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Ureters important landmarks OVER: Common/External Iliac vessels UNDER: Gonadal Vessels (injury during ligation of Ovarian Vessels) LATERAL: Internal Iliac MEDIAL: Gonadal Vessel as they enter true pelvis
Structure injured during ligation of uterine vessels in Histerectomy Ureter
Chi-Square Association of 2 CATEGORICAL variables
t-Test Means of 2 GROUPS
Meta-analysis Pools data and integrates results from several similar studies to reach an overall conclusion (LIMITED BY: quality of individual studies or bias in study selection)
ANTERIOR Drawer sign ACL (anterior cruciate ligament) injury
POSTERIOR Drawer sing PCL (posterior cruciate ligament) injury
Common injury in contact sports due to lateral force applied to a planted leg. Damage to ACL, MCL and lateral meniscus
Determines the dose rate required to maintain a steady state plasma concentration (Css) Clearance= Vd x Ke= rate elimination/plasma drug concentration
Maintenance Dose Cp x CL/F
Most important steps for prevention of central venous catheter infections *Proper hand washing * Full barrier precautions durin insertion of a central line *Chlorhexidine for skin disinfection *Avoidance of the femoral insertion site *Removal of catheter(s) when no longer needed
Gram (+) infects prosthetic devices and intravenous catheters Staphylococcus epidermidis (Novobiocin sensitive; Biofilms)
Patient with ATYPICAL depression who has a hypertensive crisis after a wine and chefs party! MAO inhibitor-tyramine crisis (especially Phenelzine)
MAO inhibitors MOA Nonselective Monoamine Oxidase Inhibitors, increase level of amine neurotransmitters (NE, 5-HT, Dopa)
Most common cardiovascular syndrome associated with SLE Pericarditis
Same sex twins Dichorionic/diamniotic (2 oocytes, 2 sperm, 2 amnios, 2 chorions)
Acute onset neurologic abnormalities + Hypoxemia + Petechial Rash Fat Emboli (patient with severe long bone fracture and/or pelvic fracture)
Types of PE FAT BAT (Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor)
Test of choice for a PE CT Pulmonary Angiography
Necrotizing Fasciitis 1) Streptococcus Pyogenes (Group A strep) 2) Staphylococcus aureus 3) Clostridium Perfringens
Pyrrolidonyl Arylamidase (PYR) positive Streptococcus Pyogenes (Group A strep)--> Gram (+), catalase (-), beta hemolytic, bacitracin sensitive, forms chains
Posterior Fossa malformations Arnold Chiari Dandy- Walker
Symmetric muscle weakness, endomysial inflammation with CD8+ Tcells, MHC I Polyomyositis (LAB: increased CK, (+) ANA, (+)anti-Jo-1, (+)anti-SRP)
Low EF, poor contractility, often 2º to Ischemic Heart disease or DCM Systolic Dysfunction
Isolated RHF Cor Pulmonale
Most common cardiomyopathy (90% cases) Dilated Cardiomyopathy (S3, Echo->dilated heart, CRX->balloon appearance of heart)
Eccentric hypertrophy of heart (sarcomeres added in series) DCM
Yeast and pseudohyphae (dimorphic), Positive Germ tube test at 37ºC Candida albicans
Four primary features of Neuroleptic Malignant Syndrome 1. Hyperthermia 2. Extreme generalized rigidity 3. Autonomic Instability 4. Altered mental status Treatment: Dantrolene (D2 agonist)
MOA of Typical Antipsychotics (Haloperidol + ¨-azines¨) Block dopamine D2 receptors, increasing cAMP
2 most common causes of 1º eugonadotropic amenorrhea 1. Imperforate hymen 2. Mullerian Duct abnormalities
1º amenorrhea in a female with fully developed 2º sex characteristics and normal levels of estrogens, gonadotropins Mullerian duct abnormality
Triad of abnormalities in ECG of Wolf Parkinson White 1. Delta wave at the start of QRS complex 2. Shortened PR interval 3. Widened QRS
Most common type of Ventricular Pre-excitation Syndrome Wolf Parkinson White (abnormal fast accessory conduction pathway from atria to ventricle; bundle of Kent, bypasses AV node)
BH4 is used as a cofactor for the synthesis of 1. Tyrosine 2. Dopamine 3. Serotonin 4. Nitric Oxide
Mononucleosis Monospot (-) CMV
(+) Monospot-heterophile antibodies detected by sheep agglutination RBCs EBV
Confirm Menopause INCREASED FSH (loss of negative feedback on FSH due to low estrogen)
Menopause before age 40 premature ovarian failure
