Q Banks: Week of 03/20/17 Flashcards
1
Q
What does opsoclonus-myoclonus syndrome likely portend in a young child?
A
Neuroblastoma
With a mean age of onset of 2 years, neuroblastoma is the most common extracranial tumor of childhood. It causes a disorder in which children can have non-rhythmic nystagmus with myoclonus.
2
Q
True or false: tardive dyskinesia specifically refers to tongue movements.
A
False. Tardive dyskinesia refers to any purposeless repetitive movements such as writhing fingers or facial grimacing.
3
Q
How is acute dystonia different from tardive dyskinesia?
A
Acute dystonia is sustained muscle contraction, whereas tardive dyskinesia is just brief movements.
4
Q
Explain the phenomenon of orthopnea.
A
Orthopnea is a sign of left-heart failure. Left-heart failure will lead to edema throughout the body due to inadequate circulation. Much of the fluid pools in the lower extremities due to the force of gravity. When a person with LH failure lies supine, that fluid quickly returns to the right heart via increased venous return. If the left heart cannot match the output of the right heart, then fluid will pool in the lungs.
5
Q
Paresthesia in the extremities and a papular rash on the groin area are indicative of a disorder that leads to the accumulation of what metabolite?
A
Globotriaosylceramide
Note: this accumulates in muscle tissue. The earliest sign of Fabry disease is inability to sweat due to loss of smooth muscles in sweat glands.
6
Q
What demyelinating disorder that results from a missing enzyme presents with ataxia, seizures, and hypotonia?
A
Metachromatic leukodystrophy
This is a defect in arylsulfatase
7
Q
What kind of pneumonia produces foul-smelling sputum?
A
Aspiration pneumonia
8
Q
In addition to alcohol overdose, drug overdose, and neurologic disorders, _____________ can also produce aspiration pneumonia.
A
seizure disorders
9
Q
Explain the utility of paraaminohippuric acid (PAH).
A
PAH is both filtered by and excreted by the kidneys. Also, it is NOT REABSORBED AT ANY POINT and so provides an approximation of renal blood perfusion.
What does this mean? Well, filtration into Bowman’s capsule is not saturable and is only limited by GFR. As such, the more PAH you put into the glomerulus, the more will be filtered. PAH is also excreted into the PCT. This is a carrier-protein mediated process that can be saturable. So if you increase the concentration of PAH, you will see the extraction ratio increase up to the point at which the carrier is saturated.
10
Q
If a patient is hypoxemic but his A-a gradient is normal (i.e., 10 or less), then the etiology has to be one of two things: __________________.
A
hypoventilation or high altitude (or any other low-oxygen air inhalation)
11
Q
PAH concentration is likely to be lowest in which part of the nephron?
A
Bowman’s space (because it is secreted into the PCT and not reabsorbed at any point)
12
Q
True or false: in hypertrophic cardiomyopathy, the interventricular septum overrides the aortic valve and blocks the outlet.
A
False-ish. The mitral valve can randomly get pushed back toward the aortic valve in those with HOCM under stress (say, while exercising). When this happens, the mitral valve AND the interventricular septum block the aortic valve.
13
Q
Give a rundown on the most important points about PCOS.
A
- The main abnormality is an elevated LH:FSH ratio. This leads to increased androgen production by theca cells.
- The androgens lead to hirsutism and infertility. Estrone levels rise when androgens are converted to estrogen peripherally.
- The elevated estrogen shuts off FSH production and thus follicles fail to develop.
- Unopposed estrogen leads to endometrial hyperplasia.
- Elevated LH leads to hypertrophy of the ovaries.
14
Q
What are some key treatments for PCOS?
A
- Weight loss can often revert the whole axis back to normal.
- Diabetes treatment (metformin) can usually restore ovulatory function if a patient wishes to conceive.
- Another route to restore fertility is to use the SERM clomiphene! It blocks estrogen selectively at the pituitary/hypothalamus and thus tricks the body into secreting more FSH.
- In those who do not want any of the above, it is recommended that they take dual hormone OCPs which will decrease LH secretion and stop the unopposed estrogen high (to reduce risk of endometrial cancer).
15
Q
_____________ make S. viridans able to adhere to fibrin.
A
Dextrans (synthesized from sucrose)
16
Q
M. leprae invades which cells?
A
Skin and nerves
17
Q
Cardiomegaly and hepatomegaly in a five-month-old will likely be present in a disorder that causes ________-positive samples on biopsy.
A
acid-Schiff (PAS)
This stains for glycogen and will be found in kids with Pompe disease.
18
Q
What histologic pattern will contact dermatitis present with?
A
Spongiosus – accumulations of fluid in between cells of the epidermis
19
Q
The right atrium and SVC are in very similar spots in an x-ray of the heart. What landmarks are they normally near?
A
- RA: below the right bronchi and roughly one or two ribs above the resting diaphragm
- SVC: about where the right bronchi is and three or four ribs above the resting diaphragm
20
Q
Explain how UAA, UGA, and UAG stimulate release of mRNA from the ribosome.
A
The three stop codons bind to releasing factors in the cytosol that trigger the release of mRNA from the ribosome.
21
Q
What cellular process leads to cavitation formation in lung diseases?
A
Release of lysosomal enzymes from macrophages and neutrophils
22
Q
Which two vasculitis disorders present with granulomas of the media?
A
Takayasu and giant cell
Imagine a giant cell destroying a Japanese city called Takayasu –that would get a lot of MEDIA coverage.
23
Q
People who get ABPA will typically have high levels of what two serum markers?
