Za Uwarudo review cards Flashcards
1
Q
<p>In addition to upregulating lipoprotein lipase, what other enzyme do fibrates inhibit? </p>
A
<p>Cholesterol 7 alpha-hydroxylase (rate limiting step in bile formation, which can potentially decrease bile secretion leading to cholesterol gallstones). </p>
2
Q
<p>What affect do estrogens have on cholesterol synthesis? </p>
A
<p>They up-regulate HMG-CoA reductase, increasing cholesterol synthesis. </p>
3
Q
<p>In the urea cycle, conversion of arginiosuccinate to arginine releases what?</p>
A
<p>Fumarate (tying the TCA cycle to the urea cycle)</p>
4
Q
<p>What functions are folate derivatives crucial for? </p>
A
<p>Nucleic acid synthesis (particularly thymidine), conversion of homocysteine into methionine, and generation of S-adenosyl-methionine (SAM, for methylation reactions). </p>
5
Q
<p>What amino acids are necessary for nucleic acid synthesis? </p>
A
<p>Glutamine, Aspartate, and Glycine (GAG)</p>
6
Q
<p>What infection is associated with Classical Galactosemia? </p>
A
<p>E. coli sepsis. </p>
7
Q
<p>When would Classical Galactosemia likely appear?</p>
A
<p>In the first few days of life (milk has lactose which contains galactose). Hereditary fructose intolerance would appear later when fructose containing foods are introduced. </p>
8
Q
<p>What accounts for the splenomegaly seen in hemolytic anemia syndromes (Sickle cell, pyruvate kinase, spherocytosis, ect)?</p>
A
<p>Red pulp hyperplasia (increased activity of reticuloendothelial macrophages). </p>
9
Q
<p>What process does acidosis stimulate in renal tubular cells? </p>
A
<p>Renal ammoniagenesis (glutamine in converted into glutamate, which is then converted into alpha-ketoglutarate, releasing NH3 into the urine to bind H+ making NH4+). </p>
10
Q
<p>What is the major mechanism of renal acid secretion in chronic acidosis? </p>
A
<p>Renal ammoniagenesis. </p>
11
Q
<p>A deficiency of what enzyme would present similarly to G6PD deficiency? </p>
A
<p>Glutathione reductase </p>
12
Q
<p>What is the role of hormone sensitive lipase? </p>
A
<p>Initiates lipolysis in adipocytes in response to stress hormones (glucagon, catecholamines, ect) leading to release of free fatty acids and glycerol. Provides substrates for gluconeogenesis and ketogenesis in times of starvation. </p>
13
Q
<p>What is Zellweger syndrome? </p>
A
<p>An inborn error of metabolism cause dby an absence of peroxisomes, leading to an inability to beta-oxidize very long chain fatty acids (VLCFA's). </p>
14
Q
<p>Where can gene enhancers or silencers be located?</p>
A
<p>Anywhere upstream, downstream, or within introns of the transcribed gene. Bind activators/repressors that directly bind RNA polymerase II/transcription factors (which are directly bound to promotor) to enhance or silence transcription. </p>
15
Q
<p>What is the probability that the sister of a male with an x-linked disease and normal parents is a carrier? </p>
A
<p>If the parents are normal then the mother is a carrier and the father has a normal X, which makes the probability of her being a carrier 50%. She then conversely has a 50% chance of passing on the affected X chromosome. </p>
16
Q
<p>What is the inheritance pattern of mitochondrial disorders? </p>
A
<p>Mitochondrial disorders are exclusively inherited from one's mother (maternal inheritance). </p>
17
Q
<p>What accounts for the variable expressiveness of mitochondrial disorders? </p>
A
<p>Heteroplasmy (mitochondria are randomly distributed among daughter cells after mitosis with some having more or less damaged mitochondrial DNA). </p>
18
Q
<p>Do mitochondrial disorders preferentially affect males or females? </p>
A
<p>Mitochondrial disorders equally affect males and females. </p>
19
Q
<p>What is the inheritance pattern of androgenic alopecia? </p>
A
<p>Polygeneic (i.e. multiple genes result in phenotype. Hypertension is another example). </p>
20
Q
<p>What are some dysmorphic features of Down's?</p>
A
<p>Epicanthal folds, upslanting palpebral fissures, a protruding tongue, and excessive skin at the nape of the neck. </p>
21
Q
<p>What is the sound ausculated with with a VSD (such as that found with Down's)?</p>
A
<p>A holosystolic murmur heard at the sternal border. </p>
22
Q
<p>Does Down's present with hypotonia or hypertonia at birth? </p>
A
<p>Hypotonia and a weak startle/Moro's reflex (Edwards would have hypertonia). </p>
23
Q
<p>How can the infertility of cystic fibrosis be differentiated from that of primary ciliary dyskinesia? </p>
A
<p>Cystic fibrosis has infertility due to an absence of the vas deferens (azoospermia) whole primary ciliary dyskinesia has infertility due to immobile sperm (the vas deferens are still patent). </p>
24
Q
<p>What is the probability that an unaffected child (with unaffected parents) and a sibling with an autosomal recessive disease is a carrier for that disease? </p>
A
<p>2/3</p>
25
What is the name for a study where one group starts with a placebo, the other with the treatment, and then after a period of time the placebo and treatments are switched?
A crossover study.
26
What is a case series study?
A descriptive study that tracks patients with a known condition (e.g. exposure, risk factor, or disease) to document the natural history or response to treatment.
27
Would blood pressures being measured over one week count as a time-frame?
No, it simply means that it took a week to get a single measurement/data point. Bring this up because of a question asking about a cross-sectional study (i.e. a snapshot taken in the present to assess prevalence) and confused measuring BP over a week as a time-frame (which made me pick case control as an answer). It would only be a time frame if multiple measurements/data points were taken over time, and if there was a control and experimental group (this question only mentioned a randomized study population).
28
What is a cross-sectional study?
A study that looks at the frequency of a disease (prevalence) at a particular point in time (snapshot). Would not have a control and experimental group like a case control or cohort study would.
29
What statistical value is the most sensitive to an outlier?
The mean (i.e. a large outlier would change the mean. The mode is the most resistant since it is the most common value and thus would not be changed by an outlier).
30
What is the embryological defect in tetralogy of fallot?
Displacement of the infundibular septum due to abnormal neural crest cell migration. While the endocardial cushions (defects seen with Down's) are also neural crest abnormality of them would result in ostium primum ASD and AV valve malformations.
31
What is the issue with total anomalous pulmonary venous return (TAPVR)?
TAPVR is when the pulmonary vein drains into the SVC, resulting in both oxygenated and deoxygenated blood entering the right atrium.
32
What type of collagen is found in granulation tissue?
Type II collagen (reticular).
33
What type of collagen would be found in scarred myocardium months after an MI?
Type I collagen (also found in tendons, dermis, ect).
34
What course does the left lead of a biventricular pacemaker take?
It passes through the coronary sinus, which resides in the atrioventricular groove on the posterior aspect of the heart.
35
If a question asks to calculate the number of false negatives of a test, what value should be used?
The sensitivity is the measurement that deals with true positive (TP) and false negatives (FN). I.e. if the sensitivity was 75% (75% of people with disease test positive) and 200 patients out of 600 had a disease then the number of FN would be 25% of 200 (50).
36
If a question asks to calculate the number of false positives, what value should be used?
The specificity is the measurement that deals with true negatives (TN) and false positives (FP). I.e. if the specificity of a test was 80% (80% of people who don't have the disease test negative) and 200 out of 600 people had a disease, the number of false positives would be 20% of 400 (80).
37
What cardiac abnormality is Freidreich Ataxia associated with?
Hypertrophic cardiomyopathy.
38
What cardiac abnormality is tuberous sclerosis associated with?
Valvular obstruction from cardiac rhabdomyomas.
39
What is Pulsus Paradoxus (sharp decrease in BP upon inspiration) associated with?
Cardiac tamponade, asthma, and COPD.
40
What is Kussmaul's sign (elevated JVP upon inspiration) associated with?
Constrictive pericarditis and restrictive pericarditis.
41
What is loratadine?
A 2nd generation H1 antagonist (less anti-muscarinic effects and less sedation). Don't be confused by the suffix ("dine" is usually associated with H2 blockers).
42
The presence of what interval in the CI of a cohort or case control study would render the results statistically insignificant?
1
43
The presence of what interval in the CI for a mean difference between two variables would render the results statistically insignificant?
0
44
What disorders can present with pheochromocytoma?
MEN2A, MEN2B, Neurofibromatosis-1, Von-hippel lindau .
45
What will giving iodine (or iodine containing substance like amiodarone) to someone with a baseline hyperthyroid state (Grave's, toxic multinodular goiter) result in?
Jod-Basedow phenomenon (hyperthyroidism in the presence of increased iodine).
46
What will giving iodine (or a iodine containing substance like amiodarone) to someone with normal thyroid function result in?
Wollf-Chiakoff effect (hypothyroidism in the presence of increased iodine).
47
What is the typical progression of a thyroiditis?
Initially hyperthyroid (damaged follicles release thyroid hormone) but progresses to hypothyroidism (damaged follicles cannot synthesize more).
48
What is the only painful/tender thyroiditis?
Subacute/de Quervain/granulomatous thyroiditis.
49
What endocrine abnormality can result in atrial fibrillation?
Hyperthyroidism (check TSH levels in an afib patient).
50
What would be an example of a wide QRS complex SVT (SVT usually narrow complex, has to be distinguished from vtach)?
