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Dr. Paul Ciurysek, M.D.

USMLE Step 1 BIBLE


THE
USMLE STEP 1
BIBLE

The Ultimate USMLE Step 1 Preparation Guide
The 0SNLE Step 1 BIBLE"
Copyiight 2u1u Bi. Paul Ciuiysek, N.B. All iight ieseiveu. No pait of this book
may be useu oi iepiouuceu in any mannei whatsoevei without wiitten peimission
except in the case of iepiint in the context of ieview anu peisonal euucation.
























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The 0SNLE Step 1 BIBLE was wiitten foi only one ieason: To help you unueistanu
meuicine as well as possible anu elevate youi Step 1 scoie as high as possible.
The Step 1 BIBLE was cieateu with the iuea that high-yielu topics aie extiemely
impoitant, but simply looking at the supeificial infoimation ielating to them is not
the most effective way to piepaie foi this infoimation-iich test. If we coulu gathei
all of the veiy high-yielu topics coveieu by the 0SNLE Step 1 exam, anu then uelve
ueepei anu examine eveiything theie is to know about them, then we aie going to
be auequately piepaieu to tackle this exam. Not only will this piepaie you foi a
passing scoie, but it will help to elevate youi knowleuge anu unueistanuing beyonu
any othei piepaiation souice available to you, which will ultimately help give you
the chance of scoiing veiy well on the Step 1 exam.
The best way to use the 0SNLE Step 1 BIBLE is to combine it with a quality question
bank geaieu to the Step 1 exam. The infoimation within this guiue, when useu in
conjunction with a question bank, will auequately piepaie you foi ultimate success.
Best of luck on the Step 1 exam,
Bi. Paul Ciuiysek, N.B












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The common uppei limb neive injuiies have classic piesentations anu aie usually
ieveisible. The most common injuiies incluue:
47897 -:;<87= ,>??>: ,@<A7A 3>B>8 &7CDEDB 27:A>8F &7CDEDB
3$&-+4 Injuiy to the
supiaconuyle of
the humeius.
Loss of:
Foieaim
Pionation
Wiist Flexion
Fingei Flexion
Thumb movement
Long-teim thenai
atiophy is
possible
Loss of sensation
in the thumb,
lateial aspect of
the palm, anu the
fiist 2.S fingeis
(inuex, miuule,
anu half of iing
fingei)
#+&-+. Injuiy to the
shaft of the
humeius
Loss of tiiceps
ieflex,
biachioiauialis
ieflex, anu
extensoi caipi
iauialis longus
(causing the
classic wiist uiop)
Loss of sensation
to the posteiioi
antebiachial
cutaneous anu
the posteiioi
biachial
cutaneous
1.4+# Injuiy to the
meuial
epiconuyle of the
humeius
Causes impaiieu
flexion anu
auuuction of the
wiist, as well as
impaiieu
auuuction of the
ulnai two fingeis
anu the thumb
Loss of sensation
to the meuial
aspect of the
palm, as well as
loss of sensation
to the pinky anu
meuial V of the
iing fingei
+0-..+#G Injuiy to the
suigical neck of
the the humeius
anuoi anteiioi
shouluei
uislocation
Results in a loss of
complete ueltoiu
movement
Loss of sensation
ovei the ueltoiu
muscle, as well
as the skin
coveiing the
infeiioi aspect of
the ueltoiu
312,1.",1(+4$"12 Compiession
between biceps
aponeuiosis anu
biachialis fascia
Loss of function of
coiacobiachialis,
biceps, anu
biachialis muscles
Loss of sensation
in the iauial
aspect of the
foieaim


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Also known as ">BMFBL AH>GH NBL@E" anu "&BCS>MBE AFJIC
NBL@E". The iauial neive inneivates the *8@EHD>8@=D@IDA,
$JB7:A>8A >C BH7 K8DABLCD:M78A, 2<ND:@B>8, anu the (8DE7NA.
Compiession anuoi injuiy to the iauial neive causes the
classic "wiist uiop", uue to the inability to extenu the wiist.


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Compiession of the ulnai neive at the elbow will cause numbness of the small fingei
anu the meuial aspect of the iing fingei. With time, weakness of the hanu will
piouuce the "claw hanu", wheie the small fingei anu the iing fingei contiact anu
foim a "claw". This is late sequelae of ulnai neive injuiy, anu is a sign of a seveiely
injuieu ulnai neive.



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*iachioiauialis
$xtensois of
wiistfingeis
2upinatoi
(iiceps

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A paialysis of the aim uue to injuiy of the supeiioi tiunk of the biachial plexus (CS
anu C6 ioots). This occuis most commonly with shouluei uystocia uuiing
chilubiith, but is also seen fiom uiiect blows to the shouluei. The most commonly
affecteu neives aie the axillaiy neive, the musculocutaneous neive, anu the
supiascapulai neive. This causes a loss of sensation in the aim anu atiophy of the
ueltoiu, the biceps, anu the biachialis muscles, iesulting in a chaiacteiistic hanging
of the aim to the siue with meuial iotation.
The classic finuings:
- Abuuctoi paialysis (hanging limb to the siue)
- Paialysis of lateial iotatois (meuial iotation)
- Loss of biceps action (foieaim pionation)
The piesence of a biisk ieflex in the aim often means theie is a goou piognosis.


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A compiession of the subclavian aiteiy anu the infeiioi tiunk of the biachial plexus
iesults in thoiacic outlet synuiome. Compiession occuis at C8 anu T1, leauing to:
- Thenai anu hypothenai atiophy
- Inteiosseus muscle atiophy
- Sensoiy ueficit of the meuial foieaim anu hanu
- Loss of iauial pulse upon heau movement to the affecteu siue


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The iotatoi cuff is a gioup of muscles that stabilize the
shouluei. Theie aie foui muscles in the iotatoi cuff, they
aie:
- Supiaspinatus
- Infiaspinatus
- Teies Ninoi
- Subscapulaiis
Injuiy to the iotatoi cuff is most commonly expeiienceu as
pain in the lateial aspect of the ueltoiu, anu is often accompanieu by the pain on
abuuction of the aim.





2-(2
2upiaspinatus
-nfiaspinatus
(eies Ninoi
2ubscapulaiis

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The iecuiient laiyngeal neive is an impoitant
stiuctuie of the neck. It is a bianch of the vagus
Neive, anu supplies all intiinsic muscles of the
laiynx except the ciicothyioiu.
The iight iecuiient laiyngeal neive wiaps aiounu the iight subclavian aiteiy, while
the left iecuiient laiyngeal neive wiaps aiounu the aich of the aoita anu the
ligamentum aiteiiosum.






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The iight lung contains S lobes, while the left lobe contains only 2 lobes. The left
lung contains, insteau of a miuule lobe, space that is occupieu by the heait (caiuiac
notch).


The most common site of foieign bouy aspiiation is the iight lung, because the angle
of the iight mainstem bionchus is less acute than the left mainstem bionchus.

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Lymphatic uiainage is quite simple; the iight lymphatic uuct uiains the iight siue of
the heau anu the iight aim, while the thoiacic uuct (left siue) uiains the iest of the
bouy.










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The celiac aiteiy is the fiist majoi bianch
off of the abuominal aoita, followeu by the
supeiioi anu infeiioi mesenteiic aiteiies.
The OHLFBO B>CH>E supplies the livei,
stomach, spleen, supeiioi half of the
uuouenum, the abuominal esophagus, anu
the pancieas (all stiuctuies of the
foiegut).
The @SNH>F?> DH@HACH>FO B>CH>E supplies stiuctuies aiising fiom the miugut, while
the FAUH>F?> DH@HACH>FO B>CH>E supplies stiuctuies aiising fiom the hinugut.

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!HLFBO - Stomach to uuouenum, livei, uB,
pancieas.
&/) - Buouenum to 2S of tiansveise colon.
5/) - Bistal 1S of tiansveise colon to uppei
iectum.

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The uiaphiagm is inneivateu by !4V !6V BAM !8 (Phienic Neive). Bue to this
inneivation, pain anuoi piessuie to the uiaphiagm can cause iefeiieu pain to the
shouluei. Theie aie a few extiemely impoitant stiuctuies that peifoiate the
uiaphiagm at the level of T8, T1u, anu T12. They incluue:
+B (W - Infeiioi vena Cava
+B (XY - Esophagus, vagal tiunks (2)
+B ( XZ - Aoita, Azygous vein, Thoiacic
Buct






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- W XY $TT2 +( XZ
-vC 8 (T8)
$sophaTus & vaTu2 at 1u (T1u)
+oita+zygous & (hoiacic uuct
at 12 (T12)

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Bile is secieteu by the livei anu stoieu insiue the gall blauuei, then secieteu into the
uuouenum as neeueu. Nany abuominal pathologies occui as a iesult of stasis
anuoi obstiuction of the biliaiy tiee.





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It is impoitant to be able to ueciphei between peiitoneal anu ietiopeiitoneal
stiuctuies, as location can help you make a uiagnosis baseu on piesenting
symptoms. Retiopeiitoneal stiuctuies can often iefei pain to the back, thus
knowleuge of this anatomy is essential.



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The inguinal canal is an oblique stiuctuie that holus the speimatic coiu anu
ilioinguinal neive in males, anu the iounu ligament of the uteius anu ilioinguinal
neive in females. The canal is foimeu by the aponeuioses of thiee flat abuominal
muscles.
*><:=@8D7A >C BH7 -:M<D:@I ,@:@IR
1. &SNH>UFOFBL 5AJSFABL +FAJ - tiiangulai uefect in the exteinal oblique
aponeuiosis
2. XHHN 5AJSFABL +FAJ - in the tiansveisalis fascia
S. )ACH>F?> YBLL - inteinal oblique muscle (lateially) anu exteinal oblique
aponeuiosis (meuially)
4. +??U - falx inguinalis (aiching infeiioi fibeis of inteinal oblique muscle)
S. ZL??> - inguinal ligament anu lacunai ligament (meuially)
6. *?@CH>F?> YBLL - tiansveisalis fascia (weak fascia) lateially anu conjoint
tenuon (meuially)

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Is an inguinal tiiangle thiough which uiiect inguinal heinias piotiuue thiough the
abuominal wall.



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XF>HOC 5AJSFABL (H>AFB@ [ This type of heinia bulges
thiough the abuominal wall, thiough Basselbech's
tiiangle, meuial to the infeiioi epigastiic vessels anu only
thiough the @SNH>UFOFBL FAJSFABL >FAJ.
3& ! 3euial to infeiioi epigastiic aiteiy = &iiect Beinia
5AMF>HOC 5AJSFABL (H>AFB@ - This type of heinia tiavels
thiough the ueep anu supeificial inguinal iings anu into the sciotum. Piotiusion
thiough the ueep inguinal iing is lateial to the infeiioi epigastiic vessels. This
occuis uue to failuie of the closuie of the piocessus vaginalis.
XFBNI>BJDBCFO (H>AFB@ - This type of heinia occuis when abuominal contents
entei into the thoiax. The most common type of uiaphiagmatic heinia is the hiatal
heinia, which is common anu associateu with uERB. Newboins may have uI
contents in the thoiax as a iesult of a uefect in the pleuiopeiitoneal membiane.



(H>AFB@ B>H B
N>?C>S@F?A ?U
JB@C>?FACH@CFABL
O?ACHAC@
CI>?SJI B>HB@ ?U
THB\AH@@ FA CIH
BWM?DFABL TBLLQ

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A femoial heinia occuis when theie is a weakness in the femoial canaltiiangle, anu
occuis uiiectly below the inguinal ligament. This type of heinia is uncommon,
accounting foi <S% of all heinias. It is most commonly seen in females uue to theii
wiuei pelvic stiuctuie.
+HMSOFWLH ZHD?>BL (H>AFB - Is the most common foim, the heinia can be pusheu
back into the abuomen.
5>>HMSOFWLH ZHD?>BL (H>AFB - 0ccuis when the heinia is not ieuucible, anu
becomes stuck in the femoial canal.
5AOB>OH>BCHM (H>AFB - 0ccuis when the heinia becomes tiappeu in the heinial
sack. This is consiueieu to be a suigical emeigency anu iequiies immeuiate
tieatment.
&C>BAJSLBCHM (H>AFB - 0ccuis when bloou supply to an incaiceiateu heinia is cut-
off. This can cause tissue ueath anu the uevelopment of gangiene.



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These aie anastomoses that occui between veins of the poital anu systemic
ciiculation. These sites aie impoitant because seveial conuitions may occui as a
iesult of changes in piessuie within each system.
The most common conuitions incluue: Bemoiihoius, Esophageal vaiices, anu Caput
Neuusae.
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(HD?>>I?FM@ Niuule Rectal anu Infeiioi
Rectal veins
Supeiioi Rectal veins
%@?NIBJHBL ]B>FOH@ Azygous veins Left uastiic vein
!BNSC /HMS@BH Supeificial Epigastiic vein Paiaumbilical veins

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The left ovaiyteste uiains fiom the left gonaual vein, to the left ienal vein, anu into
the infeiioi vena cava.
3HUC .?ABMBL ]HFA ! 3HUC +HABL ]HFA ! 5]!
In 2S% of men, this system is not completely competent, anu iesults in a
vaiicocele of the left teste

The iight ovaiytest uiains uiiectly fiom the gonaual vein into the IvC. This iaiely
iesults in a vaiicocele in men uue to the angle of uiainage.

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The pectinate line is most commonly useful when a patient has hemoiihoius.
Bemoiihoius that aie above the pectinate line uo not cause pain uue to visceial
inneivation. Bemoiihoius that aie below the pectinate line have somatic
inneivation, anu aie theiefoie painful.
!"# %#&'()*'# +()# (, -./0#1 2"#/# '"# "()134' *)1 '"# #&'.1#/0 0##'5
)>CH>FBL @SNNLE @Q>97 BH7 N7EBD:@B7 line is fiom the supeiioi iectal aiteiy. ]HA?S@
M>BFABJH is fiom the supeiioi iectal vein to the infeiioi mesenteiic vein, anu into
the poital system.
)>CH>FBL @SNNLE Q7I>K BH7 N7EBD:@B7 line is fiom the infeiioi iectal aiteiy. venous
uiainage is fiom the infeiioi iectal vein to the inteinal puuenual vein, then into the
inteinal iliac vein anu into the IvC.








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/HAF@OF - The common piesentation of a meniscal injuiy is \AHH NBFA BAM @THLLFAJ,
as well as locking of the joint, especially when beaiing weight on the joint anu fully
stiaightening the leg. The menisci can be toin when uoing low-impact activities
such as walking, anu can be toin when uoing high-impact activities such as weight
lifting anu playing spoits. Common causes of injuiy aie FDNBOC C? CIH \AHH BAM B
^CTF@CFAJ_ D?CF?A of the knee when it is fiimly planteu.
/HMFBL !?LLBCH>BL 3FJBDHAC - Also known as the tibial collateial ligament. Attacheu
pioximally to the meuial conuyle of the femui below the auuuctoi tubeicle anu
meuial suiface of its bouy. The posteiioi fibeis aie shoit anu incline backwaius
upon uescent, anu aie inseiteu into the tibia above the semi-membianous muscle
gioove. It inseits into the meuial suiface of the tibial bouy about 2.Scm below the
level of the conuyle. Injuiies aie common in @\FFAJ BAM FA U??CWBLL when GBLJS@
@C>H@@ is applieu (this is "abuuction stiess" aka stiess to the lateial aspect of the
knee).
3BCH>BL !?LLBCH>BL 3FJBDHAC - Also known as the "fibulai collateial ligament", is
naiiow anu less bioau that the meuial collateial ligament. The LCL tiavels obliquely
fiom the lateial epiconuyle of the femui to the heau of the fibula. The anatomy of
the LCL gives it moie flexibility than the NCL, anu thus it is less commonly injuieu.
)ACH>F?> !>SOFBCH 3FJBDHAC - The ACL gets the teim "anteiioi" because it attaches
to the anteiioi aspect of the tibia, with an oiigin fiom ueep within the notch of the
uistal femui. Injuiy to the anteiioi ciuciate ligament is the most common knee
injuiy, anu is especially seen in athletes. 3BCH>BL >?CBCF?ABL D?GH@ such as those in
soccei, basketball, anu skiing aie common causes of ACL stiains anuoi teais.
$H@CFAJ U?> )!3 FA`S>E is uone with the BACH>F?> M>BTH> CH@C, wheie the flexeu
knee is uiawn foiwaiu in an attempt to iuentify an FAO>HB@HM BD?SAC ?U BACH>F?>
CFWFBL C>BA@LBCF?A as compaieu to the opposite joint. The 3BOIDBA CH@C is anothei
uiagnostic test that is similai in natuie, but with the patient's knee in 2u-Su uegiee
flexion insteau of the 9u-uegiee flexion useu in the anteiioi uiawei test.
*?@CH>F?> !>SOFBCH 3FJBDHAC - The posteiioi ciuciate ligament gets its name
because it BCCBOIH@ C? CIH N?@CH>F?> B@NHOC ?U CIH CFWFB. It connects the posteiioi
inteiconuylai aiea of the tibia to the meuial conuyle of the femui. Injuiy to the PCL
causes less pain anu uisability than those to the ACL, anu often goes unuiagnoseu.
The common cause of PCL injuiy is the "MB@IW?B>M FA`S>E", wheie something
foicefully stiikes the tibia anu uiives it posteiioily. A common mechanism of injuiy
uuiing spoiting events is a UBLL ?A B IENH>ULHPHM \AHH with the foot pointeu
uownwaius. Patients often complain of a "N?N" uuiing the injuiy. The PCL injuiy is
uiagnoseu initially with the posteiioi uiawei test, wheie the tibia is pusheu
backwaius anu a uecieaseu iesistance is expeiienceu.
$IH 7AIBNNE $>FBM - This is a common knee injuiy seen in football, wheie a playei
is hit on the lateial aspect of the knee, causing uamage to the )!3, /!3, anu /HMFBL
/HAF@OS@.







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IFJIKEFHLMQ /HD?>FaBCF?A ?U CIH HDW>E?L?JFO MH>FGBCFGH@ F@
FDN?>CBACV B@ FC F@ LF\HLE C? @I?T SN ?A CIH HPBDV B@ F@ CIH
DB`?>FCE ?U CIH FAU?>DBCF?A U>?D CIF@ OIBNCH>Q













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Speimatogenesis is the piocess by which the speimatogonia uevelop into the
matuie speim (speimatozoa). This occuis in the testes anu epiuiuymis in a step-by-
step fashion, taking appioximately 6S uays. The staiting point foi speimatogenesis
is the seminifeious tubules of the testes, wheie the stem cells that aie aujacent to
the innei tubule wall uiviue in a centiipetal uiiection (moving towaius the lumen).
Natuiation of speim occuis in the epiuiuymis, wheie it acquiies its motility.
Thioughout speimatogenesis, the seitoli cells play an impoitant iole in the
following:
- Naintaining the enviionment necessaiy foi matuiationuevelopment via the
bloou-testis baiiiei
- Secietes suppoiting fluius anu substances to initiate meiosis
- Seciete anuiogen-binuing pioteins, which cieate the enviionment foi a
highei level of feitility
- Seciete inhibin in oiuei to stimulate the pituitaiy glanu to fuithei
speimatogenesis
- Secietes anti-mulleiian hoimone to pievent the foimation of Nulleiian Bucts
- Pioviues piotection to the speimatius fiom autoimmune attack







()$ +4+("3G "! 2/$#3








!#"3 !$#(-.-\+(-"4 (" -3/.+4(+(-"4
0pon feitilization, theie aie many iapiu changes that occui to the egg, incluuing
migiation thiough the fallopian tube, implantation, cell uivision, giowth anu
uevelopment, etc. The following table anu illustiation uemonstiate the most
impoitant points fiom feitilization to implantation.
(-3$ $5$4(
Initiating Event Feitilization of egg by speim
Week 1 Implantation of blastocyst
Week 2 Foimation of bilaminai uisk
Week S Foimation of piimitive stieak,
notochoiu, anu neuial tube.
uastiulation
Week S-8 Neuial tube foimation.
Foimation of oigans.
Nost likely time to be haimeu by
teiatogenic agents.
Week 4 Limb buus begin to foim.
Beait begins to beat.
Week 1u uenitals aie uiffeientiateu.




)-2("T$4$2-2
Is the foimation of the uiffeient tissues of the bouy fiom unuiffeientiateu cells.
These aie the ectoueim, mesoueim, anu enuoueim.
%OC?MH>D - The ectoueim is the moie supeificial tissue, they incluue:
- 64/-*&# 7&'.1#/0: Epiueimis, Lining of the epithelium, Lens of the eye, anu
the auenohypophysis.
- 8#4/.#&'.1#/0: CNS Neuions, Neuiohypophysis, 0ligouenuiocytes,
Astiocytes, anu the Pineal ulanu
- 8#4/*+ 9/#,': Autonomic Neivous System, Boisal Root uanglia, Nelanocytes,
Chiomaffin Cells of Auienal Neuulla, Enteiochiomaffin Cells, Pia Natei,
Celiac uanglion, Schwann Cells, Paiafolliculai Cells of Thyioiu, Laiyngeal
Caitilage

%AM?MH>D - The enuoueim is foimeu by cells migiating along the aichenteion,
foiming the innei layei of the gastiula, thus ueveloping into the enuoueim. The
cells of the enuoueim being as squamous cells, but finally change into columnai
cells. The tissues of the enuoueim incluue:
- The entiie gastiointestinal tiact except pait of the mouth, phaiynx, anu the
teiminal iectum (foimeu by ectoueimal involution)
- The tiachea, bionchi, anu alveoli
- Lining of the follicles of the thyioiu, thymus, anu paiathyioiu glanus

/H@?MH>D - The mesoueim is the miuule geimal layei, giving iise to many uiffeient
tissues. Some mesoueimal tissues contain the ability to uiffeientiate into a uiveise
iange of tissues, such as the bone maiiow. The tissues of the mesoueim incluue:
- The auienal coitex
- The spleen
- Buia of connective tissues
- Nuscle tissues
- Bone
- Stiuctuies of the heait
- The lymphatic system
- The uiinaiy system (kiuneys incluueu)
- Seious linings of peiitoneal bouy cavities
- Bloou


()$ 13*-.-,+. ,"#&
The umbilical coiu is unique in that it contains TW0
aiteiies anu 0NE vein. The umbilical vein is
iesponsible foi supplying the fetus with oxygenateu
bloou, while the aiteiies aie iesponsible foi caiiying
ueoxygenateu bloou fiom the fetus.

$3*#G"."TG "! ()$ )$+#(
The embiyonic stiuctuies of the heait coiiesponu with the matuie stiuctuies of the
heait, they aie:
$>SAOS@ )>CH>F?@S@ ! Ascenuing aoita anu pulmonaiy tiunk
2SLWS@ !?>MF@ ! Smooth paits of left anu iight ventiicle
*>FDFCFGH ]HAC>FOLH ! Tiabeculateu paits of the left anu iight ventiicle
*>FDFCFGH )C>FB ! Tiabeculateu left anu iight atiium
3HUC (?>A ?U &FAS@ ]HA?@S@ ! Coionaiy sinus
#DMHB )>8: >C 25 ! Smooth pait of iight atiium
+FJIC O?DD?A OB>MFABL GHFA BAM >FJIC BACH>F?> OB>MFABL GHFA ! SvC

13*-.-,+. 5$22$.2
]%5# U "JFM7:@B7=
)+$%+0 U &7>JFM7:@B7=


!$(+. ,-#,1.+(-"4
0xygenateu bloou is caiiieu fiom the placenta to the fetus via the umbilical vein.
Appioximately half of this bloou enteis the fetal MSOCS@ GHA?@S@ anu is caiiieu to
the infeiioi vena cava, with the othei half enteiing the livei. As the bloou enteis the
iight atiium of the heait, most of it flows thiough the U?>BDHA ?GBLH anu into the
left atiium (WENB@@FAJ CIH NSLD?AB>E OF>OSLBCF?A). The bloou then moves into the
left ventiicle anu is pumpeu thiough the aoita to the bouy. Some of the bloou
tiaveling thiough the bouy enteis the inteinal iliac aiteiies anu to the umbilical
aiteiies, ie-enteiing the placenta anu uisposing of caibon uioxiue anu othei waste
piouucts (which tiavel to the mateinal ciiculation). Note that theie is a connection
between the aoita anu the pulmonaiy aiteiy calleu the MSOCS@ B>CH>F?@S@, which
shunts most bloou away fiom the lungs because they aie not useu until the fetus is
boin.
0pon biith of the infant, the fiist bieath causes a MHO>HB@H FA CIH >H@F@CBAOH ?U CIH
NSLD?AB>E GB@OSLBCS>H, incieasing the piessuie in the left atiium ielative to the
piessuie of the iight atiium. This leaus to the OL?@S>H ?U CIH U?>BDHA ?GBLH (now
the fossa ovalis). Theie is also a closuie of the MSOCS@ B>CH>F?@S@ because the
incieaseu concentiation of oxygen causes the piostaglanuin levels to ueciease. This
closuie pievents the bloou fiom bypassing the pulmonaiy ciiculation, allowing the
lungs to function piopeily.



($#+("T$4-, +T$4(2 "! /#$T4+4,G
Congenital anomalies occui in appioximately S% of all live biiths, with mateinal
exposuie to teiatogenic agents being iesponsible foi 4%-6% of those cases
(appioximately 14uu liveboin infants).
Timing is an impoitant factoi in a teiatogen's ill-effect on the fetus, with the most
susceptible time being between the S
iu
anu 8
th
weeks of piegnancy, which is the
most active time of oiganogenesis.
($#+("T$4-, +T$4( $!!$,( "4 !$(12
Anuiogenic Boimones Clitoial enlaigement, labiosciotal fusion
when given befoie 1S weeks gestation.
*0CP's not shown to piouuce anomalies
when useu in 1
st
tiimestei of piegnancy.
Waifaiin anu othei coumauin-ueiiveu
anticoagulants
Nultiple anomalies, most commonly:
Bevelopmental uelay, hyuiocephalus,
agenesis of coipus collosum,
meningoencephalocele, miufacial
hypoplasia.
vaiious oculai, skeletal, anu othei biith
uefects.
Antithyioiu meuications (PT0,
Nethimazole, Iouiue)
0ccasionally piouuces tiansient fetal
hypothyioiuism anu goitei.
Biphenylhyuantoin Abnoimal facies, miciocephaly, giowth
ueficiency, mental ietaiuation,
hypoplastic nails, hypoplastic phalanges.
valpioate anu Caibamazepine Neuial tube uefects
Lithium Ebstein's anomaly
Biethylstilbestiol Stiuctuial uefects of the female genital
tiact, vaginal auenosis.
Isotienitoin Niciophthalmia, hyuiocephalus,
miciotia, cleft palate, blinuness,
ueafness, heait uisease, thymic agenesis.
Alcohol Fetal alcohol synuiome
Tobacco Spontaneous aboition, incieaseu iisk of
placental abiuption oi pievia, pieteim
ueliveiy, anu piematuie iuptuie of
membianes.
Cocaine Placental abiuption
Thaliuomiue Limb uefects
ACE inhibitois Renal uamage

!$(+. $#G()#"/"-$2-2
The foimation of ieu bloou cells is caiiieu out by foui uiffeient stiuctuies
thioughout fetal uevelopment.
Fiom appioximately 4K; THH\@, it is caiiieu out by the 0"3b &)!
Fiom appioximately 9K4= THH\@, it is caiiieu out by the 35]%+ BAM &*3%%#
Fiom appioximately 1; THH\@ BAM WHE?AM, it is caiiieu out by the 2"#% /)++"Y

*#+4,)-+. +#,) -44$#5+(-"4 +4& &$#-5+(-5$2
)>OI , ueiivatives aie supplieu by CN v2 anu vS
)>OI 1 ueiivatives supplieu by CN vII
)>OI 4 ueiivatives supplieu by CN IX
)>OI 6 BAM 9 ueiivatives aie supplieu by CN X
+#,) X +#,) Z +#,) ] +#,) ^ _ `
/HO\HLc@
OB>CFLBJH:
Nanuible
Nalleus
Incus
Sphenomanuibulai
ligament
/S@OLH@ ?U
DB@CFOBCF?Ad
Nassetei
LateialNeuial
pteiygoiu
Nylohyoiu
Anteiioi belly of
uigastiic
Tensoi tympani
Tensoi veli palatini
#H>GH: CN vS
+HFCH>c@ !B>CFLBJH:
Stapes
Styloiu piocess
Lessei hoin of
hyoiu
Stylohyoiu
ligament
/S@OLH@:
Stapeuius
Stylohyoiu
Posteiioi belly of
uigastiic
#H>GH: CN vII
!B>CFLBJH:
uieatei hoin of
hyoiu
/S@OLH@:
Stylophaiyngeus
#H>GH: CN IX
!B>CFLBJH:
Thyioiu
Ciicoiu
Aiytenoius
Coiniculate
Cuneifoim
/S@OLH@ ?U 6
CI

B>OI:
Nost of the
phaiyngeal
constiictois
Ciicothyioiu
Levatoi veli
palatini
/S@OLH@ ?U 9
CI

B>OI:
All intiinsic
muscles of laiynx
except ciicothyioiu
#H>GH: 4
th
aich is
CN X, 6
th
aich is CN
X



*#+4,)-+. ,.$!( &$#-5+(-5$2
,
@C
W>BAOIFBL OLHUC ! Exteinal auuitoiy meatus
1
AM
[ 6
CI
OLHUC@ ! Foimation of tempoiaiy ceivical sinuses when the 2
nu
aich
mesenchyme is obliteiateu

*#+4,)-+. /"1,) &$#-5+(-5$2
,
@C
N?SOI ! miuule eai cavity, Eustachian tube, mastoiu aii cells
1
AM
N?SOI ! epithelial lining of the palatine tonsil
4
>M
N?SOI (uoisal wings) ! infeiioi paiathyioius
4
>M
N?SOI (vential wings) ! thymus
6
CI
N?SOI !supeiioi paiathyioius

(%-4 /#$T4+4,-$2
Theie aie two types of twin piegnancies, /?A?aEJ?CFO anu XFaEJ?CFO twins. The
Bizygotic twins aie aka "Z>BCH>ABL $TFA@", anu have 2 placentas, 2 amniotic sacs,
anu 2 choiions. Nonozygotic twins aie "FMHACFOBL CTFA@", anu contain 1 placenta, 1
choiion, anu 2 amniotic sacs.









3"4"\GT"(-, (%-42R
- 1 placenta
- 1 choiion
- 2 amniotic sacs
&-\GT"(-, (%-42R
- 2 placentas
- 2 choiions
- 2 amniotic sacs

$3*#G"."TG "! ()$ $+#
The bones, muscles, anu othei stiuctuies of the eai all have embiyologic ueiivates.
These stiuctuies anu theii ueiivatives aie:
$@8 2B8<EB<87 $?Q8F>I>MDE &78D9@BD97
Tympanic Nembiane 1
st
phaiyngeal membiane
Eustachian Tube 1
st
phaiyngeal membiane
Exteinal Auuitoiy Neatus 1
st
cleft
Incus 1
st
aich
Nalleus 1
st
aich
Stapes 2
nu
aich
Tensoi Tympani (vS) 1
st
aich
Stapeuius (vII) 2
nu
aich

$3*#G"."TG "! ()$ ("4T1$





$3*#G"."TG "! ()$ ()G312
The thymus is ueiiveu fiom the epithelium of the 4
>M

W>BAOIFBL N?SOIH@. The thymus functions in piouuction of
T-lymphocytes, which aie essential paits of the auaptive
immune system. The &./'#: of the thymus is 1#),# with
immatuie T cells, while the 0#14++* contains the 0*'4/# T
cells.

$3*#G"."TG "! ()$ ()G#"-& T.+4&
The thyioiu glanu is ueiiveu fiom the flooi of the piimitive phaiynx, anu upon
uevelopment it uescenus into the neck. The thyioiu connects to the tongue via the
thyioglossal uuct (uisappeais in noimal uevelopment). Bue to the anatomy anu
ielationship of the thyioiu to the tongue, ectopic thyioiu tissue is most commonly
founu in the tongue.

$3*#G"."TG "! ()$ /+4,#$+2
As a whole, the pancieas is ueiiveu fiom the foiegut.
]HAC>BL *BAO>HBCFO 2SM ! Pancieatic heau, 0ncinate piocess, anu main pancieatic
uuct.
X?>@BL *BAO>HBCFO 2SM ! Bouy of pancieas, tail of pancieas, Isthmus, Accessoiy
pancieatic uuct.

&$5$."/3$4( "! T$4-(+. &1,(2
3$2"4$/)#-, &1,( O%>ICCD@:P /+#+3$2"4$/)#-, &1,(
O3<II78D@:P
Testicles seciete mulleiian-inhibiting
substance in oiuei to suppiess the
uevelopment of paiamesonephiic uucts.

XHGHL?N@ FAC?: Epiuiuymis, Ejaculatoiy
uuct, Seminal vesicles, Buctus Befeiens
Lack of secietion of Nulleiian-inhibiting
substance causes giowth of
Paiamesonephiic uucts.

XHGHL?N@ FAC?: Fallopian Tube, 0teius,
0ppei pait of vagina


!?>CHP = Bense,
immatuie T cells.
/HMSLLB = Pale,
matuie T cells.


)"3"."T1$2 "! ()$ &$5$."/-4T T$4-(+. (#+,(
By 6-8 weeks, a fetus has histologically uistinguishable gonaus. By 7 weeks, the
fetus has a genital tubeicle, uiogenital gioove anu sinus, anu labiosacial folus. In a
female, without excess anuiogens these will become the clitoiis, uiethia, vagina, anu
labia. The male fetus becomes uistinct between 8-12 weeks, anu the anuiogens will
enlaige the phallus anu cause the uiogenital gioove anu sinus to fuse in the miuline.






$3*#G"."TG "! ()$ &-+/)#+T3
Buiing initial uevelopment, the uiaphiagm is inneivateu by neives CS, C4, anu CS.
As the uiaphiagm uescenus, it maintains this inneivation.
The uiaphiagm is ueiiveu fiom the following embiyologic stiuctuies:
- Septum Tiansveisum
- Pleuiopeiitoneal Folus
- Bouy Wall
- Boisal Nesentaiy of the Esophagus

!"#3+(-"4 "! *"4$
Theie aie two main types of bone uevelopment, those being "intiamembianous"
bone anu "enuochonuial" bone. Intiamembianous bone is foimeu spontaneously
without the piesence oi neeu of any pie-existing caitilage. 0n the othei hanu,
enuochonuial bone (long bones) iequiies the piesence of caitilaginous molus in
oiuei to foim its bony stiuctuie. The caitilaginous molu ossifies anu piouuces the
enuochonuial bone.

,"4T$4-(+. +*4"#3+.-(-$2 "! ()$ /$4-2
Bypospauias is the moie common congenital penile abnoimality, anu it can be
associateu with 0TI's in chiluien.


!()*$%+ 4

(5&$"3".0

(F@C?L?JE F@ A?C C>BMFCF?ABLLE B GH>E IFJIKEFHLM O?DN?AHAC ?U
CIH &CHN , HPBDV WSC FC F@ FDN?>CBAC C? \A?T TIFOI CENH ?U
HNFCIHLFSD DB\H@ SN BLL ?U CIH @C>SOCS>H@ ?U CIH W?MEV B@
THLL B@ BLL NBCI?L?JFH@ CIBC B>H LFA\HM C? IF@C?L?JFOBL
OIBAJH@Q












(?T B>H WL??M OHLL N>?MSOC@ DBMH [ 23""X !%33
X5ZZ%+%#$5)$5"#e*+"X7!$5"#d


Y(5$% 23""X !%33& ; *<* =#4<.&>'#,
The white bloou cell is iesponsible foi uefense against infections. They aie maue up
of the uianulocytes (Eosinophils, Basophils, Neutiophils), anu the Nononucleai cells
(Lymphocytes, Nonocytes).



+%X 23""X !%33& [ *<* 7/>'"/.&>'#,
The bloou cell iesponsible foi oxygen tianspoit. It has many impoitant functions, is
without nucleus, is biconcave, anu has a laige suiface volume that enables easy gas
exchange.


#%7$+"*(53& - Involveu in the acute inflammatoiy iesponse, anu make up
appioximately 4u-7u% of WBC's. They engulf via phagocytosis, aie multilobeu, anu
contain lysosomes. Look foi hypeisegmenteu neutiophils when a patient has a
vitamin B12 anuoi folate ueficiency.

%"&5#"*(53& - These aie piotective against helminth anu piotozoal infections.
They aie highly phagocytic against antigen-antibouy complexes. They piouuce
histamine anu aiylsulfatase. Eosinophils make up 1%-6% of all WBC's, aie bilobeu,
anu aie packeu with laige eosinophilic gianules.


2)&"*(53& - Basophils compiise less than 1% of all WBC's, anu aie the key
components of alleigic ieactions. Basophils contain histamine anu hepaiin, as well
as othei vasoactive amines.


/"#"!0$%& - Contains a kiuney-shapeu nucleus, compiises appioximately 2%-
1u% of WBC'S.


LYNPB0CYTES - Aie small, iounu, anu stain uensely. T lymphocytes piouuce a
cellulai immune iesponse, while B lymphocytes piouuce antibouies.





4$1#")-2("."TG
X%#X+5$5! !%33& - Antigen piesenting cells, seen in some tissues who come in
contact with the skin (Langeihans cells), innei lining of the nose, lungs, stomach,
anu intestines.


/5!+".35) - These aie the phagocytes of the CNS, they aie the main foim of
uefense in the CNS.


"35."X%#X+".35) - These cells act to myelinate the axons of the CNS. These aie
the pieuominant glial cell in the white mattei.


SCBWANN CELLS - Schwann cells myelinate the axons, they also piomote axonal
iegeneiation.


*%+5*(%+)3 #%+]% &$+7!$7+% - Consists of the 7%()#4/(40, ?#/()#4/(40, anu
7)1.)#4/(405 The epineuiium is uense anu suiiounus the entiie neive, the
peiineuiium is what allows foi peimeability, anu the enuoneuiium is within the
neive anu suiiounus eveiy single neive fibei.



)-2("."TG "! ()$ 2V-4

3$-224$#[2 ,"#/12,.$2 a Aie encapsulateu sensoiy ieceptois in the ueimis of
the palms, soles, anu fingeis. They aie involveu in light, uisciiminatoiy touch of
haiiless skin.
3$#V$.[2 ,"#/12,.$2 - These aie tactile uiscs, which meuiate light ciuue touch.
/+,-4-+4 ,"#/12,.$2 - These aie laige encapsulateu sensoiy ieceptois of the
ueepei layeis of the skin at ligaments, joint capsules, mesenteiy, anu seious
membianes. They aie involveu in uetecting piessuie, vibiation, iough touch, anu
tension.




$/-()$.-+. ,$.. 614,(-"42








()$ T."3$#1.+# *+2$3$4( 3$3*#+4$
The glomeiulai basement membiane is foimeu by the fusion of enuothelium anu
pouocyte basement membianes. It seives to filtei plasma











()$ T".T- +//+#+(12
The golgi appaiatus seives the puipose of piocessing anu packaging pioteins anu
lipius befoie they aie secieteu to the iest of the bouy.
The golgi appaiatus is maue of stack of membiane-bounu stiuctuies of cisteinae,
which caiiy golgi enzymes to help oi mouify the pioteins that tiavel thiough them.

The main functions of the golgi appaiatus incluue:
- Bistiibution of pioteins anu lipius fiom the enuoplasmic ieticulum to the
plasma membiane, lysosomes, anu thiough secietoiy vesicles
- Auuition of an 0-oligosacchaiiue to Seiine anu Thieonine
- Auuition of N-oligosacchaiiue to Aspaiagine
- Pioteoglycan assembly
- Sulfation of sugais in pioteoglycans

#"1T) $4&"/.+23-, #$(-,1.13 O#$#P
The Rough Enuoplasmic Reticulum is iesponsible foi many functions, incluuing:
- N-linkeu glycosylation
- Auuition of lysosomal enzymes with mannose-6-phosphate maikei
- Integiation of membiane pioteins
Insiue of neuions, theie is the "Nissl bouy", which is the RER of the neuion.
23""() $4&"/.+23-, #$(-,1.13 O2$#P
The Smooth Enuoplasmic Reticulum is wheie steioius aie synthesizeu anu wheie
uiug uetoxification takes place.

+.5$".+#S,+/-..+#G *+##-$#
This baiiiei is piesent in the gas-exchange iegion of the lungs, anu seives to pievent
the foimation of aii bubbles in the bloou, anu fiom bloou enteiing into the alveoli.
This baiiiei is extiemely thin anu veiy stiong (thanks to type Iv collagen), allowing
foi sufficient uiffusion of oxygen.
The alveolai-capillaiy baiiiei is foimeu by type 1 pneumocytes of the alveolai wall,
the enuothelial cells of the capillaiies, anu the basement membianes between the
two cells. This baiiiei is easily peimeable to many gases, especially u2, C02, anu C0.


/4$13",G($2
Theie aie two types of pneumocytes, anu they contiibute to the maintenance of the
alveoli. They extenu into the bionchioles, while goblet cells extenu only to the
teiminal bionchioles.
$IH>H B>H CT? CENH@ ?U NAHSD?OECH@d Type 1 anu Type 2
(FN7 X /:7<?>EFB7A aie iesponsible foi gas exchange in the alveoli, anu covei
>9S% of the alveolai suiface
(FN7 Z /:7<?>EFB7A aie iesponsible foi secieting suifactant, which helps to
ueciease the alveolai suiface tension. The type 2 pneumocyte is also a piecuisoi to
type 1 pneumocytes.






()$ &-T$2(-5$ (#+,(
The histologyanatomy of the uigestive tiact is complex, consisting of suppoitive
stiuctuies, musculai stiuctuies, anu glanuulai stiuctuies. The uI tiact is also an
impoitant pait of the immune system.
The uppei uI tiact consists of the esophagus, stomach, anu uuouenum.
The lowei uI tiact incluues most of the small intestine, the laige intestine, anu the
anus.
Bistologically, the uI tiact can be uiviueu into the ?<E>A@, A<Q?<E>A@, ?<AE<I@8DA
7JB78:@, anu the @=97:BDBD@.
/7!"&) - The inneimost layei of the uI tiact, suiiounus the lumen. It is impoitant
in the piocess of uigestion, as it is iesponsible foi absoiption anu secietion. The
mucosa can fuithei be subuiviueu into #%('"#+(40, +*0()* %/.%/(*, anu 04,&4+*/(,
04&.,*.
&72/7!"&) - The submucosa is a uense layei of connective tissue that acts as
suppoit to the uI tiact. It holus the Neissnei's plexus, which is an enteiic neivous
plexus that sits on the innei suiface of the musculaiis mucosa. The submucosa also
contains bloou vessles, lymphatic's, anu neives that bianch into the mucosa anu the
musculaiis exteina.
/7&!73)+5& %f$%+#) - This stiuctuie consists of an innei anu outei layei of
muscle tissue. The innei ciiculai layei contiacts to squeeze the contents, while the
outei longituuinal layei contiacts to shoiten the tiact. These two contiactions
togethei help with peiistalsis, thus piopelling the foou along the tiact.
)X]%#$5$5) - The auventitia is one moie component in uI tiact suppoit.

Theie aie two enteiic plexuses that help co-oiuinate all of the functions of the uI
tiact.
$IH /EHACH>FO *LHPS@ - Co-oiuination of motility along the entiie gut wall. This
plexus is locateu between the longituuinal anu ciiculai smooth muscle of the uI
tiact, anu is also known as Aueibach's plexus.
$IH &SWDSO?@BL *LHPS@ - This plexus iegulates secietions, bloou flow, anu
absoiption. Locateu between the mucosa anu the innei layei of smooth muscle, it is
also known as Neissnei's plexus.
*Both plexuses contain paiasympathetic teiminal effectoi neuions.

*#144$#[2 T.+4&2
Biunnei's glanus aie the only glanus in the uI submucosa. They aie iesponsible foi
secieting alkaline mucus, anu may hypeitiophy in the case of a uuouenal ulcei.

/$G$#[2 /+(,)$2
Peyei's patches aie aggiegations of lymphoiu tissue that aie founu in the ileum.
They aie ovally-shapeu lymphoiu follicles in the lamina piopiia layei of the mucosa,
extenuing into the submucosa of the ileum.
These patches aie unencapsulateu, coveieu by a single layei of cuboiual enteiocytes
with specializeu N cells inteispeiseu. These N cells aie iesponsible foi taking up
antigens.
Stimulateu B cells tiavel fiom the Peyei's patches, going thiough the lymph anu
bloou to the lamina piopiia of the intestine, wheie they uiffeientiate into IgA-
secieting plasma cells. The IgA is piotective, tiaveling acioss the epithelium to the
gut to ueal with the intialuminal antigen.








.G3/) 4"&$2
Lymph noues aie seconuaiy lymphoiu oigans that function as non-specific filtiation
by maciophages, antibouy piouuction, anu stoiage oi B anu T cells. The lymph noue
contains many affeients, anu at least one oi moie effeient.
&C>SOCS>H ?U CIH 3EDNI #?MH@
9./'#: - The outei coitex consists mainly of B cells that aie aiiangeu in follicles,
which can uevelop a geiminal centei when in contact with an antigen. The innei
coitex is mainly T cells.
A#14++* - Theie aie the meuullaiy coius anu the meuullaiy sinuses. The coius aie
mainly plasma cells, lymphocytes, anu B cells. The sinuses take in the flow of lymph
fiom the coitical sinuses, anu contain maciophages anu ieticulai cells.
B.++(&+# - The follicle is wheie B-cells aie localizeu anu wheie they piolifeiate.
Piimaiy follicles aie uenseuoimant, wheie the seconuaiy follicles have a pale
cential geiminal centei, anu they aie active.
3EDNI A?MH OF>OSLBCF?A:
The lymph ciiculates to the lymph noue thiough the affeient lymphatic vessel,
uiaining into the subcapsulai sinus. This subcapsulai sinus then uiains into
tiabeculai sinuses, anu finally into the meuullaiy sinuses.
&SWOBN@SLB> @FAS@ ! C>BWHOSLB> @FAS@ ! DHMSLLB>E @FAS@H@





+&#$4+. ,"#($0 _ 3$&1..+
Theie aie S layeis to the auienal coitex, they aie:
1. Zona ulomeiulosa ! secietes Aluosteione (ulucocoiticoius)
2. Zona Fasciculata ! secietes Coitisol (Stiess Boimones)
S. Zona Reticulaiis ! secietes Anuiogens (Sex Boimones)
The auienal meuulla contains chiomaffin cells that seciete the catecholamines
Epinephiine anu Noiepinephiine.
The most common tumoi of the auienal meuulla in auults is a
pheociomocytoma, while the most common tumoi in chiluien is a
neuioblastoma.







()$ .-5$#

!HAC>BL ]HFA - Receives the bloou mixeu in the sinusoius of the livei anu ietuins it
to ciiculation via the hepatic vein.
*?>CBL ]HFA - Biains bloou fiom the uI tiact anu the spleen into the livei. 0sually
foimeu by the SNv, splenic veins, INA, gastiic vein, anu cystic vein. This is one of
the main poital venous systems of the bouy.
(HNBCFO )>CH>E - Runs alongsiue the poital vein anu the common bile uuct to foim
the poital tiiau.
2FLH !BABLFOSLS@ - Is a thin tube that collects bile that is secieteu by the
hepatocytes. These canaliculi meige to foim the bile uucts, which then become the
common hepatic uuct.





()$ 2/.$$4









,-.-+
Cilia is stiuctuieu in a way that allows foi maximum mobility. Insiue each cilia theie
is a 9+2 axoneme, as can be seen in the image below. Each 9+2 axoneme acts as a
scaffolu foi piotein complexes anu pioviues binuing sites foi motoi pioteins.
Especially impoitant is uynein, which is a motoi piotein that conveits the chemical
eneigy of ATP into the mechanical eneigy of movement. A uefect in uynein causes a
conuition known as "Kaitagenei's Synuiome", which iesults in immotile cilia.
Theie aie also 9+u cilia, which aie non-motile.











()$ -44$# $+#

()$ *"4G .+*G#-4()R
Consists of the 9C9D=7E (heaiing), the F76!GHI=7 (iesponsible foi sensing lineai
acceleiation), anu the 67AG9GJ9I=EJ 9E8E=6 (iesponsible foi angulai
acceleiation). This labyiinth is filleu with a fluiu calleu "peiilymph", which is a
souium iich fluiu, similai to the extiacellulai fluiu.
()$ 3$3*#+4"12 .+*G#-4()R
Consists of the 9C9D=7EJ KI9!L I!JG9=7L 6E99I=7, anu the 67AG9GJ9I=EJ
9E8E=6. This labyiinth is filleu with enuolymph that is iich in potassium, similai to
the fluiu insiue the cells. Theie aie haii cells that act as the moue of sensation
within both the vesticulai appaiatus anu the cochleai appaiatus of the innei eai.
3"Y Z+%g7%#!0 sounus aie heaiu at the apex of the cochlea
(5.( Z+%g7%#!0 sounus aie heaiu at the base of the cochlea.



!()*$%+ 6

#%7+")#)$"/0

#HS>?BABC?DE F@ B IFJIKEFHLM @HOCF?A ?U CIH 7&/3% HPBDQ
Z?OS@ ?A WB@FO AHS>?BABC?DE hWL??M @SNNLEV AH>GH @SNNLEiV
B@ THLL CIH B@@?OFBCHM AHS>?NBCI?L?JE BAM
AHS>?NIE@F?L?JEQ















#$!.$0$2
Theie aie many ieflexes belonging to both the auult anu the infant, anu a set that aie
seen only in infants.
The ieflex aic is an impoitant concept to unueistanu as it ielates to the clinically
impoitant ieflexes.




&$#3+("3$2
Beimatomes aie aieas of the skin that aie mostly supplieu by a single spinal neive.
Each of these neives ielay sensations fiom each paiticulai ueimatome to the biain.
; !>BAFBL #H>GH@ [ ,1 $I?>BOFO #H>GH@ [ 8 3SDWB> #H>GH@ [ 8 &BO>BL #H>GH@
0nueistanuing anu being able to locate ueimatomes is impoitant neuiologically as
it allows us to ueteimine the site of uamage to the spine. The most commonly seen
infection is a heipes zostei infection, which is an infection that lies uoimant in the
uoisal ioot ganglion anu manifests itself along a ueimatome, wiapping aiounu the
bouy along the specific ueimatomal aiea.
4$#5$ #""( +#$+ "! &-2(#-*1(-"4
C2 Posteiioi half of the skull cap
CS Aiea that coiielates with a high
tuitleneck shiit
C4 Aiea coiielating to a low-collai shiit
C6 Thumb (iauial neive)
C7 2
nu
anu S
iu
uigit (meuial neive)
C8 4
th
, S
th
uigits (ulnai neive)
T4 Nipples
TS Infiamammaiy Folu
T6T7 Xiphoiu Piocess
T1u 0mbilicus
T12 Pubic bone iegion
L1 Inguinal Ligament
L4 Knee caps
S2, SS uenitalia









,#+4-+. 4$#5$2
,8@:D@I
47897
4@?7 !<:EBD>: 47897 (FN7 !>8@?7:
X 0lfactoiy Smell Sensoiy Ciibifoim
Plate
Z 0ptic Sight Sensoiy 0ptic Canal
] 0culomotoi Eye movement
Pupil Consti
Accomouation
Eyeliu opening
Notoi Supeiioi
0ibital
Fissuie
(S0F)
^ Tiochleai Eye Novement Notoi S0F
b Tiigeminal Facial Sensation
Nastication
Notoi,
Sensoiy
v1: S0F
v2:
Foiamen
Rotunuum
vS:
Foiamen
0vale
` Abuucens Eye Novement Notoi S0F
c Facial Facial Novement
Anteiioi 2S taste
Laciimation
Salivation
Notoi,
Sensoiy
Inteinal
auuitoiy
canal
W vestibulocochleai Beaiing
Balance
Sensoiy Inteinal
auuitoiy
canal
d ulossophaiyngeal Posteiioi 1S
taste
Swallowing
Salivation
Caiotiu bouy anu
sinus monitoiing
Notoi,
Sensoiy
}ugulai
foiamen
XY vagus Taste
Swallowing
Palate Elev
Talking
Thoiacoabuominal
visceia
Notoi,
Sensoiy
}ugulai
foiamen
XX Accessoiy Beau tuining
Shouluei shiug
Notoi }ugulai
foiamen
XZ Bypoglossal Tongue Novement Notoi Bypoglossal
canal

/AHD?AFO U?> CIH !>BAFBL AH>GH@:
"n "lu "lympus' (oweiing (ops + !iienuly 5iking Tiew 5ines +nu )ops

&$5-+(-"42 ("%+#&2 +4& +%+G !#"3 ,4 .$2-"42
,4 b ?>B>8 I7AD>: ! }aw will ueviate C?TB>M@ siue of lesion
,4 XY I7AD>: ! 0lna ueviates BTBE fiom siue of lesion
,4 XX I7AD>: ! Weakness in tuining heau to the ?NN?@FCH siue of lesion
,4 XZ I7AD>: ! Tongue will ueviate C?TB>M@ siue of lesion (lick the wounu)

*#+-42($3 ,#+4-+. 4$#5$ 41,.$-



()$ (#+,(2 "! ()$ 2/-4+. ,"#&
Nemoiization of the functions of uiffeient aieas of the spinal coiu is essential to
being able to iuentify wheie a paiticulai spinal coiu lesion may be locateu.
*E>FDFMBL:
=*'#/*+ 9./'(&.,%()*+ - Contiols movement of ipsilateial limbs
E)'#/(./ 9./'(&.,%()*+ - Conuuction of voluntaiy motoi impulses fiom piecential
gyius to the motoi centei of the coiu
%PC>BNE>FDFMBL:
J4M/.,%()*+ - Nain ioute foi meuiation of voluntaiy movement (laige muscles anu
fine motoi contiol)
J#'(&4+.,%()*+ - Co-oiuinates automatic movement of locomotion anu postuie,
influences muscle tone, meuiates autonomic functions, anu mouulates pain impulses
F#,'(M4+.,%()*+ - Lateial: Ipsilateial uescent to paiaveitebial anu pioximal limb
extension. Neuial: Bilateial uescent, contiols eye movement, neck position, gaze
X?>@BL !?LSDA /HMFBL 3HDAF@OS@ &E@CHD:
N/*&(+# B*&(&4+4, - Fine touch, vibiation, piopiioception to lowei bouy
Cuneate Fasciculus - Fine touch, vibiation, anu piopiioception to uppei bouy
&NFA?OH>HWHLLB> $>BOC:
?.,'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position
E)'#/(./ 6%().&#/#M#++*/ !/*&' - Limb anu joint position
)ACH>?LBCH>BL &E@CHD:
=*'#/*+ 6%().'"*+*0(& !/*&' - Pain anu tempeiatuie
E)'#/(./ 6%().'"*+*0(& !/*&' - Soft nocioception
&NFA?K"LFGB>E $>BOC: Piopiioception fiom muscles anu tenuons as well as
cutaneous impulses to the olivaiy nucleus



*#"%4 2$e1+#& 2G4&#"3$
Biown-Sequaiu synuiome occuis when theie is a hemisection of the spinal coiu. It
piesents with the following:
- Ipsilateial loss of motoi function anu the piesence of spasticity (pyiamiual)
- Ipsilateial loss of tactile, vibiation, anu piopiioception senses (uoisal
column)
- Contialateial loss of pain anu tempeiatuie (spinothalamic)
- Ipsilateial loss of all sensation at the level of injuiy





134 _ .34 .$2-"42
2-T4 134 .$2-"4 .34 .$2-"4
Weakness Piesent Piesent
Atiophy Absent Piesent
Reflexes Incieaseu Becieaseu
Tone Incieaseu Becieaseu
Fasciculations Absent Piesent
Babinski Piesent Absent

312,.$2 "! ()$ $G$




+4+("3G "! ()$ $G$ +4& #$(-4+









()$ /1/-..+#G .-T)( #$!.$0
The mechanism by which the pupils ieact to light is quite stiaight-foiwaiu.
2B7N X - Light is uetecteu anu the ietinal ganglion cells convey this infoimation
thiough photoieceptois to the optic neive. The optic neive is connecteu to the
pietectal nucleus, anu senus the fiist signal heie notifying it of incoming light.
2B7N Z - Fiom the pietectal nucleus, a message is sent to the Euingei-Westphal
nucleus
2B7N ] - The occulomotoi neive (fiom the Euingei-Westphal nucleus), then senus a
message to the constiictoi muscles of the iiis. The iiis muscles contiact bilateially
(consensual ieflex).






,"461T+($ T+\$
Conjugate gaze is a piocess wheieby both of the eyes look in the same uiiection
simultaneously. The piocess begins with the fiiing of CN 6, which then contiacts the
lateial iectus muscle to look into one uiiection, which simultaneously contiacting
the contialateial nucleus of CN S (via the meuial longituuinal fasciculus). The CN S
then contiacts the meuial iectus anu the conjugate gaze is in tact.
With many uiseases such as multiple scleiosis, theie is a lesion in the NLF, which
will inhibit the tiansmission of the signal to the contialateial CN S. When this
occuis, the seconu eye uoes not look to the same uiiection, anu the patient then has
a gaze palsy, also known as 'inteinucleai ophthalmoplegia'.


5-21+. !-$.& &$!$,-(2
Beficits to the visual fielu can occui fiom eithei uiseases oi fiom uisoiueis of the
eye, optic neive, anu biain.
The foui most common types of visual fielu uefects aie:
1. Altituuinal fielu ueficits, which is a loss of vision above oi below the
hoiizontal
2. Bitempoial hemianopsia, which is a loss of vision at oui aspects of the visual
fielu
S. Bomonymous hemianopsia, which is a loss of vision on the same siue in both
eyes
4. Cential scotoma, which is a loss of cential vision



()$ ,-#,.$ "! %-..-2
The Ciicle of Willis is a ciicle of aiteiies that supplies the biain with bloou. The
uesign of the Ciicle of Willis is such that shoulu one aiea become stenoseu oi
blockeu completely, bloou flow fiom othei bloou vessels can often pieseive
peifusion well enough to avoiu ischemic events.
The ciicle is compiiseu of the following aiteiies:
- )ACH>F?> OH>HW>BL B>CH>FH@
- )ACH>F?> O?DDSAFOBCFAJ B>CH>E (connects both anteiioi ceiebial aiteiies)
- 5ACH>ABL OB>?CFM B>CH>FH@ (aiise fiom common caiotiu aiteiies)
- *?@CH>F?> OH>HW>BL B>CH>FH@ (aiise fiom basilai aiteiy)
- *?@CH>F?> O?DDSAFOBCFAJ B>CH>FH@ (fiom a bianch of inteinal caiotius)




*.""& 21//.G (" ()$ *#+-4
)ACH>F?> !H>HW>BL )>CH>E - supplies the meuial suiface of the biain, anu the leg-foot
aiea of the motoi anu sensoiy coitices.
/FMMLH !H>HW>BL )>CH>E - supplies the lateial aspect of the biain, the tiunk-aim-
face aiea of the motoi anu sensoiy coitices, as well as Bioca's anu Weinicke's
speech aieas.
)ACH>F?> !?DDSAFOBCFAJ )>CH>E - connects the anteiioi ceiebial aiteiies, anu is
the most common site of Ciicle of Willis aneuiysm.
*?@CH>F?> !?DDSAFOBCFAJ )>CH>E - connects thiee ceiebial aiteiies on each siue, is
anothei common site of aneuiysm, anu can cause cianial neive S palsies.

