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uworld > #4 > Flashcards

#4 Flashcards

1
Q

43 yo from thailand

  • 10 days of hemoptysis, night sweats
  • Tuberculin test there is no induration, however sputum sample reveal acid-fast bacilli

Explain negative TST in patient?

A

Inadequate lymphocytic response

  • Active pulmonary TB
  • False negative TST
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2
Q

22 yo man abdominal pain and vomiting

  • BMI 37
  • Serum triglyceride of 1500

Medication most helpful in preventing recurrences of his condition?

A

Fenofibrate

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3
Q

34 yo travels to remote village, no access to water for 36 hrs

What part of nephron segment responds to vasopressin by increasing absorption of a specific solute that is important in high medullary concentration of gradient?

A

Medullary segment of the collecting duct

  • ADH acts here, increase urea and water reabsorption
  • Allows maximally concentrated urine
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4
Q

7 yo boy develops red urine
- He has asthma, rhinitis and atopic dermatitis
- Treated for skin infection
- BP is 140/90
There is periorbital edema as well as in both feet

Responsible for renal injury?

A

IgG immune complexes ( sub epithelial humps’’ and granular deposition)
- It suggest poststreptoccocal glomerulonephritis
Type III hypersensitivity

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5
Q

45 yo wo fracture of left radius

  • 2 months ago she passed a renal stone
  • Serum Ca is 11.3 / PTH 75/ Phosphorus 2.4

Bone density reveals osteoporosis.

Major contributor to bone loss in patient?

A

Increased bone resorption due to paracrine stimulation of osteoclasts.
RANK-L of osteoblast binds to RNAK of osteoclast activating them.

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6
Q

56 yo recurrent epistaxis

  • Anemia, thrombocytopenia
  • Diagnosed with acute myeloid leukaemia
  • Hematopoietic steam cell transplant is recommended

Prior to transplant we deplete CD3 cells in marrow graft. This will decrease risk for?

A

Graft versus host disease

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7
Q

75 yo man worse vision at night

  • He has no problem driving during the day
  • Loss of red reflex and poor visualization of retinal detail
  • 20/100 vision in both eyes

Etiologic factor for patient’s eye condition?

A

Age related oxidative injury ( nuclear sclerosis, damage to lens crystalline )
- Patient has cataracts ‘’ progressive opacification of the lenses’’ caused by aging

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8
Q

68 yo cough, breathlessness and chest pain

  • Trachea is central in position
  • Dullness to percussion over lower right lung compared to left
  • Word 99 has a higher clarity and intensity over the right base

Cause of findings?

A

Exudation of neutrophil-rich fluid in lung parenchyma

- Bacterial pneumonia ( alveolar consolidation)

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9
Q

72 yo man lesion behind his ear

  • squamous cell carcinoma is confirmed, excision is done
  • 3 weeks later patient returns with granular lesion at excision site

What cause the postoperative changes?

A

VEGF induced tissue proliferation
, this is produced by platelets and macrophages
- Heal by secondary intention

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10
Q

Risk of PPH among women receiving TXA in addition to oxytocin is 0.8

What conclusion can be given about the effect of TXA in addition to prophylactic oxytocin after delivery on the risk of PPH?

A

The risk of PPH is reduced by 20% when TXA is added to prophylactic oxytocin

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11
Q

45 yo man end stage renal disease, undergoes renal allograft transplantation
- 6 days after patient develops fever and right lower abdominal pain

Ischemia and necrosis of transplanted ureter adjacent to the site of implantation. Proximal portion of ureter is normal.

Healthy segment is receiving blood from which artery?

A

Renal artery

- Distal ureter is supplied by superior vesical artery

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12
Q

58 yo wo left knee pain
- pain worse later in the day
Patient started on celecoxib therapy

Presence of which condition would make this medication the preferred treatment?

A

Peptic ulcer disease

- Celecoxib is a COX2 inhibitor, less risk for gastric ulceration and bleeding

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13
Q

56 yo man decreased hearing in both ears
- He worked on a factory for 12 years where he shouts to communicate

Hearing is worse at higher frequencies.

What would be abnormal in this patient?

A

Organ or corti
- Noise induced hearing loss from trauma to stereo ciliated hair cells
Due to shearing forces against tectorial membrane.

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14
Q

21 yo wo felt bloated, constipation

  • Irregular menses
  • Examination shows eroded enamel of the teeth
  • BIcarbonate îs elevated

Cause of patient condition?

