9

Mu effect

• Physical dependence

• Euphoria

• Respiratory & cardiac depression

• Reduced gastrointestinal motility

• Sedation

• Analgesia (CNS, most opioids)

Kappa effect

• Miosis

• Dysphoria

• Sedation

• Analgesia (PNS, some opioids)

Delta effect

• Antidepressant effects

• Analgesia (PNS, some opioids)

Serum alkalinization with sodium bicarbonate

tricyclic antidepressant (TCA) overdose to mitigate cardiotoxic effects (increased serum pH promotes TCA dissociation from cardiac fast sodium channels)

TCA overdose

tachycardia, hyperthermia, flushing and dilated pupils

delusional disorder

>1 delusions for > 1 months

a gram-positive coccus that forms chains and exhibits a narrow zone of complete hemolysis on blood agar (beta-hemolytic)

B streptococcus

in femoral neck fracture which creates external rotation of the bone

illiopsoas

in femoral neck fracture what cuase the abduction and elevation of the bone

Gluteus medius

Anterior dislocation of the hip cause

abduction and external rotation

Posterior disloaction of the hip cause

adduction and internal rotation

penicillin family of antibiotics

beta-lactam ring that inhibits peptidoglycan cross-linking and causes bacterial cell wall disruptions

tazobactam

beta-lactamase inhibitor

inhibit a bacterial enzyme that hydrolyzes and inactivates the beta-lactam ring

Probenecid

a uricosuric agent used for hyperuricemia with gout, blocks the renal tubular excretion of penicilins and cephalosporins and is sometimes used to increase their serum level or prolong their half-life

fibrovascular cores currounded by squamous epithelium

Squamous papillomas

Prodrome (fever, malaise(

Pruitic macules, papules & vescicles in different stages

Complications : skin infection, pneumonia, encephalitis

Primary varicella

variola virus

cause small pox, vesiculopustular rash with lesions at the same stage of development

Anticholinergics (amitriptyline, scopolamine) cause nonexertional heat stroke

inhibit diaphoresis, limiting the body’s primary mechanism of heat dissipation

Sympathomimetics (amphetamines, cocaine) cause nonexertional heat stroke by

impairing peripheral vasodilation, limiting heat transfer to the skin

Dopaminergic antagonists(chlorpromazine, haloperidol) cause nonexertional heat stroke by

disrupting hypothalamic thermoregulation, blocking dopamine transmission in the hypothalamus

Diuretics (furosemide) and beta blockers(metoprolol)

limit the cardiac response to heat stress by reducing blood volume or heat rate thereby decreasing blood floww to the skin

Malignant hyperthermia

rare autosomal dominant disorder that occurs due to uncontrolled efflux of calcium from the sarcoplasmic reticulum resulting in increasing muscle tone(myoclonus, rigidity) and hyperthermia

by anesthetics (halothane, succinylcholine)

Colchicine

binds to the intracellular protein tubulin and inhibits its polymerization into microtubules

disrupts cytoskeletal-dependent functions such as chemotaxis and phagocytosis

adverse effect of colchicine

nausea, abdominal pain, and diarrhea

microtubule role

change shape, move directinally, transport vesicles/proteins inside the cell

aging effects to kidney

• reduced renal mass and functional glomeruli : reduced glomerular filtration rate and creatinine clearance

• Reduced renal blood flow

• Reduced hormonal responsiveness

• Ability to EXCRETE solutes is relatively preserved in the aging kidney

edematous and erythematous plaque with mild central pallor

a wheal-and-flare reaction

C3b component of immune complexes formed by type 3 hypersensitivity reactions can also bind to

CR1 receptors on erthrocytes, facilitating their clearance in the liver and spleen

non-lactose-fermenting gram-negative rods that cause UTI

Psudomonas aeruginosa

Enterobacter cloacae

lactose-ferementing, gram-negative rod characterized by extensive antibiotic resistance, nosocomial infections

Gram-positive coccus that cause opportunistic UTIs, Vancomycin-resistant Enterococcus

Enterococcus faecalis

Lactose-fermenting, gram-negative rod and leading cause of complicated and uncomplicated UTIs

