Blood Vessels 1-3 Nitroprusside is an antihypertensive with mixed arterial and venous vasodilatory actions for emergency seatting

that action within 30 seconds. One major disadvantage is potential Cyanide toxicity. This Cyanide toxicity included altered mental status and lactic acidosis. However, this cyanide toxicity can be reversed by Sodium Thiosulfate. It works by donating additional sulfur to liver rhodanase to enhance metabolism and detoxification of cyanide to thiocyanate. White coat syndrome is an example of Classical Conditioning. This is unconditioned stimulus (white coat) have conditioned stimulus (fear) Rationalization usually to avoid self blame, after fired and say I did not need it anyway Reaction formation do apposite, alcoholic do alcohol sales banned Displacement Transfer emotion to specific person or thing (play ex-girl friends son In order to determine Median, it must be in order 75, 75 80 90 110, 110 Mode - Most frequent value Mean - Average Median Right at the middle / do not confuse with median and mean Familial dysbetalipoproteinemia (type III hyperlipoproteniemia) is characterized clinically by Xantomas and premature coronary peripheral vascular disease due to deficiency of ApoE3 and ApoE4. Without them the liver cannot efficiently remove Chylomicrons and VLDL remnants from the circulation, causing their accumulation in the serum and resultant elevations in cholesterol and triglyceride levels. ApoA-I ApoB-48 ApoB-100 ApoC-II LCAT activation (cholesterol esterification) Chylomicron assembly and secretion by the intestine LDL particle uptake by extrahepatic cells Lipoprotein lipase activation VLDL and Chylomicron remnant uptake by liver cells So, Median is right at the middle which is 85

ApoE-3 & ApoE-4 5 of 48 Chart

Homocysteine is converted to Cystathionine and then to Cysteine by Vitamin B6 as cofactor. Also, Homocysteine is converted to Methionine using methylcobalamin (THF) and methyl tetrahydrofolate (5-Methyl THF) with B12 as cofactor. This reaction is run as cycle back to Homocysteine by SAM as methyl donor.

Chemical Arsenic, Thorotrost, and Polyvinyl Chloride are high risk factor of Hepatic Angiosarcoma. Tumor cell express CD31 (which is Platelet Endothelial Cell Adhesion Molecule) is an endothelial cell marker. 7 of 48 Pic (CT of L1) The inferior vena cava (IVC) is formed by the union of the right and left common iliac veins at the level of L4-L5. The renal arteries and veins lie at the level of L1. The IVC returns venous blood from the lower extremities, portal system and abdominal and pelvic viscera to the right atrium of the heart. Epinephrine (a, b-1, b2 agonist) increase systolic blood pressure (a1-effect), increase heart rate (b1-effect), and decreases diastolic blood pressure (b2-effect). Pretreatment with Propranolol (betablocker) eliminates the both b-1 and b-2 effects of epinephrine (vasodilatation and tachycardia), leaving only a-effect (vasoconstriction). Thromboangitis obliterans (Buergers disease) is usually seen among heavy cigarette smoker with onset before age 35, and is associated with hypersensitivity to intradermal injections of taboco extracts. This segmental thromobosing vasculitis often extends into contiguous veins and nerves, encasing them in fibrous tissue. 10 of 48 Pic (CT of L2) The IVC courses through the abdomen and inferior thorax in a location anterior to the right half of the vertebral bodies. The renal veins joins the IVC at the level of L1/L2, and the common iliac veins merge to become the IVC at the level L4. Thus IVC filter is best location for prevent pulmonary embolism in future. Net filteration pressure = (Hydro pressure gradient) (Oncotic pressure gradient) Metabolic acidosis is characterized primarily by a decrease in serum bicarbonate (HCO3) and a decrease in pH. The PaCO2 will also decrease as a result of compensation (respiratory Alkalosis). From above Q, the treatment choice of Diabetic Ketoacidosis (DKA) is intravenous hydration and Insulin. These therapies will result in decrease in the serum glucose, osmolality, and potassium as well as increase in serum bicarbonate and sodium. Nicotinic acid, or niacin, is one of best treatment of hyperlipidemia and most effective way to increase HDL as (B3) vitamin. However, it has side effect of flushing, warmth, and itching which may be mediated by prostaglandins and can be prevented with use of Aspirin. 2

