Day 1

Question 1

Which immune response is responsible for hyperacute, acute, and chronic transplant rejection? What is the time frame for each? (FA15 p217) (FA16 p211) (SU p384-385)

Answer 1

Hyperacute - (within minutes) pre-existing recipient antibodies to donor antigen (type II hypersensitivity reaction), activate complement
clx - widespread thrombosis of graft vessels –> ischemia and necrosis
tx - graft must be removed

Acute - (Weeks to months) Cellular: CD8+ T cells activated against donor MHCs (type IV hypersensitivity reaction)
Humoral: similar to hyperacute, except antibodies develop after transplant
clx - vasculitis of graft with dense interstitial lymphocytic infiltrate
tx - prevent/reverse with immunosuppressants

Chronic - (months to years) CD4+ T cells respond to recipient APCs presenting donor peptides, including allogeneic MHC
Both cellular and humoral components (type II and IV hypersensitivity reactions)
clx - Recipient T cells react and secrete cytokines –> proliferation of vascular smooth muscle, parenchymal atrophy, interstitial fibrosis
Bronchiolitis obliterans, Accelerated atherosclerosis, Chronc graft nephropathy, Vanishing bile duct syndrome

Question 2

What is the treatment for digoxin toxicity? (FA15 p257) (FA16 p251) (SU p68) (GG p803)

Answer 2

Tx for Digoxin toxicity = Anti-dig Fab fragments

Normalize K and Mg
Brady –> atropine
Other arrhythmias –> ACLS

Question 3

For which infections is vancomycin a good choice? How does vancomycin resistance develop? (FA15
p183) (FA16 p173) (SU p338)

Answer 3

Vancomycin = GRAM + bugs only
	serious, multi-drug resistant organisms
	MRSA
	S. epidermidis
	sensitive Enterococcus species
	Clostridium Difficile (oral dose for pseudomembranous colitis)

Resistance to Vanc? –> modification of amino acid sequence D-ala D-ala to D-ala D-lac

“Pay back 2 D-alas (dollars) for VANdalizing”

Question 4

Do atypical antipsychotics primarily address the negative or positive symptoms of schizophrenia? How
does the mechanism of action of typical antipsychotics differ from the mechanism of action of the
atypical antipsychotics? (FA15 p509, 521) (FA16 p514, 525) (SU p53)

Answer 4

Positive symptoms = delusions, hallucinations, disorganized speech, Disorganized catatonic behavior
Negative symptoms = flat affect, avolition, anhedonia, asociality, alogia)

Typical = block dopamine D2 receptors (increase cAMP)
Atypical = not completely understood, different mechanisms

Question 5

A 67-year-old man with new-onset hepatic failure and normal renal function is currently taking a drug
metabolized and excreted by the kidneys. Would you need to change the loading dose or maintenance
dose of this medication because of this hepatic failure? If this patient were to develop hepatorenal
failure, would you need to change the loading dose or maintenance dose of the medicine? (FA15
p243) (FA16 p237) (SU p395)

Answer 5

In renal or liver disease:
Maintenance dose = decreased
Loading dose = same

Question 6

What substances compose the matrix of the bone? (Phys p957)

Answer 6

Organic matrix (30%)
collagen, chondroitin sulfate, hyaluronic acid
Crystalline salts (70%)
calcium, phosphate, hydroxyapatite

Question 7

While thiazide and loop diuretics are known for wasting potassium in the urine, there are other
diuretics that conserve it. Which diuretics are these? What are their mechanisms of action? What are
their important side effects? (FA15 p554) (FA16 p558) (SU p165)

Answer 7

Potassium-sparing diuretics:
	Spironolactone (aldosterone antagonists)
	Eplerenone (aldosterone antagonists)
	Triamterene (block Na channels)
	Amiloride (block Na channels)
Distal tubules

Side Effects!
Hyperkalemia –> arrhythmia
SPIRONOLACTONE –> endocrine effects (gynecomastia, antiandrogen effect)

Question 8

A 66-year-old woman is being treated in the ER for an acute MI. Nitroglycerin is given with the
expectation that it will vasodilate which vessels preferentially? Another patient in the ICU is on
hydralazine for acute treatment of his severe hypertension. How does hydralazine function? (FA15
p304-305) (FA16 p298-299) (SU p77)

