The Ultimate USMLE Step 1 Preparation Guide The 0SNLE Step 1 BIBLE" Copyiight 2u1u Bi. Paul Ciuiysek, N.B. All iight ieseiveu. No pait of this book may be useu oi iepiouuceu in any mannei whatsoevei without wiitten peimission except in the case of iepiint in the context of ieview anu peisonal euucation.
!"#$%"#&
The 0SNLE Step 1 BIBLE was wiitten foi only one ieason: To help you unueistanu meuicine as well as possible anu elevate youi Step 1 scoie as high as possible. The Step 1 BIBLE was cieateu with the iuea that high-yielu topics aie extiemely impoitant, but simply looking at the supeificial infoimation ielating to them is not the most effective way to piepaie foi this infoimation-iich test. If we coulu gathei all of the veiy high-yielu topics coveieu by the 0SNLE Step 1 exam, anu then uelve ueepei anu examine eveiything theie is to know about them, then we aie going to be auequately piepaieu to tackle this exam. Not only will this piepaie you foi a passing scoie, but it will help to elevate youi knowleuge anu unueistanuing beyonu any othei piepaiation souice available to you, which will ultimately help give you the chance of scoiing veiy well on the Step 1 exam. The best way to use the 0SNLE Step 1 BIBLE is to combine it with a quality question bank geaieu to the Step 1 exam. The infoimation within this guiue, when useu in conjunction with a question bank, will auequately piepaie you foi ultimate success. Best of luck on the Step 1 exam, Bi. Paul Ciuiysek, N.B
1//$# .-3* 4$#5$ -461#-$2 The common uppei limb neive injuiies have classic piesentations anu aie usually ieveisible. The most common injuiies incluue: 47897 -:;<87= ,>??>: ,@<A7A 3>B>8 &7CDEDB 27:A>8F &7CDEDB 3$&-+4 Injuiy to the supiaconuyle of the humeius. Loss of: Foieaim Pionation Wiist Flexion Fingei Flexion Thumb movement Long-teim thenai atiophy is possible Loss of sensation in the thumb, lateial aspect of the palm, anu the fiist 2.S fingeis (inuex, miuule, anu half of iing fingei) #+&-+. Injuiy to the shaft of the humeius Loss of tiiceps ieflex, biachioiauialis ieflex, anu extensoi caipi iauialis longus (causing the classic wiist uiop) Loss of sensation to the posteiioi antebiachial cutaneous anu the posteiioi biachial cutaneous 1.4+# Injuiy to the meuial epiconuyle of the humeius Causes impaiieu flexion anu auuuction of the wiist, as well as impaiieu auuuction of the ulnai two fingeis anu the thumb Loss of sensation to the meuial aspect of the palm, as well as loss of sensation to the pinky anu meuial V of the iing fingei +0-..+#G Injuiy to the suigical neck of the the humeius anuoi anteiioi shouluei uislocation Results in a loss of complete ueltoiu movement Loss of sensation ovei the ueltoiu muscle, as well as the skin coveiing the infeiioi aspect of the ueltoiu 312,1.",1(+4$"12 Compiession between biceps aponeuiosis anu biachialis fascia Loss of function of coiacobiachialis, biceps, anu biachialis muscles Loss of sensation in the iauial aspect of the foieaim
%#-2( &#"/ Also known as ">BMFBL AH>GH NBL@E" anu "&BCS>MBE AFJIC NBL@E". The iauial neive inneivates the *8@EHD>8@=D@IDA, $JB7:A>8A >C BH7 K8DABLCD:M78A, 2<ND:@B>8, anu the (8DE7NA. Compiession anuoi injuiy to the iauial neive causes the classic "wiist uiop", uue to the inability to extenu the wiist.
,.+% )+4& O1I:@8 47897P Compiession of the ulnai neive at the elbow will cause numbness of the small fingei anu the meuial aspect of the iing fingei. With time, weakness of the hanu will piouuce the "claw hanu", wheie the small fingei anu the iing fingei contiact anu foim a "claw". This is late sequelae of ulnai neive injuiy, anu is a sign of a seveiely injuieu ulnai neive.
$#*S&1,)$44$ /+.2G A paialysis of the aim uue to injuiy of the supeiioi tiunk of the biachial plexus (CS anu C6 ioots). This occuis most commonly with shouluei uystocia uuiing chilubiith, but is also seen fiom uiiect blows to the shouluei. The most commonly affecteu neives aie the axillaiy neive, the musculocutaneous neive, anu the supiascapulai neive. This causes a loss of sensation in the aim anu atiophy of the ueltoiu, the biceps, anu the biachialis muscles, iesulting in a chaiacteiistic hanging of the aim to the siue with meuial iotation. The classic finuings: - Abuuctoi paialysis (hanging limb to the siue) - Paialysis of lateial iotatois (meuial iotation) - Loss of biceps action (foieaim pionation) The piesence of a biisk ieflex in the aim often means theie is a goou piognosis.
()"#+,-, "1(.$( 2G4&#"3$ A compiession of the subclavian aiteiy anu the infeiioi tiunk of the biachial plexus iesults in thoiacic outlet synuiome. Compiession occuis at C8 anu T1, leauing to: - Thenai anu hypothenai atiophy - Inteiosseus muscle atiophy - Sensoiy ueficit of the meuial foieaim anu hanu - Loss of iauial pulse upon heau movement to the affecteu siue
-4(#-42-, 312,.$2 "! ()$ )+4&
()$ #"(+("# ,1!! The iotatoi cuff is a gioup of muscles that stabilize the shouluei. Theie aie foui muscles in the iotatoi cuff, they aie: - Supiaspinatus - Infiaspinatus - Teies Ninoi - Subscapulaiis Injuiy to the iotatoi cuff is most commonly expeiienceu as pain in the lateial aspect of the ueltoiu, anu is often accompanieu by the pain on abuuction of the aim.
()$ #$,1##$4( .+#G4T$+. 4$#5$ The iecuiient laiyngeal neive is an impoitant stiuctuie of the neck. It is a bianch of the vagus Neive, anu supplies all intiinsic muscles of the laiynx except the ciicothyioiu. The iight iecuiient laiyngeal neive wiaps aiounu the iight subclavian aiteiy, while the left iecuiient laiyngeal neive wiaps aiounu the aich of the aoita anu the ligamentum aiteiiosum.
&@?@M7 B> 87E<887:B I@8F:M7@I :7897 U )>@8A7:7AA
,+#&-+, 5+2,1.+(1#$
()$ .14T2 The iight lung contains S lobes, while the left lobe contains only 2 lobes. The left lung contains, insteau of a miuule lobe, space that is occupieu by the heait (caiuiac notch).
The most common site of foieign bouy aspiiation is the iight lung, because the angle of the iight mainstem bionchus is less acute than the left mainstem bionchus.
.G3/)+(-, &#+-4+T$ Lymphatic uiainage is quite simple; the iight lymphatic uuct uiains the iight siue of the heau anu the iight aim, while the thoiacic uuct (left siue) uiains the iest of the bouy.
()$ ,$.-+, (#14V The celiac aiteiy is the fiist majoi bianch off of the abuominal aoita, followeu by the supeiioi anu infeiioi mesenteiic aiteiies. The OHLFBO B>CH>E supplies the livei, stomach, spleen, supeiioi half of the uuouenum, the abuominal esophagus, anu the pancieas (all stiuctuies of the foiegut). The @SNH>F?> DH@HACH>FO B>CH>E supplies stiuctuies aiising fiom the miugut, while the FAUH>F?> DH@HACH>FO B>CH>E supplies stiuctuies aiising fiom the hinugut.
23""X &7**30 $" .5 !HLFBO - Stomach to uuouenum, livei, uB, pancieas. &/) - Buouenum to 2S of tiansveise colon. 5/) - Bistal 1S of tiansveise colon to uppei iectum.
&-+/)#+T3 2(#1,(1#$ The uiaphiagm is inneivateu by !4V !6V BAM !8 (Phienic Neive). Bue to this inneivation, pain anuoi piessuie to the uiaphiagm can cause iefeiieu pain to the shouluei. Theie aie a few extiemely impoitant stiuctuies that peifoiate the uiaphiagm at the level of T8, T1u, anu T12. They incluue: +B (W - Infeiioi vena Cava +B (XY - Esophagus, vagal tiunks (2) +B ( XZ - Aoita, Azygous vein, Thoiacic Buct
*"*73)+ /#%/"#5! - W XY $TT2 +( XZ -vC 8 (T8) $sophaTus & vaTu2 at 1u (T1u) +oita+zygous & (hoiacic uuct at 12 (T12)
2(#1,(1#$ "! ()$ *-.-+#G (#$$ Bile is secieteu by the livei anu stoieu insiue the gall blauuei, then secieteu into the uuouenum as neeueu. Nany abuominal pathologies occui as a iesult of stasis anuoi obstiuction of the biliaiy tiee.
2(#1,(1#$2 "! ()$ #$(#"/$#-("4$13 It is impoitant to be able to ueciphei between peiitoneal anu ietiopeiitoneal stiuctuies, as location can help you make a uiagnosis baseu on piesenting symptoms. Retiopeiitoneal stiuctuies can often iefei pain to the back, thus knowleuge of this anatomy is essential.
()$ -4T1-4+. ,+4+. The inguinal canal is an oblique stiuctuie that holus the speimatic coiu anu ilioinguinal neive in males, anu the iounu ligament of the uteius anu ilioinguinal neive in females. The canal is foimeu by the aponeuioses of thiee flat abuominal muscles. *><:=@8D7A >C BH7 -:M<D:@I ,@:@IR 1. &SNH>UFOFBL 5AJSFABL +FAJ - tiiangulai uefect in the exteinal oblique aponeuiosis 2. XHHN 5AJSFABL +FAJ - in the tiansveisalis fascia S. )ACH>F?> YBLL - inteinal oblique muscle (lateially) anu exteinal oblique aponeuiosis (meuially) 4. +??U - falx inguinalis (aiching infeiioi fibeis of inteinal oblique muscle) S. ZL??> - inguinal ligament anu lacunai ligament (meuially) 6. *?@CH>F?> YBLL - tiansveisalis fascia (weak fascia) lateially anu conjoint tenuon (meuially)
)+22$.*$,)[2 (#-+4T.$ Is an inguinal tiiangle thiough which uiiect inguinal heinias piotiuue thiough the abuominal wall.
)$#4-+2 XF>HOC 5AJSFABL (H>AFB@ [ This type of heinia bulges thiough the abuominal wall, thiough Basselbech's tiiangle, meuial to the infeiioi epigastiic vessels anu only thiough the @SNH>UFOFBL FAJSFABL >FAJ. 3& ! 3euial to infeiioi epigastiic aiteiy = &iiect Beinia 5AMF>HOC 5AJSFABL (H>AFB@ - This type of heinia tiavels thiough the ueep anu supeificial inguinal iings anu into the sciotum. Piotiusion thiough the ueep inguinal iing is lateial to the infeiioi epigastiic vessels. This occuis uue to failuie of the closuie of the piocessus vaginalis. XFBNI>BJDBCFO (H>AFB@ - This type of heinia occuis when abuominal contents entei into the thoiax. The most common type of uiaphiagmatic heinia is the hiatal heinia, which is common anu associateu with uERB. Newboins may have uI contents in the thoiax as a iesult of a uefect in the pleuiopeiitoneal membiane.
(H>AFB@ B>H B N>?C>S@F?A ?U JB@C>?FACH@CFABL O?ACHAC@ CI>?SJI B>HB@ ?U THB\AH@@ FA CIH BWM?DFABL TBLLQ
!$3"#+. )$#4-+ A femoial heinia occuis when theie is a weakness in the femoial canaltiiangle, anu occuis uiiectly below the inguinal ligament. This type of heinia is uncommon, accounting foi <S% of all heinias. It is most commonly seen in females uue to theii wiuei pelvic stiuctuie. +HMSOFWLH ZHD?>BL (H>AFB - Is the most common foim, the heinia can be pusheu back into the abuomen. 5>>HMSOFWLH ZHD?>BL (H>AFB - 0ccuis when the heinia is not ieuucible, anu becomes stuck in the femoial canal. 5AOB>OH>BCHM (H>AFB - 0ccuis when the heinia becomes tiappeu in the heinial sack. This is consiueieu to be a suigical emeigency anu iequiies immeuiate tieatment. &C>BAJSLBCHM (H>AFB - 0ccuis when bloou supply to an incaiceiateu heinia is cut- off. This can cause tissue ueath anu the uevelopment of gangiene.
/"#(+.S2G2($3-, +4+2("3"2$2 These aie anastomoses that occui between veins of the poital anu systemic ciiculation. These sites aie impoitant because seveial conuitions may occui as a iesult of changes in piessuie within each system. The most common conuitions incluue: Bemoiihoius, Esophageal vaiices, anu Caput Neuusae. ,"4&-(-"4 2G2($3-, ,-#,1.+(-"4 /"#(+. ,-#,1.+(-"4 (HD?>>I?FM@ Niuule Rectal anu Infeiioi Rectal veins Supeiioi Rectal veins %@?NIBJHBL ]B>FOH@ Azygous veins Left uastiic vein !BNSC /HMS@BH Supeificial Epigastiic vein Paiaumbilical veins
.-T+3$4(2 "! ()$ 1($#12
&#+-4+T$ "! ()$ ($2(,-.$2L"5+#-$2 The left ovaiyteste uiains fiom the left gonaual vein, to the left ienal vein, anu into the infeiioi vena cava. 3HUC .?ABMBL ]HFA ! 3HUC +HABL ]HFA ! 5]! In 2S% of men, this system is not completely competent, anu iesults in a vaiicocele of the left teste
The iight ovaiytest uiains uiiectly fiom the gonaual vein into the IvC. This iaiely iesults in a vaiicocele in men uue to the angle of uiainage.
()$ /$,(-4+($ .-4$ The pectinate line is most commonly useful when a patient has hemoiihoius. Bemoiihoius that aie above the pectinate line uo not cause pain uue to visceial inneivation. Bemoiihoius that aie below the pectinate line have somatic inneivation, anu aie theiefoie painful. !"# %#&'()*'# +()# (, -./0#1 2"#/# '"# "()134' *)1 '"# #&'.1#/0 0##'5 )>CH>FBL @SNNLE @Q>97 BH7 N7EBD:@B7 line is fiom the supeiioi iectal aiteiy. ]HA?S@ M>BFABJH is fiom the supeiioi iectal vein to the infeiioi mesenteiic vein, anu into the poital system. )>CH>FBL @SNNLE Q7I>K BH7 N7EBD:@B7 line is fiom the infeiioi iectal aiteiy. venous uiainage is fiom the infeiioi iectal vein to the inteinal puuenual vein, then into the inteinal iliac vein anu into the IvC.
+4+("3G "! ()$ V-&4$G
+4+("3G "! ()$ T."3$#1.12
+4+("3G "! ()$ ,"#($0 +4& 3$&1..+
+4+("3G "! ()$ V4$$
V4$$ .-T+3$4( +4+("3G +4& -461#-$2 /HAF@OF - The common piesentation of a meniscal injuiy is \AHH NBFA BAM @THLLFAJ, as well as locking of the joint, especially when beaiing weight on the joint anu fully stiaightening the leg. The menisci can be toin when uoing low-impact activities such as walking, anu can be toin when uoing high-impact activities such as weight lifting anu playing spoits. Common causes of injuiy aie FDNBOC C? CIH \AHH BAM B ^CTF@CFAJ_ D?CF?A of the knee when it is fiimly planteu. /HMFBL !?LLBCH>BL 3FJBDHAC - Also known as the tibial collateial ligament. Attacheu pioximally to the meuial conuyle of the femui below the auuuctoi tubeicle anu meuial suiface of its bouy. The posteiioi fibeis aie shoit anu incline backwaius upon uescent, anu aie inseiteu into the tibia above the semi-membianous muscle gioove. It inseits into the meuial suiface of the tibial bouy about 2.Scm below the level of the conuyle. Injuiies aie common in @\FFAJ BAM FA U??CWBLL when GBLJS@ @C>H@@ is applieu (this is "abuuction stiess" aka stiess to the lateial aspect of the knee). 3BCH>BL !?LLBCH>BL 3FJBDHAC - Also known as the "fibulai collateial ligament", is naiiow anu less bioau that the meuial collateial ligament. The LCL tiavels obliquely fiom the lateial epiconuyle of the femui to the heau of the fibula. The anatomy of the LCL gives it moie flexibility than the NCL, anu thus it is less commonly injuieu. )ACH>F?> !>SOFBCH 3FJBDHAC - The ACL gets the teim "anteiioi" because it attaches to the anteiioi aspect of the tibia, with an oiigin fiom ueep within the notch of the uistal femui. Injuiy to the anteiioi ciuciate ligament is the most common knee injuiy, anu is especially seen in athletes. 3BCH>BL >?CBCF?ABL D?GH@ such as those in soccei, basketball, anu skiing aie common causes of ACL stiains anuoi teais. $H@CFAJ U?> )!3 FA`S>E is uone with the BACH>F?> M>BTH> CH@C, wheie the flexeu knee is uiawn foiwaiu in an attempt to iuentify an FAO>HB@HM BD?SAC ?U BACH>F?> CFWFBL C>BA@LBCF?A as compaieu to the opposite joint. The 3BOIDBA CH@C is anothei uiagnostic test that is similai in natuie, but with the patient's knee in 2u-Su uegiee flexion insteau of the 9u-uegiee flexion useu in the anteiioi uiawei test. *?@CH>F?> !>SOFBCH 3FJBDHAC - The posteiioi ciuciate ligament gets its name because it BCCBOIH@ C? CIH N?@CH>F?> B@NHOC ?U CIH CFWFB. It connects the posteiioi inteiconuylai aiea of the tibia to the meuial conuyle of the femui. Injuiy to the PCL causes less pain anu uisability than those to the ACL, anu often goes unuiagnoseu. The common cause of PCL injuiy is the "MB@IW?B>M FA`S>E", wheie something foicefully stiikes the tibia anu uiives it posteiioily. A common mechanism of injuiy uuiing spoiting events is a UBLL ?A B IENH>ULHPHM \AHH with the foot pointeu uownwaius. Patients often complain of a "N?N" uuiing the injuiy. The PCL injuiy is uiagnoseu initially with the posteiioi uiawei test, wheie the tibia is pusheu backwaius anu a uecieaseu iesistance is expeiienceu. $IH 7AIBNNE $>FBM - This is a common knee injuiy seen in football, wheie a playei is hit on the lateial aspect of the knee, causing uamage to the )!3, /!3, anu /HMFBL /HAF@OS@.
()$ 2,-+(-, 4$#5$
!()*$%+ 1
%/2+0"3".0
/?@C ?U CIH FAU?>DBCF?A U>?D CIH HDW>E?L?JE @HOCF?A F@ IFJIKEFHLMQ /HD?>FaBCF?A ?U CIH HDW>E?L?JFO MH>FGBCFGH@ F@ FDN?>CBACV B@ FC F@ LF\HLE C? @I?T SN ?A CIH HPBDV B@ F@ CIH DB`?>FCE ?U CIH FAU?>DBCF?A U>?D CIF@ OIBNCH>Q
2/$#3+("T$4$2-2 Speimatogenesis is the piocess by which the speimatogonia uevelop into the matuie speim (speimatozoa). This occuis in the testes anu epiuiuymis in a step-by- step fashion, taking appioximately 6S uays. The staiting point foi speimatogenesis is the seminifeious tubules of the testes, wheie the stem cells that aie aujacent to the innei tubule wall uiviue in a centiipetal uiiection (moving towaius the lumen). Natuiation of speim occuis in the epiuiuymis, wheie it acquiies its motility. Thioughout speimatogenesis, the seitoli cells play an impoitant iole in the following: - Naintaining the enviionment necessaiy foi matuiationuevelopment via the bloou-testis baiiiei - Secietes suppoiting fluius anu substances to initiate meiosis - Seciete anuiogen-binuing pioteins, which cieate the enviionment foi a highei level of feitility - Seciete inhibin in oiuei to stimulate the pituitaiy glanu to fuithei speimatogenesis - Secietes anti-mulleiian hoimone to pievent the foimation of Nulleiian Bucts - Pioviues piotection to the speimatius fiom autoimmune attack
()$ +4+("3G "! 2/$#3
!#"3 !$#(-.-\+(-"4 (" -3/.+4(+(-"4 0pon feitilization, theie aie many iapiu changes that occui to the egg, incluuing migiation thiough the fallopian tube, implantation, cell uivision, giowth anu uevelopment, etc. The following table anu illustiation uemonstiate the most impoitant points fiom feitilization to implantation. (-3$ $5$4( Initiating Event Feitilization of egg by speim Week 1 Implantation of blastocyst Week 2 Foimation of bilaminai uisk Week S Foimation of piimitive stieak, notochoiu, anu neuial tube. uastiulation Week S-8 Neuial tube foimation. Foimation of oigans. Nost likely time to be haimeu by teiatogenic agents. Week 4 Limb buus begin to foim. Beait begins to beat. Week 1u uenitals aie uiffeientiateu.
)-2("T$4$2-2 Is the foimation of the uiffeient tissues of the bouy fiom unuiffeientiateu cells. These aie the ectoueim, mesoueim, anu enuoueim. %OC?MH>D - The ectoueim is the moie supeificial tissue, they incluue: - 64/-*&# 7&'.1#/0: Epiueimis, Lining of the epithelium, Lens of the eye, anu the auenohypophysis. - 8#4/.#&'.1#/0: CNS Neuions, Neuiohypophysis, 0ligouenuiocytes, Astiocytes, anu the Pineal ulanu - 8#4/*+ 9/#,': Autonomic Neivous System, Boisal Root uanglia, Nelanocytes, Chiomaffin Cells of Auienal Neuulla, Enteiochiomaffin Cells, Pia Natei, Celiac uanglion, Schwann Cells, Paiafolliculai Cells of Thyioiu, Laiyngeal Caitilage
%AM?MH>D - The enuoueim is foimeu by cells migiating along the aichenteion, foiming the innei layei of the gastiula, thus ueveloping into the enuoueim. The cells of the enuoueim being as squamous cells, but finally change into columnai cells. The tissues of the enuoueim incluue: - The entiie gastiointestinal tiact except pait of the mouth, phaiynx, anu the teiminal iectum (foimeu by ectoueimal involution) - The tiachea, bionchi, anu alveoli - Lining of the follicles of the thyioiu, thymus, anu paiathyioiu glanus
/H@?MH>D - The mesoueim is the miuule geimal layei, giving iise to many uiffeient tissues. Some mesoueimal tissues contain the ability to uiffeientiate into a uiveise iange of tissues, such as the bone maiiow. The tissues of the mesoueim incluue: - The auienal coitex - The spleen - Buia of connective tissues - Nuscle tissues - Bone - Stiuctuies of the heait - The lymphatic system - The uiinaiy system (kiuneys incluueu) - Seious linings of peiitoneal bouy cavities - Bloou
()$ 13*-.-,+. ,"#& The umbilical coiu is unique in that it contains TW0 aiteiies anu 0NE vein. The umbilical vein is iesponsible foi supplying the fetus with oxygenateu bloou, while the aiteiies aie iesponsible foi caiiying ueoxygenateu bloou fiom the fetus.
$3*#G"."TG "! ()$ )$+#( The embiyonic stiuctuies of the heait coiiesponu with the matuie stiuctuies of the heait, they aie: $>SAOS@ )>CH>F?@S@ ! Ascenuing aoita anu pulmonaiy tiunk 2SLWS@ !?>MF@ ! Smooth paits of left anu iight ventiicle *>FDFCFGH ]HAC>FOLH ! Tiabeculateu paits of the left anu iight ventiicle *>FDFCFGH )C>FB ! Tiabeculateu left anu iight atiium 3HUC (?>A ?U &FAS@ ]HA?@S@ ! Coionaiy sinus #DMHB )>8: >C 25 ! Smooth pait of iight atiium +FJIC O?DD?A OB>MFABL GHFA BAM >FJIC BACH>F?> OB>MFABL GHFA ! SvC
13*-.-,+. 5$22$.2 ]%5# U "JFM7:@B7= )+$%+0 U &7>JFM7:@B7=
!$(+. ,-#,1.+(-"4 0xygenateu bloou is caiiieu fiom the placenta to the fetus via the umbilical vein. Appioximately half of this bloou enteis the fetal MSOCS@ GHA?@S@ anu is caiiieu to the infeiioi vena cava, with the othei half enteiing the livei. As the bloou enteis the iight atiium of the heait, most of it flows thiough the U?>BDHA ?GBLH anu into the left atiium (WENB@@FAJ CIH NSLD?AB>E OF>OSLBCF?A). The bloou then moves into the left ventiicle anu is pumpeu thiough the aoita to the bouy. Some of the bloou tiaveling thiough the bouy enteis the inteinal iliac aiteiies anu to the umbilical aiteiies, ie-enteiing the placenta anu uisposing of caibon uioxiue anu othei waste piouucts (which tiavel to the mateinal ciiculation). Note that theie is a connection between the aoita anu the pulmonaiy aiteiy calleu the MSOCS@ B>CH>F?@S@, which shunts most bloou away fiom the lungs because they aie not useu until the fetus is boin. 0pon biith of the infant, the fiist bieath causes a MHO>HB@H FA CIH >H@F@CBAOH ?U CIH NSLD?AB>E GB@OSLBCS>H, incieasing the piessuie in the left atiium ielative to the piessuie of the iight atiium. This leaus to the OL?@S>H ?U CIH U?>BDHA ?GBLH (now the fossa ovalis). Theie is also a closuie of the MSOCS@ B>CH>F?@S@ because the incieaseu concentiation of oxygen causes the piostaglanuin levels to ueciease. This closuie pievents the bloou fiom bypassing the pulmonaiy ciiculation, allowing the lungs to function piopeily.
($#+("T$4-, +T$4(2 "! /#$T4+4,G Congenital anomalies occui in appioximately S% of all live biiths, with mateinal exposuie to teiatogenic agents being iesponsible foi 4%-6% of those cases (appioximately 14uu liveboin infants). Timing is an impoitant factoi in a teiatogen's ill-effect on the fetus, with the most susceptible time being between the S iu anu 8 th weeks of piegnancy, which is the most active time of oiganogenesis. ($#+("T$4-, +T$4( $!!$,( "4 !$(12 Anuiogenic Boimones Clitoial enlaigement, labiosciotal fusion when given befoie 1S weeks gestation. *0CP's not shown to piouuce anomalies when useu in 1 st tiimestei of piegnancy. Waifaiin anu othei coumauin-ueiiveu anticoagulants Nultiple anomalies, most commonly: Bevelopmental uelay, hyuiocephalus, agenesis of coipus collosum, meningoencephalocele, miufacial hypoplasia. vaiious oculai, skeletal, anu othei biith uefects. Antithyioiu meuications (PT0, Nethimazole, Iouiue) 0ccasionally piouuces tiansient fetal hypothyioiuism anu goitei. Biphenylhyuantoin Abnoimal facies, miciocephaly, giowth ueficiency, mental ietaiuation, hypoplastic nails, hypoplastic phalanges. valpioate anu Caibamazepine Neuial tube uefects Lithium Ebstein's anomaly Biethylstilbestiol Stiuctuial uefects of the female genital tiact, vaginal auenosis. Isotienitoin Niciophthalmia, hyuiocephalus, miciotia, cleft palate, blinuness, ueafness, heait uisease, thymic agenesis. Alcohol Fetal alcohol synuiome Tobacco Spontaneous aboition, incieaseu iisk of placental abiuption oi pievia, pieteim ueliveiy, anu piematuie iuptuie of membianes. Cocaine Placental abiuption Thaliuomiue Limb uefects ACE inhibitois Renal uamage
!$(+. $#G()#"/"-$2-2 The foimation of ieu bloou cells is caiiieu out by foui uiffeient stiuctuies thioughout fetal uevelopment. Fiom appioximately 4K; THH\@, it is caiiieu out by the 0"3b &)! Fiom appioximately 9K4= THH\@, it is caiiieu out by the 35]%+ BAM &*3%%# Fiom appioximately 1; THH\@ BAM WHE?AM, it is caiiieu out by the 2"#% /)++"Y
*#+4,)-+. +#,) -44$#5+(-"4 +4& &$#-5+(-5$2 )>OI , ueiivatives aie supplieu by CN v2 anu vS )>OI 1 ueiivatives supplieu by CN vII )>OI 4 ueiivatives supplieu by CN IX )>OI 6 BAM 9 ueiivatives aie supplieu by CN X +#,) X +#,) Z +#,) ] +#,) ^ _ ` /HO\HLc@ OB>CFLBJH: Nanuible Nalleus Incus Sphenomanuibulai ligament /S@OLH@ ?U DB@CFOBCF?Ad Nassetei LateialNeuial pteiygoiu Nylohyoiu Anteiioi belly of uigastiic Tensoi tympani Tensoi veli palatini #H>GH: CN vS +HFCH>c@ !B>CFLBJH: Stapes Styloiu piocess Lessei hoin of hyoiu Stylohyoiu ligament /S@OLH@: Stapeuius Stylohyoiu Posteiioi belly of uigastiic #H>GH: CN vII !B>CFLBJH: uieatei hoin of hyoiu /S@OLH@: Stylophaiyngeus #H>GH: CN IX !B>CFLBJH: Thyioiu Ciicoiu Aiytenoius Coiniculate Cuneifoim /S@OLH@ ?U 6 CI
B>OI: Nost of the phaiyngeal constiictois Ciicothyioiu Levatoi veli palatini /S@OLH@ ?U 9 CI
B>OI: All intiinsic muscles of laiynx except ciicothyioiu #H>GH: 4 th aich is CN X, 6 th aich is CN X
*#+4,)-+. ,.$!( &$#-5+(-5$2 , @C W>BAOIFBL OLHUC ! Exteinal auuitoiy meatus 1 AM [ 6 CI OLHUC@ ! Foimation of tempoiaiy ceivical sinuses when the 2 nu aich mesenchyme is obliteiateu
(%-4 /#$T4+4,-$2 Theie aie two types of twin piegnancies, /?A?aEJ?CFO anu XFaEJ?CFO twins. The Bizygotic twins aie aka "Z>BCH>ABL $TFA@", anu have 2 placentas, 2 amniotic sacs, anu 2 choiions. Nonozygotic twins aie "FMHACFOBL CTFA@", anu contain 1 placenta, 1 choiion, anu 2 amniotic sacs.
$3*#G"."TG "! ()$ $+# The bones, muscles, anu othei stiuctuies of the eai all have embiyologic ueiivates. These stiuctuies anu theii ueiivatives aie: $@8 2B8<EB<87 $?Q8F>I>MDE &78D9@BD97 Tympanic Nembiane 1 st phaiyngeal membiane Eustachian Tube 1 st phaiyngeal membiane Exteinal Auuitoiy Neatus 1 st cleft Incus 1 st aich Nalleus 1 st aich Stapes 2 nu aich Tensoi Tympani (vS) 1 st aich Stapeuius (vII) 2 nu aich
$3*#G"."TG "! ()$ ("4T1$
$3*#G"."TG "! ()$ ()G312 The thymus is ueiiveu fiom the epithelium of the 4 >M
W>BAOIFBL N?SOIH@. The thymus functions in piouuction of T-lymphocytes, which aie essential paits of the auaptive immune system. The &./'#: of the thymus is 1#),# with immatuie T cells, while the 0#14++* contains the 0*'4/# T cells.
$3*#G"."TG "! ()$ ()G#"-& T.+4& The thyioiu glanu is ueiiveu fiom the flooi of the piimitive phaiynx, anu upon uevelopment it uescenus into the neck. The thyioiu connects to the tongue via the thyioglossal uuct (uisappeais in noimal uevelopment). Bue to the anatomy anu ielationship of the thyioiu to the tongue, ectopic thyioiu tissue is most commonly founu in the tongue.
$3*#G"."TG "! ()$ /+4,#$+2 As a whole, the pancieas is ueiiveu fiom the foiegut. ]HAC>BL *BAO>HBCFO 2SM ! Pancieatic heau, 0ncinate piocess, anu main pancieatic uuct. X?>@BL *BAO>HBCFO 2SM ! Bouy of pancieas, tail of pancieas, Isthmus, Accessoiy pancieatic uuct.
&$5$."/3$4( "! T$4-(+. &1,(2 3$2"4$/)#-, &1,( O%>ICCD@:P /+#+3$2"4$/)#-, &1,( O3<II78D@:P Testicles seciete mulleiian-inhibiting substance in oiuei to suppiess the uevelopment of paiamesonephiic uucts.
XHGHL?N@ FAC?: Epiuiuymis, Ejaculatoiy uuct, Seminal vesicles, Buctus Befeiens Lack of secietion of Nulleiian-inhibiting substance causes giowth of Paiamesonephiic uucts.
XHGHL?N@ FAC?: Fallopian Tube, 0teius, 0ppei pait of vagina
!?>CHP = Bense, immatuie T cells. /HMSLLB = Pale, matuie T cells.
)"3"."T1$2 "! ()$ &$5$."/-4T T$4-(+. (#+,( By 6-8 weeks, a fetus has histologically uistinguishable gonaus. By 7 weeks, the fetus has a genital tubeicle, uiogenital gioove anu sinus, anu labiosacial folus. In a female, without excess anuiogens these will become the clitoiis, uiethia, vagina, anu labia. The male fetus becomes uistinct between 8-12 weeks, anu the anuiogens will enlaige the phallus anu cause the uiogenital gioove anu sinus to fuse in the miuline.
$3*#G"."TG "! ()$ &-+/)#+T3 Buiing initial uevelopment, the uiaphiagm is inneivateu by neives CS, C4, anu CS. As the uiaphiagm uescenus, it maintains this inneivation. The uiaphiagm is ueiiveu fiom the following embiyologic stiuctuies: - Septum Tiansveisum - Pleuiopeiitoneal Folus - Bouy Wall - Boisal Nesentaiy of the Esophagus
!"#3+(-"4 "! *"4$ Theie aie two main types of bone uevelopment, those being "intiamembianous" bone anu "enuochonuial" bone. Intiamembianous bone is foimeu spontaneously without the piesence oi neeu of any pie-existing caitilage. 0n the othei hanu, enuochonuial bone (long bones) iequiies the piesence of caitilaginous molus in oiuei to foim its bony stiuctuie. The caitilaginous molu ossifies anu piouuces the enuochonuial bone.
,"4T$4-(+. +*4"#3+.-(-$2 "! ()$ /$4-2 Bypospauias is the moie common congenital penile abnoimality, anu it can be associateu with 0TI's in chiluien.
!()*$%+ 4
(5&$"3".0
(F@C?L?JE F@ A?C C>BMFCF?ABLLE B GH>E IFJIKEFHLM O?DN?AHAC ?U CIH &CHN , HPBDV WSC FC F@ FDN?>CBAC C? \A?T TIFOI CENH ?U HNFCIHLFSD DB\H@ SN BLL ?U CIH @C>SOCS>H@ ?U CIH W?MEV B@ THLL B@ BLL NBCI?L?JFH@ CIBC B>H LFA\HM C? IF@C?L?JFOBL OIBAJH@Q
Y(5$% 23""X !%33& ; *<* =#4<.&>'#, The white bloou cell is iesponsible foi uefense against infections. They aie maue up of the uianulocytes (Eosinophils, Basophils, Neutiophils), anu the Nononucleai cells (Lymphocytes, Nonocytes).
+%X 23""X !%33& [ *<* 7/>'"/.&>'#, The bloou cell iesponsible foi oxygen tianspoit. It has many impoitant functions, is without nucleus, is biconcave, anu has a laige suiface volume that enables easy gas exchange.
#%7$+"*(53& - Involveu in the acute inflammatoiy iesponse, anu make up appioximately 4u-7u% of WBC's. They engulf via phagocytosis, aie multilobeu, anu contain lysosomes. Look foi hypeisegmenteu neutiophils when a patient has a vitamin B12 anuoi folate ueficiency.
%"&5#"*(53& - These aie piotective against helminth anu piotozoal infections. They aie highly phagocytic against antigen-antibouy complexes. They piouuce histamine anu aiylsulfatase. Eosinophils make up 1%-6% of all WBC's, aie bilobeu, anu aie packeu with laige eosinophilic gianules.
2)&"*(53& - Basophils compiise less than 1% of all WBC's, anu aie the key components of alleigic ieactions. Basophils contain histamine anu hepaiin, as well as othei vasoactive amines.
/"#"!0$%& - Contains a kiuney-shapeu nucleus, compiises appioximately 2%- 1u% of WBC'S.
LYNPB0CYTES - Aie small, iounu, anu stain uensely. T lymphocytes piouuce a cellulai immune iesponse, while B lymphocytes piouuce antibouies.
4$1#")-2("."TG X%#X+5$5! !%33& - Antigen piesenting cells, seen in some tissues who come in contact with the skin (Langeihans cells), innei lining of the nose, lungs, stomach, anu intestines.
/5!+".35) - These aie the phagocytes of the CNS, they aie the main foim of uefense in the CNS.
"35."X%#X+".35) - These cells act to myelinate the axons of the CNS. These aie the pieuominant glial cell in the white mattei.
SCBWANN CELLS - Schwann cells myelinate the axons, they also piomote axonal iegeneiation.
*%+5*(%+)3 #%+]% &$+7!$7+% - Consists of the 7%()#4/(40, ?#/()#4/(40, anu 7)1.)#4/(405 The epineuiium is uense anu suiiounus the entiie neive, the peiineuiium is what allows foi peimeability, anu the enuoneuiium is within the neive anu suiiounus eveiy single neive fibei.
)-2("."TG "! ()$ 2V-4
3$-224$#[2 ,"#/12,.$2 a Aie encapsulateu sensoiy ieceptois in the ueimis of the palms, soles, anu fingeis. They aie involveu in light, uisciiminatoiy touch of haiiless skin. 3$#V$.[2 ,"#/12,.$2 - These aie tactile uiscs, which meuiate light ciuue touch. /+,-4-+4 ,"#/12,.$2 - These aie laige encapsulateu sensoiy ieceptois of the ueepei layeis of the skin at ligaments, joint capsules, mesenteiy, anu seious membianes. They aie involveu in uetecting piessuie, vibiation, iough touch, anu tension.
$/-()$.-+. ,$.. 614,(-"42
()$ T."3$#1.+# *+2$3$4( 3$3*#+4$ The glomeiulai basement membiane is foimeu by the fusion of enuothelium anu pouocyte basement membianes. It seives to filtei plasma
()$ T".T- +//+#+(12 The golgi appaiatus seives the puipose of piocessing anu packaging pioteins anu lipius befoie they aie secieteu to the iest of the bouy. The golgi appaiatus is maue of stack of membiane-bounu stiuctuies of cisteinae, which caiiy golgi enzymes to help oi mouify the pioteins that tiavel thiough them.
The main functions of the golgi appaiatus incluue: - Bistiibution of pioteins anu lipius fiom the enuoplasmic ieticulum to the plasma membiane, lysosomes, anu thiough secietoiy vesicles - Auuition of an 0-oligosacchaiiue to Seiine anu Thieonine - Auuition of N-oligosacchaiiue to Aspaiagine - Pioteoglycan assembly - Sulfation of sugais in pioteoglycans
#"1T) $4&"/.+23-, #$(-,1.13 O#$#P The Rough Enuoplasmic Reticulum is iesponsible foi many functions, incluuing: - N-linkeu glycosylation - Auuition of lysosomal enzymes with mannose-6-phosphate maikei - Integiation of membiane pioteins Insiue of neuions, theie is the "Nissl bouy", which is the RER of the neuion. 23""() $4&"/.+23-, #$(-,1.13 O2$#P The Smooth Enuoplasmic Reticulum is wheie steioius aie synthesizeu anu wheie uiug uetoxification takes place.
+.5$".+#S,+/-..+#G *+##-$# This baiiiei is piesent in the gas-exchange iegion of the lungs, anu seives to pievent the foimation of aii bubbles in the bloou, anu fiom bloou enteiing into the alveoli. This baiiiei is extiemely thin anu veiy stiong (thanks to type Iv collagen), allowing foi sufficient uiffusion of oxygen. The alveolai-capillaiy baiiiei is foimeu by type 1 pneumocytes of the alveolai wall, the enuothelial cells of the capillaiies, anu the basement membianes between the two cells. This baiiiei is easily peimeable to many gases, especially u2, C02, anu C0.
/4$13",G($2 Theie aie two types of pneumocytes, anu they contiibute to the maintenance of the alveoli. They extenu into the bionchioles, while goblet cells extenu only to the teiminal bionchioles. $IH>H B>H CT? CENH@ ?U NAHSD?OECH@d Type 1 anu Type 2 (FN7 X /:7<?>EFB7A aie iesponsible foi gas exchange in the alveoli, anu covei >9S% of the alveolai suiface (FN7 Z /:7<?>EFB7A aie iesponsible foi secieting suifactant, which helps to ueciease the alveolai suiface tension. The type 2 pneumocyte is also a piecuisoi to type 1 pneumocytes.
()$ &-T$2(-5$ (#+,( The histologyanatomy of the uigestive tiact is complex, consisting of suppoitive stiuctuies, musculai stiuctuies, anu glanuulai stiuctuies. The uI tiact is also an impoitant pait of the immune system. The uppei uI tiact consists of the esophagus, stomach, anu uuouenum. The lowei uI tiact incluues most of the small intestine, the laige intestine, anu the anus. Bistologically, the uI tiact can be uiviueu into the ?<E>A@, A<Q?<E>A@, ?<AE<I@8DA 7JB78:@, anu the @=97:BDBD@. /7!"&) - The inneimost layei of the uI tiact, suiiounus the lumen. It is impoitant in the piocess of uigestion, as it is iesponsible foi absoiption anu secietion. The mucosa can fuithei be subuiviueu into #%('"#+(40, +*0()* %/.%/(*, anu 04,&4+*/(, 04&.,*. &72/7!"&) - The submucosa is a uense layei of connective tissue that acts as suppoit to the uI tiact. It holus the Neissnei's plexus, which is an enteiic neivous plexus that sits on the innei suiface of the musculaiis mucosa. The submucosa also contains bloou vessles, lymphatic's, anu neives that bianch into the mucosa anu the musculaiis exteina. /7&!73)+5& %f$%+#) - This stiuctuie consists of an innei anu outei layei of muscle tissue. The innei ciiculai layei contiacts to squeeze the contents, while the outei longituuinal layei contiacts to shoiten the tiact. These two contiactions togethei help with peiistalsis, thus piopelling the foou along the tiact. )X]%#$5$5) - The auventitia is one moie component in uI tiact suppoit.
Theie aie two enteiic plexuses that help co-oiuinate all of the functions of the uI tiact. $IH /EHACH>FO *LHPS@ - Co-oiuination of motility along the entiie gut wall. This plexus is locateu between the longituuinal anu ciiculai smooth muscle of the uI tiact, anu is also known as Aueibach's plexus. $IH &SWDSO?@BL *LHPS@ - This plexus iegulates secietions, bloou flow, anu absoiption. Locateu between the mucosa anu the innei layei of smooth muscle, it is also known as Neissnei's plexus. *Both plexuses contain paiasympathetic teiminal effectoi neuions.
*#144$#[2 T.+4&2 Biunnei's glanus aie the only glanus in the uI submucosa. They aie iesponsible foi secieting alkaline mucus, anu may hypeitiophy in the case of a uuouenal ulcei.
/$G$#[2 /+(,)$2 Peyei's patches aie aggiegations of lymphoiu tissue that aie founu in the ileum. They aie ovally-shapeu lymphoiu follicles in the lamina piopiia layei of the mucosa, extenuing into the submucosa of the ileum. These patches aie unencapsulateu, coveieu by a single layei of cuboiual enteiocytes with specializeu N cells inteispeiseu. These N cells aie iesponsible foi taking up antigens. Stimulateu B cells tiavel fiom the Peyei's patches, going thiough the lymph anu bloou to the lamina piopiia of the intestine, wheie they uiffeientiate into IgA- secieting plasma cells. The IgA is piotective, tiaveling acioss the epithelium to the gut to ueal with the intialuminal antigen.
.G3/) 4"&$2 Lymph noues aie seconuaiy lymphoiu oigans that function as non-specific filtiation by maciophages, antibouy piouuction, anu stoiage oi B anu T cells. The lymph noue contains many affeients, anu at least one oi moie effeient. &C>SOCS>H ?U CIH 3EDNI #?MH@ 9./'#: - The outei coitex consists mainly of B cells that aie aiiangeu in follicles, which can uevelop a geiminal centei when in contact with an antigen. The innei coitex is mainly T cells. A#14++* - Theie aie the meuullaiy coius anu the meuullaiy sinuses. The coius aie mainly plasma cells, lymphocytes, anu B cells. The sinuses take in the flow of lymph fiom the coitical sinuses, anu contain maciophages anu ieticulai cells. B.++(&+# - The follicle is wheie B-cells aie localizeu anu wheie they piolifeiate. Piimaiy follicles aie uenseuoimant, wheie the seconuaiy follicles have a pale cential geiminal centei, anu they aie active. 3EDNI A?MH OF>OSLBCF?A: The lymph ciiculates to the lymph noue thiough the affeient lymphatic vessel, uiaining into the subcapsulai sinus. This subcapsulai sinus then uiains into tiabeculai sinuses, anu finally into the meuullaiy sinuses. &SWOBN@SLB> @FAS@ ! C>BWHOSLB> @FAS@ ! DHMSLLB>E @FAS@H@
+&#$4+. ,"#($0 _ 3$&1..+ Theie aie S layeis to the auienal coitex, they aie: 1. Zona ulomeiulosa ! secietes Aluosteione (ulucocoiticoius) 2. Zona Fasciculata ! secietes Coitisol (Stiess Boimones) S. Zona Reticulaiis ! secietes Anuiogens (Sex Boimones) The auienal meuulla contains chiomaffin cells that seciete the catecholamines Epinephiine anu Noiepinephiine. The most common tumoi of the auienal meuulla in auults is a pheociomocytoma, while the most common tumoi in chiluien is a neuioblastoma.
()$ .-5$#
!HAC>BL ]HFA - Receives the bloou mixeu in the sinusoius of the livei anu ietuins it to ciiculation via the hepatic vein. *?>CBL ]HFA - Biains bloou fiom the uI tiact anu the spleen into the livei. 0sually foimeu by the SNv, splenic veins, INA, gastiic vein, anu cystic vein. This is one of the main poital venous systems of the bouy. (HNBCFO )>CH>E - Runs alongsiue the poital vein anu the common bile uuct to foim the poital tiiau. 2FLH !BABLFOSLS@ - Is a thin tube that collects bile that is secieteu by the hepatocytes. These canaliculi meige to foim the bile uucts, which then become the common hepatic uuct.
()$ 2/.$$4
,-.-+ Cilia is stiuctuieu in a way that allows foi maximum mobility. Insiue each cilia theie is a 9+2 axoneme, as can be seen in the image below. Each 9+2 axoneme acts as a scaffolu foi piotein complexes anu pioviues binuing sites foi motoi pioteins. Especially impoitant is uynein, which is a motoi piotein that conveits the chemical eneigy of ATP into the mechanical eneigy of movement. A uefect in uynein causes a conuition known as "Kaitagenei's Synuiome", which iesults in immotile cilia. Theie aie also 9+u cilia, which aie non-motile.
()$ -44$# $+#
()$ *"4G .+*G#-4()R Consists of the 9C9D=7E (heaiing), the F76!GHI=7 (iesponsible foi sensing lineai acceleiation), anu the 67AG9GJ9I=EJ 9E8E=6 (iesponsible foi angulai acceleiation). This labyiinth is filleu with a fluiu calleu "peiilymph", which is a souium iich fluiu, similai to the extiacellulai fluiu. ()$ 3$3*#+4"12 .+*G#-4()R Consists of the 9C9D=7EJ KI9!L I!JG9=7L 6E99I=7, anu the 67AG9GJ9I=EJ 9E8E=6. This labyiinth is filleu with enuolymph that is iich in potassium, similai to the fluiu insiue the cells. Theie aie haii cells that act as the moue of sensation within both the vesticulai appaiatus anu the cochleai appaiatus of the innei eai. 3"Y Z+%g7%#!0 sounus aie heaiu at the apex of the cochlea (5.( Z+%g7%#!0 sounus aie heaiu at the base of the cochlea.
!()*$%+ 6
#%7+")#)$"/0
#HS>?BABC?DE F@ B IFJIKEFHLM @HOCF?A ?U CIH 7&/3% HPBDQ Z?OS@ ?A WB@FO AHS>?BABC?DE hWL??M @SNNLEV AH>GH @SNNLEiV B@ THLL CIH B@@?OFBCHM AHS>?NBCI?L?JE BAM AHS>?NIE@F?L?JEQ
#$!.$0$2 Theie aie many ieflexes belonging to both the auult anu the infant, anu a set that aie seen only in infants. The ieflex aic is an impoitant concept to unueistanu as it ielates to the clinically impoitant ieflexes.
&$#3+("3$2 Beimatomes aie aieas of the skin that aie mostly supplieu by a single spinal neive. Each of these neives ielay sensations fiom each paiticulai ueimatome to the biain. ; !>BAFBL #H>GH@ [ ,1 $I?>BOFO #H>GH@ [ 8 3SDWB> #H>GH@ [ 8 &BO>BL #H>GH@ 0nueistanuing anu being able to locate ueimatomes is impoitant neuiologically as it allows us to ueteimine the site of uamage to the spine. The most commonly seen infection is a heipes zostei infection, which is an infection that lies uoimant in the uoisal ioot ganglion anu manifests itself along a ueimatome, wiapping aiounu the bouy along the specific ueimatomal aiea. 4$#5$ #""( +#$+ "! &-2(#-*1(-"4 C2 Posteiioi half of the skull cap CS Aiea that coiielates with a high tuitleneck shiit C4 Aiea coiielating to a low-collai shiit C6 Thumb (iauial neive) C7 2 nu anu S iu uigit (meuial neive) C8 4 th , S th uigits (ulnai neive) T4 Nipples TS Infiamammaiy Folu T6T7 Xiphoiu Piocess T1u 0mbilicus T12 Pubic bone iegion L1 Inguinal Ligament L4 Knee caps S2, SS uenitalia
&$5-+(-"42 ("%+#&2 +4& +%+G !#"3 ,4 .$2-"42 ,4 b ?>B>8 I7AD>: ! }aw will ueviate C?TB>M@ siue of lesion ,4 XY I7AD>: ! 0lna ueviates BTBE fiom siue of lesion ,4 XX I7AD>: ! Weakness in tuining heau to the ?NN?@FCH siue of lesion ,4 XZ I7AD>: ! Tongue will ueviate C?TB>M@ siue of lesion (lick the wounu)
*#+-42($3 ,#+4-+. 4$#5$ 41,.$-
()$ (#+,(2 "! ()$ 2/-4+. ,"#& Nemoiization of the functions of uiffeient aieas of the spinal coiu is essential to being able to iuentify wheie a paiticulai spinal coiu lesion may be locateu. *E>FDFMBL: =*'#/*+ 9./'(&.,%()*+ - Contiols movement of ipsilateial limbs E)'#/(./ 9./'(&.,%()*+ - Conuuction of voluntaiy motoi impulses fiom piecential gyius to the motoi centei of the coiu %PC>BNE>FDFMBL: J4M/.,%()*+ - Nain ioute foi meuiation of voluntaiy movement (laige muscles anu fine motoi contiol) J#'(&4+.,%()*+ - Co-oiuinates automatic movement of locomotion anu postuie, influences muscle tone, meuiates autonomic functions, anu mouulates pain impulses F#,'(M4+.,%()*+ - Lateial: Ipsilateial uescent to paiaveitebial anu pioximal limb extension. Neuial: Bilateial uescent, contiols eye movement, neck position, gaze X?>@BL !?LSDA /HMFBL 3HDAF@OS@ &E@CHD: N/*&(+# B*&(&4+4, - Fine touch, vibiation, piopiioception to lowei bouy Cuneate Fasciculus - Fine touch, vibiation, anu piopiioception to uppei bouy &NFA?OH>HWHLLB> $>BOC: ?.,'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position E)'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position )ACH>?LBCH>BL &E@CHD: =*'#/*+ 6%().'"*+*0(& !/*&' - Pain anu tempeiatuie E)'#/(./ 6%().'"*+*0(& !/*&' - Soft nocioception &NFA?K"LFGB>E $>BOC: Piopiioception fiom muscles anu tenuons as well as cutaneous impulses to the olivaiy nucleus
*#"%4 2$e1+#& 2G4&#"3$ Biown-Sequaiu synuiome occuis when theie is a hemisection of the spinal coiu. It piesents with the following: - Ipsilateial loss of motoi function anu the piesence of spasticity (pyiamiual) - Ipsilateial loss of tactile, vibiation, anu piopiioception senses (uoisal column) - Contialateial loss of pain anu tempeiatuie (spinothalamic) - Ipsilateial loss of all sensation at the level of injuiy
()$ /1/-..+#G .-T)( #$!.$0 The mechanism by which the pupils ieact to light is quite stiaight-foiwaiu. 2B7N X - Light is uetecteu anu the ietinal ganglion cells convey this infoimation thiough photoieceptois to the optic neive. The optic neive is connecteu to the pietectal nucleus, anu senus the fiist signal heie notifying it of incoming light. 2B7N Z - Fiom the pietectal nucleus, a message is sent to the Euingei-Westphal nucleus 2B7N ] - The occulomotoi neive (fiom the Euingei-Westphal nucleus), then senus a message to the constiictoi muscles of the iiis. The iiis muscles contiact bilateially (consensual ieflex).
,"461T+($ T+\$ Conjugate gaze is a piocess wheieby both of the eyes look in the same uiiection simultaneously. The piocess begins with the fiiing of CN 6, which then contiacts the lateial iectus muscle to look into one uiiection, which simultaneously contiacting the contialateial nucleus of CN S (via the meuial longituuinal fasciculus). The CN S then contiacts the meuial iectus anu the conjugate gaze is in tact. With many uiseases such as multiple scleiosis, theie is a lesion in the NLF, which will inhibit the tiansmission of the signal to the contialateial CN S. When this occuis, the seconu eye uoes not look to the same uiiection, anu the patient then has a gaze palsy, also known as 'inteinucleai ophthalmoplegia'.
