This is a list of medical mnemonics, side-notes, and generalizations I wrote down while going through my 2010 First Aid book while supplementing with 2012 Falcon, Kaplan, and a bit of Goljan. I stopped at around three-quarters of the text because I got tired and felt like not many people would be interested…(Update: sorry, but I’m too busy to go back and type the rest! ><).

P.S. If you want to find a topic fast, I suggest Ctrl+F

Behavioral Science:

Statistical distribution:

Positive skew = me A n>me D ian>m O de

n>me ian>m de Positive skew = alphabetical from greatest to least

Reportable diseases:

“It was reported that studly Mr. Shigella ate salmon, chicken, and liver”:

“It was REPORTED that STuDly MMR SHIGELLA aTB Salmon, Chicken, and Liver”

STDs: AIDs, Gonorrhea, Syphilis, Chlamydia (*NOT HIV!)

MMR: Measles, Mumps, Rubella

Shigella

TB

Salmonella

Chicken Pox

Hepatits A, B, C

Health care payment:

CARE for the Elderly, AID the destitute

Medicare - elderly, Medicaid - low income people

Early developmental milestones:

# of blocks stacked = age in years * 3

2 word sentences at 2

“pee at three”; tricycle at three

“four-square at four” = can hop at four

drawings: 3yo = circle 4yo = + 5yo = square 6yo = triangle See reference:



Biochemistry:

Stop codons: UGA, UAA, UAG

U Go Away, U Are Away, U Are Gone

EXpress EXons, INtrons are IN the way

Proto-oncogenes:

Mike’s sis returned with her two new breasts she was able to grow because of herbs.

“MYC’s SIS RETurned with HER2Neu breasts she RAS ABLe To-Grow BCl of hERBs.”

Myc

sis

ret

Her2/neu

ras

abl

TGFalpha

bcl2

ERB-B1, B2

Collagen: The higher the number, the smaller and softer it gets

Type 1 - bone (skin) - Osteogenesis Imperfecta (failed glycosylation and formation of procollagen triple helix with ER)

(skin) - Osteogenesis Imperfecta (failed glycosylation and formation of procollagen triple helix with ER) Type 2 - cartilage - death in utero

- death in utero Type 3 - blood vessels - Ehlers-Danlos (failure of cross-linking by lysyl oxidase to make collagen fibrils outside fibroblasts), berry aneurysms

- Ehlers-Danlos (failure of cross-linking by lysyl oxidase to make collagen fibrils outside fibroblasts), berry aneurysms Type 4: basement membrane - Alport’s nephritis (+ deafness and vision problems; “can’t see, can’t pee, can’t hear”)

Blotting procedures:

SNOW

DROP

S/D: Southern blot = DNA sample identified with DNA probe

N/R: Northern blot = RNA sample identified with DNA probe

O/O

W/P: Western blot = protein sample identified with antibody probe

Model systems:

Knock out = take a gene OUT

Knock in = INsert a gene

Knock down = knock down the expression of the gene via complementary mRNA antagonist

Imprinting:

Prader-Willi = Paternal deletion

AngelMan’s = Maternal deletion

Genetics:

Autosomal Dominant: have “familial” or “hereditary” in name +

“A Brainy Dwarf named Marfan von Hippel-Lindau hired MEN to Hunt for Potatoes.”

Brainy = Neurofibromatosis1, 2

Dwarf = Achondroplasia

Marfan

von Hippel-Lindau

MEN1, 2a, 2b

Huntingtons

Potato = Tuberous sclerosis

X-linked recessive:

“Duke Fabry’s Brutal Gopher Hunter, Lesch, Was-Actually a Fragile Albino Hemophiliac.”

Duke = Duchenne’s

Fabry

Brutal = Bruton’s

Gopher –> G6Pher = G6PD deficiency

Hunter = Hunter’s

Lesch-Nyhan

Was-Actually = Wiskott-Aldrich

Fragile X

ocular Albinism

Hemophilia A, B

Fragile X = Xtra large testes, jaws, ears

FraGile X = cGg trinucleotide repeat

myoTonic dystrophy = cTg trinucleotide repeat

Autosomal trisomies: Pat Ed Down = 13, 18, 21

Puberty at 13, Election at 18, Drinking at 21

Down syndrome is associated with ALL (and AML) and ALzheimers and decreased ALpha-fetoprotein –> “ALL fall DOWN”; also associated with:

Duodenal Atresia (failure to recanalize = blind duodenum –> bilious vomiting with first feed; “double-bubble”)

Celiac Disease (associated with dermatitis herpetiformis)

Annular Pancreas

Hirschprung congenital megacolon (failure of neural crest cell migration: no Auerbach or Meissner’s plexus –> constipation/meconium ileus)

Edward’s: watch 99 balloons

Patau’s: rocker bottom Pedals/feet, cleft lip/Palate, holoProsencephaly (sonic hedgehog deficiency), Polydactyly

William’s syndrome: Will Farrell in Elf: elfin faces, mental retardation, well-developed verbal skills, extreme friendliness

DiGeorge syndrome: CATCH-22

Cleft palate

Abnormal facies

Thymic aplasia (T-cell deficiency)

Cardiac defects

Hypocalcemia (secondary to parathyroid aplasia; remember third pharyngeal pouch: inferior parathyroids are grown with thymus and descend together)

microdeletion at chromosome 22q11

Vitamin B1: Thiamine

Thiamine pyrophosphate (TPP) is needed for a number of enzymes, but is rarely required alone. Whenever you need B1, you usually need FAD (B2), NAD (B3), CoA (B5), and Lipoic Acid, so just group them together: B1,2,3,5+LA.

Enzymes that use B1, 2, 3, 5 + LA:

Glycolysis/TCA: PDH (X = lactic acidosis; Tx: ketogenic Leucine, Lysine + high fat diet)

TCA: alphaKGDH

HMP: transketolase

branched chain AADH (X = Maple Syrup Urine Disease –> severe CNS defects, MR, and death)

Related problems:

Lipoic acid is antagonized by Arsenic, which causes rice water diarrhea and garlic breath.

B1 deficiency in alcoholics –> Wernicke-Korsakoff, beriberi

PDH deficiency/dysfunction –> inability to continue TCA –> diversion to lactic acidosis; brain starves for energy –> neurologic defects. To keep brain from starving, Tx with ketogenic amino acids LEUCINE and LYSINE and high fat diet (beta oxidation of fats will produce acetyl CoA –> TCA/ketogenesis).

Vitamin B6: Pyridoxine

Major pathways that use B6:

Glycogenolysis RLS: Glycogen –> G1P via glycogen phosphorylase Heme synthesis RLS: Succinyl CoA (TCA) + Glycine –> delta aminolevulinic acid (ALA) via deltaaminolevulinic acid synthase Cysteine synthesis: Homocysteine + Serine –> Cystathione via Cystathione synthase (X = homocysteinuria: Marfanoid Sx+MR+atherosclerosis)

Note: Cystinuria due to PCT reabsorption defect –> staghorn cystine kidney stones; Tx: acetazolamide to alkalinize urine ALT/AST transamination:

Alanine+alphaKG(TCA)<–ALT–>Pyruvate(glycolysis)+glutamate

Aspartate(Urea cycle)+alphaKG(TCA)<–AST–>OAA(TCA)+glutamate Amino acid production (hydroxylation, decarboxylation reactions): tyrosine –hydroxylation–> dopa –decarboxylation–> dopamine tryptophan to niacin/B3 (no B6 = no B3 = Pellagra) histidine to histamine glycine to porphyrin (in heme production; no B6 = hypochromic, microcytic anemia) glutamate to GABA (no B6 = loss of GABA = increased excitation –> convulsions/seizures)

Vitamin B12: Cobalamin

Cofactor when you see “Meth” in product or substrate:

METHylmalonylCoA –> Succinyl CoA via methylmalonylCoA isomerase homocysteine + N-METHylTHF –> METHionine + THF via homocysteine methyltransferase

Absorbed in the ileum (Crohn’s, gastric bypass, sprue, Diphyllobothrium latum) with IF (pernicious anemia); use Schilling test to determine if it’s intake/absorption or lack of IF problem. B12 stores last for YEARS. Deficiency causes an increase in methylmalonic acid (peripheral neuropathy) and homocysteine (megaloblastic anemia).

Other causes of megaloblastic anemia = folate deficiency (incr. homocysteine but not methylmalonic acid, so no neuropathy) and chronic alcoholism.

Vitamin B7: Biotin

While Vitamin B6 is needed for DEcarboxylation reactions (amino acid production), B7 is needed for CARBOXylation reactions:

PropionylCoA(oddchainFA/branchedchainAA metab)–>MethylmalonylCoA via proprionylCoA carboxylase (which goes on to form succinyl CoA of TCA with methylmalonylCoA isomerase and B12) Pyruvate(glycolysis)–>OAA (TCA) via pyruvate carboxylase AcetylCoA(TCA)–>MalonylCoA(FA synthesis RLS)

Avidin in egg-whites Avidly binds B7.

Vitamin C: Ascorbic Acid

Iron absorption and Fe2+ state maintenance Collagen synthesis: hydroxylation of proline and lysine within fibroblast ER <–SCURVY dopamine –> NE via dopamine beta hydroxylase, blocked by Reserpine

Vitamin D: the longest name with a 1: (1,25-(OH)2D3) Calcitriol = active form (PTH stimulates conversion of liver’s 25OHvitamin D to 1,25-(OH)2D3 in kidney by 1alpha hydroxylase)

Vitamin E: E is for Erythrocytes; it’s an antioxidant that prevents hemolytic anemia and neurodysfunction

Vitamin K: inject newborns with it to make sure they’re oK (prevent hemorrhage); deficiency = normal bleeding time, but increased PT and aPTT

Note:

platelet dysfunction –> BT

extrinsic (shorter) pathway –> PT (shorter name); VII; monitor w/ Warfarin

intrinsic (longer) pathway –> PTT (longer name); monitor w/ Heparin

Carbamoyl phosphate synthetase: "UP 1, 2.“

U rea cycle RLS: CPS 1

rea cycle RLS: CPS Pyrimidine synthesis RLS: CPS2

HMGCoA ___:

"You always want to REDUCE your CHOLESTEROL”: HMGCoA reductase = RLS for cholesterol synthesis

vs. HMGCoA synthase = ketogenesis (your brain wants to SYNTHESIZE KETONES when there’s no glucose)

Regulation by F2,6BP: "2 supports 1:“

PFK2 supports PFK1 –> glycolysis

F26BP supports F16BP –> glycolysis

MOA: insulin –> decreases cAMP –> decreases PKA –> dephosphorylated FBPase2 = PFK2 –> F6P to F26BP –> stimulates PFK1 –> incr F6P to F16BP (glycolysis)

Note: glucose –> decreases cAMP –> decreases CAP-cAMP binding of lac operon = RNA polymerase can’t bind to promoter

Glycolytic enzyme deficiency: RBCs solely depend on glycolysis for energy so no Pyruvate Kinase/Phosphoglycerate Kinase (ATP generating steps) = decreased ATP –> can’t maintain membrane gradient –> cell swells –> hemolytic anemia

HMP shunt/Pentose Phosphate Pathway:

G6P –> Ribulose5P + 2NADPH via RLS G6PDH

Ribulose5P –> Ribose5P –> purine synthesis

NADPH:

fatty acid and steroid synthesis oxidative burst (NADPH oxidase; X = Chronic Granulomatous Disease) p450 glutathione reductase AKA RBC antioxidation

G6PD deficiency = (x-r) –> no NADPH = no glutathione reductase = oxidative damage = hemolytic anemia (bite cells - RBCs partially eaten by macrophages (M0’s), Heinz bodies - oxidized Hb that precipitated in RBCs)

Drugs that cause hemolytic anemia in G6PD deficiency:

"Prima had to take Aspirin when she INHaled her I.B.Professor Dapsone’s Sulfurous Fava bean NitroFarts.”

Prima = Primaquine

Aspirin

INH (Isoniazid)

I.B.Professor = Ibuprofen

Dapsone

Sulfurous = Sulfonamides

Fava bean

NitroFarts = Nitrofurantoin

CGD (chronic granulomatous disease, Dx: negative Nitroblue tetrazolium reduction) = NADPH oxidase deficiency –> susceptible to Catalase+ organisms:

“The recoiling Red Asp wasn’t Sorry towards the moaning Cat because it had Noheart.”

recoiling = E.coli

red = Serratia

Asp = Aspergillus

Sorry = S. Aureus

moaning = Pseudomonas

Cat = Catalase + organism

NoHeart = Nocardia

Disorders of __ metabolism:

“__-kinase” is the enzyme that immediately follows the breakdown of __:

Glucose –> G6P via Gluco(Hexo)kinase

Fructose –> F1P via Fructokinase

Galactose –> Gal1P via Galactokinase

Deficiencies of Fructo and Galactokinases causes MILD symptoms (respective sugars are present in urine). The SEcond steps cause SEvere symptoms (AldolaseB and Uridyl transferase, respectively).

