Semester 4 flash review
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What differentiates bipolar II disorder from dysthymic disorder?
Bipolar disorder II needs at least 1 major depressive disorder and at least 1 hypomanic episode. On the other hand, dysthymic disorder involves depressed mood but never a major depressive episode within 2 years.
Major depressive episode indicates major depressive disorder. What does manic episode or mixed episode indicate?
Bipolar I disorder.
What is the first line treatment for someone who has experienced anhedonia, lack of concetration, insomnia, lack of energy, and no appetite for 2 weeks?
This person is experiencing a major depressive episode which may suggest major depressive disorder.
- - SSRI (Fluoxetine, Paroxitine, Escitalopram, citalopram, sertaline)
- - SNRI (Duloxetine, venlafaxine, desvenlafaxine)
- - Buproprion (MOA: NE & DA uptake inhibitor)
- - CBT
- - Interpesonal therapy
What do Adrenoleukodystrophy and Guillain-Barr syndrome have in common.
They both cause damage to the myelin sheath of the peripheral nervous system. Repair leads to onion bulbs.
ALD- is a leukodystrophy that casues damage because of the inability to break down VLCFA which leads to myelin damage.
GBS- an inflammatory reaction in which the immune system attacks the myelin sheath. Remember it is an ascending paralysis.
What are the three main dystrophies and how are they related?
- - X-linked, early onset, girdle weakness, cardiac fibrosis, no dystrophin present.
- - X-linked, later onset, girdle weakness, no cardiac fibrosis, low dystrophin present
- LIMB-GIRDLE DISEASE
- - autosomal*, later onset, girdle weakness (shoulder and hips)
Patient presents with ptosis, diplopia, and easy fatiguibility. What are two possible inflammatory myopathies that could present with these symptoms and how would you differentiate them?
Ach is affected.
- Myasthenia gravis- ab attack the ach receptors.
- - thymoma related
- - Positive tensilon test but negative ach test
- Lambert-Eaton Syndrome- ab attack the Ca2+ channel
- - bronchogenic carcinoma related
- - Negative tensilon test but postive ach test
16 year old patient presents with the following symptom
- Weakness in the upper limb
- Vision problems
Physical exam yields
- Dilation of left eye during swinging flashlight test
- (+) Lhermitte sign
- Inability to laterally abduct the left eye.
- Decreased vibration & proprioception in the upper extremities
What is the most likely diagnosis?
- -Marcus gunn pupil
- - bend head -> electric shock
- - 6th cranial nerve palsey
The diagnosis is most likely Multiple scelrosis.
What is the similarity between achalsia and mallory weiss sydrome?
They both cause dysphagia.
Mallory weiss sysndrome is a tear at the esophagogastric junction due to excessive retching.
Achalasia - is no relaxation of the LES because there is no NO or VIP inhibition.
2 Causes of non cardia gastric adenocarcinoma
H. Pylori or autoimmune causes -> chronic gastritis -> noncardia gastric adenocarcinoma
Atrophic gastritis w/ intestinal metaplasia -> gastric adenoma -> noncardia gastric adenocarcinoma
What is the relationship between rotavirus & calcivirus
They both cause watery diarrhea
- - naked dsRNA, <2yoa, fecal oral spread, rotarix vaccine
- - (+) ssRNA naked, >5 yoa
- - Histo crypt cell hyperplasia, and cytoplasmic vacuolization
What is the relationship between Giardia, whipples, and celiac disease?
They all cause steatorrhea
- - brush border disruption
- - via actinoycete -> lymphatic transport disruption
- Celiac Disease
- - Gluten -> immune reaction -> disruption in terminal digestion at brush border and transepithelial transport.
- HISTO: intraepithelial lymphocytes.
- AVOID: wheat, rye, or barley.
What is the relationship between Halothane and Nitric oxide?
They are both inhalational anesthetics that induce vomiting.
- Halothane: low minimum alveolar anesthetic [ ] = slow onset and slow recovery.
- - A/E halothane hepatitis via trifluoroacetic acid, bromide, & chloride ions.
- Nitric Oxide: >100% MAC = fast onset & fast recovery -> dental procedures
- - MOA: competitive inhbition of NMDA receptors (glutamate = excitation receptors for learning, memory, neuron communication, and regulation.
What is the relationship between Horner's syndrome and Syringomyelia?
Lesions that damage sympathetic outflow from the hypothalamus.
- Horner's Syndrome: lesion to cervical sympathetics
- - CLINICAL: ptosis, miosis, anhydrosis
- Syringomyelia: cyst in the spinal cord
- - interruption to preganglionic sympathetic outflow from thoracic spinal intermediolateral cell column
Which axis II disorders have difficulty in relationships?
Paranoid: distrust & suspicious of everyone
Schizoid: Not interested in relationships. independent
Schizotypal: Socially awkward -> no capacity for intimate relationships
Antisocial: Too busy violating others rights
Borderline: instable relationships. Poor impulse control and self image.
Narcissistic: grandiosity (deep down they may feel worthless)
Avoidant: fear of rejection
Dependent: relationship to relationship
Histionic: drama queen
What is the similarity between glucagon, epinephrine, and cortisol?
- They all increase:
- - gluconeogenesis
- - lipolysis
- - glycogenolysis
- - protein catabolism
- Epinephrine inhibits insulin secretion (augmented by incretins)
- Cortisol induces peripheral insulin resistance
- Glucagon stimulates insulin secretion
What is the similarity between insulinoma and type 1 diabetes?
They both cause some CNS dysfunction.
Insulinoma: episodic hypoglycemia, CNS dysfx, reversed with glucose.
