killed because these organisms produce their own H2O2 which MPO then uses to produce
free radicals. In MPO defiencicy, the enzyme MPO is absent, so both catalase positive and catalase negative
organisms will survive with pahgocytes.
An Interesting Zoo Must Have Mammals (Actin in the I-band attaches at the Z-line, Myosine in the H-band
attaches at the M line)
Many infections of P. aeruginosa often begin with exposure to a water course of creation of a moist
environment (swimmers ear, hot tub folliculitis, burn wound).
Hot tub folliculitis is a superficial and self-limited P. aeruginosa infection of the hair follicles.
Strep pyogenes is pyrrolidonyl arylamidase (PYR) positive.
All medically important fungi may be divided into a few groups according to the area of involvement:

Cutaneous mycoses (dermatophytoses and tinea versicolor)

Subcutnaeous mycoses (sporotrichosis)
Mycoses with systemic involvement (most often lungs, are histoplasmosis, coccioidoses,
blastomycoses)
Opportunistic mycoses (candida, aspergillus, mucor, rhizopus)

C. perfingens makes gas gangrene by rapidly metabolizing carbohydrates.

C. perfrigens causes late onset food poisoning.
B. anthracis produces an antiphagocytic capsule that is required for pathogenicity. The capsule is unique in
that it contains D-glutamate instead of polysaccharide.
There are 2 different types of bones in the body. The cortical or compact bone makes up the shafts of long
bones and outer envelopes of all bones. Postmenopausal osteoporosisi typically involves cancellous bone,
which is preodiminantly present in the vertebral column, distal radius, hip, and neck of femur.
The interaction of RANk with its ligand is decreased by another protein secreted by the osteoblast
osteoprotegerin (OPG), and it acts as a decoy receptor. Bone turnover increases when RANK-L is high and OPG
is low.
PTH stimulates the secretion of monocyte colony stimulating factor and RANK-L by osteobalsts, thus
stimulating osteoclastic precursor to become mature osteoclasts.
Overexpression of RANK receptors in hypoestrogenic states causes increased bone resorption due to increased
osteoclastic activity.
Black females have high bone density than whites. Even at same bone density, blacks fracture less often.
Bone density increases with increasing BMI.
When a specific ion channel opens, the respective ions will flow across the membrane in a direction that brings
the resting membrane potential closer to that ions equilibrium potential (question ID: 1381)
Bone specific alkaline phosphatase is easily denatured by heat (bone will boil!).
Pyridinoline covalently corss-links collagen fibers; these cross-links are the most commonly used method in
assessing osteoclastic activity. Hydroxyproline is also released into blood when osteoclasts resorb bone, but
meat products also increase hydroxyproline. Tartrate resistant acid phosphatase, urinary hydroxyproline, and
urinary deoxypyridinoline reflect osteoclastic activity; urinary deoxypyridinoline is the most reliable.
Tx of MG involves cholinesterase inhibitors, animmunosuppresive agent, or thymectomy.
Skeletal muscle is nicotinic cholinergic receptors; gut is muscarinic.
Clubbing: lung cancer (large cell carcinoma especially), TB, CF, bronchiectasis, pulmonary HTN, empyema,
other chronic lung dz assoacited with hypoxia; cyanotic congenital heart dz (especially tet) and bacterial
endocarditis; IBD (crohns, UC), hyperthyroidism, malaborption
Elevated levels of PGE2 and PDGF and VEGF causing fibrovascular proliferation is associated with clubbing.
Iron deficiency: spoon shaped nails
Subperiosteal thinning: hyperparathyroid (from FA: renal osetodystrophy)
Osteoclasts in Pagets dz are typically very large and can have up to 100 nuclei.
In skeletal muscle, one T-tubule contacts 2 terminal cisterns forming a triad at the junction of the A-band and
the I-band.
Genetic factors are responsible for up to 80% of the variation in peak bone mass among invididvuals.
UV-B light is necessary for activation of pro-vit D3 into pre-vitD3 which then, with heat, converts to D3 (must
still be activated in kidney though).
Prolyl and lysyl hydroxylase hydrolate proline and lysine residues of pro-collagen. Vit C is required. Without the
hydroxylation, cross linking is greatly reduced and strength is worse.

Signs and symptoms of psoas abscess include fever, back or flank pain, inguinal mass, and difficulty woalking.
Pain is exacerbated by movements that cause the psoas to be stretched or extended (such as extension fo the
hip this is the psoas sign). These pts have hip flexion and lumbar lordosis to inhibit hip flexion.
Osteopetrosis is characterized by the peristance of primary, unmineraliezzd spongiosa in the medullary
canals
Fever/malaise followed by bright red rash on cheeks 5-7 days later: B19 parvovirus. IN adults, parvovirus can
cause arthritis involving the PIP, MCP, knee and ankle joints. Symptoms generally resolve spontaneously.
Spasmodic torticollis: focal dystonia where the neck is stuck in 1 position. Blephorospasm is second most
common focal dystonia. sWriters cramp is another common dystonia.
MMPs are important in wound healing. They degrade collagen and remodel. They also encourage
myofibroblast accumulation at the wound edges and scar tissue remodeling. Myofibroblasts initiate wound
contraction during healing by second inteitn. Contracture may occur when unusually pronounced MMP activity
results in excessive wound contraction.
(are actin containing fibrobalsts myofibroblasts??)
LEMS = proximal uscle weakness.
Subdural hematoma and bilateral retinal hemorrhages = shaken baby syndrome
Spiral fractures = child abuse.
In ankylosing spondylitis there are enthesitis (inflammation where tendons insert into bone). If it happens at
the costovertebral and costosternal junctions there will be pain limiting chest wall expansion leading to
hypoventilation.
Type I muscles = postural muscles (low-level sustained force).
If a leg is immobilized for a while, skeletal muscle fibers in his leg will decrease in size. If it is more prolonged,
it can start decreasing in number as well. You can also get osteoporosis of disuse (with bone resorption).
Eye stuff (ID 862).
Hemolysis causes haptoglobin levels to decrease by binding to free haptoglobin and the complex is cleared
hepatically.
Osteomyelitis affects young boys. Iti usually affects the metaphysis because this region contains slow flowing,
sinusoidal vasculature that is conducive to microbial passage. Without treatment, it can progress to chronic
suppurative osteomyelitis.
Golgi tendon organs are sensory receptors located at the junction of the muscle and tendon that are
innervated by group Ib sensory axons. GTOs are connected in series with the contracting extrafusal skeletal
muscle fibers. When a muscle actively contracts against resistance, the increase in tension is transitted
through the tendon activated the GTO in the process. IN contrast, GTOs are relatively insensitive to changes in
muscle length because the lengthening that occurs when a muscle is passively stretched takes place primarily
in the muscle fibers and not in the tendon. The Ib fibers then synapse on inhibitory interneurons in the spinal
cord that stop the alpha motor fibers. This way, The golgi tendon circuit is a negative feedback system that
regulates and maintains muscle tension. When a muscle exerts too much force, the GTOs inhibit contraction of
the muscle, causing sudden muscle relaxation. (ID 8266)
Ia and II muscle fibers from the intrafusal muscle fibers from muscle psindles are responsible for the stretch
reflex.

Biochemistry

Orotic aciduria enzymes messed up are orotate phosphoribosyl transferase and OMP decarboxylase. These
turn orotic acid into UMP. It orotic aciduria, give uridine, which is coverted to UMP by the action of nucleoside
kinases and then UMP inhibits carbamoyl phosphate synthetase 2, thus attenuating orotic acid production.
This is a problem in pyramidine base synthesis only (not purines).
B6 (pyridoxine) is a coafactor in transamination, deamination, decarboxylation, and condensation rxns.

Amino groups are funneled into glutamate during protein catabolism. (ID 1369)
Catabolims of isoleucine, valine, threonine, methionine, cholesterol, and odd chian FAs leads to the formation
of propionic acid, which is then converted to methylmalonic acid by biotin dependent carboxylation.
Isomerization of methylmalonyl CoA forms succinyl coA, which then enters the TCA cycle. A congenital
deficiency of propianyl CoA carboxylase, the enzyme responsible for the conversion of propionyl coA to
methylmalonyl coA, leasd to a development of propionic academia, as propionyl CoA accumulates. Propionic
academia is clinically characterized by poor feeding, vomiting, hypotonia, lethargy, dehydration, and an anion
gap acidosis. Propionic acid is the intermediate in the catabolism of branched chain AAs, such as valine, and is
not produced during the catabolism of other amino acids listed. (1340)
DNA polymerase synthesize new NDA strands in 5 to 3 direction and require a free 3-OH group upon which to
begin polymerization. This 3-OH group is provided by the enzyme primase, a DNA-dependent RNA
polymerase which forms RNA primers.
Exposure to radiation, including therapeutic and palliative radiation therapy, induced DNA damage through
DNA ds fractures and the formation of oxygen free radicals.
DNA damage from exposure to UV radiation leads to the formation of pyrimidine-pyrimidien dimers (thymine
dimers).
Primary structure: AA linked by peptide bonds
Secondary structure: alpha-Helix and beta pleated hseet heald together by hydrogen bonds (every 4 in alpha
helix, between all residues of antiparallel strands in beta pleated sheets).
Tertiary structure: complex folding (many forces icnludign ionic bonds, hydrophobic interactions, H-bonds,
disulfide bonds)
Beta pleated sheets are less soluble than alpha helix and therefore aggregate (alzheimers).
PRPP is a substrate used by HGPRT during purine salvage and it accumulates when there is deficiency of the
enzyme. PRPP is created by PRPP synthetase in the first step of de novo purine synthesis. When PRPP is high,
it will be shuttled into more IMP formation and ultimately more GMP and AMP (purine) formation. This makes
sense, because without purine salvage, we will have to make more, which requires PRPP. An enzyme in
converting PRPP to IMP is PRPP amidotransferase, so this enyme will be up also. GMP requires ATP and AMP
requires GTP so that purine synthesis favors the nucleotide that is deficient.
Propionyl coA to to methylmelanyl coA, and then methylmelanyl coA becomes succinyl coA. This last step is
an isomerization using methylmalonyl CoA mutase and vit B12. With a vit B12 defcieincy, the pt will have an
isomerization problem at this step. This is called methylmalonic aciduria. (ID 1341, pg 98)
Arginase deficiency = spasticity
Thymine (pyrimidine) dimers can be removed by the action of UV specific endonucleases. This enzyme causes
nicks at damaged sites that are later excised yb the 5 to 3 exonuclease activity of DNA polymerase, which
also synthesis new DNA in the place of the damaged DNA.
Most common CF mutation is a deletion of the phenylalanine at position 508 in the CFTR protein.
Side chains of some of the lysine residues in elastin are covalently bound to form a dessmosine crosslink. This
accounts for elastins resilient properties, allowing it to stretch and bend in any direction on applying force only
to recoil to its original size when the stretching force is withdrawn.
RNA pol I makes all ribosomal RNA except the 5S rRNA, which is made by RNA pol III.
Maple syrup urine is caused by a defect in alpha keto acid dehydrogenase, leading to inability to degrade
branched chain amino acids beyond their deaminated alpha-keto acid state. This results in dystonia and poor
feeding.
Atypical or malignant PKU BH4 reductase is out. Therefore, we cant get BH4. It acts similar to PKU if
phenylalanine hydroxylase was out (like in moral PKU). However, in BH4 reductase problem we also cant
make tyrosine into DOPA, which in turn will make DA. So PRL is not tonically inhibited and they get hyperprolicatinemia.
If you cant get ornithine from the cytosol to the mitochondria, you cant finish the urea cycle. (citrulline
argininosuccinate arginine ornithine is in the cytoplasm. Ornithine citrulline is in the mitochondria).
Defects in any of the urea cycle steps, result in disorders of the urea cycle. The common problem resulting

from disorders of the urea cycle is increased blood concentration of ammonia, leading to CNS system
dysfunction. Treatment of urea cycle disorders is balancing protein intake to output.
Neuroaminidase (sialidase) deficiency is the cause of human sialidosis. Found on the surface of influenza virus.
Ceramidase deficiency causes Farber dz, an AR condition characterized by ceramide accumulation within
neurons and within granulomas in the skin.
Glutamate Alanine; ALT (B6)
Oxaloacetate Aspartate; AST (B6)
These are transaminations.
Very long chain and some branched chain FAs cannot undergo mitochondrial beta oxidation. These undergo
special oxidation (beta for VLCFA or alpha for branched cahin FA) in peroxisomes. Zellweger syndrome cant
form myelin properly. Refsum dz build up of phytanic acid (branched chain FA) in the body. Strict avoidance
of chlorophyll in the diet is required.
Pseudotumor cerebri cerebral edema in the setting of benign intracranial HTN
Parkin, PINK1, DJ-1 are assoacited with AR forms of parkinsons dz (<50) and all promote the degradation of
misfolded proteins via the Ub-proteosome system.
Fabry is assoacited also with acroparesthesia which is episodic, often debilitating, burning neuropathic pain in
the extremities.
Downs, Pataus, Ataxia telangiectasia, Bloom syndrome, and Fanconi anemia are all at risk of acute leukemia.
85% of heme is produced by bone marrow erythroid cells for hemoglobin and the remaining 15% is syntheized
in the liver, primarily for the cyt p450 detoxification enzyme system. ALA synthase is an enzyme in the heme
biosynthesis pathway that functions to condense succinyl coA and lgycin to form delta-ALA (the RLS in the
heme synthesis pathway, requires B6). Administration of drugs such as phenobarbital, griseofulvin, phenytoin,
alcohol decrease hepatic concentration of heme by inducing the cytochrome P450 enzyme system.
Enzyme deficiencies in the early steps of porphyrin synthesis cause neurologic abnormalities without
photosensitivity, while derangements after condensation of prophobilinogen cause photosensitivity.
Glucose and IV heme preparations are good at decreasing ALA synthetase activity and abrogating acute
episodes of acute intermittent porphyria. Glucose loading decreases prophyrin synthesis by repressing ALA
synthase activity, thus alleviating the abdominal pain and neuropschiatric manifestations of acute intermittent
porphyria.
During prolonged starvation, the continuous supply of energy that ketone bodies provide is especially
important to brain functioning, because the brain has no glycogen or TG stores.
Ketone bodies are converted back into acetyl coA in the mitochondria of peripheral tissue. Since RBCs dont
have mitochondria, they cant use ketone bodies. The liver also cant utilize ketone bodies for energy because
it lacks the enzyme succinylCoA-acetoacetate coA transferase (thiophorase), which is required to convert
acetoacetate into acetoacetyle coA before 2 acetyl CoAs.
Galactose problems show up soon after breastfeeding is begun. Restrict lactose which is broken down into
glucose and galactose.
Lipoic acid is involved in the decarboxylation of alpha ketoacids and the transfer of alkyl groups. The transfer
of an alkyl group from pyruvate to coA is essential for the function of pyruvate dehydrogenase.
Alkaptonuria causes orchronosis blue/black pigmentation that is most evident in the ears, nose, and cheeks.
Antibodies to CCP are usually measured by ELISA using a mixture of cyclic citrullinated peptides as the
antigen.
Antiphospholipid antibodies are found in pts with SLE and antiphospholipid antibody syndrome.
Antiphospholipid antibody syndrome causes hypercoagulability, paradoxical PTT prolongation, and recurrent
miscarriages.
If a pt failes to produce ketones during fasting, likely due to impaired beta-oxidation. Impaired beta-oxidation
most commonly results from defects involving the first enzyme in the pathway, acyl-CoA dehydrogenase. In
prolonged starvation, pts with this enzyme deficiency cannot utilize fats for energy or produce ketone bodies.

