• Inactivates EF-2:

corynebacterium diptheriae

• Actives Gs

Vibrio Cholera

• Disables Gi

Pertissus toxin

• Bacterial adenylate cyclase (no G protein involved)

Bacillus Anthracis

• Blocks GABA and glycine

Costridium tetani

• Anaphylaxis on exposure to blood products with IgA

Selective Ig deficiency

__________________________________________
• Course facial features, abscesses, eczema

Hyper IgE syndrome (Job's disorder)

[image]

________________________________________
• Thrombocytopenia, purpura, infections, eczema

Wiskott Aldrich Syndrome

[image]

________________________________________

• Delayed separation of the umbilicus

Leukocyte Adhesion Deficiency (Type I)

[image]

____________________________________________
• Neuro defects, partial albinism, recurrent infections

Chediak-Higashi Syndrome

[image]

Both are high pitched,, blowing murmurs

Mitral regurgitation is systolic heard best at Apex

Aortic regurgitation is diastolic heard best at RUSB

AD disease so the chance of normal stature is 25%

achondroplasia: 50%

die in utero: 25%

DEXA bone density scan of hip or lumbar spine

[image]

[image]

smoking, alcohol, steroid, PPI and H2 cessation

exercise

fall risk assesments at home

Vit D suplementation

Calcium supplementation

Bisphosphanates (-dronate) inhibit osteoclastic activity

PTH

can cause pill esophagitis so much be taken with a lot of fluid and sitting upright for a while after taking

can cause jaw necrosis in those susceptible (jaw pathology or surgery)

can be given during high stress time or steroid use as a prophylactic to prevent osteoperosis

What is the mechanism of action for Bisphosphanates? Give an example and what it is used for.

-dronates

(fosomax: Alendronate)

used for osteoperosis (prophylaxis also)

Paget's disease

inhibits osteoclastic activity

[image]

Teriparatide: Anabolic agent that stimulates osteoblasts

decreases hip fracture rate by 50%

do not exceed 2 yrs, must use Bisphosphonate after stopping PTH

must be given in pulsatile fashion

prolonged fashion will erode bone!

osteopetrosis is thick bones that decreases marrow space which can lead to anemia..pancytopenia

prone to fracture

cranial nerve impingement

increase in EXTRAMEDULLARY HEMATOPOIESIS

(alk phos is normal here and with osteoperosis)

due to deficiency in carbonic anhydrase II

ERLYN MEYER FLASK BONES

[image]

Epiphyseal plate

cartilage is formed and then transformed to bone

Monocytes and Macrophages

Which bony disease fits the following description?

• Reversible when vitamin D is replaced

• Excess osteoclastic activity results in disorganized bony architecture

• Bone is replaced by fibroblasts, collagen, and irregular bony trabecule

• Soft bones due to defective mineralization of osteoid

• Failure of bone resorption →thickened and dense bones

• Genetic deficiency of carbonic anhydrase II

• Reversible when vitamin D is replaced: Osteomalacia/Rickets

• Excess osteoclastic activity results in disorganized bony architecture: Paget's disease of bone

• Bone is replaced by fibroblasts, collagen, and irregular bony trabecule: Polyostotic fibrous dysplasia

• Soft bones due to defective mineralization of osteoid: Osteomalacia and rickets

• Failure of bone resorption →thickened and dense bones: Osteopetrosis

Genetic deficiency of carbonic anhydrase II: Osteopetrosis

Age

Smoking

Steroids

Chronic heparin

Low estrogen

Low testosterone

White

Thin

Not exercising

Poor Ca and Vit.D

weight bearing activity

calcium and vitamin D

avoiding smoking

avoiding steroids

avoiding chronic heparin

addressing any hypogonadism

What disease?

[image]

Pagets diseas of the bone

excess osteoclastic (osteoclasts go crazy first-possibly due to virus) and osteoblastic activity

occurs late adulthood

does not involve entire skeleton

PTH is normal

elevated alk phos

mosaic pattern of lamellar bone

increased blood flow can cause high output heart failure due to shunts

increased risk for fractures

and osteogenic osteosarcoma

lion like faces if involving the skull

[image]

hat size increase

hearing loss due to narrowing of the auditory foramen

tx: bisphosphonate and calcitonin

Achondroplasia

Activating mutation: receptor turned on inhibiting the growth of cartilage in long bones affecting endochondral bone formation(AD) most mutations sporadic

[image]

intramembranous bone formation (head, chest and flat bones) is normal

exposure of the choroidal veins

hearing loss also a possibilty due to fractures of the tiny inner ear bones

[image]

What are the clinical features of ostepetrosis?

Tx?

