WBR mnemonics

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1\. Anatomy

## GI Anatomy

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“  | Dow Jones Industrial Average Closing Stock Report  | ”

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From proximal to distal:

1. Duodenum
2. Jejunum
3. Ileum
4. Appendix
5. Colon
6. Sigmoid
7. Rectum

## Brachial Plexus Organization

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“  | Radical Teachers Drink Cold Beers | ”

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“  | Randy Travis Drinks Cold Beers | ”

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“  | Robert Taylor Drinks Cold Beer | ”

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“  | Red Trucks Drive Cats Nuts | ”

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1. Roots
2. Trunks
3. Divisions
4. Cords
5. Branches

## Cranial Nerves

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“  | On Old Olympus Towering Tops, A Finn And German Viewed Some Hops | ”

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“  | Our Only Object To Touch And Feel Virgin Girls Vagina And Hymen | ”

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1. I - olfactory
2. II - optic
3. III - oculomotor
4. IV - trochlear
5. V - trigeminal
6. VI - abducens
7. VII - facial
8. VIII - acoustic (vestibulocochlear)
9. IX - glossophrayngeal
10. X - vagus
11. XI - accessory
12. XII - hypoglossal

## Extraocular Muscles Innervation

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“  | LR6 SO4 3 | ”

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* LR 6 \- Lateral Rectus by the VI cranial nerve (Abducens)
* SO 4 \- Superior Oblique by the IV cranial nerve (Trochlear)
* 3 \- The remaining by the III cranial nerve (Occulomotor)

“  | LAST | ”

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* L \- Lateral Rectus
* A \- Abducens Nerve
* S \- Superior Oblique
* T \- Trochlear Nerve

## Facial Nerve Branches

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“  | Two Zebras Bought My Car | ”

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“  | Two Zebras Bit My Cookie | ”

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“  | To Zanzibar By Motor Car | ”

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“  | Ten Zulus Buggered My Cat | ”

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1. Temporal
2. Zygomatic
3. Buccal
4. Mandibular
5. Cervical

## Penis Innervation

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“  | Point and Shoot  | ”

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* Parasympathetic causes erection
* Sympathetic causes ejaculation

“  | S2, 3, 4 keep the penis off the floor | ”

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* Innervation of the penis by branches of the pudendal nerve, derived from spinal cord levels S 2-4

## Aorta Branches

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“  | ABC'S | ”

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* Aortic arch gives off the:

1. B \- Bracheiocephalic trunk
2. C \- Left Common Carotid
3. S \- Left Subclavian artery

## Femoral Triangle Structures in Order

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“  | N (AVEL) | ”

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* Nerve
* Artery
* Vein
* Empty space
* Lymphatics

\- Parenthesis includes things contained in the femoral sheath.

2\. Cell Biology

## Cell Division Phases

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“  | People Meet And Talk | ”

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* P \- Prophase
* M \- Metaphase
* A \- Anaphase
* T \- Telophase

## Cell Cycle Stages

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“  | Go Sally Go! Make Children! | ”

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* G1 phase - Growth phase 1
* S phase - DNA synthesis
* G2 phase - Growth phase 2
* M phase - Mitosis
* C phase - Cytokinesis

## Golgi Complex Functions

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“  | Golgi Distributes A SPAM | ”

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* Distributes proteins and lipids from ER
* Add mannose onto specific lysosome proteins
* Sulfation of sugars and slected tyrosine
* Proteoglycan assembly
* Add O-oligosugars to serine and threnonine
* Modify N-ologosugars on asparagine

## Collagen

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“  | COLLAGEN | ”

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* C \- C-terminal propeptide (procollagen) / Covalent Cross links/ C vitamin/ Connective tissue/ Cartilage/Chondroblasts/Copper Cofactor (Covalent Cross linking)
* O \- Outside the cell is where collagen normally functions/ Osteoblasts/ Osteogenesis imperfecta
* L \- Lysyl hydroxylase / Lysyl oxidase (oxidatively deaminates lysyl and hydroxylysyl residues to form collagen cross links, last biosynthesis step)
* L \- Long triple helical fibers / Ligaments
* A \- Alpha chains / Attached by H bonds form triple helix / Ascorbate for hydroxylation of lysyl and prolyl residues of pro-Alpha chains