Some cells die even after ischemic tissue is restored and show rapid surge of serum creatine kinase level. Within the damaged tissue will paradoxically die at an accelerated pace through apoptosis or necrosis after resumption of blood flow. This process is termed reperfusion injury. Reperfusion injury is thought to occur secondary to oxygen free radical generation, mitochondrial damage, and inflammation. In the pathogenesis of atherosclerotic plaques, is thought to begin with endothelial cell injury, which result in endothelial cell dysfunction and/or expose of subendothelial collagen). Exposure of subendothelial collagen promotes platelet action (adhesion, aggregation, and release) of factors that promote migration of smooth muscle cells (SMC). The release of PDGF by platelets adherent to areas of denuded vascular endothelium is thought to play an important role in promoting both the migration of SMC from the media into the intima, and their subsequent proliferation in the intima. The likelihood of acute plaque change (especially rupture) production and acute coronary syndrome (MI) via superimposed thrombosis and/or thormboembolism is most related to plaque stability. Plaque stability depends significantly on mechanical strength of the fibrous cap. Inflammatory macrophages in the intima may reduce plaque stability by secreting Metalloproteinases, which degrade collagen. The Statins group drugs (Atorvastatin, HMG-CoA inhibitors) are first line hherapy of hypercholesterolemia and very effective to lower LDL cholestorl. However, it has side effect of Myopathy (muscle pain and sky high serum creatine kinase) and hepatitis. The Myopathy will increase combo of Statin (Simvastatin, highest risk of myopathy) and Fibrates group drugs (Germifibrozil). The combination of ~fibric acid derivates and bile acid binding ~resins increase the risk of cholesterol gallstones. This effects an increase cholesterol concentration in bile. The Cilostazol (approved by FDA) is a PDE inhibitor used in patient with intermittent claudication (peripheral arterial disease). In addition to inhibition of platelet aggregation, cilostazol is also a direct arterial vasodilator. 20 of 48 Pic (red region on baby butt) Strawberry hemangiomas (capillary hemangiomas) are benign vascular tumors of childhood. They appear during the first weeks of life, initially grow rapidly, and typically regress by 5-8 years old. These tumors are composed of capillaries separated by connective tissue.

The ARBs (losartan) works by blocking AT-1 (Angiotensin) receptors and inhibition the effect of angiotensin II. This results in arterial vasodilation and decrease aldosterone secretion. Since ARBs works at the level of AT-1 receptors and do not effect ACE activity. ARBs do not interfere with bradykinin degradation or levels. By blocking AT-1 receptors, ARBs also interfere with negative feedback mechanism resulting in increased rennin, angiotensin-I, and angiotension-II level. This is also best replacement for patient with cough due to ACE inhibitor use. The most common cause of renal artery stenosis is obstruction by an atheromatous plaque at the origin of the renal artery (more frequent in male). Unilateral renal artery stenosis is a cause of secondary hypertension in 2% to 5% of hypertensive patients. The kidney affective by the stenosis may become atrophied due to oxygen and nutrient deprivation. Continuous and machine like murmur is characterize of PDA. The ductus arteriosus is derived from the sixth embryonic aortic arch. A patent ductus arteriousus can cause a thrill and a continuous murmur on physical exam. Indomethacin can be used to close a PDA, while PGE2 infusions can be used to maintain patency of this structure in cases of congenital heart disease requiring a patent left-to-right shunt in order to maintain oxygenation (i.e Tetralogy of fallot, Transpostition). Sinus Venosus smooth portion of right atrium Primitive atrium - rough portion of right and left atria Bulbus cordis smooth portion of right and left ventricular Giant cell (temporal) arteritis can cause irreversible blindness due to ophthalmic artery occlusion is server. It can be prevented by immediate admin of prednisone therapy. Simvastatin (~statin, inhinbit HMG-CoA reductase) is first line drug for hypercholesterolemia by inhibit the last step and decrease hepatic cholesterol synthesis. As a result, there is an upregulating of LDL receptors, causing increased uptake of LDL from the circulation. Bile acid-binding resins (cholestyramine) agents that inhibit bile acid reuptake and result increase hepatic cholesterol synthesis (e. g. fibrates, bile acid-binding resins agents) are associated with increased risk for gallbladder stones. Myxomatous changes in the media of large arteries are found in so-called cystic medial degeneration, which characterized by the fragmentation of elastic tissue and by separation of the elastic and fibro-muscular components of the tunica media by small, cleft-like space. This is condition of predisposes to the development of dissection aorta hematomas and aortic aneurysms. Barry aneurysms single exact cause is not known Marfan syndrome fibrinllin-1 defect which may cause dissecting of aorta 4

