Odds Ratio: AD/BC

Relative Risk: [A/(A+B)]/[C/(C+D)]

Attributable Risk: [A/(A+B) ]- [C/(C+D)]

NNT: 1/ARR

[image]

[image]

Which hormones share a common alpha subunit?

TSH

LH

FSH

Beta-hCG

Aspirin (or clopidogrel)

Beta blocker

ACE inhibitor

Statin

What are the common side effects of beta blockers?

Which patient populations should use caution when taking Beta blockers?

SE: exacerbation of asthma

raise blood glucose

mask symptoms of hypoglycemia

bradycardia

AV block

CHF

erectile dysfunction

Populations: asthma, diabetes, CHF

Multiple myeloma:

hypercalcemia

monoclonal spike on UPEP and SPEP

Bence-Jones proteins in urine

Rouleaux formation

Renal insufficiency

Lytic bone lesions on skeletal X-rays

leukemia

DKA

What type of cancer matches the following?

• Most common type of thyroid cancer 70-75%)

• Second most common type of thyroid cancer (10%)

• Activation of receptor tyrosine kinases

• Hashimoto thyroiditis is a risk factor

• Cancer arising from parafollicular C cells

• Most common type of thyroid cancer (70-75%)-Papillary

• Second most common type of thyroid cancer (10%)- Follicular

• Activation of receptor tyrosine kinases

Papillary and Medullary

• Hashimoto thyroiditis is a risk factor

Lymphoma

• Cancer arising from parafollicular C cells

Medullary

T8: IVC

T10: Esophagus and Vagus n.

T12: Aorta, Thoracic duct, Azygos vein

[image]

C3 C4 C5

3,4,5, keeps th diaphragm alive

[image]

The shoulder

[image]

the septum transversum

[image]

Which mucles are used for inspiration?

expiration?

external intercostals

scalene

sternocleidomastoids

diaphragm

[image]

Chemoreceptors in the carotid body monitor oxygen and send signals via the Glossopharyngeal nerve

[image]

Chemoreceptors in the aortic body monitor oxygen and send signals via the Vagus nerve.

[image]

Type II Pneumocyte

cuboidal cell

less abundant than Type I

[image]

Metaplasia

Cilliated columnar to squamous

A patient in the ER is having anaphylaxis. You make an incision beneath thyroid cartilage to establish airway.

What structure was cut?

Kartagener syndrome

Dynein arm defect (cilia)

[image]

Cryptosporidium

[image]

What factors/states decrease lung compliance?

How does this effect FRC?

Fibrosis,insufficienct surfactant, Pneumonia, and Pulmonary Edema decrease lung compliance

FRC is decreased

[image]

T for Taut and Tissue

has a low affinity for Oxygen, so it allows for Oxygen to be unloaded

Increased levels of Cl-, H+, CO2, 2-3BPG all favor the T form and shift dissassociation curve to the RIGHT

[image]

Nitrites (Nitroglycerin)

Chloroquine, Primaquine

Dapsone

Sulfonamides

Local Anesthetics

Metoclopramide (Reglan)

stop offending cause first, then..

IV methylene blue

Vitamin C

(gradual:cimetidine)

[image][image]

vasodilators

Bosentan, Ambrisentan

(endothelin 1 receptor antagonist, decreasing vascular resistance)

Prostaglandin analog

Sildenafil

Dihydropyridine CCB

inactivating mutation:

BMPR2 gene

very poor prognosis

Also assoc. with HIV and Kaposi sarcoma

most common in women avg age 36

COPD

Sleep Apnea

Autoimmune disease

Recurrent Thromboemboli

Right to Left Shunt

Mitral Stenosis

Living at high altitudes

-25 TATA box (Hogness box)

-75 CAAT box

if a mutation occurs, you get LESS transcription of the gene

medial hypertrophy

fibrosis of intima

atherosclerosis

[image]

What is the rate limiting enzyme for:

• urea cycle

• hexose monophosphate pathway

• fatty acid synthesis

• beta oxidation of fatty acids

Urea: CPS I

___________________________________

HMP: Glucose 6 phosphate dehydrogenase

______________________________________

fatty acid synthesis: Acetyl CoA carboxylase

_______________________________________

beta-oxidation of fatty acids: Carnitine acyltransferase

_____________________________________

ketone body: HMG CoA synthase

Cholesterol: HMG CoA reductase

bile acid synthesis: 7-alpha hydroxylase

heme synthesis: Aminolevulinate synthase

Hypoxemia

High FiO2

Advanced age

increases ventilation

makes more RBCs

elevates erythropoietin levels

more 2,3-DPG

increases mitochondria

increases renal excretion of bicarbonate

Hemoglobin: 40-45--->60

Hematocrit:15g/dl--->20g/dl

4-6G

Centrifugal force pooling blood in the abdomen and legs

-insufficient blood to the heart and brain

decrease in blood volume

decrease in RBC mass

decrease in muscle strength

decrease in maximum cardiac output

loss of calcium and phosphate from the bones

gases composed primarily of nitrogen are dissolved in the blood

at high pressures the gases begin to escape from dissolved state and form bubbles that can occlude blood vessels

[image]

(a)arterial blood or (A)alveolar gas are interchangeable in this equation)

PE: expired air

A person with a tidal volume (VT) of 0.5 L is breathing at a rate of 15 breaths/min.

The PCO2 of his arterial blood is 40 mm Hg, and the PCO2 of his expire air is 36 mm Hg. What is his rate of alveolar ventilation?

write it out!

