Anatomy Penetrating trauma to the anterior neck superior to the clavicle can cause bleeding of the subclavian artery:

: the surgeon needs to isolate the artery, by removing the clavicle to gain access: the anterior scalene muscle is attached to the top of the first rib, and behind it is the subclavian, and behind that is the first rib Surgery can result in inadvertent damage of the phrenic nerveon CXR, the damaged side will be raised since when a patient holds breath during CXR, the contracted/functioning diaphragm will move downward, but the paralyzed diaphragm will move upward since the negative pressure generated by the functioning side will pull the paralyzed diaphragm up

Biochemistry Turners syndrome: chicks who will never have menstrual periods (amenorrhea) and have a fold of skin that runs from the neck to shoulder (webbed neckcystic hygroma), short stature, short fourth metacarpal bone; associated conditions are coartation of the aorta, aortic dissection, bicuspid aortic valve, hypertension, osteoporosis (from poor estrogen production), horseshoe kidney, lymphedema in feet and hands Downs syndrome is associated with ASD more than VSD. B1 deficiency: beriberi; wet beriberi causes dilated cardiomyopathy and edema; dry beriberi causes polyneuritis (inflammation of multiple peripheral nerves) and muscle wasting; B2 deficiency causes cracking of the lops and corners of the mouth (stomatitiskind of like HSV-1) and corneal vascularization; B3 defieicney causes diarrhea, dementia, and dermatitis, and glossitis (thick tongue) First degree hearblock (long PR intervals) and Mobitz type I second degree heart block are caused by AV node abnormalities; Mobitz type II (random absence in QRS complex) is caused by defect in the His-Purkinje system Marfans cardiovascular problems: aortic aneurysms and mitral valve prolapse, and aortic dissection (due to hypertension and cystic medial necrosis); syphilis causes aortic aneurysms that can lead to aortic regurg due to weakening of the wall by disruption of vasa vasorum (tertiary syphilis is characterized by gummasskin lesions, aortitis, and neurosyphilissharp pain and decreased proprioception); Marfans also presents with joint hyperflexibility, lens disloacation, pneumothorax B blockers decrease contractility and HR, and therefore permit greater filling time during diastole, so EDV increases, and so does ejection time Dilated cardiomyopathy can be caused by viruses (T cell mediated damage against the virusinfected cells), sarcoidosis (granulomatous inflammation of the myocytes), drugs such as doxorubicin, alcohol, or cocaine (hyperadrenergic state would be seen), ischemic, or familial with antibodies against the myocytes. Nitrates such as nitroglycerin do NOT cause production of de novo NO, but release NO from their own structure; the NO mediates venodilation by binding to gunaylate cyclase and causing production of cGMP which causes dilation

Do NOT use ACE inhibitors with K sparing diuretics such as spironolactone, since it will cause severe hyperkalemia