Afib in a WPW patient. Can be distinguished from Vtach by being irregularly irregular. Important because the usual afib drugs (b-blockers, Ca2+ blockers, adenosine, digoxin) cannot be used. Use procainamide or ibutilide instead.
51
What kinase inhibitor is used for melanoma?
Vemurafenib (inhibits BRAF kinase)
52
What is a potential consequence of Kawasaki's disease?
Coronary artery aneurysm (which can lead to myocardial ischemia).
53
What type of cells are the adrenal medullary chromaffin cells, and what are they activated by?
The chromaffin cells are post-ganglionic sympathetic neurons and are stimulated by acetylcholine secreted by pre-ganglionic sympathetic neurons.
54
What is calcipotriene?
A vitamin D analog used in the treatment of psoriasis. Binds to the vitamin D receptor (a nuclear transcription factor) resulting in inhibition of keratinocyte proliferation.
55
What is ustekinumab?
An anti IL-12 and IL-23 antibody used in the treatment of psoriasis.
56
What is one of the most effective preventative measures a patient can take to reduce mortality?
Smoking cessation. (question presented a hypertensive diabetic. I was thinking smoking cessation but put exercise just to see, but smoking cessation was the correct answer after all).
57
Where are posterior pituitary hormones synthesized?
The hypothalamus (supraoptic and paraventricular nuclei). Damage to the hypothalamus can thus result in permanent DI (while damage to the posterior pituitary results in central DI it would not persist for years as the patient in the question did).
58
What can cause transient central DI?
Damage to the posterior pituitary (if the hypothalamic nuclei are intact then axonal regeneration can occur). Only damage to the hypothalamus will result in permanent central DI.
59
What is the most common complication of herpes zoster?
Persistent local pain (postherpetic neuralgia). Initially put recurrent skin rash but VZV does not cause recurrent rashes in immunocompromised hosts, only HSV does that.
60
What happens to c-peptide after it is cleaved from proinsulin?
It is stored together with the insulin in secretory vesicles. Both are released upon beta cell stimulation.
61
Elevated serum levels of what substance contributes to the insulin resistance of type II DM?
Free fatty acids. Chronically elevated FFA impairs insulin dependent glucose uptake by cells and also stimulates hepatic gluconeogenesis. (initially put c-peptide but that does not cause insulin resistance).
62
What is a large tongue and an umbilical hernia indicative of in an infant with failure to thrive?
Congenital hypothyroidism/Cretenism. Most commonly due to an absence of the thyroid peroxidase enzyme (dyshormonogenesis). Remember that it is asymptomatic at first due to persistence of maternal T4.
63
What is PPAR-gamma?
Peroxisome-proliferator-activated-receptor-gamma. An intracellular nuclear receptor that binds to the retinoic acid receptor upon activation to then transcribe genes. PPAR-alpha is similar but is the target of fibrates.
64
What drugs target PPAR-gamma?
The diabetic medications thiozolidinediones (all have the suffix "glitazone", like pioglitazone and rosaglitazone).
65
What is one of the most important products upregulated by PPAR-gamma activation?
Adiponectin, a cytokine secreted by adipose tissue that increases insulin sensitivity and fatty acid oxidation.
66
What are the cancers associated with Psammoma bodies?
Papillary thyroid carcinoma, Serous cystadenoma/cystadenocarcinoma (ovarian tumor), Mesothelioma, and Meningioma (mneumonic: PSMM, i.e. psammoma with the vowels removed).
67
What can cause secondary lactase deficiency?
Processes that damage the microvilli, like celiac's or infection (like giardia, question was 2 year old with giardiasis who then had similar diarrhea after treatment for the giardia).
68
Where are the parietal cells located in the gastric glands?
In the upper glandular layer (in the body and fundus). Arrow was pointing to the top of the glands below the gastric mucosa.
69
What is the appropriate response to a patient taking an herbal weight loss supplement?
Explain the risks of unregulated supplements to the patient.
70
What is the treatment for arsenic poisoning?
Dimercaprol, a chelating agent that increases excretion of heavy metals. Also used for lead poisoning.
71
What is essential to making the diagnosis of thrombotic thrombocytopenic purpura (TTP)?
Hemolytic anemia and thrombocytopenia (renal failure, fever, and CNS dysfunction are far less important diagnostic features).
72
Where does negative selection of T-cells occur?
In the thymic medulla (question mentioned medullary dendritic cells). Positive selection occurs in the thymic cortex.
73
What two B-cell malignancies are CD5+?
CLL/SLL and Mantle cell (11:14 translocation, cyclin D1).
74
What electrolyte abnormality does amphotericin B nephrotoxicity result?
Hypokalemia (due to increased membrane permeability of distal tubule cells, i.e. type I RTA). Hypokalemia leads to weakness and cardiac arrhythmias (PVCs, ect).
75
What is the most common presenting symptom of a pancoast tumor?
Shoulder pain due to involvement of the lower brachial plexus (specifically the inferior trunk causing C8/T1 dysfunction).
76
What is one manifestation of pulsus paradoxus?
Systolic Kortakoff sounds only heard during inspiration (drop in BP upon inspiration renders then inaudible at the time).
77
What is the MOA of prostaglandins (like latanoprost) in the treatment of glaucoma?
They increase uveoscleral outflow of aqueous humor.
78
What additional symptom could be seen in a patient with atherosclerotic renal artery stenosis?
Post-prandial pain due to intestinal ischemia also caused by atherosclerosis (don't forget that atherosclerosis is an example of a disease process that can affect multiple organ systems concomitantly).
79
What is globus sensation?
An abnormal sensation of a foreign object in the throat that is worse after swallowing saliva. It is associated with anxiety disorders.
80
What is DNA laddering?
The appearance of DNA fragments in multiples of 180 base pairs that appear on gel electrophoresis of apoptotic cells. An absence of such fragments indicates a cell that is resistant to apoptosis.
81
Can a 15:17 translocation AML occur in adults?
Yes. (I chose 9:22 because I thought 15:17 AML was exclusively in children, but apparently it can occur in adults. Histology even showed the appearance of auer rods)>
82
What is a common risk factor for postpartum endometritis (occurs in the uterus)?
Cesarean section (introduction of cervicovaginal flora into the uterus).
83
Can shingles occur in a 4 year old child?
Yes, especially if they had a primary (chickenpox) infection in the first year of life (cold with generalized rash).
84
What is reflection?
A facilitating interview technique where a physician repeats what a patient said either exactly or paraphrased (ex. "So you have been drinking more in response to your divorce?"). Shows the patient that you have been listening and strengthens the patient-physician relationship.
85
What happens to GFR immediately after and then long-term following a single nephrectomy?
Immediately after GFR is reduced to 50% compared to pre-surgery, with the remaining kidney eventually adapting to 80% of pre-surgery GFR.
86
Where are N-terminal transport signals translated?
In the cytosol, where they direct transport to the ER. If a preprohormone did not have a signal peptide then it would be stuck in the cytosol, not the ER.
87
What maintains the high concentrations of testosterone in the semineferous tubules?
Androgen binding protein (ABP) which is synthesized by the sertoli cells.
88
What arterial blood gas changes occur with a pulmonary embolism?
V/Q mismatch leads to hypoxemia, triggering ventilation reflexes (tachypnea). This decreases PaCO2 levels (respiratory alkalosis) but can't fully account for PaO2 (i.e. decreased PaCO2 and PaO2).
89
What is the pathogenesis of idiopathic pulmonary hypertension?
Pulmonary arterial endothelial dysfunction followed by an increase in the tunica media (SM).
90
What effect would adding more enzyme have on the reaction kinetics?
Increases Vmax (be careful though as this would translate to a smaller y intercept on the lineweaver-burke plot since the y-intercept is 1/Vmax).
91
What allows for apoptotic protein translation during apoptosis (elongation factors are degraded so an alternative method is used)?
Internal ribosomal entry sites (IRES). I thought IRES was only found in picornaviruses but eukaryotes also have IRES which allows pro-apoptotic proteins to continue to be translated even though caspases have degraded translation elongation factors.
92
What is the cause of peripheral artery disease (intermittent claudication)?
Atherosclerotic plaques (put DVT because I thought that could cause it, and the diabetic patient had foot ulcers which I thought was venous insufficiency, but that is a separate issue from the claudication).
93
What kind of nerve fibers are post-ganglionic autonomic nerves?
Unmyelinated nerve fibers (others include afferent fibers for heat sensation and slow burning pain, i.e. C fibers).
94
What can iron deficiency anemia present with?
Loss of taste sensation, glossal pain (burning sensation in mouth) and chelitis.
95
Would a testicular varicocele reduce when lying down?
Yes, due to increased venous drainage. Was unsure if a varicocele would reduce like that which is why I put testicular cancer.
96
Would a testicular varicocele illuminate under pen light?
No.
97
What serological effects does vitamin D supplementation have?
Increased calcium, increased phosphate, and decreased PTH.
98
What happens during the cooling step of PCR?
Binding of the primer to single stranded DNA.
99
What is the presentation of primary HSV-1 infection in a child?
Gingivostomastitis (vesces on the lips and hard palate with fever and cervical lymphadenopathy).
100
How can Hand Foot and Mouth disease be differentiated from gingivostomastitis (primary HSV-1 infection)?
Hand foot and mouth disease presents with vesicles on the buccal mucosa, tongue, and soft. Primary HSV-1 infection meanwhile will present with vesicles on the lips and hard palate
101
Is griseofulvin a cytochrome P450 inhibitor or inducer?
