Practice Test 4 Flashcards
What are the 9 possible criteria for major depressive disorder?
Need 5/9 for at least 2 weeks and at least one must be anhedonia or depressed mood
- Depressed mood most of the day
- Anhedonia
- Significant weight loss/gain, diminished appetite
- Insomnia/hypersomnia
- Psychomotor agitation/retardation almost everyday
- Fatigue or loss of energy
- Feelings of worthlessness, guilt
- Diminished ability to think or concentrate
- Recurrent thoughts of death/suicide w/ or w/o a plan
What drug class is typically the first line tx of major depressive disorder?
SSRIs-lowest side effect profile
What is the raphe nucleus responsible for?
- Plays a role in the sleep-wake cycle and patient’s level of arousal
- Primary NT in this area is serotonin
What is venlafaxine?
An SNRI - works to increase the levels of serotonin in the raphe nucleus
-Serotonin can be decreased in depression and anxiety
What is the basal nucleus of Meynert?
Contains neurons that mostly contain receptors for Ach
What is the locus ceruleus?
- Principal site for the production of norepi
- Closely associated with the SANS
What is the nucleus accumbens?
- Plays a large role in the risk reward system
- Primary NTs in this area are dopamine and GABA
What is the ventral tegmentum?
- Plays a role in cognition, motivation, orgasm, and drug addiction
- Primary NT is dopamine
What are the signs and symptoms of DiGeorge syndrome and the mnemonic to remember these?
-Digeorge syndrome is AKA?
CATCH-22 -*C*ardiac defects -*A*bnormal facies -*T*hymic hypoplasia -*C*left palate -*H*ypocalcemia -deletion on the chromosome 22 (22q11) Digeorge syndrome is AKA congenital thymic aplasia
Aberrant development of what pouch causes the thymic hypoplasia in Digeorge syndrome?
3rd pharyngeal pouch
Aberrant development of which pharyngeal pouch(es) causes the hypoCa?
3rd pharyngeal pouch-develops into inferior parathyroids
4th pharyngeal pouch-develops into superior parathyroids
The 1st pharyngeal cleft develops into what structure?
External auditory meatus
The 2nd, 3rd, and 4th pharyngeal clefts develop into?
Temporary cervical sinuses-normally obliterate but if they persist they can cause cervical cysts
What does the 1st pharyngeal pouch develop into?
Middle ear canal
What does the 2nd pharyngeal pouch develop into?
Tonsillar fossa crypts
Describe the histology associated with small cell lung cancer
Small cell lung cancer AKA oat cell carcinoma
- Arises from neuroendocrine Kulchitsky cells that line the bronchioles
- These cells have small, dark blue appearance and are capable of local hormone secretion
Small cell lung cancer can be associated with what paraneoplastic diseases?
- SIADH
- Lambert-Eaton syndrome
- Cushing’s syndrome (d/t secretion of ACTH)
What are the symptoms of SIADH?
-Hyponatriemia-Sx begin at Na < 120-Nausea, vomiting, watery diarrhea, HTN, oliguria, increased ICP, and potentially seizure and coma
What is the protocol for correcting hypoNa?
- HypoNa must be corrected slowly using hypertonic saline
- Overly rapid increase in serum Na may cause central pontine demyelination
What is Lambert-Eaton syndrome?
-AutoAbs to presynaptic Ca channels which prevents Ach release leading to proximal muscle weakness
What is Cushing’s syndrome?
- Excess cortisol as a result of ectopic ACTH production
- Sx-HTN, weight gain, moon facies, truncal obesity, buffalo hump, hyperglycemia, and/or osteoporosis
What is Conn’s syndrome?
- Hyperaldosteronism
- Primary hyperaldo-aldo secreting tumor
- Secondary hyperaldo-caused by kidney’s perception of low intravascular volume which causes increased renin
What is Kallmann syndrome?