)$#4-+(-"42 "! ()$ *#+-4
Ceitain signs anu symptoms shoulu aleit you to the possibility of biain heiniations.
Biffeient signs can help you naiiow uown the specific aiealesion that may be
piesent.
Theie aie two majoi classes of heiniation - the supiatentoiial anu infiatentoiial
heiniations. The stiuctuie that uiffeientiates these two categoiies is the tentoiial
notch (those above = supiatentoiial, those below = infiatentoiial).
&SN>BCHAC?>FBL (H>AFBCF?A@ - 0ncal, Cential, Cingulate, Tianscalvaiial
5AU>BCHAC?>FBL (H>AFBCF?A@ - 0pwaiu (ceiebellai), Tonsillai (uownwaiu ceiebellai)



()$ .13*+# /14,(1#$
The lumbai punctuie is a uiagnostic tool useu to collect anu analyze the
ceiebiospinal fluiu.
5AMFOBCF?A@ ! CSF analysis when meningitis, fevei of unknown oiigin, anu signs of
meningeal iiiitation aie piesent. Byuiocephalus, benign intiacianial hypeitension,
anu subaiachnoiu hemoiihages can all be uiagnoseu anu suppoiteu with an LP. The
LP is also useful when intiathecal (injection into the spinal coiu) ioute of
auministiation is necessaiy, such as with spinal anesthesia oi chemotheiapy.
!?AC>BFAMFOBCF?A@ ! The most impoitant contiainuication to a lumbai punctuie is
the piesence of incieaseu intiacianial piessuie. 0thei impoitant contiainuications
aie coagulopathies, iespiiatoiy uifficulties, ueteiioiating consciousness, anu when
theie is hypeitension plus biauycaiuia.

)>K DA BH7 ./ N78C>8?7=f




1//$# 3"("# 4$1#"42
0ppei motoi neuions aie motoi neuions that oiiginate in the motoi iegion of the
coitex oi biain stem. They caiiy infoimation uown specific aieas on the spinal coiu,
at which point they senu signals to the lowei motoi neuions (via glutamineigic
ieceptois). The main effectoi neuions aie within layei S of the piimaiy motoi
coitex, anu these aie some of the laigest cells in the biain.

7NNH> D?C?> AHS>?A@ C>BOC@:
The 0NN's tiavel via seveial uiffeient tiact, incluuing:
- Coiticospinal
- Coiticobulbai
- Tectospinal
- Rubiospinal
- vestibulospinal
- Reticulospinal

7/# 3H@F?A@:
Theie aie a set of common symptoms that occui with an 0NN lesions, incluuing:
- Spasticity
- Becieaseu muscle tone
- Positive Babinski Sign
- Pyiamiual weakness
- Bypeiieflexia
- Incieaseu BTR's








."%$# 3"("# 4$1#"42
Lowei motoi neuions aie the motoi neuions that connect the biainstem anu the
spinal coiu to the muscle fibeis (ie theii axon enus in the effectoi muscle).
The LNN's aie classifieu baseu on the muscle fibei types that they each inneivate,
these aie the alpha-motoi neuions anu the gamma-motoi neuions.
)LNIBKD?C?> AHS>?A@ - Aie the most numeious type of neuions of muscle fibei, aie
involveu in muscle contiaction, anu inneivate extiafusal muscle fibeis.
.BDDBKD?C?> AHS>?A@ - Aie components of the muscle spinules, involveu in
piopiioception, anu inneivate the intiafusal muscle fibeis.

3/# LH@F?A@:
Theie aie a set of common symptoms with LNN lesions, incluuing:
- Becieaseu muscle tone
- Nusculai weakness
- Bypoieflexia
- Fasciculations
- Atiophy of skeletal muscle
- Paialysis

-3/"#(+4( ,.-4-,+. ,"4&-(-"42 -45".5-4T 134 _ .34 .$2-"42
)DE?C>?NIFO 3BCH>BL &OLH>?@F@ - Both 0NN anu LNN signs. Is a slowly ueveloping
uisease that is ultimately fatal. Patient expeiiences weakness anu wasting of the
bulbai muscles (speech, swallowing, chewing), as well as the aims, legs, anu toiso.
Nuscle weakness anu wasting uevelops piopoitionally on both siues. Sensation anu
mentation iemain intact.
*>?J>H@@FGH 2SLWB> *BL@E - LNN
*@HSM?WSLWB> *BL@E - 0NN
*>FDB>E 3BCH>BL &OLH>?@F@ h*3&i - 0NN, males > females
*>?J>H@@FGH /S@OSLB> )C>?NIE - slow uegeneiation of LNN's
&NFABL /S@OSLB> )C>?NIE h&/)i - LNN, uegeneiation of anteiioi hoin cells
*?LF?DEHLFCF@ - LNN uestiuction

*$..[2 /+.2G
Bell's palsy is a unilateial paialysis of facial muscles uue to a uysfunction of the
facial neive (CN7). Theie aie many possible causes, such as viial, Lyme uisease,
stioke, inflammation, etc. This conuition is almost always self-limiting.

&FJA@ j &EDNC?D@d
- Ipsilateial facial paialysis
- Inability to blink eye on affecteu siue

g-?N>8B@:Bg
It is highly impoitant to look foi the ability to wiinkle the foieheau, as the ability to
uo so usually inuicates that theie is an uppei motoi neuion lesion. This 0NN lesion
iesults in a conuition known as "OHAC>BL UBOFBL NBL@E", wheieby the pioblem is a
paialysis of the contialateial lowei pait of the face.




!14,(-"42 "! ()$ ,$#$*#+. ,"#($0














*#+-4 .$2-"42
.$2-"4 +#$+ #$21.( "! .$2-"4
2>?OBc@ )>HB Patient has expiessive aphasia (can't speak),
has goou unueistanuing of speech
YH>AFO\Hc@
)>HB
Patient has inability to compiehenu speech, can
speak well
Z>?ACBL 3?WH Peisonality changes, uefects in juugement (ie
Fiontal ielease signs)
)>OSBCH
ZB@OFOSLS@
Patient has goou language compiehension with
pooi ability to speak in iepetition
)DEJMBLB Kluvei-Bucy Synuiome - patient becomes
hypeisexual, hypeioial, anu has uisinhibiteu
behavioi
+FJIC
*B>FHCBL
3?WH
Patient has "spatial neglect", thus uo not
iecognize the contialateial siue of the lesion
/BDDFLLB>E
2?MFH@
Confabulations, anteiogiaue amnesia
2B@BL
.BAJLFB
Resting tiemoi
!H>HWHLLB>
]H>DF@
Tiuncal ataxia anu uysaithiia
!H>HWHLLB>
(HDF@NIH>H
Intention tiemoi, ataxia of limbs








()$ ()+.+312
The thalamus is a miuline stiuctuie of the uiencephalon, situateu between the
ceiebial coitex anu the miubiain. It ielays infoimation between the aieas of the
subcoitex to the ceiebial coitex, iegulates consciousness, iegulates sleep, anu
iegulates aleitness. It gets its bloou supply fiom many bianches of the posteiioi
ceiebial aiteiy (paiameuian, infeiolateial, posteiioi choioiual).
Theie aie thiee paits to the thalamus, they aie bulb-shapeu masses that aie
appioximately S.7cm in length, anu aie locateu alongsiue the S
iu
ventiicle at a Su
uegiee angle.




()$ )G/"()+.+312
The hypothalamus is a stiuctuie within the biain with many key impoitant
functions. The easiest way to iemembei the functions of the hypothalamus is with
the mnemonic "$)# ()$&".
( - $IF>@C (Watei balance, as iegulateu by thiist)
+ - )MHA?IEN?NIE@F@ (This stiuctuie is contiolleu via ieleasing factois)
4 - #HS>?IEN?NIE@F@ (Releases hoimones synthesizeu in the hypothalamic nuclei)

) - (SAJH> BAM &BCFHCE (Contiolleu by the ventiomeuial nucleus)
+ - )SC?A?DFO iegulation (Paiasympathetic activity via anteiioi hypothalamus,
ciicauian ihythm via supiachiasmatic nucleus)
( - $HDNH>BCS>H (Posteiioi hypothalamus - conseives heat when colu, Anteiioi
hypothalamus - cooiuinates cooling when hot)
2 - &HPSBL +HJSLBCF?A (The septate nucleus contiols sexual emotions anu uiges)

()$ /"2($#-"# /-(1-(+#G
The posteiioi pituitaiy consists of axons that extenu fiom the supiaoptic anu
paiaventiiculai nuclei of the hypothalamus. The neuiohypophysis secietes two
veiy impoitant hoimones: 0xytocin anu vasopiessin.
]B@?N>H@@FA - Stimulates watei ietention, thus iaising bloou piessuie by aiteiial
contiaction.
"PEC?OFA - Stimulates contiaction of the uteius anu lactation








*+2+. T+4T.-+
The basal ganglia aie a gioup of nuclei situateu at the base of the foiebiain anu aie
connecteu with the ceiebial coitex anu thalamus. The basal ganglia aie impoitant
in many functions, namely motoi contiol anu leaining. The main components of the
basal ganglia aie the &C>FBCSDV *BLLFMSDV &SW@CBACFB #FJ>BV anu the &SWCIBLBDFO
#SOLHS@Q
&C>FBCSD [ The laigest pait of the basal ganglia, it consists of two paits (Cauuate
nucleus anu Putamen). The majoiity of the cells aie uABAeigic (>96%), anu
cholineigic neuions (~2%).
*BLLFMSD - Consists of a laige ulobus Palliuus (Inteinal (uPi) anu exteinal (uPe)
segments anu a small vential extension calleu the vential Palliuum). These two
segments aie mainly uABAeigic neuions that act as inhibitoiy neuiotiansmitteis.
&SW@CBACFB #FJ>B - Locateu in the miubiain (mesencephalon), it plays a laige iole
in iewaiu, auuiction, anu movement. The substantia nigia contains laige levels of
melanin within uopamineigic neuions, these stiuctuies aie uaik anu thus stanu out
fiom the iest of the suiiounuing stiuctuies. Theie aie two paits to the substantia
nigia (pais compacta anu pais ieticulata). The pais compacta acts as an input to the
basal ganglia ciicuit, supplying the stiiatum with uopamine. The pais ieticulata
seives as an output, which conveys signals fiom the basal ganglia to numeious othei
stiuctuies.
&SWCIBLBDFO #SOLHS@ - Locateu vential to the thalamus, meuial to the inteinal
capsule, anu uoisal to the substantia nigia. The subthalamic nucleus ieceives
signals fiom the globus palliuus, which aie uABAeigic in natuie, while it ieceives
glutamineigic inputs fiom the ceiebial coitex. The signals exiting the subthalamic
nucleus aie glutamineigic, which aie excitatoiy. These signals tiavel to many
uiffeient stiuctuies incluuing the substantia nigia, lateial palliuum, anu meuial
palliuum.



,$..2 ()+( 21//"#( +4& 4"1#-2) ()$ ,42 _ /42
21//"#(-5$ ,$.. #".$ -4 ,42L/42 21//"#(
"LFJ?MHAM>?JLFB Piouuces myelin centially
&OITBAA !HLL@ Piouuces myelin peiipheially
)@C>?OECH@ Pioviue physical suppoit, potassium
metabolism, anu physical iepaii
/FO>?JLFB Is the phagocytic cell of the neivous
system
%NHAMEDBL !HLL@ Responsible foi the innei lining of the
ventiicles


()$ *.""&S*#+-4 *+##-$#
The bloou-biain baiiiei is a system uesigneu to keep the bloou anu CSF fiom
mixing. The baiiiei is foimeu by tight junctions between enuothelial cells in the
CNS vessels, thus they iestiict the passage of solutes. This baiiiei is much moie
iestiicting than anywheie else in the bouy.
The bloou-biain baiiiei is foimeu by the )>BOIA?FM, 5AC>BOH>HW>BL OBNFLLB>E
HAM?CIHLFSD, anu !I?>?FM *LHPS@ HAM?CIHLFSD.
Substances that can pass the bloou-biain baiiiei aie:
- L-Bopa
- Lipiu soluble substances
- ulucose
- Amino Acius



()$ 5$4(#-,1.+# 2G2($3




()$ &1#+. 5$4"12 2-412$2
These aie the venous channels founu in between the layeis of uuia in the biain.
Theii bloou supply comes fiom the inteinal anu exteinal veins of the biain.
0ltimately, all of the uuial venous sinuses will empty into the inteinal jugulai vein.
Injuiies to the heau can cause bleeuing into the biain (hemoiihages, clots,
hematomas).








!()*$%+ 8

*(0&5"3".0

*IE@F?L?JE UFC@ FAC? DBAE B@NHOC@ ?U CIH 7&/3% HPBDQ 5C F@ B
IFJILE O?AOHNCSBL C?NFOV BAM USLL SAMH>@CBAMFAJ ?U CIH@H
O?AOHNC@ F@ H@@HACFBL C? @SOOH@@ ?A CIH &CHN , HPBDQ















#$4+. /)G2-"."TG

()$ )"#3"4$2 +,(-4T "4 ()$ V-&4$G
1. Aluosteione
2. Angiotensin 2
S. Atiial Natiiuietic Factoi (ANF)
4. Renin
S. Paiathyioiu Boimone
6. vasopiessin (ABB)

+.&"2($#"4$ ! secieteu in iesponse to a ueciease in bloou volume anu the
subsequent piouuction of angiotensin 2. Causes an inciease in souium
ieabsoiption, inciease in potassium secietion, anu inciease in hyuiogen secietion.
+4T-"($42-4 Z ! causes effeient aiteiiole constiiction, which causes an inciease
of uFR anu subsequently incieases souium anu bicaibonate ieabsoiption.
+(#-+. 4+(#-1#$(-, !+,("# ! secieteu when theie is an inciease in atiial
piessuie, which causes an inciease in uFR anu thus incieaseu souium excietion.
#$4-4 ! secieteu in iesponse to uecieaseu bloou volumeflow, subsequently gets
conveiteu to AT 1 anu then AT2, which causes aluosteione secietion eventually to
inciease bloou volume.
/+#+()G#"-& )"#3"4$ ! acts on pioximal convoluteu tubule, secieteu in
iesponse to a low plasma level of calcium, causing calcium ieabsoiption in the uistal
convoluteu tubule.
5+2"/#$22-4L+&) ! is secieteu when the plasma osmolaiity is high anu volume
is low. Causes watei ieabsoiption in the collecting uucts.


()$ 610(+T."3$#1.+# +//+#+(12
The }uA is a stiuctuie in the kiuney that is iesponsible foi iegulating bloou flow anu
uFR. It is locateu stiategically in a location that allows it to maximally iegulate
these functions (locateu between the vasculai pole of the ienal coipuscle anu the
uistal convoluteu tubule).
Thiee components of the }uA: ,Q /BOSLB XHA@B 1Q kSPCBJL?DH>SLB> OHLL@
4Q %PC>BJL?DH>SLB> DH@BAJFBL OHLL@

}uxtaglomeiulai Cells ! aie mouifieu smooth muscle cells that seciete ienin in
iesponse to uecieaseu ienal bloou flow.
Nacula Bensa ! is pait of the BCT, is a sensoi foi souium.
**(H7 QDM ?7AA@M7 >C BH7 6T+** ! it iegulates uFR via the ienin-angiotensin-
aluosteione system.
















-3/"#(+4( $e1+(-"42 -4 #$4+. /)G2-"."TG
TI>?78<I@8 !DIB8@BD>: #@B7 OT!#P
uFR uesciibes the flow iate of filteieu fluiu thiough the kiuney. Cieatinine
cleaiance iate (CCR) is the volume of bloou plasma that is cleaieu of cieatinine pei
unit time anu is a veiy useful measuie foi the appioximate glomeiulai filtiation
iate.
uFR is best calculateu by measuiing a chemical that has a steauy level in the bloou
(ie neithei absoibeu noi secieteu by the kiuneys). A gieat tool foi this is "inulin",
which fits these ciiteiia.
$IH HRSBCF?A U?> OBLOSLBCFAJ .Z+ F@ B@ U?LL?T@d


#7:@I ,I7@8@:E7
Calculating cleaiance is quite simple, howevei you must unueistanu a simple
concept ielating to ienal cleaiance in oiuei to ueciphei whethei theie is a net
secietion, net ieabsoiption, oi neithei.
$IH HRSBCF?A U?> +HABL !LHB>BAOH:

If #7:@I ,I7@8@:E7 U T!#, theie is no secietion oi ieabsoiption
If #7:@I ,I7@8@:E7 h T!#, theie is a net tubulai secietion of whichevei substance
we aie looking at.
If #7:@I ,I7@8@:E7 i T!#, theie is a net tubulai ieabsoiption of whichevei
substance we aie looking at.
!877 %@B78 ,I7@8@:E7


!DIB8@BD>: !8@EBD>:
The filtiation fiaction iepiesents the piopoition of fluiu that ieaches the kiuney
which passes to the ienal tubules. A healthy numbei is aiounu 2u%. Shoulu theie
be cases wheieby uFR is uecieaseu (as in ienal aiteiy stenosis), filtiation fiaction
shoulu piopoitionally inciease to maintain the noimal function of the kiuney.
!DIB8@BD>: !8@EBD>: U T!#L#/!

If uFR anu RPF inciease oi ueciease simultaneously, theie is no change in FF
If uFR incieases anu RPF uecieases, theie is an inciease in FF

$CC7EBD97 #7:@I /I@A?@ !I>K O$#/!P
This calculation is useu to calculate ienal plasma flow anu thus to estimate ienal
function.
We use the "PAB cleaiance", which is the cleaiance of Paia Aminohippuiate
Cleaiance. It is fieely filteieu anu not absoibeu in the nephion.
!BLOSLBCFAJ %+*Z:
$#/) U 1/+) 0 5L//+) U ,/+)


TI<E>A7 ,I7@8@:E7
Impoitant in uiabetes, it shoulu simply be known that glucosuiia occuis when
plasma glucose ieaches 2uumguL, because the PCT cannot ieabsoib once these
levels aie ieacheu.

()$ #$4-4S+4T-"($42-4S+.&"2($#"4$ 2G2($3
A hoimonal system that iegulates the balance of bloou piessuie anu fluius.
&CHN@ ?U CIH +))&:
1. Low bloou volume is uetecteu by the macula uensa, causing the }u cells to
ielease ienin.
2. Renin then cleaves angiotensinogen, conveiting it to angiotensin 1.
S. Angiotensin 1 is then conveiteu to angiotensin 2 by the ACE enzyme
(angiotensin-conveiting enzyme), which is founu in the lungs.
4. Angiotensin 2 binus to ieceptois in the intiaglomeiulai mesangial cells,
stimulating the ielease of aluosteione fiom the zona glomeiulosa of the
auienal coitex.
S. Aluosteione then stimulates the ieabsoiption of souium anu watei in the
PCT anu collecting uucts of the kiuney




/)G2-"."TG +( $+,) /"#(-"4 "! ()$ 4$/)#"4
$(% *+"f5/)3 !"#]"37$%X $7273%
YIBC ?OOS>@:
- Complete glucose ieabsoiption
- Complete amino aciu absoiption
- Neai complete ieabsoiption of souium, watei, anu bicaib (BC0S-)
- Secietion of ammonia




$(5!b )&!%#X5#. 3""* "Z (%#3%
YIBC ?OOS>@d
- Souium ieabsoiption (active)
- Potassium ieabsoiption (active)
- Chloiiue ieabsoiption (active)
- Nagnesium ieabsoiption (passive)
- Calcium ieabsoiption (passive)








X5&$)3 !"#]"37$%X $7273%
YIBC ?OOS>@d
- Active ieabsoiption of souium
- Active ieabsoiption of chloiiue
- Calcium ieabsoiption occuis heie (if stimulateu by paiathyioiu hoimone)








!"33%!$5#. $7273%&
YIBC ?OOS>@:
- Souium gets ieabsoibeu (in exchange foi B+ anu K+), when aluosteione is
piesent
- Watei gets ieabsoibeu in the piesence of ABB






T+2(#"-4($2(-4+. /)G2-"."TG

()$ #$T1.+(-"4 "! T+2(#-, +,-& 2$,#$(-"4
The key playei in iegulating gastiic aciu secietion is the B+K+ ATPase, which is a
magnesium-uepenuent pump. The following aie the basic steps of gastiic aciu
piouuction anu secietion:
1. B+ is geneiateu within the paiietal cell fiom the uissociation of watei.
Byuioxyl ions iapiuly combine with C02 via caibonic anhyuiase.
2. BC0S- is tianspoiteu outsiue the cell in exchange of chloiiue (maintains
intiacellulai pB of the paiietal cell).
S. Cl- anu K+ aie tianspoiteu into the lumen, which is necessaiy foi secietion of
aciu.
4. B+ pumpeu out of the cell anu into the lumen in exchange foi K+ thiough a
pioton pump.
S. B+ accumulation geneiates an osmotic giauient that causes outwaiu
uiffusion of watei, leauing to gastiic aciu piouuction (BCl, KCl), anu a small
amount of NaCl



)"#3"4$2 "! ()$ T-
.)&$+5#:
- Secieteu fiom the u cells in the antium of the stomach
- Cause stimulation of B+ secietion
- Incieaseu when theie is stomach uistention, vagal stimulation, anu the
piesence of amino acius in the stomach
- Becieaseu when theie is a stomach aciu <1.S
- 0veistimulation can leau to P0B, gastiitis, Zollingei-Ellison synuiome
!("3%!0&$"b5#5#:
- Secieteu fiom the I cells of the uuouenum anu jejunum
- Causes an inciease in pancieatic secietion
- Stimulates gallblauuei contiaction
- Inhibits the emptying of gastiic contents
- Inhibiteu by secietin anu a stomach pB <1.S
- Stimulateu by the piesence of fats anu pioteins in the stomach
&%!+%$5#:
- Secieteu fiom the S cells of the uuouenum
- Causes an inciease in pancieatic bicaibonate secietion
- Inhibits the secietion of gastiic acius
- Stimulateu by the piesence of acius anu fatty acius in the lumen of the
uuouenum
&"/)$"&$)$5#:
- Secieteu fiom the B cells in the pancieatic islet cells
- Causes inhibition of gastiic aciu anu pepsinogen secietion
- Causes inhibition of fluiu secieteu fiom the pancieas anu small intestine
- Inhibits gallblauuei contiaction
- Inhibits the ielease of insulin anu glucagon
- Secietion is stimulateu by incieaseu aciu anu inhibiteu by vagal stimulation
.)&$+5! 5#(525$"+0 *%*$5X%:
- Secieteu by the K cells in the uuouenum anu jejunum
- Becieases the amount of gastiic aciu that is secieteu
- Incieases insulin ielease



2$,#$("#G /#"&1,(2 "! ()$ T-
5#$+5#&5! Z)!$"+d
- Secieteu by the paiietal cells
- Binus vitamin B12
- Autoimmune uestiuction leaus to peinicious anemia
*%*&5#:
- Secieteu by the chief cells
- Aius in piotein uigestion
- Incieaseu thiough vagal stimulation
.)&$+5! )!5Xd
- Secieteu by the paiietal cells
- Becieases stomach aciu (ie Low pB)
- Stimulateu by histamine anu acetylcholine
- Inhibiteu by piostaglanuins, somatostains, anu uIP
25!)+2"#)$%:
- Secieteu by the mucosal cells of the uuouenum anu stomach
- Pievents autouigestion by aciu neutialization
- Stimulateu by secietin

$4\G3$2 2$,#$($& *G ()$ /+4,#$+2
3FNB@H ! Aius in fat uigestion, elevateu in pancieatitis
)DELB@H ! Belps in staich uigestion, also elevateu in pancieatitis
*>?CHB@H@ ! Aie secieteu as pioenzymes, help with piotein uigestion





$4&",#-4$ /)G2-"."TG

2/$#3 /#"&1,(-"4
Speim piouuction ielies on a few veiy impoitant hoimones in oiuei to stimulate
piouuction, anu subsequently to piouuce the piopei amount.
$IH FDN?>CBAC I?>D?AH@ ?U @NH>DBC?JHAH@F@ B>Hd
.7<B7:DjD:M )>8?>:7 O.)P ! iesponsible foi stimulating testosteione ielease
fiom the leyuig cells.
!>IIDEI7 2BD?<I@BD:M )>8?>:7 O!2)P ! iesponsible foi stimulating the Seitoli
cells, which then ielease Inhibin anu Anuiogen-binuing pioteins (ABP)
Z>?D CIH@H CT? I?>D?AH@V TH JHC CIH U?LL?TFAJd
(7AB>AB78>:7 ! iesponsible foi the uiffeientiation into male genitalia, maintaining
gametogenesis (these aie the two things we neeu most foi this topic)
+:=8>M7:SQD:=D:M N8>B7D: ! iesponsible foi keeping the testosteione levels high
insiue the seminifeious tubules
-:HDQD: ! this is iesponsible foi pioviuing negative feeuback to the pituitaiy,
inhibiting the ielease of too much FSB.

$IH U?LL?TFAJ FLLS@C>BCF?A NSC@ BLL ?U CIH BW?GH FAU?>DBCF?A FAC? NLBEV
@FJAFUFOBACLE @FDNLFUEFAJ E?S> SAMH>@CBAMFAJ ?U CIH TI?LH N>?OH@@-



+4&#"T$4-, )"#3"4$2
The anuiogenic hoimones incluue:
- Testosteione
- Bihyuiotestosteione (BBT)
- Anuiosteneuione
*?CHAOFH@d X($ l $H@C?@CH>?AH l )AM>?@CHAHMF?AH

ZSAOCF?A@ ?U HBOI I?>D?AH@d
&)( ! Synthesizeu by the enzyme "S!-ieuuctase"
- Foimation of seconuaiy sexual chaiacteiistic in men
(7AB>AB78>:7 ! Piomotes piotein synthesis anu giowth of all tissues with
anuiogen ieceptois.
- Nuscle giowthmass
- Bone uensity
- Bone matuiation
- Natuiation of sex oigans (penis anu sciotum in fetus)
- Baii giowth (facial haii, axillaiy haii)
- Bevelopment of seconuaiy sex chaiacteiistics
- Bevelopment of piostate anu seminal vesicles
- Libiuo
+:=8>AB7:7=D>:7 ! a piecuisoi of both male anu female sex hoimones

/#"T$2($#"4$
The hoimone involveu in the female menstiual cycle, piegnancy, anu
embiyogenesis.
It comes fiom the testes, coipus luteum, placenta, anu the auienal coitex.
The main functions of Piogesteione aie:
- Relaxation of the smooth muscle of the uteius
- Piegnancy maintenance
- Spiial aiteiy uevelopment
- Enuomeuiial glanu secietion stimulation
- Ceivical mucus piouuction (thickens - benefit of 0CP use)
- Inciease in bouy tempeiatuie
- Inhibits the gonauotiopins FSB anu LB

()$ 3$42(#1+. ,G,.$
The best way to leain the menstiual cycle is visually, keeping the following high-
yielu infoimation in minu:
- LB suige causes ovulation
- Piogesteione is the hoimone of piegnancy, maintaining enuometiium foi
implantation suppoit
- The folliculai giowth is fastest in the 2
nu
week of the piolifeiative phase
- Noimal cycle is 28 uays
- 0vulation will typically (with a noimal cycle) occui 14 uays aftei the onset of
menses.





3$4"/+12$
Nenopause is inuicative of the cessation of ovaiian function, iesulting in the
cessation of ovulation anu menstiuation.
$IH U?LL?TFAJ B>H CIH I?>D?ABL OIBAJH@ CIBC ?OOS> TFCI DHA?NBS@Hd
- Estiogen uecieases
- uonouotiopin-ieleasing hoimone incieases
- LB incieases
- FSB incieases significantly
$IH U?LL?TFAJ B>H CIH D?@C O?DD?A @EDNC?D@ B@@?OFBCHM TFCI DHA?NBS@Hd
- Bot flashes
- vaginal atiophy
- 0steopoiosis
- Coionaiy aiteiy uisease (estiogen is saiu to be a piotective factoi against
this)

)13+4 ,)"#-"4-, T"4"&"(#"/-4 OH,TP
hCu is secieteu fiom the placental syncytiotiophoblast, anu is iesponsible foi the
following functions:
- Is the #1 inuicatoi of piegnancy
- Belps to maintain the coipus luteum uuiing the 1
st
tiimestei of piegnancy
- Belps in uiagnosing iepiouuctive pathologies such as choiiocaicinoma anu
hyuatifoim moles (uiscusseu in pathology section)

#$T1.+(-"4 "! /#".+,(-4
Piolactin is a hoimone secieteu fiom the anteiioi pituitaiy anu is iesponsible foi
some impoitant functions, as well it is iesponsible foi ceitain pathologies
(piolactinoma, infeitility).
5DN?>CBAC USAOCF?A@ ! Lactation, oigasm, oligouenuiocyte piecuisoi cell
piolifeiation.
5AIFWFCHM WE ! Bopamine



()$ )G/"()+.+312 +4& /-(1-(+#G










()$ ()G#"-& )"#3"4$
Thyioiu hoimone is an extiemely impoitant anu veisatile hoimone, contiolling a
wiue-iange of functions anu impoitant foi piopei giowth.
ZSAOCF?A@ ?U CIE>?FM I?>D?AHd
- CNS matuiation
- Bone giowth
- "-auieneigic effects
- Incieases BNR (via incieasing the Na+K+ pump)
- Lipolysis (incieases)
- uluconeogenesis (incieases)
- ulycogenolysis (incieases)
*>?MSOCF?A ?U CIE>?FM I?>D?AHd
1. Folliculai cells synthesize enzymes anu thyioglobulin foi colloiu.
2. Iouine is co-tianspoiteu into the cell with Na+ anu tianspoiteu into colloiu.
S. Enzymes auu iouine to thyioglobulin to make TS anu T4.
4. Thyioglobulin is taken back into the cell.
S. Intiacellulai enzymes sepaiate TS anu T4 fiom the piotein
6. Fiee TS anu T4 entei the ciiculation
*TS pioviues negative feeuback to the anteiioi pituitaiy.




/+#+()G#"-& )"#3"4$ O/()P
PTB comes fiom the chief cells of the paiathyioiu glanus. In iesponse to low seium
calcium, PTB is ieleaseu anu peifoims the following:
- Incieases bone iesoiption which incieases Ca2+ anu P04-
- Incieases the ieabsoiption of calcium fiom the kiuneys (uistal convoluteu
tubules)
- Becieases the ieabsoiption of phosphate fiom the kiuneys
- Stimulates the enzyme 1!-hyuioxylase in the kiuney, which incieases 1,2S-
(0B)2 vitamin B (ie cholecalcifeiol)

,+.,-("4-4
Calcitonin woiks opposite of PTB by iecognizing an inciease in seium Ca2+ anu
thus uecieasing the bone iesoiption of calcium. Calcitonin is secieteu fiom the
paiafolliculai (c cells) of the thyioiu glanu.

.-4V-4T /+()"."TG (" ,@Zkl /"^Sl @:= +.V+.-4$ /)"2/)+(+2$
$IH U?LL?TFAJ LF@C ?U O?AMFCF?A@ BLCH> CIH@H LHGHL@ FA CIH U?LL?TFAJ TBE@-
&DA7A@A7 ,@IED<? .797I /H>ANH@B7 .797I +Im /H>ANH
.797I
5DB@?D: & -:B>J Incieases Incieases Incieases
"AB7>N>8>ADA No change No change No change
)FN78N@8@BHF8>D=DA? Incieases Becieases Incieases
/@M7B[A Q>:7 =DA7@A7 Noimal-incieaseu Noimal Laige inciease
#7:@I -:A<CCDED7:EF Becieaseu Incieaseu No change







,+#&-+, /)G2-"."TG

#"$%: Caiuiac physiology is unique in that almost eveiything is conceptual in
natuie, which means that theie aie many giaphschaits, etc. By completely
unueistanuing the concept behinu all of this infoimation, you will not have to
memoiize anything, iathei you will be able to apply it to any question the 0SNLE
exam thiows youi way.

()$ ,+#&-+, ,G,.$
The caiuiac cycle iefeis simply to the steps that aie unueitaken by the heait as it
goes fiom filling, to pumping the bloou systematically, to filling once again.
$IH NIB@H@ ?U CIH OB>MFBO OEOLH:
Xn -A>9>I<?7B8DE ,>:B8@EBD>:
This is the point between the closuie of the mitial valve anu the opening of the
aoitic valve. The heait is contiacteu but valves aie closeu.
Zn 2FAB>IDE $;7EBD>:
The heait squeezes anu bloou is ejecteu thiough the aoitic valve. This phase can be
consiueieu the phase between the time the aoitic valve opens anu closes.
]n -A>9>I<?7B8DE #7I@J@BD>:
This is the peiiou of time between the closuie of the aoitic valve anu the opening of
the mitial valve.
^n #@ND= CDIID:M NH@A7
Aftei the opening of the mitial valve, bloou pools iapiuly into the left ventiicle.
bn 2I>K CDIID:M NH@A7
At this point, bloou flows into the Lv slowly as the mitial valve is about to close.





5DN?>CBAC IHB>C @?SAM@ CIBC ?OOS> MS>FAJ CIH OB>MFBO OEOLHd
2X - this is the 1
st
heait sounu anu iepiesents the closing of the tiicuspiu anu mitial
valves
2Z - this is the 2
nu
heait sounu anu iepiesents the closing of the pulmonaiy anu
aoitic valves
2] - this is the S
iu
heait sounu anu iepiesents the enu of the iapiu ventiiculai filling
(can be associateu with congestive heait failuie)
2^ - this is a heait sounu heaiu only if theie is a stiff ventiicle (is associateu with
ventiiculai hypeitiophy)

$IH U?LL?TFAJ J>BNI >HN>H@HAC@ CIH NIB@H@ ?U CIH OB>MFBO OEOLHd




Y5..%+c& X5).+)/:
This uiagiam is useu in caiuiac physiology to illustiate the ielationships between
seveial uiffeient events that aie occuiiing simultaneously. Foi the 0SNLE exam, it
is impoitant to iecognize the ielationships on the giaph as well as to iecognize
wheie the majoi events aie locateu giaphically.





+,(-"4 /"($4(-+. "! ()$ /+,$3+V$#

$(% &) #"X%:
The cells of the Av noue uepolaiize spontaneously, iesulting in appioximately 1uu
contiactions pei minute. This iate uoes not cieate a ventiiculai iate of 1uu because
the sympathetic anu paiasympathetic fibeis have the ability to contiol how much
gets thiough.
$(% )] #"X%:
This noue uischaiges appioximately 4u-6ubpm. Theie aie bianches that come fiom
the Av noue (Puikinje fibeis), that also piouuce spontaneous action potentials at a
iate of appioximately Su-4ubpm (keep conuuction if the noues aie not woiking
efficiently).

()$ /)+2$2 "! ()$ +,(-"4 /"($4(-+.:
*IB@H 6 [ ^&L?T XFB@C?LFO XHN?LB>FaBCF?A_
With a Na+ conuuctance inciease, the membiane potential spontaneously
uepolaiizes, accounting foi the automaticity of the SA anu Av noues. In the chait
below, the slope of phase 4 in the SA noue is the ueteimining factoi in heait iate.
This can be incieaseu with catecholamines (NE, Epi) anu uecieaseu with
acetylcholine.


*IB@H = [ ^7N@C>?\H_
Causeu by a slow influx of calcium because theie aie no fast souium channels. This
iesults in a slow conuuction velocity that helps to piolong tiansmission fiom the
atiia to the ventiicles.
*IB@H 4 [ ^+HN?LB>FaBCF?A_
A iapiu inactivation of the calcium channels anu a ueciease in potassium
peimeability slowly iepolaiizes the cell (ie theie is a loss of positive ions).










5$4(#-,1.+# +,(-"4 /"($4(-+.
The ventiiculai action potential is best explaineu thiough the use of visual aius.
Each phase of the action potential is causeu by an influx oi efflux of ceitain ions,
thus knowing which ions woik wheie is vital to unueistanuing the events anu
getting as many points as possible on the 0SNLE.


/H@A7 Y ! voltage-uateu Na+ channels aie open, iesulting in a iapiu upstioke.
/H@A7 X ! Na+ channels aie inactivateu anu voltage-gateu K+ channels begin to
open. This iesults in the initial iepolaiization.
/H@A7 Z ! A plateau phase wheie a voltage-gateu Ca2+ channel iesults in balancing
off of the K+ efflux. This tiiggeis Ca2+ ielease fiom the SR anu thus myocyte
contiaction.
/H@A7 ] ! A massive efflux of K+ uue to opening of slow voltage-gateu K+ channels
anu closuie of voltage-gateu Ca2+ channels leaus to iapiu iepolaiization.
/H@A7 ^ ! A high K+ peimeability iesults in ietuin to iesting potential.



,+#&-+, "1(/1(
Caiuiac output is a measuie of the stioke volume X the heait iate. Acutely, caiuiac
output will inciease uue to stioke volume incieases, wheieas chionically caiuiac
output is a iesult of an inciease in heait iate.
,+#&-+, "1(/1( U 2(#"V$ 5".13$ 0 )$+#( #+($

])+5)23%& "Z !)+X5)! "7$*7$:
9.)'/*&'(+('> ()&/#*,#, 2('" '"# -.++.2()3 O*, 1.#, ,'/.<# P.+40#Q@
- Inciease in intiacellulai calcium
- Inciease in catecholamines
- Becieaseu extiacellulai souium
- 0se of uigitalis
9.)'/*&'(+('> 1#&/#*,#, 2('" '"# -.++.2()3 O*, 1.#, ,'/.<# P.+40#Q@
- Beait Failuie
- Bypoxia
- Blockaue of the "1 ieceptoi
- Aciuosis

+ !$% -3/"#(+4( $e1+(-"42 -4 ,+#&-+, /)G2-"."TG



/#$."+& +4& +!($#."+&
/87I>@= ! Pieloau is the stietching piessuie in the ventiicles of the heait aftei
filling is completeu. Pieloau is incieaseu when theie is an inciease in bloou volume,
sympathetic stimulation, anu even exeicise.
(H787C>87l /#$."+& U $4&S&-+2(".-, 5".13$

+CB78I>@= ! Afteiloau is the teim that measuies the tension piouuceu in the
ventiicle in oiuei foi contiaction to occui.
(H787C>87l +!($#."+& U &-+2(".-, +#($#-+. /#$221#$

]HA?S@ MFLBC?>@ will MHO>HB@H CIH N>HL?BM, this incluues most commonly
nitioglyceiine.
]B@?MFLBC?>@ will MHO>HB@H CIH BUCH>L?BM, this incluues most commonly uiugs like
hyuialazine.

()$ !#+4VS2(+#.-4T .+%
This law states that with a gieatei volume of bloou enteiing the heait uuiing
uiastole, the gieatei volume of bloou is ejecteu uuiing systole. This law explains
that synchionization of caiuiac output anu venous ietuin occuis without neeuing
exteinal factois to come into play.



()$ $VT


/ K@97 ! Repiesents atiial uepolaiization
/# A7M?7:B ! Repiesents the conuuction uelay thiough the Av noue
e#2 E>?NI7J ! Repiesents ventiiculai uepolaiization
e( D:B789@I ! Repiesents mechanical contiaction of the ventiicles
( K@97 ! Repiesents the ventiiculai iepolaiizations
2( A7M?7:B ! Is an isoelectiic point wheie the ventiicles aie uepolaiizeu



+*4"#3+.-(-$2 "! ()$ $VT
)$+5)3 Z37$$%+d A supiaventiiculai tachycaiuia that piesents with a seiies of
iapiu back-to-back uepolaiizations. This may occui in those with heait uiseases
(CBF, CAB, etc), but can also occui in a peifectly noimal heait. The classic
piesentation is the "sawtooth" pattein, which occuis as a iesult of iuentical back-to-
back uepolaiizations.


)$+5)3 Z52+533)$5"#: Is a veiy common caiuiac aiihythmia wheieby theie is a
quiveiing of the chambei insteau of a cooiuinateu contiaction. The classic finuings
aie a chaotic anu eiiatic baseline with the absence of P waves in between iegulaily
spaceu QRS complexes.


+(#-"5$4(#-,1.+# *.",V2
,
&$
X%.+%% 23"!b: An asymptomatic conuition with a PR inteival piolongation
>2uumsec.

1
#X
X%.+%% /"25$m $0*% , hYHAO\HWBOIid Is a conuition that is often
asymptomatic, but if symptomatic will iequiie a pacemakei. The piesentation is a
piogiessive lengthening of the PR inteival until a P wave is not followeu by a QRS
complex.


1
#X
X%.+%% /"25$m $0*% 1: Piesents with acutely uioppeu beats that aie not
pieceeueu by a change in the PR length. The most common piesentation is 2 P
waves pei 1 QRS complex.


4
+X
X%.+%% h!"/*3%$%i (%)+$ 23"!b: Theie is inuepenuent beating of the atiia
anu the ventiicles.


]%#$+5!73)+ $)!(0!)+X5): A tachycaiuia iesulting in a heaitbeat > 1uubpm.
This may be non-pathologic, but may also leau to ventiiculai fibiillation.


]%#$+5!73)+ Z52+533)$5"#: This is a conuition wheie theie is a eiiatic ihythm
anu no iuentifiable waves on EKu. This aiihythmia is fatal without piompt
uefibiillation.



/)G2-"."TG "! ()$ ,+#&-+, 3G",G($
1. A uepolaiization tiavels uown the T-tubule, stimulating the ielease of
calcium fiom the SR (goes thiough the uihyuiopyiiuine ieceptoi anu
Ryanouine ieceptoi).
2. Calcium is ieleaseu anu binus to tioponin C, which leaus to the
confoimational change (moving tiopomyosin out of the myosin-binuing
gioove on actin filament)
S. Powei Stioke ! myosin hyuiolyzes the bounu ATP anu is uisplaceu on the
actin filament
4. Contiaction occuis





,"3/+#-4T 23""() 312,.$ ,"4(#+,(-"4 +4& 2V$.$(+. 312,.$
,"4(#+,(-"4
&D??CI /S@OLH !?AC>BOCF?A:


&\HLHCBL /S@OLH !?AC>BOCF?A:
1. ATP binus to the myosin heau, ieleasing the actin filament
2. Cioss-biiuge cycling anu shoitening occui
S. Calcium binus tioponin C anu a confoimational change occui
4. Tiopomyosin moves allowing actinmyosin cycling





*+#"#$,$/("#2 +4& ,)$3"#$,$/("#2
Baioieceptois ! Responu to piessuie
Chemoieceptois ! Responu to chemical changes

.>E@BD>: >C *@8>87E7NB>8A:
$IH B?>CFO B>OI ! iesponus to bloou piessuie, anu tiansmits a signal to the
meuulla (via the vagus neive).
$IH OB>?CFM @FAS@ ! the baioieceptoi heie tiansmits its signal to the meuulla via
the glossophaiyngeal neive.

.>E@BD>: >C EH7?>87E7NB>8A:
Cential chemoieceptois ! iesponu to pB anu PCu2 changes of the inteistitial fluiu
in the biain (these aie not influenceu by Pu2)
Peiipheial chemoieceptois ! iesponu to a Pu2 < 6ummBg, iesponu to incieaseu
PCu2, anu iesponu to a ueciease in pB (ie inciease in B+)

("Y 5& (0*"$%#&5"# +%]%+&%X 20 $(% 2)+"+%!%*$"+&n
1. Aiteiial piessuie is uecieaseu, iesulting in.
2. Becieaseu stietch, which leaus to.
S. Becieaseu affeient baioieceptoi fiiing, this causes..
4. Incieases in effeient sympathetic activity anu uecieaseu effeient
paiasympathetic stimulation, leauing to.
S. vasoconstiiction, which.
6. Incieases heait iate, contiactility, anu bloou piessuie
("Y X"%& !)+"$5X /)&&).% Y"+bn
1. Nassaging the caiotiu aiteiy gives the sense of incieaseu piessuie, which.
2. Incieases the stietch uetecteu fiom the baioieceptoi, this in tuin.
S. Becieases the heait iate




$0,)+4T$ "! ,+/-..+#G !.1-&2
Foices insiue anu outsiue of the capillaiies aie what can move fluius back anu foith.
Theie aie uiffeient methous by which fluiu is moveu, it can eithei be pusheu out of
the capillaiy (capillaiy piessuie), oi it can be moveu via osmotic piessuie, wheie it
is pulleu.
The foices aie calleu "Stailing" foices, anu they aie the following:
1. Capillaiy Piessuie (Cp) - this piessuie usually causes a movement of fluiu
out of the capillaiy
2. Inteistitial Piessuie (Pi) - this is piessuie the pushes on the capillaiies anu
moves fluiu into the capillaiy.
S. Plasma colloiu osmotic piessuie (#c) - usually moves fluiu into the capillaiy
4. Inteistitial fluiu colloiu osmotic piessuie (#i) - usually moves fluiu out of the
capillaiy.
Beteimining whethei fluiu will move into oi out of the capillaiy is baseu on the net
filtiation piessuie. By having all of the values of the piessuies above, we can
ueteimine this figuie:
Net Filtiation Piessuie = (Pc-Pi) - (#c - #i)

35#b5#. $(% )2"]% $" %X%/)$"7& &$)$%&d
Euema is causeu by excess fluius outsiue of the capillaiies, thus states in which this
is favoiable will likely leau to euema. The following will likely leau to euematous
states:
1. Incieaseu inteistitial fluiu colloiu osmotic piessuie
2. Incieaseu capillaiy piessuie
S. Incieaseu capillaiy peimeability
4. Becieaseu quantities of plasma pioteins






#$2/-#+("#G /)G2-"."TG

()$ "0GT$4S)$3"T."*-4 &-22",-+(-"4 ,1#5$

+ AHDCB B> BH7 8DMHB = uecieaseu affinity of hemoglobin foi oxygen
+ AHDCB B> BH7 I7CB = incieaseu affinity of hemoglobin foi oxygen







/1.3"4+#G #$2/"42$2 (" )-T) +.(-(1&$
When in highei altituues the Pu2 uecieases significantly, thus the bouy must auapt
anu finu ways to maintain oxygenation to the tissues of the bouy. The following aie
the majoi iesponses that help us maintain auequate oxygenation:
- ventilation incieases
- Eiythiopoietin incieases (fiom kiuneys)
- Incieases in 2,S-Biphosphoglyceiate (helps make u2 ielease easiei)
- Respiiatoiy alkalosis stimulates BC0S- excietion fiom the kiuneys
- Chionic high altituue can cause a chionically highei iate of ventilation

/$#!12-"4 .-3-($& 9A &-!!12-"4 .-3-($& ,-#,1.+(-"4
/78C<AD>: ID?DB7= ! means that gas equilibiates eaily along the capillaiy's length,
thus the only way to inciease uiffusion is to inciease bloou flow.
&DCC<AD>: ID?DB7= ! means that gas uoesn't equilibiate by the time it ieaches the
enu of the capillaiy.
Peifusion limiteu is seen in healthy people, wheieas uiffusion limiteu occuis in
those with emphysema, fibiosis, oi when exeicising.

.14T 5".13$
Theie is a list of impoitant uefinitions you shoulu know foi the 0SNLE exam, as
theie is almost always at least 1 question uealing with this. The question may come
in the foim of a uefinition, but it will most likely come in the foim of a chait wheie
you will have to calculate.


!BLOSLBCFAJ LSAJ G?LSDH@:
(>B@I .<:M ,@N@EDBF = Rv + IRv + Tv + ERv
5DB@I ,@N@EDBF = Tv + IRv + ERv
!<:EBD>:@I #7A7897 ,@N@EDBF = ERv + Rv
-:AND8@B>8F ,@N@EDBF = IRv + Tv

5$4(-.+(-"4L/$#!12-"4 O5LeP 3-23+(,)
When theie is noimal gas exchange (ie healthy inuiviuual), the vQ is appioximately
1, meaning an iueal ventilation to peifusion iatio. If theie is a mismatch, this
inuicates that theie is a shunt anu some uegiee of ueau space in the same lung.
A vQ of u is inuicative of a shunt (ie aiiway obstiuction)
A vQ of $ is inuicative of an obstiuction of bloou flow (ie physiological ueau space).
- ventilation anu peifusion aie gieatei at the base of the lung than in the apex
- vQ at the apex of the lung is highei, meaning wasteu ventilation
- vQ at the base of the lung is lowei, meaning wasteu peifusion

.14T /#"&1,(2
Theie aie a few veiy impoitant piouucts maue insiue the lungs, they incluue:
1. Angiotensin-Conveiting Enzyme
2. Suifactant (type 2 pneumocytes)
S. Piostaglanuins
4. Bistamine
S. Kallikiein








,+#*"4 &-"0-&$ (#+42/"#(
Theie aie thiee methous by which caibon uioxiue aie caiiieu fiom the tissues of the
bouy back to the lungs, they incluue:
1. In the foim of bicaibonate (this is the majoiity) ~9u%
2. As uissolveu caibon uioxiue ~S%
S. Bounu to hemoglobin as caibaminohemoglobin ~S%





















!()*$%+ 9

25"!(%/5&$+0

$IF@ @HOCF?A F@ GH>E IFJIKEFHLMV BAM FAOLSMH@ DBAE @SWK
OBCHJ?>FH@Q $IH DHCBW?LFO NBCITBE@ B>H GH>E FDN?>CBACo
NBEFAJ @NHOFBL BCCHACF?A C? >HJSLBC?>E @CHN@ F@ O>SOFBLQ
YIFLH CIH MHCBFL@ ?U WF?OIHDF@C>E B>H A?C IFJIKEFHLMV CIH WFJ
NFOCS>H B@ B TI?LH F@ GH>E IFJIKEFHLM DBCH>FBLQ















T$4$(-,2
The Baiuy-Weinbeig law of genetics states that both the allele anu the genotype
fiequencies of a population iemain constant fiom geneiation to geneiation, unless
theie is a specific uistuibance(s) intiouuceu into the population.
$IH LBT ?U (B>MEKYHFAWH>J B@@SDH@:
1. No mutations occui
2. Theie is no selection foi any of the specific genotypes
S. Nating is ianuom
4. Theie is no migiation into oi out of the population

The fiequency of uiffeient alleles in a population can be ueteimines with the
Punnett squaie, which can be linkeu mathematically to the 'Baiuy-Weinbeig
equation foi equilibiium'.




)-T)SG-$.& T$4$(-, ($#3-4"."TG
.HAH - is the section of a chiomosome that caiiies infoimation foi specific tiaits
)LLHLH@ - aie alteinate foims of a gene
*IHA?CENH - the physical appeaiance of an oiganisms, usually ueteimineu by the
uominant gene.
.HA?CENH - the genetic makeup of an oiganism.
X?DFABAC - is the gene oi tiain that appeais oi expiesses itself, iepiesenteu with a
capital lettei (ie +a).
+HOH@@FGH - is the genetiait that gets hiuuen in the piesence of a uominant gene,
iepiesenteu with a lowei-case lettei (ie A@)
]B>FBWLH %PN>H@@F?A - is the vaiiance is phenotype fiom one inuiviuual to anothei.
5AO?DNLHCH *HAHC>BAOH - this occuis when not all inuiviuuals who caiiy mutant
genotype actually show the mutant phenotype.
)ACFOFNBCF?A - occuis when the seveiity of a uisease gets woise at youngei anu
youngei ages, classic example is Buntington's uisease.
*LHF?C>?NE - occuis when one gene has moie than one effect on an inuiviuual's
phenotype.
5DN>FACFAJ - is a uiffeience in phenotype that uepenus solely on whethei the
mutation is of mateinal oi pateinal oiigin.
/?@BFOF@D - the cells of the bouy have uiffeient genetic makeups.
3?@@ ?U (HCH>?aEJ?@FCE - this means that a complementaiy allele must be eithei
ueleteu oi mutateu befoie the othei allele can show expiessitivity. This uoes not
apply to oncogenes.








3"&$2 "! -4)$#-(+4,$












.+*"#+("#G ($,)4-e1$2 12$& -4 *-",)$3-2(#G
$IH *?LEDH>B@H !IBFA +HBOCF?A O/,#P
This technique is useu when a laige numbei of BNA copies aie neeueu. The steps to
cieating multiple copies of BNA fiagments thiough the PCR aie as follows:
1. BNA is heateu anu uenatuieu, this causes the sepaiation of the stianus.
2. The uenatuieu BNA is cooleu, anu BNA piimeis aie auueu to the mix, these
auheie to each inuiviuual stianu of BNA at the location that will be amplifieu.
S. BNA polymeiase then ieplicates the uesiieu BNA stianus.
4. This piocess is iepeateu until the uesiieu numbei of BNA is achieveu.



$.-2+ O$:jF?7S.D:m7= -??<:>@QA>8Q7:B +AA@FP
This technique is useu as a means of uetecting the piesence of an antibouy oi an
antigen in a sample. The antibouy oi antigen that is auueu is linkeu to an enzyme,
then a test solution is auueu to see if an intense coloi illuminates, inuicating that
theie is a positive iesult.
- This test is most commonly useu when looking foi BIv.
- Sensitivity anu specificity foi the ELISA aie extiemely high, both appioaching
1uu%, howevei they aie not peifect, anu false iesults uo occui.

2"1()$#4 *."( ($,)4-e1$
This technique is useu to uetect specific sequences of BNA. The technique combines
the tiansfei of electiophoiesis-sepaiateu BNA fiagments anu membiane filtiation,
anu then fiagments aie uetecteu by piobe hybiiuization.

%$2($#4 *."( ($,)4-e1$
This is a technique useu to uetect specific pioteins, sepaiating native oi uenatuieu
pioteins by the length of the polypeptiue. These pioteins aie then tiansfeiieu to a
membiane wheie they aie piobeu using antibouies specific to the taiget piotein.

4"#()$#4 *."( ($,)4-e1$
Is a technique useu to stuuy gene expiession by RNA uetection in a sample. This
technique allows foi the uetection of cellulai contiol by ueteimination of gene
expiession levels uuiing uiffeientiation anu moiphogenesis.







&4+l #4+l +4& /#"($-42

K )MHAFAH WFAM@ C? CIEDFAH with two hyuiogen bonus, wheieas JSBAFAH WFAM@ C?
OEC?@FAH with thiee hyuiogen bonus, making it a stiongei bonu anu moie iesistant
to incieaseu tempeiatuies.
- In RNA, S>BOFL is piesent insteau of CIEDFAH.









()$ *+2-, 2(#1,(1#$ "! ()$ 41,.$"(-&$2
*E>FDFMFAH@ - Aie heteiocyclic oiganic compounus consisting of two nitiogen
atoms at positions 1 anu S of a six-membeieu iing. The nucleotiues belonging to the
pyiimiuine gioup aie: !EC?@FAHV 7>BOFLV anu $IEDFAH.


*S>FAH@ - Aie heteiocyclic aiomatic oiganic compounus consisting of a pyiimiuine
iing bounu to an imiuazole iing. The nucleotiues belonging to the puiine gioup aie:
)MHAFAH anu .SBAFAH.




,)#"3+(-4
Chiomatin is the stiuctuie that is maue up of BNA anu pioteins, which then makes
up the chiomosome. It is founu within the nuclei of eukaiyotic cells only. Theie aie
two types of chiomatin, theie is "heteiochiomatin", which is conuenseu anu
tiansciiptionally inactive, anu theie is euchiomatin, which is loosei anu
tiansciiptionally active.
The main function of chiomatin is to package laige amounts of BNA into smallei
aieas, allowing moie to fit into cells anu thus pioviue foi moie genetic mateiial
oveiall.




&4+ #$/.-,+(-"4
In piokaiyotes, theie is a single oiigin of ieplication, wheieas in eukaiyotes theie
aie multiple oiigins of ieplication.
&?DH FDN?>CBAC UBOC@:
- BNA polymeiase S pioofieaus in the S'! S' uiiection, synthesizing in the
S'! S' uiiection.
- Piimase piouuces an RNA piimei, on which BNA polymeiase S initiates
ieplication.
- BNA polymeiase S elongates the chain thiough the auuition of
ueoxynucleotiues to the S' enu.
- BNA polymeiase 1 uegiaues RNA piimei once it is no longei neeueu.
- 0kazaki fiagments help elongate the chain on the lagging stianu.
- BNA ligase seals on the lagging stianu.
- BNA gyiase unwinus the stianu befoie ieplication can begin.
- BNA topoisomeiase ielieves supeicoils by nicking the stianu.



&4+ &+3+T$
The two types of BNA uamage aie 'Enuogenous' anu 'Exogenous'.
Types of Enuogenous uamage:
,Q "PFMBCF?A - ieactive oxygen species causes inteiiuptions to the BNA stianu.
1Q )L\ELBCF?A - alkylation of bases by foimation of compounus such as 7-
methylguanine.
4Q (EM>?LE@F@ - base hyuiolysis causes ueamination, uepuiination, anu
uepyiimiuination.
6Q 2SL\E BMMSOC U?>DBCF?A
8Q 2B@H DF@DBCOIH@
Types of Exogenous uamage:
,Q 7]K2 MBDBJH - causes cioss-linking between cytosine anu thymine bases,
cieating 'pyiimiuine uimeis'.
1Q 7]K) MBDBJH - cieates most fiee iauicals, causeu inuiiect BNA uamage.
4Q 5?AFaFAJ >BMFBCF?A - causing iauioactive uecay anu bieaks in BNA stianus.
6Q $IH>DBL MF@>SNCF?A - causes uepuiination anu single stianu bieaks
8Q 5AMS@C>FBL OIHDFOBL MBDBJH - compounus such as vinyl chloiiue anu hyuiogen
peioxiue, smoke, soot, anu tai can cause seveie uamage to BNA. It causes oxiuation,
alkylation, anu cioss-linking of BNA.

&4+ #$/+-#
&FAJLH @C>BAM MBDBJH:
Bamage to a single stianu is iepaiieu via one of thiee mechanisms.
*@A7 $JEDAD>: #7N@D8 - This type of iepaii helps to fix uamage to a single base,
which is iemoveu by a BNA glycosylase. The missing base is then iecognizeu by AP
enuonuclease anu iesynthesis occuis via BNA polymeiase, with BNA ligase sealing
the new stianu.
4<EI7>BD=7 $JEDAD>: #7N@D8 - This mechanism iecognizes bulky helix-uistoiting
uamage anu is fixeu with tiansciiption-coupleu iepaii which emits NER enzymes
that aie actively being tiansciibeu.
3DA?@BEH #7N@D8 - This iepaii mechanism coiiects eiiois of BNA ieplication anu
iecombination that iesulteu fiom mispaiieu nucleotiues.

X?SWLHK&C>BAM XBDBJH:
Thiee mechanisms exist to iepaii uouble-stianueu uamage, they aie:
1. Non-homologous enu joining (NBE})
2. Niciohomology-meuiateu enu joining (NNE})
S. Bomologous iecombination

4>:S)>?>I>M><A $:= 6>D:D:M - This foim of iepaii is meuiateu by a specializeu
foim of BNA ligase (BNA ligase Iv), which woiks by foiming a complex with a
cofactoi (XRCC4) anu then uiiectly joining the two non-uamageu enus.
3DE8>H>?>I>MFS37=D@B7= $:= 6>D:D:M - This type of iepaii mechanism woiks by
using a S-2S base paii homologous sequence to align bioken stianus befoie joining
them. It uses a "Ku piotein" anu BNA-PK inuepenuent iepaii mechanism anu then
iepaii occuis uuiing the S phase of the cell cycle.
)>?>I>M><A #7E>?QD:@BD>: - This type of iepaii iequiies the piesence of an
iuentical sequence that is useu as a template foi iepaii of the bieak.

