Step 1 Question Review Flashcards
Chronic lymphedema is a risk factor for the development of _______, appearing as firm, violaceous nodules in the right upper arm
Angiosarcoma
administration of Mu opioid analgesics can cause ______, leading to spasm and RUQ pain
Contraction of the SM cells of sphincter of Oddi, increasing common bile duct pressures, which can lead to biliary colic
blood flow is directly proportional to the _______ (equation)
____ is inversely proportional to the above variable
Vessel radius raised to the 4th power
Resistance is inversely proportional to radius raised to the 4th power
*SO when flow is reduced by a factor of 16, the radius must be half of the size (1/2)^4
Overdosing of nitroprusside can cause confusion and lethargy indicative of ______ toxicity. What are other signs of this toxicity?
Administration of a drug that donates _____ can cure this toxicity
Cyanide toxicity (metabolism of nitroprusside can yelped NO and cyanide ions). Cyanide inhibits ox-phosph by binding Fe3+ in cytC. Causes lactic acidosis and bright red venous blood
Sulfur- an enzyme normally transfers a sulfur to cyanide to form thiocyanate to be excreted. Sodium thiosulfate is administered in conjunction with hydroxocobalamin (binds cyanide ions to be excreted) nd sodium nitrite (promotes met-Hb formation which binds cyanide)
Haemophilus ducreyi has _______ borders, ____ forming painful ulcers and _____ lymphadenopathy. Diagnosis?
Herpes has multiple, painful ______ ulcers with an ______ and painful lymphadenopathy. Will usually also have:
Ragged borders, pus forming and suppurative (pus) LA. Gram stain of gram negative rods in ‘school of fish’ pattern
Multiple painful vesicular* ulcers/lesions on an erythematous base with lymphadenopathy. Also have dysuria, and systemic symptoms. Tzanck smear or PCR
When a patient comes in seeking opioid anagelsics, the most appropriate step by the physician is to
Identify signs of drug-seeking behaviors or prescription misuse- check past prescription history
Syndrome in a young, baseball player with an extra cervical rib that presents with ulnar nerve sensory deficits and tingling, numbness and pain of the shoulder and arm as well is likely from compression by what structures
Scalene muscles
Thoracic outlet syndrome- lower trunk and subclavian vessels likely get compressed between anterior and middle scalene and first rib (scalene triangle)
Two main players in cardiac myocyte relaxation for removing calcium intracellularly are:
Na/Ca exchanger pump- large extracellular Na gradient to pump out Calcium
Sarcoplasmic reticulum Ca-ATPase (SERCA) actively pumps calcium into the sarcoplasmic reticulum
*ryanodine receptors are involved in calcium RELEASE from SR not sequestration
TNF alpha decreases insulin binding activated GLUT4 receptor translocation via what mechanism: activated _____ that causes ______ of beta chain tyrosine kinases on the insulin receptor
What else induces resistance by the same mechanism?
Upregulated serine kinases- phosphorylate beta subunits of TK and renders them inactive even upon insulin binding, disrupting the IP3 pathway by inhibiting that TK phosphorylation
Catecholamines, glucagon, and glucocorticoids
Exercise respiratory/CV physiology: PFTs- increased RR, and \_\_\_\_\_ Arterial blood shows Venous blood CO causes the V/Q to:
Increased oxygen demand causes increased tidal volume->increased minute ventilation
No changes in paO2 or CO2- increased minute ventilation and gas exchange efficacy ensure that there is neither a decrease in O2 or accumulation of CO2
Venous- increased PvCO2, decreased pH
Increased CO and HR= increased pulmonary blood flow that is more evenly distributed throughout the lungs (V/Q ratio from apex to base is more uniform and so decreased physiologic dead space)
Minors can consent to things like _______ but not non-emergency medical treatment like ______
Emancipated minors are
Prenatal care, diagnosis and treatment of an STI, contraception and drug or alcohol rehab or emergency care
Not things like abortion- need parental consent or notification in most states
Homeless, a parent, married, military, financially independent, high school graduate
What supplies most of the inferior wall of the heart?
What is it a branch of?
PDA- posterior 1/3 of posterior IV septum and inferior wall of LV
Most people have right dominant circulations- PDA comes off of RCA
The inferior surface of the heart is formed by the 2/3 LV and 1/3 RV
Pap smear shows an immature squamous cell with dense, irregularly staining cytoplasm and perinuclear clearing, resulting in a halo and enlarged nucleus where the chromatin has condensed as part of apoptosis process
What causes this type of cell presentation?
Koliocytes*- pyknotic nucleus demonstrating raisin like appearance with halo clearing around nucleus
HPV is a ds DNA, non enveloped virus- causing warts or intraepithelial neoplasia
A Meckel diverticulum expressing numerous types of tissue like gastric, pancreatic, or endometrial is a an example of what
Ectopy- term that identifies microscopically and functionally normal cells found in an abnormal location due to embryonic maldevelopment
Uterine currettage reveals decidualized endometrium with dilated, coiled endometrial glands and vascularized edematous stroma with no embryonic or trophoblastic tissue
Ectopic pregnancy
Changes seen are from progesterone- usually prepares the endometrium for implantation
NK cells express _____ and ____ surface receptors
Activated by ____ and _____
Recognize _____
Special characteristics about maturation and antigen specificity
CD16 and 56
Activated by IL-12 and IFN-gamma
Recognize cells with absent MHC I- like virus infected cells or tumor cells
Do not require a thymus so are present in athymic patients
Have no antigen specific activities or memory ability or antigen activation systems
Z scores for 95% and 99% confidence intervals, resp is +/- ___ and ____ standard deviation
Standard intervals of standard deviation on normal bell curve=
confidence intervals of the mean can be calculated by:
Standard error=
95% of observations lie within 1.96SDs
99% of observations lie within 2.58 SDs
1 SD= 68%
2 SD= 95%
3 SD= 99%
Mean +/- 1.96x(SD/square root of n) for a 95% CI
SD/square root of n- estimates how far the sample mean is from population mean or variance of different sample means. CI better accounts for the variability due to sampling by including the SE in its calculation
Ionizing radiation (gamma and X-rays) induces damage to DNA via _____
Ds DNA breaks and formation of oxygen radicals
Opioids are pentapeptides that are derived from ______; similar to _____ and ______
POMC
Like ACTH and MSH
*why there is a close association between the stress HPA axis and opioid system
olanzapine is a _______
AE? What do you want to check in a patient
Which drug of this class is associated with QT prolongation? Prolactin elevation?
Second generation anti-psychotic (less extrapyramidal effects)
Metabolic AE- weight gain, dyslipidemia, hypergylcemia, increased risk of DM. Check fasting glucose, lipid profiles, etc.
Ziprasidone; risperidone, resp.
Ureteric bud gives rise to the ____
Metnephric mesoderm/blastema gives rise to_____
Collecting system of the kidney- collecting tubules and ducts, major and minor calyces, renal pelvis and ureters
Glomeruli, Bowman’s space, proximal tubules, loop of Henley, DCT
8 year old boy with sever dyspnea, tachypnea and inspiratory stridor, dysphagia with solid foods and shows blast cells in peripheral blood smear most likely has ___
What marker would be present
T-ALL- CD 2, 3, 4, 5, 7 or 8+
T cell ALL most commonly presents with mediastinal masses over B-cell ALL (CD10+, 19, 20)
Acute pancreatitis related to alcohol abuse as shown by the AST:ALT ratio of >2 and absence of gallstones can be confirmed as alcohol abuse with what lab test?
MCV >100 in the absence of anemia- indicating poor nutrition and folate deficiency, liver disease by direct alcohol toxicity
Hypocalcemia can occur in all types of pancreatitis*
State of chronic myocardial ischemia in which both myocardial metabolism and function are reduced to match the coronary blood flow to prevent necrosis. Can show decreased contractility and systolic dysfunction on echo/EF
Brief repetitive episode of myocardial ischemia, followed by reperfusion, protect myocardium from prolonged episodes of subsequent ischemia (multiple episodes of angina before an MI can delay cell death after complete artery occulusion)
Myocardial hibernation (decreased expression and disorganization of contractile and cytoskeletal proteins, altered adrenergic control, and reduced calcium response)- coronary revascularization and restoration of blood flow improved contractility and LV function
Ischemic preconditioning
Nitrate free intervals must be provided everyday in order to avoid
Tolerance
Usually patients skip dosing at nighttime- cardiac work is at its least during sleep
PAH from proliferative vascularity of the smooth muscle may occur as a hereditary mutation of _____
Treatment?