Hormonal changes in Menopause Increased: FSH, LH, GnRH Decreased: Estrogen
Should be removed from a patients diet suffering from Aldose B deficiency (Fructose Intolerance) decreased intake BOTH: fructose+sucrose
Phosphodiesterase Inhibitors (Cilostazol,Dipyridamole) cause Increase cAMP= VASODILATION
Oxaloacetate forms aspartate while reacting with glutamate, whats the essential cofactor for this reaction Pyridoxine (vit B6)
ALL current cases Prevalence
New cases Incidence
Incidence rate # NEW cases specified time period/Population at risk during SAME time period
Prevalence Prevalence= Incidence x Time
Prevalence > Incidence Chronic diseases
Fever, urticaria, arthralgias, proteinuria, lymphadenopathy, decreased serum C3 levels following drug use Serum sickness (Immune complex disease, type III Hypersensitivy)
Most serum sickness is now caused by drugs (not serum) acting as Haptens
NORMAL urinary excretion in Pancreatic insufficiency, DECREASED with Intestinal mucosa defects or bacterial overgrowth D-xylose absorption test
DIAGNOSE Pancreatic Insufficiency 1. Normal D-xylose absorption test 2. Increased neutral fat in stool
MOST gastric ulcers occur in? Lesser Curvature (Transitional zone)
Enzyme activated responsible for pathogenesis of Acute Pancreatitis Trypsinogen (converted to trypsin by enterokinase enteropeptidase, a brush border enzyme on the duodenal and jejunal mucosa)
Pupillary light reflex Illumination on 1 eye= bilateral pupillary constriction
Decreased bilateral pupillary constriction when light is shone in AFFECTED eye relative to UNAFFECTED eye Marcus Gunn Pupil (Afferent pupillary defect- due to optic nerve damage or severe retinal injury)
Degranulation of MAST CELLS IgE-Fc receptor aggregation on the cell surface
Digoxin (Cardiac Glycoside); MOA Direct inhibition of Na+/K+ ATPase leads to indirect inhibition of Na+/Ca2+ exchanger/antiport. INCREASING [Ca2+]i---> positive inotropy. Stimulates vagus nerve---> decreasing HR.
Digoxin (Cardiac Glycoside); CLINICAL USE 1. CHF (increases contractility) 2.Atrial fibrillation (decreases conduction at AV node and depression of SA node)
1º line treatment for Atrial Fibrillation with Rapid Ventricular Response 1. Ca2+ channel blockers (class IV, Antiarrhythmics): Diltiazem 2. Cardioselective beta blocker
2º line treatment for Atrial Fibrillation with Rapid Ventricular Response Digoxin
Treatment for Rheumatoid Arthritis TNF-alpha inhibitors
lnfliximab, Adalimumab (TNF-alpha inhibitor) 1. Crohn's disease 2. Rheumatoid arthritis 3. Psoriatic arthritis, 4. Ankylosing spondylitis 5. Inflammatory bowel disease (IBD)
All TNF-alpha inhibitors predispose to INFECTION including reactivation of latent TB. TNF blockade prevents activation of macrophages and destruction of phagocytosed microbes.
What test should be performed before starting treatment with a TNF-alpha inhibitor PPD skin test
TNF-alpha inhibitors 1. Etarnecept 2. Infliximab, adalimumab
Anti-TNF-alpha monoclonal antibody Infliximab, adalimumab
Hypertension, hypokalemia, metabolic alkalosis and LOW plasma renin Conn Syndrome (1º Hyperaldosteronism)
Conn Syndrome (1º Hyperaldosteronism) is caused by 1. Adrenal hyperplasia 2. Aldosterone-secreting adrenal adenoma
Treatment for Conn Syndrome (1º Hyperaldosteronism) 1. Surgery 2. Spironolactone (K+ sparing diretic, aldosterone antagonist)
Single MOST important risk factor associated with Aortic Disecction Hypertension
CT shows intraluminal tear forming a ¨flap¨ separating true and false lumen Aortic Disecction
Aortic Disecction associated with 1. Hypertension 2. Bicuspid aortic valve 3. Connective tissue disorders (Marfan syndrome)
Clinical LAB features of Legionella pneumophila -High fever (>39ºC) -Headache and confusion -Watery diarrhea -Hyponatremia -Sputum gram stain showing many neutrophils, but few or NO organisms -CXR: unilobar infiltrate that progresses to consolidation
Sputum gram stain showing many neutrophils, but few or NO organisms Legionella pneumophila (gram-negative, facultative intracellular)
stain used for Legionella pneumophila Silver stain
Legionella pneumophila grows on Charcoal yeast extract culture with iron and cysteine
Legionella pneumophila detected clinically by Antigen in urine.