A
- IgE
* Eosinophils
24
Q
Patients with membranous nephropathy often have antibodies to what?
A
Phospholipase A2 receptor (PLA2R) on podocytes
Note: this is what causes the immune deposits in MN.
25
What is one of the best ways to prevent kidney stones?
Proper hydration
This is true for all kinds of kidney stones.
26
What kind of purified viral genetic material can replicate in the cytoplasm?
(+) ssRNA
* dsDNA and ssDNA need RNA polymerase II – found in the nucleus – to make mRNA which can replicate in the cytoplasm
* dsRNA (i.e., Reoviruses) and (-)ssRNA need their own RNA-dependent RNA polymerases to make (+)ssRNA.
27
Why are conjugated vaccines given to young children?
Children younger than 2 years do not make an immune response to polysaccharide vaccines (e.g., the 23-valent S. pneumo vaccine). As such, these molecules must be conjugated to T cells to help recruit and activate B cells.
28
What is the molecule in Accutane?
ISOtretinoin
Be careful because tretinoin is a cream. (Think: Tretinoin is Topical.)
29
What disorder can present with elevated propionyl acid?
Ooh, this is hard. There are two:
* Defective propionyl CoA carboxylase leads to inability to metabolize propionyl to methylmalonic acid. Propionyl is a metabolite of valine, isoleucine, and methionine, so this accumulates quickly. Presenting symptoms are hypotonia, hypoglycemia, and lethargy in a newborn.
* Defective malonyl CoA mutase leads to elevated methylmalonic acid and propionyl. Presenting symptoms are similar.
Note: in both disorders, the excess organic acids inhibit the urea cycle leading to hyperammonemia. Additionally, the TCA has to run overdrive to keep up with the metabolism, so hypoglycemia and ketosis are common.
30
What intracranial tumors present with S-100 staining?
* Metastatic melanoma
* Schwannomas
Both of these cells are neural crest in origin, so hence the S-100 staining.
31
What intracranial tumor has a biphasic appearance with mixed cellularity and myxoid material?
Schwannomas
Unlike oligodendrogliomas, which have a fried egg look, Schwannomas have pink exudative material with areas of cellularity.
(Think of the Schwan truck distributing all that myxoid ice cream.)
32
What symptoms make up lateral medullary syndrome?
* Ipsilateral ptosis and miosis (disruption of the ascending sympathetic nerves)
* Ataxia (disruption of the spinocerebellar tract)
* Nystagmus (disruption of the vestibulocochlear syndrome)
* Contralateral hemiplegia (disruption of the descending corticospinal tract)
* Ipsilateral facial numbness
33
In a patient with a severe head injury with resultant midline shift, what causes extensor posturing?
Typically, the midline shift pushes down on the brainstem and disrupts the pons.
Pearl: extensor posturing results from damage below the midbrain.
34
By what mechanism does left heart failure lead to pulmonary hypertension?
The excess fluid congestion (from the left heart not moving it forward) leads to vasoconstriction via the myogenic response.
Not hypoxic vasoconstriciton!
35
Why are corticosteroids given to premature infants?
Steroids stimulate type II pneumocytes to produce surfactant.
36
Why do anovulatory cycles lead to heavy bleeding?
Ovulation triggers the release of progesterone and the decline of estrogen levels. Those changes promote a stabilization of the uterine wall. Without ovulation, estrogen remains high and continues to thicken the endometrial wall.
37
Why do you need to take a long time between MAO treatment and SSRI treatment?
Recall that MAO inhibitors are irreversible (the mouse is irreversibly killed by the mouse trap), so more MAO enzymes need to be synthesized before you can give an SSRI.
38
Congenital long QT syndrome results from mutations in _______________.
voltage-sensitive potassium channels
39
What makes pseudotumor cerebri worse?
Anything that increases intracranial pressure: bending down, Valsalva maneuver, coughing.
Note: this impairs "axoplasmic flow" to the eyes, thereby increasing
40
Where in the female reproductive organs is there cuboidal epithelium?
The germinal epithelium around the ovary!
If you can remember that this tissue is mesoderm, just think that this and the other mesoderm in the pelvis – the bladder – are both simple cuboidal.
41
What kind of epithelium lines the fallopian tubes?
Ciliated columnar
42
What role do valves play in the development of varicose veins in liver disease?
This is kind of tricky.
Normally, valves prevent backward blood flow. Continually increased venous pressure can dilate the veins and cause valve insufficiency!
43
Those with metachromatic leukodystrophy have build up of what metabolite?
Cerebroside sulfate
44
Atherosclerosis of the mesenteric arteries produces what symptom?
Pain roughly 30 minutes after eating
45
Failed fusion of the urethral folds in a male produces _____________.
hypospadias
46
______________ causes epispadias.
Abnormal position of the genital tubercle
47
What prevents C. difficile infection in a healthy person?
The microbiome (hence why antibiotics cause pseudomembranous colitis)
48
Vitamin E deficiency presents with hemolytic anemia, hyporeflexia, and ______________.
loss of proprioception
49
Those with a negative _______________ test are more likely to have lepromatous leprosy (as opposed to tuberculin leprosy).
lepromin skin test
This test assesses the strength of the T cell response to leprosy. If it positive – meaning lots of IFN-gamma, activated macrophages, and IL-1 – then it is likely that the person has tuberculin leprosy.
50
Why does sodium bicarbonate help TCA toxicity?
It raises the pH of the serum which favors the un-ionized form of the drug. The ionized form is what binds sodium channels and causes cardiac toxicity, so alkalinization helps prevent this.
