Uworld part 3

Question 1

The physiological reason behind constipation during pregnancy?

Answer 1

Increased Progesterone during pregnancy causes decreased Colonic Smooth Muscle Activity.

Question 2

Gingivostomatitis vs Herpes Labialis

Answer 2

Gingivostomatitis- Primary HSV infection.
Fever, cervical lymphadenopathy, painful oral ulcers on gingiva, lips and tongue. Swollen gums.

Herpes Labialis- HSV Reactivation—-. causes mild symptoms, ulcers on on lips and unilateral

Question 3

Which hemorrhage do neonates get if vacuum-assisted delivery has caused extracranial head injury?

Answer 3

Subgaleal Hemorrhage due to damage of emissary veins.

Question 4

Subgaleal Hemorrhage presents as?

Answer 4

Fluctuant scalp swelling that extends beyond the suture lines and potentially to the nape of neck.

Question 5

Which layers make cephalotoma and Subgaleal hemorrhage?

Answer 5

Cephalotoma is between skull and periosteum—-> Will present as a small swelling because periosteum is fixed onto skull on suture lines.
(The name ends with toma like a hematoma—> smoll)

Subgaleal Hemorrhage is in between periosteum and galeal aponeurosis.

Question 6

Hemisection of the spinal cord will produce what symptoms?

Answer 6

1) Anterior horn (lower motor neuron) injury produces ipsilateral paralysis at the level of the lesion.
2) Lateral corticospinal tract (upper motor neuron) injury results in ipsilateral paralysis below the level of the lesion.
3) Dorsal column (gracile and cuneate fasciculi) involvement causes ipsilateral loss of vibration, proprioception, and light touch (ie, 2-point discrimination) sensation below the level of the lesion.
4) Spinothalamic tract injury causes contralateral loss of pain and temperature (lateral spinothalamic) and crude touch (anterior spinothalamic) sensation 1-2 levels below the lesion.

Question 7

______________ use is appropriate in the treatment of delirium in the elderly if the patient is at risk of acute harm to self or others and behavioral interventions have failed. And which drug is appropriate for it?

Answer 7

Antipsychotics

Specifically, first generation antipsychotis like Haloperidol.

Question 8

Patient of Schizophrenia. Previous trials of haloperidol, quetiapine, and risperidone resulted in minimal improvement. Which drug should be used for treatment now?

Answer 8

Clozapine is the only medication that has consistently shown superior efficacy in treatment-resistant schizophrenia.

Question 9

HIV patient is started on an integrase inhibitor, and her viral load decreases precipitously.What is the step of viral replication is most likely to be inhibited as a result of this patient’s new treatment?

Answer 9

Production of Viral Messenger RNA.
The viral RNA after being reverse transcribed into Double stranded DNA. The viral DNA enters the nucleus and, through the actions of integrase, permanently inserts into the host cell’s chromosomes to become a provirus.In the absence of integration, the viral genome cannot be transcribed by host cellular machinery and is eventually degraded by nucleases

Question 10

Cerebral septic emboli are usually due to?

Answer 10

Cerebral septic emboli are usually due to infective endocarditis of the left-sided heart valves.

Question 11

How does acute spinal injury, such as due to vertebral sublaxation in an RA patient manifests as?

Answer 11

Acute spinal cord injury results in flaccid paralysis with decreased or absent reflexes below the level of the compression due to spinal shock; the paralysis eventually becomes spastic as spinal shock resolves over the ensuing days to weeks.

Question 12

In emphysema, the lung parenchyma has Increased/Decreased compliance.

Answer 12

Increased.

Question 13

A 48-year-old woman comes to the office due to an intermittent ear discharge over the last 2 years,
noticed decreased hearing in the right ear recently.
Otoscopy shows a small perforation in the right tympanic membrane and a pearly mass behind the membrane.
Which of the following is the most likely cause of this patient’s aural mass?

Answer 13

Squamous Cell debris.

Cholesteatomas most commonly cause painless otorrhea. They also can produce lytic enzymes and are often discovered when they erode through the auditory ossicles, causing conductive hearing loss

Question 14

Cholesteatomas may erode _______ and ____________ causing conductive hearing loss.

Answer 14

Ossicles and Mastoid air cells.

Question 15

History of alcholism. Gastric lavage fluid initially contained blood but cleared quickly. Upper endoscopy shows a linear mucosal tear at the gastroesophageal junction. The process directly responsible for causing this patient’s mucosal tear will most likely result in which acid-base disturbance?

Answer 15

Repetitive vomiting leads to metabolic alkalosis due to net loss of acidic gastric secretions.

Question 16

What will lung biopsy be like in Hypersensitivity pneumonitis?

Answer 16

lymphocytic infiltrate, poorly formed noncaseating granulomas, interstitial fibrosis (chronic only).

Question 17

What will bronchioalveolar Lavage in Hypersenstivity pneumonitis show?

Answer 17

High relative lymphocyte count on BAL.

Question 18

Which medicines precipitate acute angle closure glaucoma?

Answer 18

Acute ACG may be precipitated by topical and systemic medications that cause pupillary dilation, such as alpha-adrenergic agonists (eg, naphazoline) and drugs with strong anticholinergic effects (eg, tricyclic antidepressants, antihistamines).

Question 19

Acute Angle-Closure Glaucoma presents as?

Answer 19

rapid rise in intraocular pressure that typically causes:
severe eye pain,
conjunctival injection,
corneal edema (haziness).

Question 20

A person with Renal artery stenosis will have what signs and symptoms?

Answer 20

Refractory hypertension
Recurrent flash pulmonary edema
Abdominal bruits
Acute kidney injury after initiation of ACE inhibitor

Question 21

Histopathology of kidney with Renal artery stenosis?

Answer 21

Gross: Shrunken, atrophic kidney (Due to oxygen and nutrient deprivation-specially asked in uworld.)
Microscopic: Crowded glomeruli, tubular atrophy, interstitial fibrosis, focal inflammatory infiltrates.

Question 22

What does the following in a person’s serum indicate?

1) Presence of Anti-HAV IgM
2) Presence of Anti-HAV IgG

Answer 22

1) Presence of Anti-HAV IgM—-> Mean acute infection currently.
2) Presence of Anti-HAV IgG–> Means have had infection already, in uworld it was written as: Anicteric Viral Infection as a toddler because mostly HAV is asymtomatic and doesn’t cause jaunduce.
Persistence of Anti-IgG HAV means immune to HAV.

Question 23

To avoid excessive bleeding during the oophorectomy, the surgeon should ligate which structure?

Answer 23

Suspensory Ligament of the ovary/(also known as the infundibulopelvic ligament)

Question 24

In acute stress disorder, symptoms usually develop directly following the trauma and last from _______ to _______, after which they can resolve or develop into more chronic symptoms. When symptoms persist for more than _________, the diagnosis is changed to post-traumatic stress disorder.

Answer 24

last from 3 days to 1 month

More than 1 month/4 weeks.

Question 25

Why do patients of Diabetes Mellitus experience defective healing of ulcers/wounds?

Answer 25

In patients with diabetes mellitus, constitutively elevated blood glucose increases inflammation by stimulating the release of proinflammatory cytokines and reactive oxygen species from neutrophils.

Elevated glucose also leads to a marked decrease in IL-10 productionthat contributes to the increased susceptibility for chronic, nonhealing wounds and ulcers in patients with uncontrolled diabetes.

Question 26

Upregulation of which cytokine would most likely improve fibroblast proliferation and reepithelization in this nonhealing wound?

Answer 26

Production of IL-10 by macrophages.

Question 27

Labs of Primary Biliary Cholangitis?

Answer 27

Abnormal liver function tests due to cholestasis,
ELEVATED ALK PHOS.
Diagnosis is confirmed with demonstration of anti-mitochondrial antibodies in the serum.

Question 28

The adjustable gastric band, an inflatable silicone device that is placed around the cardiac part of the stomach. In order to encircle the stomach, the band must pass through which structure?

Answer 28

Lesser Omentum

Question 29

Which ligament contains the remnant of fetal umbilical vein?

Answer 29

Falciform Ligament, it is a derivative of the embryonic ventral mesentery and contains the round ligament, the remnant of the fetal umbilical vein.

Question 30

What are the possible causes of hypoxemia in the setting of normal A-a gradient?

Answer 30

Two major causes:

Alveolar Hypoventilation (Can be due to reduced Central respiratory drive due to overdose of sedatives, obesity syndrome, myesthenia gravis)

High Altitude (Low partial pressure of Oxygen)

Question 31

Stridor observed in a child, is due to which pathogen?

Answer 31

Croup is caused by Parainfluenza virus

Part of paramyxoviruses

Question 32

Cerebral Edema can be a consequence of rapid correction of __________?

Answer 32

Cerebral edema results from rapid correction of hypernatremia with hypotonic fluids (free water flows into brain cells). This typically occurs in patients with chronic dehydration or diabetes insipidus (antidiuretic hormone deficiency or resistance),
Also occurs in Reye’s syndrome. (NBME 16)

Question 33

Diffused myonecrosis can be caused in?

Answer 33

Refeeding syndrome due to sever hypophosphatemia leading to ATP depletion.

Question 34

Retinitis Pigmentosa. What will the fundoscopic examination show?

Answer 34

> Retinal vessel attenuation (likely due to altered metabolic demand)
Optic disc pallor (optic nerve atrophy and gliosis)
Pigment accumulation (characteristic bone-spicule pattern around vessels)

Question 35

Which drugs have to acetylated in the body?

Answer 35

Isoniazid,
Dapsone
Porcainamide
Hydralazine

Question 36

Examination shows a left shoulder droop with weakness of left arm abduction above 100 degrees. Other shoulder movements are normal, and there is no sensory loss. Which of the following muscles is most likely paralyzed in this patient?

A) Deltoid
B) Trapezius

Answer 36

A) Deltoid- WRONG. This muscle causes shoulder abduction from 30-100.Iatrogenic axillary nerve injury can occur during shoulder surgery (eg, proximal humerus fracture repair) or intramuscular injection in the deltoid.

B) Trapezius- CORRECT. Spinal accessory nerve (CN XI) is a pure motor nerve that innervates the sternocleidomastoid and trapezius, is vulnerable to penetrating trauma and iatrogenic injury (eg, cervical lymph node dissection).

Question 37

Patient who was vaccinated for Diphtheria, got diphtheria. Several days after being admitted to the hospital, he dies of myocarditis and severe heart failure. The presence of which would most likely have prevented this patient’s death?

Answer 37

Neutralizing IgG antibodies against the binding component (B subunit) of the diphtheria exotoxin.
(Uworld answer: IgG antibodies against circulating proteins)

Question 38

Following successful surgery, the patient compliments her surgeon, exclaiming that she is “a brilliant doctor who saved my life.” On the day of discharge, a nurse informs her that the surgeon is running late due to an emergency. The patient responds angrily that the surgeon is “terrible and doesn’t care about patients.” Which of the following is the most likely explanation for this patient’s behavior?

A) Acting out
B) Splitting

Answer 38

A) Acting out-(eg, if this patient reacted by tearing up her discharge paperwork or throwing her food tray at the nurse)
B) Splitting- CORRECT

Question 39

Splitting is commonly seen in _________________ and can contribute to the unstable relationships and mood instability that exemplify this disorder.

Answer 39

borderline personality disorder

Question 40

Biopsy shows large, eosinophilic squamous epithelial cells arranged in islands; cells have hyperchromatic, irregular nuclei, and scant cytoplasm. Significant keratinization is present. Which pathogen is responsible for this anal ulcer?

Answer 40

Human Pappiloma Virus 16 and 18 cause squamous cell carcinoma of the Anus.

Question 41

Which enzyme has:

> 5’ to 3’ exonuclease activity
3’ to 5’ exonuclease activity

Answer 41

> 5’ to 3’ exonuclease activity—> DNA polymerase 1, it removes RNA primers creates by RNA primase and repairs damaged DNA sequences.

> 3’ to 5’ exonuclease activity- DNA polymerase 3, has 5’ to 3’ polymerase and 3’ to 5’ exonuclease activity

Question 42

There is a small knot palpable at the left end of the scar from the surgical site, light touch of which elicits severe pain.Cutaneous sensory nerve injury and abnormal axonal regeneration are suspected. Which of the following ion channels is most likely upregulated within the affected axons?