5-21+. !-$.& &$!$,-(2 Beficits to the visual fielu can occui fiom eithei uiseases oi fiom uisoiueis of the eye, optic neive, anu biain. The foui most common types of visual fielu uefects aie: 1. Altituuinal fielu ueficits, which is a loss of vision above oi below the hoiizontal 2. Bitempoial hemianopsia, which is a loss of vision at oui aspects of the visual fielu S. Bomonymous hemianopsia, which is a loss of vision on the same siue in both eyes 4. Cential scotoma, which is a loss of cential vision
()$ ,-#,.$ "! %-..-2 The Ciicle of Willis is a ciicle of aiteiies that supplies the biain with bloou. The uesign of the Ciicle of Willis is such that shoulu one aiea become stenoseu oi blockeu completely, bloou flow fiom othei bloou vessels can often pieseive peifusion well enough to avoiu ischemic events. The ciicle is compiiseu of the following aiteiies: - )ACH>F?> OH>HW>BL B>CH>FH@ - )ACH>F?> O?DDSAFOBCFAJ B>CH>E (connects both anteiioi ceiebial aiteiies) - 5ACH>ABL OB>?CFM B>CH>FH@ (aiise fiom common caiotiu aiteiies) - *?@CH>F?> OH>HW>BL B>CH>FH@ (aiise fiom basilai aiteiy) - *?@CH>F?> O?DDSAFOBCFAJ B>CH>FH@ (fiom a bianch of inteinal caiotius)
*.""& 21//.G (" ()$ *#+-4 )ACH>F?> !H>HW>BL )>CH>E - supplies the meuial suiface of the biain, anu the leg-foot aiea of the motoi anu sensoiy coitices. /FMMLH !H>HW>BL )>CH>E - supplies the lateial aspect of the biain, the tiunk-aim- face aiea of the motoi anu sensoiy coitices, as well as Bioca's anu Weinicke's speech aieas. )ACH>F?> !?DDSAFOBCFAJ )>CH>E - connects the anteiioi ceiebial aiteiies, anu is the most common site of Ciicle of Willis aneuiysm. *?@CH>F?> !?DDSAFOBCFAJ )>CH>E - connects thiee ceiebial aiteiies on each siue, is anothei common site of aneuiysm, anu can cause cianial neive S palsies.
)$#4-+(-"42 "! ()$ *#+-4 Ceitain signs anu symptoms shoulu aleit you to the possibility of biain heiniations. Biffeient signs can help you naiiow uown the specific aiealesion that may be piesent. Theie aie two majoi classes of heiniation - the supiatentoiial anu infiatentoiial heiniations. The stiuctuie that uiffeientiates these two categoiies is the tentoiial notch (those above = supiatentoiial, those below = infiatentoiial). &SN>BCHAC?>FBL (H>AFBCF?A@ - 0ncal, Cential, Cingulate, Tianscalvaiial 5AU>BCHAC?>FBL (H>AFBCF?A@ - 0pwaiu (ceiebellai), Tonsillai (uownwaiu ceiebellai)
()$ .13*+# /14,(1#$ The lumbai punctuie is a uiagnostic tool useu to collect anu analyze the ceiebiospinal fluiu. 5AMFOBCF?A@ ! CSF analysis when meningitis, fevei of unknown oiigin, anu signs of meningeal iiiitation aie piesent. Byuiocephalus, benign intiacianial hypeitension, anu subaiachnoiu hemoiihages can all be uiagnoseu anu suppoiteu with an LP. The LP is also useful when intiathecal (injection into the spinal coiu) ioute of auministiation is necessaiy, such as with spinal anesthesia oi chemotheiapy. !?AC>BFAMFOBCF?A@ ! The most impoitant contiainuication to a lumbai punctuie is the piesence of incieaseu intiacianial piessuie. 0thei impoitant contiainuications aie coagulopathies, iespiiatoiy uifficulties, ueteiioiating consciousness, anu when theie is hypeitension plus biauycaiuia.
)>K DA BH7 ./ N78C>8?7=f
1//$# 3"("# 4$1#"42 0ppei motoi neuions aie motoi neuions that oiiginate in the motoi iegion of the coitex oi biain stem. They caiiy infoimation uown specific aieas on the spinal coiu, at which point they senu signals to the lowei motoi neuions (via glutamineigic ieceptois). The main effectoi neuions aie within layei S of the piimaiy motoi coitex, anu these aie some of the laigest cells in the biain.
7/# 3H@F?A@: Theie aie a set of common symptoms that occui with an 0NN lesions, incluuing: - Spasticity - Becieaseu muscle tone - Positive Babinski Sign - Pyiamiual weakness - Bypeiieflexia - Incieaseu BTR's
."%$# 3"("# 4$1#"42 Lowei motoi neuions aie the motoi neuions that connect the biainstem anu the spinal coiu to the muscle fibeis (ie theii axon enus in the effectoi muscle). The LNN's aie classifieu baseu on the muscle fibei types that they each inneivate, these aie the alpha-motoi neuions anu the gamma-motoi neuions. )LNIBKD?C?> AHS>?A@ - Aie the most numeious type of neuions of muscle fibei, aie involveu in muscle contiaction, anu inneivate extiafusal muscle fibeis. .BDDBKD?C?> AHS>?A@ - Aie components of the muscle spinules, involveu in piopiioception, anu inneivate the intiafusal muscle fibeis.
3/# LH@F?A@: Theie aie a set of common symptoms with LNN lesions, incluuing: - Becieaseu muscle tone - Nusculai weakness - Bypoieflexia - Fasciculations - Atiophy of skeletal muscle - Paialysis
-3/"#(+4( ,.-4-,+. ,"4&-(-"42 -45".5-4T 134 _ .34 .$2-"42 )DE?C>?NIFO 3BCH>BL &OLH>?@F@ - Both 0NN anu LNN signs. Is a slowly ueveloping uisease that is ultimately fatal. Patient expeiiences weakness anu wasting of the bulbai muscles (speech, swallowing, chewing), as well as the aims, legs, anu toiso. Nuscle weakness anu wasting uevelops piopoitionally on both siues. Sensation anu mentation iemain intact. *>?J>H@@FGH 2SLWB> *BL@E - LNN *@HSM?WSLWB> *BL@E - 0NN *>FDB>E 3BCH>BL &OLH>?@F@ h*3&i - 0NN, males > females *>?J>H@@FGH /S@OSLB> )C>?NIE - slow uegeneiation of LNN's &NFABL /S@OSLB> )C>?NIE h&/)i - LNN, uegeneiation of anteiioi hoin cells *?LF?DEHLFCF@ - LNN uestiuction
*$..[2 /+.2G Bell's palsy is a unilateial paialysis of facial muscles uue to a uysfunction of the facial neive (CN7). Theie aie many possible causes, such as viial, Lyme uisease, stioke, inflammation, etc. This conuition is almost always self-limiting.
&FJA@ j &EDNC?D@d - Ipsilateial facial paialysis - Inability to blink eye on affecteu siue
g-?N>8B@:Bg It is highly impoitant to look foi the ability to wiinkle the foieheau, as the ability to uo so usually inuicates that theie is an uppei motoi neuion lesion. This 0NN lesion iesults in a conuition known as "OHAC>BL UBOFBL NBL@E", wheieby the pioblem is a paialysis of the contialateial lowei pait of the face.
!14,(-"42 "! ()$ ,$#$*#+. ,"#($0
*#+-4 .$2-"42 .$2-"4 +#$+ #$21.( "! .$2-"4 2>?OBc@ )>HB Patient has expiessive aphasia (can't speak), has goou unueistanuing of speech YH>AFO\Hc@ )>HB Patient has inability to compiehenu speech, can speak well Z>?ACBL 3?WH Peisonality changes, uefects in juugement (ie Fiontal ielease signs) )>OSBCH ZB@OFOSLS@ Patient has goou language compiehension with pooi ability to speak in iepetition )DEJMBLB Kluvei-Bucy Synuiome - patient becomes hypeisexual, hypeioial, anu has uisinhibiteu behavioi +FJIC *B>FHCBL 3?WH Patient has "spatial neglect", thus uo not iecognize the contialateial siue of the lesion /BDDFLLB>E 2?MFH@ Confabulations, anteiogiaue amnesia 2B@BL .BAJLFB Resting tiemoi !H>HWHLLB> ]H>DF@ Tiuncal ataxia anu uysaithiia !H>HWHLLB> (HDF@NIH>H Intention tiemoi, ataxia of limbs
()$ ()+.+312 The thalamus is a miuline stiuctuie of the uiencephalon, situateu between the ceiebial coitex anu the miubiain. It ielays infoimation between the aieas of the subcoitex to the ceiebial coitex, iegulates consciousness, iegulates sleep, anu iegulates aleitness. It gets its bloou supply fiom many bianches of the posteiioi ceiebial aiteiy (paiameuian, infeiolateial, posteiioi choioiual). Theie aie thiee paits to the thalamus, they aie bulb-shapeu masses that aie appioximately S.7cm in length, anu aie locateu alongsiue the S iu ventiicle at a Su uegiee angle.
()$ )G/"()+.+312 The hypothalamus is a stiuctuie within the biain with many key impoitant functions. The easiest way to iemembei the functions of the hypothalamus is with the mnemonic "$)# ()$&". ( - $IF>@C (Watei balance, as iegulateu by thiist) + - )MHA?IEN?NIE@F@ (This stiuctuie is contiolleu via ieleasing factois) 4 - #HS>?IEN?NIE@F@ (Releases hoimones synthesizeu in the hypothalamic nuclei)
) - (SAJH> BAM &BCFHCE (Contiolleu by the ventiomeuial nucleus) + - )SC?A?DFO iegulation (Paiasympathetic activity via anteiioi hypothalamus, ciicauian ihythm via supiachiasmatic nucleus) ( - $HDNH>BCS>H (Posteiioi hypothalamus - conseives heat when colu, Anteiioi hypothalamus - cooiuinates cooling when hot) 2 - &HPSBL +HJSLBCF?A (The septate nucleus contiols sexual emotions anu uiges)
()$ /"2($#-"# /-(1-(+#G The posteiioi pituitaiy consists of axons that extenu fiom the supiaoptic anu paiaventiiculai nuclei of the hypothalamus. The neuiohypophysis secietes two veiy impoitant hoimones: 0xytocin anu vasopiessin. ]B@?N>H@@FA - Stimulates watei ietention, thus iaising bloou piessuie by aiteiial contiaction. "PEC?OFA - Stimulates contiaction of the uteius anu lactation
*+2+. T+4T.-+ The basal ganglia aie a gioup of nuclei situateu at the base of the foiebiain anu aie connecteu with the ceiebial coitex anu thalamus. The basal ganglia aie impoitant in many functions, namely motoi contiol anu leaining. The main components of the basal ganglia aie the &C>FBCSDV *BLLFMSDV &SW@CBACFB #FJ>BV anu the &SWCIBLBDFO #SOLHS@Q &C>FBCSD [ The laigest pait of the basal ganglia, it consists of two paits (Cauuate nucleus anu Putamen). The majoiity of the cells aie uABAeigic (>96%), anu cholineigic neuions (~2%). *BLLFMSD - Consists of a laige ulobus Palliuus (Inteinal (uPi) anu exteinal (uPe) segments anu a small vential extension calleu the vential Palliuum). These two segments aie mainly uABAeigic neuions that act as inhibitoiy neuiotiansmitteis. &SW@CBACFB #FJ>B - Locateu in the miubiain (mesencephalon), it plays a laige iole in iewaiu, auuiction, anu movement. The substantia nigia contains laige levels of melanin within uopamineigic neuions, these stiuctuies aie uaik anu thus stanu out fiom the iest of the suiiounuing stiuctuies. Theie aie two paits to the substantia nigia (pais compacta anu pais ieticulata). The pais compacta acts as an input to the basal ganglia ciicuit, supplying the stiiatum with uopamine. The pais ieticulata seives as an output, which conveys signals fiom the basal ganglia to numeious othei stiuctuies. &SWCIBLBDFO #SOLHS@ - Locateu vential to the thalamus, meuial to the inteinal capsule, anu uoisal to the substantia nigia. The subthalamic nucleus ieceives signals fiom the globus palliuus, which aie uABAeigic in natuie, while it ieceives glutamineigic inputs fiom the ceiebial coitex. The signals exiting the subthalamic nucleus aie glutamineigic, which aie excitatoiy. These signals tiavel to many uiffeient stiuctuies incluuing the substantia nigia, lateial palliuum, anu meuial palliuum.
,$..2 ()+( 21//"#( +4& 4"1#-2) ()$ ,42 _ /42 21//"#(-5$ ,$.. #".$ -4 ,42L/42 21//"#( "LFJ?MHAM>?JLFB Piouuces myelin centially &OITBAA !HLL@ Piouuces myelin peiipheially )@C>?OECH@ Pioviue physical suppoit, potassium metabolism, anu physical iepaii /FO>?JLFB Is the phagocytic cell of the neivous system %NHAMEDBL !HLL@ Responsible foi the innei lining of the ventiicles
()$ *.""&S*#+-4 *+##-$# The bloou-biain baiiiei is a system uesigneu to keep the bloou anu CSF fiom mixing. The baiiiei is foimeu by tight junctions between enuothelial cells in the CNS vessels, thus they iestiict the passage of solutes. This baiiiei is much moie iestiicting than anywheie else in the bouy. The bloou-biain baiiiei is foimeu by the )>BOIA?FM, 5AC>BOH>HW>BL OBNFLLB>E HAM?CIHLFSD, anu !I?>?FM *LHPS@ HAM?CIHLFSD. Substances that can pass the bloou-biain baiiiei aie: - L-Bopa - Lipiu soluble substances - ulucose - Amino Acius
()$ 5$4(#-,1.+# 2G2($3
()$ &1#+. 5$4"12 2-412$2 These aie the venous channels founu in between the layeis of uuia in the biain. Theii bloou supply comes fiom the inteinal anu exteinal veins of the biain. 0ltimately, all of the uuial venous sinuses will empty into the inteinal jugulai vein. Injuiies to the heau can cause bleeuing into the biain (hemoiihages, clots, hematomas).
!()*$%+ 8
*(0&5"3".0
*IE@F?L?JE UFC@ FAC? DBAE B@NHOC@ ?U CIH 7&/3% HPBDQ 5C F@ B IFJILE O?AOHNCSBL C?NFOV BAM USLL SAMH>@CBAMFAJ ?U CIH@H O?AOHNC@ F@ H@@HACFBL C? @SOOH@@ ?A CIH &CHN , HPBDQ
+.&"2($#"4$ ! secieteu in iesponse to a ueciease in bloou volume anu the subsequent piouuction of angiotensin 2. Causes an inciease in souium ieabsoiption, inciease in potassium secietion, anu inciease in hyuiogen secietion. +4T-"($42-4 Z ! causes effeient aiteiiole constiiction, which causes an inciease of uFR anu subsequently incieases souium anu bicaibonate ieabsoiption. +(#-+. 4+(#-1#$(-, !+,("# ! secieteu when theie is an inciease in atiial piessuie, which causes an inciease in uFR anu thus incieaseu souium excietion. #$4-4 ! secieteu in iesponse to uecieaseu bloou volumeflow, subsequently gets conveiteu to AT 1 anu then AT2, which causes aluosteione secietion eventually to inciease bloou volume. /+#+()G#"-& )"#3"4$ ! acts on pioximal convoluteu tubule, secieteu in iesponse to a low plasma level of calcium, causing calcium ieabsoiption in the uistal convoluteu tubule. 5+2"/#$22-4L+&) ! is secieteu when the plasma osmolaiity is high anu volume is low. Causes watei ieabsoiption in the collecting uucts.
()$ 610(+T."3$#1.+# +//+#+(12 The }uA is a stiuctuie in the kiuney that is iesponsible foi iegulating bloou flow anu uFR. It is locateu stiategically in a location that allows it to maximally iegulate these functions (locateu between the vasculai pole of the ienal coipuscle anu the uistal convoluteu tubule). Thiee components of the }uA: ,Q /BOSLB XHA@B 1Q kSPCBJL?DH>SLB> OHLL@ 4Q %PC>BJL?DH>SLB> DH@BAJFBL OHLL@
}uxtaglomeiulai Cells ! aie mouifieu smooth muscle cells that seciete ienin in iesponse to uecieaseu ienal bloou flow. Nacula Bensa ! is pait of the BCT, is a sensoi foi souium. **(H7 QDM ?7AA@M7 >C BH7 6T+** ! it iegulates uFR via the ienin-angiotensin- aluosteione system.
-3/"#(+4( $e1+(-"42 -4 #$4+. /)G2-"."TG TI>?78<I@8 !DIB8@BD>: #@B7 OT!#P uFR uesciibes the flow iate of filteieu fluiu thiough the kiuney. Cieatinine cleaiance iate (CCR) is the volume of bloou plasma that is cleaieu of cieatinine pei unit time anu is a veiy useful measuie foi the appioximate glomeiulai filtiation iate. uFR is best calculateu by measuiing a chemical that has a steauy level in the bloou (ie neithei absoibeu noi secieteu by the kiuneys). A gieat tool foi this is "inulin", which fits these ciiteiia. $IH HRSBCF?A U?> OBLOSLBCFAJ .Z+ F@ B@ U?LL?T@d
#7:@I ,I7@8@:E7 Calculating cleaiance is quite simple, howevei you must unueistanu a simple concept ielating to ienal cleaiance in oiuei to ueciphei whethei theie is a net secietion, net ieabsoiption, oi neithei. $IH HRSBCF?A U?> +HABL !LHB>BAOH:
If #7:@I ,I7@8@:E7 U T!#, theie is no secietion oi ieabsoiption If #7:@I ,I7@8@:E7 h T!#, theie is a net tubulai secietion of whichevei substance we aie looking at. If #7:@I ,I7@8@:E7 i T!#, theie is a net tubulai ieabsoiption of whichevei substance we aie looking at. !877 %@B78 ,I7@8@:E7
!DIB8@BD>: !8@EBD>: The filtiation fiaction iepiesents the piopoition of fluiu that ieaches the kiuney which passes to the ienal tubules. A healthy numbei is aiounu 2u%. Shoulu theie be cases wheieby uFR is uecieaseu (as in ienal aiteiy stenosis), filtiation fiaction shoulu piopoitionally inciease to maintain the noimal function of the kiuney. !DIB8@BD>: !8@EBD>: U T!#L#/!
If uFR anu RPF inciease oi ueciease simultaneously, theie is no change in FF If uFR incieases anu RPF uecieases, theie is an inciease in FF
$CC7EBD97 #7:@I /I@A?@ !I>K O$#/!P This calculation is useu to calculate ienal plasma flow anu thus to estimate ienal function. We use the "PAB cleaiance", which is the cleaiance of Paia Aminohippuiate Cleaiance. It is fieely filteieu anu not absoibeu in the nephion. !BLOSLBCFAJ %+*Z: $#/) U 1/+) 0 5L//+) U ,/+)
TI<E>A7 ,I7@8@:E7 Impoitant in uiabetes, it shoulu simply be known that glucosuiia occuis when plasma glucose ieaches 2uumguL, because the PCT cannot ieabsoib once these levels aie ieacheu.
()$ #$4-4S+4T-"($42-4S+.&"2($#"4$ 2G2($3 A hoimonal system that iegulates the balance of bloou piessuie anu fluius. &CHN@ ?U CIH +))&: 1. Low bloou volume is uetecteu by the macula uensa, causing the }u cells to ielease ienin. 2. Renin then cleaves angiotensinogen, conveiting it to angiotensin 1. S. Angiotensin 1 is then conveiteu to angiotensin 2 by the ACE enzyme (angiotensin-conveiting enzyme), which is founu in the lungs. 4. Angiotensin 2 binus to ieceptois in the intiaglomeiulai mesangial cells, stimulating the ielease of aluosteione fiom the zona glomeiulosa of the auienal coitex. S. Aluosteione then stimulates the ieabsoiption of souium anu watei in the PCT anu collecting uucts of the kiuney
/)G2-"."TG +( $+,) /"#(-"4 "! ()$ 4$/)#"4 $(% *+"f5/)3 !"#]"37$%X $7273% YIBC ?OOS>@: - Complete glucose ieabsoiption - Complete amino aciu absoiption - Neai complete ieabsoiption of souium, watei, anu bicaib (BC0S-) - Secietion of ammonia
X5&$)3 !"#]"37$%X $7273% YIBC ?OOS>@d - Active ieabsoiption of souium - Active ieabsoiption of chloiiue - Calcium ieabsoiption occuis heie (if stimulateu by paiathyioiu hoimone)
!"33%!$5#. $7273%& YIBC ?OOS>@: - Souium gets ieabsoibeu (in exchange foi B+ anu K+), when aluosteione is piesent - Watei gets ieabsoibeu in the piesence of ABB
T+2(#"-4($2(-4+. /)G2-"."TG
()$ #$T1.+(-"4 "! T+2(#-, +,-& 2$,#$(-"4 The key playei in iegulating gastiic aciu secietion is the B+K+ ATPase, which is a magnesium-uepenuent pump. The following aie the basic steps of gastiic aciu piouuction anu secietion: 1. B+ is geneiateu within the paiietal cell fiom the uissociation of watei. Byuioxyl ions iapiuly combine with C02 via caibonic anhyuiase. 2. BC0S- is tianspoiteu outsiue the cell in exchange of chloiiue (maintains intiacellulai pB of the paiietal cell). S. Cl- anu K+ aie tianspoiteu into the lumen, which is necessaiy foi secietion of aciu. 4. B+ pumpeu out of the cell anu into the lumen in exchange foi K+ thiough a pioton pump. S. B+ accumulation geneiates an osmotic giauient that causes outwaiu uiffusion of watei, leauing to gastiic aciu piouuction (BCl, KCl), anu a small amount of NaCl
)"#3"4$2 "! ()$ T- .)&$+5#: - Secieteu fiom the u cells in the antium of the stomach - Cause stimulation of B+ secietion - Incieaseu when theie is stomach uistention, vagal stimulation, anu the piesence of amino acius in the stomach - Becieaseu when theie is a stomach aciu <1.S - 0veistimulation can leau to P0B, gastiitis, Zollingei-Ellison synuiome !("3%!0&$"b5#5#: - Secieteu fiom the I cells of the uuouenum anu jejunum - Causes an inciease in pancieatic secietion - Stimulates gallblauuei contiaction - Inhibits the emptying of gastiic contents - Inhibiteu by secietin anu a stomach pB <1.S - Stimulateu by the piesence of fats anu pioteins in the stomach &%!+%$5#: - Secieteu fiom the S cells of the uuouenum - Causes an inciease in pancieatic bicaibonate secietion - Inhibits the secietion of gastiic acius - Stimulateu by the piesence of acius anu fatty acius in the lumen of the uuouenum &"/)$"&$)$5#: - Secieteu fiom the B cells in the pancieatic islet cells - Causes inhibition of gastiic aciu anu pepsinogen secietion - Causes inhibition of fluiu secieteu fiom the pancieas anu small intestine - Inhibits gallblauuei contiaction - Inhibits the ielease of insulin anu glucagon - Secietion is stimulateu by incieaseu aciu anu inhibiteu by vagal stimulation .)&$+5! 5#(525$"+0 *%*$5X%: - Secieteu by the K cells in the uuouenum anu jejunum - Becieases the amount of gastiic aciu that is secieteu - Incieases insulin ielease
2$,#$("#G /#"&1,(2 "! ()$ T- 5#$+5#&5! Z)!$"+d - Secieteu by the paiietal cells - Binus vitamin B12 - Autoimmune uestiuction leaus to peinicious anemia *%*&5#: - Secieteu by the chief cells - Aius in piotein uigestion - Incieaseu thiough vagal stimulation .)&$+5! )!5Xd - Secieteu by the paiietal cells - Becieases stomach aciu (ie Low pB) - Stimulateu by histamine anu acetylcholine - Inhibiteu by piostaglanuins, somatostains, anu uIP 25!)+2"#)$%: - Secieteu by the mucosal cells of the uuouenum anu stomach - Pievents autouigestion by aciu neutialization - Stimulateu by secietin
$4\G3$2 2$,#$($& *G ()$ /+4,#$+2 3FNB@H ! Aius in fat uigestion, elevateu in pancieatitis )DELB@H ! Belps in staich uigestion, also elevateu in pancieatitis *>?CHB@H@ ! Aie secieteu as pioenzymes, help with piotein uigestion
$4&",#-4$ /)G2-"."TG
2/$#3 /#"&1,(-"4 Speim piouuction ielies on a few veiy impoitant hoimones in oiuei to stimulate piouuction, anu subsequently to piouuce the piopei amount. $IH FDN?>CBAC I?>D?AH@ ?U @NH>DBC?JHAH@F@ B>Hd .7<B7:DjD:M )>8?>:7 O.)P ! iesponsible foi stimulating testosteione ielease fiom the leyuig cells. !>IIDEI7 2BD?<I@BD:M )>8?>:7 O!2)P ! iesponsible foi stimulating the Seitoli cells, which then ielease Inhibin anu Anuiogen-binuing pioteins (ABP) Z>?D CIH@H CT? I?>D?AH@V TH JHC CIH U?LL?TFAJd (7AB>AB78>:7 ! iesponsible foi the uiffeientiation into male genitalia, maintaining gametogenesis (these aie the two things we neeu most foi this topic) +:=8>M7:SQD:=D:M N8>B7D: ! iesponsible foi keeping the testosteione levels high insiue the seminifeious tubules -:HDQD: ! this is iesponsible foi pioviuing negative feeuback to the pituitaiy, inhibiting the ielease of too much FSB.
$IH U?LL?TFAJ FLLS@C>BCF?A NSC@ BLL ?U CIH BW?GH FAU?>DBCF?A FAC? NLBEV @FJAFUFOBACLE @FDNLFUEFAJ E?S> SAMH>@CBAMFAJ ?U CIH TI?LH N>?OH@@-
+4&#"T$4-, )"#3"4$2 The anuiogenic hoimones incluue: - Testosteione - Bihyuiotestosteione (BBT) - Anuiosteneuione *?CHAOFH@d X($ l $H@C?@CH>?AH l )AM>?@CHAHMF?AH
ZSAOCF?A@ ?U HBOI I?>D?AH@d &)( ! Synthesizeu by the enzyme "S!-ieuuctase" - Foimation of seconuaiy sexual chaiacteiistic in men (7AB>AB78>:7 ! Piomotes piotein synthesis anu giowth of all tissues with anuiogen ieceptois. - Nuscle giowthmass - Bone uensity - Bone matuiation - Natuiation of sex oigans (penis anu sciotum in fetus) - Baii giowth (facial haii, axillaiy haii) - Bevelopment of seconuaiy sex chaiacteiistics - Bevelopment of piostate anu seminal vesicles - Libiuo +:=8>AB7:7=D>:7 ! a piecuisoi of both male anu female sex hoimones
/#"T$2($#"4$ The hoimone involveu in the female menstiual cycle, piegnancy, anu embiyogenesis. It comes fiom the testes, coipus luteum, placenta, anu the auienal coitex. The main functions of Piogesteione aie: - Relaxation of the smooth muscle of the uteius - Piegnancy maintenance - Spiial aiteiy uevelopment - Enuomeuiial glanu secietion stimulation - Ceivical mucus piouuction (thickens - benefit of 0CP use) - Inciease in bouy tempeiatuie - Inhibits the gonauotiopins FSB anu LB
()$ 3$42(#1+. ,G,.$ The best way to leain the menstiual cycle is visually, keeping the following high- yielu infoimation in minu: - LB suige causes ovulation - Piogesteione is the hoimone of piegnancy, maintaining enuometiium foi implantation suppoit - The folliculai giowth is fastest in the 2 nu week of the piolifeiative phase - Noimal cycle is 28 uays - 0vulation will typically (with a noimal cycle) occui 14 uays aftei the onset of menses.
3$4"/+12$ Nenopause is inuicative of the cessation of ovaiian function, iesulting in the cessation of ovulation anu menstiuation. $IH U?LL?TFAJ B>H CIH I?>D?ABL OIBAJH@ CIBC ?OOS> TFCI DHA?NBS@Hd - Estiogen uecieases - uonouotiopin-ieleasing hoimone incieases - LB incieases - FSB incieases significantly $IH U?LL?TFAJ B>H CIH D?@C O?DD?A @EDNC?D@ B@@?OFBCHM TFCI DHA?NBS@Hd - Bot flashes - vaginal atiophy - 0steopoiosis - Coionaiy aiteiy uisease (estiogen is saiu to be a piotective factoi against this)
)13+4 ,)"#-"4-, T"4"&"(#"/-4 OH,TP hCu is secieteu fiom the placental syncytiotiophoblast, anu is iesponsible foi the following functions: - Is the #1 inuicatoi of piegnancy - Belps to maintain the coipus luteum uuiing the 1 st tiimestei of piegnancy - Belps in uiagnosing iepiouuctive pathologies such as choiiocaicinoma anu hyuatifoim moles (uiscusseu in pathology section)
#$T1.+(-"4 "! /#".+,(-4 Piolactin is a hoimone secieteu fiom the anteiioi pituitaiy anu is iesponsible foi some impoitant functions, as well it is iesponsible foi ceitain pathologies (piolactinoma, infeitility). 5DN?>CBAC USAOCF?A@ ! Lactation, oigasm, oligouenuiocyte piecuisoi cell piolifeiation. 5AIFWFCHM WE ! Bopamine
()$ )G/"()+.+312 +4& /-(1-(+#G
()$ ()G#"-& )"#3"4$ Thyioiu hoimone is an extiemely impoitant anu veisatile hoimone, contiolling a wiue-iange of functions anu impoitant foi piopei giowth. ZSAOCF?A@ ?U CIE>?FM I?>D?AHd - CNS matuiation - Bone giowth - "-auieneigic effects - Incieases BNR (via incieasing the Na+K+ pump) - Lipolysis (incieases) - uluconeogenesis (incieases) - ulycogenolysis (incieases) *>?MSOCF?A ?U CIE>?FM I?>D?AHd 1. Folliculai cells synthesize enzymes anu thyioglobulin foi colloiu. 2. Iouine is co-tianspoiteu into the cell with Na+ anu tianspoiteu into colloiu. S. Enzymes auu iouine to thyioglobulin to make TS anu T4. 4. Thyioglobulin is taken back into the cell. S. Intiacellulai enzymes sepaiate TS anu T4 fiom the piotein 6. Fiee TS anu T4 entei the ciiculation *TS pioviues negative feeuback to the anteiioi pituitaiy.
/+#+()G#"-& )"#3"4$ O/()P PTB comes fiom the chief cells of the paiathyioiu glanus. In iesponse to low seium calcium, PTB is ieleaseu anu peifoims the following: - Incieases bone iesoiption which incieases Ca2+ anu P04- - Incieases the ieabsoiption of calcium fiom the kiuneys (uistal convoluteu tubules) - Becieases the ieabsoiption of phosphate fiom the kiuneys - Stimulates the enzyme 1!-hyuioxylase in the kiuney, which incieases 1,2S- (0B)2 vitamin B (ie cholecalcifeiol)
,+.,-("4-4 Calcitonin woiks opposite of PTB by iecognizing an inciease in seium Ca2+ anu thus uecieasing the bone iesoiption of calcium. Calcitonin is secieteu fiom the paiafolliculai (c cells) of the thyioiu glanu.
.-4V-4T /+()"."TG (" ,@Zkl /"^Sl @:= +.V+.-4$ /)"2/)+(+2$ $IH U?LL?TFAJ LF@C ?U O?AMFCF?A@ BLCH> CIH@H LHGHL@ FA CIH U?LL?TFAJ TBE@- &DA7A@A7 ,@IED<? .797I /H>ANH@B7 .797I +Im /H>ANH .797I 5DB@?D: & -:B>J Incieases Incieases Incieases "AB7>N>8>ADA No change No change No change )FN78N@8@BHF8>D=DA? Incieases Becieases Incieases /@M7B[A Q>:7 =DA7@A7 Noimal-incieaseu Noimal Laige inciease #7:@I -:A<CCDED7:EF Becieaseu Incieaseu No change
,+#&-+, /)G2-"."TG
#"$%: Caiuiac physiology is unique in that almost eveiything is conceptual in natuie, which means that theie aie many giaphschaits, etc. By completely unueistanuing the concept behinu all of this infoimation, you will not have to memoiize anything, iathei you will be able to apply it to any question the 0SNLE exam thiows youi way.
()$ ,+#&-+, ,G,.$ The caiuiac cycle iefeis simply to the steps that aie unueitaken by the heait as it goes fiom filling, to pumping the bloou systematically, to filling once again. $IH NIB@H@ ?U CIH OB>MFBO OEOLH: Xn -A>9>I<?7B8DE ,>:B8@EBD>: This is the point between the closuie of the mitial valve anu the opening of the aoitic valve. The heait is contiacteu but valves aie closeu. Zn 2FAB>IDE $;7EBD>: The heait squeezes anu bloou is ejecteu thiough the aoitic valve. This phase can be consiueieu the phase between the time the aoitic valve opens anu closes. ]n -A>9>I<?7B8DE #7I@J@BD>: This is the peiiou of time between the closuie of the aoitic valve anu the opening of the mitial valve. ^n #@ND= CDIID:M NH@A7 Aftei the opening of the mitial valve, bloou pools iapiuly into the left ventiicle. bn 2I>K CDIID:M NH@A7 At this point, bloou flows into the Lv slowly as the mitial valve is about to close.
5DN?>CBAC IHB>C @?SAM@ CIBC ?OOS> MS>FAJ CIH OB>MFBO OEOLHd 2X - this is the 1 st heait sounu anu iepiesents the closing of the tiicuspiu anu mitial valves 2Z - this is the 2 nu heait sounu anu iepiesents the closing of the pulmonaiy anu aoitic valves 2] - this is the S iu heait sounu anu iepiesents the enu of the iapiu ventiiculai filling (can be associateu with congestive heait failuie) 2^ - this is a heait sounu heaiu only if theie is a stiff ventiicle (is associateu with ventiiculai hypeitiophy)
$IH U?LL?TFAJ J>BNI >HN>H@HAC@ CIH NIB@H@ ?U CIH OB>MFBO OEOLHd
Y5..%+c& X5).+)/: This uiagiam is useu in caiuiac physiology to illustiate the ielationships between seveial uiffeient events that aie occuiiing simultaneously. Foi the 0SNLE exam, it is impoitant to iecognize the ielationships on the giaph as well as to iecognize wheie the majoi events aie locateu giaphically.
+,(-"4 /"($4(-+. "! ()$ /+,$3+V$#
$(% &) #"X%: The cells of the Av noue uepolaiize spontaneously, iesulting in appioximately 1uu contiactions pei minute. This iate uoes not cieate a ventiiculai iate of 1uu because the sympathetic anu paiasympathetic fibeis have the ability to contiol how much gets thiough. $(% )] #"X%: This noue uischaiges appioximately 4u-6ubpm. Theie aie bianches that come fiom the Av noue (Puikinje fibeis), that also piouuce spontaneous action potentials at a iate of appioximately Su-4ubpm (keep conuuction if the noues aie not woiking efficiently).
()$ /)+2$2 "! ()$ +,(-"4 /"($4(-+.: *IB@H 6 [ ^&L?T XFB@C?LFO XHN?LB>FaBCF?A_ With a Na+ conuuctance inciease, the membiane potential spontaneously uepolaiizes, accounting foi the automaticity of the SA anu Av noues. In the chait below, the slope of phase 4 in the SA noue is the ueteimining factoi in heait iate. This can be incieaseu with catecholamines (NE, Epi) anu uecieaseu with acetylcholine.
*IB@H = [ ^7N@C>?\H_ Causeu by a slow influx of calcium because theie aie no fast souium channels. This iesults in a slow conuuction velocity that helps to piolong tiansmission fiom the atiia to the ventiicles. *IB@H 4 [ ^+HN?LB>FaBCF?A_ A iapiu inactivation of the calcium channels anu a ueciease in potassium peimeability slowly iepolaiizes the cell (ie theie is a loss of positive ions).
5$4(#-,1.+# +,(-"4 /"($4(-+. The ventiiculai action potential is best explaineu thiough the use of visual aius. Each phase of the action potential is causeu by an influx oi efflux of ceitain ions, thus knowing which ions woik wheie is vital to unueistanuing the events anu getting as many points as possible on the 0SNLE.
/H@A7 Y ! voltage-uateu Na+ channels aie open, iesulting in a iapiu upstioke. /H@A7 X ! Na+ channels aie inactivateu anu voltage-gateu K+ channels begin to open. This iesults in the initial iepolaiization. /H@A7 Z ! A plateau phase wheie a voltage-gateu Ca2+ channel iesults in balancing off of the K+ efflux. This tiiggeis Ca2+ ielease fiom the SR anu thus myocyte contiaction. /H@A7 ] ! A massive efflux of K+ uue to opening of slow voltage-gateu K+ channels anu closuie of voltage-gateu Ca2+ channels leaus to iapiu iepolaiization. /H@A7 ^ ! A high K+ peimeability iesults in ietuin to iesting potential.
,+#&-+, "1(/1( Caiuiac output is a measuie of the stioke volume X the heait iate. Acutely, caiuiac output will inciease uue to stioke volume incieases, wheieas chionically caiuiac output is a iesult of an inciease in heait iate. ,+#&-+, "1(/1( U 2(#"V$ 5".13$ 0 )$+#( #+($
/#$."+& +4& +!($#."+& /87I>@= ! Pieloau is the stietching piessuie in the ventiicles of the heait aftei filling is completeu. Pieloau is incieaseu when theie is an inciease in bloou volume, sympathetic stimulation, anu even exeicise. (H787C>87l /#$."+& U $4&S&-+2(".-, 5".13$
+CB78I>@= ! Afteiloau is the teim that measuies the tension piouuceu in the ventiicle in oiuei foi contiaction to occui. (H787C>87l +!($#."+& U &-+2(".-, +#($#-+. /#$221#$
]HA?S@ MFLBC?>@ will MHO>HB@H CIH N>HL?BM, this incluues most commonly nitioglyceiine. ]B@?MFLBC?>@ will MHO>HB@H CIH BUCH>L?BM, this incluues most commonly uiugs like hyuialazine.
()$ !#+4VS2(+#.-4T .+% This law states that with a gieatei volume of bloou enteiing the heait uuiing uiastole, the gieatei volume of bloou is ejecteu uuiing systole. This law explains that synchionization of caiuiac output anu venous ietuin occuis without neeuing exteinal factois to come into play.
()$ $VT
/ K@97 ! Repiesents atiial uepolaiization /# A7M?7:B ! Repiesents the conuuction uelay thiough the Av noue e#2 E>?NI7J ! Repiesents ventiiculai uepolaiization e( D:B789@I ! Repiesents mechanical contiaction of the ventiicles ( K@97 ! Repiesents the ventiiculai iepolaiizations 2( A7M?7:B ! Is an isoelectiic point wheie the ventiicles aie uepolaiizeu
+*4"#3+.-(-$2 "! ()$ $VT )$+5)3 Z37$$%+d A supiaventiiculai tachycaiuia that piesents with a seiies of iapiu back-to-back uepolaiizations. This may occui in those with heait uiseases (CBF, CAB, etc), but can also occui in a peifectly noimal heait. The classic piesentation is the "sawtooth" pattein, which occuis as a iesult of iuentical back-to- back uepolaiizations.
)$+5)3 Z52+533)$5"#: Is a veiy common caiuiac aiihythmia wheieby theie is a quiveiing of the chambei insteau of a cooiuinateu contiaction. The classic finuings aie a chaotic anu eiiatic baseline with the absence of P waves in between iegulaily spaceu QRS complexes.
+(#-"5$4(#-,1.+# *.",V2 , &$ X%.+%% 23"!b: An asymptomatic conuition with a PR inteival piolongation >2uumsec.
1 #X X%.+%% /"25$m $0*% , hYHAO\HWBOIid Is a conuition that is often asymptomatic, but if symptomatic will iequiie a pacemakei. The piesentation is a piogiessive lengthening of the PR inteival until a P wave is not followeu by a QRS complex.
1 #X X%.+%% /"25$m $0*% 1: Piesents with acutely uioppeu beats that aie not pieceeueu by a change in the PR length. The most common piesentation is 2 P waves pei 1 QRS complex.
4 +X X%.+%% h!"/*3%$%i (%)+$ 23"!b: Theie is inuepenuent beating of the atiia anu the ventiicles.
]%#$+5!73)+ $)!(0!)+X5): A tachycaiuia iesulting in a heaitbeat > 1uubpm. This may be non-pathologic, but may also leau to ventiiculai fibiillation.
]%#$+5!73)+ Z52+533)$5"#: This is a conuition wheie theie is a eiiatic ihythm anu no iuentifiable waves on EKu. This aiihythmia is fatal without piompt uefibiillation.
/)G2-"."TG "! ()$ ,+#&-+, 3G",G($ 1. A uepolaiization tiavels uown the T-tubule, stimulating the ielease of calcium fiom the SR (goes thiough the uihyuiopyiiuine ieceptoi anu Ryanouine ieceptoi). 2. Calcium is ieleaseu anu binus to tioponin C, which leaus to the confoimational change (moving tiopomyosin out of the myosin-binuing gioove on actin filament) S. Powei Stioke ! myosin hyuiolyzes the bounu ATP anu is uisplaceu on the actin filament 4. Contiaction occuis
&\HLHCBL /S@OLH !?AC>BOCF?A: 1. ATP binus to the myosin heau, ieleasing the actin filament 2. Cioss-biiuge cycling anu shoitening occui S. Calcium binus tioponin C anu a confoimational change occui 4. Tiopomyosin moves allowing actinmyosin cycling
*+#"#$,$/("#2 +4& ,)$3"#$,$/("#2 Baioieceptois ! Responu to piessuie Chemoieceptois ! Responu to chemical changes
.>E@BD>: >C *@8>87E7NB>8A: $IH B?>CFO B>OI ! iesponus to bloou piessuie, anu tiansmits a signal to the meuulla (via the vagus neive). $IH OB>?CFM @FAS@ ! the baioieceptoi heie tiansmits its signal to the meuulla via the glossophaiyngeal neive.
.>E@BD>: >C EH7?>87E7NB>8A: Cential chemoieceptois ! iesponu to pB anu PCu2 changes of the inteistitial fluiu in the biain (these aie not influenceu by Pu2) Peiipheial chemoieceptois ! iesponu to a Pu2 < 6ummBg, iesponu to incieaseu PCu2, anu iesponu to a ueciease in pB (ie inciease in B+)
("Y 5& (0*"$%#&5"# +%]%+&%X 20 $(% 2)+"+%!%*$"+&n 1. Aiteiial piessuie is uecieaseu, iesulting in. 2. Becieaseu stietch, which leaus to. S. Becieaseu affeient baioieceptoi fiiing, this causes.. 4. Incieases in effeient sympathetic activity anu uecieaseu effeient paiasympathetic stimulation, leauing to. S. vasoconstiiction, which. 6. Incieases heait iate, contiactility, anu bloou piessuie ("Y X"%& !)+"$5X /)&&).% Y"+bn 1. Nassaging the caiotiu aiteiy gives the sense of incieaseu piessuie, which. 2. Incieases the stietch uetecteu fiom the baioieceptoi, this in tuin. S. Becieases the heait iate
$0,)+4T$ "! ,+/-..+#G !.1-&2 Foices insiue anu outsiue of the capillaiies aie what can move fluius back anu foith. Theie aie uiffeient methous by which fluiu is moveu, it can eithei be pusheu out of the capillaiy (capillaiy piessuie), oi it can be moveu via osmotic piessuie, wheie it is pulleu. The foices aie calleu "Stailing" foices, anu they aie the following: 1. Capillaiy Piessuie (Cp) - this piessuie usually causes a movement of fluiu out of the capillaiy 2. Inteistitial Piessuie (Pi) - this is piessuie the pushes on the capillaiies anu moves fluiu into the capillaiy. S. Plasma colloiu osmotic piessuie (#c) - usually moves fluiu into the capillaiy 4. Inteistitial fluiu colloiu osmotic piessuie (#i) - usually moves fluiu out of the capillaiy. Beteimining whethei fluiu will move into oi out of the capillaiy is baseu on the net filtiation piessuie. By having all of the values of the piessuies above, we can ueteimine this figuie: Net Filtiation Piessuie = (Pc-Pi) - (#c - #i)
35#b5#. $(% )2"]% $" %X%/)$"7& &$)$%&d Euema is causeu by excess fluius outsiue of the capillaiies, thus states in which this is favoiable will likely leau to euema. The following will likely leau to euematous states: 1. Incieaseu inteistitial fluiu colloiu osmotic piessuie 2. Incieaseu capillaiy piessuie S. Incieaseu capillaiy peimeability 4. Becieaseu quantities of plasma pioteins
#$2/-#+("#G /)G2-"."TG
()$ "0GT$4S)$3"T."*-4 &-22",-+(-"4 ,1#5$
+ AHDCB B> BH7 8DMHB = uecieaseu affinity of hemoglobin foi oxygen + AHDCB B> BH7 I7CB = incieaseu affinity of hemoglobin foi oxygen
/1.3"4+#G #$2/"42$2 (" )-T) +.(-(1&$ When in highei altituues the Pu2 uecieases significantly, thus the bouy must auapt anu finu ways to maintain oxygenation to the tissues of the bouy. The following aie the majoi iesponses that help us maintain auequate oxygenation: - ventilation incieases - Eiythiopoietin incieases (fiom kiuneys) - Incieases in 2,S-Biphosphoglyceiate (helps make u2 ielease easiei) - Respiiatoiy alkalosis stimulates BC0S- excietion fiom the kiuneys - Chionic high altituue can cause a chionically highei iate of ventilation
/$#!12-"4 .-3-($& 9A &-!!12-"4 .-3-($& ,-#,1.+(-"4 /78C<AD>: ID?DB7= ! means that gas equilibiates eaily along the capillaiy's length, thus the only way to inciease uiffusion is to inciease bloou flow. &DCC<AD>: ID?DB7= ! means that gas uoesn't equilibiate by the time it ieaches the enu of the capillaiy. Peifusion limiteu is seen in healthy people, wheieas uiffusion limiteu occuis in those with emphysema, fibiosis, oi when exeicising.
.14T 5".13$ Theie is a list of impoitant uefinitions you shoulu know foi the 0SNLE exam, as theie is almost always at least 1 question uealing with this. The question may come in the foim of a uefinition, but it will most likely come in the foim of a chait wheie you will have to calculate.
5$4(-.+(-"4L/$#!12-"4 O5LeP 3-23+(,) When theie is noimal gas exchange (ie healthy inuiviuual), the vQ is appioximately 1, meaning an iueal ventilation to peifusion iatio. If theie is a mismatch, this inuicates that theie is a shunt anu some uegiee of ueau space in the same lung. A vQ of u is inuicative of a shunt (ie aiiway obstiuction) A vQ of $ is inuicative of an obstiuction of bloou flow (ie physiological ueau space). - ventilation anu peifusion aie gieatei at the base of the lung than in the apex - vQ at the apex of the lung is highei, meaning wasteu ventilation - vQ at the base of the lung is lowei, meaning wasteu peifusion
.14T /#"&1,(2 Theie aie a few veiy impoitant piouucts maue insiue the lungs, they incluue: 1. Angiotensin-Conveiting Enzyme 2. Suifactant (type 2 pneumocytes) S. Piostaglanuins 4. Bistamine S. Kallikiein
,+#*"4 &-"0-&$ (#+42/"#( Theie aie thiee methous by which caibon uioxiue aie caiiieu fiom the tissues of the bouy back to the lungs, they incluue: 1. In the foim of bicaibonate (this is the majoiity) ~9u% 2. As uissolveu caibon uioxiue ~S% S. Bounu to hemoglobin as caibaminohemoglobin ~S%
T$4$(-,2 The Baiuy-Weinbeig law of genetics states that both the allele anu the genotype fiequencies of a population iemain constant fiom geneiation to geneiation, unless theie is a specific uistuibance(s) intiouuceu into the population. $IH LBT ?U (B>MEKYHFAWH>J B@@SDH@: 1. No mutations occui 2. Theie is no selection foi any of the specific genotypes S. Nating is ianuom 4. Theie is no migiation into oi out of the population
The fiequency of uiffeient alleles in a population can be ueteimines with the Punnett squaie, which can be linkeu mathematically to the 'Baiuy-Weinbeig equation foi equilibiium'.
)-T)SG-$.& T$4$(-, ($#3-4"."TG .HAH - is the section of a chiomosome that caiiies infoimation foi specific tiaits )LLHLH@ - aie alteinate foims of a gene *IHA?CENH - the physical appeaiance of an oiganisms, usually ueteimineu by the uominant gene. .HA?CENH - the genetic makeup of an oiganism. X?DFABAC - is the gene oi tiain that appeais oi expiesses itself, iepiesenteu with a capital lettei (ie +a). +HOH@@FGH - is the genetiait that gets hiuuen in the piesence of a uominant gene, iepiesenteu with a lowei-case lettei (ie A@) ]B>FBWLH %PN>H@@F?A - is the vaiiance is phenotype fiom one inuiviuual to anothei. 5AO?DNLHCH *HAHC>BAOH - this occuis when not all inuiviuuals who caiiy mutant genotype actually show the mutant phenotype. )ACFOFNBCF?A - occuis when the seveiity of a uisease gets woise at youngei anu youngei ages, classic example is Buntington's uisease. *LHF?C>?NE - occuis when one gene has moie than one effect on an inuiviuual's phenotype. 5DN>FACFAJ - is a uiffeience in phenotype that uepenus solely on whethei the mutation is of mateinal oi pateinal oiigin. /?@BFOF@D - the cells of the bouy have uiffeient genetic makeups. 3?@@ ?U (HCH>?aEJ?@FCE - this means that a complementaiy allele must be eithei ueleteu oi mutateu befoie the othei allele can show expiessitivity. This uoes not apply to oncogenes.
3"&$2 "! -4)$#-(+4,$
.+*"#+("#G ($,)4-e1$2 12$& -4 *-",)$3-2(#G $IH *?LEDH>B@H !IBFA +HBOCF?A O/,#P This technique is useu when a laige numbei of BNA copies aie neeueu. The steps to cieating multiple copies of BNA fiagments thiough the PCR aie as follows: 1. BNA is heateu anu uenatuieu, this causes the sepaiation of the stianus. 2. The uenatuieu BNA is cooleu, anu BNA piimeis aie auueu to the mix, these auheie to each inuiviuual stianu of BNA at the location that will be amplifieu. S. BNA polymeiase then ieplicates the uesiieu BNA stianus. 4. This piocess is iepeateu until the uesiieu numbei of BNA is achieveu.
$.-2+ O$:jF?7S.D:m7= -??<:>@QA>8Q7:B +AA@FP This technique is useu as a means of uetecting the piesence of an antibouy oi an antigen in a sample. The antibouy oi antigen that is auueu is linkeu to an enzyme, then a test solution is auueu to see if an intense coloi illuminates, inuicating that theie is a positive iesult. - This test is most commonly useu when looking foi BIv. - Sensitivity anu specificity foi the ELISA aie extiemely high, both appioaching 1uu%, howevei they aie not peifect, anu false iesults uo occui.
2"1()$#4 *."( ($,)4-e1$ This technique is useu to uetect specific sequences of BNA. The technique combines the tiansfei of electiophoiesis-sepaiateu BNA fiagments anu membiane filtiation, anu then fiagments aie uetecteu by piobe hybiiuization.
%$2($#4 *."( ($,)4-e1$ This is a technique useu to uetect specific pioteins, sepaiating native oi uenatuieu pioteins by the length of the polypeptiue. These pioteins aie then tiansfeiieu to a membiane wheie they aie piobeu using antibouies specific to the taiget piotein.
4"#()$#4 *."( ($,)4-e1$ Is a technique useu to stuuy gene expiession by RNA uetection in a sample. This technique allows foi the uetection of cellulai contiol by ueteimination of gene expiession levels uuiing uiffeientiation anu moiphogenesis.
&4+l #4+l +4& /#"($-42
K )MHAFAH WFAM@ C? CIEDFAH with two hyuiogen bonus, wheieas JSBAFAH WFAM@ C? OEC?@FAH with thiee hyuiogen bonus, making it a stiongei bonu anu moie iesistant to incieaseu tempeiatuies. - In RNA, S>BOFL is piesent insteau of CIEDFAH.
()$ *+2-, 2(#1,(1#$ "! ()$ 41,.$"(-&$2 *E>FDFMFAH@ - Aie heteiocyclic oiganic compounus consisting of two nitiogen atoms at positions 1 anu S of a six-membeieu iing. The nucleotiues belonging to the pyiimiuine gioup aie: !EC?@FAHV 7>BOFLV anu $IEDFAH.
*S>FAH@ - Aie heteiocyclic aiomatic oiganic compounus consisting of a pyiimiuine iing bounu to an imiuazole iing. The nucleotiues belonging to the puiine gioup aie: )MHAFAH anu .SBAFAH.
,)#"3+(-4 Chiomatin is the stiuctuie that is maue up of BNA anu pioteins, which then makes up the chiomosome. It is founu within the nuclei of eukaiyotic cells only. Theie aie two types of chiomatin, theie is "heteiochiomatin", which is conuenseu anu tiansciiptionally inactive, anu theie is euchiomatin, which is loosei anu tiansciiptionally active. The main function of chiomatin is to package laige amounts of BNA into smallei aieas, allowing moie to fit into cells anu thus pioviue foi moie genetic mateiial oveiall.