51
What features should you look for to diagnose overflow incontinence?
* Some type of obstruction of urinary outflow (e.g., impaired detrusor contractility in diabetic neuropathy or tumor obstruction of the urethra
* Sudden uncontrollable urination WITHOUT prior sense of needing to go
* Enuresis
* Increased post-void residual volume (due to obstruction or weak detrusor not pushing all the fluid out)
52
What biochemical signals mediate the hypothalamic suppression seen in anorexics with amenorrhea?
Decreased leptin levels
This is kind of cool. When fat stores drop – such as from strenuous exercise, anorexia, or chronic illness – leptin levels drop. The decrease in leptin tells the hypothalamus to stop secreting GnRH and thus women stop having periods.
53
How can p-57 staining help diagnose hydatidiform moles?
Partial moles will be p-57 positive.
(Think of it like this: partial moles have 69 chromosomes, which is above 57. Complete moles have 46 chromosomes which is less than 57.)
54
The musculocutaneous nerve innervates which sensory area?
Lateral forearm
55
Describe the lymph drainage from the rectum and colon.
* Inferior 1/3 of rectum: inguinal nodes
* Middle 1/3 of rectum: internal iliac nodes
* Superior 1/3 of rectum: inferior mesenteric nodes
The rest of the colon follows the artery drainage
56
Injuries to the superior gluteal nerve produce what physical exam finding?
Contralateral hip drop while walking
Normally, the superior gluteal muscle pulls the iliac crest to the trochanter of the femur when standing on that leg alone (to help maintain balance). When this can't happen, the hip rises and the contralateral hip falls.
57
Injections in the __________ area have a high probability of damaging the superior gluteal nerve.
superomedial portion of the buttocks
58
The PR interval is actually a misnomer. The distance is measured _____________.
from the start of the P wave to the start of the Q wave
59
What should you do if you learn that a patient has a serious illness but the patient tells you they don't want to know any diagnostic/prognostic information?
Provided they are capable of making decisions (e.g., they aren't intoxicated, delirious, demented, or cognitively disabled), then they are able to refuse hearing the information. Don't tell them.
60
A patient presents with a peripheral lung mass. What histologic features can distinguish mesothelioma from adenocarcinoma?
• Mesothelioma:
- tonofilaments (think of the TV lawyers promising mesothelioma victims a TON OF money)
- long microvilli
- psammoma bodies
• Adenocarcinoma:
- glandular elements
- short microvilli
61
Recall that alpha-1-antitrypsin deficiency usually produces ________________ emphysema, while smoking produces ____________ emphysema.
lower-lobe, pan acinar; upper-lobe, centriacinar
62
Compare and contrast the molecular properties of elastin and collagen.
• Elastin:
- does not form a helix
- uses fibrillin as a scaffold
- has mostly neutral amino acids, but some lysine residues
- not hydroxylated post-translationally
- desmosine crosslinks form in which lysine is deaminated and binds to another lysine
• Collagen:
- forms a triple helix
- uses disulfide bonds to crosslink
- has lots of glycine-XX repeats
- many hydroxylated lysine and proline residues
63
Why does HDV need HBV to replicate?
HDV cannot enter host cells. It needs to be packaged into HBV envelope to become infectious.
(Think of the hippie parents who clothed their HDV kids in robes.)
64
True or false: a patient with koilonychia and dysphagia likely has an esophageal adenocarcinoma that is causing blood loss.
While this is possible, it's much more likely that the patient has Plummer-Vinson syndrome. PVS is characterized by a triad of iron deficiency anemia, esophageal webs, and glossitis.
65
Which is more common, HCC or liver metastases?
Metastases (20x more common)
66
What type of drug is cyclobenzaprine?
Muscle relaxant
67
```
Explain each of the terms for adverse medication effects below:
• Exaggerated sensitivity
• Idiosyncratic reaction
• Predictable drug reaction
• Immune reaction
• Pseudoallergy
```
* Predictable drug reaction: an effect that occurs in most people with dose-dependent frequency
* Exaggerated sensitivity: a known effect of a drug that occurring at a much lower dose than expected (e.g., tinnitus with one tablet of aspirin)
* Idiosyncratic reaction: a known effect that only occurs in rare cases and is not tied to dose
* Immune reaction: allergy to drug
* Pseudoallergy: a reaction that looks like an immune reaction (such as anaphylaxis), but that doesn't involve immune cells
68
Naproxen can cause what side effect?
Gastric ulcers (it is an NSAID)
69
How does the concentration of dihydrotestosterone compare to the concentration of testosterone?
It usually parallels it and is slightly less than the concentration of testosterone. It has a similar half-life, so DHT will usually fall concurrently with testosterone.
70
Which branch of the splenic artery has poor anastomoses?
The short gastric
71
Explain what is meant by the fact that verapamil "slows diastolic depolarization."
Verapamil blocks calcium channels in the SA and AV nodes. The SA node is what stimulates atrial contraction. Depolarization is mediated by voltage-sensitive calcium channels in the pacemaker cells. Blocking the calcium channels thus slows depolarization, which occurs during diastole.
72
Those with homocystinuria usually have elevated levels of what other amino acid?
Methionine
Because homocysteine can't get converted to cystathionine, more of it gets shunted to methionine.
73
What is another term for the pseudodiverticula seen in diverticulosis?
Pulsion diverticula
The PULSing segmentation of the colon leads to pulsion outpouchings.
74
What toxic metabolite accumulates in fructose intolerance?
