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Syndactyly Mucormycosis Leptospira Bacillary
Angiomatosis
Diphtheria
(bull’s neck)
Stormy
fermentation
Ataxia-
Telangiectasia
Follicular
Dendritic Cell
Korsakoff
Syndrome
Tardive
Dyskinesia
DiGeorge
Syndrome
Bartonella
(Cat Scratch)
Owl Eye
(CMV)
Clue Cells
(Vaginosis)
Norwalk Virus Negri Bodies
(Rabies)
Spina Bifida Occulta Keloid scar Solar Elastosis Nutmeg Liver
(Right CHF and
Budd-Chiari)
Brushfield Spots Simian Crease Rocker Bottom
Feet
Cystic Hygroma
Zebra bodies
(Niemann Pick)
Gaucher cells Kyphoscoliosis
(EDS9)
Lisch Nodules
(NF1)
Fragile X
Syndrome
Angelman Sx Patau Sx Edwards Sx
Raynaud’s
Phenomenon
Sclerodactyly CREST
syndrome
Hairy
Leukoplakia
Malar Rash Kaposi Sarcoma Mees Lines
(Arsenic Poisoning)
Basophilic
Stippling
Dysplastic
Melanoma SX
Seborrheic
Keratosis
PsoriasisAcanthosis
Nigricans
Munro
Microabscess
Dermatitis
Herpetiformis
Ichthyosis
Vulgaris
Xerosis
Erythema
Multiforme
Pityriasis Rosea Granuloma
Annulare
Erythema
Nodosum
Bowen’s Disease Actinic Keratosis Keratoacanthoma Basal Cell
Carcinoma
Birbeck Granules
(Langherhans
Histiocytosis)
Dacriocytes
(Myelofibrosis)
Target Cells Acanthocytes
Echinocytes Schistocytes Sickle Cell Heinz Bodies
Howell-Jolly
Bodies
Pappenheimer
Bodies
Ring
Sideroblasts
Prussian Blue
Stain (copper)
Crew cut
Skull RX
Chipmunk Face
(Thalassemia)
Onion Skin
(Arteriolosclerosis)
Flea Bitten Kidney
(Malignant HTN)
Tree-Bark
of Aorta
Boxcar Nuclei
(Left CHF)
Roth Spots
(Endocarditis)
Osler’s Nodes
Janeway Lesions Splinter
Hemorrhages
Notching of the
Ribs. (P-D C)
Spider Cells
(rhabdomyoma)
Skin Flushing
(Carcinoid HD)
Ghon Focus
(Primary TB)
Simon Focus
(Reactive TB)
Ziehl-Neelsen
Miliary
Tuberculosis
Cavitary
Tuberculosis
Pott’s Disease
(Spinal TB)
Bilateral Hilar
Lymphadenopathy
Blue Bloater
(Bronchitis)
Pink Puffer
(Emphysema)
Barrel Chest
(Emphysema)
Curschmann
Spirals (Asthma)
Charcot-Leyden
Crystals
Bronchiectasis “White out”
(ARDS)
Tension
Pneumothorax
Pneumothorax Glomerular Crescent
Formation
Mallory Bodies
(Alcoholic Hepatitis)
Councilman Bodies
(Viral Hepatitis)
Cowdry Body
(HVS encephalitis)
Lewy Bodies
(Parkinson’s)
Rosenthal Fibers
(Astrocytoma 1)
Pseudorosettes
(Ependymoma)
Psammoma Bodies
(Meningioma)
Downey Cell
(Mononucleosis)
Smudge/Parachute
cells (CLL)
Hairy Cell Leukemia
Burkitt’s Lymphoma
(African)
Starry Sky
(Burkitt’s Lymphoma)
4 leaf clover
(ATLL)
Sezary Syndrome
(Mycosis Fungoides)
Reed-Sternberg
(Hodgkin Lymphoma)
“Popcorn Cell”
Lymphocyte-Rich
Hodgkin
“Auer Rods”
(Acute Myelogenous
Leukemia)
Pelger-Huet cell
(Myelodisplastic
Syndrome)
Sulfur Granules
(Actino and more)
Call-Exner bodies
(Granulosa tumor)
“Signet-ring” cells
(Krukenberg tumor)
Paget cells
Classic
Seminoma
Schiller-Duval
(Yolk-sac tumor)
Pretibial
Myxedema
Exophthalmos
(Graves disease)
Periorbital
Edema
Hurthle Cells (H.
Tyroiditis)
Orphan Annie
eye (Papillary C.)
Blue Sclera
(Osteogenesis I.)
