Application key pearls Flashcards
1
Q
3F
rumbling murmur auscultated in the neck that goes away when child is supine and the neck rotated
Dx?
A
venous hum
benign peds murmur that will go away as child grows
2
Q
Neonate with supravalvular aortic stenosis
A
Williams syndrome
Chromosome 7 – AD
increases vit D sensitivity
3
Q
Location of SA node?
A
junction of SVC and RA
4
Q
Location of AV node
A
inferior to the opening of the coronary sinus = posteroinferior interatrial septum near the coronary sinus
5
Q
Location of coronary sinus?
A
between the opening of the IVC and the tricuspid valve
6
Q
2-year-old boy has cardiac myxoma
-peri-oral melanosis = hyperpigmentation around the mouth/lips)
-hyperthyroidism
Dx?
A
Carney complex –> bilateral pigmented zona fasciculata hyperplasia = Cushing syndrome, but can be hyperthyroidism or growth hormone
7
Q
What kind of pulse is seen in AS?
A
a slow-rising pulse = pulsus parvus et tardus
8
Q
Heyde syndrome is
A
the combo of AS + angiodysplasia = painless rectal
bleeding in elderly due to superficial tortuous vessels on the bowel wall
9
Q
AR
A
which causes bounding pulses with head-bobbing = pulse has brisk upstroke with precipitous downstroke
10
Q
What’s the structural change in the heart with HOCM?
A
asymmetric septal hypertrophy –>
the anterior mitral valve leaflet to block off the LV outflow tract under states of lesser preload
11
Q
Marfans syndrome AR
A
causes increase in LV cavity size
12
Q
Marfans syndrome MVP
A
result of myxomatous degeneration
13
Q
Who gets MS
A
previous rheumatic fever which is a type 2 hypersensitivity
14
Q
33F
pregnant at 20 weeks
new-onset dyspnea
crackles in both lung fields
diastolic rumbling murmur
A
MS b/c of increases plasma vol
15
Q
Who gets PS
A
Tetralogy of Fallot - DiGeorge Syndrome
Noonan syndrome
16
Q
Who gets TR
A
Carcinoid syndrome
note gets louder w/ inspiration
17
Q
Orlistat
A
pancreatic lipase inhibitor
18
Q
Evolocumab
Alirocumab
A
PCSK9 inhibitors = prevents the breakdown of LDL receptors
19
Q
Ivabradine
A
inhibits myocardial funny Na channels
causes luminous phenomenon = brightness in an areas of the visual field
20
Q
Sacubitril
A
neprolysin inhibitor = breaks down ANP & BNP
21
Q
Polyarteritis nodosa
A
HepB +
Beads on a string
22
Q
When is rapidly progressive glomerulonephritis (RPGN) the answer?
A
acute deterioration in renal function (high Cr, high BUN, oliguria) in someone who has a vasculitis
- granulomatosis with polyangiitis = formerly Wegener
- eosinophilic granulomatosis with polyangiitis = formerly Churg-Stauss
- microscopic polyangiitis
- Goodpasture syndrome
23
Q
Biopsy shows what in RPGN?
A
fibrin crescents =
1. parietal cell hyperplasia
2. leukocytic infiltrate
24
Q
c-ANCA =
A
anti-proteinase 3 (anti-PR3)
25
p-ANCA =
anti-myeloperoxidase (anti-MPO)
26
Sulfa drug
kidney issue
no blood in urine
Dx?
membranous glomerulonephropathy (MG)
27
Biopsy finding in MG?
subepithelial deposits
“spike and dome”
28
- HepB or C
nephrotic syndrome
Dx?
MG = membranous glomerulonephropathy
29
Autoantibodies in membranous glomerulonephropathy?
positive for anti-phospholipase A2 receptor antibodies
30
Late finding seen histologically in diabetic nephropathy is Kimmelstiel-Wilson nodules which are composed of
hyaline
DN = mesangial matrix expansion
31
Beckwith-Wiedemann syndrome?