Fructose 1-phosphate
75
Why might a woman with primary biliary cirrhosis have pruritis?
Two mechanisms:
• PBC leads to the accumulation of bile acid in the skin.
• Insufficient fat absorption can lead to vitamin A deficiency which leads to hyperkeratosis.
76
Where is the AV node?
Near the coronary sinus in the interatrial septum
Note: UWorld says that "between the tricuspid valve and the IVC" is incorrect, even though it actually looks like it's between the two. The coronary sinus is between the IVC and tricuspid valve, so that's probably what they were getting at. The AV node is just superior to the coronary sinus in the septum.
77
Describe schizotypal personality disorder and what it might be confused with.
* Magical thinking (clairvoyance, superstition) that is not disabling – if it were disabling it would be considered schizophrenia
* Social anxiety even in the presence of family... don't get tempted to put social anxiety disorder
78
Minimal change disease can precipitate after any disorder that ___________________.
induces a cytokine response: insect bites, vaccinations, or URIs
79
Which antibiotic can be deactivated by bacteria that develop acetylating mutations?
Aminoglycosides
80
The most sensitive pregnancy serum tests can detect b-HCG _________ days after fertilization.
8 days
Note: implantation doesn't occur until roughly 6-7 days, so this is near the absolute limit. Urine levels aren't detectable until about 14 days.
81
A woman presents with near-complete occlusion of the left anterior descending artery, but she doesn't have any myocardial necrosis. What most likely explains this discrepancy?
Slow growth of the atheroma
If an occlusion grows slowly, then anastomoses can develop from the right coronary and prevent necrosis.
82
Why does muscarinic inhibition lead to flushing?
Eccrine sweat glands are stimulated by acetylcholine. If you inhibit this then sweating is prevented. Blood vessels dilate to help give off heat.
83
Describe cystic medial degeneration.
Normally the tunica media has a woven look because of the elastic fibers. In cystic medial degeneration, little holes develop between the elastic fibers and fill with myxomatous material. This progresses until lots of little holes develop in it. This weakens the wall and leads to degeneration.
Note: sweet peas contain an enzyme that inhibits lysyl oxidase which prevents the springiness of elastin. This mimics Marfans.
84
What is a false aneurysm?
When a hole develops in an artery, blood can fill in the connective tissue outside the artery. It looks like an aneurysm, but it's actually a hematoma.
85
How is the glucose fermentation of Shigella distinct from that of E. coli?
Shigella produces acid while E. coli produces gas.
86
True or false: Shiga toxin is needed for Shigella to invade the intestine.
False. Nontoxigenic strains of Shigella can also cause inflammatory diarrhea.
87
Implementation of standardized ______________ has been shown to decrease preventable medical errors.
patient handoffs
This has been shown to decrease the frequency of missed follow up on labs.
88
Lymphangiosarcoma – classically seen after lymph node resection for breast cancer – is also called __________.
angiosarcoma
89
Medulloblastomas and _____________ both arise in the cerebellum, so histology is needed to differentiate the two.
pilocytic astrocytomas
Look for Rosenthal fibers in PA and "sheets of small cells with high N:C ratio" in medulloblastoma.
90
SIADH is often diagnosed by neurologic findings such as confusion or seizures. If so many aquaporins are increasing the body's water content, why isn't edema a presenting sign?
SIADH does cause water retention. However, the water overload is generally subclinical because the body compensates by decreasing aldosterone secretion and increasing BNP/ANP secretion. Thus, the excess water is diuresed along with more sodium. This aggravates the hyponatremia.
TL;DR SIADH leads to euvolemic hyponatremia.
91
How is postpartum hemorrhage treated?
Bilateral ligation of the internal iliac arteries
The other branches of the internal iliac arteries have sufficient blood flow from collateral sources. Furthermore, the ovarian arteries can provide enough blood to the uterus to prevent necrosis.
92
____________ ulcers are very rarely malignant.
Duodenal
93
There are two molecules of ______________ in MHC I.
beta microglobulin
94
What cells are characteristic of HIV dementia?
Microglial nodules
Recall that HIV also infects macrophages. In HIV dementia, infected macrophages pass into the brain and aggregate in nodules that produce subcortical dementia.
95
Intracardiac fistulas are an uncommon complication of ___________________.
endocarditis
96
List the three steps of tumor chemical modification that allow for invasion of blood vessels.
1) Decreased expression of E-cadherins – this allows cells to float free from the tumor
2) Upregulation of laminin – this allows cells to bind ECM
3) Expression of metalloproteases – invasion through basement membrane
97
True or false: the additional rise in insulin secretion with oral intake (vs. IV infusion) is called the secretin effect.
False. It is the INCRETIN effect.
Incretins are the two hormones secreted by intestinal the intestine in response to oral intake of glucose: GLP and GIP.
98
Why do people with multiple sclerosis feel fatigued in the heat?
Heat decreases the conductance of axons, and since those with MS have problems with conduction they will often feel worse in the heat.
99
You already know that M1, M3, alpha 1, H1, and V1 use the Gq receptor. What other four receptors use Gq?
GnRH
Oxytocin
Angiotensin II
TRH
GOAT
Note: oxytocin and angiotensin II should be easier to remember since they involve smooth muscle constriction.
100
Which cytokine activates eosinophils?
IL-5 (EOSIN = five letters)
101
True or false: CMV only causes retinitis in immunosuppressed patients (i.e., not babies).
False.
