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Goljan High Yield
| Question | Answer |
|---|---|
| PO2 | driving force for diffusion of O2 into tissue |
| SaO2 | percent heme groups occupied by O2 |
| Cyanosis | decreased O2 saturation (SaO2); O2 content |
| Oxygen | electron acceptor in oxidative pathway |
| Hypoxia | inadequate O2 leads to ATP depletion |
| Ischemia | decreased arterial (or venous) blood flow |
| Respiratory acidosis | retention of CO, always decreases PaO2 |
| Ventilation defect | impaired delivery of O2 to alveoli; intrapulmonary shunting of blood (e.g., RDS) |
| Perfusion defect | absent blood flow to alveoli; increased alveolar dead space (e.g., pulmonary embolus) |
| Diffusion defect | O2 cannot cross alveolar-capillary interface; interstitial lung disease (e.g., sarcoidosis) |
| Methemoglobin | ↓ SaO2; heme Fe+3; oxidizing agents (sulfur/nitro drugs); Rx with IV methylene blue |
| Clinical methemoglobinemia | cyanosis not corrected by O2; chocolate colored blood |
| Carbon monoxide | ↓ SaO2; left-shift O2 binding curve; inhibits cytochrome oxidase |
| Causes carbon monoxide poisoning | car exhaust, space heaters, smoke inhalation |
| S/S carbon monoxide poisoning | headache; cherry red color skin |
| Cyanide | inhibits cytochrome oxidase; systemic asphyxiant |
| Carbon monoxide + cyanide poisoning | house fires |
| Left-shifted O2 curve | ↓ 2, 3 BPG, carbon monoxide, alkalosis, HbF, methemoglobin, hypothermia |
| Right-shifted O2 curve | ↑ 2, 3 BPG, high altitude, acidosis, fever |
| High altitude | respiratory alkalosis enhances glycolysis; ↑ synthesis 2,3 BPG |
| Mitochondrial poisons | damages membrane and drains off protons; alcohol, salicylates |
| Uncoupling agents in mitochondria | drain off protons; dinitrophenol, thermogenin (brown fat) |
| Complication mitochondrial poisons/uncoupling agents | hyperthermia |
| Decreased ATP | impaired Na+/K+ ATPase pump (cellular swelling); reversible |
| Anaerobic glycolysis | ATP synthesis in hypoxia; lactate ↓ intracellular pH, denatures proteins |
| Irreversible injury hypoxia | membrane/mitochondrial damage |
| Mitochondrial damage | release cytochrome c activates apoptosis |
| Irreversible injury hypoxia | ↑ cytosolic Ca2+ activates phospholipase, proteases, endonuclease |
| Free radicals | unpaired electron in outer orbit; damage cell membranes and DNA |
| Free radicals | superoxide, hydroxyl, peroxide, drugs (acetaminophen) |
| Superoxide dismutase | neutralizes superoxide |
| Glutathione | neutralizes peroxide, drug FRs |
| Catalase | neutralizes peroxide |
| Lipofuscin | indigestible lipid of lipid peroxidation; brown pigment increased in atrophy and FR damage |
| Reperfusion injury in heart | superoxide FRs + calcium |
| Mitochondrial injury | cytochrome c in cytosol initiates apoptosis |
| SER hyperplasia | alcohol, barbiturates, phenytoin |
| Complications SER hyperplasia | increases drug metabolism (e.g., oral contraceptives); low vitamin D |
| Chediak-Higashi | membrane protein defect in transferring lysosomal enzymes to phagocytic vacuoles |
| Chediak-Higashi | AR; giant lysosomes |
| I cell disease | absent enzyme marker in Golgi apparatus (mannose 6-phosphate); empty lysosomes |
| Rigor mortis | stiff muscles after death due to ATP depletion |
| Fatty change in liver | MCC alcohol (increase in NADH); DHAP → G3P → TG |
| Fatty change in liver | VLDL pushes nucleus to side |
| Causes fatty change | ↑ synthesis TG/FAs, beta-oxidation of FAs, synthesis apoproteins/release VLDL |
| Fatty change in kwashiorkor | ↓ synthesis of apoproteins |
| Ferritin | primary iron storage protein; soluble in blood; serum level reflects marrow storage iron |
| Hemosiderin | insoluble ferritin degradation product visible with Prussian blue stain |
| Atrophy | reduction in cell/tissue mass by either loss or cell shrinkage |
| Brain atrophy | ischemia; Alzheimer’s |
| Exocrine gland atrophy in CF | duct obstruction by thick secretions |
| Labile cells | stem cells (skin, marrow, GI tract) →←→⇦ |
| Stable cells | in G0 phase (smooth muscle, hepatocytes); can enter cell cycle (growth factors, hormones) |
| Permanent cells | cannot replicate; cardiac/striated muscle; neurons |
| Hypertrophy | increase in cell size (structural components, DNA) |
| LVH | increased preload (valve regurgitation), increased afterload (hypertension, aortic stenosis) |
| RVH | pulmonary hypertension |
| Bladder smooth muscle hypertrophy | prostate hyperplasia constricts urethra |
| Removal of kidney | hypertrophy of remaining kidney |
| Hyperplasia | increase in number of cells |
| Endometrial hyperplasia | unopposed estrogen (obesity, taking estrogen) |
| RBC hyperplasia | increased EPO (blood loss, ectopic secretion, high altitude) |
| Prostate hyperplasia | increased dihydrotestosterone (DHEA) |
| Gynecomastia | hyperplasia male breast tissue; normal in newborn, adolescent, elderly |
| Metaplasia | one adult cell type replaces another cell type |
| Squamous metaplasia in bronchus | smoking |
| Intestinal metaplasia in stomach | Paneth cells, goblet cells; H pylori chronic atrophic gastritis |
| Squamous metaplasia bladder | Schistosoma hematobium infection |
| Barrett’s esophagus | glandular metaplasia of distal esophagus; due to GERD |
| Dysplasia | atypical hyperplasia and metaplasia are precursors for cancer |
| Squamous dysplasia in cervix | human papilloma virus |
| Squamous dysplasia in bronchus | smoking |
| Necrosis | death of groups of cells |
| Coagulation necrosis | preservation of structural outline (due to ↑ lactic acid) |
| Infarction | pale (e.g., heart, kidney); hemorrhagic (e.g., lung, small bowel); dry gangrene |
| Liquefactive necrosis | brain infarct, bacterial infections; wet gangrene |
| Caseous necrosis | variant coagulation necrosis; granulomas due to TB/systemic fungi |
| Granulomas | activated macrophages (epithelioid cells); multinucleated giant cells; CD4 TH1 cells |
| Epithelioid cells | γ-interferon released by CD4 T cells activates macrophages |
| Multinucleated giant cells | fusion of epithelioid cells |
| Granulomas | type IV hypersensitivity |
| Enzymatic fat necrosis | associated with pancreatitis; soap formation (Ca2+ + fatty acids) |
| Fibrinoid necrosis | necrosis of immune reactions (immune vasculitis/endocarditis) |
| Postmortem necrosis | autolysis; no inflammatory reaction |
| Dystrophic calcification | calcification of damaged tissue; normal serum calcium |
| Dystrophic calcification | pancreatitis; atherosclerotic plaque |
| Metastatic calcification | calcification of normal tissue; increased serum calcium or phosphorus |
| Nephrocalcinosis | metastatic calcification of collecting tubule basement membranes |
| S/S nephrocalcinosis | polyuria due to nephrogenic diabetes insipidus; renal failure |
| Apoptosis | gene regulated individual cell death |
| Signals activating apoptosis | mullerian inhibitory factor, tumor necrosis factor, hormone withdrawal |
| Signal modulators of apoptosis | TP53 suppressor gene, BCL-2 genes |
| BCL-2 genes | anti-apoptosis gene; prevents cytochrome c from leaving mitochondria |
| Caspases | responsible for enzymatic cell death in apoptosis; proteases and endonucleases |
| Markers of apoptosis | eosinophilic cytoplasm, pyknotic (ink dot) nucleus |
| Apoptosis | loss Mullerian epithelium in male fetus; thymus involution; killing cancer cells |
| Histamine | key chemical in acute inflammation; mast cell; arteriole vasodilation; ↑ venular permeability |
| Rubor acute inflammation | redness; arteriole vasodilation (histamine) |
| Calor acute inflammation | heat; arteriole vasodilation (histamine) |
| Tumor acute inflammation | swelling; ↑ vessel permeability (histamine) |
| Dolor acute inflammation | pain; bradykinin, PGE |
| Acute inflammation | neutrophil dominant; ↑ IgM |
| Initial vessel events | transient vasoconstriction → arteriolar vasodilation → ↑ venular permeability |
| Neutrophil rolling acute inflammation | due to selectins |
| Integrins | neutrophil adhesion molecules; C5a and leukotriene B, activate; neutrophil margination |
| CD11/CD18 | markers for integrins |
| Endothelial cell adhesion molecules | activated by IL-1 and TNF |
| ICAM | intercellular adhesion molecule |
| VCAM | vascular cell adhesion molecule Leukocyte adhesion molecule defect |
| Activation neutrophil adhesion molecules | neutrophilic leukocytosis; corticosteroids |
| Activation neutrophil adhesion molecules | neutropenia; endotoxins |
| Chemotaxis | directed movement; C5a and LTB4 |
| Opsonizing agents | IgG, C3b; enhance phagocytosis |
| Neutrophils, monocytes, macrophages | receptors for IgG, C3b |
| O2-dependent MPO system | most potent microbicidal system; neutrophils, monocytes |
| ProductionofsuperoxidefromO2 | NADPH oxidase with NADPH cofactor; produces respiratory burst |
| Nitro blue tetrazolium (NBT) | test for respiratory burst |
| Superoxide dismutase | converts superoxide to peroxide |
| Myeloperoxidase | lysosomal enzyme that combines peroxide + Cl to form bleach (HOCl) |
| Microbicidal defects | chronic granulomatous disease childhood (XR), myeloperoxidase deficiency (AR) |
| Chronic granulomatous disease | absent NADPH oxidase; no respiratory burst |
| Chronic granulomatous disease | Staphylococcus aureus not killed (catalase positive) |
| Chronic granulomatous disease | Streptococcus killed (catalase negative) |
| Myeloperoxidase deficiency | AR; respiratory burst present; no bleach produced |
| Opsonization defect | Bruton’s agammaglobulinemia (XR, decreased IgG) |
| Phagocytosis defect | Chediak-Higashi (see cell injury); also has defect in microtubule polymerization |
| COX inhibitors | non-steroidals (non-selective), selective COX-2 inhibitors |
| PGE2 | vasodilation, fever |
| PGI2 | vasodilator; prevent platelet aggregation |
| Nitric oxide | vasodilator; FR gas from conversion arginine to citrulline |
| IL-1 and TNF | fever, synthesis acute phase reactants in liver, leukocytosis |
| IL-6 | stimulated by IL-1; stimulates synthesis of acute phase reactants |
| Acute phase reactants | fibrinogen, ferritin, C-reactive protein |
| Bradykinin | kinin produced in conversion of factor XII to factor XI |
| Bradykinin | pain, vasodilator, vessel permeability; cough/angioedema, ACE inhibitors |
| Anaphylatoxins | C3a and C5a; directly stimulate mast cell release of histamine |
| Prostaglandin I2 | synthesized by endothelial cells; vasodilator, inhibits platelet aggregation |
| Lipoxygenase | hydroxylation of arachidonic acid |
| Zileuton | inhibits lipoxygenase |
| Zafirlukast, montelukast | block lipoxygenase receptor |
| LTC4, -D4, -E4 | bronchoconstrictors |
| TXA2 | synthesized by platelets; platelet aggregation, vasoconstriction, bronchoconstriction |
| Dipyridamole | inhibits thromboxane synthase |
| Corticosteroids | inhibits phospholipase A2, activation neutrophil adhesion molecules |
| Corticosteroids | neutrophilic leukocytosis, lymphopenia, eosinopenia |
| Fever | right shift OBC; hostile to bacterial/viral replication |
| Chronic inflammation | monocyte/macrophage; ↑ IgG; repair by fibrosis |
| Granuloma | cellular immunity; macrophages interact with TH1 class cells (memory cells) |
| Positive PPD | Langerhan’s cells process PPD and interact with TH1 class cells |
| Suppurative inflammation | abscess; Staphylococcus aureus (coagulase) |
| Cellulitis | subcutaneous inflammation; Streptococcus pyogenes (hyaluronidase) |
| Pseudomembranous inflammation | toxins from Corynebacterium diphtheriae, Clostridium difficile |
| Cell cycle | key checkpoint G1 to S phase |
| TP53 and RB suppressor genes | arrests cell in G1 phase for DNA repair or apoptosis |
| BAX gene | stimulates apoptosis; activated by TP53 suppressor gene if too much DNA damage |
| Extracellular matrix | basement membrane, interstitial matrix |
| Complete restoration | cell must be capable of duplication, no damage to basement membrane |
| Scar tissue | end-product of repair by connective tissue |
| Collagen | triple helix of cross-linked α chains |
| Collagen | cross-links at points of hydroxylation (lysyl oxidase) increase tensile strength |
| Type I collagen | bones, tendons |
| Type II collagen | early wound repair |
| Type IV collagen | basement membrane |
| Type X collagen | epiphyseal plate |
| Laminin | key basement membrane glycoprotein |
| Fibronectin | key interstitial matrix glycoprotein |
| Angiogenesis in repair | basic fibroblast growth factor, vascular endothelial growth factor |
| Key event in wound repair | granulation tissue formation; fibronectin responsible |
| Granulation tissue | becomes scar tissue |
| Collagenases | zinc cofactor (metalloprotease); type III collagen replaced by type I collagen |
| Tensile strength of healed wound | 80% original strength |
| Inhibition wound healing | infection (MCC S. aureus), zinc deficiency, DM |