Answer 8

Nitroglycerin = vasodilates vascular smooth muscles VEINS»>ARTERIES Decreases preload

Hydralazine = vasodilates arterioles&raquo_space; veins Decreases afterload

Question 9

What risk factors are associated with cholesterol gallstones? What risk factors are associated with
pigment gallstones? (FA15 p375) (FA16 p372) (SU p135)

Answer 9

Fat, Forty, Female, Fertile

Cholesterol stones = obesity, Crohn’s, advanced age, estrogen therapy, multiparity, rapid wt loss, Native American

Pigmented stones = Crohn’s, hemolysis, alcoholic cirrhosis, advanced age, biliary infection, TPN

Question 10

A 35-year-old woman with multiple sclerosis presents to clinic with internuclear ophthalmoplegia.
What is internuclear ophthalmoplegia? (FA15 p486) (FA16 p490) (SU p35)

Answer 10

Medial Longitudinal Fasciculus (MLF): pair of tracts that allows for crosstalk between CN VI and CN III nuclei. Coordinates both eyes to move in same horizontal direction. Highly myelinated (must communicate quickly so eyes move at same time). Lesions may be unilateral or bilateral (latter classically seen in multiple sclerosis).

Lesion in MLF = INTERNUCLEAR OPHTHALMOPLEGIA (INO), a conjugate horizontal gaze palsy.

Question 11

A female infant is brought to the clinic for evaluation of her genitalia. On exam, clitoromegaly and labial fusion is noted. Lab studies reveal elevated 17-hydroxyprogesterone levels. What is the most common form of adrenal hyperplasia? Which hormone levels are altered as a result of this enzyme deficiency? What are the clinical manifestations of this enzyme deficiency? (FA15 p318) (FA16 p312) (SU p168, 186)

Answer 11

MC form of Adrenal Hyperplasia = 21-hydroxylase deficiency

Decreased:
	aldosterone
	cortisol
Increased:
	sex hormones

Increased renin / increased 17-hydroxyprogesterone

Clx -
	Hypotension
	Volume depletion
	Hyperkalemia (due to decreased aldosterone)
	Masculinization in females

Infancy = Salt Wasting
Childhood = Precocious Puberty

Question 12

What is the mechanism of action of the following antiemetics? (FA15 p251, 380) (FA16 p245, 376) (SU
p139-141) (GG p1341-1344)
Scopolamine
Promethazine
Prochlorperazine
Metoclopramide
Ondansetron

Answer 12

Muscarinic antagonist
CNS
motion sicknesss / decreases oral secretions

M1 antagonist

-------------------------------
Histamine antagonist
D2 dopamine antagonist
---------------------------------
D2 dopamine antagonist
----------------------------------
D2 receptor antagonist / increases resting tone, contractility, LES tone, motility
Does not influence colon transport time

5-HT3 antagonist, decrease vagal stimulation POWERFUL central-acting antiemetic
clx: post-op and chemo/cancer therapy pts

Side effects = headache, constipation, QT interval prolongation

Question 13

A 25-year-old man complains of a scrotal mass and pain made worse by coughing or sneezing. A
scrotal exam reveals a palpable scrotal protrusion with the Valsalva maneuver. What type of hernia is
this patient experiencing? What type of hernia protrudes through Hesselbach’s triangle? What
structures form Hesselbach’s triangle? (FA15 p352) (FA16 p349) (SU p250-251)

Answer 13

Scrotal Mass = Indirect inguinal hernia

Hesselbach’s triangle = Direct inguinal hernia

Hesselbacj’s trinangle: Femoral Vessels / Inguinal ligament / Rectus abdominis muscle

Question 14

How does a decrease in renal artery pressure cause an increase in blood pressure? (FA15 p534) (FA16
p540) (SU p147)

Answer 14

Decrease in renal artery pressure causes secretion of RENIN by JG cells. ANGIOTENSINOGEN is released from the liver and converted to ANGIOTENSIN I by RENIN. ANGIOTENSIN I is then converted to ANGIOTENSIN II by ACE from the lungs and kidney.