Griseofulvin is a P450 inducer (it is the azole antifungals that are inhibitors, but griseofulvin is an inducer).
102
Are macrolides cytochrome P450 inhibitors or inducers?
Macrolides (erythromycin, ect). are P450 inhibitors.
103
What statin is not metabolized by CYP P450 enzymes?
Pravastatin.
104
What prokaryotic DNA polymerase has 5'-3' exonuclease activity?
DNA polymerase I
105
What is the MOA of C. difficile toxins A and B?
They inactivate rho regulatory proteins leading to disruption of the enterocyte actin cytoskeleton.
106
Does niacin reduce the risk of cardiovascular events?
Even though niacin is the most effective at raising HDL, it does not reduce the risk of cardiovascular events. Only statins actually reduce risk, and are indicated regardless of baseline lipid levels.
107
Can IgA nephropathy present with anemia or thrombocytopenia?
No. If a child has bloody diarrhea and then presents a few days later with anemia, thrombocytopenia, and renal failure then it is Hemolytic Uremic Syndrome (HUS - microangiopathic anemia due to microthrombi), not IgA nephropathy.
108
What is gallstone ileus?
When a large gallstone causes a fistula between the gallbladder and GI tract (usually duodenum).
109
Where does a gallstone lodge in the GI tract following gallstone ileus?
The gallstone tends to lodge in the ileum (narrowest portion of the small bowel).
110
What are two systemic sequelae of diphtheria toxin?
Neurologic toxicity and myocarditis/heart failure.
111
What do viridans Streptococci adhere to in the setting of endocarditis?
Fibrin-platelet aggregates.
112
What does binding of ATP to the myosin head in skeletal muscle do?
Myosin head detachment from the actin filament (the need of ATP to release the myosin head from actin is what accounts for rigor mortis after death).
113
Is zero order kinetics a constant amount metabolized or a constant proportion metabolized?
Zero order kinetics is a constant amount metabolized (ex will always metabolize 10 mg ethanol no matter how much is ingested) while first order kinetics is a constant proportion (amount metabolized will increase with drug amount but the proportion is constant).
114
What happens to the kinetics of a first order drug as it reaches saturation/maximum amount that the body can metabolize?
It switches over to zero order kinetics (constant amount metabolized). (ex if 500 mg is the maximum amount that the liver can metabolize of drug x then once the concentration of drug x reaches that then any increase in the concentration will still result in 500 mg being metabolized).
115
What are the toxicities of aminoglycosides?
Nephrotoxicity and ototoxicity.
116
What should severe comedomal acne in a young athlete raise suspicion of?
Anabolic steroid abuse.
117
What does elevated acetylcholinesterase levels in amniotic fluid suggest?
A neural tube defect (failure of the neural plate edges to fuse).
118
What is the MOA of shiga toxin?
Halts protein synthesis via inactivating the 60S ribosomal subunit.
119
What should be done if a patient comes into the ER seeking pain medication?
Obtain the patient's prescription history.
120
Can hexokinase act on fructose?
Yes, Hexokinase converting fructose to fructose-6-phosphate is how patients with essential fructosuria (fructokinase deficiency) are still able to metabolize fructose.
121
What will a chronic arteriovenous fistula do to the cardiac output - venous return curve?
While an acute AV fistula will only affect TPR initially (no change to mean systemic pressure), chronically an AV fistula will both increase CO as well as venous return (increased mean systemic pressure).
122
What is the best course of action to ensure medicine compliance in a patient who requires supervision and who's family has been unable to do so?
Involve a social worker in the discharge planning.
123
What is the leading cause of cancer mortality in men and women?
Lung cancer (followed by breast/prostate 2nd and then colon 3rd).
124
What is a general rule of thumb for the relationship between GFR and serum creatinine?
Every time GFR is halved, serum creatinine doubles.
125
What accounts for the short duration of action of propofol?
Tissue redistribution of the drug (lipophilic drugs rapidly distribute to organs with high blood flow like the brain and then subsequently redistribute to organs with less blood flow).
126
What is key to the diagnosis of aplastic anemia?
The absence of splenomegaly
127
What accounts for intestinal atresias of the midgut (jejunum, ileum, proximal colon)?
Vascular occlusion in utero.
128
What can improper rotation of the gut result in?
Malrotation of the gut and risk of volvulus (coffee bean sign).
129
What are the features of glucocorticoid induced myopathy?
Proximal muscle weakness without pain and with normal CK levels (hypothyroid and other myopathies have elevated CK levels).
130
When eliciting the knee reflex, a brisk contraction of the quadriceps with delayed relaxation is suggestive of what condition?
Delayed DTRs which is a sign of hypothyroidism. Hypothyroidism can also present with brittle nails.
131
What antibiotic used in the treatment of C. difficile inhibits RNA polymerase?
Fidaxomicin.
132
What are the oral options for treatment of C. difficile?
Vancomycin and fidaxomicin (metronidazole is given IV in C. diff patients).
133
What are the symptom of legionella?
Pneumonia, diarrhea, and hyponatremia (confusion).
134
What medications should be avoided in HOCM patients?
Vasodilators and diuretics (both decrease pre-load which worsens the LVOT obstruction).
135
What is holoprosencephaly (fused cerebral hemispheres) an example of?
A developmental field defect (initially put agenesis but that would be a complete absence of neural tissue).
136
What is the clinical course of a follicular lymphoma?
A long, waxing and waning clinical course (i.e. LN that fluctuates in size over the course of a year, ect).
137
What is the major virulence factor of H. influenzae?
Polyribosylribitol phosphate (PRP) which comprises its polysaccharide capsule (prevents complement activation).
138
What do the CGG repeats in fragile X syndrome lead to?
DNA methylation of the FMR1 gene (gene silencing).
139
What is the extra heart sound heard in mitral stenosis?
An opening snap (i.e. when the mitral valve is opening at the beginning of systole).
140
hat kind of visual field defect would result from retinal lesions in the macula?
Central scotoma.
141
What effect does aldosterone have on the salivary glands?
It promotes K+ secretion (saliva contains HCO3- and K+, could theoretically become hypokalemic from excessive salivation).
142
What accumulates within astrocytes in hyperammonemia?
Glutamine (combines ammonia with glutamate to make glutamine, disrupting excitatory neurotransmission).
143
What is projection?
Defense mechanism of misattributing one's own unconscious/undesired thoughts/feelings onto another person who does not have them (ex. child of a divorced couple who thinks his parents are mad at them).
144
What is identification?
Defense mechanism of modeling one's behavior after someone else. (ex child of a child abuser becoming an abuser).
145
What is the negative predictive value (NPV)?
The probability that a negative test result is actually negative (ex. patient who was told they do not have cancer asking what the chances are that they actually do not have it). Initially put specificity but that is an intrinsic, unchanging aspect of a test.
146
Is S. pneumoniae bile soluble?
Yes (Strep viridans are bile insoluble).
147
What defines akathesia?
Subjective restlessness and an inability to sit still that presents days to weeks after starting anti-psychotic therapy.
148
What is the preparation stage of change?
Planning a behavior change (ex an alcoholic planning to call a rehab center).
149
What does noise induced hearing loss result from?
Trauma to the stereociliated hair cells of the organ of corti.
150
What does 3'-5' exonuclease activity allow DNA polymerase to do?
Removal of mismatched base pairs during DNA replication (proof reading activity).
151
What test is most specific for diagnosing acute cholecystitis?
Failed gallbladder visualization on radionuclide biliary scan (gallstone blocks uptake of contrast dye).
152
What is isoproterenol?
A non-specific beta agonist (causes increased contractility through beta-1 activation and vasodilation through beta-2 activation).
153
What serum abnormality (aside from hyperbilirubinemia) can be seen in primary biliary cirrhiosis?
PBC is an ecample of a hyperlipidemic state and thus can present with xanthelemas (lipid filled macrophage filled skin lesions).
154
What does an anterolateral supracondylar humerus fracture damage?
The radial nerve.
155
What does an anteromedial supracondylar humerus fracture damage?
The median nerve and brachial artery.
156
What is an ecological study?
When the frequencies of a given characteristic and a given outcome are studied using population data.
157
Is there a serum assay for tetanus toxin?
No. Diagnosis of tetanus requires a thorough examination and history.
158
What will puncture of the common femoral artery (continuation of the external iliac) superior to the inguinal ligament result in?
Retro-peritoneal hemorrhage (runs beneath the peritoneum so would not result in pelvic hemorrhage).
159
Where can the great saphenous vein be accessed?
Just inferolateral to the pubic tubercle (right before it crosses the cribiform fascia to join the femoral vein).
160
Can Gaucher's present with pancytopenia?
Yes (would see Gaucher cells [enlarged macrophages with a "crinkled" appearance] on bone marrow biopsy).
161
What is one of the arrythmias that can result from digoxin toxicity?
Bradycardia with junctional escape beats (combined with color vision issues and hyperkalemia suggests digoxin toxicity).
162
If a person with a history of cognitive decline over a year suddenly has a change of mental status in the hospital, what is the most likely diagnosis?
Delirium. Even if there was a prior history of cognitive decline, the acute and sudden onset of acute mental status change is most likely delirium and due to an underlying medical condition like pneumonia, ect.
163
What does it mean if it takes a dose an inhaled anesthetic longer to reach it's partial pressure in the blood?
