Clinicals Most Common

CLINICALS MOST COMMON
GLOBAL INSTITUTE OF MEDICAL SCIENCES

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Terms Definitions
PO2 driving force for diffusion of O2 into tissue
SaO2 percent heme groups occupied by O2
Cyanosis decreased O2 saturation (SaO2); O2 content
Oxygen electron acceptor in oxidative pathway
Hypoxia inadequate O2 leads to ATP depletion
Ischemia decreased arterial (or venous) blood flow
Respiratory acidosis retention of CO, always decreases PaO2
impaired delivery of O2 to alveoli;

Ventilation defect
intrapulmonary shunting of blood (e.g., RDS)
absent blood flow to alveoli; increased alveolar

Perfusion defect
dead space (e.g., pulmonary embolus)
O2 cannot cross alveolar-capillary interface;

Diffusion defect
interstitial lung disease (e.g., sarcoidosis)
↓ SaO2; heme Fe+3; oxidizing agents

Methemoglobin
(sulfur/nitro drugs); Rx with IV methylene blue
cyanosis not corrected by O2; chocolate

Clinical methemoglobinemia
colored blood
↓ SaO2; left-shift O2 binding curve; inhibits

Carbon monoxide
cytochrome oxidase
Causes carbon monoxide poisoning car exhaust, space heaters, smoke inhalation
S/S carbon monoxide poisoning headache; cherry red color skin
inhibits cytochrome oxidase; systemic

Cyanide
asphyxiant

Carbon monoxide + cyanide

house fires
poisoning
↓ 2, 3 BPG, carbon monoxide, alkalosis, HbF,

Left-shifted O2 curve
methemoglobin, hypothermia
Right-shifted O2 curve ↑ 2, 3 BPG, high altitude, acidosis, fever
respiratory alkalosis enhances glycolysis; ↑

High altitude
synthesis 2,3 BPG
damages membrane and drains off protons;

Mitochondrial poisons
alcohol, salicylates
drain off protons; dinitrophenol, thermogenin

Uncoupling agents in mitochondria
(brown fat)
Complication mitochondrial
hyperthermia
poisons/uncoupling agents
impaired Na+/K+ ATPase pump (cellular

Decreased ATP
swelling); reversible
ATP synthesis in hypoxia; lactate ↓ intracellular

Anaerobic glycolysis
pH, denatures proteins
Irreversible injury hypoxia membrane/mitochondrial damage
Mitochondrial damage release cytochrome c activates apoptosis
↑ cytosolic Ca2+ activates phospholipase,

Irreversible injury hypoxia
proteases, endonuclease
unpaired electron in outer orbit; damage cell

Free radicals
membranes and DNA
superoxide, hydroxyl, peroxide, drugs

Free radicals
(acetaminophen)
Superoxide dismutase neutralizes superoxide
Glutathione neutralizes peroxide, drug FRs

Catalase neutralizes peroxide
indigestible lipid of lipid peroxidation; brown

Lipofuscin
pigment increased in atrophy and FR damage
Reperfusion injury in heart superoxide FRs + calcium
Mitochondrial injury cytochrome c in cytosol initiates apoptosis
SER hyperplasia alcohol, barbiturates, phenytoin
increases drug metabolism (e.g., oral

Complications SER hyperplasia
contraceptives); low vitamin D
membrane protein defect in transferring

Chediak-Higashi
lysosomal enzymes to phagocytic vacuoles
Chediak-Higashi AR; giant lysosomes
absent enzyme marker in Golgi apparatus

I cell disease
(mannose 6-phosphate); empty lysosomes
Rigor mortis stiff muscles after death due to ATP depletion
MCC alcohol (increase in NADH); DHAP → G3P

Fatty change in liver
→ TG
Fatty change in liver VLDL pushes nucleus to side
↑ synthesis TG/FAs, beta-oxidation of FAs,

Causes fatty change
synthesis apoproteins/release VLDL
Fatty change in kwashiorkor ↓ synthesis of apoproteins
primary iron storage protein; soluble in blood;

Ferritin
serum level reflects marrow storage iron
insoluble ferritin degradation product visible

Hemosiderin
with Prussian blue stain
reduction in cell/tissue mass by either loss or

Atrophy
cell shrinkage

Brain atrophy ischemia; Alzheimer's
Exocrine gland atrophy in CF duct obstruction by thick secretions
Labile cells stem cells (skin, marrow, GI tract) →←→⇦
in G0 phase (smooth muscle, hepatocytes); can

Stable cells
enter cell cycle (growth factors, hormones)
cannot replicate; cardiac/striated muscle;

Permanent cells
neurons
increase in cell size (structural components,

Hypertrophy
DNA)
increased preload (valve regurgitation),

LVH increased afterload (hypertension, aortic
stenosis)
RVH pulmonary hypertension
Bladder smooth muscle hypertrophy prostate hyperplasia constricts urethra
Removal of kidney hypertrophy of remaining kidney
Hyperplasia increase in number of cells
Endometrial hyperplasia unopposed estrogen (obesity, taking estrogen)
increased EPO (blood loss, ectopic secretion,

RBC hyperplasia
high altitude)
Prostate hyperplasia increased dihydrotestosterone (DHEA)
hyperplasia male breast tissue; normal in

Gynecomastia
newborn, adolescent, elderly
Metaplasia one adult cell type replaces another cell type
Squamous metaplasia in bronchus smoking
Paneth cells, goblet cells; H pylori chronic

Intestinal metaplasia in stomach
atrophic gastritis

Squamous metaplasia bladder Schistosoma hematobium infection
glandular metaplasia of distal esophagus; due

Barrett's esophagus
to GERD
atypical hyperplasia and metaplasia are

Dysplasia
precursors for cancer
Squamous dysplasia in cervix human papilloma virus
Squamous dysplasia in bronchus smoking
Necrosis death of groups of cells
preservation of structural outline (due to ↑

Coagulation necrosis
lactic acid)
pale (e.g., heart, kidney); hemorrhagic (e.g.,

Infarction
lung, small bowel); dry gangrene
Liquefactive necrosis brain infarct, bacterial infections; wet gangrene
variant coagulation necrosis; granulomas due

Caseous necrosis
to TB/systemic fungi
activated macrophages (epithelioid cells);

Granulomas
multinucleated giant cells; CD4 TH1 cells
γ-interferon released by CD4 T cells activates

Epithelioid cells
macrophages
Multinucleated giant cells fusion of epithelioid cells
Granulomas type IV hypersensitivity
associated with pancreatitis; soap formation

Enzymatic fat necrosis
(Ca2+ + fatty acids)
necrosis of immune reactions (immune

Fibrinoid necrosis
vasculitis/endocarditis)
Postmortem necrosis autolysis; no inflammatory reaction

calcification of damaged tissue; normal serum

Dystrophic calcification
calcium
Dystrophic calcification pancreatitis; atherosclerotic plaque
calcification of normal tissue; increased serum

Metastatic calcification
calcium or phosphorus
metastatic calcification of collecting tubule

Nephrocalcinosis
basement membranes
polyuria due to nephrogenic diabetes insipidus;

S/S nephrocalcinosis
renal failure
Apoptosis gene regulated individual cell death
mullerian inhibitory factor, tumor necrosis

Signals activating apoptosis
factor, hormone withdrawal
Signal modulators of apoptosis TP53 suppressor gene, BCL-2 genes
anti-apoptosis gene; prevents cytochrome c

BCL-2 genes
from leaving mitochondria
responsible for enzymatic cell death in

Caspases
apoptosis; proteases and endonucleases
eosinophilic cytoplasm, pyknotic (ink dot)

Markers of apoptosis
nucleus
loss Mullerian epithelium in male fetus; thymus

Apoptosis
involution; killing cancer cells
key chemical in acute inflammation; mast cell;

Histamine
arteriole vasodilation; ↑ venular permeability
Rubor acute inflammation redness; arteriole vasodilation (histamine)
Calor acute inflammation heat; arteriole vasodilation (histamine)
Tumor acute inflammation swelling; ↑ vessel permeability (histamine)
Dolor acute inflammation pain; bradykinin, PGE

Acute inflammation neutrophil dominant; ↑ IgM
transient vasoconstriction → arteriolar

Initial vessel events
vasodilation → ↑ venular permeability
Neutrophil rolling acute

due to selectins
inflammation
neutrophil adhesion molecules; C5a and

Integrins
leukotriene B, activate; neutrophil margination
CD11/CD18 markers for integrins
Endothelial cell adhesion molecules activated by IL-1 and TNF
ICAM intercellular adhesion molecule
vascular cell adhesion molecule Leukocyte

VCAM
adhesion molecule defect
Activation neutrophil adhesion

neutrophilic leukocytosis; corticosteroids
molecules
Activation neutrophil adhesion

neutropenia; endotoxins
molecules
Chemotaxis directed movement; C5a and LTB4
Opsonizing agents IgG, C3b; enhance phagocytosis
Neutrophils, monocytes,
receptors for IgG, C3b
macrophages
most potent microbicidal system; neutrophils,

O2-dependent MPO system
monocytes
NADPH oxidase with NADPH cofactor; produces

ProductionofsuperoxidefromO2
respiratory burst
Nitro blue tetrazolium (NBT) test for respiratory burst
Superoxide dismutase converts superoxide to peroxide

lysosomal enzyme that combines peroxide + Cl

Myeloperoxidase
to form bleach (HOCl)
chronic granulomatous disease childhood (XR),

Microbicidal defects
myeloperoxidase deficiency (AR)
Chronic granulomatous disease absent NADPH oxidase; no respiratory burst
Staphylococcus aureus not killed (catalase

Chronic granulomatous disease
positive)
Chronic granulomatous disease Streptococcus killed (catalase negative)
AR; respiratory burst present; no bleach

Myeloperoxidase deficiency
produced
Bruton's agammaglobulinemia (XR, decreased

Opsonization defect
IgG)
Chediak-Higashi (see cell injury); also has

Phagocytosis defect
defect in microtubule polymerization
non-steroidals (non-selective), selective COX-2

COX inhibitors
inhibitors
PGE2 vasodilation, fever
PGI2 vasodilator; prevent platelet aggregation
vasodilator; FR gas from conversion arginine to

Nitric oxide
citrulline
fever, synthesis acute phase reactants in liver,

IL-1 and TNF
leukocytosis
stimulated by IL-1; stimulates synthesis of

IL-6
acute phase reactants
Acute phase reactants fibrinogen, ferritin, C-reactive protein
kinin produced in conversion of factor XII to

Bradykinin
factor XI

pain, vasodilator, vessel permeability;

Bradykinin
cough/angioedema, ACE inhibitors
C3a and C5a; directly stimulate mast cell

Anaphylatoxins
release of histamine
synthesized by endothelial cells; vasodilator,

Prostaglandin I2
inhibits platelet aggregation
Lipoxygenase hydroxylation of arachidonic acid
Zileuton inhibits lipoxygenase
Zafirlukast, montelukast block lipoxygenase receptor
LTC4, -D4, -E4 bronchoconstrictors
synthesized by platelets; platelet aggregation,

TXA2
vasoconstriction, bronchoconstriction
Dipyridamole inhibits thromboxane synthase
inhibits phospholipase A2, activation neutrophil

Corticosteroids
adhesion molecules
neutrophilic leukocytosis, lymphopenia,

Corticosteroids
eosinopenia
right shift OBC; hostile to bacterial/viral

Fever
replication
Chronic inflammation monocyte/macrophage; ↑ IgG; repair by fibrosis
cellular immunity; macrophages interact with

Granuloma
TH1 class cells (memory cells)
Langerhan's cells process PPD and interact with

Positive PPD
TH1 class cells
Suppurative inflammation abscess; Staphylococcus aureus (coagulase)
subcutaneous inflammation; Streptococcus

Cellulitis
pyogenes (hyaluronidase)

toxins from Corynebacterium diphtheriae,

Pseudomembranous inflammation
Clostridium difficile
Cell cycle key checkpoint G1 to S phase
arrests cell in G1 phase for DNA repair or

TP53 and RB suppressor genes
apoptosis
stimulates apoptosis; activated by TP53

BAX gene
suppressor gene if too much DNA damage
Extracellular matrix basement membrane, interstitial matrix
cell must be capable of duplication, no damage

Complete restoration
to basement membrane
Scar tissue end-product of repair by connective tissue
Collagen triple helix of cross-linked α chains
cross-links at points of hydroxylation (lysyl

Collagen
oxidase) increase tensile strength
Type I collagen bones, tendons
Type II collagen early wound repair
Type IV collagen basement membrane
Type X collagen epiphyseal plate
Laminin key basement membrane glycoprotein
Fibronectin key interstitial matrix glycoprotein
basic fibroblast growth factor, vascular

Angiogenesis in repair
endothelial growth factor
granulation tissue formation; fibronectin

Key event in wound repair
responsible
Granulation tissue becomes scar tissue
Collagenases zinc cofactor (metalloprotease); type III collagen

replaced by type I collagen
Tensile strength of healed wound 80% original strength
Inhibition wound healing infection (MCC S. aureus), zinc deficiency, DM
defects in collagen synthesis and structure;

Ehlers-Danlos syndrome
hyperelasticity
↓ collagen tensile strength by decreasing cross-

Scurvy
links at points of hydroxylation
Keloid excessive type III collagen; common in blacks
exuberant granulation tissue; bleeds when

Pyogenic granuloma
touched
clean wound; appose wound margins with

Healing by primary intention
suture
infected wound; leave wound open;

Healing by secondary intention
myofibroblasts important
regenerative nodules; abnormal

Liver injury
cytoarchitecture
Lung injury type II pneumocyte repair cell
CNS injury astrocyte and microglial cell repair cells; gliosis
WBC alterations in acute neutrophilic leukocytosis, left shift, toxic

inflammation granulation
Erythrocyte sedimentation rate increased fibrinogen enhances rouleaux
indicator of acute inflammation and

C-reactive protein
inflammatory atheromatous plaque
diffuse ↑ of γ-globulins; ↑ IgG; chronic

Polyclonal gammopathy
inflammation
Total body water ECF (plasma, interstitial fluid) + ICF (cytosol)

H20 shift between ECF and ICF; controlled by

Osmosis
serum Na+ and glucose
increased fluid in interstitial space or body

Edema
cavities; transudate, exudate, lymph
protein and cell-poor fluid in interstitial

Transudate
space/body cavity; alteration Starling's forces
oncotic pressure (albumin) keeps fluid in

Starling's forces
vessels, hydrostatic pressure pushes fluid out
decreased oncotic pressure and/or increased

Pitting edema
hydrostatic pressure
pulmonary edema in LHF; pitting edema of legs

↑ Hydrostatic pressure
in RHF; portal hypertension
Renal retention sodium and water ↑ hydrostatic pressure and ↓ oncotic pressure
Causes of renal retention of ↓ cardiac output (activation RAA system),

sodium/water primary renal disease
↓ Oncotic pressure
kwashiorkor; nephrotic syndrome; cirrhosis
(hypoalbuminemia)
Ascites in cirrhosis ↓ oncotic pressure, ↑ hydrostatic pressure
protein and cell rich (pus); acute inflammation

Exudate
with ↑ vessel permeability
radical mastectomy; filariasis; inflammatory

Lymphedema
carcinoma (lymphatics plugged by tumor)
Thrombus endothelial injury, stasis, hypercoagulability
fibrin clot with entrapped RBCs, WBCs,

Venous thrombus
platelets; deep veins below knee (stasis)
anticoagulants that prevent venous clot

Heparin/warfarin
formation

endothelial injury; platelets held together by

Arterial thrombus
fibrin
Aspirin prevents platelet thrombus in arteries
Pulmonary thromboembolism femoral vein site of origin
Systemic thromboembolism majority from left heart
long bone fractures; delayed symptoms (48

Fat embolus
hrs); thrombocytopenia, hypoxemia
Amniotic fluid embolism DIC; lanugo hair in maternal pulmonary arteries
1 atmosphere pressure increase with 33 foot

Diving
descent into water; N2 gas dissolved in tissue
release of N2 gas from tissue with rapid ascent;

Decompression sickness
ischemic damage
Dyspnea, chest pain underwater pulmonary embolus
Dyspnea, chest pain rising to

spontaneous pneumothorax
surface
Hypovolemic shock (blood loss) ↓ CO and LVEDP; ↑ PVR
Cardiogenic shock ↓ CO; ↑ LVEDP and PVR
Septic shock ↑ CO (↑ venous return); ↓ PVR (vasodilation)
most susceptible organ in shock; straight

Kidneys
portion proximal tubule most susceptible
ischemic ATN, multiorgan failure, ↑ AG

Shock complications
metabolic acidosis
Tumors parenchyma neoplastic component
epithelial (e.g., adenoma) or connective tissue

Benign tumors
(e.g., lipoma, leiomyoma)
Carcinoma epithelial origin; squamous cell carcinoma,

adenocarcinoma, transitional cell carcinoma
Basal cell carcinoma invades but does not metastasize
lower lip, oral pharynx, larynx, lung,

Squamous cell carcinoma
esophagus, skin, cervix
distal esophagus → colon, kidney, liver,

Adenocarcinoma
pancreas, prostate, breast, lung, endometrium
Transitional cell carcinoma renal pelvis, ureter, bladder
malignancy of connective tissue origin; e.g.,

Sarcoma
osteogenic sarcoma (bone)
Liposarcoma MC sarcoma in adults
Embryonal rhabdomyosarcoma MC sarcoma in children
ectoderm, endoderm, mesoderm derivatives;

Teratoma
bone/teeth visible on x-ray
normal tissue, normal site; bronchial

Hamartoma
hamartoma, Peutz Jeghers polyp
normal tissue aberrant tissue location;

Choristoma
pancreatic tissue stomach wall
different morphologic patterns, same germ cell

Mixed tumor
layer; pleomorphic adenoma parotid
Leukemia malignancy of stem cells in bone marrow
Lymphoma malignancy of lymph nodes
Extranodal lymphoma sites stomach (MC), Peyer's patches
Malignant tumors invade and metastasize; benign tumors do not
increases telomere length; found in all

Upregulate telomerase
neoplastic cells
Monoclonality key finding in neoplastic vs. normal cells

intercellular adhesion; lose adhesion in

E-Cadherin
malignant cells
receptors for laminin (basement membrane),

Malignant cells
fibronectin (ECM)
Invasion enzyme type IV collagenase (basement membrane)
basic fibroblast growth factor, vascular

Angiogenesis
endothelium growth factor
lymphatic, hematogenous, seeding; often more

Metastasis
common than primary cancer
Carcinoma lymph node -> hematogenous
renal cell carcinoma (renal vein, vena cava),

Vessel invading carcinomas
hepatocellular carcinoma
Sarcoma hematogenous
ovarian cancer, periphery lung, CNS via spinal

Seeding
fluid
Sites where metastasis more

lung, bone, brain, liver, adrenal
common primary cancer
Sites where primary cancer more

GI tract, kidney, urogenital
common than metastasis
osteoblastic (radiodense); osteolytic

Bone metastasis
(radiolucent)
Bone sites metastasis vertebra MC (Batson venous plexus)
prostate cancer; increased serum AP,

Osteoblastic metastasis
hypercalcemia
Osteolytic metastasis breast cancer
carcinoid tumors, small cell carcinoma,

EM neurosecretory granules
neuroblastoma

EM thin and thick myofilaments rhabdomyosarcoma
EM Birbeck granules histocytic neoplasms (Langerhan's histiocytosis)
Primary prevention stop smoking; sun screen; high fiber diet
leukemia (MC), CNS tumors, Burkitt's, Ewing's,

Cancers in children
neuroblastoma
hepatitis B vaccine; prevents hepatocellular

Cancer vaccine
carcinoma
Cancer incidence men prostate → lung → colorectal
Cancer incidence women breast → lung → colorectal
Cancer mortality men lung → prostate → colorectal
Cancer mortality women lung → breast → colorectal
Gynecologic cancers endometrium → ovary → cervix
decreased incidence of cervical cancer; detects

Cervical Pap smear
cervical dysplasia
Malignant melanoma fastest increasing in world
Southeast China nasopharyngeal carcinoma (EBV)
Southeast Asia hepatocellular carcinoma (HBV + aflatoxin)
Japan stomach cancer
Africa Burkitt's lymphoma, Kaposi sarcoma (HHV-8)
Squamous dysplasia oropharynx,

risk for squamous cell carcinoma (SCC)
larynx, bronchus, cervix
Chronic irritation sinus orifices,

risk for SCC
third degree burn scars
Actinic (solar) keratosis risk factor for SCC
Glandular metaplasia of esophagus risk factor for adenocarcinoma

(Barrett's)
Endometrial hyperplasia risk factor for adenocarcinoma
Glandular (intestinal) metaplasia of

risk factor for adenocarcinoma
stomach (Helicobacter)
Chronic ulcerative colitis risk factor for adenocarcinoma
Villous adenoma of rectum risk factor for adenocarcinoma
Tubular adenoma of colon risk factor for adenocarcinoma
Scar tissue in lung risk factor for adenocarcinoma
Regenerative nodules in cirrhosis risk factor for hepatocellular carcinoma
Complete hydatidiform mole risk factor for choriocarcinoma
Dysplastic mole MC risk factor for malignant melanoma
UVB light MC risk factor for BCC, SCC, melanoma
HHV-8 MC risk factor for Kaposi's sarcoma
EBV MC risk factor for nasopharyngeal carcinoma
Polycyclic hydrocarbons MC risk factor for larynx (SCC), lung cancers
Asbestos MC risk factor for mesothelioma
MC risk factor for oral cavity, mid-esophagus