(postranslational modification)

* G \- Gly in every third position / Glycosylation of hydroxyl group of hydroxylysine with Glucose and Galactose;GOlgi allows procollagen to GO outside of cell
* E \- Extracellular matrix / Eye (cornea, sclera) / Ehlers-Danlos Syndrome
* N \- N-terminal propeptide (procollagen) / Nonhelical terminal extensions

3\. Molecular Biology

## Carbon Monoxide: Electron Transport Chain Target

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“  | CO blocks CO | ”

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Carbon monoxide (CO) blocks Cytochrome Oxidase (CO)

## Hemoglobin Binding Curve: Right Shift Causes

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“  | CADET, face right! | ”

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* C = Increase in carbon dioxide
* A = Acidosis (low ph)
* D = Increase in 2,3 DPG aka 2,3 BPG
* E = Exercise
* T = increase in temperature

## G-proteins Receptors

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“  | QISS & QIQ" (Kiss and Kick) | ”

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In alphabetical order

* Q: alpha 1
* I: alpha 2
* S: beta 1
* S: beta 2
* &
* Q: M1
* I: M2
* Q: M3

## Adrenaline Mechanism

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“  | ABC of Adrenaline | ”

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* Adrenaline--> activates
* Beta receptors--> increases
* Cyclic AMP

4\. Biochemistry

## Enzymes Classification

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“  | Over The HILL | ”

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* O \- Oxidoreductases
* T \- Transferases
* H \- Hydrolases
* I \- Isomerases
* L \- Ligases
* L \- Lyases

## Glycolysis Enzymes

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“  | Hungry Peter Pan And The Growling Pink Panther Eat Pies | ”

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* Hexokinase
* Phosphohexo isomerase
* Phosphofructokinase-1 (6-phosphofructo-1 kinase)
* Aldolase, Triose phosphate isomerase
* Glyceraldehyde 3-phosphate dehydrogenase
* Phosphoglycerate kinase
* Phosphoglycerate mutase
* Enolase
* Pyruvate kinase

## Glycolysis Steps

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“  | Goodness Gracious, Father Franklin Did Go By Picking Pumpkins (to) Prepare Pies | ”

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* Glucose
* Glucose-6-P
* Fructose-6-P
* Fructose-1,6-diP
* Dihydroxyacetone-P
* Glyceraldehyde-P
* 1,3-Biphosphoglycerate
* 3-Phosphoglycerate
* 2-Phosphoglycerate (to)
* Phosphoenolpyruvate [PEP] Pyruvate • 'Did', 'By' and 'Pies' tell you the first part of those three: di-, bi-, and py-.

• 'PrEPare' tells location of PEP in the process.

5\. Metabolism

## Metabolism Sites

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“  | Use both arms to HUG | ”

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1. Heme synthesis
2. Urea cycle
3. Gluconeogenesis

These reactions occur in both cytoplasm and mitochondria

## AcetylCoA and AcetacetylCoA

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“  | A Lighter Lease (A LyTr LeIs) | ”

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Amino acids forming them:

* A=AcetylCoA or Acetoacetyl CoA
* Ly=Lysine
* Tr=Tryptophan
* Le=Leucine
* Is=Isoleucine

## Citric Acid Cycle Compounds

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“  | Our City Is Kept Safe And Sound From Malice | ”

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* Oxaloacetate
* Citrate
* Isocitrate
* alpha-Ketoglutarate
* Succinyl-CoA
* Succinate
* Fumarate
* Malate

“  | Can I Keep Selling Sex For Money, Officer? | ”

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* Citrate
* Isocitrate
* alpha-Ketogluterate
* Succinyl CoA
* Succinate
* Fumerate
* Malate
* Oxaloacetate

“  | Oh! Can I Keep Some Succinate For Myself? | ”

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“  | Oh Citric Acid Is Of (course) A SiLly STupid Funny Molecule | ”

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* Oxaloacetate
* Citrate
* Isocitrate, alpha-Ketoglutarate
* Succinyl CoA
* Succinate
* Fumarate
* Malate

## Citric Acid Cycle Enzymes

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“  | Corrupt Anti Intelligence Agent Spoke Slander For Money | ”

