UWorld Practice Questions #5 Flashcards
1
Q
What nerve and muscles are affected when a pt has a Trendelenburg gait?
A
Contralateral (to the side of hip drop) superior gluteal nerve impacting glut medius and glut minimus.
2
Q
Injection into what area of the buttock risk superior gluteal nerve injury?
A
Injections into the superior-medial quadrant.
3
Q
Of HbA, HbS and HbC, what is the order of speed w/ which they migrate on hemoglobin electrophoresis?
A
HbA migrates fastest b/c it’s the most negative. HbS migrates less quickly b/c it replaced a negative w/ a neutral charge. HbC migrates the slowest b/c it has a missense mutation that replaces a negative charge w/ a positive one.
4
Q
In which bipolar disorder are depressive episodes required for dx?
A
Bipolar II. They may also occur in bipolar I (the one w/ frank mania) but are not required.
5
Q
What is cyclothymic disorder?
A
2+ years of fluctuating mild hypomanic and depressive sxs that do not meet criteria for hypomanic or major depressive disorder.
6
Q
What does Legionella traditionally contaminate?
A
Natural bodies of water, municipal water supplies, and water based cooling systems –> these can be sources of outbreak.
7
Q
At the level of the true pelvis, the ureter cross the internal iliac artery just _______ to it?
A
Passes just anterior to the internal iliac artery.
8
Q
What structure contains the ovarian vessels?
A
The suspensory ligament of the ovary
9
Q
How do integrins and fibronectins work in terms of extracellular matrix stuff?
A
Integrins are transmembrane proteins that can bind to different proteins in the ECM like collagen, laminin and fibronectin.
Fibronectins bind to integrins, collagen and glycosaminoglycans serving to mediate cell adhesion and migration.
10
Q
True or false, alcoholic macrocytosis can occur independent of folate/B12 deficiency?
A
True!
11
Q
Mutations to filaggrin are linked to what skin disease?
A
Atopic dermatitis
12
Q
When does dermatitis herpetiformis typically present in life?
A
Usually in the 4th or 5th decade. It is uncommon in childhood.
13
Q
Why isn’t there necrosis and scarring distal to an un-ruptured atherosclerotic occlusion?
A
Because these develop slowly over time and allow time for collateral vessels to develop and perfuse the hypoperfused area that is distal to the occlusion.
14
Q
What are conditions that make atherosclerotic plaques less stable and thus more prone to rupture?
A
Thin fibrous cap, rich lipid core, and active inflammation in the atheroma.
15
Q
Ulcers found beyond the duodenal bulb suggest what?
A
Zollinger-Elison Syndrome
16
Q
What does a gastrin level that rises in response to secretin indicate?
A
Zolinger-Elison syndrome. This is because normally secretin inhibits gastrin secretion but in ZES it will paradoxically stimulate secretion from gastrinomas.
17
Q
What are the characteristics of lateral medullary syndrome (aka Wallenberg syndrome) and what is the deficit causing it?
A
- vertigo/nystagmus –> vestibular nucleus
- ipsilateral cerebellar signs –> inferior cerebellar peduncle
- Loss of pain/temp in ipsalateral face and contralateral body –> spinal trigeminal nucleus and spinothalamic tract
- bulbar weakness (dysphagia, dystonia) –> nucleus ambiguuus
- Horner syndrome –> sympathetic fibers going to head
18
Q
What malignancy are pts w/ PCOS at risk of?
A
Endometrial hyperplasia and endometrial adenocarcinoma (all that unopposed estrogen as there is decreased progesterone in PCOS).
19
Q
What is vaginal adenosis and what is it a precursor/risk for?
A
It is persistance of the glandular columnar epithelium in the vagina and is a precursor for clear cell adenocarcinoma of the vagina.
20
Q
What cardiac defect are Berry aneurysms associated with?
A
Coarctation of the aorta (if coarctation exists, these aneurysms are more prone to rupture!)
21
Q
What is menotropin and how is it used?
A
Menotropin is human menopausal gonadotropin. It is functionally similar to FSH and is used to encourage the development of a dominant follicle during assisted fertility/reproduction.
22
Q
Disorganized lamellar bone in a mosiac pattern is consistent with what?
A
Paget disease of the bone
23
Q
What are the bone changes seen in hyperparathyroidism?
A
Subperiosteal thinning appearing as subperiosteal erosions, and osteolytic cysts in long bones. –> this is all called osteitis fibrosa cystica.
24
Q
When is osteoid matrix accumulation around trabeculae seen?
A
Vitamin D deficiency
25
What is trabecular thinning with fewer interconnections characteristic of?
Osteoporosis.
26
Why is dextrose administration an effective tx for acute intermittent porphyria?
Because tx and prevention are based on inhibiting ALA synthase and thus preventing the accumulation of toxic intermediates. Heme and glucose will downregulate ALA synthase (by inhibiting PPAR-gamma, which induces synthesis of ALA synthase), hence the efficacy of dextrose for tx.
27
How can non-selective B blockers contribute to hyperkalemia?
By blocking the B2 mediated K+ uptake by cells.
28
What kind of drug is indapamide?
A thiazide diuretic
29
What is bicalutamide and what can it be used for?
It is a testosterone receptor antagonist and can be used in the tx of prostate cancer.
