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Step 1 > QB - DISEASES2 > Flashcards

QB - DISEASES2 Flashcards

1
Q

Deficiency in pyridoxine

A

Pyridoxine required as cofactor for 1st step in heme synthesis

Decreased heme synthesis –> microcytic, hypochromic pyridoxine-responsive anemia (sideroblastic anemia)

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2
Q

Alveolar cells containing golden cytoplasmic granules –> dark w/ Prussian blue staining; what is pathology?

A

Prussian blue stains for IRON

Pt. has “heart failure cells” - macrophages that have engulfed a lot of RBCs in pulmonary circulation (due to pulmonary congestion/edema secondary to chronic LEFT heart failure)

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3
Q

Turner’s syndrome: levels of FSH/LH?

A

Elevated LH and FSH – no negative feedback due to ovarian failure (no breast development, no menarche)

Small chance that some women can have spontaneous puberty –> possibility for pregnancy

Most can only become pregnant w/ donor oocytes - will need supplemental estrogen/progesterone to prepare and maintain uterine lining

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4
Q

Fibroadenoma

A

most common benign tumor of breast
occur in multiples, in both breasts
increase in size during luteal phase of menstrual cycle/lactation
freely moveable, palpable mass (young)

cellular, myxoid stroma that encircles epithelium-lined glandular and cystic spaces

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5
Q

Ductal carcinoma in situ (DCIS)

A

precancerous breast lesion
malignant clonal cell proliferation (contained by surrounding ductal BM)
Myopethelial (basal) layer preserved/uninvolved

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6
Q

Paget disease of nipple

A

Malignant cells spread from superficial DCIS into nipple skin (does not cross BM)

unilateral erythema and scale crust around nipple

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7
Q

Sclerosing adenosis

A

Central acinar compression/distortion (by surrounding fibrotic tissue) and peripheral ductal dilation

common finding in fibrocystic change

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8
Q

Mammary duct ectasia

A

Ductal dilation, inspissated breast secretions

Chronic granulomatous inflammation in periductal and interstitial areas

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9
Q

Medullary carcinoma

A

Solid sheets of vesicular, pleomorphic, mitotically active cells w/ significant lymphoplasmacytic infiltrate around/within tumor – pushing, noninfiltrating border

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10
Q

Temporal arteritis

A

Inflammation in MEDIUM-sized and LARGE arteries – mononuclear infiltrates & multinucleated giant cells = “giant cell vasculitis”

Granulomas in media of arteries

Narrowing of vessel –> decrease in blood supply to perfused areas:
1) headache
2) craniofacial pain (jaw & tongue claudication) – while chewing
3) polymyalgia rehumatica – neck, torso, shoulder, pelvic girdle pain & morning stiffness; fever, fatigue, weight loss may also occur
4) sudden vision loss (monocular)

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11
Q

Reversal treatment for ingestion of rat poison

A

Pts. susceptible to GI bleeding (no coagulation factors)

Give fresh frozen plasma and vitamin K1

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12
Q

Hamartoma

A

Excessive growth of tissue type native to organ of involvement

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13
Q

Most common benign lung tumor

A

Hamartoma (pulmonary chondroma)
“coin lesion” in pts. 50-60yrs old

Incidental finding on CXR – “popcorn calcifications”

contain islands of mature hyaline cartilage, fat, smooth muscle & clefts lined by respiratory epithelium

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14
Q

Type of lung cancer w/ neuroendocrine markers

A

Small cell carcinoma of the lung

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15
Q

Keratin pearls characteristic of what type of malignancy?

A

Squamous cell carcinoma

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16
Q

Membranous GN

A

Nephrotic

Generalized edema
Heavy proteinuria (>3.5g/day)
Hypoalbuminemia
Hyperlipidemia

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17
Q

IgA nephropathy (Berger disease)

A

Children/young adults
Painless hematuria
2-3 days after upper respiratory infection

(contrast w/ Post-STREP GN which occurs 2-3 weeks after upper respiratory or skin infection; anti-streptolysin O antibody; low C3 levels)

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18
Q

Squamous cell carcinomas of bladder

A

RARE
Associated w/ Schistosoma haematobium infection

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19
Q

Urothelial carcinoma

A

Formerly transitional cell carcinoma
makes up 90% of bladder cancers

Painless gross hematuria
Tumor penetration of bladder wall = major prognostic indicator
(carcinoma in situ - confined to epithelium)

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20
Q

Vitelline duct connects what two structures; when it it obliterated? What condition results if duct persists?