Erlenmeyer Flask
(Osteopetrosis)
Pott’s Disease
(TB osteomielitis)
Avascular Necrosis Knobby Knees
(Osgood-Schlatter)
Sheperd’s Crook
(Fibrous dysplasia)
Osteoid Osteoma Osteochondroma Soap-Bubble
(Osteoclastoma)
Paget’s Disease Osteosarcoma Homer-Wright
Rosettes
Onion Skin
(Ewing sarcoma)
Bone Spur
(Osteoarthritis)
Heberden /
Bouchard Nodes
Rheumatoid
Arthritis
Baker’s Cyst
(RA)
Boutonniere
deformity (RA)
Rheumatoid
Nodules
Uric Acid
Crystals
Calcium
Pyrophosphate
Lipoblast (Liposarcoma) Dermatofibroma “Herringbone pattern”
(Fibrosarcoma)
“Storiform”
(Malignant
Histiocytoma)
Cell Nucleus Rough Endoplasmic
Reticulum
Smooth Endoplasmic
Reticulum
Golgi Apparatus
Peroxisome
and Lysosome
Mitochondria Tight Junction Desmosome
Cilia Simple
cuboidal
Simple
Columnar
Goblet Cells
Simple
squamous
Pseudostratified
columnar
Transitional
Epithelium
Stratified
squamous
Stratified
cuboidal
Mixed serous and
mucus
Loose connective
tissue
Macrophages
Collagen fibers Basal lamina Hyaline
Cartilage
Elastic
Cartilage
Osteoblasts Mature bone Osteoclasts Intramembranous
Bone
Endochondral Bone
(left to right)
Skeletal muscle
(I band-light, A band-
dark)
Cardiac muscle
(junctional complexes
and single nucleus)
Smooth muscle (gap
junctions and fusiform
fibers)
Nissl Stain
(Neurons)
Axon Hillock (Light
staining area)
Peripheral Nerve Node of Ranvier
Nucleolus White blood cells Plasma cell
(clockface pattern)
Hassall’s Corpuscle
(thymus)
Hyaline cartilage
ring (Trachea)
Bronchus
w/Hyaline cartilage
Clara cells
(Bronchioles)
Alveolar
Pneumocytes
Dust cell & Pore of
Kohn
GI tract Esophagus-
Stomach transition
Brunner’s glands
(Duodenum)
Seminiferous
tubule
Interstitium
between tubules
Uterine wall Stomach
Tongue Papillae
Pharyngeal/Aort
ic Arch
Associated Cranial
Nerve
Key Aortic Arch Derivatives
1 Trigeminal (V) Maxillary artery
2 Facial (VII) Stapedial artery
3 Glossopharyngeal (IX) Common carotid artery
Prox. Internal carotid artery
4 Superior laryngeal
branch of Vagus (X)
True aortic arch
Subclavian arteries
5 Obliterated Obliterated
6 Recurrent laryngeal
branch of Vagus (X)
Pulmonary arteries Ductus
arteriosus
Manouvers
Increase
Preload
Right side Deep breath. (Inspiration)
Laying supine
Left side Expiration
Increase
Afterload
Aortic/Systemic Hand grip
Sustained squatting
Pulmonary NOT IMPORTANT
Valsalva Increases
thoracic
pressure
Reduces right sided
murmurs
Decreases Heart rate and
BP (Parasympathetic)
. A P . 2-3rd
5-6th
.
Aortic
Pulmonary
Tricuspid
Mitral
Close at beginning of S
Open at beginning of D
Close at beginning of D
Open at beginning of S
Sounds are generated at the time of closure.
S1 beginning of systole
S2 beginning of diastole
Stenosis – Anterograde Insufficiency – Retrograde
MT
A: Systolic – Aortic stenosis
P: Systolic – Mitral insufficiency
T: Systolic – Tricuspid insufficiency
T: Diastolic – Tricuspid stenosis
M: Diastolic – Mitral stenosis and aortic insufficiency
T
P
Murmur
Systolic
Bicuspid aortic
valve
Early systolic
High-frequency
click
Right 2nd
interspace
Hypertrophic
Cardiomyopathy
Crescendo-
decrescendo
murmur
Between apex
and left sternal
Radiates to the
suprasternal
notch
Louder standing
up
Aortic Stenosis
Early Systolic
Click
Pulse late and
weak
Old age /
Rheumatic F.