Watch out when you see “ALDO-” because it means something bad is going to happen:

Glucose –> Sorbitol via Aldose Reductase + NADPH (CATARACTS)

Note: Sorbitol –> Fructose via SorbitolDH

Note: Sorbitol –> Fructose via SorbitolDH Galactose –> Galactilol via Aldose Reductase + NADPH (CATARACTS)

Fructose1P –> Glyceraldehide and DihydroxyacetoneP via Aldolase B (FRUCTOSE INTOLERANCE)

Essential amino acids:

TV FILM HWRK (Threonine(T), Valine(V), PHENYLALANINE(F), Isoleucine(I), Leucine(L), Methionine(M), Histidine(H), TRYPTOPHAN(W), ARGININE®, LYSINE(K))

Negatively charged amino acids:

Negative experience to be burned by Acid:

Aspartic acid and glutamic acid

Note: Aspartate and Glutamate (as N-acetyl glutamate) are involved in Urea cycle elimination of ammonia

Amino acids with three titratable H+:

Ricky Can’t Hate ED

RKY C H ED

Arginine® - 12.5

Lysine(K) - 10.5

Tyrosine(Y) - 10.1

Cysteine© - 8.2

Histidine(H) - 6

Aspartic acid(E) - 4.3

Glutamic acid(D) - 3.7

The numbers aren’t important except for Histidine. Just know the order and that it goes in descending pH’s. FYI: COO-=2, NH3+=9.5

KNOW: Ketogenic amino acids:

Leucine and Lysine –> USED TO TREAT PDH DEFICIENCY

Cycles: Urea cycle and TCA overlap:

OAA(TCA) + Glutamate <–AST–> Aspartate(Urea) + alphaKG(TCA)

Aspartate(Urea) + Citrulline(Urea) –> Arginosuccinate(Urea) –> Arginine(Urea) + Fumarate(TCA)

Urea cycle enzyme deficiency –> decreased TCA intermediates –> TCA INHIBITION + HYPERAMMONEMIA (b/c decreased NH4+ excretion).

Sx: asterixis, slurred speech, somnolence, blurry vision, vomiting

Tx: less protein in diet + Benzoate/Phenylbutyrate (bind a.a.–>excrete)

OTC = major urea cycle enzyme:

Ornithine + carbamoyl-phosphate –> Citrulline via OTC

OTC deficiency (x-r) = shunting of carbamoyl phosphate from urea cycle to pyrimidine synthesis:

carbamoyl phosphate + aspartate –> orotic acid

Orotic Aciduria –> decreased BUN + hyperammonemia

Amino acid derivatives:

Phenylalanine –(Phenylalanine hydroxylase + THB + NADPH via Dihydropterin reductase)–> Tyrosine (X = PKU (a-r): screened by Guthrie test 2-3 days after birth; Tx: decr Phen, incr Tyr diet): –> Fumarate via Homogentinsic acid oxidase (X = Alkaptonuria) –> Thyroxine –(Tyrosine hydroxylase/B6, blocked by Metyrosine)–> Dopa: –> Melanin (X = Albinism: decreased pigment) –(Dopa decarboxylase/B6, blocked by Carbidopa)–> Dopamine –(Dopamine Hydroxylase/VitC, blocked by Reserpine)–> NE –(PNMT/SAM)–> Epinephrine

–(Phenylalanine hydroxylase + THB + NADPH via Dihydropterin reductase)–> (X = PKU (a-r): screened by Guthrie test 2-3 days after birth; Tx: decr Phen, incr Tyr diet): Tryptophan (X in Hartnup’s): –(B6)–> Niacin=B3 –> NAD+/NADP+ (X = Pellagra) –(BH4)–> Serotonin –> Melatonin (sleep)

(X in Hartnup’s):

Lysosomal storage diseases:

Tay-SaX = HeXosaminidase A –> incr GM2: no hepatosplen; cherry macula, onion skin lysosomes

“Fab-Gal is into Ceramics”

Fabry’s = alphaGALactosidase A –> incr Ceramide trihexose: peripheral neuropathy, angiokeratoma, CV/renal disease

Fabry’s = alphaGALactosidase A –> incr Ceramide trihexose: peripheral neuropathy, angiokeratoma, CV/renal disease “Gauched out my femur when I was on a sugar high”

Gaucher, Femur Necrosis, Sugar High = GlucoCerebrosidase

Gaucher’s = betaGlucocerebrosidase –> incr glucocerebroside: aseptic femur necrosis, hepatosplenomegaly, crumpled tissue paper cytoplasm

Gaucher, Femur Necrosis, Sugar High = GlucoCerebrosidase Gaucher’s = betaGlucocerebrosidase –> incr glucocerebroside: aseptic femur necrosis, hepatosplenomegaly, crumpled tissue paper cytoplasm Blind Intelligent Intergalactic Crab

Intelligent Intergalactic = Galactocerebroside

Krabbe’s = Galactocerebrosidase –> incr galactocerebroside: blindness, peripheral neuropathy, developmental delay, globoid cells

Intelligent Intergalactic = Galactocerebroside Krabbe’s = Galactocerebrosidase –> incr galactocerebroside: blindness, peripheral neuropathy, developmental delay, globoid cells Niemann Pick’s his nose with hisphinger

Niemann-Pick = Sphingomyelinase –> incr Sphingomyelin: cherry macula with hepatosplenomegaly, neurodegeneration, foam cells

Niemann-Pick = Sphingomyelinase –> incr Sphingomyelin: cherry macula with hepatosplenomegaly, neurodegeneration, foam cells “Sulfur tides are multicolored”

Sulfur tide = Sulfatide

Multicolored = Metachromic

Metachromic leukodystrophy = Aryl sulfatase A –> incr Sulfatides: central and peripheral demyelination with ataxia, dementia

Mucopolysaccharidoses:

HurLer’s = alpha-L-iduronidase –> incr heparan sulfate, dermatan sulfate: corneal clouding, gargoylism, airway obstruction

Hunter’s = iduronate sulfatase –> incr heparan sulfate, dermatan sulfate: NO CORNEAL CLOUDING because Hunter’s need to see clearly

Major apolipoproteins:

“II:LL”

C-II = cofactor for Lipoprotein Lipase

Treat abetalipoproteinemias (deficient apoB100, B48 –> night blindness, acanthocytes (spiky RBC), steatorrhea, ataxia) with Vitamin E

Embryology:

Important Genes for Embryogenesis:

Sonic the Hedgehog fights a One-Eyed Monster:

Sonic Hedgehog mutation –> Holoprosencephaly

Sonic Hedgehog mutation –> Holoprosencephaly FGF gene = Fibroblast Growth Factor: Growth Factor lengthens limbs

FGF mutation –> Achondroplasia (A-D dwarfism)

FGF mutation –> Achondroplasia (A-D dwarfism) HOX (Homeobox) gene: "Boxes help with organization"

organizes/determines limb location (Vitamin A toxicity alters HOX expression –> cleft palate, cardiac abnormalities, spontaneous abortion)

Rules of Early Development:

Week 2: 2 germ layers (epiblast, hypoblast), 2 cavities (amniotic, yolk sac), 2 placental components (cytotrophoblast, syncytiotrophoblast)

Week 3: 3 germ layers (ectoderm, mesoderm, endoderm)

Week 4: 4 heart chambers, 4 limb buds

Note: neural tube closes by week 4:

def. folic acid–> spina bifida, etc.

neural tube defect has incr alpha-fetoprotein+AChesterase

(**Gastroschisis and Omphalocele, pretty much ANY internal organ extrusion results in incr alpha-fetoprotein)

“SAD DAVE”:

SAD: Sensory = Alar Plate/Afferent nerves = Dorsal

DAVE: Dorsal=Afferent, Ventral=Efferent

Embryologic derivatives:

Ectoderm: Surface: what you see (epidermis, hair, nails, teeth enamel, eye lens…) + anterior pituitary (Rathke’s pouch) Neuro: everything connected to the CNS (brain, spinal cord, oligodendocytes, posterior pituitary, retina, pineal gland…) + pupillary muscles

Mesoderm: Neural crest: skull and PNS stuff (skull, head muscles, dentine, pia/arachnoid, Schwann cells, DRG, cranial nerves, celiac ganglion, parafollicular C cells of thyroid…) + adrenal medulla (chromaffin cells) + melanocytes (last to migrate) Paraxial: axial stuff (axial skeleton, skeletal muscles, connective tissue and dermis…) + dura mater Intermediate: urogenital ridge (kidneys and ureters, vas deferens, gonads, uterus and uterine tubules…) Lateral: non-skeletal muscle and blood-related organs (visceral muscle and connective tissue, blood, lymph, spleen, cardiovascular system…) + adrenal cortex

Note: spleen = mesoderm, but supplied by celiac artery of the foregut MESODERMAL DEFECTS = “VACTERL ”: V ertebral defects, A nal a tresia, C ardiac defects, T racheo- E sophageal fistulas, R enal defects, L imb defects

Endoderm: ear/mouth to anus hollow lining and organs + bladder and vagina tympanic cavity/auritory tube, tonsils, thymus, thyroid, parathyroid larynx, trachea, bronchi, lungs GIT, liver, gallbladder, pancreas urinary bladder, urethra, lower 2/3 vagina (this explains how patients can still have a vagina even if the paramesonephric ducts fail to develop)

Notochord –> nucleus pulposus of intervertebral disk

Teratogens:

“Amina couldn’t hear because she was too absorbed in her reading.”

Aminoglycosides prevent mRNA reading by interfering with 16S of 30S and cause CNVIII ototoxicity

(Note: Congenital Syphilis also causes CNVIII ototoxicity + Saber shins + Saddle nose + Hutchinson’s teeth + Mulberry Molars + frontal bossing)

Aminoglycosides prevent mRNA reading by interfering with 16S of 30S and cause CNVIII ototoxicity (Note: Congenital Syphilis also causes CNVIII ototoxicity + Saber shins + Saddle nose + Hutchinson’s teeth + Mulberry Molars + frontal bossing) Maternal Diabetes: hyperglycemia –> incr fetal insulin –> decr lung development = can’t breathe; “mermaids also can’t breathe air” –>

maternal diabetes causes ARDs and sirenomelia/anal atresia (also, transposition of great vessels)

Umbilical cord:

Allantois: 2 arteries, 1 vein (“arteries” is 2x as long as “vein”)

AllaNtois –(urachus)–> mediaN umbilical ligament

UmbiLical artery –> mediaL umbilical ligament

Umbilical vein - ligamentum teres hepatis

Allantois –> Urachus (wk3): urachus failure to obliterate = bladder to navel connection: umbilical urination or bladder outpouching

Omphalomesenteric duct –> Vitelline duct (wk7): duct failure to obliterate = colon to navel connection: umbilical meconium or Meckel’s diverticulum

Heart embryology:

Primitive __ –> trabeculated (rough) portion of __

Smooth atrium = sinus venosus

Smooth ventricle = bulbus cordis

SVC = right common and anterior cardinal veins

Aorta/Pulmonary artery = truncus arteriosus, separated by spiraling neural crest migration (X = Transposition of Great Vessels, Tetralogy of Fallot)

“PGA open”: PG keeps DA open (decr PG –> close DA with Indomethacin, NSAIDs)

Aortic arch derivatives: "left side of body to right side, top to bottom"

I: maxillary artery (external carotid) - @ face

II: hyoid/stapedial artery - @ midline throat

III: common and internal carotid arteries - @ midline neck

IV: right subclavian artery and aortic arch - @ right/middle chest

VI: pulmonary artery (inc. ductus arteriosus connection to aorta) - @ right side of heart

Neural tube defects:

The longer the name, the worse the symptoms:

Occulta: spinal canal opening but no herniation, tuft of hair

Meningocele: herniation of meninges

Meningomyelocele: herniation of spinal cord

Pharyngeal/Branchial “CAP”:

Cleft = ectoderm (~external hollow spaces)

Arches = mesoderm (~muscles)