Angiotensin II acts on receptors type AT1 on vascular smooth muscle

Constricts efferent arterioles of glomerulus, this increases FF to preserve GFR in low volume state

Aldosterone secreted to increase Na channel and Na/K pump in principal cells / enhances K and H excretion by way of principal cell K channels and alpha-intercalated cell H ATPase / creates favorable Na gradient for Na and H2O reabsorption

ADH from posterior pituitary, increase aquaporin insertion in principal cells / H2O reabsorption

increase PCT Na/H activity / Na, HCO3, H2O reabsorption (can permit contraction alkalosis

Stimulates hypothalamus / stimulates THIRST

Question 15

What are the three endogenous androgens in order from the most potent to the least potent? (FA15
p577) (FA16 p582) (SU p169)

Answer 15

Endogenous Androgens
MOST POTENT
	DHT
	Testosterone
	Androstenedione

Question 16

What is Osler-Weber-Rendu syndrome? (FA15 p83) (FA16 p71) (SU p90) (R p730) (H p409)

Answer 16

Hereditary Hemorrhagic Telangiectesia
inherited disorder of blood vessels / branching skin lesions (telegiectesia), recurrent epistaxis, skin discoloration, arteriovenous malformations (AVMs), GI bleeding, hematuria.

Question 17

What is the fibrous band attached to the testis and scrotum that aids in normal testicular descent?
What is this structure called in females? (FA15 p569) (FA16 p573) (SU p198-200)

Answer 17

Gubernaculum (band of fibrous tissue) anchors testes within scrotum –> ovarian ligament +round ligament

Question 18

What are the effects of NSAIDs’ inhibition of PGE2? (FA15 p445) (FA16 p447) (SU p243) What role do
prostaglandins and angiotensin II play on the renal arterioles? (FA15 p530, 532) (FA16 p535, 537) (SU
p148)

Answer 18

NSAIDs – reversibly inhibits cyclooxygenase (both COX-1 and COX-2) blocks prostaglandin synthesis
clx – antipyretic / analgesic / anti-inflamm / Indomethacin used to close PDA
Side effects – interstitial nephritis, gastric ulcer (prostaglandins protect gastric mucosa), renal ischemia (prostaglandins vasodilate afferent arteriole)

Prostaglandins preferentially dilate afferent arteriole (increase RPF, increases GFR, so no change in FF)
ATII - stimulates Na/H exchange –> increase Na, H2O, and HCO3 reabsorption (permitting contraction alkalosis)

Question 19

What is the difference between a case-control study, a cohort study, and a clinical trial? (FA15 p48)
(FA16 p32) (SU p17-18) Which studies use odds ratios, and which use relative risks? (FA15 p48, 50)
(FA16 p32, 34) (SU p18)

Answer 19

Case-control study - look for prior exposure or risk factor “what happened” (OR)

Cohort study - Prospective (RR)

Clinical trial - experimental study involving humans.

Question 20

T cells are found in the paracortex of the lymph node between the follicles and the medulla. Which
cytokines are secreted by the two different types of helper T cells (Th1 and Th2)? (FA15 p202) (FA16
p194) (SU p373-374)

Answer 20

Th1 - IL-2 / IFN-gamma

Th2 - IL-4 / IL-5 / IL-10 / IL-13

Question 21

A 32-year-old man is being treated for alcohol dependence with disulfiram. One night, he begins drinking and later has severe nausea and vomiting. What is the mechanism of action of disulfiram? What other drugs have a disulfiram-like effect? (FA15 p95) (FA16 p83) (SU p305) (GG p643-644)

Answer 21

Mechanism of action of Disulfiram - inhibits acetaldehyde dehydrogenase (acetaldehyde accumulates, contributing to hangover symptoms)

Fomepizole - inhibits alcohol dehydrogenase, antidote for methanol and ethylene glycol poisoning

Metronidazole
Certain Cephalosporins
Griseofulvin
1st gen Sulfonylureas

Question 22

What is PPAR-γ? How is it relevant to the treatment of diabetes mellitus? (FA15 p338-339) (FA16 p334-335) (SU p181)

Answer 22

PPAR-gamma - genes activated by PPAR regulate fatty acid storage and glucose metabolism. activation of PPAR increase insulin sensitivity and levels of adiponectin.