It means that it's more soluble in the blood (high blood/gas partitioning coefficient i.e. slower onset of action).
164
What enzymes in the TCA cycle are dependent on NAD+?
PDH, isocitrate dehydrogenase, alpha-ketoglutarate dehydrogenase, and malate dehydrogenase. (initially put succinate dehydrogenase but that is FAD+ dependent).
165
What would be seen 6 months after an ischemic stroke? (Wallerian degeneration process in the CNS)
Persistent myelin debris (unlike the PNS, clearance of myelin debris is sowed due to the BBB impairing microglia migration as well as oligodendrocyte apoptosis). Can lead to a glial scar.
166
What does Wallerian degeneration refer to?
The process of axonal degeneration and breakdown of the myelin sheath that occurs distal to the site of injury.
167
What is the most appropriate response when a patient brings up a history of sexual abuse?
Acknowledge the sexual abuse while gently asking if they would like to further discuss it. (ex that sounds like an awful experience, are you comfortable talking about it?"
168
What is the target of kegel exercises?
The levator ani (pelvic floor). Strengthening the levator ani/pelvic floor results in increased urethral support, decreasing stress incontinence.
169
What would be seen grossly upon inspection of a lacunar infarct?
A small fluid filled cyst. The initial insult in a lacunar stroke is lipohyalinosis/microatheroma resultin in small vessel occlusion.
170
What antibiotic used in the treatment of MRSA can cause myopathy?
Daptomycin (creates transmembrane channels resulting in loss of membrane potential).
171
Is daptomycin effective in pneumonia?
No, because it is inactivated by surfactant
172
What is permissiveness in pharmacologic terms?
When one compound allows an other to exert its maximal effect (ex cortisol has no vasoconstrictive effects on it's own, but allows maximal effect of NE through alpha-1 upregulation).
173
What receptors are responsible to the decrease in respiration seen in COPD patients put on 100% O2?
The peripheral chemoreceptors (aortic arch and carotid bodies).
174
What is clinically relevant about CO2 being a perfusion limited gas?
The PCO2 will be normal in states of diffusion impairment (normal PAO2, low PaO2, normal PaCO2). It is also the reason why tachypnea in PE will blow off CO2 (respiratory alkalosis) but not correct the hypoxemia.
175
What nerve innervates the posterior portion of the external auditory canal?
The auricular branch of the vagus (stimulation can lead to vasovagal syncope).
176
Is malpractice a medical error category?
No, it is a legal term. If a physician for example missed an obvious test result (TSH levels, ect) and did not address it, the medical error category would be preventable adverse event.
177
Where is the location of Kiesselbach's plexus?
The nasal septum.
178
Where does the assembly of the procollagen alpha triple helix occur?
In the endoplasmic reticulum.
179
Where does the N and C terminal propeptide removal step of collagen synthesis occur?
In the extracellular space.
180
A lesion in what structure would cause a homonymous hemianopsia with marcus gunn pupils (impaired afferents)?
Optic tract. A LGB/LGN lesion would also cause contralateral homonymous hemianopsia but would not affect the pupillary reflex.
181
What pancreatic bud gives rise to the main pancreatic duct?
The ventral pancreatic bud
182
What pancreatic bud gives rise to the accessory pancreatic duct?
The dorsal pancreatic duct (as wells as most of the pancreas i.e. most of head, body, tail)
183
What is most similar between the systemic and pulmonary circulations during both exercise and rest?
Blood flow per minute (RV output must match LV output).
184
Over-expression of what marker is associated with more aggressive breast cancer?
HER2
185
What is the time frame for a true ventricular aneurysm?
1 months (due to the presence of scar tissue defining a true aneurysm).
186
What is the most likely cause of death 5 days after a massive anterior MI?
Ventricular free wall rupture, which would present as profound hypotension, cardiac tamponade, ect).
187
If a patient has dysphagia and the PMH only mentions GERD, what structure on imaging should be pointed to?
GERD can cause dysphagia on its own, so the involved structure would be the esophagus itself (between the trachea and spine) and not an exogenous structure compressing it (led me to look for the LA even though the MRI was at the level of the aortic arch).
188
What is the MOA of the Bacillus anthraxis edema toxin?
It is a calmodulin dependent adenylate cyclase that increases cAMP, leading to edema and neutrophil/macrophage function.
- Similar to the pertussis toxin
189
What happens to LH/FSH with continuous Leuprolide administration?
There is a transient increase before suppression happens.
190
What is the morphology of Candida?
Pseudohyphae with blastoconida
191
In addition to baclofen, what agent can be used for spasticity in multiple sclerosis/brain and or spinal disease?
Tizanidine (alpha-2 agonist).
192
What should you do if you suspect illiteracy in a patient?
Use visual aids.
193
What property of an anesthetic is indicated by the arteriovenous concentration gradient?
The peripheral tissue solubility. (A high concentration gradient between the arteries and veins suggests more is uptaken by the periphery and thus it will take longer for the brain to be saturated/slow onset of action. The reverse is also true).
194
What would damage to the radial nerve at the axilla (crutch palsy) result in?
Weakness of hand, wrist and forearm (triceps) extension with sensory loss.
195
What would damage to the radial nerve at the midshaft humerus result in?
Weakness of hand/wrist extension with sparing of the triceps and sensory loss over the posterior hand.
196
What would damage to the radial nerve at the supinator canal result in?
Weakness of hand extension with sparing of the triceps and preserves sensation.
197
What is lead time bias?
When there is an apparent increase in survival time among patients undergoing screening when they actually have an unchanged prognosis. (detected earlier but still die at the same time. Overall mortality rates, not survival time, should be used in assessing the efficacy of early screening).
198
What is length time bias?
When subjects with a rapidly progressive form of disease are less likely to be detected by screening compared to those with slowly progressive disease.
199
What electrolyte abnormalities can cause nephrogenic DI?
Hypercalcemia and hypokalemia.
200
What are the signs of stimulant (cocaine, amphetamine) withdrawal?
Depression, fatigue, hypersomnia, hyperphagia, and vivid dreams.
201
In addition to non-caseating granulomas what is seen histologically with Crohn's?
Thickening of the muscularis mucosae.
202
What QT prolonging drug has the least risk of torsades de pointes?
Amiodarone (initially put verapamil but that has no effect on the OT interval).
203
What does early antibiotic treatment of GAS pharyngitis lead to?
Decreased incidence of rheumatic fever (PSGN incidence is not affected).
204
What does pre-T ALL present with?
An anterior mediastinal mass, which can compress surrounding structures (dyspnea, dysphagia, SVC syndrome, ect).
205
What accounts for the dyspnea seen in left heart failure?
Decreased lung compliance (due to fluid accumulation in the lung interstitium).
206
What is the major determinant of whether an atherosclerotic plaque will cause ischemic myocardial injury?
The rate of growth (slow growing plaques allow the formation of collateral circulation).
207
What is the MOA of isoniazid resistance?
Decreased activity of bacterial catalase-peroxidase
208
What artery does the AV nodal artery come off of?
Whatever is the dominant artery (RCA in right dominant, left circumflex in left dominant).
209
What lab finding would be seen in perinatal HBV infection?
High viral load and HBeAg.
210
What is the major adverse effect of gancyclovir?
Neutropenia (especially if combined with TMP-SMX or zidovudine).
211
What is found at the 3' end of tRNA?
A CCA sequence that is used as a recognition site for proteins and whose 3' hydroxyl group serves as the amino acid binding site.
212
In addition to increased methylmalonic acid, what lab findings are found with methylmalonic acidemia?
Increased propionic acid, hypoglycemia, increased ketones, and hyperammonemia.
213
What should be done if a physician suspects child abuse?
Interview the child alone and do a physical. After that can Child Protective Services be contacted.
214
What are the signs of neonatal abstinence syndrome (NAS)? (i.e. neonatal opioid withdrawal)
Hypertonia, diarrhea, sneezing, mydriasis, tachypnea, irritability, ect. Treatment is methadone.
215
What is the treatment for TCA toxicity?
Sodium bicarbonate.
216
The serum marker is elevated in parotitis? (enlarged, tender parotid gland, i.e. from preauricular area to angle of mandible).
Elevated amylase in the absence of pancreatitis is diagnostic of parotitis.
217
What should be suspected in an intubated patient who develops preauricular swelling/pain that extends to the mandible?
Acute parotitis (usually due to S. aureus or anaerobes) (other risk factors include decreased salivary flow, such as xerostomia from anti-cholinergics, ect).
218
What precautions are needed for C. difficile?
Non-sterile gloves and gown (contact precautions).
219
If a meta-analysis comparing SBP between cocoa eaters and control groups found a difference of -2.2 with a 95% CI of [-2.7 to -1.3], what does that mean?
There was a statistically significant reduction in SBP. Remember, if the CI does not contain the null value (0 if comparing means and 1 for an odds ratio) then the results are statistically significant.
220
What are the pressures in the right ventricle?
25/10.
221
What are the pressures for the pulmonary artery?
25/12 (slightly higher diastolic compared to the right ventricle).
222
Loss of the anal wink reflex and saddle anesthesia correspond to loss of what segments?
S2-S4 (commonly cauda equina syndrome).
223
When does the blastocyst implant and begin hCG secretion (development of syncytiotrophic tissue)?
Days 6-7
224
What is effect modification?
When the effect of an exposure on an outcome is modified by another variable.
225
How can effect modification be identified?
Stratified analysis (analyzing the cohort as different subgroups, such as smokers and non-smokers, ect.).