30
What prevents the descending colon from undergoing ischemia when the IMA is obstructed during procedures like abdominal aortic aneurysm?
Anastamoses from the SMA (thru the marginal artery)
31
What does the appearance of vacuoles and phospholipid containing amorphous densities in mitochondria signify?
Irreversible cell damage.
32
What are the clinical manifestations of neonatal abstinence syndrome (withdrawal from opiates)?
irritability, hypertonia, jittery movements, seizures (rarely), diarrhea, vomiting, feeding intolerance, sweating, sneezing and pupillary dilation.
33
What makes up the anti-phagocytic capsule of B. anthracis?
Repeats of D-glutamate
34
What is meant by the term, "peritichous flagella?" Give an example of an organism that demonstrates this.
Means flagella uniformly across the entire surface of the bacterial cell. Proteus mirabilis is an example.
35
What is the most important prognostic factor for likelihood of melanoma to metastasize?
Vertical growth and thus its depth of invasion (called Breslow depth).
36
Multinucleated giant melanocytes are characteristic of what?
Lentigo maligna
37
Golden cytoplasmic granules in macrophages that turn blue w/ Prussian-blue staining are characteristic of what?
hemosiderin laden macrophages aka HF cells.
38
What enzyme does 5-FU inhibit
Thymidylate synthase
39
What is N5-formyl-tetrahydrofolate?
Leucovorin aka folinic acid
40
Dermatomyositis can occur as a paraneoplastic syndrome as part of an underlying malignancy. Which ones are most common?
Ovarian, lung, colorectal cancers and non-hodgkin lymphoma.
41
What is alirocumab?
It is a monoclonal antibody against PCSK9 - blocks the normal effect resulting in increased levels of LDL receptors on hepatocyte membranes.
42
What is the management of pyruvate dehydrogenase deficiency?
ketogenic diet. This means less pyruvate will be produced and so you won't get the life-threatening lactic acidosis
43
What are the exclusively ketogenic amino acids?
Leucine and lysine
44
What is an abortive viral infection?
Where the virus enters the cell but does not successfully produce new viral particles. Therefore, it does NOT cause disease.
45
In terms of pharmacology, what is meant by the term "efficacy"?
Efficacy refers to the maximal ceiling of a drug with respect to a specific pharmacodynamic end point (i.e. how much it can dilate a blood vessel).
46
Name 2 vitamins that enteric bacteria are known for producing?
Vitamin K and folate
47
What enzymatic system can be involved in converting pro-carcinogens into carcinogens?
Cytochrome P450 monooxygenase
48
What is the difference btwn suppression and repression in terms of defense mechanisms?
In suppression the person is aware of the unpleasant feeling and consciously chooses to put the feelings aside to better focus on reality. Conversely, in repression the unpleasant feelings are not allowed to enter conscious awareness.
49
How can you distinguish btwn pituitary adenoma and ectopic ACTH secretion (i.e. paraneoplastic syndrome) for Cushing syndrome?
High dose dexamethasone suppression test. For pituitary adenoma this challenge will decrease the ACTH and cortisol levels whereas for the ectopic secretion the levels will remain unchanged.
50
When are cortisol levels highest in normal individuals?
In the morning
51
What is the translocation for BCR-ABL in CML? Also, what does this produce?
9;22, leading to a constitutively active tyrosine kinase
52
What is the difference btwn flutamide and finasteride?
Flutamide is an androgen receptor antagonist whereas finasteride is a 5a reductase inhibitor.
53
What sort of proteins do RAS genes code for? As such, when are they active?
RAS genes code for G proteins that are active when bound to GTP and inactive when bound to GDP
54
What is the mechanism of constitutively activating RAS mutations?
Mutations that decrease the instrinsic GTPase activity of RAS such that it is constantly in the GTP bound/on form.
55
Anterior compartment syndrome in the lower leg would impair what nerve? How about posterior compartment?
Anterior --> deep peroneal nerve
Posterior --> tibial nerve (maybe one other one too, not sure)
56
How does an MLF lesion present?
Internuclear ophthalmoplegia where there is weak adduction of the eye on the ipsilateral side and abduction nystagmus of the contralateral eye.
See p. 490 of First Aid for good diagram
57
What is a paraganglioma?
A tumor of chromaffin cells (like a pheochromocytoma) that arises outside of the adrenal medulla.
58
What is the histological appearance of medullary thyroid cancer?
Nests or sheets of polygonal or spindle-shaped cells w/ extracellular amyloid deposits.
59
Which thyroid cancer is known for having psammoma bodies?
Papillary thyroid cancer
60
What is the most common benign liver tumor?
Cavernous hemangioma
61
Which liver tumor can regress when oral contraceptives are stopped?
Hepatic adenoma
62
Chronic rhinosinusitis, asthma and peripheral eosinophikia are characteristic of what?
Churg-Strauss syndrome (aka eosinophilic granulomatosis w/ polyangiits).
63
What skin effect can be seen from constant application of topical corticosteroids? Why?
Dermal atrophy w/ loss of dermal collagen, drying, cracking and or tightening of the skin. This occurs b/c the steroids decrease production of ECM collagen and glycosaminoglycans.
64
What characterized dermatitis herpetiformis histologically?