The CMV neonatal infection profile includes the following:
- chorioretinitis
- sensorineural deafness
- seizures
- ventricular calcifications
- jaundice
- hepatosplenomegaly
- extramedullary hematopoiesis
- microcephaly
102
Those with _____________ aphasia typically cannot write.
Broca
103
Which NRTI has a strong association with type IV hypersensitivity reactions?
Abacavir (particularly in those with HLA-B57:01)
104
What syndrome shares photosensitive rash and immunodeficiencies with xeroderma pigmentosum?
Bloom syndrome – defects in DNA helicase
105
What should a person with signs of atypical depression be given first?
SSRIs ("drugs that block a serotonin transporter")
MAO inhibitors are never first line due to their side effects, even though they have superior efficacy in treating atypical depression.
106
An evacuated, tissue-lined area of necrosis in the brain likely resulted from _______________.
lysosomal degradation from an old cerebral infarction
107
Systemic sclerosis often results in what cardiovascular abnormality?
Pulmonary hypertension (from collagenous thickening of the pulmonary arteries)
108
What causes "obliteration of the vascular bed" in the lungs?
Emphysema!
The destruction of the alveoli can progress to destroy the capillaries of the lung and cause pulmonary hypertension.
109
Systemic sclerosis results from what cellular process?
Activated T cells releasing TGF-beta and causing excess deposition of collagen
110
Matching in a case-control study – pairing similar participants from the exposed and unexposed groups – controls for __________________.
confounding
111
What causes mitral valve prolapse?
Myxomatous degeneration of leaflet connective tissue
112
Why does squating decrease MVP?
The increase venous return promotes increased end-diastolic left ventricular volume. This puts more tension on the papillary muscles and pulls down on the valve.
113
Which two blood vessels are most suseptible to atherosclerosis?
The coronary arteries and the abdominal aorta
114
Translation of mRNA proceeds in the ______________ direction.
5' to 3'
115
Stop codons do not add ________________.
amino acids
116
What properties make up the Reid index?
(thickness of mucous gland) / (thickness of epithelium to cartilage but not including cartilage)
117
Describe the complication of stenting that can present with livedo reticularis.
Stenting can cause emboli of cholesterol from the coronary plaque. This will lead to infarction of peripheral tissues and a skn pattern of red, lacy macules. It often presents with needle-shaped cholesterol deposits in the kidneys and azotemia.
118
Impaired eye closure on one side indicates ______________.
Bell's palsy
119
Differentiate the terms promoter, enhancer, and activator.
* Promoters are regions of DNA directly upstream (in the 5' direction) of the target gene. They bind RNA polymerase II and are required for transcription.
* Enhancer elements can be anywhere upstream, downstream, or in exons. They bind activators (proteins) that bend back and activate RNA polymerase II. They are not required for transcription.
* Activators are proteins that bind enhancers and interact with RNA polymerase II.
120
Which vitamin is necessary for decarboxylation of ketoacids?
Thiamine
121
Describe which layers of tissue the spermatic cord passes through.
You'll recall that the spermatic cord and the tissues that it is derived from can be remembered with the mnemonic ICE TIE:
* Internal spermatic fascia = Transversalis
* Cremasteric muscle = Internal oblique
* External spermatic fascia = External oblique
Importantly, the internal oblique passes OVER the inguinal canal and makes its contribution via a branching of the muscle. Thus, the deep inguinal ring is an opening in the transversalis and the superficial inguinal ring is an opening in the external oblique.
122
Describe which vessels pass near the ureter in the pelvis.
The ureter passes anterior to the internal iliac artery by the rim of the pelvis and then inferior/anterior/medial to the uterine artery.
123
Differentiate Charcot-Bouchard aneurysms from lacunar aneurysms.
* Charcot-Bouchard aneurysms result from chronic hypertension. When they rupture, they typically cause large hemorrhages in deep brain structures.
* Lacunar aneurysms results from hypertensive arteriolar sclerosis with lipohyalinosis. When these are blocked by thrombi, the effects are often not noticeable on CT. However, they can later (like, a couple weeks) lead to fluid-filled cavities.
124
True or false: NTDs lead to elevated AFP.
True!
The only things that lead to decreased AFP are trisomy 21 and 18.
125
If a woman has irregular periods and low AFP during pregnancy, what likely occurred?
An error in the estimated gestational age (because of the irregular periods)
126
Diabetic neuropathy is caused by what pathologic process?
Endoneural arteriolar hyalinization
127
Drugs that treat hypertension by selectively dilating arteries have what counterproductive effect?
Activation of the RAAS because arterial sensors woul register low BP
128
Varenicline is a _______________ of the nicotine receptor.
partial agonist and competitive inhibitor (meaning it blocks nicotine from cigarettes while stimulating some nicotine response)
129
What does kallikrein do?
It converts kininogen to bradykinin.
130
Explain the phenomenon of hyperoxia-induced hypercapnia.
Wow, this is a hard topic.
In a nutshell, when you give supplemental oxygen to a person with baseline hypoxia, it can trigger elevated levels of pCO2 which precipitate lethargy and confusion. This happens by three ways:
1) In a person with longstanding COPD, only the most ventilated alveoli are perfused with blood because of hypoxic vasoconstriction. Increasing the pO2 will cause all pulmonary vessels to dilate. Thus, more blood gets shunted to less ventilated alveoli. This increases physiologic dead space and makes ventilation less efficient.
2) High oxygen causes hemoglobin to give off CO2. Thus, this rather simply raises pCO2.
3) High pO2 sends signals via the carotid and aortic chemoreceptors to slow ventilation.