Pouches = endoderm (~immune organs above the neck)

Branchial CLEFT - ectoderm: ~external hollow spaces

Cleft 1: external auditory meatus

Clefts 2-4: temporary cervical sinus (fail to obliterate = lateral neck branchial cleft cyst)

Branchial cleft cyst (lateral neck) vs Thyroglossal duct cyst (midline neck, moves with swallowing because “attached to tongue”)

Branchial ARCH - mesoderm: ~muscles

The nerves that supply the branchial arches are all BOTH motor and sensory:

“Some(I) Say(II) Marry(III) Money(IV) But(V) My(VI) Brother(VII) Says(VIII) Big(IX) Brains(X) Matter(XI) Most(XII)” (S = sensory, M = motor, B = both)

**LOOK AT THE NERVES TO FIGURE OUT WHICH MUSCLES MAKE UP WHAT ARCH** or use the following mnemonic:

“Chewing made me grimace so I swallowed, choked, then called for help.”

chewing = arch 1 (V2,3) = muscles of mastication, ant. 2/3 tongue + malleus/incus/tensor tympani

grimace = arch 2 (VII) = facial expression + stapes/stapedius (defect = Treacher Collins’ mandibular hypoplasia and facial abnormalities)

swallowed = arch 3 (IX)= stylopharyngeus (defect = fissure from neck to tonsils)

choked = arch 4 (X, sup laryngeal)= pharyngeal constrictors and cricothyroid

called for help = arch 6 (X, inf laryngeal)= intrinsic larynx muscles except cricothyroid

Note: Arch 4&6 make up post. 1/3 tongue

Branchial POUCH - endoderm: ~immune organs above the neck + middle ear

Pouch 1 = auditory tube, middle ear, mastoid air cells

Pouch 2 = tonsils and tonsillar sinus

Pouch 3 = inferior parathyroid + thymus (they descend together)

Pouch 4 = superior parathyroid + parafollicular C cells of thyroid

Failure of 3rd and 4th Pouch = DiGeorge’s: no thymus (= T cell deficiency), no parathyroids (= hypocalcemia –> tetany)

“C3, 4, 5 keeps the diaphragm alive.”

Kidney embryology: main player = Metanephros:

Ureteric Bud = ureter–>pelvis–>collecting ducts

JOINS

Metanephric Mesenchyme = glomerulus–>DCT

Defective ureteric bud = renal agenesis; B/L renal agenesis –> oligohydramnios –> Potter’s: pulmonary hypoplasia + face/limb deformities

**MC site of obstruction = Ureteropelvic junction with kidney –> fetal hydronephrosis

Genital embryology:

Male = Mesonephric

Pemale = Paramesonephric

“Men are Wolves” = “Wolffian ducts” –> "SEVEN" in “SEVEN UP” (Seminal vesicles, Epididymis, Vas deferens, Ejaculatory duct, N = nothing)

“Women Mull over past arguments” = “Mullerian ducts” –> fallopian tubes, uterus, and upper 1/3 of vagina (lower 2/3 from urogenital sinus of endoderm)

Female = default genitals

Hormone overview:

Prolactin stimulates Dopamine inhibits Prolactin

Prolactin inhibits GnRH

GnRH –> incr FSH, LH

L in LH and Leydig: LH stimulates Leydig cells to produce testosterone –> develop Wolffian duct

S in FSH, Sertoli, and Sperm: FSH stimulates Sertoli cells to produce Sperm, Inhibin, and Mullerian inhibiting factor (MIF); MIF inhibits female paramesonephric duct development

Genital homologues:

Urogenital sinus: B ulbourethral glands = B artholins greater vestibular glands pro S tate gland = S kene urethral and paraurethral glands



Extrophy of bladder is associated with Epispadias (faulty positioning of genital tubercle)

vs. Hypospadias = more common, failure of urethral fold closure, incr risk of UTI

Microbiology:

Encapsulated organisms: (+Quellung reaction: quell makes capsules swell)

“Claustrophobic Pastor Salmon Echoed Back: Yersinful Crypt-dark Strip Clubs are Pseudo-Homes to Nice Men Francis and Bruce.”

Claustrophobic = Clostridium

Pastor = Pasturella

Salmon = Salmonella

Echoed = E.coli

Back = Bacillus anthracis (D-glutamate)

Yersinful = Yersinia

Crypt-dark = Cryptococcus (India Ink, narrow-based budding in meningitis)

Strip = Streptococcus

Clubs = Klebsiella

Pseudo = Pseudomonas

Homes = Haemophilus

Nice men = Neisseria meningitidis

Francis = Francisella

Bruce = Brucella

“BAD” - Bacillus Anthracis’ unique capsule contains D-glutamate

“Staff of grapes” = Staphylococcus is in clusters

VS. Streptococcus = pairs/chains

Spirochetes: "Spiraling Boris Lept then Tripped"

Spiraling = Spirochetes

Boris = Borrelia (Giemsa stain = aniline dye; relapsing fever = result of antigenic variation)

Lept = Leptospira

Tripped = Treponema (Dark Field Microscopy, VDRL cardiolipin screening, FTA-ABS confirmation)

Mycoplasma vs Mycobacteria

Bacteria have cell walls (Mycobacteria have mycolic acid in their cell walls that stain acid-fast)

Plasma membranes have sterols (Mycoplasma have sterols and no cell wall)

Stains:

GiemsA stains BorreliA, MalariA, ChlamydiA, TrypanosomA

PASs the sugar and whip cream (PAS stains glycogen and Dx Whipple’s disease)

“Legions who Sustained injuries get Silver stars”: Legionella, grow with Cysteine, silver stain; water source

Special Culture:

“Nice Homes have chocolate”: Neisseria and Haemophilus grow on Chocolate agar +: Neisseria = Thayer Martin media: Vancomycin (vs G+), Polymyxin (vs g-), Nystatin (vs fungi) Haemophilus = V (NAD+) and X (hematin)

“If I Tell-U the Corny joke Right, you’ll Laugh”: TellURight = tellurite agar Corny = Corynebacterium Laugh = Lofflers media

“TB and J”: M. tuberculosis on lowenstEIN-Jensen agar (takes 3-4 weeks to grow, but diagnostic)

Obligate aerobes:

“If No AER, Anthrax and TB can’t survive!”

No = NOcardia

Aer = pseudomonas AERuginosa

Anthrax = B. anthracis

TB = M. tuberculosis

Microaerophils = “bacters”: Campylobacter, Helicobacter

Obligate anaerobes: "These BACTERia ACTIN CLOSTRophobic enviroments (non-healing ulcers):

BACTERia = Bacteroides (E.G., B. fragilis)

ACTIN = Actinomyces

CLOSTRophobic = CLOSTRidium

Obligate Intracellular: "REACh for My COX if you want me INSIDE you.“

R = Rickettsia

E = Ehrlichia

A = Anaplasma

Ch = Chlamydia

My = Mycoplasma

Cox = Coxiella

Inside = intracellular

Facultative intracellular: "Legions of Salmon, Rabbits, N’ Cows Tumble IN My yard.”

Legions = Legionella

Salmon = Salmonella

Rabbits = Francisella

N = Neisseria

Cows = Brucella

Tumble = Listeria

In = intracellular

My = Mycobacterium

Note: intracellular pathogens require cell-mediated immunity (CMI), so neonates are at risk (E.G., Listeria –> neonatal meningitis: tumbles, has endotoxin, and a narrow zone of beta hemolysis)

Bacterial virulence factors:

protein A for staph. Aureus: binds Fc of Ig to prevent opsonization and phagocytosis

M protein (prevents phagocytosis) –> strep. pyogene’s rheuMatic fever (Sx: subcutaneous plaques, polyarthritis, erythema marginatum, chorea, carditis)

IgA protease (to colonize respiratory mucosa) + antiphagocytic capsule (infects ASPLENIC patients b/c decr M0 and IgM/complement C3 activation (E.G., Sickle Cell autosplenectomy)) + causes meningitis = SHiN

Note: can also undergo “transformation” (pick up DNA from environment)

S trep pneumo H . i nfluenza type B (B polysaccharide) N eisseria meningitidis

patients b/c decr M0 and IgM/complement C3 activation (E.G., Sickle Cell autosplenectomy)) + causes meningitis = SHiN Note: can also undergo “transformation” (pick up DNA from environment)

Exotoxin vs Endotoxin:

EXotoxin = from EXogenous source (plasmid or bacteriophage) and EXcreted from bacteria, EXtremely toxic (even small dose), EXact effects (different toxins produce different symptoms); ~heat-labile

ENDOtoxin (Lipid A)- ENDOgenous (made from bacterial chromosome, ENtegral to outer membrane of most g-Neg bacteria (and Listeria(G+))); heat stable; causes gENeral fever, shock/sepsis via direct MACROPHAGE response (binds CD14- M0 marker) –> release TNF and IL-1 (no Th involvement) M0 activation: IL1 = Fever TNF alpha = fever, hemorrhagic tissue necrosis Nitric oxide = hypotension/shock alternate complement pathway: C3 a = A naphylaxis (basophil and mast cell degranulation –> hypotension, edema) C5a = neutrophil chemotaxis Hageman factor: coagulation cascade–> DIC/microthrombi

M0 marker) –> release TNF and IL-1 (no Th involvement)

Exotoxin subclass: SUPERANTIGENS: bind directly to MHCII and TH1(CD4) –> explosive release of IFNgamma and IL2 (non-specific immune response):

S. aureus = TSST-1 –> Toxic Shock Syndrome (fever, rash, shock)

S. pyogenes = Erythrogenic toxin –> Scarlet fever with Toxic-Shock-like symptoms

Note: S. pyogenes also has Streptolysin O (lyses RBC); Dx: Rheumatic Fever with anti-Streptolysin-O antibody (ASOAb)

E. coli ADP ribosylating A-B toxin:

“Labile like Air, Stable like Ground”:

heat-Labile toxin stimulates Adenylate cyclase

heat-Stable toxin stimulates Guanylate cyclase

Both cause watery diarrhea.

Bacterial Toxins Envoded in Lysogenic Phage: "ABCDE"

Shig A -like toxin - EHEC 0157:H7 - cleaves host cell rRNA/inactivates 60S; also, incr cytokines –> HUS

-like toxin - EHEC 0157:H7 - cleaves host cell rRNA/inactivates 60S; also, incr cytokines –> HUS B otulinum toxin - inhibits ACh vesicle release from presynaptic neuron –> flaccid paralysis

otulinum toxin - inhibits ACh vesicle release from presynaptic neuron –> flaccid paralysis C holera toxin - activates Gs –> incr cAMP –> incr Cl- secretion into gut = decr Na+ absorption –> watery diarrhea

holera toxin - activates Gs –> incr cAMP –> incr Cl- secretion into gut = decr Na+ absorption –> watery diarrhea D iptheria toxin - ADP-ribosylating A-B toxin (like Pseudomonas exotoxin A) - B binds, A enters and ribosylates EF2 –> no more protein synthesis –> cell death; pseudomembrane formation

iptheria toxin - ADP-ribosylating A-B toxin (like Pseudomonas exotoxin A) - B binds, A enters and ribosylates EF2 –> no more protein synthesis –> cell death; pseudomembrane formation Erythrogenic (superantigen) toxin of Strep. pyogenes –> Scarlet Fever - activates both TH1(CD4) and MHCII –> incr INFgamma + IL2 –> incr M0 and T-cell non-specific immune response –> ~Toxic Shock

Gram Positives: crystal violet + iodine = blue

Coag negative Staph: "SENsitive": S taph. E pi = N ovobiocin SENSITIVE" (VS. Staph. saprophyticus = Novobiocin resistant)

taph. pi = ovobiocin SENSITIVE" (VS. Staph. saprophyticus = Novobiocin resistant) alpha hemolytic Strep: "OVeRPasS": O ptochin V iridans R esistant, P neumonia S ensitive

Note: Strep pneumonia is bile soluble (= can’t be cultured in bile, unlike gamma hemolytic Strep)

ptochin iridans esistant, neumonia ensitive Note: Strep pneumonia is bile soluble (= can’t be cultured in bile, unlike gamma hemolytic Strep) beta hemolytic Strep: "BBBR": B eta hemolytic, group B strep (Strep agalactiae), B acitracin R esistant (VS. group A strep (Strep. pyogenes) = bacitracin sensitive)

OR

“B-BRAS” - Bacitracin: group B = resistant, group A = sensitive

eta hemolytic, group strep (Strep agalactiae), acitracin esistant (VS. group A strep (Strep. pyogenes) = bacitracin sensitive) OR “B-BRAS” - Bacitracin: group B = resistant, group A = sensitive gamma hemolytic Strep: grows in bile; "stomach is used to salty foods" = Enterococci grows in 6.5%NaCl (VS. Strep. bovis –> does NOT grow in 6.5%NaCl)

Exposure/PRIMARY TB:

Ghon complex = Ghon focus of LOWER lobe + peri-hilar lymph nodes

You think they are “Ghon” but they’re just waiting to become secondary TB (fibrocaseous cavitary lesion of UPPER lobe)

gram negative: acetone + saffranin = pink

N. Meningities ferMents Maltose, has a capsule, and vaccine (gonorrhea doesn’t; NOTE**: gonorrhea’s pilus protein undergoes antigenic variation !!)