BMPR2 inactivating mutation (normally inhibits SM proliferation)
Endothelin is a potent vasoconstrictor and promotes SM proliferation and is found in high concentrations in patients with PAH
Endothelin receptor antagonists (bosentan and ambrisentan) alleviate vasoconstriction to lower PAH and improve dyspnea
Can also use prostacyclin analogs or PDE-5 inhibitors
The anterior compartment of the leg includes:
Most common site for compartment syndrome
Foot extensor muscles, anterior tibial artery and veins, deep peroneal nerve
Damage to this nerve causes decreased sensation between the first and second toes, decreased dorsiflexion of foot, foot drop and claw foot
Medicare can cover younger people (<65) who have _____
Medicaid covers
Disabilities, end stage renal disease, or ALS
Homeless, undocumented immigrants, pregnant women and low income families
Increased levels of ____ can cause nephrogenic DI (polyuria,polydipsia), weakness, constipation and confusion
Calcium
Patient with signs of lung cancer + right sided face and arm swelling, engorgement of subcutaneous veins on the same side of the neck most likely has:
Right sided brachiocephalic vein obstruction
Similar to SVC syndrome but only on ONE side!!!
External jugular drains into subclavian, subclavian joins IJV to form BCV
Right lymphatic duct drains into the BCV
RAS proteins exist in two different states
What is bound to them to differentiate these two states and what is frequently mutated in the setting of cancer
What signaling pathway activates RAS
Activated RAS does what
Inactive GDP bound state
Active GTP bound state (has intrinsic GTPase activity that allows hydrolysis of GTP to prevent accumuation- mutations can lead to decreased GTPase)
Growth factor binds TK, causing autophosphorylation
Activated RAS then results in the activation of mito gen-activated protein kinase (MAPK), which enters the nucleus and influences gene transcription
A patient with wide, fixed splitting of the S2 has _____
This defect may require repair to prevent irreversible changes in the ________
ASD
Increased blood flow through the pulmonary artery may cause laminated medial hypertrophy that can become so severe it leads to an increased pulmonary vascular resistance higher than systemic. This would then cause a R—>L shunt through the ASD and late onset cyanosis, clubbing and polycythemia
*if pulmonary HTN were corrected, right atrial and ventricular changes could be corrected
When data is misclassified due to preconceived expectations or prior knowledge concerning the study. Subjective outcomes*
Non random, inappropriate methods that lead to different attrition rates between groups that reduces the generalizability of the study- like many patients dropping from a trial due to severity of their side effects
Observer bias
Selection bias
drugs that high a high ______ and ______ are more likely to be metabolized by the liver, instead of the kidney
High lipophilicity and, hence a higher volume of distribution
Processed to more hydrophilic parts and excreted in bile
*low Vd- confined to the bloodstream and cannot diffuse through cell membrane. Highly protein bound and hydrophilic- urine excretion
Drug that is not well absorbed orally will exhibit first pass metabolism, but won’t be available for hepatic clearance because of low lipophilicity
Low CNS penetration and low rate of resdistribution imply low lipophilicity
Elderly female patient presents with a firm, palpable gallbladder showing extensive calcification on CT throughout the gall bladder wall is likely from ______
High risk for_____
Porcelain GB is likely from chronic cholecystitis and found with multiple gallstones
Adenocarcinoma of the GB***
Patient with ESRD due to type I DM has excessive bleeding around the IV site when a catheter is inserted into the right IJV before his dialysis treatment
Labs- prolonged bleeding time, normal platelets, normal PT/aPTT
What is the diagnosis?
What other syndrome can have this appearance on LABs?
Uremic platelet dysfunction- accumulation of uremic toxins impair platelet aggregation and adhesion, resulting in a qualitative platelet disorder, characterized by isolated prolonged bleeding time.
Improved with dialysis
vWF deficiency (aPTT could be elevated or normal)
Pathophysiology of vitiligo is:
Partial or complete loss of epidermal melanocytes by autoimmune destruction in an area of skin- and therefore a complete absence of melanin
What types of adrenergic receptors are on the pancreatic beta cell
What is the predominance and balance/responsiveness of each?
Alpha 2 and Beta 2
Alpha 2- inhibits insulin secretion. This inhibitory response predominates
Beta 2- promote insulin secretion
Epi would activate both receptors, but alpha 2 response is stronger resulting in decreased insulin secretion*
_____ and _____ stimulate the RLS step of cholesterol synthesis (HMG COA reductase)
Insulin and thyroxine
Most important complication during the recovery phase of kidney tubule damage is ________
Hypokalemia- increased permeability of the epithelium results in hypokalemia primarily which can manifest as muscle weakness and arrhythmias (flat t wave, u wave, st depression and premature contractions)
Payor pays a fixed predetermined fee to cover all medical services required by a patient is termed
Insurer pays a provider a single payment to cover all expenses associated with an incident of care
Capitation- like in HMO (vs point of service plans are different in that they allow patients to see providers outside of their network with co-pays and deductibles)
Global payment- for elective surgeries, in which the global payment covers the surgery and any pre-post operation visits
What in the primary inhibitor of beta-ox of FA? At what step?
Malonyl-CoA inhibits the carnitine acyltransferase, preventing the transfer of acyl groups into the mitochondria for FA breakdown
Ensures that FA synthesis and oxidation are not occurring at the same time*
Citrate gets shunted from the mitochondrial into the cytosine, broken down into acetyl coa which is then converted to Malonyl coa for FA synthesis
Anti-RH(D) antibodies are what isotype of Ig?
IgG, cross placenta and cause lysis of fetal RBCs- IgG form from a prior birth with a blood type of RH+ that crosses into the maternal circulation, causing her to form antibodies that are capable of crossing the placenta and attacking her next fetus
Prevent this by giving a primigravid mother anti-IgG against RhD at the 28th week and during postpartum period to prevent maternal Rh alloimmunization when fetal blood mixes with maternal
A complete mole will typically have what genotype?
Paternal 46,XX- duplication of a haploid 23,X sperm
46,XY moles can occur when two different sperm fertilize an empty ovum which is uncommon
When an initial embryonic disturbance leads to multiple malformations by disrupting the development of adjacent tissues and structures within that region is called ______
Example: spectrum of structural abnormalities of the brain and face occur due to the incomplete division of the forebrain
Developmental field defect
Holoprosencephaly: this cleavage is supposed to occur at 5 weeks gestation. Failure can result in an array of midline defects* from mild (closely set eyes, cleft lip) to severe (Cyclopes, primitive nasal structure proboscis, midfacial clefts)
This defect is typical of Trisomy 13, sonic hedgehog mutations and maternal alcohol consumption
A young, previously healthy patient dies suddenly from a spontaneous intracranial hemorrhage from a cerebral aneurysm rupture. What cardiac defect does he most likely have?
Coarctation of the aorta- usually assoc with berry aneurysms
VSZ infection that does not have viral kinases should be treated with what
Cidofovir* a nucleotide or foscarnet a pyrophosphate analog DNA pol inhibitor
Acyclovir, valacyclovir, famcyclovir and gancyclovir all require viral kinase activation to go from a nucleoside to a nucleotide
Amphotericin B causes renal toxicity by two mechanisms:
How can renal toxicity cause heart issues/what would you see on ECG
Decreased GFR and direct tubule epithelium toxicity
Nephrotoxicity can lead to anemia and electrolyte abnormalities. Most importantly is hypokalemia, due to increase in membrane permeability of the distal tubule. Hypokalemia can cause weakness and arrhythmias.
ECG of hypokalemia would include flat T wave, ST depression and U waves and premature contractions
What affect does estrogen have on thyroid hormone functioning?
Increases TBG which increases TOTAL T4/T3
Increase bound T4 and decreases free T4, which stimulates TSH which then increases T4 available for binding and restores free T4 levels (euthyroid) **why you want to check free T4 when suspecting hyperthyroidism
Deletion or addition of a number of bases not divisible by 3 would cause ________; affecting the length of the mRNA transcript
Nonsense mutations occur in exons and affect _______
Frameshift deletions
Affect protein translation* point mutations are unlikely to affect the total mRNA size* (and hence the cDNA length)
What two exceptions drain into the deep inguinal lymph nodes instead of superficial?
Glans of penis and posterior calf
_____ increases GLUT4 expression on muscle which can cause hypoglycemia in patients with diabetes due to the lack of a _______
Exercise
Counter-regulatory response: no drop in insulin (due to insulin shots) and turning on of glucagon to increase blood glucose
An unexpected occurrence involving death or serious injury that requires immediate investigation
Malpractice is _____
Sentinel event- inpatient suicide, death of full term infant, retained object after surgery
Not an actual category of medical errors (near miss, preventable AE, non preventable AE) but a legal term that is a consequence to any type of error that result in harm
Angiomatous lesion involving cerebellum or retina, cystic kidney masses indicates what disease? What other findings are associated?
