UWorld Notes-2 PDF

QId: 540 Immunology - Allergy & Immunology
Activation of complement by IgM prior to antigen binding is prevented because of the

hidden C1 binding site. Once IgM binds to the antigen, conformational change -- >
exposure of the C1 binding site.
QId: 8539 Immunology - Allergy & Immunology
C3a, C4a, C5a - anaphylotoxins

C5a - recruits and activates neutrophils, monocytes, eosinophils and basophils.
C3a - only eosinophils and basophils
QId: 10570 Biostatistics - Biostatistics &

Epidemiology
Nested case-control studies start as cohort studies which are studied over time to check
for any development of disease. Participants who develop an outcome of interest become
cases for a case-control study.
Qualitative study uses focus groups, interviews adn other anthropologic techniques to
obtain information for explaining quantitative results.
Systemic reviews and meta-analyses combine teh results fo several published studies to
estimate the pooled effect.
QId: 154 Pharmacology - Cardiovascular System
Ca channel blockers -- > precapillary arteriolar dilation -- > edema.

ACE inhibitors and ARBs cause postcapillary venodilation -- > normalize pressure when
used with Ca channel blockers -- > decreased edema.
QId: 2023 Anatomy - Cardiovascular System
3 main groups of venous circulation in embryo:

Umbilical - degenerates
Vitelline - forms portal circulation
Cardinal - systemic venous circulation
QId: 475 Pathology - Cardiovascular System

Adenocarcinomas produce a thromboplastin-like substance capable of causing chronic
intravascular coagulations that can disseminate and tend to migrate.
Statins - proven to show mortality benefits in coronary events. Along with inhibition of
cholesterol synthesis, it has anti-inflammatory properties, improve endothelial dysfunction
and appear to stabilize atherosclerotic plaques.
Pravastatin, unlike other statins, is not metabolized by the liver through P-450 3A4
Cardiac changes due to aging - sigmoid interventricular septum (bowing of the lower
part), decrease in LV chamber size (apex-to-base shortening), calcified aortic valve.
QId: 2105 Pathophysiology - Cardiovascular

System
AR due to aortic root dilation (Marfans') - best hear at the right upper sternal border.
AR due to valvular pathology (eg: bicuspid valve, RHD) - best heard at left third intercostal
space.
Low-dose aspirin -- > non-specific inhibition of COX-1 and 2. Side effects mainly due to
inhibition of COX-1. Used as anti-platelet-aggregation (TXA2) -- > increased risk of
bleeding by itself.
Inhibition of COX-1 -- > impaired synthesis of prostaglandins E2 and I2 -- > gastiric
hyperacidity -- > impaired mucosal defense -- > mucosal injury and bleeding.
GI bleeding can be a serious side effect. PPIs can be used along with aspirin to prevent
the side effect.
Very high doses can cause hyperpnea (direct stimulation of respiratory center in medulla)
and vertigo (ototoxicity).

Ischemic tissues - higher than normal resting membrane potential -- > delayed
voltage-dependent recovery of sodium channels from the inactivated to the resting state --
> increased binding of class IB agents.
QId: 14780 Pharmacology - Cardiovascular

System
RCA - SA node, AV node, most of Bundle of His and proximal part of right bundle branch
LCA - Bundle of His, left bundle branch, remaining part of right bundle branch
Ischemic heart disease/obstructive coronary disease -- > dilated cardiomyopathy because

of volume overload from decreased contractility

System
Bicuspid valve - early onset aortic stenosis around 50 years of age in > 50% patients (10
years earlier then normal).
It is due to increased hemodynamic stress, accelerating the normal aging process.

System
Increased afterload decreases murmur in AS and HCM.

In AS, pressure gradient across aortic valve decreases -- > decreased murmur.

Myocardial hibernation - chronic ischemia -- > metabolism and cardiac function reduced
to match the decreased coronary blood flow -- > new equilibrium preventing necrosis;
dereased expression and disorganization of contractile and cytoskeletal proteins, altered
adrenergic control and reduced calcium responsiveness -- > decreased contractility and
LV systolic dysfunction.
Revascularization -- > restoration of blood flow -- > improved cardiac function.
Ischemic preconditioning - brief repetitive episodes of myocardial ischemia with

intermittent reperfusion -- > protection of myocardium from prolonged episodes of
ischemia.
Repetitive episodes of angina prior to MI can delay cell death after complete coronary
occlusion and therefore provide greater time for myocardial salvage with coronary
revascularization.
QId: 13600 Genetics - Cardiovascular System
Arrhythmogenic right ventricular cardiomyopathy - fibrosis and scarring of RV -- >

ventricular arrhythmias and SCD.
Cause - impaired desmosome function due to mutations in genes encoding desmosomal
proteins (eg: desmoplakin, plakoglobin).
QId: 7640 Pharmacology - Cardiovascular

System
Torsades de pointes can be differentiated from other polymorphic tachycardia because it is

always associated with prolonged QT interval.
Infective endocarditis pathogenesis - disruption of normal endocardial surface -- > focal

adherence of fibrin and platelets (usually at the areas of maximal turbulence to blood flow
like atrial surface of incompetent AV valves) -- > sterile fibrin-platelet nidus -- >
colonization of nidus due to bacteremia -- > microbial growth -- > further activation of
coagulation system.
Macroscopic vegetations contain fibrin and platelets on the surface with RBC debris,
WBCs and clusters of microorganisms embedded deep within the lesion.

System
Severe AS -- > LVH -- > stiff ventricle -- > ventricular filling depends on atrial contraction.
In the setting of atrial fibrillation, atrial kick lost -- > decreased preload -- > exaggeration
of the reduced cardiac output.
Fluid also backs up into pulmonary veins -- > pulmonary edema.
Therefore, in patients with severe AS who present with atrial fibrillation, cardioversion is
indicated.
QId: 1516 Physiology - Cardiovascular System
NO and adenosine are important for maintaining the coronary blood flow in the
autoregulatory range of blood pressures.

System
Reperfusion injury due to:

Free radicals generated from parenchymal cells, endothelial cells and leukocytes.
Irreversible mitochondrial dammage (mitochondrial permeability transition)
Inflammation, which attracts circulating neutrophils
Complement pathway activation
Hypertension -- > medial hypertrophy of aortic vasa vasorum -- > reduced blood flow to
the aortic media -- > medial degeneration with a loss of smooth muscle cells --> aortic
enlargement and increased wall stiffness -- > increased aortic wall stress -- > intimal
tearing -- > dissection.
Aortic stenosis - endothelial damage -- > fibroblast proliferation and release of osteopontin
from macrophages -- > differentiation of fibroblasts into osteoblast-like cells -- > aberrant
bone matrix deposition -- > progressive valvular calcification and stenosis
QId: 467 Pathology - Dermatology
A bluish neoplasm underneath the nail bed can be a glomus tumor or a subungual
melanoma.
QId: 1214 Pharmacology - Dermatology
Topical steroids -- > anti-inflammatory actions and also decrease in production of ECM
collagen and GAGs -- > atrophy of dermis, drying, cracking and/or tightening of skin
QId: 15431 Microbiology - Dermatology
Cat and dog hookworms (Ancylostoma braziliense, A. caninum) - cannot penetrate the
basement membrane -- > don't mature into adults in humans (incidental hosts).
Plane xanthomas - PBC
Xanthomas - foamy macrophages; enclosed by inflammatory cells and fibrotic stroma

Xanthelasma - foam cells without any inflammation/fibrosis.
Vitiligo - autoimmune activity, neurohumoral toxicity, self-destruction via toxic

intermediates during melanin synthesis.
QId: 15379 Pathophysiology - Dermatology
Bacterial metabolism of apocrine secretions -- > body odor due to sweat.

Bromhidrosis - excessive and offensive body odor.
QId: 7585 Pharmacology - Dermatology
Pathophysiology of acne:
Follicularepidermalhyperproliferation
Excessive sebum production
Inflammation
Propionibacterium acnes
Dihydrotestosterone -- > follicular epidermal proliferation and excessive sebum production
Lithium and EGFR inhibitors also cause acne.