| Ehlers-Danlos syndrome | defects in collagen synthesis and structure; hyperelasticity |
| Scurvy | ↓ collagen tensile strength by decreasing cross-links at points of hydroxylation |
| Keloid | excessive type III collagen; common in blacks |
| Pyogenic granuloma | exuberant granulation tissue; bleeds when touched |
| Healing by primary intention | clean wound; appose wound margins with suture |
| Healing by secondary intention | infected wound; leave wound open; myofibroblasts important |
| Liver injury | regenerative nodules; abnormal cytoarchitecture |
| Lung injury | type II pneumocyte repair cell |
| CNS injury | astrocyte and microglial cell repair cells; gliosis |
| WBC alterations in acute inflammation | neutrophilic leukocytosis, left shift, toxic granulation |
| Erythrocyte sedimentation rate | increased fibrinogen enhances rouleaux |
| C-reactive protein | indicator of acute inflammation and inflammatory atheromatous plaque |
| Polyclonal gammopathy | diffuse ↑ of γ-globulins; ↑ IgG; chronic inflammation |
| Total body water | ECF (plasma, interstitial fluid) + ICF (cytosol) |
| Osmosis | H20 shift between ECF and ICF; controlled by serum Na+ and glucose |
| Edema | increased fluid in interstitial space or body cavities; transudate, exudate, lymph |
| Transudate | protein and cell-poor fluid in interstitial space/body cavity; alteration Starling’s forces |
| Starling’s forces | oncotic pressure (albumin) keeps fluid in vessels, hydrostatic pressure pushes fluid out |
| Pitting edema | decreased oncotic pressure and/or increased hydrostatic pressure |
| ↑ Hydrostatic pressure | pulmonary edema in LHF; pitting edema of legs in RHF; portal hypertension |
| Renal retention sodium and water | ↑ hydrostatic pressure and ↓ oncotic pressure |
| Causes of renal retention of sodium/water | ↓ cardiac output (activation RAA system), primary renal disease |
| ↓ Oncotic pressure (hypoalbuminemia) | kwashiorkor; nephrotic syndrome; cirrhosis |
| Ascites in cirrhosis | ↓ oncotic pressure, ↑ hydrostatic pressure |
| Exudate | protein and cell rich (pus); acute inflammation with ↑ vessel permeability |
| Lymphedema | radical mastectomy; filariasis; inflammatory carcinoma (lymphatics plugged by tumor) |
| Thrombus | endothelial injury, stasis, hypercoagulability |
| Venous thrombus | fibrin clot with entrapped RBCs, WBCs, platelets; deep veins below knee (stasis) |
| Heparin/warfarin | anticoagulants that prevent venous clot formation |
| Arterial thrombus | endothelial injury; platelets held together by fibrin |
| Aspirin | prevents platelet thrombus in arteries |
| Pulmonary thromboembolism | femoral vein site of origin |
| Systemic thromboembolism | majority from left heart |
| Fat embolus | long bone fractures; delayed symptoms (48 hrs); thrombocytopenia, hypoxemia |
| Amniotic fluid embolism | DIC; lanugo hair in maternal pulmonary arteries |
| Diving | 1 atmosphere pressure increase with 33 foot descent into water; N2 gas dissolved in tissue |
| Decompression sickness | release of N2 gas from tissue with rapid ascent; ischemic damage |
| Dyspnea, chest pain underwater | pulmonary embolus |
| Dyspnea, chest pain rising to surface | spontaneous pneumothorax |
| Hypovolemic shock (blood loss) | ↓ CO and LVEDP; ↑ PVR |
| Cardiogenic shock | ↓ CO; ↑ LVEDP and PVR |
| Septic shock | ↑ CO (↑ venous return); ↓ PVR (vasodilation) |
| Kidneys | most susceptible organ in shock; straight portion proximal tubule most susceptible |
| Shock complications | ischemic ATN, multiorgan failure, ↑ AG metabolic acidosis |
| Tumors | parenchyma neoplastic component |
| Benign tumors | epithelial (e.g., adenoma) or connective tissue (e.g., lipoma, leiomyoma) |
| Carcinoma | epithelial origin; squamous cell carcinoma, adenocarcinoma, transitional cell carcinoma |
| Basal cell carcinoma | invades but does not metastasize |
| Squamous cell carcinoma | lower lip, oral pharynx, larynx, lung, esophagus, skin, cervix |
| Adenocarcinoma | distal esophagus → colon, kidney, liver, pancreas, prostate, breast, lung, endometrium |
| Transitional cell carcinoma | renal pelvis, ureter, bladder |
| Sarcoma | malignancy of connective tissue origin; e.g., osteogenic sarcoma (bone) |
| Liposarcoma | MC sarcoma in adults |
| Embryonal rhabdomyosarcoma | MC sarcoma in children |
| Teratoma | ectoderm, endoderm, mesoderm derivatives; bone/teeth visible on x-ray |
| Hamartoma | normal tissue, normal site; bronchial hamartoma, Peutz Jeghers polyp |
| Choristoma | normal tissue aberrant tissue location; pancreatic tissue stomach wall |
| Mixed tumor | different morphologic patterns, same germ cell layer; pleomorphic adenoma parotid |
| Leukemia | malignancy of stem cells in bone marrow |
| Lymphoma | malignancy of lymph nodes |
| Extranodal lymphoma sites | stomach (MC), Peyer’s patches |
| Malignant tumors | invade and metastasize; benign tumors do not |
| Upregulate telomerase | increases telomere length; found in all neoplastic cells |
| Monoclonality | key finding in neoplastic vs. normal cells |
| E-Cadherin | intercellular adhesion; lose adhesion in malignant cells |
| Malignant cells | receptors for laminin (basement membrane), fibronectin (ECM) |
| Invasion enzyme | type IV collagenase (basement membrane) |
| Angiogenesis | basic fibroblast growth factor, vascular endothelium growth factor |
| Metastasis | lymphatic, hematogenous, seeding; often more common than primary cancer |
| Carcinoma | lymph node -> hematogenous |
| Vessel invading carcinomas | renal cell carcinoma (renal vein, vena cava), hepatocellular carcinoma |
| Sarcoma | hematogenous |
| Seeding | ovarian cancer, periphery lung, CNS via spinal fluid |
| Sites where metastasis more common primary cancer | lung, bone, brain, liver, adrenal |
| Sites where primary cancer more common than metastasis | GI tract, kidney, urogenital |
| Bone metastasis | osteoblastic (radiodense); osteolytic (radiolucent) |
| Bone sites metastasis | vertebra MC (Batson venous plexus) |
| Osteoblastic metastasis | prostate cancer; increased serum AP, hypercalcemia |
| Osteolytic metastasis | breast cancer |
| EM neurosecretory granules | carcinoid tumors, small cell carcinoma, neuroblastoma |
| EM thin and thick myofilaments | rhabdomyosarcoma |
| EM Birbeck granules | histocytic neoplasms (Langerhan’s histiocytosis) |
| Primary prevention | stop smoking; sun screen; high fiber diet |
| Cancers in children | leukemia (MC), CNS tumors, Burkitt’s, Ewing’s, neuroblastoma |
| Cancer vaccine | hepatitis B vaccine; prevents hepatocellular carcinoma |
| Cancer incidence men | prostate → lung → colorectal |
| Cancer incidence women | breast → lung → colorectal |
| Cancer mortality men | lung → prostate → colorectal |
| Cancer mortality women | lung → breast → colorectal |
| Gynecologic cancers | endometrium → ovary → cervix |
| Cervical Pap smear | decreased incidence of cervical cancer; detects cervical dysplasia |
| Malignant melanoma | fastest increasing in world |
| Southeast China | nasopharyngeal carcinoma (EBV) |
| Southeast Asia | hepatocellular carcinoma (HBV + aflatoxin) |
| Japan | stomach cancer |
| Africa | Burkitt’s lymphoma, Kaposi sarcoma (HHV-8) |
| Squamous dysplasia oropharynx, larynx, bronchus, cervix | risk for squamous cell carcinoma (SCC) |
| Chronic irritation sinus orifices, third degree burn scars | risk for SCC |
| Actinic (solar) keratosis | risk factor for SCC |
| Glandular metaplasia of esophagus (Barrett’s) | risk factor for adenocarcinoma |
| Endometrial hyperplasia | risk factor for adenocarcinoma |
| Glandular (intestinal) metaplasia of stomach (Helicobacter) | risk factor for adenocarcinoma |
| Chronic ulcerative colitis | risk factor for adenocarcinoma |
| Villous adenoma of rectum | risk factor for adenocarcinoma |
| Tubular adenoma of colon | risk factor for adenocarcinoma |
| Scar tissue in lung | risk factor for adenocarcinoma |
| Regenerative nodules in cirrhosis | risk factor for hepatocellular carcinoma |
| Complete hydatidiform mole | risk factor for choriocarcinoma |
| Dysplastic mole | MC risk factor for malignant melanoma |
| UVB light | MC risk factor for BCC, SCC, melanoma |
| HHV-8 | MC risk factor for Kaposi’s sarcoma |
| EBV | MC risk factor for nasopharyngeal carcinoma |
| Polycyclic hydrocarbons | MC risk factor for larynx (SCC), lung cancers |
| Asbestos | MC risk factor for mesothelioma |
| Polycyclic hydrocarbons | MC risk factor for oral cavity, mid-esophagus SCC |
| Barrett’s esophagus | MC risk factor for distal esophagus adenocarcinoma |
| H. pylori | MC risk factor for stomach adenocarcinoma and lymphoma |
| Tubular adenoma, villous adenoma | MC risk factors for colon adenocarcinoma |
| HBV and HCV | MC risk factors for hepatocellular carcinoma |
| Vinyl chloride | MC risk factor for liver angiosarcoma |
| Gallstones, porcelain gallbladder | MC risk factor for gallbladder adenocarcinoma |
| Polycyclic hydrocarbons | MC risk factor for pancreas adenocarcinoma |
| Polycyclic hydrocarbons | MC risk factor for renal cell carcinoma |
| Polycyclic hydrocarbons | MC risk factor for urinary bladder |
| HPV + lack of circumcision | MC risk factor for penis SCC |
| Age | MC risk factor for prostate adenocarcinoma |
| Cryptorchid testis | MC risk factor for seminoma |
| Age >50 with excess estrogen exposure | MC risk factor for breast and endometrial carcinoma |
| HPV 16/18 | MC risk factor for vulva, vagina, cervix SCC |
| DES | MC risk factor for vagina/cervix clear cell carcinoma |
| Nulliparity | MC risk factor for surface derived ovarian cancer |
| Complete mole | MC risk factor for choriocarcinoma |
| Turner syndrome (XO) | MC risk factor for dysgerminoma of ovary |
| Turner syndrome (XO/XY) | gonadoblastoma of ovary |
| Ionizing radiation | MC risk factor for papillary cancer of thyroid |
| Family history (MEN IIa/IIb) | MC risk factor for medullary carcinoma thyroid |
| Hashimoto’s thyroiditis | MC risk factor for malignant lymphoma thyroid |
| Ionizing radiation | MC risk factor for osteogenic sarcoma |
| EBV | MC risk factor for primary CNS lymphoma in AIDS and Burkitt’s lymphoma |
| Ionizing radiation | MC risk factor for acute/chronic myelogenous leukemia |
| EBV | MC risk factor for Burkitt’s lymphoma |
| HTLV-1 | MC risk factor for T cell leukemia/lymphoma |
| Bacterial causes of cancer | H. pylori (stomach adenocarcinoma and lymphoma) |
| Parasitic causes of cancer | S. hematobium (SCC bladder), C. sinensis (cholangiocarcinoma) |
| Carcinogenesis | mutations involving regulatory genes |
| Regulatory genes | proto-oncogenes, suppressor genes, anti-apoptosis genes |
| Types mutations | point mutation MC, translocation, amplification (↑ copies), overexpression (↑ activity) |
| Translocations | Burkitt’s t(8;14); CML t(9;22); follicular lymphoma t( 14;18); APL leukemia t( 15;17) |
| Key cancer genes | TP53 suppressor gene, RAS protooncogene |
| Point mutation | inactivates suppressor genes (e.g., TP53), activates proto-oncogenes (e.g., RAS) |
| Amplification | activates ERB-B2 |
| Overexpression | enhances activity of BCL-2 |
| S/S POC | function-growth factor synthesis; mutation-overexpression |
| ERB-B2 POC | function growth factor receptor; activation bad prognostic sign for breast carcinoma |
| RAS POC | function-GTP signal transduction; point mutation; 30% of all human cancer |
| ABL POC | function-non-receptor tyrosine kinase activity; translocation (9;22) causing CML |
| MYC POC | function nuclear transcription; translocation (8; 14) causing Burkitt’s lymphoma |
| Inactivation suppressor genes | majority are point mutations; loss of suppression |
| Sporadic retinoblastoma | two hit theory; two separate point mutations of RB suppressor gene on |
| AD retinoblastoma | one hit theory; one already inactivated in germ cells |
| TP53 suppressor gene functions | G,-S phase inhibition, DNA repair, activation BAX apoptosis gene |
| Inactivation TP 53 suppressor gene | inactivation causes majority of human cancers |
| RB suppressor gene function | G1-S phase inhibition |
| Inactivation RB suppressor gene | retinoblastoma, osteogenic sarcoma |
| APC suppressor gene function | prevents nuclear transcription by catenin |
| Inactivation APC suppressor gene | familial polyposis (FAP) |
| BRCA1/2 suppressor genes function | DNA repair Inactivation |
| BRCA 1/2 suppressor genes | breast, ovarian cancers |
| BCL-2 function | anti apoptosis gene (keeps cytochrome c in mitochondria) |
| BCL-2 gene | t(14;18) translocation of heavy chain causes overexpression; follicular B cell lymphoma [think t(14;18) = t(l4;lB) for foLLicular B] |
| Xeroderma pigmentosum | AR; defect in DNA repair enzymes; ↑ risk for UVB light cancers |
| Hereditary non-polyposis syndrome (HNPCC) | AD; inactivation DNA mismatch genes; colorectal cancer |
| Chromosome instability syndromes | AR; susceptibility to DNA damage; leukemias, lymphomas |
