Q Banks: Week of 03/13/17 (#2)

Question 1

The kidney forms by the metanephric bud invading the metanephric ________________. Where is the division (in the adult kidney structures)?

Answer 1

blastema/mesoderm

The mesoderm makes up the glomerulus to the DCT. The bud makes up the ureter to the collecting tubule.

Question 2

Recurrent, spontaneous lobar hemorrhages are frequently due to what pathologic process?

Answer 2

Cerebral amyloid angiopathy

In this disorder, beta-pleated sheets are deposited in the cerebral arteries and lead to various stages of lobar hemorrhage.

Question 3

What are Charcot-Bouchard aneurysms?

Answer 3

Hemorrhages in the basal ganglia commonly due to chronic hypertension

Question 4

Discuss the differences in symptom presentation from hemorrhagic and ischemic strokes.

Answer 4

• Hemorrhagic strokes:

• more often due to amyloid deposition or embolism
• symptoms (headache or neurologic deficit) gradually worsen

•Ischemic strokes:

• more often due to thrombus
• symptoms abruptly start and may improve with time

Question 5

What cell type is needed to prevent Candida infection?

Answer 5

Trick question –there are two types:

• T lymphocytes are needed to prevent superficial infections.
• Neutrophils are needed to prevent Candidemia (remember that (1) Candida is catalase-positive and (2) that T cells take time to respond and are thus not capable to preventing a systemic blood infeciton).

Question 6

Which disorder of the glomerulus often recurs every few months in those who get it?

Answer 6

IgA nephropathy

It often appears after a respiratory illness (3 days or so, unlike the two weeks needed for PSGN), and then recurs with future illnesses or at random.

Question 7

Which enzyme needs riboflavin?

Answer 7

Succinate dehydrogenase

So there are four dehydrogenases in the TCA cycle: pyruvate dehydrogenase, isocitrate dehydrogenase, succinate dehydrogenase, and malate dehydrogenase. Thiamine gets converted to NAD+ and is used by all but succinate dehydrogenase. Succinate dehydrogenase needs riboflavin which gets converted to FAD+.

The best mnemonic I have for this is to remember that riboflavin deficiency causes angular stomatitis (cracking rash at the corner of the lips). You kiss with your lips… and kissing is referred to as SUCking FAce (SUCcinate – FAd+).

Question 8

What does anaplastic mean?

Answer 8

Completely undifferentiated (ana –plastic = without form)

Question 9

At what level do cilia stop in the lungs?

Answer 9

The terminal bronchioles are the last division to have cilia.

Trachea: cartilage, cilia, goblet cells
Bronchi: cartilage, clila, goblet cells
Proximal bronchioles: cilia, goblet cells
Terminal bronchioles: cilia, club cells
Respiratory bronchioles: clara cells, macrophages
Alveoli: type II pneumocytes, type I pneumocytes, macrophages

Note: this is tricky because “terminal bronchioles” sounds like the last set of bronchioles but that’s not the case.

Question 10

Why do Janeway lesions present as non-tender, while Osler nodes are tender?

Answer 10

• Osler nodes are immune deposits in the skin. The immune complexes trigger an inflammatory response that causes pain.
• Janeway lesions are septic emboli that do not elicit as much of an immune response.

Question 11

What are the three stop codons?

Answer 11

• UGA (U Go Away)
• UAA (U Are Away)
• UAG (U Are Gone)

Note: switching from one of these to another would be a silent mutation!

Question 12

What is the Wolf-Parkinson-White triad?

Answer 12

• Delta wave (initial slope upward inside of the Q downward zag)
• Widened QRS
• Shortened PR interval

Question 13

What are the two guiding principles in managing patients with suspected intimate partner violence?

Answer 13

• Ask supportive, open-ended questions
• Ensure that the patient has an emergency safety plan
• Confirm that violence is wrong

Reporting is not mandatory in all states. Victims may get flighty if you confront too directly.

Question 14

______________ often presents as metastases to the lungs.

Answer 14

RCC

RCC does not produce renal symptoms until far into the disease. Thus, metastasis is a common presentation. The lungs happen to be the most common site of metastasis.

Question 15

Talk about the two subtypes of macular degeneration.

Answer 15

For starters, macular degeneration is simply a progressive loss of vision due to oxidative damage to the retina. It is the most common cause of age-related vision loss and frequently presents with difficulty reading in low light.