Bone fracture

Pancytopenia

extramedullary hematopoiesis in the spleen and liver

vision and hearing impairment

hydrocephalus

renal tubular acidosis (carbonic anhydrase II deficiency)

Tx: bone marrow transplant in hopes to make normal monocytes-->normal osteoclasts

defective mineralization of osteoid due to low levels of Vitamin D

Can be caused by:

decreased sun exposure

poor diet

malabsorption

liver failure and renal failure

Rickets' rachitic rosary is due to: deposition of osteoid

Alk phos will increase

(alkaline envirmonment is needed to calcify the osteoid)

all normal labs in osteoperosis

just remember that

metaphysis

(in adults: epiphysis)

Osteoma is a benign tumor of the bone that usually arises on the surface of facial bones and is associated with Gardner's syndrome

(FAP with osteomas)

benign tumor of OsteoBlasts

occurs in young adults<25 yo

arises in cortex (surface) and diaphesis of long bones

bone pain that resolves with aspirin

bony mass with radiolucent core

[image]

What is the difference between an osteoblastoma and an osteoid osteoma?

both are benign tumors of osteolasts

Osteoblastoma:

larger >2cm, arises in vertebrae, bone pain DOESNOT respond to ASA

[image]

_______________________________________

Osteoid Osteoma:

smaller, usually in long bones, bone pain releived by ASA

[image][image]

osteochondroma

tumor with an overlying cartilage cap

this overlying cartilage can transform to chondrosarcoma which is malignant

[image]

[image][image]

notice the angle which is created from the periosteum being lifted off the bone: characteristic of osteosarcoma

pleomorphic cells creating osteoid

Teenagers:
Familial Rb

[image]

Elderly:

Paget's disease

Radiation

[image]

Giant cell tumor

giant soap bubbles in epiphysis on xray

[image]

neuroectoderm

small round blue cell (lymphocytes) with t11,22

think Patrick Ewing 11+22=33

[image]

chondroma

Which primary bone tumor fits the following description?
• Most common malignant primary bone tumor of children
• Most common malignant primary bone tumor in adults
• Most common benign bone tumor
• 11 ;22 translocation
• Soap-bubble appearance on x-ray
• Onion-skin appearance of bone
• May actually be a hamartoma
• Codman's triangle on x-ray

• Associated with Gardner syndrome

• Most common malignant primary bone tumor of children:Osteosarcoma

• Most common malignant primary bone tumor in adults: Multiple myeloma

• Most common benign bone tumor: Osteochondroma

• 11 ;22 translocation : Ewing Sarcoma

• Soap-bubble appearance on x-ray: Giant cell tumor

• Onion-skin appearance of bone: Ewing Sarcoma

• May actually be a hamartoma: Osteochondroma

• Codman's triangle on x-ray: Osteosarcoma

• Associated with Gardner syndrome: Osteoma

IgM autoantibody against Fc portion of IgG

Neutrophils and high protein in synovial fluid

Rheumatoid factor

Rheumatoid Arthritis

Anemia of chronic disease

inflammatory state-->acute phase reactants(hepcidin)--> traps iron

Secondary Amyloidosis

acute phase reactants--->SAA--->AA -->AA seposits in tissues

Psoriatic arthritis

[image]

Leukemia and Myeloproliferative diosrders

Lesch-Nyan

Renal failure

Uric acid crystals

triggers: alcohol and meat consumption

Uric acid crystal depositions within the soft tissue

fibrosis surrounding the white chalky deposits of the uric acid crytals

labs: negative birefringence needle shaped crystals in synovial fluid (lying flat they are yellow and under parallel light)

[image][image]

Insulin

Insulin like growth factor-1

Platelet-derived growth factor

Fibroblast growth factor

Prolaction

Growth hormone

INCREASE dietary absorption of calcium

INCREASE dietary absorption of phosphate

INCREASE bone resorption of calcium and phosphate

PTH increases serum calcium

PTH decreases serum phosphate

"Phosphate Trashing Hormone"

SCC

Renal cell carcinoma

Breast cancer

Multiple Myeloma

Wha cell type produces PTH?

What cells produce calcitonin?

Chief cells of the parathyroid

Calcitonin is produced by the parafollicular C cells of the thyroid

 Trousseau's sign & Chvostek's sign

Tap Cheek and Cuff

Solitary parathyroid adenoma

Parathyroid hyperplasia

Hypoparathyroidism

-thyroid surgery

-autoimmune destruction of the parathyroids

DiGeorge syndrome

What nerve is damaged when a patient presents with the following symptom (upper
extremity)?
• Claw hand

• Wristdrop

• Scapular winging

• Unable to wipe bottom

• Loss of forearm pronation

• Weak lateral rotation of arm

• Loss of arm and forearm flexion

• Loss of forearm extension

• Unable to raise arm above horizontal

Claw hand: Ulnar

• Wristdrop: Radial

• Scapular winging: Long Thoracic

• Unable to wipe bottom: Thoracodorsal

• Loss of forearm pronation: Median

• Weak lateral rotation of arm: Suprascapular

• Loss of arm and forearm flexion: Musculocutaneous

• Loss of forearm extension: Radial

• Unable to raise arm above horizontal: Long thoracic(scapular lateral rotation) and spinal accessory (trapezius)

