Pregnancy results in significant plasma expansion and widespread vasodilation, leading to

increased renal plasma flow and glomerular filtration rates.  Serum creatinine is reduced by
approximately 0.4 mg/dL in this population; therefore, a rise in serum creatinine, even to
levels that are normal in nonpregnant patients, represents significant renal dysfunction.

Acetazolamide: decrease PaCO2, no change Ca and increase urine k and pH.

Case series is a descriptive observational study design in which a (generally small)

group of patients with a similar diagnosis or treatment is described at a point in time or
followed over a certain time period.
no comparison group

Methylation of the CpG region adjacent to the MGMT gene (promotor region) causes
inhibition of repairing DNA damage.

Erythropoietin (EPO) is produced primarily by peritubular fibroblast cells in the renal cortex in
response to decreased renal oxygen delivery (eg, decreased blood hemoglobin content). 2nd
proximal tubule.

Irreversible inhibitors bind to enzymes through strong covalent bonds; this typically renders
the enzyme permanently ineffective, decreasing the Vmax.

Secondary lactase deficiency can occur after inflammatory (eg, celiac disease) or infectious (eg,
giardiasis) processes damage the microvilli of the small intestines. Clinical presentation
includes abdominal distension and cramping, flatulence, and diarrhea.

Patients with bipolar II disorder have a history of hypomanic (not manic) episodes and one or
more major depressive episodes.

Benzodiazepines increased frequency of chloride channel opening in the presence of

GABA

Barbiturates (eg, phenobarbital) increase the duration of opening of the GABA A

receptor–chloride channel in the presence of GABA

This patient's aortic valve calcifications most likely represent dystrophic calcification affecting
an aging aortic valve. Dystrophic calcification is considered a hallmark of cell injury and death,
occurring in all types of necrosis (eg, coagulative, fat, caseous, liquefactive) in the setting of
normal calcium levels.

Conversion disorder (functional neurologic symptom disorder). Neurologic symptom(s)

incompatible with anatomy or pathophysiology.

Mifepristone is a progesterone antagonist that binds progesterone receptors with greater

affinity than the natural hormone.  Progesterone receptor blockade results in apoptosis and
necrosis of the uterine decidua and prevents further development of a first trimester
pregnancy.
Serum potassium is routinely monitored with diuretics (especially loop diuretics),
spironolactone, ACE inhibitors, and angiotensin II receptor blockers.

Metformin: before uses you gotta check the serum creatinine.

Thyroid function tests are routinely performed in patients taking lithium and

amiodarone.

The late phase of dermatologic type I hypersensitivity reactions manifests as an indurated skin
lesion hours after exposure to the allergen due to local tissue damage caused by major basic
protein released from eosinophils.

Desmopressin: increases circulating factor vIII and endothelial secretion of vWF to stop
bleeding.

Pudendal nerve injury can occur due to excessive stress on the pelvic floor during labor and
delivery (eg, prolonged second stage). Nerve injury leads to denervation and weakness of the
perineal musculature (eg, external anal sphincter), which can present as new-onset fecal
incontinence.

In response to myocardial stretching due to volume overload, atrial and ventricular

cardiomyocytes secrete atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).
These peptides are subsequently broken down and inactivated by the metalloprotease
neprilysin.

Glucose-6-phosphate dehydrogenase is the rate-limiting enzyme in the pentose phosphate

pathway, the major source of cellular NADPH. This molecule is necessary for reducing
glutathione (protects red blood cells from oxidative damage) and for the biosynthesis of
cholesterol, fatty acids, and steroids.

Lamotrigine can be used to treat partial and generalized seizures and works by blocking
voltage-gated sodium channels. Stevens-Johnson syndrome and toxic epidermal necrolysis are
rare, life-threatening adverse effects characterized by flu-like symptoms followed by
widespread mucocutaneous epidermal necrosis.

Etanercept is a tumor necrosis factor-alpha (TNF-α) inhibitor added to methotrexate to treat

moderate-to- severe rheumatoid arthritis in patients who have failed methotrexate alone.  It is
a fusion protein linking a soluble TNF-α receptor to the Fc component of human
immunoglobulin G1 (IgG1).  Etanercept reduces the biological activity of TNF-α by acting as a
decoy receptor

Ulnar nerve injury most commonly occurs at the elbow (eg, compression due to resting arm on
a hard surface while using a computer) and usually presents with discomfort and sensory
loss/paresthesia in the fifth digit, medial half of the fourth digit, and the hypothenar eminence.
In severe cases, patients can also have weakness on wrist flexion and adduction (ie, ulnar
deviation) along with finger weakness/clumsiness.

The superficial and deep inguinal rings are physiologic openings in the external abdominal
oblique aponeurosis and the transversalis fascia, respectively
Lenalidomide increases E3 ubiquitin ligase binding to transcription factors overexpressed in
myeloma, which results in increased transcription factor destruction by the proteosome and
subsequent cancer cell death.

An increase in estrogen activity, as seen in pregnancy or postmenopausal estrogen

replacement therapy, increases the level of thyroxine-binding globulin. This leads to an
increase in total thyroid hormone levels (T4), but feedback control maintains normal levels of
free (biologically active) thyroid hormone.

carbamazepine, valproic acid, sulfonamides, or nifedipine cause Aplastic anemia.

Antidepressants (eg, selective serotonin reuptake inhibitors) take 4-6 weeks to achieve
maximal clinical effect

Myasthenia gravis (MG) is caused by autoantibodies against postsynaptic nicotinic

acetylcholine receptors, leading to fewer functional receptors and fatigable muscle weakness.
Nondepolarizing neuromuscular blocking agents (eg, vecuronium) are competitive antagonists
of nicotinic receptors; due to the depletion of receptors, patients with MG are extremely
sensitive to these agents.

Myasthenia gravis is associated with abnormalities of the thymus (e.g. thymoma, thymic
hyperplasia). The thymus and inferior parathyroid glands arise from the 3rd pharyngeal pouch.

Injury to the radial nerve at the supinator muscle may occur due to repetitive
pronation/supination of the forearm, direct trauma, or subluxation of the radius. Patients
typically have weakness during finger and thumb extension (ie, finger-drop) without wrist drop
or sensory déficits

In fructokinase deficiency, hexokinase takes over the role of fructose metabolism, converting
dietary fructose into fructose-6-phosphate

The musculocutaneous nerve innervates the major forearm flexors (eg, biceps brachii,
brachialis) and coracobrachialis (flexes and adducts the arm) and provides sensory innervation
to the lateral forearm.

This patient has pain and deformity of the long bones with hearing loss (due to bony deformity
of the skull); these are typical features of Paget's disease of bone.

Osteoblasts are cells with a single nucleus that arise from mesenchymal stem cells found in the
periosteum and bone marrow. In contrast, osteoclasts originate from the mononuclear
phagocytic cell lineage and are ultimately formed when several precursor cells fuse to create a
multinucleated mature cell. Osteoclasts in Paget's disease are typically very large and can have
up to 100 nuclei (normal osteoclasts have 2-5).

Osteoprotegerin (OPG) is a physiologic decoy receptor that decreases binding of RANK-L to

RANK. Inhibition of RANK-L to RANK receptor interaction reduces the differentiation and
survival of osteoclasts, resulting in decreased bone resorption and increased bone density

Hypoglycemia due to excessive endogenous insulin production is associated with elevated

levels of C-peptide. This can occur due to autonomous insulin-producing tumors (insulinomas)
or intake of insulin secretagogues (eg, sulfonylureas). Self-induced hypoglycemia via oral
hypoglycemics

Field cancerization can occur when a large area of cells is exposed to carcinogens that induce
mutations, leading to a higher risk of forming cancers.

Patients with M pneumoniae infections often develop mild, transient hemolytic anemia that
resolves as IgM antibody titers decline (6-8 weeks after infection begins).

Nifedipine (calcium channel blocker) and indomethacin (cyclooxygenase inhibitor) are tocolytic
drugs used to stop preterm labor.  The decreased intracellular calcium from nifedipine blocks
myosin kinase phosphorylation, which in turn leads to myometrial relaxation.  Indomethacin
stops prostaglandin synthesis, which decreases uterine contractility.

Both vitamin K and fresh frozen plasma are used for reversing warfarin-induced
anticoagulation.  Fresh frozen plasma rapidly reverses warfarin's effects whereas
vitamin K requires time for clotting factor re-synthesis.

Protamine is used for heparin reversal.  It acts by binding and chemically inactivating
heparin.

Cell membrane receptors can be divided into two broad categories: ionotropic receptors
example: Nicotinic cholinergic receptor (ion channels that open directly upon ligand binding)
and metabotropic receptors (these receptors utilize second messengers to indirectly influence
their corresponding ion channels).

Evidence of right ventricular hypertrophy (ie, boot-shaped heart) on chest x-ray are
consistent with tetralogy of Fallot. And evidence of right ventricular hypertrophy (ie,
boot-shaped heart). Decreased of pulmonary arterial pressure and left atrial pressure/
increased of right ventricular pressure.

There is a III/VI systolic crescendo-decrescendo murmur best heard along the left upper sternal
border: pulmonic stenosis.

Cytotoxic CD8 lymphocytes play an important role in host defense against viral infections. 
They are also capable of destroying tumor cells and contribute to rejection reactions.

Zinc-finger: Examples include steroid (eg, estrogen, aldosterone, cortisol), thyroid hormone,
and fat-soluble vitamin receptors
Dopamine agonists have a chemical structure similar to the neurotransmitter dopamine and
directly stimulate dopamine receptors.  The 2 classes of dopamine agonists are ergot
compounds (eg, bromocriptine) and nonergot compounds (eg, pramipexole, ropinirole)

The ventromedial nucleus is vital in monitoring blood glucose and mediates satiety.  Lesions of
this area of the hypothalamus (eg, trauma, infection, brain tumors) can result in hyperphagia
and obesity.  Conversely, the lateral nucleus signals hunger.  Lesions can result in loss of
appetite (eg, failure to thrive)
Posterior urethral valves can present with bilateral hydronephrosis and calyceal dilation due to
obstruction of urine flow in the urethra.  However, posterior urethral valves result from a
malformation of the Wolffian duct, and therefore only occur in males.