• Dry type: oxidative damage can cause the accumulation of Drusen deposits which are pieces of ECM in the retina. This can impair vision by impacting the macula.
• Wet type: following prolonged deposition of ECM, the retina can become hypoxic. That hypoxia stimulates angiogenesis which can impair the macular by covering it up.

Question 16

You’ll almost certainly be expected to differentiate Parvovirus from HHV-6. Discuss their differences.

Answer 16

•Parvovirus:

• ssDNA virus
• naked
• resides in erythrocytes (hence aplastic anemia)
• causes fever followed by a rash that starts on the cheeks and moves to the body (like the airplane in the Sketchy scene with the flames that start on the nose and move toward the body)
• more common in children ages 3-8

•HHV-6:

• dsDNA virus
• enveloped
• resides in CD4 cells
• causes infantile febrile seizures followed by a rash that spares the face
• more common in children 2 and younger

Question 17

______________ upregulate the production of COX-2.

Answer 17

IL-1 and TNF-alpha

Question 18

How is drug-induced lupus distinct from standard lupus?

Answer 18

DIL usually lacks the cutaneous, renal, and neurologic symptoms!

Question 19

Autoimmune gastritis results in destruction of ____________ mucosa.

Answer 19

oxyntic

Question 20

The main cause of the rise in bacteremia over the past few decades is __________________.

Answer 20

use of IV catheters

Question 21

Remember that ________________ is a synonym for penicillin-binding protein.

Answer 21

transpeptidase

Question 22

Which antibiotic works by binding to a glycoprotein?

Answer 22

Vancomycin

Question 23

True or false: cephalosporins are resistant to beta-lactamases.

Answer 23

False. They are resistant to some beta-lactamases but not all.

Question 24

True or false: the most common site of neuroblastoma is the cerebellopontine angle.

Answer 24

False.

• Neuroblastomas develop in the adrenal medulla.
• They extend across the midline.
• Mutations in N-Myc (chr. 2) are common).
• They are the most common extracranial solid tumor in children.
• They can present with elevated BP, though not to the extent that pheochromocytoma does.
• Elevations in vanillylmandelic acid.

Question 25

What histologic sign is suggestive of pilocytic astrocytoma?

Answer 25

Rosenthal fibers: eosinophilic corkscrews

Question 26

What electrolyte imbalance is common in cystic fibrosis?

Answer 26

Hyponatremia

The reason the sweat of those with CF is “salty” is that they can’t pump Cl back into the cell. As a result, Na is also not pumped in. This can produce excess volume loss, particularly with exertion or heat.

This manifests as dehydration.

Question 27

Patients with injuries to the common peroneal nerve have what findings?

Answer 27

• Loss of sensation on the lateral shin
• Loss of foot eversion (disrupted superficial peroneal)
• Loss of dorsiflexion (disrupted deep peroneal)

Note: the loss of dorsiflexion produces a “foot drop” when walking because the foot is unable to dorsiflex against gravity.

Question 28

Patients with advanced sickle cell anemia sometimes need _____________ supplementation.

Answer 28

folic acid

If they have megaloblastic anemia with insufficient reticulocyte response, then this is likely.

Question 29

Bisphosphonates bind to what molecule in bone?

Answer 29

Hydroxyapatite (like how the dONATE bin is right next to the dinosaur’s mouth with a big APPETITE in the Sketchy scene)

Question 30

Increased levels of ______________ in an atheroma lead to increased risk of plaque rupture.

Answer 30

metalloproteases

Question 31

Constipation, umbilical hernia, and large _______________ are suggestive of neonatal hypothyroidism.

Answer 31

fontanelle/tongue

Question 32

CF often presents with ______________ stool at birth.

Answer 32

inspissated meconium (thickened, congealed)

Question 33

True or false: B cells undergo negative selection in the lymph nodes.

Answer 33

False. B cells mature primarily in the marrow. The only maturation step that occurs in lymph nodes is isotype switching.

Question 34

What might make someone a good candidate for tranylcypromine?

Answer 34

This is a tricky question.

First, MAO inhibitors like tranylcypromine are better at treating atypical depression. Atypical depression is major depression with less common features such as increased sleep or appetite, leaden paralysis, or –the most common manifestation –mood reactivity. Mood reactivity is when a person with depression feels good in response to good events but then returns to feeling depressed later. (This is in contrast to a person with typical depression who would likely not feel better in response to a good event.)

Question 35

If someone presents with a DVT but has a high risk for bleeding (such as recent hemorrhagic stroke), how can they be managed?