Gluconeogenesis is thus impaired due to lack of energy while glucose consumption is markedly increased,
resulting in severe hypoglycemia.
Glycine is the smallest AA and it fits into the space when three alpha collagen chain come together to form
helix.
Neutrophils are the primary cell responsible for the intense inflammatory response in pts with gout due to the
phagocytosis of MSU crystals. Colchincine stops the chemotaxis of neutrophils.
Promoters: TATA is 25 nuc upstream. CAAT box is 70 nucleotides upstream.
Marfans syndrome is a defect in fibrillin, an extracellular glycoprotein that is abundant in the zonular fibers of
the lens, the periosteum, and the aortic media.
Pompe dz presents not with hypoglycemia, but with hepatomegaly and icnresed risk of cirrhosis (also
cardiomegaly, macroglossia, hypotonia, MR). Pathology shows abnormal accumulation in the lysosomes.
The 16S rRNA strand is the only piece of rRNA found in the prokaryotic 30S ribosomal subunit. This rRNA
within the 30S subunit expresses a sequence complementary to the Sine-Delgarno sequence in all prokaryotic
mRNA. The Shine-Delgarno sequence is located 10 bases upstream from the AUG start codon on prokaryotic
mRNA. These 2 complementary sequences allow the mRNA and the 30s ribosomal subunit to bind in
preparation for protein translation. Once the mRNA is bound to the 30S subunit, an initator tRNA binds to the
AUG start codon, the 50S ribosomal subunit joins the complex, and the protein synthesis begins.
B5 (CoA) is important in oxaloacetate to citrate and then succinyl-CoA, but also synthesis of vit A, D,
cholesterol, steroids, heme A, FAs, AAs, proteins. Deficiency of pantothenic acid is rare, though it has been
observed in severely malnourished people who complain of paresthesias and dysesthesias (burning feet
syndrome) and GI distress.
Splicing is performed by spliceosomes, which consist of snRNPs plus proteins. Synthesis of snRNP occurs in
the nucleus, catalyzed by RNA pol II.
Debranching enzyme deficiency can be differentiated from other glycogen storage dz by demonstrating the
accumulation of abnormally short outer dextrin-like structures in the cytosol of hepatocytes with an absence of
histopathological fatty infiltration of the liver.
TGs stored in adipose tissue is metabolized to free FAs and glycerol by hormone sensitive lipase. Glycerol is
then transported to the liver where it is phosphorylated to G3P via liver specific glyercol kinase. G3P is then
converted to DHAP. DHAP can then be used for glycolysis (ATP) or gluconeogenesis (glucose). Glycerol in the
liver can also be used for TG synthesis.
PolyA tail protects mRNA from degradation within the cytoplasm after it exits the nucleus.
Cholesterol and FA synthesis use NADPH as an electorn donor.
Examples of proteins that are able to bind DNA include transcription factors, steroids, thyroid proteins, vit D
receptors, retinoic acid receptors, DNA transcription and replication proteins, and others. N-myc can bind DNA.
C-myc is up in burkitt lymphoma.
Homobox genes typically code for DNA-binding transcription factors which alter the expression of genes
involved in morphogenesis.
The insulin receptor is a tetrameric structure consisting of 2 alpha and 2 beta subunits. The alpha subunits are
extracellular and they provide the binding site for insulin. The beta subunits are intracellular and contain
tyrosin kinase domains that are activated when insulin attaches to the alpha subunits. A series of downstream
signaling is then triggered, starting with the autophosphorylation of the IR. Then the IRS gets involved. TNFalpha is a proinflammatory cytokine that induces insulin resistance through the activation of serine kinases,
which then result in phosphorylation of the IRS-1 serine residues. This inhibits IRS tyrosine phosphorylation by
insulin. Posphorylation of serine residues in the beta subunit of the IR also hinders downstream signaling,
resulting in resistance to the normal actions of insulin. Catecholamines, glucocorticoids, and glucagon can also
induce insulin resistance by this same mechanism, and intracellular FFAs are suspected of increasing serine
kinase activity as well.
Transmembrane domain 7 alpha helical segments each containing 20 AAs with hydrophobic, nonpolar R
groups.
Nonpolar hydrophobic AA: valine, alanine, isoleucine, methionine, phenylalanine.

Cortisol is a cytoplasmic receptor that is bound to HSPs. When cortisol binds to the carboxyl terminal, the
HSPs liberate, the receptors dimerize, and go to the nucleus. They control gene expression by binding to tDNA
at the hromoen-responsive elements in the promoter region of target genes.
Cortisol increases PNMT.
If delta G is negative, Keq will be greater than 1, and the concentration of products at equilibrium will exceed
that of the substrates. If delta G is positive, Keq will be less than 1, and the formation of substrates will be
favored.
A Keq of 0 is not mathematically possible
A Keq of 1 would occur in a state where G is 0
A Keq of 1.5 would occur in a state where G is negative
Gluconeogenesis: alanine glucose which begins with the transamination of alanine to pyruvate
RER is the site of secretory, lysosomal, and integral membrane proteins.
ATP is generated from the TCA cycle via oxidative phosphorylation. ATP can also be generated by substrate
level phosphorylation, a process which involves the direct transfer of a phosphate group to ADP from a reactive
intermediate. Substrate level phosphorylation can occur in botht he cytoplasm and the mitochondrial matrix.
IN the citric acid cycl, GTP by succinyl coA synthetase during the conversion of succinyl coA to succinate.
Mitochondrial GTP can undergo transphosphorylation whereby GTP donates a high energy phosphate to ADP to
form ATP. IN gluconeogenesis, the hydrolysis of GTP is required for the phosphorylation and decarboxylation of
oxaloacetate to PEP by PEP carboxykinase.
AAs with 3 titratable protons: histidine, arginine, lysine, aspartic acid, glutamic acid, cysteine, tyrosine
Histidinemia exists: speech defects, psychomotor and retardation, emotional disturbance. Big in Japan. Lack of
histidase.
Fever, leukocytosis, hypotension, tachycardia shock
Lactic acidosis is an angion-gap metabolic acidosis that results from overproduction and/or impaired clearance
of lactic acid. In septic shock, impaired tissue oxygenation decreases oxidative phosphorylation, leading to the
shunting of pyruvate to lactate after glycolysis. Hence, there is an increase in lactic acid formation. Hepatic
hypoperfusion also contributes to buildup of lactic acid, as the liver is the primary site of lactate clearance.
Aspiration pneumonia: superior lower lobe or posterior upper lobe. Anaerobic cause this: peptostreptococcus,
bacteroides, fusobacterium, prevotella
Protons dissociate from AAs when the pH exceeds the pKa associated with each given proteon.
Fructose F6P via hexokinase. This is how ppl with essential fructosuria metbaolize dietary fructose
otherwise it is not active in most pts.
The alpha subunit of the inactivated G-protein is bound to GDP. Upon activation of the receptor, the alpha
subunit undergoes a conformation change and GDP is released. Subsequent binding of GTP then allows for the
dissociation of the alpha subunit from the remainder of the G protein complex. There are multiple subtypes of
alpha G proteins, each with different secdonary effects. Gs is cAMP then activates PKA. PKA phosphorylates
the serine tor threonine residues in some enzymes, leading to actiation or deactivation.
Diabeics get hyperosomolar hyperglycemia, a metabolic derangement often precipitated by infection.
Chaaracterized by dehydration, hyperglycemia, hyperosomoalrty without ketoacidosis.
Glucose into beta cell. Beta cell enters glycolysis. TCA cycle happens. ATP is made. High ATP;ADP ratios within
the beta cells results in the closure of KATP channel, which causes insulin secretion by opening the voltage
dependent calcium channels. GLucokinase is a major glucose sensor in the beta cell. This is a rate limiting
step in the beta cell. This is MODY.
Nuclear receptors; PPAR, FAs, retinoids, thyroid.
mtDNA has 22 tRNAs and 2 rRNAs
Herpsensitivity pneumitis low CD4:CD8; AIDS low CD4:CD8; sarcoidosis high CD4:CD8
Cyanide poisoning is bitter, almond breath.

Within the brain, astrocytes and neurons interact to regulate the metabolism of glutamate, glutamine, and
ammonia in a process known as the glutamate-glutamine cycle. Glutamate released by neurons during
neurtotranmission is taken up by astrocytes and converted to glutamine, a non-neuroactive compound.
Glutamine is then released by astrocytes and taken up by neurons, where it is either converted back to
glutamate for use as a NT or transaminated into a-KG for use in the Krebs cycle. Hyperammonemia in hepatic
encephalopathy results in depletion of a-KG, caushing inhibition of the Krebs cycle. Excess ammonia also
depletes glutamate, an excitatory NT, and causes accumulation of glutamine, resulting in astrocyte swelling
and dysfunction.
Calcium influx into endothelial cells causes eNOS activation and ultimately arginine NO and citrulline. The
NO then goes into the smooth muscle cells and activates guanylyl cyclase to make cGMP. This then casues
vasodilation by decreasing calcium levelsin the smooth muscle cytoplasm via PKG.
tRNA is the only RNA species that contains the nucleoside thymidine.
Leptin is produced by adipocytes, and large fat cells produce more leptin than small ones. Serum leptin
concentrations are highly correlated with body fat content. Leptin decreases food intake int eh following
important ways:
Leptin decreases the production of Neuropeptide Y, a potent apetite stimulatnt, in the arcuate nuc of
the hypothalamus
Leptin stimulates the produdciton of POMC in the arcuate nucleus. a-MSH is produced by cleavage of
POMC and inhibits food intake
Bacterial mRNA can be polycistronic, meaning that one mRNA codes for several proteins. An example is the
bacterial lac operon, which codes for proteins necessary for lactose metabolism by E. coli; the transcription
and translation of these bacterial proteins is regulated by a single promoter, operator, and set of regulatory
elements.
Clutluring E coli in lactose containing media results in the binding of lactose to the repressor protein. This
bidnign causes a conformational change which prevents the attachment of the repressor protein to the
operator region, which, in turn, increses transcription of the lac operon structural genes and, subsequently
increases utilization of lactose for energy. Culturing E. coli in glucose-containing media with or without lactose
represses the expression of the lac operon. Glucose decreses the activity of Adenylyl cyclase and leads to a
reduction of intracellular cAMP. Depletion of cAMP by the presence of glucose decreases the expression of the
lac operon structural genes. High cAMP levels activate a protein called catabolite activator protein (CAP),
which binds cAMP to form a cAMP-CAP complex which then binds to a region upstream from the promoter
region and acts as positive regulator of the lac operon.
Enteropeptidase is produced in the duodenum and cleaves tryspinogen to trypsin.
SOS activates RAS which then actiaves RAF to activate MAP Kinase kinase after GF ligand binds to an
autophosphorylating tyroskine kinase.
Telomeres add to 3 end of DNA
Syndromes of premature aging, such as Blood syndrome, are assoacited with shortened telomeres.
Bitots spots are seen in Vit A deficiency. They are abnormal squamous cell proliferation and keratinization of
the conjunctiva.
Leishmaniasis in histiocytes in Iraq, desert
Neurology
Trigem nerve arises from the lateral aspect of the mid-pons at the level of the middle cerebellar peduncle.
Infarcts of anterior pons: CST (contralateral hemiparesis and Babinski) and corticobulbar tract (CL facial palsy
and dysarthria). Can also cause CL dysmetria and dysdiadochokinesia, resulting ina syndreom known as
ataxic hemiparesis. These are CL cerebellar deficitis (cerebellar lesions are ipisilateral deficits)
Tumor adjacent to the falx cerebri and compressing the medial surface of the hemisphere. Typical meningioma
location. Commonly located in the parasagittal region, but can also be found adjacent to the lateral convexity
of the hemisphere, in the region of the sphenoid wing and olfactory groove (would present with HA and
anosmia).
Tinnitus and unilateral hearing loss = CPA angle tumor such as an acoustic neuroma.

