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

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

Behavioral Science:

Statistical distribution:

Positive skew = meAn>meDian>mOdePositive 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, RubellaShigellaTBSalmonellaChicken PoxHepatits A, B, C

Health care payment:

CARE for the Elderly, AID the destituteMedicare - elderly, Medicaid - low income people

Early developmental milestones:

# of blocks stacked = age in years * 32 word sentences at 2“pee at three”; tricycle at three“four-square at four” = can hop at fourdrawings:

3yo = circle4yo = +5yo = square6yo = triangleSee reference:

Biochemistry:

Stop codons: UGA, UAA, UAGU 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.”

MycsisretHer2/neurasablTGFalphabcl2ERB-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 withER)Type 2 - cartilage - death in uteroType 3 - blood vessels - Ehlers-Danlos (failure of cross-linking by lysyl oxidase to make collagen fibrils outsidefibroblasts), berry aneurysmsType 4: basement membrane - Alport’s nephritis (+ deafness and vision problems; “can’t see, can’t pee, can’thear”)

Blotting procedures:

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SNOWDROP

S/D: Southern blot = DNA sample identified with DNA probeN/R: Northern blot = RNA sample identified with DNA probeO/OW/P: Western blot = protein sample identified with antibody probe

Model systems:

Knock out = take a gene OUTKnock in = INsert a geneKnock down = knock down the expression of the gene via complementary mRNA antagonist

Imprinting:

Prader-Willi = Paternal deletionAngelMan’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, 2Dwarf = AchondroplasiaMarfanvon Hippel-LindauMEN1, 2a, 2bHuntingtonsPotato = Tuberous sclerosis

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

Duke = Duchenne’sFabryBrutal = Bruton’sGopher —> G6Pher = G6PD deficiencyHunter = Hunter’sLesch-NyhanWas-Actually = Wiskott-AldrichFragile Xocular AlbinismHemophilia A, B

Fragile X = Xtra large testes, jaws, ears

FraGile X = cGg trinucleotide repeatmyoTonic dystrophy = cTg trinucleotide repeat

Autosomal trisomies: Pat Ed Down = 13, 18, 21Puberty 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 PancreasHirschprung 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 palateAbnormal faciesThymic aplasia (T-cell deficiency)Cardiac defectsHypocalcemia (secondary to parathyroid aplasia; remember third pharyngeal pouch: inferior parathyroids aregrown with thymus and descend together)microdeletion at chromosome 22q11

Vitamin B1: ThiamineThiamine 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: alphaKGDHHMP: transketolasebranched 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, beriberiPDH 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 andhigh fat diet (beta oxidation of fats will produce acetyl CoA —> TCA/ketogenesis).

Vitamin B6: PyridoxineMajor pathways that use B6:

1. Glycogenolysis RLS: Glycogen —> G1P via glycogen phosphorylase2. Heme synthesis RLS: Succinyl CoA (TCA) + Glycine —> delta aminolevulinic acid (ALA) via deltaaminolevulinic

acid synthase3. 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 toalkalinize urine

4. ALT/AST transamination:Alanine+alphaKG(TCA)<—ALT—>Pyruvate(glycolysis)+glutamateAspartate(Urea cycle)+alphaKG(TCA)<—AST—>OAA(TCA)+glutamate

5. Amino acid production (hydroxylation, decarboxylation reactions):1. tyrosine —hydroxylation—> dopa —decarboxylation—> dopamine2. tryptophan to niacin/B3 (no B6 = no B3 = Pellagra)

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3. histidine to histamine4. glycine to porphyrin (in heme production; no B6 = hypochromic, microcytic anemia)5. glutamate to GABA (no B6 = loss of GABA = increased excitation —> convulsions/seizures)

Vitamin B12: CobalaminCofactor when you see “Meth” in product or substrate:

1. METHylmalonylCoA —> Succinyl CoA via methylmalonylCoA isomerase2. homocysteine + N-METHylTHF —> METHionine + THF via homocysteine methyltransferase

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

Other causes of megaloblastic anemia = folate deficiency (incr. homocysteine but not methylmalonic acid, so noneuropathy) and chronic alcoholism.

Vitamin B7: BiotinWhile Vitamin B6 is needed for DEcarboxylation reactions (amino acid production), B7 is needed for CARBOXylationreactions:

1. PropionylCoA(oddchainFA/branchedchainAA metab)—>MethylmalonylCoA via proprionylCoA carboxylase (whichgoes on to form succinyl CoA of TCA with methylmalonylCoA isomerase and B12)

2. Pyruvate(glycolysis)—>OAA (TCA) via pyruvate carboxylase3. AcetylCoA(TCA)—>MalonylCoA(FA synthesis RLS)

Avidin in egg-whites Avidly binds B7.

Vitamin C: Ascorbic Acid

1. Iron absorption and Fe2+ state maintenance2. Collagen synthesis: hydroxylation of proline and lysine within fibroblast ER <—SCURVY3. 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’s25OHvitamin 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, butincreased PT and aPTTNote:

platelet dysfunction —> BTextrinsic (shorter) pathway —> PT (shorter name); VII; monitor w/ Warfarinintrinsic (longer) pathway —> PTT (longer name); monitor w/ Heparin

Carbamoyl phosphate synthetase: ”UP 1, 2.”