Microbiology Diagnose syphilis with VDRL and confirm with FTA-ABS Endotoxins are a characteristic of gram negative bacteria and Listeria Corynebacterium diptheriae causes pharyngitis, cough/sore throat with cervical lymphadenopathy has an exotoxin endoced by a Beta-prophage; it grows on tellurite agar with metachromatic (blue/red) granules; can use Elek test for toxin pharyngitis (i.e. sore throat) with lymphadenopathy and fever can also be Strep, EBV, CMV (mono), and HIV Strep viridians is the most common cause of bacterial endocarditis, and it is more common in patients who have had prior damage, such as mitral valve prolapse Salmonella typhi causes rose spots on abdomen, fever, headache, and diarrheabut not bloody diarrhea unlike Shigella and Salmonella spp. (others) Giving antibiotics to women may encourage Candida to grow since low pH is maintained by lactobacilli, and without them, pH increases; Candida will cause a vaginal itching with vaginal discharge with cheese-like consistency Adverse effects of metronidazole include GI discomfort and disulfiram-like effect when combined with alcohol, headache, and metallic taste Gardnerella vaginialis has a gray discharge, and Trichomonas vaginalis has yellow-green frothy vaginal discharge; both are given metronidazole Macrolides such as azithromycin bind to 23S of the 50S subunit, and inhibit protein synthesis by blocking translocationgive mainly only for Mycoplasma; clindamycin blocks peptide formation at 50S subunit; tetracyclines block aa-tRNA from attaching to 30S; aminoglycosides cause misreading of the mRNA and prevent formation of the initiation complex Rash starting on palms and soles can ONLY be: rocky mountain spotted fever (which also presents with hepatosplenomegaly, headache, fever, and possibly thrombocytopenia due to DIC), N. gonorrhea, secondary syphilis; although not rash, Coxsackie A can cause hand-foot painful ulcertations Tricuspid vegatations/endocarditis due to S. aureus due to IV drug abuse can seed septic emboli from the right side of the heart to the lung, which presents with cough, pleuretic chest pain, diffuse pulmonary infiltrates, and pyopneumothorax Rabies pro-symptoms are fever, headache, sore throat, tenderness around bite site; they progress to encephalitis, foaming of the mouth due to inability to swallow, spasms, and seizures Coccidioides immitis presents with symptoms similar to TB: night sweats, lung cavitations, weight loss, but with additional signs: erythema, arthralgias/artirhitis; Legionella would cause many of the same symptoms, but would also have GI symptoms, and is due to a contaminated water source; also causes hy[ponatremia which is unique to this pneumonia

Conjunctivitis in a neonate from 2-5 days after birth is Neisseria gonorrhea and from 5-14 days after birth is Chlamydia trachomatis (inflammation, swelling around eyelids, and presence of yellow discharge). The feared complication of C. trachomatis is pneumonia. H. pylori associated gastric ulcers have punched-out lesions, with underlying tissue replaced by scar tissue and chronic inflammatory cells; signet ring cells are found in infiltrating gastric carcinoma, which is NOT associated with H. pylori. Chlamydia has cytoplasmic inclusions on a Giemsa; treat with azithromycin or doxycycline Mucor can cause life threatening meningitis in patients with diabetes Community acquired lobar pneumonia in elderly person with BROWN SPUTUM is probably S. pneumonia Bronchiolitis by RSV: fever, cough, sneezing, rhinorrhea (runny nose), difficulty breathing In order of increasing susceptibility to chemical sterilization: prions, spores, mycobacterium, nonenveloped viruses, etc.; prions are esp. resistant Influenza virus infection predisposes patient to subsequent viral or bacterial infection due to damage of the epitehalium of the upper respiratory tract, compromising ability to keep lower respiratory tract sterile. S. aureus, S. pneumonia, H. influenza are commonly secondary to flu Tiny yeasts inside macrophages describes Histoplasma; spherules with endospores: Coccidiodes Nyastatin is used to treat oral candidiasis, and it binds ergosterol to form pores in membranes

Immunology Acute transplant rejection is mediated by T cells; symptoms are fatigue, low fever, heart failure, and arrhythmias Chronic rejection of transplant occurs by B cells

Cardiovascular Pericardial tamponade: Becks triad: distant heart sounds, JVD which does not improve upon inspiration as occurs in CHF (Kussmauls sign), hypotension, pulsus paradoxes where upon inspiration, the blood pressure decreases more than 10, since the right ventricle bulges out into the left ventricle upon inspiration (more blood is coming in, and the RV cannot expand outward because of tamponade and instead bulges into LV) and decreases blood in LV, so it cannot pump out that much, and there is decrease in systolic bp Constrictive pericarditis occurs post-radiation (which thickens the pericardium), or post-viral infection, trauma, neoplasm, etc. Esmolol is used in SVT over other cardioselective B blockers bc it has fast-on, fast off pharmacokinetics (i.e. short acting)used for A fib, AVRT, and AVNRT S3 is shortly after the beginning of diastole, and is due to the vibration of the distended ventricle filling rapidly. In children, normal, but in adults, suggests volume overload, such as CHF S4 is atrial kick, at the end of diastolesuggests decrease in ventricular compliance as in ventricular hypertrophy from chronic hypertension