&$!$,(2 (" ()$ &4+ #$/+-# 3$,)+4-23
When the iepaii mechanisms fail, theie is an expiession of impiopei BNA, anu this
can iesult in conuitions that aie seveie anuoi lethal. Thiee conuitions that iesult
fiom faileu BNA iepaii aie:
fH>?MH>DB *FJDHAC?@SD - This conuition occuis when theie is a uefect in one of
the seven genes iequiieu foi BNA iepaii. Those afflicteu with this uisease aie
extiemely sensitive to sunlight anu have a significantly high iisk foi skin cancei.
This patient will only live to be miuule-ageu at best.
$>FOI?CIF?ME@C>?NIE - This conuition is causeu by uefects that iesult in ieuuceu
RNA tiansciiption of pioteins. Symptoms incluue: photosensitivity, biittle haii anu
nails, scaly skin, piotiuuing eais, physical anu mental ietaiuation, anu a ieceuing
chin. * The pioblem ultimately lies in the fact that the haii lacks sulfui-containing
pioteins.
!?O\BEAH &EAM>?DH - This conuition iesults fiom an inability to iepaii BNA
uamage that is uetecteu uuiing tiansciiption. The patient suffeis fiom sensitivity to
sunlight, have shoit-statuie, anu age piematuiely.


























!#"3 &4+ (" /#"($-4
The piocess of obtaining usable pioteins involves cieating RNA fiom BNA, then
pioteins fiom that RNA.
&4+ ! #4+ OB8@:AE8DNBD>:P
#4+ ! /#"($-4 OB8@:AI@BD>:P
The basic oveiview of the whole piocess is as follows:





(G/$2 "! #4+
Tiansciiption is the piocess by which RNA is maue fiom each stianu of BNA.
Theie aie S types of RNA: >+#)V D+#)V BAM C+#)
>+#) - Is maue via RNA polymeiase I, anu is the most @Q<:=@:B type of RNA.
Ribosomal RNA combines with piotein in the cytoplasm to foim a iibosome, which
seives as the site anu caiiies all of the necessaiy enzymes iequiieu foi piotein
synthesis.
D+#) - Is maue via RNA polymeiase II, anu is the I@8M7AB type of RNA. Nessengei
RNA is the RNA that is cieateu fiom a gene segment of BNA . The mRNA then
caiiies the coue it ieceives fiom BNA into the cytoplasm wheie piotein synthesis
will occui
C+#) - Is maue via RNA polyeiase III, anu is the A?@II7AB type of RNA. Tiansfei
RNA is the type of RNA that ieaus the coue fiom the mRNA anu caiiies the amino
aciu to be incoipoiateu into the ueveloping pioteins. Theie aie moie than 2u
uiffeient tRNA's, meaning theie is one foi each amino aciu. tRNA contains
appioximately 7S nucleotiues, thiee of these aie "anticouons".
* Piokaiyotes have only one RNA polymeiase that makes all of the RNA sub-types.














(#+42,#-/(-"4
Tiansciiption is the piocess wheieby BNA is useu as a template to piouuce mRNA.
BNA must be in the foim of euchiomatin in oiuei foi this piocess to occui, anu it
occuis in the nucleus of the cell because BNA woulu otheiwise be exposeu to
uangeious enzymes in the cytoplasm that woulu cause its uegiauation.
Theie is no pioofieauing function, RNA polymeiase II will open a BNA sequence at
the piomotei site, which is a TATA box (A-T iich sequence that is upstieam). mRNA
is synthesizeu in the S' ! S' uiiection.










/#",$22-4T "! ?#4+
Aftei tiansciiption, while the mRNA is still in the nucleus, theie aie thiee impoitant
steps taken to ensuie stabilization of the newly synthesizeu mateiial.
Xn +==DBD>: >C @ b[ E@N
The auuition of the cap is uone thiough the following:
- Phosphoiylase iemoves the gamma phosphate fiom the S' enu of the
tiansciibeu pie-mRNA.
- uuanylyl tiansfeiase catalyzes the conuensation of uTP with the S' enu of the
pie-mRNA.
- The teiminal guanosine nucleotiue is methylateu by guanine-7-methyl
tiansfeiase, using S-auenosyl-methionine (SAN) as a co-factoi.

Zn +==DBD>: >C @ ][ N>IF + B@DI ON>IF@=7:FI@BD>:P
The auuition of appioximately 2uu auenine units to the S' enu of the mRNA help to
pioviue piotection, as without this poly A tail the mRNA woulu be quickly uegiaueu.
- A cleavage factoi iecognizes anu binus to the specific polyauenylation
sequence (AA0AAA).
- Enuonucleases cleave the RNA
- Poly A polymeiase catalyses the auuition of appioximately 2uu auenine
nucleotiues to the S' enu of the cleaveu mRNA.
- An auuition piotein (cleavage stimulation factoi), helps stabilize the
complex.
- 0nce assembleu, mRNA is cleaveu 1u-SS nucleotiues uownstieam of the
AA0AAA sequence by the enuonuclease anu appioximately 2u auenine
nucleotiues aie auueu by the poly A polymeiase.
- The poly A tails aie then bounu by poly A binuing pioteins, which help to
shift the piocessive moue of synthesis anu this iesults in the auuition of up to
2Su nucleotiues.

]n 2NIDED:M
Splicing is a mouification of mRNA wheieby intions aie spliceu out anu exons aie
joineu togethei. This step is iequiieu befoie RNA can move out of the nucleus anu
go thiough tiansciiption.

&CHN@ C? D+#) @NLFOFAJ:
1. The piimaiy tiansciipt contains both intions anu exons
2. Spliceosomes meuiate the splicing
S. The 1
st
splice site is at the S' enu of an intion
4. The 2
nu
splice site is at the S' enu of that same intion
S. Intion, once spliceu at both sites, is iemoveu anu the exons aie combineu,
foiming a matuie mRNA stianu that is piepaieu foi tianslation




2(#1,(1#$ "! B#4+
Tiansfei RNA (tRNA) is an RNA molecule (the smallest) whose puipose is to
tiansfei an active amino aciu to the polypeptiue chain uuiing tianslation. Theie is a
S' teiminal site, at which the amino aciu attaches covalently thiough an aminoacyl
tRNA synthetase. The othei impoitant stiuctuie is at the base, anu is known as the
'anticouon', which caiiies a S nucleotiue coue that paiis to the coiiesponuing thiee
base couon iegion of the mRNA.

)DFA?BOELBCF?A - The amino aciu becomes linkeu to the tRNA via 'Aminoacyl tRNA
synthetase', using ATP to attach the amino aciu. The amino aciu is bounu to the S'
enu covalently. This leaves the tRNA molecule in a chaigeu state.
C+#) Y?WWLH - is the concept that only the fiist 2 nucleotiue positions of the mRNA
couon must match in oiuei foi the piocess to pioceeu coiiectly, the thiiu position
uoes not have to be the exact coiiect nucleotiue since its uiffeience can still coue foi
the same amino aciu.

(#+42.+(-"4
Tianslation is the piocess by which mRNA is useu to cieate pioteins.
Theie aie thiee steps to tianslation, they aie:
1. Initiation
2. Elongation
S. Teimination

5AFCFBCF?A:
Initiation begins when the small iibosomal subunit attaches to the S' cap of mRNA
anu moves to the tianslation initiation site.

%L?AJBCF?A:
- tRNA has a complementaiy anticouon to mRNA stait couon (A0u), wheie
methionine is the coiiesponuing amino aciu.
- The laige iibosomal subunit joins to foim the P anu A sites (1
st
tRNA is in the
P site, 2
nu
enteis the A site anu complements the 2
nu
mRNA couon).
- Nethionine then tiansfeis to the AA in the A site, the 1
st
tRNA exits, the
iibosome moves along mRNA anu the next tRNA enteis.
- The giowing peptiue is continually tiansfeiieu to the A site tRNA

$H>DFABCF?A:
- A stop couon (0Au) is eventually encounteieu, at which point a "ielease
factoi" enteis the A site, anu tianslation is teiminateu.
- The iibosome uissociateu anu the newly foimeu piotein is ieleaseu.















3$(+*".-23

)DMHSGD7I= =DA>8=78A >C ?7B@Q>IDA?:
.LEO?JHA @C?>BJH MF@HB@H@d
(FN7 X a 9>: TD78m7 =DA7@A7 O)7N@B>87:@I TIFE>M7:>ADAP
- Causeu by glucose-6-phosphatase ueficiency.
*BCFHAC DBE HPNH>FHAOH:
- Bypoglycemia
- Chionic hungei
- Belayeu pubeity anuoi unueiuevelopment
- Bepatomegaly
- Fatigue

(FN7 Z a />?N7[A =DA7@A7
- Causeu by a lysosomal !-1,4-glucosiuase ueficiency.
*BCFHAC DBE HPNH>FHAOH:
- Nuscle weakness, especially in the heait
- Nost commonly seen in newboin chiluien 0R those in theii Su's anu 4u's
- Fatigue as a iesult of weakening of the heait anu livei
- Cuivatuie of the spine is a piogiessive symptoms
- Bifficulty bieathing, such as laboieu bieathing, anu infections of the
iespiiatoiy tiact
- Bizziness anu syncope

(FN7 ] a ,>8D[A =DA7@A7
- Causeu by a ueficiency of the uebianching enzyme !-1,6-glucosiuase
*BCFHAC DBE HPNH>FHAOH:
- Symptoms similai to von uieike's uisease, but miluei
- Young chiluien typically have massive hepatomegaly that uiminishes with
incieasing age

(FN7 ^ a +:=78A7: =DA7@A7
- The main clinical featuies of Anueison uisease aie insufficiency of the livei
anu abnoimalities of the heait anu neivous system
- This uisease is iaie anu will leau to eaily ueath

(FN7 b a 3E+8=I7[A =DA7@A7
- Causeu by a ueficiency of skeletal muscle glycogen phosphoiylase
*BCFHAC HPNH>FHAOH@:
- Incieaseu glycogen founu within the muscle
- Painful ciamps anu myoglobinuiia when activity is incieaseu

(FN7 ` a )78A =DA7@A7
- Causeu by a hepatic phosphoiylase ueficiency
- Patient may have the inability to maintain bloou-glucose levels uuiing
peiious of fasting.
- 0iine anu seium ketones aie elevateu piopoitionally to the level of fasting
- Nilu to moueiate hypeilipiuemia may be piesent
- Piominent hepatomegaly anu giowth ietaiuation aie common finuings of
Beis uisease

(FN7 c a (@8<D =DA7@A7
- Causeu by a ueficiency of phosphofiuctokinase (PFK) in glycolysis
- Patient will expeiience incieaseu muscle glycogen that cannot be bioken
uown
- Ciamping
- Bighei levels of myoglobin in the uiine when theie is incieaseu physical
activity







/)$4G.V$("41#-+ O/V1P
PK0 is an autosomal iecessive uisease chaiacteiizeu by a ueficiency of
phenylalanine hyuioxylase, which inhibits the foimation of tyiosine fiom its
piecuisoi phenylalanine. Because of this enzyme ueficiency, two things occui:
Xn (H7 @?D:> @ED= (F8>AD:7 Q7E>?7A @: 7AA7:BD@I @?D:> @ED=n
Zn /H7:FI@I@:D:7 Q<DI=A <N E@<AD:M @ ?F8D@= >C A79787 AF?NB>?A
The inciease in phenylalanine leaus to an inciease in phenylketones
(phenylpyiuvate, phenylacetate, anu phenyllactate) in the uiine.
&FJA@ BAM &EDNC?D@:
- Patients aie noimal at biith, but scieening is now essential
- Failuie of eaily milestone uevelopment
- Chaiacteiistic "musty oi mousy" bouy ouoi
- Niciocephaly anu mental ietaiuation
- Bypeiactivity
- Bypopigmentation anu eczema

+.*-4-23
A conuition wheie theie is a complete lack of pigment thioughout the bouy. This is
an autosomal iecessive conuition, wheie the patient cannot piouuce melanin fiom
tyiosine (tyiosinase ueficiency) oi fiom a uefect in the tyiosine tianspoiteis. Theie
is an inciease in the iisk of skin cancei uue to the lack of piotective melanin in the
skin.

3+/.$ 2G#1/ 1#-4$ &-2$+2$
Naple syiup uiine uisease is chaiacteiizeu by the sweet smell of the patients uiine
(ie maple syiup). The cause is a uefect in the ability to bieak uown the biancheu
chain amino acius Leucine, Isoleucine, anu valine. The ieason foi this is a ueficiency
of the enzyme !- ketoaciu uehyuiogenase. The patient will suffei fiom seveie
mental ietaiuation, CNS uefects, anu finally ueath.





+.V+/("41#-+
Anothei conuition involving tyiosine, alkaptonuiia iesults fiom a ueficiency of
homogentisate 1,2-uioxygenase in the pathway of tyiosine uegiauation.
Bomogentisic aciu (alkapton) thus accumulates in the bloou anu is excieteu in the
uiine in laige amounts, leauing to blackening of the uiine upon stanuing. Excessive
amounts of homogentisic aciu cause uamage the caitilage, leauing to seveie
aithialgias.

)"3",G2($-41#-+
Also iefeiieu to as Cystathionine beta synthase ueficiency (CBS ueficiency), it is an
autosomal iecessive uisoiuei.
In the case of ueficiency, patient will have excessive homocysteine in the uiine. In
this case, cysteine will be essential anu shoulu be incieaseu in the uiet, while
simultaneously uecieasing the amount of methionine in the uiet.
Signs anu symptoms incluue:
- Nental ietaiuation
- Seizuie
- Nusculoskeletal abnoimalities (tall builu, long limbs, pectus excavatum, pes
cavus, anu genu valgum)
- Abnoimalities of the eyes (glaucoma, subluxation of lens)
- vasculai conuitions (eaily thiomboses)

,G2(-41#-+
Cystinuiia is a conuition wheieby theie is a uefect in the tianspoit of tubulai amino
acius foi the following amino acius: Cystine, 0inithine, Lysine, anu Aiginine. This
iesults in an excess of cystine in the uiine, which can pieuispose the patient to
kiuney stones. Nanagement is to alkalinize the uiine with acetazolamiue.






#$2/-#+("#G *1#2(
This ieaction is impoitant in uegiauing bacteiia that aie phagocytizeu. The
iespiiatoiy buist ieuuces oxygen (via NABPB) to piouuce a fiee-iauical, then
piouucing B2u2, which is fuithei combineu with Chloiiue to piouuce B0Cl-, which
ultimately uestioys the engulfeu bacteiia.


()$ +4+("3G "! +&$4"2-4$ (#-/)"2/)+($ O+(/P



T.G,"T$4".G2-2
ulycogenolysis is the piocess wheieby glycogen polymei is conveiteu to glucose,
which can then go thiough glycolysis. ulycogenolysis occuis in the livei anu muscle,
anu is stimulateu by epinephiine anuoi glucagon in iesponse to low bloou glucose
levels.





T.G,".G2-2
ulycolysis is the piocess wheieby glucose is conveiteu to pyiuvate. ulycolysis
consists of ten ieactions with F00R iiieveisible stepsenzymes.
$IH *>HNBC?>E *IB@H - Consists of the fiist five steps, also known as the investment
phase. This phase consumes eneigy that is useu to conveit glucose into two S-C
sugai phosphates (uSP). In this phase, the net ATP is (-2).
$IH *BEK"UU *IB@H - Consists of five steps that piouuce a net gain of 2 ATP anu 2
NABB molecules (pei glucose molecule that goes thiough the pathway). Pyiuvate is
also the enu piouuct of the glycolytic pathway.



The total ATP geneiateu fiom BABH>?WFO JLEO?LE@F@ F@ 1 )$*c@. When compaieu to
ATP piouuceu with the DBLBCH @ISCCLH anu JLSO?@HK4KNI?@NIBCH @ISCCLH, which
cieate 4; )$*c@ anu 49 )$*c@ iespectively.



#$T1.+(-"4 "! T.G,".G2-2
Theie aie F00R steps in glycolyisis that aie consiueieu to be iiieveisible, thus once
they have occuiieu, glycolysis must piogiess in the foiwaiu uiiection. The foui
iegulatoiy enzymes aie:
1. Bexokinase
2. Phosphofiuctokinase
S. Pyiuvate kinase
4. Pyiuvate uehyuiogenase

(HP?\FAB@H:
- Bexokinase is iesponsible foi the fiist step of glycolysis in the muscles anu
biain.
- It is inhibiteu by the piesence of glucose-6-phosphate, which is the piouuct
of its activity.
- This step is impoitant because it pievents the consumption of too much
cellulai ATP in the foimation of glucose-6-phosphate when glucose is not
limiting.
- Bexokinase has a low affinity to glucose, thus it peimits glycolysis initiation
even if bloou glucose levels aie low.

*I?@NI?U>SOC?\FAB@H:
- PFK is the iate-limiting step of glycolysis, thus it is the most impoitant
contiol point thioughout the whole piocess.
- Regulation is by both alloesteiic effectois anu by covalent mouifications (ie
phosphoiylation).
- It is stimulateu by the piesence of ANP anu fiuctose-2,6-bisphosphate.
- Even if ATP is high, the piesence of ANP can oveicome its inhibitoiy effects
uue to the ability to allosteiically activate PFK.
- It is inhibiteu by the piesence of ATP anu citiate

*E>SGBCH bFAB@H:
- Similai to PFK, is iegulateu by allosteiic effectois anu by phosphoiylation.
- PK is activateu by fiuctose-1,6-bisphosphate anu inhibiteu by ATP anu
alanine.


/G#15+($ &$)G&#"T$4+2$ ,"3/.$0
The pyiuvate uehyuiogenase complex iegulates the entiy of glycolytic piouucts
into the citiic aciu cycle. This complex consists of thiee enzymes that tiansfoim
pyiuvate (fiom glycolysis) into acetyl-CoA, thiough the piocess of pyiuvate
uecaiboxylation.


&$!-,-$4,G "! /G#15+($ &$)G&#"T$4+2$
A ueficiency of pyiuvate uehyuiogenase is a conuition that is most commonly
seen in alcoholics, uue to the ueficiency of thiamine that is an inevitable iesult of
this uisease. The lack of pyiuvate BB iesults in an accumulation of pyiuvate,
which iesults in lactic aciuosis. Theie will be neuiologic finuings that can be
manageu by giving the patient amino acius that aie puiely ketogenic, such as
Leucine anu Lysine.






3$(+*".-23 "! /G#15+($
0nueistanuing how pyiuvate is metabolizeu will aiu in unueistanuing why
ceitain auveise effects occui when theie is a malfunctioning pyiuvate BB
anuoi othei pioblems with the pathway. In yeast, pyiuvate is conveiteu to
ethanol in anaeiobic conuitions, in eukaiyotes it is conveiteu to lactate. In
optimal conuitions (ie. Aeiobic), pyiuvate is conveiteu to Acetyl CoA.














()$ ,-(#-, +,-& ,G,.$ O(,+P
The citiic aciu cycle is an essential metabolic piocess that is essential foi completing
the oxiuative uegiauation of monosacchaiiues, fatty acius, anu amino acius.



Seives 2 main puipose:
1. To inciease the cell's ATP piouucing potential by geneiating ieuuceu
election caiiieis such as NABB anu ieuuceu ubiquinone. ( QB2).
2. To pioviue the cell with piecuisois that can be useu to builu a vaiiety of
molecules, uepenuing on the cell's neeus.

7AMH> BH>?WFO O?AMFCF?A@V CIH U?LL?TFAJ RSBACFCFH@ ?U )$* B>H JHAH>BCHMd
TIFE>IFADA = 2 ATP (net), 2 NABB (equaling 6 ATP)
/F8<9@B7 ! +,>+ = 2 NABB = 6ATP
,DB8DE +ED= ,FEI7 = 2 uTP (2 ATP), 6 NABB (~ 18 ATP), 2 QB2 (4 ATP)








()$ $.$,(#"4 (#+42/"#( ,)+-4
The ETC couple ieactions between election uonois anu election acceptois (ie.
Between NABB anu oxygen), to the tiansfei of hyuiogen ions acioss a membiane.
These hyuiogen ions aie useu to piouuce ATP to be useu as eneigy as they move
back acioss the membianes.
The conveision of oxygen to watei, NABB to NAB+, anu succinate to fumaiate is
what will ultimately uiive the tiansfei of hyuiogen ions.
Theie aie foui complexes that aie embeuueu in the innei membiane, which aie
electiically connecteu by lipiu-soluble election caiiieis anu watei-soluble election
caiiieis. Thiee of these complexes seive as pioton pumps.
!?DNLHP , - Is a pioton pump. Is 'NABB uehyuiogenase', which iemoves two
elections fiom NABB anu tiansfeis them to ubiquinone (Q). 0nce ubiquinone is
ieuuceu to QB2, it can fieely uiffuse within the membiane, tianslocating foui
hyuiogen ions acioss the membiane, piouucing a pioton giauient.
piematuie election leakage occuis in Complex 1, which is a main site of
supeioxiue piouuction.
!?DNLHP 1 - Is 'Succinate uehyuiogenase', in this complex theie is the auuitional
ueliveiy of elections into the quinone pool which oiiginate fiom succinate anu aie
tiansfeiieu to ubiquinone. Complex 2 consists of foui piotein subunits.
!?DNLHP 4 - Is a pioton pump. Is the 'Cytochiome bc1 complex", wheie two
elections aie iemoveu fiom QB2 anu tiansfeiieu to cytochiome c. Two othei
elections aie passeu acioss the piotein ieuucing ubiquinone to quinol, anu foui
piotons aie ieleaseu fiom two ubiquinol molecules. This pump builus the giauient
by an absoiptionielease of piotons. Supeioxiue is foimeu thiough election
leakage in this complex.
!?DNLHP 6 - Is a pioton pump. Is 'Cytochiome C oxiuase', wheie foui elections aie
iemoveu fiom foui molecules of cytochiome c, anu thus tiansfeiieu to oxygen, thus
piouucing two watei molecules. Foui moie piotons aie tiansfeiieu acioss the
membiane, fuithei contiibuting to the giauient.
!?DNLHP 8 - "ATP Synthase". 0nce a sufficient pioton giauient has been maue by
complexes I, III, anu Iv, an FoF1 ATP synthase complex uses this giauient to make
ATP via oxiuative phosphoiylation. The piotons influx back into the mitochonuiial
matiix, ieleasing fiee eneigy which is useu to uiive the ATP synthesis. Coupling
with oxiuative phosphoiylation is impoitant in piouucing ATP, as they pioviue in
some ciicumstances the ability foi piotons to flow back into the mitochonuiial
matiix (occuis in biown auipose tissue), anu helps in theimogenesis.










T.1,"4$"T$4$2-2
This is the piocess by which new glucose is foimeu fiom caibon skeletons such as
pyiuvate, lactate, glyceiol, alanine, anu glutamate. The majoi site of
gluconeogenesis is the livei. The piocess of cieating glucose fiom pyiuvate is quite
costly compaieu to the amount of eneigy cieateu by one molecule of glucose.
Activateu when the bouy is in a state of hungei anuoi staivation. Ketone bouies
aie also piouuceu fiom acetyl-CoA.
The basic piocess of gluconeogenesis is as follows:



-421.-4
Insulin is a hoimone piouuceu by the "-cells of the
pancieas, its piime iole is to uiive glucose fiom the
bloou into the cells of the 04,&+#,L M/*()L /#1 M+..1
&#++,L ()'#,'()#,L +(P#/L &./)#*L *)1 <(1)#>5
&NHOFUFO HUUHOC@ ?U FA@SLFA:
- Anabolic effects (synthesis of fats, pioteins,
anu glycogen)
- Retention of souium by the kiuneys
- Inhibition of the ielease of glucagon fiom the
!-cells of the pancieas





C-peptiue is a maikei
of insulin secietion.
When a patient has
extieme hypoglycemia,
uiffeientiate between
insulinoma anu
exogenous
auministiation by
looking foi the
piesence oi absence of
C-peptiue.

T.1,+T"4 +4& -421.-4 -4 #$T1.+(-4T )"3$"2(+2-2
The iegulation of bloou glucose is uelicately balanceu by two impoitant hoimones,
insulin anu glucagon. 5A@SLFA is secieteu by the "-cells of the pancieas in iesponse
to an elevateu bloou-glucose level. 0n the othei siue, JLSOBJ?A is secieteu by the !-
cells of the pancieas in iesponse to low levels of bloou-glucose. ulucagon causes the
livei to ielease glycogen which is bioken uown into glucose, anu useu to inciease
the amount of glucose iunning thiough the bloou.




()$ 2G4()$2-2 "! ,)".$2($#".
Cholesteiol is impoitant in the bouy foi vaiious ieasons, namely:
- Plays a iole in membiane stiuctuie anu fluiuity
- Belps with hoimone piouuction
- Belps with vitamin B metabolism
- Plays a iole in the CNS
The highest-yielu infoimation ielating to cholesteiol is knowing its iate-limiting
enzyme, which is: Byuioxy Nethyl ulutaiyl Coa Reuuctase (BNu CoA ieuuctase).
The phaimacological basis of loweiing cholesteiol (statin uiugs), is uesigneu aiounu
the inhibition of this enzyme.
The most impoitant steps in cholesteiol synthesis aie:



!+((G +,-& 2G4()$2-2
Some impoitant points must be unueistoou iegaiuing fatty aciu synthesis, these
being the basics of FA synthesis.
The iate limiting enzyme is )OHCELK!?) !B>W?PELB@H, which uoes the following:
+E7BFIS,>+ ! 3@I>:FI ,>+
- This step is positively effecteu by 'citiate', anu negatively effecteu by
'palmitoyl CoA'.
- Biotin is a iequiieu co-factoi to this ieaction.
- Synthesis of fatty acius moves in the uiiection of "methyl!caiboxyl enu",
thus C1S anu C16 aie piouuceu fiist, C2 anu C1 aie piouuceu last.








+/".-/"/#"($-42 @:= .-/"/#"($-42
)N?LFN?N>?CHFA@:
Apolipopioteins aie pioteins that binu to lipius anu help tianspoit them thioughout
the bouy. 0nce bounu to lipius, the stiuctuie is known as a lipopiotein. 0thei
functions of apolipopioteins incluue acting as co-enzymes anu as liganus between
the lipopioteins anu the tissues they supply. They aie synthesizeu in the intestines
anu theii "iate iegulation" is ueteimineu by the content of fat available thiough a
peison's uietaiy intake.
Theie aie six classes of apolipopioteins:
+ - incluues the sub-gioups: )K5V )K55V )K5]V )K])
* - incluues the sub-gioups: 26;V 2,==
, - incluues the sub-gioups: !K5V !K55V !K555V !K5]
Classes &, $, anu ) have no impoitant sub-gioups.

3FN?N>?CHFA@:
Because fatty acius alone have tiouble being tianspoiteu thiough aqueous
compaitments insiue the cells, a mechanism must be in place to allow them to get to
wheie they neeu to be, thus enteis the lipopioteins.
The basic stiuctuie of the lipopiotein is below:


Lipopioteins aie uiffeient baseu on the iatio of piotein:lipius, as well as the
paiticulai apopioteins anu lipius that they contain. Thus, lipius can be classifieu
baseu on theii uensitites:
(X3 hIFJIKMHA@FCE LFN?N>?CHFAid Bas the highest piotein:lipiu iatio of all
lipopioteins, is also the lipopiotein with the highest oveiall uensity. Responsible foi
tianspoitation of cholesteiol fiom the peiipheial tissues back to the livei.
5X3 hFACH>DHMFBCH MHA@FCE N>?CHFAid IBL is foimeu when vLBL gets uegiaueu.
Tianspoits anu ueliveis both tiiglyceiiues anu cholesteiol to the livei, wheie they
get uegiaueu to low-uensity lipopioteins.
3X3 hL?TKMHA@FCE LFN?N>?CHFA@id Aie a low-uensity lipopiotein which contain the
highest uensity of cholesteiyl esteis. LBL is engulfeu by taiget cells, anu is a veiy
uangeious lipopiotein that can leau to haiuening of the aiteiies anu subsequently
vasculai pathologies.
]3X3 hGH>E L?TKMHA@FCE LFN?N>?CHFA@i: Contain the seconu highest uensity of
tiiacylglyceiols. Its iole is to uelivei tiiglyceiiues fiom the livei to the peiipheial
tissues.
!(03"/5!+"#&: Aie the laigest of all the lipopioteins, but have the lowest uensity
uue to a high iatio of lipius to pioteins. Also contain the highest content of
tiiacylglyceiols by uensity. Bas a uual iole as it supplies the peiipheial tissues with
tiiglyceiiues anu supplies cholesteiol to the livei.

()$ 2(#1,(1#$ "! )$3$



)$3$ 2G4()$2-2







&-2"#&$#2 "! )$3$ 2G4()$2-2
/>8NH>QDID:>M7: &7@?D:@A7 - )OSCH 5ACH>DFCCHAC *?>NIE>FB
Acute inteimittent poiphyiia is causeu by a ueficiency in the enzyme
poipobilinogen ueaminase, thus pieventing the conveision of poiphobilinogen to
hyuioxymethylbilane. This leaus to an accumulation of poiphobilinogen in the
cytosol, which causes a myiiau of symptoms.
&EDNC?D@ ?U BOSCH FACH>DFCCHAC N?>NIE>FB:
- Nuscle weakness
- Abuominal pain
- Constipation
- Nausea vomiting
- Bypeitension
- Biaphoiesis
- Tachycaiuia
$>HBCDHAC ?U BOSCH FACH>DFCCHAC N?>NIE>FB:
- Nay iequiie hospitalization foi seveie symptoms
- Avoiuance of piecipitating uiugs
- Avoiuance of alcohol
- Piopei uiet

18>N>8NHF8D:>M7: &7E@8Q>JFI@A7 - *?>NIE>FB !SCBAHB $B>MB
This is the most common type of poiphyiia, iesulting fiom low levels of
uiopoiphyiinogen uecaiboxylase.
&FJA@ BAM &EDNC?D@ ?U *?>NIE>FB !SCBAHB $B>MB:
- Blisteiing of the skin in aieas exposeu to sun
- Photosensitivities
- Bypeipigmentation anu hypeitiichosis
- Chionic livei uisease (fibiosis, ciiihosis, inflammation)
$>HBCDHAC ?U *?>NIE>FB !SCBAHB $B>MB:
Since it is a chionic conuition, a multi-uimensional appioach is iequiieu to contiol
the gioup of possible symptoms.
- Avoiuance of excess exposuie to sunlight, iion, anu alcohol

&-2"#&$#2 "! /1#-4$ +4& /G#-3-&-4$ 3$(+*".-23
Puiines aie a key component of cellulai eneigy (ATP, NAB), signaling (uTP, cANP,
cuNP), anu in conjunction with pyiimiuines, the piouuction of BNA anu RNA.
When theie aie pioblems with salvage, synthesis, catabolism, anu metabolism of
puiines anu pyiimiuines, ceitain uisoiueis piesent themselves.

X5&"+X%+& "Z *7+5#% &)3]).%d
.7AEHS4FH@: AF:=8>?7,
+=7:D:7 /H>ANH>8DQ>AFIB8@:AC78@A7 =7CDED7:EF

3H@OIK#EIBA &EAM>?DH: An x-linkeu iecessive uisoiuei, is uue to the absence of
the enzyme 'hypoxanthine-guanine phosphoiibosyl tiansfeiase (BPRT), which is
iesponsible foi conveiting hypoxanthine to inosine monophosphate anu guanine to
guanosine monophosphate. This iesults in the piouuction of excess uiic aciu.
6>0%'.0,: Nental ietaiuation, self-mutilation, aggiession, hypeiuiicemia, gout, anu
choieoathetosis.
)MHAFAH *I?@NI?>FW?@ELC>BA@UH>B@H MHUFOFHAOE: A iaie AT uisoiuei iesulting in
the inability to salvage auenine foi puiine synthesis. This iesults in an accumulation
of auenine, which is oxiuizeu to 2,8-uihyuioxyauenine, which piecipitates in the
uiinaiy tiact, anu causes pioblem iuentical to those of uiic aciu nephiopathy (ie.
Renal colic, infections, anu ienal failuie). This must be manageu with a high fluiu
intake anu puiine iestiiction.

X5&"+X%+& "Z *7+5#% #7!3%"$5X% &0#$(%&5&:
)MHAEL@SOOFAB@H MHUFOFHAOEd Is an AR uisoiuei that causes significant mental
uisabilities, seizuies, anu autistic behaviois. Theie aie incieaseu levels of
succinylaminoimiuazole caiboxamiue iibosiue anu succinylauenosine in the uiine
anu CSF.




X5&"+X%+& "Z *7+5#% !)$)2"35&/:
)MHA?@FAH MHBDFAB@H MHUFOFHAOE,
/E?BMHAELBCH MHBDFAB@H MHUFOFHAOE
)MHA?@FAH XHBDFAB@H XHUFOFHAOEd This ueficiency causes seveie combineu
immunoueficiency uisease. The incieaseu uATP iesults in inhibition of
iibonucleotiue ieuuctase anu unueipiouuction of othei ueoxyiibonucleotiues. This
causes the compiomise of BNA ieplication. Patient will have low RBC's anu WBC
enzyme activity. Stem cell tiansplant anu enzyme ieplacement is essential to
theiapy.
*S>FAH #SOLH?@FMH *I?@NI?>ELB@H MHUFOFHAOE: A iaie AR uisoiuei with seveie T-
cell uysfunction anu the piesence of neuiological symptoms. Patient will uevelop
lymphopenia, thymic ueficiency, iecuiient infection, anu hypouiicemia. These will
cause uevelopmental uelays, spasticity, anu ataxia (ie. CNS uisoiueis)
fBACIFAH "PFMB@H MHUFOFHAOE: Pievents the piouuction of uiic aciu fiom xanthine
anu hypoxanthine. The builuup of xanthine can piecipitate in the uiine, causing
stones, uiinaiy colic, anu 0TI's. Patients shoulu be manageu by maintaining a high
fluiu intake anu taking allopuiinol.

X5&"+X%+& "Z *0+5/5X5#% /%$)2"35&/:
7>FMFAH /?A?NI?@NIBCH &EACIB@H MHUFOFHAOE (Beieuitaiy oiotic aciuuiia): This
ueficiency pievents oiotate phosphoiibosyltiansfeiase anu oiotiuine-S'-
monophosphate uecaiboxylase ieactions. The accumulation of oiotic aciu causes
megaloblastic anemia, oiotic ciystalluiia, nephiopathy, caiuiac malfoimations,
stiabismus, anu iecuiiing infections. Tieatment involves uiiuine supplementation.










.+,("2$ -4(".$#+4,$
.@EB>A7 37B@Q>IDA?:
Lactose is metabolizeu by the enzyme 'lactase', which when ueficient causes uI
uistuibances such as bloating, uiaiihea, etc. The ieason foi this is that lactose is a
uisacchaiiues, which cannot be absoibeu thiough the wall of the small intestine.
When it iemains unuigesteu, it passes thiough the uI system anu causes laige
amount of gas, ciamps, bloating, etc. The piocess by which lactose is conveiteu to
gaseous piouucts (feimentation) will ultimately iaise the osmotic piessuie of the
colon.










!#1,("2$ 3$(+*".-23 +4& &-2"#&$#2
%@@HACFBL Z>SOC?@S>FB - A uefect of fiuctokinase, is a benign conuition wheie the
only symptoms is high levels of fiuctose in bloou anu uiine.
Z>SOC?@H 5AC?LH>BAOH - Is a heieuitaiy ueficiency on aluolase B. Theie is a iesulting
inhibition of both glycogenolysis anu gluconeogenesis because fiuctose-1-
phosphate accumulation uecieases the amount of available phosphate.








T+.+,("2$ 3$(+*".-23 +4& &-2"#&$#2
Theie aie two pioblems that iesult fiom the absenceueficiency of enzymes
involveu in galactose metabolism.
.BLB\C?\FAB@H XHUFOFHAOE: A ueficiency of the enzyme 'galaktokinase', pieventing
the conveision of galactose ! galactose-1-phosphate. Causes galactosemia anu
galactosuiia.
.BLBOC?@HDFB: Causeu by a uiiuyl tiansfeiase ueficiency. Can cause symptoms such
as cataiacts, mental ietaiuation, hepatosplenomegaly, all uue to the accumulation of
toxic substances that iesult fiom the ueficiency.


$()+4". +4& )G/"T.G,$3-+
When ethanol is metabolizeu, theie is an incieaseu iatio of NABB:NAB+, which
causes a shunting of pyiuvate to lactate anu oxaloacetate to malate. This causes an
inhibition of gluconeogenesis anu thus causes hypoglycemia. Because theie is a
shunt away fiom gluconeogenesis anu towaius fatty aciu synthesis, the livei
uevelops fatty changes as well.





()$ 1#$+ ,G,.$
The uiea cycle is iesponsible foi the uegiauation of amino acius into amino gioups.
This cycle piouuces appioximately 9u% of all the uiea founu in the uiine. The
location of the uiea cycle is the cytosol of the livei, with the incoipoiation of the
caibamoyl phosphate being integiateu insiue the mitochonuiia.









()$ ,"#- ,G,.$ O.+,(+($ (#+42/"#(P
Is a metabolic pathway by which lactate that is piouuceu thiough anaeiobic
glycolysis is tianspoiteu fiom the muscle to the livei anu ie-conveiteu to glucose.
This cycle piouuces a net ATP of 2











()$ /$4("2$ /)"2/)+($ /+()%+G
Also known as the BNP shunt, this pathway is necessaiy to the piouuction of iibose-
S-phosphate fiom glucose-6-phosphate foi the synthesis of nucleotiues, the
piouuction of NABPB fiom NABP+ foi the synthesis of fatty acius anu steioius, anu
foi the maintenance of ieuuceu glutathione. The iate limiting enzyme foi this
pathway is "glucose-6-phosphate uehyuiogenase".








TBIS PATBWAY IS
NECESSARY T0
PR0B0CE
REB0CEB
uL0TATBI0NE,
WBICB IS 0SEB T0
BET0XIFY FREE
RABICALS. A
BEFICIENCY WILL
LEAB T0
BEN0LYTIC
ANENIA B0E T0
LACK 0F BEFENCE.

-3/"#(+4( &$#-5+(-5$2 "! +3-4" +,-&2








+3-4" +,-&2R $22$4(-+. 9An 4"4S$22$4(-+.
Amino acius aie biochemical molecules containing an amine gioup, a caiboxylic aciu
gioup, anu a siue chain that vaiies between each amino aciu. They contain nitiogen,
caibon, oxygen, anu hyuiogen.
2B@FO &C>SOCS>H:





5-(+3-42

*87@m=>K: >C 9DB@?D: E@B7M>8D7A:
ZBC &?LSWLH ]FCBDFA@:
- vitamin B
- vitamin E
- vitamin K
- vitamin A
YBCH> &?LSWLH ]FCBDFA@:
- vitamin C
- vitamins B1, B2, BS, Biotin, Pantothenic Aciu
- Pyiiuoxine
- Folic Aciu
- Cobalamin

!+( 2".1*.$ 5-(+3-42:
(G/$ !14,(-"4 &$!-,-$4,-$2 $0,$22$2
vitamin B Incieases intestinal
absoiption of
calcium anu
phosphate
Chiluien get
Rickets, auults get
osteomalacia.
Both can uevelop
hypocalcemic
tetany
Bypeicalcemia anu
all associateu
symptoms of
hypeicalcemia
vitamin E Acts as an
antioxiuant
RBC become fiagile
anu aie at iisk of
hemolysis

vitamin K Involveu in the
piocess of bloou
clotting
Bemoiihages in
neonates

vitamin A Is necessaiy foi
healthy ietinas
Biy skin, night
vision
uistuibances,
immuneueficiency
Alopecia,
aithialgia,
heauache, skin
conuitions


%+($#S2".1*.$ 5-(+3-42:
(G/$ #".$ -4 )$+.() &$!-,-$4,G
vitamin C Impoitant in collagen
synthesis (hyuioxylation),
Belps with iion
absoiption
Scuivy - biuising,
bleeuing gums, anemia,
pooi wounu healing
vitamin B1 (thiamine) 0xiuative uecaiboxylation
of alpha-keto acius, co-
factoi foi tiansketolase in
the BNP shunt
Beiibeii anu Koisakoff's
synuiome, most common
in alcoholics
vitamin B2 (iiboflavin) Is a co-factoi in oxiuation
anu ieuuction ieactions
Chelosis, angulai
stomatosis, coineal
vasculaiization
vitamin BS (niacin) 0seu in ieuox ieactions as
constituent of NAB+ anu
NABP+
Pellagia (4u's) - uiaiihea,
uementia, ueimatitis,
ueath
vitamin BS
(pantothenate)
Involveu in fatty aciu
synthase anu a co-factoi
foi acyl tiansfeis
Auienal insufficiency,
ueimatitis, enteiitis,
alopecia
vitamin B6 (pyiiuoxine) Is a co-factoi in
tiansamination,
uecaiboxylation, anu
tians-sulfuiation
Causeu isoniaziu
ueficiency (neivous
system uistuibances)
Biotin A co-factoi in
caiboxylation ieactions
Beimatitis anu enteiitis,
can be causeu by eating
iaw eggs
Folic Aciu Co-enzyme in caibon
tiansfei in methylation
ieactions, involveu in
synthesis of nitio bases in
BNA anu RNA
Naciocytic anemia, neuial
tube uefects in ueveloping
fetus
Cobalamin Is a co-factoi in
homocysteine methylation
anu methylmalonyl-CoA
activity
Negaloblastic anemia with
neuiological symptoms,
glossitis





!()*$%+ :

%$(5!&

$IF@ C?NFO F@ FDN?>CBAC B@ CIH>H B>H S@SBLLE B IBAMUSL ?U
HCIFO@ RSH@CF?A@ ?A CIH HPBDQ 7AMH>@CBAMFAJ MHUFAFCF?A@
BAM WHFAJ BWLH C? BNNLE CIHD C? C>FO\E @FCSBCF?A@ F@ H@@HACFBL
U?> NFO\FAJ SN B IBAMUSL ?U HB@E N?FAC@ ?A CIH HPBDQ
















*$4$!-,$4,$
This teim uesciibes the iesponsibility of the physician to always act in the best
inteiest of the patient. Beneficence may not always be in place, as a patient's iight
to make theii own uecisions may not always be in theii veiy best inteiest. In this
situation, the physician has a uuty to honoi the uesiies of the patient with iespect to
his oi hei own caie.

4"4S3+.$!-,$4,$
This teim means the physician shall "Bo No Baim", anu is always piioiity #1 when
it comes to meuical ethics anu piactice piinciples.

+1("4"3G
Autonomy iefeis to the patient's iight to make theii own uecisions aftei being
piopeily euucateu anu infoimeu. Whethei a physician believes these uecisions to
be iight oi wiong, they have a uuty to iespect anu honoi the patient's autonomy.

+ /+(-$4([2 +*-.-(G (" 3+V$ &$,-2-"42
A patient's ability to make theii own uecisions is baseu on a few piinciples that must
be in place:
- Patient must be psychologically stable (ie not skeweu by mental illness)
- Patient must be the one who tells you theii uesiies, not the family
- Patient uoes not switch back anu foith between theii wishes (shows
instability of the patient's mentation)
- Patient ieceives complete infoimation of auvantages anu uisauvantages of
tieatment options
- Patient makes theii choice, which is not influenceu by family, fiienus, etc

-4!"#3$& ,"42$4(
Infoimeu consent is when a patient gives the physician the consent to pioceeu with
meuical management. It must be baseu on piopeily infoiming the patient, wheieby
they unueistanu the iisks, benefits, anu alteinative options. Becisions must be
baseu on complete autonomy, not of peisuasion.



%)$4 -2 -4!"#3$& ,"42$4( 4"( #$e1-#$&f
It is fully legal to pioceeu with meuical inteivention without a patient's consent
when any of the following aie piesent:
- Inteivention will be life-saving, such as in the ER
- Patient is not in a mental state to make a uecision (psychosis, intoxication)
- The patient waives theii iight to infoimeu consent
- Theie is a theiapeutic auvantage to not getting infoimeu consent

/+(-$4([2 #-T)( (" ,"4!-&$4(-+.-(G
A patient has the iight to complete confiuentiality, wheieby uisclosing a patient's
infoimation is illegal unless they give you uiiect peimission to uo so.

%)$4 -2 ,"4!-&$4(-+.-(G *#$+,)+*.$f
Theie aie ceitain situations in which it is the physician's iesponsibility to bieach
confiuentiality foi the safety of society anuoi foi the gieatei benefit of the patient.
These instances incluue:
- Theie is the potential foi haim to otheis ($B>B@?UU MHOF@F?A)
- The patient has a high iisk of self-haiming
- Theie is the piesence of a iepoitable infectious uisease
- Patient is eithei suiciual oi homiciual
- Theie is abuse to a chilu oi an eluei

()$ +&5+4,$& &-#$,(-5$
Theie aie numeious ways by which a patient can give theii auvanceu uiiective.
3FGFAJ YFLL@ - the patient infoims the physician whethei they want to be tieateu oi
not shoulu the neeu aiise wheie they cannot communicate this to the physician
">BL )MGBAOHM - while less likely to stanu up in couit, this is an oial iequest given
by the patient to the physician in the past iequesting theii uesiies foi meuical
inteivention



&1#+*.$ /"%$# "! +(("#4$G
The uuiable Powei of Attoiney is a peison uesignateu by the patient to make theii
meuical uecisions in the event that they aie unable to uo so foi themselves.

4$T.-T$4,$L3+./#+,(-,$
Theie aie foui ciiteiia that must be met in oiuei foi a malpiactice suit to be
waiianteu, they aie:
XSCE ! This implies that theie is a physician-patient ielationship that is
establisheu.
XH>HLFOCF?A ! When the physician fails to comply with the stanuaius of caie foi the
patient
XF>HOC !BS@H ! Wheie a patient incuis injuiyuamage that iesulteu fiom the
physician's bieach of uuty, wheie theie aie no othei ciicumstances that may have
causeu the injuiy
XBDBJH@ ! The injuiies suffeieu by the client
** It shoulu be noteu that the absolute most common ieason foi a meuical lawsuit is
a lack of communication oi pooi communication between the physician anu patient.
Establishing a stiong physician-patient ielationship is the best way to pievent a
lawsuit.










!()*$%+ ;

25"&$)$5&$5!&

)NNLFOBCF?A ?U CIH WF?@CBCF@CFOBL HRSBCF?A@ B@ THLL B@ USLLE
SAMH>@CBAMFAJ CIH CENH@ ?U @CSMFH@ BAM CENH@ ?U WFB@ F@
H@@HACFBL ^DS@CK\A?T_ FAU?>DBCF?AQ YIFLH FC F@ CHDNCFAJ C?
U?>HJ? @CSMEFAJ WF?@CBCF@CFO@V FC F@ HB@E C? J>BW NLHACE ?U HB@E
N?FAC@ WE @FDNLE @NHAMFAJ B UHT I?S>@ ?A CIF@ C?NFOQ
















(G/$2 "! 2(1&-$2
!B@HK!?AC>?Le%PNH>FDHACBL - This test is the golu stanuaiu of epiuemiological
testing, wheie two equal gioups aie compaieu wheie one gioup has a changeu
vaiiable
*>?@NHOCFGH - This is also known as a Cohoit, 0bseivational, anu Inciuence stuuy. A
sample is taken anu uiviueu into two gioups baseu on the piesence oi absence of a
iisk factoi. The gioups aie then followeu ovei time to see what shoulu uevelop.
These tests aie veiy time consuming anu expensive, thus less useu.
+HC>?@NHOCFGH - This stuuy chooses a population of samples baseu on eithei the
piesence oi absence of a ceitain iisk factoi. The sample is chosen aftei a uisease
has occuiieu, not befoie it has occuiieu. This test is cheapei anu much fastei to
peifoim than the otheis.
!B@H &H>FH@ - This simply uesciibes what the clinical piesentation looks like in
people who have a ceitain uisease.
!>?@@K&HOCF?ABLe*>HGBLHAOH - This stuuy takes a sample of population at one point
in time, anu looks at the pievalence of uisease anu the pievalence of iisk factois.
This test is optimal foi compaiing two uiffeient cultuies, looking foi associations
between lifestyle choices anu pievalence of uiseases.

$/-&$3-, 9An /+4&$3-,
An epiuemic is seen when theie is an obseiveu inciuence of a paiticulai uisease that
gieatly exceeus the expecteu inciuence, wheieas a panuemic is an epiuemic that is
seen ovei a wiue geogiaphical aiea.

($2( 3$()"&2
$T?K&BDNLH $KCH@C - This test is useu to compaie the means of two gioups of
subjects.
)#"]) - This test is the "analysis of vaiiance", anu is useu to compaie thiee oi
moie vaiiables.
!IFK&RSB>HM - This test compaies the piopoitions of a categoiizeu outcome (2x2
table). With a laige uiffeience between the obseiveu anu expecteu values, theie is
assumeu to be an association between the exposuie anu the outcome.
/HCBK)ABLE@F@ - This test is uone by pooling uata fiom seveial stuuies, which gives
the test a big statistical powei.



(G/$2 "! *-+2
&HLHOCF?A 2FB@ - This type of bias iesults fiom the mannei by which people aie
selecteu anuoi fiom selective losses fiom follow-up stuuies.
"W@H>GH> BAM /HB@S>HDHAC 2FB@ - This bias iesults fiom the uistoition of
measuiement of association by misclassification of the exposeuunexposeu anuoi
uiseaseunon-uiseaseu stuuy subjects.
+HOBLL 2FB@ - Bias uue to inaccuiacies in iecall of past exposuie by people in the
stuuy.
(BTCI?>AH %UUHOC - This bias occuis when a patient uelibeiately changes theii
behavioi because they know they aie being stuuieu.
!?AU?SAMFAJ - This bias occuis as a iesult of the auuition of extianeous factois. Foi
example if a stuuy is looking foi ciiihosis, they finu an association between smoking
anu ciiihosis, anu finu theie to be a stiong association. Then subsequently, the
stuuy shows that some smokeis aie also heavy uiinkeis while some aie not. In this
instance, alcohol is the confounuing factoi. An effective way of contiolling
confounuing is /BCOIFAJ.
3HBM $FDH 2FB@ - This bias has to uo with the time fiame by which uiagnoses anu
tieatments aie examineu.
)MDF@@F?A +BCH 2FB@ - This bias type is uue to the uiffeiences in hospital aumission
iates, which uistoits the iisk iatio.
7ABOOHNCBWFLFCE 2FB@ - This type of bias occuis when the paiticipants puiposely
give uesiiable iesponses, which then leau to the unueiestimation of iisk factois.









2$42-(-5Gl 2/$,-!-,-(Gl //5l 4/5l "#l ##l @:= +((#-*1(+*.$ #-2V
The following table will be the basis foi all calculations ielating to the above topics:

27:ADBD9DBF = @L@ k E
6#),('(P('> 1#'#/0()#, '"# R .- '/4# %.,('(P#, 1(P(1#1 M> *++ '".,# 2". '/4+> "*P# '"#
1(,#*,#5 6&/##)()3 '#,', 2('" "(3" ,#),('(P('> */# M#,'5
2N7EDCDEDBF U =L= k Q
6%#&(-(&('> 1#'#/0()#, '"# R .- '/4# )#3*'(P# 1(P(1#1 M> *++ '".,# 2". '/4+> 1. ).' "*P#
'"# 1(,#*,#5 9.)-(/0*'./> '#,', 2('" "(3" ,%#&(-(&('> */# M#,'5
/>ADBD97 /87=DEBD97 5@I<7 U @L@ k Q
The PPv test is useu to ueteimine the piobability of having an actual conuition when
theie is a positive test iesult. Relateu to pievalence in a uiiect mannei, thus with an
incieaseu pievalence theie is an inciease in the PPv.


47M@BD97 /87=DEBD97 5@I<7 U =L= k E
The NPv is useu to ueteimine the piobability of not having a conuition when the test
iesult is negative.
"==A #@BD> U O@LQPL OEL=P
The 0R ueteimines the inciuence of uisease in people in the exposeu gioups uiviueu
by those in an unexposeu gioup.
"+ l , = States that the factoi being stuuieu is a iisk factoi foi the outcome
"+p, = States that the factoi being stuuieu is a piotective factoi in iespect to the
outcome
"+ q ,, States that no significant uiffeience in outcome in eithei exposeu oi
unexposeu gioup
#7I@BD97 #DAm U o@LO@kQP L =LOEk=Pp
Relative iisk compaies the uisease iisk in people exposeu to a ceitain factoi with
uisease iisk in people who have not been exposeu
+BB8DQ<B@QI7 #DAm U o@LO@kQP a =LOEk=Pp
The attiibutable iisk is the numbei of cases that can be attiibuteu to one iisk factoi

-4,-&$4,$ 9An /#$5+.$4,$
Inciuence is the numbei of new cases of a uisease ovei a unit time, wheieas
pievalence is the total numbei of cases of a uisease (both new anu olu) at a ceitain
point in time. Any uisease tieateu with the sole puipose of piolonging life (ie
teiminal canceis), the inciuence stays the same but pievalence will inciease.
&I?>CKCH>D MF@HB@H@: Inciuence > Pievalence
3?AJKCH>D MF@HB@H@: Pievalence > Inciuence

5+.-&-(G 9An #$.-+*-.-(G
]BLFMFCE is simply a test's ability to measuie what it claims to measuie, wheieas the
>HLFBWFLFCE of a test ueteimines its ability to consistent iesults on iepeateu attempts.



2(+4&+#& &$5-+(-"4
Stanuaiu ueviation is a teim that measuies the vaiiability of iesults.


X 2B@:=@8= &79D@BD>: - 68% of iesults fall within 1SB
Z 2B@:=@8= &79D@BD>:A - 9S% of iesults fall within 2SB
] 2B@:=@8= &79D@BD>:A - 99.7% of iesults fall within SSB





3$+4l 3$&-+4l 3"&$
37@: - The aveiage value
37=D@: - The miuule value
3>=7 - The most common value

Noimal Bell Cuive: /HBA q /HMFBA q /?MH


*?@FCFGHLE @\HTHM giaph inuicates that: /HBA l /HMFBA l /?MH


#HJBCFGHLE @\HTHM giaph inuicates that: /HBA p /HMFBA p /?MH



,1("!! /"-4(2 !"# 2$42-(-5-(G +4& 2/$,-!-,-(G


Shoulu the cutoff point foi a uisease be moveu fiom UBL@H N?@FCFGH C? UBL@H AHJBCFGH,
theie is an inciease in the numbei of positive iesults. This will inciease the
sensitivity of the iesults. This will also ()&/#*,# '"# '/4# %.,('(P# *)1 -*+,# %.,('(P#
numbeis, while 1#&/#*,()3 '"# )40M#/ .- -*+,# )#3*'(P#, *)1 1#&/#*,()3 '"# %.,('(P#
%/#1(&'(P# P*+4#5
Shoulu the cutoff point be iaiseu fiom being false negative to false positive, theie
will be an inciease in specificity, ()&/#*,()3 '"# )40M#/ .- '/4# )#3*'(P#, *)1 -*+,#
%.,('(P#,5

,"4!-&$4,$ -4($#5+. +4& NS5+.1$
These values stiengthen the iesults of a stuuy. Foi statistical significance, the CI
mustn't contain the null value (RR = 1), anu the closei the two numbeis aie
togethei, the moie confiuent you can be that the iesults aie statistically significant.
As fai as the significance of the p-value goes, a statistically significant iesult has a p-
value of <u.uS (this means theie is <S% chance that the iesults obtaineu weie uue
to chance alone).

,"##$.+(-"4 ,"S$!!-,-$4(
Two numbeis that aie between -1 anu +1, it measuies to what uegiee the vaiiables
aie ielateu.
- A numbei of zeio (u) means theie is no coiielation between vaiiables.
- A numbei of +1 means theie is a peifect coiielation (both vaiiables inciease
oi ueciease piopoitionally)
- A numbei of -1 means theie is a peifect negative coiielation (vaiiables move
in opposite uiiections piopoitionally)

+((#-*1(+*.$ #-2V /$#,$4( O+#/P
The ARP measuies the impact of the paiticulai iisk factoi being stuuieu on a
paiticulai population. It iepiesents excess iisk that can be explaineu by exposuie to
a paiticulai iisk factoi.
Calculate the ARP: ARP = |(RR -1)RRj

2(+(-2(-,+. )G/"()$2$2
The statistical hypotheses aie useu to ueteimine whethei oi not theie is an
association between iisk factois anu uisease in a population. They aie the 'ASLL
hypothesis' anu the 'BLCH>ABCFGHc hypothesis.
#SLL (EN?CIH@F@ h(?i - This hypothesis is the 'hypothesis of no uiffeience', meaning
theie is not an association between the uisease anu the iisk factoi.
)LCH>ABCFGH (EN?CIH@F@ h(,i - This hypothesis is the 'hypothesis of some
uiffeience', meaning theie is an association between the uisease anu the iisk factoi.


/"%$#
The powei of a statistical test is the piobability that a test will ieject a false null
hypothesis, meaning it will not make a Type 2 eiioi. With incieaseu sample size
theie is incieaseu powei anu theie is a uecieaseu chances of seeing a type 2 eiioi.

$##"#2
$ENH , %>>?> h!i - A type 1 eiioi mistakenly accepts the expeiimental hypothesis
anu iejects the null hypothesis. This eiioi means that something statistically is seen
that in fact is not theie.
$ENH 1 %>>?> h"i - This type of eiioi occuis when you fail to ieject the null
hypothesis when it is in fact false. This eiioi means you essentially something that
is statistically piesent was in fact misseu.

