Wilms tumor
neonatal hypoglycemia
macrosomia /macroglossia
hemihypertrophy
+/- omphalocele
caused by WT2 gene mutation
32
45F
confirmed Dx of early-stage small cell lung cancer
wobbly gait
autoimmune = paraneoplastic anti-Hu anti-Yo
33
12-hour-old newborn
becomes blue when breastfeeding
becomes pink again when crying
Dx?
atresia of the choanae (CHARGE syndrome)
1. Coloboma of the eye
2. Heart defects
3. Atresia of the choanae
4. Retardation
5. Genitourinary abnormalities
6. Ear abnormalities/deafness
34
medial longitudinal fasciculus (MLF) syndrome
The side that cannot adduct is the side that is messed up
the normal sides will have the nystagmus
35
32M
waxing and waning tinnitus & hearing loss
difficulty hearing conversations at dinner and in groups
has family Hx of similar Sx
Dx?
Meniere disease = defective endolymphatic drainage
36
30F
MDD
Easily angered
Clumsy + shaky
history findings?
AD triplet expansion in HTT gene
Exhibits anticipation = succeeding generation earlier onset or increased severity
37
19M
headache + neck pain
Fever
Pt is oriented to person only
Unchallenged ridigity
Defense mechanism of the brain
Microglial - essential role in bacterial meningitis
38
46M
ED w/ stone refractory to acetaminophen
1st line analgesia
Ketorolac = NSAID favored for managing renal colic
Nonopioids are tried 1st
39
Tramadol
Metabolized into opioid
ADRs constipation + Respiratory depression (w/ toxicity)
40
71F
sudden difficulty walking
Horners sx
Palate sags + gag reflex
Loss of facial pinprick sensation
PICA = Pick a horse that can swallow
Lateral medullary syndrome
41
Loss of pinprick sensation to face
Ipsilateral spinal trigeminal tract
42
55F
1 hr history of worst headache ever
Pupils 4 mm bilaterally
Pupils briskly reactive to light
Hyperintensities in the ambient & superior cisterns
Middle cerebral artery ruptured
SAH = subarachnoid space
Superior cisterns = subarachnoid
43
55F
Headache
Hyperdensity w/n basal ganglion or internal capsule
Ruptured Lenticulostriate arteries = intraparenchymal hemorrhage
44
Middle meninges artery rupture
Epidural hematoma
45
68M
Floaters + flashes of light in his eye
History = DM 2 HTN
Detachment of the retina
MOA
Dissection of neuronal + pigment epithelial layers of retina
Blood supply to photoreceptors cells is lost
46
Capillary damage w/ blood leakage into retina
dx
Diabetic retinopathy
47
45F
ED w/ suddenly onset of worst headache
Alter + oriented x3
Sluggish to answer questions
Non-contrast CT scan= no abnormalities
next steps
SAH next steps = Lumbar puncture
After 12 hrs CT is not as sensitive —> LP providing evidence of xanthochromia ( yellow CSF) b/c bilirubin
48
28F
Tx with escitalpram
What caused sx
Raphe nuclei = produces Serotonin
Drug targets metabotropic + ligand-gated 5-hydroxytryptamine receptors in nervous system
49
40M
Hypotension
Increases serum CRT/BUN
Found on urinalysis
Brown granular casts = ATN
50
61M
ED back pain
Osteomyelitis confirmed & Abx for 2 wks
Which Abx can causes brown granular casts
Aminoglycosides = GNATS-mycin
51
61M
ED back pain
Osteomyelitis confirmed & Abx for 2 wks
Which Abx can causes brown granular casts + leukocytes (eosinophils)
Cephalosporins + penicillins
52
63F
Flaccid paralysis post Epsom salt enema for constipation
Prolong PR interval
Widened QRS complexes
Which electrolyte abnormality is present
Hypermagnesemia
This blocks neuromuscular junction
53
35W 25 weeks pregnant