VHL disease- presence of capillary hemangioblastomas (high vascularity with hyperchromatic nuceli) in brainstem, cerebellum, retina or spinal cord. Angiomatosis (cavernous hemangiomas in skin, mucosa and organs, bilaterally RCC, pheochromocytoma
- different from TS: harmatomas of CNS and angiomyoLIPOMAs of kidney. Not lesions that are characterized by high vascularity
- think hypoxia inducible factor defective so increase angiogenesis for my blood/oxygen tumors
Probability of independent events being the same=
The probability of at least 1 event turning out differently is given by=
Product of separate probabilities : (95% NPV) chances of 8 people who don;t have the disease as having a negative result is .95^8
Of 1 turning out differently is 1-P(all events being the same)
Burn patient is what type of shock? Skin would appear- PCWP- CO- SVR- Treat-
Hypotensive shock
Cold,clammy Decreased PCWP Decreased CO Increased afterload IV fluids- ringer’s lactate (sodium lactate)
Shock symptoms with no fever, no response to saline, and high CO, low PWCP, and low SVR is indicative of _________
What is the treatment usually
Early septic shock- **decreased SVR
Isotonic saline- 9%
Vaginal bleeding, very elevate hCG and the cervical os is closed with ultrasound showing an empty uterus
Ectopic pregnancy
Why does mycobacterium leprae have a predilection for the extremities?
Thrives in cooler temperatures
Someone who has a massive PE from DVT is given a drug and a week later is found to have a platelet count of 55,000. This thrombocytopenia was most likely caused by _______
Heparin induced thrombocytopenia- development of IgG ABs against heparin bound platelet factor-4. These complexes activate platelets—> thrombosis and thrombocytopenia
*aspirin doesn’t destroy platelets
Teenager with daily headaches, bilateral aching temples, more confused, clumsy with frequent falls and has a broad-based ataxia gait and is slow to answer questions
Toxicity?
Inhaled glue
What factor inside muscle cells gets released upon muscle damage and damages kidneys?
Myoglobin break down products damage the kidney cells
Epimere forms
Hypomere forms
The dorsal back muscles
The ventral thoracic and abdominal muscles
Which area should be avoided to leave the SA node intact?
The junction of the SVC and the right atrium
What supplies dentition to the lower teeth?
Branch of what nerve?
Inferior alveolar nerve (dental)- innervate the lower teeth
Branch of the mandibular nerve
Tactile fremitus is inc/dec in pneumonia?
In pleural effusion?
INCREASED!
Decreased
Child comes in with round shiny bumps in areas where she has eczema, her friend had similar bumps on their play date last week. PE shows firm, smooth, umbilicated papules in clusters. What viral group is this?
What histology is typically seen
Poxvirus- molluscum contagiosum
Guarneri bodies inclusions- sites of cytoplasm replication of viruses
Dumbbell shaped core
*different from varicella- skin lesions all develop at the same rate unlike chicken pox
Patient with right cerebral cortex wound from an accident has left lower extremity paralysis- what would the reflex response be?
Hyperreflexia- UMN damage even if paralysis of these muscles
Patient has extreme sensitivity to light and exposure to sun causes the formation of vesciles and blisters on the skin. There is an increased synthesis of compounds in the skin that are subject to excitation by visible light. What pathway is most likely deficient?
Heme synthesis- porphyria. Accumulated uroporphyrinogen III
Patient with sudden onset of uncontrollable irregular movements of the left side of the body, irregular flailing movements of the proximal appendicular muscles on the left is due to a lesion in ______
Right subthalamic nucleus (contralateral hemiballism)
Which test is best to confirm hyperthyroidism in someone who has an elevated serum total thyroxine (T4)
Measure the free T4
T3 is more actively regulated, so small increases or decreases are managed in states of hyper or hypothyroidism
What percentage of people fall within the +/- 1 standard deviation
68%
95%- 2 standard deviations
99.7%- 3 standard deviations from the mean
Splice sites usually consist of what nucleotide pairs?
5’ GT (u) and AG 3’
Loratadine, fexofenadine, desloratadine, cetirizine are all
______ used for ______
Second generation anti-histamines
Used for allergies over first generation- less sedating because of decreased entry into CNS
Next best step in management of third degree heart block with a pulse of 40 and BP 92/56 is ______ and administration of ______
Insertion of a venous pacemaker (until a permanent one can be placed) and administration of atropine to increase HR by decreasing vagal activity
Adipose brown fat does what to the proton gradient of the ox phosph chain
This does what to the ATP:O2 ratio
Uncoupling agent that increases the permeability of the membrane causing a decreased proton gradient to generate heat
Increased oxygen consumption and ATP synthesis stops
Also aspirin and 2,4 dinitrophenol
What things does vitamin B6 help synthesize? (6 things/groups)
ALT/AST Glycogen phosphorylase reaction Cystathione/cystine Heme Niacin Histamine and NTS
Adipose brown fat does what to the proton gradient of the ox phosph chain
This does what to the ATP:O2 ratio
Uncoupling agent that increases the permeability of the membrane causing a decreased proton gradient to generate heat
Increased oxygen consumption and ATP synthesis stops
Also aspirin and 2,4 dinitrophenol
What things does vitamin B6 help synthesize? (6 things/groups)
ALT/AST Glycogen phosphorylase reaction Cystathione/cystine Heme Niacin Histamine and NTS
How does anion gap acidosis from increased lactic acid occur in sepsis?
End organ hypoperfusion in septic shock impairs tissue oxygenation and decreases oxidative phosphorylation, leading to buildup of NADH and shunting to lactate production
Hepatic hypoperfusion during sepsis also contributes to lactic acid accumulation as the liver is the primary site of lactate clearance/conversion back to glucose
The most common cause of congenital bilateral absence of the vas deferens is _____
Cystic fibrosis
In the case of no legal documentation or health care proxy, medical decisions fall to _____
Next of kin- spouse
Contact ethics committee if family members cannot agree
Gram positive, motile rod that produces a very narrow zone of beta hemolysis that can multiply at refrigerated temperatures is likely eliminated from the body by what immune response?
Cell-mediated immunity (cytotoxic T cells and activation of macrophages)- Listeria monocytogenes is a facultative intracellular pathogen
*avoids antibodies by actin polymerization, forming ‘rocket tails’ between cells
Disease characterized by anti-mitochondrial antibodies is characterized by ____ and is biopsy findings will appear most similar to ______
PBC- destruction of small and mid-sized intrahepatic ducts with resulting cholestasis
Shows patchy lymphocytic inflammation with destruction in intrahepatic bile ducts with granulomas and bile staining of hepatocytes
GVHD will most typically affect the liver via lymphocyte infiltration and destruction of small intrahepatic bile ducts
Niacin dependent enzymes of the TCA cycle include:
Pyruvate dehydrogenase—> Acetyl CoA
Isocitrate dehydrogenase—>alpha-KG
Alpha-ketoglutarate DH complex —>succinyl-CoA
Malate DH—> oxaloacetate
What is the anatomical landmark to help locate the optimal site for lumbar puncture?
Iliac crest
Optimal location of needle is L3-L4 space or L4-L5 space. The L4 vertebral body lies on a line drawn between the highest points of the iliac crests
The GF binding and tyrosine kinase autophosphorylation—>PI3K activation—>Akt (Protein kinase B) activation, which will lead to _______ activation and what result?
How is this last step inhibited?
mTOR translocation to the nucleus and gene transcription which induces cell growth and proliferation
PTEN inhibits mTOR by removing a phosphate from PIP3
EBV preferentially infects ____ by binding the ____ cell surface receptor
_____ clonally expand in response to this infection, showing atypical cells on blood smear
B lymphocytes by binding the CD21 cell surface receptor
Cytotoxic CD8+ T cells clonally expand to destroy the virus
A patient with LVHCM from mutated ____ likely has LV outflow obstruction created by ______ and the IV septum
Sarcomere proteins- protein C and beta-myosin heavy chain
Anterior mitral leaflets- shift toward aortic valve during systole causing eccentric mitral regurg and LVOT
Important genes upregulated by thiazolidinediones include ____ and _____
These genes are upregulated by binding of ____
GLUT4 on adipocytes and skeletal muscle to increase uptake
Adiponectin, a cytokine secreted by fat tissue that increases the number of insulin-responsive adipocytes and stimulates FA oxidation
Binding of PPAR-gamma: nuclear receptor that alters the transcription of these genes
Recently diagnosed with nephrotic syndrome and then sudden development of abdominal flank pain, gross hematuria, and a left-sided varicocele suggests _______ due to loss of _____ from the prior nephrotic syndrome
Renal vein thrombosis- due to loss of antithrombin III in nephrotic syndrome, resulting in a hypercoaguable state
Primary route of copper elimination is via
Secretion into bile by liver and excretion in stool
Liver also regulates copper incorporation into an alpha-2 globulin to form ceruloplasmin and released into circulation in this form
Fracture of the _____ bone, region where the frontal, parietal, temporal, and sphenoid bones meet in the skull
What artery is affected? Branch of ?
What can this artery damage progress to?