Microabscesses containing fibrin and neutrophils in the dermal papillae tips
65
What skin condition is lamotrigine use associated w/?
Steven Johnson Syndrome
66
What is the path of CSF flow? Include ventricles and foramina
Lateral ventricles --> interventricular foramen of Monro --> third ventricle --> cerebral aqueduct --> fourth ventricle --> foramina of Luschka and Magendie --> subarachnoid space
67
What is a common sequelae of subarachnoid hemorrhage and how does it present?
Secondary vasospasm of the arteries surrounding the ruptured aneurysm. This usually occurs 4-12 days after and can cause ischemia presenting w/ focal neuro deficits and/or new onset confusion.
I think this is the most common sequelae as more than half the pts can get it.
68
What are the uterine arteries a branch of?
The internal iliac arteries
69
What lab value is elevated in suppurative parotitis?
amylase
70
What are RF for suppurative parotitis?
Dehydration, intubation, meds that decrease salivary flow, salivary flow obstruction, and recent intense teeth cleaning
71
What does gamma-glutamyl transpeptidase elevation suggest?
That alk phos elevation is due to liver and NOT bone pathology.
72
What is cinacalcet and when is it normally used?
It allosterically activates the Ca sensor in the parathyroid gland to suppress Ca++ secretion and is normally used in dialysis pts w/ secondary hyperparathyroidism.
73
What is sevelamer and when is it used?
It is a non-absorbable phosphate binding polymer that decreases P absorption and is used in dialysis pts w/ hyperphosphatemia
74
True or false, aspergillomas are asymptomatic?
False! They can be asymptomatic but can also present w/ cough and hemoptysis.
75
What are some extra-dermatological potential manifestations of psoriasis?
psoriatic arthritis, nail changes (yellow-brown discoloration, pitting, thickening or crumbling), conjunctivitis or uveitis
76
Which variant of thyroid cancer is known for having RAS mutations?
Follicular thyroid cancer
77
Inactivating p53 mutations are most commonly seen in which variant of thyroid cancer?
Anaplastic thyroid cancer
78
Of gastric and duodenal ulcers, which one is more likely to be malignant?
Gastric ulcers. Duodenal ones are rarely malignant and don't need to be biopsied.
79
What is the pathophysiology of biliary atresia and how do pts present?
Pathophysiology: normal biliary tree at birth but then it subsequently undergoes destruction (they think due to viral or antibody mediated mechanism).
Pts present w/ jaundice w/in the first two months of life, dark urine (more bili in urine), acholic aka pale stools (minimal bili in stool), and w/ hepatomegaly and an elevated direct bili.
80
What fungal infection are central vascular catheters and total parenteral nutrition RF for?
Candidemia
81
How does theophyline toxicity present? Note that this drug has a narrow therapeutic index and is metabolized by the hepatic cytochrome oxidase system
Excess CNS stim (tremor, insomnia, seizures), GI disturbances, cardiac abnormalities (hypotension, tachycardia, arrhythmia).
82
What part of the body is injured in Osgood-Schlatter disease?
The secondary ossification center of the tibial tubercle.
83
What characterizes GBM histologically?
pseudopalisading necrosis and new vessel formation
84
Which brain tumor has a whorled pattern of growth and often has psammoma bodies?
meningioma
85
Name 3 infiltrative diseases that can cause restrictive cardiomyopathy?
Amyloidosis, sarcoidosis, and hemochromatosis.
86
In what condition is there extracellular deposition of wild type transthyretin?
senile systemic amyloidosis
87
About half of pts w/ giant cell arteritis also have what?
polymyalgia rheumatica
88
Transmural inflammation of the vessel wall w/ fibrinoid necrosis is consistent with?
Polyarteritis nodosa
89
What would bx of calf muscle in Duchenne pt w/ pseudohypertrophy show later in the disease?
Replacement of muscle w/ fat and connective tissue.
90
What is the timeframe for when the following things present in alcohol withdrawal?
- Tremor/tremulousness, anxiety, insomnia, diaphoresis, GI upset and tremors?
- seizures?
- visual, auditory or tactile hallucinations?
- delerium tremens (confusion, agitation, fever, tachycardia, HTN, hallucinations)?
- Tremor/tremulousness, anxiety, insomnia, diaphoresis, GI upset and tremors --> 6-24 hours
- seizures --> 12-48 hours
- visual, auditory or tactile hallucinations --> 12-48 hours
- DTs --> 48-96 hours
91
What gives the elastic character to elastin?
Tropoelastin interacts w/ fibrillin (a scaffold) and lysyl oxidase forms desmosine cross-links btwn neighboring polypeptides. Said cross links are what account for its elastic properties.
92
What do E6 and E7 viral proteins in oncogenic HPV interact w/?
E6 --> p53
E7 --> Rb
*Together these interactions inhibit cell cycle regulation and lead to cell proliferation.
93
What does topoisomerase I do and what drug(s) inhibit it?
Induces single strand breaks in DNA to prevent negative supercoiling. Irinotecan and topotecan inhibit it.
94
What does topoisomerase II do and what drug(s) inhibit it?
Induces transient double strand breaks in DNA to reduce both positive and negative supercoiling. Etoposide inhibits it
95
What does the presence of odynophagia usually indicate in the setting of GERD?
