Rx Qmax Flashcards
1
Q
How do you calculate attributable risk?
A
It is the risk difference between the exposed and unexposed group (e.g. lung cancer in smokers vs. non smokers).
Attributable risk = Ie - Iu
*Ie = incidence exposed group and Iu = incidence unexposed group.
2
Q
What is the area of the brain infarcted in Broca’s aphasia? Wernicke’s?
A
Broca’s = inferior frontal gyrus of the frontal lobe
Wernicke’s = superior temporal gyrus of the temporal lobe
3
Q
What is the mechanism of action of fibrates?
A
Activate PPAR (a nuclear transcription factor) which leads to increased activity of lipoprotein lipase which will lower TG levels.
4
Q
What does urachus plus the allantois become post-embryonically?
A
The median umbilical ligament. Note this is different from the medial umbilical ligaments which is what umbilical arteries become.
5
Q
What is the most appropriate treatment for gatroparesis?
A
Metoclopromide
6
Q
What is Sheehan syndrome?
A
It is post-partum hypopituitarism. Most commonly presents w/ failure to lactate and eventually progresses to hypothyroidism, hypoadrenalism, hyponatremia and hyperkalemia.
7
Q
What do CD55 and CD59 - flow cytometry results in the setting of dark urine in the morning indicate?
A
Paraoxysmal nocturnal hemoglobinuria. Due to impaired synthesis of GPI anchor and it results in hemolysis and hemosiderin in the urine.
8
Q
What is the pathophysiology of G6PD deficiency leading to hemolysis?
A
NADPH is regenerated by the HMP pathway that G6P functions in and is necessary to keep glutathione reduced which will in turn detoxify free radicals and peroxides. W/o it they build up and the oxidative damage causes RBC lysis.
9
Q
What characterizes Patau’s sndrome (trisomy 13)?
A
Cleft lip, microphthalmia (small eyes), mental retardation, polydactyl, congenital heart disease and renal defects.
10
Q
Why can blood transfusions cause hypocalcemia?
A
Because blood is anticoagulated w/ sodium citrate and citric acid and this can cause plasma levels of calcium to drop.
11
Q
What are the zones of the prostate that proliferate in BPH?
A
Glandular cells of periurethral and transition zones.
12
Q
What is the equation for GFR using inulin?
A
GFR = (urine inulin concentration x urine flow rate) / plasma inulin concentration
13
Q
What are the CT findings indicative of diverticulitis?
A
Thickened, enhancing colonic wall and pericolic fat stranding.
Histo will show an attenuated (meaning thinned) muscularis propria)
14
Q
What is the name of the heme synthesis enzymes that are inhibited in lead poisoning?
A
delta-aminoleuvulinic acid dehydratase (earlier in pathway) and ferrochelatase.
15
Q
What are the four inactivated or killed vaccines? What is unique about the immune response they induce?
A
Rabies, influenza (injection, not nasal spray), polio (Salk, not oral), hepatitis A.
They induce only humoral immunity.
16
Q
How does saliva concentration vary based on high vs. low flow rate?
A
Saliva is isotonic (and more basic) at high flow rates and hypotonic (and more acidic) at low flow rates as the ductal epithelium has more time to modify the secretion by reabsorbing Na+ and Cl– and secreting K+.
Thus, in a condition like mumps where there is increased flow rate the saliva will have lower concentrations of K+.
17
Q
Mediastinal lymphadenopathy is often seen in Hodgkin’s lymphoma. Which subtype is it particularly associated with?
A
Nodular sclerosing subtype. Often seen in young women and usually there are few RS cells seen.
18
Q
What are the associated sxs of acute intermittent porphyria?
A
port-colored wine, abdominal pain, neuropathy, increased sympathetic tone, and neuropsych disturbances.
19
Q
From which aortic arch does the ductus arteriosus develop?
A
The 6th aortic arch. Also gives rise to proximal part of the pulm arteries.
20
Q
What are the most common paraneoplastic syndromes that thymomas (tumors of the thymus) cause?
A
Myasthenia gravis, pure RBC aplasia, hypogammaglobinemia
21
Q
What does WAGR syndrome stand for?