Pterion
Middle meningeal artery lacerations- epidural hematoma—>uncial herniation with oculomotor nerve palsy
Branch of the maxillary artery, which enters the skull at the foramen spinosum
Left cerebellar hemisphere lesion would result in _____ sided deficits in _____, ______, and ______
LEFT- ipsilateral. Connect with lateral descending motor systems
Disdiadochokinesia, limb dysmetria (overshoot/undershoot during targeted movement), and intention tremor
Severe chest pain not relieved by rest or nitroglycerin and ECG showing peaked T waves, ST elevation and eventual Q waves in I, aVL and V1-V3 is from
Most commonly caused by
A trans mural MI in the anterolateral LV (prinzmetal’s angina can present like this but would respond to nitroglycerin)
An acute plaque change- rupture which produces a superimposed thrombus that completely occluded the involved coronary artery
*A lesser degree of occlusion superimposed on an acute plaque change would more likely cause unstable angina, subendocardial MI, SCD.
A stable plaque without an overlying thrombus but obstructing over 75% of the artery lumen would likely cause stable angina
Risk of wrong site surgery can be reduced by
Dual identifiers (usually a nurse and physician) independently
An elevated HbA2 percentage is suggestive of ______
Beta thalassemia minor- becomes elevated in these patients to compensate for beta globin chain underproduction, but the resulting microcytic cells are prone to hemolysis, which can cause a falsely low HbA1C levels
vitamin B12 deficiency is likely in which of the following patients?
- patient who underwent a total gastrectomy 8 months ago
- patient who became a vegan 6 years ago
Vegan- it takes 4-5 years to develop B12 deficiency
The total gastrectomy patient would likely eventually develop deficiency, but not after 8 months.
during the wound healing process, fibroblast migration and proliferation are controlled by _____ and _____
PDEF and TGF-beta
Hospice care requires a survival prognosis of
Less than 6 months
Mycoplasma that appear as long parallel chains of mycolic acids represent the presence of ______, which has what activity?
Cord factor- virulence
Surround the organism forming a Micelle and prevents macrophage-mediation destruction within the phagolysosome and helps drive caseating granuloma formation
Histological analysis of a _______ in the heart shows scattered cells within a mucopolysaccharide stroma typically with a mid-diastolic rumble heard best at the apex
These produce large amounts of:
Atrial myxoma
IL-6- weight loss, fever
VEGF- angiogenesis, hemorrhaging of the tumor
Most anal fissures/tears occur that the ______ likely due to decreased blood flow in this area
Posterior midline- due to passage of hard stool in patients with chronic constipation
*fissures not on the midline are more likely due to unusual causes and warrant further investigation (IBD, malignancy, infection)
A severe side effect to aggressive osmotic diuresis, mannitol, in those with increased ICP trauma patients is ______
Pulmonary edema- caused by the rapid rise in volume that increases overall hydrostatic pressure in vasculature. Continued rise in plasma osmolality causes more water and potassium to move out of cells and brain into vasculature, worsening edema.
Bugs that cause necrotizing fasciitis- 3
Which one is pyrrolidonyl arylamidase (PYR+) positive
Strep pyogenes- PYR + *replacing the bacitracin test
Staph aureus
Clostridium perfringens
Esophageal manometric study of a patient having difficulty swallowing solids and liquids shows periodic, simultaneous and non-peristaltic contractions of large amp/duration
What would barium swallow look like?
Diffuse esophageal spasm from impaired inhibitory neurotransmission- several segments contract inappropriately at the same time, which gives a disorganized non-peristaltic appearance
Barium swallow would show corkscrew esophagus
MOA of TCA that causes death induced arrhythmias and anti-cholinergic toxidrome presentation
Inhibition of fast sodium channels, slowing down the myocardial depolarization and leads to arrhythmias- most common cause of death in overdose
Reverse transcription PCR is used to detect and quantify levels of what?
mRNA
The DNA template here is generated by the reverse transcriptase on the mRNA sample, producing a cDNA to the mRNA (contains the Exons of a gene and the untranslated regions) that is then amplified by PCR
_____ can cause irregular uterine enlargement, which can cause heavy bleeding, reproductive difficulties or put pressure on adjacent organs; like the colon causing constipation
Patients will commonly say they relieve the pressure by ‘splinting’ to defecate, which involve manual deflection of the obstruction
Fibroids- a posterior subserosal uterine leiomyoma in this case
This presentation is similar to a prolapsed posterior vaginal wall but without uterine enlargement and with the feeling that something is “falling out of the vagina”
____ and _____ are nuclear transcription factors that directly bind DNA via a leucine zipper motif
______ tests are used to ID and isolated proteins that bind DNA (TFs, nucleases and histones)
C-Jun and C-Fos
Southwestern blotting- proteins separated by gel electrophoresis and transferred to a filter membrane, labeled ds DNA probes are used to detect a specific protein of interest
If there is suspicion of abuse, _____ is the next step
Ask permission to interview the child alone
Parental refusal to be interviewed alone is considered concerning for abuse
Then call CPS
_____ is an inducible enzyme unregulated during inflammatory reaction by IL-1 and TNF-alpha but is undetectable in normal tissues under normal conditions.
What drug can directly inhibit this enzyme?
COX-2- produces pro-inflammatory AA metabolites (PGD2 and E2: vascular permeability and fever)
Celecoxib
(Glucocorticoids decrease the transcription of COX-2)
Dementia therapies target enhanced _____ transmission, neuroprotection via _____ or ______ receptor antagonism
Cholinergic transmission (donepezil, a cholinesterase inhibitor)
Antioxidants (Vit E: alpha tocopherol)
Antagonize NMDA receptors (memantine)
_____ is a major pathogen in burn patients
Pseudomonas- wound infections: shows erythema, induration, and gram negative, oxidase positive organisms that do not ferment lactose
The imbalance of estrogen and progesterone places patients with PCOS at increased risk for _____ later in life
Endometrial hyperplasia and adenocarcinoma
narcolepsy will typically have a decreased level of _____ in the CSF
Hypocriten-1 (orexin-A)- produced by neurons in the lateral hypothalamus
Renal scarring/cortical atrophy in the upper and lower poles of the kidney is distinctive of:
What pathology usually underlies the above
If uncorrected, this can lead to:
Recurrent pylonephritis- typically from retrograde flow of infected urine especially in vesicoureteral reflux (ureter enters bladder wall at a perpendicular angle)
Ongoing injury leads to renal scarring, most commonly at the upper and lower poles. Can eventually lead to secondary HTN
4 year old boy showing precocious puberty signs and labs show a high serum 17-hydroxyprogesterone and testosterone level likely has:
Treatment
CAH due to 21 hydroxylase deficiency from autosomal recessive defect in the gene
Treatment is to suppress ACTH- since there is lack of cortisol production, ACTH is secreted in high amounts, and this just stimulated more androgen production from adrenals. Give small doses of exogenous corticosteroids to suppress ACTH
Patient is prescribed ACE-i, ARBS or diuretics and BP stays elevated and plasma renin is within normal range values indicates
Medication noncompliance
Induction of meds would block RAAS and/or decrease BP, causing increased feedback to increase renin
______ is present when the effect of the main exposure on the outcome is modified by the presence of another variable
How can this be differentiated from confounding variables?
Effect modification
Stratified analysis shows the strata to have different measurements of association in effect modification. If confounding variables are present, stratified analysis will show no significant difference between the strata
What affect do beta-blockers have on hyperthyroid treatment?
Blunt adrenergic manifestation of hyperthyroidism, but also reduce the conversion of T4–>T3 by binding 5’monodeiodinase in peripheral tissues.
This is also decreased by glucocorticoids and propylthiouracil
What congenital heart disease causes cyanosis at birth that improves with squatting, prominent RV impulse and a systolic murmur?
What causes this malformation?
Tetralogy of Fallot- abnormal neural crest cell migration leads to anterior and cephalic deviation of the infundibular septum, resulting in a malaligned VSD and an overriding aorta. Typically causes RV outflow tract obstruction and then RV hypertrophy
*a VSD alone would cause a left to right shunt, which does not present with cyanosis at birth
Leuprolide is a ______
Can cause transient rise in ___ and ____ on initial administration
GnRH analog
Transient rises in LH and testosterone production on initial administration
What type of breathing pattern is typically seen in patients with
CHF?
Cheyne-stokes breathing- apnea is followed by gradually increasing then decreasing tidal volumes
chronic hyperventilation with hypocapnia induces apnea during sleep when the partial pressure ofCO2 falls below a certain threshold. Apnea will cause excessive buildup of CO2 and this stimulates a ventilatory response that overshoots, causing pCO2 to fall below threshold again.
Pain from an _______ is exacerbated by movements that cause stretching of the muscle, such as extension of the hip
Psoas major abscess- patients will typically position themselves with their hip flexed and lumbar lordosis
Psoas major muscle functions to extend the hips*
What DNA virus is partially double stranded, circular and enveloped?