Headache + blurred vision + SOB
Flaccid paralysis + hypotension + Brady after IV to
ECG = prolonged PR & QRS
Best initial tx
IV Ca++ w/ loop diuretics
Preeclampsia tx = Mg which leads to the ECG readings peaked T waves + Prolong PR & QRS
54
70M
Syncopal episodes
Orthostatic hypotension
High serum Na+ levels
Tx
Isotonic (.9) then hypotonic (.45%) saline w/ 5% dextrose
55
65F
paresthesia
mean corpuscular high
Pernicious anemia
56
Pernicious anemia MOA
Parietal cells destruction in the upper glandular layer of stomach
57
1F
green-yellow vomit post feeding
bilious emesis most likely due to intestinal atresia which causes an obstruction
58
Duodenal atresia
recanalization issue seen in 21
Gastric + Proximal duodenal dilations = double bubble
59
Jejunal/Ileal atresia
vascular occlusion (SMA) seen in gastroschisis + volvulus
Dilated loops in small intestine + air/fluid levels
60
Failure of neural crest cell migration to distal colon (rectum)--> aganglionic colon segments = functional obstruction
Hirschsprung disease
61
Hirschsprung diseases biopsys show
absence of submucosal + myenteric plexi
xray = transition zone (narrow-caliber)
62
334F
known Hep B carrier
IV drug user
Sx of liver issues
Labs + for HBsAg and Hep D RNA
Life cycle?
Coating of viral particles
Hep B surface antigen is required to coat Hep D antigen before it can infect + multiply
63
Jak-STAT pathway used for
1. cytokines = interferon
2. hematopoietic growth factors = EPO + G-CSF
3. hormones that bind to cell surface (i.e. GH)
64
cAMP- PKA pathway used for
PTH
ACTH
TSH
ADH
65
DAG-PKC & IP3-Ca++/calmodulin pathways used for
GnRH
TRH
ADH
Releasing in hypothalamus
66
35M
gynecomastia
increased estrogen > androgens
this occurs if
1. increases aromatase activity
2. decreased Leydig activity (testosterone production)
67
3wkG
blood-streaked stool
mom = premature rupture of membranes
X-ray = Lucency (gas pockets) that run along the bowel wall
Pneumatosis intestinalis = Necrotizing enterocolitis
preterm infant + GI issues
68
Kehr sign
seen in splenic laceration = shoulder pain due to peritoneal irritation (stimulates phrenic nerve)
69
4dayM
increased indirect bilirubin
Jaundice
increased Bilirubin production (infant RBCs have shorter lifespan)
Increased enterohepatic bilirubin circulation (infant have sterile guts = decreased urobilinogen (reduction))
70
54M
Hepatoslenomegaly
eosinophils
bleeding esophageal varices
Schistosomiasis
note S. haematobium = urinary
71
Chronic iron-deficiency anemia + eosinophilia
Hookworm
72
Return from Africia
hepatosplenomegaly
anemia
acute = fever chills malaise
malaria
Giema stain
73
27F
RLQ pain
inflamed terminal ileum or sigmoid colon
Crohn Disease
noncaseating granulomas
skip lesions
mouth & anus spread
Rectum SPARED
Fistulae
74
42M
painless blood in stool
digital rectal exam = mucosal lesions ABOVE dentate line
Internal hemorrhoids
MOA: prolonged distension of anal AV plexus = anal canal is now inflamed + thrombose + prolapse
Have no pain b/c no somatic sensory innervation
75
42M
painful blood in stool
digital rectal exam = mucosal lesions BELOW dentate line
External hemorrhoids
76
Where do Internal hemorrhoids drain
Superior rectal vein which communicates w/ inferior mesenteric vein
77
Where do external hemorrhoids drain
Inferior rectal vein which communicates w/ internal pudendal vein
78
Anastrozole
Decreases androgen aromatizations
Used to tx slow the progression of ER+ tumors