A
Wilm’s tumor, Aniridia (complete or partial loss of the iris), Genital anomalies, mental Retardation
22
Q
What are the signs of Kawasaki disease?
A
conjunctival injection, rash, adenopathy (cervical), strawberry tongue, hand/foot changes (edema), fever
23
Q
What is the physiologic mechanism by which exercise improves type 2 DM?
A
Increases the translocation of GLUT4 (which are insulin dependent) channels to cell surface. This leads to increased insulin sensitivity.
24
Q
The mesolimbic tract contributes to what type of sxs in schizophrenia? How about the mesocortical? Bonus: what tract is affected that produces amenorrhea?
A
- Mesolimbic –> positive sxs. Block reduces them
- Mesocortical –> negative sxs. Block produces/exacerbates them
- Amenorrhea is caused by dopamine block of the tuberoinfundibular tract.
25
Which HLA antigens confer greater risk for T1DM?
DR3 and DR4.
26
What is the medical management for a GH secreting putuitary tumor (i.e. if pt declined or could not go thru surgery)?
Octreotide - a somatostatin analog. It will inhibit the release of GH at the pituitary.
Note, this med is also used to tx carcinoid tumor and secretory pancreatic tumors.
27
What is second line tx in BPH is an a1 antagonist is ineffective or intolerable?
5alpha-reductase inhibitors. They work by preventing the conversion of testosterone to DHT, and this prevents prostate gland enlargement. Of note, this therapy typically takes 6-12 months to be effective.
28
What is the order of hormone loss in something like Sheehan syndrome where you get infarct to the pituitary and have resulting panhypopituitarism?
GH, FSH, LH, ACTH, TSH, PRL
29
Natural disease history and histo findings for Whipple's disease?
Early disease has migratory arthralgia of large joints (often misdiagnosed) and then progresses to abdominal pain and watery diarrhea.
On histo you see vacuolated macrophages crowding the lamina propria.
30
What is the typical presentation of systemic juvenile idiopathic arthritis?
Quotidian fever (characteristically a fever spike once a day during which the child is ill appearing and then normal temp during interval before the next spike), rash, arthralgias, arthritis and rash. It is a diagnosis of exclusion and by definition occurs in kids younger than 16.
31
What is the presentation of Kartenger syndrome (a form of primary ciliary dyskinesia)?
Bronchiectasis, situs inversus and chronic sinusitis.
32
What are the four stages of Paget's disease?
1) an initial osteolytic lesion involving marked bone resorption, (2) a mixed period of disorganized bone formation, (3) a third stage of osteoblastic-induced sclerosis and (4) a final, quiescent stage in which osteoclastic and osteoblastic activity is minimal.
On labs, see an elevated alk phos during periods of increased bone turnover and the phosphorous is normal.
33
What is the first line pharmacologic agent for septic shock?
Norepinephrine
34
The pain of gastric ulcers ________ after a meal, whereas the pain of duodenal ulcers _______ after a meal.
Increases, decreases
35
Why does salicylate (aka aspirin) toxicity initially present with alkalosis in early stages?
Because it stimulates respiratory centers. It progresses to anion gap acidosis over time from acidic metabolites.
36
What is the end result of niacin therapy for cholesterol lowering?
Decreased hepatic TG and VLDL synthesis (mechanism not understood) causing lowered LDL and total cholesterol levels as well as elevated HDL.
37
50% of patients with temporal arteritis (aka giant cell arteritis) may also present with what condition?
Polymyalgia rheumatica. It is where you have symmetrical aching of proximal muscles and girdle weakness.
38
What is the classic presentation of a thyroglossal duct cyst?
A deep, painless, midline anterior neck swelling that moves with swallowing and elevates on tongue protrusion.
39
What is the classic triad of Wernicke's encephalopathy?
The classic triad of Wernicke encephalopathy is confusion, ataxia, and ophthalmoplegia.
40
What are the four primary symptoms portrayed in Gerstmann syndrome? Damage to what area of the brain causes it?
Agraphia (inability to write), acalculia (inability to understand rules for calculation or arithmetic), finger agnosia, and left-right disorientation.