Alveolar vent.=(Tidal volume-Dead Space) x Breaths/min

Dead space= VT X [PA(CO2)-PE(CO2)]/PA(CO2)

=0.5L x (40-36)/40

=0.05

Alveolar vent.=(0.5-0.05)x 15

=0.45 x 15

=6.75 L/min

Which lung capacity(ies) cannot be measured by spirometry?

Why?

Functional Residual capacity(FRV)

It is the volume of the sum of th ERV and RV. RV cannot be measured by spirometry

Total Lung Capacity ( TLC )

sum of all four lung volumes

includes RV so it also cannot be measured by spirometry

What is FEV1?

How does itrelate to FVC?

disease states?

• Forced Expiratory Volume

volume of air that can be expired in te first second of a forced maximal expiration

• normally 80% of the forced vital capacity

FEV1/FVC= 0.8

• Obstructive lung disease (like asthma) FEV1 is reduced more than FVC, so FEV1/FVC<0.8

• Restrictive lung disease (like fibrosis), both FEV1 and FVC are reduced and FEV1/FVC is normal or increased

Remember chart below as NOR (Norm. Obstr. Res.)

[image]

C= V/P

the slope of the pressure-volume curve

Emphysema=increased compliance=increased FRC

Patients with emphysema have a very high lung compliance due to the poor elastic recoil, they have no problem inflating the lungs but have extreme difficulty exhaling air. In this condition extra work is required to get air out of the lungs. Compliance also increases with increasing age.

In a pt with emphysema, lung compliance is increased and the tendency of the lungs to collapse is decreased. Therefore, the original FRC, the tendency for the lungs to colapse is less than the tendency for the chest wall to expand. The lung-chest wall system will seek a new, higher FRC, so that the opposing forces can be balanced, the barrel chest reflects this higher volume

[image]

What size alveoli have a low collapsing pressure? What is the mathematics behind this?

How does surfactant change this equation?

Large alveoli have a low collapsing pressure becayse they have a larger radius as exemplified by: P= 2T/r

surfactant decreases T (surface tension) allowing smaller alveoli to have a lower collapsing pressure

[image]

DPPC

Phospholipd called Dipalmitoyl phosphatidylcholine that disrupts intermollecular forces between liquid molecules lining the alveoli --->decreasing surface tension and collapsing pressure

That the fetus has mature levels of surfactant

if less than 2:1, the fetus is at risk for neonatal RDS because they lack surfactant and th lungs will exhibit:

• atelectasis (lung collapse)

• difficulty reinflating te lungs (decreased compliance)

• hypoxemia (decreased V/Q)

[image]

Airflow is inversely related to Resistance

If radius decreased by a factor of 4, Resistance will increase by a factor of (4^4) 256, and airfow will decrease by a factor of 256

the medium sized bronchi

not the smallest airways bc they are in a parallel arrangemen which decreases resistance

A balloon catheter in the esophagus measures what?

[image]

intrapleural pressure

What is the V/Q at the apex of the lung?

base of the lung?

During airway obstruction?

blood flow obstruction?

V/Q at:

apex: 3

base: 0.6

obstruction of airway: towards 0 (V is decreasing)

blood flow obstruction: towards infinity (Q is decreasing)

• dissolved CO2

• as bicarbonate

• Carbaminohemoglobin

Venous: CO2 increases

Arterial: no change

What is the genetic syndrome that fits the following description?

Alcoholics with B1 deficiency and neurologic defects

Cyclosporine

decrease methionine and increase cysteine

increase B6

increase B12

add folate

(dietary/supplements)

Sodium Stibogluconate (cutaneous)

Amphotericin B (visceral)

Sulfadiazine + Pyrimethamine

[image]

[image]

[image]

What are the major sympotoms of DVT?

How do you diagnose?

unilateral swollen foot/ankle +/- pain

+/- Homan's sign (pain with ankle dorsiflexion)

+/- palpable cord

Dx: Ultrasound

[image][image]

[image]

SubQ heparin

SCDs (sequential compression devices)/compression stockings

long term warfain

[image]

pleuritic chest pain

shortness of breath

cought

hemoptysis(rare)

fever

tachypnea

tachycardia

confusion

know this image in and out!

[image]

CT

(not for renal pts or diabetics on metformin)

or V/Q scan

or

Pulmonary angiogram

an obstructive lung disease

expiration is impaired

decreased FVC, FEV1 and FEV1/FVC

air trapping leads to increased FRC and a barrel-shapped chest

[image]

an obstructive lung disease

increased lung compliance and air trapping--> increased FRC and barrel-shapped chest

decreased FVC, FEV1, FEV1/FVC

a combination of chronic bronchitis and emphysema

primarily emphysema: pink puffers

primarily bronchitis: blue bloaters

[image]

COPD pts due primarily to emphysema

mild hypoxemia and normocapnia *normal PCO2*

[image]

COPD pts primarily due to bronchitis

severe hypoxemia

cyanosis hypercapnia

R.ventricular failure

systemic edema

[image]

Central acinar emphysema

[image]

Fat emboli with patent foramen ovale

[image]

bronchial asthma

[image]

[image]

Extrinsic and Intrinsic

Extrinsic: immune asthma mediated by type I HSR involving IgE bound to mast cells. Begins in childhood, usually family hx

[image]