Congenital
Bicuspid valve
Angina, syncope,
CHF
Pulmonary
Stenosis
Tetralogy of
Fallot
Harsh ejection
murmur
Systolic thrill
Mitral
Regurgitation
Holosystolic
Radiates to axilla
Increases After
load
Tricuspid
Regurgitation
Holosystolic
Increase right
heart Flow
Taking a Deep
breath
IV drug users w/
endocarditis
Septal Defects
Ventricular
Harsh
Holosystolic
Atrial
Fixed Splitting of
S2
Diastolic
Atrial
Regurgitation
Blowing murmur
Widened pulse
pressure
Pulmonary
Regurgitation
Mitral Stenosis
Opening snap
Rheumatic Fever
Tricuspid
Stenosis
100
50
0
Time
Aortic valve
closes
Aortic valve
opens
Mitral valve
opens
Mitral valve
closes
Normal Pressure tracing
Left atrium
Left Ventricle
Aorta
a
c
x
v
y
A: Right atrial contraction
B: Bulging of tricuspid valve during right ventricular contraction
X: Right atrial relaxation
V: Continued inflow of venous blood
Y: Passive emptying of right atrium after tricuspid valve opening
Jugular Venous Tracing
Hemodynamic
measurements in shock
Parameter Hypovolemic
shock
Cardiogenic
Shock
Obstructive
Shock
Septic Shock
Central venous pressure
(right-sided preload)
Pulmonary capillary wedge
pressure (left-sided preload)
Cardiac index (LV output)
Systemic vascular resistance
(afterload)
Mixed venous oxygen
saturation
Pterygopalatine Fossa
 Laterally – Infratemporal fossa
 Medially – Nasal Cavity (Sphenopalatine foramen)
 Inferiorly – Oral Cavity (Greater and lesser palatine canals)
 Anteriorly – Orbit (Inferior orbital fissure)
 Posteriorly – Pharynx
Cerebral Nuclei
 Locus Caeruleus – Neuromelanin cells (Norepinephrine)
 Basal nucleus of Meynert – Cholinergic neurons (Alzheimer)
 Caudate nucleus – GABA and Cholinergic acetylcholine
(Huntington and Parkinson)
 Raphe nuclei – Serotonergic bodies
 Substantia nigra – Dopamine and GABA (Parkinson)
 Ventral tegmental area – mesolimbic Dopamine (Schizophrenia)
Elevated AFP
• Gastroschisis
• Omphalocele
• Anencephaly
• Spina Bifida
Decreased AFP
• Down
Syndrome
Elevated Ache
• Anencephaly
• Spina Bifida
Normal Brain Chiari Malformation Type 2
Dandy-Walker Malformation
Neural Tube
Prosencephalon
Telencephalon
Cerebral
hemispheres
(Cerebral cortex,
basal ganglia, deep
white matter)
Diencephalon
Thalamus
Motor and sensory
relay nuclei
Hypothalamus
Control of
endocrine and
autonomic function
Epithalamus
Pineal gland
Subthalamus
Component of basal
Ganglia
Posterior lobe of
the pituitary
Neural Retina
Mesencephalon Rhombencephalon
Metencephalon
Cerebellum
Pons
CN V, VI, VII, VIII
Myelencephalon
Medulla oblongata
CN VIII-XIII
Reflex Cord Segment Involved Muscle Tested
Knee (Patellar) L2-L4 (femoral n.) Quadriceps
Ankle S1 (tibial n.) Gastrocnemius
Elbow C5-C6
(musculocutaneous n.)
Biceps
Elbow C7-C8 (radial n.) Triceps
Forearm C5-C6 (radial n.) Brachioradialis
Korsakoff syndrome
Amnesia, confabulation and
preserved long-term memory
Lesions in the anterior and medial
thalami
Wernicke Encephalopathy
Encephalopathy, ocular dysfunction
and ataxia
Atrophy of Mamillary bodies
Cerebellar Degeneration
Tremor, unsteady gait
Loss of Purkinje cells in the
cerebellar vermis
Upper Motor Neuron
Lesion
• Spastic Paresis
• Hyperreflexia
• Babinski sign
• Increased muscle tone
• Clasp knife reflex
• Disuse atrophy of
muscles
• Decreased speed of
voluntary movements
• Large area of the body
involved
Lower Motor Neuron
Lesion
• Flaccid paralysis
• Areflexia
• No Babinski
• Fasciculations
• Decreased muscle tone
or atonia
• Atrophy of muscle(s)
• Loss of voluntary
movements
• Small area of the body
affected
Foramen Rotundum- CN V2 (Maxillary Nerve)
CN V3 (Mandibular Nerve)Foramen Ovale-
Superior Orbital Fissure
CN II (Optic Nerve)
Ophthalmic Artery
CN III (Oculomotor Nerve)
CN IV (Trochlear Nerve)
CN V1 (Ophthalmic Nerve)
CN VI (Abduncens Nerve)
Ophthalmic Veins
Optic Canal
Cribiform Plate- CN I (Olfactory Nerve)
Foramen Spinosum
Foramen Lacerum-
Middle Meningeal A.
Meningeal N. (V3)
Internal Carotid Artery
Skull Foramen Traversing Structures
Anterior Cranial Fossa Cribiform plate CN I olfactory bundles
Middle Cranial Fossa Optic canal CN II, ophthalmic artery, central
retinal vein
Superior Orbital fissure CN III, IV, V1, VI, ophthalmic
vein, sympathetic fibers
Foramen rotundum CN V2 (maxillary)
Foramen ovale CN V3 (mandibular)
Foramen spinosum Middle meningeal artery and
vein
Posterior Cranial Fossa Internal acoustic meatus CN VII, VIII
Jugular foramen CN IX, X, XI, jugular vein
Hypoglossal canal CN XII
Foramen magnum Spinal roots of CN XI, brain
stem, vertebral arteries
Spinal Cord Hemisection
(Brown-Sequard Sx)
Ipsilateral
• Spastic Weakness
• Altered vibratory sense
Contralateral
• Loss of pain and temperature
NO Cranial Nerve signs
Brain-Stem Lesions
Ipsilateral
• Cranial Nerve signs to lesion
• Horner’s Syndrome
Contralateral
• All deficits
(Wallenberg syndrome IX,X)
Cortex or Capsular Lesions
Ipsilateral
• None
Contralateral
• Anesthesia
• Lower face weakness
• Sensory deficits
Cerebellar Lesion (Hemisphere)
Ipsilateral
• Intention tremor
• Dysmetria
• Dyadochokinesia
• Scanning dysarthria
• Nystagmus
• Hypotonia (Insult to deep nuclei)
Vermal Lesion
• Gait Ataxia (alcoholism)
• Truncal Ataxia (medulloblastoma)
Cerebellar Lesion (Vermal Lesion)
• Gait Ataxia (alcoholism)
• Truncal Ataxia (medulloblastoma)
Parkinson Disease
Bradykinesia, cogwheel rigidity, resting tremor, shuffling gait,
Stooped posture, masked face, depression and dementia
Pathognomonic: Lewy bodies
Loss of dopaminergic neurons from substantia nigra
Huntington Disease
Chorea (rapid movements), athetosis (slow movements),
personality changes, dementia
Type of disease: Autosomal Dominant (Chromosome 4)
Degeneration of GABA neurons, causing atrophy of head
of caudate nucleus
Wilson Disease
Tremor, asterixis, parkinsonian symptoms, chorea, fatty change,
Neuropsychiatric symptoms, hepatitis or cirrhosis, tremor may
be “wing beating”.