The syndrome results from damage to the dominant visual association cortex, which is located in the left angular gyrus near the temporoparietal junction in the dominant parietal lobe.
41
How may you distinguish between a patient with homocystinuria (caused by a deficiency in cystathione synthase for example) and a patient with Marfan syndrome?
Elevated levels of homocysteine in the blood. Additionally, these patients have a downward dislocation of the lens as opposed to an upward dislocation. And they are at increased risk of intellectual disability whereas Marfan pts are not. Also, these pts are at increased risk for thromboembolic events.
42
What is the mechanism of action by which isoniazid works?
Isoniazid causes a decrease in the synthesis of mycolic acids that make up the unique cell envelope of Mycobacterium tuberculosis.
43
What type of kidney stone is shaped like an envelope or dumbell? Are they radioopaque or radiolucent?
Calcium oxalate stones. They are radioopaque.
*Note that calcium stones are the most common type and that these are more common that calcium phosphate stones.
44
What is the deficiency that causes chronic granulomatous disease and what organisms are patients susceptible to infection with?
NADPH oxidase deficiency (patients can't make oxidative burst w/ neuts).
They're susceptible to infection with catalase positive organisms --> S. aureus, Serratia marcescens, and Burkholderia cepacia.
45
What is the time frame of onset for delerium tremens in alcohol withdrawal? How about alcoholic hallucinations?
48-96 hours for DTs. 12-48 hours for hallucinations.
Can be distinguished b/c in alcoholic hallucinations there is typically not global clouding of sensorium and the vitals are usually stable (DTs have tachycardia, HTN and hyperthermia).
46
What are the classic signs or acute graft versus host disease?
Dermatitis, hepatitis (as seen by elevated liver enzymes) and gastroenteritis. It occurs weeks after transplantation occurs.
47
What MSK actions are limited in patients w/ carpal tunnel syndrome? Why?
Pts have a compromised ability to abduct, flex, and oppose the thumb. This is due to compression of the thenar branches of the median nerve. Pts may also struggle with flexion of the 2nd and 3rd digits at the MCP as, as well as extension of these joints at the PIPs and DIPs.
There is no cutaneous deficit as the palmar cutaneous branch of the median nerve is not compressed.
48
In addition to colorectal cancer, what malignancy are pts w/ FAP at increased risk for?
Medullablastoma due to APC mutation.
49
What cells is EBV capable of infecting?
Epithelial cells and B cells. In B cells, CD21 acts as the receptor for EBV to enter the cells.
50
What type of kidney stone is shaped like an envelope or dumbell? Are they radioopaque or radiolucent?
Calcium oxalate stones. They are radioopaque.
51
What is CA 19-9 a tumor marker for? How about CA 125?
CA 19-9 --> Pancreatic adenocarcinoma
CA 125 --> Ovarian cancer
52
What is the typical characterization for the rash of dermatitis herpetiformis?
erythematous, vesicular rash
53
What is the characteristic presentation of narcolepsy? Deficiency of what neuropeptides can cause it?
Narcolepsy is characterized by sleep attacks (an overwhelming, sudden-onset sense of sleepiness), sleep paralysis (inability to move right before or right after sleep), and hypnagogic or hypnopompic hallucinations (hallucinations before or after falling asleep, respectively). Up to 90% of pts will have cataplexy.
Due to loss of the neuropeptides orexin-A and orexin-B produced in the lateral hypothalamus. These peptides promote wakefulness and prevent inappropriate entry into REM or non-REM sleep.
54
What is first line treatment for moderate (no associated anemia) UC?
Anti-inflammatory drugs like mesalamine or sulfasalazine. Stuff like infliximab or colectomy are reserved for more severe cases (i.e. associated anemia or cardiovascular effects).
55
What is the cut-off for MGUS based on serum levels of M protein?
MGUS is defined by the presence of <3 g/dL of M protein in the serum in an asymptomatic individual. It is a diagnosis of exclusion.
56
When should one suspect bronchial asthma as the most likely diagnosis?
If eosinophils are present in the sputum of a patient along with hazy whorls of mucus known as Curschmann spirals as well as Charcot-Leyden crystals (breakdown products of eosinophils), bronchial asthma is the most likely diagnosis.