__________________________________________

Intrinsic: nonimmune: associated with chronic bronchitis or other variants (exercise induced or cold induced) begins in adult life and not associated with allergy hx

bronchial smooth muscle hypertrophy

Goblet cell hyperplasia

Basement membrane thickening and hyalinization

eosinophil proliferation

intrabronchial mucus plugs containing

-Curschmann spirals (whirl like accumulations of epithelial cells)

-Charcot-leyden crystals (crystalloids of eosinophil derived proteins

A drop in systemic blood pressure (>10mmHg) during inspiration

[image]

DNAAACP

Drugs

Neoplasm

Atopic diseases (allergy, asthma, Churg-Strauss)

Addison's disease

Acute Interstitial Nephritis

Collagen Vascular disease

Parasites (Loffler eosinophilic pneumonitis: ascaris,strongyloides, hookworms)

an obstructive lung disease due to permanent enlargement of parts of the airways of the lung

may result from a number of infective and acquired causes, including pneumonia, tuberculosis, immune system problems, and cystic fibrosis

can result from and in chronic necrotizing infection of the bronchi

poor cilary motility

common in CSF pts, Kartagener Syndrome pts,Pseudomonas infection and chronic smokers with emphysema

[image]

What asthma medication fits the following statement

• Inhaled treatment of choice for acute exacerbations

• Blocks leukotriene receptors

• Inhaled long-acting beta-2 agonist

• Narrow therapeutic index, drug of last resort

• Inhaled treatment of choice for chronic asthma

• Blocks conversion of arachidonic acid to leukotriene

• Inhaled treatment that blocks muscarinic receptors

• Inhibits mast cell release of mediators, used for prophylaxis only

• Inhaled treatment of choice for chronic asthma

Inhaled steroid

• Inhaled treatment of choice for acute exacerbations

Albuterol or Levalbuterol

• Narrow therapeutic index, drug of last resort

Theophylline or Aminophylline

• Blocks conversion of arachidonic acid to leukotriene

Zileuton

• Inhibits mast cell release of mediators, used for prophylaxis only

Cromolyn

• Inhaled treatment that blocks muscarinic receptors

Ipratropium/Tiotropium

• Inhaled long-acting beta-2 agonist

Salmeterol

• Blocks leukotriene receptors

Monteklast (young as 1 yr old)

and Zafirlukast (5 years or older)

What pathology fits the following high-yield statement?
• Opacities seen on x-ray on both sides of the carina

• Dermatitis, diarrhea, dementia, possibly death

• Greenish rings around the periphery of the iris

• Elastic skin, joint hypermobility

•  Enlarged, hard, left supraclavicular lymph node

• Opacities seen on x-ray on both sides of the carina Sarcoidosis
•  [image]

____________________________________________

• Dermatitis, diarrhea, dementia, possibly death

Niacin deficiency (Pellagra)

[image]

___________________________________________

• Greenish rings around the periphery of the iris

Wilson's disease

[image]

___________________________________

• Elastic skin, joint hypermobility

Ehlers-Danlos

[image]

______________________________________________

•  Enlarged, hard, left supraclavicular lymph node

Virchow's node commonly in stomach cancer

[image]

This image shows thickened alveoar septa and alveoli lined with eosinophilc hyaline membranes. What is the diagnosis?

[image]

Diffuse Alveolar Damage

a restrictive lung disease causing Adult RDS

35th week of gestation

Tx: put the mom on steroids if you have to deliver prematurely

prematurity

maternal diabetes

cesarian delivery

Tx: give them surfactant and/or steroids

neonatal RDS

mom could have been given steroids 24-48hrs prior to delivery

Shock

Infection

Toxic gas inhalation

Acute pancreatitis

Aspiration

Heroin overdose

High concentration sof O2 for extended time

GRUELING

Granulomas (noncaseating)

Rheumatoid Arthritis

Uveitis   [image]

Eryhtema Nodosum[image]

Lymphadenopathy

Idiopathic

Not TB

Gammaglobulinemia

hypergammaglobulinemia, hypercalcemia, and hypercalciuria

elevated serum ACE levels

causes interstitial fibrosis in the lungs and restrictive lung disease

black females most often

[image]

a category of restrictive lung disease caused by occupational/chemical hazards

Coal and Silica:

primarily affect the upper lobes

macrophages go in and cause fibrosis

does not increase risk of cancer

________________________________________

Asbestos:

affects the lower lobes

Asbestos is the only one that increases your risk for lung cancer (bronchogenic carcinoma) and mesotelioma

[image]

Diagnosis: Asbestosis fiber

Asbestosis

increased risk for mesothelioma and bronchogenic carcinoma

CXR shows pleural effusions.

What are the clinical findings?

Dullness to resonance

Decreased fremitus

Decreased breath sounds

A tall, thin male teenager has abrupt onset dyspnea and left-sided chest pain. Percussion on the affected side reveals hyperresonance, and breath sounds are diminished.  What is the diagnosis?