Atypical lymphocytes found on blood smear and the virion is shown to possess an RNA dep-DNA pol activity
Hepatitis B- partially ds DNA to fully ds DNA to mRNA to ssDNA by its polymerase then to partially ds DNA again
Atypical lymphocytes are nonspecific symptoms of an infection* (EBV and CMV have high counts of these)
Diffusion across the alveolar membrane of O2 and CO2 is diffusion/perfusion limited (choose) normally
If the above answer is poor, equilibrium will occur slowly or not at all, resulting in what measurements of alveolar O2 and CO2
Perfusion limited
Tracheal air and alveolar air would have about the same pO2 values (around 150) and very low pCO2 levels
*in diffusion limited states, CO2 has much higher diffusion and is not nearly as affected as pO2 if there is diffusion limited problems
______ is the one non-glucose monosaccharide that can bypass ________, a key enzyme involved in regulating the rate of glycolysis, which is why it is metabolized faster than the other monosaccharides and is rapidly cleared from bloodstream
Metabolism of it in the liver consist of :
Fructose; bypass Phosphofructokinase
Phosphorylation by fructokinase to F-1-P. Aldolase B converts this to DHAP and glyceraldehyde (can be converted to G-3-P or DHAP) and enters the glycolysis pathway
purulent arthritis of the knee, oligoarticular joint pain, and vesiculopustular lesions on extremities indicates:
Disseminated gonoccocal infection due to Nisseria gonorrhoeae
*triad of polyarthralgia, dermatitis, and tenosynovitis
Septic arthritis by staph in young adults is usually linked to IV drug use and do not have dermatitis or polyarthralgia
Placing whole blood into a narrow tube and observing RBCs settling at the bottom, forming a rouleaux, is what test?
What cytokine stimulates production of the above?
ESR to identify acute phase reactants
IL-6 produces APR
Patient on an NE IV drip shows vein blanching and tissue surrounding the site to become cold, hard and pale- what is occurring?
What is the treatment?
NE extravasation from vein into the subcutaneous tissue causing overactivation of alpha 1 receptors, vasoconstriction and necrosis
Treatment- subcutaneous dose of alpha blocker (like phentolamine)
Fetal hydronephrosis- most common obstructive cause/site along the ureter and most common non-obstructive cause/site along ureter
Obstructive- ureteropelvic junction. Due to inadequate recanalization causing a narrowing
Non-obstructive- vesicoureteral reflux- from incomplete closure of this junction (ureter cannot be compressed enough to prevent backflow of Urine during bladder contraction)
Ventricular arrhythmias occurring shortly after an MI are typically treated with _______ class due to predominantly binding to rapidly depolarizing and ischemic ventricular myocardial fibers and has minimal effect on normal ventricular myocardium
Lidocaine Class IB like lidocaine are weakest sodium channel blockers/dissociate the fastest and predominantly bind to sodium channels in the inactivated state and dissociation occurs so rapidly that they rarely have an effect on normal myocardium Ischemic myocardium has higher than normal RMP, which delays recovery of sodium channels from the inactive state, which allows increased binding of class IB
Trendelenburg gait (hip drop as ipsilateral foot is lifted off the ground) is produced by damage to what nerve/muscle? What quadrant is an injection placed in to cause damage here?
Contralateral superior gluteal nerve (L4-S1) or gluteus medius muscle
Injections in the superiomedial quadrant can cause this gait (nerve runs through the superior sciatic foramen above the piriformis)
Following IV administration of a highly lipophilic anesthetic, the drug will be _____distributed to organs first with _______, then soon after redistributed to organs with ______
Example of drug
Rapidly distributed going to highly vascularized organs first like the brain, kidney, liver and lung then redistributed quickly to poorly vascularized tissue like skeletal muscle, bone and fat
Propofol
Small cell lung cancer causing progressively worsening dizziness, limb and truncal ataxia, dysarthria, and visual disturbances from:
Pathogenesis?
Paraneoplastic cerebellar degeneration
Due to immune response against tumor cells that cross react with purkinjie neuron antigens causing rapid degeneration
*Anti-Yo, anti-P/Q, and anti-Hu antibodies in serum
What factors utilize the cAMP signaling pathway?
FSH/LH, ACTH, TSH, CRH, hCG, ADH V2, MSH, PTH/calcitonin, GHRH, glucagon, histamine H2
(Fat CAMP)
FSH/LH/hCG; ACTH/CRH/MSH; TSH, V2/H2, PTH/calcitonin; glucagon
G protein/inositol triphosphate (IP3) pathway activates ______ intracellular messenger that does what; end with increased intracellular _____ which leads to activation of _____
What utilizes this pathway?
G protein activation activates phospholipase C, which degrades phospholipids into IP3 and DAG. IP3 leads to increased intracellular calcium that leads to activation of protein kinase C with DAG
GnRH, oxytocin, ADH (V1), TRH, Histamine H1, AG II, Gastrin
What modulators utilize the cGMP intracellular signaling pathway
BNP, ANP, EDRF (NO)
Nonreceptor TK signaling pathway utilizes _____as a second messenger. This path is used by what ligands?
JAK/STAT pathway
Prolactin, GH, immunomodulators (cytokines, IL-2, 6 and IFN), G-CSF, erythopoietin, thrombopoietin
*think acidophils, cytokines, and blood components
Intracellular signaling pathway for how insulin activates glycogen synthesis
What other intracellular signaling pathway is present upon insulin binding and what does it result in?
What other modulators use TK signaling?
TK binding leads to phosphorylation of insulin receptor substrate (IRS-1), this activates several pathways: activation of phosphatidylinositol-3-kinase (PI3K) stimulates metabolic function like translocation of GLUT4 and glycogen synthesis by activating protein phosphatase, an enzyme that activates glycogen synthase by dephosphorylation
Another pathway activated is the MAP kinase pathway that leads to mitogenic functions such as DNA synthesis and cell growth
Others using TK: Growth factors! (Map kinase*) IGF-1, FGF, PDGF, EGF
_____ is a highly conserved DNA sequence that is usually about 180 nucleotides in length. A gene containing this sequence typically codes for ______
Homeobox
Typically codes for transcription factors that bind to regulatory regions on DNA, altering expression of genes involved in the segmental organization of the embryo: make sure structural elements of the body are formed in the correct position along the cranio-caudal axis
Cumulative incidence=
Total number of new cases/number of people at RISK at the beginning of the period. It does not account for deaths in the period under study. At risk population does not include those who already have the disease
_____ transduce signals from growth factor receptors such as epidermal growth factor that have intrinsic tyrosine kinase activity
ras proteins and MAP kinase
Child with blue-black pigment of the sclera, ear cartilage, nose/cheeks, arthralgias in adulthood and urine that turns black upon exposure to air
What is the disease?
What is the enzyme that is deficient?
What accumulates?
Alkaptonuria
Deficiency of homogentisate oxidase in the degradative pathway of tyrosine to fumarate; pigment forming homogentisic acid accumulates in tissue and urine
Auto recessive
all vitamins and minerals are present in breast milk in adequate amounts except _____ and ______
Vitamin D and K
Need vitamin D supplementation in exclusively breast fed infants. Vitamin K supplement is given intramuscularly at delivery
drugs metabolized by N-acetylation in the liver causing drug induced lupus
Who is at greater risk for developing DILE?
Procainamide, hydralazine, isoniazid
Slow acetylators
most specific diagnostic finding for pyelonephritis is:
WBC casts
MOA how Crohn’s forms gallstones and kidney stones, resp.
Gallstone- reduced bile acid reabsorption in terminal ileum causes an increased cholesterol:bile acid ratio, supersaturating the bile with cholesterol, leading to stones
Kidney- increased oxalate absorption (due to decreased calcium available for binding it in the gut) contributes to calcium oxalate stones
first branchial arch
Syndromes associated with defective first branchial arch formation?
Cartilage- maxillary process and mandibular process, malleus and incus, and sphenomandibular ligament
Muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, anterior 2/3 of tongue, tensor veli palatini
Nerve- CN V3
Pierre robin sequence- micrognathia, glossoptosis, cleft palate, airway obstruction
Treacher Collins- neural crest dysfunction: mandibular hypoplasia, facial abnormalities
Aortic arch derivatives: First- Second- Third- Fourth- Sixth-
Maxillary artery- branch of the external carotid
Stapedial artery and hyoid artery
Common carotid and proximal internal carotid
Left= aortic arch. Right= proximal right subclavian
Left= Proximal pulmonary arteries. Ductus arteriosus
where can the great saphenous vein be assessed? Route?