- TYPE1 DM: no insulin = glucose >250mg/dl, ketone breath = DKA
- - Gets better with insulin
What do Nephropathy, retinopathy, neuropathy have in common.
The common denominator is the cause. They are all caused by vascular insufficiency, microangiopathy, which is caused by chronic diabetes mellitus. High glucose gets taken up in the blood vessels which then turn thick and weak leading to leakage and insufficient perfusion to the organs and in the end necrosis.
What is the relationship between an insulinoma and gastrinoma?
Both may be casued by a pancreatic endocrine tumor.
Associated with MEN 1 gene which also affects the parathyroid and pituitary.
- Hyperinsulinism (55%)
- Hypergastrinemia ( 36%)
- VIPoma (5%)
What is the relationship between Trichomonas & gardnerella?
- - foul smelling
- - are dx via wet mount
- - treated w/ metronidazole (nitroimidazole)
- -along with candida cause vaginitis
- - sexually transmitted
- - normal flora or sexually transmitted
What is the treatment for the patient that is complaining of adnexal pain, vaginal discharge, N/V/F
Possible complications if untreated
- ectopic pregnancy
- Fitz-Hugh Curtis syndrome (perihepatitis & peritoneal fibrous adhesions)
- N. Gonorrhea- treat w/ ceftriaxsone(cephalosporin) or if allergic w/ streptomycin
C. Trachomatis(D-K)- treat w/ doxycycline or azithromycin
What is the diagnosis and treatment of a sexually transmitted disease that presents with one of the following
- painless chancre
-cutaneous lesions or condylmata lata
The organism is treponema pallidum = syphilis
- 1st stage = DFA for antigen under darkfield micro.
- later stage = reagin(VDRL, RPR card, ART) if (+)
- then anti-treponemal ab (FTAB or TPPA)
Treatment = Benzathione penicillin or Penicillin G
A patient presents with one of the followning
-painless lesion, fever, headache, myalgia
-inflammation & swelling of LN
- ulcers, fistulas, genital elephantiasis or groove signs
Where has this patient recently traveled to?
These are the three stages of lymphogranuloma venerum which is caused by chlamydia trachomatis (L1,L2,L3)
It is seen in Africa, Asia, South America
What do adenovirus and BK virus have in common?
- - are naked dsDNA and cause Urinary tract infections
- - linear DNA
- - transmit via contact, fomite, droplets
- - DX: ELISA of viral isolation from urine
- BK virus
- - circular DNA
- - transmit via respiratory route
- - DX: immunohistochemistry for large T ag
What viral disease causes
PRIMARY: painful lesions, inguinal lymphadenopathy, dysuria, fever & malaise
RECURRENT: lesions & vulvar irritation
- Herpes simplex
- - enveloped dsDNA linear
- - Transmitted via sex, saliva spread or skin inoculation
- - DX: tzanck (giant multinucleated cells) or immunofluorescence
- - TX: acyclovir
What are 4 raised skin lesions
- 1. Papule = <5mm
- 2. Nodule = > 5mm
- 3. Plaque = >5mm w/ elevated flat top
- 4. Wheal (urticaria)
What is the relationship between epehlis, cafe au lait, or lentigo?
- Epehlis and lentigo look alike grossly
- Ephelis and cafe au lait look alike histologically
- - change with season
- Cafe au lait
- - neurofibromatosis
- - Dont darken with sun
- - elongation and thinning of rete ridges (hyperplasia of melanocytes at basal layer)
What is the relationship between melanocytic & dysplastic nevi
Both can lead to melanoma
Melanocytic = well-defined borders, < 6mm across, and hormone sensitive
Dysplastic = > 5 mm, irregular borders, and variegation
What is the treamtent for the agent that causes a rash that is red, slightly swollen, well demarcated, warm, and tender to the touch.
Gram stain is violet.
The CA is streptococcus group A. Gram (+) and catalase(-)
What are the main differences between the two types of IBD?
- Crohn's Disease:
- - segmental & transmural
- - all of GI tract
- - knife-like fissures/ deep ulcers
- - granulomas
- - cobblestone appearance
- Ulcerative Colitis:
- - Mucosa & submucosa only
- - rectum & colon
- - Broad fissures w/ pseudopolyps
Female patient presents with
- abdominal discomfort relieved by defecation
- change in appearance of stool
- change in frequency of stool
What would be treatment options for this patient?
- IBS is the disease
- 1. opiod agonist (loparimide, diphenoxylate)
- 2. Bile salt Resin (cholestyramine)
- 3. Octreotide (~ somatostatin)
- 4. Alosetron (5HT3 receptor antagonist)
- 5. Spasmolytic (dicyclomine- muscarinic receptor antagonist)
What are the two kidney conditions that will lead to RBC casts in the urine
- Acute glomerulonephritis (post infectious glomerulonephritis)
Both = rapidly progressive glomerulonephropathy
Patient presents w/ dysuria, frequency, and urgency.
Dipstick test shows leukocyte esterase (+)
What would you use to narrow down the possible agents?
- Nitrite (+): enterobactericeae
- - E. Coli
- - Proteus Mirabilis (urease +)
- - Klebsiella Pneumoniae (lactose fermentor)
- - Staphlococcus saprophyticus (coagulase -)
- - enterococcus (group D strep)
What is the difference between somatization disorder and hypochondriac
Somatization usually with depression or anxiety. They really need more care than a cure. Multiple symptoms. Manifestation of an emotional or mental problem into a physical problem.
Hypochondriac- someone has a disease and they see themselves as having the same disease. Delusional. They demand treatment. Maybe they want the same attention that a person with the actual disease is getting.
Patient comes in complaining of amenorrhea and discharge coming from her nipples.
What are your differentials?
What is the most likely cause and what is its treatment?