Pulmonary arterial hypertension results from endothelial dysfunction that leads to an increase
in vasoconstrictive, proproliferative mediators (eg, endothelin, thromboxane A2) and a
decrease in vasodilative, antiproliferative mediators (eg, nitric oxide, prostacyclin). 

Pemphigus vulgaris: Biopsy of an active lesion will show intraepithelial cleavage with detached
keratinocytes (acantholysis), retained keratinocytes along the basement membrane, and an
eosinophilic inflammatory infiltrate.

Blood solubility of an anesthetic is indicated by its blood/gas partition coefficient - anesthetics

with higher blood solubility have larger blood/gas partition coefficients.  Nitrous oxide (N2O) is
an example of a poorly soluble gas with a blood/gas partition coefficient of 0.47. 

cGMP activates protein kinase G, which mediates a number of intracellular effects (eg, smooth
muscle relaxation, platelet activation, sperm metabolism).

 This mixture of two types of genetic material is called heteroplasmy and is responsible for the
clinical variability of mitochondrial diseases.

Heavy chain constant regions are isotype-specific and distinguish the 5 isotypes (IgM, IgG, IgA,
IgE, and IgD), while the variable regions are antigen-specific.  Light chains are antigen-specific
and do not determine isotype. 

  Lecithinase (toxin A) is produced by Clostridium perfringens, and hydrolyzes lecithin in cell

membranes.  This results in cell lysis and the development of gas gangrene.

Trehalose dimycolate is a cell wall component and major virulence factor of Mycobacterium
tuberculosis.  It protects M tuberculosis from being killed by macrophages and stimulates
granuloma formation.

Polyribosylribitol phosphate is a capsule component and major virulence factor for

Haemophilus influenzae type b (Hib).  Hib is the most common cause of epiglottitis, which
presents with fever, stridor, and dyspnea.

Abnormal spasm or diminished relaxation of the cricopharyngeal muscles during

swallowing (cricopharyngeal motor dysfunction) is thought to be the underlying
mechanism of Zenker diverticulum formation. 

Mediastinal lymphadenitis (eg, due to tuberculosis, fungal infections) can cause

scarring/traction of the mid-portion of the esophagus, resulting in the formation of true
diverticula (containing all gut wall layers).

Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) is an autosomal

dominant condition marked by the presence of telangiectasias in the skin as well as the
mucous membranes of the lips, oronasopharynx, respiratory tract, gastrointestinal tract,
and urinary tract.  Rupture of these telangiectasias may cause epistaxis, gastrointestinal
bleeding, or hematuria.
Factor VII deficiency: normal bleeding time, normal ptt and abnormal pt(high)

Restless legs syndrome is characterized by an uncomfortable sensation in the legs

accompanied by an urge to move them; symptoms worsen with inactivity and at night and are
temporarily relieved with movement.  Dopamine agonists (eg, pramipexole, ropinirole) are the
preferred therapy for persistent symptoms. + iron

Sturge-Weber syndrome (encephalotrigeminal angiomatosis) is a rare congenital

neurocutaneous disorder characterized by the presence of cutaneous facial angiomas as
well as leptomeningeal angiomas

Alpha-1 antitrypsin (AAT) deficiency causes liver disease characterized by intracytoplasmic

accumulation of a misfolded and abnormally polymerized AAT protein

Formation of Mallory-Denk bodies (eg, cytoplasmic eosinophilic inclusions within hepatocytes).

Pattern recognition receptors (PRRs) are part of the innate immune response; they recognize
damaged host proteins or conserved microbial molecules and trigger inflammation.  Toll-like
receptors, a type of PRR on macrophages and dendritic cells, recognize lipopolysaccharide and
promote the release of inflammatory cytokines (eg, IL-1/6/12, TNF-alpha) via NF-kB signaling.

Von Hippel–Lindau disease is a rare, autosomal dominant condition characterized by

the presence of capillary hemangioblastomas in the retina and/or cerebellum, as well as
congenital cysts and/or neoplasms in the kidney, liver, and pancreas.  Patients are also at
increased risk for renal cell carcinoma, which can be bilateral.

Administration of the drug caused an increase in systolic and diastolic blood pressures and a
reflexive (delayed) decrease in heart rate and slowed atrioventricular node conduction; these
are the typical effects of a selective α1-adrenergic agonist (eg, phenylephrine, methoxamine).

Protein kinase A is responsible for the intracellular effects of the G protein-mediated adenylate
cyclase second messenger system.  Hormone receptors that use this system include the TSH,
glucagon, and PTH receptors.

Preventable medical errors involve harm to the patient by an act of commission or omission
rather than from the underlying disease and are the result of failure to follow evidence-based
best practice guidelines.

Dantrolene relaxes skeletal muscle by reducing the release of Ca2+ from the sarcoplasmic
reticulum.  Dantrolene is used to treat malignant hyperthermia and neuroleptic malignant
syndrome. 

High-output heart failure results from markedly decreased systemic vascular resistance (eg,
large arteriovenous fistula) that leads to increased venous return and increased cardiac
output. 

Phosphodiesterase 5 inhibitors (eg, sildenafil, tadalafil) can cause a transient bluish

discoloration to vision. (Blue vision)
Hypersensitivity pneumonitis results from an exaggerated immunologic response to an inhaled
antigen (eg, mold, animal protein), and presents with cough and dyspnea of variable acuity. 
Bronchoalveolar lavage typically shows high relative lymphocyte count (eg, >20%), which helps
support the diagnosis.

Major adaptive immune mechanisms that prevent reinfection with the influenza virus include
anti-hemagglutinin antibodies.

Cryptococcus neoformans: Round or oval budding yeast can also be visualized with
India ink stain.  M

Mold fungi (eg, Rhizopus) form sporangia, which produce and contain spores

Patients with orbitofrontal cortex injury often experience personality changes, disinhibition,
and irritability secondary to impairment of the behavioral and emotional modulatory systems.

Malpractice is a legal determination; it involves situations in which the treatment provided is

below the accepted standard of practice and has resulted in injury or death to the patient. 

In Wilson disease, defective ATP7B results in impaired biliary excretion of copper.

Ventricular septal defect causes presure: Right atrium (unchanged), right ventricle/left
atrium/left ventricle increase

Cervical spine trauma can cause dissection of the vertebral artery, resulting in ischemic.
Wallenberg syndrome, characterized by vertigo/nystagmus, ipsilateral cerebellar signs, loss of
pain/temperature sensation in the ipsilateral face and contralateral body, bulbar weakness,
and ipsilateral Horner syndrome.

Tumor necrosis factor alpha (TNF-α) is a proinflammatory cytokine that induces insulin
resistance through the activation of serine kinases, which then phosphorylate serine residues
on the beta subunits of IR and IRS-1

Normal alveolar PO2 is 104 mm Hg, which lies between the tracheal (150 mm Hg) and systemic
venous blood (40 mm Hg) PO2 concentrations.  Likewise, normal alveolar PCO2 is 40 mm Hg,
also between its respective tracheal (0 mm Hg) and systemic venous blood concentrations (45
mm Hg). Transfer of O2 and CO2 between the blood and the alveoli depends on both perfusion
and diffusion.

Hereditary hemochromatosis is an autosomal recessive disorder that can cause cirrhosis

due to increased intestinal absorption of iron.

Pulmonary hypertension can be recognized on physical examination by a loud pulmonic

component of S2 and an accentuated, palpable impulse at the left sternal border (left
parasternal lift due to right ventricular heave).

This patient's clinical presentation is consistent with idiopathic intracranial hypertension

(pseudotumor cerebri).  This condition typically presents in young obese women with daily
headache, bilaterally symmetric papilledema, and transient visual disturbances related to
impaired cerebral venous outflow and elevated intracranial pressure.  Symptoms
characteristically worsen during the Valsalva maneuver (eg, bending down, coughing) because
intracranial pressure increases.

 Choroidal inflammation is characteristic of posterior uveitis, which typically presents with

painless vision loss and floaters.  Ophthalmic examination may show inflammation/leukocytes
in the vitreous humor.  Uveitis is often associated with systemic inflammatory disorders (eg,
inflammatory bowel disease, ankylosing spondylitis).

Flecainide are potent sodium channel blockers that have increased effect at faster heart rates
(use-dependence).  This makes them more effective at treating tachyarrhythmias, but can also
cause prolonged QRS duration (a proarrhythmic effect) at higher heart rates.

Silicosis is associated with increased risk of mycobacterial infections, particularly

Mycobacterium tuberculosis, due to impaired macrophage function.  It is thought that
macrophage phagolysosomes are disrupted by internalized silica particles, leading to impaired
phagocytosis and increased apoptosis.

Vegetations are caused by bacterial colonization and growth on a sterile fibrin-platelet nidus
that forms on the damaged/disrupted endothelial surface of the valvular apparatus.

Cyproheptadine is an antihistamine with antiserotonergic properties that can be used as an

antidote in severe cases of serotonin syndrome that do not respond to supportive

CD40-ligand (CD40L) is expressed primarily on activated T cells.  It binds to CD40 on antigen-

presenting cells, including B cells, leading to their full activation (costimulation).  Therefore,
CD40L plays a vital role in both the cell-mediated and humoral immune response.

Protease inhibitors inhibit HIV protease from cleaving the gag-pol polyproteins, which results
in the formation of immature, noninfectious virions due to impaired production of functional
viral proteins.

Benzodiazepines (eg, lorazepam, diazepam, chlordiazepoxide) are used as first-line therapy

for psychomotor agitation associated with alcohol withdrawal and to prevent progression to
seizures and delirium. 

Digoxin slows conduction through the AV node via increased parasympathetic (vagal) tone.