Seborrheic keratoses in malignancy -- > tumor production of cytokines or growth factors

(IGF-1, FGF).
Acanthosis nigricans in malignancy - similar mechanism.
Acanthosis nigricans - benign and malignant

Benign - insulin resistance (insulin and IGF stimulate epidermal and dermal proliferation).
Malignant - due to underlying malignancy (usually gastric adenocarcinoma).
Urticaria - superficial dermal edema

Angioedema - deep dermis and subcutaneous tissue edema
QId: 1244 Biochemistry - Dermatology
Collagen - tensile strength

Elastin - elasticity
Glycosaminoglycans - compressibility
QId: 8904 Pathophysiology - Dermatology
Ephelides (freckles) are due to increased melanin production in melanocytes.

Solar lentigines are due to increased melanocytes.
Erythema multiforme - circulating pathogens phagocytosed by peripheral mononuclear

cells and are brought to the epidermis where DNA fragments are transferred to
keratinocytes via direct cell-to-cell spread (upregulation of adhesion molecules).
Pathogen-specific cytotoxic T-cells then recognize foreign antigens produced by
keratinocytes and initiate an inflammatory cascade that results in epithelial damage.
QId: 13911 Microbiology - Dermatology
HIV patients/immunocompromised patients are unable to contain scabies infection due to

impaired cell-mediated immunity -- > crusted scabies.
QId: 1633 Anatomy - Ear, Nose & Throat (ENT)
Noise-induced hearing loss is due to trauma to the stereociliated hair cells of the organ of
Corti.
QId: 582 Pathophysiology - Endocrine, Diabetes &

Metabolism
Cryptorchidism - seminiferous tubules are damages; Leydig cells are preserved -- >
increased FSH and normal LH.
QId: 8531 Pathology - Endocrine, Diabetes &

Metabolism
Preproinsulin loses singal peptide -- > proinsulin which is packaged in the golgi -- >
cleaved into insulin and C-peptide in secretory granules.
QId: 15770 Pharmacology - Endocrine, Diabetes &

Metabolism
SGLT-2 inhibitors -- > decreased sodium resorption -- > increase phosphate absorption in
distal tubule -- > PTH secretion -- > decreased bone density.

Metabolism
Adiponectin - secreted by fat tissue that increases the number of insulin-responsive

adipocytes and stimulates fatty acid oxidation.
QId: 954 Physiology - Endocrine, Diabetes &

Metabolism
5a reductase = 2 types. Type 1 present in postpubescent skin, type 2 in genitals.
QId: 11917 Biochemistry - Endocrine, Diabetes &

Metabolism
Fasting -- > stress hormones (catecholamines, ACTH and glucagon) act on Gs receptor of
adipocytes -- > activation of hormone sensitive lipase -- > TAGs broken down into
glycerol and FFA -- > glycerol enters gluconeogenesis pathway and FFAs are broken
down into ketone bodies.
LPL has similar function, but it is involved in transporting FFAs into adipocytes storage
and used by tissues for energy production (not maintenance during starvation).

Metabolism
Liver can synthesize ketone bodies but cannot utilize them because it lacks an enzyme
(succinyl CoA acetoacetate CoA transferase/thiophorase) which is required to convert
acetoacetate to acetoacetyl CoA.

Metabolism
Islet amyloid polypeptide is a protein secreted by pancreatic ß cells.

It is low in Type 1 DM due to destruction of islet cells.

Metabolism
Amino acids undergo transamination transferring their amine nitrogen to glutamate

(predominantly) which is then deaminated to produce ammonia -- > converted to urea via
urea cycle

Metabolism
Glucose polymer = starch; starch has an unbranched portion = amylose and branched
portion = amylopectin.

Metabolism
Intracellular cortisol receptors are bound to the heat shock proteins in the inactivated state.
Metabolism
G protein-coupled receptors - 3 domains.

Extracellular domain - ligand binding
Transmembrane domain - anchoring the cell membrane
Intracellular domain - heterotrimeric G proteins
Extracellular domain - polar amino acids

Transmembrane domain has non-polar amino acids -- > embedded in the phospholipid
bilayer.
Hemoglobin = iron + protoporphyrin IX

1 subunit = 2a and 2ß chains in a-helical heme-binding pocket lined by non-polar amino
acids.

Metabolism
Small quantities of pancreatic lipase leaks into pancreatic capillaries -- > triglyceride
conversion to free fatty acids -- > FFA have a toxic and inflammatory effects on the
pancreas -- > pancreatitis.

Metabolism
Metabolic syndrome - insulin resistance --> decreased lipogenesis and increased lipolysis
--> increased lipolysis --> increases free fatty acids --> gluconeogenesis and decreased
insulin-dependant glucose uptake --> more insulin resistance

Metabolism
Mutations in neurophysins = AD hereditary hypothalamic diabetes insipidus

Metabolism
Insulin degludec - polymer formation at injection site -- > slowed uptake
Detemir - fatty acid side chain added to lysine -- > binds to circulating albumin -- > slow
release
Glargine - pH of 4 -- > microprecipitate formation -- > delayed absorption
NPH - crystalline suspension of insulin+protamine+zinc -- > delayed absorption

Metabolism
TNF-a phosphorylates serine residues of ß part of insulin receptors -- > inhibited

downstream regulation -- > insulin-resistance. (Phosphorylation of threonine residues =
similar effect).

Metabolism
People with ß-thalassemia and DM -- > falsely low HbA1c -- > measure glycated serum
proteins (fructosamine).
Iron, folate and B12 deficiency -- > decreased production of new red cells -- > increased
circulation of old cells -- > falsely elevated HbA1c (also seen in diabetic nephropathy).
Treatment of vitamin deficiencies -- > more release of new red cells -- > falsely low
HbA1c.

Metabolism
Side chain cleavage enzyme involved in steroid synthesis converts cholesterol to

pregnenoloone (first enzyme) -- > impaired synthesis of all steroid hormones and
accumulation of cholesterol esters -- > progressive damage.
DHT required fro fusion of labial folds during male fetal development. 5a reductase
deficiency -- > ambiguous genitalia at birth

Metabolism
FGFR-1 = Kallmann syndrome

FGFR3 = Achondroplasia
Metabolism
Vitamin D toxicity increases osteoclast activity and bone turnover

Metabolism
Excess thyroid hormone (either from underlying disorder or exogenous administration) --

> increased expression of beta adrenergic receptors -- > cardiovascular complications.
Increased SBP, decreased DBP, high-output cardiac failure, angina in susceptible patients
from increased contractility, atrial fibrillation.

Metabolism
MODY patients - autosomal dominant, young, non-obese patients; worsens during

pregnancy due to insulin resistance, non-progressive even without treatment.

Metabolism
Corticosteroids reduce peripheral lymphocyte counts by inhibition of immunoglobin

synthesis, stimulation of lymphocyte apoptosis and lymphocyte redistribution from
intravascular compartment to lymph nodes, spleen and bone marrow. T cells reduced to a
greater degree than B cells.

Metabolism
Insulin resistance is associated with increased triglycerides and decreased HDL, but NOT
increased LDL.

Metabolism
Insulin tyrosine kinase receptor has 2 a and 2 ß subunits.
a subunit - extracellular, binds insulin.
ß subunit - intracellular, has tyrosine domains.
Metformin increases insulin sensitivity by activating AMP-activated protein kinase.
GLP-1 acts through Gs-coupled receptors (adenylyl cyclase system).
QId: 1809 Embryology - Female Reproductive System &

Breast
All females with Mullerian agenesis should undergo renal ultrasound as up to 50% will
have co-existing anomaly.
QId: 11926 Pathophysiology - Female Reproductive System &

Breast
ß-hCG -- > relaxin -- > dilated arterioles -- > increased GFR with unchanged (or even
reduced) bladder capacity -- > stress incontinence.
Pregnancy hormones decrease urethral tone and relax the pelvic floor muscles -- >
incontinence.
QId: 11929 Pathology - Female Reproductive System &

Breast
E6 binds to p53 -- > ubiquination and proteasomal degradation --> uncontrolled cell
division and impaired apoptosis of damaged DNA.
E7 binds to Rb -- > displaces bound transcription factors -- > uregulated DNA replication
and cyclin-mediated cell cycling.
QId: 207 Physiology - Female Reproductive System &

Breast
Menotropin - human menopausal gonadotrophin mimics FSH and triggers the formation of
dominant ovarian follicle.
Exogenous hCG - a subunit is similar to LH -- > mimics LH surge -- > ovulation induction
QId: 7214 Pathology - Gastrointestinal &

Nutrition
In extramedullary hematopoesis, precursor cells are displaced from the bone marrow and
infiltrate the liver and spleen -- > organomegaly.
QId: 369 Pathophysiology - Gastrointestinal &

Nutrition
Albumin level is relatively normal in acute liver injury due to its long half life (20 days).

