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Goljan HY Systemic
Goljan HY Systemic Pathology
| Question | Answer |
|---|---|
| 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 |
| Dihydrotestosterone (DHT) | develops prostate and male external genitalia |
| Male pseudohermaphrodite | genetic male; phenotypically female |
| Testicular feminization | XR; deficient androgen receptors; MCC male pseudohermaphrodite |
| Klinefelter’s syndrome | XXY; 1 Barr body; female secondary sex characteristics |
| Herpes genitalis | recurrent painful vesicles; multinucleated squamous cells with intranuclear inclusions |
| Human papilloma virus | condyloma acuminata; koilocytosis (wrinkled nuclei surrounded by a halo) |
| Chlamydia trachomatis | metaplastic squamous cells with vacuoles containing elementary bodies |
| S/S | non-specific urethritis, cervicitis, PID, ophthalmia neonatorum |
| Neisseria gonorhoeae | urethritis, cervicitis, PID; ophthalmia neonatorum, gram negative diplococcus |
| Ophthalmia neonatorum first week | N gonorrhoeae |
| Ophthalmia neonatorum second week | C. trachomatis |
| Lymphogranuloma venereum | C. trachomatis subtype |
| S/S | scrotal/vulva lymphedema; granulomatous microabscesses; rectal strictures in females |
| Chancroid | painful ulcer, adenopathy, Hemophilus ducreyi |
| Granuloma inguinale | Calymmatobacterium granulomatis; raised ulceration but no lymphadenopathy |
| Treponema pallidum | spirochete; produces vasculitis of arterioles (plasma cell infiltrate) |
| Primary syphilis | painless chancre |
| Secondary syphilis | rash on palms/soles; condyloma lata; generalized adenopathy |
| Tertiary syphilis | neurosyphilis (e.g., tabes dorsalis), aortic arch aneurysm, gummas |
| RPR/VDRL | reagin antibodies against cardiolipin; ↓ titer with Rx of syphilis |
| RPR/VDRL | false positive with anticardiolipin antibodies (common in SLE) |
| FTA-ABS | confirmatory test for syphilis; not distinguish active from treated disease |
| FTA-ABS | remains positive after Rx |
| Trichomonas vaginalis | flagellate protozoan; cervicitis/vaginitis; Rx metronidazole both partners |
| Gardnerella vaginalis | vaginal pH >5; bacterial vaginosis; clue cells; Rx metronidazole |
| Candida vaginitis | white, curd-like discharge; DM, antibiotics, pregnancy; Rx fluconazole |
| Vulvar squamous cancer | MC vulvar cancer; HPV association |
| Vulvar leukoplakia | biopsy to R/O squamous dysplasia/cancer |
| Lichen sclerosis vulva | epidermal atrophy; slight risk for squamous cancer |
| Squamous hyperplasia vulva | leukoplakia; no cancer risk |
| Paget’s disease | intraepithelial adenocarcinoma (mucin production) of vulva |
| Malignant melanoma | vulva location; similar to Paget cells but not mucin positive |
| Gartner’s duct cyst | lateral wall vagina; persistent mesonephric duct |
| Embryonal rhabdomyosarcoma | bloody, grape-like vaginal mass young girl |
| Vaginal adenosis | maternal exposure to DES; precursor clear cell adenocarcinoma vagina |
| Vaginal squamous cancer | usually extension of cervical cancer |
| Rokitansky-Kiister-Hauser | absence of vagina and uterus |
| Nabothian cysts | endocervical glands covered by metaplastic squamous epithelium |
| Pathologic cervicitis | trichomonas, HSV-2, C. trachomatis (follicular cervicitis) |
| Cervical Pap | superficial squamous (estrogen), intermediate (progesterone), parabasal (no hormone) |
| Normal | 70% superficial, 30% intermediate |
| Atrophic | 100% parabasal cells |
| Hyperestrinism | 100% superficial cells |
| Pregnancy | 100% intermediate cells |
| Endocervical cells | sign of adequately performed Pap smear |
| Cervical polyp | bleeding after intercourse; non-neoplastic |
| Cervical dysplasia | begins in transformation zone; associated with low and high risk HPV |
| Risk factors cervical dysplasia/cancer | early onset sexual activity; multiple partners; smoking; OC |
| CIN | cervical intraepithelial dysplasia; mild, moderate, severe (in-situ) |
| Cervical cancer | ↓ incidence (Pap smear); 45-yr-old; COD renal failure from obstruction of ureters |
| S/S | cervical discharge; bleeding after intercourse |
| Sequence to menarche | breast budding, growth spurt, pubic hair, axillary hair, menarche |
| Proliferative phase cycle | estrogen-dependent; ↑estrogen inhibits FSH and stimulates LH |
| Ovulation | day 14-I6; LH surge; subnuclear vacuoles; ↑body temperature |
| Secretory phase cycle | progesterone-dependent |
| Menses | drop in estrogen/progesterone stimulates apoptosis; plasmin prevents clotting |
| FSH | stimulates follicle and aromatase synthesis in granulosa cells |
| LH | stimulates androgen synthesis in proliferative phase and progesterone synthesis in secretory phase |
| Day 21 | day of implantation of fertilized egg |
| Pregnancy | ↑plasma volume > RBC mass; ↑GFR; ↑thyroxine/cortisol (increased binding proteins) |
| hCG | LH analogue produced by syncytiotrophoblast |
| hCG | stimulates corpus luteum of pregnancy to synthesize progesterone for 8-10 weeks |
| Estrone | estrogen of postmenopausal woman; aromatization of adrenal androstenedione |
| Estradiol | estrogen of non-pregnant woman in reproductive life; aromatization of testosterone |
| Estriol | estrogen of pregnancy |
| Menopause | ↑ FSH (best screen; due to ↓estrogen), ↑LH |
| S/S | secondary amenorrhea, hot flushes |
| Hirsutism | ↑ hair in normal areas |
| Virilization | hirsutism + male secondary sex characteristics (clitoromegaly) |
| Test for hirsutism/virilization | ↑ testosterone - ovarian source; ↑DHEA-sulfate - adrenal source |
| Polycystic ovarian syndrome (POS) | ↑ LH; ↓ FSH; ↑ estrogen and androgens |
| S/S | hirsutism, oligomenorrhea, infertility; enlarged ovaries with subcortical cysts; LH:FSH >2:1 |
| Menorrhagia | excess menstrual flow; MCC iron deficiency in women |
| Dysmenorrhea | painful menses; 1° PGF2α, 2° endometriosis |
| DUB | bleeding related to hormone rather than anatomic causes |
| Anovulatory DUB | menarche and perimenopause; estrogen excess without progesterone |
| Ovulatory DUB | irregular shedding, inadequate luteal phase |