Note:

-N. meningitidis = respiratory/oral spread –> meningococcemia and Waterhouse-Friderichsen adrenal hemorrhage (hypotension and DIC)

-N. gonorrhea = STD–> high fever, septic arthritis, neonatal conjunctivitis, PID, Fitz-Hugh-Curtis (cervicitis–>salpingitis–>liver capsule infection)

undergoes !!) Note: -N. meningitidis = respiratory/oral spread –> meningococcemia and Waterhouse-Friderichsen adrenal hemorrhage (hypotension and DIC) -N. gonorrhea = STD–> high fever, septic arthritis, neonatal conjunctivitis, PID, Fitz-Hugh-Curtis (cervicitis–>salpingitis–>liver capsule infection) Enterobacteriae: CAPSULE = VIRULENCE FACTOR, all ferment glucose Lactose fermenters (pink on MacConkey, blue on Eosin-Methylene blue) = “SEEK”: Serratia, Enterobacter, E. coli (blue-black metallic sheen), Klebsiella Non-lactose fermenters = “PSSY”: Proteus, Salmonella, Shigella, Yersinia H2S producing (black on Hektoen Agar) + motile (flagellar H antigen): Proteus (swarming, urease+, staghorn ammonium struvite stones), Salmonella Note: Salmonella and Shigella both invade mucosa –> bloody diarrhea; Salmonella is motile (w/ 2 flagellar antigen variants ) and produces H2S, S. typhi of Typhoid fever causes abdominal rose spots and can remain chronically in gallbladder; Shigella is more virulent, moves by actin polymerization and 60S deactivating toxin induces HUS.



oxidase + organisms: "when you go Camping at a quiet Pasture you’d Moan More with Nice Vibrators"

Camping = Campylobacter

Pasture = Pasturella

Moan = Pseudomonas

More = Moraxella

Nice = Neisseria

Vibrators = Vibrio

VDRL false positives: "VDRL"

V = viruses: EBV, hepatitis

D = drugs

R = Rheumatic fever (Dx w/ S. pyogenes ASO titers)

L = Lupus and Leprosy

Chlamydia: Dx via Giemsa stain (ChlamydiA, MalariA, BorreliA + TrypanosomA)

Elementary body is Enfectious and Enters cells via Endocytosis

Reticulate body Replicates in cell by fission

“Tricky Dick”: TRIC = serotypes D–K : –> MC PID, cervicitis, ectopic pregnancy –> Fitz-Hugh-Curtis liver capsule infection (from spread of PID) + “violin string” adhesions of parietal peritoneum to liver –> neonatal pneumonal/conjunctivitis –> REITER’S : "Can’t see, can’t pee, can’t climb a tree" = conjunctivitis, urethritis, arthritis VS. trAChoma = serotypes A-C –> blindness

VS. L1-L3 = Lymphogranuloma venerum : ulcers –> lymphadenopathy, rectal strictures mistaken for PID

= serotypes : VS. = serotypes A-C –> VS. L1-L3 = : ulcers –> lymphadenopathy, mistaken for PID Tx: mothers and infants with Chlamydia with Erythromycin estolate, though there is a risk of maternal acute cholestatic hepatitis

Atypical (walking) pneumonias: "My Clammy Legion walked"; Tx: macrolides

My = Myco plasma (IgM = cold agglutinins –> agglutinate or lyse RBCs; grown on Eaton’s agar; Tx: tetracycline or macrolide)

(IgM = cold agglutinins –> agglutinate or lyse RBCs; grown on Eaton’s agar; Tx: tetracycline or macrolide) Clammy = Chlamydia (Tx: tetracycline or macrolide)

Legion = Legionella (Tx: macrolide)

Fungi:

Dimorphic: "cold = mold, heat = yea(s)t" + “Blast His Cock” = East Coast to West Coast (Tx: Ketoconazole)

Blast = Blastomycosis = east of Mississippi River

His = Histoplasmosis = Mississippi River and Ohio river

Cock = Coccidiomycosis = Southwest US: CA, AZ

“His Woodpecker Blasted Wood into Dust”:

His Woodpecker = Histoplasmosis from bird/bat droppings = macrophage filled with round yeast; “Histo Hides within macrophages”

Blasted Wood = B lastomycosis in wood = B road- B ased- B udding fungi; the handle of a b aseball b at looks like it’s b udding off the shaft)

lastomycosis in wood = road- ased- udding fungi; the handle of a aseball at looks like it’s udding off the shaft) Dust = Coccidiomycosis = large spherule filled with endospores; “barrel-shaped arthroconidia”; “Cock is filled with Sperm, Coccidio is filled with Spores”

Actinomyces = Acute Angles, Septate

(VS. Mucormycosis/Rhizopus = Wide angles, non-septate; ~in Diabetics)

Helminth drugs:

Worms = Bendazole

Praziquantel = foods: Pork, Fish, Crab, Snails Pork = Taenia Fish = Diphyllo, Clonorchis Crab = Paragonimus Snails = Schistosoma



Antigenic shift vs. drift: "SPED"

Shift (reassortment via segmented viruses) = Pandemic

Epidemic = Drift (random mutations)

Vaccines:

Live: "See MMR. Sabin’s small yellow chickens live.“ MMR = Measles, Mumps, Rubella Sabin (Polio, oral) small pox yellow fever chicken pox/shingles

Killed: "RIP Always” Rabies Influenza Polio (SalK = Killed, injected) Adenovirus

Recombinant: "H_V" Worms = Bendazole Praziquantel = foods: Pork, Fish, Crab, Snails



Viruses:

DNA viruses: "HeHe PoPa ParAde": first three = enveloped

He = Herpes

He = HepaDNA (HBV; carries special RT: DNAdDNAp)

Po = Pox (smallpox, molluscum contagiosum; carries DNAdRNAp and replicates in cytoplasm)

Pa = Papilloma (HPV: (6,11): condylomata acuminata/genital warts, koilocytes=squamous cell with perinuclear cytoplasmic halo; (16,18): CIN; anal squamous cell CA) + Polyoma (JC, PML demyelinating encephalopathy)

Par = Parvo = B19/Erythema infectiosum (ssDNA)

Ade = Adenovirus (swimming pool conjunctivitis, gastroenteritis)

Herpes: "2 Simple Chickens Barred Sight from Rose Patches"

2 Simple = HSV1,2

Chickens = HHV3: Chicken pox (truncal rash –> extremities; lesions of different age)/shingles

B arred = HHV4: E B V (mono, B urkitt’s, large cell non-Hodgkins @ Waldeyer’s ring, nasopharyngeal CA, hairy leukoplakia on lateral tongue; infects B cells via CD21 -EBV receptor)

arred = HHV4: E V (mono, urkitt’s, large cell non-Hodgkins @ Waldeyer’s ring, nasopharyngeal CA, hairy leukoplakia on lateral tongue; infects cells via -EBV receptor) Sight = HHV5: CMV (retinitis, negative mono-spot mono, TORCH; both intranuclear “owl-eye” and cytoplasmic inclusion bodies)

Rose = HHV6: Roseola/Erythema subitum (high fever –> rash)

Patches = HHV8: Kaposi-sarcoma

RNA viruses:

+RNA = “PiToFlaCoCa”: middle 3 = enveloped

Pi = PicoRNA = PECoRnA: P = Polio (both colonizes nasopharynx and causes meningitis like Hib –> myalgia and paralysis) E = Echovirus: swimming pool aseptic meningitis/myocarditis C = Coxsackie: aseptic meningitis/myocarditis, hand-foot-mouth (palm and sole vesicular rash also seen in secondary syphilis and Rickettsial Rocky Mountain Spotted Fever) Rn = RHINOvirus (stuffy NOSE from common cold) A = HAV

To = Toga “Togas Rubelled against Germany with TORCHs” = Togavirus, Rubella, German Measles ( post-auricular occipital lymphadenopathy , fine truncal rash), TORCH infection (blueberry muffin rash, deaf, cataracts, PDA ) VS. Rubeola: "a PARA Ruby weasles caught SSPEcial measles" = Paramyxo, Rubeola, SSPE complication, Measles VS. Roseola: HHV6 (high fever/seizures –> truncal rash)

Fla = Flavi (HCV, yellow, dengue, St. Louis, West Nile) yellow fever causes yellowing skin (jaundice) and black vomit

Co = Corona (common cold, SARS)

Ca = Calici = “Norwalk, CA Cruises” (gastroenteritis from cruises)

-RNA = all enveloped + RNAdRNApol

Reovirus = dsRNA, segmented: ROTAvirus = right out the anus (childhood winter gastroenteritis)

HepEvirus = HEV (water epidemic, only dangerous if pregnant)

Orthomyxo: O for octo = 8 segments –> reassortment = Influenza pandemic (Ag shift)

Paramyxo = PaRaMyX2o: P or PARA = Parainfluenza = croup R = RSV; Tx: Ribavirin (vs. IMPDH of purine synthesis; AE: hemolytic anemia, teratogen) or “RSVP Liz” where “P Liz” = Palivizumab which binds Paramyxo F protein, preventing respiratory epithelial syncytia formation Mx2 = Measles and Mumps: Measles: "A PARA RUBY weasles caught SSPEcial Measles" = paramyxo, rubeola, SSPE complication, Measles’ 3 C’s = cough, coryza, conjunctivitis + Koplik spots; rash from head down like Rubella Mumps: parotitis, orchitis, aseptic meningitis



Segmented viruses: "BOAR"

B = Bunya (Hanta hemorrhagic fever)

O = Orthomyxo (Influenza)

A = Arena (mouse Lassa encephalitis)

R = Reovirus (right out the anus childhood diarrhea)

Hepatitis:

HAV = Picorna (+RNA); fecal-oral (ice cubes, shellfish)

HBV = HepaDNA (env, dsDNA); blood (renal dialysis, needle stick), sex, mother; Dx: PCR

HCV = Flavi (env, +RNA); blood (IVDA, transfusion); Dx: RT-PCR

HDV = Delta (defective env, -RNA); infects with HBV

HEV = HepEvirus (+RNA); fecal-oral (water epidemic)

ToRCHS: hepatosplenomegaly, jaundice, thrombocytopenia, growth retardation

T = Toxoplasma: ToxoTriad: intracranial calcifications, chorioretinitis, hydrocephalus = SAME TRIAD AS CMV!!; from cat feces, ring-enhancing brain abscess); Tx: Sulfadiazine+Pyrimethamine

R = Rubella (Togavirus, +RNA): PDA, cataracts, deaf, blueberry muffin rash; maternal rash and arthritis

C = CMV: Toxoplasma triad (intracranial calcification, chorioretinitis, hydrocephalus) + UNILATERAL hearing loss, seizures

H = HSV (+HIV): temporal lobe encephalitis, herpetic lesions (fingers)

S = Syphilis: hydrops fetalis stillbirth > Hutchinson teeth, saddle nose, saber shins

Note: B19 also causes hydrops fetalis

Bactericidal drugs (all else = bacteriostatic): "Sephiroth Met Vancouver Penpal Amina in Florida, then KILLED HER D:“