- - pregnancy
- - primary hypothyroidism
- - corticosteroid
- - Drugs
- Hyperprolactinemia is most likely (prolactinoma)
- - bromocriptine or cabergoline (DA agonist)
Patient complains of their ring fitting too tightly recently.
What test would you perform and how would you treat this patient?
- IGF-1 (high)
- Glucose load (GH does not decrease)
DX: excess GH hormone = acromegaly
- - octreotide (somatostatin)
- - sandostatin (SR octreotide)
- - Pegvisomant (GH antagonist)
Treatment for patient who has small cell lung carcinoma and low dark urine otuput.
What are the hypoglycemic agents that stimulate insulin release?
- Sulfonylureas: (Tolbutamide, chlorpropamide, Glyburide, Glipizide, Glimepiride)
- bind ATP sensitive K channels -> insulin release
- Meglitinides: (repaglinide)
- Similar to suflonylureas but at different site
What is insulin resistance associated with?
- pro-inflammatory states
- microangiopathic conditions
What are the 3 signs of Von Gierkes?
MAINLY its a G-6-phosphatase deficiency
- 1. hepatomegaly: no breakdown of glycogen or formation of glucose
- 2. hypoglycemia: no glucose from the liver
- 3. acidosis: pyruvate accumulation and uric acid accumulation
Poorly demarcated lobules, large uniform cells, delicate fibrous septa w/ lymphocytes.
MARKERS: PLAP & hCG
What is this? And what is the prognosis?
Seminoma, a germ cell tumor
- Occurs between 30-40yoa, metastizes to para aortic LN
- Gross: solid mass w/ homogenous yellow grey cut surface.
Prognosis: 90% cure rate w/ radiotherapy & chemotherapy
What is this? What is it grossly? How to DX? and TX?
HISTO: glandular with 1 layer of epithelium, large nuclei & nucleoli.
Metastasis: perineural, LN, blood (osteoblastic metastasis)
- Prostate Adenocarcinoma
- GROSSLY: gritty stone-like consistent nodules in the peripheral zone.
DX: Transrectal core needle biopsy, radionuclide bone scan
TX: prostatectomy, radiotherapy, orchiectomy, LH antagonist
Relationship between Acute bacterial prostatitis and chronic bacteria prostatis
- clinical- fevers, chills, dysuria, painful & boggy prostate.
- Labs- neutrophils & microorganisms in secretions.
- clinical- lower back pain, dysuria, perineal or suprapubic discomfort.
- Labs- mononuclear cells & bacterial culture.
What are the causes of breast pain that is tight or burning and localized & unilateral.
- Noncyclic breast pain
- proximal tissue pain
- FA imbalance
What is usually the cause for breast pain that has nonbloody discharge, is bilateral, and itchy?
What age group would you expect it in?
- Fibrocystic changes
- CA: reproductive hormone levels.
- It is smooth, well defined and mobile.
Females in their 30's are usually the ones to get this.
Dimorphic fungi- oval shaped, yeast budding, rosettes or sleeves
- plant puncture wound -> lymphocutaneous -> LN
Infects only keratinized tissue
its monomorphic filamentous fungi
anthropophilic/ high inlfammation reaction
- - trichophyton (skin hair, nails)
- - microsporium (skin & hair)
- - Epidermophyton (skin & nails)
Patient presents w/ flu-like illness that either regresses or leads to:
headache, myalgia, conjunctival suffusion(Weils disease) and eventually MSOF.
What is the virulence factors of the organism and how do you treat it.
- Leptospira interrogans
- Virulence: hook-like OMPs and 2 periplasmic flagella(burrowing)
TX: cefotaxime, doxycycline, penicillin, ampicillin, & amoxicillin
Patient presents with:
irregular fever, headache, chills, myalgias, polyarthralgias, petechia, & maculopapular rashes on hands and feet.
Histo: pleomorphic rod that contains long filaments & produce granules & swellings
How do you treat this?
TX: Penicillin G (prophylaxis for 3 days after bite)
Drugs that can inhibit lanosterol 14 demethylase
- IV: fluconazole(goes everywhere) & itraconazole
Topical: ketoconazole(inhibit human sterol synthesis) & miconazole
2 drugs that inhbit squalene epoxidase.
What are their similarities and differences?
Both available topically and attack dermatophytes & M. furfur.
Terbinafine: distributed to keratinized tissue and also attacks Candida
Tolnaftate: For cutanous mycoses (not palm,soles, nails)
Differentiate between the 3 enterobacteriacea that cause watery diarrhea
- secrete toxin to inc cGMP or cAMP
- Low grade fever
- biofilm then cytotoxin which leads to loss of microvilli which causes malabsorption
- Low grade fever
- intimin/BFP attach leads to actin condensation which leads to loss of structure and malabsorption
- High grade fever
- *no toxin
What are the characterisitcs of rotavirus
- dsRNA naked
- <2 yoa diarrhea
- Vaccine: rotarix & RotaTeq (or IgA is the best protection so breast milk)
What are the characterisitcs of calicivirus
- caliciviridae (also norovirus)
- (+) ssRNA naked
- > 5 yoa diarrhea
- villi, crypt cell hyperplasia, cytoplasmic vacuolization
Protozoa that causes bloody diarrhea
- Entamoeba histolytica:
- deep ulcers in colon (flask shaped)
- digests epithelium and RBC
- Trophozoite= spokes wheel nuclei
- Cyst = 4 nuclei w/ inclusions
- ameoba abcsesses
What type of diuresis presents with >2.5L/day
- can be caused by a PTH secreting tumor in the lung
Water Diuresis <250mOsm/kg & SG <1.010
- PTH -> hypercalcemia -> NDI
What type of polyuria does diabetes mellitus cause
Solute Diuresis >250mOsm/kg & SG > 1.010
What is the difference between positive symptoms and negative symptoms schizphrenia?