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* Citrate synthatase
* Aconitase
* Isocitrate dehydrogenase
* Alpha ketogluturate dehydrogenase
* Succinyl CoA synthetase
* Succinate dehydrogenase
* Fumarase
* Malate Dehydrogenase

## Essential Amino Acids

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“  | P ri V a T e TIM HALL | ”

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“  | PVT. TIM HALL | ”

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“  | "PVT. TIM HALL always argues, never tires" | ”

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* P \- Phe
* V \- Val
* T \- Thr
* T \- Trp
* I \- Ile
* M \- Met
* H \- His
* A \- Arg
* L \- Leu
* L \- Lys
* Pvt. is short for Private in the military
* Arg and His are considered semi-essential
* Alternatively: MATT VIL PHLy

## Creatine Phosphate: Amino Acid Precursors

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“  | Nice GAMs! | ”

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* G \- Glycine
* A \- Arginine
* M \- Methionine

## Branched Chain Amino Acids Catabolism Steps

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“  | Truck hit the Ox to Death | ”

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* T \- Transamination
* O \- Oxidative decarboxylation
* D \- Dehydrogenation

## Branched-chain Amino Acids Used by Skeletal Muscle (Fasting State)

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“  | Muscles LIVe fast | ”

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* Leucine
* Isoleucine
* Valine

## Urea Cycle

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“  | Ordinarily Careless Crappers Are Also Frivolous About Urination!  | ”

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* O \- Ornithine
* C \- Carbamoyl
* C \- Citrulline
* A \- Aspartate
* A \- Arginosuccinate
* F \- Fumarate
* A \- Arginine
* U \- Urea

## Pyrimidines Nucleotides

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“  | CUT the PY (pie) | ”

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* Cytosine
* Uracil
* Thiamine
* The
* PYrimidines

6\. Enzyme Deficiencies

## G6PD: Oxidant Drugs Inducing Hemolytic Anemia

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“  | AAA | ”

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* Antibiotic (eg: sufamethoxazole)
* Antimalarial (eg: primaquine)
* Antipyretics (eg: acetanilid, but not aspirin or acetaminophen)

## Pompe's Disease

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“  | Type "Police: Po + lys" | ”

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* POmpe's disease is a LYSosomal storage disease (alpha 1,4 glucosidase)

## Galactosemia

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“  | GALIPUT | ”

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* Galactose 1 Phosphate Uridyl Transferase
* There is an assay called the Galiput test for this

## Fabry's Disease

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“  | FABRY ' S | ”

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* F \- Foam cells found in glomeruli and tubules / Febrile episodes
* A \- Alpha galactosidase A deficiency / Angiokeratomas
* B \- Burning pain in extremities / BUN increased in serum / Boys
* R \- Renal failure
* Y \- YX genotype (male, X linked recessive)
* S \- Sphingolipidoses

## Hurler Syndrome Features

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“  | HURLER'S | ”

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* Heptosplenomegaly
* Ugly facies
* Recessive (AR inheritance)
* L-iduronidase deficiency (alpha)
* Eyes clouded
* Retarded
* Stubby fingers/Short

## Acute Intermittent Porphyria

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“  | 5 P's  | ”

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* Pain in abdomen
* Polyneuropathy
* Psychologial abnormalities
* Pink urine
* Precipitated by drugs (eg barbiturates, oral contraceptives, sulpha drugs)

7\. Vitamins

## B Vitamins

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“  | The Rhythm Nearly Proved Contagious | ”

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In increasing order:

* T \- Thiamine (B1)
* R \- Riboflavin (B2)
* N \- Niacin (B3)
* P \- Pyridoxine (B6)
* C \- Cobalamin (B12)

## Niacin Deficiency

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“  | The famous 4 D's | ”

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1. Diarrhea
2. Dermatitis
3. Dementia
4. Death (if untreated)

“  | The 3D's of pellagra | ”

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Vitamin B3 (niacin, nicotinic acid) deficiency

1. Dermatitis
2. Diarrhea
3. Dementia

## Folate Deficiency Causes

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“  | A FOLIC DROP | ”

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* Alcoholism
* Folic acid antagonists
* Oral contraceptives
* Low dietary intake
* Infection with Giardia
* Celiac sprue
* Dilatin
* Relative folate deficiency
* Old
* Pregnant

## Fat Soluble Vitamins

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“  | The FAT cat is in the ADEK (attic) | ”

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Fat soluble vitamins are A,D,E,K.'