Polycyclic hydrocarbons
SCC
MC risk factor for distal esophagus

Barrett's esophagus
adenocarcinoma
MC risk factor for stomach adenocarcinoma

H. pylori
and lymphoma
Tubular adenoma, villous adenoma MC risk factors for colon adenocarcinoma
HBV and HCV MC risk factors for hepatocellular carcinoma
Vinyl chloride MC risk factor for liver angiosarcoma

Gallstones, porcelain gallbladder MC risk factor for gallbladder adenocarcinoma
Polycyclic hydrocarbons MC risk factor for pancreas adenocarcinoma
Polycyclic hydrocarbons MC risk factor for renal cell carcinoma
Polycyclic hydrocarbons MC risk factor for urinary bladder
HPV + lack of circumcision MC risk factor for penis SCC
Age MC risk factor for prostate adenocarcinoma
Cryptorchid testis MC risk factor for seminoma
Age >50 with excess estrogen MC risk factor for breast and endometrial
exposure carcinoma
HPV 16/18 MC risk factor for vulva, vagina, cervix SCC
MC risk factor for vagina/cervix clear cell

DES
carcinoma
MC risk factor for surface derived ovarian

Nulliparity
cancer
Complete mole MC risk factor for choriocarcinoma
Turner syndrome (XO) MC risk factor for dysgerminoma of ovary
Turner syndrome (XO/XY) gonadoblastoma of ovary
Ionizing radiation MC risk factor for papillary cancer of thyroid
Family history (MEN IIa/IIb) MC risk factor for medullary carcinoma thyroid
Hashimoto's thyroiditis MC risk factor for malignant lymphoma thyroid
Ionizing radiation MC risk factor for osteogenic sarcoma
MC risk factor for primary CNS lymphoma in

EBV
AIDS and Burkitt's lymphoma
MC risk factor for acute/chronic myelogenous

Ionizing radiation
leukemia

EBV MC risk factor for Burkitt's lymphoma
HTLV-1 MC risk factor for T cell leukemia/lymphoma
H. pylori (stomach adenocarcinoma and

Bacterial causes of cancer
lymphoma)
S. hematobium (SCC bladder), C. sinensis

Parasitic causes of cancer
(cholangiocarcinoma)
Carcinogenesis mutations involving regulatory genes
proto-oncogenes, suppressor genes, anti-

Regulatory genes
apoptosis genes
point mutation MC, translocation, amplification

Types mutations
(↑ copies), overexpression (↑ activity)
Burkitt's t(8;14); CML t(9;22); follicular

Translocations
lymphoma t(14;18); APL leukemia t(15;17)
Key cancer genes TP53 suppressor gene, RAS protooncogene
inactivates suppressor genes (e.g., TP53),

Point mutation
activates proto-oncogenes (e.g., RAS)
Amplification activates ERB-B2
Overexpression enhances activity of BCL-2
function-growth factor synthesis; mutation-

S/S POC
overexpression
function growth factor receptor; activation bad

ERB-B2 POC
prognostic sign for breast carcinoma
function-GTP signal transduction; point

RAS POC
mutation; 30% of all human cancer
function-non-receptor tyrosine kinase activity;

ABL POC
translocation (9;22) causing CML
MYC POC function nuclear transcription; translocation (8;

14) causing Burkitt's lymphoma
majority are point mutations; loss of

Inactivation suppressor genes
suppression
two hit theory; two separate point mutations of

Sporadic retinoblastoma
RB suppressor gene on
one hit theory; one already inactivated in germ

AD retinoblastoma
cells
G,-S phase inhibition, DNA repair, activation

TP53 suppressor gene functions
BAX apoptosis gene
Inactivation TP 53 suppressor gene inactivation causes majority of human cancers
RB suppressor gene function G1-S phase inhibition
Inactivation RB suppressor gene retinoblastoma, osteogenic sarcoma
APC suppressor gene function prevents nuclear transcription by catenin
Inactivation APC suppressor gene familial polyposis (FAP)
BRCA1/2 suppressor genes function DNA repair inactivation
BRCA 1/2 suppressor genes breast, ovarian cancers
anti apoptosis gene (keeps cytochrome c in

BCL-2 function
mitochondria)
t(14;18) translocation of heavy chain causes

BCL-2 gene overexpression; follicular B cell lymphoma
[think t(14;18) = t(l4;lB) for foLLicular B]
AR; defect in DNA repair enzymes; ↑ risk for

Xeroderma pigmentosum
UVB light cancers
Hereditary non-polyposis syndrome AD; inactivation DNA mismatch genes;

(HNPCC) colorectal cancer
AR; susceptibility to DNA damage; leukemias,

Chromosome instability syndromes
lymphomas

Bloom syndrome, ataxia telangiectasia,

Examples chromosome instability
Wiskott-Aldrich syndrome
chemicals (MC), viruses, radiation, H. pylori,

Carcinogens
physical (squamous cancer in bum scar)
Polycyclic hydrocarbons key chemical carcinogen (cigarette smoke)
produced from Aspergillus; hepatocellular

Aflatoxins
carcinoma
Asbestos lung cancer, mesothelioma
Thorium dioxide hepatocellular carcinoma, cholangiocarcinoma
Aniline dyes transitional cell carcinoma
Vinyl chloride angiosarcoma of liver
Benzene leukemia
Cyclophosphamide transitional cell carcinoma of bladder
Burkitt's; CNS lymphoma (AIDS); Hodgkin's

EBV
mixed cellularity; nasopharyngeal carcinoma
HBV and HCV hepatocellular carcinoma
cervical, penis, and anorectal squamous

HPV
cancers
HHV-8 Kaposi sarcoma
basal cell carcinoma, squamous cell carcinoma,

UVB cancers
malignant melanoma
Key host defense cytotoxic CD8 T cells (type IV hypersensitivity)
Cachexia due to tumor necrosis factor-α
Most common anemia anemia chronic disease
Most common coagulopathy hypercoagulability

Most common COD in cancer gram negative infection
Clubbing possible marker for lung cancer
Non-bacterial thrombotic
possible marker for pancreatic cancer
endocarditis mitral valve
metastasis more important than nodal

TNM staging
involvement
AFP hepatocellular carcinoma, yolk sac tumors
PSA prostate cancer
CEA recurrence colorectal cancer
BJ (Bence-Jones) protein multiple myeloma
β-human chorionic gonadotropin choriocarcinoma
Calcitonin medullary carcinoma thyroid; hypocalcemia
Small cell carcinoma lung ADH (hyponatremia), ACTH (ectopic Cushing's)
EPO (polycythemia), PTH-related peptide

Renal cell carcinoma
(hypercalcemia)
EPO (polycythemia), insulin-like factor

Hepatocellular carcinoma
(hypoglycemia)
calcitonin (hypocalcemia), ACTH (ectopic

Medullary carcinoma of thyroid
Cushing's)
Squamous cell carcinoma of lung PTH-related peptide (hypercalcemia)
Erythropoietin synthesized in peritubular capillaries
measure of effective erythropoiesis; correct for

Reticulocyte count
degree of anemia
hematopoiesis outside bone marrow (e.g.,

Extramedullary hematopoiesis
spleen)
Newborn physiologic anemia drop in Hb due to replacement of HbF RBCs

with HbA
Hb and Hct decreased; greater increase in

Pregnancy
plasma volume than RBC mass
Anemia normal O2 saturation and arterial PO2
average volume of RBCs; useful for anemia

MCV
classification
MCHC average Hb concentration in RBCs
MCHC ↓ in microcytic anemias; ↑ in spherocytosis
Thalassemias ↓ MCV, ↑ RBC count
RBC size variation; ↑ iron deficiency; normal in

RDW
other microcytic anemias
anaerobic glycolysis; no mitochondria or HLA

Mature RBC
antigens
↑ iron deficiency; ↓ anemia chronic disease,

Total iron binding capacity
sideroblastic anemia
↓ iron deficiency, anemia chronic disease; ↑

% Saturation
sideroblastic anemia
↓ iron deficiency; ↑ anemia chronic disease,

Serum ferritin
sideroblastic anemia; normal thalassemia
iron deficiency MC, anemic chronic disease,

Microcytic anemias
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
AR; two α-globin gene deletions; normal Hb

α-Thalassemia trait
electrophoresis
three α-globin gene deletions; hemolytic

HbH disease
anemia; four β-globin chains
four α-globin gene deletions; four γ-globin

Hb Bart's disease
chains
β-Thalassemia minor AR; DNA splicing defect; ↑ HbA2 and F; ↓ HbA
nonsense mutation with stop codon; hemolytic

β-Thalassemia major
anemia; ↑↑ HbF, ↑ HbA2
defect in mitochondrial heme synthesis

Sideroblastic anemia
producing ringed sideroblasts
alcohol, pyridoxine deficiency (isoniazid Rx of

Causes sideroblastic anemia
TB), Pb poisoning
inhibition ferrochelatase, d-aminolevulinic acid

Pb poisoning
dehydrase, ribonuclease
growth retardation; Pb in epiphyses (lead lines);

S/S Pb poisoning children
abdominal colic; encephalopathy
peripheral neuropathy; proximal renal tubule

S/S Pb poisoning adult
damage (Fanconi's syndrome)
coarse basophilic stippling RBCs; ↓ MCV; ↑

Lab Pb poisoning
blood Pb; ↑ d-aminolevulinic acid
animal products; requires intrinsic factor for

Vitamin B12
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
involved in propionate metabolism; end-

Vitamin B12
product succinyl CoA
vegan, pernicious anemia MC, fish tapeworm,

Causes B12 deficiency pancreatitis, bacterial overgrowth, Crohn's
disease
autoimmune destruction parietal cells; chronic

Pernicious anemia
gastritis body/fundus; achlorhydria; ↑ gastrin
alcohol MCC, poor diet, drugs, malabsorption,

Causes folate deficiency
pregnancy, goat milk
alcohol, OC, phenytoin, methotrexate,

Drugs and folate deficiency
trimethoprim, 5-fluorouracil
Intestinal conjugase in folate

inhibited by phenytoin
metabolism
Jejunal uptake of monoglutamate

inhibited by alcohol and OC
form of folate
Dihydrofolate reductase inhibited by methotrexate, trimethoprim
Thymidylate synthetase inhibited by 5-fluorouracil
Folate deficiency MCC of increased serum homocysteine
pancytopenia; hypersegmented neutrophils; ↑

Lab in B12/folate deficiency
homocysteine
Lab findings unique to B12 ↑ gastrin (pernicious anemia), ↑ methylmalonic

deficiency acid
B12 reabsorbed absorbed after

PA
administration of intrinsic factor

bacterial overgrowth
administration of antibiotics


chronic pancreatitis
administration of pancreatic extract
initially normal Hb and Hct; 0.9% saline

Acute blood loss
uncovers RBC deficit
drugs (e.g., phenylbutazone); infection (e.g.,

Aplastic anemia
parvovirus); benzene
Lab findings aplastic anemia pancytopenia; hypocellular bone marrow
Anemia in renal disease normocytic; decreased EPO
macrophage phagocytosis of RBCs; ↑

Extravascular hemolysis
unconjugated bilirubin and urine UBG
↓ serum haptoglobin; hemoglobinuria;

Intravascular hemolysis
hemosiderinuria
AD; defect in spectrin; extravascular hemolysis;

Congenital spherocytosis
splenomegaly
normocytic anemia; dense RBCs, ↑ MCHC, ↑

Blood findings in spherocytosis
osmotic fragility
missing decay accelerating factor; complement

PNH
destruction RBCs, neutrophils, platelets
pancytopenia; hemoglobinuria; positive sugar

S/S PNH
water (Ham's) test and acidified serum test
AR; missense mutation (valine for glutamic acid

HbSS
6th positive β-globin chain)
↑ deoxyhemoglobin (hypoxemia, acidosis); HbS

Causes of sickling
> 60%
HbF inhibits sickling; hydroxyurea ↑ HbF
vasoocclusive crises, hemolytic anemia

Pathophysiology HbSS
(extravascular)

dactylitis (6-9 months); Streptococcus

HbSS children
pneumoniae sepsis (dysfunctional spleen)
HbSS osteomyelitis Salmonella paratyphi
aplastic crisis (parvovirus B-19), acute chest

syndrome, autosplenectomy, calcium
HbSS complications
bilirubinate gallstones, priapism, aseptic
necrosis
microhematuria from sickling in renal medulla;

HbAS
renal papillary necrosis
HbAS-HbA 55-60%, HbS 40-45%; HbSS-HbS

Hb electrophoresis
90-95%, HbF 5-10%
sickle cells; target cells; Howell-Jolly bodies

Blood findings in HbSS
(nuclear remnants)
XR; oxidant damage (peroxide) to Hb (e.g.,

G6PD deficiency
primaquine; dapsone; fava beans)
Heinz bodies (denatured Hb; special stain); bite

Blood findings G6PD deficiency
cells
↓ ATP; RBCs dehydrated; ↑ 2,3-BPG (right-

Pyruvate kinase deficiency
shifted OBC)
Warm type AIHA IgG; extravascular hemolysis; e.g., SLE, drugs
IgM intravascular hemolysis; e.g., CLL,

Cold type AIHA
Mycoplasma
IgG antibody against penicillin attached to RBC

Penicillin
(type II hypersensitivity)
drug alters Rh antigens; IgG antibody against

Methyldopa
Rh antigens (type II hypersensitivity)
drug-IgM IC; intravascular hemolysis; type III

Quinidine
hypersensitivity

Lab findings AIHA positive direct Coombs'; spherocytes
mechanical damage causing intravascular

Micro-macroangiopathic hemolysis
hemolysis
Causes of micro/macro hemolysis aortic stenosis (MCC), DIC, TIP, HUS
Peripheral blood findings schistocytes; iron deficiency from

micro/macro hemolysis hemoglobinuria
intravascular hemolysis correlates with fever;

Malaria
falciparum-ring forms and gametocytes
exaggerated WBC response to infection; usually

Leukemoid reaction
due to infection
marrow infiltrative disease peripheralizes

Leukoerythroblastic reaction
myeloblasts/nucleated RBCs
Causes of leukoerythroblastic
bone metastasis MCC, myelofibrosis
reaction
type I hypersensitivity (e.g., penicillin reaction);

Eosinophilia
invasive helminthic infection
Helminthes not producing

pinworms, adult worms in ascariasis
eosinophilia
mononucleosis; CMV; toxoplasmosis; viral

Atypical lymphocytes
hepatitis; phenytoin
due to EBV; EBV attaches to CD21 receptors on

Mononucleosis
B cells
exudative tonsillitis, generalized

Clinical findings mono
lymphadenopathy, hepatosplenomegaly
atypical lymphocytosis; IgM heterophile

Lab findings mono
antibodies against horse RBCs
T cell deficiencies (HIV); combined B/T

Lymphopenia
deficiency (adenine deaminase deficiency)

Lymphocytosis viral infections, whooping cough
Corticosteroids lymphopenia, eosinopenia, neutrophilia
neoplastic stem cell disorder; splenomegaly;

Chronic MPD
marrow fibrosis; risk for leukemia
polycythemia vera, myelofibrosis and myeloid

Examples of MPD
metaplasia
↓ plasma volume; ↑ RBC count; normal RBC

Relative polycythemia
mass
Absolute polycythemia ↓ RBC count and RBC mass
Appropriate polycythemia hypoxic stimulus for EPO to generate RBCs
Causes of appropriate absolute lung disease, cyanotic heart disease, high

polycythemia altitude
normal plasma volume; ↑ RBC mass; ↓ SaO2; ↑

Appropriate absolute polycythemia
EPO
Inappropriate absolute
no hypoxic stimulus for EPO
polycythemia
Causes of inappropriate
ectopic secretion EPO, polycythemia vera
polycythemia
↑ plasma volume and RBC mass; normal SaO2;

Polycythemia vera
↓ EPO
normal plasma volume; ↑ RBC mass; normal

Ectopic EPO (renal cell carcinoma)
SaO2; ↑ EPO
marrow fibrosis; extramedullary hematopoiesis;

Myelofibrosis myeloid metaplasia
splenomegaly
tear drop RBCs; dry bone marrow aspirate

Lab findings in myelofibrosis
(marrow fibrosis)
Essential thrombocythemia MPO with increase in abnormal appearing

platelets
severe anemia in elderly; 30% develop

Myelodysplastic syndrome
leukemia; ringed sideroblasts
Benzene aplastic anemia; acute leukemia
ALL, newborn-14; AML, 15-60; CML, 40-60;

Leukemia by age
CLL, >60
acute, blasts >30% in bone marrow; chronic,

Acute vs. chronic leukemia
blasts <10% in bone marrow
AML Auer rods in myeloblasts
t(15;17); defect in retinoic acid; Rx retinoic acid

Acute promyelocytic leukemia
(↑ maturation); DIC
Acute monocytic leukemia gum infiltration
t(9;22) of ABL POC; Philadelphia chromosome

CML
22; ↓ alkaline phosphatase score
early pre-B (80%); CALLA (CD10) and TdT

ALL
positive; CNS and testicle involvement
ALL t(12;21) offers good prognosis
B cell neoplasm; ↓ γ-globulins; MCC

CLL generalized lymphadenopathy patients> 60-
yrs-old
HTLV-1; CD4 T cells; skin infiltration; lytic bone

Adult T cell leukemia
lesions with hypercalcemia
positive TRAP stain; splenomegaly; Rx with

Hairy cell leukemia
purine nucleosides; (+)CD11c
germinal follicles, B cells; paracortex, T cells;

Nodal sites
sinuses, histiocytes
Testicular cancer metastasizes to para-aortic nodes

metastasizes to left supraclavicular nodes

Stomach cancer
(Virchow node)
Phenytoin atypical lymphocytosis
Bartonella henselae; granulomatous

Cat scratch disease
microabscesses
t(14;18); overexpression of BCL-2 anti-

Follicular B-cell lymphoma
apoptosis gene
t(8;14); EBV association; common childhood

Burkitt lymphoma
NHL; "starry sky" appearance
risk factors H. pylori (stomach); Sjogren's

Extra nodal lymphomas
syndrome
CD4 T cell neoplasm; skin lesions with

Mycosis fungoides
Pautrier's microabscesses
Sezary syndrome leukemic phase of mycosis fungoides
Polyclonal gammopathy sign of chronic inflammation
M component (spike); sign of plasma cell

Monoclonal gammopathy
disorder
serum and urine immunoelectrophoresis; bone

Confirmatory tests
marrow aspirate
light chains in urine; predictive of a malignant

Bence Jones protein
plasma cell disorder
M spike; lytic bone lesions; pathologic

Multiple myeloma
fractures; hypercalcemia; renal failure
MC monoclonal gammopathy; may progress to

MGUS
myeloma
elderly patient; no BJ protein; no malignant

Findings in MGUS
plasma cells

lymphoplasmacytic lymphoma; IgM M spike;

Waldenstrom's macroglobulinemia
hyperviscosity
neoplastic component, Reed Stemberg (RS) cell;

Hodgkin's lymphoma
CD15 & CD30 positive
Lymphocyte predominant Hodgkin's infrequent classic RS cells
female dominant; supraclavicular nodes +

Nodular sclerosing Hodgkin's
anterior mediastinal nodes
male dominant; numerous RS cells; EBV

Mixed cellularity Hodgkin's
association
stage of disease and type of Hodgkin's most

Hodgkin's prognosis
important factors
Alkylating agents in Rx of Hodgkins ↑ risk for second malignancies (leukemia; NHL)
Langerhan's histiocytes CD1 positive; Birbeck granules
malignant histiocytosis <2 yrs old; diffuse

Letterer-Siwe disease
eczematous rash; organ involvement
malignant; lytic skull lesions, diabetes

Hand-Christian-Christian disease
insipidus, exophthalmos
benign histiocytosis; lytic bone lesions with

Eosinophilic granuloma
pathologic fractures
release histamine (pruritus; swelling);

Mast cells metachromatic granules positive with toluidine
blue
localized mastocytosis; skin lesions swell and

Urticaria pigmentosum
itch with scratching
twisted β-sheet; apple green birefringence with

Amyloid
Congo red
AL amyloid derived from light chains; plasma

Primary amyloidosis
cell disorders

AA amyloid derived from serum-associated

Secondary amyloidosis
amyloid; chronic infections
amyloid precursor protein gene product

Alzheimer's disease
chromosome 21; amyloid-β
macrophages have fibrillary appearance;

Gaucher's disease
deficiency glucocerebrosidase
macrophages have soap bubble appearance;

Niemann Pick's disease
deficiency sphingomyelinase
splenomegaly; peripheral blood cytopenias;

Hypersplenism
portal hypertension MCC
Howell Jolly bodies; susceptible to

Splenic dysfunction
Streptococcus pneumoniae sepsis
tissue plasminogen activator, heparin, PGI2