226
How can effect modification be differentiated from a confounding bias?
Stratified analysis will show that different strata will have different measures of association with effect modification (ex. smokers have a different outcome compared to non-smokers). Meanwhile, stratified analysis will show no significant association between the strata (ex. shoe size in children may initially seem associated with intelligence, but when stratified by age the association disappears).
227
What serum findings can be found in primary hyperparathyroidism?
Hypercalcemia, hypophosphatemia, and hypercalciuria (despite increased resorption).
228
How many calories per gram are carbohydrates and protein?
4 calories per gram.
229
What would a laterally directed stab wound in the left 5th ICS at the midclavicular line damage?
The left lung (initially put the right ventricle but that would be the sternocostal border, i.e. more medial). If the stab wound was medially directed then the left ventricle would have been damaged (apex of the heart at the left 5th ICS in the midclavicular line).
230
What trisomy can present with cleft lip/palate, cutis aplasia, and omphacele?
Trisomy 13 (Patau).
231
What drug can cause congenital cutis aplasia?
Methimazole.
232
If a patient has parotid hypertrophy, lanugo hair, low BMI, and amenorrhea, what is the most likely diagnosis?
Anorexia nervosa (specifically the binge eating type. Looks like bulimia but remember that bulimia has normal body weight, ect).
233
What is the greatest risk of a cavernous hemangioma?
Intracerebral hemorrhage.
234
What is a cavernous hemangioma?
A vascular malformation that most commonly occurs in the brain parenchyma. Have a risk of seizures and intracerebral hemorrhage.
235
What would suggest mullerian agenesis?
A short vagina (absence of upper vagina) and a rudimentary uterus in a patient with normal secondary sex characteristics and primary amenorrhea.
236
What cytokine is associated with giant cell arteritis?
IL-6
237
What is tazobactam?
A beta-lactamase inhibitor
238
What is the most modifiable risk factor for falls in the elderly?
Medications (an elderly patient with falls should have a medication review for high risk drugs such as anti-depressants, benzos, ect).
239
Can malignancy present in a lung cavitary lesion?
Typically no. Hemoptysis and the presence of a mass from a prior TB cavity in a patient who has had to weight loss is much more likely to be an aspergilloma.
240
What procedures can result in enteroccocus endocarditis? (remember that enterococcus is catalase negative, gamma hemolytic, and bile/salt tolerant).
Cystoscopy, colonoscopy, and obstetric procedures.
241
Are beta-1 selective beta blockers (metoprolol) safe in COPD?
Yes (If a patient with stable COPD has an MI then metoprolol is safe for use).
242
What should be considered in a patient with obstructive jaundice and weight loss?
Pancreatic adenocarcinoma (smoking is a major risk factor).
243
What kind of bladder dysfunction can multiple sclerosis patients develop?
Spastic/hypertonic bladder (UMN lesion).
244
What is the pathogenesis of gallstones in Crohn's disease?
Increased bile acid wasting/decreased bile acid reabsorption
245
What can occur in the setting of cervical spine trauma resulting in vertebral artery dissection?
Lateral medullary syndrome (PICA comes off the vertebral, the AICA comes off the basilar).
246
How can lateral medullary syndrome be distinguished from lateral pons?
Both involve the vestibular nuclei (vertigo/nystagmus), spinothalamic and spinal V tracts, ipsilateral cerebellar signs, and ipsilateral horner's. Facial droop/weakness is what localizes to the pons, while dysphagia and hoarseness (nucleus ambiguus) localizes to the medulla.
247
What could be responsible for a significant increase in pol mutations in an HIV patient on HAART?
Anti-retroviral resistance (for pol specifically it indicates protease that is resistant to protease inhibitors).
248
What are the signs of Dengue fever?
Flu-like febrile illness with myalgias and joint pain (bone break fever), maculopapular rash, and retro-orbital pain
249
What are the signs of Dengue hemorrhagic fever?
Dengue fever plus thrombocytopenia (petechiae in addition to maculopapular rash) and spontaneous bleeding.
250
What serological values would be seen in long-term steroid use?
Decreased CRH, ACTH, and cortisol. (not only are the adrenals atrophied but the corresponding pituitary and hypothalamic cells as well)
251
What hormone are spider angiomatas associated with?
Estrogen (gynecomastia and spider angiomatas in cirrhosis share the same underlying pathophys)
252
What is pure red cell aplasia?
A selective decrease in erythroid precursors (isolated anemia). Associated with thymomas (like myasthenia gravis).
253
What is the appearance of the "ground glass" hepatocytes in chronic HBV infection?
Hepatocytes with finely granular, pale pink cytoplasm.
254
What is the histopathological finding of Reye's syndrome?
Microvesicular steatosis w/o inflammation.
255
What drugs can provide rapid relief of rheumatoid arthritis?
NSAIDs and corticosteroids (DMARDs like sulfasalazine take weeks).
256
What statistical test would be used to estimate the association between simvastatin use and high fibrinogen levels?
Chi-square test (assesses categorical/qualitative variables) (ANOVA and t-test are for comparing means, i,e, quantitative variables).
257
Where will lipophilic drugs (like propofol) eventually accumulate?
In tissues with that are poorly vascularized (skeletal muscle, fat, bone).
258
What is the intrapleural pressure at FRC?
-5 cm H2O
259
What antibiotic can cause aplastic anemia?
Chloramphenicol
260
What causes superior displacement of the medial portion of a fractured clavicle?
The sternocleidomastoid.
261
What causes inferior displacement of the lateral portion of a fractured clavicle?
The pectoralis major and the weight of the arm.
262
What cardiac hemodynamics are found in acute mitral regurgitation?
Decreased afterload, increased preload, and increased ejection fraction.
263
What is seen with long term use of levodopa in Parkinson's patients?
Periodic fluctuations in motor function (days of good motion and days of bradykinesia). In advanced PD occurs independently of drug dose and is unpredictable.
264
What muscle groups are used when sitting up from a supine position?
The external obliques, the rectus abdominus, and the hip flexors (psoas major).
265
What kind of heart dysfunction can result from viral myocarditis?
Dilated cardiomyopathy (suspect this in a young patient who develops heart failure following a viral prodrome).
266
What determines the prognosis of colon cancer, the grade (# mitotic figures, tumor cell differentiation, ect) or the stage (tumor penetration into intestinal wall, ect)?
The stage is the biggest determinant of cancer prognosis, not grade.
267
What does weight gain, constipation, hair loss, and dry skin in a patient with bipolar disorder suggest?
Lithium induced hypothyroidism.
268
What kind of inguinal hernia does a patent processus vaginalis predispose to?
An indirect inguinal hernia.
269
What is the histology of a granulosa cell tumor?
Cuboidal cells in sheets that form follicle/rosette like structures with a central pink/eosinophilic center.
270
In a 3rd degree heart block, what cells act as the pacemaker?
The AV node (defect is in the His-Purkinje but the AV node is still acting as the pacemaker).
271
What is the most likely identity of a hyperpigmented, raised bump under the breast that responds to the menstrual cycle?
An accessory nipple (failure of involution of the mammary ridge). Don't confuse it for a congenital nevus.
272
How many half lives corresponds to 75% elimination of a drug?
2 half lives.
273
In addition to constrictive pericarditis, what else can cause a rapid y descent?
Restrictive cardiomyopathy (secondary to amyloid in the question).
274
What is the goal of stimulus control therapy for insomnia?
To dissociate the bedroom from any stimulating activities or fear of not sleeping (ex leave the bedroom if can't sleep after 20 minutes).
275
If a question gives you the frequency of affected individuals of an autosomal recessive disease when asking for the chances of passing it on to a child, what is the next step?
Use the Hard-Weinberg equation to find the carrier frequency. Specifically use square root of disease frequency (q^2) to find mutant allele frequency (q) and then use that to find carrier frequency (2q).
276
What is a man angry at his wife over a divorce lashing out at his daughter an example of?
Displacement.
277
In addition to RAAS, what else is activated in CHF that contributes to the symptoms (edema, ect)?
Sympathetic nervous system (vasoconstriction to maintain blood pressure).
278
What should new onset odontophagia (pain with swallowing) in a GERD patient raise suspicion of?
Erosive esophagitis with ulceration.
279
What nerve can a mass/hematoma overlying the psoas damage?
The femoral (loss of sensation over the anterior thigh and weakness of the quadriceps).
280
What has the highest oxygen content in the fetal circulation?
The umbilical vein (then enters the IVC via the ductus venosus). Blood leaves by the umbilical arteries (lowest oxygen content).
281
What immunodeficiency predisposes to disseminated Candida infection (candidemia, endocarditis)?
Neutropenia is important for preventing disseminated Candida (CD4+ T cells are important for preventing cutaneous Candida infections).
282
What is the most common cause of aminoglycoside resistance?
Antibiotic modifying enzymes (acetylation, ect).
283
What is the MOA of foscarnet?
It directly inhibits herpesviridae DNA polymerase/RNA polymerase as well as HIV reverse transcriptase. Unlike the other anti herpesviridae drugs it does not requires intracellular phosphorylation.
284
What two vitamins is breast milk typically deficient in?
Vitamin K (given parenterally at birth) and vitamin D (vitamin D supplementation should be considered in exclusively breastfed infants).
285
What is the only non-glucose monosaccharide that bypasses PFK-1?
Fructose (hence why fructose-1-phosphate has the fastest rate of metabolism of the monosaccharides).
286
What should empiric treatment of coagulase-negative Staph include?