Urea cycle RLS: CPS1Pyrimidine synthesis RLS: CPS2

HMGCoA ___:

“You always want to REDUCE your CHOLESTEROL”: HMGCoA reductase = RLS for cholesterol synthesisvs. HMGCoA synthase = ketogenesis (your brain wants to SYNTHESIZE KETONES when there’s no glucose)

Regulation by F2,6BP: ”2 supports 1:”

PFK2 supports PFK1 —> glycolysisF26BP 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 topromoter

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

HMP shunt/Pentose Phosphate Pathway:

G6P —> Ribulose5P + 2NADPH via RLS G6PDHRibulose5P —> Ribose5P —> purine synthesis

NADPH:

1. fatty acid and steroid synthesis2. oxidative burst (NADPH oxidase; X = Chronic Granulomatous Disease)3. p4504. 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 = PrimaquineAspirinINH (Isoniazid)I.B.Professor = IbuprofenDapsoneSulfurous = SulfonamidesFava beanNitroFarts = 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.colired = SerratiaAsp = AspergillusSorry = S. Aureusmoaning = PseudomonasCat = Catalase + organismNoHeart = Nocardia

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

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Glucose —> G6P via Gluco(Hexo)kinaseFructose —> F1P via FructokinaseGalactose —> Gal1P via Galactokinase

Deficiencies of Fructo and Galactokinases causes MILD symptoms (respective sugars are present in urine). The SEcondsteps 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 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(R), LYSINE(K))

Negatively charged amino acids:Negative experience to be burned by Acid:Aspartic acid and glutamic acidNote: 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 EDRKY C H ED

Arginine(R) - 12.5Lysine(K) - 10.5Tyrosine(Y) - 10.1Cysteine(C) - 8.2Histidine(H) - 6Aspartic acid(E) - 4.3Glutamic 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/cdecreased NH4+ excretion).Sx: asterixis, slurred speech, somnolence, blurry vision, vomitingTx: less protein in diet + Benzoate/Phenylbutyrate (bind a.a.—>excrete)

OTC = major urea cycle enzyme:Ornithine + carbamoyl-phosphate —> Citrulline via OTCOTC deficiency (x-r) = shunting of carbamoyl phosphate from urea cycle to pyrimidine synthesis:carbamoyl phosphate + aspartate —> orotic acidOrotic 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 —(DopamineHydroxylase/VitC, blocked by Reserpine)—> NE —(PNMT/SAM)—>Epinephrine

Tryptophan(X in Hartnup’s):—(B6)—> Niacin=B3 —> NAD+/NADP+ (X = Pellagra)—(BH4)—> Serotonin —> Melatonin (sleep)

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/renaldisease“Gauched out my femur when I was on a sugar high”Gaucher, Femur Necrosis, Sugar High = GlucoCerebrosidaseGaucher’s = betaGlucocerebrosidase —> incr glucocerebroside: aseptic femur necrosis, hepatosplenomegaly,crumpled tissue paper cytoplasmBlind Intelligent Intergalactic CrabIntelligent Intergalactic = GalactocerebrosideKrabbe’s = Galactocerebrosidase —> incr galactocerebroside: blindness, peripheral neuropathy, developmentaldelay, globoid cellsNiemann Pick’s his nose with hisphingerNiemann-Pick = Sphingomyelinase —> incr Sphingomyelin: cherry macula with hepatosplenomegaly,neurodegeneration, foam cells“Sulfur tides are multicolored”Sulfur tide = SulfatideMulticolored = MetachromicMetachromic leukodystrophy = Aryl sulfatase A —> incr Sulfatides: central and peripheral demyelination withataxia, dementia

Mucopolysaccharidoses:

HurLer’s = alpha-L-iduronidase —> incr heparan sulfate, dermatan sulfate: corneal clouding, gargoylism, airwayobstructionHunter’s = iduronate sulfatase —> incr heparan sulfate, dermatan sulfate: NO CORNEAL CLOUDING becauseHunter’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:

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Sonic the Hedgehog fights a One-Eyed Monster:Sonic Hedgehog mutation —> HoloprosencephalyFGF gene = Fibroblast Growth Factor: Growth Factor lengthens limbsFGF mutation —> Achondroplasia (A-D dwarfism)HOX (Homeobox) gene: ”Boxes help with organization”organizes/determines limb location (Vitamin A toxicity alters HOX expression —> cleft palate, cardiacabnormalities, 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 budsNote: 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 = DorsalDAVE: Dorsal=Afferent, Ventral=Efferent

Embryologic derivatives:

Ectoderm:Surface: what you see (epidermis, hair, nails, teeth enamel, eye lens…) + anterior pituitary (Rathke’spouch)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 materIntermediate: urogenital ridge (kidneys and ureters, vas deferens, gonads, uterus and uterinetubules…)Lateral: non-skeletal muscle and blood-related organs (visceral muscle and connective tissue, blood,lymph, spleen, cardiovascular system…) + adrenal cortexNote: spleen = mesoderm, but supplied by celiac artery of the foregutMESODERMAL DEFECTS = “VACTERL”: Vertebral defects, Anal atresia, Cardiac defects,Tracheo-Esophageal fistulas, Renal defects, Limb defects

Endoderm: ear/mouth to anus hollow lining and organs + bladder and vaginatympanic cavity/auritory tube, tonsils, thymus, thyroid, parathyroidlarynx, trachea, bronchi, lungsGIT, liver, gallbladder, pancreasurinary bladder, urethra, lower 2/3 vagina (this explains how patients can still have a vagina even ifthe 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)Maternal Diabetes: hyperglycemia —> incr fetal insulin —> decr lung development = can’t breathe; “mermaidsalso 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 ligamentUmbiLical artery —> mediaL umbilical ligamentUmbilical vein - ligamentum teres hepatis

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

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

Heart embryology:

Primitive __ —> trabeculated (rough) portion of __Smooth atrium = sinus venosusSmooth ventricle = bulbus cordisSVC = right common and anterior cardinal veinsAorta/Pulmonary artery = truncus arteriosus, separated by spiraling neural crest migration (X = Transposition ofGreat 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) - @ faceII: hyoid/stapedial artery - @ midline throatIII: common and internal carotid arteries - @ midline neckIV: right subclavian artery and aortic arch - @ right/middle chestVI: 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 hairMeningocele: herniation of meningesMeningomyelocele: 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 meatusClefts 2-4: temporary cervical sinus (fail to obliterate = lateral neck branchial cleft cyst)

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

Branchial ARCH - mesoderm: ~musclesThe 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 tympanigrimace = arch 2 (VII) = facial expression + stapes/stapedius (defect = Treacher Collins’ mandibular hypoplasiaand facial abnormalities)swallowed = arch 3 (IX)= stylopharyngeus (defect = fissure from neck to tonsils)choked = arch 4 (X, sup laryngeal)= pharyngeal constrictors and cricothyroidcalled 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 cellsPouch 2 = tonsils and tonsillar sinusPouch 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 ductsJOINSMetanephric 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 = MesonephricPemale = 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 (lower2/3 from urogenital sinus of endoderm)

Female = default genitals

Hormone overview:

Prolactin stimulates Dopamine inhibits ProlactinProlactin inhibits GnRHGnRH —> incr FSH, LHL in LH and Leydig: LH stimulates Leydig cells to produce testosterone —> develop Wolffian ductS in FSH, Sertoli, and Sperm: FSH stimulates Sertoli cells to produce Sperm, Inhibin, and Mullerian inhibitingfactor (MIF); MIF inhibits female paramesonephric duct development

Genital homologues:

Urogenital sinus:Bulbourethral glands = Bartholins greater vestibular glandsproState gland = Skene 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 andBruce.”