That it has progressed to erosive esophagitis and that there is an ulcer now.
96
Describe the phenomenon of aldosterone escape
It is the physiology that explains why people w/ hyperaldo don't develop frank volume overload (or at least rarely do). What happens is the increased Na reabsorption stimulates increased renal blood flow (w/ resulting pressure natriuresis) and increased ANP that also prevents volume overload from occurring --> this is why pts w/ Conn syndrome have a normal serum Na.
97
In the Rhinne test, if bone conduction is greater than air conduction, what does that signify?
Conductive hearing loss for that ear
98
Where does hearing localize to in the Weber test for conductive and sensorineural hearing loss?
Conductive --> goes to affected ear
Sensorineural --> goes to opposite ear
99
What does GAS's M protein do?
It is antiphagocytic and inhibits the activation of complement
100
Which nephritic/nephrotic syndrome is associated w/ anti-phospholipase A2 receptor antibodies?
Idiopathic membranous nephropathy
101
What does selegiline do?
It is an inhibitor of MAO type B
102
How does cauda equina syndrome present?
Severe bilateral radicular pain, saddle anesthesia and hyporeflexia w/ anal and urinary incontinence occurring later in the disease course.
103
What do cavernous hemangiomas in the brain increase risk of?
Seizures and parenchymal hemorrhage
104
True or false, pts w/ SLE can commonly get serositis?
True! It commonly presents w/ pericarditis or pleuritis
105
Which manifestation of Wernicke-Korsakoff syndrome tends to be permanent?
The impairment in memory and learning (what produces the anterograde amnesia and confabulation).
106
What are the two morphological variants of gastric adenocarcinoma and what is their growth pattern?
1 = intestinal type. Forms a solid mass that projects into the gastric lumen and is composed of glandular forming columnar or cubodial cells.
2 = diffuse type (linitis plastica). It grows diffusely infiltrating the entire stomach wall, has signet ring cells.
107
Where is the spine involvement in rheumatoid arthritis and what are the consequences?
Cervical spine involvement. Can lead to cord compression and subluxation.
108
Where do the gonadal arteries arise from?
From the abdominal aorta, right below the renal arteries.
109
What is meant by the payment scheme of "capitation?"
Capitation is where the payor (individual, employer, etc.) pays a fixed, pre-determined fee to cover all medical expenses required by the patient(s) the payor is covering.
Note that this is the payment model for HMOs
110
In what circumstance are Charcot-Bouchard aneurysms seen?
In long standing HTN
111
Which cephalosporins have activity against pseudomonas?
ceftazidime (3rd gen) and cefepime (4th gen)
112
What is the perineal body? When can it be injured?
It is the central tendinous point of the perineum, separates the urogenital and anal triangles, and is integral for support.
It can be injured during an episiotomy.
113
What pathologically accumulates in Tay-Sachs (due to Hexosaminidase deficiency)?
GM2 ganglioside
114
In what condition is there accumulation of globtriaosylceramide (aka ceramide trihexoside)?
Fabry
115
What pathologically accumulates in Gaucher's disease?
B-glucocerebroside
116
Describe the mechanism of action of foscarnet
It is an anti-viral that does NOT require intracellular activation. It inhibits DNA polymerase in herpes virus and reverse transcriptase in HIV.
117
What is the mechanism of action of sofosbuvir?
It inhibits non-structural protein 5B (NS5B) (which is an RNA dependent RNA polymerase) in HCV and thus prevents replication.
Requires intracellular activation.
118
What is the viral hepatitis B marker that signifies increased infectivity and increased risk of vertical transmission?
HBeAg
119
Which ovarian neoplasm may produce psammoma bodies?
Papillary serous carcinoma of the ovary
120
Which lung neoplasm may produce psammoma bodies?
Mesothelioma
121
Which brain tumor characteristically has perivascular rosettes?
Ependymomas
122
Which brain tumor characteristically has small blue cells and may former Homer-Wright rosettes
Medulloblastoma
123
It is important to test pts w/ ZES for what?
MEN1 as there is a strong association
124
Where do the herpesviruses get their envelopes from?
From the host cell nuclear membrane
125
Proximal tubular cell ballooning and vacuolar degeneration in a pt w/ renal failure is consistent w/ what?
Acute tubular necrosis
126
Ingestion of what is highly associated w/ oxalate renal crystals?
Ethylene glycol
127
How does TNF-a lead to insulin resistance? What other signals can have the same effect?
It will activate serine kinases and phosphorylate serine residues on the subunits of the insulin receptor that undergo autophosphorylation. This will disrupt normal signaling. Note that phosphorylating threonine residues here has the same effect.
Glucagon, epi and glucocorticoids can have a similar effect
128
Which SERM has agonist activity on bone and antagonist activity at breast tissue?
Raloxifene and tamoxifen. Tamoxifen not used for osteoporosis b/c it has strong agonist activity at the endometrium, whereas raloxifene is an antagonist at the uterus.
129
Name 4 significant RFs for the development of cholesterol gallstones
```
1 = multiparity
2 = obesity/metabolic syndrome
3 = oral contraceptive use
4 = rapid weight loss
```
130
Through which transporter is fructose absorbed in the small bowel?
GLUT-5
131
Why is the oxygen content of blood in the coronary sinus the lowest of anywhere in the body?