- mesolimbic involved
- Psychotic- delusion and hallucination
- Disorganized- speech, behavior, and inappropriate affect
- mesocortical involved
- Flat affect, alogia, and avoltion
Patient presents with Hallucinations and somatic delusions for 1 month. What are possible side effects when treating this patient?
This is positive symptom schizophrenia invovling the mesolimbic division
- TX: D2 receptor block
- A/E: motor defects, inc prolactin, blockage of H1,A1 or muscarinic receptor.
- 1. Haloperidol
- 2. Chlorpromazine: (A/E: neuroleptic malignant syndrome or malignant hyperthermia)
15 yoa Patient presents with Flat affect, alogia, and avolition for 1 month. What is the best treatment for this patient?
This patient is presenting with the negative smptoms of schizophrenia so the best start is with atypical medication. Since the patient is 15 yoa it might be best to give:
- - Partial agonist @ 5HT1 & D2/ antagonist @ 5HT2A
- - No H1, A1, M1 block
What behavioral treatment of depression focuses on mood related pattern of thinking?
- Cognitive-Behavioral therapy
- GOAL: recognize negative thoughts & behaviors and replace them with healthier ways of thinking.
- - behavior activation(schedule enjoyable time and ID obstacles.
- - cognitive restructuring
What are the hormones synthesized by the throid gland?
Thyroxine, triiodothyronine, and calcitonin
What are the characteristics of a nodule that does not induce the production of T3 and T4 and is related to a RET mutation?
- Papillary carcinoma:
- - Psammoma bodies
- - optically clear nuclei (orphan annie)
- - coffee bean groove nuclei
- - intranuclear inclusion
What is the difference between a moth eaten colloid scalloped thyroid and a thyroid gland with lymphocytes and hurthle cells
- 1. Associated with Graves disease
- - Dec TSH but increased T3 and T4
- 2. Associated with Hashimoto's thyroiditis
- - Inc TSH but decreased T3 and T4
Both are diffuse firm nodules.
Patient with known hyperthyroidism presents with extreme fever, flushing, and agitation after an infection
PE: reveals a diffusely enlarged firm thyroid gland.
What is the possible diagnosis and its treatment?
- - B-blockers (because b receptor sensitivty has increased)
- - Propylthiouracil (blocks T4 to T3; also blocks thryoid peroxidase)
- - Hydrocortisone (help adrenal gland deal with stress and blocks T4 to T3)
- Iodide (Wolff-Chaikoff effect)
Male patient complains weakness and shortness of breath and bloody diarrhea.
Hb = 9g/dL
Hct = 35%
MCV= 70 fL
Serum ferrtin = 20ng/mL
What is most likely helminth to cause this clinical presentation?
Hook Worm: Ancyclostome or Necator
- Found in the tropics
- drinks blood --> iron deficiency anemia.
- Moving around --> bloody diarrhea.
Patient presents with a simple seizure of the left arm. Patient also complains of headache, fever, and nuchal rigidity.
Mini mental status exam shows some mental impairment.
What is the helminth most likely responsible for this presentation.
- Taenia solium
- From human to human = cystericercosis
- Usally found in Mexico, SA, and Asia
Patient complains of abdominal pain, explosive diarrhea, and vomiting.
Organism grows on Thiosulfate-citrate-bile salt agar.
Fecal WBC in stool
- Vibrio parahaemolyticus.
- Inflammatory diarrhea
- Tissue invasion
Enterobactericeae that cause inflammatory diarrhea
- SLT= hemolytic uremic syndrome leads to acute renal failure in kids
- DX: non-sorbitol fermentor
- mucoid bloody diarrhea
- Present with FEVER
- DX: glucose fermentor/ H2S/ non-lactose fermentor
- Typhi (fever & rose spots via macrophages)
- Nontyphi ( N/V/F/nonbloody diarrhea/ abd cramps)
- DX: Glucose fermentor, NON-MOTILE
- Endocytose, replicate, invade and form mucosal abscesses.
- Dysenteriae (fever, abd cramp, tenesmus, mucoid bloody diarrhea & friable rectal mucosa)
What are the conditions that lead to intestinal adenocarcinoma?
1. Familial adenomatous poluposis (Gardeners & Turcot)
2. Sessile serrated adenoma (R colon involved)
3. Intestinal adenomas(tubular or villous)
4. microsatellite instability
Polyps that are overgrowth of normal tissue and have mucocutaneous hyperpigmentation.
Patient has mucosal freckles.
Peutz- Jeghers, a hamartoma (sessile and pedunculated)
A type IV collagen defect that results in renal failure and subtle nerve deafness.
Injury & remodel -> thick & thin GBM
interstitial fibrosis w/ foam cells
mesangial hypercellularity & sclerosis.
Can be caused by Thin BM disease(benign familial hematuria)
A congenital cystic kidney disease that damages the collecting duct and presents with a spongiform kidney in kids.
Also presents with congenital hepatic fibrosis
- PKHD1 leads to fibrocystin mutation
If B/L at birth leads to renal failure
A patients blood gas profile reads
PaCO2 = 25
What is the best way to treat this patient
- Patient has metabolic acidosis.
- Possible causes are MUDPILES or DURHAM
TX: 0.7x body wt x (12-HCO3)
A patient with COPD comes in cyanotic, blood gas is drawn and shows what?
- pH= low (6.1)
- HCO3 = high (40)
- PaCO2 = high (50)
This is respiratory acidosis.
What are the causes of edema?