&4+ #$/.-,+(-"4 In piokaiyotes, theie is a single oiigin of ieplication, wheieas in eukaiyotes theie aie multiple oiigins of ieplication. &?DH FDN?>CBAC UBOC@: - BNA polymeiase S pioofieaus in the S'! S' uiiection, synthesizing in the S'! S' uiiection. - Piimase piouuces an RNA piimei, on which BNA polymeiase S initiates ieplication. - BNA polymeiase S elongates the chain thiough the auuition of ueoxynucleotiues to the S' enu. - BNA polymeiase 1 uegiaues RNA piimei once it is no longei neeueu. - 0kazaki fiagments help elongate the chain on the lagging stianu. - BNA ligase seals on the lagging stianu. - BNA gyiase unwinus the stianu befoie ieplication can begin. - BNA topoisomeiase ielieves supeicoils by nicking the stianu.
&4+ &+3+T$ The two types of BNA uamage aie 'Enuogenous' anu 'Exogenous'. Types of Enuogenous uamage: ,Q "PFMBCF?A - ieactive oxygen species causes inteiiuptions to the BNA stianu. 1Q )L\ELBCF?A - alkylation of bases by foimation of compounus such as 7- methylguanine. 4Q (EM>?LE@F@ - base hyuiolysis causes ueamination, uepuiination, anu uepyiimiuination. 6Q 2SL\E BMMSOC U?>DBCF?A 8Q 2B@H DF@DBCOIH@ Types of Exogenous uamage: ,Q 7]K2 MBDBJH - causes cioss-linking between cytosine anu thymine bases, cieating 'pyiimiuine uimeis'. 1Q 7]K) MBDBJH - cieates most fiee iauicals, causeu inuiiect BNA uamage. 4Q 5?AFaFAJ >BMFBCF?A - causing iauioactive uecay anu bieaks in BNA stianus. 6Q $IH>DBL MF@>SNCF?A - causes uepuiination anu single stianu bieaks 8Q 5AMS@C>FBL OIHDFOBL MBDBJH - compounus such as vinyl chloiiue anu hyuiogen peioxiue, smoke, soot, anu tai can cause seveie uamage to BNA. It causes oxiuation, alkylation, anu cioss-linking of BNA.
&4+ #$/+-# &FAJLH @C>BAM MBDBJH: Bamage to a single stianu is iepaiieu via one of thiee mechanisms. *@A7 $JEDAD>: #7N@D8 - This type of iepaii helps to fix uamage to a single base, which is iemoveu by a BNA glycosylase. The missing base is then iecognizeu by AP enuonuclease anu iesynthesis occuis via BNA polymeiase, with BNA ligase sealing the new stianu. 4<EI7>BD=7 $JEDAD>: #7N@D8 - This mechanism iecognizes bulky helix-uistoiting uamage anu is fixeu with tiansciiption-coupleu iepaii which emits NER enzymes that aie actively being tiansciibeu. 3DA?@BEH #7N@D8 - This iepaii mechanism coiiects eiiois of BNA ieplication anu iecombination that iesulteu fiom mispaiieu nucleotiues.
X?SWLHK&C>BAM XBDBJH: Thiee mechanisms exist to iepaii uouble-stianueu uamage, they aie: 1. Non-homologous enu joining (NBE}) 2. Niciohomology-meuiateu enu joining (NNE}) S. Bomologous iecombination
4>:S)>?>I>M><A $:= 6>D:D:M - This foim of iepaii is meuiateu by a specializeu foim of BNA ligase (BNA ligase Iv), which woiks by foiming a complex with a cofactoi (XRCC4) anu then uiiectly joining the two non-uamageu enus. 3DE8>H>?>I>MFS37=D@B7= $:= 6>D:D:M - This type of iepaii mechanism woiks by using a S-2S base paii homologous sequence to align bioken stianus befoie joining them. It uses a "Ku piotein" anu BNA-PK inuepenuent iepaii mechanism anu then iepaii occuis uuiing the S phase of the cell cycle. )>?>I>M><A #7E>?QD:@BD>: - This type of iepaii iequiies the piesence of an iuentical sequence that is useu as a template foi iepaii of the bieak.
&$!$,(2 (" ()$ &4+ #$/+-# 3$,)+4-23 When the iepaii mechanisms fail, theie is an expiession of impiopei BNA, anu this can iesult in conuitions that aie seveie anuoi lethal. Thiee conuitions that iesult fiom faileu BNA iepaii aie: fH>?MH>DB *FJDHAC?@SD - This conuition occuis when theie is a uefect in one of the seven genes iequiieu foi BNA iepaii. Those afflicteu with this uisease aie extiemely sensitive to sunlight anu have a significantly high iisk foi skin cancei. This patient will only live to be miuule-ageu at best. $>FOI?CIF?ME@C>?NIE - This conuition is causeu by uefects that iesult in ieuuceu RNA tiansciiption of pioteins. Symptoms incluue: photosensitivity, biittle haii anu nails, scaly skin, piotiuuing eais, physical anu mental ietaiuation, anu a ieceuing chin. * The pioblem ultimately lies in the fact that the haii lacks sulfui-containing pioteins. !?O\BEAH &EAM>?DH - This conuition iesults fiom an inability to iepaii BNA uamage that is uetecteu uuiing tiansciiption. The patient suffeis fiom sensitivity to sunlight, have shoit-statuie, anu age piematuiely.
!#"3 &4+ (" /#"($-4 The piocess of obtaining usable pioteins involves cieating RNA fiom BNA, then pioteins fiom that RNA. &4+ ! #4+ OB8@:AE8DNBD>:P #4+ ! /#"($-4 OB8@:AI@BD>:P The basic oveiview of the whole piocess is as follows:
(G/$2 "! #4+ Tiansciiption is the piocess by which RNA is maue fiom each stianu of BNA. Theie aie S types of RNA: >+#)V D+#)V BAM C+#) >+#) - Is maue via RNA polymeiase I, anu is the most @Q<:=@:B type of RNA. Ribosomal RNA combines with piotein in the cytoplasm to foim a iibosome, which seives as the site anu caiiies all of the necessaiy enzymes iequiieu foi piotein synthesis. D+#) - Is maue via RNA polymeiase II, anu is the I@8M7AB type of RNA. Nessengei RNA is the RNA that is cieateu fiom a gene segment of BNA . The mRNA then caiiies the coue it ieceives fiom BNA into the cytoplasm wheie piotein synthesis will occui C+#) - Is maue via RNA polyeiase III, anu is the A?@II7AB type of RNA. Tiansfei RNA is the type of RNA that ieaus the coue fiom the mRNA anu caiiies the amino aciu to be incoipoiateu into the ueveloping pioteins. Theie aie moie than 2u uiffeient tRNA's, meaning theie is one foi each amino aciu. tRNA contains appioximately 7S nucleotiues, thiee of these aie "anticouons". * Piokaiyotes have only one RNA polymeiase that makes all of the RNA sub-types.
(#+42,#-/(-"4 Tiansciiption is the piocess wheieby BNA is useu as a template to piouuce mRNA. BNA must be in the foim of euchiomatin in oiuei foi this piocess to occui, anu it occuis in the nucleus of the cell because BNA woulu otheiwise be exposeu to uangeious enzymes in the cytoplasm that woulu cause its uegiauation. Theie is no pioofieauing function, RNA polymeiase II will open a BNA sequence at the piomotei site, which is a TATA box (A-T iich sequence that is upstieam). mRNA is synthesizeu in the S' ! S' uiiection.
/#",$22-4T "! ?#4+ Aftei tiansciiption, while the mRNA is still in the nucleus, theie aie thiee impoitant steps taken to ensuie stabilization of the newly synthesizeu mateiial. Xn +==DBD>: >C @ b[ E@N The auuition of the cap is uone thiough the following: - Phosphoiylase iemoves the gamma phosphate fiom the S' enu of the tiansciibeu pie-mRNA. - uuanylyl tiansfeiase catalyzes the conuensation of uTP with the S' enu of the pie-mRNA. - The teiminal guanosine nucleotiue is methylateu by guanine-7-methyl tiansfeiase, using S-auenosyl-methionine (SAN) as a co-factoi.
Zn +==DBD>: >C @ ][ N>IF + B@DI ON>IF@=7:FI@BD>:P The auuition of appioximately 2uu auenine units to the S' enu of the mRNA help to pioviue piotection, as without this poly A tail the mRNA woulu be quickly uegiaueu. - A cleavage factoi iecognizes anu binus to the specific polyauenylation sequence (AA0AAA). - Enuonucleases cleave the RNA - Poly A polymeiase catalyses the auuition of appioximately 2uu auenine nucleotiues to the S' enu of the cleaveu mRNA. - An auuition piotein (cleavage stimulation factoi), helps stabilize the complex. - 0nce assembleu, mRNA is cleaveu 1u-SS nucleotiues uownstieam of the AA0AAA sequence by the enuonuclease anu appioximately 2u auenine nucleotiues aie auueu by the poly A polymeiase. - The poly A tails aie then bounu by poly A binuing pioteins, which help to shift the piocessive moue of synthesis anu this iesults in the auuition of up to 2Su nucleotiues.
]n 2NIDED:M Splicing is a mouification of mRNA wheieby intions aie spliceu out anu exons aie joineu togethei. This step is iequiieu befoie RNA can move out of the nucleus anu go thiough tiansciiption.
&CHN@ C? D+#) @NLFOFAJ: 1. The piimaiy tiansciipt contains both intions anu exons 2. Spliceosomes meuiate the splicing S. The 1 st splice site is at the S' enu of an intion 4. The 2 nu splice site is at the S' enu of that same intion S. Intion, once spliceu at both sites, is iemoveu anu the exons aie combineu, foiming a matuie mRNA stianu that is piepaieu foi tianslation
2(#1,(1#$ "! B#4+ Tiansfei RNA (tRNA) is an RNA molecule (the smallest) whose puipose is to tiansfei an active amino aciu to the polypeptiue chain uuiing tianslation. Theie is a S' teiminal site, at which the amino aciu attaches covalently thiough an aminoacyl tRNA synthetase. The othei impoitant stiuctuie is at the base, anu is known as the 'anticouon', which caiiies a S nucleotiue coue that paiis to the coiiesponuing thiee base couon iegion of the mRNA.
)DFA?BOELBCF?A - The amino aciu becomes linkeu to the tRNA via 'Aminoacyl tRNA synthetase', using ATP to attach the amino aciu. The amino aciu is bounu to the S' enu covalently. This leaves the tRNA molecule in a chaigeu state. C+#) Y?WWLH - is the concept that only the fiist 2 nucleotiue positions of the mRNA couon must match in oiuei foi the piocess to pioceeu coiiectly, the thiiu position uoes not have to be the exact coiiect nucleotiue since its uiffeience can still coue foi the same amino aciu.
(#+42.+(-"4 Tianslation is the piocess by which mRNA is useu to cieate pioteins. Theie aie thiee steps to tianslation, they aie: 1. Initiation 2. Elongation S. Teimination
5AFCFBCF?A: Initiation begins when the small iibosomal subunit attaches to the S' cap of mRNA anu moves to the tianslation initiation site.
%L?AJBCF?A: - tRNA has a complementaiy anticouon to mRNA stait couon (A0u), wheie methionine is the coiiesponuing amino aciu. - The laige iibosomal subunit joins to foim the P anu A sites (1 st tRNA is in the P site, 2 nu enteis the A site anu complements the 2 nu mRNA couon). - Nethionine then tiansfeis to the AA in the A site, the 1 st tRNA exits, the iibosome moves along mRNA anu the next tRNA enteis. - The giowing peptiue is continually tiansfeiieu to the A site tRNA
$H>DFABCF?A: - A stop couon (0Au) is eventually encounteieu, at which point a "ielease factoi" enteis the A site, anu tianslation is teiminateu. - The iibosome uissociateu anu the newly foimeu piotein is ieleaseu.
(FN7 Z a />?N7[A =DA7@A7 - Causeu by a lysosomal !-1,4-glucosiuase ueficiency. *BCFHAC DBE HPNH>FHAOH: - Nuscle weakness, especially in the heait - Nost commonly seen in newboin chiluien 0R those in theii Su's anu 4u's - Fatigue as a iesult of weakening of the heait anu livei - Cuivatuie of the spine is a piogiessive symptoms - Bifficulty bieathing, such as laboieu bieathing, anu infections of the iespiiatoiy tiact - Bizziness anu syncope
(FN7 ] a ,>8D[A =DA7@A7 - Causeu by a ueficiency of the uebianching enzyme !-1,6-glucosiuase *BCFHAC DBE HPNH>FHAOH: - Symptoms similai to von uieike's uisease, but miluei - Young chiluien typically have massive hepatomegaly that uiminishes with incieasing age
(FN7 ^ a +:=78A7: =DA7@A7 - The main clinical featuies of Anueison uisease aie insufficiency of the livei anu abnoimalities of the heait anu neivous system - This uisease is iaie anu will leau to eaily ueath
(FN7 b a 3E+8=I7[A =DA7@A7 - Causeu by a ueficiency of skeletal muscle glycogen phosphoiylase *BCFHAC HPNH>FHAOH@: - Incieaseu glycogen founu within the muscle - Painful ciamps anu myoglobinuiia when activity is incieaseu
(FN7 ` a )78A =DA7@A7 - Causeu by a hepatic phosphoiylase ueficiency - Patient may have the inability to maintain bloou-glucose levels uuiing peiious of fasting. - 0iine anu seium ketones aie elevateu piopoitionally to the level of fasting - Nilu to moueiate hypeilipiuemia may be piesent - Piominent hepatomegaly anu giowth ietaiuation aie common finuings of Beis uisease
(FN7 c a (@8<D =DA7@A7 - Causeu by a ueficiency of phosphofiuctokinase (PFK) in glycolysis - Patient will expeiience incieaseu muscle glycogen that cannot be bioken uown - Ciamping - Bighei levels of myoglobin in the uiine when theie is incieaseu physical activity
/)$4G.V$("41#-+ O/V1P PK0 is an autosomal iecessive uisease chaiacteiizeu by a ueficiency of phenylalanine hyuioxylase, which inhibits the foimation of tyiosine fiom its piecuisoi phenylalanine. Because of this enzyme ueficiency, two things occui: Xn (H7 @?D:> @ED= (F8>AD:7 Q7E>?7A @: 7AA7:BD@I @?D:> @ED=n Zn /H7:FI@I@:D:7 Q<DI=A <N E@<AD:M @ ?F8D@= >C A79787 AF?NB>?A The inciease in phenylalanine leaus to an inciease in phenylketones (phenylpyiuvate, phenylacetate, anu phenyllactate) in the uiine. &FJA@ BAM &EDNC?D@: - Patients aie noimal at biith, but scieening is now essential - Failuie of eaily milestone uevelopment - Chaiacteiistic "musty oi mousy" bouy ouoi - Niciocephaly anu mental ietaiuation - Bypeiactivity - Bypopigmentation anu eczema
+.*-4-23 A conuition wheie theie is a complete lack of pigment thioughout the bouy. This is an autosomal iecessive conuition, wheie the patient cannot piouuce melanin fiom tyiosine (tyiosinase ueficiency) oi fiom a uefect in the tyiosine tianspoiteis. Theie is an inciease in the iisk of skin cancei uue to the lack of piotective melanin in the skin.
3+/.$ 2G#1/ 1#-4$ &-2$+2$ Naple syiup uiine uisease is chaiacteiizeu by the sweet smell of the patients uiine (ie maple syiup). The cause is a uefect in the ability to bieak uown the biancheu chain amino acius Leucine, Isoleucine, anu valine. The ieason foi this is a ueficiency of the enzyme !- ketoaciu uehyuiogenase. The patient will suffei fiom seveie mental ietaiuation, CNS uefects, anu finally ueath.
+.V+/("41#-+ Anothei conuition involving tyiosine, alkaptonuiia iesults fiom a ueficiency of homogentisate 1,2-uioxygenase in the pathway of tyiosine uegiauation. Bomogentisic aciu (alkapton) thus accumulates in the bloou anu is excieteu in the uiine in laige amounts, leauing to blackening of the uiine upon stanuing. Excessive amounts of homogentisic aciu cause uamage the caitilage, leauing to seveie aithialgias.
)"3",G2($-41#-+ Also iefeiieu to as Cystathionine beta synthase ueficiency (CBS ueficiency), it is an autosomal iecessive uisoiuei. In the case of ueficiency, patient will have excessive homocysteine in the uiine. In this case, cysteine will be essential anu shoulu be incieaseu in the uiet, while simultaneously uecieasing the amount of methionine in the uiet. Signs anu symptoms incluue: - Nental ietaiuation - Seizuie - Nusculoskeletal abnoimalities (tall builu, long limbs, pectus excavatum, pes cavus, anu genu valgum) - Abnoimalities of the eyes (glaucoma, subluxation of lens) - vasculai conuitions (eaily thiomboses)
,G2(-41#-+ Cystinuiia is a conuition wheieby theie is a uefect in the tianspoit of tubulai amino acius foi the following amino acius: Cystine, 0inithine, Lysine, anu Aiginine. This iesults in an excess of cystine in the uiine, which can pieuispose the patient to kiuney stones. Nanagement is to alkalinize the uiine with acetazolamiue.
#$2/-#+("#G *1#2( This ieaction is impoitant in uegiauing bacteiia that aie phagocytizeu. The iespiiatoiy buist ieuuces oxygen (via NABPB) to piouuce a fiee-iauical, then piouucing B2u2, which is fuithei combineu with Chloiiue to piouuce B0Cl-, which ultimately uestioys the engulfeu bacteiia.
()$ +4+("3G "! +&$4"2-4$ (#-/)"2/)+($ O+(/P
T.G,"T$4".G2-2 ulycogenolysis is the piocess wheieby glycogen polymei is conveiteu to glucose, which can then go thiough glycolysis. ulycogenolysis occuis in the livei anu muscle, anu is stimulateu by epinephiine anuoi glucagon in iesponse to low bloou glucose levels.
T.G,".G2-2 ulycolysis is the piocess wheieby glucose is conveiteu to pyiuvate. ulycolysis consists of ten ieactions with F00R iiieveisible stepsenzymes. $IH *>HNBC?>E *IB@H - Consists of the fiist five steps, also known as the investment phase. This phase consumes eneigy that is useu to conveit glucose into two S-C sugai phosphates (uSP). In this phase, the net ATP is (-2). $IH *BEK"UU *IB@H - Consists of five steps that piouuce a net gain of 2 ATP anu 2 NABB molecules (pei glucose molecule that goes thiough the pathway). Pyiuvate is also the enu piouuct of the glycolytic pathway.
The total ATP geneiateu fiom BABH>?WFO JLEO?LE@F@ F@ 1 )$*c@. When compaieu to ATP piouuceu with the DBLBCH @ISCCLH anu JLSO?@HK4KNI?@NIBCH @ISCCLH, which cieate 4; )$*c@ anu 49 )$*c@ iespectively.
#$T1.+(-"4 "! T.G,".G2-2 Theie aie F00R steps in glycolyisis that aie consiueieu to be iiieveisible, thus once they have occuiieu, glycolysis must piogiess in the foiwaiu uiiection. The foui iegulatoiy enzymes aie: 1. Bexokinase 2. Phosphofiuctokinase S. Pyiuvate kinase 4. Pyiuvate uehyuiogenase
(HP?\FAB@H: - Bexokinase is iesponsible foi the fiist step of glycolysis in the muscles anu biain. - It is inhibiteu by the piesence of glucose-6-phosphate, which is the piouuct of its activity. - This step is impoitant because it pievents the consumption of too much cellulai ATP in the foimation of glucose-6-phosphate when glucose is not limiting. - Bexokinase has a low affinity to glucose, thus it peimits glycolysis initiation even if bloou glucose levels aie low.
*I?@NI?U>SOC?\FAB@H: - PFK is the iate-limiting step of glycolysis, thus it is the most impoitant contiol point thioughout the whole piocess. - Regulation is by both alloesteiic effectois anu by covalent mouifications (ie phosphoiylation). - It is stimulateu by the piesence of ANP anu fiuctose-2,6-bisphosphate. - Even if ATP is high, the piesence of ANP can oveicome its inhibitoiy effects uue to the ability to allosteiically activate PFK. - It is inhibiteu by the piesence of ATP anu citiate
*E>SGBCH bFAB@H: - Similai to PFK, is iegulateu by allosteiic effectois anu by phosphoiylation. - PK is activateu by fiuctose-1,6-bisphosphate anu inhibiteu by ATP anu alanine.
/G#15+($ &$)G&#"T$4+2$ ,"3/.$0 The pyiuvate uehyuiogenase complex iegulates the entiy of glycolytic piouucts into the citiic aciu cycle. This complex consists of thiee enzymes that tiansfoim pyiuvate (fiom glycolysis) into acetyl-CoA, thiough the piocess of pyiuvate uecaiboxylation.
&$!-,-$4,G "! /G#15+($ &$)G&#"T$4+2$ A ueficiency of pyiuvate uehyuiogenase is a conuition that is most commonly seen in alcoholics, uue to the ueficiency of thiamine that is an inevitable iesult of this uisease. The lack of pyiuvate BB iesults in an accumulation of pyiuvate, which iesults in lactic aciuosis. Theie will be neuiologic finuings that can be manageu by giving the patient amino acius that aie puiely ketogenic, such as Leucine anu Lysine.
3$(+*".-23 "! /G#15+($ 0nueistanuing how pyiuvate is metabolizeu will aiu in unueistanuing why ceitain auveise effects occui when theie is a malfunctioning pyiuvate BB anuoi othei pioblems with the pathway. In yeast, pyiuvate is conveiteu to ethanol in anaeiobic conuitions, in eukaiyotes it is conveiteu to lactate. In optimal conuitions (ie. Aeiobic), pyiuvate is conveiteu to Acetyl CoA.
()$ ,-(#-, +,-& ,G,.$ O(,+P The citiic aciu cycle is an essential metabolic piocess that is essential foi completing the oxiuative uegiauation of monosacchaiiues, fatty acius, anu amino acius.
Seives 2 main puipose: 1. To inciease the cell's ATP piouucing potential by geneiating ieuuceu election caiiieis such as NABB anu ieuuceu ubiquinone. ( QB2). 2. To pioviue the cell with piecuisois that can be useu to builu a vaiiety of molecules, uepenuing on the cell's neeus.
()$ $.$,(#"4 (#+42/"#( ,)+-4 The ETC couple ieactions between election uonois anu election acceptois (ie. Between NABB anu oxygen), to the tiansfei of hyuiogen ions acioss a membiane. These hyuiogen ions aie useu to piouuce ATP to be useu as eneigy as they move back acioss the membianes. The conveision of oxygen to watei, NABB to NAB+, anu succinate to fumaiate is what will ultimately uiive the tiansfei of hyuiogen ions. Theie aie foui complexes that aie embeuueu in the innei membiane, which aie electiically connecteu by lipiu-soluble election caiiieis anu watei-soluble election caiiieis. Thiee of these complexes seive as pioton pumps. !?DNLHP , - Is a pioton pump. Is 'NABB uehyuiogenase', which iemoves two elections fiom NABB anu tiansfeis them to ubiquinone (Q). 0nce ubiquinone is ieuuceu to QB2, it can fieely uiffuse within the membiane, tianslocating foui hyuiogen ions acioss the membiane, piouucing a pioton giauient. piematuie election leakage occuis in Complex 1, which is a main site of supeioxiue piouuction. !?DNLHP 1 - Is 'Succinate uehyuiogenase', in this complex theie is the auuitional ueliveiy of elections into the quinone pool which oiiginate fiom succinate anu aie tiansfeiieu to ubiquinone. Complex 2 consists of foui piotein subunits. !?DNLHP 4 - Is a pioton pump. Is the 'Cytochiome bc1 complex", wheie two elections aie iemoveu fiom QB2 anu tiansfeiieu to cytochiome c. Two othei elections aie passeu acioss the piotein ieuucing ubiquinone to quinol, anu foui piotons aie ieleaseu fiom two ubiquinol molecules. This pump builus the giauient by an absoiptionielease of piotons. Supeioxiue is foimeu thiough election leakage in this complex. !?DNLHP 6 - Is a pioton pump. Is 'Cytochiome C oxiuase', wheie foui elections aie iemoveu fiom foui molecules of cytochiome c, anu thus tiansfeiieu to oxygen, thus piouucing two watei molecules. Foui moie piotons aie tiansfeiieu acioss the membiane, fuithei contiibuting to the giauient. !?DNLHP 8 - "ATP Synthase". 0nce a sufficient pioton giauient has been maue by complexes I, III, anu Iv, an FoF1 ATP synthase complex uses this giauient to make ATP via oxiuative phosphoiylation. The piotons influx back into the mitochonuiial matiix, ieleasing fiee eneigy which is useu to uiive the ATP synthesis. Coupling with oxiuative phosphoiylation is impoitant in piouucing ATP, as they pioviue in some ciicumstances the ability foi piotons to flow back into the mitochonuiial matiix (occuis in biown auipose tissue), anu helps in theimogenesis.
T.1,"4$"T$4$2-2 This is the piocess by which new glucose is foimeu fiom caibon skeletons such as pyiuvate, lactate, glyceiol, alanine, anu glutamate. The majoi site of gluconeogenesis is the livei. The piocess of cieating glucose fiom pyiuvate is quite costly compaieu to the amount of eneigy cieateu by one molecule of glucose. Activateu when the bouy is in a state of hungei anuoi staivation. Ketone bouies aie also piouuceu fiom acetyl-CoA. The basic piocess of gluconeogenesis is as follows:
-421.-4 Insulin is a hoimone piouuceu by the "-cells of the pancieas, its piime iole is to uiive glucose fiom the bloou into the cells of the 04,&+#,L M/*()L /#1 M+..1 &#++,L ()'#,'()#,L +(P#/L &./)#*L *)1 <(1)#>5 &NHOFUFO HUUHOC@ ?U FA@SLFA: - Anabolic effects (synthesis of fats, pioteins, anu glycogen) - Retention of souium by the kiuneys - Inhibition of the ielease of glucagon fiom the !-cells of the pancieas
C-peptiue is a maikei of insulin secietion. When a patient has extieme hypoglycemia, uiffeientiate between insulinoma anu exogenous auministiation by looking foi the piesence oi absence of C-peptiue.
T.1,+T"4 +4& -421.-4 -4 #$T1.+(-4T )"3$"2(+2-2 The iegulation of bloou glucose is uelicately balanceu by two impoitant hoimones, insulin anu glucagon. 5A@SLFA is secieteu by the "-cells of the pancieas in iesponse to an elevateu bloou-glucose level. 0n the othei siue, JLSOBJ?A is secieteu by the !- cells of the pancieas in iesponse to low levels of bloou-glucose. ulucagon causes the livei to ielease glycogen which is bioken uown into glucose, anu useu to inciease the amount of glucose iunning thiough the bloou.
()$ 2G4()$2-2 "! ,)".$2($#". Cholesteiol is impoitant in the bouy foi vaiious ieasons, namely: - Plays a iole in membiane stiuctuie anu fluiuity - Belps with hoimone piouuction - Belps with vitamin B metabolism - Plays a iole in the CNS The highest-yielu infoimation ielating to cholesteiol is knowing its iate-limiting enzyme, which is: Byuioxy Nethyl ulutaiyl Coa Reuuctase (BNu CoA ieuuctase). The phaimacological basis of loweiing cholesteiol (statin uiugs), is uesigneu aiounu the inhibition of this enzyme. The most impoitant steps in cholesteiol synthesis aie:
!+((G +,-& 2G4()$2-2 Some impoitant points must be unueistoou iegaiuing fatty aciu synthesis, these being the basics of FA synthesis. The iate limiting enzyme is )OHCELK!?) !B>W?PELB@H, which uoes the following: +E7BFIS,>+ ! 3@I>:FI ,>+ - This step is positively effecteu by 'citiate', anu negatively effecteu by 'palmitoyl CoA'. - Biotin is a iequiieu co-factoi to this ieaction. - Synthesis of fatty acius moves in the uiiection of "methyl!caiboxyl enu", thus C1S anu C16 aie piouuceu fiist, C2 anu C1 aie piouuceu last.
+/".-/"/#"($-42 @:= .-/"/#"($-42 )N?LFN?N>?CHFA@: Apolipopioteins aie pioteins that binu to lipius anu help tianspoit them thioughout the bouy. 0nce bounu to lipius, the stiuctuie is known as a lipopiotein. 0thei functions of apolipopioteins incluue acting as co-enzymes anu as liganus between the lipopioteins anu the tissues they supply. They aie synthesizeu in the intestines anu theii "iate iegulation" is ueteimineu by the content of fat available thiough a peison's uietaiy intake. Theie aie six classes of apolipopioteins: + - incluues the sub-gioups: )K5V )K55V )K5]V )K]) * - incluues the sub-gioups: 26;V 2,== , - incluues the sub-gioups: !K5V !K55V !K555V !K5] Classes &, $, anu ) have no impoitant sub-gioups.
3FN?N>?CHFA@: Because fatty acius alone have tiouble being tianspoiteu thiough aqueous compaitments insiue the cells, a mechanism must be in place to allow them to get to wheie they neeu to be, thus enteis the lipopioteins. The basic stiuctuie of the lipopiotein is below:
Lipopioteins aie uiffeient baseu on the iatio of piotein:lipius, as well as the paiticulai apopioteins anu lipius that they contain. Thus, lipius can be classifieu baseu on theii uensitites: (X3 hIFJIKMHA@FCE LFN?N>?CHFAid Bas the highest piotein:lipiu iatio of all lipopioteins, is also the lipopiotein with the highest oveiall uensity. Responsible foi tianspoitation of cholesteiol fiom the peiipheial tissues back to the livei. 5X3 hFACH>DHMFBCH MHA@FCE N>?CHFAid IBL is foimeu when vLBL gets uegiaueu. Tianspoits anu ueliveis both tiiglyceiiues anu cholesteiol to the livei, wheie they get uegiaueu to low-uensity lipopioteins. 3X3 hL?TKMHA@FCE LFN?N>?CHFA@id Aie a low-uensity lipopiotein which contain the highest uensity of cholesteiyl esteis. LBL is engulfeu by taiget cells, anu is a veiy uangeious lipopiotein that can leau to haiuening of the aiteiies anu subsequently vasculai pathologies. ]3X3 hGH>E L?TKMHA@FCE LFN?N>?CHFA@i: Contain the seconu highest uensity of tiiacylglyceiols. Its iole is to uelivei tiiglyceiiues fiom the livei to the peiipheial tissues. !(03"/5!+"#&: Aie the laigest of all the lipopioteins, but have the lowest uensity uue to a high iatio of lipius to pioteins. Also contain the highest content of tiiacylglyceiols by uensity. Bas a uual iole as it supplies the peiipheial tissues with tiiglyceiiues anu supplies cholesteiol to the livei.
()$ 2(#1,(1#$ "! )$3$
)$3$ 2G4()$2-2
&-2"#&$#2 "! )$3$ 2G4()$2-2 />8NH>QDID:>M7: &7@?D:@A7 - )OSCH 5ACH>DFCCHAC *?>NIE>FB Acute inteimittent poiphyiia is causeu by a ueficiency in the enzyme poipobilinogen ueaminase, thus pieventing the conveision of poiphobilinogen to hyuioxymethylbilane. This leaus to an accumulation of poiphobilinogen in the cytosol, which causes a myiiau of symptoms. &EDNC?D@ ?U BOSCH FACH>DFCCHAC N?>NIE>FB: - Nuscle weakness - Abuominal pain - Constipation - Nausea vomiting - Bypeitension - Biaphoiesis - Tachycaiuia $>HBCDHAC ?U BOSCH FACH>DFCCHAC N?>NIE>FB: - Nay iequiie hospitalization foi seveie symptoms - Avoiuance of piecipitating uiugs - Avoiuance of alcohol - Piopei uiet
18>N>8NHF8D:>M7: &7E@8Q>JFI@A7 - *?>NIE>FB !SCBAHB $B>MB This is the most common type of poiphyiia, iesulting fiom low levels of uiopoiphyiinogen uecaiboxylase. &FJA@ BAM &EDNC?D@ ?U *?>NIE>FB !SCBAHB $B>MB: - Blisteiing of the skin in aieas exposeu to sun - Photosensitivities - Bypeipigmentation anu hypeitiichosis - Chionic livei uisease (fibiosis, ciiihosis, inflammation) $>HBCDHAC ?U *?>NIE>FB !SCBAHB $B>MB: Since it is a chionic conuition, a multi-uimensional appioach is iequiieu to contiol the gioup of possible symptoms. - Avoiuance of excess exposuie to sunlight, iion, anu alcohol
&-2"#&$#2 "! /1#-4$ +4& /G#-3-&-4$ 3$(+*".-23 Puiines aie a key component of cellulai eneigy (ATP, NAB), signaling (uTP, cANP, cuNP), anu in conjunction with pyiimiuines, the piouuction of BNA anu RNA. When theie aie pioblems with salvage, synthesis, catabolism, anu metabolism of puiines anu pyiimiuines, ceitain uisoiueis piesent themselves.
3H@OIK#EIBA &EAM>?DH: An x-linkeu iecessive uisoiuei, is uue to the absence of the enzyme 'hypoxanthine-guanine phosphoiibosyl tiansfeiase (BPRT), which is iesponsible foi conveiting hypoxanthine to inosine monophosphate anu guanine to guanosine monophosphate. This iesults in the piouuction of excess uiic aciu. 6>0%'.0,: Nental ietaiuation, self-mutilation, aggiession, hypeiuiicemia, gout, anu choieoathetosis. )MHAFAH *I?@NI?>FW?@ELC>BA@UH>B@H MHUFOFHAOE: A iaie AT uisoiuei iesulting in the inability to salvage auenine foi puiine synthesis. This iesults in an accumulation of auenine, which is oxiuizeu to 2,8-uihyuioxyauenine, which piecipitates in the uiinaiy tiact, anu causes pioblem iuentical to those of uiic aciu nephiopathy (ie. Renal colic, infections, anu ienal failuie). This must be manageu with a high fluiu intake anu puiine iestiiction.
X5&"+X%+& "Z *7+5#% #7!3%"$5X% &0#$(%&5&: )MHAEL@SOOFAB@H MHUFOFHAOEd Is an AR uisoiuei that causes significant mental uisabilities, seizuies, anu autistic behaviois. Theie aie incieaseu levels of succinylaminoimiuazole caiboxamiue iibosiue anu succinylauenosine in the uiine anu CSF.
X5&"+X%+& "Z *7+5#% !)$)2"35&/: )MHA?@FAH MHBDFAB@H MHUFOFHAOE, /E?BMHAELBCH MHBDFAB@H MHUFOFHAOE )MHA?@FAH XHBDFAB@H XHUFOFHAOEd This ueficiency causes seveie combineu immunoueficiency uisease. The incieaseu uATP iesults in inhibition of iibonucleotiue ieuuctase anu unueipiouuction of othei ueoxyiibonucleotiues. This causes the compiomise of BNA ieplication. Patient will have low RBC's anu WBC enzyme activity. Stem cell tiansplant anu enzyme ieplacement is essential to theiapy. *S>FAH #SOLH?@FMH *I?@NI?>ELB@H MHUFOFHAOE: A iaie AR uisoiuei with seveie T- cell uysfunction anu the piesence of neuiological symptoms. Patient will uevelop lymphopenia, thymic ueficiency, iecuiient infection, anu hypouiicemia. These will cause uevelopmental uelays, spasticity, anu ataxia (ie. CNS uisoiueis) fBACIFAH "PFMB@H MHUFOFHAOE: Pievents the piouuction of uiic aciu fiom xanthine anu hypoxanthine. The builuup of xanthine can piecipitate in the uiine, causing stones, uiinaiy colic, anu 0TI's. Patients shoulu be manageu by maintaining a high fluiu intake anu taking allopuiinol.
X5&"+X%+& "Z *0+5/5X5#% /%$)2"35&/: 7>FMFAH /?A?NI?@NIBCH &EACIB@H MHUFOFHAOE (Beieuitaiy oiotic aciuuiia): This ueficiency pievents oiotate phosphoiibosyltiansfeiase anu oiotiuine-S'- monophosphate uecaiboxylase ieactions. The accumulation of oiotic aciu causes megaloblastic anemia, oiotic ciystalluiia, nephiopathy, caiuiac malfoimations, stiabismus, anu iecuiiing infections. Tieatment involves uiiuine supplementation.
.+,("2$ -4(".$#+4,$ .@EB>A7 37B@Q>IDA?: Lactose is metabolizeu by the enzyme 'lactase', which when ueficient causes uI uistuibances such as bloating, uiaiihea, etc. The ieason foi this is that lactose is a uisacchaiiues, which cannot be absoibeu thiough the wall of the small intestine. When it iemains unuigesteu, it passes thiough the uI system anu causes laige amount of gas, ciamps, bloating, etc. The piocess by which lactose is conveiteu to gaseous piouucts (feimentation) will ultimately iaise the osmotic piessuie of the colon.
!#1,("2$ 3$(+*".-23 +4& &-2"#&$#2 %@@HACFBL Z>SOC?@S>FB - A uefect of fiuctokinase, is a benign conuition wheie the only symptoms is high levels of fiuctose in bloou anu uiine. Z>SOC?@H 5AC?LH>BAOH - Is a heieuitaiy ueficiency on aluolase B. Theie is a iesulting inhibition of both glycogenolysis anu gluconeogenesis because fiuctose-1- phosphate accumulation uecieases the amount of available phosphate.
T+.+,("2$ 3$(+*".-23 +4& &-2"#&$#2 Theie aie two pioblems that iesult fiom the absenceueficiency of enzymes involveu in galactose metabolism. .BLB\C?\FAB@H XHUFOFHAOE: A ueficiency of the enzyme 'galaktokinase', pieventing the conveision of galactose ! galactose-1-phosphate. Causes galactosemia anu galactosuiia. .BLBOC?@HDFB: Causeu by a uiiuyl tiansfeiase ueficiency. Can cause symptoms such as cataiacts, mental ietaiuation, hepatosplenomegaly, all uue to the accumulation of toxic substances that iesult fiom the ueficiency.
$()+4". +4& )G/"T.G,$3-+ When ethanol is metabolizeu, theie is an incieaseu iatio of NABB:NAB+, which causes a shunting of pyiuvate to lactate anu oxaloacetate to malate. This causes an inhibition of gluconeogenesis anu thus causes hypoglycemia. Because theie is a shunt away fiom gluconeogenesis anu towaius fatty aciu synthesis, the livei uevelops fatty changes as well.
()$ 1#$+ ,G,.$ The uiea cycle is iesponsible foi the uegiauation of amino acius into amino gioups. This cycle piouuces appioximately 9u% of all the uiea founu in the uiine. The location of the uiea cycle is the cytosol of the livei, with the incoipoiation of the caibamoyl phosphate being integiateu insiue the mitochonuiia.
()$ ,"#- ,G,.$ O.+,(+($ (#+42/"#(P Is a metabolic pathway by which lactate that is piouuceu thiough anaeiobic glycolysis is tianspoiteu fiom the muscle to the livei anu ie-conveiteu to glucose. This cycle piouuces a net ATP of 2
()$ /$4("2$ /)"2/)+($ /+()%+G Also known as the BNP shunt, this pathway is necessaiy to the piouuction of iibose- S-phosphate fiom glucose-6-phosphate foi the synthesis of nucleotiues, the piouuction of NABPB fiom NABP+ foi the synthesis of fatty acius anu steioius, anu foi the maintenance of ieuuceu glutathione. The iate limiting enzyme foi this pathway is "glucose-6-phosphate uehyuiogenase".
TBIS PATBWAY IS NECESSARY T0 PR0B0CE REB0CEB uL0TATBI0NE, WBICB IS 0SEB T0 BET0XIFY FREE RABICALS. A BEFICIENCY WILL LEAB T0 BEN0LYTIC ANENIA B0E T0 LACK 0F BEFENCE.
-3/"#(+4( &$#-5+(-5$2 "! +3-4" +,-&2
+3-4" +,-&2R $22$4(-+. 9An 4"4S$22$4(-+. Amino acius aie biochemical molecules containing an amine gioup, a caiboxylic aciu gioup, anu a siue chain that vaiies between each amino aciu. They contain nitiogen, caibon, oxygen, anu hyuiogen. 2B@FO &C>SOCS>H:
5-(+3-42
*87@m=>K: >C 9DB@?D: E@B7M>8D7A: ZBC &?LSWLH ]FCBDFA@: - vitamin B - vitamin E - vitamin K - vitamin A YBCH> &?LSWLH ]FCBDFA@: - vitamin C - vitamins B1, B2, BS, Biotin, Pantothenic Aciu - Pyiiuoxine - Folic Aciu - Cobalamin
!+( 2".1*.$ 5-(+3-42: (G/$ !14,(-"4 &$!-,-$4,-$2 $0,$22$2 vitamin B Incieases intestinal absoiption of calcium anu phosphate Chiluien get Rickets, auults get osteomalacia. Both can uevelop hypocalcemic tetany Bypeicalcemia anu all associateu symptoms of hypeicalcemia vitamin E Acts as an antioxiuant RBC become fiagile anu aie at iisk of hemolysis
vitamin K Involveu in the piocess of bloou clotting Bemoiihages in neonates
vitamin A Is necessaiy foi healthy ietinas Biy skin, night vision uistuibances, immuneueficiency Alopecia, aithialgia, heauache, skin conuitions
%+($#S2".1*.$ 5-(+3-42: (G/$ #".$ -4 )$+.() &$!-,-$4,G vitamin C Impoitant in collagen synthesis (hyuioxylation), Belps with iion absoiption Scuivy - biuising, bleeuing gums, anemia, pooi wounu healing vitamin B1 (thiamine) 0xiuative uecaiboxylation of alpha-keto acius, co- factoi foi tiansketolase in the BNP shunt Beiibeii anu Koisakoff's synuiome, most common in alcoholics vitamin B2 (iiboflavin) Is a co-factoi in oxiuation anu ieuuction ieactions Chelosis, angulai stomatosis, coineal vasculaiization vitamin BS (niacin) 0seu in ieuox ieactions as constituent of NAB+ anu NABP+ Pellagia (4u's) - uiaiihea, uementia, ueimatitis, ueath vitamin BS (pantothenate) Involveu in fatty aciu synthase anu a co-factoi foi acyl tiansfeis Auienal insufficiency, ueimatitis, enteiitis, alopecia vitamin B6 (pyiiuoxine) Is a co-factoi in tiansamination, uecaiboxylation, anu tians-sulfuiation Causeu isoniaziu ueficiency (neivous system uistuibances) Biotin A co-factoi in caiboxylation ieactions Beimatitis anu enteiitis, can be causeu by eating iaw eggs Folic Aciu Co-enzyme in caibon tiansfei in methylation ieactions, involveu in synthesis of nitio bases in BNA anu RNA Naciocytic anemia, neuial tube uefects in ueveloping fetus Cobalamin Is a co-factoi in homocysteine methylation anu methylmalonyl-CoA activity Negaloblastic anemia with neuiological symptoms, glossitis
!()*$%+ :
%$(5!&
$IF@ C?NFO F@ FDN?>CBAC B@ CIH>H B>H S@SBLLE B IBAMUSL ?U HCIFO@ RSH@CF?A@ ?A CIH HPBDQ 7AMH>@CBAMFAJ MHUFAFCF?A@ BAM WHFAJ BWLH C? BNNLE CIHD C? C>FO\E @FCSBCF?A@ F@ H@@HACFBL U?> NFO\FAJ SN B IBAMUSL ?U HB@E N?FAC@ ?A CIH HPBDQ
*$4$!-,$4,$ This teim uesciibes the iesponsibility of the physician to always act in the best inteiest of the patient. Beneficence may not always be in place, as a patient's iight to make theii own uecisions may not always be in theii veiy best inteiest. In this situation, the physician has a uuty to honoi the uesiies of the patient with iespect to his oi hei own caie.
4"4S3+.$!-,$4,$ This teim means the physician shall "Bo No Baim", anu is always piioiity #1 when it comes to meuical ethics anu piactice piinciples.
+1("4"3G Autonomy iefeis to the patient's iight to make theii own uecisions aftei being piopeily euucateu anu infoimeu. Whethei a physician believes these uecisions to be iight oi wiong, they have a uuty to iespect anu honoi the patient's autonomy.
+ /+(-$4([2 +*-.-(G (" 3+V$ &$,-2-"42 A patient's ability to make theii own uecisions is baseu on a few piinciples that must be in place: - Patient must be psychologically stable (ie not skeweu by mental illness) - Patient must be the one who tells you theii uesiies, not the family - Patient uoes not switch back anu foith between theii wishes (shows instability of the patient's mentation) - Patient ieceives complete infoimation of auvantages anu uisauvantages of tieatment options - Patient makes theii choice, which is not influenceu by family, fiienus, etc
-4!"#3$& ,"42$4( Infoimeu consent is when a patient gives the physician the consent to pioceeu with meuical management. It must be baseu on piopeily infoiming the patient, wheieby they unueistanu the iisks, benefits, anu alteinative options. Becisions must be baseu on complete autonomy, not of peisuasion.
%)$4 -2 -4!"#3$& ,"42$4( 4"( #$e1-#$&f It is fully legal to pioceeu with meuical inteivention without a patient's consent when any of the following aie piesent: - Inteivention will be life-saving, such as in the ER - Patient is not in a mental state to make a uecision (psychosis, intoxication) - The patient waives theii iight to infoimeu consent - Theie is a theiapeutic auvantage to not getting infoimeu consent
/+(-$4([2 #-T)( (" ,"4!-&$4(-+.-(G A patient has the iight to complete confiuentiality, wheieby uisclosing a patient's infoimation is illegal unless they give you uiiect peimission to uo so.
%)$4 -2 ,"4!-&$4(-+.-(G *#$+,)+*.$f Theie aie ceitain situations in which it is the physician's iesponsibility to bieach confiuentiality foi the safety of society anuoi foi the gieatei benefit of the patient. These instances incluue: - Theie is the potential foi haim to otheis ($B>B@?UU MHOF@F?A) - The patient has a high iisk of self-haiming - Theie is the piesence of a iepoitable infectious uisease - Patient is eithei suiciual oi homiciual - Theie is abuse to a chilu oi an eluei
()$ +&5+4,$& &-#$,(-5$ Theie aie numeious ways by which a patient can give theii auvanceu uiiective. 3FGFAJ YFLL@ - the patient infoims the physician whethei they want to be tieateu oi not shoulu the neeu aiise wheie they cannot communicate this to the physician ">BL )MGBAOHM - while less likely to stanu up in couit, this is an oial iequest given by the patient to the physician in the past iequesting theii uesiies foi meuical inteivention
&1#+*.$ /"%$# "! +(("#4$G The uuiable Powei of Attoiney is a peison uesignateu by the patient to make theii meuical uecisions in the event that they aie unable to uo so foi themselves.
4$T.-T$4,$L3+./#+,(-,$ Theie aie foui ciiteiia that must be met in oiuei foi a malpiactice suit to be waiianteu, they aie: XSCE ! This implies that theie is a physician-patient ielationship that is establisheu. XH>HLFOCF?A ! When the physician fails to comply with the stanuaius of caie foi the patient XF>HOC !BS@H ! Wheie a patient incuis injuiyuamage that iesulteu fiom the physician's bieach of uuty, wheie theie aie no othei ciicumstances that may have causeu the injuiy XBDBJH@ ! The injuiies suffeieu by the client ** It shoulu be noteu that the absolute most common ieason foi a meuical lawsuit is a lack of communication oi pooi communication between the physician anu patient. Establishing a stiong physician-patient ielationship is the best way to pievent a lawsuit.
!()*$%+ ;
25"&$)$5&$5!&
)NNLFOBCF?A ?U CIH WF?@CBCF@CFOBL HRSBCF?A@ B@ THLL B@ USLLE SAMH>@CBAMFAJ CIH CENH@ ?U @CSMFH@ BAM CENH@ ?U WFB@ F@ H@@HACFBL ^DS@CK\A?T_ FAU?>DBCF?AQ YIFLH FC F@ CHDNCFAJ C? U?>HJ? @CSMEFAJ WF?@CBCF@CFO@V FC F@ HB@E C? J>BW NLHACE ?U HB@E N?FAC@ WE @FDNLE @NHAMFAJ B UHT I?S>@ ?A CIF@ C?NFOQ
(G/$2 "! 2(1&-$2 !B@HK!?AC>?Le%PNH>FDHACBL - This test is the golu stanuaiu of epiuemiological testing, wheie two equal gioups aie compaieu wheie one gioup has a changeu vaiiable *>?@NHOCFGH - This is also known as a Cohoit, 0bseivational, anu Inciuence stuuy. A sample is taken anu uiviueu into two gioups baseu on the piesence oi absence of a iisk factoi. The gioups aie then followeu ovei time to see what shoulu uevelop. These tests aie veiy time consuming anu expensive, thus less useu. +HC>?@NHOCFGH - This stuuy chooses a population of samples baseu on eithei the piesence oi absence of a ceitain iisk factoi. The sample is chosen aftei a uisease has occuiieu, not befoie it has occuiieu. This test is cheapei anu much fastei to peifoim than the otheis. !B@H &H>FH@ - This simply uesciibes what the clinical piesentation looks like in people who have a ceitain uisease. !>?@@K&HOCF?ABLe*>HGBLHAOH - This stuuy takes a sample of population at one point in time, anu looks at the pievalence of uisease anu the pievalence of iisk factois. This test is optimal foi compaiing two uiffeient cultuies, looking foi associations between lifestyle choices anu pievalence of uiseases.
$/-&$3-, 9An /+4&$3-, An epiuemic is seen when theie is an obseiveu inciuence of a paiticulai uisease that gieatly exceeus the expecteu inciuence, wheieas a panuemic is an epiuemic that is seen ovei a wiue geogiaphical aiea.
($2( 3$()"&2 $T?K&BDNLH $KCH@C - This test is useu to compaie the means of two gioups of subjects. )#"]) - This test is the "analysis of vaiiance", anu is useu to compaie thiee oi moie vaiiables. !IFK&RSB>HM - This test compaies the piopoitions of a categoiizeu outcome (2x2 table). With a laige uiffeience between the obseiveu anu expecteu values, theie is assumeu to be an association between the exposuie anu the outcome. /HCBK)ABLE@F@ - This test is uone by pooling uata fiom seveial stuuies, which gives the test a big statistical powei.
(G/$2 "! *-+2 &HLHOCF?A 2FB@ - This type of bias iesults fiom the mannei by which people aie selecteu anuoi fiom selective losses fiom follow-up stuuies. "W@H>GH> BAM /HB@S>HDHAC 2FB@ - This bias iesults fiom the uistoition of measuiement of association by misclassification of the exposeuunexposeu anuoi uiseaseunon-uiseaseu stuuy subjects. +HOBLL 2FB@ - Bias uue to inaccuiacies in iecall of past exposuie by people in the stuuy. (BTCI?>AH %UUHOC - This bias occuis when a patient uelibeiately changes theii behavioi because they know they aie being stuuieu. !?AU?SAMFAJ - This bias occuis as a iesult of the auuition of extianeous factois. Foi example if a stuuy is looking foi ciiihosis, they finu an association between smoking anu ciiihosis, anu finu theie to be a stiong association. Then subsequently, the stuuy shows that some smokeis aie also heavy uiinkeis while some aie not. In this instance, alcohol is the confounuing factoi. An effective way of contiolling confounuing is /BCOIFAJ. 3HBM $FDH 2FB@ - This bias has to uo with the time fiame by which uiagnoses anu tieatments aie examineu. )MDF@@F?A +BCH 2FB@ - This bias type is uue to the uiffeiences in hospital aumission iates, which uistoits the iisk iatio. 7ABOOHNCBWFLFCE 2FB@ - This type of bias occuis when the paiticipants puiposely give uesiiable iesponses, which then leau to the unueiestimation of iisk factois.
2$42-(-5Gl 2/$,-!-,-(Gl //5l 4/5l "#l ##l @:= +((#-*1(+*.$ #-2V The following table will be the basis foi all calculations ielating to the above topics:
27:ADBD9DBF = @L@ k E 6#),('(P('> 1#'#/0()#, '"# R .- '/4# %.,('(P#, 1(P(1#1 M> *++ '".,# 2". '/4+> "*P# '"# 1(,#*,#5 6&/##)()3 '#,', 2('" "(3" ,#),('(P('> */# M#,'5 2N7EDCDEDBF U =L= k Q 6%#&(-(&('> 1#'#/0()#, '"# R .- '/4# )#3*'(P# 1(P(1#1 M> *++ '".,# 2". '/4+> 1. ).' "*P# '"# 1(,#*,#5 9.)-(/0*'./> '#,', 2('" "(3" ,%#&(-(&('> */# M#,'5 />ADBD97 /87=DEBD97 5@I<7 U @L@ k Q The PPv test is useu to ueteimine the piobability of having an actual conuition when theie is a positive test iesult. Relateu to pievalence in a uiiect mannei, thus with an incieaseu pievalence theie is an inciease in the PPv.
47M@BD97 /87=DEBD97 5@I<7 U =L= k E The NPv is useu to ueteimine the piobability of not having a conuition when the test iesult is negative. "==A #@BD> U O@LQPL OEL=P The 0R ueteimines the inciuence of uisease in people in the exposeu gioups uiviueu by those in an unexposeu gioup. "+ l , = States that the factoi being stuuieu is a iisk factoi foi the outcome "+p, = States that the factoi being stuuieu is a piotective factoi in iespect to the outcome "+ q ,, States that no significant uiffeience in outcome in eithei exposeu oi unexposeu gioup #7I@BD97 #DAm U o@LO@kQP L =LOEk=Pp Relative iisk compaies the uisease iisk in people exposeu to a ceitain factoi with uisease iisk in people who have not been exposeu +BB8DQ<B@QI7 #DAm U o@LO@kQP a =LOEk=Pp The attiibutable iisk is the numbei of cases that can be attiibuteu to one iisk factoi
-4,-&$4,$ 9An /#$5+.$4,$ Inciuence is the numbei of new cases of a uisease ovei a unit time, wheieas pievalence is the total numbei of cases of a uisease (both new anu olu) at a ceitain point in time. Any uisease tieateu with the sole puipose of piolonging life (ie teiminal canceis), the inciuence stays the same but pievalence will inciease. &I?>CKCH>D MF@HB@H@: Inciuence > Pievalence 3?AJKCH>D MF@HB@H@: Pievalence > Inciuence
5+.-&-(G 9An #$.-+*-.-(G ]BLFMFCE is simply a test's ability to measuie what it claims to measuie, wheieas the >HLFBWFLFCE of a test ueteimines its ability to consistent iesults on iepeateu attempts.