A form of hypogonadotropic hypogonadism
- Pathogenesis-Abnormal development of neurons associated with the olfactory bulb in the hypothalamus, which leads to decreased synthesis of GnRH
- Lack of or delayed puberty, gonad development
- ANOSMIA/hyposmia
What are the lab findings associated with Kallmann syndrome?
-Decreased FSH, LH, testosterone, and sperm count
5 alpha reductase deficiency is characterized by?
- Inability to convert testosterone to DHT
- DHT is required for the development of male external genitalia, before birth
- These pts have ambiguous genitalia until puberty
- Normal LH, FSH, and testosterone levels
What happens at puberty in pts with 5 alpha reductase deficiency?
When the patient hits puberty increased levels of 5 alpha reductase in peripheral tissue convert testosterone leading to masculinization
What is androgen insensitivity syndrome?
AKA testicular feminization
- Caused by a defect in the androgen receptor
- Results in genotypical males to have female phenotypes, except testes are present
- Levels of testosterone, estrogen, and LH are elevated
What is klinefelter syndrome?
-Male with phenotypical female features-gynecomastia and female hair distribution
What would a patient with an XYY phenotype look like?
Tall male with severe acne and antisocial behavior
What are the symptoms of zinc deficiency?
- Hypogonadism
- Anosmia
- Dysgeusia (taste)
- Poor wound healing
What paraneoplastic syndrome can be associated with squamous cell carcinoma?
Pseudohyperparathyroidism-production of PTHrp (Serum PTH levels would be normal but would have hyperCa and hypophosphatemia)
What would squamous cell carcinoma look like on chest x ray?
Hilar mass near the bronchi
How is chronic kidney disease officially diagnosed clinically?
Decreased GFR for 6 months
What does a serum BUN:Cr ratio > 20 indicate?
Pre renal cause of renal dysfx such as hypotension and renal artery stenosis
What does a serum BUN:Cr ratio of 10-20 indicate?
Postrenal cause of renal dysfx (or normal)
-Ureteral obstruction or BPH
What does a serum BUN:Cr ratio of < 10 indicate?
Intrarenal cause of renal dysfx-glomerulonephritis or acute tubular necrosis
What characteristics promote cast formation?
- Low urine pH
- Low urine flow rate
- High urinary salt concentration
Where in the renal tubule do casts usually form?
Distal convoluted tubule or collecting duct
Casts in the urine are usually indicative of a disease of what origin?
Intrarenal origin
Waxy and broad casts are indicative of?
Advanced renal failure
Brown and muddy casts are indicative of?
Acute tubular necrosis (Casts may be absent in 20-30% of patients)
What is the definition of acute kidney injury?
- Abrupt (days-weeks) decline in renal function
- Manifested by acute elevation in plasma BUN and serum creatinine
- Usually reversible
What is acute tubular necrosis?
- When an acute ischemic or toxic event results in tubular cell damage/death
- MCC of acute kidney injury in the intrarenal category
- Follows a well-defined 3 part sequence-initiation, maintenance, and recovery
- Normal sized kidneys on US
What are hyaline casts indicative of?
- Can show up in the urine of healthy people
- Can also occur in patients with dehydration, low urine flow, acidic patients, or vigorous exercise
- Very non-specific
Red blood cell casts can be indicative of?
- Glomerulonephritis, particularly nephritic syndrome
- SLE, Goodpasture syndrome, post-strep GN
What is nephritic syndrome?
Characterized by:
- Urine protein loss of less than 3.5 g/day, rbc casts, hypoproteinemia, edema and hyperlipidemia
- Typically associated with systemic illnesses
What is the classic presentation of Goodpasture syndrome?
Pulmonary hemorrhage and glomerulonephritis
How would a nephritis causing diseases (Goodpasture’s or SLE) be diagnosed?
Kidney biopsy and histologic examination of the glomerulus
What are white blood cell casts indicative of?