Associate Legionella pneumophila Smokers and patients with Chronic Lung disease. Aerosol transmission from environmental water source (air conditioning systems, hot water tanks,etc)
X-linked defect affecting the methylation and expression of the FMRI gene. Fragile X; Trinucleotide repeat disorder (CGG)
2nd most common cause of genetic mental retardation (after Down syndrome) Fragile X
Macro­orchidism, long face with a large jaw, large everted ears, autism, mitral valve prolapse. Fragile X (X-linked; FMRI gene;Trinucleotide repeat disorder (CGG))
Trinucleotide repeat disorder (CGG) Fragile X (X-linked defect affecting the methylation and expression of the FMRI gene)
ACE inhibitors INCREASE: renin, AT I, bradykinin DECREASE: AT II, aldosterone
Acute hemolytic cystitis (dysuria+hematuria) in children Adenovirus (naked, dsDNA, linear)
Thrombocytopenic purpura, recurrent Infections, Eczema Wiskott-Aldrich syndrome
Wiskott-Aldrich syndrome treatment HLA-matched bone marrow transplantation
mutation in WAS gene (X-linked recessive); T cells unable to reorganize actin cytoskeleton. Wiskott-Aldrich syndrome
Findings in Wiskott-Aldrich syndrome 1. Decreased to normal: IgG, IgM 2. Increased: IgE, IgA 3. FEWER and SMALLER PLATELETS
Aminoacids with 3 titratable protons Histidine Arginine Lysine Aspartic acid Glutamic acid Cysteine Tyrosine
Can be injured during axillary node dissection after mastectomy Long thoracic nerve (C5-C7)
Inability to anchor scapula to thoracic cage--> cannot abduct arm above horizontal position Mucle deficit: Serratus anterior Injury: Long thoracic nerve (C5-C7)
¨winged scapula¨ Long thoracic nerve (C5-C7) injury
Wide pulse pressure, bounding pulses and head bobbing Aortic regurgitation
Female>65yoa with unilateral headache, jaw claudication, pelvic girdle pain and morning stiffness Temporal (giant cell) arteritis
Temporal (giant cell) arteritis is associated with Polymyalgia rheumatica.
Lab finding in Temporal (giant cell) arteritis INCREASED ESR. LM: granulomas in the media of the arteries, consisting of mononuclear infiltrates and multinucleate giant cells
Temporal (giant cell) arteritis should be treated with high-close corticosteroids prior to biopsy to PREVENT Vision Loss
Temporal (giant cell) arteritis most commonly affects Branches of Carotid Artery
Most common cause of Acute Gastroenteritis in children and adults in INDUSTRIALIZED COUNTRIES Campylobacter (Comma or S-shaped, oxidase positive, grows at 42°C)
Campylobacter transmission Fecal-oral through foods such as poultry, meat, unpasteurized milk.
Major cause of bloody diarrhea, especially in children. Campylobacter (Comma or S-shaped, oxidase positive, grows at 42°C)
Common antecedent to Guillain-Barre syndrome and reactive arthritis. Campylobacter (Comma or S-shaped, oxidase positive, grows at 42°C)
Histone that ties nucleosome beads together in a string. H1 Histone
ONLY histone that is NOT in the nucleosome core H1 Histone
Single amino acid replacement in beta globin chain; substitution of Glutamic acid for Valine at position 6 Missense mutation; Sickle Cell anemia
Metalloproteinases secreted by inflammatory macrophages in the intima and may reduce plaque stability by degrading collagen
Bilateral metastases to ovaries. Abundant mucus, signet ring cells. Krukenberg's tumor (Stomach Cancer)
Vaccine contains type B capsular polysaccharide (polyribosylribitol phosphate) conjugated to diphtheria toxoid H. influenzae Hib conjugated vaccine: increased IMMUNOGENICITY
Death from cardiac cause within 1 hour of onset of symptoms Sudden Death
sudden cardiac death most commonly due to lethal arrhythmia (e.g., ventricular fibrillation)
Lippid-lowerin agent that can EXACERBATE Gout Niacin (Vitamin B3)
Niacin (Vitamin B3) side effects 1. Red, flushed face 2. Hyperglycemia (acanthosis nigricans) 3. Hyperuricemia (exacerbates gout)
Contralateral hemianopia with macular sparing PCA
Post-traumatic stress disorder Disturbance lasts > I month, with onset of symptoms beginning anytime after event
Persistent reexperiencing previous traumatic event. Nightmares, flashbacks, intense fear, helplessness, or horror. Leads to avoidance of stimuli associated with the trauma and persistent arousal. Post-traumatic stress disorder
Post-traumatic stress disorder, Treatment psychotherapy, SSRis.