Progressive neurologic dz with cystic degeneration of putamen = Wilsons. It is lateral to GP and internal
capsule.
Sciatica can result from herniations, spinal canal stenosis, irritation by bone spurs, and irritation by the
piriformis.
Posterior external auditory canal vagus nerve. The rest of the external auditory canal (including the external
portion of the tympanic membrane is the mandibular division fo the trigem; the inner portion fo the tympanic
membrane is the IX). Vasovagal syncope is parasympathetic outflow via the vagus nerve leads to decreased
heart rate and blood pressure.
Frontal cortex lesions defecits of higher brain function, altering patterns of spontaneity, creativity, sexual
interest, and social behavior.
Damage to the caudate nucleus is associated with transient hemiparesis as well as frontal lobe symptoms such
as inattentiveness, abulia, and forgetfulness. There may also be agitiation, psychosis, choreoathetosis, and
other dyskinesias.
Lacunar infarcts results from occlusion of the small penetrating arteries that supply these structures, most
commonly in the setting of chronic uncontrolled HTN or diabetes. Lipohyalinosis and microatheromas are
believed to be the primary causes of lacunar infarcts. Can have mural foam cells or fibrinoid necrosis.
An aneurysm arising from either the superior cerebellar or posterior cerebral artery can cause third nerve
palsy (non pupil sparing) unilateral HA, eye pain, diplopia, dilated nonreactive pupil, ptosis, with ipsilateral
eye in a down and out position.
VII chorda tympani branch of facial supplies taste to ant 2/3 of tongue.
Internal capsle gets blood from anterior choroidal artery.
Intraventicular hemorrhage is a common complication of prematurity that can lead to long term
neurodevelopmental impairment. It cocurs most frequently in infants born before 32 weeks or with <1500g.
Usually occurs within the first 5 postnatal days. IVH in a newborn can be clinically silent or present with an
altered level of consciousness, hypotonia, and decreased spontaneous movements. Sx of catastrophic
bleeding include bulging anterior fontanelle, hypotension, decerebrate posturing, tonic-clonic seizures,
irregular respirations and ocma. IVH in preterm infants usually originate form germinal matrix, a highly cellular
and vascularized layer in the subventricular zone from which neurons and glial cells migrate out during brain
development.
Hydrocephalus in early infancy presents with macrocephaly, irritability, poor feeding, muscle hypertonicity,
and hyperreflexia (caused by stretching of the periventricular pyramidal tracts UMN lesiosn).
CNVII and CNV can also be affected by schwannomas.
Hyperacusis of from paralysis of the stapedius CN VII. Ipsilateral hyperacusis is a common finding in Bells
palsy.
Chronic loss of upper extremity pain and temperature sensation, upper extremity weakness and hyporeflexia,
lower extremity weakness and hyperreflexia, and kyphoscoliosis = syringomelia.
3 important DA pathways:
Mesolimbic-mesocortical
o Regulates behavior schizophrenia
Nigrostriatal
o Coordination of voluntary movements parkinsons
Tuberoinfundibular
o Controls PRL secretion hyperprolactinemia
Myeres loop is pie in the ski.
Pseudotumor cerebri hydrocephalus a condition that classically occurs in overweight young females and is
related to decreased CSF outflow at the arachnoid villi. Elevated intracranial pressure with normal CSF content
and normal neuro imaging. Manifests as HA and papilledema. Optic nerve atrophy and blindness are the
concern.
Oxaloacetate forms aspartate while reacting with glutamate. This is transamination with B6 necessary.

The concept of a latent period can be applied to both dz pathogenesis and exposure to risk modifiers. The
initial steps in pathogenesis and/or exposure to a risk factor sometimes occur years before clinical
manifestations of a dz are evident. Additionally, exposure to risk modifiers may need to be continuous over a
certain period of time before influencing the outcome.
Ataxia telangeiectasia is an AR disorder resulting from a defect in DNA-repair genes. The DNA of these pts is
hypersensitive to ionizing radiation. Manifestations include cerebellar ataxia, oculocutaneous telangiectasias,
repeated sinopulmonary infections, and an increased incidence of malignancy.
A number of inherited disorders are caused by deficiency DNA-repair enzymes:
Ataxia telangiectasia is characterized by DNA HS to ionizing radiation
In xerdoerma pigemntosia, DNA is hypersensitive to UV radiation, causing premature skin agin and
increased risk of skin cancer (melanoma, sqcc)
Fanconi anemia is caused by HS of DNA to cross linking agents
Bloom syndrome is characterized by generalized chromosomal instability. Increased susceptibility to
neoplasms is present
HNPCC occurs due to a defect in DNA mismatch repair enzymes. It leads to increased susceptibility to
colon cancer.
Neisseria meningitidis is a common cause of bacterial meningitis. Espeically in the setting of college dorms. It
presents with high fever, chills, altered mentation, petechial skin rash from Neisseria induced small vessel
vasculitis (especially affecting the palms and soles), and ultimately septic shock. Tx with IV ceftriaxone for 2
weeks.
Bare lymphocyte syndrome is an immunodeficiency from a defect in expression of HLA class II antigens ont eh
surfaces of antigen presenting cells. MHC class II is needed to present foreign antigen to T cells to elicit a cell
mediated AND a humoral response (because T cells must first activate B cells to mature and undergo class
switching).
Paresthesias, weakness, dizziness, nausea and history of fish consumption strongly suggests food poisoning by
pufferfish. It has tetrodotoxin, a toxin produced by microorganisms assoacited with the fish. Tetrodotoxin
binds to voltage gated Na cahnnels in nerve and cardiac tissue, preventing Na influx and depolarization and AP
conduction. Symptoms of tetrodotoxin poisoning occur quickly after ingestion and include dizziness,
weakness, and loss of reflexes, paresthesias of the face and extremities, nausea, vomiting, diarrhea. Death
can occur form respiratory failure and hypotension.
Morphine tolerance is a common problem in the tx of pain. The exact mechanism of teoelrance is unknown but
may involve increased pshophoarylation of opiod receptors, increased adenylyl cyclase activity, or increased
NO levels. Activation of NMDA receptors by glutamate is believed to enhance morphine tolerance by
increasing phosphorylation or opioid receptors and increasing NO levels. NMDA receptor blockers, like
ketamine, block the actions of glutamate and effectively decrease morphine tolerance.
Morphine opens K channels, which allows efflux of K and hyperpolarization of the neuron terminating the pain
transmission.
MG or restrictive lung or chest wall dz would cause a normal diaphgram to fatigue rapidly.
The length constant (space constant) is a measure of how far alonga n axon an electrical impulse can
propagate. More specifically, the length constant is the distance at which the originating potential decreased
to 37% of its original amplitude. A decrease in the length constant can result form increased charge
dissipation along a nerve axon. One of the purposes of myelin is to reduce charge dissipation by increasing
membrane resistance, thus increasing the length constant. Demyelination will decrease the length constant
and result in impaired stimulus transmission. Myelination causes the length constant to increase and the time
constant to decrease both of which improve conduction speed.
The action potential results form changes in the membrane perm to K and Na ions. Depolarization results from
massive inclux of Na through voltage gated Na channels. Repolarization occurs due to closure of voltage
gagted Na channels and opening of voltage gated K channels. K ion permeance is highest during the
repoarlization of the AP.
Beta endorphin is one endogenous opioid peptide that is derived from POMC. POMC is a polypeptide that goes
through enzymatic cleavage and modification to produce not only beta-endorphines but also ACTH and MSH.
The fact that beta endorphins and ACTH are derived from the same precursor suggests a close physiologic
relationship between the stress axis and the opioid system.
Tetanoaspasmin travels upt he motor neuron axon by retrograde transport to the spinal cord and medulla. The
organism itself does not travel but rather remains at the local wound site.

Meningococcal sepsis may be associated with DIC and hemorrhagic destruction of the bilateral adrenal glands.
This constellation of findings is known as the waterhouse-friedrichson syndrome. N meningitis sepsis does
NOT necessarily include meningitis.
Tetanus vaccine is a toxoid. We start it 2 months after birth. [968]
Painful spasms with swallowing or inspiration are the reason for dysphagia in rabies.
Rabies travels retrograde to the DRG and then back to brain. It gets into the peripheral nerve axons by
binding to ACh receptors. At this point, post exposure prophylaxis is no longer effective.
Neisseria is in the nasopharynx.
Neisser meningitiidis gains access to the CNS by first colonizing the nasopharynx and subsequently invading
the mucosal epithelium and gaining access to the bloodstream. Through the blood, it spreads to the choroid
plexus, gains access to the CNS through the BBB and intiiates an inflammatory process.
Enteroviruses are the most common cause of aseptic meningitis.
Strep pneumo is the most common cuase of bacterial meningitis in adults of all ages. It often follows a
pulmonary infection or mild upper respiratory infection. Alcoholics, sickle cell pts, aslepnic individuals, and
those in generally poor health are at greater risk for S. pneumonia meningitis.
Staph is common cause of meningitis in neurosurgical pts.
Strep pneumo is leading cause of community acquired pneumonia, otitis media, and meningitis in adults.
Primary CNS lymphoma occurs in immunocomprosmised pts and is of B lymphocyte origin. Latent EBV
infection is strongly assoacited with AIDS related primary CNS lymphoma.
The three Ds of botulinum toxin: diplopia, dysphagia, dysphonia
Listeriosis occurs exclusively in immunocomrpoised pts. Eat contaminated food, then into bloodstream. Grows
in macrophages. Listeria can resemble corneybacterium but tumbiling motility is unique to listeria.
Cryptococcus:
Yeast only
Thick polysaccharide capsule (virulence factor)
Hydrocephalus, intracranial calcifications, and chorioretinitis are classic triad of toxoplasmosis.
Toxoplasmosis is acquired in utero it is transplacental.
Staph epidermidis is assoacited with foreign bodies (VP shunts included). It forms biofilms. It is an
excrecelluar polysaccharide matrix.
CSF culture showing growth on MacConkey agar implies CNS infection with enteric bacteria specifically, E.
Coli. E coli is a frequent cause of neonatal meningitis, second only to GBS. The capsule synthesized by some
E coli (K1 antigen) is a virulence factor that allows the bacteria to survive hematogenous spread and to
establish meningeal infection. Most strains of E. coli causing neonatal meningitis do possess this K1 antigen.
Most important mechanism of the development of diabetic neuropathy is non enzymatic glycosylation of
proteins leads to increased thickness, hyalinization, and narrowing of the walls of the arteries. These changes
lead to diabetic microangiopathy of endoneural arterioles. Ischemic nerve damage follows. Or intracellular
hypergcymia occurs in peripheral nerves. Accumulating glucose is converted into sorbitol and fructose by
aldose reductase. Sorbitol increases cell osmolarity and facilitates water influx into the cell. The result is
osmotic damage to axons and schwann cells.
Menieres dz is characterized by the triad of tinnitus, vertigo, and sensorineural hearing loss. Its pathogenesis
is related to an increased volume and pressure of endolymph in the vestibular apparatus.
Medullobalstoma symptoms: increased intracranial pressure (morning Has, vomiting, lethargy). Cerebellar
dysfunction occurs as the tumor compresses adjacent strucutrs.
Microglia move to the area of ischemic infarct in apporxiamtely 3-5 days after the onset of ischemia and
phagocytize the fragments of neurons, myelin, and necrotic debris. A cystic space replaces the necrosis, and
astrocytes form a glial scal along the peripheray.

Orientation
Comprehension
Concentration
Short term ememory
Long term memeory
Language
Visual spacial

Name location and current date

Following multistep commands
Reciting months of the year backwards
Recalling three unrelated words 5 minutes later
Providing the details of signgifiant life events
Writing a sensible sentence containing a noun and
verb
Drawing a clock face

Permanent memory loss and confabulation dont come back from Wernicke korsakoffs.
Tremulousness is commonly the first symptom of alcohol w/d. Other symptoms are GI distress, agitation,
anxiety, and other autonomic disturbances. Delerium tremens is the most severe manifestation of alcohol
withdrawal and typically begins between 2-3 days after the last drink.
Germinomas are the most common tumor of the pineal gland precocious puberty, aqueductal compression
leading to obstructive hydrocephalus, parinaud syndrome.
Oligoclonal bands of antibodies to the measles virus are found in the CSF of patients with SSPE. Antibodies to
the M component of the measles virus are absent.
Opsoclonus-myoclonus is a paraneoplastic syndrome associated with neuroblastoma. This tumor, associated
with increased number of copies of the N-myc gene, is the most common extracranial neoplasm in children. It
is non rhythmic conjugate eye movements assoacited with myoclonus.
The hippocampus is the area of the brain demonstrating the greatest degree of atrophy in Alzheimers dz.
Synaptophysin is a protein found in the presynaptic vesicles of neurons, neuroendocrine and neuroectodermal
cells. CNS tumors of neuronal origin frequently stain positively for synaptophysin on immunohistology.
Neoplasms of glial origin (astrocytomas, ependymomas, and oligodendrogliomas) stain for GFAP.
Loss of oligodendrocytes in MS.
Epidural between bone and dura.
Subdural between dura and arachnoid.
Subarachnoid between arachnoid and pia.
Tabes dorsalis get severe stabbing pains as well as loss of proprioception and vibration sense.
Paraneoplastic syndromes occur due to the tumor cells producing substances that frequently induce an
autoimmune rxn and cause damage and degeneration of healyhy organs and tissues. Neurologic
paraneoplastic syndromes such as paraneoplsatic cerebellar degeneration are AI.
Benzodiazepines;
Triazolam (alprazolam) short duration of action (<6 hr)
Lorazepam intermediate duration of action (6-24 hr)
Diazepam long duration of action (>24 hr)
Flurazepam long duration of action
Chlordiazepoxide long duration of action
A temporary course of benzodiazepines are sometimes used during SSRI intiation if thre is a significant
increase in anxiety-related problems, since it takes SSRIs 4 weeks to kick in.
Schizoaffective disorder:
Multiple psychotic episodes with concurrent major depressive or manic symptoms
>2 weeks of delusions of hallucination in absence of mood ysmptoms
Mood symptoms present for majority of total illness
Major depressive or bipolar disorder with psychotic features are psychotic symptoms occur exclusively during
mood episodes.
Differentiating schizoaffective disorder form bipolar disorder or major depression with psychotic features
requires determing the temporal relationship of psychotic sx to mood sx. In bipolar disorder and major
depression with psychotic features, the psychotic sx occur exclusively during manic or depressive episodes.
When the pts mood is euthymic, there are no psychotic symptoms. To dx schizoaffective disorder, psychosis
must occur in the absence of major episdoes, but mood symptoms have to be present for most of the illness.