Acute pyelonephritis or acute tubulointerstitial nephritis
-Direct inflammation and infection of the kidney
What is the presentation of pyelonephritis?
-Dysuria, flank pain, fever, nausea and vomiting
What is tubulointerstitial nephritis?
-Tubulointerstitial=broad term used to refer to kidney diseases that involve structures in the kidney outside of the glomerulus
What is acute interstitial nephritis?
- Tubular damage caused by drugs or infx -> renal tubular dysfx with or without renal failure
- Damage is generally reversible
What is the principal mechanism that causes acute tubulointerstitial nephritis?
- Hypersensitivity reaction to drugs such as penicillins, NSAIDs, and sulfa drugs
- Can also be caused by infx-viral or bacterial-often associated with obstruction or reflux
What is the anterior interosseous nerve?
- Branch of the median n
- Found in the interosseous membrane with the interosseous a.
- Provides only motor innervation to the deep muscles of the hand (FPL, lateral half of FDP, and pronator quadratus)
What type of fracture can lead to compression or inflammation of the anterior interosseous n?
-Significant distal forearm injury (such as a Galeazzi fracture)
What would be the deficits of a patient with a lesion of the median nerve?
Motor and sensory deficits
-Sensory changes over the lateral 3.5 digits on the palmar side and distal 1/3 of the dorsum of the thumb, 2nd and 3rd digit
What is the musculocutaneous nerve?
Part of the brachial plexus-innervates part of the upper extremity
- Arises from the lateral cord from levels of C5, C6, and C7
- Innervates the biceps, coracobrachialis, and upper aspect of the brachialis
- Also provides sensation to the lateral aspect of the forearm
What nerves are most often involved in Erb’s palsy?
AKA waiter’s tip
Upper trunk C5-C6-suprascapular, musculocutaneous, and axillary
Isolated injury of the musculocutaneous nerve presents as?
Weakness of elbow flexion and forearm supination
What is the radial nerve?
-Provides sensation to the posterior aspect of the forearm and dorsal aspect of the lateral hand and medial 2/3 of the thumb
Radial nerve injury presents as?
Saturday night palsy/using crutches incorrectly
- Loss of finger extension and wrist (wrist drop)
- Motor weakness with elbow extension (triceps innervation) and extensor muscles of the forearm
- Sensory changes across the posterior forearm and lateral 3.5 digits
What is the ulnar nerve?
- Provides sensation to part of the 4th digit and whole 5th digit
- Provides motor innervation for the flexion, abduction, and opposition of the 5th digit
Ulnar nerve injury presents as?
Inability to adduct and abduct their fingers -> claw hand deformity
What are the symptoms of a tension headache?
- Ascending headache with hypertonicity of the head and neck
- Diffuse pain
- Absence of neurologic sx or photosensitivity
- Bilateral
What is the acute treatment for a tension headache?
Acetaminophen and NSAIDs
What is the prophylactic headache for tension headache?
- Patient education regarding posture and lifestyle medications
- TCAs (amitriptyline)
- Behavioral modification including biofeedback, relaxation, and CBT for stress management
What is a cluster headache?
- Unilateral and periorbital with rapid onset
- Commonly assoc with nasal stuffiness and watery eyes
- Often have a “cluster” of headaches w/in a short time frame
- More common in males
What are migraine headaches?
-May be accompanied by the sensation of an aura, photosensitivity, nausea, vomiting, unilateral pain, and possibly temporary neuro symptoms
Migraines without aura (non-classic) are described as?
- Lasting 4-72 hours
- With at least 2 of the following: unilateral location, pulsating feeling, moderate/severe intensity, aggravation by physical activity
- And at least 1 of the following: nausea, vomiting, photophobia, phonophobia
- And at least 5 attacks
What are cerebral aneurysms?
- Occur in one of the narrow arteries of the circle of willis
- When an aneurysm ruptures patients typically complain of an acute onset thunder clap headache “Worst headache of my life”
- Assoc with subarachnoid hemorrhage
What is pseudotumor cerebri?