131
With age, the interventricular septum becomes more ______-shaped.
sigmoid
132
If a patient's heart demonstrates less hypokinesia following stent placement, what state was the myocardium likely in prior to the surgery?
Myocardial hibernation
The myocardium can slow metabolism in chronic ischemic states without dying. Thus, when oxygen returns it can start working again.
133
What is ischemic preconditioning?
Repeated short episodes of ischemia can allow the heart to suffer longer episodes of ischemia.
134
Which kind of bile duct malady presents with granulomas?
PBC
135
A tumor stains positive for synaptophysin. What tissue did this likely arise from?
Neurons
These are extremely rare tumors. Recall that synaptophysin is necessary for the secretion of neurotransmitters, so only neurons have this.
136
Which brain tumors have GFAP?
All glial cells: oligodendrocytes, astrocytes, and ependymal cells.
137
Where is the "deep brachial" artery?
Posterior to the humerus
I put quotes around this because I remember learning this artery as the profunda brachii. The brachial artery is anterior to the humerus.
138
What GI problem is common in Down syndrome and congenital hypothyroidism?
Umbilical hernia – a failure of the umbilical ring to close
Normally, the umbilical ring closes and helps form the linea alba – the fibrous band in the rectus abdominus. If this doesn't occur, a reducible bulge of intestines can protrude to the surface of the skin.
139
What disorder presents with impaired ability to relax muscles?
Myotonic dystrophy
Hypotonia is floppiness and myotonia is persistent contraction.
```
MyoTonia
My Testicles (gonadal atrophy)
My Toupee (alopecia)
My caTaracts (cataracts)
```
CTG repeats
140
List the four genetic mutations known to be associated with Alzheimer's.
• Early-onset:
- Amyloid precursor protein (21)
- Presenilin 1 (14)
- Presenilin 2 (1)
• Late-onset:
- Apolipoprotein E4 (remember that E2 is protective – "TOO lucky to get dementia.")
141
What causes supine hypertension in pregnant women?
IVC compression with subsequent decreases in venous return
This causes nausea, dizziness, and hypotension while pregnant women are supine and generally only occurs after 20 weeks' gestation.
142
Which menstrual phase is characterized by coiled, tortuos glands?
The secretory phase
Remember that the proliferative phase comes first and has straight glands, and the secretory phase comes second and has coiled (S-shaped just like Secretory) glands.
143
What enzyme helps hepatocytes convert triglycerides into glucose?
Glycerol kinase
Remember that fatty acids cannot be converted to glucose – they only undergo beta oxidation. It is the glycerol backbone that serves as the carbon substrate for gluconeogenesis, and the enzyme glycerol kinase is what initiates this process.
144
If a patient has SVT, it is usually recommended to try ___________ before administering adenosine.
vagal maneuvers (like Valsalva)
145
How do cGMP agents stimulate vasodilation?
They activate a cGMP-dependent protein kinase that decreases intracellular calcium.
146
Febrile seizures need to be differentiated from what other syndrome?
Heat-stroke seizures
If a child has no history of viral/bacterial illness and has a seizure after being left in a hot car, for example, they likely had a heat stroke from the heat. Aggressive cooling has been shown to decrease organ damage.
147
Those with CHF typically have __________________ arterial resistance.
increased
The decreased cardiac output (HFrEF) causes decreased perfusion. Thus, the blood vessels constrict via sympathetic input to maintain pressure. Moreover, CHF causes overactivation of the RAAS system, and angiotensin II also increases arterial resistance.
148
Don't forget that dermatomyosistis can arise from _______________.
underlying paraneoplastic syndrome (often gastric or ovarian adenocarcinomas)
149
One of the things Sketchy did not include in the Group A Streptococcus scene is that _________________.
S. pyogenes is PYR positive
| Think of a Pastry Youth Retreat that would Positively want to visit the pie shop in that scene.
150
True or false: probenecid and allopurinol should be added to COX inhibitors in the management of acute gout.
False. These agents can actually cause a transient increase in uric acid and worsen acute attacks. They are indicated for chronic gout only.
151
True or false: McCune-Albright syndrome leads to the strengthening and early maturity of bones.
False. Although MAS does lead to symptoms of early puberty and you might think it would cause estrogen-induced maturation of bone, it actually causes excess release of IL-6 that degrades bones and leads to fibrous bone dysplasia.
152
Explain how non-traumatic injuries can cause tamponade.
Any process that irritates the myocardium or pericardium can lead to the progressive accumulation of inflammatory fluid around the heart. Thus, radiation, viral myocarditis, and connective tissue disorders like lupus can cause tamponade.
153
Because restrictive pericarditis and tamponade present with similar symptoms and can both result from viral infection, how can you differentiate the two?
Constrictive pericarditis takes weeks to develop and often requires multiple episodes of myocarditis, whereas tamponade can result in as little as a week after myocarditis and only requires one infection.
154
What is the most common cause of death in those with type 2 diabetes?
Coronary artery disease
While diabetes does raise risk for stroke and renal failure, coronary artery disease is the leading killer by a large margin. Even those with ESRD usually die of coronary artery disease.
In a similar thread, diabetes is one of the best predictors of future MI.
155
Wernicke encephalopathy presents with ataxia, nystagmus, and memory impairment. Which of these effects is likely to persist despite the best treatment?
Memory impairment
This results from the Korsakoff hemorrhages to the mammillary bodies that are near the hippocampus and involved in memory processing.