## Hypervitaminosis A

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“  | Increased Vitamin A makes you HARD | ”

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* H \- Headache / Hepatomegaly
* A \- Anorexia / Alopecia
* R \- Really painful bones
* D \- Dry skin / Drowsiness

8\. History Taking

## Alcoholism Screening

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“  | CAGE | ”

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* Have you ever felt it necessary to CUT DOWN on your drinking?
* Have you ever been ANNOYED when people suggest you cut down on your drinking?
* Have you ever felt GUILTY about your drinking?
* Have you ever felt the need to have a drink in the morning for an EYE OPENER?

## Chief Complaint

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“  | OPQRST | ”

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* O \- Onset of pain: what was the patient doing when the pain started?
* P \- Palliative or Provocative factors for the pain
* Q \- Quality of pain (burning, stabbing, aching, etc.)
* R \- Radiation (up to jaw, down left arm, etc.)
* S \- Severity of pain (usually 1 - 10 scale)
* T \- Timing of pain (eg: after meals, in the morning, how long it lasts, etc.)

“  | SOCRATES | ”

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* S \- Site of pain
* O \- Onset of pain
* C \- Character of pain: dull, sharp, aching, stabbing, tearing
* R \- Radiation of pain: central abdominal pain radiating to Right Iliac Fossa
* A \- Associated factors: eg. nausea/vomiting
* T \- Timing of pain/duration
* E \- Exacerbating/alleviating factors
* S \- Severity of pain (1 - 10 scale)

“  | ASCLAST | ”

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* A \- Aggravatiing and Alleviating factors
* S \- Severity
* C \- Character, quality
* L \- Location
* A \- Associated symptoms
* S \- Setting
* T \- Timing

NOTE: ASCLAST means let the patient talk first, then ask him/her specific questions.

## Hospital Admission Orders

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“  | DAVE WILMINGTON | ”

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* Diet
* Activity
* Vital signs: how often to monitor
* Excrement: test urine/stool
* Weight: how often to monitor
* I / O: monitor input/output
* Labs: which/how often
* Meds: which/route/interval
* I V fluids: what/at what rate
* Nursing care: e.g. position, wound care, up in chair, ostomy care
* General care: e.g. physical/respiratory therapy
* Tests: e.g. X-ray/EKG/EEG
* Observe for: reaction/seizure/neuro exams
* Notify parameters: e.g. Temperature > 100 F / respiration changes

After noting date and time of admission as well as diagnosis and condition (ADC), use the mnemonic to ensure all areas are addressed, but not all apply to every patient.

“  | ADC VAAN DIML, pronounced ADC van dim(e)L  | ”

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* Admit: 23 hours, full admit, service of attending
* Diagnosis
* Condition: "Stable"/"Guarded"
* Vitals: post-op, routine, q 1 hour
* Allergies
* Activities: strict bed rest/fall precautions/ad lib/bathroom privileges
* Nursing: strict I&O's/daily weights/call P.R.N.
* Diet: NPO/regular/clears/advance diet as tolerated/2000 cal ADA/renal
* IV fluids: D5, 1/2 NS, 20 KCL at 110 ml/hr, LR @ 100 ml/hr
* Meds: scheduled and PRN's
* Labs and X-ray: CBC in AM, PCXR in PACU

Note that IV fluids follows Diet. If one writes NPO, then all such patients get maintenance fluids (use the 4-2-1 rule).