Peroxisome proliferator-activated receptor gamma
nuclear receptor and transcription factor found in adipose tissue
plays a role in adipocyte differentiation
TZD binds PPAR-gamma and improve insulin sensitivity

Question 23

The thalamus is a relay station that conducts signals to and from the brain. Which thalamic nuclei are
the relay stations for each of the following body sensations/activities? (FA15 p456) (FA16 p458) (SU
p40)
• Auditory sensation
• Visual sensation
• Motor to the body
• Facial sensation
• Body sensation

Answer 23

Medial geniculate nucleus
-------------------------
Lateral geniculate nucleus
-------------------------
Ventral lateral nucleus
-------------------------
Ventral postero-medial nucleus
-------------------------
Ventral postero-lateral nucleus

Question 24

A 40-year-old man arrives at your clinic for his first physical in 20 years. He reeks of cigarette smoke,
and you notice his jacket bears the logo of his favorite tobacco company. He proudly informs you that
he got this great jacket by redeeming his cigarette cartons. At what stage of change in overcoming his
smoking habit is this man? (FA15 p517) (FA16 p521)

Answer 24

Precontemplation - not yet acknowledging that there is a problem

Contemplation
Preparation
Action
Maintenance
Relapse

Question 25

A 23-year-old man comes to your clinic with a fever of 39°C, a headache, and myalgias. This is the second fever he has had in the last two weeks. He recently finished treatment to eradicate the lice infestation that he acquired during a recent trip to Mexico. What organism might be responsible for this man’s recurrent fever? (FA15 p142) (FA16 p132)

Answer 25

(X) Rickettsia prowazekii (Epidemic typhus : recurrent fever from human louse) ``` Borrelia Recurrentis = relapsing fever due to variable surface antigens (louse/lice) Sudden fever Muscle or joint aches Nausea Rash ```

Question 26

What physiologically is taking place in decompression sickness? (Phys p538)

Answer 26

Decompression sickness gases (especially nitrogen) that had dissolved in the blood at high pressures form bubbles that can occlude blood vessels

Question 27

Which drugs are known to cause aplastic anemia? What is the treatment for aplastic anemia? (FA15 p258, 393) (FA16 p252, 391) (SU p396, 263-264)

Answer 27

Carbamazepine, Methimazole, NSAIDs, Benzene, Chloramphenicol, Propylthiouracil / anti-Cancer drugs immunosuppressive agents (antithymocyte globulin, cyclosporine), bone marrow allograft, RBC/platelet transfusion, bone marrow stimulation GM-CSF

Question 28

Is a 34-year-old schizophrenic patient having active hallucinations, who is not oriented to time, place, or person, able to legally agree to a plan of care? What factors must be in place in order for a patient to have the capacity to make a decision? (FA15 p57) (FA16 p40) (SU p21)

Answer 28

No Needs to make and communicate a clear choice Needs to be informed and understand risks, benefits, and alternatives Decision must be stable over time Decision is consistent with patient's values and goals Decision is not based on hallucinations or delusions

Question 29

A 34-year-old woman develops a painful right eye with decreased visual acuity. Exam demonstrates a firm right eye. What type of glaucoma is the patient experiencing? What is the difference between the mechanism of closed- and open-angle glaucoma? What is the fundoscopic finding associated with glaucoma? What is the treatment for closed- and open-angle glaucoma? (FA15 p480, 494) (FA16 p484, 498) (SU p37)

Answer 29

Sudden vision loss, Rock hard eye ==> Acute Closed Angle Glaucoma (narrow angle glaucoma) Open angle -- microscopic blockage of trabecular meshwork (insidious, peripheral vision loss) Closed angle -- forward movement of lens against central iris / obstruction of normal aqueous flow through pupil Fundoscopic finding -- "cupping" ``` TX open - Latanoprost (topical prostaglandins) Topical beta blockers Topical alpha 2 agonists Topical acetazolamide Topical muscarinic agonists Surgery ``` closed - Timolol (topical beta blocker) Apraclonidine (topical alpha 2 agonist) Pilocarpine (topical muscarinic agonist) Acetazolamide PO or IV IV mannitol Laser Iridotomy

Question 30

A 1-year-old boy is brought to the clinic for evaluation of his skin. The patient’s skin was normal at birth but now is erythematous, scaly, and has many new freckles. Workup and an astute attending reveal that this child has xeroderma pigmentosum. What cancers will this child be at higher risk of developing? (FA15 p235) (SU p253)