Pathognomonic: Kayser-Fleischer ring
Hemiballism
CONTRALATERAL Wild, flinging movements of limbs
Pathognomonic: Hypertensive Patients
Hemorrhagic destruction of subthalamic nucleus
Tourette Syndrome
Motor and vocal tics, commonly associated with OCD and ADHD
Treatment: Antipsychotic agents
Excess of striatal dopamine
POLIO
Flaccid Paralysis, Muscle atrophy, Fasciculations, Areflexia
TABES DORSALIS
Paresthesias, Pain, Polyuria/Urine retention, Associated w/neurosyphilis,
+Romberg sign, suppressed reflexes, pupillary reflex defects.
ALS
Spastic paralysis in lower limbs, flaccid paralysis in upper limbs, increased
tone and reflexes.
ANTERIOR SPINAL ARTERY OCCLUSION
Pain, temperature and spastic weakness bilateral signs, spastic bladder
Vibratory and pressure senses spared
SUBACUTE COMBINED DEGENERATION
Paresthesias, bilateral spastic weakness, Babinski sign, antibodies
to the intrinsic factor (Vitamin B12 pernicious anemia)
SYRINGOMYELIA
Bilateral loss of pain and temperature upper limbs. “Cape-like”
It eventually gets to flaccid paralysis and atrophy of the upper limb
May be associated with hydrocephalus and Arnold Chiari II.
BROWN-SÉQUARD SYNDROME (HEMISECTION)
Ipsilateral Horner’s sx, paresis, loss of position and vibratory senses.
Contralateral loss of pain and temperature.
Hypothalamus
Anterior Region
Paraventricular and
Supraoptic Nuclei
Synthesize ADH and
Oxytocin
Suprachiasmatic
Nucleus
Circadian Rhythms
Tuberal Region
Arcuate Nucleus
Release hormones in
the anterior pituitary
Ventromedial Nucleus Satiety center
Posterior Region Mamillary Bodies Wernicke-Korsakoff
Hypotalamic Zone
Anterior
Senses elevation of
temperature
Posterior
Senses decrease of
temperature
Lateral Feeding center
Preoptic Area .
Sensitive to androgens
and estrogens
Expressive Aphasia- Agraphia, decreased ability to repeat words
or answer questions. Single-syllable words (pt frustrated)
Left MCA infarct
Lower face weakness if associated w/Primary motor cortex
Receptive Aphasia-Oral aphasia (they don’t understand) if restricted
to area 22. They use “word salad” to speak, paraphasic speech.
Aware and not concerned, fluent speech but incoherent.
May have hearing loss.
Gerstmann Syndrome- Alexia with agraphia, often seen with
acalculia, finger agnosia (particularly right hand).
Conductive Aphasia- Speech and comprehension may be normal,
but patient paraphrases and needs word-finding pauses.
Pt cannot repeat words or execute verbal commands.
Aware and frustrated. Cannot speak or write
Area 7, 39 ,40
Asomatognosia/Neglect- Unawareness or neglect of contralateral
Half of the body. Pt ignores left side of his body or things.
Visual Agnosia- Inability to recognize visual patterns or objects.
If lesions 20 and 21 involved pt develops prosopagnosia which is
the inability to recognize faces.
Transcortical Apraxia- From an occlusion of the ACA
Inability to move the left arm to respond to verbal commands
NO motor weakness.
Alexia without Agraphia- From an occlusion of the left PCA
Right homonymous hemianopsia w/macular sparing.
Visual information cannot reach the language area.
Color anomia, pt unable to read, able to write.
Kluver-Bucy Syndrome- Hypersexuality, hyperphagia and
visual agnosia.
Global Aphasia- Both Broca and Wernicke are damaged.
Includes labored telegraphic speech and poor comprehension.
NO motor weakness. Naming severely impaired
Transcortical Aphasia- Capacity to repeat statements unimpaired
Patient cannot speak spontaneously.
NO motor weakness.