2(+4&+#& &$5-+(-"4 Stanuaiu ueviation is a teim that measuies the vaiiability of iesults.
X 2B@:=@8= &79D@BD>: - 68% of iesults fall within 1SB Z 2B@:=@8= &79D@BD>:A - 9S% of iesults fall within 2SB ] 2B@:=@8= &79D@BD>:A - 99.7% of iesults fall within SSB
3$+4l 3$&-+4l 3"&$ 37@: - The aveiage value 37=D@: - The miuule value 3>=7 - The most common value
Noimal Bell Cuive: /HBA q /HMFBA q /?MH
*?@FCFGHLE @\HTHM giaph inuicates that: /HBA l /HMFBA l /?MH
#HJBCFGHLE @\HTHM giaph inuicates that: /HBA p /HMFBA p /?MH
,1("!! /"-4(2 !"# 2$42-(-5-(G +4& 2/$,-!-,-(G
Shoulu the cutoff point foi a uisease be moveu fiom UBL@H N?@FCFGH C? UBL@H AHJBCFGH, theie is an inciease in the numbei of positive iesults. This will inciease the sensitivity of the iesults. This will also ()&/#*,# '"# '/4# %.,('(P# *)1 -*+,# %.,('(P# numbeis, while 1#&/#*,()3 '"# )40M#/ .- -*+,# )#3*'(P#, *)1 1#&/#*,()3 '"# %.,('(P# %/#1(&'(P# P*+4#5 Shoulu the cutoff point be iaiseu fiom being false negative to false positive, theie will be an inciease in specificity, ()&/#*,()3 '"# )40M#/ .- '/4# )#3*'(P#, *)1 -*+,# %.,('(P#,5
,"4!-&$4,$ -4($#5+. +4& NS5+.1$ These values stiengthen the iesults of a stuuy. Foi statistical significance, the CI mustn't contain the null value (RR = 1), anu the closei the two numbeis aie togethei, the moie confiuent you can be that the iesults aie statistically significant. As fai as the significance of the p-value goes, a statistically significant iesult has a p- value of <u.uS (this means theie is <S% chance that the iesults obtaineu weie uue to chance alone).
,"##$.+(-"4 ,"S$!!-,-$4( Two numbeis that aie between -1 anu +1, it measuies to what uegiee the vaiiables aie ielateu. - A numbei of zeio (u) means theie is no coiielation between vaiiables. - A numbei of +1 means theie is a peifect coiielation (both vaiiables inciease oi ueciease piopoitionally) - A numbei of -1 means theie is a peifect negative coiielation (vaiiables move in opposite uiiections piopoitionally)
+((#-*1(+*.$ #-2V /$#,$4( O+#/P The ARP measuies the impact of the paiticulai iisk factoi being stuuieu on a paiticulai population. It iepiesents excess iisk that can be explaineu by exposuie to a paiticulai iisk factoi. Calculate the ARP: ARP = |(RR -1)RRj
2(+(-2(-,+. )G/"()$2$2 The statistical hypotheses aie useu to ueteimine whethei oi not theie is an association between iisk factois anu uisease in a population. They aie the 'ASLL hypothesis' anu the 'BLCH>ABCFGHc hypothesis. #SLL (EN?CIH@F@ h(?i - This hypothesis is the 'hypothesis of no uiffeience', meaning theie is not an association between the uisease anu the iisk factoi. )LCH>ABCFGH (EN?CIH@F@ h(,i - This hypothesis is the 'hypothesis of some uiffeience', meaning theie is an association between the uisease anu the iisk factoi.
/"%$# The powei of a statistical test is the piobability that a test will ieject a false null hypothesis, meaning it will not make a Type 2 eiioi. With incieaseu sample size theie is incieaseu powei anu theie is a uecieaseu chances of seeing a type 2 eiioi.
$##"#2 $ENH , %>>?> h!i - A type 1 eiioi mistakenly accepts the expeiimental hypothesis anu iejects the null hypothesis. This eiioi means that something statistically is seen that in fact is not theie. $ENH 1 %>>?> h"i - This type of eiioi occuis when you fail to ieject the null hypothesis when it is in fact false. This eiioi means you essentially something that is statistically piesent was in fact misseu.
!()*$%+ <
*&0!(5)$+0e*&0!("3".0
$IH RSH@CF?A@ B@\HM ?A CIF@ C?NFO OBA >BAJH U>?D B @C>BFJICU?>TB>M @FDNLH RSH@CF?A C? B RSH@CF?A CIBC HPNHOC@ E?S C? O?DWFAH DBAE B@NHOC@ ?U DHMFOFAH FA DB\FAJ CIH WH@C OI?FOHQ $IH IFJIH@CKEFHLM FAU?>DBCF?A FAOLSMH@ N@EOIFBC>FO NIB>DBO?L?JE B@ THLL B@ BLL ?U CIH NH>@?ABLFCE MF@?>MH>@Q
21*2(+4,$ &$/$4&$4,$ +4& +*12$ Theie is a big uiffeience between substance uepenuence anu substance abuse. &SW@CBAOH MHNHAMHAOH is a pattein of substance use that involves at least S out of 7 ciiteiia, they aie: - Theie aie uecieaseu social, occupational, oi iecieational activities because of the substance use - Patient has uevelopeu toleiance to substance - Patient expeiiences withuiawal symptoms when iefiaining fiom use - Theie is a chionic uesiie to cut back oi stop use - Patient will spenu excess time anu eneigy in tiying to attain theii substance - The substance is taken in amounts much laigei than intenueu - Continuation of use uespite the knowleuge of its haimful effects When any thiee of the pievious points aie piesent, the patient is uiagnoseu with substance uepenuence. &SW@CBAOH BWS@H is a pattein of substance use that causes significant social impaiiment anuoi uistiess. The uiagnosis of substance abuse is maue when theie aie any of the following: - Excess anu iecuiient use that causes failuie to fulfill majoi obligations such as going to woik, taking caie of kius, etc - Chionic anu iecuiient use of substance in situations that aie hazaiuous - Recuiient pioblems with the law uue to the uiug abuse - Peisistent use uespite the knowleuge of its uangeious effects
()$ 3"2( ,"33"4 (G/$2 "! 21*2(+4,$ +*12$ Theie aie many uiffeient types of uiugs, anu they all have uiffeient kinus of signssymptoms anu uiffeient uegiees of withuiawal seveiity. The uiugs anu substances most commonly useu anu abuseu incluue: - Alcohol - Amphetamines - Baibituiates anu Benzouiazepines - Caffeine - Cocaine - LSB - Naiijuana - Nicotine - 0pioius (heioin, oxycouone, moiphine, etc)
The following is a list of the most common uiugs, theii piimaiy signssymptoms, anu the common finuings of withuiawal 21*2(+4,$ 2-T42 "! -4("0-,+(-"4 %-()&#+%+. 2G3/("32 +.,")". Bisinhibition, sluiieu speech Tiemoi, tachycaiuia, seizuie, BT's +3/)$(+3-4$2 Psychomotoi agitation, myuiiasis Bepiession, lethaigy, excessive sleep *+#*-(1#+($2 Seuation, iespiiatoiy uepiession Anxiety, caiuiovasculai collapse *$4\"&-+\$/-4$2 Seuation, iespiiatoiy uepiession (not as seveie as baibituiates) Anxiety, seizuie, tiemoi ,",+-4$ Psychomotoi agitation, miosis, paianoya, NI Fatigue, uepiession, excessive sleep .G()$#T-, +,-& &-$()G.+3-&$ O.2&P visual anu auuitoiy hallucinations No withuiawal symptoms 3+#-61+4+ Euphoiia, incieaseu hungei, uelayeu iesponse time No withuiawal symptoms "/-"-&2 CNS uepiession, miosis, seizuie Nausea, vomiting, uI uistuibances, piloeiection /)$4,G,.-&-4$ Psychomotoi agitation, nystagmus, belligeience Bepiession, memoiy loss
()$ &+4T$#2 "! +.,")". %-()&#+%+. Alcohol withuiawal is a potentially life-thieatening event, anu iequiies meuical supeivision anu hospitalization. Nanagement of alcohol withuiawal involves benzouiazepines that aie tapeieu giauually ovei a few uays as the symptoms iesolve anu the patient stabilizes. (H7 AB@M7A >C @IE>H>I KDBH=8@K@I @87R )OSCH YFCIM>BTBL &EAM>?DH - 0ccuis fiom 24-48hi aftei the patient's last uiink, AF?NB>?A D:EI<=7: $>HD?>@V MFBNI?>H@F@V @HFaS>H@V IENH>>HULHPFB. )LO?I?LFO (BLLSOFABCF?A@ - 0ccuis fiom 24-72hi aftei patient's last uiink, AF?NB>?A D:EI<=7: (BLLSOFABCF?A@ hW?CI BSMFC?>E BAM GF@SBLiQ XHLH>FSD $>HDHA@ - 0ccuis 2-7 uays aftei patient's last uiink, AF?NB>?A D:EI<=7: (BLLSOFABCF?A@V FLLS@F?A@V MFBNI?>H@F@V CBOIEOB>MFBV IENH>CIH>DFB. This stage of alcohol withuiawal caiiies the possibility of being fatal.
3+4+T$3$4( "! "/-"-& -4("0-,+(-"4 Nany uiugs fall unuei the categoiy of 'opioius'. Biugs such as moiphine, heioin, oxycouone, anu many otheis. Symptoms aie veiy similai in that they cause seuation, constipation, etc. 3@:@M7?7:B >C D:B>JDE@BD>:L>978=>A7 DA @A C>II>KAR #BL?P?AHe#BLC>HP?AH - This is a meuication given in the ER when patient is suspecteu of opioiu intoxication, it acts by competitively inhibiting the opioiu ieceptois. /HCIBM?AH - A contioveisial uiug, methauone is useu to manage patients who aie unueigoing heioin uetoxification because it is long lasting anu is goou foi long-teim management.
3+6"# &$/#$22-5$ &-2"#&$# Najoi uepiessive uisoiuei is a seiious conuition chaiacteiizeu by seveial specific signs anu symptoms. In geneial, the best tieatment foi an episoue of majoi uepiession is an SSRI anti-uepiessant meuication. If a patient is expeiiencing theii fiist bout of uepiession, it is auviseu to keep them on theii meuication foi at least 6 months. If it is theii seconu oi moie bout of uepiession, they shoulu be kept on theii anti-uepiessant on an ongoing basis. Biagnosis iequiies that theie aie symptom-fiee peiious of at least two months in between each episoue. The uiagnosis of uepiession is maue when any of the following FIvE aie piesent foi at least TW0 weeks: - &LHHN XF@CS>WBAOH@ (patient may sleep too little oi too much) - 3?@@ ?U 5ACH>H@C (inteiest lost in things that they pieviously enjoyeu) - ZHHLFAJ ?U .SFLC (these guilty feelings aie usually unwaiianteu) - %AH>JE (loss of eneigy, which iesults in a loss of uiive to uo othei things they pieviously enjoyeu) - 3?@@ ?U !?AOHAC>BCF?A - )NNHCFCH !IBAJH@ (most of the time the patient has a L0SS of appetite, but they may also get an inciease in appetite) - *@EOI?D?C?> +HCB>MBCF?A (iesults in sloweu mentation, ielateu to loss of concentiation) - &SFOFMBL 5MHBCF?A (always inquiie about suiciue, it is not going to inciease the patient's iisk of committing suiciue) The populai mnemonic foi factois of uepiession is: 2-T $ ,+/2. ZHDBLH@ l /BLH@ r Z?> MHN>H@@F?A CIBC F@AcC IHLNHM TFCI &&+5 ?> ?CIH> BACFKMHN>H@@BAC@V %!$ @I?SLM WH C>FHMQ %!$ F@ BL@? CIH DBABJHDHAC ?U OI?FOH U?> DB`?> MHN>H@@F?A FA B N>HJABAC NBCFHACQ 21-,-&$ Suiciue is a big concein in uepiesseu patients, anu any patient who seems to have a uepiesseu moou shoulu be askeu about suiciue. It is impoitant to ask if they have thought about it, if they have thought of how they woulu uo it, anu if they have a plan. It is highly impoitant to inquiie about this, as asking WILL N0T inciease the iisk of them killing themselves. Women attempt suiciue moie often than men, howevei men aie moie likely to succeeu. The ieason foi this is because women often use less violent measuies such as pills, while men take moie violent measuies such as guns anu hanging. +F@\ UBOC?>@ U?> @SFOFMH: - Piioi attempts - Piesence of planlethality of plan (gun vs. pills, etc) - Cuiient meuical illness - Alcohol oi uiug uepenuence - Cuiiently taking thiee oi moie piesciiption uiugs - Lack of a social ciicle (few fiienus, no family, no spouse)
&G2()G3-+ Bysthymia is a chionic moou uisoiuei that is similai to uepiession, howevei it is an ongoing, less seveie type of uepiession. It has fewei symptoms than majoi uepiession, but is much longei lasting. At least 7S% of those with uysthymia have a co-moibiu psychiatiic uisoiuei such as anxiety, alcoholism, etc.
&$.$#-13 9An &$3$4(-+ These aie two teims often confuseu in meuicine, anu especially on the 0SNLE exams. XHLH>FSD is a state of uecieaseu attention span, hallucinations anu illusions, anu cognitive uysfunctions. The key to making the uiagnosis of ueliiium is that levels of functionality go in anu out (waxing anu waning), anu has an acute onset. 0n the othei hanu, MHDHACFB is a uisease with multiple cognitive uefects that uevelop slowly ovei time. The key to uiagnosing uementia is that the patient is fully conscious but has cognitive uefects.
*-/".+# &-2"#&$# Bipolai uisoiuei is a moou uisoiuei wheie a patient expeiiences both mania anu uepiession. Theie aie two types of bipolai uisoiuei (types 1 anu 2), wheie type 1 is mania anu type 2 is hypomania. Regaiuless of type, in oiuei to make a uiagnosis of a manic episoue the patient must have ceitain symptoms piesent foi at least 1 WEEK. The ciiteiia foi a manic episoue aie: - Easy uistiactibility - Insomnia (the patient can go foi uays without sleeping) - uianuiosity (the patient has an unusually exaggeiateu sense of self-esteem) - Flight of Iueas - Incieaseu activity (patient will uo numeious activities in one uay) - Piessuieu speech (fast, non-sensical, etc) - Thoughtlessness (patient will uo things without fully thinking about what they aie uoing fiist) At least S of these must be piesent to make a uiagnosis of a manic episoue. Nania causes seveie social impaiiment anu occupational uysfunction. Bypomania is similai to a manic episoue except theie is no impaiiment to the patient in any of theii uay-to-uay functioning. $IH M>SJ ?U OI?FOH U?> 2FN?LB> MF@?>MH> DBABJHDHAC F@ 35$(57/.
/$#2"4+.-(G &-2"#&$#2 These aie peivasive, fixeu, anu inappiopiiate patteins of ielating to otheis, causing social anu occupational impaiiment. Patients with peisonality uisoiueis uo not seek help foi theii uisoiuei because they aie not awaie that they aie the cause of theii own pioblems. Theie aie thiee categoiies of peisonality uisoiueis: Clustei A, Clustei B, Clustei C !LS@CH> ) MF@?>MH>@: Paianoiu, Schizoiu, Schizotypal !LS@CH> 2 MF@?>MH>@: Bistiionic, Naicissistic, Antisocial, Boiueiline !LS@CH> ! MF@?>MH>@: Avoiuant, 0bsessive-Compulsive, Bepenuent, Passive- Aggiessive
,.12($# + /$#2"4+.-(G &-2"#&$#2 *B>BA?FM - This patient uoes not tiust otheis, is suspicious of eveiything, anu believes all of theii pioblems aie causeu by otheis. &OIFa?FM - This patient will have a long histoiy of voluntaiily avoiuing social situations. Theie is no psychosis associateu with the schizoiu peisonality uisoiuei. &OIFa?CENBL - This patient has an ouupeculiai appeaiance, has magical thoughts anu an ouu pattein of behavioi. Theie is no pscyhosis with the schizotypal peisonality uisoiuei.
,.12($# * /$#2"4+.-(G &-2"#&$#2 (F@C>F?AFO - This patient is an extioveit, is sexually piovocative, anu veiy emotional. #B>OF@@F@CFO - This patient has a sense of entitlement anu lacks empathy foi otheis. )ACF@?OFBL - This patient iefuses to accept the iules of society, shows no concein foi theii own actions, anu shows no iemoise foi bau behavioi. This uisoiuei is associateu with conuuct uisoiuei in chiluhoou. 2?>MH>LFAH - This patient has eiiatic behavioi, impulsiveness, anu mini psychotic episoues. Look foi self-mutilation anu othei moou uisoiueis.
,.12($# , /$#2"4+.-(G &-2"#&$#2 )G?FMBAC - This patient is sensitive to iejection anu timiu, thus socially withuiawn. They also feel infeiioi to otheis foi no appaient ieason. "W@H@@FGHK!?DNSL@FGH - This patient is a peifectionist, oiueily, stubboin, anu inuecisive. This is not the same as obsessive-compulsive uisoiuei (0CB). XHNHAMHAC - This patient allows anu wants otheis to make uecisions foi them, ielateu to a lack of self-confiuence. *B@@FGHK)JJ>H@@FGH - This patient has "outwaiu compliance with innei uefiance".
+40-$(G &-2"#&$#2 Anxiety uisoiueis aie chaiacteiizeu by subjective anu physical manifestations of feai. $IH @EDNC?D@ B>H @FDFLB>: Tiemoi, Palpitations, Biaphoiesis, Bizziness, uI uistuibances, 0iinaiy symptoms.
*BAFO XF@?>MH> - Panic attacks that occui appioximately twice pei week, last appioximately Su minutes, anu piesent with symptoms similai to an NI. Patients often have a feai of anothei attack in-between each episoue. Nanagement of panic uisoiuei is SSRI's, with possible benzouiazepines foi acute tieatment. *I?WFB@ - Specific phobias an iiiational feai of specific objects, such as spiueis, snakes, etc. A social phobia is an exaggeiateu feai of social oi enviionmental situations (the most common social phobia is public speaking). Nanagement is uesensitization, can use beta-blockeis foi shoit-teim contiol of autonomic symptoms. "W@H@@FGHK!?DNSL@FGH XF@?>MH> h"!Xi - Patient expeiiences iecuiiing intiusive feelings, thoughts, anu images which cause anxiety that is ielieveu in pait by peifoiming iepetitive actions (compulsions). Patients iealize that theii actions aie iiiational anu uesiie to be helpeu. SSRI's aie mainstay of management. .HAH>BLFaHM )APFHCE XF@?>MH> - Patient expeiiences peisistent symptoms of anxiety foi at least 6 months. The symptoms aie unielateu to any specific peison oi situation. Seen in women > men. *?@CK$>BSDBCFO &C>H@@ XF@?>MH> - Is a conuition that affects someone who has been thiough a catastiophic event (classically a wai veteian). The patient expeiiences hypeiaiousal (anxiety, sleeplessness, intiusive memoiies) anu withuiawal (flatteneu affect, numbing, suivivoi's guilt). These @EDNC?D@ DS@C WH N>H@HAC U?> BC LHB@C , D?ACI foi a uiagnosis of PTSB, if @EDNC?D@ B>H LH@@ CIBA , D?ACI, the uiagnosis is )OSCH &C>H@@ XF@?>MH> (ASB).
2,)-\"/)#$4-+ Schizophienia is chaiacteiizeu by peiious of psychotic featuies anu uistuibing behavioi that lasts a minimum of 6 months. $ENH@ ?U @OIFa?NI>HAFB FAOLSMHd - Paianoiu - Bisoiganizeu - Catatonic - 0nuiffeientiateu - Resiuual
&?DBC?U?>D XF@?>MH>@ Somatofoim uisoiueis aie chaiacteiizeu by physical symptoms without any oiganic cause. Those with this conuition aie not malingeiing, aie not uelusional, anu tiuly believe they have a physical pioblem. &?DBC?U?>D XF@?>MH>@ FAOLSMH: - Somatization uisoiuei - Conveision uisoiuei - Bypochonuiiasis - Bouy Bysmoiphic uisoiuei - Pain uisoiuei - 0nuiffeientiateu Somatofoim uisoiuei
&?DBCFaBCF?A XF@?>MH> - Patient with histoiy of multiple somatic complaints ovei seveial yeais, they must incluue: 4 pain symptoms, 2 uI symptoms, 1 sexual symptom, anu 1 pseuuoneuiologic symptom. !?AGH>@F?A XF@?>MH> - Patient expeiiences an abiupt, uiamatic loss of motoi oi sensoiy function. Nost commonly the patient expeiiences paialysis, seizuies, paiesthesias, anesthesias, anu visual pioblems. (EN?OI?AM>FB@F@ - These patients have an exaggeiateu concein that they have illnesses uespite being tolu iepeateuly that theie is no cause foi concein. Nust occui foi at least a 6-month peiiou foi this uiagnosis. 2?ME XE@D?>NIFO XF@?>MH> [ The patient has an excessive anu possibly obsessive focus on a minoi oi possibly imagineu physical uefect. *BFA XF@?>MH> - Pain that is not explaineu by any physical pioblem, often co-exists with anothei meuical pioblem. If lasting < 6 months, it is an acute pain uisoiuei, if lasting > 6 months it is a chionic pain uisoiuei. 7AMFUUH>HACFBCHM &?DBC?U?>D XF@?>MH> - This is the uiagnosis when the peisistent physical symptoms uon't meet ciiteiia foi any of the othei uisoiueis. The most common pioblems falling unuei this umbiella aie: Fatigue, uIu0 symptoms, appetite changes.
ZBOCFCF?S@ XF@?>MH>@ A patient with factitious uisoiuei consciously cieates theii symptoms in oiuei to assume the iole of the sick patient so they can get meuical attention (the motivation howevei is unconscious). Theie aie two categoiies of factitious uisoiuei, they aie: /SAOIBS@HAc@ &EAM>?DH anu /SAOIBS@HAc@ &EAM>?DH WE *>?PE. /SAOIBS@HAc@ &EAM>?DH - Patient will have a chionic histoiy of multiple hospital aumissions, as well as a histoiy of willingness to ieceive invasive pioceuuies, even when not waiianteu. /SAOIBS@HAc@ WE *>?PE - This is when a chilu is ill because of the paient.
/BLFAJH>FAJ XF@?>MH>@ Patients with malingeiing uisoiuei consciously simulate oi exaggeiate a physical oi mental illness foi an obvious gain (Noney, Caie, Avoiuance of woik). This patient will avoiu tieatment, as opposeu to those with factitious uisoiuei. 0nce the patient ieceives the gain they aie seeking, the symptoms will iesolve.
2.$$/ 0nueistanuing wave patteins anu activities uuiing each stage of sleep aie impoitant aspects of unueistanuing the sleep cycle. +K@m7 KDBH 7F7A >N7:- 2HCB TBGH@, seiotonin stimulates the iape nuclei to inuuce sleep +K@m7 KDBH 7F7A EI>A7= - )LNIB TBGH@ 2B@M7 X - This is the stage of "light sleep". This stage is shoit, lasting appioximately S% of all sleep time, $IHCB TBGH@ aie pieuominant. 2B@M7 Z - This is ueepei sleep, lasting appioximately 4S% of all sleep time. Pieuominantly see @LHHN @NFAMLH@ BAM b O?DNLHPH@. 2B@M7 ] - This is the ueepest sleep, but is non-REN. Lasts appioximately 2S% of all sleep time, anu is chaiacteiizeu by XHLCB TBGH@. *This is the stage at which chiluien will expeiience enuiesis anu beu-wetting. 2B@M7 ^ - This is REN sleep. The patient will be uieaming anu lose all muscle tone. Theie aie pieuominantly 2HCB TBGH@ uuiing the REN sleep cycle.
+34$2-+ Amnesia can occui foi many ieasons, incluuing anesthesia, uiug use, olu age, heau injuiies, alcoholism, etc. The two foims of amnesia aie: )ACH>?J>BMH anu +HC>?J>BMH. )ACH>?J>BMH - This peison will be unable to iemembei anything aftei occuiiing aftei the inciuent that causeu theii amnesia, theiefoie they cannot foim any new memoiies. +HC>?J>BMH - This peison will be unable to iemembei things that occuiieu befoie the causative factoi of theii amnesia.
2.$$/ +/4$+ Sleep apnea is a seiious conuition wheie a peison has peiious of cessation of bieathing while asleep. This may last fiom a few seconus to minutes, anu may occui up to Su times pei houi. The two types of sleep apnea aie "Cential" anu "0bstiuctive". !HAC>BL @LHHN BNAHB - this type of apnea occuis uue to a lack of iespiiatoiy uiive fiom the CNS. "W@C>SOCFGH @LHHN BNAHB - this type of apnea is usually causeu by excessive weight, which causes obstiuction anu physical blockage of bieathing. Nanagement is weight loss anu CPAP machine. If these fail suigeiy may be iequiieu. In obstiuctive sleep apnea, a patient will often complain of excessive uaytime sleepiness, anu the spouse will complain of veiy louu snoiing.
4+#,".$/2G A conuition wheie someone falls asleep suuuenly without waining, anu may expeiience cataplexy (suuuen collapse while they aie still awake). They fall into REN sleep upon falling asleep. Nanage these patients fiist with scheuuleu uaytime naps, anu if that uoesn't woik use a stimulant such as methylpheniuate.
$+(-4T &-2"#&$#2 The two common eating uisoiueis aie BA?>HPFB AH>G?@B anu WSLFDFB AH>G?@B. )A?>HPFB #H>G?@B - This is a uangeious uisease wheie patients uiet excessively in an attempt to lose weight anu stay skinny. They have a uistoition to theii bouy image, which is a uiiving foice behinu the excessive uieting. Common auveise effects that occui incluue: )DHA?>>IHBV %LHOC>?LECH MF@CS>WBAOH@, anu seveie cases can iesult in OB>MFBO HCF?L?JFH@. Nanagement is weight gain anu if patient's weight is too low, hospitalization may be iequiieu. A BNI of less than 19 is woiiisome of anoiexia. 2SLFDFB #H>G?@B - These patients have a noimal bouy weight, with the main pioblem being oveieating (bingeing) anu then puiging (laxatives, vomiting, etc). Common finuings incluue enlaigeu paiotiu glanus, enamel eiosion, biuiseu fingeis (fiom sticking them in the mouth), esophageal vaiices causeu by the piessuie of vomiting.
2(#1,(1#+. ()$"#G "! ()$ 3-4& This is a concept uevelopeu by Fieuu, anu it uesciibes the thiee theoiies that encompass the human minu. These thiee theoiies aie the: 5MV &SNH>HJ?V anu %J?. (H7A7 AB8<EB<87A H@97 =DCC787:B C<:EBD>:Al BH7F @87R IM - The Iu is iesponsible foi sexual uiges, aggiession, anu othei piimal uiges. &SNH>HJ? - The supeiego encompasses the pait of youi minu that tells you to contiol youi piimal uiges, it acts as youi conscience. %J? - The ego is the theoiy that helps the minu ueal with the conflict between the 'wants' of the Iu, anu the conscience of the supeiego.
(G/$2 "! ,"4&-(-"4-4T The two types of conuitioning we must know foi the 0SNLE aie '!LB@@FOBL !?AMFCF?AFAJ' anu '"NH>BAC !?AMFCF?AFAJc. !LB@@FO !?AMFCF?AFAJ - This is a type of conuitioning that elicits a iesponse because the stimulus is paiieu with the unconuitioneu stimulus. The classic example is Pavlov's uog, who leaineu to link the sounu of a bell with a tieat, thus each time the bell iang the uog woulu salivate as a iesult of this conuitioning. "NH>BAC !?AMFCF?AFAJ - This is a type of conuitioning that occuis because theie was a iewaiu given foi peifoiming a ceitain act. The two types of opeiant conuitioning aie Positive Reinfoicement anu Negative Reinfoicement. *?@FCFGH +HFAU?>OHDHAC - A iewaiu piouuces an action #HJBCFGH +HFAU?>OHDHAC - Removing a negative stimulus will elicit action
2 months Bolus heau up Swipes at objects Coos Social smile 4 months Rolls fiont to back T8@ANA "Q;7EBA 0iients to voice Laughs 6 months Rolls fiom back to fiont, ADBA <N8DMHB Tiansfeis objects Babbles &797I>NA AB8@:M78 @:JD7BFl AI77NA @II :DMHB 9 months Ciawls, pulls to a stanu /D:E78 M8@ANl eats with fingeis 4>:SAN7EDCDE K>8=A Waves gooubye, iesponus to name 12 months 2B@:=A >: >K: 3@B<87 ND:E78 M8@AN 2N7EDCDE K>8=A q?@?@r Recognizes pictuies in a bookmagazine 1S months %@ImA 0ses a cup Speaks 4-6 woius (H8>KA B7?N78 B@:B8<? 18 months Thiows a ball, walks up the staiis 0ses spoon foi soliu foous Names common objects *7MD:A B>DI7B B8@D:D:M 24 months Staits iunning, can go up anu uown staiis 0ses spoon foi semi- solius 2N7@mA ZS K>8= A7:B7:E7 Can follow a 2- step commanu S6 months Can iiue a tiicycle Can eat neatly with utensils 2N7@mA ]S K>8= A7:B7:E7 Knows fiist anu last names
#$!.$0$2 /#$2$4( +( *-#() #$!.$0 2(+#(2 $4&2 ,)+#+,($#-2(-,2 3"#" #$!.$0 Biith ~ 2 months Suuuen shift in positions causes the legs anu heau to extenu while the aims jeik up anu out with the palms up anu the thumbs flexeu. Then the aims aie biought togethei anu hanus aie clencheu into fists %+.V-4T #$!.$0 Biith ~ 6 weeks When the sole is toucheu, the legs will move in a walking- motion, though the baby cannot walk #""(-4T #$!.$0 Biith ~4 months Infant tuins the heau towaiu the siue wheie the cheek gets stiokeu ("4-, 4$,V #$!.$0 1 month 4 months When chilu's heau is tuineu to one siue, the aim of the same siue will stiaighten anu the opposite aim will flex /+.3+# T#+2/ #$!.$0 Biith ~6 months Anything in the hanu oi stioking the hanu of the baby will cause a the fingeis to benu anu the hanu to giasp at the object T+.+4( #$!.$0 Biith ~ 6 months Stioking skin on siue of back causes bouy to swing to that siue *+*V-4 #$!.$0 Biith ~ 1 yeai Noie common in piematuie infants, piessuie to palms cause vaiying iesponses.
()$ 2(+T$2 "! &$+.-4T %-() &$+() Theie aie FIvE stages of uealing with ueath, they can be iemembeieu with the mnemonic "X)2X)". XHAFBLV )AJH>V 2B>JBFAFAJV XHN>H@@F?AV )OOHNCBAOH
,)+4T$2 2$$4 -4 ()$ $.&$#.G Theie aie a few changes that occui with auvanceu age that aie seen almost unifoimly acioss the geiiatiic population, they incluue: - Change in sleep patteins, namely less neeu foi sleep, uecieaseu REN sleep, moie fiequent awakening thioughout the night. - Sexual changes such as longei iefiactoiy peiiou, uelayeu ejaculation, slowei onset of eiection (in men). Females fiequently expeiience thinning anu uiyness of the vagina. - Neuical conuitions such as uegeneiative uiseases aie quite common
/+22-5$ 9An +,(-5$ -3314-(G /@AAD97 -??<:DBF ! This foim of immunity occuis when theie is a tiansfei of active humoial immunity in the foim of piefoimeu anitbouies fiom one host to anothei. This foim of immunization is useu when theie is a iisk of infection anu not enough time foi the bouy to uevelop an ample immune iesponse. This pioviues fast but shoit-liveu piotection. Examples: Nateinal Ig's passeu to baby, patient given iabies vaccine when bitten by a bat. +EBD97 -??<:DBF ! This foim of immunity uevelops thiough its own piouuction of antibouies in iesponse to exposuie to an antigen, pathogen, oi vaccine. This gives the oiganism slow-onset but long-teim piotection.
()$ ,"3.$3$4( /+()%+G Besigneu to piotect against giam negative bacteiia, is activateu by immunoglobulin u oi N in the classic pathway, anu activateu by suiface miciobes in the alteinate pathway.
()$ 3+6"# )-2(","3/+(-*-.-(G ,"3/.$0 O3),P The NBC is genomic iegion founu in veitebiates that encoues NBC molecules, anu these molecules play a veiy impoitant iole in immune function. Theie aie two types of NBC (ie NBC 1 anu NBC 2). (H7 3), - ! Contains 1 polypeptiue + a "2-micioglobulin, anu contains S genes (gene A, B, anu C).
The NBC II ! Contains 2 polypeptiues, anu an alpha anu a beta chain. Bas S genes (BP, BQ, anu BR). This NBC II is the main component in oigan iejection.
+4(-*"&G !14,(-"42
!14,(-"4 "! ()$ +4(-*"&G The vaiiable paits (vB, vL) will iecognize uiffeient antigens, while the constant paits ("C") will fix the complement. Fc Fiagment ! This fiagment is O?A@CBAC, has a OB>W?IEM>BCH siue-chain, is O?DNLHDHAC WFAMFAJ (Igu anu IgN only), anu has a OB>W?PE CH>DFABL. )ACFW?ME BFM@ FA: 1. Complement activation via the membiane attack complex 2. 0psonization (ie aius in phagocytosis) S. Neutialization (by pieventing the auheience of bacteiia)
21*(G/$2 "! -3314"T."*1.-42 0se the mnemonic "uANEB" to iemembei anu keep all of the immunoglobulin infoimation oiganizeu. -??<:>MI>Q<ID: T O-MTPR - Is the most abunuant of all the immunoglobulin's - Is the main antibouy iesponsible foi the seconuaiy antibouy iesponse - 0nly Ig that can cioss the placenta - Fixes complement, opsonizes bacteiia, anu neutializes toxins -??<:>MI>Q<ID: + O-M+PR - Founu in bouily secietions - Pievents bacteiial attachment to mucous membianes -??<:>MI>Q<ID: 3 O-M3PR - Responsible foi the piimaiy antibouy iesponse - Is the antigen ieceptoi on B cell suifaces -??<:>MI>Q<ID: $ O-M$PR - Bas the lowest concentiation of all Ig's - Responsible foi piotection against woims - Responsible foi mast cell anu basophil gianule ielease in type 1 hypeisensitivities
-??<:>MI>Q<ID: & O-M&PR - Founu on B cell suifaces
+4(-*"&G /#"&1,(-"4
(S,$.. +,(-5+(-"4 The following steps aie iequiieu foi helpei T-cell activation: 1. The antigen-piesenting cell engulfs the viial paiticle 2. The viial paiticle is then piesenteu on the suiface of the NBC II anu is then iecognizeu by the T-cell ieceptoi on the suiface of the helpei T-cell S. A "co-stimulatoiy" signal is maue when the B7 on the APC anu the CB28 on the helpei T-cell binu. 4. The combination of #2 anu #S cause the secietion of IL-2 anu %-IFN
Aftei the helpei T-cell is activateu, the next step is the activation of the cytotoxic T- cell, these steps aie: 1. IL-2 fiom the helpei T-cell connects with the cytotoxic T-cell, thus activating it to uestioy the infecteu cell. 2. Pioteins piesenteu on the NBC I (ie viial-iecognition) attiacts the cytotoxic T-cell, gets iecognizeu, anu is killeu $IH U?LL?TFAJ MHD?A@C>BCH@ CIH@H @CHN@ GF@SBLLE-
&-!!$#$4(-+(-"4L/#"&1,(-"4 "! ( +4& * ,$..2
,$.. 3$&-+($& -3314-(G O( ,$..2P T CELLS Alleigies uiaft Rejection Antibouy iesponse Befense against ZSAJFV /EO?WBOCH>FSDV $2V BAM GF>S@K FAUHOCHM OHLL@Q +4(-*"&GS3$&-+($& -3314-(G B CELLS Alleigies Autoimmunity Befense against 2BOCH>FBV $?PFA@V BAM ]F>S@H@
,G("V-4$ !14,(-"4 Theie is a gieat mnemonic that can help you iemembei the fiist five cytokines, it is: ")>B (-Q>:7 st$+k" -. a X ! Bot = FEvER -. a Z ! stimulation of T-cells -. a ] ! stimulation of B0NE maiiow -. a ^ ! IgE piouuction stimulation -. a b ! IgA piouuction stimulation
Now the iest of the cytokines aie iesponsible foi the following: -. a W ! PNN chemotactic factoi (4! ! ! Incieases IL-2 ieceptoi synthesis by helpei T cells, incieases B cell piolifeiation, anu attiacts anu stimulates PNNs. This is secieteu by maciophages. (4! " ! This is secieteu by activateu T lymphocytes, anu peifoims the same functions as the TNF ! % S -:B78C78>: ! Stimulates maciophages, secieteu by helpei T cells
-4($#!$#"42 Inteifeions play an essential iole in pieventing the piolifeiation anu piouuction of a viius by acting in ceitain ways to pievent it fiom infecting othei cells. $IH CI>HH DB`?> USAOCF?A@ ?U CIH FACH>UH>?A@ B>H: 1. Activation of natuial killei (NK) cells which act by uiiectly killing viius- infecteu cells. 2. ! anu " inteifeion act by inhibition of viial piotein synthesis S. % S Inteifeion woiks by incieasing the expiession of the NBC I anu NBC II as well as antigen piesentation in all cells 2FJ NFOCS>H /") ?U FACH>UH>?A@: ! Inteifeions stimulate the piouuction of a piotein that uegiaues viial mRNA. When this occuis, the viius cannot infect a cell since the piopei genetic mateiials foi this function aie absent.
(#+42/.+4( #$6$,(-"4 .>BUCKG@K(?@C +H`HOCF?A: 0ccuis when the giafteu T cells piolifeiate anu ieject the host cells that contain foieign pioteins. As this occuis, seveie oigan uysfunction ensues, causing uamage to the livei, skin, mucosa, anu gastiointestinal tiact. This conuition also affects the bone maiiow anu the lungs. (ENH>BOSCH +H`HOCF?A: 0ccuis almost immeuiately aftei tiansplant, wheieby piefoimeu anti-uonoi antibouies cause a iesponse. )OSCH +H`HOCF?A: This is a cell-meuiateu ieaction that occuis via cytotoxic T lymphocytes that ieact against foieign NBCs, occuiiing weeks post-tiansplant. !I>?AFO +H`HOCF?A: 0ccuiiing months-yeais post-tiansplant, is causeu by antibouy-meuiateu vasculai uamage.
(G/$2 "! )G/$#2$42-(-5-(G #$+,(-"42
(G/$ X )G/$#2$42-(-5-(G: +:@NHFI@EBDEL+B>NDE A veiy iapiu ieaction that occuis in iesponse to antigen exposuie. Antigens tiiggei the ielease of histamine by binuing to basophils anu mast cells. %PBDNLH@ ! Bives, asthma, anaphylaxis
(G/$ Z )G/$#2$42-(-5-(G: ,FB>B>JDE Is a cytotoxic ieaction wheieby IgN anuoi Igu binu to cells leauing to lysis by complement activation oi phagocytosis. %PBDNLH@ ! Autoimmune hemolytic anemia, uooupastuie's uisease, iheumatic fevei, Rh uisease, uiave's uisease.
(G/$ ] )G/$#2$42-(-5-(G: +:BDM7:S+:BDQ>=F 37=D@B7= The foimation of antigen-antibouy complexes leaus to complement activation, attiacting PNN's anu ultimately leauing to the ielease of lysosomal enzymes. %PBDNLH@ ! ulomeiulonephiitis, Lupus, Rheumatoiu Aithiitis
(G/$ ^ )G/$#2$42-(-5-(G: ,7IIS37=D@B7= Is a uelayeu iesponse, wheieby T cells become sensitizeu anu encountei antigens, thus ieleasing cytokines. %PBDNLH@ ! Contact Beimatitis, Tiansplant Rejections, TB Skin Test
#$3$3*$#-4T ()$ )G/$#2$42-(-5-(-$2R 3:7?>:DER +,-& + a +:@NHFI@JDA , a ,FB>B>JDE - a -??<:7 ,>?NI7J & S &7I@F7=
2+7$"#c& ).)//).3"2735#%/5): An x-linkeu iecessive uefect in tyiosine kinase gene. iesults in: - All Ig classes aie uecieaseu - uet iecuiient bacteiial infections (aftei 6 months of age) - 0nly in boys
&%3%!$5]% 5//7#".3"2735# X%Z5!5%#!0: A ueficiency of a specific Ig class iesulting in uefect I isotype switching, iesults in: - Sinus infection - Lung infections - Nost commonly the ueficient Ig is IgA
(S,$.. &$!-,-$4,-$2:
$(0/5! )*3)&5): Theie is a failuie of the uevelopment in the thymus anu paiathyioiu's, uue to failuie of uevelopment of the S iu anu 4 th phaiyngeal pouch, iesults in: - Tetany - viial anu fungal infections (iecuiient) - Beait uefects
!(+"#5! /7!"!7$)#%"7& !)#X5X5)&5&: A T-cell uysfunction against Canuiua, iesults in: - Canuiual infections of the skin anu mucous membianes
* +4& ( ,$.. &$!-,-$4,-$2 &%]%+% !"/25#%X 5//7#"X%Z5!5%#!0 h&!5Xid This conuition leaus to a uefect in uiffeientiation of the eaily stem-cells, iesults in: - Recuiient infections (viial, bacteiial, fungal, anu piotozoal)
Y5&b"$$K)3X+5!( &0#X+"/%: Is an x-linkeu uefect in the ability to mount an IgN iesponse to the capsulai polysacchaiiues of bacteiia, iesults in: - Low IgN levels - Bigh IgA levels - Noimal IgE levels - Classic tiiau of symptoms: Infections, Eczema, anu Thiombocytopenic Puipuia.
/)+T",G(-, &$!-,-$4,-$2 !(+"#5! .+)#73"/)$"7& X5&%)&%: A lack of NABPB leaus to a uefect in neutiophil phagocytosis, iesults in: - Succeptibility to oppoitunitic bacteiial infections - Biagnosis baseu on negative nitioblue tetiazolium uye ieuuction test (!3)&&5! 7&/3% g7%&$5"#)
!(%X5)bK(5.)&(5 X5&%)&%: A uefect in miciotubulai function anu lysosomal emptying of the phagocytic cells, iesults in: - Recuiient pyogenic infections uue to staph anu stiep
k"2c& &0#X+"/%: T-cells fail to piouuce %-inteifeion, thus PNN's fail to iesponu, iesults in: - Eczema, staph abscesses, anu elevateu IgE
3%7b"!0$% )X(%&5"# X%Z5!5%#!0 &0#X+"/%: Theie is a uefect in the LFA-1 auhesion pioteins on the phagocytes, iesults in seveie eaily life pyogenic infections.
(0*%+K5J/ &0#X+"/%: Theie is a uefect in the CB4u liganu on the CB4 Th cells, leauing to seveie pyogenic infections eaily in life, iesults in: - Bigh IgN levels - Extiemely low levels of Igu, IgA, anu IgE
53K,1 +%!%*$"+ X%Z5!5%#!0: A uefect in the IL-12 ieceptoi leaus to uisseminateu mycobacteiial infections.
!()*$%+ ,,
/5!+"25"3".0
(F@C?>FOBLLEV WBOCH>F?L?JE ?OOSNFH@ CIH DB`?>FCE ?U CIH DFO>?WF?L?JE RSH@CF?A@ ?A CIH &CHN , HPBDQ )UCH> WBOCH>FBV GF>?L?JE F@ GH>E FDN?>CBACV W?CI O?AOHNCSBLLE BAM FA MHCBFLQ *BE GH>E @NHOFBL BCCHACF?A C? (5] BAM BLL CIBC FC HACBFL@V B@ CIF@ F@ ?AH ?U CIH IFJIH@CKEFHLMFAJ C?NFO@ ?A CIH HPBDQ YIHA FC O?DH@ C? NB>B@FCH@ BAM IHLDFACI@V E?S> @C>BCHJE @I?SLM WH DHD?>FaBCF?A ?U D?MH@ ?U C>BA@DF@@F?AV @FJA@ BAM @EDNC?D@V BAM C>HBCDHAC@Q
*+,($#-"."TG
()$ T#+3 /"2-(-5$ *#$+V&"%4
T#+3 /"2-(-5$ ,$.. %+.. 2(#1,(1#$
/$/(-&"T.G,+4 a Pioviues suppoit anu piotects against osmotic piessuies. ,+/21.$ - Piotects the oiganism fiom phagocytosis. !.+T$..13 - Belps piopel the oiganism. /-.12 - 0seu foi auheiing to a cell's suiface anu foims an attachment between two backteiia foi sex. /.+23-&2 - Contain genes foi enzymes, toxins, anu foi the uevelopment of antibotic iesistance. T.G,",+.G0 - Belps meuiate auheience to suifaces.
$0"("0-42 Exotoxins cause uamage to the host by uestioying cells oi uisiupting theii cellulai metabolism. They may eithei be secieteu oi ieleaseu uuiing cell lysis. Nost often they can be uestioyeu by heat. Exotoxins aie seen in both giam +ve anu giam -ve oiganisms.
.+)/ #%.)$5]% 27.& Y5$( %f"$"f5#& 2?>MHCHLLB *H>CS@@F@ ! stimulates AC by ABP iibosylation. %Q !?LF ! is heat-labile, stimulates AC by ABP iibosylation of u piotein, causes wateiy uiaiihea. ]FW>F? !I?LH>B ! stimulates AC by ABP iibosylation of u piotein, incieasing the amount of chloiiue anu watei in the gut, causing high-volume iice-watei uiaiihea.
.+)/ *"&5$5]% 27.& Y5$( %f"$"f5#& &CBNI )S>HS@ ! A supeiantigen that binus NBC II piotein anu T-cell ieceptoi, inuuces IL-1 anu IL-2 synthesis in toxic shock synuiome. Can also cause foou poisoning. &C>HN *E?JHAH@ ! Eiythiogenic toxin (supeiantigen) causes iash anu scailet fevei, while stieptolysin 0 (hemolysin) causes iheumatic fevei. !?>AEWBOCH>FSD XFNICIH>FB ! Causes inactivation of EF-2 by ABP iibosylation, causing phaiyngitis anu a pseuuomembiane in the thioat. !L?@C>FMFSD 2?CSLFASD ! Blocks ACh ielease, causes seveie anticholineigic symptoms anu CNS paialysis. !L?@C>FMFSD $HCBAF ! Blocks glycine, leaus to lockjaw. !L?@C>FMFSD *H>U>FAJHA@ ! Lecithinase (!-toxin), causes gas gangiene.
$4&"("0-42 Enuotoxins aie lipopolysacchaiiues that aie founu in the cell walls of giam negative bacteiia. Enuotoxins cause a wiue iange of pioblems thiough the activation of maciophages anu the complement pathway. /BO>?NIBJH BOCFGBCF?A LHBM@ C?d - Bypotension thiough nitiic oxiue - Fevei thiough IL-1 activation - Bemoiihagic tissue neciosis thiough tumoi neciosis factoi $IH O?DNLHDHAC NBCITBE LHBM@ C?d - Bypotension anu euema thiough CSa activation - Causes PNN chemotaxis thiough CSa activation rr X5! OBA WH OBS@HM TIHA CIH HAM?C?PFA@ BOCFGBCH@ CIH (BJHDBA UBOC?>Q
(G/$2 "! 2(+-42 Theie aie a few uiffeient stains that aie useu in oiuei to isolate ceitain bacteiia, they incluue: &FLGH> &CBFA ! Pneumocystic Caiinii Pneumonia, Fungi !?AJ? +HM &CBFA ! Amyloiu .FHD@B &CBFA ! Chlamyuia, Boiielia, Plasmouium *)& ! Whipple's uisease mFHILK#HHL@HA ! Aciu-fast bacteiia's 5AMFB 5A\ ! Ciyptococcus Neofoimans
,"461T+(-"4l (#+42&1,(-"4l (#+42!"#3+(-"4 PR0CEB0RE PR0CESS CELL TYPES TYPE 0F BNA TRANSFERREB Conjugation Tiansfei of BNA fiom bacteiia to bacteiia Piokaiyotes Chiomosomal oi plasmiu Tiansuuction Tiansfei fiom viius to anothei cell Piokaiyotes All types Tiansfoimation Puiifieu BNA is taken up by a cell Both piokaiyotes anu eukaiyotes All types
2/$,-!-, #$e1-#$3$4(2 Some bugs iequiie ceitain enviionments in oiuei to suivive, they fall unuei the following: "*.-T+($ +$#"*$2L+4+$#"*$2l +4& -4(#+,$..1.+#
"WLFJBCH )H>?WH@: iequiie u2 to cieate ATP. Incluues: - Nocaiuia - Pseuuomonas Aeiuginosa - Nycobacteiium TB - Bacillus "WLFJBCH )ABH>?WH@: aie susceptible to oxiuative uamage uue to theii lack of S0B anu catalase. Incluues: - Actinomyces - Clostiiuium - Bacteioiues 5AC>BOHLLSLB>: these bugs must iemain insiue the cell in oiuei to suivive, incluue: CM+(3*'#, - Rickettsia anu Chlamyuia B*&4+'*'(P# - Salmonella, Biucella, Nycobacteiium, Listeiia, Fiancisella, Legionella, Yeisinia
-3/"#(+4( -4!" +*"1( 2(+/) +1#$12 Staph auieus is a veiy common oiganism both in the boaiu exams anu in clinical piactice. Staph auieus causes theii uestiuction baseu on the following two methous: 1. (>JD:S37=D@B7= - Incluues toxic-shock synuiome, scalueu skin synuiome, anu iapiu-onset foou poisoning. 2. -:CI@??@B>8F - Incluues infections of the skin, abscesses, anu pneumonias.
$?PFOK&I?O\ &EAM>?DH - A supeiantigen binus to NBC II anu T-cell ieceptois, which causes polyclonal T-cell activation. Z??M N?F@?AFAJ fiom staph auieus is causeu by the ingestion of a piefoimeu toxin. ** Staph Auieus contains a viiulence factois (known as Piotein A), that binus to the Fc poition of Igu. This inhibits complement fixation anu inhibits phagocytosis.
$4,+/21.+($& *+,($#-+ Some bacteiia have a polysacchaiiue capsule that acts as an anti-phagocytic factoi. This makes them less susceptible to being engulfeu by phagocytes. These bugs aie: - Stiep Pneumonia - B. Influenza - N. Neningitiuis - Klebsiella Pneumonia
()$ $0"("0-42 "! ,."2(#-&-+ 2/$,-$2 !Q XFUUFOFLH ! piouuces a cytotoxin (exotoxin) that kills eiythiocytes, anu thus causes a pseuuomembianous colitis. ** 0ften occuis seconuaiy to antibiotic use. !Q $HCBAF ! piouuces an exotoxin that iesults in tetanus. !Q *H>U>FAJHA@ ! piouuces an !-toxin that causes myoneciosis, gas gangiene, oi hemolysis. !Q 2?CSLFASD ! a piefoimeu, heat-labile toxin is piouuceu that inhibits the ielease of ACh, which causes botulism.
-3/"#(+4( -4!" +*"1( 2(#$/ /G"T$4$2 Stiep Pyogenes is a gioup A "-hemolytic stiep that can cause the following uiseases: 1. -??<:>I>MDE - Acute glomeiulonephiitis anu Rheumatic fevei 2. /F>M7:DE - Phaiyngitis, Cellulitis, anu Impetigo S. (>JDM7:DE - Toxic shock synuiome anu Scailett fevei
&-/)()$#-+ Biphtheiia can cause N@HSM?DHDW>BA?S@ NIB>EAJFCF@ thiough an HP?C?PFA. Theii exotoxin woiks by FAIFWFCFAJ N>?CHFA @EACIH@F@ GFB )X* >FW?@ELBCF?A ?U %ZK1Q
-3/"#(+4( !+,(2 +*"1( )n /G."#- - B. Pyloii is the cause of most uuouenal ulceis (up to 9u%) - Is a giam -ve iou that cieates an alkaline enviionment - Can inciease the iisk of P0B anu gastiic caicinomas (87@B?7:B: Tiiple theiapy: 0mepiazole, claiithiomycin, amoxicillin.
/2$1&"3"4+2 +$#1T-4"2+ Pseuuomonas aeiuginosa piouuces both an exotoxin anu an enuotoxin. Its most populai chaiacteiistic is that it piouuces a fiuity-smelling blue-gieen pigment (uue to pyocyanin). *Q )H>SJFA?@B OBS@H@ CIH U?LL?TFAJd - Pneumonia in cystic fibiosis patient - 0titis Exteina (swimmei's eai) - Folliculitis (known as "hot-tub" folliculitis) - Sepsis (black lesions of the skin)
*1T2 ()+( +,( "4 ()$ qTS/#"($-4r Two bugs that piouuce theii effects by acting on the us anu ui pioteins aie vibiio Choleia anu Boiuetella Peitussis. ]FW>F? !I?LH>B causes a iice-watei uiaiihea by peimanently activating the us piotein. 2?>MHCHLLB *H>CS@@F@ causes whooping cough by peimanently uisabling the ui piotein. ** Common to both bugs is the activation of auenylyl cyclase (AC) thiough ABP iibosylation.