| Examples chromosome instability | Bloom syndrome, ataxia telangiectasia, Wiskott-Aldrich syndrome |
| Carcinogens | chemicals (MC), viruses, radiation, H. pylori, physical (squamous cancer in bum scar) |
| Polycyclic hydrocarbons | key chemical carcinogen (cigarette smoke) |
| Aflatoxins | produced from Aspergillus; hepatocellular carcinoma |
| Asbestos | lung cancer, mesothelioma |
| Thorium dioxide | hepatocellular carcinoma, cholangiocarcinoma |
| Aniline dyes | transitional cell carcinoma |
| Vinyl chloride | angiosarcoma of liver |
| Benzene | leukemia |
| Cyclophosphamide | transitional cell carcinoma of bladder |
| EBV | Burkitt’s; CNS lymphoma (AIDS); Hodgkin’s mixed cellularity; nasopharyngeal carcinoma |
| HBV and HCV | hepatocellular carcinoma |
| HPV | cervical, penis, and anorectal squamous cancers |
| HHV-8 | Kaposi sarcoma |
| UVB cancers | basal cell carcinoma, squamous cell carcinoma, malignant melanoma |
| Key host defense | cytotoxic CD8 T cells (type IV hypersensitivity) |
| Cachexia | due to tumor necrosis factor-α |
| Most common anemia | anemia chronic disease |
| Most common coagulopathy | hypercoagulability |
| Most common COD in cancer | gram negative infection |
| Acanthosis nigricans, seborrheic keratoses; possible markers for gastric adenocarcinoma | |
| Clubbing | possible marker for lung cancer |
| Non-bacterial thrombotic endocarditis mitral valve | possible marker for pancreatic cancer |
| TNM staging | metastasis more important than nodal involvement |
| AFP | hepatocellular carcinoma, yolk sac tumors |
| PSA | prostate cancer |
| CEA | recurrence colorectal cancer |
| BJ (Bence-Jones) protein | multiple myeloma |
| β-human chorionic gonadotropin | choriocarcinoma |
| Calcitonin | medullary carcinoma thyroid; hypocalcemia |
| Small cell carcinoma lung | ADH (hyponatremia), ACTH (ectopic Cushing’s) |
| Renal cell carcinoma | EPO (polycythemia), PTH-related peptide (hypercalcemia) |
| Hepatocellular carcinoma | EPO (polycythemia), insulin-like factor (hypoglycemia) |
| Medullary carcinoma of thyroid | calcitonin (hypocalcemia), ACTH (ectopic Cushing’s) |
| Squamous cell carcinoma of lung | PTH-related peptide (hypercalcemia) |
| Erythropoietin | synthesized in peritubular capillaries |
| Reticulocyte count | measure of effective erythropoiesis; correct for degree of anemia |
| Extramedullary hematopoiesis | hematopoiesis outside bone marrow (e.g., spleen) |
| Newborn physiologic anemia | drop in Hb due to replacement of HbF RBCs with HbA |
| Pregnancy | Hb and Hct decreased; greater increase in plasma volume than RBC mass |
| Anemia | normal O2 saturation and arterial PO2 |
| MCV | average volume of RBCs; useful for anemia classification |
| MCHC | average Hb concentration in RBCs |
| MCHC | ↓ in microcytic anemias; ↑ in spherocytosis |
| Thalassemias | ↓ MCV, ↑ RBC count |
| RDW | RBC size variation; ↑ iron deficiency; normal in other microcytic anemias |
| Mature RBC | anaerobic glycolysis; no mitochondria or HLA antigens |
| Total iron binding capacity | ↑ iron deficiency; ↓ anemia chronic disease, sideroblastic anemia |
| % Saturation | ↓ iron deficiency, anemia chronic disease; ↑ sideroblastic anemia |
| Serum ferritin | ↓ iron deficiency; ↑ anemia chronic disease, sideroblastic anemia; normal thalassemia |
| Microcytic anemias | iron deficiency MC, anemic chronic disease, thalassemia, sideroblastic anemia |
| Iron deficiency child | MCC Meckel’s diverticulum |
| Iron deficiency woman < 50 | MCC menorrhagia |
| Iron deficiency man < 50 | MCC peptic ulcer disease |
| Iron deficiency men/woman > 50 | MCC colon cancer |
| Stages iron deficiency | ↓ ferritin; ↓ Fe and % saturation, ↑ TIBC; normocytic then microcytic anemia |
| Anemia chronic disease | MC anemia in malignancy and alcoholics |
| α-Thalassemia trait | AR; two α-globin gene deletions; normal Hb electrophoresis |
| HbH disease | three α-globin gene deletions; hemolytic anemia; four β-globin chains |
| Hb Bart’s disease | four α-globin gene deletions; four γ-globin chains |
| β-Thalassemia minor | AR; DNA splicing defect; ↑ HbA2 and F; ↓ HbA |
| β-Thalassemia major | nonsense mutation with stop codon; hemolytic anemia; ↑↑ HbF, ↑ HbA2 |
| Sideroblastic anemia | defect in mitochondrial heme synthesis producing ringed sideroblasts |
| Causes sideroblastic anemia | alcohol, pyridoxine deficiency (isoniazid Rx of TB), Pb poisoning |
| Pb poisoning | inhibition ferrochelatase, d-aminolevulinic acid dehydrase, ribonuclease |
| S/S Pb poisoning children | growth retardation; Pb in epiphyses (lead lines); abdominal colic; encephalopathy |
| S/S Pb poisoning adult | peripheral neuropathy; proximal renal tubule damage (Fanconi’s syndrome) |
| Lab Pb poisoning | coarse basophilic stippling RBCs; ↓ MCV; ↑ blood Pb; ↑ d-aminolevulinic acid |
| Vitamin B12 | animal products; requires intrinsic factor for reabsorption in terminal ileum |
| Vitamin B12 | transfers methyl group to homocysteine |
| R factor | binds with B12 in mouth, removed by pancreatic enzymes in small intestine |
| Vitamin B12 | involved in propionate metabolism; end-product succinyl CoA |
| Causes B12 deficiency | vegan, pernicious anemia MC, fish tapeworm, pancreatitis, bacterial overgrowth, Crohn’s disease |
| Pernicious anemia | autoimmune destruction parietal cells; chronic gastritis body/fundus; achlorhydria; ↑ gastrin |
| Causes folate deficiency | alcohol MCC, poor diet, drugs, malabsorption, pregnancy, goat milk |
| Drugs and folate deficiency | alcohol, OC, phenytoin, methotrexate, trimethoprim, 5-fluorouracil |
| Intestinal conjugase in folate metabolism | inhibited by phenytoin |
| Jejunal uptake of monoglutamate form of folate | inhibited by alcohol and OC |
| Dihydrofolate reductase | inhibited by methotrexate, trimethoprim |
| Thymidylate synthetase | inhibited by 5-fluorouracil |
| Folate deficiency | MCC of increased serum homocysteine |
| Lab in B12/folate deficiency | pancytopenia; hypersegmented neutrophils; ↑ homocysteine |
| Lab findings unique to B12 deficiency | ↑ gastrin (pernicious anemia), ↑ methylmalonic acid |
| B12 reabsorbed absorbed after administration of intrinsic factor | PA |
| B12 reabsorbed absorbed after administration of antibiotics | bacterial overgrowth |
| B12 reabsorbed absorbed after administration of pancreatic extract | chronic pancreatitis |
| Acute blood loss | initially normal Hb and Hct; 0.9% saline uncovers RBC deficit |
| Aplastic anemia | drugs (e.g., phenylbutazone); infection (e.g., parvovirus); benzene |
| Lab findings aplastic anemia | pancytopenia; hypocellular bone marrow |
| Anemia in renal disease | normocytic; decreased EPO |
| Extravascular hemolysis | macrophage phagocytosis of RBCs; ↑ unconjugated bilirubin and urine UBG |
| Intravascular hemolysis | ↓ serum haptoglobin; hemoglobinuria; hemosiderinuria |
| Congenital spherocytosis | AD; defect in spectrin; extravascular hemolysis; splenomegaly |
| Blood findings in spherocytosis | normocytic anemia; dense RBCs, ↑ MCHC, ↑ osmotic fragility |
| PNH | missing decay accelerating factor; complement destruction RBCs, neutrophils, platelets |
| S/S PNH | pancytopenia; hemoglobinuria; positive sugar water test and acidified serum test |
| HbSS | AR; missense mutation (valine for glutamic acid 6th positive β-globin chain) |
| Causes of sickling | ↑ deoxyhemoglobin (hypoxemia, acidosis); HbS > 60% |
| HbF | inhibits sickling; hydroxyurea ↑ HbF |
| Pathophysiology HbSS | vasoocclusive crises, hemolytic anemia (extravascular) |
| HbSS children | dactylitis (6-9 months); Streptococcus pneumoniae sepsis (dysfunctional spleen) |
| HbSS osteomyelitis | Salmonella paratyphi |
| HbSS complications | aplastic crisis (parvovirus B-19), acute chest syndrome, autosplenectomy, calcium bilirubinate gallstones, priapism, aseptic necrosis |
| HbAS | microhematuria from sickling in renal medulla; renal papillary necrosis |
| Hb electrophoresis | HbAS-HbA 55-60%, HbS 40-45%; HbSS-HbS 90-95%, HbF 5-10% |
| Blood findings in HbSS | sickle cells; target cells; Howell-Jolly bodies (nuclear remnants) |
| G6PD deficiency | XR; oxidant damage (peroxide) to Hb (e.g., primaquine; dapsone; fava beans) |
| Blood findings G6PD deficiency | Heinz bodies (denatured Hb; special stain); bite cells |
| Pyruvate kinase deficiency | ↓ ATP; RBCs dehydrated; ↑ 2,3-BPG (right-shifted OBC) |
| Warm type AIHA | IgG; extravascular hemolysis; e.g., SLE, drugs |
| Cold type AIHA | IgM intravascular hemolysis; e.g., CLL, Mycoplasma |
| Penicillin | IgG antibody against penicillin attached to RBC (type II hypersensitivity) |
| Methyldopa | drug alters Rh antigens; IgG antibody against Rh antigens (type II hypersensitivity) |
| Quinidine | drug-IgM IC; intravascular hemolysis; type III hypersensitivity |
| Lab findings AIHA | positive direct Coombs’; spherocytes |
| Micro-macroangiopathic hemolysis | mechanical damage causing intravascular hemolysis |
| Causes of micro/macro hemolysis | aortic stenosis (MCC), DIC, TIP, HUS |
| Peripheral blood findings micro/macro hemolysis | schistocytes; iron deficiency from hemoglobinuria |
| Malaria | intravascular hemolysis correlates with fever; falciparum-ring forms and gametocytes |
| Leukemoid reaction | exaggerated WBC response to infection; usually due to infection |
| Leukoerythroblastic reaction | marrow infiltrative disease peripheralizes myeloblasts/nucleated RBCs |
| Causes of leukoerythroblastic reaction | bone metastasis MCC, myelofibrosis |
| Eosinophilia | type I hypersensitivity (e.g., penicillin reaction); invasive helminthic infection |
| Helminthes not producing eosinophilia | pinworms, adult worms in ascariasis |
| Atypical lymphocytes | mononucleosis; CMV; toxoplasmosis; viral hepatitis; phenytoin |
| Mononucleosis | due to EBV; EBV attaches to CD21 receptors on B cells |
| Clinical findings mono | exudative tonsillitis, generalized lymphadenopathy, hepatosplenomegaly |
| Lab findings mono | atypical lymphocytosis; IgM heterophile antibodies against horse RBCs |
| Lymphopenia | T cell deficiencies (HIV); combined B/T deficiency (adenine deaminase deficiency) |
| Lymphocytosis | viral infections, whooping cough |
| Corticosteroids | lymphopenia, eosinopenia, neutrophilia |
| Chronic MPD | neoplastic stem cell disorder; splenomegaly; marrow fibrosis; risk for leukemia |
| Examples of MPD | polycythemia vera, myelofibrosis and myeloid metaplasia |
| Relative polycythemia | ↓ plasma volume; ↑ RBC count; normal RBC mass |
| Absolute polycythemia | ↓ RBC count and RBC mass |
| Appropriate polycythemia | hypoxic stimulus for EPO to generate RBCs |
| Causes of appropriate absolute polycythemia | lung disease, cyanotic heart disease, high altitude |
| Appropriate absolute polycythemia | normal plasma volume; ↑ RBC mass; ↓ SaO2; ↑ EPO |
| Inappropriate absolute polycythemia | no hypoxic stimulus for EPO |
| Causes of inappropriate polycythemia | ectopic secretion EPO, polycythemia vera |
| Polycythemia vera | ↑ plasma volume and RBC mass; normal SaO2; ↓ EPO |
| Ectopic EPO (renal cell carcinoma) | normal plasma volume; ↑ RBC mass; normal SaO2; ↑ EPO |
| Myelofibrosis myeloid metaplasia | marrow fibrosis; extramedullary hematopoiesis; splenomegaly |
| Lab findings in myelofibrosis | tear drop RBCs; dry bone marrow aspirate (marrow fibrosis) |
| Essential thrombocythemia | MPO with increase in abnormal appearing platelets |
| Myelodysplastic syndrome | severe anemia in elderly; 30% develop leukemia; ringed sideroblasts |
| Benzene | aplastic anemia; acute leukemia |
| Leukemia by age | ALL, newborn-14; AML, 15-60; CML, 40-60; CLL, >60 |
| Acute vs. chronic leukemia | acute, blasts >30% in bone marrow; chronic, blasts <10% in bone marrow |
| AML | Auer rods in myeloblasts |
| Acute promyelocytic leukemia | t(15;17); defect in retinoic acid; Rx retinoic acid (↑ maturation); DIC |
| Acute monocytic leukemia | gum infiltration |
| CML | t(9;22) of ABL POC; Philadelphia chromosome 22; ↓ alkaline phosphatase score |
| ALL | early pre-B (80%); CALLA (CD10) and TdT positive; CNS and testicle involvement |
| ALL | t(12;21) offers good prognosis |
| CLL | B cell neoplasm; ↓ γ-globulins; MCC generalized lymphadenopathy patients> 60-yrs-old |
| Adult T cell leukemia | HTLV-1; CD4 T cells; skin infiltration; lytic bone lesions with hypercalcemia |
| Hairy cell leukemia | positive TRAP stain; splenomegaly; Rx with purine nucleosides |
| Nodal sites | germinal follicles, B cells; paracortex, T cells; sinuses, histiocytes |
| Testicular cancer | metastasizes to para-aortic nodes |
| Stomach cancer | metastasizes to left supraclavicular nodes (Virchow node) |
| Phenytoin | atypical lymphocytosis |
| Cat scratch disease | Bartonella henselae; granulomatous microabscesses |
| Follicular B-cell lymphoma | t(14;18); overexpression of BCL-2 anti-apoptosis gene |