Anticoagulants
ATIII, protein C/S
enhances ATIII activity (neutralizes all factors

Heparin
except V, VIII, fibrinogen)
Protein C/S neutralize V and VIII
coagulation factors, thromboxane A2 (platelet

Procoagulants
aggregation, vasoconstrictor)
inactivate factors V and VIII; enhance

Protein C and S
fibrinolysis
complexes with factor VIII to enhance VIII:C

von Willebrand factor
activity; platelet adhesion
receptors for von Willebrand factor and

Platelets
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)
cross-links insoluble fibrin; strengthens fibrin

Factor XIII
clots
Vitamin K-dependent factors prothrombin, VII, IX, X, protein C and S
fibrinogen, prothrombin, V, VIII; fluid is called

Factors consumed in a clot
serum
cleaves fibrinogen and insoluble fibrin into

Plasmin
degradation products
evaluates platelet function (adhesion, release

Bleeding time
reaction, aggregation)
Aspirin MCC of a prolonged bleeding time
ristocetin cofactor assay; vWF antigen assay;

Tests for vWF
agar electrophoresis
PT evaluates extrinsic pathway to fibrin clot
PTT evaluates intrinsic pathway to stable fibrin clot
fibrin(ogen) degradation products; D-dimers

Fibrinolysis tests
(cross-linked insoluble fibrin)
cannot form temporary plug; epistaxis;

S/S platelet dysfunction
petechiae; bleeding from scratches
Idiopathic thrombocytopenic children; antibodies against GpIIb:IIIa; no

purpura (ITP) splenomegaly
Chronic autoimmune
SLE; antibodies against GpIIb:IIIa receptors
thrombocytopenic purpura
thrombocytopenia due to IgG antibody against

Heparin
heparin attached to PF4 on platelets

PF4 heparin neutralizing factor
thrombocytopenia MC hematologic
HIV
abnormality; similar to ITP
platelet thrombi develop in areas of endothelial

TTP damage in small vessels; consumption of
platelets
fever, thrombocytopenia, renal failure,

S/S hemolytic anemia with schistocytes, CNS
deficits
thrombocytopenia, prolonged bleeding time,

Lab findings TTP
normal PT and PTT
similar to TTP; endothelial injury from Shiga-

HUS like toxin of 0157:H7 E. coli in undercooked
beef
no stable fibrin clot-late rebleeding;

S/S factor deficiency
menorrhagia; GI bleeding; hemarthroses
XR; hemarthroses; prolonged PTT, ↓ factor VIII

Hemophilia A
activity, normal VIII antigen
AD; platelet adhesion defect + factor VIII

von Willebrand's disease
deficiency
↓ vWF, VIII antigen, and VIII:C; prolonged

Lab findings in VWD
bleeding time
Rx of choice for mild von Willebrand's disease

Desmopressin acetate
and hemophilia A
Circulating anticoagulants antibodies destroy coagulation factors
Lab finding in circulating prolonged PT and/or PTT corrected with mixing

anticoagulant studies
Vitamin K deficiency ↓ epoxide reductase activity (↓ function vitamin

K); hemorrhagic diathesis; ↑ PT
antibiotics MC, newborn, malabsorption,

Causes vitamin K deficiency
warfarin
activation coagulation system from release of

DIC tissue thromboplastin and/or endothelial cell
damage
consumption coagulation factors by fibrin clots;

DIC
patient also anticoagulated
septic shock MCC, rattlesnake bite, massive

Causes
trauma, amniotic fluid
S/S bleeding from all scratches, holes, needle sites
thrombocytopenia, ↑ PT and PTT, D-dimers

Lab findings DIC
(best test), anemia
lupus anticoagulant and anticardiolipin

Antiphospholipid antibodies
antibodies; vessel thrombosis
inhibits epoxide reductase; PT best test but PTT

Warfarin
also prolonged
full anticoagulation in 3 days when -

Warfarin
carboxylated prothrombin disappears
ingredient in rat poison; danger to children in

Warfarin
households with grandparents on warfarin
intramuscular vitamin K (6-8 hrs), fresh frozen

Rx warfarin over anticoagulation
plasma (immediate)
enhances ATIII; PTT best test but PT also

Heparin
prolonged
estrogen ↑ coagulation factor synthesis and

OC
ATIII; predisposes to thrombosis
Factor V Leiden MC hereditary thrombosis; resistant to

degradation by protein C/S
no prolongation of PTT with administration of

ATIII deficiency
heparin
post-warfarin therapy in patient with

Hemorrhagic skin necrosis
heterozygote protein C deficiency
specialized cells that transfer foreign antigens

M cells
to lymphocytes in Peyer's patches
some patients have anti-AB-IgG antibodies;

Blood group O
increased incidence duodenal ulcers
Blood group A increased incidence of gastric carcinoma
do not have natural blood group antibodies at

Newborns
birth (e.g., anti-A-lgM)
may lose natural blood group antibodies; no

Elderly
hemolytic reaction to mismatched blood
inherited in autosomal codominant fashion; Rh

Rh antigens
antigens include D, C, c, E, e
antibodies against Rh or non-Rh blood group

Atypical antibodies
antigens (e.g., anti-D)
receptor for Plasmodium vivax; blacks often

Duffy antigen
lack Duffy antigen
indirect Coomb's test; detects atypical

Antibody screen
antibodies in serum
MC infection transmitted by blood transfusion;

Cytomegalovirus
MC antibody
Hepatitis C MCC of post-transfusion hepatitis
patient serum reacted against donor RBCs;

Major crossmatch
does not guarantee RBC survival

blood group O; no antigens on the surface of

Universal donor
RBCs
blood group AB; no natural blood group

Universal recipient
antibodies in serum
Packed RBC transfusion raises Hb by 1 gm/dL and Hct by 3%
Cryoprecipitate fibrinogen and factor VIII
replacement for multiple factor deficiencies

Fresh frozen plasma
(e.g., cirrhosis, DIC)
Allergic transfusion reaction type I IgE-mediated hypersensitivity reaction
recipient anti-HLA antibodies react against

Febrile transfusion reaction
donor leukocytes
transfusion of ABO incompatible blood (e.g., A

Intravascular HTR
person receives B blood)
antibody attaches to donor RBCs; macrophage

Extravascular HTR
phagocytosis and hemolysis
present in both types of hemolytic transfusion

Positive direct Coomb's test
reactions
S/S jaundice, no increase in Hb, hemoglobinuria
mother O and baby A or B; transplacental

ABO HDN
passage of maternal anti-AB-IgG
positive direct Coomb's test; spherocytes; MCC

ABO HDN
unconjugated hyperbilirubinemia first 24 hrs
mother Rh (D antigen) negative and fetus Rh (O

Rh HDN
antigen) positive
no hemolysis in first Rh incompatible

Rh HDN
pregnancy
Rh HDN maternal anti-D crosses placenta; potential for

hydrops fetalis; high risk for kernicterus
anti-D; coats D antigen site on fetal RBCs in

Rh immune globulin
maternal circulation
positive direct Coomb's; severe anemia and

Rh HDN lab
hyperbilirubinemia
protects mother from Rh sensitization

ABO HDN
(development of anti-D antibodies)
O Rh negative mother with A Rh

A+ cells destroyed by mothers anti A-lgM
positive baby
converts unconjugated bilirubin in skin into

Blue fluorescent light
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
split in A2 and P2; due to increased blood in

Inspiration
right side of heart
abnormal; due to blood entering volume

S3
overloaded ventricle in early diastole
Causes S3 valve regurgitation; congestive heart failure
abnormal; due to blood entering non-

S4 compliant ventricle with atrial contraction in
late diastole
Causes S4 volume overloaded ventricle, hypertrophy

Murmurs stretching valve ring or damage to valve
increases right sided abnormal heart sounds

Inspiration
and murmurs
increases left sided abnormal heart sounds and

Expiration
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
primary vehicle for carrying liver-synthesized

VLDL
triglyceride
Familial hypercholesterolemia (type

AD; deficiency of LDL receptors; ↑ LDL
II)
deficiency apo E; ↑ remnants (chylomicron,

Type III hyperlipoproteinemia
intermediate density)
Type IV hyperlipoproteinemia ↑ VLDL; alcoholics
deficiency apo B48 (chylomicrons) and B100

Apo B deficiency
(VLDL); ↓ CH and TG
Clinical findings in apo B deficiency malabsorption; hemolytic anemia
Atherosclerosis reaction to injury of endothelial cells
smoking, ↑ LDL, ↑ homocysteine, Chlamydia

Risk factors
pneumoniae infection
Cells involved platelets, macrophages, smooth muscle cells, T

cells with cytokine release
Fibrous plaque pathognomonic lesion of atherosclerosis
marker of an inflammatory atheromatous

C-reactive protein
plaque
Inflammatory atheromatous plaque predisposes to platelet thrombosis
↑ vessel thrombosis; folate (MC)/vitamin B12

Increased plasma homocysteine
deficiency
small vessel disease of DM and hypertension;

Hyaline arteriolosclerosis
excess protein in vessel wall
Mechanisms hyaline
non-enzymatic glycosylation
arteriolosclerosis in DM
glucose attaches to amino acids in BM; causes ↑

Non-enzymatic glycosylation
permeability to protein
Mechanisms hyaline
pressure pushes proteins into vessel wall
arteriolosclerosis in hypertension
due to atherosclerosis; flank pain, hypotension,

Abdominal aortic aneurysm rupture
pulsatile mass
vasculitis of vasa vasorum of aortic arch; aortic

Syphilitic aneurysm
regurgitation
due to hypertension and collagen tissue

Aortic dissection
disorders (e.g., Marfan)
elastic tissue degeneration creates spaces filled

Cystic medial degeneration
with mucopolysaccharides
due to wall stress from hypertension and

Intimal tear in aorta
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
AD; fibrillin defect; aortic

Marfan's regurgitation/dissection; lens dislocation; MVP
with sudden death
MC COD Marfan's and Ehlers Danlos aortic dissection
stasis of blood flow; deep veins below knee MC

Phlebothrombosis
site
Pulmonary thromboembolism emboli originate from femoral veins
Superficial migratory
sign of carcinoma of head of pancreas
thrombophlebitis
Thoracic outlet syndrome absent radial pulse with positional change
lymphedema hands/feet in newborn; preductal

Turner's syndrome
coarctation
arteriovenous fistula; due to hyperestrinism

Spider telangiectasia
(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
palpable purpura; e.g., Henoch Schonlein

Small vessel vasculitis
purpura
vessel thrombosis with infarction; e.g., classical

Muscular artery vasculitis
polyarteritis nodosa
Elastic artery vasculitis absent pulse, stroke
Takayasu's arteritis pulseless disease; young Asian woman
temporal artery granulomatous vasculitis;

Giant cell arteritis
ipsilateral blindness (ophthalmic artery)

muscular artery vasculitis with vessel

Classical polyarteritis nodosa
thrombosis infarction
vessel inflammation at different stages;

Path findings
aneurysms from vessel weakness
infarctions in kidneys, skin, GI tract, heart;

S/S
HBsAg in 30%
angiography identifies aneurysms and

Diagnosis
thrombosis
coronary artery
Kawasaki's disease
vasculitis/thrombosis/aneurysms in children
chest pain; desquamating rash; swelling

Kawasaki's disease|S/S
hands/feet; cervical lymphadenopathy
Kawasaki's disease|Rx IV γ-globulin
Buerger's disease (thromboangiitis

smoker's digital vasculitis; digital infarction
obliterans)
Raynaud's syndrome digital vasculitis in PSS and CREST syndrome
S/S digital pain; white-blue-red color changes
protein gels in cold temperature; Raynaud's

Cryoglobulinemia
syndrome; HCV association
S/S acral cyanosis relieved by coming indoors
association with c-ANCA; sinusitis, lung

Wegener's granulomatosis
infarction, crescentic GN
palpable purpura; crescentic GN; association

Microscopic polyangiitis
with p-ANCA
IgA-anti-IgA ICs; palpable purpura

Henoch-Schönlein purpura
buttocks/legs; arthritis; IgA GN
Serum sickness vasculitis e.g., horse antivenin in Rx of rattlesnake

envenomation
Rocky Mountain spotted fever tick borne
sepsis causes petechia/ecchymoses; potential

Meningococcemia
for Waterhouse Friderichsen syndrome
defect in renal excretion of sodium; ↑ plasma

Essential HTN blacks
volume, ↓ PRA
atherosclerosis renal artery in men;

Renovascular HTN
fibromuscular hyperplasia renal artery women
epigastric bruit; ↑ PRA affected kidney, ↓ PRA

S/S
unaffected kidney
1º HPTH, Graves/hypothyroidism, Cushing's, 1º

Endocrine HTN
aldosteronism, phaeochromocytoma
LVH MC complication; AMI MC COD followed by

Hypertension
stroke and renal failure
Afterload resistance ventricles contract against
Preload volume ventricles must eject
increased afterload; e.g., essential HTN, aortic

Concentric LVH
stenosis
increased preload; e.g., valve regurgitation; left

LVH with dilation/hypertrophy
to right shunts
forward failure; pulmonary edema, pillow

LHF
orthopnea, paroxysmal nocturnal dyspnea
LHF due to decreased ventricular contractility

Systolic dysfunction
(ischemia)
LHF due to decreased ventricular compliance

Diastolic dysfunction
(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
MC COD in United States; left anterior

AMI
descending coronary artery thrombosis MCC
coronary artery atherosclerosis; subendocardial

Exertional angina
ischemia; ST depression
coronary artery vasospasm; transmural

Prinzmetal's angina
ischemia; ST elevation
Sudden cardiac death death within 1 hr of symptoms
severe coronary artery atherosclerosis; absence

Path findings
of occlusive thrombosis
anterior portion left ventricle, anterior 2/3rds

LAD coronary artery
IVS
posterior portion left ventricle and papillary

RCA
muscle, inferior 1/3rd IVS, right ventricle
rupture of inflammatory plaque produces

AMI
platelet thrombus
Ventricular fibrillation MC COD in AMI
AMI no gross changes until 24 hrs
retrosternal pain radiating down arms,

S/S AMI
diaphoresis
AMI ruptures 3rd-7th day
Anterior wall rupture MC type; LAD thrombosis; cardiac tamponade
Posteromedial papillary muscle RCA thrombosis; mitral regurgitation with LHF

rupture
IVS rupture LAD thrombosis; left to right shunt; RHF
Mural thrombus anterior AMI; danger embolization
first week in transmural AMI; 6 wks later

Pericarditis
autoimmune
S/S friction rub; leaning forward relieves pain
late manifestation of AMI; precordial systolic

Ventricular aneurysms
bulge; CHF MC COD
RCA thrombosis; hypotension, RHF, preserved

Right ventricular infarction
left ventricular function
CK-MB and troponins; CK-MB absent by 3 days;

Diagnosis of AMI
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
EF = stroke volume/left ventricular end-

Ejection fraction
diastolic volume; 80/120 = 0.66
use internal mammary artery and saphenous

By-pass surgery
veins ("arterialize" after 10 yrs)
Angioplasty complication localized dissection with thrombosis
Umbilical vein highest O2 saturation
shunts blood from pulmonary artery to aorta;

Ductus arteriosis in fetus
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)
patent foramen ovale; ↑ SaO2 right atrium (RA),

ASD
RV, PA; MC adult congenital heart disease
endocardial cushion defect (combined ASD and

Down syndrome
VSD)
machinery murmur; close with indomethacin; ↑

PDA
SaO2 PA
degree of pulmonic stenosis determines if

Tetralogy of Fallot
cyanosis is present
Tetralogy of Fallot ↓ left ventricle, aorta
Tetralogy of Fallot ASD and PDA are cardioprotective
cyanosis; aorta empties RV; PA empties left

Complete transposition
ventricle
Complications cyanotic heart 2° polycythemia; infective endocarditis;

disease metastatic abscesses
Pre-ductal coarctation Turner's syndrome
Post-ductal coarctation constriction distal to ligamentum arteriosum
upper extremity HTN; claudication; rib-

S/S
notching; activation RAA also causes HTN
type II hypersensitivity; group A streptococcus

Acute rheumatic fever
pharyngeal infection
sterile vegetations mitral valve (regurgitation);

Acute rheumatic fever
myocarditis with Aschoff nodule
polyarthritis (MC), carditis, erythema

S/S
marginatum, rheumatoid nodules, chorea
chronic rheumatic fever; opening snap followed

Mitral stenosis
by mid-diastolic rumble

left atrial dilation hypertrophy - atrial

Mitral stenosis
fibrillation, thrombus, pulmonary edema, RHF
myxomatous degeneration of mitral valve;

MVP
common in Marfan syndrome, Ehlers Danlos
mid-systolic click followed by a murmur;

Mitral valve prolapse|S/S
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
LHF, infective endocarditis, acute rheumatic

Causes
fever
systolic ejection murmur; syncope and angina

Aortic stenosis
with exercise; hemolytic anemia
Aortic stenosis murmur increased worsens obstruction and increases murmur

preload intensity
Aortic stenosis murmur decreased decreases obstruction and decreases murmur

preload intensity
Causes bicuspid aortic valve; age-related sclerosis
bounding pulses; early diastolic blowing

Aortic regurgitation
murmur
diastolic murmur; regurgitant flow on anterior

Austin Flint murmur
leaflet mitral valve
Significance Austin Flint murmur sign for AV replacement
essential HTN, infective endocarditis, acute

Causes aortic regurgitation
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
Streptococcus viridans MCC; Staphylococcus

Infective endocarditis (IE)
aureus MCC IVDA
Staphylococcus epidermidis (coagulase

IE prosthetic heart valve
negative)
IE ulcerative bowel disease Streptococcus bovis
IC vasculitis-Roth spot, splinter hemorrhages;

S/S
regurgitant murmurs; metastatic abscesses
positive blood culture Libman Sacks

Lab findings
endocarditis
MCC of myocarditis (lymphocyte infiltrate in

Coxsackievirus
myocardium) and pericarditis
Parasitic cause myocarditis leishmania in Chagas disease
Pericardial effusion all chamber pressures are uniformally increased
muffled heart sounds, pulsus paradoxus,

S/S
inspiratory neck vein distention
echocardiogram, pericardiocentesis,
Dx and Rx
respectively
drop in blood pressure >10 mmHg with

Pulsus paradoxus
inspiration
Constrictive pericarditis TB MCC worldwide; pericardial knock
generalized chamber enlargement; low ejection

Congestive cardiomyopathy
fraction
postpartum, cardiotoxic drugs, hypothyroidism,

Causes
alcohol
Hypertrophic cardiomyopathy MCC of sudden death in young person (due to

conduction defects)
anterior leaflet mitral valve drawn against

Site of obstruction
asymmetric thickened IVS
Effect decreased preload on systolic worsens obstruction and increases murmur

murmur intensity
Effect increased preload on systolic reduces obstruction and decreases murmur

murmur intensity
Restrictive cardiomyopathy decreased compliance
iron, amyloid, glycogen; sarcoidosis; tropical

Causes
endocardial fibrosis
benign tumor left atrium; embolization;

Cardiac myxoma
syncope
childhood tumor; association with tuberous

Cardiac rhabdomyoma
sclerosis
hypokalemia; MCC diuretic therapy (e.g.,

U wave
thiazides; loop diuretics)
Peaked T wave hyperkalemia; MCC renal failure
subendocardial ischemia (e.g., classical angina

ST depression
pectoris)
transmural ischemia (e.g., AMI), pericarditis,

ST elevation
ventricular aneurysm
MC chronic arrhythmia; absent P waves; danger

Atrial fibrillation
for embolization
wide QRS complexes; MC arrhythmia in

Ventricular premature beats
coronary care unit
Ventricular fibrillation MCC of death in an AMI
Anterior AMI Q waves in I and V1-V4

Q waves in II, III, and aVF; right coronary artery

Inferior AMI
thrombosis.
short PR interval with normal P wave; delta

Wolff-Parkinson-White
wave on upstroke of R wave
Alveolar O2 calculation % O2 breathing (713) - PCO2/0.8
primary lung disease; left to right shunts in

Increased A-a gradient
heart
total amount of air expelled after a maximal

Forced vital capacity
inspiration
Forced expiratory volume/1 second amount of air expelled in 1 second after

(FEV1) maximal inspiration
cyanotic when breast feeding; turns pink when

Choanal atresia
crying
Nasal polyps allergic (MC; adults only), aspirin, cystic fibrosis
Nasal polyp in a child requires sweat test to exclude cystic fibrosis
patient on aspirin (pain syndrome) with nasal

Triad asthma
polyps, asthma
snoring with intervals of apnea (respiratory

Obstructive sleep apnea (OSA)
acidosis with hypoxemia)
danger cor pulmonale; requires sleep test; Rx.