| Primary amenorrhea | no menses by 16 years old |
| Secondary amenorrhea | no menses for 3 months |
| Amenorrhea-hypothalamic/pituitary dysfunction | ↓ FSH/LH; e.g., hypopituitarism |
| Amenorrhea-ovarian dysfunction | ↑FSH/LH; e.g., Turner’s syndrome |
| Amenorrhea-end-organ disease | normal FSH/LH; e.g., imperforate hymen |
| Asherman syndrome | surgical removal of stratum basalis |
| Primary amenorrhea-normal secondary sex characteristics | constitutional delay MCC |
| Primary amenorrhea-lack secondary sex characteristics | Turner’s |
| Turner’s syndrome | XO; no Barr bodies; XO/XY types have gonadoblastomas; streak gonads (no eggs) |
| S/S | newborn with lymphedema hands/feet; cystic hygroma in neck (web); short stature; 1° amenorrhea |
| Secondary amenorrhea | pregnancy MCC; prolactinoma; anorexia nervosa; pituitary adenoma |
| Asherman syndrome | removal of stratum basalis causing scarring; secondary amenorrhea |
| Endometritis | group B streptococcus; intrauterine device (Actinomyces); chronic - plasma cells |
| Endometrial polyp | menorrhagia; not a precursor for endometrial cancer |
| Adenomyosis | functioning endometrial glands and stroma in myometrium; enlarged uterus |
| Endometriosis | functioning glands and stroma outside uterus; reverse menses; ovary MC site |
| S/S | dysmenorrhea, painful stooling, bowel obstruction; “powder burn” appearance |
| Endometrial hyperplasia | unopposed estrogen; simple/complex types; precursor endometrial cancer |
| Causes | obesity, estrogen Rx, polycystic ovarian syndrome |
| Endometrial cancer | obesity, nulliparity, estrogen Rx, early menarche/late menopause; OC protective |
| S/S | bleeding in postmenopausal woman |
| Leiomyoma uterus | menorrhagia, obstructive delivery; not a precursor for leiomyosarcoma |
| Leiomyosarcoma | MC sarcoma |
| Ectopic pregnancy | PID MC risk factor; intraperitoneal hemorrhage; screen with ß-hCG |
| Follicular cyst | MC ovarian mass in young woman |
| Risk factors ovarian tumors | nulliparity and genetic factors; OC protective |
| Serous ovarian tumors | surface-derived; ↑ bilaterality; psammoma bodies in malignant type |
| Mucinous ovarian tumors | surface-derived; pseudomyxoma peritonei in malignant type |
| Endometrioid carcinoma | resembles endometrial cancer; association with endometriosis |
| Cystic teratoma | MC benign germ cell tumor (<1% malignant); hair/teeth; calcifications |
| Dysgerminoma | MC malignant germ cell tumor; associated with streak gonads of Turners |
| Yolk sac tumor | MC germ cell tumor young girl; ↑AFP; Schiller-Duval bodies |
| Meigs syndrome | ovarian fibroma, ascites, right-sided pleural effusion |
| Granulosa tumor | low grade malignant; hyperestrinism, Call Exner bodies |
| Thecoma | benign; yellow color; hyperestrinism |
| Leydig cell and Sertoli cell tumors | hyperandrogenism |
| Gonadoblastoma | XY phenotype of Turner’s |
| Krukenberg tumors | metastatic stomach cancer; signet ring cells |
| Single umbilical artery | ↑ incidence congenital defects |
| Syncytiotrophoblast | lining of villi; produces hCG and human placental lactogen |
| Human placental lactogen | responsible for mild glucose intolerance in pregnancy |
| Abruptio placenta | retroplacental clot; painful bleeding; hypertension, cocaine, smoking |
| Placenta previa | placenta implanted over cervical os; painless bleeding |
| Placenta accreta | direct implantation into myometrium without intervening decidua; hysterectomy |
| Twin placenta | monochorionic always identical twins; dichorionic may be identical or fraternal |
| Siamese twins | monoamniotic monochorionic twin placenta |
| Enlarged placenta | DM, Rh HDN, syphilis |
| Complete mole | benign neoplasm of chorionic villi; dilated villi; no embryo; 46 XX (both male) |
| S/S | preeclampsia in first trimester; ↑ incidence choriocarcinoma |
| Partial mole | embryo present; 68 XXY; no transformation into choriocarcinoma |
| Choriocarcinoma | malignancy of trophoblastic tissue (syncytiotrophoblast, cytotrophoblast) |
| Risk factors | complete mole (MC), spontaneous abortion, normal pregnancy |
| S/S | ↑hCG; lung metastasis; good prognosis |
| Chorioamnionitis | group B streptococcus (S. agalactiae) infection |
| Preeclampsia | abnormal placentation causing placental ischemia; ↑ in vasoconstrictors (ATII) |
| S/S | hypertension, proteinuria, pitting edema; begins in third trimester |
| Spontaneous abortion | 50% have karyotype deformity (trisomy 16) |
| Amniotic fluid | fetal urine |
| Polyhydramnios | TE fistula, duodenal atresia, open neural tube defects |
| Oligohydramnios | infantile polycystic disease |
| ↑ Serum AFP | open neural tube defect |
| ↓ Serum AFP | Down syndrome |
| Urine estriol | fetal adrenal, placental, maternal liver involved in its production |
| Down syndrome triad | ↑ ß-hCG, ↓ serum AFP, ↓ urine estriol |
| Fibrocystic change | MC breast mass <50-yrs-old; atypical hyperplasia cancer risk; lumpy, painful breasts |
| Sclerosing adenosis | component of FCC; involves terminal lobules often has microcalcifications |
| Fibroadenoma | benign stromal tumor; MC movable mass in women <35-yrs-old |
| Intraductal papilloma | benign tumor lactiferous duct/sinus; MCC bloody nipple discharge <50-yr-old |
| Invasive ductal cancer | MCC breast mass in woman >50-yrs-old |
| Breast cancer risk | unopposed estrogen; family history first-degree relatives |
| Breast cancer | painless mass upper outer quadrant in woman >50-yrs-old |
| Mammography | screening test to detect non-palpable masses |
| Palpable breast mass | order fine needle aspiration (not a mammogram) |
| Ductal carcinoma in situ | necrotic centers (comedo); microcalcifications common |
| Paget’s disease of breast | invasive ductal cancer into nipple; Paget’s cells similar to vulvar Paget’s |
| Medullary carcinoma | bulky tumor with large cells and lymphoid infiltrate; more common in Pt with BRCA 1 mutation |
| Inflammatory carcinoma | orange peel appearance; lymphatics blocked by tumor (lymphedema) |
| Lobular cancer | MC cancer of terminal lobule; ↑ bilaterality |