Acute stress disorder 3 days- 1 month
Most common childhood systemic vasculitis. Often follows URI Henoch-Schonlein purpura
Henoch-Schonlein purpura, Classic triad: Classic triad: • Skin: palpable purpura on buttocks/legs • Arthralgia • GI : abdominal pain, melena, multiple lesions of same age
Henoch-Schonlein purpura associated with IgA nephropathy
Vasculitis 2º to IgA + C3 complex deposition Henoch-Schonlein purpura
Virchow's triad • Stasis • Hypercoagulability (e.g., defect in coagulation cascade proteins, most commonly factor V Leiden) • Endothelial damage (exposed collagen triggers clotting cascade)
Gestational Diabetes •Increased INSULIN-->Islet cell hyperplasia= HYPOglycemia in neonate
The pancreas is derived from Duodenal portion of the Foregut
GI embriology Foregut-pharynx to duodenum. Midgut-duodenum to proximal 2/3 transverse colon. Hindgut-distal 1/3 transverse colon to anal canal above pectinate line
The ventral pancreatic bud becomes 1. Uncinate process 2. Pancreatic head 3. Main pancreatic duct
The dorsal pancreatic bud becomes Everything else! 1.Tail 2.Body 3.Isthmus 4. Accessory pancreatic duct
Airway an GI infections, Autoimmune disease, Atopy, Anaphylaxis to IgA containing products Selective IgA deficiency (Most common 1º immunodeficiency)
Most common 1º immunodeficiency Selective IgA deficiency
The consistency and reproducibility of a test (reliability). Absence of random variation. Precision
Reduces precision in a test. Random error
Increases precision in a test. Decrease in standard deviation.
Deficiency of surfactant Patchy alveolar atelectasis (collapse)
Causes hepatocellular cytoplasm to take finely granular, eosinophilic appearance ¨ground glass¨-like HBV
Infection with N. gonorrhea does NOT result in lasting immunity due to Its ability to modify its outer membrane protein, ANTIGENIC VARIATION
1º cause of urinary tract obstruction in elderly male patient BPH (Benign Prostatic Hyperplasia)
Distension/dilation of renal pelvis and calyces Hydronephrosis
Most common site of obstruction (hydronephrosis) in fetus. Ureteropelvic junction
Causes of Hydronephrosis -Urinary tract obstruction (e.g, renal stones, BPH, cervical cancer, injury to ureter) -Retroperitoneal fibrosis -Vesicoureteral reflux
Systolic heart sounds 1. Aortic/Pulmonic stenosis 2. Mitral/Tricuspid regurgitation 3. Ventricular septal defect
Diastolic heart sounds 1. Aortic/Pulmonic regurgitation 2. Mitral/Tricuspid stenosis
Most common congenital cardiac defect VSD (L-to-R shunt)
L-to-R shunts; frequency VSD>ASD>PDA
L-to-R shunts; LATE cyanosis ¨blue KIDS¨ 1.VSD 2.ASD 3.PDA 4.Eisenmenger syndrome
Holosystolic, harsh-sounding murmur. Loudest at tricuspid area, accentuated with hand grip maneuver due to increased afterload. Ventricular septal defect
R-to-L shunts; EARLY cyanosis ¨blue BABIES¨; 5 T´s 1) Truncus arteriosus (1 vessel) 2) Transposition of great vessels (2 switched vessels) 3) Tricuspid atresia (3=tri) 4) Tetralogy of Fallot (4=tetra) 5) TAPVR (5 letters in the name); Total anomalous pulmonary venous return
Follows opening snap. Delayed rumbling late diastolic murmur. Enhanced by maneuvers that increase LA return (e.g., expiration). Mitral Stenosis
Opening snap Mitral Stenosis
Chronic Mitral Stenosis results in LA dilation
3 points of insertion of Sternocleidomastoid Muscle 1. ¨Sterno¨: manubrium of Sternum 2. ¨Cleido¨: medial part of Clavicle 3. ¨Mastoid¨: Mastoid process of the skull
Sternocleidomastoid Muscle function and innervation -CN XI -Function: turn head in the opposite direction