Blood flow is directly proportional to the vessel radius raised to the fourth power. More blood flow as larger radius Ressistance to blood flow is inversely proportional to the vessel radius to the fourth power. More resistance as smaller radius First-dose hypotension is an adverse effect and concern when initiating ACE inhibitors. Predisposing risk factor of first-dose hypotension include hyponatremia, hypovolemia, secondary to diuretics, low baseline blood pressure, high rennin or aldosterone level, renal impairment, and heart failure. To minimize risk for first-dose hypotension, identify patients at risk and initiate therapy at low dosage and follow with cautions dosage titration and blood pressure monitoring. Patient taking thiazide or loop diuretics can by hypovolemic and hyponatremic, thus potentiation and increase the effects of initiating of first dose hypotension. 29 of 49 Chart Pharyngeal arches Head, neck, and upper thorax region development Arch I Arch II Arch III Arch IV Arch V Arch VI CN-V CN-VII CN-IX CN-X None CN-X Maxilary artery Stapedial artery (regress) Common carotid artery / Prox internal carotid artery True aortic artery / Subclavian arteries None Pulmonary arteries / Ductus arteriosus

The symptom of orthostatic hypotension is bp fall of >20 mm in systolic or >10 mm in diastolic when up right posture. Standing causes pooling of significant amount of blood (500-1000mL) into the veins below the heart. This can be caused by understimulation (blockage) of a1adrenoreceptors that lead to symptoms of cerebral hypoperfusion (lightheadedness and syncope) during standing. The a1-mediated vasoconstricution prevents cerebral hypoperfusion upon standing. So, a-adrenergic blockers disrupt this mechanism and cause orthostatic hypotension. Among the arteritides (any organ artery Except Pulmonary), Transmural inflammation with fibrinoid necrosis is most characteristic of Polyarteritis Nodosa (PAN). Fever, malaise, weight loss, abdominal pain, and melena are frequent symptoms of PAN. PAN is associated with Hepatitis B infection in 30% of case. Thus, patient with transwmural inflammation of arteries may in risk of Hep B or Liver infection.

Heavy smoker is suggestion of COPD and right ventricular dilation is sign of secondary Cor Pulmonale. Right heart failure cause increase in the net plasma filtration and cause low limb edema. However, increased lymphatic drainage can compensate for moderate Central Venous Pressure (CPV) elevation to prevent the development of clinically apparent interstitial edema. 33 of 48 Pic Marked, one-sided kidney atrophy (one kidney is enlarged for compensatory hypertrophy) is suggestive of Renal Artery Stenosis (RAS). It occurs in elderly individuals due to atherosclerotic changes in the arterial intima in old patient or in women of childbearing age due to fibromuscular dysplasia. Hypertension, stable angina, headaches and an abdominal bruit are present. Do not confuse with Ischemic Tubular Necrosis (ITN). Abdominal pain due to acute pancreasetitis is the most likely presentation for

hyperchylomicronemia (hypertriglyceridemia). Patient with this disorder are not usually at increased risk for premature coronary artery disease. Skin xanthomas may be present in hypertriglyceridemia. This patient with LPL deficiency, heparin-induced LPL activity is significantly reduced. Do not confuse with tubular/tendon xanthomas and xanthelasmas, because they are present with hypercholesterolemia (high LDL). Persistant lymphedema (with chronic dilatation of lymphatic channels) predisposes to the development of lymphangiosarcoma, a rare malignant neoplasm of the endothelial lining of lymphatic channels. This cancer may arise approximately 10 years after radical mastectomy with axillary lymph node dissection for breast cancer. Among the arteritides (any organ artery Except Pulmonary), Transmural inflammation with fibrinoid necrosis is most characteristic of Polyarteritis Nodosa (PAN). Fever, malaise, weight loss, abdominal pain, and melena are frequent symptoms of PAN. PAN is associated with Hepatitis B infection in 30% of case. Thus, patient with transwmural inflammation of arteries may in risk of Hep B or Liver infection. So, remember PAN can happen to any organ but spare Pulmonary artery.