| Phyllodes tumor | low grade malignant tumor of stroma |
| ER-PR positive tumors | tumors responding to hormones; candidate for tamoxifen (anti-estrogen) |
| ERB-B2 oncogene positive breast cancer | aggressive breast cancer |
| Gynecomastia | estrogen stimulation of male breast |
| Gynecomastia | normal in newborn, puberty (no surgery), old age; (micronodular) cirrhosis MC pathologic cause |
| Overactive endocrine syndrome | most often adenomas; use suppression tests (most do not suppress) |
| Tumors that suppress | prolactinoma (bromocriptine), pituitary Cushings (high dose dexamethasone) |
| Underactive endocrine syndrome | autoimmune destruction MCC; stimulation tests |
| Hypopituitarism adults | non-functioning adenoma MCC, Sheehan’s postpartum necrosis (stop lactation) |
| Hypopituitarism in children | craniopharyngioma (Rathke’s pouch remnant) MCC; visual field defects |
| S/S ↓ FSH and LH | amenorrhea, ↓ testosterone in male |
| Growth hormone functions | muscle growth, gluconeogenesis; release of insulin growth factor (IGF) |
| IGF | synthesized in liver; bone and cartilage growth |
| S/S ↓ GH/IGF in children | growth retardation; ↓ height and weight |
| Sleep and arginine infusion | stimulation tests for GH and IGF |
| S/S ↓ GH/IGF in adults | hypoglycemia |
| S/S ↓ TSH | secondary hypothyroidism; ↓ T4, ↓ TSH; muscle weakness, dry skin |
| S/S ↓ ACTH | secondary hypocortisolism; ↓ cortisol, ↓ ACTH; fatigue; hypoglycemia |
| Metyrapone | stimulation test for ACTH reserve |
| Metyrapone | blocks adrenal 11-hydroxylase → ↑ ACTH and 11-deoxycortisol (proximal to block) |
| Metyrapone test ↓ ACTH and 11-deoxycortisol | pituitary/hypothalamic dysfunction |
| Metyrapone test ↑ ACTH and 11-deoxycortisol | Addison's disease |
| Diabetes insipidus | loss ADH (central), refractory to ADH (nephrogenic); always diluting urine |
| Central diabetes insipidus (CDI) | ↓ UOsm and ↑ POsm with water deprivation; vasopressin causes ↑ UOsm > 50% |
| Causes CDI | pituitary stalk transection, hypothalamic lesion (site for ADH synthesis) |
| Nephrogenic diabetes insipidus (NDI) | ↓ UOsm and ↑ POsm with water deprivation; vasopressin causes ↑ UOsm < 50% |
| Causes NDI | lithium, demeclocycline, nephrocalcinosis, severe hypokalemia |
| Gigantism | GH secreting pituitary adenoma before epiphyses have fused |
| Acromegaly | GH secreting pituitary adenoma after epiphyses have fused |
| S/S acromegaly | cardiomyopathy; large hands, feet, jaw; hyperglycemia |
| Prolactin | inhibited by dopamine |
| Prolactinoma | MC pituitary tumor; secondary amenorrhea and galactorrhea; prolactin inhibits GnRH |
| Rx | surgery or bromocriptine (dopamine analog) |
| Other causes hyperprolactinemia | primary hypothyroidism, drugs |
| Inappropriate ADH syndrome | hyponatremia <120 mEq/L; ↑ UOsm (always concentrating urine) |
| Causes | small cell carcinoma lung, CNS injury, chlorpropamide |
| Rx | restrict water; demeclocycline in small cell carcinoma |
| Serum T4 | ↑ or ↓ in free hormone or thyroid binding globulin (TBG) |
| ↑ Serum T4 and normal TSH | ↑ TBG; due to ↑ in estrogen |
| ↑ Serum T4 and ↓ TSH | thyrotoxicosis |
| ↓ Serum T4 and normal TSH | ↓ TBG; due to anabolic steroids |
| ↓ Serum T4 and ↑ TSH | primary hypothyroidism |
| ↓ Serum T4 and ↓ TSH | secondary hypothyroidism |
| TSH | negative feedback with T4 and T3; best screening test |
| I131 uptake | ↑ in Graves; ↓ in thyroiditis, patient taking excess thyroid, hypothyroidism |
| Cold nodule | non-functioning nodule; no uptake I131 |
| Hot nodule | functioning nodule; ↑ uptake I131 |
| Thyroglossal duct cyst | midline cystic mass |
| Branchial cleft cyst | cyst in anterolateral neck |
| Acute/subacute thyroiditis | painful thyroid; early thyrotoxicosis; ↓ I131 uptake |
| Hashimoto’s thyroiditis | MCC hypothyroidism; HLA Dr3/Dr5; inhibitory IgG TSH receptor antibody |
| Hashimoto’s thyroiditis | ↑ anti microsomal and thyroglobulin antibodies |
| S/S | muscle weakness, periorbital puffiness, ↓ reflexes, diastolic hypertension, constipation, dry skin |
| Lab | ↓ T4, ↑ TSH |
| Cretinism | maternal hypothyroidism before fetal thyroid developed, genetic disorder |
| S/S | mental retardation; short stature and increased weight; coarse skin |
| Thyrotoxicosis | any cause ↑ thyroid hormone activity; Graves disease, excess hormone, thyroiditis |
| Hyperthyroidism | ↑ synthesis thyroid hormone; Graves disease and toxic nodular goiter |
| Graves disease | autoantibody against TSH receptor (type II reaction); HLA Dr3 |
| S/S unique to Graves | exophthalmos, pretibial myxedema |
| S/S thyrotoxicosis | tachycardia/atrial fibrillation, systolic hypertension, diarrhea, brisk reflexes |
| Lab thyrotoxicosis | ↑ T4, ↓ TSH, ↑ glucose, ↑ calcium |
| I131 uptake | ↑ Graves, toxic nodular goiter; ↓ thyroiditis, excess hormone, hypothyroidism |
| Rx Graves disease | ß-blocker; drug to decrease hormone synthesis (propylthiouracil) |
| Toxic nodular goiter | hyperthyroidism; develops out of a multinodular goiter; no exophthalmos |
| Goiter | enlarged thyroid; iodine deficiency MCC; relative thyroid hormone deficiency |
| S/S | rapid enlargement due to hemorrhage into cyst; Rx thyroxine |
| Solitary thyroid nodule woman | most often benign (cyst) |
| Solitary thyroid nodule man or child | often malignant |
| Papillary carcinoma thyroid | MC thyroid cancer; radiation exposure; psammoma bodies |
| Follicular carcinoma thyroid | invades blood vessels |
| Medullary carcinoma thyroid | parafollicular cells; calcitonin; amyloid (calcitonin conversion) |
| MEN I syndrome | 3 P's; pituitary tumor, parathyroid adenoma, pancreatic tumor (ZE or ß-islet cell tumor) |
| MEN IIa syndrome | 2 P's; medullary carcinoma thyroid, pheochromocytoma, parathyroid adenoma |
| MEN IIb syndrome | 1 P; medullary carcinoma thyroid, pheochromocytoma, mucosal neuromas |
| Alkalotic pH | tetany with normal total calcium, ↓ ionized calcium and ↑ PTH |
| Hypoalbuminemia | ↓ total calcium, normal ionized calcium and PTH |
| Tetany | ↓ ionized calcium level; threshold potential comes closer to resting potential |