Claustrophobic = ClostridiumPastor = PasturellaSalmon = SalmonellaEchoed = E.coliBack = Bacillus anthracis (D-glutamate)Yersinful = YersiniaCrypt-dark = Cryptococcus (India Ink, narrow-based budding in meningitis)Strip = StreptococcusClubs = KlebsiellaPseudo = PseudomonasHomes = HaemophilusNice men = Neisseria meningitidisFrancis = FrancisellaBruce = Brucella

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

“Staff of grapes” = Staphylococcus is in clustersVS. Streptococcus = pairs/chains

Spirochetes: ”Spiraling Boris Lept then Tripped”

Spiraling = SpirochetesBoris = Borrelia (Giemsa stain = aniline dye; relapsing fever = result of antigenic variation)Lept = LeptospiraTripped = 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

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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 agarCorny = CorynebacteriumLaugh = 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 = NOcardiaAer = pseudomonas AERuginosaAnthrax = B. anthracisTB = M. tuberculosis

Microaerophils = “bacters”: Campylobacter, Helicobacter

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

BACTERia = Bacteroides (E.G., B. fragilis)ACTIN = ActinomycesCLOSTRophobic = CLOSTRidium

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

R = RickettsiaE = EhrlichiaA = AnaplasmaCh = ChlamydiaMy = MycoplasmaCox = CoxiellaInside = intracellular

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

Legions = LegionellaSalmon = SalmonellaRabbits = FrancisellaN = NeisseriaCows = BrucellaTumble = ListeriaIn = intracellularMy = Mycobacterium

Note: intracellular pathogens require cell-mediated immunity (CMI), so neonates are at risk (E.G., Listeria —> neonatalmeningitis: 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 phagocytosisM 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 M0and IgM/complement C3 activation (E.G., Sickle Cell autosplenectomy)) + causes meningitis = SHiNNote: can also undergo “transformation” (pick up DNA from environment)

Strep pneumoH. influenza type B (B polysaccharide)Neisseria meningitidis

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-labileENDOtoxin (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 MACROPHAGEresponse (binds CD14-M0 marker) —> release TNF and IL-1 (no Th involvement)

M0 activation:IL1 = FeverTNF alpha = fever, hemorrhagic tissue necrosisNitric oxide = hypotension/shock

alternate complement pathway:C3a = Anaphylaxis (basophil and mast cell degranulation —> hypotension, edema)C5a = neutrophil chemotaxis

Hageman factor: coagulation cascade—> DIC/microthrombi

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 symptomsNote: 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 cyclaseheat-Stable toxin stimulates Guanylate cyclase

Both cause watery diarrhea.

Bacterial Toxins Envoded in Lysogenic Phage: ”ABCDE”

ShigA-like toxin - EHEC 0157:H7 - cleaves host cell rRNA/inactivates 60S; also, incr cytokines —> HUSBotulinum toxin - inhibits ACh vesicle release from presynaptic neuron —> flaccid paralysisCholera toxin - activates Gs —> incr cAMP —> incr Cl- secretion into gut = decr Na+ absorption —> waterydiarrheaDiptheria toxin - ADP-ribosylating A-B toxin (like Pseudomonas exotoxin A) - B binds, A enters and ribosylatesEF2 —> no more protein synthesis —> cell death; pseudomembrane formationErythrogenic (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”: Staph. Epi = Novobiocin SENSITIVE” (VS. Staph. saprophyticus =

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Novobiocin resistant)alpha hemolytic Strep: ”OVeRPasS”: Optochin Viridans Resistant, Pneumonia SensitiveNote: Strep pneumonia is bile soluble (= can’t be cultured in bile, unlike gamma hemolytic Strep) beta hemolytic Strep: ”BBBR”: Beta hemolytic, group B strep (Strep agalactiae), Bacitracin Resistant (VS. groupA 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 nodesYou think they are “Ghon” but they’re just waiting to become secondary TB (fibrocaseous cavitary lesion ofUPPER lobe)

gram negative: acetone + saffranin = pink

N. Meningities ferMents Maltose, has a capsule, and vaccine (gonorrhea doesn’t; NOTE**: gonorrhea’s pilusprotein undergoes antigenic variation!!)Note:-N. meningitidis = respiratory/oral spread —> meningococcemia and Waterhouse-Friderichsen adrenalhemorrhage (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), KlebsiellaNon-lactose fermenters = “PSSY”: Proteus, Salmonella, Shigella, YersiniaH2S producing (black on Hektoen Agar) + motile (flagellar H antigen): Proteus (swarming, urease+,staghorn ammonium struvite stones), SalmonellaNote: Salmonella and Shigella both invade mucosa —> bloody diarrhea; Salmonella is motile (w/ 2flagellar antigen variants) and produces H2S, S. typhi of Typhoid fever causes abdominal rose spotsand can remain chronically in gallbladder; Shigella is more virulent, moves by actin polymerization and60S deactivating toxin induces HUS.