1. Parinaud’s Syndrome
2. Korsakoff’s psychosis
3. Contralateral leg weakness
4. Superior quadrantanopia w/macular sparing
5. Alexia without agraphia
6. Hoarseness
7. Difficulty chewing
8. Temperature regulation
9. Rathke’s pouch
10. Truncal ataxia
D
E
A
C
B
M
F
G
H
I
L
K
1. M- Pineal gland Tumor
2. L- Mamillary body degeneration
3. D- Motor homunculus (precentral gyrus)
4. B- Lingual Gyrus (Meyer’s Loop)
5. A- Splenium of Corpus Callosum lesion
6. H- Vagus nerve rostral medulla
7. G- Trigeminal nerve rostral pons
8. I- Hypothalamus
9. K-Anterior Pituitary gland
10. J- Posterior part of the cerebellar vermis
J
Autosomal Recessive Autosomal Dominant
Onset
Early uniform onset
(Infancy or childhood)
Variable onset (may be
delayed into adulthood)
Penetrance Complete Penetrance
Incomplete penetrance with
variable expression
Mutation Usually an enzyme protein
Usually a structural protein or
receptor
Requires Mutation of both alleles Mutation of one allele

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USMLE Step 1 General review - Appendix

  • 1.
  • 2. Syndactyly Mucormycosis Leptospira Bacillary Angiomatosis Diphtheria (bull’s neck) Stormy fermentation Ataxia- Telangiectasia Follicular Dendritic Cell
  • 4. Spina Bifida Occulta Keloid scar Solar Elastosis Nutmeg Liver (Right CHF and Budd-Chiari) Brushfield Spots Simian Crease Rocker Bottom Feet Cystic Hygroma
  • 5. Zebra bodies (Niemann Pick) Gaucher cells Kyphoscoliosis (EDS9) Lisch Nodules (NF1) Fragile X Syndrome Angelman Sx Patau Sx Edwards Sx
  • 6. Raynaud’s Phenomenon Sclerodactyly CREST syndrome Hairy Leukoplakia Malar Rash Kaposi Sarcoma Mees Lines (Arsenic Poisoning) Basophilic Stippling
  • 8. Erythema Multiforme Pityriasis Rosea Granuloma Annulare Erythema Nodosum Bowen’s Disease Actinic Keratosis Keratoacanthoma Basal Cell Carcinoma
  • 9. Birbeck Granules (Langherhans Histiocytosis) Dacriocytes (Myelofibrosis) Target Cells Acanthocytes Echinocytes Schistocytes Sickle Cell Heinz Bodies
  • 10. Howell-Jolly Bodies Pappenheimer Bodies Ring Sideroblasts Prussian Blue Stain (copper) Crew cut Skull RX Chipmunk Face (Thalassemia) Onion Skin (Arteriolosclerosis) Flea Bitten Kidney (Malignant HTN)
  • 11. Tree-Bark of Aorta Boxcar Nuclei (Left CHF) Roth Spots (Endocarditis) Osler’s Nodes Janeway Lesions Splinter Hemorrhages Notching of the Ribs. (P-D C) Spider Cells (rhabdomyoma)
  • 12. Skin Flushing (Carcinoid HD) Ghon Focus (Primary TB) Simon Focus (Reactive TB) Ziehl-Neelsen Miliary Tuberculosis Cavitary Tuberculosis Pott’s Disease (Spinal TB) Bilateral Hilar Lymphadenopathy
  • 13. Blue Bloater (Bronchitis) Pink Puffer (Emphysema) Barrel Chest (Emphysema) Curschmann Spirals (Asthma) Charcot-Leyden Crystals Bronchiectasis “White out” (ARDS) Tension Pneumothorax
  • 14. Pneumothorax Glomerular Crescent Formation Mallory Bodies (Alcoholic Hepatitis) Councilman Bodies (Viral Hepatitis) Cowdry Body (HVS encephalitis) Lewy Bodies (Parkinson’s) Rosenthal Fibers (Astrocytoma 1) Pseudorosettes (Ependymoma)
  • 15. Psammoma Bodies (Meningioma) Downey Cell (Mononucleosis) Smudge/Parachute cells (CLL) Hairy Cell Leukemia Burkitt’s Lymphoma (African) Starry Sky (Burkitt’s Lymphoma) 4 leaf clover (ATLL) Sezary Syndrome (Mycosis Fungoides)
  • 16. Reed-Sternberg (Hodgkin Lymphoma) “Popcorn Cell” Lymphocyte-Rich Hodgkin “Auer Rods” (Acute Myelogenous Leukemia) Pelger-Huet cell (Myelodisplastic Syndrome) Sulfur Granules (Actino and more) Call-Exner bodies (Granulosa tumor) “Signet-ring” cells (Krukenberg tumor) Paget cells
  • 17. Classic Seminoma Schiller-Duval (Yolk-sac tumor) Pretibial Myxedema Exophthalmos (Graves disease) Periorbital Edema Hurthle Cells (H. Tyroiditis) Orphan Annie eye (Papillary C.) Blue Sclera (Osteogenesis I.)
