DENTAL ANATOMY: KNOW COLD, BOARDS DA GENERAL FIRST AID, boards memorization aids, BOARDS key associations first aid, BOARDS First Aid Rapid review, Microbiology boards First Aid, USMLE Step 1 Mnemonics, First Aid Mnemonics, Step 1 Mnemonics II: Immun…

Widest tooth mesio-distally
Mandibular first molar

Widest anterior tooth mesio-distally
Maxillary central

Only tooth with pulp wider mesa-distally than face-buccally
Maxillary central

Widest tooth facio-lingually
Maxillary first molar

Widest anterior tooth facio-lingually
Maxillary canine

Only tooth more narrow facially than lingually
Maxillary first molar

Tallest two teeth inciso-gingivally
Maxillary canine then mandibular canine

Top three teeth with the tallest crown
Mandibular canine, maxillary central, maxillary canine

Which tooth has the longest root inciso-gingivally
Maxillary canine

Which tooth is the smallest
Mandibular central-also most symmetrical

Which tooth is most narrowest mesa-distally
Mandibular central

What is the narrowest and smallest rooted premolar
Mandibular 1

What are the top two teeth that are likely to be congenitally missing or malformed
Third molars and then maxillary lateral incisors

Which tooth has the best lingual anatomy
maxillary lateral incisor

Which tooth is most likely to have dense-in-dente
maxillary lateral incisor

What is the most likely premolar to be congenitally missing
Mandibular 2 pre-molar

Which tooth has the most constriction from pulp chamber to canals
Maxillary 1 pre-molar.

Which anterior tooth is most likely to have a bifurcated root
Mandibular canine

Which tooth has 2 triangular ridges on 1 cusp
Maxillary 1 molar

What is the only tooth with a mesio-lingual groove
Mandibular first pre-molar

Which tooth is the only with a medially inclined root
Mandibular canine

Which pre-molar is likely to have 1 root and 1 canal
Mandibular 2 premolar

What two teeth have crown concavities
Maxillary 1 molar (distal) and Maxillary 1 premolar (mesial)

What tooth has a longer mesial maxillary first pre-molar cusp slope than distal
Primary maxillary canine

Which root has facial and lingual depression
the Maxillary first molar palatal root

What is the largest embrasure of the anterior teeth
Between the maxillary canine and lateral incisor.

What is the largest occlusal embrasure
Between the maxillary canine and 1 PM.

Faciolingual inter-proximal contacts of anterior teeth
Middle 3rd of crown

Incisogingval inter-proximal contacts of anterior teeth
Maxillary (starting at midline): I-I, J-J, M-J, M-
Mandibular (starting at midline): I-I, I-I, I-I, M-

Posterior tooth inter-proximal contacts in faciolingual
Middle 3rd of crown, closer to facial.

Posterior tooth inter-proximal contacts in occlusio-gingival
Middle 3rd of crown. Exception: Mesial surface of maxillary and mandibular 1 Molar’s contact is at the junction of the occlusal and middle 3rd’s of the crown’s.

What is the largest embrasure for every tooth
Lingual. Exceptions: Both embrasures of maxillary first molars have larger buccal embrasures. Also, mandibular incisors have equal buccal and lingual embrasures.

Facial and lingual heights of contour for all anterior teeth
Gingival 3rd of crown.

Lingual heights of contour for all posterior teeth
At or near the middle 3rd of crown. Mandibular 2nd premolar lingual is occlusal 3rd. Mandibular 1st approaches the middle 3rd.

Facial heights of contour for all posterior teeth
Gingival 3rd of crown. Exceptions: mandibular posterior teeth are closer to occlusal at the junction of gingival and middle 3rd.

Which anterior tooth has a more convex and full distal surface than mesial surface
The Maxillary canine.

Mandibular eruption dates
679-0161

Maxillary eruption dates
781-0062

WHICH TEETH HAVE A MOST COMMON TRANSVERSE RIDGE
MAXILLARY PREMOLAR AND MANDIBULAR MOLARS

WHICH TOOTH HAS MORE PROMINENT BUCCAL CUSPS RIDGES
MAXILLARY FIRST PREMOLAR

ANATOMICAL OR CLINICAL CROWN: PORTION OF THE TOOTH THAT EXTENDS FROM THE CEMENTOENAMEL JUNCTION TO THE INCISAL EDGE OR THE OCCLUSAL SURFACE (ENAMEL COVERED PORTION OF THE CROWN)
ANATOMICAL CROWN

ANATOMICAL OR CLINICAL CROWN: ENAMEL COVERED PORTION OF THE TOOTH
ANATOMICAL

ANATOMICAL OR CLINICAL CROWN: THE PORTION OF THE TOOTH THAT EXTENDS INCISALLY OR OCCLUSALLY FROM THE GINGIVAL MARGIN (CLINICALLY VISIBLE PORTION OF THE TOOTH)
CLINICAL

ANATOMICAL OR CLINICAL CROWN: CLINICALLY VISIBLE PORTION OF THE TOOTH
CLINICAL

WHAT STRUCTURES DOES THE OCCLUSAL SURFACE CONSIST OF
CUSPS RIDGES AND GROOVES

WHAT STRUCTURES CONSIST OF OCCLUSAL TABLE
WITHIN CUSPS AND MARGINAL RIDGES

TERM: AN EXTRA FORMATION OF ENAMEL ON THE CROWN OF A TOOTH. OFTEN MANIFESTS AS SUPERNUMERARY CUSPS SUCH AS CUSP OF CARABELLI
TUBERCLE

TERM: OFTEN MANIFESTS AS SUPERNUMERARY CUSPS SUCH AS CUSP OF CARABELLI
TUBERCLE

TERM: AN EXTRA FORMATION OF ENAMEL ON THE CROWN OF A TOOTH.
TUBERCLE

WHICH THIRD OF THE ANTERIOR TEETH ARE CINGULA LOCATED
CERVICLE THIRD

TERM: A ROUND EXTENSION OF ENAMEL ON THE INCISAL EDGE OF ALL INCISORS
MAMELONS

HOW MANY MAMELONS ARE THERE USUALLY PER INCISOR
3

TERM: A LARGE ELEVATION OF ENAMEL LOCATED ON THE OCCLUSAL SURFACE OF ALL POSTERIOR TEETH AND THE INCISAL EDGE OF CANINES
CUSP

TERM: LARGE ELEVATION OF ENAMEL
CUSP

WHAT ARE LOBES SEPARATED BY
DEVELOPMENTAL DEPRESSIONS IN ANTERIOR TEETH AND DEVELOPMENTAL GROOVES FOR POSTERIOR TEETH

TERM: A LINEAR ELEVATION OF THE ENAMEL SURFACE
RIDGE

WHAT CUSP ON THE MAXILLARY FIRST MOLAR COMPLETE THE SECOND TRIANGLE
DL CUSP

WHAT DIRECTION IS THE MANDIBULAR LATERAL INCISOR GOING TOWARDS FROM OCCLUSAL ASPECT
DISTO-LINGUALLY

WHAT HELPS FORM THE MESIAL AND DISTAL CONTACT AREAS
LINGUAL HEIGHT OF CONTOURS

WHAT ALLOWS FOR ADEQUATE GINGIVAL HEALTH
LINGUAL HEIGHT OF CONTOURS

WHAT IS THE EXCEPTION FOR LOCATION OF FACIAL HOC
MANIBULAR MOLARS

WHAT IS THE FACIAL HOC FOR MANDIBULAR MOLARS
JUNCTION OF MIDDLE AND CERVICAL THIRD

WHAT IS THE EXCEPTION FOR LINGUAL HOC
MANDIBULAR PM2

WHAT IS THE LOCATION OF LINGUAL HOC FOR MANDIBULAR PM2
OCCLUSAL THIRD

WHERE IS THE MANDIBULAR PRIMATE SPACE BETWEEN
CANINE AND FIRST MOLAR (DISTAL TO CANINE)

WHERE IS THE MANDIBULAR PRIMATE SPACE BETWEEN
LATERAL INCISOR AND CANINE (MESIAL TO CANINE)

THIS TERM: ALLOWS FOR THE PROPER ALIGNMENT OF THE PERMANENT INCISOR
PRIMATE SPACE

THIS TERM OCCURS IN ABOUT 50% OF PRIMARY DENTITION
PRIMATE SPACE

WHAT IS THE ARCH LENGTH OF PRIMARY TEETH FOR THE MAXILLARY AND MANDIBLE
MAXILLARY IS 68.2 AND MANDIBULAR IS 61.8

DESCRIBE THE CENTRAL GROOVE FOR THE MANDIBULAR SECOND MOLAR
STRAIGHT

WHAT ARE THE MOST COMMONLY CONGENITALLY MISSING TEETH IN ORDER
3RD MOLARS 2 MAXILLARY LATERAL INCISORS 3 SECOND PREMOLARS

ARE SUPERNUMERARY TEETH MORE COMMON IN MAXIILLARY OR MANDIBULAR ARCH
MAXILLARY

TERM: A SUPERNUMERARY TEETH LOCATED IN BETWEEN THE CENTRAL INCISORS
MESIODENS

IN ANKYLOSIS, WHAT IS THE TOOTH FUSED TO
THE ALVEOLAR BONE

WHAT TYPE OF TOOTH IS TAURODONTISM MOST ASSOCIATED WITH
MOLAR

WHEN DOES TAURODONTISM GENERALLY OCCUR
PATIENTS WITH AMELOGENESIS IMPERFECTA, KLINEFELTER’S SYNDROME OR DOWN’S SYNDROME

WHAT TEETH IS INVAGINATUS MOSTLY ASSOCIATED WITH
MAXILLARY LATERAL INCISORS

TERM: A PROMINENT DENS EVAGINATUS OFTEN SEEN ON MAXILLARY LATERAL INCISORS
TALON CUSP

TERM: EXCESSIVE DEPOSITION OF CEMENTUM
HYPERCEMENTOSIS

WHAT TEETH DO CERVICAL ENAMEL PROJECTION USUALLY ASSOCIATED WITH
MOLARS

TERM: AN APICAL EXTENSION OF ENAMEL USUALLY LOCATED AT FURCATION ENTRANCE ON MOLAR TEETH
CERVICAL ENAMEL PROJECTION

TERM: A SMALL, FOCAL MASS OF ENAMEL FORMED APICAL TO THE CEJ
ENAMEL PEARL

TERM: FUSION OF TWO COMPLETELY FORMED TEETH AT THEIR ROOTS MUST HAVE CONFLUENT CEMENTUM
CONCRESCENCE

WHAT MUST CONCRECENCE MUST HAPPEN TO OCCUR
CONFLUENT CEMENTUM

TERM: FUSION OF TWO UNIQUE TOOTH BUDS
FUSION

WHAT MUST FUSION HAVE TO OCCUR
MUST HAVE CONFLUENT DENTIN

WHAT DOES THE SEVERITY OF FUSION DEPEND ON
THE STAGE OF TOOTH DEVELOPMENT AT WHICH THE FUSION OCCURS

TERM: DEVELOPMENT OF TWO CROWNS FROM ONE TOOTH BUD
GEMINATION

TERM: SHARE A SINGLE ROOT AND A SINGLE CANAL
GEMINATION

CONTAIN A FREE ANOMERIC CARBON THAT CAN BE OXIDIZED
REDUCING SUGARS

TERM: IF THE OXYGEN ON

curve of wilson
wilson = wide

BULL
buccal upper, lingual lower
-these are the nonworking cusps
(BULLS never work)

V3 innervated muscles
“My Ass Meets The Toilet”
-Mylohyoid
-Anterior digastric
-Muscles of mastication
-Tensor veli palatini
-Tensor tympani

muscles of mastication
“MTPP” (empty pee pee)
-Masseter
-Temporal
-Pterygoid (medial)
-Pterygoid (lateral)

branches of the vagus nerve
“APES CRAP”
-Auricular
-Pharyngeal
-Esophageal
-Superior Laryngeal
-Cardiac branches
-Recurrent laryngeal
-Anterior vagal trunk
-Posterior vagal trunk

cranial nerves (sensory motor or both)
“Some Say Money Matters But My Brother Says Big Brains Matter Most”
S = sensory
M = motor
B = both

Ansa cervicalis innervations
“GENius THinks SOmeone STupid SHot Irene”
GENiohyoid
THyrohyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior omohyoid

Sterilization rules
critical = enter tissue, must be sterilized
semi-critical = touches mucous membranes, require high level disinfectants

polar amino acids
SERiously CYSter, Gimme THat Ass
Serine
Cystine
Glutamine (not glycine because “gimmie” has an M in it)
Threonine
Asparagine

non polar amino acids
“All International Losers Must Gulp Vampire Poison”
Alanine
Isoleucine
Leucine
Methionine
Glycine
Valine
Proline

3 cardinal rules of tooth eruption
-Ladies first (before boys)
-skinny kids are faster (vs “stocky” kids)
-Mandibular before maxillary

Actinic (solar) keratosis
Precursor to squamous cell carcinoma

Acute gastric ulcer associated with CNS injury
Cushing’s ulcer (?ICP stimulates vagal gastric secretion)

Acute gastric ulcer associated with severe burns
Curling’s ulcer (greatly reduced plasma volume results in sloughing of gastric mucosa)

Alternating areas of transmural inflammation and normal colon
Skip lesions (Crohn’s disease)

Aneurysm, dissecting
Hypertension

Aortic aneurysm, abdominal and descending aorta
Atherosclerosis

Aortic aneurysm, ascending
Marfan’s syndrome (idiopathic cystic medial degeneration)

Atrophy of the mammillary bodies
Wernicke’s encephalopathy (thiamine deficiency causing ataxia, ophthalmoplegia, and confusion)

Autosplenectomy (fibrosis and shrinkage)
Sickle cell anemia (HbS)

Bacteria associated with gastritis, PUD, and stomach cancer
H. pylori

Bacterial meningitis (adults and elderly)
S. pneumoniae

Bacterial meningitis (newborns and kids)
Group B streptococcus (newborns), S. pneumoniae/Neisseria meningitidis (kids)

Benign melanocytic nevus
Spitz nevus (most common in first two decades)

Bleeding disorder with Gp1b deficiency
Bernard-Soulier disease (defect in platelet adhesion to von Willebrand’s factor)

Brain tumor (adults)
Supratentorial: mets > astrocytoma (including glioblastoma multiforme) > meningioma > schwannoma

Brain tumor (kids)
Infratentorial: medulloblastoma (cerebellum) OR supratentorial: craniopharyngioma (cerebrum)

Breast cancer
Infiltrating ductal carcinoma (in the United States, 1 in 9 women will develop breast cancer)

Breast mass
Fibrocystic change, Carcinoma (in postmenopausal women)

Breast tumor (benign)
Fibroadenoma

Cardiac 1° tumor (kids)
Rhabdomyoma (often seen in tuberous sclerosis)

Cardiac manifestation of lupus
Libman-Sacks endocarditis (non bacterial, affecting both sides of mitral valve)

Cardiac tumor (adults)
Metastasis, primary myoma (4:1 left to right atrium; “ball and valve”)

Cerebellar tonsillar herniation
Chiari malformation (often presents with progressive hydrocephalus or syringomyelia)

Chronic arrhythmia
Atrial fibrillation (associated with high risk of emboli)

Chronic atrophic gastritis (autoimmune)
Predisposition to gastric carcinoma (can also cause pernicious anemia)

Clear cell adenocarcinoma of the vagina
DES exposure in utero

Compression fracture
Osteoporosis (type I: postmenopausal woman; type II: elderly man or woman)

Congenital adrenal hyperplasia, hypotension
21-hydroxylase deficiency

Congenital cardiac anomaly
VSD

Congenital conjugated hyperbilirubinemia (black liver)
Dubin-Johnson syndrome (inability of hepatocytes to secrete conjugated bilirubin into bile)

Constrictive pericarditis
Tuberculosis (developing world), systemic lupus erythematosus, SLE (developed world)

Coronary artery involved in thrombosis
LAD > RCA > LCA

Cretinism
Iodine deficit/ hypothyroidism

Cushing’s syndrome
Corticosteorid therapy, Excess ACTH secretion by pituitary, Small cell lung carcinoma

Cyanosis (early; less common)
Tetralogy of Fallot, Transposition of great vessels, Truncus arteriosus

Cyanosis (late; more common)
VSD, ASD, PDA

Death in CML
Blast crisis

Death in SLE
Lupus nephropathy

Dementia
Alzheimer’s disease and Multiple infarct

Demyelinating disease in young women
Multiple sclerosis

DIC
Gram-negative sepsis, DIC, Obstetric complications, Cancer, Burn trauma

Dietary deficit
Iron

Diverticulum in pharynx
Zenker’s diverticulum (diagnosed by barium swallow)

Ejection click
Aortic/pulmonic stenosis

Esophageal cancer
Squamous cell carcinoma (worldwide); Adenocarcinoma (US)

Food poisoning (exotoxin mediated)
Staphylococcus aureus, Bacillus cereus

Glomerulonephritis (adults)
Berger’s disease (lgA nephropathy)

Gynecologic malignancy
Endometrial carcinoma (most common in U.S.); Cervical carcinomam (most common worldwide)

Heart murmur, congenital
Mitral valve prolapse

Heart valve in bacterial endocarditis
Mitral (rheumatic fever); tricuspid (IV drug abuse); aortic (2nd in rheumatic fever)

Helminth infection (U.S.)
Enterobius vermicularis, Ascaris lumbricoides

Hematoma-epidural
Rupture of middle meningeal artery (Trauma; lentiform shaped)

Hematoma-subdural
Rupture of bridging veins (crescent shaped)

Hemochromatosis
Multiple blood transfusions or hereditary HFE mutation (can result in CHF, “bronze diabetes,” and ? risk of hepatocellular carcinoma)

Hepatocellular carcinoma
Cirrhotic liver (often associated with hepatitis B and C)

Hereditary bleeding disorder
von Willebrand’s disease

Hereditary harmless jaundice
Gilbert’s syndrome (benign congenital unconjugated hyperbilirubinemia)

HLA-B27
Ankylosing spondylitis, Reiter’s syndrome, Ulcerative colitis, and Psoriasis

HLA-DR3 or -DR4
Diabetes mellitus type 1, rheumatoid arthritis, SLE

Holosystolic murmur
VSD, tricuspid regurgitation, mitral regurgitation

Hypercoagulability, endothelial damage, blood stasis
Virchow’s triad (results in venous thrombosis)

Hypertension, 2°
Renal disease

Hypoparathyroidism
Accidental excision during thyroidectomy

Hypopituitarism
Pituitary adenoma (usually benign tumor)

Infection 2° to blood transfusion
Hepatitis C

Infections in chronic granulomatous disease
Staphylococcus aureus, E. coli, Aspergillus (catalase positive)

Kidney stones
Calcium = radiopaque, Struvite (ammonium) = radiopaque (formed by urease-positive organisms such as Proteus vulgaris or Staphylococcus), Uric acid = radiolucent

Late cyanotic shunt (uncorrected L ? R becomes R ? L)
Eisenmenger’s syndrome (caused by ASD, VSD, PDA; results in pulmonary hypertension/polycythemia)

Liver disease
Alcoholic cirrhosis

Lysosomal storage disease
Gaucher’s disease

Male cancer
Prostatic carcinoma

Malignancy associated with noninfectious fever
Hodgkin’s lymphoma

Malignant skin tumor
Basal cell carcinoma (rarely metastasizes)

Mental retardation
Down Syndrome and Fragil X syndrome

Metastases to bone
Breast, lung, thyroid, testes, prostate, kidney

Metastases to brain
Lung, breast, skin (melanoma), kidney (renal cell carcinoma), GI

Metastases to liver
Colon, gastric, pancreatic, breast, and lung carcinomas

Mitochondrial inheritance
Disease occurs in both males and females, inherited through females only

Mitral valve stenosis
Rheumatic heart disease

Mixed (UMN and LMN) motor neuron disease
ALS

Myocarditis
Coxsackie B

Neoplasm (kids)
ALL and Cerebellar medulloblastoma

Nephrotic syndrome (adults)
Focal segmental glomerulosclerosis

Nephrotic syndrome (kids)
Minimal change disease (associated with infections/vaccinations; treat with corticosteroids)

Neuron migration failure
Kallmann Syndrome

Nosocomial pneumonia
Klebsiella, E. coli, Pseudomonas aeruginosa

Obstruction of male urinary tract
BPH

Opening snap
Mitral stenosis

Opportunistic infection in AIDS
Pneumocystis jiroveci (formerly carinii) pneumonia

Osteomyelitis
S. aureus

Osteomyelitis in sickle cell disease
Salmonella

Osteomyelitis with IV drug use
Pseudomonas, S. aureus

Ovarian metastasis from gastric carcinoma or breast cancer
Krukenberg tumor (mucin-secreting signet-ring cells)

Ovarian tumor (benign, bilateral)
Serous cystadenoma

Ovarian tumor (malignant)
Serous cystadenocarcinoma

Pancreatitis (acute)
Gallstones, alcohol

Pancreatitis (chronic)
Alcohol (adults); Cystic fibrosis (kids)

Patient with ALL /CLL / AML /CML
ALL: child, CLL: adult > 60, AML: adult ~60, CML: adult 30-60

Pelvic inflammatory disease
Neisseria gonorrhoeae (monoarticular arthritis)

Philadelphia chromosome t(9;22) (bcr-abl)
CML (may sometimes be associated with ALL/AML)

Pituitary tumor
Prolactinoma and Somatotropic “acidophilic” adenoma

Primary amenorrhea
Turner syndrome (45XO)

Primary bone tumor (adults)
Multiple myeloma

Primary hyperaldosteronism
Adenoma of adrenal cortex

Primary hyperparathyroidism
Adenomas, Hyperplasia, Carcinoma

Primary liver cancer
Hepatocellular carcinoma (chronic hepatitis, cirrhosis, hemochromatosis, ?-1 antitrypsin)

Pulmonary hypertension
COPD

Recurrent inflammation/thrombosis of small/medium vessels in extremities
Buerger’s disease (strongly associated with tobacco)

Renal tumor
Renal cell carcinoma: associated with von Hippel-Lindau and adult polycystic kidney disease; paraneoplastic syndromes (erythropoietin [EPO], renin, PTH, ACTH)

Right heart failure due to a pulmonary cause
Cor pulmonale

S3 (protodiastolic gallop)
? ventricular filling (L ? R shunt, mitral regurgitation, LV failure [CHF])

S4 (presystolic gallop)
Stiff/hypertrophic ventricle (aortic stenosis, restrictive cardiomyopathy)

Secondary hyperparathyroidism
Hypocalcemia of chronic kidney disease

Sexually transmitted disease
Chlamydia (usually coinfected with gonorrhea)

SIADH
Small cell carcinoma of the lung

Site of diverticula
Sigmoid colon

Sites of atherosclerosis
Abdominal aorta > coronary > popliteal > carotid

Stomach cancer
Adenocarcinoma

Stomach ulcerations and high gastrin levels
Zollinger-Ellison syndrome (gastrinoma of duodenum or pancreas)

t(14;18)
Follicular lymphomas (bcl-2 activation)

t(8;14)
Burkitt’s lymphoma (c-myc activation)

t(9;22)
Philadelphia chromosome, CML (bcr-abl fusion)

Temporal arteritis
Risk of ipsilateral blindness due to thrombosis of ophthalmic artery; polymyalgia rheumatica

Testicular tumor
Seminoma

Thyroid cancer
Papillary carcinoma

Tumor in women
Leiomyoma (estrogen dependent, not precancerous)

Tumor of infancy
Hemangioma (usually regresses spontaneously by childhood)

Tumor of the adrenal medulla (adults)
Pheochromocytoma (usually benign)

Tumor of the adrenal medulla (kids)
Neuroblastoma (malignant)

Type of Hodgkin’s
Nodular sclerosis (vs. mixed cellularity, lymphocytic predominance, lymphocytic depletion)

Type of non-Hodgkin’s
Diffuse large cell

UTI
E. coli, Staphylococcus saprophyticus (young women)

Viral encephalitis affecting temporal lobe
HSV-1

Vitamin deficiency (U.S.)
Folic acid (pregnant women are at high risk; body stores only 3- to 4-month supply; prevents neural tube defects)

Abdominal Pain, ascites, hepatomegaly
Budd-Chiari Syndrome

Achilles Tendon Xanthoma
Familial hypercholesterolemia (decreased LDL receptor signalling)

Adrenal Hemorrhage, hypotension, DIC
Waterhouse-Friedrichson Syndrome (meningococcemia)

Arachnodactyly, lens dislocation, aortic dissection, hyperflexible joints
Marfan’s syndrome

Athlete with polycythemia
Secondary to erythropoietin injection

Back pain, fever, night sweats, weight loss
Pott’s Disease (vertebral tuberculosis)

Bilateral hilar adenopathy, uveitis
Sarcoidosis (noncaseating granulomas)

Blue sclera
Osteogenesis Imperfecta (Type 1 collagen defect)

Bluish line on gingiva
Lead poisoning (Burton’s line)

Bone pain, bone enlargement, arthritis
Paget’s disease of bone (Increased osteoblastic and osteoclastic activity)

Bounding pulses, diastolic heart murmur, head bobbing
Aortic Regurgitation

“Butterfly” facial rash and Raynaud’s phenomenon in a young female
Systemic Lupus Erythematosus

Cafe-au-lait spots, Lisch nodules (iris hamartoma)
Neurfibromatosis type 1 (+ pheochromocytoma, optic gliomas)

Cafe-au-lait spots, polyostotic fibrous dysplasia, precocious puberty, multiple endocrine abnormalities
McCune-Albright Syndrome (mosaic G-protein signaling mutation)

Calf pseudohypertrophy
Muscular Dystrophy (most commonly Duchenne’s): X-linked recessive deletion of dystrophin gene.

“Cherry-red spot” on macula
Tay-Sachs (ganglioside accumulation) or Niemann-Pick (sphingomyelin accumulation), central retinal artery occlusion.

Chest pain on exertion
Angina (stable: with moderate exertion; unstable: with minimal or no exertion)

Chest pain, pericardial effusion/friction rub, persistent fever following MI
Dressler’s syndrome (autoimmune-mediated post-MI fibrinous pericarditis, 1-12 weeks after acute episode)

Child uses arms to stand up from squat
Gowers’ sign (Duchenne Muscular Dystrophy)

Child with fever later develops red rash on face that spreads to body
“Slapped cheeks” (erythema infectiosum/fifth disease: Parvovirus B19)

Chorea, dementia, caudate degeneration
Huntington’s disease (autosomal-dominant CAG repeat expansion)

Chronic exercise intolerance with myalgia, fatigue, painful cramps, myoglobinuria
McArdle’s disease (muscle glycogen phosphorylase deficiency)

Cold intolerance
Hypothyroidism

Conjugate lateral gaze palsy, horizontal diplopia
Internuclear ophthalmoplegia (Damage to MLF; bilateral = Multiple Sclerosis; Unilateral = stroke)

Continuous “machinery” heart murmur
PDA (close with indomethacin; open or maintain with misoprostol)

Cutaneous/dermal edema due to connective tissue deposition
Myxedema (caused by hypothyroidism or Grave’s disease = pretibial)

Dark purple skin/mouth nodules
Kaposi’s sarcoma (usually AIDS patients; associated with HHV-8)

Deep, labored breathing/hyperventilation
Kussmaul breathing (diabetic ketoacidosis)

Dermatitis, dementia, diarrhea
Pellagra (niacin/vitamin B3 deficiency)

Dilated cardiomyopathy, edema, alcoholism or malnutrition
Wet beriberi (thiamine/Vitamine B1 deficiency)

Dog or cat bite resulting in infection
Pasteurella multocida (cellulitis at inoculation site)

Dry eyes, dry mouth, arthritis
Sjögren’s syndrome (autoimmune destruction of exocrine glands)

Dysphagia (esophageal webs), glossitis, iron deficiency anemia
Plummer-Vinson syndrome (may progress to esophageal squamous cell carcinoma)

Elastic skin, hypermobility of joints
Ehlers-Danlos Syndrome (Type III collagen defect)

Enlarged, hard left supraclavicular node
Virchow’s node (abdominal metastasis)

Erythroderma, lymphadenopathy, hepatosplenomegaly, atypical T cells
Sézary Syndrome (cutaneous T-cell lymphoma) or mycosis fungoides

Facial muscle spasm upon tapping
Chvostek’s sign (hypocalcemia)

Fat, female, forty, and fertile
Cholelithiasis (gallstones)

Fever, chills, headache, myalgia following antibiotic treatment for syphilis
Jarisch-Herxheimer reaction (rapid lysis of spirochetes results in toxin release)

Fever, cough, conjunctivitis, coryza, diffuse rash
Measles (Morbillivirus)

Fever, night sweats, weight loss
B symptoms (staging) of lymphoma

Fibrous plaques in soft tissue of penis
Peyronie’s disease (connective tissue disorder)

Gout, mental retardation, self-mutilating behavior in a boy
Lesch-Nyhan syndrome (HGPRT deficiency, X-linked recessive)

Green-yellow rings around peripheral cornea
Kayser-Fleischer rings (copper accumulation from Wilson’s disease)

Hamartomatous GI polyps, hyperpigmentation of mouth/feet/hands
Peutz-Jeghers syndrome (inherited, benign polyposis can cause bowel obstruction; increased cancer risk, mainly GI)

Hepatosplenomegaly, osteoporosis, neurologic symptoms
Gaucher’s disease (glucocerebrosidase deficiency)

Hereditary nephritis, sensorineural hearing loss, cataracts
Alport syndrome (mutation in alpha 5 chain of type IV collagen)

Hyperphagia, hypersexuality, hyperorality, hyperdocility
Klüver-Bucy syndrome (bilateral amygdala lesion)

Hyperreflexia, hypertonia, Babinski sign present
Upper Motor Neuron Damage

Hyporeflexia, hypotonia, atrophy, fasciculations
Lower motor neuron damage

Hypoxemia, polycythemia, hypercapnia
“Blue bloater” (chronic bronchitis: hyperplasia of mucous cells)

Indurated, ulcerated genital lesion
Nonpainful: chancre (primary syphilis, Treponema pallidum)
Painful, with exudate: chancroid (Haemophilus ducreyi)

Infant with cleft lip/palate, microcephaly or holoprosencephaly, polydactyly, cutis aplasia
Patau’s syndrome (trisomy 13)

Infant with failure to thrive, hepatosplenomegaly and neurodegeneration
Niemann-Pick disease (genetic sphingomyelinase deficiency)

Infant with hypoglycemia, failure to thrive and hepatomegaly
Cori’s disease (debranching enzyme deficiency)

Infant with microcephaly, rocker-bottom feer, clenched hands, and structural heart defect
Edwards’ syndrome (trisomy 18)

Jaundice, palpable distended non-tender gallbladder
Courvoisier’s sign (distal obstruction of biliary tree)

Large rash with bull’s-eye appearance
Erythema chronicum migrans from Ixodes tick bite (Lyme disease: Borrelia)

Lucid interval after traumatic brain injury
Epidural hematoma (middle meningeal artery rupture)

Male child, recurrent infections, no mature B cells
Bruton’s disease (X-linked agammaglobulinemia)

Mucosal bleeding and prolonged bleeding time
Glanzmann’s thrombasthenia (defect in platelet aggregation due to lack of Gp2b/3a)

Muffled heart sounds, distended neck veins, hypotension
Beck’s triad of cardiac tamponade

Multiple colon polyps, osteomas/soft tissue tumors, impacted/supernumerary teeth
Gardner’s syndrome (subtype of FAP)

Myopathy (infantile hypertrophic cardiomyopathy), exercise intolerance
Pompe’s disease (lysosomal alpha-1,4-glucosidase deficiency)

Neonate with arm paralysis following difficult birth
Erb-Duchenne palsy (superior trunk [C5-C6] brachial plexus injury : “waiter’s tip”)

No lactation postpartum, absent menstruation, cold intolerance
Sheehan’s syndrome (pituitary infarction)

Nystagmus, intention tremor, scanning speech, bilateral internuclear ophthalmoplegia
Multiple sclerosis

Oscillating slow/fast breathing
Cheyne-Stokes respirations (central apnea in CHF or increased intracranial pressure)

Painful blue fingers/toes, hemolytic anemia
Cold agglutinin disease (autoimmune hemolytic anemia caused by Mycoplasma pneumoniae, infectious mononucleosis)

Painful, pale, cold fingers/toes
Raynaud’s phenomenon (vasospasm in extremities)

Painful, raised red lesions on pad of fingers/toes
Osler’s node (infectious endocarditis, immune complex deposition)

Painless erythematous lesions on palms and soles
Janeway lesions (infectious endocarditis, septic emboli/microabscesses)

Painless jaundice
Cancer of the pancreatic head, obstructing bile duct

Palpable purpura on buttocks/legs, joint pain, abdominal pain (child), hematuria
Henoch-Schönlein purpura (IgA vasculitis affecting skin and kidneys)

Pancreatic, pituitary, parathyroid tumors
MEN1 (autosomal dominant)

Periorbital and/or peripheral edema, proteinuria, hypoalbuminemia, hypercholesterolemia
Nephrotic syndrome

Pink complexion, dyspnea, hyperventilation
“Pink puffer” (emphysema: centriacinar [smoking], panacinar [alpha-1-antitrypsin deficiency])

Polyuria, renal tubular acidosis type II, growth failure, electrolyte imbalances, hypophosphatemic rickets
Fanconi’s syndrome (proximal tubular reabsorption defect)

Positive anterior “drawer sign”
Anterior cruciate ligament injury

Pruritic, purple, polygonal planar papules and plaques (6 P’s)
Lichen planus

Ptosis, miosis, anhidrosis
Horner’s syndrome (sympathetic chain lesions)

Pupil accommodates but doesn’t react
Argyll Robertson pupil (neurosyphilis)

Rapidly progressive leg weakness that ascends following GI/upper respiratory infection
Guillain-Barré syndrome (acute autoimmune inflammatory demyelinating polyneuropathy)

Rash on palms and soles
Coxsackie A, secondary syphilis, Rocky Mountain spotted fever

Recurrent colds, unusual eczema, high serum IgE
Hyper-IgE syndrome (Job’s syndrome: neutrophil chemotaxis abnormality)

Red “currant jelly” sputum in alcoholic or diabetic patient
Klebsiella pneumonia

Red “currant jelly” stools
Acute mesenteric ischemia (adults), intussusception (infants)

Red, itchy, swollen rash of nipple/areola
Paget’s disease of the breast (represents underlying neoplasm)

Red urine in the morning, fragil RBCs
Paroxysmal nocturnal hemoglobinuria

Renal cell carcinoma (bilateral), hemangioblastomas, angiomatosis, pheochromocytoma
von Hippel-Lindau disease (dominant tumor suppressor gene mutation)

Resting tremor, rigidity, akinesia, postural instability
Parkinson’s disease (nigrostriatal dopamine depletion)

Retinal hemorrhages with pale centers
Roth’s spots (bacterial endocarditis)

Severe jaundice in neonate
Crigler-Najjar syndrome (congenital unconjugated hyperbilirubinemia)

Severe RLQ pain with palpation of LLQ
Rovsing’s sign (acute appendicitis)

Severe RLQ pain with rebound tenderness
McBurney’s sign (appendicitis)