Classic presentation:

Spontaneous (Simple) Pneumothoax

What pathology fits the following high-yield phrase?
• Gout + mental retardation + lip-biting

• Lack of Gpllb/llla --> defect in platelets --> prolonged bleeding

• Anti-histone antibodies

• Psammoma bodies 

• Lytic bone lesions on x-ray

• Gout + mental retardation + lip-biting

Lesch-Nyhan

________________________________________

• Lack of Gpllb/llla --> defect in platelets --> prolonged bleeding

Glanzmann's thrombasthenia

________________________________________

• Anti-histone antibodies

drug induced SLE

_______________________________________

• Psammoma bodies 

Serous cystadenocarcinoma of ovary

Meningioma

Mesotelioma

Papillary adenocarcinoma of thyroid

_____________________________________

• Lytic bone lesions on x-ray

Multiple Myeloma

atelectasis will occur (sudden collapse)

trachea deviates toward the lesion

absent breath sounds in affected region

decreased resonance

decreased fremitus

decreased breath sounds over the effusion

dullness

decreased fremitus

NO TRACHEAL DEVIATION

[image][image]

Severe & life threatening

air escapes into pleural space and can't get out

lung collapses

tracheal deviation AWAY from the lesion

decreased/absent breath sounds

absent fremitus

subcutaneous emphysema

[image]

[image][image]

SPHERE

Superior Vena Cava Syndrome (compressing SVC causing congestion in head and arms)

[image]

Pancoast Tumor carcinoma in apex of the lung that can affect the sympathetic cervical plexus causing...

Horner's Syndrome miosis, anhydrosis, ptosis

[image]

Endocrine paraneoplastic effects

-PTH-->hypercalcemia

-ADH-->SIADH

-Antibodies to calcium receptors-->Lambert-Eatons

-ACTH---> Cushings SYNDROME

Recurrent Laryngeal Symptoms (hoarseness)

Effusions

Dysphagia

Laryngeal Invasian

[image]

Adenocarcinoma:most common in nonsmokers and females, excellent prognosis

Squamous Cell Carcinoma: linked to cigarettes most commonly

Small cell (oat) carcinoma:undifferintiated, very aggressive

Large cell carcinoma: highly anaplastic, undiffereintiated, poor prognosis

Bronchial carcinoid tumor : excellent prognosis, rarely metastasizes

This image is from the lungs. What is the diagnosis and genetic link?

[image]

small dark blue cells are indicative of

Small cell (oat) lung cancer

associated with L-myc oncogene

Centrally located

can produce ACTH (Cushings syndrome),

ADH (SIADH), or

Antibodies against calcium channels (Lambert Eaton Syndrome: weakness that improves with use)

Inoperable

Tx: Chemo

Adenocarcinoma

&

Large cell carcinoma

Brain

[image]

Bone

[image]

Liver

[image]

RADON gas

[image]

Which infectious agent fits the following description?

 Common cause of pneumonia in immunocompromised patients

Answer:

Most common cause of atypical / walking pneumonia

_Answer:

• Common causative agent for pneumonia in alcoholics

Answer:

Can cause an interstitial pneumonia in bird handlers

Answer:

Often the cause of pneumonia in a patient with a history of exposure to bats and bat droppings

Answer:

Often the cause of pneumonia in a patient who has recently visited South California, New Mexico, or
West Texas

Cocciodes

Answer:

pneumonia associated with Q fever

Answer:

Associated with pneumonia acquired from air conditioners

Group B strep

or

E.Coli

Strep pneumoniae

Klebsiella

characterized by: intra-alveolar exudate-->consolidation

[image]

S. pneumonia, S.aureus, H.Influenzae, Klebsiella

characterized by: acute inflammatory infiltrates from bronchioles into adjacent alveoli

patchy distribution involving more than one lobe

[image]

[image]

Viruses (RSV, Influenza, Adenovirus)

Mycoplasma, Legionella, Chlamydia

characteristically more widespread and ill defined

indolent course

[image]

What's going on in this CXR?

[image]

Most strinkingly is the pulmonary abscess in the left lung

[image]

Cavity with obvious air fluid level distinction

[image]

Know this image about pleural effusions

(im tired of writing questions lol)

Propofol

[image]

Tuberculosis

[image][image]

30-year-old comatose man on ventilatory support in the ICU develops an infection and dies.

Autopsy reveals a pus-filled cavity in his right lung. What is the likely etiology?

CXR shows collapse of middle lobe of right lung and mass in right bronchus; patient has history of recurrent pneumonias.

What is the diagnosis?

Bronchogenic Carcinoma

lack of air is a great place for pneumonia to develop

What infectious agent is the cause of pneumonia based on the following lab test?
• Gram (+) cocci in clusters

• Gram (+) cocci in pairs

• Gram (-) rods in 80-year-old

• Gram (+) coed in neonate

• Gram (-) rods in neonate

• Gram (+) cocci in clusters

Staph aureus

• Gram (+) cocci in pairs

Strep. pneumoniae

• Gram (-) rods in 80-year-old

E.Coli

• Gram (+) cocci in neonate

Group B strep

• Gram (-) rods in neonate

E.Coli

A benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue

usually seen in adolescent males

can present with profuse epitaxis (nose bleeding)

[image]

Nasopharyngeal Carcinoma

biopsy: cervical lymphadenopathy--spreads to lymph nodes: keratin positive pleomorphic epithelial cells in a background of lymphocytes

[image][image]

[image]

H.Influenza Type B

especially in nonimmunized children

presntation- high fever, sore throat, drooling w/dysphagia, muffled voice, inspiratory stridor

can be life threatening if acute airway obstruction

[image][image]

aka Croup

Parainfluenza virus

hoarse barking cough and inspiratory stridor

rest

caused from myxoid degeneration

[image]

What causes laryngeal papillomas?

