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Board questions > Uworld 6 > Flashcards

Uworld 6 Flashcards

1
Q

cumulative incidence calculation

A

total number of new cases of a disease over a specific period divided by the number of people at risk at the beginning of the period

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2
Q

histologic findings of basal zone hyperplasia, elongation of the lamina propria papillae, and scattered eosinophils and neutrophils

A

GERD

gastroesophageal junction incompetence is primary mechanism

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3
Q

How does ionizing radiation do its thing?

What tissue does it most affect?

A

DNA double strand breakage or free radical formation

affects rapidly dividing tissues because they cannot repair fast enough - so the malignancy, but also epithelial surfaces

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4
Q

Lithium taken during pregnancy is associated with…

A

Ebstein’s anomaly

characterized by apical displacement of the tricuspid valve leaflets, decreased RV volume, and atrialization of the RV

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5
Q

What is the non-glucose monosaccarhide that is able to bypass phosphofructokinase?

because of this, what happens?

A

fructose

metabolized by the liver faster than the other monosaccharides and is rapidly cleared from the bloodstream following dietary absorption

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6
Q

activation of the carotid sinus baroreceptor sends afferents through what pathway?

efferents then come via…

A

afferent limb goes to medullary centers via the Hering nerve, a branch of the Glossopharyngeal nerve

the efferent limb of the carotid sinus carries parasympathetic impulses via the vagus nerve

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7
Q

You are suspiscious of CF in a pt, but the Cl- sweat test came back normal. What is another useful diagnostic adjunct?

A

measure the nasal transepithelial protential difference

  • saline solution applied to nose
  • CF pts will have increased Na absorption
    • CFTR channel secretes Cl- into lumen and has a tonic inhibitory effect on the opening of the epithelial Na channel (ENaC) which decreases Na reabsorption into the cell
    • high luminal salt content helps retain water in the lumen, forming well-hydrated mucus
  • so Na is absorbed intracellularly but Cl- in the saline solution is retained in the lumen
  • the higher relative amounts of negatively charged Cl- on the epithelial surface results in a more negative transepithelial voltage difference
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8
Q

cyclic breathing in which apnea is followed by gradually increasing then decreasing tidal volumes until the next apneic period

what is this called?

When is it seen?

A

Cheyne-Stokes breathing

often seen in advanced CHF

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9
Q

Rb protein regulates what part of the cell cycle?

A

G1 to S

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10
Q

Mycoplasma pneumoniae attaches to the respiratory epithelium using…

they are also present where?

A

surface antigens - I-antigen

also present on the plasma membrane of erythrocytes

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11
Q

hydralazine and minoxidil are…

A

selective arteriolar vasodilators to lower BP by reducing systemic vascular resistance

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12
Q

taking too many NSAIDs in a kid - what kidney injury?

A

minimal change disease

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13
Q

What is the earliest sign of diabetic nephropathy?

A

moderately increased albuminuria

screening is best achieved using an albumin-specific urine assay (regular dipstick UA has low sensitivity)

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14
Q

Milrinone MOA

A

PDE-3 enzyme inhibitor that can be used in pts with refractory heart failure due to LV systolic dysfunction

positive inotrope and vasodilator

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15
Q

the fact that a researcher’s beliefs in the efficacy of treatment can potentially affect the outcome is known as

A

Pygmalion effect

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16
Q

the paracortex of the lymph node is populated by…

when would this area become enlarged?

A

T lymphocytes and dendritic cells

becomes enlarged by the proliferation of T lymphocytes during adaptive cellular immune responses (eg viral infections)

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17
Q

Where in the lymph nodes are B cells localized and proliferate?

A

follicles in the outer cortex

primary follicles are dense and dormant; secondary follicles have a pale germinal center containing proliferating B cells and follicular dendritic cells

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18
Q

What does the medulla of the lymph node hold?

A

consists of medullary cords and sinuses

medullary cords contain B cells, plasma cells, and macrophages;

medullary sinuses contain reticular cells and macrophages

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19
Q

intracellular protozoa with rod-shaped kinetoplasts

dx?

how does this spread?

A

cutaneous leishmaniasis

bites from infected sand flies

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20
Q

How long do depression symptoms have to be going on to count as MDD?

A

greater than or equal to 2 weeks

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21
Q

What are the time frames and ddx leading up to schizophrenia?

A
  • brief psychotic disorder (1 day to 1 month)
    • sudden onset, full return to function
  • schizophreniform disorder (1 month to 6 months)
    • same ssx as schizophrenia, functional decline not required
  • schizophrenia (greater than 6 mo)
    • includes at least 1 mo of active ssx, can include prodromal and residual periods
    • requires functional decline
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22
Q

pts with prolactinoma and high levels of circulating prolactin, what will happen hormonally?

A

suppress GnRH secretion from HT, leading to reduced secretion of LH and subsequent hypogonadism, anovulation, and amenorrhea

estrogen deficiency

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23
Q

If a mutation affects an exon, the mutation will be detectable in the….

deletion or addition of a number of bases that is not divisible by 3 in the coding region of a gene will cause…

A

mRNA sequence

frameshift mutation

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24
Q

excessive raw egg white consumption can lead to

A

biotin deficiency

due to high levels of biotin-binding avidin in egg whites

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25
Q

biotin/B7 is an important cofactor for what kind of enzymes? what does it do?