E.coli

Catalse-positive, coagulase-negative, gram-positive coccus that typically causes UTIs in sexually active women

differentiated from S epidermidis by being novobiocin resistant

Staphylococcus saprophyticus

Facial pain, headache, and nasal eschar in the patient with diabetic ketoacidosis (pH7.1, positive ketones, and dry mucous membranses in a young patient with recent unintended weight loss)

mucorcycosis

mucosal biopsy that shows fungi appear as ribbon-like broad nonseptate hyphae with right-angle branching

necrotic eschar

Mucormycosis

septated narrow hyphae with sharp-angle branching

Aspergillus

blood cultures useful in diagnosing

candidemia

serologic testing is important in recurrent episodes of fever and bronchial obstruction in a patient with asthma

diagnosis of allergic bronchopulmonary aspergillosis (ABPA) where increased titers of IgE and antibodies to Aspergillus fumigatus are seen

congenital hypothyroidism symptoms

• asymptomatic at birth

• After maternal thyroxine wanes (weeks to months)

  • Lethargy, poor feeding

  • Enlarged fontanelle

  • Protruding tongue, puffy face, umbilical hernia

  • Constipation

  • Prolonged jaundice

  • Dry skin

Diagnosis of congenital hypothyroidism

increased TSH and low free thyroxine levels

Treatment for congenital hypothyroidism

Levothyroxine

cause of ineffective therapy of levothryoxine to congenital hypothyroidism

rapid growth, decreased absorption of levothryoxine

low total T4 but normla TSH and free T4 levels

Thyroxine-binding globulin deficiency

less total T4 available → free T4 level normalizes (euthyrodi) → TSH level normalizes

In prerenal acute kidney injury fractional excretion of sodium is

less than 1%

in prerenal acute kidney injury urine osmolality is

>500mOsm/kg

what can you see in prerenal acute kidney injury microscopy

Hyaline casts

causes of acute tubular necrosis

Renal ischemia (hemorrhage, sepsis) or nephrotoxins (aminoglycosides, radiocontrast)

fractional excretion of sodium and urine osmolatity in acute tubular necrosis

>2%, ~ 300 mOsm/kg

first-line/maintenace for panic disorder and treatment for acute distress

SSRI/SNRI

benzodiazepines

generalized anxiety disorder lasts for more than

6 mths

diff of somatic symptom disorder from panic disorder

patients experience physical symptoms persistently (daily, unrelenting, fatigue)

graft versus host disease is caused by

donor CD3+ T cells recognize host cells as foreing → widespread, multisystem inflammatory response

what are the undesirable effects of depleting CD3+ T cells

• increase the risk of leukemia relapse

• increase the risk of viral infections

immunoglobulin deficiency is normal effect of

myeloablative chemoradiotherapy that improves over time with engraftment (proliferation and differentiation) of donor HSCs

Octreotide

long-acting octapeptide somatostatin analogue that has an altered amino acid sequence in the non-receptor binding domain, more resistant to degradation than native somatostatin

inhibits GH secretion and reduces IGF-1 release

GH is mediated by

insulin like growth factor -1

Elastase breaks down ____ and is released by ________ during acute inflammation

collagen, neutrophils and macrophages

central round nuclei and abundant greyish, vacuolated cytoplasm

Macrophages

eccentric nucleus, perinuclear paleness (large Golgi apparatus) and spoke-wheel chromatin

Plasma cells

contain cytotoxic granules composed of perforin and grnzymes which are released in response to foreign antigens on the surface (MHC class 1 receptors)

Reactive lymphocytes

generate and release major basic protein that acts as a cytotoxin and helminthotoxin and mediates epithelial damgae, exfoliation and bronchospasm in hypersensitivity disease

bilobed nucleus and stain intensely pink

Eosinophils

basophilic stippling in

thalassemia or alcoholism

myopic shift

loss of red reflex in the lens

cataract

Patients with long-term intrauterine devices at increased risk for

Actinomyces infection

patient with IUDs and acute-angle branching, gram-positive bacilli

Actinomyces infection

treatment for Actinomyces infection

penicillin

smooth, cream-colored colonies consisting of branching pseudohyphae and blastoconidia treatment