Short stature, increased incidence of tumors/leukemia, aplastic anemia
Fanconi’s anemia (genetic loss of DNA crosslink repair; often progresses to AML)

Single palmar crease
Simian crease (Down syndrome)

Situs inversus, chronic sinusitis, bronchiectasis, infertility
Kartagener’s syndrome (dynein arm defect affecting cilia)

Skin hyperpigmentation, hypotension, fatigue
Addison’s disease (primary adrenocortical insufficiency causes increased ACTH and increased alpha-MSH production)

Slow, progressive muscle weakness in boys
Becker’s muscular dystrophy (X-linked missense mutation in dystrophin; less severe than Duchenne’s)

Small, irregular red spots on buccal/lingual mucosa with blue-white centers
Koplik spots (measles; rubeola virus)

Smooth, flat, moist, painless white lesions on genitals
Condylomata lata (secondary syphilis)

Splinter hemorrhages in fingernails
Bacterial endocarditis

“Strawberry tongue”
Scarlet fever, Kawasaki disease, toxic shock syndrome

Streak ovaries, congenital heart disease, horseshoe kidney, cystic hygroma at birth, short stature, webbed neck, lymphedema
Turner syndrome (45,XO)

Sudden swollen/painful big toe joint, tophi
Gout/podagra (hyperuricemia)

Swollen gums, mucosal bleeding, poor wound healing, spots on skin
Scurvy (vitamin C deficiency: can’t hydroxylate proline/lysine for collagen synthesis)

Anticentromere antibodies
Scleroderma (CREST)

Antidesmoglein (epithelial) antibodies
Pemphigus vulgarus (blistering)

Anti-glomerular basement membrane antibodies
Goodpasture’s syndrome (glomerulonephritis and hemoptysis)

Antihistone antibodies
Drug-induced SLE (hydralazine, isoniazid, phenytoin, procainamide)

Anti-IgG antibodies
Rheumatoid arthritis (systemic inflammation, joint pannus, boutonnière deformity)

Antimitochondrial antibodies (AMAs)
Primary biliary cirrhosis (female, cholestasis, portal hypertension)

Antineutrophil cytoplasmic antibodies (ANCAs)
Vasculitis (c-ANCA: granulomatosis with polyangiitis [Wegener’s]; p-ANCA: microscopic polyangiitis, Churg-Strauss syndrome)

Anti-proteinase 3 antibodies
aka C-ANCA; Wegener’s granulomatosis

Anti-myeloperoxidase
aka P-ANCA; microscopic polyangiitis, Churg-Strauss syndrome

Antinuclear antibodies (ANAs: anti-Smith and anti-dsDNA)
SLE (type III hypersensitivity)

Antiplatelet antibodies
Idiopathic thrombocytopenic purpura

Anti-topoisomerase antibodies
Diffuse systemic scleroderma

Anti-transglutaminase/anti-gliadin/anti-endomysial antibodies
Celiac disease (diarrhea, distention, weight loss)

“Apple core” lesion on abdominal x-ray
Colorectal cancer (usually left-sided)

Azurophilic peroxidase-positive granular inclusions in granulocytes and myeloblasts
Auer rods (acute myelogenous leukemia, especially the promyelocytic [M3] type)

Bacitracin response
Sensitive: Streptococcus pyogenes (group A); resistant: Streptococcus agalactiae (group B)

“Bamboo spine” on x-ray
Ankylosing spondylitis (chronic inflammatory arthritis: HLA-B27)

Basophilic nuclear remnants in RBCs
Howell-Jolly bodies (due to splenectomy or nonfunctional spleen)

Bloody tap on LP
Subarachnoid hemorrhage

“Boot shaped” heart on x-ray
Tetralogy of Fallot, RVH

Branching gram-positive rods with sulfur granules
Actinomyces israelii

Bronchogenic apical lung tumor on imaging
Pancoast tumor (can compress sympathetic ganglion and cause Horner’s syndrome)

“Brown” tumor of bone
Hyperparathyroidism or osteitis fibrosa cystica (deposited hemosiderin from hemorrhage gives brown color)

Cardiomegaly with apical atrophy
Chagas’ disease (Trypanosoma cruzi)

Cellular crescents in Bowman’s capsule
Rapidly progressive crescentic glomerulonephritis

“Chocolate cyst” of ovary
Endometriosis (frequently involves both ovaries)

Circular grouping of dark tumor cells surrounding pale neurofibrils
Homer-Wright rosettes (neuroblastoma, medulloblastoma, retinoblastoma)

Colonies of mucoid Pseudomonas in lungs
Cystic fibrosis (autosomal-recessive mutation in CFTR resulting in fat-soluble vitamin deficiency and mucous plugs)

Decreased alpha-fetoprotein in amniotic fluid/maternal serum
Down syndrome or other chromosomal abnormality

Degeneration of dorsal column nerves
Tabes dorsalis (tertiary syphilis), subacute combined degeneration (Vitamin B12 or E deficiency; dorsal columns and lateral corticospinal tracts affected)

Depigmentation of neurons in substantia nigra
Parkinson’s disease (basal ganglia disorder: rigidity, resting tremor, bradykinesia)

Desquamated epithelium casts in sputum
Curschmann’s spirals (bronchial asthma; can result in whorled mucous plugs)

Disarrayed granulosa cells in eosinophilic fluid
Call-Exner bodies (granulosa-theca cell tumor of the ovary)

Dysplastic squamous cervical cells with nuclear enlargement and hyperchromasia
Koilocytes (HPV: predisposes to cervical cancer)

Enlarged cells with intranuclear inclusion bodies
“Owl’s eye” appearance of CMV

Enlarged thyroid cells with ground-glass nuclei
“Orphan Annie’s eyes” nuclei (papillary carcinoma of the thyroid)

Eosinophilic cytoplasmic inclusion in liver cell
Mallory bodies (alcoholic liver disease)

Eosinophilic cytoplasmic inclusion in nerve cell
Lewy body (Parkinson’s disease)

Eosinophilic globule in liver
Councilman body (toxic or viral hepatitis, often yellow fever)

Eosinophilic inclusion bodies in cytoplasm of hippocampal nerve cells
Negri bodies of rabies (Lyssavirus)

Extracellular amyloid deposition in gray matter of brain
Senile plaques (Alzheimer’s disease)

Giant B cells with bilobed nuclei with prominent inclusions (“owl’s eye”)
Reed-Sternberg cells (Hodgkin’s lymphoma)

Glomerulus-like structure surrounding vessel in germ cells
Schiller-Duval bodies (yolk sac tumor)

“Hair on end” (crew-cut) appearance on x-ray
Beta-thalassemia, sickle cell anemia (marrow expansion)

hCG elevated
Choriocarcinoma, hydatidiform mole (occurs with and without embryo)

Heart nodules (granulomatous)
Aschoff bodies (rheumatic fever)

Heterophile antibodies
Infectious mononucleosis (EBV)

Hexagonal, double-pointed, needle-like crystals in bronchial secretions
Bronchial asthma (Charcot-Leyden crystals: eosinophilic granules)

High level of D-dimers
DVT, pulmonary embolism, DIC

Hilar lymphadenopathy, peripheral granulomatous lesion in middle or lower lung lobes (can calcify)
Ghon complex (primary TB: Mycobacterium bacilli)

“Honeycomb lung” on x-ray or CT
Interstitial pulmonary fibrosis

Hypercoagulability (leading to migrating DVTs and vasculitis)
Trousseau’s syndrome of malignancy (adenocarcinoma of pancreas or lung)

Hypersegmented neutrophils
Megaloblastic anemia (B12 deficiency: neurologic symptoms; folate deficiency: no neurologic symptoms)

Hypertension, hypokalemia, metabolic alkalosis
Conn’s syndrome (Primary hyperaldosteronism)

Hypochromic, microcytic anemia
Iron deficiency anemia, lead poisoning, thalassemia (fetal hemoglobin sometimes present)

Increased alpha-fetoprotein in amniotic fluid/maternal serum
Dating error, anencephaly, spina biffida (neural tube defects)

Increased uric acid levels
Gout, Lesch-Nyhan syndrome, tumor lysis syndrome, loop and thiazide diuretics.

Intranuclear eosinophilic droplet-like bodies
Cowdry type A bodies (HSV or CMV)

Iron-containing nodules in alveolar septum
Ferruginous bodies (asbestosis: increased risk of mesothelioma)

Keratin pearls on a skin biopsy
Squamous cell carcinoma

Large lysosomal vesicles in phagocytes, immunodeficiency
Chédiak-Higashi disease (congenital failure of phagolysosome formation)

“Lead pipe” appearance of colon on barium enema x-ray
Ulcerative colitis (loss of haustra)

Linear appearance of IgG deposition on glomerular basement membrane
Goodpasture’s syndrome

Low serum ceruloplasmin
Wilson’s disease (hepatolenticular degeneration)

“Lumpy bumpy” appearance of glomeruli on immunofluorescence
Poststreptococcal glomerulonephritis (immune complex deposition of IgG and C3b)

Lytic (“hole punched”) lesions on x-ray
Multiple myeloma

Mammary gland (“blue domed”) cyst
Fibrocystic change of the breast

Monoclonal antibody spike
Multiple myeloma (usually IgG or IgA)
Monoclonal gammopathy of undetermined significance (MGUS; normal consequence of aging)
Waldenström’s (M protein = IgM) macroglobulinemia
Primary amyloidosis

Mucin-filled cell with peripheral nucleus
Signet ring (gastric carcinoma)

Narrowing of bowel lumen on barium x-ray
“String sign” (Crohn’s disease)

Necrotizing vasculitis (lungs) and necrotizing glomerulonephritis
Granulomatous with polyangiitis (Wegener’s: C-ANCA positive) and Goodpasture’s syndrome (anti-basement membrane antibodies)

Needle-shaped, negatively birefringent crystals
Gout (monosodium urate crystals)

Nodular hyaline deposits in glomeruli
Kimmelstiel-Wilson nodules (diabetic nephropathy)

Novobiocin response
Sensitive: Staphylococcus epidermidis; resistant: Staphylococcus saprophyticus

“Nutmeg” appearance of liver
Chronic passive congestion liver due to right heart failure

“Onion skin” periosteal reaction
Ewing’s sarcoma (malignant round-cell tumor)

Optochin response
Sensitive: Streptococcus pneumoniae; resistant: Viridans streptococcus

Periosteum raised from bone, creating a triangular area
Codman’s triangle on x-ray (osteosarcoma, Ewing’s sarcoma, pyogenic osteomyelitis)

Podocyte fusion or “effacement” on electron microscopy
Minimal change disease (child with nephrotic syndrome)

Polished, “ivory like” appearance of bone at cartilage erosion
Eburnation (osteoarthritis resulting in boney sclerosis)

Protein aggregates in neurons from hyperphosphorylation of protein tau
Neurofibrillary tangles (Alzheimer’s disease) and Pick’s bodies (Pick’s disease)

Psammoma bodies
Meningiomas, papillary thyroid carcinoma, mesothelioma, papillary serous carcinoma of the endometrium and ovary

Pseudopalisading tumor on brain biopsy
Glioblastoma multiforme

RBC casts in urine
Acute glomerulonephritis

Rectangular, crystal-like, cytoplasmic inclusions in Leydig cells
Reinke crystals (Leydig cell tumor)

Renal epithelial casts in urine
Acute toxic/viral nephrosis

Rhomboid crystals, positively birefringent
Pseudogout (calcium pyrophosphate dihydrate crystals)

Rib notching
Coarctation of the aorta

Ring-enhancing brain lesion in AIDS
Toxoplasma gondii, CNS lymphoma

Sheets of medium-sized lymphoid cells with scattered pale, tingible body-laden macrophages (“starry sky” histology)
Burkitt’s lymphoma (t[8;14] c-myc activation, associated with EBV; “black sky” made up of malignant cells)

Silver-staining spherical aggregation of tau proteins in neurons
Pick bodies (Pick’s disease: progressive dementia, changes in personality)

“Soap bubble” in femur or tibia on x-ray
Giant cell tumor of bone (generally benign)

“Spikes” on basement membrane, “dome like” subepithelial deposits
Membranous glomerulonephritis (may progress to nephrotic syndrome)

Stacks of RBCs
Rouleaux formation (high ESR, multiple myeloma)

Stippled vaginal epithelial cells
“Clue cells” (Gardnerella vaginalis)

“Tennis racket” shaped cytoplasmic organelles (EM) in Langerhans cells
Birbeck granules (Langerhans cell histiocytosis or histiocytosis X: eosinophilic granuloma)

Thrombi made of white/red layers
Lines of Zahn (arterial thrombus, layers of platelets/RBCs)

“Thumb sign” on lateral x-ray
Epiglottitis (Haemophilus influenzae)

Thyroid-like appearance of kidney
Chronic bacterial pyelonephritis

Tram-track appearance of capillary loops of glomerular basement membranes on light microscopy
Membranoproliferative glomerulonephritis

Triglyceride accumulation in liver cell vacuoles
Fatty liver disease (alcoholic or metabolic syndrome)

“Waxy” casts with very low urine flow
Chronic end-stage renal disease

WBC casts in urine
Acute pyelonephritis

WBCs that look “smudged”
CLL (almost always B cell)

“Wire loop” glomerular capillary appearance on light microscopy
Lupus nephropathy

Yellowish CSF
Xanthochromia (e.g. due to subarachnoid hemorrhage)

What cell wall structure is unique to gram positive bacteria?
lipoteichoic acid

What three cell wall structures are unique to gram negative bacteria?
1. outer cell membrane (LPS and endotoxin)
2. porin
3. periplasmic space (b-lactamase location)

What does the PAS (periodic acid-Schiff) stain?
glycogen, mucopolysaccharides
(PASs the sugar!)

What is a silver stain used for?
-legionella
-fungi
-helicobacter pylori

What type of stain is best for Cryptococcus neoformans (an encapsulated yeast)?
india ink

What type of stain is best for acid fast bacteria such as nocardia and mycobacteria?
Ziehl-Neelsen (carbol fuchsin)

What stain is best for detection of malarial infection?
giemsa stain-detects the parasite plasmodium which is the cause of malaria

Chlamydia, Borrelia, Rickettsia, Trypanosomes and Plasmodium are all best detected by which stain?
giemsa stain

What media is needed for isolation of H. influenza?
chocolate agar

What media is needed for the isolation of N. gonorrhoeae and N. meningitidis?
Thayer-Martin agar

What media is best used to isolate lactose-fermenting enterics?
MacConkey agar
(fermentation produces acid causing colonies to turn PINK)

What media is best used to isolate E. coli?
eosin-methylene blue (EMB) agar
(colonies with green metallic sheen)

What type of media is best used to isolate M. tuberculosis?
Lowenstein-Jensen agar

What bacterial structure protects against phagocytosis?
capsule

What bacterial structure makes bacteria resistant to dehydration, heat and chemicals?
spore

What bacterial structure gives bacteria a rigid structure and protects against osmotic pressure?
peptidoglycan

What is the chemical composition of plasmid?
DNA

What structure of bacteria contains a variety of genes for antibiotic resistance, enzymes and toxins?
plasmid

What type of media is best used to isolate fungi?
Sabouraud agar

(SAB’s a FUN GUY!)

What media is best used to isolate M. pneumoniae?
Eaton agar
(requires cholesterol)

Name 7 encapsulated bacteria.
SHiNE SKiS
1. Streptococcus pneumoniae
2. Haemophilus influenza
3. Neisseria meningitidis
4. E. coli
5. Salmonella
6. Klebsiella pneumoniae
7. group B Strep

*remember capsule serves as anti-phagocytic virulence factor!!!!

Which bacteria is known for causing rice water stools?
vibrio cholerae

What bacteria is responsible for whooping cough?
bordetella pertussis

Which toxin prevents the release of INHIBITORY (GABA and glycine) neurotransmitters from Renshaw cells in the spinal cord?
Clostridium tetani

*causes spasticity, rises sardonicus (spasm of facial muscles as if pt. was grinning), and “lockjaw”

Which toxin produces flaccid paralysis by preventing the release of STIMULATORY (ACh) signals at neuromuscular junctions?
Clostridium botulinum

What bacteria is associated with myonecrosis (gas gangrene) and hemolysis (“double zone” of hemolysis on blood agar)?
Clostridium perfringens

What bacteria is associated with Toxic Shock Syndrome Toxin (TSST-1)?
staphylococcus aureus

Which bacteria is associated with exotoxin A and can manifest to toxic shock syndrome?
streptococcus pyogenes

You gram stain an organism and it shows gram positive with branching filaments. It’s anaerobic and negative for acid fast. What is most likely the organism?
actinomyces

You gram stain an organism and it shows gram positive with branching filaments. It’s aerobic and positive for acid fast. What is most likely the organism?
nocardia

Your gram stain shows gram positive cocci in clusters and that is catalase positive. What is most likely the organism?
staphylococcus

Your gram stain shows gram positive cocci in chains and are catalase negative. What is most likely the organisms?
streptococcus

neisseria
gram negative cocci

moraxella catarrhalis
gram negative cocci

Name 3 examples of bacteria that are aerobes.
“Nagging Pests MustBreathe”

1. Nocardia
2. Pseudomonas aeruginosa
3. MycoBacterium tuberculosis

Name 4 examples of bacteria that are anaerobes.
“Frankly Can’t Breathe Air”

1. Fusobacterium
2. Clostridium
3. Bacteroides
4. Actinomyces

Which drug class is ineffective against anaerobes because they require O2 to enter into bacterial cell?
Aminoglycosides

Where is the only place in the body that anaerobes are considered normal flora?
GI tract

Since encapsulated bacteria have antiphagocytic virulence factor how are they removed from the body?
-they are opsonized and then cleared by the spleen
-asplenics are therefore at an increased risk for infection

People with chronic granulomatous disease (NADPH oxidase deficiency) have recurrent infections with which type of organisms?
catalase positive organisms

Staph is catalase _______ and strep is catalase ________.
staph= catalase positive

strep= catalase negative

What pigment is associated with actinomyces israelii?
yellow “sulfur” granules composed of filaments of bacteria

What pigment is associated with S. aureus?
yellow pigment (think PUS)

What pigment is associated with pseudomonas aeruginosa?
blue-GREEN

What color pigment is associated with serratia marcenscens?
red pigment

Which virulence factor binds to Fc region of IgG?
Protein A

-prevents oponization and phagocytosis
-expressed by S. aureus

Which virulence factor is an enzyme that cleaves IgA?
IgA protease

-secreted by: S. pneumoniae, H. influenza type B, Neisseia
-in order to colonize respiratory mucosa

-“SHiN”

Which virulence factor helps prevent phagocytosis, is expressed by group A streptococci, shares similar epitotes to human cellular proteins and possible underlies the autoimmune response seen in acute rheumatic fever?
M protein

What is needle like protein appendage that facilities direct delivery of toxins from certain gram negative bacteria to host eukaryotic cells?
-type III secretion system
-aka injectisome

What type of bacteria can have the type III secretions system (injectisome)?
gram negative bacteria

-pseudomonas
-salmonella
-shigella
-e. coli

Endotoxin is specific to which type of bacteria and structure?
gram negative bacteria-outer cell membrane

true or false? Exotoxin can be feature of both gram positive and gram negative bacteria.
true

review exotoxin vs endotoxin chart-pg 123 FA

What is exotoxin for pseudomonas aeruginosa?
-mechanism of action ?
-exotoxin A
-MOA= inactivate elongation factor (EF-2)

What is the mechanism of action of the exotoxin diphtheria of corynebacterium diphtheria?
inactivate the elongation factor (EF-2)

What is the mechanism of action of the exotoxin shiga toxin of shigella spp.?
inactivate 60s ribosome by removing adenine from rRNA

What is the exotoxin for the bacteria enterohemorrhagic E. coli (EHEC)?
Shiga-like toxin (SLT)
-same mechanism as shiga toxin–>inactivate 60s ribosome by removing adenine from rRNA

What bacteria/toxin is most likely responsible for edematous borders of black eschar in cutaneous anthrax?
bacillus anthracis
-edema toxin

What is the exotoxin for clostridium perfringens?
alpha toxin
-degrades phospholipids
-causes gas gangrene

What is the exotoxin for streptococcus pyogenes (group A strep)?
streptolysin O
-degrades cell membrane

MEMORIZE flow chart pg 127 FA-gram positive algorithm

Listeria
gram positive rods (bacilli)

corynebacterium
gram positive rods (bacilli)
-CLUB SHAPED

clostridium
gram positive rods (bacilli)
-anaerobe

bacillus
gram positive rods (bacilli)
-aerobe

Which type of hemolysis shows partial hemolysis (green)?
alpha hemolysis

Which type of hemolysis shows complete hemolysis (clear)?
beta hemolysis

If an organism shows no hemolysis it is said to be which type?
gamma hemolysis

Group D strep shows which type of hemolysis?
gamma hemolysis (no hemolysis)

Group A and Group B strep show which type of hemolysis?
beta hemolysis (complete)

S. pneumoniae and viridans streptococci show which type of hemolysis?
alpha hemolysis (partial)

Which gram positive cocci is resistant to novobiocin?
S. saprophyticus

Which gram positive cocci is sensitive to novobiocin?
S. epidermidis

What are the two type of enterococci that are most common commensal organisms in human colonic flora?
-E. faecalis
-E. faecium

What type of bacteria can cause bacteremia, subacute endocarditis and is associated with colon cancer?
streptococcus bovis

What bacteria will show as black colonies on cystine-tellurite agar?
corynebacterium diphtheria

-remember: gram positive rods (bacilli) that are club shaped

Lab results show a gram positive rod with metachromatic (blue/red) granules and +Ekek test for toxin. What bacteria?
corynebacterium diphtheria

What is the second most common cause of UTI in young women?
Staphylococcus saprophyticus

What is the first most common cause of UTI in young women?
E. coli

What bacteria infects prosthetic devices and intravenous catheters by producing adherent biofilms?
Staphylococcus epidermidis

Lancet-shaped, gram-postive diplococci
streptococcus pneumoniae

What is the most common cause of meningitis?
streptococcus pneumoniae

What is the most common cause of otitis media in children?
streptococcus pneumoniae

What is the most common cause of both pneumonia and sinusitis?
streptococcus pneumoniae

A patient has “rusty” sputum. What is mot likely the causative agent?
streptococcus pneumoniae

alpha hemolytic and optochin sensitive gram positive cocci
streptococcus pneumoniae

What bacteria are alpha hemolytic, cause dental caries and are normal flora of the oropharynx?
viridians group streptococci

Viridian group streptococci are optochin__________.
optochin resistant

group A strep is also know as _______________.
streptococcus pyogenes

The bacteria that is beta hemolytic and resistant to bacitracin is?
streptococcus agalactiae (group B strep)

The bacteria that is beta hemolytic and sensitive to bacitracin is?
streptococcus pyogenes (group A strep)

group B strep is also know as _______________.
streptococcus agalactiae

Where does group B strep (streptococcus agalactiae) colonize?
vagina

What is best for detecting a recent S. pyogenes infection?
ASO titer

What causes scarlet fever?
group A strep (S. pyogenes)

strawberry tongue, sandpaper like rash, circumoral pallor, subsequent desquamation
scarlet fever–>Caused by group A strep (S. pyogenes)

What needs to be done to potentially kill spores?
autoclave at 121 degrees celcius for 15 min

What are the two best drugs used for psuedomembranous colitis?
1. metroconidizole (flagyl)
2. oral vancomycin

What is the only bacteria with a polypeptide capsule (contains D-glutamate)?
B. anthracis

What bacteria has been known to cause reheated rice syndrome and causes a watery, non bloody diarrhea with GI pain within 8-18 hours?
Bacillus cereus

Bacteria acquired from unpasteurized dairy products and cold deli meats
Listeria monocytogenes

What is the ONLY gram positive organism to produce endotoxin?
listeria monocytogenes

bacteria that forms “rocket tails” that allow for cell to cell spread across cell membranes thereby avoiding antibody
listeria monocytogenes

What is the DOC for actinomyces infections?
PCN

What is the DOC for nocardia infections?
sulfonamides

What is the reservoir for leprosy in the U.S?
armadillos

Haemophilus influenza requires which two factors?
factors V and X

Which gram negative diplococci is a maltose fermenter?
N. meningitidis

Which gram negative bacteria produce hydrogen sulfide, H2S?

What media is used to test if it is a hydrogen sulfide producer?

1. Proteus
2. salmonella
3. Yersinia

media= TSI agar (triple sugar iron)

Pontiac fever is caused by what organism?
Legionella pneumophila

Which organism is most often associated with wound infection in burn victims?
Pseudomonas aeriginosa

Hot tub folliculitis
Pseudomonas aeriginosa

Which organism is most often cause of osteomyelitis in puncture wounds?
Pseudomonas aeriginosa

Which organism is cause of ecthyma gangrenosum?
Pseudomonas aeriginosa

What is the most common serotype for EHEC (entrohemorrhagic E. coli) in the U.S?
O157:H7

What intestinal flora causes lobar pneumonia in diabetics and alcoholics when aspirated?
klebsiella

Which gram negative bacteria are curved (comma or s shaped)?
-vibrio
-campylobacter
-h. pylori

At what temperature does campylobacter jejuni grow?
42 degrees celcius

What type pf diarrhea does campylobacter jejune cause?
bloody

What is the only species of salmonella that has a reservoir of humans only?
salmonella typhi

*all other species of salmonella have a reservoir of both humans and animals

What is the reservoir for shigella?
humans only

Which species of salmonella has a vaccine?
-salmonella typhi

*oral vaccine contains live attenuated S. top
*IM vaccine contains Vi capsular polysaccharide

What is the treatment for typhoid fever caused by salmonella typhi?
ceftriaxone or fluoroquinolone

What is the mechanism of the enterotoxin of vibrio cholerae?
cholerae toxin permanently activates Gs thus increasing cAMP

What are two dangerous risk factors for peptic ulcers caused by H. pylori?
1. adenocarcinoma
2. MALT lymphoma

What is the best way to visualize treponemes?
dark field microscopy and fluorescent antibody staining

*this is because they are thin!!

Spiral shaped bacteria with axial filaments
spirochetes

What are they three type of spirochetes?
1. Borrelia (biggest-only one able to visualize with aniline dyes-Wright stain or Giemsa)
2. Leptospira
3. Treponema-very thin, seen with dark field microscopy

*BLT

What organism causes Weil disease?
leptospria interrogans

Where is leptospira interrogates most common?
among surfers in the tropics (ex: Hawaii)

What bacterial species causes Lyme Disease?
Borrelia burgdorferi (a gram negative spirochete!)

*transmitted by Ixodes deer tick

What transmits Lyme disease?
Ixodes deer tick

*caused by bacteria Borrelia burgdorferi

What bacteria causes Syphilis?
Treponema pallidum (gram negative spirochete)

true or false: Syphilis lesions are painless.
true

Which type of syphilis is localized disease presenting with painless chancre?
primary

Which type of syphilis is systemic and presents with maculopapular rash over body and can include palms and soles and condylomata lat (smooth, moist, painless, wart-like lesions on genitals)?
secondary

What test is widely used for dx of syphilis and is very sensitive but not specific?
VDRL

*need a specific test to confirm dx such as FTA-ABS

What are the three organisms that are transmitted through Ixodes ticks?
1. Borrela burgdorferi-lyme disease
2. anaplasma species-anaplasmosis
3. babesia-babesiosis

What bacteria is known to be transmitted by parrots and other birds?
chlamydophila psittacosis

What species of bacteria causes cat scratch disease?
Bortonella

*Bartonella henselae or Bartonella quintana

What bacteria species causes Q fever?
coxiella burnetti

What is the classic triad of symptoms for Rocky Mountain Spotted Fever?
1. Fever
2. headache
3. rash (rash typically starts at wrists and ankle then spreads to trunk, palms and soles)

Which species of Rickettsia causes Rocky Mountain Spotted Fever?
Rickettsia rickettsii

What is the vector for Rocky Mountain Spotted Fever?
dog tick

(Dermacentor variabilis, Rocky Mountain wood tick (Dermacentor andersoni), and brown dog tick-Rhipicephalus sanguineus)

What is the vector for Rickettsia typhi?
fleas

Describe the differences in the presentation on rashes in Rickettsia rickettsii and Rickettsia typhi.
Rickettsia rickettsii-rash typically starts at wrists and ankle then spreads to trunk, palms and soles

Rickettsia typhi-rash starts centrally (trunk) and spreads sparing the soles and palms

What is the vector for the bacterial infection Ehrlichiosis?
tick

Which bacterial infection histologically shows MONOCYTES with morulae (berry like inclusions) in the cytoplasm?
Ehrlichiosis

Which bacterial infection histologically shows GRANULOCYTES with morulae (berry like inclusions) in the cytoplasm?
Anaplasmosis

What disease is caused when spores of Coxiella burnetti are inhaled from cattle/sheep?
Q fever

What is the treatment for chlamydiae infections?
-azithromycin (one time treatment-favored)
or
-doxycycline

Q fever is result of which bacteria?
coxiella burnetti

Does Q fever involve an arthorpod?
no-although closely related to the rickettsia genus it is not in the genus and does NOT involve arthropod

What are the two forms of chlamydiae?
1. elementary body-infectious, enters the cell via endocytosis and transforms into a reticulate body

2. reticulate body-replicates in cell by fission, reorganizes into elementary bodies

What is the classic case of atypical “walking” pneumonia?
mycoplasma pneumoniae

At what temperatures are dimorphic fungi molds and what temperature are they yeasts?
cold (20 degrees celsius) = mold

heat (37 degrees celsius)= yeast

What is best to treat a systemic fungal infection?
amphotericin B

Fungal infection in bird or bat droppings
histoplasmosis

fungus with broad-base budding
blastomycosis

budding yeast with “captain’s wheel” formation
paracoccidioidomycosis

Which fungus is not dimorphic and forms as a sheprule in tissue (not yeast)?
coccidioidomycosis

Which fungus is predominantly in Mississippi, the Ohio River Valley and the midwest?
histoplasmosis

Which fungus is predominantly east of the Mississippi River and in Central America?
Blastomyces

Which fungus is predominantly in the Southwestern US, California and is known fro the San Joaquin Valley fever?
coccidiomycosis

Which fungus is predominantly located in Latin America?
paracoccidioidomycosis

What do dermatophytes require for growth?
keratin

Name the three main groups of dermatophytes.
1. microsporum
2. trichophyton
3. epidermophyton

fungal infection that occurs on the head or scalp
tinea capitis

fungal infection that occurs on the body
tinea corporis

fungal infection that occurs in the inguinal area
tinea cruris

fungal infection that occurs on the nails
tinea unguium (onychomycosis)

What cutaneous fungal infection is caused by Malassezia fur fur?
tinea versicolor

You see a spaghetti and meatball appearance on a microscopy slide. What is most like the cause and condition?
malassezia fur fur; tinea versicolor

Causative agent of oral thrush (white patches in mouth)
candida albicans

Causative agent of vulvovaginitis
candida albicans

septate hyphae that branch at 45 degree angles (ACUTE angles)
aspergillus fumigatus

fungus that is heavily encapsulated, found in pigeon droppings and form soap bubble lesions in brain
cryptococcus neofromans

fungal infection that shows as diffuse bilateral ground glass opacities on chest X-ray and CT
pneumocystis jirovecii

-causes pneumocystis pneumonia (PCP)–>a diffuse interstitial pnuemonia

dimorphic, cigar shaped budding yeast
sporothrix schenckii

Which fungus found on vegetation can typically be transmitted through a thorn (rose gardner’s disease)?
sporothrix schenckii

*causes ascending lymphangitis

protozoa commonly infects hikers and campers who drink untreated water
giardia lamblia

protozoa that are transmitted by cysts in water and cause bloating, flatulence and foul-smelling, fatty diarrhea
giardia lamblia

protozoa that is transmitted by cysts in water and cause bloody diarrhea, liver abscess (“anchovy paste” exudate), and RUQ pain
entamoeba histolytica

protozoa that histologically shows a flask shaped ulcer
entamoeba histolytica

oocysts in water that cause severe diarrhea in AIDS patients and mild diarrhea in immunocompetent hosts
cryptosporidium

Which congenital infection can occur when pregnant women change cat litter boxes?
tocoplasma gondii (toxoplamsosis)

What is the most common transmission of toxoplasma gondii?
cysts in meats

-but can also be transmitted by oocysts in cat feces

rapidly fatal meningeoncephalitis contracted from swimming in freshwater lakes
naegleria fowleri

African sleeping sickness contracted by the bite of a tsetse fly is caused by what organism?
trypanosoma brucei

What is the vector for the organism babesia?
ixodes tick

What organisms can be transmitted through the IXODES tick?
1. borrelia burgdorferi (lyme disease)
2. babesia (babesiosis)
3. anaplasma spp. (anaplasmosis)

What organism is spread by the redivide bug (the “kissing bug”)?
trypanosoma cruzi

-causes chagas disease

Which protozoa organism causes vaginitis, a foul smelling, greenish discharge?
trichomonas vaginalis

What is the number 1 cause of anal itching in children?
enterobius vermicularis (pinworm)

What is the proper name for the giant roundworm?
ascaris lumbricoides

Which nematode (roundworm) have larvae found in soil and penetrate the skin?
strongyloides stercoralis

Intestinal infection causing microcytic anemia by sucking blood from intestinal walls
hookworms! (they penetrate the skin)

-ancylostoma duodenale
-necator americanus

Which nematode (roundworm) enters the bloodstream via fecal/oral or undercooked meats (especially pork) and then infects striated muscle causing inflammation of muscle?
trichinella spiralis

Which nematode (round worms) is contracted by a female mosquito and then takes 9 months to 1 year to cause elephantiasis by the worms blockage of lymphatic vessels?
wuchereria bancrofti

Which tapeworm is ingested from raw freshwater fish?
diphyllobothrium latum

-can cause vit b12 deficiency and megaloblastic anemia

Which tapeworm is caused by the ingestion of eggs from dog feces?
echinococcus granulosus

-sheep are immediate host

Which tapeworm is caused by ingestion of larvae in undercooked pork?
taenia solium

Which trematodes come from snail hosts?
schistosoma

Which species of schistosoma is known to cause bladder cancer?
schistosoma haemoatobium

Which species of schistosomas are known to cause portal hypertension?
1. schistosoma mansoni (africa, latin america)
2. schistosoma japonicum (asia)

Which viral vaccines are live vaccines?
1. smallpox
2. chickenpox (varicella)
3. yellow fever
4. polio-sabin
5. influenza (nasal spray only)
6. MMR (measles, mumps, rubella)Wh

Which serotypes belong to HPV?
types 6, 11, 16, 18

*6, 11 warts (1, 2)
*16, 18 cervical cancer

All DNA viruses are double stranded with the exception of which one?
parvovirus
(it is the smallest DNA virus)

Live viral vaccines induce which type(s) of immunity?
both humoral and cell-mediated immunity

Killed viral vaccines induce which type(s) of immunity?
only humoral immunity

All DNA viruses are linear except for which ones?
1. papillovirus
2. polyomavirus
3. hepadnavirus

*these are all CIRCULAR

Cause of sporadic encephalitis with altered mental status and seizures
HSV-1

Which herpesvirus is latent in sacral ganglia?
HSV-2

Which herpesvirus is latent in mononuclear cells?
CMV (HSV-5)

mononucleosis with a negative mono spot test
CMV (HSV-5)

mononucleosis with a positive mono spot test
EBV (HSV-4)

Which herpesvirus is associated with lymphomas (endemic Burkitt lymphoma and Hodgkin lymphoma)?
EBV (HSV-4)

Which herpesvirus has cells characteristic of owl eye inclusions?
CMV (HSV-5)

What cells are effected in EBV (HSV-4)?
-B cells through CD21
-irregular lymphocytes seen on blood smear are reactive cytotoxic T cells and not the infected B cells

What type of smear is used for open skin herpes vesicles to detect giant cells (commonly seen in HSV-1, HSV-2, VZV (HSV3))?
Tzanck smear

*Tzanck heavens I don’t have herpes.