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

Camping = CampylobacterPasture = PasturellaMoan = PseudomonasMore = MoraxellaNice = NeisseriaVibrators = Vibrio

VDRL false positives: ”VDRL”

V = viruses: EBV, hepatitisD = drugsR = 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 EndocytosisReticulate 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 parietalperitoneum 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 —> blindnessVS. L1-L3 = Lymphogranuloma venerum: ulcers —> lymphadenopathy, rectal strictures mistaken for PIDTx: mothers and infants with Chlamydia with Erythromycin estolate, though there is a risk of maternal acutecholestatic hepatitis

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

My = Mycoplasma (IgM = cold agglutinins —> agglutinate or lyse RBCs; grown on Eaton’s agar; Tx: tetracyclineor 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 RiverHis = Histoplasmosis = Mississippi River and Ohio riverCock = Coccidiomycosis = Southwest US: CA, AZ

“His Woodpecker Blasted Wood into Dust”:

His Woodpecker = Histoplasmosis from bird/bat droppings = macrophage filled with round yeast; “Histo Hideswithin macrophages”Blasted Wood = Blastomycosis in wood = Broad-Based-Budding fungi; the handle of a baseball bat looks like it’sbudding off the shaft)Dust = Coccidiomycosis = large spherule filled with endospores; “barrel-shaped arthroconidia”; “Cock is filled withSperm, Coccidio is filled with Spores”

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

Helminth drugs:

Worms = BendazolePraziquantel = foods: Pork, Fish, Crab, Snails

Pork = TaeniaFish = Diphyllo, ClonorchisCrab = ParagonimusSnails = Schistosoma

Antigenic shift vs. drift: ”SPED”

Shift (reassortment via segmented viruses) = PandemicEpidemic = Drift (random mutations)

Vaccines:

Live: ”See MMR. Sabin’s small yellow chickens live.”

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MMR = Measles, Mumps, RubellaSabin (Polio, oral)small poxyellow feverchicken pox/shingles

Killed: ”RIP Always”RabiesInfluenzaPolio (SalK = Killed, injected)Adenovirus

Recombinant: ”H_V”Worms = BendazolePraziquantel = foods: Pork, Fish, Crab, Snails

Viruses:

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

He = HerpesHe = 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 perinuclearcytoplasmic 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 = HSV1,2Chickens = HHV3: Chicken pox (truncal rash —> extremities; lesions of different age)/shinglesBarred = HHV4: EBV (mono, Burkitt’s, large cell non-Hodgkins @ Waldeyer’s ring, nasopharyngeal CA, hairyleukoplakia on lateral tongue; infects B cells via CD21-EBV receptor)Sight = HHV5: CMV (retinitis, negative mono-spot mono, TORCH; both intranuclear “owl-eye” and cytoplasmicinclusion 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/myocarditisC = Coxsackie: aseptic meningitis/myocarditis, hand-foot-mouth (palm and sole vesicular rash alsoseen 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, SSPEcomplication, MeaslesVS. 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 = croupR = 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 syncytiaformationMx2 = Measles and Mumps:

Measles: ”A PARA RUBY weasles caught SSPEcial Measles” = paramyxo, rubeola, SSPEcomplication, Measles’ 3 C’s = cough, coryza, conjunctivitis + Koplik spots; rash from headdown like RubellaMumps: 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: PCRHCV = Flavi (env, +RNA); blood (IVDA, transfusion); Dx: RT-PCRHDV = Delta (defective env, -RNA); infects with HBVHEV = 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+PyrimethamineR = Rubella (Togavirus, +RNA): PDA, cataracts, deaf, blueberry muffin rash; maternal rash and arthritisC = CMV: Toxoplasma triad (intracranial calcification, chorioretinitis, hydrocephalus) + UNILATERAL hearing loss,seizuresH = 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) = CephalosporinMet = MetronidazoleVancouver = VancomycinPenpal = PenicillinAmina = AminoglycosidesFlorida = Fluoroquinolones

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Antimicrobial drugs:

1. inhibits PG cross-linking —> no cell wall: ”Ceph Chills-in ‘Nam watching PG movies”:1. Ceph = Cephalosporin2. Chills-in = ‘cillins (binds PBP, block transpeptidase cross-linking; Penicillin = endocarditis prophylaxis

(before surgery/dental), syphilis prophylaxis)3. ‘Nam = AztreoNAM (binds PBP3 for Pencillin-allergy pts; vs “SEEK Pseudomonas”- Serratia, E.coli,

Enterobacter, Klebsiella, Pseudomonas), MeropeNEM and ImipeNEM+Cilastatin (Merpenem/Imipenemvs. everything, esp. Enterobacter, but causes SEIZURES; Cilastatin inhibits renal dihydropeptidase I toinhibit renal tubule Imipinem inactivation)

2. blocks PG synthesis:1. Bacitracin (vs. S. pyogenes (GAS))2. Vancomycin (binds D-Ala-D-Ala and interferes with PG-elongating transglycosylase

1. vs. resistant G+ inc, MRSA and C.diff!!2. “TON of AE’s”: T = thrombophlebitis, O = ototoxic, N = nephrotoxic + Red Man (slow infusion

and pretreat with anti-histamine to prevent)) 3. vs. g- by disrupting cell membranes: Polymyxins (neosporin) - detergent vs cell membrane; AE: neurotoxicity,

acute renal tubular necrosis4. vs. G+/g- by blocking folate —> no nucleotide synthesis (megaloblastic anemia):

1. Sulfonamides (comp inhibit PABA for dihydropteroate synthetase —> no DHF synthesis; AE: infantkernicterus (avoid in pregnancy), SJ, nephrotox, G6PD hemolysis)

1. Sulfamethoxazole-Trimethoprim (TMP-SMX) vs UTI, P. jirovecii prophylaxis in AIDS2. Sulfadiazine+Pyrimethamine vs Toxoplasma3. Sulfadoxin+Pyrimethamine vs Malaria

2. Trimethoprim, Pyrimethamine (DHF—Xdihydrofolate reductase—>THF like Methotrexate)5. vs. URIs (S. pneumo), UTIs, GITIs, and Pseudomonas by blocking topoII (DNA gyrase) and IV: Fluoroquinolones

(AE: cartilage/tendon rupture, incr QT, G6PD hemolysis)6. vs. Mycobacterum, prophylaxis for Hib and N.men by blocking DNAdRNAp = no transcription: Rifampin7. Protein synthesis inhibitors: ”Quinn get in Line and take 50MC’s to 30ST”:

