Q Banks: Week of 02/20/17

Question 1

Rapidly progressive glomerulonephritis presents with what pathology in the glomerulus?

Answer 1

Fibrin leaks into Bowman’s capsule and leads to a crescent-shaped fibrin deposit that ultimately destroys the glomerulus. This can result from ANCA, lupus, or Goodpasture.

Question 2

Rheumatic fever can result in what cardiac problems?

Answer 2

• Acute: pancarditis with mitral regurgitation

* Chronic: mitral stenosis

Question 3

Describe the neurodegenerative disorder that has X-linked dominant inheritance.

Answer 3

Rett syndrome presents with hand wringing and a deceleration of head growth.

(Think of DOMinic wearing an eXtra-Large shirt saying “Frankly, my dear, I don’t give a damn.” The GWTW scene should make you think of Rhett, because that’s the main male character.)

Question 4

What system is used to evaluate melanoma prognosis?

Answer 4

The Clark scale, which measures vertical growth

Question 5

Why is C-peptide a better indicator of insulin secretion than insulin?

Answer 5

C-peptide has less of a first-pass hepatic metabolism than insulin, so fluctuates less and is less variable in those with hepatic insufficiency.

Question 6

____________ can cause left-sided heart failure.

Answer 6

Mitral regurgitation

Question 7

In terms of pressure, how does blood pressure differ between the right ventricle and the pulmonary trunk?

Answer 7

The right ventricle fluctuates from almost 0 mm Hg to 25 mm Hg, while the pulmonary trunk fluctuates from roughly 10 mm Hg to 25 mm Hg.

Question 8

What is the best way to manage a patient with low literacy?

Answer 8

Explain procedures with visual materials as much as possible and assess for comprehension.

Question 9

Explain how to manage a patient who refuses medical intervention in emergent scenarios.

Answer 9

• If the patient is not conscious and no legal surrogate is present, then treat to stabilize the patient and re-assess when the patient is conscious and able to make an informed decision.
• If the patient is conscious and able to make an informed decision, then discharge the patient against medical advice.
• If the patient is intoxicated, have the legal surrogate (most often family) make decisions for the patient until the patient is sober. If the patient still refuses treatment when sober and is able to make an informed judgment, then discharge the patient against medical advice.

Question 10

A patient who presents with fever, back pain, an inguinal mass, and who positions himself with lordosis and flexion of the hip most likely has what?

Answer 10

Psoas abscess

The psoas muscle originates from the transverse processes of the spine and inserts onto the lesser trochanter. It is the main flexor of the hip.

Abscesses can arise in those with diabetes or immunosuppression.

Question 11

tRNA is composed of how many nucleotides?

Answer 11

Roughly 90

Question 12

tRNA synthetase recognizes what motif on the 3’ acceptor stem of tRNA?

Answer 12

CCA, which is added post-translationally

Question 13

The _______ loop mediates binding to the correct tRNA synthetase while the ________ loop mediates binding to the ribosome.

Answer 13

D; T

TR:DT

Question 14

Which kind of RNA has modified bases such as pseudouridine and ribothymidine?

Answer 14

tRNA

Question 15

Why does T3 remain normal until relatively late in Hashimoto’s?

Answer 15

T3 has an extremely short half-life, so it fluctuates. Even in a frankly hypothyroid person, the T3 may be able to temporarily be normal.

Question 16

From the peripheral tissues to the heart, histidine residues on hemoglobin carry _____________.

Answer 16

protons; while bicarb gets pumped out of RBCs, protons usually remain trapped inside

Question 17

Dislocating the hook of the hamate can pinch the _________ nerve as it passes through the Guyon canal.

Answer 17

ulnar

Question 18

Period acid-Schiff staining highlights ___________.

Answer 18

glycoproteins and polysaccharides (such as glycogen or fungal cell walls) by oxidizing carbon-carbon bonds and producing aldehyde

Question 19

Once again, review the mechanisms and effects of milrinone and nesiritide.

Answer 19

•Milrinone: (“one in a million”)

• Phosphodiesterase inhibitor (“don’t phoster disinterest”)
• Increases cardiac contractility (donkey flexing his biceps)
• Dilates arteries (dilated big donkey ears)

•Nesiritide: (fight the tide)

• cGMP analog (“bump the GruMP”)
• natriuresis (washing away the peanuts)
• dilated arteries (red dilated trunk)
• dilated veins (dilated jeans)

Question 20

In some neurons, __________ help potassium repolarize the cell.