## Post-Op Fever Causes

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“  | Five W's | ”

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* Wind: pneumonia, atelectasis
* Wound: wound infections
* Water: urinary tract infection
* Walking: DVT/PE (walking can help reduce DVT/PE)
* Wonderdrugs: especially anesthesia

## Predisposing Conditions for Pulmonary Embolism

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“  | TOM SCH PREFER | ”

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* T \- Trauma
* O \- Obesity
* M \- Malignancy
* S \- Surgery
* C \- Cardiac disease
* H \- Hospitalization
* P \- Past history
* R \- Rest (bed-bound)
* E \- Estrogen, pregnancy, post-partum
* F \- Fracture
* E \- Elderly
* R \- Road trip

## Compartment Syndrome Signs (Arterial Occlusion)

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“  | 6 P's | ”

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1. Pain
2. Pale (Pallor)
3. Perishing with Cold (Poikilothermia)
4. Pulseless
5. Paresthesias
6. Paralysis

9\. Pathology

## Causes of Diseases

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“  | VITAMIN C | ”

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* Vascular
* Infectious
* Trauma
* Auto-immune
* Metabolic
* Idiopathic/Iatrogenic
* Neoplastic
* Congenital

## Signs of Inflammation

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1. Rubor: redness/erythema
2. Calor: raised temperature
3. Tumor: swelling
4. Dolor: pain
5. Functio Laesa: loss of function

\- Described by Celsus

## Hypersentivity Reactions (Gell & Goombs Classification)

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“  | ACID | ”

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“  | Anna Cycled Immediately Downhill  | ”

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1. Type I Anaphylaxis
2. Type II Cytotoxic-mediated
3. Type III Immune-complex
4. Type IV Delayed hypersensitivity

## Multiple Endocrine Neoplasia (MEN)

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Each of the MENs is a disease of three or two letters plus a feature; all are autosomal dominant.

“  | MEN I: 3 P's | ”

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1. Pituitary
2. Parathyroid
3. Pancreas
4. Plus Adrenal cortex

“  | MEN II: 2 C's | ”

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1. Carcinoma of thyroid
2. Catacholamines (pheochromocytoma)

\- MEN IIA: parathyroid \- MEN IIB (MEN III): mucocutaneous neuromas for

## Acute Pneumonia Infiltrates

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* Pyogenic bacteria: PMN infiltrate
* Miscellaneous microbes: Mononuclear infiltrate

## Takayasu's Disease/Pulseless Disease

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“  | When you have Takayasu's, I can't Tak'a yu pulse | ”

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## CBC Normal Differential

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“  | Never Let Monkeys Eat Bananas  | ”

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“  | Nice Ladies Make Easter Bread"  | ”

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“  | 60, 30, 6, 3, 1 | ”

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1. Neutrophils: 60%
2. Lymphocytes: 30%
3. Monocytes: 6%
4. Eosinophils: 3%
5. Basophils: 1%

10\. Causes

## Metabolic Acidosis Causes

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“  | MUDPILES | ”

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* Methanol poisoning
* Uremia
* Diabetic Keto-acidosis
* Para-aldehyde ingestion
* Ischemia
* Lactic Acidosis
* Ethanol poisoning
* Salicylate ingestion

## Metabolic Acidosis (Normal Anion-Gap) Causes

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### With Hyperkalemia

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“  | RAISE K+ | ”

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* RTA type 4
* Aldosterone or mineralocorticord deficiency
* Iatrogenic: NH4Cl, HCl
* "Stenosis": obstructive uropathy
* Early uremia

### With hypokalemia

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“  | ReDUCE K+ | ”

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* Renal TA type 1 and 2
* Diarrhoea
* Urine diversion into gut
* Carbonate anhydrase inhibitor
* Ex-hyperventilation

## BUN & Creatinine Elevation Causes

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“  | ABCD | ”

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* A \- Azotremia (pre-renal)
* B \- Bleeding (GI)
* C \- Catabolic status
* D \- Diet (high protein parenteral nutrition)

## Hypercalcemia Causes

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“  | PAM SCHMIDT | ”

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* Paget's Disease
* Amyloid
* Multiple Myeloma
* Sarcoid
* Cancer
* Hormomal (para-thyroid)
* Milk-alkali Syndrome
* Immobilization
* D-vitamin overdose
* Thyrotoxicosis

“  | MISHAP | ”

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* Malignancy
* Intoxication (hypervitaminosis)
* Sarcoidosis
* Hyperparathyroidism
* Alkali (Milk) syndrome
* Paget's Disease (bone)

Also consider Addison's disease, thiazide diuretics and simple lab error

## Acute Pancreatitis Causes

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“  | GET SMASHED | ”

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1. Gall stones
2. Ethanol
3. Trauma
4. Steroids
5. Mumps
6. Autoimmune disease
7. Scorpion venom
8. Hyperlipidemia
9. ERCP (dye)
10. Drugs (Azathioprine, Asparginase, Mercaptopurines, Pentamidine)

Alcohol and Gallstones are the most common causes.