1. Quinn, Line 50MC’s = Quin-Dalfo, Linezolid, Macrolides, Chloramphenicol/Clindamycin block 50S1. Quin-Dalfo (streptogramins): Quinupristin prevents elongation, Dalfopristin changes 50S

conformation for better Quin-binding2. Linezolid: binds 50S P-site and blocks 70S assembly

Tx: Quin-Dalfo and Linezolid is good for ALL RESISTANT BACTERIA: VRE, MRSA 3. MACrolidEs (“ACE”mycin = Azithro, Clarithro, Erythromycin): “MacroLIDEs prevent sLIDing of

mRNA” = inhibit translocation by binding to 23S of 50S1. Tx: “PUS” - atypical Pneumonia, URI’s, STDs2. AE: PROLONG QT, acute cholestatic hepatitis, incr serum concentration of

warfarin3. resistance via METHYLATION OF drug binding site on 50S rRNA

Note: Azithromycin = AIDS MAC prophylaxis4. Chloramphenicol: “ChLorAMPS Peptidyltransferase” - prevents peptide bond formation; Tx:

meningitis (H. flu, N. men, Strep. pneumo); AE: aplastic anemia and gray baby; resistance viaACETYLATION

5. Clindamycin: also blocks peptide bond formation at 50S; vs. ANAEROBES (B. fragilis, C.perfringens) like Metronidazole; AE: Pseudomembranous colitis like Ampicillin

2. 30ST = Streptomycin (aminoglycosides), Tetracycline block 30S1. “Amina didn’t hear the GNATS because she was busy reading”:

Aminoglycosides (GNATS = Genta, Neo, Amikacin, Tobra, and Stretomycins) causeototoxicity (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 of30S (acetylation, etc)

2. Tetracyclines block TRNA from binding A-site and discolors Teeth/bones1. caTion-chelator, do NOT take with antacids, milk, or iron-containing prep!2. AE: photosensitivity (“SAT for photo” - sulfonamides, amiodarone,

TETRACYCLINE)3. vs. ”VACUUM TH BedRoom” - Vibrio, acne, Chlamydia, ureaplasma, urealyticum,

Mycoplasma pneumonia, Tularemia, H. pylori, Borrelia, Rickettsia4. 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 = HaemophilusE = E. coliL = ListeriaP = ProteusS = Salmonella

Note: Ampicillin = intrapartum injection, GBS prophylaxis

“TCP Takes Care of Pseudomonas”:

TicarcillinCarbenicillinPiperacillin

Cephalosporins:

1st generation (“cefa”): G+ + PEcK: Proteus, E.coli, Klebsiella2nd 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 = #1CefTAZidime 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 = GiardiaE = Entamoeba histolytica (liver abscess)T = TrichomonasG = GardnerellaA = 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 (InhAoverexpression = resistance) and betaketoacylACPsynthase (KasA); KatG gene encodes catalase peroxidasethat 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 ofviruses; induces cyp450; prophylaxis for N. men and Hib; AE: red secretions, stop therapy with purpura, bone

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marrow suppressionE = 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” = Amantadine Rimantidine block M2 protein (viral uncoating) vs. Influenza A; AE: AtaxiAHerpes = “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 (unlikeganciclovir, 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”

AbacavirDidanosineEmtriciabineLamivudineAZT (Zidovudine)Stavudine

NNRTI’s: ”Move to Delaware? Effin’ Never!”DelavirdineEfavirenzNevirapine

FUsion inhibitor = enFUvirtide (gp41 binder)

Interferons: activates NK cells; AE: Neutropenia

IFNalpha - “alpha B C” —> Tx: HBV, HCVIFNbeta - “PMS sounds like BMS” —> Tx: Multiple SclerosisNOTE**: alpha and beta IFNs decr viral replication and incr antiviral protein synthesis that impairs viral mRNAtranslationIFNgamma - “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 spleenVS. T-cells are found in the deeper medulla(LN)/PALS(spleen)

Lymph drainage:

rectum above pectinate line = internal iliacumbilicus to legs (inc, superficial genitals and anal canal below pectinate line) = superficial inguinaltestes = para-aortic

MHC I and II: ”Rule of 8’s”

1*8 = MHCI x CD8 = 82*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 M0IL2: T = T-cell proliferation; secreted by Th1IL3: Bone = Bone marrow stimulation (acts like GM-CSF); secreted by T cellsIL4: E = IgE (and IgG) class switching; secreted by Th2IL5: A = IgA (and eosinophil) production; secreted by Th2

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

IL8: ”8” looks like multilobed nucleus of neutrophil = PMN chemotaxisLTB4’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 transplantrejection

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 recurrentinfections (viral/bacterial/fungal)

Rx vs TNF: Tx: Rheumatoid arthritis

vs. TNF: Infliximabvs. TNF receptor: Adalimumabfake TNF receptor: Etanercept

Complement:

C_a for anaphylaxis (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:

Bruton’s agammaglobulinemia = (x-r) Boys with BTK (tyrosine kinase) defect —> Blocked B-cell differentiation:

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recurrent Bacterial infection after 6 months (when mom’s IgG disappears) b/c no Ig’sSelective Ig(A) deficiency: milk Allergies, blood product Anaphylaxis, giardiA infections; IgA is missing in mucusso recurrent sinus and lung infections**Note: IgA deficiency also seen in Ataxia-Telangiectasia:defective DNA repair enzymes, sensitive to ionizingradiation, cerebellar atrophy —> ataxia, spider angiomas (telangiectasias); assoc. w/ lymphomas and acuteleukemiasHyper-IgE/Job’s Syndrome: ”I’m Hyper Excited for my FATEd Job”

Hyper Excited = Hyper IgEF = coarse FaciesA = cold, noninflamed Staph AbcessesT = retained primary TeethE = EczemaJob = Job’s