Answer 30

``` XERODERMA PIGMENTOSUM -Skin cancer Melanoma Basal Cell Carcinoma Squamous Cell Carcinoma ```

Question 31

What organism causes Hansen disease? What animal serves as the reservoir for this organism in the U.S.? Where in the body does this organism live? (FA15 p134) (FA16 p125) (SU p467-468)

Answer 31

Hansen Disease (Leprosy) - Caused by Mycobacterium Leprae - ARMADILLOS - infects skin and superficial nerves "glove and stocking" which happens to be the coolest part of the bdy

Question 32

What is BNP, and how is it useful in cases of heart failure? (FA15 p285) (FA16 p279) (H p2216)

Answer 32

BNP = B-type (brain) natriuretic peptide released from ventricular myocytes in response to increased tension (stretch) Similar physiologic action to ANP, longer half-life BNP blood test used for diagnosing HF (very good negative predictive value (useful as a diagnostic test) Available in recombinant form (nesiritide) for treatment of HF

Question 33

A 9-year-old child is brought into the clinic for evaluation of a right wrist drop and confusion. Physical exam reveals a bluish line on the gingivae. What peripheral smear finding is consistent with lead poisoning? What is the treatment for lead poisoning in this patient? (FA15 p388, 391) (FA16 p386, 389) (SU p259-260)

Answer 33

Basophilic Stippling ==> Lead poisoning --> bluish line on the gingivae Lead inhibits ferrochelatase and ALA dehydratase --> decrease heme synthesis and increase RBC protoporphyrin also inhibits rRNA degradation --> RBCs retain aggregates of rRNA (basophilic stippling) L: lead lines on gingivae (Burton lines) and metaphyses of lone bones on x-ray E: encephalopathy and erythrocyte basophilic stippling A: abdominal colic and sideroblastic anemia D: drops of wrist and foot --> 1st line: Dimercaprol & EDTA Succimer used for chelation for kids "SUCks to be a kids who eats lead" (EDTA +succimer / severe --> Dimercaprol +succimer)

Question 34

A 62-year-old man complains of weak urine stream and hesitancy when trying to urinate. His physician prescribes finasteride. How does this agent treat benign prostatic hyperplasia? (FA15 p597) (FA16 p603) (SU p217, 223) (GG p1205)

Answer 34

FINASTERIDE --> 5alpha-reductase inhibitor | decreases conversion of testosterone to DHT

Question 35

A kidney transplant patient begins to experience renal failure seven years after receiving her kidney transplant. What type of rejection is this, and how is it mediated? (FA15 p217) (FA16 p211) (SU p385)

Answer 35

Chronic (months to years) Mediated by CD4+ T cells responding to recipient APCs presenting donor peptides Both cellular and humoral components (type II and type IV hypersensitivity reactions) (Obliterative vascular fibrosis)

Question 36

What test is used to detect corneal abrasions?

Answer 36

*** | Fluorescein dye test!!

Question 37

What physiology accounts for the automaticity of the AV and SA nodes? (FA15 p281) (FA16 p275) (SU p62-63) (Phys p111-112)

Answer 37

* ** 1) Gradually increasing Na channel conductance 2) Slow, spontaneous depolarization during diastole 3) When threshold reached, action potential generated

Question 38

What is p value? What is an acceptable p value? (FA15 p54) (FA16 p38) (SU p19)

Answer 38

*** p value probability that the study results occurred by chance alone p<0.05 is considered statistically significant

Question 39

A patient with an epilepsy diagnosis is pregnant with her first child. She is concerned that her child may also have seizures. What are the most common causes of seizures in children? In adults? In the elderly? (FA15 p489) (FA16 p494) (SU p44)

Answer 39

*Order* ``` Seizures Causes in Children Genetic Infection (febrile) Trauma Congenital Metabolism ``` ``` Seizure causes in Adults Tumor Trauma Stroke Infection ``` ``` Seizures causes in Elderly stroke tumor trauma metabolic infection ```

Question 40

Which diuretics lower serum calcium levels? What is the mechanism by which these cause hypocalcemia? (FA15 p553-554) (FA16 p557-558) (SU p164-165)

Answer 40

Loops Lose Ca++ --> decrease paracellular Ca++ reabsorption --> hypocalcemia *** Inhibits cotransport system (Na+/K+/2CL) Ca++ reabsorbed passively via electrochemical gradient

Question 41

What is the difference between a promoter region and an enhancer region? (FA15 p68) (FA16 p54) (SU p284)

Answer 41

Promoter region -- site where RNA polymerase II and multiple other transcription factors bind to DNA upstream from gene locus **TATA box / CAAT box When RNA polymerase binds there, it PROMOTES gene expression and transcription Enhancer region -- stretch of DNA that alters gene expression by binding transcription factors **does not have to be upstream ENHANCES gene expression by binding transcription factors

Question 42

What medications are considered first line in the treatment of ADHD? (GG p303)

Answer 42