Answer 35

With a filter in the IVC that could catch bits of thrombus

Question 36

You’ve learned that galactose 1-phosphate UDP transferase deficiency presents with cataracts, hepatomegaly, jaundice, and vomiting, but there’s one bizarre association that they didn’t mention in DEMS: __________________.

Answer 36

increased susceptibility to E. coli sepsis!

Question 37

Why can’t those with ASDs get heart surgery after so many years?

Answer 37

Another tricky question.

Recall that ASDs initially cause a left-to-right shunt because the pressure in the left atrium is greater than the pressure in the right atrium. This leads to increased volume pumped into the pulmonary arteries. The increased volume stimulates pulmonary smooth muscle hypertrophy with subsequent pulmonary hypertension. (This is the same reason ASDs present with fixed-split S2s.) If you were to close the ASD at this point, the right ventricle would not be able to pump against the pressure because the extra volume from the ASD gives more preload to the right ventricle which allows it to pump with more force.

Question 38

Discuss the presentations of carnitine deficiency and MCAD deficiency.

Answer 38

• Carnitine deficiency:

• Hypoketotic hypoglycemia (note: lack of ketones in urine suffices for the “hypoketotic” diagnostic)
• Cardiomyopathy
• Muscle weakness
• Myopathy

•MCAD:
- Hypoketotic hypoglycemia

Both result from failures of beta-oxidation.

Question 39

A patient with a history of alcoholism presents with pulmonary infiltrate. How can you differentiate gastric acid aspiration from aspiration of oropharyngeal bacteria?

Answer 39

• Gastric acid aspiration will present with immediate symptoms (not gradual development); fever and cavitations will likely not be present.
• Bacterial aspiration will present with gradual development, fever, productive cough, and may have cavitary lesions.

Question 40

Beryllium can cause what lung disease?

Answer 40

Sarcoidosis

Question 41

Vitiligo will lead to _______________ of the melanocytes.

Answer 41

death/absence

Question 42

Osteomyelitis is common in young boys. Which part of the bone is most common for infection to seed?

Answer 42

The metaphysis

The metaphysis has the most abundant blood supply and blood moves more slowly through this part of the bone (compared to the diaphysis and epiphysis).

(“This is where my femur MET its bacteria.”)

Question 43

What is the most common long-term histologic outcome of acute tubular necrosis?

Answer 43

Re-epithelialization

Atrophy and fibrosis can result, but if the basement membrane is preserved around the tubules, then the tubules will likely repair.

(Heads up: you got this question wrong in Rx and UWorld.)

Question 44

What happens to sodium and water in nephrotic syndrome?

Answer 44

Initially, the drop in oncotic pressure in the blood (from loss in the nephrons) leads to fluid shunting into the interstitial tissues. As a consequence, the blood vessels sense decreased fluid volume and so the RAAS and ADH are stimulated.

Question 45

What effects does mitral insufficiency have on the LV?

Answer 45

MI leads to eccentric hypertrophy in the LV due to fluid overload.

Question 46

What pathologic changes happen to the heart in longstanding hypertension?

Answer 46

• Concentric hypertrophy in the LV

* Enlargement of the LA b/c it needs to push extra hard against the stiff LV

Question 47

List the four first-generation antihistamines.

Answer 47

• Chlorpheniramine
• Diphenhydramine
• Hydroxyzine
• Promethazine

Question 48

Neurofibromatosis 1 presents with the following:

• Café au lait spots
• Cutaneous neurofibromas
• Lisch nodules
• ________________
• ________________

Answer 48

pheochromocytoma; optic gliomas

Think of the NF-1 patient you saw wearing an adrenal beanie blind because of optic disruption.

Question 49

True or false: neurofibromas arise from neural ectoderm.

Answer 49

False. It arises from neural crest tissue.

Question 50

Patients with defects in metabolism of isoleucine, valine, methionine, and threonine –all three-carbon amino acids –are lacking which enzyme?

Answer 50

Propionyl CoA carboxylase

This presents with hypoglycemia and anion-gap metabolic acidosis around birth.

Note: it is only the R groups that are considered in the “three-chain” distinction. For instance, alanine has three carbons in a row, but it is not considered a three-chain amino acid because two of the three are in the backbone of the molecule.

Question 51

Which are the three tiers of benzodiazepine duration?

Answer 51

• Short: triazolam, oxazepam, midazolam
• Intermediate: alprazolam, temazepam, lorazepam
• Long: chlordiazepoxide, flurazepam, diazepam

TOM
TAL
FDC

(“Triazepam is faster than temazepam –it is a speeding TRIceratops.”)