| S/S | thumb adducts into palm, twitching after tapping of facial nerve |
| PTH | maintains ionized Ca2+; ↑ Ca2+ renal reabsorption; ↓ phosphate/bicarbonate reabsorption in kidneys |
| Primary HPTH | ↑ Ca2+, hypophosphatemia, ↑ PTH |
| Cause | adenoma MCC, hyperplasia, cancer |
| S/S | renal stone, peptic ulcers, pancreatitis, hypertension, metastatic calcification |
| Secondary HPTH | ↓ Ca2+, ↑ PTH; hypovitaminosis D from renal failure MCC |
| Malignancy-induced hypercalcemia | ↑ Ca2+, ↓ PTH; all other non-parathyroid causes same results |
| Causes hypercalcemia | osteolytic lesions, sarcoidosis, ↑ vitamin D, PTH-related peptide, myeloma |
| Tertiary HPTH | hypercalcemia developing from secondary HPTH |
| Primary hypoparathyroidism | ↓ Ca2+ and ↓ PTH |
| Causes | previous thyroid surgery, autoimmune, DiGeorge syndrome |
| S/S | tetany; calcification basal ganglia |
| Pseudohypoparathyroidism | ↓ Ca2+ with normal to ↑ PTH; end-organ resistance to PTH |
| Other causes ↓ Ca2+ | hypomagnesemia (↓ PTH), ↓ vitamin D, DiGeorge |
| ↓ Ca2+ and ↓ PTH | primary hypoparathyroidism |
| ↓ Ca2+ and ↑ PTH | secondary hyperparathyroidism |
| ↑ Ca2+ and ↑ PTH | primary hyperparathyroidism |
| ↑ Ca2+ and ↓ PTH | malignancy induced hypercalcemia; other causes hypercalcemia |
| Waterhouse-Friderichsen syndrome | meningococcemia with bilateral adrenal hemorrhage due to DIC |
| Addison’s disease | autoimmune destruction adrenal cortex MCC, adrenogenital syndrome, metastasis |
| S/S | hypotension (salt loss), hyperpigmentation (ACTH), hypoglycemia |
| Lab | ↓ sodium, ↓ cortisol, ↑ potassium, ↑ ACTH |
| Adrenogenital syndrome | AR; enzyme deficiency; hypocortisolism; hyperpigmentation from ↑ ACTH |
| 21-Hydroxylase deficiency | ↑ 17 KS, ↓ 17 OH, lose salt, hypotension; female pseudohermaphrodite |
| 11-Hydroxylase deficiency | ↑ 17 KS, ↑ 17 OH, retain salt, hypertension; female pseudohermaphrodite |
| 17-Hydroxylase deficiency | ↓ 17 KS, ↓ 17 OH, retain salt, hypertension; male pseudohermaphrodite |
| MCC Cushings | long-term corticosteroid therapy |
| Tests Cushings syndrome | low/high dose dexamethasone suppression; urine free cortisol (best test) |
| Normal dexamethasone suppression | cortisol analogue; ↓ ACTH and ↑ cortisol |
| Pituitary Cushings | MCC Cushing’s; ACTH secreting pituitary tumor |
| Lab | low dose dexamethasone not suppress cortisol; high dose suppresses |
| Adrenal Cushings | adrenal adenoma secreting cortisol; suppressed ACTH |
| Lab | no suppression with low/high dose dexamethasone |
| Ectopic Cushings | ACTH secreting small cell carcinoma of lung; high ACTH and cortisol levels |
| Lab | no suppression with low/high dose dexamethasone |
| S/S Cushings | purple stria, truncal obesity, hypertension, DM |
| Primary aldosteronism | benign adenoma in zona glomerulosa |
| S/S | hypertension and muscle weakness (hypokalemia), no pitting edema |
| Lab | hypernatremia, hypokalemia, metabolic alkalosis, ↑ urine K+ and Na+ |
| Pheochromocytoma | benign tumor in adrenal medulla in adults |
| Associations | von Hippel Lindau, neurofibromatosis, MEN IIa and IIb |
| S/S | labile hypertension, anxiety, sweating, headache |
| Lab | ↑ 24 hr urine for VMA and metanephrines |
| Neuroblastoma | malignant tumor adrenal medulla child; widespread metastasis; hypertension |
| ß-islet cell tumor (insulinoma) | benign tumor; hypoglycemia, ↑ insulin and C-peptide |
| Patient taking excess insulin | hypoglycemia, ↑ insulin, ↓ C-peptide |
| Glucagonoma | malignant α-islet cell tumor; hyperglycemia and rash |
| Zollinger Ellison syndrome | malignant islet cell tumor secreting gastrin; peptic ulcers |
| Somatostatinoma | malignant δ islet cell tumor; DM, malabsorption, cholelithiasis, achlorhydria |
| VIPoma | malignant islet cell tumor; diarrhea, hypokalemia, achlorhydria |
| DM | organ damage correlates with glycemic control |
| Type 1 | young, thin person; no insulin; HLA DR3/4; insulitis; islet cell antibodies; ketoacidosis |
| Type 2 | older person; obese; relative insulin deficiency (↓ insulin receptors, postreceptor problems) |
| Type 2 | family history; fibrotic islet cells with amyloid; hyperosmolar nonketotic coma |
| ↑ Non-enzymatic glycosylation | glucose attaches to amino acids in basement membranes |
| Non-enzymatic glycosylation | ↑ vessel permeability producing hyaline arteriolosclerosis |
| Osmotic damage | glucose converted into sorbitol by aldose reductase |
| Osmotic damage | lens (cataracts), Schwann cell (neuropathy), pericytes retinal vessels (microaneurysms) |
| Pathogenesis hyperglycemia | ↑ gluconeogenesis (most important), glycogenolysis |
| Pathogenesis hyperlipidemia | no insulin to stimulate capillary lipoprotein lipase; ↑ chylomicrons/VLDL |
| Pathogenesis ketoacidosis | ↑ oxidation fatty acids with excess acetyl CoA; liver synthesis ketone bodies |
| Most commons due to DM | neuropathy, blindness, CRF, hyperglycemia, non-traumatic amputation |
| Glycosylated HbA1c | measure of long term glycemic control (8-12 weeks) |
| Gestational DM | ↑ placental size, human placental lactogen |
| Complications | macrosomia (↑ muscle/fat from insulin), RDS, newborn hypoglycemia (↑ insulin) |
| Hypoglycemia | insulin/oral hypoglycemics MCC, liver disease; carnitine deficiency |
| Carnitine deficiency | no ß-oxidation of fatty acids; all cells compete for glucose |
| Monosodium urate crystals (MSU) | yellow when parallel to slow ray of compensator |
| Calcium pyrophosphate crystals (pseudogout) | blue when parallel to slow ray of compensator |
| Osteoarthritis | degeneration articular cartilage; subchondral cysts; eburnation; osteophytes at margins |
| Joints | weight bearing (femoral head); DIP joint (Heberden’s nodes), PIP joints (Bouchard nodes) |
| Neuropathic joint | 2° to neurologic disease; DM, syringomyelia, tabes dorsalis |
| Rheumatoid arthritis (RA) | female dominant; HLA Dr4 |
| RF | IgM antibody against Fc portion IgG; causes inflammation of synovial tissue |
| Pannus | inflamed hyperplastic synovial tissue destroys articular cartilage; joint fusion |
| Joints | MCP and PIP joints |