S/S
O2 with continuous positive airway pressure
maxillary sinusitis MC in adults; ethmoiditis MC

Sinusitis
in children; S. pneumoniae MC
association with EBV; metastasize to cervical

Nasopharyngeal carcinoma
nodes
smoking MCC; hoarseness; squamous cell

Laryngeal carcinoma
carcinoma

Resorption atelectasis MCC of fever 24-36 hours after surgery
↓ percussion; absent fremitus, breath sounds;

S/S
inspiratory lag; elevated diaphragm
decreased production surfactant; airway

RDS
collapse; hyaline membranes
synthesize surfactant (lecithin,

Type II pneumocytes
phosphatidylcholine); stored in lamellar bodies
reduces surface tension in airways; ↑ synthesis

Surfactant
cortisol, thyroxine; ↓ synthesis insulin
Causes RDS prematurity, maternal diabetes, C-section
maternal hyperglycemia → fetal hyperglycemia

Maternal diabetes
→ fetal insulin which ↓ surfactant
O2 FR injury (blindness, bronchopulmonary

Complications RDS
dysplasia); necrotizing enterocolitis
Typical community acquired

Streptococcus pneumoniae MCC
pneumonia
Typical pneumonia bronchopneumonia, lobar pneumonia
productive cough; consolidation - ↓ percussion,

S/S
↑ tactile fremitus
Atypical community acquired interstitial pneumonia; Mycoplasma

pneumonia pneumoniae MCC
low grade fever, non-productive cough, no

S/S
signs consolidation
Pseudomonas, aeruginosa MCC (respirators);

Nosocomial pneumonia
others - S. aureus, E. coli
MCC common cold; hand to mouth

Rhinovirus
transmission

Respiratory syncytial virus MCC pneumonia and bronchiolitis in child
Parainfluenza virus MCC croup in child; trachea area of obstruction
basophilic intranuclear inclusion surrounded by

Cytomegalovirus
halo
superimposed pneumonia with S. aureus

Influenza
increases mortality
Rubeola Warthin-Finkeldey multinucleated giant cells
atypical pneumonia; association with coronary

Chlamydia pneumoniae
artery disease
pneumonia in newborns; staccato cough;

Chlamydia trachomatis
wheezing
Coxiella burnetii only rickettsia without a vector
Mycoplasma pneumoniae crowded condition; cold agglutinins;

pneumonia azithromycin
Streptococcus pneumoniae
gram positive diplococcus; azithromycin
pneumonia
tension pneumatocysts in children with cystic

Staphylococcus aureus pneumonia
fibrosis
toxin produces ADP ribosylation of elongation

Corynebacterium diphtheriae
factor 2
exacerbation chronic bronchitis; acute

Haemophilus influenzae
epiglottis in children
Inspiratory stridor child croup, epiglottitis
MCC of pneumonia and death in cystic fibrosis;

Pseudomonas aeruginosa
green sputum
Klebsiella pneumoniae mucoid sputum in alcoholic
Legionella pneumophila silver stain; water coolers/mist (grocery

produce, restaurants, zoo rain forest)
strict aerobe; MC COD due to infectious disease

Mycobacterium tuberculosis
worldwide
Candida albicans vessel invader; yeasts and pseudohyphae
Cryptococcus immitis pigeon excreta; narrow-based bud
septate hyphae with fruiting body; fungus ball,

Aspergillus fumigatus
extrinsic asthma, vessel invader
non-septate; vessel invader; frontal lobe

Mucor species
abscess in diabetic ketoacidosis
Southwest deserts; inhale arthrospores in dust;

Coccidioides immitis
spherule with endospores
S/S erythema nodosum (painful nodules lower legs)
Ohio/central Mississippi river valley; excreta

Histoplasma capsulatum
bats (spelunker), chickens
simulates TB; yeasts phagocytosed by

H. capsulatum
macrophages
overlaps histoplasmosis; broad-based buds;

Blastomyces dermatitidis
skin lesion simulates cancer
cysts and trophozoites; pneumonia in HIV; Rx.

Pneumocystis carinii
trimethoprim/sulfamethoxazole
upper portion lower lobe, lower portion upper

Primary TB
lobe
Ghon focus (subpleural caseation); Ghon

Primary TB
complex (spread to hilar nodes)
cavitating lesion in upper lobe; kidney MC

Reactivation TB
extrapulmonary site
Mycobacterium avium intracellulare atypical TB; MC TB in AIDS

(MAI)
AR; 3 nucleotide deletion chromosome 7;

CF
defective CFTR (degraded in Golgi apparatus)
pneumonia, malabsorption, males sterile; +

S/S
sweat test; P. aeruginosa pneumonia MC COD
MCC aspiration oropharyngeal material (mixed

Lung abscess
aerobe/anaerobe); x-ray - air/fluid level
Aspiration sitting posterobasal segment right lower lobe
Aspiration supine superior segment right lower lobe
right middle lobe, posterior segment right

Aspiration right side
upper lobe
Pulmonary thromboembolism most derive from femoral vein
branch of aorta/intercostal artery; protects

Bronchial artery
against developing pulmonary infarction
Saddle embolus sudden death due to acute right heart strain
dyspnea and tachypnea; pleuritic chest pain;

S/S pulmonary infarction
pleural effusion
ventilation/perfusion scan; respiratory

Dx
alkalosis; hypoxemia
pleuritic inflammation; pulmonary embolus,

Pain on inspiration
pneumonia, pneumothorax
Pathogenesis pulmonary
hypoxemia and respiratory acidosis
hypertension (PH)
vasoconstriction pulmonary vessels;

Hypoxemia + respiratory acidosis
vasodilation cerebral vessels
1° lung disease (COPD, restrictive), recurrent

Causes PH
emboli, mitral stenosis, OSA, left-right shunts

Cor pulmonale PH + RVH
dyspnea; accentuated P2 (PH); parasternal

S/S
heave (RVH)
↓ compliance, ↑ elasticity; interstitial

Restrictive lung disease
fibrosis/edema
↓ all volumes and capacities; ↑ FEV1sec/FVC

Restrictive lung disease (RLD)
ratio
RLD; non-cardiogenic pulmonary edema due to

ARDS
alveolar injury
neutrophil destruction of type I and II

ARDS
pneumocytes; hyaline membranes
septic shock (MC), aspiration gastric contents,

Causes
severe trauma
inhalation mineral dust causing interstitial

Pneumoconiosis
fibrosis; particles <0.5 μm to reach alveoli
Caplan syndrome pneumoconiosis + rheumatoid nodules in lungs
"black lung" disease; progressive massive

Coal worker's
fibrosis; no increased incidence cancer or TB
quartz; nodular opacities; foundry workers; ↑

Silicosis
incidence cancer and TB
roofing material, old buildings (9/11), pipe-

Sources asbestos
fitter shipyard
Ferruginous bodies asbestos fiber coated by iron
benign pleural plaques (MC); bronchogenic

Asbestosis
carcinoma (MC cancer); mesothelioma
Mesothelioma malignancy of serosa; no smoking association
Sarcoidosis RLD; MC non-infectious lung and liver

granulomatous disease
dyspnea, hilar adenopathy (non-caseating

S/S
granulomas), uveitis, nodular skin lesions
↑ ACE, hypercalcemia (macrophages synthesize

Lab findings
1-α-hydroxylase)
intradermal injection sarcoid antigens causes

Kveim test
skin reaction
RLD; lung reaction against thermophilic

Farmer's lung
bacteria in moldy hay
RLD; reaction against nitrogen dioxide in

Silo filler's disease
fermenting corn
RLD; reaction against cotton, linen, hemp

Byssinosis
products in textile industry
RLD; anti-BM antibodies; begins in lungs and

Goodpasture's syndrome
ends in renal failure
Collagen vascular RLD SLE, rheumatoid arthritis, systemic sclerosis
amiodarone, bleomycin, busulfan,

Drugs RLD cyclophosphamide, methotrexate,
nitrofurantoin
Obstructive lung disease ↑ compliance, ↓ elasticity
↑ RV, TLC; ↓ TV, VC; ↓ FEV1sec and FVC; ↓

Obstructive lung disease
FEV1sec/FVC ratio
asthma, emphysema, chronic bronchitis,

Obstructive lung disease
bronchiectasis
extrinsic (type I hypersensitivity) and intrinsic

Asthma
types
S/S expiratory wheezing (inflamed terminal

bronchioles); LTC4,-D4,-E4

bronchoconstrictors
derive from crystalline material in eosinophil

Charcot-Leyden crystals
granules
initial respiratory alkalosis; respiratory acidosis

Lab findings
requires intubation
destruction elastic tissue respiratory unit; lung

Emphysema
hyperinflation; smoking MCC; pink puffer
Respiratory unit respiratory bronchiole, alveolar duct, alveoli
↑ AP diameter; depressed diaphragms; vertical

Radiograph emphysema
heart
Pathogenesis ↓ AAT, ↑ neutrophil destruction of elastic tissue
destruction/distention respiratory bronchioles

Centriacinar emphysema
upper lobe in smokers; THINK
destruction/distention entire respiratory unit

Panacinar emphysema
lower lobes; AAT deficiency
upper lobe destruction/distention alveolar

Paraseptal emphysema
ducts, alveoli; pneumothorax
normal to decreased PCO2 (respiratory

Lab findings
alkalosis)
productive cough 3 months/2 consecutive

Chronic bronchitis
years; blue bloater (cyanosis)
terminal bronchioles (proximal to respiratory

Site of obstruction
unit)
Lab findings respiratory acidosis/hypoxemia
obstruction/infection key causes; dilated

Bronchiectasis
bronchioles extend to periphery
Causes CF MCC, TB, immotile cilia syndrome

absent dynein arm in cilia; sinusitis, infertility,

Immotile cilia syndrome
bronchiectasis, situs inversus
squamous cancer and small cell cancer; men >

Central lung cancers
women
Peripheral lung cancers adenocarcinoma; women > men
Squamous lung cancer cavitate; secrete PTH-related protein
Small cell carcinoma neuroendocrine tumor; secrete ACTH and ADH
no smoking relationship; lung consolidation

Bronchioloalveolar carcinoma
resembling pneumonia
usually adenocarcinoma developing in old TB

Scar carcinoma
scar
low grade malignant; hemoptysis; rare cause

Bronchial carcinoid
carcinoid syndrome
more common than primary cancer; breast

Metastatic lung cancer
cancer MCC
squamous carcinoma posterior mediastinum;

Pancoast tumor
destruction superior cervical ganglion
Horner's syndrome - lid lag, miosis,

S/S
anhydrosis; lower brachial plexus injury
Solitary coin lesion granuloma MCC
primary lung cancer obstructs vessel; venous

Superior vena caval syndrome
congestion
thymoma; nodular sclerosing Hodgkin's;

Anterior mediastinal masses
teratomas
Posterior mediastinal masses usually neurogenic tumors of ganglia
B cell hyperplasia of thymus MC abnormality;

Myasthenia gravis
association with thymoma

association with hypogammaglobulinemia,

Thymoma
autoimmune disease, pure RBC aplasia
Pleural effusions transudates or exudates; CHF MCC
rupture subpleural or intrapleural bleb;

Spontaneous pneumothorax
air/pleural cavity pressure same
pleuritic chest pain, dyspnea, tracheal shift

S/S
ipsilateral side, absent breath sounds
flap-like pleural tear; increased pleural cavity

Tension pneumothorax
pressure; compression atelectasis
S/S as above except tracheal shift to opposite side
Cleft lip/palate failure of fusion of facial processes
multinucleated giant cell with acidophilic

Herpes labialis
intranuclear inclusions on Tzanck prep
EBV glossitis; pre-AIDS defining lesion; not

Hairy leukoplakia
precursor to cancer
Mumps bilateral parotitis; unilateral orchitis; ↑ amylase
pseudomembrane pharynx and trachea with

Diphtheria
cervical lymphadenopathy
Congenital syphilis notched central incisors
anaerobic gram + filamentous bacteria;

Actinomycosis
complication extracted dental abscess
S/S draining sinuses with sulfur granules
Exudative tonsillitis majority are viral; 20% group A streptococcus
common in newborn; pre-AIDS defining lesion;

Oral thrush
yeasts and pseudohyphae
Dental caries Streptococcus mutans

Peutz-Jegher's syndrome mucosal pigmentation; hamartomatous polyps
biopsy to rule out squamous dysplasia or

Leukoplakia/erythroleukoplakia
cancer
smoking and alcohol association; lower lip MC

Squamous cell carcinoma
site
Smokeless tobacco verrucoid squamous cell carcinoma
Gum hyperplasia phenytoin, pregnancy, scurvy
MC benign tumor of salivary glands; parotid MC

Pleomorphic adenoma
site
MC malignant tumor major and minor salivary

Mucoepidermoid carcinoma
glands
Dysphagia for solids only lesion obstructing esophagus; e.g., cancer, web
iron deficiency anemia causes esophageal web,

Plummer-Vinson syndrome
glossitis, achlorhydria (↓ HCl in gastric acid)
motor abnormality; e.g., achalasia MCC, PSS or

Dysphagia for solids and liquids
CREST syndrome
polyhydramnios; proximal esophagus ends

TE fistula
blindly; distal esophagus derives from trachea
vertebral abnormalities, anal atresia, TE fistula,

VATER syndrome
renal disease/radius abnormality
MC pulsion diverticulum of esophagus; halitosis

Zenker's diverticulum
(stinky breath, food gets stuck); near UES
relaxation of lower esophageal sphincter (LES)

GERD
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
dilated left gastric vein; sign of portal

Esophageal varices
hypertension due to cirrhosis
tear of distal esophagus from retching in

Mallory Weiss syndrome
alcoholic or bulimic
rupture of distal esophagus from retching;

Boerhaave's syndrome
pneumomediastinum
pneumomediastinum (air in subcutaneous

Hamman's mediastinal crunch
tissue)
LES ganglion cells contain VIP - relaxes LES
failure of LES relaxation (no VIP); absent

Achalasia
ganglion cells in the myenteric plexus
aperistalsis/dilation of esophagus;
S/S
regurgitation of undigested food at night
X-ray achalasia bird's beak appearance
Chagas' disease; leishmania destroy ganglion

Acquired achalasia
cells
Distal adenocarcinoma esophagus MC primary cancer; due to Barrett's esophagus
Squamous cell carcinoma of

smoking MCC; alcohol also causes
esophagus
sign of upper GI bleed; acid changes Hb to

Melena
hematin; peptic ulcer disease MCC
Hematemesis vomiting blood; peptic ulcers MCC
hypertrophy pyloric muscle; vomiting non-bile

Congenital pyloric stenosis
stained fluid in 2-4 weeks
Acute hemorrhagic (erosive)

NSAIDs MCC
gastritis

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
curved rod; urease producer; MCC PUD,

H. pylori
adenocarcinoma, gastric lymphoma
lesser curvature pylorus and antrum; poor

Gastric ulcer
defense against acid; food aggravates pain
never malignant; ↑ acid production; food

Duodenal ulcer
relieves pain
air under diaphragm causes pain in left

Perforated peptic ulcer
shoulder
giant rugal hyperplasia; protein loss from

Menetrier's disease
increased mucus
malignant islet cell tumor secreting gastrin;

Zollinger-Ellison syndrome
part of MEN I syndrome
PUD in usual locations; sometimes multiple

S/S
ulcers
ZE, achlorhydria, gastric distention, H2 or

Hypergastrinemia
proton blockers; renal failure
Leiomyoma MC benign tumor of stomach
H pylori related; ↓ incidence; lesser curvature

Intestinal type adenocarcinoma
pylorus/antrum
linitis plastica; signet ring cells; Krukenberg

Diffuse type adenocarcinoma
tumors ovaries
stomach MC site for extranodal lymphomas; H.

Gastric lymphoma
pylori associated
Malabsorption steatorrhea; chronic pancreatitis, bile salt

deficiency, small bowel disease
liver disease, bile salt resins, cholestasis,

Causes bile salt deficiency
bacterial overgrowth, Crohn's
failure to reabsorb xylose indicates small bowel

D-xylose screen
disease
Calcification of pancreas chronic pancreatitis cause of malabsorption
autoimmune disease; antibodies against gliadin

Celiac disease
in gluten; flat villi
Celiac disease association with dermatitis herpetiformis
systemic infection; foamy macrophages with

Whipple's disease bacteria (PAS+ inclusions) in small bowel
submucosa
S/S fever, polyarthritis, skin pigmentation
Campylobacter jejuni MCC; positive fecal smear

Invasive diarrhea
for leukocytes
loss isotonic fluid; enterotoxins from E. coli and

Secretory diarrhea
V. cholerae
hypotonic loss fluid; laxatives, lactase

Osmotic diarrhea
deficiency
Rotavirus MCC diarrhea in children
Norwalk virus MCC diarrhea in adults
common cause diarrhea in AIDS; MCC

Cytomegalovirus
cholecystitis and pancreatitis in AIDS
preformed toxin causes food poisoning; culture

Staphylococcus aureus
food
preformed toxin in fried rice and tacos; gram

Bacillus cereus
positive rods in stool

preformed neurotoxin (blocks acetylcholine

Clostridium botulinum (adult)
release); paralysis and mydriasis
colonization of bowel with release of

Clostridium botulinum (child)
neurotoxin; eating honey
pseudomembranous colitis; post-antibiotics;

Clostridium difficile
toxin assay stool; Rx metronidazole
produces dysentery (bloody diarrhea);

Shigella sonnei
associated with HUS
gastroenteritis; animal reservoirs - poultry,

Salmonella enteritidis
turtles
Salmonella paratyphi sepsis; osteomyelitis in HbSS
typhoid fever; human transmission;

Salmonella typhi
bradycardia, neutropenia, splenomegaly
Carrier state site gallbladder
MCC intestinal TB in United States (swallow TB);

M. tuberculosis
Peyer's patch site of infection
secretory diarrhea (traveler's diarrhea); toxin

Enterotoxigenic E. coli
stimulates guanylate cyclase
secretory diarrhea; toxin stimulates adenylate

Vibrio cholerae
cyclase to produce cAMP
solution must contain glucose to reabsorb Na+

Oral Rx cholera
(co-transport)
mesenteric lymphadenitis; sepsis in iron

Yersinia enterocolitica
overload states
dysentery; trophozoites phagocytose RBCs;

Entamoeba histolytica
liver abscess; Rx metronidazole
Cryptosporidium parvum MCC diarrhea in AIDS; acid-fast oocysts

MC protozoal cause of diarrhea; cause of

Giardia lamblia
malabsorption; Rx metronidazole
Trichuris trichiura rectal prolapse in children
Enterobius vermicularis anal pruritus; urethritis in girls; no eosinophilia
intestinal obstruction due to adult worms; no

Ascaris lumbricoides
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
vomiting bile-stained fluid at birth; double

Duodenal atresia
bubble sign; Down syndrome
absent ganglion cells in submucosal/myenteric

Hirschsprung disease
plexus rectosigmoid
proximal bowel dilated but peristalses; no stool

S/S
in rectal vault
Hirschsprung association Down syndrome; Chagas disease
terminal ileum telescopes into cecum;

Intussusception
obstruction plus bloody diarrhea
Meconium ileus complication of cystic fibrosis
second MCC of small bowel obstruction;

Indirect inguinal hernia
common in weight lifting
obstruction of small bowel with gallstone + air

Gallstone ileus
in biliary tree

MC due to sigmoid colon twisting around

Volvulus
mesentery
protrudes through center of triangle of

Direct inguinal hernia
Hesselbach; no obstruction
common in black children; may entrap bowel in

Umbilical hernia
adults
Sigmoid colon MC site for polyps, cancer, diverticula
Small bowel infarction diffuse abdominal pain with bloody diarrhea
embolism (atrial fibrillation), thrombosis SMA

Causes small bowel infarction
or SMV
Ischemic colitis splenic flexure pain with bloody diarrhea
Mesenteric angina pain in splenic flexure 30 minutes after eating
submucosal dilation of venules in cecum; cause

Angiodysplasia
of hematochezia
massive loss of blood per rectum; diverticulosis

Hematochezia
MCC
Meckel's diverticulum persistence omphalomesenteric duct
bleeding MC (iron deficiency in children),

S/S
diverticulitis
mimics acute appendicitis; cannot differentiate

Meckel's diverticulitis
without radionuclide scan
diverticulitis MC complication; MCC

Sigmoid diverticulum
hematochezia and fistula formation
Diverticulitis "left-sided acute appendicitis"
mucosal/submucosal ulceration; starts in

Ulcerative colitis
rectum; crypt abscess; ↑ risk adenocarcinoma
S/S left lower quadrant crampy pain with bloody

diarrhea
primary sclerosing cholangitis, seronegative

UC associations
HLA B27 + spondyloarthropathy
transmural inflammation; terminal ileum

Crohn's disease
involved 80%; granulomas; skip lesions
colicky pain and diarrhea; fistulas (anal, bowl to

S/S
bowel)
appendix MC site; terminal ileum MC site for

Carcinoid tumor
carcinoid syndrome
liver metastasis; flushing/diarrhea due to

Carcinoid syndrome
serotonin; increased urine 5-HIAA
precursor lesion colon cancer; size and number

Tubular adenomas
determine risk of malignancy
greatest risk for colon cancer (30%); secrete

Villous adenoma
mucus rich in protein and potassium
AD with 100% penetrance for developing colon

Familial polyposis
cancer
AD, polyposis plus osteomas and desmoid

Gardner's syndrome
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
due to lymphoid hyperplasia in children and

