Key Questions Flashcards
A
The ECG findings of an irregularly irregular rhythm with normal QRS complexes and irregular, dysmorphic P waves along with tachycardia are characteristic of atrial fibrillation. Additional symptoms of atrial fibrillation may include a fluttering feeling in the chest, fatigue, or signs of embolism such as a stroke or organ ischemia.
Step 2: Disease Mechanism
Atrial fibrillation may be caused by many things, including structural and ischemic heart disease, heart failure, obesity, diabetes mellitus, and hyperthyroidism, suggested here by her intake of diet pills, in which thyroxine may be included to cause weight loss. Hyperthyroidism is a common cause of atrial fibrillation, as the excess thyroid hormone may increase catecholamine secretion and upregulation of b-adrenergic receptors. Some of the symptoms of hyperthyroidism may include hypertension, heat intolerance, fatigue, anxiety, tremulousness, and weight loss. Over-the-counter diet pills often have thyroid hormone derivatives in them and excessive use can lead to these symptoms and atrial fibrillation.
The other choices are incorrect:
Atrioventricular nodal reentrant tachycardia typically shows tachycardia with normal QRS complexes and regular RR intervals.
Thyroid-stimulating antibodies are seen in Graves disease, an autoimmune cause of hyperthyroidism. The patient lacks the goiter and exophthalmos characteristic of Graves disease.
Heart failure may cause atrial fibrillation, but this patient lacks the edema, dyspnea, and jugular vein distention associated with heart failure.
Mitral valve stenosis and mitral valve prolapse would be associated with heart murmurs on exam.
An 18-year-old woman is referred to a specialist because she has not yet begun to menstruate. Her blood pressure is 160/99 mm Hg. Physical examination is remarkable for Tanner stage 1 of breast development. Laboratory studies show a serum potassium level of 3.3 mEq/L. She is found to have high levels of a particular hormone.
The hormone most likely to be elevated in this patient is produced in which area of the adrenal gland?
Capsule
Medulla
Zona fasciculata
Zona glomerulosa
Zona reticularis
17α-Hydroxylase deficiency is a rare form of CAH that presents with hypertension, hypokalemia, and hypogonadism.
It is characterized by decreased glucocorticoid and sex steroid synthesis and increased mineralocorticoid production.
Mineralocorticoids are produced in the zona glomerulosa of the adrenal cortex.
A 65-year-old woman comes to the clinic because of a 4-month history of frequent bouts of diarrhea, and epigastric pain that wakes her during the night and improves with eating. She has a history of recurrent calcium kidney stones and a parathyroid adenoma. Physical examination is normal. Laboratory tests reveal an elevated serum gastrin level.
Which of the following additional serum concentrations is most likely elevated in this patient?
Catecholamines
Phosphate
Prolactin
Thyroxine
Uric acid
MEN 1 is associated with Parathyroid, Pancreatic, and Pituitary tumors (the 3 Ps).
The most common pituitary tumor type is prolactinoma, which increases serum prolactin levels.
37-year-old woman comes to her primary care physician because of a 2-week history of frequent urination. She reports voiding large volumes of urine seven to eight times per day. There is no hematuria. Medical history includes diabetes mellitus treated with metformin and schizoaffective disorder treated with paliperidone and lithium. Vital signs are normal. Serum studies show a sodium concentration of 130 mEq/L and a glucose concentration of 102 mg/dL. Urine osmolality is 75 mOsm/kg.
Which of the following is the most likely diagnosis?
Central diabetes insipidus
Hyperglycemic osmotic diuresis
Low total body sodium
Nephrogenic diabetes insipidus
Psychogenic polydipsia
Syndrome of inappropriate secretion of ADH
This patient has hyponatremia with very dilute urine (low urine osmolality <100 mOsm/kg), suggesting a diagnosis of psychogenic (primary) polydipsia. It is the only form of hyponatremia associated with low urine osmolarity. This overconsumption of water is most often seen in patients with psychiatric disorders as seen here. The excess water consumption (often >10 L per day) overwhelms the ability of the kidney to excrete all the water, leading to water retention and reduced serum osmolarity (with hyponatremia). Note that lithium commonly leads to polyuria, but with hypernatremia, not hyponatremia as seen here.
The other choices are incorrect; these are incorrect causes of hyponatremia:
The kidneys in patients with hyperglycemia who have a serum glucose level >300 mg/dL (not seen here) will filter more glucose than the proximal tubule can absorb, leading to osmotic diuresis, glucosuria, and polyuria.