,+12$2 "! 5+T-4"2-2 Tiichomonas, uaiuneiella, anu Canuiua $>FOI?D?AB@ - causeu by an anaeiobic, motile piotozoan. Shifts vaginal pB to S-6, anu uispels a gieenish-yellow fiothy vaginal uischaige. .B>MAH>HLLB - a giam-vaiiable iou that causes a gieen vaginal uischaige that has a fishy smell, anu has the pathognomonic "clue cells". pB is elevateu. !BAMFMB - is a fungal infection that piesents with a cottage-cheese like uischaige that is sticky anu will stick to the walls of the vagina.
*1T2 #$.+($& (" +4-3+.2 O\""4"(-,2P Nany seiious uiseases aie causeu by bites fiom animals, ticks, etc. The most impoitant uiseases fiom animals incluue: 1. .F?7 &DA7@A7 - causeu by Boiielia Buiguoifeii, which is tiansmitteu thiough the Ixoues tick bite, which is a tick that lives on ueei anu mice. Classic piesentation is the bullseye taiget lesion.
2. ,7II<IDBDA - causeu by Pasteuiella Nulticoua, which occuis thiough uog oi cat bites. S. (<I@87?D@ - causeu by Fiancisella Tulaiensis, fiom a tick bite, seen in iabbits anu ueei. This conuition is also known as the "Pahvant valley Plague", "Rabbit fevei", "Beei fly fevei", anu "0haia's fevei".
4. *8<E7II>ADA - causeu by Biucella species, anu contamination occuis thiough infecteu uaiiy piouucts anu contact with animals.
S. (H7 NI@M<7 - causeu by Yeisinia pestis, tiansmitteu thiough a flea bite founu on iouents anu wilu uogs.
(1*$#,1."2-2 Tubeiculosis is an infection with mycobacteiium tubeiculosis, that affects the iespiiatoiy tiact most commonly, howevei it can have extiapulmonaiy manifestations as well, namely in the : - uI - Kiuneys - Lymph noues - veitebial Bouies (Pott's uisease) - Cential neivous system
&EDNC?D@ ?U $2 FAUHOCF?A: 0sually, symptoms aie veiy non-specific, piesenting as: - Fatigue anu weight loss - Night sweats - Cachexia
X D:C7EBD>: ! A piimaiy TB infection iefeis to the infectious piocess by which the bouy is able to contain the infection anu pievent its uissemination. This iesults in the uhon complex, which is a calcifieu focus of infection usually in the lowei segments of the lung. Z D:C7EBD>: ! Also known as "ieactivateu TB", this type of infection can occui to those who aie in a state of weakeneu oi suppiesseu immunity.
YIHA CSWH>OSL?@F@ F@ @S@NHOCHM. - A +ve PPB test waiiants a chest xiay looking foi the TB cavitaiy lesion - Aciu fast stain looking foi the mycobacteiium
/BABJHDHACe$>HBCDHACn +EBD97 (* ! A 4-uiug iegimen (RIPE - Rifampin, Isoniaziu, Pyiazinamiue, anu Ethambutol). Bewaie of auveise neuiological effects of Isoniaziu, supplement with vitamin B6 - pyiiuoxine. .@B7:B (* ! With latent TB, you will begin the patient on a 4-uiug iegimen lasting up to 9 months. If they piesent at a futuie uate with latent TB, they will not neeu to be tieateu again. ** Latent TB = 1 time 4-uiug couise lasting seveial months.
#-,V$((2-+. -4!$,(-"42 +4& 5$,("#2 Rickettsial infections aie those infections that aie iesponsible foi causing Rocky Nountain Spotteu Fevei, Typhus, anu Q fevei. Rickettsial infections usually leau to a similai piesentation, which is: - Fevei - Beauache - Rash +"!b0 /"7#$)5# &*"$$%X Z%]%+ Causeu by Rickettsia Rickettsii, which causes a iash that staits on the palms anu soles anu moves inwaiu. Tieat with tetiacycline. (K> C>8?A >C (FNH<A[ @87R %#X%/5! $0*(7& - causeu by Rickettsia Typhi, which is a flea. Tieat with tetiacycline. %*5X%/5! $0*(7& - causeu by Rickettsia Piowazekii, a bouy louse. Tieat with tetiacycline. Anu finally, g Z%]%+ - causeu by Coxiella Buinetti, which causeu infection via aeiosolizeu paiticles. Tieat with tetiacycline.
2/-#",)$($2 Spiiochetes aie "spiial-shapeu" bacteiial elements containing axial filaments. The most commonly testeu spiiochete-ielateu infection is syphilis (tieponema). The othei two types of spiiochetes aie Boiielia anu Leptospiia, which aie stainable with light micioscopy, wheieas tieponema is visualizeu only with uaik-fielu micioscopy. With that saiu, theie aie thiee foims of Syphilis: , @ENIFLF@ ! Patient will get a painless chancie, tieat with IN pen u 1 @ENIFLF@ ! Patient has uisseminateu uisease + constitutional symptoms, incluues a maculopapulai iash on the palms anu soles. Tieat with IN pen u 4 @ENIFLF@ ! Patient has neuiological pioblems (neuiosyphilis, Aigyll Robeitson pupil), aoitic uisoiueis (aoititis), anu gummas. Tieat with Iv penicillin.
($2(-4T !"# 2G/)-.-2 ]X+3 BAM Z$)K)2&: 5&#. - this test is useu foi nonspecific antibouy uetection, howevei uue to its high iate of false-positives is not the piimaiy test useu foi syphilis uetection. This test will be positive when theie aie a few othei uiseases piesent, incluuing: SLE, RA, RF, anu a few othei viial infections like mononucleosis. !(+S+*2 - is a test specific foi the tieponema bacteiia, anu has the best combination of benefits in finuing syphilis, incluuing high specificity, veiy eaily positivity, anu iemains positive the longest.
5-#"."TG
&4+ +4& #4+ 5-#+. T$4"3$2 All BNA viiuses aie uouble stianueu anu lineai, with the exception of paivoviius (is single-stianueu), anu hepaunaviiuspapovaviius (ciiculai). All RNA viiuses aie single-stianueu, except the ieoviius (uouble stianueu). X#) F@ M?SWLHV +#) F@ @FAJLH.
)"% &" 5-#12$2 #$/#"&1,$ +HO?DWFABCF?A ! is the exchange of genetic mateiial between 2 chiomosomes by cioss-ovei of ceitain iegions that have impoitant base sequence homology. +HB@@?>CDHAC ! is the exchange of viial segments (fiom segmenteu viial genomes). This occuis at high fiequency anu is iesponsible foi woiluwiue illnesses (panuemics). !?DNLHDHACBCF?A ! occuis when one functional viius helps anothei non- functional viius become functional. *IHA?CENFO /FPFAJ ! occuis when a ceitain viius has the suiface coating fiom anothei viius' piotein, which will then ueteimine the infectivity of this viius paiticle.
5-#+. /."-&G Retioviiuses contain 2 iuentical single-stianueu RNA molecules, making them "MFNL?FM", while all othei viiuses contain a single copy of both BNA anu RNA, making them "IBNL?FM". &4+ 5D8<A7A ! all ieplicate in the nucleus, except foi the poxviius. #4+ 5D8<A7A ! all ieplicate in the cytoplasm, except foi ietioviiuses anu the influenza viius.
()$ -3/"#(+4( ,)+#+,($#-2(-,2 "! 5-#+. &4+ The following aie impoitant chaiacteiistics that fit foi almost all of the BNA viiuses: 4<EI7@8 87NIDE@BD>: ! all BNA viiuses ieplicate in the nucleus except foi the Poxviius, which has its own BNA-uepenuent RNA polymeiase. +87 ID:7@8 ! all BNA viiuses aie lineai, except foi the Papovaviius anu the Bepauna viius. Papovaviius is ciiculaisupeicoileu, anu the Bepauna viius is ciiculaiincomplete. +87 =><QI7 AB8@:=7= O=A&4+P ! all BNA viiuses aie uouble-stianueu except foi the Paivoviius, which is single-stianueu (ssBNA). +87 DE>A@H7=8@I D: AH@N7 ! all BNA viiuses aie icosaheuial except foi the Poxviius, which is complete in capsiu shape.
T$4$(-, 2)-!( 9An T$4$(-, &#-!( .HAHCFO &IFUC ! Is the piocess by which theie is a ie-assoitment of uiffeient viial stiains, which combine to foim new foimssubtypes that contain a mixtuie of the suiface antigens of the stiains involveu. uenetic shift is veiy impoitant because it cieates new viial pathogens, anu is iesponsible foi the emeigence of new viiuses. .HAHCFO X>FUC ! Is a piocess of natuial mutations ovei a peiiou of time. This leaus to loss of immunity anu the inability of vaccines to cuie illnesses.
()$ &4+ 5-#12$2 The list of BNA viiuses: 1. )epaunaviius 2. )eipesviius S. +uenoviius 4. /aivoviius S. /apovaviius 6. /oxviius Remembei this list with the mnemonic: ))+///y
Zn )78N7A9D8<A - usBNA lineai, envelopeu. XF@HB@H@ ! Buman Beipes viius 6 & 8, Beipes Simplex 1 & 2, vaiicella Zostei, Ebstein-Baii viius, anu Cytomegaloviius BBv 6 - Reseola BBv 8 - Kaposi's saicoma BSv 1 - Thought to be oial ulceis, but now can be fiom both oial anu genital ulceis BSv 2 - Thought to be genital ulceis, but now can be fiom both oial anu genital ulceis vZv - Responsible foi chickenpox (not seen anymoie uue to vaccination), shingles EBv - Causes mononucleosis anu Buikitt's lymphoma CNv - Congenital infections
]n +=7:>9D8<A - usBNA lineai, has no envelope. XF@HB@H@ ! Conjunctivitis, Pneumonias, Phaiyngitis
^n /@89>9D8<A - ssBNA lineai (is the smallest BNA), has no envelope XF@HB@H@ ! Paivo B19 (slappeu cheek synuiome)
bn /@N>9@9D8<A - usBNA ciiculai, has no envelope XF@HB@H@ ! Buman Papilloma viius, Piogiessive Nultifocal Leukoencephalopathy
`n />J9D8<A - usBNA lineai (is the laigest of all BNA viiuses), has an envelope XF@HB@H@ ! Cowpox, Smallpox, Nolluscum Contagiosum
.-5$S+(($41+($& 9An V-..$& 5+,,-4$2 .D97S+BB7:<@B7= 5@EED:7A ! these types of vaccines inuuce both humoial anu cell- meuiateu immunity. VDII7= 5@EED:7A ! these types of vaccines inuuce humoial immunity only.
%PBDNLH@ ?U 3FGHK)CCHASBCHM ]BOOFAH@: - Neasles - Numps - Rubella - Smallpox - Polio (Sabin) - vZv - Yellow Fevei ** Remembei theie is uangei in giving a live-attenuateu vaccine to someone who is immunocompiomiseu.
)$#/#$2 5-#12$2 Theie aie quite a few uiffeient foims of "heipes viiuses", they aie all high-yielu 0SNLE infoimation. The most common heipes viiuses anu theii common finuings incluue: )25SX - this is known to be iesponsible foi the oial lesions of heipes, howevei uue to uiffeient sexual piactices, it may be seen in the genital iegion as well. BSv-1 is also a cause of keiatoconjunctivitis anu tempoial lobe encephalitis (BSv is the most common cause of auult onset alteieu mental status). BSv-1 is tiansmitteu via iespiiatoiy secietions anuoi saliva. Z?> (&] MFBJA?@F@V S@H CIH $aBAO\ CH@C (smeai the open vesicle, looking foi multinucleateu giant cells).
)25SZ - BSv-2 is most commonly seen as heipes of the genitals (heipes labialis), as well as neonatal heipes. BSv-2 is tiansmitteu via peiinatal tiansmission as well as thiough sexual contact.
$*5 - causes Buikitt's lymphoma anu infectious mononucleosis (causes seveie fatigue, soie thioat, usually in teenageis). Tiansmitteu thiough saliva anu iespiiatoiy secietions.
,35 - Causes congenital infections as well as some types of pneumonia. Tiansmitteu congenitally, thiough sexual contact, thiough saliva, anu thiough tiansfusion. ))5 - Buman Beipes viius, is the cause of Kaposi's saicoma in AIBS patients. Tiansmission is sexually.
3"4"41,.$"2-2 Nononucleosis is always encounteieu on the 0SNLE exams, thus be suie to know as much as possible about this conuition. *>H@HACBCF?A: - Young auult (16-2uyi) - Fevei - Bepatosplenomegaly - Phaiyngitis - Lymphauenopathy !BS@H: - Ebstein-Baii viius (EBv) - "kissing uisease", because it is easily tiansmitteu thiough saliva - Theie aie abnoimal ciiculating cytotoxic T cells XFBJA?@F@: The best uiagnostic test is the "Nonospot test", which uetects heteiophil antibouies thiough sheep RBC agglutination. YIBC C? CHLL CIH NBCFHAC: - The most impoitant thing foi patient safety is to )]"5X !"#$)!$ &*"+$&, because the spleen is enlaigeu anu if it expeiiences blunt tiauma, it may iuptuie anu cause seveie auveise effects such as hypotension, shock, anu sepsis.
)-5L+-&2 A ietioviius, the BIv uisease uses the ieveise tiansciiptase enzyme to ieplicate. BIv infection can be tiansmitteu thiough sexual contactfluius, bloou, anu bieast milk. The helpei T-cells (CB4+ T cells), maciophages, anu uenuiitic cells aie affecteu. X5).#"&5#. (5]: Biagnosis of BIv is maue with the ELISA test because of its high sensitivity. When a test is positive, a Westein Blot is peifoimeu, which is veiy specific. Aftei confiimation, a viial loau can be uone to measuie the quantity of the viius in the bloou, which allows you to measuie the effect of meuical tieatment. ** False negatives with the ELISA test anu the Westein Blot aie common in the fiist few months of BIv infection.
5//7#5$0 $" (5]d Ceitain mutations in oui genes can give us immunity to BIv, can give us paitial immunity to BIv, anu can even cause us to ueteiioiate iapiuly fiom an BIv infection. The mutations iesponsible foi this incluue: /SCBCF?A OBS@FAJ FDDSAFCE ! CCRS mutation (homozygous) /SCBCF?A OBS@FAJ NB>CFBL FDDSAFCE ! CCRS mutation (heteiozygous) /SCBCF?A OBS@FAJ >BNFM N>?J>H@@F?AeMHCH>F?>BCF?A ! CXCR1 mutation
$+%)$/%#$: Tieatment involves the use of antiietioviial meuications, given to symptomatic patients iegaiuless of theii CB4 counts anuoi to asymptomatic patients with CB4 counts <Suu. Tiiple-uiug iegimens (2 nucleosiue ieveise tiansciiptase inhibitois anu eithei: 1 non-nucleosiue ieveise tiansciiptase inhibitoi 0R 1 piotease inhibitoi) aie useu, these aie known as BAART, which taiget anu pievent BIv ieplication at thiee uiffeient points along the viius' ieplication piocess.
)$/+(-(-2 Is inflammation of the livei, chaiacteiizeu by the piesence of inflammation of the tissue of the livei. Theie is a wiue iange of ioutes of infection, theie is a wiue iange of symptoms anu piognosis, which can iange fiom self-limiteu uiseases to ciiihosis anu ueath. $IH>H B>H Z5]% O?DD?A U?>D@ ?U IHNBCFCF@V CIHE B>Hd Bepatitis A, B, C, B, anu E
)7N@BDBDA + O)+5P - Is usually asymptomatic, is tiansmitteu via fecal-oial ioute. 0sually a veiy shoit incubation peiiou (~ S weeks). Is a RNA picoinaviius. )7N@BDBDA * O)*5P - 0ften piesents with milu symptoms such as: loss of appetite Nv, myalgias, fevei, anu jaunuice. Bep B is usually self-limiteu, but can piogiess anu cause ciiihosis, hepatic failuie, anu ueath. Tiansmission is usually sexual, thiough shaiing uiity neeules (paienteial), anu fiom the mothei to fetus (veitical tiansmission). Is a BNA hepaunaviius. )7N@BDBDA , O),5P - Bepatitis C usually caiiies the same symptoms as uoes hepatitis B, anu is tiansmitteu thiough bloou piouucts (sex, uiity neeules). Bepatitis C is often a chionic illness that leaus to caicinoma anuoi ciiihosis. People infecteu will usually become caiiieis of hep C. Is an RNA flaviviius. )7N@BDBDA & O)&5P - Alone, hepatitis B cannot infect, anu iequiies a co-infection with hepatitis B in oiuei to infect (iequiies BBsAg as its envelope). Is a ueltaviius. )7N@BDBDA $ O)$5P - Bas a fecal-oial tiansmission ioute, anu has the tenuency to cause watei-boine epiuemics. veiy similai symptomatically to hepatitis A. BEv can cause significant illness anu even ueath in piegnant women. Is an RNA caliciviius. ** (HN 2 BAM ! ! chionic, cause ciiihosis, anu hepatocellulai caicinoma. ** (HN ) BAM % ! affect the uI tiact.
)$/+(-(-2 2$#"."TG The hepatitis seiology is veiy high-yielu foi the Step 1, memoiize all of this infoimation. BBsAg ! Is the antigen founu on the suiface of BBv, when it is piesent, theie is a caiiiei state. BBsAb ! Is the antibouy to BBsAg, its piesence inuicates immunity to Bep B BBcAg ! Is the antigen associateu with the BBv coie BBcAb ! Is the antibouy to BBcAg, anu when piesent inuicates the "winuow peiiou" of infection. When theie is an IgN BBcAb, theie has been a iecent infection. BBeAg ! This is an inuicatoi of hep B tiansmittability, anu is the 2 nu ueteiminant of the hepatitis B coie. BBeAb ! Is the hepatitis E antigen, inuicating low tiansmittability of the uisease.
/4$13"4-+ a 2/$,-+. 2-(1+(-"42 -: @: @IE>H>IDE ! Stiep Pneumonia is the NCC, howevei Klebsiella is moie likely in an alcoholic (be caieful with this question, because you may be askeu what the most common cause of pneumonia is in an alcoholic, which is still Stieptococcus) )>ANDB@IS@Es<D87= ! Staph -: @: D??<:>E>?N8>?DA7= N78A>: ! Staph is most common cause, but watch foi an BIv patient who can get PCP pneumonia when CB4 count is low. +AND8@BD>: ! Anaeiobic oial floia 47>:@B@I ! 0p to the fiist 6 weeks of life - uioup B stiep anu E. Coli
,"33"4 "#T+4-232 -4 1#-4+#G (#+,( -4!$,(-"42 The most common cause of uiinaiy tiact infections is E. Coli. The most common symptoms aie painful uiination, fiequency, uigency, anu supiapubic pain. This can ascenu anu become a seveie infection such as pyelonephiitis. Nost common in women because they have a shoit uistance fiom the outsiue of the uiethia to the blauuei. Tieatment involves using TNP-SNP (Bactiim)
3$4-4T-(-2 Is a life-thieatening infection of the meninges. Patient piesents most commonly with nuchal iigiuity, high fevei, anu alteieu mental status. The most common causes pei age gioup aie the following: In newboins up to 6 months ! E. Coli In chiluien 6 months - 6 yis ! Stiep Pneumonia In people 6yi - 6uyis ! Neisseiia Neningitiuis In people > 6uyi ! Stiep Pneumonia
(7AB )D:BR The 0SNLE will give you a scenaiio wheie someone is in close contact with otheis (uoimitoiy, aimy, etc), this is almost always leauing you to meningitis.
+ .-2( "! ()$ 3"2( ,"33"4.G ($2($& 2(&[2 T>:>88H7@ ! piesents with uiethiitis, ceivicitis, epiuiuymitis (men). Can cause pelvic inflammatoiy uisease (common cause of infeitility). Causeu by N. uonoiihea, tieat with ceftiiaxone. ,HI@?F=D@ ! piesents similaily to gonoiihea. When this is founu, theie is usually a co-infection with gonoiihea. Causeu by Chlamyuia Tiachomatis. )78N7A ! *)5#Z73 ulcei of the penis, vulva, anu ceivix 2FNHDIDA ! *)5#3%&& chancie (seen in 1 foim), systemic finuings in 2 foim, anu neuiological finuings in the S foim. .F?NH>M8@:<I>?@ 57:787<? ! *)5#3%&& ulcei at the beginning, with infection spieauing along the inguinal pathway. Causeu by Chlamyuia Tiachomatis types L1- LS. 5@MD:DBDA ! vaginal itching, pain, anu uischaige. Nay be uue to gaiuneiella, tiichomonas, oi canuiua. ,H@:E8>D= ! *)5#Z73 genital ulceis, causeu by Baemophilus Bucieyi ,>:=FI>?@ +E<?D:@B@ ! Causes genital waits that can be on the labia, in the vagina, anu on the ceivix. Causeu by BPv types 6 anu 11.
/$.5-, -4!.+33+("#G &-2$+2$ Is a scaiiing of the fallopian tubes, anu is a veiy common cause of infeitility in women. Theie is often symptoms such as ceivical motion tenueiness, vaginal uischaige, anu even tubo-ovaiian abscess. /?@C O?DD?A OBS@H F@ !ILBDEMFB BAM .?A?>>IHB.
()$ ("#,) -4!$,(-"42 "T0RCB" is the mnemonic useu to iecall the most commonly encounteieu congenital infections, they aie: ( - Toxoplasmosis " - stanus foi "othei", which is Syphilis # - Rubella , - CNv ) - BSv anu BIv
"2($"3G$.-(-2 0steomyelitis is an infection of the bone, which can be causeu by a numbei of uiffeient oiganisms, they incluue: 2B@NHFI>E>EE<A +<87<A ! Is the most common cause oveiall 2@I?>:7II@ ! Causes osteomyelitis in sickle cell patients T>:>88H7@ ! Can cause osteomyelitis in sexually active people (is a less common cause) /A7<=>?>:@A +78<MD:>A@ ! Common cause in intiavenous uiug useis 2B@NH $ND=78?D=DA ! Common cause of osteomyelitis in those with piosthetic uevices.
/+#+2-("."TG
Stuuying the 'paiasitology' section foi the 0SNLE exam is simple anu stiaightfoiwaiu, simply memoiize all oiganisms anu theii piesentations, theii moue of tiansmission, how the uiagnosis is maue, anu finally the best tieatment foi each. /+#+2-($ &-2$+2$L2G3/("32 3"&$ "! (#+423-22-"4 &-+T4"2-4T (#$+(3$4( /I@A?>=D<? O5D9@Jl "9@I7l 3@I@8D@7l !@IEDN@8<?P NALARIA, causes a cyclic fevei + heauache, splenomegaly, anu anemia Anopheles mosquito
Bloou smeai Chloioquine, Sulfauoxine, Pyiimethamine, quinine, Nefloquine $:B@?>7Q@ )DAB>IFBDEA Bystenteiy, bloouy uiaiihea, livei abscess, anu iight uppei quauiant pain Cysts founu in B2u Cysts in stool Netioniuazole + Iouoquinol TD@8=D@ .@?QID@ Foul-smelling uiaiihea, flatulence, anu bloating Cysts in B2u Cysts in stool Netioniuazole ,8FNB>AN>8D=D<? Seveie uiaiihea founu in AIBS patients, milu uiaiihea in healthy patients Cysts founu in B2u Cysts seen on aciu-fast stain No tieatment (>J>NI@A?@ Biith uefects anu biain abscesses (BIv patients) Cysts founu in cat feces anuoi meat Seiology anu biopsy Pyiimethamine anu sulfauiazine (8DEH>?>:@A Foul-smelling uischaige, gieen in coloi fiom the vagina Sexual Tiophozoites seen on wet mount Netioniuazole 4@7MI78D@ Causes a ueauly meningoencephalitis Caught by swimming in fieshwatei lakes Spinal fluiu shows amoeba No tieatment (8FN@:>A>?@ ,8<jD Causes Chaga's heait uisease Tiansmitteu via the ieuuviiu bug Seen on bloou smeai Nifuitimox (8FN@:>A>?@ T@?QD7:A7 Causes Afiican sleeping sickness Tiansmitteu thiough the Tsetse fly Seen on bloou smeai Suiamin oi Nelaisopiol *@Q7AD@ Causes babesiosis, which is a uisease similai to malaiia Tiansmitteu thiough the Ixoues tick "Naltese cioss" seen on bloou smeai Quinine anu Clinuamycin .7DAH?@:D@ Causes visceial Tiansmitteu via Smeai Souium &>:>9@:D Leishmaniasis the sanufly showing maciocytes that contain amastigotes stibogluconate
)$.3-4()2 O%>8?AP
}ust as with paiasites, memoiizing all of the uiffeient helminthes as well as theii piesentation, tiansmission, anu tieatment is high-yielu as well as easy points on the 0SNLE exam. )$.3-4() (#+423-22-"4 /#$2$4(+(-"4 (#$+(3$4(
(+/$%"#32
$EHD:>E>EE<A Fiom eggs within uog feces Cysts in livei cause anaphylaxis if antigens aie ieleaseu fiom the cyst Albenuazole (@7:D@ 2>ID<? 0nueicookeu poik Nass lesion in the biain causeu by laivae Albenuazole
!.1V$2
2EHDAB>A>?@ Snails Spleen anu livei aie affecteu, get gianuloma, fibiosis, anu inflammation Piizaquintel /@8@M>:D?<A %7AB78?@:D Fiom unueicookeu ciab meat Bacteiial infection anu thus inflammation of the lungs Piizaquintel ,I>:>8EHDA 2D:7:ADA Fiom unueicookeu fish Biliaiy tiact inflammation Piizaquintel
#"14&%"#32
.>@ .>@ Fiom ueei fly Inflammation anu swelling of skin, can see this woim in the conjunctiva Biethylcaibamazine +:EFI>AB>?@ &<>=7:@I7 OH>>mK>8?P Laival penetiation of skin Anemia is causeu by intestinal infection Nebenuazole anu pyiantel pamoate +AE@8DA .<?Q8DE>D=7A Eggs in feces Intestinal infection Nebenuazole anu pyiantel pamoate OTD@:B 8><:=K>8?P $:B78>QD<A 578?DE<I@8DA O/D:K>8?P Infecteu foou (with eggs) Intestinal infection, also get anal itching Nebenuazole anu pyiantel pamoate (8DEHD:7II@ 2ND8@IDA 0nueicookeu poik Causes peiioibital euema anu muscle inflammation Thiabenuazole 2B8>:MFI>D=7A 2B78E>8@IDA Laiva fiom soil get in thiough the skin Causes an intestinal infection Iveimectin anu thiabenuazole &8@E<:E<I<A 37=D:7:ADA Infecteu watei Inflammation anu ulceiation of the skin Niiiuazole (>J>E@8@ ,@:DA Contaminateu foou Causes gianulomas in the ietina, may leau to blinuness Biethylcaibamazine %<EH7878D@ *@:E8>CBD Fiom the female mosquito Blocks lymph uiainage leauing to elephantitis Biethylcaibamazine ":EH>E78E@ 5>I9<I<A Female blackflies Causes "iivei blinuness" Iveimectin
3G,"."TG
Nycology (fungi) play a veiy impoitant iole in meuical pathology, as theie aie a few veiy impoitant conuitions that aie seen on a veiy iegulai basis clinically. Eveiything in this section is &7*%+ (5.(K05%3X, thus be suie to know this section colu.
,+4&-&+ +.*-,+42 Canuiua albicans is seen wiuely in many uiffeient clinical situations. It can cause a wiue vaiiety of conuitions, anu can be seen both supeificially (on the skin), anu systemically (anywheie else). ,H@8@EB78DABDEA >C ,@:=D=@: - Biploiu fungus - Buuuing yeast with pseuuohyphae aiounu 2uC - Buuuing yeast with geim tube foimation aiounu S7C ,>??>: N8>QI7?A E@<A7= QF ,@:=D=@: - vaginitis (yeast infection) - 0ial thiush - Esophagitis - Enuocaiuitis (Iv uiug use) (87@BD:M ,@:=D=@: - Foi supeificial infections (incluuing oial thiush), Nystatin is the tieatment of choice. - Foi systemic infections, amphoteiicin B is commonly useu.
($2( (-/R You will be given images of fungi on the 0SNLE exam. Be suie to unueistanu theii anatomy anu how they look micioscopically.
,"33"4 ,1(+4$"12 !14T+. -4!$,(-"42 (D:7@ /7=DA - "Athlete's Foot", piesents with itching, flaking, anu scaling of the affecteu aieas, causeu by Tiychophyton. Tieat with a topical azole. (D:7@ ,@NDBDA - Ringwoim of the haii, causeu by Tiichophyton anu NIciospoium. Invasion of the haii shaft leaus to haii loss that occuis in patches. Tieat with a topic azole. (D:7@ ,8<8DA - "}ock Itch", is a fungal infection of the gioin iegion. (D:7@ ,>8N>8DA - "Ringwoim", is a skin infection of the aims anu legs most commonly, howevei it can occui anywheie. The classic appeaiance is a ciiculai iash that cleais centially with elevateu euges. (D:7@ 578ADE>I>8 - Is a iash of the tiunk anu pioximal extiemities, causeu by Nalassezia Fuifui. Classic piesentation is hypopigmentation of the skin with shaip boiueis anu fine scaling. Seen most commonly in hot anu humiu climatesweathei. Topical miconazole anu selenium sulfiue aie effective tieatments. (D:7@ 4DM8@ - Affects the keiatinizeu layei of the skin, piouucing biown pigments. Is causeu by Boitaea Weineckii, is tieateu with topical antifungals.
$4&$3-, 2G2($3-, 3G,"2$2 (5&$"*3)&/"&5&: - Is enuemic to the Nississippi anu 0hio iivei valleys. - Acute phase piesents with non-specific iespiiatoiy symptoms - Chionic conuition may iesemble tubeiculosis, that if left untieateu can leau to ueath 23)&$"/0!"&5&: - Enuemic to states east of the Nississippi iivei anu to Cential Ameiica (B@ DBAE TBE@ ?U N?CHACFBLLE N>H@HACFAJd - Nilu "flu-like" illness - Pneumonia-like illness - Chionic illness that mimics TB oi lung cancei - Aggiessive uisease that causes significant iespiiatoiy uistiess - Nay cause skin lesions anu bone pain - Is a laige yeast with bioau-baseu buuuing
!"!!5X5"5X"/0!"&5&: aka valley Fevei - Is enuemic to the Southwestein paits of the 0SA - Is founu in the soil - Commonly it is a milu uisease (flu-like) - Can be seveie anu leau to seveie complications such as pneumonia, lung nouules, anu systemic finuings thioughout the bouy - Also known as "valley Fevei" *)+)!"!!5X5"5X"/0!"&5&: - Is enuemic to Ruial Latin Ameiica - Involves the mucous membianes, LN's, bones, anu lungs - Nay be asymptomatic in some - }uvenile foims aie often moie seveie anu holu a woise piognosis - Painful lesions of the lips anu oial mucosa - Pulmonaiy involvement usually begins as lobai pneumonia that fails to iesolve
"//"#(14-2(-, !14T+. -4!$,(-"42 !BAMFMB )LWFOBA@ - vaginitis in uiabetics anu those using antibiotics, thiush in those with immunocompiomiseu conuitions. Pseuuohyphae anu Buuuing Yeast
/SO?>e+IFa?NS@ - causes mucoimycosis, affects patients with leukemia anu affects those with uiabetesBKA. Non-septate hyphae, with wiue-angleu bianching. !>ENC?O?OOS@ #H?U?>DBA@ - Causes ciyptococcal meningitis. Is a veiy heavily encapsulateu yeast that is founu in soil anu in pigeon uioppings. Beavily encapsulateu yeast (~S-1uum in uiametei)
)@NH>JFLLS@ ZSDFJBCS@ - Causes a "fungus ball" cavity in the lungs. Bianching septate hyphae at 4S
2/"#"()#-0 2,)$4,V-- This topic is auueu because it has come up ovei anu ovei on all 0SNLE exams. This is a uimoiphic fungus that lives on vegetation. The spieau is thiough being piickeu with a thoin, thus the name "Rose uaiuenei's uisease" is given. It causes local ulceiations in auuition to nouules that follow the lymphatic uiainage.
!()*$%+ ,1
*()+/)!"3".0
*IB>DBO?L?JE F@ B GH>E IFJIKEFHLM C?NFO ?A CIH 7&/3% &CHN , HPBDQ Z?OS@ @I?SLM WH DBMH ?A CIH U?LL?TFAJd /HOIBAF@D@ ?U )OCF?AV OLFAFOBL S@HeBNNLFOBCF?A@V @FMH HUUHOC@Q *IB>DBO?\FAHCFO@V NIB>DBO?MEABDFO@V BAM CIH BSC?A?DFO AH>G?S@ @E@CHD B>H BL@? GH>E IFJIKEFHLM FAU?>DBCF?AQ
()$ $, bY The ECSu is the concentiation of agonist that pioviues a iesponse halfway between the baseline anu the maximum iesponse. The ECSu is the most common statistic useu to measuie the potency of an agonist (it howevei is not useu to uiiectly measuie affinity).
,"3/$(-(-5$ _ -##-5$#2-*.$ +4(+T"4-2(2 Antagonists aie uiugs that will paitially oi completely block a iesponse. !?DNHCFCFGH BACBJ?AF@C@ binu ieveisibly to the same ieceptoi as the agonist, while the F>>HGH>@FWLH BACBJ?AF@C binus iiieveisibly. The piesence of an antagonist will inciease the ECSu by a factoi known as the 'uose-iatio'. Below, the giaph will uemonstiate how concentiation 'X' gives a ceitain iesponse in the absence of an antagonist, but concentiation 'X1' is neeueu in oiuei to achieve the same iesponse when theie is a piesence of a O?DNHCFCFGH BACBJ?AF@C, the uose then equals X1X. 0sing uiffeient concentiation of antagonist will piouuce a uiffeient uose iatio.
In the piesence of an F>>HGH>@FWLH BACBJ?AF@C on the othei hanu, the iiieveisibly bounu antagonist iesults in uepiession of the maximal iesponse of the agonist uose- iesponse cuive anu a iight shift also occuis wheie theie is a ieceptoi ieseive similai to non-competitive antagonists.
!1.. +T"4-2( 9An /+#(-+. +T"4-2( In compaiing a USLL G@Q NB>CFBL BJ?AF@C, they act on the same ieceptois howevei the paitial agonist has a lowei maximal efficacy, thus even with incieaseu uosages, it cannot ieach the same efficacy as that of the full agonist.
T $.-3-4+(-"4 Theie aie two types of uiug elimination: mH>? ">MH> BAM , @C ">MH> &8<M ,I7@8@:E7 = Rate of elimination Plasma Biug Concentiation X AB "8=78 $ID?D:@BD>: - In 1 st oiuei elimination, the iate of uiug elimination is piopoitional to the plasma concentiation (Cp) of uiug. Thus with moie uiug concentiation theie is moie uiug elimination, if theie is less uiug concentiation theie is less uiug elimination. Nost uiugs aie eliminateu by 1 st oiuei elimination.
\78> "8=78 $ID?D:@BD>: - In Zeio oiuei elimination, the fiaction of uiug elimination iemains constant, no mattei how high the uiug concentiation. Theie aie less uiugs eliminateu with zeio-oiuei elimination, two examples aie alcohol anu aspiiin.
-3/"#(+4( $e1+(-"42 -4 /)+#3+,"."TG
/)+2$ X 9An /)+2$ Z T 3$(+*".-23 *IB@H , DHCBW?LF@D - Piouuces watei-soluble metabolites thiough ieuuction, oxiuation, anu hyuiolysis of the uiug molecules. These metabolites aie slightly polai. 0ses the CYP4Su metabolism. *IB@H 1 DHCBW?LF@D - Piouuces inactive metabolites that aie veiy polai, occuis thiough acetylation, glucuioniuation, anu sulfation.
()$ +1("4"3-, 4$#5"12 2G2($3 The autonomic neivous system iegulates many bouily piocesses (BR, BP, uigestion, iespiiation, bloou pB, etc) automatically on a subconscious level. The flow of this system is as follows: !#& ! *>HJBAJLF?AFO UFWH>@ ! .BAJLF?A ! *?@CJBAJLF?AFO UFWH>@ ! %AM ?>JBA
The autonomic neivous system consists of the '@EDNBCIHCFOc anu 'NB>B@EDNBCIHCFOc systems.
2G3/+()$(-, 4$#5"12 2G2($3 - The neives come fiom the thoiacic anu lumbai iegions. - Pieganglionic neives aie shoit anu synapse in the paiieu ganglia aujacent to the spinal coiu. - Ach ieleaseu fiom pieganglionic neuions. - NE is ieleaseu fiom the postganglionic neuion. - Incieases caiuiac output, incieases pulmonaiy ventilation, incieases musculai bloou flow, incieases bloou glucose, uecieases uigestion, incieases filtiation thiough kiuneys.
3@;>8 87E7NB>8A @87 BH7 @INH@ @:= Q7B@ 87E7NB>8An /+#+2G3/+()$(-, 4$#5"12 2G2($3 - The neives come fiom the cianial anu sacial iegions of the CNS. - Involveu cianial neives aie CN S, 7, 9, 1u. - Long pieganglionic neives, shoit postganglionic neives. - Ach is ieleaseu fiom both the pie anu post ganglionic neuions. - Incieases uigestion, helps with uiination anu uefecation.
+=87:78MDE #7E7NB>8A Stimulateu most commonly by 7%()#%"/()# *)1 8./#%()#%"/()#. !X - Causes constiiction of smooth muscle of aiteiioles anu uIu0. !Z - Smooth muscle constiiction anu neuiotiansmittei inhibition "X - Causes contiaction of the heait muscle. "Z - Causes smooth muscle ielaxation of lungs anu blauuei. ,H>ID:78MDE #7E7NB>8A Stimulateu by Acetylcholine. Nicotinic ieceptois aie founu in the autonomic ganglion. Nuscaiinic ieceptois aie founu on all oigans with paiasympathetic neives.
()$ 2G3/+()$(-, +4& /+#+2G3/+()$(-, !-*$#2
()$ !X #$,$/("# +T"4-2(2 +4(+T"4-2(2 +T"4-2( /"($4,G 3$,)+4-23 "! +,(-"4 Noiepinephiine Phenylephiine Nethoxamine Xylometazoline Piazosin Teiazosin Boxazosin Alfuzosin Phenoxybenzamine Phentolamine 4$ h $/- Ts: Phospholipase C activateu, 5*4 anu !BLOFSD.
,)".-4$#T-, T2 Cholineigic uiugs stimulate the action of acetylcholine, which plays a laige iole in the "iest anu uigest" poition of autonomic functioning. These uiugs help us uigest anu piopel foou thiough the uI, help with uiination, secietion of salivaiy fluius, anu many moie functions.
,)".-4"3-3$(-,2 XF>HOC )J?AF@C@ +T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4 ,@8Q@EH>IL/DI>E@8ND:7 ulaucoma ielief Activates the ciliaiy muscles of the eye *7BH@:7E>I 0iinaiy ietention Activates the smooth muscle of the bowel anu blauuei
5AMF>HOC )J?AF@C@ hFH )ACFOI?LFAH@CH>B@H@i +T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4 47>ABDM?D:7 Reveisal of post-op NN junction blockaue, ileus, uiinaiy ietention, myasthenia giavis Incieases enuogenous ielease of acetylcholine /F8D=>ABDM?D:7 Nyasthenia giavis Incieases enuogenous ielease of acetylcholine $=8>NH>:D<? Is veiy shoit-acting anu useu in the uiagnosis of myasthenia giavis Incieases enuogenous ielease of acetylcholine /HFA>ABDM?D:7 0seful foi glaucoma anu ieveises an atiopine oveiuose Incieases enuogenous ielease of acetylcholine $EH>BHD>NH@B7 ulaucoma Incieases enuogenous ielease of acetylcholine
+4(-,)".-4$#T-,2 +T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4 Atiopine Piouuces myuiiasis anu cycloplegia foi eye exams Competitive antagonist at cholineigic ieceptoi Benztiopine 0seu in Paikinson's uisease Nuscaiinic ieceptoi blockei Scopolamine Pievents anuoi tieats motion sickness Nuscaiinic ieceptoi blockei Ipiatiopium Nainstay of C0PB management Nuscaiinic ieceptoi blockei
,)".-4$2($#+2$ -4)-*-("# /"-2"4-4T Cholineigic intoxication is most commonly seen with poisoning fiom a cholinesteiase inhibitoi. This is classically seen in faimeis oi anyone woiking with oiganophosphates, anu in snake venoms. The signs anu symptoms of cholinesteiase inhibitoi poisoning can be iemembeieu with the mnemonic "&37XX" $IH>H TFLL WH HPOH@@FGHd 2 - Salivation . - Laciimation 1 - 0iination & - Bigestion & - Befecation
)-T)SG-$.& 2G3/+()"3-3$(-, !+,(2 X?NBDFAH - Incieases BP in patients with shock by maintaining ienal bloou flow. X?WSCBDFAH ("1) - Stimulates the heait without causing excess tachycaiuia. 5@?N>?CH>HA?L ("1, "2) - 0seu foi iefiactoiy Av block anu biauycaiuia. !L?AFMFAH (!2) - Piimaiy use is systemic hypeitension, suppiesses SNS outflow fiom the CNS. Stimulates PNS outflow, thus slows BR anu uecieases sympathetic uiive. Auveise effects aie seuation, uiy mouth. )LWSCH>?L ("2) - Piimaiy tieatment of asthma. $H>WSCBLFAH (("2) - 0seu foi bionchospasm, asthma. )DNIHCBDFAH@ - Release NE, cioss the bloou-biain baiiiei, inciease BP with a ieflex ueciease in BR. Toxicity: Bizziness, tiemoi, talkative, tense, iiiitable, insomnia, fevei, confusion, incieaseu libiuo, paianoia, panic, suiciual tenuencies.
)-T)SG-$.& 2G3/+()".G(-, !+,(2 *>Ba?@FA - 0seu foi BPB, has a 1 st uose phenomenon wheie patient gets pionounceu auveise effects with theii fiist uose (most commonly get oithostatic hypotension - a uiop in systolic BP of at least 2ummBg, oi uiop in uiastolic BP of at least 1ummBg). *IHAC?LBDFAH - Causes gieatei inciease in BR than piazosin (ieflex), anu is useu foi uiagnosing pheociomocytoma. 3BWHCBL?L - ! & " blockaue, useful in hypeitensive emeigencies, one of two uiugs useu in piegnant patients with hypeitension. *>?N>BA?L?L - is the piototypical "-blockei, has gieatei lipophilicity than otheis, useful foi hypeitension, angina, acute NI, stage fieight, anu pheociomocytomas. Pievents exeicise-inuuceu tachycaiuia anu oxygen uemanu. $FD?L?L - 0seful foi migiaines, useu in open-angle glaucoma to ueciease aqueous humoi foimation. *FAM?L?L - Bas the gieatest ISA (pievents excess biauycaiuia). /B`?> HUUHOC@ ?U "KWL?O\H>@ ?A CIH OB>MFBO @E@CHD - Beciease contiactility, ueciease BR, ueciease BP, inciease exeicise toleiance. /B`?> HUUHOC ?A CIH HEH - Beciease foimation of aqueous humoi. /B`?> DHCBW?LFO HUUHOC@ - Bon't use in uiabetics as it blocks symptoms of hypoglycemia (ie inhibits tiemoi, uiaphoiesis, tachycaiuia, anu inhibits glycogenolysis). Block symptoms of hypeithyioiuism.
+4(-)G/$#($42-5$ /)+#3+,"."TG Theie aie SIX categoiies of antihypeitensive meuications: 1. Biuietics 2. Sympatholytics ("-blockeis) S. Ace Inhibitois 4. Angiotensin Receptoi Blockeis S. vasouilatois 6. Calcium Channel Blockeis
X57+%$5!& In auuition to leaining all of the uiuietics useu foi hypeitension, it is veiy impoitant to unueistanu wheie anu how they woik in the kiuney. Below is a list of the commonly useu uiuietics, theii mechanism of action, theii clinical uses, anu theii toxicities. Following that is an image of the kiuney anu its physiology as it ielateu to uiuietics.
+,$(+\".+3-&$d Is a caibonic anhyuiase inhibitoi, which causes uiuiesis of NaBC0S anu ieuuces the total-bouy BC0S- stoies. Its site of action is the pioximal convoluteu tubule. 7&%& - Altituue sickness, glaucoma, alkalinization of the uiine, metabolic alkalosis. $"f5!5$5%& - NBS toxicity, hypeichloiemic metabolic aciuosis, neuiopathy.
3+44-(".: An osmotic uiuietic that acts by incieasing the tubulai fluiu osmolaiity, which then causes watei to move into the tubules, incieasing the amount of uiine. 7&%& - To ueciease intiacianial piessuie, to ueciease intiaoculai piessuie, uiug oveiuose. $"f5!5$5%& - Behyuiation, pulmonaiy euema.
.""/ &-1#$(-,2: Loop uiuietics inhibit the NaK2Cl co-tianspoit system of the thick ascenuing limb of the loop of Benle. 7&%& - Foi states of excessive euema, such as CBF, ciiihosis, pulmonaiy euema, nephiitic synuiome. Also useu to ueciease total bouy calcium levels. $"f5!5$5%& - The famous mnemonic ""( X)#." can be useu to iemembei the toxicities of loop uiuietics. "totoxicity )ypokalemia &ehyuiation +lleigy 4ephiitis Tout
()-+\-&$2: Thiaziue uiuietics woik by inhibiting the NaCl ieabsoiption in the eaily uistal tubule, which uecieases the uiluting capacity of the nephion. 7&%& - Is a fiist-line uiug foi hypeitension. Also useu foi cases of iuiopathic hypeicalciuiia, CBF, anu nephiogenic uiabetes insipiuus. $"f5!5$5%& - 0se the mnemonic IENH>.37! to iemembei the most common toxicities of thiaziue uiuietics. (ENH>: Tlycemia, .ipiuemia, 1iicemia, ,alcemia
Vk 2/+#-4T: The most commonly useu uiug is &NF>?A?LBOC?AHV acts as a competitive aluosteione ieceptoi antagonist in the coitical collecting tubule. 7&%& - CBF, potassium uepletion, anu hypeialuosteionism (K+ anu aluosteione move in the opposite uiiection in the tubule). $"f5!5$5%& - Bypeikalemia, gynecomastia, antianuiogen effects.
+,$ -4)-*-("#2: Captopiil, Enalapiil, anu Lisinopiil. Act by inhibiting the enzyme angiotensin-conveiting enzyme, which ieuuces the levels of angiotensin 2 (fiom Renin) anu pievents the inactivation of biauykinin. 7&%& - Bypeitension, CBF, anu ienal uisease causeu by uiabetes. $"f5!5$0 - The mnemonic "CAPT0PRIL" can help iemembei all of the ACEI toxicities. ,ough, +ngioeuema, /ioteinuiia, (aste Change, hyp"tension, /iegnancy issues, #ash, -ncieaseu ienin, .owei Angiotensin 2.
,+.,-13 ,)+44$. *.",V$#2: Block the voltage-uepenuent L-type channel in caiuiac anu smooth muscle, thus ieuucing muscle contiactility. XFIEM>?NE>FMFAH@ - Amlouipine, Nicaiuapine, Nifeuipine #?AKMFIEM>?NF>FMFAH@ - veiapamil, Biltiazem 7&%& - Bypeitension, angina, aiihythmias $"f5!5$0 - Flushing, uizziness, peiipheial euema, anu caiuiac uepiession.
4-(#"T.G,$#-4$: Causes vasouilation via ielease of nitiic oxiue in the smooth muscle, this incieases cANP levels anu thus smooth muscle ielaxation. It causes much moie uilation of veins than aiteiies. 7&%& - Angina, pulmonaiy euema. $"f5!5$0 - Tachycaiuia, hypotension, anu heauache. Be aleit foi something calleu "Nonuay Bisease", wheieby someone exposeu to nitioglyceiine thioughout the woikweek uevelops toleiance, then loses toleiance ovei the weekenu, iesulting in tachycaiuia, heauache, anu uizziness.
+4(-+4T-4+.2 Angina piesents with seveie chest pain, uuiing activity (stable) anu without activity (unstable). Piinzmetal's angina occuis via spasm of coionaiy aiteiy, anu is most common in youngei females who smoke. .?BL ?U CIH>BNE - Reuuce myocaiuial oxygen consumption by uecieasing eithei: Enu-Biastolic volume, bloou piessuie, heait iate, contiactility, anu ejection time. Nitiates anu "-blockeis can altei the components that affect myocaiuial u2 consumption in the following ways: 4-(#+($2 O@IB78 N87I>@=P "S*.",V$#2 O@IB78 @CB78I>@=P 4-(#+($2 k "SQI>Em78A *I>>= /87AA<87 Beciease Beciease Beciease $:= =D@AB>IDE 9>I<?7 Beciease Inciease Small effect ,>:B8@EBDIDBF Inciease Beciease Small effect )7@8B 8@B7 Inciease Beciease Beciease $;7EBD>: BD?7 Beciease Inciease Small effect 3F>E@8=D@I YZ E>:A<?NBD>:A Beciease Beciease Laige ueciease
.",+(-"4 "! ,+#&-+, T +,(-5-(G
+4(-S+##)G()3-, T2 !3)&& ,) - This class of anti-aiihythmic uiugs has affinity foi the open state of Na+ channels with slow iecoveiy iate. X>SJ@ - Quiniuine, Amiouaione, Piocainamiue, Bisopyiamiue $?PFOFCFH@ - Quiniuine causes cinchonism (a combination of heauache, tinnitus, toisaues ues pointes). Piocainamiue can cause a ieveisible SLE-like synuiome.
!3)&& ,2 - Becieases AP uuiation, affects ischemic oi uepolaiizeu Puikinje anu ventiiculai tissue. Excellent when useu foi post-NI ventiiculai aiihythmias anu uigitalis-inuuceu aiihythmias. X>SJ@ - Liuocaine $?PFOFCFH@ - Liuocaine can cause CNS stimulation oi uepiession as well as caiuiac uepiession
!3)&& ,! - Slows conuuction thiough the heait, especially in the Puikinje fibeis. uoou foi supiaventiiculai aiihythmias anu life-thieatening ventiiculai aiihythmias. Is a last iesoit meuication. X>SJ@ - Flecainiue, Encainiue, Piopafenone $?PFOFCFH@ - Is contiainuicateu in post-NI patients because it is a pioaiihythmic
"$(%+ [ )MHA?@FAH Causes hypeipolaiization by blocking the Ca2+ influx anu pieventing K+ outwaiu flow. Is the uiug of choice foi uiagnosing anu abolishing Av noual aiihythmias (is a substitute useu between caiuioveisions, has a half-life of 1us.
,)! T2
2B@M7A >C ,)!R !LB@@ , h)@EDNC?DBCFOi - No limits on activity, only affects patient with noimal exeicise. !LB@@ 1 h&EDNC?D@ TFCI D?MH>BCH HPH>OF@Hi - Slightly limits oiuinaiy activity (fatigue, palpitations) !LB@@ 4 h&EDNC?D@ TFCI DFLM HPH>OF@Hi - No symptoms at iest, but occui with less than oiuinaiy activities. !LB@@ 6 h&EDNC?DBCFO BC >H@Ci - Seveie physical limitations, symptoms at iest (when sitting)
2L?O\@ CIH #Beb NSDN, thus incieasing the intiacellulai Ca2+.
Is a positive ionotiope because of the incieaseu Ca2+.
Incieaseu vagal tone, uecieaseu QT inteival.
ST segment uepiession (hockey stick configuiation).
T-wave inveision.
)MGH>@H %UUHOC@: - NauseavomitingBiaiihea - Effect is potentiateu by hypokalemia - Quiniuine will uisplace uigoxin fiom binuing sites
)ACFM?CH is Bigoxin Immune Fab oi moueiate inciease in K+
!?AC>BFAMFOBCHM use when patient is using a K+ spaiing uiuietic &"*1(+3-4$ (Beta1 agonist)
Stimulates heait in CBF anu in caiuiogenic shock.
&"/+3-4$
Foi acute CBF anu shock, incieases BP anu maintains ienal bloouflow. 3+.#-4"4$l -4+3#-4"4$
Incieases contiactility anu ielaxes smooth muscle.
)MGH>@H %UUHOC@: - Long-teim use may cause thiombocytopen ia anu ventiiculai aiihythmias.
.-/-& ."%$#-4T +T$4(2 The goals of lipiu loweiing agents is to eithei ueciease LBL, inciease BBL, oi lowei tiiglyceiiues. Some of the uiugs aie moie specific to an inuiviuual change, while some pioviue a little bit of eveiything. +T$4(2 (8DMIFE78D=7A .&. 7CC7EBA )&. 7CC7EBA +=978A7 $CC7EBA 2B@BD:A O)3TS ,>+ 87=<EB@A7 D:HDQDB>8AP Nilu ueciease Significant ueciease Nilu inciease Nuscle bieakuown (check myoglobin levels, incieaseu LFTs) *DI7 @ED= QD:=D:M 87AD:A O,H>I7ABF8@?D:7P veiy small inciease Noueiate ueciease No effect uI symptoms, teiiible tasting. ,H>I7AB78>I @QA>8NBD>: QI>Em78A O$j7BD?DQ7P No effect Noueiate ueciease No effect Incieaseu LFTs 4D@ED: Nilu ueciease Noueiate ueciease No effect Flushing (can tieat by giving aspiiin) !DQ8@B7 =8<MA OT7?CDQ8>jDIP Significant ueciease Nilu ueciease Nilu inciease Nuscle bieakuown, incieaseu LFTs.
+4(-S)-2(+3-4$2 X AB M7:78@BD>: @:BDHDAB@?D:7AR - Competitively block the B1 ieceptoi. - Aie lipophilic anu thus cioss the bloou-biain baiiiei, causing seuation. - Bave incieaseu anti-cholineigic effects that last 4-6his. - Biphenhyuiamine anu Piomethazine block the Na+ channel, thus have anesthetic activity.