Acute appendicitis
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)
enterohepatic circulation to liver and kidney

UBG
(color of urine)
Alcoholic liver disease serum AST>ALT; ↑ serum GGT
Viral hepatitis serum ALT>AST
Cholestasis markers serum AP and GGT
macrophage degradation of heme; lipid

Unconjugated bilirubin
soluble; never in urine
Conjugated bilirubin (CB) water soluble; never normal in urine
Gilberts, spherocytosis, physiologic jaundice

% CB <20% (unconjugated)
newborn, ABO/Rh HDN
AD; ↓ uptake and conjugation; bilirubin

Gilbert's disease
increases with fasting
unconjugated hyperbilirubinemia; begins on

Physiologic jaundice newborn
day three
% CB 20-50% viral/alcoholic hepatitis
bile duct obstruction (intra or extrahepatic);

% CB >50%
carcinoma head of pancreas
Negative urine bilirubin + trace

normal urine
urobilinogen
Positive urine bilirubin, absent

obstructive jaundice
urobilinogen
Positive urine bilirubin + increased

hepatitis
urobilinogen
Negative urine bilirubin + increased

extravascular hemolytic anemia
urobilinogen
Markers of severity of liver disease albumin, PT

protective antibodies; day care centers, jails,

Hepatitis A
homosexuals, traveling; not chronic
protective antibodies; accidental needle stick,

Hepatitis B
IVDA; hepatocellular carcinoma
no protective antibodies; post-transfusion

Hepatitis C hepatitis; chronic state; hepatocellular
carcinoma
no protective antibodies; requires HBsAg to

Hepatitis D
replicate
Anti-HBs alone vaccination
Anti-HBs + anti-HBc-IgG recovered from HBV
HBsAg + HBeAg + HBVDNA + anti- acute HBV/chronic HBV infective carrier if >6
HBc-IgM 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
E. coli in adults; S. pneumoniae in children;

Spontaneous peritonitis
complication of ascites
Granulomatous hepatitis TB MC bacteria
Entamoeba histolytica; flask shaped ulcers in

Amebiasis
cecum; liver abscess; Rx
Echinococcus granulosis; sheep dog definitive

Echinococcosis
host; man intermediate host
Schistosoma mansoni; adult worms in portal

Schistosomiasis
vein; "pipe stem cirrhosis"
Clonorchis sinensis; ingesting encysted larvae

Clonorchiasis
in fish; cholangiocarcinoma

Congestive hepatomegaly
"nutmeg" liver; RHF MCC
(centrilobular necrosis)
Budd-Chiari syndrome; painful hepatomegaly;

Hepatic vein thrombosis
ascites; portal hypertension
Portal vein thrombosis ascites, portal hypertension, no hepatomegaly
Alcohol related disorders fatty change; alcoholic hepatitis; cirrhosis
↑ synthesis of glycerol 3P (substrate for TG

Hypertriglyceridemia in alcoholics
synthesis)
↓ gluconeogenesis (↑ NADH causes pyruvate to

Hypoglycemia in alcoholics
convert to lactate)
↑ lactate, ↑ ßOHB (acetyl CoA converted to AcAc

Ketoacidosis in alcoholics
and then ßOHB)
granulomatous destruction triad bile ducts;

Primary biliary cirrhosis
anti-mitochondrial antibody
association with ulcerative colitis; MCC of

Primary sclerosing cholangitis
cholangiocarcinoma
Extrahepatic biliary atresia neonatal cholestasis
Drugs causing hepatitis acetaminophen, isoniazid, halothane
Anabolic steroids intrahepatic cholestasis
intrahepatic cholestasis; hepatic adenoma

Estrogen/oral contraceptives
(intraperitoneal hemorrhage)
Methotrexate liver fibrosis, fatty change
Liver angiosarcoma vinyl chloride
AR; increased iron reabsorption; liver target

Hemochromatosis
organ
S/S cirrhosis; "bronze diabetes" - skin

pigmentation + destruction of islet cells;

malabsorption
Lab ↑ serum ferritin, iron, % saturation; ↓ TIBC
AR disease; defect in copper excretion in bile

Wilson's disease
and synthesis of ceruloplasmin
cirrhosis, movement disorder (necrosis in

S/S putamen), Kayser Fleisher ring (Descemet's
membrane)
↓ ceruloplasmin (causes ↓ total copper); ↑

Lab
serum/urine free copper
pre-eclampsia; Hemolytic anemia, ELevated

HELLP syndrome
transaminases, Low Platelets
AR, cannot secrete AAT from liver cell;

AAT deficiency in child
cirrhosis; hepatocellular carcinoma
coma and microvesicular fatty change post viral

Reye syndrome
infection; increased ammonia
irreversible fibrosis; regenerative nodules;

Cirrhosis
portal hypertension
alcohol (MC), HBV/HCV, hemochromatosis,

Causes cirrhosis
Wilson's, AAT deficiency, 1° biliary
Hepatic encephalopathy mental status changes; ↑ serum ammonia
ascites; varices; splenomegaly; hemorrhoids;

Portal hypertension
caput medusae
portal hypertension; hypoalbuminemia;

Cause of ascites
secondary aldosteronism
use aldosterone blocker (acidosis increases loss

Rx
ammonium in stool)
gynecomastia; spider angiomas; female hair

Hyperestrinism in men
distribution

↓ BUN, glucose, sodium, potassium, calcium (↓

Lab findings cirrhosis
vitamin D); ↑ PT
estrogen related (steroids, oral contraceptives);

Liver cell adenoma
intraperitoneal hemorrhage
metastasis MC cancer; lung cancer MC primary

Liver cancer
site
chronic HBV and HCV MCC; ↑ AFP;

Hepatocellular carcinoma
hepatic/portal vein invasion
primary sclerosing cholangitis MCC, C.C

Cholangiocarcinoma
sinensis
bile with too much cholesterol and too little bile

Pathogenesis of cholesterol stones
salts
sign of extravascular hemolytic anemia

Black pigment stones
(spherocytosis, HbSS)
stone impacted in cystic duct; right upper

Acute cholecystitis
quadrant colicky pain with radiation to shoulder
Chronic cholecystitis chemical inflammation
risk factors - cholelithiasis and porcelain

Gallbladder cancer
gallbladder
causes - alcohol and gallstones; ↑ amylase and

Acute pancreatitis
lipase (more specific)
S/S epigastric pain with radiation into back
localized ileus of duodenum due to acute

Sentinel loop
pancreatitis
abdominal mass; persistence of ↑ serum

Pancreatic pseudocyst
amylase >1 week
alcohol abuse, CF; malabsorption, pain, type I

Chronic pancreatitis
diabetes

Pancreatic cancer smoking MCC
jaundice/acholic (gray/pale) stools; palpable

S/S gallbladder; superficial migratory
thrombophlebitis (Trousseau's sign); ↑ CA 19-9
First sign tubule cell dysfunction inability to concentrate urine
chronic renal failure; cannot concentrate or

Fixed specific gravity
dilute urine
Negative urine bilirubin + trace

normal urine
urobilinogen
Positive urine bilirubin, absent

obstructive jaundice
urobilinogen
Positive urine bilirubin + increased

hepatitis
urobilinogen
Negative urine bilirubin + increased

extravascular hemolytic anemia
urobilinogen
Positive urine nitrite + positive

urinary tract infection
urine leukocyte esterase
positive urine leukocyte esterase but negative

Sterile pyuria
standard culture; TB, C. trachomatis
↑ BUN and creatinine; ↓ renal blood flow (e.g.

Prerenal azotemia
heart failure, hypovolemia)
↑ BUN and creatinine due to intrinsic renal

Renal azotemia
disease (acute tubular necrosis)
↑ BUN and creatinine due to obstruction to

Postrenal azotemia
urine flow
<15:1 (renal failure); >15:1 (prerenal or

Serum BUN:creatinine ratio
postrenal azotemia)
BUN 80 mg/dL:creatinine 8 mg/dL ratio 10/1 - renal failure

ratio 40/1 - prerenal azotemia or postrenal

BUN 80 mg/dL:creatinine 2 mg/dL
azotemia
Creatinine clearance measures GFR
Proteinuria important sign of renal dysfunction
RBC casts nephritic type of glomerulonephritis
acute pyelonephritis, acute tubulointerstitial

WBC casts
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
MC childhood cystic disease; abnormal

Renal dysplasia
development; flank mass
fetal juvenile polycystic kidney disease; Potter's

Maternal oligohydramnios
facies in newborn
AD; hypertension MC sign; cerebral berry

Adult polycystic kidney disease
aneurysms
Visceral epithelial cells synthesize basement membrane
Glomerular BM negative charge due to heparan sulfate
oliguria; RBC casts; hypertension; mild to

Nephritic syndrome
moderate proteinuria
proteinuria >3.5 g/day; ascites and pitting

Nephrotic syndrome
edema; fatty casts; fusion of podocytes
Immunofluorescence linear (anti-glomerular BM antibodies); granular

(IC deposition)
MC GN; usually nephritic; episodic hematuria;

IgA GN
mesangial IC (lgA-anti-IgA) deposits
nephritic; subepithelial deposits;

Post-streptococcal GN
skin/pharyngeal infections; anti-DNAase B
nephritic; subendothelial deposits; anti-DNA

SLE type IV GN
antibodies
crescents from parietal cell proliferation; worst

Crescentic GN
GN; Goodpasture's, Wegener's
nephritic; anti-BM antibodies (glomerular +

Goodpasture's
pulmonary capillary); crescentic GN
young male with hemoptysis progressing to

S/S
renal failure
Minimal change disease (lipoid

MCC childhood nephrotic syndrome
nephrosis)
podocyte fusion; loss of negative charge in

Lipoid nephrosis
glomerular BM
Focal segmental glomerulosclerosis nephrotic syndrome; AIDS and IV heroin abuse
MCC adult nephrotic syndrome; subepithelial

Membranous GN
deposits; epimembranous spikes
Causes membranous GN HBV, ACE inhibitors, cancer
nephrotic; subepithelial deposits; HCV

Type I MPGN
association; tram tracks
nephrotic; C3 nephritic factor;

Type II MPGN
intramembranous ICs (dense deposit disease)
DM nodular glomerulosclerosis microalbuminuria first sign
DM glomerulosclerosis nodules with collagen in mesangium; hyaline

arteriolosclerosis of arterioles
inhibit angiotensin II vasoconstriction of

ACE inhibitors
efferent arterioles
XD hereditary nephritis with sensorineural

Alport's syndrome
hearing loss
prerenal azotemia MCC; renal tubular cell casts;

Ischemic ATN
BUN:creatinine ratio <15:1
disruption of BM in proximal tubule and thick

Ischemic ATN
ascending limb
aminoglycosides, IVP dye, Pb/mercury

Nephrotoxic ATN
poisoning
Nephrotoxic ATN proximal tubule dysfunction; intact BM
prerenal azotemia, ATN, glomerulonephritis,

Oliguria
postrenal azotemia
vesicoureteral reflux with ascending infection;

Acute pyelonephritis
WBC casts, fever, flank pain
Chronic pyelonephritis U-shaped scars overlying blunt calyces
Drug-induced tubulointerstitial
type I/IV reaction; e.g., penicillin
nephritis
ARF, fever, rash, eosinophilia, eosinophiluria,

S/S
WBC casts
aspirin plus acetaminophen; renal papillary

Analgesic nephropathy
necrosis; IVP with ring defect
BJ protein produces foreign body reaction in

Myeloma kidney
tubules
prevent by giving allopurinol prior to

Urate nephropathy
chemotherapy

fixed specific gravity; BUN:creatinine <15:1;

CRF
waxy and broad casts
hypovitaminosis D (no 1-α-hydroxylase);

Renal osteodystrophy CRF
produces osteomalacia
Renal osteodystrophy CRF osteoporosis from metabolic acidosis
secondary HPTH with increased osteoclastic

Renal osteodystrophy CRF
activity
pericarditis, prolonged bleeding time,

S/S CRF
normocytic anemia, pathologic fractures
kidney of hypertension; shrunken kidneys due

Benign nephrosclerosis
to hyaline arteriolosclerosis
renal failure; encephalopathy; BP >210/120

Malignant hypertension
mm Hg; IV nitroprusside
necrotizing arteriolitis; "flea bitten" kidney;

Renal findings
hyperplastic arteriolosclerosis
pale infarcts; hematuria; common in

Renal infarction
polyarteritis nodosa
renal stone MCC; atrophy of cortex/medulla;

Hydronephrosis
postrenal azotemia
most contain calcium (calcium

Renal stones oxalate/phosphate); hypercalciuria MC risk
factor
colicky pain radiating into groin, hematuria; x-

S/S
ray usually shows stone
due to urease producing organisms (Proteus);

Staghorn calculus
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
flank mass, hematuria; ectopic hormones (EPO,

S/S
PTH related peptide), left-sided varicocele
Renal pelvis transitional cell smoking MCC, phenacetin, aniline dyes,

carcinoma cyclophosphamide
hypertension, unilateral abdominal mass in

Wilm's tumor
child; aniridia/hemihypertrophy in AD types
Urine draining from umbilicus persistent urachus
Retroperitoneal fibrosis produces hydronephrosis
Bladder extrophy abdominal wall defect + epispadias
most commonly due to prostatic hyperplasia

Bladder diverticula
with urethral obstruction
E. coli; females > males; no fever, flank pain, or

Acute cystitis
WBC casts
smoking MCC, aniline dyes, cyclophosphamide;

Bladder transitional cell carcinoma
papillary
S/S hematuria; hydronephrosis
Bladder adenocarcinoma risk factors persistent urachus, extrophy
Bladder squamous cell carcinoma Schistosoma hematobium infection
ventral opening on penis due to failure closure

Hypospadias
of urethral folds
dorsal opening on penis due to defect in genital

Epispadias
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
undescended testis; risk for seminoma applies

Cryptorchidism
to cryptorchid testis and normal testis
mumps usually unilateral (infertility

Orchitis
uncommon)
<35 - N. gonorrhoeae, C. trachomatis; >35 - E.

Epididymitis
coli, P. aeruginosa
scrotal pain relieved by elevation of scrotum

S/S
(Prehn's sign)
left-sided scrotal mass; spermatic vein drains

Varicocele
into left renal vein; infertility common
may be due to invasion of left renal vein by

Varicocele
renal cell carcinoma
persistent tunica vaginalis; scrotum

Hydrocele
transilluminates
Torsion of testicle testicle high in canal; absent cremasteric reflex
unilateral painless mass that does not

Testicular cancer
transilluminate
cryptorchid testis, Klinefelter's, testicular

Risk factors
feminization
MC cancer; radiosensitive; large cells with

Seminoma
lymphoid infiltrate; small percentage have ↑hCG
Spermatocytic variant >65 yrs of age
hemorrhage/necrosis; hematogenous spread

Embryonal carcinoma
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
MC type in elderly; metastasis not primary

Malignant lymphoma
cancer
DHT derived stimulation embryo; periurethral

Prostate
area - hyperplasia; peripheral area - cancer
Prostatitis perineal pain, fever; WBCs at end of voiding
DHT/estrogen-mediated; glandular/smooth
Benign prostatic hyperplasia
muscle hyperplasia
all men develop; urethral obstruction MC

S/S (hesitancy, dribbling, nocturia), hematuria,
dysuria Rx
DHT-mediated; palpable with rectal exam;

Prostate cancer
osteoblastic metastasis (↑ AP)
sensitive but not specific for prostate cancer; ↑

PSA
in hyperplasia
Kallmann's syndrome absent GnRH, anosmia, absence of taste
failure to sustain an erection; psychogenic in

Impotence
most cases (erections present at night)
Erection parasympathetic response
Ejaculation sympathetic response
Leydig cell failure ↑ LH; ↓ testosterone, sperm count; normal FSH
↑ FSH (↓inhibin); ↓ sperm count; normal LH and

Seminiferous tubule failure
testosterone
Leydig and seminiferous tubule

↑ FSH and LH; ↓ testosterone and sperm count
failure
Y chromosome determines genetic sex

develops seminal vesicles, epididymis, vas

Testosterone
deferens
Dihydrotestosterone (DHT) develops prostate and male external genitalia
Male pseudohermaphrodite genetic male; phenotypically female
XR; deficient androgen receptors; MCC male

Testicular feminization
pseudohermaphrodite
XXY; 1 Barr body; female secondary sex

Klinefelter's syndrome
characteristics
recurrent painful vesicles; multinucleated

Herpes genitalis
squamous cells with intranuclear inclusions
condyloma acuminata; koilocytosis (wrinkled

Human papilloma virus
nuclei surrounded by a halo)
metaplastic squamous cells with vacuoles

Chlamydia trachomatis
containing elementary bodies
non-specific urethritis, cervicitis, PID,

S/S
ophthalmia neonatorum
urethritis, cervicitis, PID; ophthalmia

Neisseria gonorhoeae
neonatorum, gram negative diplococcus
Ophthalmia neonatorum first week N gonorrhoeae
Ophthalmia neonatorum second

C. trachomatis
week
Lymphogranuloma venereum C. trachomatis subtype
scrotal/vulva lymphedema; granulomatous

S/S
microabscesses; rectal strictures in females
Chancroid painful ulcer, adenopathy, Hemophilus ducreyi
Calymmatobacterium granulomatis; raised

Granuloma inguinale
ulceration but no lymphadenopathy

spirochete; produces vasculitis of arterioles

Treponema pallidum
(plasma cell infiltrate)
Primary syphilis painless chancre
rash on palms/soles; condyloma lata;

Secondary syphilis
generalized adenopathy
neurosyphilis (e.g., tabes dorsalis), aortic arch

Tertiary syphilis
aneurysm, gummas
reagin antibodies against cardiolipin; ↓ titer

RPR/VDRL
with Rx of syphilis
false positive with anticardiolipin antibodies

RPR/VDRL
(common in SLE)
confirmatory test for syphilis; not distinguish

FTA-ABS
active from treated disease
FTA-ABS remains positive after Rx
flagellate protozoan; cervicitis/vaginitis; Rx

Trichomonas vaginalis
metronidazole both partners
vaginal pH >5; bacterial vaginosis; clue cells;

Gardnerella vaginalis
Rx metronidazole
white, curd-like discharge; DM, antibiotics,

Candida vaginitis
pregnancy; Rx fluconazole
Vulvar squamous cancer MC vulvar cancer; HPV association
Vulvar leukoplakia biopsy to R/O squamous dysplasia/cancer
epidermal atrophy; slight risk for squamous

Lichen sclerosis vulva
cancer
Squamous hyperplasia vulva leukoplakia; no cancer risk
intraepithelial adenocarcinoma (mucin

Paget's disease
production) of vulva

vulva location; similar to Paget cells but not

Malignant melanoma
mucin positive
Gartner's duct cyst lateral wall vagina; persistent mesonephric duct
Embryonal rhabdomyosarcoma bloody, grape-like vaginal mass young girl
maternal exposure to DES; precursor clear cell

Vaginal adenosis
adenocarcinoma vagina
Vaginal squamous cancer usually extension of cervical cancer
Rokitansky-Kiister-Hauser absence of vagina and uterus
endocervical glands covered by metaplastic

Nabothian cysts
squamous epithelium
trichomonas, HSV-2, C. trachomatis (follicular

Pathologic cervicitis
cervicitis)
superficial squamous (estrogen), intermediate

Cervical Pap
(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
begins in transformation zone; associated with

Cervical dysplasia
low and high risk HPV
Risk factors cervical early onset sexual activity; multiple partners;

dysplasia/cancer smoking; OC
cervical intraepithelial dysplasia; mild,

CIN
moderate, severe (in-situ)

↓ incidence (Pap smear); 45-yr-old; COD renal

Cervical cancer
failure from obstruction of ureters
S/S cervical discharge; bleeding after intercourse
breast budding, growth spurt, pubic hair,

Sequence to menarche
axillary hair, menarche
estrogen-dependent; ↑estrogen inhibits FSH

Proliferative phase cycle
and stimulates LH
day 14-I6; LH surge; subnuclear vacuoles;

Ovulation
↑body temperature
Secretory phase cycle progesterone-dependent
drop in estrogen/progesterone stimulates

Menses
apoptosis; plasmin prevents clotting
stimulates follicle and aromatase synthesis in

FSH
granulosa cells
stimulates androgen synthesis in proliferative

LH phase and progesterone synthesis in secretory
phase
Day 21 day of implantation of fertilized egg
↑plasma volume > RBC mass; ↑GFR;

Pregnancy
↑thyroxine/cortisol (increased binding proteins)
hCG LH analogue produced by syncytiotrophoblast
stimulates corpus luteum of pregnancy to

hCG
synthesize progesterone for 8-10 weeks
estrogen of postmenopausal woman;

Estrone
aromatization of adrenal androstenedione
estrogen of non-pregnant woman in

Estradiol
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
hirsutism + male secondary sex characteristics

Virilization
(clitoromegaly)
↑ testosterone - ovarian source; ↑DHEA-sulfate

Test for hirsutism/virilization
- adrenal source
Polycystic ovarian syndrome (POS) ↑ LH; ↓ FSH; ↑ estrogen and androgens
hirsutism, oligomenorrhea, infertility; enlarged