Superficial vein that courses along the medial side of the foot, courses anterior to the medial malleolus, up the medial aspect of the leg and thigh. Drains into the femoral vein in the femoral triangle, which is inferolateral to the pubic tubercle, where it can be assessed
insulin production begins with preproinsulin which begins with a N-terminal signal peptide that directs it to _____
Then it is cleaved and this form goes to the ______; where it is ____ and cleaved once more to make insulin
The RER to continue translation
Then the signal peptide is cleaved to make proinsulin and is sent to the Golgi to be packaged into secretory granules
Proinsulin is cleaved to insulin and C-peptide in secretory granules and are stored here until needed for release via exocytosis
Development of respiratory distress, confusion, and upper body petechial rash within days of severe long bone fractures:
Stains black with osmium tetroxide
Fat embolism syndrome in lung
Cancer treatment utilizing a dsRNA molecule that is complementary to a region of mRNA encoding pathogenic factors (like c-Myc in Burkitt’s) causing a significant reduction in this protein and in cell growth
What process does this treatment work through?
RNA interference- inhibits RNA translation via pottranscriptonal gene silencing
SiRNA and miRNA are examples - forms a ds RNA in the nucleus, exported to cytoplasm, cleaved into a short RNA helix by a protein called dicer*, these individual strands are incorporated into RNA-induced silencing complex where miRNA binds a complementary sequence on target mRNAs= mRNA degradation or translational repression
The overexpressed protein in Burkitt’s lymphoma has what activity?
C-Myc: nuclear phosphoprotein that functions as a transcription activator controlling cell proliferation, differentiation and apoptosis
Follow the path of fetal circulation
Which segment has the highest blood oxygen sat?
Oxygenated blood from the placenta is delivered to the fetus via the Umbilical vein- has 80% O2 saturation
Blood from the umbilical vein is first delivered to the liver, where it bypasses hepatic circulation via the ductus venosus* and enters the IVC—>heart—> mixes with deoxygenated blood from SVC—> pulmonary circulation (or through foramen ovale)—> bypass lungs via ductus arteriosus to descending aorta—>fetal tissue
Deoxygenated blood is delivered back to placenta by paired umbilical arteries
colorectal carcinomas from a history of UC are typically more _____, with a _____ grade, and evolve from ______ lesions, and is frequently multi/unifocal?
What mutation sequence underlies these carcinomas?
Colitis associated colorectal carcinomas are usually more aggressive, higher grade tumors.
They usually evolve from nonpolypoid/flat lesions, and are multifocal
Molecular pathogenesis is also different from sporadic disease in that it starts with mutation in p53 early and APC mutations occur later
a blueish neoplasm occurring under the nail bed- arises from ______, which is involved in what?
Modified smooth muscle cells of the thermoregulatory glomus body
Each glomus body is composed of an afferent arteriole, muscular AV anastomosis, and an efferent vein. Goal is to shunt blood away from the skin surface in cold temperature to prevent heat loss. Primarily in the pads of fingers, toes, dermis of nail bed and ears
Alpha-anti trypsin deficiency results in what type of lung disease?
What will PFTs look like?
Where does alpha-AT accumulate?
Obstructive- panacinar emphysema; lower lobes
Decreased FEV1/FVC ratio, increased TLC, decreased diffusing capacity for CO
Accumulates in ER of hepatocytes- PAS + globules
A CMV infection in an immunocompetent individual would likely present as ______
Mononucleosis like syndrome but with negative heterophile antibodies
The spinothalamic tract and dorsal columns mediate _____ information to the brain and synapse where in the brain?
What nucleus receives these modalities for the face?
A patient with one sided hemisensory loss likely suffered what type of stroke?
Pain, temperature, vibration, proprioception, light touch, pressure
Ventral postero-LATERAL nuclei of the thalamus
Facial sensation, pain and taste synapse in the ventral posterior-MEDIAL nucleus of the thalamus
A contralateral thalamic stroke* of the ventral posterior nucleus (a lesion to the posterior limb of the internal capsule would likely also affect the anterior IC, affecting motor signaling; rarely would cause a pure sensory)
Hemodynamic profile shows a difference between lower pressure aortic and higher LV pressure during systole, signifying ______ murmur. This murmur intensity is proportional to ______
Aortic stenosis
Intensity of the murmur is proportional to the pressure gradient between the LV and aorta during systole
______ is most appropriate next step in a patient presenting with a panic attack- chest pain, tachycardia, shortness of breath, and tremulousness and fear/feeling of dying in otherwise young healthy patient with normal ECG
Benzodiazepine administration
Patient with bleeding gums, cork-screw hairs, and low nutrient diet. The enzymes that are hypoactive are found in what organelle?
What disease is characterized by problems forming the triple helix of collagen?
What disease is characterized by inability to cleave disulfide rich terminal regions to make tropocollagen or crosslinking?
Patient has scurvy from Vit C def- enzymes that are hypoactive are in the RER*- hydroxylation step of lysine and proline takes place here and requires vitamin C
Osteogenesis imperfecta- occurs in RER, glycosylation of pro-alpha chain hydroxylysine residues and formation of procollagen via hydrogen and disulfide bonds to form triple helix
Ehlers-Danlos- these steps occurs in the extracellular matrix
Dephenoxylate is an ________ used as an antidiarrheal due to its MOA of:
Opioid agonist at the Mu receptor- slows motility
Close presynaptic calcium channels, open post synaptic potassium channels and decrease synaptic transmission to inhibit release of Ach, NE, serotonin, glutamate, substance P
Sepsis after surgery, patient found to have a central venous catheter, blood cultures and culture of the catheter tip on sheep blood agar grow elliptical, purple budding organisms. What is the likely organism?
Candida
_______ are likely to cause multiple spontaneous abortions or children born with severe anomalies (genetic term)
Unbalanced chromosome rearrangements
Antihistamines and ______ are used to treat allergic rhinitis
Alpha agonists- short term
Multiple history of malignancies seen at an early age from ______ mutation resulting in malignancy Li-Fraumeni syndrome: osteosarcoma, breast adenocarcinoma, leukemia and adrenal cortical gland tumors.
P53 mutation- impaired regulation of apoptosis
Blocks G1-S phase
Smoking causes what set of changes in respiratory defense function?
______ mucous production/secretion, ____ activity of airway cilia, and ______ alveolar macrophage function
Increased mucus, decreased activity of airway cilia, decreased alveolar macrophage function
Inactivation of GTPase of the Galpha subunit of G proteins would result in increased ______
Adenylyl cyclase
Guanylyl cyclase is broken down by PDE *
Patient with sickle cell disease presents with flank pain, low Hct, and UA shows gross blood and no WBC casts likely has
Renal papillary necrosis- GROSS blood and flank pain* esp in sickle cell patients, DM or severe pyelonephritis
In older men the most common pathogen causing prostatitis is ________
E. Coli
In younger men- chlamydia and gonorrhea
What 5 drugs are chosen during hypertensive emergencies?
Clevidipine, fendoldopam (D1 agonist vasodilates and increases natriuresis), labetalol, nicardipine or nitroprusside
Defect in _______ causes coarse facial features, gingival hyperplasia, clouded corneas, restricted joint movements, claw hand deformity, and a high plasma level of lysosomal enzymes
Defect in golgi’s ability to phosphorylate mannose residues (low mannose-6-phosphate on glycoproteins) causing proteins to be secreted extracellularly instead of into the lysosomes
I-cell disease*
Kidney _____ cells convert ________ to 1,25 dihydroxycholecalciferol via what enzyme?
What form is absorbed by the skin?
What form is produced by the liver?
What is the active form of vitamin D?
PCT cells convert 25-hydroxycholecalciferol via 1alphahydroxylase
Skin- cholecalciferol Vit D3
25 hydroxylase in liver produces 25-OHD3 to send to kidney to activate to the active form calcitriol
_________ occurs in areas of with repetitive sequences, where the DNA pol dissociated and upon reassociated, reattached at a position one or two positions ahead or behind on the repeat sequence. Underlies short tandem repeat mutation/microsatellites
Single strand mispairing
Which muscle is being tested on resisted empty can/thumbs down test of rotator cuff?
What are the other muscles of the rotator cuff and their actions/innervations?
Supraspinatus- abducts arm initially, Suprascapular nerve
Infraspinatus- externally rotates arm (pitching injury) suprascapular n
Teres minor- adducts and external rotates, axillary n
Subscapularis- adducts and internally rotates, upper and lower subscapular nerves
What organelle is affected if a patient shows signs accumulated VLFCA, phytanic acids, and pipecolic acid
Peroxisomes
*alpha oxidation is a strict peroxisome function that metabolizes phytanic acid to pristanic acid
Antibiotic therapy is likely to have what effect when given to a patient with salmonella?
Prolong fecal excretion of the organism (shortens for shigella)
Only to be given to patients with severe salmonella illness
Infant with micrognathia, glossoptosis, cleft palate and airway obstruction showing periauricular skin tags:
What pharyngeal arch is defective in this patient?
What normally makes up this arch
What other syndrome includes defects in this arch?
