Adam Shared "Newest Learn" - 136 Picmonics

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Newest Learn

Gallstone Ileus and Gallbladder Carcinoma
Gallstone Ileus
Gallstone enters and obstructs the small intestine
Due to cholecystitis with fistula formation between the gallbladder and small intestine
As the stone advances it may cause intermittent "tumbling" obstruction with diffuse abdominal pain and vomiting
Vomiting, pneumobilia (air in the biliary tree), hyperactive bowel sounds, and dilated loops of bowels
Until finally lodging in the ileum, the narrowest section of the bowels, several days later
Diagnosis: abdominal CT scan which reveals gallbladder wall thickening, pneumobilia, and an obstructing stone
Treatment is surgical and involves removal of the stone and either simultaneous or delayed cholecystectomy
In addition to experiencing colicky pain and vomiting, patients may report distension and inability to pass flatus or stool
May show signs of hypovolemia (eg, hypotension, tachycardia)
Gallbladder Carcinoma
Adenocarcinoma arising from the glandular epithelium that lines the gallbladder
Risk factors: gallstones and especially when also combined with porcelain gallbladder
Presents as cholecystitis in elderly women
Poor Prognosis
U. Right Upper Quadrant pain, thickened gallbladder, patchy uniform calcification
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Biliary Colic
Waxing and waning right upper quadrant pain
Due to gallbladder contracting against a stone lodged in the cystic duct
Relieved with stone passing
Common bile duct obstruction may result in acute pancreatitis or obstructive jaundice
Associated with nausea/vomiting
Neurohormonal activation (eg, by CCK after a fatty meal) triggers contraction of gallbladder
Labs are normal, ultrasound shows cholelithiasis
Features that distinguish biliary colic from cholecystitis are pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis
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Chronic Cholecystitis
Chronic inflammation of the gallbladder
Due to chronic chemical irritation from longstanding cholelithiasis with or without superimposed bouts of acute cholecystitis
Characterized by herniation of gallbladder mucosa into the muscular wall (Rokitansky-Aschoff sinus)
Presents with vague right upper quadrant pain, especially after eating
Porecelain gallbladder is a late complication
Shrunken, hard gallbladder due to chronic inflammation, fibrosis and dystrophic calcification
Increased risk of carcinoma
Treatment: cholecystectomy, especially if porcelain gallbladder is present
Porcelain Gallbladder
Plain x-rays can show a rimlike calcification, CT scan typically reveals a calcified rim in the gallbladder wall with a central bile-filled dark area
Cholecystectomy considered for porcelain gallblad der, particularly if symptomatic or have incomplete mural calcification
Prophylactic cholecystectomy if they have symptoms of gallbladder disease (eg, biliary colic) or if punctate calcifications are present
Curvilinear gallbladder calcifications minimally increase cancer risk and generally do not require intervent ion
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Bacterial infection, tissue necrosis - causes early release from bone marrow (left shift)
Left shift - decreased Fc receptors (CD16)
Increased neutrophil precursors, such as band cells and metamyelocytes
High cortisol states - impairs adhesion of a marginated pool of neutrophils in pulmonary vasculature
Chronic inflammatory (autoimmune and infectious), malignancy
Allergic reactions (type 1 hypersensitivity), parasitic infection, Hodgkin's lymphoma
Due to eosinophilic chemotactic factor
Chronic myeloid leukemia (CML)
Viral infections, B. pertussis (lymphocytosis promoting factor - blocks lymphocytes from entering lymph nodes)
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Coagulation Factor Inhibitor and Disorders of Fibrinolysis
Coagulation Factor Inhibitor
Antibody against coagulation factor; anti-FVIII most commonly
Mimics hemophilia A
PTT does not correct upon mixing studies
In hemophilia A, mixing studies corrects PTT
Disorder of Fibrinolysis
Excess plasmin activity leading to excessive fibrinogen cleavage
Radical prostatectomy - Release of urokinase which activates plasmin
Cirrhosis of the liver - reduced production of a2-antiplasmin
Mimics DIC: Increased PT/PTT and bleeding time
Differentiated by DIC because increased fibrinogen split products without increased D-dimer
Treatment: aminocaproic acid (blocks plasminogen activation)
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Chronic Rheumatic Heart Disease
Valve scarring that arises as a consequence of rheumatic fever
Mitral valve - results in stenosis with a classic 'fish-mouth' appearance
Almost always involves the mitral valve; leads to thickening of chordae tendineae and susps
Occasionally involves the aortic valve; leads to fusion of the commissures; effectively causing aortic stenosis
Other valves are less commonly involved
Complications include infectious endocaritis
Due to repeat exposure to group A B-hemolytic streptoccoi results in relapse of the acute phase --> chronic disease
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III—Dysbetalipoproteinemia FA 17 90
Autosomal recessive
Defective ApoE3 and ApoE4
Increased Chylomicron/VLDL remnants
Premature atherosclerosis
Tuberoeruptive xanthomas
Xanthoma striatum palmare