Answer 42

If the regenerating axons cannot find their distal target, regeneration can result in formation of a disorganized mass of axonal processes, Schwann cells, vascular hyalinization, and fibrosis known as a NEUROMA.
Neuromas induce increased expression of voltage-gated sodium channels, which are important for the generation and propagation of action potentials. That is why there’s severe pain upon touching it.

Question 43

Patient of Polymyalgia Rheumatica, been on prednisone. Labs show normal serum creatinine, 25-hydroxyvitamin D, and calcium levels.DXA reveals a significant decline when compared to her bone density measured at age 65. What is most likely contributing to this patient’s bone loss?

Answer 43

Inhibition of osteoclast precursor cell replication and differentiation.
( Basically, that’s the effect of prednisone)

Question 44

Tell Glucocorticoids effects on Bone?

Answer 44

1) Inhibition of osteoclast precursor cell replication and differentiation.
2) Increase RANK and RANK-L.
3) Reduces Ca reabsorption in kidney, Ca absorption in intestines.
4) Decreases OPG and IGF-1

Question 45

Site of Radiofrequency ablation for treatment of rapid ventricular response?

Answer 45

For rapid ventricular response, AV node ablation is done. The site of catheter ablation will be endocardial surface of the right atrium, near the insertion of the septal leaflet of the tricuspid valve and the orifice of the coronary sinus/ Interatrial septum near the opening of coronary sinus.

Question 46

Bedside ultrasound shows intraperitoneal free fluid. Urine dipstick test is positive for blood. CT scan of the abdomen and pelvis is most likely to reveal which of the following injuries in this patient?

A) Bladder Dome Rupture
B) Bladder Neck Rupture

Answer 46

A) Bladder Dome Rupture- CORRECT.
B) Bladder Neck Rupture-Would lead to extraperitoneal extravasation of urine rather than intraperitoneal leakage of urine.

Question 47

Bladder injury presents with?

Answer 47

Suprapubic tenderness, Hematuria.

Question 48

What peculiar about HSV encephalitis CSF findings?

Answer 48

Cerebrospinal fluid (CSF) analysis usually reveals a HEMORRHAGIC lymphocytic pleocytosis with increased protein and normal glucose.

Question 49

An MRI of the brain reveals an abnormal signal in the bilateral temporal lobes. A drug that inhibits what would be most effective in treating this patient’s condition?

Answer 49

The treatment for HSV encephalitis is intravenous acyclovir.

Acyclovie inhibits VIRAL DNA POLYMERASE so this was the correct answer.

Question 50

During inspection of the external auditory canal, a speculum is inserted into the meatus in close contact with its posterior wall, causing the patient to suddenly become lightheaded and faint. He recovers spontaneously within a few minutes with no residual confusion. Which of the following nerves was most likely irritated during the procedure?

A) Vagus
B) Vestibulocochlear

Answer 50

A) Vagus- CORRECT. This patient has experienced vasovagal syncope after stimulation of his posterior external auditory canal by an otoscope speculum.Auricular branch of Vagus Nerve provides sensation to external auditory meatus.

B)Vestibulocochlear

Question 51

One of the most important mediators of sepsis is?

Answer 51

tumor necrosis factor-alpha (TNF-α)

Question 52

A punch biopsy from one of the areas subjected to this topical steroid therapy would most likely show what?

Answer 52

Dermal Atrophy.

Question 53

Cause of hyperpigmentation in stasis dermatitis is?

Answer 53

Hemosiderin deposition.

Question 54

Hematogenous Osteomyelitis of long bones affects which particular parts of that bone in children?

Answer 54

METAPHYSIS.

Question 55

What is the most common location of hematogenous osteomyelitis in an adult?

Answer 55

The vertebral body is the most common location for hematogenous osteomyelitis in adults. This is also the location of Pott disease, osteomyelitis of the vertebral body caused by Mycobacterium tuberculosis.

Question 56

Ewing sarcoma typically arises in _________ of the long bones, especially the femur

Answer 56

diaphysis

Question 57

Diffuse maculopapular skin rash that includes the palms and soles. They may also develop condylomata lata, which are painless, wart-like, elevated plaques, on moist areas of the skin such as the scrotum and perineum.Which disease is this?

Answer 57

Secondary Syphillis.

Question 58

Histopathologic examination of syphilitic lesions (at all stages) classically demonstrates?

Answer 58

Classically demonstrates proliferative endarteritis of small vessels with a surroundingplasma cell–rich infiltrate.

Question 59

Metaphysis of long bones, what diseases affect this part of the bones?

Answer 59

Hemtogenous Osteomyelitis in kids,
Osteochondroma,
Osteosarcoma
Epiphyseal widening and metaphyseal cupping in Rickets/Osteomalacia.

Question 60

Epiphysis of long bones, what diseases affect this part of the bones?

Answer 60

Slipped capital femoral epiphysis in obese young women.
Giant Cell tumour (Tumour cells express RANKL)
Epiphyseal Dysplasia seen in Refsum disease (AR disorder of defective alpha-oxidation)
Estrogen causes closure of epiphyseal plate during puberty.
Epiphyseal widening and metaphyseal cupping in Rickets/Osteomalacia.
Warfarin exposure during pregnancy causes stippled epiphysis in the neonate.

Question 61

Diaphysis of long bones, what diseases affect this part of the bones?

Answer 61

Ewing’s Sarcoma,
Myeloma
Osteoid Osteoma
Fibrous Cell Dysplasia

Question 62

3 year old child having abrupt onset vomiting and then watery diarrhea? Wow. That’s new. Which virus is it?

Answer 62

RotaVirus.

Question 63

RotaVirus is what?

Answer 63

Segmented, Double Stranded RNA virus,

Question 64

What will the histolopathology show in a child infected with rotavirus?

Answer 64

Blunting of the villi in duodenum and Proximal Jejenum.

Question 65

CT scan of the head reveals significant dilation of the lateral ventricles. If this condition is left uncorrected, which of the following is the most likely complication that will be seen in this patient?

A) Lower Extremity Hyporeflexia
B) Muscle Hypertonicity

Answer 65

A) Lower Extremity Hyporeflexia
B) Muscle Hypertonicity- CORRECT ———–>Hypertonicity and hyperreflexia result from upper motor neuron injury caused by stretching of the periventricular pyramidal tracts.

Question 66

CT scan of the head reveals significant dilation of the lateral ventricles. If this condition is left uncorrected, which of the following is the most likely complication that will be seen in this patient?

A) Lower Extremity Hyporeflexia
B) Muscle Hypertonicity

Answer 66

A) Lower Extremity Hyporeflexia
B) Muscle Hypertonicity- CORRECT ———–>Hypertonicity and hyperreflexia result from upper motor neuron injury caused by stretching of the periventricular pyramidal tracts.

Question 67

CT scan of the head reveals significant dilation of the lateral ventricles. If this condition is left uncorrected, which of the following is the most likely complication that will be seen in this patient?

A) Lower Extremity Hyporeflexia
B) Muscle Hypertonicity

Answer 67

A) Lower Extremity Hyporeflexia—->Lower extremity hyporeflexia would result from damage to the lower motor neurons, which can occur in poliomyelitis or spinal muscular atrophy.

B) Muscle Hypertonicity- CORRECT ———–>Hypertonicity and hyperreflexia result from upper motor neuron injury caused by stretching of the periventricular pyramidal tracts.(Same concept as NPH causing detrusor hyperactivity leading to urinary incontinence)

Question 68

Manifestation of testicular torsion?

Answer 68

Testicular torsion presents with:
Acute, severe, progressive unilateral scrotal pain.

Classic examination findings include
>scrotal edema and discoloration,
>a high-riding testicle,
>an absent cremasteric reflex (ie, absence of testicular elevation when stroking the ipsilateral thigh).

Question 69

Manifestation of epididmytis?

Answer 69

> History of Neisseria Gonorrhea/Scrotal trauma
Scrotal pain gets better upon manual elevation of the testicle.
Urinary symptoms (eg, dysuria, frequency, urgency) are typical.

Question 70

CT scan of the head reveals subarachnoid hemorrhage. Repeat imaging of the brain shows no new hemorrhage, but there is enlargement of the entire ventricular system compared to the previous CT scan. Which of the following is the most likely cause of
this patient’s neurologic deterioration in the hospital?

A) Blockage of Cerebral Aqueduct by blood products.
B) Impaired absorption of CSF.

Answer 70

A) Blockage of Cerebral Aqueduct by blood products- WRONG because this will lead to non-communicating hydrocephalus.In that hydrocephalus, enlargement of only the lateral and third ventricles is expected; the fourth ventricle is distal to the obstruction and remains normal in size. Typically occurs with intracerebral hemorrhage complicated by intraventricular bleeding.

B) Impaired absorption of CSF- CORRECT. The key statement in the vignette is ENLARGEMENT OF THE ENTIRE VENTRICULAR SYSTEM, this means the hydrocephalus is COMMUNICATING.

Question 71

While receiving the intravenous vancomycin infusion, the patient reports a burning, itching sensation. She reports no history of drug allergy but has never received these antibiotics. What is the most likely underlying cause of this patient’s current condition?

Answer 71

Direct Mast Cell activation.

Question 72

Iris Hamartoma is found in which disease?

Answer 72

NF1, hamartomas are called Lisch Nodules.

Question 73

Define Hamartoma?

Answer 73

Hamartoma (disorganized overgrowth of tissues in

their native location, eg, Peutz-Jeghers polyps)

Question 74

Cardiac rhabdomyoma (NOT MYXOMA) histology?

Answer 74

Hamartomatous growths.

Question 75

Hamartomatous polyps of colon are found in which two diseases?

Answer 75

Peutz-Jeghers syndrome and juvenile polyposis.

Question 76

Tuberous sclerosis, hemartomas are found in which 2 organs?

Answer 76

CNS and Skin.

Question 77

Peutz-Jeghers syndrome manifests as?

Answer 77

Hamartomatous GI polyps, hyperpigmented macules on mouth, feet, hands, genitalia

Question 78

Most common benign lung tumour is?

Answer 78

The most common benign lung tumor is a hamartoma (also called pulmonary chondroma).Present as incidental findings on chest x-ray, with the appearance of a well-defined coin lesion with “popcorn calcifications.”

Question 79

What is the most common location for a hamartoma, and what would be the histology?

Answer 79

LUNG. (I knoowww, weird)

Lung hamartomas often contain islands of mature hyaline cartilage (asked in uworld), fat, smooth muscle and clefts lined by respiratory epithelium.

Question 80

The drug (argatroban) used to treat this patient’s current condition has which mechanism of action?

A) Binds to thrombin active site
B) Blocks GPIIb/IIIa surface receptors
C) Blocks ADP receptors

Answer 80

A) Binds to thrombin active site- CORRECT, other direct thrombin activators are Bivalirudin, dabigatran
B) Blocks GPIIb/IIIa surface receptors- That’s APIXABAN
C) Blocks ADP receptors- Clopidogrel does this.

Question 81

What are muscles of mastication responsible for depressing the mandible?

Answer 81

Pterygoids.

Question 82

The patient is diagnosed with an anterior dislocation of the left temporomandibular joint. The jaw is most likely maintained in a dislocated position due to continued spasm of which muscle?

Answer 82

Lateral Pterygoids

Question 83

Histopathologic examination shows a diffuse infiltrate of lymphoid cells with numerous mitotic figures.Interspersed macrophages surrounded by clear spaces are also seen. The gene translocated in these lymphoid cells produces a protein that is most directly responsible for which function?

Answer 83

The answer was Transcription activation,
the histology is that of starry-sky appearance seen in Burkitt’s lymhoma. Burkitt’s lymphoma occurs when c-myc mutation occurs, and c-myc is a transcription factor.

Question 84

MRI of the head of an HIV patient, shows diffuse cerebral atrophy with no focal mass lesions or areas of demyelination. Viral proliferation in which of thecentral nervous system cells is most likely involved in this patient’s disease process?

Answer 84

Vignette explains the scenario of HIV associated dementia.
CNS infection is associated with a change in viral tropism (ie, ability to infect different cell types) to microglia andmacrophages, which allows the virus to penetrate deeper into the brain parenchyma.

Question 85

MRI of the head of an HIV patient, shows diffuse cerebral atrophy with no focal mass lesions or areas of demyelination. Viral proliferation in which of thecentral nervous system cells is most likely involved in this patient’s disease process?

