Week 5 Flashcards by Oliver Fischer

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

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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

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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

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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

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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

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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

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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)

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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

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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

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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)

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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

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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

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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

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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

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What is the rate-limiting enzyme for glycolysis? For gluconeogenesis?

Glycolysis - Phosphofructokinase 1
Fructose-1,6-bisphosphatase

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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

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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)

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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

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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

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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

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Which anticancer agent fits the following description? Given for estrogen-sensitive breast cancers

Tamoxifen

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Which anticancer agent fits the following description? S-phase antimetabolite; myelosuppression reversible with leucovorin

Methotrexate

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Which anticancer agent fits the following description? S-phase antimetabolite; myelosuppression not reversible with leucovorin

5-Fluorouracil

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Which anticancer agent fits the following description? Ototoxic and nephrotoxic (much like aminoglycosides and loop diuretics)

Cisplatin, Carboplatin

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Which anticancer agent fits the following description? 2 agents known for causing pulmonary fibrosis

Bleomycin, Busulfan

Which anticancer agent fits the following description? Inhibits topoisomerase II

* Etoposide * Teniposide

Which GI ligaments match the following descriptions? Separates the greater and lesser sacs

* Gastrohepatic * Gastrosplenic

Which GI ligaments match the following descriptions? May be cut during surgery to access the lesser sac

Gastrohepatic

Which GI ligaments match the following descriptions? 2 ligaments that connect the spleen to other structures

Splenorenal, Gastrosplenic

Which GI ligaments match the following descriptions? Contains the portal triad

Hepatoduodenal

A 27-year-old woman has been experiencing 1-2 panic attacks every month for the past 3 months. She reports that she cannot establish a specific trigger for the panic attacks but the attacks are beginning to affect her work performance. You choose to use a benzodiazepine as needed, in combination with cognitive behavioral therapy. **How does the mechanism of benzodiazepines differ from the mechanism of barbiturates? What toxicities of barbiturates can be fatal? **

Both affect GABAa receptors which are chloride channels **Benzos** - FREQUENCY increase the frequency of Cl^-channel opening **Barbiturates** - DURATION increase the duration of Cl^- channel opening CNS effects **Respiratory depression - Hypoventilation Cardiovascular depression - Bradycardia**

A kidney transplant patient begins to experience renal failure seven years after receiving her kidney transplant. What type of rejection is this, and how is it mediated?

* Chronic rejection * T-cell an antibody-mediated vascular damage - Obliterative vascular fibrosis

A 66-year-old man crashes on his motorcycle and suffers a head injury that leaves him in a coma. Prior to this injury the man was met with his lawyer to write out specific instructions in case an event like this happened. What is it that this man and his lawyer put together?

**Written Advance Directive (Living Will)** - helps take pain and suffering off next of kin and medical care decisions if incapacitated

You are counseling a preoperative patient who has concerns about side effects related to anesthesia. Which intravenous anesthetic fits the following description Associated with hallucinations and bad dreams

Ketamine

Which intravenous anesthetic fits the following description? Most common drug used for endoscopy

Midazolam(Versed)

Which intravenous anesthetic fits the following description? Used for rapid anesthesia induction

Propofol

Which intravenous anesthetic fits the following description? Decreases cerebral blood flow (important in brain surgery)

Barbiturates

What is the cause of hypertrophic cardiomyopathy? Inheritance? Gross morphology and pathogenesis

**Genetic mutations (in at least 9 different gene segments) encoding sarcomeric proteins.** * β-myosin heavy chain * Cardiac troponin T * α-Tropmyosin * Myosin-binding protein C **AD with variable penetrance** * Myocyte hypertrophy and disarray * Massive hypertrophied LV * ↓ Compliance and poor chamber filling * Impaired diastolic filling * Reduction of stroke volume

A 60-year-old male long-time patient of yours comes to your office complaining of sexual dysfunction. What is your immediate differential diagnosis? What drugs are known for causing sexual dysfunction?

**Differential** * Hormonal disturbances * Low testosterone * Hyperprolactinemia * Depression * Diabetes mellitus * Psychological origin * Medication adverse effects **Drugs** * Antihypertensives (beta-blockers) * Neuroleptics * SSRIs * Ethanol

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 36-year-old female smoker wants to begin taking birth control. What are some disadvantages and contraindications that need to be discussed before initiating oral contraceptive pills?

* **Smokers over 35** - increased risk of CV events * **Patients with Hx of thromboembolism** - increased risk of blood clots and thromboembolism * **History of any estrogen-dependent cancer**

What is a cholesteatoma, and how does it present?

* **Overgrowth of desquamated keratin debris within the middle ear space** * May eventually erode the ossicles and external auditory canal * Commonly associated with chronic middle ear infections: **PE:** * Grayish-white "pearly" lesion behind the TM * Conductive hearing loss * Vertigo

A 25-year-old man presents with an anterior midline neck mass that moves with swallowing. The most common midline mass of the neck is a thyroglossal duct cyst. What feature of this neck mass distinguishes the mass from a branchial cleft cyst? What is the remnant of the thyroglossal duct? Explain the development of the thyroid gland.