## Back Pain Causes

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“  | DISK MASS | ”

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* D-Degeneration: DJD, Osteoporosis, spondylosis
* I-Infection: UTI, PID, Potts, osteomyelitis, prostatitis, Injury/fracture, compression fracture
* S-Spondylitis, ankylosing Spondyloarthropathies (rheumatoid arthritis, Reiters, SLE)
* K-Kidney stones/infarction/infection (pyelo/abscess)
* M-Multiple myeloma, Metastasis from breast, prostate, lung, thyroid, kidney CA
* A-Aneurysm, Abdominal pain referred to the back (see acute abdominal pain)
* S-Slipped disk, Spondylolisthesis
* S-Strain, Scoliosis/lordosis, Skin: herpes zoster

11\. Treatment

## Syncope Management

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“  | If the face is red, raise the head! | ”

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“  | If the face is pale, raise the tail! | ”

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## Malignant Hyperthermia Treatment

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“  | Sunday Hot Day, Better Give Iced Fluids Today! | ”

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* S\- Stop all triggering agents, give 100% O2
* H\- Hyperventillate
* D\- Dantrolene 2.5 mg/kg
* B\- Bicarbonate
* G\- Glucose and Insulin
* I\- IV Fluids, Cooling Blanket
* F\- Fluid Output; Furosemide
* T\- Tachycardia, be prepared to treat V Tach

12\. Genetics

## Down Syndrome Features

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“  | CHILD HAS PROBLEM! | ”

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* Congenital heart disease/ Cataracts
* Hypotonia/ Hypothyroidism
* Incure 5th finger/ Increased gap between 1st and 2nd toe
* Leukemia risk x2/ Lung problem
* Duodenal atresia/ Delayed development
* Hirshsprung's disease/ Hearing loss
* Alzheimer's disease/ Alantoaxial instability
* Squint/ Short neck
* Protruding tongue/ Palm crease
* Round face/ Rolling eye (nystagmus)
* Occiput flat/ Oblique eye fissure
* Brushfield spot/ Brachycephaly
* Low nasal bridge/ Language problem
* Epicanthic fold/ Ear folded
* Mental retardation/ Myoclonus

“  | DOWN | ”

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* Decreased alpha-fetoprotein and unconjugated estriol (maternal)
* One extra chromosome twenty-one
* Women of advanced age
* Non-disjunction during maternal meiosis

“  | Drink at 21 | ”

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Chromosome 21

## Patau's Syndrome - Chromosome 13

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“  | Puberty at 13  | ”

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## Edward's Syndrome - Chromosome 18

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“  | Election voter at 18  | ”

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## DiGeorge (Velocardiofacial) Syndrome

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“  | CATCH 22 | ”

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* Cardiac abnormalities
* Abnormal facies
* Thymic aplasia
* Cleft palate
* Hypocalcemia
* 22q11 deletion

## Marfan Syndrome Features

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1. Mitral valve prolapse - MVP
2. Aortic Aneurysm
3. Retinal detachment
4. Fibrillin
5. Arachnodactyly
6. Negative Nitroprusside test (differentiates from homocystinuria)

## Adult Polycystic Kidney Disease

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“  | '"Polycystic kidney"' has 16 letters | ”

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Also, and is due to a defect on chromosome 16.

“  | APKD | ”

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ADult Polycystic Kidney Disease is Autosomal Dominant

13\. Pediatrics

## APGAR Score

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“  | APGAR | ”

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* Appearance (color): blue/pale, trunk pink, all pink
* Pulse (heart rate): 0, <100, 100+
* Grimace (reflex irritability): 0, grimace, grimace+cough
* Activity (muscle tone): limp, some, active
* Respiration (respiratory effort): 0, irregular, regular

\- Score 0-2 at 1 and 5 minutes in each of 5 categories, being 10 the perfect score.