Any pathology with right sided valvessuspect IV drug use or carcinoid syndrome (pulmonic stenosis and tricuspid insufficiency); give octreotide for carcinoid syndrome Cancer markers: alpha-fetoprotein: detects hepatocellular cancer; 5-Hydroxyindoleacetic acid (5HIAA) is metabolite of serotonincarcinoid tumor; Cancer antigen-125 (CA-125): monitor treatment (not diagnose) ovarian cancer; carbohydrate antigen 19-9: monitors (not diagnoses) pancreatic cancer; carcinoembryoic antigen (CEA) monitors (not diagnoses) mainly colorectal and pancreatic, but also some gastric and breast cancers Mullers maneuver involves asking the patient to breath in against a closed mouth and nose; this can detect closed upper airways and is the opposite of the Valsalva maneuver Direct acting symptahomimetics bind to postsynaptic adrenergic receptors without interacting with presynaptic neurons; indirect acting sympathomimetics cause catecholamine release from presynaptic terminals without interacting with receptors on postsynaptic neurons; disadvanteage of indirect acting sympathomimetics such as ephedrine is their ability to enter the CNS and produce undesirable stimulation; direct are more selective, and are generally shorter acting. If cyanosis is occurring later in life (around age 5-10), then Eisenmengers syndrome has happened and reversed the shunt from left to right (which does not cause cyanosis) to right to left (which does cause cyanosis); the causes of left to right shunt which eventually reverse are: ASD, VSD (caused by incomplete fusion of the right bulbar ridge, left bulbar ridge and AV cushions), and PDA. All other congenital abnormalities will present with cyanosis at birth such as tetralogy of fallot (due to anterosuperior displacement of infundibular septum), transposition of great vessels, tricuspid atresia, and truncus arteriosis which all have right to left shunt. VSD will present with a holosystolic murmur , and should be given sildenafil to vasodilate the pulmonary vasculature to reduce right to left shunting (after Eisenmengers syndrome has occurred) since more blood can go into the vasculaturethis is only transient solution, since defect has to be surgically repaired. Acute renal failure can cause elevated BUN and creatinine, and the inability of the kidney to secrete K, leading to hyperkalemiathat leads to peaked T waves and arrhythmias and even cardiac arrest. In a patient with renal failure, EKG must be checked. Hypokalemia will cause U waves and flattened T waves, and arrhythmias and paralysis Differeing bp in the arms is concern for aortic dissection, since false lumen can occlude the subclavian take off from the aorta on one side Two high risk complications of coarctation of aorta are bacterial endocarditis and cerebral hemorrhage; it can also lead to hypertensive cardiomyopathy and ascending aortic dissection Chronotropy=HR and increases rate of SA node firing by increasing Na and Ca current (does SA node even have Na current?), dromotropy=rate of conduction by increasing AV node conduction by increasing Ca current, lusotropy=rate of relaxation Kawasaki disease: fever, conjunctivitis, vesicles/ulcers/cracked/swollen of lips and oral mucosa, rash/edematous hands and feet, desquamation of skin on fingertips Perforated nasal septum is a complication associated with Wegners granulomatosis Statins and fibrates both cause myositis (inflammation of muscle) with release of creatine kinase and hepatotoxicity; fibrates also cause cholesterol gallstones. Fibrates upregulate LPL which increases TG clearance. Niacin causes flushing, hyperglycemia, and hyperuricemia, and works by inhibiting lipolysis in adipose tissue and reduces hepatic triglyceride synthesis and hepatic VLDL