A

carboxylase enzymes

functions as a CO2 carrier and plays an essential role in carbohydrate, lipid, and amino acid metabolism;

in liver, the conversion of pyruvate to oxaloacetate for gluconeogenesis requires pyruvate carboxylase and biotin

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26
Q

extensive hepatocellular damage causing the liver to rapidly atrophy and appear shrunken on autopsy; s/p surgery (any surgery)

what is this likely due to?

A

fulminant hepatitis likely due to halogenated anesthetics (halothane in particular)

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27
Q

What will be lab findings from inhaled-anesthetic hepatotoxicity?

A

markedly elevated serum aminotransferase levels

prolonged PT (due to fialed hepatic synthetic function and deficiency of factor VII- shortest half life)

leukocytosis

eosinophilia

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28
Q

What are two important congenital syndromes that can cause QT prolongation?

A
  • Jervell and Lange-Neilsen syndrome
    • AR with neurosensory deafness
  • Romano-Ward Syndrome (more common)
    • AD no deafness

both can predispose to Torsades at a young age, causing syncopal episodes and SCD

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29
Q

AT II will stimulate the release of what two things, leading to what?

A

aldosterone and endothelin 1

increase Na+ and water reabsorption and systemic vascular resistance to help maintain BP

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30
Q

What is the most common mechanism of aminoglycoside (genatmicin) resistance?

A

antibiotic-modifying enzymes adding chemical groups (acetyl, adenyl, and phosphate)

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31
Q

Chronic use of opioids generally cause development of tolerance to analgesic effects and most AEs, except for

A

constipation and miosis

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32
Q

What are the MCC of acute pancreatitis?

A

gallstones and alcoholism

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33
Q

First symptom of this disease is usually severe pruritis (especially at night)

A

primary biliary cirrhosis

AI destruction of the intrahepatic bile ducts and cholestasis (elevated alkaline phosphatase)

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34
Q

fatty streaks are composed of what?

A

collection of lipid laden macrophages (foam cells) in the intima that can eventually progress to atherosclerotic plaques

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35
Q

AE of spironolactone (not the K+ sparing part)

A

antiandrogenic effects, can cause gynecomastia, decreased libido, and impotence

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36
Q

What are the two main virulence factors of Bacillus anthracis?

A
  • polypeptide capsule
    • composed of poly-gamma-D-gltuamic acid
    • inhibits phagocytosis
  • trimeric exotoxin
    • composed of protective ag, edema factor, lethal factor
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37
Q

calmodulin-dependent adenylate cyclase that increases cyclic AMP concentration, leading to accumulation of fluid within/between cells and suppression of neutrophil and macrophage function

A

edema toxin in bacillus anthracis

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38
Q

Bacillus anthracis edema factor functions similarly to what other toxin/pathogen?

A

similar to adenylate cyclase toxin, produced by Bordetella pertussis

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39
Q

end-organ hypoperfusion in septic shock impairs tissue oxygenation and decreases oxidative phosphorylation, leading to a buildup of NADH and….

A

shunting pyruvate to lactate following glycolysis

lactic acidosis

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40
Q

What are the physiologic end effects of lactose intolerance?

A
  • increased breath hydrogen content
  • decreased stool pH

both from the fermentation of undigested lactose by gut bacteria leading to increased production of short chain FA that acidify the stool and create excess H+ to be exhaled

  • elevated stool osmolality
    • from high amounts of undigested lactose, which attracts excess water in the bowel lumen
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41
Q

ptosis, downward and laterally deviated eye, impaired pupillary constriction and accomodation, and diagonal diplopia

dx?

why does this eye position occur?

A

oculomotor nerve palsy

unopposed action of the superior oblique (CN IV) and lateral rectus (CN VI) muscles

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42
Q

more than 2 layers of proliferating cells within the Bowman space would be considered…

these form in response to…

A

glomerular crescents

immune or inflammatory-mediated injury to golmerular capillaries

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43
Q

What do crescents in rapidly progressive gomerularnephritis consist of?

A

consist of golmerular parietal cells, lymphocytes, and macrophages, along with abundant fibrin deposits

crescents eventually become fibrotic, disrupting glomerular function and causing renal injury

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44
Q

low systemic vascular resistance and decreased preload is consistent with what kind of shock?

what is the MCC?

A

distributive shock

MCC due to bacterial infection

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45
Q

under hypoxic conditions, intracellular accumulation of NADH inhibits ….

as a result…

A

pyruvate dehydrogenase

increased amounts of pyruvate are converted to lactate by lactate dehydrogenase, which regenerates NAD+ from NADH

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46
Q

pyruvate is converted to oxaloacetate by

A

pyruvate carboxylase

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47
Q

2-phosphoglycerate is converted to phosphoenolpyruvate by…

then PEP is metabolized by … to pyruvate

A

enolase

pyruvate kinase

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48
Q

MOA of spironolactone and eplerenone?

A

aldosterone receptor antagonists, inhibit the effects of aldosterone and reduce secretion of K+ and H+ by the collecting tubule

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49
Q

What is the mechanism of glucose being transported into cells?

What is unique about them?

A

facilitated diffusion

move high concentration to low concentration with the help of transmembrane glucose transporter proteins (GLUT)

carrier proteins are stereoselective and have preference for D-glucose

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50
Q

Where does lymph drainage go from the testes, glans penis, scrotum, and cutaneous posterior calf?