Answer 85

Vignette explains the scenario of HIV associated dementia.
CNS infection is associated with a change in viral tropism (ie, ability to infect different cell types) to microglia andMACROPHAGES, which allows the virus to penetrate deeper into the brain parenchyma.

Question 86

On cardiac auscultation, a low-frequency diastolic heart sound is heard shortly after the second heart sound when the patient lies in the left lateral decubitus position. What is the pathology?

Answer 86

These are the auscultatory findings of S3.

S3 after 40years of age suggests ventricular volume overload or enlargement. It is often heard with aortic/mitral regurgitation or systolic heart failure (eg, dilated or ischemic cardiomyopathy)

Question 87

When can ventricular gallop sounds be heard best?

Answer 87

Left ventricular gallops (S3 and/or S4) are best heard with the bell of the stethoscope over the cardiac apex while the patient is in the left lateral decubitus position. Listening at end expiration makes the sound even more audible (asked in uworld specifically) by decreasing lung volume and bringing the heart closer to the chest wall.

Question 88

This patient’s severe constipation and new-onset second-degree atrioventricular (AV) block (causingsyncope) in the setting of new medication use for atrial fibrillation (AF) is likely due to

Answer 88

nondihydropyridine CCBs therapy. Diltiazem and verapamil.

Question 89

Indapamide is a ___________ used for treatment of hypertension.

Answer 89

Thiazide diuretic

Question 90

Lidocaine is occasionally used in management of symptomatic ventricular arrhythmias, usually in the setting of ____________.

Answer 90

Acute myocardial infarction

Question 91

This patient with bone pain, fatigue, anemia, kidney disease, and hypercalcemia has ____________.

Answer 91

Multiple myeloma (MM)

Question 92

A patient is treated with an infusion of a boronic acid-containing dipeptide that has a high affinity for the proteasome catalytic site. This treatment would most likely result in WHAT?

Answer 92

CELL APOPTOSIS (Specific answer in uworld) 
In MM, neoplastic B lymphocytes mature into plasma cells that typically synthesize large amounts of monoclonal immunoglobulin (Ig) or Ig fragments (eg, IgG light chains). As a result of this increased protein production, plasma cells are particularly susceptible to the effects of proteasome inhibitors such as bortezomib, a boronic acid-containing dipeptide.

Question 93

Hypercalcemia of MM (likely primarily due to tumor-induced bone resorption) is treated with??

Answer 93

hydration, corticosteroids (mild hypercalcemia), and bisphosphonates (moderate to severe hypercalcemia)

Question 94

There is a small, round punched-out lesion with an overlying thin membrane on the patient’s scalp. What is the lesion called and in which disease is it found?

Answer 94

Cutis Aplasia, found in Trisomy 13 aka Patau Syndrome.

Question 95

A 45-year-old woman comes to the clinic with a 3-month history of persistent shoulder and back pain and easy fatigability. She also has pain and stiffness in all her muscles that worsens in the morning and evening.She does not participate in any regular exercise because her pain is exacerbated with activity..
oft tissue tenderness is present at several locations bilaterally above and below the waist.Diagnosis?

Answer 95

Fibromyalgia, physical examination is normal except Multiple tender points at characteristic locations.

Question 96

Histopathology of psoriasis lesions?

Answer 96

Epidermal thickening (Acanthosis) with elongated, clubbed rete ridges,
Parakeratosis (retained nuclei in stratum corneum)

Question 97

Describe the skin rash of Dress syndrome?

Answer 97

Diffuse morbilliform skin rash that can progress to a confluent erythema with follicular accentuation.

Question 98

Biopsy of the mass reveals abnormal cells with the t(14;18) chromosomal translocation. This chromosomal change is most likely to cause which of the following abnormalities in gene expression?

Answer 98

Bcl-2 overexpression.
The classic cytogenetic abnormality in follicular lymphoma is the t(14;18) translocation, which moves the Bcl-2 (B-cell lymphoma-2) protooncogene from chromosome 18 to chromosome 14,

Question 99

Bcr-ABL hybrid formation occurs in ___________.

Answer 99

CML.

Question 100

Serum levels of which of the following are most likely to be elevated in an acutely ill patient?

A) Procalcitonin
B)Transferrin

Answer 100

A) Procalcitonin- CORRECT
B)Transferrin- This is a negative acute phase reactant. Transferrin and transthyretin (Prealbumin) are REDUCED in an acutely ill patient.

Question 101

A person with BPH, will show what on renal biopsy?

Answer 101

Parenchymal Pressure Atrophy due to bladder outlet obstruction.
Increased hydrostatic force is needed to overcome the obstruction, causing hypertrophy of the bladder wall musculature and dilation of the ureters, renal pelvis, and calyces (hydronephrosis). If left untreated, urinary reflux can lead to significant pressure-induced parenchymal atrophy with scarring and eventual chronic kidney disease.

Question 102

A pregnant woman’s BPis 115/75 mm Hg when sitting, 110/70 mm Hg when standing, and 80/60 mm Hg when supine. Physical examination shows a uterus consistent in size with 36 weeks gestation. What isthe most likely explanation for this patient’s hypotension while supine?

Answer 102

Supine hypotension syndrome (or aortocaval compression syndrome)
It occurs predominantly in women > 20 weeks gestation, and is due to the gravid uterus compressing and obstructing the inferior vena cava. This reduces the venous return (preload), which subsequently lowers the cardiac output leading to hypotension.

Question 103

Spilling of Hydatid cyst contents during surgery cause _______________.

Answer 103

ANAPHYLAXIS.

You did septic shock and it was so wronggggg

Question 104

Classic findings include hypoxemia, tachypnea, and retractions with diffuse wheezes and crackles in a 2 year old. What is the causative organism?

Answer 104

RSV causing Broncholitis!!!!

Question 105

How does a pregnant woman who gets infected by Parvovirus B19, affect her intrauterine infant?

Answer 105

Fetal infection with parvovirus can lead to interruption of erythropoiesis, causing profound anemia and congestive heart failure. Fetal congestive heart failure can cause pleural effusions, pericardial effusions, and ascites.

Question 106

The basal ganglia are supplied by the _____________ which are deep, small vessel branches off the middle cerebral arteries.

Answer 106

lenticulostriate arteries

Question 107

How will a putaminal hemorrhage present as?

(Qid12007

Answer 107

Because of their location, putaminal hemorrhages almost always affect the adjacent internal capsule, leading to dysarthria, contralateral hemiparesis, and contralateral hemisensory loss due to disruption of the corticobulbar, corticospinal, and somatosensory fibers.

Question 108

Which immune cells are responsive for the skin induration seen in a positive tubercilin test?

Answer 108

CD4+ T cells and Macrophages

You did CD8+ which is wrongggg

Question 109

During the data analysis phase, the researchers decide to set alpha at 0.01 rather than 0.05. Which of the following is the most likely result of this change?

A) Any significant findings will be reported with greater confidence.
B) There will be a higher probability of finding statistically significant results.

Answer 109

A) Any significant findings will be reported with greater confidence.——-> CORRECT.

Question 110

Which of the following anticoagulants is most effective in inactivating thrombin?

A) Enoxaparin
B) Fondaparinux
C) Unfractionated Heparin

Answer 110

A) Enoxaparin
B) Fondaparinux
C) Unfractionated Heparin- CORRECT.

Only unfractionated heparin (not LMWH) has a pentasaccharide chain long enough (>18 saccharide units) to bind to both antithrombin and thrombin.As a result, unfractionated heparin has equal activity against Factor Xa and thrombin, while LMWH has greater activity against Factor Xa than thrombin.

Question 111

Compared to a healthy infant, thispatient of VSD, likely has which of the following intracardiac pressure changes?

RA
RV
LA
​​​​​​​LV

Answer 111

RA- Unchanged
RV- Increased
LA- Increased
​​​​​​​LV- Increased

Question 112

A 42-year-old previously healthy woman comes to the office due to fever and sore throat.
Physical examination shows tonsillar exudate and a nontender cervical lymph node that measures 3.5 cm in diameter. She recovers from the infection, but the lymph node doesn’t disappear. The size of the LN fluctuates. Which neoplasm is it?

Answer 112

Follicular Lymphoma

Question 113

A patient in an acute manic attack is hopitalized and started on being treated. On the 5th day of hospitalization, he has fever and inability to get up. What is your diagnosis?

Answer 113

His subsequent development of fever, confusion, abnormal vital signs, and difficulty moving 5 days later is consistent with neuroleptic malignant syndrome (NMS), an uncommon but life-threatening complication of dopamine antagonists.

NMS is characterized by hyperthermia, severe muscular rigidity, altered mental status, and autonomic dysfunction(eg, labile blood pressure, tachycardia, diaphoresis). It most commonly occurs within the first 2 weeks of initiation of therapy but can occur anytime during treatment. NMS is thought to be primarily due to dysregulation of dopamine.

Question 114

Why is there reduced Vitamin D in chronic kidney disease?

Answer 114

Chronic kidney disease (CKD) results in impaired conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D due to the following factors:

FGF23 levels increase early in CKD, causing direct inhibition of 1-alpha-hydroxylase

Reduced glomerular filtration limits the delivery of 25-hydroxyvitamin D to proximal tubule cells

Reduced functional renal mass limits production of 1-alpha-hydroxylase

Question 115

MOA of the drug used for treatment of Rocky Mountain fever?

Answer 115

First-line therapy is doxycycline, which inhibits protein synthesis by binding the 30s bacterial ribosomal subunit.

Question 116

A pregnant woman who had been shifted to Propylthiouracil, now comes for a follow up checkup at 16 weeks of gestation. She is being shifted to Methimazole now. Why?

Answer 116

Methimazole is preferred for most patients due the hepatotoxicity of PTU; So after first trimester of pregnancy, the patient is shifted back to Methimazole.

Question 117

Microscopic examination of the vessel walls shows diffuse inflammation of the adventitia and marked thickening of the inner layers due to proliferation of loose connective tissue; the arterial lumen is significantly narrowed. Which of the following is the most likely diagnosis?

A) Granulomatosis with polyangiitis.
B) Polyarteritis Nodosa

Answer 117

A) Granulomatosis with polyangiitis——>Granulomatosis with polyangiitis usually causes manifestations in the upper/lower airways (eg, rhinosinusitis, hemoptysis) and kidneys (eg, glomerulonephritis). The gastrointestinal tract is not typically affected. Biopsy generally reveals a leukocytoclastic vasculitis with minimal or no luminal narrowing or fibrinoid necrosis.
B) Polyarteritis Nodosa- CORRECT.

Question 118

Urgent laparotomy reveals bilateral renal infarcts and multiple segments of necrosis and perforation in the small bowel.Microscopic examination of the vessel walls shows diffuse inflammation of the adventitia and marked thickening of the inner layers due to proliferation of loose connective tissue; the arterial lumen is significantly narrowed. Which of the following is the most likely diagnosis?

A) Granulomatosis with polyangiitis.
B) Polyarteritis Nodosa

Answer 118

A) Granulomatosis with polyangiitis——>Granulomatosis with polyangiitis usually causes manifestations in the upper/lower airways (eg, rhinosinusitis, hemoptysis) and kidneys (eg, glomerulonephritis). The gastrointestinal tract is not typically affected. Biopsy generally reveals a leukocytoclastic vasculitis with minimal or no luminal narrowing or fibrinoid necrosis.
B) Polyarteritis Nodosa- CORRECT.

Question 119

How does Abruptio placenta manifest?

Answer 119

Sudden-onset vaginal bleeding
Abdominal pain
High-frequency contractions
Tender, firm uterus

Question 120

Auscultation of pulmonary fibrosis reveals?

Answer 120

Auscultation may reveal end-inspiratory crackles at the lung bases.

Question 121

Incidental findings include a left lower lobe lung nodule and foci of calcifications in the spleen. Chest imaging shows several small calcified nodules in both lungs and a calcified mediastinal lymph node, when person is a lifelong non-smoker and TST is negative. What is your diagnosis?

Answer 121

Granulomatous calcifications by Histoplasma Capsulatum
H capsulatum is able to replicate within the macrophage and spread through the draining lymphatic system and (often) into the reticuloendothelial system (eg, spleen, liver).

Question 122

Inherited defects involving the _________ signaling pathway result in disseminated mycobacterial disease in infancy or early childhood.

Answer 122

> interferon-γ

>Patients require lifelong treatment with antimycobacterial agents

Question 123

What can the vignette related to HyperIgM syndrome says regarding the exact etiology of this disease?