S/S
ovaries with subcortical cysts; LH:FSH >2:1
excess menstrual flow; MCC iron deficiency in

Menorrhagia
women
Dysmenorrhea painful menses; 1° PGF2α, 2° endometriosis
bleeding related to hormone rather than

DUB
anatomic causes
menarche and perimenopause; estrogen excess

Anovulatory DUB
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
↓ FSH/LH; e.g., hypopituitarism
dysfunction
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
constitutional delay MCC
secondary sex characteristics
Primary amenorrhea-lack secondary

Turner's
sex characteristics
XO; no Barr bodies; XO/XY types have

Turner's syndrome
gonadoblastomas; streak gonads (no eggs)
newborn with lymphedema hands/feet; cystic

S/S hygroma in neck (web); short stature; 1°
amenorrhea
pregnancy MCC; prolactinoma; anorexia

Secondary amenorrhea
nervosa; pituitary adenoma
removal of stratum basalis causing scarring;

Asherman syndrome
secondary amenorrhea
group B streptococcus; intrauterine device

Endometritis
(Actinomyces); chronic - plasma cells
menorrhagia; not a precursor for endometrial

Endometrial polyp
cancer
functioning endometrial glands and stroma in

Adenomyosis
myometrium; enlarged uterus
functioning glands and stroma outside uterus;

Endometriosis
reverse menses; ovary MC site
dysmenorrhea, painful stooling, bowel

S/S
obstruction; "powder burn" appearance
unopposed estrogen; simple/complex types;

Endometrial hyperplasia
precursor endometrial cancer
obesity, estrogen Rx, polycystic ovarian

Causes
syndrome
Endometrial cancer obesity, nulliparity, estrogen Rx, early

menarche/late menopause; OC protective
S/S bleeding in postmenopausal woman
menorrhagia, obstructive delivery; not a

Leiomyoma uterus
precursor for leiomyosarcoma
Leiomyosarcoma MC sarcoma
PID MC risk factor; intraperitoneal hemorrhage;

Ectopic pregnancy
screen with ß-hCG
Follicular cyst MC ovarian mass in young woman
Risk factors ovarian tumors nulliparity and genetic factors; OC protective
surface-derived; ↑ bilaterality; psammoma

Serous ovarian tumors
bodies in malignant type
surface-derived; pseudomyxoma peritonei in

Mucinous ovarian tumors
malignant type
resembles endometrial cancer; association with

Endometrioid carcinoma
endometriosis
MC benign germ cell tumor (<1% malignant);

Cystic teratoma
hair/teeth; calcifications
MC malignant germ cell tumor; associated with

Dysgerminoma
streak gonads of Turners
MC germ cell tumor young girl; ↑AFP; Schiller-

Yolk sac tumor
Duval bodies
ovarian fibroma, ascites, right-sided pleural

Meigs syndrome
effusion
low grade malignant; hyperestrinism, Call Exner

Granulosa tumor
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
lining of villi; produces hCG and human

Syncytiotrophoblast
placental lactogen
responsible for mild glucose intolerance in

Human placental lactogen
pregnancy
retroplacental clot; painful bleeding;

Abruptio placenta
hypertension, cocaine, smoking
placenta implanted over cervical os; painless

Placenta previa
bleeding
direct implantation into myometrium without

Placenta accreta
intervening decidua; hysterectomy
monochorionic always identical twins;

Twin placenta
dichorionic may be identical or fraternal
Siamese twins monoamniotic monochorionic twin placenta
Enlarged placenta DM, Rh HDN, syphilis
benign neoplasm of chorionic villi; dilated villi;

Complete mole
no embryo; 46 XX (both male)
preeclampsia in first trimester; ↑ incidence

S/S
choriocarcinoma
embryo present; 68 XXY; no transformation

Partial mole
into choriocarcinoma
malignancy of trophoblastic tissue

Choriocarcinoma
(syncytiotrophoblast, cytotrophoblast)
complete mole (MC), spontaneous abortion,

Risk factors
normal pregnancy

S/S ↑hCG; lung metastasis; good prognosis
Chorioamnionitis group B streptococcus (S. agalactiae) infection
abnormal placentation causing placental

Preeclampsia
ischemia; ↑ in vasoconstrictors (ATII)
hypertension, proteinuria, pitting edema;

S/S
begins in third trimester
Spontaneous abortion 50% have karyotype deformity (trisomy 16)
Amniotic fluid fetal urine
TE fistula, duodenal atresia, open neural tube

Polyhydramnios
defects
Oligohydramnios infantile polycystic disease
↑ Serum AFP open neural tube defect
↓ Serum AFP Down syndrome
fetal adrenal, placental, maternal liver involved

Urine estriol
in its production
Down syndrome triad ↑ ß-hCG, ↓ serum AFP, ↓ urine estriol
MC breast mass <50-yrs-old; atypical

Fibrocystic change
hyperplasia cancer risk; lumpy, painful breasts
component of FCC; involves terminal lobules

Sclerosing adenosis
often has microcalcifications
benign stromal tumor; MC movable mass in

Fibroadenoma
women <35-yrs-old
benign tumor lactiferous duct/sinus; MCC

Intraductal papilloma
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
painless mass upper outer quadrant in woman

Breast cancer
>50-yrs-old
Mammography screening test to detect non-palpable masses
order fine needle aspiration (not a

Palpable breast mass
mammogram)
necrotic centers (comedo); microcalcifications

Ductal carcinoma in situ
common
invasive ductal cancer into nipple; Paget's cells

Paget's disease of breast
similar to vulvar Paget's
bulky tumor with large cells and lymphoid

Medullary carcinoma infiltrate; more common in Pt with BRCA 1
mutation
orange peel appearance; lymphatics blocked by

Inflammatory carcinoma
tumor (lymphedema)
Lobular cancer MC cancer of terminal lobule; ↑ bilaterality
Phyllodes tumor low grade malignant tumor of stroma
tumors responding to hormones; candidate for

ER-PR positive tumors
tamoxifen (anti-estrogen)
ERB-B2 oncogene positive breast

aggressive breast cancer
cancer
Gynecomastia estrogen stimulation of male breast
normal in newborn, puberty (no surgery), old

Gynecomastia age; (micronodular) cirrhosis MC pathologic
cause
most often adenomas; use suppression tests

Overactive endocrine syndrome
(most do not suppress)

prolactinoma (bromocriptine), pituitary

Tumors that suppress
Cushings (high dose dexamethasone)
Underactive endocrine syndrome autoimmune destruction MCC; stimulation tests
non-functioning adenoma MCC, Sheehan's

Hypopituitarism adults
postpartum necrosis (stop lactation)
craniopharyngioma (Rathke's pouch remnant)

Hypopituitarism in children
MCC; visual field defects
S/S ↓ FSH and LH amenorrhea, ↓ testosterone in male
muscle growth, gluconeogenesis; release of

Growth hormone functions
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
secondary hypothyroidism; ↓ T4, ↓ TSH; muscle

S/S ↓ TSH
weakness, dry skin
secondary hypocortisolism; ↓ cortisol, ↓ ACTH;

S/S ↓ ACTH
fatigue; hypoglycemia
Metyrapone stimulation test for ACTH reserve
blocks adrenal 11-hydroxylase → ↑ ACTH and

Metyrapone
11-deoxycortisol (proximal to block)
Metyrapone test ↓ ACTH and 11-

pituitary/hypothalamic dysfunction
deoxycortisol
Metyrapone test ↑ ACTH and 11-

Addison's disease
deoxycortisol
loss ADH (central), refractory to ADH

Diabetes insipidus
(nephrogenic); always diluting urine

↓ UOsm and ↑ POsm with water deprivation;

Central diabetes insipidus (CDI)
vasopressin causes ↑ UOsm > 50%
pituitary stalk transection, hypothalamic lesion

Causes CDI
(site for ADH synthesis)
Nephrogenic diabetes insipidus ↓ UOsm and ↑ POsm with water deprivation;

(NDI) vasopressin causes ↑ UOsm < 50%
lithium, demeclocycline, nephrocalcinosis,

Causes NDI
severe hypokalemia
GH secreting pituitary adenoma before

Gigantism
epiphyses have fused
GH secreting pituitary adenoma after epiphyses

Acromegaly
have fused
cardiomyopathy; large hands, feet, jaw;

S/S acromegaly
hyperglycemia
Prolactin inhibited by dopamine
MC pituitary tumor; secondary amenorrhea and

Prolactinoma
galactorrhea; prolactin inhibits GnRH
Rx surgery or bromocriptine (dopamine analog)
Other causes hyperprolactinemia primary hypothyroidism, drugs
hyponatremia <120 mEq/L; ↑ UOsm (always

Inappropriate ADH syndrome
concentrating urine)
small cell carcinoma lung, CNS injury,

Causes
chlorpropamide
restrict water; demeclocycline in small cell

Rx
carcinoma
↑ or ↓ in free hormone or thyroid binding

Serum T4
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
negative feedback with T4 and T3; best

TSH
screening test
↑ in Graves; ↓ in thyroiditis, patient taking

I131 uptake
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
painful thyroid; early thyrotoxicosis; ↓ I131

Acute/subacute thyroiditis
uptake
MCC hypothyroidism; HLA Dr3/Dr5; inhibitory

Hashimoto's thyroiditis
IgG TSH receptor antibody
Hashimoto's thyroiditis ↑ anti microsomal and thyroglobulin antibodies
muscle weakness, periorbital puffiness, ↓

S/S reflexes, diastolic hypertension, constipation,
dry skin
Lab ↓ T4, ↑ TSH
maternal hypothyroidism before fetal thyroid

Cretinism
developed, genetic disorder
mental retardation; short stature and increased

S/S
weight; coarse skin

any cause ↑ thyroid hormone activity; Graves

Thyrotoxicosis
disease, excess hormone, thyroiditis
↑ synthesis thyroid hormone; Graves disease

Hyperthyroidism
and toxic nodular goiter
autoantibody against TSH receptor (type II

Graves disease
reaction); HLA Dr3
S/S unique to Graves exophthalmos, pretibial myxedema
tachycardia/atrial fibrillation, systolic

S/S thyrotoxicosis
hypertension, diarrhea, brisk reflexes
Lab thyrotoxicosis ↑ T4, ↓ TSH, ↑ glucose, ↑ calcium
↑ Graves, toxic nodular goiter; ↓ thyroiditis,

I131 uptake
excess hormone, hypothyroidism
ß-blocker; drug to decrease hormone synthesis

Rx Graves disease
(propylthiouracil)
hyperthyroidism; develops out of a

Toxic nodular goiter
multinodular goiter; no exophthalmos
enlarged thyroid; iodine deficiency MCC;

Goiter
relative thyroid hormone deficiency
rapid enlargement due to hemorrhage into cyst;

S/S
Rx thyroxine
Solitary thyroid nodule woman most often benign (cyst)
Solitary thyroid nodule man or child often malignant
MC thyroid cancer; radiation exposure;

Papillary carcinoma thyroid
psammoma bodies
Follicular carcinoma thyroid invades blood vessels
parafollicular cells; calcitonin; amyloid

Medullary carcinoma thyroid
(calcitonin conversion)

3 P's; pituitary tumor, parathyroid adenoma,

MEN I syndrome
pancreatic tumor (ZE or ß-islet cell tumor)
2 P's; medullary carcinoma thyroid,

MEN IIa syndrome
pheochromocytoma, parathyroid adenoma
1 P; medullary carcinoma thyroid,

MEN IIb syndrome
pheochromocytoma, mucosal neuromas
tetany with normal total calcium, ↓ ionized

Alkalotic pH
calcium and ↑ PTH
↓ total calcium, normal ionized calcium and

Hypoalbuminemia
PTH
↓ ionized calcium level; threshold potential

Tetany
comes closer to resting potential
thumb adducts into palm, twitching after

S/S
tapping of facial nerve
maintains ionized Ca2+; ↑ Ca2+ renal

PTH reabsorption; ↓ phosphate/bicarbonate
reabsorption in kidneys
Primary HPTH ↑ Ca2+, hypophosphatemia, ↑ PTH
Cause adenoma MCC, hyperplasia, cancer
renal stone, peptic ulcers, pancreatitis,

S/S
hypertension, metastatic calcification
↓ Ca2+, ↑ PTH; hypovitaminosis D from renal

Secondary HPTH
failure MCC
↑ Ca2+, ↓ PTH; all other non-parathyroid

Malignancy-induced hypercalcemia
causes same results
osteolytic lesions, sarcoidosis, ↑ vitamin D,

Causes hypercalcemia
PTH-related peptide, myeloma
Tertiary HPTH hypercalcemia developing from secondary

HPTH
Primary hypoparathyroidism ↓ Ca2+ and ↓ PTH
previous thyroid surgery, autoimmune,

Causes
DiGeorge syndrome
S/S tetany; calcification basal ganglia
↓ Ca2+ with normal to ↑ PTH; end-organ

Pseudohypoparathyroidism
resistance to PTH
hypomagnesemia (↓ PTH), ↓ vitamin D,

Other causes ↓ Ca2+
DiGeorge
↓ Ca2+ and ↓ PTH primary hypoparathyroidism
↓ Ca2+ and ↑ PTH secondary hyperparathyroidism
↑ Ca2+ and ↑ PTH primary hyperparathyroidism
malignancy induced hypercalcemia; other

↑ Ca2+ and ↓ PTH
causes hypercalcemia
meningococcemia with bilateral adrenal

Waterhouse-Friderichsen syndrome
hemorrhage due to DIC
autoimmune destruction adrenal cortex MCC,

Addison's disease
adrenogenital syndrome, metastasis
hypotension (salt loss), hyperpigmentation

S/S
(ACTH), hypoglycemia
Lab ↓ sodium, ↓ cortisol, ↑ potassium, ↑ ACTH
AR; enzyme deficiency; hypocortisolism;

Adrenogenital syndrome
hyperpigmentation from ↑ ACTH
↑ 17 KS, ↓ 17 OH, lose salt, hypotension; female

21-Hydroxylase deficiency
pseudohermaphrodite
↑ 17 KS, ↑ 17 OH, retain salt, hypertension;

female pseudohermaphrodite

↓ 17 KS, ↓ 17 OH, retain salt, hypertension;

male pseudohermaphrodite
MCC Cushings long-term corticosteroid therapy
low/high dose dexamethasone suppression;

Tests Cushings syndrome
urine free cortisol (best test)
Normal dexamethasone
cortisol analogue; ↓ ACTH and ↑ cortisol
suppression
Pituitary Cushings MCC Cushing's; ACTH secreting pituitary tumor
low dose dexamethasone not suppress cortisol;

Lab
high dose suppresses
adrenal adenoma secreting cortisol; suppressed

Adrenal Cushings
ACTH
no suppression with low/high dose

Lab
dexamethasone
ACTH secreting small cell carcinoma of lung;

Ectopic Cushings
high ACTH and cortisol levels
no suppression with low/high dose

Lab
dexamethasone
S/S Cushings purple stria, truncal obesity, hypertension, DM
Primary aldosteronism benign adenoma in zona glomerulosa
hypertension and muscle weakness

S/S
(hypokalemia), no pitting edema
hypernatremia, hypokalemia, metabolic

Lab
alkalosis, ↑ urine K+ and Na+
Pheochromocytoma benign tumor in adrenal medulla in adults
von Hippel Lindau, neurofibromatosis, MEN IIa

Associations
and IIb

labile hypertension, anxiety, sweating,

S/S
headache
Lab ↑ 24 hr urine for VMA and metanephrines
malignant tumor adrenal medulla child;

Neuroblastoma
widespread metastasis; hypertension
benign tumor; hypoglycemia, ↑ insulin and C-

ß-islet cell tumor (insulinoma)
peptide
Patient taking excess insulin hypoglycemia, ↑ insulin, ↓ C-peptide
malignant α-islet cell tumor; hyperglycemia

Glucagonoma
and rash
malignant islet cell tumor secreting gastrin;

Zollinger Ellison syndrome
peptic ulcers
malignant δ islet cell tumor; DM,

Somatostatinoma
malabsorption, cholelithiasis, achlorhydria
malignant islet cell tumor; diarrhea,

VIPoma
hypokalemia, achlorhydria
DM organ damage correlates with glycemic control
young, thin person; no insulin; HLA DR3/4;

Type 1
insulitis; islet cell antibodies; ketoacidosis
older person; obese; relative insulin deficiency

Type 2
(↓ insulin receptors, postreceptor problems)
family history; fibrotic islet cells with amyloid;

Type 2
hyperosmolar nonketotic coma
glucose attaches to amino acids in basement

↑ Non-enzymatic glycosylation
membranes
↑ vessel permeability producing hyaline

Non-enzymatic glycosylation
arteriolosclerosis

glucose converted into sorbitol by aldose

Osmotic damage
reductase
lens (cataracts), Schwann cell (neuropathy),

Osmotic damage
pericytes retinal vessels (microaneurysms)
↑ gluconeogenesis (most important),

Pathogenesis hyperglycemia
glycogenolysis
no insulin to stimulate capillary lipoprotein

Pathogenesis hyperlipidemia
lipase; ↑ chylomicrons/VLDL
↑ oxidation fatty acids with excess acetyl CoA;

Pathogenesis ketoacidosis
liver synthesis ketone bodies
neuropathy, blindness, CRF, hyperglycemia,

Most commons due to DM
non-traumatic amputation
measure of long term glycemic control (8-12

Glycosylated HbA1c
weeks)
Gestational DM ↑ placental size, human placental lactogen
macrosomia (↑ muscle/fat from insulin), RDS,

Complications
newborn hypoglycemia (↑ insulin)
insulin/oral hypoglycemics MCC, liver disease;

Hypoglycemia
carnitine deficiency
no ß-oxidation of fatty acids; all cells compete

Carnitine deficiency
for glucose
yellow when parallel to slow ray of

Monosodium urate crystals (MSU)
compensator
Calcium pyrophosphate crystals

blue when parallel to slow ray of compensator
(pseudogout)
degeneration articular cartilage; subchondral

Osteoarthritis
cysts; eburnation; osteophytes at margins
Joints weight bearing (femoral head); DIP joint

(Heberden's nodes), PIP joints (Bouchard nodes)
2° to neurologic disease; DM, syringomyelia,

Neuropathic joint
tabes dorsalis
Rheumatoid arthritis (RA) female dominant; HLA Dr4
IgM antibody against Fc portion IgG; causes

RF
inflammation of synovial tissue
inflamed hyperplastic synovial tissue destroys

Pannus
articular cartilage; joint fusion
Joints MCP and PIP joints
morning stiffness; ulnar deviation of hands;

S/S
carpal tunnel (entrapped median nerve)
methotrexate often used as initial therapy,

Rx
aspirin
destruction lacrimal and minor salivary glands;

Sjogren's syndrome
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
underexcretion of uric acid; big toe first

Gouty arthritis
affected; tophus in soft tissue sign chronic gout
Gout associations alcohol, Pb poisoning
MSU crystals produce foreign body giant cell

Tophus
reaction next to joint
Uricosuric agents probenecid and sulfinpyrazone
Allopurinol ↓ synthesis uric acid; xanthine oxidase inhibitor
Pseudogout involves knee; linear calcification in articular

cartilage
HLA-B27 seronegative (RF negative)

Ankylosing spondylitis
spondyloarthropathy; male dominant
sacroiliitis; bamboo spine causing kyphosis;

S/S
aortitis; uveitis
C. trachomatis MC, psoriasis, ulcerative colitis,

Associations
Shigella, Campylobacter, Yersinia
HLA-B27; Chlamydia urethritis; arthritis;

Reiter's syndrome
conjunctivitis; Achilles tendon periostitis
hematogenous spread of Staphylococcus

Osteomyelitis children
aureus to metaphysis
Osteomyelitis in HbSS Salmonella paratyphi
Pseudomonas aeruginosa puncture of foot when wearing rubber foot

osteomyelitis wear
Tuberculous osteomyelitis usually involves vertebra (Pott's disease)
Disseminated gonococcemia female dominant; C6-C9 deficiency
septic arthritis (knee); tendinitis/synovitis and

Disseminated gonococcemia
skin pustules in feet/wrists
bite Ixodes tick; Borrelia burgdorjeri; reservoirs

Lyme disease
white footed mouse, white tailed deer
erythematous concentric rash (erythema

Early S/S
chronicum migrans), Rx doxycycline
arthritis, Bell's palsy (often bilateral),

Late S/S
myocarditis, Rx doxycycline
carried by Ixodes tick; Babesia are

Babesiosis
intraerythrocytic parasites; hemolytic anemia
Cat bite potential for Pasteurella multocida septic

arthritis
inflammation proximal tibial apophysis at

Osgood Schlatter's
patellar tendon insertion; knobby knee
AD; ↓ synthesis type I collagen; pathologic

Osteogenesis imperfecta
fractures; blue sclera
Blue sclera reflection choroidal veins
AD; impaired enchondral calcification and

Achondroplasia
premature closure of epiphyses
normal head/vertebral column, short

S/S
extremities
AD/AR; osteoclast defect; too much bone;