Sxs that begin when moving to a new area can also be a clue.
57
What causes hemiballismus?
Infarct to/damage of the contralateral subthalamic nucleus.
58
What are the characteristic findings of asbestosis?
Ferruginous bodies, asbestos fibers coated with iron and calcium, and pleural plaques (dense layers of collagen fibers that accumulate on the pleural surface). When stained with Prussian blue, asbestos fibers resemble blue dumbbells on microscopy.
59
Why are Crohn's pts at increased risk for renal calculi?
Fatty acid absorption is impaired resulting in more in the GI lumen which binds Ca++ and frees up oxalate so that more can be absorbed. The excess oxalate can precipitate as stones.
60
In addition to alcoholic cirrhosis, positive family history, HCV and HBV infection, what is an important risk factor for hepatocellular carcinoma? When is this most commonly seen?
Aflatoxin exposure (toxin made by Aspergillus flavus). Seen more commonly in pts who have spent time in Asia or Africa b/c in USA the FDA regulates foods w/ lots of exposure to it, but not the case in those places.
61
What is the strongest risk factor for transitional cell carcinoma of the bladder?
Analine dye exposure, for example occurring in patients that have worked in the textile industry. Other weaker ones include poorly controlled DM, chronic bladder inflammation, smoking.
62
What are the different manifestations associated w/ tuberous sclerosis (an autosomal dominant disorder)?
- Subependymal brain tubers
- Epilepsy
- Intellectual disability
- Renal angiomyolipomas
- Cardiac rhabdomyomas
- Astrocytomas
- Pulmonary lymphangioleiomyomatosis
- Cutaneous manifestations: hypopigmented ash-leaf spot, shagreen patch, and facial angiofibromas
63
What are the manifestations of Sturge-Weber syndrome?
Caused by somatic mosiacism w/ activating mutation in one copy of the GNAQ gene.
(1) Port-wine stain (nevus flammeus in CN V1–2 distribution), (2) Glaucoma (3) Epilepsy, (4) Intellectual disability, and (5) Tram-track intracranial calcifications.
64
What other sorts of cancers are patients with familial retinoblastoma at increased risk for?
Patients with hereditary retinoblastoma are at increased risk for soft tissue sarcomas, osteosarcomas, melanomas, and several types of brain cancer.
65
What is the standard prophylactic regimen in an HIV patient against Pneumocystis jirovecii? What if they have sulfa allergies?
trimethoprim-sulfamethoxazole. If sulfa allergies use aerosolized pentamidine.
66
Which of the arachidonic acid pathway products are bronchoconstrictors and lead to asthma sxs?
LTC4, LTD4 and LTE4.
Note, as leukotrienes these are part of the 5-lipoxygenase branch of the arachidonic acid pathway.
67
Which antibiotic has the strongest association w/ causing aplastic anemia?
Chloramphenicol. Why it is rarely used in USA anymore.
Note, sulfa drugs can cause aplastic anemia too but the association is weaker.
68
What is first line medical therapy for narcolepsy?
Modafinil. It is an atypical dopamine reuptake blocker.
69
Define chronic bronchitis. What is seen on pathology and what are some presenting sxs?
Chronic bronchitis = productive cough for 3+ months in 2 or more years. It is obstructive (FEV1/FVC < 80%)
Path shows mucus gland hypertrophy and hyperplasia.
Physical findings include wheezing, cyanosis, and lung crackles. Cor pulmonale, or right heart failure, is a common complication.
70
Define PPV. How is it calculated?
Positive predictive value (PPV) is the probability that, given a positive test result, the patient actually has the disease. It is calculated by dividing the number of true positive (TP) results by the total number of subjects who tested positive (TP + FP).
Thus, PPV = TP/TP+FP
71
Exposure to hydrocarbon solvents such as those found in the dry-cleaning industry as well as cigarette smoking have been associated with an increased risk of developing Goodpasture syndrome. What is the treatment for this disease?
Emergent plasmapheresis and immune supressant drugs (i.e. cyclophosphamide).
72
What is a defining feature of early salicylate toxicity/overdose?