``` 1st for ADHD: Stimulants -Methylphenidate (Ritalin, Concerta) -Dextroamphetamine (Adderall) SSRI -Atomoxetine (Strattera) If insomnia --> clonidine ```

Question 43

What are the signs of right-sided heart failure? What are the signs of left-sided heart failure? What is most often the cause of right-sided heart failure? (FA15 p297) (FA16 p292) (SU p83-86)

Answer 43

``` Right-sided HF SXS Hepatomegaly Nutmeg liver JVD Peripheral Edema Left-sided HF SXS Orthopnea Paroxysmal Nocturnal Dyspnea Pulmonary Edema ```

Question 44

What abnormal lab values would lead you to suspect alcoholic hepatitis? (FA15 p369) (FA16 p367) (SU p136)

Answer 44

AST>ALT Swollen and necrotic hepatocytes with neutrophilic infiltration Mallory bodies

Question 45

How many umbilical vessels are there? Which umbilical vessel has the highest oxygen content? (FA15 p563) (FA16 p567) (SU p63)

Answer 45

3: two arteries, one vein umbilical vein has the highest oxygen content

Question 46

What organisms are particularly known for causing infective endocarditis? (FA15 p128-130, 147) (FA16 p119-121, 137) (SU p87) (H p1052) (R p559)

Answer 46

``` Infective Endocarditis Staphylococcus Aureus (30%) Viridans Strep (20-30%) Streptococcus mutans Enteroccocci (10%) Coagulase-negative staph (5-10%) Staphylococcus epidermidis ``` ``` **Know it is endocarditis, but no cultures growing --> HACEK Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella ```

Question 47

A 60-year-old male long-time patient of yours comes to your office complaining of sexual dysfunction. What is the differential diagnosis? What drugs are known for causing sexual dysfunction? (FA15 p516) (FA16 p520) (SU p221)

Answer 47

``` Sexual Dysfunction Desire disorders (hypoactive sexual desire / sexual aversion) Sexual arousal disorders (erectile dysfunction) Orgasmic disorders (anorgasmia, premature ejaculation) Sexual pain disorders (dyspareunia, vaginismus) ``` DDx: Drugs (antihypertensives like beta-blockers, neuroleptics, SSRIs, ethanol) Diseases (depression, diabetes, STIs) Psychological (performance anxiety)

Question 48

A 44-year-old woman is seen in the ER for shortness of breath, malaise, and high fever. Chest x-ray reveals a right-sided consolidation, and her labs reveal a WBC count of 12,000. Which organism is overall the most common cause of lobar pneumonia? What organisms are the most common causes of interstitial (walking) pneumonia? (FA15 p616) (FA16 p624) (SU p109)

Answer 48

MC for Lobar Pneumonia Strep Pneumoniae Staph Aureus H. Influ Klebsiella MC for Interstitial (walking/atypical) Pneumonia Mycoplasma Chlamydia Legionella Viruses (RSV, CMV, influenza, adenovirus)

Question 49

Which type of lymphoma has a presentation that is very similar to CLL and fewer constitutional signs/symptoms? (FA15 p402) (FA16 p402) (SU p272)

Answer 49

Small lymphocytic lymphoma (one of the non-Hodgkin) ** Lymphoma -- cancer of the lymphocytes within the lymph nodes ~40 different types of lymphoma (Hodgkin's vs all other non-Hodgkin's) SLL same disease as CLL but SLL is in lymph nodes and CLL is in the blood and marrow

Question 50

A 30-year-old man is at an inpatient facility for opioid addiction. What symptoms might this patient experience while discontinuing opioids? (FA15 p518) (FA16 p522) (SU p53)

Answer 50