Answer 20

voltage-gated chloride channels

Question 21

Talk about what the different colors of sputum mean.

Answer 21

• Red: extravasation of blood (seen in S. pneumoniae or Klebsiella)
• Green: myeloperoxidase, which is a hem-containing molecule made by neutrophils (seen in many pneumonias)
• Blue-green: high bacterial load of pigment-secreting bacteria such as Pseudomonas

Question 22

Viral myocarditis typically causes ___________ cardiomyopathy.

Answer 22

dilated

Question 23

Atrial fibrillation can be caused by ______________.

Answer 23

alcohol consumption (“holiday heart”)

Question 24

Describe the origin and function of the lingual nerve.

Answer 24

The lingual nerve arises from the mandibular division of the trigeminal nerve and provides sensory innervation to the tongue.

Question 25

Electrical stimulation of the ____________ nerve has been shown to decrease the symptoms of obstructive sleep apnea because OSA typically results from neuromuscular weakness.

Answer 25

hypoglossal nerve (which moves the tongue forward)

Question 26

In addition to actively killing bacteria, reactive oxygen species also ______________.

Answer 26

activate granular enzymes such as elastase

Question 27

Often presenting with pancytopenia, hepatosplenomegaly, and fatigue, _________ can mimic ALL in children.

Answer 27

Gaucher disease

If they give you a bone marrow aspirate, look for the crinkly macrophages.

Question 28

With renal problems, holosystolic murmurs, and recent illness, _____________ can look a lot like PSGN.

Answer 28

infective endocarditis

Absence of edema and presence of a fever will usually guide you to IE instead of PSGN.

Question 29

What will bone marrow aspirate show in a patient with hairy cell leukemia?

Answer 29

Typically, oversecretion of cytokines causes bone marrow fibrosis and thus BM aspirate will come up empty (a “dry tap”).

Question 30

Which tissue layer is missing in pseudodiverticula?

Answer 30

The muscular layer

Question 31

Many women with giant cell arteritis will have episodes of ________________.

Answer 31

monocular vision loss

Question 32

Other than bleomycin, _____________ can also cause pulmonary fibrosis.

Answer 32

methotrexate (remember the lung-shaped bonsai in the Sketchy video)

Question 33

Where are the SA and AV nodes?

Answer 33

• SA: in the right atrium near the opening of the SVC

* AV: in the right atrium near the septal cusp of the tricuspid valve

Question 34

In addition to podocyte effacement, minimal change disease also presents with ______________.

Answer 34

loss of basement membrane anions

Question 35

In addition to villous atrophy, celiac also presents with what two histologic pathologies?

Answer 35

Gland hyperplasia and lymphocyte infiltrate

Question 36

The fourth and sixth pharyngeal arches give rise to what important cartilages?

Answer 36

Cricoid and thyroid (which makes sense given that the vagus nerve innervates these arches)

Question 37

The hyoid bone arises from what pharyngeal arches?

Answer 37

Tricky question: the lesser horn (which is superior and anterior) is derived from the second arch, and the greater horn (which is inferior and posterior) is derived from the third arch.

Question 38

How do the mechanisms of succinylcholine and vecuronium differ?

Answer 38

The curare drugs –such as vecuronium –are nondepolarizing blockers, while succinylcholine is a depolarizing block.

Question 39

Why do depolarizing NMJ blockers (like succinylcholine) cause equal depression of all four trials of the TOF test while nondepolarizing agents like vecuronium cause progressive diminishing of each trial?

Answer 39

Nondepolarizing agents (the curare drugs) block the reuptake of acetylcholine by presynaptic neurons, so with each trial in the TOF test less acetylcholine is released.

Depolarizing agents do not block acetylcholine reuptake, so roughly equal amounts of acetylcholine will be released in all four trials. If you continue or return later, however, you can deplete the acetylcholine reserves because more needs to be released each time.

Question 40

What does polyadenylation do?

Answer 40

It signals an mRNA transcript for export from the nucleus and enhances cytoplasmic stability.

Question 41

Trace the direct and indirect pathway through the basal ganglia.

Answer 41

•Direct:

• Facilitates movement
• Excitation of the D1 receptors on the striatum excites the striatum. The striatum releases inhibitory molecules on the GPI. The GPI is normally inhibitory, so inhibiting it allows the thalamus to mediate movement.