A

Bullimia nervosa

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15
Q

82 yo wo lower extremity swelling

  • pulsation in her neck
  • Underwent pacemaker implantation due to sick sinus syndrome
  • Pulsatile liver, episodes of lightheadedness.

Diagnosis?

A

Tricuspid valve regurgitation
- Right sided heart failure

  • It could be constrictive pericarditis, but because of pacemaker, tricuspid regurgitation is more common.
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16
Q

69 yo chest tightness when walks uphill

  • Hyperlipidemia and type 2 DM
  • He is given drug that is metabolized to S-nitrosothiols

Which component of cardiovascular system is most susceptible?

A

Large veins
- Stable angina pectoris give nitrate
preload is reduced, decreased oxygen demand

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17
Q

Drug has been shown to prolong survival without curing the malignancy.
What changes can we expect in number of incident and prevalent cases?

A

Incident will not change, prevalent cases will increase

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18
Q

43 yo wo with pain and tingling affecting 1st 3 digits of both hands

  • Patient suffers chronic renal failure and receives hemodialysis
  • Diminished sensation over the thumb, index and middle fingers

Mechanism of patient’s condition?

A

Nerve compression within an anatomic compartment

Carpal tunnel syndrome - median nerve distribution

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19
Q

63 yo man 2hs of chest pain

  • Systolic murmur is heard
  • Found coronary artery occlusion
  • Next morning no more murmur and patient appears comfortable.

Initial murmur is explained by what structure?

A

Papillary muscle

- MI with systolic murmur from mitral regurgitation

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20
Q

Newborn has elevated TSH and low thyroxine

  • Ectopic thyroid below tongue
  • Cause of normal physical examination?
A

Transplacental transfer of thyroxine

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21
Q

newborn with feet are plantar flexed and adducted with the soles pointing medially.

Abnormal findings represent which anomalies?

A

Deformation

- Talipes equinovarus

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22
Q

2 yo boy found unresponsive with vomitus in his mouth

  • Cough, diarrhea for past 3 days
  • Parents gave aspirin
  • Hepatomegaly is present
  • Ammonia is 106

Examination of brain would reveal?

A

Diffuse astrocyte swelling
- Onset encephalopathy and liver failure following administration of aspirin for viral infection = Reye syndrome which cause mitochondrial toxicity

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23
Q

27 yo acute chest pain

  • Height 182 and weight 72kg
  • Pectus excavated and bilateral pulmonary crackles with decrescendo diastolic murmur in right upper sternal border

What are the histologic changes seen on autopsy?

A

Fragmentation of elastic lamellae in the aortic media
- Patient has marfan syndrome, leading to aortic dissection with acute aortic regurgitation
‘‘failure synthesis of fibrillar’’

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24
Q

34 yo wo bleeding from right nipple

  • Breast no palpable masses
  • No enlarged axillary lymph nodes

Histopathologic changes?

A

Epithelial cell lining fibrovascular cores

- Intraductal papilloma

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25
Q

Analysis of 4 groups based on treatment with statin

Most appropriate to compare levels between groups?

A

Analysis of variance

26
Q

Barbecue with 100 attendees
- Following day 28 had diarrhea

Attack rate of people who had potato salad?

A

Total number who had potato salad is 73

Among those 25 became ill
Attack rate is 25/73 = 34%

27
Q

60 yo wo

  • Hypertension, schizophrenia history well treated for years
  • Exhibits facial grimacing and lip smacking

Diagnosis?

A

Tardive dyskinesia caused by long term treatment with dopamine antagonist

28
Q

34 yo man received blood transfusion

  • Splenic laceration
  • Patient develops difficulty breathing, chills and pain
  • Urine drainage is brown

Cause of patient findings?

A

Complement mediated cell lysis
- Acute hemolytic transfusion reaction, it occurs minutes to hours is type II hypersensitivity.

Pre-existing anti-ABO antibodies

29
Q

44 yo man chronic cough and progressive weight loss

  • Emigrated from southeast Asia
  • Apical left lung infiltrate
  • Grows acid-fast bacilli

What process contributes to formation of longhand giant cell?

A

Cytokine secretion by CD4 T lymphocytes

- Pulmonary tuberculosis release of interferon gamma, which leads to macrophage activation.

