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1
Q

Worthless tid-bit

Where does the horizontal fissure of the right lung rest with respect to the ribs?

A

At the level of the 4th rib

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2
Q

Most likely form of necrosis seen in the kidney would be?

A

Coagulative

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3
Q

Are metaplasia/dysplasia reversible processes?

A

Both are

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4
Q

MSK exam reveals weakened strength with supination and wrist extension. You suspect disk herniation of what vertebrae?

A

C5-C6

Cervical nerve C6

(Remember, cervical nerve root exit suprior to cooresponding vertebrae)

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5
Q

What is the diagnostic criteria for SLE?

A

4 out of 11:

S: Serositis O: Oral Ulcers A: Arthiritis P: Photosensitivity B: Blood disorders R: Renal Dysfunction A: ANA I: Immumological (dsDNA, Smith, phospholipid) N: Neurological (Seizures/psychosis) M: Malar Rash D: Discoid Rash

SOAP BRAIN MD

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6
Q

“Wet” Gangrenous necrosis is associated with which two anatomical regions? What is the mechanism of necrosis?

A

Limbs and GI tract as a result of bacterial infection as opposed to “dry” gangrenous necrosis which is associated with ischemic necrosis.

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7
Q

Review B12 transport and metabolism and answer: B12 def. macro/normo/microcytic anemia?

A

Do it today and Macrocytic

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8
Q

Indirect Inguinal Hernia

Common age of incidence?

Relationship to inferior epigastric artery?

Course of herniation?

A

More common in infants/younger boys due to failure of the processes vaginalis to close. They course through the inguinal canal, into the scrotum, and run LATERAL to the inferior epigastric.

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9
Q

Explain how lipid soluble nutrients and lipids enter systemic circulation

A

Lipids are broken down and along with fat soluble molecules are taken up by small intestine enterocytes. Formed into chylomicrons and taken up by LYMPHATIC LACTEALS running parallel to vasculature. The lacteals combine with the throacic duct and chylomircons travel to liver after introduction to systemic circulation at the L subclavian vein.

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10
Q

Name 2 USMLE HLA-DR4 Associations?

A

RA

Juvenile Diabetes

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11
Q

Saponification of fats can lead to Fatty Necrosis which is normally seen in what organ/organ system?

A

The Pancreas (Lipase from the pancreas leads to fatty breakdown)

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12
Q

Pathological hypertrophy is usually associated with progression to cancer except for…

A

benign prostatic HYPERPLASIA

(Pathoma)

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13
Q

This X-ray is the result of a patient with cough, night sweats, and fever for multiple days. What is the most likely diagnosis? What type of necrosis would best characterize the lesion?

A

Most likely diagnosis is active TB. TB is associated with caseous necrosis.

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14
Q

What is the single USMLE HLA-B5 assocation?

A

Behcet’s Syndrome

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15
Q

What brachial cord did the surgeon slice through to cause wrist drop?

A

Posterior cord arising from C5-C8 contributions of all three trunks. T1 contributes to the inferior trunk but not to the posterior cord. Wrist drop is due to loss of radial nerve innervation.

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16
Q

What are the 4 USMLE conditions associated with HLA-DR2?

A

MS

SLE

narcolepsy

Goodpasture’s

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17
Q

Direct inguinal hernia

Common age range of incidence?

Position relative to inferior epigastric artery?

Contiributing defect?

A

More common in older men

Runs MEDIAL to inf. epigastric artery

Protrusion of abdominal contents through weakened abdominal wall, usually in the inguinal triangle (Hesselbach’s Triangle)

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18
Q

Most likely form of necrosis seen as a result of a pleural effusion would be?

A

Liquefactive

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19
Q

What relative levels of homocysteine and methymalonic acid would you expect to see in B12 deficiency? What about with folate deficiency?

A

Homocysteine and methylmalonic acid increased with B12 deficiency

Homocysteine increased and methylmalonic acid normal with Folate deficiency

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20
Q

Describe the basic mechanism for each of the hypersensitivity reactions?

Type I, II, III, and IV

A

Type I: IgE. Immediate d/t IgE mediated crosslinking of mast cell/basophil receptor cross linking

Type II: IgM/G cytotoxic response mediated by opsonization, compliment mediated lysis, and ADCC (NK cells)

Type III: IgG Immune complexes activate compliment->PMN->lysosomal release

Type IV: Delayed type hypersensitivity T-cell mediated.

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21
Q

APML and keratomalacia are both processes due to a defect in the cellular availability of what?