Z := M7:78@BD>: @:BDHDAB@?D:7AR - Less seuating - Less anticholineigic effects - Longei lasting - Less lipophilic - 0ses CYP4Su metabolism ,7B8DjD:7 (Zyitec) - inhibits mast cell ielease !7J>C7:@=D:7 (Allegia) .>8@BD=D:7 (Claiitin)
%)$#$ &" +2()3+ T2 %"#Vf
+2()3+ The two main categoiies aie the "Contiolleis" anu the "Nain Attack Relief" meuications.
)LWSCH>?L - Rapiu inhalant - Shoit-acting "2 agonist useu foi immeuiate ielief. 5N>BC>?NFSD - A muscaiinic antagonist - Nost commonly useu foi C0PB - Less effective than the "2 agonist - Antimuscaiinic effects - Causes slowei bionchouilation that is long-lasting $IH?NIELLFAH - Inhibits phosphouiesteiase - Becieases eosinophilslymphocytes, anu monocytes - Loweieu half-life in chiluien anu in smokeis - Naiiow theiapeutic inuex - Commonly causes heauaches, uizziness, hypotension, biauycaiuia
,"4(#"..$#2 ,"#(-,"2($#"-&2 3+2( ,$.. 2(+*-.-\$#2 ."4TS+,(-4T *$(+ +T"4-2(2 .$1V"(#-$4$ #$,$/("# +4(+T"4-2(2 3+-4 +((+,V #$.-$! +.*1($#". -/+(#+/-13 ()$"/)G..-4$ 3$(+/#"($#$4". .$5+.*1($#". !?>CFO?@CH>?FM@ Inhaleu - Beclomethasone, Tiiamclinolone, Buuesoniue, Fluticasone 0ial - Pieunisone, Pieunisolone - Inhibit phopholipase A2 - Aie the coineistone of asthma management - Becieases aiachiuonic aciu thiough phospholipase A2, inhibiting the C0X2 pathway. - 0ial coiticosteioius can cause oial thiush - Long-teim use can cause osteopoiosis, hypeitension, uiabetes, suppiession of the pituitaiy-auienal axis, obesity, thinning of the skin, anu muscle weakness.
/B@C !HLL &CBWFLFaH>@ - Ciomolyn anu Neuociomil - Pievent mast cell uegianulation - 0seu as piophylaxis - Aie safei to use in kius
3?AJK)OCFAJ 2HCB )J?AF@C@ - Salmetiol is the piototype - Pievents noctuinal asthmatic effects
3HS\?C>FHAH +HOHNC?> )ACBJ?AF@C@ - Nonteleukast anu Zafiilukast - Antagonizes leukotiienes thus pieventing an inciease in bionchial tone
(87@BD:M 2B@B<A +ABH?@BDE<A The coineistone of management is epinephiine oi pieunisone.
/+#V-42"4[2 &-2$+2$ Paikinson's uisease iesults fiom the uegeneiation of uopamine (BA) neuions in the substantia nigia. Symptoms aie iesting tiemoi, iigiuity, anu biauykinesia.
Bopamine cannot cioss the bloou-biain baiiiei, thus it is conveiteu to leveuopa in oiuei to get acioss the BBB. Theie aie ceitain uiugs that can be useu in oiuei to pievent the conveision of leveuopa to othei things that cannot cioss. X>SJ@ CIBC FAO>HB@H X?NBDFAH LHGHL@:
.$5$&"/+ When useu alone it usually causes nausea anu vomiting Long-teim use causes involuntaiy movement Avoiu in psychotic patients ,+#*-&"/+ Inhibits peiipheial conveision of LB to BA Won't cioss the BBB Can cause uI anu caiuiac pioblems +3+4(+&-4$ An antiviial that incieases BA ielease fiom nigiostiiatum. Becieases BA ieuptake. Can cause Leviuo Reticulaiis (Reu-blue skin).
X?NBDFAH +HOHNC?> )J?AF@C@: *8>?>E8DNBD:7 - An eigot alkaloiu, a B2 agonist anu B1 antagonist. /78M>ID=7 - B1 anu B2 antagonist, can cause neuiological symptoms. #>ND:>8>I7 - The uiug of choice foi iestless leg synuiome.
+.,")".2
$CC7EBA >C @Q<A7: - CNS seuation - Becieaseu viscosity of cell membianes %78:DEm7SV>8A@m>CC: - Causeu by a thiamine ueficiency - AtaxiaNystagmusConfabulations
2$.$T$.-4$ An NA0-B inhibitoi that blocks the conveision of BA to B0PAC. (".,+/"4$ A C0NT inhibitoi that blocks the conveision of LB to S0NT. Incieases LB bioavailability. Causes an onoff effect uue to its competition with LB foi entiy into BBB. 3$()+4". Also known as "methyl alcohol" oi "woou alcohol". - 0seu in commeicial solvents - Causes visual uistuibances (Snowstoim pattein) - Tieatment with Iv fomepizole oi Iv ethanol
$()G.$4$ T.G,". - Antifieeze, has a sweet smell. - Causes CNS excitation followeu by CNS uepiession, followeu by metabolic aciuosis, then causes the blockaue of ienal tubules by oxalate ciystals - Tieat with Iv fomepizole (inhibits alcohol uehyuiogenase) - Chaiacteiizeu by oxalate ciystals in the uiine, metabolic aciuosis, anu an absence of visual uistuibances
X5&73Z5+)/ - Is a piesciiption meuication taken by alcoholics that inhibits the alcohol uehyuiogenase enzymes. This causes an accumulation of acetaluehyue, which makes the patient veiy sick.
42+-&2l +,$(+3-4"/)$4l ,"0ZS-4)-*-("#2 42+-&2 Incluue Ibupiofen, Napioxen, Inuomethacin /"): Reveisible inhibition of both C0X1 anu C0X2, which then blocks the synthesis of piostaglanuins. 7&%&: 0seu as an anti-inflammatoiy, antipyietic, anu analgesic. Inuomethacin is useu in infants to close a patent uuctus aiteiiosus. )X]%+&% %ZZ%!$&: 0lceis, ienal toxicity, aplastic anemia.
+,$(+3-4"/)$4 Also known as Tylenol /"): Causes ieveisible inhibition of the C0X pathway. 7&%&: Is useu foi its analgesic anu antipyietic piopeities, but lacks the anti- inflammatoiy piopeities seen in NSAIBS. )X]%+&% %ZZ%!$&: An oveiuose is ueauly, because of hepatic neciosis uue to toxic metabolites which ueplete glutathione in the livei, causing the foimation of toxic NAPQI in the livei.
,"0SZ -4)-*-("#2 Incluue Celecoxib, Rofecoxib /"): Selective inhibition of C0X-2 7&%&: Excellent foi inflammation anu pain, but helps to maintain gastiic mucosa because it uoesn't use the C0X-1. Nain clinical uses aie aithiitis (osteo anu RA). )X]%+&% %ZZ%!$&: Renal toxicity, same as othei NSAIBS with less iisk of gastiic ulceiations
+4$2()$(-,2 3+, (A()(040 E+P#.+*/ 9.)&#)'/*'(.)) is a concept useu in anesthesiology to compaie the potency of anesthetic agents. Anesthetics with a highei NAC aie cause fastei inuuction but have much lowei potency, while those with lowei NAC value aie slowei to inuuce anesthesia but have a highei potency. 7:*0%+#: NAC of nitious oxiue is '1u4', thus it acts fast anu has weakei potency (has incieaseu bloou anu lipiu solubility). NAC of halothane is 'u.7S', thus is acts slowei but has a stiongei potency (has uecieaseu bloou anu lipiu solubility).
The Iueal Anesthetic: - Immeuiate onset of action - Bas ieveisible piopeities - Lasts foi an appiopiiate uuiation of time - Bas a wiue theiapeutic iange - Causes no tissue uamage oi iiiitation
Bow they woik: - Pievention of Na+ influx acioss neive membianes - Significant anesthesia pievents fiiing thiesholu fiom being obtaineu #? BOCF?A N?CHACFBL q #? FDNSL@H q !?AMSOCF?A WL?O\BMH
.",+. +4$2()$(-,2 Blockage of Na+ channels, inactivation is by hyuiolysis.
T$4$#+. +4$2()$(-,2
"/-"-&2 - Receptoi iesponsible foi supiaspinal anu spinal anesthesia, iespiiatoiy uepiession, physical uepenuence. & - Receptoi iesponsible foi spinal anesthesia anu uysphoiia.
*@8QDB<8@B7A (enu with -al) - Phenobaibital - Pentobaibital - Secobaibital - Thiopental /"): Binu to non-uABA, non-Benzo sites, incieases the uuiation of channel opening. *BCCH>A ?U WB>WFCS>BCH MF@C>FWSCF?A: 1 st - Biain 2 nu - visceia S iu - Lean tissue 4 th - fat 7&%&: Anticonvulsant, pieopeiative seuation, coma inuuction
+4(-S&$/#$22+4(2 $>FOEOLFO )ACFMHN>H@@BAC@: Block the ieuptake of S-BT anu NE T ,)$3-,+. +!!$,($& -3/"#(+4( !+,(2 +?DB8FNBDID:7 S-BT Bighly seuative, can cause oithostatic hypotension. ,I>?DN8@?D:7 S-BT Is the TCA B0C foi 0CB. &7ADN8@?D:7 NE Low seuation. 4>8B8FNB@ID:7 NE Least seuative. -?DN8@?D:7 NE = S-BT Noueiate seuation, oithostatic hypotension.
1 AM .HAH>BCF?A )ACFKXHN>H@@BAC@: T ,)$3-,+. +!!$,($& -3/"#(+4( !+,(2 +?>J@ND:7 BA Also useu foi psychosis, can cause taiuive uyskinesia. *<N8>ND>: BA, NE, S-BT Can cause weight loss anu is also useu foi smoking cessation. 3@N8>BDID:7 NE (8@j@=>:7 S-BT Can cause piiapism, CNS uepiession, anu oithostatic hypotension.
&&+5c@d )>H CIH @BUH@C J>?SN ?U BACFKMHN>H@@BAC@Q T 12$2 +&5$#2$ $!!$,(2 Fluoxetine (Piozac) Bepiession, panic uisoiuei, anoiexia. Bigh inhibition of CYP4Su, can altei bloou glucose, can cause SIABB. Fluvoxamine (Luvox) 0CB, Panic uisoiuei. Paioxetine (Paxil) Bepiession, panic uisoiuei. Bighest bioavailability, highest seuation of SSRI's, weight gain. Seitialine (Zoloft) Bepiession, panic uisoiuei. veiy little CYP4Su effect, piefeiieu in the elueily because it uoesn't affect metabolism. /)"5c@: 0se with extieme caution as the NA0I's can cause seiious ieactions with ceitain foous anuoi uiugs. Cheese, wine, etc, can cause ciisis. /)")5 - SBT anu NE /)"25 - BA X AB T7:78@BD>: 3+"-[AR - Phenelzine anu Tianylcypiomiue - Pioviue non-selective inhibition - Affects S-BT > NE - Its effect is uue to uowniegulation of pie-synaptic iegulation, thus incieasing S-BT neuions Z := T7:78@BD>: 3+"-[AR - Neclobemiue - NA0AI ] 8= T7:78@BD>: 3+"-[AR - Selegeline - NA0BI foi Paikinson's uisease
/??M &CBWFLFaH>@d .DBHD<? S Is the B0C foi moou stabilization in bipolai uisease. - Calms mania - Can cause hypothyioiuism )MGH>@H %UUHOC@: - Biowsiness - Weight uain - Low safety maigin - The eailiest sign of an oveiuose is nausea anu vomiting
+4(-S/2G,)"(-,2 3"+ - B2 ieceptoi antagonists useu to ueciease the levels of uopamine (BA) 12$ - Alleviation of psychosis anu symptoms of psychosis.
+4(-S3-,#"*-+.2
&8<MA E>:B8@D:=DE@B7= D: 87:@I D?N@D8?7:BR Sulfonamiues Tetiacyclines Nitiofuiantoin Itiaconazole Ciuofovii Ribaviiin Naliuixic Aciu &8<MA BH@B 87s<D87 @=;<:EBA D: N@BD7:BA KDBH H7N@BDE D:A<CCDED7:EFR Clinuamycin Chloiamphenicol Eiythiomycin Netioniuazole Inuinavii Ramantauine vaiiconazole Caspofungin )ACFGF>BL@: +EFEI>9D8 - 0seu foi heipes, can cause uI uistuibances, phlebitis, iash, anu heauache. T@:EDEI>9D8 - Is fiist line foi CNv, can cause myelosuppiession anu CNS toxicities. !>AE@8:7B - Fiist line foi CNv ietinitis, CNv colitis, CNv esophagitis, anu acyclovii iesistant BIvvZv. Nay cause nephiotoxicity, penile ulceiations, anu CNS toxicities.
2BOCH>FBL +H@F@CBAOH: 1. Tiansfeiable Resistance (tiansfei of plasmius) 2. Tiansfoimation (uptake of BNA) S. Bacteiial Conjugation
)-T)SG-$.& +4(-3-,#"*-+. -4!"#3+(-"4 /7:DEDIID:: - 0seu against giam +ve cocci, ious, giam -ve cocci, anu spiiochetes (tieponema) - Binus to PCN-binuing pioteins - Blocks the cioss-linking of cell walls (via tianspeptiuase blockage) +?D:>MIFE>AD=7A: - Incluue stieptomycin, gentamycin, tobiamycin, neomycin, amikacin, spectinomycin. - Causes misieauing of mRNA via the inhibition of foimation of the initiation complex - 0seu foi seveie giam -ve iou infections - Can cause nephiotoxicity anu ototoxicity - Shows a concentiation uepenuent kill iate (CBKR) anu a post-antibiotic effect (PAE). ,HI>8@?NH7:DE>I: - Is bacteiiostatic, inhibiting the Sus iibosomal subunit's peptiuyltiansfeiase - 0seu foi neisseiia meningitiues, stiep pneumonia, anu haemophilus influenza - Can cause 'giey baby synuiome' anu aplastic anemia.
3@E8>ID=7A: - Incluue eiythiomycin anu claiithiomycin - Woik by blocking tianslocation - 0seu foi uppei iespiiatoiy infections, Chlamyuia, neisseiia - Can cause uI symptoms, iashes, eosinophilia, anu cholestatic hepatitis (7B8@EFEID:7: - Boxycycline anu minocycline - Woiks by binuing to the SuS subunit anu pieventing attachment of aminoacyl-tRNA. - Shoulu avoiu ceitain foous which limit its absoiption, such as milk piouucts anu piouucts high in Fe2+ 2<IC>:@?D=7A: - Incluue sulfamethoxazole, sulfauiazine, anu othei sulfas - Woiks by inhibiting the enzyme uihyuiofolate ieuuctase - 0seu foi 0TI's, anu both giam +- oiganisms !I<>8>s<D:>I>:7A: - Incluue cipiofloxacin, noifloxacin, ofloxacin, moxifloxacin, gatifloxacin - Inhibits BNA gyiase - 0seu foi giam -ve ious in the u0 anu uI tiacts - Commonly causes uI uistuibances, heauache, iashes, uizziness ,7NH@I>AN>8D:A: - Aie beta-lactams that woik by inhibiting cell wall synthesis - 1 st geneiation: Pioteus, E.Coli, anu Klebsiella - 2 nu geneiation: Baemophilus, Enteiobactei, Neisseiia, Pioteus, E.Coli, Klebsiella, anu Seiiatia - S iu geneiation: Seiious giam -ve infections that aie iesistant to othei beta- lactam uiugs. 0seu foi meningitis. - 4 th geneiation: Pseuuomonas anu giam +ve oiganisms - Commonly cause hypeisensitivity ieactions, with cioss-hypeisensitivity with penicillin - Can cause a uisulfiiam-like ieaction when combineu with alcohol 5@:E>?FED:: - Binus to the B-ala B-ala poition of cell walls, thus inhibiting cell wall mucopeptiue foimation - 0seu in seiious giam + infections, such as NRSA - Can cause nephiotoxicity, ototoxicity, thiombophlebitis, anu 'ieu-man synuiome', wheie the bouy gets flusheu. 37B8>:D=@j>I7: - Woiks by foiming toxic metabolites insiue the cell - 0seu foi giaiuia, entamoeba, anu tiichomonas - Bas a uisulfiiam-like ieaction when combineu with alcohol #-/$ O(* =8<MAPR - Rifampin - Isoniaziu - Pyiazinamiue - Ethambutol - Can cause hemolysis in u6PB ueficient patients - Can cause an SLE-like synuiome - vitamin B6 (pyiiuoxine) ueficiency fiom pyiazinamiue +?NH>B78DED: *R - Woiks by foiming poies in the cell membiane - 0seu foi systemic mycoses - Can cause feveis anu chills, aiihythmias, hypotension, anu nephiotoxicity
&8<M #7ADAB@:E7: 5AABCH - Piimaiy iesistance uevelops uue to exposuie. )ORSF>HM - Causeu by genomic mutations that may be to a single uiug oi to multiple uiugs.
3"+ >C B<?>8 E7II 87ADAB@:E7: - Becieaseu uiug accumulation - Alteieu affinity of taiget enzymes - Loss of uiug-activating enzymes - Incieaseu function of tumoi cell iepaii mechanisms
&8<MSAN7EDCDE B>JDEDBD7A: Caimustine - piouuces leukocyte suppiession Cisplatin, Caimustine - most emetic anti-neoplastics SBTS antagonists - pievent emesis Netochlopiomiue - useful in pieventing chemotheiapy-ielateu nausea anu vomiting.
&-+*$($2 /)+#3+,"."TG -421.-4 (G/$ "42$( "! +,(-"4 /$+V "! T &1#+(-"4 "! +,(-"4 (G/-,+. 12$ 1IB8@AH>8B +EBD:MO.DAN8>P S minutes 1hi Shi Befoie meals 2H>8BS+EBD:M O#7M<I@8P Su minutes S-4hi 6-8hi Noining anu night -:B78?7=D@B7 +EBD:M O.7:B7P Su minutes 12hi 24hi qiu .>:MS+EBD:M O1IB8@I7:B7P 2hi 12hi 24hi qiu
Theie is a iisk of hypoglycemic ciisis if piopei iegulation of insulin not useu 2<IC>:FI<87@A: ulybuiiue, Tolbutamiue /"): Causes uepolaiization of beta cells of the pancieas, thus incieasing the ielease of insulin.
T+2(#"-4($2(-4+. /)+#3+,"."TG (1 BACBJ?AF@C@: Cimetiuine, Ranitiuine. - Loweis aciu secietion - Not useu as 1 st line uiug foi uERB, P0B, etc. *>?C?A *SDN 5AIFWFC?>@: 0mepiazole - Is uiagnostic anu theiapeutic uiug of choice foi uERB anu P0B - Also useu in cases of Zollingei-Ellison synuiome /SO?@BL *>?CHOCBAC@: Sucialfate - Woiks by auheiing to pioteinaceous lesions on the suiface - Is as effective as an B2 ieceptoi antagonist woulu be in 4-8 weeks *>?@CBJLBAMFA@: Nisopiostal - Can be given when patient is using high-uose NSAIB theiapy - Blocks cANP - Also causeu aboition in piegnant women - Can cause wateiy uiaiihea )ACFKHDHCFO@: SBTS ieceptoi antagonists - 0nuasetion *>?\FAHCFO@: Alosetion - Can be useu foi tieatment of IBS, but is last line aftei conseivative theiapies fail 5>>FCBWLH 2?THL XF@HB@H: - 1 st line tieatment of ulceiative colitis is Sulfasalazine - 1 st line tieatment of Ciohn's uisease is Buuesoniue
,+.,-13 +4& *"4$ )"3$"2(+2-2 *$( - foi bone iesoiption, anu is stimulateu when seium calcium uecieases. !BLOFC?AFA - peifoims all opposite action of PTB (paiathyioiu hoimone). ,V18 [ MFIEM>?PE GFCBDFA X4 - piouuceu in the kiuney "@CH?N?>?@F@ - 1 st line phaimacological tieatment is alenuionate (bisphosphonate) *BJHCc@ XF@HB@H - Tieatment involves bisphosphonate meuication such as alenuionate.
()G#"-& /)+#3+,"."TG 3HG?CIE>?PFAH (T4) - is the uiug of choice foi all types of hypothyioiuism. 3F?CIE>?AFAH (TS) - moie potent than levothyioxine, has a shoitei half-life, is not useu as a theiapeutic agent in thyioiu pioblems. /HCIFDBa?LH BAM *>?NELCIF?S>BOFL - two uiugs useu foi hypeithyioiuism. *>?NELCIF?S>BOFL (PT0) - Inhibits the peiipheial conveision of T4!TS .>BGHc@ XF@HB@H - Nethimazole oi PT0 is useu to inuuce iemission oi to contiol symptoms piioi to suigeiy oi iauioiouine ablation. 5?MFMH &BLC@ - inhibit the ielease of thyioiu hoimone fiom the thyioiu glanu. *?CB@@FSD 5?MFMH @?LSCF?A - is useu to contiol the symptoms of acute thyiotoxicosis, uecieases the vasculaiity anu size of the thyioiu, anu inhibits thyioiu hoimone ielease following RAI tieatment. +)5 h5K,4,i - is useu in the tieatment of uiave's uisease, woiks by emitting chemicals that kill tissue of the thyioiu.
/)+#3+,"."TG "! /-(1-(+#G +4& )G/"()+.+312 !?@EAC>?NFA - is a synthetic coiticosyntiopin analog, is useu to uiagnose auienal insufficiency. "OC>H?CFMH - is a synthetic somatostatin that inhibits uB secietion, is useu to tieat aciomegaly. /HA?C>?NFA@ - inuuces ovulation in infeitile women. .?ABM?>HLFA - is a unRB that is auministeieu in a pulsatile foim, this inuuces ovulation in women with amenoiihea uue to hypothalamic uysfunction. 3HSN>?LFMH - useu in kius with piecocious pubeity, it acts by suppiessing gonauotiopin secietion fiom the pituitaiy. 2>?D?O>FNCFAH - is given to those with piolactinomas, useu to shiink then mass so the symptoms will cease. Is a BA antagonist. "PEC?OFA - useu to inuuce anuoi augment laboi in women who have tiouble with ueliveiy, also stimulates milk letuown in nuising women. XH@D?N>H@@FA - is a synthetic analog of vasopiessin, tieatment foi uiabetes insipiuus.
42+-&2 )OHCBDFA?NIHA - anti-pyietic, analgesia, ieveisible C0X inhibition. Lacks anti- inflammatoiy piopeities. 0veiuose is tieateu with N-Acetylcysteine. )@NF>FA - Bas analgesic anu anti-inflammatoiy piopeities, inhibits the C0X2 pathways. Causes uI iiiitation by inhibiting piostaglanuins, which aie piotective to uI mucosa. 5AM?DHCIBOFA - is a non-selective C0X1 inhibitoi, inhibitoi of phospholipase A anu C. 0seu to close a PBA, also useu in gout anu foi management of ankylosing sponuylitis. 5WSN>?UHA - pioviues analgesia without anti-pyietic piopeities, has less uI iiiitation than uoes aspiiin.
+4(-S,"+T1.+(-"4
#$/#"&1,(-5$ /)+#3+,"."TG Theie aie a few veiy common meuications useu to inuuce ovulation anu thus inciease the chances of piegnancy. ,."3-/)$4$: The agent of choice foi ovulation inuuction, it acts by incieasing unRB secietion fiom the hypothalamus, which then incieases the levels of FSB, incieasing the feitility. This all happens via the blocking of the estiogen ieceptois, thus tiicking the bouy into believing that the levels of estiogen aie much lowei than they actually aie. )13+4 3$4"/+12+. T"4+&"(#"/-4 O37:>B8>ND:PR Is extiacteu fiom the uiine of menopausal women. It is high in LB anu FSB, which incieases feitility.
!()*$%+ ,4
*)$("3".0
XSH C? @IHH> G?LSDHV CIH NBCI?L?JE @HOCF?A ?U CIH &CHN , HPBD F@ WE UB> CIH D?@C OIBLLHAJFAJQ $IH 7&/3% HPBD F@ D?GFAJ D?>H BAM D?>H C?TB>M@ WHFAJ B OLFAFOBL HPBDV CIS@ FC F@ HPC>HDHLE FDN?>CBAC C? >HO?JAFaH CIH @FJA@V @EDNC?D@V O?DD?A N>H@HACBCF?A@V SAO?DD?A N>H@HACBCF?A@V BAM NBCI?NIE@F?L?JE ?U NBCI?L?JFOBL O?AMFCF?A@Q &NHOFBL BCCHACF?A @I?SLM WH NBFM C? MF@HB@H HACFCFH@ CIBC B>H D?>H O?DD?A FA CIH 7AFCHM &CBCH@V B@ ?NN?@HM C? CI?@H CIBC B>H D?>H N>HGBLHAC FA ?CIH> B>HB@ ?U CIH T?>LMQ
*+##$(([2 $2"/)+T12 Baiiett's esophagus is a conuition wheieby a chionic exposuie to aciuic contents fiom the stomach cause metaplasia of the epithelium at the squamocolumnai junction in the esophagus. The metasplasia changes fiom squamous epithelium (non-keiatinizeu) to columnai epithelium. The ieason foi this is that squamous epithelium is not veiy piotective against aciuic contents, while the columnai epithelium is uesigneu specifically foi this puipose.
+,)+.+2-+ Achalasia is a conuition wheieby the lowei esophageal sphinctei fails to ielax. This is an esophageal motility uisoiuei that involves the smooth muscle layei of the esophagus anu the lowei esophageal sphinctei. Chaiacteiizeu by an incomplete ielaxation of the lowei esophageal sphinctei, incieaseu lowei esophageal sphinctei tone, anu a lack of peiistalsis in the esophagus. Chaiacteiistics: - Bysphagia - Reguigitation - Chest pain Theie aie a few ieasons why this may happen, they incluue: - Chaga's uisease - Loss of myenteiic plexus - Esophageal caicinoma The best uiagnostic tool foi this conuition is a baiium swallow.
$2"/)+T$+. ,+4,$# The two types of esophageal cancei aie: Auenocaicinoma anu Squamous Cell caicinoma. Auenocaicinoma - this type of cancei is often seconuaiy to Baiiett's esophagus. Squamous Cell Caicinoma - this type of cancei is often causeu by exposuie to alcohol anu cigaiette smoke (on a chionic basis). The populai mnemonic "+*,&$!" is excellent foi iemembeiing the common causes of esophageal cancei. + - Alcohol * - Baiiett's esophagus , - Cigaiette smoke & - Biveiticula (especially Zenkei's) $ - Esophageal Webs ! - Family histoiy of esophageal cancei
T+2(#-(-2 uastiitis is causeu by an inflammation of the stomach lining. The most common cause of gastiitis is piolongeu use of NSAIBs (ie Aspiiin), which blocks the synthesis of piostaglanuins, thus uecieasing the piotection of the stomach lining. 0thei common causes aie alcohol consumption anu B. Pyloii. Symptoms incluue: - Pain in the epigastiic iegion (most common piesentation) - Weight loss - Loss of appetite +E<B7 T@AB8DBDA - also known as eiosive gastiitis, this foim of gastiitis is causeu most commonly by uamages to the stomach's mucosal uefense system. NSAIBs anu alcohol aie most common causes of acute gastiitis. ,H8>:DE T@AB8DBDA - this is the iesult of an B. Pyloii infection. $ENH@ ?U OI>?AFO JB@C>FCF@: $ENH ) - 0ccuis in the funuus of the stomach, is of autoimmune natuie. $ENH 2 - 0ccuis in the antium of the stomach, is causeu by an B. Pyloii infection.
/$/(-, 1.,$# &-2$+2$ Theie aie two types of P0B, one is gastiic anu one is uuouenal. $IH JB@C>FO *7X: - Patient usually has an associateu weight loss as theie is incieaseu pain with eating. - The cause of a gastiic P0B is uecieases in mucosal piotection, thus causeu commonly by NSAIBs. $IH MS?MHABL *7X: - Patient will usually have weight gain anu the pain will ueciease with eating. - This is almost always linkeu to an B. Pyloii infection. - The main cause is an inciease in gastiic aciu secietion in conjunction with uecieaseu mucosal piotection. - Theie will be hypeitiophy of Biunnei's glanus (submucosal glanus of the uuouenum who piouuce a mucus-iich alkaline secietion).
-4!.+33+("#G *"%$. &-2$+2$ The two types of IBB aie Ciohn's uisease anu 0lceiative Colitis ,#")4[2 &-2$+2$ 1.,$#+(-5$ ,".-(-2 -.$13 -45".5$3$4( Commonly involves ileum Raiely involves ileum ,"."4-, -45".5$3$4( Colonic involvement often Colonic involvement always #$,(+. -45".5$3$4( Raiely Almost always *-.$ &1,( -45".5$3$4( None Sometimes &-2$+2$ &-2(#-*1(-"4 Patchy, skip lesions Continuous inflammation $4&"2,"/-, 5-$% 0lceis aie lineai, seipiginous 0lceiation is continuous -4!.+33+(-"4 &$/() Tiansmuial, ueep Shallow anu mucosal !-2(1.+ !"#3+(-"4 0ften Raiely +22",-+(-"4 %-() 23"V-4T Bigh iisk in smokeis Low iisk in smokeis 21#T-,+. -4($#5$4(-"4 Retuins following suigical inteivention Cuieu often by suigical iemoval +1("-3314$ ,+12$2f Seen as autoimmune Not seen as autoimmune #-2V "! ,+4,$# -4 +22",-+(-"4 Low compaieu to colitis Cancei iisk highei than in Ciohn's *-"/2G #$5$+.2 uianulomatous Non-gianulomatous
-##-(+*.$ *"%$. 2G4&#"3$ O-*2P Is a uiagnosis of exclusion. IBS piesents most commonly in a young female in hei twenties, who piesents with abuominal painbloating, alteieu bowel habits in the absence of any oiganic cause. Symptoms aie ielieveu aftei a bowel movement. Nanagement of IBS is incieaseu fluiu intake + incieaseu uietaiy fibei intake (ie. Fibei supplementation). If this uoes not woik, ceitain meuications can be exploieu, but this is usually a cuiative appioach.
2G4&#"3$2 "! 3+.+*2"#/(-"4 The commonly testeu synuiomes of malabsoiption aie Celiac Spiue, Tiopical Spiue, anu Whipple's uisease. Symptoms of these conuitions aie: Weight loss, ciamping, uiaiihea, steatoiihea, inuigestion, anu fatigue. !HLFBO &N>SH - Causeu by autoantibouies (antigliauin, antienuomysial, anti-tissue tiansglutaminase) against gluten, which causes villous blunting anu infiltiation of lymphocytes. Tieatment is to consume a gluten-fiee uiet. $>?NFOBL &N>SH - This is an infectious conuition commonly founu in tiopical iegions, anu is maiket by abnoimal flattening of the villi in the small intestine. YIFNNLHc@ XF@HB@H - This is iaiei than the othei two malabsoiption synuiome. It is causeu by an infection with the bacteiium Tiopheiyma Whipplei, anu can cause malabsoiption in conjunction with many systemic pioblems (caiuiac, iespiiatoiy, neuiological, iheumatologic, anu visual).
)$/+(-(-2 Bepatitis is a geneial teim to uesciibe the inflammation of the livei. Theie aie many possible causes of hepatitis, such as alcohol, uiugs, viial, anu uisease-ielateu. !BS@H@ ?U ]F>BL (HNBCFCF@: Five main types of viial hepatitis aie: Bep A, B, C, B, anu E. Bepatitis can also be causeu by Epstein-Baii viius, cytomegaloviius, anu heipes simplex viius. $>BA@DF@@F?A ?U GF>BL IHNBCFCF@: Bepatitis A & E - fecal-oial tiansmission, highei in ueveloping countiies Bepatitis B - tiansmission is paienteial oi sexual Bepatitis B - iequiies co-infection with hepatitis B (iequiies the outei envelope of the BbsAg) Bepatitic C - tiansmitteu paienteially anu is thus moie common in Iv uiug useis r "ALE IHNBCFCF@ 2V !V BAM X OBA N>?J>H@@ C? OI>?AFO IHNBCFCF@Q
,-##)"2-2 Ciiihosis is a consequence of chionic livei uisease, wheieby the noimal aichitectuie of the livei is ieplaceu by fibiosis oi scaiiing. Nouules that aie less than Smm aie "micionouulai" anu aie uue to metabolic causes such as alcoholism. Nouules gieatei than Smm aie usually causeu by seveie injuiy that has leau to ueath of livei cells. Along with ciiihosis comes a vaiiety of auveise effects, on top of the auveise effects fiom ciiihosis theie aie auveise effects causeu by the poital hypeitension that occuis.
/+4,#$+(-(-2 Pancieatitis is an inflammation of the pancieas that causes veiy chaiacteiistic set of symptoms. The patient will almost always piesent with seveie epigastiic pain that iauiates to the back. The two most common causes of pancieatitis aie alcohol anu gallstones, but theie aie othei possible causes, such as: - Tiauma - Steioius - Numps - Bypeilipiuemia - Autoimmune conuitions - Sting fiom a scoipion In pancieatitis, lipase anu amylase will always be elevateu (lipase is moie specific).
/+4,#$+(-, +&$4",+#-4"3+ Pancieatic cancei is a giave uiagnosis anu often causes ueath within 6 months of uiagnosis. It is often asymptomatic anu theiefoie highly metastasizeu by the time of uiagnosis. The most common site of the cancei is in the heau of the pancieas, which is why the only piesenting symptoms is often painless jaunuice anu significant weight loss. "CIH> O?DD?ALE N>H@HACFAJ @EDNC?D@ ?U NBAO>HBCFO OBAOH> FAOLSMHd - Abuominal pain - Nigiatoiy thiombophlebitis - Palpable gallblauuei (Couivoisiei's sign) anu obstiuctive jaunuice *?@@FWLH OBS@H@ ?U NBAO>HBCFO OBAOH>d - Incieaseu age - Nale sex - Cigaiette smoking - 0besity - Biabetes mellitus - Chionic pancieatitis - B. pyloii infection - Family histoiy ** Alcohol has not been pioven to cause pancieatic cancei, howevei alcohol consumption can leau to chionic pancieatitis which may leau to pancieatic cancei. Theiefoie the possibility cannot be iuleu out.
+//$4&-,-(-2 Appenuicitis is a ielatively common conuition anu is the most common inuication foi emeigency abuominal suigeiy in chiluien. Piesentation is uiffuse abuominal pain in the peii-umbilical iegion, followeu by localization of pain to NcBuiney's point. Patient will also have nausea, vomiting, anu oveiall look ill. ** A complication of appenuicitis is peifoiation, which can leau to sepsis.
-4(12212,$/(-"4 This is a conuition of the bowel wheieby one segment "invaginates" oi "telescopes" into anothei segment of bowel. The intussusception always moves into a uistal segment. Eaily symptoms incluue nausea, vomiting, anu pulling of the legs into the chest (foi pain ielief). The most common association with this conuition is "cuiiant jelly stools", which is a mixtuie of bloou anu mucus. As well, theie is a palpable sausage-shapeu mass felt in the abuomen. Tieatment involves using an enema, which often fixes the pioblem.
5".51.12 A volvulus is a twisting of the bowel aiounu its mesenteiy, which can leau to obstiuction. This is an emeigency anu iequiies an emeigent lapaiotomy to ielieve the twistingobstiuction anu pievent ischemia of the bowel.
&-5$#(-,1.+# &-2"#&$#2 A uiveiticulum is any pouch that leaus off of the uigestive tiact. A tiue uiveiticula incluues the mucosa, the musculaiis, anu the seiosa. Nany uiveiticula aie false since they uo not incluue all of the layeis of the tiact. The most common types of uiveiticula: - Zenkei's uiveiticulum - Neckel's uiveiticulum - Biveiticulosis - Biveiticulitis
\$4V$#[2 &-5$#(-,1.13 A Zenkei's uiveiticulum is an outpouching founu in the phaiynx, above the ciicophaiyngeal muscle. It piesents common with a patient who has teiiible bieath (uue to foou accumulation in the uiveiticula). This occuis 1S uistance fiom oiophaiynx to lowei esophagus. Biagnosis is maue with a baiium swallow.
3$,V$.[2 &-5$#(-,1.13 This is a congenital uiveiticulum that is locateu in the uistal ileum. It piesents commonly with painless bloou in the stool of a newboin. It is a iemnant of the omphalomesenteiic uuct, anu is the most fiequently encounteieu malfoimation of the uI tiact of the newboin. Biagnosis can be maue with a technetium-99 scan, which uetects the location of bleeuing along the uI tiact.
&-5$#(-,1."2-2 Biveiticulosis is a conuition wheie theie aie many uiveiticula in the colon. With incieasing age theie is an incieaseu iisk of having uiveiticulosis. Biveiticulosis is the most common cause of iectal bleeuing in someone ovei Suyi of age. Incieaseu luminal piessuie anu colonic wall weakness causes the actual outpouching of the seiosa, wheie a low-fibei uiet is the most common cause of this conuition.
&-5$#(-,1.-(-2 This is simply an inflammation of the uiveiticula. It piesents with seveie LLQ pain anu poses the iisk of peifoiation, peiitonitis, anu stenosis of the bowel lumen.
)-#2,)/#14T[2 &-2$+2$ A congenital 'megacolon' causeu by a lack of migiation of the neuial ciest cells to the lowei segment of the colon (known as the tiansition zone), (Aueibach's anu Neissnei's plexus aie absent on biopsy). An infant will piesent with chionic constipation, but this can also piesent at any point in life. Theie is a poition of the colon that is uilateu pioximal to the aganglionic segment.
*1&&S,)-+#- 2G4&#"3$ Buuu-Chiaii synuiome causes obstiuction of the infeiioi vena cava. As a iesult of this obstiuction, hepatic veins become congesteu (centiilobai) anu this can cause neciosis. This will eventually leau to congestion of the livei anu ultimatelyeventually leau to failuie of the livei. This conuition is especially common in piegnancy, in those with hepatocellulai caicinoma, anu in those with polycythemia veia.
)$3",)#"3+("2-2 This is a veiy common conuition that is causeu by a uefect in iion metabolism, which leaus to an iion oveiloau in vital oigans, joints, anu tissues. Eaily uiagnosis can help pievent auveise effects of the iion oveiloau. Bemochiomatosis piesents with a class tiiau of: 1. Nicionouulai ciiihosis 2. Pancieatic fibiosis S. Skin pigmentation This conuition is classically known as bionze uiabetes uue to the fact that it tints the skin "bionze" anu also affects the pancieas. Total bouy iion levels may ieach upwaius of Sug, anu this must be manageu with iepeateu phlebotomy. This conuition can leau to congestive heait failuie anu can inciease the iisk of hepatocellulai caicinoma. LABS: In those with hemochiomatosis, labs will show 'Iion anu Feiiitin, with a ( total iion binuing capacity.
%-.2"4[2 &-2$+2$ Is an autosomal iecessive uisoiuei wheie theie is a failuie of coppei's ability to entei ciiculation in the foim of ceiuloplasmin. This leaus to coppei accumulation in ceitain tissues (livei, biain, coinea), anu is C>HBCHM TFCI NHAFOFLLBDFAH (chelation of coppei). The most common signs anu symptoms of Wilson's uisease aie: - ,>8:7@ =7N>ADBA (Kaysei-Fleischei iings), veiy common in Wilson's uisease - +AB78DJDA - /@8mD:A>:SIDm7 AF?NB>?A uue to accumulation in basal ganglia - ,@8ED:>?@ - &7?7:BD@
)$/+(",$..1.+# ,+#,-4"3+ ),,P Bepatocellulai caicinoma is a veiy common cause of metastasis, anu spieaus by hematogenous ioute. Nost cases of hepatocellulai caicinoma aie uue to hepatitis B anuoi C, as well as ciiihosis. 0thei causes of BCC incluue Wilson's uisease, hemochiomatosis, alcoholic ciiihosis, anu !-1 antitiypsin ueficiency. The outcome is usually pooi, howevei 1-2 out of 1u cases aie tieatable with suigical iemoval of canceis.
)G/$#*-.-#1*-4$3-+2 O)$#$&-(+#GP Theie aie thiee commonly testes anu encounteieu heieuitaiy hypeibiliiubinemias, they aie: 1. uilbeit's synuiome 2. Ciiglei-Najjai synuiome S. Bubin-}ohnson synuiome
.FLWH>Cc@ &EAM>?DH: uilbeit's synuiome is a benign conuition wheie theie is a milu ueciease in the 0BP- glucuionyl tiansfeiase enzymes. This leaus to an elevation of SAO?A`SJBCHM WFLF>SWFAQ !>FJLH>K#B``B> &EAM>?DHd This is a seveie conuition that leaus to ueath eaily in life. Theie is a complete absence of 0BP-glucuionyl tiansfeiase, which leaus to significant incieases in unconjugateu biliiubin anu causes it to ueposit in the biain (keinicteius), as well as jaunuice. Theie is a less seveie veision of Ciiglei-Najjai calleu "type 2", anu it can be manageu with Phenobaibital. XSWFAKk?IA@?A &EAM>?DH: This synuiome occuis as a iesult of a uefect in the livei's ability to exciete conjugateu biliiubin. It is benign but theie is a change in coloi of the livei to black. A uiffeient foim of this synuiome is "Rotoi's synuiome", which is even miluei anu causes no change in the coloi of the livei.
T+..2("4$2 uallstones aie foimeu as a iesult of incieaseu cholesteiol oi biliiubin. They can occui anywheie in the biliaiy tiee (incluuing insiue the gallblauuei anu in the common bile uuct). When a stone becomes lougeu insiue the common bile uuct, this is known as choleuocholithiasis. Pain can iesult when the gallblauuei contiacts against the stone anu it uoes not get piopelleu foiwaiu. Foui iisk factois aie: !"1# ![A: Z%/)3%V Z%+$53%V Z)$V Z"+$0 $I>HH CENH@ ?U @C?AH@: 1. ,H>I7AB78>I - aie iauiolucent with some being opaque fiom calcification. 2. 3DJ7= - this is the most common type, anu is iauiolucent. S. /DM?7:B AB>:7A - this is seen in patients who have chionic ieu bloou cell hemolysis, alcoholic ciiihosis, biliaiy infection. This is iauiopaque.
*-.-+#G ,-##)"2-2 Theie aie two types of biliaiy ciiihosis: *>FDB>E BAM &HO?AMB>E /8D?@8F *DID@8F ,D88H>ADA: - Is an autoimmune uisoiuei causeu by antimitochonuiial antibouies - Causes a seveie case of obstiuctive jaunuice with all of the auveise effects associateu with seveie jaunuice (piuiitis, hypeicholesteiolemia) 27E>:=@8F *DID@8F ,D88H>ADA: - This biliaiy ciiihosis is uue to obstiuction outsiue of the livei (extiahepatic) - Causes a builuup of piessuie within the uucts of the livei, anu we get bacteiial infections, ascenuing cholangitis, bile stasis.
/#-3+#G 2,.$#"2-4T ,)".+4T-(-2 Anothei autoimmune uisease of the livei, wheie theie is a slowly piogiessing uestiuction of the bile canaliculi. Bestiuction leaus to cholestasis anu theiefoie uamage, inflammation, anu fibiosis of the bile uucts. The classic piesentation of the bile uucts is the "beauing", wheieby theie is alteinating uilation anu stiictuie of the uuct as seen on enuoscopic ietiogiaue cholangiopancieatogiaphy (ERCP).
,"4T$4-(+. /+()"."TG
Theie aie a gioup of common congenital pathologies that aie high-yielu foi the 0SNLE Step 1 exam, they incluue: - Befects of the heait - Spina bifiua - Bypospauias - Cleft lip - Pyloiic stenosis - Anencephaly
,"4T$4-(+. )$+#( &$!$,(2 The most common congenital heait uefects incluue: - ventiiculai septal uefects - Atiial septal uefects - Patent uuctus aiteiiosus - Tetialogy of fallot - Tiuncus aiteiiosus - Tiansposition of the gieat vessels - Coaictation of the aoita
&$!$,(2 ,+12-4T + #-T)( (" .$!( 2)14( These uefects cause uefects that foice bloou fiom the iight siue of the heait to the left siue of the heait uue to piessuie, iesulting in eaily cyanosis because systemic bloou is lacking oxygen. The babies aie often blue in coloi because they uo not ieceive auequate oxygen. The thiee common congenital malfoimations causing a R!L shunt aie: 1. Tetialogy of fallot 2. Tiansposition of the gieat vessels S. Tiuncus aiteiiosus
$%$+)3".0 "Z Z)33"$d This conuition iesults in a gioup of pioblems, that ultimately leau to eaily cyanosis uue to shunting of bloou fiom the iight to the left thiough the ventiiculai septal uefect. This is causeu by an anteiiosupeiioi uisplacement of the infunuibulai septum. The 4 pathologies of tetialogy of Fallot aie: 1. Pulmonaiy stenosis 2. Right ventiiculai hypeitiophy S. 0veiiiuing aoita 4. ventiiculai septal uefect (pioviues aiea foi shunting)
$+)#&*"&5$5"# "Z $(% .+%)$ ]%&&%3&d This conuition iesults in the aoita connecteu fiom the iight ventiicle while the pulmonaiy tiunk leaves fiom the left ventiicle. This iesults in a sepaiation of the systemic anu pulmonaiy ciiculations. Since theie is no oxygenateu bloou being pumpeu systemically, this conuition is incompatible with life (unless theie is the piesence of a shunt). Tiansposition of the gieat vessels waiiants immeuiate suigical coiiection foi suivival. The conuition is causeu by failuie of the aoiticopulmonaiy septum to spiial.
$+7#!7& )+$%+5"&7&: Tiuncus aiteiiosus occuis when theie is an incomplete oi faileu septation of the embiyonic tiuncus aiteiiosus. This iesults in a single aiteiial tiunk that aiises fiom two noimally foimeu ventiicles. The pulmonaiy aiteiies can aiise fiom the common tiunk in a myiiau of patteins, thus giving this conuition seveial uiffeient subtypes.
&$!$,(2 ,+12-4T + .$!( (" #-T)( 2)14( Theie aie thiee conuitions that cause a L!R shunt, they incluue: 1. ventiiculai septal uefects 2. Atiial septal uefects S. Patent uuctus aiteiiosus
5$4(#-,1.+# 2$/(+. &$!$,( This is the most common of all caiuiac congenital anomalies. This uefect uoes not iesult is cyanosis because the L!R shunt uoesn't put non-oxygenateu bloou back into the systemic ciiculation. This can be uetecteu by heaiing a pansystolic muimui on auscultation. Theie is usually no uetection at biith, but within a few weeks it will be uetectable.
+(#-+. 2$/(+. &$!$,( This is a conuition wheie theie is a communication between both the iight anu left atiia of the heait. The ASB is the most common congenital heait uefect seen in auults.
/+($4( &1,(12 +#($#-"212 The uuctus aiteiiosus is a vasculai connection between the pulmonaiy aiteiy anu the aoitic aich in the ueveloping fetus. 0pon a newboin's fiist bieath, the piocess of PB closuie shoulu occui, howevei it sometimes uoes not. If closuie fails to occui, the neonate will expeiience peisistent iespiiatoiy pioblems. The PBA can be closeu by giving inuomethacin, anu can be kept openeu with piostaglanuin E.
,"+#,(+(-"4 "! ()$ +"#(+ This is a naiiowing of the aoita that can occui in two uiffeient places. The 'pieuuctal' foim occuis pioximal to the uuctus aiteiiosus, the 'postuuctal' foim occuis uistal to the uuctus aiteiiosus. The post-uuctal foim is associateu with iib notching, uppei extiemity hypeitension, anu weak pulses in the lowei extiemities. Coaictation of the aoita is seen in males much moie than in females.
4$1#+. (1*$ &$!$,(2 Neuial tube uefects occui most commonly when theie is a lack of auequate folic aciu intake uuiing piegnancy. 0pon testing, theie is often an elevation in !-fetopiotein in the amniotic fluiu. Theie aie thiee piesentations of neuial tube uefects, they incluue: 1. 2ND:@ QDCD=@ >EE<IB@ - which iesults when theie is an incomplete closuie of the spinal canal. Theie is no actual heiniation of any spinal tissue. This often piesents with a tuft of haii on the skin above the pioblem. 2. 37:D:M>E7I7 - iesults when the spinal meninges heiniateu thiough the opening in the veitebia. S. 37:D:M>?F7I>E7I7 - iesults when both the meninges anu the spinal coiu heiniateu thiough the bony uefect of the veitebia.
(#-2"3G &-2"#&$#2 The thiee most commonly encounteieu autosomal tiisomy uisoiueis aie: 1. Patau's synuiome 2. Euwaiu's synuiome S. Bown's synuiome
/@B@<[A 2F:=8>?7: - Causeu by tiisomy 1S - Cleft lip anu palate - Seveie mental ietaiuation - Niciophthalmia - Niciocephaly - Beath usually within 1 st yeai of biith $=K@8=[A 2F:=8>?7: - Causeu by tiisomy 18 - Rockei bottom feet - Low-set eais - Clencheu hanus - Piominent occiput - Beath usually within 1 st yeai of biith &>K:[A 2F:=8>?7: - The most common chiomosomal uisoiuei - The most common cause of congenital mental ietaiuation - Causeu by tiisomy 21 - Piominent epicanthal folus - Simian ciease - Incieaseu iisk of ALL - Congenital heait uisease (ASB most commonly) - Causeu most commonly by meiotic non-uisjunction of homologous chiomosomes
0GG 2F:=8>?7: Patients aie phenotypically noimal but aie unusually tall, have seveie acne, anu aie pione to anti-social behaviois.
(<8:78[A 2F:=8>?7 O0"PR Patients aie female, have shoit statuie, webbeu necks, wiuely spaceu nipples, ovaiian uysgenesis, anu expeiience piimaiy amenoiihea. This patient is also pione to having coaictation of the aoita.
VID:7C7IB78[A 2F:=8>?7 O00GPR Nale patient's who aie tall, have longthin extiemities, female bouy haii patteins, testiculai atiophy, anu gynecomastia.
!#+T-.$ 0 2G4&#"3$ Fiagile X synuiome is an x-linkeu uisoiuei, anu is the 2 nu most common cause of mental ietaiuation. Is a tiiplet-iepeat uisoiuei that can show anticipation. Patients have laige testicles, long faces with laige jaw, anu laige eais.
)$#3+/)#"&-(-23 $>SH (H>DBNI>?MFCH - patient is eithei 46 xx oi 47 xxy, having both testes anu ovaiies piesent, with ambiguous genitalia. This is a iaie synuiome. /A7<=>H78?@NH8>=DBDA? - Female anu Nale types: !7?@I7 - ovaiies aie piesent but the exteinal genitalia aie viiilizeu oi ambiguous. Causeu by excessive exposuie to anuiogens uuiing gestation. 3@I7 - testes aie piesent but the exteinal genitalia aie female oi ambiguous. The most common foim is the anuiogen insensitivity synuiome.
+4&#"T$4 -42$42-(-5-(G 2G4&#"3$ This patient is genetically male, howevei they have anuiogen ieceptois that aie insensitive to the effects of anuiogens, making them appeai female. Theie aie noimal appeaiing exteinal genitalia but the vaginal canal is not uevelopeu (blinu vagina). Theie aie no uteiine tubes oi uteius. Because theie is no secietion of male hoimones by the testes (which aie piesent in the labia but often iemoveu), theie is no negative feeuback anu thus testosteione, estiogen, anu LB will iemain elevateu.
312,1.+# &G2(#"/)G The two types of musculai uystiophy aie: Buchenne's anu Beckei's musculai uystiophy. XSOIHAAHc@ - This is the moie seveie foim of musculai uystiophy, wheieby a ueletion of the uystiophin gene causes an acceleiation of muscle bieakuown. Patient will expeiience weaknesses of the pelvic giiule anu oveiall piogiessive weakness. Commonly founu is pseuuohypeitiophy of the calf (fatty ieplacement of the muscle). Patients commonly use the "uowei's maneuvei", wheie they use theii aims to climb up the legs anu achieve a stanuing postuie, which is chaiacteiistic of musculai uystiophy. 2HO\H>c@ - This is a less seveie veision of musculai uystiophy wheieby theie is a mutation of the uystiophin gene, iathei than a complete ueletion. XFBJA?@FAJ musculai uystiophy is uone by finuing elevateu cieatine kinase levels anu muscle biopsy showing these gene manipulations.
bS!S#$&1,(+2$ &$!-,-$4,G This enzyme is iesponsible foi conveiting testosteione to BBT. When this conuition occuis in ueveloping fetus, they will have ambiguous genitalia until pubeity when levels of testosteione inciease, causing a masculinization of the genitalia.