Chediak-Higashi (a-r): ”Grandpa Al couldn’t eat Eastern food with his fingers.”Grandpa = Gram positive cocci infections: Staph and StrepAl = partial albinismcouldn’t eat = defective microtubules = defective phagocytosis and lysosomal fusionEastern = 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 bothalleles 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 CAsis: astrocytoma, osteosarcomareturned = ret: MENIIher2new = Her2/neu: breast cancerwas = ras: colon, bladder, lung, pancreas, renal CAable = abl: CML, ALL (“ALL able CaMeLs are from Philadelphia t(9;22)”)to-grow-faster = TGF: astrocytoma, HCCb/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 tumorS = serous cystadenocarcinoma of ovaryM = mesotheliomaM = 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 = CHFSick = Sickle CellToo 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 maximumeffect 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)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 firstPhase 2: conjugation (acetylation, glucuronidation, sulfation) —> yields very polar renally excreted inactivemetabolites

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 —> cascadeGi = inhibit adenylyl cyclase —> decr cAMP —> decr PKAGq = 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 BPGi = alpha 2: decr SNS, decr insulinGs = beta 1: incr heart rate and contractility, incr renin, incr lipolysisGs = beta 2: decr Diastolic BP, vaso/bronchodilation, incr heart rate, contractility, incr lipolysis, incr insulinrelease (think “Beta2 stimulates Beta islet cells of pancreas”), decr uterine toneGq = M1: CNS, enteric nervous systemGi = M2: decr HR, decr atrial contractilityGq = M3: incr secretions, peristalsis, miosis, accommodation (ciliary muscle contraction)Gs = D1: renal perfusion (renal artery dilation)Gi = D2: brain neurotransmitterGq = H1: pruritus/pain, incr nasal/bronchial mucus, contract bronchiolesGs = H2: incr gastric acid secretion (inhibited by “-idines”)Gq = V1: incr vascular SM contractionGs = V2: incr H2O reabsorption in kidneys CD (ADH action)

Signaling pathways:

cAMP (Gs, Gi): ”FLAT CHAMP + calcitonin + glucagon”F = FSHL = LHA = ACTHT = TSHC = CRHH = hCGA = ADH (V2)M = MSH

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P = PTHcalcitoninglucagon (incr cAMP —> activates PKA —> incr F16BPase —> gluconeogenesis RLS)

IP3 (Gq): ”hIP3othalamic GGOAT”GHRHGnRHoxytocinADH (V1)TRH

cGMP: vasodilators

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

tyrosine kinase: ”the TyK Grows In Milk”

GHIGF-1FGFPDGFInsulinProlactin

steroid receptor: cytoplasmic (except thyroid hormone = intranuclear)

(Adrenal cortex:) Aldosterone, Glucocorticoid, Testosterone, EstrogenProgesteroneVitamin DT4/T3 (intranuclear receptor)

Glaucoma drugs: ”AABBCDF”

AA = Alpha Agonist: vasoconstriction —> decr aq humor synthesis (not for closed angle glaucoma)BB = Beta Blocker (Timolol): decr aq humor secretionC = Cholinomimetic (Carbachol, Pilocarpine; “Phys is for the Eyes” Physostigmine, Echothiophate): incr outflow(contract ciliary muscle and open trabecular meshwork into canal of Schlemm)D = Diuretic: Acetazolamide (carbonic anhydrase inhibitor), Mannitol: decr aq humor secretionF = 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 urinaryretentionAnticholinesterases = “-stigmines” + Edrophonium + Echothiophate

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

DiarrheaUrinationMiosisBradycardiaBronchospasmExcitation of skeletal muscle and CNSLacrimationSalivationSweating

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 allNicotinic 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/ PENIcillamineNITRoprusside turns into Cyanide which is Tx’d w/ NITRite, hydroxocobalamin, and thiosulfateMETHylene blue and VitC Tx’s METHemoglobinETHANOL 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, ComaCutaneous flushing: ”VANC” = Vancomycin, Adenosine, Niacin, Ca2+ channel blockersDilated cardiomyopathy = Doxorubicin and DaunorubicinTorsades de Pointes: ”The Method to get 31Awesome QT’s is to wear a Halo and Risper that you bought aMacro-PIe from Quinn.”

Method = Methadone31Awesome = Class III, Class Ia antiarrhythmicsHalo = haloperidolRisper = risperidoneMacro = macrolidePI = HIV protease inhibitorsQuinn = Chloroquine/Mefloquine

Aplastic anemia: ”Chlora SAID “Ptuey” to Meth”:Chlora = ChloramphenicalSAID = NSAIDPTUey = PTU (antithyroid)Meth = Methimazole (antithryoid)

Hemolysis in G6PD: ”Prima had to take Aspirin after INHaling her I.B.Professor Dapsone’s Sulfurous Fava BeanNitrofarts”

PrimaquineAspirinINHIbuprofenDapsoneSulfonamidesFava beanNitrofurantoin

“Pseudomembranous colitis makes you want to ClAmp your ass”: CLindamycin, AMPicillinPhotosensitivity: ”SAT for a Photo”:

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S = SulfonamidesA = AmiodaroneT = Tetracyclines

Stevens-Johnson rash: “‘Seizures, Sulfa’s, and Cillins + Allopurinol”Seizure drugs: ethosuximide, lamotrigine, carbamazepine, phenobarbital, phenytoinSulfa drugsPenicillinAllopurinol

SLE-like syndrome: ”SHIPP”SulfonamidesHydralazine (“Hydra’s neck Loops (Lupus) around in circles”)INHPhenytoinProcainamide

Disulfiram-like reaction: ”Drunk Ceph said he was Pro-Car (okay to drive) at Night, but to avoid a Gruesomeaccident, Chlora made him Suffer the Metro.”