HPV 6 and 11

benign tmor of vocal cord

single in adults

multiple in children

presents with hoarseness

[image]

[image]

Squamous cell carcinoma of vocal cord

RFs: alcohol and tobacco (Can arise from laryngeal papilloma but rare!)

presents with hoarseness, cough, stridor

Chest X-Ray

sputum gram stain and culture

blood cultures

1[image]

2.[image]

3.[image]

4.[image]

1. healthy lungs

2.Interstitial pneumona

3.Lobar pneumonia

4.Bronchopneumonia

Virus

Bronchonpneumonia and Lobar pneumonia

Strep. pneumonia (95%)most common cause of CAP

 Klebsiella -enteric flora that is aspirated

commonly seen with abscess

Congestion

Red Hepatization

Grey Hepatization

Resolution

(Type II Pneumocyte helps to regenrate the lining of the lung during this phase)

[image]

Staph Aureus (After viral pneumonia and assoc with abscesses/empyema)

H.influenzae (Secondary and COPD)

Psuedomonas(CF pts)

Moraxella (CAP and COPD)

Legionella ( silver stain, arises from water source)

relatively mild, minimal sputum, cough, low fever

diffuse interstitial infiltrates, air sacs fairly empty

caused by atypical bugs

most common causes:

1) Mycoplasma pneumonia (military recruits-IgM cold agglutinin hemolytic anemia)

Chlamydia pneumoniae (young adults)

RSV (infants)

CMV (immunosuppressed, post transplant)

Influenza Virus (elderly, immunocompromised, preexisting lung disease-->increased risk for bacterial secondary pneumonia)

Coxiella burnetti (ricketssial: High fever -Q fever, farmers and vets exposed to spores from ticks or placentas)

What are the common cause of Aspiration Pneumonia?

What usually presents with it?

anaerobic bacteria in oropharynx

Bacteroides

Fusobacterium

Peptococcus

right lower lobe abscess

Apex

caseous necrosis

fevers, night sweats, cough with hemoptysis

weight loss

red acid fast bacilli

[image]

can involve any tissue

high yield:

Meningitis (granulomas at base of brain)

Cervical lymphadenopathy

Sterile pyuria in kidney

Pott disease of lumbar vertebrae

COPD is an Obstructive Lung disease so think about it like obstruction in air GETTING OUT of the lungs

The FVC and FEV1 are measurement of how much air is expelled from the lungs so those values will decrease.

The normal FEV1/FVC ratio is 80% but it will go down in COPD

TLC will increase due to air trapping

normal is 7 L

COPD is about 8 L

Measure of mucinous glands  in the submucosa relative to the thickness of the bronchial wall

in Chronic Bronchitis it is greater than 50% due to submucosal ggland hypertrophy and hyperplasia

[image]

normally should be less than 40%

productive cough (more mucinous glands)

cyanosis ↑PACO2 ↓PaO2

increased risk of infection

(mucus plug→blocked tube→infection behind block)

Increased risk of cor pulmonale

hypoxia→vasoconstriction of pulmonary BVs→increased pressure back into right heart→right heart hypertrophy→right heart failure

think of healthy alveoli like a bunch of tiny ballons and the emphysemic lung like an large old shopping bag (dilated alvelolar air sacs). Which will push air out better?

They lose elasticity which decreases elastic recoil of the alveoli and collapse of the small airways leading to air trapping

[image]

Healthy lungs have a constant and ongoing level of inflammation at the level of the alveolar air sacs

A byproduct of this inflammation is the production of proteases that cause tissue damage

Healthy lungs have antiproteases, alpha-1-antitrypsin that is very important to exist in a balance to prevent tissue damage.

Causes a Panacinar emphysema: the entire acinar and more commin in lower lobes accompanied with Liver cirrhosis (pink, PAS positive globules: PiZ homozygous allele is associated with disease-protein accumulates in Endoplasmic Reticulum) Heterozygotes are mild but should be advised not to smoke!

(Centriacinar: more severe in upper lobes in smokers, they develop emphysema bc the inflammation and proteases is way more than the normal antiproteases can handle)

dyspnea

cough with minimal sputum

prolonged expiration with pursed lips

(to increase back pressure and assist in expelling air)

weight loss

(bc the mechanical breathing takes a lot of work)

increased AP diameter of chest

Pink Puffers

FRC

FRC is increased in emphysema (barrel chest)

FRC is decreased in fibrosis of the lung (incaving of chest)

1)releases preformed histamine granules resulting in:

histamine induced vasodilation (arterioles)

histamine induced increased vascular permeability (postcapillary venule)

2) Produce LTC4, LTD4, LTE4

(vasoconstriction, contrict bronchus, increased vascular permeability)

[image]......

Late phase: Major basic proteins perpetuates bronchoconstriction

What is bronchiectasis?

What disease states do you see this?

abnormal dilatation of the large airways

loss of tone results in air trapping and obstruction of expelling air

Cystic Fibrosis

Kartagener Syndrome (dyeinin arm of cilia)

Tumor or Foreign body

Necrotizing infection

Allergic bronchopulmonary aspergillosis (Seen in asthmatics and CF pts: HSR)

[image]

hypoxemia with cor pulmonale

secondary amyloidosis

A problem with FILLING the lungs

FEV1/FVC ratio is increased however both are decreased (FCV1 is decreased more than FEV1, so due to fibrosis which causes the air to accelerate out and FEV1 isn't as decreased as in obstructive lung disease )

TLC is decreased (can't bring as much air into the lung)

Idiopathic Pulmonary Fibrosis

TGF-Beta from injured pneumocytes induces fibrosis

[image]

What causes interstitital fibriosis?