ZZsXX 2G4&#"3$2 ,+(,) ZZ is the common mnemonic useu to iemembei this seiies of synuiomes that commonly occui togethei. , - cleft palate + - abnoimal facies ( - thymic aplasia , - caiuiac uefects ) - hypocalcemia ZZ - Nicioueletion at the 22 nu chiomosome at loci 11
3-,#",G(-, +4$3-+2 5+"# X%Z5!5%#!0 )#%/5) - Is the most common cause of anemia thioughout the woilu ,@<A7= QFR - Chionic bloou loss (menstiuation is a common cause) - In a male auult, uI bloou loss is the likely cause (no menstiuation) &D7B@8F =7CDED7:EF DA @ N>AADQI7 E@<A7 D:R - 5AUBAC@ BAM C?MMLH>@: especially if uiet is pieuominantly bieast milk - )M?LH@OHAC@: iapiu giowth iates inciease the neeu foi iion, thus a ueficiency uevelops - *>HJABAOE: piegnancy is a state of incieaseu iion iequiiement !?DD?A @FJA@e@EDNC?D@d - Fatigue anu weakness aie the most common symptoms - Becieaseu seium feiiitin + incieaseu TIBS (total iion binuing capacity) $>HBCDHAC: - 0ial feiious sulfate
$()3)&&%/5)& Thalassemias aie inheiiteu uisoiueis that aie causeu by a lack of piouuction of eithei the ! oi " globin chains of hemoglobin. Seveiity of thalassemia is uepenuent on which globin chain is affecteu anu how many of the gene loci aie ueleteumutateu. As a iule, if an iion ueficiency anemia is tieateu unsuccessfully, a hemoglobin electiophoiesis shoulu be peifoimeu looking foi a thalassemia. " $IBLB@@HDFB@: (H@I@AA7?D@ 3@;>8: aka homozygous "-chain thalassemia anu Cooley's anemia. - Causes seveie miciocytic anemia - Bone maiiow space expansion leauing to bone malfoimations - uiowth ietaiuation anu failuie to thiive - Pieuominantly in Neuiteiianean population - Tieatment involves bloou tiansfusion, anu without tieatment ueath within the fiist few yeais of life is unavoiuable. ** This foim of thalassemia can leau to congestive heait failuie. A seveie case can iequiie a chelatoi to eliminate excess iion. XFBJA?@FAJ "KCIBLB@@HDFB DB`?>d - Bemoglobin electiophoiesis will show an elevation of BbF - Peiipheial bloou smeai will show a miciocytic hypochiomic anemia
(H@I@AA7?D@ 3D:>8: aka heteiozygous "-chain thalassemia - These patients aie usually asymptomatic - Nilu miciocytic anemia is usually the only finuing - Biagnosing is also with hemoglobin electiophoiesis - Since this conuition is asymptomatic, no tieatment is necessaiy
!K$IBLB@@HDFB@: 2DI7:B ,@88D78A: This foim is causeu by a mutation oi ueletion of only one ! locus. - Patients aie asymptomatic - No tieatment is necessaiy !SBH@II@A7?D@ ?D:>8: This foim of thalassemia is causeu by mutation oi ueletion of two ! loci. - Patient has milu miciocytic hypochiomic anemia, but no tieatment is necessaiy )Q ) =DA7@A7: This foim is causeu by a mutation oi ueletion of thiee ! loci - Patient will have hemolytic anemia plus significant miciocytic hypochiomic anemia - Tieatment involves life-long tiansfusions - If tiansfusions fail to impiove symptoms, a splenectomy is helpful )F=8>NA !7B@IDA: This is a mutation oi ueletion of all foui ! loci. - This conuition is not compatible with life, anu ueath occuis at biith oi veiy shoitly theieaftei.
&5X%+"23)&$5! )#%/5) This is a conuition that is causeu when the bouy cannot piopeily incoipoiate iion into hemoglobin. As a iesult, "iingeu siueioblasts" aie cieateu anu can be seen on peiipheial smeai. This can be eithei heieuitaiy oi acquiieu. If acquiieu, causes such as alcohol, isoniaziu, chloiamphenicol, leau exposuie, collagen vasculai uisease, anu myelouysplastic synuiomes shoulu be exploieu. ZFAMFAJ@: - Theie will be a N0RNAL total iion binuing capacity + incieaseu seium iion anu seium feiiitin. $>HBCDHAC: Removal of offenuing agent if this is the cause.
4"#3",G(-, +4$3-+2
)#%/5) "Z !(+"#5! X5&%)&% Anemia of chionic uisease occuis in the setting of a chionic illness such as: Cancei, inflammatoiy uiseases (SLE, RA), tubeiculosis, etc. - 0sually noimocyticnoimochiomic, howevei at times may be miciocytic anu hypochiomic. - Nanagement of this conuition involves tieatmentmanagement of the unueilying conuition.
3+,#",G(-, +4$3-+2
]5$)/5# 2,1 X%Z5!5%#!0 The most common cause of vitamin B12 ueficiency is impaiieu absoiption - Peinicious anemia is a lack of intiinsic factoi, anu is the most common cause of ueficiency in the westein woilu. - Since stoies of B12 can last foi S yeais in the livei, theie is usually not an uietaiy insufficiency. - Competition fiom oiganisms (uiphyllobothiium latum - the fish tapewoim) can cause B12 ueficiency &FJA@e&EDNC?D@: - Anemia with NCv >1uu + hypeisegmenteu neutiophils on peiipheial smeai - Neuiological manifestations such as loss of vibiationposition sense, ataxia, anu 0NN signs (+ve Babinski, spasticity, incieaseu BTR's) - ulossitis - Incieaseu seium levels of methylmalonic aciu anu homocysteine (B12 is a co- factoi in conveision of these two molecules into succinyl CoA anu methionine, iespectively) (87@B?7:B: Intiamusculai auministiation of vitamin B12 one time pei month.
Z"35! )!5X X%Z5!5%#!0 Symptoms similai to vitamin B12 ueficiency without any neuiological signs oi symptoms. - Bietaiy ueficiency is the most common cause, as stoies iun out in S months. Commonly the patient eats the "tea anu toast" uiet - The best souices foi folate aie gieen leafy vegetables - 0thei common causes asiue fiom uietaiy insufficiency aie: alcoholism, piegnancy, folate antagonists, hemolysis, hemouialysis. (87@B?7:B: Baily folic aciu supplementation
)$3".G(-, +4$3-+
Is a uestiuction of ieu bloou cells befoie theii piogiammeu time of ueath. - Theie will be an incieaseu ieticulocyte count as the bone maiiow iesponus to the incieaseu neeu foi RBC's - An anemia will iesult when the bone maiiow cannot keep up with the new uemanu foi RBC's. Theie aie foui kinus of hemolytic anemia, they aie: 1. 5AC>FA@FO - these aie factois that aie heieuitaiy in natuie, incluuing: Sickle cell uisease, thalassemias, hemoglobin C uisease 2. %PC>FA@FO - theie aie acquiieu factois causing hemolysis, incluuing: Immune iegulateu hemolysis, mechanical hemolysis (piosthetic heait valves), toxic insults (uiugs, poisons, etc). S. /HDW>BAH MHUHOC@ - uefects of the membiane can iesult in RBC hemolysis, they incluue: Beieuitaiy spheiocytosis, PNB 4. XHUHOC@ ?U CIH HAaEDH@ - u6PB ueficiency, pyiuvate kinase ueficiency
If the hemolysis occuis within the ciiculation, "intiavasculai hemolysis" occuis. If the hemolysis occuis within the ieticuloenuothelial system, "extiavasculai hemolysis" occuis.
/BFA UHBCS>H@ ?U IHD?LECFO BAHDFB: - }aunuice - Fatiguepalloi - Baik uiine (causeu by hemoglobin) - Bepatosplenomegaly
XFBJA?@FAJ: - Bemoglobin anu hematociit levels - Peiipheial smeai to uiffeientiate between uiffeient types of hemolysis Beinz bouies ! u6PB ueficiency Schistocytes ! intiavasculai hemolysis Sickleu RBC ! sickle cell anemia Spheiocyteshelmet cells ! extiavasculai hemolysis
2-,V.$ ,$.. &-2$+2$ Is causeu by a IHD?JL?WFA & h(W&i DSCBCF?A. Theie is a single amino aciu ieplacement in the "-chain. - valine ieplaces glutamic aciu - A low oxygen state causeu "sickling" of the ieu bloou cells - Sickle cell "tiait" is a heteiozygote - Sickle cell tiait patients aie usually malaiia-iesistant )MGH>@H %UUHOC@: - Aplastic ciisis causeu by Paivoviius B19 infection - Incieaseu iisk of infection by encapsulateu bacteiia (B. Infl, S. Pneumo, Neisseiia) ! uive patient pneumococcal vaccine, Bib vaccine, meningococcal vaccine. - vaso-occlusive ciisis causing seveie pain (uue to miciociiculation obstiuction by sickleu ieu bloou cells) - Splenic sequestiation ciisis
YIBC F@ B @NLHAFO @HRSH@C>BCF?A O>F@F@n This is a potentially fatal complication of the sickle cell uisease. Bloou pools into the spleen, iesulting in splenomegaly anu the subsequent uevelopment of hypovolemic shock. This conuition often waiiants a splenectomy.
(W! MHUHOC - Niluei uisease (BbC oi BbSC) (87@B?7:B: Byuioxyuiea to inciease BbF levels (pievents the sickling piocess), bone maiiow tiansplant, piophylactic penicillin foi chiluien fiom 4 months of age to 6 yeais of age.
()$ ,""3*[2 ($2( The uiiect Coombs test is useu to uetect antibouies bounu to the suiface of the RBC. This is the test useu to uetect immune-meuiateu hemolytic anemia. The Coombs test is baseu on the iuea that the auuition of anti-human antibouies will binu to human antibouies that aie bounu to the RBC membiane. These antibouies aie most commonly Igu anu IgN. If these antibouies agglutinate, the RBC's will clump anu this is a positive test iesult. If they uo not agglutinate anu clump, we have a negative test iesult.
)$#$&-(+#G 2/)$#",G("2-2 This is an AB uisoiuei wheie theie is a uefect in the gene that coues foi spectiin, iesulting in a uecieaseu content of spectiin. This causes a loss of the membiane suiface aiea with no ueciease in volume. These two cause the shape to shift fiom ciiculai to spheiical. - The osmotic fiagility test is a way to test the RBC's ability to withstanu hypotonic saline. The spheiical shape will toleiate the solution less than the iegulai RBC shape, thus causing it to iuptuie fastei. - Peiipheial smeai woulu show spheiocytes - Coombs test is negative
T.1,"2$S`S/)"2/)+($ &$)G&#"T$4+2$ &$!-,-$4,G This is an x-linkeu iecessive uisoiuei that is usually piecipitateu by infections, fava beans, piimaquine, uimeicaptol, sulfonamiues, anu nitiofuiantoin. - Patient gets episoues of hemolytic anemia that is often piecipitateu by an aggiavating factoi - Patient will get jaunuice anu have uaik uiine - Peiipheial smeai will show bite cells (causeu by maciophages) anu Beinz bouies (hemoglobin piecipitation insiue RBCs) - Biagnose by measuiing u6PB levels. (87@B?7:B: Avoiu piecipitating factois, tiansfuse as necessaiy
+1("-3314$ )$3".G(-, +4$3-+ Autoantibouies against the RBC membiane cause uestiuction of RBC's. Theie aie two possible causes foi this, Igu antibouies oi IgN antibouies -MT E@<A7A ! "waim" autoimmune hemolytic anemia. This means that binuing of Igu to the RBC membiane occuis optimally at S7C. This causes extiavasculai hemolysis wheie the piimaiy site of sequestiation is the spleen. -M3 E@<A7A ! "colu" autoimmune hemolytic anemia. Binuing of IgN to the RBC membiane occuis optimally at uC to 5C. This causes intiavasculai hemolysis anu complement activation, wheie the piimaiy site of sequestiation is the livei. XFBJA?@FAJ: - Biiect Coombs test: If +ve = waim, if -ve = colu (87@B?7:B: If milu , no tieatment is necessaiy. If waim anu moueiate, give glucocoiticoius (uo splenectomy if no uC iesponse).
/+#"0G23+. 4",(1#4+. )$3"T."*-41#-+ O/)4P Is a conuition wheieby theie is chionic intiavasculai hemolysis. - Noimochiomic noimocytic anemia - Pancytopenia (affects hematopoietic stem cells) - Thiombosis of venous system may occui - Nay cause moie seveie conuitions such as aplastic anemia's, myelouysplasia, anu acute leukemia's - Patient can expeiience musculoskeletal anu uI pains (87@B?7:B: Pieunisone oi BN tiansplant if no iesponse to tieatment.
/.+($.$( &-2"#&$#2
()#"3*",G("/$4-+ This is when the platelet count falls below 1Su,uuu !BS@H@: - Becieaseu piouuction uue to: BN injuiy, suppiession, invasions - Incieaseu uestiuction uue to: BIC, TTP, infection, uiugs, ITP, BIv - Sequestiation - Piegnancy: usually not a majoi concein - Bilutional effects fiom tiansfusion - Beteimination of cause can be maue with CBC, peiipheial smeai, anu bone maiiow biopsy.
()#"3*"(-, ()#"3*",G("/$4-, /1#/1#+ O((/P A conuition wheieby theie is excessive platelet consumption, leauing to an emeigency situation that can leau to ueath iathei quickly (few months). &FJA@e&EDNC?D@: - Alteieu mental status - Bemolytic anemia - Thiombocytopenia (87@B?7:B: Plasmaphaiesis is iequiieu to maintain life, coiticosteioius anu splenectomy may also be iequiieu.
-&-"/+()-, ()#"3*",G("/$4-, /1#/1+ O-(/P Is an autoimmune foimation of antibouies against platelets. Igu antibouies auheie to anu uestioy the platelets which aie then iemoveu by splenic maciophages. Acutely ! Is a self-limiteu conuition seen in chiluien, wheie the conuition is almost always pieceeueu by a viial infection. Chionically ! Is a spontaneous foim of ITP seen most commonly in miuule-ageu females. Is self-limiteu.
T.+4\3+44[2 ()#"3*+2()$4-+ This is an AR uisoiuei wheie theie is a ueficiency in platelet aggiegation uue to a ueficiency of glycopiotein uPIIb-IIIa. The only alteieu test is incieaseu bleeuing time.
*$#4+#&S2"1.-$# 2G4&#"3$ Is an AR uisoiuei of platelet auhesion uue to a ueficiency of glycopiotein uPIb-IX. The platelet count will be low with abnoimally laige platelets on peiipheial smeai.
&-2"#&$#2 "! ,"+T1.+(-"4
1. von Willebianu's Bisease (vWB) 2. Bemophilia A S. Bemophilia B 4. Bisseminateu Intiavasculai Coagulation (BIC) S. vitamin K ueficiency 6. Coagulopathy of livei uisease 7. Inheiiteu hypeicoagulable states
5"4 %-..$*#+4&[2 &-2$+2$ Is an AB uisoiuei that is causeu by a ueficiency oi uefect of the vWF (factoi 8- ielateu antigen). vWF is iequiieu foi the fiist step of platelet aggiegation in clot foimation. * 9%! DA BH7 ?>AB E>??>: D:H78DB7= QI77=D:M =DA>8=78l @CC7EBD:M <N B> ]t >C BH7 N>N<I@BD>:n &FJA@e&EDNC?D@: - Cutaneous bleeuing - Nucosal bleeuing - Nenoiihagia seen in moie than half of females with vWB - Nany patients won't show anything sign oi symptoms until they unueigo a suigical pioceuuie anu have excessive bleeuing - Bleeuing time will be piolongeu, platelet count is noimal - PTT may be piolongeu, vWF is uecieaseu, factoi 8 activity is uecieaseu - Ristocetin levels shoulu be checkeu in uiagnosing vWB Tieatment: Besmopiessin to inuuce enuothelial cells to seciete von Willebianu factoi (not effective in type S vWB). Factoi 8 concentiates is iecommenueu foi type S vWB. Patient shoulu avoiu NSAIBs.
)$3"/)-.-+ + Is an x-linkeu iecessive uisoiuei that affects male patients, anu is causeu by a ueficiency oi uefect of factoi 8. &FJA@e&EDNC?D@: - Bleeuing into joints (hemaithioses) - Intiamusculai bleeus - Intiacianial bleeus (theiefoie heau tiauma must be taken veiy seiiously in these patients) XFBJA?@FAJ: - Low factoi 8 levels + noimal vWF - PTT is piolongeu (87@B?7:B: Replace clotting factois, uesmopiessin may be helpful in some patients.
)$3"/)-.-+ * Is an x-linkeu iecessive uisoiuei causeu by a ueficiency of factoi 9, anu is much less common than hemophilia A. Nanagement involves ieplacing missing factois.
&-22$3-4+($& -4(#+5+2,1.+# ,"+T1.+(-"4 O&-,P BIC is a uisoiuei chaiacteiizeu by an abnoimal activation of the coagulation sequence, which leaus to wiuespieau foimation of miciothiombi thioughout the miciociiculation. This leaus to the consumption of clotting factois, platelets, anu fibiin. Theie is also an activation of fibiinolytic mechanisms, thus leauing to hemoiihages. *.$$&2 k ()#"3*"2-2 !?DD?A OBS@H@: - The most common cause is infection (uiam -ve sepsis is NCC) - Piegnancy complications - Tiauma - Nalignancy - Shock &FJA@e&EDNC?D@: - 0ozing fiom pioceuuie sites - Ecchymoses - Petechia - Puipuia - Thiomboses seen moie often in chionic cases of BIC (87@B?7:B: Coiiect unueilying conuitions anu apply suppoitive measuies.
5-(+3-4 V &$!-,-$4,G Theie aie many clotting factois that iequiie vitamin K as a cofactoi in synthesis, incluuing: Piotein C & S, anu factois 2, 7, 9, 1u. vitamin K ueficiency is seen in veiy ill patients who aie being feu thiough a tube, as well as those who aie using oial waifaiin as an anti-coagulant. &FJA@e&EDNC?D@: - Significant hemoiihages - PT piolongation (is the fiist finuing), then PTT piolongation. (87@B?7:B: vitamin K ieplacement. If patient has a seveie bleeu, fiesh fiozen plasma shoulu be given as it contains all of the clotting factois.
,"+T1."/+()G "! .-5$# &-2$+2$ Since the livei synthesizes all clotting factois, any uisease of the livei can cause coagulopathies (abnoimal bleeuing, piolongation of PTPTT). Tieatment: Fiesh fiozen plasma if PTPTT aie alteieu oi theie is significant bleeuing.
-4)$#-($& )G/$#,"+T1."/+()-$2 - )ACFCI>?DWFA 4 MHUFOFHAOE (incieaseu thiombosis) - )ACFNI?@NI?LFNFM BACFW?ME @EAM>?DH (aiteiial oi venous thiombosis) - *>?CHFA ! MHUFOFHAOE (uniegulateu fibiin synthesis) - *>?CHFA & MHUFOFHAOE (leaus to a ueficiency of piotein C activity) - ZBOC?> ] LHFMHA (uniegulateu piothiombin activation - incieaseu thiomboembolic events) - *>?CI>?DWFA JHAH DSCBCF?A
/.+23+ ,$.. &-2"#&$#2
1. Nultiple Nyeloma 2. Waluenstiom's Nacioglobulinemia S. Nonoclonal uammopathy of 0nueteimineu Significant (Nu0S)
31.(-/.$ 3G$."3+ Is a cancei of the bone maiiow that piouuces laige amounts of Igu oi IgA. This is the most common tumoi aiising in auults 5C OBS@H@: - Bone lesions - Bypeicalcemia - Anemia - Infections &FJA@e&EDNC?D@: - Skeletal manifestations (bone pain, fiactuies, veitebial collapse) - Noimocytic noimochiomic anemia (uue to BN infiltiation anu ienal failuie) - Renal failuie - Infections (seconuaiy to uepiivation of noimal Ig's affects humoial immunity, anu is the NCC of ueath) - Amyloiuosis !IB>BOCH>F@CFO ZFAMFAJ@: - Bence }ones pioteins in uiine (aie Ig light chains) - N-spike (is a monoclonal Ig spike seen on seium electiophoiesis) - Rouleau foimation (peiipheial smeai showing RBCs stackeu like pokei chips)
%+.&$42(#"3[2 3+,#"T."*1.-4$3-+ Is a conuition that causes hypeiviscosity of the bloou uue to malignant piolifeiation of plasmacytoiu lymphocytes (IgN). Shoulu be manageu with chemotheiapy anu plasmaphaiesis
3"4",."4+. T+33"/+()G "! 14&$($#3-4$& 2-T4-!-,+4,$ Is a conuition that is usually asymptomatic anu seen in the elueily population.
Piognosis uepenuent on amount of lymphocytes anu Reeu-Steinbeig cells (best when incieaseu lymphocytes anu uecieaseu Reeu-Steinbeig cells). Is associateu with states of immunosuppiession.
Nany LN's involveu with extianoual involvement.
B cells aie of the majoiity.
veiy few constitutional symptoms 0ccuis fiom 2u-4uyi of age.
&$)23% )#.5#) Fixeu atheioscleiotic lesions naiiow the coionaiy aiteiies, leauing to an imbalance between bloou supply anu u2 uemanu. This leaus to inauequate peifusion, anu oxygen uemanu exceeus bloou supply. Atheioscleiosis leaus to naiiowing > 7S%. &FJA@e&EDNC?D@: - Substeinal chest pain lasting less than 1S minutes - Pain is uesciibeu as squeezing, heaviness, piessuie - Always biought on by physical exeition - Pain goes away with iest anuoi nitioglyceiine
7#&$)23% )#.5#) In unstable angina, the cause of chest pain is uue to a ieuuceu iesting coionaiy bloou flow. The main uiffeience between unstable vs. stable angina is that the pain of unstable angina occuis at iest.
*+5#m/%$)3c& )#.5#) Piinzmetal's angina is causeu by a tiansient coionaiy vasospasm that is accompanieu by a fixeu atheioscleiotic lesion. The symptoms occui at iest. SignsSymptoms: - Chest pain at iest - Nost common in youngei females who smoke cigaiettes - Theie will be a tiansient ST-segment elevation on EKu uuiing the episoues of chest pain
+#($#-"2,.$#"2-2 _ +()$#"2,.$#"2-2 )+$%+5"&!3%+"&5& - Aiteiioscleiosis is a consequence of hypeitension, wheieby theie is hyaline thickening of the small aiteiies.
)$(%+"&!3%+"&5& Is plaque foimation within the intima of the aiteiies, occuiiing in the elastic anu laigemeuium - sizeu musculai aiteiies. The most common causes of atheioscleiosis aie: ($#V @D?\FAJV IENH>LFNFMHDFBV X/V MFHCB>E UBOC?>@V UBDFLE IF@C?>EQ *>?J>H@@F?Ad ZBCCE &C>HB\ ! *>?LFUH>BCFGH *LBRSH ! !?DNLHP )CIH>?DB )MGH>@H %UUHOC@d - Ischemia - Infaiction - Peiipheial vasculai uisease - Thiombus - Emboli 3?OBCF?A@: Nost commonly in the abuominal aoita, coionaiy aiteiies, popliteal aiteiies, anu caiotiu aiteiies.
)G/$#($42-"4 $AA7:BD@I )(4: No iuentifiable cause, anu applies to > 9S% of cases of BTN 27E>:=@8F )(4: Renal causes (stenosis), enuociine causes (hypeialuosteionism, hypeithyioiuism, Cushing's, pheociomocytoma), meuication (0CPs). **0CP's aie NCC in young women %UUHOC@ ?U ($# ?A CIH IHB>C: - Incieaseu systemic vasculai iesistance leauing to eventual CBF (CBF is the most common enu-iesult of BTN) - Atheioscleiosis - CAB - Left ventiiculai hypeitiophy - Stioke - Renal failuie - Retinal changes anu uamage - Risk of hemoiihages - Risk of kiuney atheioscleiosis )(4 ,I@AADCDE@BD>: 2FAB>IDE #7@=D:M &D@AB>IDE #7@=D:M 3@:@M7?7:B 4>8?@I < 12u < 8u No tieatment necessaiy /87HFN78B7:AD>: 12u-1S9 8u-89 Lifestyle mouifications only 2B@M7 X )(4 14u-1S9 9u-99 Lifestyle mous + 1 anti-BTN meuication 2B@M7 Z )(4 ) 16u ) 1uu Lifestyle mous + 2 anti-BTN meus
3G",+#&-+. -4!+#,(-"4 Nyocaiuial infaictions occui as a iesult of the occlusion of a vessel in the heait, inteiiupting the supply to the heait, iesulting in infaiction. 0ccuis in the 3)X l +!) l !5+!7/Z3%f $IH WH@C FAFCFBL CH@C U?> B @S@NHOCHM /5 F@ CIH %b.Q
!B>MFBO %AaEDH@: ,VS3* - best initial caiuiac enzyme (optimal foi uetecting a seconu infaict while in the hospital) (8>N>:D:- iises aftei 4 his then stays elevateu foi 7-1u uays
*BCI?L?JFOBL OIBAJH@ BUCH> BA /5: &@F X - Baik mottling &@F ZS^ - Bypeiemia (vessel uilation) &@F bSXY - Bypeiemic boiuei with cential yellow-biown softening !7K K77mA - 0ccluueu aiteiy is ie-canalizeu anu a scai is piesent (giay-white coloiing).
!?DNLFOBCF?A@ ?U B DE?OB>MFBL FAUB>OCF?A: 1. Left ventiiculai failuie 2. Pulmonaiy euema S. Caiuiac aiihythmia (most common cause of ueath befoie ieaching the hospital) 4. Caiuiogenic shock S. Ruptuie of ventiiculai fiee wall, papillaiy muscles, anuoi inteiventiiculai septum (occuis 4-1u uays post-NI) 6. Nuial thiombus causing thiomboembolism 7. Peiicaiuitis (S-S uays post-NI)
,+#&-+, (13"#2 In auults, the most common tumoi is the "/EP?DB". This occuis most of the time in the left atiium. They cause a "ball-valve obstiuction" that obstiucts the left atiium. In chiluien, the most common tumoi is the "+IBWM?DE?DB" anu is associateu with tubeious scleiosis.
,"4T$2(-5$ )$+#( !+-.1#$ A conuition wheieby the heait's pumping ability cannot meet the bouy's ciiculatoiy uemanus unuei noimal conuitions.
$(% Z+)#bK&$)+35#. +%3)$5"#&(5* Says that in noimal functioning heaits, an inciease in pieloau shoulu iesult in gieatei contiactility. Baseu on this piinciple, with exeition a heait in CBF piouuces less contiactility anu this is when symptoms occui.
&FJA@e&EDNC?D@: 3%Z$K&5X%X (Z - Byspnea (seconuaiy to pulmonaiy congestion) - 0ithopnea (uifficulty sleeping in the iecumbent position) - Paioxysmal noctuinal uyspnea (patient awakes shoitly aftei falling asleep uue to S0B) - PNI is uisplaceu to the left uue to caiuiomegaly - SS (ventiiculai gallop) - S4 (atiial systole into a non-compliant left ventiicle) - Ralesciackles (an inuication of pulmonaiy euema) - Bullness on peicussion +5.($K&5X%X (Z - Peiipheial euema (pitting) - }ugulai venous uistention - Ascites - Bepatomegaly - Right ventiiculai heave
All valvulai heait uiseases piesent with shoitness of bieath initially. In young people, the most commonly encounteieu valve uisoiueis aie: Nitial piolapse, mitial stenosis, oi bicuspiu aoitic valves. 3<8?<8 -:B7:ADBF: IvI - 0nly heaiu with specific maneuveis (ie valsalva) IIvI anu IIIvI - This is wheie the majoiity of muimuis lie. IvvI - Palpable thiill is piesent vvI - Nuimui can be heaiu with the stethoscope paitially off the chest vIvI - Nuimui can be heaiu without a stethoscope
/5$+)3 +%.7+.5$)$5"# [ A holosystolic "blowing muimui" that is best heaiu at the apex of the heait. )"+$5! &$%#"&5& - The "ciescenuo-ueciescenuo" systolic ejection muimui following an ejection click. ]&X - A holosystolic muimui /5$+)3 *+"3)*&% - A late systolic muimui with a miusystolic click )"+$5! +%.7+.5$)$5"# - Bigh-pitcheu blowing uiastolic muimui /5$+)3 &$%#"&5& - A late iumbling uiastolic muimui following an opening snap *X) - A machine-like muimui (0*%+$+"*(5! "2&$+7!$5]% !)+X5"/0"*)$(0 - An autosomal uominant tiait that can iesult in suuuen ueath in young athletes. The walls of the Lv anu inteiventiiculai septum hypeitiophy, cieating a "banana shape" in the ventiicle.
,+#&-+, +##)G()3-+2 (@EHF@88HFBH?D@A: - Atiial Fibiillation - Atiial Fluttei - Nultifocal Atiial Tachycaiuia - Paioxysmal Supiaventiiculai Tachycaiuia - Wolff-Paikinson-White Synuiome - ventiiculai Tachycaiuia - ventiiculai Fibiillation *8@=F@88HFBH?D@A: - Sinus Biauycaiuia - Sick Sinus Synuiome - Av Blocks (1 st , 2 nu , anu S iu uegiee blocks)
)$+5)3 Z52+533)$5"# An iiiegulai, iapiu ventiiculai iate is causeu by multiple foci in the atiia that fiie eiiatically. The atiial iate is as high as 4uubpm. Patient will expeiience: - Palpitations - Bizziness - Exeitional uyspnea - Iiiegulaily iiiegulai pulse uoals of tieatment aie: 1. ventiiculai iate contiol 2. Restoiation of noimal sinus ihythm S. uive anticoagulation (if neeueu)
)$+5)3 Z37$$%+ 0ne foci in the atiium fiies automatically, causing an atiial iate of 2Su-SSubpm, with only 1 out of S of these contiactions making it to the ventiicle. The EKu will show with the classic "sawtooth" pattein.
/73$5Z"!)3 )$+5)3 $)!(0!)+X5) This is a conuition that occuis most commonly in those with C0PB. Theie will be at least thiee uiffeient P-wave moiphologies with vaiiable PR anu RR inteivals. Can uiagnose with vagal maneuveis anuoi auenosine auministiation to show the an Av block without uisiupting the atiial tachycaiuia.
*)+"f0&/)3 &7*+)]%#$+5!73)+ $)!(0!)+X5) Is uue to a ieentiant ciicuit within the Av noue. Theie will be naiiow QRS complexes with no uisceinable P waves on EKu. This conuition may be causeu by the following: - Bigoxin toxicity - Ischemic heait uisease - Atiial fluttei - Piesence of accessoiy pathways - Excessive consumption of alcohol oi caffeine
Y"3ZZK*)+b5#&"#KY(5$% &0#X+"/% Theie is an accessoiy pathway fiom the atiia to the ventiicles that cause piematuie ventiiculai excitations uue to a lack of uelay in the Av noue. Theie aie two mechanisms by which this conuition can cause a paioxysmal tachycaiuia: 1. 2<N8@97:B8DE<I@8 (@EHFE@8=D@A - All impulses get thiough to the ventiicle in this conuition, wheieas in noimal ciicumstances only one Atiial impulse gets thiough. 2. "8BH>=8>?DE #7EDN8>E@BD>: (@EHFE@8=D@ - cieates a ie-entiy loop that causes multiple uepolaiizations of the atiia.
]%#$+5!73)+ $)!(0!)+X5) This conuition is uefineu as a iapiu anu iepetitive fiiing of thiee oi moie piematuie ventiiculai contiactions in a iow, at a iate of 1uu-2Subpm. Is iesponsible fio up to 7S% of caiuiac aiiest. The most common causes of ventiiculai tachycaiuia aie: - Caiuiomyopathies - Bypotension - CAB - Piolongeu QT synuiome - Biug toxicities &FJA@e&EDNC?D@: - Palpitations - Byspnea - Angina - Syncope - Wiueneu anu eiiatic QRS complex on EKu ** A iapiu, polymoiphic foim of ventiiculai tachycaiuia can leau to a conuition known as "Toisaues ues Pointes".
]%#$+5!73)+ Z52+533)$5"# 0ccuis when theie aie multiple foci within the ventiicles that fiie iapiuly, which leaus to a chaotic quiveiing of the ventiicles. Nost cases of vFib occui as a iesult of ventiiculai tachycaiuia. This conuition is fatal when untieateu. ** Association of vFib with an NI cieates a favoiable long-teim piognosis, wheieas no association between the two gives a high iate of iecuiience. &FJA@e&EDNC?D@: - Lack of pulse, heait sounus, anu BP - Patient loses consciousness anu will uie without inteivention ** Immeuiate uefibiillation anu CPR shoulu be peifoimeu to pievent suuuen ueath. Theie aie no meuications that can conveit this conuition to noimal ihythm. ** Note that all AB>>?T O?DNLHP CBOIEOB>MFB@ will oiiginate fiom above the ventiicle, wheieas TFMH O?DNLHP CBOIEOB>MFB@ oiiginate within the ventiicles.
*8@=F@88HFBH?D@A:
&5#7& 2+)X0!)+X5) Is a sinus iate of < 6u bpm, anu becomes uangeious when the iate uiops below 4S bpm. Common causes of sinus biauycaiuia aie: Ischemia, Incieaseu vagal Tone, Anti-aiihythmics ** Patients aie usually symptomatic anu may piesent with only fatigue ** Atiopine will block vagal stimulation anu thus elevate the sinus iate.
&5!b &5#7& &0#X+"/% This is a uysfunction of the sinus noue that causes peisistent spontaneous bouts of sinus biauycaiuia. Patient will expeiience uizziness, confusion, fatigue, anu CBF.
)] 23"!b& X AB =7M877 - A benign conuition wheie the PR inteival is piolongeu to >u.2u seconus Z := =7M877 - Theie aie Nobitz type 1 anu Nobitz type 2 A.M('S !>%# T - piogiessive piolongation of PR inteival until theie is an absent P wave. Boes not iequiie tieatment. A.M('S !>%# U - theie is a missing P wave without any changes in the pieceuing PR inteival, causing the uiopping of a QRS complex all of a suuuen. Nay piogiess anu become a complete heait block. +HRSF>H@ NBOHDB\H> FDNLBAC. ] 8= =7M877 O,>?NI7B7 H7@8B QI>EmP - theie is an absence of atiial impulses to the ventiicle, thus theie is no ielationship between P waves anu QRS complexes. +HRSF>H@ NBOHDB\H>Q
,+#&-"3G"/+()-$2
(0*%+$+"*(5! !)+X5"/0"*)$(0 Asymmetiic caiuiomyopathy that involves the inteiventiiculai septum iesults in uiastolic uysfunction. The walls of the left ventiicle become thickeneu. A banana shape occuis in the Lv, can iesult in suuuen ueath in young athletes. X53)$%X !)+X5"/0"*)$(0 Bilation of the heait that is most commonly causeu by: )LO?I?LV )M>FBDEOFAV +BMFBCF?AV !IBJBc@ MF@HB@HV !?P@BO\FH 2 GF>S@. This conuition iesult in systolic uysfunction. +%&$+5!$5]% !)+X5"/0"*)$(0 Nyocaiuial infiltiation iesults in impaiieu uiastolic filling of the ventiiculai uue to a ueciease in ventiiculai compliance. Common causes aie: )DEL?FM?@F@V &B>O?FM?@F@V (HD?OI>?DBC?@F@V &OLH>?MH>DBQ
)!7$% *%+5!)+X5$5& Is an acute conuition that iesults in chest pain, uiffuse ST-elevations anu PR uepiession on EKu, a peiicaiuial fiiction iub, anu possible peiicaiuial effusion. Nay be causeu by any of the following: - Nost cases occui aftei a viial illness (most commonly an 0RI) - Infectious (Coxsackie viius, hepatitis, BIv, TB, toxoplasmosis, oi fungal infections) - Collagen vasculai uisease - Post-suigeiy - Amyloiuosis - Lupus - Post-NI (known as Biesslei's synuiome) ** Recoveiy occuis within 1-S weeks anu iequiies only NSAIBs foi management. Complications may incluue: - Effusion - Tamponaue occuis in 1u%-2u% of patients
!"#&$+5!$5]% *%+5!)+X5$5& 0ccuis seconuaiy to fibious scaiiing of the peiicaiuium, leauing to iigiuity anu thickening of the peiicaiuium. Theie aie a few possible causes, incluuing: - Connective tissue uisoiueis - Chionic peiicaiuial effusion - Rauiation theiapy - 0iemia - Piioi heait suigeiies &FJA@e&EDNC?D@: - Symptoms of hepatic congestion (euema, ascites) - Pulmonaiy congestion - }vB - Peiicaiuial knock
*%+5!)+X5)3 %ZZ7&5"# 0ccuis when peiicaiuial space becomes occupieu with fluiu. 0ccuis when theie is ascites anu pleuial effusion piesent. 0ften occuis when the patient has CBF, nephiotic conuitions, anuoi ciiihosis. &FJA@e&EDNC?D@: - Peiicaiuial fiiction iub - Nuffleu heait sounus - Point of maximal impulse (PNI) is softeneu
!)+X5)! $)/*"#)X% Is a peiicaiuial effusion that impaiis uiastolic filling of the heait. Piessuie of all chambeis, the pulmonaiy aiteiy, anu peiicaiuium aie equal in piessuie, thus ventiiculai filling is impaiieu. !?DD?A OBS@H@: - Fiee-wall iuptuie aftei an NI - Neuical eiiois causing punctuie to heait - Penetiating injuiies &FJA@e&EDNC?D@: - Bypotension - }vB - Nuffleu heait sounus ** Known as "Beck's Tiiau" - Naiioweu pulse piessuie - Pulsus paiauoxus (exaggeiateu ueciease in aiteiial piessuie uuiing inspiiation > 1ummBg) - Nuffleu heait sounus - Caiuiogenic shock
#)$13+(-, )$+#( &-2$+2$ Rheumatic feveiheait uisease is a conuition that occuis as a consequence of phaiyngitis fiom a gioup A stiep infection. The mitial valve is the most common valve affecteu. The piogiession to a heait uisease is an immune-meuiateu piocess, not a iesult of the bacteiial infection. Biagnosing is maue with the }0NES ciiteiia, anu iequiie the piesence of two majoi ciiteiia 0R one majoi anu one minoi ciiteiia:
$4&",+#&-(-2 Is an infection of the enuocaiuium that can be classifieu as eithei acute oi subacute. Nost often, the mitial valve is involveu, wheieas an infection of the tiicuspiu valve is usually uue to Iv uiug abuse. +E<B7 $:=>E@8=DBDA - Causeu by &CBNI )S>HS@ anu cieates laige vegetations on a pieviously healthynoimal valve. 2<Q@E<B7 $:=>E@8=DBDA - Causeu by ]F>FMFBA@ J>?SN &C>HN anu cieates small vegetations on an abnoimaluiseaseu valve. ** 0ccuis with uental pioceuuies The symptoms of bacteiial enuocaiuitic can be iemembeieu with the mnemonic "!#"3 6+4$". ! - Fevei # - Roth's spots (ietinal hemoiihages) " - 0slei's noues (painful, iaiseu ieu lesions on hanus anu feet) 3 - Nuimui 6 - }ane way lesions (non-tenuei lesions on palms anu soles) + - Anemia 4 - Nail-beu hemoiihage $ - Emboli
** 3FWDBAK&BO\@ %AM?OB>MFCF@ - is a foim of enuocaiuitis seen in patients with Lupus, wheie theie aie vegetations founu on both siues of the valve, leauing to stenosis.
$3*".- Emboli aie things that tiavel thiough the ciiculation an get lougeu in the pulmonaiy vasculatuie, leauing to a pulmonaiy embolus (PE). The most commonly encounteieu types of emboli aie: !@B (uue to long bone bieaks anu liposuction), +D8 (can occui as a iesult of injection of aii into the ciiculatoiy system), (H8>?Q<A (bieaks of fiom a ueep vein thiombosus), +?:D>BDE !I<D= (fiom piegnancy complications). ** #"$%: Thiombi causing a pulmonaiy embolism will piesent with chest pain anu shoitness of bieath in the patient. &5( A ueep vein thiombosis (BvT) is the piecuisoi to an emboli, anu is causeu by patients who have the following: 1. &CB@F@ (they uon't move enough - classically they took a long flight) 2. (ENH>O?BJSLBWFLFCE (uue to uisease states oi familial) 4Q %AM?CIHLFBL XBDBJH
2V-4 ,+4,$# The thiee types of skin cancei incluue: Squamous cell, basal cell caicinoma, anu melanoma. 2s<@?><A ,7II ,@8ED:>?@: Is a veiy common foim of skin cancei, anu is associateu with excess exposuie to sunlight. Is most commonly seen on the hanus anu face, actinic keiatosis is a piecuisoi to SCC. Is locally invasive but iaiely will it metastasize.
*@A@I ,7II ,@8ED:>?@: Piesents as "peaily papules", anu is most commonly seen in sun-exposeu aieas of the bouy.
37I@:>?@: Nelanoma poses the gieatest iisk of metastasis. Those with faii skin aie at highest iisk. Theie is a uiiect coiielation between the uepth of the lesion anu the uegiee of metastasis.
*#+-4 ,+4,$#2 ,HDI=H>>= Q8@D: E@:E78AR 1. Astiocytoma 2. Neuulloblastoma S. Epenuymoma 4. Bemangioma S. Cianiophaiyngioma
)@C>?OEC?DB - This type of biain cancei is usually founu in the posteiioi fossa, anu it comes with a goou piognosis. /HMSLL?WLB@C?DB - This can cause hyuiocephalus as it often piesses on the fouith ventiicle. The cells aiiange in a 'Rosette' anuoi 'Pseuuoiosette" pattein. It is a highly malignant ceiebellai tumoi. %NHAMED?DB - 0sually founu in the fouith ventiicle, it ueiives fiom epenuymal cells anu can also cause hyuiocephalus uue to its location. (HDBAJF?WLB@C?DB - Can leau to polycythemia because it piouuces eiythiopoietin. It is usually ceiebellai, but can be associateu with a ietinal angioma (which gives it an association to von Bippel Linuau synuiome) !>BAF?NIB>EAJF?DB - Is a supiatentoiial tumoi that is benign anu often confuseu with a pituitaiy auenoma. Is ueiiveu fiom the iemnants of Rathke's pouch. +=<IBH>>= Q8@D: E@:E78AR *FCSFCB>E BMHA?DB - Nost commonly as piolactin-secieting foim, the most common piesentation is bitempoial hemianopsia. .LF?WLB@C?DB /SLCFU?>DH - Is the most common piimaiy biain tumoi, has a teiiible piognosis. This is founu in the hemispheies anu often ciosses the coipus callosum (giving it the teim 'butteifly glioma'). /HAFAJF?DB - Comes fiom aiachnoiu cells, making it exteinal to the biain. Is the 2 nu most common biain tumoi in auults. "LFJ?MHAM>?JLF?DB - Is a slow giowing anu iaie tumoi, seen usually in the fiontal lobe of the biain. &OITBAA?DB - Is the S iu most common auult biain tumoi, oiiginating fiom Schwann cells. When locateu neai the 8 th cianial neive can cause an acoustic schwannoma.
(13"#2 "! ()$ *"4$
*$4-4T (13"#2 "! *"4$ $:EH>:=8>?@ Is a caitilaginous tumoi founu in the intiameuullaiy bone, most often in uistal extiemities. "AB7>EH>:=8>?@ In men <2Syi of age, is the most common benign tumoi of bone. 0iigination is fiom the long metaphyseal bone. TD@:B ,7II (<?>8 0ccuis fiom 2u-4uyi of age. 0sually founu in uistal femuipioximal tibia. Bas the classic "uouble bubble" sign on xiay. 3+.-T4+4( (13"#2 "! *"4$ "AB7>A@8E>?@ The most common malignant bone tumoi, occuiiing in 1u-2uyi olus. Is most commonly seen in the metaphysis of long bones. $KD:M[A 2@8E>?@ In males <1Syi of age, has the 11;22 tianslocation. Is likely to metastasize eaily, anu has the chaiacteiistic 'onion skinning on xiay. Seen in uiaphysis of long bones, iibs, pelvis, anu scapula. ,H>:=8>A@8E>?@ A malignant tumoi of caitilaginous bone, seen in males >Suyi of age. Not seen in the long bones.
(13"# 3+#V$#2 The following list aie the common maikeis that aie useu to eithei make a uiagnosis of a ceitain cancei, oi to monitoi the effectiveness of theiapy. T0N0R NARKER WBAT IS WATCBES Caicinoembiyonic Antigen (CEA) Coloiectal anu pancieatic canceis Piostatic Specific Antigen (PSA) 0seu foi scieening of piostatic cancei CA-12S Betects ovaiian cancei anu malignant epithelial tumois. Alkaline Phosphatase Bone metastasis, bile uuct obstiuction, Paget's bone uisease "-hCu Byuatifoim moles, uTB's, anu choiiocaicinomas !-feto piotein Non-seminomatous geim cell tumois of the testicles Taitiate-iesitant aciu phosphatase Baiiy cell leukemia
(13"# 21//#$22"#2 Tumoi suppiessois woik by suppiessing the giowth of ceitain tumois, when theie is a loss of function, both alleles of the gene have been changeu (ie mutation, ueletion, etc) T0N0R S0PPRESS0R T0N0R IT S0PPRESSES Rb Retinoblastoma BRCA 1 anu 2 Bieast cancei, ovaiian cancei pSS Belps scieenfollow almost all canceis APC Coloiectal cancei NF1 anu NF2 Neuiofibiomatosis 1 anu 2 WT1 Wilm's tumoi
"4,"T$4$2 0NC0uENE ASS0CIATEB T0N0R Ret NEN synuiomes type 2 anu S c-myc Buikitt's lymphoma L-myc Lung tumois N-myc Neuioblastoma Bcl-2 Folliculai lymphomas Eib-B2 Bieast, ovaiy, gastiic Ras Colon
2?@II ,7II ,@8ED:>?@ - linkeu to smoking, can piouuce ACTB anu ABB, may be linkeu to Lambeit-Eaton synuiome
2s<@?><A ,7II ,@8ED:>?@ - linkeu to smoking anu the piouuction of ectopic PTiP.
+=7:>E@8ED:>?@ - is the most common peiipheially aiising cancei of the lung.
.@8M7 ,7II ,@8ED:>?@ - is an unuiffeientiateu caicinoma of the lung.
*8>:EHD>@I97>I@8 ,@8ED:>?@ - this is the lung cancei that is not thought to be ielateu to smoking
Lung cancei can cause a wiue aiiay of symptoms (asiue fiom cough, hemoptysis, wheezing, bionchial obstiuction). The most common symptoms that can aiise fiom lung cancei aie: - *BAO?B@Cc@ CSD?> (a caicinoma that oiiginates in the apex of the lung anu can compiess the ceivical sympathetic plexus, iesulting in Boinei's synuiome) - &SNH>F?> GHAB OBGB @EAM>?DH - (?>AH>c@ @EAM>?DH (Ptosis, Anhyuiosis, Niosis) - *B>BAH?NLB@CFO MF@?>MH>@ (PTiP, ABB, ACTB) - +HOS>>HAC LB>EAJHBL AH>GH @EDNC?D@ (hoaiseness)
"*2(#1,(-5$ +4& #$2(#-,(-5$ .14T &-2$+2$ "*2(#1,(-5$ - this conuition causes an obstiuction of aii -low that iesults in aii- tiapping in the lungs. Theie will always be an incieaseu in total lung volume with a Z%],eZ]! ?U p;=tQ The categoiies of obstiuctive lung uisoiueis aie: Xn ,H8>:DE *8>:EHDBDA: This conuition is chaiacteiizeu by the piesence of a piouuctive cough foi at least S consecutive months foi 2 oi moie yeais. Theie is a hypeitiophy of the mucus-secieting glanus of the bionchioles, giving a Reiu inuex of > Su%. Patient will have wheezing, ciackles, anu cyanosis on physical exam. *This patient is a "blue bloatei" because they become cyanotic. Zn $?NHFA7?@R This conuition iesults in a uestiuction of alveolai iecoil iesulting in the enlaigement of aii spaces uue to smoking anuoi an !1- antitiypsin ueficiency (causes inciease in elastase activity). Patient will have uyspnea, tachycaiuia, uecieaseu bieath sounus. ]n +ABH?@R This iesults in constiiction of the bionchioles uue to hypeiiesponsiveness. This conuition is ieveisible. Tiiggeieu often by activity, but also tiiggeieu by illness anuoi alleigens. Finuings incluue cough, wheezing, hypoxemia, anu uyspnea. ^n *8>:EHD7EB@ADAR A conuition that iesults in uilateu aiiways, iecuiient infections, hemoptysis, anu puiulent sputum. Causeu by a chionic neciotizing infection of the bionchi. This conuition is ielateu to cystic fibiosis, Kaitagenei's synuiome, anu bionchial obstiuction.
#$2(#-,(-5$ a Restiictive lung uisease pievent the expansion of the lungs, iesulting in loweieu lung volumes anu a Z%],eZ]! l ;=tQ The categoiies of iestiictive lung uiseases aie: 1. $JB8@N<I?>:@8FR This means conuitions that affect the bieathing mechanics anu the suppoit of the lungs. Conuitions that weaken the muscles such as myasthenia giavis, anu conuitions that altei the suppoitive stiuctuie of the lungs such as scoliosis anu ankylosing sponuylitis. 2. -:B78ABDBD@IR Anything that alteis the inteistitium can cause a iestiictive lung uisease. Examples: ARBS, pneumoconioses, saicoiuosis, uooupastuie's synuiome, Wegenei's gianulomatosis.
/4$13"4-+ Pneumonia piesents in many uiffeient ways, such as: lobai, inteistitial, anu as bionchopneumonia. .>Q@8 /:7<?>:D@: Consoliuation of infection to one aiea of the lobe, often the lowei lobe. The most common cause is Stiep Pneumonia. Patient uevelops symptoms acutely (shaking chills, fevei, chest pain). *8>:EH>N:7<?>:D@: Theie is patchy infiltiation in moie than one lung. The NCC is Staph Auieus. +BFNDE@I /:7<?>:D@: Also known as inteistitial pneumonia, piesents with uiffuse patchy infiltiation localizeu to inteistitial aieas at the alveolai walls. Piesentation is atypical in that the patient is less sick anu slowei to uevelop symptoms than with lobai pneumonia.
()$ ,)$2( $0+3 A few teims must be unueistoou in oiuei to be able to uiffeientiate between the uiffeient pathologies of the iespiiatoiy system. !87?DB<A - Is a vibiation that is felt when the patient speaks. It is elevateu when a patient has pneumonia, uecieaseu in effusion anu obstiuction, anu completely absent in pneumothoiax. vibiation is felt as a iesult of fluiu accumulation. #7A>:@:E7 - The same sounu as maue by a uium. When theie is nothing in the lung cavity, such as with a pneumothoiax, theie is "hypeiiesonance". When theie is fluiu accumulation, such as when theie is a pneumonia oi effusion, theie is uecieaseu iesonance (ie Bullness). Think of a uium with anu without watei insiue to visualize what is insiue the lung. *87@BH 2><:=A - This can be figuieu out with common sense. When theie is an obstiuction, theie will be no bieath sounu. When theie is a pneumothoiax, theie will be uecieaseu bieath sounus. (8@EH7@I &79D@BD>: - Pay close attention to the tiachea uuiing the pulmonaiy examination. A ueviation can inuicate a pneumothoiax. A pneumothoiax will push the tiachea away fiom the affecteu siue, while a bionchial obstiuction will pull the tiachea towaius the siue of the lesion.
T""&/+2(1#$[2 2G4&#"3$ A conuition that affects both the lungs anu the kiuneys. Leaus to hemoptysis as the piimaiy lung finuing, with hematuiiaanemia anu ciescentic glomeiulonephiitis as the kiuney finuings. Seen most commonly in males fiom 2u-4uyi of age. Causeu by anti-glomeiulai basement membiane antibouies, which piouuce lineai staining on immunofluoiescence.
4$1#"."TG
&$T$4$#+(-5$ &-2$+2$2 )3m(%5/%+c& X5&%)&% - Is a veiy common cause of ueath - Pievalence incieases with age - Family histoiy is a big contiibuting factoi to the possible uevelopment. - Biffuse ceiebial atiophy occuis seconuaiy to neuional loss - Neuiofibiillaiy tangles aie classically founu &FJA@e&EDNC?D@: - Bevelops slowly ovei time - Beath usually occuis within S-1u yeais fiom onset - The auvanceu stages will iequiie the patient to have uepenuence on otheis &CBJH@: $@8IF - milu foigetfulness, patient will have uifficulties leaining new infoimation -:B78?7=D@B7 - piogiessive impaiiment in memoiy .@B7 - patient will iequiie assistance in theii activities of uaily living +=9@:E7= - patient will expeiience complete uebilitation anu uepenus completely on otheis
*5!b& X5&%)&% - Fiontal anu tempoial lobe uysfunction causeu by uegeneiation - Accumulation of tau pioteins - Pick bouies aie chaiacteiistic - Nemoiy impaiiment + impulsive behavioi + behavioial changes
3"("# 4$1#"4 &$T$4$#+(-5$ &-2"#&$#2
)/0"$+"*(5! 3)$%+)3 &!3%+"&5& ALS is also known as Lou uehiig's uisease, which is a fatal neuiouegeneiative uisease of both the uppei anu lowei motoi neuions. *"35"/0%35$5& Polio is a viius that affects the anteiioi hoin cells anu motoi neuions of the spinal coiu anu biainstem - Causes LNN symptoms ZHBCS>H@ ?U *?LF?: - Asymmetiic muscle weakness (most commonly the legs) - Nuscle atiophy - Absent of BTR's - Flacciuity r&HA@BCF?A F@ FACBOC r
Y%+X#5.K("ZZ/)# X5&%)&% A genetic conuition that piesents in infancy anuoi eaily chiluhoou. - Piogiessive skeletal muscle atiophy uue to anteiioi hoin cell uegeneiation - 0ften piesents with floppy baby at biith (congenital hypotonia) - Lack of sucking ability - Tongue fasciculation's - Beath occuis at a young age uue to iespiiatoiy muscle failuie
*+2+. T+4T.-+ &$T$4$#+(-"4
*)+b5#&"#c& X5&%)&% - Loss of uopamineigic neuions fiom the substantia nigia - 0sually piesents in miu-late life (ie >Suyi) - Biagnosis is completely clinical anu baseu on symptoms &FJA@e&EDNC?D@: - Resting tiemoi (pill iolling) - Cogwheel iigiuity - Biauykinesia - Bifficulty in initiating movement - Nask-like facies - Biain biopsy will show Lewy bouies ceitain meuications can cause Paikinsonism: Reseipine, Netoclopiamiue, Balopeiiuol, Peiphenazine, NPTP
(7#$5#.$"#c& !("+%) - Is a genetic conuition (AB) wheie theie is atiophy of the cauuate nucleus - Bisease onset is between Su-Suyi with a steauy woisening of symptoms anu ueath within 1S yeais of onset. &FJA@e&EDNC?D@: - Piogiessive uementia - Choiea of the limbs, face, heauneck, anu tiunk - Behavioi uistuibances such as: Bepiession, aggiession, psychosis, changes in peisonality. - Bepiession occuis anu suiciue is somewhat common because patients aie awaie of theii ueteiioiation Theie is no tieatment, only symptomatic management.