Fantasy is an immature defense mechanism that substitutes an imaginary, less disturbing view of the world to
avoid awareness of painful feelings.
Conversion disorder refers to the unconscious manifestation of neurologic symptoms when pathophysiological
explanations for the sx cannot be found. It occurs more commonly in women and often occurs after a
significant life stress.
Massive aggression is a way of expressing aggression towards others by passively refusing to meet their
needs.
Opiod pain releivers are the most common OD death.
Avoidant personality disorder is a maladaptive pattern of behavior characterized by feelings of inadequacy,
timidity, and fear of rejection.
Serum sickness is a type III HS reaction characterized by deposition of circulating, complement fixing immune
complexes and resulting vasculitis. Associated findings include fever, urticarial, arthralgias,
glomerulonephritis, lymphadenopathy, and low serum C3 level 5-10 days after intravascular exposure to
antigen.
Body temperature over 40C is called hyperpyrexia and may lead to permanent brain damage if left untreated.
Emergent treatment of hyperpyrexia should consist of increased body heat loss (cooling) and decreasing the
hypothalamic set point (antipyretics). Facilitating body heat loss takes precedence because it is effective
immediately as opposed to antipyretics which take time, so put in cold blanket.
The most common cause of death in patients with TCA overdose are refractory hypotension and cardiac
arrhythmias. Inhibition of fast Na channels (anti muscarinic) in cardiac myocytes (and His-Purkinje system) is
thought to be the major underlying cellular event. Fluid resuscitation with normal saline and hypertonic
NaHCO3 administration are crucial in these pts.
Extrapyramidal symptoms assoacited with the antipsychotics are tremor and rigidity (look like parkinsons).
But odnt give DA agonists, instead give benztropine and amantadine.
Another extramyrapidal sign is inner restlessness and an inability to sit of stand in one position. Akathisia is
frequently misdiagnosed because the restlessness is misinterpreted as worsening psychotic agitation. The pts
antipsychotic dose is often increased rather than decreased, exacerbating the akathisia.
Methadone is good for heroin addicts because its long half life allows for prolonged effects to suppress
withdrawal symptoms in heroin dependent pts.
The arteriorvenous concentration gradient reflects the overall tissue solubility of an anesthetic. Anesthetics
with high tissue solubility are characterized by large arteriovenous concentration gradients and slower onset of
action. If an inhaled anesthetic has low peripheral tissue uptake/solubility, then it will have a rapid onset.
Potent anesthetics have low MACs. The AV concentration gradient influences the rate of induction, not
anesthetic potency.
Atypical depression: mood reactivity, leaden fatigue, rejection sensitivity, increased sleep and appetite. MAOis
are used in atypical depression.
Pralidoxime is the only medication that reverses both muscarinic and nicotinic effects of organophosphates by
restoring cholinesterase from its bond with these substances.
Antidepressants can induce mania in susceptible pts, especially those with unrecognized bipolar disorder. Pts
treated with antidepressants should be monitored for mood elevation and symptoms suggestive of mania that
require emergency treatment.
Primidone is metabolized to phenobarbital and phenylehtylmalonamide (PEMA). All 3 compounds are active
anticonvulsants.
GABAa and GABAc are ion channels while GABAb receptor is linked to a GPCR. Benzodiazepines, barbiturates,
and alcohol all bind to GABAa and facilitate the inhibitor action of GABA in the CNS.
Pts must wait 2 weeks after discontinuing MAOis before starting SSRI therapy allowing sufficient time for MAO
regeneration.
The most common side effect of diazepam is sedation so dont give it with other CNS depressants. Dont use
with alcohol, barbs, neuroleptics, or 1st generation antihistamines.

Dantrolene blocks ryanodine receptors and prevents release of Ca into the cytoplasm of skeletal muscle fibers.
Valproic acid is the drug of choice for myoclonic seizures. This drug suppresses abnormal electric activity in
the cortex by affecting GABA and NMDA receptors, as well as Na and K channels.
Naloxone mostly binds mu, so it is best for opioid intoxication. It is an antagonist.
TCAs have anticholinergic affects and will cause urinary retention.
COMPT inhibitors stop peripheral breakdown of L-DOPA and increase the L-DOPA reaching the brain.
Drugs that cause 5HT syndrome: antidepressants, tramadol, ondansetron, linezolid, triptans
5HT syndrome: hyperreflexia, myoclonus, clonus, rigidity; hyperthermia, tachycardia, diaphoresis, tremor;
agitation, confusion
Atropine is indicated for the treatment of rbadycardia as it decreases vagal influence on the SA and AV node.
A common side effect is increased intraocular pressure. It may precipitate acute closed-angle glaucoma in
susceptible individuals.
Vitamin B6 increases the pierphal metabolism of L-DOPA, which decreases its effectiveness.
People with MG that get an exacerbation get it for 2 reasons: myasthenic crisis in which they are undertreated
and they dont have enough ACh in the synaptic cleft to compete with the autoantibodies. IIn this case, give
edrophonium (tensilon test), which increases NM transmission and provides temporary improvement of
symptoms. They can also get exacerbation from a cholinergic crisis. This is if the pt has too high dose of
cholinesterase inhibitor and excessive ACh in the synaptic cleft. The increased ACh causes excessive
stimulation of the skeletal muscles and results in muscle refractory to future impulses. Cholinergic crises also
present with muscle weakness. Since the NMJ becomes insensitive to ACh, an infusion of edrophonium
produces no improvement.
Lorazepam and oxazepam are short acting benzodiazepines preferred in pts with advanced liver dysfunction.
Long acting benzos (chlordiazepoxide, diazepam) are generally preferred though to treat DT in alcohol w/d.
Tryptophan is a precuroser to 5HT so that is the AA responsible for 5HT syndrome.
Depressed pt with hyperreflexia and ankle clonus (with tremulesness, diarrhea, cramping too) = 5HT syndrome
A chronically progressive pre-senile dementia with cortical atrophy but no other radiological or laboratory
abnormalities permits a dx of Alzheimers.
Drugs with high blood/gas partition coefficients are most soluble in the blood, demonstate slower equilibrium
with the brain, and have longer onset times.
Clozapine agranulocytosis check blood regularly.
Nicotinic receptor Na into the cell (and Ca), K out of the cell
Lithium is exclusively excreted by the kidneys, with filtration and resorption in the PT following sodium
reabsorption. Renal injury, toxins and drugs that lead to increased PT absorption of Na (NSAIDs, thiazide
diuretics, ACE inhibitors) also increase Li levels and elevate the risk of Li toxicity. Hemodialysis is the most
effective way of acutely reducing the blood Li level.
Adding carbidopa can reduce most of the peripheral side effects of levodopa. However, behavioral changes
from levodopa can actually worsen with addition of carbidopa because more DA becomes available to the
brain.
The on-off phenomenon is an unpredictable and dose-independent characteristic of advanced Parkinson
disease there is no clear etiology of this phenomemom. ON the other hand, the wearing off phenomenon
of Parkinson disease is due to progressive destruction of straitoniagral DA neurons over a period of time. The
on off phenomenon is not temporary and will not self resolve spontaneously.
Massive hepatic necrosis is a rare but severe complication of halothane exposure. It occurs due to direct liver
injury by halothane metabolites and formation of autoantibodies against liver proteins. Light microscopy
shows massive centrilobular hepatic necrosis.
Cholinergics bind muscarinics and endothelial cells and cause vasodilation.

Hematology/Oncology
Valine non polar
Glutamic acid charged
Sickling occurs under conditions of anoxia, including low pH and high 2,3 DPG.
Signal
-

transduction systems:
MAP-kinase pathway
PI3K/Akt (PKB)/mTOR pathway
Inositol phospholipid pathway
cAMP pathway
JAK/STAT pathway

High oxygen affinity hemoglobins have a decreased P50 that is represented by a leftward shift of the oxygendissociation curve. High oxygen affinity hemoglobins have reduced ability to release oxygen within the
peripheral tissues, leading to renal hypoxia, increased EPO synthesis, and compensatory erythrocytosis.
Folate deficiency inhibits the formation of dTMP, which limits DNA synthesis and promotes megaloblastosis and
erythroid precuroser cell apoptosis. Because thymidine supplementation can moderately increase dTMP
levels, it can reduce erythroid precursor cell apoptosis.
The conversion of 1,3 bPG to 2,3 BPG is increased in hypoxia and crhonic anemia. It helps RBCs deliver oxygen
to tissues. It is bade from 1,3 bisphosphoglycerate (BPG) via bisphosophoglycerate mutase.
Heme in the liver is synethesized for CYP use, while heme in the bone marrow is generated for hemoglobin
use.
Phenobarbitol, griseofulvin, phenytoin all can lead to acute porphyria.
Leftward shift of hemoglobin dissociation curve means that oxygen is less available to tissues.
Pyruvate kinase deficiency causes hemolytic anemia due to failure of glycolysis and resultant failure to
generate sufficient ATP to maintain erythrocyte structure. (Pyruvate kinase is a step in glycolysis that makes
ATP). In this case, splenic hypertrophy results form increased work of splenic parenchyma, which must remove
these deformed erythrocytes from the circulation.
The Kozak consensus sequence plays a role in the initiation of translation. A mutation 3 bases upstream from
the start codon (AUG) in this sequence is associated with thalassemia intermedia. Thalamssemia intermedia
results in hypochromic, microcytic anemia.
Heme oxygenase converts heme to biliverdin, a greenish pigment that cuases the greenish color to develop in
hematomas several days after an injury. Lysis of erythrocytes in hematomas causes release of hemoglobin
intot he soft tissue, and the heme molecule is ultaimtely degraded to bilirubin.
To see hemoglobin type, use electrophoresis.
JAK2 mutations in chornic myeloproliferative disorders is a constitutively active form, and consequently,
cytokine independent activation of STAT transcription factors.
If a hemoglobin molecule is dissociated, the individual subunits will have a hyperbolic oxygen-dissociation
curve.
Methhemoglobinemia cuases dusky discoloration to the skin (similar to cyanosis), and because methemoglobin
is unable to carry oxygen, a state of functional anemia is induced.
The blood partial pressure of O2 is a measure of O2 dissolved in the plasma and is not realted to hemoglobin
function. In CO poisoning, anemia (low Hb) or Polycythemia (high Hb) PO2 is always normal. However,
percent saturation is worse in CO posinoing and O2 ceontent is decreased in both CO posinoing and anemia
with low Hb.
Nitrites induce methemoglobinemia.
Nitrites are oxidizing agetns that are effective in the treatment of cyanide poisoning due to their ability to
cause methemoglobinemia. Methemoglobinemia contains ferric rather than ferrous iron. Cyanide binds to

ferric iron more avidly than to mitochondrial cytochrome enzymes, which saves these mitochondrial enzymes
from cyanides toxic effects.
In the lungs, the binding of oxygen to hemoglobin drives the release of H and CO2 from hemoglobin (Haldane
effect). In the peripheral tissues, high concentrations of CO2 and H facilitate oxygen unloading from
hemoglobin (bohr effect). [1386]
Dysphagia and spoon nails are specific for iron deficiency anemia.
Liver takes up unconjugated bilirubin through a passive organic anion transporting polypeptide (OATP). It
secretes direct (conjugated) conjugated bilirubin into the biliary system through active transport form an ABC
protein known as MRP2 (an organic anion transporter). If you block MRP2 you will get an isolated conjugated
hyperbilirubinemia. The conjugated bilirubin is water soluble and will then be excreted in urine. [1457]
Tumor lysis syndrome can develop during chemotherapy for cancers with rapid cell turnover (poorly
differentiated lymphomas and leukemias), substantial tumor burden, or high sensitivity to chemotherapy. It is
characterized by hyperphosphatemia, hypocalcemia, hyperkalemia, and hyperuricemia. Prevention of tumor
lysis syndrome involves hydration and the use of hypouricemic agents such as allopurinol or rasburicase.
CO binds to hemoglobin with much higher affinity than O2, thus preventing oxygen binding to hemoglobin. It
also reduces oxygen unloading from hemoglobin in the tissues. CO poisoning does not affect the PaO2 and
does not precipitate methemoglobiemia.
AML M2 is t(8;21)
M3 acute promyelocytic leukemia
Pol gene mutations are responsible for acquired resistance to HIV reverse transcriptase inhibitors and HIV
protease inhibitors.
Env gene mutations enable espae from host neutralizing antibodies.
The 15;17 translocation in AML M3 is the PML/RARalpha retinoic acid fusion gene.
Hepcidin is an acute phase reactant synthesized in the liver hepatocytes. It binds ferroportin, causing it to be
internalized and degraded. This decreases absoalteral iron transport in the intestine and also inhibits the
release of iron by macrophages. High iron levels and inflammatory conditions increase the synthesis of
hepcidin, while diminished iron levels and hypoxia decrease hepcidin levels.
Yeasts and pseudohyphae and a positive germ tube test are diagnostic of candida infection.
Parvovirus is highly tropic for erythroid precursor cells and replicates in the bone marrow.
Heparin and drugs that directly inhibit thrombin formation can prolong Thrombin Time (TT).
CD4 and HIV gp120; CD21 and EBV gp350; erythrocyte P antigen and parvovirus B19.
Type O mothers have antibodies that are predominately IgG and can cross the pplacenta A and B are IGM
Neutropenia with ticlopidine presents with fever and mouth ulcers. You should monitor CBC for 3 months on
ticlopidine.
Preventing intracellular dehydration is a treatment modality for sickle cell anemia using Gardos channel
blockers. The calcium-dependent (Gardos) K-channel regulates the transport of K and water throught he red
blood cell membrane when blocked, K and water efflux is reduced, preventing dehydration of erythrocytes
and reducing the polymerization of HbS.
TNFa is shown to induce cachexia. It induces paraneoplastic cachexia by suppressing appetite, inhibiting
lipoprotein lipase and increase insulin resistance of peripheral tissues.
Radiation = double stranded DNA breaks and free oxygen radical damage
Anaplastic tumors are composed of pleomorphic cells with large, hyperchromatic nuclei that grow in a
disorganized fashion. Anaplastic tumors may also contain numerous, abnormal mitoses and giant tumor cells.
The human multidrug resistance (MDR1) gene codes for P-glycoprotein, a transmembrane ATP-dependent
efflux pump protein that has a broad specificity for hydrophobic compounds. This protein can both reduce the