Fetal hemoglobin (Hb F) production begins around 8 weeks gestation and replaces all
embryonic hemoglobin by 14 weeks gestation, when erythropoiesis in the fetal liver and
spleen is established.  Hb F consists of 2 alpha and 2 gamma protein subunits (α2γ2). 

Cerebral aneurysms are a common complication of autosomal dominant polycystic kidney

disease, occurring in almost 25% of patients.

Vertebral anomalies in association with renal anomalies are suggestive of VACTERL association
(vertebral, anal atresia, cardiac defects, tracheoesophageal fistula, renal defects, and limb
defects)

Bilaterally enlarged, cystic fetal kidneys and oligohydramnios are findings consistent with
autosomal recessive polycystic kidney disease (ARPKD). ARPKD is caused by a mutation in
PKHD1, the gene for fibrocystin. Fibrocystin is found in the epithelial cells of both the renal
tubule and the bile ducts; deficiency leads to the characteristic polycystic dilation of both
structures.

Lung abscess is a necrotic infection of the pulmonary parenchyma that usually presents with
several days of fever, cough productive of copious sputum (often foul-smelling), and chest x-
ray evidence of cavitation with air-fluid level. Neutrophils are the key player in the formation
of lung abscess.

This patient's depression, fatigue, hypersomnia, hyperphagia, and vivid dreams are
characteristic of cocaine withdrawal.

Therapy with lithium reduces the ability of the kidneys to concentrate urine primarily by
antagonizing the action of vasopressin (antidiuretic hormone) in the collecting tubules and
ducts. 

The teniae coli are 3 separate smooth muscle ribbons that travel longitudinally on the outside
of the colon and converge at the root of the vermiform appendix. If the appendix cannot be
identified by palpation during an appendectomy, it can be located by following the teniae coli
to their origin at the cecal base.

Pseudomonas aeruginosa is a nonlactose-fermenting, oxidase-positive, motile, Gram-negative

rod.

Antibodies against HIV surface glycoproteins (eg, gp120) help neutralize circulating virus and
reduce viral load. However, HIV surface glycoproteins display a high degree of antigenic
variation, which prevents the formation of a completely effective antibody response.

Corticosteroids (Fluticasone): inhibit the production of inflammatory mediators (eg, cytokines,

prostaglandins, leukotrienes), reduce leukocyte extravasation into the respiratory epithelium,
and induce apoptosis of inflammatory cells. In addition, corticosteroids decrease smooth
muscle proliferation and mucus production by goblet cells.

Generalized anxiety disorder is characterized by excessive, uncontrollable worry about

multiple issues. Symptoms must persist for at least 6 months.

Normal pressure hydrocephalus occurs due to decreased cerebrospinal fluid absorption,

resulting in ventriculomegaly with normal intracranial pressure. This causes stretching of the
descending cortical fibers (corona radiata) from the frontal lobe and contributes to the classic
triad of symptoms (ie, dementia, gait abnormalities, urinary incontinence). Loss of cortical
inhibition of the sacral micturition center leads to urge incontinence.

This patient most likely has the syndrome of inappropriate antidiuretic hormone secretion
(SIADH), which can be caused by a multitude of drugs, including carbamazepine,
cyclophosphamide, and selective serotonin reuptake inhibitors.

Actinomyces is an anaerobic, gram-positive bacillus with acute-angle branching. It can colonize

intrauterine devices (IUDs) and may cause pelvic inflammatory disease (eg, fever, abdominal
pain, mucopurulent cervical discharge). Treatment is with IUD removal and penicillin.
Therapeutic hypothermia (maintenance of temperature at 33-35 C [91.4-95 F]) leads to
improved neurologic outcomes in a variety of hypoxia-induced injuries (eg, after cardiac arrest,
seizures). The formation of ROS after ischemic injury is temperature dependent, so it can be
decreased by therapeutic hypothermia.

This patient has reduced awareness of hypoglycemia, likely due to the use of a
nonselective beta blocker (eg, propranolol) for chronic treatment of migraines and/or
hypertension.
In addition, nonselective beta blockers can contribute to the severity of hypoglycemia;
epinephrine stimulates hepatic gluconeogenesis and peripheral glycogenolysis, but this
effect is diminished by nonselective beta blockers.

Infliximab: hypersensitivity reaction called serum sickness.  This is typically marked by fever,
urticarial rash, and joint pain 5-14 days after exposure.  Most cases resolve spontaneously
over days as mononuclear phagocytes continue to remove the excess ICs.

Transport of glucose into the cells of most tissues occurs by means of facilitated diffusion (no
energy). Glucose moves from areas of high concentration to areas of low concentration with
the help of transmembrane glucose transporter proteins (GLUT). These carrier proteins are
stereoselective and have preference for D-glucose.

Adhesion of cells to the extracellular matrix involves integrin-mediated binding to fibronectin,

collagen, and laminin

Metabolic alkalosis can also occur in the absence of significant chloride depletion.  Conditions
of mineralocorticoid excess (eg, primary hyperaldosteronism) cause metabolic alkalosis
primarily due to aldosterone-mediated H+ loss from the kidneys.  These patients have
hypervolemia (eg, hypertension), resulting in a pressure natriuresis with high urine chloride
levels; the metabolic alkalosis does not correct with Cl - repletion (saline unresponsive) due to
the persistent mineralocorticoid effect.

Hypertrophic cardiomyopathy is a common cause of sudden cardiac death in young patients. It

is inherited in an autosomal dominant pattern and most commonly involves mutations in the
genes encoding beta-myosin heavy chain or myosin-binding protein C.

The spinal accessory nerve is vulnerable to injury in the posterior triangle of the neck. Injury
results in weakness of the trapezius muscle, which presents with drooping of the shoulder,
impaired abduction of the arm above 100 degrees, and lateral displacement of the scapula.

Carpal tunnel syndrome is caused by median nerve compression at the wrist within the
carpal tunnel.

Fracture of the scaphoid bone may result from a fall on an outstretched hand and should be
suspected if examination shows tenderness in the anatomic snuff box. Scaphoid fracture can
disrupt retrograde blood supply to the proximal scaphoid, increasing risk of avascular necrosis.

Epstein-Barr virus (EBV) commonly infects B cells, stimulating them to proliferate continuously
("transformation" or "immortalization"). EBV is an oncogenic virus that promotes polyclonal B
cell proliferation and heterophile antibody production. The heterophile antibody test is
sensitive and highly specific for EBV infection.
Cholinesterase inhibitors glycopyrrolate, hyoscyamine, or propantheline.

Ectopic pregnancy: adnexal mass

Age-related changes to the respiratory system include decreased chest wall compliance and
decreased alveolar elastic recoil with resulting alveolar enlargement and air trapping. These
changes limit the potential increase in tidal volume and also increase the alveolar-arterial O2
gradient (ie, decrease the efficiency of alveolar-capillary gas exchange), reducing the ability to
compensate for hypoxemia.

Because disruption of the sleep-wake cycle is both a risk factor and manifestation of delirium,
facilitation of nocturnal sleep (eg, minimizing noise & patient interventions, appropriate
day/night lighting) is helpful for delirium prevention and management.

the cytoplasmic surface of the cell membrane and that catalyzes the transfer of acetyl groups
to exogenous substances.  The bacteria are most likely resistant to which of the following
antibiotics? Gentamicin

Bevacizumab is a monoclonal antibody that binds vascular endothelial growth factor (VEGF),
preventing it from binding to its cell surface receptor.  This inhibits angiogenesis—the process
by which new blood vessels sprout from surrounding, uninjured vessels and grow into the
wound—because angiogenesis is largely stimulated by VEGF.

Vaccine administration is a known precipitant of vasovagal syncope, especially in adolescents.

Because syncope-related falls can lead to serious injury (eg, skull fractures, intracranial
hemorrhage), patients should be closely monitored for 15 minutes following vaccine
administration. (cardioinhibitory and vasodepressor response)

Crystalline-induced kidney injury most commonly occurs from acyclovir or sulfonamide (eg,
sulfadiazine) usage. Urinalysis demonstrates needle or rosette-shaped crystals.

Guyon canal syndrome is caused by compression of the ulnar nerve at the wrist within
Guyon canal.

The most common eye-related complication of congenital cytomegalovirus infection is

chorioretinitis.

Acute intermittent porphyria (AIP):  ALA synthase is upregulated by CYP450 inducers (eg,
most antiepileptics, griseofulvin, rifampin) and downregulated by heme and glucose.

The Romberg test is a test of proprioception in which patients are observed for
unsteadiness as they stand with their feet close together, arms to the sides, and eyes
closed. Failure to maintain this posture indicates sensory ataxia, which may be caused
by defects in the posterior column or peripheral nerves (eg, tabes dorsalis, vitamin B12
deficiency).
Patients who show little or no change in their unsteadiness with their eyes closed
(negative Romberg sign) likely have cerebellar ataxia due to impaired motor
coordination.
Leydig cells, which are analogous to female theca cells, produce testosterone in
response to stimulation by luteinizing hormone.

Sertoli cells, which are analogous to female granulosa cells, produce the hormone
inhibin in response to FSH from the anterior pituitary.

Lack of interaction between CD40L and CD40 on B cells prevents the development of
secondary germinal centers and impairs B-cell activation and immunoglobulin class switching.

Lateral rectus does not affect in aneurysms causing CN III palsy most often involve the
posterior communicating artery. 

On auscultation, the best indicator of mitral stenosis (MS) severity is the length of time
between S2 (specifically the A2 component, caused by aortic valve closure) and the opening
snap (OS).

Common side effects of HMG-CoA reductase inhibitors (statins) include muscle and liver
toxicity. Hepatic transaminases should be checked prior to initiating therapy and repeated if
symptoms of hepatic injury occur.

Marfan syndrome is a connective tissue disorder in which defective fibrillin-1 decreases tissue
integrity and increases expression of transforming growth factor-beta. Cardiac effects include
myxomatous degeneration and prolapse of the mitral valve with associated regurgitation,
which manifests as a midsystolic click and mid-to-late systolic murmur.