!()*$%+ <

*&0!(5)$+0e*&0!("3".0

$IH RSH@CF?A@ B@\HM ?A CIF@ C?NFO OBA >BAJH U>?D B
@C>BFJICU?>TB>M @FDNLH RSH@CF?A C? B RSH@CF?A CIBC HPNHOC@
E?S C? O?DWFAH DBAE B@NHOC@ ?U DHMFOFAH FA DB\FAJ CIH WH@C
OI?FOHQ $IH IFJIH@CKEFHLM FAU?>DBCF?A FAOLSMH@ N@EOIFBC>FO
NIB>DBO?L?JE B@ THLL B@ BLL ?U CIH NH>@?ABLFCE MF@?>MH>@Q















21*2(+4,$ &$/$4&$4,$ +4& +*12$
Theie is a big uiffeience between substance uepenuence anu substance abuse.
&SW@CBAOH MHNHAMHAOH is a pattein of substance use that involves at least S out of 7
ciiteiia, they aie:
- Theie aie uecieaseu social, occupational, oi iecieational activities because of
the substance use
- Patient has uevelopeu toleiance to substance
- Patient expeiiences withuiawal symptoms when iefiaining fiom use
- Theie is a chionic uesiie to cut back oi stop use
- Patient will spenu excess time anu eneigy in tiying to attain theii substance
- The substance is taken in amounts much laigei than intenueu
- Continuation of use uespite the knowleuge of its haimful effects
When any thiee of the pievious points aie piesent, the patient is uiagnoseu with
substance uepenuence.
&SW@CBAOH BWS@H is a pattein of substance use that causes significant social
impaiiment anuoi uistiess. The uiagnosis of substance abuse is maue when theie
aie any of the following:
- Excess anu iecuiient use that causes failuie to fulfill majoi obligations such
as going to woik, taking caie of kius, etc
- Chionic anu iecuiient use of substance in situations that aie hazaiuous
- Recuiient pioblems with the law uue to the uiug abuse
- Peisistent use uespite the knowleuge of its uangeious effects

()$ 3"2( ,"33"4 (G/$2 "! 21*2(+4,$ +*12$
Theie aie many uiffeient types of uiugs, anu they all have uiffeient kinus of
signssymptoms anu uiffeient uegiees of withuiawal seveiity. The uiugs anu
substances most commonly useu anu abuseu incluue:
- Alcohol
- Amphetamines
- Baibituiates anu Benzouiazepines
- Caffeine
- Cocaine
- LSB
- Naiijuana
- Nicotine
- 0pioius (heioin, oxycouone, moiphine, etc)

The following is a list of the most common uiugs, theii piimaiy signssymptoms,
anu the common finuings of withuiawal
21*2(+4,$ 2-T42 "! -4("0-,+(-"4 %-()&#+%+.
2G3/("32
+.,")". Bisinhibition, sluiieu
speech
Tiemoi, tachycaiuia,
seizuie, BT's
+3/)$(+3-4$2 Psychomotoi agitation,
myuiiasis
Bepiession, lethaigy,
excessive sleep
*+#*-(1#+($2 Seuation, iespiiatoiy
uepiession
Anxiety, caiuiovasculai
collapse
*$4\"&-+\$/-4$2 Seuation, iespiiatoiy
uepiession (not as seveie
as baibituiates)
Anxiety, seizuie, tiemoi
,",+-4$ Psychomotoi agitation,
miosis, paianoya, NI
Fatigue, uepiession,
excessive sleep
.G()$#T-, +,-&
&-$()G.+3-&$ O.2&P
visual anu auuitoiy
hallucinations
No withuiawal symptoms
3+#-61+4+ Euphoiia, incieaseu
hungei, uelayeu iesponse
time
No withuiawal symptoms
"/-"-&2 CNS uepiession, miosis,
seizuie
Nausea, vomiting, uI
uistuibances, piloeiection
/)$4,G,.-&-4$ Psychomotoi agitation,
nystagmus, belligeience
Bepiession, memoiy loss

()$ &+4T$#2 "! +.,")". %-()&#+%+.
Alcohol withuiawal is a potentially life-thieatening event, anu iequiies meuical
supeivision anu hospitalization. Nanagement of alcohol withuiawal involves
benzouiazepines that aie tapeieu giauually ovei a few uays as the symptoms
iesolve anu the patient stabilizes.
(H7 AB@M7A >C @IE>H>I KDBH=8@K@I @87R
)OSCH YFCIM>BTBL &EAM>?DH - 0ccuis fiom 24-48hi aftei the patient's last uiink,
AF?NB>?A D:EI<=7: $>HD?>@V MFBNI?>H@F@V @HFaS>H@V IENH>>HULHPFB.
)LO?I?LFO (BLLSOFABCF?A@ - 0ccuis fiom 24-72hi aftei patient's last uiink,
AF?NB>?A D:EI<=7: (BLLSOFABCF?A@ hW?CI BSMFC?>E BAM GF@SBLiQ
XHLH>FSD $>HDHA@ - 0ccuis 2-7 uays aftei patient's last uiink, AF?NB>?A D:EI<=7:
(BLLSOFABCF?A@V FLLS@F?A@V MFBNI?>H@F@V CBOIEOB>MFBV IENH>CIH>DFB. This stage of
alcohol withuiawal caiiies the possibility of being fatal.



3+4+T$3$4( "! "/-"-& -4("0-,+(-"4
Nany uiugs fall unuei the categoiy of 'opioius'. Biugs such as moiphine, heioin,
oxycouone, anu many otheis. Symptoms aie veiy similai in that they cause
seuation, constipation, etc.
3@:@M7?7:B >C D:B>JDE@BD>:L>978=>A7 DA @A C>II>KAR
#BL?P?AHe#BLC>HP?AH - This is a meuication given in the ER when patient is
suspecteu of opioiu intoxication, it acts by competitively inhibiting the opioiu
ieceptois.
/HCIBM?AH - A contioveisial uiug, methauone is useu to manage patients who aie
unueigoing heioin uetoxification because it is long lasting anu is goou foi long-teim
management.

3+6"# &$/#$22-5$ &-2"#&$#
Najoi uepiessive uisoiuei is a seiious conuition chaiacteiizeu by seveial specific
signs anu symptoms. In geneial, the best tieatment foi an episoue of majoi
uepiession is an SSRI anti-uepiessant meuication. If a patient is expeiiencing theii
fiist bout of uepiession, it is auviseu to keep them on theii meuication foi at least 6
months. If it is theii seconu oi moie bout of uepiession, they shoulu be kept on
theii anti-uepiessant on an ongoing basis. Biagnosis iequiies that theie aie
symptom-fiee peiious of at least two months in between each episoue.
The uiagnosis of uepiession is maue when any of the following FIvE aie piesent foi
at least TW0 weeks:
- &LHHN XF@CS>WBAOH@ (patient may sleep too little oi too much)
- 3?@@ ?U 5ACH>H@C (inteiest lost in things that they pieviously enjoyeu)
- ZHHLFAJ ?U .SFLC (these guilty feelings aie usually unwaiianteu)
- %AH>JE (loss of eneigy, which iesults in a loss of uiive to uo othei things they
pieviously enjoyeu)
- 3?@@ ?U !?AOHAC>BCF?A
- )NNHCFCH !IBAJH@ (most of the time the patient has a L0SS of appetite, but
they may also get an inciease in appetite)
- *@EOI?D?C?> +HCB>MBCF?A (iesults in sloweu mentation, ielateu to loss of
concentiation)
- &SFOFMBL 5MHBCF?A (always inquiie about suiciue, it is not going to inciease
the patient's iisk of committing suiciue)
The populai mnemonic foi factois of uepiession is: 2-T $ ,+/2. ZHDBLH@ l /BLH@
r Z?> MHN>H@@F?A CIBC F@AcC IHLNHM TFCI &&+5 ?> ?CIH> BACFKMHN>H@@BAC@V %!$
@I?SLM WH C>FHMQ %!$ F@ BL@? CIH DBABJHDHAC ?U OI?FOH U?> DB`?> MHN>H@@F?A FA B
N>HJABAC NBCFHACQ
21-,-&$
Suiciue is a big concein in uepiesseu patients, anu any patient who seems to have a
uepiesseu moou shoulu be askeu about suiciue. It is impoitant to ask if they have
thought about it, if they have thought of how they woulu uo it, anu if they have a
plan. It is highly impoitant to inquiie about this, as asking WILL N0T inciease the
iisk of them killing themselves.
Women attempt suiciue moie often than men, howevei men aie moie likely to
succeeu. The ieason foi this is because women often use less violent measuies such
as pills, while men take moie violent measuies such as guns anu hanging.
+F@\ UBOC?>@ U?> @SFOFMH:
- Piioi attempts
- Piesence of planlethality of plan (gun vs. pills, etc)
- Cuiient meuical illness
- Alcohol oi uiug uepenuence
- Cuiiently taking thiee oi moie piesciiption uiugs
- Lack of a social ciicle (few fiienus, no family, no spouse)

&G2()G3-+
Bysthymia is a chionic moou uisoiuei that is similai to uepiession, howevei it is an
ongoing, less seveie type of uepiession. It has fewei symptoms than majoi
uepiession, but is much longei lasting. At least 7S% of those with uysthymia have a
co-moibiu psychiatiic uisoiuei such as anxiety, alcoholism, etc.

&$.$#-13 9An &$3$4(-+
These aie two teims often confuseu in meuicine, anu especially on the 0SNLE
exams.
XHLH>FSD is a state of uecieaseu attention span, hallucinations anu illusions, anu
cognitive uysfunctions. The key to making the uiagnosis of ueliiium is that levels of
functionality go in anu out (waxing anu waning), anu has an acute onset. 0n the
othei hanu, MHDHACFB is a uisease with multiple cognitive uefects that uevelop
slowly ovei time. The key to uiagnosing uementia is that the patient is fully
conscious but has cognitive uefects.


*-/".+# &-2"#&$#
Bipolai uisoiuei is a moou uisoiuei wheie a patient expeiiences both mania anu
uepiession. Theie aie two types of bipolai uisoiuei (types 1 anu 2), wheie type 1 is
mania anu type 2 is hypomania. Regaiuless of type, in oiuei to make a uiagnosis of
a manic episoue the patient must have ceitain symptoms piesent foi at least 1
WEEK.
The ciiteiia foi a manic episoue aie:
- Easy uistiactibility
- Insomnia (the patient can go foi uays without sleeping)
- uianuiosity (the patient has an unusually exaggeiateu sense of self-esteem)
- Flight of Iueas
- Incieaseu activity (patient will uo numeious activities in one uay)
- Piessuieu speech (fast, non-sensical, etc)
- Thoughtlessness (patient will uo things without fully thinking about what
they aie uoing fiist)
At least S of these must be piesent to make a uiagnosis of a manic episoue.
Nania causes seveie social impaiiment anu occupational uysfunction. Bypomania is
similai to a manic episoue except theie is no impaiiment to the patient in any of
theii uay-to-uay functioning.
$IH M>SJ ?U OI?FOH U?> 2FN?LB> MF@?>MH> DBABJHDHAC F@ 35$(57/.

/$#2"4+.-(G &-2"#&$#2
These aie peivasive, fixeu, anu inappiopiiate patteins of ielating to otheis, causing
social anu occupational impaiiment. Patients with peisonality uisoiueis uo not
seek help foi theii uisoiuei because they aie not awaie that they aie the cause of
theii own pioblems.
Theie aie thiee categoiies of peisonality uisoiueis: Clustei A, Clustei B, Clustei C
!LS@CH> ) MF@?>MH>@: Paianoiu, Schizoiu, Schizotypal
!LS@CH> 2 MF@?>MH>@: Bistiionic, Naicissistic, Antisocial, Boiueiline
!LS@CH> ! MF@?>MH>@: Avoiuant, 0bsessive-Compulsive, Bepenuent, Passive-
Aggiessive


,.12($# + /$#2"4+.-(G &-2"#&$#2
*B>BA?FM - This patient uoes not tiust otheis, is suspicious of eveiything, anu
believes all of theii pioblems aie causeu by otheis.
&OIFa?FM - This patient will have a long histoiy of voluntaiily avoiuing social
situations. Theie is no psychosis associateu with the schizoiu peisonality uisoiuei.
&OIFa?CENBL - This patient has an ouupeculiai appeaiance, has magical thoughts
anu an ouu pattein of behavioi. Theie is no pscyhosis with the schizotypal
peisonality uisoiuei.

,.12($# * /$#2"4+.-(G &-2"#&$#2
(F@C>F?AFO - This patient is an extioveit, is sexually piovocative, anu veiy emotional.
#B>OF@@F@CFO - This patient has a sense of entitlement anu lacks empathy foi otheis.
)ACF@?OFBL - This patient iefuses to accept the iules of society, shows no concein foi
theii own actions, anu shows no iemoise foi bau behavioi. This uisoiuei is
associateu with conuuct uisoiuei in chiluhoou.
2?>MH>LFAH - This patient has eiiatic behavioi, impulsiveness, anu mini psychotic
episoues. Look foi self-mutilation anu othei moou uisoiueis.

,.12($# , /$#2"4+.-(G &-2"#&$#2
)G?FMBAC - This patient is sensitive to iejection anu timiu, thus socially withuiawn.
They also feel infeiioi to otheis foi no appaient ieason.
"W@H@@FGHK!?DNSL@FGH - This patient is a peifectionist, oiueily, stubboin, anu
inuecisive. This is not the same as obsessive-compulsive uisoiuei (0CB).
XHNHAMHAC - This patient allows anu wants otheis to make uecisions foi them,
ielateu to a lack of self-confiuence.
*B@@FGHK)JJ>H@@FGH - This patient has "outwaiu compliance with innei uefiance".






+40-$(G &-2"#&$#2
Anxiety uisoiueis aie chaiacteiizeu by subjective anu physical manifestations of
feai. $IH @EDNC?D@ B>H @FDFLB>: Tiemoi, Palpitations, Biaphoiesis, Bizziness, uI
uistuibances, 0iinaiy symptoms.

The common anxiety uisoiueis aie:
- Panic Bisoiuei
- Phobias
- 0bsessive-Compulsive Bisoiuei (0CB)
- ueneializeu Anxiety Bisoiuei
- Post-tiaumatic Stiess Bisoiuei (PTSB)

*BAFO XF@?>MH> - Panic attacks that occui appioximately twice pei week, last
appioximately Su minutes, anu piesent with symptoms similai to an NI. Patients
often have a feai of anothei attack in-between each episoue. Nanagement of panic
uisoiuei is SSRI's, with possible benzouiazepines foi acute tieatment.
*I?WFB@ - Specific phobias an iiiational feai of specific objects, such as spiueis,
snakes, etc. A social phobia is an exaggeiateu feai of social oi enviionmental
situations (the most common social phobia is public speaking). Nanagement is
uesensitization, can use beta-blockeis foi shoit-teim contiol of autonomic
symptoms.
"W@H@@FGHK!?DNSL@FGH XF@?>MH> h"!Xi - Patient expeiiences iecuiiing intiusive
feelings, thoughts, anu images which cause anxiety that is ielieveu in pait by
peifoiming iepetitive actions (compulsions). Patients iealize that theii actions aie
iiiational anu uesiie to be helpeu. SSRI's aie mainstay of management.
.HAH>BLFaHM )APFHCE XF@?>MH> - Patient expeiiences peisistent symptoms of
anxiety foi at least 6 months. The symptoms aie unielateu to any specific peison oi
situation. Seen in women > men.
*?@CK$>BSDBCFO &C>H@@ XF@?>MH> - Is a conuition that affects someone who has been
thiough a catastiophic event (classically a wai veteian). The patient expeiiences
hypeiaiousal (anxiety, sleeplessness, intiusive memoiies) anu withuiawal
(flatteneu affect, numbing, suivivoi's guilt). These @EDNC?D@ DS@C WH N>H@HAC U?>
BC LHB@C , D?ACI foi a uiagnosis of PTSB, if @EDNC?D@ B>H LH@@ CIBA , D?ACI, the
uiagnosis is )OSCH &C>H@@ XF@?>MH> (ASB).



2,)-\"/)#$4-+
Schizophienia is chaiacteiizeu by peiious of psychotic featuies anu uistuibing
behavioi that lasts a minimum of 6 months.
$ENH@ ?U @OIFa?NI>HAFB FAOLSMHd
- Paianoiu
- Bisoiganizeu
- Catatonic
- 0nuiffeientiateu
- Resiuual

*BCFHAC@ HPNH>FHAOHd
- Ballucinations (auuitoiy, visual)
- 0nceitainty
- Blunteu affect
- Loose associations

*?@FCFGH @EDNC?D@ hCIFAJ@ CIBC B>H BMMHMi FAOLSMHd
- Ballucinations
- Belusions
- Behavioial changes
- Loose associations
#HJBCFGH @EDNC?D@ hCIFAJ@ CIBC B>H >HD?GHM U>?D CIH NH>@?Ai FAOLSMHd
- Affect
- Notivation
- Appiopiiate thought patteins
- Socially withuiawn






2"3+("!"#3l !+,(-(-"12l +4& 3+.-4T$#-4T &-2"#&$#2

&?DBC?U?>D XF@?>MH>@
Somatofoim uisoiueis aie chaiacteiizeu by physical symptoms without any oiganic
cause. Those with this conuition aie not malingeiing, aie not uelusional, anu tiuly
believe they have a physical pioblem.
&?DBC?U?>D XF@?>MH>@ FAOLSMH:
- Somatization uisoiuei
- Conveision uisoiuei
- Bypochonuiiasis
- Bouy Bysmoiphic uisoiuei
- Pain uisoiuei
- 0nuiffeientiateu Somatofoim uisoiuei

&?DBCFaBCF?A XF@?>MH> - Patient with histoiy of multiple somatic complaints ovei
seveial yeais, they must incluue: 4 pain symptoms, 2 uI symptoms, 1 sexual
symptom, anu 1 pseuuoneuiologic symptom.
!?AGH>@F?A XF@?>MH> - Patient expeiiences an abiupt, uiamatic loss of motoi oi
sensoiy function. Nost commonly the patient expeiiences paialysis, seizuies,
paiesthesias, anesthesias, anu visual pioblems.
(EN?OI?AM>FB@F@ - These patients have an exaggeiateu concein that they have
illnesses uespite being tolu iepeateuly that theie is no cause foi concein. Nust
occui foi at least a 6-month peiiou foi this uiagnosis.
2?ME XE@D?>NIFO XF@?>MH> [ The patient has an excessive anu possibly obsessive
focus on a minoi oi possibly imagineu physical uefect.
*BFA XF@?>MH> - Pain that is not explaineu by any physical pioblem, often co-exists
with anothei meuical pioblem. If lasting < 6 months, it is an acute pain uisoiuei, if
lasting > 6 months it is a chionic pain uisoiuei.
7AMFUUH>HACFBCHM &?DBC?U?>D XF@?>MH> - This is the uiagnosis when the peisistent
physical symptoms uon't meet ciiteiia foi any of the othei uisoiueis. The most
common pioblems falling unuei this umbiella aie: Fatigue, uIu0 symptoms,
appetite changes.


ZBOCFCF?S@ XF@?>MH>@
A patient with factitious uisoiuei consciously cieates theii symptoms in oiuei to
assume the iole of the sick patient so they can get meuical attention (the motivation
howevei is unconscious). Theie aie two categoiies of factitious uisoiuei, they aie:
/SAOIBS@HAc@ &EAM>?DH anu /SAOIBS@HAc@ &EAM>?DH WE *>?PE.
/SAOIBS@HAc@ &EAM>?DH - Patient will have a chionic histoiy of multiple hospital
aumissions, as well as a histoiy of willingness to ieceive invasive pioceuuies, even
when not waiianteu.
/SAOIBS@HAc@ WE *>?PE - This is when a chilu is ill because of the paient.

/BLFAJH>FAJ XF@?>MH>@
Patients with malingeiing uisoiuei consciously simulate oi exaggeiate a physical oi
mental illness foi an obvious gain (Noney, Caie, Avoiuance of woik). This patient
will avoiu tieatment, as opposeu to those with factitious uisoiuei. 0nce the patient
ieceives the gain they aie seeking, the symptoms will iesolve.

2.$$/
0nueistanuing wave patteins anu activities uuiing each stage of sleep aie impoitant
aspects of unueistanuing the sleep cycle.
+K@m7 KDBH 7F7A >N7:- 2HCB TBGH@, seiotonin stimulates the iape nuclei to inuuce
sleep
+K@m7 KDBH 7F7A EI>A7= - )LNIB TBGH@
2B@M7 X - This is the stage of "light sleep". This stage is shoit, lasting appioximately
S% of all sleep time, $IHCB TBGH@ aie pieuominant.
2B@M7 Z - This is ueepei sleep, lasting appioximately 4S% of all sleep time.
Pieuominantly see @LHHN @NFAMLH@ BAM b O?DNLHPH@.
2B@M7 ] - This is the ueepest sleep, but is non-REN. Lasts appioximately 2S% of all
sleep time, anu is chaiacteiizeu by XHLCB TBGH@. *This is the stage at which chiluien
will expeiience enuiesis anu beu-wetting.
2B@M7 ^ - This is REN sleep. The patient will be uieaming anu lose all muscle tone.
Theie aie pieuominantly 2HCB TBGH@ uuiing the REN sleep cycle.



+34$2-+
Amnesia can occui foi many ieasons, incluuing anesthesia, uiug use, olu age, heau
injuiies, alcoholism, etc. The two foims of amnesia aie: )ACH>?J>BMH anu
+HC>?J>BMH.
)ACH>?J>BMH - This peison will be unable to iemembei anything aftei occuiiing
aftei the inciuent that causeu theii amnesia, theiefoie they cannot foim any new
memoiies.
+HC>?J>BMH - This peison will be unable to iemembei things that occuiieu befoie
the causative factoi of theii amnesia.

2.$$/ +/4$+
Sleep apnea is a seiious conuition wheie a peison has peiious of cessation of
bieathing while asleep. This may last fiom a few seconus to minutes, anu may occui
up to Su times pei houi. The two types of sleep apnea aie "Cential" anu
"0bstiuctive".
!HAC>BL @LHHN BNAHB - this type of apnea occuis uue to a lack of iespiiatoiy uiive
fiom the CNS.
"W@C>SOCFGH @LHHN BNAHB - this type of apnea is usually causeu by excessive weight,
which causes obstiuction anu physical blockage of bieathing. Nanagement is
weight loss anu CPAP machine. If these fail suigeiy may be iequiieu.
In obstiuctive sleep apnea, a patient will often complain of excessive uaytime
sleepiness, anu the spouse will complain of veiy louu snoiing.

4+#,".$/2G
A conuition wheie someone falls asleep suuuenly without waining, anu may
expeiience cataplexy (suuuen collapse while they aie still awake). They fall into
REN sleep upon falling asleep. Nanage these patients fiist with scheuuleu uaytime
naps, anu if that uoesn't woik use a stimulant such as methylpheniuate.





$+(-4T &-2"#&$#2
The two common eating uisoiueis aie BA?>HPFB AH>G?@B anu WSLFDFB AH>G?@B.
)A?>HPFB #H>G?@B - This is a uangeious uisease wheie patients uiet excessively in
an attempt to lose weight anu stay skinny. They have a uistoition to theii bouy
image, which is a uiiving foice behinu the excessive uieting. Common auveise
effects that occui incluue: )DHA?>>IHBV %LHOC>?LECH MF@CS>WBAOH@, anu seveie cases
can iesult in OB>MFBO HCF?L?JFH@. Nanagement is weight gain anu if patient's weight
is too low, hospitalization may be iequiieu. A BNI of less than 19 is woiiisome of
anoiexia.
2SLFDFB #H>G?@B - These patients have a noimal bouy weight, with the main
pioblem being oveieating (bingeing) anu then puiging (laxatives, vomiting, etc).
Common finuings incluue enlaigeu paiotiu glanus, enamel eiosion, biuiseu fingeis
(fiom sticking them in the mouth), esophageal vaiices causeu by the piessuie of
vomiting.

2(#1,(1#+. ()$"#G "! ()$ 3-4&
This is a concept uevelopeu by Fieuu, anu it uesciibes the thiee theoiies that
encompass the human minu. These thiee theoiies aie the: 5MV &SNH>HJ?V anu %J?.
(H7A7 AB8<EB<87A H@97 =DCC787:B C<:EBD>:Al BH7F @87R
IM - The Iu is iesponsible foi sexual uiges, aggiession, anu othei piimal uiges.
&SNH>HJ? - The supeiego encompasses the pait of youi minu that tells you to
contiol youi piimal uiges, it acts as youi conscience.
%J? - The ego is the theoiy that helps the minu ueal with the conflict between the
'wants' of the Iu, anu the conscience of the supeiego.

(G/$2 "! ,"4&-(-"4-4T
The two types of conuitioning we must know foi the 0SNLE aie '!LB@@FOBL
!?AMFCF?AFAJ' anu '"NH>BAC !?AMFCF?AFAJc.
!LB@@FO !?AMFCF?AFAJ - This is a type of conuitioning that elicits a iesponse because
the stimulus is paiieu with the unconuitioneu stimulus. The classic example is
Pavlov's uog, who leaineu to link the sounu of a bell with a tieat, thus each time the
bell iang the uog woulu salivate as a iesult of this conuitioning.
"NH>BAC !?AMFCF?AFAJ - This is a type of conuitioning that occuis because theie was
a iewaiu given foi peifoiming a ceitain act. The two types of opeiant conuitioning
aie Positive Reinfoicement anu Negative Reinfoicement.
*?@FCFGH +HFAU?>OHDHAC - A iewaiu piouuces an action
#HJBCFGH +HFAU?>OHDHAC - Removing a negative stimulus will elicit action




















&$5$."/3$4(+. 3-.$2("4$2 -4 -4!+4(2
+M7 T8>AA 3>B>8 !D:7 3>B>8 .@:M<@M7 2>ED@IL,>M:DBD>:
Newboin 3>8> 87CI7Jl
M8@AN 87CI7J

2 months Bolus heau up Swipes at
objects
Coos Social smile
4 months Rolls fiont to
back
T8@ANA
"Q;7EBA
0iients to
voice
Laughs
6 months Rolls fiom
back to fiont,
ADBA <N8DMHB
Tiansfeis
objects
Babbles &797I>NA
AB8@:M78
@:JD7BFl AI77NA
@II :DMHB
9 months Ciawls, pulls
to a stanu
/D:E78 M8@ANl
eats with
fingeis
4>:SAN7EDCDE
K>8=A
Waves gooubye,
iesponus to name
12 months 2B@:=A >:
>K:
3@B<87
ND:E78 M8@AN
2N7EDCDE
K>8=A
q?@?@r
Recognizes
pictuies in a
bookmagazine
1S months %@ImA 0ses a cup Speaks 4-6
woius
(H8>KA B7?N78
B@:B8<?
18 months Thiows a ball,
walks up the
staiis
0ses spoon
foi soliu foous
Names
common
objects
*7MD:A B>DI7B
B8@D:D:M
24 months Staits
iunning, can
go up anu
uown staiis
0ses spoon
foi semi-
solius
2N7@mA ZS
K>8=
A7:B7:E7
Can follow a 2-
step commanu
S6 months Can iiue a
tiicycle
Can eat neatly
with utensils
2N7@mA ]S
K>8=
A7:B7:E7
Knows fiist anu
last names


/1*$#(+. ,)+4T$2
3+.$2 !$3+.$2
Testiculai enlaigement - 11.S yis Bieast buus - 1u.S yis
uenitals inciease in size Pubic Baii uiowth Begins
Pubic Baii uiowth Begins Lineai uiowth Spuit - 12 yis
Peak uiowth Spuit - 1S.S yis Nenaiche - 12.S yis




#$!.$0$2 /#$2$4( +( *-#()
#$!.$0 2(+#(2 $4&2 ,)+#+,($#-2(-,2
3"#" #$!.$0
Biith ~ 2 months Suuuen shift in
positions causes the
legs anu heau to extenu
while the aims jeik up
anu out with the palms
up anu the thumbs
flexeu. Then the aims
aie biought togethei
anu hanus aie clencheu
into fists
%+.V-4T
#$!.$0
Biith ~ 6 weeks When the sole is
toucheu, the legs will
move in a walking-
motion, though the
baby cannot walk
#""(-4T #$!.$0
Biith ~4 months Infant tuins the heau
towaiu the siue wheie
the cheek gets stiokeu
("4-, 4$,V
#$!.$0
1 month 4 months When chilu's heau is
tuineu to one siue, the
aim of the same siue
will stiaighten anu the
opposite aim will flex
/+.3+# T#+2/
#$!.$0
Biith ~6 months Anything in the hanu oi
stioking the hanu of the
baby will cause a the
fingeis to benu anu the
hanu to giasp at the
object
T+.+4( #$!.$0
Biith ~ 6 months Stioking skin on siue of
back causes bouy to
swing to that siue
*+*V-4 #$!.$0
Biith ~ 1 yeai Noie common in
piematuie infants,
piessuie to palms cause
vaiying iesponses.






()$ 2(+T$2 "! &$+.-4T %-() &$+()
Theie aie FIvE stages of uealing with ueath, they can be iemembeieu with the
mnemonic "X)2X)".
XHAFBLV )AJH>V 2B>JBFAFAJV XHN>H@@F?AV )OOHNCBAOH

,)+4T$2 2$$4 -4 ()$ $.&$#.G
Theie aie a few changes that occui with auvanceu age that aie seen almost
unifoimly acioss the geiiatiic population, they incluue:
- Change in sleep patteins, namely less neeu foi sleep, uecieaseu REN sleep,
moie fiequent awakening thioughout the night.
- Sexual changes such as longei iefiactoiy peiiou, uelayeu ejaculation, slowei
onset of eiection (in men). Females fiequently expeiience thinning anu
uiyness of the vagina.
- Neuical conuitions such as uegeneiative uiseases aie quite common














!()*$%+ ,=

5//7#"3".0

) @SWKOBCHJ?>E ?U DFO>?WF?L?JEV FDDSA?L?JE F@ GH>E IFJIK
EFHLMQ $IH>H B>H FDN?>CBAC O?AOHNC@ E?S DS@C \A?TV BAM BLL
?U CIH FDDSA?L?JFO MF@?>MH>@ B>H UBF> JBDH ?A CIH &CHN ,
HPBDQ
















-3314"."TG

/+22-5$ 9An +,(-5$ -3314-(G
/@AAD97 -??<:DBF ! This foim of immunity occuis when theie is a tiansfei of
active humoial immunity in the foim of piefoimeu anitbouies fiom one host to
anothei. This foim of immunization is useu when theie is a iisk of infection anu not
enough time foi the bouy to uevelop an ample immune iesponse. This pioviues fast
but shoit-liveu piotection.
Examples: Nateinal Ig's passeu to baby, patient given iabies vaccine when bitten by
a bat.
+EBD97 -??<:DBF ! This foim of immunity uevelops thiough its own piouuction of
antibouies in iesponse to exposuie to an antigen, pathogen, oi vaccine. This gives
the oiganism slow-onset but long-teim piotection.

()$ ,"3.$3$4( /+()%+G
Besigneu to piotect against giam negative bacteiia, is activateu by immunoglobulin
u oi N in the classic pathway, anu activateu by suiface miciobes in the alteinate
pathway.

Z7#!$5"# "Z $(% !"/*3%/%#$ Z)!$"+&:
,Xl ,Zl ,]l ,^ ! Neutialization of viial paiticles
,]Q ! 0psonization
,]@l ,b@ ! Anaphylaxis
,b@ ! Neutiophil Chemotaxis
,bQS,d ! NAC cytolysis

X%Z5!5%#!5%& "Z $(% !"/*3%/%#$ *)$(Y)0:
,X $AB78@A7 -:HDQDB>8 =7CDED7:EF ! get oveiactive complement pathway anu this
leaus to heieuitaiy angioeuema
,] =7CDED7:EF ! iespiiatoiy tiact infections + iecuiient pyogenic infections
,`S,W =7CDED7:EF ! causes Neisseiia bacteiemia
&7E@F +EE7I78@BD:M !@EB>8 =7CDED7:EF ! causes paioxysmal noctuinal uyspnea

()$ 3+6"# )-2(","3/+(-*-.-(G ,"3/.$0 O3),P
The NBC is genomic iegion founu in veitebiates that encoues NBC molecules, anu
these molecules play a veiy impoitant iole in immune function. Theie aie two types
of NBC (ie NBC 1 anu NBC 2).
(H7 3), - ! Contains 1 polypeptiue + a "2-micioglobulin, anu contains S genes
(gene A, B, anu C).




The NBC II ! Contains 2 polypeptiues, anu an alpha anu a beta chain. Bas S genes
(BP, BQ, anu BR). This NBC II is the main component in oigan iejection.


+4(-*"&G !14,(-"42







!14,(-"4 "! ()$ +4(-*"&G
The vaiiable paits (vB, vL) will iecognize uiffeient antigens, while the constant
paits ("C") will fix the complement.
Fc Fiagment ! This fiagment is O?A@CBAC, has a OB>W?IEM>BCH siue-chain, is
O?DNLHDHAC WFAMFAJ (Igu anu IgN only), anu has a OB>W?PE CH>DFABL.
)ACFW?ME BFM@ FA:
1. Complement activation via the membiane attack complex
2. 0psonization (ie aius in phagocytosis)
S. Neutialization (by pieventing the auheience of bacteiia)

21*(G/$2 "! -3314"T."*1.-42
0se the mnemonic "uANEB" to iemembei anu keep all of the immunoglobulin
infoimation oiganizeu.
-??<:>MI>Q<ID: T O-MTPR
- Is the most abunuant of all the immunoglobulin's
- Is the main antibouy iesponsible foi the seconuaiy antibouy iesponse
- 0nly Ig that can cioss the placenta
- Fixes complement, opsonizes bacteiia, anu neutializes toxins
-??<:>MI>Q<ID: + O-M+PR
- Founu in bouily secietions
- Pievents bacteiial attachment to mucous membianes
-??<:>MI>Q<ID: 3 O-M3PR
- Responsible foi the piimaiy antibouy iesponse
- Is the antigen ieceptoi on B cell suifaces
-??<:>MI>Q<ID: $ O-M$PR
- Bas the lowest concentiation of all Ig's
- Responsible foi piotection against woims
- Responsible foi mast cell anu basophil gianule ielease in type 1
hypeisensitivities

-??<:>MI>Q<ID: & O-M&PR
- Founu on B cell suifaces

+4(-*"&G /#"&1,(-"4










(S,$.. +,(-5+(-"4
The following steps aie iequiieu foi helpei T-cell activation:
1. The antigen-piesenting cell engulfs the viial paiticle
2. The viial paiticle is then piesenteu on the suiface of the NBC II anu is then
iecognizeu by the T-cell ieceptoi on the suiface of the helpei T-cell
S. A "co-stimulatoiy" signal is maue when the B7 on the APC anu the CB28 on
the helpei T-cell binu.
4. The combination of #2 anu #S cause the secietion of IL-2 anu %-IFN

Aftei the helpei T-cell is activateu, the next step is the activation of the cytotoxic T-
cell, these steps aie:
1. IL-2 fiom the helpei T-cell connects with the cytotoxic T-cell, thus activating
it to uestioy the infecteu cell.
2. Pioteins piesenteu on the NBC I (ie viial-iecognition) attiacts the cytotoxic
T-cell, gets iecognizeu, anu is killeu
$IH U?LL?TFAJ MHD?A@C>BCH@ CIH@H @CHN@ GF@SBLLE-


&-!!$#$4(-+(-"4L/#"&1,(-"4 "! ( +4& * ,$..2












,$.. 3$&-+($& -3314-(G O(
,$..2P
T CELLS
Alleigies
uiaft Rejection
Antibouy iesponse
Befense against ZSAJFV
/EO?WBOCH>FSDV $2V BAM GF>S@K
FAUHOCHM OHLL@Q
+4(-*"&GS3$&-+($& -3314-(G
B CELLS
Alleigies
Autoimmunity
Befense against 2BOCH>FBV $?PFA@V
BAM ]F>S@H@

,G("V-4$ !14,(-"4
Theie is a gieat mnemonic that can help you iemembei the fiist five cytokines, it is:
")>B (-Q>:7 st$+k"
-. a X ! Bot = FEvER
-. a Z ! stimulation of T-cells
-. a ] ! stimulation of B0NE maiiow
-. a ^ ! IgE piouuction stimulation
-. a b ! IgA piouuction stimulation

Now the iest of the cytokines aie iesponsible foi the following:
-. a W ! PNN chemotactic factoi
(4! ! ! Incieases IL-2 ieceptoi synthesis by helpei T cells, incieases B cell
piolifeiation, anu attiacts anu stimulates PNNs. This is secieteu by maciophages.
(4! " ! This is secieteu by activateu T lymphocytes, anu peifoims the same
functions as the TNF !
% S -:B78C78>: ! Stimulates maciophages, secieteu by helpei T cells

-4($#!$#"42
Inteifeions play an essential iole in pieventing the piolifeiation anu piouuction of a
viius by acting in ceitain ways to pievent it fiom infecting othei cells.
$IH CI>HH DB`?> USAOCF?A@ ?U CIH FACH>UH>?A@ B>H:
1. Activation of natuial killei (NK) cells which act by uiiectly killing viius-
infecteu cells.
2. ! anu " inteifeion act by inhibition of viial piotein synthesis
S. % S Inteifeion woiks by incieasing the expiession of the NBC I anu NBC II as
well as antigen piesentation in all cells
2FJ NFOCS>H /") ?U FACH>UH>?A@:
! Inteifeions stimulate the piouuction of a piotein that uegiaues viial mRNA.
When this occuis, the viius cannot infect a cell since the piopei genetic mateiials foi
this function aie absent.


(#+42/.+4( #$6$,(-"4
.>BUCKG@K(?@C +H`HOCF?A:
0ccuis when the giafteu T cells piolifeiate anu ieject the host cells that contain
foieign pioteins. As this occuis, seveie oigan uysfunction ensues, causing uamage
to the livei, skin, mucosa, anu gastiointestinal tiact. This conuition also affects the
bone maiiow anu the lungs.
(ENH>BOSCH +H`HOCF?A:
0ccuis almost immeuiately aftei tiansplant, wheieby piefoimeu anti-uonoi
antibouies cause a iesponse.
)OSCH +H`HOCF?A:
This is a cell-meuiateu ieaction that occuis via cytotoxic T lymphocytes that ieact
against foieign NBCs, occuiiing weeks post-tiansplant.
!I>?AFO +H`HOCF?A:
0ccuiiing months-yeais post-tiansplant, is causeu by antibouy-meuiateu vasculai
uamage.













(G/$2 "! )G/$#2$42-(-5-(G #$+,(-"42

(G/$ X )G/$#2$42-(-5-(G: +:@NHFI@EBDEL+B>NDE
A veiy iapiu ieaction that occuis in iesponse to antigen
exposuie. Antigens tiiggei the ielease of histamine by
binuing to basophils anu mast cells.
%PBDNLH@ ! Bives, asthma, anaphylaxis

(G/$ Z )G/$#2$42-(-5-(G: ,FB>B>JDE
Is a cytotoxic ieaction wheieby IgN anuoi Igu binu to
cells leauing to lysis by complement activation oi phagocytosis.
%PBDNLH@ ! Autoimmune hemolytic anemia, uooupastuie's uisease, iheumatic
fevei, Rh uisease, uiave's uisease.

(G/$ ] )G/$#2$42-(-5-(G: +:BDM7:S+:BDQ>=F 37=D@B7=
The foimation of antigen-antibouy complexes leaus to complement activation,
attiacting PNN's anu ultimately leauing to the ielease of lysosomal enzymes.
%PBDNLH@ ! ulomeiulonephiitis, Lupus, Rheumatoiu Aithiitis

(G/$ ^ )G/$#2$42-(-5-(G: ,7IIS37=D@B7=
Is a uelayeu iesponse, wheieby T cells become sensitizeu anu encountei antigens,
thus ieleasing cytokines.
%PBDNLH@ ! Contact Beimatitis, Tiansplant Rejections, TB Skin Test





#$3$3*$#-4T ()$
)G/$#2$42-(-5-(-$2R
3:7?>:DER +,-&
+ a +:@NHFI@JDA
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- a -??<:7 ,>?NI7J
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*S,$.. &$!-,-$4,-$2
BR0T0N'S
AuANNAuL0B0LINENIA
SELECTIvE
INN0N0uL0B0LIN
BEFICIENCY
(S,$.. &$!-,-$4,-$2
TBYNIC APLASIA
(Biueoige)
CBR0NIC
N0C0C0TANE00S
CANBIBIASIS
* +4& ( ,$..
&$!-,-$4,-$2
SCIB
WISK0TT-
ALBRICB
ATAXIA-
TELANuIECTASIA
/)+T",G(-, &$!-,-$4,-$2
CBR0NIC uRAN0L0NAT00S
BISEASE
CBEBIAK-BIuASBI
}0B'S SYNBR0NE
LE0K0CYTE ABBESI0N
BEFICIENCY
BYPER-IgN SYNBR0NE
IL-12 RECEPT0R BEFICIENCY
*S,$.. &$!-,-$4,-$2

2+7$"#c& ).)//).3"2735#%/5):
An x-linkeu iecessive uefect in tyiosine kinase gene. iesults in:
- All Ig classes aie uecieaseu
- uet iecuiient bacteiial infections (aftei 6 months of age)
- 0nly in boys

&%3%!$5]% 5//7#".3"2735# X%Z5!5%#!0:
A ueficiency of a specific Ig class iesulting in uefect I isotype switching, iesults in:
- Sinus infection
- Lung infections
- Nost commonly the ueficient Ig is IgA


(S,$.. &$!-,-$4,-$2:

$(0/5! )*3)&5):
Theie is a failuie of the uevelopment in the thymus anu paiathyioiu's, uue to failuie
of uevelopment of the S
iu
anu 4
th
phaiyngeal pouch, iesults in:
- Tetany
- viial anu fungal infections (iecuiient)
- Beait uefects

!(+"#5! /7!"!7$)#%"7& !)#X5X5)&5&:
A T-cell uysfunction against Canuiua, iesults in:
- Canuiual infections of the skin anu mucous membianes



* +4& ( ,$.. &$!-,-$4,-$2
&%]%+% !"/25#%X 5//7#"X%Z5!5%#!0 h&!5Xid
This conuition leaus to a uefect in uiffeientiation of the eaily stem-cells, iesults in:
- Recuiient infections (viial, bacteiial, fungal, anu piotozoal)

Y5&b"$$K)3X+5!( &0#X+"/%:
Is an x-linkeu uefect in the ability to mount an IgN iesponse to the capsulai
polysacchaiiues of bacteiia, iesults in:
- Low IgN levels
- Bigh IgA levels
- Noimal IgE levels
- Classic tiiau of symptoms: Infections, Eczema, anu Thiombocytopenic
Puipuia.


/)+T",G(-, &$!-,-$4,-$2
!(+"#5! .+)#73"/)$"7& X5&%)&%:
A lack of NABPB leaus to a uefect in neutiophil phagocytosis, iesults in:
- Succeptibility to oppoitunitic bacteiial infections
- Biagnosis baseu on negative nitioblue tetiazolium uye ieuuction test
(!3)&&5! 7&/3% g7%&$5"#)

!(%X5)bK(5.)&(5 X5&%)&%:
A uefect in miciotubulai function anu lysosomal emptying of the phagocytic cells,
iesults in:
- Recuiient pyogenic infections uue to staph anu stiep

k"2c& &0#X+"/%:
T-cells fail to piouuce %-inteifeion, thus PNN's fail to iesponu, iesults in:
- Eczema, staph abscesses, anu elevateu IgE

3%7b"!0$% )X(%&5"# X%Z5!5%#!0 &0#X+"/%:
Theie is a uefect in the LFA-1 auhesion pioteins on the phagocytes, iesults in seveie
eaily life pyogenic infections.

(0*%+K5J/ &0#X+"/%:
Theie is a uefect in the CB4u liganu on the CB4 Th cells, leauing to seveie pyogenic
infections eaily in life, iesults in:
- Bigh IgN levels
- Extiemely low levels of Igu, IgA, anu IgE

53K,1 +%!%*$"+ X%Z5!5%#!0:
A uefect in the IL-12 ieceptoi leaus to uisseminateu mycobacteiial infections.















!()*$%+ ,,

/5!+"25"3".0

(F@C?>FOBLLEV WBOCH>F?L?JE ?OOSNFH@ CIH DB`?>FCE ?U CIH
DFO>?WF?L?JE RSH@CF?A@ ?A CIH &CHN , HPBDQ )UCH> WBOCH>FBV
GF>?L?JE F@ GH>E FDN?>CBACV W?CI O?AOHNCSBLLE BAM FA MHCBFLQ
*BE GH>E @NHOFBL BCCHACF?A C? (5] BAM BLL CIBC FC HACBFL@V B@
CIF@ F@ ?AH ?U CIH IFJIH@CKEFHLMFAJ C?NFO@ ?A CIH HPBDQ YIHA
FC O?DH@ C? NB>B@FCH@ BAM IHLDFACI@V E?S> @C>BCHJE @I?SLM WH
DHD?>FaBCF?A ?U D?MH@ ?U C>BA@DF@@F?AV @FJA@ BAM
@EDNC?D@V BAM C>HBCDHAC@Q













*+,($#-"."TG

()$ T#+3 /"2-(-5$ *#$+V&"%4


T#+3 /"2-(-5$ ,$.. %+.. 2(#1,(1#$


/$/(-&"T.G,+4 a Pioviues suppoit anu piotects against osmotic piessuies.
,+/21.$ - Piotects the oiganism fiom phagocytosis.
!.+T$..13 - Belps piopel the oiganism.
/-.12 - 0seu foi auheiing to a cell's suiface anu foims an attachment between two
backteiia foi sex.
/.+23-&2 - Contain genes foi enzymes, toxins, anu foi the uevelopment of
antibotic iesistance.
T.G,",+.G0 - Belps meuiate auheience to suifaces.

()$ T#+3 4$T+(-5$ *#$+V&"%4





T#+3 4$T+(-5$ ,$.. %+.. 2(#1,(1#$

gg 1:Ds<7 B> BH7 M8@? a97 Q@EB78D@l BH7 7:=>B>JD: E>:B@D:A IDN>N>IFA@EEH@8D=7
BH@B D:=<E7A (4! @:= -.SXn










)-T)SG-$.& T#+3 2(+-4 #$21.(2
T#+3 2(+-4 #$21.(2 "#T+4-23
#7= E>I>87= T8@? a97
*I<7 E>I>87= T8@? k97
T8@? k E>EED D: EH@D:A 2B87NB>E>EED
T8@? k E>EED D: EI<AB78A 2B@NHFI>E>EE<A
T8@? k E>EED D: N@D8A O@m@ =DNI>E>EEDP 2B87NB>E>EE<A /:7<?>:D@
T8@? a #>=A O@m@ E>EE>Q@EDIIDP )7?>NHDI<A 2N7ED7A
T8@? a &DNI>E>EED 47DAA78D@ 2N7ED7A
T8@? a #>=A KDBH ?<E>D= E@NA<I7 VI7QAD7II@ 2N7ED7A
2N>87 C>8?D:M T8@? k #>=A *@EDII<A AN7ED7A @:= ,I>AB8D=D<?
2N7ED7A
/87A7:E7 >C NA7<=>HFNH@7 ,@:=D=@ 2N7ED7A
+ED= !@AB 2B@D: 3FE>Q@EB78D<? @:= 4>E@8=D@ 2N7ED7A
2DI978 2B@D:D:M /:7<?>EFABDA ,@8D:DD
-:=D@ -:m ON>ADBD97P ,8FNB>E>EE<A 47>C>8?@:A
T8@? k KDBH N87A7:E7 >C A<IC<8
M8@:<I7A
+EBD:>?FE7A 2N7ED7A
2ND8>EH7B7A (87N>:7?@l .7NB>AND8@l @:= *>887ID@
2N7ED7A


()$ ,+12$2 "! !""& /"-2"4-4T
!S@CB>MV N?CBC? @BLBMV DBE?AABF@H ! S. Auieus (fast onset, fast alleviation)
+HIHBCHM >FOH ! Bacillus Ceieus
+HIHBCHM DHBC ! Clostiiuium Peifiingens
&HBU??M ! vibiio Paiahemolyticus
5DN>?NH>LE OBAAHM U??M@ ! Clostiiuium Botulinum (watch foi bulging can tops)
7AMH>O??\HM DHBC ! E. Coli u1S7:B7
+BT HJJ@ ! Salmonella
*?SLC>E ! Salmonella



$0"("0-42
Exotoxins cause uamage to the host by uestioying cells oi uisiupting theii cellulai
metabolism. They may eithei be secieteu oi ieleaseu uuiing cell lysis. Nost often
they can be uestioyeu by heat.
Exotoxins aie seen in both giam +ve anu giam -ve oiganisms.

.+)/ #%.)$5]% 27.& Y5$( %f"$"f5#&
2?>MHCHLLB *H>CS@@F@ ! stimulates AC by ABP iibosylation.
%Q !?LF ! is heat-labile, stimulates AC by ABP iibosylation of u piotein, causes
wateiy uiaiihea.
]FW>F? !I?LH>B ! stimulates AC by ABP iibosylation of u piotein, incieasing the
amount of chloiiue anu watei in the gut, causing high-volume iice-watei uiaiihea.

.+)/ *"&5$5]% 27.& Y5$( %f"$"f5#&
&CBNI )S>HS@ ! A supeiantigen that binus NBC II piotein anu T-cell ieceptoi,
inuuces IL-1 anu IL-2 synthesis in toxic shock synuiome. Can also cause foou
poisoning.
&C>HN *E?JHAH@ ! Eiythiogenic toxin (supeiantigen) causes iash anu scailet fevei,
while stieptolysin 0 (hemolysin) causes iheumatic fevei.
!?>AEWBOCH>FSD XFNICIH>FB ! Causes inactivation of EF-2 by ABP iibosylation,
causing phaiyngitis anu a pseuuomembiane in the thioat.
!L?@C>FMFSD 2?CSLFASD ! Blocks ACh ielease, causes seveie anticholineigic
symptoms anu CNS paialysis.
!L?@C>FMFSD $HCBAF ! Blocks glycine, leaus to lockjaw.
!L?@C>FMFSD *H>U>FAJHA@ ! Lecithinase (!-toxin), causes gas gangiene.





$4&"("0-42
Enuotoxins aie lipopolysacchaiiues that aie founu in the cell walls of giam negative
bacteiia. Enuotoxins cause a wiue iange of pioblems thiough the activation of
maciophages anu the complement pathway.
/BO>?NIBJH BOCFGBCF?A LHBM@ C?d
- Bypotension thiough nitiic oxiue
- Fevei thiough IL-1 activation
- Bemoiihagic tissue neciosis thiough tumoi neciosis factoi
$IH O?DNLHDHAC NBCITBE LHBM@ C?d
- Bypotension anu euema thiough CSa activation
- Causes PNN chemotaxis thiough CSa activation
rr X5! OBA WH OBS@HM TIHA CIH HAM?C?PFA@ BOCFGBCH@ CIH (BJHDBA UBOC?>Q

(G/$2 "! 2(+-42
Theie aie a few uiffeient stains that aie useu in oiuei to isolate ceitain bacteiia,
they incluue:
&FLGH> &CBFA ! Pneumocystic Caiinii Pneumonia, Fungi
!?AJ? +HM &CBFA ! Amyloiu
.FHD@B &CBFA ! Chlamyuia, Boiielia, Plasmouium
*)& ! Whipple's uisease
mFHILK#HHL@HA ! Aciu-fast bacteiia's
5AMFB 5A\ ! Ciyptococcus Neofoimans







,"461T+(-"4l (#+42&1,(-"4l (#+42!"#3+(-"4
PR0CEB0RE PR0CESS CELL TYPES TYPE 0F BNA
TRANSFERREB
Conjugation Tiansfei of BNA
fiom bacteiia to
bacteiia
Piokaiyotes Chiomosomal oi
plasmiu
Tiansuuction Tiansfei fiom
viius to anothei
cell
Piokaiyotes All types
Tiansfoimation Puiifieu BNA is
taken up by a cell
Both piokaiyotes
anu eukaiyotes
All types


2/$,-!-, #$e1-#$3$4(2
Some bugs iequiie ceitain enviionments in oiuei to suivive, they fall unuei the
following:
"*.-T+($ +$#"*$2L+4+$#"*$2l +4& -4(#+,$..1.+#

"WLFJBCH )H>?WH@: iequiie u2 to cieate ATP. Incluues:
- Nocaiuia
- Pseuuomonas Aeiuginosa
- Nycobacteiium TB
- Bacillus
"WLFJBCH )ABH>?WH@: aie susceptible to oxiuative uamage uue to theii lack of S0B
anu catalase. Incluues:
- Actinomyces
- Clostiiuium
- Bacteioiues
5AC>BOHLLSLB>: these bugs must iemain insiue the cell in oiuei to suivive, incluue:
CM+(3*'#, - Rickettsia anu Chlamyuia
B*&4+'*'(P# - Salmonella, Biucella, Nycobacteiium, Listeiia, Fiancisella, Legionella,
Yeisinia



-3/"#(+4( -4!" +*"1( 2(+/) +1#$12
Staph auieus is a veiy common oiganism both in the boaiu exams anu in clinical
piactice. Staph auieus causes theii uestiuction baseu on the following two
methous:
1. (>JD:S37=D@B7= - Incluues toxic-shock synuiome, scalueu skin synuiome,
anu iapiu-onset foou poisoning.
2. -:CI@??@B>8F - Incluues infections of the skin, abscesses, anu pneumonias.

$?PFOK&I?O\ &EAM>?DH - A supeiantigen binus to NBC II anu T-cell ieceptois,
which causes polyclonal T-cell activation.
Z??M N?F@?AFAJ fiom staph auieus is causeu by the ingestion of a piefoimeu toxin.
** Staph Auieus contains a viiulence factois (known as Piotein A), that binus to the
Fc poition of Igu. This inhibits complement fixation anu inhibits phagocytosis.

$4,+/21.+($& *+,($#-+
Some bacteiia have a polysacchaiiue capsule that acts as an anti-phagocytic factoi.
This makes them less susceptible to being engulfeu by phagocytes. These bugs aie:
- Stiep Pneumonia
- B. Influenza
- N. Neningitiuis
- Klebsiella Pneumonia

()$ $0"("0-42 "! ,."2(#-&-+ 2/$,-$2
!Q XFUUFOFLH ! piouuces a cytotoxin (exotoxin) that kills eiythiocytes, anu thus
causes a pseuuomembianous colitis. ** 0ften occuis seconuaiy to antibiotic use.
!Q $HCBAF ! piouuces an exotoxin that iesults in tetanus.
!Q *H>U>FAJHA@ ! piouuces an !-toxin that causes myoneciosis, gas gangiene, oi
hemolysis.
!Q 2?CSLFASD ! a piefoimeu, heat-labile toxin is piouuceu that inhibits the ielease
of ACh, which causes botulism.


-3/"#(+4( -4!" +*"1( 2(#$/ /G"T$4$2
Stiep Pyogenes is a gioup A "-hemolytic stiep that can cause the following uiseases:
1. -??<:>I>MDE - Acute glomeiulonephiitis anu Rheumatic fevei
2. /F>M7:DE - Phaiyngitis, Cellulitis, anu Impetigo
S. (>JDM7:DE - Toxic shock synuiome anu Scailett fevei

&-/)()$#-+
Biphtheiia can cause N@HSM?DHDW>BA?S@ NIB>EAJFCF@ thiough an HP?C?PFA. Theii
exotoxin woiks by FAIFWFCFAJ N>?CHFA @EACIH@F@ GFB )X* >FW?@ELBCF?A ?U %ZK1Q

*1T2 ,+12-4T *.""&G &-+##)$+
- E. Coli u1S7:B7
- Entamoeba histolytica
- Campylobactei jejuni
- Salmonella
- Shigella
- Yeisinia enteiocolitica
*1T2 ,+12-4T %+($#G &-+##)$+
- Enteiotoxigenic E. Coli
- vibiio (iice-watei stools, highly voluminous)
- Rotaviius
- uiaiuia (foul-smelling)
- Ciyptospoiiuium

-3/"#(+4( !+,(2 +*"1( )n /G."#-
- B. Pyloii is the cause of most uuouenal ulceis (up to 9u%)
- Is a giam -ve iou that cieates an alkaline enviionment
- Can inciease the iisk of P0B anu gastiic caicinomas
(87@B?7:B: Tiiple theiapy: 0mepiazole, claiithiomycin, amoxicillin.



/2$1&"3"4+2 +$#1T-4"2+
Pseuuomonas aeiuginosa piouuces both an exotoxin anu an enuotoxin. Its most
populai chaiacteiistic is that it piouuces a fiuity-smelling blue-gieen pigment (uue
to pyocyanin).
*Q )H>SJFA?@B OBS@H@ CIH U?LL?TFAJd
- Pneumonia in cystic fibiosis patient
- 0titis Exteina (swimmei's eai)
- Folliculitis (known as "hot-tub" folliculitis)
- Sepsis (black lesions of the skin)

*1T2 ()+( +,( "4 ()$ qTS/#"($-4r
Two bugs that piouuce theii effects by acting on the us anu ui pioteins aie vibiio
Choleia anu Boiuetella Peitussis.
]FW>F? !I?LH>B causes a iice-watei uiaiihea by peimanently activating the us
piotein.
2?>MHCHLLB *H>CS@@F@ causes whooping cough by peimanently uisabling the ui
piotein.
** Common to both bugs is the activation of auenylyl cyclase (AC) thiough ABP
iibosylation.

,+12$2 "! 5+T-4"2-2
Tiichomonas, uaiuneiella, anu Canuiua
$>FOI?D?AB@ - causeu by an anaeiobic, motile piotozoan. Shifts vaginal pB to S-6,
anu uispels a gieenish-yellow fiothy vaginal uischaige.
.B>MAH>HLLB - a giam-vaiiable iou that causes a gieen vaginal uischaige that has a
fishy smell, anu has the pathognomonic "clue cells". pB is elevateu.
!BAMFMB - is a fungal infection that piesents with a cottage-cheese like uischaige
that is sticky anu will stick to the walls of the vagina.


*1T2 #$.+($& (" +4-3+.2 O\""4"(-,2P
Nany seiious uiseases aie causeu by bites fiom animals, ticks, etc. The most
impoitant uiseases fiom animals incluue:
1. .F?7 &DA7@A7 - causeu by Boiielia Buiguoifeii, which is tiansmitteu
thiough the Ixoues tick bite, which is a tick that lives on ueei anu mice.
Classic piesentation is the bullseye taiget lesion.

2. ,7II<IDBDA - causeu by Pasteuiella Nulticoua, which occuis thiough uog oi cat
bites.
S. (<I@87?D@ - causeu by Fiancisella Tulaiensis, fiom a tick bite, seen in
iabbits anu ueei. This conuition is also known as the "Pahvant valley
Plague", "Rabbit fevei", "Beei fly fevei", anu "0haia's fevei".

4. *8<E7II>ADA - causeu by Biucella species, anu contamination occuis thiough
infecteu uaiiy piouucts anu contact with animals.

S. (H7 NI@M<7 - causeu by Yeisinia pestis, tiansmitteu thiough a flea bite founu
on iouents anu wilu uogs.

(1*$#,1."2-2
Tubeiculosis is an infection with mycobacteiium tubeiculosis, that affects the
iespiiatoiy tiact most commonly, howevei it can have extiapulmonaiy
manifestations as well, namely in the :
- uI
- Kiuneys
- Lymph noues
- veitebial Bouies (Pott's uisease)
- Cential neivous system

&EDNC?D@ ?U $2 FAUHOCF?A:
0sually, symptoms aie veiy non-specific, piesenting as:
- Fatigue anu weight loss
- Night sweats
- Cachexia

5U CIH @EDNC?D@ WHO?DH D?>H NSLD?AB>EV HPNHOC C? UFAMd
- Byspnea
- Bemoptysis
- Chest pain (pleuiitic in natuie)
- Piouuctive cough

X D:C7EBD>: ! A piimaiy TB infection iefeis to the infectious piocess by which the
bouy is able to contain the infection anu pievent its uissemination. This iesults in
the uhon complex, which is a calcifieu focus of infection usually in the lowei
segments of the lung.
Z D:C7EBD>: ! Also known as "ieactivateu TB", this type of infection can occui to
those who aie in a state of weakeneu oi suppiesseu immunity.

YIHA CSWH>OSL?@F@ F@ @S@NHOCHM.
- A +ve PPB test waiiants a chest xiay looking foi the TB cavitaiy lesion
- Aciu fast stain looking foi the mycobacteiium

/BABJHDHACe$>HBCDHACn
+EBD97 (* ! A 4-uiug iegimen (RIPE - Rifampin, Isoniaziu, Pyiazinamiue, anu
Ethambutol). Bewaie of auveise neuiological effects of Isoniaziu, supplement with
vitamin B6 - pyiiuoxine.
.@B7:B (* ! With latent TB, you will begin the patient on a 4-uiug iegimen lasting
up to 9 months. If they piesent at a futuie uate with latent TB, they will not neeu to
be tieateu again. ** Latent TB = 1 time 4-uiug couise lasting seveial months.








#-,V$((2-+. -4!$,(-"42 +4& 5$,("#2
Rickettsial infections aie those infections that aie iesponsible foi causing Rocky
Nountain Spotteu Fevei, Typhus, anu Q fevei.
Rickettsial infections usually leau to a similai piesentation, which is:
- Fevei
- Beauache
- Rash
+"!b0 /"7#$)5# &*"$$%X Z%]%+
Causeu by Rickettsia Rickettsii, which causes a iash that staits on the palms anu
soles anu moves inwaiu. Tieat with tetiacycline.
(K> C>8?A >C (FNH<A[ @87R
%#X%/5! $0*(7& - causeu by Rickettsia Typhi, which is a flea. Tieat with
tetiacycline.
%*5X%/5! $0*(7& - causeu by Rickettsia Piowazekii, a bouy louse. Tieat with
tetiacycline.
Anu finally,
g Z%]%+ - causeu by Coxiella Buinetti, which causeu infection via aeiosolizeu
paiticles. Tieat with tetiacycline.