A

Midgut lumen w/ yolk sac;
Obliterates 7th week

Persistence of vitelline duct = connection between intestinal lumen + umbilicus

Meckel diverticulum most common vitelline duct anomaly: partial closure of vitelline duct –> patent portion attached to ileum (fibrous band may connect tip of Meckel’s diverticulum w/ umbilicus) – can present w/ rectal bleeding/intestinal obstruction

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21
Q

Umbilical hernia

A

Weakness of abdominal wall at umbilicus - midline protrusions covered by skin

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22
Q

Omphalocele

A

Midline defect in abdominal wall - incomplete closure – abdominal organs protrude through defect covered w/ peritoneal sac

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23
Q

Facor XIII deficiency

A

clot instability –> delayed, recurrent bleeding after trauma

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24
Q

Protein C acts w/ Protein S to inactivate what factors?

A

Factor V and factor VIII

Inability to inhibit Factor V and VIII –> procoagulation state
Factor V Leiden mutation –> procoagulation (bc factor V can’t be inactivated)

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25
Q

Factor X activates thrombin; what does thrombin activate?

A

Thrombin activates factor V, VIII, and XI

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26
Q

ALS is combined UMN and LMN lesions: what structures involved?

A

Loss of neurons in anterior horn (LMN) - muscle weakness & atrophy

Degeneration/atrophy of lateral corticospinal tracts (UMN) - spasticity & hyperreflexia

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27
Q

Treatment of ALS

A

Riluzole
MOA: decreases glutamate release

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28
Q

What structures are damaged in poliomyelitis?

A

Enteroviral infection damages motor neurons in anterior horn –> LMN disease

Flaccid paralysis, atrophy, areflexia, fasciculation

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29
Q

Huntington disease; what structures are damaged?

A

Caudate nucleus + putamen

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30
Q

Symptoms of Friedrich ataxia

A

AR disorder – children 5-15yrs old
Ataxia
hypertrophic cardiomyopathy
kyphoscoliosis
foot abdnormalities
diabetes mellitus

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31
Q

Pathogenesis of Vitamin B12

A

Subacute combined degeneration of:
posterior & lateral spinal columns

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32
Q

Tumor staging vs. grading

A

Stage - TNM system (tumor size, nodal involvement, metastasis)
Grade - differentiation (high = high cellularity, nuclear peomorphism, poorly differentiated)

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33
Q

Tumor with high bromodeoxyuridine uptake; what does this indicate?

A

Bromodeoxyuridine = thymidine analog

Thymidine = nucleotide
High nucleotide uptake occurs in S phase (cells ready to divide)

Tumor that has high thymidine uptake = high grade tumor & poor prognosis

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34
Q

Older female, weight loss, abdominal discomfort, jaundice, epigastric mass; what GI association?

A

Pancreatic cancer

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35
Q

Low pitched holosystolic murmur heard best at left sternal border; accentuation w/ handgrip exercise; what is defect and why is it heard better w/ maneuver?

A

VSD

handgrip maneuver –> increases afterload (pressure in systemic circulation that LV & aorta have to pump against)

increased afterload (pressure) causes more blood to be shunted from LV to RV (lower pressure system) so the murmur is heard louder

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36
Q

Early diastolic murmur heard better with handgrip exercise?

A

Aortic regurgitation

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37
Q

Mid-systolic pulmonary ejection murmur

A

due to increased flow across pulmonic valve

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38
Q

Incomplete obliteration of processus vaginalis = connection btwn peritoneum & scrotum; what are 2 conditions that can occur from this connection?

A

Hydrocele (fluid leakage)
Indirect inguinal hernia (abdominal contents herniate down)

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39
Q

Enzyme missing in albinism

A

Tyrosinase (uses tyrosine as substrate for melanin)

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40
Q

Enzyme missing in alkatonuria

A

Homogentisic acid oxidase

Accumulation of homogentisic acid in body that needs to be renally excreted

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41
Q

Gene mutations associated w/ Alzheimer’s

A

APP (chromosome 21)
presenilin 1 & 2
apoE4

APP & presenilin mutations promote AB-amyloid formation

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42
Q

Familial hypercholesterolemia

A

AD disorder

LDL receptor mutations – liver can’t take up LDL –> severe elevation in total cholesterol

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43
Q

Hypertrophic cardiomyopathy mutation

A

AD trait

mutation in B-myosin heavy chain

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44
Q

Renal artery stenosis often caused by atherosclerosis; what cells undergo hyperplasia/hypertrophy? Why?