Because the coronary sinus drains most of the blood from the heart and the myocardium is known for having very high oxygen extraction - more so than systemic circulation. So O2 content is lower.
132
What do subpleural blebs set a pt up for?
Pneumothorax
133
What is the murmur of HOCM?
Systolic ejection murmur that decreases w/ increased afterload (i.e. handgrip).
134
How does the copper IUD work?
It release copper ions that elicit an inflammatory reaction in the uterus that is toxic to sperm and prevents fertilization.
135
Anti-neutrophil myeloperoxidase antibodies can also be described as what?
p-ANCA
136
Describe mononeuritis multiplex in Churg-Strauss syndrome
It is where this small to medium sized vasculitis affects epineural vessels leading to neural involvement.
137
What is the most common mutation in HOCM?
Beta-myosin heavy chain
138
What does infarct of the angular gyrus of the dominant parietal lobe cause?
Gerstmann syndrome
139
How does Gerstmann syndrome present?
- Agraphia (inability to right)
- Acalculia (inability to do mathematical equations)
- Finger agnosia
- Left-right disorientation
140
What is alexia?
Inability to read
141
What is the first area of the brain damaged during global ischemia? What is another vulnerable area?
First area damaged = hippocampus.
Another vulnerable area is Purkinje cells of the cerebellum.
142
What are gastroschisis and omphalocele associated w/ on maternal quad screen? What else can the lab abnormality indicate?
Elevated AFP.
Can also indicated NTD and multigestations.
143
Describe the pathogenesis of liquefactive necrosis in the brain?
Ischemic injury to neurons causes them to release lysosomal enzymes that digests tissues. Phagocytic cells migrate in and remove debris and astrocytes proliferate to form a gliosis/scar that encases the cystic cavity that is formed.
144
What is the pathophysiology of familial dysbetalipoproteinemia and how does it present?
Defect of ApoE3 and ApoE4 which are present on VLDL and chylomicrons. These Apo molecules are what bind to hepatic apolipoprotein receptors, so particles can't be removed from circulation and patients present w/ elevations in cholesterol and TG levels, xanthomas, and premature coronary and peripheral vascular disease.
145
What is the pathophys of familial chylomicronemia and how does it present?
AR disorder due to defective lipoprotein lipase activity that causes increased synthesis and decreased clearance of chylomicron particles. Can also be caused by ApoC2 deficiency (ApoC2 activates lipoprotein lipase).
Presents w/ elevated chylomicrons and stuff like acute pancreatitis, lipemia retinalis, and eruptive xanthomas.
146
Which inherited hyperlipedemia present w/ elevated VLDL?
Familial hypertriglyceridemia
147
True or false, passive aggression is a mature defense mechanism?
False! It is however an immature one where the person avoids conflict by expressing hostility covertly.
148
What area does the musculocutaneous nerve provide sensation to?
The lateral forearm
149
What provides sensation to the posterior arm and forearm?
Branches of the radial nerve
150
What is the main RF for ovarian torsion?
A large ovarian mass (cyst, neoplasm, etc.)
151
What is the equation for renal filtration fraction?
FF = GFR/RPF
152
What is the pathogenesis of rebound rhinorrhea (nasal congestion w/o cough, sneezing or post-nasal drip)?
If you are using a ton of topic nasal decongestants (i.e. a1 antagonists like phenylephrine, xylometazoline, or oxymetazoline), after prolonged use there is negative feedback on the circuit and there is less release of norepi and so normal vasoconstrictive tone is lost. This produces edema and congestion. Risk is use of decongestants for 3+ days and tx is stopping the meds.
Note that this phenomenon is called tachyphylaxis (also seen w/ NO admin)
153
How does acute arsenic poisoning present and what is the first line tx?
Presentation: vomiting, diarrhea, abd pain, hypotension, garlic odor on breath, and there can be QT prolongation that progresses to torsades.
Tx = dimercaprol (which increases the urinary excretion of heavy metals)
154
What are the most common sources of arsenic poisoning?
Insecticide, contaminated water (often from wells), and pressure-treated wood
155
How does acute cyanide poisoning present and what is the first line tx?
Confusion, abdominal pain, vomiting and flushing/cherry-red skin color.
Tx = hydroxycobalmin
156
What is the mechanism of action of fibrates?
They activate PPAR-alpha which leads to decreased VLDL production and increased lipoprotein lipase activity.
157
What is the mechanism of cilostazol and when is it used?
It acts as a phosphodiesterase in platelets to increase cAMP levels which in turn inhibits platelet aggregation. It also acts as a direct arterial vasodilator. Together these effects make it useful for symptomatic relief of pts w/ peripheral artery disease.
158
When is arteriovenous nicking seen?
On the fundoscopic exam of pts w/ chronic htn
159
Deposition of eosinophilic hyaline material in the intima and media of small arteries and arterioles is characteristic of what?
Hyaline arteriolosclerosis. Typically seen in pts w/ HTN or DM.
160
High activity of what enzyme(s) leads to thin-cap atherofibromas?
Lots of metalloproteinases secreted by macrophages during the process of cap remodeling.
161
What is the signaling pathway that leads to T cell activation?