How do you diagnose and treat?

Idiopathic

Drugs: ex. Bleomycin, Amiodarone, Radiation Therapy

Pneumoconiosis (chronic exposure to small fibrogenic particles causing fibrosis mediated by macrophages)

Dx: CT

Tx: Lung transplantation

build up of carbon in the macrophages or hilar lymph nodes of the lung

occurs in normal lungs from pollution

Silicosis

(upper lobes of lung)

Beryliosis

(sounds like sarcoidosis but look for clues)

Cancer of the lung pleura

Asbestos exposure increases the risk but it increases the risk for lung cancer more than mesothelioma

Look for asbestos bodies/furriganous bodies

[image]

Systemic disease of noncaseating granulomas in mutliple organs and hilar lymph node of the lung

African American female. Biopsy shows epithelioid histiocytes and asteroid body. What is the diagnosis? And what labs would you expect?

Sarcoidosis

Labs:elevated serum ACE

hypercalcemia bc al noncaseating granulomas have excess activity of 1 alpha hydroxylase which will activate Vitamin D resulting in hypercalcemia

Tx: steroids but usually resolves spontaneously

can mimic sjorgen syndrome

can see cutaneous nodules and erythema nodosum

uveitis

(pigeon breeder's lung)

eosinophils in granulomatous reaction to inhaled organic antigens in bird poop

presents with fever, cough, dyspnea hours after exposure and resolves with removal of antigen

chronic exposure leads to interstitial fibrosis

Mean Arterial Pressure >25mmHg

(normal is 10mmHg)

atherosclerosis of pulmonary trunk

mooth muscle hypertrophy of pulmonary arteries

Intimal fibrosis

Plexiform lesions (severe)

[image]

clinical sign

exertional dyspnea

inactivating mutation of BMPR2 →proliferation of vascular smooth muscle

classically seen in young adult females

Hypoxema(COPD, Interstitial lung disease) or increased volume in pulmonary circuit (congenital heart disease)

recurrent pulmonary embolism

ARDS

forms from leakage of protein rich fluid into the air sacs that reorganizes around the sac as the hyaline membrane

causes hypoxemia and cyanosis

ad collapsing of the lung -->respiratory distress

White out on CXR

[image]

What cells contribute to the pathology of ARDS generally?

What is the treatment?

Complication of recovery?

Activation of neutrophils induces protease-mediated and Free radical damage of Type I and Type II pneumocytes

Tx: Ventilation with PEEP

recovery can be complicated by interstitial fibrosis bc

Type II pneumocytes are knocked out

know it

Because the fetal pancreas will secrete more insulin to deal with the glucose overload.

Insulin inhibits surfactant production

Because vaginal birth induces the fetal stress response and steroids stimulate surfactant production.

without that stress, the infant is at higher risk of being delivered with insufficient surfactant resulting in RDS

persistence of PDA due to hypoxemia (O2 induces closure)

Necrotizing enterocolitis

supplemental oxygen can increase the risk of free radical injury which can cause blindness and damage to the lungs (bronchopulmonary dysplasia)

Compare against a prior Xray and see if it has changed

If new or growing, get a Biopsy

Granuloma

(TB, fungus or histoplasma in midwest)

Broncial hamartoma (often calcified)

disorganized lung tissue+cartilage

Squamous Cell Carcinoma

often related to PTHrpeptide (paraneoplastic syndrome)

Which type of lung cancer cannot be treated with surgery?

Which type of lung cancer cannot be treated with surgery?

adrenal gland

Adenocarcinoma

most often cancer seen in pleural involvement also because it is a peripheral tumor

Mesothelial cells

[image]

Which structure on this image is not a foregut derivative but gets its arterial supply from a foregut artery?

[image]

Spleen

mesoderm dorsal mesentary tissue that recieves artery from Superior Mesenteric

NTD

 like meningocele

glucose----->sorbitol-->fructose

↓             ↓

      NADPH       NADH

Ca is released from the sarcoplasmic reticulum and binds to Troponin C.

The Troponin-Ca complex pulls tropomyosin away, exposing myosin binding sites

exotoxin (exfoliatin)-mediated skin damage

wide spread sloughing with gentle pressure (Nikolsky's sign)

RBF= renal artery pressure-renal vein pressure

____________________________

renal vascular resistance

RBF=   PAH Clearance/ (1-hematocrit)

PAH clearance= (urine PAH*urine flow rate)/plasma PAH

Anterior dislocation of the shoulder/humerus

Axillary nerve injury and deltoid paralysis

1)diet and light exercise

2)insulin

renal vein

[image]

1)Cooling them with cold blankets bc this is an immediate effect

2) administer an antipyretic (acetaminophen) this will take some time to have its effect

Alkaptonuria is a deficient pathway from

Tyrosine---->Fumurate

specifically Homogenistate--->Maleyacetoacetate

due to a deficiency of homogenistate oxidase

SSRIs

(fluoxetine, paroxetine, sertraline, fluvoxamine, escitalopram, citalopram)

they treat major depression, OCD, eating disorders, premenstrual dysmorphic disorder and anxiety

Know it.

If you go blank remember

O.N.R

from left to right

Obstructive--Normal---Restrictive

Tracheal obstruction is the bubble in the middle

Mycobacteria leprae

Leprosy

1.- At which nephron site does the amount of K+ in tubular fluid exceed the amount of filtered K+ in a person on a high K+diet?

2.- At which nephron site is the tubular fluid/plasma osmolarity lowest in a person who has been deprived of water?