•Indirect:

• Inhibits movement
• Stimulation of the D2 receptors on the striatum leads to inhibition of the striatum. The striatum thus stops secreting inhibitory molecules on the GPE. The GPE normally inhibits the STN. Without the inhibition from the striatum, the GPE excites the STN. The STN normally excites the GPI, so this extra excitation leads to more GPI inhibition.

Question 42

Which part of the brain is stimulated with electrical shocks to relieve refractory Parkinson’s disease?

Answer 42

The subthalamic nuclei

Important: electrical stimulation inhibits the part of the brain that it is shocking, so inhibiting the STN decreases the overactivation of the GPI characteristic of Parkinson’s.

Question 43

True or false; urea clearance is mediated by passive diffusion.

Answer 43

False. ADH activates urea channels in the medullary collecting duct.

Question 44

Dilated cardiomyopathy presents with decreased ________________.

Answer 44

contractility

Question 45

One of the most evidence-based ways to reduce suicide likelihood is ________________.

Answer 45

removing firearms

Question 46

Dilated veins in the fundus of the stomach but NOT in the esophagus or antrum indicate _____________.

Answer 46

splenic vein thrombosis

Question 47

To make an autonomous decision, what four things are needed?

Answer 47

• Communicate understanding of the (1) info on procedure, (2) consequences of doing it and not doing it, (3) rationale for choice, and (4) choice.

Question 48

Inducing methemoglobinemia is the treatment for which kind of poisoning?

Answer 48

Cyanide poisoning

Cyanide is toxic because it binds and inhibits cytochrome c. Methemoglobin, with its oxidized form of iron, binds cyanide more tightly than the reduced form of iron. Thus, patients with cyanide poisoning are given amyl nitrate as a way of shuttling cyanide out of the tissues.

Question 49

What is the most common cardiac defect found in Down syndrome?

Answer 49

Complete atrioventricular canal defect

In this disorder, there is an ASD, VSD, and presence of only one valve. It results from defects in the endocardial cushion.

Question 50

How do the murmurs of tetralogy of Fallot and complete atrioventricular canal defects differ?

Answer 50

TOF presents with a harsh, holosystolic murmur heard over the left sternal border. CACD will also have this, but a diastolic sound will also be heard (from the ASD).

Question 51

What constellation of symptoms are seen in disorders of hamartin genes?

Answer 51

Tuberous sclerosis presents with the following:

• cardiac rhabdomyomas
• CNS hamartomas
• renal cysts
• cutaneous angiofibromas

Question 52

Which PFT is most diminished in obesity-induced restrictive lung disease?

Answer 52

ERV

It’s as if the extra weight pushes air out at the end of normal expirations and

Question 53

A patient dies suddenly one week after a heart attack. How can you differentiate the likelihood of ventricular rupture versus ventricular aneurysm?

Answer 53

Aneurysms occur roughly one month or more after a heart attack and do not usually cause sudden death, whereas ventricular rupture occurs between days 5 and 14 and do cause sudden death. The case described is thus more likely to be a ventricular rupture.

Question 54

Describe the presentation of de Quervain’s thyroiditis?

Answer 54

Usually presenting after a viral illness, de Quervain’s is a form of thyroiditis thought to be caused by cross-reactive damage to the thyroid. In response to this damage, the thyroid then releases T4 which leads to a temporary hyperthyroid state. Radioiodine uptake will be low because it is the destruction-induced release of preformed T4 that is leading to symptoms, not increased production. Also, TSH will be low.

Question 55

What is used to screen for diabetic nephropathy?

Answer 55

Urinary albumin

Question 56

What is the genetic mechanism behind fragile X?

Answer 56

Trinucleotide repeats of CGG lead to hypermethylation and thus silencing of the FMR gene.

Question 57

Ruptured berry aneurysms to _____________ hemorrhage.

Answer 57

subarachnoid

Question 58

Describe cystinuria.

Answer 58

• Autosomal recessive disorder
• Because cystine, ornithine, arginine, and lysine can be absorbed as oligopeptides, patients do not usually develop nutritional deficiencies
• Absorption of free forms of any of those four amino acids will be impaired
• Inability to resorb COAL from the nephron leads to cystine kidney stones. OAL are relatively soluble and do not cause problems.
• Recurrent nephrolithiasis is the only symptom.