Increased hydrostatic pressure (CHF, DVT)
Decreased Plasma oncotic pressure (nephrotic syndrome)
Inlfammation (cellulitis, bee sting)
What is the difference between granulosa of proliferation and granulosa lutein?
- Makes estrogen out of androgen from the theca layer
- Granulosa lutein:
- Makes estrogen out of androgen form the theca lutein layer
- Makes progesterone
Well circumsrcibed, elevated, covered w/ crusts or scales lesion.
Clinical: Itching or burning vagina.
What 2 conditions can it lead to?
VIN -> CIS(Bowens disease)
Differentiated -> keratonizing SCC (also lichen sclerosis)
Undifferentiated -> basaloid carcinoma (HPV 16,18,31 association)
How do you treat the virus that presents with the following:
- intial febrile stage followed by rash formation.
-IF chronic hemolytic anemia -> aplastic crisis
- B19 virus
- aplastic crisis because kills mitotically active erythroid progenitor cells
- healthy = supportivc
- Anemic= blood transfusion
- Chronic infection = Ig IV
What virus presents with red lesions on back, fever, lymphadenopathy, macular rash, mild arthralgia.
Enters via nasopharynx -> LN -> rash athralgia
- Rubella virus
- Enveloped ssRNA virus
Patient has a comminicating hydrocephalus. Is admitted to the hospital and on physical exam presents with dilated left pupil that does not constrict and is located down and out. Patient also has homonymous hemianopsia of the right eye.
Patient presents with Kernohans notch. (leg extension)
What is the most likely cause for this presentation and what other complications must you worry about?
The communicating hydrocephalus lead to a herniation. The specific herniation for this case is an uncal herniation becasue of the involvement of cranial nerve III (dilated and down and out position)
The other complication that you have to worry about in this patient is death because in an uncal herniation there will be increase pressure on the brainstem -> duret hemorrhages in the mesencephalon and pons presenting with decorticate posture, lethargy and death if allowed to affect the recticular formation.
Patient presents with bipolar disorder I disorder. What are possible treatments that focus on the manic part of the disorder?
Which onns must be monitored?
- Lithium: Narrow TI (MOA = Na+ substitute)
- - check function of kidneys, thyroid, and fasting blood glucose levels.
- ANTICONVULSANTS: deplete inositol -> increase nerual plasticity and growth
- - Carbamazepine: SJ syndrome, suicide, w/ alcohol = depressant
- - Valproate: Monitor plasma levels and weight
What is the difference between intelligence and achievment?
Intelligence is the capacity to learn so therefore it can not be improved theoretically. Used for mental retardation.
Achievement is what you have or should have learned depending on your age. This can improve. If it is low check for any developmental problems or lack of opportunity or abuse and neglect that might explain a poor achievement score.
What are the criteria for alcohol dependence?
At least 3 for the past 12 months
- - tolerance or withdrawal
- - use more than intended
- - want to cut down
- - spends too much time obtaining substance
- - give up important activities for substance
- - use even if they know of the problem
A 28 year old male patient presents with scary hallucinations prior to having a tonic-clonic seizure. The patients girlfriend stated that he usually gives up hanging out with friends to stay home and drink by himself.
What are possible treatment options for this patient.
This patient is alcohol dependent and the symptome he is presenting with are those of alcohol withdrawal specifically delirium tremens
- BZ (diazepam, lorazepam, or oxazepam)
- Antisz (carbamazepine or valproate)
- Clonidine (agonist at presynaptic auto receptors of alpha adrenergic sites)
What are the actions of Parathyroid hormone?
- 1. decrease phosphate reabsorption
- 2. increase calcium reabsorption
- 3. 1,25-(OH)2D3 -> inc intestinal calcium absorption
- 1. increase relaease of clacium into plasma
What drugs can be used in a patient who has kidney failure and labs that read
BUN & CREATININE: high
Serum Calcium: low
- This is secondary hyperparathyroidism:
- Kidney cannot excrete PO4, absorb Ca or make calcitriol
- 1. Calcitriol- inhibit PTH synthesis
- 2. Paricalcitol- Dec PTH absorption from GI
- 3. Sevelamer- phosphate binder -> no GI PO4 absorption
- 4. Cinacalet- Ca senzitizer of PTH
A patient presents with the following signs
(+) chvostek sign
(+) trousseau sign
What is the most likely diagnosis?
- It is most likely hypoparathyroidsm
- - low PTH
- - hypocalcemia
- - hyperphosphatemia
Drug that is a PTH analog at moderate doses which allows it to have an anbolic effect on bone for advanced osteoporosis or fractures
but it is contraindicated in Pagets disease, open epiphyses, or skeletal irradiation.
What is the role of orlistat?
Inhibits lipases in GI lumen -> no TG hydrolysis -> decrease fat absorption by 30%
Embryo origin of the adrenal medulla and cortex?
- Medulla form the neural crest cell ectoderm
- - EPI & NEP
- Cortex from the mesoderm
- - Glomerulus- aldosterone
- -Fasiculata - cortisol
- - Reticularis- androgens
Patient is presenting with an acute abdomen. On PE patient has cullen's sign and Grey Turner's sign. What are the most likely causes for this presentation?
This patient has acute pancreatitis-> enzyme induced necrosis and is in the peritoneum
- abdominal ulcers
2 types of acute cholecystitis
calculous -> ischemia +/- bacteria
Acalculous - caused by ischemia
40 yoa male patient presents to the ER with SOB and dizziness. Patient complains of vomiting bright red blood this morning.
What would be the most effective treatment for this patient.
The most likely cause of this patients symptoms is esophageal varices rupture leading to an acute bleed which is causing the symptoms.