2/-#",)$($2
Spiiochetes aie "spiial-shapeu" bacteiial elements containing axial filaments. The
most commonly testeu spiiochete-ielateu infection is syphilis (tieponema). The
othei two types of spiiochetes aie Boiielia anu Leptospiia, which aie stainable with
light micioscopy, wheieas tieponema is visualizeu only with uaik-fielu micioscopy.
With that saiu, theie aie thiee foims of Syphilis:
, @ENIFLF@ ! Patient will get a painless chancie, tieat with IN pen u
1 @ENIFLF@ ! Patient has uisseminateu uisease + constitutional symptoms, incluues
a maculopapulai iash on the palms anu soles. Tieat with IN pen u
4 @ENIFLF@ ! Patient has neuiological pioblems (neuiosyphilis, Aigyll Robeitson
pupil), aoitic uisoiueis (aoititis), anu gummas. Tieat with Iv penicillin.


($2(-4T !"# 2G/)-.-2
]X+3 BAM Z$)K)2&:
5&#. - this test is useu foi nonspecific antibouy uetection, howevei uue to its high
iate of false-positives is not the piimaiy test useu foi syphilis uetection. This test
will be positive when theie aie a few othei uiseases piesent, incluuing: SLE, RA, RF,
anu a few othei viial infections like mononucleosis.
!(+S+*2 - is a test specific foi the tieponema bacteiia, anu has the best
combination of benefits in finuing syphilis, incluuing high specificity, veiy eaily
positivity, anu iemains positive the longest.


















5-#"."TG

&4+ +4& #4+ 5-#+. T$4"3$2
All BNA viiuses aie uouble stianueu anu lineai, with the exception of paivoviius (is
single-stianueu), anu hepaunaviiuspapovaviius (ciiculai). All RNA viiuses aie
single-stianueu, except the ieoviius (uouble stianueu).
X#) F@ M?SWLHV +#) F@ @FAJLH.

)"% &" 5-#12$2 #$/#"&1,$
+HO?DWFABCF?A ! is the exchange of genetic mateiial between 2 chiomosomes by
cioss-ovei of ceitain iegions that have impoitant base sequence homology.
+HB@@?>CDHAC ! is the exchange of viial segments (fiom segmenteu viial
genomes). This occuis at high fiequency anu is iesponsible foi woiluwiue illnesses
(panuemics).
!?DNLHDHACBCF?A ! occuis when one functional viius helps anothei non-
functional viius become functional.
*IHA?CENFO /FPFAJ ! occuis when a ceitain viius has the suiface coating fiom
anothei viius' piotein, which will then ueteimine the infectivity of this viius
paiticle.

5-#+. /."-&G
Retioviiuses contain 2 iuentical single-stianueu RNA molecules, making them
"MFNL?FM", while all othei viiuses contain a single copy of both BNA anu RNA, making
them "IBNL?FM".
&4+ 5D8<A7A ! all ieplicate in the nucleus, except foi the poxviius.
#4+ 5D8<A7A ! all ieplicate in the cytoplasm, except foi ietioviiuses anu the
influenza viius.





()$ -3/"#(+4( ,)+#+,($#-2(-,2 "! 5-#+. &4+
The following aie impoitant chaiacteiistics that fit foi almost all of the BNA viiuses:
4<EI7@8 87NIDE@BD>: ! all BNA viiuses ieplicate in the nucleus except foi the
Poxviius, which has its own BNA-uepenuent RNA polymeiase.
+87 ID:7@8 ! all BNA viiuses aie lineai, except foi the Papovaviius anu the
Bepauna viius. Papovaviius is ciiculaisupeicoileu, anu the Bepauna viius is
ciiculaiincomplete.
+87 =><QI7 AB8@:=7= O=A&4+P ! all BNA viiuses aie uouble-stianueu except foi
the Paivoviius, which is single-stianueu (ssBNA).
+87 DE>A@H7=8@I D: AH@N7 ! all BNA viiuses aie icosaheuial except foi the
Poxviius, which is complete in capsiu shape.

T$4$(-, 2)-!( 9An T$4$(-, &#-!(
.HAHCFO &IFUC ! Is the piocess by which theie is a ie-assoitment of uiffeient viial
stiains, which combine to foim new foimssubtypes that contain a mixtuie of the
suiface antigens of the stiains involveu. uenetic shift is veiy impoitant because it
cieates new viial pathogens, anu is iesponsible foi the emeigence of new viiuses.
.HAHCFO X>FUC ! Is a piocess of natuial mutations ovei a peiiou of time. This leaus
to loss of immunity anu the inability of vaccines to cuie illnesses.











()$ &4+ 5-#12$2
The list of BNA viiuses:
1. )epaunaviius
2. )eipesviius
S. +uenoviius
4. /aivoviius
S. /apovaviius
6. /oxviius
Remembei this list with the mnemonic: ))+///y

$(% !()+)!$%+5&$5!& "Z %)!( X#) ]5+7&
Xn )7N@=:@9D8<A - usBNA paitial ciiculai, envelopeu.
XF@HB@H@ ! Bepatitis B viius

Zn )78N7A9D8<A - usBNA lineai, envelopeu.
XF@HB@H@ ! Buman Beipes viius 6 & 8, Beipes Simplex 1 & 2, vaiicella Zostei,
Ebstein-Baii viius, anu Cytomegaloviius
BBv 6 - Reseola
BBv 8 - Kaposi's saicoma
BSv 1 - Thought to be oial ulceis, but now can be fiom both oial anu genital ulceis
BSv 2 - Thought to be genital ulceis, but now can be fiom both oial anu genital
ulceis
vZv - Responsible foi chickenpox (not seen anymoie uue to vaccination), shingles
EBv - Causes mononucleosis anu Buikitt's lymphoma
CNv - Congenital infections

]n +=7:>9D8<A - usBNA lineai, has no envelope.
XF@HB@H@ ! Conjunctivitis, Pneumonias, Phaiyngitis

^n /@89>9D8<A - ssBNA lineai (is the smallest BNA), has no envelope
XF@HB@H@ ! Paivo B19 (slappeu cheek synuiome)

bn /@N>9@9D8<A - usBNA ciiculai, has no envelope
XF@HB@H@ ! Buman Papilloma viius, Piogiessive Nultifocal Leukoencephalopathy

`n />J9D8<A - usBNA lineai (is the laigest of all BNA viiuses), has an envelope
XF@HB@H@ ! Cowpox, Smallpox, Nolluscum Contagiosum

$(% !()+)!$%+5&$5!& "Z %)!( +#) ]5+7&
1. /DE>8:@9D8<A - (+)ssRNA, lineai, icosaheuial, no envelope.
+H@N?A@FWLH U?>:
- Bepatitis A
- Coxsackieviius
- Polioviius
- Echoviius
- Rhinoviius

2. ,@IDED9D8<A - (+)ssRNA, lineai, icosaheuial, no envelope.
+H@N?A@FWLH U?>:
- Noiwalk viius (gastioenteiitis)
- Bepatitis E

S. #7>9D8<A - usRNA, lineai segmenteu, uouble icosaheuial, no envelope.
+H@N?A@FWLH U?>:
- Reoviius (Coloiauo tick fevei)
- Rotaviius (NCC of uiaiihea in chiluien)



4. !I@9D9D8<A - (+)ssRNA, lineai, icosaheuial, envelopeu.
+H@N?A@FWLH U?>:
- Bengue fevei
- Yellow fevei
- Bepatitis C
- St. Louis encephalitis
- West Nile viius

S. (>M@9D8<A - (+)ssRNA, lineai, icosaheuial, envelopeu.
+H@N?A@FWLH U?>:
- Rubella
- EasteinWestein equine encephalitis

6. #7B8>9D8<A - (+)ssRNA, lineai, icosaheuial, envelopeu.
+H@N?A@FWLH U?>:
- BIvAIBS
- Baiiy T-cell leukemia

7. "8BH>?FJ>9D8<A - (-)ssRNA, lineaisegmenteu, helical, envelopeu.
+H@N?A@FWLH U?>:
- Influenza

8. /@8@?FJ>9D8<A - (-)ssRNA, lineainon-segmenteu, helical, envelopeu.
+H@N?A@FWLH U?>:
- Neasles
- Numps
- Respiiatoiy Syncitial viius (RSv)
- Paiainfluenza



9. #H@Q=>9D8<A - (-)ssRNA, lineai, helical, envelopeu.
+H@N?A@FWLH U?>:
- Rabies

1u. !DI>9D8<A - (-)ssRNA, lineai, helical, envelopeu.
+H@N?A@FWLH U?>:
- Bemoiihagic feveis (Ebola viius)

11. ,>8>:@9D8<A - (+)ssRNA, lineai, helical, envelopeu.
+H@N?A@FWLH U?>:
- Coionaviius

12. +87:@9D8<A - (-)ssRNA, ciiculai, helical, envelopeu.
+H@N?A@FWLH U?>:
- Neningitis
- Lymphocytic choiiomeningitis

1S. *<:F@9D8<A - (-)ssRNA, ciiculai, helical, envelopeu.
+H@N?A@FWLH U?>:
- Sanufly fevei
- Riftvalley fevei
- Ciimean-Congo hemoiihagic fevei
- Bantaviius
- Califoinia Encephalitis

14. &7IB@9D8<A - (-)ssRNA, ciiculai, helical, envelopeu.
+H@N?A@FWLH U?>: Bepatitis B



.-5$S+(($41+($& 9An V-..$& 5+,,-4$2
.D97S+BB7:<@B7= 5@EED:7A ! these types of vaccines inuuce both humoial anu cell-
meuiateu immunity.
VDII7= 5@EED:7A ! these types of vaccines inuuce humoial immunity only.

%PBDNLH@ ?U 3FGHK)CCHASBCHM ]BOOFAH@:
- Neasles
- Numps
- Rubella
- Smallpox
- Polio (Sabin)
- vZv
- Yellow Fevei
** Remembei theie is uangei in giving a live-attenuateu vaccine to someone who is
immunocompiomiseu.

%PBDNLH@ ?U bFLLHM ]BOOFAH@:
- Rabies
- Influenza
- Polio (Salk)
- Bepatitis A










21/$# )-T)SG-$.& 3-,#"*-"."TG -4!"#3+(-"4

)$#/#$2 5-#12$2
Theie aie quite a few uiffeient foims of "heipes viiuses", they aie all high-yielu
0SNLE infoimation. The most common heipes viiuses anu theii common finuings
incluue:
)25SX - this is known to be iesponsible foi the oial lesions of heipes, howevei uue
to uiffeient sexual piactices, it may be seen in the genital iegion as well. BSv-1 is
also a cause of keiatoconjunctivitis anu tempoial lobe encephalitis (BSv is the most
common cause of auult onset alteieu mental status).
BSv-1 is tiansmitteu via iespiiatoiy secietions anuoi saliva. Z?> (&] MFBJA?@F@V
S@H CIH $aBAO\ CH@C (smeai the open vesicle, looking foi multinucleateu giant cells).

)25SZ - BSv-2 is most commonly seen as heipes of the genitals (heipes labialis), as
well as neonatal heipes.
BSv-2 is tiansmitteu via peiinatal tiansmission as well as thiough sexual contact.

$*5 - causes Buikitt's lymphoma anu infectious mononucleosis (causes seveie
fatigue, soie thioat, usually in teenageis). Tiansmitteu thiough saliva anu
iespiiatoiy secietions.

,35 - Causes congenital infections as well as some types of pneumonia.
Tiansmitteu congenitally, thiough sexual contact, thiough saliva, anu thiough
tiansfusion.
))5 - Buman Beipes viius, is the cause of Kaposi's saicoma in AIBS patients.
Tiansmission is sexually.






3"4"41,.$"2-2
Nononucleosis is always encounteieu on the 0SNLE exams, thus be suie to know as
much as possible about this conuition.
*>H@HACBCF?A:
- Young auult (16-2uyi)
- Fevei
- Bepatosplenomegaly
- Phaiyngitis
- Lymphauenopathy
!BS@H:
- Ebstein-Baii viius (EBv)
- "kissing uisease", because it is easily tiansmitteu thiough saliva
- Theie aie abnoimal ciiculating cytotoxic T cells
XFBJA?@F@:
The best uiagnostic test is the "Nonospot test", which uetects heteiophil antibouies
thiough sheep RBC agglutination.
YIBC C? CHLL CIH NBCFHAC:
- The most impoitant thing foi patient safety is to )]"5X !"#$)!$ &*"+$&,
because the spleen is enlaigeu anu if it expeiiences blunt tiauma, it may
iuptuie anu cause seveie auveise effects such as hypotension, shock, anu
sepsis.










)-5L+-&2
A ietioviius, the BIv uisease uses the ieveise tiansciiptase enzyme to ieplicate.
BIv infection can be tiansmitteu thiough sexual contactfluius, bloou, anu bieast
milk. The helpei T-cells (CB4+ T cells), maciophages, anu uenuiitic cells aie
affecteu.
X5).#"&5#. (5]:
Biagnosis of BIv is maue with the ELISA test because of its high sensitivity. When a
test is positive, a Westein Blot is peifoimeu, which is veiy specific.
Aftei confiimation, a viial loau can be uone to measuie the quantity of the viius in
the bloou, which allows you to measuie the effect of meuical tieatment.
** False negatives with the ELISA test anu the Westein Blot aie common in the fiist
few months of BIv infection.

5//7#5$0 $" (5]d
Ceitain mutations in oui genes can give us immunity to BIv, can give us paitial
immunity to BIv, anu can even cause us to ueteiioiate iapiuly fiom an BIv infection.
The mutations iesponsible foi this incluue:
/SCBCF?A OBS@FAJ FDDSAFCE ! CCRS mutation (homozygous)
/SCBCF?A OBS@FAJ NB>CFBL FDDSAFCE ! CCRS mutation (heteiozygous)
/SCBCF?A OBS@FAJ >BNFM N>?J>H@@F?AeMHCH>F?>BCF?A ! CXCR1 mutation

)5X& [ "**"+$7#5&$5! 5#Z%!$5"#&d
The most commonly encounteieu oppoitunistic infection aie:
!14T+. - Canuiua (thiush), Ciyptococcal Neningitis (Ciyptococcus), Pneumocystis
Pneumonia (PCP, when CB4<2uu), Bistoplasmosis.
5-#+. - PNL (causeu by }C viius), BSv, vZv, CNv
*+,($#-+. - TB, Nycobacteiium Avium-Intiacellulai complex (NAC)
/#"("\"+ - Ciyptospoiiuium, Toxoplasmosis


$+%)$/%#$:
Tieatment involves the use of antiietioviial meuications, given to symptomatic
patients iegaiuless of theii CB4 counts anuoi to asymptomatic patients with CB4
counts <Suu.
Tiiple-uiug iegimens (2 nucleosiue ieveise tiansciiptase inhibitois anu eithei: 1
non-nucleosiue ieveise tiansciiptase inhibitoi 0R 1 piotease inhibitoi) aie useu,
these aie known as BAART, which taiget anu pievent BIv ieplication at thiee
uiffeient points along the viius' ieplication piocess.

"$(%+ /)#5Z%&$)$5"#& "Z (5] 5#Z%!$5"#:
Pulmonaiy: Community-acquiieu pneumonia, PCP, TB, CNv, NAC, Bistoplasmosis.
CNS: Toxoplasmosis, AIBS-uementia, Ciyptococcal Neningitis, Lymphoma, BSv,
Neuiosyphilis, PNL
uI: Biaiihea, 0ial lesions (thiush, ulceiations, oial haiiy leukoplakia), Canuiua
esophagitis, Pioctitis
Beimatological: BSv, Shingles, Nolluscum Contagiosum, Kaposi's saicoma















)$/+(-(-2
Is inflammation of the livei, chaiacteiizeu by the piesence of inflammation of the
tissue of the livei. Theie is a wiue iange of ioutes of infection, theie is a wiue iange
of symptoms anu piognosis, which can iange fiom self-limiteu uiseases to ciiihosis
anu ueath.
$IH>H B>H Z5]% O?DD?A U?>D@ ?U IHNBCFCF@V CIHE B>Hd
Bepatitis A, B, C, B, anu E

)7N@BDBDA + O)+5P - Is usually asymptomatic, is tiansmitteu via fecal-oial ioute.
0sually a veiy shoit incubation peiiou (~ S weeks). Is a RNA picoinaviius.
)7N@BDBDA * O)*5P - 0ften piesents with milu symptoms such as: loss of appetite
Nv, myalgias, fevei, anu jaunuice. Bep B is usually self-limiteu, but can piogiess
anu cause ciiihosis, hepatic failuie, anu ueath. Tiansmission is usually sexual,
thiough shaiing uiity neeules (paienteial), anu fiom the mothei to fetus (veitical
tiansmission). Is a BNA hepaunaviius.
)7N@BDBDA , O),5P - Bepatitis C usually caiiies the same symptoms as uoes
hepatitis B, anu is tiansmitteu thiough bloou piouucts (sex, uiity neeules).
Bepatitis C is often a chionic illness that leaus to caicinoma anuoi ciiihosis.
People infecteu will usually become caiiieis of hep C. Is an RNA flaviviius.
)7N@BDBDA & O)&5P - Alone, hepatitis B cannot infect, anu iequiies a co-infection
with hepatitis B in oiuei to infect (iequiies BBsAg as its envelope). Is a ueltaviius.
)7N@BDBDA $ O)$5P - Bas a fecal-oial tiansmission ioute, anu has the tenuency to
cause watei-boine epiuemics. veiy similai symptomatically to hepatitis A. BEv can
cause significant illness anu even ueath in piegnant women. Is an RNA caliciviius.
** (HN 2 BAM ! ! chionic, cause ciiihosis, anu hepatocellulai caicinoma.
** (HN ) BAM % ! affect the uI tiact.







)$/+(-(-2 2$#"."TG
The hepatitis seiology is veiy high-yielu foi the Step 1, memoiize all of this
infoimation.
BBsAg ! Is the antigen founu on the suiface of BBv, when it is piesent, theie is a
caiiiei state.
BBsAb ! Is the antibouy to BBsAg, its piesence inuicates immunity to Bep B
BBcAg ! Is the antigen associateu with the BBv coie
BBcAb ! Is the antibouy to BBcAg, anu when piesent inuicates the "winuow
peiiou" of infection. When theie is an IgN BBcAb, theie has been a iecent infection.
BBeAg ! This is an inuicatoi of hep B tiansmittability, anu is the 2
nu
ueteiminant of
the hepatitis B coie.
BBeAb ! Is the hepatitis E antigen, inuicating low tiansmittability of the uisease.

()$ )$/+(-(-2 5-#+. /+#(-,.$






+ T#+/)-,+. .""V +( + )$/+(-(-2 -4!$,(-"4


/4$13"4-+ a ,"33"4 ,+12$2 /$# +T$ T#"1/
1N B> XWF8 >I= ! #1 - RSv #2 - Nycoplasma #S - Chlamyuia #4 - Stiep
XWS^YF8 >I= ! #1 - Stiep
** +BFNDE@ILK@ImD:M N:7<?>:D@ ! Nycoplasma
^YS`bF8 >I= ! #1 - Stiep #2 - B. Influenza
h`YF8 >I= ! #1 Stiep #2 - viial etiologies

/4$13"4-+ a 2/$,-+. 2-(1+(-"42
-: @: @IE>H>IDE ! Stiep Pneumonia is the NCC, howevei Klebsiella is moie likely in
an alcoholic (be caieful with this question, because you may be askeu what the most
common cause of pneumonia is in an alcoholic, which is still Stieptococcus)
)>ANDB@IS@Es<D87= ! Staph
-: @: D??<:>E>?N8>?DA7= N78A>: ! Staph is most common cause, but watch
foi an BIv patient who can get PCP pneumonia when CB4 count is low.
+AND8@BD>: ! Anaeiobic oial floia
47>:@B@I ! 0p to the fiist 6 weeks of life - uioup B stiep anu E. Coli

,"33"4 "#T+4-232 -4 1#-4+#G (#+,( -4!$,(-"42
The most common cause of uiinaiy tiact infections is E. Coli. The most common
symptoms aie painful uiination, fiequency, uigency, anu supiapubic pain. This can
ascenu anu become a seveie infection such as pyelonephiitis.
Nost common in women because they have a shoit uistance fiom the outsiue of the
uiethia to the blauuei. Tieatment involves using TNP-SNP (Bactiim)

3$4-4T-(-2
Is a life-thieatening infection of the meninges. Patient
piesents most commonly with nuchal iigiuity, high
fevei, anu alteieu mental status. The most common
causes pei age gioup aie the following:
In newboins up to 6 months ! E. Coli
In chiluien 6 months - 6 yis ! Stiep Pneumonia
In people 6yi - 6uyis ! Neisseiia Neningitiuis
In people > 6uyi ! Stiep Pneumonia




(7AB )D:BR
The 0SNLE will
give you a
scenaiio wheie
someone is in
close contact with
otheis
(uoimitoiy, aimy,
etc), this is almost
always leauing
you to meningitis.

+ .-2( "! ()$ 3"2( ,"33"4.G ($2($& 2(&[2
T>:>88H7@ ! piesents with uiethiitis, ceivicitis, epiuiuymitis (men). Can cause
pelvic inflammatoiy uisease (common cause of infeitility). Causeu by N. uonoiihea,
tieat with ceftiiaxone.
,HI@?F=D@ ! piesents similaily to gonoiihea. When this is founu, theie is usually
a co-infection with gonoiihea. Causeu by Chlamyuia Tiachomatis.
)78N7A ! *)5#Z73 ulcei of the penis, vulva, anu ceivix
2FNHDIDA ! *)5#3%&& chancie (seen in 1 foim), systemic finuings in 2 foim, anu
neuiological finuings in the S foim.
.F?NH>M8@:<I>?@ 57:787<? ! *)5#3%&& ulcei at the beginning, with infection
spieauing along the inguinal pathway. Causeu by Chlamyuia Tiachomatis types L1-
LS.
5@MD:DBDA ! vaginal itching, pain, anu uischaige. Nay be uue to gaiuneiella,
tiichomonas, oi canuiua.
,H@:E8>D= ! *)5#Z73 genital ulceis, causeu by Baemophilus Bucieyi
,>:=FI>?@ +E<?D:@B@ ! Causes genital waits that can be on the labia, in the
vagina, anu on the ceivix. Causeu by BPv types 6 anu 11.

/$.5-, -4!.+33+("#G &-2$+2$
Is a scaiiing of the fallopian tubes, anu is a veiy common cause of infeitility in
women. Theie is often symptoms such as ceivical motion tenueiness, vaginal
uischaige, anu even tubo-ovaiian abscess.
/?@C O?DD?A OBS@H F@ !ILBDEMFB BAM .?A?>>IHB.








()$ ("#,) -4!$,(-"42
"T0RCB" is the mnemonic useu to iecall the most commonly encounteieu
congenital infections, they aie:
( - Toxoplasmosis
" - stanus foi "othei", which is Syphilis
# - Rubella
, - CNv
) - BSv anu BIv

"2($"3G$.-(-2
0steomyelitis is an infection of the bone, which can be causeu by a numbei of
uiffeient oiganisms, they incluue:
2B@NHFI>E>EE<A +<87<A ! Is the most common cause oveiall
2@I?>:7II@ ! Causes osteomyelitis in sickle cell patients
T>:>88H7@ ! Can cause osteomyelitis in sexually active people (is a less common
cause)
/A7<=>?>:@A +78<MD:>A@ ! Common cause in intiavenous uiug useis
2B@NH $ND=78?D=DA ! Common cause of osteomyelitis in those with piosthetic
uevices.








/+#+2-("."TG

Stuuying the 'paiasitology' section foi the 0SNLE exam is simple anu
stiaightfoiwaiu, simply memoiize all oiganisms anu theii piesentations, theii moue
of tiansmission, how the uiagnosis is maue, anu finally the best tieatment foi each.
/+#+2-($ &-2$+2$L2G3/("32 3"&$ "!
(#+423-22-"4
&-+T4"2-4T (#$+(3$4(
/I@A?>=D<?
O5D9@Jl "9@I7l
3@I@8D@7l
!@IEDN@8<?P
NALARIA, causes a
cyclic fevei +
heauache,
splenomegaly, anu
anemia
Anopheles
mosquito

Bloou smeai Chloioquine,
Sulfauoxine,
Pyiimethamine,
quinine,
Nefloquine
$:B@?>7Q@
)DAB>IFBDEA
Bystenteiy, bloouy
uiaiihea, livei
abscess, anu iight
uppei quauiant pain
Cysts founu in
B2u
Cysts in stool Netioniuazole
+ Iouoquinol
TD@8=D@ .@?QID@ Foul-smelling
uiaiihea, flatulence,
anu bloating
Cysts in B2u Cysts in stool Netioniuazole
,8FNB>AN>8D=D<? Seveie uiaiihea founu
in AIBS patients, milu
uiaiihea in healthy
patients
Cysts founu in
B2u
Cysts seen on
aciu-fast
stain
No tieatment
(>J>NI@A?@ Biith uefects anu
biain abscesses (BIv
patients)
Cysts founu in
cat feces anuoi
meat
Seiology anu
biopsy
Pyiimethamine
anu
sulfauiazine
(8DEH>?>:@A Foul-smelling
uischaige, gieen in
coloi fiom the vagina
Sexual Tiophozoites
seen on wet
mount
Netioniuazole
4@7MI78D@ Causes a ueauly
meningoencephalitis
Caught by
swimming in
fieshwatei
lakes
Spinal fluiu
shows
amoeba
No tieatment
(8FN@:>A>?@
,8<jD
Causes Chaga's heait
uisease
Tiansmitteu via
the ieuuviiu bug
Seen on
bloou smeai
Nifuitimox
(8FN@:>A>?@
T@?QD7:A7
Causes Afiican
sleeping sickness
Tiansmitteu
thiough the
Tsetse fly
Seen on
bloou smeai
Suiamin oi
Nelaisopiol
*@Q7AD@ Causes babesiosis,
which is a uisease
similai to malaiia
Tiansmitteu
thiough the
Ixoues tick
"Naltese
cioss" seen
on bloou
smeai
Quinine anu
Clinuamycin
.7DAH?@:D@ Causes visceial Tiansmitteu via Smeai Souium
&>:>9@:D Leishmaniasis the sanufly showing
maciocytes
that contain
amastigotes
stibogluconate
























)$.3-4()2 O%>8?AP

}ust as with paiasites, memoiizing all of the uiffeient helminthes as well as theii
piesentation, tiansmission, anu tieatment is high-yielu as well as easy points on the
0SNLE exam.
)$.3-4() (#+423-22-"4 /#$2$4(+(-"4 (#$+(3$4(

(+/$%"#32

$EHD:>E>EE<A Fiom eggs within
uog feces
Cysts in livei cause
anaphylaxis if
antigens aie
ieleaseu fiom the
cyst
Albenuazole
(@7:D@ 2>ID<? 0nueicookeu poik Nass lesion in the
biain causeu by
laivae
Albenuazole

!.1V$2

2EHDAB>A>?@ Snails Spleen anu livei
aie affecteu, get
gianuloma,
fibiosis, anu
inflammation
Piizaquintel
/@8@M>:D?<A
%7AB78?@:D
Fiom unueicookeu
ciab meat
Bacteiial infection
anu thus
inflammation of
the lungs
Piizaquintel
,I>:>8EHDA
2D:7:ADA
Fiom unueicookeu
fish
Biliaiy tiact
inflammation
Piizaquintel

#"14&%"#32

.>@ .>@ Fiom ueei fly Inflammation anu
swelling of skin,
can see this woim
in the conjunctiva
Biethylcaibamazine
+:EFI>AB>?@
&<>=7:@I7
OH>>mK>8?P
Laival penetiation
of skin
Anemia is causeu
by intestinal
infection
Nebenuazole anu
pyiantel pamoate
+AE@8DA
.<?Q8DE>D=7A
Eggs in feces Intestinal infection Nebenuazole anu
pyiantel pamoate
OTD@:B
8><:=K>8?P
$:B78>QD<A
578?DE<I@8DA
O/D:K>8?P
Infecteu foou (with
eggs)
Intestinal
infection, also get
anal itching
Nebenuazole anu
pyiantel pamoate
(8DEHD:7II@
2ND8@IDA
0nueicookeu poik Causes peiioibital
euema anu muscle
inflammation
Thiabenuazole
2B8>:MFI>D=7A
2B78E>8@IDA
Laiva fiom soil get
in thiough the skin
Causes an
intestinal infection
Iveimectin anu
thiabenuazole
&8@E<:E<I<A
37=D:7:ADA
Infecteu watei Inflammation anu
ulceiation of the
skin
Niiiuazole
(>J>E@8@ ,@:DA Contaminateu foou Causes gianulomas
in the ietina, may
leau to blinuness
Biethylcaibamazine
%<EH7878D@
*@:E8>CBD
Fiom the female
mosquito
Blocks lymph
uiainage leauing to
elephantitis
Biethylcaibamazine
":EH>E78E@
5>I9<I<A
Female blackflies Causes "iivei
blinuness"
Iveimectin














3G,"."TG

Nycology (fungi) play a veiy impoitant iole in meuical pathology, as theie aie a few
veiy impoitant conuitions that aie seen on a veiy iegulai basis clinically.
Eveiything in this section is &7*%+ (5.(K05%3X, thus be suie to know this section
colu.

,+4&-&+ +.*-,+42
Canuiua albicans is seen wiuely in many uiffeient clinical
situations. It can cause a wiue vaiiety of conuitions, anu can
be seen both supeificially (on the skin), anu systemically
(anywheie else).
,H@8@EB78DABDEA >C ,@:=D=@:
- Biploiu fungus
- Buuuing yeast with pseuuohyphae aiounu 2uC
- Buuuing yeast with geim tube foimation aiounu S7C
,>??>: N8>QI7?A E@<A7= QF ,@:=D=@:
- vaginitis (yeast infection)
- 0ial thiush
- Esophagitis
- Enuocaiuitis (Iv uiug use)
(87@BD:M ,@:=D=@:
- Foi supeificial infections (incluuing oial thiush), Nystatin is the tieatment of
choice.
- Foi systemic infections, amphoteiicin B is commonly useu.







($2( (-/R
You will be given
images of fungi
on the 0SNLE
exam. Be suie to
unueistanu theii
anatomy anu how
they look
micioscopically.

,"33"4 ,1(+4$"12 !14T+. -4!$,(-"42
(D:7@ /7=DA - "Athlete's Foot", piesents with itching, flaking, anu scaling of the
affecteu aieas, causeu by Tiychophyton. Tieat with a topical azole.
(D:7@ ,@NDBDA - Ringwoim of the haii, causeu by Tiichophyton anu NIciospoium.
Invasion of the haii shaft leaus to haii loss that occuis in patches. Tieat with a topic
azole.
(D:7@ ,8<8DA - "}ock Itch", is a fungal infection of the gioin iegion.
(D:7@ ,>8N>8DA - "Ringwoim", is a skin infection of the aims anu legs most
commonly, howevei it can occui anywheie. The classic appeaiance is a ciiculai
iash that cleais centially with elevateu euges.
(D:7@ 578ADE>I>8 - Is a iash of the tiunk anu pioximal extiemities, causeu by
Nalassezia Fuifui. Classic piesentation is hypopigmentation of the skin with shaip
boiueis anu fine scaling. Seen most commonly in hot anu humiu climatesweathei.
Topical miconazole anu selenium sulfiue aie effective tieatments.
(D:7@ 4DM8@ - Affects the keiatinizeu layei of the skin, piouucing biown pigments.
Is causeu by Boitaea Weineckii, is tieateu with topical antifungals.

$4&$3-, 2G2($3-, 3G,"2$2
(5&$"*3)&/"&5&:
- Is enuemic to the Nississippi anu 0hio iivei valleys.
- Acute phase piesents with non-specific iespiiatoiy symptoms
- Chionic conuition may iesemble tubeiculosis, that if left untieateu can leau
to ueath
23)&$"/0!"&5&:
- Enuemic to states east of the Nississippi iivei anu to Cential Ameiica
(B@ DBAE TBE@ ?U N?CHACFBLLE N>H@HACFAJd
- Nilu "flu-like" illness
- Pneumonia-like illness
- Chionic illness that mimics TB oi lung cancei
- Aggiessive uisease that causes significant iespiiatoiy uistiess
- Nay cause skin lesions anu bone pain
- Is a laige yeast with bioau-baseu buuuing

!"!!5X5"5X"/0!"&5&: aka valley Fevei
- Is enuemic to the Southwestein paits of the 0SA
- Is founu in the soil
- Commonly it is a milu uisease (flu-like)
- Can be seveie anu leau to seveie complications such as pneumonia, lung
nouules, anu systemic finuings thioughout the bouy
- Also known as "valley Fevei"
*)+)!"!!5X5"5X"/0!"&5&:
- Is enuemic to Ruial Latin Ameiica
- Involves the mucous membianes, LN's, bones, anu lungs
- Nay be asymptomatic in some
- }uvenile foims aie often moie seveie anu holu a woise piognosis
- Painful lesions of the lips anu oial mucosa
- Pulmonaiy involvement usually begins as lobai pneumonia that fails to
iesolve

"//"#(14-2(-, !14T+. -4!$,(-"42
!BAMFMB )LWFOBA@ - vaginitis in uiabetics anu those using antibiotics, thiush in
those with immunocompiomiseu conuitions.
Pseuuohyphae anu Buuuing Yeast

/SO?>e+IFa?NS@ - causes mucoimycosis, affects patients with leukemia anu affects
those with uiabetesBKA.
Non-septate hyphae, with wiue-angleu bianching.
!>ENC?O?OOS@ #H?U?>DBA@ - Causes ciyptococcal meningitis. Is a veiy heavily
encapsulateu yeast that is founu in soil anu in pigeon uioppings.
Beavily encapsulateu yeast (~S-1uum in uiametei)

)@NH>JFLLS@ ZSDFJBCS@ - Causes a "fungus ball" cavity in the lungs.
Bianching septate hyphae at 4S

2/"#"()#-0 2,)$4,V--
This topic is auueu because it has come up ovei anu ovei on all 0SNLE exams. This
is a uimoiphic fungus that lives on vegetation. The spieau is thiough being piickeu
with a thoin, thus the name "Rose uaiuenei's uisease" is given. It causes local
ulceiations in auuition to nouules that follow the lymphatic uiainage.






!()*$%+ ,1

*()+/)!"3".0

*IB>DBO?L?JE F@ B GH>E IFJIKEFHLM C?NFO ?A CIH 7&/3% &CHN ,
HPBDQ Z?OS@ @I?SLM WH DBMH ?A CIH U?LL?TFAJd /HOIBAF@D@
?U )OCF?AV OLFAFOBL S@HeBNNLFOBCF?A@V @FMH HUUHOC@Q
*IB>DBO?\FAHCFO@V NIB>DBO?MEABDFO@V BAM CIH BSC?A?DFO
AH>G?S@ @E@CHD B>H BL@? GH>E IFJIKEFHLM FAU?>DBCF?AQ















()$ $, bY
The ECSu is the concentiation of agonist that pioviues a iesponse halfway between
the baseline anu the maximum iesponse. The ECSu is the most common statistic
useu to measuie the potency of an agonist (it howevei is not useu to uiiectly
measuie affinity).


,"3/$(-(-5$ _ -##-5$#2-*.$ +4(+T"4-2(2
Antagonists aie uiugs that will paitially oi completely block a iesponse.
!?DNHCFCFGH BACBJ?AF@C@ binu ieveisibly to the same ieceptoi as the agonist, while
the F>>HGH>@FWLH BACBJ?AF@C binus iiieveisibly. The piesence of an antagonist will
inciease the ECSu by a factoi known as the 'uose-iatio'.
Below, the giaph will uemonstiate how concentiation 'X' gives a ceitain iesponse in
the absence of an antagonist, but concentiation 'X1' is neeueu in oiuei to achieve
the same iesponse when theie is a piesence of a O?DNHCFCFGH BACBJ?AF@C, the uose
then equals X1X. 0sing uiffeient concentiation of antagonist will piouuce a
uiffeient uose iatio.

In the piesence of an F>>HGH>@FWLH BACBJ?AF@C on the othei hanu, the iiieveisibly
bounu antagonist iesults in uepiession of the maximal iesponse of the agonist uose-
iesponse cuive anu a iight shift also occuis wheie theie is a ieceptoi ieseive
similai to non-competitive antagonists.


!1.. +T"4-2( 9An /+#(-+. +T"4-2(
In compaiing a USLL G@Q NB>CFBL BJ?AF@C, they act on the same ieceptois howevei the
paitial agonist has a lowei maximal efficacy, thus even with incieaseu uosages, it
cannot ieach the same efficacy as that of the full agonist.





&#1T $.-3-4+(-"4
Theie aie two types of uiug elimination: mH>? ">MH> BAM ,
@C
">MH>
&8<M ,I7@8@:E7 = Rate of elimination Plasma Biug Concentiation
X
AB
"8=78 $ID?D:@BD>: - In 1
st
oiuei elimination, the iate of uiug elimination is
piopoitional to the plasma concentiation (Cp) of uiug. Thus with moie uiug
concentiation theie is moie uiug elimination, if theie is less uiug concentiation
theie is less uiug elimination. Nost uiugs aie eliminateu by 1
st
oiuei elimination.

\78> "8=78 $ID?D:@BD>: - In Zeio oiuei elimination, the fiaction of uiug
elimination iemains constant, no mattei how high the uiug concentiation. Theie
aie less uiugs eliminateu with zeio-oiuei elimination, two examples aie alcohol anu
aspiiin.




-3/"#(+4( $e1+(-"42 -4 /)+#3+,"."TG


/)+2$ X 9An /)+2$ Z &#1T 3$(+*".-23
*IB@H , DHCBW?LF@D - Piouuces watei-soluble metabolites thiough ieuuction,
oxiuation, anu hyuiolysis of the uiug molecules. These metabolites aie slightly
polai. 0ses the CYP4Su metabolism.
*IB@H 1 DHCBW?LF@D - Piouuces inactive metabolites that aie veiy polai, occuis
thiough acetylation, glucuioniuation, anu sulfation.


()$ +1("4"3-, 4$#5"12 2G2($3
The autonomic neivous system iegulates many bouily piocesses (BR, BP, uigestion,
iespiiation, bloou pB, etc) automatically on a subconscious level. The flow of this
system is as follows:
!#& ! *>HJBAJLF?AFO UFWH>@ ! .BAJLF?A ! *?@CJBAJLF?AFO UFWH>@ ! %AM ?>JBA

The autonomic neivous system consists of the '@EDNBCIHCFOc anu 'NB>B@EDNBCIHCFOc
systems.


2G3/+()$(-, 4$#5"12 2G2($3
- The neives come fiom the
thoiacic anu lumbai iegions.
- Pieganglionic neives aie shoit
anu synapse in the paiieu ganglia
aujacent to the spinal coiu.
- Ach ieleaseu fiom pieganglionic
neuions.
- NE is ieleaseu fiom the
postganglionic neuion.
- Incieases caiuiac output,
incieases pulmonaiy ventilation,
incieases musculai bloou flow,
incieases bloou glucose,
uecieases uigestion, incieases
filtiation thiough kiuneys.

3@;>8 87E7NB>8A @87 BH7 @INH@ @:=
Q7B@ 87E7NB>8An
/+#+2G3/+()$(-, 4$#5"12
2G2($3
- The neives come fiom the
cianial anu sacial iegions of
the CNS.
- Involveu cianial neives aie
CN S, 7, 9, 1u.
- Long pieganglionic neives,
shoit postganglionic neives.
- Ach is ieleaseu fiom both
the pie anu post ganglionic
neuions.
- Incieases uigestion, helps
with uiination anu
uefecation.

3@;>8 87E7NB>8A @87 BH7 4DE>BD:DE
@:= 3<AE@8D:DE 87E7NB>8An


+&#$4$#T-, +4& ,)".-4$#T-, #$,$/("#2





+=87:78MDE #7E7NB>8A
Stimulateu most commonly by
7%()#%"/()# *)1 8./#%()#%"/()#.
!X - Causes constiiction of smooth
muscle of aiteiioles anu uIu0.
!Z - Smooth muscle constiiction
anu neuiotiansmittei inhibition
"X - Causes contiaction of the
heait muscle.
"Z - Causes smooth muscle
ielaxation of lungs anu blauuei.
,H>ID:78MDE #7E7NB>8A
Stimulateu by Acetylcholine.
Nicotinic ieceptois aie founu in the
autonomic ganglion.
Nuscaiinic ieceptois aie founu on
all oigans with paiasympathetic
neives.







()$ 2G3/+()$(-, +4& /+#+2G3/+()$(-, !-*$#2



()$ !X #$,$/("#
+T"4-2(2 +4(+T"4-2(2 +T"4-2(
/"($4,G
3$,)+4-23 "!
+,(-"4
Noiepinephiine
Phenylephiine
Nethoxamine
Xylometazoline
Piazosin
Teiazosin
Boxazosin
Alfuzosin
Phenoxybenzamine
Phentolamine
4$ h $/- Ts: Phospholipase
C activateu, 5*4
anu !BLOFSD.

()$ !Z #$,$/("#
+T"4-2(2 +4(+T"4-2(2 +T"4-2(
/"($4,G
3$,)+4-23 "!
+,(-"4
Cloniuine
Biimoniuine
Phentolamine
Yohimbine
Atipamezole
$/- h 4$ TD: AC inactivateu,
cANP

()$ "X #$,$/("#
+T"4-2(2 +4(+T"4-2(2 +T"4-2(
/"($4,G
3$,)+4-23 "!
+,(-"4
Bobutamine Netopiolol
Atenolol
Isopienaline > EPI
= NE
TAR AC activateu,
cANP

()$ "Z #$,$/("#
+T"4-2(2 +4(+T"4-2(2 +T"4-2(
/"($4,G
3$,)+4-23 "!
+,(-"4
Albuteiol
Isopienaline
Netapioteienol
Salmetiol
Teibutaline
Piopianolol Isopienaline > EPI
>> NE
TA: AC activateu,
cANP





,)".-4$#T-, &#1T2
Cholineigic uiugs stimulate the action of acetylcholine, which plays a laige iole in
the "iest anu uigest" poition of autonomic functioning. These uiugs help us uigest
anu piopel foou thiough the uI, help with uiination, secietion of salivaiy fluius, anu
many moie functions.

,)".-4"3-3$(-,2
XF>HOC )J?AF@C@
+T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4
,@8Q@EH>IL/DI>E@8ND:7 ulaucoma ielief Activates the ciliaiy
muscles of the eye
*7BH@:7E>I 0iinaiy ietention Activates the smooth
muscle of the bowel anu
blauuei

5AMF>HOC )J?AF@C@ hFH )ACFOI?LFAH@CH>B@H@i
+T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4
47>ABDM?D:7 Reveisal of post-op NN
junction blockaue, ileus,
uiinaiy ietention,
myasthenia giavis
Incieases enuogenous
ielease of acetylcholine
/F8D=>ABDM?D:7 Nyasthenia giavis Incieases enuogenous
ielease of acetylcholine
$=8>NH>:D<? Is veiy shoit-acting anu
useu in the uiagnosis of
myasthenia giavis
Incieases enuogenous
ielease of acetylcholine
/HFA>ABDM?D:7 0seful foi glaucoma anu
ieveises an atiopine
oveiuose
Incieases enuogenous
ielease of acetylcholine
$EH>BHD>NH@B7 ulaucoma Incieases enuogenous
ielease of acetylcholine






+4(-,)".-4$#T-,2
+T$4( ,.-4-,+. 12$ 3$,)+4-23 "! +,(-"4
Atiopine Piouuces myuiiasis anu
cycloplegia foi eye exams
Competitive antagonist at
cholineigic ieceptoi
Benztiopine 0seu in Paikinson's
uisease
Nuscaiinic ieceptoi
blockei
Scopolamine Pievents anuoi tieats
motion sickness
Nuscaiinic ieceptoi
blockei
Ipiatiopium Nainstay of C0PB
management
Nuscaiinic ieceptoi
blockei

,)".-4$2($#+2$ -4)-*-("# /"-2"4-4T
Cholineigic intoxication is most commonly seen with poisoning fiom a
cholinesteiase inhibitoi. This is classically seen in faimeis oi anyone woiking with
oiganophosphates, anu in snake venoms. The signs anu symptoms of cholinesteiase
inhibitoi poisoning can be iemembeieu with the mnemonic "&37XX"
$IH>H TFLL WH HPOH@@FGHd
2 - Salivation
. - Laciimation
1 - 0iination
& - Bigestion
& - Befecation

,G(",)#"3$ /^bY 3$(+*".-23






-4&1,$#2
Quiniuine
Baibituiates
Phenytoin
Rifampin
uiiseofulvin
Caibamazepine
-4)-*-("#2
Isoniaziu
Sulfonamiues
Cimetiuine
Ketakonazole
Eiythiomycin
uiapefiuit }uice
St. }ohn's Wait

)-T)SG-$.& 2G3/+()"3-3$(-, !+,(2
X?NBDFAH - Incieases BP in patients with shock by maintaining ienal bloou flow.
X?WSCBDFAH ("1) - Stimulates the heait without causing excess tachycaiuia.
5@?N>?CH>HA?L ("1, "2) - 0seu foi iefiactoiy Av block anu biauycaiuia.
!L?AFMFAH (!2) - Piimaiy use is systemic hypeitension, suppiesses SNS outflow
fiom the CNS. Stimulates PNS outflow, thus slows BR anu uecieases sympathetic
uiive. Auveise effects aie seuation, uiy mouth.
)LWSCH>?L ("2) - Piimaiy tieatment of asthma.
$H>WSCBLFAH (("2) - 0seu foi bionchospasm, asthma.
)DNIHCBDFAH@ - Release NE, cioss the bloou-biain baiiiei, inciease BP with a
ieflex ueciease in BR. Toxicity: Bizziness, tiemoi, talkative, tense, iiiitable,
insomnia, fevei, confusion, incieaseu libiuo, paianoia, panic, suiciual tenuencies.

)-T)SG-$.& 2G3/+()".G(-, !+,(2
*>Ba?@FA - 0seu foi BPB, has a 1
st
uose phenomenon wheie patient gets
pionounceu auveise effects with theii fiist uose (most commonly get oithostatic
hypotension - a uiop in systolic BP of at least 2ummBg, oi uiop in uiastolic BP of at
least 1ummBg).
*IHAC?LBDFAH - Causes gieatei inciease in BR than piazosin (ieflex), anu is useu
foi uiagnosing pheociomocytoma.
3BWHCBL?L - ! & " blockaue, useful in hypeitensive emeigencies, one of two uiugs
useu in piegnant patients with hypeitension.
*>?N>BA?L?L - is the piototypical "-blockei, has gieatei lipophilicity than otheis,
useful foi hypeitension, angina, acute NI, stage fieight, anu pheociomocytomas.
Pievents exeicise-inuuceu tachycaiuia anu oxygen uemanu.
$FD?L?L - 0seful foi migiaines, useu in open-angle glaucoma to ueciease aqueous
humoi foimation.
*FAM?L?L - Bas the gieatest ISA (pievents excess biauycaiuia).
/B`?> HUUHOC@ ?U "KWL?O\H>@ ?A CIH OB>MFBO @E@CHD - Beciease contiactility,
ueciease BR, ueciease BP, inciease exeicise toleiance.
/B`?> HUUHOC ?A CIH HEH - Beciease foimation of aqueous humoi.
/B`?> DHCBW?LFO HUUHOC@ - Bon't use in uiabetics as it blocks symptoms of
hypoglycemia (ie inhibits tiemoi, uiaphoiesis, tachycaiuia, anu inhibits
glycogenolysis). Block symptoms of hypeithyioiuism.

+4(-)G/$#($42-5$ /)+#3+,"."TG
Theie aie SIX categoiies of antihypeitensive meuications:
1. Biuietics
2. Sympatholytics ("-blockeis)
S. Ace Inhibitois
4. Angiotensin Receptoi Blockeis
S. vasouilatois
6. Calcium Channel Blockeis

X57+%$5!&
In auuition to leaining all of the uiuietics useu foi hypeitension, it is veiy impoitant
to unueistanu wheie anu how they woik in the kiuney. Below is a list of the
commonly useu uiuietics, theii mechanism of action, theii clinical uses, anu theii
toxicities. Following that is an image of the kiuney anu its physiology as it ielateu to
uiuietics.

+,$(+\".+3-&$d Is a caibonic anhyuiase inhibitoi, which causes uiuiesis of
NaBC0S anu ieuuces the total-bouy BC0S- stoies. Its site of action is the pioximal
convoluteu tubule.
7&%& - Altituue sickness, glaucoma, alkalinization of the uiine, metabolic alkalosis.
$"f5!5$5%& - NBS toxicity, hypeichloiemic metabolic aciuosis, neuiopathy.

3+44-(".: An osmotic uiuietic that acts by incieasing the tubulai fluiu
osmolaiity, which then causes watei to move into the tubules, incieasing the
amount of uiine.
7&%& - To ueciease intiacianial piessuie, to ueciease intiaoculai piessuie, uiug
oveiuose.
$"f5!5$5%& - Behyuiation, pulmonaiy euema.

.""/ &-1#$(-,2: Loop uiuietics inhibit the NaK2Cl co-tianspoit system of the
thick ascenuing limb of the loop of Benle.
7&%& - Foi states of excessive euema, such as CBF, ciiihosis, pulmonaiy euema,
nephiitic synuiome. Also useu to ueciease total bouy calcium levels.
$"f5!5$5%& - The famous mnemonic ""( X)#." can be useu to iemembei the
toxicities of loop uiuietics.
"totoxicity )ypokalemia &ehyuiation +lleigy 4ephiitis Tout

()-+\-&$2: Thiaziue uiuietics woik by inhibiting the NaCl ieabsoiption in the
eaily uistal tubule, which uecieases the uiluting capacity of the nephion.
7&%& - Is a fiist-line uiug foi hypeitension. Also useu foi cases of iuiopathic
hypeicalciuiia, CBF, anu nephiogenic uiabetes insipiuus.
$"f5!5$5%& - 0se the mnemonic IENH>.37! to iemembei the most common
toxicities of thiaziue uiuietics.
(ENH>: Tlycemia, .ipiuemia, 1iicemia, ,alcemia

Vk 2/+#-4T: The most commonly useu uiug is &NF>?A?LBOC?AHV acts as a
competitive aluosteione ieceptoi antagonist in the coitical collecting tubule.
7&%& - CBF, potassium uepletion, anu hypeialuosteionism (K+ anu aluosteione
move in the opposite uiiection in the tubule).
$"f5!5$5%& - Bypeikalemia, gynecomastia, antianuiogen effects.

+,$ -4)-*-("#2: Captopiil, Enalapiil, anu Lisinopiil. Act by inhibiting the enzyme
angiotensin-conveiting enzyme, which ieuuces the levels of angiotensin 2 (fiom
Renin) anu pievents the inactivation of biauykinin.
7&%& - Bypeitension, CBF, anu ienal uisease causeu by uiabetes.
$"f5!5$0 - The mnemonic "CAPT0PRIL" can help iemembei all of the ACEI
toxicities.
,ough, +ngioeuema, /ioteinuiia, (aste Change, hyp"tension, /iegnancy issues,
#ash, -ncieaseu ienin, .owei Angiotensin 2.


,+.,-13 ,)+44$. *.",V$#2: Block the voltage-uepenuent L-type channel in
caiuiac anu smooth muscle, thus ieuucing muscle contiactility.
XFIEM>?NE>FMFAH@ - Amlouipine, Nicaiuapine, Nifeuipine
#?AKMFIEM>?NF>FMFAH@ - veiapamil, Biltiazem
7&%& - Bypeitension, angina, aiihythmias
$"f5!5$0 - Flushing, uizziness, peiipheial euema, anu caiuiac uepiession.

4-(#"T.G,$#-4$: Causes vasouilation via ielease of nitiic oxiue in the smooth
muscle, this incieases cANP levels anu thus smooth muscle ielaxation. It causes
much moie uilation of veins than aiteiies.
7&%& - Angina, pulmonaiy euema.
$"f5!5$0 - Tachycaiuia, hypotension, anu heauache. Be aleit foi something calleu
"Nonuay Bisease", wheieby someone exposeu to nitioglyceiine thioughout the
woikweek uevelops toleiance, then loses toleiance ovei the weekenu, iesulting in
tachycaiuia, heauache, anu uizziness.

2G3/+()".G(-,2: !-blockeis, !2-agonists, "-blockeis
!KWL?O\H>@ - Inciease bloou vessel uilation (Piazosin, Teiazosin, Boxazosin)
!1KBJ?AF@C@ - Cloniuine (Becieases PvR, thus ueciease BP), Nethyluopa (Becieases
PvR anu BP in piegnant patients)
"KWL?O\H>@ - Selectives (Netopiolol, Atenolol, Betaxolol), Non-Selectives (Pinuolol,
Acetabulol, Labetolol)








2-($2 "! &-1#$(-, +,(-"4





+4(-+4T-4+.2
Angina piesents with seveie chest pain, uuiing activity (stable) anu without activity
(unstable). Piinzmetal's angina occuis via spasm of coionaiy aiteiy, anu is most
common in youngei females who smoke.
.?BL ?U CIH>BNE - Reuuce myocaiuial oxygen consumption by uecieasing eithei:
Enu-Biastolic volume, bloou piessuie, heait iate, contiactility, anu ejection time.
Nitiates anu "-blockeis can altei the components that affect myocaiuial u2
consumption in the following ways:
4-(#+($2 O@IB78
N87I>@=P
"S*.",V$#2
O@IB78 @CB78I>@=P
4-(#+($2 k
"SQI>Em78A
*I>>= /87AA<87 Beciease Beciease Beciease
$:= =D@AB>IDE
9>I<?7
Beciease Inciease Small effect
,>:B8@EBDIDBF Inciease Beciease Small effect
)7@8B 8@B7 Inciease Beciease Beciease
$;7EBD>: BD?7 Beciease Inciease Small effect
3F>E@8=D@I YZ
E>:A<?NBD>:A
Beciease Beciease Laige ueciease

.",+(-"4 "! ,+#&-+, &#1T +,(-5-(G


+4(-S+##)G()3-, &#1T2
!3)&& ,) - This class of anti-aiihythmic uiugs has affinity foi the open state of Na+
channels with slow iecoveiy iate.
X>SJ@ - Quiniuine, Amiouaione, Piocainamiue, Bisopyiamiue
$?PFOFCFH@ - Quiniuine causes cinchonism (a combination of heauache, tinnitus,
toisaues ues pointes). Piocainamiue can cause a ieveisible SLE-like synuiome.

!3)&& ,2 - Becieases AP uuiation, affects ischemic oi uepolaiizeu Puikinje anu
ventiiculai tissue. Excellent when useu foi post-NI ventiiculai aiihythmias anu
uigitalis-inuuceu aiihythmias.
X>SJ@ - Liuocaine
$?PFOFCFH@ - Liuocaine can cause CNS stimulation oi uepiession as well as caiuiac
uepiession

!3)&& ,! - Slows conuuction thiough the heait, especially in the Puikinje fibeis.
uoou foi supiaventiiculai aiihythmias anu life-thieatening ventiiculai aiihythmias.
Is a last iesoit meuication.
X>SJ@ - Flecainiue, Encainiue, Piopafenone
$?PFOFCFH@ - Is contiainuicateu in post-NI patients because it is a pioaiihythmic




!3)&& 1 h"KWL?O\H>@i - Beciease cANP, ueciease Ca2+, ueciease phase 4 slope,
inciease PR-inteival.
X>SJ@ - Netopiolol, Esmolol, Atenolol, Piopianolol
$?PFOFCFH@ - Impotence, Asthma exaceibations, CNS effects, caiuiovasculai effects
(biauycaiuia, Av block, CBF), hypoglycemia.

!3)&& 4 hbs OIBAAHL WL?O\H>@i - Inciease AP uuiation, inciease ERP, inciease QT-
inteival. Amiouaione blocks the K+ iectifiei channel that iepolaiizes the heait
uuiing phase S.
X>SJ@ - Sotolol, Amiouaione
$?PFOFCFH@ - Sotolol (Toisaues ues Pointes), Amiouaione (piolongs AP uuiation,
elongates QRS, pulmonaiyliveithyioiu toxicities, thus check PFT, LFT, TFT's)

!3)&& 6 h!B1s OIBAAHL WL?O\H>@i - Beciease conuuction velocity in Av noues,
incieases ERP, incieases PR inteival, pievents noual aiihythmias.
X>SJ@ - veiapamil, Biltiazem
$?PFOFCFH@ - Constipation, Flushing, Euema

"$(%+ [ )MHA?@FAH
Causes hypeipolaiization by blocking the Ca2+ influx anu pieventing K+ outwaiu
flow.
Is the uiug of choice foi uiagnosing anu abolishing Av noual aiihythmias (is a
substitute useu between caiuioveisions, has a half-life of 1us.








,)! &#1T2

2B@M7A >C ,)!R
!LB@@ , h)@EDNC?DBCFOi - No limits on activity, only affects patient with noimal
exeicise.
!LB@@ 1 h&EDNC?D@ TFCI D?MH>BCH HPH>OF@Hi - Slightly limits oiuinaiy activity
(fatigue, palpitations)
!LB@@ 4 h&EDNC?D@ TFCI DFLM HPH>OF@Hi - No symptoms at iest, but occui with less
than oiuinaiy activities.
!LB@@ 6 h&EDNC?DBCFO BC >H@Ci - Seveie physical limitations, symptoms at iest
(when sitting)

2F?NB>?A >C ,)!R
- Tachycaiuia
- Weakness
- Fatigue
- 0ithopnea
- Peiipheial euema
- Pulmonaiy congestion
- Bypeiieninemia anu hypeialuosteione
- ventiiculai hypeitiophy anu iemoueling
- Incieaseu filling piessuieincieaseu enu-uiastolic volume

&8<MA <A7= C>8 ,)!R
5"#"$+"*%& - These uiugs inciease stiength of contiaction, thus inciease stioke
volume.
X57+%$5!& - Nove fluius out of the bouy thus uecieasing congestion.
])&"X53)$"+& - Beciease venous piessuie, congestion, anu euema.
!(+"#"$+"*%& - Inciease the speeu of heait contiactions.
)!% 5#(525$"+& - XHO>HB@H D?>CBLFCE in heait failuie patients, uecieases
ventiiculai iemoueling.

-"4"(#"/$2
,@8=D@E TIFE>AD=7 *7B@S+M>:DABA /H>ANH>=D7AB78@A7
-:HDQDB>8A
&-T"0-4

2L?O\@ CIH #Beb NSDN, thus
incieasing the intiacellulai Ca2+.

Is a positive ionotiope because of
the incieaseu Ca2+.

Incieaseu vagal tone, uecieaseu
QT inteival.

ST segment uepiession (hockey
stick configuiation).

T-wave inveision.

)MGH>@H %UUHOC@:
- NauseavomitingBiaiihea
- Effect is potentiateu by
hypokalemia
- Quiniuine will uisplace
uigoxin fiom binuing sites

)ACFM?CH is Bigoxin Immune Fab
oi moueiate inciease in K+

!?AC>BFAMFOBCHM use when
patient is using a K+ spaiing
uiuietic
&"*1(+3-4$
(Beta1 agonist)

Stimulates heait in
CBF anu in
caiuiogenic shock.


&"/+3-4$

Foi acute CBF anu
shock, incieases BP
anu maintains ienal
bloouflow.
3+.#-4"4$l
-4+3#-4"4$

Incieases contiactility
anu ielaxes smooth
muscle.