A

testes - directly to para-aortic (retroperitoneal) LN

glans penis and cutaneous portion of posterior calf - deep inguinal LN

scrotum - superficial inguinal nodes

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51
Q

What drugs increase the frequency of chloride channels opening?

What drugs increase the duration of chloride channels opening?

A

increased frequency - benzodiazepines

increased duration - barbituates

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52
Q

What are the MCC of metabolic alkalosis?

How does each of these causes occur?

A
  1. vomiting or nasogastric suctioning
    • loss of H+ and Cl- ions in gastric secretions causes a net gain of alkali
    • loss of Cl- also impaire HCO3- excretion
    • present with hypotension and low urine Cl-
    • saline responsive
  2. thiazide or loop diuretic use
    • block absorption of Na+ and Cl- ions at the DCT and LOH, respectively
    • distal delivery NaCl increases while the volume depletion stimulates aldosterone
    • increase Na+ reabsorption at the expense of K+ and H+ urinary loss
    • present with high urine Cl- when diuretic use is ongoing, and low urine Cl- after it is stopped
    • saline responsive
  3. mineralocorticoid excess state
    • hyperaldosteronism (Conn Syndrome) or primary hypercortisolism (Cushing Syndrome)
    • increases Na+ reabsorption and urinary K+ and H+ losses, leading to a relative increase in serum HCO3-
    • present with HTN and high urine Cl- due to expanded ECF vol causing pressure natriuresis
    • saline unresponsive
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53
Q

blowing, holosystolic murmur heard best over teh cardiac apex with radiation to the axilla

A

mitral regurg

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54
Q

engorged alveolar capillaries with pink, acellular material within the alveoli is characteristic of…

this is consistent with…

A

increased pulmonary venous pressure amd transudation of fluid plasma across the alveolar-capillary membrane

acute pulmonary edema caused by increased alveolar capillary hydrostatic pressure from L-sided heart failure

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55
Q

What is happening in third degree AV block?

A

conduction between the SA node and AV node is impaired, so AV node has taken over, complete dissociation between the atria and ventricle contraction

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56
Q

CFTR gene mutation with deltaF508 causes what?

A

deletion causes abnormal protein folding and failure of glycosylation

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57
Q

acute morbidity of acute rheumatic fever is likely due to

A

pancarditis

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58
Q
A
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59
Q

DNA binding proteins include what?

A
  • transcription factors
    • myc, CREB
  • steroid receptors
    • cortisol, aldosterone, progesterone
  • thyroid hormone receptor
  • fat soluble vitamin receptors
    • vit D, retinoic acid
  • DNA transcription and replication proteins
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60
Q

How does the Hep B vaccine work?

A
  • recombinant HBsAg to generate protective immunity against the virus
  • HBsAg is collection of envelope glycoproteins found on the surface of HBV
    • they mediate attachment of virus to hepatocytes and subsequent viral entry
  • pts who adequately respond generate anti-HBs antibodies
    • bind to circulating viral particles and prevent attachment to and penetration of hepatocytes
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61
Q

How can noninfectious viruses become infectious?

A

tissue tropism of viruses is primarily mediated by viral surface glycoproteins that bind to specific host cell receptors

mutations to viral surface glycoproteins can alter tissue tropism

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62
Q

What is hemagglutinin?

A

viral surface glycoprotein, binds the sialic acid receptor on human respiratory epithelial cells

antigenic changes to this can alter the tissue tropism of the virus and allow it to infect more species/humans

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63
Q

histology and symptoms of Neimann-Pick disease

A
  • cells that appear enlarged, foamy, and vacuolated on EM
    • lipid laden foam cells accumulate in liver and spleen and CNS
  • hepatosplenomegaly, hypotonia, and neurodegeneration
  • period of normal development, then infants fail to attain new skills and lose previously acquired milestones
  • retinal accumulation leads to cherry-red macular spot
  • death by 3 yo
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64
Q

What elements are required for PCR?

A
  1. source DNA template that includes target region to be amplified along with flanking sequences adjacent to the target region
  2. oligonucleotide sequence of these flanking regions must be known in order to make the primers necessary to start PCR
  3. thermostable DNA polymerase used to replicate the DNA template from a pool of supplied deoxynucleotide triphosphates using 3 steps:
    1. denaturing
    2. annealing
    3. elongation
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65
Q

Most of the K+ filtered by the glomeruli is reabsorbed in the…

the late distal and cortical collecting tubules are the primary sites for ….

K+ depletion stimulates…. to reabsorb extra K+

….. secrete K+ under conditions of normal or increased K+ load

A

PCT and LOH

regulation of K+ in the urine

alpha-intercalated cells

principal cells

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66
Q

drug associated with violent behavior, dissociation, hallucinations, amnesia, nystagmus, and ataxia

A

PCP - phencyclidine

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67
Q

PCP MOA

A

NMDA gluatamate receptor antagonist and monoamine reuptake inhibitor

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68
Q

markedly elevated blood pressure, HA/vomiting suggesting increased ICP, in conjunction with bilateral abdominal bruits would suggest…

A

renovascular hypertension from bilateral renal artery stenosis (RAS)

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69
Q

What hormones change in response to increased renal artery stenosis and what happens to K+?