[image]

Anterior talofibular ligament

Calcaneofibular ligament

Posterior talofiblar ligament

Patellofemoral syndrome

[image]

Which muscles of the rotator cuff are responsible for the following:

• Initial 15 degrees of arm abduction

• Lateral rotation of arm

• Medial rotation of arm

• Initial 15 degrees of arm abduction:Supraspinatus

• Lateral rotation of arm: Infraspinatus and teres minor

• Medial rotation of arm: Subscapularis

[image]

Tennis: Lateral epicondylitis

Golf: Medial epicondylitis

[image]

Flouoroquinolones

will land you on the FLOOR

C5, C6

loss of abductors

loss of lateral rotators

Loss of biceps

arm left in adduction, medial rotation pronation posture

Which lipid-lowering agent matches the following description?

• SE: facial flushing

• SE: elevated LFTs, myositis

• SE: Gl discomfort bad taste

• Best effect on HDL

• Best effect on triglycerides/VLDL

• Best effect on LDL/cholesterol

• Binds C.diff. toxin

• SE: facial flushing: Niacin

• SE: elevated LFTs, myositis: Fibrates, Statins

• SE: Gl discomfort bad taste: Bile acid binding resin

• Best effect on HDL:Niacin

• Best effect on triglycerides/VLDL: Fibrates

• Best effect on LDL/cholesterol: Statins

• Binds C.diff. toxin: Cholestyramine

nonsystemic joint pain that gets worse with use

less than an hour stiffness in the morning

NSAIDs block prostaglandin synthesis

prostaglandins optimize bloodflow to renal vasculature

NSAIDs

Colchicine

Steroids

Pseudogout

Rhomboid crystals of calcium pyrophosphate

external ear

olecranon bursa

achilles tendon

Cytotoxic T cells react to foreign MHC

Timeframe: weeks after transplantation

Calcinosis

Raynaud

Esophageal dysmotility

Sclerodactyly

Telegiectasia

Calcinosis

Sclerodactlyly

Telagienctasia

Patient has Lupus

renal evaluation every year

defective gene on X chromosome

deletion of dystrophin gene which leads to degenration of individual muscle fibers

[image]

Polymyalgia rheumatica:

muscle weakness

increased CPK

increased Aldolase

Positive ANA

Anti-Jo-1

dermatomyositis

"can't comb hair and climb stairs"

Anti-Jo-1

perimysial inflammation with perifasicular atrophy

Dermatomyositis

[image]

Polymyositis (CD8 T cells)

[image]

What type of cells are responsible for whats going on here?

[image]

Endomysial inflammation

CD8 T cells

Polymyositis

X-Linked Muscular Dystrophy

due to deletions of dystrophin

degenerative disorder characterized by muscle wasting

Duchenne's X-linked Muscular Dystrophy

dystrophin is the longest gene in human chrmosome so it is more susceptible to delteitons

most often sporadic

present with proximal muscle weakness at 1 years old

progresses to distal muscles

calf pseudodystrophy

CK is elevated

calf looks bag but its full of fat

[image]

death due to cardiac or respiratory failure

Becker Muscular Dystrophy

clinically milder than Duchenne's bc mutation not deletion

Lambert Eaton Syndrome

antibodies against presynaptic calcium channels at he NMJ

impairs release of Acetylcholine

eyes usually spared

AChesterases dont improve symptoms

Lipoma

Liposarcoma (lipoblast) is the most common malignant soft tissue tumor in adults

Rhabdomyosarcoma

head, neck, vagina

desmin positive

[image]

This is a picture of a young girl's vagina

What kind of tumor is this?

[image]

Rhabdomyosarcoma

more info:

two most common forms are embryonal rhabdomyosarcoma and alveolar rhabdomyosarcoma. In the former, which is more common in younger children, the cancer cells resemble those of a typical 6-to-8-week embryo. In the latter, which is more common in older children and teenagers, they resemble those of a typical 10-to-12-week embryo.

Rhabdomyosarcoma is a relatively rare form of cancer. When RMS does occur, it is most commonly seen in children aged one to five years old. Less commonly, it can also present in teens aged 15 to 19, and can even develop in adulthood, though this is even more rare.

St. Jude Children's Research Hospital reports that Childhood Rhabdomyosarcoma is the most common soft tissue sarcoma in children. Soft tissue sarcomas make up about 3% of childhood cancers.