Decrease estrogen production
79
54M
Hep C history
Several episodes of vomiting BRIGHT red blood
ab distention + gynecomastia
Altered mental status
Cirrhosis (Hep c ab distention + gynecomastia) + recent GI bleed = Hepatic encephalopathy
80
Hepatic encephalopathy
increases nitrogen delivery to gut (from GI bleed) can be converted into ammonia which can be absorbed into the bloodstream
accumulation of ammonia can increase inhibitory NT
81
Metyrapone stimulation test
tests the HPA axis function
it inhibits 11-b-hydroxylase = decrease cortisol
decrease cortisol = increase ACTH
82
2F
BM with blood
telescoped duodenal
biopsy shows glands
Meckel diverticulum incomplete obliteration of vitelline duct
ectopic tissue = gastric mucosa + thyroid etc
83
73M
epigastric pain 30-40 after meals
HTN + hyperlipid + CABG
normal endoscopy
Chronic mesenteric ischemia
linked to stable angina
84
Penicillamine
increases urinary excretion of copper
copper chelation agent
85
16F
sx of hyperthyroidism
Small thyroid gland
decrease TSH
undetectable thyroglobulin levels
elevated free T4 (thyroxine)
Exogenous hyperthyroidism
causes atrophy of the thyroid follicles w/ decreased colloid
86
MOST common cause of hepatic metastases =
Colorectal cancer and it spreads via the portal venous circulation
86
MOST common cause of hepatic metastases =
Colorectal cancer and it spreads via the portal venous circulation
87
True diverticulum has
mucosa
submucosa
muscularis
88
30M
bilious emesis
Bulging pouch connected to ileum
Meckel diverticulum
88
Herniated muscular layers
Colonic & Zenker (upper esophageal) diverticula = false diverticula
mucosa + submucosa layers
89
23M
hepatomegaly
unprotected sex
never been vax for Hep
HepBsAg
90
Hep C vs Hep B
Hep C = generally asymptomatic spread = IV drugs
Hep B = Sex + IV drugs + vertical transmission
91
76F
hypoglycemia w/ skipping a meal
Sulfonylureas = gly or gli
Meglitinides = glide
92
52F
post-menopausal is given tx
how will the pts condition change the thyroids affects on the body
or 25F
prego
Increase TBG & Total T4 & T3
Estrogen --> increases thyroxine-binding globin
TBG lowers free T4 and T3 --> increase TSH transiently
Increases TSH = increased Total T4 (TGB + free T4) & T3
93
Newborn
High TSH
low T4 (thyroxine)
Primary hypothyroidism
Thyroid dysgenesis
TSH resistance
94
Newborn w/
Increases TSH & T4
Thyroid hormone resistance
95
46M
HIV
oropharyngeal = poor dentition
Endoscopic: Esophageal hyperemia + linear ulceration
Microscopic: cytoplasmic inclusions
CMV
96
46M
HIV
oropharyngeal = poor dentition
Endoscopic: punched-out ulcer
Microscopic: multinuclear squamous cells + eosinophilic
HSV-1
97
46M
HIV
oropharyngeal = poor dentition
Endoscopic: gray/white erythematous mucosa
Microscopic: yeast
Candida albicans = most common
98
46M
HIV
oropharyngeal = poor dentition
Endoscopic: gray/white erythematous mucosa
Microscopic: yeast
Candida albicans = most common
99
Who has GLUT 4 receptors
Skeletal Muscles + Adipocytes
100
70F
Blacked colored stool
endoscopy = gastric antrum irregular borders + ulcer
Biopsy of ulcer = glandular structures containing intestinal-like columnar cells
Gastric adenocarcinoma
predisposes pt =
1. excessive salt-preserved foods
2. H. pylori infection
3. n-nitroso-containing compounds
4. autoimmune atrophic gastritis
101
63M
- Immunosuppression meds
- 2cm ulcerated mass from the anal verge into the rectum
- Biopsy =
1. eosinophilic squamous epithelial cells