| Burkitt lymphoma | t(8;14); EBV association; common childhood NHL; “starry sky” appearance |
| Extra nodal lymphomas | risk factors H. pylori (stomach); Sjogren’s syndrome |
| Mycosis fungoides | CD4 T cell neoplasm; skin lesions with Pautrier’s microabscesses |
| Sezary syndrome | leukemic phase of mycosis fungoides |
| Polyclonal gammopathy | sign of chronic inflammation |
| Monoclonal gammopathy | M component (spike); sign of plasma cell disorder |
| Confirmatory tests | serum and urine immunoelectrophoresis; bone marrow aspirate |
| Bence Jones protein | light chains in urine; predictive of a malignant plasma cell disorder |
| Multiple myeloma | M spike; lytic bone lesions; pathologic fractures; hypercalcemia; renal failure |
| MGUS | MC monoclonal gammopathy; may progress to myeloma |
| Findings in MGUS | elderly patient; no BJ protein; no malignant plasma cells |
| Waldenstrom’s macroglobulinemia | lymphoplasmacytic lymphoma; IgM M spike; hyperviscosity |
| Hodgkin’s lymphoma | neoplastic component, Reed Stemberg (RS) cell; CD15 CD30 positive |
| Lymphocyte predominant Hodgkin’s | infrequent classic RS cells |
| Nodular sclerosing Hodgkin’s | female dominant; supraclavicular nodes + anterior mediastinal nodes |
| Mixed cellularity Hodgkin’s | male dominant; numerous RS cells; EBV association |
| Hodgkin’s prognosis | stage of disease and type of Hodgkin’s most important factors |
| Alkylating agents in Rx of Hodgkins | ↑ risk for second malignancies (leukemia; NHL) |
| Langerhan’s histiocytes | CD1 positive; Birbeck granules |
| Letterer-Siwe disease | malignant histiocytosis <2 yrs old; diffuse eczematous rash; organ involvement |
| Hand-Christian-Christian disease | malignant; lytic skull lesions, diabetes insipidus, exophthalmos |
| Eosinophilic granuloma | benign histiocytosis; lytic bone lesions with pathologic fractures |
| Mast cells | release histamine (pruritus; swelling); metachromatic granules positive with toluidine blue |
| Urticaria pigmentosum | localized mastocytosis; skin lesions swell and itch with scratching |
| Amyloid | twisted β-sheet; apple green birefringence with Congo red |
| Primary amyloidosis | AL amyloid derived from light chains; plasma cell disorders |
| Secondary amyloidosis | AA amyloid derived from serum-associated amyloid; chronic infections |
| Alzheimer’s disease | amyloid precursor protein gene product chromosome 21; amyloid-β |
| Gaucher’s disease | macrophages have fibrillary appearance; deficiency glucocerebrosidase |
| Niemann Pick’s disease | macrophages have soap bubble appearance; deficiency sphingomyelinase |
| Hypersplenism | splenomegaly; peripheral blood cytopenias; portal hypertension MCC |
| Splenic dysfunction | Howell Jolly bodies; susceptible to Streptococcus pneumoniae sepsis |
| Anticoagulants | tissue plasminogen activator, heparin, PGI2 ATIII, protein C/S |
| Heparin | enhances ATIII activity (neutralizes all factors except V, VIII, fibrinogen) |
| Protein C/S | neutralize V and VIII |
| Procoagulants | coagulation factors, thromboxane A2 (platelet aggregation, vasoconstrictor) |
| Protein C and S | inactivate factors V and VIII; enhance fibrinolysis |
| von Willebrand factor | complexes with factor VIII to enhance VIII:C activity; platelet adhesion |
| Platelets | receptors for von Willebrand factor and fibrinogen; synthesize thromboxane A2 |
| GpIb | platelet receptor for von Willebrand factor |
| GpIIb:IIIa | platelet receptor for fibrinogen |
| Extrinsic system factor | VII |
| Intrinsic system factors | XII, XI, IX, VIII |
| Final common pathway factors | X, V, prothrombin (II), fibrinogen (I) |
| Factor XIII | cross-links insoluble fibrin; strengthens fibrin clots |
| Vitamin K-dependent factors | prothrombin, VII, IX, X, protein C and S |
| Factors consumed in a clot | fibrinogen, prothrombin, V, VIII; fluid is called serum |
| Plasmin | cleaves fibrinogen and insoluble fibrin into degradation products |
| Bleeding time | evaluates platelet function (adhesion, release reaction, aggregation) |
| Aspirin | MCC of a prolonged bleeding time |
| Tests for vWF | ristocetin cofactor assay; vWF antigen assay; agar electrophoresis |
| PT | evaluates extrinsic pathway to fibrin clot |
| PTT | evaluates intrinsic pathway to stable fibrin clot |
| Fibrinolysis tests | fibrin(ogen) degradation products; D-dimers (cross-linked insoluble fibrin) |
| S/S platelet dysfunction | cannot form temporary plug; epistaxis; petechiae; bleeding from scratches |
| Idiopathic thrombocytopenic purpura (ITP) | children; antibodies against GpIIb:IIIa; no splenomegaly |
| Chronic autoimmune thrombocytopenic purpura | SLE; antibodies against GpIIb:IIIa receptors |
| Heparin | thrombocytopenia due to IgG antibody against heparin attached to PF4 on platelets |
| PF4 | heparin neutralizing factor |
| HIV | thrombocytopenia MC hematologic abnormality; similar to ITP |
| TTP | platelet thrombi develop in areas of endothelial damage in small vessels; consumption of platelets |
| S/S | fever, thrombocytopenia, renal failure, hemolytic anemia with schistocytes, CNS deficits |
| Lab findings TTP | thrombocytopenia, prolonged bleeding time, normal PT and PTT |
| HUS | similar to TTP; endothelial injury from Shiga-like toxin of 0157:H7 E. coli in undercooked beef |
| S/S factor deficiency | no stable fibrin clot-late rebleeding; menorrhagia; GI bleeding; hemarthroses |
| Hemophilia A | XR; hemarthroses; prolonged PTT, ↓ factor VIII activity, normal VIII antigen |
| von Willebrand’s disease | AD; platelet adhesion defect + factor VIII deficiency |
| Lab findings in VWD | ↓ vWF, VIII antigen, and VIII:C; prolonged bleeding time |
| Desmopressin acetate | Rx of choice for mild von Willebrand’s disease and hemophilia A |
| Circulating anticoagulants | antibodies destroy coagulation factors |
| Lab finding in circulating anticoagulant | prolonged PT and/or PTT corrected with mixing studies |
| Vitamin K deficiency | ↓ epoxide reductase activity (↓ function vitamin K); hemorrhagic diathesis; ↑ PT |
| Causes vitamin K deficiency | antibiotics MC, newborn, malabsorption, warfarin |
| DIC | activation coagulation system from release of tissue thromboplastin and/or endothelial cell damage |
| DIC | consumption coagulation factors by fibrin clots; patient also anticoagulated |
| Causes | septic shock MCC, rattlesnake bite, massive trauma, amniotic fluid |
| S/S | bleeding from all scratches, holes, needle sites |
| Lab findings DIC | thrombocytopenia, ↑ PT and PTT, D-dimers (best test), anemia |
| Antiphospholipid antibodies | lupus anticoagulant and anticardiolipin antibodies; vessel thrombosis |
| Warfarin | inhibits epoxide reductase; PT best test but PTT also prolonged |
| Warfarin | full anticoagulation in 3 days when -carboxylated prothrombin disappears |
| Warfarin | ingredient in rat poison; danger to children in households with grandparents on warfarin |
| Rx warfarin over anticoagulation | intramuscular vitamin K (6-8 hrs), fresh frozen plasma (immediate) |
| Heparin | enhances ATIII; PTT best test but PT also prolonged |
| OC | estrogen ↑ coagulation factor synthesis and ATIII; predisposes to thrombosis |
| Factor V Leiden | MC hereditary thrombosis; resistant to degradation by protein C/S |
| ATIII deficiency | no prolongation of PTT with administration of heparin |
| Hemorrhagic skin necrosis | post-warfarin therapy in patient with heterozygote protein C deficiency |
| M cells | specialized cells that transfer foreign antigens to lymphocytes in Peyer’s patches |
| Blood group O | some patients have anti-AB-IgG antibodies; increased incidence duodenal ulcers |
| Blood group A | increased incidence of gastric carcinoma |
| Newborns | do not have natural blood group antibodies at birth (e.g., anti-A-lgM) |
| Elderly | may lose natural blood group antibodies; no hemolytic reaction to mismatched blood |
| Rh antigens | inherited in autosomal codominant fashion; Rh antigens include D, C, c, E, e |
| Atypical antibodies | antibodies against Rh or non-Rh blood group antigens (e.g., anti-D) |
| Duffy antigen | receptor for Plasmodium vivax; blacks often lack Duffy antigen |
| Antibody screen | indirect Coomb’s test; detects atypical antibodies in serum |
| Cytomegalovirus | MC infection transmitted by blood transfusion; MC antibody |
| Hepatitis C | MCC of post-transfusion hepatitis |
| Major crossmatch | patient serum reacted against donor RBCs; does not guarantee RBC survival |
| Universal donor | blood group O; no antigens on the surface of RBCs |
| Universal recipient | blood group AB; no natural blood group antibodies in serum |
| Packed RBC transfusion | raises Hb by 1 gm/dL and Hct by 3% |
| Cryoprecipitate | fibrinogen and factor VIII |
| Fresh frozen plasma | replacement for multiple factor deficiencies (e.g., cirrhosis, DIC) |
| Allergic transfusion reaction | type I IgE-mediated hypersensitivity reaction |
| Febrile transfusion reaction | recipient anti-HLA antibodies react against donor leukocytes |
| Intravascular HTR | transfusion of ABO incompatible blood (e.g., A person receives B blood) |
| Extravascular HTR | antibody attaches to donor RBCs; macrophage phagocytosis and hemolysis |
| Positive direct Coomb’s test | present in both types of hemolytic transfusion reactions |
| S/S | jaundice, no increase in Hb, hemoglobinuria |
| ABO HDN | mother O and baby A or B; transplacental passage of maternal anti-AB-IgG |
| ABO HDN | positive direct Coomb’s test; spherocytes; MCC unconjugated hyperbilirubinemia first 24 hrs |
| Rh HDN | mother Rh (D antigen) negative and fetus Rh (O antigen) positive |
| Rh HDN | no hemolysis in first Rh incompatible pregnancy |
| Rh HDN | maternal anti-D crosses placenta; potential for hydrops fetalis; high risk for kernicterus |
| Rh immune globulin | anti-D; coats D antigen site on fetal RBCs in maternal circulation |
| Rh HDN lab | positive direct Coomb’s; severe anemia and hyperbilirubinemia |
| ABO HDN | protects mother from Rh sensitization (development of anti-D antibodies) |
| O Rh negative mother with A Rh positive baby | A+ cells destroyed by mothers anti A-lgM |
| Blue fluorescent light | converts unconjugated bilirubin in skin into harmless water soluble dipyrrole |
| MV auscultation | apex |
| TV auscultation | left parasternal border |
| AV auscultation | right 2nd intercostal space |
| PV auscultation | left 2nd intercostal space |
| S1 | closure MV and TV |
| S2 | closure AV and PV |
| Inspiration | split in A2 and P2; due to increased blood in right side of heart |
| S3 | abnormal; due to blood entering volume overloaded ventricle in early diastole |
| Causes S3 | valve regurgitation; congestive heart failure |
| S4 | abnormal; due to blood entering non-compliant ventricle with atrial contraction in late diastole |
| Causes S4 | volume overloaded ventricle, hypertrophy |
| Murmurs | stretching valve ring or damage to valve |
| Inspiration | increases right sided abnormal heart sounds and murmurs |
| Expiration | increases left sided abnormal heart sounds and murmurs |
| Stenosis murmurs | problem in opening valve |
| Regurgitation murmurs | problem in closing valve |
| Valves opening in systole | AV and PV |
| Valves opening in diastole | MV and TV |
| Valves closing in systole | MV and TV |
| Valves closing in diastole | AV and PV |
| LDL | primary vehicle for carrying cholesterol |
| VLDL | primary vehicle for carrying liver-synthesized triglyceride |
| Familial hypercholesterolemia (type II) | AD; deficiency of LDL receptors; ↑ LDL |
| Type III hyperlipoproteinemia | deficiency apo E; ↑ remnants (chylomicron, intermediate density) |
| Type IV hyperlipoproteinemia | ↑ VLDL; alcoholics |
| Apo B deficiency | deficiency apo B48 (chylomicrons) and B100 (VLDL); ↓ CH and TG |
| Clinical findings in apo B deficiency | malabsorption; hemolytic anemia |
| Atherosclerosis | reaction to injury of endothelial cells |
| Risk factors | smoking, ↑ LDL, ↑ homocysteine, Chlamydia pneumoniae infection |
| Cells involved | platelets, macrophages, smooth muscle cells, T cells with cytokine release |
| Fibrous plaque | pathognomonic lesion of atherosclerosis |
| C-reactive protein | marker of an inflammatory atheromatous plaque |
| Inflammatory atheromatous plaque | predisposes to platelet thrombosis |
| Increased plasma homocysteine | ↑ vessel thrombosis; folate (MC)/vitamin B12 deficiency |
| Hyaline arteriolosclerosis | small vessel disease of DM and hypertension; excess protein in vessel wall |
| Mechanisms hyaline arteriolosclerosis in DM | non-enzymatic glycosylation |
| Non-enzymatic glycosylation | glucose attaches to amino acids in BM; causes ↑ permeability to protein |
| Mechanisms hyaline arteriolosclerosis in hypertension | pressure pushes proteins into vessel wall |
| Abdominal aortic aneurysm rupture | due to atherosclerosis; flank pain, hypotension, pulsatile mass |