Answer 123

>Deficient CD40L- CD40 interaction
> Failure of Antibody class switching in B cells
>Patient has defective signaling between activated CD4+ T cells and B lymphocytes.

Concept for you:
Class switching allows B cells to modify production of immunoglobulins from one isotype to another (eg, from IgM to IgA). Normally, class switching occurs when an activated CD4+ T cell uses its CD40 ligand (CD40L) to bind to CD40 on the B cell surface.

Question 124

A 22 year old patient who was treated for Neisseria Gonorrhea and had developed antibodies against the pili, get re-infected with Neisseria Gonorrhea after having sex with a person with Neisseria Gonorrhea. Can you explain why?

Answer 124

Most likely reason for the lack of long-lasting immunity against the bacteria despite antibody formation in this patient is ANTIGENIC VARIATION of pili (At a time, only one pili gene is activated, so only 1 pilus type is activated. The patient makes anitbody against it, but then next time because of antigenic recombination and produces a new type of pili.

Question 125

MOA of Ethosuxamide?

Answer 125

Blocks thalamic T-type Ca2+ channels

Question 126

A 45 year old patient with many co-mobidities comes to you and says that he’s has ADHD. He has no ADHD and doesn’t meet the criteria for ADHD diagnosis. Why won’t you prescribe him stimulants?

A) Do not prescribe him stimulants due to the potential risks.
B) Do not prescribe him stimulants until he reports clearer symptoms of ADHD.

Answer 126

So, the trick here is that, WE WON’T PRESCRIBE HIM STIMULANTS BECAUSE THEY ARE HARMFUL FOR HIM BECAUSE OF HIS AGE AND CO-MORBIDITIES EVEN IF HE MEETS THE CRITERIA FOR ADHD.

The correct answer is: Do not prescribe him stimulants due to the potential risks.
Even, if ADHD is diagnosed, nonstimulant ADHD medications will be given as they carry fewer risks.

Question 127

A bone marrow biopsy shows macrophages with wrinkled, paperlike cytoplasm due to the accumulation of glycolipids within lysosomes. Which enzyme is deficient?

Answer 127

Gaucher’s disease—–> Deficient Glucocerebrosidase (Brain shaped candyyy for halloween)

Question 128

Enzyme replacement therapy for Gaucher’s is given via which route (Oral/IV), Enters the cell via (Endocytosis/Passive Diffusion) and the drug itself is (Steroid/protein)?

Answer 128

Almost all enzymes in the body are proteins, and proteins cannot be given orally because proteolysis occurs in the GI if they ingested. Hence, insulin, immunoglobulins and other polypeptide based drugs are given intravenously. The polypeptide drug or the lysosomal enzyme in this case will be taken up by endocytosis.

Question 129

How is a replacement enzyme such as Glucocerbrosidase endocytosed by the cell?
(Qid 18421)

Answer 129

Once in the circulation, exogenous glucocerebrosidase can enter cells by binding to mannose 6-phosphate receptors. It is then taken up by the endosomes, to lysosomes.

Question 130

S/E of Methimazole?

Answer 130

Edema, Rash, Agranulocytosis

Question 131

What should be given after a TIA?

Answer 131

Secondary prevention includes antiplatelet agents (eg, aspirin, clopidogrel) to prevent thrombus formation and statin therapy (HMG-CoA reductase inhibitor; eg, atorvastatin, rosuvastatin) to reduce atherosclerotic plaque formation.

Question 132

Boy’s urine turned black overnight. Which conversion is defective?

Answer 132

The disease is Alkaptonuria.
The deficient enzyme is HAD–> Homogentisic Acid Deoxygenase. HAD specifically converts homogentisate to Maleyl-acetoacetate.

But this enzyme affects the pathway, in which tyrosine is converted into fumarate. And fumarate then enters TCA cycle.

Question 133

Cardiac rhythm strip showing an irregularly irregular rhythm with varying R-R intervals and no discernible P waves is consistent with _______________.
Catheter ablation of ______________ is used for the treatment of symptomatic,

Answer 133

paroxysmal atrial fibrillation (AF).

Pulmonary vein trigger sites (pulmonary vein isolation)

Question 134

ECG of ____________ typically demonstrates regular R-R intervals and wide QRS complexes.

Answer 134

ventricular tachycardia

Question 135

The cavo-tricuspid isthmus is usually part of the reentry circuit in _____________.

Answer 135

Atrial flutter

Question 136

Monomorphic ventricular tachycardia most commonly originates from areas of ischemic myocardium; however, it can sometimes originate from nonischemic sites in the _____________ or _______________.

Answer 136

Papillary muscles or right ventricular outflow tract.

Question 137

The sinoatrial node is the site of origin of sinus tachycardia; ECG shows _____________.

Answer 137

regular rhythm with P waves and a rate >100/min.

Question 138

Biopsy of lesion caused by sporothrix schenki

Answer 138

Biopsy of the lesion typically reveals a granuloma consisting of histiocytes, multinucleated giant cells, and neutrophils, surrounded by plasma cells. From the site of inoculation, the fungus spreads along the lymphatics, forming subcutaneous nodules and ulcers.

Question 139

5 week old baby boy, diagnosed of CF. Gets a seizure.
A head CT scan shows a right-sided intracranial hemorrhage. Which of the following is the most likely cause of this infant’s presentation?

A) Impaired Gamma carboxylation
B) Failure of Rhodopsin Production
C) Reduced activation of intranuclear receptors

Answer 139

Cf patients are at increased risk of fat-soluble vitamins (A,D,E,K), specially a neonate who hasn’t gotten intramuscular Vitamin K supplementation on birth.

A) Impaired Gamma carboxylation- CORRECT, Vitamin K deficiency in neonates results in INTRA-CRANIAL HEMORRHAGES.
B) Failure of Rhodopsin Production-Vitamin A deficiency impairs rhodopsin formation and leads to night blindness and xerophthalmia.
C) Reduced activation of intranuclear receptors- Occurs in vitamin D deficiency, and exclusively breastfed infants require vitamin D supplementation to prevent hypocalcemia and rickets due to the low content of this vitamin in breast milk.

Question 140

A person with Acute Hepatitis C infection, has HIGH TITERS OF IgG DIRECTED AGAINST HepC ENVELOPE PROTEIN. Why is the patient still unable to have an effective immune response against this infection?
(IgG bhee hein, per infection khatam nahi ho raha? Whyyy?)

Answer 140

Hep C virus, once inside the body MUTATES. It mutates such that its envelope proteins keep on changing. This is largely due to the fact that the virion-encoded RNA-dependent RNA polymerase has no proofreading 3’ → 5’ exonuclease activity, which results in many errors during replication.

So when the body makes adequate amount of IgG against a specific envelope protein, by that time the envelope protein has been changed. The tremendous antigenic variety of HCV has significantly slowed efforts to develop an effective vaccine.

Question 141

Funduscopy reveals small yellow retinal lesions clustered in the macula. Which of the following would you expect most on visual field examination?

A) Central Scotomas
B) Arcuate Scotomas

Answer 141

A) Central Scotomas- CORRECT
B) Arcuate Scotomas- occur due to damage to a particular region of the optic nerve head/ a nerve bundle defect on the temporal side of the optic disk.

Question 142

Romberg’s Sign is a test of ______________. A positive Romberg’s Sign indicates ___________.

Answer 142

Proprioception.

Sensory Ataxia.

Question 143

Causes of Sensory Ataxia?

Answer 143

Sensory ataxia may be caused by defects in the posterior column or peripheral nerves, which are classically caused by tabes dorsalis (syphilis) or vitamin B12 deficiency.

Question 144

Maternal HBsAg, HBeAg, and anti-HBc are all positive; anti-HBs is negative.The infant’s laboratory results will most likely show what?

Answer 144

An infant who is born to a HepB postive mother, has a high risk of getting HepB if the mother’s viral load is high, or if she is HepBeAg postive.

HepBeAg hogaa tou bhae bachay ko HepB zroor hoga.
A hepB postive infant will have high viral load and will be HepBeAg positive.

Question 145

Mechanism of osteoperosis in a patient of prolactinoma?

Answer 145

Low estrogen levels lead to increased production of inflammatory cytokines (especially IL-1 and tumor necrosis factor–alpha), increasing expression of the receptor activator of nuclear factor kappa B ligand (RANKL) and resulting in increased osteoclast activity.

Question 146

GERD’s histological findings on esophageal biopsy?

Answer 146

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

(In the uworld question statement it was written as elongation of the lamina propria papillae with several eosinophils and neutrophils scattered within the squamous epithelium.)

Question 147

The patient says that her pain level is 10 on a scale of 0-10 and becomes frustrated when the physician suggests nonprescription pain medication. What should the most appropriate next step by the physician?

Answer 147

Obtain confirmation of the patient’s prescription history.

Question 148

In psoas abscess, the person will be comfortable in which position?

Answer 148

hip flexion, external rotation, and lumbar lordosis.

Because psoas is used in hip extension

Question 149

elevated unconjugated bilirubin levels typically indicate increased bilirubin formation (such as that seen in ___________ ) or a slowing in bilirubin conjugation (such as that seen in a patient of _____________ ).

Answer 149

Hemolysis, Gilbert syndrome

Question 150

A 4-year-old girl developed acute-onset colicky abdominal pain, vomiting, and loose bloody stools during a family vacation. A few days later, her parents bring her to the emergency department because she has urinated only once in the past 10 hours and the urine was red. Urinalysis shows proteinuria and hematuria. Which of the following mechanisms is the most likely cause of this patient’s condition?

A) Microthrombi in small blood vessels.
B) Systemic IgA-mediated vasculitis
C) Widespread activation of coagulation cascade

Answer 150

A) Microthrombi in small blood vessels- CORRECT.—->Erythrocytes passing through the damaged capillaries suffer shear injury and are broken down to schistocytes.

B) Systemic IgA-mediated vasculitis-Henoch-Schönlein purpura (HSP) is a systemic leukocytoclastic vasculitis caused by IgA immune complex deposition within small blood vessels of the skin, kidneys, intestines, and joints.

C) Widespread activation of coagulation cascade- Disseminated intravascular coagulation refers to massive, widespread activation of the coagulation cascade due to release of procoagulant substances caused by sepsis, malignancy, or trauma.

Question 151

Primary myelofibrosis, a hematopoietic stem cell malignancy associated with the clonal expansion of ___________. Neoplastic cells secrete the cytokine _____________ , which stimulates bone marrow fibroblasts to fill the medullary space with collagen, and subsequently causes ______________.

Answer 151

Megakaryocytes
Transforming growth factor-beta
Bone Marrow Fibrosis

Question 152

Signs and Symptoms of Primary Myelofibrosis?

Answer 152

In primary myelofibrosis—-> there’s BM fibrosis.—–> Cells squeezing out of it becomes dacrocytes (Tear-drop cells).
Cells are not being made because BM is fibrosis—->Pancytopenia
>Extramedullary Hematopoiesis—–> Splenomegaly, Palpable liver edges on examinaton.

Question 153

Primary myelofibrosis, a hematopoietic stem cell malignancy associated with the clonal expansion of ___________. Neoplastic cells secrete the cytokine _____________ , which stimulates bone marrow fibroblasts to fill the medullary space with collagen, and subsequently causes ______________.

Answer 153

Megakaryocytes
Transforming growth factor-beta
Bone Marrow Fibrosis

Question 154

Signs and Symptoms of Primary Myelofibrosis?

Answer 154

In primary myelofibrosis—-> there’s BM fibrosis.—–> Cells squeezing out of it becomes dacrocytes (Tear-drop cells).
Cells are not being made because BM is fibrosis—->Pancytopenia
>Extramedullary Hematopoiesis—–> Splenomegaly, Palpable liver edges on examinaton.

Question 155

Dry tap is seen in which diseases?

Answer 155

Hairy Cell Leukemia, Primary Myelofibrosis

Question 156

Qid 1554
Compared to the amount of potassium delivered to the glomerular capillaries, the percentage of potassium remaining in this individual’s tubular fluid is most likely to vary by what amounts?