Seph(iroth) = Cephalosporin

Met = Metronidazole

Vancouver = Vancomycin

Penpal = Penicillin

Amina = Aminoglycosides

Florida = Fluoroquinolones

Antimicrobial drugs:

inhibits PG cross-linking –> no cell wall: "Ceph Chills-in ‘Nam watching PG movies”: Ceph = Cephalosporin Chills-in = 'cillins (binds PBP, block transpeptidase cross-linking; Penicillin = endocarditis prophylaxis (before surgery/dental), syphilis prophylaxis) 'Nam = AztreoNAM (binds PBP3 for Pencillin-allergy pts; vs “SEEK Pseudomonas”- Serratia, E.coli, Enterobacter, Klebsiella, Pseudomonas), MeropeNEM and ImipeNEM+Cilastatin (Merpenem/Imipenem vs. everything, esp. Enterobacter, but causes SEIZURES; Cilastatin inhibits renal dihydropeptidase I to inhibit renal tubule Imipinem inactivation) blocks PG synthesis: Bacitracin (vs. S. pyogenes (GAS)) Vancomycin (binds D-Ala-D-Ala and interferes with PG-elongating transglycosylase vs. resistant G+ inc, MRSA and C.diff!! “TON of AE’s”: T = thrombophlebitis, O = ototoxic, N = nephrotoxic + Red Man (slow infusion and pretreat with anti-histamine to prevent)) vs. g- by disrupting cell membranes: Polymyxins (neosporin) - detergent vs cell membrane; AE: neurotoxicity, acute renal tubular necrosis vs. G+/g- by blocking folate –> no nucleotide synthesis (megaloblastic anemia): Sulfonamides (comp inhibit PABA for dihydropteroate synthetase –> no DHF synthesis; AE: infant kernicterus (avoid in pregnancy), SJ, nephrotox, G6PD hemolysis) Sulfamethoxazole-Trimethoprim (TMP-SMX) vs UTI, P. jirovecii prophylaxis in AIDS Sulfadiazine+Pyrimethamine vs Toxoplasma Sulfadoxin+Pyrimethamine vs Malaria Trimethoprim, Pyrimethamine (DHF–Xdihydrofolate reductase–>THF like Methotrexate) vs. URIs (S. pneumo), UTIs, GITIs, and Pseudomonas by blocking topoII (DNA gyrase) and IV: Fluoroquinolones (AE: cartilage/tendon rupture, incr QT, G6PD hemolysis) vs. Mycobacterum, prophylaxis for Hib and N.men by blocking DNAdRNAp = no transcription: Rifampin Protein synthesis inhibitors: "Quinn get in Line and take 50MC’s to 30ST": Quinn, Line 50MC’s = Quin-Dalfo, Linezolid, Macrolides, Chloramphenicol/Clindamycin block 50S Quin-Dalfo (streptogramins): Quinupristin prevents elongation, Dalfopristin changes 50S conformation for better Quin-binding Linezolid: binds 50S P-site and blocks 70S assembly

Tx: Quin-Dalfo and Linezolid is good for ALL RESISTANT BACTERIA: VRE, MRSA MACrolidEs (“ACE"mycin = Azithro, Clarithro, Erythromycin): "MacroLIDEs prevent sLIDing of mRNA” = inhibit translocation by binding to 23S of 50S Tx: “PUS” - atypical Pneumonia, URI’s, STDs AE: PROLONG QT, acute cholestatic hepatitis, incr serum concentration of warfarin resistance via METHYLATION OF drug binding site on 50S rRNA Note: Azithromycin = AIDS MAC prophylaxis Chloramphenicol: “ChLorAMPS Peptidyltransferase” - prevents peptide bond formation; Tx: meningitis (H. flu, N. men, Strep. pneumo); AE: aplastic anemia and gray baby; resistance via ACETYLATION Clindamycin: also blocks peptide bond formation at 50S; vs. ANAEROBES (B. fragilis, C. perfringens) like Metronidazole; AE: Pseudomembranous colitis like Ampicillin 30ST = Streptomycin (aminoglycosides), Tetracycline block 30S “Amina didn’t hear the GNATS because she was busy reading”:

Aminoglycosides (GNATS = Genta, Neo, Amikacin, Tobra, and Stretomycins) cause ototoxicity (and nephrotox) and act by binding to 16S and causing mRNA misreading; vs. g- rods; REQUIRES O2 UPTAKE so ineffective against anaerobes; resistance via modification of 30S (acetylation, etc) Tetracyclines block TRNA from binding A-site and discolors Teeth/bones caTion-chelator, do NOT take with antacids, milk, or iron-containing prep! AE: photosensitivity (“SAT for photo” - sulfonamides, amiodarone, TETRACYCLINE) vs. "VACUUM TH BedRoom" - Vibrio, acne, Chlamydia, ureaplasma, urealyticum, Mycoplasma pneumonia, Tularemia, H. pylori, Borrelia, Rickettsia resistance via decr uptake, incr export NOTE: DEMECLOCYCLINE = DIURETIC = ADH ANTAGONIST (Tx: SIADH)

Ampicillin and Amoxicillin are Anti-G+ Aminopenicillins that “HELPS” kill Pseudomonas with Sulbactam/Clavulanic acid (beta lactamase inhibitor):

H = Haemophilus

E = E. coli

L = Listeria

P = Proteus

S = Salmonella

Note: Ampicillin = intrapartum injection, GBS prophylaxis

“TCP Takes Care of Pseudomonas”:

Ticarcillin

Carbenicillin

Piperacillin

Cephalosporins:

1st generation (“cefa”): G+ + PEcK: Proteus, E.coli, Klebsiella

2nd generation (“fur fox fo'tetan”): G+ + HEN-PEcKS: Haemophilus, Enterobacter, Neisseria, Proteus, E. coli, Klebsiella, Serratia “Fur cap” - Cefuroxime for Community Acquired Pneumonia “Linda Brought a Fragile Fox fo'Tito” - Clindamycin, B. fragilis, Cefuroxime, Cefotetan

3rd generation (“trix” “tax” “taz”): Meningitis, Gonorrhea, Typhoid fever (Salmonella) Ceftriaxone = #1 CefTAZidime is for Pseudomonas like TAZobactam+Piperacillin (but causes neutropenia)

4th generation (Cefepime) = G+ + pseudomonas

Metronidazole: forms toxic metabolite that damages DNA; Tx: "GET GAP on the METRO"

G = Giardia

E = Entamoeba histolytica (liver abscess)

T = Trichomonas

G = Gardnerella

A = Anaerobes (B. fragilis, C. difficile)

P = H. Pylori (+ bismuth + amoxicillin/tetracycline)

Anti-TB: "INH-SPIRE": AE: hepatotoxic

INH = Isoniazid (inactivates mycolic acid synthesis enzymes enoyl-acyl carrier protein reductase (InhA overexpression = resistance) and betaketoacylACPsynthase (KasA); KatG gene encodes catalase peroxidase that activates INH); solo-TB prophylaxis; AE: hepatotoxicity, neurotoxicity (prevented by B6), drug-induced lupus (anti-histone Ab)

S = Streptomycin (aminoglycoside vs 30S mRNA reading)

P = Pyrazinamide - active in acidic pH, inhibits mycobacterial growth in M0; AE: hyperuricemia/gout

(I = INH)

R = Rifampin - inhibits DNA-dRNAp = no transcription (rapid resistance) AND blocks packaging and assembly of viruses; induces cyp450; prophylaxis for N. men and Hib; AE: red secretions, stop therapy with purpura, bone marrow suppression

E = Ethambutol - AE: optic neuropathy (red green colorblindness)

Antifungal:

Amphotericin B: AmphoTEARicin TEARS holes in fungal membrane (binds ergosterol and forms pores) AmphoTERRible: AE: fever/chills, hypotension, nephrotox, arrhythmia, anemia, IV phlebitis



Antiviral:

“ARM2 cure A FLU” = A mantadine Rimantidine block M2 protein (viral uncoating) vs. Influenza A ; AE: A taxi A

mantadine Rimantidine block M2 protein (viral uncoating) vs. Influenza ; AE: taxi Herpes = “Cyclovir’s” (virally activated guanosine analogs) + Trifluridine (thymidine analog)

CMV = “Cid’s Gang loved seeing Foamy Scarlet” = Cidofovir (Cytosine analog + Probenicid to prevent excretion), Ganciclovir (intraocular implant), Fomivirsen (intraocular injection, anti-sense RNA therapy), FOScarnet (unlike ganciclovir, doesn’t require thymidine kinase activation; pyroFOSphate analog that directly inhibits DNApol)

HIV therapy:

Protease inhibitors = “navir’s” (AE: GI intolerance, hyperglycemia, lipodystrophy, cyp450 inhibitor)

NRTI’s: "Abe Did Embark on a L-AZy Start" Abacavir Didanosine Emtriciabine Lamivudine AZT (Zidovudine) Stavudine

NNRTI’s: "Move to Delaware? Effin’ Never!“ Delavirdine Efavirenz Nevirapine

FUsion inhibitor = enFUvirtide (gp41 binder)

Interferons: activates NK cells; AE: Neutropenia

IFNalpha - "alpha B C” –> Tx: HBV, HCV

IFNbeta - “PMS sounds like BMS” –> Tx: Multiple Sclerosis

NOTE**: alpha and beta IFNs decr viral replication and incr antiviral protein synthesis that impairs viral mRNA translation

NOTE**: alpha and beta IFNs decr viral replication and incr antiviral protein synthesis that impairs viral mRNA translation IFNgamma - “G in gamma is for cGd” –> Tx: Chronic Granulomatous Disease (NADPH oxidase deficiency)

NOTE**: IFNgamma incr MHCI and II expression, activates M0 –> TNFalpha, IL1, IL6

Immunology:

B-cells are always found in (white) Follicles closer to the outside of the LN or spleen

VS. T-cells are found in the deeper medulla(LN)/PALS(spleen)

Lymph drainage:

rectum above pectinate line = internal iliac

umbilicus to legs (inc, superficial genitals and anal canal below pectinate line) = superficial inguinal

testes = para-aortic

MHC I and II: "Rule of 8’s"

1*8 = MHCI x CD8 = 8

2*4 = MHCII x CD4 = 8

Natural Killer cells: detects MHCI

“Gotta KIL to survive” (KIR + KIL = survive)

KIR only = release perforins and granzymes –> apoptosis

Antibody cleavage:

Papain cleaves Ab into 3 pieces: Pa Pa In (evenly splits into 3)

Protease cleaves Ab into 2 pieces: Prot Ease (evenly splits into 2; complement can still bind hinge)

Cytokines: "Hot T-Bone stEAk"

IL1 (and IL6): hot = fever; secreted by M0

IL2: T = T-cell proliferation; secreted by Th1

IL3: Bone = Bone marrow stimulation (acts like GM-CSF); secreted by T cells

IL4: E = IgE (and IgG) class switching; secreted by Th2

IL5: A = IgA (and eosinophil) production; secreted by Th2

Neutrophil chemotaxis: "CILK": C5a, IL8, LTB4, Kallikrein

IL8: "8" looks like multilobed nucleus of neutrophil = PMN chemotaxis

LTB4’s “B” also looks like neutrophil multilobed nucleus

Immunosuppression Rx vs. IL2: "(IL)2 Pro-Cyclists Secreted Tacks in Response to Serious/Sirius Dax"; prevent transplant rejection

vs. production: Cyclosporin (via inhibit calcineurin)

vs. secretion: Tacrolimus (via binding FK-protein)

vs. response to: Sirolimus (via MTOR)

vs. receptor: Daclizumab

**NOTE: MCC SCID = defective IL2 receptor > ADA deficiency; decr T –> decr B activation: all types of recurrent infections (viral/bacterial/fungal)

Rx vs TNF: Tx: Rheumatoid arthritis

vs. TNF: Infliximab

vs. TNF receptor: Adalimumab

fake TNF receptor: Etanercept

Complement:

C_ a for a naphylaxis (histamine release –> edema –> hypotension, anaphylaxis)

for naphylaxis (histamine release –> edema –> hypotension, anaphylaxis) C_b for binding bacteria (opsonizes and forms pores)

“low 3 causes 3”: C3 deficiency causes HSRIII (immune complex deposit), seen especially in glomerulonephritis; susceptible to S. pneumo and Hib –> severe recurrent pyogenic sinus and respiratory tract infections

**Remember “SHiN”: S(trep. pneumo) + Hi(b) = C3 deficiency; N(eisseria) = C5-C9/MAC deficiency

Passive immunity: "To Be Healed Rapidly" - Tetanus Botulism HBV, Rabies/(RSV in premies every winter month)

Immune deficiencies:

B ruton’s agammaglobulinemia = (x-r) B oys with B TK (tyrosine kinase) defect –> B locked B -cell differentiation: recurrent B acterial infection after 6 months (when mom’s IgG disappears) b/c no Ig’s

ruton’s agammaglobulinemia = (x-r) oys with TK (tyrosine kinase) defect –> locked -cell differentiation: recurrent acterial infection after 6 months (when mom’s IgG disappears) b/c no Ig’s Selective Ig( A ) deficiency: milk A llergies, blood product A naphylaxis, giardi A infections; IgA is missing in mucus so recurrent sinus and lung infections

**Note: IgA deficiency also seen in Ataxia-Telangiectasia :defective DNA repair enzymes, sensitive to ionizing radiation, cerebellar atrophy –> ataxia, spider angiomas (telangiectasias); assoc. w/ lymphomas and acute leukemias

) deficiency: milk llergies, blood product naphylaxis, giardi infections; IgA is missing in mucus so recurrent sinus and lung infections **Note: IgA deficiency also seen in :defective DNA repair enzymes, sensitive to ionizing radiation, cerebellar atrophy –> ataxia, spider angiomas (telangiectasias); assoc. w/ lymphomas and acute leukemias Hyper-IgE/Job’s Syndrome: "I’m Hyper Excited for my FATEd Job" Hyper Excited = H yper Ig E F = coarse F acies A = cold, noninflamed Staph A bcesses T = retained primary T eeth E = E czema Job = Job’s

Chediak-Higashi (a-r): "Grandpa Al couldn’t eat Eastern food with his fingers.“ Grandpa = Gram positive cocci infections: Staph and Strep Al = partial albinism couldn’t eat = defective microtubules = defective phagocytosis and lysosomal fusion Eastern = Higashi ("higashi” means “East” in Japanese) with his fingers = peripheral neuropathy



Pathology:

Proto-oncogenes: tumor promoters; damage one allele –> gain of function (VS. tumor suppressors need to damage both alleles to lose function)

“Mike’s sis returned with her2new breasts that she was able to-grow-faster b/c of herbs.”