Vancomycin, due to widespread methcillin resistance (assume resistance to penicillins and cephalosporins).
287
What is the role of dystrophin?
It links the sarcolemma to the cytoskeleton.
288
What type of receptor is the calcium sensing receptor (CaSR)?
G-protein coupled receptor.
289
What is the most likely site of thrombus formation in atrial fibrillation?
The left atrial appendage.
290
What is actinic elastosis/solar elastosis?
An accumulation of abnormal elastin in the dermis due to photoaging/sun exposure. Presents as erythematous, scaling, wrinkling patches and can causesbruising/ecchymoses. Don't confuse with actinic keratosis.
291
What part of the vertebra is the best place to access the neural canal
The lamina (portion between the transverse and horizontal processes.
292
What is the venous drainage of the cecum?
The ileocolic vein to the superior mesenteric vein to the portal vein.
293
What does increased alpha-fetoprotein in the amniotic fluid suggest?
Spina bifida (thought it was Down's but that has deceased alpha-fetoprotein).
294
What is the best way to test for C. diff diarrhea?
Test the stool for the C. diff toxin.
295
What is responsible for the rash in scarlet fever?
Erythrogenic toxin.
296
What kind of atelectasis can occur following radiation therapy?
Contraction atelectasis (radiation induced fibrotic changes).
297
What muscle is responsible for flexion of the DIP?
The flexor digitorum profundus (the flexor digitorum superficialis does the PIP).
298
If a patient is fired from his job after being prescribed benzodiazepines and his wife calls letting you know of this, what is the next best step?
Contact the patient (put the answer that you can't accept the wife's claims because of HIPAA but that is wrong).
299
What receptor does dopamine activate at high doses?
Alpha-1 (vasoconstriction).
300
What is the most likely diagnosis in a child with epistaxis/bruising following a viral illness who has normal coagulation studies, an isolated thrombocytopenia, and increased megakaryocytes on BM biopsy?
Idiopathic/Immune thrombocytopenia (ITP) (antibodies against GpIIb/IIIa).
301
What vitamin D derivative accumulates during hypercalcemia induced feedback inhibition of 1-alpha hyfroxylase?
24,25-dihydroxycholecaliferol (25-hydroxycholecalciferol is shunted over to this in the absence of 1-alpha hydroxylase).
302
Meiotic non-dysjunction is most likely to occur in what cell in spermatogenesis?
Primary spermatocyte (undergo meiosis I to become secondary spermatocytes).
303
What is the best way to ensure compliance to a plan of behavioral modifications such as exercise and dietary changes?
Provide follow-up appointments to assess the patient's progress in attaining their goals.
304
What should a physician do if their patient confides they have sexual thoughts about them?
Have a chaperone join for the remainder of the examination.
305
How do you calculate relative risk reduction (RRR)?
RRR = 1 - RR (Relative risk = incidence in experimental group/incidence in control)
306
Aside from oxytocin, what contributes to uterine contractions in labor?
Release of prostaglandins from the decidua (initially put oxytocin from the fetus but the fetus doesn't make oxytocin).
307
How do you tell trigeminal neuralgia from TMJ dysfunction?
While both can cause sharp unilateral facial pain, TMD would have additional symptoms like clicking/locking of the jaw, jaw muscle spasms, and ear involvement. If it's just shooting pain brought on by chewing or brushing teeth then it is more likely to be trigeminal neuralgia than TMD.
308
What is the most likely diagnosis of unilateral breast enlargement in a male undergoing normal puberty with a family history of breast cancer?
Gynecomastia (a normal finding in puberty and not breast cancer).
309
What is an inflamed (neutrophils on arthocentesis) unilateral knee in a 65 year old with a slight fever most likely?
It is most likely gout as opposed to N. gonorrhea.
310
If a person last minute changes their mind about surgery before receiving anesthesia, what is the most appropriate response?
Ask them about their concerns and why they want to cancel the operation.
311
If a physician who receives a call requesting emergency contraception but they don't prescribe that out of moral reasons, what is the most appropriate response?
Tell them that you will have a colleague call back with them to discuss their concerns (put call the local Women's health clinic put that was wrong).
312
What would be expected in the urine of someone with calcium oxalate nephrolithiasis?
Low urinary citrate levels (citrate binds calcium in the urine and promotes excretion).
313
What does a serum pH of 7.25, PaCO2 of 70, and HCO3- of 25 suggest?
Acute respiratory acidosis (such as heroin overdose, ect). This is due to the HCO3- being normal (25). If it was chronic respiratory acidosis (such as chronic bronchitis) then the HCO3- would be elevated due to renal compensation.
314
What are cytoplasmic P bodies?
Distinct foci in eukaryotic cells that are involved in mRNA regulation and turnover. Have a fundamental role in translation repression and mRNA decay.
315
What is important in the management of somatic symptom disorder?
Scheduling regular outpatient visits with the same provider.
316
What would be the most appropriate therapy for a beta-lactamase producing Bacteroides infection?
Piperacillin-Tazobactam (broad coverage against a large number of gram positive, gram negative, and anaerobes [Bacteroides]).
317
At what lung volume is pulmonary vascular resistance the lowest?
FRC
318
When does myocardial contractility cease in ischemic insult?
Mycocardial contractility stops about about 60 seconds/1 minute into an ischemic event.
319
If a patient is started on empiric antibiotics and then has their condition deteriorate several days after because the sputum results were not checked, how could this medical error have been prevented?
Use of standardized patient hand-offs (Had been transferred from the admitting physician by that point and thus the hand-off sheet was the source).
320
What occurs in the respiratory mucosa in cystic fibrosis aside from decreased Cl- excretion?
Increased Na+ absorption (more negative trans-epithelial membrane potential test) (CFTR increases Cl- excretion and inhibits Na+ re-absorption so that more NaCl is in the lumen, resulting in increased hydration).
321
What is the pathogenesis of diverticulitis?
Pulsion (increased intraluminal pressure during strained bowel movements).
322
What is chlordiazepoxide?
A long-acting benzodiazepine.
323
What are patients with a history of irregular menses at risk for in regards to pregnancy screening?
They are at risk for inaccurate pregnancy dating, which is important to know for screening tests such as alpha-fetoprotein (need to know the true gestational age to know whether alpha-FP levels are abnormal).
324
Where is the primary site of ribosomal assembly?
The nucleoulus (round, dense basophilic body within the nucleus). Is the primary site of RNA polymerase I activity (rRNA).
325
What would sudden onset jerking movements in both arms in a teenage with no other medical conditions most probably be?
Myoclonic seizures (generalized due to the involvement of both arms). Would be best treated with valproic acid.
326
Do generalized myoclonic seizures have mental status changes or a post-ictal state?
No.
327
What type of lymphoid (either B or T cell) proliferation is highly suggestive of malignancy?
Monoclonal
328
Does a VSD necessarily have to present with eisenmenger syndrome in an 11 year old?
No, a small VSD could have no pulmonary involvement if caught early enough. A holosystolic murmur heard at the left sternal border that worsens with handgrip is a VSD (thought a VSD would have pulmonary involvement in an 11 year so I put HCM, but that would improve with handgrip).
329
What is seen immediately following a myocardial infarction?
Normal myocardium (coagulative necrosis does not happen until after 4 hours).
330
What comprises most of the right side of the cardiac silhouette on CXR?
The right atrium (with the SVC superior and IVC inferior).
331
What nerve can be damaged during an appendectomy?
The iliohypogastric nerve (loss of sensation over the suprapubic area).
332
What agents can be used for Neisseria meningitis prophylaxis?
Rifampin, ciprofloxacin, and ceftriaxone.
333
What type of ion channel is the CFTR?
An ATP-gated chloride channel (even though it is modulated by cAMP it is not directly bound by cAMP).
334
What is leukoclastic vasculitis?
A vasculitis the only affects the skin (palpable purpura) and typically arises due to drug or pathogen exposure (HBV/HCV, penicillins, cephalosporins, sulfonamides, phenytoin, allopurinol).
335
What hormone causes upregulation of PMNT (epinephrine production) in the adrenal medulla?
Cortisol.
336
What bias does matching (i.e. matching subjects based on having similar characteristics) protect against?
Confounding.
337
What histopathological changes occur in idiopathic pulmonary fibrosis?
Loss of type I pneumocytes and hyperplasia of type II pneumocytes.
338
If a self-proclaimed family member shows up to the ER asking about the status of an unconscious patient, what is the best response?
Inform them that the patient is stable (basic information) but that they will have to wait for the patient to give permission for details to be shared (confidentiality/HIPAA).
339
What can happen in cystic fibrosis infants who are exclusively breast fed?
They may develop hyponatremia (vomiting, lethargy) due to excessive salt loss in the sweat.
340
What is the gross appearance of a glioblastoma?
Poorly defined with areas of necrosis and hemorrhage.
341
Where is the best place to do a femoral nerve block?
At the inguinal crease (lateral border of the femoral artery).
342
What lab value should be measured for the assessment of metabolic alkalosis?
The urine chloride (low urine chloride represents saline responsive alkalosis like volume contraction, while high urine chloride represents saline unresponsive like aldosterone excess).
343
What is acalculous cholecystitis?
Acute inflammation of the gallbladder in the absence of gallstones. Commonly occurs in critically ill patients (sepsis, burns, trauma, ect).
344
In what portion of the nephron does ADH help to reabsorb urea to create the medullary concentration gradient?