Drugs such as antidepressants and sulfonylureas can cause a syndrome of inappropriate secretion of ADH (SIADH). However, in SIADH the urine is concentrated (>300 mOsm/kg) because the high ADH causes renal water reabsorption.
Patients with low total body sodium show clinical signs of volume depletion like hypotension and orthostasis. This patient does not have these findings, and the urine would be concentrated (>300 mOsm/kg), not dilute as seen here.
These cause hypernatremia, not hyponatremia:
Central diabetes insipidus is caused by the lack of posterior pituitary ADH secretion, most often seen after brain surgery, head trauma, or central nervous system tumors. It leads to dilute urine, polyuria, and hypernatremia.
Nephrogenic diabetes insipidus is common in patients taking lithium. Lithium causes ADH unresponsiveness in the collecting duct, leading to dilute urine, polyuria, and hypernatremia.
A 70-year-old woman is brought to the emergency department by her family because of worsening confusion, vomiting, weight loss, and increased urination for the past week. Her temperature is 38.4°C (101.2°F). On examination, mucous membranes are tacky and there is decreased skin turgor. There is tenderness over the costovertebral angle and above the pubis. Laboratory studies show a sodium level of 130 mEq/L, bicarbonate of 23 mEq/L, chloride of 95 mEq/L, and glucose of 850 mg/dL. Urinalysis reveals numerous bacteria, WBC, and WBC casts.
Which of the following physiological changes would most likely be expected in this patient?
Acidosis suppression of the Na+/K+-ATPase
Decrease in gluconeogenesis
Increased lipolysis
Increased production of acetoacetic acid
Movement of water into the intracellular space
Potassium movement from the cells to the blood
HHS is a hyperglycemic crisis seen in type 2 DM that causes extremely high blood glucose levels without high ketone levels.
In hyperglycemia, movement of potassium from the cells to the blood occurs due to solvent drag as water leaves cells due to the osmolar gradient, pulling potassium with it.
A 39-year-old woman with subclinical hypothyroidism comes to the physician because of a 8-month history of progressively worsening headaches and irregular menses. Her menses had previously occurred at regular 30-day intervals with moderate flow, but her last menstrual period was 12 weeks ago. She also reports that her interest in sexual intercourse has recently decreased. Her serum prolactin level is elevated. Which of the following is the most appropriate pharmacotherapy for this patient?
A.Bromocriptine
B. Ethinyl estradiol
C. Methyldopa
D. Metoclopramide
E. L-thyroxine
Comentarios: Correct. This patient presents with decreased libido, secondary amenorrhea, and hyperprolactinemia. Her headaches suggest a prolactinoma as the etiology. Dopamine agonists like bromocriptine or cabergoline are the first-line treatment for prolactinomas. These drugs act by increasing tonic dopamine signaling to inhibit lactotrophs in the anterior pituitary. This suppresses prolactin secretion and induces shrinkage of the tumor. Treatment for prolactinoma is indicated in cases such as this one, when the patient is symptomatic (e.g., headache, visual change, hypogonadism) or if the clinician believes that symptoms are imminent.
A 3-year-old boy is brought to the emergency department by his parents because of high fever, vomiting, and sleepiness that began while at daycare today. Temperature is 39.4°C (103°F), pulse is 126/min, and blood pressure is 80/53 mm Hg. There is a rash noted on the trunk and both lower legs, as shown. When the patient’s neck is flexed, his hips and knees flex. Laboratory studies show:
Na+: 127 mEq/L
K+: 5.6 mEq/L
Glucose: 48 mg/dL
Creatinine: 0.7 mg/dL
Alanine aminotransferase: 30 IU/L
WBCs: 16,000/mm3
Platelets: 80,000/mm3
The urinalysis is normal.
Which of the following is the most likely explanation for his abnormal serum studies?
Adrenal hemorrhage
Hemolytic uremic syndrome
Immune-complex vasculitis
Immunoglobulin A vasculitis
Kawasaki disease
Reye syndrome
This patient presents with hypotension, meningeal signs (positive Brudzinski sign), high fever, tachycardia, and lethargy. These suggest septic shock due to meningitis. The pictured petechial rash (pinpoint, red-brown round spots 1 to 2 mm wide) is characteristic of systemic infection with Neisseria meningitidis, which can be spread in children at schools and daycare.