**Thyroglossal Duct Cyst** * Midline location * Moves with swallowing **Foramen Cecum** * Thyroid diverticulum arises from the floor of th primitive pharynx * Descends into the neck * Thyroid remains connected to the tongue by the thyroglossal duct, which normally disappears

Hyper- or hypothyroidism? Constipation

Hypothyroidism

Hyper- or hypothyroidism? Elevated TSH

Hypothyroidism

Hyper- or hypothyroidism? Fine hair

Hyperthyroidism

Hyper- or hypothyroidism? Brittle hair

Hypothyroidism

Hyper- or hypothyroidism? Dry skin

Hypothyroidism

Hyper- or hypothyroidism? Pot-bellied, pale neonate

Cretinism (severe fetal hypothyroidism)

Hyper- or hypothyroidism? Proptosis

Hyperthyroidism

A 54-year-old white man presents with a single non-healing skin lesion on the right ala of the nose for 6 months. The skin lesion has a rolled border with central ulceration and associated telangiectasia. You decide to use 5-fluorouracil (5-FU) a topical treatment for this skin lesion. **What type of cancerous lesion does this patient have? What are some other uses for 5-FU?**

**BCC** - **commonly described as a "_pearly papule" + telangiectasias_** 5-FU used for **colon cancer and other solid tumors Topical treatment for actinic keratoses** which can become squamous cell skin cancers

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)

A 15-year-old boy is brought to the pediatric ER with change of mental status and vomiting. Capillary blood glucose (CBG) is 550 mg/dL. What are the signs and symptoms of diabetic ketoacidosis (DKA)? What is the treatment?

***D**iabetic **K**etoacidosis **FAND*** * *D**ehydration (very common) * *K**ussmaul respirations - deep regular labored breathing * *F**ruity breath (Ketones) * *A**bdominal pain * *N**ausea/vomiting * *D**elirium and altered mental status **Treatment** * IV **fluids** * IV **K⁺**to replete potassium stores * IV **insulin** * **Follow the anion gap** (give insulin until anion gap closes - tells you no more ketones being made, don't stop insulin until anion gap is completely closed!)

You are seeing a 3-year-old boy while on an international rotation in Uganda. The patient is experiencing right sided jaw edema. What viral illness is associated with Burkitt lymphoma? Is Burkitt lymphoma a neoplasm of mature T-cells or B-cells? Where are T-cells found in the spleen? Where are B-cells found in the spleen?

EBV B cell lymphoma T cells found in periarterial lymphatic sheath (PALS), White pulp of the spleen B cells - White pulp of the spleen

A 40-year-old man is beginning to have symptoms of a resting tremor, postural instability, and mask-like (expressionless) facies. Name the antiviral drug and its mechanism of action that could be used against this disease.

* Parkinson disease * Amantadine * Increases release of dopamine

A fetus at 34 weeks gestational age is diagnosed with intrauterine growth retardation on third trimester sonogram. **What weight is the cut-off for low birth weight?** **What complications associated with low birth weight might the physician discuss with the expectant parents?**

* **\<2500 g** * **Physical and emotional problems** * **Infections** (sepsis, pneumonia, meningitis) * **Respiratory distress syndrome** * **Necrotizing enterocolitis** * **Intraventricular hemorrhage** * **Persistent fetal circulation**

An elderly man is in the ICU after a joy ride on his classic American motorcycle went horribly wrong. The patient was placed in the ICU because of multiple rib fractures that resulted in a flail chest which, combined with his mild COPD, made his respiratory status very fragile. During the first few days in the ICU, the patient was clear-headed. However, now he is uncooperative and is trying to crawl out of bed and leave the unit. He also doesn’t seem to have any idea where he is or why he is in the hospital. **What are the main differences between delirium and dementia?** **Which is more commonly reversible?**

**Delirium - rapid decline in cognitive function** * Waxing/waning levels of consciousness * Acute onset * Secondary to other illnesses * Abnormal EEG * Reversible (like sepsis) **Dementia - slow decline in cognitive function** * No alterations in consciousness * Slow decline in cognitive function * Not caused by acute medical illnesses * Normal EEG * Irreversibly

**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**

What is the difference between a dislocated shoulder and a separated shoulder?

**Dislocated** — head of humerus rotates out of glenoid cavity **Separated** — clavicle separates from acromion and coracoid process of the scapula

A 6-week-old child is referred to the pediatric cardiologist for failure to thrive, exertional cyanosis, and washing machine-like heart murmur. **What are the early cyanotic heart diseases?** **What are the late cyanotic heart diseases?**

Early cyanotic heart diseases * Truncus arteriosus (One finger) * Transposition of the great vessels (cross 2 fingers) * Tricuspid atresia (3) * Tetralogy of Fallot (4 tetra) * Total Anomalous Pulmonary Venous Return (TAPVR) (5 words and total so it's five)) Late cyanotic heart diseases * ASD * VSD * PDA

A study of post-diabetes education examination scores reveals results in a normal gaussian distribution. What percentage of the sample population falls 1 standard deviation, 2 standard deviations, and 3 standard deviations?

* 1 SD: 68% * 2 SD: 95% * 3 SD: 99.7%