The medullary portion of the collecting duct (is then secreted into the thin ascending limb of the loop of henle, resulting in urea recycling).
345
What is the most appropriate initial phrase for starting an interview?
"What can you tell me about your pain?". Ect. Always start with an open ended phrase that let's the patient talk, no matter what circumstances may be present.
346
What neonatal meningitis pathogen is resistant to 3rd generation cephalosporins (ceftriaxone and cefotaxime)?
Listeria monocytogenes (treat with ampicillin instead).
347
What anti-retroviral can't be given to those with HLA-B*57:01?
Abacavir (results in a severe hypersensitivity reaction).
348
Can Klinefelter's present with mild intellectual disability?
Yes. Always remember that intellectual disability can be a part of Klinefelter's.
349
What should be suspected in a patient who presents with fever, jaundice, and a recent history of surgery?
Anesthesia induced hepatotoxicity (halothane most likely). Severe disease can cause a shrunken liver on autopsy.
350
What would show up first in liver failure, an elevated PT or hypoalbuminemia?
Elevated PT, since factor VII has a relatively short half-life while albumin has a long half life.
351
In addition to reflex tachycardia, what else can arteriole specific vasodilators (hydralazine, minoxidil) result in?
Sympathetic RAAS activation (retained sodium and fluid).
352
What cells can perform glycolysis to yield pyruvate and yet yield no ATP?
RBCs (sacrifice the ATP generated to produce 2,3-BPG ).
353
What basal ganglia nuclei can be inhibited by deep brain stimulation in the treatment of medically intractable Parkinson's?
The globus pallidus internus and subthalamic nucleus (both serve to inhibit the thalamus, thus inhibition results in disinhibition of the thalamus, resulting in improved movement).
354
If the Pringle maneuver (pinching of the hepatoduodenal ligament) was performed but there was still bleeding from the liver, what vessel is most likely involved?
The IVC (or hepatic veins).
355
What space does CN XI travel through in the neck?
The posterior triangle of the neck (injury here would result in trapezius dysfunction - shoulder droop and difficulty in arm abduction).
356
What 2nd generation sulfonylurea has a shorter half-life and thus decreased risk of hypoglycemia?
Glipizide (conversely glyburide and glimepiride have longer half lives and an increased risk of hypoglycemia).
357
How does HDV depend on HBV for replication?
HDV particles must be coated with HBsAg in order to be viable.
358
What is seen histologically in VZV lesions?
Multi-nucleated cells with intranuclear inclusions.
359
In addition to statins and blood pressure control, what additional medication should be given following a TIA (transient ischemic attack) secondary to an atherosclerotic artery?
Low dose aspirin (risk of upper GI bleed).
360
What happens to pulmonary function due to normal aging?
Increased RV, decreased FVC, and an unchanged TLC.
361
What kind of melanocytic nevus is common in adults?
Compound melanocytic nevus (junctional nevus is common in children).
362
What is Cheyne-Stokes breathing?
A cyclic breathing pattern in which apnea is followed by gradually increasing then gradually decreasing tidal volumes until the next apnic period. Seen in CHF patients.
363
What can a stab wound above the clavicle and in between the midclavicular line and lateral sternal line damage?
The apex of the lung.
364
When does the aortic valve open?
When left ventricular pressure exceeds that of the aortic pressure (i.e. not at the point on a cardiac cycle graph when the LV pressure is just starting to rise).
365
What is the role of Rifaximin in the treatment of hepatic encephalopathy?
Causes decreased intraluminal ammonia production (kills ammonia producing bacteria). Increasing conversion of ammonia to ammonium is the MOA of lactulose (fermented by GI bacteria into acidic by products).
366
What are the most common agents of septic abortion (retained products of conception)?
Gram negative bacilli and Staph aureus.
367
What is one of the ways O2 supplementation can lead to hypercapnia in COPD patients aside from decreased peripheral chemoreceptor stimulation?
O2 supplementation leads to pulmonary vasodilation (decreased PVR), which diverts blood flow away from well ventilated regions, leading to increased physiologic dead space (V/Q mistmatch).
368
What is the deep inguinal canal an opening in?
The transversalis fascia
369
What is the superficial inguinal canal an opening in?
The external oblique aponeurosis (an un-descended testis in the inguinal canal must be reduced through this).
370
What is antral gastritis most likely?
H. pylori (can cause duodenal ulcers and iron deficiency anemia).
371
What renal finding can be seen in the kidneys of someone with chronic hemolytic anemia?
Hemosiderosis (iron deposition due to hemoglobinuria).
372
What amino acids can be converted into propionyl-CoA?
Valine, isoleucine, methionine, threonine.
373
What occurs in the first few weeks following TB exposure?
Intracellular replication of the bacteria (cord factor inhibits phagolysosome fusion) (granuloma formation happens after a couple of weeks).
374
What is necessary for the development of acute pyelonephritis?
Vesicoureteral reflux (either anatomic or functional i.e. due to repeated bouts of cystitis).
375
What regenerates NAD+ in anaerobic glycolysis?
Lactate dehydrogenase (a LDH deficiency would shut down anaerobic glycolysis due to a depletion of NAD+).
376
What would decrease regurgitant flow in mitral valve regurgitation?
Decreasing systemic vascular resistance/aortic pressure (diverts flow away from the LA into the aorta).
377
What is the histology of a liposarcoma?
Lipoblasts with scalloped nuclei and multiple mitotic figures (compare this with lipoma which is mature fat cells with no scalloped nuclei and little mitotic figures).
378
What point corresponds with S2 (closure of the AV valves) on Wigger's diagram?
Where the dicrotic notch appears.
379
A special stain on a kidney biopsy that shows staining in a region in between a glomerulus and a tubule is likely staining for what?
Renin (JG apparatus in between the DCT and the afferent arteriole of the glomerulus).
380
What is a calcified mass on MRI that is in between the kidneys and just anterior to the IVC/Aorta in a patient with epigastric pain most likely?
A pancreatic pseudocyst
381
What strand do the primers anneal to during PCR?
The 3' strand (allows for 5'-3' DNA synthesis).
382
Why is heparin safe in pregnancy?
It is highly water soluble (does not cross the placenta).
383
What is acitretin?
A retinoid (teratogenic) used in the treatment of psoriasis.
384
What is an agglutination inhibition test?
When a serum/urine sample is added to a solution containing antibodies to the substance of interest. Latex particles coated with the substance are then added. If no agglutination occurs it's a positive result (serum/urine substance bound the Ab), and if agglutination occurs it's a negative result (Ab free to bind to latex).
385
What is the sodium status in DKA?
Hyponatremic (hyperosmotic hyponatremia due to hyperglycemia).
386
What structure do Kayser-Fleisher rings involve?
The cornea.
387
How can a fibroadenoma be distinguished from fat necrosis? (i.e. just because trauma was in the question stem doesn't mean it's fat necrosis)
Fibroadenoma is round/regular while fat necrosis is irregular and may have overlying ecchymosis. Plus a fibroadenoma will respond to estrogen (change in size).
388
How is CO2 incorporated into DNA?
Is combined with glutamine by carbamoyl phosphate synthase II in the cytoplasm.
389
What kind of cerebral edema can a neoplasm cause?
Vasogenic edema (Imaging showing a brain mass = vasogenic edema).
390
What triad of symptoms may be seen in disseminated N. gonorrheae infection?
Polyarthritis, vesiculopustular rash, and tenosynovitis.
391
What type of necrosis is characteristic of CNS hypoxia?
Liquefactive necrosis.
392
Age related changes to what can increase the risk of digoxin toxicity?
Renal clearance (decreases with age).
393
What receptor causes uterine relaxation?
Beta-2
394
What is the best approach to febrile seizure?
Supportive care only.
395
Can IgA nephropathy be recurrent?
Yes (i.e. initial hematuria 3-4 days after a mucosal infection with recurrent episodes every couple of months).
396
What vessel is most likely to show atherosclerotic changes?
The abdominal aorta.
397
What is the first line treatment for pinworm/Enterobius?
Albendazole.
398
What is the differential diagnosis for a blue neoplasm underneath a nail?
Either a subungal melanoma or a benign glomangioma ( neoplasm of glomus bodies which are responsible for skin thermoregulation).
399
What cell type forms the fibrous cap of an atheroma?
Vascular smooth muscle cells.
400
When during an action potential is the membrane most permeable to K+?
Repolarization (the down-shoot).
401
What is the most common genotype of a complete hydatidiform mole?
46 XX (duplication of paternal X w/i an empty ovum).
402
Where do most anal fissures occur?
In the posterior midline distal to the dentate line (decreased blood supply here).
403
What ligament is thickened in neurogenic claudication?
The ligamentum flavum.
404
What cephalosporins are effective against Pseudomonas?
Cefepime and ceftazidime.
405
In addition to VEGF, what substance helps drive angiogenesis?
Fibroblast growth factor (FGF).
406
When is the murmur of aortic stenosis loudest?
At the peak of left ventricular pressure (middle of the LV peak on Wigger's diagram).
407
What cholinergic toxicity (i.e organophosphate) sign can't be reversed with atropine?
Muscle weakness (nicotinic mediated, not muscarinc).
408
Why are viral RNA polymerases unstable (i.e. high mutation rate)?
They lack 3'-5' exonuclease proofreading activity.
409
What comprises a cholesteatoma (pearly mass behind the tympanic membrane)?
Squamous cell debris.
410
What agent used in hypertensive emergency/crisis increases renal perfusion and natriuresis?
