HyGuru Review Flashcards
(354 cards)
1
Q
Diastolic murmur with an opening snap
A
Mitral stenosis
2
Q
Wha perfuses the lower esophagus?
A
Esophageal arteries which come from the thoracic aorta via bronchial arteries
3
Q
Which vessels create anastomosis for the lungs?
A
Right, superior left, and inferior left bronchial arteries. All stemming from thoracic aorta
4
Q
What vessels are at a imbalance in the case of esophageal varices?
A
Left gastric vein (portal contribution) and Azygous vein (systemic contribution)
5
Q
How can you treat esophageal varices?
A
Octreotide (somatostatin analog)
- Beta blockers as prophylaxis
6
Q
How do gastric varices happen?
A
Splenic vein thrombosis blocking the gastric fundus to drain via the short gastric veins.
7
Q
What are some scenarios that can lead to a splenic vein thrombosis?
A
Pancreatitis
Polycythemia vera
Nephrotic syndrome
PNH
8
Q
What is really “buzzy” for polycythemia vera?
A
Itchy after a hot shower
9
Q
What is the mechanism behind Paroxysmal Nocturna Hemoglobinuria?
A
Lack of GPI anchor on the RBC, leads to decrease/abscence of DAF (CD55/59). Compliment cannot inactivate leading to hemolysis.
10
Q
A 16 yo M presents after experiencing light headedness after a tackle. He is noted on labs to have a HgB of 8.4. CXR reveals L rib fractures 9-11. whats the dx
A
Splenic rupture
* Keep in mind a pneumothorax can also develop
* also duodenal hematoma
11
Q
Blunt abdominal trauma - low Hct
What organs are you thinking about?
A
Liver and spleen
12
Q
Encapsulated gram negative diplococci
A
Neisseria
13
Q
Encapsulated gram positive diplococci, lacet shaped
A
Strep pneumonia
14
Q
Encapsulated Gram negative coccobacilli
A
Hemuphilis influenzae
15
Q
What would you see in a SCD pt undergoing recurrent sequestration. He is vaccinated. What would peripheral smear likely show?
A
Howell Jolly body
- basophilic nuclear remnant
- seen in both functional or anatomical asplenia
16
Q
What embryological derivative does the spleen come from?
A
Mesoderm
17
Q
A 30 yo female presents with postpartum hemorrhage shortly after delivering her term infant and passes away. She has a history of previous C-section. Pathology shows placental tissue remnant invasion into the uterine wall. Whats the dx?
A
Placenta accreta
18
Q
What do syncitiotrophoblasts produce?
A
Beta HCG and the placenta
19
Q
Heavy menses, homogenous, bulky, globular mass, histo shows endometrial tissue invading the myometrium, whats the diagnosis?
A
Adenomyosis
20
Q
How can you treat DIC?
A
Cryoprecipitate
- replenishes fibrinogen
21
Q
Female is in DIC, pregnant, drug history of cocaine, tobacco, and HTN presents with painful uterine bleeding. OBGYN discovers a premature separation of the placenta? Whats the DX?
A
Abruptio placenta
22
Q
Female pt pregnant and hx of multiple pregnancies and c-section presents with painless uterine bleeding. OBGYN sees an attachment of placenta to lower uterine segment or cervix.
What is the dx, how do you treat?
A
Placenta Previa, do a C-section to reduce blood supply being cut off.
23
Q
Female pt with hx delivery of C-section is delivering her baby and OBGYN discovers she is hemorrhaging as the placenta is being delivered. Doc notices the Placenta attached to the myometrium. Whats the dx
A
Placenta Accreta
24
Q
Can Placenta Previa and Placenta accrete co-exist?
A
yes
25
Pregnant female comes to the ED after her water just broke, There is bleeding with no pain, and pelvic examination shows fetal vessels over cervical os. Whats the dx?
Vasa previa
- umbilical (velamentous cords) inserts into the placenta instead of the normal chorioaminotic membrane.