156
Chest pain that is worse with deep inspiration and leads to tenderness on palpation is likely _______________.
costochondritis
157
"Diffuse erythema of the antral mucosa" is likely _______________.
chronic gastritis from H. pylori
158
Distinguishing between Aspergillus and Mucor can be difficult on histologic slide. Be sure to look for _____________.
septations (that indicate Aspergillus)
| Think of how Aspergillus grows on peanuts and peanuts are formed in septate pods.
159
Isosorbide dinitrate must be given in much higher doses than sublingual nitrate because _______________.
of high first-pass metabolism
160
Wow, somehow I never learned in D&D, ID, or Sketchy that botulism presents with both NMJ dysfunction and ___________________.
anticholinergic symptoms (like dry mouth and dilated pupils)
Botulism toxin inhibits the release of acetylcholine from motor neurons and PNS neurons.
161
What causes fetal hydronephrosis?
Disruption of the proximal ureter!
Vesicoureteral dysfunction produces dilated ureters, not hydronephrosis.
162
If lots of participants leave a study and the majority are from one group (e.g., those exposed to a certain agent), then the results are likely affected by ______ bias.
selection
163
What is misclassification bias?
When either the exposure/intervention or outcome is not classified correctly
164
Differentiate Chiari I and II.
I: cerebellar tonsil herniation; often asymptomatic
II: cerebellar vermis herniation; frequently symptomatic
("Two affects the tube," meaning Chiari II can cause myelomeningocele or hydrocephalus from aqueductal stenosis.)
165
What effects did Sketchy not mention that cholinergic agonists can cause?
Sweating
| Flushing (from M3-mediated NO production in the arteries of the skin)
166
Differentiate (1) somatic symptom disorder, (2) illness anxiety disorder, and (3) conversion disorder.
• Somatic symptom disorder is a preoccupation with one or more unexplained symptoms.
– Example: a woman with recurrent stomach aches undergoes extensive testing and is found to be completely normal on exam. She then focuses intensely on what it might be or keeps thinking it could be a serious disease that the doctors missed. This ultimately impacts her quality of life to a significant degree.
* Conversion disorder is when someone undergoes substantial life stress (for instance, a divorce or job loss) and then presents with physical complaints such as headache or stomach ache without underlying cause.
* Illness anxiety disorder is when a healthy person worries extensively about getting sick.
167
What causes exophthalmos?
TSH stimulates receptors in the rear of the eye that induces lymphocytic infiltrate.
168
True or false: decreased time from A2 to opening snap predicts worse prognosis.
True.
When mitral stenosis starts, there is usually a long lag between A2 and the opening snap because the left atrium hasn't developed a stronger tone. As time progresses, the left atrium gets stronger and the A2-OS time lag decreases.
169
The main indicator of hypo- and hyperventilation is _____________________.
PaCO2
170
Describe HEV.
* ssRNA
* Naked (think nakeeey)
* Causes high mortality in pregnant women
* No chronic infeciton
171
Ventricular arrhythmias commonly occur after _____________.
an MI (24 - 48 hours)
Treat with amiodarone or IB antiarrhythmics.
172
What fungus commonly contaminates sputum cultures?
Candida!
If they give you a history that seems like a non-fungal illness (for instance, a TB story) and then tell you that his sputum grew pseudohyphae at 37º, this is likely Candida from his mouth!
Candida is a commensal organism in most people's oral cavities.
173
True or false: ceftriaxone and moxifloxacin can kill P. aeruginosa.
False.
This is a little tricky. Other fluoroquinolones (ciprofloxacin and levofloxacin) can kill Pseudomonas and other 3rd-generation cephalosporins (ceftazidime) can kill it, but not these agents.
174
How does baclofen work?
It is a GABA-B agonist.
| "GABAclofen"
175
Why does hyperglycemia damage the eyes?
Glucose can be metabolized to sorbitol. Sorbitol is an oxidative agent that normally gets metabolized to fructose. In hyperglycemia, the sorbitol pathway gets hypersaturated and more sorbitol accumulates.
176
Wedge-shaped necrosis in the kidney usually indicates ______________.
embolism
177
What condition is characterized by hemorrhagic telangiectasias?
Osler-Weber-Rendu syndrome
* Autosomal dominant disorder
* Can present in any of the mucous membranes of the body (lung, oropharynx, esophagus)
(Think "Oser's Web's Rupture.")
178
In most cases, abdominal aortic aneurysm results from what pathologic process?
Chronic transmural inflammation – this results from chronic hypertension
Note: cystic medial necrosis is the function by which AAA presents in those with Marfans.
179
Where do aortic dissections usually originate?
* Type A: ascending aorta
* Type B: near the left subclavian
Type B will present with elevated right arm BP compared to left, because the subclavian tear can occlude the left subclavian.
180
If something doesn't add up, then _____________________.
read the question slowly and thoroughly
181
Not considering Turner syndrome, coarctation of the aorta is often associated with what other cardiovascular complications?
Berry aneurysms
These are especially prone to rupture given that those with coarctation of the aorta have high BP in the carotid arteries.
182
You know that Mycoplasma can agglutinate RBCs in the cold. What symptom can this cause in patients with walking pneumonia?
Transient anemia
183
What is the best therapy for bulimia nervosa?
SSRIs (remember the receptionist in the Sketchy scene puking in the drawer)
184
Many cases of beta-thalassemia result from what kind of biochemical mutation?
Defects in mRNA production (such as promoter region defects)
185
Acidophilic cells in the liver of someone with acute hepatitis are what cellular manifestation?
Apoptosis
186
Why is bile only absorbed by the distal ileum?
