Week 5 Flashcards
29-year-old woman presents to the ER with an acute onset of severe right-sided pelvic pain that began 6 hours ago while she was playing basketball with her son. She also reports nausea and vomiting. There is no fever. A pelvic exam reveals an absence of bleeding, a normal-appearing vaginal discharge, and a right adnexal mass with tenderness. On abdominal exam, there are no peritoneal signs. CBC is normal. Beta-hCG is negative. What is the most likely diagnosis?
Predisposing factors?
How do you confirm the diagnosis?
Ovarian Torsion - Ovary rotates around the infundibulopelvic ligament and the uteroovarian ligament
Predisposing factors: Ovarian cyst or neoplasm
Confirm the diagnosis with a pelvic ultrasound
You are asked to perform a pulmonary function test on a young asthmatic. What is the definition of tidal volume? Of residual volume? Of vital capacity?
- *Tidal volume** - volume of air in a normal, quiet breath
- *Residual volume** - Volume of air left in your lungs after a forced expiration
- *Vital capacity** - Maximum amount of air that you can take into your lungs, minus residual volume
What physiologically is taking place in decompression sickness?
Gases that had dissolved at high pressures comes out of solution and form bubbles that occlude blood vessels
An active 31-year-old woman who frequently hikes comes to your office on Monday. A few days ago she went hiking and now has diarrhea. From what she describes, you begin to suspect Giardia infection. What are the typical symptoms of a Giardia infection of the GI tract?
- Bloating
- Flatulence
- Foul-smelling, fatty diarrhea
Giardia is almost always contracted from drinking from a stream or river
A 34-year-old AIDS patient is brought to the ER by his partner. The patient is sleeping when you arrive but his partner reports that over the past few days the patient has been increasingly confused and lethargic.
What opportunistic CNS infections are common in AIDS patients?
- JC viral encephalopathy (causes PML - progressive multifocal leukoencephalopathy)
- **Toxoplasma gondii ** causing brain abscess (cat litter boxes, pork)
- Cryptococcus neoformans (yeast in pigeon droppings) causing meningitis or encephalitis
- Cytomegalovirus -retinitis: inflammation of retina and optic nerve
- AIDS dementia
A 20-year-old man is stabbed in the back at a party. He is brought to the ER and taken to the OR by the neurosurgeon. The knife blade is found to have hemisected the spinal cord. What clinical findings will this patient have? Which division of the dorsal column relays sensory information from the lower extremities?
Brown-Sequard syndrome
Ipsilateral:
- Loss of motor function
- Loss of vibration sense and fine touch
- Loss of proprioception
- Loss of 2-point discrimination
- Weakness
Contralateral:
- Loss of pain sensation
- Loss of temperature sensation
Fasciculus gracilis
A patient who recently suffered a brain hemorrhage as a result of a motor vehicle accident is now complaining of difficulty concentrating. You perform a full neurological exam and suspect that her symptoms may be due to a frontal lobe lesion.
How would patient symptom complaints differ between a parietal and a frontal lobe lesion?
Frontal lobe - similar to alcohol
- Disinhibition
- Problems with concentration/orientation
- Poor judgment
- Reemergence of primitive reflexes (if severe)
Parietal lobe
- Spatial neglect syndrome (contralateral to the lesion)
A young man with sickle cell anemia comes in for periodic blood transfusions as part of his therapy. What long-term complication is associated with having to receive multiple blood transfusions?
iron overload
You are rotating with an anesthesiologist and learning to calculate dosages of anesthetics with her. How does the rate of elimination differ between zero-order elimination and first-order elimination? Which type of elimination behaves as though the enzymes responsible for the elimination are saturated?
- *Zero order** - constant amount eliminated per unit time
- *First order** - constant fraction eliminated per unit time
Zero order - amount metabolized stays constant reglardless of plasma concentration
A 40-year-old woman comes to the ER with a painful, red right eye. The eye is rock hard on gentle palpation. What is the diagnosis and what’s the next step?
Close Angle (Narrow Angle) Glaucoma - ophthalmic emergency due to pressure build up between lens and iris
- Avoid epinephrine
- β-blocker (timolol)
- α2-blocker (apraclonidine)
- Cholinergic agonist (pilocarpine)
In cystic fibrosis thick, mucous secretions inhibit digestive enzymes, which can lead to fat soluble vitamin deficiency. What are the fat soluble vitamins? What are the corresponding symptoms of fat soluble vitamin deficiency?
ADEK
- *A** - Night blindness, dry skin
- *D** - Children - Rickets, Adults - Osteomalacia, hypocalcemia and tetany
- *E** - Fragile erythrocytes, muscle weakness, CNS demyelination
- *K** - Coagulation factor defects - Heavy menstrual bleeding, anemia, bruising, bleeding gums, epistaxis, osteoporosis, CAD
A 34-year-old man has had an elevated BUN and creatinine for the past 4 days. The patient’s urine osmolality is 600mOsm/L, urine Na 5mmol/24hours, FeNa 0.5%, and Serum BUN/Creatinine 25:1. What type of azotemia does this patient have? What is the primary mechanism of this patient’s azotemia? What are some causes of postrenal azotemia?
FENa < 1%, the kidneys are sensing low blood pressure, being underperfused, desperately trying to hang onto sodium and water so excreting a small fraction that comes through
BUN: creatinine ratio >20:1 it is pre-renal
Low renal blood flow -> low GFR
Postrenal Azotemia: Obstruction of urine outflow
- Urinary tract stones
- BPH
- Tumors
- Congenital anomalies
At what positive G force does visual “black-out” occur? Why does this occur?