A

Both due to defect in cellular Vit. A availability. APML is due to defect in PARalpha receptor (t15:17) that binds Vit. A and keratomalcia occurs due to decreased vit.A needed to prevent elithelial metaplasia

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22
Q

Most likely form of necrosis seen in a patient with a systemic fungi infection would be?

A

Caseous

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23
Q

The outflow tracts of the cardiac ventricles arise from what part of the primitive heart tube?

Are the outflow tracts considered the smooth or trabeculated parts of the heart?

A

Bulbus Cordis

The outflow tracts are also referred to as the smooth part of the ventricles

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24
Q

Where is the vomit reflex organized? What is special about it?

A

Coordinated by the Chemoreceptor trigger zone (CTZ) in the medulla. Lacks BBB allowing it to directly sense toxic substances

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25
Q

Most likely form of necrosis seen in the blood vessels would be?

A

Fibrinoid

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26
Q

8 yo boy is brought in 2wks post URI for limb weakness. LE 2/5 bilaterally and UE 4/5 strengths. An unnecessary nerve biopsy shows myelin decrease. What is the likely cause? Is this likely ascending or descending weakness?

A

Post-infectious Guillain-Barre Sydrome. Infection induces autoimmunity to Schwann cells. Schwann cells produce peripheral myelin and their destruction results in decreased nerve conduction presenting as weakness. Symmetric, ascending muscle weakness starting in LE progressing to UE.

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27
Q

Most likely form of necrosis seen in patients with TB would be?

A

Caseous

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28
Q

Pt’s high fever is accompanied by this diffuse, rough textured (1-2mm papules) erythematous rash. Significant HEENT findings possible?

What pathogen is most likely?

A

Likely see erythematous tonsils, facial flushing and strawberry tongue that is classic of Scarlet fever caused by Steptococcus pyrogenes

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29
Q

What are the 4 USMLE HLA-B27 associations?

A

Seronegative Arthropathies (PAIR)

Psoriatic Arthritis

Alkylosing Spondylitis

IBD related arthritis

Reiter’s Syndrome (Reactive Arthritis)

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30
Q

A deficinecy in Intrinsic Factor would cause a problem with what physiology? Anatomoical location? What 4 neurological symptoms would you look for?

A

IF mediates B12 absorption in the TERMINAL ILEUM which in turn hinders fatty acid pathways and myelin production. Signs: 1) Peripheral neuropathy 2) Posterior Column def.-vibration/propreception 3) Lateral corticospinal def.-Spasticity 4) Dementia

31
Q

Cranial Nerve VII innervates the derivatives of what phayngeal arch?

A

Pharyngeal Arch 2

32
Q

A 3 yo boy’s mother is worried that her son keeps needing antibiotics, he has been on 3 courses in the last year. You do T-cell and Immunoglobin levels showing T-cells normal, Ig levels decreased. What is the most likely Dx? Is acquired or congenital? Possible molecular explaination?

A

Bruton’s agammaglobulinemia: X-linked defect in the BTK gene, a receptor tyrosine kinase

33
Q

Most likely form of necrosis seen in the brain would be?

A

Liquefactive

34
Q

What nerve roots are tested by the following DTR?

Biceps, Triceps, Patellar, Achilles

A

Count em up:

S1,S2 Achilles

L3,L4 Patellar

C5,C6 Biceps

C7,C8 Triceps

35
Q

Most likely form of necrosis seen in the liver would be?

A

Coagulative

36
Q

Cytokines directing Th1 and Th2 T-cell differentiation?

A

Th1=IL-12

Th2=IL-4

37
Q

Treatment for BPH historically includes the use of what 3 medications?

A

1) alpha1-antagonists (terazosin/tamsulosin)
2) 5alpha-reductase inh.(finasteride)
3) PDE5 inh.

38
Q

Pathological metaplasia is usually associated with progression to cancer except in the case of…

A

apocrine metaplasia

(Pathoma)

39
Q

Is the diphtheria vaccine a toxoid, toxin, live organism, or attenuated?

A

Toxoid-Functions through induction of antibodies that will cross-react with Diphtheria toxin.

40
Q

An infant presents with recurrent bacterial infections and your attending asked if there was a delay in umbilical cord seperation. What are they concerned about? What would the neutrophil level be?

A

Leaukocyte Adhension Deficiency Type 1 due to a defect in LFA-1 integrin. This is associated with increased risk to bacterial infections and an elevated PMN count.

41
Q

Cranial Nerve V innervates muscles derived from what pharyngeal arch? What 8 muscles are included?