influx of drugs into the cytosol and can increase efflux from the cytosol, thereby preventing the action of
chemotherapeutic agents.
N5-fomryl-tetrahydrogolate = folinic acid, leucovorin (can overcome MTX with these)
Tumor invasiveness is the biggest prognostic factor in bladder cancer. This is stage. Tumor penetration of the
wall is the major determinant of prognosis. This is true for colon cancer too.
The laminin in basement membranes may post a physical barrier to the sproudting of new BVs in angiogenesis
in neoplastic and granulation tissue induced by VEGF and FGF.
The CYPs make the free radicals of carbon tetrachloride.
Metalloproteases are zinc containing enzymes.
A cerebellar tumor iina child is most likely a pilocytic astrocytoma or a medulloblastoma. These 2 tumors can
be differenetiated on brain imaging. Pilocytic astrocytomas have both cystic and solid components, while
medulloblastomas are always solid.
High grade tumors display cellular and ncuelar pleomorphism (variations in shape and size) and a high number
of mitoses.
Staging/grading by brain tumors is challenging because size doesnt matter much if its in a bad location, it
doesnt met, and grading doesnt work well. We use uptake of bromodeoxyuridine as a measure. It is a
thymidine analog. Nucleotide uptake is therefore high in the S phase of the cell cycle. High uptake suggests
large numbers of cells in S phase and then high grade and poor prognosis.
Gastric cancer rates drop cimilar to lung cancer rates in women rise.
ARP (attributable risk percent) is ARP = (RR-1)/RR
ID: 1284
HER2/neu is a 185 kD transmembrane glycoprotein that has intracellular tyrosine kinase activity aand is a
member of the family of epidermal growth factor receptors. Overexpression of this protein is associated with
increased rates of breast and ovarian cancer.
Benign lymph node enlargement in response to antigenic stimulation is assoacited with a polyclonal
proliferation of lymphocytes. A monoclonal lymphocytic proliferation is strong evidence of malignancy.
Peau in peau dorange means pitting. So if you see pitting, think lymphatic obstruction.
Integrin mediated adhesion of cells to basement membrane and the ECM involves the binding of integrins to
fibronectin, laminin, and collagen.
Most chemical carcinogens enter the body in an inactive state (pro-carcinogens). These pro carcinogens are
converted into active metabolites by the cytochrome P450 oxidase system. Individual susceptibility to
chemical carcinogens depends on the activity of these CYP enzymes, which is genetically determined.
Cyclin D; CDK 4
Cyclin E; CDK 6
Acrolein is the toxic metabolite that causes hemorrhagic cystitis with cyclophosphamide.
In a vit B12 def pt, once you add B12, the rate of effective erythropoiesis increases immediately and immature
erythrocyts are released from the bone marrow into the bloodstream. They peak around 1 week after therapy.
Patients with chronic hemolytic anemia are predisposed to folic acid deficiency and macrocytic changes due to
increased erythrocyte turnover. This is seen in SS dz and others.
Auer rods stain for peroxidase.
Pure RBC aplasia is a rare form of marrow failure characterized by severe hypoplasia of marrow erythroid
elements in the setting of normal granulopoiesis and thrombopoiesis. Pure RBC aplasia is assoacited with
thymoma, lymphocytic leukemias, and parvo B19 virus.

The schilling test helps to differeneitate between dietary deficiency of B12, pernicious anemia, and
malabsorption syndromes. Low absorption of cobalamin not correctable by intrinsic factor is indicative of a
malabsorption syndrome such as ileal dz, pancreatic insufficiency, or bacterial overgrowth.
G6PD defieicny exacerbation: dark urine, anemia, high reticulocyte count
Dx of AML requires >20% myeloblasts.
Blast cells in the peripheral blood are strongly suggestive of leukemia. ALL is the most common malignancy in
childhood. T cell ALL is less common (20% of all ALL) and presents as a medistinal mass that can cause
respiratory symptoms, dysphagia, or SVC syndrome.
Sickle trait patients usually have normal peripheral smears and indices, reticulate counts, and MCHC values.
Sickle cell trait RBCs will sickle when SODIUM METABISULFITE is added.
HUS presents in young children as acute renal failure, microangiopathic hemolytic anemia, and
thrombocytopenia. Characteristic laboratory abnormalities include decreased RBC count, hematocrit and
platelet count and increased bleed time, LDH, and BUN and Cr.
Pigmented gallstones are a complication of any hemolytic anemia, including hereditary spherocytosis.
Pt with hypochromic, microcytic anemia is most commonly due to iron deficiency. Blood loss (especially in the
GI tract) must be ruled out in a pt with iron-defieincy anemia.
To distinguish between aplastic anemia and myeolorpoliferative dz that can cause pancytopenia, bone marrow
bx is required.
Pancytopenia in SLE is AI type II HS (ABs against blood cells).
Abnormal bleeding in pts with uremia (kidney failure and on dialysis) is due to a qualitative disorder with
normal platelet count, PT, and PTT. Only the bleeding time is prolonged.
Steroid use increases RBC production.
TTP occurs in adults with predominant neurologic symptoms; HUS in children with renal invovelemnt.
A pt with signs of renal failure and toe gangrene or livedo reticularis following an invasive vascular procedure
likely has atheroembolic renal dz. Light microscopy shows cholesterol emboli obstructing renal arterioles.
Polycythemia vera presentation (ID: 8591): frequent headaches, weakness, dizziness, excessive sweating.
Plethora and ruddiness of the face and moderate splenomegaly. High crit and Hb.
Total iron binding capacity (TIBC) reflects increased serum transferrin.
ID: 1109
Increased bone marrow erythropoiesis (following iron replacement in an iron deficiency anemia) results in an
accelerated release of immature RBCs (reticulocytes) into the blood. Reticulocytes contain bluish cytoplasm
and reticular precipitates of residual rRNA.
Factor VIII is synthesized by the liver and stored in endothelial cells. Desmopressin acetate is a synthetic
vasopressin analog that released vW factor and factor VIII from the endothelium. It is used to treat mild to
moderate hemophilia A.

Respiratory
Umbilical vein ductus venosus IVC

Phosphatdiylcholine (Lecithin) and phosphotidylglycerol are major constituents of surfactant. Sphingomyelin

stays about constant os the L:S ratio at the end should be 2:1.
In the respiratory tract, the nose, paranasal sinuses, nasopharynx, and tracheobronchial tree are lined with
pseudostratified columnar, mucus-secreting epithelium. Stratified squamous epithelium is found only in the
oropharynx, laryngopharynx, anterior epiglottis, upper half of the posterior epiglottis, and vocal folds (true
cords).
Elastase is a neutral protease contained in macrophage lysosomes and in the large, azurphil granules of
neutrophils. Normally, elastase release from infiltrating neutrophils and macrophages is balanced by the
antielastase activity of serum A1AT. Excess elastase activity in lung acini is thought to be a major factor in the
development of centriacinar and panacinar emphysema.
The apex of each lung extends into the neck approximately 3-4 cm above the first rib.
The apex of the heart lies behind the 5th left intercostal space at the left midclavicular line (LV). The
steroncostal (anterior) surface of the heart is formed by the RV. The diaphagmantic (inferior) surface is formed
by the left and right ventricles, and is in contact with the central tendon of the diaphgram. The posterior
surface of the ehart is formed mainly by the LA.
The RA makes up the majority of the right border of the heart on PA chest films. The RV forms the anterior wall
of the heart and is best seen on lateral CXR. The SVC and IVC compose the superior and inferior borders of the
cardiac silhouette on the right side.
Lower border of the
pleura
Right
Left
*Lower border of lung is 2

Midclavicular line

Midaxillary line

7th rib
Upper border of 10th rib
th
7 rib
Lower border of 10th rib
spaces above the end of the pleura

Paravertebral line
12th rib
12th rib

The process of bicarb diffusing out of a RBC and chloride diffusing in to maintain electroneutrality is called
chloride shift. It is the reason why high RBC chloride content in venous blood.
Hypoxic vasoconstriction increase arteriolar resistance increases as the blood oxygen decreases occurs in
the pulmonary circulation so that blood flow is diverted away from underventilated regions of the lung and
towards more well-ventilated areas.
Eosinophils release major basic protein, a protent anti-helminthic toxin capable of causing damage to epithelial
and endothelial cells.
Delayed type hypersensitivity reactions are Th1 lymphocytes that release IFN-g to cause recruitment and
stimulation of macrophages. Type IV HS reactions take days to reach their peak activity; this is in contrast to
the other HS reactions, which cause clinical effects within minutes of antigen exposure.
Cheyne stokes respiration describes cyclic breathing in which apnea is followed by gradually increasing tidal
volumes and then gradually decreasing tidal volumes untilt he next apneic period. It is commonly seen in
advanced heart failure.
Kussmaul breathing is in DKA
Aspergillus does not invade lung tissue, but grows inside the cavity forming a fungus ball or aspergilloma.
This condition may be asymptomatic or it may cause hemoptysis. It will appear as a radiopaque structure that
shifts when the pt changes position.
The center of the airway pressure volume curve is the FRC of the lungs; it identifies the resting state where the
airway pressure equals zero. At the FRC, the intrapleural pressure is -5 cm H20. It gets to -7.5 in inspiration.
Medium sized bronchi are responsible for the most airway resistance, terminal bronchioles is the least.
The tissue destruction caused yb MTB infection is the direct result of host immune activation and inflammation
through a type IV HS reaction. The characteristic pathologic lesion consists of granulomatous ifnlmmation and
caseous necrosis.
Mycolic acid is a long branched chain saturated FA used in the mycobacterial cell wall and in the formation of
virulence factors. It is responsible for the acid fast-ness of MTB. INH inhibits mycolic acid synthesis.

Dust particles smaller than 2 microns in size reach the alveoli. They are taken up by macrophages and
sitmulate CT growth. The pneumoconiosis are diseases that result from the inhalation of fine dust particles.
Rifampin is used as monotherapy prophylaxis for HiB and N. meningitidis it is used in combination therapy for
MTB and leprosy.
Cromolyn and nedocromil are mast cell stbalizing agents.
Sweat is initially isotonic. Then CFTR helps reabsorb Cl (and Na follows), so that at the end, sweat is
hypotonic. With excessive Na loss, CF pts can get hypovolemia and intravascular volume contraction if they
sweat too muchc.
Restrictive lung dz has increased expiratory flow rates due to decreased lung compliance (increased elastic
recoil) and increased radial traction exerted on the conducting airways by the fibrotic lung.
Chronic rejection is a major problem in lung transplant recipients. It affects small airways, causing bronchiolitis
obliterans. Lymphocytic inflammation, necrosis, and fibrosis of the bronchiolar wall occur. Ultimately, there is
occlusion fo the bronchiolar lumen.
Eosinophils are recruited and activated yb IL-5 secreted by Th2 helper T cells in asthma.
Peptidoglycan cell wall protects form osmotic forces. If a gram + bug treated with an antibiotic is then placed
in a hypotonic solution and lyses, you know the peptidoglycan cell wall must have been disrupted byt eh ABX
so that the osmotic forces destroyed the bacteria.
HIV+ women should be given zidovudine (AZT, ZDV) during pregnancy and then IV at brith and then the baby
should get it for 6 months post-brith as well.
The work done against the elastic resistance of the lung is increased when tidal volume is increased, while the
workd one aginst airflow resistance is increased when the breathing frequency is increased. If the 2
components are summated and the total work is plotted against respiratory frequency, there will be an optimal
breathing rate at which the total work of breathing is minimized. For the normal adult, this is 15 breaths per
minutes. For pts with stiff lungs (increased elastic resistance), the work of breathing is minimized when the
respiratory rate is high and the tidal volume is low. Therefore, rapid and shallow breaths are facored in
diseases that increase elastic resistance (pulmonary fibrosis, pulmonary edema, ARDS). IN contrast, dz that
cause high airlow resistance (asthma, COPD), pts breathe at a lower rate (slow, deep rbeaths) in order to
mimize the work of breathing.
Mycoplasma pneumonia is the causative agent of walking pneumonia and many cases of tracheobronchitis. It
is an organism with no peptidoglycan cell wall; it only has a phospholipid bilayer cell membrane. It shares
antigens with human erythrocytes, and when the body mounts a response against these antigens, it also lyses
red blood cells leading to anemia. The ABs cauisn this RBC destruction re referred to as cold agglutinins. After
the immune system is not longer activated (when the bacteria is cleared) the concentration of the antibodies
decreases and the anemia resolves spontaneously. M pneumo also causes SJS and joint poins.
Legionella shows neutrophils but no organisms. Think legionella of pneumonia, fever, and GI symptoms
(maybe confusion and CNS too). Factulative intracellular gram negative bacilli that can cause a systemic
infection. Symptoms frequently include high fever, cough, confusion, and diarrhea. The most common
laboratory abnormality is hyponatremia, and sputum gram stain shows many neutrophils but few or no
organisms.
The MTB are phagocytosed by alveolar macrophages (the small ones that make it down there) and the
sulfatide virulence factor expressed by MTB allows for intracellular bacterial proliferation. Continued
proliferation eventually kilsl the macrophage and causes cellular lysis, allowing MTB to be phagocytozied by
and infect additional macrophages. Virulence factors expressed by the MTB promote the recruitment of
additional native, inactivated macrophages and also undermine the immunologic intracellular signaling
between antigen present cells and helper T cells. Eventually antigen carrying macrophages or dendritic cells
migrate to the lymph nodes and induce a helper T cell response. This occurs 2-4 weeks following initial
infection.
An obstructive lesion in a maintstem bronchus can prevent ventilation of an entire lung, leading to lung
collapse. Characteristic findings on CXR include unilateral pulmonary opacification and deviation of the
mediastinum toward the opacified lung. (2116).
Mycoplasma lack peptidoglycan cell walls and are resistant thereafore, to agents that attack the peptidoglycan
cell wall such as penicllins, cephalosporins, carabpenems, and vancomycin. Mycoplasma infections can be
treated with antiribosomal agents like tetracycline and erythromycin.