Pierre robin sequence- defective 1st pharyngeal arch
Maxillary process, mandibular process, malleus and incus, muscles of masstication, tensor tympani, anterior 2/3 of tongue, tensor veli palatini
Treacher-Collins syndrome- neural crest dysfunction- mandibular hypoplasia and facial abnormalities
Patient with long standing type 2 DM treated with gemfibrozil comes in with a complaint of pain in his feet, more severe at night and is relieved by taking a hot bath. Achilles DTR is diminished and sensation to pinprick and vibration is decreased from just above the ankle distally. How would the patient describe the pain? (One word)
Burning
drug against nematodes and cestodes that increases the permeability of the cell membranes to calcium causing paralysis, dislodgment and death of the parasite
Praziquantel
Which of the bone structures assists in producing new bone to heal fractures?
Periosteum.
Presents with signs of fat malabs (vitamin deficiency and steatorrhea), failure to thrive, retinitis pigmentosa, spinocerebellar degeneration due to vitamin E deficiency, progressive ataxia and acanthocytes
Abetalipoproteinemia- deficiency of ApoB48 and B100
Auto recessive disease. Chlyomicrons, VLDL and LDL are absent
_______ is also known as osteoclasts activating factor
IL-1- increased in mechanisms that show lytic bone lesions
Infant 46, XX girl with ambiguous external genitalia and clitoromegaly with elevated levels of testosterone and androstenedione. During pregnancy, the mother experienced facial hair growth and voice deepening. What enzyme was likely deficient?
Aromatase deficiency
21alpha hydroxylase CAH is most common cause of this presentation in newborns, but does not cause mother virilization
Which type of porphyria causes photosensitivity?
Which type causes abdominal pain, port wine colored urine, neuropsychiatric disturbances and is usually precipitated by cytP450 inducers?
Porphyria cutanea tarda- deficiency of uroporphyrinogen decarboxylase
Acute intermittent porphyria - earlier step of porphyrin synthesis is affected. Porphobilinogen deaminase deficiency
Bacteria suspended in isotonic solution displays a spherical configuration and then disintegrates rapidly when placed in a hypotonic solution- what aspect of the bacteria is likely damaged from this observation?
Bacterial cell wall of Gram + bacteria- usually resists damage by osmotic forces/changes in tonicity
Common causes of myopathy with increased CK include
Elevated CK myopathy, muscle cramps and proximal weakness, delayed tendon reflexes with weight gain, bradycardia and brittle nails/splitting of nails is likely which of the above?
Hypothyroidism, muscular dystrophy, inflammatory muscle disease, and statins
Hypothyroid myopathy
Patient with acute pancreatitis with normal gallbladder and no alcohol use- what lab would you check and why?
Serum TGs, if over 1000, FFA conc likely exceeds the binding capacity of albumin and leads to direct injury to pancreatic acinar cells
Infant presents with 4 days of high fevers that commonly elicit seizures followed days later by a maculopapular rash on trunk- what virus?
Roseola- HHV6
Compare to measles- rubeola paramyxoviridae that presents with 3C’s, then koplik spots, then maculopapular rash that STARTS on the face and spread downward (roseola rash starts on the trunk and spreads to face)
What structure is affected by transtentorial herniations?
What structure is affected by subfalcine herniations?
What structure is affected by tonsillar herniations?
Oculomotor nerve and PCA (uncal herniation from the medial temporal lobe herniations through the gap between the crus cerebri and the tentorium)
ACA is compressed- cingulate gurus herniated under falx cerebri
Medulla is compressed- cerebellar tonsil herniated through foramen magnum
What birth defect is associated with prenatal screening finding of decreased AFP or increased unchallenged translucency on US?
Down syndrome
Calculating RBF=
Renal plasma flow divided by 1-Hct
Renal plasma flow= PAH clearance= urine [PAH]xurine flow rate/ plasma [PAH]
RBF= PAH clearance/1-Hct (1-Hct)=plasma volume
Malignant tumor arising from _______ and is most commonly preceded by a pregnancy and weeks later causes vaginal bleeding, uterine enlargement and significantly increased beta hCG
Early spread to other organs via ______; most commonly to what organ?
Gestational choriocarcinoma- malignant proliferation of trophoblasts
Rapidly invades the uterine wall and undergoes hematogenous spread- most commonly to the lungs (“cannonball” metastasis)
Pro-carcinogens are converted to active metabolites by _____
Microsomal cyt P450 monoxygenase
Gastric varices can be seen in portal HTN and _____ due to chronic pancreatitis. What veins drain into this vein?
Splenic vein thrombosis - this vein runs along the posterior surface of the pancreas and can develop a blood clot from pancreatic inflammation
Short gastric veins drain the fundus of the stomach into the splenic vein, so these can experience increased pressure and cause gastric varices in the fundus
Young patient with signs of acute coronary syndrome and MI and increased methionine levels likely has ________ deficiency
What becomes essential?
Other associated findings with this disease?
Cystathionine synthase deficiency resulting in homocystinuria and shunting of the pathway to methionine synthesis
Cysteine becomes an essential AA- and vitamin B6
Osteoporosis, marfanoid habitus, ocular changes (down and in lens subluxation), CV events, and kyphosis
Patient with bipolar disorder experiencing tremor, ataxia, and involuntary movements started a new BP medication weeks ago. What anti-hypertensive is most likely being used?
Thiazides, ACE- anything that decreases volume or GFR increases lithium toxicity (chronic presents at neurological deficits)
Lithium gets reabs with sodium in the PCT- decreased volume will cause later increased reabs of sodium and water in PCT and therefore increased lithium
Amatoxins in mushrooms inhibit ______ predominantly in what organ?
mRNA synthesis (inhibiting DNA dep RNA pol II) typically in liver cells- taken to the liver from gut via portal vein
what are the 3 stop codons?
UAA, UAG, UGA
Toxicity/overdose of insecticides/pesticides contains _____, which gives a garlic odor to the breath, copious watery diarrhea, and QT prolongation, binds to _______; impairing cell respiration and GNG by inhibiting pyruvate DH
What is the treatment?
Arsenic poisoning; binds sulfhydryl groups and inhibits lipoic acid
Dimercaprol- has a sulfhydryl group to combine with arsenic
Combination of hemolytic anemia (antibodies to CD55 and CD59 found on flow cytometry), hypercoagulability/thrombosis and pancytopenia indicates ________, which is a mutation in the ______ gene that synthesizes _______
Paroxysmal nocturnal hemoglobinuria- defect in the PIGA gene that usually synthesizes GIP anchor protein that holds decay accelerating factor and MAC inhibitory protein to the RBC membrane in order to inhibit complement activation
Without this anchor factor, CD55/DAF and CD59/MIP are absent and there is complement mediated lysis of RBC, WBC and platelets
Hemolysis occurs more often at night due to the respiratory acidosis that occurs during sleep pattern breathing
Thrombosis occurs due to lysis of platelets releasing prothrombotic factors and free Hb from RBCs
Patient has diplopia when walking down stairs or reading things up close, eye shows hypertropia and extortion- what nerve is affected? What is the normal function of the muscle(s) it innervates?
Trochlear nerve- superior oblique muscle- usually intorsion upon abduction and downward gaze upon adduction
Lesion is vertical deviation and extorted
Compensation- chin is tucked and head is tilted away from the affected eye to compensate for hypertropia and extortion
Chronic allograft rejection would show
Acute allograft rejection would show
Obliterating intimal thickening, tubular atrophy, and interstitial fibrosis (shrunken organ; arteriolosclerosis)
Interstitial lymphocytic infiltrates
Infant with neurological deficits and increased serum lactate levels has what primary enzymatic deficiency? What AA/diet treats this condition?
Pyruvate dehydrogenase deficiency- causes buildup of pyruvate that gets shunts to lactate via LDH and alanine via ALT.
X-linked
Treatment is a ketogenic diet- high fat and ketogenic AA like lysine and leucine, which are broken down to acetyl-CoA and cannot be metabolized to pyruvate or glucose.
What kind of murmur does a VSD have?
What would happen to the SpO2 in the LV?
Holosystolic, harsh sounding murmur best heard over the lower left sternal border.
Stays relatively normal with smaller VSDs; larger VSDs allow equalization of chamber pressures
Pulmonary lesion culture grows Fusobacterium and Peptostreptococcus- indicative of?
Anaerobic bacteria that are a part of the normal flora in mouth
Highly suggestive of lung abscess with foul smelling sputum- aspiration is most common cause
Also bacteriodes and prevotella
Thiazides increase Ca reabsorption from tubules through 2 major mechanisms:
Indicated in patients with _____
Blocking Na/CL cotransporter on the apical side decreases intracellular Na concentration, which stimulates the basolateral Na/Ca anti-porter, pumping Na into the cell and reabsorbing calcium into the blood from the tubules.