Visual blackout occurs at 4-6 G
Centrifugal force is pooling blood in the abdomen and legs
- Insufficient blood return to the heart
- Insufficient pumping of blood to the brain
A 57-year-old man comes to his internist complaining of peripheral edema, flushing, and constipation after starting a calcium-channel blocker for his hypertension. Which calcium channel blockers work primarily on the heart? Which ones work on vascular smooth muscle?
Heart - Verapamil
Vascular smooth muscle - Dihydropyridines (nifedipine, felodipine, amlodipine, etc)
Diltiazem is half-half
What is the rate-limiting enzyme for glycolysis? For gluconeogenesis?
- Glycolysis - Phosphofructokinase 1
- Fructose-1,6-bisphosphatase
In performing a lumbar puncture to obtain a sample of CSF, what structures are pierced, starting with the most exterior?
Skin & superficial fascia
Ligaments
- Supraspinous ligament
- Interspinous ligament
- Ligamentum flavum
Epidural space
Dura mater
Subdural space
Arachnoid mater -> CSF lives
A 3-day-old preterm infant delivered at 34-weeks gestational age develops respiratory distress syndrome (RDS). What types of pneumocytes are affected in RDS? What is the mechanism that leads to poor O2-CO2 exchange at the gas exchange barrier in preterm infants with RDS? What structures make up the gas exchange barrier?
Type II pneumocytes secrete surfactant
Gas exchange barrier
- Type I epithelial cells
- Basement membrane
RDS: inflammation and hyaline membranes (fibrin, cellular debris, RBCs, neutrophils, and macrophages)
How many umbilical vessels are there? Which umbilical vessel has the highest oxygen content?
3: 2 umbilical arteries, 1 umbilical vein (highest oxygen content) Ductus venosus and pulmonary artery have higher oxygen than the aorta
A 43-year-old man presents with right-sided flank pain and hematuria. A helical abdominal CT reveals a right-sided 1.5cm ureterovesicular calculus. The stone is passed after being treated with fluids, pain control and lithotripsy. Incidentally the abdominal CT also reveals an isthmus connecting the inferior poles of the kidneys.
During fetal development, what structure traps the inferior poles of the kidney resulting in a horseshoe kidney? Do patients with horseshoe kidneys have abnormal renal function?
- Inferior mesenteric artery
- No abnormal renal function
A 25-year-old man “took a sick blow” to his right shoulder after colliding into a tree narrowing while mountain biking. The patient’s right arm is hanging by his right side in pronation and medial rotation. The patient’s clavicle, right arm and shoulder x-rays do not reveal a fracture or dislocation.
What are the common causes of Erb-Duchenne palsy?
Where is the brachial plexus insult with Erb-Duchenne palsy?
Severe traction/tear of the upper trunk of the brachial plexus (C5 and C6 roots)
Findings:
- Limb hangs by side (paralysis of abductors)
- Medially rotated (paralysis of lateral rotators (infraspinatus (supraclavicular nerve)
- Forearm is pronated (loss of biceps)
Causes:
- Blow to the shoulder, fall off motor cycle, horse
- Trauma during delivery
Erb-Duchenne - C5, C6 roots
Which anticancer agent fits the following description? Given for estrogen-sensitive breast cancers
Tamoxifen
Which anticancer agent fits the following description? S-phase antimetabolite; myelosuppression reversible with leucovorin
Methotrexate
Which anticancer agent fits the following description? S-phase antimetabolite; myelosuppression not reversible with leucovorin
5-Fluorouracil
Which anticancer agent fits the following description? Ototoxic and nephrotoxic (much like aminoglycosides and loop diuretics)
Cisplatin, Carboplatin
Describe the flow of blood into and out of the thyroid gland.
Arterial supply
- External carotid artery -> Superior thyroid artery
- Thyrocervical trunk -> Inferior thyroid artery
Venous drainage
- Superior thyroid vein
- Middle thyroid vein
- Inferior thyroid vein
A 53-year-old electrician develops a gradual onset of poorly localized right shoulder pain that improves with ibuprofen and rest. The patient has full range of motion in his right shoulder, but has pain with overhead movements. The patient exhibits weakness when performing the “empty can” test which isolates the supraspinatus portion of the rotator cuff. This finding most likely indicates an impingement syndrome of the right shoulder.
What muscles compose the rotator cuff?
“SITS”
- Supraspinatus (allows you to abduct arm first 15°) Test with empty can test - point thumb down and raise can - if hurts = rotator cuff impingement syndrome
- Infraspinatus (lateral rotator)
- Teres minor (lateral rotator)
- Subscapularis (medial rotator)
Presentation of anterior vs. posterior shoulder dislocation.
- Arm position*
- Neurovascular compromise*
- Classic scenario*
- Physical exam*
Anterior dislocation
- Arm position: External rotation and slight abduction
- Neurovascular compromise: Axillary artery and nerve at risk
- Classic scenario: Blow to abducted, externally rotated, extended arm (blocking basketball shot)
- PE: Prominent acromion; Loss of shoulder roundness, Bankart and Hill-Sak lesions possible, supraspinatus tndon injury
Posterior dislocation
- Arm position: Internal rotation and adduction; Unable to externally rotate
- Neurovascular compromise: Unusual
- Classic scenario: Blows to the anterior shoulder; Seizures and electrocution (violent muscle contractions)
- PE: Posterior prominence; Anterior shoulder is flat