3.- At which nephron site is the tubular fluid inulin concentration highest during antidiuresis?

4.- At which nephron site is the tubular fluid inulin concentration lowest?

5.- At which nephron site is the tubular fluid glucose concentration highest?

[image]

1. At which nephron site does the amount of K+ in tubular fluid exceed the amount of filtered K+ in a person on a high K+ diet?

E) K+ is secreted by the late distal tubule and collecting ducts. Because this secretion is affected by dietary K+, a person who is on a high-K+ diet can secrete more K+ into the urine than was originally filtered. At all os the other nephron sites, the amount of K+ in the tubular fluid is either equal to the amount filtered (A) or less than the amount filtered (because K+ is reabsorbed in the proximal tubule and the loop of Henle).

2.- At which nephron site is the tubular fluid/plasma osmolarity lowest in a person who has been deprived of water?

D) A person who is deprived of water will have high circulating levels of antidiuretic hormone(ADH). The tubular fluid/plasma (TF/P) osmolarity is 1.0 throughout the proximal tubule, regardless of ADH status. In antidiuresis, TF/P osmolarity > 1.0 at site C because of equilibration of the tubular fluid with the large corticopapillary osmotic gradient. At site E, TF/P osmolarity > 1.0 because of water reabsorption out of the collecting ducts and equilibration with the corticopapillary gradient. At site D, the tubular fluid is diluted because NaCl is reabsorbed in the thick ascending limb without water, making TF/P osmolarity < 1.0.

3.- At which nephron site is the tubular fluid inulin concentration highest during antidiuresis?

E) Because inulin, once filtered, is neither reabsorbed nor secreted, its concentration in tubular fluid reflects the amount of water remaining in the tubule. In antidiuresis, water is reabsorbed throughout the nephron (except in the thick ascending limb and cortical diluting segment). Thus, inulin concentration in the tubular fluid progressively rises along the nephron as water is reabsorbed, and will be highest in the final urine.

4.- At which nephron site is the tubular fluid inulin concentration lowest?

A) The tubular fluid inulin concentration depends on the amount of water present. As water reabsorption occurs along the nephron, the inulin concentration progressively increases. Thus, the tubular fluid inulin concentration is lowest in Bowman's space, prior to any water reabsorption.

5.- At which nephron site is the tubular fluid glucose concentration highest?

A) Glucose is extensively reabsorbed in the early proximal tubule by the Na+-glucose cotransporter. The glucose concentration in tubular fluid is highest in Bowman's space before any reabsorption has occurred.

In a person that is water deprived, what part of the nephron contains the most dilute urine?

most concentrated?

most dilute: DCT and thick ascending limb

most concentrated: Collecting duct

Draw the putamen and globus pallidus

[image]

Know it

Also know that wilson's disease causes cystic degeneration of the putamen

Aortic regurg

peak intensity after closure of the incompetent aortic valve at the point where left atrial pressure is increasing (building another contraction)

Clozapine

Respiridone is MOST LIKELY to cause EPS like Tardive dyskinesia (perioral movements due to typical antipsychotic tx

Valproate, Lithium, or Carbamazepine

plus

Atypical antipsychotic like Olanzapine

Surface epithelial tumors:

Serous (cystic full of serous/watery fluid)

Mucinous (cystic full of mucus)

*can be benign, borderline or malignant*

Mucinous and serous tumors can be benign, borderline, or malignant,
1. Benign tumors (cyst adenomas) are composed of a single cyst with a simple, llat
lining (Fig. 13.12); most commonly arise in premenopausal women (30-40 years
old)
2. Malignant tumors (cystadenocarci nomas) are composed of complex cysts with
a thick, shaggy lining; most commonly arise in postmenopausal women (60-70
years old)
3. Borderline tumors have features in between benign and malignant tumors.
I. Better prognosis than clearly malignant tumors, but still carry metastatic
potential
4. BRCAl mutation carriers have an increased risk for serous carcinoma of the
ovary and fallopian tube,
i. HRCA1 carriers often elect to have a prophylactic salpingo-oophorectomy
(along with prophylactic mastectomy due to the increased risk for breast
cancer).
E. Less common subtypes of surface epithelial tumors include endometrioid and
Brenner tumor.
1. Endometrioid rumors are composed of endomelrial-like glands and are usually
malignant.
i. May arise from endometriosis
ii. 15% of endometrioid carcinomas of the ovary are associated with an
independent endometrial carcinoma (endometrioid type).
2, Brenner tumors are composed of bladder-like epithelium and are usually benign.
F. Surface tumors clinically present late with vague abdominal symptoms (pain and
fullness) or signs of compression (urinary frequency).