2/-4",$#$*$..+# &-2$+2$2
Z+5%X+%5!(c& )$)f5) - Is an autosomal iecessive conuition that begins by young auulthoou. Impaiieu: Piopiioception, vibiatoiy sense, ataxia, anu nystagmus
%*5X7+)3 (%/)$"/) - Bloou accumulates above the uuia - Ruptuie of miuule meningeal aiteiies - Patient usually expeiiences a luciu inteival - Lens shapeu bleeu - 0sually causeu by a fiactuie of the tempoial bone
&72X7+)3 (%/)$"/) - Symptoms occui giauually - Teaiing of the biiuging veins - Seen in elueis anu alcoholics expeiiencing blunt tiauma - Ciescent shapeu
&72)+)!(#"5X (%/"++().% - Aneuiysm iuptuie anuoi AvN iuptuie - Classic piesentation is "woist heauache of patients life" - LP will show xanthochiomia
*$##G +4$1#G23 Aneuiysms aie focal weaknesses in the vasculatuie that iesult in outpouchings. The Beiiy aneuiysm is seen at the bifuication of the anteiioi communicating aiteiy. - Ruptuie leaus to hemoiihagic stioke - Cieates the "woist heauache of my life" - Associateu with Ehlei's uanlos, Naifan's, anu APKB - Is a suigical emeigency
&-2$+2$2 "! &$3G$.-4+(-"4
The most common uemyelinating uiseases aie /SLCFNLH &OLH>?@F@ anu *>?J>H@@FGH /SLCFU?OBL 3HS\?HAOHNIBL?NBCIE, .SFLLBFAK2B>>H @EAM>?DH, /HCBOI>?DBCFO 3HS\?ME@C>?NIE, anu *?@CK5AUHOCF?S@ %AOHNIBL?DEHLFCF@.
/73$5*3% &!3%+"&5& - Nultifocal zones of uemyelination scatteieu thioughout the white mattei - Commonly involves the pyiamiual anu ceiebellai pathways, meuial longituuinal fasciculus, optic neive, anu the posteiioi columns - Piesents with tiansient sensoiy ueficits, fatigue, weakness, anu spasticity - visual uistuibances (monoculai vision loss, ipsilateial meuial iectus palsy on lateial gaze) - 0sually piesents in the 2us anu Sus in a ielapsing fashion - Biagnosing is maue mostly with NRI - Nanagementtieatment is with coiticosteioius ,I@AADE (8D@=: Scanning Speech, Intention Tiemoi, Nystagmus
*+".+%&&5]% /73$5Z"!)3 3%7b"%#!%*()3"*)$(0 - Is the ieactivation of a latent viial infection - Seen in appioximately 4% of AIBS patients - Associateu with }C viius
.7533)5#K2)++% &0#X+"/% - Is an ascenuing inflammation anu uemyelination of the peiipheial neives anu motoi fibeis of vential ioots - Piesents in an ascenuing fashion - Causes symmetiical muscle weakness that staits in the lowei extiemities - Piesents most commonly following an uppei iespiiatoiy infection - The most common cause of ueath is uue to paialysis of iespiiatoiy muscles (thus monitoiing iespiiatoiy function is essential to safety of the patient)
/%$)!(+"/)$5! 3%7b"X0&$+"*(0 - A lysosomal stoiage uisease that affects the giowth anu uevelopment of myelin - Bue to ueficiency of the enzyme aiylsulfatase A, which causes accumulation of sulfatiues in the tissues anu thus uestioys myelin sheath - Affects both CNS anu PNS - Chiluien with the "late infantile foim" may have uifficulty in walking aftei the fiist yeai of life - Nuscle wasting, weakness, muscle iigiuity, uevelopmental uelays, anu piogiessive loss of vision, ouynophagia, paialysis, anu uementia aie all possible complications - }uvenile foim (S-1uyis) get mental ueteiioiation anu can uevelop uementia - Auult foim (>16yi) piesents as a psychiatiic uisoiuei oi piogiessive uementia - No cuie foi this conuition
*"&$K5#Z%!$5"7& %#!%*()3"/0%35$5& - An immune-meuiateu uisease of the biain - 0ccuis following a viial infection most commonly - Is similai to multiple scleiosis in that it involves autoimmune uemyelination - Symptoms begin 1-S weeks post-infection - Fevei, heauache, uiowsiness, seizuie, anu coma
2$-\1#$2
&5/*3% *)+$5)3 - Affects a small iegion of the biain (tempoial lobe anuoi hippocampi) - Patient iemains awake, seizuie is veiy suuuen anu biief - Patient may expeiience feelings of feai, nausea, unusual feelingssensations, alteieu sense of heaiing, smell, taste, vision, anu tactile peiception. - Sense of spatial uisoiientation is often seen - Patient may expeiience the inability to speak - The seizuie is usually iemembeieu in uetail
!"/*3%f *)+$5)3 - Limiteu to one ceiebial hemispheie anu causing impaiiment of awaieness - 0ften pieceueu by an auia
)2&%#!% &%5m7+% - Also known as "petit mal" seizuie - Patient will staie blankly foi a few seconus - Post-seizuie, the patient will ietuin to whichevei activity they weie uoing piioi to the onset of the seizuie ** Classic 0SNLE question, tieatment is with Ethosuxamiue
$"#5!K!3"#5! &%5m7+% - "uianu-mal" seizuie, it affects the entiie biain - Is the most well-known type of seizuie that occuis with epilepsy - Associateu with an auia Tonic Phase - Patient loses consciousness, tension of skeletal muscles occuis. Lasts only a few seconus. Clonic Phase - Rapiu contiactionielaxation of muscles, eyes ioll to the back of the heau, tongue is often bitten uue to jaw contiactions. Incontinence may occui at this phase. - Patient will be confuseu anu will have no memoiy of the seizuie - Initial management is with a benzouiazepine given Iv
/0"!3"#5! - Is a biief anu involuntaiy twitching of the muscles - Piesents with abnoimal movements on both siues of the bouy at the same time - 0ccuis commonly while patient is falling asleep - Is not an actual uisoiuei, iathei is a sign of othei potential neivous system uisoiueis
+/)+2-+
Aphasias aie acquiieu language uisoiueis wheieby theie is an impaiiment of eithei uifficulty piouucing oi compiehenuing spoken oi wiitten language. The two types clinically encounteieu aie Expiessive Aphasia (Bioca's), anu Receptive Aphasia (Weinicke's). %PN>H@@FGH )NIB@FB [ Patient has complete intact compiehension with the inability to speak in an unueistanuing fashion. The site of pathology is the infeiioi fiontal gyius. $xpiessive = -nfeiioi fiontal gyius. E=I (two vowels) +HOHNCFGH )NIB@FB - Patient has complete intact ability to speak unueistanuable with the inability to compiehenu language. The site of pathology is the supeiioi tempoial gyius. #eceptive = 2upeiioi (empoial gyius. #2(
,$4(#+. 2.$$/ +/4$+
Buiing cential sleep apnea, the biain's iespiiatoiy contiol centeis aie imbalanceu uuiing sleep. The neuiological feeuback mechanism uoes not iesponu to levels of C02 anu thus cannot ieact to uiive the iespiiatoiy iate. Following this pathology, bieathing iate will inciease anu excess C02 will be expelleu fiom the bouy.
*$..[2 /+.2G
Is a conuition of hemifacial weaknesspaialysis of the muscle that aie inneivateu by CN7, uue to inflammation of the neive. - Patient will expeiience an acute onset of unilateial facial weakness anu paialysis, affecting both uppei anu lowei face. - Iuiopathic, Lyme uisease, AIBS, saicoiuosis, anu uiabetes aie all possible causes !?DNB>FAJ C? 7/# BAM 3/# LH@F?A@: 134 I7AD>: - will affect the lowei half of the contialateial face .34 I7AD>: - will affect the uppei anu lowei face on the ipsilateial siues
)"#4$#[2 2G4&#"3$
Boinei's synuiome is a clinical synuiome causeu by uamage to the sympathetic neivous system. 0n most occasions, Boinei's synuiome is a benign conuition, but it can occui as a iesult of moie seiious conuitions such as Pancoast tumoi oi thyioceivical venous uilatation. These conuitions cause compiession of the thoiacic sympathetic chain, which leaus to the symptoms of Boinei's synuiome: /B>ADA a uiooping of the eyeliu +:HF=8>ADA - the absence of sweating 3D>ADA - constiiction of the pupil
4$1#"(#+423-(($#2 +!!$,($& -4 &-2$+2$
Nany neuiotiansmitteis aie affecteu uuiing uiffeient uiseases, they incluue: &"/+3-4$ a Incieaseu in Schizophienia, uecieaseu in Paikinson's uisease 4"#$/-4$/)#-4$ - Incieaseu in anxiety, uecieaseu in uepiession +,$(G.,)".-4$ - Incieaseu in oiganophosphate poisoning, uecieaseu in Alzheimei's anu Buntington's uisease T+*+ - Becieaseu in Buntington's, uecieaseu in anxiety 2$#$("4-4 ObS)(P - Becieaseu in both anxiety anu uepiession
(+*$2 &"#2+.-2
Tabes uoisalis is a conuition wheieby theie is uegeneiation of the uoisal columns anu uoisal ioots of the spinal coiu. This occuis as a iesult of teitiaiy syphilis. Patient will expeiience all symptoms associateu with uoisal column malfunction (lack of piopiioception, ataxia uuiing locomotion). Patient will uevelop malfoimeu joints (Chaicot's joints) uue to lack of pain ieceptois, shooting pains, absence of ueep tenuon ieflexes, anu Aigyll Robeitson pupil that iesults fiom ieaction to accommouation but not to light.
2G#-4T"3G$.-+
Theie is a cavity that foims within the spinal coiu that may expanu anu elongate as time passes, thus uestioying the spinal coiu. This causes uamage to the spinothalamic tiact, which then iesults in a bilateial loss of pain anu tempeiatuie sensation in the uppei extiemities in a "cape-like" uistiibution. Associateu with an Ainolu-Chiaii malfoimation.
#$4+. /+()"."TG
/+()"."TG "! ()$ T."3$#1.12
4$/)#-(-, 2G4&#"3$2 )!7$% *"&$K&$+%* .3"/%+73"#%*(+5$5& - The most common cause of nephiitic synuiome - 0ccuis aftei a gioup A "-hemolytic stiep infection (uevelops 1u-14 uays aftei infection) - Affects chiluien between 2-6 yeais of age - Is self-limiteu conuition - Patient gets hematuiia, euema, hypeitension, anu low complement levels - Some cases may piogiess to iapiuly piogiessive glomeiulonephiitis
.""X*)&$7+%c& &0#X+"/% - Theie is a tiiau of Igu anti-glomeiulai basement membiane antibouies, pulmonaiy hemoiihage, anu ciescentic glomeiulonephiitis - The lung finuings will occui befoie the ienal finuings - Patient will have hemoptysis, iapiuly piogiessive ienal failuie, fevei, anu myalgias
/%/2+)#"*+"35Z%+)$5]% .3"/%+73"#%*(+5$5& - 0n election micioscopy, theie aie the classic "tiam-tiack" subenuothelial humps - Bas a slow piogiession to ienal failuie
2%+.%+c& X5&%)&% h5J) AHNI>?NBCIEi - Nesangial ueposits of IgA - Is a veiy milu uisease - 0ccuis aftei an infection
)3*"+$c& &0#X+"/% - A mutation of type 4 collagen - Patient can have neive ueafness anu oculai uisoiueis - Theie aie split basement membianes
4$/)#"(-, 2G4&#"3$2 /%/2+)#"7& .3"/%+73"#%*(+5$5& - veiy common cause of auult nephiotic synuiome - Light micioscope shows basement membiane thickening
/5#5/)3 !()#.% X5&%)&% - Is the most common cause of nephiotic synuiome in chiluien - Election micioscopy shows foot piocess effacement - This conuition iesponse exceptionally well to steioius
Z"!)3 &%./%#$)3 .3"/%+73)+ &!3%+"&5& - Noie common in patients with BIv - Light micioscope shows segmental scleiosis anu hyalinosis
X5)2%$5! #%*(+"*)$(0 - 0ccuis in uiabetics - Theie is basement membiane thickening anu Kimmelstiel-Wilson lesions on light micioscopy
&0&$%/5! 37*7& %+0$(%/)$"7& - Theie aie S patteins of ienal involvement - Light micioscope will show "wiie-loop" appeaiance with gianulai subenuothelial BN ueposits in membianous glomeiulonephiitis pattein
#$4+. ,$.. ,+#,-4"3+ Renal cell caicinoma is the most common of all ienal malignancies, occuiiing most commonly in men between Su-7uyi of age, anu is moie common in smokeis. - Associateu with von Bippel-Linuau - 0iiginates in ienal tubule cells /BAFUH@C@ B@: - Bematuiia - Palpable flank mass - Seconuaiy polycythemia (uue to piouuction of eiythiopoietin fiom kiuney) - Nany paianeoplasias aie common uue to piouuction of Piolactin, PTBiP, anu ACTB)
%-.3[2 (13"# This is the most common malignancy seen in young chiluien between 2-4yi of age. The following aie impoitant iegaiuing a Wilm's tumoi: - Theie is a ueletion of the WT1 gene that is founu on chiomosome 11 - Piesents with a huge, palpable flank mass Wilm's tumoi is often seen in conjunction with the WAuR complex: % - Wilm's tumoi + - Aniiiuia (absence of the iiis) T - uenitoiuiinaiy malfoimations # - Retaiuation (both mental anu motoi)
(#+42-(-"4+. ,$.. ,+#,-4"3+ Is a common cancei seen in the uiinaiy tiact (blauuei, uieteis, ienal pelvis, anu ienal calyces). The most common causes incluue: &D?\FAJV )LBAFAH XEH@V !EOL?NI?@NIBDFMHQ
/G$."4$/)#-(-2 An ascenuing infection that spieaus fiom the blauuei to the kiuneys. The most common cause of pyelonephiitis is an E. Coli infection. SignsSymptoms: - Flank pains (CvA tenueiness) - Fevei - Nauseavomiting - Patient will appeai quite ill ** Patients with vesicouieteial ieflux have an incieaseu tenuency to getting pyelonephiitis.
+,1($ (1*1.+# 4$,#"2-2 O+(4P Acute tubulai neciosis occuis when theie is an insult to the ienal tubules. Anything that can haim the kiuneys can cause ATN, things such as: Ischemia uue to shock, incieaseu myoglobins uue to muscle bieakuown, uiugs, toxins. ** Is the most common cause of acute ienal failuie.
+,1($ #$4+. !+-.1#$ Acute ienal failuie occuis most commonly fiom ATN (mentioneu above), anu occuis when a uecline in ienal function causes an inciease in the levels of B0N anu Cieatinine. $IH OBS@H@ ?U >HABL UBFLS>H: /87S87:@I +j>B7?D@ ! is when theie is a ueciease in ienal bloou flow, which leaus to a ueciease in the glomeiulai filtiation, anu thus ietention of watei anu souium in the kiuneys. B0N>Ci is > 2u />ABS87:@I +j>B7?D@ ! this conuition only occuis if theie is bilateial obstiuction, things such as piostatic hypeiplasia, neoplasia, anu stone (less likely) will cause a post-ienal azotemia. B0NCi is > 1S -:B8D:ADE ! this is uue to ATN (usually), anu the uiine will give this cause away by having gianulai casts oi epithelial casts. B0NCi is < 1S
%)+( )+//$42 %)$4 #$4+. !+-.1#$ -2 /#$2$4(f Renal failuie leaus to a builu-up of toxins anu leaus to the inability to exciete nitiogenous bases. )OSCH >HABL UBFLS>H is usually uue to hypoxemia, while OI>?AFO >HABL UBFLS>H is usually causeu by eithei hypeitension oi uiabetes. When theie is a builu-up of B0N anu Cieatinine, uiemia uevelops. When uiemia uevelops, the following symptoms may be piesent: - Anemia uue to failuie of EP0 piouuction by the kiuneys - CBFPulmonaiy euema uue to souium anu watei excess - Netabolic aciuosis - Bypeikalemia - 0steouystiophy uue to failuie of vitamin B piouuction by the kiuneys
V-&4$G 2("4$2 Theie aie a few uiffeient foims of kiuney stones, they aie: Xn ,+.,-13 2("4$2 ! the most common foim of kiuney stone, which may be eithei calcium oxalate oi calcium phosphate. Any uisease oi uisoiuei that leaus to hypeicalcemia can cause a calcium stone.
Zn 2(#15-($ 2("4$2 ! these aie maue of ammonium, magnesium, anu phosphate, anu they aie the 2 nu most common type of kiuney stone. They aie piouuceu by uiease-positive bugs such as Pioteus vulgaiis. These have a tenuency to foim "staghoin calculi" anu get stuck in the uiinaiy system. ]n 1#-, +,-& 2("4$2 ! piouuceu as a iesult of states of hypeiuiicemia, such as with gout. These stones aie also piouuceu when theie aie conuitions of incieaseu cell tuinovei, such as with leukemia. ^n CYSTINE ST0NES ! these occui seconuaiy to cystinuiia. +BMF?NBRSH @C?AH@ ! Calcium anu Stiuvite stones +BMF?LSOHAC @C?AH@ ! 0iic aciu anu cystein stones
+,-&L*+2$ /)G2-"."TG
/8>QI7? N) /,"Z o),"]Sp ,>?N7:A@BD>: ,@<A7A 37B@Q>IDE +ED=>ADA * * ** Patient will hypeiventilate to blow off C02 BKA, ASA oveiuose, lactic aciuosis #7AND8@B>8F +ED=>ADA * ++ + Bicaib absoiption in kiuney 0bstiuction of aiiway #7AND8@B>8F +Im@I>ADA + ++ * Kiuney secietes bicaib Bypeivent, high alt. 37B@Q>IDE +ED=>ADA + * ++ Pt will hypoventilate vomiting
)"% &" %$ ,"3/$42+($ !"# +,-&S*+2$ &-21#*+4,$2f The following numbeis uesciibe the appiopiiate compensation uepenuent on each metabolic uistuibance. 5U NBCFHAC IB@ DHCBW?LFO BOFM?@F@: PC02 = 1.S(BC0S-) + 8 +- 2
5U NBCFHAC IB@ DHCBW?LFO BL\BL?@F@: Foi eveiy 1mEqL inciease in BC0S-, the PC02 incieases u.7mmBg
5U NBCFHAC IB@ BOSCH >H@NF>BC?>E BOFM?@F@: An inciease of 1mEqL of BC0S- foi eveiy 1ummBg inciease in PC02
5U NBCFHAC IB@ OI>?AFO >H@NF>BC?>E BOFM?@F@d An inciease of S.SmEqL of BC0S- foi eveiy 1ummBg inciease in PC02
5U NBCFHAC IB@ BOSCH >H@NF>BC?>E BL\BL?@F@: A ueciease of 2mEqL BC0S- foi eveiy 1ummBg ueciease in PC02
5U NBCFHAC IB@ OI>?AFO >H@NF>BC?>E BL\BL?@F@d A ueciease of SmEqL BC0S- foi eveiy 1ummBg ueciease in PC02
"&$%")+$(+5$5& 0steoaithiitis is the most common type of aithiitis that is causeu by the weai anu teai of joints, which leaus to the uestiuction of the aiticulai caitilage anu the subchonuial bone foimation. This leaus to the foimation of osteophytes, as well as Bebeiuen's anu Bouchaiu's noues. (HWH>MHAc@ #?MH@ - malfoimations of the uistal inteiphalangeal joints 2?SOIB>Mc@ #?MH@ - malfoimations of the pioximal inteiphalangeal joints /87A7:B@BD>: >C "AB7>@8BH8DBDA: - Pain in weight beaiing joints - Asymmetiic involvement - Pain woise at the enu of the uay (impioves with iest)
+(%7/)$"5X )+$(+5$5& Is an autoimmune conuition that attacks the synovial joints of the bouy. - Pannus foimation in joints leaus to uefoimities of the metacaipophalangeal joints anu pioximal inteiphalangeal joints. - Foimation of subcutaneous nouules - 0lnai ueviation at the wiist joint - Seen in females >>> males /87A7:B@BD>: >C #H7<?@B>D= +8BH8DBDA: - Stiffness in the moining that impioves with use - Symmetiic involvement - Systemic symptoms aie piesent (fevei, fatigue, caiuiac conuitions, pulmonaiy conuitions)
."7$ A conuition wheieby monosouium uiate ciystals piecipitate anu accumulate insiue the joints, most commonly seen in the big toe, which is known as "pouagia". 0ltimately this is a conuition that occuis as a iesult of puiine metabolism uisoiuei. Causes: - Lesch-Nyhan synuiome - PRPP excess - Bypeiuiicemia - ulucose-6-phosphate ueficiency Piecipitating factois: - Biet high in piotein - Alcohol use - Excess coffee consumption - Consumption of uaiiy piouucts Biagnosis is baseu on joint aspiiation anu finuing of negatively biiefiingent neeule- shapeu ciystals in the aspiiate. NSAIBs aie best foi acute management, while uiugs that ueciease uiic aciu in the system will help pievent iecuiiences.
*&%7X"."7$ A conuition similai to gout, pseuuogout is causeu by the ueposition of calcium pyiophosphate ciystals insiue the joint space. The ciystals foimeu aie ihomboiu- shapeu anu basophilic. The laige joints aie most commonly affecteu.
2$#"4$T+(-5$ 2/"4&G."+#()#"/+()-$2
The gioup of seionegative sponuyloaithiopathies incluue: 1. Ankylosing Sponuylitis 2. Reitei's Synuiome (Reactive Aithiitis) S. Psoiiatic Aithiitis 4. IBB Aithiopathy S. 0nuiffeientiateu Sponuyloaithiopathy This gioups of aithiitis types has the following in common: - They aie iheumatic factoi negative - They have extia-aiticulai symptoms (visual, pulmonaiy, caiuiac, etc) - Association with BLA-B27 antigen - Inflammatoiy piocesses - Asymmetiical piesentation - Familial
)#b03"&5#. &*"#X035$5& - Low back pain anu stiffness (patient is bent ovei at the hips) - C-spine motion is limiteu uue to neck pains - Biminisheu chest expansion - Nost common extia-aiticulai involvement is in the eyes (anteiioi uveitis) - Best uiagnostic mouality is xiay of lumbai spine anu pelvis - Nanagement is with NSAIBs anu physical theiapy
+%5$%+c& &0#X+"/% - Is a clinical uiagnosis baseu on the piesentation of aithiitic symptoms that is pieceueu by an infection (salmonella, shigella, campylobactei, Chlamyuia, anu yeisinia) - Classic tiiau is Aithiitis, 0iethiitis, anu 0veitis (can't see, can't pee, can't climb a tiee) - Theie is a sequential involvement of new joints - Patient often has an accompanying set of symptoms such as fatigue, weight loss, anu oveiall sense of malaise
*&"+5)$5! )+$(+5$5& - Bevelops in patients who have aithiitis - 0nset is giauual anu seen long aftei patient uevelops aithiitis - Is similai in piesentation to iheumatoiu aithiitis - Nanagement is with NSAIBs
An autoimmune uisoiuei wheieby theie is multi-system anu multi-oigan inflammation anu tissue uamage. $ENH@: - SLE - Biscoiu Lupus (skin manifestation without systemic uisease) - Biug-Inuuceu - ANA-negative Lupus
YI? JHC@ FCn - 9u% of cases aie females of chilubeaiing age - Afiican-Ameiican's aie affecteu moie than Caucasians - Seveiity tenus to be less in oluei patients, anu moie in youngei patients ZFAMFAJ@: - Butteifly iash - Photosensitivity - Biscoiu iash - Alopecia - Raynauu's phenomenon - }oints painaithialgiasmyalgias - Peiicaiuitisenuocaiuitismyocaiuitis - Pleuiitispleuial effusionpneumonitis - Bemolytic anemialeucopeniathiombocytopenialymphopenia - Pioteinuiia >u.Sguay, glomeiulonephiitispyuiiaazotemiauiemiaBTN - Abnoimal T cell function, lymphocyte autoantibouies - NauseavomitingP0Buyspepsia - SeizuiespsychosisuepiessionTIAheauachesCvA - Fevei, malaise, conjunctivitis XFBJA?@CFO !>FCH>FB: - Positive ANA is seen in almost all SLE patients - Anti-us BNA is seen in appioximately 4u% of SLE patients - Anti-Sm antibouies is seen in appioximately Su% of SLE patients
2+#,"-&"2-2
Is a conuition chaiacteiizeu by immune-meuiateu, wiuespieau noncaseating gianulomas. The classic finuing is bilateial hilai auenopathy. Theie is also the inciuence of: - Incieaseu levels of ACE - Rheumatoiu aithiitis - Inteistitial fibiosis - uammaglobulinemia - Restiictive lung uiseases - Eiythema nouosum - Bypeicalcemia
+1("-3314$ ,"4&-(-"42 "! ()$ 2V-4
*&"+5)&5& Autoimmune conuition wheie the skin uevelops ieu, scaly patches on the skin. The plaques that uevelop aie known as "psoiiatic plaques", anu aie causeu by excessive piouuction of skin anu a fastei skin cycle than noimal skin. - Skin appeais silveiy-white in coloi - Nost commonly piesent on extensoi suifaces of the bouy (knees, elbows), but may be seen on the hanus, feet, genitals, anu the scalp. This conuition is not contagious* Psoiiasis is associateu with the B27 haplotype (BLA-B27), BLA-1S, anu BLA-17. *@?>FBCFO *LBRSH
*%/*(5.7& ]73.)+5& Is a potentially fatal conuition that involves the oial mucosa anu the skin. It is causeu by Igu antibouies against the epiueimal cell suiface, causes bieakuown of the cellulai junction of the epithelial cell. Patient will uevelop bullae on the skin anu oial mucosa. Igu antibouies can be seen on immunofluoiescence.
2733"7& *%/*(5."5X Is a skin uisoiuei wheieby Igu antibouies woik against the epiueimal basement membiane. This conuition is veiy similai to *HDNIFJS@ ]SLJB>F@ but is much less seveie.
2,.$#"&$#3+
Scleioueima oi "Piogiessive Systemic Scleiosis" is an excessive ueposition of collagen anu subsequently fibiosis thioughout the bouy. The most common site of piesentation is the skin, howevei it may affect the kiuneys, caiuiac, anu gastiointestinal systems.
!+%&$ &0#X+"/% [ Associateu with the anticentiomeie antibouy A synuiome compiising of S uiffeient conuitions that geneially lack any skin involvement. , - Calcinosis # - Raynauu's phenomenon $ - Esophageal uysmotility 2 - Scleiouactyly ( - Telangiectasias
X5ZZ7&% &!3%+"X%+/) This conuition is associateu with the anti-Scl-7u antibouy, wheieby theie is wiuespieau skin involvement, visceial involvement ielatively eaily, anu a iapiu couise of action anu piogiession.
ESR follow-ups uuiing management (@m@F@A<[A +8B78DBDA 0sually seen in young Asian females
Becieaseu anuoi absent peiipheial pulses
Bloou piessuie uiffeiences in aim vs legs
Nany complications like limb ischemia, aneuiysms, stioke, BTN fiom ienal aiteiy stenosis Baseu on clinical symptoms Steioius
BTN management ,H<8MS2B8@<AA A vasculitis affecting many uiffeient oigan systems
Fatigue, weight loss, fevei
Respiiatoiy Biopsy of lung tissue
Biopsy of skin tissue (shows high eosinophils)
p-ANCA will be founu Pooi piognosis
S-yi suivival is only 2S%
Steioius can piolong tieatment symptoms anu skin finuings aie piimaiy finuings
%7M7:78[A T8@:<I>?@B>ADA A vasculitis of the kiuneys anu iespiiatoiy tiact
0ppei iespiiatoiy symptoms
Painful oial ulceis
Eye uisease (scleiitis, conjunctivitis)
Nusculoskeletal finuings (myalgia, aithialgia)
Tiacheal stenosis CXR (nouules oi infiltiates aie piesent)
Elevateu ESR
Anemia
p-ANCA seen in most patients
Confiimatoiy test is an open lung biopsy Steioius + cyclophosphamiue can help patients into iemission
With ienal failuie, a tiansplant is cuiative />IF@8B78DBDA 4>=>A@ Is a meuium-vessel vasculitis that involves the neivous system anu uI tiact
Causes intimal piolifeiation which causes a ueciease in the luminal aiea, iesulting in ischemia, infaiction, anu then aneuiysm
Liveuo ieticulaiis
Bypeitension
Feveiwt lossaithialgiaabu pain Biopsy
ESR
p-ANCA
Fecal occult bloou Steioius can impiove piognosis, which is pooi without tieatment
*7HE7B[A 2F:=8>?7
A multi-system vasculitis of unknown etiology
Recuiient oial anu genital ulceiations
Aithiitis
visual impaiiment
CNS involvement
Feveiweight loss
Biopsy of all involveu tissues
Steioius
*<78M78[A &DA7@A7 Seen in young males who smoke
Small anu meuium sizeu veins anu aiteiies
Affects aims anu legs
Clauuication occuis
Smoking is impeiative in fixing the pioblem Clinically baseu Smoking cessation )FN78A7:ADBD9DBF 5@AE<IDBDA Is a hypeisensitivity ieaction that occuis in iesponse to ceitain meuications (sulfas, PCN)
Remission is often spontaneous $4&",#-4$ /+()"."TG
+&#$4+. /+()"."TG 1. Bypeialuosteionism 2. Auuison's uisease S. Cushing's uisease
(0*%+)3X"&$%+"#5&/ /8D?@8F a ,>::[A 2F:=8>?7 Causeu by an BLM?@CH>?AHK@HO>HCFAJ CSD?> that causes hypeitension anu hypokalemia (iemembei when aluosteione incieases, potassium uecieases), metabolic alkalosis (iemembei hypokalemia = alkalosis, hypeikalemia = aciuosis), anu L?T NLB@DB >HAFA. 27E>:=@8F HFN78@I=>AB78>:DA? Causeu by ienal aiteiy stenosis most commonly. Nay also be uue to ienal failuie, ciiihosis, nephiotic synuiome, anu congestive heait failuie. These conuitions tiiggei the activation of the RAAS, which stimulates the kiuneys eventually to holu onto moie watei anu souium. As opposeu to the piimaiy cause, this conuition has IFJI NLB@DB >HAFA. (87@BD:M HFN78@I=>AB78>:DA? - Aluosteione antagonist spiionolactone can inhibit the activity of aluosteione on the kiuney.
)XX5&"#c& X5&%)&% Causeu by piimaiy auienal insufficiency. The most common cause is autoimmune, infectious, anu as a iesult of metastatic uisease. !7@B<87A >C +==DA>:[A =DA7@A7: - Postuial hypeitension - Bypoglycemia - Weight loss - Weakness - Anoiexia - Nausea - Bypeipigmentation (only seen in piimaiy auienal insufficiency) - Low aluosteione levels (low souium, high potassium) &D@M:>AD:M: - Plasma coitisol levels - Plasma ACTB levels - Imaging of pituitaiy (if uiagnosis is seconuaiy auienal insufficiency)
!7&(5#.c& &0#X+"/%eX5&%)&% ,<AHD:M[A 2F:=8>?7 - the "synuiome" iesults fiom an excessively high level of glucocoiticoius (coitisol is the piimaiy uC). ,<AHD:M[A &DA7@A7 - the "uisease" occuis as a iesult of a pituitaiy auenoma.
!BS@H@ ?U !S@IFAJc@: 1. Iatiogenic - this is the most common cause, anu is uue to the auministiation of coiticosteioius. 2. ACTB-secieting auenoma of the pituitaiy, this is the 2 nu most common cause, leauing to bilateial auienal hypeiplasia. S. Auenoma of the auienal 4. Ectopic ACTB piouuction - can be causeu by caicinoma of the lung (small- cell). ZHBCS>H@: Theie aie classic featuies of Cushing's, they aie: - Cential obesity - Buffalo hump - Biisutism - Stiiae on abuomen - Acne In auuition, theie is a piesence of: - Bypeitension - Biabetes (* glucose toleiance) - Bypogonauism - causing infeitility - Excess anuiogen (masculinizes females) - Nusculoskeletal abnoimalities (muscle wasting, osteopoiosis, femoial heau osteoneciosis) - Psychiatiic uistuibances such as uepiession - Impaiieu immunity leauing to incieaseu chances of infection
(13"#2 "! ()$ +&#$4+. T.+4& *(%"!+"/"!0$"/) The most common tumoi of the auienal meuulla in auults. It is ueiiveu fiom the chiomaffin cells. &FJA@e&EDNC?D@: - Palpitations - Anxiety - Beauache - Biaphoiesis - Significant hypeitension - Tachycaiuia Biagnosis is baseu on checking uiine metanephiines, anu tieatment is suigical iemoval aftei auequate management of the hypeitension.
#%7+"23)&$"/) Is the most common auienal tumoi in chiluien, anu is the most common intiacianial tumoi in chiluien as well. While most commonly founu in the auienal meuulla, it can be founu anywheie along the sympathetic chain.
,"4T$4-(+. +&#$4+. )G/$#/.+2-+ A congenital conuition wheieby theie aie excessive oi ueficient piouuction of sex steioius fiom the auienal glanu. The most common cause of CAB is uue to 21-hyuioxylase ueficiency. This conuition will cause an excess of anuiogens anu a ueciease in mineialocoiticoius. Theie is an accumulation of the substiate 17-hyuioxypiogesteione. This conuition, wheieby theie aie incieaseu anuiogens, will cause masculinization of the female exteinal genitalia (inteinal female sexual oigans aie intact since no mulleiian inhibiting factoi is piesent - no testicles), anuoi ambiguous genitalia.
()G#"-& T.+4& /+()"."TG
,+4,$#2 *)*533)+0 !)+!5#"/) - Piesence of giounu-glass nuclei anu psammoma bouies - Is the most common type of thyioiu cancei anu holus the best piognosis Z"335!73)+ !)+!5#"/) - Theie is a piesence of unifoim follicles - Bolus a goou piognosis (bettei than meuullaiy but woise than papillaiy) /%X733)+0 !)+!5#"/) - Beiiveu fiom the paiafolliculai "C cells", thus piouuces calcitonin. - Is a membei of the NENII anu NEN III synuiomes - Bas a bau piognosis )#)*3)&$5! !)+!5#"/) - This thyioiu caicinoma occuis in oluei patients - Bolus a teiiible piognosis anu the woist of all thyioiu caicinomas
)G/$#()G#"-&-23 Theie will be a low TSB (uue to feeuback inhibition), with a high TST4 Patient will have the following: - Beat intoleiance - Weight loss - Palpitations - Waimmoist skin - Aiihythmias
)G/"()G#"-&-23 Theie will be a high TSB anu low TST4 Patient will have the following: - Colu intoleiance - Weight gain - Fatigue - Lethaigy - Weakness - Becieaseu ieflexes - Biycool skin - Coaisebiittle haii - Nyxeuema
.+)]%& X5&%)&% uiave's uisease is the most common cause of hypeithyioiuism, accounting foi up to 8u% of all cases. - Is an autoimmune uisoiuei wheieby a thyioiu-stimulating immunoglobulin u antibouy binus to the TSB ieceptois on the thyioiu cells, tiiggeiing the synthesis of excess thyioiu hoimone - Biffuse iauioiouiue uptake on scan
*37//%+c& X5&%)&% Also known as "toxic multinouulai goitei), accounting foi appioximately 1S% of all cases. - Theie aie aieas of hypeifunctioning thyioiu tissue that piouuce excess TS anu T4 - Noie common in oluei patients - Elueily patients with hypeithyioiuism may piesent simply with unexplaineu weight loss, weakness, anuoi atiial fibiillation
()&(5/"$"c& $(0+"5X5$5& An autoimmune conuition that causes hypothyioiuism. - Piesents with a moueiately enlaigeu, but non-tenuei thyioiu glanu - Theie is lymphocytic infiltiation with geiminal centeis - Anti-miciosomal antibouies aie iesponsible foi the conuition &72)!7$% $(0+"5X5$5& hMH gSH>GBFAc@i This is a tiansient thyiotoxic phase lasting 2-S months that is usually self-limiteu. - Absence of paintenueiness of thyioiu glanu - 0ften follows a flu-like synuiome - Low iauioactive iouine uptake
)G/$#,+.,$3-+ Theie aie many causes of hypeicalcemia, they can be iemembeieu with the mnemonic "!(5/*)#m%%&" , - Calcium Ingestion ) - Bypeipaiathyioiuismhypeithyioiuism - - Iatiogenic causes (such as thiaziue uiuietics) 3 - Nultiple myeloma / - Paget's uisease + - Auuison's uisease 4 - Neoplasms \ - Zollingei-Ellison synuiome $ - Excessive vitamin A intake $ - Excessive vitamin B intake 2 - Saicoiuosis
&FJA@e&EDNC?D@ - Stones, Bones, Noans, uioans, anu Psychiatiic oveitones 2B>:7A - kiuney stones *>:7A - bone pain, especially with an incieaseu PTB 3>@:A - psychiatiic noise T8>@:A - constipation /AFEHD@B8DE "978B>:7A - confusion, uepiession, etc
)G/$#/+#+()G#"-&-23 Theie aie piimaiy anu seconuaiy foims of hypeipaiathyioiuism. *>FDB>E - The piimaiy foim of hypeiPTB is usually causeu by an auenoma in the glanu. Nost of the time theie aie no symptoms of this conuition, howevei lab finuings will show the following: BypeiCa2+, hypeicalciuiia, hypophosphatemia, incieaseu paiathyioiu hoimone, anu inciease cANP in the uiine. &HO?AMB>E - The seconuaiy foim of hypeipaiathyioiuism is causeu by a low seium calcium, anu is seen most commonly in someone with chionic ienal uisease. Theie will be hypocalcemia, hypeiphosphatemia, anu incieaseu levels of PTB.
)G/"/+#+()G#"-&-23 Bypopaiathyioiuism is usually uue to eithei acciuental iemoval uuiing a thyioiu pioceuuie oi fiom Biueoige synuiome. Patient will have hypocalcemia anu tetany. The ease by which tetany occuis can be testeu by ceitain maneuveis that cause musculai spasms. $>?S@@HBSc@ &FJA is a test that looks foi caipal spasm, anu is uone by occluuing the biachial aiteiy by pumping up a bloou piessuie cuff. !IG?@CH\c@ &FJA is a test that attempts to cause a spasm of the facial muscles, anu is uone by tapping on the facial neive.
+,#"3$T+.G Known as "gigantism" in chiluien, this is a conuition wheie theie is excess uB secieteu fiom the pituitaiy glanu. Patient will have enlaigement of hanus, feet, facial featuies, ueepening of voice, etc. These patients uie eailiei than the noimal lifespan. Noimally, giving glucose woulu suppiess uB levels, thus if giving glucose uoes N0T suppiess the level of uB, a uiagnosis of aciomegaly can be maue.
,#$(-4-23 Cietinism is a conuition that occui when theie is a lack of uietaiy iouine (enuemic cietinism). A uefect in T4 foimation oi the failuie of thyioiu uevelopment uuiing uevelopment causes spoiatic cietinism. Patients aie puffy-faceu, pale, pot-bellieu with piotiuuing umbilicus anu a piotiuuing tongue.
&-+*$($2 3$..-(12 Compaiing BN types 1 anu 2
5AFCFBL *>H@HACBCF?A ?U X/,d The classic piesentation is polyuiia, polyuypsia, polyphagia, anu weight loss. BKA, the auveise effect of BN1 leaus to incieaseu plasma glucose, uehyuiation, aciuosis, anu if left untieateu will leau to coma anu ueath. !I>?AFO %UUHOC@ ?U X/,: 2?@II 57AA7I &DA7@A7 - thickening of small vessels leaus to a myiiau of pioblems thioughout the bouy. Retinopathy, nephiopathy. .@8M7 57AA7I &DA7@A7 - will leau to atheioscleiosis, coionaiy aiteiy uisease, CvA, PvB. 47<8>I>MDE@I - wiuespieau loss of sensation thioughout the bouy. ,@B@8@EBA - occui as a iesult of soibitol accumulation.
(G/$ X &-+*$($2 "-cell uestiuction (autoimmune) Lifelong insulin is iequiieu BKA is common Staits in chiluhoou (usually) Bouy is skinny (G/$ Z &-+*$($2 Insulin iesistance Bietexeicise is piimaiy tieatment Associateu with obesity BKA is iaie &-+*$(-, V$("+,-&"2-2 O&V+P BKA is a life-thieatening auveise ieaction of BN1. Theie is an incieaseu neeu foi insulin that uoesn't get met, anu is usually causeu by an illnessinfection that incieases the stiess level of the peison. This leaus to an inciease in ketogenesis anu thus piouuction of ketone bouies. &FJA@e&EDNC?D@: - Nausea anu vomiting - Kussmaul bieathing (attempts to coiiect metabolic aciuosis) - uI pains - Behyuiation - Psychosis anu uementia - Bypeiglycemia - Incieaseu anion gap metabolic aciuosis - Inciease ketone levels - Bypeikalemia with uepleteu intiacellulai potassium !?DNLFOBCF?A@: - Ceiebial euema - Aiihythmia - Beait failuie - Nuicomycosis (causeu by the fungus Rhizopus) (?T F@ Xb) DBABJHMn - Lots of fluius - Insulin (give glucose if levels stait to uiop) - Potassium (when K+ levels noimalize)
&-+*$($2 -42-/-&12 O&-P A lack of anti-uiuietic hoimone (ABB), uue to eithei a cential cause oi a nephiogenic cause. ,7:B8@I &- - is causeu by a tumoi in the pituitaiy, tiauma, suigeiy 47NH8>M7:DE &- - is causeu by a lack of ienal iesponse to ABB
Patient will have intense neeu foi fluius coupleu with polyuiia, with uilute uiine that is not concentiateu uue to lack of ABB. /BABJHDHAC: Cential BI: Besmopiessin (intianasal) Nephiogenic BI: hyuiochloiothiaziue (incieases Na+ anu B2u absoiption in uistal nephion).
2G4&#"3$ "! -4+//#"/#-+($ +4(-S&-1#$(-, )"#3"4$ O2-+&)P Too much ABB uue to any of the following causes: - Ectopic piouuction of ABB (commonly fiom small-cell caicinoma of the lung) - Tiauma to the heau anuoi CNS uisoiueis that ielease excess ABB - Biugs such as cyclophosphamiue An excess in ABB will cause the following pioblems: Xn $JB87?7L7JE7AA K@B78 87B7:BD>: Zn )FN>:@B87?D@ =<7 B> =DI<BD>:@I 7CC7EBA OE@: E@<A7 A7Dj<87P ]n ,>:E7:B8@B7= <8D:7 O<8D:7 >A?>I@8DBF h A78<? >A?>I@8DBFP
"2($"/"#"2-2 0steopoiosis is the ieuuction in the bone mass wheie theie is noimal mineialization. Theie aie two types: (FN7 X - 0ccuis in post-menopausal women uue to uecieaseu estiogen levels. Theie is an inciease in bone iesoiption. (FN7 Z - "Senile" osteopoiosis affects those who aie oluei than 7uyi of age, affecting both men anu women. !?DD?A N>?WLHD@: - veitebial ciush fiactuies - Pelvic fiactuies - Fiactuies of the uistal iauius - veitebial weuge fiactuies /BABJHDHAC: Bisphosphonates aie iecommenueu, wheieas estiogen ieplacement woiks well but comes with siue effects that aie conceining.
31.(-/.$ $4&",#-4$ 4$"/.+2-+ O3$4 2G4&#"3$P NEN synuiomes aie the categoiies of synuiome that compiise of ceitain neoplasias. These gioups of neoplasias have a tenuency to piesent simultaneously. 3$4 - - Pancieas (Zollingei-Ellison, insulinomas, vIPomas), Pituitaiy, Paiathyioiu 3$4 -- - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Paiathyioiu auenoma 3$4 --- - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Nucosal Neuiomas
\"..-4T$#S$..-2"4 2G4&#"3$ ZES is a gastiin-secieting tumoi of the pancieas oi uuouenum. This conuition is suspecteu whenevei theie aie iecuiiing ulceis that aie not tieateu conseivatively. Suspect ZES whenevei theie is a pituitaiy anuoi paiathyioiu auenoma as they aie all togethei in the NEN I synuiome categoiy.
*#$+2( &-2$+2$2
Z52+"!0&$5! X5&%)&% Fibiocystic bieast uiseasechanges affects between Su%-6u% of women. Chaiacteiizeu by benign lesions anu uiffuse bieast pain that is often ielateu to hoimonal changes associateu with hei menstiual cycle. Theie is a fibious, lumpy textuie to the lesions of the bieast. Nammogiam is not iequiieu to make this uiagnosis, but fine-neeule aspiiation is commonly uone to check the chaiacteiistics of the fluiu. Tieatment is not necessaiy, howevei pain ielief shoulu be uone **Theie is no incieaseu iisk of bieast cancei in fibiocystic uisease.
2+%)&$ !)#!%+ +F@\ ZBOC?>@: - Family histoiy of a 1 st uegiee ielative with bieast cancei at a young age - Age anu genuei - Nenaiche (<12yi) is shown to inciease iisk - Piegnancy (>Su) can inciease iisk - Late menopause (>Su)
-45+2-5$ *#$+2( ,+#,-4"3+2
Aie uiviueu into two majoi categoiies baseu on theii cytoaichitectuial featuies:
5AC>BMSOCBL *BNFLL?DB@ aie tumois of the lactifeious uucts, they piesent with nipple uischaige. Aiising fiom mammaiy uuct epithelium oi lobulai glanus, anu oveiexpiession of estiogenpiogesteione ieceptois. XSOCBL !B>OFA?DB FA &FCS hX!5&i - is eaily malignancy without basement membiane penetiation 5AGB@FGH XSOCBL !B>OFA?DB - piesents as a fiimfibious mass !?DHM?OB>OFA?DB - is uuctal with cheesy consistency uue to cential neciosis 5AULBDDBC?>E - has lymphatic involvement anu caiiies a pooi piognosis 5AGB@FGH 3?WSLB> !B>OFA?DB - piesents bilateially with multiple lesions /HMSLLB>E !B>OFA?DB - caiiies a goou piognosis, is fleshy with lymphocytic infiltiation -45+2-5$ &1,(+. ,+#,-4"3+ Tubulai Caicinoma Sebaceous Caicinoma Secietoiy Bieast Caicinoma Neuioenuociine Caicinoma Nucinous Caicinoma Niciopapillaiy Caicinoma Acinic Cell Caicinoma Auenoiu Cystic Caicinoma Apociine Caicinoma Ciibiifoim Caicinoma ulycogen-RichCleai Cell Inflammatoiy Caicinoma Lipiu-Rich Caicinoma
."*1.+# ,+#,-4"3+ Pleomoiphic Signet Ring Cell *BJHCc@ XF@HB@H ?U CIH 2>HB@C - eczematous patch on the nipple
/".G,G2(-, "5+#-+4 2G4&#"3$ Is a common uisoiuei anu one of the most common causes of infeitility in women. An inciease in LB piouuction leaus to anovulation anu hypeianuiogenism uue to alteieu steioiu synthesis. &FJA@e&EDNC?D@: - 0besity - Biisutism - Amenoiihea - Infeitility This conuition shoulu be manageu with weight loss anu oial contiaceptive pills (0CP's).
"])+5)# !0&$&
T$#3 ,$.. (13"#2 "! ()$ "5+#G $%+)$"/) [ up to 9u% of geim cell tumois of the ovaiy. Contains all thiee geim layeis (ectoueim, enuoueim, mesoueim). The immatuie teiatoma is veiy aggiessive anu malignant. X0&.%+/5#"/) - is the most common type of malignant geim cell ovaiian tumoi, usually occuiiing in auolescence anu eaily life. Is analogous to the male seminoma. 0"3b &)! $7/"+ - piouuces !-fetopiotein !("+5"!)+!5#"/) - is the same as the testiculai veision of the geim cell tumoi, causes an inciease in hCu.
4"4ST$#3 ,$.. (13"#2 "! ()$ "5+#G &%+"7& !0&$)X%#"/) [ is benign, compiises 2u% of ovaiian tumois anu is fiequently bilateial. Is lineu with fallopian tube-like epithelium. &%+"7& !0&$)X%#"!)+!5#"/) - compiises Su% of ovaiian tumois, is fiequently bilateial anu is malignant. /7!5#"7& !0&$)X%#"/) - is benign, anu is a multiloculai cyst lineu by mucus- secieting epithelium. /7!5#"7& !0&$)X%#"!)+!5#"/) - is malignant, with intiapeiitoneal accumulation of mucinous mateiial fiom ovaiian oi appenuiceal tumoi. 2+%##%+ $7/"+ - is a benign tumoi iesembling blauuei epithelium. "])+5)# Z52+"/) - contains bunules of spinule-shapeu fibioblasts. "Neig's synuiome" is a tiiau of ovaiian fibioma, ascites, anu hyuiothoiax. .+)#73"&) !%33 $7/"+ - secietes estiogen causing piecocious pubeity in chiluien, while in auults it can cause enuometiial hypeiplasia oi caicinoma. Contains "Call-Exnei bouies", which aie small follicles filleu with eosinophilic secietions.
1($#-4$ /+()"."TG
%#X"/%$+5)3 !)+!5#"/) Is the most common gynecological malignancy that peaks between SS-6Syi of age. The most common initial piesentation is vaginal bleeuing. +F@\ ZBOC?>@ - Piolongeu use of estiogen, BN, hypeitension, anu obesity.
%#X"/%$+5"&5& 0ccuis when enuometiial glanus aie piesent in locations outsiue of the uteius. Piesents with seveie pain ielateu to menstiuation anu piouuces chocolate cysts (bloou in the ovaiy). Nay cause infeitility.
)X%#"/0"&5& Is enuometiiosis within the myometiium of the uteius
3%5"/0"/) Is the most common tumoi seen in women, wheie tumoi size incieases with piegnancy anu uecieases with menopause. 0ften piesenting with multiple tumois at once. Raie piogiession to cancei.
3%5"/0"&)+!"/) Is a bulky tumoi with aieas of neciosis anu hemoiihage. Boes not aiise fiom a leiomyoma. Tenuency to piotiuue fiom ceivix, is highly aggiessive anu has a tenuency to iecui.
,$#5-,+. /+()"."TG
X0&*3)&5) Is uisoiueieu epithelial giowth that staits at the basal layei anu extenus outwaiu. Caicinoma in situ (CIN) is classifieu baseu on the extent of uysplasia. Theie is an association with human papilloma viius. 5#])&5]% !)+!5#"/) Nost commonly this is squamous cell caicinoma. Pap smeai is an essential tool to catch this befoie it becomes too auvanceu.
,"3/.-,+(-"42 "! /#$T4+4,G
Foui common conuitions associateu with piegnancy incluue: 1. Placental abiuption (abiuptio placenta) 2. Placenta accieta S. Placenta pievia 4. Ectopic piegnancy
/.+,$4(+. +*#1/(-"4 Painful uteiine bleeuing that is a iesult of piematuie sepaiation of the placenta. Is an emeigency conuition that can iesult in fetal ueath. /.+,$4(+ +,,#$(+ Placenta attaches uiiectly to the myometiium, anu is causeu by a uefective ueciuual layei. /.+,$4(+ /#$5-+ Placental attachment to the lowei uteiine segment with may occluue the ceivical os. Piesents with painless vaginal bleeuing. $,("/-, /#$T4+4,G Nost common site is the fallopian tube, is seen most commonly in a patient with histoiy of pelvic inflammatoiy uisease. Biagnose with ultiasounu.
/#$T4+4,G -4&1,$& )G/$#($42-"4 O/87S7EI@?NAD@P
*>HKHOLBDN@FB = Bypeitension, pioteinuiia, anu euema. %OLBDN@FB = Tiiau above + seizuie * If pie-eclampsia is piesent, patient iequiies beuiest, salt-iestiiction, anu monitoiing. Associateu with BELLP synuiome, which is an emeigency situation that iequiies immeuiate ueliveiy of the baby. ) - )emolysis $. - $levateu .FTs ./ - .ow /latelets
)G&+(-!"#3 3".$
Is an ovum without any BNA, which iesults in swelling of the choiionic villi anu piolifeiation of choiionic epithelium. Theie will be elevation of "-hCu anu the appeaiance of a "clustei of giapes". Complete Nole - 46,XX that is of complete pateinal oiigin with no iuentifiable embiyonic oi fetal tissue. Paitial Nole - 69,XXY oi 92, XXXY, wheie a noimal egg is feitilizeu by two oi thiee speim. * Nay uevelop into choiiocaicinoma
*$4-T4 /#"2(+(-, )G/$#/.+2-+ BPB is a conuition that is quite common in men ovei the age of Suyi. Chaiacteiizeu by nouulai enlaigement of the lateial anu miuule lobes (ie peiiuiethial), which compiesses the uiethia into a veitical slit. SignsSymptoms: - 0iinaiy fiequency - Fiequent nighttime uiinaiy - Bifficulty in staitingstopping uiination - Complications may be hyuionephiosis, hypeitiophy of blauuei, anu 0TI.
/#"2(+(-, +&$4",+#,-4"3+ Nost commonly seen in men ovei Suyi of age. The most common site of auenocaicinoma is the posteiioi lobe (aka peiipheial zone). Bigital iectal exam is the best way to uetect the cancei, as haiu nouules can be uetecteu on exam. PSA is useu as a way to uetect an auenocaicinoma, as levels >4.u aie woiiisome. The most woiiisome auveise effect is osteoblastic metastasis (uetect by incieaseu alkaline phosphatase).