Tinnitus
73
How does chronic exposure to nitrates (such as a worker in an explosives factory working with heavy metals) lead to cardiac ischemia?
Exposure to nitrates causes vasodilation and there is compensatory vasoconstriction. In the heart this can lead to cardiac ischemia. This can produce "Monday disease" where industrial exposure causes the development of tolerance for vasodilating action of nitrates during the work week and loss of tolerance over the weekend. On Monday people present w/ tachycardia, dizziness, and headaches.
74
Which cancer drugs bind to microtubules and stabilize them so they can't break down and which cancer drugs prevent them from polymerizing in the first place?
Paclitaxel and other taxol drugs hyerstabilize MTs so they can't break down.
Vinca alkaloids like vincristine and vinblastine prevent MTs from polymerizing in the first place.
75
What are the most common causes of total thyroidectomy?
The two most common complications associated with total thyroidectomy are hypoparathyroidism and recurrent laryngeal nerve injury. Tingling of the lips in this patient can occur due to hypocalcemia, resulting from hypoparathyroidism if one or more of the parathyroid glands are accidentally removed during total thyroidectomy.
76
Why shouldn't St. John's Wort be used in combination with many anti-depressants?
Because it can precipitate serotonin syndrome. The major mechanism by which SJW contributes to serotonin syndrome is via 5-HT re-uptake inhibition.
77
What is the dominant component of pulmonary surfactant?
Phosphatidylcholine. In fact, about 75% of the phospholipids in surfactant are composed of phosphatidylcholine.
78
What do COX-2 selective inhibitors increase the risk of a coagulative cardiac event?
COX-2 inhibitors selectively decrease PGI2 (which opposes platelet aggregation), leaving the action of TxA2 (which promotes platelet aggregation) unopposed.
Stuff like celocoxib is a COX-2 inhibitor and it will spare the gastric mucosa at the cost of more cardiac risk.
79
What are the risk factors for acute pyelonephritis?
- Sex (females under the age of 40, males over the age of 40)
- Catheterization
- Age (infant, elderly)
- Renal lesions
- Reflux (vesicoureteral)
- Immunodeficient
- NIDDM, IDDM (noninsulin-dependent diabetes mellitus, insulin-dependent diabetes mellitus)
- Urinary obstruction
- Pregnant
*The helpful mnemonic to remember the risk factors for acute pyelonephritis is SCARRIN’ UP (acute pyelonephritis heals by scarrin’ up the area, producing a pyelonephritic scar):
80
In what sort of patients may Aschoff bodies be found?
They are found in the cardiac tissue of patients w/ rheumatic heart disease.
81
Define status epilipticus:
It is continuous seizure activity for more than 5 minutes without regaining consciousness between episodes; or 2 or more discrete seizures between which there is incomplete recovery of consciousness.
Initial tx = benzo
82
What causes HIV encephalopathy?
HIV encephalopathy is caused by infection of macrophages and microglia in the brain.
Commonly occurs in pts w/ long-standing HIV infection that is poorly controlled and has low CD4+ counts.
83
How do the neurotransmitters (Ach, Dopa, Ne and 5HT) relate to sleep?
Acetylcholine in the reticular formation induces rapid eye movement (REM) sleep, but the levels of acetylcholine decrease with age. Therefore, elderly patients who have naturally decreased levels of acetylcholine typically notice a reduction in REM sleep, total sleep time, and delta sleep.
Dopa and NE promote wakefulness and arousal.
Serotonin (5HT) promotes longer sleep duration.
84
Which medications are associated w/ a disulfiram reaction?
First generation sulfonylureas (i.e. chlorpropamide), metronidazole, procarbazine, griseofulvin, and some cephalosporins.
85
What is the subtype of Hodgkin lymphoma which, unlike the other subtypes, is NOT strongly associated w/ EBV?
nodular sclerosing Hodgkin lymphoma is not associated w/ EBV infection.
86
Embryologically, what is the thymus derived from?
The third pharyngeal pouch.
87
Name two drugs that are used for long term immunosuppression (i.e. following kidney transplant)?