Although fatty acid oxidation results in greater ATP production, it requires more oxygen use in comparison to glucose utilization and glycolysis. In stable angina, atherosclerosis leads to reduced oxygen deliver to cardiac mitochondria resulting in a mismatch between myocardial oxygen demand and supply. Thus, fatty oxidation inhibitors are newer agents that inhibit fatty acid oxidation and shift energy production to glucose oxidation, which promoting oxygen efficiency. This not only decreases the amount of oxygen needed per one ATP synthesize to support cardiac function, but also decreases potentially toxic fatty acid metabolite production. The HbA1c value over 7.0% and more than 30 mg/day loss of albumin in the urine is sign of diabetic nephropathy in diagetic patient. This is very common clinical issue given the prevalence of diabetes in the US population. The ACE-I (~pril) class of drugs together with the ARBs (losartan) class of drugs have been shown to decrease the progression of diabetic nephropathy. Churg Strauss Syndrome = Microscopic polyangitis The presence of antibodies against neutrophil myeloperoxidase (also known as perinuclear staining antineutrophil cytoplasmic antibodies, P-ANCA), suggest Microscopic Polyangitis (Churg Strauss vasculitis in this patient. Thus, P-ANCA, adult onset asthma in non allergic person, and eosinophila makes Churg-Strauss Syndrome. Goodpasture syndrome autoantibody against the a-3 chain of collagen IV Damage alveolar and glomerular basement membranes Immune complex vasculitis associated with IgA and C3 deposition is typical of HenochSchonlein Purpura (HSP). HSP is most common in childrend 3 to 11 years old and is most often related to a recent infection. Most children present with palpable skin lesions (rash), with or without abdominal pain and arthralgias. Although usually self-limiting, patients afflicted with HSP should be observed carefully because glomerulonephritis and even end-stage renal disease are possible complication. Wegeners Granulomatosis Saddle nose, oligouria and C-ANCA, not with IgA The temporal (giant cell) arteritis is common form of adult vasculitis and granulomatous inflammation of media occus. It predominantly involves medium to smaller branches of the carotid artery especially the temporal arteries. The resulting headache, facial pain, jaw claudication, and visual deterioration generally respond well to gluco-corticoid therapy like prednisone. Half life of drug 0 to 50% 50 to 75% 75 to 88% 88 to 95% 95 to 99% 1 half life 2 3 4 5 7

43 of 48 Pic (fat filled right coronary artery) Familiary hypercholesterolemia, one of most common autosomal dominant disorders, is the result of heterozygous or homozygous LDL receptor gene mutations of liver, which cause hypatocyte under-expression of functional LDL receptors. This condition can lead to accelerated atherosclerosis and early-onset coronary artery disease. ACE inhibitors block the effect of ACE (convert AT-I to II), decreasing angiotension-II and aldosterone levels. By decreasing angiotension-II levels, ACE inhibitors directly interrupt negative feed-back loops, thus increasing renin and angiotensin-I level. Without effective ACE, bradykinin metabolism decrease and bradykinin levels will increase. Bradykinin (Kinin) is a potent vasodilator that ultimately increases vascular permeability causing significant angioedema (face swelling, difficulty breathing, and cough). This can be reversed by use of losartan instead of ACE inhibitor. Another side effect of ACE inhibitor is renal failure by altering renal hemodynamics. ACE inhibitor results efferent arteriole dilation (normally constricted stimulated by AT-II). It leads to decreasing glomerular pressure (dilated efferent) and renal perfusion (dilated efferent). For patients dependent on efferent arteriole constriction to maintain renal perfusion (those with renal artery stenosis), ACE inhibitors can be detrimental causing acute renal failure or complicating existing renal disease. ACE inhibitor works most likely on efferent renal vessels. Up to 25% of central venous catheters-associated bloodstream infections have been estimated to occur annually in the US. Indwelling central catheters (intravascular dveices) predispose to bacteremia and sepsis. It should be monitored regularly for signs and symptoms of infection. Also this infection is suspected in hospitalized patients with new onset fever or bactermia. The most common cause of hospital acquired bloodstream infections are S. aureus. The arteriolar walls are Homogeneous deposition of eosinophilic hyaline material in the intima and media of small arteries and arterioles characterized hyaline arteriolosclerosis, which is typically produced by long-standing non-malignent hypertension and/or diabetes.