Bechet syndrome

caused by immune complex vasculitis

Trigeminal nerve ganglia

stress and sunlight can reactivate the virus and can lead to cold sores on lips

[image]

Smoking and alcohol

leukoplakia and erythroplakia (more suggestive) are precursor lesions

Warthin Tumor

benign and almost always in the parotid

[image]

Mucoepidermoid Carcinoma

[image]

Mallory Weiss can lead to Boerhaave Syndrome

[image]

Chaga's disease

damage to the myenteric plexus ganglion

Barrett's esophagus

Metaplasia

NKSC--->NCCC

alcohol

tobacco

very hot tea

achalasia

esophageal web

esophageal injury (lye ingestion ex)

Upper 1/3: cervical nodes

Middlw 1/3: mediastinal or tracheobronchial nodes

Lower 1/3:celiac and gastric nodes

Gastroschisis

malformation of abdominal wall

abnormal fusion

Omphalocele

persistent herniation of bowel into umbilical cord

failure of normal herniated intestines to return to body cavity during development

contents covered by peritoneum and amnion

2 wks after birth

projectile nonbillious vomitting

olive like mass (the stenotic sphincter)

Tx: myotomy

rupture causing:

gastroduodenal bleed

acute pancreatitis

Diffuse type Stomach cancer

thickened gastric wall

[image]

Leser Trelat sign and acanthosis nigricans 

[image][image]

Gastric carcinoma

meckel diverticulum

2%population

2 inches long

2 ft from ileocecal valve

presents within first 2 years of life

can present with bleeding, volvulus, intussusception or obstruction

duodenum

Dermatitis herpetiformis

resolves with gluten free diet

[image]

neuendocrine cells positive for chromogranin

Cough, Coryza, Conjunctivites, Koplick spots, descending pruritic maculopapular rash, High fever for four days

Rubeola (Measles)

RNA single stranded negative sense

Paramyxovirus

[image]

• Pneumonia

• Subacute Sclerosing PanEncephalitis (5-15 years later personality changes, seizure, myoclonus, ataxia and eventually coma or death)

Orthomyxovirus

RNA single stranded negative sense

replicates in nucleus

Meningitis

Unilateral orchitis is teenage boys

Hemagluttinin A

Fusion protein

Neuroaminidase

[image]

RSV is a Paramyxovirus (RNA single stranded negative sense) that attaches to te G protein of respiratory epithelial cells

Fusion proteins

non-pregnant adults: Ribavarin

prevention in premature babies: Palivuzimab

RSV

Parainfluenzae (croup, inspiratory stridor, steeple sign)

Rubeola

Mumps

What are the virulence factors of Laryngotracheobronchitis?

What do you see on CXR?

Laryngotracheobronchitis is parainfluenza virus (croup) of the Paramyxovirus family

virulence factors:

Neuroaminidase

Fusion Protein

Hemagluttinin A

On chest X-Ray: steeple sign

[image]

Rhabdovirus

helical capsid

common carrier in bats, squirrels, skunks, foxes and raccoons

binds nicotinic acetylcholine receptors in th epost synaptic membrane of the motor endplate

after an incubation period of weeks to months the 

travels rtrograde and replicates in motor neurons and travels to te dorsal root ganglia before spreading to the brain

negri bodies in neurons: eosinophilic cytoplasmic inclusions in the hippocampus cytoplasm (pyramidal cells of hippocampus) and purkinje cells

sx: fever and encephalitis

passive and active immunization

passive: preformed Ab

active: killed vaccine

Ebola virus

and Marburg virus

petechiae

hemorrhagic fever

hypovolemic shock

end organ failure

fruit bat and primates: reservoir

rodent vector:

Hantavirus

Aedes mosquito vector:

California Encephalitis

Rift Valley Fever

Reovirus

replicates in cytoplasm, segmented (11)

Reovirus

Rotavirus: NSP4 ENTEROTOXIN causes the watery secretory diarrhea by increasing chloride permeability

Cat scratch disease (stellate shaped)

Crohn disease

Berrylium exposure

sarcoidosis

reaction to foreign material

TB (AFB stain)

Fungus (SILVER stain)

Macrophages present antigen via MHC II to CD4 T cells

Macrophages secrete IL-12, inducing CD4 T cells to differentiate into TH1 subtype

TH1 cells secrete IFN-gamma which converts macrophages to epitheloid histiocytes and giant cells

Ribonucleaoprotein antibodies

Sjorgens's syndrome is also associatedw ith RA and an increased risk of B cell lymphoma (bilateral parotid enlargement is common but look for further unilateral enlargement of the parotid gland late in the disease process)

DNA Topoisomerase I

Scleroderma is characterized by ANA and Anti-DNA TOPOISOMERASE I

small and large bowel: CRYPTS

skin: BASAL LAYER

bone marrow: HEMATOPOIETIC CELLS CD34+

Fibroblasts (type III collagen)

capillaries (provide nutrients)

myofibroblasts (wound conrtacture)

granulation is replaced by a scar and mature scars have Type I collagen same collagen in BONES!

collegenase removes type III collagen and requires zinc

FGF: angiogeneisis and skeletal development

VEGF: angiogenisis

crosslinking procollagen

copper (crosslinking too) and zinc(*colagenase)