Stimulation of the appropriate receptor on the T cell leads to calcineuirn activation. Calcineurin will then dephosphorylate nuclear factor of activated T cells (NFAT) which goes to the nucleus and binds to an IL-2 promoter. IL-2 is important for growth and differentiation of T cells.
162
What does the NF-1 gene encode and what does this protein do?
Neurofibromin which is a tumor suppressor gene.
163
What are common aeroallergens that can precipitate asthma?
Dust mites, cockroaches, pet dander, mold, and pollen.
164
WHy don't pregnant women experience lactation during pregnancy even though they have really high PRL levels?
Because high levels of progesterone exist too and this inhibits lactation. Once progesterone levels drop after delivery, lactation can occur.
165
What is the difference between the lining of a true cyst and a the pseudocyst that can be seen in pancreatitis?
True cysts are lined by epithelium whereas pancreatic pseudocysts are lined by granulation tissue that fibroses over time.
166
How can anticonvulsants that induce the cytochrome P450 system contribute toward osteoporosis?
By increasing the catabolism of vitamin D
167
Due to gravity, aspiration pneumonia most typically develops in the most dependent portions of the lung. What are the most dependent portions when supine and when standing?
Supine --> Posterior segments of upper lobes and superior segments of lower lobes (w/ right main bronchus more suspecptible due to angle and stuff)
Standing --> basilar segments of lower lobes.
168
In addition to activating fibrin from fibrinogen, which factors does thrombin activate?
V, VIII, and XIII
169
What are the PTH, Ca and P levels in primary osteoporosis?
They tend to be normal
170
What is the most aggressive type of lung cancer? Name four markers it stains positive for.
Small cell lung cancer.
It has neuroendocrine differentiation and stains positive for neural cell adhesion molecule, neuron specific enolase, chromagranin, and synaptophysin.
171
Deficiency of which B vitamins presents w/ chelosis, stomatitis, and glossitis?
B6 (pyridoxine) and B2 (riboflavin)
172
What are angiomyolipomas and what disorder are they associated with?
They are benign tumors composed of blood vessels, smooth muscle and fat. Bilateral renal angiomyolipomas are associated w/ tuberous sclerosis.
173
Describe tuberous sclerosis
AD condition characterized by cortical tubers and subependymal hamartomas in the brain w/ consequent seizures and intellectual disability. Cardiac rhabdomyomas, facial angiofibromas, and ash-leaf patches can also occur
174
Describe sturge-weber syndrome
Congentinal vascular disorder characterized by facial port-wine stain and leptomeningeal capillary venous malformation.
175
What are effects of glucocorticoids at the liver?
Upregulate gluconeogenesis and glycogen synthesis.
176
What paraneoplastic syndrome(s) is small cell lung cancer associated w/? How about squamous cell?
Small cell --> SIADH and ACTH release
Squamous --> PTH-RP
177
What kind of drugs are etanercept, infliximab, and adalimumab?
TNF-a antagonists
178
What is the Reid index?
It is a way to quantify disease progression in COPD. In COPD disease progression is all about narrowing of the airway, mainly through submucosal gland enlargement. The Reid index is the submucosal gland layer width / the width of the surrounding epithelial layers and the underlying cartilage layer. As disease gets worse, the Reid index increases (normal baseline is > 0.4).
179
What is essential tremor and what is first line medical therapy?
AKA familial tremor and is AD inheritance. Presents w/ intention tremor where tremor is worse holding a specific position (i.e. drinking water). First line med is propanolol.
180
Inhibin supresses FSH where?
At the anterior pituitary, does NOT act at the hypothalamus. Conversely, testosterone inhibits LH at the pit and GnRH at the hypothalamus.
181
What do the BRCA genes do?
They are involved in repair of dsDNA breaks.
182
What are Curling and Cushing ulcers?
Curling --> ulcers arising in the proximal duodenum in the setting of severe trauma/burns
Cushing --> ulcers in the esophagus, stomach or duodenum in the setting of intracranial injury (increased ICP stimulates vagus nerve to stim more acid secretion).
Both of these are examples of stress-related mucosal disease.
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Which cells are responsible for uptake of Shigella species?
M cells (located w/in a Peyer's patch)
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Where are paneth cells located and what do they secrete?
They are located at the base of intestinal crypts and secrete lysozyme and defensins.
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What does psoriasis look like histologically?
Hyperkeratosis, acanthosis, elongation of the rete ridges, mitotic activity above the basal epidermal layer, and a reduced or absent stratum granulosum.
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What is Auspitz sign?
Pinpoint bleeding when scale is removed from the plaque. Seen in psoriasis.
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How does subacute granulomatous (aka DeQuervian) thyroiditis present?
Painful enlargement of the thyroid gland with accompanying transient hyperthyroid sxs (proceeding to be hypothyroid usually), usually shortly following a viral illness. Pts will have an elevated ESR/CRP and decreased iodine uptake.
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What does subacute granulomatous thyroiditis look like histologically?
Initially a neutrophilic infiltrate w/ microabscess formation. As it progresses this is replaced w/ a more inflammatory infiltrate containing macrophages and multinucleated giant cells.
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How does Riedel's thyroiditis present?
Thyroid replaced by inflammatory infiltrate and fibrous tissue and may even extend into local structures. Pts have a fixed, hard, painless goiter.
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What is the main tx for urea cycle disorders?