  • 18. Erlenmeyer Flask (Osteopetrosis) Pott’s Disease (TB osteomielitis) Avascular Necrosis Knobby Knees (Osgood-Schlatter) Sheperd’s Crook (Fibrous dysplasia) Osteoid Osteoma Osteochondroma Soap-Bubble (Osteoclastoma)
  • 19. Paget’s Disease Osteosarcoma Homer-Wright Rosettes Onion Skin (Ewing sarcoma) Bone Spur (Osteoarthritis) Heberden / Bouchard Nodes Rheumatoid Arthritis Baker’s Cyst (RA)
  • 20. Boutonniere deformity (RA) Rheumatoid Nodules Uric Acid Crystals Calcium Pyrophosphate Lipoblast (Liposarcoma) Dermatofibroma “Herringbone pattern” (Fibrosarcoma) “Storiform” (Malignant Histiocytoma)
  • 21. Cell Nucleus Rough Endoplasmic Reticulum Smooth Endoplasmic Reticulum Golgi Apparatus Peroxisome and Lysosome Mitochondria Tight Junction Desmosome
  • 23. Stratified cuboidal Mixed serous and mucus Loose connective tissue Macrophages Collagen fibers Basal lamina Hyaline Cartilage Elastic Cartilage
  • 24. Osteoblasts Mature bone Osteoclasts Intramembranous Bone Endochondral Bone (left to right) Skeletal muscle (I band-light, A band- dark) Cardiac muscle (junctional complexes and single nucleus) Smooth muscle (gap junctions and fusiform fibers)
  • 25. Nissl Stain (Neurons) Axon Hillock (Light staining area) Peripheral Nerve Node of Ranvier Nucleolus White blood cells Plasma cell (clockface pattern) Hassall’s Corpuscle (thymus)
  • 26. Hyaline cartilage ring (Trachea) Bronchus w/Hyaline cartilage Clara cells (Bronchioles) Alveolar Pneumocytes Dust cell & Pore of Kohn GI tract Esophagus- Stomach transition Brunner’s glands (Duodenum)
  • 28.
  • 29. Pharyngeal/Aort ic Arch Associated Cranial Nerve Key Aortic Arch Derivatives 1 Trigeminal (V) Maxillary artery 2 Facial (VII) Stapedial artery 3 Glossopharyngeal (IX) Common carotid artery Prox. Internal carotid artery 4 Superior laryngeal branch of Vagus (X) True aortic arch Subclavian arteries 5 Obliterated Obliterated 6 Recurrent laryngeal branch of Vagus (X) Pulmonary arteries Ductus arteriosus
  • 30. Manouvers Increase Preload Right side Deep breath. (Inspiration) Laying supine Left side Expiration Increase Afterload Aortic/Systemic Hand grip Sustained squatting Pulmonary NOT IMPORTANT Valsalva Increases thoracic pressure Reduces right sided murmurs Decreases Heart rate and BP (Parasympathetic)
  • 31. . A P . 2-3rd 5-6th . Aortic Pulmonary Tricuspid Mitral Close at beginning of S Open at beginning of D Close at beginning of D Open at beginning of S Sounds are generated at the time of closure. S1 beginning of systole S2 beginning of diastole Stenosis – Anterograde Insufficiency – Retrograde MT A: Systolic – Aortic stenosis P: Systolic – Mitral insufficiency T: Systolic – Tricuspid insufficiency T: Diastolic – Tricuspid stenosis M: Diastolic – Mitral stenosis and aortic insufficiency T P
  • 32.
  • 33. Murmur Systolic Bicuspid aortic valve Early systolic High-frequency click Right 2nd interspace Hypertrophic Cardiomyopathy Crescendo- decrescendo murmur Between apex and left sternal Radiates to the suprasternal notch Louder standing up Aortic Stenosis Early Systolic Click Pulse late and weak Old age / Rheumatic F. Congenital Bicuspid valve Angina, syncope, CHF Pulmonary Stenosis Tetralogy of Fallot Harsh ejection murmur Systolic thrill Mitral Regurgitation Holosystolic Radiates to axilla Increases After load Tricuspid Regurgitation Holosystolic Increase right heart Flow Taking a Deep breath IV drug users w/ endocarditis Septal Defects Ventricular Harsh Holosystolic Atrial Fixed Splitting of S2 Diastolic Atrial Regurgitation Blowing murmur Widened pulse pressure Pulmonary Regurgitation Mitral Stenosis Opening snap Rheumatic Fever Tricuspid Stenosis
  • 34. 100 50 0 Time Aortic valve closes Aortic valve opens Mitral valve opens Mitral valve closes Normal Pressure tracing Left atrium Left Ventricle Aorta
  • 35. a c x v y A: Right atrial contraction B: Bulging of tricuspid valve during right ventricular contraction X: Right atrial relaxation V: Continued inflow of venous blood Y: Passive emptying of right atrium after tricuspid valve opening Jugular Venous Tracing
  • 36. Hemodynamic measurements in shock Parameter Hypovolemic shock Cardiogenic Shock Obstructive Shock Septic Shock Central venous pressure (right-sided preload) Pulmonary capillary wedge pressure (left-sided preload) Cardiac index (LV output) Systemic vascular resistance (afterload) Mixed venous oxygen saturation
  • 37.
  • 38.
  • 39.