Keloid

Prazosin, terazosin, doxazosin, tamulosin

alpha1 antagonist-->peripheral vascular smooth muscle relaxation

also decreases prostate and bladder neck contraction

"first dose syncope"

Ursodiol

-inhibits HMGCoA reductase

decreases intestinal reabsorption

inhibits secretion of chosterol into bile

[image]

think obese women like Ursula get cholesterol gallstones

Quinilone inhibits DNA gyrase specificaly subunit A (mutations in this gyrA subunit can confer resistance)

DNA gyrase is a type II Topoisomerase enzyme present in bacteria. It introduces negative supercoils into both the DNA double helix in advance of the replication fork . This process requires ATP because it cuts and reseals, cuts and reseals, cuts and reseals...

Basically uncoils it from the nucleosome and histones ahad of the replication fork so it can replicate

Quinolones and Flourouquinolones are the same family of drugs

others..Ciprofloxacin blocks DNA gyrase in gram- bacteria

[image]

inhibits DNA gyrase (aka topoisomerase II) in gram - bacteria

Topoisomerase II can change the topology of the DNA by making transient double strand breaks (does not mess with covakent structure of DNA)

Congenital CMV

What does it cause?

facts?

more likely to be asymptomatic! (80-90%)

2nd trimester highest risk for transmission form mom

#1 cause of mental retardation from congenital viral infections

most comon cause of congenital sensorineural hearing loss (this is why all babies are screened for hearing deficits)

Blueberry muffin rash (Thrombocytopenia with petechial rash)

Jaundice and heapatosplenomegaly

Sensorineural deafness

ventriculomegaly (brain) and periventricular calcifications

seizures and mental retardation

Who is at highest risk for getting CMV pneumonia?

transplant patients

AIDS pts with CD4 count <50

they are also at risk for CMV esophagitis (singular deep and linear to distinguish from herpes)

and CMV colitis

[image]

1st. line: Ganciclovir

2nd line: Foscarnet (for the infections with UL97 gene mutation)

Herpes zoster opthalmicus

DNA virus, envelopes

VZV

If their CD4 count is >200

it is a live vaccine so do not give to toehr immunocompromised pts or AIDS pts with a  low CD4 count

What is the treatment for chickenpox?

shingles?

Treatment for chickenpox: Acyclovir

(kids over 12 and adults)

Treatment for shingles: Famciclovir

Vaccines for both are available: They are LIVE ATENUATED so do not give to immunocompomised pts or AIDS pts with CD4 count <200

mother infected with varicella can cuase these manifestations in the fetus:

blindness

limb hypoplasia

cutaneous dermatomal scarring

[image]

High fever lasting four days which can cause seizures

Rash appars after the fever goes away

rash spares the face

Roseola

HHV6

Herpes family DNA Virus

No treatment outside of supportive care

Kaposi Sarcoma

DNA enveloped virus

causes disregulation of VEGF causing angiogenesis giving these lesions the violet color on the hard palate, nose, chest, legs, GIT

[image][image][image][image]

*can also cause  B-cell lymphoma

-Men who have sex with men

Russian men

Africa (endemic)

Bacillary angiomatosis by bacterial infection of Bartonella Hensalae

examine lesion microscopic

lymphocytic infiltrate: HHV8:Kaposi

neutrophilic: Bartonella Henselae

Albrigh's Hereditary Osteodystrophy

Type 1a pseudohypoparathyroidism

[image]

Carnitine Acyltransferase I

[image]

Hydrochlorothiazide (Thiazide diuretic helps body concentrate th urine)

Amilioride (closes Na channels in the collecting tubules -especially lithium caued DI)

Indomethacin (reduces renal blood flow)

Slowly Adapting __   Rapidly Adapting

Superficial: Merkel Receptor    Meissner's Corpuscle

Deep:         Ruffini endings      Pacinian Corpuscle

The slowly adapting sends electrical signal throughout continuous stimulation

Rapidly adapting sends electrical signals only at the beginning and the endof stimulus

example of someone poking you versus, touching you for a long time and letting go

[image]

Aδ

(A delta)

fast and myelinated

also a cold thermoreceptor

[image]

C-polymodal

slow and unmyelinated

also warm thermoreceptor

What sensation receptor is this?

[image]

Pacinian corpuscle

vibration and pressure

rapidly adapting in the deep layer

A woman in labor that did not receie epidural and is in a lot of pain in genital region

palpate ischial spine through vaginal wall and inject lidocaine in that region

[image]

Between L3 and L4 right above iliac crest

[image]

demyeliation of the schwann cells

ascending muscle weakness

bilateral facial muscle paralysis

idiopathic and is associated with GI infection (Campylobacter example)

[image]

[image]

What sensory receptor communicates with the following information?