Protein restriction. Want growing kid to get enough essential amino acids for growth but not so much that there is excess ammonia.
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What is the defect in osteogenesis imperfecta?
Impaired osteoid production by osteoblasts, due to impaired ability to produce type I collagen.
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What are the significant adverse effects of methotrexate?
Bone marrow suppression causing pancytopenia, stomatitis, heptotoxicity and can also cause pulm fibrosis.
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What are the two major mechanisms of development of diabetic neuropathy?
1 = non-enzymatic glycosylation of proteins causing hyalinization of arterioles that feed nerves. This ischemia causes damage.
2 = accumulation of sorbitol (due to excess activity of aldose reductase) leading to osmotic damage.
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What is the defect in Charcot-Marie Tooth disease?
Mutation in a myelin protein.
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Where does the coronary sinus lie?
In the atrioventricular groove. Note that 3 lead biventricular pacemakers can wire the third lead through this space in order to reach, and thus be able to pace, the left ventricle.
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What are 3 myeloproliferative disorders that have a JAK2 mutation?
Polycythemia vera, essential thrombocytosis, and primary meylofibrosis.
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What does mantle cell lymphoma overexpress?
Cyclin-D1
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What is "merocrine" exocrine gland function? Give examples
Where cells secrete via exocytosis. Examples are salivary glands, eccrine sweat glands, and apocrine sweat glands (which formerly were thought to use apocrine method).
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What is apocrine gland function? Give an example
Cells secrete via membrane bound vesicles.
Mammary glands do this.
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What is holocrine gland function? Give examples
Where cell lysis releases the entire content of the cytosol and plasma membrane. Sebaceous glands (i.e. acne) and meibomian glands do this.
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What is specific phobia and what is the best tx?
It is marked anxiety about a specific object or situation for > 6 months.
CBT is the first line tx
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What is one thing that is unique about EHEC compared to other E. coli species in terms of its biochemistry?
EHEC does NOT ferment sorbitol, while other E. coli species do.
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On autopsy of patients that suffered an amniotic fluid embolism, the maternal pulm arteries will have fetal squamous cells and mucin in them. How does this rare complication present?
Cardiogenic shock, hypoxemic respiratory failure, DIC, and seizures or coma can occur.
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What do amatoxins (i.e. alpha amanitin from mushrooms) inhibit?
RNA polymerase II which synthesizes mRNA.
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What is the mechanism of hydroxyurea in treating sickle cell?
It increased synthesis of hemoglobin F
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How do Gardos channel blockers tx sickle cell?
They block efflux of K+ and H20 from the RBC, this prevents it from getting dehydrated and thus preventing sickling.
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What are 5 effects of the PPAR-alpha agonist T2DM drugs?
Increased insulin sensitivity at muscle and liver, increase fatty acid uptake, increased adiponectin production (this increases the # of insulin-sensitive adipocytes), decreased TNF-a production, and decreased leptin production.
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What does damage to the frontal cortex cause?
B/c this area controls executive functions and response inhibition, lesions lead to personality change, inability to organize or plan, and disinhibition.
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What sort of receptors are monoamine receptors?
G protein coupled receptors
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Colitis associated colorectal cancers are more likely to be ____ compared to normal sporadic ones?
More likely to be multifocal
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What electrolyte abnormalities can foscarnet cause?
Hypomagnesia (due to renal wasting) and hypocalcemia
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What is an adverse rxn of gancylovir?
Neutropenia. Can be augmented by other marrow suppressing agents like TMP-SMX
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What are three RF for endometriosus?
Nullparity, early menarche and prolonged menses
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How does a glucagonoma present?
Hyperglycemia or overt DM. A characteristic finding is necrolytic migratory erythema, an elevated painful and pruritic rash typically affecting the face, groin and extremities. Over time the papules of this rash coalesce to form plaques w/ a central clearing that often appears brown or bronze colored.
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What does Zn deficiency cause?
Erythematous skin lesions mainly around body orifices, impaired taste, and impaired wound healing.
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What is the difference btwn Janeway lesions and Osler nodes?
Janeway lesions and nontender lesions on palms and soles and represent vascular microthrombi from endocarditis.
Osler nodes are tender lesions on the fingertips and toepads and are the result of immune complexes.
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How does inspiration affect preload?
It will increase preload to the R heart due to drop in intrathoracic pressure. However, b/c the pressure decrease increases pulmonary vasculature compliance, there isn't a corresponding increase in L heart preload, and there is actually a transient decrease in L heart venous return (does not affect L sided murmurs like mitral regurg or VSD - if anything they decrease slightly).
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What is the most common primary cardiac neoplasm and where do they most commonly arise?
Myxoma. Like 80% arise in the L atrium.
Histo it's composed of scattered cells w/in a mucopolysaccharid stroma, abnormal blood vessels, and hemorrhage.
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What auto-antibody is granulomatosis w/ polyangiitis associated with?
C-ANCA
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What is PAS stain highlighting in staining of Whipple's disease?
glycoprotein present in the cell walls of Tropheryma whippelii.
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How can high flow O2 lead to hypercapnia (causing lethargy and confusion) in a COPD exacerbation?