| S/S | morning stiffness; ulnar deviation of hands; carpal tunnel (entrapped median nerve) |
| Rx | methotrexate often used as initial therapy, aspirin |
| Sjogren’s syndrome | destruction lacrimal and minor salivary glands; RA; anti-SS-Ro/SS-La (SSa and SSb) |
| S/S | dry eyes and dry mouth |
| Caplan syndrome | pneumoconiosis + rheumatoid nodules in lungs |
| Felty’s syndrome | RA + splenomegaly with hypersplenism |
| Gouty arthritis | underexcretion of uric acid; big toe first affected; tophus in soft tissue sign chronic gout |
| Gout associations | alcohol, Pb poisoning |
| Tophus | MSU crystals produce foreign body giant cell reaction next to joint |
| Uricosuric agents | probenecid and sulfinpyrazone |
| Allopurinol | ↓ synthesis uric acid; xanthine oxidase inhibitor |
| Pseudogout | involves knee; linear calcification in articular cartilage |
| Ankylosing spondylitis | HLA-B27 seronegative (RF negative) spondyloarthropathy; male dominant |
| S/S | sacroiliitis; bamboo spine causing kyphosis; aortitis; uveitis |
| Associations | C. trachomatis MC, psoriasis, ulcerative colitis, Shigella, Campylobacter, Yersinia |
| Reiter’s syndrome | HLA-B27; Chlamydia urethritis; arthritis; conjunctivitis; Achilles tendon periostitis |
| Osteomyelitis children | hematogenous spread of Staphylococcus aureus to metaphysis |
| Osteomyelitis in HbSS | Salmonella paratyphi |
| Pseudomonas aeruginosa osteomyelitis | puncture of foot when wearing rubber foot wear |
| Tuberculous osteomyelitis | usually involves vertebra (Pott’s disease) |
| Disseminated gonococcemia | female dominant; C6-C9 deficiency |
| Disseminated gonococcemia | septic arthritis (knee); tendinitis/synovitis and skin pustules in feet/wrists |
| Lyme disease | bite Ixodes tick; Borrelia burgdorjeri; reservoirs white footed mouse, white tailed deer |
| Early S/S | erythematous concentric rash (erythema chronicum migrans), Rx doxycycline |
| Late S/S | arthritis, Bell’s palsy (often bilateral), myocarditis, Rx doxycycline |
| Babesiosis | carried by Ixodes tick; Babesia are intraerythrocytic parasites; hemolytic anemia |
| Cat bite | potential for Pasteurella multocida septic arthritis |
| Osgood Schlatter’s | inflammation proximal tibial apophysis at patellar tendon insertion; knobby knee |
| Osteogenesis imperfecta | AD; ↓ synthesis type I collagen; pathologic fractures; blue sclera |
| Blue sclera | reflection choroidal veins |
| Achondroplasia | AD; impaired enchondral calcification and premature closure of epiphyses |
| S/S | normal head/vertebral column, short extremities |
| Osteopetrosis | AD/AR; osteoclast defect; too much bone; pathologic fractures |
| Osteoporosis | ↓ bone mass and density; pathologic fractures |
| Postmenopausal osteoporosis | estrogen deficiency - ↑ osteoclastic activity, ↓ osteoblastic activity |
| S/S | vertebral compression fractures, Colles fracture |
| Colles fracture | fractured distal radius with dinner fork appearance |
| Prevention | estrogen (under investigation), calcium, vitamin D, stress exercises (walking, weight lifting) |
| Aseptic necrosis femoral head | femoral head fracture, corticosteroids, sickle cell disease; MRI best test |
| Scaphoid bone fracture | aseptic necrosis in wrist bone |
| Volkmann’s ischemic contracture | fracture of distal radius; damage to brachial artery and median nerve |
| Legg-Perthe’s disease | aseptic necrosis of ossification center (femoral head) in children |
| Paget’s disease | elderly males; lytic/blastic bone lesions produce thick, weak bone |
| S/S | pathologic fractures; ↑ serum AP; ↑ risk for osteogenic sarcoma |
| Osteoid osteoma | radiolucent lesion in cortex proximal femur; nocturnal pain relieved by aspirin |
| Osteogenic sarcoma | adolescent male; RB suppressor gene association; distal femur; ↑ AP |
| Radiograph | “sunburst” appearance, Codman’s triangle |
| Ewing’s sarcoma | primitive neuroectodermal tumor; round cell tumor |
| Radiograph | “onion skinning” |
| Osteochondroma | MC benign bone tumor; exophytic growth off metaphysis of distal femur |
| Chondrosarcoma | MC malignant cartilaginous tumor; pelvic bones, proximal femur |
| Giant cell tumor | epiphysis distal femur/proximal tibia; giant cells + neoplastic mononuclear cells |
| Muscle weakness | primary muscle disease, neurosynapse disease, neurogenic disease |
| Duchenne’s muscular dystrophy | XR; deficiency dystrophin; ↑ serum CK at birth; waddling gait |
| Dystrophin | attaches portions of cell membrane to sarcomere; important in contraction |
| Becker’s dystrophy | XR, defective dystrophin |
| Myotonic dystrophy | AD; trinucleotide repeat disorder; cannot release grip |
| Myasthenia gravis | autoantibody against acetylcholine receptors (type II); thymic hyperplasia B cells |
| S/S | diplopia at end of day first sign; dysphagia solids/liquids upper esophagus; thymoma |
| Dupuytren’s contracture | fibromatosis palmar fascia |
| Lipoma | MC soft tissue tumor |
| Liposarcoma | MC adult sarcoma |
| Embryonal rhabdomyosarcoma | MC childhood sarcoma |
| Autoimmune disease | loss of self-tolerance |
| Serum ANA | greatest sensitivity for detecting SLE |
| SLE | type III reaction; confirm with anti-dsDNA, anti-Sm |
| S/S | malar rash, photophobia, joint pain, fibrinous pericarditis, nephritic GN |
| Drug-induced lupus | procainamide, hydralazine; anti-histone antibodies |
| Antiphospholipid antibodies | lupus anticoagulant, anti-cardiolipin antibodies; vessel thrombosis |
| PSS | excess collagen; anti-topoisomerase antibodies |
| S/S | dysphagia solids/liquids, Raynaud’s, interstitial lung disease, renal failure |
| CREST | centromere antibody/calcinosis; Raynaud; esophageal dysmotility; sclerodactyly; telangiectasia |
| Dermatomyositis/polymyositis | ↑ serum CK; risk of malignancy |
| Mixed connective tissue disease | anti-ribonucleoprotein antibody |
| Antibody against acetylcholine receptor | myasthenia gravis |
| Antibody against basement membrane | Goodpasture’s syndrome |
| Antibody against endomysium and gliadin | celiac disease |
| Antibody against insulin and islet cell | type I diabetes |