secretion. Bile acid resins taste bad and cause GI problems with decrease fat soluble vitamin absorptionthey also increase TG. Coronary vasodilation is mediated by NO, O2, and adenosine; cerebral arteries are mediated by CO2, and skeletal muscle by lactate Digoxin causes an increase in cardiac contractility and thus CO; increase in CO causes a decrease in symp activitiy and reduces vascular resistance; digoxin causes hyperkalemia, yellow halos, and GI upset. It binds to the K binding site on the Na/K ATPase, so if there is hypokalemia, there is a lot of available spots on the ATPase for dig to bind, so it will have a greater effect Libman Sacks endocarditis occurs on the mitral valve and results in mitral stenosis IV drug abuse leading to tricuspid endocarditis does not usually present with the typical Oslers nodes, Roths spots, and Janeway lesions. The tricuspid vegetations by IV use can easily embolize and cause a PE secondary to the endocarditis, similar to PE secondary to DVT (which would present as pleuritic chest pain); note that Libman Sacks endocarditis cannot embolize Class IB is best after MI; class IC is Contraindicated post-MI and in structural abnormalities NE will increase bp by vasoconstriction on alpha1 receptors, and therefore the HR will decrease; isoproterenol does not act on alpha receptors, only betas, so it will cause vasodilation by B2, and HR will increase. Epi will also decrease bp and cause increase in HR Tuberous sclerosis is an autosomal dominant condition which presents with a classic triad of seizures, mental retardation and facial angiofibromas (acnelike papules on the face). TS is characterized by nodular proliferation of astrocytes in the cerebral cortex. Half of patients develop rhadomyomas, which are benign, but may compromise cardiac function, esp. AV valves. They may also get angioliposmas of the kidney Torsades de pointes can be caused by low K levels, long QT (congenital or acquired through drugs), K channel blockers such as sotalol, and class IA bc they also are K channel blockers, such as quinidine. Note that quinidine also causes tinnitus and headaches; treat torsade with MgSO4 In hypertrophic cardiomyopathy, Ca channel blockers and beta blockers can be used to improve symptoms but they do not decrease mortality, which only an ICD does Mitral stenosis has high pitched opening snap in diastole with low-pitched harsh rumbling murmur Infants of diabetic mothers are at risk for hypoglycemia that causes seizures (since the mothers hyperinsulinemia will cause low glucose), and pulmonary problems such as tachypnea, and respiratory distress syndrome as well as and transposition of the great vessels, and VSD, Carotid sinus baroreceptors synapse through cranial nerve IX to the nucleus tractus solitarius of the medulla Class I antiarrythmics all have a greater affinity for cardiac tissue that is depolarized whether it is due to hypoxia or frequently depolarized due to tachycardia, which is why they selectively target only these tissues Because abdomainal aneursyms are usually below the renal arteries, and the main artery that comes off the abdominal aorta is the IMA, the descending and sigmoid colons can be damaged during repairs of the abdominal aortic aneurysm Digoxin blocks the Na/K ATPase, but also stimulates the vagus nerve IVC compression is common in women in the third trimester of pregnancy, and this can cause hypotension when lying down due to decreased venous return to the heart

Rheumatic fever histology: focal area of interstitial inflammation with fragmented collagen, mononuclear (Anitschkows) cells, and multinucleated giant (Aschoffs) cells

Hemostasis Fat embolism will present with dyspnea and petechiae on chest, with possible neurologic abnormalities PE will present with pleuritic chest pain, pleural effusion, dyspnea, hemoptysis DVT can present with Homans sign where dorsiflexion of the foot is difficult due to tender calf muscle; it can also result in edema since there is less venous return due to obstruction, and that would cause increase capillary hydrostatic pressure (similar to CHF which also causes edema due to stasis and increased cap pressure)

Neuroscience ACh is synthesized in the basal nucleus of Meynert NE is synthesized in the locus ceruleus Serotonin is synthesized in the raphe nucleus Dopamine is synthesized in the ventral tegmentum and substantia nigra