Dimorphic fungi: sporothrix, coccidio, histo, blasto, paracoccidio

SaO2<92% (PaO2<65) can cause secondary polycythemia.
pCO2 is the most potent cerebral vasodilator. It decreases cerebral vascular resistance leading to increased
cerebral perfusion and increase ICP. Pts with COPD usually have a low PO2 (hypoxia) and high PCO2
(hypercapnea). Thus, their cerebral circulation is most likely to be increased.
PaCO2 is the major stimulator of respiration in healhy people. Even a lsight increase in PaCO2 results in
increased pulmonary ventilation. In prolonged hypercapnea, hwoever, high PaCO2 ceases to sitmulate the
respiratory drive. In such pts, respiration is stimulated by hypoxia (low PaO2) sensed by peripheral
chemoreceptors. Rapid increases in the fraction of inspired oxygen may lead to respiratory failure in these pts.
Central cehmoreceptors in the medulla are indirectly sensitive to changes in PaCo2 and direcyl sensitive to
changes in pH. These receptors are not sensitive to PaO2.
Nocardia is also catalase positive.
Post op = PE (not sedative for pain).
The most common side effect of inhaled glucocorticoids is oropharyngeal candidiasis. Use a spacer and learn
to rinse the mouth.
Echinocandins are a newer group of antifungal mediations that inhibit synthesis of the polysaccharide glucan,
an essential component of the fungal cell wall.
Lobar pneumonia is in 4 stage:
Congestion (day 1)
o Red, heavy and boggy lobe
o Vascular dilatation, alveolar exudate contains mostly bacteria
Red hepatization (day 2-3)
o Red, firm lobe (liver like consistency)
o Alveolar exudate contains erythrocytes, neutrophils, and fibrin
Gray hepatization (day 4-6)
o Gray brown firm lobe
o RBCs disintegrate, alveolar exudate contains neturophils and fibrin
Resolution
o Enzymatic digestion of the exudate
The normal PAO2 is 104. Incoming systemic venous blood as a PO2 of 40. Blood PO2 nromally reaches the
PAO2 by the time it passes through the first third of the alveolar capillaries due to high rate of O2 diffusion
through the respiratory membrane. PaO2 below 80 is called hypoxemia. Then you have to look at the A-a
gradient to see the reason. Normal A-a gradient will be: high altitude (low air O2) or hypoventilation. High A-a
gradient will be: V/Q mismatch, R to L shunt, Diffusion barrier (fibrosis).
Pulmonary alveolar proteinosis present with gradual worsening of dyspnea and productive cough. On histologic
examination there is bilateral patchy pulmonary opacification due to intraalveolar accumulation of amorphous
protein and phospholipid material (constituents of surfactant).
MC benign lung tumor is a hamartoma.
Influenza vaccine is thought to prevent serious cases of the flu by increasing the host circulating antibodies
against the hemagglutinin of the selected viral strains. Upon subsequent exposure to live virus, these ABs
interfere with the bidnign fo the HA to the sialic acid conitaining oligosaccharides of hose cell plasma
membrane glycoprotein receptors. The live virus is prevented from entering cells via receptor mediated
endocytosis.
The azoles (not just ketoconazole) inhibit the CYPs.
Varenciline is a partial agonist of nicotinic ACh receptors. It can assist pts with cessation of tobacco use by
reducing withdrawal cravings and attenuating the rewarding effects of nicotine.
An accentuated pulmonary component of the second heart sound suggests an increase in pulmonary artery
pressure and PAH, in turn, causes cor pulmonale and symptoms of right heart failure (dyspnea on exertion, LE
edema, HSM).
Bronchoalviolar carincoma is a subtype of lung adenocarcinoma. This uncommon tumor occurs in nonsmokers
and arises form alveolar epithelium. It is located in the peripheral parts of the lung and is often multifocal. On

microscopic examination it is composed of tall, columnar cells that line the alveolar septa without evidence of
vascular or stromal invasion.
Neuroendocrine cancers are positive for neuroendocrine markers such as neuron specific enolase,
chromogranin, and synaptophysin. This is small cell carcinoma and bronchial carcinoid.
In noncardiogenic pulmonary edema (ARDS), the pulmonary capillary wedge pressure is normal.
Nontypable strains of H. influenza are strains of H. influenza that do not form an antiphagocytic capsule. They
are part of the normal flora of the upper respiratory tract, but can cause otitis media, sinusitis, and bronchitis.
Immunity to nontypable strains, as well as capsular strains other than type B, is not conffered by vaccination
with the Hib vaccine.
Panic attacks are assoacited with hyperventilation and decreased PCO2. Hypocapnia causes cerebral
vasocontrsitction and decreased cerebral blood flow.
Pyraziniamide is not active against extracellular MTB because it needs the acid in the macrophage
phagolysosome.
COPD can cause hypoxia sufficient to stimulate increased EPO production by the cortical cells of the kidney.
Metabolic alkalosis is most commonly caused yb vomiting, NG suction, diuretic use, hyperaldosteronism.
Measuring the urinary chloride concentration and determining the pts volume status helps to identify the
cause of metabolic alkalosis.
Lung apex = superior sulcus.
The three cytokines IL1, IL-6, TNF alpha (and IFNgamma according to FA) mediate systemic inflammatory
response and stimulate hepatic secretion of acute-phase proteins (fibrinogen).
At high altitude, PaO2 declines to 60.
Mast cells release histamine and tryptase. Tryptase is specific to mast cells and is used as a marker.
ID: 1620
Cord factor is 2 mycolic acid molecules bound to the disaccharide trehalose. It is a mycoside.
Tissue damage and resultant abscess formation is primarily caused by lysosomal enzyme release from
neutrophils and macrophages.
The pathogens most often responsible for secondary bacterial pneumonia are: S. pneumo, S. aureus, and H. flu
The green discoloration of pus or sputum noted during bacterial ifnections is associated with the release of
MPO from neutrophil azuophilic granules. MPO is a heme containing pigmented molecule.
The presence of fluid in the pulmonary interstitium decreases lung compliance. (like in CHF leading pulmonary
edema).
In a pt with ARDS, the pulmonary capillary wedge pressure is normal. They have a decrease in lung
compliance, an increase in the work of breathing, and a worsened V/Q mismatch.
Give good hydration with acyclovir to prevent crystalline nephropathy.
Acid excretion in urine occurs in the form of free hydrogen ions and titratable acids (NH4 or H2PO4). During
metabolic acidosis, excretion of free H+ and titratable acids increases, excretion of bicarb decreases, and
urinary pH decreases. In diabetic ketoacidosis, there will be high H2PO4 to buffer the acid.
Concurrent use with NSAIDs and furosemide decrease furosemide diuretic action because it also indeces PGs
which helps with blood flow and drug delivery to the kidney.
Salicylates 4-5 hours after ingestion is not acute any longer, so no respiratory alkalosis. Now it goes into the
metabolic acidosis. It may be mixed.
Every time GFR halves, serum Cr doubles. It is an exponential looking curve.

The late distal and cortical collecting tubules are the primary sites for regulation of K concentration in the
urine. K depletion stimulates alpha interacalated cells to reabsorb extra K; principal cells secrete K under
conditions of normal or increased K load.
55% of urea is normally absorbed.
11th and 12th ribs are floating ribs. The distal tip of the 12th rib can be displaced into the retroperitoneum when
fractured, lacterating the left kidney.
Minimal change is a selective proteinuria you just lose albumin and transferrin (the low molecular weight)
proteins.
Metbaolic acidosis is normally partially compensated for by a respiratoyr alkalsosis. When the steady state
PaCO2 persists above the range given by winters formula, the patient has superimposed degree of respiratory
acidosis and failure. (1979)
Vasopressin produces a V2 receptor mediated increase in permability to water and urea at the luminal
membrane of the inner medullary collecting duct. The increase in urea reabsorption corresponds to a decrease
in the frational excretion of urea and a decrease in renal clearance of urea from plasma.
NSAID assoacited chornic renal injury is morphologically characterized by papillary necrosis and chronic
interstitial nephritis. Glomerular and vascular abnormalities, if present, are usually mild or may be seen only in
advanced stages. NSAIDs-assoacited nephropathy is common, especially in patients suffering from chronic
pain.
Spironolactone reduces mortaility in heart failure pts. Possibly from decreased ventricular remodeling.
Digoxin is renally excreted and must be reduced dosage in the elderly.
Anti GBM antibodies react with the alpha3 chain of collagen type IV, found in the glomerular BM. This is
goodpasture syndrome.
Severe hypokalemia and hypomagnesemia are commonly seen during therapy with amphoterrible B. This is
from nephrotoxicity. Decreases GFR and direct toxic effects on the tubular epithelium. Also increased
membrane permeability.
Consider MM when an elderly pt present with the following findings:
Easy fatigability
Constipation (due to hypercalcemia)
Bone pain most commonly in the back and ribs
Renal failure
Bence jones proteins are filtered by the glomerulus in small amounts and then are reabsorbed in the tubules.
When levels exceed the reabsorptive capacity of the tubules, these light chains precipitate with Tamm Horsfall
protein and form eosinophilic casts. These casts impede renal function (obstruct lumens, compress
epithelium). They also cause atrophy.
Renal vein thrombosis is a complication of nephrotic syndrome and presents with flank pain, hematuria, and
left sided varicoclele.
Murobonab (OKT3) is an Anti-CD3 anitbody that inhibits T lymphocytes, which is useful in the treatment of
acute rejection in pts with kidney, heart, and liver transplants.
The filtration of PAH is not a process that can be saturated. At any given blood concentration, a constant
portion of PAH will be filtered from the glomerular capillaries into BS. Secretion of PAH is a carrier enzyme
mediated process and therefore is able to be saturated. As the blood concentration of PAH increases, the
secretion of PAH by proximal tubular epithelial cells increases but only up to a maximum value of 80mg/min.
This maximum secretion corresponds with the transport maximum of the secretion enzymes, and at this level,
secretion plateaus and any increase in the urine PAH concentration are due to increased filtration.
HSP is a leukocytoclastic vasculitis, IGA mediated HS.
Foscarnet is an analog of pyrophosphage that can chelate calcium and promote nephrotoxic renal magnesium
wasting. These toxicities can result in symptomatic hypocalcemia and hypomagnesemia.
Mediastinal masses cause SVC syndrome.
Allergic asthma is the most common type (animal dander).

MCD can be from an atopic problem, immunizations, or recent repiratory infection.

ID: 8587
ID: 102
Gastrointestinal
The liver has glycerol kinase to make glycerol into DHAP. Liver is only organ with glycerol kinase. It uses it for
triglyceride synthesis, glycolysis, gluconeogenesis.
We dont have an HCV virus because it the envelope proteins keep mutating.
Apoptosis in hepatitis is around councilman bodies.
Few shigella, entomeaba histolytica and giardia is needed. It lives well in acid.
Inhaled anesthetics such as halothane are associated with fulminant hepatitis. PT time will be up, AST will be
elevated and eosinophilia.
Prolonged PT and albumin level is the worst indicator of liver function.
Intestinal carcinoma of the stomach projects into the lumen of the stomach; diffuse carcinoma fo the stomach
is within the stomach wall.
We excrete old ceruloplasmin (alpha 2 microglobulin made form copper) and excess copper in the bile and
stool.
Excess ammonia combines with alpha-KG to make glutamate. Glutamate then is released at the synapse.
Excess is reabsorbed by the astrocyte and converted to glutamine. This accumulation of glutamine in the
astrocyte leads to cellular swelling and dysfunction.
Person with history of generalized atherosclerosis and epigastric pain post prandially that does not respond to
antacids = chronic mesenteric ischemia. It is post prandial pain out of proportion to exam findings.
Aflatoxin messes up p53.
Glucose decreases adenylate cyclase, which decreases cAMP. Low cAMP leads to low CAP-DNA binding, which
upltimately results in low gene expression of the structural genes of the lac operon.
UC associated CRC is early p53 mutations and late APC mutations. They are multifocal in nature. The
extendend and duration of colitis is the biggest determinant.
Black stones from hemolysis are from unconjugated bilirubin increases.
H pylori is found in greatest amounts in the prepyloric area of the gastric antrum.
Crohns gets gallstones because the terminal ileium is affected, they cant reabsorb their bile salts, and the
cholesterol precipitates.
Crohns get oxalate stones because: they cant reabsorb their bile, which leads to malabsorption of fat. The
unreabsorbed fat then binds calcium in the GI tract. Calcium is normally bound to oxalate. Now it isnt, and
oxalate is freely absorbed (it suually is unabsorbale bound to calcium). The reabsorbed oxalate leads to
stones.
Cox-2 increases risk of adenomatous polyp formation int eh colon. Aspirin can help decrease risk.
Opioid analgesics can cause sphincter of Odi contraction and spasm leading to biliary colic and RUQ pain.
ID: 1716
The Sabin live attenuated polio virus is good at making IgA in the oral mucosa.
VIP increases intestinal chloride loss in the stool. Then water, Na, and K follow.
C dif diagnosis by detecting toxin genes in stool via PCR.
H pylori leads to ulcers because it reduces the number of antral somatostatin releasing cells, so gastrin is left
unchekd.