Fluconazole

Trichomonas vaginalis and Gardnerella vaginalis treatment

Metronidazle

filamentous, wide-branching, gram-positive rods

Nocardia : Trimethoprim-sulfamethoxazole

goodpasture syndrome

autoantibodies against the alpha 3 chain of type 4 collagen

immunofluorescence shows linear deposition of IgG and C3 on the GBM

Goodpasture syndrome

anticardiolipin antibodies

antiphospholipid antibody syndrome

The rotator cuff tendons

• S : supraspinatus

• I : infraspinatus

• T : teres minor

• S : subscapularis

contributes to extension & external rotation of humerus

flexion & internal rotation of humerus

abducts humerus beyond 15 degrees

Deltoids

decongestants

alpha-adrenergic agonists

Tachyphylaxis

decreased production of endogenous norepinephrine from the nerve terminals due to a negative feedback mechanism resulting in relative vasodilation

occurs after humans ingest Taenia solium eggs in contaminated food or water

Neurocysticerocosis

most common CNS neoplasm and often presents with seizure

extraaxial, dural-based mass that compresses brain tissue

whorls of uniform, oval tumor cells with eosinophilic cytoplasm

Meningioma

Norovirus

linear, nonenveloped, single-stranded RNA genome

Adenoviral gastroenteritis

fever and watery diarrhea

watery diarrhea with or without blood, abdominal pain, fever and leukocytosis

C.difficile

trisomy 18

micrognathia, low-set ears, prominent occiput, rocker bottom feet, clenched hands with overlapping fingers, ventricular septal defect, patent ductus arteriosus, horseshoe kidney, Meckel’s diverticulum, malrotation

Proopiomelanocortin (POMC)

endogenous opioid peptides is cleaved from a larger precursor protein

the precursor protien is the POMC which undergoes variable posttranslational modifications (enzymatic cleavage) to yield smaller, mature peptides with diverse functions

POMC derived peptide, beta-endorphin

produces analgesic effect

Proopiomelanocortin (POMC)

• Beta-endorphin : produces analgesic effect

• Adrenocorticotropic hormone (ACTH) : stimulates cortisol release

• Melanocyte-stimulating hormone : regulates melanin production

Most commonly due to X-linked recessive CD40L deficiency

Hyper-IgM syndrome

aortic arch anomalies, thymic hypoplasia/ aplasia, hypocalcemia, hypertelorism, low set ears, micrognathia, and cleft palate

DiGeorge syndrome

midline facila defects (holoprosencephaly, cleft lip/palate, musculoskeletal abnormalities (polydactyly) and gastrointestinal anomalies (omphalocele, umbilical hernia)

Trisomy 13 (Patau syndrome)

Most commonly due to X-linked recessive CD40L deficiency

Impaired T-cell interaction with APCs → lack of germinal centers

Impaired T-cell activation of B cells

• Lack of immunoglobulin class switching

• low Memory B-cell production

Hyper-IgM syndrome

low cobalamin levels occur due to

pernicious anemia, gastrectomy, ileal resections, infection by the tapeworm DIphyllobothrium latum, strict vegan diets containing no animal products for a prolonged period (3-4 yrs)

Vitamin B12 deficiency cause impaired myelin synthesis by

• Methylmalonic acid buildup bc of no Mehtylmalonyl-CoA mutase (vitamin B12)

and

Vitamin B12 deficiency cause impaired DNA synthesis by building up

• Homocysteine bc lack of Methionine synthase ( impaired DNA synthase)

Spinal cord lesion below the lesion

UMN signs

spinal cord lesion at the level of the lesion

LMN signs occur

Tabes dorsalis

degeneration of the dorsal root ganglia and dorsal columns

patients have impaired vibratory sensation and proprioception

Syringomyelia

central cavitation of the cervical spinal cord that is associated with damage to the anterior white commissure of the spinothalamic tract

bilateral loss of pain/temperature in the upper extremities

Pervasive pattern of distrust & suspiciousness beginning in early adulthood & occuring in a variety of settings

Paranoid personality disorder

Tularemia transmission

• Wild animal (hare, rabbit) hunting/skinning

• Tick or mosquito bite

• bioterrorism agent

• Nonspecific systemic symptoms (fever, malaise)

• Ulceroglandular disease

  • Single papuloulcerative lesion (sometimes absent)

  • Tender, suppurative regional lymphadenopathy

• Pneumonia

• Poorly staining, gram-negative coccobacillus

• Most strains require cysteine for growth

• Evades most immune defenses & replicates within macrophages/neutrophils

Fancisella tularensis

Warfarin

decrease production of vitamin K-dependent clotting factors