| Syphilitic aneurysm | vasculitis of vasa vasorum of aortic arch; aortic regurgitation |
| Aortic dissection | due to hypertension and collagen tissue disorders (e.g., Marfan) |
| Cystic medial degeneration | elastic tissue degeneration creates spaces filled with mucopolysaccharides |
| Intimal tear in aorta | due to wall stress from hypertension and structural weakness |
| Types of dissection | proximal (MC); distal or combination of both |
| S/S proximal aortic dissection | chest pain radiating to back, lack of pulse; cardiac tamponade MC COD |
| Marfan’s | AD; fibrillin defect; aortic regurgitation/dissection; lens dislocation; MVP with sudden death |
| MC COD Marfan’s and Ehlers Danlos | aortic dissection |
| Phlebothrombosis | stasis of blood flow; deep veins below knee MC site |
| Pulmonary thromboembolism | emboli originate from femoral veins |
| Superficial migratory thrombophlebitis | sign of carcinoma of head of pancreas |
| Thoracic outlet syndrome | absent radial pulse with positional change |
| Turner’s syndrome | lymphedema hands/feet in newborn; preductal coarctation |
| Spider telangiectasia | arteriovenous fistula; due to hyperestrinism (cirrhosis, pregnancy) |
| Capillary hemangioma in newborn | regress with age; do not surgically remove |
| Kaposi’s sarcoma | HHV-8; vascular malignancy; MC cancer in AIDS |
| Bacillary angiomatosis | Bartonella henselae; vascular infection in AIDS |
| Small vessel vasculitis | palpable purpura; e.g., Henoch Schonlein purpura |
| Muscular artery vasculitis | vessel thrombosis with infarction; e.g., classical polyarteritis nodosa |
| Elastic artery vasculitis | absent pulse, stroke |
| Takayasu’s arteritis | pulseless disease; young Asian woman |
| Giant cell arteritis | temporal artery granulomatous vasculitis; ipsilateral blindness (ophthalmic artery) |
| Classical polyarteritis nodosa | muscular artery vasculitis with vessel thrombosis infarction |
| Path findings | vessel inflammation at different stages; aneurysms from vessel weakness |
| S/S | infarctions in kidneys, skin, GI tract, heart; HBsAg in 30% |
| Diagnosis | angiography identifies aneurysms and thrombosis |
| Kawasaki’s disease | coronary artery vasculitis/thrombosis/aneurysms in children |
| S/S | chest pain; desquamating rash; swelling hands/feet; cervical lymphadenopathy |
| Rx | IV γ-globulin |
| Buerger’s disease (thromboangiitis obliterans) | smoker’s digital vasculitis; digital infarction |
| Raynaud’s syndrome | digital vasculitis in PSS and CREST syndrome |
| S/S | digital pain; white-blue-red color changes |
| Cryoglobulinemia | protein gels in cold temperature; Raynaud’s syndrome; HCV association |
| S/S | acral cyanosis relieved by coming indoors |
| Wegener’s granulomatosis | association with c-ANCA; sinusitis, lung infarction, crescentic GN |
| Microscopic polyangiitis | palpable purpura; crescentic GN; association with p-ANCA |
| Henoch-Schönlein purpura | IgA-anti-IgA ICs; palpable purpura buttocks/legs; arthritis; IgA GN |
| Serum sickness vasculitis | e.g., horse antivenin in Rx of rattlesnake envenomation |
| Rocky Mountain spotted fever | tick borne |
| Rickettsia infection; vasculitis causes petechia on palms → trunk | |
| Meningococcemia | sepsis causes petechia/ecchymoses; potential for Waterhouse Friderichsen syndrome |
| Essential HTN blacks | defect in renal excretion of sodium; ↑ plasma volume, ↓ PRA |
| Renovascular HTN | atherosclerosis renal artery in men; fibromuscular hyperplasia renal artery women |
| S/S | epigastric bruit; ↑ PRA affected kidney, ↓ PRA unaffected kidney |
| Endocrine HTN | 1º HPTH, Graves/hypothyroidism, Cushing’s, 1º aldosteronism, phaeochromocytoma |
| Hypertension | LVH MC complication; AMI MC COD followed by stroke and renal failure |
| Afterload | resistance ventricles contract against |
| Preload | volume ventricles must eject |
| Concentric LVH | increased afterload; e.g., essential HTN, aortic stenosis |
| LVH with dilation/hypertrophy | increased preload; e.g., valve regurgitation; left to right shunts |
| LHF | forward failure; pulmonary edema, pillow orthopnea, paroxysmal nocturnal dyspnea |
| Systolic dysfunction | LHF due to decreased ventricular contractility (ischemia) |
| Diastolic dysfunction | LHF due to decreased ventricular compliance (hypertrophy) |
| RHF | backward failure; ↑ venous hydrostatic pressure; neck vein distention, hepatomegaly, edema |
| ACE inhibitors | decrease afterload and preload in heart failure |
| Diuretics in CHF | reduce preload |
| Non-pharmacologic Rx in CHF | restrict salt and water |
| AMI | MC COD in United States; left anterior descending coronary artery thrombosis MCC |
| Exertional angina | coronary artery atherosclerosis; subendocardial ischemia; ST depression |
| Prinzmetal’s angina | coronary artery vasospasm; transmural ischemia; ST elevation |
| Sudden cardiac death | death within 1 hr of symptoms |
| Path findings | severe coronary artery atherosclerosis; absence of occlusive thrombosis |
| LAD coronary artery | anterior portion left ventricle, anterior 2/3rds IVS |
| RCA | posterior portion left ventricle and papillary muscle, inferior 1/3rd IVS, right ventricle |
| AMI | rupture of inflammatory plaque produces platelet thrombus |
| Ventricular fibrillation | MC COD in AMI |
| AMI | no gross changes until 24 hrs |
| S/S AMI | retrosternal pain radiating down arms, diaphoresis |
| AMI ruptures | 3rd-7th day |
| Anterior wall rupture | MC type; LAD thrombosis; cardiac tamponade |
| Posteromedial papillary muscle rupture | RCA thrombosis; mitral regurgitation with LHF |
| IVS rupture | LAD thrombosis; left to right shunt; RHF |
| Mural thrombus | anterior AMI; danger embolization |
| Pericarditis | first week in transmural AMI; 6 wks later autoimmune |
| S/S | friction rub; leaning forward relieves pain |
| Ventricular aneurysms | late manifestation of AMI; precordial systolic bulge; CHF MC COD |
| Right ventricular infarction | RCA thrombosis; hypotension, RHF, preserved left ventricular function |
| Diagnosis of AMI | CK-MB and troponins; CK-MB absent by 3 days; troponins last 7-10 days |
| LDH isoenzymes | no longer used; LDH 1/2 flip indicates AMI |
| Reinfarction | reappearance CK-MB after 3 days |
| ECG findings in AMI | inverted T waves; ST elevation; Q waves |
| Ejection fraction | EF = stroke volume/left ventricular end-diastolic volume; 80/120 = 0.66 |
| By-pass surgery | use internal mammary artery and saphenous veins (“arterialize” after 10 yrs) |
| Angioplasty complication | localized dissection with thrombosis |
| Umbilical vein | highest O2 saturation |
| Ductus arteriosis in fetus | shunts blood from pulmonary artery to aorta; PGE keeps it open |
| Ductus arteriosus in newborn | closes and becomes ligamentum arteriosum |
| Eisenmenger’s syndrome | cyanosis due to reversal of left to right shunt |
| VSD | MC congenital heart disease; ↑ SaO2 right ventricle (RV), pulmonary artery (PA) |
| ASD | patent foramen ovale; ↑ SaO2 right atrium (RA), RV, PA; MC adult congenital heart disease |
| Down syndrome | endocardial cushion defect (combined ASD and VSD) |
| PDA | machinery murmur; close with indomethacin; ↑ SaO2 PA |
| Tetralogy of Fallot | degree of pulmonic stenosis determines if cyanosis is present |
| Tetralogy of Fallot | ↓ left ventricle, aorta |
| Tetralogy of Fallot | ASD and PDA are cardioprotective |
| Complete transposition | cyanosis; aorta empties RV; PA empties left ventricle |
| Complications cyanotic heart disease | 2° polycythemia; infective endocarditis; metastatic abscesses |
| Pre-ductal coarctation | Turner’s syndrome |
| Post-ductal coarctation | constriction distal to ligamentum arteriosum |
| S/S | upper extremity HTN; claudication; rib-notching; activation RAA also causes HTN |
| Acute rheumatic fever | type II hypersensitivity; group A streptococcus pharyngeal infection |
| Acute rheumatic fever | sterile vegetations mitral valve (regurgitation); myocarditis with Aschoff nodule |
| S/S | polyarthritis (MC), carditis, erythema marginatum, rheumatoid nodules, chorea |
| Mitral stenosis | chronic rheumatic fever; opening snap followed by mid-diastolic rumble |
| Mitral stenosis | left atrial dilation hypertrophy - atrial fibrillation, thrombus, pulmonary edema, RHF |
| MVP | myxomatous degeneration of mitral valve; common in Marfan syndrome, Ehlers Danlos |
| S/S | mid-systolic click followed by a murmur; palpitations, chest pain, rupture of chordae |
| MVP click/murmur close to S1 | decrease preload (stand, Valsalva, anxiety) |
| MVP click/murmur close to S2 | increase preload (supine, squat, clench fist) |
| Mitral regurgitation | pansystolic murmur; S3 and S4 common |
| Causes | LHF, infective endocarditis, acute rheumatic fever |
| Aortic stenosis | systolic ejection murmur; syncope and angina with exercise; hemolytic anemia |
| Aortic stenosis murmur increased preload | worsens obstruction and increases murmur intensity |
| Aortic stenosis murmur decreased preload | decreases obstruction and decreases murmur intensity |
| Causes | bicuspid aortic valve; age-related sclerosis |
| Aortic regurgitation | bounding pulses; early diastolic blowing murmur |
| Austin Flint murmur | diastolic murmur; regurgitant flow on anterior leaflet mitral valve |
| Significance Austin Flint murmur | sign for AV replacement |
| Causes aortic regurgitation | essential HTN, infective endocarditis, acute rheumatic fever, dissection |
| Tricuspid regurgitation | pansystolic murmur ↑ intensity with inspiration |
| Causes | endocarditis IV drug abuse; RHF; carcinoid heart disease |
| Carcinoid heart disease | tricuspid regurgitation, pulmonic stenosis |
| Infective endocarditis (IE) | Streptococcus viridans MCC; Staphylococcus aureus MCC IVDA |
| IE prosthetic heart valve | Staphylococcus epidermidis (coagulase negative) |
| IE ulcerative bowel disease | Streptococcus bovis |
| S/S | IC vasculitis-Roth spot, splinter hemorrhages; regurgitant murmurs; metas1atic abscesses |
| Lab findings | positive blood culture Libman Sacks endocarditis |
| Coxsackievirus | MCC of myocarditis (lymphocyte infiltrate in myocardium) and pericarditis |
| Parasitic cause myocarditis | leishmania in Chagas disease |
| Pericardial effusion | all chamber pressures are uniformally increased |
| S/S | muffled heart sounds, pulsus paradoxus, inspiratory neck vein distention |
| Dx and Rx | echocardiogram, pericardiocentesis, respectively |
| Pulsus paradoxus | drop in blood pressure >10 mmHg with inspiration |
| Constrictive pericarditis | TB MCC worldwide; pericardial knock |
| Congestive cardiomyopathy | generalized chamber enlargement; low ejection fraction |
| Causes | postpartum, cardiotoxic drugs, hypothyroidism, alcohol |
| Hypertrophic cardiomyopathy | MCC of sudden death in young person (due to conduction defects) |
| Site of obstruction | anterior leaflet mitral valve drawn against asymmetric thickened IVS |
| Effect decreased preload on systolic murmur | worsens obstruction and increases murmur intensity |
| Effect increased preload on systolic murmur | reduces obstruction and decreases murmur intensity |
| Restrictive cardiomyopathy | decreased compliance |
| Causes | iron, amyloid, glycogen; sarcoidosis; tropical endocardial fibrosis |
| Cardiac myxoma | benign tumor left atrium; embolization; syncope |
| Cardiac rhabdomyoma | childhood tumor; association with tuberous sclerosis |
| U wave | hypokalemia; MCC diuretic therapy (e.g., thiazides; loop diuretics) |
| Peaked T wave | hyperkalemia; MCC renal failure |
| ST depression | subendocardial ischemia (e.g., classical angina pectoris) |
| ST elevation | transmural ischemia (e.g., AMI), pericarditis, ventricular aneurysm |
| Atrial fibrillation | MC chronic arrhythmia; absent P waves; danger for embolization |
| Ventricular premature beats | wide QRS complexes; MC arrhythmia in coronary care unit |
| Ventricular fibrillation | MCC of death in an AMI |
| Anterior AMI | Q waves in I and V1-V4 |
| Inferior AMI | Q waves in II, III, and aVF; right coronary artery thrombosis. |
| Wolff-Parkinson-White | short PR interval with normal P wave; delta wave on upstroke of R wave |
| Alveolar O2 calculation | % O2 breathing (713) - PCO2/0.8 |
| Increased A-a gradient | primary lung disease; left to right shunts in heart |
| Forced vital capacity | total amount of air expelled after a maximal inspiration |
| Forced expiratory volume/1 second (FEV1) | amount of air expelled in I second after maximal inspiration |
| Choanal atresia | cyanotic when breast feeding; turns pink when crying |
| Nasal polyps | allergic (MC; adults only), aspirin, cystic fibrosis |
| Nasal polyp in a child | requires sweat test to exclude cystic fibrosis |
| Triad asthma | patient on aspirin (pain syndrome) with nasal polyps, asthma |
| Obstructive sleep apnea (OSA) | snoring with intervals of apnea (respiratory acidosis with hypoxemia) |