Mike = myc: C-myc - Burkitt’s, N-myc - adrenal Neuroblastoma, L-myc - small cell lung CA

sis: astrocytoma, osteosarcoma

returned = ret: MENII

her2new = Her2/neu: breast cancer

was = ras: colon, bladder, lung, pancreas, renal CA

able = abl: CML, ALL (“ALL abl e CaMeLs are from Philadelphia t(9;22)”)

e CaMeLs are from Philadelphia t(9;22)”) to-grow-faster = TGF: astrocytoma, HCC

b/c = bcl2: follicular lymphoma

herbs = ERB-B1,2: ERB-B1 - lung squamous cell CA, ERB-B2 - breast, ovarian, gastric CA

Psammoma bodies: concentric Ca2+ spheres; looks like thumbprint; "PSaMMoma":

P = papillary thyroid tumor

S = serous cystadenocarcinoma of ovary

M = mesothelioma

M = meningioma

ESR (marker of inflammation): inflammatory product fibrinogen coats RBC causing aggregation –> weight pulls RBC down = fall at faster rate in test tube

incr/faster ESR = inflammation: infection, cancer, pregnancy, SLE…

decr/slower ESR = “de-prESsed Heart is Sick from Too Much Blood.” Heart = CHF Sick = Sickle Cell Too Much Blood = Polycythemia



Pharmacology:

Kompetitive inhibitors incr Km, decrease affinity/potency (amount of drug needed for effect); sigmoid effect curve shifts right; Lineweaver-Burke lines cross at Y-axis

(VS non-competitive inhibitors decr Vm, decrease efficacy (maximal effect of drug); sigmoid effect curve’s vertical maximum effect is reduced; Lineweaver-Burke lines join at X-axis)

Zero-order elimination: constant amount of drug eliminated per unit time = “PEA” - Phenytoin, Ethanol, Aspirin

Urine pH and drug elimination: medicine gets trapped in opposite urine pH:

acid (phenobarb, MTX, TCA, aspirin) trapped in basic bicarbonate

**Note: Acetazolamide alkalinizes urine by getting rid of bicarbonate; Tx: cysteine stones and altitude sickness (hyperventilation –> respiratory alkalosis)

**Note: Acetazolamide alkalinizes urine by getting rid of bicarbonate; Tx: cysteine stones and altitude sickness (hyperventilation –> respiratory alkalosis) base (amphetamine) trapped in acidic ammonium chloride

Phase I vs Phase II metabolism: "1 red ox went 2 conjugate polar bears.“

Phase 1: cyp450 red-ox (+ hydrolysis); geriatrics lose phase 1 first

Phase 2: conjugation (acetylation, glucuronidation, sulfation) –> yields very polar renally excreted inactive metabolites

Therapeutic index: "TILED” with TI= LD#/ED# and the #’s adding up to 100; safer drugs have higher TI’s

G-protein-linked 2nd messenger:

Gs = adenylyl cyclase –> ATP-to-cAMP –> PKA –> cascade

Gi = inhibit adenylyl cyclase –> decr cAMP –> decr PKA

Gq = phospholipase C –> lipids-to-PIP2 –> IP3 incr intracellular Ca2+, DAG stim PKC –> cascade

“Kiss and Kick 'til you’re Sick of Sex”

“QISS QIQ SIQ SQS”

Gq = alpha 1: SM contraction, mydriasis; incr Systolic and Diastolic BP

Gi = alpha 2: decr SNS, decr insulin

Gs = beta 1: incr heart rate and contractility, incr renin , incr lipolysis

and contractility, , incr lipolysis Gs = beta 2: decr Diastolic BP , vaso/ bronchodilation , incr heart rate, contractility, incr lipolysis, incr insulin release (think “ Beta 2 stimulates Beta islet cells of pancreas”), decr uterine tone

, vaso/ , incr heart rate, contractility, incr lipolysis, (think “ 2 stimulates islet cells of pancreas”), Gq = M1: CNS, enteric nervous system

Gi = M2: decr HR, decr atrial contractility

Gq = M3: incr secretions, peristalsis, miosis, accommodation (ciliary muscle contraction)

Gs = D1: renal perfusion (renal artery dilation)

(renal artery dilation) Gi = D2: brain neurotransmitter

Gq = H1: pruritus/pain, incr nasal/bronchial mucus, contract bronchioles

Gs = H2: incr gastric acid secretion (inhibited by “-idines”)

(inhibited by “-idines”) Gq = V1: incr vascular SM contraction

Gs = V2: incr H2O reabsorption in kidneys CD (ADH action)

Signaling pathways:

cAMP (Gs, Gi): "FLAT CHAMP + calcitonin + glucagon" F = FSH L = LH A = ACTH T = TSH C = CRH H = hCG A = ADH (V2) M = MSH P = PTH calcitonin glucagon (incr cAMP –> activates PKA –> incr F16BPase –> gluconeogenesis RLS)

IP3 (Gq): "hIP3othalamic GGOAT"

GHRH

GnRH

oxytocin

ADH (V1)

TRH

cGMP: vasodilators

ANP

NO (NO venodilates decreasing preload VS beta-blockers arteriodilate and reduce afterload)

tyrosine kinase: "the TyK Grows In Milk"

GH

IGF-1

FGF

PDGF

Insulin

Prolactin

steroid receptor: cytoplasmic (except thyroid hormone = intranuclear)

(Adrenal cortex:) Aldosterone, Glucocorticoid, Testosterone, Estrogen

Progesterone

Vitamin D

T4/T3 (intranuclear receptor)

Glaucoma drugs: "AABBCDF"

AA = A lpha A gonist: vasoconstriction –> decr aq humor synthesis ( not for closed angle glaucoma)

= lpha gonist: vasoconstriction –> decr aq humor synthesis ( for closed angle glaucoma) BB = B eta B locker (Timolol): decr aq humor secretion

= eta locker (Timolol): decr aq humor secretion C = C holinomimetic (Carbachol, Pilocarpine; “Phys is for the Eyes” Physostigmine, Echothiophate): incr outflow (contract ciliary muscle and open trabecular meshwork into canal of Schlemm)

= holinomimetic (Carbachol, Pilocarpine; “Phys is for the Eyes” Physostigmine, Echothiophate): incr outflow (contract ciliary muscle and open trabecular meshwork into canal of Schlemm) D = D iuretic: Acetazolamide (carbonic anhydrase inhibitor), Mannitol: decr aq humor secretion

= iuretic: Acetazolamide (carbonic anhydrase inhibitor), Mannitol: decr aq humor secretion F = PGF2alpha (Latanoprost): incr uveoscleral outflow; AE: dyes irises brown

Cholinomimetics:

Bethanechol: "Give Beth-ann-a-call if you want your PNS stimulated": Tx: post-op neurogenic ileus and urinary retention

Anticholinesterases = “-stigmines" + Edrophonium + Echothiophate

Organophosphate poisoning: "DUMBBELSS”: Tx: Atropine, Pralidoxime

Diarrhea

Urination

Miosis

Bradycardia

Bronchospasm

Excitation of skeletal muscle and CNS

Lacrimation

Salivation

Sweating

Atropine poisoning: "what would happen if you got lost in the desert: Hot, Dry, Red, Blind (cycloplegia), Mad (delirium), urinary retention(/constipation)“

Hexamethonium: "Put a Hex on reFLEX bradycardia” - Hexamethonium prevents NE reflex bradycardia by blocking all Nicotinic receptors (ganglion blocker inhibits Na/K ligand-gated channels)

ACh receptors:

Nicotinic = Na/K ligand-gated channels (ANS and NMJ) (Hexamethonium/Mecamylamine blocks these)

Muscarinic = G-coupled receptors; M1,2,3=QIQ (Atropine blocks these)

Specific antidontes:

DeFERoxamine Tx’s Fe (iron)

“Children Suck on Lead pencils”: Succimer Tx’s Lead poisoning in children (Tx is CaEDTA in adults)

DiMERcaprol Tx’s MERcury, arsenic, gold

“Copper Penny”: Copper, arsenic, gold Tx w/ PENIcillamine

NITRoprusside turns into Cyanide which is Tx’d w/ NITRite, hydroxocobalamin, and thiosulfate

METHylene blue and VitC Tx’s METHemoglobin

ETHANOL Tx’s mETHANOL poisoning

“Heparin’s H looks like a Proton”: PROTamine Tx’s Heparin toxicity

Drug reactions:

TCA’s “3 C’s”: Cardiotoxicity, Convulsions, Coma

Cutaneous flushing: "VANC" = Vancomycin, Adenosine, Niacin, Ca2+ channel blockers

D ilated cardiomyopathy = D oxorubicin and D aunorubicin

ilated cardiomyopathy = oxorubicin and aunorubicin Torsades de Pointes: "The Method to get 31Awesome QT’s is to wear a Halo and Risper that you bought a Macro-PIe from Quinn.“ Method = Methadone 31Awesome = Class III, Class Ia antiarrhythmics Halo = haloperidol Risper = risperidone Macro = macrolide PI = HIV protease inhibitors Quinn = Chloroquine/Mefloquine

Aplastic anemia: "Chlora SAID "Ptuey” to Meth": Chlora = Chloramphenical SAID = NSAID PTUey = PTU (antithyroid) Meth = Methimazole (antithryoid)

Hemolysis in G6PD: "Prima had to take Aspirin after INHaling her I.B.Professor Dapsone’s Sulfurous Fava Bean Nitrofarts" Primaquine Aspirin INH Ibuprofen Dapsone Sulfonamides Fava bean Nitrofurantoin

“Pseudomembranous colitis makes you want to ClAmp your ass”: CLindamycin, AMPicillin

Photosensitivity: "SAT for a Photo": S = Sulfonamides A = Amiodarone T = Tetracyclines

Stevens-Johnson rash: "'Seizures, Sulfa’s, and Cillins + Allopurinol" Seizure drugs: ethosuximide, lamotrigine, carbamazepine, phenobarbital, phenytoin Sulfa drugs Penicillin Allopurinol

SLE-like syndrome: "SHIPP" Sulfonamides Hydralazine (“Hydra’s neck Loops (Lupus) around in circles”) INH Phenytoin Procainamide

Disulfiram-like reaction: "Drunk Ceph said he was Pro-Car (okay to drive) at Night, but to avoid a Gruesome accident, Chlora made him Suffer the Metro.“ Ceph = Cephalosporin Procar = Procarbazine Night = Nitrofurantoin Gruesome = Griseofulvin Chlora = Chloramphenicol Suffer = Sulfonylureas Metro = Metronidazole