Bladder: Occupational exposures (rubber, plastics, aromatic amine–containing dyes, textiles,

leather)

Sensitization to aeroallergens occurs when inhaled antigens induce T-helper (Th) cells to
differentiate into Th2 cells. Th2 cells then promote B-cell maturation and isotype class
switching to IgE.

Chronic lung transplant rejection is marked by submucosal lymphocytic inflammation in the

walls of the small airways. (bronchiolitis obliterans)

The likelihood of plaque rupture is related to plaque stability rather than plaque size or the
degree of luminal narrowing. Plaque stability largely depends on the mechanical strength of
the fibrous cap. Inflammatory macrophages in the intima may reduce plaque stability by
secreting metalloproteinases, which degrade extracellular matrix proteins (eg, collagen).

Prone positioning (lying face down) is sometimes used to improve arterial oxygenation in
patients with severe acute respiratory distress syndrome. It likely does so by reducing
atelectasis of posterior alveoli to reduce intrapulmonary shunting and improve ventilation-
perfusion matching throughout the lungs.

Bipolar I disorder is diagnosed in patients with ≥1 episodes of mania. Manic episodes are
characterized by elevated/irritable mood, impulsivity, hyperactivity, decreased need for sleep,
pressured speech, and grandiosity and may occur with psychotic features.

Ovarian venous drainage is asymmetric; the left ovarian vein drains into the left renal vein
(Choice D) while the right ovarian vein drains directly into the IVC
Diphtheria can be prevented with the diphtheria-pertussis-tetanus (DPT) childhood
vaccination, which generates neutralizing IgG antibodies against the binding component (B
subunit) of the diphtheria exotoxin.

Streptococcus pneumoniae is able to undergo transformation, which allows the bacterium to

take up exogenous DNA fragments and express the encoded proteins. Through this method,
strains of S pneumoniae that do not form a capsule can acquire the genes that code for the
capsule and therefore gain virulence.

Cystinuria is an autosomal recessive disorder caused by defective transportation of cystine,

ornithine, arginine, and lysine across the intestinal and renal tubular epithelium. Recurrent
nephrolithiasis is the only clinical manifestation. Urinalysis shows pathognomonic hexagonal
cystine crystals.

Insulin also suppresses glucagon by directly acting on the alpha cells, enhancing the metabolic
effects of insulin.

Reye syndrome administration of salicylates (eg, aspirin), which cause damage to the
mitochondria and impair fatty acid beta-oxidation within hepatocytes.

Ion pump failure due to ATP deficiency during cardiac ischemia causes intracellular
accumulation of Na+ and Ca2+. The increased intracellular solute concentration draws free
water into the cell, causing the cellular and mitochondrial swelling that is observed
histologically.

Withdrawal of the PPI results in overstimulation of the parietal cells with hyperfunctioning of
the unblocked ATPase, leading to rebound gastric acid hypersecretion and reflux symptoms. 
PPIs can be slowly tapered to help prevent this adverse effect.

Andexanet alfa is a factor Xa decoy that has no proteolytic effect. It is administered to patients
on factor Xa inhibitors (eg, rivaroxaban, apixaban) who have life-threatening bleeding in order
to reverse the anticoagulation effect.

Epidural hematoma is an accumulation of blood between the bone and dura mater. It typically
occurs due to a tear of the middle meningeal artery associated with fracture of the pterion
region of the skull (often involving the temporal bone).

Subdural hematoma (SDH) is located between the dura mater and arachnoid mater and results
from tearing of the bridging cortical veins. It typically presents in older patients with
profoundly depressed mental status at onset (acute SDH) or an insidious onset of headache
and confusion (chronic SDH)

Subarachnoid hemorrhage results in blood accumulation between the arachnoid mater and pia
mater. It most often occurs due to rupture of berry aneurysms or arteriovenous malformations
of the anterior communicating, posterior communicating, or middle cerebral arteries.

Bilateral renal artery stenosis: decreased of renal perfusion, intraglomeruar pressure and
filtration fraction
Cervical radiculopathy typically results in neck and/or arm pain associated with neurologic
deficits that follow a dermatomal/myotomal pattern. Osteophytes that form due to
degenerative changes in the vertebral joints can progressively narrow the neural foramina
leading to nerve root compression.

Heterotopic bone formation in muscles is characteristic of myositis ossificans, a benign

condition that develops after contusion to large muscle groups (eg, quadriceps femoris), not
small muscles such as the lumbricals.

Linear deposits of calcium hydroxyapatite in the periarticular structures cause a painful

inflammatory condition called calcific peritendinitis.

Dupuytren contracture is caused by progressive fibrosis of the superficial palmar fascia due to
excessive fibroblast proliferation. Pathognomonic fibrotic nodules and cords form along the
flexor tendons, limiting extension of the affected digits.

cataracts can develop earlier in individuals, such as this patient, with exposure to systemic or
ophthalmic glucocorticoids (eg, prednisone)

Pregnancy increases the risk of venous thromboembolism Low-molecular-weight heparin

(LMWH) (eg, enoxaparin, dalteparin) is preferred as it has a relatively long half-life (4.5 hours)
and does not require routine laboratory monitoring.

This increase in insulin resistance is primarily due to the action of human placental lactogen
(hPL), a peptide hormone secreted by the syncytiotrophoblast. 

Decreases the probability of a type I error along with the probability of finding
statistical significance (eg, p-value < 0.05 to p-value < 0.01).
Reducing the significance level alpha (α) in a study allows researchers to report any
significant findings with greater confidence.

Legg-Calvé-Perthes disease is a disease of young children that results in isolated idiopathic

osteonecrosis of the hip (red circle).

Granulomas are characterized microscopically by aggregates of activated macrophages that

assume an epithelioid appearance. Multinucleated giant cells, derived from the fusion of
several macrophages, can also be found in granulomas.

Excess granulation tissue formation (hypergranulation) usually occurs in a wound left to heal
by secondary intention. Light microscopy would show proliferation of fibroblasts, collagen
deposition, inflammatory cells, and numerous capillaries.

Torsade de pointes, a form of polymorphic ventricular tachycardia that can cause syncope
and sudden cardiac death.

TSH from the anterior pituitary stimulates the thyroid to produce thyroxine (T4) and a small
amount of triiodothyronine (T3). T4 is converted in peripheral tissues to T3 (active form) and
reverse T3 (inactive form). TSH secretion is under negative feedback by thyroid hormone on
the hypothalamus and pituitary.

potassium hydroxide (KOH) preparation of skin scrapings

The major clinical manifestations of factor V Leiden include deep vein thrombosis (DVT),
cerebral vein thrombosis, and recurrent pregnancy loss. Because pulmonary
thromboembolism occurs in approximately 50% of all individuals with untreated DVTs, the
young woman presented here is at significant risk of developing a pulmonary
thromboembolism at some point in her lifetime.

Gastric parietal cells and chief cells produce hydrochloric acid (HCl) and pepsinogen,
respectively

Chronically increased intrabdominal pressure (eg, obesity, chronic cough from COPD)
can cause weakened pelvic floor muscle support. In addition, prior pregnancies
(including cesarean deliveries) typically increase the laxity of pelvic floor muscles and
connective tissue. In patients with SUI, the weakened pelvic floor muscles can no
longer stabilize the urethra, leading to urethral hypermobility, an increased
urethrovesical angle, and resultant urinary incontinence. On examination, patients
typically have leakage of urine during the Valsalva maneuver. Patients with severe
pelvic floor laxity can also develop herniation of the bladder into the vagina (ie,
cystocele), which further worsens SUI symptoms.

Concentric left ventricular hypertrophy (LVH) is a common complication of chronic

hypertension, characterized by uniformly thickened ventricular walls and enlarged
cardiomyocytes and nuclei. The vasoconstrictors angiotensin II and endothelin likely have a
prominent role in the development of concentric LVH independent of their effects on blood
pressure.

A compensatory increase in adenosine expression occurs in response to myocardial ischemia

and reperfusion of the heart. Adenosine dilates blood vessels, especially coronary arteries, to
improve circulation

Calcitonin gene-related peptide (CGRP) is a neuropeptide that is a potent vasodilator, and it

may have a role in protecting the heart from heart failure and LVH.

Interleukin-1 is a proinflammatory cytokine implicated in atherosclerosis development; high

levels are expected in coronary artery disease

An idiosyncratic drug reaction is an unpredictable reaction due to genetic differences or

complex metabolic interactions in certain patients. The use of trimethoprim-sulfamethoxazole
in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency can lead to oxidative
cellular injury and nonimmune hemolytic anemia.

When urinary citrate is low (hypocitraturia), increased calcium availability leads to formation
of calcium-oxalate complexes that can precipitate and form calcium oxalate stones. 
Hypocitraturia often occurs in the setting of chronic metabolic acidosis (eg, distal renal tubular
acidosis, chronic diarrhea) due to enhanced renal citrate reabsorption.

Ribosome biogenesis occurs primarily within the nucleolus, a dense round structure inside the
nucleus that is in direct contact with the rest of the nucleoplasm.  The nucleolus contains
ribosomal DNA coding for the 28S, 5.8S, and 18S ribosomal RNA (rRNA) components, and it is
here where most of the rRNA is transcribed.
Dantrolene, which blocks ryanodine receptors to prevent the release of calcium from the
sarcoplasmic reticulum into the cytoplasm of skeletal muscle. Intracellular calcium release
from the abnormal ryanodine receptor (RYR1).

Lateral epicondylitis (ie, tennis elbow) is characterized by overuse of wrist extensor muscles
(eg, extensor carpi radialis, extensor digitorum), leading to angiofibroblastic tendinosis at their
attachment on the lateral epicondyle.