A

JG cells: renal artery stenosis cause hypoperfusion –> renin production increased in order to prodce more ATII –> vasoconstriction & aldosterone release
(JG cells are modified smooth m. cells in afferent & efferent arterioles)

Macula densa cells - distal tubule: sense osmolarity/volume of urine –> transmit back to JG cells

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45
Q

Damage to common peroneal n. – what structure is involved?

A

Fibular head – occurs from lateral blows to knee/leg cast

Pain/numbness of dorsum of foot
Weakness in dorsiflexion of foot (foot drop)
Weakness in eversion of foot

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46
Q

Deep peroneal n. (action)

A

Sensory to region btwn 1st and 2nd digits
Anterior compartment of leg (dorsiflexors of foot and toes) – in conjuction w/ common peroneal n.

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47
Q

Tibial n. (action)

A

Plantar flexion & inversion of foot

48
Q

Important structures coursing near medial malleolus

A

Anteriorly:
Saphenous n.
Great saphenous vein

Posteriorly:
Posterior tibial a.
Tibial n.

Tendons of:
flexor digitorum longus
flexor hallucis longus
tibialis posterior

49
Q

What type of gating does CFTR gene have?

A

ATP-gated

F508 mutation
chromosome 7

CFTR hydraes mucosal surfaces; promotes secretion from ducts of exocrine pancrease; hypotonic sweat

Transport through eccrine ducts –> salt removed from ductal lumen
(hence chloride sweat test to detect elevated levels of salts)

50
Q

Where does cGMP-gated Na+ channels play a role?

A

Vision

51
Q

Persistent allantois remnant; what clinical features present?

A

Urine discharge from umbilicus

Allantois –> urachus (duct btwn bladder and urogenital sinus)

Failure of urachus to obliterate:
1) patent urachus – urine from umbilicus
2) vesicourachal diverticulum
3) urachal sinus (purulent discharge from umbilicus)
4) urachal cyst

52
Q

Physical manifestations of 47, XXX

A

Silent - normal females
some slightly decreased IQ scores

53
Q

Physical manifestations of 47, XXY

A

Tall male
gynecomastia, small testes, infertility

Klinefelter syndrome

54
Q

Physical manifestations of 47, XYY

A

Tall, severe acne
Delay in motor & language development

55
Q

Calcitriol

A

Active form of vitamin D converted in the KIDNEYS from 25-hydroxycholecalciferol

56
Q

Actions of calcitriol

A

Increase Ca2+ & phosphate absorption

57
Q

Chronic renal failure: what happens to PTH, Ca2+, phosphate, calcitriol?

A

Chronic renal failure = due to secondary hyperparathyroidism (high PTH)

Decreased renal parenchyma –> decreased calcitriol production

Lab values:
high PTH
low Ca2+
high phosphate
low calcitriol

58
Q

Why does Ca2+ levels decrease in chronic renal failure?

A

Decrease excretion of phosphate –> phosphate binds Ca2+ to form complexes –> less free Ca2+

59
Q

What two values always counteract each other in renal disease?

A

PTH and phosphate

High phosphate (lack of renal excretion) –> low Ca2+ –> elevate PTH

60
Q

Conn’s syndrome

A

primary hyperaldosteronism (zona glomerulosa hyperplasia)

primary adrenal hyperplasia
renal Na+ retention
excess K+ secretion
results in HTN and hypokalemia

Hypokalemia (muscle weakness); parethesias

61
Q

Weight gain + easy bruising; what adrenal condition?

A

Cushing’s syndrome
Glucocorticoid excess

Inhibited collagen and matrix GAG synthesis –> weaker skin/CT –> easy bruising

Zona fasiculata

62
Q

Hirsutism (excessive hair growth); what adrenal condition?

A

Androgen excess - adrenal tumor causing androgen hypersecretion
zona reticularis

63
Q

Diarrhea & flushing; what condition association?