A

decreased renal artery perfusion activates RAS

  • increase renin
  • increase AT II
  • increase aldosterone
    • increases renal Na+ reabsorption and K+ and H+ excretion
  • hypokalemia and metabolic alkalosis
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70
Q

Tx for neuroleptic malignant syndrome and MOA

A

discontinue cuasative agent and supportive care

dantrolene can be used - antagonizes ryanodine receptors and inhibits calcium release from the SR

bromocriptine, a dopamine agonist has also shown clinical benefit

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71
Q

What is the MC CNS tumor in I/C pts?

how does it appear microscopically?

A

primary CNS lymphoma

dense, cellular aggregates of uniform, atypical lymphoid cells

most arise from B-cells

DLBCL is MC subtype

commonly positive for CD20 and CD79a

universally associated with EBV

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72
Q

Asian kid with fever for past 5 days; more irritable than usual and had 2 or 3 episodes of vomiting

PE: bilateral conjunctival injection with no exudates, tongue bright red and cracked lips, nonpitting edema on hands and feet

dx?

at risk for developing?

A

Kawasaki disease

risk cornary artery aneurysm

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73
Q

during wound healing, excessive matrix metalloproteinase activity and myelofibroblast accumulation int he wound margins can result in…

A

contractures

contractures produce deformities of the wound and surrounding tissues, most often on palms, soles, anterior thorax, or at serious burn sites

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74
Q

a poorly soluble gas will have what kind of blood/gas coeffecient?

A

poorly soluble gas has decreased blood/gas coefficient

blood saturates quickly, leading to a fast rise in partial pressure

increased pressure speeds brain saturation, decreasing onset time

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75
Q

….. soluble anesthetics dissolve easily in the blood, and thus …. amounts must be absorbed before the blood becomes saturated

A

highly

larger

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76
Q

blood solubility of an anesthetic is indicated by its…

A

blood/gas coefficient

anesthetics with higher blood solubility have larger blood/gas coefficients

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77
Q

What is an example of a poorly soluble gas and a highly soluble gas?

A
  • poorly soluble gas - Nitrous oxide
    • small amount needed to saturate the blood
    • rapid rise in partial pressure in the blood
    • rapid equilibration with the brain
    • rapid onset of action
  • highly soluble gas - halothane
    • large amount needed to saturate the blood
    • slow rise in partial pressure in blood
    • slow equilibration with the brain
    • slow onset of action
78
Q

colonoscopy showing flask shaped ulcers

A

entamoeba histolytica

79
Q

younger pt with abdominal pain, heme-positive stool, and noncaseating granulomas on microscopy

dx?

how do you describe these noncaseating granulomas?

A

Crohn disease

accumulation of epithelioid macrophages that frequently form multinucleated giant cells without central necrosis, surrounded by a cuff of lymphocytes

80
Q

What does the obturator nerve innervate?

A

obturator externus, then divides into anterior and posterior branches that supply the rest of the thigh adductor muscles (adductor longus, brevis, magnus)

anterior division of the nerve gives off a terminal cutaneous branch that provides sensation over the distal medial thigh

81
Q

contact dermatitis, granulomatous inflammation, and reactive skin testing are all what types of hypersensitivity reactions?

A

type IV HS rxn (T cell mediated) delayed type hypersensitivity

82
Q

ANP and BNP are broken down and inactivated by the …

A

metalloprotease neprilysin

83
Q

A neprilysin inhibitor like sacubitril will…

A

enhance activity of ANP and BNP

84
Q

adrenal crisis is characterized by…

A

severe hypotension, abdominal pain, vomiting, weakness, and fever

85
Q

AR disorder with bilateral sensorineural hearing loss and congenital long QT syndrome, predisposing to sudden cardiac death

dx?

why does this happen?

A

Jervell and Lange-Nielsen syndrome

occurs secondary to mutations in genes (eg KCNQ1, KCNE1) that encode the alpha and beta subunits of voltage-gated potassium channels

86
Q

AD condition that can be associated with mutations in cardiac sodium or L-type calcium channels, leading to characteristic EKG changes and an increased risk of ventricular tachyarrhythmias and SCD

dx?

what are the EKG changes?

A

Brugada syndrome

pseudo RBBB, ST segment elevation in V1-V3

87
Q

what are treatments for hepatic encephalopathy?

A

lactulose (increase conversion of amonia to ammonium) and rifaximin (decreases intraluminal ammonia production)

88
Q

What are common triggers for hepatic encephalopathy?

A

GI bleeding can precipitate HE as hemoglobin breakdown leads to increased nitrogen products in the gut

excess dietary protein intake

infection

sedatives

metabolic derangements (eg hypokalemia)

89
Q

How do you dx cholecystitis?

A

dx made by identifying signs of GB inflammation on US

if inconclusive, nuclear medicine hepatobiliary scanning can be used to assess cystic duct patentcy

90
Q

digital clubbing, a thickening of the distal phalanges associated with…

what pt dx would you see?

A

a number of chronic diseases causing hypoxia

large cell lung cancer, tuberculosis, cystic fibrosis, and suppurative lung diseases like empyema, bronchiectasis, and chronic lung abscesses

91
Q

chest XR in acute decompensated heart failure shows

A

prominent pulmonary vessels, patchy bilateral airspace opacification, and blunting of the costophrenic angles due to pleural effusions

92
Q

Why do pregnant women get GERD?