``` Opioid withdrawal Sweating (perspiration) Dilated Pupils Piloerection ("cold turkey") Fever , Rhinorrhea ("flu-like symptoms") * Yawning Nausea / Stomach cramps / Diarrhea Restless leg syndrome ```

Question 51

In your own words, describe what type I () error is. (FA15 p54) (FA16 p38) (SU p19)

Answer 51

you observed or stated a difference that did not exist **study shows a difference between two groups, when no difference exists

Question 52

What trace element is essential to the function of carbonic anhydrase and lactate dehydrogenase? (Phys p856)

Answer 52

** Zinc (certain type of protein folding)

Question 53

A 30-year-old man who is experiencing shortness of breath is diagnosed with obstructive lung disease on pulmonary function testing. The patient does not have a history of asthma and has never smoked. The patient is subsequently diagnosed with α1-antitrypsin deficiency. How does the emphysema caused by smoking differ from the emphysema caused by α1-antitrypsin deficiency? (FA15 p371, 610) (FA16 p369, 618) (SU p105)

Answer 53

Alpha1-antitrypsin deficiency : uninhibited elastase in alveoli --> decrease elastic tissue --> panacinar emphysema **normally protects lung from ELASTASE --> neutrophils do their job but end up destroying connective tissue Smoking emphysema --> upper lobes --> Centriacinar emphysema

Question 54

In what clinical scenarios would you see a “nutmeg” liver? (FA15 p297, 370) (FA16 p292, 368) (SU p84, 135)

Answer 54

CHF (right-sided) Budd-Chiari Syndrome (thrombosis or compression of hepatic veins with centrilobular congestion and necrosis --> congestive liver disease) + no JVD ** increase central venous pressure increase resistance to portal flow

Question 55

You are performing a radical mastectomy and exercise extreme caution as you dissect laterally along the serratus anterior muscle. You do this in order to avoid severing which motor nerve, which would result in what sequela? (FA15 p419) (FA16 p420) (SU p239)

Answer 55

Long thoracic nerve Winged scapula

Question 56

A patient comes to the clinic complaining of severe low back pain that radiates down the back of her leg. What is the most likely explanation for her pain? (COA p474-475)

Answer 56

Sciatica ** herniated intervertebral disc -- nucleus pulposis protrudes thru vertebral canal, compresses the nerve root

Question 57

What problem/abnormality is associated with the following buzzwords? • Calf pseudohypertrophy (FA15 p624) (FA16 p630) (SU p249) • Gower maneuver (FA15 p85) (FA16 p73) (SU p249) • Subluxation of the lenses (FA15 p83) (FA16 p71) (SU p236) • Café-au-lait spots (FA15 p83) (FA16 p71) • Tuft of hair on lower back (FA15 p449) (FA16 p451) (SU p24)

Answer 57

``` Duchenne Muscular Dystrophy (x-linked recessive, gower sign, frameshift mutation of dystrophin gene) ------------------------------- ------------------------------- Marfan Syndrome FBN1 gene on chr15 ``` ``` ** Homocystinuria ----------------------------- Neurofibromatosis type 1 McCune-Albright syndrome ----------------------------- Spina Bifida Occulta skin dimple ```

Question 58

What type of cell differentiation and maturation takes place at the thymus? (FA15 p199) (FA16 p191) (SU p367, 372-373) The thymus also functions to positively restrict major histocompatibility complex (MHC) at the corticomedullary junction. On which cells would you expect to find MHC I? MHC II? (FA15 p200) (FA16 p192) (SU p371)

Answer 58

T cells = thymus MHC I -- CD8+ cytotoxic T cells (found on most all nucleated cells) MHC II -- CD4+ helper T cells (only on APCs)

Question 59

A 59-year-old man with a 50-pack-year history of smoking sees you for management of his COPD. What is the clinical definition of chronic bronchitis? (FA15 p610) (FA16 p618) (SU p104)

Answer 59

CHRONIC BRONCHITIS Productive cough >3 months per year for >2 consecutive years EMPHYSEMA Permanent enlargement of alveolar air spaces

Question 60

A 50-year-old woman develops a new onset of low back pain without a specific injury. A lumbar x-ray reveals lytic lesions which raise suspicion for multiple myeloma. What is the characteristic finding on electrophoresis with multiple myeloma? What is the classic finding in the urine of a patient with multiple myeloma? (FA15 p401) (FA16 p401) (SU p276)

Answer 60

M spike on serum protein electrophoresis Urine? Bence-Jones proteins (Ig light chains, cannot detect via dipstick only urine electrophoresis)

Question 61

What is the mechanism of action of local anesthetics? Which nerve fibers are blocked first with local anesthesia? (FA15 p499) (FA16 p503)

Answer 61

Local Anesethetics - block Na channels by binding to specific receptors on inner portion of channel - prevents nerve firing - first blocked: small myelinated fibers

Question 62

What medications are used in the treatment of urge incontinence? (GG p232)

Answer 62

Urge incontinence - oxybutinin vs. bethanecol ``` ** Anticholinergic drugs - oxybutynin - tolterodine - darifenacin - solifenacin - trospium ```

Question 63

What are the three different eukaryotic RNA polymerases? What type of RNA does each make? (FA15 p68) (FA16 p54) (SU p284)

Answer 63

RNA polymerase I - makes rRNA RNA polymerase II - makes mRNA RNA polymerase III - makes tRNA

Question 64

Which cell types do not require insulin for the uptake of glucose? (FA15 p314) (FA16 p308) (SU p174)

Answer 64

Normally, GLUT4 needed to transport glucose into tissue (muscle, fat, etc), triggered by insulin. BRICK L ``` B: brain R: RBC I: intestine C: cornea K: kidneys L: liver ```

Question 65

What are the layers of the epidermis beginning with the most superficial layer? What is Auspitz sign? (FA15 p436, 439) (FA16 p437, 440) (SU p251-252)

Answer 65