Ototoxicity/Nephrotoxicity: "Mice use Platinum earring Loops to crawl into your Ear and make you deaf” Mice = -mycins = aminoglycosides and vancomycin Platinum = Cisplatin Loops = Loop diuretics

p450 interactions: p450 inducers: "Queen Barb’s riFamily induced Saint John to eat a Pheny-looking Greasy Carb" Queen = Quinidine Barbara = Barbiturate riFamily = Rifampin induced Saint John = Saint John’s Wort Pheny-looking = Phenytoin (AE: gingival hyperplasia) Greasy = Griseofulvin Carb = Carbamazepine See reference: p450 inhibitors: "Without a Key, Kim was inhibited from PIES and Juice" Key = Ketoconazole Kim = Cimetidine inhibited PI = HIV Protease Inhibitors E = Erythromycin S = Sulfonamides Juice = grapefruit juice See reference:

Toxicity bear: Cumulatively Toxic Drugs and their Rescues Asparagine: neurotoxicity Cisplatin: ototoxic/nephrotoxic; Tx: Amifostine Vincristine/Vinblastine: "Christ my nerves, Blast my bones" - Vincristine = peripheral neuropathy, Vinblastine = myelosuppression Bleomycin: pulmonary fibrosis Doxorubicin: cardiotoxic; Tx; Dexrozoxane (for cardiotoxicity), Dimethyl-sulphoxide (for ROS ulcers) Cycl ophosphamide: Acrolein = nephro/bladder toxic (Tx: Mesna); also SIADH effects (Tx: Demeclo cycl ine) Methotrexate: nephrotoxic (Tx: Leucovorin), myelosuppression (Tx; Filgrastim) See reference:



Cardiovascular:

Contractility decreases with: "ABBCCC":

A = Acidosis

BB = Beta blocker

CCC = hyperCO2, CHF, non-DHP Ca2+ channel blockers

Heart murmurs:

“MR. ASS and MS. ARD” = MR = mitral regurg AS = aortic stenosis S = systolic murmurs and MS = mitral stenosis AR = aortic regurg D = diastolic murmurs

holosystolic = all regurg’s + VSD

murmurs that increase with breathing: rIght murmurs increase with Inspiration lEft murmurs increase with Expiration



“Wolf = Lone Canis” - Wolff-Parkinson-White is treated with amiodaRONE and ProCAINamide

AV blocks:

“First, a girl stays out 'til 12 even though her curfew is 10.”

“Then, the teenager stays out later and later, 'til her mom throws a fit.”

“Afterwards, despite the teenager being good, the mom throws random fits probably because of menopause.”

“Finally, the young woman is old enough to whatever she wants separately from her parents."

1st degree: increased PR

2nd degree: Type 1 Wenckebach: incr PR until QRS drop Type 2: random QRS drop

3rd degree: PR and QRS = independent rates; seen in Lyme disease

DiGeorge "Tet’s”: TETralogy of Fallow + TETany from hypocalcemia (lack of parathyroids) (also, truncus arteriosus)

“PGA open”: PGE kEEps PDA open (PGE1 analogs: Alprostadil, Misoprostol); close with Indomethacin

Evolution of MI: "4 and death are both pronounced “shi” in Japanese"

Initially: nothing

4 hours-4days later: PMN’s, coagulative necrosis, risk of arrhythmia (esp. V-fib)

4-10 days later: M0’s thinned walls –> increased risk of rupture and tamponade

>10 days: risk for ventricular aneurysm (bulging scar because fibrosis made it lose its ability to contract) <–ventricular remodeling can be prevented with ACE-I’s

Bacterial endocarditis: "FROM JANE":

Fever

Roth spots: round retinal white spots surrounded by hemorrhage

Osler’s nodes: tender raised red lesions on fingers and toe pads

Murmur (new)

Janeway lesions: non-tender small red lesions on palms and soles

Anemia

Nail-bed (splinter) hemorrhage

Emboli

IVDA = right-sided bacterial endocarditis: "don’t TRI drugs" (tricuspid valve)

SLE causes LSE (Libman Sacks endocarditis with warty sterile vegetations on both sides of valve, assoc. w/ mitral regurg)

Rheumatic heart disease of S. pyogenes (beta-hemolytic, bacitracin-sensitive Strep): "AAAAAA"

group A Strep

Strep a utoimmune ( A b to a ntiphagocytic M protein –> MVP –> Mitral Stenosis), fever

utoimmune ( b to ntiphagocytic M protein –> MVP –> Mitral Stenosis), fever A schoff bodies (granulomas with giant cells) = subcutaneous nodules

schoff bodies (granulomas with giant cells) = subcutaneous nodules A nitschkow cells (activated histiocytes)

nitschkow cells (activated histiocytes) elevated A SO titers and ESR

SO titers and ESR migratorypolyArthritis

+ Erythema martginatum, Syndenham’s/St. Vitus’ chorea (of face, tongue, and upper limb)

“ACE-inhibitors are ACE’s at controlling HTN”:

essential hypertension

HTN+CHF (decreases both preload and afterload)

HTN+DM (protective against Diabetic nephropathy)

Antihypertensive therapy: "ABCD":

ACE-I/ARBs

Beta blockers

Calcium channel blockers

Diuretics (“LOOps LOOse Calcium”, Thiazides retain calcium)

“Aden Diaz is Mine OK?”: Adenoxine, Diazoxide and Minoxidil Open K+ channels

Antiarrhythmics: "No Bad Boy Keeps Clean"

Type I: Na+ blocker (incr QT)

Type II: Beta blocker (incr PR); Tx OD w/ Glucagon

Type III: K+ blocker (incr QT)

Type IV: Ca2+ blocker (incr PR); Tx coronary and cerebral vasospasms

Type I antiarrhythmics:

Ia: "The Queen Werewolf Disappeared"

Quinidine, Procainamide, Disopyramide (incr AP)

Quinidine, Procainamide, Disopyramide (incr AP) Ib: "To Funny Little Mexico"

Tocainide, Phenytoin, Lidocaine, Mexiletine (decr AP)

Tocainide, Phenytoin, Lidocaine, Mexiletine (decr AP) Ic: "Properly Fleeing Endangerment"

Propafenone, Flecainide, Encainide

Type III: Amiodarone: "check PFTs, LFTs, and TFTs"

pulmonary fibrosis

hepatotoxicity

hypo/hyperthyroidism (amiodarone = mostly iodine, resembles thyroid hormone)

+ photodermatitis (“SAT for a photo”)

Endocrine:

Adrenal cortex: "GFR: The deeper you go, the sweeter it gets.“

"salt”: zona Glomerulosa: aldosterone

“sugar”: zona Fasciculata: cortisol

“sex”: zona Reticularis: androgens

Adenohypophysis = Anterior pituitary (RAthke’s pouch of ectoderm): "FLAT PEG"

FSH

LH

ACTH

TSH

Prolactin

endorphins (share POMC origin with ACTH and MSH)

GH

Basophilic = “B-FLAT”: Basophilic-FSH, LH, ACTH, TSH (VS Acidophils-Prolactin, GH)

Neurohypophysis = Posterior pituitary (Neural tube of ectoderm): secretes hypothalamic substances: "A Pair of Ox were Supra Dehydrated"

Paraventricular nucleus - Oxytocin

Supraoptic nucleus - Vasopressin (ADH)

Adrenal steroids: "In an enzyme deficiency, if the first digit is a 1, then the patient will be hypertensive. If the second digit is a 1, then the patient will look male.“

17alpha hydroxylase deficiency: HTN, feminine

21 hydroxylase deficiency (MC): hypotension, masculine

11 beta hydroxylase deficiency: HTN, masculine

PTH = phosphate trashing hormone (note: decreased free serum Mg2+, decreases PTH secretion; common causes of decr Mg2+ = alcohol, aminoglycosides, diarrhea, diuretics)

Calcitonin = from parafollicular C cells of thyroid = neural Crest derivative, secreted in medullary thyroid Cancer (MENII)

(Signaling pathway mnemonics were covered earlier)

Thyroid hormone functions: "T3 = 5B’s”

Brain (CNS) maturation (defect = mental retardation seen in Cretinism)

Bone growth (synergism with GH; defect = Cretinism)

Beta1 adrenergic effects (Thyroid Storm: incr HR, contractility –> arrhythmia; Tx with propanolol or PTU (OK in pregnant))

incr BMR

incr Blood sugar: glycogenolysis, gluconeogenesis, lipolysis

Pheochromocytoma (PCC): "Rule of 10’s"

10% malignant

10% bilateral

10% extra-adrenal

10% calcify

10% kids

10% familial

Neuroblastoma (MCC adrenal medulla tumor in children) = N-myc oncogene, stain = Neurofilaments, tumor marker = Bombesin

see Homer-Wright pseudorosettes and incr HVA (Dopamine derivative) in urine

scenario: ~2yo with retroperitoneal ab mass presents with HTN hypotonia, myoclonus, and non-rhythmic conjugate eye movements (opsoclonus-myoclonus)

mass may invade into an intervertebral epidural space and look like a “dumbbell”

HypOthyroidism = cOld intolerance; HypErthyroidism = hEat intolerance

“CHIMPANZEES” cause Hypercalcemia:

Calcium ingestion (incr antacids –> milk-alkali syndrome)

Hyperparathyroid/Hyperthyroid

Iatrogenic: Thiazides

Multiple myeloma

Paget’s disease (when patients are immobilized, normally normocalcemic)

Addison’s disease

Neoplasms (e.g., breast cancer = osteolytic)

Zollinger-Ellison syndrome (pancreatic tumor –> incr gastrin; associated with MENI (parathyroid tumor)

Excess vitamin D

Excess vitamin A (incr bone resorption –> incr Ca2+)

Sarcoidosis (or granulomatous disease)

Hyperparathyroidism:

Primary: Osteitis fibrosa cystica = “stones, bones, and groans” = kidney stones, brown bone tumors, weakness and constipation; incr cAMP in urine

VS Secondary: Renal osteodystrophy = renal disease –> decr Vit D –> decr Ca2+ –> incr PTH –> bone lesions

Hypocalcemia signs:

C = C hvostek sign = C heek tapping –> facial muscle C ontraction

hvostek sign = heek tapping –> facial muscle ontraction T = Trosseau’s sign = Tight BP cuff –> hand Tetany (spasm)

Dexamethasone vs Demeclocycline vs Desmopressin:

Dexamethasone = steroid to Dx ACTH disease/syndrome

DemecloCYCLine = tetracycline ADH antagonist vs CYCLophosphamide-induced SIADH; Tx: SIADH

DesmoPRESSIN = vasoPRESSIN (ADH) analog; Tx: central Diabetes insipidus

(Note: nephrogenic DI is treated by hydrochlorothiazide (Ca2+ sparing diuretic), indomethacin (decr renal blood flow), or amiloride (K+ sparing aldosterone receptor antagonist diuretic that closes Na+ channels that also reabsorbs Li to Tx Li-induced DI)

Multiple endocrine neoplasias (MEN): (A-D)

MENI (Wermer’s): "3P’s" pancreatic - ~Zollinger-Ellison gastrinoma - peptic ulcers parathyroid - incr PTH - hypercalcemia pituitary - ~prolactin or GH - amenorrhea, lactation

MENIIa (Sipple’s): "2P’s" parathyroid - incr PTH - hypercalcemia PCC - incr catecholamines (Epi/Nor), urine VMA and Metanephrine medullary thyroid (parafollicular C) - polygonal, incr calcitonin - hypocalcemia

MENIIb: "1P" PCC - incr catecholamines, urine VMA/metanephrine medullary thyroid (parafollicular C) - incr calcitonin - hypocalcemia Marfan’s habitus + oral/intestinal mucosal neuromas

Note: MENII’s are associated with ret oncogene

Also, “the II in MENII stands for the 2C’s in PCC”

Diabetic drugs:

“Metformin Glitters in Sunny Gliptin Tides”

Metformin = incr glucose uptake in muscle and fat via GLUT4 (aka incr insulin sensitivity in peripheral tissue) and decr liver glucose production via incr AMPK and decr PEPCK (OAAtoPEP) and decr G6Pase (G6PtoGlucose) production

= in muscle and fat via GLUT4 (aka in peripheral tissue) and decr liver glucose production via incr AMPK and decr PEPCK (OAAtoPEP) and decr G6Pase (G6PtoGlucose) production - Glitaz ones = incr insulin sensitivity via PPARgamma/adiponectin

ones = via PPARgamma/adiponectin Sulfonamides = incr pancreatic insulin production via blocking ATP-dep. K+ efflux

= pancreatic production via blocking ATP-dep. K+ efflux - Gliptin s, - Tides = incr insulin, decr glucagon , decr gastric motility (incr satiety)

s, - = , decr gastric motility (incr satiety) + Acarbose/Miglitol = decr starch hydrolysis and glucose GI uptake