• Pricking pain (fast, myelinated)

• Burning or dull pain and itch (slow, unmyelinated)

• Vibration and pressure

• Dynamic/changing light, discriminatory touch

• Static/unchanging light touch

• Proprioception information - muscle length monitoring

• Proprioception information - muscle tension monitoring

• Pricking pain (fast, myelinated) Aδ fibers

• Burning or dull pain and itch (slow, unmyelinated)

C polymodal fibers

• Vibration and pressure: Pacinian Corpuscle

• Dynamic/changing light, discriminatory touch : Meissner's Corpuscle

• Static/unchanging light touch :                  Merkel's receptor (looks like melanocyte)

• Proprioception information - muscle length monitoring:

Muscle Spindle

• Proprioception information - muscle tension monitoring:

Golgi Tendon Organ

normal cell count and increase in protein

*albuminocytologic disassociation*

Cell bodies of spiral ganglion→ cochlear nuclei→ contralateral superior auditory (olive) nucleus→lateral lemniscus→Inferior colliculus→medial geniculate body (thalamus)→primary auditory cortex

SG→Cochlear Nuclei→CSAN→LL→MGB→PAC

[image]

Aminoglycosides

Gentamicin and Streptomycin

How do you diagnose acute otitis media?

common cuases?

Tx?

pus and/or bulging, immobile tympanic membrane

most common caused by

Strep pneumonia

Haemophilus influenza (non-typeable)

Moraxella catarrhalis

Hearing Should Matter

Tx: Amoxicillin

Amoxicillin with Calvulanic acid

Cephalosporins

rcurrent : tympanostomy tubes (to equalize pressure)

"swimmer's ear"

Pseudomonas

Staph Aureus

[image]

Tx: irrigation and topical antibiotics

pulling ear and using otoscope is painful

overgrowth of keratin debris in the middle ear space often due to chronic middle ear infections, negative middle ear pressure or perforated tympanic membrane

greyish white or pearly lesion

requires surgery

can cause hearing loss and vertigo

[image]

What are the Weber and Rinne Tests?

What do they diagnose? How?

Weber test: should hear sound same on both sides but if have conductive hearing loss will hear it louder on the affected side

sensironeural hearing loss will hear it louder on the unaffected side

Rinne test:test for conductive hearing loss only: conductive hearing loss they will hear it louder when on the bone then when in the air

[image]

Meniere's Disease

Endolymphatic Hydrops

[image]

Strep pneumo

Non-typable H.flu

Moraxella Catarrhalis

What disorder is associated with the following mutation?

• FGF receptor 3
• FMRI gene

• FGF receptor 3:  Achondroplasia

• FMRI gene: fRagIle X syndrome

just know these

[image]

Melasma

"melasma mama"

Rapidly spreading cellulitis with tenderness beyond the red border

caused by Group A strep

strep pyogenes

TRUE! makes it come back worse

only give them topical steroids

Which skin disorder matches the following statement?

• Pruritic, purple, polygonal papules

• Life threatening rash with bullae

• Pruritus associated with asthma

• Pruritic vesicles associated with celiac disease

• Allergy to nickel

• Thickened scar esp. around face/chest

• Antibodies against epidermal basement membrane

• Antibodies against cell-cell adhesions

• Parakeratotic scaling

• Keratin-filled cysts

• Sand-paper; predisposition to squamous cell cancer

• Skin rash and proximal muscle weakness

• Honey-crusting lesions common about the nose and lips

• Hyperkeratosis and koilocytosis

• Histology shows palisading nuclei

• Pruritic, purple, polygonal papules: Lichen Planus

• Life threatening rash with bullae: Stevens Johnson Syndrome

• Pruritus associated with asthma: Atopic dermatitis

• Pruritic vesicles associated with celiac disease:Dermatitis herpetiformis

• Allergy to nickel:Contact dermatitc (type IV HSR)

• Thickened scar esp. around face/chest:Keloid

• Antibodies against epidermal basement membrane: Bullous pemphigoid

• Antibodies against cell-cell adhesions: Pemphigus Vulgaris

• Parakeratotic scaling: Psoriasis

• Keratin-filled cysts: Seborrheic keratosis

• Sand-paper; predisposition to squamous cell cancer: Actinic keratosis

• Skin rash and proximal muscle weakness: Dermatomyositis

• Honey-crusting lesions common about the nose and lips: Impetigo

• Hyperkeratosis and koilocytosis: Verrucae (HPV)

• Histology shows palisading nuclei:Basal cell carcinoma

classic characteristics of neoplasia

(G6PD or androgen receptor isoform ratio is not 1:1 anymore which distinguishes neoplasia from hyperplasia (polyclonality))

Ig light chain phenotype

(kappa or lambda ratio normally is 3:1  and will increase to something like 20:1 in lymphoma)

this distinguishes between reactive hyperplasia and lymphoma

remember neoplasias can be benign or malignant but they are all monoclonal!

about 30 divisions

with each division, additional mutations are produced. the later in detection, the poorer the prognosis

Hepatocellular carcinoma

dervied from aspergillus in stored grains

SCC of skin

lung cancer

angiosarcoma

Angiosarcoma of liver

occupational exposure

used to make polyvinyl chloride (PVC) for use in pipes

Smoking

also Napthylamine (which is in cigarette smoke)

Equations

• MAP = CO x Total Peripheral Resistance (TPR)
• MAP = 2/3 Diastolic Pressure + 1/3 Systolic Pressure
• MAP = 1/3 Pulse Pressure + Diastolic Pressure

Which number corresponds to the stroke volume?