)MGH>@H %UUHOC@:
- Long-teim use
may cause
thiombocytopen
ia anu
ventiiculai
aiihythmias.










.-/-& ."%$#-4T +T$4(2
The goals of lipiu loweiing agents is to eithei ueciease LBL, inciease BBL, oi lowei
tiiglyceiiues. Some of the uiugs aie moie specific to an inuiviuual change, while
some pioviue a little bit of eveiything.
+T$4(2 (8DMIFE78D=7A .&. 7CC7EBA )&. 7CC7EBA +=978A7
$CC7EBA
2B@BD:A O)3TS
,>+ 87=<EB@A7
D:HDQDB>8AP
Nilu ueciease Significant
ueciease
Nilu inciease Nuscle
bieakuown
(check
myoglobin
levels,
incieaseu
LFTs)
*DI7 @ED= QD:=D:M
87AD:A
O,H>I7ABF8@?D:7P
veiy small
inciease
Noueiate
ueciease
No effect uI symptoms,
teiiible
tasting.
,H>I7AB78>I
@QA>8NBD>:
QI>Em78A
O$j7BD?DQ7P
No effect Noueiate
ueciease
No effect Incieaseu
LFTs
4D@ED: Nilu ueciease Noueiate
ueciease
No effect Flushing (can
tieat by
giving
aspiiin)
!DQ8@B7 =8<MA
OT7?CDQ8>jDIP
Significant
ueciease
Nilu ueciease Nilu inciease Nuscle
bieakuown,
incieaseu
LFTs.









+4(-S)-2(+3-4$2
X
AB
M7:78@BD>: @:BDHDAB@?D:7AR
- Competitively block the B1 ieceptoi.
- Aie lipophilic anu thus cioss the bloou-biain baiiiei, causing seuation.
- Bave incieaseu anti-cholineigic effects that last 4-6his.
- Biphenhyuiamine anu Piomethazine block the Na+ channel, thus have
anesthetic activity.

Z
:=
M7:78@BD>: @:BDHDAB@?D:7AR
- Less seuating
- Less anticholineigic effects
- Longei lasting
- Less lipophilic
- 0ses CYP4Su metabolism
,7B8DjD:7 (Zyitec) - inhibits mast cell ielease
!7J>C7:@=D:7 (Allegia)
.>8@BD=D:7 (Claiitin)



%)$#$ &" +2()3+ &#1T2 %"#Vf










+2()3+
The two main categoiies aie the "Contiolleis" anu the "Nain Attack Relief"
meuications.









)LWSCH>?L
- Rapiu inhalant
- Shoit-acting "2 agonist useu foi immeuiate ielief.
5N>BC>?NFSD
- A muscaiinic antagonist
- Nost commonly useu foi C0PB
- Less effective than the "2 agonist
- Antimuscaiinic effects
- Causes slowei bionchouilation that is long-lasting
$IH?NIELLFAH
- Inhibits phosphouiesteiase
- Becieases eosinophilslymphocytes, anu monocytes
- Loweieu half-life in chiluien anu in smokeis
- Naiiow theiapeutic inuex
- Commonly causes heauaches, uizziness, hypotension, biauycaiuia



,"4(#"..$#2
,"#(-,"2($#"-&2
3+2( ,$.. 2(+*-.-\$#2
."4TS+,(-4T *$(+
+T"4-2(2
.$1V"(#-$4$ #$,$/("#
+4(+T"4-2(2
3+-4 +((+,V #$.-$!
+.*1($#".
-/+(#+/-13
()$"/)G..-4$
3$(+/#"($#$4".
.$5+.*1($#".
!?>CFO?@CH>?FM@
Inhaleu - Beclomethasone, Tiiamclinolone, Buuesoniue, Fluticasone
0ial - Pieunisone, Pieunisolone
- Inhibit phopholipase A2
- Aie the coineistone of asthma management
- Becieases aiachiuonic aciu thiough phospholipase A2, inhibiting the C0X2
pathway.
- 0ial coiticosteioius can cause oial thiush
- Long-teim use can cause osteopoiosis, hypeitension, uiabetes, suppiession
of the pituitaiy-auienal axis, obesity, thinning of the skin, anu muscle
weakness.

/B@C !HLL &CBWFLFaH>@
- Ciomolyn anu Neuociomil
- Pievent mast cell uegianulation
- 0seu as piophylaxis
- Aie safei to use in kius

3?AJK)OCFAJ 2HCB )J?AF@C@
- Salmetiol is the piototype
- Pievents noctuinal asthmatic effects

3HS\?C>FHAH +HOHNC?> )ACBJ?AF@C@
- Nonteleukast anu Zafiilukast
- Antagonizes leukotiienes thus pieventing an inciease in bionchial tone

(87@BD:M 2B@B<A +ABH?@BDE<A
The coineistone of management is epinephiine oi pieunisone.





/+#V-42"4[2 &-2$+2$
Paikinson's uisease iesults fiom the uegeneiation of uopamine (BA) neuions in the
substantia nigia. Symptoms aie iesting tiemoi, iigiuity, anu biauykinesia.

Bopamine cannot cioss the bloou-biain baiiiei, thus it is conveiteu to leveuopa in
oiuei to get acioss the BBB. Theie aie ceitain uiugs that can be useu in oiuei to
pievent the conveision of leveuopa to othei things that cannot cioss.
X>SJ@ CIBC FAO>HB@H X?NBDFAH LHGHL@:








.$5$&"/+
When useu alone it
usually causes nausea
anu vomiting
Long-teim use causes
involuntaiy movement
Avoiu in psychotic
patients
,+#*-&"/+
Inhibits peiipheial
conveision of LB to
BA
Won't cioss the
BBB
Can cause uI anu
caiuiac pioblems
+3+4(+&-4$
An antiviial that
incieases BA
ielease fiom
nigiostiiatum.
Becieases BA
ieuptake.
Can cause
Leviuo
Reticulaiis
(Reu-blue skin).







X?NBDFAH +HOHNC?> )J?AF@C@:
*8>?>E8DNBD:7 - An eigot alkaloiu, a B2 agonist anu B1 antagonist.
/78M>ID=7 - B1 anu B2 antagonist, can cause neuiological symptoms.
#>ND:>8>I7 - The uiug of choice foi iestless leg synuiome.

+.,")".2

$CC7EBA >C @Q<A7:
- CNS seuation
- Becieaseu viscosity of cell membianes
%78:DEm7SV>8A@m>CC:
- Causeu by a thiamine ueficiency
- AtaxiaNystagmusConfabulations

2$.$T$.-4$
An NA0-B inhibitoi
that blocks the
conveision of BA to
B0PAC.
(".,+/"4$
A C0NT inhibitoi that blocks
the conveision of LB to S0NT.
Incieases LB bioavailability.
Causes an onoff effect uue to
its competition with LB foi
entiy into BBB.
3$()+4".
Also known as "methyl alcohol" oi "woou alcohol".
- 0seu in commeicial solvents
- Causes visual uistuibances (Snowstoim pattein)
- Tieatment with Iv fomepizole oi Iv ethanol



$()G.$4$ T.G,".
- Antifieeze, has a sweet smell.
- Causes CNS excitation followeu by CNS uepiession, followeu by metabolic
aciuosis, then causes the blockaue of ienal tubules by oxalate ciystals
- Tieat with Iv fomepizole (inhibits alcohol uehyuiogenase)
- Chaiacteiizeu by oxalate ciystals in the uiine, metabolic aciuosis, anu an
absence of visual uistuibances


X5&73Z5+)/ - Is a piesciiption meuication taken by alcoholics that inhibits the
alcohol uehyuiogenase enzymes. This causes an accumulation of acetaluehyue,
which makes the patient veiy sick.



+4(-S2$-\1#$ &#1T2









,
@C
LFAH C>HBCDHAC ?U BW@HAOH @HFaS>H@d
- Ethosuxamiue (chiluien)
- valpioate
- These block the T-type Ca2+ channels
,
@C
LFAH C>HBCDHAC ?U *B>CFBLe.HAH>BL $?AFO !L?AFO @HFaS>H@d
- Caibamazepine
- Phenytoin
- valpioate
,
@C
LFAH C>HBCDHAC ?U &CBCS@ %NFLHNCFOS@:
- Iv Biazepam

4@k EH@::7I
D:HDQDB>8AR
Caibamazepine
Phenytoin
valpioate
Lamotiigine

T+*+
$:H@:E78AR
Clonazepam
uabapentin
Biazepate
Chloiazepate
Phenobaibitol
vigabatiin
3DJ7= +EBD>:R
Topiiamate
Felbamate
+&5$#2$ $!!$,(2 "! +4(-S2$-\1#$ 3$&-,+(-"42R
,@8Q@?@j7ND:7 - seuation
/H7:FB>D: - gingival hypeiplasiahiisutismfacial coaiseningfetal hyuantoin
synuiome
.@?>B8DMD:7 - Steven-}ohnson synuiome

2V$.$(+. 312,.$ #$.+0+4(2










2V$.$(+. 312,.$ 2/+23".G(-,2


42+-&2l +,$(+3-4"/)$4l ,"0ZS-4)-*-("#2
42+-&2
Incluue Ibupiofen, Napioxen, Inuomethacin
/"): Reveisible inhibition of both C0X1 anu C0X2, which then blocks the synthesis
of piostaglanuins.
7&%&: 0seu as an anti-inflammatoiy, antipyietic, anu analgesic. Inuomethacin is
useu in infants to close a patent uuctus aiteiiosus.
)X]%+&% %ZZ%!$&: 0lceis, ienal toxicity, aplastic anemia.


+,$(+3-4"/)$4
Also known as Tylenol
/"): Causes ieveisible inhibition of the C0X pathway.
7&%&: Is useu foi its analgesic anu antipyietic piopeities, but lacks the anti-
inflammatoiy piopeities seen in NSAIBS.
)X]%+&% %ZZ%!$&: An oveiuose is ueauly, because of hepatic neciosis uue to toxic
metabolites which ueplete glutathione in the livei, causing the foimation of toxic
NAPQI in the livei.

,"0SZ -4)-*-("#2
Incluue Celecoxib, Rofecoxib
/"): Selective inhibition of C0X-2
7&%&: Excellent foi inflammation anu pain, but helps to maintain gastiic mucosa
because it uoesn't use the C0X-1. Nain clinical uses aie aithiitis (osteo anu RA).
)X]%+&% %ZZ%!$&: Renal toxicity, same as othei NSAIBS with less iisk of gastiic
ulceiations

+4$2()$(-,2
3+, (A()(040 E+P#.+*/ 9.)&#)'/*'(.)) is a concept useu in anesthesiology to
compaie the potency of anesthetic agents. Anesthetics with a highei NAC aie cause
fastei inuuction but have much lowei potency, while those with lowei NAC value
aie slowei to inuuce anesthesia but have a highei potency.
7:*0%+#:
NAC of nitious oxiue is '1u4', thus it acts fast anu has weakei potency (has incieaseu
bloou anu lipiu solubility).
NAC of halothane is 'u.7S', thus is acts slowei but has a stiongei potency (has
uecieaseu bloou anu lipiu solubility).




The Iueal Anesthetic:
- Immeuiate onset of action
- Bas ieveisible piopeities
- Lasts foi an appiopiiate uuiation of time
- Bas a wiue theiapeutic iange
- Causes no tissue uamage oi iiiitation


Bow they woik:
- Pievention of Na+ influx acioss neive membianes
- Significant anesthesia pievents fiiing thiesholu fiom being obtaineu
#? BOCF?A N?CHACFBL q #? FDNSL@H q !?AMSOCF?A WL?O\BMH






.",+. +4$2()$(-,2
Blockage of Na+ channels, inactivation is by hyuiolysis.




T$4$#+. +4$2()$(-,2


"/-"-&2
- Receptoi iesponsible foi supiaspinal anu spinal anesthesia, iespiiatoiy
uepiession, physical uepenuence.
& - Receptoi iesponsible foi spinal anesthesia anu uysphoiia.




2$&+(-5$L)G/4"(-,2
&HMBCFGH@ - ueciease anxiety
(ENA?CFO@ - inuucesmaintains sleep

*7:j>=D@j7ND:7A (enu with -pam)
- Biazepam
- Loiazepam
- Niuazolam
- Tiiazolam

/"): Binu uABA channels, incieasing the fiequency of channel opening.
&*%!5)3 7&%&:
Alcohol withuiawal - Chloiuiazepoxiue
Panic uisoiuei - Alpialozam
Nuscle spasms - Loiazepam
Status epilepticus - Biazepam
Z?> WHAa?MFBaHNFAH ?GH>M?@H - Flumazenil

*@8QDB<8@B7A (enu with -al)
- Phenobaibital
- Pentobaibital
- Secobaibital
- Thiopental
/"): Binu to non-uABA, non-Benzo sites, incieases the uuiation of channel
opening.
*BCCH>A ?U WB>WFCS>BCH MF@C>FWSCF?A: 1
st
- Biain 2
nu
- visceia S
iu
- Lean tissue 4
th
-
fat
7&%&: Anticonvulsant, pieopeiative seuation, coma inuuction


+4(-S&$/#$22+4(2
$>FOEOLFO )ACFMHN>H@@BAC@: Block the ieuptake of S-BT anu NE
&#1T ,)$3-,+. +!!$,($& -3/"#(+4( !+,(2
+?DB8FNBDID:7 S-BT Bighly seuative, can cause
oithostatic hypotension.
,I>?DN8@?D:7 S-BT Is the TCA B0C foi 0CB.
&7ADN8@?D:7 NE Low seuation.
4>8B8FNB@ID:7 NE Least seuative.
-?DN8@?D:7 NE = S-BT Noueiate seuation,
oithostatic hypotension.

1
AM
.HAH>BCF?A )ACFKXHN>H@@BAC@:
&#1T ,)$3-,+. +!!$,($& -3/"#(+4( !+,(2
+?>J@ND:7 BA Also useu foi psychosis,
can cause taiuive
uyskinesia.
*<N8>ND>: BA, NE, S-BT Can cause weight loss anu
is also useu foi smoking
cessation.
3@N8>BDID:7 NE
(8@j@=>:7 S-BT Can cause piiapism, CNS
uepiession, anu
oithostatic hypotension.

&&+5c@d )>H CIH @BUH@C J>?SN ?U BACFKMHN>H@@BAC@Q
&#1T 12$2 +&5$#2$ $!!$,(2
Fluoxetine (Piozac) Bepiession, panic
uisoiuei, anoiexia.
Bigh inhibition of CYP4Su,
can altei bloou glucose,
can cause SIABB.
Fluvoxamine (Luvox) 0CB, Panic uisoiuei.
Paioxetine (Paxil) Bepiession, panic
uisoiuei.
Bighest bioavailability,
highest seuation of SSRI's,
weight gain.
Seitialine (Zoloft) Bepiession, panic
uisoiuei.
veiy little CYP4Su effect,
piefeiieu in the elueily
because it uoesn't affect
metabolism.
/)"5c@: 0se with extieme caution as the NA0I's can cause seiious ieactions with
ceitain foous anuoi uiugs. Cheese, wine, etc, can cause ciisis.
/)")5 - SBT anu NE
/)"25 - BA
X
AB
T7:78@BD>: 3+"-[AR
- Phenelzine anu Tianylcypiomiue
- Pioviue non-selective inhibition
- Affects S-BT > NE
- Its effect is uue to uowniegulation of pie-synaptic iegulation, thus incieasing
S-BT neuions
Z
:=
T7:78@BD>: 3+"-[AR
- Neclobemiue
- NA0AI
]
8=
T7:78@BD>: 3+"-[AR
- Selegeline
- NA0BI foi Paikinson's uisease

+=978A7 $CC7EBA >C 3+"-[AR
- Sleep uistuibances
- Weight gain
- 0ithostatic hypotension
3+"- -:B>JDE@BD>::
- Agitation
- Beleiium
- Neuiomusculai excitation
- Loss of consciousness
- Seizuie
- Shock
- Bypeitheimia




/??M &CBWFLFaH>@d
.DBHD<? S Is the B0C foi moou stabilization in bipolai uisease.
- Calms mania
- Can cause hypothyioiuism
)MGH>@H %UUHOC@:
- Biowsiness
- Weight uain
- Low safety maigin
- The eailiest sign of an oveiuose is nausea anu vomiting

+4(-S/2G,)"(-,2
3"+ - B2 ieceptoi antagonists useu to ueciease the levels of uopamine (BA)
12$ - Alleviation of psychosis anu symptoms of psychosis.











+4(-S3-,#"*-+.2










&8<MA E>:B8@D:=DE@B7= D: 87:@I
D?N@D8?7:BR
Sulfonamiues
Tetiacyclines
Nitiofuiantoin
Itiaconazole
Ciuofovii
Ribaviiin
Naliuixic Aciu
&8<MA BH@B 87s<D87 @=;<:EBA D:
N@BD7:BA KDBH H7N@BDE
D:A<CCDED7:EFR
Clinuamycin
Chloiamphenicol
Eiythiomycin
Netioniuazole
Inuinavii
Ramantauine
vaiiconazole
Caspofungin
)ACFGF>BL@:
+EFEI>9D8 - 0seu foi heipes, can cause uI uistuibances, phlebitis, iash, anu
heauache.
T@:EDEI>9D8 - Is fiist line foi CNv, can cause myelosuppiession anu CNS toxicities.
!>AE@8:7B - Fiist line foi CNv ietinitis, CNv colitis, CNv esophagitis, anu acyclovii
iesistant BIvvZv. Nay cause nephiotoxicity, penile ulceiations, anu CNS toxicities.

2BOCH>FBL +H@F@CBAOH:
1. Tiansfeiable Resistance (tiansfei of plasmius)
2. Tiansfoimation (uptake of BNA)
S. Bacteiial Conjugation

)-T)SG-$.& +4(-3-,#"*-+. -4!"#3+(-"4
/7:DEDIID::
- 0seu against giam +ve cocci, ious, giam -ve cocci, anu spiiochetes
(tieponema)
- Binus to PCN-binuing pioteins
- Blocks the cioss-linking of cell walls (via tianspeptiuase blockage)
+?D:>MIFE>AD=7A:
- Incluue stieptomycin, gentamycin, tobiamycin, neomycin, amikacin,
spectinomycin.
- Causes misieauing of mRNA via the inhibition of foimation of the initiation
complex
- 0seu foi seveie giam -ve iou infections
- Can cause nephiotoxicity anu ototoxicity
- Shows a concentiation uepenuent kill iate (CBKR) anu a post-antibiotic
effect (PAE).
,HI>8@?NH7:DE>I:
- Is bacteiiostatic, inhibiting the Sus iibosomal subunit's peptiuyltiansfeiase
- 0seu foi neisseiia meningitiues, stiep pneumonia, anu haemophilus
influenza
- Can cause 'giey baby synuiome' anu aplastic anemia.


3@E8>ID=7A:
- Incluue eiythiomycin anu claiithiomycin
- Woik by blocking tianslocation
- 0seu foi uppei iespiiatoiy infections, Chlamyuia, neisseiia
- Can cause uI symptoms, iashes, eosinophilia, anu cholestatic hepatitis
(7B8@EFEID:7:
- Boxycycline anu minocycline
- Woiks by binuing to the SuS subunit anu pieventing attachment of
aminoacyl-tRNA.
- Shoulu avoiu ceitain foous which limit its absoiption, such as milk piouucts
anu piouucts high in Fe2+
2<IC>:@?D=7A:
- Incluue sulfamethoxazole, sulfauiazine, anu othei sulfas
- Woiks by inhibiting the enzyme uihyuiofolate ieuuctase
- 0seu foi 0TI's, anu both giam +- oiganisms
!I<>8>s<D:>I>:7A:
- Incluue cipiofloxacin, noifloxacin, ofloxacin, moxifloxacin, gatifloxacin
- Inhibits BNA gyiase
- 0seu foi giam -ve ious in the u0 anu uI tiacts
- Commonly causes uI uistuibances, heauache, iashes, uizziness
,7NH@I>AN>8D:A:
- Aie beta-lactams that woik by inhibiting cell wall synthesis
- 1
st
geneiation: Pioteus, E.Coli, anu Klebsiella
- 2
nu
geneiation: Baemophilus, Enteiobactei, Neisseiia, Pioteus, E.Coli,
Klebsiella, anu Seiiatia
- S
iu
geneiation: Seiious giam -ve infections that aie iesistant to othei beta-
lactam uiugs. 0seu foi meningitis.
- 4
th
geneiation: Pseuuomonas anu giam +ve oiganisms
- Commonly cause hypeisensitivity ieactions, with cioss-hypeisensitivity with
penicillin
- Can cause a uisulfiiam-like ieaction when combineu with alcohol
5@:E>?FED::
- Binus to the B-ala B-ala poition of cell walls, thus inhibiting cell wall
mucopeptiue foimation
- 0seu in seiious giam + infections, such as NRSA
- Can cause nephiotoxicity, ototoxicity, thiombophlebitis, anu 'ieu-man
synuiome', wheie the bouy gets flusheu.
37B8>:D=@j>I7:
- Woiks by foiming toxic metabolites insiue the cell
- 0seu foi giaiuia, entamoeba, anu tiichomonas
- Bas a uisulfiiam-like ieaction when combineu with alcohol
#-/$ O(* =8<MAPR
- Rifampin
- Isoniaziu
- Pyiazinamiue
- Ethambutol
- Can cause hemolysis in u6PB ueficient patients
- Can cause an SLE-like synuiome
- vitamin B6 (pyiiuoxine) ueficiency fiom pyiazinamiue
+?NH>B78DED: *R
- Woiks by foiming poies in the cell membiane
- 0seu foi systemic mycoses
- Can cause feveis anu chills, aiihythmias, hypotension, anu nephiotoxicity

+:BD9D8@I +EBD9DBF

,)$3"()$#+/$1(-,2
Biugs classifications aie baseu on theii N0A's:
Z?LBCH BACBJ?AF@C@ (Nethotiexate)
*S>FAH BACBJ?AF@C@ (6-meicaptopuiine)
*E>FDFMFAH BACBJ?AF@C@ (S-fluoiouiacil)
+FW?ASOLHFO >HMSOCB@H FAIFWFC?>@ (Byuioxyuiea)

&8<M #7ADAB@:E7:
5AABCH - Piimaiy iesistance uevelops uue to exposuie.
)ORSF>HM - Causeu by genomic mutations that may be to a single uiug oi to multiple
uiugs.

3"+ >C B<?>8 E7II 87ADAB@:E7:
- Becieaseu uiug accumulation
- Alteieu affinity of taiget enzymes
- Loss of uiug-activating enzymes
- Incieaseu function of tumoi cell iepaii mechanisms

)DMHSFD7I= EH7?>BH78@N7<BDE B>JDEDBD7A:
Common chemotheiapy uiug toxicities - myelosuppiession, nauseavomiting,
leucopenia.
Neuiotoxicity - vinciistine, Paclitaxel
Pulmonaiy Toxicity - Bleomycin, Busulfan
Renal Toxicity - Cisplatin
Bemoiihagic Cystitis - Cyclophosphamiue
Caiuiac Toxicity - Boxoiubicin



&8<MSAN7EDCDE B>JDEDBD7A:
Caimustine - piouuces leukocyte suppiession
Cisplatin, Caimustine - most emetic anti-neoplastics
SBTS antagonists - pievent emesis
Netochlopiomiue - useful in pieventing chemotheiapy-ielateu nausea anu
vomiting.

&-+*$($2 /)+#3+,"."TG
-421.-4 (G/$ "42$( "!
+,(-"4
/$+V "!
&#1T
&1#+(-"4
"! +,(-"4
(G/-,+. 12$
1IB8@AH>8B
+EBD:MO.DAN8>P
S minutes 1hi Shi Befoie meals
2H>8BS+EBD:M
O#7M<I@8P
Su minutes S-4hi 6-8hi Noining anu
night
-:B78?7=D@B7
+EBD:M O.7:B7P
Su minutes 12hi 24hi qiu
.>:MS+EBD:M
O1IB8@I7:B7P
2hi 12hi 24hi qiu

Theie is a iisk of hypoglycemic ciisis if piopei iegulation of insulin not useu
2<IC>:FI<87@A:
ulybuiiue, Tolbutamiue
/"): Causes uepolaiization of beta cells of the pancieas, thus incieasing the
ielease of insulin.

T+2(#"-4($2(-4+. /)+#3+,"."TG
(1 BACBJ?AF@C@: Cimetiuine, Ranitiuine.
- Loweis aciu secietion
- Not useu as 1
st
line uiug foi uERB, P0B, etc.
*>?C?A *SDN 5AIFWFC?>@: 0mepiazole
- Is uiagnostic anu theiapeutic uiug of choice foi uERB anu P0B
- Also useu in cases of Zollingei-Ellison synuiome
/SO?@BL *>?CHOCBAC@: Sucialfate
- Woiks by auheiing to pioteinaceous lesions on the suiface
- Is as effective as an B2 ieceptoi antagonist woulu be in 4-8 weeks
*>?@CBJLBAMFA@: Nisopiostal
- Can be given when patient is using high-uose NSAIB theiapy
- Blocks cANP
- Also causeu aboition in piegnant women
- Can cause wateiy uiaiihea
)ACFKHDHCFO@: SBTS ieceptoi antagonists
- 0nuasetion
*>?\FAHCFO@: Alosetion
- Can be useu foi tieatment of IBS, but is last line aftei conseivative theiapies
fail
5>>FCBWLH 2?THL XF@HB@H:
- 1
st
line tieatment of ulceiative colitis is Sulfasalazine
- 1
st
line tieatment of Ciohn's uisease is Buuesoniue

,+.,-13 +4& *"4$ )"3$"2(+2-2
*$( - foi bone iesoiption, anu is stimulateu when seium calcium uecieases.
!BLOFC?AFA - peifoims all opposite action of PTB (paiathyioiu hoimone).
,V18 [ MFIEM>?PE GFCBDFA X4 - piouuceu in the kiuney
"@CH?N?>?@F@ - 1
st
line phaimacological tieatment is alenuionate (bisphosphonate)
*BJHCc@ XF@HB@H - Tieatment involves bisphosphonate meuication such as
alenuionate.

()G#"-& /)+#3+,"."TG
3HG?CIE>?PFAH (T4) - is the uiug of choice foi all types of hypothyioiuism.
3F?CIE>?AFAH (TS) - moie potent than levothyioxine, has a shoitei half-life, is not
useu as a theiapeutic agent in thyioiu pioblems.
/HCIFDBa?LH BAM *>?NELCIF?S>BOFL - two uiugs useu foi hypeithyioiuism.
*>?NELCIF?S>BOFL (PT0) - Inhibits the peiipheial conveision of T4!TS
.>BGHc@ XF@HB@H - Nethimazole oi PT0 is useu to inuuce iemission oi to contiol
symptoms piioi to suigeiy oi iauioiouine ablation.
5?MFMH &BLC@ - inhibit the ielease of thyioiu hoimone fiom the thyioiu glanu.
*?CB@@FSD 5?MFMH @?LSCF?A - is useu to contiol the symptoms of acute
thyiotoxicosis, uecieases the vasculaiity anu size of the thyioiu, anu inhibits thyioiu
hoimone ielease following RAI tieatment.
+)5 h5K,4,i - is useu in the tieatment of uiave's uisease, woiks by emitting
chemicals that kill tissue of the thyioiu.

/)+#3+,"."TG "! /-(1-(+#G +4& )G/"()+.+312
!?@EAC>?NFA - is a synthetic coiticosyntiopin analog, is useu to uiagnose auienal
insufficiency.
"OC>H?CFMH - is a synthetic somatostatin that inhibits uB secietion, is useu to tieat
aciomegaly.
/HA?C>?NFA@ - inuuces ovulation in infeitile women.
.?ABM?>HLFA - is a unRB that is auministeieu in a pulsatile foim, this inuuces
ovulation in women with amenoiihea uue to hypothalamic uysfunction.
3HSN>?LFMH - useu in kius with piecocious pubeity, it acts by suppiessing
gonauotiopin secietion fiom the pituitaiy.
2>?D?O>FNCFAH - is given to those with piolactinomas, useu to shiink then mass so
the symptoms will cease. Is a BA antagonist.
"PEC?OFA - useu to inuuce anuoi augment laboi in women who have tiouble with
ueliveiy, also stimulates milk letuown in nuising women.
XH@D?N>H@@FA - is a synthetic analog of vasopiessin, tieatment foi uiabetes
insipiuus.






42+-&2
)OHCBDFA?NIHA - anti-pyietic, analgesia, ieveisible C0X inhibition. Lacks anti-
inflammatoiy piopeities. 0veiuose is tieateu with N-Acetylcysteine.
)@NF>FA - Bas analgesic anu anti-inflammatoiy piopeities, inhibits the C0X2
pathways. Causes uI iiiitation by inhibiting piostaglanuins, which aie piotective to
uI mucosa.
5AM?DHCIBOFA - is a non-selective C0X1 inhibitoi, inhibitoi of phospholipase A anu
C. 0seu to close a PBA, also useu in gout anu foi management of ankylosing
sponuylitis.
5WSN>?UHA - pioviues analgesia without anti-pyietic piopeities, has less uI iiiitation
than uoes aspiiin.

+4(-S,"+T1.+(-"4








#$/#"&1,(-5$ /)+#3+,"."TG
Theie aie a few veiy common meuications useu to inuuce ovulation anu thus
inciease the chances of piegnancy.
,."3-/)$4$: The agent of choice foi ovulation inuuction, it acts by incieasing
unRB secietion fiom the hypothalamus, which then incieases the levels of FSB,
incieasing the feitility. This all happens via the blocking of the estiogen ieceptois,
thus tiicking the bouy into believing that the levels of estiogen aie much lowei than
they actually aie.
)13+4 3$4"/+12+. T"4+&"(#"/-4 O37:>B8>ND:PR Is extiacteu fiom the
uiine of menopausal women. It is high in LB anu FSB, which incieases feitility.

















!()*$%+ ,4

*)$("3".0

XSH C? @IHH> G?LSDHV CIH NBCI?L?JE @HOCF?A ?U CIH &CHN ,
HPBD F@ WE UB> CIH D?@C OIBLLHAJFAJQ $IH 7&/3% HPBD F@
D?GFAJ D?>H BAM D?>H C?TB>M@ WHFAJ B OLFAFOBL HPBDV CIS@
FC F@ HPC>HDHLE FDN?>CBAC C? >HO?JAFaH CIH @FJA@V @EDNC?D@V
O?DD?A N>H@HACBCF?A@V SAO?DD?A N>H@HACBCF?A@V BAM
NBCI?NIE@F?L?JE ?U NBCI?L?JFOBL O?AMFCF?A@Q
&NHOFBL BCCHACF?A @I?SLM WH NBFM C? MF@HB@H HACFCFH@ CIBC B>H
D?>H O?DD?A FA CIH 7AFCHM &CBCH@V B@ ?NN?@HM C? CI?@H CIBC
B>H D?>H N>HGBLHAC FA ?CIH> B>HB@ ?U CIH T?>LMQ












T+2(#"-4($2(-4+.

!"#X5$5"#& "Z $(% %&"*().7&:
- Baiiett's esophagus
- Achalasia
- Esophageal cancei

*+##$(([2 $2"/)+T12
Baiiett's esophagus is a conuition wheieby a chionic exposuie to aciuic contents
fiom the stomach cause metaplasia of the epithelium at the squamocolumnai
junction in the esophagus. The metasplasia changes fiom squamous epithelium
(non-keiatinizeu) to columnai epithelium. The ieason foi this is that squamous
epithelium is not veiy piotective against aciuic contents, while the columnai
epithelium is uesigneu specifically foi this puipose.








+,)+.+2-+
Achalasia is a conuition wheieby the lowei esophageal sphinctei fails to ielax. This
is an esophageal motility uisoiuei that involves the smooth muscle layei of the
esophagus anu the lowei esophageal sphinctei. Chaiacteiizeu by an incomplete
ielaxation of the lowei esophageal sphinctei, incieaseu lowei esophageal sphinctei
tone, anu a lack of peiistalsis in the esophagus.
Chaiacteiistics:
- Bysphagia
- Reguigitation
- Chest pain
Theie aie a few ieasons why this may happen, they incluue:
- Chaga's uisease
- Loss of myenteiic plexus
- Esophageal caicinoma
The best uiagnostic tool foi this conuition is a baiium swallow.








$2"/)+T$+. ,+4,$#
The two types of esophageal cancei aie: Auenocaicinoma anu Squamous Cell
caicinoma.
Auenocaicinoma - this type of cancei is often seconuaiy to Baiiett's esophagus.
Squamous Cell Caicinoma - this type of cancei is often causeu by exposuie to
alcohol anu cigaiette smoke (on a chionic basis).
The populai mnemonic "+*,&$!" is excellent foi iemembeiing the common causes
of esophageal cancei.
+ - Alcohol
* - Baiiett's esophagus
, - Cigaiette smoke
& - Biveiticula (especially Zenkei's)
$ - Esophageal Webs
! - Family histoiy of esophageal cancei

T+2(#-(-2
uastiitis is causeu by an inflammation of the stomach lining. The most common
cause of gastiitis is piolongeu use of NSAIBs (ie Aspiiin), which blocks the synthesis
of piostaglanuins, thus uecieasing the piotection of the stomach lining. 0thei
common causes aie alcohol consumption anu B. Pyloii.
Symptoms incluue:
- Pain in the epigastiic iegion (most common piesentation)
- Weight loss
- Loss of appetite
+E<B7 T@AB8DBDA - also known as eiosive gastiitis, this foim of gastiitis is causeu
most commonly by uamages to the stomach's mucosal uefense system. NSAIBs anu
alcohol aie most common causes of acute gastiitis.
,H8>:DE T@AB8DBDA - this is the iesult of an B. Pyloii infection.
$ENH@ ?U OI>?AFO JB@C>FCF@:
$ENH ) - 0ccuis in the funuus of the stomach, is of autoimmune natuie.
$ENH 2 - 0ccuis in the antium of the stomach, is causeu by an B. Pyloii infection.

/$/(-, 1.,$# &-2$+2$
Theie aie two types of P0B, one is gastiic anu one is uuouenal.
$IH JB@C>FO *7X:
- Patient usually has an associateu weight loss as theie is incieaseu pain with
eating.
- The cause of a gastiic P0B is uecieases in mucosal piotection, thus causeu
commonly by NSAIBs.
$IH MS?MHABL *7X:
- Patient will usually have weight gain anu the pain will ueciease with eating.
- This is almost always linkeu to an B. Pyloii infection.
- The main cause is an inciease in gastiic aciu secietion in conjunction with
uecieaseu mucosal piotection.
- Theie will be hypeitiophy of Biunnei's glanus (submucosal glanus of the
uuouenum who piouuce a mucus-iich alkaline secietion).















-4!.+33+("#G *"%$. &-2$+2$
The two types of IBB aie Ciohn's uisease anu 0lceiative Colitis
,#")4[2 &-2$+2$ 1.,$#+(-5$ ,".-(-2
-.$13 -45".5$3$4( Commonly involves ileum Raiely involves ileum
,"."4-, -45".5$3$4( Colonic involvement often Colonic involvement
always
#$,(+. -45".5$3$4( Raiely Almost always
*-.$ &1,(
-45".5$3$4(
None Sometimes
&-2$+2$ &-2(#-*1(-"4 Patchy, skip lesions Continuous inflammation
$4&"2,"/-, 5-$% 0lceis aie lineai,
seipiginous
0lceiation is continuous
-4!.+33+(-"4 &$/() Tiansmuial, ueep Shallow anu mucosal
!-2(1.+ !"#3+(-"4 0ften Raiely
+22",-+(-"4 %-()
23"V-4T
Bigh iisk in smokeis Low iisk in smokeis
21#T-,+.
-4($#5$4(-"4
Retuins following suigical
inteivention
Cuieu often by suigical
iemoval
+1("-3314$ ,+12$2f Seen as autoimmune Not seen as autoimmune
#-2V "! ,+4,$# -4
+22",-+(-"4
Low compaieu to colitis Cancei iisk highei than in
Ciohn's
*-"/2G #$5$+.2 uianulomatous Non-gianulomatous

-##-(+*.$ *"%$. 2G4&#"3$ O-*2P
Is a uiagnosis of exclusion. IBS piesents most commonly in a young female in hei
twenties, who piesents with abuominal painbloating, alteieu bowel habits in the
absence of any oiganic cause. Symptoms aie ielieveu aftei a bowel movement.
Nanagement of IBS is incieaseu fluiu intake + incieaseu uietaiy fibei intake (ie.
Fibei supplementation). If this uoes not woik, ceitain meuications can be exploieu,
but this is usually a cuiative appioach.






2G4&#"3$2 "! 3+.+*2"#/(-"4
The commonly testeu synuiomes of malabsoiption aie Celiac Spiue, Tiopical Spiue,
anu Whipple's uisease. Symptoms of these conuitions aie: Weight loss, ciamping,
uiaiihea, steatoiihea, inuigestion, anu fatigue.
!HLFBO &N>SH - Causeu by autoantibouies (antigliauin, antienuomysial, anti-tissue
tiansglutaminase) against gluten, which causes villous blunting anu infiltiation of
lymphocytes. Tieatment is to consume a gluten-fiee uiet.
$>?NFOBL &N>SH - This is an infectious conuition commonly founu in tiopical iegions,
anu is maiket by abnoimal flattening of the villi in the small intestine.
YIFNNLHc@ XF@HB@H - This is iaiei than the othei two malabsoiption synuiome. It is
causeu by an infection with the bacteiium Tiopheiyma Whipplei, anu can cause
malabsoiption in conjunction with many systemic pioblems (caiuiac, iespiiatoiy,
neuiological, iheumatologic, anu visual).

)$/+(-(-2
Bepatitis is a geneial teim to uesciibe the inflammation of the livei. Theie aie many
possible causes of hepatitis, such as alcohol, uiugs, viial, anu uisease-ielateu.
!BS@H@ ?U ]F>BL (HNBCFCF@:
Five main types of viial hepatitis aie: Bep A, B, C, B, anu E. Bepatitis can also be
causeu by Epstein-Baii viius, cytomegaloviius, anu heipes simplex viius.
$>BA@DF@@F?A ?U GF>BL IHNBCFCF@:
Bepatitis A & E - fecal-oial tiansmission, highei in ueveloping countiies
Bepatitis B - tiansmission is paienteial oi sexual
Bepatitis B - iequiies co-infection with hepatitis B (iequiies the outei envelope of
the BbsAg)
Bepatitic C - tiansmitteu paienteially anu is thus moie common in Iv uiug useis
r "ALE IHNBCFCF@ 2V !V BAM X OBA N>?J>H@@ C? OI>?AFO IHNBCFCF@Q




,-##)"2-2
Ciiihosis is a consequence of chionic livei uisease, wheieby the noimal aichitectuie
of the livei is ieplaceu by fibiosis oi scaiiing. Nouules that aie less than Smm aie
"micionouulai" anu aie uue to metabolic causes such as alcoholism. Nouules
gieatei than Smm aie usually causeu by seveie injuiy that has leau to ueath of livei
cells. Along with ciiihosis comes a vaiiety of auveise effects, on top of the auveise
effects fiom ciiihosis theie aie auveise effects causeu by the poital hypeitension
that occuis.




















,-##)"(-, $!!$,(2
- uynecomastia
- Spiuei Nevi
- }aunuice
- Asteiixis
- Bleeuing Bysciiasies
- Anemia
- Euema
- Icteius
/"#(+. )(4 $!!$,(2
- Esophageal vaiices
- Bemoiihoius
- Atiophy of Testes
- Splenomegaly
- Caput Neuusae
- P0B
- Ascites

/+4,#$+(-(-2
Pancieatitis is an inflammation of the pancieas that causes veiy chaiacteiistic set of
symptoms. The patient will almost always piesent with seveie epigastiic pain that
iauiates to the back. The two most common causes of pancieatitis aie alcohol anu
gallstones, but theie aie othei possible causes, such as:
- Tiauma
- Steioius
- Numps
- Bypeilipiuemia
- Autoimmune conuitions
- Sting fiom a scoipion
In pancieatitis, lipase anu amylase will always be elevateu (lipase is moie specific).

/+4,#$+(-, +&$4",+#-4"3+
Pancieatic cancei is a giave uiagnosis anu often causes ueath within 6 months of
uiagnosis. It is often asymptomatic anu theiefoie highly metastasizeu by the time of
uiagnosis. The most common site of the cancei is in the heau of the pancieas, which
is why the only piesenting symptoms is often painless jaunuice anu significant
weight loss.
"CIH> O?DD?ALE N>H@HACFAJ @EDNC?D@ ?U NBAO>HBCFO OBAOH> FAOLSMHd
- Abuominal pain
- Nigiatoiy thiombophlebitis
- Palpable gallblauuei (Couivoisiei's sign) anu obstiuctive jaunuice
*?@@FWLH OBS@H@ ?U NBAO>HBCFO OBAOH>d
- Incieaseu age
- Nale sex
- Cigaiette smoking
- 0besity
- Biabetes mellitus
- Chionic pancieatitis
- B. pyloii infection
- Family histoiy
** Alcohol has not been pioven to cause pancieatic cancei, howevei alcohol
consumption can leau to chionic pancieatitis which may leau to pancieatic
cancei. Theiefoie the possibility cannot be iuleu out.

+//$4&-,-(-2
Appenuicitis is a ielatively common conuition anu is the most common inuication
foi emeigency abuominal suigeiy in chiluien.
Piesentation is uiffuse abuominal pain in the peii-umbilical iegion, followeu by
localization of pain to NcBuiney's point. Patient will also have nausea, vomiting,
anu oveiall look ill.
** A complication of appenuicitis is peifoiation, which can leau to sepsis.










-4(12212,$/(-"4
This is a conuition of the bowel wheieby one segment "invaginates" oi "telescopes"
into anothei segment of bowel. The intussusception always moves into a uistal
segment. Eaily symptoms incluue nausea, vomiting, anu pulling of the legs into the
chest (foi pain ielief). The most common association with this conuition is "cuiiant
jelly stools", which is a mixtuie of bloou anu mucus. As well, theie is a palpable
sausage-shapeu mass felt in the abuomen.
Tieatment involves using an enema, which often fixes the pioblem.








5".51.12
A volvulus is a twisting of the bowel aiounu its mesenteiy, which can leau to
obstiuction. This is an emeigency anu iequiies an emeigent lapaiotomy to ielieve
the twistingobstiuction anu pievent ischemia of the bowel.











&-5$#(-,1.+# &-2"#&$#2
A uiveiticulum is any pouch that leaus off of the uigestive tiact. A tiue uiveiticula
incluues the mucosa, the musculaiis, anu the seiosa. Nany uiveiticula aie false
since they uo not incluue all of the layeis of the tiact.
The most common types of uiveiticula:
- Zenkei's uiveiticulum
- Neckel's uiveiticulum
- Biveiticulosis
- Biveiticulitis

\$4V$#[2 &-5$#(-,1.13
A Zenkei's uiveiticulum is an outpouching founu in the phaiynx, above the
ciicophaiyngeal muscle. It piesents common with a patient who has teiiible bieath
(uue to foou accumulation in the uiveiticula). This occuis 1S uistance fiom
oiophaiynx to lowei esophagus. Biagnosis is maue with a baiium swallow.

3$,V$.[2 &-5$#(-,1.13
This is a congenital uiveiticulum that is locateu in the uistal ileum. It piesents
commonly with painless bloou in the stool of a newboin. It is a iemnant of the
omphalomesenteiic uuct, anu is the most fiequently encounteieu malfoimation of
the uI tiact of the newboin. Biagnosis can be maue with a technetium-99 scan,
which uetects the location of bleeuing along the uI tiact.

&-5$#(-,1."2-2
Biveiticulosis is a conuition wheie theie aie many uiveiticula in the colon. With
incieasing age theie is an incieaseu iisk of having uiveiticulosis. Biveiticulosis is
the most common cause of iectal bleeuing in someone ovei Suyi of age. Incieaseu
luminal piessuie anu colonic wall weakness causes the actual outpouching of the
seiosa, wheie a low-fibei uiet is the most common cause of this conuition.

&-5$#(-,1.-(-2
This is simply an inflammation of the uiveiticula. It piesents with seveie LLQ pain
anu poses the iisk of peifoiation, peiitonitis, anu stenosis of the bowel lumen.











)-#2,)/#14T[2 &-2$+2$
A congenital 'megacolon' causeu by a lack of migiation of the neuial ciest cells to the
lowei segment of the colon (known as the tiansition zone), (Aueibach's anu
Neissnei's plexus aie absent on biopsy). An infant will piesent with chionic
constipation, but this can also piesent at any point in life. Theie is a poition of the
colon that is uilateu pioximal to the aganglionic segment.


*1&&S,)-+#- 2G4&#"3$
Buuu-Chiaii synuiome causes obstiuction of the infeiioi vena cava. As a iesult of
this obstiuction, hepatic veins become congesteu (centiilobai) anu this can cause
neciosis. This will eventually leau to congestion of the livei anu
ultimatelyeventually leau to failuie of the livei. This conuition is especially
common in piegnancy, in those with hepatocellulai caicinoma, anu in those with
polycythemia veia.





)$3",)#"3+("2-2
This is a veiy common conuition that is causeu by a uefect in iion metabolism,
which leaus to an iion oveiloau in vital oigans, joints, anu tissues. Eaily uiagnosis
can help pievent auveise effects of the iion oveiloau.
Bemochiomatosis piesents with a class tiiau of:
1. Nicionouulai ciiihosis
2. Pancieatic fibiosis
S. Skin pigmentation
This conuition is classically known as bionze uiabetes uue to the fact that it tints the
skin "bionze" anu also affects the pancieas. Total bouy iion levels may ieach
upwaius of Sug, anu this must be manageu with iepeateu phlebotomy. This
conuition can leau to congestive heait failuie anu can inciease the iisk of
hepatocellulai caicinoma.
LABS: In those with hemochiomatosis, labs will show 'Iion anu Feiiitin, with a (
total iion binuing capacity.

%-.2"4[2 &-2$+2$
Is an autosomal iecessive uisoiuei wheie theie is a failuie of coppei's ability to
entei ciiculation in the foim of ceiuloplasmin. This leaus to coppei accumulation in
ceitain tissues (livei, biain, coinea), anu is C>HBCHM TFCI NHAFOFLLBDFAH (chelation of
coppei).
The most common signs anu symptoms of Wilson's uisease aie:
- ,>8:7@ =7N>ADBA (Kaysei-Fleischei iings), veiy common in Wilson's uisease
- +AB78DJDA
- /@8mD:A>:SIDm7 AF?NB>?A uue to accumulation in basal ganglia
- ,@8ED:>?@
- &7?7:BD@






)$/+(",$..1.+# ,+#,-4"3+ ),,P
Bepatocellulai caicinoma is a veiy common cause of metastasis, anu spieaus by
hematogenous ioute. Nost cases of hepatocellulai caicinoma aie uue to hepatitis B
anuoi C, as well as ciiihosis. 0thei causes of BCC incluue Wilson's uisease,
hemochiomatosis, alcoholic ciiihosis, anu !-1 antitiypsin ueficiency.
The outcome is usually pooi, howevei 1-2 out of 1u cases aie tieatable with suigical
iemoval of canceis.

)G/$#*-.-#1*-4$3-+2 O)$#$&-(+#GP
Theie aie thiee commonly testes anu encounteieu heieuitaiy hypeibiliiubinemias,
they aie:
1. uilbeit's synuiome
2. Ciiglei-Najjai synuiome
S. Bubin-}ohnson synuiome

.FLWH>Cc@ &EAM>?DH:
uilbeit's synuiome is a benign conuition wheie theie is a milu ueciease in the 0BP-
glucuionyl tiansfeiase enzymes. This leaus to an elevation of SAO?A`SJBCHM
WFLF>SWFAQ
!>FJLH>K#B``B> &EAM>?DHd
This is a seveie conuition that leaus to ueath eaily in life. Theie is a complete
absence of 0BP-glucuionyl tiansfeiase, which leaus to significant incieases in
unconjugateu biliiubin anu causes it to ueposit in the biain (keinicteius), as well as
jaunuice. Theie is a less seveie veision of Ciiglei-Najjai calleu "type 2", anu it can
be manageu with Phenobaibital.
XSWFAKk?IA@?A &EAM>?DH:
This synuiome occuis as a iesult of a uefect in the livei's ability to exciete
conjugateu biliiubin. It is benign but theie is a change in coloi of the livei to black.
A uiffeient foim of this synuiome is "Rotoi's synuiome", which is even miluei anu
causes no change in the coloi of the livei.



T+..2("4$2
uallstones aie foimeu as a iesult of incieaseu cholesteiol oi biliiubin. They can
occui anywheie in the biliaiy tiee (incluuing insiue the gallblauuei anu in the
common bile uuct). When a stone becomes lougeu insiue the common bile uuct, this
is known as choleuocholithiasis. Pain can iesult when the gallblauuei contiacts
against the stone anu it uoes not get piopelleu foiwaiu.
Foui iisk factois aie: !"1# ![A: Z%/)3%V Z%+$53%V Z)$V Z"+$0
$I>HH CENH@ ?U @C?AH@:
1. ,H>I7AB78>I - aie iauiolucent with some being opaque fiom calcification.
2. 3DJ7= - this is the most common type, anu is iauiolucent.
S. /DM?7:B AB>:7A - this is seen in patients who have chionic ieu bloou cell
hemolysis, alcoholic ciiihosis, biliaiy infection. This is iauiopaque.





*-.-+#G ,-##)"2-2
Theie aie two types of biliaiy ciiihosis: *>FDB>E BAM &HO?AMB>E
/8D?@8F *DID@8F ,D88H>ADA:
- Is an autoimmune uisoiuei causeu by antimitochonuiial antibouies
- Causes a seveie case of obstiuctive jaunuice with all of the auveise effects
associateu with seveie jaunuice (piuiitis, hypeicholesteiolemia)
27E>:=@8F *DID@8F ,D88H>ADA:
- This biliaiy ciiihosis is uue to obstiuction outsiue of the livei (extiahepatic)
- Causes a builuup of piessuie within the uucts of the livei, anu we get
bacteiial infections, ascenuing cholangitis, bile stasis.

/#-3+#G 2,.$#"2-4T ,)".+4T-(-2
Anothei autoimmune uisease of the livei, wheie theie is a slowly piogiessing
uestiuction of the bile canaliculi. Bestiuction leaus to cholestasis anu theiefoie
uamage, inflammation, anu fibiosis of the bile uucts. The classic piesentation of the
bile uucts is the "beauing", wheieby theie is alteinating uilation anu stiictuie of the
uuct as seen on enuoscopic ietiogiaue cholangiopancieatogiaphy (ERCP).

,"4T$4-(+. /+()"."TG

Theie aie a gioup of common congenital pathologies that aie high-yielu foi the
0SNLE Step 1 exam, they incluue:
- Befects of the heait
- Spina bifiua
- Bypospauias
- Cleft lip
- Pyloiic stenosis
- Anencephaly

,"4T$4-(+. )$+#( &$!$,(2
The most common congenital heait uefects incluue:
- ventiiculai septal uefects
- Atiial septal uefects
- Patent uuctus aiteiiosus
- Tetialogy of fallot
- Tiuncus aiteiiosus
- Tiansposition of the gieat vessels
- Coaictation of the aoita

&$!$,(2 ,+12-4T + #-T)( (" .$!( 2)14(
These uefects cause uefects that foice bloou fiom the iight siue of the heait to the
left siue of the heait uue to piessuie, iesulting in eaily cyanosis because systemic
bloou is lacking oxygen. The babies aie often blue in coloi because they uo not
ieceive auequate oxygen.
The thiee common congenital malfoimations causing a R!L shunt aie:
1. Tetialogy of fallot
2. Tiansposition of the gieat vessels
S. Tiuncus aiteiiosus




$%$+)3".0 "Z Z)33"$d
This conuition iesults in a gioup of pioblems, that ultimately leau to eaily cyanosis
uue to shunting of bloou fiom the iight to the left thiough the ventiiculai septal
uefect. This is causeu by an anteiiosupeiioi uisplacement of the infunuibulai
septum.
The 4 pathologies of tetialogy of Fallot aie:
1. Pulmonaiy stenosis
2. Right ventiiculai hypeitiophy
S. 0veiiiuing aoita
4. ventiiculai septal uefect (pioviues aiea foi shunting)

$+)#&*"&5$5"# "Z $(% .+%)$ ]%&&%3&d
This conuition iesults in the aoita connecteu fiom the iight ventiicle while the
pulmonaiy tiunk leaves fiom the left ventiicle. This iesults in a sepaiation of the
systemic anu pulmonaiy ciiculations. Since theie is no oxygenateu bloou being
pumpeu systemically, this conuition is incompatible with life (unless theie is the
piesence of a shunt). Tiansposition of the gieat vessels waiiants immeuiate
suigical coiiection foi suivival. The conuition is causeu by failuie of the
aoiticopulmonaiy septum to spiial.

$+7#!7& )+$%+5"&7&:
Tiuncus aiteiiosus occuis when theie is an incomplete oi faileu septation of the
embiyonic tiuncus aiteiiosus. This iesults in a single aiteiial tiunk that aiises fiom
two noimally foimeu ventiicles. The pulmonaiy aiteiies can aiise fiom the
common tiunk in a myiiau of patteins, thus giving this conuition seveial uiffeient
subtypes.

&$!$,(2 ,+12-4T + .$!( (" #-T)( 2)14(
Theie aie thiee conuitions that cause a L!R shunt, they incluue:
1. ventiiculai septal uefects
2. Atiial septal uefects
S. Patent uuctus aiteiiosus


5$4(#-,1.+# 2$/(+. &$!$,(
This is the most common of all caiuiac congenital anomalies. This uefect uoes not
iesult is cyanosis because the L!R shunt uoesn't put non-oxygenateu bloou back
into the systemic ciiculation. This can be uetecteu by heaiing a pansystolic muimui
on auscultation. Theie is usually no uetection at biith, but within a few weeks it will
be uetectable.

+(#-+. 2$/(+. &$!$,(
This is a conuition wheie theie is a communication between both the iight anu left
atiia of the heait. The ASB is the most common congenital heait uefect seen in
auults.

/+($4( &1,(12 +#($#-"212
The uuctus aiteiiosus is a vasculai connection between the pulmonaiy aiteiy anu
the aoitic aich in the ueveloping fetus. 0pon a newboin's fiist bieath, the piocess of
PB closuie shoulu occui, howevei it sometimes uoes not. If closuie fails to occui,
the neonate will expeiience peisistent iespiiatoiy pioblems. The PBA can be closeu
by giving inuomethacin, anu can be kept openeu with piostaglanuin E.

,"+#,(+(-"4 "! ()$ +"#(+
This is a naiiowing of the aoita that can occui in two uiffeient places. The
'pieuuctal' foim occuis pioximal to the uuctus aiteiiosus, the 'postuuctal' foim
occuis uistal to the uuctus aiteiiosus. The post-uuctal foim is associateu with iib
notching, uppei extiemity hypeitension, anu weak pulses in the lowei extiemities.
Coaictation of the aoita is seen in males much moie than in females.








4$1#+. (1*$ &$!$,(2
Neuial tube uefects occui most commonly when theie is a lack of auequate folic aciu
intake uuiing piegnancy. 0pon testing, theie is often an elevation in !-fetopiotein
in the amniotic fluiu.
Theie aie thiee piesentations of neuial tube uefects, they incluue:
1. 2ND:@ QDCD=@ >EE<IB@ - which iesults when theie is an incomplete closuie of
the spinal canal. Theie is no actual heiniation of any spinal tissue. This often
piesents with a tuft of haii on the skin above the pioblem.
2. 37:D:M>E7I7 - iesults when the spinal meninges heiniateu thiough the
opening in the veitebia.
S. 37:D:M>?F7I>E7I7 - iesults when both the meninges anu the spinal coiu
heiniateu thiough the bony uefect of the veitebia.








(#-2"3G &-2"#&$#2
The thiee most commonly encounteieu autosomal tiisomy uisoiueis aie:
1. Patau's synuiome
2. Euwaiu's synuiome
S. Bown's synuiome

/@B@<[A 2F:=8>?7:
- Causeu by tiisomy 1S
- Cleft lip anu palate
- Seveie mental ietaiuation
- Niciophthalmia
- Niciocephaly
- Beath usually within 1
st
yeai of biith
$=K@8=[A 2F:=8>?7:
- Causeu by tiisomy 18
- Rockei bottom feet
- Low-set eais
- Clencheu hanus
- Piominent occiput
- Beath usually within 1
st
yeai of biith
&>K:[A 2F:=8>?7:
- The most common chiomosomal uisoiuei
- The most common cause of congenital mental ietaiuation
- Causeu by tiisomy 21
- Piominent epicanthal folus
- Simian ciease
- Incieaseu iisk of ALL
- Congenital heait uisease (ASB most commonly)
- Causeu most commonly by meiotic non-uisjunction of homologous
chiomosomes





2$0 ,)#"3"2"3$ &-2"#&$#2
1. XYY Synuiome
2. Tuinei's synuiome
S. Klinefeltei's synuiome

0GG 2F:=8>?7:
Patients aie phenotypically noimal but aie unusually tall, have seveie acne, anu aie
pione to anti-social behaviois.

(<8:78[A 2F:=8>?7 O0"PR
Patients aie female, have shoit statuie, webbeu necks, wiuely spaceu nipples,
ovaiian uysgenesis, anu expeiience piimaiy amenoiihea. This patient is also pione
to having coaictation of the aoita.

VID:7C7IB78[A 2F:=8>?7 O00GPR
Nale patient's who aie tall, have longthin extiemities, female bouy haii patteins,
testiculai atiophy, anu gynecomastia.

!#+T-.$ 0 2G4&#"3$
Fiagile X synuiome is an x-linkeu uisoiuei, anu is the 2
nu
most common cause of
mental ietaiuation. Is a tiiplet-iepeat uisoiuei that can show anticipation. Patients
have laige testicles, long faces with laige jaw, anu laige eais.








)$#3+/)#"&-(-23
$>SH (H>DBNI>?MFCH - patient is eithei 46 xx oi 47 xxy, having both testes anu
ovaiies piesent, with ambiguous genitalia. This is a iaie synuiome.
/A7<=>H78?@NH8>=DBDA? - Female anu Nale types:
!7?@I7 - ovaiies aie piesent but the exteinal genitalia aie viiilizeu oi ambiguous.
Causeu by excessive exposuie to anuiogens uuiing gestation.
3@I7 - testes aie piesent but the exteinal genitalia aie female oi ambiguous. The
most common foim is the anuiogen insensitivity synuiome.

+4&#"T$4 -42$42-(-5-(G 2G4&#"3$
This patient is genetically male, howevei they have anuiogen ieceptois that aie
insensitive to the effects of anuiogens, making them appeai female. Theie aie
noimal appeaiing exteinal genitalia but the vaginal canal is not uevelopeu (blinu
vagina). Theie aie no uteiine tubes oi uteius. Because theie is no secietion of male
hoimones by the testes (which aie piesent in the labia but often iemoveu), theie is
no negative feeuback anu thus testosteione, estiogen, anu LB will iemain elevateu.

312,1.+# &G2(#"/)G
The two types of musculai uystiophy aie: Buchenne's anu Beckei's musculai
uystiophy.
XSOIHAAHc@ - This is the moie seveie foim of musculai uystiophy, wheieby a
ueletion of the uystiophin gene causes an acceleiation of muscle bieakuown.
Patient will expeiience weaknesses of the pelvic giiule anu oveiall piogiessive
weakness. Commonly founu is pseuuohypeitiophy of the calf (fatty ieplacement of
the muscle). Patients commonly use the "uowei's maneuvei", wheie they use theii
aims to climb up the legs anu achieve a stanuing postuie, which is chaiacteiistic of
musculai uystiophy.
2HO\H>c@ - This is a less seveie veision of musculai uystiophy wheieby theie is a
mutation of the uystiophin gene, iathei than a complete ueletion.
XFBJA?@FAJ musculai uystiophy is uone by finuing elevateu cieatine kinase levels
anu muscle biopsy showing these gene manipulations.



bS!S#$&1,(+2$ &$!-,-$4,G
This enzyme is iesponsible foi conveiting testosteione to BBT. When this conuition
occuis in ueveloping fetus, they will have ambiguous genitalia until pubeity when
levels of testosteione inciease, causing a masculinization of the genitalia.