AKA idiopathic intracranial HTN
- increase in ICP in the absence of any distinct pathological entity or mass
- Sx include headache, nausea, vomiting, diplopia
- Fundoscopic exam shows papilledema
- Most common in young obese women
What is the protocol for oral contraceptive administration in postpartum patients?
OCPs can be detrimental to milk production during the first 3 weeks postpartum
-When lactation is better established past 6 weeks, combined OCPs are a reasonable option
What is Ehlers-Danlos syndrome?
- Autosomal dominant
- CT disorder that involves a defect in the gene encoding for types 3 and 4 collagen (fibrillar type)
- Hypermobile joints and hyperextensible skin and bruising
- Aortic aneurysms
- Dental crowding
- Mitral valve prolapse
What is osteogenesis imperfecta?
- Autosomal dominant
- Type 1 collagen defect (caused by glycine deficiency)
- Blue-gray discoloration of the sclera
- Frequent fractures (due to minor trauma)
What is Stickler syndrome?
- Autosomal dominant
- Affects collagen synthesis
- Characterized by craniofacial abnormalities (flat face), hearing loss, ocular problems (nearsighted, eye pain d/t inc IOP, and joint problems
What is Marfan syndrome?
- Autosomal dominant
- Defect in the gene FBN1 (encodes fibrillin-1)
- Most serious complications are heart valve defects and aortic involvement
- May also affect the lungs, eyes (subluxation of the crystalline lens), and the dural sac surrounding the spinal cord (dural ectasia)
What is pseudoxanthoma elasticum?
- Autosomal recessive
- Causes fragmentation and mineralization of the elastic fibers in certain tissues
- Mainly involves the skin, Bruch’s membrane of the eye, and vascular tissues in the form of premature atherosclerosis
- Small yellowish papules develop on the neck, axillae, and groin
What is haemophilus influenzae?
Gram negative (red) coccobacillus
What is the appearance of klebsiella pneumoniae on gram stain and who is commonly infected by this pathogen?
- Causes community acquired pneumonia in chronic alcoholics
- Gram negative rod
What is the appearance of moraxella catarrhalis on gram stain?
Gram negative diplococci
What is the appearance of staph aureus on gram stain?
Gram positive cocci in clusters
Staph aureus most often causes community acquired pneumonia in whom?
Patients with the flu (seasonal flu or H1N1 (swine) flu)
What is the histologic diagnosis of squamous cell carcinoma based on?
The presence of keratin production by tumor cells and/or intercellular desmosomes (bridges)
What is the histologic appearance of carcinoid tumors?
- Cytologically bland cells that are round/oval shaped
- Finely dispersed chromatin
- Inconspicuous small nucleoli
Bronchial carcinoid tumors are thought to arise from?
Specialized bronchial cell (Kulchitsky cell)
- Belong to the diffuse system of neuroendocrine cells, including enterochromaffin cells of the GI tract (the origin of GI carcinoids)
- These tumors have the ability to modify amine precursors like L-dopa of 5-hydroxytryptophan -> secrete biologically active neuroamines
What is carcinoid syndrome?
- Caused by systemic release of vasoactive substances such as serotonin
- Acute sx-cutaneous flushing, diarrhea, and bronchospasm
- Long term sequelae-venous telangiectasias, right sided valvular heart dz, and fibrosis in the retroperitoneum
What is large cell carcinoma?
- Malignant epithelial neoplasm lacking gladular or squamous differentiation by light microscopy and lacking cytologic features of small cell carcinoma
- Sheets of round/polygonal cells with prominent nucleoli and abundant pale cytoplasm
- Dx of exclusion
What is histologic appearance of adenocarcinoma of the lung?
- MC type of lung cancer
- Histologic diagnosis requires either neoplastic gland formation or intracytoplasmic mucin