Bowman’s Capsule
End of Proximal Tubule
End of Thick Ascending Loop of Henle
End of Collecting Duct

Answer 156

Bowman’s Capsule- 100%
End of Proximal Tubule- 35%
End of Thick Ascending Loop of Henle- 10%
End of Collecting Duct- 110%

Potassium regulation is therefore primarily mediated by the principal and α-intercalated cells of the late distal and cortical collecting tubules. Hypokalemia stimulates reabsorption of K+ via apically located H+/K+-ATPases on α-intercalated cells and can cause the amount of K+ in the collecting tubule to approach 1% of the filtered load. Conversely, an increased K+ load stimulates principal cells to secrete K+ through apical K+ channels. High dietary K+ intake can cause the amount of K+ in the collecting tubules to actually exceed the filtered load (ie, >100%).

Question 157

Photosensitive rash causes?

Answer 157

SLE,
Porphyria Cutanea Tarda (Blistering cutaneous photosensitivity and hyperpigmentation),
Drugs (Sulfonamides, Tetracyclines, Amiodaron, 5 FU),
Angiosarcoma (Rare blood vessel malignancy that causes lesions in sun-exposed areas),
Actinic Keratosis (Premalignant lesions because of sun-exposure, risk of SCC)
SunBurns (Apoptosis of keratinocytes due to UVB)

Question 158

Photosensitive rash causes?

Answer 158

SLE, Porphyria Cutanea Tarda (Blistering cutaneous photosensitivity and hyperpigmentation), Drugs (Sulfonamides, Tetracyclines, Amiodaron, 5 FU)

Question 159

Autoimmune Hemolytic Anemia is an (extravascular/intravascular) hemolytic anemia, and causes elevated ____________.

Answer 159

Extravascular, causes elevated Reticulocytes.

Many other causes of anemia are associated with low reticulocyte count, including bone marrow suppression (eg, parvovirus), iron deficiency anemia, vitamin B12/folate deficiency, and anemia of chronic disease. CKD.

Question 160

Auscultatory findings of MVP?

Answer 160

A midsystolic click and systolic murmur are heard best at the apex without radiation.

Question 161

When completing the rest of the sexual history, which of the following questions is most appropriate for the physician to ask?

A) What are the genders of your current and previous sexual partners?
B) Can you tell me about your previous romantic relationships?

Answer 161

A) What are the genders of your current and previous sexual partners?- CORRECT.

B) Can you tell me about your previous romantic relationships?—>An individual may be sexually active outside of a romantic relationship or may not view an interaction as romantic.

Question 162

Neuroimaging reveals a small aneurysm arising from the segment of right internal carotid artery within the cavernous sinus. If this patient’s aneurysm continues to expand, which finding is most likely to be observed?

Answer 162

Weakness of right lateral rectus muscle.

Question 163

Intravenous norepinephrine is administered in response to the patient’s hypotension. Which of the following cellular changes is most likely to occur in direct response to the medication?

A) CAMP increase in Cardiac Muscle
B) CAMP increase in vascular smooth muscles
C) DAG decrease in Vascular Smooth Muscle

Answer 163

A) CAMP increase in Cardiac Muscle- CORRECT
B) CAMP increase in vascular smooth muscles- cAMP is increased after β2 adrenoreceptors are stimulated; however, because norepinephrine does not significantly stimulate β2 adrenoreceptors, cAMP concentrations in vascular smooth muscle are not increased.
C) DAG decrease in Vascular Smooth Muscle-Norepinephrine-mediated stimulation of α1 adrenoreceptors increases, rather than decreases, IP3 (increased calcium release) and DAG concentrations in vascular smooth muscle cells.

Question 164

Receptors affected in Lambert Eaton and Myesthenia Gravis?

Answer 164

In Lambert Eaton, VOLTAGE-GATED CA CHANNELS ARE AFFECTED. (Pre-synaptic)
In Myesthenia Gravis, the antibodies are against POST-SYNAPTIC NICOTINIC ACH RECEPTORS.
(Because of this, the nicotinic Ach Receptors are endocytosed and hence movement decreases with repetition)

Question 165

A patient is intubated for hip replacement surgery. The anesthesiologist suddenly notices that the patient develops hyperkalemia. Which drug has been used for intubation and what is the pathophysiology of this side effect?

Answer 165

Succinylcholine is used.
Succinylcholine works on Post- Synaptic Nicotinic Ach Receptors—–> It stimulates them, and produces SUSTAINED DEPOLARIZATION OF THE MYOCYTE. Because of the sustained depolarization/continuous stimulation of these receptors (Sodium influx, K efflux)—-> There’s hyperkalemia because of continued postassium efflux.

Question 166

The skeletal Muscle of a knockout mouse is able to contract despite total depletion of intracellular calcium in the muscle cells. What protein defect most like explains this finding?

Answer 166

Tropomyosin is defective.

Tropomyosin is attached to Actin, and stops it from contracting. Only leaves it for contraction when Troponin-C binds to Ca. Hence, in defective tropomyosin, actin is free to contract!!

Question 167

With the following disease, phenomenon—> tell the receptors that are responsible?

Lambert-Eaton
Myasthenia Gravis
Hyperkalemia after succinyl choline

Answer 167

Lambert-Eaton- Mutation in Pre-synaptic voltage gated Ca channels, that release Ach into the synaptic celft.
Myasthenia Gravis- Mutation in Post synaptic Nicotinic Ach Receptors, that open when Ach binds to them and they cause Sodium influx and Potassium efflux——> depolarizing the skeletal muscle cell.
Hyperkalemia after succinyl choline——> Same as the channels affected in MS.

Question 168

With the following disease, phenomenon—> tell the receptors that are responsible?

Inhaled Anesthetics (Isoflurane/Desflurane) or Succinyl Choline causing Malignant Hyperthermia?

Dantrolene used for treatment?

Answer 168

Inhaled Anesthetics (Isoflurane/Desflurane) or Succinyl Choline causing Malignant Hyperthermia—–> occurs in patients who have an Autosommal Dominant mutation in VOLTAGE-SENSTIVE RYANODINE RECEPTORS——-> cause extensive release of Calcium from sarcoplasmic reticulum—-> Ca binds to Trop C and causes excessive contraction.

Dantrolene used for treatment–> Inhibits voltage sensitive Ryanodine Receptors

Question 169

Story of muscle contraction?

Answer 169

Anterior Motor Horns on the spinal cord—> Corticospinal tract fibers release Ach and Nicotinic Ach Post synaptic receptors on Anterior Motor neuron cells start getting depolarized———–> Aaagay jaisay jaisay depolarization signal travel kerta hai along the length of the neuron comes the pre-synaptic membrane of this same neuron making up the motor end plate junction——–> Because of depolarization VOLTAGE SENSTIVE CALCIUM CHANNELS CAUSE THE RELEASE OF ACH INTO SYNAPTIC CLEFT——–> Motor end plate waalay junction kay post-synaptic end per Nicotinic Ach receptors hotay hein which cause sodium influx and K efflux——> Sodium influx and K efflux cause depolarization of cell—–> Change in voltage causes L-type Ca channels in T-tubules open up——> Ca enters the cells and this cause mechanical interaction of L-type Ca channels with the Ryanodine Receptors—–> Ryanodine Receptors cause release of Calcium from Sarcoplasmic Reticulum.

Question 170

SERCA?

Answer 170

Ca-ATPASE pump.

This actively pumps intracellular Ca back into Sarcoplasmic Reticulum.

Question 171

Sarcomere

A band?
I Band?

Answer 171

A band- DARK (Has the letter A in it), has myosin and actin overlapping.

I band is the LIGHT band. (Has the letter I in it)—> It is light because only has Actin in it.

Question 172

When sarcomere contracts, the A band has more _________, making it appear __________.

Answer 172

Actin, darker.

Question 173

When sarcomere contracts, the length of the _________ doesn’t change, but ________ and ________ shorten.

Answer 173

Length of the A band doesn’t change, but I and H band shortens.

Question 174

What 2 compensatory mechanisms allow the biceps muscle to INCREASED THE FORCE OF CONTRACTION during heavy exercise?

Answer 174

1. Inreased FREQUENCY of action potentials—> sustained contraction of muscle fibres called tetanus.
2. Increased RECRUITEMENT of muscle fibres—> increased force of muscle contraction.

Question 175

How does exercise promote angiogenesis?

Answer 175

Sudden drop in Oxygen in the tissues results in INCREASED VEGF—-> leads to increased angiogenesis.

Question 176

What will the urinalysis of a patient of acute pyelonephritis show?

Answer 176

WBC casts

Question 177

What will the urinalysis of a patient of acute glomerulonephritis show?

Answer 177

RBC casts.

Question 178

What will the urinalysis of a patient of acute cystitis show

Answer 178

WBCs.

Question 179

What will the urinalysis of a patient of acute Nephrotic Syndrome show?

Answer 179

Fatty casts/Oval Fat bodies.

Question 180

What will the urinalysis of a patient of Bladder Cancer/Kidney stones show?

Answer 180

RBCs, NO CASTS.

Question 181

Trastuzumab and cardiac side effects.

Answer 181

Causes cardiotoxicity—-> manifests as REDUCED LEFT VENTRICULAR EJECTION FRACTION WITHOUT ANY OTHER ABNORMALITY.
Hence, reduced cardiomyocyte contractility with no fibrosis.
(Likely because HER2 signaling plays a role in minimizing oxidative stress on cardiomyocytes and preserving cardiomyocyte function)
In FA, it says Trastuzumab may also lead to dilated cardiomyopathy,

Question 182

Chemotherapeutic drugs for Melanoma and their mechanism of actions.

Answer 182

Interferons
Aldesleukin—> IL-2 inhibitor
Dabrafenib, venurafinib—> small molecule inhibitors of BRAF positive oncogene melanoma.

Question 183

Patient with dry mucous membranes, tenderness in calves and thighs, dark urine and elevated creatine kinase will show what in urine analysis?

Answer 183

This is a typical manifestation of Rhabdomyolysis. Urine Analysis will show granular/Muddy brown casts because it causes Acute tubular Necrosis.

Question 184

Manifestation of Cauda Equina Syndrome?

Answer 184

Progressive low back pain, (Due disruption of nerve roots to sciatic nerve)
bilateral lower extremity weakness (Due disruption of nerve roots to sciatic nerve)
bowel/bladder dysfunction—> leads to constipation and difficulty urinating as parasympathetic innervation via pelvic splanchnic nerves is lost.
and impaired perineal sensation—> disrupted pudendal nerve.

Question 185

Which conversion is defective in congenital Lactose Intolerance?

Answer 185

Lactaste Enzyme converts Lactose to Galactose.

Question 186

Secondary lactose intolerance is common after __________ infections.

Answer 186

giardial

Question 187

Patient is single now, and so are you. You are also attracted to her. She asks you out, what are you supposed to say as her doctor?

A) Decline the invitation, and explain that going on a date with her would be unethical.
B) Decline the invitation, explaining that physician-patient relationship must be terminated before going on a date.

Answer 187

A) Decline the invitation, and explain that going on a date with her would be unethical- CORRECT

B) Decline the invitation, explaining that physician-patient relationship must be terminated before going on a date —-> What’s shown in sabaat is INCORRECT.—>the patient should not be forced to choose between having the physician be a treatment provider or a romantic partner.

Question 188

Catheter embolization is planned via the femoral artery. During the procedure, the arterial catheter is most likely to proceed in which of the following orders?

Answer 188

External Iliac—> common Iliac——-> Abdominal Aorta—-> IMA——> Femoral artery.

Question 189

Although the eukaryotic genome is significantly larger and more complex than that of the prokaryote, eukaryotic DNA replication still occurs in a timely manner. Which of the following features of eukaryotic replication best explains this observation?

Answer 189

Multiple origins of replication

Question 190

Her husband says, “I’m trying to do everything I can to get her blood pressure under control. I cook healthy food and remind her to take the medication, but I’m not sure she’s taking it.” The patient says, “Taking the medication is a hassle; I know my pressure has been high but I feel absolutely fine.” Which of the following responses by the physician is the most appropriate?

A) May patients find if difficult to take the medicine daily. What hassles have you been experiencing while taking your medicines daily?

B) Your husband is correct to be concerned. What is your understanding of why controlling you BP is important for your health?

Answer 190

A) May patients find if difficult to take the medicine daily. What hassles have you been experiencing while taking your medicines daily?– CORRECT.

B) Your husband is correct to be concerned. What is your understanding of why controlling you BP is important for your health?—>this statement aligns the physician with the husband rather than with the patient. She may feel attacked, which could put her on the defensive.