A

Carcinoid syndrome

Serotonin(5-HT)-secreting tumor derived from neuroendocrine cells of GI tract

64
Q

Chronic myeloproliferative disorders (4)

A

CML - leukocytosis w/ marked left shift
Essential thrombocytosis - thrombocytosis
Polycythemia vera - erythrocytosis
Primary myelofibrosis - bone marrow fibrosis

65
Q

Mutation in myeloproliferative disorders (except for CML):
primary myelofibrosis, essential thrombocytois, essential thrombocytosis

A

JAK2 - tyrosine kinase (phosphorylation)

JAK2 causes persistent activation of STAT (signal transducers & activator of transcription)

66
Q

Primary myelofibrosis

A

atypical megakaryocytic hyperplasia

clonally expanded megakaryocytes activate fibroblast proliferation –> replacement of marrow space with collagen –> pancytopenia

peripheral smear: teardrop-shaped RBCs and nucleated RBCs

67
Q

Why is there hepatomegaly and splenomegaly in myelofibrosis?

A

Loss of bone marrow hematopoiesis –> extramedullary hematopoiesis

68
Q

Alcoholic is brought into hospital and stated on IV fluids + dextrose; develops ataxia, confusion, ophthalmoplegia. What enzyme is deficient in this patient’s TCA cycle?

A

a-ketoglutarate dehydrogenase
cofactors (5):
Thiamine (deficient in alcoholics)
Lipoic acid
CoA
FAD
NAD+

conversion from a-ketoglutarate to succinyl-CoA

69
Q

Presence of unilateral fetal hydronephrosis –> what structure is possibly affected?

A

Ureteropelvic junction (junction btwn kidney & ureters) – last to canalize in fetal development

Transient hydronephrosis due to metanephros producing urine before canalization of ureteric bud is complete

70
Q

Origin of ureteric bud?

A

Metanephros

71
Q

Origin of collecting ducts, calices, renal pelvis, ureters, renal parenchyma?

A

Metanephros

72
Q

Most common cause of bacterial meningitis in adults of all ages?

A

Streptococcus pneumoniae

Lancet-shaped, Gram+ cocci in pairs

Increase neutrophils, decrease glucose, increase opening pressure

Pt. w/ confusion, severe headache, nausea, nuchal rigidity

73
Q

Pt. with Parkinsons complains of “freezing up” moments followed by episodes of not experiencing any rigidity; why?

A

Drug response is UNPREDICTABLE and NOT dose-dependent

“On-off”phenomenon:
Sudden loss of anti-Parkinsonian effects of levodopa (L-dopa) –> hypokinesis and rigidity; other times, levodopa works.

74
Q

What kind of pathology is associated w/ elevated conjugated bilirubin?

A

Hepatobiliary disease (cirrhosis or hepatitis) – bilirubin conjugates will reflux back to plasma when secretion of bilirubin into bile is slow

75
Q

What kind of pathology is associated w/ elevated Unconjugated bilirubin?

A

Increased bilirubin formation (hemolysis)
Slowing in bilirubin conjugation (Gilbert syndrome)

76
Q

Gilbert syndrome

A

UDP glucuronyl transferases decreased

Bilirubin glucoronidation decreased

77
Q

What is the association btwn Wilson’s disease and the liver?

A

Pt. younger than 30 yrs w/ unexplained chronic hepatitis (elevated AST and ALT)

Presence of ceruplasmin & urinary copper excretion
Kayser-Fleischer rings

78
Q

Superior mesenteric artery syndrome; what are predisposing factors? At what level does SMA leave aorta?

A

Transverse portion of duodenum gets entrapped btwn SMA and aorta –> partial intestinal obstruction

Predisposing factors:
Aortomesenteric angle decreased
Diminished mesenteric fat
Pronounced lordosis
Surgical correction of scoliosis

79
Q

What malignancies is Down syndrome associated w/?

A

AML
ALL
early Alzheimer

80
Q

Cause of Cushing’s syndrome: ACTH dependent vs ACTH independent

A

ACTH dependent:
a) Cushing’s disease - pituitary ACTH hypersecretion
b) Ectopic ACTH syndrome - paraneoplastic ACTH secretion

ACTH independent:
a) adrenal adenoma or carcinoma

81
Q

Embryonic aortic arch that ductus arteriosus derives from

A

6th

82
Q

Patent ductus arteriosus; what to keep it open; what to close it?

