Goljan HY Systemic Word Scramble
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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 |
Created by:
megankirch
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