  • 40. Pterygopalatine Fossa  Laterally – Infratemporal fossa  Medially – Nasal Cavity (Sphenopalatine foramen)  Inferiorly – Oral Cavity (Greater and lesser palatine canals)  Anteriorly – Orbit (Inferior orbital fissure)  Posteriorly – Pharynx Cerebral Nuclei  Locus Caeruleus – Neuromelanin cells (Norepinephrine)  Basal nucleus of Meynert – Cholinergic neurons (Alzheimer)  Caudate nucleus – GABA and Cholinergic acetylcholine (Huntington and Parkinson)  Raphe nuclei – Serotonergic bodies  Substantia nigra – Dopamine and GABA (Parkinson)  Ventral tegmental area – mesolimbic Dopamine (Schizophrenia)
  • 41. Elevated AFP • Gastroschisis • Omphalocele • Anencephaly • Spina Bifida Decreased AFP • Down Syndrome Elevated Ache • Anencephaly • Spina Bifida
  • 42. Normal Brain Chiari Malformation Type 2 Dandy-Walker Malformation
  • 43. Neural Tube Prosencephalon Telencephalon Cerebral hemispheres (Cerebral cortex, basal ganglia, deep white matter) Diencephalon Thalamus Motor and sensory relay nuclei Hypothalamus Control of endocrine and autonomic function Epithalamus Pineal gland Subthalamus Component of basal Ganglia Posterior lobe of the pituitary Neural Retina Mesencephalon Rhombencephalon Metencephalon Cerebellum Pons CN V, VI, VII, VIII Myelencephalon Medulla oblongata CN VIII-XIII
  • 44. Reflex Cord Segment Involved Muscle Tested Knee (Patellar) L2-L4 (femoral n.) Quadriceps Ankle S1 (tibial n.) Gastrocnemius Elbow C5-C6 (musculocutaneous n.) Biceps Elbow C7-C8 (radial n.) Triceps Forearm C5-C6 (radial n.) Brachioradialis
  • 45. Korsakoff syndrome Amnesia, confabulation and preserved long-term memory Lesions in the anterior and medial thalami Wernicke Encephalopathy Encephalopathy, ocular dysfunction and ataxia Atrophy of Mamillary bodies Cerebellar Degeneration Tremor, unsteady gait Loss of Purkinje cells in the cerebellar vermis
  • 46. Upper Motor Neuron Lesion • Spastic Paresis • Hyperreflexia • Babinski sign • Increased muscle tone • Clasp knife reflex • Disuse atrophy of muscles • Decreased speed of voluntary movements • Large area of the body involved Lower Motor Neuron Lesion • Flaccid paralysis • Areflexia • No Babinski • Fasciculations • Decreased muscle tone or atonia • Atrophy of muscle(s) • Loss of voluntary movements • Small area of the body affected
  • 47. Foramen Rotundum- CN V2 (Maxillary Nerve) CN V3 (Mandibular Nerve)Foramen Ovale- Superior Orbital Fissure CN II (Optic Nerve) Ophthalmic Artery CN III (Oculomotor Nerve) CN IV (Trochlear Nerve) CN V1 (Ophthalmic Nerve) CN VI (Abduncens Nerve) Ophthalmic Veins Optic Canal Cribiform Plate- CN I (Olfactory Nerve) Foramen Spinosum Foramen Lacerum- Middle Meningeal A. Meningeal N. (V3) Internal Carotid Artery
  • 48. Skull Foramen Traversing Structures Anterior Cranial Fossa Cribiform plate CN I olfactory bundles Middle Cranial Fossa Optic canal CN II, ophthalmic artery, central retinal vein Superior Orbital fissure CN III, IV, V1, VI, ophthalmic vein, sympathetic fibers Foramen rotundum CN V2 (maxillary) Foramen ovale CN V3 (mandibular) Foramen spinosum Middle meningeal artery and vein Posterior Cranial Fossa Internal acoustic meatus CN VII, VIII Jugular foramen CN IX, X, XI, jugular vein Hypoglossal canal CN XII Foramen magnum Spinal roots of CN XI, brain stem, vertebral arteries
  • 49. Spinal Cord Hemisection (Brown-Sequard Sx) Ipsilateral • Spastic Weakness • Altered vibratory sense Contralateral • Loss of pain and temperature NO Cranial Nerve signs
  • 50. Brain-Stem Lesions Ipsilateral • Cranial Nerve signs to lesion • Horner’s Syndrome Contralateral • All deficits (Wallenberg syndrome IX,X)
  • 51. Cortex or Capsular Lesions Ipsilateral • None Contralateral • Anesthesia • Lower face weakness • Sensory deficits
  • 52. Cerebellar Lesion (Hemisphere) Ipsilateral • Intention tremor • Dysmetria • Dyadochokinesia • Scanning dysarthria • Nystagmus • Hypotonia (Insult to deep nuclei) Vermal Lesion • Gait Ataxia (alcoholism) • Truncal Ataxia (medulloblastoma)
  • 53. Cerebellar Lesion (Vermal Lesion) • Gait Ataxia (alcoholism) • Truncal Ataxia (medulloblastoma)
  • 54. Parkinson Disease Bradykinesia, cogwheel rigidity, resting tremor, shuffling gait, Stooped posture, masked face, depression and dementia Pathognomonic: Lewy bodies Loss of dopaminergic neurons from substantia nigra Huntington Disease Chorea (rapid movements), athetosis (slow movements), personality changes, dementia Type of disease: Autosomal Dominant (Chromosome 4) Degeneration of GABA neurons, causing atrophy of head of caudate nucleus Wilson Disease Tremor, asterixis, parkinsonian symptoms, chorea, fatty change, Neuropsychiatric symptoms, hepatitis or cirrhosis, tremor may be “wing beating”. Pathognomonic: Kayser-Fleischer ring