``` Californians Like Girls in String Bikinis Stratum Corneum Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale ``` Auspitz sign -- bleeding from exposure of dermal papillae when scales are scraped off

Question 66

What is Kallmann syndrome? (FA15 p579) (FA16 p586) (SU p201) (H p2878)

Answer 66

Failure to complete puberty (hypogonadotropic hypogonadism) Usually sporadic but often X-linked if familial Much more common in males Defective migration of GnRH cells and formation of olfactory bulb decreased synthesis of GnRH in the hypothalamus ANOSMIA Low FSH, low LH, low testosterone

Question 67

A 67-year-old man with congestive heart failure lost his job and medical insurance, so he stops buying and taking his digoxin, and develops dyspnea. What will this do to his cardiac output (CO)? What are the mechanisms behind his development of dyspnea?

Answer 67

Digoxin -- positive inotrope --> increases myocardial contractility After stopping digitalis --> Cardiac Output will decrease due to loss of positive inotropic effect Decreased CO --> decreased pumping of blood from LV --> backup of blood in pulmonary vasculature --> pulmonary edema --> dyspnea

Question 68

A 17-year-old girl is brought to the emergency room for abdominal pain and vomiting. She has a fever, and further questioning and exam reveal that the pain is in the right lower quadrant and has rebound tenderness. She says the pain began around the umbilicus. She is very nauseated and vomits again during the exam. What must be ruled out prior to coming to the final diagnosis in this patient? (FA15 p363) (FA16 p360) (SU p118, 125)

Answer 68

beta-hCG to r/o preganancy or ectopic

Question 69

A 31-year-old man is post-op day 1 after an exploratory laparotomy. The surgery was performed emergently for intraperitoneal hemorrhage after a motorcycle crash. His creatinine today is elevated to 2.0 mg/dL. His pain is currently uncontrolled. Explain why an NSAID could lead to a potential complication in this patient. (FA15 p530, 533) (FA16 p535, 538) (SU p243-244)

Answer 69

NSAIDs -- inhibits COX and blocks prostaglandins Prostaglandins preferentially DILATES afferent arteriole (increase RPF, GFR, so no change in FF) Afferent arteriole of glomeruruls does not dilate -> decreased plasma flow -> decreased GFR

Question 70

Which phagocyte dysfunction disease increases patient susceptibility to Staphylococcus aureus and Escherichia coli? What is the cause of this disease? (FA15 p215) (FA16 p209) (SU p308, 383)

Answer 70

Chronic granulomatous disease -- defect in NADPH oxidase --> decrease reactive oxygen species X-linked recessive In absence of NADPH oxidase, phagocytes can use hydrogen peroxide from the environment to create oxygen free-radical BUT, organisms w/ catalase --> no hydrogen peroxide in the environment