The phrenic nerve arises from the C3-C5 segments of the spinal cord and innervates the
ipsilateral hemidiaphragm. Intrathoracic spread of lung cancer may affect the phrenic nerve,
causing hiccups and diaphragmatic paralysis with dyspnea.. Involvement of the recurrent
laryngeal nerve may cause hoarseness.

The psoas muscle originates from the anterior surface of the transverse processes and lateral
surface of the vertebral bodies and functions primarily as a hip flexor. Psoas abscess may form
due to direct spread of infection from an adjacent structure (eg, vertebral bodies, appendix,
hip joint) or from hematogenous seeding from a distant site. T12-L5

The Fas receptor acts to initiate the extrinsic pathway of apoptosis. Mutations involving the
Fas receptor or Fas ligand can prevent apoptosis of autoreactive lymphocytes, thereby
increasing the risk of autoimmune disorders such as systemic lupus erythematosus.

Leukocyte adhesion deficiency is due to the absence of CD18 antigens,  delayed umbilical cord
separation, and peripheral leukocytosis.

Tardive dyskinesia consists of abnormal involuntary movements of the mouth, tongue, face,
extremities, or trunk associated with prolonged exposure to antipsychotics. Characteristic
movements include lip smacking, facial grimacing, tongue protrusions, and choreoathetoid
movements of the head, limbs, and trunk.

 Acute dystonic reaction: Sudden-onset, sustained muscle contractions

 Akathisia: Subjective restlessness with inability to sit still
 Drug-induced parkinsonism: Tremor, rigidity, bradykinesia, masked facies

Refeeding syndrome occurs after the reintroduction of carbohydrates in patients with chronic
malnourishment, which stimulates insulin secretion and drives phosphorus intracellularly in an
effort to maintain cellular energy metabolism (eg, ATP production); this redistribution of
phosphorus can result in severe hypophosphatemia. Example into hepatic and muscle cells.

Sciatica is a nonspecific term for low back pain that radiates down the leg due to
compression of the lumbosacral nerve roots (eg, from vertebral disc herniation). The S1
nerve root is commonly involved. Patients may also have weakness on thigh extension,
knee flexion, and foot plantarflexion with an absent ankle jerk reflex.
Hip extension (gluteus maximus) Foot plantarflexion (gastrocnemius)

Vestibular schwannomas arise from the vestibulocochlear nerve (CN VIII) and are usually
located at the cerebellopontine angle  + pons

Craniopharyngiomas arise from remnants of Rathke's pouch and are typically located in
the suprasellar region
Meningiomas are most commonly found in the falcine/parasagittal region or over the
convexities of the cerebral hemispheres

Aortic regurgitation causes an increase in total stroke volume with abrupt distension and rapid
falloff of peripheral arterial pulses, resulting in a wide pulse pressure. This leads to bounding
peripheral pulses and head bobbing with each heartbeat.

Exogenous androgen supplements can be used as a male contraceptive. Elevated androgen

levels caused by use of androgen supplements can inhibit production of LH and block
production of endogenous androgens by Leydig cells.

Preeclampsia causes widespread endothelial dysfunction, resulting in dysregulated vascular

tone, increased vascular permeability, and decreased end-organ perfusion. Therefore, a
common presentation is headache with visual changes (eg, scotomata) due to dysregulated
cerebral blood flow and retinal artery vasospasm.

Orexin A and B are excitatory neuropeptides that are produced in the lateral hypothalamus
during wakefulness and inhibit the transition to REM sleep

Migraines leads to abnormal neuronal activation of trigeminal afferents and the release of
calcitonin gene-related peptide, a vasoactive neuropeptide involved in the transmission of pain
signals.

Orotic aciduria is a rare autosomal recessive disorder of de novo pyrimidine synthesis that
occurs due to a defect in uridine 5'-monophosphate (UMP) synthase. Children typically present
with physical and mental retardation, megaloblastic anemia, and large amounts of urinary
orotic acid. Uridine supplementation can improve symptoms as uridine is converted to UMP
via nucleoside kinases.

In females, the paramesonephric ducts fuse to form the fallopian tubes, uterus, cervix, and
upper vagina. Disruptions of this process can lead to a variety of müllerian tract anomalies, and
renal anomalies are a common comorbidity. Incomplete lateral fusion of the paramesonephric
ducts results in a bicornuate uterus characterized by an indentation in the center of the
fundus.

Complete agenesis of the paramesonephric ducts leads to Mayer-Rokitansky-Küster-Hauser

syndrome. The lower vagina originates from the urogenital sinus, and affected patients would
experience infertility due to a blind vaginal pouch and lack of müllerian structures

Insulin causes activation of PFK-2, leading to increased fructose 2,6-bisphosphate levels and
augmented glycolysis.  High concentrations of fructose 2,6-bisphosphate also inhibit
gluconeogenesis, leading to decreased conversion of alanine and other gluconeogenic
substrates to glucose.

The infusion of excessive normal saline (sodium chloride) is a common cause of nonanion gap
metabolic acidosis.  The excess intravascular chloride (Cl −) causes intracellular shifting of
bicarbonate (HCO3−), reducing serum HCO3− and decreasing blood pH. Serum Cl increases and
urine Na increases

Because the upper face receives bilateral input from the motor cortices, central nervous
system lesions typically cause unilateral lower facial weakness that spares the forehead. In
contrast, peripheral lesions (eg, Bell palsy) cause weakness of the entire side of the face. Bell
palsy may also result in decreased tear production, hyperacusis, and reduced taste sensation.

This patient's forehead lesions are characteristic of actinic keratoses (AKs), which are small,
scaly, erythematous lesions with a sandpaper texture occurring on sun-exposed areas. On light
microscopy, AKs show hyperkeratosis (hyperplasia of the stratum corneum), parakeratosis
(retention of nuclei in the stratum corneum), and atypical keratinocytes with pleomorphic
nuclei and multiple mitoses. There may also be pigment irregularities and dilated blood vessels
affecting the surrounding skin, which are consistent with chronic sun exposure.

Basal cell carcinoma (BCC) is the most common skin cancer. It arises on sun-exposed areas and
has a very low tendency to metastasize (in contrast to melanoma). BCC often presents as
pearly papules with central depression or ulceration. Histologically, BCC features nests of
basaloid cells and peripheral palisading of nuclei

Psoriasis commonly presents as hyperkeratotic plaques that affect the scalp, knees, and
elbows.  It is characterized histologically by clubbed rete ridges, hyperkeratosis, neutrophils in
the stratum corneum, and perivascular lymphocytic infiltrates.

Monoclonal antibodies (mAbs) are not eliminated by hepatic or renal clearance. Therefore, no
dose adjustment is necessary with impaired hepatic/renal function or use of cytochrome P450
inducers or inhibitor

Vibrio cholerae must survive the acidic environment of the stomach to reach the small
intestine and cause disease. Because the organism is easily destroyed by acid, a high burden of
organisms must be ingested to cause infection. However, conditions that decrease gastric
acidity (eg, antacid use) lower the minimum infectious dose of V cholerae by multiple orders of
magnitude.

The most important determinant of intravenous infusion rate is the radius (diameter) of the
intravenous catheter. For patients requiring a rapid blood transfusion, the shortest possible
catheter with the widest possible diameter (eg, a large-bore peripheral intravenous catheter)
should be selected.

Asymptomatic left ventricular systolic dysfunction is a common stage in the progression of

heart failure. Neurohormonal mechanisms, including the sympathetic nervous system and
renin-angiotensin-aldosterone system + increase atrial natriuretic peptide

Chronic kidney disease can cause hyperphosphatemia due to decreased renal excretion of
phosphorus. Dietary phosphorus restriction is recommended, but oral phosphate binders are
often needed. Sevelamer is a nonabsorbable anion-exchange resin that binds intestinal
phosphate to reduce absorption.

The cardio-selective beta-1-blockers include atenolol, betaxolol, bisoprolol, esmolol,

acebutolol, metoprolol, and nebivolol.

Hyperkalemia is a common adverse effect of trimethoprim-sulfamethoxazole due to the

trimethoprim-induced blockade of the sodium channels in the collecting duct, which prevents
sodium-potassium exchange and reduces renal excretion of potassium (similar to the action of
amiloride)
The phase 4 slow depolarization in cardiac pacemaker cells occurs due to the closure of
repolarizing K+ channels, the slow influx of Na+ through funny channels, and the opening of T-
type Ca2+ channels.  Acetylcholine and adenosine reduce the rate of spontaneous
depolarization in cardiac pacemaker cells by prolonging phase 4.

During wound healing, excessivematrix metalloproteinase activity and myofibroblast

accumulation in the wound margins can result in contracture.  Contractures produce
deformities of the wound and surrounding tissues, most often on the palms, soles, anterior
thorax, or at serious burn sites.

S aureus have been infected with a bacteriophage that transmits genes for Panton-Valentine
leukocidin (PVL), a cytotoxin that destroys leukocytes and causes tissue necrosis.

Acromegaly can affect the joints in both the axial and the appendicular skeleton. Excessive
growth hormone and insulin-like growth factor-1 cause hyperplasia of articular chondrocytes
and synovial hypertrophy, leading to later degeneration of articular cartilage and periarticular
bone.Hypertrophy of the articular cartilage

Local defense against Candida is performed by T cells, whereas systemic infection is prevented
by neutrophils. For this reason, localized candidiasis is common in patients who have HIV, but
neutropenic individuals are more likely to have the systemic form of the disease.

There is a firm, nontender, nonmobile mass in the right anterior neck. Otoscopic examination
shows a clear right middle ear effusion. Needle biopsy of the neck mass is consistent with
regional nodal spread of squamous cell carcinoma. Which of the following is the most likely
site of the primary tumor? Nasopharynx

Vitamin B3 (niacin) deficiency: decreased of isocitrate dehydrogenase

Silicosis is associated with inhaled silica (eg, mining, sand blasting); histology demonstrates
nodules composed of whorled collagen fibers and dust-laden macrophages

Erythromycin stimulates upper gastrointestinal motility by acting as an agonist on motilin

receptors in the muscularis externa. Therefore, it can be used to treat gastroparesis (ie,
delayed gastric emptying), a condition that frequently occurs in patients with long standing
diabetes mellitus.