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Lymph node 190
A 2° lymphoid organ that has many afferents, 1 or more efferents
Encapsulated, with trabeculae
Functions are nonspecific filtration by macrophages, storage of B and T cells, and immune response activation
Follicle (Cortex)
Site of B-cell localization and proliferation
In outer cortex; 1° follicles are dense and dormant; 2° follicles have pale central germinal centers and are active
Consists of medullary cords (closely packed lymphocytes and plasma cells) and medullary sinuses
Medullary sinuses communicate with efferent lymphatics and contain reticular cells and macrophages
Houses T cells
Region of cortex between follicles and medulla
Contains high endothelial venules through which T and B cells enter from blood. Not well developed in patients with DiGeorge syndrome
Paracortex enlarges in an extreme cellular immune response (eg, viral infection)
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Thymoma 229
Benign neoplasm of thymus
Pure red cell aplasia - Anemia with low reticulocytes
Good syndrome - Hypogammaglobulinemia
Myasthenia gravis - Antibodies against postsynaptic ACh receptors at NMJ
Superior vena cava syndrome
Healthy Thymus
Cortex is dense with immature T cells
Medulla is pale with mature T cells and Hassall corpuscles containing epithelial reticular cells
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Dopamine 246
D1 = D2 > β > α
Unstable bradycardia, HF, shock
Inotropic and chronotropic effects at lower doses due to β effects
Vasoconstriction at high doses due to α effects
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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
Sulfa drugs
Potentially fatal delayed hypersensitivity reaction
Latency period (2–8 weeks) followed by fever, morbilliform skin rash, and frequent multiorgan involvement
Withdrawal of offending drug, corticosteroids
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Familial Mediterranean Fever
Genetic disease with dysfunction of neutrophils that causes systemic amyloidosis
Usually seen in people of Mediterranean origin
High SAA that deposits as AA amyloid
Acute fever
Serosal inflammation (serosal inflammation of heart might mimic MI, of gut may mimic appendicitis, arthritis)
Occurs in episodes
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Chondroma and Osteoid Osteoma
Benign tumor of cartilage
Arises in the medulla of small bones of the hands and feet
Osteoid Osteoma
Benign tumor of osteoblasts (produces osteoid) surrounded by a rim of reactive bone
Young adults <25 years of age (more common in males)
Arises in cortex of long bones on the diaphysis
Bone pain (often worst at night) that resolves with aspirin
Imaging reveals a bony mass (<2cm) with a radiolucent core (osteoid)
Osteoblastoma is similar in disease course but is larger than 2cm, arises in vertebra and presents with bone pain not relieved by aspirin
Serial examination and x-rays every 4-5 months to monitor the lesion
NSAIDs for pain, surgical resection is typically reserved for patients with refractory symptoms,
Most lesions spontaneously resolve over several years
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Angiotensin II 540
Acts at angiotensin II receptor, type 1 (AT1) on vascular smooth muscle
Increase BP
Constricts efferent arteriole of glomerulus
Increases FF to preserve renal function (GFR) in low-volume states (ie, when decreased RBF)
Aldosterone release (adrenal cortex)
Increses Na+ channel insertion and activity of Na+/K+ pump
Enhances K+ and H+ excretion by way of principal cell K+ channels and α-intercalated cell H+ ATPases
Creates favorable Na+ gradient for Na+ and H2O reabsorption
ADH release (posterior pituitary)
Increased aquaporin insertion in principal cells
H2O reabsorption
Increased PCT Na+/H+ activity
Na+, HCO3 –, and H2O reabsorption (can permit contraction alkalosis)
Stimulates hypothalamus (thirst)
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Spleen 191
Located in LUQ of abdomen, anterior to left kidney, protected by 9th-11th ribs
Sinusoids are long, vascular channels in red pulp (red arrows) with fenestrated “barrel hoop” basement membrane
T cells are found in the periarteriolar lymphatic sheath (PALS) within the white pulp (white arrows)
B cells are found in follicles within the white pulp
The marginal zone, in between the red pulp and white pulp, contains macrophages and specialized B cells
Where antigenpresenting cells (APCs) capture blood-borne antigens for recognition by lymphocytes
Macrophages found nearby in spleen remove encapsulated bacteria
Decreased IgM causes decreased complement activation causing decreased C3b opsonization
Increases susceptibility to encapsulated organisms
Howell-Jolly bodies (nuclear remnants)
Target cells
Thrombocytosis (loss of sequestration and removal)
Lymphocytosis (loss of sequestration)
Vaccinate patients undergoing splenectomy against encapsulated organisms (pneumococcal, Hib, meningococcal)
Feared long-term complication is sepsis with encapsulated bacteria, most commonly Streptococcus pneumoniae
Daily oral penicillin prophylaxis for three to five years following splenectomy or until adulthood (for pediatric patients)
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Normally degraded by monoamine oxidase (MAO)
Levels increase in patients taking MAO inhibitors who ingest tyramine-rich foods (eg, aged cheese, wine, pepperoni, pickled foods and soy sauce).