White Cell disorders ALL therapy requires prophylaxis to the scrotum and CSF With CLL, there is a lot of white cells, some of which are smudged; CLL complications are autoimmune hemolytic anemia, hypogammaglobulinemia, and if more mutations occur, progression to large diffuse B cell lymphoma, where there will be splenomegaly and LAD Hairy cell leukemia is positive for tartrate acid phosphatase (TRAP); has splenomegaly (red pulpunusual), and no LAD In mycoses fungoides, the Sezary syndrome hematogenous spread have cerebriform nuclei In myelofibrosis, the megakaryocytes produce PDGF, which results in marrow fibrosis (unlike essential thrombocythemia, which does not result in marrow fibrosis, or hyperuricemia and gout, and does not progress to acute leukemia as do the other myeloproliferative disorders) Burkitt lymphoma has starry sky appearance: macrophages ingesting apoptotic tumor cells scatted in a sheet of monotonous lymphoid cells Hodgkin lymphoma: B cell called Reed-Sternberg cell has multilobed nuclei and prominent nuclei (owl eyed nuclei) with abundant pale cytoplasmpositive CD30 and 15

Gastrointestinal Pathology Kruckeberg tumor A. Arise in the left colon: a. Hyperplastic polyps (rectosigmoid)

Ulcerative colitis Colonic diverticula (sigmoid colon most commonresults in left lower quadrant pain) Volvulus (sigmoid colon in adults) Hirschprung disease (sigmoid colon and rectum, because neural crest cells keep go from north to south, and if they stop early, everything lower will not be innervated) f. ischemic colitis (generally, splenic flexure gets hit worst since that is the part of the colon last supplied by the SMA) g. colorectal carcinoma by the adenoma-carcinoma pathway B. Arise in the right colon or side: a. Crohn disease (the terminal ileum and cecum which is why right lower quadrant pain) b. Angiodysplasia c. Volvulus (cecum in adults) d. Appenidicitis (right sided pain, but starts as periumbilical, then becomes right-sided) e. Colorectal carcinoma by the microsatellite instability (MSI) pathway

b. c. d. e.

Exocrine Pancreas, Gall Bladder, and liver Pathology Serum tumor marker for pancreatic cancer is CA 19-9 Serum tumor marker for colorectal cancer is CEA (for assessing treatment, not for screening) Whipple procedure for pancreatic cancer Uridine glucoronyl transferase (UGT) in hepatocytes conjugates bilirubin Porcelain gallbladder is a late complication of chronic cholecystitis with a shrunken, hard gallbladder, that is calcified; it is a risk factor for gallbladder cancer Hemochromatosis is due to mutations in the HFE gene; presents with triad of cirrhosis, diabetes, and bronze skin Hepatic adenoma is associated with oral contraceptive use (also hypercoagulability is associated with contraceptives) Disorders associated with down syndrome: Hirshprungs disease, duodenal atresia, ALL (>5 years), acute megakaryoblastic leukemia (<5 years) Primary biliary cirrhosis: associated with antimitochondrial antibodies; symptoms are jaundice, hepatosplenomegaly, itching of skin/pruritis, dark urine, light stools Cholangitis has a classic triad of right upper quadrant pain, jaundice, and fever/chills

Kidney and Urinary Tract Pathology Minimal change disease: selective proteinuria (loss of albumin but no Ig) Diabetes mellitus causes hyaline arteriolosclerosis of the efferent arteriole of the nephron, causing hyperfiltration of albumin; later this can lead to nephrotic syndrome with Kimmelstiel Wilson nodules that have sclerosis on the mesangium

Endocrine Pathology Hypothyroidism in children is cretinism: caused by dyshormogenetic goiter, maternal hypothyroidism, iodine deficiency Sheehan syndrome during pregnancy