Question 191

Physical examination shows increased tension within the anterior compartment. What nerve and vessels are most likely to be compromised by this patient’s acute complication?

Answer 191

Deep Peroneal Nerve, Anterior Tibial Artery and Vein.

Question 192

Recurrent sinopulmonary infections in CF are due to which 3 pathogens?

Answer 192

> Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia complex (fastidious gram negative bacterium)

Question 193

The immunodeficiency in Chediak-Hegashi Syndrome results from a defect in ___________ cell function and neutrophil __________________.

Answer 193

Naturak Killer Cell function

phagosome-lysosome fusion

Question 194

What does the peripheral blood smear show in Chediak-Hegashi Syndrome?

Answer 194

Giant Cytoplasmic Granules/ Giant Lysosomal inclusions in neutrophils visible on light microscopy of peripheral Blood smear.

Question 195

The physician prescribes a gel containing clindamycin and benzoyl peroxide to be used in the morning and topical tretinoin to be used at night. What is the primary reason for using benzoyl peroxide as a component of this patient’s medication combination?

Answer 195

Reduction of antibiotic resistance.

Question 196

Empiric treatement for meningitis needs to more drugs in special occassions?

Answer 196

Empiric treatment of meningitis is often third generation cephalosporin—> Ceftriaxone.

Vancomycin is added for gram + strep pneumo.
Ampicillin is added for Lysteria in neonates, elderly.

Question 197

Empiric treatment for community acquired pneumonia/ventilator acquired pneumonia?

Answer 197

ceftriaxone.

Question 198

Which drug is used to treat pseudomonas infections?

Answer 198

Cefotazidime.

Question 199

What is the first line of treatement for Neisseria Gonorrhea?

Answer 199

Single IM dose of Ceftriaxone.

Question 200

Which cephalosporin has an activity against MRSA?

Answer 200

Cephtaroline—–> covers MRSA but doesn’t cover pseudomonas.

Question 201

How can we a pathogen become resistant against cephalosporins?

Answer 201

changing PBPS,

producing extensive spectrum Beta-lactamases.

Question 202

On examination, there is a firm, palpable mass at the base of tongue. Cervical lymph nodes are also palpable. Which of the following histologic features is most likely to be seen on biopsy of the tongue lesion?

A) Fibrovascular cores surrounded by Squamous Epithelium
B) Irregular foci of keratinization

Answer 202

A) Fibrovascular cores surrounded by Squamous Epithelium-Squamous papillomas are benign tumors that have fibrovascular cores.

B) Irregular foci of keratinization- CORRECT.

Question 203

What will biopsy of a leshimaniasis lesion show?

Answer 203

Biopsy of the lesion reveals intracellular, round-oval protozoa with rod-shaped kinetoplasts.

Or it can be said that rod shaped cytoplasmic inclusions and extracellular amastigotes.

Question 204

This patient with acute kidney injury has muddy brown casts on urine microscopy; in the setting of recent major surgery this presentation suggests acute tubular necrosis (ATN) due to ____________________.

Answer 204

intraoperative renal ischemia.

In uworld the correct answer was, this condition is ischemic tubular necrosis

Question 205

In crytalline induced injury, urine analysis will show crystals of what shape?

Answer 205

Needle shaped or rosette-shaped crystals are seen on urine analysis.

Question 206

Crytalline induced injury can be caused by which 2 drugs?

Answer 206

Acyclovir

Sulfonamide.

Question 207

The pathophysiology of chronic mesenteric ishchemia is analogous to the mechanism of which other disease?

Answer 207

Stable angina.

Question 208

How would chronic mesenteric ischemia present as?

Answer 208

postprandial epigastric pain and associated food aversion/weight loss in the setting of generalized atherosclerosis (eg, coronary and carotid artery disease)

Question 209

A kid can get brain abscess due to which reasons?

Answer 209

TOF
Sinusitis
Mastoiditis (asked in uworld)—> normally from strep pneumo.
Dental infection

Question 210

What does Adenosine deaminase deficiency manifest as and how is this concept used in pharmacology?

Answer 210

Adenosine Deaminase (ADA) is important for degradation of adenosine and deoxyadenosine.
Decreased ADA—-> Increased deoxyATP–> lymphotoxicity!!!
(Major cause of SCID)

ADA inhibitors are obviously going to cause lymphotoxicity so cladribine is used in hairy cell leukemia for treatment.

Question 211

Which drugs affect the excretion of uric acid into urine?

Answer 211

Probenecid–> decreased reabsorption of uric acid in kidney tubules, and let’s it get excreted into the urine.

Rasburicase–> ASE means to split. So this drug splits uric acid into a more soluble form ALLANTOIN and this way it gets excreted out in the urine more easily.

Aspirin—> Low aspirin INHIBITS uric acid excretion in urine.

Question 212

Manifestation of Lesch-Nyhan?

Answer 212

Orange sand in diaper ( Sodium urate crystals in urine)
Dystonia,
self-mutilation, agression
Hyperuricemia, Gout
Intellectual disability

X-linked recessive.

Question 213

Which conversions are defective in Lesch-Nyhan Syndrome?

Answer 213

Guanine is not being converted to GMP,
Hypoxanthine is not being converted back to IMP

due to deficiency of HGPRT.

Question 214

In neonatal lupus, which antibodies are found?

Answer 214

Anti-SSA antibodies/ Anti-RO

Question 215

Polymyositis and Dermatomyositis characteristics?

Answer 215

Polymyositis——> MHC1 overexpression on sarcolemma/ Endomysial inflammation with CD8+ cells.

Dermatomyositis———> perimysial inflammation, atrophy and presence of CD4+ T cells.
Dysphagia due to perifasicular atrophy of muscle fibres in proximal esophageal muscularis propria.

Question 216

Cause of esophageal dysmotility in CREST syndrome?

Similar to cause of esophageal dysmotility in dermatomyositis

Answer 216

Atrophy and fibrous replacement of muscularis propria in LOWER ESOPHAGUS.

Causes INCREASED RISK OF BARRET’S and FIBROUS STRICTURE FORMATION.

Question 217

Function of gap junctions, and in which condition are they increased?

Answer 217

Gap Junctions are channel proteins permit electrical and chemical signals between cells.

Number of Gap junctions INCREASE at the time of labour, and that INCREASES myometrial excitability.

Question 218

Antibodies against desmosomes and hemidesmosomes?

Answer 218

Desmosomes——> pemphigus vulgaris.

Hemidesmosomes——> bullous pemphigoid

Question 219

Lichen Planus lesion are found to have what characteristic?

Answer 219

Characterized my CD8+ T-cells along dermoepidermoid junction, saw tooth appearance at Dermal and epidermal junction.

Question 220

Poxvirus lesions?

Answer 220

Umbulicated papules, moluscum bodies seen.

Question 221

In staphylococcal scalded skin syndrome, the exotoxin affects what part of skin?

Answer 221

Exfoliative exotoxins cleave Desmoglein in Desmosomes
(Just like pemphigus vulgaris)

Exotoxin destroys kertinocyte attachements in STRATUM GRANULOSUM.

Question 222

Mutations in Fas will result in autoimmune disorders because?

Answer 222

Because of activation-induced T-lymphocyte.

Fas is present on T-lymphocytes, once activated Fas now becomes FasL and can interact with Fas on other T-lymphocytes or itself. When FasL interactes—->Fas receptor trimerizes into death domain—–> FADD then activates procaspases into caspases and causes apoptosis.

Question 223

2 mechanisms of extrinsic apoptosis?

Answer 223

tumor necrosis factor (TNF) when bound to tumor necrosis factor receptor 1 (TNFR1) or the Fas ligand when bound to cell surface receptor Fas.

Question 224

It is determined that the patient’s insulin deficiency is causing increased production of gluconeogenic precursors that are subsequently converted to glucose in the liver. Which enzyme is most likely to provide these precursor substrates?

Answer 224

Glycerol Kinase- answer!
This patient in diabetic ketoacidosis is experiencing increased triglyceride breakdown in adipose tissue due to her insulin deficiency. Triglycerides stored in adipose tissue are metabolized to free fatty acids and glycerol by hormone-sensitive lipase in response to low insulin and high catecholamine levels. Adipocytes are unable to metabolize glycerol, so it is secreted into the circulation and transported to the liver, where it is phosphorylated to glycerol-3-phosphate by glycerol kinase.

Question 225

What factors are produced by liver and need Vitamin K epoxide reductase dependant Gamma-glutamyl carboxylation?

Answer 225

2, 7, 9, 10, CS.

Question 226

What factors deficiency can be diagnosed by elevated PT?

Answer 226

Tests function of extrinsic and common pathway:

1,2,5,7,10

Question 227

What factors deficiency can be diagnosed by elevated aPTT?

Answer 227

Useful to test function of INTRINSIC pathway.

Can be used to test deficiency of all factors except for Factor 7 and 13.

Question 228

Hemophillia is an intrinsic/extrinsic pathway defect so labs will show elevated pt/aptt?

Answer 228

INTRINSIC—> Elevated aPTT.

Question 229

What do you know about Dysbetalipoproteinemia?

Answer 229

ApoE is defective.
Raised blood levels of chylomicrons and VLDL.
Tuboeruptive and palmar xanthomas.

Question 230

How can insulin resistance lead to formation of xanthelasmas in a patient?

Answer 230

Diabetic patient with insuline resistance——-> Hepatic overproduction of VLDL——-? HYPERTRIGLYCERIDEMIA—> xanthelasma/xanthoma formation.

Question 231

Tendon Xanthomas are seen in which dyslipidemia?

Answer 231

Type 2/Familial hypercholestrolemia—-> Defective LDL receptors or absent ApoB-100.

These people get MI before the age of 20—-> Premature coronary artery disease.

Question 232

Xanthomas are yellow nodules composed of___________ in the dermis.

Answer 232

lipid-laden histiocytes

Question 233

plane xanthomas (linear lesions in skin folds that are strongly associated with ____________.

Answer 233

primary biliary cirrhosis/ Primary Bililary Cholangitis.

Question 234

Immunoblot analysis suggests a lack of ApoE3 and ApoE4 in his circulating lipoproteins. What is most likely impaired in this patient?

Answer 234

Chylomicrons reuptake by liver cells is impared.

Question 235

Maculopapular rash seen in palms and soles:

Answer 235

Palms and soles rash is seen in Coxsackievirus
A infection (hand, foot, and mouth disease),
Rocky Mountain spotted fever, and 2° Syphilis
(you drive CARS using your palms and soles).

Palmar xanthomas in Defective ApoE.
palmarplantar erythrodysesthesia
(hand-foot syndrome) because of 5-FU
Janeway lesions in Bacterial endocarditis–> Painless erythamatous lesions.

Question 236

Mechanism of Janeway lesions?

Answer 236

Janeway lesions in Bacterial endocarditis–> Painless erythamatous lesions—> because of microabscesses/Microthrombi to skin vessels.

Question 237

Trigger finger?

Answer 237

Swelling of fibrous flexor sheath.

Question 238

What happens in depuytren’s contracture?

Answer 238

Fibrosis of palmar aponeurosis.

Question 239

Mechanism of Action of Praziquantel?

Answer 239

Increased Ca permeability, Increased vacuolization.

(Used in treatment of schistosoma, Diphylobethrum latum, clonorchesis senesis.

Question 240

Granular IF is seen in which kidney conditions?

Answer 240

PSGN (Due to IgG, IgM and C3 deposition)
DPGN IN SLE (LM will show wire looping of capillaries)
Membranous Nephropathy

Question 241

What can neutrophils smell?

Answer 241

IL-8, LTB4, C5a, Bacterial Products.

Question 242

What makes bacteria tastier for neutrophils to eat?

Answer 242

IgG, C3b

Question 243

Which cytokine is strongly associated with septic shock?

Answer 243

TNF-alpha

Question 244

Which 2 substances are associated with pain?

Answer 244

Prostaglandin, Bradykinin.

Question 245

Which cytokine causes Fever?

Answer 245

IL-1

Question 246

Pathway of how is acute inflammation triggered?

Answer 246

Interation with a pathogen——->NF-κB is stimulated (major transcription factor)———> This converts Phospholipase C into Arachidonic Acid.

Arachidonic acid produces two major kind of substances.

1) FOR LUNG—-> Lypoogenase—> Leukotrienes.
2) Cycloxygenase——–> PGE2, PGI2, TXA2.

Question 247

Actions of TXA2?