| S/S | danger cor pulmonale; requires sleep test; Rx. O2 with continuous positive airway pressure |
| Sinusitis | maxillary sinusitis MC in adults; ethmoiditis MC in children; S. pneumoniae MC |
| Nasopharyngeal carcinoma | association with EBV; metastasize to cervical nodes |
| Laryngeal carcinoma | smoking MCC; hoarseness; squamous cell carcinoma |
| Resorption atelectasis | MCC of fever 24-36 hours after surgery |
| S/S | ↓ percussion; absent fremitus, breath sounds; inspiratory lag; elevated diaphragm |
| RDS | decreased production surfactant; airway collapse; hyaline membranes |
| Type II pneumocytes | synthesize surfactant (lecithin, phosphatidylcholine); stored in lamellar bodies |
| Surfactant | reduces surface tension in airways; ↑ synthesis cortisol, thyroxine; ↓ synthesis insulin |
| Causes RDS | prematurity, maternal diabetes, C-section |
| Maternal diabetes | maternal hyperglycemia → fetal hyperglycemia → fetal insulin which ↓ surfactant |
| Complications RDS | O2 FR injury (blindness, bronchopulmonary dysplasia); necrotizing enterocolitis |
| Typical community acquired pneumonia | Streptococcus pneumoniae MCC |
| Typical pneumonia | bronchopneumonia, lobar pneumonia |
| S/S | productive cough; consolidation - ↓ percussion, ↑ tactile fremitus |
| Atypical community acquired pneumonia | interstitial pneumonia; Mycoplasma pneumoniae MCC |
| S/S | low grade fever, non-productive cough, no signs consolidation |
| Nosocomial pneumonia | Pseudomonas, aeruginosa MCC (respirators); others - S. aureus, E. coli |
| Rhinovirus | MCC common cold; hand to mouth transmission |
| Respiratory syncytial virus | MCC pneumonia and bronchiolitis in child |
| Parainfluenza virus | MCC croup in child; trachea area of obstruction |
| Cytomegalovirus | basophilic intranuclear inclusion surrounded by halo |
| Influenza | superimposed pneumonia with S. aureus increases mortality |
| Rubeola | Warthin-Finkeldey multinucleated giant cells |
| Chlamydia pneumoniae | atypical pneumonia; association with coronary artery disease |
| Chlamydia trachomatis | pneumonia in newborns; staccato cough; wheezing |
| Coxiella burnetii | only rickettsia without a vector |
| Mycoplasma pneumoniae pneumonia | crowded condition; cold agglutinins; azithromycin |
| Streptococcus pneumoniae pneumonia | gram positive diplococcus; azithromycin |
| Staphylococcus aureus pneumonia | tension pneumatocysts in children with cystic fibrosis |
| Corynebacterium diphtheriae | toxin produces ADP ribosylation of elongation factor 2 |
| Haemophilus influenzae | exacerbation chronic bronchitis; acute epiglottis in children |
| Inspiratory stridor child | croup, epiglottitis |
| Pseudomonas aeruginosa | MCC of pneumonia and death in cystic fibrosis; green sputum |
| Klebsiella pneumoniae | mucoid sputum in alcoholic |
| Legionella pneumophila | silver stain; water coolers/mist (grocery produce, restaurants, zoo rain forest) |
| Mycobacterium tuberculosis | strict aerobe; MC COD due to infectious disease worldwide |
| Candida albicans | vessel invader; yeasts and pseudohyphae |
| Cryptococcus immitis | pigeon excreta; narrow-based bud |
| Aspergillus fumigatus | septate hyphae with fruiting body; fungus ball, extrinsic asthma, vessel invader |
| Mucor species | non-septate; vessel invader; frontal lobe abscess in diabetic ketoacidosis |
| Coccidioides immitis | Southwest deserts; inhale arthrospores in dust; spherule with endospores |
| S/S | erythema nodosum (painful nodules lower legs) |
| Histoplasma capsulatum | Ohio/central Mississippi river valley; excreta bats (spelunker), chickens |
| H. capsulatum | simulates TB; yeasts phagocytosed by macrophages |
| Blastomyces dermatitidis | overlaps histoplasmosis; broad-based buds; skin lesion simulates cancer |
| Pneumocystis carinii | cysts and trophozoites; pneumonia in HIV; Rx. trimethoprim/sulfamethoxazole |
| Primary TB | upper portion lower lobe, lower portion upper lobe |
| Primary TB | Ghon focus (subpleural caseation); Ghon complex (spread to hilar nodes) |
| Reactivation TB | cavitating lesion in upper lobe; kidney MC extrapulmonary site |
| Mycobacterium avium intracellulare (MAI) | atypical TB; MC TB in AIDS |
| CF | AR; 3 nucleotide deletion chromosome 7; defective CFTR (degraded in Golgi apparatus) |
| S/S | pneumonia, malabsorption, males sterile; + sweat test; P. aeruginosa pneumonia MC COD |
| Lung abscess | MCC aspiration oropharyngeal material (mixed aerobe/anaerobe); x-ray - air/fluid level |
| Aspiration sitting | posterobasal segment right lower lobe |
| Aspiration supine | superior segment right lower lobe |
| Aspiration right side | right middle lobe, posterior segment right upper lobe |
| Pulmonary thromboembolism | most derive from femoral vein |
| Bronchial artery | branch of aorta/intercostal artery; protects against developing pulmonary infarction |
| Saddle embolus | sudden death due to acute right heart strain |
| S/S pulmonary infarction | dyspnea and tachypnea; pleuritic chest pain; pleural effusion |
| Dx | ventilation/perfusion scan; respiratory alkalosis; hypoxemia |
| Pain on inspiration | pleuritic inflammation; pulmonary embolus, pneumonia, pneumothorax |
| Pathogenesis pulmonary hypertension (PH) | hypoxemia and respiratory acidosis |
| Hypoxemia + respiratory acidosis | vasoconstriction pulmonary vessels; vasodilation cerebral vessels |
| Causes PH | 1° lung disease (COPD, restrictive), recurrent emboli, mitral stenosis, OSA, left-right shunts |
| Cor pulmonale | PH + RVH |
| S/S | dyspnea; accentuated P2 (PH); parasternal heave (RVH) |
| Restrictive lung disease | ↓ compliance, ↑ elasticity; interstitial fibrosis/edema |
| Restrictive lung disease (RLD) | ↓ all volumes and capacities; ↑ FEV1sec/FVC ratio |
| ARDS | RLD; non-cardiogenic pulmonary edema due to alveolar injury |
| ARDS | neutrophil destruction of type I and II pneumocytes; hyaline membranes |
| Causes | septic shock (MC), aspiration gastric contents, severe trauma |
| Pneumoconiosis | inhalation mineral dust causing interstitial fibrosis; particles <0.5 μm to reach alveoli |
| Caplan syndrome | pneumoconiosis + rheumatoid nodules in lungs |
| Coal worker’s | “black lung” disease; progressive massive fibrosis; no increased incidence cancer or TB |
| Silicosis | quartz; nodular opacities; foundry workers; ↑ incidence cancer and TB |
| Sources asbestos | roofing material, old buildings (9/11), pipe-fitter shipyard |
| Ferruginous bodies | asbestos fiber coated by iron |
| Asbestosis | benign pleural plaques (MC); bronchogenic carcinoma (MC cancer); mesothelioma |
| Mesothelioma | malignancy of serosa; no smoking association |
| Sarcoidosis | RLD; MC non-infectious lung and liver granulomatous disease |
| S/S | dyspnea, hilar adenopathy (non-caseating granulomas), uveitis, nodular skin lesions |
| Lab findings | ↑ ACE, hypercalcemia (macrophages synthesize 1-α-hydroxylase) |
| Kveim test | intradermal injection sarcoid antigens causes skin reaction |
| Farmer’s lung | RLD; lung reaction against thermophilic bacteria in moldy hay |
| Silo filler’s disease | RLD; reaction against nitrogen dioxide in fermenting corn |
| Byssinosis | RLD; reaction against cotton, linen, hemp products in textile industry |
| Goodpasture’s syndrome | RLD; anti-BM antibodies; begins in lungs and ends in renal failure |
| Collagen vascular RLD | SLE, rheumatoid arthritis, systemic sclerosis |
| Drugs RLD | amiodarone, bleomycin, busulfan, cyclophosphamide, methotrexate, nitrofurantoin |
| Obstructive lung disease | ↑ compliance, ↓ elasticity |
| Obstructive lung disease | ↑ RV, TLC; ↓ TV, VC; ↓ FEV1sec and FVC; ↓ FEV1sec/FVC ratio |
| Obstructive lung disease | asthma, emphysema, chronic bronchitis, bronchiectasis |
| Asthma | extrinsic (type I hypersensitivity) and intrinsic types |
| S/S | expiratory wheezing (inflamed terminal bronchioles); LTC4,-D4,-E4 bronchoconstrictors |
| Charcot-Leyden crystals | derive from crystalline material in eosinophil granules |
| Lab findings | initial respiratory alkalosis; respiratory acidosis requires intubation |
| Emphysema | destruction elastic tissue respiratory unit; lung hyperinflation; smoking MCC; pink puffer |
| Respiratory unit | respiratory bronchiole, alveolar duct, alveoli |
| Radiograph emphysema | ↑ AP diameter; depressed diaphragms; vertical heart |
| Pathogenesis | ↓ AAT, ↑ neutrophil destruction of elastic tissue |
| Centriacinar emphysema | destruction/distention respiratory bronchioles upper lobe in smokers; THINK |
| Panacinar emphysema | destruction/distention entire respiratory unit lower lobes; AAT deficiency |
| Paraseptal emphysema | upper lobe destruction/distention alveolar ducts, alveoli; pneumothorax |
| Lab findings | normal to decreased PCO2 (respiratory alkalosis) |
| Chronic bronchitis | productive cough 3 months/2 consecutive years; blue bloater (cyanosis) |
| Site of obstruction | terminal bronchioles (proximal to respiratory unit) |
| Lab findings | respiratory acidosis/hypoxemia |
| Bronchiectasis | obstruction/infection key causes; dilated bronchioles extend to periphery |
| Causes | CF MCC, TB, immotile cilia syndrome |
| Immotile cilia syndrome | absent dynein arm in cilia; sinusitis, infertility, bronchiectasis, situs inversus |
| Central lung cancers | squamous cancer and small cell cancer; men > women |
| Peripheral lung cancers | adenocarcinoma; women > men |
| Squamous lung cancer | cavitate; secrete PTH-related protein |
| Small cell carcinoma | neuroendocrine tumor; secrete ACTH and ADH |
| Bronchioloalveolar carcinoma | no smoking relationship; lung consolidation resembling pneumonia |
| Scar carcinoma | usually adenocarcinoma developing in old TB scar |
| Bronchial carcinoid | low grade malignant; hemoptysis; rare cause carcinoid syndrome |
| Metastatic lung cancer | more common than primary cancer; breast cancer MCC |
| Pancoast tumor | squamous carcinoma posterior mediastinum; destruction superior cervical ganglion |
| S/S | Horner’s syndrome - lid lag, miosis, anhydrosis; lower brachial plexus injury |
| Solitary coin lesion | granuloma MCC |
| Superior vena caval syndrome | primary lung cancer obstructs vessel; venous congestion |
| Anterior mediastinal masses | thymoma; nodular sclerosing Hodgkin’s; teratomas |
| Posterior mediastinal masses | usually neurogenic tumors of ganglia |
| Myasthenia gravis | B cell hyperplasia of thymus MC abnormality; association with thymoma |
| Thymoma | association with hypogammaglobulinemia, autoimmune disease, pure RBC aplasia |
| Pleural effusions | transudates or exudates; CHF MCC |
| Spontaneous pneumothorax | rupture subpleural or intrapleural bleb; air/pleural cavity pressure same |
| S/S | pleuritic chest pain, dyspnea, tracheal shift ipsilateral side, absent breath sounds |
| Tension pneumothorax | flap-like pleural tear; increased pleural cavity pressure; compression atelectasis |
| S/S | as above except tracheal shift to opposite side |
| Cleft lip/palate | failure of fusion of facial processes |
| Herpes labialis | multinucleated giant cell with acidophilic intranuclear inclusions on Tzanck prep |
| Hairy leukoplakia | EBV glossitis; pre-AIDS defining lesion; not precursor to cancer |
| Mumps | bilateral parotitis; unilateral orchitis; ↑ amylase |
| Diphtheria | pseudomembrane pharynx and trachea with cervical lymphadenopathy |
| Congenital syphilis | notched central incisors |
| Actinomycosis | anaerobic gram + filamentous bacteria; complication extracted dental abscess |
| S/S | draining sinuses with sulfur granules |
| Exudative tonsillitis | majority are viral; 20% group A streptococcus |
| Oral thrush | common in newborn; pre-AIDS defining lesion; yeasts and pseudohyphae |
| Dental caries | Streptococcus mutans |
| Peutz-Jegher’s syndrome | mucosal pigmentation; hamartomatous polyps |
| Leukoplakia/erythroleukoplakia | biopsy to rule out squamous dysplasia or cancer |
| Squamous cell carcinoma | smoking and alcohol association; lower lip MC site |
| Smokeless tobacco | verrucoid squamous cell carcinoma |
| Gum hyperplasia | phenytoin, pregnancy, scurvy |
| Pleomorphic adenoma | MC benign tumor of salivary glands; parotid MC site |
| Mucoepidermoid carcinoma | MC malignant tumor major and minor salivary glands |
| Dysphagia for solids only | lesion obstructing esophagus; e.g., cancer, web |
| Plummer-Vinson syndrome | iron deficiency anemia causes esophageal web, glossitis, achlorhydria (↓ HCl in gastric acid) |
| Dysphagia for solids and liquids | motor abnormality; e.g., achalasia MCC, PSS or CREST syndrome |
| TE fistula | polyhydramnios; proximal esophagus ends blindly; distal esophagus derives from trachea |
| VATER syndrome | vertebral abnormalities, anal atresia, TE fistula, renal disease/radius abnormality |
| Zenker’s diverticulum | MC pulsion diverticulum of esophagus; halitosis (stinky breath, food gets stuck); near UES |