Nutrition
Councilman bodies - eosinophilic apoptotic bodies; hepatocytes undergo cytotoxic T cell

mediated apoptosis -- > councilman bodies.
QId: 17005 Anatomy - Gastrointestinal &

Nutrition
Greater splanchnic nerve: T5-10

Lesser splanchnic nerve: T9-12
(Sympathetic nerve roots)
Pelvic splanchnic nerve: S2-4; parasympathetic
QId: 1136 Microbiology - Gastrointestinal &

Nutrition
Organisms causing disease with small inoculum (10-500):

C. jejuni
E.histolytica
Shigella species
G. lamblia
Organism causing disease with larger inoculum (10^4 - 10^8):

Salmonella
Vibrio
C. perfringens
E. coli
QId: 79 Pathology - Gastrointestinal & Nutrition

Gallbladder outflow obstruction -- > hydrolysis of luminal lecithins to lysolecithins -- >
disruption of protective mucus layer -- > mucosal exposure to detergent action of bile salts
-- > chemical irritation and prostaglandin release -- > inflammation -- > hypomotility -- >
distention and increased pressure -- > ischemia -- > bacterial invasion

Nutrition
Secretin causes paradoxical increase in gastrin secretion in tumors because of abnormal

adenylate cyclase activation.

Nutrition
H. pylori can only colonize gastric tissue though it causes duodenal ulcer.
Duodenal ulcer - colonization of bacteria in gastric antrum -- > decreased somatostatin
secretion -- > increased gastrin -- > increased acid secretion -- > ulcer.
Gastric ulcer - colonization of bacteria in gastric corpus; not associated with increased
acid (normal or decreased); direct mucosal damage and chronic inflammation.
QId: 14880 Anatomy - Gastrointestinal &

Nutrition
Failure of the posterolateral diaphragmatic foramina to fuse = Bochdalek hernia.
Herniation of viscera through omental foramen (foramen of Winslow) = lesser sac hernia

Nutrition
HFE protein interacts with the transferrin receptor on the cell surface to facilitate
endocytosis of the iron-transferring complex. Once inside the cell, transferrin is degraded
and the iron is added to the labile iron pool.
In HFE mutation, improper interaction with the transferrin receptor -- > decrease iron
uptake -- > sensing of falsely low iron levels -- > increased DMT expression -- > more
absorption of iron and decreased hepcidin release from liver -- > increased ferroportin
action -- > all leading to IRON OVERLOAD.
QId: 57 Pathology - Gastrointestinal & Nutrition

Aflatoxin - B1 most common and most toxic.
p53 mutations -- > G:C --> T:A transversion

Nutrition
Alcohol -- > secretion of protein rich fluid from pancreas -- > precipitates and calcifies --
> ductal plugs -- > pancreatitis

Nutrition
Bronchopulmonary sequestration = congenital malformation where extra, nonfunctional

lung tissue is present without communication to the tracheobronchial tree; can cause
recurrent pneumonia

Nutrition
Pentagastrin is a synthetic gastrin analog that stimulates secretion of gastric acid.

Diagnostic agent in medullary carcinoma of thyroid - increases calcitonin secretion on
administration and in carcinoid tumour - increases secretion of serotonin.
QId: 8425 Biochemistry - Gastrointestinal &

Nutrition
Leptin = satiety
It decreases production of neuropeptide Y, a potent appetite stimulant in the arcuate
nucleus of hypothalamus.
It stimulates the production of POMC in the arcuate nucleus -- > a MSH produced by
cleavage -- > inhibition of food intake
In most individuals however, persistent elevation of leptin levels desensitizes the receptor
(like insulin resistance).

Nutrition
Systemic mastocytosis - clonal mast cell proliferation occurs in the bone marrow, skin,
and other organs.
Associated with KIT (CD 117) receptor tyrosine kinase.
? mast cell tryptase -- > histamine release -- > syncope, flushing, hypotension, pruritis and
urticaria.
Stimulates gastric cells -- > ? gastrin production -- > ulcers; also acid neutralizes
pancreatic and intestinal secretions -- > diarrhea and other GI symptoms.

Nutrition
Dumping syndrome - gastric bypass surgery, pyloric sphincter damage -- > hyperosmolar
chyme in the small intestine -- > fluid shift from plasma to intestine -- > diarrhea

Nutrition
Hereditary pancreatitis - mutations in trypsinogen or SPINK1 gene.

Trypsin can act as its own inhibitor cleaving it at a second site (other than the one where it
activates it own self).
Mutation -- > abnormal trypsin -- > inactivating cleavage -- > autodigestion -- >
pancreatitis

Nutrition
Unlike methanol or ethylene glycol, acute ethanol intoxication does NOT usually cause
high anion gap metabolic acidosis.
Chronic alcoholism can cause ketoacidosis in malnourished patients.

Nutrition
60% of ingested copper = absorbed in stomach and duodenum -- > loosely bound to
albumin -- > transported to liver -- > combines with a2 globulin -- > ceruloplasmin.
Senescent ceruloplasmin and extra copper secreted into bile and excreted in stool =
primary route of excretion.

Nutrition
PAS - periodic acid oxidizes carbon-carbon bonds -- > aldehydes that produce brilliant
magenta color upon reacting with the fuchsin-sulfurous acid.
Peroxidase staining - used to differentiate subtypes of acute leukemia; horseradish

peroxidase - useful in immunoblotting (Western blot).
Sudan black/Nile red - identify neutral lipids

Nutrition
In C. difficile infection, NAAT is used to detect the toxin B-encoding gene -- > highly
sensitive and specific.
Enzyme immunoassay is also used to detect toxins (highly specific) but not highly
sensitive.

Nutrition
Hemochromatosis manifestion -- > at least 20g of iron deposition.

Nutrition
Alcohol stimulates pancreas to secrete protein rich fluid with decreased water content -- >
precipitation of proteins -- > pancreatitis.
Alcohol causes RBC macrocytosis due to folate-deficiency, liver disease and/or direct
toxicity of alcohol on the marrow.

Nutrition
Parasitosis-related inflammation and immune-mediated cross-reaction with ganglia -->

achalasia in T. cruzi infection.
QId: 2033 Genetics - General Principles
Telomeres contain TTAGGG repeats.

QId: 1436 Biochemistry - General Principles
Bloom syndrome - helicase dysfunction -- > growth retardation, facial anomalies,

photosensitive rash and immunodeficiency.
Before the initiation of replication, origin of replication is identified and bound by a

multi-subunit protein, the origin recognition complex, which dissociates dsDNA into
ssDNA, locally. ssDNA is stabilized by ssDNA-binding proteins; helicase then binds to
ssDNA and continues the separation of the DNA by moving the replication fork.
Epistasis - allele of one gene affects the phenotypic expression of alleles in another gene.
Irreversible inhibitors - strong covalent bonds with enzyme

Competitive inhibitors have high affinity to the enzyme but do NOT decrease the affinity
of the substrate to the enzyme.
QId: 542 Immunology - General Principles
The invariant chain of the MHC II complex acts to guide the molecule during sorting in the
Golgi and occupy the binding binding site until it reaches the acidified endosome.
Collagen requires hydroxyproline to introduce the ring configuration to cause a kink in

polypeptide chain -- > increased rigidity of a helix.
Hydroxylysine is requires for cross-linking -- > increasing tensile strength.
QId: 1756 Immunology - General Principles
Intrinsic apoptotic signals - phosphatidylserine or thombospondin

CAAT box - promoter of transcription in eukaryotic genome; located 70-80 bases
upstream from the transcription start site.
Hogness box (TATA) - second promoter region right to CAAT; located 25 bases upstream
from start site.
Best way to analyse if a gene is being expressed = check if it's being transcribed = mRNA
(Northern blotting).
Telomerase RNA component (TERC) - built-in RNA template at the end of chromosomes.
Telomerase reverse transcriptase (TERT) - reads TERC and adds TTAGGG DNA
sequence repeats.
Stem cells have long telomeres and high telomerase activity -- > indefinite proliferation in a
controlled manner.
Mitochondrial proteins - synthesized in the cytosol and contain specific mitochondrial

targeting sequences. Translocases detect these sequences and shuttle the proteins into and
between the different mitochondrial compartments.
Nuclear proteins - for nuclear proteins to be imported into the nucleus, they must first
present a nuclear localization signal to the nuclear pore complexes on the nuclear envelope.
Nuclear export requires a different signal.
Peripheral membrane proteins - proteins are covalently attached to a hydrophobic lipid

anchor (lipidation) so they can be targeted to the plasma membrane.
Transition - mutation causing purine -- > purine change