Hyperthyroidism causes increased bone turnover with net bone loss, potentially leading to
osteoporosis. The bone loss is driven by triiodothyronine, which stimulates osteoclast
differentiation, increased bone resorption, and release of calcium.

Ovulation is then induced by administration of human chorionic gonadotropin, which mimics

the LH surge. Menotropin (human menopausal gonadotropin) is a treatment option that acts
like FSH and triggers the formation of a dominant ovarian follicle.

Parvovirus B19 replicates in erythrocyte precursors in the bone marrow. 

The locus ceruleus is a paired brainstem nucleus located in the posterior rostral pons near the
lateral floor of the fourth ventricle and functions as the principal site for norepinephrine
synthesis in the brain.
Urine sediment in acute ureterolithiasis typically shows free red blood cells (hematuria) and
crystals consistent with the type of stone. Ultrasound can reveal ureteral and calyceal dilation
(hydronephrosis), but small stones themselves may not be visible.

  In this case, the peripheral blood smear demonstrates hypochromic, microcytic erythrocytes
and a variety of erythrocyte shapes (poikilocytosis), raising strong suspicion for severe iron
deficiency anemia (IDA).  Young women often develop IDA from heavy menstruation.

Right-sided colon cancers (eg, ascending colon) tend to grow as large, bulky masses that
protrude into the colonic lumen due to the relatively large caliber of the ascending colon. 
They are more likely to bleed and therefore more likely to cause IDA.  The bleeding is usually
occult and detected by positive fecal occult blood testing.  By contrast, left-sided tumors (eg,
rectosigmoid colon) tend to be smaller. 

Inadequate canalization of the ureteropelvic junction, the connection site between the kidney
and the ureter, is the most common cause of unilateral fetal hydronephrosis.

Subgaleal hemorrhage is a potentially fatal neonatal bleed that occurs during delivery when
emissary veins between the dural sinuses and scalp are sheared. The accumulation of blood
between the periosteum and galea aponeurosis presents with a diffuse, progressive, fluctuant
scalp and neck swelling; massive blood loss can lead to shock and death if not promptly
recognized.

In the presence of oxygen, pyruvate produced during glycolysis is converted by pyruvate

dehydrogenase to acetyl coenzyme A, which is subsequently metabolized by oxidative
phosphorylation. However, if inadequate oxygen is present in the tissues, pyruvate is
converted to lactate by lactate dehydrogenase, leading to lactic acidosis.

Under hypoxic conditions, intracellular accumulation of NADH inhibits pyruvate

dehydrogenase.  As a result, increased amounts of pyruvate are converted to lactate by
lactate dehydrogenase which regenerates NAD + from NADH

Prostacyclin (prostaglandin I2) inhibits platelet aggregation and Thromboxane A2 activated

platelets aggregation

Polymerase chain reaction is used to amplify small fragments of DNA (eg, genes, exons,
noncoding regions). For example: the nucleotide sequence of the regions flanking target exon

The disease range is defined by depth of placental invasion: placenta accreta (attachment to
the myometrium), placenta increta (invasion into the myometrium), and placenta percreta
(invasion through the myometrium and serosa).

Placenta accreta disorders occur due to placental invasion through defects in the decidua
basalis of the endometrium, which are commonly caused by uterine scarring from prior
uterine surgery (eg, cesarean delivery, dilation and curettage)

Panic disorder involves recurrent, unexpected panic attacks characterized by an abrupt surge
of fear accompanied by physical and cognitive symptoms. Individuals experience persistent
worry about future attacks and typically restrict their activities as a result.

In patients with mitral regurgitation, left ventricular afterload is determined by the balance of
resistance between forward flow (aortic pressure) and regurgitant flow (left atrial pressure). A
reduction in systemic vascular resistance increases the ratio of forward to regurgitant blood
flow and improves cardiac output.

The pathogenesis of ankylosing spondylitis likely originates with defects in the intestinal
mucosal barrier and exposure to the gut microbiome that lead to an enhanced IL-17–mediated
inflammatory response. IL-17 stimulates production of additional inflammatory factors,
primarily tumor necrosis factor-alpha and prostaglandins, which have synergistic
proinflammatory effects and induce bony erosions and abnormal bone regrowth in the
skeleton.

Repetitive traction at the tibial tubercle due to quadriceps contraction can lead to avulsion and
fragmentation of the tibial tubercle in skeletally immature children, causing Osgood-Schlatter
disease.

Propofol: A highly lipophilic GABA agonist that may be used for long-term sedation.
Disadvantages include vasodilation, which can result in hypotension and an increase in
serum triglycerides and lipase.

Etomidate: A GABA agonist that has the advantage of being the most hemodynamically
neutral. It does not cause changes in heart rate, blood pressure, or cardiac output.
However, it inhibits cortisol synthesis, which can lead to (reversible) adrenocortical
suppression. Because of this, it is often avoided in patients with septic shock, and it
should not be used as maintenance of sedation after induction.

Ketamine: An N-methyl-D-aspartate (NMDA) antagonist that is similar to PCP; it

preserves the respiratory drive during induction of anesthesia. In contrast to propofol
and etomidate, it also provides an analgesic effect. Ketamine stimulates the release of
catecholamines (ie, sympathomimetic), which can cause bronchodilation but also
increase the heart rate, myocardial contractility, and cerebral blood flow, potentially
putting the patient at risk for cardiovascular events or increased intracranial pressure.

Molluscum contagiosum is caused by a poxvirus and presents with small, firm, rounded,
papules that often have a central umbilication(central indentation).

Influenza virus is a segmented, negative-sense RNA virus that is enveloped within a host-
derived plasma membrane. Interaction with the host cell is dependent upon a viral surface
glycoprotein called hemagglutinin, which binds to the sialic acid receptor on human respiratory
epithelial cells.

A chest tube for drainage of pleural effusion is placed through the skin and subcutaneous fat
into the 4th or 5th intercostal space in the anterior axillary or midaxillary line. The tube
traverses through the serratus anterior muscle, intercostal muscles, and parietal pleura.

This patient's disorganization, forgetfulness, excessive procrastination, difficulty completing

tasks, irritability, restlessness, and distractibility are suggestive of adult attention-deficit
hyperactivity disorder (ADHD). Evidence of behavioral problems since childhood (some
symptoms prior to age 12 are required) and the chronic nature of his difficulties further
support this diagnosis. ADHD frequently persists into adulthood and may go unrecognized or
misdiagnosed as an anxiety, mood, or personality disorder.
Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve,
typically due to tight clothing. It presents with pain, paresthesia, and numbness in the lateral
thigh without motor weakness. Risk factors include obesity, pregnancy, and diabetes mellitus.

Penicillins and cephalosporins are common triggers for drug-induced hemolytic anemia
because they can bind to the erythrocyte surface and act as haptens for IgG attachment.
Subsequent clearance of IgG-coated erythrocytes by splenic macrophages leads to hemolytic
anemia. Withdrawal of the offending drug usually leads to complete resolution of symptoms.

Ionizing radiation induces DNA damage (eg, double-strand breakage, free radical generation)
that predominantly affects highly proliferative cells (eg, skin stem cells, hematogenous
progenitors, intestinal crypt cells). These rapidly dividing cells are the first to be lost following
significant radiation exposure, resulting in hair loss, pancytopenia, diarrhea, and
nausea/vomiting.

Medullary thyroid cancer is a neuroendocrine tumor that arises from calcitonin-secreting C

(parafollicular) cells. It is often seen in the context of multiple endocrine neoplasia type 2 (A
and B), although the majority of cases are sporadic. Both sporadic and familial medullary
thyroid cancers are associated with mutations in the RET proto-oncogene

Carotid sinus massage leads to increased afferent firing from the carotid sinus, which in turn,
increases vagal parasympathetic tone.  This slows conduction through the AV node and
prolongs the AV node refractory period, helping to terminate the reentrant tachycardia

Exposure to ionizing radiation (x-rays and gamma rays) causes double-strand DNA breaks. The
fractured ends can be joined by nonhomologous end joining.

The resting membrane potential is the difference in the electrical charges across the cell
membrane under steady-state conditions. The ions that are most permeable to the cell
membrane make the largest contribution to the resting membrane potential. In general, a high
potassium efflux and some sodium influx are responsible for the value of the resting potential,
which is typically about -70 mV.

c-jun es el nombre de un gen que codifica la proteína c-Jun, la cual, tras combinarse con la ...
«Recruitment of the retinoblastoma protein to c-Jun enhances transcription activity mediated.
DNA-binding protein.

Ras is a proto-oncogene that codes for a membrane-bound G-protein.

The β1-adrenergic receptor is a classic Gs-protein-coupled receptor located in the cell

membrane.

S-100 proteins are homodimeric calcium-binding proteins

Arginase is a urea cycle enzyme that produces urea and ornithine from arginine. Arginase
deficiency results in progressive spastic diplegia, growth delay, and abnormal movements.
Treatment includes an arginine-free, low-protein diet.

Group B Streptococcus is a common cause of neonatal meningitis.  Its major virulence factor is
a polysaccharide capsule with abundant sialic acid, which dramatically reduces the
effectiveness of host defense mechanisms due to molecular mimicry
Strongyloides stercoralis is transmitted in tropical/subtropical climates when human
skin comes into direct contact with filariform larvae. The larvae penetrate the skin, enter
the bloodstream, pass through the lungs, and are swallowed into the digestive system.
Common manifestations include linear skin rash and irritative digestive/respiratory
symptoms.
endemic to Southeast Asia (eg, Myanmar), Africa, and the Western Pacific.