What test is done to identify herpes encephalitis?
CSF PCR (polymerase chain reaction)

All RNA viruses are single stranded with the exception of which virus?
reovirus

Which virus is the number one cause of fatal diarrhea in children?
Rotavirus
-an RNA virus part of the reovirus family

HAV is part of which viral family?
picornavirus (ss-linear RNA virus)

What medication is used to treat RSV?
ribavirin

Which is the only double stranded RNA virus?
Reovirus family

Which is the only double stranded RNA virus?

Which viral vaccines are subunit vaccines?
-HBV (anitgen= HBsAg)
-HPV

Which two viruses cause the common cold?
-rhinovirus (picornavirus family)
-coronavirus

Which virus causes croup?
parainfluenza (paramyxovirus family)

Influenza virus is part of what family?
orthomyxovirus family

A flavivirus transmitted by Aedes mosquitos
yellow fever virus

(it causes jaundice and fever -hence yellow fever virus
and also causes black vomitus)

Which is worse a genetic shift of influenza virus or a genetic drift of the virus?
gentic shift is worse than genetic drift

-shift–>causes pandemics
-drift–>causes epidemics

Infant is born and has a blueberry muffin like appearance
congenital rubella virus
-togavirus family
-rubella virus is a torches infection!

seal like barking cough in child
parainfluenza (croup)
-paramyxovirus family

protein that all paramyxoviruses (mumps, measles, parainfluenza, RSV) contain that causes respiratory epithelial cells to fuse and form multinucleated cells
surface F (fusion) protein

steeple sign on neck X-ray of the trachea (narrowing of trachea and subglottis)
croup
-croup is caused by the parainfluenza virus
-parainfluenza virus is part of the paramyxovirus family

prodromal fever with cough, coryza, conjunctivitis and eventually koplik spots (buccal mucosa) followed by maculopapular rash
measles (rubeola) virus
-paramyxovirus family

uncommon viral disease that causes parotitis, orchitis (inflammation of the testes) and aseptic meningitis
Mumps
-paramyxovirus

butllet shaped virus with negri bodies in infected neurons
rabies virus
-rhabdovirus family

a filovirus that targets endothelial cells, phagocytes and hepatocytes and is transmitted by direct contact with bodily fluids or fomites
ebola virus

Which hepatitis virus is a picornavirus?
HAV

Which hepatitis virus is a DNA hepadnavirus?
HBV

Which hepatitis virus is a flavivirus?
HCV

Which hepatitis virus is a delta virus?
HDV

Which hepatitis virus is a hepevirus?
HEV

What serologic marker is best to detect current acute infection of hepatitis A?
anti-HAV (IgM)

What serologic marker is best to detect previous infection or prior vaccination of hepatitis A?
anti-HAV (IgG)

What antigen is found on the surface of HBV and indicates hepatitis B infection?
HBsAg

What is the antibody to HBsAg and indicates immunity to hepatitis B?
Anti-HBs

What antigen is associated with the core of HBV?
HBcAg

Antigenic determinant of HBV core and indicates viral replication and highly transmittable
HBeAg

What are the tests used to diagnose HIV?
1. ELISA is done first to rule out.
-sensitive
2. Western blot assay is done if ELISA is positive to rule in.
-specific

Antibody to HBeAg and indicates low transmissibility
Anti-HBe

Capsid protein in the HIV virus
p24

What synthesizes dsDNA from genomic RNA in the HIV virus?
Reverse transcriptase

Transmembrane protein for fusion and entry into host cell in HIV virus
gp41

Capsid protein in the HIV virus
p24

What synthesizes dsDNA from genomic RNA in the HIV virus?
Reverse transcriptase

Diagnosis of AIDS has a CD4+ count of?
<200 CD4+

Docking glycoprotein for attachment to host CD4+ T cell in HIV virus
gp120

What is the antibody to the core serologic marker HBcAg of hepatitis B infection?
Anti-HBc

-IgM indicates acute/recent infection
-this could be sole positive marker during window period
-IgG indicates prior exposure or chronic infection

normal alpha helical protein (PrP^c) is changed to beta pleated form (PrP^sc) and is transmitted to CNS related tissues and this new form resists protease degradation and facilities more conversions of the proteins
prions disease
-creutzfeldt-jakob disease-rapid progressive dementia
-bovine spongiform encephalopathy-aka mad cow disease
-kuru-cannibalism

What is another name for a urinary tract infection?
cystitis

What is the 3rd leading cause of UTI?
klebsiella pnuemoniae

Which infections can cause meningitis in neonates?
1. group B strep
2. e. coli
3. listeria

cherry red epiglottis and thumbprint sign on X-ray
H. influenza type B

grayish oropharayngeal exudate and painful throat
corynebacterium diphtheriae

Hardy Weinberg and Maggie May Do Not Smoke
No: Mutation, Migration, Drift, Non-Random Mating, Selection of Locus

Cell Cycle:
D4-E2
A2-B1
CyclinD binds CDK4 & CyclinE binds CDK2-> initiates S Phase (Phosphorylate Rb–> free E2F T.Factor)
CyclinA binds CDK2 & CyclinB binds CDK1 –> cdc25 initiates mitosis

Golgi Transport- COPI goes back to get COPII
COPI- Retrograde
COPII- Anterograde

Blotting- SNoW DRoP
Southern- DNA
Northern- RNA
Western- Protein

Angelman’s Syndrome- SAMI the happy puppet
Seizures, Ataxia, Mental Retardation, Inappropriate laughter

Pader-Willi Syndrome- MOHHH the fatty
Mental Retardation, Obesity, Hyperphagia, Hypotonia, Hypogonadism

6 C’s of Huntington
Ch4, CAG, Low ACh/GABA, Caudate Nucleus atrophy, Chorea, Crazy

MARFAN
MVP, Aneurysm (Aortic/Berry), Retinal detachment/lens subluxation, Fibrillin, Arachnodactyly, Negative Nitroprusside test (diff. from homocystinuria)

Neurofibromatosis 1 (CH17): CAFESPOT
Cafe-au-lait spots, Axillary/Inguinal freckles, Fibromas, Eye (Lisch nodules), Scoliosis, Pheochromocytoma, Optic gliomas

Tuberous Sclerosis: TUBEROUS
TUberocalcification in the perivent & astrocytomas
Blood in urine (Renal cysts & angiomyolipomas)
Eye (retinal hamartomas)
Rhabdomyosarcoma/Retardation
Off-white skin (Ash Leaf Spots)
sUb-Ungual fibromas
Shagreen Patches & Sebaceous Adenomas

von Hippel Landau (CH3): HIPPEL
Hemangioma (retina, cerebellum, & medulla)
Increased RCC (bilaterally)
Pheochromocytoma
Pancreatic serous cystadenoma
Eye dysfunction
Liver, Pancreas, & Kidney Cysts

Cystic Fibrosis: CFPANCREAS
Chronic bronchitis/bronchiectasis
Failure to thrive
Pancreatic Insufficiency (steatorrhea & low ADEK)
Alkalosis
Neonatal GI obstruction (meconium ileus)
Clubbing of fingeRs
Elevated electrolytes in sweat (Cl>60)
Atresia of vas deferens (infertility)
Staph/Pseudomonas in sputum

Fragile X Syndrome
Xtra large ears, jaw, and testes

Trinucleotide Repeats: CAG, CTG, CGG, GAA
Huntington’s Disease
MyoTonic Dystrophy
FraGile X Syndrome
Friedreich’s Ataxia

DEP 21, 18, 13
Down Syndrome
Edward’s Syndrome
Patau’s Syndrome

22q11: CATCH22
Cleft palate, Abnormal facies, Thymus aplasia, Cardiac defects, Hypocalcemia

Riboflavin (B2, 2ATP, 2C’s)
Niacin (B3, 3ATP, 3D’s for Pellagra)
R- Cheilosis & Corneal vascularization
N- Diarrhea, Dermatitis, Dementia

ABC for Carboxylases
ATP, Biotin, & CO2

Essential AA: PVT TIM HALL
Phenylalanine, Valine, Threonine, Tryptophan, Isoleucine, Methionine, Histidine, Arginine, Leucine, & Lysine

Glucogenic AA- His Valentine Met Arg
Ketogenic AA- Key to Loosing is Lying
G- Histidine, Valine, Methionine, Arginine
K- Leucine & Lysine

AA with Three Titratable Curves: CHAGLAT
Cysteine, Histidine, Aspartic Acid, Glutamic Acid, Lysine, Arginine, Tyrosine

Urea Cycle: Coffee And Alcohol For Aggressive Urine Overload
Citrulline, Aspartate, Arginosuccinate, Fumurate, Arginine, Urea, & Ornithine

Cystinuria AA- COLA
Cysteine, Ornithine, Lsyine, Arginine
-Hereditary defect of renal tubular AA transporter
-can lead to Cystine stones (staghorn)

Maple Syrup Urine Disease- I Love Vermont maple syrup from Branched trees
Isoleucine, Leucine, Valine (branched AA)

Glycogen Storage Diseases- Very Poor Carb Metabolism
von Gierke’s (I)- Glycogen-6-phosphate
Pompe’s (II)- Lysosomal a-1,4- glucosidase (acid maltase)
Cori’s (III)- a-1,6-glucosidase (debranching enzyme)
McArdle’s (V)- Glycogen Phosphorylase

Fabulous gay* Fabry has a hand/foot* fetish, fabulous shades*, raised red-purple skin blemishes*, ceramic tiles*, and enjoys creamy cum from Alpha males
Fabry’s Disease, Peripheral Neuropathy, Cloudy Cornea, Angiokeratomas, Ceramide Trihexoside, Alpha-Galactosidase A

Wrinkly* old Gaucher sitting in a wheel chair* & eating sweet brain candy* + has HSM
Gaucher’s Disease, wrinkly looking G cells, aseptic necrosis of femur/bone crisis, B-glucocerebrosidase

Neimann* Marcus is having a swinging* sale, all neurons cut at half price*. You buy a cherry-red* foam* sofa for HSM
Neimann Pick Disease, Sphingomyelinase, Progressive Neurodegeneration, Cherry-Red spot on macula, Foam Cells, Hepatosplenomegaly

Taysach’s Disease- TAYSACHS
Testing Recommended
Amaurosis Fugax/Cherry-red spot on macula
Young death (<4) Slow development delays Ashkenazi Jews CNS Degeneration Hexosaminidase A Storage of GM2 ganglioside in lysosomes with onion skinning (and no HSM)

Blind* galactic* Crabs* come to eat the peripheral nerves* of children with their globoid* goblets
Krabbe’s Disease, Optic atrophy, Galactocerebrosidase, Peripheral Neuropathy, Developmental Delay, Globoid Cells

Hurler’s Syndrome- HURLER
HSM
Ugly gargoyle faces
Recessive
L-idouronidase (a)
Eyes clouded
Retardation
Short stubby fingers

Aggressive Hunter with eagle vision
Hunter’s Syndrome- mild Hurler’s but with aggression and no corneal clouding

X-linked recessive disorders- Be Wise, Fool’s GOLD Heeds, Silly Hopes
Bruton’s Agammaglobulinemia, Wiskott-Aldrich Syndrome, Fabry’s Disease, G6PD Deficiency, Ocular Albinism, Lesch-Nyhan Syndrome, Duchenne (&Becker’s) Muscular Dystrophy, Hunter’s Syndrome, Hemophilia A/B

Aortic Arch Derivatives
1 is Maximal, second=S, 3=C, 4=4 limbs (systemic), 6=P
1- Maxillary Artery
2- Stapedial & Hyoid Artery
3- Common Carotid (& prox ICA)
4- Aortic Arch (left) and Prox Subclavian (right)
6- Pulmonary Artery (DA)

Branchial Apparatus- CAP
Cleft- Ectoderm
Arch- Mesoderm
Pouch- Endoderm

A-I Activates Lcat
B-100-Binds to LDL receptor mediates VLDL secretion
C-II -cofactor for lipoprotein lipase.
b-48- mediates chylomicrone secretion.
E- mediates Extra – remnant- uptake

T-ALL, Teenagers, Thymic Mass
T-ALL common in teenagers as a mediastinal (thymic) mass

Hairy Cell Leukemia is TRAP +
Trapped in red pulp
Trapped in fibrosed BM
& Can’t enter lymph nodes
HCL: TRAP+, Splenomegaly, Dry Tap, & absent lymphadenopathy

TCA’s: AACIDD-N
Amoxapine
Amitriptyline
Clomipramine
Imipramine
Desipramine
Doxepin
Nortriptyline

SSRI’s: Effective For Sadness, Panic, & Compulsions
Escitalopram, Fluoxetine/Fluvoxamine, Sertraline, Paroxetine, & Citalopram

Serotonin Syndrome may cause HARM
Hyperthermia
Autonomic instability
Rigidity
Myoclonus
(antidote: cyproheptadine- 5HT2 antagonist)

MAOi- TIPS
Tranylcypromine
Isocarboxacid
Phenelzine
Selegiline (MAO-B)

Parasympathetic: DUMBELSS
Diarrhea
Urination
Miosis
Bradycardia/Bronchospasm
Emesis
Lacrimation
Salivation/Sweating

Radial nerve innervates the BEST muscles
Brachioradialis
Extensors of wrist/fingers
Supinator
Triceps

PEA drugs have zero-order elimination
Phenytoin
Ethanol
Aspirin

Therapeutic Index- TILE
TI=LD50/ED50

qiss & qiq till your siq of sqs
a1, a2, b1, b2, m1, m2, m3, d1, d2, h1, h2, V1, & V2

Hemolysis in G6PD Deficiency: hemolysis IS PAIN
Isoniazid, Sulfonamides, Primaquine, Aspirin, Ibuprofen, Nitrofurantoin (Dapsone)

Pulmonary Fibrosis: GO BAN ME
What do pneumocytes release that causes fibrosis?
Gold, Bleomycin/Busulfan, Amiodarone/Acyclovir/Azathioprine, Nitrofurantoin, Melphalan/MTX
(TFG-B)

Gynecomastia: Some Drugs Create Awesome Knockers
Spironolactone, Digitalis, Cimetidine, Alcohol, Ketoconazole

Nephrotoxicity/Ototoxicity: CLAV
Cisplatin, Loop Diuretics, Aminoglycosides, Vancomycin

P-450 Inducers: BCG PQRST
Barbiturates
Carbamezapine/Chronic Alcohol
Griseofulvin
Phenytoin
Quinidine
Rifampin
St. John’s Wort

P-450 Inhibitors: ICA KEGS
Isoniazid
Cimetidine
Alcohol (acute)
Ketoconazole
Erythromycin
Grapefruit Juice/Gemfibrozil
Sulfonamides

Aminoglycosides: GNATS
Gentomycin, Neomycin, Amikicin, Tobramycin, Streptomycin

R’s of Rifampin
RNA polymerase inhibition
Revs up CYP450
Red/Orange urine & secretions
Resistance increased if used alone

Micro: Nagging Pests Must Breath O2 &
Anaerobes Can’t Breathe Air
-Nocardia, Pseudomonas, Mycobacterium (TB), Bacillus
-Clostridium, Bacteroides, Actinomyces

Facultative Anaerobes- Some Nasty Bugs May Live FacultativeLy
Salmonella, Neisseria, Brucella, Mycobacterium, Listeria, Francisella, Legionella

Micro- PUNCH K
Proteus, Ureaplasma, Nocardia, Cryptococcus, H pylori, Klebsiella

Micro- No SPACE for Kats
Nocardia, Staph aureus/Serratia Marscencans, Pseudomonas capecia, Aspergillus/Actinomyces, Candida, E. coli, & Klebsiella

Which toxins are carried on specialized lysogenic phages (transduction)? (ABCDE)
shigA-like toxin
Botulinum Toxin
Cholera Toxin
Diphtheria Toxin
Erythrogenic Toxin (S pyogenes)

Corynebacterium diphtheria (ABCDEFGH)
ADP-Ribosylation
Beta-Prophage
C
Diphtheria
Elongation Factor-2
Granules (metachromic)
Heart (myocarditis/arrhythmia)

French legionnaire with his silver helmet, sitting around campfire with his iron dagger; he’s not sissy
Legionella pneumophilia
Silver stain
Charcoal yeast extract (Iron & Cysteine)

PSEUDOmonas
Pneumonia (cystic fibrosis)
Sepsis (black lesion on skin)
External otitis (swimmer’s ear)
UTI (catheter)
Druggie/Diabetics- Osteomyelitis
Hot Tub Folliculitis

Tetracyclines VACUUM the BedRoom but Stones stop it
Vibrio cholera, Acne, Chlamydia, Ureaplasma, Tularemia, Mycoplasma pneumonia, H. pylori, Borrelia burgdorferi, Rickettsia
(milk, antacids, & iron ingestion prevent absorption)

Chlamydia trachomatis serotypes
Types A, B, C: Africa/Blindness/Chronic Infection
Types D-K: STD diseases
Types L1-3: Lymphogranuloma venereum & primary ulcers/rectal disease (mistaken for IBD)

Leukemia ages
0-14: ALL
15-39: AML
40-59: AML (30% Blasts)/CML
60+: CLL

Nematodes EATSANd (roundworms)
(Ingested)
Enterobius vermicularis
Ascaris lumbricoides
Trichinella spiralis
(Cutaneous)
Strongyloides stercoralis
Ancylostoma duodenale
Necator americanus

Fever in Post-Op Period
Wind
Water
Wound
Walking
Wein
Wonder Drugs
Wind: Atelectasis (1-2)
Water: UTI (3-5)
Wound: Infection (5-7)
Walking: DVT
Wein: Thrombophlebitis
Wonder Drugs: Antibiotic

+ Strand RNA: Pico Called Flavio To Return Renzo’s Corona
Picorna
Calici
Flavi
Toga
Retro
Reo
Corona

HHAPPPPy Virus
Herpesvirus, Hepadnavirus, Adenovirus, Parvovirus (B19), Papillomavirus (HPV), Polyomavirus (JC), Poxvirus

Picornavirus- PERCH
PolioV, EchoV, RhinoV, CoxsackieV, HAV)

PaRaMyxovirus
Parainfluenza (Croup)
RSV (Bronchiolotis)
Rubeola (Measles)
Mumps

Influenza: Oh Shift vs Drift
-Genetic *Shift* (pandemic) due to *reassortment* (deadly)
-Genetic *Drift* (epidemic) due to *random* mutation

TORCHeS infections
-TOxoplasmosis: Chorioretinitis, Hydrocephalus, Intracranial calcifications
-Rubella: PDA, Cataracts, Deafness (+blueberry muffin rash)
-CMV: Unilateral deafness, seizures, petechial rash
-HSV: Temporal encephalitis, vesicular lesions
-HIV: recurrent infections, chronic diarrhea (zidovudine for mom)
-Syphilis

Ampicillin & Amoxicillin HELPS
HiB, E coli/Enterococci, Listeria, Proteus, Salmonella
(Also Gram + from penicillin)

Aztreonam kills PESKy bugs when the kidney can’t handle aminoglycosides
Proteus, E coli, Serratia, Pseudomonas

Vancomycin is bad to G+, but NOT good for our histamine
Nephrotoxicity, Ototoxicity, Thrombophlebitis
Red Man Syndrome (Histamine; give antihistamines)

“Navir tease a SRINA protease S/E”
-Saquinavir: HyperG, LipoD
-Ritonavir: Pancreatitis
-Indinavir: HyperG, LipoD, Nephrolithiasis, Hyperbilirubinemia
-Nelfinavir: ?
-Amprenavir: HyperG, LipoD

HIV NRTI: ZDZ SLATEr is competitive (& S/E)
-Zidovudine: BM suppression, Megaloblastic Anemia & GI intolerance
-Didanosine: Peripheral Neuropathy, Pancreatitis, Hepatic Steatosis
-Zalcitabine: ”
-Stavudine: ”
-Lamivudine, Abacavir, Tenofovir, Emtricitabine
-Most: Lactic acidosis (not abacavir)

HIV NNRTI: NED is noncompetitive (& S/E)
-Nevirapine, Efavirenz, Declaviridine
-Same as NRTI + Rash

AVRP
Accuracy=Valid
Reliable=Precision

Gluconeogenesis Irreversible Enzymes: Pathway Produces Fresh Glucose
Pyruvate Carboxylase (M): Pyruvate -> Oxaloacetate
PEP Carboxykinase (C): Oxaloacetate -> PEP
Fructose-1,6-BPase (C; RLS): F-1,6-BP -> F6P
Glucose-6-Phosphatase (ER): G6P -> Glucose

My homie ty is fuming and is going to bust a cap in your bones
Deficiency in Homogentisic Acid Oxidase in pathway of Tyrosine to Fumurate. AR/Benign.
-Dark CT, Brown sclera, urine darkens, debilitating arthlagias

Papez Circuit: MATCH
Mammillary Bodies
Anterior Thalamic Nucleus
Cingulate Gyrus
Hippocampus

Hypothalamus (TALE)
Limbic System (5 F’s)
-Temp, Appetite, Libido, Emotions
-Feeding, Fleeing, Fighting, Feeling, Sex

Cerebellar Deep Nuclei: Don’t Eat Greasy Food
Dentate, Emboliform, Globose, Fastigial (L->M)

Wallenberg’s Horny ADVICe
Horner’s Syndrome (Descending Symp. Tract)
Ataxia (ICP)
Dysphagia (Nucleus Ambiguus)
Vertigo, Nystagmus, N/V (Vestibular Nuclei)
Ipsilateral pain/temp loss of face (TTT)
Contralateral pain/temp loss of body (STT)

PSaMMoma
Papillary carcinoma of the thyroid/RCC/Prolactinoma
Serous cystadenocarcinoma of the ovary/endometrium
Meningioma
Mesothelioma

MC Brain Tumors in Adults (MGM-Studios) & Kids (AMEy)
Adults: Mets, GM, Meningioma, Schwannoma
Kids: Astrocytoma, Medulloblastoma, Ependymoma

Charcot’s Triad (MS)
Scanning Speech
Nystagmus
Intention Tremor

Got SANDDy drugs for my epilepsy
Sedation
Ataxia
Nystagmus
Diplopia
Dizziness

Phenytoin Side Effects
P-450 activation
Hirsutism
Enlarged gums
Neuropathy (peripheral)
Yellow-browining of skin
Teratogen (fetal hydantoin syndrome)
Osteomalacia
Interferes B12 metabolism
Nystagmus

Inhaled Anesthetics: MSHINE
Methoxyflurane
Sevoflurane
Halothane
Isoflurane
N2O
Enflurane

68/95/99 Rule
Standard Deviations
1=68%
2=95%
3=99.7%

Can’t See, Can’t Hear, Can’t Pee
Alport’s Syndrome (Type IV Collagen defect)

Cholinergic intoxication: (SLUDGE)
Salivation
Lacrimation
Urination
Diaphoresis and defecation
GI upset
Excessive brady- or tachycardia (muscarinic or nicotinic)

DM Antibodies
Anti-Insulin Ab
Anti-Islet Cell cytoplasm Ab
Anti-glutamic acid decarboxylase Ab (GAD)
Anti-Tyrosine phosphatase Ab

Viruses a/w DM 1
Rubella, Coxsackie, Mumps

Metabolic Syndrome (3/5)
Abdominal Obesity
Triglycerides >150
HDL <40 (<50) Fasting Glucose >100
BP >135/85

Diabetic Retinopathy
-Background retinopathy: no neovascularization, cotton wool spots; hemorrhages, exudates, microaneurysms, venous dilatation, & macular edema
-Proliferative retinopathy: neovascularization with risk of vitreal hemorrhage (fragile) & retinal detachment (Laser photocoagulation)

Treatment for hypoglycemia
Diazoxide

How is acromegaly diagnosed?
-Increase in GH 1-2hrs after 100g glucose load (normally d/t insulin)
-IGF-1 is also elevated

Standard test for diagnosing Chronic Adrenal Insufficiency
Cosyntropin test

Drugs that Induce Pancreatitis
Furosemide, Thiazides, sulfasalazine, 5-ASA, Azathioprine, L, Asparginase, Valproid Acid, Didanosine, Pentamidine, Metronidazole, Tetracyclines

Neutrophils Like Making Everything Better
WBC differential from highest to lowest:
Neutrophils (54-62%)
Lymphocytes (25-33%)
Monocytes (3-7%)
Eosinophils (1-3%)
Basophils (0-0.75%)

Causes of eosinophilia: NAACP
Neoplastic
Asthma
Allergic processes
Collagen vascular diseases
Parasites (invasive)

Basophilic staining
Basophilic – staining readily with basic stains

MHC classes
MHC x CD = 8
class II x CD4 = 8
class I x CD 8 = 8

Basophilic stippling: BASte the ox TAiL
thalassemias
anemia of chronic disease
lead poisoning

teardrop cell: RBC “sheds a tear”
RBC “sheds a tear” because it’s been forced out of its home in the bone marrow –> BM infiltration (myelofibrosis)

target cells: “HALT” said the hunter to his target
HbC disease
Asplenia
Liver disease
Thalassemia

Lead poisoning: LEAD
Lead Lines on gingivae (Burton’s lines) and on metaphyses of long bones on x rays
Encephalpathy and Erythrocyte basophilic stippling
Abdomninal colic and sideroblastic Anemia
Drops (wirst and foot drop)
Dimercaprol and EDTA = 1st line treatment

WARM weather is GGGreat
warm agglutinin in autoimmune hemolytic anemia = IgG

COLD ice cream – yuMMM
cold agglutinin in autoimmune hemolytic anemia = IgM

the 7 “P”‘s of acute intermittent porphyria
affect enzyme = Porphobilinogen deaminase
accumulated substrate = Porphobilinogen (+delta-ALA, uroporphyrin)
Painful abdomen
Port wine-colored urine
Polyneuropathy
Psychological disturbances
Precipitated by drugs

DIC causes: “STOP Making New Thrombi”
Sepsis (gram-negative)
Trauma
Obstetric complications
acute Pancreatitis
Malignancy
Nephrotic syndrome
Transfusion

Multiple Myeloma: CRAB
hyperCalcemia
Renal insufficiency
Anemia
Bone lytic lesions/Back pain

the M’s of multiple myeloma
Multiple Myeloma: Monoclonal M protein

Philadelphia CreaML cheese
Philadelphia chromosome (t9;22) associated with CML

warfarin: “The EX-PresidenT went to WAR(farin)”
EXtrinsic pathway –> increased PT

Dactinomycin: “children act out”
used to treat childhood tumors (Wilm’s tumor, Ewing’s sarcoma, rhabdomyosarcoma)

Vinblastine Blasts bone marrow (suppression)
tx: solid tumor, leukemias, lymphomas

vincristine & vinblastine: “Microtubules are the vines of your cells”
vincristine and vinblastine bind to tubulin in M phase & block polymerization of microtubules

Lead Poisoning: “It SUCks to be a kid who eats lead”
Succimer used for chelation for kids

teardrop cells: the Bone marrow is crying because it’s fibrosed
myelofibrosis

Paclitaxel: “It is taxing to stay polymerized”
hyperstabilizes polymerized microtubules in M phase

Gram Stain Limitations: “These Rascals May Microscopically Lack Color”
Treponema
Rickettsia
Mycobacteria
Mycoplasma
Legionella pneumophila
Chlamydia

Giemsa Stain: “Certain Bugs Really TRY my Patience”
Chlamydia
Borrelia
Rickettsiae
TRYpanosomes
Plasmodium

PAS (periodic acid-Schiff) stains: “PASs the SUGAR”
stains glycogen and mucopolysaccharides

special culture requirements: “to connect to Neisseria, please use your VPN client”
Thayer Martin Media =
Vancomycin
Polymyxin
Nystatin

special culture: Bordet for Bordetella
Bordet-Gengou agar for Bordetella pertussis

special culture: “Sab’s a fun guy!”
Sabouraud’s agar for Fungi

obligate aerobes: “Nagging Pests Must Breathe”
Nocardia
Pseudomonas aeruginosa
Mycobacterium tuberculosis
Bacillus

obligate anaerobes: “anaerobes Can’t Breathe Air”
Clostridium
Bacteroides
Actinomyces

obligate intracellular bugs: “Stay inside when it is Really Cold”
Rickettsia
Chlamydia

facultative intracellular bugs: “Some Nasty Bugs May Live FacultativeLY”
SSalmonella
Neisseria
Brucella
Mycobacterium
Listeria
Francisella
Legionella
Yersinia pestis

encapsulated bacteria: “Quellung = capsular “Swellung”
positive quellung reaction – if encapsulated bug is present, capsule swells when specific anticapsular antisera are added

encapsulated bugs: “SHiNE SKiS”
streptococcus penumoniae
Haemophilus influenzae type B
Neisseria meningitidis
Escherichia coli
Salmonella
Klebsiella pneumoniae
group B Strep

Catalase positive bugs: “you need PLACESS for your CATs”
Pseudomonas
Listeria
Aspergillus
Candida
E. coli
S. aureus
Serratia

urease positive bugs: “CHuck Norris hates PUNKSS”
cryptococcus
H. pylori
Proteus
Ureaplasma
Nocardia
Klebsiella
S. epidermidis
S. saprophyticus

pigment producing bacteria: “ISRAEL has YELLOW SAND”
actinomyces israeli – yellow “sulfur” granules

pigment producing bacteria: “aureus = Latin for gold”
s. aureus – yellow pigment

pigment-producing bacteria: “AERUGula is GREEN”
pseudomonas aeruginosa = blue-green pigment

pigment producing bacteria: “red maraschino cherries”
serratia marcescens – red pigment

IgA protease: “SHiN”
secreted by:
S. pneumoniae
H. influenze type B
Neisseria

ETEC toxins: “LABILE in the Air, STABLE on the Ground”
heat-labiel toxin overactivates Adenylate cyclase

Heat stable toxin overactivates guanylate cyclase

ENDOTOXIN
Edema
Nitric Oxide
DIC/Death
Outer membrane
TNF-alpha
O-antigen
eXtremely heat stable
Il-1
Neutrophil chemotaxis

transformation (bacterial genetics): “SHiN”
s. pneumnoiae
H. influenzae type B
Neisseria

lysogeny (specialized transduction): “ABCDE”
shigA-like toxin
Botulinum toxin
Cholera toxin
Diphtheria toxin
Erythrogenic toxin of strep pyogenes

STAPHylococci identification: “On the office’s STAPH retreat, there was NO StRESs”
NOvobiocin:
Saprophyticus = Resistent
Epidermidis = Sensitive

Streptococci identification: OVRPS
Optochin:
Viridians = Resistant
Pneumoniae = Sensitive

Streptococci Identification: B-BRAS
Bacitracin:
group B strep = Resistant
group A strep = Sensitive

“Staph makes catalase because they have more “staff””
Staph = Catalase Positive

Streptococcus Pneumoniae: “S. pneumoniae MOPS are Most OPtochin Sensitive”
Strep pneumo = most common cause of:
Meningitis
Otitis media (in children)
Pneumonia
Sinusitis

Viridans group streptococci: “Viridans group strep live in the mouth because they are not afraid OF-THE-CHIN”
= op-to-chin resistant

= normal flora of the oropharynx

Streptococcus pyogenes (group A) – diagnosis of Rheumatic Fever = “J<3NES" criteria
Joints – polyarthritis
<3 = Carditis N = Nodules (subcutaneous) E = Erythema marginatum S = Sydenham's chorea

strep pyogenes: “PHaryngitis can result in rheumatic “PHever” and glomerulonePHritis”
previous pharyngitis infection can result in rheumatic fever and acute glomerulonephritis

strep agalactiae (group B strep): “Group B for Babies!”
group B strep causes pneumonia, meningitis, and sepsis mainly in babies

Strep bovis (group D strep): “Bovis in the Blood = Cancer in the Colon”
Bovis causes bacteremia and subacute endocarditis in colon cancer patients

Corynebacterium diphtheriae: “ABCDEFG”
A = ADP-ribosylation (MOA)
B = Beta-prophage (exotoxin = encoded on)
C = Corynebacterium
D = Diphtheria
E/F = Elongation Factor 2 (inhibits)
G = Granules (lab dx based on metachromatic (blue and red) granules

C. botulinum: “BOTulinum is from bad BOTtles of food and honey”
in babies: ingestion of spores in honey
in adults: ingestion of preformed toxin in cans

C. difficile: “DIfficile cause DIarrhea”
can cause watery or bloody diarrhea

Actinomyces vs. Nocardia: “SNAP”
Sulfur granules = Actinomyces
Nocardia = Pulmonary infection

“LEpromatous leprosy can be LEthal”

lactose-fermenting bacteria: “Lactose is KEE therefore test with macConKEES agar”
Citrobacter
Klebsiella
E. coli
Enterobacter
Serratia

Grow pink colonies on MacConkey’s agar

Neisseria: “MeninGococci ferment Maltose and Glucose. Gonoccoci ferment Glucose”
Meningococci = ferments maltose and glucose
Gonococci ferment glucose

haEMOPhilus causes?
E = epligottitis (cherry red in children)
M = meningitis
O = otitis media
P = pneumonia

Haemophilus influenzae: “When a child has the flu, mom goes to five (V) and dime (X) store to buy some chocolate”
Culture of H. influenzae on chocolate agar requires factors V (NAD+) and X (hematin) for growth

can also be grown with S. aureus, which provides factor V

Legionella pneumophila: “Think of a French SOLDIER with his SILVER helmet, sitting around a CAMPFIRE with his IRON dagger – he is no SISSY”
soldier = Legionnaire
Silver = silver stain
campfire = charcoal yeast extract (culture)
Iron = culture with Iron
Sissy = cysteine (culture with cysteine)

PSEUDOmonas aeruginosa causes?
P = pneuomonia (esp. in CF pts)
S = sepsis (black lesions on skin)
E = external otitis (swimmer’s ear)
U = UTI
D = drug use
DO = diabetic osteomyelitis

also: hot tub folliculitis

AERuginosa = AERobic
pseudomonas aeruginosa = aerobic organism

EIEC
I = invasive –> dysentery

ETEC
T = Traveler’s diarrhea (watery)

EPEC
P = Pediatric – diarrhea in children

EHEC
H = causes Hemolytic-uremic syndrome

Kelbsiella: 4A’s
Aspiration pneumonia
Abscess in lungs and liver
Alcoholics
di-A-betics

SALMONella = salmon swim
salmonella have flagella

“CAMPylobacter likes the hot CAMPfire”
grows @ 42?