Transversion - purine -- > pyrimidine or vice versa.
QId: 1298 Pathology - Hematology & Oncology
Sepsis -- > DIC as the LPS is a procoagulant

Muscle tissue immunohistochemistry - actin, caldesmon or desmin

Endothelium - CD34 or vWF
QId: 15299 Pharmacology - Hematology &

Oncology
Palbociclib - CDK 4/6 inhibitors; inhibit activation of cyclin dependent Rb phosphorylation

-- > Rb in hypophosphorylated form (active) -- > non-progression of cell cycle.
Keratin = alanine+glycine
small structure -- > coil tightly
large number of hydrogen bonds
increased sulfur containing cysteine -- > disulfide bonds -- > more rigidity and toughness
QId: 14772 Pathology - Hematology &

Oncology
Cachexia caused by TNF-a, IL-6 -- > stimulation of ubiquitin-proteasome pathway -- >

skeletal muscle degradation -- > wasting.

Oncology
MDR genes in tumour cells -- > P-glycoprotein production - a transmembrane protein that
functions as an ATP-dependent efflux pump -- > efflux of chemotherapeutic agents,
specially hydrophobic agents like anthracyclines.
It is normally expressed in intestinal and renal tubular epithelial cells to eliminate foreign
particles.
Also present in the capillary endothelium of vessels of blood-brain-barrier, prevents
penetration of foreign compounds into the CNS.
Bony metastasis - PB/KTL - lead kettle - prostate, breast, kidney, thyroid, lung.
Oncology
HbS polymerizes in deoxygenated and dehydrated form.

HbF -- > increased oxygen affinity -- > decreased sickling
Gardos channel blockers (calcium-dependent potassium channels) --> reduced potassium
and water efflux when blocked -- > decreased dehydration -- > decreased polymerization
(sickling)

Oncology
COX 1 - physiologic role like platelet aggregation and protecting GI mucosa.
Renal vascular endothelial and smooth muscle cells have COX 1 and COX 2 -- > selective
COX 2 inhibitors can also reduce renal function.
Aspirin acetylates serine residues of platelet COX enzyme --> irreversible inhibition of
plateletaggregation
HBV and HCV infect hepatocytes -- > increased hepatocyte turnover and generation of
local inflammatory cytokines -- > mutations -- > malignant transformation.
Additional HBV features: incorporates into host DNA by host topoisomerase I (though not
required for replication) -- > insertional mutations in regions that control cell growth and
differentiation.
Also, it produces HBx, a transcriptional activation of several genes associated with cellular
growth and interferes with p53 function.

Oncology
UFH has a chain long enough to bind to antithrombin and thrombin to inactivate the
complex.
LMWH cannot bind to thrombin efficiently -- > poor inactivator of thrombin (mainly
inactivates Xa as it requires binding only to AT III and not the factor Xa itself).

AML M6 - erythroid precursor cells; elderly patients
AML M7 - platelet precursor cells; 1,22 translocation and Downs'
Procarcinogens are metabolized by P450 monooxygenase, which is present in the hepatic

microsomes and ER of various other tissues.
It metabolizes steroids, alcohol, toxins and other substances -- > soluble and easier to
excrete.
However, also converts pro-carcinogens -- > carcinogens -- > DNA mutations.
Glutathione-S-transferase - detoxification of some chemical carcinogens; converts into

inactive metabolites.
QId: 1474 Genetics - Hematology & Oncology
Radiation therapy causes cell death by:

DNA double-strand breakage - single-strand breakage can be easily repaired; hence,
double-stranded break necessary for cell death.
Free radical formation - formed by ionizing water
Reactive hyperplasia of lymph node - benign, polyclonal cells; has cell pleomorphism,
increased mitosis and nuclear changes.
Malignancy of lymph node - Monoclonal lineage of tumour cells.

T-cell malignancy - examine for rearrangement of TCR genes; done through PCR or other
molecular methods.
B-cell malignancy - rearrangement of the genes for immunoglobulin variable regions.
Tumor cells detach from neighboring cells through decreased expression of E-cadherins;
adhere to basement membrane through increased expression of laminins; invade basement
membrane through increased MMPs, cathepsin D protease, etc.
QId: 1240 Biochemistry - Hematology &

Oncology
NADH methemoglobin reductase reduces ferric iron to ferrous iron, regenerating
hemoglobin from methemoglobin; deficiency -- > congenital methemoglobinemia.
CO reversibly binds to heme.
QId: 787 Physiology - Hematology & Oncology
Renal tubular cells secrete lactoferrin -- > binds to free iron in urine (recovers for
metabolic use)
QId: 16442 Pathophysiology - Hematology &

Oncology
Heat stroke/sever hyperthermia -- > blood shunting away from essential organs to release
heat -- > tissue ischemia/necrosis -- > release of tissue factor (procoagulant factors) -- >
DIC
QId: 1375 Microbiology - Hematology &

Oncology
Adenovirus has hexon and penton capsomeres on its surface. Rodlike structures (fibers)
that project from the penton base are responsible for mediating adsorption to host cells.
The cell receptor is a transmembrane protein member of the immunoglobulin superfamily.
QId: 11912 Genetics - Hematology & Oncology
Telomerase - RNA-dependent DNA polymerase; 2 molecules: human telomerase reverse

transcriptase adn telomerase RNA.
In human cells, present only is cells that divide rapidly (germ cells, stem cells, etc)
>90% cancer cells contain telomerase activity -- > continued proliferation without
apoptosis

Oncology
MTX undergoes polyglutamation -- > trapping inside cells. This inhibits folic acid and
DHF -- > accumulation of DHF polyglutamate inside cells
Oncology
Dactylitis in sickle cell disease is common in the first few years of life as the bones still
contain hematopoietic bone marrow.

Oncology
Positively charged histidine and lysine in HbA attracts negatively charged 2,3 BPG -- >
decreased oxygen affinity.
In HbF, histidine is replaced by serine -- > decreased positive charge -- > decreased
affinity to 2,3 BPG -- > increased oxygen affinity (to extract oxygen from mother).
Folate and B12 deficiency = defective purine and pyrimidine synthesis; RNA and protein
synthesis is normal -- > cytoplasmic growth with impaired cell division -- > macrocytosis.
Pancreatic insufficiency -- > B12 deficiency as the pancreatic enzymes cleave R factor
from B12 -- > B12 binding to intrinsic factor.

Oncology
6-MP is activated by HGPRT and inactivated by xanthine oxidase and thiopurine

methyltransferase

Oncology
Cholestyramine binds warfarin in the intestine, decreasing the therapeutic effect.
Treatment of iron-deficiency anemia -- > increased erythropoeisis -- > accelerated release

of both mature RBCs and reticulocytes into the bloodstream.
These reticulocytes are slightly larger than mature RBCs and though they do not have
nuclear remnants, they stain blue for Wright-Giemsa stain due to residual rRNA.
Oncology
Pappenheimer bodies - aggregated iron deposits in RBCs in sideroblastic anemia

Howell-Jolly bodies - clusters of DNA remnants in RBCs in hyposplenism/asplenism
Heinz bodies - aggregates of denatured hemoglobin in RBCs in G6PD deficiency.
Basophilic stippling - precipitated ribosomes in RBCs in thalassemia, alcohol abuse and
lead/heavy metal poisoning.
Splenic conditioning - removal of excess membrane on RBCs by the macrophages in the

red pulp.
Post-splenectomy - target cells seen in peripheral smear up to few weeks. Later,
macrophages in nonsplenic tissue take up the task of "pruning."
Target cells are less prone to osmotic stress than normal RBCs due to excess membrane.

Oncology
P-glycoprotein is a multidrug transporter that can be used by cancer cells to pump

cytotoxic chemotherapy out of the cell.

Oncology
Leukamoid reaction = neutrophils with Dohle bodies - basophilic peripheral granules

(ribosomes attached to ER).
Neutrophils may also have toxic granulation and cytoplasmic vacuoles.