A

elevated levels of progesterone and estrogen cause relaxation of the smooth muscle of the lower esophageal sphincter

later in prego, it can be from the gravid uterus pressing up on the stomach leading to an altered LES angle or increased gastric pressure

93
Q

alkaptonuria is a relatively benign childhood disorder marked by what in adult life?

what causes this disorder?

A

severe arthritis

AR disorder caused by deficiency of homogentisic acid dioxygenase, which normally metabolizes homogentisic acid into maleylacetoacetate

94
Q

accumulated homogentisic acid like in alkaptonuria, causes

A

pigment deposits in CT throughout the body

during adulthood, these black-blue deposits become apparent in the sclerae and ear cartilage; deposits also occur in the large joints and spine, causing ankylosis, motion restriction, an significant pain

95
Q

In response to LV pressure overload, there will be …. of genes encoding for contractile proteins of the cardiac sarcomere, including….

A

upregulation

beta-myosin heavy chain

96
Q

What kind of mutation causes Hemoglobin C?

A

missense mutation that results in a glutamate residue being substituted by lysine in the beta globin chain

97
Q

Why does isoniazid cause neuropathy?

A

is chemically similar to B6/pyridoxine; bc of the similarity, isoniazid can compete with vit B6 in the synthesis of mutliple neurotransmitters (including GABA), resulting in defective end products

98
Q

What is the major trophic hormone of the zona fasciculata and reticularis? whereas the zona glomerulosa is regulated by…

A

ACTH

angiotensin II

99
Q

What is your concern if you are intubating a pt with RA?

A

long-standing RA frequently involves the cervical spine and causes joint destruction with vertebral malalignment (subluxation); C1-C2 joint is most often involved

endotracheal intubation can acutely worsen the subluxation and cause compression of the spinal cord and/or vertebral arteries

100
Q

What can happen with anterior dislocation of the head of the humerus?

A
  1. flattening of the deltoid
  2. protrusion of the acromion
  3. anterior axillary fullness
  4. axillary nerve is nerve MC injured
    • innervates the deltoid and teres minor
    • gives sensation to skin overlying lateral shoulder
101
Q

How can tumor cells gain resistance to chemo?

A

MDR1 gene - prototype product of this gene is P-glycoprotein, a transmembrane protein that functions as an ATP-dependent efflux pump

has a broad specificity for hydrophobic compounds; can both reduce the influx of drugs into the cytosol and can icnrease efflux from the cytosol, thereby preventing the action of chemo agents

102
Q

What are common triggers for erythema multiforme and why does it happen?

A

acute, inflammatory skin disorder usually develops during an ongoing infection; triggered by HSV or resp. inf like mycoplasma pna

caused by the deposition of infectious antigens in keratinocytes, leading to a strong cell-mediated (eg cytotoxic T cell) immune response

103
Q

What is the first line treatment for essential tremor?

A

propanolol

non-specific beta-adrenergic antagonist

104
Q

insurance plan with low monthly premiums, low copayments and deductibles, and low total cost for the pt;

reduce utilization by confining the pt to a limited panel of providers, requiring referrals from a PCP prior to seeing specialists, and denying payment for services that do not meet established EBM

A

HMO - health maintenance organization

105
Q

What is a qualitative screening test that detects the presence of urinary cysteine?

A

sodium cyanide-nitroprusside test

106
Q

fever, decreased urine output, and renal failure within the first several weeks of a renal transplant is suspiscious for…

which can be classified as…

How is this mediated?

A

acute rejection

cellular or antibody mediated rejection

mediated by host T lymphocytes sensitization against graft (foreign) MHC antigens, and is characterized by a dense infiltrate of mononuclear cells (eg lymphocytes) affecting the renal interstitium, tubules, and arterial intima

107
Q

When does Graft v Host occur?

A

eg, s/p BMT, in which host lacks competent T lymphocytes

transplanted T lymphocytes attack host antigens that are recognized as foreign

108
Q

How can you prevent acute rejection?

A

using calcineurin inhibitors such as cyclosporine or tacrolimus

109
Q

What kind of cholesterol drug will cause hypertriglyceridemia?

A

bile acid-binding resins (cholestyramine, colestipol, colesevelam)

110
Q

How does vitamin C play a role in collagen synthesis?

A

Within the RER, specific proline and lysine residues are post-translationally hydroxylated to hydroxyproline and hydroxylysine by prolyl hydroxylase and lysyl hydroxylase

vitamin C is a required cofactor for this post-translational modification

111
Q

holosystolic murmurs are associated with…

A

tricuspid regurg, mitral regurg, and VSDs

112
Q

a holosystolic murmur that increases in intensity on inspiration most likely represents…

A

tricuspid regurg

113
Q

acne vulgaris is an inflammatory disorder of …

A

pilosebaceous follicles

114
Q

New onset odynophagia in the setting of chronic GERD should raise suspiscion for..

A

erosive esophagitis with esophageal ulcers

115
Q

What happens to the spleen with portal hypertension?

A

splenomegaly with congestive hypersplenism; venous congestion causes apparent expansion of teh red pulp of the spleen, which is composed of blood-filled sinuses and cords lined by reticuloendothelial-type cells

116
Q

what hormones/drugs can reduce portal blood flow?

A

somatostatin and octreotide inhibit the release of endogenous hormones like glucagon and VIP that would induce splanchnic vasodilation, thereby indirectly reducing portal blood flow

117
Q

What type of nephropathy is normally associtated with normal serum complement levels?