  IgA antibodies usually bind to pili and other membrane proteins involved in bacterial
adherence to mucosa, thus inhibiting mucosal colonization by the
microorganism.Certain bacteria (eg, N gonorrhoeae, N meningitidis, Streptococcus
pneumoniae, Haemophilus influenzae)

Porphyria cutanea tarda (PCT) is caused by uroporphyrinogen decarboxylase

(UROD) deficiency, It causes abdominal pain and neuropsychiatric manifestations (due
to metabolite buildup) with photosensitivity.

Psychotropic drugs, including antipsychotics such as aripiprazole; antidepressants, such

as sertraline and amitriptyline; and benzodiazepines are most commonly associated with
increased fall risk. Cardiovascular drugs that reduce circulating blood volume or blood
pressure such as calcium channel blockers (eg, amlodipine), beta blockers, and diuretics
are also associated with falls

Immunosenescense is the normal age-related decline that impairs most aspects of

immune function, including the production of naive B and T cells.

Pathophysiology of benign neonatal hyperbilirubinemia involves increased bilirubin

production and decreased bilirubin conjugation as well as increased enterohepatic
circulation. Indirect hyperbilirubinemia and jaundice typically peak in the first few days
of life and usually resolve without intervention.

Vitamin K-dependent coagulation factors (II, VII, IX, and X) are synthesized in the
liver. Factor VII has the shortest half-life of the coagulation factors. Failure of the
prothrombin time to correct with vitamin K supplementation indicates factor VII
deficiency, which is often due to underlying liver disease

The dorsal pancreatic bud forms the pancreatic tail, body, most of the head, and the
small accessory pancreatic duct. The smaller ventral bud gives rise to the uncinate
process, a portion of the pancreatic head, and the proximal portion of the main
pancreatic duct.

The Weber test is performed by placing a vibrating tuning fork on the middle of
forehead equidistant from both ears.  The vibration carried by bone conduction is
normally heard equally in both ears; vibration heard louder in one ear is abnormal.

The Rinne test compares air versus bone conduction (via the mastoid bone). As the
vibration of the tuning fork fades, air-conducted sound is normally louder and heard
longer than bone-conducted sound. The Rinne test is considered positive (normal) if the
sound is heard best at the external auditory meatus (air conduction) and negative
(abnormal) if the patient hears the vibration better at the mastoid (bone conduction).
The H band is the region of the sarcomere that contains only thick (myosin) filaments.
The H band is the part of the A band (which is on either side of the M line) where thick
filaments have no overlapping thin (actin) filaments.

The patient's history is suggestive of carotid sinus hypersensitivity, triggered by

pressure on the carotid sinus by a tight shirt collar. The carotid sinus baroreceptors are
important in blood pressure control and use arterial wall stretch as an indicator of
systemic blood pressure. The carotid sinus reflex has an afferent limb that arises from
the baroreceptors in the carotid sinus and travels to the medullary centers via the Hering
nerve, a branch of the glossopharyngeal nerve (CN IX).

This patient with right-sided pure hemisensory loss has likely suffered from a thalamic stroke.

Lacunar infarctions are the result of small vessel occlusion (eg, due to lipohyalinosis
and microatheroma formation) in the penetrating vessels supplying the deep brain
structures. Uncontrolled hypertension and diabetes mellitus are major risk factors for
this condition.
Lipohyalinosis occurs secondary to leakage of plasma proteins through damaged
endothelium and is characterized by hyaline thickening of the vascular wall,
collagenous sclerosis, and accumulation of mural foamy macrophages. 
Microatheromas result from atherosclerotic accumulation of lipid-laden macrophages
within the intimal layer of a penetrating artery near its origin off the parent vessel. 
These changes predispose to small-vessel occlusion and infarction of central nervous
system (CNS) tissue with liquefactive necrosis and the formation of a fluid-filled
cavity

The transverse portion of the duodenum lies horizontally at the level of L3, between the aorta
and superior mesenteric artery.

Vibrio vulnificus is a curved, gram-negative, free-living bacterium that grows in marine

environments. Transmission primarily occurs due to the consumption of raw seafood (eg,
oysters) or wound contamination. Manifestations are often mild, but individuals with liver
disease or iron overload are at very high risk of severe, fulminant infection (eg, sepsis,
necrotizing fascitis). Risk factors: liver disease and hemocromatosis.

West Nile virus is a single-strand flavivirus transmitted by mosquitoes, most commonly in the
summer. Most infections are asymptomatic or may present with a flu-like illness (West Nile
fever), often with a maculopapular or morbilliform rash. Neuroinvasive disease manifests as
meningitis, encephalitis, or asymmetric flaccid paralysis; patients may have parkinsonian
features

The coronary sinus communicates freely with the right atrium and will become dilated
secondary to any factor that causes increased right atrial pressure. The most common cause is
pulmonary hypertension, leading to elevated right heart pressures

REM sleep is characterized by dreaming and voluntary muscle paralysis, and occurs more often
during the final third of the night. Nightmares occur during REM sleep and can be
differentiated from sleep terrors, a non-REM parasomnia characterized by incomplete arousals
and lack of recall of dream content
Chronic alcohol consumption can generate reactive oxygen species (ROS), which activate
stellate cells and cause cirrhosis.

The preferred first-line treatment for acute gouty arthritis is a nonsteroidal anti-
inflammatory drug, but these are contraindicated in patients with a recent history of
peptic ulcer. Other treatment options include colchicine and oral or intraarticular
glucocorticoids. Important side effects of colchicine include nausea, abdominal pain,
and diarrhea.

Methimazole and propylthiouracil are thioamide drugs used for treating hyperthyroidism. They
inhibit thyroid peroxidase, the enzyme responsible for both iodine organification and coupling
of iodotyrosines

sympathetic output to the detrusor muscle (provided by postganglionic neurons that release
norepinephrine) would be significantly affected by the medication.

The Jarisch-Herxheimer reaction is an acute inflammatory reaction that occurs within hours of
treatment for spirochetal infections (eg, syphilis). The rapid lysis of spirochetes releases
inflammatory bacterial lipoproteins into the circulation and causes acute fever, rigors, and
myalgias.(Drug induced bacterial cell wall disintegration)

Peripartum cardiomyopathy is a relatively uncommon cause of dilated cardiomyopathy that

may be related to impaired function of angiogenic growth factors. Dilated cardiomyopathy
involves compensatory eccentric hypertrophy, which increases ventricular compliance and also
allows for temporary maintenance of cardiac output. Over time, overwhelming wall stress
leads to left ventricular failure with reduced ejection fraction and symptomatic heart failure.

Hormone-sensitive lipase is found in adipose tissue, where it functions to drive the breakdown
of stored triglycerides into free fatty acids and glycerol. During times of starvation, this enzyme
provides substrates for hepatic gluconeogenesis and ketone body formation.

Orotic acid is a precursor of pyrimidine.

HIV-associated nephropathy is due to viral infection of kidney epithelial cells and typically
manifests with hematuria, hypertension, and edema. Biopsy classically shows focal segmental
glomerulosclerosis and significant interstitial inflammation.

Sporotrichosis typically presents as papulonodular lesions distributed along the lymphatics and
is histologically characterized by granulomatous and neutrophilic inflammation

Ethanol inhibits gluconeogenesis and can cause hypoglycemia once hepatic glycogen stores are
depleted.

Müllerian agenesis (ie, vaginal agenesis or Mayer-Rokitansky-Küster-Hauser syndrome) results

in hypoplasia/aplasia of the müllerian structures (ie, uterus/cervix/upper vagina/fallopian
tubes), leading to variable uterine development (eg, rudimentary uterus) with no upper
vagina (eg, shortened vagina with blind vaginal pouch).

A complete hydatidiform mole usually results when an empty ovum is fertilized by a haploid
sperm. Subsequent duplication of the paternal genetic complement (23X) results in the
characteristic 46,XX genotype.
Trastuzumab is a monoclonal antibody that blocks human epidermal growth factor receptor-2
(HER2) to disrupt malignant cell signaling and encourage apoptosis. Because HER2 helps
preserve cardiomyocyte function, trastuzumab can cause cardiotoxicity that manifests as a
decrease in myocardial contractility without cardiomyocyte destruction or myocardial fibrosis.

Because prostate cancer is an androgen-dependent tumor, patients with advanced disease are
generally treated with surgical or medical orchiectomy. Medical orchiectomy uses GnRH
analogues (buserelin) to reduce LH production, which subsequently reduces androgen
production in the testes. Because there is an initial surge in androgens at the start of therapy
(due to stimulation of the GnRH receptor), patients prescribed GnRH therapy are usually
treated with a few weeks of androgen-receptor inhibitors (eg, bicalutamide).

Hearing loss pte tips: Decreasing background noise Facing the patient directly when speaking
and refraining from touching the face or mouth Speaking clearly and loudly (ie, natural
amplification) without shouting or shrieking, which distorts the sound of speech Speaking at a
normal pace because speaking too slowly can decrease contextual clues and make it hard for
patients to understand

The brachiocephalic vein drains the ipsilateral jugular and subclavian veins. The bilateral
brachiocephalic veins combine to form the superior vena cava (SVC). Brachiocephalic vein
obstruction causes symptoms similar to those seen in SVC syndrome, but only on one side of
the body. This may be the result of external compression by an apical lung tumor or
thrombotic occlusion as can occur when a central catheter has been in place for an extended
period.

Polyethylene glycol is an osmotic laxative.

Peripheral chemoreceptors found in the carotid and aortic bodies are the primary sites for
sensing PaO2 and are stimulated by hypoxemia. When supplemental oxygen is administered,
the rapid increase in PaO2 can reduce peripheral chemoreceptor stimulation and decrease the
respiratory rate.

Normal aging is characterized by a gradual increase in ventilation-perfusion mismatch (due to

basilar microatelectasis causing shunt effect) and increased dead space (loss of alveolar
surface area).  This manifests as a wider alveolar-arterial oxygen gradient (ie, decline in PaO 2)
without hypoventilation (normal PaCO2).