Overripe fruits
Excess tyramine enters presynaptic vesicles and displaces other neurotransmitters (eg, NE)
Increased active presynaptic neurotransmitters
Increased diffusion of neurotransmitters into synaptic cleft increasing sympathetic stimulation
Classically results in a hypertensive crisis
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Nasal Polyps, Angiofibroma and Nasopharngeal Carcinoma
Nasal Polyp
Protrusion of edematious, inflamed nasal mucosa
Secondary to repeated bouts of rhinitis; occurs in cystic fibrosis and aspirin-intolerant asthma, kartagener
Aspirin-intolerant asthma consists of asthma, aspirin-induced bronchospasms, nasal polyps
Surgery often temporary relief, polyps recur; ultimate treatment should be management of underlying etiology
Not just aspirin, any NSAIDs
Can do aspirin desensitization if aspirin is required
Treatment includes management of the patient's underlying asthma and chronic rhinosinusitis
Avoidance of NSAIDs, and desensitization if NSAID use is required
Leukotriene inhibitors (zileuton) and leukotriene antagonists (montelukast) --> improved resp/nasal symptoms
Considered a pseudoallergy
Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue; classically seen in adolescent males
Profuse epistaxis
Can cause nasal obstruction and nasal drainage
Nasopharyngeal Carcinoma
EBV association; classically African children/Chinese Adults
Risk is thought to be higher in these locations due to diet (salt-cured food, early exposure to salted fish) and genetic predisposition
Pleomorphic keratin-positive epithelial cells (poorly differentiated squamous cell carcinoma) in a background of lymphocytes
Often presents with cervical lymph node involvement
EBV assays are often used to monitor treatment response and disease relapse
Invades adjacent tissues --> congestion, epistaxis, headache, CN palsy, serous otitis media (eustachian obstruction)
Nasal congestion with epistaxis, headache, cranial nerve palsies (eg , facial numbness), serous otitis media (eustachian tube obstruction)
Early metastatic spread to the cervical lymph nodes may cause a nontender neck mass
Nasopharyngeal endoscopy should be considered
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Growth hormone (Somatotropin) 311
Secreted by anterior pituitary
Stimulates linear growth and muscle mass through IGF-1 (somatomedin C) secretion by liver
Increased insulin resistance (diabetogenic)
Released in pulses in response to growth hormone–releasing hormone (GHRH)
Secretion increased during exercise, deep sleep, puberty, hypoglycemia, ghrelin
Secretion inhibited by glucose and somatostatin release via negative feedback by somatomedin
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Anatomy of the Heart 265
SA node is supplied by branches of the RCA
The AV nodal artery is usually derived from the dominant Coronary artery ie the one that gives rise to the PDA
Right (acute) marginal artery
Supplies right ventricle
Posterior descending/interventricular artery (PDA)
Supplies AV node, posterior 1/3 of interventricular septum, 2/3 posterior walls of ventricles, and posteromedial papillary muscle
Inferior wall of left ventricle
Left anterior descending artery (LAD)
Supplies anterior 2/3 of interventricular septum, anterolateral papillary muscle, and anterior surface of left ventricle
Left circumflex coronary artery (LCX)
Supplies lateral and posterior walls of left ventricle, anterolateral papillary muscle
Diagonal branches from the LAD artery also run downward to supply the anterolateral wall of the left ventr icle
The right coronary supplies the right ventric le and inferoposterior walls of the left ventricle
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Peroxisome and Related Disorders 43
Membrane-enclosed organelle involved in catabolism of:
Very-long-chain fatty acids (through β-oxidation), branched-chain fatty acids, amino acids, and ethanol
Peroxisomal disorders commonly lead to neurologic diseases due to deficits in synthesis of plasmalogens
Important phospholipids in myelin
P. Contains catalase which breaks down H2O2 into H2O
Zellweger syndrome
Hypotonia, seizures, hepatomegaly, early death
Refsum disease
Scaly skin, ataxia, cataracts/night blindness, shortening of 4th toe, epiphyseal dysplasia
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