Appendicitis is caused by an obstruction of the lumen. Mucus then cant flow out of the appendix and there is
a dilation of the appendix. This restricts venous outflow, resulting in hypoxia which causing ischemia and
associated bacterial invasion.
ID: 402
Cholera is very acid labile, and any drug that decreases acidity will increase chance of cholera infection
(omeprazole).
The HbSAg of hep B must coat the HDAg of hep D before it can infect hepatocytes and multiply.
Pregnant women or on oral contraceptives get cholesterol gallstones because estrogen increases cholesterol
secretion and progesterone reduces gallbladder motility.
In all cases of acute viral hepatitis, ballooning degeneration, mononuclear cell infiltrates, and Councilman
bodies are seen. For HIV, no bx is necessary for dx.
Cardiology/Vessels/Endocrine
Daptomycin is a lipopeptide ABX that is used for MRSA. It causes depolarization of bacterial cellular
membrane and inhibition of DNA, RNA, and protein synthesis. Daptomycin is associated with increased CPK
(creatinine phosphokinase) and increased risk of myopathy.
The aortic isthmus (conncetion between arch and descending) is the most common cause of traumatic aortic
injury. It is where the left subclavian comes off.
ID: 1625
Liver can tolerate arterial occlusion better than other organs because it has dual blood supply. In order it goes:
brain, myocardium, kidney, spleen, liver.
In a pt with severe aortic stenosis and subsequent LVH, LV filling is dependent significantly on atrial contraction
to get the blood into the hypertrophied ventricle. If there is a-fib, and the LA is no longer contracting properly
to fill the LV, then the LV will have reduced preload to the point where systemic hypotension occurs. This can
also lead to increased LA pressure leading to acute pulmonary edema.
Dystrophic calcification is a hallmark of preceding cell injury and necrosis (even in heart valves). There is first
an intiaiton phase (which transpires within the mitochondria of dead or dying cells) and propagation (which can
eventually perforate the cell membrane from within).
CD31 is PECAM1 which is an endothelial cell marker. CD34 is also an endothelial cell marker as is vW factor.
After the age of 50, isolated systolic HTN becomes common. Systolic blood pressure greater than 160 with a
diastolic BP below 90 is found in 20% of pts over 80. Isolated systolic HTN is caused by age-realted decreases
in the compliance of the aorta and its proximal major branches. Numerous alterations in vessel wall structure
and function, including atherosclerotic changes, have been porposed to explain this stiffening.
A PCWP higher than the LV EDP means that there is something impeding flow (MS) between the LA and LV
COX-2 has a MW of 72kD. It is usually undetectable in tissues unless inflammation induces it.
Third degree AV block, impulses are coming from the AV node. QRS is still narrow since ventricular
depoarlization proceeds normally. It beats at 45-55 beats per minute.
If heart sounds are only heard at first during expiration, think about pulsus peridoxus. Pulsus peroxus can
happen in severe obstructive pulmonary disease such as asthma. Beta drenergic agonists control acute
asthma exacerrbations by causing bronchial smooth muscle relaxation via increased incracellular cAMP.
The a wave on jugular venous tracing is absent in pts with a-fib.
The adaptation to volume overload is eccentric hypertrophy (chamber dilation due to increased end diastolic
volume) with predominantly in series synthesis of new mycocardial sarcomeres. Concentric hypertrophy, the
response to pressure overload, involves in parallel dposition of new sarcomeres, which produces net
ventricular wall thciking and a reduction in ventricular chamber size (decreased EDV). Pressure overload may
occur to stenosis or systemic HTN. The major long term hemodynamic compensatory response to the volume
overload of AR includes an increase in left ventricular preload (LV EDV) in associated with eccentric LVH.

Treatment with statins causes hepatocytes to increase their LDL receptor density as a means of increasing
their uptake of circulating LDL
Amiodarone does not predispose to Torsades like the other 1As and IIIs.
The CaATPase pump uses active transport to sequester calcium within the SR and ressstablish the ion gradient.
The sarcolemmal Na/Ca transmembrane protein does not require ATP and accepts 3 extracellular Na ions in
exchange for one intracellular Ca ion. This calcium efflux is necessary for relaxation.
Beurgers dz is usually seen among heavy cigarette smokers with onset before age 35. It is associated with HS
to intradermal injections of tobacco extracts. This segmental thrombosing vasculitis often extends into
contiguous veins and enrves, encasing them in fibrous tissue.
Pain of pericarditis is sharp and pleuritic. It is exacertbated by swallowing; relieved by leaning forwards.
Varicose veins are dilated, tortuous veins resulting from impairment of the venous valves and reflux of venous
blood. This leads to venous stasis/congestion, edema, and increased incidence of superficial venous
thrombosis. Thromboembolism is a very infrequent complication of varicose veins, while venous stasis ulcers
are very common and often occur over the medial malleolus. The resulting chronic venous insufficiency
causes stasis dermatitis, which manifests as erythema and scaling with progressive dermal fibrosis and
hyperpigmentation.
NE is greater influence on alpha and beta 1. Less on beta 2.
Treatment of coagulase-negative staph infection involves initial empric treatment with vancomycin with or
without rifampin or gentamicin due to the widespread antibiotic resistance of S. epidermidis, especially in
nosocomial infections.
Dilation of the LV in response to increased preload can result in functional MR, which can be eliminated by
preload reduction and reduced by afterload reduction.
LV dysfunction can lead to increased pulmonary arterial pressure due to reactive vasoconstriction secondary to
pulmonary venous congestion. Reactive changes in the pulmonary vasculature (endothelial dysfunction
resulting in further vasoconstriction) also contribute to pulmonary HTN.
In a crossover study, subjects are randomly allocated to a sequence of 2 or more treatments given
consecutively. A washout (no treatment) period is often added between treatment intervals to limit the
confounding effects of prior treatment.
The IR is a tetrameric structure consisting of 2 alpha and 2 beta subunits. The alpha subunits are extracellular
and provide the bidning site for snsulin. The beta subunits contain TK domains. Downstream signaling is
initiated, started by the autophosphorylation fo the insulin receptor.
TNF alpha is a proinflammatory that induces insulin resistance through the activation of serine kianses, which
then result in phosphorylation of the IRS-1 serine residues. This inhibits IRS-1 tyrosine phosphorylation by
insulin. Phosphorylation of serine residues in the beta subunit of insulin receptors also hinders downstream
signaling, resulting in resistance to the normal actions of insulin. Phosphorylation of threonine residues has
similar effects. Catecholamines, gulcocorticoids, and glucagon can also induce insulin resistance by this same
mechanism, and intracellular FFAs are suspected of increasing serine kinase activity as well.
Romano-ward and Jervell and Lange-Nielsen syndrome are thought to result from mutations in a K channel
protein that contributes to the delayed rectifier current (I k) of the cardiac action potential.
More than a 10% increase in urine osmolality following administration of vasopressin during a water
deprivation test suggests CDI. A urine osmolality increase above 50% suggests complete central DI.
Unlike epinephrine, glucagon has an insignificant effect on skeletal muscle cells and adipocytes. Glucagon
does gluconeogenesis in the liver.
DKA presents as volume depletion (hypotension and tachycardia) with ketones and glucose in the urine. It
occurs most commonly in type I DM. Regular insulin is preferred for the acute treatment of DKA.
Nitroglycerine causes venous pooling, leading to reflex tachycardia. Nitroglycerine reduces myocardial oxygen
consumption, and is used for treating angina pectoris.
Exopthalmous does not improve with beta blocker therapy.
Familial hyperchoelsteroemia is HEPATOCYTE underexpression of LDL receptors.

Carotid sinus is acutally part of the internal carotid.

Hydrophobic = valine, alanine, methionine, pheynalanine, isoleucine
Subperiosteal thinning is a characteristic feature of hyperparathyroidism. Radiologically, this thinning appears
as subperiosteal erosions in the medial sides of the second and third phalances of the head, and as a granular,
salt and pepper appearance of the calvarium.
Nitrates acut primarily as venodilators causing a decrease in cardiac work by decreasing left ventricular filling
volume or preload.
Visceral obesity as measured by wasit-to-hop ratio is important determinant of insulin resistance.
The pathogenesis of nonbacterial thrombotic endocarditis (NBTE) often involves a hypercoagulable state.
When the hypercoagulability is the result of the procoagulant effects of circulating products of cancer,s, the
resulting cardiac valve vegetations may also be called amrantic endocarditis. The pathophysiology of NBTE is
similar to that of Trousseaus syndrome which may also by induced by disseminated cancers.
Cortisol has several permissive effects cortisol increases vascular and bronchial smooth muscle reactivity to
catecholamines.
Angioedema most commonly involves swelling of the tongue, lips, and eyelids and patients can also
experience laryngeial edema and difficulty breathing.
Combineduse of non dihydropyridine calcium cahnnel blockers and beta blockers can have additive
chronotopic effects yielding severe bradycardia and hypotension.
Cpasaicin reduces pain by decreasing the level of substance P in the PNS.
GH increases growth through production of IGF-1 from the liver. IGF-1 causes bone growth by stimulating the
proliferation of cartilage in bone cells.
High GH levels but low IGF-1 is larons dwarfism a defective GH receptor.
SVR decreases during exercise because of massive vasodilation so BP doesnt increase much.
ACTH is the major trophic hormone of the fasciulata and reticularis, whereas the glomerulosa is primarily
regulated by ATII. Prolonged ACTHstimulation casues hyperplasia of the fasciculate and reticularis, resulting in
excessive cortisol production (cushing syndrome).
The vascular reaction to endothelial and intimal injury is intimal hyperplasia and fibrosis, predominantly
mediated by reactive smooth muscle cells that migrate from the media to the intima.
Adenosine and dipyridamole are selective vasodilators of coronary vessels that can cause coronary steal.
Immunization with diphtheria toxoid induces production of circulating IgG against the exotoxin B subunit,
effectively preventing disease.
Nuclear receptors: thyroid, retinoids, PPAR, FAs
Treatment of CAH involves low dose exogenous corticosteroids to suppress excessive ACTH secretion and
reduce stimulation of the adrenal cortex.
Finasteride causes a discordant decrease in DHT level.

Reproductive
ILioinguinal, pudendal, and genitofemoral blockade would provide complete perineal and genital anesthesia.
Iliohypogastric nerve is derived from T12/L1 and courses in that dermatome to innervate the ksin overlying the
iliac crests.

IN the absence of ovulation, the ovarian follicle does not degenerate and becomes a CL. As a result, no
progesterone is produced and estrogen levels remain persistently high, causing the endometrium to remain in
the proliferative phase. Chronically proliferative endometrium becomes disorganized and fragile with unstable
venous capillaries, resulting in irregiular preiods of stromal breakdown with variable, but often heavy, bleeding.
Loss to follow up = selection bias
Primary amenorrhea in a pt with fully developed secondary sexual characteristics suggests the presence of an
anatomic defect in the gential tract, most commonly an imperforate hymen or a mullerian duct anomly.
Adolescent girls with undiagnosed imperforate hymen commonly present with cyclic abdominal or pelvic pain
and physical examination findings suggestive of hematocolpos.
Homologous chromosomes separate in meiosis 1 or a failure of sister chromatids to separate during meiosis II
or mitosis (8328).
Human placental lactogen increases insulin resistance, simtulated proteolysis and lipolysis, and inhibits
gluconeogenesis. Maternal insulin resistance results from increased secretion of hPL, placental growth
hormone, estrogens, progesterone, and glucocorticoids.
Unbalanced translocations and mosaicism cause downs if it isnt non-disjunction.
Entrococci produce aminoglycose modifying enzymes that transfer different chemical groups (acetyl, adenyl,
or phosphate) to the aminoglycoside and therefore impair antibiotic binding to ribosomal subunits.
Downs has excess skin on the nape of the neck.
Mucor dx needs bx.
Congenital torticollis is typically noted by 2-4 weeks of age, after which the child prefers to hold the ehad tilted
to one side. It is most commonly the result of malposition of the ehad in utero or birth trauma. Most cases
resolve with conservative therapy and stretching exercises. There can be a palpable swelling int eh childs neck
which might be the bulging of the SCM contracted. Chin points away from contracted muscle.
IFNgamma is produced mainly by NK and T cells and function to promote Th1 differneitation, induce MHC class
II expression, and activate macrophages. ??? WHAT? ID: 1468
Major adaptive immune mechanisms that prevent reinfection with the influenza virus include antihemagglutinin IgG antibodies in circulation and mucosal anti-hemagglutinin IgA antibodies in the nasopharynx.
Orbital fractures usually involve the medial or inferor walls because the bone bordering the ethmoid and
maxillary sinuses is thin.
Right brachiocephalic vein drains the right lymphatic duct, which drains lymph from the right upper extremity,
the right face and neck, the right hemithroax, and the right upper quadrant of the abdomen.
CMV only causes mono in the immunocompetent host.
Direct hernias is caused by weakness of the transversalis fascia in Hesselbachs triangle. They are covered by
the external spermatic fascia.
The ureters cross over the common/external iliac vessels and under the gonadal vessels (and ovarian vessles
in the female). They pass lateral to the internal iliac vessels and medial to the gonadal vessels as they enter
the true pelvis. ID: 1804
Septic arthritis is N. gonnarhea in a sexually active young adult. It is S. auerus in a non-sexually active child or
adult.
Cricothyrotomy incision passes through the superficial cervical fascia, pretracheal fascia, and the cricothyroid
membrane.
Cardiomyoapthy is the most common cause of death (myocarditis) in diphtheria. Treatment includes
diphtheria antitoxin (passive immunization), antibiotics, and active immunization. Of these, passive
immunization with antitoxin is the most important and has the greatest effect on prognosis of a pt with
cornybacterium diphtheria.
Antimuscarin drugs: atropic, TCAs (amitryptaline), H1 antagonists (diphenhydramine), neuroleptics,
antiparkinsonian drugs.