Step 2: Disease Mechanism
Infection with N meningitidis can cause adrenal hemorrhage, or Waterhouse-Friderichsen syndrome. This leads to adrenal insufficiency. The low cortisol secretion may cause hypoglycemia and may worsen the hypotension already caused by sepsis. In addition, there may be hyponatremia and hyperkalemia due to low adrenal aldosterone release. Other infections may also cause this syndrome, including Pseudomonas, gonococcus, Streptococcus pneumoniae, and Staphylococcus aureus.
A medical investigator is developing new methods to treat hypertensive crisis in patients with pheochromocytoma. She simulates hypertensive crises in rats by injecting a substance that leads to hyperstimulation of the part of the adrenal gland responsible for secreting catecholamines.
Which of the following molecules was most likely injected in this study?
Acetylcholine
Cortisol
Dopamine
Epinephrine
Norepinephrine
-The adrenal medulla secretes catecholamines in response to direct stimulation by preganglionic sympathetic neurons. These neurons use the neurotransmitter acetylcholine to trigger catecholamine release from the adrenal medulla.
-NOT ASKING ABOUT HORMONES RELEASED BY MEDULLA.
A 40-year-old man comes to the emergency department because of sudden-onset, severe chest discomfort and headache. Pulse is 120/min and regular, and blood pressure is 180/90 mm Hg. Serum electrolytes, creatinine, and glucose are normal. Laboratory testing reveals increased urine metanephrines.
In normal subjects, which of the following cells is the main synthetic source of the circulating substance that is most likely causing this patient’s findings?
Adrenal zona fasciculata
Adrenal zona glomerulosa
Adrenal zona reticularis
Parasympathetic neurons
Posterior pituitary gland
Postganglionic sympathetic nerves
Pheochromocytoma, a rare catecholamine-producing tumor of the adrenal gland, presents with hypertension and sometimes episodic headache, tachycardia, and tremor.
Normal levels of circulating catecholamines are mostly due to leakage of norepinephrine from postsynaptic sympathetic neurons.
A 27-year-old male presents to the clinic with “tender bumps” in his groin for the past 2 days. He had unprotected intercourse with both men and women while on vacation in the Caribbean 1 month ago. He recently noticed a small, painless ulcer on his penis, which resolved on its own. Physical examination reveals bilateral, tender, inguinal lymphadenopathy with 2-cm overlying ulcerations.
Which of the following is the most likely cause of this patient’s condition?
Chlamydia trachomatis
Haemophilus ducreyi
Herpes simplex virus
Klebsiella granulomatis
Treponema pallidum
LGV is caused by C trachomatis serotype L1-L3 and initially presents as a self-limited, painless genital ulcer that can progress to ulcerated tender lymphadenopathy (buboes) after 4 to 6 weeks.
Oral glucose tolerance
GH stimulation test
Serum Prolactin levels
Serum GH levels
Oral glucose test–>supresses GH (normally incr glucose–>diabetogenic effects)
-GH stimulation test (insufficency)
Androgen synthesis
E.
Pituitary Prolactinoma–>promoting compression sympts (decr TSH)
A
-Pituitary adenoma–>compressing (HEADACHES)
-Cosyntropin use in diff adrenal insuficency 1* and 2/3*
-In 1* giving it–>will NOR change cortisol values (gland not working).
-Water Friederich Syndrome–> is 1* Adrenal Insufficency
-Lymphocytes (Hashimotos)
Plasma cells–>Riedel thyroiditis
-Pulmunary Neoplasm–>20% that have squamous cell carcinoma have ACTH secretion. High risk factor dor this tumor is SMOKING.
-Usually presents with respiratory symptoms.
A.
Dysgerminoma
-Early age
-Sympt explained by HCG, lymphocytes are seen.
- Large,solid, intact capsule
- Good respond to radiotherapy
- -Metastasis to para-aortic lymphnodes (same as Semoinoma)
-You see Schiller Duval Body–>Yolk sac tumor
-NO pain or ass estrogen sympt rules out Granulosa (ass with young age)and Thecoma.
-A immature Teratoma –>will appear very blue cells (embryonal cells( with neural epi)
Granulosa ovarian tumor.
-Coffe bean cells with excessive bleeding indicating incr estrogen.
-Calcifications are Mesoderm derived
Teratoma also appear as cyst.