A

IgA nephropathy

118
Q

recurrent hematuria that occurs spontaneously or within 5-7 days of an upper respiratory or pharyngeal infection (synpharyngitic hematuria)

A

IgA nephropathy

119
Q

what type of cancer arises from parafollicular calcitonin-secreting C cells?

what does it look like on histology?

A

medullary thyroid cancer

nests or sheets of polygonal or spindle-shaped cells with extracellular amyloid deposits derived from calcitonin

120
Q

How do you treat drug induced parkinsonism?

A

decrease or discontinue offending agent and treat with anticholinergic like benztropine

121
Q

Where do loop diuretics work?

A

thick ascending limb of Henle’s loop

inhibit Na-K-2Cl symporter

122
Q

brown v black pigment stones v sludge

A

gallbladder hypomotility results in excessive dehydration of bile; promotes biliary sludge - precursor to stones

brown stones are a/w biliary tract infections (microbes producing beta-glucruonidases)

black stones occur with chronic hemolytic anemias (SCD) and increased enterohepatic cycling of bilirubin

123
Q

needle shaped intravascular cholesterol clefts, a characteristic finding in atheroembolic disease is likely to develop

A

acute kidney injury due to partial or complete occlusion of the arcuate or interlobular arteries

other organ systems commonly involved include skin, GI, and CNS

124
Q

What do thiazide diuretics do to different substances?

A
  • raise levels of
    • calcium
    • uric acid
    • glucose
    • cholesterol
    • triglyceride levels
  • lower serum levels of
    • sodium
    • potassium
    • magnesium
125
Q

What disease state comes with hypertriglyceridemia and what is the best method of treatment for this?

A

severe hypertriglyceridemia, pancreatic lipases can cause toxic levels of FFAs to be released within the pancreatic tissue, leading to acute pancreatitis

fibrates (eg fenofibrate) are the most effective tx

126
Q

What part of the nephron is impermeable to water?

A

the ascending limb of the loop of Henle is impermeable to water regardless of serum vasopressin levels

127
Q

absence of CD18 antigens

dx?

why is CD18 necessary?

A

Leukocyte adhesion deficiency (LAD)

necessary for the formation of integrins, which are essential for leukocyte adhesion to endothelial surfaces and migration to peripheral tissues in response to infection or inflammation

128
Q

LAD related infections are notable for…

A
  • lack of purulence due to absence of leukocytes in peripheral tissues
  • impaired wound healing, including late separation (>21 days) of the umbilical cord
  • persistent leukocytosis is common finding due to leukocytes not being able to migrate out of blood vessels
129
Q

If 3 leads are used in a biventricular pacemaker, where are the leads placed within the heart?

A
  • first 2 are placed in the RA and RV
    • easy to place, need to traverse the L subclavian vein and SVC
  • third lead is used to pace the LV
    • more difficult to position, passes the L ventricular pacing lead from the RA into the coronary sinus, which resides in the atrioventricular goove on the posterior aspect of the heart
130
Q

intraoperative finding of a green inspissated mass in the distal ileum points to the dx of…

A

meconium ileus

131
Q

what would cause a decrease in airflow resistance, leading to supernormal expiratory flow rate?

A

ILD progressing to pulmonary fibrosis with thickening and stiffening of the pulmonary interstitium.

this causes increased lung elastic recoil, as well as airway widening due to increased outward pulling (radial traction) by the surrounding fibrotic tissue

132
Q

Where does Fe absorption occur?

A

predominantly in doudenum and proximal jejunum

133
Q

Where is vitamin C absorbed?

Where is pyridoxine absorbed?

A

distal small bowel through an active transport process

jejunum and ileum by passive diffusion

134
Q

How are biotin and pantothenic acid adsorbed?

A

in small and large intestine via the Na-dependent multivitamin transporter; deficiency of either of these vitamins is rare

135
Q

disease of young children that results in isolated idiopathic osteonecrosis of the hip

A

Legg-Calves-Perthes disease

136
Q

What gene mutation is a/w McCune-Albright syndrome?

A

mosiac somatic mutation during embryogenesis in the GNAS gene encoding the stimulatory alpha subunit of G protein

mutation causes constitutive activation of the Gprotein/cAMP/adenylate cyclase signaling cascade

137
Q

What are the abnormal symptoms associated with Legionella pneumonia?

A
  • contaminated water source
  • high fever
  • relative bradycardia
  • neuro ssx (HA and confusion)
  • GI ssx
138
Q

What is the MC lab abnormality a/w Legionella?

A

hyponatremia

may be related to inappropriate ADH secretion and/or renal tubulointerstitial disease

139
Q

Pt presents with peripheral vision loss causing ‘near miss’ car accidents from both the L and R; all other testing is normal on exam

dx?

what would be other ssx commonly missed?

A

bitemporal hemianopsia

consider pituitary tumor

prolactinomas can cause galactorrhea and amenorrhea in women while in males they present with hypogonadism

140
Q

consider what when a pt under the age of 50 presents with hypercoagulability who present with thromboses in the absence of any obvious explanations

A

inherited causes

Factor V Leiden mutation and mutations in the prothrombin gene are the MC inherited causes of hypercoagulability

141
Q

pts plasma is resistant to the normally antithrombotic effects of activated protein C

dx?