spirochetes: “BLT”
B = Borrelia
L = Leptospira
T = Treponoma

Borrelia: B is Big
Borrelia is the only spirochete that can be visualized using aniline dyes

Lyme Disease: “FAKE a key LYME pie”
F = facial nerve palsy (typically bilateral)
A = arthritis
K = kardiac block
E = erythema migrans

VDRL false positives: “VDRL”
V = viruses (mono, hepatitis)
D = drugs
R = rheumatic fever
L = lupus and leprosy

Gardnerella Vaginalis: “I don’t have a CLUE why I smell FISH in the VAGINA GARDEN!”
CLUE cells
FISHy smelling discharge
VAGINA = vaginosis
GARDEN = gardnerella

“Rickettsii on the wRists, Typhus on the Trunk”
rash of Rickettsii starts at wrists adn ankles then spreads to trunk, palms, and soles

rash of Tyhpus starts on the trunk

rashes: “you drive CARS using your PALMS and SOLES”
Palm and sole rash seen in:
Coxsackievirus A
Rocky mountain spotted fever
secondary Syphilis

“Q fever is Queer”
unusual because it has no rash or vector and its causative organism can survive outside in its endospore form

2 forms of Chlamydia: Elementary vs. Reticulate
Elementary body is “Enfectious” and Enters cell via Endocytosis

Reticulate body Replicates in cell by fission

Chlamydia trachomatis serotypes: Types ABC
ABC = Africa/Blindness/Chronic infection

HIstoplasmosis HIdes
histoplasmosis resides within macrophages

Blastomycosis: Blasto Buds Broadly
Broad-base budding

Coccidiomycosis: “Coccidio Crowds”
spherule filled with endospores

Paracoccidioidomycosis: “Paracoccidio parasails with the CAPTAIN”S WHEEL all the way to LATIN AMERICA”
Latin America
budding yeast with Captain’s wheel” formation

Aspergillus fumigatus: Think A
A for Acute Angles in Aspergillus

sporothrix schenckii: “plant a ROSE in the POT”
ROSE = rose gardner’s disease (spores are introduced into skin by thorn prick)

POT = tx with potassium iodide

Giardia lamblia: “FAT-rich GHIRARDELLI chocolates”
fatty stools of Giardia

Naegleria fowleri: “NALGENE bottle filled with FRESHWATER containing NAEGLERIA”
transmission = swimming in freshwater lakes

Trypanosoma: “it SURe is nice to go to sleep; MELAtonin helps with sleep”
SURe = SURamin for blood born dx tx
MELA = MALErsoprol tx for CNS penetration

Nematodes (worms) tx: “worms are BENDy”
tx with a BENDazole

Onchocerca volvulus: “black flies, black skin nodules, black sight”
transmission = female black fly bite
black skin nodules = hyperpigmented skin
black sight = river blindness

IVERmectin for rIVER blindness
tx for river blindness (onchocerca volvulus) = ivermectin

Nematode routes of infection: ingested
“You’ll get sick if you EAT these!”
E = Enterobius
A = Ascaris
T = Trichinella

Nematode routes of infection: cutaneous
“These get into your feel from the SANd”
S = strongyloides
A = Ancylostoma
N = Necator

Live attenuated vaccines: “LIVE! one night only! see SMALLY YELLOW CHICKENs get vaccinated with SABIN’s and MMR! It’s INcredible!”
LIVE = live attenuated
SMALL = smallpox
YELLOW = yellow fever
CHICKENs = chicken pox
SABIN’s = Sabin’s polio virus
MMR = MMR (measles, mumps, rubella)
IN = influenza (intranasal)

Killed vaccines: “salK = Killed, RIP Always”
R = rabies
I = influenza (injected)
P = salk Polio
A = HAV

DNA viral genomes: “All are dsDNA, except for “PART-OF-A-VIRUS” is ssDNA”
“PART-OF-A-VIRUS” = parvovirus = ssDNA

RNA viral genomes: “all are ssRNA except “REpeat-O-virus” is dsRNA”
“REpeat-O-virus” = REOvirus

viral envelopes: “give PAPP smears and CPR to a NAKED HEPpy”
P = papillomavirus
A = adenovirus
P = picornavirus
P = polyomavirus
C = calcivirus
P = parvovirus
R = reovirus
HEP = hepevirus

NAKED = nonenveloped

DNA viruses = HHAPPPPy viruses
H = hepadno
H = herpes
A = adenovirus
P = poxvirus
P = parvovirus
P = papilloma virus
P = polyoma virus

cytomegalovirus: “SIGHTomegalovirus”
causes AIDS retinitis in immunosuppressed patients

polyoma virus:
JC = Junky Cerebrum
BK = Bad Kidney
JC virus causes progressive multifoca leukoencephalopathy

BK virus targets the kidney

“TZANCK heavens I do not have herpes”
HSV identification with Tzanck test to detect multinucleated giant cells

Picornaviruses = PERCH
P = poliovirus
E = echovirus
R = rhinovirus
C = coxsackievirus
H = HAV

PaRaMyxoviruses
P = parainfluenza
R = RSV
M = measles, mumps

Negative-stranded viruses: “Always Bring Polymerase Or Fail Replication”
virion brings its own RNA-dependent RNA

A = arenaviruses
B = bunyaviruses
P = paramyxoviruses
O = rthomyxoviruses
F = filoviruses
R = rhabdoviruses

segmented viruses: BOAR
B = bunyaviruses
O = orthomyxoviruses (influenza)
A = arenaviruses
R = reoviruses

Rhinovirus: “RHINO has a runny NOSE”
causes the common cold

ROTAvirus = “Right Out The Anus”
= most important global cause of infantile gastroenteritis

major cause of acute diarrhea in the US during winter, especially day care centers and kindergartens

genetic shift/drift: “Sudden Shift is more deadly than graDual Drift”
drift = minor changes based on random mutation

shift = high frequency recombination

3 C’s of measles
cough
coryza
conjunctivitis

Mumps: “Mumps makes your parotid glands and tests as big as POM-poms”
P = parotitis
O = orchitis (swelling of testes)
M = aseptic Meningitis

Hepatitis A virus
A Virus
Asymptomatic
Acute
Alone (no carriers)

Hepatitis C virus
C virus
Chronic
Cirrhosis
Carcinoma
Carrier

Hep D virus
D virus
Defective virus
Dependent on HBV

Hep E virus
E virus
Enteric
Expectant mothers
Epidemic

“HAV and HEV are fecal-oral: the vowels hit your bowels”
naked viruses do not rely on an envelope so they are not destroyed by the gut

Four stages of HIV infection: F
1. Flu-like (acute)
2. Feeling fine (latent)
3. Falling count
4. Final crisis

“Food poisoning from reheated rice? BE SERIOUS!”
Bacillus cereus

common causes of pneumonia in children (4 weeks – 18 yo):
“Runts May Cough Chunky Sputum”
R = rsv
M = mycoplasma
C = chlamydia trachomatis (infants – 3 yr)
C = chlamydia pneumoniae (school age children)
S = streptococcus pneumoniae

ToRCHeS infections
= microbes that may pass from mother to fetus

To = toxoplasma gondii
R = rubella
C = CMV
H = HIV
He = herpes simplex virus 2
S = syphilis

STD chancroid: “it’s so painful, you “DO CRY”
Haemophilus DUCREYI

= painful genital ulcer

Pseudomonas aeruginosa: “presume pseudomonas “AIRuginosa” when AIR or burns are involved”

asplenic patient is at risk for SHiN infections
S = s. pneumoniae
H.I = H. influenzae type B
N = N. meningitidis

“Use naf for staph”
nafcillin

AMinoPenicillins are AMPed-up penicillin
= wider spectrum

coverage of ampicillin: ampicillin/amoxicillin HELPSS kill enterococci
H = haemophilus influenzae
E – e. coli
L = listeria monocytogenes
P = proteus mirabilis
S = salmonella
S = shigella
enterococci

B-lactamase inhibitors: CAST
CA = clavulanic Acid
S = sulbactam
T = tazobactam

“Organisms typically not covered by cephalosporins are LAME”
L = listeria
A = atypicals (chlamydia, mycoplasma)
M = MRSA
E = enterococci

1st generation cephalosporins: “PEcK”
P = proteus mirabilis
Ec = E. coli
K – klebsiella pneumonia

2nd generation cephalosporins: “HEN PEcKS”
H = haemophilus influenzae
E = enterobacter aerogenes
N = neisseria spp
P = proteus mirabilis
Ec = e. coli
K = klebsiella pneumoniae
S = serratia marcescens

with imipenem, “the kill is LASTIN’ with ciLASTATIN”
imipenim is always administered with cilastatin (inhibitor of renal dehydropeptidase I)

Vancomycin: does NOT have many problems (only a few)
N = nephrotoxicity
O = ototoxicity
T = thrombophlembitis

Resistance to Vancomycin: “pay back 2 D-ALAs (dollars) for VANdalizing (vancomycin)”
R occurs with amino acid change of D-ala D-ala to D-ala D-lac

protein synthesis inhibitors: “Buy AT 30 CCEL (sell) @ 50”
30s inhibitors:
A = aminoglycosides
T = Tetracylines

50s inhibitors:
C = chloramphenicol
C = clindamycin
E = erythromycin
L = linezolid

Aminoglycosides: “MEAN (aminoglycoside) GNATS caNNOT kill anaerobes”
G = gentamicin
N = neomycin
A = amikacin
T = tobramycin
S = streptomycin

N = nephrotoxicity
N = neuromuscular blockade
O = ototoxicity
T = teratogen

MOA aminoglycosides: “A initiates the Alphabet”
MOA = inhibits the formation of initiation complex

Demeclocyline acts as a Diuretic in SIADH

Macrolides toxicity: “MACRO”
M = motility issues
A = arrhythmia caused by prolonged QT
C = acute Cholestatic hepatitis
R = rash
O = eOsinophilia

Trimethoprim toxicity: TMP
TMP = Treats Marrow Poorly

causes: megaloblastic anemia, leukopenia, granulocytopenia

Fluoroquinolone toxicity: “fluoroquinoLONES hurt attachments to your BONES”
can cause tendonitis and tendon rupture

metronidazole: “GET GAP on the Metro with Metronidazole!”
G = giardia
E = entamoeba
T = trichomonas
G = gardnerella vaginalis
A = anaerobes (C. difficile, bacteroides)
P = H. Pylori

TB tx: “RIPE for treatment”
R = rifampin
I = isoniazid
P = pyrazinamide
E = ethambutol

Isoniaid (INH) toxicity: “INH Injures Neurons and Hepatocytes”
Neurotoxicity
hepatotoxicity

Rifampin: 4 R’s
RNA polymerase inhibitor
Revs up microsomal P-450
Red/orange body fluids
Rapid resistance if used alone

“AmphoTERicin “TEARs” holes in the fungal membrane by forming pores”
binds ergosterol and forms membrane pores that allow leakage of electrolytes

“AMPHOTERRIble”
amphotericin toxicity:
fever/chills
hypotension
nephrotoxicity
arrhythmias
anemia
IV phlebitis

FOScarnet = pyroFOSphate analog
foscarnet binds to the pyrophosphate-biding site of viral DNA polymerase and inhibits

ABX to avoid during pregnancy: “SAFe Children Take Really Good Care”
S = sulfonamides
A = aminoglycosides
F = fluoroquinolones
C = clarithromycin
T = tetracyclines
R = ribavirin
G = griseofulvin
C = chloramphenicol

splenic dysufnction –> increased susceptibility to encapsulated organisms: SHiN SKiS
S = strep pneumo
H = haemophilus influnzae type B
N = neisseria meningitidis
S = salmonella
K = klebsiella pneumoniae
S = group B streptococci

HLA subtype B27 disease associations: PAIR
P = psoriasis
A = ankylosing spondylitis
I = inflammatory bowel disease
R = reiter’s syndrome

Fc portion of antibody: C’s
Constant
Carboxy terminal
Complement binding @ CH2
Carbohydrate side chains

complement activation of classic pathway: “GM makes CLASSIC cars”
classic pathways = IgG or IgM mediated

complement functions: “C3b binds bacteria”
C3b – opsonization

complement functions: “C3a and C5a = anaphylaxis”

cytokines: “Hot T-Bone stEAk”
IL-1 = fever (hot)
IL-2 = stimulates T cells
IL-3 = stimulates BONE marrow
IL-4 = stimulates IgE production
IL-5 = stimulates IgA production

Il-8: “CLEAN UP on AISLE 8”
Il-8 recruits neutrophils to clear infections

cell surface proteins for B cells: “you can drink Beer @ the Bar when you’re 21”
B = B cells
B = epstein-Barr virus
21 = CD-21

“Interferons Interfere with viruses”
interferons = proteins that place uninfected cells in an anti-viral state; induce the production of a ribonuclease that inhibits viral protein

Passive immunity: ” To Be Healed Rapidly”
“after exposure to Tetanus toxin, Botulinum toxin, HBV, or Rabie virus, patients are given preformed AB ” To Be Healed Rapidly”

Type 1 hypersensitivty: “First and Fast”
First = first type
Fast = anaphylaxis

Type 2 hypersensitivity: “type 2 is cy-2-toxic”
cytotoxic (antibody mediated)

Type 3 hypersensitivity: “imagine an immune complex as 3 things stuck together”
antigen-AB-complement

Type 4 hypersensitivity = “4th and last”
delayed

Type 4 hypersensitivity = 4 T’s
T lymphocytes
Transplant rejections
TB skin tests
Touching

hypersensitivities: ACID
A = anaphylactic and atopic (1st)
C = cytotoxic (2nd)
I = immune complex (3)
D = delayed (4)

Bruton’s agammaglobulinemia: Think B’s
Bruton’s
Boys
no B cells maturation

Hyper-IgE syndrome (Job’s syndrome): FATED
F = coarse Facies
A = staphylococcal Abscesses
T = retained primary Teeth
E = increased IgE
D = dermatologic problems (eczema)

Wiskott-Aldrich syndrome: Triad TIE
T = thrombocytopenic purpura
I = infections
E = eczema

fetal erythropoiesis: “Young Liver Synthesizes Blood”
Y = yolk sac (3-10 wk)
L = liver (6wk – birth)
S = spleen (15-30 wk)
B = bone marrow (22 wk – adult)

umbiLical arteries become what postnatal derivative?
mediaL umbilical ligaments

allaNtois becomes postnatal derivative?
urachus aka mediaN umbilical ligament

cardiac output variables: SV CAP
Stroke Volume is affected by:
C = contractility (directly)
A = afterload (inversely)
P = preload (directly)

JVP:
a = a
c = c
v = v
A wave = Atrial contraction
C wave = RV Contraction
V wave = increased right atrial pressure due to filling against a closed tricuspid Valve

sx of aortic stenosis = SAD
S = syncope
A = angina
D = dyspnea on exertion

5T’s of right-to-left shunt –> early cyanosis (blue babies)
Tetralogy (of fallot)
Transposition (of great vessels)
Truncus (persistent t. arteriosus)
Tricuspid (atresia)
TAPVR (total anomalous pulmonary venous return – pulmonary veins drain into SVC)

Tetralogy of Fallot: PROVe
P = pulmonary infundibular stenosis
R = RVH
O = Overriding aorta
V = VSD

INfantile type of coarctation of aorta:
INfantile = IN close to the heart

aDult type of coarctation of aorta
aDult: Distal to Ductus

Patent Ductus Arteriosus: ENDomethacin ENDs patency of PDA while PGE kEEps it open
Indomethacin – close PDA
PGE – keep it open

etiologies of dilated (congestive) cardiomyopathy: ABCCCD
A = alcohol abuse
B = wet Beriberi
C = coxsackie B virus myocarditis
C = chronic cocaine use
C = chagas disease (trypanosoma cruzi)
D = doxorubicin toxicity

most = idiopathic
others: hemochromatosis & peripartum

bacterial endocarditis: “don’t TRI DRUGS”
tricuspid valve endocarditis associated with IV drug abuse

sx of bacterial endocarditis: “bacteria FROM JANE”
F = fever
R = roth’s spots
O = osler’s nodes
M = murmur
J = janeway lesions
A = anemia
N = nail-bed hemorrhage
E = emboli

sx of Rheumatic Fever: “FEVERSS”
F = fever
E = erythema marginatum
V = valvular damage
E = ESR increased
R = red-hot joints (migratory polyarthritis)
S = subcutaneous nodules
S = Sydenham’s chorea

Class Ia anti-arrhythmics: “the Queen Proclaims Diso’s PYRAMID”
Quinidine
Procainamide
Disopyramide

class 1b anti-arrhytmics: “1’d Buy LIDy’s MEXIcan Tacos”
Lidocaine
Mexicletine
Tocainide

class 1b anti-arrhythmics: “1B is Best post-MI”
1B = useful in acute ventricular arrhythmias especially post-MI

class 1c anti-arrhythmics: “1C is Contraindicated in structural heart disease and post-MI”
flecainide and propafenone = contraindicated in structural heart disease or post-MI

class III anti-arrhythmics (K+ channel blockers): “AIDS”
A = amiodarone
I = ibutilide
D = dofetilide
S = sotalol

epidermal layers: “California Like Girls in String Bikinis”
C = corneum
L = lucidum
G = granulosum
S = spinosum
B = basale

CADherins
= CAlcium dependent ADhesion proteins

INTEGRIns
integrins = membrane proteins that maintain integrity of BM by binding to laminin in BM

BULLOus pemphigoid
= BULLOw the BM –> autoantibodies against hemidesmosomes

Rotator cuff muscles: “SItS”
S = supraspinatus
I = infraspinatus
t = teres minor
S = subscapularis

wrist bones: “So Long To Pinky, Here Comes The Thumb”
S = scaphoid
L = lunate
T = triquetrum
P = pisiform
H = hamate
C = capitate
T = trapezoid
T = trapezium

Radial nerve muscle innervation: “BEST extensors”
B = brachioradialis
E = extensors of wrist and fingers
S = supinator
T = triceps

“Pope’s blessing”
caused by proximal median nerve lesion

Hand Muscles: OAF
Oppose, Abduct, Flex

interosseous hand muscles: DAB
Dorsals ABduct

interosseous hand muscles: PAD
Palmars ADduct

peroneal nerve: PED
Peroneal Everts and Dorsiflexes

if injured, foot dropPED

tibial nerve: TIP
Tibial Inverts and Plantarflexes

if injured, can’t stand on TIPtoes

muscle contraction: HIZ shrinkage
shortening of H and I bands and between Z lines

muscle contraction: A band is Always the same length
A band remains the same length

“1 slow red ox”
Type 1 muscle fibers
slow twitch
red fibers
increased oxidative phosphorylation

oteoBlasts
osteoBlasts Build Bone

Ewing’s Sarcoma: “going out for Ewings and onion rings”
onion skin appearance in bone

Patrick EWING’s jersey # = 11 + 22 = 33
associated with translocation t(11;22)

gonoccocal arthritis is an STD
S = synovitis
T = tenosynovitis
D = dermatitis

seronegative spondyloarthropathies: PAIR
P = psoriatic arthritis
A = ankylosing spondylitis
I = inflammatory bowel disease
R = reactive arthritis

Reactive Arthritis: “can’t see, can’t pee, can’t climb a tree”
classic triad: conjunctivitis, urethritis, arthritis

SLE: “I’M DAMN SHARP”
I = immunoglobulins (anti-dsDNA, anti-Sm, antiphospholipid)
M = malar rash
D = discoid rash
A = antinuclear antibody
M = mucositis
N = neurologic disorders
S = serositis
H = hematologic disorders
A = arthritis
R = renal disorders
P = photosensitivity

scleroderma: C for Crest
C = antiCentromere antibody
C = calcinosis
R = raynaud’s phenomenon
E = esophageal dysmotility
S = sclerodactyly
T – telangiectasia

6’s P’s of Lichen Planus
pruritic
purple
polygonal
planar
papules
plaques

ABCDE of melanoma
A = asymmetry
B = border irregularity
C = color variation
D = diameter >6mm
E = evolution over time

L for Lipoxygenase and Leukotriene
lipoxygenase pathway yields leukotrienes

Neutrophils arrive B4 others
LTB4 is a neutrophil chemotactic agent

PGI2
Platelet gathering inhibitor

etanerCEPT is a TNF decoy reCEPTor

The L’s of the left lung
Left has 2 Lobes and a Lingula

relation of pulmonary artery to bronchus: RALS
Right Anterior
Left Superior

T12 of diaphragm: “@ T-1-2 it’s the red, white, and blue”
red = aorta
white = thoracic duct
blue = azygos vein

“I ate ten eggs at twelve”
I = IVC
ate = T8
ten = T10
eggs = esophagus
at = aorta
twelve = T12

C3, 4, 5 keeps the diaphragm alive
diaphragm is innervated by C3, 4, and 5 = phrenic nerve

muscles of respiration for inspiration during exercise: “S”
inSpiration, Scalene muscles, Sternocleidomastoids

physiologic dead space: “Taco, Paco, PEco, Paco”
order of variables in the equation:

VT x ((PaCO2 – PECO2)/PaCO2)

hemoglobin: Taut in Tissue, Relaxed in Respiratory
Taut form has low affinity for O2 –> delivers O2 to tissue
Relaxed form has high affinity for O2 –> acquires O2 in lungs

METHemoglobinemia can be treated with METHylene blue

causes of a Right shift in oxy-hemo dissociation curve:
C-BEAT
C = Co2 (increased)
B = BPG (increased)
E = exercise
A = acid/altitude
T = termperature

types of PE: an embolus moves like a FAT BAT
F = fat
A = air
T = thrombus
B = bacteria
A = amniotic fluid
T = tumor

SPHERE of complications in lung cancer
S = superior vena cava syndrome
P = pancoast tumor
H = horner’s syndrome
E = endocrine (paraneoplastic)
R = recurrent laryngeal symptoms
E = effusion (pleural or pericardial)

lung cancer types not associated with cancer: think “br”
BRonchioloalveolar (adenocarcinoma)
BRonchial carcinoid tumor

“A”‘s of small cell carcinoma
ACTH
ADH
Antibodies against presynaptic calcium channel
amplification of myc oncogenes

“C”s of squamous cell carcinoma
cavitation
cigarettes
hyperCalcemia

Babies who can’t “Pee” in utero develop “Potter’s”
potter’s syndrome – caused by oligohydramnios

“water under the bridge”
ureters pass under the uterine artery and the vas deferens

HIKIN’: HIgh K INtracellular
potassium located intracellularly

DO Insulin LAB work for patients with hyperkalemia?
shifts K+ OUT of cells:
Digitalis
hyperOsmolarity
Insulin deficiency
Lysis of cells
Acidosis
Beta-blockers

INsulin shifts K+ INto cells
insulin can cx hypokalemia

high serum concentrations of calcium: “stones, bones, groans, psychiatric overtones”
renal stones
bone pain
abdominal pain
anxiety, altered mental status

increased anion gap: “MUDPILES”
Methanol (formic acid)
Uremia
Diabetic ketoacidosis
Propylene glycol
Iron tablets or INH
Lactic acidosis
Ethylene glycol
Salicylates (late)

normal anion gap: “HARD-ASS”
Hyperalimentation
Addison’s disease
Renal tubular acidosis
Diarrhea
Acetazolamide
Sprionolactone
Saline infusion

nephrItic syndrome
= an Inflammatory process

WAGR complex
wilm’s tumor
aniridia
genitourinary malformation
retardation

transitional cel carcinoma is associated with problems in your “Pee SAC”
Phenacetin
Smoking
Aniline dyes
Cyclophosphamides

“ACID”azolamide causes ACIDosis
acetazolamide causes hyperchloremic metabalic acidosis

furosemide toxicity: “OH DANG”
Ototoxicity
Hypokalemia
Dehydration
Allergy (sulfa)
Nephritis (interstitial)
Gout

HCTZ toxicity: “HyperGLUC”
hyperglycemia
hyperlipidemia
hyperuricemia
hypercalcemia

K+ sparing diuretics: “the K+ STAys”
spironolactone (and eplerenone)
triamterene
amiloride

toxicity: captopril’s CATCHH
Cough
Angioedema
Teratogen
Creatinine increase
Hyperkalemia
Hypotension

3 M’s of Mesoderm
Microglia like Macrophages originate from Mesoderm

the hypothalamus wears TAN HATS
Thirst and water balance
Adenohypophysis control
Neurohypophysis releases hormones produced in the hypothalamus
Hunger
Autonomic regulation
Temperature regulation
Sexual urges

lateral area of the hypothalamus: “if you zap your lateral nucleus, you shrink laterally”
lateral areas controls hunger –> destruction causes anorexia and failure to thrive

ventromedial area of hypothalamus: “if you zap your ventromedial nucleus, you grow ventrally and medially”
ventromedial nucleus controls satiety –> desctruction causes hyperphagia

A/C = anterior cooling
anterior nucleus of hypothalamus = cool off (cooling, parasympathetic)

posterior nucleus of they hypothalamus: “if you zap your posterior hypothalamus, you become a poikilotherm”
posterior nucleus = gets fired up (heating, sympathetic)

suprachiasmatic nucleus of the hypothalamus: “you need sleep to be charismatic”
suprahciasmatic nucleus controls circadian rhythm

“Makeup goes on the face”
vpM nucleus – face sensation and taste

Lateral = Light
LGN – vision

Medial = Music
MGN – hearing

the famous 5 F’s of the limbic system
Feeding
Fleeing
Fighting
Feeling
Sex

deep nuclei of the cerebellum (lateral –> medial): “Don’t Eat Greasy Foods”
Dentate
Emboliform
Globose
Fastigial

D1 Receptor of basal ganglia = D1Rect pathway

INdirect pathway of the bg = INhibitory

parkinson’s dx: Your body becomes a TRAP
Tremor
cogwheel Rigidity
Akinesia
Postural instability

5 C’s of Huntington’s
CAG repeats
Caudate loses ACh and GABA
Chorea
Chromosome 4
Crazy (dementia)

Huntington’s: CAG
expansion of CAG repeats

Caudate lose Ach and Gaba

Broca’s Broken Boca

Wernicke’s is Wordy but makes no sense – Wernicke’s = What?

“don’t PICK A HORSE that CAN’T”
PICA stroke: hoarseness and dysphagia

“FACIAL DROOP means AICA’s POOPED”
AICA stroke –> paralysis of face

foramina of Luschka = Lateral

foramen of Magendie = Medial

“wet, wobbly, and wacky”
clinical triad of normal pressure hydrocephalus:
urinary incontinence
ataxia
cognitive dysfunction

lumbar puncture: to keep the cord alive, keep teh spinal needle between L3 and L5

Legs are Lateral in Lateral corticospinal and spinothalamic tracts

Lower MN lesions = everything is LOWERED
less muscle mass, decreased muscle tone, decreased reflexes, downgoing toes

UPper MN = everything UP
increased tone, increased DTRs, toes up

Friedreich’s ataxia: Friedreich is Fratastic: he’s your favorite FRAT brother, always stumbling, staggering and falling
staggering gait
frequent falling

Horner’s syndrome: PAM is HORNy
Ptosis
Anhidrosis
Miosis

T4 @ the teat pore
T4 = nipple

T10 @ the belly butTEN
T10 = umbilicus

L1 is IL
Inguinal Ligament

Down on ALL 4’s (L4)
L4 includes the kneecaps

S2, 3, 4 keep the penis off the floor
S2, S3, S4 keep the penis off the floor

CNs that lie medially @ brainstem: 3(x2) = 6(x2) = 12
III, VI, and XII

your eyes are above your ears, and the superior colliculus (visual) is above the inferior colliculus (auditory)

Cranial Nerves: Some Say Money Matters But My Brother Says Big Boobs Matter Most
S = sensory
M = motor
B = both

S = 1, 2, 8
M = 3, 4, 7, 11, 12
B = 5, 9, 10

nucleus Solitarius = visceral Sensory information

nucleus aMbiguus = Motor innervation of pharynx, larynx, and upper esophagus

Divisions of CN V exit owing to Standing Room Only
V1 = Superior orbital fissure
V2 = foramen Rotundum
V3 = foramen Ovale

M’s Munch and Lateral Lowers
Masseter, teMporalis, and Medial pterygoid close jaw
Lateral pterygoid opens

LR6SO4R3
6 innervates the Lateral Rectus
4 innervates the superior oblique
3 innervates the rest of the extraocular muscles

IOU: to test the inferior oblique, have the patient look up

Charcot’s classic triad of MS is a SIN
Scanning speech
Intention tremor, Incontinence, Internuclear opthalmoplegia
Nystagmus

Tuberous Sclerosis: HAMARTOMAS
Hamartomas in CNS and skin
Adenoma sebaceum
Mitral regurgitation
Ash-leaf spots
cardiac Rhabdomyoma
Tuberous Sclerosis
autosomal dOminant
Mental retardation
renal Angiomyolipoma
Seizures

“tram it all” in with tramadol
tramadol works on multiple neurotransmitters

ethosuximide: EFGH
Ethosuximide
Fatigue
GI
Headache

barbiDURATes increase DURATion

FREnzodiazepines increase FREquency
they increase the frequency of the chloride channel opening

IV anesthetics: BB King on OPIOIDS PROPOses FOOLishly
Barbituates
Benzodiazepines
Ketamine
Opioids
Propofol

amIdes have 2 I’s in name
lidocaine
mepivacaine
bupivacaine

dopamine agonists: BALSA
Bromocriptine
Amantadine
Levodopa
Selegiline
Antimuscarinics

sumatriptan: a SUMo wrestler TRIPs ANd falls on your HEAD
used to tx cluster headache attacks

HeteroChromatin = Highly Condensed

Methylation makes DNA Mute
histone methylation inactivates transcription of DNA

Acetylation makes DNA Active
histone acetylation relaxes DNA coiling, allowing for transcription

PURe As Gold
Purines = A & G

CUT the PYRamid
pyrimidines = C, U, and T

THYmine has the meTHYl
thymine has a methyl group

amino acids necessary for purine synthesis: GAG
Glycine
Aspartate
Glutamine

nucleoSide
base + ribose (Sugar)

nucleoTide
base + ribose + phosphaTe

Lesch-Nyhan Syndrome: “He’s Got Purine Recovery Trouble”
absence of HGPRT enzyme

STOP the NONSENSE!
nonsense mutation = change resulting in early stop codon

types of RNA: Rampant, Massive, and Tiny
rRNA = most abundant
mRNA = longest
tRNA = smallest

codons: AUG inAUGurates protein synthesis
AUG = start codon

stop codons:
UGA = U Go Away
UAA = U Are Away
UAG = U Are Gone

INtrons are INtervening sequences and stay IN the nucleus, whereas EXons EXit and are EXpressed

tRNA: CCA: Can Carry Amino acids
CCA is attached at 3′ end of tRNA and amino acid is covalently bound to the 3′ end

Eukaryotes = Even
40S + 60S –> 80S

prOkaryotes = Odd
30S + 50S –> 70S

ATP tRNA Activation (charging)

GTP – tRNA Gripping and Going places (translocation)

tRNA: elongation think of “going APE”
A site = incoming Aminoacyl-tRNA
P site = accommodates growing Peptide
E site = holds empty tRNA as it Exits

collagen: Be So Totally Cool, Read Books
B = bone
S = skin
T = tendon
C = cartilage
R = reticulin
B = books

type 1 collagen: bONE

type II collagen: cartwolage

type III collagen: THREE-D
defective in Ehlers-Danlos

type IV collagen: under the floor (BM)
basement membrane

blotting procedures: SNoW DRoP
southern = DNA
northern = RNA
western = protein

16 letters in “polycystic kidney”
ADPKD associated with mutated gene on chromosome 16

5 letters in “polyp”
familial adenomatous polyposis = mutated APC gene on chromosome 5

“Hunting 4 food”
huntington’s disease – repeat on chromosom 4

17 letters in “von Recklinghausen”
von recklinghausen’s disease (neurofibromatosis type 1) associated with chromosome 17

type 2 = 22
neurofibromatosis type 2 associated with gene on chromosome 22

von hippel-lindau = 3 words
associated with deletion of VHL gene on chromosome 3

X-linked recessive disorders: Be Wise Fool’s GOLD Heeds Silly HOpe
Bruton’s agammaglobulinemia
Wiskott-Aldrich syndrome
Fabry’s disease
G6PD deficiency
Ocular albinism
Lesch-Nyhan Syndrome
Duchenne’s (and Becker’s) muscular dystrophy
Hunter’s Syndrome
Hemophilia A and B
Ornithin transcarbamoylase deficiency

Duchenne’s = Deleted Dystrophin

Fragile X = eXtra large testes, jaw, ears

trinucleotide repeat do: “Try hunting for my fried eggs”
trinucleotide
huntington’s
myotonic dystrophy
friedreich’s ataxia

trinucleotide repeats: “X-Girlfriend’s First Aid Helped Ace My Test”
fragile X = cGg
Friedreich’s ataxia = gAa
Huntington’s = cAg
MYotonic dystrophy = cTg

Trisomies:
Drinking Age = 21
Election Age = 18
Puberty = 13
trisomy 21 = Down’s
trisomy 18 = Edwards
trisomy 13 = Pataus

CATCH-22
cleft palate
abnromal facies
thymic aplasia
cardiac defects
hypocalcemia 2? to Parathyroid aplasia
chromosome 22q11

PAIR
Seronegative arthropathies, associated with HLA-B27:

P – Psoriatic arthritis
A – Ankylosis spondylitis (SI joint)
I – Inflammatory bowel dz (UC)
R – Reiter’s syndrome (“can’t see, can’t pee, can’t climb a tree”)

NO Rheumatic factor

Hot T-Bone stEAk
Important interleukin cytokines:

IL-1: fever (hot)
IL-2: T cell stimulator
IL-3: Bone marrow stimulator (sim to GM-CSF)
IL-4: IgE (class switching from IgG), B cell growth
IL-5: IgA, eosinophils

GM makes classic cars
IgG and IgM activate the classic complement pathway (Ag:Ab complexes –> C1…)

C3a, C5a
Anaphylaxis

C3b
opsonization. Binds Bacteria.

To Be Healed Rapidly
Exposure to the following is indication for receiving preformed Ab’s (i.e., passive immunity):

T – Tetanus toxin
B – Botulinum toxin
H – HBV
R – Rabies virus, RSV

Note IgG half life = 21 days

ACID
Types of hypersensitivity:

Type I: Anaphylactic and Atopic
Type II: Cytotoxic (antibody-mediated)
Type III: Immune complex
Type IV: Delayed (cell mediated)

4 T’s
4 T’s of Delayed (T-cell-mediated) type hypersensitivity (IV).

T lymphocytes
Transplant rejections
TB skin tests
Touching (contact dermatitis – poison ivy)

MECH – sensitized T cells encounter Ag –> release lymphokines –> mac activation.

NO Ab involved!

FATED
Hyper-IgE syndrome (Job’s):

F – Facies (coarse)
A – Abscesses – COLD!, noninflammed staph
T – Teeth – retained primary
E – increased IgE!
D – Dermatologic (eczema)

MECH – cells fail to produce IFN-gamma –> inability of neutrophils to respond to chemotactic stimuli

TIE
Triad of Wiskott-Aldrich syndrome:

T – Thrombocytopenic purpura
I – Infections
E – Eczema

MECH – XR, progressive deletion of B and T cells

Labs: decreased IgM, (& increased IgE and IgA)

REd =
REd = REperfusion

Red (hemorrhagic) infarcts occur in loose tissues with collaterals (liver, lungs, intestine) following reperfusion –> damage by free radicals.

