6/5 Mixed

Question 1

Giant Cell (Temporal) Arteritis

Answer 1

Elderly woman with jaw claudication, and episode of amaurosis fugax, polymyalgia rheumatica (pain in shoulder and hip girdles), headache, diplopia, blurred vision, ischemic optic neuropathy
Dx: C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)- highly sensitive, always very elevated, temporal artery biopsy

Question 2

Microsomal monooxygenase overreactivity causing cancer

Answer 2

Most chemical carcinogens enter the body in an inactive state (pro-carcinogens)
These are converted into active metabolites by the cytochrome p450 oxidase system
Individual susceptibility to chemical carcinogens depends on the activity of these enzymes, which is genetically determined

Question 3

Sebaceous glands

Answer 3

Are a type of HOLOCRINE exocrine gland

Can cause inflammatory acne

Question 4

Gastric varices only in the fundus

Answer 4

The short gastric veins drain blood from the gastric fundus into the splenic vein
Pancreatic inflammation (pancreatitis, pancreatic cancer) can cause a blood clot within the splenic vein, which can increase pressure in the short gastric veins and lead to gastric varices ONLY in the FUNDUS

Question 5

Loss of cardiomyocyte contractility occurs within 60 seconds after the onset of total ischemia

Answer 5

When ishcemia lasts less that 30 minutes, restoration of blood flow leads to reversible contractile dysfunction (myocardial stunning), with contractility gradually returning to normal over the next several hours to days
However, after about 30 minutes of total ischemia, ischemic injury becomes irreversible

Question 6

Prior disease

Answer 6

PrP (prion protein) is a normal cellular protein found in neurons that has an a-helical secondary structure. if this protein undergoes a conformational change to a B-pleated sheet, it is highly resistant to proteases, causing intracellular accumulation
Accumulation of an abnormal prior protein is considered a cause of prion diseases
Characteristic microscopic findings are vacuoles in the gray matter (spongiform encephalopathy) with no inflammatory changes)
Ex.Creutzfeldt-Jakob disease

Question 7

Macrocytic Megaloblastic anemia

Answer 7

Underlying feature is a defect in DNA synthesis
In chronic alcoholics, this can result from a nutritional deficiency of vitamin B12 or folate, which impairs synthesis of purine and pyrimidine bases (ex. diminished thymidine synthesis)

Question 8

Body dysmorphic disorder

Answer 8

Preoccupation with a perceived defect in appearance and repetitive behaviors in response to the preoccupation
It can present with absent insight/delusional beliefs and result in significant psychosocial dysfunction

Question 9

Aromatase Inhibitors (anastrozole, letrozole, exemestane)

Answer 9

Decrease the synthesis of estrogen from androgens, suppressing estrogen levels and slowing progression of Er-positive tumors
Estrogen is the main hormone responsible for the growth and development of ER+ breast tumors
Good in postmenopausal women

Question 10

Combination oral contraceptive pills to treat hirsutism

Answer 10

Suppress pituitary LH secretion and subsequently decrease ovarian androgen production

Question 11

Complications of invasive vascular procedures

Answer 11

Atheroembolic renal disease
May involve the kidneys (MC), GI tract, CNS, and the skin
Light microscopy shows a partially or completely obstructed arterial lumen with needle-shaped cholesterol clefts within the atheromatous thrombus
Signs of embolism = blue toe, livedo reticularis, normal peripheral pulses)

Question 12

Capitation

Answer 12

An arrangement in which a payer pays a fixed, predetermined free to provide all the services required by a patient
Payers may negotiate a capitated contract with an insurance company that then pays the providers or a large medical group may negotiate directly with the payer

Question 13

Child language development: age 2

Answer 13

Children should have a vocabulary of 50-200 words and be using 2-word phrases

Question 14

Gallbladder hypomotolity

Answer 14

Causes bile concentration, while promotes bile precipitation and accumulation of viscous biliary sludge that predisposes to gallstone formation and bile duct obstruction

Question 15

Pulmonary actinomycosis

Answer 15

Develops most commonly following aspiration and can be confused with lung abscesses, malignancy, or tuberculosis
Microscopic findings include filamentous, branching, gram-positive bacteria or sulfur granules
Found in dental caries, margins of gums in patients with poor dendition

Question 16

Lymph node malignancy

Answer 16

Monoclonal lymphocytic proliferation is strong evidence of malignancy

“monoclonal T-cell receptor gene rearrangements”

Question 17

ACE inhibitor first-dose hypotension

Answer 17

ACEi can cause first-dose hypotension in patients with volume depletion (from diuretic use) or heart failure)
To reduce the risk of first-dose hypotension, ACEi therapy should be initiated at low dosages

Question 18

Meconium ileus

Answer 18

Distal small bowel obstruction due to abnormally dehydrated meconium in a patient with cystic fibrosis (CF)
Persistent, treatment resistant infectious pneumonias, bronchiectasis, and cor pulmonale account for most deaths due to CF