A

mutation in Factor V gene, which renders factor Va resistant to inactivation by activated protein C

142
Q

What is the MCC of aPTT prolongation?

A

Lupus anticoagulants

(seen in antiphospholipid antibody syndrome)

143
Q

cells that are large with overlapping nuclei containing finely dispersed chromatin, giving them an empty or ground-glass appearance; numerous intranuclear inclusions and grooves can be seen; psammoma bodies can also be present

A

papillary carcinoma

144
Q

partial opioid receptor agonist that binds with high affinity but has low intrinsic activity

in pts on long-term opioid tx, what can happen if they take this drug?

A

buprenorphine

displaces other opioids and precipitates withdrawal

145
Q

….. uses CCR5 for viral entry and is considered ….. because CCR5 is expressed in high concentrations on both …. and lymphocytes

…. is the predominant HIV type

A

R5 virus

macrophage-tropic

macrophages

R5

146
Q

….. uses CXCR4 for viral entry and is considered ….. because CxCR4 is expressed primarily on T lymphocytes but only …..

A

X4 virus

T lymphotropic

minimally on macrophages

147
Q

HIV tropism is determined by a gene sequence in the variable (V3) region of the …

which encodes for the HIV surface ….

what does that do?

A

env gene

glycoprotein 120 - mediates viral attachment to the CD4 receptor and chemokine coreceptor

148
Q

where do the majority of anal fissures occur?

why there?

A

posterior midline of the anal verge

likely due to the relatively poor perfusion of the posterior anal canal, which makes its mucosa sensitive to trauma and slows healing times

149
Q

acute ischemic stroke affecting the angular gyrus of the dominant parietal lobe, a brain region supplied by the middle cerebral artery

dx?

what are presenting ssx?

A

Gerstmann syndrome

agraphia, acalculia, finger agnosia, L-R disorientation

can also be a/w alexia and aphasia

150
Q

referred pain to the shoulder due to peritoneal irritation is called

A

Kehr sign

151
Q

Niacin can be synthesized endogenously by…

This vitamin is an essential component of what?

A

tryptophan

NAD and NADP

152
Q

What are these precursors for?

arginine

carotene

cholesterol

orotic acid

phenylalanine

A
  • arginine
    • nitric oxide, urea, ornithine, and agmatine
    • also needed for formation of creatine
  • carotene
    • Vitamin A
  • cholesterol
    • steroid hormones
  • orotic acid
    • pyrimidine
  • phenylalanine
    • tyrosine, needed for catecholamines
153
Q

What happens to PTH, active vitamin D, and urinary calcium levels in multiple myeloma?

A

low PTH and active vit D

elevated urinary calcium

154
Q

young obese women with daily headache, bilaterally symmetric papilledema, and transient visual disturbances related to impaired cerebral venous outflow and elevated ICP

A

idiopathic intracranial hypertension (pseudotumor cerebri)

155
Q

How does increased ICP affect the optic nerves?

A

increased ICP compresses the optic nerves, resulting in impaired axoplasmic flow and optic disc edema

156
Q

What drugs would imitate physiologic insulin release?

A

combo long acting and rapid acting insulin

glargine - replicate basal insulin

lispro - given with meals to control postprandial glucose elevations

157
Q

surface marker characteristically expressed on monocytes and macrophages, serves as a receptor for LPS (binding of LPS to this receptor results in activation of macrophage)

A

CD14

158
Q

Rhabdomyolysis labs

A

elevated CK, and myoglobinuria (positive urine dipstick for blood without RBCs on microscopy)

159
Q

Warfarin induced skin necrosis occurs how?

A

Warfarin inhibits proteins C and S (natural anticoagulants), which can lead to skin necrosis, particularly in patients with protein C or S deficiency

160
Q

Where does colchicine inhibit part of the arachidonic acid pathway?

A

reduces formation of leukotriene B4/ leukocyte attraction

161
Q

risk factors for diverticulosis include

A

diet high in red meat and fat and low in fiber, as well as obesity, physical inactivity, and smoking

162
Q

amorphous extracellular matrix with scattered stellate or globular myxoma cells within abundant mucopolysaccharide ground substance would be seen in what type of tumor?

A

myxoma, most common primary cardiac neoplasm

163
Q

physical exam of a pt with an atrial myxoma would often have

A

mid-diastolic murmur (tumor plop) that results from the motion of the tumor mass obstructing the mitral valve orifice

164
Q

A left shift of the oxygen-hemoglobin dissociation curve will cause what?

A

affinity of hemoglobin for oxygen is increased - this will reduce the ability of hemoglobin to release oxygen within the peripheral tissues; low O2 levels stimulate compensatory erythrocytosis

pts are typically asymptomatic at that point

165
Q

What are the disease states that are results of mutations that can cuase the production of hemoglobin with high oxygen affinity?

A

hemoglobins Chesapeake and Kempsey

166
Q

age related change compensating for myopia (increased eye axial length, image focused in front of retina), allowing vision to improve

A

presbyopia - inability to focus on near objects - progressive denaturation of lens proteins and changes in lens curvature cause the lens to become less elastic and lose its accomodating power (image will focus behind the retina)

167
Q

causes of restrictive cardiomyopathy

A

idiopathic or caused by infiltrative diseases (amyloidosis, sarcoidosis, hemochromatosis), radiation fibrosis, or endomyocardial fibrosis

168
Q

endomyocardial biopsy typically revealing cross-striations of normal myocardial cells with other areas of myocardium infiltrated by an amorphous and acellular pink material

A

senile systemic amyloidosis

169
Q

What is the best indicator for severity of mitral regurg?