Bile is a charged molecule and requires special transporters to be absorbed. These are found in the distal ileum.
187
Those with IBD are more likely to suffer from colorectal cancer than the average population. What features are different in IBD-associated CR cancer?
* More likely to be multifocal
* More common to develop p53 mutations first (kind of goes with the B27 number thing)
* More likely to be flat, not polypy
* More common in younger patients
* More common to be in the proximal colon
188
The cardiac apex is formed by which ventricle?
The left (hence hearing the mitral valve there)
189
True or false: the lungs cover the entire anterior surface of the heart.
Mostly true. The sternum also covers the anterior heart, but there is a tiny window between the sternum and the lungs in the fifth intercostal space that is not covered by the lungs/sternum. In general, though, you need to cut through the lungs or sternum to get to the heart.
190
The pituitary is immediately surrounded by what vascular structure?
The cavernous sinus
191
Which cranial nerves pass through the cavernous sinus?
III - VI (but not V3)
192
Methimazole and propylthiouracil both inhibit thyroid peroxidase. What's a big difference in their mechanism/pharmacodynamics, though?
Propylthiouracil also inhibits peripheral conversion of T4 to T3!
(Remember: "Ptu is Peripheral, too.")
193
What infection has been shown to cause lactose intolerance?
Giardia
194
What four arteries are most likely to develop atherosclerosis (in order)?
1) Abdominal aorta
2) Coronary arteries
3) Popliteal arteries
4) Carotid arteries
195
Which three drugs decrease mortality in those with CHF?
* Beta-blockers
* ACE inhibitors
* Angiotensin receptor blockers (even in combination with ACE inhibitors!)
196
Infarctions in the _______________ are extremely rare due to the double blood supply.
liver
197
Endometriosis in the rectouterine pouch can cause _______________.
retroverted uterus from adhesions
198
What is a physical exam sign that can help distinguish adenomyosis from endometriosis?
Adenomyosis presents with enlarged uterus, while endometriosis does not.
199
What presentation is common for acalculous cholecystitis?
Those with poor perfusion (history of sepsis or shock) can have ischemic damage to the gallbladder. Suspect this is someone without a history of colicky pain and with recent reason for ischemia.
200
What neurologic deficits are common in the rupture of a berry aneurysm?
None!
Charcot-Bouchard aneurysms are more likely to cause neurologic deficits.
201
Hydronephrosis from vesicoureteral reflux can ultimately lead to ____________________.
secondary hypertension in a child
202
Why is interferon-gamma necessary for the elimination of tuberculosis?
Mycobacteria are intracellular, and interferon-gamma is necessary to upregulate MHC.
203
True or false: dopamine increases cardiac output by decreasing systemic vascular resistance.
False. It does so by directly stimulating beta-1 receptors.
Note: this occurs at higher doses than the amount required to vasodilate the kidneys.
204
There are four stages of lung pathology that lobar pneumonias pass through. List and describe ethe timeline and characteristics of each.
• Congestion:
- first 24 hours
- red, boggy lung with exudate but no neutrophils
• Red hepatization:
- days 2 and 3
- red, firm lung with neutrophil infiltrate
• Gray hepatization:
- days 3-6
- gray, firm lung with neutrophils
• Resolution:
- post day 6
- restoration of normal architecture
Note: dissemination can occur in immunocompromised hosts, and reorganization can lead to disadvantageous architecture (like adhesions)
205
List two features of chronic vitamin A overdose.
* Hepatomeglay
| * Dry skin
206
In a period of cerebral ischemia (e.g., temporary cardiac arrest), what areas of the brain are usually injured first?
* Pyramidal cells of the hippocampus
* Purkinje cells of the cerebellum
(I don't know if this is a coincidence, but these are the exact same cells affected by rabies! Just imagine someone with rabies shutting off a firehose connecting to the boat and tree in that scene – get it, aquaphobia = ischemia?)
207
Why do girls wth Turner syndrome have peripheral edema?
They have impaired lymph drainage. (This is related to the lymph dilations of the cystic hygromas.)
208
The V/Q ratio is much _______________ in the apex when compared with the base.
higher
Recall that perfusion is much greater at the base of the lungs due to the effects of gravity. Ventilation is greater, too, but not the same degree.
209
Why does increased alveolar size decrease ventilation?
Increased alveoli have less compliance. Because they are less compliant, they generate less inward force than smaller alveoli and thus pull in less air.
This is why the alveoli at the bottom of the lungs have greater ventilation.
210
What is the difference between bulimia and binge-eating disorder?
Bulimia implies some form of compensation for overeating such as vomiting, fasting, or excessive exercise. Binge-eating disorder, on the other hand, merely refers to the act of periodically overeating with control in the absence of compensatory behaviors.
211
What is the difference between schizoaffective disorder and major depression with psychotic features?
Schizoaffective disorder must have a two-week or more episode of psychotic symptoms without mood disturbances. If the psychotic symptoms only arise in the presence of mood disorders, then it is MDD with psychotic features.
212
There are some weird paraneoplastic syndrome I hadn't heard of. For instance, small cell carcinoma can cause ________________ and RCC can cause _____________________.
subacute degeneration of the cerebellum; erythrocytosis from EPO production
213
Diabetes insipidus presents with ________ serum sodium.
high (because you're not pulling water in to dilute the serum)
214
Describe the presentation of primary polydipsia.
* Usually occurs with psychiatric illness or psychological stress
* Presents with low serum sodium
* On water deprivation test, urine will increase in concentration and not respond to DDAVP when maximally concentrated
* Treat with water restriction