Osteopetrosis
pathologic fractures
Osteoporosis ↓ bone mass and density; pathologic fractures
estrogen deficiency - ↑ osteoclastic activity, ↓

Postmenopausal osteoporosis
osteoblastic activity
S/S vertebral compression fractures, Colles fracture
fractured distal radius with dinner fork

Colles fracture
appearance
estrogen (under investigation), calcium, vitamin

Prevention
D, stress exercises (walking, weight lifting)
femoral head fracture, corticosteroids, sickle

Aseptic necrosis femoral head
cell disease; MRI best test
Scaphoid bone fracture aseptic necrosis in wrist bone
fracture of distal radius; damage to brachial

Volkmann's ischemic contracture
artery and median nerve
aseptic necrosis of ossification center (femoral

Legg-Perthe's disease
head) in children

elderly males; lytic/blastic bone lesions

Paget's disease
produce thick, weak bone
pathologic fractures; ↑ serum AP; ↑ risk for

S/S
osteogenic sarcoma
radiolucent lesion in cortex proximal femur;

Osteoid osteoma
nocturnal pain relieved by aspirin
adolescent male; RB suppressor gene

Osteogenic sarcoma
association; distal femur; ↑ AP
Radiograph "sunburst" appearance, Codman's triangle
primitive neuroectodermal tumor; round cell

Ewing's sarcoma
tumor
Radiograph "onion skinning"
MC benign bone tumor; exophytic growth off

Osteochondroma
metaphysis of distal femur
MC malignant cartilaginous tumor; pelvic

Chondrosarcoma
bones, proximal femur
epiphysis distal femur/proximal tibia; giant

Giant cell tumor
cells + neoplastic mononuclear cells
primary muscle disease, neurosynapse disease,

Muscle weakness
neurogenic disease
XR; deficiency dystrophin; ↑ serum CK at birth;

Duchenne's muscular dystrophy
waddling gait
attaches portions of cell membrane to

Dystrophin
sarcomere; important in contraction
Becker's dystrophy XR, defective dystrophin
AD; trinucleotide repeat disorder; cannot

Myotonic dystrophy
release grip

autoantibody against acetylcholine receptors

Myasthenia gravis
(type II); thymic hyperplasia B cells
diplopia at end of day first sign; dysphagia

S/S
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
type III reaction; confirm with anti-dsDNA,

SLE
anti-Sm
malar rash, photophobia, joint pain, fibrinous

S/S
pericarditis, nephritic GN
procainamide, hydralazine; anti-histone

Drug-induced lupus
antibodies
lupus anticoagulant, anti-cardiolipin

Antiphospholipid antibodies
antibodies; vessel thrombosis
PSS excess collagen; anti-topoisomerase antibodies
dysphagia solids/liquids, Raynaud's, interstitial

S/S
lung disease, renal failure
centromere antibody/calcinosis; Raynaud;

CREST esophageal dysmotility; sclerodactyly;
telangiectasia
Dermatomyositis/polymyositis ↑ serum CK; risk of malignancy
Mixed connective tissue disease anti-ribonucleoprotein antibody

Antibody against acetylcholine

myasthenia gravis
receptor
Antibody against basement

Goodpasture's syndrome
membrane
Antibody against endomysium and

celiac disease
gliadin
Antibody against insulin and islet

type I diabetes
cell
Antibody against intrinsic factor

pernicious anemia
and parietal cell
Antibody against microsome and

Hashimoto's thyroiditis
thyroglobulin
Antibody against mitochondria primary biliary cirrhosis
Antibody against proteinase 3 of

Wegener's granulomatosis
neutrophil (cANCA)
Antibody against myeloperoxidase

microscopic polyangiitis
of neutrophils (pANCA)
Antibody against TSH receptor Graves disease
↑ thickness of stratum corneum; absent

Ichthyosis vulgaris
granular layer
Solar lentigo "liver spot" in elderly; increased melanocytes
trauma to fragile vessels on dorsum of hands;

Senile purpura
normal finding in elderly
Acute eczema weeping rash with vesicles
Chronic eczema dry, thickened, pruritic skin
dry skin, eczema (type I reaction); children -

Atopic dermatitis
face, intertriginous areas

Allergic contact dermatitis type IV hypersensitivity; poison ivy, nickel rash
Contact photodermatitis tetracycline; rash in sun exposed areas
KOH preparation shows fungi located in

Superficial dermatophytoses
stratum corneum
Trichophyton tonsurans MCC (negative Wood's

Tinea capitis
lamp)
Tinea capitis child with dog Microsporum canis (positive Wood's lamp)
hypopigmentation; Malassezia furfur;

Tinea versicolor
"spaghetti" (hyphae)/"meatball" KOH
Seborrheic dermatitis dandruff; Malassezia furfur
poxvirus; bowl-shaped with central depression

Molluscum contagiosum
filled with keratin
Rubeola Koplik's spots; Warthin-Finkeldey giant cells
teratogenic; rash; postauricular adenopathy;

Rubella
arthritis in adults
"slapped face"; RBC aplasia, aplastic anemia

Parvovirus
(HbSS), spontaneous abortions, arthritis
Roseola HSV-6; high fever and then rash
toxin-producing S. aureus; tampon wearing;

Toxic shock syndrome
hypotension, desquamating rash
group A streptococcus with erythrogenic toxin;

Scarlet fever
strawberry tongue
precursor for squamous cell carcinoma; recur

Actinic (solar) keratosis
when scrapped off
elevated salmon-colored plaques covered by

Psoriasis
silver-colored scales; nail pitting
Pityriasis rosea herald patch followed by rash in lines of

cleavage
chickenpox; rash at different stages; Reye

Varicella
syndrome association
Herpes zoster vesicular rash following a sensory dermatome
HSV and Varicella-zoster virus remain latent in sensory ganglia
group A streptococcus; honey crusted lesions

Impetigo
on face
autoimmune disease; IgG antibodies against

Pemphigus vulgaris
intercellular attachment sites
intraepidermal bullae; acantholytic cells; row of

Pemphigus vulgaris
tombstones
autoimmune disease; IgG antibodies against

Bullous pemphigoid
basement membrane
Bullous pemphigoid subepidermal bullae
Pemphigus vulgaris/bullous
type II hypersensitivity
pemphigoid
autoimmune disease; IgA ICs; subepidermal

Dermatitis herpetiformis
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
androgen dependent (receptor on sebaceous

Acne vulgaris
glands)
Propionibacterium acnes lipases produce fatty

Acne vulgaris
acids causing inflammation

pustular, erythematous lesion on face

Acne rosacea
resembling malar rash
type I and III reactions; type I due to mast cell

Urticaria
release of histamine (drugs, fire ant bites)
Angioedema subcutaneous swelling
ACE inhibitor (bradykinin); C1 esterase inhibitor

Causes
deficiency (C2 and C4 decreased)
traumatic implantation of Sporothrix fungus

Sporotrichosis
into subcutaneous tissue
rose gardener, lobster fisherman (sphagnum

Causes
moss)
S/S chain of subcutaneous nodules
intact cellular immunity (positive lepromin skin

Tuberculoid leprosy
test); granulomas; no organisms
autoamputation of digits; skin depigmentation

S/S
and anesthesia
defective cellular immunity (negative lepromin

Lepromatous leprosy
skin test); no granulomas
leonine face, erythema nodosum during

S/S
treatment
Grenz zone (zone free organisms) foamy

Histology
macrophages with organisms
Rx dapsone
painful nodule on shins; subcutaneous fat

Erythema nodosum
inflammation
Associations coccidioidomycosis, TB, leprosy
Keratoacanthoma benign neoplasm; mimics squamous cancer;

spontaneously resolves
basal cell carcinoma, squamous cell carcinoma,

UVB light cancers
malignant melanoma
autoimmune destruction melanocytes

Vitiligo
producing skin depigmentation
pigmented, wart-like lesion; "stuck on"

Seborrheic keratosis
appearance
multiple outcroppings seborrheic keratosis;

Leser-Trelat sign
consider stomach cancer
verrucoid pigmented lesion usually in axilla;

Acanthosis nigricans
associated with gastric cancer
Chloasma pregnancy mask due to increased melanocytes
Nevocellular nevus benign pigmented tumor modified melanocytes
nevus cells proliferate along basal cell area,

Histology
dermis, or both
Dysplastic nevus precursor for malignant melanoma
malignant tumor of melanocytes; most rapidly

Malignant melanoma
increasing cancer worldwide
A, asymmetry; B, irregular border; C, color

ABCD for melanoma
change; D, increased diameter
severe sunburn at early age (MC), dysplastic

Risk factors
nevi
spreads laterally in epidermis/superficial

Radial growth phase
dermis but does not result in metastasis
malignant cells penetrate into dermis; potential

Vertical growth
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
photosensitive bullous disease; deficiency

Porphyria cutanea tarda
uroporphyrinogen decarboxylase
hypertrichosis, fragile skin, port wine colored

S/S
urine (uroporphyrins)
Black widow (Latrodectus)

neurotoxin; abdominal muscle cramps
envenomation
Brown recluse (Loxosceles)

necrotoxin; skin ulcer
envenomation
choroid plexus in ventricles; enters

CSF subarachnoid space; removed by arachnoid
granulations
less protein and glucose than serum; scant

CSF
number of cells; ↑ chloride
yellow colored CSF due to bilirubin pigment;

Xanthochromia
indicates subarachnoid hemorrhage
sign of cerebral edema (intracranial

Papilledema of optic nerve
hypertension)
intracranial hypertension; medial portion

Uncal herniation
temporal lobe through tentorium cerebelli
midbrain hemorrhage; CN III palsy (pupil

S/S
down/out); mydriasis
Mydriasis in uncal herniation compression of parasympathetic system

Cerebellar tonsils herniate into

intracranial hypertension
foramen magnum
Hydrocephalus ↑ CSF volume with distention of ventricles
Non-communicating blockage aqueduct Sylvius MCC newborn
choroid plexus papilloma; scarring of arachnoid

Communicating
granulations
progressive dementia, wide-based gait, urinary

Adults with hydrocephalus
incontinence; THINK
folate must be adequate before pregnancy; ↑

Open neural tube defects
AFP
dimple overlying skin L5-S1; vertebral arch not

Spina bifida occulta
completely closed
Meningocele vertebral defect with meninges
Meningomyelocele vertebral defect with meninges and spinal cord
elongation medulla/cerebellar tonsils through

Arnold Chiari syndrome
foramen magnum
hydrocephalus, syringomyelia,
S/S
meningomyelocele
Dandy Walker syndrome hypoplasia of cerebellar vermis; hydrocephalus
enlarged cervical cord; fluid filled cyst in

Syringomyelia
cervical spinal cord
loss pain/temperature upper extremities

S/S (spinothalamic); motor loss in hands (anterior
horn cells)
AD; mental retardation; hamartomas

Tuberous sclerosis
CNS/kidney; shagreen patches skin
Tuberous sclerosis angiomyolipomas kidneys; rhabdomyoma of

heart
AD; pigmented neurofibromas; cafe au lait

Neurofibromatosis
spots
pheochromocytoma, brain tumors, acoustic

Associations
neuromas
Meningitis nuchal rigidity
↑ CSF protein, normal CSF glucose, ↑

CSF findings viral meningitis
lymphocytes
CSF findings bacterial meningitis ↑ CSF protein, ↓ CSF glucose, ↑ neutrophils
inflammation of brain; mental status

Encephalitis
abnormalities; coma
Coxsackievirus MCC viral meningitis
HSV-1 hemorrhagic necrosis in temporal lobes
skunk and bat common vectors; Negri bodies in

Rabies
neurons; hydrophobia; flaccid paralysis
intranuclear inclusions; periventricular

CMV
calcification in congenital infection
destruction of anterior horn cells; flaccid

Polio virus
paralysis
slow virus disease due to rubeola (measles

Subacute sclerosing panencephalitis
virus)
Progressive multifocal slow virus disease due to JC virus; common in

leukoencephalopathy AIDS
Creutzfeldt-Jakob disease prions; spongiform encephalopathy
contact with human brain or contaminated beef

Risk factors
(bovine disease)
Meningitis newborn Streptococcus agalactiae (group B) MCC; E. coli,

2nd MCC
newborn meningitis; gram + rods; pregnant

Listeria monocytogenes
mother should avoid soft cheeses
MCC meningitis 1 month - 18-yrs-old;

Neisseria meningitidis
petechia and DIC characteristic
Streptococcus pneumoniae MCC meningitis >18-yrs-old
complication primary TB; base of brain

Mycobacterium tuberculosis
meningitis with vasculitis
Neurosyphilis CSF with positive VDRL
Meningovascular syphilis vasculitis causing strokes
General paresis syphilis with dementia and brain atrophy
posterior root ganglia/posterior column; ataxia;

Tabes dorsalis absent deep tendon reflexes; Argyll-Robertson
pupil
pupil accommodates but does not react to

Argyll-Robertson pupil
direct light; THINK
MC opportunistic CNS fungal disease; positive

Cryptococcus neoformans
India ink
Mucor species frontal lobe abscess in diabetic ketoacidosis
MCC space occupying lesion in AIDS; avoid cat

Toxoplasma gondii
litter and raw meat in pregnancy
calcification basal ganglia; blindness; mental

Congenital toxoplasmosis
retardation
Naegleria and Acanthamoeba amoeba in fresh water; meningoencephalitis
pork tapeworm; adult with worms definitive

Taenia solium
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
contusion on opposite side of injury; frontal

Contrecoup injuries
and temporal lobes
temporoparietal skull fracture; tear middle

Epidural hematoma
meningeal artery
tear bridging veins; venous blood clot;

Subdural hematoma
fluctuating levels of consciousness
neurons more susceptible to damage than

Hypoxic injury
neuroglial cells
liquefactive necrosis at watershed areas in

Laminar necrosis
cortex
pale infarction (liquefactive necrosis) extending

Atherosclerotic stroke
to periphery of cerebral cortex
thrombosis of middle cerebral artery or carotid

Causes atherosclerotic stroke
artery
contralateral weakness/sensory loss;

MCA stroke
expressive aphasia if left hemisphere stroke
loss vision described as curtain going down

Amaurosis fugax
and then up
embolus atherosclerotic plaque to branch of

Cause
retinal artery (Hollenhorst plaque)
vertigo, ataxia, ipsilateral sensory loss

Vertebrobasilar stroke
face/contralateral hemiparesis/sensory
hemorrhagic infarction extending to periphery

Embolic stroke
cerebral cortex due to embolization
Intracerebral hemorrhage complication hypertension

Cause of intracerebral hemorrhage rupture of aneurysm of lenticulostriate vessels
Location of intracerebral
basal ganglia MC site
hemorrhage
rupture of congenital berry aneurysm; severe

Subarachnoid hemorrhage
occipital headache
microinfarctions; due to hyaline

Lacunar stroke
arteriolosclerosis (hypertension, diabetes)
Pure motor stroke posterior limb internal capsule
Pure sensory stroke thalamus
autoimmune destruction myelin

Multiple sclerosis sheath/oligodendrocytes; plaques in white
matter
scanning speech, intention tremor, nystagmus,

S/S
paresthesias, weakness
Bilateral internuclear
multiple sclerosis; demyelination MLF
ophthalmoplegia
CSF with oligoclonal bands sign of demyelination
rapid intravenous correction of hyponatremia in

Central pontine myelinolysis
alcoholic
Alzheimer's disease MCC dementia Alzheimer's disease
↑ amyloid-ß destroys neurons; occipital lobe

Alzheimer's disease
spared
↑ density of neurofibrillary tangles and senile

Alzheimer's disease
plaques
develop Alzheimer's disease at early age; 3

Down syndrome
functioning chromosome 21s
Apo E gene allele ε4 gene product has high affinity for amyloid-ß

depigmentation substantia nigra neurons; Lewy

Parkinson's disease
bodies; ↓ dopamine
extrapyramidal (muscle rigidity), resting

S/S
tremor, festinating (shuffling) gait
CO poisoning, Wilson's, MPTP (meperidine

Causes
derivative), drugs
AD; atrophy of the head of the caudate nucleus;

Huntington's disease
trinucleotide repeat disorder (anticipation)
S/S movement disorder; dementia
degeneration of lower/upper motor neurons;

Amyotrophic lateral sclerosis (ALS)
no sensory changes
Werdnig Hoffman disease childhood type of ALS
AR; excess copper; cystic degeneration of

Wilson's disease
putamen/globus pallidus
posterior column (↓ proprioception, vibration);

Vitamin B12 deficiency
lateral corticospinal tract (UMN)
Wernicke-Korsakoff syndrome, cerebellar

Alcohol
atrophy, central pontine myelinolysis
thiamine deficiency; IV with glucose can prompt

Wernicke encephalopathy
acute attack
mammillary body hemorrhage (ring

Wernicke encephalopathy
hemorrhages)
S/S confusion, ataxia, nystagmus, ophthalmoplegia
limbic system; antegrade and retrograde

Korsakoff's psychosis
memory deficits
AD; deficiency uroporphyrinogen synthase; ↑

Acute intermittent porphyria (AIP)
porphobilinogen

drug induced (alcohol, barbiturates); abdominal

S/S
pain ("bellyful of scars"); dementia
urine in AIP colorless; turns port wine color

Window sill test
with exposure to light (porphobilin)
heme infusions (inhibits δ-aminolevulinic acid

Rx
synthetase)
Adult brain tumors 70% supratentorial; frontal lobe MC site
Childhood brain tumors 70% infratentorial; cerebellum MC site
Adult brain tumors (descending

GBM, meningioma, acoustic neuroma
order)
high grade astrocytoma; hemorrhage and

GBM
necrosis; may cross corpus callosum
female dominant; arise from arachnoid

Meningioma
granulations; psammoma bodies; seizures
schwannoma of the VIIIth nerve; tinnitus;

Acoustic neuroma
sensorineural hearing loss; neurofibromatosis
Childhood brain tumors astrocytoma cerebellum (MC), medulloblastoma
MC primary brain tumor; frontal lobe MC site in

Astrocytoma
adult; cerebellum MC site in child
malignant tumor cerebellum; invades fourth

Medulloblastoma
ventricle
arises in 4th ventricle in children and cauda

Ependymoma
equina in adults
Oligodendroglioma frontal lobe tumor with dystrophic calcification
metastasis MCC; primary CNS lymphoma

CNS lymphomas
associated with EBV in AIDS
Metastasis MC brain malignancy; lung cancer MC site of

origin; junction gray and white matter
benign tumor Schwann cell; MC peripheral

Schwannoma
nerve tumor; alternating dark and light areas
AIDS dementia due to HIV; multinucleated microglial cells
MCC of blindness in AIDS; Rx. ganciclovir

CMV retinitis
(foscarnet if unsuccessful)
myelin destruction (sensory; paresthesias);

Peripheral neuropathy
axon destruction (muscle atrophy)
DM MCC; thiamine/pyridoxine deficiency; vinca

Peripheral neuropathy
alkaloids (vincristine)
MCC autoimmune demyelination of peripheral

Guillain-Barre syndrome
and spinal nerves
M. pneumoniae, influenza vaccine,

Risk factors
Campylobacter jejuni
ascending paralysis; CSF increased protein,

S/S
lymphocytes; Rx. plasmapheresis
AD; common peroneal nerve palsy; inverted

Charcot-Marie-Tooth
bottle appearance
facial muscle paralysis due to inflammation of

Idiopathic Bell's palsy
cranial nerve VII
facial nerve MC cranial nerve involved; bilateral

Lyme disease
Bell's palsy
Bacterial conjunctivitis Staphylococcus aureus
Viral conjunctivitis adenovirus MC; HSV-1 (dendritic ulcers)
amaurosis fugax, central retinal artery or vein

Sudden loss of vision
occlusion
Uveitis inflammation of iris, choroid, ciliary body;

blurry vision; ankylosing spondylitis,

sarcoidosis
multiple sclerosis MCC; methyl alcohol

Optic neuritis
poisoning
increased intraocular pressure; fluid cannot exit

Glaucoma
canal of Schlemm; causes optic atrophy
Optic atrophy blindness; pale disc; glaucoma, optic neuritis
Macular degeneration MCC permanent visual loss in elderly
increased endolymph; tinnitus, vertigo,

Meniere's disease
sensorineural hearing loss
Presbycusis MCC sensorineural hearing loss in elderly
MCC conductive hearing loss in elderly; fusion

Otosclerosis
of ear ossicles
Impacted wax in outer ear canal conduction hearing loss
Weber test lateralizes to left ear,

conduction loss left ear
bone>air conduction (Rinne test)
Weber test lateralizes to left ear,

sensorineural hearing loss right ear
air>bone conduction both ears
MCC conduction hearing loss in children; S.