A

Pharyngeal Arch 1

1) Temporalis 2)Masseter 3)Medial Pterygoid 4)Lateral Pterygoid 5)Mylohyoid 6)Tensor palatini 7)Tensor Tympani 8)Anterior Belly of Digastric

All by Mandibular Division (CNV3)

42
Q

Function of Subscapularis

Innervation?

A

Medial rotation and adduction at shoulder joint

Supscapularis n. of the Posterior cord (C5-C7)

43
Q

A patient presents to clinic with a testicular mass that does not transilluminate and a biopsy is positive for Schiller-Duval bodies. Most likely diagnosis? AFP nl, low or high? How old is your pt?

A

Not Transilluminate=>Cancer

Schiller-Duval=>Yolk Sac Tumor (endodermal sinus tumor)

AFP elevated and most likely less than 3yo

44
Q

The trabeculated parts of the atria are derived from what part of the primitive heart tube?

A

Primitive Atrium

45
Q

A 51 y/o male presents with increased urge to urinate, nocturia, and increased frequency. What other symptoms would you try to elucidate in the interview? What is the role of the organ involved?

A

Sxs of BPH: inc. frequency, nocturia, urinary retention, hesitation, inc. urgency, and weak stream

The prostate is involved in alkalyzing the semen to neutralize the acidic vagina.

46
Q

65-75% of semen is produced by what organ?

A

Seminal Vesicles

47
Q

Patient with Trendelenburg Limp.
How do we define this limp? What causes it? Underlying insult?

A

Inability of patient to stabalize hip during strides and shifts weight to good leg during walking. Often caused by pediatric polio that damaged the Superior Gluteal n. (L4-S1)

48
Q

Name the 3 USMLE HLA-DR3 Associations?

A

SLE

Juvenile Diabetes

Grave’s Dz

49
Q

Pt presents with flaccid intraepidermal bullae covering a significant proportion of their body. You will check their mouth for similar lesions because you are concerned about? Disease Mechanism? Treatment?

A

Pemphigus vulgaris: not a good prognosis due to autoimmune nature and increased risk of infections. Oral lesions can accompany external lesions. Often painful. IgG attacks desmosomal components and decreases epidermal intergrity. Steroids can be helpful in management.

50
Q

Which of the following is not contained in the femoral sheath?

Femoral nerve, artery, vein, or lymphatics

A

Nerve is not contained in the sheath and is most lateral

51
Q

What reflex can you use to test for L1-L2 injury? explain how this relfex works. What does the internal oblique have to do with this?

A

Cremaster reflex induced by stroking internal thigh and watching for contraction of the cremaster muscle. Innervated by ilioinguinal nerve arising from L1 root. Can be damaged during trauma or hernia repair. Cremester muscle is derived from the internal oblique muscle.

52
Q

MSK exam reveals deltoid and infraspinatus weakness. You suspect disk herniation of what vertebrae?

A

C4-C5

C5 nerve root

(Remember, cervical nerve roots exit superior to cooresponding vertebrae)

53
Q

Young patient wishes to get more information on their Hyper IgM Syndrome. What can you tell them about the mechanism of disease? PMN level? Any increased susceptability?

A

Presents with elevated IgM but decreased antibodies of other classes since class switching is hindered. T-cells do not express CD40L and cannot instruct B-cell switching. Associated with neutopenia and Pneumocytosis jiroveci.

54
Q

Stylopharyngeus m. is a derivative of what pharyngeal arch? Innervation?

A

Derivative of Pharyngeal Arach 3 by CN IX: Glossopharyngeal nerve.

(The only muscle innervated by CN IX)

55
Q

Most likely form of necrosis seen in limbs following ischemia would be?

A

Gangrenous-“dry” form as a result of ischemic coagulation

56
Q

MSK exam reveals decreased elbow extension weakness. You suspect disk herniation of what vertebrae?

A

C6-C7

C7 nerve root

(Remember, cervical nerve roots exit superior to cooresponding vertebrae)

57
Q

The ascending aorta and pulmonary trunk both arise from what embryological structure?

A

Truncus arteriosus

58
Q

A 20 month old girl presents with decreased IgA and ataxia. Most likely Dx? Pathological Mechanism? What vascular abnormality would support your diagnosis in this patient?

A

Ataxia Telangiectasia caused by a defect in the ATM gene. Also called Louis-Bar Syndrome. Telangiectasia, capillary dilations on the skin (or organs) are often present.

59
Q

A patient presents a few weeks post infection with polyarthritis of large joints, carditis, nodules over elbows, erythematous lesions, and involuntary motions. The most likely diagnosis would be?