2. hyper-chromatic
3. irregular nuclei
4. scant cytoplasm
5. keratinization
HPV
102
Preproinsulin made in
RER in B-cells (pancreatic)
103
Proinsulin is made in
stored in secretory granules = cytoplasm
104
3 dayM
Poor feeding + emesis + lethargy
Laparotomy - fibrous bands from cecum + right colon to retro-peritoneum = extrinsic compression of duodenum
Intestinal malrotation = midgut rotation + intestinal fixation
105
72F
large amount of BRIGHT red blood w/ stool
Colonoscopy = multiple outpouching
Colonic diverticulosis
106
Colonic diverticulosis MOA
disruption of vasa recta (terminal vessels derived from SMA & IMA) penetrate through the smooth muscular layer of colon = intraluminal colon wall lacks structural integrity (absence of muscularis propria)
107
Colonic diverticulosis tx
resuscitation IV + colonoscopy
persistent bleeding = angiography + surgery
108
Terminal ileum vs Proximal Duodenum
Terminal ileum = villi + colonic crypts epithelial cells secrete Bicarb
Proximal Duodenum = submucosal glands (Brunner) secrete bicarb
109
2F
karyotype 46XX
evaluation of ambiguous genitalia is the result of
11b-hydroxylase deficiency
Causes excess androgen --> virilization
if an infant = aromatase deficiency
110
2M
karyotype 46XY
evaluation of ambiguous genitalia is the result of
5-a reductase deficiency
111
15M
Pancreatitis
hypo-reflexia + decreased proprioception
mild hemolytic anemia
Vit E
112
BPH tx
5-a reductase inhibitor
finasteride
decreases conversion of testosterone to DHT
113
finasteride ADR
decreased libido
erectile dysfunction
decreased ejaculate vol
5-a reductase inhibitor
114
8month
poor feeding
Enterovirus in brain biopsy
X-linked agammaglobulinemia = BTK gene mutation
low circulating B-lymphocyte count
115
19F
O-neg packed RBCs given
facial swelling
generalized hives = urticaria
SOB = wheezing
Selective IgA deficiency
sinopulmonary + GI infections
linked to blood products --> anaphylaxis
116
7M
acetaminophen
facial swelling = cheeks + lips + tongue
C1 inhibitor deficiency = low C4
increased C1 + bradykinin
117
Decreased in ______ leads to reduced efficacy in Ig by a single plasma cells
number of Ag epitopes recognized
118
Sequestered Ag post trauma =
Immune privilege = inherent response
119
widespread capillary occlusion during graft procedure
Hyperacute rejection
120
Hypersensitivity of hyperacute rejection =
2
Ab rxn to donor Ag
121
Dense interstitial lymphocytic infiltrates = which hypersensitivity rxn
4 = seen in Acute rejection
recipient CD8+ T cells attacking donor MHC molecules
122
Difference between Graft vs Host disease & Chronic transplant rejection
GVHD = Grafted T cells proliferate in immunocompromised hosts & reject host cells = seeing them as “foreign” proteins
Chronic = CD4+ cells secrete inflammatory cytokines to cause smooth muscle proliferation, parenchymal atrophy, and interstitial fibrosis
123
DHR assay converts DHR to rhodamine (green)
this is abnormal in pts with
Chronic granulomatous disease (defective NADPH)
124
Young F
irregular heavy menses since the start
PE normal
Labs + pap + US normal
MOA?
anovulatory cycles as a result of metrorrhagia (dysfunctional uterine bleeding in young women)
unopposed estrogen (no progestrone)
125
Infant that is breastfeed
increased indirect bulirubin is the result of
glucuronyl transferase deficiency
126
40M
Irish-English
fatigue
diminished libido
erectile dysfunction
hyperpigmentation on skin
dx?