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bacterial infection of the breast usually caused by Staph aureus

assoc. with breast feeding

warm, erythematous breast

tx: drainage and dicloxacillin like antibiotic

can progress to abscess (mass)

infection in the subareolar region

usually seen in smokers due to low Vitamin A

causing fibrosis, subareolar mass and nipple retraction

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mammary duct ectasia

mass with green brown nipple discharge

chronic inflammation with plasma cells

classically seen in post menopausal multiparous women

Fat necrosis of the breast

calcification due to (saponification)

Fibrocystic change of the breast

no increased risk for cancer

normal change in premenopausal women

Fibrocystic change with apocrine metaplasia is benign but add:

 ductal hyperplasia, sclerosing adenosis:2xincreased risk for invasive carcinoma in BOTH breasts

atypical hyperplasia: 5x increased risk for invasive carcinoma in BOTH breasts

Intraductal papilloma

(if myoepithelial cells are absent think papillary carcinoma and often seen in postmenopausal woman)

Fibroadenoma

tumor of fibrous tissue and glands

mobile, marble-like mass

estrogen sensitive

no increased risk for carcinoma

fibroadenoma like tumor with an overgrowth of the fibrous component

creates leaflike projections

can be malignant and usually in postmenopausal

Pagets disease of the breast

Nipple ulceration and erythema and implies underlying carcinoma in the breast

detected as calcifications

doesn't have to be this obvious

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Fat necrosis (saponification)

and

Sclerosing adenosis

high grade cells with necrosis and dystrophic calcification in center of ducts

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Invasive Ductal carcinoma

desmoplastic strom is the structural support that grow with the tumor

subtypes:

Tubular Carcinoma (good prognosis)

Mucinous Carcinoma (good prognosis and seen in elederly)

Inflammatory Carcinoma (cancer in dermal lymphatics: seems like acute mastitis, but antiobiotics dont resolve it, poor prognosis bc near lymph)

Medullary Carcinoma (high grade cells with lots of inflammatory cells, assoc. with BRCA1 mutations)

LCIS

risk factor for invasive carcinoma

no basement membrane invasion

found incidentally

does not make a mass or calcification

dyscohesive cells lacking E-Cadherin

often multifocal and bilateral

Tx: Tamoxifen and close follow up

low risk of progressiont o invasive carcinoma

Invasive Lobular Carcinoma

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Metastasis

and the most useful factor is spread to axillary lymph nodes bc most pts don't present with metastasis

sentinel lymph node biopsy is examined to see if there is spread

Her2/neu is a cell surface receptor due to gene amplification

we have synthetic antibodies against this receptor. What is it?

Breast cancer that is negative for ER, PR and Her2/neu

poor prognosis

AA women at increased risk

BRCA2

rare

associated with Kleinfelter syndrome

subareolar mass in older males

usually invasive ductal carcinoma (bc men don't usually develop lobules)

Sulfonylureas

(1st gen:Tolbutamide, Chlorpopramide)

(2nd gen:Glipizide, Glimiperide, Glyburide)

increase endogenous insulin

Creatinine>2.0

Metformin is absolutely contraindicated in patients with renal failure due to the risk of lactic acidosis. An elevated serum creatinine suggests a decrease in GFR and the presence of renal failure.

Metformin is a drug in the biguanide class used to treat diabetes mellitus type II. Metformin treats hyperglycemia by inhibiting gluconeogenesis. Metformin carries no risk of hypoglycemia, but is known to occasionally cause lactic acidosis in patients with renal failure, liver dysfunction, CHF, alcoholism, and sepsis.