Answer 247

Causes an INCREASE in everything:

↑ Platelet Aggregation
↑ Vascular Tone
↑ Bronchial Tone.

Question 248

Actions of PGE2?

Answer 248

Causes

Pain, fever.
↑ Uterine tone.

Everything else goes DOWN.
↓ Vascular tone
↓ Bronchial Tone

Question 249

Actions of PGI/ Prostacyclin?

Answer 249

Everything goes down!!

Question 250

What is the chain of people that are taken the word for a patient who has no living will and no durable power of attorney?

Answer 250

Living will—> Durable Power of attorney—> Spouse—-> Children—-> Parent—-> Sibling.

Question 251

This really old patient (84 years old) comes in Diabetic ketoacidosis and the doctor advises her to get insulin injected and amputation of both the limbs. She refuses to get this done, and wishes no longer to keep going. Psychiatric consultation was placed and patient has capacity of about refusing care. What will be your most appropriate next step?

A) Discharge the patient, against medical advice
B) Offer insulin, though allow patient to refuse.

Answer 251

B) Offer insulin, though allow patient to refuse- CORRECT. (You gotta be on your best behaviour bro)

Question 252

The patient has to come her primary car provider since the past 3 months with a multitude of problems. She says she’ll sue the doctor and the hospital malpractice. She wants to get an MRI done for her lower back pain. She states that her insurance company will pay for the test. What will be your next step?
A) Advise the patient that if she can convince her insurance company to approve exam, that there will be no issue in ordering this through her primary car provider.

B) Explain that the MRI is not necessary and it will be unethical to document inaccurate findings.

Answer 252

A) Advise the patient that if she can convince her insurance company to approve exam, that there will be no issue in ordering this through her primary car provider—> Insurance company will be like what you talking about bro?

B) Explain that the MRI is not necessary and it will be unethical to document inaccurate findings- CORRECT.

Question 253

What is the main precipitant of malpractice lawsuit filed by a patient?

Answer 253

The perception that the physician is uncaring.

Question 254

Mini rules for ethics cases?

Answer 254

1. Always own up to your mistakes. ALWAYS (Even if you have a chance to cover it up)
2. Family CANNOT require the doctor to withold information from the patient (Such as family member comes to you saying please don’t tell grandpa about his cancer).
3. Confidentiality can be broken in danger (HIV positive–> sharing needles, sexual partners.)
4. Pregnant woman can refuse treatment even if the fetus is at risk.
5. The physician doesn’t have to inform the patients that he is HIV positive.

Question 255

The macrophage story when they see neutrophils engulfing a pathogen?

Answer 255

1. Well, the job is already done (Macrophages release IL-10 and TGF-beta)
2. Oops, the job is not done just yetttt. (Macrophages release IL-8 to ask for more neutrophils to come to the site)
3. Abscess formation
4. We’ll have to revert to CHRONIC INFLAMMATION.

Question 256

Cytochrome P450 inducers?

Answer 256

Queen Barb steals phen, refuses to eat greasy carbs continuously.

Q----> Quinidine
B---> Barbiturates
S--> St John's Wort
P---> Phenytoin
R--> Rifampin
Greasy--> Griseofulvin
Carbs--> Carbamezepine
Continuously---> Chronic Alcohol

Glucocorticoids.

Question 257

CYP450 Inhibitors?

Answer 257

Mnemonic is MAGIC RACKS.

M--> Macrolides
A---> Amiodarone
G---> Grape fruit juice
I---> Isoniazid
c---> Cimetidine

R---> Ritonavir
A---> Acute Alcohol
C---> Cirpro
K--> Ketoconazole
S---> Sulfonamides

GQ—-> Gemfebrozil, Quindine.

Question 258

Difference between pedegrees of Autosommal Dominant and X-linked Dominant diseases?

Answer 258

In, Autosommal dominant disease there is male-to-male transmission.
In, X-linked dominant—> Father will never transmit the disease to his son, that means NO MALE-TO-MALE TRANSMISSION.
(If the mother is a patient, she’ll pass it on to 50% of her daughters and 50% of her sons. If a father is affected, he will pass it on to 100% of the daughters and never to sons)

Question 259

Mitochondrial DNA shows _______.

Answer 259

Heteroplasmy.

Question 260

3 Etiologies of SCID?

Answer 260

1. Lack of Cytokine receptors (Cytokine receptors are important to activate CD4+ helper cells—-> These cells further activate B cells to produce antibodies and also activate CD8+ cells.)
2. Adenosine Deaminase deficiency—> build up of adenosine and deoxyadenosine is toxic to lymph nodes.
3. MHC Class 2 receptor (These are important to activate CD4+ Helper T cells. Because CD4+ activate B-cells to fight off bacteria and protozoa. And no T cells means increase susceptibility to Viral and fungal infections.)

Question 261

Treatment of SCID?

Answer 261

Sterile Isolation

Stem cell transplant.

Question 262

In X-linked agammaglobulinemia, which cells are missing?

Answer 262

Plasma cells are missing—> Hence, no immunoglobulins in the blood.

(Naive B cells are unable to mature into plasma cells in this disease.)

Question 263

In X-linked agammaglobulinema, what 3 infections are commonly seen?

Answer 263

> Recurrent Bacterial infections (Because we need Plasma cells to produce antibodies to fight off bacteria)
Giardia(Lack of Mucosal IgA)
Enterovirus (Lack of Mucosal IgA)

(Represents after 6 months of life—> That’s when maternal immunoglobulins are run out)

Question 264

The infections caused in ______________ are similar to the ones caused in X-linked agammaglobulinemia. But what is the difference?

Answer 264

Usually diagnosed in later adulthood/after puberty.

↑ autoimmune disease and Lymphoma, Bronchiectasis.

Question 265

Which disease is associated with IgA deficiency?

Answer 265

Celiac Disease!!

Question 266

For Hyper IgM syndrome, what story do you need to remember to know the actual defect of this disease?

Answer 266

The problem is in B-CELL CLASS SWITCHING.
There are 2 ways by which B-cells can be activated:
1—> B cells with IgM receptor activated by an antigen which binds to IgM—> This causes maturation of B cell into a plasma cells that only releases IgM.
2—-> By CLASS SWITCHING—> B cell internalizes an antigen—> presents it as MHC Class 2 for T-helper cells—> Second signal is produced, when this same B cells presents CD40 receptor and interacts with CD40 L on CD4+ helper T cells—> Activated CD4+ release IL-4 and IL-5 and cause class switching of B cells.

The problem in Hyper IgM Syndrome is that the second signal where CD40 receptor interacts with CD40 ligand to activate CD4+ helper T cells!!

Question 267

How will AIRE mutation manifest as?

Defective central tolerance in Thymus

Answer 267

CHAR
C---> mucocutaneous candidiasis
H--> Hypoparathyroidism
A--> Adrenal insufficiency
R--> Recurrent Candida

Question 268

How will AIRE mutation manifest as?

Defective central tolerance in Thymus

Answer 268

CHAR
C---> mucocutaneous candidiasis
H--> Hypoparathyroidism
A--> Adrenal insufficiency
R--> Recurrent Candida

Question 269

2 ways by which negative selection occurs in Bone marrow of B-cells?

Answer 269

1) RAG gene editor–> edits light chains of the immunoglobulin receptor on B cells.
2) Apoptosis if the cells bind too tightly to self antigens.

Question 270

2 mechanisms of peripheral tolerance?

Answer 270

1–> Apoptosis via Fas pathway (If there’s continuous lack of co-stimulatory interaction between CD 28 on T-cells and B7 on dendritic cell)
2—> Cell Anergy

Question 271

What triggers Anergy, Apoptosis in peripheral tolerance?

Answer 271

When a CD4+ cell’s TCR binds to MHC Class 2 on the dendritic cell, there should be co-stimulation between CD28 on T cell and B7 on Dendritic cell.
This lack of co-stimulatory interaction causes it to either go into Anergy or Apoptosis.

Question 272

How do T-regs inhibit immune response?

2 mechanisms

Answer 272

1—> T-regs, comes and bind its own receptor CTLA4 to B7 on dendritic cells. Now, there’s lack of co-stimulation between CD28 on CD4+ helper T cells and B7 on dendritic cell.—>Cells go into Anergy—> reduced immune response.

2—> Release IL-10, TGF-BETA.

Question 273

How does PTPN22 lead to autoimmunity?

Answer 273

PTPN22 is a gene for TYROSINE PHOSPHATASE. PTPN 22 polymorphism (gain of function mutation) —-> defective signalling—> cells don’t go into anergy or apoptosis—> self reactive cells start attacking.

Question 274

_________________ can be one explanation for overlapping features seen in autoimmune diseases.

Answer 274

Epitope spreading.

Question 275

Autoimmune disorders are more common in middle-aged females because?

Answer 275

Estrogen reduced the apoptosis of self reactive B-cells.

Question 276

Main thing about SLE?

Answer 276

Antibodies directed against host nuclear material—>Antigen-antibody complexes get deposited in various tissues—-> this causes complement activation in the tissues—> Reduced CH50, C3, C4 levels.

Some keratinocytes undergo apoptosis—> fragments of shrunken/pieces of nuclear material are in the skin—> Self-reactive B cells comes and forms antibodies against this nuclear material—-> Antigen-antibody complexes are formed but in low quantity—> Next time, again keratinocytes undergo apoptosis and leave a little nuclear material in the tissue, the antibodies comes and bind to nuclear antigens and make antigen-antibody complexes again—> These antigen-antibody complexes are taken up by dendritic cells via TLR——> This amplify the immune response and now B cells will produce so many antibodies.

Question 277

In SLE, the antibodies are against host’s ___________..

Answer 277

Nuclear Material

Question 278

People with _________ deficiency are prone to getting SLE. Why?

Answer 278

Early Complement deficiency.
Because in a normal person when an antigen-antibody complex is formed—> it tends to be removed via complement activation—> C1q attaches to the Antigen-antibody complex and this causes attachment of C2 and C4—> Now, C3 convertase converts C3 into C3a and C3b—> C3b opsonizes the antigen-antibody complex——> Erythrocytes have receptor CR1 which recognizes C3b on these molecules and takes them to spleen—> splenic macrophages remove this antigen-antibody complexes.

But in a person who has an early complement deficiency, antigen-antibody complexes won’t be removed efficiently and trigger a huge immune response!

Question 279

SLE is a type ___ HSR but if the patient presents with anemia, thrombocytopenia and leukopenia this is due to type ____ HSR.

Answer 279

SLE is a TYPE 3 HSR. But blood manifestations are due to antobodies directly destroying the blood cells–> Hence, that’ll be due to Type 2 HSR.

Question 280

Classic endocardial finding in SLE?

Answer 280

Libbmann-Sack endocarditis which is actually vegetations on BOTH sides of the AV valve.
(Wow, so strange!!)

Produced platelet-rich/sterile thrombi in the blood.

Question 281

Which antibody testing can be a prognostic tool in SLE?

Answer 281

Anti-dsDNA
(This tells the involvement of Renal tissue—> Renal damage is a common cause of death in SLE patients)

(Dramay waali ANA abb double ho chuki hai– Anti-double stranded DNA)

Question 282

What test will you do to diagnose syphilis in an SLE patient?

Answer 282

FTA-ABS.

In FTA-ABS–> antibodies against the bacterial treponemal antigen is added–> once those antibodies bind, fluorescence is added–> so that we can see those antigen-antibody complexes under microscope.
FTA-ABS remains postive for a lifetime, even after syphillis is treated.

Question 283

Which antibody causes falsely-elevated PTT in SLE?

Answer 283

Lupus coagulant antibody.

Question 284

______________ antibody is a characteristic of drug-induced lupus.

Answer 284

Anti-histone antibodies.

These people already have ANA antibodies

Question 285

The paradox of antiphospholipid syndrome associated with SLE?

Answer 285

Elevated PTT, but a hypercoagulable state–> That is why, DVT/hepatic vein thrombosis/ Placental thrombosis occurs in these people.

Question 286

In SLE Renal failure, what is the particular condition if the patient gets:

1. Nephrotic Syndrome?
2. Nephritic Syndrome?

Answer 286

1. Nephrotic Syndrome—–> Membranous Nephropathy.

2. Nephritic Syndrome—> DPGN.

Question 287

Sjogren’s manifestation?

Answer 287

“Can’t chew a cracker, dirt in my eyes.”
>Dry eyes.
>Dry mouth
> Recurrent dental caries.