| Antibody against intrinsic factor and parietal cell | pernicious anemia |
| Antibody against microsome and thyroglobulin | Hashimoto’s thyroiditis |
| Antibody against mitochondria | primary biliary cirrhosis |
| Antibody against proteinase 3 of neutrophil (cANCA) | Wegener’s granulomatosis |
| Antibody against myeloperoxidase of neutrophils (pANCA) | microscopic polyangiitis |
| Antibody against TSH receptor | Graves disease |
| Ichthyosis vulgaris | ↑ thickness of stratum corneum; absent granular layer |
| Solar lentigo | “liver spot” in elderly; increased melanocytes |
| Senile purpura | trauma to fragile vessels on dorsum of hands; normal finding in elderly |
| Acute eczema | weeping rash with vesicles |
| Chronic eczema | dry, thickened, pruritic skin |
| Atopic dermatitis | dry skin, eczema (type I reaction); children - face, intertriginous areas |
| Allergic contact dermatitis | type IV hypersensitivity; poison ivy, nickel rash |
| Contact photodermatitis | tetracycline; rash in sun exposed areas |
| Superficial dermatophytoses | KOH preparation shows fungi located in stratum corneum |
| Tinea capitis | Trichophyton tonsurans MCC (negative Wood’s lamp) |
| Tinea capitis child with dog | Microsporum canis (positive Wood’s lamp) |
| Tinea versicolor | hypopigmentation; Malassezia furfur; “spaghetti” (hyphae)/”meatball” KOH |
| Seborrheic dermatitis | dandruff; Malassezia furfur |
| Molluscum contagiosum | poxvirus; bowl-shaped with central depression filled with keratin |
| Rubeola | Koplik’s spots; Warthin-Finkeldey giant cells |
| Rubella | teratogenic; rash; postauricular adenopathy; arthritis in adults |
| Parvovirus | “slapped face”; RBC aplasia, aplastic anemia (HbSS), spontaneous abortions, arthritis |
| Roseola | HSV-6; high fever and then rash |
| Toxic shock syndrome | toxin-producing S. aureus; tampon wearing; hypotension, desquamating rash |
| Scarlet fever | group A streptococcus with erythrogenic toxin; strawberry tongue |
| Actinic (solar) keratosis | precursor for squamous cell carcinoma; recur when scrapped off |
| Psoriasis | elevated salmon-colored plaques covered by silver-colored scales; nail pitting |
| Pityriasis rosea | herald patch followed by rash in lines of cleavage |
| Varicella | chickenpox; rash at different stages; Reye syndrome association |
| Herpes zoster | vesicular rash following a sensory dermatome |
| HSV and Varicella-zoster virus | remain latent in sensory ganglia |
| Impetigo | group A streptococcus; honey crusted lesions on face |
| Pemphigus vulgaris | autoimmune disease; IgG antibodies against intercellular attachment sites |
| Pemphigus vulgaris | intraepidermal bullae; acantholytic cells; row of tombstones |
| Bullous pemphigoid | autoimmune disease; IgG antibodies against basement membrane |
| Bullous pemphigoid | subepidermal bullae |
| Pemphigus vulgaris/bullous pemphigoid | type II hypersensitivity |
| Dermatitis herpetiformis | autoimmune disease; IgA ICs; subepidermal bullae with neutrophils |
| Dermatitis herpetiformis | association with celiac disease |
| Erythema multiforme | vesicles and bullae; bullseye appearance |
| Risk factors | drugs, M. pneumoniae infection |
| Stevens Johnson syndrome | erythema multiforme involving mouth |
| Acne vulgaris | androgen dependent (receptor on sebaceous glands) |
| Acne vulgaris | Propionibacterium acnes lipases produce fatty acids causing inflammation |
| Acne rosacea | pustular, erythematous lesion on face resembling malar rash |
| Urticaria | type I and III reactions; type I due to mast cell release of histamine (drugs, fire ant bites) |
| Angioedema | subcutaneous swelling |
| Causes | ACE inhibitor (bradykinin); C1 esterase inhibitor deficiency (C2 and C4 decreased) |
| Sporotrichosis | traumatic implantation of Sporothrix fungus into subcutaneous tissue |
| Causes | rose gardener, lobster fisherman (sphagnum moss) |
| S/S | chain of subcutaneous nodules |
| Tuberculoid leprosy | intact cellular immunity (positive lepromin skin test); granulomas; no organisms |
| S/S | autoamputation of digits; skin depigmentation and anesthesia |
| Lepromatous leprosy | defective cellular immunity (negative lepromin skin test); no granulomas |
| S/S | leonine face, erythema nodosum during treatment |
| Histology | Grenz zone (zone free organisms) foamy macrophages with organisms |
| Rx | dapsone |
| Erythema nodosum | painful nodule on shins; subcutaneous fat inflammation |
| Associations | coccidioidomycosis, TB, leprosy |
| Keratoacanthoma | benign neoplasm; mimics squamous cancer; spontaneously resolves |
| UVB light cancers | basal cell carcinoma, squamous cell carcinoma, malignant melanoma |
| Vitiligo | autoimmune destruction melanocytes producing skin depigmentation |
| Seborrheic keratosis | pigmented, wart-like lesion; “stuck on” appearance |
| Leser-Trelat sign | multiple outcroppings seborrheic keratosis; consider stomach cancer |
| Acanthosis nigricans | verrucoid pigmented lesion usually in axilla; associated with gastric cancer |
| Chloasma | pregnancy mask due to increased melanocytes |
| Nevocellular nevus | benign pigmented tumor modified melanocytes |
| Histology | nevus cells proliferate along basal cell area, dermis, or both |
| Dysplastic nevus | precursor for malignant melanoma |
| Malignant melanoma | malignant tumor of melanocytes; most rapidly increasing cancer worldwide |
| ABCD for melanoma | A, asymmetry; B, irregular border; C, color change; D, increased diameter |
| Risk factors | severe sunburn at early age (MC), dysplastic nevi |
| Radial growth phase | spreads laterally in epidermis/superficial dermis but does not result in metastasis |
| Vertical growth | malignant cells penetrate into dermis; potential for metastasis |
| Lentigo malignant melanoma | face of elderly |
| Superficial spreading melanoma | lower extremities, back |
| Nodular melanoma | aggressive tumor with no radial growth phase |
| Acral lentiginous melanoma | palms, soles, under nails; may occur in blacks |
| Prognosis | depends most on depth of invasion |