Oncology
IV dextrose inhibits PPAR-gamma, a transcription factor that induces synthesis of ALA

synthase -- > improvement in symptoms.
QId: 957 Microbiology - Hematology &

Oncology
M. pneumoniae binds to respiratory epithelium by binding through an oligosaccharide

(I-antigen) also found on RBCs -- > cross-reactive, cold, IgM antibodies -- > attachment
to RBCs, complement system activation -- > intravascular hemolysis.
Oncology
Oropharyngeal tumors due to HPV are more likely to occur in younger individuals, present
at an earlier stage, lack mutations to p53 and over-express the tumor suppressor gene p16
(aids diagnosis).

Oncology
Acute phase chemotherapy-induced vomiting - due to release of serotonin from intestinal

cells -- > give 5HT3 antagonists
Delayed phase - due to substance P stimulation -- > neurokinin-1 receptor activation -- >
give NK1 receptor antagonists
Malignancy-related anorexia - treat with progesterone analogs, corticosteroids or

cannabinoids.
Malignancy-related hypercalcemia - treat with bisphosphonates
Opioid-induced constipation - treat with methylnaltrexone (decreased ability to cross BBB

-- > no withdrawal)

Oncology
Akt - serine/threonine-specific protein kinase (protein kinase B); seen in receptor tyrosine
kinase signal transduction.
PTEN - phosphatase and tensin homolog; removes phosphate group from PIP3.
QId: 1101 Microbiology - Infectious Diseases
Protective antigen of B. anthracis binds to the receptor on macrophages -- > formation of

channel -- > delivery of lethal and edema factor into the cell.
Lethal factor - zinc metalloproteinase, inhibits MAP kinase signal transduction -- > cell
death.
Edema factor - calmodulin-dependent adenylate cyclase, increases cAMP concentration --
> fluid accumulation within and between cells, suppression of neutrophil and macrophage
function.
Perinatal transmission is most commonly during delivery; transplacental transmission can

also occur.
Children generally immunotolerant - no symptoms nor elevated liver enzymes.
HbeAg levels in mother determines the chances of transmission (viral load), almost all
infants affected.
Can progress to chronic disease (90% without treatment).
Immediate HBV vaccination and immunoglobulin after birth might prevent progression to
chronic disease.
QId: 112 Immunology - Infectious Diseases
Candida - defense by T-lymphocytes and neutrophils; defective lymphocytes = localized

infection; defective neutrophils = disseminated infection
Chagas cardiomyopathy is caused by chronic, low-grade, parasite-mediated myocarditis --

> destruction of cardiac fibres -- > fibrosis -- > dilated cardiomyopathy with apical
atrophy.
Complications - arrhythmias, ventricular aneurysm with intracardiac thrombus,

biventricular heart failure
QId: 14921 Pathology - Infectious Diseases
Positive APRs - fibrinogen, CRP, ferritin, hepcidin, ceruloplasmin, haptoglobin, von

Willebrand factor and complement.
ESR indirect measure of positive APRs
Negative APRs - albumin, transferrin and transthyretin (prealbumin)
Mefloquine destroyes extrahepatic schizonts but is not useful for hepatic schizonts as it
gets inactivated in the liver.
People taking chemoprophylaxis should continue taking mefloquine for 4 weeks upon
returning from the endemic region to ensure that the parasites released from the liver are
destroyed when they infect the RBCs.
Diphtheria vaccination -- > neutralizing IgG against the binding component (B subunit) of
the diphtheria exotoxin.
Shigella invades M cells, lyses its containment vacuole and enters the cytosolic
compartment -- > induces apoptosis and spreads to adjacent cells via protrusions created
through host-cell actin polymerization -- > robust immune response (mainly neutrophils).
QId: 739 Immunology - Infectious Diseases
Too much IgA can cause disseminated infection of Neisseria species as it does not fix
complement and does not allow complement-fixing antibodies (IgM and IgG) to attach and
cause lysis.
E. histolytica - contact dependent cytotoxicity: amebic lectin binds the host cell, introduces
an amebic porin into the host cell membrane and causes cell lysis.
Vesicular lesion on hard palate and gums = HSV 1

On buccal mucosa (along with palms and soles) = Coxsackie
Disseminated gonococcal infection - triad of polyarthralgia, tenosynovitis and

dermatitis/purulent arthritis.
Chemotherapy-induced neutropenia -- > invasion of commensal organisms -- > infection

(neutropenic fever; no other signs).
QId: 483 Histology - Infectious Diseases

HPV can infect the true vocal cords as it is covered by stratified squamous epithelium
(required for constant repair of surface cells by basal cells coz they undergo constant
friction and abrasion).
Disseminated gonorrheal infection - triad of arthritis, dermatitis and tenosynovitis.
Gonococcal LOS is similar in structure to the human cell membrane glycosphingolipids.
S. typhi is able to evade destruction via macrophage mediated oxidative burst due to a
specialized capsular antigen Vi -- > replicates in macrophages, lymphatic and
reticuloendothelial system -- > symptoms.
Ulceration of Peyer patches -- > GI bleeding -- > perforation.
Neurologic manifestations of measles:

Encephalitis - within days
Acute disseminated encephalomyelitis - within weeks
Subacute sclerosing panencephalitis - within years.
V. vulnificus can cause food-poisoning when ingested through contaminated sea food.
It can also cause wound infections, particularly in patients with liver disease or iron
overload as iron acts as a catalyst -- > exponential growth.
Wound infection - rapidly progressive necrotizing fasciitis with hemorrhagic, bullous

lesions and septic shock.
Treatment - urgent antibiotics, surgery and BP support.

Tenofovir mainly secreted by PCT -- > toxicity leads to PCT dysfunction through
mitochondrial dysfunction -- > cell damage.
Histo - loss of brush border in PCT, GBM denudation, eosinophilic intracytoplasmic
inclusions (giant mitochondria).
HIV-induced nephropathy - FSGS and interstitial inflammation
Hypertensive glomerulosclerosis - vascular thickening, glomerulosclerosis and renal

interstitial fibrosis.
QId: 11658 Anatomy - Male Reproductive

System
Right gonadal artery - in front of IVC adn behind ileum

Left gonadal artery - behind the left colic and sigmoid arteries and iliac colon.
Cross anteriorly over the ureter and run parallel to external iliac vessels and eventually
traverse the inguinal canal to supply the testes via the spermatic cord.
Internal iliac supplies pelvic wall/viscera, buttock, female reproductive organs, bladder and
medial thigh.
Internal pudendal supplies anal canal, scrotum and penis.
Obturator artery supplies pelvis, bladder and parts of femoral head and medial thigh
muscles
QId: 11532 Behavioral science - Miscellaneous

(Multisystem)
Physician burnout - emotional exhaustion, cynicism, depersonalization, decreased sense of

personal accomplishment -- > suboptimal patient care and medical error. Physician usually
shows lack of concern or callousness toward patients (rather than forgetfulness).
QId: 908 Pathology - Nervous System
HSV 1 travels through olfactory tracts -- > olfactory lobe i.e. medial temporal lobe; hence,
the predilection for temporal lobe encephalitis.
Hemorrhagic inflammation -- > elevated erythrocytes in CSF (unlike other meningitis
findings).
QId: 1399 Microbiology - Nervous System
Nerve conduction velocity is NORMAL in botulinum toxin poisoning.
PNS axon injury - Schwann cells degrade the injured myeline and secrete chemokines to
recruit macrophages to clear debris. Also secretes trophic factors -- > effective clearance
of debris and regeneration of axon.
CNS injury - slow recruitment of microglia due to blood-brain barrier and

oligodendrocytes undergo apoptosis -- > defective clearance -- > persitent debris for
months together.
Astrocytes form glial scar -- > barrier for regeneration.
N. meningitidis enetration into CNS is through cerebral capillary endothelial surface and
choroid plexus.
QId: 1361 Physiology - Nervous System
M3 receptors is present on the endothelial surface of peripheral blood vessels; stimulation

-- > release and synthesis of NO -- > smooth muscle relaxation -- > vasodilation
Elsewhere, it activates Gq receptors -- > Ca2+ release -- > smooth muscle contraction
(eg: intestine, detrusor muscle in the bladder, pupillary constriction, exocrine gland
secretion, etc).
Parkinson disease - Lewy bodies (a synuclein)

Lewy body dementia - intracellular Lewy bodies
Huntington disease - aggregates of huntingtin protein
Alzheimer disease - ß amyloid core (senile plaques) and hyperphosphorylated tau protein
(neurofibrillary tangles)
Frontotemporl demetia - hyperphosphorylated tau (Pick bodies) or ubiquitinated TDP-43
QId: 1687 Anatomy - Nervous System