Fenoldopam (a D1 agonist).
411
What does an AV fistula do to the PV loop?
Increases preload/EDV (more blood entering the venous system from the arteries) as well as decreased afterload.
412
What drugs are given for Grave's ophthalmopathy?
Glucocorticoids (decrease inflammatory infiltrate).
413
What is the accumulation effect?
When the duration of exposure is necessary for a statistically relevant effect (ex people who took antioxidants for less than 5 years had no reduction in stroke incipience [p=0.4] while those who took it longer did [p=0.05]).
414
What are central dopamine effects that can be seen in L-Dopa/carbidopa therapy?
Anxiety and agitation.
415
Where does blunt aortic trauma commonly occur?
The aortic isthmus (attachment of the ligamentum arteriosum next to the left subclavian).
416
What can be given to prevent post-operative hypocalcemia due to parathyroid removal/damage?
Oral calcium and vitamin D (calcitriol).
417
What is a potential cause of direct/conjugated hyperbilirubinemia in a neonate with mild hepatomegaly?
Biliary atresia (extrahepatic obstruction).
418
What is the role of menotropin and hCG in the treatment of anovulation infertility?
Menotropin (FSH analog) is given to develop the follicle. Subsequently hCG 9same alpha unit as LH) is given to simulate the LH surge (induce ovulation).
419
What causes a dilated coronary sinus?
Increased right heart pressure (such as that seen in pulmonary hypertension).
420
What is the sequence of genome replication for HBV?
dsDNA to (+) RNA to dsDNA progeny (reverse transcriptase).
421
If a question asks why excretion or reabsorption does not increase with increased plasma concentrations past a certain point, what is the answer?
Carrier transport is saturated (can't be "max excretion/reabsorption is reached" because filtration is not enzyme or protein mediated so it doesn't have a maximal value).
422
What is the main virulence factor for salmonella osteomyelitis?
Capsule leading to resistance to opsonization/phagocytosis.
423
How can you tell if elevated ALP is due to biliary or bone causes?
Check the gamma-glutamyl transpeptidase levels (elevated if biliary and normal if bone).
424
What kind of mitral regurgitation can occur in decompensated heart failure?
Secondary MR (enlarged LV stretches the mitral annulus causing a functional MR. Treating the heart failure should make the holosystolic murmur go away).
425
What are the adverse side-effects of EPO/EPO-analogs?
Thromboembolic events and hypertension.
426
What is post-prandial epigastric pain associated with weight loss/food aversion in the setting of generalized atherosclerosis suggestive of?
Chronic mesenteric ischemia.
427
What is the role of sodium thiosulfate in cyanide poisoning?
Serves as a sulfur donor (used to metabolize cyanide).
428
What is the underlying cause of an abdominal aortic aneurysm?
Chronic transmural inflammation.
429
How does TNF-alpha induce insulin resistance?
| same mechanism as catecholamines, glucagon, and cortisol
Phosphorylates serine residues on the insulin receptor and IRS-1.
430
What eye condition can congenital CMV cause?
Chorioretinitis (like toxoplasmosis).
431
What happens to RPF, GFR, and the FF in severe hypotension?
Both RPF and GFR drop, but RPF drops more the GFR, resulting in an increased FF.
432
What lipid laden cells would be seen 1 week after a CNS infarct?
Microglia (phagocytose myelin)
433
What can a child with a learning disability (difficulties in reading, writing, or math) present with?
Anxiety, inattention, and hyperactivity (embarrassed/being teased by peers. Don't confuse this for ADHD).
434
Is binge eating followed by fasting binge eating disorder or bulimia nervosa?
Bulimia (not just vomiting, is defined by binge eating followed by a compensatory behavior to prevent weight loss).
435
What suppresses lactation/prolactin during pregnancy?
Progesterone (precipitous drop after delivery allows lactation to occur).
436
Prophylaxis with what antibiotic prevents Mycobacterium avium complex (MAC) infection in AIDS patients?
Azithromycin.
437
What is the most important determinant of prognosis in PSGN?
Age (adults have a worse prognosis).
438
What vitamin can help improve maple syrup urine disease?
Thiamine.
439
What is the treatment for multiple myeloma?
Bortezomib, a proteasome inhibitor that leads to apoptosis.
440
How do non-dihydropyridine Ca2+ blockers (verapamil, diltiazem) affect nodal cells?
They slow the phase 4/spontaneous depolarization (L-type Ca2+ channels contribute to both phase 4 and the phase 0 up-shoot).
441
A patient with signs of lung cancer and edema/congestion on one side of the upper extremities and face is indicative of what?
Brachiocephalic vein compression (unlike SVC compression which affects the entire face and upper extremities brachiocephalic vein compression results in unilateral venous congestion).
442
Are CYP enzymes found in the gut wall?
Yes (would be inhibited by grapefruit juice, ect).
443
What does bilateral wedge-shaped cerebral infarcts suggest?
Hypoxic-ischemic encephalopathy (the wedge shapes are the watershed zones b/t the ACA/MCA/PCA which are more affected by ischemia).
444
Sickle cells sickle in the presence of what process?
Oxygen unloading (remember that HbS sickles in hypoxic, acidic environments, i.e. peripheral tissues where O2 unloading occurs).
445
What is the most appropriate test for Down's at 12 weeks gestation?
Chorionic villi sampling.
446
What happens to respiratory rate, tidal volume, and airway resistance in the setting of rib fractures?
Increased RR, decreased TV, and no change in airway resistance.
447
Where does the aminoacyl-tRNA enter the ribosome during elongation?
The A site ("A" for aminoacyl-tRNA)
448
What happens to the cross-sectional area of the pulmonary microcirculation during exercise?
It increases due to extension and recruitment of microvessels.
449
If a newborn has HIV antibodies, what can be inferred about the mother's and the newborn's HIV status?
The mother has HIV but the newborn's status can't be determined from AB alone (has HIV ab due to placental transfer of IgG).
450
What does absent tactile fremitus, hyperresonance on percussion, and an absence of breath sounds at the left lung base imply?
A left pneumothorax.
451
How do oral fluids help in cholera?
They stimulate the Na/glucose symporter (increased Na+ reabsorption limits Cl- secretion).
452
What is the histology of a syphilis chancre?
Obliterative endarteritis with lymphocytes and plasma cells.
453
What TCA cycle enzymes would be inhibited in a patient with Wernicke's encephalopathy?
PDH, alpha-ketoglutarae dehydrogenase (require both NAD+ and thiamine, both of which are affected n chronic alcohol abuse.
454
What does demyelination do to the length and time constants of a neuron?
Decreases the length constant and increases the time constant.
455
What vitamins are seen in excess in small intestinal bacterial overgrowth?
Folate and vitamin K (remember that enteric bacteria produce these).
456
Where is the AV node located?
In the interatrial septum near the opening of the coronary sinus and the septal leaflet of the tricuspid valve.
457
What should an itchy erythematous rash over the breast raise suspicion of?
Inflammatory breast cancer (rash is peau d'orange from dermal lymphatic obstruction).
458
What is responsible for the thrombocytopenia seen in ITP?
Immune destruction of platelets.
459
What SERM can be used for osteoporosis while also decreasing the risk of breast cancer?
Raloxifene.
460
What sympathetic receptors are on pancreatic beta cells?
Alpha-2 (decrease insulin release) and beta-2 (increase insulin release).
461
What is viral phenotypic mixing?
When a virus co-infecting a cell receives capsid proteins from another virus but still retains the original genome (i.e. new particles can infect new cell type but the progeny can't).
462
A child with clubbing/cyanosis in the lower extremities but not the upper is suggestive of what?
A patent ductus arteriosus (PDA).
463
What population is at risk for drug induced lupus?
Slow acetylators.
464
What characterizes breast ductal carcinoma in situ?
Ducts distended by pleomorphic cells with prominent central necrosis. Often detected as microcalcifications on mammography with a normal breast exam.
465
What is one presentation of acute HBV infection?
A serum sickness like reaction with arthralgias and a urticarial rash (in addition to elevated liver enzymes, ect).
466
What characterizes acute contact dermatitis?
Spongiosis (edema in the epidermis).
467
What can be protective against ovarian cancer?
OCP use (others include multiparity and breast feeding).
468
What is pituitary apoplexy?
An intra-pituitary hemorrhage that occurs in the setting of a pre-existing adenoma (i.e. signs like headache and bitemporal hemianopsia will present before the hemorrhage). The acute bleeding will then result in a sudden, severe headache and signs of hypopituitarism.
469
What are penicilins structuraly similar to?
D-alanine-D-alanine (vancomycin meanwhile binds to D-ala-D-ala).
470
What structures does the facial nerve transmit parasympathetic fibers to?
The lacrimal glands as well as the submandibular and sublingual salivary glands.
471
How can a lacunar stroke (hypertensive arteriolar sclerosis) be differentiated from a Charcot-Bouchard aneurysm?
While both are associated with hypertension and affect the same brain areas, a lacunar stroke will have an initially normal head CT (rules out intraparenchymal hemorrhage, i.e. Charcot-Bouchard aneurysm).
472
What is the underlying mechanism behind acyclovir nephrotoxicity?
Crystallization within the tubules (can be prevented with adequate hydration).
473
What is systemic mastocytosis?
Diffuse clonal expansion of mast cells due to a KIT tyrosine kinase mutation, resulting in widespread histamine release (hypotension, pruritis, urticaria/maculopapular rash, and increased gastric acid due to histamine's effects on parietal cells).