30
Q

4 day old infant

  • Episodes of tonic posturing
  • Diapers smell like caramelized sugar

Deficient in an enzyme that requires which substance?

A

Thiamine
- Maple syrup urine disease , mutations in branched-chain-alpha keto acid will not breakdown leucine, isoleucine and valine.

31
Q

29 yo wo depression

  • Brief periods of confident and optimistic
  • Energetic despite sleeping only 3-4 hours a night

Diagnosis?

A

Bipolar II disorder

- History of hypomanic episodes

32
Q

Enzyme found to catalyze methylation of cytosine residues in DNA using SAM as the methyl donor

This enzyme plays crucial role in which process?

A

Imprinting
- DNA methylation of adenine and cytosine by DNA methyltranseferase
Cytosine methylation used in genomic imprinting in fragile X syndrome ( methylation of cytosine-guanine repeats CpGs islands)

33
Q

24 yo wo joint pain fatigue, edema, weight gain

  • Oral mucosal ulcers, facial puffiness, 3+ peripheral edema
  • Protein excretion is 4.5
  • Serum antinuclear antibodies are present, glomerular capillary wall thickening with no increase cellularity.

Stained with methenamine silver, irregular spikes protruding from glomerular basement membrane are seen

Condition?

A

Membranous glomerulopathy

- Electron dense immune deposits

34
Q

Left ventricular pressure volume loop compared at rest to heavy exercise difference in diagram?

A

The loop will increase in every direction of pressure/volume axes

35
Q

33 yo wo urinary tract infection

  • On arrival she is lethargic, no additional history is available
  • Overnight patient develops respiratory distress after being given imipenem and vancomycin
  • Physician notes from home hospital arrive saying she is allergic in the morning

Statement associated with reduced malpractice?

A

I am so sorry an error led to your allergic reaction. I will do my best to help you through it

36
Q

23 yo wo vaginal bleeding and abdominal cramps

  • Last menstrual period was 6 weeks ago.
  • Gestational sac in fallopian tube
  • Methothrezate is administered

Which substance will accumulate in embryonic tissue as a result?

A

Dihydrofolate polyglutamate

- Folate antagonist which inhibits DHF reductase therefore DHF accumulates.

37
Q

25 yo stung by several wasps

  • Throat tightness and dizziness
  • Respirations are 32/min, BP80/40
  • Diffuse erythematous plaques over trunk + edema of ankles

Cause of hypotension?

A

Chemical mediator induced increased vascular permeability

  • Anaphylaxis is type I hypersensitivity, production of allergen specific IgE produces release of chemical mediators ( histamine, prostaglandin, leukotrienes)
38
Q

17 yo right ring finger injury
- Patient can flex the metacarpophalangeal and proximal interphalangeal joints but can’t flex distal interphalangeal joint

Tendon most likely injured?

A

Flexor digitorum profundus

39
Q

26 yo man worsening right sided scrotal pain

  • Testicular torsion with ischemic damage , undergoes orchiectomy
  • Worries about risk of sexual dysfunction and infertility

Effect on erectile function an sperm count?

A

Normal erectile function and decreased sperm count

40
Q

34 yo wo cardiac snap followed by a rumbling diastolic murmur heard over cardiac apex

In a volume pressure loop, snap most close to?

A

Open of mitral valve ( point lower left )

41
Q

42 yo man fever and loose stools during trip to southeast asia

  • Previous episode of salmonella last year
  • He has macular rash on trunk
  • Culture grow gram negative, non lactose fermenting rods

What explains prolonged patient severe disease compared to prior episode?

A

Extensive intraphagocytic multiplication

- Typhoid fever ‘’ invasive salmonella’’

42
Q

21 yo man painful ulcer on right side of penis

  • Tourist visiting from Botswana
  • HIV positive
  • Irregular ragged borders, covered with grey exudate
  • Enlarged inguinal lymph node in right groin

Diagnosis?

A

Chancroid

- Hemophilus ducreyi

43
Q

46 yo wo somnolent and difficult to arouse
- skin is flushed, oral mucosa dry and pupils are dilated

Overdose of which drug?

A

Amitriptyline

44
Q

23 yo man fatigue and malaise

  • Hepatomegaly
  • Unprotected sex with different female partners

Likely present?

A

Serum HBs Ag

45
Q

Transport across membrane and solute concentration graph

  • 1 rises rapidly and becomes steady
  • 2 rises linearly

What makes the difference?