The blood supply to the proximal ureter comes from branches of the renal artery. At the distal
ureter, arterial blood supply arises from the superior vesical artery. In between, the arterial
supply to the ureter is anastomotic and highly variable, with possible afferent branches from
the gonadal, common and internal iliac, aorta, and uterine arteries.

P50 refers to the partial pressure of oxygen at which hemoglobin is 50% saturated.
Hemoglobins with high oxygen affinity have a decreased P50 that is represented by a leftward
shift of the oxygen dissociation curve. The reduced ability to release oxygen within the
peripheral tissues leads to renal hypoxia, increased erythropoietin synthesis, and
compensatory erythrocytosis.

C. immitis is endemic to the southwestern United States (i.e., southern and central California,
Arizona, New Mexico, and western Texas), northern Mexico, and some regions of Central and
South America. 
Atrial fibrillation is recognized by an irregularly irregular rhythm with variable R-R intervals and
absence of P waves on ECG. The development of AF most commonly involves ectopic electrical
foci in the pulmonary veins that trigger fibrillatory conduction in abnormal (remodeled) atrial
tissue.

Tetanus is a clinical diagnosis that should be suspected in patients who have characteristic
symptoms (eg, lockjaw, muscle pain/spasms, difficulty swallowing), particularly if they are
unlikely to be adequately vaccinated or have an antecedent cutaneous injury.

However, an absence of HLA-DR+ cells indicates defective expression of major

histocompatibility complex (MHC) class II molecules. Impared of presentation processed in
lysosomes

Saccular (berry) aneurysms are the most common cause of SAH. These aneurysms
usually occur at the circle of Willis, with the anterior communicating artery being the
most common site. Berry aneurysms are associated with Ehlers-Danlos syndrome and
autosomal dominant polycystic kidney disease. Arteriovenous malformations also
predispose certain individuals to SAH. Berry aneurysms of the circle of Willis are
associated with autosomal dominant polycystic kidney disease.

Patients with advanced or castration-resistant prostate cancer are often treated with an 17-
alpha-hydroxylase inhibitors (eg, abiraterone), which block the generation of androgens in the
adrenal glands, testes, and tumor cells. This reduces systemic androgen levels, which limit
prostate cancer growth.

Using a much smaller threshold for the p-value is a method to minimize this. For this reason, a
p-value of 5 × 10−8 ("genome-wide p-value"), as seen here, is often chosen in GWAS.

Elastase is a neutral protease contained in macrophage lysosomes and in the azurophilic

(primary) granules of neutrophils.
alpha-1 antitrypsin is considered to be the primary source of AAT, local production by
monocytes, macrophages, and epithelial cells may contribute to the formation

Isoniazid is an antimycobacterial agent that specifically inhibits the synthesis of mycolic acids,
which are essential components of the unique mycobacterial peptidoglycan cell wall. Without
mycolic acids, the mycobacteria lose their acid-fastness and become unable to synthesize new
cell walls or multiply.

Turner syndrome is a genetically heterogeneous condition that is most commonly due to

meiotic nondisjunction during gametogenesis

Iron absorption occurs predominantly in the duodenum and proximal jejunum, and
bypass of this segment of small bowel results in iron deficiency anemia. Deficiency
involving thiamine, folate, vitamin B12, fat-soluble vitamins (especially vitamin D),
and calcium is also common following gastrojejunostomy.

Intense exercise creates a high demand for ATP, and the primary method of ATP production
varies with the duration of exercise. The phosphocreatine shuttle is the primary source of ATP
at the beginning of exercise, followed sequentially by anaerobic glycolysis and then oxidative
phosphorylation.
Binding of IFN-γ to its receptor on a macrophage causes transcription of IFN-γ-regulated genes
through activation of the JAK-STAT signaling pathway.

Most available rodenticides contain brodifacoum, a long-acting 4-hydroxycoumarin

derivative. A patient who has ingested a quantity of rodenticide sufficient to cause
coagulopathy and abnormal bleeding (similar to warfarin toxicity) requires immediate
treatment with fresh frozen plasma in addition to vitamin K.

Cryoprecipitate (precipitate obtained from FFP by centrifugation/thawing) contains

factor VIII, factor XIII, von Willebrand factor, and fibrinogen.

Vitamin A overuse can result in intracranial hypertension, skin changes and

hepatosplenomegaly.

Paroxysmal supraventricular tachycardia. Treatment can be with vagal stimulation, such

as carotid sinus massage or the Valsalva maneuver
The rectus abdominis is the most important muscle in achieving the increased
intraabdominal and intrathoracic pressure.

Mefloquine is a schizonticide that actively destroys replicating parasites within red blood cells.
However, it is inactivated in the liver and has no efficacy against hepatic schizonts.

Transposition of the great arteries is characterized by parallel circulations of

deoxygenated and oxygenated blood. Initial management includes maintaining a left-to-
right mixing lesion (eg, patent ductus arteriosus, patent foramen ovale) to provide
systemic circulation with partially oxygenated blood
For example, administration of prostaglandin E1 maintains patency of the ductus
arteriosus.

Neonatal hypoglycemia is common in infants of diabetic mothers. The pathophysiology

involves maternal hyperglycemia, which in turn causes fetal hyperglycemia and compensatory
hyperfunctioning of the pancreas (ie, hyperinsulinemia). After birth, persistently elevated
insulin levels lead to transient hypoglycemia.

All patients with a major depressive episode should be screened for a past history of manic
episodes to differentiate major depressive disorder (unipolar depression) from bipolar
disorder. This is particularly relevant in this patient as his atypically rapid response to the
selective serotonin reuptake inhibitor sertraline is suggestive of treatment-emergent mania. If
further history substantiates a diagnosis of bipolar disorder, antidepressant monotherapy
should be avoided, as all antidepressants carry a risk of inducing mania.

Anthracycline chemotherapeutic agents (eg, doxorubicin, daunorubicin) cause

cardiotoxicity mainly through the formation of anthracycline–topoisomerase II DNA
cleavage complexes that affect healthy cardiomyocytes. it manifests as dilated
cardiomyopathy. preventing administration of dexrazoxane,( a chelating)

The recurrent laryngeal nerve travels in close proximity to the inferior thyroid artery and can
be injured during thyroid surgery, resulting in vocal cord paralysis (eg, hoarseness).
Patients with hematologic malignancies that have high tumor cell burdens or rapid turnover
rates are at high risk for electrolyte abnormalities following the initiation of cytotoxic
chemotherapy due to the massive lysis of tumor cells. Patients generally develop
hyperphosphatemia, hyperkalemia, hyperuricemia, and elevated lactate dehydrogenase.

The brachial artery runs alongside the median and ulnar nerves in the medial bicipital groove
of the upper arm. Proximal to the elbow, the median and ulnar nerves diverge, and the
brachial artery continues with the median nerve through the cubital fossa. Injury to the
median nerve at the cubital fossa frequently injures the brachial artery.

Cancer immunotherapy(HER) often includes the administration of monoclonal antibodies

against a target overexpressed on the cancer cell surface. The Fc portion of the bound
antibody is identified by natural killer cells via CD16, leading to antibody-dependent cellular
cytotoxicity via the release of granzymes and perforin.

Mycophenolate is an immunosuppression drug used to prevent organ transplant rejection. It

functions via the inhibition of inosine 5'-monophosphate dehydrogenase (IMPDH), an enzyme
in the de novo purine synthesis pathway.

Sirolimus inhibits the mammalian target of rapamycin (mTOR) to interrupt IL-2 signal
transduction and provide relatively specific lymphocyte suppression.
Tacrolimus and cyclosporine inhibit calcineurin to block transcription of IL-2

During the normal cardiac cycle, central aortic pressure is higher than right ventricular
pressure during systole and diastole. Consequently, an intracardiac fistula between the aortic
root and right ventricle will most likely demonstrate a left-to-right cardiac shunt as blood
continuously flows from the aortic root (high pressure) to the right ventricle (low pressure).

The pulmonary vascular bed is unique in that tissue hypoxia results in a vasoconstrictive
response. Such hypoxic vasoconstriction occurs in the small muscular pulmonary arteries to
divert blood flow away from underventilated lung regions and toward well-ventilated lung
areas to minimize ventilation-perfusion mismatch, leading to more efficient overall gas
exchange.

Craniopharyngiomas are suprasellar tumors found in children and composed of calcified cysts
containing cholesterol crystals. They arise from remnants of Rathke's pouch, an embryonic
precursor of the anterior pituitary.

A health maintenance organization (HMO) is an insurance plan with low monthly premiums,
low copayments and deductibles, and low total cost for the patient. HMOs reduce utilization
by confining patients to a limited panel of providers, requiring referral from a primary care
provider prior to specialist consultations, and denying payment for services that do not meet
established guidelines.

Temporomandibular joint disorder is associated with dysfunction of the temporomandibular

joint and hypersensitivity of the mandibular nerve (CN V3). This can result in pathologic
contraction of the muscles of mastication, including the masseter and pterygoids.

Antibody-drug conjugates improve drug efficacy and minimize toxicity by allowing

conventional chemotherapeutic agents (eg, cisplatin) to selectively target and kill cancer cells
while sparing healthy cells (ie, targeted delivery).
The human leukocyte antigen (HLA) genes encode major histocompatibility complex (MHC)
molecules that are key to activation of the immune system in response to foreign (non-self)
antigens. All the HLA genes are clustered together, meaning that there is a low rate of
crossover and that offspring essentially inherit 2 HLA haplotypes, one from each parent.
Therefore, the probability that a sibling would be an identical HLA match is 1/4.

Osteoporosis is a common cause of fragility fractures, which occur in the absence of significant
trauma. Chronic or recurrent use of glucocorticoids (eg, prednisone) promotes osteoporosis
and increases the risk of fractures.

Norepinephrine-dopamine reuptake inhibitors (eg, methylphenidate, atomoxetine) are central

stimulants. They can promote wakefulness to treat narcolepsy or enhance concentration to
treat attention deficit hyperactivity disorder.