Ist generation Sulfonylureas

Tolbutamide

Chlorpropamide (especially)

Diabetic drug that is a GLP-1 agonist (analog)

• GLP-1 is an incretin released from the small intestine that aids glucose-dependent insulin secretion
  • basis for drug mechanism is the observation that more insulin secreted with oral glucose load compared to IV
    
• exenatide is a GLP-1 agonist
  • ↑ insulin
  • ↓ glucagon release

Bile acid resins

Cholestyramine

Colestipol

Colsevelam

inhibits reabsorption of bile acids in the jejunum and illeum

decrease LDL levels

cause GI upset and bad taste

These and the statins are not good for ppl that lack LDL receptors (familial hypercholesterolemia

Spironolactone

potassium sparing

competitive aldosterone receptor antagonist that works at the cortical collecting tubule and late distal tubule of nephron

others: Triamterene and Amiloride: potassium sparing diuretic that blocks sodium channels in distal cortical collecting tubule. used in pts that lack endogenous aldosterone (Addisons)

Triamterene and Amiloride

: potassium sparing diuretic that blocks sodium channels in distal cortical collecting tubule. used in pts that lack endogenous aldosterone (Addisons)

Lewy bodies of parkinsons

Picks disease also

Wind, Water, Wound, Walking, Wonder drugs

Atelectasis

UTI

Infection (few days after)

DVT

Drug reaction

Know it

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Which ligament cotains the uterine vessels?

CARDINAL

Which ligament contains the ovarian vessels?

SUSPENSORY

What type of epithelium is found in the vaginal canal to the ectocervix?

endocervix to fallopian tube?

ovary?

vaginal canal: stratified squamous

endocervix to fallopian tube:simple columnar

ovary:simple cuboidal

Seminal vesicles

epididymus

ejaculatory duct

ductus deferens

What are the positve sx of schizophrenia?

Negative sx?

Positive: hallucinations, delusions, strange behavior, loose associations

Negative: flat affect, social withdrawl, thought blocking, alogia, poor grooming, poor motivation

things you see with Wilm's tumor

W-Wilm's tumor

A-Aniridia

G-Genitourinary malformations

R-Retardation

Testicular feminization

defect in the DHT receptor

phenotypically female

elevated testosterone, LH, and estrogen

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Testosterone cannot be converted to DHT

phenotypic male

early defect is ambiguous genitalia

increased Testosterone at puberty causes normal genitalia

normal testosterone, estrogen and LH

Tay sachs

Niemann Pick or

Central retinal artery occlusion

cGMP phosphodiesterase inhibitor

causes an increase in cGMP and an increase in relaxtion of smooth muscle in corpus cavernosusm and erection

Side effect: hypotension if taking nitrates

impaired blue green color vision

flushing

headache

dyspepsia

Candida albicans

often cause by poor hygeine in uncircumcised men

BPH and male pattern baldness

5alpha reductase inhibitor which prevents conversion of Testosterone to DHT

Flutamide

used to treat prostate adenocarcinoma

Phenylalanine

↓

Tyrosine

↓

DOPA

↓

Dopamine

↓

Norepinephrine

↓

Epinephrine

What are these drugs for?

Cholestyramine

Venlafaxine

Fluphenazine

Phentolamine

Cholestyramine: Bile acid binding resin

(lipid lowering agent and can bind C.diff toxin)

Venlafaxine: SNRI antidepressant

Fluphenazine: Typical neuroleptic

Phentolamine: Reversible non selective alpha blocker

What are these drugs for?

Captopril

Tazodone

Carteolol

Clarithromycin

Captopril: ACE inhibitor

Tazodone: antidepressant (Assoc. with priapism)

Carteolol: Beta blocker (glaucoma)

Clarithromycin: Macrolide

What are these drugs used for?

Famotidine

Fluvoxamine

6-mercaptopurine

Selegiline

Terbinafine

Clozapine

Famotidine: H2 blocker

Fluvoxamine: SSRI

6-mercaptopurine: Anti-cancer drug

Selegiline: MAOI (parkinsons)

Terbinafine: Antifungal

Clozapine: Atypical antipsychotic

Theca cells (stimulated by LH) has 17alpha hydroxylase and can turn cholesterol into androtenedione

Granulosa cells (stimulated by FSH) have aromatase and turn the andostenedione into estradiol

decreased estrogen

Increased GnRH

Increased FSH

Increased LH

trichomonas

bacterial vaginosis (gardenella ex)

fallopian tubes

uterus

upper portion of vagina

Leuprolide given pulsatile is a GnRH__

Leuprolide given continuously is a GnRH___

pulsatile: agonist

continuously: agonist

Leptospira (spirochete)

Hanatavirus (virus)

What class of med do these drugs belong?

Primaquine

Saquinavir

Betaxolol

Prazosin

Thiopental

Tranylcypromine

Setraline

Temazepam

Desipramine

Captopril

Busulfan

Moxifloxacin

Zanamivir

Miconazole

Primaquine: Antimalarial

Saquinavir: Protease inhibitor

Betaxolol: Beta1-blocker

Prazosin: alpha1-blocker

Thiopental: Barbituate

Tranylcypromine: MAOI

Setraline: SSRI

Temazepam: Benzodiazepine

Desipramine: TCA

Captopril: ACE inhibitor

Busulfan: DNA alkylating agent

Moxifloxacin: Flouroquinolone

Zanamivir: Antiviral

Miconazole: Antifungal