Diabetes drugs mechanisms of action:

“PPARazzi camera flashes GLITA” - PPARgamma -'Glitazones

“GULP TIDES” - GLP1 -'Tides

“Dr.PPer and Lipton” - DPP4 inhibitor -'Gliptins

Acarbose - Alpha glucosidase

Remember:

insulin –> decreases cAMP –> decreases PKA –> dephosphorylated FBPase2 = PFK2 –> F6P to F26BP –> F26BP stimulates PFK1 –> incr F6P to F16BP (glycolysis)

glucose –> decreases cAMP –> decreases CAP-cAMP binding of lac operon = RNA polymerase can’t bind to promoter

Gastrointestinal:

Retroperitoneal structures: "I ASK DR. PC"

Primary retroperitoneal (never pushed into sac): IVC Ab aorta Suprarenal glands Kidneys/Ureters

Secondary retroperitoneal (pushed into sac, but escaped): Duodenum (2, 3, 4) Rectum Pancreas (head, body) Colon (ascending, descending)



OR "SAD PUCKER" = suprarenal, abdominal aorta, duodenum, pancreas, ureter, colon, kidney, esophagus, rectum

Digestive tract histology: "Brunch DIP":

Brunner’s (submucosal, alkaline mucus secreting) glands = Duodenum

Ileum = Peyer’s Patches (M cells take up antigen; also location of IgA-secreting plasma cells)

Note: Shigella is taken up by the M-cells of Peyer’s Patches; viruses like Adenovirus may invade Peyer’s Patches and cause intussusception; Sabin (live Polio vaccine) increases IgA immunity

Enteric nerve plexuses: "AUerbach is on the AUtside, MeiSSner’s is SSubmucosal"

Auerbach’s = Myenteric = coordinates Motility by being wedged between the inner/circular and outer/longitudinal muscles

Meissner’s = Submucosal = regulates Secretions, blood flow, and absorption between mucosa and inner/circular muscles

Defect in Auerbach’s causes Achalasia

Lack of both Auerbach and Meissner’s due to failure of neural crest cell migration causes Hirschsprung’s Congenital Megacolon, assoc. with Down Syndrome (see failure to pass meconium, like in Cystic Fibrosis)

Portosystemic anastomoses:

The mnemonic is from Systemic (IVC) to Portal (Celiac, SMV, IMV) veins:

“MI Superior’s an Ass. He makes me feel Inferior about my Superficial appearance by poking near my Belly-button so I Eat Less.”

Rectal anastomoses: (X=hemorrhoids)

“ MI Superior is an Ass ”:

Systemic: M iddle and I nferior Rectal

to

Portal: Superior Rectal

“ is an ”: Systemic: iddle and nferior Rectal to Portal: Umbilical anastomoses: (X=caput medusae)

“ Inferior about my Superficial appearance by poking near my Belly-button ”:

Systemic: Inferior , Superficial Epigastric

to

Portal: Paraumbilical

“ about my appearance by poking ”: Systemic: , Epigastric to Portal: Esophageal anastomoses: (X=esophageal varices)

“Eat Less”: (X = esophageal varices)

Systemic: Esophageal (azygos)

to

Portal: Left Gastric

Liver anatomy: "1ABC"

“1ABC”: Zone 1 = A pical surface of hepatocytes face B ile C analiculi = periportal zone Also, when you think of “ABC”, you should think of Hepatitis A, B, C… Zone 1 = first affected by viral hepatitis because closest to hepatic artery (Remember: Portal triad = bile duct, hepatic artery, and portal vein)

“The 3rd letter in the alphabet = C”: Zone 3 = C entrilobular (peri C entral vein) = where blood drains into the hepatic vein because it’s so far from the hepatic artery, it’s the first place to suffer from ischemia also, since blood pools in veins, you can think of drugs/poisons pooling there, too

Bottom line: Zone 1 = susceptible to viruses, Zone 3 = susceptible to drugs/ischemia

Femoral region: "NAVEL with the Venous near the Penis"

Lateral to medial: Nerve, Artery, Vein, Empty space, (deep inguinal) Lymphatics/Lacunar ligament

Note: femoral sheath does not contain femoral nerve

Inguinal canal: "INternal (deep) inguinal ring = INdirect hernia that may go INto the scrotum" = lateral to inferior epigastric vessels

VS. "an alien Directly bursting from your stomach" = direct hernia = protrudes from abdominal wall medial to inferior epigastric vessels:



or “MD’s don’t LIe”: Medial = Direct, Lateral = Indirect

“Fem-Fem”: femoral hernias occur more often in females (and is the leading cause of bowel incarceration)

GI secretory products:

“IF you PARTY too hard, you’ll vomit out a lot of GASTRIC ACID.”:

Parietal cells secrete IF (intrinsic factor) and HCl (gastric acid)

Parietal cells secrete IF (intrinsic factor) and HCl (gastric acid) “Pep-pep to the Chief”:

Chief cells make Pepsin

Vitamin/Mineral absorption:

Duodenum: "FED" = Fe (iron) in Duodenum

Jejunum: "The Jester is a Fat Fool" = Jejunum absorbs most Fats and Folate

Ileum: The ileum is the last part of the small intestine; it’s where you say “Bye Bye to the SI”: Byle acid, B12/IF is reabsorbed in the Ileum

Bilirubin:

Rules of thumb: The two-named diseases don’t go together The one named diseases are milder

IN direct = UN conjugated = water IN soluble: Crigler-Najjar, Gilbert =

“KING KONG” –> “CING CUNG” –> C riggler- I ndirect/ U nconjugated- N ajjar- G ilbert

You get Crigler-Najjar/Gilbert’s when you’re unable to conjugate bilirubin into a water-soluble/excretable form ~ Glucuronyl transferase deficiency

direct = conjugated = water soluble: Crigler-Najjar, Gilbert = “KING KONG” –> “CING CUNG” –> riggler- ndirect/ nconjugated- ajjar- ilbert You get Crigler-Najjar/Gilbert’s when you’re unable to conjugate bilirubin into a water-soluble/excretable form ~ Glucuronyl transferase deficiency Direct = conjugated = Water soluble: Dubin-Johnson, Rotor’s =

“Dubin-Johnson called Rotor-rooter to fix his WaterPipes.”

You get direct bilirubinemia when there’s a problem with bile Pipes/excretion (E.G., biliary tree obstruction)

Note: Dubin-Johnson is “worse” than Rotor’s in that the liver is pigmented black

Achalasia: "AABBCC"

Ach alasia

alasia loss of A uerba ch ’s myenteric plexus

uerba ’s myenteric plexus B irds beak on B arium swallow

irds beak on arium swallow associated with Chaga’s and CREST

Boerhaave syndrome = “Been-Heaving”; transmural complication of Mallory-Weiss

BARRett’s esophagus = Becomes Adenocarcinoma, Results from Reflux

Esophageal cancer risk factors: "ABCDEFGH"

Alcohol, Achalasia

Barrett’s esophagus

Cigarettes

Diverticuli (e.g., Zenker’s)

Esophageal web (e.g., Plummer-Vinson), Esophagitis

Familial

GERD

Hot dogs (nitrosamines)

Esophageal cancer epidemiology and locations:

S quamous cell = S pread out worldwide (most prevalent worldwide); upper 2/3s (where striated muscle can be found)

quamous cell = pread out worldwide (most prevalent worldwide); upper 2/3s (where striated muscle can be found) Adenocarcinoma = most prevalent in America (lower 1/3, location of pure smooth muscle)

Gastritis:

Acute gastritis (erosive): “Burned by Curling iron”: Curling’s ulcer = stress ulcer from burns:

decr plasma volume –> sloughing of gastric mucosa “Cushion the brain”: Cushing’s ulcer = stress ulcer from head injury:

incr ICP –> incr vagal stimulation –> incr ACh –> incr H+)

Chronic gastritis (non-erosive): "AB-pairing" Type A (fundus/ B ody) = A utoimmune/ A nemia:

AutoAb to parietal cells, pernicious anemia (Ab to IF), achlorhydria Type B ( A ntrum) = B acterial:

H.pylori infection (duodenal > stomach ulcer), increased risk of MALT lymphoma



Peptic ulcer disease:

G astric ulcer pain = G reater with food

astric ulcer pain = reater with food Duodenal ulcer pain = Decreases with food (will see hypertrophy of Brunner’s glands and clean “punched out” margins unlike carcinoma raised/irregular margins)

Inflammatory bowel disease (IBD): Crohn’s vs Ulcerative Colitis

Crohn’s: "A Creepy Fat old Crone (Granny) went Skipping on Cobblestones while pumping her Arthritic Fist in the air.“ Creepy Fat = Creeping fat Crone = Crohn’s disease (Granny) non-caseating Granulomas Skipping = transmural Skip lesions Cobblestone = Cobblestone mucosa Arthritic = Migratory polyarthritis Fist = Fistulas "Gum to Bum” lesions and extraintestinal manifestations (systemic) like erythema nodosum (~shins), ankylosing spondylitis, and uveitis Note: this is disordered response to intestinal bacteria

Ulcerative colitis: "If you have a Lead Pipe jammed up your Rectum, you’ll get Bloody Diarrhea.“ Lead Pipe = loss of haustra leads to "lead pipe” appearance on imaging Rectum = UC always involves the rectal mucosa/submucosa and procedes continuously up unlike Crohn’s which tends to spare the rectum Bloody diarrhea (another trait not shared with Crohn’s) Note: this is autoimmune UC is also associated with friable pseudopolyps, pyoderma gangrenosum, and primary sclerosing cholangitis



Meckel’s diverticulum: "Rule of 2’s"

2 inches long

2 feet from ileocecal valve

2% of population

2yo (or younger)

2 types of ectopic epithelia: gastric or pancreatic

Colonic polyps: "VILLous = VILLainOUS" because villous polyps are more likely to be malignant (villous > tubulovillous > tubulous)

Colorectal cancer (CRC):

Familial adenomatous polyposis (FAP): "polyposis" = thousands of polyps; F APC ancer involves APC gene; always involves rectum

VS. HNPCC/Lynch which doesn’t have many polyps and involves the PROXIMAL colon

ancer involves gene; always involves rectum VS. HNPCC/Lynch which doesn’t have many polyps and involves the PROXIMAL colon Gardner’s syndrome = “Gardeners Grow all kinds of things”: Gardner’s = FAP + osteomas + lipomas/soft tissue tumors + retinal hyperplasia

Turcot’s syndrome: "TURcot = TURban"; FAP + malignant CNS tumor (medulloblastoma)

Presentation of CRC: Think of the colon as a funnel that shrinks towards the anus (and also that visceral nerves don’t have as many localized pain receptors as the anus):

distal colon (left side, near anus) = obstruction, sharp colicky pain, hematochezia

proximal colon (right side) = iron deficiency anemia, dull pain, fatigue

CRC: "Apple core" lesion on barium enema x-ray, CEA tumor marker

Molecular pathogenesis of CRC: alphabetical order

lose APC (decreased intercellular Adhesion) then mutate kRAS (unregulated signal transduction MAPK) then lose p53 (no apoptosis)

Wilson’s disease (hepatolenticular degeneration): a-r inadequate copper excretion, treated with penicillamine (“copper penny”): "ABCDEF"

Asterixis, Ataxia, Anemia (hemolytic)

Basal ganglia degeneration (Parkinsonism)

decr Ceruloplasmin, Cirrhosis, Corneal deposits, Cancer (HCC)

Dementia

Encephalopathy

Fanconi’s Syndrome: defective PCT reabsorption

Gallstones (cholelithiasis): Risk factors = 4F’s:

Fat

Fertile

Female

Forty

Acute pancreatitis causes: "GET SMASHED" –> DIC, ARDS…

Gallstones

Ethanol

Trauma

Steroids

Mumps

Autoimmune disease

Scorpion Sting

Hypercalcemia, Hyperlipidemia

ERCP

Drugs (E.G., Sulfa drugs)

Antacid adverse effects:

Al = Alu MINIMUM amount of feces: constipation

amount of feces: constipation Mg = Must Go to the bathroom: diarrhea

And this was where I stopped. If you have specific questions, feel free to ask me (but don’t forget to leave me a way to contact you!).

I hope this list comes in handy for someone. Good luck with the exam!

Update (3/31/13): Unfortunately, I’m very busy with clerkships/shelves and studying for the Step2CK, so I won’t be able to post the rest of my mnemonics, but my Ask box is always open for advice! ^^ Thanks for understanding.