Spasticity - initial flexion -- > extensor muscle activation due to disinhibition of the stretch
reflex; overcome with continued flexion.
NE (locus ceruleus) - posterior rostral pons near the floor of the fourth ventricle
Dopamine (ventral tegmentum and ScN) - midbrain
Dynorphine (opioid) - periaqueductal gray, rostral ventral medulla and dorsal horn of spinal
cord.
QId: 146 Pharmacology - Nervous System
Ca channel blockers in SAH provides protective effects through cerebral vasodilation and
possibly decreased calcium-dependent excitotoxicity.
The action of an anesthetic depends on the peripheral tissue uptake.
If an anesthetic has a very large arteriovenous concentration gradient (wrt peripheral

tissues and NOT the brain), more anesthetic agent is needed to saturate the blood to reach
the brain -- > slow onset of action.
Optic gliomas = immature astrocytes with microcystic degeneration and Rosenthal fibers
Migraine - due to activation of trigeminal afferents -- > release of vasoactive neuropeptides

(substance P and calcitonin gene-related peptide/CGRP) -- > vasodilation and plasma
protein extravasation -- > neurogenic inflammation.
Neuronal sensitization also occurs causing the central nociceptive pathways to become
more sensitive to painful and non-painful stimuli.
Triptans -- > 5-HT1B (on blood vessels) and 5-HT1D (on nerve terminal) -- > inhibit
release of vasoactive peptides, promote vasoconstriction and block pain pathways.
C. neoformans in the brain clogs the arachnoid villi with yeast antigens and capsular
proteins through replication -- > obstructed CSF outflow -- > elevated ICP -- > headache,
nausea, vomiting, neck rigidity, papilledema, etc.
QId: 11793 Pathophysiology - Nervous System
Long-standing rheumatoid arthritis -- > involvement of cervical spine -- > joint destruction
with vertebral malalignment (subluxation).
Atlantoaxial joint - most often involved as the atlas (C1) has a high degree of mobility
relative to the axis (C2).
Demyelinating neuropathies - DELAYED nerve conduction velocity

Axonal neuropathies - REDUCED signal amplitude
Myasthenia gravis - muscle stimulation studies -- > decreased motor signal strength with
repetitive stimuli
Botulinum toxin - muscle stimulation studies -- > decreased motor signal strength that
increases with repetitive stimuli.
Diabetic neuropathy - length-dependent axonopathy (long fibers affected first; eg: feet)
Small-fiber injury - positive symptoms (eg: paresthesias, pain, etc).
Large-fiber involvement - negative symptoms (eg: loss of proprioception, diminished
reflexes, etc).
Lacunar midbrain strokes -- > CN III involvement because of densely packed fibers.
Contralateral superior rectus affected as the subnucleus fibers decussate at this point.
Bilateral ptosis - levator palpebrae involvement (both innervated by a single subnucleus).

UMN lesions - weakness more pronounced in upper extremity extensors and lower
extremity flexors; also, upper extremity supination is weaker than pronation -- > pronator
drift.
Mutated or absent matrix protein (required for viral assembly) prevents mature virion
particles from forming. The virus continues to replicate intracellularly, evading immune
response -- > accumulation of viral nucleocapsids within neurons and oligodendrocytes --
> intranuclear inclusions -- > inflammation, demyelination and gliosis in many cerebral
areas.
Parotid gland - CN IX
Submandibular and sublingual nerve - CN VII
Anterior 2/3 of posterior limb of internal capsule = motor fibers (corticospinal tract).
Posterior 1/3 = sensory fibers
Involvement usually causes pure motor stroke or sensory motor stroke.
PAS-positive intracytoplasmic vacuoles are found in conditions involving ion-channel

myopathies
Xanthoastrocytoma - astrocytoma in children and young adults; can progress to GBM; has
reticulin deposits and chronic inflammatory infiltrates.
Colloid cyst - benign tumor located in the third ventricle; cyst formation and rare mitoses;
can lead to lethal obstructive hydrocephalus.

Phenytoin -- > increased expression of PDGF -- > stimulation of gingival macrophages --
> proliferation of alveolar bone and gingival cells.
Effects on cerebellum and vestibular system -- > ataxia and nystagmus.
QId: 1318 Physiology - Nervous System
Spatial summation - multiple neurons stimulate a post-synaptic neuron -- > action potential
Temporal summation - a single neuron sends multiple sequential stimuli -- > action potential
Myelination of neuron -- > decreases membrane capacitance (amount of charge stored by

the membrane) and increases membrane resistance (reduces charge leakage through the
membrane) -- > increased length constant and decreased time constant.
Demyelination reverses these processes.
Multiple sclerosis histo - plaques characterized by perivenular inflammatory infiltrates

made up primarily of autoreactive T lymphocytes and macrophages against myelin
components -- > disruption of BBB -- > infiltrating macrophages containing myelin debris
and recruitment of B cells to perivascular spaces -- > myelin-specific antibodies.
Chemotherapy agents -- > intestine epithelial destruction -- > stimulation of 5-HT3

receptors -- > vagal afferent stimulation reaching area postrema in medulla -- > vomiting.
Directly stimulate area postrema by causing local release of substance P, activates NK1
receptors -- > vomiting.
Focal onset seizures - CBZ, lamotrigine, levetiracetam, phenytoin (Phenytoin and CBZ can
also be used in seizures with secondary generalization).
Generalized onset seizures - levetiracetam, valproate; absence - ethosuxamide and
valproate.
High-frequency stimulation of the ventral intermediate nucleus of the thalamus may reduce
thalamic excitation and lessen excessive movements in patients with medically intractable
essential tremor.
Rubrospinal tract = upper limb flexor predominance

Vestibulospinal tract = extensor predominance
Cortical inhibition to red nucleus but not as much to vestibular nucleus.
QId: 11949 Pathology - Poisoning & Environmental

Exposure
Lead was eliminated from gasoline in 1985 and from paint in 1977.
Houses built before 1978 predisposes to lead poisoning
QId: 791 Pathophysiology - Pregnancy, Childbirth &

Puerperium
Sarcoma botryoides is a rhabdomyosarcoma in young girls; jellylike cystic appearance and

arises from the bladder or vaginal mucosa.
QId: 11838 Behavioral science - Psychiatric/Behavioral & Substance

Abuse
Benzodiazepines are avoided in patients with a history of substance abuse.
QId: 11577 Pharmacology - Psychiatric/Behavioral & Substance

Abuse
Naltrexone is the first line of treatment for alcohol use disorder; inhibits rewarding and
reinforcing effects of alcohol; long acting depot injection for nonadherent individuals.
Acamprosate - NMDA receptor modulation
Disulfiram - second-line as the effectiveness depends on supervised administration.

Abuse
Psychodynamic psychotherapy - developing insight into unresolved conflicts and the
influence of past relationships on current life situations. ("Dynamic" Jake in Brooklyn 99).
Supportive psychotherapy is bolstering adaptive psychological defenses to help individuals

cope with acute crises or chronic psychiatric illness.

Abuse
Metyrosine blocks the rate-limiting step of catecholamine synthesis (tyrosine hydroxylase)

-- > sympatholytic effects
Reserpine blocks monoamine entry into presynaptic vesicles -- > sympatholytic effects.

Abuse
REM sleep behavior disorder - loss of normal REM sleep atonia -- > enactment of dreams

Abuse
Erectile dysfunction - psychological, diabetes or disorders affecting nerve function.

Premature ejaculation - prostatitis, thyroid disorders

Abuse
Orbitofrontal cortex - associated with limbic system -- > behavioral and emotional changes
(bilateralinvolvement)
Prefrontal cortex - dysexecutive syndrome characterized by inability to carry out
motivation, organization, planning and purposeful action.