Question 288

Sjogren’s is associated with which disease?

Answer 288

Rheumatoid arthritis, because a primary disease of Sjogren’s has RF.

Question 289

Nobody is going to ask about Anti-SSA and Anti-SSB antibodies directly, because the name kind of gives it away.
Anti-SSA and Anti-SSB are basically __________.

Anti-SSA can cause ________________.

Answer 289

Anti-ribonucleoprotein antibodies.
(antibodies against ribosomes!!)

Congenital Heart block associated with Neonatal lupus.
(Anti-SSA can cross placenta)

Question 290

Which tissue biopsy will you take for Sjogren’s syndrome and what will it show?

Answer 290

Lip biopsy to see minor salivary glands. (We need to exclude other causes of dry eyes and dry mouth–> sarcoidosis, amyloidos)
It’d show LYMPHOCYTIC SIALADENITIS.

Question 291

Sjogren’s disease is associated with which neoplasm?

Answer 291

B-cell lymphoma (Presents late in disease—> when one parotid is much more enlarged than the other one.)

Question 292

In systemic sclerosis, the antibodies are basically against ____________?

Answer 292

Mesenchymal Antigens.

( When mesenchymal/ CT damage below a blood vessel occurs—–> there’s endothelial dysfunction—-> this causes increased expression of adhesion molecules of endothelial cells—> immune response triggered!!)

↑ Endothelin—> Hence, vasoconstriction.
↑ PDGF, TGF-B—-> causes fibrosis!

Question 293

Antibodies seen in Diffuse and limited scleroderma?

Answer 293

Diffuse Scleroderma–> Anti DNA polymerae 1 and Anti RNA polymerase 3.

Limited Scleroderma—> CREST so Anti-centromere antibodies.

Question 294

Antibodies seen in mixed connective tissue disease?

Answer 294

1, ANA (Antinuclear antibodies)
2. Antibodies against U1 ribonucleoprotein (RNP)
( Don’t confuse it with Anti-SM antibodies of SLE which are against snrps–> SNRPS are also called U-RNA because they are full of Uridine)

Question 295

Tympanic Membrane is embryologically derived from which layer?

Answer 295

Endoderm–> Inner mucosal layer.
Mesoderm–> middle fibrous layer.
Ectoderm–> Outer epithelial layer. (Epithelial lining at the bottom of the auditory meatus)

Question 296

Where are the stem cells of large and small bowel found?

Answer 296

Stem cells are found in the mucosal crypts.

Need to know this!!

Question 297

What is the CD receptor for BM stem cells?

SO HIGH-YIELD

Answer 297

CD34

Question 298

What is the stem cell of the lung?

Answer 298

Type 2 pneumocytes.

Question 299

Tissue quiescence is seen in which tissue?

Answer 299

Liver and PCT.

Stable cells

Question 300

Permanent tissues?

MSN

Answer 300

Myocardium
Skeletal Muscles
Neurons.

Question 301

How do permanent tissues replace damaged tissue?

Answer 301

By repair/ fibrosis.

Question 302

We get a scar on skin, when the skin cut is deep enough to cause loss of _________

Answer 302

Basal layer which contains stem cells/regenerative capacity cells of the skin!

Question 303

What is the key difference in a granulation tissue and a scar?

Answer 303

Granulation tissue has type 3 collagen.

Scar has type 1 collagen.

Question 304

Conversion of granulation tissue into a scar is done by which enzyme?

Answer 304

Collagenase which requires ZINC as a co-factor.

High yield

Question 305

FGF is a factor for growth of?

Answer 305

Blood Vessels, skeletal development.

Question 306

Which cells of the granulation tissue cause contraction of the wound?

Answer 306

Myofibroblasts.

Question 307

Keloid is characterized by excess of _________.

Answer 307

Type 3 collagen.

Question 308

Patient taking oral doxycycline comes to you with worsening acne. The medicine worked well for her symptoms before but she has been started on iron supplement for abnormal uterine bleeding recently. What is the cause of her acne?

(You have done this question right twice, but both the times you forgot the concept of it)

Answer 308

The absorption of the drug is reduced hence, the medicine stopped working for her acne.

Tetracyclines, Fluoroquinolones and Levothyroxine——-> interact with polyvalent cations such as Iron, Mg, Ca, Aluminum—-> reduced absorption in the gut because the drug-drug interaction results in complexes formed in the GIT.

Question 309

Most of the drugs are excreted via the kidneys with or without prior modification in the liver. However, what is the property of the drug that is EXCRETED/CLEARED by liver and not kidney?

Answer 309

The drug will have 2 properties:
> Highly lipophilic (high yield)
(This makes the drug enter the hepatocytes easily, and they cannot be excreted by the kidneys as they rapidly cross tubular cell membranes after filtration to reenter the tissues.)
> High Volume of Distribution 
(Obviously--> greasy mean high Vd)

Question 310

Qid (You did it right, but you have no idea about the correct concept)

It says that propofol has been given to patient for anesthesia. The graph shows that the concentration of the drug reduces in Blood, while there’s a hump-shaped graph of the drug concentration in BRAIN.
The graph, going upwards—> that is increased drug concentration but occurring later than the rise in concentration in the brain is of which tissue?

Answer 310

The graph is in your phone, you should have look at it.

This concept tells that from blood/arteries the drug goes quickly to highly vascular peripheral compartments (Brain, Lungs, Kidney, Liver, Heart) and a bit later to less-vascularized peripheral compartments (Skeletal Muscles, Fat, Bone)

If you want the drug to reach less vascularized peripheral compartments of the body, you’d need a drug with HIGH VOLUME OF DISTRIBUTION.

Question 311

While calculating the appropriate dosage, the hospital pharmacy uses an adjusted body weight that is lower than the patient’s actual body weight, for a patient whose BMI is 46. Which of the following best explains the use of this adjusted parameter for aminoglycoside?

(You did this wrong, and you had no idea about the concept. But I hope you remember it now.)

Answer 311

Adjusted body weight dosing is done for medicines which have a very low therapeutic window (eg, heparins, aminoglycosides, anesthetics).

This is related to the concept of volume of distribution of a drug. The volume of distribution of Aminoglycosides is very low, because this drug is basically LARGE POSITIVELY CHARGED PARTICLES. This makes the drug to stay in the plasma/exracellular fluid compartment. In obese patients, the adipose mass is increased and the extracellular fluid almost stays the same. So we should not give them low Vd drugs according to their weight, when the drug will stay in the extracellular fluid compartment and that will be the same as that of slim people!!
(Hence, in this obese patient the drug concentration has been lowered)

Question 312

How can a drug cross blood brain barrier?
(2 ways)

You did this wrong on uworld.

Answer 312

1» Disruption of tight junctions making up the blood brain barrier.
2» Inhibition of Efflux pumps/ Inhibition of ATP-driven P-glycoproteins/ Inhibition of MDR1

(P-glycoproteins also known as multi0drug resistance proteins are efflux pumps that remove a wide range of substrates of drugs from the tissues—> If they are inhibited, the bioavailability of the drug increases, and the drug can also cross the BBB)

Question 313

The cause of Morphine toxicity?

You did this wrong on NBME16

Answer 313

Morphine is metabolized in liver into 2 metabolites—->morphine-3-glucoronide and morphine-6-glucoronide. Morphine-6-glucoronide is particularly responsible for toxicity, acting as a more potent mu opioid receptor agonist than morphine itself.

The accumulation of these 2 metabolites causes MORPHINE TOXICITY–> These metabolites are ACTIVE and excreted renally.
Hence, opioid toxicity is common in renal dysfunction.

Question 314

Filgrastim is a ______________ used to stimulate the proliferation and differentiation of granulocytes in patients with neutropenia, as can occur after chemotherapy.

Answer 314

granulocyte colony-stimulating factor (G-CSF) analog

Question 315

What is used to treat methotrexate overdose?

Answer 315

Leucovorin, or folinic acid, is a drug used in the treatment of methotrexate overdose. It also enhances the cytotoxic action of 5-fluorouracil (5-FU) and is used in combination with 5-FU in some cases of colorectal cancer.

Question 316

Why does cyclophosphamide cause hemorrhagic cystitis?

Answer 316

The metabolite of Cyclophosphamide is ACROLEIN. Acrolein is toxic to uroepithelial cells.

Question 317

Why don’t monoclonal antibodies, require any dose adjustment in hepatic or renal dysfunction or even when the patient is taking a drug that affects Cytochrome P450 enzyme?

(You did this right, but didn’t know the concept)

Answer 317

Monoclonal antibodies are very large molecules that can only be administered IV and not orally.
MAbs are not metabolized, or removed hepatically or renally.
They are removed from the circulation in 2 ways:
»> Upon binding to their targets, MAbs get internalized via receptor-mediated endocytosis.
»> Immunoglobulins are constitutively taken up by reticuloendothelial macrophages (via binding to Fc receptors) and vascular endothelial cells (via pinocytosis)

Question 318

Why are aminoglycosides/vancomycin less effective in neonates as compared to adults using the weight-based dosage regimen?

Answer 318

same weight-based dosing regimen means—–> (eg, 5 mg/kg).Dose given per kg.

However, in neonates it shows LESS effectiveness.WHY?

Neonateshave an increased proportion of total body water with a lower content of body fat compared to adults. This difference in body composition results in water-soluble drugs (eg, aminoglycosides, vancomycin) having a larger than expected volume of distribution relative to body mass, leading to lower plasma concentrations when the drug is administered at the same weight-based dosage as given to adult patients.

Question 319

What are 2 peculiar things about aminoglycosides’ pharmacokinetics?

Answer 319

1»» Very water soluble, so in neonates who have greater water-content than an adult—–> It results in larger than expected volume of distribution leading to lower plasma conc in neonates.
2»» Basically is LARGE POSITIVELY CHARGED PARTICLES ( That means less Vd—> so stay in the plasma heee)—> Need to give lesser dose to obese patients kiyun kay you have calculated the dose according to his weight but this drug will stay in the plasma aur motay aur patlay logon mein plasma volume same hee hota hai!

Question 320

IL-2 searched in FA.

Answer 320

> Cortisol inhibits IL-2 production (Hence, exogenous corticosteroids can reactivate latent TB and Candidiasis)
JAK/STAT pathway.
IL-2 stimulates production of TH2 cells, T-regs in the LN.
IL-2 released by TH1 cells activates macrophages and Cytotoxic T cells in peripheral blood.
Most common cause of SCID—–> Defective IL-2R gamma chain.
Basil-iximab, dacli-zumab=Monoclonal antibody; blocks IL-2R
Sirolimus/Rapamycin—> mTOR inhibitor; binds FKBP=Prevents response to IL-2. Given in renal transplants
Immunosuppressant that prevent IL-2
transcription and are calceneurin inhibitors—> Cyclosporine (binds cyclophilin) and Tacrolimus (binds FK506 binding protein (FKBP)
IL-2 receptor analog—-> for treatment of RCC, Malignant melanoma.

Question 321

> Interleukin receptor ANTAGONIST is called?

Used in which disease?

Answer 321

IL-1 inhibtor is used in treatment of RA.

Called anakinra.

Question 322

Monoclonal Antibodies used in the treatment of RA?

Answer 322

Monoclonal antibodies that inhibit TNF-alpha (eg, adalimumab, etanercept) or IL-1 receptors (eg, anakinra) are widely used in the treatment of RA and can slow progression of the disease.

Question 323

Palpable purpura is seen in?

Answer 323

HOPE DREAM.
H– Henoch Schonlein Purpura
P– Polyarteritis Nodosa

D-- Disseminated Gonococcal Infection
R-Rocky Mountain spotted fever
E- Erythema gangrenosum 
A-- Acute meningiococcemia
M-- Microscopic polyangiitis

Question 324

Which virus has the following?

1. RNA dependent DNA polymerase?
2. DNA dependent RNA polymerase?

Answer 324

1. RNA dependent DNA polymerase—-> Reverse transcriptase of Hepadnavirus/HBV
2. DNA dependent RNA polymerase—> Pox virus, all negative stranded RNA
   ( Rifampin inhibits exactly this enzyme—> impairs mRNA synthesis)

Question 325

Villous Blunting or Atrophy is seen in which conditions?

Answer 325

1. Celiac Disease
2. Secondary Lactose intolerance
3. Rota Virus
4. Infection with EPEC.