A

S3

the absence of S3 can exclude severe chronic MR

pts with severe MR develop left-sided volume overload with an S3 gallop due to the large volume of regurgitant flow reentering the ventricle during mid-diastole

170
Q

What things do you need for production of cholesterol gallstones?

A

increased cholesterol

decreased bile acids

decreased phosphatidylcholine

171
Q

What drugs have the highest likelihood of causing drug-induced lupus erythematosus?

A

procainamide and hydralazine

172
Q

anemia in lead poisoning is due to…

A

inhibition of ferrochelatase and delta-aminolevulinic acid (ALA) dehydratase in the heme biosynthesis pathway

because protoporphyrin IX cannot combine with Fe2+ to form heme due to ferrochelatase inhibition, it instead incorporates a zinc ion, leading to elevated zinc protoporphyrin levels

in addition, ALA levels are increased

173
Q

Why does AKI occur in rhabdomyolysis?

What appears in the urine?

A

due to myoglobin degradation and heme pigment release; heme pigment causes ATN through direct cytotoxicity and renal vasoconstriction (ie ischemia)

injured tubular epithelial cells, with their deeply pigmented, randular contents, slough off into the tubular lumen, forming granular muddy brown casts

heme pigment in myoglobin cross-reacts with the urine dipstick reagent that detects hemoglobin, leading to a false-positive result for blood in the urine; however, micro shows no RBCs

174
Q

prophylaxis for HIV pt from MAC

A

weekly azithromycin

recommended for HIV pts with CD4 ct less than 50

175
Q

physical findings of azoospermia, small/firm testes, absent secondary male characteristics (including deep voice, beard, and male-pattern pubic hair), and tall stature; gynecomastia is also common

dx?

what does gynecomastia cause an increased risk for?

A

primary hypogonadism

increased risk of malignant transformation

176
Q

What are the hormone levels in Klinefelter syndrome?

A

atrophied, hyalinized seminiferous tubules (resulting in low inhibin levels) and damged leydig cells (resulting in low testosterone); lack of FB inhibition results in excess gonadotropins (increased FSH and LH), which in turn will increase estrogen levels

177
Q

intense lymphocytic infiltrate, often with germinal centers; residual follicles may be surrounded by Hurthle cells (large oxyphilic cells filled with granular cytoplasm

this is the histology seen with what disease?

A

chronic lymphocytic (hashimoto) thyroiditis

178
Q

high levels of dietary alfatoxin exposure is associated with what?

A

G:C to T:A transversion in codon 249 of the p53 gene, which greatly increases risk of hepatocellular carcinoma

179
Q

actions of the rotator cuff muscles

A

infraspinatus - external ro

supraspinatus -abduction

teres minor - adduction and external ro

subscapularis - adduction and internal ro

180
Q

What happens to PaCO2 in a panic attack?

A

hyperventilation results in decreased PaCO2

hypocapnia can cause decreased cerebral perfusion with neuro sequelae

181
Q

Drug to give pt with post-surgery urinary retention?

What should you not give?

A

bethanechol - muscarinic agonist to contract detrusor muscle

oxybutynin - antimuscarinic agent used for urge incontinence

182
Q

duration of action of common benzos

A
  • short
    • triazolam, midazolam
  • intermediate
    • oxazepam, alprazolam, lorazepam, clonazepam
  • long
    • diazepam, chlordiazepoxide, flurazepam
183
Q

assuming a normal rate of metabolic CO2 production, hypocapnia implies

A

alveolar hyperventilation

184
Q

First line tx for psoriasis plaques

A

topical corticosteroids and vitamin D analogs (calcipotriene, calcitriol)

185
Q

How do you identify PCP pna?

A

cannot be cultured, so dx requires ID in resp. secretions; methanamine silver stain is frequently used to identify the cell wall - crescent, crushed ping pong ball, or circular ring around clear center

186
Q

histo of small intestine mucosa contain enlarged, foamy macrophages packed with both rod-shaped bacilli and PAS positive, diastase-resistant granules (which consist of lysosomes and partially digested bacteria)

A

Tropheryma whippelii

187
Q

cardiovascular and renal presentations of SLE

A
  • CV - accelerated atherosclerosis, small-vessel necrotizing vaculitis, pericarditis, and Libman-Sacks endocarditis (small sterile vegetations on both sides of the valve)
  • renal - diffuse proliferative glomerulonephritis (diffuse thickening of the glomerular capillary walls with “wire loop” structures on light microscopy
188
Q

fever, maculopapular rash, and acute renal failure occuring within a few weeks of starting a beta-lactam abx are highly suggestive of…

A

drug-induced acute interstitial nephritis

189
Q

Acute interstitial nephritis is mediated by what? what does this involve?

A

mediated either by IgE or cell-mediated (IV HS rxn)

invovles renal interstitium, causing interstitial edema and leukocyte infiltration, granuloma formation can be observed

190
Q

How are GFR and Cr related?

A

when GFR is normal, relatively large decreases in GFR result in only small increases in serum Cr.

when GFR is significantly decreased, small decrements in GFR produce relatively large changes in serum concentration

—- every time GFR halves, serum Cr doubles

Board questions (24 decks)

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