| Prevention | sunscreen >15 |
| Porphyria cutanea tarda | photosensitive bullous disease; deficiency uroporphyrinogen decarboxylase |
| S/S | hypertrichosis, fragile skin, port wine colored urine (uroporphyrins) |
| Black widow (Latrodectus) envenomation | neurotoxin; abdominal muscle cramps |
| Brown recluse (Loxosceles) envenomation | necrotoxin; skin ulcer |
| CSF | choroid plexus in ventricles; enters subarachnoid space; removed by arachnoid granulations |
| CSF | less protein and glucose than serum; scant number of cells; ↑ chloride |
| Xanthochromia | yellow colored CSF due to bilirubin pigment; indicates subarachnoid hemorrhage |
| Papilledema of optic nerve | sign of cerebral edema (intracranial hypertension) |
| Uncal herniation | intracranial hypertension; medial portion temporal lobe through tentorium cerebelli |
| S/S | midbrain hemorrhage; CN III palsy (pupil down/out); mydriasis |
| Mydriasis in uncal herniation | compression of parasympathetic system |
| Cerebellar tonsils herniate into foramen magnum | intracranial hypertension |
| Hydrocephalus | ↑ CSF volume with distention of ventricles |
| Non-communicating | blockage aqueduct Sylvius MCC newborn |
| Communicating | choroid plexus papilloma; scarring of arachnoid granulations |
| Adults with hydrocephalus | progressive dementia, wide-based gait, urinary incontinence; THINK |
| Open neural tube defects | folate must be adequate before pregnancy; ↑ AFP |
| Spina bifida occulta | dimple overlying skin L5-S1; vertebral arch not completely closed |
| Meningocele | vertebral defect with meninges |
| Meningomyelocele | vertebral defect with meninges and spinal cord |
| Arnold Chiari syndrome | elongation medulla/cerebellar tonsils through foramen magnum |
| S/S | hydrocephalus, syringomyelia, meningomyelocele |
| Dandy Walker syndrome | hypoplasia of cerebellar vermis; hydrocephalus |
| Syringomyelia | enlarged cervical cord; fluid filled cyst in cervical spinal cord |
| S/S | loss pain/temperature upper extremities (spinothalamic); motor loss in hands (anterior horn cells) |
| Tuberous sclerosis | AD; mental retardation; hamartomas CNS/kidney; shagreen patches skin |
| Tuberous sclerosis | angiomyolipomas kidneys; rhabdomyoma of heart |
| Neurofibromatosis | AD; pigmented neurofibromas; cafe au lait spots |
| Associations | pheochromocytoma, brain tumors, acoustic neuromas |
| Meningitis | nuchal rigidity |
| CSF findings viral meningitis | ↑ CSF protein, normal CSF glucose, ↑ lymphocytes |
| CSF findings bacterial meningitis | ↑ CSF protein, ↓ CSF glucose, ↑ neutrophils |
| Encephalitis | inflammation of brain; mental status abnormalities; coma |
| Coxsackievirus | MCC viral meningitis |
| HSV-1 | hemorrhagic necrosis in temporal lobes |
| Rabies | skunk and bat common vectors; Negri bodies in neurons; hydrophobia; flaccid paralysis |
| CMV | intranuclear inclusions; periventricular calcification in congenital infection |
| Polio virus | destruction of anterior horn cells; flaccid paralysis |
| Subacute sclerosing panencephalitis | slow virus disease due to rubeola (measles virus) |
| Progressive multifocal leukoencephalopathy | slow virus disease due to JC virus; common in AIDS |
| Creutzfeldt-Jakob disease | prions; spongiform encephalopathy |
| Risk factors | contact with human brain or contaminated beef (bovine disease) |
| Meningitis newborn | Streptococcus agalactiae (group B) MCC; E. coli, 2nd MCC |
| Listeria monocytogenes | newborn meningitis; gram + rods; pregnant mother should avoid soft cheeses |
| Neisseria meningitidis | MCC meningitis 1 month - 18-yrs-old; petechia and DIC characteristic |
| Streptococcus pneumoniae | MCC meningitis >18-yrs-old |
| Mycobacterium tuberculosis | complication primary TB; base of brain meningitis with vasculitis |
| Neurosyphilis | CSF with positive VDRL |
| Meningovascular syphilis | vasculitis causing strokes |
| General paresis | syphilis with dementia and brain atrophy |
| Tabes dorsalis | posterior root ganglia/posterior column; ataxia; absent deep tendon reflexes; Argyll-Robertson pupil |
| Argyll-Robertson pupil | pupil accommodates but does not react to direct light; THINK |
| Cryptococcus neoformans | MC opportunistic CNS fungal disease; positive India ink |
| Mucor species | frontal lobe abscess in diabetic ketoacidosis |
| Toxoplasma gondii | MCC space occupying lesion in AIDS; avoid cat litter and raw meat in pregnancy |
| Congenital toxoplasmosis | calcification basal ganglia; blindness; mental retardation |
| Naegleria and Acanthamoeba | amoeba in fresh water; meningoencephalitis |
| Taenia solium | pork tapeworm; adult with worms definitive host; adult with larva intermediate host |
| Cysticercosis | larval form of T. solium; produces blindness and calcified cysts in CNS (seizures) |
| Coup injuries | contusions at site of injury |
| Contrecoup injuries | contusion on opposite side of injury; frontal and temporal lobes |
| Epidural hematoma | temporoparietal skull fracture; tear middle meningeal artery |
| Subdural hematoma | tear bridging veins; venous blood clot; fluctuating levels of consciousness |
| Hypoxic injury | neurons more susceptible to damage than neuroglial cells |
| Laminar necrosis | liquefactive necrosis at watershed areas in cortex |
| Atherosclerotic stroke | pale infarction (liquefactive necrosis) extending to periphery of cerebral cortex |
| Causes atherosclerotic stroke | thrombosis of middle cerebral artery or carotid artery |
| MCA stroke | contralateral weakness/sensory loss; expressive aphasia if left hemisphere stroke |
| Amaurosis fugax | loss vision described as curtain going down and then up |
| Cause | embolus atherosclerotic plaque to branch of retinal artery (Hollenhorst plaque) |
| Vertebrobasilar stroke | vertigo, ataxia, ipsilateral sensory loss face/contralateral hemiparesis/sensory |
| Embolic stroke | hemorrhagic infarction extending to periphery cerebral cortex due to embolization |
| Intracerebral hemorrhage | complication hypertension |
| Cause of intracerebral hemorrhage | rupture of aneurysm of lenticulostriate vessels |