Question 19

Raltegravir

Answer 19

Integrase inhibitor
Disrupts HIV genome integration into the host cell’s chromosomes, preventing host cell machinery from being used to synthesize HIV mRNA

Question 20

SLE

Answer 20

Loss of immune self-tolerance with production of autoantibodies against nuclear antigens
Binding of autoantibodies to self antigens leads to deposition of immune complexes in tissue and consumption of complement
Butterfly rash, inflammatory arthritis, ulcer on hard palate

Question 21

Acute arsenic poisoning

Answer 21

Impairs cellular respiration and presents with abdominal pain, vomiting, diarrhea, hypotension and a garlic odor on the breath
Insecticides and contaminated water and common sources of arsenic
Rx: Dimercaprol is the chelating agent of choice

Question 22

Zollinger-Ellison syndrome

Answer 22

Caused by gastrinomas located in the small intestine/pancreas and presents with peptic ulcers (especially DISTAL duodenal ulcers), heartburn, and diarrhea
Patients typically have elevated gastrin levels that rise in response to exogenous secretin administration
(vs. secretin inhibits release of gastrin from normal gastric G cells)

Question 23

Antithyroid drug SE

Answer 23

Agranulocytosis is a rare but very serious complication of antithyroid drugs (methimazole, propylthiouracil) that commonly presents with sudden onset of fever and sore throat
If agranulocytosis is suspected, the eliciting drug should be discontinued immediately and a white blood cell count with differential obtained to confirm the diagnosis

Question 24

Rx of essential tremow

Answer 24

First line treatment is the nonspecific B-adrenergic antagonist propranolol

Question 25

White/yellow membrane-like plaques on colonoscopy

Answer 25

C. difficile

Question 26

Abdominal aortic aneurysm

Answer 26

Transmural aortic wall inflammation, abnormal collagen remodeling and cross linking and loss of elastin and smooth muscle cells
Leads to weakening and progressive expansion of the aortic wall, resulting in aneurysm formation

Question 27

Osteoarthritis of the hands

Answer 27

Osteophyte formation leading to hard bony enlargement of the distal interphalangeal joints (Herberden nodes) and proximal interphalangeal joints (Bouchard nodes)
Brief morning stiffness may be present

Question 28

Ion pump failure due to ATP deficiency during cardiac ischemia

Answer 28

Causes intracellular accumulation of Na and Ca
The increased intracellular solute concentration draws free water into the cell, causing the cellular and mitochondrial swelling that is observed histologically

Question 29

Multiple endocrine neoplasia type 1

Answer 29

Hyperparathyroidism, endocrine pancreatic tumors (gastrinoma), pituitary tumors)
Genetic defect involves the MEN1 gene

Question 30

Confounding bias

Answer 30

Occurs when the exposure disease relationship is muddied by the effect of an extraneous factor that has correlations with both the exposure and the disease
Confounding bias can result in the false association of an exposure with a disease

Question 31

Vasopressin and desmopressin

Answer 31

Causes a V2 receptor-mediated increased in water and urea permeability at the inner medullary collecting duct
The resulting rise in urea reabsorption (decreased urea clearance) enhances the medullary osmotic gradient, allowing the production of maximally concentrated urine

Question 32

Diastolic heart failure (DHF)

Answer 32

Caused by decreased ventricular compliance and is characterized by normal left ventricular (LV) ejection fraction, normal LV end-diastolic volume, and elevated LV filling pressures
Hypertension, obesity and infiltrative disorders (e.g. transthyretin-related amyloidosis, sarcoidosis) are important causes of DHF

Question 33

Traumatic aortic rupture

Answer 33

Most often caused by the rapid deceleration that occurs in motor vehicle collisions
The most common site of injury is the aortic isthmus, which is tethered by the ligamentum arteriosum and is relatively fixed and immobile compared to the adjacent descending aorta

Question 34

Post streptococcal glomerulonephritis

Answer 34

Elevated anti-streptolysin O (ASO) titers, elevated anti-DNase B titers, decreased C3 and total complement levels and the presence of cryoglobulins.

C4 IS USUALLY NORMAL!

Question 35

Hepatic angiosarcoma

Answer 35

Associated with exposure to carcinogens such as arsenic, thorotrast, and polyvinyl chloride
Tumor cells express CD31, an endothelial cell marker
Rare vascular tumor

Question 36

Erosions

Answer 36

Mucosal defects that do not fully extend through the muscularis MUCOSA.
Ulcers penetrate through the mucosal layer and extend into the submucosal layer

Question 37

Trigeminal nerve and stroke symptoms

Answer 37

CN V arises at the level of the middle cerebellar peduncle at the lateral aspect of the midpons
Infarcts involving the anterior portion of the medial pons can produce dysarthria and contralateral ataxic hemiparesis

Question 38

Chronic rejection in lung transplant

Answer 38

Affects small airways, causing bronchiolitis obliterans

It is characterized by lymphocytic inflammation, fibrosis, and ultimately, destruction of the bronchioles