Otitis media
pneumoniae MCC
Malignant external otitis in diabetic Pseudomonas aeruginosa
60-70% total lymphocyte count; ↓ AIDS,

T cells
DiGeorge, adenine deaminase deficiency
10-20% total lymphocyte count; ↓ Bruton's,

B cells
adenine deaminase deficiency
Antigen presenting cells B cells, macrophages, dendritic cells
Langerhan's cells antigen presenting cell in skin

Major histocompatibility complex chromosome 6; HLA genes for self-identity
Class I proteins recognized by CD8 T cells and NK cells
Class II proteins recognized by CD4 TH cells
IgE antibodies; mast cells; wheal and flare with

Type I reactions
bee sting
antibody-mediated; Goodpasture's syndrome,

Type II reactions
rheumatic fever
immune complex-mediated; SLE

Type III reactions
glomerulonephritis
Type IV reactions cellular immunity; granuloma, positive PPD
Delayed reaction hypersensitivity

CD4 TH cells and macrophages
reactions
CD8 T cells; killing viral infected cells and

Cytotoxic reactions
neoplastic cells
Graft viability ABO compatibility most important; HLA match
Fetus allograft that is not rejected
type II hypersensitivity; ABO incompatibility or

Hyperacute rejection
anti-HLA antibodies
predominately cell-mediated reaction; MC

Acute rejection
rejection
Graft vs. host reaction jaundice, rash, bloody diarrhea
MC hereditary immunodeficiency; giardiasis,

IgA immunodeficiency
allergies
XR; pre B cannot develop into B cells; S.

Bruton's agammaglobulinemia
pneumoniae infections
failure 3rd/4th pharyngeal pouches to develop;

DiGeorge syndrome
T cell deficiency; absent thymus

absent thymic shadow; Candida, Pneumocystis

S/S DiGeorge syndrome
infections; hypoparathyroidism
AR; combined B and T cell deficiency; gene

Adenine deaminase deficiency
therapy
XR; combined B and T cell deficiency; eczema,

Wiskott Aldrich syndrome
thrombocytopenia
AIDS MC acquired immunodeficiency HIV
MC sexually-transmitted; anal intercourse in

HIV transmission
homosexuals MCC
HIV transmission in health care accidental needle stick from HIV positive
workers patient
Follicular dendritic cell reservoir for HIV in lymph nodes in latent phase
HIV positive plus CD4, TH cell ≤200 cells/μL or

AIDS
AIDS-defining condition
Pneumocystis carinii pneumonia MC AIDS-defining disorder
Screening test for HIV ELISA test; detects anti-gp120
Confirmatory test for HIV Western blot
p24 antigen; positive prior to seroconversion

HIV test with two peaks
and when AIDS is diagnosed
MC cancer in AIDS Kaposi sarcoma
MC infections CD4 TH <100

CMV, toxoplasmosis, M. avium-intracellulare
cells/μL
deficiency C1 esterase inhibitor; ↓ C2, C4,

Hereditary angioedema
normal C3
H2O shift between ECF and ICF; controlled by

Osmosis
serum Na+ and glucose
Serum Na+ ~ TBNa+/TBW decreased TBNa+ dehydration; increased

TBNa+ pitting edema
serum Na+ normal; adult diarrhea, loss whole

Isotonic loss
blood; Rx with 0.9% saline
serum Na+ normal; Rx with salt and H2O

Isotonic gain
restriction
ICF expanded; central pontine myelinolysis with

Hyponatremia
rapid IV correction
Hyponatremia hypotonic gain pure

inappropriate ADH syndrome
water
Hyponatremia hypotonic gain

pitting edema; cirrhosis, RHF
TBNa+ and TBW
Hyponatremia hypertonic loss dehydration; loop diuretic, Addison's, 11-

TBNa+ hydroxylase deficiency
hypernatremia or hyperglycemia; ICF

Hypertonic state
contraction
Hypernatremia hypertonic gain

pitting edema; sodium bicarbonate
TBNa+
Hypernatremia hypotonic loss water diabetes insipidus
Hypernatremia hypotonic loss

osmotic diuresis, sweat, baby diarrhea
TBNa+ and TBW
Acidosis potential for hyperkalemia (shift out of ICF)
Alkalosis potential for hypokalemia (shift into ICF)
loop and thiazide diuretics MCC; alkalosis,

Hypokalemia
albuterol/insulin; U wave
renal failure MCC; acidosis, ß-blocker, digitalis

Hyperkalemia
toxicity; peaked T wave
Rx hyperkalemia calcium gluconate → insulin with glucose →

loop diuretic
PaCO2 >45 mm Hg; compensation metabolic

Respiratory acidosis
alkalosis
chronic bronchitis, ARDS, barbiturate

Respiratory acidosis
poisoning, paralysis diaphragms
PaCO2 <33 mm Hg; compensation metabolic

Respiratory alkalosis
acidosis
pulmonary embolus, anxiety, early bronchial

Respiratory alkalosis
asthma, restrictive lung disease
HCO3- >28 mEq/L; compensation respiratory

Metabolic alkalosis
acidosis
loop/thiazide diuretics, vomiting, primary

Metabolic alkalosis
aldosteronism
HCO3- <2 mEq/L; compensation respiratory

Metabolic acidosis
alkalosis
↑ AG metabolic acidosis add anions of acid to extracellular fluid
lactate, AcAc, ß-OHB, salicylate, oxalate

↑ AG metabolic acidosis (ethylene glycol), formate (methyl alcohol),
phosphate/sulfate (renal failure)
compete with alcohol for alcohol

Ethylene glycol, methyl alcohol
dehydrogenase
antifreeze; converted to oxalic acid; renal

Ethylene glycol poisoning
failure
window wiper fluid; converted to formic acid;

Methyl alcohol poisoning
blindness
lose HCO3-; e.g., diarrhea, proximal/distal

Normal AG metabolic acidosis
renal tubular acidosis
AFP increased in open neural tube defects;

decreased in Down syndrome
PCR uses DNA polymerase
inactive X chromosome on nuclear membrane;

Barr body
1 Barr body in females
point mutation with different amino acid; sickle

Missense mutation
cell trait/disease, Marfan
point mutation producing stop codon; ß-

Nonsense mutation
thalassemia major
insertion or deletion nucleotides alters reading

Frameshift mutation
frame; Tay-Sachs
disease worse in future generations

Trinucleotide repeat
(anticipation)
fragile X (XR), Huntington's (AD), myotonic

Trinucleotide repeat disorders
dystrophy (AD)
Nondisjunction meiosis; unequal numbers of chromosomes
Robertsonian translocation Down syndrome with 46 chromosomes
Microdeletion syndrome genomic imprinting; chromosome 15
Paternal microdeletion Prader-Willi; obese, mental retardation
Angelman's syndrome; happy puppy syndrome,

Maternal microdeletion
mental retardation
Advanced maternal age increased risk for trisomies
Down syndrome trisomy 21; leading cause mental retardation
slanted eyes; simian crease; endocardial

S/S
cushion defect; Alzheimer's
XO; no Barr bodies; short stature and primary

Turner's syndrome
amenorrhea; streak ovaries

XXY; 1 Barr body; female secondary sex

Klinefelter's syndrome
characteristics
homozygous (aa) for disease; heterozygotes

AR
(Aa) asymptomatic
most inborn errors metabolism, sickle cell,

AR
cystic fibrosis, hemochromatosis, Wilson's
homozygote (aa) or heterozygote (Aa) express

AD
disease
spherocytosis, Marfan's syndrome,

AD neurofibromatosis, von Willebrand, familial
polyposis, polycystic kidney
delayed manifestation; penetrance; variable

AD
expressivity
male transmits to all daughters; female carrier

XR
transmits to 50% of sons
G6PD deficiency, Bruton, Lesch-Nyhan,

XR testicular feminization, fragile X, hemophilia
A/B
mental retardation; macroorchidism at puberty;

Fragile X
trinucleotide repeat
XR; deficiency HGPRT; hyperuricemia; mental

Lesch Nyhan
retardation
Multifactorial inheritance gout, type 2 diabetes, essential hypertension
maternal transmission to all children; no

Mitochondrial DNA disorder
paternal transmission
Y chromosome determines genetic sex
develops seminal vesicles, epididymis, vas

Testosterone
deferens

Dihydrotestosterone develops prostate and male external genitalia
Male pseudohermaphrodite genetic male; phenotypically female
Female pseudohermaphrodite genetic female; phenotypically male
XR; deficient androgen receptors; MCC male

Testicular feminization
pseudohermaphrodite
↑ 17 KS, ↓ 17 OH, lose salt, hypotension; female

pseudohermaphrodite
↑ 17 KS, ↑ 17 OH, retain salt, hypertension;

female pseudohermaphrodite
↓ 17 KS, ↓ 17 OH, retain salt, hypertension;

male pseudohermaphrodite
Calculate prevalence carrier rate 1:30; couples at risk
Calculate carrier rate 1:3600; 3600 /4 = 900; √900) = 1:30
Malformation intrinsic problem with morphogenesis
HOX gene involved in embryogenesis
MCC of malformations; mental retardation;

Alcohol
atrial septal defect
Isotretinoin acid craniofacial and cardiac defects
Female with cystic acne needs Rx do pregnancy test before placing female on
with retinoic acid drug
problem with mullerian development; clear cell

DES
carcinoma of vagina
Thalidomide limb abnormalities
Vertical transmission transplacental (MC), delivery, breast feeding
MC congenital infection; periventricular

Congenital CMV
calcification; culture urine

basal ganglia calcification; blindness; avoid cat

Congenital toxoplasmosis
litter in pregnancy
Congenital rubella sensorineural hearing loss (MC); cataracts
transplacental after 5-6 months; saddle nose,

Congenital syphilis
rhagades, blindness, deformed teeth
Congenital herpes contracted during delivery; encephalitis
extrinsic problem in fetal development;

Deformation
oligohydramnios causing Potter's facies
leading cause premature death and cancer in

Tobacco
United States
most addictive substance; attaches to nicotinic

Nicotine
cholinergic receptors
lung, oropharynx, larynx, pancreas, kidney,

Tobacco induced cancers
bladder
CNS depressant (cortex, limbic system); legally

Alcohol
drunk 80-100 mg/dL
induces SER hyperplasia; increases alcohol

Alcohol
metabolism
folate/thiamine deficiency; sideroblastic

Alcohol MCC of
anemia; liver fatty change; pancreatitis
hypoglycemia; lactic/ketoacidosis; ↑
Alcohol
triglyceride; AST>ALT; ↑ GGT
Ketoacidosis in alcoholic ß-hydroxybutyric acid
poppy plant; non-cardiogenic pulmonary

Heroin
edema; focal segmental glomerulosclerosis
MPTP meperidine derivative; produces parkinsonism
Cocaine blocks uptake of dopamine/norepinephrine;

mydriasis; AMI, CNS infarction
tetrahydrocannabinol (THC) binds basal ganglia

Marijuana receptors; delayed reaction time; red
conjunctiva
Intravenous drug abuse HBV hepatitis MC systemic disease
damage by FR acetaminophen; liver cell

Acetaminophen toxicity
necrosis; renal papillary necrosis
N-acetylcysteine (increases synthesis of

Rx acetaminophen toxicity
glutathione)
metabolic acidosis + respiratory alkalosis;

Salicylate toxicity
hyperthermia; tinnitus, vertigo
thromboembolism; cholestasis;
Estrogen risks
endometrial/breast cancer
cholestasis, thrombosis, folate deficiency,

Oral contraceptives
hypertension, hepatic adenoma
Hemolytic anemia penicillin, methyldopa, quinidine
Aplastic anemia benzene, chloramphenicol
Qualitative platelet dysfunction NSAIDs
Thrombocytopenia heparin, quinidine
methotrexate, 5-fluorouracil, phenytoin, OC,

Macrocytic anemia
alcohol
Congestive cardiomyopathy doxorubicin, daunorubicin
Interstitial fibrosis bleomycin, methotrexate
Hemorrhagic gastritis iron toxicity, NSAIDs
acetaminophen, isoniazid, salicylates,

Liver necrosis
halothane, isotretinoin acid

Cholestasis anabolic steroids, OC
Fatty change in liver amiodarone, tetracycline, alcohol
Photosensitive rash tetracycline
SLE procainamide, hydralazine
Isopropyl alcohol ↑ acetone; CNS dysfunction
microcytic anemia, nephrotoxic ATN (proximal

Lead
tubule), gout, encephalopathy, neuropathy
fish (tuna, salmon); nephrotoxic ATN;

Mercury
constricted visual fields
blocks acetylcholine esterase; miosis; paralysis;

Organophosphates
Rx. atropine, pralidoxime
Polyvinyl chloride plastic pipes; angiosarcoma of liver
Scorpion sting paralysis, hypertension, pancreatitis
rattlesnakes, water moccasin, copperhead; DIC;

Crotaline bite
serum sickness
neurotoxin; binds to presynaptic nerve

Coral snake bite
terminals and acetylcholine receptors
Contact gunshot wound soot + gunpowder (fouling)
Intermediate gunshot wound powder tattooing
no powder tattooing; exit wound larger than

Distant gunshot wound
entrance
leading cause accidental death between 1-39

Motor vehicle accidents
yrs of age
Burns Pseudomonas aeruginosa sepsis MC COD
First degree burn painful; complete healing
Second degree burn painful; blister; complete healing

Third degree burn painless; scarring
Frostbite painless; ice crystallization in cells
AC worse than DC; decreasing resistance (wet

Electrical injury
skin) increases current
House fires carbon monoxide and cyanide poisoning
Heat exhaustion fever and sweating
Heat stroke fever and anhydrosis
Near drowning survival following asphyxia due to submersion
initial laryngospasm then relaxation and water

Wet drowning
into lungs
Dry drowning intense laryngospasm without aspiration
Cold water drowning shunts blood from periphery to central core
Drowning hypoxemia key COD
headache MC; non-cardiogenic pulmonary

Acute mountain sickness
edema (immediate descent)
normal %O2; decreased barometric pressure;

High altitude
respiratory alkalosis; ↑ 2, 3 BPG
Ionizing radiation DNA most susceptible protein
lymphoid tissue most radiosensitive; bone least

Ionizing radiation
radiosensitive
leukemia (most common); thyroid cancer;

Ionizing radiation cancers
osteogenic sarcoma
basal cell carcinoma (most common);

UVB-related cancers
squamous cancer; melanoma
Carbohydrates digestion begins in mouth
Fats digestion begins in small intestine

Essential fatty acid deficiency dermatitis, hair loss, poor wound healing
Proteins digestion begins in stomach
↓ protein intake; ↓ visceral protein; ↓ albumin

Kwashiorkor
(pitting edema); fatty liver
total calorie deprivation; ↓ somatic protein;

Marasmus
broomstick extremities
starvation; secondary amenorrhea (↓ GnRH);

Anorexia nervosa
osteoporosis; ventricular MC COD
binging with vomiting; hypokalemic metabolic

Bulimia nervosa
alkalosis; ventricular MC COD
Body mass index (BMI) weight in kg/height in m2
hypertension (MC), cholecystitis, osteoarthritis,

Obesity
type 2 DM, endometrial/breast cancer
obesity gene product released from adipose;

Leptin
maintains energy balance
Rx acute promyelocytic leukemia; matures

All-trans retinoic acid
blasts to neutrophils
maintain visual purple, prevent squamous

Vitamin A
metaplasia, growth
night blindness; blindness; squamous

Vitamin A deficiency
metaplasia
↑ intracerebral pressure; papilledema; hepatic

Vitamin A toxicity
necrosis
Vitamin D maintain ionized Ca2+; mineralization of bone
skin photoconversion or reabsorb in gut → 1st

hydroxylation liver → 2nd hydroxylation
Vitamin D metabolism
proximal tubule (1-α-hydroxylase) Vitamin D
deficiency

renal failure MCC; malabsorption; liver disease;

Causes
↓ sunlight
↓ Ca2+, ↓ phosphate (malabsorption), ↑

Lab
phosphate renal failure, ↑ PTH
Hypervitaminosis D ↑ Ca2+, renal stones
Vitamin E prevents FR damage of cell membrane
hemolytic anemia; posterior

Vitamin E deficiency
column/spinocerebellar tract degeneration
↓ synthesis vitamin K-dependent

Vitamin E toxicity
procoagulation factors; anticoagulated
Vitamin K γ-carboxylates vitamin K-dependent factors
↓ epoxide reductase activity (↓ function vitamin

Vitamin K deficiency
K); hemorrhagic diathesis; ↑ PT
Warfarin inhibits epoxide reductase
antibiotics MC, newborn, malabsorption,

Causes vitamin K deficiency
warfarin
transketolase; dehydrogenase reactions (NADH

Thiamine functions
for ATP synthesis)
pyruvate → acetyl CoA; pyruvate

Example of dehydrogenase reaction
dehydrogenase
Thiamine deficiency alcohol MCC; ↓ ATP synthesis
dry beriberi - Wernicke's, Korsakoff's,

S/S peripheral neuropathy; wet beriberi -
cardiomyopathy
Niacin oxidation-reduction reactions; NAD; NADP
Niacin deficiency pellagra; dermatitis, diarrhea, dementia
Tryptophan synthesis niacin, serotonin

Hartnup's disease (↓ reabsorption neutral

Tryptophan deficiency
amino acids); carcinoid syndrome
S/S niacin deficiency diarrhea, dermatitis, dementia
Corn deficient in niacin and tryptophan
heme synthesis, transamination,

Pyridoxine
neurotransmitter synthesis
Cause taking isoniazid
sideroblastic anemia; convulsions; peripheral

Pyridoxine (B6) deficiency
neuropathy
DNA maturation, odd chain fatty acid

Vitamin B12/folate
metabolism (propionyl CoA)
Vitamin B12/folate deficiency macrocytic anemia
carboxylase reactions (pyruvate →

Biotin
oxaloacetate)
Cause eating raw eggs (avidin binds vitamin)
S/S alopecia, dermatitis
antioxidant, reduce ferric iron, hydroxylation

Vitamin C
proline/lysine, dopamine → norepinephrine
scurvy; hemorrhagic diathesis; poor wound

Vitamin C deficiency
healing
lowers ionized Ca2+ producing tetany; total

Alkalotic state
Ca2+ normal
Hypoalbuminemia lowers total Ca2+; no tetany
Hypophosphatemia decreased ATP; myoglobinuria
causes hypocalcemia by inhibiting PTH

Hypomagnesemia
synthesis/release

poor wound healing; dysgeusia (cannot taste);

Zinc deficiency
anosmia; perioral rash
iron deficiency; poor wound healing (cofactor

Copper deficiency
lysyl oxidase); aortic dissection
Iodine deficiency produces goiter and hypothyroidism
Chromium deficiency glucose intolerance
Selenium antioxidant that neutralizes peroxide
Fluoride deficiency dental caries

Clinicals Most Common

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CLINICALS MOST COMMON

GLOBAL INSTITUTE OF MEDICAL SCIENCES

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SaO2 percent heme groups occupied by O2

Cyanosis decreased O2 saturation (SaO2); O2 content

Oxygen electron acceptor in oxidative pathway

Hypoxia inadequate O2 leads to ATP depletion

Ischemia decreased arterial (or venous) blood flow

Respiratory acidosis retention of CO, always decreases PaO2

impaired delivery of O2 to alveoli;

absent blood flow to alveoli; increased alveolar

O2 cannot cross alveolar-capillary interface;

↓ SaO2; heme Fe+3; oxidizing agents

cyanosis not corrected by O2; chocolate

↓ SaO2; left-shift O2 binding curve; inhibits

S/S carbon monoxide poisoning headache; cherry red color skin

inhibits cytochrome oxidase; systemic

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Carbon monoxide + cyanide

↓ 2, 3 BPG, carbon monoxide, alkalosis, HbF,

Right-shifted O2 curve ↑ 2, 3 BPG, high altitude, acidosis, fever

respiratory alkalosis enhances glycolysis; ↑

damages membrane and drains off protons;

drain off protons; dinitrophenol, thermogenin

impaired Na+/K+ ATPase pump (cellular

ATP synthesis in hypoxia; lactate ↓ intracellular

Irreversible injury hypoxia membrane/mitochondrial damage

Mitochondrial damage release cytochrome c activates apoptosis

↑ cytosolic Ca2+ activates phospholipase,

unpaired electron in outer orbit; damage cell

superoxide, hydroxyl, peroxide, drugs

Superoxide dismutase neutralizes superoxide

Glutathione neutralizes peroxide, drug FRs

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Catalase neutralizes peroxide

indigestible lipid of lipid peroxidation; brown

Reperfusion injury in heart superoxide FRs + calcium

Mitochondrial injury cytochrome c in cytosol initiates apoptosis

SER hyperplasia alcohol, barbiturates, phenytoin

increases drug metabolism (e.g., oral

membrane protein defect in transferring

Chediak-Higashi AR; giant lysosomes

absent enzyme marker in Golgi apparatus

Rigor mortis stiff muscles after death due to ATP depletion

MCC alcohol (increase in NADH); DHAP → G3P

Fatty change in liver VLDL pushes nucleus to side

↑ synthesis TG/FAs, beta-oxidation of FAs,

Fatty change in kwashiorkor ↓ synthesis of apoproteins

primary iron storage protein; soluble in blood;

insoluble ferritin degradation product visible

reduction in cell/tissue mass by either loss or

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Brain atrophy ischemia; Alzheimer's

Exocrine gland atrophy in CF duct obstruction by thick secretions

Labile cells stem cells (skin, marrow, GI tract) →←→⇦

in G0 phase (smooth muscle, hepatocytes); can

cannot replicate; cardiac/striated muscle;