When given at high amounts, this can occur. The pathophysiology is V/Q mismatch. Normally there is vasoconstriction in areas of hypoxia which shunts blood to the areas of best perfusion. But high flow O2 can undo this vasoconstriction, shunt blood back away from well ventilated alveoli, and lead to increased in physiologic dead space.
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What structure does renal clear cell carcinoma originate from?
Epithelium of the proximal renal tubule
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What drugs can be used to prevent cerebral vasospasm following rupture of a berry aneurysm?
CCBs like nimodipine
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What produces the esophageal dysmotility in CREST syndrome?
Atrophy and fibrous replacement in the muscularis
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Which glaucoma drugs increase aqueous humor outflow?
Prostaglandins (like latanoprost - these drugs are 1st line for open-angle glaucoma), and muscarinic agonists
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Which glaucoma drugs decrease aqueous humor production?
B blockers, carbonic anhydrase, A2 adrenergic agonists.
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What condition is the most common to predispose to infective endocarditis of native valves in DEVELOPED countries?
Mitral valve prolapse w/ regurgitation
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Is the fluid that accumulates in the alveolar lumen in acute HF due to L sided MI transudate or exudate?
Transudate (it's an ultrafiltrate due to hemodynamic changes)
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What is sucrose broken down into?
Fructose and glucose
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What does chronic coal dust inhalation cause?
Coal worker pneumoconiosis which has a progressive interstitial lung fibrosis due to macrophages ingesting coal particles and releasing inflammatory cytokines.
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How are teh largest inhaled particles cleared from the lungs?
They are trapped in the upper airways and are cleared via coughing and sneezing.
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What are the adrenergic receptors on pancreatic B cells and what does agonist activity at said receptors cause?
B2 --> agonism increases insulin release
a2 --> agonism decreases insulin release (this one is predominant which is why sympathetic activity generally increases insulin secretion)
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What does the ventromedial hypothalamic nucleus do?
It mediates satiety. Destruction leads to hyperphagia
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What does the lateral hypothalamic nucleus do?
It mediates hunger. Destruction leads to anorexia
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Which hypothalamic nucleus mediates heat dissipation and which one mediates heat conservation?
Heat dissipation --> Anterior nucleus
Heat conservation --> Posterior nucleus
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What causes teh "honeycombing" (cystic spaces) seen in idiopathic pulm fibrosis?
Alveolar wall collapse
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What is the murmur of mitral regurg?
A blowing holosystolic murmur, heard best over the cardiac apex, w/ radiation to the axilla.
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What is the murmur of mitral stenosis?
Opening snap at start of diastole that is followed by a low pitched mid-diastolic rumbling
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When is a pericardial knock heard and in what condition?
It's a brief, high-frequency precordial sound that is heard shortly after S2. It is seen in constrictive pericarditis.
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What sort of poisoning does ingestion of rat poison mimic? What is the acute tx for this type of poisoning?
Mimics warfarin poisoning as most rat poison has "superwarfarin" in it. Acute tx is FFP as it contains all of the clotting factors and proteins, as well as giving vitamin K.
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What does cryoprecipitate contain?
factor VIII, factor XIII, vWf and fibrinogen
242
Describe paraneoplastic cerebellar syndrome?
It is most commonly associated w/ small cell lung cancer and is where the anti-tumor antibodies cross react w/ Purkinje neuron antigens leading to progressive cerebellar signs (dysarthria, ataxia, etc.)
Most common abs are anti-Yo, anti-Hu and anti-P/Q but abs are not always seen.
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In what organelle are lysine and proline residues hydroxylated in collagen synthesis?
RER
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What do optimal handoffs contain?
Checklist of tasks and clinical status of each patient
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What cells produce aqueous humor?
Epithelial cells of the ciliary body
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What changes are seen for the following timeframes after myocardial ischemia (from MI) onset?
- 0-4 hours
- 4-12 hours
- 12-24 hours
- 1-5 days
- 5-10 days
- 10-14 days
- 2 weeks - 2 months
- 0-4 hours: minimal change
- 4-12 hours: early coagulation necrosis (cytoplasmic hypereosinophilia), edema, hemorrhage and wavy fibers
- 12-24 hours: coagulation necrosis and marginal contraction band necrosis
- 1-5 days: coagulation necrosis and neutrophilic infiltrate
- 5-10: macrophage phagocytosis of dead cells
- 10-14 days: granulation tissue and neovascularization
- 2 weeks - 2 months: collagen deposition and scar formation
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Distinguish between binge eating disorder and bulimia nervosa?
Both have binge eating behavior but w/ bulimia nervosa there are compensatory behaviors like vomiting, excessive exercising, fasting, etc. Whereas w/ binge eating disorder there are no compensatory behaviors.
248
True or false, the rash of erythema multiforme represents disseminated herpes infection?
False, it is a systemmic immune response to a local infection
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Thoracentesis should be performed between what rib levels at the midclavicular, midaxillary and paravertebral lines?
Midclavicular --> 6-8
Midaxillary --> 8-10
Paravertebral --> 10-12
*Note that generally the parietal pleura extends for about 2 rib levels down below the level of the visceral pleura adherent to the lung
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Where do intercostal veins, arteries and nerves run?
They run on the bottom of ribs. This is why when doing a thoracentesis or chest tube you want to insert it right along the top of a rib to avoid hitting these structures.