Ceph = CephalosporinProcar = ProcarbazineNight = NitrofurantoinGruesome = GriseofulvinChlora = ChloramphenicolSuffer = SulfonylureasMetro = Metronidazole

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

p450 interactions:p450 inducers: ”Queen Barb’s riFamily induced Saint John to eat a Pheny-looking Greasy Carb”

Queen = QuinidineBarbara = BarbiturateriFamily = RifampininducedSaint John = Saint John’s WortPheny-looking = Phenytoin (AE: gingival hyperplasia)Greasy = GriseofulvinCarb = CarbamazepineSee reference:

p450 inhibitors: ”Without a Key, Kim was inhibited from PIES and Juice”

Key = KetoconazoleKim = CimetidineinhibitedPI = HIV Protease InhibitorsE = ErythromycinS = SulfonamidesJuice = grapefruit juiceSee reference:

Toxicity bear: Cumulatively Toxic Drugs and their RescuesAsparagine: neurotoxicityCisplatin: ototoxic/nephrotoxic; Tx: AmifostineVincristine/Vinblastine: ”Christ my nerves, Blast my bones” - Vincristine = peripheral neuropathy,Vinblastine = myelosuppression

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Bleomycin: pulmonary fibrosisDoxorubicin: cardiotoxic; Tx; Dexrozoxane (for cardiotoxicity), Dimethyl-sulphoxide (for ROS ulcers)Cyclophosphamide: Acrolein = nephro/bladder toxic (Tx: Mesna); also SIADH effects (Tx:Demeclocycline)Methotrexate: nephrotoxic (Tx: Leucovorin), myelosuppression (Tx; Filgrastim)See reference:

Cardiovascular:

Contractility decreases with: ”ABBCCC”:

A = AcidosisBB = Beta blockerCCC = hyperCO2, CHF, non-DHP Ca2+ channel blockers

Heart murmurs:

“MR. ASS and MS. ARD” = MR = mitral regurgAS = aortic stenosisS = systolic murmursandMS = mitral stenosisAR = aortic regurgD = diastolic murmurs

holosystolic = all regurg’s + VSDmurmurs that increase with breathing:

rIght murmurs increase with InspirationlEft 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 PR2nd degree:

Type 1 Wenckebach: incr PR until QRS dropType 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: nothing4 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”:

FeverRoth spots: round retinal white spots surrounded by hemorrhageOsler’s nodes: tender raised red lesions on fingers and toe padsMurmur (new)Janeway lesions: non-tender small red lesions on palms and solesAnemiaNail-bed (splinter) hemorrhageEmboli

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 Strepautoimmune (Ab to antiphagocytic M protein —> MVP —> Mitral Stenosis), feverAschoff bodies (granulomas with giant cells) = subcutaneous nodulesAnitschkow cells (activated histiocytes)elevated ASO titers and ESRmigratorypolyArthritis

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

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

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essential hypertensionHTN+CHF (decreases both preload and afterload)HTN+DM (protective against Diabetic nephropathy)

Antihypertensive therapy: ”ABCD”:

ACE-I/ARBsBeta blockersCalcium channel blockersDiuretics (“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/ GlucagonType 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)Ib: ”To Funny Little Mexico”Tocainide, Phenytoin, Lidocaine, Mexiletine (decr AP)Ic: ”Properly Fleeing Endangerment”Propafenone, Flecainide, Encainide

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

pulmonary fibrosishepatotoxicityhypo/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”

FSHLHACTHTSHProlactinendorphins (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 wereSupra Dehydrated”

Paraventricular nucleus - OxytocinSupraoptic 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 isa 1, then the patient will look male.”

17alpha hydroxylase deficiency: HTN, feminine21 hydroxylase deficiency (MC): hypotension, masculine11 beta hydroxylase deficiency: HTN, masculine

PTH = phosphate trashing hormone (note: decreased free serum Mg2+, decreases PTH secretion; common causes of decrMg2+ = 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 inpregnant))incr BMRincr Blood sugar: glycogenolysis, gluconeogenesis, lipolysis

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

10% malignant10% bilateral10% extra-adrenal10% calcify10% kids10% 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 urinescenario: ~2yo with retroperitoneal ab mass presents with HTN hypotonia, myoclonus, and non-rhythmicconjugate 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/HyperthyroidIatrogenic: ThiazidesMultiple myelomaPaget’s disease (when patients are immobilized, normally normocalcemic)Addison’s disease

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Neoplasms (e.g., breast cancer = osteolytic)Zollinger-Ellison syndrome (pancreatic tumor —> incr gastrin; associated with MENI (parathyroid tumor)Excess vitamin DExcess 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, weaknessand constipation; incr cAMP in urineVS Secondary: Renal osteodystrophy = renal disease —> decr Vit D —> decr Ca2+ —> incr PTH —> bonelesions

Hypocalcemia signs:

C = Chvostek sign = Cheek tapping —> facial muscle ContractionT = Trosseau’s sign = Tight BP cuff —> hand Tetany (spasm)

Dexamethasone vs Demeclocycline vs Desmopressin:

Dexamethasone = steroid to Dx ACTH disease/syndromeDemecloCYCLine = tetracycline ADH antagonist vs CYCLophosphamide-induced SIADH; Tx: SIADHDesmoPRESSIN = vasoPRESSIN (ADH) analog; Tx: central Diabetes insipidus(Note: nephrogenic DI is treated by hydrochlorothiazide (Ca2+ sparing diuretic), indomethacin (decr renal bloodflow), or amiloride (K+ sparing aldosterone receptor antagonist diuretic that closes Na+ channels that alsoreabsorbs Li to Tx Li-induced DI)

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

MENI (Wermer’s): ”3P’s”pancreatic - ~Zollinger-Ellison gastrinoma - peptic ulcersparathyroid - incr PTH - hypercalcemiapituitary - ~prolactin or GH - amenorrhea, lactation

MENIIa (Sipple’s): ”2P’s”parathyroid - incr PTH - hypercalcemiaPCC - incr catecholamines (Epi/Nor), urine VMA and Metanephrinemedullary thyroid (parafollicular C) - polygonal, incr calcitonin - hypocalcemia

MENIIb: ”1P”PCC - incr catecholamines, urine VMA/metanephrinemedullary thyroid (parafollicular C) - incr calcitonin - hypocalcemiaMarfan’s habitus + oral/intestinal mucosal neuromas

Note: MENII’s are associated with ret oncogeneAlso, “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-Glitazones = incr insulin sensitivity via PPARgamma/adiponectinSulfonamides = incr pancreatic insulin production via blocking ATP-dep. K+ efflux-Gliptins, -Tides = incr insulin, decr glucagon, 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 -‘GliptinsAcarbose - 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 topromoter

Gastrointestinal:

Retroperitoneal structures: ”I ASK DR. PC”

Primary retroperitoneal (never pushed into sac):IVCAb aortaSuprarenal glandsKidneys/Ureters

Secondary retroperitoneal (pushed into sac, but escaped):Duodenum (2, 3, 4)RectumPancreas (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 = DuodenumIleum = 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 Patchesand 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/longitudinalmusclesMeissner’s = Submucosal = regulates Secretions, blood flow, and absorption between mucosa and inner/circularmuscles

Defect in Auerbach’s causes AchalasiaLack of both Auerbach and Meissner’s due to failure of neural crest cell migration causes Hirschsprung’s CongenitalMegacolon, 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 IEat Less.”