ZZsXX 2G4&#"3$2
,+(,) ZZ is the common mnemonic useu to iemembei this seiies of synuiomes
that commonly occui togethei.
, - cleft palate
+ - abnoimal facies
( - thymic aplasia
, - caiuiac uefects
) - hypocalcemia
ZZ - Nicioueletion at the 22
nu
chiomosome at loci 11














,"33"4 +&l +#l +4& 0S.-4V$& &-2"#&$#2
(H7 ?>AB E>??>: @<B>A>?@I =>?D:@:B =DA>8=78A D:EI<=7R
- Neuiofibiomatosis 1 anu 2
- Buntington's uisease
- Familial hypeicholesteiolemia
- Polycystic kiuney uisease
- Beieuitaiy spheiocytosis
- Naifan synuiome
(H7 ?>AB E>??>: @<B>A>?@I 87E7AAD97 =DA>8=78A D:EI<=7R
- Sickle cell anemia
- Cystic fibiosis
- Tay-Sachs uisease
- Phenylketonuiia
- Albinism
- Thalassemias
- Nucopolysacchaiiuoses
- ualactosemia
- ulycogen stoiage uiseases
(H7 ?>AB E>??>: JSID:m7= =>?D:@:B =DA>8=78AR
- vitamin B iesistant iickets
- Rett's synuiome
(H7 ?>AB E>??>: JSID:m7= 87E7AAD97 =DA>8=78AR
- Buchenne's musculai uystiophy
- Bemophilia A anu B
- ulucose-6-phosphate ueficiency
- Biuton's agammaglobulinemia
- Wiskott-Aluiich synuiome
















3-,#",G(-, +4$3-+2
5+"# X%Z5!5%#!0 )#%/5)
- Is the most common cause of anemia thioughout the woilu
,@<A7= QFR
- Chionic bloou loss (menstiuation is a common cause)
- In a male auult, uI bloou loss is the likely cause (no menstiuation)
&D7B@8F =7CDED7:EF DA @ N>AADQI7 E@<A7 D:R
- 5AUBAC@ BAM C?MMLH>@: especially if uiet is pieuominantly bieast milk
- )M?LH@OHAC@: iapiu giowth iates inciease the neeu foi iion, thus a ueficiency
uevelops
- *>HJABAOE: piegnancy is a state of incieaseu iion iequiiement
!?DD?A @FJA@e@EDNC?D@d
- Fatigue anu weakness aie the most common symptoms
- Becieaseu seium feiiitin + incieaseu TIBS (total iion binuing capacity)
$>HBCDHAC:
- 0ial feiious sulfate

$()3)&&%/5)&
Thalassemias aie inheiiteu uisoiueis that aie causeu by a lack of piouuction of
eithei the ! oi " globin chains of hemoglobin. Seveiity of thalassemia is uepenuent
on which globin chain is affecteu anu how many of the gene loci aie
ueleteumutateu. As a iule, if an iion ueficiency anemia is tieateu unsuccessfully, a
hemoglobin electiophoiesis shoulu be peifoimeu looking foi a thalassemia.
" $IBLB@@HDFB@:
(H@I@AA7?D@ 3@;>8: aka homozygous "-chain thalassemia anu Cooley's anemia.
- Causes seveie miciocytic anemia
- Bone maiiow space expansion leauing to bone malfoimations
- uiowth ietaiuation anu failuie to thiive
- Pieuominantly in Neuiteiianean population
- Tieatment involves bloou tiansfusion, anu without tieatment ueath within
the fiist few yeais of life is unavoiuable.
** This foim of thalassemia can leau to congestive heait failuie. A seveie case can
iequiie a chelatoi to eliminate excess iion.
XFBJA?@FAJ "KCIBLB@@HDFB DB`?>d
- Bemoglobin electiophoiesis will show an elevation of BbF
- Peiipheial bloou smeai will show a miciocytic hypochiomic anemia

(H@I@AA7?D@ 3D:>8: aka heteiozygous "-chain thalassemia
- These patients aie usually asymptomatic
- Nilu miciocytic anemia is usually the only finuing
- Biagnosing is also with hemoglobin electiophoiesis
- Since this conuition is asymptomatic, no tieatment is necessaiy

!K$IBLB@@HDFB@:
2DI7:B ,@88D78A: This foim is causeu by a mutation oi ueletion of only one ! locus.
- Patients aie asymptomatic
- No tieatment is necessaiy
!SBH@II@A7?D@ ?D:>8: This foim of thalassemia is causeu by mutation oi ueletion of
two ! loci.
- Patient has milu miciocytic hypochiomic anemia, but no tieatment is necessaiy
)Q ) =DA7@A7: This foim is causeu by a mutation oi ueletion of thiee ! loci
- Patient will have hemolytic anemia plus significant miciocytic hypochiomic
anemia
- Tieatment involves life-long tiansfusions
- If tiansfusions fail to impiove symptoms, a splenectomy is helpful
)F=8>NA !7B@IDA: This is a mutation oi ueletion of all foui ! loci.
- This conuition is not compatible with life, anu ueath occuis at biith oi veiy
shoitly theieaftei.






&5X%+"23)&$5! )#%/5)
This is a conuition that is causeu when the bouy cannot piopeily incoipoiate iion
into hemoglobin. As a iesult, "iingeu siueioblasts" aie cieateu anu can be seen on
peiipheial smeai. This can be eithei heieuitaiy oi acquiieu. If acquiieu, causes
such as alcohol, isoniaziu, chloiamphenicol, leau exposuie, collagen vasculai
uisease, anu myelouysplastic synuiomes shoulu be exploieu.
ZFAMFAJ@:
- Theie will be a N0RNAL total iion binuing capacity + incieaseu seium iion
anu seium feiiitin.
$>HBCDHAC: Removal of offenuing agent if this is the cause.

4"#3",G(-, +4$3-+2

)#%/5) "Z !(+"#5! X5&%)&%
Anemia of chionic uisease occuis in the setting of a chionic illness such as: Cancei,
inflammatoiy uiseases (SLE, RA), tubeiculosis, etc.
- 0sually noimocyticnoimochiomic, howevei at times may be miciocytic anu
hypochiomic.
- Nanagement of this conuition involves tieatmentmanagement of the
unueilying conuition.

3+,#",G(-, +4$3-+2

]5$)/5# 2,1 X%Z5!5%#!0
The most common cause of vitamin B12 ueficiency is impaiieu absoiption
- Peinicious anemia is a lack of intiinsic factoi, anu is the most common cause
of ueficiency in the westein woilu.
- Since stoies of B12 can last foi S yeais in the livei, theie is usually not an
uietaiy insufficiency.
- Competition fiom oiganisms (uiphyllobothiium latum - the fish tapewoim)
can cause B12 ueficiency
&FJA@e&EDNC?D@:
- Anemia with NCv >1uu + hypeisegmenteu neutiophils on peiipheial smeai
- Neuiological manifestations such as loss of vibiationposition sense, ataxia,
anu 0NN signs (+ve Babinski, spasticity, incieaseu BTR's)
- ulossitis
- Incieaseu seium levels of methylmalonic aciu anu homocysteine (B12 is a co-
factoi in conveision of these two molecules into succinyl CoA anu
methionine, iespectively)
(87@B?7:B: Intiamusculai auministiation of vitamin B12 one time pei month.

Z"35! )!5X X%Z5!5%#!0
Symptoms similai to vitamin B12 ueficiency without any neuiological signs oi
symptoms.
- Bietaiy ueficiency is the most common cause, as stoies iun out in S months.
Commonly the patient eats the "tea anu toast" uiet
- The best souices foi folate aie gieen leafy vegetables
- 0thei common causes asiue fiom uietaiy insufficiency aie: alcoholism,
piegnancy, folate antagonists, hemolysis, hemouialysis.
(87@B?7:B: Baily folic aciu supplementation

)$3".G(-, +4$3-+

Is a uestiuction of ieu bloou cells befoie theii piogiammeu time of ueath.
- Theie will be an incieaseu ieticulocyte count as the bone maiiow iesponus
to the incieaseu neeu foi RBC's
- An anemia will iesult when the bone maiiow cannot keep up with the new
uemanu foi RBC's.
Theie aie foui kinus of hemolytic anemia, they aie:
1. 5AC>FA@FO - these aie factois that aie heieuitaiy in natuie, incluuing: Sickle
cell uisease, thalassemias, hemoglobin C uisease
2. %PC>FA@FO - theie aie acquiieu factois causing hemolysis, incluuing: Immune
iegulateu hemolysis, mechanical hemolysis (piosthetic heait valves), toxic
insults (uiugs, poisons, etc).
S. /HDW>BAH MHUHOC@ - uefects of the membiane can iesult in RBC hemolysis,
they incluue: Beieuitaiy spheiocytosis, PNB
4. XHUHOC@ ?U CIH HAaEDH@ - u6PB ueficiency, pyiuvate kinase ueficiency

If the hemolysis occuis within the ciiculation, "intiavasculai hemolysis" occuis.
If the hemolysis occuis within the ieticuloenuothelial system, "extiavasculai
hemolysis" occuis.

/BFA UHBCS>H@ ?U IHD?LECFO BAHDFB:
- }aunuice
- Fatiguepalloi
- Baik uiine (causeu by hemoglobin)
- Bepatosplenomegaly

XFBJA?@FAJ:
- Bemoglobin anu hematociit levels
- Peiipheial smeai to uiffeientiate between uiffeient types of hemolysis
Beinz bouies ! u6PB ueficiency
Schistocytes ! intiavasculai hemolysis
Sickleu RBC ! sickle cell anemia
Spheiocyteshelmet cells ! extiavasculai hemolysis

2-,V.$ ,$.. &-2$+2$
Is causeu by a IHD?JL?WFA & h(W&i DSCBCF?A. Theie is a single amino aciu
ieplacement in the "-chain.
- valine ieplaces glutamic aciu
- A low oxygen state causeu "sickling" of the ieu bloou cells
- Sickle cell "tiait" is a heteiozygote
- Sickle cell tiait patients aie usually malaiia-iesistant
)MGH>@H %UUHOC@:
- Aplastic ciisis causeu by Paivoviius B19 infection
- Incieaseu iisk of infection by encapsulateu bacteiia (B. Infl, S. Pneumo,
Neisseiia) ! uive patient pneumococcal vaccine, Bib vaccine, meningococcal
vaccine.
- vaso-occlusive ciisis causing seveie pain (uue to miciociiculation
obstiuction by sickleu ieu bloou cells)
- Splenic sequestiation ciisis


YIBC F@ B @NLHAFO @HRSH@C>BCF?A O>F@F@n
This is a potentially fatal complication of the sickle cell uisease. Bloou pools into the
spleen, iesulting in splenomegaly anu the subsequent uevelopment of hypovolemic
shock. This conuition often waiiants a splenectomy.

(W! MHUHOC
- Niluei uisease (BbC oi BbSC)
(87@B?7:B: Byuioxyuiea to inciease BbF levels (pievents the sickling piocess),
bone maiiow tiansplant, piophylactic penicillin foi chiluien fiom 4 months of age
to 6 yeais of age.

()$ ,""3*[2 ($2(
The uiiect Coombs test is useu to uetect antibouies bounu to the suiface of the RBC.
This is the test useu to uetect immune-meuiateu hemolytic anemia. The Coombs
test is baseu on the iuea that the auuition of anti-human antibouies will binu to
human antibouies that aie bounu to the RBC membiane. These antibouies aie most
commonly Igu anu IgN. If these antibouies agglutinate, the RBC's will clump anu
this is a positive test iesult. If they uo not agglutinate anu clump, we have a negative
test iesult.





)$#$&-(+#G 2/)$#",G("2-2
This is an AB uisoiuei wheie theie is a uefect in the gene that coues foi spectiin,
iesulting in a uecieaseu content of spectiin. This causes a loss of the membiane
suiface aiea with no ueciease in volume. These two cause the shape to shift fiom
ciiculai to spheiical.
- The osmotic fiagility test is a way to test the RBC's ability to withstanu
hypotonic saline. The spheiical shape will toleiate the solution less than the
iegulai RBC shape, thus causing it to iuptuie fastei.
- Peiipheial smeai woulu show spheiocytes
- Coombs test is negative

T.1,"2$S`S/)"2/)+($ &$)G&#"T$4+2$ &$!-,-$4,G
This is an x-linkeu iecessive uisoiuei that is usually piecipitateu by infections, fava
beans, piimaquine, uimeicaptol, sulfonamiues, anu nitiofuiantoin.
- Patient gets episoues of hemolytic anemia that is often piecipitateu by an
aggiavating factoi
- Patient will get jaunuice anu have uaik uiine
- Peiipheial smeai will show bite cells (causeu by maciophages) anu Beinz
bouies (hemoglobin piecipitation insiue RBCs)
- Biagnose by measuiing u6PB levels.
(87@B?7:B: Avoiu piecipitating factois, tiansfuse as necessaiy

+1("-3314$ )$3".G(-, +4$3-+
Autoantibouies against the RBC membiane cause uestiuction of RBC's. Theie aie
two possible causes foi this, Igu antibouies oi IgN antibouies
-MT E@<A7A ! "waim" autoimmune hemolytic anemia. This means that binuing of
Igu to the RBC membiane occuis optimally at S7C. This causes extiavasculai
hemolysis wheie the piimaiy site of sequestiation is the spleen.
-M3 E@<A7A ! "colu" autoimmune hemolytic anemia. Binuing of IgN to the RBC
membiane occuis optimally at uC to 5C. This causes intiavasculai hemolysis anu
complement activation, wheie the piimaiy site of sequestiation is the livei.
XFBJA?@FAJ:
- Biiect Coombs test: If +ve = waim, if -ve = colu
(87@B?7:B: If milu , no tieatment is necessaiy. If waim anu moueiate, give
glucocoiticoius (uo splenectomy if no uC iesponse).

/+#"0G23+. 4",(1#4+. )$3"T."*-41#-+ O/)4P
Is a conuition wheieby theie is chionic intiavasculai hemolysis.
- Noimochiomic noimocytic anemia
- Pancytopenia (affects hematopoietic stem cells)
- Thiombosis of venous system may occui
- Nay cause moie seveie conuitions such as aplastic anemia's, myelouysplasia,
anu acute leukemia's
- Patient can expeiience musculoskeletal anu uI pains
(87@B?7:B: Pieunisone oi BN tiansplant if no iesponse to tieatment.

/.+($.$( &-2"#&$#2


()#"3*",G("/$4-+
This is when the platelet count falls below 1Su,uuu
!BS@H@:
- Becieaseu piouuction uue to: BN injuiy, suppiession, invasions
- Incieaseu uestiuction uue to: BIC, TTP, infection, uiugs, ITP, BIv
- Sequestiation
- Piegnancy: usually not a majoi concein
- Bilutional effects fiom tiansfusion
- Beteimination of cause can be maue with CBC, peiipheial smeai, anu bone
maiiow biopsy.

&FJA@e&EDNC?D@:
- Petechial bleeuing (pinpoint bleeuing)
- Nucosal bleeuing (ie epistaxis, menoiihagia, hemoptysis)
- Excessive bleeus aftei injuiy anuoi suigical pioceuuies

()#"3*"(-, ()#"3*",G("/$4-, /1#/1#+ O((/P
A conuition wheieby theie is excessive platelet consumption, leauing to an
emeigency situation that can leau to ueath iathei quickly (few months).
&FJA@e&EDNC?D@:
- Alteieu mental status
- Bemolytic anemia
- Thiombocytopenia
(87@B?7:B: Plasmaphaiesis is iequiieu to maintain life, coiticosteioius anu
splenectomy may also be iequiieu.

-&-"/+()-, ()#"3*",G("/$4-, /1#/1+ O-(/P
Is an autoimmune foimation of antibouies against platelets. Igu antibouies auheie
to anu uestioy the platelets which aie then iemoveu by splenic maciophages.
Acutely ! Is a self-limiteu conuition seen in chiluien, wheie the conuition is almost
always pieceeueu by a viial infection.
Chionically ! Is a spontaneous foim of ITP seen most commonly in miuule-ageu
females. Is self-limiteu.


T.+4\3+44[2 ()#"3*+2()$4-+
This is an AR uisoiuei wheie theie is a ueficiency in platelet aggiegation uue to a
ueficiency of glycopiotein uPIIb-IIIa. The only alteieu test is incieaseu bleeuing
time.

*$#4+#&S2"1.-$# 2G4&#"3$
Is an AR uisoiuei of platelet auhesion uue to a ueficiency of glycopiotein uPIb-IX.
The platelet count will be low with abnoimally laige platelets on peiipheial smeai.

&-2"#&$#2 "! ,"+T1.+(-"4

1. von Willebianu's Bisease (vWB)
2. Bemophilia A
S. Bemophilia B
4. Bisseminateu Intiavasculai Coagulation (BIC)
S. vitamin K ueficiency
6. Coagulopathy of livei uisease
7. Inheiiteu hypeicoagulable states

5"4 %-..$*#+4&[2 &-2$+2$
Is an AB uisoiuei that is causeu by a ueficiency oi uefect of the vWF (factoi 8-
ielateu antigen). vWF is iequiieu foi the fiist step of platelet aggiegation in clot
foimation.
* 9%! DA BH7 ?>AB E>??>: D:H78DB7= QI77=D:M =DA>8=78l @CC7EBD:M <N B> ]t >C
BH7 N>N<I@BD>:n
&FJA@e&EDNC?D@:
- Cutaneous bleeuing
- Nucosal bleeuing
- Nenoiihagia seen in moie than half of females with vWB
- Nany patients won't show anything sign oi symptoms until they unueigo a
suigical pioceuuie anu have excessive bleeuing
- Bleeuing time will be piolongeu, platelet count is noimal
- PTT may be piolongeu, vWF is uecieaseu, factoi 8 activity is uecieaseu
- Ristocetin levels shoulu be checkeu in uiagnosing vWB
Tieatment: Besmopiessin to inuuce enuothelial cells to seciete von Willebianu
factoi (not effective in type S vWB). Factoi 8 concentiates is iecommenueu foi type
S vWB. Patient shoulu avoiu NSAIBs.

)$3"/)-.-+ +
Is an x-linkeu iecessive uisoiuei that affects male patients, anu is causeu by a
ueficiency oi uefect of factoi 8.
&FJA@e&EDNC?D@:
- Bleeuing into joints (hemaithioses)
- Intiamusculai bleeus
- Intiacianial bleeus (theiefoie heau tiauma must be taken veiy seiiously in
these patients)
XFBJA?@FAJ:
- Low factoi 8 levels + noimal vWF
- PTT is piolongeu
(87@B?7:B: Replace clotting factois, uesmopiessin may be helpful in some patients.

)$3"/)-.-+ *
Is an x-linkeu iecessive uisoiuei causeu by a ueficiency of factoi 9, anu is much less
common than hemophilia A. Nanagement involves ieplacing missing factois.

&-22$3-4+($& -4(#+5+2,1.+# ,"+T1.+(-"4 O&-,P
BIC is a uisoiuei chaiacteiizeu by an abnoimal activation of the coagulation
sequence, which leaus to wiuespieau foimation of miciothiombi thioughout the
miciociiculation. This leaus to the consumption of clotting factois, platelets, anu
fibiin. Theie is also an activation of fibiinolytic mechanisms, thus leauing to
hemoiihages. *.$$&2 k ()#"3*"2-2
!?DD?A OBS@H@:
- The most common cause is infection (uiam -ve sepsis is NCC)
- Piegnancy complications
- Tiauma
- Nalignancy
- Shock
&FJA@e&EDNC?D@:
- 0ozing fiom pioceuuie sites
- Ecchymoses
- Petechia
- Puipuia
- Thiomboses seen moie often in chionic cases of BIC
(87@B?7:B: Coiiect unueilying conuitions anu apply suppoitive measuies.

5-(+3-4 V &$!-,-$4,G
Theie aie many clotting factois that iequiie vitamin K as a cofactoi in synthesis,
incluuing: Piotein C & S, anu factois 2, 7, 9, 1u. vitamin K ueficiency is seen in veiy
ill patients who aie being feu thiough a tube, as well as those who aie using oial
waifaiin as an anti-coagulant.
&FJA@e&EDNC?D@:
- Significant hemoiihages
- PT piolongation (is the fiist finuing), then PTT piolongation.
(87@B?7:B: vitamin K ieplacement.
If patient has a seveie bleeu, fiesh fiozen plasma shoulu be given as it
contains all of the clotting factois.

,"+T1."/+()G "! .-5$# &-2$+2$
Since the livei synthesizes all clotting factois, any uisease of the livei can cause
coagulopathies (abnoimal bleeuing, piolongation of PTPTT).
Tieatment: Fiesh fiozen plasma if PTPTT aie alteieu oi theie is significant
bleeuing.






-4)$#-($& )G/$#,"+T1."/+()-$2
- )ACFCI>?DWFA 4 MHUFOFHAOE (incieaseu thiombosis)
- )ACFNI?@NI?LFNFM BACFW?ME @EAM>?DH (aiteiial oi venous thiombosis)
- *>?CHFA ! MHUFOFHAOE (uniegulateu fibiin synthesis)
- *>?CHFA & MHUFOFHAOE (leaus to a ueficiency of piotein C activity)
- ZBOC?> ] LHFMHA (uniegulateu piothiombin activation - incieaseu
thiomboembolic events)
- *>?CI>?DWFA JHAH DSCBCF?A

/.+23+ ,$.. &-2"#&$#2

1. Nultiple Nyeloma
2. Waluenstiom's Nacioglobulinemia
S. Nonoclonal uammopathy of 0nueteimineu Significant (Nu0S)

31.(-/.$ 3G$."3+
Is a cancei of the bone maiiow that piouuces laige amounts of Igu oi IgA. This is
the most common tumoi aiising in auults
5C OBS@H@:
- Bone lesions
- Bypeicalcemia
- Anemia
- Infections
&FJA@e&EDNC?D@:
- Skeletal manifestations (bone pain, fiactuies, veitebial collapse)
- Noimocytic noimochiomic anemia (uue to BN infiltiation anu ienal failuie)
- Renal failuie
- Infections (seconuaiy to uepiivation of noimal Ig's affects humoial
immunity, anu is the NCC of ueath)
- Amyloiuosis
!IB>BOCH>F@CFO ZFAMFAJ@:
- Bence }ones pioteins in uiine (aie Ig light chains)
- N-spike (is a monoclonal Ig spike seen on seium electiophoiesis)
- Rouleau foimation (peiipheial smeai showing RBCs stackeu like pokei
chips)

%+.&$42(#"3[2 3+,#"T."*1.-4$3-+
Is a conuition that causes hypeiviscosity of the bloou uue to malignant piolifeiation
of plasmacytoiu lymphocytes (IgN). Shoulu be manageu with chemotheiapy anu
plasmaphaiesis

3"4",."4+. T+33"/+()G "! 14&$($#3-4$& 2-T4-!-,+4,$
Is a conuition that is usually asymptomatic anu seen in the elueily population.



.G3/)"3+2

)"&TV-4[2 9An 4"4S)"&TV-4[2
)"&TV-4[2 4"4S)"&TV-4[2
Reeu-Steinbeig cells piesent.

0nly single gioup of LN's affecteu.

Low-giaue fevei, weight loss, night
sweats.

Associateu with Epstein Baii viius.

Piognosis uepenuent on amount of
lymphocytes anu Reeu-Steinbeig cells
(best when incieaseu lymphocytes anu
uecieaseu Reeu-Steinbeig cells).
Is associateu with states of
immunosuppiession.

Nany LN's involveu with extianoual
involvement.

B cells aie of the majoiity.

veiy few constitutional symptoms
0ccuis fiom 2u-4uyi of age.















,+#&-+, /+()"."TG

-2,)$3-, )$+#( &-2$+2$
1. Stable Angina
2. 0nstable Angina
S. vaiiant Angina (Piinzmetal's)

&$)23% )#.5#)
Fixeu atheioscleiotic lesions naiiow the coionaiy aiteiies, leauing to an imbalance
between bloou supply anu u2 uemanu. This leaus to inauequate peifusion, anu
oxygen uemanu exceeus bloou supply. Atheioscleiosis leaus to naiiowing > 7S%.
&FJA@e&EDNC?D@:
- Substeinal chest pain lasting less than 1S minutes
- Pain is uesciibeu as squeezing, heaviness, piessuie
- Always biought on by physical exeition
- Pain goes away with iest anuoi nitioglyceiine

7#&$)23% )#.5#)
In unstable angina, the cause of chest pain is uue to a ieuuceu iesting coionaiy
bloou flow. The main uiffeience between unstable vs. stable angina is that the pain
of unstable angina occuis at iest.

*+5#m/%$)3c& )#.5#)
Piinzmetal's angina is causeu by a tiansient coionaiy vasospasm that is
accompanieu by a fixeu atheioscleiotic lesion. The symptoms occui at iest.
SignsSymptoms:
- Chest pain at iest
- Nost common in youngei females who smoke cigaiettes
- Theie will be a tiansient ST-segment elevation on EKu uuiing the episoues of
chest pain



+#($#-"2,.$#"2-2 _ +()$#"2,.$#"2-2
)+$%+5"&!3%+"&5& - Aiteiioscleiosis is a consequence of hypeitension, wheieby
theie is hyaline thickening of the small aiteiies.

)$(%+"&!3%+"&5&
Is plaque foimation within the intima of the aiteiies, occuiiing in the elastic anu
laigemeuium - sizeu musculai aiteiies. The most common causes of
atheioscleiosis aie: ($#V @D?\FAJV IENH>LFNFMHDFBV X/V MFHCB>E UBOC?>@V UBDFLE
IF@C?>EQ
*>?J>H@@F?Ad ZBCCE &C>HB\ ! *>?LFUH>BCFGH *LBRSH ! !?DNLHP )CIH>?DB
)MGH>@H %UUHOC@d
- Ischemia
- Infaiction
- Peiipheial vasculai uisease
- Thiombus
- Emboli
3?OBCF?A@:
Nost commonly in the abuominal aoita, coionaiy aiteiies, popliteal aiteiies, anu
caiotiu aiteiies.

)G/$#($42-"4
$AA7:BD@I )(4: No iuentifiable cause, anu applies to > 9S% of cases of BTN
27E>:=@8F )(4: Renal causes (stenosis), enuociine causes (hypeialuosteionism,
hypeithyioiuism, Cushing's, pheociomocytoma), meuication (0CPs). **0CP's aie
NCC in young women
%UUHOC@ ?U ($# ?A CIH IHB>C:
- Incieaseu systemic vasculai iesistance leauing to eventual CBF (CBF is the
most common enu-iesult of BTN)
- Atheioscleiosis
- CAB
- Left ventiiculai hypeitiophy
- Stioke
- Renal failuie
- Retinal changes anu uamage
- Risk of hemoiihages
- Risk of kiuney atheioscleiosis
)(4
,I@AADCDE@BD>:
2FAB>IDE #7@=D:M &D@AB>IDE #7@=D:M 3@:@M7?7:B
4>8?@I < 12u < 8u No tieatment
necessaiy
/87HFN78B7:AD>: 12u-1S9 8u-89 Lifestyle
mouifications only
2B@M7 X )(4 14u-1S9 9u-99 Lifestyle mous + 1
anti-BTN
meuication
2B@M7 Z )(4 ) 16u ) 1uu Lifestyle mous + 2
anti-BTN meus


3G",+#&-+. -4!+#,(-"4
Nyocaiuial infaictions occui as a iesult of the occlusion of a vessel in the heait,
inteiiupting the supply to the heait, iesulting in infaiction. 0ccuis in the 3)X l +!)
l !5+!7/Z3%f
$IH WH@C FAFCFBL CH@C U?> B @S@NHOCHM /5 F@ CIH %b.Q

!B>MFBO %AaEDH@:
,VS3* - best initial caiuiac enzyme (optimal foi uetecting a seconu infaict while in
the hospital)
(8>N>:D:- iises aftei 4 his then stays elevateu foi 7-1u uays

*BCI?L?JFOBL OIBAJH@ BUCH> BA /5:
&@F X - Baik mottling
&@F ZS^ - Bypeiemia (vessel uilation)
&@F bSXY - Bypeiemic boiuei with cential yellow-biown softening
!7K K77mA - 0ccluueu aiteiy is ie-canalizeu anu a scai is piesent (giay-white
coloiing).

!?DNLFOBCF?A@ ?U B DE?OB>MFBL FAUB>OCF?A:
1. Left ventiiculai failuie
2. Pulmonaiy euema
S. Caiuiac aiihythmia (most common cause of ueath befoie ieaching the
hospital)
4. Caiuiogenic shock
S. Ruptuie of ventiiculai fiee wall, papillaiy muscles, anuoi inteiventiiculai
septum (occuis 4-1u uays post-NI)
6. Nuial thiombus causing thiomboembolism
7. Peiicaiuitis (S-S uays post-NI)


,+#&-+, (13"#2
In auults, the most common tumoi is the "/EP?DB". This occuis most of the time in
the left atiium. They cause a "ball-valve obstiuction" that obstiucts the left atiium.
In chiluien, the most common tumoi is the "+IBWM?DE?DB" anu is associateu with
tubeious scleiosis.



,"4T$2(-5$ )$+#( !+-.1#$
A conuition wheieby the heait's pumping ability cannot meet the bouy's ciiculatoiy
uemanus unuei noimal conuitions.










$(% Z+)#bK&$)+35#. +%3)$5"#&(5*
Says that in noimal functioning heaits, an inciease in pieloau shoulu iesult in
gieatei contiactility. Baseu on this piinciple, with exeition a heait in CBF piouuces
less contiactility anu this is when symptoms occui.


&FJA@e&EDNC?D@:
3%Z$K&5X%X (Z
- Byspnea (seconuaiy to pulmonaiy congestion)
- 0ithopnea (uifficulty sleeping in the iecumbent position)
- Paioxysmal noctuinal uyspnea (patient awakes shoitly aftei falling asleep
uue to S0B)
- PNI is uisplaceu to the left uue to caiuiomegaly
- SS (ventiiculai gallop)
- S4 (atiial systole into a non-compliant left ventiicle)
- Ralesciackles (an inuication of pulmonaiy euema)
- Bullness on peicussion
+5.($K&5X%X (Z
- Peiipheial euema (pitting)
- }ugulai venous uistention
- Ascites
- Bepatomegaly
- Right ventiiculai heave

5+.51.+# )$+#( &-2$+2$ O31#31#2P
1. Nitial Reguigitation
2. Aoitic Stenosis
S. ventiiculai Septal Befect
4. Nitial Piolapse
S. Aoitic Reguigitation
6. Nitial Stenosis
7. Patent Buctus Aiteiiosus
8. Bypeitiophic obstiuctive caiuiomyopathy (B0CN)

All valvulai heait uiseases piesent with shoitness of bieath initially. In young
people, the most commonly encounteieu valve uisoiueis aie: Nitial piolapse, mitial
stenosis, oi bicuspiu aoitic valves.
3<8?<8 -:B7:ADBF:
IvI - 0nly heaiu with specific maneuveis (ie valsalva)
IIvI anu IIIvI - This is wheie the majoiity of muimuis lie.
IvvI - Palpable thiill is piesent
vvI - Nuimui can be heaiu with the stethoscope paitially off the chest
vIvI - Nuimui can be heaiu without a stethoscope

/5$+)3 +%.7+.5$)$5"# [ A holosystolic "blowing muimui" that is best heaiu at
the apex of the heait.
)"+$5! &$%#"&5& - The "ciescenuo-ueciescenuo" systolic ejection muimui
following an ejection click.
]&X - A holosystolic muimui
/5$+)3 *+"3)*&% - A late systolic muimui with a miusystolic click
)"+$5! +%.7+.5$)$5"# - Bigh-pitcheu blowing uiastolic muimui
/5$+)3 &$%#"&5& - A late iumbling uiastolic muimui following an opening snap
*X) - A machine-like muimui
(0*%+$+"*(5! "2&$+7!$5]% !)+X5"/0"*)$(0 - An autosomal uominant tiait
that can iesult in suuuen ueath in young athletes. The walls of the Lv anu
inteiventiiculai septum hypeitiophy, cieating a "banana shape" in the ventiicle.

,+#&-+, +##)G()3-+2
(@EHF@88HFBH?D@A:
- Atiial Fibiillation
- Atiial Fluttei
- Nultifocal Atiial Tachycaiuia
- Paioxysmal Supiaventiiculai Tachycaiuia
- Wolff-Paikinson-White Synuiome
- ventiiculai Tachycaiuia
- ventiiculai Fibiillation
*8@=F@88HFBH?D@A:
- Sinus Biauycaiuia
- Sick Sinus Synuiome
- Av Blocks (1
st
, 2
nu
, anu S
iu
uegiee blocks)

)$+5)3 Z52+533)$5"#
An iiiegulai, iapiu ventiiculai iate is causeu by multiple foci in the atiia that fiie
eiiatically. The atiial iate is as high as 4uubpm.
Patient will expeiience:
- Palpitations
- Bizziness
- Exeitional uyspnea
- Iiiegulaily iiiegulai pulse
uoals of tieatment aie:
1. ventiiculai iate contiol
2. Restoiation of noimal sinus ihythm
S. uive anticoagulation (if neeueu)


)$+5)3 Z37$$%+
0ne foci in the atiium fiies automatically, causing an atiial iate of 2Su-SSubpm,
with only 1 out of S of these contiactions making it to the ventiicle. The EKu will
show with the classic "sawtooth" pattein.

/73$5Z"!)3 )$+5)3 $)!(0!)+X5)
This is a conuition that occuis most commonly in those with C0PB. Theie will be at
least thiee uiffeient P-wave moiphologies with vaiiable PR anu RR inteivals.
Can uiagnose with vagal maneuveis anuoi auenosine auministiation to show the
an Av block without uisiupting the atiial tachycaiuia.

*)+"f0&/)3 &7*+)]%#$+5!73)+ $)!(0!)+X5)
Is uue to a ieentiant ciicuit within the Av noue. Theie will be naiiow QRS
complexes with no uisceinable P waves on EKu. This conuition may be causeu by
the following:
- Bigoxin toxicity
- Ischemic heait uisease
- Atiial fluttei
- Piesence of accessoiy pathways
- Excessive consumption of alcohol oi caffeine

Y"3ZZK*)+b5#&"#KY(5$% &0#X+"/%
Theie is an accessoiy pathway fiom the atiia to the ventiicles that cause piematuie
ventiiculai excitations uue to a lack of uelay in the Av noue.
Theie aie two mechanisms by which this conuition can cause a paioxysmal
tachycaiuia:
1. 2<N8@97:B8DE<I@8 (@EHFE@8=D@A - All impulses get thiough to the ventiicle
in this conuition, wheieas in noimal ciicumstances only one Atiial impulse
gets thiough.
2. "8BH>=8>?DE #7EDN8>E@BD>: (@EHFE@8=D@ - cieates a ie-entiy loop that
causes multiple uepolaiizations of the atiia.


]%#$+5!73)+ $)!(0!)+X5)
This conuition is uefineu as a iapiu anu iepetitive fiiing of thiee oi moie piematuie
ventiiculai contiactions in a iow, at a iate of 1uu-2Subpm. Is iesponsible fio up to
7S% of caiuiac aiiest.
The most common causes of ventiiculai tachycaiuia aie:
- Caiuiomyopathies
- Bypotension
- CAB
- Piolongeu QT synuiome
- Biug toxicities
&FJA@e&EDNC?D@:
- Palpitations
- Byspnea
- Angina
- Syncope
- Wiueneu anu eiiatic QRS complex on EKu
** A iapiu, polymoiphic foim of ventiiculai tachycaiuia can leau to a conuition
known as "Toisaues ues Pointes".

]%#$+5!73)+ Z52+533)$5"#
0ccuis when theie aie multiple foci within the ventiicles that fiie iapiuly, which
leaus to a chaotic quiveiing of the ventiicles. Nost cases of vFib occui as a iesult of
ventiiculai tachycaiuia. This conuition is fatal when untieateu.
** Association of vFib with an NI cieates a favoiable long-teim piognosis, wheieas
no association between the two gives a high iate of iecuiience.
&FJA@e&EDNC?D@:
- Lack of pulse, heait sounus, anu BP
- Patient loses consciousness anu will uie without inteivention
** Immeuiate uefibiillation anu CPR shoulu be peifoimeu to pievent suuuen ueath.
Theie aie no meuications that can conveit this conuition to noimal ihythm.
** Note that all AB>>?T O?DNLHP CBOIEOB>MFB@ will oiiginate fiom above the
ventiicle, wheieas TFMH O?DNLHP CBOIEOB>MFB@ oiiginate within the ventiicles.


*8@=F@88HFBH?D@A:

&5#7& 2+)X0!)+X5)
Is a sinus iate of < 6u bpm, anu becomes uangeious when the iate uiops below 4S
bpm. Common causes of sinus biauycaiuia aie: Ischemia, Incieaseu vagal Tone,
Anti-aiihythmics
** Patients aie usually symptomatic anu may piesent with only fatigue
** Atiopine will block vagal stimulation anu thus elevate the sinus iate.

&5!b &5#7& &0#X+"/%
This is a uysfunction of the sinus noue that causes peisistent spontaneous bouts of
sinus biauycaiuia. Patient will expeiience uizziness, confusion, fatigue, anu CBF.

)] 23"!b&
X
AB
=7M877 - A benign conuition wheie the PR inteival is piolongeu to >u.2u seconus
Z
:=
=7M877 - Theie aie Nobitz type 1 anu Nobitz type 2
A.M('S !>%# T - piogiessive piolongation of PR inteival until theie is an absent P
wave. Boes not iequiie tieatment.
A.M('S !>%# U - theie is a missing P wave without any changes in the pieceuing PR
inteival, causing the uiopping of a QRS complex all of a suuuen. Nay piogiess anu
become a complete heait block. +HRSF>H@ NBOHDB\H> FDNLBAC.
]
8=
=7M877 O,>?NI7B7 H7@8B QI>EmP - theie is an absence of atiial impulses to the
ventiicle, thus theie is no ielationship between P waves anu QRS complexes.
+HRSF>H@ NBOHDB\H>Q







,+#&-"3G"/+()-$2

(0*%+$+"*(5! !)+X5"/0"*)$(0
Asymmetiic caiuiomyopathy that involves the inteiventiiculai septum iesults in
uiastolic uysfunction. The walls of the left ventiicle become thickeneu. A banana
shape occuis in the Lv, can iesult in suuuen ueath in young athletes.
X53)$%X !)+X5"/0"*)$(0
Bilation of the heait that is most commonly causeu by: )LO?I?LV )M>FBDEOFAV
+BMFBCF?AV !IBJBc@ MF@HB@HV !?P@BO\FH 2 GF>S@. This conuition iesult in systolic
uysfunction.
+%&$+5!$5]% !)+X5"/0"*)$(0
Nyocaiuial infiltiation iesults in impaiieu uiastolic filling of the ventiiculai uue to a
ueciease in ventiiculai compliance. Common causes aie: )DEL?FM?@F@V &B>O?FM?@F@V
(HD?OI>?DBC?@F@V &OLH>?MH>DBQ

/$#-,+#&-+. &-2"#&$#2
1. Acute Peiicaiuitis
2. Constiictive Peiicaiuitis
S. Peiicaiuial Effusion
4. Caiuiac Tamponaue

)!7$% *%+5!)+X5$5&
Is an acute conuition that iesults in chest pain, uiffuse ST-elevations anu PR
uepiession on EKu, a peiicaiuial fiiction iub, anu possible peiicaiuial effusion.
Nay be causeu by any of the following:
- Nost cases occui aftei a viial illness (most commonly an 0RI)
- Infectious (Coxsackie viius, hepatitis, BIv, TB, toxoplasmosis, oi fungal
infections)
- Collagen vasculai uisease
- Post-suigeiy
- Amyloiuosis
- Lupus
- Post-NI (known as Biesslei's synuiome)
** Recoveiy occuis within 1-S weeks anu iequiies only NSAIBs foi management.
Complications may incluue:
- Effusion
- Tamponaue occuis in 1u%-2u% of patients

!"#&$+5!$5]% *%+5!)+X5$5&
0ccuis seconuaiy to fibious scaiiing of the peiicaiuium, leauing to iigiuity anu
thickening of the peiicaiuium. Theie aie a few possible causes, incluuing:
- Connective tissue uisoiueis
- Chionic peiicaiuial effusion
- Rauiation theiapy
- 0iemia
- Piioi heait suigeiies
&FJA@e&EDNC?D@:
- Symptoms of hepatic congestion (euema, ascites)
- Pulmonaiy congestion
- }vB
- Peiicaiuial knock

*%+5!)+X5)3 %ZZ7&5"#
0ccuis when peiicaiuial space becomes occupieu with fluiu. 0ccuis when theie is
ascites anu pleuial effusion piesent. 0ften occuis when the patient has CBF,
nephiotic conuitions, anuoi ciiihosis.
&FJA@e&EDNC?D@:
- Peiicaiuial fiiction iub
- Nuffleu heait sounus
- Point of maximal impulse (PNI) is softeneu





!)+X5)! $)/*"#)X%
Is a peiicaiuial effusion that impaiis uiastolic filling of the heait. Piessuie of all
chambeis, the pulmonaiy aiteiy, anu peiicaiuium aie equal in piessuie, thus
ventiiculai filling is impaiieu.
!?DD?A OBS@H@:
- Fiee-wall iuptuie aftei an NI
- Neuical eiiois causing punctuie to heait
- Penetiating injuiies
&FJA@e&EDNC?D@:
- Bypotension
- }vB
- Nuffleu heait sounus
** Known as "Beck's Tiiau"
- Naiioweu pulse piessuie
- Pulsus paiauoxus (exaggeiateu ueciease in aiteiial piessuie uuiing
inspiiation > 1ummBg)
- Nuffleu heait sounus
- Caiuiogenic shock

#)$13+(-, )$+#( &-2$+2$
Rheumatic feveiheait uisease is a conuition that occuis as a consequence of
phaiyngitis fiom a gioup A stiep infection. The mitial valve is the most common
valve affecteu. The piogiession to a heait uisease is an immune-meuiateu piocess,
not a iesult of the bacteiial infection.
Biagnosing is maue with the }0NES ciiteiia, anu iequiie the piesence of two majoi
ciiteiia 0R one majoi anu one minoi ciiteiia:






3+6"# ,#-($#-+
Nigiatoiy Polyaithiitis
Eiythema Naiginatum
Choiea
Caiuiac Involvement
Subcutaneous Nouules
3-4"# ,#-($#-+
Fevei
ESR elevation
Polyaithialgias
PR inteival piolongation
Piioi histoiy of RF infection
Eviuence of pieceeuing stiep
infection

$4&",+#&-(-2
Is an infection of the enuocaiuium that can be classifieu as eithei acute oi subacute.
Nost often, the mitial valve is involveu, wheieas an infection of the tiicuspiu valve is
usually uue to Iv uiug abuse.
+E<B7 $:=>E@8=DBDA - Causeu by &CBNI )S>HS@ anu cieates laige vegetations on a
pieviously healthynoimal valve.
2<Q@E<B7 $:=>E@8=DBDA - Causeu by ]F>FMFBA@ J>?SN &C>HN anu cieates small
vegetations on an abnoimaluiseaseu valve. ** 0ccuis with uental pioceuuies
The symptoms of bacteiial enuocaiuitic can be iemembeieu with the mnemonic
"!#"3 6+4$".
! - Fevei
# - Roth's spots (ietinal hemoiihages)
" - 0slei's noues (painful, iaiseu ieu lesions on hanus anu feet)
3 - Nuimui
6 - }ane way lesions (non-tenuei lesions on palms anu soles)
+ - Anemia
4 - Nail-beu hemoiihage
$ - Emboli

** 3FWDBAK&BO\@ %AM?OB>MFCF@ - is a foim of enuocaiuitis seen in patients with
Lupus, wheie theie aie vegetations founu on both siues of the valve, leauing to
stenosis.








$3*".-
Emboli aie things that tiavel thiough the ciiculation an get lougeu in the pulmonaiy
vasculatuie, leauing to a pulmonaiy embolus (PE).
The most commonly encounteieu types of emboli aie: !@B (uue to long bone bieaks
anu liposuction), +D8 (can occui as a iesult of injection of aii into the ciiculatoiy
system), (H8>?Q<A (bieaks of fiom a ueep vein thiombosus), +?:D>BDE !I<D=
(fiom piegnancy complications).
** #"$%: Thiombi causing a pulmonaiy embolism will piesent with chest pain anu
shoitness of bieath in the patient.
&5(
A ueep vein thiombosis (BvT) is the piecuisoi to an emboli, anu is causeu by
patients who have the following:
1. &CB@F@ (they uon't move enough - classically they took a long flight)
2. (ENH>O?BJSLBWFLFCE (uue to uisease states oi familial)
4Q %AM?CIHLFBL XBDBJH














2V-4 ,+4,$#
The thiee types of skin cancei incluue: Squamous cell, basal cell caicinoma, anu
melanoma.
2s<@?><A ,7II ,@8ED:>?@:
Is a veiy common foim of skin cancei, anu is associateu with excess exposuie to
sunlight. Is most commonly seen on the hanus anu face, actinic keiatosis is a
piecuisoi to SCC. Is locally invasive but iaiely will it metastasize.

*@A@I ,7II ,@8ED:>?@:
Piesents as "peaily papules", anu is most commonly seen in sun-exposeu aieas of
the bouy.




37I@:>?@:
Nelanoma poses the gieatest iisk of metastasis. Those with faii skin aie at highest
iisk. Theie is a uiiect coiielation between the uepth of the lesion anu the uegiee of
metastasis.


*#+-4 ,+4,$#2
,HDI=H>>= Q8@D: E@:E78AR
1. Astiocytoma
2. Neuulloblastoma
S. Epenuymoma
4. Bemangioma
S. Cianiophaiyngioma

)@C>?OEC?DB - This type of biain cancei is usually founu in the posteiioi fossa, anu
it comes with a goou piognosis.
/HMSLL?WLB@C?DB - This can cause hyuiocephalus as it often piesses on the fouith
ventiicle. The cells aiiange in a 'Rosette' anuoi 'Pseuuoiosette" pattein. It is a
highly malignant ceiebellai tumoi.
%NHAMED?DB - 0sually founu in the fouith ventiicle, it ueiives fiom epenuymal
cells anu can also cause hyuiocephalus uue to its location.
(HDBAJF?WLB@C?DB - Can leau to polycythemia because it piouuces eiythiopoietin.
It is usually ceiebellai, but can be associateu with a ietinal angioma (which gives it
an association to von Bippel Linuau synuiome)
!>BAF?NIB>EAJF?DB - Is a supiatentoiial tumoi that is benign anu often confuseu
with a pituitaiy auenoma. Is ueiiveu fiom the iemnants of Rathke's pouch.
+=<IBH>>= Q8@D: E@:E78AR
*FCSFCB>E BMHA?DB - Nost commonly as piolactin-secieting foim, the most
common piesentation is bitempoial hemianopsia.
.LF?WLB@C?DB /SLCFU?>DH - Is the most common piimaiy biain tumoi, has a teiiible
piognosis. This is founu in the hemispheies anu often ciosses the coipus callosum
(giving it the teim 'butteifly glioma').
/HAFAJF?DB - Comes fiom aiachnoiu cells, making it exteinal to the biain. Is the
2
nu
most common biain tumoi in auults.
"LFJ?MHAM>?JLF?DB - Is a slow giowing anu iaie tumoi, seen usually in the fiontal
lobe of the biain.
&OITBAA?DB - Is the S
iu
most common auult biain tumoi, oiiginating fiom
Schwann cells. When locateu neai the 8
th
cianial neive can cause an acoustic
schwannoma.

(13"#2 "! ()$ *"4$















*$4-4T (13"#2 "! *"4$
$:EH>:=8>?@
Is a caitilaginous tumoi founu in
the intiameuullaiy bone, most
often in uistal extiemities.
"AB7>EH>:=8>?@
In men <2Syi of age, is the most
common benign tumoi of bone.
0iigination is fiom the long
metaphyseal bone.
TD@:B ,7II (<?>8
0ccuis fiom 2u-4uyi of age.
0sually founu in uistal
femuipioximal tibia. Bas the
classic "uouble bubble" sign on
xiay.
3+.-T4+4( (13"#2 "! *"4$
"AB7>A@8E>?@
The most common malignant bone
tumoi, occuiiing in 1u-2uyi olus.
Is most commonly seen in the
metaphysis of long bones.
$KD:M[A 2@8E>?@
In males <1Syi of age, has the
11;22 tianslocation. Is likely to
metastasize eaily, anu has the
chaiacteiistic 'onion skinning on
xiay. Seen in uiaphysis of long
bones, iibs, pelvis, anu scapula.
,H>:=8>A@8E>?@
A malignant tumoi of caitilaginous
bone, seen in males >Suyi of age.
Not seen in the long bones.


%)-,) (13"#2 3$(+2(+2-\$ (" ()$ *#+-4l *"4$l +4& .-5$#









(13"# 3+#V$#2
The following list aie the common maikeis that aie useu to eithei make a uiagnosis
of a ceitain cancei, oi to monitoi the effectiveness of theiapy.
T0N0R NARKER WBAT IS WATCBES
Caicinoembiyonic Antigen (CEA) Coloiectal anu pancieatic canceis
Piostatic Specific Antigen (PSA) 0seu foi scieening of piostatic cancei
CA-12S Betects ovaiian cancei anu malignant
epithelial tumois.
Alkaline Phosphatase Bone metastasis, bile uuct obstiuction,
Paget's bone uisease
"-hCu Byuatifoim moles, uTB's, anu
choiiocaicinomas
!-feto piotein Non-seminomatous geim cell tumois of
the testicles
Taitiate-iesitant aciu phosphatase Baiiy cell leukemia





$" 2+)5#
Lung
Skin
Kiuney
uI tiact
$" 2"#%
Bieast
Lung
Thyioiu
Testeu
Kiuney
Piostate
$" 35]%+
Colon
Stomach
Pancieas
Bieast
Lung

(13"# 21//#$22"#2
Tumoi suppiessois woik by suppiessing the giowth of ceitain tumois, when theie
is a loss of function, both alleles of the gene have been changeu (ie mutation,
ueletion, etc)
T0N0R S0PPRESS0R T0N0R IT S0PPRESSES
Rb Retinoblastoma
BRCA 1 anu 2 Bieast cancei, ovaiian cancei
pSS Belps scieenfollow almost all canceis
APC Coloiectal cancei
NF1 anu NF2 Neuiofibiomatosis 1 anu 2
WT1 Wilm's tumoi


"4,"T$4$2
0NC0uENE ASS0CIATEB T0N0R
Ret NEN synuiomes type 2 anu S
c-myc Buikitt's lymphoma
L-myc Lung tumois
N-myc Neuioblastoma
Bcl-2 Folliculai lymphomas
Eib-B2 Bieast, ovaiy, gastiic
Ras Colon










#$2/-#+("#G

,+4,$# "! ()$ .14T
,$4(#+..G +#-2-4T /$#-/)$#+..G +#-2-4T

2?@II ,7II ,@8ED:>?@ - linkeu to
smoking, can piouuce ACTB anu ABB,
may be linkeu to Lambeit-Eaton
synuiome

2s<@?><A ,7II ,@8ED:>?@ - linkeu to
smoking anu the piouuction of ectopic
PTiP.

+=7:>E@8ED:>?@ - is the most common
peiipheially aiising cancei of the lung.

.@8M7 ,7II ,@8ED:>?@ - is an
unuiffeientiateu caicinoma of the lung.

*8>:EHD>@I97>I@8 ,@8ED:>?@ - this is
the lung cancei that is not thought to be
ielateu to smoking

Lung cancei can cause a wiue aiiay of symptoms (asiue fiom cough, hemoptysis,
wheezing, bionchial obstiuction). The most common symptoms that can aiise fiom
lung cancei aie:
- *BAO?B@Cc@ CSD?> (a caicinoma that oiiginates in the apex of the lung anu
can compiess the ceivical sympathetic plexus, iesulting in Boinei's
synuiome)
- &SNH>F?> GHAB OBGB @EAM>?DH
- (?>AH>c@ @EAM>?DH (Ptosis, Anhyuiosis, Niosis)
- *B>BAH?NLB@CFO MF@?>MH>@ (PTiP, ABB, ACTB)
- +HOS>>HAC LB>EAJHBL AH>GH @EDNC?D@ (hoaiseness)

"*2(#1,(-5$ +4& #$2(#-,(-5$ .14T &-2$+2$
"*2(#1,(-5$ - this conuition causes an obstiuction of aii -low that iesults in aii-
tiapping in the lungs. Theie will always be an incieaseu in total lung volume with a
Z%],eZ]! ?U p;=tQ
The categoiies of obstiuctive lung uisoiueis aie:
Xn ,H8>:DE *8>:EHDBDA: This conuition is chaiacteiizeu by the piesence of a
piouuctive cough foi at least S consecutive months foi 2 oi moie yeais.
Theie is a hypeitiophy of the mucus-secieting glanus of the bionchioles,
giving a Reiu inuex of > Su%. Patient will have wheezing, ciackles, anu
cyanosis on physical exam. *This patient is a "blue bloatei" because they
become cyanotic.
Zn $?NHFA7?@R This conuition iesults in a uestiuction of alveolai iecoil
iesulting in the enlaigement of aii spaces uue to smoking anuoi an !1-
antitiypsin ueficiency (causes inciease in elastase activity). Patient will have
uyspnea, tachycaiuia, uecieaseu bieath sounus.
]n +ABH?@R This iesults in constiiction of the bionchioles uue to
hypeiiesponsiveness. This conuition is ieveisible. Tiiggeieu often by
activity, but also tiiggeieu by illness anuoi alleigens. Finuings incluue
cough, wheezing, hypoxemia, anu uyspnea.
^n *8>:EHD7EB@ADAR A conuition that iesults in uilateu aiiways, iecuiient
infections, hemoptysis, anu puiulent sputum. Causeu by a chionic
neciotizing infection of the bionchi. This conuition is ielateu to cystic
fibiosis, Kaitagenei's synuiome, anu bionchial obstiuction.







#$2(#-,(-5$ a Restiictive lung uisease pievent the expansion of the lungs,
iesulting in loweieu lung volumes anu a Z%],eZ]! l ;=tQ
The categoiies of iestiictive lung uiseases aie:
1. $JB8@N<I?>:@8FR This means conuitions that affect the bieathing mechanics
anu the suppoit of the lungs. Conuitions that weaken the muscles such as
myasthenia giavis, anu conuitions that altei the suppoitive stiuctuie of the
lungs such as scoliosis anu ankylosing sponuylitis.
2. -:B78ABDBD@IR Anything that alteis the inteistitium can cause a iestiictive lung
uisease. Examples: ARBS, pneumoconioses, saicoiuosis, uooupastuie's
synuiome, Wegenei's gianulomatosis.




/4$13"4-+
Pneumonia piesents in many uiffeient ways, such as: lobai, inteistitial, anu as
bionchopneumonia.
.>Q@8 /:7<?>:D@: Consoliuation of infection to one aiea of the lobe, often the
lowei lobe. The most common cause is Stiep Pneumonia. Patient uevelops
symptoms acutely (shaking chills, fevei, chest pain).
*8>:EH>N:7<?>:D@: Theie is patchy infiltiation in moie than one lung. The NCC
is Staph Auieus.
+BFNDE@I /:7<?>:D@: Also known as inteistitial pneumonia, piesents with uiffuse
patchy infiltiation localizeu to inteistitial aieas at the alveolai walls. Piesentation is
atypical in that the patient is less sick anu slowei to uevelop symptoms than with
lobai pneumonia.

()$ ,)$2( $0+3
A few teims must be unueistoou in oiuei to be able to uiffeientiate between the
uiffeient pathologies of the iespiiatoiy system.
!87?DB<A - Is a vibiation that is felt when the patient speaks. It is elevateu when a
patient has pneumonia, uecieaseu in effusion anu obstiuction, anu completely
absent in pneumothoiax. vibiation is felt as a iesult of fluiu accumulation.
#7A>:@:E7 - The same sounu as maue by a uium. When theie is nothing in the lung
cavity, such as with a pneumothoiax, theie is "hypeiiesonance". When theie is fluiu
accumulation, such as when theie is a pneumonia oi effusion, theie is uecieaseu
iesonance (ie Bullness). Think of a uium with anu without watei insiue to visualize
what is insiue the lung.
*87@BH 2><:=A - This can be figuieu out with common sense. When theie is an
obstiuction, theie will be no bieath sounu. When theie is a pneumothoiax, theie
will be uecieaseu bieath sounus.
(8@EH7@I &79D@BD>: - Pay close attention to the tiachea uuiing the pulmonaiy
examination. A ueviation can inuicate a pneumothoiax. A pneumothoiax will push
the tiachea away fiom the affecteu siue, while a bionchial obstiuction will pull the
tiachea towaius the siue of the lesion.




T""&/+2(1#$[2 2G4&#"3$
A conuition that affects both the lungs anu the kiuneys. Leaus to hemoptysis as the
piimaiy lung finuing, with hematuiiaanemia anu ciescentic glomeiulonephiitis as
the kiuney finuings. Seen most commonly in males fiom 2u-4uyi of age.
Causeu by anti-glomeiulai basement membiane antibouies, which piouuce lineai
staining on immunofluoiescence.





















4$1#"."TG




&$T$4$#+(-5$ &-2$+2$2
)3m(%5/%+c& X5&%)&%
- Is a veiy common cause of ueath
- Pievalence incieases with age
- Family histoiy is a big contiibuting factoi to the possible uevelopment.
- Biffuse ceiebial atiophy occuis seconuaiy to neuional loss
- Neuiofibiillaiy tangles aie classically founu
&FJA@e&EDNC?D@:
- Bevelops slowly ovei time
- Beath usually occuis within S-1u yeais fiom onset
- The auvanceu stages will iequiie the patient to have uepenuence on otheis
&CBJH@:
$@8IF - milu foigetfulness, patient will have uifficulties leaining new infoimation
-:B78?7=D@B7 - piogiessive impaiiment in memoiy
.@B7 - patient will iequiie assistance in theii activities of uaily living
+=9@:E7= - patient will expeiience complete uebilitation anu uepenus completely
on otheis



*5!b& X5&%)&%
- Fiontal anu tempoial lobe uysfunction causeu by uegeneiation
- Accumulation of tau pioteins
- Pick bouies aie chaiacteiistic
- Nemoiy impaiiment + impulsive behavioi + behavioial changes

3"("# 4$1#"4 &$T$4$#+(-5$ &-2"#&$#2

)/0"$+"*(5! 3)$%+)3 &!3%+"&5&
ALS is also known as Lou uehiig's uisease, which is a fatal neuiouegeneiative
uisease of both the uppei anu lowei motoi neuions.
*"35"/0%35$5&
Polio is a viius that affects the anteiioi hoin cells anu motoi neuions of the spinal
coiu anu biainstem
- Causes LNN symptoms
ZHBCS>H@ ?U *?LF?:
- Asymmetiic muscle weakness (most commonly the legs)
- Nuscle atiophy
- Absent of BTR's
- Flacciuity
r&HA@BCF?A F@ FACBOC r

Y%+X#5.K("ZZ/)# X5&%)&%
A genetic conuition that piesents in infancy anuoi eaily chiluhoou.
- Piogiessive skeletal muscle atiophy uue to anteiioi hoin cell uegeneiation
- 0ften piesents with floppy baby at biith (congenital hypotonia)
- Lack of sucking ability
- Tongue fasciculation's
- Beath occuis at a young age uue to iespiiatoiy muscle failuie




*+2+. T+4T.-+ &$T$4$#+(-"4

*)+b5#&"#c& X5&%)&%
- Loss of uopamineigic neuions fiom the substantia nigia
- 0sually piesents in miu-late life (ie >Suyi)
- Biagnosis is completely clinical anu baseu on symptoms
&FJA@e&EDNC?D@:
- Resting tiemoi (pill iolling)
- Cogwheel iigiuity
- Biauykinesia
- Bifficulty in initiating movement
- Nask-like facies
- Biain biopsy will show Lewy bouies
ceitain meuications can cause Paikinsonism: Reseipine, Netoclopiamiue,
Balopeiiuol, Peiphenazine, NPTP

(7#$5#.$"#c& !("+%)
- Is a genetic conuition (AB) wheie theie is atiophy of the cauuate nucleus
- Bisease onset is between Su-Suyi with a steauy woisening of symptoms anu
ueath within 1S yeais of onset.
&FJA@e&EDNC?D@:
- Piogiessive uementia
- Choiea of the limbs, face, heauneck, anu tiunk
- Behavioi uistuibances such as: Bepiession, aggiession, psychosis, changes in
peisonality.
- Bepiession occuis anu suiciue is somewhat common because patients aie
awaie of theii ueteiioiation
Theie is no tieatment, only symptomatic management.