6-mercaptopurine and Azathioprine
88
What does GCSF stimulate?
myeloid stem cell
89
What does aminocaproic acid do?
It is an antifibrinolytic that acts by blocking the conversion of plasminogen to plasmin, effectively counteracting the mechanism of tPA. Can be used to counteract bleeding from tPA administration.
90
What is the protein that is overexpressed as a result of the 14:18 translocation in follicular lymphoma? What is its function
BCL-2 (from chromosome 18) is overexpressed. It inhibits apoptosis.
91
Why is breathing through pursed lips helpful for emphysema patients?
In patients with emphysematous lung disease, the connective tissue that generates elastic recoil in the alveoli is lost, leading to low pressure in small airways, which causes their collapse during exhalation. Breathing through pursed lips decreases the pressure gradient between the alveoli and the lungs, allowing for enough pressure in small airways to keep them open.
92
What is the basic theory of operant conditioning?
The basic theory of operant conditioning is that behaviors can be modified by environmental consequences through reinforcement or punishment.
93
Which labs are important to monitor in a patient taking amiodarone?
Pulmonary function tests, liver function tests, and thyroid function tests --> all necessary due to potential adverse effects on these organ systems.
94
What make up Aschoff bodies seen in cardiac biopsy specimens of pts w/ mitral stenosis (often due to rheumatic fever)?
Aschoff bodies consist of T lymphocytes, plasma cells, and activated macrophages called Anitschkow cells, which are pathognomonic for rheumatic heart disease. These macrophages have abundant cytoplasm and a nucleus in which the chromatin condenses into a wavy ribbon, earning them the nickname "caterpillar cells."
95
Why can't you give 5-FU via oral administration?
Because it causes severe ulceration of the GI mucosa if given orally. As such, admin is reserved to topical or IV routes.
96
Which gene deletion is Wilms tumor most common associated with? What chromosome is it on?
WT1 (a tumor suppressor gene) on chromosome 11.
97
Coxsackie virus was the most common cause of myocarditis in the 1990s. What is the most common cause now?
Parvovirus B19 and human herpesvirus 6 have become more common causes.
98
Distinguish Osler's nodes and Janeway lesions
Osler nodes are on the finger and toe pads and are tender and raised.
Janeway lesions are on the palms and soles and are non-tender.
99
How do you calculate a stool osmotic gap? What can an indicate?
Stool osmotic gap = stool osmolarity (usually 290) - 2(stool Na + stool K+). Calculation is used to distinguish btwn osmotic and secretory diarrhea.
If greater than 100 this indicates an osmotic diarrhea. If it is less than 50 this indicates secretory diarrhea.
100
Hepatitis A and E are similar. What is one thing about E that is unique from A?
It has selective mortality for pregnant women and is more likely to cause fulminant hepatitis in that population
101
What is the characteristic presentation of basal cell skin cancer?
It is characterized by pink or flesh-colored pearly papules (shiny) with central telangiectasias found in sun-exposed areas.
102
BRAF and RAS are associated w/ ______ and ______ thyroid cancer respectively
BRAF --> papillary
RAS --> follicular
103
What is first line treatment for echinococcus granulosus? In what population should you suspect it?
This is a parasitic tapeworm and infection should be considered in shepherds or people around dogs a lot as it is in dog feces. First line treatment is albendazole.
104
What is the equation for predicted CO2 in metabolic alkalosis?
Expected CO2 = (0.7 × HCO3–) + 20 ± 5). If CO2 is below this range then there is concomitant respiratory alkalosis.
105
What sorts of infections are patients with chronic granulomatous disease susceptible to?
Catalase positive organisms.
CGD is the result of a deficiency in the enzyme nicotinamide adenine dinucleotide phosphate oxidase, which converts molecular oxygen (O2) to the superoxide oxygen radical (O2-). Without this step, neutrophils are unable to generate a respiratory burst, leading to increased susceptibility to infection.
106
What is the effect of Angiotensin II at the proximal tubule of the kidney? How does this effect HCO3- and H+.
It increases the activity of the sodium H+ exchanger. The net result of increased Na+-H+ exchange is an increase in HCO3- reabsorption and no net change in H+ reabsorption.