| GERD | relaxation of lower esophageal sphincter (LES) with acid reflux |
| GERD | MCC nocturnal cough and asthma |
| AIDS esophagitis | Candida MC, CMV, HSV |
| Barrett’s esophagus | glandular metaplasia distal esophagus in GERD |
| Complications of Barrett’s | precursor for adenocarcinoma, stricture |
| Esophageal varices | dilated left gastric vein; sign of portal hypertension due to cirrhosis |
| Mallory Weiss syndrome | tear of distal esophagus from retching in alcoholic or bulimic |
| Boerhaave’s syndrome | rupture of distal esophagus from retching; pneumomediastinum |
| Hamman’s mediastinal crunch | pneumomediastinum (air in subcutaneous tissue) |
| LES ganglion cells | contain VIP - relaxes LES |
| Achalasia | failure of LES relaxation (no VIP); absent ganglion cells in the myenteric plexus |
| S/S | aperistalsis/dilation of esophagus; regurgitation of undigested food at night |
| X-ray achalasia | bird’s beak appearance |
| Acquired achalasia | Chagas’ disease; leishmania destroy ganglion cells |
| Distal adenocarcinoma esophagus | MC primary cancer; due to Barrett’s esophagus |
| Squamous cell carcinoma of esophagus | smoking MCC; alcohol also causes |
| Melena | sign of upper GI bleed; acid changes Hb to hematin; peptic ulcer disease MCC |
| Hematemesis | vomiting blood; peptic ulcers MCC |
| Congenital pyloric stenosis | hypertrophy pyloric muscle; vomiting non-bile stained fluid in 2-4 weeks |
| Acute hemorrhagic (erosive) gastritis | NSAIDs MCC |
| Mucous barrier stomach | maintained by PGE; misoprostol PGE analog |
| Type A chronic gastritis | due to PA; achlorhydria with ↑ serum gastrin |
| Type B chronic gastritis | due to H. pylori; involves pylorus and antrum |
| H. pylori | curved rod; urease producer; MCC PUD, adenocarcinoma, gastric lymphoma |
| Gastric ulcer | lesser curvature pylorus and antrum; poor defense against acid; food aggravates pain |
| Duodenal ulcer | never malignant; ↑ acid production; food relieves pain |
| Perforated peptic ulcer | air under diaphragm causes pain in left shoulder |
| Menetrier’s disease | giant rugal hyperplasia; protein loss from increased mucus |
| Zollinger-Ellison syndrome | malignant islet cell tumor secreting gastrin; part of MEN I syndrome |
| S/S | PUD in usual locations; sometimes multiple ulcers |
| Hypergastrinemia | ZE, achlorhydria, gastric distention, H2 or proton blockers; renal failure |
| Leiomyoma | MC benign tumor of stomach |
| Intestinal type adenocarcinoma | H pylori related; ↓ incidence; lesser curvature pylorus/antrum |
| Diffuse type adenocarcinoma | linitis plastica; signet ring cells; Krukenberg tumors ovaries |
| Gastric lymphoma | stomach MC site for extranodal lymphomas; H. pylori associated |
| Malabsorption | steatorrhea; chronic pancreatitis, bile salt deficiency, small bowel disease |
| Causes bile salt deficiency | liver disease, bile salt resins, cholestasis, bacterial overgrowth, Crohn’s |
| D-xylose screen | failure to reabsorb xylose indicates small bowel disease |
| Calcification of pancreas | chronic pancreatitis cause of malabsorption |
| Celiac disease | autoimmune disease; antibodies against gliadin in gluten; flat villi |
| Celiac disease | association with dermatitis herpetiformis |
| Whipple’s disease | systemic infection; foamy macrophages with bacteria (PAS+ inclusions) in small bowel submucosa |
| S/S | fever, polyarthritis, skin pigmentation |
| Invasive diarrhea | Campylobacter jejuni MCC; positive fecal smear for leukocytes |
| Secretory diarrhea | loss isotonic fluid; enterotoxins from E. coli and V. cholerae |
| Osmotic diarrhea | hypotonic loss fluid; laxatives, lactase deficiency |
| Rotavirus | MCC diarrhea in children |
| Norwalk virus | MCC diarrhea in adults |
| Cytomegalovirus | common cause diarrhea in AIDS; MCC cholecystitis and pancreatitis in AIDS |
| Staphylococcus aureus | preformed toxin causes food poisoning; culture food |
| Bacillus cereus | preformed toxin in fried rice and tacos; gram positive rods in stool |
| Clostridium botulinum (adult) | preformed neurotoxin (blocks acetylcholine release); paralysis and mydriasis |
| Clostridium botulinum (child) | colonization of bowel with release of neurotoxin; eating honey |
| Clostridium difficile | pseudomembranous colitis; post-antibiotics; toxin assay stool; Rx metronidazole |
| Shigella sonnei | produces dysentery (bloody diarrhea); associated with HUS |
| Salmonella enteritidis | gastroenteritis; animal reservoirs - poultry, turtles |
| Salmonella paratyphi | sepsis; osteomyelitis in HbSS |
| Salmonella typhi | typhoid fever; human transmission; bradycardia, neutropenia, splenomegaly |
| Carrier state site | gallbladder |
| M. tuberculosis | MCC intestinal TB in United States (swallow TB); Peyer’s patch site of infection |
| Enterotoxigenic E. coli | secretory diarrhea (traveler’s diarrhea); toxin stimulates guanylate cyclase |
| Vibrio cholerae | secretory diarrhea; toxin stimulates adenylate cyclase to produce cAMP |
| Oral Rx cholera | solution must contain glucose to reabsorb Na+ (co-transport) |
| Yersinia enterocolitica | mesenteric lymphadenitis; sepsis in iron overload states |
| Entamoeba histolytica | dysentery; trophozoites phagocytose RBCs; liver abscess; Rx metronidazole |
| Cryptosporidium parvum | MCC diarrhea in AIDS; acid-fast oocysts |
| Giardia lamblia | MC protozoal cause of diarrhea; cause of malabsorption; Rx metronidazole |
| Trichuris trichiura | rectal prolapse in children |
| Enterobius vermicularis | anal pruritus; urethritis in girls; no eosinophilia |
| Ascaris lumbricoides | intestinal obstruction due to adult worms; no eosinophilia |
| Necator americanus | hookworm; iron deficiency anemia |
| Strongyloides stercoralis | rhabditiform larvae in stool not eggs |
| Diphyllobothrium latum | fish tapeworm; vitamin B12 deficiency |
| Signs of small bowel obstruction | colicky pain; constipation and obstipation |
| Radiograph small bowel obstruction | air-fluid levels on x-ray |
| MCC small bowel obstruction | adhesions from previous surgery |
| Duodenal atresia | vomiting bile-stained fluid at birth; double bubble sign; Down syndrome |
| Hirschsprung disease | absent ganglion cells in submucosal/myenteric plexus rectosigmoid |
| S/S | proximal bowel dilated but peristalses; no stool in rectal vault |
| Hirschsprung association | Down syndrome; Chagas disease |
| Intussusception | terminal ileum telescopes into cecum; obstruction plus bloody diarrhea |
| Meconium ileus | complication of cystic fibrosis |
| Indirect inguinal hernia | second MCC of small bowel obstruction; common in weight lifting |
| Gallstone ileus | obstruction of small bowel with gallstone + air in biliary tree |
| Volvulus | MC due to sigmoid colon twisting around mesentery |
| Direct inguinal hernia | protrudes through center of triangle of Hesselbach; no obstruction |
| Umbilical hernia | common in black children; may entrap bowel in adults |
| Sigmoid colon | MC site for polyps, cancer, diverticula |
| Small bowel infarction | diffuse abdominal pain with bloody diarrhea |
| Causes small bowel infarction | embolism (atrial fibrillation), thrombosis SMA or SMV |
| Ischemic colitis | splenic flexure pain with bloody diarrhea |
| Mesenteric angina | pain in splenic flexure 30 minutes after eating |
| Angiodysplasia | submucosal dilation of venules in cecum; cause of hematochezia |
| Hematochezia | massive loss of blood per rectum; diverticulosis MCC |
| Meckel’s diverticulum | persistence omphalomesenteric duct |
| S/S | bleeding MC (iron deficiency in children), diverticulitis |
| Meckel’s diverticulitis | mimics acute appendicitis; cannot differentiate without radionuclide scan |
| Sigmoid diverticulum | diverticulitis MC complication; MCC hematochezia and fistula formation |
| Diverticulitis | “left-sided acute appendicitis” |
| Ulcerative colitis | mucosal/submucosal ulceration; starts in rectum; crypt abscess; ↑ risk adenocarcinoma |
| S/S | left lower quadrant crampy pain with bloody diarrhea |
| UC associations | primary sclerosing cholangitis, seronegative HLA B27 + spondyloarthropathy |
| Crohn’s disease | transmural inflammation; terminal ileum involved 80%; granulomas; skip lesions |
| S/S | colicky pain and diarrhea; fistulas (anal, bowl to bowel) |
| Carcinoid tumor | appendix MC site; terminal ileum MC site for carcinoid syndrome |
| Carcinoid syndrome | liver metastasis; flushing/diarrhea due to serotonin; increased urine 5-HIAA |
| Tubular adenomas | precursor lesion colon cancer; size and number determine risk of malignancy |
| Villous adenoma | greatest risk for colon cancer (30%); secrete mucus rich in protein and potassium |
| Familial polyposis | AD with 100% penetrance for developing colon cancer |
| Gardner’s syndrome | AD, polyposis plus osteomas and desmoid tumors |
| Turcot’s syndrome | AD, polyposis plus brain tumors |
| Colorectal cancer | second MC cancer and cancer killer in adults |
| Left-sided colorectal cancer | obstruct; MC location rectosigmoid |
| Right-sided colorectal cancer | bleed |
| Acute appendicitis | due to lymphoid hyperplasia in children and obstruction by fecalith in adults |
| External hemorrhoids | thrombose |
| Internal hemorrhoids | bleed; prolapse out of rectum |
| Urobilinogen (UBG) | breakdown product CB in bowel (color of stool) |
| UBG | enterohepatic circulation to liver and kidney (color of urine) |
| Alcoholic liver disease | serum AST>ALT; ↑ serum GGT |
| Viral hepatitis | serum ALT>AST |
| Cholestasis markers | serum AP and GGT |
| Unconjugated bilirubin | macrophage degradation of heme; lipid soluble; never in urine |
| Conjugated bilirubin (CB) | water soluble; never normal in urine |
| % CB <20% (unconjugated) | Gilberts, spherocytosis, physiologic jaundice newborn, ABO/Rh HDN |
| Gilbert’s disease | AD; ↓ uptake and conjugation; bilirubin increases with fasting |
| Physiologic jaundice newborn | unconjugated hyperbilirubinemia; begins on day three |
| % CB 20-50% | viral/alcoholic hepatitis |
| % CB >50% | bile duct obstruction (intra or extrahepatic); carcinoma head of pancreas |
| Negative urine bilirubin + trace urobilinogen | normal urine |
| Positive urine bilirubin, absent urobilinogen | obstructive jaundice |
| Positive urine bilirubin + increased urobilinogen | hepatitis |
| Negative urine bilirubin + increased urobilinogen | extravascular hemolytic anemia |
| Markers of severity of liver disease | albumin, PT |
| Hepatitis A | protective antibodies; day care centers, jails, homosexuals, traveling; not chronic |
| Hepatitis B | protective antibodies; accidental needle stick, IVDA; hepatocellular carcinoma |
| Hepatitis C | no protective antibodies; post-transfusion hepatitis; chronic state; hepatocellular carcinoma |
| Hepatitis D | no protective antibodies; requires HBsAg to replicate |
| Anti-HBs alone | vaccination |
| Anti-HBs + anti-HBc-IgG | recovered from HBV |
| HBsAg + HBeAg + HBVDNA + anti-HBc-IgM | acute HBV/chronic HBV infective carrier if >6 months |
| Anti HBc-IgM alone | serologic gap; not infective |
| HBsAg + anti-HBc-IgM | chronic HBV healthy carrier |
| Fulminant hepatic failure | viral hepatitis and acetaminophen MCCs |
| Spontaneous peritonitis | E. coli in adults; S. pneumoniae in children; complication of ascites |
| Granulomatous hepatitis | TB MC bacteria |
| Amebiasis | Entamoeba histolytica; flash shaped ulcers in cecum; liver abscess; Rx |
| Echinococcosis | Echinococcus granulosis; sheep dog definitive host; man intermediate host |
| Schistosomiasis | Schistosoma mansoni; adult worms in portal vein; “pipe stem cirrhosis” |
| Clonorchiasis | Clonorchis sinensis; ingesting encysted larvae in fish; cholangiocarcinoma |
| Congestive hepatomegaly (centrilobular necrosis) | “nutmeg” liver; RHF MCC |
| Hepatic vein thrombosis | Budd-Chiari syndrome; painful hepatomegaly; ascites; portal hypertension |
| Portal vein thrombosis | ascites, portal hypertension, no hepatomegaly |
| Alcohol related disorders | fatty change; alcoholic hepatitis; cirrhosis |
| Hypertriglyceridemia in alcoholics | ↑ synthesis of glycerol 3P (substrate for TG synthesis) |
| Hypoglycemia in alcoholics | ↓ gluconeogenesis (↑ NADH causes pyruvate to convert to lactate) |
| Ketoacidosis in alcoholics | ↑ lactate, ↑ ßOHB (acetyl CoA converted to AcAc and then ßOHB) |
| Primary biliary cirrhosis | granulomatous destruction triad bile ducts; anti-mitochondrial antibody |
| Primary sclerosing cholangitis | association with ulcerative colitis; MCC of cholangiocarcinoma |
| Extrahepatic biliary atresia | neonatal cholestasis |
| Drugs causing hepatitis | acetaminophen, isoniazid, halothane |
| Anabolic steroids | intrahepatic cholestasis |
| Estrogen/oral contraceptives | intrahepatic cholestasis; hepatic adenoma (intraperitoneal hemorrhage) |