- TX: octreotide or terlipressen(vasopressin analog)
- - then endoscopy if still bleeding retreat with meds or move on to balloon tamponade (w/without TIPS)
3 yoa male patient presents with colicky pain, bilious vomiting and red currant jelly in their stool.
What would be your initial treatment?
- This patient has intussusception.
- Most likely ileocolic
- First treatment is to use barium enema pressure to push out the intussuscetpion.
A 6 year old female patient presents with right upper quadrant pain, fever, jaundice, and splenomegaly.
What started this?
Charcot's triad -> ascending cholangitis from hereditary spherocytosis(AD spectrin defect -> Na swelling -> macrophages eat -> hemolysis -> black pigment stones -> obstruction -> cholangitis
Patient presents with Henoch-Schonlein purpura syndrome.
What are the symptoms?
This is IgA nephropathy AKA Berger Disease
patient presents with proteinuria and hematuria.
What are the three main causes associated with this pathology?
This is the crescent shape of RPGN
1. Anti-GBM (linear IgG)
2. Immune complex disease (progression of other glomerular diseases)
3. Pauci immune (ANCA, systemic vasculitis)
Patient presents with maltese cross and > 3.5 g/day of protein in their urine. They also have hyperlipidemia. What are the causes?
This is nephrotic syndrome. All have loss of foot processes.
- 1. Minimal change disease (TX: steroids)
- 2. Focal segmental Glomerulosclerosis* (juxtamedullary glomeruli sections no deposits, maybe trapped)
- 3. Membranous GN (subepithelial -> thickened GBM, granular IgG and C3 on IF)
- 4. Membranoproliferative GN (Double GBM or ribbon like pattern)
A patient is currently on a thiazolidinedione.
What kidney complication are you most worried about in this patient?
Thiazolidinedione is a type II diabetic drug that activates PPARy -> dec insulin resistance in muscle & adipose tissue.
Since this patient is a diabetic you are worried about the metabolic and vascular disorders of the kidney.
1. Glomerular - GBM thickening, diffuse mesangial sclerosis, and nodular glomerulosclerosis
2. Nonglomerular- Arterioscelrosis, pyelonephritis, or tubular BM thickening (PAS stain)
Which systemic glomerulonephritis would you expect to get a positive Congo red stain?
- Renal amyloidosis.
- amyloid is deposited in the GBM, mesangium, and vessels.
What is the pathogenicity of a patient that presents with intraductal papilloma
- It is a proliferative fibrocystic change that involves:
- - hyperplastic changes ( > 4 layers of epithelium)
- - sclerosing adenosis, which leads to the papilloma
- - mild atypia is present
There is a risk of developing breast carcinoma.
Inflammation of the breast that involves periductal plasma cel infiltration and distended lactiferous ducts.
Presents as a firm mass on palpation
Mammary duct ectasia
large tumor cells in syncytium-like sheets surrounded by dense lymphocytic infiltrate.
What is it.
- Meduallry carcinoma of the breast.
- GROSS: large soft circumscribed mass
HISTO: Malignant cells in chords, tubules, & solid sheets in dense reactive fibrous stroma.
Associated with pagets disease of the breast.
This is invasive ductal carcinoma.
You will also see Large pale vacuolated malignant cells within the squamos epithelium.
It would present as an irregular hard mass.
HISTO: no intercellular bridges in spongiosis layer.
Increases with immunosuppression
pearly telangietic -> rodent ulcers on the nose
Basal Cell carcinoma
Thickened hyperpigmented skin in flexure areas.
HISTO: see-saw pattern in the epidermis.
Seen w/ achondroplasia
- Acanthosis Nigricans
- Associated with FGFR3 which is why you will seen in patients with achondroplasia.
Treatment for methamphetamine abuse
Methamphetamine is a stimulant inhbits the reuptake of 5HT, DA, and NE
- - Disulfiram- inhibit dopamine B-hydroxylase -> reduce NE
- - Buproprion- replace methamphetamine because it inhibits uptake of DA and NE.
viruses that both cause hemorrhagic and contagious conjunctivitis in post neonates.
What symptom separates them?
- - pharyngeal-conjunctival fever
- Enterovirus 70 & Coxsackie virus A 24
- - pain and photophobia
An OIP that causes conjunctivits in neonates that must be treated or will lead to pneumonia.
What is the organism and what is the treatment.
- Chlamydia Trachomatis
- DFA or iodine stain will show inclusion bodies
- Must treat with oral erythromycin.
- - excreted in bile
- - prokinetic effects
- - it is a macrolide which attacks the 50S ribosomal subunit.
A 30 yoa patient is brought into the emergency room after a motor vehicle accident.Patient states that he did not see the car as it hit him from the left. On physical examination you note that the patient has no peripheral vision via the visual field confrontation. The patient then furthers explains that he has been having trouble seeing at night for about 10 years.
What is the most likely diagnosis and what additional characterisitc finding would you expect in this patient?
- This patient most likely has retinitis pigementosum which is destruction of the photoreceptors of the retinal pigmented epithelium. This explains the night blindness and tunnel vision that this patient is experiencing.
- On fundscopy you will see mottling of the RPE with black bone pigmentation.
What is the test used to confirm your diagnosis of a 20 year old female who presents with hyponatremia, hyperkalemia, salt craving and recently bronze pigmented skin?
This is Addison's disease (lack of cortisol)
Diagnosis is made via using cosyntopin. In Addisons disease there will be no increase in cortisol.
- replacement of mineralocorticoids & glucocorticoids for life.
How do you differentiate between the two main casues of increased aldosterone?
By the renin level
- Conn Syndrome:
- low level of renin
- usually cause of a tumor or hyperplasia
- Secondary hyperaldosteronism:
- High level of renin
- usually the cause of a decrease in renal perfusion
5 year old patient presents with constipation, weak proximal muscles, bluish discoloration around the eyes.