Abuse
Long term activation of mu-opioid receptors on nociception-transmitting neurons -- >
increased pain sensitivity due to:
Increased turnover of inhibitory receptors (downregulation) and decoupling of receptors

from their second messenger system (receptor decoupling)
Upregulation of excitatory N-methyl-D-aspartate receptors
Opioid-induced hyperalgesia

Abuse
Delirium due to an underlying medical cause which causes the patient to be a harm to self
or others can be treated with haloperidol (NOT benzodiazepines) till the underlying
disorder gets corrected.
QId: 962 Microbiology - Pulmonary & Critical

Care
Capsulated H. influenza binds to H factor, a circulating regulator protein in humans which

normally prevents complement deposition on human cells -- > defective opsonization -- >
evades phagocytosis
QId: 7661 Physiology - Pulmonary & Critical

Care
Patients weaning off of ventilator = weak respiratory muscles -- > hypoventilation -- >
triggered respiratory center -- > tachypnea.
Tachypnea with constant minute ventilation -- > low tidal volumes.
Low tidal volumes -- > increased fraction of dead space ventilation.
QId: 1876 Pathology - Pulmonary & Critical

Care
In fat embolism, some fat globules escape the lungs via precapillary arteriovenous shunts
that open due to increased pulmonary artery pressure (obstruction from embolus) -- >
emboli through pulmonary veins -- > systemic circulation -- > CNS symptoms and also in
dermal capillaries -- > petechial rash due to RBC extravasation.
QId: 8260 Pathophysiology - Pulmonary & Critical
Care
Elastic resistance - increases at high lung volumes and decreases with respiratory rate -- >
rapid, shallow breathing in restrictive diseases
Airflow resistance - increases at high respiratory rate (turbulence) and decreases at high
lung volumes (diameter) -- > increased at low lung volumes (decreased airway diameter)
-- > slow, deep breathing in obstructive diseases

Care
Reduction in expiratory reserve volume is the most common indicator of obesity-related

disease.

Care
Hemosiderin-laden macrophages -- > CHRONIC lung congestion.

Acute pulmonary edema - engorged capillaries and alveoli with acellular pink material.

Care
Fimbriae in H. influenza help in attachment to endothelial cells during colonization of

respiratory tract but are NOT a major virulence factor.
a-hemolysin - S. aureus destroys cell membrane of RBC and WBC.
Hyaluronidase - S. aureus, S. pyogenes, C. perfringens digest ECM and enhance their
ability to spread.

Care
CD4+ - asthma
CD8+ - COPD
QId: 1249 Biochemistry - Pulmonary & Critical

Care
Elastic property of elastin due to:
Cross-linking by desmosine cross-links (lysyl oxidase oxidatively deaminates lysine
residues)
High content of non-polar amino acids (glycine, alanine, valine)

Care
Anti-proteinases - a-1 antitrypsin, a-2 macroglobulin, tissue inhibitors of MMPs (TIMPs)
Neutrophil elastase inhibited by a1 antitrypsin; macrophage elastase inhibited by TIMPs.

Each elastase can degrade each other's inhibitor -- > deletarious effects when present
together

Care
M. tuberculosis are arranged in long, slender, serpentine cords due to the presence of a
hydrophobic surface glycolipid called cord factor.
Cord factor = 2 mycolic acid molecules + disaccharide trehalose -- > bound form -- >
trehalose dimycolate.
Cord factor -- > cylindrical micelles around the organism -- > prevent
macrophage-mediated destruction within phagolysosome -- > VIRULENCE.
Also forms a highly toxic crystalline monolayer on hydrophobic surface -- > caseating
granulomas.

Care
Influenza virus attacks the tracheobronchial epithelium and results in decreased cell size
and loss of cilia -- > secondary bacterial colonization and infection.
QId: 15126 Pharmacology - Pulmonary & Critical

Care
Pirfenidone - inhibits TGF-ß

Nintedanib - tyrosine kinase inhibitor of PDGF, FGF, VEGF
Reslizumab - IL-5 inhibitor
Roflumilast - PDE-4 inhibitors (COPD)
Care
IPF - loss of type 1 pneumocytes and hyperplasia of type 2 pneumocytes.

ARDS - loss of type 1 and 2 pneumocytes with fibroblast proliferation in later stages
QId: 1194 Pharmacology - Pulmonary & Critical

Care
Enoxaparin (4-5 hrs) preferred during pregnancy due to longer half-life and lesser need for
monitoring
Unfractionated heparin (half-life 1-2 hrs) used during labor due to immediate
discontinuation of anticoagulation and prevention of bleeding risks.
Dabigtran and Apixaban - fetal abnormalities in animal studies

Care
Pulmonary hamartoma (most common location for a hamartoma) - also called pulmonary
chondroma.
Made up of hyaline cartilage, fat, smooth muscle and clefts lined by respiratory epithelium

Care
Viral infections are more common triggers than bacterial infection for COPD exacerbation.
Green sputum during the exacerbation is caused by release of myeloperoxidase from

neutrophils and can be present in either viral or bacterial infection.

Care
Hyponatremia in Legionella - possibly due to SIADH, impaired reabsorption from proximal

tubule due to direct effect, cytokines or natriuretic peptide.

Care
Restrictive lung diseases divided into intrinsic and extrinsic causes.
Intrinsic has reduced DLCO.; eg: interstitial lung disease
Extrinsic has normal DLCO; eg: obesity, neuromuscular disease, etc.
QId: 844 Anatomy - Pulmonary & Critical Care
Intercostal vessels and nerve lie along the subcostal groove.

Thoracentesis should be performed just above the upper border of the rib to prevent injury.

Care
Pulmonary alveolar proteinosis - associated with cigarette smoking, lipoproteinacious

material within the alveoli.

Care
Occupational asthma - immunolgic and non-immunologic causes

Immunologic - IgE mediated; eg: formaldehyde, amines, dyes.
Non-immunologic- large exposure of irritant -- > denudation of airway mucosa -- >
persistent inflammation, loss of epithelial relaxation factors and mast cell degranulation; eg:
chlorine and ammonia
QId: 481 Physiology - Pulmonary & Critical

Care
Resistance inversely proportional to cross-sectional area.
Trachea - small cross-sectional area -- > high resistance

Medium-sized bronchi - smaller cross-sectional area -- > higher resistance
Terminal bronchioles - large cross-sectional area -- > low resistance
Alveoli - massive cross-sectional area -- > essentially zero!
QId: 978 Pathophysiology - Renal, Urinary Systems &

Electrolytes
PTHrP closely resembles PTH at the bioactive amino-terminal region -- > increased bone
resorption, decreased renal excretion and increase renal excretion of phosphorus.
PTHrP does NOT significantly increase 1,25-dihydroxyvitamin D production due to

structural differences after the first 13 amino acids.
Malignancy-associated hypercalcemia due to humoral hypercalcemia of malignancy is

more common (80%) than due to osteolytic lesions.
QId: 15239 Pathophysiology - Renal, Urinary Systems &

Electrolytes
Hyperfiltration - Hyperglycemia -- > increased glucose reabsorption along with increased

sodium reabsorption -- > decreased sodium delivery to macula densa -- > tubuloglomerular
feedback mechanism activated -- > increased GFR -- > glomerular hypertrophy.
Incipient DN - Over time, there is mesangial expansion, glomerular basement membrane

thickening, arteriolar hyalinosis, podocyte expansion -- > microalbuminuria.
Overt DN - mesangial nodules, tubulointerstitial fibrosis, overt proteinuria and decreased

GFR.
QId: 15250 Pathology - Renal, Urinary Systems &

Electrolytes
Atheroembolic disease is due to cholesterol dislodging from large vessels, usually post an
invasive vascular procedure (eg: coronary angiography, aortic surgery).
Commonly involved organs - kidney, skin (blue toe, livedo reticularis), GI tract (bleeding,
infarction) and CNS (stroke, amaurosis fugax). Pulmonary circulation RARELY involved.

Electrolytes
Higher calcium intake -- > paradoxical decrease in urinary calcium. Calcium in the gut
binds with oxalate -- > excreted in feces -- > less available to get absorbed and excreted in
urine.
Potassium is reabsorbed with citrate in the renal tubules. Higher potassium intake -- >
lesser reabsorption -- > more citrate in urine -- > lesser stones.
QId: 2010 Physiology - Renal, Urinary Systems &
Electrolytes
Serum concentration at which glucose appears in urine = 200 mg/dL
Serum concentration at which the transporters in the renal tubules are saturated = 375mg/
dL

Electrolytes
100% K+ filtered through Bowman's space.

2/3rd of that reabsorbed in PCT
25-30% of left over absorbed in TAL of Henle
Absorption in PCT and loop of Henle takes place irrespective of serum K+ level.
Main regulation takes place at collecting duct.