| Location of intracerebral hemorrhage | basal ganglia MC site |
| Subarachnoid hemorrhage | rupture of congenital berry aneurysm; severe occipital headache |
| Lacunar stroke | microinfarctions; due to hyaline arteriolosclerosis (hypertension, diabetes) |
| Pure motor stroke | posterior limb internal capsule |
| Pure sensory stroke | thalamus |
| Multiple sclerosis | autoimmune destruction myelin sheath/oligodendrocytes; plaques in white matter |
| S/S | scanning speech, intention tremor, nystagmus, paresthesias, weakness |
| Bilateral internuclear ophthalmoplegia | multiple sclerosis; demyelination MLF |
| CSF with oligoclonal bands | sign of demyelination |
| Central pontine myelinolysis | rapid intravenous correction of hyponatremia in alcoholic |
| Alzheimer’s disease | MCC dementia Alzheimer’s disease |
| Alzheimer’s disease | ↑ amyloid-ß destroys neurons; occipital lobe spared |
| Alzheimer’s disease | ↑ density of neurofibrillary tangles and senile plaques |
| Down syndrome | develop Alzheimer’s disease at early age; 3 functioning chromosome 21s |
| Apo E gene allele ε4 | gene product has high affinity for amyloid-ß |
| Parkinson’s disease | depigmentation substantia nigra neurons; Lewy bodies; ↓ dopamine |
| S/S | extrapyramidal (muscle rigidity), resting tremor, festinating (shuffling) gait |
| Causes | CO poisoning, Wilson’s, MPTP (meperidine derivative), drugs |
| Huntington’s disease | AD; atrophy of the head of the caudate nucleus; trinucleotide repeat disorder (anticipation) |
| S/S | movement disorder; dementia |
| Amyotrophic lateral sclerosis (ALS) | degeneration of lower/upper motor neurons; no sensory changes |
| Werdnig Hoffman disease | childhood type of ALS |
| Wilson’s disease | AR; excess copper; cystic degeneration of putamen/globus pallidus |
| Vitamin B12 deficiency | posterior column (↓ proprioception, vibration); lateral corticospinal tract (UMN) |
| Alcohol | Wernicke-Korsakoff syndrome, cerebellar atrophy, central pontine myelinolysis |
| Wernicke encephalopathy | thiamine deficiency; IV with glucose can prompt acute attack |
| Wernicke encephalopathy | mammillary body hemorrhage (ring hemorrhages) |
| S/S | confusion, ataxia, nystagmus, ophthalmoplegia |
| Korsakoff's psychosis | limbic system; antegrade and retrograde memory deficits |
| Acute intermittent porphyria (AIP) | AD; deficiency uroporphyrinogen synthase; ↑ porphobilinogen |
| S/S | drug induced (alcohol, barbiturates); abdominal pain (“bellyful of scars”); dementia |
| Window sill test | urine in AIP colorless; turns port wine color with exposure to light (porphobilin) |
| Rx | heme infusions (inhibits δ-aminolevulinic acid synthetase) |
| Adult brain tumors | 70% supratentorial; frontal lobe MC site |
| Childhood brain tumors | 70% infratentorial; cerebellum MC site |
| Adult brain tumors (descending order) | GBM, meningioma, acoustic neuroma |
| GBM | high grade astrocytoma; hemorrhage and necrosis; may cross corpus callosum |
| Meningioma | female dominant; arise from arachnoid granulations; psammoma bodies; seizures |
| Acoustic neuroma | schwannoma of the VIIIth nerve; tinnitus; sensorineural hearing loss; neurofibromatosis |
| Childhood brain tumors | astrocytoma cerebellum (MC), medulloblastoma |
| Astrocytoma | MC primary brain tumor; frontal lobe MC site in adult; cerebellum MC site in child |
| Medulloblastoma | malignant tumor cerebellum; invades fourth ventricle |
| Ependymoma | arises in 4th ventricle in children and cauda equina in adults |
| Oligodendroglioma | frontal lobe tumor with dystrophic calcification |
| CNS lymphomas | metastasis MCC; primary CNS lymphoma associated with EBV in AIDS |
| Metastasis | MC brain malignancy; lung cancer MC site of origin; junction gray and white matter |
| Schwannoma | benign tumor Schwann cell; MC peripheral nerve tumor; alternating dark and light areas |
| AIDS dementia | due to HIV; multinucleated microglial cells |
| CMV retinitis | MCC of blindness in AIDS; Rx. ganciclovir (foscarnet if unsuccessful) |
| Peripheral neuropathy | myelin destruction (sensory; paresthesias); axon destruction (muscle atrophy) |
| Peripheral neuropathy | DM MCC; thiamine/pyridoxine deficiency; vinca alkaloids (vincristine) |
| Guillain-Barre syndrome | MCC autoimmune demyelination of peripheral and spinal nerves |
| Risk factors | M. pneumoniae, influenza vaccine, Campylobacter jejuni |
| S/S | ascending paralysis; CSF increased protein, lymphocytes; Rx. plasmapheresis |
| Charcot-Marie-Tooth | AD; common peroneal nerve palsy; inverted bottle appearance |
| Idiopathic Bell’s palsy | facial muscle paralysis due to inflammation of cranial nerve VII |
| Lyme disease | facial nerve MC cranial nerve involved; bilateral Bell’s palsy |
| Bacterial conjunctivitis | Staphylococcus aureus |
| Viral conjunctivitis | adenovirus MC; HSV-1 (dendritic ulcers) |
| Sudden loss of vision | amaurosis fugax, central retinal artery or vein occlusion |
| Uveitis | inflammation of iris, choroid, ciliary body; blurry vision; ankylosing spondylitis, sarcoidosis |
| Optic neuritis | multiple sclerosis MCC; methyl alcohol poisoning |
| Glaucoma | increased intraocular pressure; fluid cannot exit canal of Schlemm; causes optic atrophy |
| Optic atrophy | blindness; pale disc; glaucoma, optic neuritis |
| Macular degeneration | MCC permanent visual loss in elderly |
| Meniere’s disease | increased endolymph; tinnitus, vertigo, sensorineural hearing loss |
| Presbycusis | MCC sensorineural hearing loss in elderly |
| Otosclerosis | MCC conductive hearing loss in elderly; fusion of ear ossicles |
| Impacted wax in outer ear canal | conduction hearing loss |
| Weber test lateralizes to left ear, bone>air conduction (Rinne test) | conduction loss left ear |
| Weber test lateralizes to left ear, air>bone conduction both ears | sensorineural hearing loss right ear |
| Otitis media | MCC conduction hearing loss in children; S. pneumoniae MCC |
| Malignant external otitis in diabetic | Pseudomonas aeruginosa |
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