A

PGE2 = maintain patency
Indomethacin = close PDA (usually ductus arteriosus closes after birth when partial pressures of O2 increase and PGE2 decrease)

“Machinery-like” continuous murmur, bounding pulse with thrill palpated over upper left sternal edge

After closure, known as ligamentum arteriosum

83
Q

How is gastric acid secretion by parietal cells in mucosal glands (fundus & body of stomach) stimulated?

A

1) Histamine –> H2 receptors –> increase intracellular cAMP
2) Acetylcholine –> M3 muscarinic receptors –> increase intracellular Ca2+

3) Gastrin –> gastrin receptor:
– increase intracellular Ca2+ concentration
– histamine synthesis & release by ECL (enterochromaffin-like cells) in stomach***

84
Q

What action does increased intracellular Ca2+ and cAMP have on gastric acid secretion?

A

Ca2+ increase (activates things)
cAMP activate protein kinases
BOTH lead to increased transport of H+ by H+K+ ATPase into gastric lumen

85
Q

Systemic mastocytosis (symptoms)

A

Mast cell proliferation –> increased histamine release –> gastric acid secretion increases

Gastric hypersecretion:
Inactivates pancreatic & intestinal enzymes –> diarrhea
Gastric ulcerations

Increase mast cells:
Syncope
Flushing
Hypotension –> Tachycardia
Bronchospasm
Pruritis, urticaria, dermatographism

86
Q

Pernicious anemia

A

Autoantibody to parietal cells/intrinsic factor

IF not produced –> vit. B12 not absorbed –> neurologic symptoms

87
Q

Substances that pancreatic tumors secrete:

A

1) Gastrin: ZE syndrome
2) Insulin: fasting hypoglycemia
3) Glucagon: diabetes mellitus & RASH*
4) Somatostatin: diarrhea, cholelithiasis, diabetes mellitus

88
Q

Opening snap (extra heart sound) shortly after S2 heart sound (AV close); Diastolic rumbling murmur after opening snap best heard at heart apex

A

Mitral stenosis

Diastolic rumbling murmur due to turbulent flow through stenottic mitral valve during LV filling

Extra heart sound (opening snap) due to abrupt halting of leaflet motion during mitral valve opening due to fusion of mitral valve leaflet tips

89
Q

Congenital torticollis

A

2-4 weeks old
Child prefers to hold head tilted to one side (cries when you try to move child’s nexk; could present w/ firm swelling in neck)

Due to malposition of head in utero or birth trauma (breech delivery) –> SCM m. injury & fibrosis

90
Q

What can bind to antithrombin? What does antithrombin do?

A

Unfractioned heparin and LMWH bind antithrombin –> antithrombin activity against Factor Xa

Unfractioned heparin able to bind to both antithrombin & thrombin –> allow antithrombin to inactivate thrombin

91
Q

Enoxaparin

A

LMWH

92
Q

Fondaparinux

A

Synthetic pentasaccharide factor Xa inhibitor

93
Q

Relationship of ureters w/ common/external iliac vessels and gonadal vessels?

A

Ureters:
course on TOP of psoas muscle
cross OVER common/external iliac vessels
cross UNDER gonadal vessels (ovarian vessels in females) - “water under the bridge”

enter true pelvis:
pass LATERAL to internal iliac vessels
pass MEDIAL to gonadal vessels as they enter true pelvis

94
Q

Ventromedial nucleus of hypotahalmus destroyed

A

Person eats more and becomes obese
(ventromedial nucleus responsible for satiety)

95
Q

Lateral nucleus of hypothalamus destroyed

A

Person starves (lateral nuclei responsible for hunger)

96
Q

Supraoptic and paraventricular nuclei destroyed

A

No release of ADH or oxytocin (later carried down to neurohypophysis)

97
Q

Anterior hypothalamic nuclei vs. posterior hypothalamic nuclei in relation to heat production

A

Anterior hypothalamic nuclei = vasodilation & sweating = COOL

Posterior hypothalamic nuclei = conserve heat, heat production = HOT

98
Q

What morphological change occurs in vessels in primary pulmonary HTN? What causes it?