Question 52

Sunlight stimulates which conversion in the production of vitamin D?

Answer 52

7-dehydrocholesterol to cholecalciferol

(This is kind of a stretch, but the best mnemonic I have is that you have to take 7 items of clothing off to sunbathe: shoes (x2), socks (x2), jacket, pants, shirt.)

Question 53

What is somatic symptom disorder (not somatisization!)?

Answer 53

Somatic symptom disorder is when children get preoccupied with somatic symptoms of an illness.

Question 54

What are two classic signs of psychogenic causes of erectile dysfunction?

Answer 54

• Morning erection is preserved (which would be lost in vascular or neurogenic causes of ED)
• Sudden onset; for instance, if the ED just started full on one night, it is actually more likely to be psychogenic in nature

Question 55

Shoulder pain, rigid abdomen, and hypotension in a patient with clear lung sounds likely indicates ______________ after a trauma.

Answer 55

splenic laceration

The bleeding near the diaphragm can cause phrenic irritation (should pain referred), hemiperitoneum (rigid abdomen), and internal bleeding (hypotension).

Question 56

C-KIT mutations in a patient with flushing, diarrhea, and rash would likely cause what other GI manifestations?

Answer 56

Increased gastric acid secretion

This describes systemic mastocytosis –a disorder in which mast cells expand and release histamine (hence flushing and gastric acid secretion).

(Think of people allergic to KITtens… they’ll definitely be releasing histamines.)

Question 57

Why is giant cell arteritis considered a medical emergency? That is, what complication are you trying to prevent with steroid administration?

Answer 57

Ischemic optic neuropathy!

The granulomatous necrosis of the cranial arteries can affect the ophthalmic artery and lead to permanent blindness if untreated.

Question 58

Where (in the tubule) are uric acid stones most likely to develop?

Answer 58

In the collecting duct

Uric acid will be ionized at neutral or basic pHs. The collecting tubule usually has the lowest pH in the nephron because protons are secreted here. Thus, the low pH will protonate uric acid and make it non-ionized. The non-ionized form of molecules is more likely to precipitate.

Question 59

How does theophylline work?

Answer 59

It is a phosphodiesterase inhibitor (which is why you’re not supposed to take it and drink caffeine) that raises levels of cAMP. This effect mimics beta-adrenergic stimulation and causes bronchodilation and thus has utility in asthma therapy.

Overdose of theophylline –such as when it is administered with a CYP inhibitor –leads to tremor and seizures.

Question 60

Mutations in SF-1 lead to _________ cell failure.

Answer 60

Sertoli

Question 61

Foreign material left in the body –such as sutures –can lead to a ________________ response.

Answer 61

granulomatous (look for circular aggregates of lymphatic cells with multinucleated giant cells)

Question 62

In addition to activating hormone sensitive lipase, fibrates also _________________.

Answer 62

decrease VLDL production in the liver (by PPAR alpha) and raise HDL

Question 63

Pick’s disease –frontotemporal dementia –presents with what inclusions in neurons?

Answer 63

Tau proteins

Question 64

The bladder is considered a __________-peritoneal organ.

Answer 64

extra

The peritoneum spills over the lateral sides of the bladder. Thus, the bladder is only covered by the aponeurosis of the abdominal fascia anteriorly.

Question 65

Lightning most often causes death by _____________.

Answer 65

inducing arrhythmia

Question 66

The hyperestrogenic state of ascites results in what three abnormalities?

Answer 66

• Spider angiomata (remember that estrogen has vasoconstrictive properties)
• Hair loss
• Testicular atrophy

Question 67

True or false: LDL receptor defect is AR.

Answer 67

False. Heterozygotes for LDL receptor defects have cholesterols that are 2-3x normal, while homozygotes have level 5-6x normal. Both will have symptoms.

Question 68

Although the ANCAs are considered pauci-immune disorders because immunofluorescence does not show anything in the glomerulus, there is another IF test that will: __________________.

Answer 68

pouring the patient’s serum onto neutrophils and then tagging for antibodies!

Question 69

Describe leukocytoclastic vasculitis.

Answer 69

Administration of certain drugs –penicillins, sulfonamides, phenytoin –can lead to palpable purpura and fibrinoid necrosis of blood vessels roughly one week later. This is a vasculitis called leukocytoclastic vasculitis.