Neutrophils love the feeling of CILK
Neutrophil chemotactic factors:

C – C5a
I – IL-8
L – Leukotriene B4
K – Kallikrein

“What Grade did you get in Histo?
Tumor grading is the degree of cellular differentiation based on histological appearance.

TNM
Tumor staging system:

T – size of Tumor
N – Nodal involvement
M – Metastases

Stage = Spread

L-myc, N-myc
Oncogenes. Gain of function mutation in one allele –> cancer.

L-myc: Lung tumor
N-myc: Neuroblastoma (adrenal!)

K-ras, H-ras, N-ras
Oncogenes. Gain of function mutation in one allele –> cancer.

K-ras: Kolon, panKreatic
H-ras: (Hematuria) – bladder and kidney tumors
N-ras: melaNomas

DPC, DCC
Tumor suppressor genes:

DPC – Deleted in Pancreatic Cancer
DCC – Deleted in Colon Cancer

TRAP the hairy B cell
Tumor marker for hairy cell leukemia – a B cell neoplasm

Tartrate-resistant acid phosphatase.

PSaMMoma
Psammoma bodies – laminated, concentric, “rings on a tree” spherical calcifications:

P – Papillary (adenocarcinoma of thyroid)
S – Serous (cystadenoma of ovary)
M – Meningioma
M – Mesothelioma (asbestos exposure)

Lots of Bad Stuff Kill Glia
Metastases to brain (# metastases = # primary brain tumors):

Lung, Breast, Skin (melanoma), Kidney (RCC), GI

Typically, multiple well-circumcribed tumors at gray-white border.

Cancer Sometimes Penetrates Benign Liver
Metastases to liver (metastases >> primary liver tumors):

Colon, Stomach, Pancreas, Breast, Lung.

*Think breast & lung, plus what is drained by portal venous system to liver.

P.T. Barnum Loves Kids
Metastases to bone (metastases >> primary):

Prostate, Thyroid, Breast, Lung, Kidney

Lung = Lytic (IL-1)
Prostate = blastic

PEA
Drugs with zero order elimination

P – Phenytoin
E – Ethanol
A – Aspirin (at high or toxic concentrations)

Rate of elimination is constant, regardless of concentration.

Constant amount (NOT fraction) of of drug eliminated per unit time.

TILE
Therapeutic Index equation:

TI = LD50 / ED50

Safer drugs have higher TI’s

“Qiss and qiq till you’re siq of sqs”
G-protein linked 2nd messengers:

q – alpha 1 – vasoconstriction –> inc BP
i – alpha 2 – dec sympathetic outflow
s – beta 1 – inc HR, contractility, renin, lipolysis
s – beta 2 – vaso-/bronchodilation, inc HR

q – M1 – CNS, ENS
i – M2 – dec HR, dec contractility of atria
q – M3 – peristalsis, gastric acid, bronchoconstriction, miosis, accommodation

“Qiss and qiq till you’re siq of sqs”
G-protein linked 2nd messengers:

s – D1 – relaxes renal vascular sm muscle
i – D2 – modulates NT release, esp in brain
q – H1 – (nasal, bronchial mucus production)

s – H2 (gastric acid secretion)
q – V1 – vasopressin (sm m contraction)
s – V2 – vasopressin (inc H2O permeability)

HAVe 1 M&M
Receptors that use the Gq pathway:

H1, alpha-1, V1, M1, M3

Gq -> phospholipase C -> -> IP3 (-> Ca++ from ER) + DAG (-> Protein Kinase C)

MAD 2’s
Receptors that use the Gi pathway:

M2, alpha-2, D2

Gi –> inhibition of Adenylate cyclase –> dec cAMP –> dec protein kinase A

DUMBBELSS
S/S of cholinesterase inhibitor poisining (i.e., excessive parasympathetic activity):

D – diarrhea
U – urination
M – miosis
B – bradycardia
B – bronchospasm
E – excitability of skeletal musles
L – lacrimation
S – sweating
S – salivation

Caused by parathion = organophosphate = insecticide

Antidote = atropine + pralidoxime (regenerates active cholinesterase)

Side effects of atropine
Hot as a hare (inc body temp)
Dry as a bone (dry mouth, skin)
Red as a beet (flushed skin)
Blind as a bat (cycloplegia, mydriasis)
Mad as a hatter (delirium)
Bloated as a toad (constipation, urinary retention)

Blow
low doses of epinephrine are selective for beta-1 receptors –>

Adrenal Cortex (zones/hormones)
GFR – Salt/Sugar/Sex (outer to inner)
zona Glomerulosa (aldosterone)
zona Fasciculata (Cortisol, sex)
zona Reticularis (sex hormones)

Anterior Pituitary
“B-FLAT”
– Basophils – FSH, LH, ACTH, TSH
“PiG”
– Acidophils: GH, prolactin

Insulin Independent Glucose Uptake
“BRICK-L” = Insulin Independent
-Brain, RBCs (Glut 1)
-Intestine (Glut 2)
-Cornea
-Kidney (Glut 2)
-Liver (Glut 2)

Summary of Cortisol Action
“Cortisol is BBIIIG”
– maintains Blood pressure (upregulates alpha1 which increases sensitivity to catecholamines)
– Bone formation decreases
– anti-Inflammatory (leukotrienes, prostoglandins, histamine, neutrophil adhesion, IL-2)
– Insulin resistance (diabetogenic)
– Inhibits Fibroblasts (thinning of connective tissue leads to striae)
– Gluconeogenesis, lipolysis, proteolysis

Actions of PTH
“Buy Calcium and Phosphate Declines”
– Bone resorption of Ca, PO4-
– Ca reabsorption in DCT
– PO4: decrease reabsorption in PCT
– D3 (calcitriol): increase in active vitamin D (PTH Stimulates kidney 1alpha hydroxylase)

Endocrine Hormones Signalling through Gs/AC/cAMP
“FLAT ChAMP”
– FSH, LH, ACTH, TSH, CRH, hCG, ADH (V2 receptor – kidney), MSH, PTH
– Calcitonin, GHRH, Glucagon

Endocrine Hormones Signalling through cGMP
– ANP
– NO (EDRF)

Endocrine Hormones Signalling through Gs/PLC/IP3-DAG-Ca
“GOAT HAG”
– GnRH, Oxytocin, ADH (V2 receptor – smooth muscle), TRH
– Histamine (H1), Angiotensin II, Gastrin

Endocrine Hormones Signalling through Steroid Receptor
“VETTT CAP”
Vitamin D, Estrogen, Testosterone, T3/T4, Cortisol, Aldosterone, Progesterone

Endocrine Hormones Signalling through Intrinsic Tyrosine Kinase (MAP Kinase pathway)
Insulin, IGF-1, FGF, PDGF, EGF
– think growth factors
also VEGF, NGF, M-CSF

Endocrine Hormones Signalling through non-receptor Tyrosine Kinase (JAK/STAT pathway)
“PIG”
-Prolactin
-Immunomodulators (e.g. cytokines: IL-2, IL-6, IL-8, IFN)
-GH
Think acidophiles and cytokines
also erythropoeitin, alpha/gamma-interferon, GM-CSF

Thyroid Hormone Function (especially T3 in tissue)
“4 B’s”
-Brain maturation (cretinism)
-Bone Growth (synergism with GH)
-Beta-adrenergic (mainly beta1?) effects (increase CO, HR, SV, contractility)
– Basal Metabolic Rate Increases via Na/K ATPase activity = Increase 02 consumption, RR, body temp

Pheochromocytoma Characteristics
“Rule of 10’s”
-10% malignant, 10% bilateral, 10% extra-adrenal, 10% calcify, 10% kids
“5-P’s”
– Pressure (increase BP), Pain (headache), Perspiration, Palpitations (tachycardia), Pallor

Cretinism
“5 P’s”
-Pot-bellied
-Pale
-Puffy-faced child with Protruding umbilicus and Protuberant tongue

primary tooth that has the most distinctly prominent facial cervical ridge is
mn 1st molar

which primary tooth tooth usually has cusp of carabelli?
mx 2nd molar

primary tooth that has oblique ridge?
mx 2nd molar

primary 2nd molar has ____ cusps than primary 1st molar
more cusps

cervical ridge is most prominent for primary MAX tooth on the _____ surface of the ____
MF surface of mx 1st molar

last primary teeth to erupt is
mx 2nd molar

only primary posterior tooth to have oblique and transverse ridges and DL groove
2nd molar

mandibular primary primate space is between
canine and first molar

primary maxillary 1st molar has crown that resembles what permanent teeth?
permanent premolar

primary maxillary 1st molar has roots that resembles what permanent teeth?
permanent molar

facial view of primary mn 1st molar, the CEJ is most apically positioned towards what
mesial 1/3

usual pattern for eruption for primary teeth is
central, lateral, 1st molars, canines, 2nd molars

(mn before mx except lateral incisors)

primary mn 1st molar usually exhibits
distal triangular fossa

primary central incisors exhibits prominent cervical ridge where
facial and lingual surfaces

from facial view, crown of primary canine has mesio-incisal slope _____ than the distoincisal
longer

cusp tip of primary canine is generally off set to the
distal

T/F: primary molar lacks identifiable root trunk
true

which teeth has the smallest faciolingual crown dimension of all teeth
primary mn central incisors

which primary tooth has most distinct transverse ridge?
primary mn 1st molar

roots are more divergent in primary tooth than in permanent tooth

primary teeth that differs most from permanent teeth is
1st molars

highest and sharpest cusp on primary mn1 st molar is
ML cusp

calcification of primary roots is usually done at
3-4 years of age

primary max 1st molar most often bears the greatest resemblance to
premolar

primary 1st mn molar does not look like any permanent tooth

primary 1st max molar resembles
premolar

primate space develops in maxillary primary dentition between
laterals and canines

primate space develops in mandibular primary dentition between
canines and 1st molars

direction of primary enamel rods in the cervical third is in a _____ direction
occlusal

primary teeth are ____ mineralized than permanent teeth. Therefore, they are ____
less mineralized

therefore, more worn

primary spacing for anterior teeth is most frequently caused by
growth of the dental arches

difference in space from primary to permanent dentition is
2-4 mm

mamelons that remain beyond age 10 generally indicate
open bite

groove pattern for the mn 1st molar is considered a
Y or Dryopethicus pattern

groove pattern for the mn 2nd molar is considered a
+ or cross pattern

occlusal outline from an occlusal view for the mx 1st molar is
rhomboid

cross section of the mn canine at the CEJ is
ovoid but wider mesiodistally at the labial side.

occlusal outline from an occlusal view for the mn 1st premolar is
diamond

crown form of canines from a facial view is
pentagonal

when viewed from the occlusal , the arrangement of teeth are
parabolic

viewed from the occlusal, the 4 posterior teeth in the mn arch are aligned in _____
a straight line

viewed from the occlusal, the basic coronal outline of a mn 2nd premolar is
pentagonal

geometric form of anterior teeth when viewed from the proximal is
triangular

from facial or lingual view, canines have a ______ outline
pentagonal

cervical cross section of the max 1st premolar exhibits ____ shaped root outline
kidney shaped

cervical cross section of the max 1st premolar exhibits ____ shaped pulp chamber floow
kidney shaped

cross sectional outline at the cervical is roughly _______ for the permanent max 2nd molars
triangular

in cross section, the root of the mn canine is
irregularly ovoid

max 3rd molars from an occlusal view frequently have _____ shape because they are missing the DL cusp
heart shaped

non-working condyle moves
1. downward
2. forward
3. medial

side shift of the mandible is also known as the
Bennett movement

the upper compartment of the TMJ is that space between
disc and the articular fossa and eminence

thickest section of the articular disc when seen in the sagittal plane is the
posterior section

anterior guidance plays the greatest role in disoccluding the posterior teeth in ______
latero-protrusive manner

anterior guidance describes
the influence on mandibular movement provided by the contact between the anterior teeth as the mandible moves through excursive movements

Mandibular movement provided by the contact between the anteriors as the mandible moves through excursive movements
anterior guidance

During protrusive movements, the (anterior/posterior) teeth should disclude immediately
posterior

In optimal occlusion, the condyles are resting on the (anterior/posterior) slopes of the articular eminences
posterior

In optimal occlusion, the condyles are in their most super (posterior/anterior) position
anterior

ligaments associated with teh TMJ serve to
1. protect surrounding and supporting tissues from damage

physiological rest position is established when mastication muscles are in
tonic equilibrium

principle muscle that retrudes the mandible are
posterior fibers of the termporalis m

what ligament limits the extend of jaw opening?
temporomandibular ligament

temporomandibular ligament initiates _______ of the condyle down the articular eminence
translation

extrinsic muscle of the tongue that causes tongue to retract?
styloglossus

bennet movement occurs during the ______ earliest stage of lateral movement
earliest

muscles primarily for protrusive movement?
lateral pterygoid muscles

prime mover in effecting left working movement
right lateral pterygoid

TMJ has how many synovial cavities?
2 (upper and lower)

condyle on the working side generally rotates about a ______ axis and translates ______
rotates about a vertical axis and translates laterally

Bennett movement is the bodily shift of the mandible towards the _____ condyle
working condyle

TMJ is protected by
synovial fluid
fibrocartilage
ligament suspension
masticatory muscles

dsk of the TMJ is moved forward mainly by
superior head of the lateral pterygoid

intercuspal position is mainly determined by
tooth contact

physiological rest position is a ____ guided position
muscle guided

centric relation is a _____ guided position
ligament guided

centric occlusion =
intercuspal position

teeth contact in intercuspal position during ______
NON masticatory swallowing

forward movement of the condyle from the articular fossa is done by
lateral pterygoid m

physiological rest is a also called
postural position

in posselt’s envelop of motion, which is the most superior point
maximum intercuspal position

in posselt’s envelop of motion, which is the most inferior point
maximum opening

glenoid fossa is a
depression in the temporal bone, just anterior to the auditory canal

what covers the articulating osseous structures of the TMJ?
dense avascular fibrous CT

which muscle does not elevate the mandible?
lateral pterygoid m.

lower compartment of the TMJ is located between
condyle and disk

when the mandible moves from CO (centric occlusion) to edge to edge, the condyles move
forward and downward

An increased horizontal overlap necessitates (shorter/taller) cusps on posterior teeth
shorter

An increased horizontal overlap necessitates (shallower/deeper) grooves on posterior teeth
shallower

A decreased horizontal overlap accommodates (shorter/taller) cusps on posterior teeth
taller

An decreased horizontal overlap necessitates (shallower/deeper) grooves on posterior teeth
deeper

Protrusive path is also known by what 2 other names?
1. angle of eminence
2. condylar inclination (CI)

(Steep/flat) condylar inclination produces rapid disclusion
steep

The (posterior/anterior) teeth control guidance of the mandible, whereas the (posterior/anterior) teeth determine it’s superior closing movement
anterior, posterior

transverse ridge results from the union of
facial and lingual triangular ridges

for multi-rooted teeth, dentin continues to form MOST rapidly at the
floor and the roof of the pulp chamber

dentin that is most highly mineralized is
intra or peritubular dentin

there a total of ___ teeth in the permanent dentition that normally have cingulums
12

(all anterior teeth generally have cingulums)

softest dental tissue
cementum

hardest dental tissue
enamel

all premolars are wider
FL than MD

_____ fibers of the PDL provide the major support for a tooth during function
Oblique fibers

pulp chamber of a major tooth contains
blood vessels and nerves

occlusal table of a posterior tooth makes up _____ of the total FL dimension
55-65%

in a healthy mouth, the alveolar process is thinnest around _____
facial of the mandibular central incisors

epithelial attachment is always an actual part of a tooth’s periodontium

continued eruption of a tooth through the surrounding tissue makes the clinical crown appear ____
longer

for molar teeth, the root canals join the pulp chamber ______ to the CEJ
apical

_____ periodontal fibers travel from 1 root to an adjacent root surface
transseptal

overjet and overbite provide some degree for protection for lips, cheeks and tongue

caries stimulate the production of
tertiary dentin

hypercementosis is
excess of calcified tissue formation at the root apex

predominant CT in PDL fibers is
collagen (produced by fibroblasts)

facial view: the apex of the lingual root is in line with the _______
facial groove of the tooth

the number of lobes that form the anterior teeth is
4

curve of spee
anterior posterior curvature of the occlusal surfaces as seen in a facial view

oblique PDL ligament fibers reduce the likelihood of a
forceful impaction into the alveolus

height of contour is in the _______ for the facial surfaces of all teeth
gingival 1/3

concrescence
cemtnal union of 2 fully formed teeth that were originally separate entities

apex of a tooth is fully formed _____ years after it erupts in the mouth
2-3 years

number of lobes that form the posterior teeth
coincides with the number of cusps

cervical line of permanent teeth has the greatest depth of curvature on the _____ aspect
mesial

from the proximal view, the incisal ridge of the crown is in line with the
center of the root

perikymata are the result of
normal enamel apposition

oblique periodontal ligament fibers are most likely to be found in the _____ of the root
middle 1/3

accessory pulp canals may be found in the ____ 1/3 of the root
cervical

accessory pulp canals may contain _____
nervous and vascular tissue

accessory pulp canals may be found in the furcation areas of molars

accessory pulp canals allow the pulp tissue to communicate with the ____
PDL space

function of the pulp is
to form and supply nutrients to dentin and transmit sensory stimuli

primary function of the dental pulp is to form
dentin

shortest interdental papilla is between
mandibular 2nd premolar and 1st molar

percentage of dentin that is organic is
20-30%

interradicular fibers are NOT periodontal fibers

approximately ____ of permanent root formation is completed at the time the tooth erupts
50%

development grooves separates cusp ridges from
marginal ridges

facial masticatory mucosa (attached gingival) is narrowest for
mn 1st premolar

DEJ occurs at the junction of
the dental papilla and inner enamel epithelium

maintenance of the epithelial attachment is NOT a function of the PDL

PDL fibers are made up of
collagen

PDL fibers support the tooth connecting to the dental alveolar bone via the
cementum

supernumerary teeth when seen in the maxillar are usually found between
centrals or as 4th molars

main component of enamel
inorganic matter (not collagen)

direction of the enamel rods in permanent teeth in the cervical 3rd s in a _____ direction
gingival

usual overjet is ____ mm
2-4 mm

difference in space from primary to permanent dentition is ____ mm
2-4

all teeth have distal and mesial marginal ridges

primary pulp horns are _____ in primary molars
higher

pulp chambers of primary tooth are ____
larger

crowns of primary anterior teeth are______MD and shorter incisocervically than permanent counterparts
wider

roots of primary anterior teeth taper _______ than their permanent counterparts
more rapidly

roots of primary molars are _____ and _____ than permanent counterparts
longer and mores lender

enamel ends on primary teeth ends abruptly at the cervical line which is different from permanent teeth
enamel of permanent becomes thinner at the cervical line

occlusal table of primary mn 1st molar
rhomboid

with DF angle as botuse

primary 1st and 2nd molars 1st show calcification at _____
5-6 months in uteral

when are the roots of a deciduous tooth completely formed?
in about 1 year after eruption of that tooth

first tooth to ever erupt
primary mn central incisor

*at about 6.5 months

1st permanent tooth to begin calcification
mn 1st molar (at birth)

1st succedaneous tooth to erupt
mn central incisor

(around 6-7 yrs old)

mn and mx molars are NOT succedaneous

permanent max central incisors erupt at around
7-8 years of age

permanent max lateral incisors erupt at around
8-9 years of age

hardest tooth to have class II cavity prep
primary mn 1st molar

only incisor with MD diameter greater than crown height
max inciors

largest permanent tooth
max 1st molar

largest primary tooth
mn 2nd molar

permanent occlusal pit groove pattern of primary max 1st molar is
H shaped

permanent mn 1st molar most closely resembles which primary tooth?
primary mn 2nd molar

primary teeth to have the greatest FL diameter
primary 2nd molars

primary teeth with most noticeable morphologic deviations from permanent teeth are
1st molars

apnea occuring after hyperventilation is due to
decreased carbon dioxide tension

apnea
temporary cessation of breathing, especially during sleep

strong stimulation of spindles in the masseter muscle causes
contraction of the muscle

Lecithin hydrolysis yields
2 fatty acids, 1 glycerol, 1 phosphoric acid and 1 choline residue

pantothenic acid is an integral part of
coenzyme A

which AA lessens the need for phenylalanine?
tyrosine

type of bond that link AA to form proteins
amide

most immediate source of oxaloacetic acid during metabolism is
aspartic acid

neutral fats contain mixtures of 1 or more fatty acids esterfied with
glycerol

vitamin A functions to
promote differentiation of epithelial cells

starch
1. insoluble
2. energy store in plants
3. large amount of a-glucose molecules

Amylose
straight chain

amylopectin
highly branched with alpha 1,6 linkages

diassacharide are 2 sugar units joined together by ______ bond
covalent

maltose
2 glucose molecules

lactose
glucose and galactose

sucrose
glucose and fructose

miosis
constriction of the pupil of the eye

(done by short ciliary nerves of the eye for accomodation, which are innervated by parasympathetics from CN III)

myopia
nearsightedness

*eye is too long for refractive power of the lens
*focus at point in front of retina

in myopia, cornea is
steeper and eye is longer than nomral eye

to treat myopia, you need _____ lenses
concave

hyperopia
farsightedness

*eye is too short for refractive power of the lens
*focus at point behind of retina

in hyperopia, cornea is
flatter and eye is shorter

to treat hyperopia, you need _____ lenses
convex

GAG in synovial fluid and ECM of loose CT?
hyaluronate

GAG in cartilage, bone and heart valves?
Chondroitin sulfate

GAG in basement membranes?
heparan sulfate

GAG in in mast cells?
heparin

GAG in skin, blood vessels and heart valves?
dermatan sulfate

GAG in Cornea, bone, cartilage =?
Keratan sulfate

most abundant GAG?
chondroitin sulfate

most heterogenous GAG?
keratan sulfate

which form of sugars are the most common in nature?
D

ground substance of ECM is made up of
proteoglycan molecules (GAGs)

which enzyme promotes depolymerization of ECM?
hyaluronidase

one of the building blocks of GAGs is always a
amino sugar

dextran
polysaccharides of glucose produced by bacteria and yeast

what enzyme produces dextrans?
glucosyltransferase (dextran sucrase)

*substrate is sucrose

Levans
fructans

*side product of dextran production

reserve nutrients for bacteria
fructans

saturated fat contains ______ double bonds
None

unsaturated fats contain _____ double bonds
one or more

cell derive energy from fatty acids through
beta oxidation

linoleic acid
polyunsaturrated fatty acid

steatorrhea
fat malabsorption

lecithin hydrolysis yields
1. 2 fatty acid
2. glycerol
3. phosphoric acid
4. choline

water soluble emulsifiers

cephalins
phospholipids found in nervous tissue of brain and spinal cord

*like lecithin but contain serine or ethanolamine in place of choline

sphingomyelin hydrolysis yilds
1. sphingosine
2. choline
3. fatty acid
4. phosphoric acid

least dense lipoprotein
chylomicrons

most dense lipoprotein
HDL

*highest in protein content, lowest in triglyceride content

primary plasma carriers of cholesterol are
LDLs

LDLs are rich in
cholesterol

VLDL are rich in
triglycerides

HDL are rich in
protein

ketone bodies are only formed in the
liver

can brain use ketone bodies? what about fatty acids
brain can use ketone bodies but NOT fatty acids

can liver use ketone bodies?
NO

rate limiting step in the synthesis of ketone bodies?
HMG-CoA synthase

key intermediate/rate limiting step in the synthesis of fatty acids is
malonyl-CoA

*formed from acetyl-CoA, bicarb and ATP

pantothenic acid (vitamin B5) is important for what?
coenzyme A

ketosis occurs when_____
occurs when fatty acids are not completely metabolized

*occurs with starvation, fasting and alcoholism

symptoms of ketosis
1. ketones in urine
2. ketone bodies in blood
3. potassium loss in urine
4. fruity odor of acetone on breath

fatty acid synthesis takes place where?
in the cytosol

fatty acid breakdown occurs where?
mitochondria

fatty acid are oxidized by which pathway?
beta-oxidation

beta oxidation also produces acetyl-CoA for the TCA cycle

are triglycerides part of the membrane?
NO

hypoglycemia _______ secretion of glucagon
increases 2-3x the

hyperglycemia _______ secretion of glucagon
reduced to .5x

unlike insulin, glucagon acts almost _____ on the liver
exclusively

what activates adenylate cyclase in the adipocyte plasma membrane?
glucagon and epinephrine

activation of adenyl cyclase raises
intracellular concentration of cAMP

glucagon and epinephrine stimulates what?
triacylglycerol lipase —> stimulates lipolysis

rate limiting steps in kreb cycle
1. citrate synthase
2. isocitrate dehydrogenase
3. alpha-ketoglutarate dehydrogenase complex

cori cycle
lactic acid cycle

where does gluconeogenesis occur?
in the cytoplasm

Collagen: location of types
Type 1: bONE (majority; bone)
Type 2: carTWOlage (cartilage)
Type 3: reTHREEcular fibers (fibers of reticular lamina in basement membranes; product of CT)
Type 4: “Four on the Floor” (primary material of basement membranes)
Type 7: anchoring fibrils of basement membrane (3+4=7; anchors basal lamina to reticular lamina)

3 types of ducts in salivary gland
1. Intercalated duct: (think “international flights”)
-transports saliva to larger ducts
-lined by simple cuboidal epithelium

2. Striated duct: (think of a PEZ dispenser)
-modifies salivary electrolytes (resorbs Na/Cl, secretes K/HCO3) (think of tiny PEZ candy)
-lined by simple low columnar epithelium (PEZ dispensers are column-like)

3. Terminal excretory duct: (self explanatory)
-transports saliva to oral cavity
-lined by pseudostratified columnar epithelium

Perichondrium locations
“Perichondrium is not a FAN of these locations”

Fibrocartilage (ex. TMJ articular disc, intervertebral discs, etc.)

Articular cartilage of joints

Nasal/costal cartilage

*Note perichondrium the surface of all other types of all other cartilage!

Elastic cartilage locations?
All start with “E”

External ear, Eustachian tube, Epiglottis

*Hyaline (precursor to endochondral bone formation) = nose, trachea, bronchi, larynx, ribs, articular surfaces, and long bones

*Fibrocartilage = intervertebral discs, TMJ articular disc, symphysis of pubis, meniscus of knee.

Cartilage growth types
Appositional = on the surface of existing cartilage (think apical)

Interstitial = within existing cartilage (think inter) via “centers”

Bone growth types
Intramembranous ossification: (“IntraMembranous involves IMmature bone”)
mesenchymal cells – osteoblasts – immature woven bone secretion (around collagen) – osteoclast resorption – osteoblasts replace with mature bone – final calcification

Endochondral ossification: (think chondral for preliminary cartilage layer)
bony cuff around hyaline cartilage (grows to replace/kill chondrocytes) – calcification – resorption of calcified cartilage – new osteoblastic matrix forms mature bone

Bone remodeling?
“HHHow’s the remodeling?”

-Howship’s lacunae (Hollow resorption bays on bone surface)
-Hydrolytic enzymes (produced by osteoclasts)
-pH lowered to dissolve bone matrix

Types of mature bone
Cancellous (spongy w/ branches of trabeculae – some of it is “cancelled” out)

Compact (solid)

White blood cell relative concentrations
“Never Let Monkeys Eat Bananas” (greatest to least)

Neutrophils (65%)
Lymphocytes (25%)
Monocytes (6%)
Eosinophils (3%)
Basophils (1%)

Bradycardia vs. Tachycardia
Remember that Tom Brady is a slow runner!

Bradycardia: <60bpm Tachycardia: >100bpm

Layers & Tunica’s
*Blood Vessel Layers: (lumen to outermost)*
1. Tunica intima (SSE; basement membrane)
-arteries have additional elastic layer (int. elastic mem.)

2. Tunica media (smooth m. & elastic fibers (thicker in a’s))

3. Tunica adventitia (collagen & elastic fibers (thicker in v’s))
-large vessels contain vaso vasora

*Upper Digestive Layers: (inner to outer)*
1. Mucosa
-epithelium
-lamina propria (CT & Lymphatic tissue)
-muscularis mucosae (smooth m.)

2. Submucosa (dense irregular CT, glands, nerves)

3. Muscularis externa (smooth m.; PERISTALSIS)
-circular & longitudinal

4. Serosa
-mesothelium (SSE)
-CT (adipose, vasculature, lymphatics)

5. Adventitia (loose CT)

Tunica albuginea: thick outer fibrous layer of CT in penis, testes, and ovaries (think “ginea” for “genitals”)

Spermatic cord contents?
VALT

Vas deferens (aka ductus deferens)
Autonomic nerves
Lymph vessels
Testicular arteries & veins

Penis Tissues
Corpora cavernosa – 2 dorsal sections of erectile tissue (think of a “cave” covering a hole (the urethra))
Corpora spongiosum – 1 ventral section containing urethra (think: the spongy layer is more delicate so it hides underneath)

*remember that the tunica albuginea is the capsule that surrounds them all

Layers of Adrenal Cortex
Layers of Adrenal Cortex
GFR corresponds w/ salt, sugar, sex

Glomerulosa ? mineralcorticoids (e.g. aldosterone)
Fasciculata ? glucocorticoids (e.g. cortisol, hydrocortisone)
Reticularis ? gonadocorticoids (e.g. sex steroids, androgens)

Epidermal layers?
“Bad Sprinters Get Leg Cramps” (inner to outer)

1. Stratum Basale (mitotic activity; melanocytes, keratinocytes)

2. Stratum Spinsoum (spinous cell layer – cytoplasmic processes & Langerhan cells)

3. Stratum Granulosum (flattened; keratohyalin Granules)

4. Stratum Lucidum (clear layer in thick skin)

5. Stratum Corneum (keratinized layer) (“Korn”)

Oral mucosa layers?
“California Girls’ String Bikinis”
(outer to inner)

1. Stratum Corneum (Korny Keratinized layer)

2. Stratum Granulosum (Keratohyalin granules)

3. Stratum Spinosum (prickle layer; langerhans)

4. Stratum Basale (mitotic activity; least differentiated)

Subepithelial CT of oral mucosa?
ALL forms of epithelium (e.g. lining, masticatory, specialized) have a LAMINA PROPRIA (2 layered: papillary & dense)
DEEP TO THE BASEMENT MEMBRANE.

Lamina Propria contains the Papillary layer with Papillae (Progections interdigitating with ePithelial rete Pegs (ridges)).

*Reticular layer also included in the lamina propria.

Sweat glands of sympathetic NS?
Sympathetic = Apocrine (think A for Arousal)

Parasympathetic = eccrine

Remember:
Eccrine (aka merocrine) = solely secretion from granules (“me alone”)

Apocrine = secretion w/ portion of cytoplasm (think A for “apex” (just the tip))

Holocrine = secretion with a portion of the cell (think “whole” portion of the cell)

Oral tissue origins
IEE = Enamel

Dental Papilla = Dentin, Pulp

Dental follicle = Cementum, Alveolar Bone, PDL (it connects the 2 previous ones!)

Tomes fibers vs. Tomes process
Tomes fibers: odontoplastic processes (dentin!)

Tomes processes: ameleoblastic processes (enamel)

Enamel tufs vs. spindles vs. lamellae?
Enamel tufts: hypocalcified, inner 1/3 of enamel (from DEJ) (think of tufts – 3 more years)

Enamel spinDles: short Dentinal tubules that became trapped during apposition of enamel and got enamel calcified around them

Enamel lamellae: partially calcified vertical defects in enamel that look like cracks (traverse entire length of grown from surface to DEJ)

Widest mesio-distally
mandibular first molar

only tooth with a pulp wider M-D than F-L
Max. central incisor

Widest F-L
Permanent Max. 1st molar, primary 2nd max molar

Only tooth that is narrower facially than lingually
maxillary first molar

Tallest tooth inciso-gingivally
1) Max. canine
2) Mand. canine

Tallest crown inciso-gingically
Mandibular canine

Longest root inciso-gingivally
Maxillary canine

Most symmetrical
Mandibular central

Smallest
Mandibular central

Narrowest-M-D
Mandibular central

Narrowest and smallest-rooted pre-molar
Mandibular first Pm

Most congenitally malformed or missing
1) 3rd molars
2) maxillary lateral

Premolar most likely to be congenitally missing
Mandibular second Pm

Best developed lingual anatomy
Maxillary lateral (lingual pit and lingual groove)

Most likely to have dens-in-dente
Maxillary lateral

Greatest constriction from pulp chamber to canals
Maxillary first Pm

Premolar most likely to have 1 root and 1 canal
Mandibular second Pm

Anterior tooth most likely to have a bifurcated root
Mandibular canine

Only tooth with 2 triangular ridges on 1 cusp
Maxillary first molar

Only tooth with a M-L groove
Mandibular first Pm

Only tooth with a root that is inclined mesially
Mandibular canine

Only tooth with crown concavities
1) Maxillary first Pm (mesial)
2) Primary maxillary canine

Contact points for maxillary teeth
IJ, JM, JM, MM, MM, MM, MM, M
I: Incisal 1/3
J: Junction of incisal and middle 1/3s
M: Middle 1/3

Contact points for mandibular teeth
II, II, IM, MM, MM, MM, MM, M

Facial heights of contour are most prominent on
mandibular posterior teeth

Facial heights of contour are least prominent on
Mandibular anterior teeth

Height of contour for teeth (facial and lingual)
Facial: Anterior AND posterior at cervical 1/3, except for mandibular 1st molars (junction of cervical and middle 1/3)
Lingual:
Anterior: cervical 1/3
Posterior: middle 1/3, except for mandibular 1st Pm(occlusal 1/3)

the CEJ dips deeper on
Anterior than posterior
Mesial than distal
Maxillary than mandibular

Facial embrasures are narrower than lingual embrasures except for
Maxillary first molar(facial wider) and between Mandibular centrals (same)

Largest incisal embrasure is between
Maxillary lateral and canine

Second largest incisal embrasure is between
Mandibular lateral and canine

Largest overall occlusal embrasure is between
Maxillary canine and first Pm

Primary teeth show evidence of calcification in utero in ___ trimester
2nd

Which tooth shows the first evidence of calcification at birth?
Permanent mandibular molars

Permanent anterior shows the first evidence of calcification before age ___
1

Permanent Pms show the first evidence of calcification around age ___
2

Wisdom teeth show the first evidence of calcification around age ______
7-9

Maxillary teeth usually erupt before mandibular teeth (True/false)
FALSE
Mandibular teeth usually erupt before maxillary

When a tooth erupts, its root is about _____% formed
50%

The roots of primary teeth will complete about ___ years after eruption; the roots of permanent teeth will complete about ____ years after eruption
1.5
2.5

Maxillary incisors have incisal edges that are centered/lingual/labial to the long axis of the tooth
centered

Mandibular incisors have incisal edges that are centered/lingual/labial to the long axis of the tooth
lingual

Maxillary canines have incisal edges that are centered/lingual/labial to the long axis of the tooth
facial

Mandibular canines have incisal edges that are centered/lingual/labial to the long axis of the tooth
Lingual/centered

From a facial view, all teeth have a crown shaped like a
trapezoid

From a proximal view, what is the shape of anterior and posterior teeth?
Anterior: triangle
Max. post: trapezoid
Mand. post: rhomboid

Teeth with one facial cusp have a mesial cusp slope that is shorter/longer than the distal cusp slope, except for primary maxillary canine and permanent maxillary first Pm
shorter

Crowns of teeth tend to get shorter from ____ to _____
canine to third molar

All teeth develop from ___ lobes except permanent first molars and mandibular 2nd Pm
4 lobes
Permanent first molars and mandibular 2nd Pm have 3-cusp type, developing from 5 lobes

The distal side of a tooth is typically bigger than the mesial side (true/false)
false. the mesial side is usually bigger

Enamel is the hardest substance in the human body. it is about _____% calcified.
97%

The roots of all teeth are inclined __________, except for mandibular canine
Distally
mandibular canine inclines mesially

If one root has 2 canals, they will be oriented _________ and _________
facially and lingually

Teeth erupt with as many pulp horns as they have cusps. (True/false)
true

All DNA viruses are ds except
parvo

All RNA viruses are ss except
reo

Positive stranded RNA viruses
Retro, Toga, Flavi, Coronoa, Hepe, Calici, Picorna
I went to a retro toga party and drank flavored corona while eating hippy california pickles.