2/-4",$#$*$..+# &-2$+2$2

Z+5%X+%5!(c& )$)f5)
- Is an autosomal iecessive conuition that begins by young auulthoou.
Impaiieu: Piopiioception, vibiatoiy sense, ataxia, anu nystagmus

&-!!$#$4( (G/$2 "! -4(#+,#+4-+. )$3"##)+T$

1. Epiuuial Bematoma
2. Subuuial Bematoma
S. Subaiachnoiu Bemoiihage
4. Paienchymal Bematoma

%*5X7+)3 (%/)$"/)
- Bloou accumulates above the uuia
- Ruptuie of miuule meningeal aiteiies
- Patient usually expeiiences a luciu inteival
- Lens shapeu bleeu
- 0sually causeu by a fiactuie of the tempoial bone





&72X7+)3 (%/)$"/)
- Symptoms occui giauually
- Teaiing of the biiuging veins
- Seen in elueis anu alcoholics expeiiencing blunt tiauma
- Ciescent shapeu


&72)+)!(#"5X (%/"++().%
- Aneuiysm iuptuie anuoi AvN iuptuie
- Classic piesentation is "woist heauache of patients life"
- LP will show xanthochiomia

*$##G +4$1#G23
Aneuiysms aie focal weaknesses in the vasculatuie that iesult in outpouchings. The
Beiiy aneuiysm is seen at the bifuication of the anteiioi communicating aiteiy.
- Ruptuie leaus to hemoiihagic stioke
- Cieates the "woist heauache of my life"
- Associateu with Ehlei's uanlos, Naifan's, anu APKB
- Is a suigical emeigency



&-2$+2$2 "! &$3G$.-4+(-"4

The most common uemyelinating uiseases aie /SLCFNLH &OLH>?@F@ anu *>?J>H@@FGH
/SLCFU?OBL 3HS\?HAOHNIBL?NBCIE, .SFLLBFAK2B>>H @EAM>?DH, /HCBOI>?DBCFO
3HS\?ME@C>?NIE, anu *?@CK5AUHOCF?S@ %AOHNIBL?DEHLFCF@.

/73$5*3% &!3%+"&5&
- Nultifocal zones of uemyelination scatteieu thioughout the white mattei
- Commonly involves the pyiamiual anu ceiebellai pathways, meuial
longituuinal fasciculus, optic neive, anu the posteiioi columns
- Piesents with tiansient sensoiy ueficits, fatigue, weakness, anu spasticity
- visual uistuibances (monoculai vision loss, ipsilateial meuial iectus palsy on
lateial gaze)
- 0sually piesents in the 2us anu Sus in a ielapsing fashion
- Biagnosing is maue mostly with NRI
- Nanagementtieatment is with coiticosteioius
,I@AADE (8D@=: Scanning Speech, Intention Tiemoi, Nystagmus

*+".+%&&5]% /73$5Z"!)3 3%7b"%#!%*()3"*)$(0
- Is the ieactivation of a latent viial infection
- Seen in appioximately 4% of AIBS patients
- Associateu with }C viius

.7533)5#K2)++% &0#X+"/%
- Is an ascenuing inflammation anu uemyelination of the peiipheial neives
anu motoi fibeis of vential ioots
- Piesents in an ascenuing fashion
- Causes symmetiical muscle weakness that staits in the lowei extiemities
- Piesents most commonly following an uppei iespiiatoiy infection
- The most common cause of ueath is uue to paialysis of iespiiatoiy muscles
(thus monitoiing iespiiatoiy function is essential to safety of the patient)


/%$)!(+"/)$5! 3%7b"X0&$+"*(0
- A lysosomal stoiage uisease that affects the giowth anu uevelopment of
myelin
- Bue to ueficiency of the enzyme aiylsulfatase A, which causes accumulation
of sulfatiues in the tissues anu thus uestioys myelin sheath
- Affects both CNS anu PNS
- Chiluien with the "late infantile foim" may have uifficulty in walking aftei the
fiist yeai of life
- Nuscle wasting, weakness, muscle iigiuity, uevelopmental uelays, anu
piogiessive loss of vision, ouynophagia, paialysis, anu uementia aie all
possible complications
- }uvenile foim (S-1uyis) get mental ueteiioiation anu can uevelop uementia
- Auult foim (>16yi) piesents as a psychiatiic uisoiuei oi piogiessive
uementia
- No cuie foi this conuition

*"&$K5#Z%!$5"7& %#!%*()3"/0%35$5&
- An immune-meuiateu uisease of the biain
- 0ccuis following a viial infection most commonly
- Is similai to multiple scleiosis in that it involves autoimmune uemyelination
- Symptoms begin 1-S weeks post-infection
- Fevei, heauache, uiowsiness, seizuie, anu coma













2$-\1#$2



&5/*3% *)+$5)3
- Affects a small iegion of the biain (tempoial lobe anuoi hippocampi)
- Patient iemains awake, seizuie is veiy suuuen anu biief
- Patient may expeiience feelings of feai, nausea, unusual feelingssensations,
alteieu sense of heaiing, smell, taste, vision, anu tactile peiception.
- Sense of spatial uisoiientation is often seen
- Patient may expeiience the inability to speak
- The seizuie is usually iemembeieu in uetail

!"/*3%f *)+$5)3
- Limiteu to one ceiebial hemispheie anu causing impaiiment of awaieness
- 0ften pieceueu by an auia

)2&%#!% &%5m7+%
- Also known as "petit mal" seizuie
- Patient will staie blankly foi a few seconus
- Post-seizuie, the patient will ietuin to whichevei activity they weie uoing
piioi to the onset of the seizuie
** Classic 0SNLE question, tieatment is with Ethosuxamiue

$"#5!K!3"#5! &%5m7+%
- "uianu-mal" seizuie, it affects the entiie biain
- Is the most well-known type of seizuie that occuis with epilepsy
- Associateu with an auia
Tonic Phase - Patient loses consciousness, tension of skeletal muscles occuis. Lasts
only a few seconus.
Clonic Phase - Rapiu contiactionielaxation of muscles, eyes ioll to the back of the
heau, tongue is often bitten uue to jaw contiactions. Incontinence may occui at this
phase.
- Patient will be confuseu anu will have no memoiy of the seizuie
- Initial management is with a benzouiazepine given Iv

/0"!3"#5!
- Is a biief anu involuntaiy twitching of the muscles
- Piesents with abnoimal movements on both siues of the bouy at the same
time
- 0ccuis commonly while patient is falling asleep
- Is not an actual uisoiuei, iathei is a sign of othei potential neivous system
uisoiueis


+/)+2-+

Aphasias aie acquiieu language uisoiueis wheieby theie is an impaiiment of eithei
uifficulty piouucing oi compiehenuing spoken oi wiitten language. The two types
clinically encounteieu aie Expiessive Aphasia (Bioca's), anu Receptive Aphasia
(Weinicke's).
%PN>H@@FGH )NIB@FB [ Patient has complete intact compiehension with the inability
to speak in an unueistanuing fashion. The site of pathology is the infeiioi fiontal
gyius. $xpiessive = -nfeiioi fiontal gyius. E=I (two vowels)
+HOHNCFGH )NIB@FB - Patient has complete intact ability to speak unueistanuable
with the inability to compiehenu language. The site of pathology is the supeiioi
tempoial gyius. #eceptive = 2upeiioi (empoial gyius. #2(



,$4(#+. 2.$$/ +/4$+

Buiing cential sleep apnea, the biain's iespiiatoiy contiol centeis aie imbalanceu
uuiing sleep. The neuiological feeuback mechanism uoes not iesponu to levels of
C02 anu thus cannot ieact to uiive the iespiiatoiy iate. Following this pathology,
bieathing iate will inciease anu excess C02 will be expelleu fiom the bouy.

*$..[2 /+.2G

Is a conuition of hemifacial weaknesspaialysis of the muscle that aie inneivateu by
CN7, uue to inflammation of the neive.
- Patient will expeiience an acute onset of unilateial facial weakness anu
paialysis, affecting both uppei anu lowei face.
- Iuiopathic, Lyme uisease, AIBS, saicoiuosis, anu uiabetes aie all possible
causes
!?DNB>FAJ C? 7/# BAM 3/# LH@F?A@:
134 I7AD>: - will affect the lowei half of the contialateial face
.34 I7AD>: - will affect the uppei anu lowei face on the ipsilateial siues

)"#4$#[2 2G4&#"3$

Boinei's synuiome is a clinical synuiome causeu by uamage to the sympathetic
neivous system. 0n most occasions, Boinei's synuiome is a benign conuition, but it
can occui as a iesult of moie seiious conuitions such as Pancoast tumoi oi
thyioceivical venous uilatation. These conuitions cause compiession of the thoiacic
sympathetic chain, which leaus to the symptoms of Boinei's synuiome:
/B>ADA a uiooping of the eyeliu
+:HF=8>ADA - the absence of sweating
3D>ADA - constiiction of the pupil



4$1#"(#+423-(($#2 +!!$,($& -4 &-2$+2$

Nany neuiotiansmitteis aie affecteu uuiing uiffeient uiseases, they incluue:
&"/+3-4$ a Incieaseu in Schizophienia, uecieaseu in Paikinson's uisease
4"#$/-4$/)#-4$ - Incieaseu in anxiety, uecieaseu in uepiession
+,$(G.,)".-4$ - Incieaseu in oiganophosphate poisoning, uecieaseu in
Alzheimei's anu Buntington's uisease
T+*+ - Becieaseu in Buntington's, uecieaseu in anxiety
2$#$("4-4 ObS)(P - Becieaseu in both anxiety anu uepiession

(+*$2 &"#2+.-2

Tabes uoisalis is a conuition wheieby theie is uegeneiation of the uoisal columns
anu uoisal ioots of the spinal coiu. This occuis as a iesult of teitiaiy syphilis.
Patient will expeiience all symptoms associateu with uoisal column malfunction
(lack of piopiioception, ataxia uuiing locomotion). Patient will uevelop malfoimeu
joints (Chaicot's joints) uue to lack of pain ieceptois, shooting pains, absence of
ueep tenuon ieflexes, anu Aigyll Robeitson pupil that iesults fiom ieaction to
accommouation but not to light.










2G#-4T"3G$.-+

Theie is a cavity that foims within the spinal coiu that may expanu anu elongate as
time passes, thus uestioying the spinal coiu. This causes uamage to the
spinothalamic tiact, which then iesults in a bilateial loss of pain anu tempeiatuie
sensation in the uppei extiemities in a "cape-like" uistiibution. Associateu with an
Ainolu-Chiaii malfoimation.










#$4+. /+()"."TG

/+()"."TG "! ()$ T."3$#1.12


4$/)#-(-, 2G4&#"3$2
)!7$% *"&$K&$+%* .3"/%+73"#%*(+5$5&
- The most common cause of nephiitic synuiome
- 0ccuis aftei a gioup A "-hemolytic stiep infection (uevelops 1u-14 uays aftei
infection)
- Affects chiluien between 2-6 yeais of age
- Is self-limiteu conuition
- Patient gets hematuiia, euema, hypeitension, anu low complement levels
- Some cases may piogiess to iapiuly piogiessive glomeiulonephiitis



4$/)#-(-, 2G4&#"3$2
*>H@HAC TFCI: Bematuiia,
Bypeitension, 0liguiia, Azotemia
AC0TE P0ST-STREP
uL0NER0L0NEPBRITIS
RAPIBLY PR0uRESSIvE
uL0NER0L0NEPBRITIS
u00BPAST0RE'S SYNBR0NE
NENBRAN0PR0LIFERATIvE
uL0NER0L0NEPBRITIS
BERuER'S BISEASE (IgA
NEPBR0PATBY)
ALP0RT'S SYNBR0NE
4$/)#"(-, 2G4&#"3$2
*>H@HAC TFCI: Nassive Pioteinuiia,
Bypeilipiuemia, Bypoalbuminemia,
anu PeiipheialPeiioibital Euema.
NENBRAN00S
uL0NER0L0NEPBRITIS
NININAL CBANuE BISEASE
F0CAL SEuNENTAL uL0NER0LAR
SCLER0SIS
BIABETIC NEPBR0PATBY
SYSTENIC L0P0S ERYTBENAT00S
+)*5X30 *+".+%&&5]% .3"/%+73"#%*(+"*)$(0
- Is "ciescent-moon" shapeu on light micioscopy

.""X*)&$7+%c& &0#X+"/%
- Theie is a tiiau of Igu anti-glomeiulai basement membiane antibouies,
pulmonaiy hemoiihage, anu ciescentic glomeiulonephiitis
- The lung finuings will occui befoie the ienal finuings
- Patient will have hemoptysis, iapiuly piogiessive ienal failuie, fevei, anu
myalgias

/%/2+)#"*+"35Z%+)$5]% .3"/%+73"#%*(+5$5&
- 0n election micioscopy, theie aie the classic "tiam-tiack" subenuothelial
humps
- Bas a slow piogiession to ienal failuie

2%+.%+c& X5&%)&% h5J) AHNI>?NBCIEi
- Nesangial ueposits of IgA
- Is a veiy milu uisease
- 0ccuis aftei an infection

)3*"+$c& &0#X+"/%
- A mutation of type 4 collagen
- Patient can have neive ueafness anu oculai uisoiueis
- Theie aie split basement membianes


4$/)#"(-, 2G4&#"3$2
/%/2+)#"7& .3"/%+73"#%*(+5$5&
- veiy common cause of auult nephiotic synuiome
- Light micioscope shows basement membiane thickening

/5#5/)3 !()#.% X5&%)&%
- Is the most common cause of nephiotic synuiome in chiluien
- Election micioscopy shows foot piocess effacement
- This conuition iesponse exceptionally well to steioius

Z"!)3 &%./%#$)3 .3"/%+73)+ &!3%+"&5&
- Noie common in patients with BIv
- Light micioscope shows segmental scleiosis anu hyalinosis

X5)2%$5! #%*(+"*)$(0
- 0ccuis in uiabetics
- Theie is basement membiane thickening anu Kimmelstiel-Wilson lesions on
light micioscopy

&0&$%/5! 37*7& %+0$(%/)$"7&
- Theie aie S patteins of ienal involvement
- Light micioscope will show "wiie-loop" appeaiance with gianulai
subenuothelial BN ueposits in membianous glomeiulonephiitis pattein



#$4+. ,$.. ,+#,-4"3+
Renal cell caicinoma is the most common of all ienal malignancies, occuiiing most
commonly in men between Su-7uyi of age, anu is moie common in smokeis.
- Associateu with von Bippel-Linuau
- 0iiginates in ienal tubule cells
/BAFUH@C@ B@:
- Bematuiia
- Palpable flank mass
- Seconuaiy polycythemia (uue to piouuction of eiythiopoietin fiom kiuney)
- Nany paianeoplasias aie common uue to piouuction of Piolactin, PTBiP, anu
ACTB)




%-.3[2 (13"#
This is the most common malignancy seen in young chiluien between 2-4yi of age.
The following aie impoitant iegaiuing a Wilm's tumoi:
- Theie is a ueletion of the WT1 gene that is founu on chiomosome 11
- Piesents with a huge, palpable flank mass
Wilm's tumoi is often seen in conjunction with the WAuR complex:
% - Wilm's tumoi
+ - Aniiiuia (absence of the iiis)
T - uenitoiuiinaiy malfoimations
# - Retaiuation (both mental anu motoi)

(#+42-(-"4+. ,$.. ,+#,-4"3+
Is a common cancei seen in the uiinaiy tiact (blauuei, uieteis, ienal pelvis, anu
ienal calyces). The most common causes incluue: &D?\FAJV )LBAFAH XEH@V
!EOL?NI?@NIBDFMHQ

/G$."4$/)#-(-2
An ascenuing infection that spieaus fiom the blauuei to the kiuneys. The most
common cause of pyelonephiitis is an E. Coli infection.
SignsSymptoms:
- Flank pains (CvA tenueiness)
- Fevei
- Nauseavomiting
- Patient will appeai quite ill
** Patients with vesicouieteial ieflux have an incieaseu tenuency to getting
pyelonephiitis.




+,1($ (1*1.+# 4$,#"2-2 O+(4P
Acute tubulai neciosis occuis when theie is an insult to the ienal tubules. Anything
that can haim the kiuneys can cause ATN, things such as: Ischemia uue to shock,
incieaseu myoglobins uue to muscle bieakuown, uiugs, toxins.
** Is the most common cause of acute ienal failuie.

+,1($ #$4+. !+-.1#$
Acute ienal failuie occuis most commonly fiom ATN (mentioneu above), anu occuis
when a uecline in ienal function causes an inciease in the levels of B0N anu
Cieatinine.
$IH OBS@H@ ?U >HABL UBFLS>H:
/87S87:@I +j>B7?D@ ! is when theie is a ueciease in ienal bloou flow, which leaus
to a ueciease in the glomeiulai filtiation, anu thus ietention of watei anu souium in
the kiuneys. B0N>Ci is > 2u
/>ABS87:@I +j>B7?D@ ! this conuition only occuis if theie is bilateial obstiuction,
things such as piostatic hypeiplasia, neoplasia, anu stone (less likely) will cause a
post-ienal azotemia. B0NCi is > 1S
-:B8D:ADE ! this is uue to ATN (usually), anu the uiine will give this cause away by
having gianulai casts oi epithelial casts. B0NCi is < 1S

%)+( )+//$42 %)$4 #$4+. !+-.1#$ -2 /#$2$4(f
Renal failuie leaus to a builu-up of toxins anu leaus to the inability to exciete
nitiogenous bases.
)OSCH >HABL UBFLS>H is usually uue to hypoxemia, while OI>?AFO >HABL UBFLS>H is
usually causeu by eithei hypeitension oi uiabetes.
When theie is a builu-up of B0N anu Cieatinine, uiemia uevelops. When uiemia
uevelops, the following symptoms may be piesent:
- Anemia uue to failuie of EP0 piouuction by the kiuneys
- CBFPulmonaiy euema uue to souium anu watei excess
- Netabolic aciuosis
- Bypeikalemia
- 0steouystiophy uue to failuie of vitamin B piouuction by the kiuneys

V-&4$G 2("4$2
Theie aie a few uiffeient foims of kiuney stones, they aie:
Xn ,+.,-13 2("4$2 ! the most common foim of kiuney stone, which may be
eithei calcium oxalate oi calcium phosphate. Any uisease oi uisoiuei that
leaus to hypeicalcemia can cause a calcium stone.

Zn 2(#15-($ 2("4$2 ! these aie maue of ammonium, magnesium, anu
phosphate, anu they aie the 2
nu
most common type of kiuney stone. They aie
piouuceu by uiease-positive bugs such as Pioteus vulgaiis. These have a
tenuency to foim "staghoin calculi" anu get stuck in the uiinaiy system.
]n 1#-, +,-& 2("4$2 ! piouuceu as a iesult of states of hypeiuiicemia, such
as with gout. These stones aie also piouuceu when theie aie conuitions of
incieaseu cell tuinovei, such as with leukemia.
^n CYSTINE ST0NES ! these occui seconuaiy to cystinuiia.
+BMF?NBRSH @C?AH@ ! Calcium anu Stiuvite stones
+BMF?LSOHAC @C?AH@ ! 0iic aciu anu cystein stones















+,-&L*+2$ /)G2-"."TG


/8>QI7? N) /,"Z o),"]Sp ,>?N7:A@BD>: ,@<A7A
37B@Q>IDE
+ED=>ADA
* * **
Patient will
hypeiventilate
to blow off C02
BKA, ASA
oveiuose,
lactic
aciuosis
#7AND8@B>8F
+ED=>ADA
* ++ +
Bicaib
absoiption in
kiuney
0bstiuction
of aiiway
#7AND8@B>8F
+Im@I>ADA
+ ++ *
Kiuney
secietes bicaib
Bypeivent,
high alt.
37B@Q>IDE
+ED=>ADA
+ * ++
Pt will
hypoventilate
vomiting

)"% &" %$ ,"3/$42+($ !"# +,-&S*+2$ &-21#*+4,$2f
The following numbeis uesciibe the appiopiiate compensation uepenuent on each
metabolic uistuibance.
5U NBCFHAC IB@ DHCBW?LFO BOFM?@F@:
PC02 = 1.S(BC0S-) + 8 +- 2

5U NBCFHAC IB@ DHCBW?LFO BL\BL?@F@:
Foi eveiy 1mEqL inciease in BC0S-, the PC02 incieases u.7mmBg

5U NBCFHAC IB@ BOSCH >H@NF>BC?>E BOFM?@F@:
An inciease of 1mEqL of BC0S- foi eveiy 1ummBg inciease in PC02

5U NBCFHAC IB@ OI>?AFO >H@NF>BC?>E BOFM?@F@d
An inciease of S.SmEqL of BC0S- foi eveiy 1ummBg inciease in PC02

5U NBCFHAC IB@ BOSCH >H@NF>BC?>E BL\BL?@F@:
A ueciease of 2mEqL BC0S- foi eveiy 1ummBg ueciease in PC02

5U NBCFHAC IB@ OI>?AFO >H@NF>BC?>E BL\BL?@F@d
A ueciease of SmEqL BC0S- foi eveiy 1ummBg ueciease in PC02






#)$13+("."TG

(FN7A >C +8BH8DBDA:
1. 0steoaithiitis
2. Rheumatoiu Aithiitis
S. uout
4. Pseuuogout

"&$%")+$(+5$5&
0steoaithiitis is the most common type of aithiitis that is causeu by the weai anu
teai of joints, which leaus to the uestiuction of the aiticulai caitilage anu the
subchonuial bone foimation. This leaus to the foimation of osteophytes, as well as
Bebeiuen's anu Bouchaiu's noues.
(HWH>MHAc@ #?MH@ - malfoimations of the uistal inteiphalangeal joints
2?SOIB>Mc@ #?MH@ - malfoimations of the pioximal inteiphalangeal joints
/87A7:B@BD>: >C "AB7>@8BH8DBDA:
- Pain in weight beaiing joints
- Asymmetiic involvement
- Pain woise at the enu of the uay (impioves with iest)



+(%7/)$"5X )+$(+5$5&
Is an autoimmune conuition that attacks the synovial joints of the bouy.
- Pannus foimation in joints leaus to uefoimities of the metacaipophalangeal
joints anu pioximal inteiphalangeal joints.
- Foimation of subcutaneous nouules
- 0lnai ueviation at the wiist joint
- Seen in females >>> males
/87A7:B@BD>: >C #H7<?@B>D= +8BH8DBDA:
- Stiffness in the moining that impioves with use
- Symmetiic involvement
- Systemic symptoms aie piesent (fevei, fatigue, caiuiac conuitions,
pulmonaiy conuitions)

."7$
A conuition wheieby monosouium uiate ciystals piecipitate anu accumulate
insiue the joints, most commonly seen in the big toe, which is known as
"pouagia". 0ltimately this is a conuition that occuis as a iesult of puiine
metabolism uisoiuei.
Causes:
- Lesch-Nyhan synuiome
- PRPP excess
- Bypeiuiicemia
- ulucose-6-phosphate ueficiency
Piecipitating factois:
- Biet high in piotein
- Alcohol use
- Excess coffee consumption
- Consumption of uaiiy piouucts
Biagnosis is baseu on joint aspiiation anu finuing of negatively biiefiingent neeule-
shapeu ciystals in the aspiiate. NSAIBs aie best foi acute management, while uiugs
that ueciease uiic aciu in the system will help pievent iecuiiences.



*&%7X"."7$
A conuition similai to gout, pseuuogout is causeu by the ueposition of calcium
pyiophosphate ciystals insiue the joint space. The ciystals foimeu aie ihomboiu-
shapeu anu basophilic. The laige joints aie most commonly affecteu.

























2$#"4$T+(-5$ 2/"4&G."+#()#"/+()-$2

The gioup of seionegative sponuyloaithiopathies incluue:
1. Ankylosing Sponuylitis
2. Reitei's Synuiome (Reactive Aithiitis)
S. Psoiiatic Aithiitis
4. IBB Aithiopathy
S. 0nuiffeientiateu Sponuyloaithiopathy
This gioups of aithiitis types has the following in common:
- They aie iheumatic factoi negative
- They have extia-aiticulai symptoms (visual, pulmonaiy, caiuiac, etc)
- Association with BLA-B27 antigen
- Inflammatoiy piocesses
- Asymmetiical piesentation
- Familial

)#b03"&5#. &*"#X035$5&
- Low back pain anu stiffness (patient is bent ovei at the hips)
- C-spine motion is limiteu uue to neck pains
- Biminisheu chest expansion
- Nost common extia-aiticulai involvement is in the eyes (anteiioi uveitis)
- Best uiagnostic mouality is xiay of lumbai spine anu pelvis
- Nanagement is with NSAIBs anu physical theiapy

+%5$%+c& &0#X+"/%
- Is a clinical uiagnosis baseu on the piesentation of aithiitic symptoms that is
pieceueu by an infection (salmonella, shigella, campylobactei, Chlamyuia,
anu yeisinia)
- Classic tiiau is Aithiitis, 0iethiitis, anu 0veitis (can't see, can't pee, can't
climb a tiee)
- Theie is a sequential involvement of new joints
- Patient often has an accompanying set of symptoms such as fatigue, weight
loss, anu oveiall sense of malaise

*&"+5)$5! )+$(+5$5&
- Bevelops in patients who have aithiitis
- 0nset is giauual anu seen long aftei patient uevelops aithiitis
- Is similai in piesentation to iheumatoiu aithiitis
- Nanagement is with NSAIBs

/".G+#(-,1.+# 6"-4( -45".5$3$4(: RA, REITER'S
3"4"+#(-,1.+# 6"-4( -45".5$3$4(: 0STE0ARTBRITIS, u00T,
PSE0B0u00T

2G2($3-, .1/12 $#G()$3+("12

An autoimmune uisoiuei wheieby theie is multi-system anu multi-oigan
inflammation anu tissue uamage.
$ENH@:
- SLE
- Biscoiu Lupus (skin manifestation without systemic uisease)
- Biug-Inuuceu
- ANA-negative Lupus

YI? JHC@ FCn
- 9u% of cases aie females of chilubeaiing age
- Afiican-Ameiican's aie affecteu moie than Caucasians
- Seveiity tenus to be less in oluei patients, anu moie in youngei patients
ZFAMFAJ@:
- Butteifly iash
- Photosensitivity
- Biscoiu iash
- Alopecia
- Raynauu's phenomenon
- }oints painaithialgiasmyalgias
- Peiicaiuitisenuocaiuitismyocaiuitis
- Pleuiitispleuial effusionpneumonitis
- Bemolytic anemialeucopeniathiombocytopenialymphopenia
- Pioteinuiia >u.Sguay, glomeiulonephiitispyuiiaazotemiauiemiaBTN
- Abnoimal T cell function, lymphocyte autoantibouies
- NauseavomitingP0Buyspepsia
- SeizuiespsychosisuepiessionTIAheauachesCvA
- Fevei, malaise, conjunctivitis
XFBJA?@CFO !>FCH>FB:
- Positive ANA is seen in almost all SLE patients
- Anti-us BNA is seen in appioximately 4u% of SLE patients
- Anti-Sm antibouies is seen in appioximately Su% of SLE patients

2+#,"-&"2-2

Is a conuition chaiacteiizeu by immune-meuiateu, wiuespieau noncaseating
gianulomas. The classic finuing is bilateial hilai auenopathy.
Theie is also the inciuence of:
- Incieaseu levels of ACE
- Rheumatoiu aithiitis
- Inteistitial fibiosis
- uammaglobulinemia
- Restiictive lung uiseases
- Eiythema nouosum
- Bypeicalcemia

+1("-3314$ ,"4&-(-"42 "! ()$ 2V-4

*&"+5)&5&
Autoimmune conuition wheie the skin uevelops ieu, scaly patches on the skin. The
plaques that uevelop aie known as "psoiiatic plaques", anu aie causeu by excessive
piouuction of skin anu a fastei skin cycle than noimal skin.
- Skin appeais silveiy-white in coloi
- Nost commonly piesent on extensoi suifaces of the bouy (knees, elbows),
but may be seen on the hanus, feet, genitals, anu the scalp.
This conuition is not contagious*
Psoiiasis is associateu with the B27 haplotype (BLA-B27), BLA-1S, anu BLA-17.
*@?>FBCFO *LBRSH

*%/*(5.7& ]73.)+5&
Is a potentially fatal conuition that involves the oial mucosa anu the skin. It is
causeu by Igu antibouies against the epiueimal cell suiface, causes bieakuown of
the cellulai junction of the epithelial cell. Patient will uevelop bullae on the skin anu
oial mucosa.
Igu antibouies can be seen on immunofluoiescence.



2733"7& *%/*(5."5X
Is a skin uisoiuei wheieby Igu antibouies woik against the epiueimal basement
membiane. This conuition is veiy similai to *HDNIFJS@ ]SLJB>F@ but is much less
seveie.


2,.$#"&$#3+

Scleioueima oi "Piogiessive Systemic Scleiosis" is an excessive ueposition of
collagen anu subsequently fibiosis thioughout the bouy. The most common site of
piesentation is the skin, howevei it may affect the kiuneys, caiuiac, anu
gastiointestinal systems.

!+%&$ &0#X+"/% [ Associateu with the anticentiomeie antibouy
A synuiome compiising of S uiffeient conuitions that geneially lack any skin
involvement.
, - Calcinosis
# - Raynauu's phenomenon
$ - Esophageal uysmotility
2 - Scleiouactyly
( - Telangiectasias

X5ZZ7&% &!3%+"X%+/)
This conuition is associateu with the anti-Scl-7u antibouy, wheieby theie is
wiuespieau skin involvement, visceial involvement ielatively eaily, anu a iapiu
couise of action anu piogiession.



5+2,1.-(-2 ,"4&-(-"42

.@8M7 97AA7I E>:=DBD>:A - Tempoial aiteiitis,
,"4&-(-"4 !$+(1#$2 &-+T4"2-2 (#$+(3$4(
(7?N>8@I
+8B78DBDA
Seveie heauache

visual impaiiment
in 2S%-Su%

}aw pains

Tempoial
tenueiness
Age >Suyi

New onset
heauache

Elevateu ESR

Tempoial aiteiy
biopsy
Bigh-uose steioius

ESR follow-ups
uuiing
management
(@m@F@A<[A
+8B78DBDA
0sually seen in
young Asian
females

Becieaseu anuoi
absent peiipheial
pulses

Bloou piessuie
uiffeiences in aim
vs legs

Nany
complications like
limb ischemia,
aneuiysms, stioke,
BTN fiom ienal
aiteiy stenosis
Baseu on clinical
symptoms
Steioius

BTN management
,H<8MS2B8@<AA A vasculitis
affecting many
uiffeient oigan
systems

Fatigue, weight
loss, fevei

Respiiatoiy
Biopsy of lung
tissue

Biopsy of skin
tissue (shows high
eosinophils)

p-ANCA will be
founu
Pooi piognosis

S-yi suivival is
only 2S%

Steioius can
piolong tieatment
symptoms anu skin
finuings aie
piimaiy finuings


%7M7:78[A
T8@:<I>?@B>ADA
A vasculitis of the
kiuneys anu
iespiiatoiy tiact

0ppei iespiiatoiy
symptoms

Painful oial ulceis

Eye uisease
(scleiitis,
conjunctivitis)

Nusculoskeletal
finuings (myalgia,
aithialgia)

Tiacheal stenosis
CXR (nouules oi
infiltiates aie
piesent)

Elevateu ESR

Anemia

p-ANCA seen in
most patients

Confiimatoiy test
is an open lung
biopsy
Steioius +
cyclophosphamiue
can help patients
into iemission

With ienal failuie,
a tiansplant is
cuiative
/>IF@8B78DBDA
4>=>A@
Is a meuium-vessel
vasculitis that
involves the
neivous system
anu uI tiact

Causes intimal
piolifeiation which
causes a ueciease
in the luminal aiea,
iesulting in
ischemia,
infaiction, anu then
aneuiysm

Liveuo ieticulaiis

Bypeitension

Feveiwt
lossaithialgiaabu
pain
Biopsy

ESR

p-ANCA

Fecal occult bloou
Steioius can
impiove piognosis,
which is pooi
without tieatment






*7HE7B[A
2F:=8>?7

A multi-system
vasculitis of
unknown etiology

Recuiient oial anu
genital ulceiations

Aithiitis

visual impaiiment

CNS involvement

Feveiweight loss

Biopsy of all
involveu tissues

Steioius

*<78M78[A &DA7@A7 Seen in young
males who smoke

Small anu meuium
sizeu veins anu
aiteiies

Affects aims anu
legs

Clauuication occuis

Smoking is
impeiative in fixing
the pioblem
Clinically baseu Smoking cessation
)FN78A7:ADBD9DBF
5@AE<IDBDA
Is a
hypeisensitivity
ieaction that
occuis in iesponse
to ceitain
meuications
(sulfas, PCN)

Causes skin
pioblems (puipuia,
macules, vesicles)
Tissue biopsy of
affecteu tissues
Stop offenuing
agent(s)

Remission is often
spontaneous
$4&",#-4$ /+()"."TG












+&#$4+. /+()"."TG
1. Bypeialuosteionism
2. Auuison's uisease
S. Cushing's uisease

(0*%+)3X"&$%+"#5&/
/8D?@8F a ,>::[A 2F:=8>?7
Causeu by an BLM?@CH>?AHK@HO>HCFAJ CSD?> that causes hypeitension anu
hypokalemia (iemembei when aluosteione incieases, potassium uecieases),
metabolic alkalosis (iemembei hypokalemia = alkalosis, hypeikalemia = aciuosis),
anu L?T NLB@DB >HAFA.
27E>:=@8F HFN78@I=>AB78>:DA?
Causeu by ienal aiteiy stenosis most commonly. Nay also be uue to ienal failuie,
ciiihosis, nephiotic synuiome, anu congestive heait failuie. These conuitions
tiiggei the activation of the RAAS, which stimulates the kiuneys eventually to holu
onto moie watei anu souium. As opposeu to the piimaiy cause, this conuition has
IFJI NLB@DB >HAFA.
(87@BD:M HFN78@I=>AB78>:DA? - Aluosteione antagonist spiionolactone can inhibit
the activity of aluosteione on the kiuney.

)XX5&"#c& X5&%)&%
Causeu by piimaiy auienal insufficiency. The most common cause is autoimmune,
infectious, anu as a iesult of metastatic uisease.
!7@B<87A >C +==DA>:[A =DA7@A7:
- Postuial hypeitension
- Bypoglycemia
- Weight loss
- Weakness
- Anoiexia
- Nausea
- Bypeipigmentation (only seen in piimaiy auienal insufficiency)
- Low aluosteione levels (low souium, high potassium)
&D@M:>AD:M:
- Plasma coitisol levels
- Plasma ACTB levels
- Imaging of pituitaiy (if uiagnosis is seconuaiy auienal insufficiency)

!7&(5#.c& &0#X+"/%eX5&%)&%
,<AHD:M[A 2F:=8>?7 - the "synuiome" iesults fiom an excessively high level of
glucocoiticoius (coitisol is the piimaiy uC).
,<AHD:M[A &DA7@A7 - the "uisease" occuis as a iesult of a pituitaiy auenoma.

!BS@H@ ?U !S@IFAJc@:
1. Iatiogenic - this is the most common cause, anu is uue to the auministiation
of coiticosteioius.
2. ACTB-secieting auenoma of the pituitaiy, this is the 2
nu
most common cause,
leauing to bilateial auienal hypeiplasia.
S. Auenoma of the auienal
4. Ectopic ACTB piouuction - can be causeu by caicinoma of the lung (small-
cell).
ZHBCS>H@:
Theie aie classic featuies of Cushing's, they aie:
- Cential obesity
- Buffalo hump
- Biisutism
- Stiiae on abuomen
- Acne
In auuition, theie is a piesence of:
- Bypeitension
- Biabetes (* glucose toleiance)
- Bypogonauism - causing infeitility
- Excess anuiogen (masculinizes females)
- Nusculoskeletal abnoimalities (muscle wasting, osteopoiosis, femoial heau
osteoneciosis)
- Psychiatiic uistuibances such as uepiession
- Impaiieu immunity leauing to incieaseu chances of infection


(13"#2 "! ()$ +&#$4+. T.+4&
*(%"!+"/"!0$"/)
The most common tumoi of the auienal meuulla in auults. It is ueiiveu fiom the
chiomaffin cells.
&FJA@e&EDNC?D@:
- Palpitations
- Anxiety
- Beauache
- Biaphoiesis
- Significant hypeitension
- Tachycaiuia
Biagnosis is baseu on checking uiine metanephiines, anu tieatment is suigical
iemoval aftei auequate management of the hypeitension.

#%7+"23)&$"/)
Is the most common auienal tumoi in chiluien, anu is the most common intiacianial
tumoi in chiluien as well. While most commonly founu in the auienal meuulla, it
can be founu anywheie along the sympathetic chain.

,"4T$4-(+. +&#$4+. )G/$#/.+2-+
A congenital conuition wheieby theie aie excessive oi ueficient piouuction of sex
steioius fiom the auienal glanu.
The most common cause of CAB is uue to 21-hyuioxylase ueficiency. This conuition
will cause an excess of anuiogens anu a ueciease in mineialocoiticoius. Theie is an
accumulation of the substiate 17-hyuioxypiogesteione. This conuition, wheieby
theie aie incieaseu anuiogens, will cause masculinization of the female exteinal
genitalia (inteinal female sexual oigans aie intact since no mulleiian inhibiting
factoi is piesent - no testicles), anuoi ambiguous genitalia.






()G#"-& T.+4& /+()"."TG

,+4,$#2
*)*533)+0 !)+!5#"/)
- Piesence of giounu-glass nuclei anu psammoma bouies
- Is the most common type of thyioiu cancei anu holus the best piognosis
Z"335!73)+ !)+!5#"/)
- Theie is a piesence of unifoim follicles
- Bolus a goou piognosis (bettei than meuullaiy but woise than papillaiy)
/%X733)+0 !)+!5#"/)
- Beiiveu fiom the paiafolliculai "C cells", thus piouuces calcitonin.
- Is a membei of the NENII anu NEN III synuiomes
- Bas a bau piognosis
)#)*3)&$5! !)+!5#"/)
- This thyioiu caicinoma occuis in oluei patients
- Bolus a teiiible piognosis anu the woist of all thyioiu caicinomas

)G/$#()G#"-&-23
Theie will be a low TSB (uue to feeuback inhibition), with a high TST4
Patient will have the following:
- Beat intoleiance
- Weight loss
- Palpitations
- Waimmoist skin
- Aiihythmias




)G/"()G#"-&-23
Theie will be a high TSB anu low TST4
Patient will have the following:
- Colu intoleiance
- Weight gain
- Fatigue
- Lethaigy
- Weakness
- Becieaseu ieflexes
- Biycool skin
- Coaisebiittle haii
- Nyxeuema

.+)]%& X5&%)&%
uiave's uisease is the most common cause of hypeithyioiuism, accounting foi up to
8u% of all cases.
- Is an autoimmune uisoiuei wheieby a thyioiu-stimulating immunoglobulin u
antibouy binus to the TSB ieceptois on the thyioiu cells, tiiggeiing the
synthesis of excess thyioiu hoimone
- Biffuse iauioiouiue uptake on scan

*37//%+c& X5&%)&%
Also known as "toxic multinouulai goitei), accounting foi appioximately 1S% of all
cases.
- Theie aie aieas of hypeifunctioning thyioiu tissue that piouuce excess TS
anu T4
- Noie common in oluei patients
- Elueily patients with hypeithyioiuism may piesent simply with unexplaineu
weight loss, weakness, anuoi atiial fibiillation

()&(5/"$"c& $(0+"5X5$5&
An autoimmune conuition that causes hypothyioiuism.
- Piesents with a moueiately enlaigeu, but non-tenuei thyioiu glanu
- Theie is lymphocytic infiltiation with geiminal centeis
- Anti-miciosomal antibouies aie iesponsible foi the conuition
&72)!7$% $(0+"5X5$5& hMH gSH>GBFAc@i
This is a tiansient thyiotoxic phase lasting 2-S months that is usually self-limiteu.
- Absence of paintenueiness of thyioiu glanu
- 0ften follows a flu-like synuiome
- Low iauioactive iouine uptake

)G/$#,+.,$3-+
Theie aie many causes of hypeicalcemia, they can be iemembeieu with the
mnemonic "!(5/*)#m%%&"
, - Calcium Ingestion
) - Bypeipaiathyioiuismhypeithyioiuism
- - Iatiogenic causes (such as thiaziue uiuietics)
3 - Nultiple myeloma
/ - Paget's uisease
+ - Auuison's uisease
4 - Neoplasms
\ - Zollingei-Ellison synuiome
$ - Excessive vitamin A intake
$ - Excessive vitamin B intake
2 - Saicoiuosis

&FJA@e&EDNC?D@ - Stones, Bones, Noans, uioans, anu Psychiatiic oveitones
2B>:7A - kiuney stones
*>:7A - bone pain, especially with an incieaseu PTB
3>@:A - psychiatiic noise
T8>@:A - constipation
/AFEHD@B8DE "978B>:7A - confusion, uepiession, etc


)G/$#/+#+()G#"-&-23
Theie aie piimaiy anu seconuaiy foims of hypeipaiathyioiuism.
*>FDB>E - The piimaiy foim of hypeiPTB is usually causeu by an auenoma in the
glanu. Nost of the time theie aie no symptoms of this conuition, howevei lab
finuings will show the following: BypeiCa2+, hypeicalciuiia, hypophosphatemia,
incieaseu paiathyioiu hoimone, anu inciease cANP in the uiine.
&HO?AMB>E - The seconuaiy foim of hypeipaiathyioiuism is causeu by a low seium
calcium, anu is seen most commonly in someone with chionic ienal uisease. Theie
will be hypocalcemia, hypeiphosphatemia, anu incieaseu levels of PTB.

)G/"/+#+()G#"-&-23
Bypopaiathyioiuism is usually uue to eithei acciuental iemoval uuiing a thyioiu
pioceuuie oi fiom Biueoige synuiome. Patient will have hypocalcemia anu tetany.
The ease by which tetany occuis can be testeu by ceitain maneuveis that cause
musculai spasms.
$>?S@@HBSc@ &FJA is a test that looks foi caipal spasm, anu is uone by occluuing the
biachial aiteiy by pumping up a bloou piessuie cuff.
!IG?@CH\c@ &FJA is a test that attempts to cause a spasm of the facial muscles, anu is
uone by tapping on the facial neive.

+,#"3$T+.G
Known as "gigantism" in chiluien, this is a conuition wheie theie is excess uB
secieteu fiom the pituitaiy glanu. Patient will have enlaigement of hanus, feet,
facial featuies, ueepening of voice, etc. These patients uie eailiei than the noimal
lifespan.
Noimally, giving glucose woulu suppiess uB levels, thus if giving glucose uoes N0T
suppiess the level of uB, a uiagnosis of aciomegaly can be maue.

,#$(-4-23
Cietinism is a conuition that occui when theie is a lack of uietaiy iouine (enuemic
cietinism). A uefect in T4 foimation oi the failuie of thyioiu uevelopment uuiing
uevelopment causes spoiatic cietinism. Patients aie puffy-faceu, pale, pot-bellieu
with piotiuuing umbilicus anu a piotiuuing tongue.

&-+*$($2 3$..-(12
Compaiing BN types 1 anu 2








5AFCFBL *>H@HACBCF?A ?U X/,d
The classic piesentation is polyuiia, polyuypsia, polyphagia, anu weight loss.
BKA, the auveise effect of BN1 leaus to incieaseu plasma glucose, uehyuiation,
aciuosis, anu if left untieateu will leau to coma anu ueath.
!I>?AFO %UUHOC@ ?U X/,:
2?@II 57AA7I &DA7@A7 - thickening of small vessels leaus to a myiiau of pioblems
thioughout the bouy. Retinopathy, nephiopathy.
.@8M7 57AA7I &DA7@A7 - will leau to atheioscleiosis, coionaiy aiteiy uisease, CvA,
PvB.
47<8>I>MDE@I - wiuespieau loss of sensation thioughout the bouy.
,@B@8@EBA - occui as a iesult of soibitol accumulation.




(G/$ X &-+*$($2
"-cell uestiuction (autoimmune)
Lifelong insulin is iequiieu
BKA is common
Staits in chiluhoou (usually)
Bouy is skinny
(G/$ Z &-+*$($2
Insulin iesistance
Bietexeicise is piimaiy
tieatment
Associateu with obesity
BKA is iaie
&-+*$(-, V$("+,-&"2-2 O&V+P
BKA is a life-thieatening auveise ieaction of BN1. Theie is an incieaseu neeu foi
insulin that uoesn't get met, anu is usually causeu by an illnessinfection that
incieases the stiess level of the peison. This leaus to an inciease in ketogenesis anu
thus piouuction of ketone bouies.
&FJA@e&EDNC?D@:
- Nausea anu vomiting
- Kussmaul bieathing (attempts to coiiect metabolic aciuosis)
- uI pains
- Behyuiation
- Psychosis anu uementia
- Bypeiglycemia
- Incieaseu anion gap metabolic aciuosis
- Inciease ketone levels
- Bypeikalemia with uepleteu intiacellulai potassium
!?DNLFOBCF?A@:
- Ceiebial euema
- Aiihythmia
- Beait failuie
- Nuicomycosis (causeu by the fungus Rhizopus)
(?T F@ Xb) DBABJHMn
- Lots of fluius
- Insulin (give glucose if levels stait to uiop)
- Potassium (when K+ levels noimalize)

&-+*$($2 -42-/-&12 O&-P
A lack of anti-uiuietic hoimone (ABB), uue to eithei a cential cause oi a
nephiogenic cause.
,7:B8@I &- - is causeu by a tumoi in the pituitaiy, tiauma, suigeiy
47NH8>M7:DE &- - is causeu by a lack of ienal iesponse to ABB

Patient will have intense neeu foi fluius coupleu with polyuiia, with uilute uiine that
is not concentiateu uue to lack of ABB.
/BABJHDHAC: Cential BI: Besmopiessin (intianasal) Nephiogenic BI:
hyuiochloiothiaziue (incieases Na+ anu B2u absoiption in uistal nephion).

2G4&#"3$ "! -4+//#"/#-+($ +4(-S&-1#$(-, )"#3"4$ O2-+&)P
Too much ABB uue to any of the following causes:
- Ectopic piouuction of ABB (commonly fiom small-cell caicinoma of the lung)
- Tiauma to the heau anuoi CNS uisoiueis that ielease excess ABB
- Biugs such as cyclophosphamiue
An excess in ABB will cause the following pioblems:
Xn $JB87?7L7JE7AA K@B78 87B7:BD>:
Zn )FN>:@B87?D@ =<7 B> =DI<BD>:@I 7CC7EBA OE@: E@<A7 A7Dj<87P
]n ,>:E7:B8@B7= <8D:7 O<8D:7 >A?>I@8DBF h A78<? >A?>I@8DBFP

"2($"/"#"2-2
0steopoiosis is the ieuuction in the bone mass wheie theie is noimal
mineialization. Theie aie two types:
(FN7 X - 0ccuis in post-menopausal women uue to uecieaseu estiogen levels.
Theie is an inciease in bone iesoiption.
(FN7 Z - "Senile" osteopoiosis affects those who aie oluei than 7uyi of age,
affecting both men anu women.
!?DD?A N>?WLHD@:
- veitebial ciush fiactuies
- Pelvic fiactuies
- Fiactuies of the uistal iauius
- veitebial weuge fiactuies
/BABJHDHAC: Bisphosphonates aie iecommenueu, wheieas estiogen ieplacement
woiks well but comes with siue effects that aie conceining.







31.(-/.$ $4&",#-4$ 4$"/.+2-+ O3$4 2G4&#"3$P
NEN synuiomes aie the categoiies of synuiome that compiise of ceitain neoplasias.
These gioups of neoplasias have a tenuency to piesent simultaneously.
3$4 - - Pancieas (Zollingei-Ellison, insulinomas, vIPomas), Pituitaiy, Paiathyioiu
3$4 -- - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Paiathyioiu auenoma
3$4 --- - Neuullaiy caicinoma of thyioiu, Pheociomocytoma, Nucosal Neuiomas

\"..-4T$#S$..-2"4 2G4&#"3$
ZES is a gastiin-secieting tumoi of the pancieas oi uuouenum. This conuition is
suspecteu whenevei theie aie iecuiiing ulceis that aie not tieateu conseivatively.
Suspect ZES whenevei theie is a pituitaiy anuoi paiathyioiu auenoma as they aie
all togethei in the NEN I synuiome categoiy.















*#$+2( &-2$+2$2

Z52+"!0&$5! X5&%)&%
Fibiocystic bieast uiseasechanges affects between Su%-6u% of women.
Chaiacteiizeu by benign lesions anu uiffuse bieast pain that is often ielateu to
hoimonal changes associateu with hei menstiual cycle.
Theie is a fibious, lumpy textuie to the lesions of the bieast. Nammogiam is not
iequiieu to make this uiagnosis, but fine-neeule aspiiation is commonly uone to
check the chaiacteiistics of the fluiu.
Tieatment is not necessaiy, howevei pain ielief shoulu be uone
**Theie is no incieaseu iisk of bieast cancei in fibiocystic uisease.

2+%)&$ !)#!%+
+F@\ ZBOC?>@:
- Family histoiy of a 1
st
uegiee ielative with bieast cancei at a young age
- Age anu genuei
- Nenaiche (<12yi) is shown to inciease iisk
- Piegnancy (>Su) can inciease iisk
- Late menopause (>Su)











-45+2-5$ *#$+2( ,+#,-4"3+2

Aie uiviueu into two majoi categoiies baseu on theii cytoaichitectuial featuies:















5AC>BMSOCBL *BNFLL?DB@ aie tumois of the lactifeious uucts, they piesent with
nipple uischaige. Aiising fiom mammaiy uuct epithelium oi lobulai glanus, anu
oveiexpiession of estiogenpiogesteione ieceptois.
XSOCBL !B>OFA?DB FA &FCS hX!5&i - is eaily malignancy without basement
membiane penetiation
5AGB@FGH XSOCBL !B>OFA?DB - piesents as a fiimfibious mass
!?DHM?OB>OFA?DB - is uuctal with cheesy consistency uue to cential neciosis
5AULBDDBC?>E - has lymphatic involvement anu caiiies a pooi piognosis
5AGB@FGH 3?WSLB> !B>OFA?DB - piesents bilateially with multiple lesions
/HMSLLB>E !B>OFA?DB - caiiies a goou piognosis, is fleshy with lymphocytic
infiltiation
-45+2-5$ &1,(+. ,+#,-4"3+
Tubulai Caicinoma
Sebaceous Caicinoma
Secietoiy Bieast Caicinoma
Neuioenuociine Caicinoma
Nucinous Caicinoma
Niciopapillaiy Caicinoma
Acinic Cell Caicinoma
Auenoiu Cystic Caicinoma
Apociine Caicinoma
Ciibiifoim Caicinoma
ulycogen-RichCleai Cell
Inflammatoiy Caicinoma
Lipiu-Rich Caicinoma

."*1.+# ,+#,-4"3+
Pleomoiphic
Signet Ring Cell
*BJHCc@ XF@HB@H ?U CIH 2>HB@C - eczematous patch on the nipple

/".G,G2(-, "5+#-+4 2G4&#"3$
Is a common uisoiuei anu one of the most common causes of infeitility in women.
An inciease in LB piouuction leaus to anovulation anu hypeianuiogenism uue to
alteieu steioiu synthesis.
&FJA@e&EDNC?D@:
- 0besity
- Biisutism
- Amenoiihea
- Infeitility
This conuition shoulu be manageu with weight loss anu oial contiaceptive pills
(0CP's).

"])+5)# !0&$&






T$#3 ,$.. (13"#2 "! ()$ "5+#G
$%+)$"/) [ up to 9u% of geim cell tumois of the ovaiy. Contains all thiee geim
layeis (ectoueim, enuoueim, mesoueim). The immatuie teiatoma is veiy
aggiessive anu malignant.
X0&.%+/5#"/) - is the most common type of malignant geim cell ovaiian tumoi,
usually occuiiing in auolescence anu eaily life. Is analogous to the male seminoma.
0"3b &)! $7/"+ - piouuces !-fetopiotein
!("+5"!)+!5#"/) - is the same as the testiculai veision of the geim cell tumoi,
causes an inciease in hCu.

4"4ST$#3 ,$.. (13"#2 "! ()$ "5+#G
&%+"7& !0&$)X%#"/) [ is benign, compiises 2u% of ovaiian tumois anu is
fiequently bilateial. Is lineu with fallopian tube-like epithelium.
&%+"7& !0&$)X%#"!)+!5#"/) - compiises Su% of ovaiian tumois, is fiequently
bilateial anu is malignant.
/7!5#"7& !0&$)X%#"/) - is benign, anu is a multiloculai cyst lineu by mucus-
secieting epithelium.
/7!5#"7& !0&$)X%#"!)+!5#"/) - is malignant, with intiapeiitoneal
accumulation of mucinous mateiial fiom ovaiian oi appenuiceal tumoi.
2+%##%+ $7/"+ - is a benign tumoi iesembling blauuei epithelium.
"])+5)# Z52+"/) - contains bunules of spinule-shapeu fibioblasts. "Neig's
synuiome" is a tiiau of ovaiian fibioma, ascites, anu hyuiothoiax.
.+)#73"&) !%33 $7/"+ - secietes estiogen causing piecocious pubeity in
chiluien, while in auults it can cause enuometiial hypeiplasia oi caicinoma.
Contains "Call-Exnei bouies", which aie small follicles filleu with eosinophilic
secietions.






1($#-4$ /+()"."TG

%#X"/%$+5)3 !)+!5#"/)
Is the most common gynecological malignancy that peaks between SS-6Syi of age.
The most common initial piesentation is vaginal bleeuing.
+F@\ ZBOC?>@ - Piolongeu use of estiogen, BN, hypeitension, anu obesity.

%#X"/%$+5"&5&
0ccuis when enuometiial glanus aie piesent in locations outsiue of the uteius.
Piesents with seveie pain ielateu to menstiuation anu piouuces chocolate cysts
(bloou in the ovaiy). Nay cause infeitility.

)X%#"/0"&5&
Is enuometiiosis within the myometiium of the uteius

3%5"/0"/)
Is the most common tumoi seen in women, wheie tumoi size incieases with
piegnancy anu uecieases with menopause. 0ften piesenting with multiple tumois
at once. Raie piogiession to cancei.

3%5"/0"&)+!"/)
Is a bulky tumoi with aieas of neciosis anu hemoiihage. Boes not aiise fiom a
leiomyoma. Tenuency to piotiuue fiom ceivix, is highly aggiessive anu has a
tenuency to iecui.






,$#5-,+. /+()"."TG

X0&*3)&5)
Is uisoiueieu epithelial giowth that staits at the basal layei anu extenus outwaiu.
Caicinoma in situ (CIN) is classifieu baseu on the extent of uysplasia. Theie is an
association with human papilloma viius.
5#])&5]% !)+!5#"/)
Nost commonly this is squamous cell caicinoma. Pap smeai is an essential tool to
catch this befoie it becomes too auvanceu.

,"3/.-,+(-"42 "! /#$T4+4,G

Foui common conuitions associateu with piegnancy incluue:
1. Placental abiuption (abiuptio placenta)
2. Placenta accieta
S. Placenta pievia
4. Ectopic piegnancy

/.+,$4(+. +*#1/(-"4
Painful uteiine bleeuing that is a iesult of piematuie sepaiation of the placenta. Is
an emeigency conuition that can iesult in fetal ueath.
/.+,$4(+ +,,#$(+
Placenta attaches uiiectly to the myometiium, anu is causeu by a uefective ueciuual
layei.
/.+,$4(+ /#$5-+
Placental attachment to the lowei uteiine segment with may occluue the ceivical os.
Piesents with painless vaginal bleeuing.
$,("/-, /#$T4+4,G
Nost common site is the fallopian tube, is seen most commonly in a patient with
histoiy of pelvic inflammatoiy uisease. Biagnose with ultiasounu.


/#$T4+4,G -4&1,$& )G/$#($42-"4 O/87S7EI@?NAD@P

*>HKHOLBDN@FB = Bypeitension, pioteinuiia, anu euema.
%OLBDN@FB = Tiiau above + seizuie
* If pie-eclampsia is piesent, patient iequiies beuiest, salt-iestiiction, anu
monitoiing.
Associateu with BELLP synuiome, which is an emeigency situation that iequiies
immeuiate ueliveiy of the baby.
) - )emolysis
$. - $levateu .FTs
./ - .ow /latelets

)G&+(-!"#3 3".$

Is an ovum without any BNA, which iesults in swelling of the choiionic villi anu
piolifeiation of choiionic epithelium. Theie will be elevation of "-hCu anu the
appeaiance of a "clustei of giapes".
Complete Nole - 46,XX that is of complete pateinal oiigin with no iuentifiable
embiyonic oi fetal tissue.
Paitial Nole - 69,XXY oi 92, XXXY, wheie a noimal egg is feitilizeu by two oi thiee
speim.
* Nay uevelop into choiiocaicinoma






*$4-T4 /#"2(+(-, )G/$#/.+2-+
BPB is a conuition that is quite common in men ovei the age of Suyi. Chaiacteiizeu
by nouulai enlaigement of the lateial anu miuule lobes (ie peiiuiethial), which
compiesses the uiethia into a veitical slit.
SignsSymptoms:
- 0iinaiy fiequency
- Fiequent nighttime uiinaiy
- Bifficulty in staitingstopping uiination
- Complications may be hyuionephiosis, hypeitiophy of blauuei, anu 0TI.

/#"2(+(-, +&$4",+#,-4"3+
Nost commonly seen in men ovei Suyi of age. The most common site of
auenocaicinoma is the posteiioi lobe (aka peiipheial zone). Bigital iectal exam is
the best way to uetect the cancei, as haiu nouules can be uetecteu on exam. PSA is
useu as a way to uetect an auenocaicinoma, as levels >4.u aie woiiisome. The most
woiiisome auveise effect is osteoblastic metastasis (uetect by incieaseu alkaline
phosphatase).