Hypovolemia increases Na and H20 reabsorption in the PCT, which increases passive paracellular Ca reabs
Nephrolithiasis secondary due to hypercalciuria
Impaired ________ causes hypoglycemia after prolonged periods of fasting and inappropriately low levels of ketone bodies. _______ enzyme deficiency is the most common cause and catalyze the first step of this process
Fatty acid beta-oxidation
Defect in Acyl-CoA dehydrogenase
X linked recessive deficit of CD40L and CD40 interaction causes _______, presenting with recurrent sinopulmonary and GI infections, opportunistic pathogens, and failure to thrive in children.
Normally, what allows for this missing process to occur?
Hyperimmunoglobulin M syndrome - defective signaling between CD4+ T cells and B cells, which results in a defect of class switching
Isotype switching occurs by splicing out DNA coding for different heavy chain constant regions. The variable region/antigenic specificity of the AB stays the same.
Breast pathology that is associated with ‘orange peel’ skin rash- erythematous, itchy, firm and coarse. Significant edema, lymphadenopathy, but no mass
Inflammatory breast cancer- cancerous cells obstructing lymphatic drainage after spread to dermal lymphatic spaces
*can easily be mistaken for mastitis- but note no fever and longer time frame of rash than an infection
Prevention of neonatal tetanus focuses on ________
Vaccinating PREGNANT women or those who may become pregnant- pass IgG trans placentally to the fetus
The carpal tunnel contains the flexor digitorum _____, _______ and the ____ nerve. It is covered by the _________, which attaches to the hamate and pisiform on the ulnar side and the scaphoid and trapezium on radial side
Flexor digitorum profundus tendons and superficialis tendons, flexor pollicis longus, and the median nerve
Covered by the transverse carpal ligament (flexor retinaculum)
CAAT box and TATA box (promoter regions) promote initiation of transcription by acting as binding sites for _____ and _____
Transcription factors and RNA pol II
Characteristic histologic findings of GERD/Gastroesophageal junction incompetence
Basal Zone hyperplasia
Lamina propria papillae
Scattered eosinophils and neutrophils
Hematogenous Osteomyelitis in children usually affects what part of long bones?
Metaphysis - contains slow flowing, sinusoidal vasculature that is conducive to microbial passage
Lipid lowering agent that decreases hepatic synthesis of TGs and VLDL and reduces clearance of HDL. Most effective at raising HDL, but does not ________ so is typically only used in those who have failed other lipid lowering agents.
AE?
Niacin- does not reduce the risk of cardiac events
Decreases the renal excretion of uric acid- acute gouty arthritis
Hepatoxicity, hyperglycemia and flushed faces
Flat, greasy, purple/brown pigmented ‘stuck on’ appearance lesions- histologically would show what?
Rapid onset of multiple of these lesions would be associated with what?
Seborrheic keratosis- show keratin filled cysts, hyperkeratosis (proliferation of stratum corneum)
Underlying GI or lymphoid malignancy- Leser-Trelat sign
DoC in a patient with DM and HTN to prevent chronic kidney disease
ACE-I and ARBS (if intolerant to bradykinin/substance P increase causing cough)
Early course of DM II is characterized by increased ____, but later course shows resistance and decreased levels. At this point, what will be elevated in the blood that further contributes to the disease? (Besides glucose)
Insulin production increases
Insulin resistance stage- show elevated FFA levels (insulin usually have antilipolytic effects) and further contributes to insulin resistance by impairing insulin dependent glucose uptake and increasing GNG in liver
Corneal reflex involves ____ afferent limb and _____ efferent limb
What nerve innervates the levator palpebrae muscle (when paralyzes, creates ptosis)
CN V1 and CN VII
CN III
Ether and other organic solvents dissolve ______ viruses
Enveloped- causing them to lose their infectivity
A conscious choice not to dwell on a particular thought or feeling=
Making excuses for unacceptable feelings/actions, usually to avoid self blame=
Involuntarily withholding an idea or feeling from conscious awareness=
Suppression- mature defense
Rationalization- immature defense
Repression- immature defense
Gardos Ca channel blockers hinder ________ from the cell, preventing _____ of erythrocytes and reducing polymerization of HbS
Efflux of potassium and water from the cell, preventing dehydration of RBCs in sickle cell patients
NF 1 is on chromosome _____ ; which codes for what protein and presents with ______
NF2 is on chromosome _____; which codes for what protein and presents with _______
NF1 is on chromosome 17, which codes for neurofibromin (Ras GTPase activating protein), and presents with cafe-au-last spots, multiple neurofibromas, lisch nodules (gold/tan domes on surface of iris)
NF2 is on chromosome 22, which codes for Merlin (schwannomin) and presents with bilateral acoustic neuromas (remember: 2–22-2 neuromas (proliferation of myelin))
Complement binds to the Fc portion of IgM and IgG closer/further from the hinge region?
Which portion does the antigen attach to?
Closer* more proximal end of Fc (near the disulfide bonds). The distal end of Fc portion serves at the site of attachment to the phagocytic cells
Antigen attaches to the Fab region (variable region) of the light chain and heavy chain
What type of collagen is seen in scar formation? What other structures contain this type of collagen?
What type of collagen is seen in granulation tissue?
Type I in scar formation- as seen 2 weeks+ after an MI
Type I is also seen in bone,tendons, ligaments, dermis, cornea and BVs
Type III collagen in granulation tissue
During transient ischemic attacks on myocardium, anaerobic metabolism takes over, which creates a decrease in production of ______, which leads to _____ and _____ accumulation in the cell
Which accumulation leads to failure of further myocardium contraction?
ATP—> Na and Ca accumulation (Na/K pump and SR Ca ATPases fail)- this then causes water to flow into the cell and swell (increase in cell size)
*if sarcoplasmic reticulum cannot sequester Ca, it will lead to a cessation of contraction within the ischemic zones of myocardium
Formation of atheroma: endothelial cell injury leads to increased expression of surface _____ to allow adherence and migration of monocytes
Once there, they release cytokines and GFs that promote migration and proliferation of _____, which are stimulated to synthesize extracellular matrix proteins and formation of the _______
Vascular cell adhesion molecules
Vascular smooth muscle cells
Fibrous cap
Pituitary adenoma: ACTH and cortisol is/not suppressed by high dose dexamethasone test
Ectopic ACTH production (lung cancer: ACTH and cortisol is/not suppressed by high dose dexamethasone test
Pituitary adenoma IS suppressed by high dose
Ectopic is NOT suppressed by even high doses of dexamethasone
Think of ectopic ACTH as being non responsive to central feedback since it is not apart of the normal CNS pathway
As blood conc of PAH increases, the extraction rate decreases progressively due to effects on (filtration/secretion: choose), why?
Secretion; carrier mediated transport is saturated as PAH conc increases. There is a Max secretion rate*
PAH is constantly filtered no matter the blood conc, so this is not affected and cannot be saturated.
________ carcinoma is characterized by overlapping nuclei containing finely dispersed chromatin, intranuclear inclusions and grooves due to invagination of nuclear membrane, and psammoma bodies (calcium deposits)
Papillary carcinoma of thyroid- overlapping nuclei with finely dispersed chromatin give the cells an empty or ground glass appearance (orphan Annie nuclei)
Tumors with psammoma bodies- PSaMMoma: papillary thyroid, serous cystadenocarcinoma of ovary, mesothelioma, and meningioma
Traumatic aortic rupture caused by a rapid deceleration (MVC) most commonly injures ______ site on the aorta
Aortic isthmus, which is tethered by the ligamentum arteriosum (right after the brachiocephalic, common carotid, and subclavian artery branch off)
treat restless leg syndrome with _____ (mechanism of drug)
Most common cause of RLS is _____
Dopamine agonists (ropinirole, pramipexole)
Iron deficiency or diabetic neuropathy in older adults
History of calculous cholecystitis is now found to have air in the gallbladder and biliary tree. Where did the stone most likely end up?
Perforation of the gallbladder wall usually into the duodenum via a fistula will cause gas to be present in the gallbladder; the stone will move unimpeded until hitting the ileum, causing a gallstone ileus** and subsequent small bowel obstruction.
Enteric bacteria produce _____ and _____
SIBO is a risk factor in _____ surgery
SIBO results in a deficiency of what vitamins and minerals?
Vitamin K and folate- overproduced in SIBO
Increased risk in gastric bypass surgery- bloating, nausea, abdominal discomfort, and malabsorption
Deficiency of vitamins B12, A, D, and E and iron.
Pregnant mother with a history of irregular menses that last 3-4 days undergoes a quadruple screening test that shows decreased AFP. What is the likely etiology of the low AFP?
Dating error- women with irregular menses are at risk for inaccurate pregnancy dating, which is vital for an accurate quadruple screening test
If correct, a low AFP indicates aneuploidies like trisomy 18 and 21
Which step involved in processing and handling of mRNA occurs only within the cytoplasm?
Interaction with P bodies- that hold micro-RNA induced mRNA silencing control, exonucleases and recapping enzymes for translation repression and mRNA decay.
Posttranslational modifications like 5’ capping, poly A tail, and intron splicing occur before leaving the nucleus