Rectal anastomoses: (X=hemorrhoids)”MI Superior is an Ass”:Systemic: Middle and Inferior Rectal

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toPortal: Superior RectalUmbilical anastomoses: (X=caput medusae)”Inferior about my Superficial appearance by poking near my Belly-button”:Systemic: Inferior, Superficial EpigastrictoPortal: ParaumbilicalEsophageal anastomoses: (X=esophageal varices)”Eat Less”: (X = esophageal varices)Systemic: Esophageal (azygos)toPortal: Left Gastric

Liver anatomy: ”1ABC”

“1ABC”:Zone 1 = Apical surface of hepatocytes face Bile Canaliculi = periportal zoneAlso, 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 = bileduct, hepatic artery, and portal vein)

“The 3rd letter in the alphabet = C”:Zone 3 = Centrilobular (periCentral vein) = where blood drains into the hepatic veinbecause it’s so far from the hepatic artery, it’s the first place to suffer from ischemiaalso, 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 ligamentNote: femoral sheath does not contain femoral nerve

Inguinal canal: ”INternal (deep) inguinal ring = INdirect hernia that may go INto the scrotum” = lateral to inferior epigastricvesselsVS. ”an alien Directly bursting from your stomach” = direct hernia = protrudes from abdominal wall medial to inferiorepigastric 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)“Pep-pep to the Chief”:Chief cells make Pepsin

Vitamin/Mineral absorption:

Duodenum: ”FED” = Fe (iron) in DuodenumJejunum: ”The Jester is a Fat Fool” = Jejunum absorbs most Fats and FolateIleum: The ileum is the last part of the small intestine; it’s where you say “Bye Bye to the SI”: Byle acid, B12/IF isreabsorbed in the Ileum

Bilirubin:

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

INdirect = UNconjugated = water INsoluble: Crigler-Najjar, Gilbert = “KING KONG” —> “CING CUNG” —> Criggler-Indirect/Unconjugated-Najjar-GilbertYou 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”

Achalasialoss of Auerbach’s myenteric plexusBirds beak on Barium swallowassociated with Chaga’s and CREST

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

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BARRett’s esophagus = Becomes Adenocarcinoma, Results from Reflux

Esophageal cancer risk factors: ”ABCDEFGH”

Alcohol, AchalasiaBarrett’s esophagusCigarettesDiverticuli (e.g., Zenker’s)Esophageal web (e.g., Plummer-Vinson), EsophagitisFamilialGERDHot dogs (nitrosamines)

Esophageal cancer epidemiology and locations:

Squamous cell = Spread out worldwide (most prevalent worldwide); upper 2/3s (where striated muscle can befound)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/Body) = Autoimmune/Anemia:AutoAb to parietal cells, pernicious anemia (Ab to IF), achlorhydriaType B (Antrum) = Bacterial:H.pylori infection (duodenal > stomach ulcer), increased risk of MALT lymphoma

Peptic ulcer disease:

Gastric ulcer pain = Greater with foodDuodenal 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 theair.”

Creepy Fat = Creeping fatCrone = Crohn’s disease(Granny) non-caseating GranulomasSkipping = transmural Skip lesionsCobblestone = Cobblestone mucosaArthritic = Migratory polyarthritisFist = Fistulas“Gum to Bum” lesions and extraintestinal manifestations (systemic) like erythema nodosum (~shins),ankylosing spondylitis, and uveitisNote: 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 imagingRectum = UC always involves the rectal mucosa/submucosa and procedes continuously up unlikeCrohn’s which tends to spare the rectumBloody diarrhea (another trait not shared with Crohn’s)Note: this is autoimmuneUC is also associated with friable pseudopolyps, pyoderma gangrenosum, and primary sclerosingcholangitis

Meckel’s diverticulum: ”Rule of 2’s”

2 inches long2 feet from ileocecal valve2% of population2yo (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; FAPCancer involves APC gene;always involves rectumVS. HNPCC/Lynch which doesn’t have many polyps and involves the PROXIMAL colonGardner’s syndrome = “Gardeners Grow all kinds of things”: Gardner’s = FAP + osteomas + lipomas/soft tissuetumors + retinal hyperplasiaTurcot’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 haveas many localized pain receptors as the anus):

distal colon (left side, near anus) = obstruction, sharp colicky pain, hematocheziaproximal 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 orderlose APC (decreased intercellular Adhesion) then mutate kRAS (unregulated signal transduction MAPK) then lose p53 (noapoptosis)

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

Asterixis, Ataxia, Anemia (hemolytic)Basal ganglia degeneration (Parkinsonism)decr Ceruloplasmin, Cirrhosis, Corneal deposits, Cancer (HCC)DementiaEncephalopathyFanconi’s Syndrome: defective PCT reabsorption

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

FatFertileFemaleForty

Acute pancreatitis causes: ”GET SMASHED” —> DIC, ARDS…

6/18/13 6:33 PMarghlblargh!

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GallstonesEthanolTraumaSteroidsMumpsAutoimmune diseaseScorpion StingHypercalcemia, HyperlipidemiaERCPDrugs (E.G., Sulfa drugs)

Antacid adverse effects:

Al = AluMINIMUM amount of feces: constipationMg = 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 tocontact 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 topost the rest of my mnemonics, but my Ask box is always open for advice! ^^ Thanks for understanding.

Posted 1 year ago — 55 notes #USMLE #anatomy #bacteriology #biochemistry #biostatistics #histology #immunology #microbiology #neurology #neuroscience #parasitology #pathology #physiology #psychiatry #ross #virology

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Great & Long mnemonic lists! It may be helpful to find some tips when you study….

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