Hypetrophic cardiomyopathy = AD
GLUT-3 placenta
IN pts with heart failure, compensatory activation of the RAA pathway and sympathetic nervous system results
in increased afterload (from excessive vasoconstriction), excess fluid retention, and deleterious cardiac
remodeling.
Neurophysins are proteins involved in the posttranslational processing of oxytocin and vasopressin. These
hormones and their resepective neurophysins are produced within the neuronal cell bodies of the
paraventricular and suproptic neucli, and they are released into the circulation from axon terminals in the post
pit gland.
LVH and prior MI protect against LV rupture (3-7 days out from MI).
Protease inhibitors cause cushings
Recurrences of genital herpes can be reduced through daily treatment with oral valacyclovir, acyclovir, or
famciclovir; these drugs suppress reactivation of latent HSV infections.
Rheumatic fever and post-strep glomerulonephritis are the late sequelae of strep pyogenes (GAS). Post strep
glomerulonephritis can follow either a skin infection (impetigo) or an episode of pharyngitis. Rheumatic fever
is associated only with strep throat infection.
Urge incontinence is uninhibited bladder contraction by the detrusor.
Eosinophils play a role in host defense during parasitic infection. When stimulated by IgE bound to a parasitic
cell, they destroy the parasite via antibody dependent cellular cytotoxicity with enzymes from their
cytoplasmic granules. Another function of eosinophils is regulation of type 1 HS rections.
Depression of the entire HPA axis by glucocorticoid therapy is the most common cause of adrenal insufficiency.
Adrenal crises can be precipitated in these pts under stressful situations (infections, surgery) if their
glucocorticoid dose is not appropriately increased.
LV heart failure = kurly b lines
Early antibiotic tx (penciling) of GAS is important for prevention of acute rheumatic fever. If you have RF you
need surgery.
Ergonovine can provoke coronary vasospasm, and can aid in the dx of prinzmetals. This condition is treated
with vasodilating nitrates and calcium channel blockers.
hCG can be given in a large dose to simulate the LH surge
S3 can be accentuated by having the pt lie in the left lateral decubitis position and fully exhale.
S3 is associated with mitral regurg and CHF increased filling pressures. It is the sound of blood filling into a
partially filled or stiff LV (S4 is also from atrial contraction into a stiff ventricle).
In NDI and CDI the serum Na concentration is >142. In primary polydipsia it is <137.
TZDs increase adiponectin levels in type II DM, which are actually normally low in these pts.
Hyperaldosteronism produces renal Na retention and excess K secretion, resulting in hypertension and
hypokalemia. Additionally, pts with Conns syndrome commonly experience a metabolic alkalsosis. The
hypokalemia may cause muscle weakness. Hypokalemic alkalosis may promote paresthesias.
Class ICs antiarrhythmics are potent Na channel blockers that exhibit strong use-dependence by prolonging
the QRS duration to a greater extent at higher heart rates. Class III antiarrhythmics block the repolarizing K
current and demonstrate reverse use-dependence (the slower the heart rate, the more the QTc interval is
prolonged).
Ishcemic preconditioning is the development of resistance to infarction by cardiac myocytes preveiously
exposed to repetitive non-lethal ischemia. Cardiac hibernation.
ACE inhibitors can cause first dose hypotension if the pt is on diuretics before hand.

T3 cannot be conveted to rT3 or to T4. Exogenous T3 administriation causes decreased TSH levels, which act
upon the thyroid gland to reduce endogenous T4 production (and thus reduce peripheral conversion to rT3).
Jervell lange neilseon decreased outward K current during the repolarization phase of the cardiac action
potential QT prolongation.
Valvular inflammation and damage and scarring predispose to infective endocarditis.
Glomus = thermoregulation
Loss of cardiac myocyte contractility occurs within 60 seconds after the onset of total ischemia. When
ischemia lasts less than 30 minuts, restoration of blood flow leads to reversible contractile dysfunction
(myocardial stunning), with contractility gradually returning to normal over the next hours-days. However,
after 30 minutes of total ischemia, ischemic injury becomes irreversible.
Lactic acidosis occurs in pts with septic shock because of tissue hypoxia, which results in impaired oxidative
phosphorylation and the shunting of lactate following glycolysis. Hepatic hypoperfusion also contributes to the
buildup of lactic acid, as the liver is the primary site of lactate clearance.
In a pt with MR, the most reliable auscultatory finding indicating a high regurgitant volume (severe MR) and LV
volume overload is a left sided S3 gallop. The intensity of the holosystolic murmur does not correlate well with
regurgitant volume as larger regurgitant orifices often present with softer murmurs.
The classic presentation of pernicious anemia is an older, mentally slow woman of northern European descent
who is lemon colored (anemic and icteric), has a smooth shiny tongue (atrophic glossitis), and demonstrats a
shuffling, broad based gait.
Anion inhibitor (perchlorate, pertechnetate) block iodide absorption by the thyroid gland via competitive
inhibition.
Thionamides (methimazole, PTU) decrease the formation of thyroid hormones by inhibiting thyroid peroxidase.
Iodide salts inhibit synthesis as well as release of thyroid hormone.
ID 1973
Isolated diastolic HF: LV end diastolic pressure is increased, but LV end diastolic volume and ejection fraction
are normal.
Trousseaus syndrome migratory superficial thrombophlebitis is an indication of visceral cancer. It is a
paraneoplastic syndrome of hypercoagulability may be seen. Superficial venous thrombosis may appear in
one site and then resolve, only to recur in another site.
One of the most common reasons for elevated AFP in pregnancy screening is underestimation of gestational
age.
Senile calcific aortic valve degeneration becomes clinically apparent in the 7 th decade of life (the guy in the
question was 75). AS assoacited with congentially bicuspid aortic valves tends to present by the 6 th decade.
Aortic valve infective endocarditis causes aortic regurg.
Glucokinase is a glucose sensor within the pancreatic beta cells. Inactivating mutations of the enzyme result in
mild hyperglycemia that can be exacerbated by pregnancy.
Pts who overdose on beta blockers should be treated with glucagon, which increases HR and contractility
indepdnent of adrenergic receptors. Glucagon activates GCPRs on cardiac myocytes, causing activation of
adenylate cyclase and raising intracellular cAMP. The result is calcium release from intracellular stores and
icnresed SA node firing.
Topical preparations of alpha adrenergic agonists cause vasoconstriction of the nasal mucosa vessels and are
used as decongestants. Overuse of these drugs cuases negative feedback, resulting in decreased NE synthesis
and release from nerve endings, which diminishes their effect (tachyphylaxis).
Nitroprusside is the agent of choice in treating hypertensive emergency. It has a quick onset of action and
short duration of action. Nitroprusside is intiitally metabolized to cyanide, with subsequent conversion to
thiocyanate by liver rhodanase. Thus, one major disadvantage of its use involves the risk for developing
cyanide toxicity. Na thiosulfate is used to treat cyanide toxicity and works by donating sulfur to liver
rhodanase to enhance conversion of cyanide to thiocyanate.

SLE can cause acute coronary syndrome at a young age even with angiographically normal coronary arteries.
Glucocorticoids are predominantly catabolic, causing muscle weakness, skin thinning, impaired wound healing,
osteoporosis, and immunosuppression. However, they increase liver protein synthesis, specifically enzymes
involve din gluconeogenesis and glycogenesis. This, along with peripheral antagonism of the effects of insulin,
contributes to the development of hyperglycemia.
Propranolol decreases the rate of T4 T3 conversion (which is why we use it along with PTU and prednisone
for thyroxicosis. And because beta blockers stop sympathetic adrenergic impulses).
A-fib occurs due to irregular, chaotic electrical activity within the atria. While some of the atrial impulses are
transmitted to the ventricles, most are not due to the AV nodal refractory period.
For class 1 antiarrhythmics, Na-channel binding strength is 1C>1A>1B. IC antiarrhythmics demonstrate the
most use dependence, and class IB drugs have the least.
MS is always caused by rheumatic heart disease.
SIADH has clinically normal body fluid volume
Fenfularmine/phentermine (appetite suppressants) cause pulmonary HTN.
P53 mtuations are common in anaplastic thyroid cancer.
Hypothryoid is a common cause of an elevated creatine kinase level due to hypothyroid myopathy.
Sometimes, it can be the first manifestation of hypothyroidism. Other common causes of elevated CK include
medications (statins), AI dz (polymyositis/dermatomyositis), duchennes.
Carveidolol is a particularly good beta blocker at reducing mortality in CHF. They slow ventricular rate and
decrease afterload.
Thyroid peroxidase catalyses iodide oxidation, the formation of mono and diiodotyrosine, and coupling that
forms T3 and T4.
Nitric oxide is the most important mediator of coronary vascular dilation in large arteries and pre-arteriolar
vessels. Adenosine, a product of ATP metabolism, acts as a vasodilatory element in the small coronary
arterioles.
Cyanosis restricted to the lower body in a child is suggestive of patent ductus arteriosus. Coarctation can limit
lower extremity exercise tolerance but does not cause cyanosis in children or adults.
The only way to distinguish between insulinoma and sulfonylurea or meglitidine abuse is by screening the
urine or blood for hypoglycemic agents.
An ACTH surge with a resultant increase in steroid half-product excretion is a normal reaction to metyrapone
administration, because metyrapone blocks the last step of cortisol synthesis. Metyrapone blocks 11-BHydroxylase.
11-deoxycortisol shows up in the urine as 17-hydroxy-corticosteroid. ID: 608
Niacin for high TGs after fibrates.
The QRS complex corresponds to ventricular depolarization and phase 0 on the action potential graph.
Ventricular myocyte depolarization is mediated by inward Na movement and can be moedulated by class I
antiarrythmics.
Both ventricular hypertrophy and volume overlaod cause release of both ANP and BNP from the ventricular
myocytes to facilitate natriuersis.
Dilated cardiomyopathy is dilation of all 4 chambers of the heart, systolic dysfunction, and myocardial failure.
A systolic pressure gradient between the left ventricle and aorta would not be expected in dilated
cardiomyopathy and is more suggestive of LV outflow tract obstruction (AS).
WBC count is necessary in any pt receiving either methimazole or PTU who presents with a fever because they
cause agranulocytosis.
S4 restrictive cardiomyopathy and LVH

Massaging the carotid prolonges the AV node refractory period to help SVT. Can also use adenosine.
Amenorrhea from anorexia is due to loss of pulsatile secretion of GnRH from the hypothalamus. The defect is
in the hypothalamus, not the ovaries or pituitary.
The initital commited step of gluconeogenesis is the conversion of pyruvate to oxaloacetate, and oxaloacetate
to phosphoenolpyruvate.
Ion pump failure due to ATP deficiency during cardiac ischemia causes intracellular accumulation of Na and Ca.
The increased intracellular solute concentration draws free water into the cell, causing the cellular and
mitochondrial swelling that is observed histologically.
New onset murmur in a young adult = bacterial endocarditis. Glomerulonephritis secondary to circulating
immune compelxes can be complicate bacterial endocarditis and result in acute renal insufficiency.
AV shunts increase preload and decrease afterload by routing blood directly from arterial to venous system,
bypassing the arterioles. High volume AV shunts can eventually result in high-output cardiac failure.
Pericardial knock is sounds that occurs earlier in diastole than the S3 heart sound. It is from constrictive
pericarditis reducing ventricular compliance via an external force. Reduced INTRINSIC ventricular wall
compliance is a cause of S3.
Loss of consciousness brought about by severe hypoglycemia is typically treated with intramuscular glucagon
in the non-medical setting and with IV dextrose in the medical setting.
Abdominal pain due to acute pancreatitis is the most likely presentation for hyperchylomicronemia.
Niacin can potentiate the effects of some anti-hypertensive medications because of its vasodilatory effects.
Decrease the dose.
Niacin also increases insulin resistance and oftentimes necessitates an increase in diabetes medications.
Amyloid specific organ:
Cardiac atria: ANP
Thyroid gland: calcitonin
Pancreatic islets: amylin
Cerebrum/cerebral blood vessels: beta amyloid
Pituitary gland: prolactin
Prednisone is used for Graves opathalmopathy.
Pts with adult type coarctation of the aorta commonly die of HTN associated complications, including LV failure,
ruptured dissecting aortic aneurysm, and intracranial hemorrhage. These pts are at increased risk for ruptured
intracranial aneurysms because of the increased incidence of congenital berry aneurysms of the circle of willis
as well as aortic arch HTN.
Effect modification is present when the effect of the main exposure on the outcome is modified by the
presence of another variable. Effect modification is not bias.
The murmur of AR is best heard at the left sternal border, with the pt leaning forward at end expiration.
Damage to the posterior pituitary produces only transient central DI. Permanent central DI usually rsults form
dmage to hypothalamic nuclei or the pituitary stalk.
Glucagonoma = DM, necrolytic erythema, and anemia
Pericarditis pain radiates to the neck and shoulders and is relieved by sitting up.
Pretibial myxedema (lower leg skin thickening and induration it manifests as nonpitting edema that is
sometimes scaly in appearance resembling an orange peel) and exopathlamos are SPECIFIC for
hyperthyroidism due to Graves.
GLUT transporters are carrier mediated transport.
Woman who lived in the US her whole life doesnt have rheumatic fever probably, more common in her would
be MVP leading to vegitations on the valave.
Adenosine can cause chest burning (bronchospasm), flushing, and high grade block.

Janeway lesions are small, erythematous, possibly hemorrhagic macules that may appear on the soles of the
fett and palms of the hands in a patient with bacterial endocarditis. These lesions are caused by septic
microemboli to cutaneous blood vessels. The emboli are fragments of infected intracardiac vegetations.
FFA and serum TGs are believed to increase insulin resistance in overweight individuals.
PPARgamma is an intracellular nuclear receptor.