Germ cell tumor

2nd most common type of ovarian tumor (15% of cases)
B, Usually occur in women of reproductive age
C. Tumor subtypes mimic tissues normally produced by germ cells.
1. Fetal tissue—cystic teratoma and embryonal carcinoma
2. Oocytes—dysgermi no ma
3. Yolk sac—endodermal sinus tumor
4. Placental tissue—choriocarcinoma
D. Cystic teratoma
1. Cystic tumor composed of fetal tissue derived from two or three embryologic
layers (e.g., skin, hair, bone, cartilage, gut, and thyroid, Fig. 13.13)
i. Most common germ cell tumor in females; bilateral in 10% of cases
2. Benign, but presence of immature tissue (usually neural) or somatic malignancy
(usually squamous cell carcinoma of skin) indicates malignant potential.
3. Struma ovarii is a teratoma composed primarily of thyroid tissue.
£. Dysgerminoma
1. Tumor composed of targe cells with clear cytoplasm and central nuclei (resemble
oocytes, Fig. 13.14); most common malignant germ cell tumor
2. Testicular counterpart is called seminoma, which is a relatively common germ
cell tumor in males.
3. Good prognosis; responds to radiotherapy
4. Serum l.DH may be elevated.
F. Endodermal sinus tumor
1. Malignant tumor that mimics the yolk sac; most common germ cell tumor in
children
2. Serum AFP is often elevated.
3. Schiller-Duval bodies (glomerulus-! ike structures) are classically seen on
histology (Fig, 13.15).
G. Choriocarcinoma
1. Malignant tumor composed of trophoblasts and syncytlotrophoblasts; mimics
placental tissue, but villi are absent
2. Small, hemorrhagic tumor with early hematogenous spread
3. High beta-hCG is characteristic (produced by syncytiotrophoblasts); may lead to
thecal cysts in the ovary

4. Poor response to chemotherapy
11. Embryonal carcinoma
1. Malignant tumor composed of large primitive cells
2. Aggressive with early metastasis

Effect of teratogens generally depends on the dose, agent, and time of exposure

 First two weeks of gestation—spontaneous abortion

Weeks 3-8—risk of organ malformation

Months 3-9—risk of organ hypoplasia

Placenta previa

[image]

Placental abruption

common cause of stillbirth

presents with third trimester bleeding and fetal insufficiency

Placenta accreta

due to minimal deciidua and difficulty to deliver the placenta

post partum bleeding and usually have to do a hysterectomy

preeclampsia

due to abnormality in maternal-fetal vascular interface in placenta and can see fibrinoid necrosis in vessels of the placenta

Eclampsia: all that with seizures, immediate delivery

HELLP

Hemolysis from shearing RBCs on thrombi

Elevated Liver enzymes

Low Platelets

sleeping on stomach

smoking in household

prematurity

(1month-1 year)

Hydatidiform mole

B-hCG excessively high for level of gestation

Uterus is bigger than normal as well

will usually pass grapelike masses through vagina

OR snow storm appearance in ultrasound and absent fetal heart sounds in clinic

[image]

complete vs partial

complete: two sperm 46 chromosomes, all edemetous villi,complete proliferation of trophoblasts along the villi, very high beta HGCG from syncitiotrophoblast, greater risk for choriocarcinoma

partial: 69 chromosomes, part fetus, part mole, partial edema, partial risk, partialtrophoblast proliferation

Tx: D&C

and do a Beta-HCG to make sure its gone and screen for choriocarcinoma

SPORADIC GERM CELL

(gestational pathway does respond well)

hypospadiasis

failure of the urethral folds to close

Epispadias

associated with bladder exstrophy

STD caused by Chlamydia Trachomatis (L1-L3)

Lymphogranuloma Venereum

can result in healing with fibrosis and can cause perianal involvement causing rectal strictures

High risk HPV (2/3rds)

lack of circumcision

Precursor lesions:

Bowen disease (shaft)

Erythroplasia of Queyrat (glans)

Bowenoid papulosis (reddish papules)

Cryptoorchidism

most common congenital abnormality in male infants

most resolve but after 2yo surgery to avoid testicular atrophy and infertility and increased risk for seminoma

inflammation of the testicle

STDs,(chalmydia D-K, Neisseria in younger pts)

E.coli, Pseudomonas,(older pts)

Mumps

Autoimmune (granulomatous inflammation)

hemorrhagic infarction of the testes bc artery is still open but vein is closed

twisiting of spermatic cord

can be due to congenital faiure of the testes to attach to inner lining of scrotum

presents in adolescence usually: testicular pain and absent cremasteric reflex

Varicolcele

usually left sided bc the testicular vein drains into the left renal vein

seen in a large percentage of infertile males possibly due to testicle being bathed in warm fluid

hydrocele

incomplete closure of processus vaginalis in infants

blockage of lymphatic drainage in adults

can be transilluminated bc its only fluid

Surface epithelium

Germ cell

Sex cord and stroma

never do a biopsy bc you can seed in the scrotum and also all testicular tumors are malignant

15-40  yo

risk: cryptorcidism(undescended testicle)

Kleinfelter syndrome

seminoma(good prognosis) or nonseminoma(worse)

nonseminomous: Embryonal carcinoma

can secrete AFP and beta hCG

Yolk sac tumor

Schiller-Duval body (glomeruloid like structure)

malignant tumor AFP is elevated

Choriocarcinoma

Beta hCG elevated *synctiotrophoblasts*

hyperthyroidism or gynecomastia

spreads early via blood

benign in females

malignant in males

Leydig cell tumor

[image]

Diffuse B cell lymphoma

most commonly. Look for other defining characteristics to lead you to a testicular cancer otherwise go for lymphoma especially if bilateral

Acute Prostatitis

Chlamydia or Gonnorrhea in young pts

E.Coli or Pseudomonas in older pts

know it

BPH is driven by DHT

and occurs in the periurethral zone of the rostate thats why we see a difficulty urinating

PSA is often slightly elevated (4-10)

alpha1 antogonist: terazosin to relax smooth muscle

selective alpha 1A antagonist: tamulosin

5alpha reductase inhibitor: take a while to produce results

Prostate adenocarcinoma

diets high in saturated fats, race, age