A

Rheumatic Fever d/t Streptococcus pyogenes(Group A B-hemolytic streptococci)

JONES Criteria: J=large Joint polyarthritis, O=Carditis, N=Nodules over bony prominences, E=erythema marginatum, S=Sydenham’s chorea, involuntary, purposeless movements

JONES Criteria as laid out in STEP1 Book

60
Q

An infection recognized by the innate immune system triggers the synthesis of acute phase reactants from which organ?

A

Liver ie. opsonins

61
Q

A patient presenting with Brown-Sequard Syndrome would be expected to exhibit what 5 clinical findings on exam?

A

1) Ipsilateral UMN signs below the level of the lesion
2) Ipsilateral LMN signs at the level of the lesion
3) Complete loss of sensation at the level of the lesion
4) Loss of contralateral pain and temperature sensation below the level of the lesion
5) Ipsilateral loss of light touch, propreception, and vibration below the level of the lesion

62
Q

Complete the Table for Signs of UMN and LMN Lesions

A

LMN=”Everything Lowered”

UMN=”Everything Up”

Remember: UMN Tone and Reflexes are acutely depressed

63
Q

The primitive heart ventricles give rise to what structure(s)? Be specific

A

Trabeculated portions of the left and right ventricles. Can you remember what gives rise to the smooth parts?

64
Q

Similar to the brain, the heart’s venous drainage converges at a single location. What embryological structure does this location arise from?

A

Like the brain’s confluence of sinuses, venous drainge of the heart converges at the coronary sinus. The coronary sinus is derived from the Left Horn of Sinus Venosus. Is there a Right Horn? What does it give rise to?

65
Q

The smooth part of the Right Atrium is dervied from which embryological structure?

A

Right Horn of the Sinus Venosus

66
Q

What do each of these embryological structures give rise to? Be specific

A

Truncus Arteriosus= Ascending Aorta and Pulm Trunk

Bulbus Cordis= Smooth parts(outflow tracks) ot L/R Ventricles

Primitive Ventricle= Trabeculated L/R Venrticles

Primitive Atria= Trabeculated L/R Atria

Left Horn of Sinus Venosus= Coronary Sinus

Right Horn Sinus Venosus= Smooth Part R Atrium

67
Q

SVC arises from what embryological structure(s)?

A

R Common Cardinal Vein and R Anterior Cardinal Vein

68
Q

A patient with a history of missionary work presents with back pain, fevers, night sweats, and weight loss. Given this brief historical picture, what is the most likely diagnosis?

A

Pott’s Disease, also called vertebral tuberculosis or tuberculosis spondylitis. This is an extra-pulmonary manifestation of TB.

69
Q

A 7 day old girl of a family who recently immigrated is brought into clinic with a cleft palate, polydactyly and holoproencephaly. What is the most likely diagnosis? Chromosomal abnormality?

A

These three signs are closely associated with Patau’s Syndrome (Trisomy 13). Microencephaly or holoproencephaly are common. <1yr life expectancy.

70
Q

A infant’s born of a mother without prenatal care has an exam positive for microencephaly, rocker-bottom feet, and clenched hands. What is highest on the differential? Next steps? Life Expectancy?

A

Characteristic of Edwards (Trisomy 18). Karyotyping and cardiac US are the next steps to confirm the diagnosis. Cardiac abnormalities are often asso. with Edwards. 1 year life expectancy

71
Q

A mother brings her infant in because it doesn’t cry normally and she is rather annoyed. A karyotype confirms a microdeletion of Chromosome 5. What other exam findings would be likely? Any organ systems of interest to evaluate?

A

The annoying cry is because the patient has Cri-du-chat syndrome. On exam it is common to see: “round face”, microencephaly, intellectual disability, and characteristic (accentuated) epicanthal folds. Cardiac evaluation for VSD is worthy.

72
Q

Which mother should expect her child to live past 1 year? A or B?

A

Patient A’s baby will most likely live longer. Patient A’s screen is consistent with Down Syn while Patient B’s is consistent with Edward’s Syn. Edward’s life expectancy is 1 yr.

73
Q

Aberrant development of the 3rd and 4th branchial pouches is associated with what genetic deletion? How would the aberrant development manifest clinically?

A

aberrant development is the result of the 22q11 deletion associated wwith DiGeorge Syndrome/Velocardiofacial Syn. The clinical presenation varies but includes one or all of the following: Cleft palate, Abnormal facies, T-cell deficiency 2/2 Thymic aplasia, Cardiac defects, and Hypocalcemia

CATCH-22

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