  • 55. Hemiballism CONTRALATERAL Wild, flinging movements of limbs Pathognomonic: Hypertensive Patients Hemorrhagic destruction of subthalamic nucleus Tourette Syndrome Motor and vocal tics, commonly associated with OCD and ADHD Treatment: Antipsychotic agents Excess of striatal dopamine
  • 56. POLIO Flaccid Paralysis, Muscle atrophy, Fasciculations, Areflexia TABES DORSALIS Paresthesias, Pain, Polyuria/Urine retention, Associated w/neurosyphilis, +Romberg sign, suppressed reflexes, pupillary reflex defects. ALS Spastic paralysis in lower limbs, flaccid paralysis in upper limbs, increased tone and reflexes. ANTERIOR SPINAL ARTERY OCCLUSION Pain, temperature and spastic weakness bilateral signs, spastic bladder Vibratory and pressure senses spared
  • 57. SUBACUTE COMBINED DEGENERATION Paresthesias, bilateral spastic weakness, Babinski sign, antibodies to the intrinsic factor (Vitamin B12 pernicious anemia) SYRINGOMYELIA Bilateral loss of pain and temperature upper limbs. “Cape-like” It eventually gets to flaccid paralysis and atrophy of the upper limb May be associated with hydrocephalus and Arnold Chiari II. BROWN-SÉQUARD SYNDROME (HEMISECTION) Ipsilateral Horner’s sx, paresis, loss of position and vibratory senses. Contralateral loss of pain and temperature.
  • 58. Hypothalamus Anterior Region Paraventricular and Supraoptic Nuclei Synthesize ADH and Oxytocin Suprachiasmatic Nucleus Circadian Rhythms Tuberal Region Arcuate Nucleus Release hormones in the anterior pituitary Ventromedial Nucleus Satiety center Posterior Region Mamillary Bodies Wernicke-Korsakoff Hypotalamic Zone Anterior Senses elevation of temperature Posterior Senses decrease of temperature Lateral Feeding center Preoptic Area . Sensitive to androgens and estrogens
  • 59. Expressive Aphasia- Agraphia, decreased ability to repeat words or answer questions. Single-syllable words (pt frustrated) Left MCA infarct Lower face weakness if associated w/Primary motor cortex Receptive Aphasia-Oral aphasia (they don’t understand) if restricted to area 22. They use “word salad” to speak, paraphasic speech. Aware and not concerned, fluent speech but incoherent. May have hearing loss. Gerstmann Syndrome- Alexia with agraphia, often seen with acalculia, finger agnosia (particularly right hand).
  • 60. Conductive Aphasia- Speech and comprehension may be normal, but patient paraphrases and needs word-finding pauses. Pt cannot repeat words or execute verbal commands. Aware and frustrated. Cannot speak or write Area 7, 39 ,40 Asomatognosia/Neglect- Unawareness or neglect of contralateral Half of the body. Pt ignores left side of his body or things. Visual Agnosia- Inability to recognize visual patterns or objects. If lesions 20 and 21 involved pt develops prosopagnosia which is the inability to recognize faces.
  • 61. Transcortical Apraxia- From an occlusion of the ACA Inability to move the left arm to respond to verbal commands NO motor weakness. Alexia without Agraphia- From an occlusion of the left PCA Right homonymous hemianopsia w/macular sparing. Visual information cannot reach the language area. Color anomia, pt unable to read, able to write. Kluver-Bucy Syndrome- Hypersexuality, hyperphagia and visual agnosia.
  • 62. Global Aphasia- Both Broca and Wernicke are damaged. Includes labored telegraphic speech and poor comprehension. NO motor weakness. Naming severely impaired Transcortical Aphasia- Capacity to repeat statements unimpaired Patient cannot speak spontaneously. NO motor weakness.
  • 63. 1. Parinaud’s Syndrome 2. Korsakoff’s psychosis 3. Contralateral leg weakness 4. Superior quadrantanopia w/macular sparing 5. Alexia without agraphia 6. Hoarseness 7. Difficulty chewing 8. Temperature regulation 9. Rathke’s pouch 10. Truncal ataxia D E A C B M F G H I L K 1. M- Pineal gland Tumor 2. L- Mamillary body degeneration 3. D- Motor homunculus (precentral gyrus) 4. B- Lingual Gyrus (Meyer’s Loop) 5. A- Splenium of Corpus Callosum lesion 6. H- Vagus nerve rostral medulla 7. G- Trigeminal nerve rostral pons 8. I- Hypothalamus 9. K-Anterior Pituitary gland 10. J- Posterior part of the cerebellar vermis J
  • 64. Autosomal Recessive Autosomal Dominant Onset Early uniform onset (Infancy or childhood) Variable onset (may be delayed into adulthood) Penetrance Complete Penetrance Incomplete penetrance with variable expression Mutation Usually an enzyme protein Usually a structural protein or receptor Requires Mutation of both alleles Mutation of one allele