Electrolytes
Renal stenosis -- > activation of RAAS -- > improved GFR and filtration fraction but still
NOT enough to normalize.
Unaffected kidney (in unilateral stenosis) is exposed to elevated systemic pressures -- >
pressure natriuresis.

Electrolytes
Urea is filtered through the glomerulus, passively reabsorbed in PCT and inner medullary
collecting ducts and passively secreted by the thin regions of the loop of Henle.
Remainder of the nephron is impermeable to urea.
10-70% of filtered urea load is excreted depending on the urinary flow rate and
concentration.
Urea clearance < GFR
QId: 11786 Immunology - Renal, Urinary Systems &

Electrolytes
Most other cells have an alternative pathway for purine synthesis that lymphocytes lack
(mainly dependent on IMP) -- > mycophenolate is relatively specific for suppression of B
and T cells.
QId: 11945 Pharmacology - Renal, Urinary Systems &

Electrolytes
EPO -- > increases risk of thrombosis, stroke and BP (possibly due to direct activation of
endothelial and smooth muscle cells through EPO receptors).
QId: 1680 Anatomy - Renal, Urinary Systems &

Electrolytes
Proximal ureter - supplied by renal artery

Distal ureter - superior vesical artery
Middle ureter - variable; branches from gonadal, common and internal iliac, aorta and
uterine arteries.

Electrolytes
Uremia -- > poor peripheral conversion of T4 to T3 -- > functional hypothyroidism
QId: 1211 Pharmacology - Renal, Urinary Systems &

Electrolytes
Anaestheisa and analgesia -- > over-distension of the bladder, a decreased micturition

reflex, decreased contractility of the bladder detrusor muscle and incomplete emptying --
> retention.
QId: 721 Pathology - Rheumatology/Orthopedics &

Sports
Osteomyelitis common in children; seen in the metaphysis of long bones as it has

slow-flowing, sinusoidal vasculature that is conducive to microbial passage.
Adults are not as susceptible due to anatomical changes owing to fusion of the epiphysis.
Osteomyelitis of the vertebrae through hematogenous spread is seen in adults.
QId: 8671 Anatomy - Rheumatology/Orthopedics &
Sports
Femoral nerve injured due to retroperitoneal hematoma or abscess as it passes laterally

between psoas and iliacus muscle; also, during surgery/childbirth, trauma (pelvic fracture).
Obturator nerve - pelvic surgery
Peroneal nerve - compression of the nerve at proximal fibula (eg: leg casting).
Tibial nerve - knee trauma and tarsal tunnel syndrome.
Superior gluteal nerve - injection at wrong site

Sports
Inflammation -- > antibodies against citrullination -- > synovial hyperplasia through

activated T-cell recruitment of mononuclear cells -- > relative hypoxia -- > production of
hypoxia-inducible factor 1 and VEGF by local macrophages and fibroblasts -- > synovial
angiogenesis.
Over time, granulation tissue, synovial cells and inflammatory cells all form a pannus,
which erodes the cartilage and the subchondral bone.
Ossification of the pannus can also occur -- > ankylosis.

Sports
Atlantoaxial subluxation is common in inflammatory disorders like rheumatoid arthritis,

ankylosing spondylitis, psoriatic arthritis, etc.
QId: 639 Physiology - Rheumatology/Orthopedics &

Sports
IGF - decreases collagen degradation by inhibiting MMP-13

TGF-ß - increases collagen synthesis and decreases bone resorption.
QId: 1382 Physiology - Rheumatology/Orthopedics &

Sports
Resting membrane potential = mainly efflux of K+ ions (-80 mV) and little influx of Na+
ions (+60 mV) -- > RMP of -70 mV
QId: 11749 Pharmacology - Rheumatology/Orthopedics &

Sports
Azathioprine and 6-MP are degraded into inactive metabolites by xanthine oxidase and
thiopurine methyltransferase.
QId: 295 Pathophysiology - Rheumatology/Orthopedics &

Sports
Atrophy at cellular level - decreased mitochondria and ER.

Sports
Sclerostin is a glycoprotein produced by osteoclasts.

It inhibits osteoblast bone formation.
Romosozumab binds sclerostin -- > increased osteoblast activity.
QId: 11770 Pathophysiology - Rheumatology/Orthopedics &

Sports
B-cell activating factor (BAFF) - TNF ligand family; inadequate levels -- >
immunodeficiency; high levels -- > autoimmune diseases like SLE.

Sports
Monoclonal antibody - mab

Receptor molecule - cept
Kinase inhibitor - nib
QId: 10464 Behavioral science - Social Sciences

(Ethics/Legal/Professional)
Patient-physician relationship, if already terminated --> personal relationship.
Do NOT terminate a physician-patient relationship for the sole purpose of dating.
Dating is unethical in psychiatric patients even after termination due to the nature of
evaluation.
QId: 1128 Behavioral science - Social Sciences

(Ethics/Legal/Professional)
Vegetative state - state of wakefulness without awareness

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QId: 540 Immunology - Allergy & Immunology

Activation of complement by IgM prior to antigen binding is prevented because of the

QId: 8539 Immunology - Allergy & Immunology

C3a, C4a, C5a - anaphylotoxins

QId: 10570 Biostatistics - Biostatistics &

QId: 154 Pharmacology - Cardiovascular System

Ca channel blockers -- > precapillary arteriolar dilation -- > edema.

QId: 2023 Anatomy - Cardiovascular System

3 main groups of venous circulation in embryo:

QId: 475 Pathology - Cardiovascular System

QId: 711 Pharmacology - Cardiovascular System

QId: 161 Pharmacology - Cardiovascular System

QId: 181 Pathology - Cardiovascular System

QId: 2105 Pathophysiology - Cardiovascular

QId: 713 Pharmacology - Cardiovascular System

QId: 900 Pharmacology - Cardiovascular System

QId: 14780 Pharmacology - Cardiovascular

QId: 15196 Pathology - Cardiovascular System

Ischemic heart disease/obstructive coronary disease -- > dilated cardiomyopathy because

QId: 33 Pathophysiology - Cardiovascular

QId: 85 Pathophysiology - Cardiovascular

Increased afterload decreases murmur in AS and HCM.

QId: 43 Pathology - Cardiovascular System

Ischemic preconditioning - brief repetitive episodes of myocardial ischemia with

QId: 13600 Genetics - Cardiovascular System

Arrhythmogenic right ventricular cardiomyopathy - fibrosis and scarring of RV -- >

QId: 7640 Pharmacology - Cardiovascular

Torsades de pointes can be differentiated from other polymorphic tachycardia because it is

QId: 2075 Pathology - Cardiovascular System

Infective endocarditis pathogenesis - disruption of normal endocardial surface -- > focal

QId: 244 Pathophysiology - Cardiovascular

QId: 1516 Physiology - Cardiovascular System

QId: 293 Pathophysiology - Cardiovascular

Reperfusion injury due to:

QId: 464 Pathology - Cardiovascular System

QId: 14964 Pathology - Cardiovascular System

QId: 467 Pathology - Dermatology

QId: 15431 Microbiology - Dermatology

QId: 1108 Pathology - Dermatology

Plane xanthomas - PBC

Xanthomas - foamy macrophages; enclosed by inflammatory cells and fibrotic stroma

QId: 1110 Pathology - Dermatology

Vitiligo - autoimmune activity, neurohumoral toxicity, self-destruction via toxic

QId: 15379 Pathophysiology - Dermatology

Bacterial metabolism of apocrine secretions -- > body odor due to sweat.

QId: 7585 Pharmacology - Dermatology

Dihydrotestosterone -- > follicular epidermal proliferation and excessive sebum production

Lithium and EGFR inhibitors also cause acne.

Seborrheic keratoses in malignancy -- > tumor production of cytokines or growth factors

QId: 936 Pathology - Dermatology

Acanthosis nigricans - benign and malignant

QId: 1114 Pathology - Dermatology

Urticaria - superficial dermal edema

QId: 1244 Biochemistry - Dermatology

Collagen - tensile strength

QId: 8904 Pathophysiology - Dermatology

Ephelides (freckles) are due to increased melanin production in melanocytes.

QId: 15695 Pathology - Dermatology

Erythema multiforme - circulating pathogens phagocytosed by peripheral mononuclear

QId: 13911 Microbiology - Dermatology

HIV patients/immunocompromised patients are unable to contain scabies infection due to

QId: 582 Pathophysiology - Endocrine, Diabetes &

QId: 8531 Pathology - Endocrine, Diabetes &