Loss of high-frequency hearing 1st; sudden extremely loud noises can produce hearing loss due to tympanic membrane rupture. Damage to stereocilliated cells in organ of Corti
Damage to stereocilliated cells in organ of Corti Noise-induced hearing loss
Beta1-selective antagonists (Beta1 > Beta2) 1. Acebutolol (partial agonist), 2. Betaxolol, 3. Esmolol (short acting), 4. Atenolol, 5. Metoprolol
Beta 1 receptors are found in -Cardiac tissue -JGA cells
Law of Laplace Collapsing pressure (P)= 2 (surface tension)/radius
2º Hyperaldosteronism -Renal artery stenosis, -Chronic renal failure, -CHF, -Cirrhosis, -Nephrotic syndrome -Malignant HTN -REnin-secreting tumor (reninoma)
Renal perception of low intravascular volume results in an overactive renin-angiotensin system. Associated with HIGH plasma RENIN. 2º Hyperaldosteronism
Hypertension, HIGH= plasma RENIN, HIGH= plasma ALDOSTERONE 2º Hyperaldosteronism
Treatment of 2º Hyperaldosteronism Spironolactone
Acute salicylate toxicity Respiratory alkalosis
Chronic salicylate toxicity Metabolic acidosis with compensation (hyperventilation), Increased anion gap
NADPH is required for -Reductive reactions, e.g., glutathione reduction inside RBCs, Fatty acid and Cholesterol biosynthesis. -Ribose for nucleotide synthesis and glycolytic intermediates.
2 distinct phases of HMP shunt (oxidative and nonoxidative), occur in CYTOPLASM
HMP shunt sites Sites: lactating mammary glands, liver, adrenal cortex (sites of fatty acid or steroid synthesis), RBCs.
Interferes with Gamma-carboxylation of glutamic acid residues Warfarin
Vitamin K deficiency Decreased synthesis of factors II, VII, IX, X, protein C, protein S. vWF carries/protects VIII.
Warfarin inhibits Epoxide reductase
Warfarin; CLINICAL USE Chronic anticoagulation (after STEMI, venous thromboembolism prophylaxis, and prevention of stroke in atrial fibrillation).
Follow Warfarin administration with PT/ INR values
Thyroid hormones alter gene transcription by binding to receptor situated inside NUCLEUS
Diagnosis of Strongyloides stercoralis Rhabtidiform (non-infectious form) in stool
Route of transmission; Strongyloides stercoralis Filariform larvae (infectious form) in soil penetrates the skin
UMN lesion signs 1. Hyperreflexia 2. Hypertonia 3. Babinski (+) 4. Spastic paralysis 5. Clasp knife spasticity
LMN lesion signs 1. Weakness 2. Atrophy 3. Fasciculations 4. Hypotonia 5. Hyporeflexic 6. Flaccid paralysis
Major virulence factor of S. pyogenes (Group A streptococci) M protein
deficiency causes Cheilosis, Angular Stomatitis, Corneal vascularization. Riboflavin (Vitamin B2)
Component of flavins FAD and FMN, used as cofactors in redox reactions,e.g, the succinate dehydrogenase reaction in the TCA cycle Riboflavin (Vitamin B2)
Screen pregnant women at 35-37 weeks. Patients with positive culture receive intrapartum penicillin prophylaxis. Streptococcus agalactiae (group B streptococci)
Intrapartum penicillin prophylaxis. Streptococcus agalactiae (group B streptococci)
Streptococcus agalactiae (group B streptococci) -Bacitracin resistant, -Beta-hemolytic, -Produces CAMP factor, -Hippurate test positive. Colonizes vagina; causes pneumonia, meningitis, and sepsis, mainly in babies.
1º line treatment for Essential Tremor Propranolol (non-specific beta-adrenergic antagonist)
Action tremor; exacerbated by holding posture/limb position Essential Tremor
Autosomal dominant. Patients often self-medicated with EtOH, which decreases tremor amplitude. Essential Tremor
Created by: heidy39



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