Hereditary hemochromatosis
Celtic descent
127
60M
CHF
Normal renal function
which drug increases survival
ACEi = slows the abnormal ventricular remodeling to improve survival
128
Percussion of facial nerve -- twitching =
hypocalcemia
129
Ethmoid = CNs
Sphenoid = CNs
Temporal = CNs
Occipital = CNs
Ethmoid = CN1 (Olfactory)
Sphenoid = CN2-6
Temporal = CN7-11
Occipital = CN9-12
130
Norepinephrine increases
1. systolic & diastolic pressures
2. α1-mediated = vasoconstriction
3. mean arterial pressure
131
NE causes
Reflex bradycardia
132
1. Unconscious proprioception
2. Fine touch + vibration + proprioception
3. Pain & Temperature B/L
Unconscious proprioception = spinocerebellar tract
Fine touch + vibration + proprioception = DCML
Pain & Temperature B/L = Syringomelia
133
The fibers of the ________ tract decussate at the spinal level which they innervate
anterior corticospinal
134
Extrapyramidal tracts are upper motor neuron pathways that contribute to the
autonomic innervation of body tissues
1. reticulospinal tract
2. rubrospinal tract
3. tectospinal tract
4. vestibulospinal tract
135
Pyramidal tracts are upper motor neuron pathways that contribute to the
innervation of skeletal muscle
1. corticospinal tract
2. corticobulbar tract
136
Muscles in the lower quadrant innervated by
CN VII (facial) = only contralateral innervation
137
Muscles in the superior quadrant receive
B/L upper motor innervation via the corticobulbar tract
138
Ventral midbrain degeneration = dx
Parkinson's
Ventral midbrain = substantial nigra
139
Xray = egg on a string
Transposition of the great vessels
140
Scrotum drains to
Superficial inguinal nodes
141
Testes drain into
Para-aortic (lumbar) node
142
Prostate + corpus cavernous drain
Internal inguinal node
143
Decrease progesterone causes spiral arteries to
Vasospasm = bleeding + menstruation
144
Progesterone allows
For spiral arteries to proliferate
Endometrial thickening
Tortious endometrial glands
145
CKD
normal platelet count
normal coagulation studies
excessive bleeding
Platelet dysfunction = unregulated NO = decreased adhesion + activation + aggregation
146
Decreased slope of venous return
seen in systolic heart failure
increases atrial pressure
causes peripheral edema
147
proximal to distal, the parts of the urethra are
prostatic
membranous
bulbar
penile
148
______ poisoning inhibits enzymes that normally prevent the production of reactive oxidative species (ROS), resulting in increased oxidative damage
Mercury
149
55M
Bone pain
hearing loss
elevated ALP
Paget = Osteitis deformans
150
Ramsay Hunt syndrome vs Bell's Palsy
Ramsay Hunt syndrome = latent varicella-ZOSTER virus reactivates in the geniculate ganglion (involving CN VII and CN VIII)
Bell's palsy = HSV CN 7
151
DiGeorge w/ harsh systolic murmur LLSB
Persistent truncus arteriosus
152
increase in urine pH can increase the risk of,
nephrolithiasis
Acetazolamide (carbonic anhydrase inhibitor) decreases bicarbonate reabsorption and alkalinizes the urine
153
urinary incontinence
bladder exstrophy
Epispadias = Dorsal + Upper side
abnormal genital tubercle
154
Urinary incontinence
inguinal hernias
cryptorchidism
Hypospadias = Ventral + Lower side
failure of urethral folds to close
155
Sclerotic phase of Paget disease of bone is defined by predominant
osteoblastic activity
156
Congenital adrenal hyperplasia
Decreased aldosterone
Decrease BP
Increase K+
157
Oral Scabies tx
Ivermectin = parasite paralysis through distinct mechanisms:
1. stimulation of nerve and muscle cell glutamate-dependent chloride channels = influx of chloride, hyperpolarization
2. GABA-mediated
158
Smoking cessation
Varenicline = partial nicotinic receptor agonist
Bupropin = NE & dopamine antagonist
lowers seizure threshold in pts w/ bulimia