VMA/HMA levels are low
blue cell tumor
What is the diagnosis
Affects the adrenal gland and comes from the neural crest cells.
What is the significance of long-acting glucocorticoids?
Betamethasone & Dexamethasone
- They are available IV,oral and topical
- They cross placenta because they are less protein bound
- Used in premature delivery to increase the production of surfactant
What inhibits the 11 hydroxylase enzyme
- antagonist of corticosteroids
What do sickle cell anemia and Dubin Johnson syndrome have in common?
They are both causes of jaundice via the liver.
Sickle cell- is a hemolytic problem which will cause prehepatic jaundice and buildup of unconjugated biliriubin.
Dubin Johnson syndrome is a problem with the excretion of bilirubin which leads to build up and jaundice.
A single gene disorder in which a patient will present with asterixis, bronze skin, and hyperglycemia.
How would you diagnose it and treat it?
- Asterixis suggest liver failure most likely cirrhosis.
- Bronze skin and hyperglycemia suggests hemochromatosis.
Hemochromatosis leads to accumulation of iron in the liver and pancreas. Diagnosis via Prussian blue stain of a biopsy.
Treatment would include phlebotomy.
A paitents serology report reads:
alpha-HBsAG IgG; alpha-HBc IgG
What is this patients current status?
This patient has a resolved chronic infection with HBV virus.
What is genomic descriptor for the virus that is most likely to lead to chronic hepatitis?
It is HCV a +ssRNA enveloped virus.
What are the two main differences between the two main causes of kidney disease that causes eosinophilic dirty granular casts?
This is acute tubular necrosis.
- 1. Ischemia:
- segmental necrosis
- pale swollen cortex
- 2. Toxins:
- Straight necrosis
- red swollen cortex
Aspirin can lead to which 2 kidney conditions
- 1. Acute drug induced intersitial neprhitis:
- 2 weeks later -> granulomas & tubulitis
- 2. Analgesic nephropathy:
- Papillary necrosis & calcification & tubulointerstitial nephritis
What type of nurtitional recommendations would you make for a patient that has a GFR between 60-89mL/min?
- This is stage 2 of acute renal failure
- Calories- 35cal/kg/day
- Phosphorus - 40mg/kg
- Sodium- 2-3g/ day
- calcium tablets
- water soluble vitamins
protein restriction only in stage III and beyond.
Name the three malignant kidney tumors and a characteristic of each
- Renal cell carcinoma:
- chromophobic-perinuclear halos
- + colloidal iron stain
- Wilms tumor:
- Blastemam, eptihelium & immature stroma.
- Presents with abdominal mass
- Urolithelial tumors:
- Presents with painless hematuria
A benign kidney tumor that is similar in histologic appearance to chromophobe renal cell carcinoma. What is it that differentiates it?
Oncocytoma- filled with mitochondria
it stains (-) for colloidal iron stain
What is aprepitant and what is it used for?
How is it different from odansentron
- Neurokinin receptor antagonist: aprepitant
- Used for after chemo acute and delayed antiemetic.
- 5HT3 antagonists: odansetron
- Used only for after chemo acute antiemetic
What are two blue cell tumors?
Embryonal rhabdomyosarcoma and neuroblastoma
What tumor of the testis presents with Schuller-Duval bodies?
- Yolk sac tumors
- seen in children less than 3 years
Testicular cancer that contains large, hyperchromatic syncytiotrophoblastic cells.
Which antibiotics are known for increasing the QT interval?
- Macrolides and quinolones
- Erythromycin, Clarithromycin, Azithromycin.
Dont use with other drugs that increase QT intervals such as: antiarrhythmics, H1-antagonists, neuroleptics, TCA, and antimalarials.
What types of disease in the female reproductive system:
N/C > 1:2
Large multiple nucleoli
What are two anti-neoplastics that work using topoisomerase 2 as a target.
- Etoposide (natural product):
- Stabilizes topoisomerase2-DNA complex -> no religation of the strand
- Doxorubicin (cytotoxic):
- Free radical formation that is posionous to Topoisomerase 2
What is the antidote to the anti-neoplastic that gets metabolized into N mustard, a strong electrophile.
Cyclophosphamide -> N mustard
Mesna = antidote
Which anti-neoplastic drug blocks DHF reductase in the S phase?
Methotrexate. (cell cycle specific)
What are the three skin disorders that have the following characteristics:
epidermal, vascular or subcutaneous injury
- These are characteristics of acute inflammatory diseases
- 1. Urticaria:
- Mononuclear cells, eosinophils, superficial dermal edema, & superficial lymphatic swelling
2. Eczematous Dermatitis:
- Mononuclear inflammatory infiltrate w/ eosinophiles
- Could become chronic
3. Erythema Multiforme:
Target lesions- center = CD8 & periphery = CD4
What is the inflammatory skin disease with the following characterisitcs:
interepidermal monroes abscess, acanthosis, hyperplasia, parakeratosis.
Demostrates Auspitz sign
Psoriasis: Chronic inflammatory skin disease
Mehcanism of cerebral ischemia
Spreading depolarization -> excitotoxicity-> impaired microcirculation-> neuronal apoptosis
- 12-24 hours = neuronal swelling and nuclear pyknosis
- 24-48 hours = discoloration, laminar cortical necrosis and brain is soft and edematous
48-96 hours = macrophages come which lead to liquefactive necrosis
A 14 year old patient presents with altered mental status, purpura, photophobia, fever, headache, and nuchal rigidity.
What development must you worry about in this patient?
How do you prevent this clincal presentation?