All viruses are haploid except
Retroviruses have 2 identical ssRNA

All DNA viruses replicate in nucleus except
pox (carries own DNA-dependent RNA polymerase)

All RNA viruses replicate in cytoplasms except
influenzea and retro

Naked Viruses
Papilloma, Adenoa, Parvo, Polyoma, Calci, Picorno, Reo, Hep
DNA=PAPP RNA=CPR to a naked hepe

Enveloped viruses get their membranes from cell membranes except
Herpes – from nuclear membrane

DNA are linear except
Papilloma, polyoma, hepadna

Are icosahedral except
Pox

Negative stranded viruses
Must bring RNA dependent RNA polymerase to code for Sense strand to allow cell to translate
Arena, Bunya, Paramyxo, Orthomyxo, Filo, Rhabdo
Always Bring Polymers Or Fail Replication

Segmented Viruses
BOAR
Bunya, Orthomyxo, Arena, Reo

Picornoviruses
PERCH
Polio, Echo, Rhino, coxsackie, HAv
Rna translated to one large polypeptide that is cleaved by proteasess. All can pass through stomach acidity except rhinovirus.

Amelogenesis – 2 step process
-first step produces a partially mineralized (30%) enamel
-second step: involves significant influx of additional mineral coincident with the removal of organic material and water to attain the greater than 96% mineral content

-Stages-
1. Morphogenetic stage
2. Histodifferentiation stage
1. cells of inner enamel epithelium
-late cap-bell stage
2. late bell-early matrix deposition

-Stages-
3. Presecretory-Initial secretory
-differentiating ameloblasts acquire their phenotype, change polarity, develop an extensive protein synthetic apparatus, and prepare to secrete the organic matrix of enamel
-lacks Tome’s processes (removal of basla lamina and deposition of aprismatic [initial] enamel)

-Stages-
4. Secretory stage
-ameloblasts elaborate and organize the entire enamel thickness – resulting in formation of a highly ordered tissue
-well defined Tome’s processes
-whole thickness of enamel is deposited at this stage

-Stages-
5: Maturation stage
-removal of organic material
-maturation and thickening of mineral crystals
-modulation between 2 ameloblast morphologies: ruffle-ended and smooth-ended

-the protective phase is the last stage

Preameloblasts
-cells differentiate, develop secretory phenotype:
-cell polarization
-development of secretory apparatus

-preameloblast-preodontoblast interactions are essential for their coordinated co-differentiation

a) basal terminal web
b) blunt processes
a) exists between preameloblasts
b) of preameloblasts are seen extending into the stratum intermedium

presecretory ameloblasts
fully developed secretory cells
-disintigration of the basal lamina between odontoblasts
-extend their cell processes through the basal lamina into the dentin

early secretory ameloblasts
-start to secrete mineralized enamel matrix
-this can only occur when the basal lamina is gone and upon mineralization of the underlying dentin matrix
-lack distal tome’s processes

Responsible for deposition of the initial aprismatic enamel?
early secretory ameloblasts

Mature ameloblasts form…
Tomes processes

Tomes processes
-consist of proximal and distal parts
-apical terminal web separates Tome’s processes from the ameloblast cell body

a) apical terminal web
b) basal terminal web
a) distal junctional complex
-separates the Tome’s processes from the ameloblast cell bodies
b) proximal junctional complex

a) Type 1 face
b) Type 2 face
a) secretory face of tomes process
-enamel matrix is released here
b) the “sliding” face

Secretory granules
-contain enamel matrix proteins

First mineral in secretory enamel?
amorphous calcium phosphate
-its morphology and organization is identical to older crystalline secretory enamel

What regulates the formation and organization of mineral particles?
enamel matrix proteins found in secretory enamel

Enamel matrix protiens
-**Amelogenin** [major ECM protein- 90%]
-Ameloblastin [ECM protein]
-Enamelin [ECM protein]
-DSPP – main or noncolllagenous protein of dentin [only at very early stages]
-DMP1 – major non collagenous protein of dentin (only at very early stages)
-MMP20 [Enamelysin] matrix metaloproteinase

-Amelogenin
-90% of organic component in secretory enamel
-hydrophobic
-proline and glutamine rich protein containing short hydrophobic C-terminal domain

…Amelogenin
-undergoes proteolytic cleavage during the secretory stage
-cleavage products are important in amelogenesis
-it assembles into spherical aggregates of 15-50nm in diameter called nanospheres
-regulates crystal morphology
-inhibits crystal nucleation and transiently stabilizes amorphous calcium phosphate

Amelogenin mutations lead to what?
X-linked Amelogenesis imperfecta

2 Gene versions of Amelogenin:
a) AMELX
b) AMELY
a) on X chromosome – functional
b) on Y chromosome – nonfunctional
-Y is used in the forensics for sex determination

Amelogenin structure
-hydrophobic
-rich in Pro and Glu
-has a beta strand conformation
-Central portion contains XYP repeats – adopts extended PPII conformation (like collagen type 1)
-13 amino acid C-terminal telopeptide is hydrophilic with no identifiable structure

-What cleaves Amelogenin?
MMP20
-this is essential for proper enamel formation

MMP20 [Enamellysin] Tooth-Specific Metaloproteinase
-Expressed in enamel during the secretory stage, also expressed in dentin
-Cleaves Enamel matrix proteins: Amelogenin, Ameloblastin, and Enamelis in a specific manner
-Also cleaves DSPP
-Specific proteolytic cleavages by MMPP20 are ESSENTIAL for proper enamel formation

Mutations in MMP20
also lead to Amelogenesis imperfecta

Ameloblastin
-Acidic enamel matrix protein
-5% of enamel matrix
-negatively charged, polar, hydrophobic
-cleaved immediately after secretion
-expressed by ameloblasts in all stages of enable formation

Ameloblastin KO
-failure of enamel epithelium to differentiate into ameloblasts and to attach to dentin

What is an important cell-matrix adhesion protein?
-Ameloblastin!

Enamelin
-Enamel glycoprotein
-least abundant enable protein (2-3% in secretory enamel)
-largest enamel protein
-acidic glycoprotein of secretory enamel
-cleaved immediately after its secretion
-mutations cause autosomal dominant AI

32 KDa Enamelin fragment
-Enamelin is normally cleaved immediately after secretion
-but 32 KDa fragment remains in deep enamel
-MMP20 can only cleave this after de-glycosylation

Mineral thickening
-starts at the secretory stage
-primarily due to the cleavage and removal of C-terminal fragment of amelogenin

-Enamel matruation
-Crystal size increases dramatically
-length stays the same, but width and thickness greatly increase
-the removal of organic matrix is accompanied by thickening of crystals
-basal lamina is deposited by ameloblasts over enamel at the beginning of maturation stage

KLK4
enzymatically degrades enamel proteins
-it is a nonspecific serene proteinase

Modulation cycle
-maturation ameloblasts modulate between smooth and ruffle morphologies
-respond to 2 phases of maturation cycle: protein removal and mineral deposition
-maturation begins with the first ruffle ended maturation ameloblast

ruffle ended ameloblasts
-tight apical junctions
-open basal junctions
-60%

smooth ended ameloblasts
-well developed basal junctions
-open apical junctions
-20%

Penn Foster Vet Tech Anatomy & Physiology

The nervous system is the body’s
control center

The central nervous system consists of
brain and spinal cord and their associated structures

the peripheral nervous system is comprised of
the nerves traveling from the brain or spinal cord to the target organs and back

the somatic nervous system carries out
conscious activities, such as walking, eating and so on

the autonomic nervous system perfroms functions that
don’t require conscious thought, such as breathing, blood pressure, and heart rate

the basic structural and functional unit of the nervous system is the
neuron, or nerve cell

2 important types of neurons are
sensory neurons and motor neurons

sensory neurons carry signals of
touch, taste, etc. to the brain

motor neurons carry instructions from
the brain to the muscles, causing them to move.

the primary purpose of a neuron is to
transmit an electrical signal that acts either to signal other neurons or to cause a change in a target organ, such as a muscle or gland

depolarization is
the change in membrane potential that occurs when a nerve is stimulated

repolarization is
the reestablishment of normal resting membrane potential

some of the more important neurotransmitters include the following:
acetylcholine, norepinephrine, gamma-aminobutyric acid (GABA), dopamine, enkephalins, serotonin

reflexes
involuntary motor movements initiated by specific sensory input

recptors
nerve endings that detect changes in the environment

gustatory sense
sense of taste

olfactory sense
sense of smell

auditory sense
sense of hearing

the third eyelid found in some species is referred to by which name
nictitating membrane

which receptors are involved with the proprioception sense
stretch receptors in the muscles, tendons and ligaments

ipsilateral reflex refers to
reflex where the stimulus and response are both on the same side of the body

what is the test for a proprioception deficit
flip over a foot while the animal is standing and see if the animal corrects the position

what is true of gray matter
it makes up the oter tissue layer in the brain

which causes the greatest degree of light refraction in the eye
cornea

rotation of the head is detected primarily by the
semicircular canals

the _____connects the two halves of the brain
corpus callosum

which stucture contains the muscles that adjust the shape of the lens of the eye
ciliary body

the reflective tapetum lucidum is formed on the
choroid

what is a visceral sense
thirst

norepinephrine, dopamine, and epinephrine belong to a group of neurotransmitters known as
catecholamines

calls that support neurons structurally and functionally are called
neuroglia

what supplies a rich network of blood vessels that supply nutrients and oxygen to the superficial tissues of the brain and spinal cord
meninges

a reflex arc commonly used to assess the depth of anesthesia is the ______reflex
pupillary light

nociceptors are not found in which organ
brain

the area of the brain through which sensory signals pass to the cerebrum is called the
thalamus

what is the correct pathway by which sound is transmitted between the ossicles of the middle ear
malleus, incus, stapes

central temperature receptors that monitor the body’s internal termperature are located within which structure of the brain
hypothalamus

the tactile sense is the sense of
touch

the function of mucus in the nasal cavities is to
dissolve odor molecules for detection by the receptor cells

Anatomy: Chapter 4 Tissues

The role of brown fat is to warm the body; whereas, the role of white fat is to store nutrients.
True

Healing of a surgical incision through the body wall will tend to increase the amount of areolar tissue.
False

The wall of the alveolus (air sac) in the lung is composed of which type of epithelium?
simple squamous epithelium

The proximal tubule of the nephron (kidney tubule) in the kidney is composed of which type of epithelium?
simple cuboidal epithelium

The epithelium of the esophagus is composed of which type of epithelial tissue?
stratified squamous epithelium

Which part of the neuron (a specialized nerve cell) receives signals from other cells and is also the main metabolic region of the neuron?
Soma

Which of the three muscle cell types has multiple nuclei?
Skeletal

Which muscle cell type has visible striations but is not under voluntary control?
Cardiac

Without macrophages, wound healing is delayed. Why?
Macrophages phagocytose many foreign materials, as well as cell debris and dead cells. This cleans the wound, allowing granulation tissue to form.

Which of the following statements is NOT characteristic of the areolar connective tissue pictured in the figure?
Areolar connective tissue is avascular.

Which of the following statements is INCORRECT?
The cutaneous membrane is made of a simple columnar epithelium

Which of the following statements is true of connective tissue?
Collagen fibers provides high tensile strength.

Which tissue type is responsible for regulating and controlling body functions?
nervous tissue

Which of the following epithelial tissue locations is NOT correctly matched to its function?
skin: absorption

Which tissue type arises from all three embryonic germ layers?
epithelial tissue

Select the correct statement regarding tissue repair.
Inflammation causes capillaries to dilate and become permeable.

Pseudostratified epithelium consists of multiple cell layers.
False

An exocrine gland that has an unbranched duct would be classified as a ________.
multicellular simple gland

Intercalated discs and striations are found in skeletal muscle.
False

Nervous tissue consists mainly of neurons and collagen fibers.
False

The correct order of events in tissue repair, from first to last, is ________.
inflammation, organization, and regeneration

Pseudostratified columnar epithelium ciliated variety ________.
lines most of the respiratory tract

Aging tends to increase bony spread within the body as chondrocytes die.
False

Macrophages are found in areolar and lymphatic tissues.
True

Select the correct statement regarding adipose tissue.
Its primary function is nutrient storage.

The first step in tissue repair involves ________.
inflammation

Smooth muscle cells possess central nuclei but lack striations.
True

Glands, such as the thyroid, that secrete their products directly into the blood rather than through ducts are classified as ________.
Endocrine

Which type of gland produces hormones?
endocrine glands

What are the three main components of connective tissue?
ground substance, fibers, and cells

Blood is considered a type of connective tissue.
True

________ is a water-soluble, complex glycoprotein that is secreted by goblet cells.
Mucin

What is the most obvious structural feature of areolar connective tissue?
the loose arrangement of its fibers

Which cells are commonly found wedged between simple columnar epithelial cells?
goblet cells

After open heart surgery, the heart’s pumping efficiency may be reduced because__________.
both adhesions and fibrosis will interfere with the heart’s normal pumping activity and reduce its effectiveness

Injured cartilage might heal more quickly if a treatment were discovered that would __________.
stimulate blood vessels to develop within cartilage

Which of the following is not found in the matrix of cartilage but is found in bone?
blood vessels

Which type of epithelium lines the interior of the urinary bladder?
transitional epithelium

How is hyaline cartilage different from elastic or fibrocartilage?
Fibers are not normally visible.

Groups of cells that are similar in structure and perform a common or related function form a(n) ________.
tissue

Simple cuboidal epithelia are usually found in areas where secretion and absorption occur.
True

Select the correct statement regarding the stem cells of connective tissue.
“Blast” cells are undifferentiated, actively dividing cells.

Chondroblasts ________.
within the cartilage divide and secrete new matrix

________ epithelium appears to have two or three layers of cells, but all the cells are in contact with the basement membrane.
Pseudostratified columnar

Which of the following is not a step in tissue repair?
Formation of new stem cells

Depending on the functional state of the bladder, transitional epithelium may resemble stratified squamous or stratified cuboidal epithelium.
True

________ is the tissue that regulates and controls body functions.
Nervous tissue

Select the correct statement regarding epithelia.
Stratified squamous epithelia are present where protection from abrasion is important.

A major characteristic of fibrocartilage is its unique amount of flexibility and elasticity.
False

Which tissue type consists of a sheet of cells that covers a body surface or lines a body cavity?
epithelial tissue

Which type of membrane is a dry membrane exposed to the air?
cutaneous membrane

Which of the following statements is INCORRECT?
Simple cuboidal epithelia are found in areas that stretch.

Aunt Jessie woke up one morning with excruciating pain in her chest. She had trouble breathing for several weeks. Following a visit to the doctor, she was told she had pleurisy. What is this condition and what did it affect?
Pleurisy is inflammation of the serous membranes covering the lungs. Inflamed pleural serous membranes create friction, resulting in pain as the lungs move during breathing.

Which of the following describes a holocrine gland?
Holocrine glands secrete their products by rupturing.

Endocrine glands are often called ducted glands.
False

Merocrine glands produce their secretions by accumulating their secretions internally until the cell ruptures.
False

Which of the following is NOT a role of connective tissue?
absorption

Heart muscle cells would tend to separate without ________
intercalated discs

Which statement best describes connective tissue?
usually contains a large amount of matrix

Edema occurs when
areolar tissue soaks up excess fluid in an inflamed area

Which tissues have little to no functional regenerative capacity?
cardiac muscle and nervous tissue in the brain and spinal cord

Which of the following would be of most importance to goblet cells and other glandular epithelium?
Golgi bodies

Mesenchymal cells are most commonly found in ________ connective tissue.
embryonic

Inability to absorb digested nutrients and secrete mucus might indicate a disorder in which tissue?
simple columnar

Which tissue repair process results in the formation of scar tissue?
fibrosis

Which of the following is a property of epithelial tissue?
Epithelial tissue is innervated.

Connective tissues ________.
primarily consist of extracellular matrix

Connective tissues that possess a large quantity of collagen fibers often provide the framework for organs such as the spleen and lymph nodes.
False

A many-layered epithelium with cuboidal basal cells and flat cells at its surface would be classified as ________.
stratified squamous

The basic difference between dense irregular and dense regular connective tissues is in the amount of elastic fibers and adipose cells present.
False

Choose the correct pairing for a tissue and its embryonic origin.
Epithelium is derived from all three primary germ layers: ectoderm, mesoderm, and endoderm.

Which of the following is true about the mode of secretion of exocrine glands?
Merocrine glands are not altered by the secretory process.

The shape of the external ear is maintained by ________.
elastic cartilage

In adult humans, most cancers are carcinomas or adenocarcinomas. These include cancers of the skin, lung, colon, breast, and prostate. Which of the four basic tissue types is involved, and why?
Epithelial tissue: it is exposed to the environment and is constantly dividing, both factors allowing more opportunity for damage and overcoming growth control mechanisms.

Connective tissue matrix is composed of ________.
fibers and ground substance

Why are adipose, blood, and bone all considered to be connective tissues?
They have a common origin, mesenchyme.

Which of the following glands might utilize the secretory mechanism and duct structure shown in A?
salivary

The reason that intervertebral discs exhibit a large amount of tensile strength, which allows them to absorb shock, is because they possess ________.
collagen fibers

Elastic cartilage tissue is found in the walls of the large arteries that leave the heart.
False

Cell type not found in areolar connective tissue.
chondrocytes

Which is the most atypical connective tissue since it does not connect things or provide structural support?
blood

Choose the answer that shows the correct order for the standard preparation of a histological specimen.
(1) fixation, (2) sectioning, (3) staining

Arteries, veins, and lymphatics keep clots from sticking as long as their ________ is intact and healthy.
endothelium

An infection may occur in a tissue injury. Why?
The increased availability of nutrients allows microorganisms to replicate. The skin and mucous membranes are body’s first line of defense and are mostly impenetrable to microorganisms, unless broken or damaged by tissue injury.

All connective tissues arise from an embryonic tissue called mesenchyme.
True

Which of the following is true about epithelia?
Endothelium provides a slick surface lining all hollow cardiovascular organs.

What tissue has lacunae, calcium salts, and blood vessels?
osseous tissue

Which of the following is a single-celled layer of epithelium that forms the lining of serous membranes?
simple squamous

Where is transitional epithelium found?
in areas subjected to stretching

Goblet cells are found within pseudostratified ciliated columnar epithelium.
True

Cartilage has good regenerative capacity, while most epithelial tissues do not.
False

All epithelia have two surfaces, an apical surface and a basal surface, that differ in both structure and function.
True

Salivary glands exhibit simple tubuloalveolar glandular arrangement.
False

Which of the following increases the surface area of certain epithelial tissues?
microvilli

Exocrine glands ________.
secrete substances onto body surfaces

Squamous cells are flattened and scalelike when mature.
True

The simple columnar epithelium that form absorptive cells of the digestive tract have which characteristic?
dense microvilli

Which tissue is correctly paired with its primary cell type?
bone: osteoblast

Epithelial tissues always exhibit apica-basal polarity; meaning that cell regions near the apical surface differ from those near the basal surface.
true

After a heart attack, fibrosis occurs at the site of cardiac muscle cell death. This reduces the efficiency of the heart’s pumping activity because __________.
fibrous connective tissue is incapable of contracting

The shock-absorbing pads between the vertebrae are formed of fibrocartilage.
true

Smooth muscle ________.
is under involuntary control

Tendons and ligaments are composed mainly of dense irregular connective tissue.
false

________ are highly phagocytic cells that are a part of the body’s defense system. These cells can be localized (fixed), or they can wander throughout the body.
macrophages

The blast cell for blood production is the ________.
hemocytoblast

Select the TRUE statement.
Dense connective tissue is often called fibrous connective tissue

The fiber type that gives connective tissue great tensile strength is ________.
collagen

Functions of connective tissues include binding, support, insulation, and protection.
true

Mucous cells are ________.
unicellular exocrine glands

Which is true concerning muscle tissue?
highly cellular and well vascularized

Cartilage tissue tends to heal less rapidly than bone tissue.
true

In connective tissue, the role of collagen fibers is to ________.
provide tensile strength

Anatomy of Local Anesthesia

Compare local infiltration with nerve block local anesthesia.
Local infiltration is only on terminal nerve endings and is used for soft tissue only; gingival surgery.

Nerve block anesthetize close to a nerve trunk

Compare the effectiveness of maxillary anesthesia with the effectiveness of mandibular anesthesia.
maxillary anesthesia is more effective because its the bone is thinner in the anterior portion and there is less anatomical variances in it.

How effective is local infiltration in the maxillary?
More effective then mandible

PSA block; Area anesthetized?
Pulpal anesthesia in the maxillary 1st, 2nd, and 3rd molars

Tissue Anesthetized:
Maxillary molars (exception of mesiobuccal root of the first molar in some cases):

Pulps & periodontal ligaments
Overlying buccal gingivae
Overlying alveolar bone

Maxillary sinus, posterior portion.

GP block may also be necessary.

PSA block; Target area and injection site?
Posterior superior alveolar (PSA) nerve as it exists the maxilla

Site of Injection:
In the height of the mucobuccal fold on a 45º angle
at the apex of the 2nd maxillary molar
distal to the zygomatic process of the maxilla

PSA block; Symptoms and possible complications?
Symptoms of anesthesia: none
Complications: hematoma
Vascular penetration: the pterygoid plexus of veins and/or maxillary a.
Harmless anesthesia of branches of the mandibular nerve

PSA block; How do you avoid complications?
Aspirate

MSA block; Area anesthetized?
Indicated for:
Dental procedures on the maxillary premolars and mesiobuccal root of the maxillary 1st molar.
GP block may also be necessary.

MSA block; Target area and injection site?
Target area:
MSA nerve at the apex of the maxillary 2nd premolar

The injection site for the MSA block is the tissue at the height of the mucobuccal fold at the apex of the maxillary second premolar.

MSA block; Symptoms and possible complications?
Symptoms:
Harmless tingling or numbness of the upper lip

ASA block; Area anesthetized?
Tissue anesthetized
Pulp and periodontal ligaments of the
Maxillary incisors
Maxillary canine
Maxillary premolars*

(*) if MSA is not present

Other tissue anesthetized
Adjacent vestibular gingivae and alveolar mucosa
Upper lip – skin and mucous membrane
Lateral external nose
Lower eyelid – skin/conjunctivae
Maxillary sinus – anterior half

ASA block; Target area and injection site?
Landmarks:
Located in a depression below the infraorbital rim*
Medial to the pupil of the eye* – if patient is looking straight

Target area:
At the apex of the maxillary canine Site of Injection:
The injection site is directed to the apex of the maxillary canine – at the height of the mucobuccal fold

The injection site for the ASA block is the tissue at the height of the mucobuccal fold at the apex of the maxially canine, just anterior to and parallel with the canine eminence.

ASA block; Symptoms and possible complications?
Symptoms:
Tingling and numbness of lower eyelid, side of the nose, & upper lip

Complications are rare.
Hematoma across the lower eyelid that resolves in a few weeks
Vascular penetration: hematoma that resolves in a few weeks
Intraorbital injection: Temporary blindness and/or double vision

IO block; Area anesthetized?
Indicated for:
Dental procedures on the maxillary incisors, canine and usually premolar teeth.
Nasopalatine block may also be necessary.

IO block; Target area and injection site?
Landmarks:
Located in a depression below the infraorbital rim*
Medial to the pupil of the eye* – if patient is looking straight

The target area for the IO block is the ASA and MSA nerves as they ascend to join the infraorbital nerve after the infraorbital nerve enters the infraorbital foramen.

The approximate depth of needle penetration for the IO block may vary, but typically is approximately 16 mm. In a patient with a higher or deeper mucobuccal fold or more inferior infraorbital foramen, less tissue penetration will be required than in a patient with a much lower or shallower mucobuccal fold or more superior infraorbital foramen.

The injection site for the IO block is the tissue at the height of the mucobuccal fold at the apex of the maxillary first premolar.

IO block; Symptoms and possible complications?
Watch your frenums;
insert needle more posterior with MSA block to avoid going through.
In some cases, adjustment can be made by retracting it more anterior.
Make sure to leave at least 5 to 10 mm on each side of frenum

GP block: Area anesthetized?
Tissue Anesthetized:
Posterior to the maxillary canines
Palatal mucosa
Lingual gingivae
Underlying bone of the palate
Posterior portion of the hard palate

GP block; Target area and injection site?
Target Area:
Greater palatine nerve as it enters the greater palatine foramen
Anterior to the greater palatine foramen
At the apex of the maxillary 2nd (children) or 3rd molar

Site of Injection:
Depression by the greater palatine foramen
Depression about midway between the median raphe & lingual gingival margin of the molar tooth

GP block; Discuss the use of pressure anesthesia on the hard tissues of the palate.
Pressure use creates dull ache that blocks pain from needle

GP block; Symptoms and possible complications?
Complications: None. Patient may gag if lesser palatine is anesthetized

NP block; Area anesthetized?
Tissue Anesthetized:
Palatal mucosa & lingual gingivae of the six anterior maxillary teeth
Corresponding lingual plate of alveolar bone
Mucoperiosteum of anterior 1/3 of the hard palate

NP block; Target area and injection site?
Site of Injection:
Lateral to the incisive papilla – never directly because is extremely painful.
Incisive foramen is located posterior to and between the central incisor teeth

NP block; Discuss the use of pressure anesthesia on the hard tissues of the palate.

NP block; Symptoms and possible complications?
Symptoms:
Numbness in the anterior portion of the palate

Complications:
Hematoma is rare
Avoid enter the incisive canal – it will enter into the nasal cavity.

AMSA block; Area anesthetized?
2nd premolar through central incisor.

AMSA block; Target area and injection site
Tissues of the hard palate. Injection: Midway between median palatal sutures and max premolars.

AMSA block; Discuss the use of pressure anesthesia on the hard tissues of the palate.
Pressure reduces pain

AMSA block; Symptoms and possible complications?
Blanching occurs after given injection can cause postoperative ischemia and sloughing. slow injection can stop that.

Compare the effectiveness of mandibular injections with the effectiveness of maxillary injections.
less effective because of more density in areas.

How effective is an infiltration in the mandible?
The mandible is denser than the maxilla over similar teeth, especially in the area of the mandibular posterior teeth, therefore nerve blocks are preferred to local infiltration in most parts of the mandible.

What portion of the mandible is more effective using
infiltration?

IA block; Area anesthetized?

IA block; Are bilateral injections advisable?

IA block; Target area and injection site?
Target Area for Traditional IA:
The inferior alveolar nerve on medial aspect of the ramus prior to its entry into the mandibular foramen
Within the pterygomandibular space (infratemporal fossa)
Lingual, mental and incisive nerves are also anesthetized.

injection site:
Identify the
coronoid notch (with associated temporalis tendon).
laterally and
the pterygomandibular raphe & anterior border of the medial pterygoid m medially.
Injection site varies. Most frequent recommendation is a little above the occlusal plane, 3/4th of the anteroposterior distance between the above landmarks.
Successful technique results in anesthesia of the mandibular teeth on the ipsilateral side to the midline, associated buccal and lingual soft tissue, ipsilateral -lateral aspect of the tongue and lower lip

IA block; Symptoms and possible complications?
Symptoms:
Numbness or tingling of lower lip
Numbness or tingling of the body of the tongue and floor of the mouth

Possible complications:
Lingual shock
Facial paralysis if the facial nerve is mistakenly anesthetized
Muscle soreness
Hematoma

IA block; How do you avoid complications?

IA block; Discuss troubleshooting the IA block depending on the contact of the needle with the bone.
If bone is contacted early, needle tip is located too far anterior on the ramus.
Correction: withdraw needle partially or completely and bring syringe barrel more
closely over the mandibular anterior teeth, moves needle tip more posteriorly. If bone is not contacted when inserting even with the usual depth of penetration by the needle, needle tip is located too far posterior on the ramus. Correction: withdraw needle partially
or completely and bring syringe barrel more closely over the mandibular molars, moves needle tip more anteriorly. If bone is not contacted, do not deposit the local anesthetic agent. The needle tip may be too posterior and located in the parotid salivary gland where CN VII innervates creating complications.

IA block; What is the accessory innervation that can prevent a successful IA block?
Accessory
innervation of the mylohyoid.

Buccal block; Area anesthetized?
Tissue Anesthetized:
Tissue associated with Mandibular molars:
Buccal periodontium
Associated gingiva
Periodontal ligament
Alveolar bone
Skin & mucosa of the cheek

Buccal block; Target area and injection site?
Target:
Buccal nerve, also known as long buccal nerve, as it passes over the anterior border of the ramus, and through the buccinator
The tissue just distal and buccal to the last molar tooth is the target area for injection

Buccal block; Symptoms and possible complications?
Symptoms & Complications:
Numbness of Mandibular molars:
Buccal periodontium
Associated gingiva
Periodontal ligament
Alveolar bone
Rare complications
Hematoma are rare

Mental block; Area anesthetized?
For dental procedures on the mandibular incisors, canine, and variably first and second premolars

Mental block; Target area and injection site?
Target
Mental nerve at the mental foramen

Injection area:
AT the height of the mucobuccal fold over the mental foramen
Immediately below the apex of the mandibular second premolar *, or just anterior or posterior to it

Mental block; Symptoms and possible complications?
Symptoms and Complications:
Numbness of facial gingiva and mucosa of these teeth and lower lip to the midline
Harmless.
Rare complication.
Hematoma is rare

Incisive block; Area anesthetized?
The pulp and facial tissue of the mandibular premolars and anterior teeth.

Incisive block; Target area and injection site?
Same as the mental block: it is anterior to where the mental nerve enters the mental foramen to merge wit the incisive nerve to form the IA nerve.

Incisive block; Symptoms and possible complications?
Same as the symptoms of the mental block with harmless tingling and numbness of the lower lip, except that there is pulpal anesthesia of the involved teeth, and there is an absence of discomfort during dental procedures. As with a mental block, a hematoma rarely occurs. Injection site: anterior to the depression created by the mental foramen at the depth of the mucobuccal fold with the needle in a horizontal manner, the syringe barrel resting on the lower lip.

Gow-Gates mandibular block; Area anesthetized?
Nerves anesthetized are the inferior alveolar, mental, incisive, lingual, mylohyoid, and auriculotemporal, as well as the (long) buccal nerves in most cases. Considered a mandibular block because it anesthetizes almost the entire V3.

Gow-Gates mandibular block; Reasons for use?
Used in quadrant dentistry in which buccal soft tissue anesthesia from most distal mandibular molar to midline and lingual soft tissues is necessary, and in some cases when a conventional IA block is unsuccessful. Success rate is higher than that of an IA block even taking into account a slightly more complicated procedure. Injection lasts longer that the IA block due to injection area being less vascular, but does require more anesthetic.

Gow-Gates mandibular block; Target area and injection site?
The anteromedial border of the neck of the mandibular condyle, just inferior to the insertion of the lateral pterygoid muscle. Injection site: located intraorally on the oral mucosa on the mesial of the mandibular ramus, just distal to the height of the mesiolingual cusp of the maxillary second molar following an imaginary line extraorally from the ipsilateral intertragic notch of the ear to the ipsilateral labial commissure.

Gow-Gates mandibular block; Symptoms and possible complications?
Numbness of mandibular teeth to midline, buccal mucoperiosteum and mucous membranes, lingual soft tissue and periosteum, anterior 2/3 of the tongue, the floor of the mouth, and the body of the mandible and inferior ramus, as well as the skin over the zygomatic bone and the posterior buccal and temporal regions. Two disadvantages: numbness of lower lip and temporal region, and longer time necessary for the anesthetic to take effect. The injection is contraindicated in cases with limited ability o open mouth, but trismus is rarely involved.

18 – Anatomy and Spinal Anesthesia

Where is LA injected in spinal anesthesia?
-CSF contained within the subarachnoid (intrathecal) space

Where is LA injected in epidural anesthesia?
-the space that lies within the vertebral canal but outside or superficial to the dural sac

Does caudal anesthesia represent a type of spinal or epidural anesthesia?
-special type of pidural anesthesia in which LA solution is injected into the caudal epidural space through a needle introduced through the saral hiatus.

Advantages of spinal anesthesia over epidural:
-takes less time to perform
-causes less discomfort during placement
-requires less local anesthetic
-produces more intense sensory and motor block
-correct placement of needle confirmed by backflow of CSF

Advantages of epidural anesthesia?
-decreased risk of post-dural puncture headache (assuming a negligible incidence of inadvertent dural puncture)
-a lower incidence of systemic hypotension
-the ability to produce a segmental sensory block
-greater control over the intensity of sensory anesthesia and motor block achieved by adjustment of LA concentration
-the routine placement of catheters for epidural anesthesia imparts additional benefit by allowing titration of the block tot he duration of surgery
-Catheter allows long-term administration of LA or opioid-containing solutions (or both

the vertebral (spinal) canal extends from what to what?
-foramen magnum to sacral hiatus
-contains spinal cord and nerve roots

What is important about he kyphosis and lordosis of the spinal canal
-influences distribution of LA solution in the SA space
-has little effect on the spread of LA solutions in the epidural space

what are the components of a vertebra?
-anterior vertebral body and posterior arch
-the posterior arch is created by fusion of lateral cylindrical pedicles with two flattened posterior laminae
-a transverse process extends out laterally at each junction of the pedicale and laminae
-a single spinous process projects posteriorly from the juntio of the two laminae.
-each pedicle is notched on its superior and inferior surfaces, and when two adjacent vertebrae are articulated, these notches form the intervertebral foramina through which the spinal nerves emerge

How man true vertebrae are there? where are they located
24
-7 cervical
-12 thoracic
-5 lumbar

How many false vertebrae are there? where are they located
5 – fused t form the bony sacrum

thus the sacrum and coccyx are dital extensions of the vertebral column, and the sacral canal is a continuouation of the vertebral canal through the sacrum.

what structures do you advance through when placing an epidural? Spinal?
Skin –> supraspinous ligament –> interspinous ligament –> ligamentum flavum (“pop”) –> Epidural fat

Epidrual fat –> Dura mater/arachnoid (“pop) –> Spinal

Good images on page 254 and 255

what is the sacral hiatus?
-fused lamina of the fourth and fifth sacral vertebrae

in what percentage of adults is the sacral hiatus absent
-8%, thereby preventing entry through the sacrococygeal ligament into the sacral canal and performance of caudal anesthesia

what ligament do you go through when performing caudal anesthesia
sacrococygeal

Sacral landmarks:
1. iliac crest
2. bony knob at the lower end of the neck
3. lower wing of the scapula
4. Posterior superior iliac spine
1. transverses the body of the L4 vertebra
2. C7
3. T7
4. S2

what is the most caudal limit of the dural sac in adults?
-about S2 (PSIS)

Describe the development of the spinal cord and its growth
-begins at the rostral border of the medulla and, in the fetus, extends the entire length of the vertebral canal (all the way to S2)
-b/c of disproportionate growth of neural tissue and the vertebral canal, the spinal cord generally terminates around the third lumbar vertebra at birth and at the lower border of the first lumbar vertebra in adults

what happens to the spinal nerves b/c of the disproportionate growth?
-spinal nerves become progressively longer and more closely aligned with the longitudinal axis of the vertebral canal

what is the conus?

where does it begin in newborns? adults?