| Methotrexate | liver fibrosis, fatty change |
| Liver angiosarcoma | vinyl chloride |
| Hemochromatosis | AR; increased iron reabsorption; liver target organ |
| S/S | cirrhosis; “bronze diabetes” - skin pigmentation + destruction of islet cells; malabsorption |
| Lab | ↑ serum ferritin, iron, % saturation; ↓ TIBC |
| Wilson’s disease | AR disease; defect in copper excretion in bile and synthesis of ceruloplasmin |
| S/S | cirrhosis, movement disorder (necrosis in putamen), Kayser Fleisher ring (Descemet’s membrane) |
| Lab | ↓ ceruloplasmin (causes ↓ total copper); ↑ serum/urine free copper |
| HELLP syndrome | pre-eclampsia; Hemolytic anemia, ELevated transaminases, Low Platelets |
| AAT deficiency in child | AR, cannot secrete AAT from liver cell; cirrhosis; hepatocellular carcinoma |
| Reye syndrome | coma and microvesicular fatty change post viral infection; increased ammonia |
| Cirrhosis | irreversible fibrosis; regenerative nodules; portal hypertension |
| Causes cirrhosis | alcohol (MC), HBV/HCV, hemochromatosis, Wilson’s, AAT deficiency, 1° biliary |
| Hepatic encephalopathy | mental status changes; ↑ serum ammonia |
| Portal hypertension | ascites; varices; splenomegaly; hemorrhoids; caput medusae |
| Cause of ascites | portal hypertension; hypoalbuminemia; secondary aldosteronism |
| Rx | use aldosterone blocker (acidosis increases loss ammonium in stool) |
| Hyperestrinism in men | gynecomastia; spider angiomas; female hair distribution |
| Lab findings cirrhosis | ↓ BUN, glucose, sodium, potassium, calcium (↓ vitamin D); ↑ PT |
| Liver cell adenoma | estrogen related (steroids, oral contraceptives); intraperitoneal hemorrhage |
| Liver cancer | metastasis MC cancer; lung cancer MC primary site |
| Hepatocellular carcinoma | chronic HBV and HCV MCC; ↑ AFP; hepatic/portal vein invasion |
| Cholangiocarcinoma | primary sclerosing cholangitis MCC, C.C sinensis |
| Pathogenesis of cholesterol stones | bile with too much cholesterol and too little bile salts |
| Black pigment stones | sign of extravascular hemolytic anemia (spherocytosis, HbSS) |
| Acute cholecystitis | stone impacted in cystic duct; right upper quadrant colicky pain with radiation to shoulder |
| Chronic cholecystitis | chemical inflammation |
| Gallbladder cancer | risk factors - cholelithiasis and porcelain gallbladder |
| Acute pancreatitis | causes - alcohol and gallstones; ↑ amylase and lipase (more specific) |
| S/S | epigastric pain with radiation into back |
| Sentinel loop | localized ileus of duodenum due to acute pancreatitis |
| Pancreatic pseudocyst | abdominal mass; persistence of ↑ serum amylase >1 week |
| Chronic pancreatitis | alcohol abuse, CF; malabsorption, pain, type I diabetes |
| Pancreatic cancer | smoking MCC |
| S/S | jaundice/acholic (gray/pale) stools; palpable gallbladder; superficial migratory thrombophlebitis (Trousseau's sign); ↑ CA 19-9 |
| First sign tubule cell dysfunction | inability to concentrate urine |
| Fixed specific gravity | chronic renal failure; cannot concentrate or dilute urine |
| Negative urine bilirubin + trace urobilinogen | normal urine |
| Positive urine bilirubin, absent urobilinogen | obstructive jaundice |
| Positive urine bilirubin + increased urobilinogen | hepatitis |
| Negative urine bilirubin + increased urobilinogen | extravascular hemolytic anemia |
| Positive urine nitrite + positive urine leukocyte esterase | urinary tract infection |
| Sterile pyuria | positive urine leukocyte esterase but negative standard culture; TB, C. trachomatis |
| Prerenal azotemia | ↑ BUN and creatinine; ↓ renal blood flow (e.g. heart failure, hypovolemia) |
| Renal azotemia | ↑ BUN and creatinine due to intrinsic renal disease (acute tubular necrosis) |
| Postrenal azotemia | ↑ BUN and creatinine due to obstruction to urine flow |
| Serum BUN:creatinine ratio | <15:1 (renal failure); >15:1 (prerenal or postrenal azotemia) |
| BUN 80 mg/dL:creatinine 8 mg/dL | ratio 10/1 - renal failure |
| BUN 80 mg/dL:creatinine 2 mg/dL | ratio 40/1 - prerenal azotemia or postrenal azotemia |
| Creatinine clearance | measures GFR |
| Proteinuria | important sign of renal dysfunction |
| RBC casts | nephritic type of glomerulonephritis |
| WBC casts | acute pyelonephritis, acute tubulointerstitial nephritis |
| Fatty casts with Maltese crosses | nephrotic syndrome |
| Hyaline casts | normal unless associated with proteinuria |
| Renal tubular cell casts | acute tubular necrosis |
| Waxy or broad casts | chronic renal failure |
| Cystinuria | hexagonal crystals |
| Horseshoe kidney | Turner’s syndrome; lower poles fused |
| Renal dysplasia | MC childhood cystic disease; abnormal development; flank mass |
| Maternal oligohydramnios | fetal juvenile polycystic kidney disease; Potter’s facies in newborn |
| Adult polycystic kidney disease | AD; hypertension MC sign; cerebral berry aneurysms |
| Visceral epithelial cells | synthesize basement membrane |
| Glomerular BM | negative charge due to heparan sulfate |
| Nephritic syndrome | oliguria; RBC casts; hypertension; mild to moderate proteinuria |
| Nephrotic syndrome | proteinuria >3.5 g/day; ascites and pitting edema; fatty casts; fusion of podocytes |
| Immunofluorescence | linear (anti-glomerular BM antibodies); granular (IC deposition) |
| IgA GN | MC GN; usually nephritic; episodic hematuria; mesangial IC (lgA-anti-IgA) deposits |
| Post-streptococcal GN | nephritic; subepithelial deposits; skin/pharyngeal infections; anti-DNAase B |
| SLE type IV GN | nephritic; subendothelial deposits; anti-DNA antibodies |
| Crescentic GN | crescents from parietal cell proliferation; worst GN; Goodpasture’s, Wegener’s |
| Goodpasture’s | nephritic; anti-BM antibodies (glomerular + pulmonary capillary); crescentic GN |
| S/S | young male with hemoptysis progressing to renal failure |
| Minimal change disease (lipoid nephrosis) | MCC childhood nephrotic syndrome |
| Lipoid nephrosis | podocyte fusion; loss of negative charge in glomerular BM |
| Focal segmental glomerulosclerosis | nephrotic syndrome; AIDS and IV heroin abuse |
| Membranous GN | MCC adult nephrotic syndrome; subepithelial deposits; epimembranous spikes |
| Causes membranous GN | HBV, ACE inhibitors, cancer |
| Type I MPGN | nephrotic; subepithelial deposits; HCV association; tram tracks |
| Type II MPGN | nephrotic; C3 nephritic factor; intramembranous ICs (dense deposit disease) |
| DM nodular glomerulosclerosis | microalbuminuria first sign |
| DM glomerulosclerosis | nodules with collagen in mesangium; hyaline arteriolosclerosis of arterioles |
| ACE inhibitors | inhibit angiotensin II vasoconstriction of efferent arterioles |
| Alport’s syndrome | XD hereditary nephritis with sensorineural hearing loss |
| Ischemic ATN | prerenal azotemia MCC; renal tubular cell casts; BUN:creatinine ratio <15:1 |
| Ischemic ATN | disruption of BM in proximal tubule and thick ascending limb |
| Nephrotoxic ATN | aminoglycosides, IVP dye, Pb/mercury poisoning |
| Nephrotoxic ATN | proximal tubule dysfunction; intact BM |
| Oliguria | prerenal azotemia, ATN, glomerulonephritis, postrenal azotemia |
| Acute pyelonephritis | vesicoureteral reflux with ascending infection; WBC casts, fever, flank pain |
| Chronic pyelonephritis | U-shaped scars overlying blunt calyces |
| Drug-induced tubulointerstitial nephritis | type I/IV reaction; e.g., penicillin |
| S/S | ARF, fever, rash, eosinophilia, eosinophiluria, WBC casts |
| Analgesic nephropathy | aspirin plus acetaminophen; renal papillary necrosis; IVP with ring defect |
| Myeloma kidney | BJ protein produces foreign body reaction in tubules |
| Urate nephropathy | prevent by giving allopurinol prior to chemotherapy |
| CRF | fixed specific gravity; BUN:creatinine <15:1; waxy and broad casts |
| Renal osteodystrophy CRF | hypovitaminosis D (no 1-α-hydroxylase); produces osteomalacia |
| Renal osteodystrophy CRF | osteoporosis from metabolic acidosis |
| Renal osteodystrophy CRF | secondary HPTH with increased osteoclastic activity |
| S/S CRF | pericarditis, prolonged bleeding time, normocytic anemia, pathologic fractures |
| Benign nephrosclerosis | kidney of hypertension; shrunken kidneys due to hyaline arteriolosclerosis |
| Malignant hypertension | renal failure; encephalopathy; BP >210/120 mm Hg; IV nitroprusside |
| Renal findings | necrotizing arteriolitis; “flea bitten” kidney; hyperplastic arteriolosclerosis |
| Renal infarction | pale infarcts; hematuria; common in polyarteritis nodosa |
| Hydronephrosis | renal stone MCC; atrophy of cortex/medulla; postrenal azotemia |
| Renal stones | most contain calcium (calcium oxalate/phosphate); hypercalciuria MC risk factor |
| S/S | colicky pain radiating into groin, hematuria; x-ray usually shows stone |
| Staghorn calculus | due to urease producing organisms (Proteus); alkaline urine pH; ammonia smell |
| Angiomyolipoma | hamartoma; associated with tuberous sclerosis |
| Renal cell carcinoma | smoking MCC; invasion renal vein/vena cava; lung, bone mets; yellow colored |
| S/S | flank mass, hematuria; ectopic hormones (EPO, PTH related peptide), left-sided varicocele |
| Renal pelvis transitional cell carcinoma | smoking MCC, phenacetin, aniline dyes, cyclophosphamide |
| Wilm’s tumor | hypertension, unilateral abdominal mass in child; aniridia/hemihypertrophy in AD types |
| Urine draining from umbilicus | persistent urachus |
| Retroperitoneal fibrosis | produces hydronephrosis |
| Bladder extrophy | abdominal wall defect + epispadias |
| Bladder diverticula | most commonly due to prostatic hyperplasia with urethral obstruction |
| Acute cystitis | E. coli; females > males; no fever, flank pain, or WBC casts |
| Bladder transitional cell carcinoma | smoking MCC, aniline dyes, cyclophosphamide; papillary |
| S/S | hematuria; hydronephrosis |
| Bladder adenocarcinoma | risk factors persistent urachus, extrophy |
| Bladder squamous cell carcinoma | Schistosoma hematobium infection |
| Hypospadias | ventral opening on penis due to failure closure of urethral folds |
| Epispadias | dorsal opening on penis due to defect in genital tubercle |
| Peyronie’s disease | painful curvature penis due to fibromatosis |
| Priapism | persistent/painful erection; HbSS |
| Squamous cell carcinoma penis | HPV and lack of circumcision most important risk factors |
| Cryptorchidism | undescended testis; risk for seminoma applies to cryptorchid testis and normal testis |
| Orchitis | mumps usually unilateral (infertility uncommon) |
| Epididymitis | <35 - N. gonorrhoeae, C. trachomatis; >35 - E. coli, P. aeruginosa |
| S/S | scrotal pain relieved by elevation of scrotum (Prehn’s sign) |
| Varicocele | left-sided scrotal mass; spermatic vein drains into left renal vein; infertility common |
| Varicocele | may be due to invasion of left renal vein by renal cell carcinoma |
| Hydrocele | persistent tunica vaginalis; scrotum transilluminates |
| Torsion of testicle | testicle high in canal; absent cremasteric reflex |
| Testicular cancer | unilateral painless mass that does not transilluminate |
| Risk factors | cryptorchid testis, Klinefelter’s, testicular feminization |
| Seminoma | MC cancer; radiosensitive; large cells with lymphoid infiltrate; small percentage have ↑hCG |
| Spermatocytic variant | >65 yrs of age |
| Embryonal carcinoma | hemorrhage/necrosis; hematogenous spread before lymphatic; ↑AFP, hCG |
| Yolk sac tumor | MC testicular cancer in boys; ↑AFP |
| Choriocarcinoma | most aggressive testicle cancer; ↑hCG |
| Teratoma | more often benign in children than adult |
| Teratocarcinoma | teratoma + embryonal carcinoma |
| Malignant lymphoma | MC type in elderly; metastasis not primary cancer |
| Prostate | DHT derived stimulation embryo; periurethral area - hyperplasia; peripheral area - cancer |
| Prostatitis | perineal pain, fever; WBCs at end of voiding |
| Benign prostatic hyperplasia | DHT/estrogen-mediated; glandular/smooth muscle hyperplasia |
| S/S | all men develop; urethral obstruction MC (hesitancy, dribbling, nocturia), hematuria, dysuria Rx |
| Prostate cancer | DHT-mediated; palpable with rectal exam; osteoblastic metastasis (↑ AP) |
| PSA | sensitive but not specific for prostate cancer; ↑ in hyperplasia |
| Kallmann’s syndrome | absent GnRH, anosmia, absence of taste |
| Impotence | failure to sustain an erection; psychogenic in most cases (erections present at night) |
| Erection | parasympathetic response |
| Ejaculation | sympathetic response |
| Leydig cell failure | ↑ LH; ↓ testosterone, sperm count; normal FSH |
| Seminiferous tubule failure | ↑ FSH (↓inhibin); ↓ sperm count; normal LH and testosterone |
| Leydig and seminiferous tubule failure | ↑ FSH and LH; ↓ testosterone and sperm count |
| Y chromosome | determines genetic sex |
| Testosterone | develops seminal vesicles, epididymis, vas deferens |
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