This patient has meningitis caused by Neirsseria meningitidis. This can develop to waterhouse Friderichsen syndrome which includes DIC and renal insufficiency.
Prevention of this meningitis is accomplished by giving menomune (polysaccharide) or menveo (conjugate)
What are the 4 stimulant treatments for ADHD?
- Amphetamine salts
- methyphenidate hydrochloride
A newborn presents with periventricular calcification, obstructive hydrocephalus, chorioretinitis.
The doctor suspects this is meninigitis, which of the ToRCH organisms is responsible for this presentation?
- immunoperoxidase stain (+) for toxoplasma tachyzoites
How would you confirm the diagnosis of meninitis caused by mycobacterium tuberculosis?
Via Lowenstein-Jensen egg based medium
What is the treatment for a patient that presents with headche, fever, and nuchal rigidity.
There is also frotnal atrophy w/ iron deposits in nerve and glial cells.
- This is neuropsyphillis.
- Treatment is penicillin G IV.
What are the characterisitics of the viral meningitis that casues ascending paralysis?
Rabies (-) ssRNA enveloped virus
- prodrome = paresthesia
acute neurologic = furious rabies & paralytic rabies
Coma and death
- DX: skin w/ DFA stain
- CSF & serum ab
- negri body inclusion
What viral meningitis does measles virus cause?
Measles are (-)ssRNA enveloped viruses that cause subacute sclerosing panencephalitis.
- diffuse brain necrosis
- neurofibrillary degeneration
- viral inclusion in neurons & glia
Where do you usually find astrocytomas in children and adults?
- Children in cerebellar
- adults in cortex (supratentorial)
What are the characteristics of the most common tumor in kids?
- Highly malignant
- sensitive to radiation & chemotherapy
- Rosettes = diagnostic
What is the histology of a spontaneous abortion?
Chorionic villi, decidual cells, & Arias stella
What syndrome presents with
Elevated liver enzymes
This is HELLP of pre-eclampsia and eclampsia.
What is the possible complication of the disorder that presents with vaginal bleed and passage of grapes at 16-20th weeks.
Morphology: no blood vessels, swollen villi.
This is complete hydaditiform mole and its major complication is choriocarcinoma, which has 100% remission with chemotherapy.
What are the secondary causes of noninhertied congenital defects in infants?
- Fetal alcohol syndrome
- Fetal hyperinsulinemia
- Folic acid deficiency
- Teratogens (weeks 3-8)
What is the mechanism of a male getting a disease in which testicular atrophy, MVP, and breast cancer are seen?
- This is klinefelter syndrome.
- It is a trinucleotide repeat of CAG -> less active androgen receptor and high levels of LH/FSH -> no testosterone being made via downregulation of the Leydig cells.
Which autosomal recessive disease is characterized by a G-6-phosphatase deficiency leading to hepatomegaly? And how would diagnose it.
- VOn Gierke disease
- DX: via PAS stain of liver biopsy
Which autosomal recessive disorder presents as wrinkle tissue paper histologically and has a lysosomal storage disroder?
Gaucher: B-glucocerebrosidase def. -> macrophage buildup in the lier and bone marrow.
DX: B-glucocerebrosidase in amniotic fluid.
Which herbal medications are ok to use with pregnancy?
Echinacea: for colds, boils, and acne
Arnica: For ecchymosis, sprains, strains, osteoarthritis
Cranberry: For UTI
Saw Palmetto: For BPH & non-hormone dependent cancers
Which herbal medication is used for depression and herpes simplex nerve pain.
St. John's wort
Which drug is used for liver issues and is an antidote to amanita mushroom.
It also has interaction with P450.
What is the treatment against the organism that you are worried about when CD4 levels get below 50
The organism is Mycobacterium avium complex.
Clarithromycin or azithromycin is given prophylatically.
At what T cell level must you start worrying about pneumocysits jiroveci.
< 200 start giving trimethoprim/sulfamethoxazole
What infections are you worried about at T cell levels of 50-100
- Toxoplasmosis (T/S)
- Cryptococcosis (Fluconazole)
- CMV (ganciclovir)
What orgnaisms are not covered with cephalosporins?
MOA of the 2 prokinetic drugs
Metoclopramide- D 2 antagonist
Erythromycin- stimulate motilin receptor (macrolide)
What are the 2 stool softeners
Alvimopan and methylnaltrexone are?
Opiod receptor antagonist used as laxatives
Drugs that are used for IBD
Aminosalicylates (sulfasalazine & mesalamine)
Glucocorticoids (prednisone, hydrocortisone, budesonide)
Antimetabolites (azathioprine, methotrexate)
Patient presents with abdominal pain, malaise, fatigue
Histo: atypical hepatocytes in trabecular.
A patient presents with the following
BUN/CR > 20
Urinary Na > 40
Urine Osm >500
Hyaline cast are seen in the urine
What are some of the predisposing factors?
- This patient has pre-renal causes of ARF
- - IV volume depletion
- - DEC Cardiac output
- - systemic vasodilation
- - renal vasoconstriction
What is the beta lactam that inhibits only gram (-) bacteria
- is good for penicilllin and cephalosporin allergy
- and can treat pseudomonas aeruginosa
What drug is good against mycobacterium tuberculosis, yersinia pestis, and francisella tularemia.
- long postantibiotic ffect
A/E = ototoxic, nephrotoxic, and neuromuscular blockade
What drug is good against atypicals
Not effective against proteus and pseudomonas
MOA: binds 16 sRNA of 30S subunit
- Doxycycline (yersinia plague and excreted in feces)
What drugs are responsible for inhibiting the 50S ribosomal subunit?
- NOVEL (linezolid, quinipristin/dalfopristin)
What would you like to do?
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