-roots are ariented parallel to this axis and resemble a horse’s tail – from which the name cauda equine is derived
-nerve roots of the cauda equine move relatively freely within the CSF, a fortunate arrnagment that permits them to be displaced rather than pierced by and advancing needle

newborn – conus at L3 vertebra body
Adult – conus at L1 vertebra body

what are the meninges?
-in addition to the CSF, there are 3 meninges layers of connective tissue that protect the spinal cord

what are the 3 meninges layers? characteristics?
1. Dura – outermost
2. Arachnoid – closely adherent to the inner surface of the dura
3. Pia – innermost layer

Dura:
1. originates where?
2. terminates where?
3. Characteristics?
1. foramen magnum as an extension of the inner (meningeal) layer of cranial dura
2. terminates between S1 and S4.
3. tough fibroelastic membrane that provides structural support and a fairly impenetrable barrier that normally prevents displacement of an epidural catheter into the fluid-filled subarachnoid space

Arachnoid Membrane:
1. characteristics?
2. Function?
3. Relationship to each other
1. More delicate than the dura,
2. serves as the major pharmacologic barrier preventing movement of drug fromt he epidural to the subarachnoid space
**conceptually, the dura provides support and the arachnoid membrane imparts impermeability

3. b/c te dura and arachnoid are closely adherent, a spinal needle that penetrates the dura will generally pass through the arachnoid membrane

Pia:
1. characteristics?
2. what is the denticulate ligament?
1. highly vascular structure closely applied to the cord that forms the inner border of the sufarachnoid space

2. along the lateral surface between the dorsal and ventral roots, an extension of the pia membrane forms the denticulate ligament
-a dense serrated longitudinal projection that provides lateral suspension through its attachement tot he dura

Pia:
3. what happens to the pia as the spinal cord tapers to form the conus medullaris
3. the pia continues inferiorly as a thin filament, the filum terminale
-distally, the filum terminale becomes enveloped by the dura at the caudal termination of the dural sac (generally around S2) and continuous inferiorly to attach to the posterior wall of the coccyx

Spinal Nerves:
1. where do spinal nerves originate?
-along the dorsolateral and ventrolateral aspect of the spinal cord, rootlets emerge and coalesce to form the dorsal (afferent) and ventral (efferent) spinal nerve roots)

2. distal to the dorsal root ganglion, these nerve roots merge to form how man pairs of spinal nerves? Number by location?
31
-8 cervicle
-12 thoracic
-5 lumbar
-5 sacral
-1coccygeal

3. location of sensory fibers in spinal nerves? effect on pt position and type of LA used
-b/c the sensory fibers traverse the posterior aspect of the subarachnoid space, they tend to lie dependent in a supine pt, thus makingthem particularly vlnerable to hyperbaric (heavier than CSF) solutions containing ocal anesthetic

4. what happens as nerves pass through the intervertebral foramen?
-they become encased by the dura, arachnoid, and pia, which form the epineurium, perineurium, and endoneurium, respectively

5. what happens to the dura as the spinal nerves pass through the intervertebral foramen?
-becomes thinned in this area (often called the dural sleeve), thereby facilitating penetration of LA.

Spinal Nerves: Preganglionic Sympathetic Nerve Fibers:
1. originate where?
2. Leave spinal cord where?
3. How do they leave the spinal nerve?
4. How do they rejoin the spinal nerve?
1. intermediolateral gray columns of the thoracolumbar cord
2. leave with ventral nerve roots passin tinto the spinal nerve trunks
3. they then leave the nerve via the white rami communicates and project to the paravertebral sympathetic ganglia or more distant sites (adrenal medulloa, mesenteric and celiac plexus)
4. after a cholinergic synapse (nicotinic) in the autonomic ganglia, the postsynaptic sympathetic nerve fibers join the spinal nerves via the gray rami communicantes and innervate diverse adrenergic effector sites

Cervical Nerve:
1. the first cervical nerve passes where?
2. where do the 7th cervical nerve pass
3. 8th cervical nerve
1. between the occipital bone and the posterior arch of the first cervical vertebra (atlas), and this relationship continues
2. passes above the seventh cervical vertebrae
3. the eighth cervical nervepasses between the seventh cervical vertebra and the first thoracic vertebra.
**Below this point, each spinal nerve passes through the inferior notch of the corresponding vertebra

Subarachnoid Space:
1. Location?
2. Contents?
3. what produces CSF?
4. is the spinal and carnial arachnoid spaces continuous?
1. between the arachnoid and the pia
2. CSF
3. choroid plexus of the lateral, third, and fourth ventricles
4. yes, carnail nerve can be blocked by local anesthetic migrating into the CSF above the foramen magnum

Epidural Space:
1. location
2. composition
3. bound cranially by what? Caudally? Anteriorly? Posteriorly? Lateral?
1. between the dura and the wall of the vertebral canal
2. irregular column of fat, lymphatics, and blood vessels
3.
Cranially – foramen magnum
Caudally – sacrococcygeal ligament
Anteriorly – posterior longitudinal ligamne
Posteriorly – both the ligamentum flavum and the vertebral lamina
Laterally – vertebral pedicles

Epidural Space:
4. Is the epidural space a closed space?
5. where is the depth of the epidural space the largest (size of epidural space)? Smallest
4. NO – communicates with the paravertebral spaces by way of the intervertebral foramina.
5.
largest – about 6 mm – midline at L2. is about 4-5 mm in the midthoracic region
Smallest – where the lumbar and cervical enlargements of the spinal cord (T9-T12 and C3-T2, respectively) encroach n the epidural space with roughly 3 mm left between eh ligamentum flavum and the dura

**There is controversy regarding whether the epidural space has compartments or is continuous

Blood Vessels: Arterial
1. arterial supply of spinal cord
1. two posterior arteries, a single anterior artery

Blood Vessels: Arterial
2. where do the posterior spinal arteries arise from? are areas supplies by posterior arteries relatively protected from ischemic damage?
2. emerge from the crania vault and supple the dorsal (sensory) portion of the spinal cord
-b/c they are paired and have rich collateral anastomotic links from the subclavian and intercostal arteries, this area of the spinal cord is relatively protected from ischemic damage.

Blood Vessels: Arterial
3. anterior spinal arteries – origination? at risk for ischemic changes?
3. originates from the vertebral artery and supplies the ventral (motor) portin of the spinal cord
-receives branches from the intercostal and iliac arteries, but these branches are variabl in number and location
-More susceptible to ischemia

Blood Vessels: Arterial
4. what is the Artery of Adamkiewicz?
4. the largest anastomatic link with the anterior spinal artery,
aka. the radicularis magna
-arises from the aorta in the lower thoracic or upper lumbar region
-most commonly – is on the left and enters the vertebral canal through the L1 intervertebral foramen.

Blood Vessels: Arterial
5. what is the function of the artery of Adamkiewicz?
-critical to blood supply of the lower two thirds of the spinal cord
-damage to this artery during surgy on the aorta (anortic aneurysm resection) or by a strapy epidural needle will produce characteristic bilateral lower extremity motor loss (anterior spinal artery syndrome)

Blood Vessels: Venous
1. what drains the contents of the vertebral canal? where are these veins located?
1. vertebral venous plexus
-prominent in the lateral epidural space and ultimately empty into the azgos venous system

Blood Vessels: Venous
2. what is the azygos venous system?
2. enters the chest, arches over th right lung, and then empties into the superior vena cava

Blood Vessels: Venous
3. what is the effect of a tumor or increased intra-abdominal pressure that compress the vena cava and epidural placement
– blood is diverted from the inferior vena cava and engorges veins n the epidural space, which increases the likelihood of accidental vascular cannulation during attempted epidural anesthesia.
-in addition, b/c the vertebral veins are enlarged, the effective volume of the epidural space is reduced, thereby resulting in greater longitudinal spread of injected local anesthetic solutions

Preoperative preparation of neuraxial anesthesia:
1. serious, but rare, complication
2. more common, but less severe?
1. nerve damage, bleeding, infection
2. postdural puncture headache. possibility of failed block.

what are the absolute contraindications to neuraxial anesthesia?
1. pt refusal
2. infection at the site of planned needle puncture (bacteremia is not an contraindication)
3. elevated ICP
4. bleeding diathesis

Neuraxial anesthesia and infection
-bacteremia not a contraindication
-benefit of epidural outweighs the small risk of infection from bactermia
-make sure appropriate antibiotic therapy has been initiated before the block – may decrease the risk of infection

Is preexisting neuroogic disease a absolute or relative contraindications?
Relative
-make sure there is an benefit before performing in pt with multiple sclerosis. Local anesthetic toxicity can be confused for multiple sclerosis exascerbation

in what heart conditions should neuraxial anesthesia be cautiously used?
-mitral stenosis, idiopathic hypertrophic subaortic stenosis, and aortic stenosis intolerant of acute decrease in SVR
“Full, Fast, Forward”

where can you reference regarding neuraxial anesthesia and abnormal coagulations?
American Society of Regional Anethesia and Pain Medicine. www.asra.com

what must be in place before performing a spinal
– IV
– Standard monitors

what is important about the selection of interspace used for a spinal?
-the interspace selected for spinal anesthesia has considerable impact on the distribute of anesthetic within the subarachnoid space.
-for example, the likelihood of a “failed spinal” increases as interspaces that are more caudal are used, with up to a 7% incidence occurring when the L4-L5 interspace is selected.

How high is it generally accepted to go with a spinal?
-rostral interspaces are associated with higher success rates, this benefit must be balanced against the potential for traumatic injury to he spinal cord
-the spinal cord in adults usually lies between the L1 and L2 vertebrae.
-spinal anesthesia is not ordinarily performed above the L2-L3 interspace.

What percentage of adults have a spinal cord that extends beyond the L2 vertebrae?
-2% of adults have a spinal cord that extends beyond the L3 vertebrae.

what is the problem with using the iliac crest as a landmark?
-the conceptual line that is often used to identify L4 vertebra often results in selection of an interspace that is one or more levels higher than believed

1. what are the two types of spinal needles commonly used?
2. what gauges are often used?
1. open-ended (beveled or cutting)
closed tapered-tip pencil-point needle with a side port

2. 22-25 gauge

the incidence of PDPH directly correlates with what?
-size of the needle

in what age of pt is PDPH more likely to occur in?
-younger
-24 or 25-gauge pencil point needle is often selected.

what are the differences of the pencil-point versus the open needle
Pencil-Point (Whitacre or Sprotte)
Open-ended (Quinke)

Pencil-point needle requires more force to insert
-but provides better tactile feel of the various tissues encountered as the needle is advanced
-less incidence of PDPH.

what are the 3 approaches for a spinal anesthetic
1. midline
2. paramedian
3. taylor

Midline Approach:
1. technique?
2. layers passed through by the needle
3. how are dura fibers oriented
1. identify the upper border the the inferior spinous process. Pierce the skin and then advance in a slight cephalic direction
2. skin, SubQ, supraspinous ligament, interspinous ligament, ligamentum flavum, and the epidural space –> pierce the dura/arachnoid
3. largely oriented along the longitudinal aixs of the dural sac

what is important about the orientation of the dural fibers?
-orienting the bevel of a cutting needle parallel to this axis tends to spread rather than cut th fibers, which may reduce the risk for PDPH

Paramedian Approach
1. technique
2. most common error?
3. what is the first resistance encountered in this technique
1. insert needle typically 1 cm lateral to the midline, varies in the rostra-caudal plane according to the pt’s anatomy and anesthesia provider’s preference.
2. underestimate the distance to the subarachnoid space and direct the needle too medially, with resultant passage across the midline
3. needle bypasses the supraspinous and interspinous ligaments, and the ligamentum flavum will be the first resistance

Taylor Approach:
1. described by who? Why?
-urologist John A. Taylor – paramedian technique to access the L5-S1 interspace
– Though generally the widest interspace, it is often inaccessible from the midline b/c of the acute downward orientation of the L5 spinous process

Taylor Approach:
2. technique?
-spinal needle is passed from a point 1 cm caudad and 1 cm medial to the PSIS and advanced cephalad at a 55-degree angle with a medial orientation based on the width of the sacrm (See picture on 265)
-technically challenging but very useful b/c it is minimally dependent on pt flexion for successful passage of the needle into the subarachnoid space.

what should be done if blood-tinged CSF is seen?
-occasionally blood-tinged CSF initially appears at the hub of the needle. If clear CSF is subsequently seen, the spinal anesthetic can be completed.
-conversely, of blood-tinged CSF continues to flow, the needle should be removed and reinserted.

what should be done if paresthesia is experienced
-spinal anesthesia should NEVER be administered in the presence of paresthesia. The occurrence of a paresthesia during needle placement mandates withdrawal of the needle

in which needle, cutting or pencil point, can the needle to adjusted to direct the direction of LA injectin?
Pencil-Point: the side port can be positioned to encourage the desired distribution of local anesthetic solution within the suarachnoid space, which is generally cephalad.

-the position of cutting edge needle makes no difference.

the distribution of local anesthetic solution in CSF is influences principally by what 3 factors?
1. the baricity of the solution
2. contour of the spinal canal
3. position of the pt in the first few minutes after injection of LA solution into the subarachnoid space.

the duration of LA in a spinal depends on what 2 factors?
1. drug selected
2. presence or absence of a vasoconstrictor (epinephrine or phenylephrine)

During recovery, anesthesia regresses in what fashionn
-from the highest dermatome in a caudad direction

Baricity – what is the most commonly selected LA soultino for spinal anesthesia?
-hyperbaric – achieved by the addition of glucose (dextrose)

what is the pricinple advantage of hyperbaric solution
-greater cephalad spread of anesthesia

what are the commercially available hyperbaric solutions
1. 0.75% bupivacaine with 8.25% glucose
2. 5% lidocaine with 7.5% glucose
3. Tetracaine
–formulated as a 1% plaine solution, most often used as a 0.5% solution with 5% glucose.
-achieved by dilution of anesthetic with an equal volume of 10% glucose.

what anatomy factor is important in determining the subarachnoid distribution of hyperbaric local anesthetic solutions
-contour of the vertebral canal
-for example, in the supine horizontal position, the pt’s thoracic and sacral kyphosis will be dependent relative the the peak created by the lumbar lordosis.
-anesthetic delivered cephalad to this peak will thus move towards the thoracic kyphosis,w hich is normally around T6-T8
Placing the pt in a head-down (Trendelenburg) position will further accentuate this cephalad spread of LA solution and help ensure an adequate level of spinal anesthesia for abdominal surgery.

Do hypobaric solutions have much of a clinical use
No

What happens with isobaric solution when injected in the subarachnoid space?
-it undergoes limited spread

Isobaric solution – advantages?
-more profound motor block and more prolonged duration of action than achieved with equivalent hyperbaric local anesthetic solutions. B/c the distribution of local anesthetic is not affected by gravity, spinal anesthesia can be performed w/out concern that the resultant block might be influenced by pt position.

what clinical circumstances are well suited for isobaric solution?
-perennial or lower extremity procedures, as well as surgery involving the lower part of the trunk (hip arthroplasty, inguinal hernia repair)

does isobaric solution result in a segmental anesthesia?
-although spread of local anesthetic solution may be limited caudally, subarachnoid injections does nt produce segmental anesthesia b/c the nerves innervating more caudad structures are vulnerable to block as the pas through the region of high local anesthetic oncentrations

How does adding epinephrine to a spinal anesthesia increase the duration of action?
-reduction in spinal cord blood flow, which decreases loss of local anesthetic fromt e perfused areas and thus increases the duration of exposure to local anesthetic?

Epinephrine results in the largest increase of duration of action of what local anesthetic? why?
TETRACAINE – produces intense vasodilation

the effect of lidocaine is more modest

bupivacaine actually decreases both spinal cord and dural blood flow

what has the addition of epinephrine to lidocaine for spinal anesthesia been questioned?
-b/c of reports of nerve injury attributed to spinal lidocaine, and epinephrine may increase lidocaine neurotoxicity.

Epinephrine has been associated with significant “fluelike” side effects when coadministered with spinal _________
chloroprocaine

what opioid when added to spinal anesthesia doesn’t necessitate admission to hospital for monitoring of respiratory depression?
what is the common dose
Fentanyl – 25 mcg added to spinal anesthesia

how does opioid added to spinal local anesthetic produce analgesia?
-effect is mediated at the dorsal horn of the spinal cord, where opioids mimic the effect of endogenous enkephalins.

what are the characteristics of local anesthetics to consider when deciding which to use?
1. duration of action
2. potential side effects
3. differences in relative intensity of sensory and motor block

what anesthetic is best suited for short-duration spinal anesthesia?
Lidocaine

Lidocaine:
1. duration of action
2. More motor or sensory
3. positive characteristics?
1. 60-90 minutes
2. excellent sensory anesthesia and fairly profound motor block
3. above features, also positive recovery profile

Lidocaine:
4. what are the 2 major side effects of spinal lidocaine?
1. neurotoxicity
2. transient neurologic symptoms

Lidocaine:
5. Neurotoxicity?
-despite a long history of apparent safe use subsequent reports of major and minor complications associated with spinal lidocaine have tarnished its reputation and jeopardized its continued use
-at first thought to happen with only continuous spinal anesthesia and resulting high amounts of lidocaine. Has since been determined to occur after single shot

***Current suggestion –> reduction in lidocaine dose from 100 mg to 60-75 mg and dilution of the commercial formulation of 5% lidocaine with an equal volume of saline or CSF before subarachnoid injection

Lidocaine:
6. what is Transient neurologic symptoms? what increases your risk for this?
-pain or dysesthesia in the back, buttocks, and lower extremities
– lithotomy, knee arthroscopy and outpatient status

**the etiology of transient neurologic symptoms is not established, but their occurrence has reinforced dissatisfaction with lidocaine and general interest in alternative local anesthetics for short-duration spinal anesthesia

what are the alternatives to lidocaine for short duration spinal anesthesia?
1. Mepivacaine – probably has an incidence of transient neurologic symptoms less than lidocaine and may offer some benefit
2. Procaine – has very short duration of action, the incidence of nausea is relatively frequent, and yet the incidence of TNS is probably only marginally better
3. Chloroprocaine – next slides

Chloroprocaine – use in spinal anesthesia?
-low-dose (40-60 mg) preservative-free chloroprocaine – excellent short-duration spinal anesthesia with little, if any, risk for TNS

Chloroprocaine
1. can epinephrine be added?
2. Can opioids and clonidine be added?
1. no for spinal anesthesia – has sideffects
2. yes for fentanyl and clonidine – provide the expected enhancement of chloroprocaine spinal anesthesia

what local anesthetics are used for long duration spinal anesthesia?
Bupivacaine and tetracaine

**although ropivacaine has been used as a spinal anesthetic, the advantages over bupivacaine are not obvious

1. what are the concentrations of bupivacaine
2. what are the concentrations of tetracaine?
1. 0.75% solution with 8.25% glucose for hyprbaric anesthesia
2. Tetracaineis prepared as 1% plain solution, which can be diluted with glucose, saline, or water to produce hyperbaric, isobaric, or hypobaric solution, respectively.

the recommended dose for bupivacaine and tetracaine is similar – what is it? duration of actin?
5-20 mg, durations of action 90-120 minutes

what is the difference in motor vs sensory blockade of the two?
Bupivacaine – more sensory than motor
Tetracaine – slightly more pronounced motor block

can epinephrine be added to tetracaine to increase the duration of action of spinal anesthesia?
-no, results in a significant incidence of TNS

Documentation of anesthesia level:
1. time for spinal anesthesia to develop?
2. what fibers are affected first
3. how should anesthetic level be tested?
4. level of SNS anesthesia vs level of sensory block? vs level of motor block.
1. 30-60 seconds
2. nerve fibers that transmit cold sensation (C and A delta) are among the first to be blocked
3. early indication of level of a spinal anesthetic can be obtained by evaluating the pt’s ability to discriminate temperature changes a s produced by “wetting” the skin with an alcohol sponge. in the area blocked by the spinal anesthetic, the alcohol produces a warm or neutral sensation rather than the cold perceived in the unblocked areas.
4. level of SNS > level sensory > level of motor

what time frame is most critical for adjusting the level of anesthesia?
first 5-10 minutes

Sensory level anesthesia necessary for surgical procedures:
1. hemorrhoidectomy
2. foot surgery
3. lower extremity surgery
4. Hip surgery, TURP, Vaginal delivery
5. lower abdominal surgery, appendectomy
6. upper abdominal surgery, C-section
1. S2-S5
2. L2-L3 (knee)
3. L1-L3 (inguinal ligament)
4. T10 (umbilicus)
5. T6-T7 ( xiphoid process)
6. T4 (nipple)

Segmental levels and significance of sensory block:
1. Fifth digit
2. Inner aspect of the arm and forearm
3. apex of the axilla
4. Nipple
5. Tip of the xyphoid
6. Umbilicus
7. inguinal ligament
8. Outer aspect of the foot
1. C8: all cardiaccelerator fibers blocked
2. T1-T2: some degree of cardioaccelerator block
3. T3: easily determined landmark
4. T4-T5: Possibility of cardioaccelerator block
5. T7: Splanchnic fibers (T5-L1) may be blocked
6. T10: SNS block limited to legs
7. T12: no SNS block
8: S1: Confirms block of the most difficult root to anesthetize

what is the order of nerves anesthetized by LA in subarachnoid space?
First – unmyelinated (sympathetic) fibers
Second – larger myelinated (sensory and motor) fibers

dermatome comparison between sympathetic fibers and sensory fibers
SNS block typically exceeds the somatic sensory block by two dermatomes
this estimate may be conservative, with SNS block somties exceeding somatic sensory block by as many as sic dermatomes, which explains why systemic hypotension may accompany even low sensory levels of spinal anesthesia

what is the physiology behind pts experiencing dypnea after receiving a spinal anesthetic?
dyspneic despite adequate ventilation/c of inadequate sensation of breathing from loss of proprioception in the abdominal and thoracic muscles
alveolar oxygenation is the same

SNS block above what level inhibits GI SNS stimulation
above T5 –> unopposed PSN activity –> contracted intestines and relaxed sphincters
contracted ureters

is there a difference in perioperative mortality rate between regional anesthesia and general inrelatively healthy pts scheduled for elective surgery?
no

what neurologic complications can occur after spinal anesthesia?
1. Trauma – either directly provoked by a needle or catheter or indirectly by compression from hematoma or abscess
2. TNS – unclear etiology – don’t inject LA when paresthesia are present to avoid nerve injury

what % of pts receiving spinal anesthesia experience hypotension (systolic <90)? Why?
1/3 of pts

Modest hypotension (e.g., <20 mm Hg) is probably due to decreases in systemic vascular resistance More intense hypotension (>20 mm Hg) probably is the result of decreases in venous return and cardiac output.

the degree of hypotension often parallels the sensory level of spinal anesthesia nd the intravascular fluid volume status of the patient.

what are the treatment options for spinal induced hypotension
1. Restoration of venous return and increase cardiac output
–internal autotransfusion – tilt table down 5-10 degrees
–IV hydration

2. Sympathomimetics

does tilting the table down 5-10 degrees effect level of anesthesia
-facilitates venous return without greatly exaggerating cephalad spread of spinal anesthetic.

what are the first line sympathomimetics for spinal induced hypotension
1. ephedrine
2. phenylephrine
3. Epinephrine – when first two fail, to avid cardiac arrest from severe hypotension

**Phenylephrine – increases SVR but may decrease CO and does not correct the decreased venous return contributing to the spinal anesthesia
In the past, phenylephrine was contraindicated in parturients b/c of possible detrimental effects on uterine blood flow, which has not been confirmed.

what percent of pt’s experience bradycardia after a spinal?
-10-15%

what are the two possible causes of bradycardia after spinal?
1. block of cardioaccelerator fibers originating from T1 through T4
2. decreased venous return (Bezold-Jarisch reflex)

how is severe bradycardia and asystole treated?
Stepwise fashion: Aggressive stepwise escalation of treatment
1. ephedrine, 5 to 50 mg IV
2. atropine, 0.4-1.0 mg IV
3. epinephrine 0.05 to 0.25 mg IV

development of profound bradycardia or asystole –> 1.0 mg IV of epinephrine

what is the basic physiology behind a postdural puncture headache
-hole in dura results in loss of CSF at a rate exceeding production
-loss of CSF causes downward displacement of the brain and resultant stretch on sensitive supporting structures
-Pain results form distension of the blood vessels, which must compensate for the for the loss of CSF b/c of the fixed volume of the skull

how long after a spinal does a PDPH manifest
12-48 hrs after transgression of the dura, but can occur immediately even up to severe months after the event

what are the characteristic features of PDPH
-POSTURAL COMPONENT: it appears or intensifies with sitting or standing iand is partially or completely relieved by recumbency.
this feature is so distinctive that it is difficult to consider the diagnosis in its absence.

where is a PDPH felt
-occipital or frontal (or both) and usually described as dull or throbbing.

what associated symptoms might be experienced
N/V, anorexia, and malaise

why might pt’s experience ocular disturbances: manifested by diplopia, blurred vision, photophobia, or “spots” with a PDPH
stretch of CNs, most likely CN VI

Which pt’s are at high risk for PDPH? Low risk?
High Risk
-after puberty (age is important risk factor)
-Females, even it not pregnant
-hx of PDPH

Low Risk:
Children

How are PDPH treated?
Initial treatment – convervative:
-bed rest, IV fluids, analgesics, and possibly caffeine (500 mg IV

Definitive treatment:
-blood patch – 15-20 mL

at what level should a blood patch be given?
near or preferably below the site of initial puncture b/c there is preferential cephalad spread.

how long should pt lay flat after blood patch?
2 hrs

Blood patch – what is responsible for immediate relief and long term relif
immediate – volume effect of injected blood
Long-term – sealing or “patching” of dural tear.

High Spinal Anesthesia – your pt develops apnea and loss of consciousness after spinal anesthesia – what is the reason?
-often attributed to ischemic paralysis of the medullary ventilator centers b/c of profound hypotnsion and associated decreases in cerebral blood flow. Also LA effect above the foramen magnum.

what is the treatment for high or total spinal anesthesia
1. maintenance of the airway and ventilation
2. support circulation with sympathomimetics and IV fluid administration
3. Pts placed in head-down position to facilitate venous return
**an attempt to limit the cephalad spread of LA solution in CSF by placing pt’s in a head-up position is not recommended b/c this position with encourage venous pooling, was well as potentially jeopardizing cerebral blood flow, which may contribuate to medullary ischemia
4. Tracheal intbuation

why does nausea occur with spinal anesthesia
-systemic hypotension sufficient to produce cerebral ischemia
-Treat with sympathomimetic drugs

Spinal anesthesia and urinary retention
-Spinal interferes with innervation of the bladder
-large amounts of fluid –> bladder distension if no foley
-IVF needed to maintain preload, prevent hypotension and asystole
-inclusion of epinephrine in spinal will increase the time of urinary retention

Chapter 9 Anatomy of Local Anesthesia

Type of injection that anesthetize a a small area-one or two teeth and associated structures-when the local anesthetic agent is deposited near the terminal nerve endings
Local infiltration

Which is more successful injections, mandibular or maxillary?
Maxillary

Type of injection that anesthetizes a larger area than the local infiltration because the local anesthetic agent is deposited near large nerve trunks
Nerve block

Abnormal sensation from an area such as burning or pricking
Paresthesia

What nerve provides sensory information for the teeth and associated tissue
Fifth cranial or trigeminal nerve

Two types of local anesthetic injections that are commonly used are:
Local infiltration and nerve block

Used to achieve pulpal anesthesia in the maxillary third, second, first molars in patients
Posterior superior alveolar block (PSA)

When dental procedure involves two or more maxillary molars or their associated buccal tissue
PSA

Anesthetizes the buccal periodontist overlying the maxillary third, second, and first molar including the associated gingiva, periodontal ligament, and alveolar bone
PSA

Pulpal
Tooth

Mesiobuccal root of the maxillary first molar is not innervated by the PSA nerve, but by the:
MSA

Target area for the PSA block is the PSA nerve as it enters the:
Maxilla through the posterior superior alveolar foramina on the maxilla’s infra temporal surface.

Injection site for the PSA block is at the:
Height of the mucho buccal fold superior to the apex of the maxillary second molar, distal to the zygomatic process of the maxilla

Angulation of the needle for PSA
upward or superiorly at 45 degree angle to the occlusal plane, inward or medically at 45 degree angle occlusal plane, and backward or posteriorly at a 45 degree angle to the long axis of the maxillary molar

Indicated for dental procedures on the maxillary premolars and mesiobuccal root of the maxillary first molar
Middle superior alveolar block (MSA)

What does the MSA block anesthetize
The pulp of the maxillary first and second premolars and possibly the mesiobuccal root of the maxillary first molar and the associated buccal periodontal tissue including the gingiva, periodontal ligament, alveolar bone

Target area for the MSA block is the MSA nerve:
At the apex of the maxillary second premolar

Injection site for the MSA is:
At the height of the mucobuccal fold at the apex of the maxillary second premolar

Where is the needle inserted for the MSA?
Into the mucobuccal fold until the tip is located superior to the apex of the maxillary second premolar without contacting the maxilla

Commonly used in conjunction with an MSA block instead of using an infraorbital block alone:
Anterior superior alveolar block (ASA block)

What does the ASA block anesthetize:
The pulp of the maxillary canine and incisor teeth, as well as the associated facial periodontal tissue including the gingiva, periodontal ligament, and alveolar bone

Target area for the ASA block is the ASA nerve at the:
Apex of the maxillary canine

Injection site for ASA block:
Height of the mucobuccal fold at the apex of the maxillary canine, just anterior to and parallel with the canine eminence

Where is the needle tip placed for the ASA block?
Superior to the apex of the maxillary canine without contacting the maxilla; approx. at 10 degree angle off an imaginary line drawn parallel to the long axis of the maxillary canine tooth

A useful block that anesthetizes both the MSA and ASA nerves, covering the region for both the MSA and ASA block
Infra orbital block (IO block)

What injection anesthetizes the maxillary premolars, canine, and incisors:
IO block

What injection is indicated when the dental procedures involve more than two maxillary premolars or anterior teeth and the overlying facial periodontium including the gingiva, periodontal ligament, and alveolar bone?
infraorbital block / IO Block

Where is the target area for the IO block?
ASA and MSA nerves; branches of the IO nerve to the lower eyelid, side of the nose, and upper lip are also inadvertently anesthetized

Where is the injection site for the IO block?
height of the mucobuccal fold at the apex of the maxillary first premolar; the approx depth of the needle penetration for the IO block may vary in pts

Where is the needles inserted for the IO block?
into the mucobuccal fold while keeping the finger of the other hand on the infraorbital foramen during the injection to help keep the syringe toward the foramen; the needle is advanced while keeping it parallel with the long axis of the tooth to avoid premature contact with the maxilla

When is the greater palatine or GP block used?
during dental procedures that involve more than two maxillary posterior teeth or palatal soft tissue dital to the maxillary canine

Where in the oral cavity does the GP block anesthetize?
posterior part of the hard palate, anteriorly as far as the maxillary first premolar and medially to the midline as well as the lingual (palatal) gingival tissue in the area

What does the GP block NOT provide?
pulpal anesthesia of the area teeth

What is the target area for the GP block?
anterior to where the GP nerve enters the greater palatine foramen from its location bw the mucoperiosteum and horizontal plate of the palatine bone of the posterior hard palate

Where is the injection site for the GP block?
palatal tissue anterior to the depression created by the greater palatine foramen

Why isn’t infiltration anesthesia of the mandible not as successful as that of the maxilla?
the bone of the mandible is denser than the maxilla over similar teeth, esp in the area of the mandibular posterior teeth

what is preferred over local infiltration for the mandible?
nerve blocks

Useful anesthesia of the bilateral anterior part of the hard palate, from the mesial of the maxillary right first premolar to the mesial of the maxillary left first premolar
Nasopalatine block (NP)

Used when lingual (or palatal) soft tissue anesthesia is required for two or more maxillary anterior teeth
NP block

T/F-NP block does not provide pulpal anesthesia
True

What is the target area for the NP nerve?
Both the right and left NP nerves as they enter the incisive foramen of the maxilla from the mucosa of the anterior hard palate, beneath the incisive papilla

Where is the injection site for NP block?
Lingual (or palatal) tissue lateral to the incisive papilla, which is located at the midline, about 10 mm lingual to the maxillary central incisor teeth

Where is the needle inserted for NP block?
Previously blanched palatal tissue at a 45 degree angle to the palate. The needle is advanced into the tissue until the maxilla is contacted

Useful for soft tissue and pulpal anesthesia of large area covered by the ASA, MSA, GP, NP blocks in the maxillary arch
Anterior middle superior alveolar (AMSA)

ch 9: anatomy of local anesthesia

Compare local infiltration with nerve block local anesthesia.
type of injection used determined by type and length of procedure
–local infiltration or nerve block

local infiltration
anesthetizes a small area, including one or two teeth and associated tissue, by injection near their apices
–near terminal nerve endings
–varying degrees of success

nerve block
affects a larger area than local infiltration and thus, more teeth
–agent deposited near large nerve trunks
–higher degree of success than infiltration

Compare the effectiveness of maxillary anesthesia with mandibular anesthesia.
less variation in anatomy of maxillae and palatine bones and associated nerves with respect to local anesthetic landmarks compared to mandible
–maxillary injections more routine, and usually without need for troubleshooting

How effective is local infiltration in the maxillae as compared to the mandible?
most local anesthesia of maxilla more successful than that of mandible because the facial plates of bone of the maxillae are less dense

Posterior superior alveolar block
–Area anesthetized?
–pulpal anesthesia in maxillary third, second and first molars
–buccal periodontium and bone of maxillary molars
–indicated when procedure involves two or more maxillary molars or their buccal tissue

Posterior superior alveolar block
Target area and injection site?
Target: PSA nerve at it enters maxilla through posterior superior alveolar foramina
–up, in and back 45 degrees
–posterior and medial to maxillary tuperosity
–Injection: height of mucobuccal fold superior to apex of maxillary 2nd molar, distal to zygomatic process