A

Increase thickness of smooth muscles in arterioles (medial hypertrophy); fibrosis of intima

Inherited disease
Decreased apoptosis of endothelial and smooth muscles cells in pulmonary aa

Presents in women; dyspnea and exercise intolerance

99
Q

Rx for primary pulmonary HTN

A

Bosentan - endothelin-receptor antagonist
(endothelin vasoconstricts and stimulates endothelial proliferation) – blocking of endothelin –> decrease pulmonary arterial pressure (lessen RV hypertrophy)

100
Q

Pt. w/ chronic aortic stenosis (AS) experiences a. fib; what symptoms exacerbated? What could happen to venous pressures?

A

Reduced ventricular preload –> CO decrease –> dangerous systemic hypotension

Acute a. fib can also increase steady state pulmonary venous pressures sufficiently to cause acute pulmonary edema

101
Q

Hyperpyrexia (temp?); what should be done first?

A

Greater than 40C

Can lead to permanent brain damage

Give acetaminophen to kids (inhibits COX in CNS, decrease PGE synthesis); avoid ASA due to Reye syndrome

102
Q

Bacterial LPS can stimulate high fevers; what substances released to induce fever?

A

IL-1
IL-6
TNF

103
Q

What vessel is derived from the common cardinal veins?

A

SVC

104
Q

How does left heart failure lead to increased pulmonary arterial pressure?

A

LH failure –> backup of fluids in lungs –> pulmonary edema causes collapse of alveoli –> less ventilation –> VASOCONSTRICTION to shunt blood away from O2 poor areas –> pulmonary arterial HTN due to vasoconstriction –> increase afterload for right ventricle –> right heart failure

105
Q

Indirect vs. Direct vs. Femoral hernias

A

Indirect: male infants - LATERAL to inferior epigastric vessels; persistent processus vaginalis; failure of inguinal ring to close

Direct: older men; bulges from Hesselbach’s triangle; MEDIAL to inferior epigastric vessels; due to weakness of transversalis fascia

Femoral: women; protrudes from femoral ring; medial to femoral vessels; INFERIOR to inguinal ligament

106
Q

Hesselbach’s triangle

A

Inguinal ligament - inferiorly
Inferior epigastric vessels - laterally
rectus abdominus - medially
Transversalis fascia - floor of triangle

107
Q

Uncinate process of pancrease/major pancreatic duct - derived from?

A

Ventral bud

108
Q

Pancreas divisum

A

Dorsal & ventral buds don’t fuse

Clinically silent usually

Can predispose to recurrent pancreatitis; accessory duct drains majority of pancreas

109
Q

Middle meningeal a. vs. middle cerebral a.

A

Middle MENINGEAL - branch of MAXILLARY – branch of EXTERNAL carotid a.
can be ruptured due to trauma in area where frontal, parietal, temporal, and sphenoid bones meet –> EPIDURAL hematoma –> transtenorial herniation, palsy of CNIII

Middle CEREBRAL - branch of INTERNAL carotid a.
can lead to SUBARACHNOID or intracerebral hemorrhage

110
Q

What does a decrease in CO in CHF patients do to renin-angiotensin system?

A

Decrease CO –> low stretch in glomerular afferent arterioles –> renin-angiotensin system activation to bring BP up –> vasoconstriction –> increased arterial resistance and afterload (the pressure LV has to pump against)

111
Q

Where is angiotensinogen converted to angiotensin I?

A

Liver

112
Q

Systolic dysfunction

A

Decrease in myocardial contractility

113
Q

Diastolic dysfunction

A

Inability of heart to relax sufficiently to allow adequate filling of blood

114
Q

Zollinger-Ellison; why is it associated w/ diarrhea?

A

Hypersecretion of gastrin via pancreatic tumor

Peptic ulcers result

Diarrhea – due to inactivation of intestinal & pancreatic enzymes by EXCESSIVE GASTRIC ACID

115
Q

Polyarteritis nodosa (PAN)

A

Segmental TRANSMURAL NECROTIZING inflammation

Medium/small sized arteries

Necrotic tissue/immune complexes/complement/plasma proteins w/ smudgy eosinophilic deposit (fibrinoid necrosis) – immune complex vasculitis

116
Q

Buerger’s disease (thromboangiitis obliterans)

A

Thrombosing vasculitis - medium/small sized arteries

Tibial and radial arteries

Heavy smokers, onset prior to 35

117
Q

Takayasu arteritis

A

Giant cell (temporal) arteritis
Jaw claudication
Affects aortic arch
Females <40yrs

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