A

Presence of a protein transporter

46
Q

Neurotransmitter leads to calcium influx initiating a toxic cascade that results in rapid cell death

Blockade of what receptor will decrease this neuronal injury?

A

Glutamate receptor

- NMDA receptor activation

47
Q 
17 yo boy gynecomastia
- Sparse facial and pubic hair
- Testosterone and LH are high
FSH is normal. 
- Oligospermia is present

Mechanism causing this condition?

A

Androgen receptor dysfunction

-Insensitivity syndrome

48
Q

Older patients with acute traumatic blood loss have a much lower reticulocyte count and a much longer time to recovery to pretrauma hemoglobin level when compared to younger patients

age related process causing this?

A

Decreased bone marrow mass

- Higher quantity of fat in bone marrow

49
Q

25 yo man right arm weakness

  • diminished pinprick and temperature sensation over small are of right upper lateral arm
  • Atrophy of right deltoid with 3/5 strength on right shoulder abduction

Injury to which nerve?

A

Axillary

50
Q

53 yo wo aching pain in legs we see varicose veins

Cause of symptoms?

A

Incompetence of Venous valves causes venous stasis dermatitis.

51
Q

58 yo rectal examination shows firm palpable mass in rectal vault

  • Mass in the middle third of the rectum
  • Metastases in the pararectal lymph nodes are present

Which lymph nodes should be sample for further assessment?

A

Internal iliac
- Lymphatic channels proximal to the anal dentate line drain into the inferior mesenteric and internal iliac lymph nodes.

52
Q

Ran of ribosomes is synthesized where?

A

Nucleolus, only the 5S rRNA is transcribed outside of the nucleolus

53
Q

72 yo man with waxing and waning chest pressure

  • Similar sensation last 5-10 min when he walks
  • BP211/105
  • ECG nonspecific ST segment changes

Medication cause:
Stroke volume unchanged
SVR decreased
HR decreased

What medication was given?

A

Labetalol

- Non selective vasodilatory beta -alpha blocker cause peripheral vasodilation but has no effect on stroke volume

54
Q

16 yo girl usual state at lunch

  • Now respirations are 30/min
  • Disoriented and drowsy
  • normal size reactive pupils
  • Bicarbonate is 14, glucose 78, lactic acid 7.5

cause of findings?

A

Aspirin intoxication

- Tinnitus, hyperventilation, nausea and vomiting, increased lactic acid

55
Q

25 yo has a stillbirth a 18weeks gestation.

  • Pain in knees and feet
  • Elementary school teacher
  • Fetal autopsy shows pleural effusion, pulmonary hypoplasia and ascites

Infection with?

A

Nonenvoleped, single-stranded DNA virus

- Fetal hydros fetalis, infection with parvovirus B19

56
Q

60yo man, intermittent, squeezing substernal pain

  • COPD
  • ECG shows sinus rhythm with 2mm anterior ST segment elevation
  • Troponin I levels are elevated

Appropriate treatment for this patient?

A

Metoprolol

Acute MI give cardioselective beta blockers

57
Q

35 yo man painful tongue sore

  • Fever for 2 weeks
  • Unprotected sex with a stranger 1 month ago
  • Rash over trunk and cervical lymphadenopathy
  • Ulcer located on the median sulcus of the tongue 2cm anterior to foramen cecum

Pain sensation form ulcer is carried by which nerve?

A

Mandibular division of trigeminal nerve

58
Q

64 yo lesions on forehead

  • Gardener much of his life
  • Lesions have a rough grainy texture
  • Atypical keratinocytes with hyperkeratosis and parakeratosis

Risk of developing?

A

Squamous cell carcinoma

- He has actinic keratoses

59
Q

26 yo wo had a pulmonary embolism during previous pregnancy.

  • Heparin was initiated 6 days ago, now she has lower extremity edema
  • Platelet count normal prior to therapy

What predisposed this patient to condition?

A

Anti-platelet factor 4/heparin antibodies

  • HITT
60
Q

43 yo man epigastric pain radiating to his back

  • BMI is 34
  • Triglycerides is 1200 / Amylase 400
  • Insulin is administered to reduced lipid levels

Insulin will stimulate which enzyme?

A

Upregulates Lipoprotein lipase, liberated fatty acids are taken up by adipose cells lowering triglycerides

  • Acute pancreatitis
  • Insulin also reduces activity of hormone sensitive lipase in adipose tissue

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