PSA
Symptoms and possible complications?
usually none since no soft tissue, only hard
–lip or tongue does not feel numb, so patient may think anesthesia isn’t working
— complications if needle too far distal; may penetrate pterygoid plexus of veins and maxillary arty if overinserted; hematoma
–also anesthesia of branches of mandibular nerve

PSA
How do you avoid complications?
correct angulation; upward/superiorly at 45 degree angle to maxillary occlusal plane and 45 degree angle to midsaggital plane on skull
–syringe barrel exteneded from ipsilateral labial commisure to help with angulation

Middle superior alveolar block
area anesthetized
maxillary premolars and mesiobuccal root of maxillary first molar
–MSA nerve present in only 28% of population
–if need lingual/palatal anesthesia, also use greater palatine block

MSA
Target area and injection site?
Target: at apex of maxillary 2nd premolar
Injection site: height of mucobuccal fold at apex of maxillary 2nd premolar, without contacting maxilla to reduce trauma

MSA
Symptoms and possible complications?
harmless tingling and numbness of upper lip, absence of discomfort during dental procedures
–overinsertion/hematoma complications rare

Anterior superior alveolar block
Area anesthetized?
–pulp of maxillary canine and incisor teeth, facial tissue/gingiva, PDL and bone
–need nasopalatine block if lingual tissue anesthesia desired
–commonly used with MSA instead of using IO block alone
–crossover innervation to contralateral side possible

ASA
Target area and injection site?
Target: ASA nerve at apex of maxillary canine
Injection site: height of mucobuccal fold at apex of maxillary canine, just anterior to and parallel with canine eminence; without contacting maxilla

ASA
Symptoms and possible complications?
–harmless tingling and numbness of upper lip
–absence of discomfort during dental procedures
–overinsertion and hematoma complications rare

Infraorbital block
Area anesthetized?
–anesthetizes both MSA and ASA nerves; and IO
–maxillary premolars, canine and incisors; sometimes mesiobuccal root of 1st molar
–when dental procedures involve more than 2 maxillary premolars or anterior teeth and facial tissue
–need nasopalatine for lingual
–crossover innervation possible, so bilateral injection may be needed

IO block
Target area and injection site?
Target: ASA and MSA nerves as they move superiorly to join IO nerve; keep finger on IO foramen during injection to keep syringe toward foramen

Injection site: height of mucobuccal fold at apex of maxillary first premolar

IO
Symptoms and possible complications?
–branches of IO nerve to lower eyelid, side of nose and upper lip inadvertently anesthetized
–overinsertion and possible puncture of orbit
–hematomas rare

Greater palatine block
–area anesthetized?
–posterior part of hard palate, anteriorly as far as maxillary first premolar and mekially to midline as well as lingual/palatal gingiva tissue
–no pulpal of area teeth
–may also need ASA, PSA, MSA or IO block and sometimes nasopalatine

GP block
Target area and injection site?
target: anterior to where GP nerve enters greater palatine foramen; depression on palatal surface at junction of maxillary alveolar process and hard palate, at apex of maxillary 2nd or 3rd molar

injection site: in palatal tissue anterior to depression of GP foramen; midway between medial palatine raphe and lingual gingival margin of maxillary molar

GP block
Discuss the use of pressure anesthesia on the hard tissue of the palate.
because tissue is dense and adheres firmly to underlying bone, pressure produces a dull ache that blocks pain impulses from needle penetration and reduces patient discomfort

GP block
Symptoms and possible complications?
numbness in posterior hard palate and absence of discomfort during dental procedures
–possible gagging if soft palate inadvertently and harmlessly anesthetized

Nasopalatine block
–Area anesthetized?
anesthesia of bilateral anterior part of hard palate, from mesial of maxillary right 1st premolar to mesial of maxillary left 1st premolar
–used when lingual/palatal soft tissue anesthesia required for two or more maxillary teeth
–use pressure!
–may also need MSA, ASA or IO

NP block
Target area and injection site?
target: both right and left NP nerves as they enter incisive foramen of maxilla from the mucosa of anterior hard palate, beneath incisive papilla

injection site: lingual/palatal tissue lateral to incisive papilla, 10 mm lingual to maxillary central incisor;
–never directly into incisive papilla!
–needle 45 degree angle to palate

NP block
Discuss the use of pressure anesthesia on the hard tissue of the palate.
pressure/blanching on palatal tissue on contralateral side of incisicive papilla to reduce pain

NP block
Symptoms and possible complications?
numbness in anterior palate; absence of discomfort during dental procedures
–hematomas rare

Anterior middle superior alveolar block
–Area anesthetized?
soft tisse and pulpal anesthesia of large area covered by ASA, MSA, GP and NP blocks in maxillary arch
–multiple teeth/maxillary 2nd premolar through maxillary central incisor and associated tissue without causing anesthesia to upper lip and face
–with the PSA, will anesthetize a quadrant

AMSA block
What needs to be considered with this injection in regard to devices?
injection best accomplished with a computer-controlled deliver device (CCDD) because it regulates the pressure and volume ration of solution delivered, which is not readily attained with a manual syringe

AMSA block
Target area and injection site?
Target: tissue of hard palate, anterior to middle part of dental plexus, so to anesthetize teeth and facial/lingual tissue of surrounding palate

injection site: area biscecting the apices of maxillary premolars, and midway between median palatal raphe and lingual ginginval margin
–45 degree angle from contralateral premolars; maxilla contacted

AMSA block
Discuss the use of pressure anesthesia on the hard tissue of the palate.
blanching pressure during injection to relieve pain
–if excessive, may cause postoperative tissue ischemia and sloughing.
–slow or stop injection to keep this from happening

AMSA block
Symptoms and possible complications?
–variable numbness of large area that is normally innervated by ASA, MSA, GP and NP blocks
–excessive blanching

Compare effectiveness of mandibular injections with maxillary injections.
infiltration anesthesia of mandible not as successful as that of maxilla because overall the bone of mandible is denser than the maxilla over similar teeth; especially in area of posterior teeth
–nerve blocks preferred to local anesthesia

How effective is an infiltration in the mandible and what part of the mandible is more effective using infiltration?
local infiltrations on facial surface of anterior mandible are more successful than more posterior injections but less successful than injections over maxillae in similar locations
–because of differences in density of facial plates of bone

Inferior alveolar block
–area anesthetized
–most common injection
–mandibular teeth for pulpal anesthesia
–lingual periodontium for all mandibular teeth
–facial periodontium of mandib anterior and premolar teeth
–NOT a complete mandibular block
–need B to get buccal of molars

IA block
Are bilateral injections advisable?
no; because bilateral mandibular injections produce complete anesthesia of body of tongue and floor of mouth, which can cause difficulty swallowing and speech

IA block
Target area and injection site?
Target area: inferior alveolar nerve at mandibular foramen on medial surface of mandibular ramus, inferior to lingula and at same height as coronoid notch

Injection site: mandibular tissue on medial border of ramus; palpated at depth of pterygomandibular space on medial surface of ramus

IA block:
things to remember
–use hard tissue as landmarks to reduce errors!
–being too far inferior to injection site is most common reason for missed IA blocks
–ALWAYS important not to deposit anesthetic agent unless bone is contacted so don’t put in parotid salivary gland
–if insertion/deposition too shallow then only lingual nerve may be anesthetized

if failure of anesthesia of IA block
mainly on mandibular first molar, there may be accessory innervation of mandibular teeth
–need to get mylohyoid nerve
–may need to do Gow-Gates

if a bifid IA nerve detected gy noting a doubled mandibular canal on intraoral radiograph
may get incomplet anesthesia of mandible
–deposit agent more inferior to usual anatomic landmarks

IA block
Symptoms and possible complications?
harmless numbing and tingling of lower lip because mental nerve is anesthetized
–probably means that IA nerve is anesthetized, but not reliable indicator of depth of anesthesia, especially pulpal

IA block
Symptoms and possible complications?
harmless numbness and tingling of body of tongue and floor of mouth
–indicates that lingual nerve anesthetized; not necessarily anesthesia of IA nerve
–most reliable indicator of successful IA block is absence of discomfort

IA block
“lingual shock”
needle passes by lingual nerve during administration; patient makes involuntary movement
–symptom momentary and anesthesia will quickly occur

IA block
transient facial paralysis
–if facial nerve mistakenly anesthetized
–incorrect administration of anesthetic into deeper parotid salivary gland because mandibular bone not contacted
–temporary loss of use of muscles of facial expression; including inability to close eyelid and drooping of labial commisure

IA block
hematoma
–injection has highest positive aspiration rate
–muscle soreness or limited movement of mandible rarely seen
–self-inflicted trauma such as lower lip biting

IA block
paresthesia
–from trauma to lingual nerve
–abnormal sensation from an area such as burning or prickling
–may be due to lack of adequate fascia around lingual nerve or possibly neruotoxicity from local anesthetic agent

Discuss troubleshooting the IA block depending on the contact of the needle with the bone.

What is the accessory innervation that can prevent a successful IA block?
mylohyoid nerve?

Buccal block
Area anesthetized?
–also “long buccal block”
–anesthesia of buccal periodontium of mandibular molars including gingiva, PDL and bone
–not necessary when buccal tissue not impacted by dental procedures performed

buccal block
Target area and injection site?
Target: buccal nerve/long buccal nerve on anterior border of mandibular ramus; through the buccinator muscle before it enters buccal region

injection site: buccal tissue distal and buccal to the most distal mandibular molar in mandibular arch
–advance needle until it contacts mandible and then inject

buccal block
Symptoms and possible complications?
rare because of location and small size of anesthetized area
–only absence of discomfort
–sometimes self-inflicted trauma like cheek bites
–hematomas rare

mental block
Area anesthetized?
facial periodontium of mandibular premolars and anterior teeth on one side, including gingiva, PDL and bone; NO PULPAL!
–need incisive block or IA block if pulpal anestesia necessary
–no lingual tissue anesthesia of involved teeth

mental block
Target area and injection site?
target area:
anterior to mental foramen where mental nerve enters on surface of mandible, usually between apices of mandibular 1st and 2nd premolars

injection site:
anterior to depression created by mental foramen at depth of mucobuccal fold with needle horizontal and resting on lower lip, without contacting mandible; between apices of premolars

mental block
Symptoms and possible complications?
harmless tingling and numbness of lower lip; absence of discomfort
–hematomas rare

incisive block
–area anesthetized
pulp and facial tissue of mandibular teeth anterior to mental foramen, usually mandibular premolars and anterior teeth (canine and incisors)
–also lower lib and skin of chin to midline
–IA if need lingual anesthesia
–useful when crossover innervation from contralateral incisive nerve and still discomfort on mandib anterior teeth after giving an IA block

incisive block
target area and injection site
target: mental foramen (usually between apices of mandib premolars)
–same as mental block; anterior to where mental nerve enters mental foramen to merge with incisive nerve to form IA nerve

insertion site: anterior to depression created by mental foramen at depth of mucobuccal fold with needle horizontal and resting on lower lip, without contacting mandible; between apices of premolars

incisive block
Symptoms and possible complications?
same as symptoms of mental block
–harmless tingling, numbness of lower lip
–do have pulpal anesthesia of involved teeth
–hematomas rare

Gow-gates mandibular block
area anesthetized
G-G block
–inferior alveolar, metnal, incisive, lingual, mylohyoid and auriculotemporal as well as long buccal nerves
–a mandibular block because it anesthetizes entire V3

G-G block
Reasons for use?
quadrant dentistry when need buccal soft tissue anesthetized from most distal mandib molar to midline and lingual soft tissue is necessary
— sometimes when IA block is unsuccessful
–higher success rate than IA block
–success possibly due to additional anesthesia to mylohyoid nerve

G-G block
Target area and injection site?
target: anteromedial border of neck of mandibular condyle, just inferior to insertion of lateral pterygoid muscle

injection site: intraorally on oral mucosa on mesal of mandibular ramus; just distal to height of mesiolingual cusp of maxillary 2nd molar with direction determined by following a line extraorally from intertragic notch to ipsilateral labial commisure

G-G block
Symptoms and possible complications?
inadvertantly, anterior 2/3 of tongue, floor of mouth and body of mandible and inferior ramus, as well as skin over zygomatic bone and posterior buccal and temporal regions

G-G block
2 main disadvantages
1. numbness of lower lip and temporal region
2. longer time necessary for anesthetic to take effect because of larger size of nerve trunk being anesthetized and distance of trunk from site of deposition

G-G block
advantage
injection lasts longer than IA block because area of injection is less vascular and a larger volume of anesthetic may be necessary

G-G block
contraindicaitons
in cases with limited ability to open mouth

The skull bones involved in local anesthetic administration by dental professionals prior to dental care are the maxilla, the mandible, and the
palatine bone

To increase the reliability of local anesthesia procedures, the dental professional MUST learn to rely MAINLY on both visualization and palpation of
hard tissue

Which structures should the dental profession AVOID inadvertently injecting?
major blood vessels and glandular tissue

Which nerve branches are anesthetized before MOST dental procedures?
trigeminal nerve

Which of the following are NOT considerations that need to be followed when working with a patient with an oral infection?
will need less amounts of local anesthetic agent;

The effectiveness of local anesthetic agents is greatly reduced when administered adjacent to areas of infection, so additional amounts of local anesthetic agent may be needed keeping the maximal recommended dosage always in mind for each patient.

What SHOULD always be attempted in all injections before administration in order to avoid injection into blood vessels?
aspiration

What complication can occur if the needle is advanced too far distally into the tissue during a posterior superior alveolar block?
extraoral hematoma

What structure can be initially involved in a spread of infection if the needle is contaminated during a posterior superior alveolar block?
cavernous sinus

Which of the following structures are NOT usually anesthetized during a posterior superior alveolar block?
lip and tongue

Which of the following nerves may involve crossover-innervation after administration of the local anesthetic agent in many patients?
anterior superior alveolar nerve
–so bilateral injections of the ASA block or local infiltration over the contralateral maxillary central incisor may be indicated.

What structure can be punctured if the dental professional does NOT keep the needle in contact with the bone at the roof of the infraorbital foramen to prevent overinsertion when administering an injection in that area?
orbit

Which of the following is NEVER anesthetized during an administration of the greater palatine block?
pulpal anesthesia

Which of the following injections need to have pressure anesthesia used in order to administer a MORE pain-free block?
greater palatine block

Which of the following injections is the MOST commonly used during dental procedures even if it is NOT always successful?
Inferior alveolar block

Which of the following structures need to be contacted for a successful and safe inferior alveolar block?
mandibular bone

1. An extraoral hematoma can result from an incorrectly administered posterior superior alveolar local anesthetic block because the needle was overinserted and penetrated which of the following?
pterygoid plexus of veins

PSA: up, in, back at 45 degrees each way

2. Which of the following local anesthetic blocks has the same injection site as the incisive local anesthetic block?
mental block

–at depth of mucobuccal fold anterior to the depression created by mental foramen, WITHOUT contacting mandible!

3. Which of the following nerves is NOT anesthetized during an IA local anesthetic block?
buccal

–buccal only gets buccal gingiva of molars

4. Which of the folloing local anesthetic blocks uses pressure anethesia of the tissue to reduce patient discomfort?
greater palatine block

5. Which of the following are usually anesthetized during an infraorbital local anesthetic block?
upper lip, side of nose, lower eyelid

6. If the mesiobuccal root of the maxillary first molar is NOT anesthetized by a posterior superior alveolar local anesthetic block, the dental professional should administer a
MSA/middle superior alveolar block

7. Which of the following is an important landmark to locate before performing an inferior alveolar local anesthetic block?
coronoid notch

8. The injection site for the greater palatine local anesthetic block is usually located on the palate near which of the following?
maxillary second or third molar

9. If an extraction of a permanent maxillary lateral incisor is scheduled, which of the following local anesthetic blocks can be administered instead of the infraorbital block?
nasopalatine block

(with ASA)

10. Transient facial paralyses can occur with which incorrectly administered local anesthetic block?
inferior alveolar block
IA
–have to contact bone first!
–it goes into parotid salivary gland instead

11. Which local anesthetic block anesthetizes the largest intraoral area?
inferior alveolar block

12. Which of these situations can occur if bone is contacted early during an inferior alveolar local anesthetic block?
needle tip is too far anteriorly on ramus

13. In which of the following locations is the outcome MOST successful when using local infiltrations of local anesthetic?
anterior maxillary?

14. If working withing the mandibular anterior sextant, which local anesthetic block is most successful and comfortable for the patient?
bilateral incisive

15. Which of the following local anesthetic blocks anesthetizes the buccal tissue of the mandibular molars?
buccal block

16. The mental foramen is usually located between the apices of which of the following mandibular teeth?
first and second premolars

17. To have complete anesthesia of the maxillary quadrant, which of the following local anesthetic blocks needs to be administered along with the anterior middle superior alveolar block?
posterior superior alveolar block

18. Which of the following can serve as a landmark for the anterior middle superior alveolar local anesthetic block?
premolar teeth

19. Which of the following is considered a mandibular local anesthetic block because it anesthetizes MOST of the mandibular nerve?
Gow-gates block

20. Which of the following landmarks are noted when administering a Gow-Gates mandibular local anesthetic block?
maxillary second molar

Anatomy of dental anesthesia injection sites

types of dental injections
supraperiosteal (infiltration) injections

block injections

anterior superior alveolar nerve injection site
just boave root tip of canine

anterior superior alveolar nerve area anesthetized
incisors and canine

Middle superior alveolar nerve injection site
above root tips of the first premolar

middle superior alveolar nerve area anesthetized?
premolars and anterior root of 1stmolar

posterior superior alveolar nerve injection site
above root tips of 3rd molar

posterior superior alveolar nerve area anesthetized
2nd and 3rd molars and posterior roots of 1st molar

maxillary arch block injections
infraorbital

maxillary

greater palatine

nasopalatine

posterior superior alveolar

infraorbital nerve block injection site
infraorbital foramen

infraorbital nerve block area anesthetized
incisors, canine, premolars and anterior root of 1st molar

labial-buccal gingiva from midline to 1st molar

infraorbital nerve gives off
anterior and middle alveolar nerve so you can block them where they are coming off

relationship of levator labii superioris and levator anguli oris to infraorbital foramen
levator labii superioris superifical to foramen and levator anguli oris a is a deep muscle below the infraorbital formane.

infraorbital nerve and vessels sandwiched between these 2 muscles and injection must pierce these muscles

posterior superior alveolar nerve block injection site
posterior superior alveolar foramen

posterior superior alveolar nerve block area anesthetized
2nd and 3rd molars and posterior roots of 1st molar

labial-buccal gingiva of 2nd and 3rd molars and posterior 1st molar

nasopalatine nerve block injection site
incisive foramen

nasopalatine nerve block area anesthetized
primary hard palate

lingual gingival of incisors and canine

greater palatine is a branch of
V2

greater palatine nerve block injection site
greater palatine foramen

greater palatine nerve block area anesthetized
secondary hard palate

lingula gingiva from 3rd molar forward to canine

Maxillary nerve block injection site
pterygopalatine fossa via the greater palatine foramen and canal

Maxillary nerve block area anesthetized
half of upper arch teeth, half of the labial-buccal and lingual gingiva and half of the hard and soft palate

mandibular arch infiltration injections
with the exception of young children and the mandibular incisors of adults, mandibular infiltration injections are not effective because the mandibular teeth are surrounded by thicker bone that inhibits diffusion of anesthetic solution

standard inferior alveolar nerve block injection site

standard inferior alveolar nerve block injection site area anesthetized
half of the mandibular arch teeth( all of mandi teeth in the quadrant)

buccal gingiva from midline back to 1st molar

anatomical landmarks for standard inferior alveolar nerve block
coronoid process

retromolar fossa

temporal crest

lingula

mandibular foramen

sphenomandibular ligament (needle pierce above this ligament)

pterygomandibular raphe

pterygomandibular triangle(injectionsite is down in the apex of the triangle through the buccinator muscle)

pterygomandibular raphe
a tendinous thickening of the buccopharyngeal fascia, separating and giving origin to the buccinator muscle anteriorly and the superior constrictor of the pharynx posteriorly.

pterygomandibular triagle
lateral- ramus of mandible (temporal crest)

medial- pterygomandibular raphe

base of triangle- maxilla

path of need for inferior alveolar nerve block
penetrates the buccinator just lateral to the pterygomandibular raphe and then passes along the medial surface of the ramus of the mandible (just lateral to the medial pterygoid) to reach the inferior alveolar nerve

possible complications in inferior alveolar nerve block
anesthetic in parotid- temporary facial nerve paraylysis

anesthetic in msucle- trismus

possible damage to shepnomandibular ligament(you are supposed to inject above this ligament)

Lingual nerve block injection site
tissue adjacent to lingual side of roots of the 3rd molar

lingual nerve area anesthetized
lingual gingival of mandibular arch

to anesthetize both lingual and inferior alveolar nerve inject at
mandibular foramen and 5-10mm anterior to the madinbular foramen

which will anesthetize

half of mandibular arch teeth, lingual gingiva of amdnibular arch and buccal gingiva from midline back to 1st molar

mental nerve block injection site
mental foramen

mental nerve block area anesthetize
incisors, canine and premolars

buccal gingnival from midline back to 1st molar

long buccal nerve is a branch of
V3

long buccal nerve injection site
tissue adjcacent to buccal side of roots of 3rd molar

long buccal nerve area anesthetized
buccal gingiva of molars

path of need for inferior alveolar nerve block

standard inferior alveolar nerve block injection site
mandibular foramen

Anatomy: Nervous System & Local Anesthesia Ch 8&9

v1 ophthalmic, lacrimal, trigeminal, greater petrosal, facial
the nerves that allow us to cry are _______________ and __________________ nerve from the _________________ nerve and the ______________ ________________ nerve from the ____________ nerve.

auriculotemporal nerve of trigeminal and lesser petrosal nerve of glossopharyngeal
what cranial nerves innervate the parotid gland?

chorda tympani nerve of facial and lingual nerve of trigeminal
which cranial nerves innervate the submandibular and sublingual salivary glands?

greater petrosal, facial
the ___________ _____________ nerve of the _____________ nerve innervates the minor salivary glands
-associated to the hard and soft palate
-von Ebner’s buccal/labial lingual mucosa

trigeminal, facial, glossopharyngeal, vagus, hypoglossal
which cranial nerves innervate the tongue?

hypoglossal nerve (XII)
which cranial nerve provides movement to the tongue?

lingual nerve of trigeminal (V), chorda tympani nerve of facial (VII), glossopharyngeal nerve (IX) (base)
what cranial nerves provide general sensation to the tongue?

chorda tympani nerve of facial, glossopharyngeal nerve, vagus
what cranial nerves provide taste sensation to the tongue?

greater petrosal nerve, chorda tympani nerve
what are the mixed facial nerve divisions?

posterior auricular nerve, stylohyoid nerve, posterior digastric nerve
what are the efferent facial nerve divisions?

temporal, zygomatic, buccal, mandibular, cervical
what are the facial nerve simple branches to the muscles of facial expression (not separate nerves) originate in the parotid gland

facial paralysis, transient, permanent
____________ _____________ can be unilateral/bilateral or ________________/_____________

stroke, trauma, brain injury
what three things can possibly cause facial paralysis?

transient facial paralysis
caused by an incorrectly administered IANB

drooping, dribbling, increased, infection
transient facial paralysis will present with ___________ eyebrow/eyelid/labial commissure, _______________ (may not be able to eat/talk well), _______________ susceptibility to _____________.

expression, close, whistle
when a patient has transient facial paralysis, they cannot show _________________, ___________ their eyes, or ________________.

Bell’s Palsy
unknown cause – thought to be from a virus

paralysis
occurs in one or more of the branches of the facial nerve

anti-virals (botox), inflammatory drugs, physical therapy
what are 3 treatments for Bell’s Palsy?

Tic douloureux, right
another name for the trigeminal neuralgia
It occurs on the ____________ side of the face and is usually more affected than the left.

v2 maxillary and v3 mandibular of trigeminal
trigeminal neuralgia involves what nerve and branches?

tics, spasms, eyes, ala
in trigeminal neuralgia, excruciating painful _____ or short-term muscle ______________ occur often near the _________ or _______.

anti-depressant drugs, anti-convulsant drugs, surgery, neurectomy, chemical (alcohol) injection
what are 5 treatments for trigeminal neuralgia?

anterior superior alveolar (ASA)
what nerve block has crossover anesthesia?

greater palatine block (GP) and nasopalatine block (NP)
what nerve blocks use pressure anesthesia?

inferior alveolar block (IA)
what nerve block inserts at the lingula on the mandible?

parotid
The Inferior alveolar block (IA) can anesthetize the ______________ gland by mistake

posterior superior alveolar block
anesthetizes the maxillary molars
-except mesiobuccal cusp of 1st molar & associated tissue

greater palatine block
anesthetizes the posterior palatal gingiva and periodontium of premolars and molars

anterior superior alveolar block
anesthetizes the central and lateral incisors, canines and associated tissue

middle superior alveolar block
anesthetizes the maxillary premolars, mesiobuccal root of first molar and associated tissue

infraorbital block
anesthetizes the maxillary anterior teeth and premolars, as well as the mesiobuccal root of maxillary first molar in approximately 28% of cases

nasopalatine block
anesthetizes the anterior hard palate and palatal periodontium and gingiva of maxillary anterior teeth bilaterally

anterior middle superior alveolar block
anesthetizes the maxillary anterior teeth and premolars
-ASA, MSA-not mesiobuccal root of 1st molar), NP, GP
-facial periodontium & gingiva of anesthetized teeth to midline; hard palate & palatal periodontium & gingiva of ipsilateral maxillary posterior teeth & maxillary anterior teeth bilaterally
-no regional soft tissue anesthesia of upper lip & face

inferior alveolar block
anesthetizes the mandibular teeth to the midline
-mandibular quadrant except for buccal molar gingiva
-inferior alveolar, mental, incisive, lingual nerve

buccal block
anesthetizes buccal periodontium & gingiva of mandibular molars

mental block
anesthetizes the chin, lower lip, tissues of mandibular premolars & anterior teeth

incisive block
anesthetizes the mandibular anterior teeth & premolars to the midline
-facial periodontium & gingiva
-lower lip and skin of chin to midline
-mental & incisive nerve

Gow-Gates mandibular block
anesthetizes the inferior alveolar nerve, lingual, (long) buccal, mental, incisive, mylohyoid, auriculotemporal nerves
-mandibular teeth to midline

vazirani-akinosi mandibular block
anesthetizes the inferior alveolar nerve, lingual, mental, incisive, mylohyoid nerves
-mandibular teeth to midline

buccal nerve
which nerve is not anesthetized during an inferior alveolar local anesthetic block?

upper lip, side of nose, lower eyelid
what regions are usually anesthetized during an infraorbital local anesthetic block?

middle superior alveolar block
if the mesiobuccal root of the maxillary 1st molar is not anesthetized by a PSA block, the dental professional should additionally administer what block?

coronoid notch
which of the following is an important landmark to locate before administering an inferior alveolar block?

maxillary second or third molar
the injection site for the greater palatine local anesthetic block is usually located on the palate near what?

nasopalatine block
if an extraction of a permanent maxillary lateral incisor is scheduled, which of the following local anesthetic blocks needs to be administered?

inferior alveolar block
transient facial paralysis can occur with which incorrectly administered local anesthetic block?

inferior alveolar block
which local anesthetic block anesthetizes the largest intraoral area?

needle tip is too far anteriorly on mandibular ramus
what situation can occur if bone is contacted immediately after the needle is inserted into the soft tissue when administering an inferior alveolar block?

facial surface of maxillary anterior sextant
what location is the outcome most clinically effective when using a supraperiosteal injection of local anesthetic?

bilateral incisive block
if working within the mandibular anterior sextant on the exposed roots of the teeth, which local anesthetic block is most clinically effective and comfortable for the patient?

buccal block
which of the following blocks anesthetizes the associated buccal periodontium & gingiva of mandibular molars?

first and second premolars
the mental foramen is usually located on the lateral surface of the mandible inferior to the apices of what mandibular teeth?

posterior superior alveolar block
to have complete anesthesia of the maxillary quadrant, what anesthetic block needs to be administered along with an AMSA block?

premolars
what serves as a landmark for the AMSA block?

gow-gates block
what is considered a true mandibular local anesthetic block because it anesthetizes the entire mandibular nerve?

maxillary second molar
what landmark should be noted when administering a gow-gates block?

inferior alveolar block
what block is usually associated with self-inflicted trauma?

mental block
what block has a high risk of positive aspiration?

vazirani-akinosi block
what block usually anesthetizes the mylohyoid nerve?

closed-mouth block
the vazirani-akinosi block is what type of block?

neck of mandibular condyle
the target area for gow-gates block is?

inferior alveolar block
the lingual nerve is anesthetized by what nerve block?

Anatomy & Physiology – Body Temp Fluctuations Essay Sample

Anatomy & Physiology – Body Temp Fluctuations Essay Sample

A young hiker has been on a long walk. He is now sitting in front of a small campfire, drinking a hot cup of soup. It is dark and a frost is beginning to form on his tent. Explain the hiker’s heat gains and losses, and what mechanisms would come into effect to keep his temperature at the desired 37ºC.

Humans are subject to vast changes in environmental temperatures, but our complex biochemical systems have a major limitation in that enzymes only operate within a relatively narrow temperature range. Accordingly the human body have anatomical and physiological mechanisms that keep body temperatures within acceptable limits, regardless of environmental conditions. This homeostatic process is called thermoregulation and it involves constantly balancing heat-producing and heat-losing mechanisms. If the body temperature is not maintained within these acceptable limits serious physiological changes can occur. If the body temperature falls below 36ºC or goes above 40ºC this can cause disorientation, and a temperature above 42ºC can cause convulsions and permanent cell damage.

We continuously produce heat as a by-product of metabolism. When energy use increases due to physical activity, or when our cells are more active metabolically, additional heat is generated. The heat produced by biochemical reactions is retained by water, which accounts for nearly two thirds of body weight. Water is a very effective conductor of heat, so the heat produced in one region of the body is rapidly distributed by diffusion, as well as through the blood stream. If the body temperature is to be remain constant, that heat must be lost to the environment at the same rate it is generated. When environmental conditions rise above or fall below ‘ideal’ the body must control the gains and losses to maintain homeostasis.

In the example of the hiker his system responds to the varying temperature changes that occur in his environment and his body. The heat loss centre and the heat gain centre in the preoptic area of the anterior hypothalamus coordinate these changes within his body. It is important to note that behavioural changes also play a part in heat gain and loss for example if our hiker becomes hot he may remove some clothing to cool down and if he becomes cold he may put on some additional clothing or undertake some activity to create energy and therefore warmth (such as star jumps, huddling up etc.).

Our hiker has just been on a long walk and this prolonged and perhaps strenuous activity creates heat gain in the body due to the increase in metabolic rate. In order to maintain an optimum body temperature his system will have already been involved in a variety or heat loss mechanisms. The heat loss centre will have stimulated three major effects: The inhibition of the vasomotor centre causes peripheral vasodilation and warm blood flows to the surface of the body, the skin takes on a reddish colour and skin temperature rises. The heat generated can be dissipated to the surrounding environment via any exposed skin, this process is known as radiation. If the hike was vigorous, blood flow to the skin will have increased and in turn the sweat glands will have been stimulated to increase their secretory output. As the perspiration flows across the body’s surface evaporative heat losses accelerate. Finally, if the exercise is strenuous enough it may also have stimulated increased respiration, so as the respiratory centres are stimulated the depth of respiration increases and the hiker may even begin to respire through an open mouth rather than through the nasal passageways. This would also increase the evaporative heat losses through the lungs.

In addition heat loss may be achieved by conduction as the clothes in direct contact with the hiker’s skin take up some of the heat and via convection as air passing over any exposed areas of the hiker’s body (such as the face and hands) is heated and rises, cool air replaces it and convection currents are initiated. Convection can also cool the body through clothes as long as they are not windproof.

Once our hiker reaches his camp for the night he may remove some outer clothing to aid the heat loss following physical exertion. He may even sit down on a log or on the ground. Heat loss will continue until a tipping point is reached. The hiker’s optimum body temperature will have been reached but as it is getting dark and colder as the sun goes down he will rapidly begin to lose too much heat and a whole new set of negative feedback mechanisms will begin to promote heat gain. The function of the heat gain centre of the brain is to prevent hypothermia, when the temperature at the preoptic nucleus drops below acceptable levels the heat-loss centre is inhibited and the heat gain centre is activated.

The hiker can support this feedback mechanism with some behavioural modification: He is no longer active and so there is little physical activity to generate heat. He starts a fire and this external heat source is very effective. In addition he makes himself a cup of hot soup, this helps to raise the core temperature of the hiker’s body from within. It would also help is he were to minimise conductive heat loss by sitting on a blanket or mat rather than the ground.

The hiker’s system will begin to react to the new conditions. First it will attempt to conserve the heat it already has in the system. The sympathetic vasomotor centre decreases blood flow to his skin, thereby reducing losses by radiation, convection and conduction. As the blood flow is restricted his skin cools and may become paler in colour as the blood is not so near the surface. This does not damage the epithelial cells, which are designed to tolerate these changes for extended periods. The hiker’s body hair muscles will contract and his body hair will stand on end (piloerection), this traps air in a thick layer next to his skin, decreasing heat loss. Blood returning from the hiker’s limbs is shunted into a network of deep veins that lie within the insulating layer of subcutaneous fat and wrap around the deep arteries. Heat is thus conducted from the warm blood flowing outward to the limbs to the cooler blood returning from the periphery. This is known as concurrent exchange and it works to trap the heat close to the body core and restrict heat loss.

As the hiker makes his fire and drinks his soup his body will engage in active heat generation. The mechanisms for generating heat can be split into two main categories known as shivering thermogenesis and nonshivering thermogenesis. In shivering thermogenesis a gradual increase in muscle tome increases the energy consumption of skeletal muscle tissue throughout the body. The more energy consumed, the more heat is produced. Our hiker may begin to shiver and this increases the workload of the muscles elevating oxygen and energy consumption. The heat that is produced warms the deep vessels to which blood has been shunted by the sympathetic vasomotor centre mentioned above. Shivering is very effective and can elevate the body temperature by up to 400%.

Nonshivering thermogenesis involves the release of hormones that increase the metabolic activity of all tissues. The heat gain centre stimulates the suprarenal medullae via the sympathetic division of the autonomic nervous system and adrenaline is released increasing the metabolic rate of most tissues with immediate effect. Also the preoptic nucleus regulates the production of thyrotropin-releasing hormone (TRH) by the hypothalamus, which in turn stimulates the release of TSH (thyroid stimulating hormone). The thyroid responds to this release of TSH by increasing the rate at which thyroxine is released into the blood and elevating the rate of carbohydrate catabolism and also the rate of catabolism of all other nutrients.

As the hiker drinks his warm soup and it passes through his system the liver becomes active and heat is produced as a by-product. Metabolic rate and heat production are increased after eating. In addition the digestive organs will produce heat during peristalsis and during the chemical reactions involved in digestion.

As we can see there are a multitude of involuntary and also some voluntary mechanisms that work constantly to regulate the fluctuations in the hikers body temperature.