26
What phase of the menstrual cycle is characterized by dilated, tortuous/mucus glands with large vacuoles?
What hormone leads this process?
Secretory, led via progesterone.
27
What phase of the menstrual cycle occurs in the ovary?
What hormone leads?
Luteal, led via progesterone.
28
A young female recently started menses. She presents with prolonged bleeding and IDA. TSH and coagulation factors are normal. What is the likely diagnosis?
Anovulatory cycles
29
What can result from anorexia?
Low estrogen. Leads to decrease in menses and osteopenia presenting a stress fractures.
30
What structure helps facilitate entry into the neural canal?
Lamina
31
Point tenderness to vertebral column, whats the dx?
Compression fracture
32
Name the labeled structures:
A- Oculomotor
B- Trigeminal CN V
C- Trochlear
D- Abducens
E- CN VIII (vestibulocochlear)
33
Where does the middle cerebral artery branch from?
Internal carotid
34
What supplies the visual cortex?
Posterior cerebral arteries.
35
Pts with ADPKD and Marfan have aneurysms where?
Junction of ACA and Anterior communicating artery. Aka a berry aneurysm
36
D
37
How can you remember the brachial plexus?
MARMUduke (the dog)
38
What nerve is affected in winged scapula?
Long thoracic nerve
(C5-C7)
39
A 30 yo M presents after an acute pop sensation while curling a dumbbell. He is unable to now flex his arm or supinate. What is the likely nerve roots affects?
C5-C6.
Musculocutaneous nerve
40
Describe brachial plexus lesion at musculocutaneous:
- biceps innervations
- loss of sensation of forearm
41
Describe brachial plexus lesion at Axillary:
Deltoid innervation
- Fx of surgical neck of humerus
- flattened deltoid
42
Describe brachial plexus lesion at Radial:
Extensors and triceps innervation
- fx of mid shaft of humerus
- wrist drop (flexed wrists)
43
Describe brachial plexus lesion at median:
Lateral 3.5 fingers; aBduction of thumb
- palmar cutaneous -> thenar sensation
- fx of supracondylar, distal shaft
- carpal tunnel (risk factor: hypoT4)
44
Describe brachial plexus lesion at Ulnar:
Medial 3.5 fingers; aDuction of thumb
- fx of hook of hamate in cycler
45
What are the labs for osteoporosis?
All normal
46
What are the risk factors for osteoperosis?
Steroids, low Ca2+, low vitamin D, non weight bearing exercises
47
What is the protective medication for osteoporosis in post-menopausal women?
Reloxifene
- estrogen antagonist in the breast and agonist at the bone
48
What system manifestations does steroid therapy cause?
GI: Peptic ulcers and hemorrhage
HTN
MSK: avascular necrosis, proximal muscle weakness, osteoporosis via RANK-L on osteoclasts, growth plate issues
Metabolic derangements
49
How do steroids manifest Peptic ulcers?
Reduced Arachadonic acid leading to decrease prostaglandins, decreases the mucosal lining.
50
How do steroids manifest HTN?
Increased up regulation of sympathomimetic receptors
51
How do steroids manifest metabolic derangements?
- increase lipolysis
- increase gluconeogenesis
- increased proteolysis
- increase insulin resistance
52
Whats the Dx?
- medial to the inferior epigastric arteries
- Dx: Direct inguinal hernia
- Direct inguinal hernias are due to weakening of transversals fascia
53
What is the mnemonic for direct and indirect hernias?
MDs dont lie:
- medial = direct, directly into abdomen
-Lateral = indirect, scrotum, caused by failure of processes vaginalis; deep inguinal ring
54
Where does the inferior epigastric artery branch from?
External iliac artery
55
What are the risk factors for gout?
Alcoholism, red meat, diuretic use (thiazides mostly- remember hyper GLUC)
56
Parallel polar light -> gout -> MSU -> what color?
yellow
57
Parallel polar light -> Calcium Pyrophosphate disease (Pseudogout) -> what color?
blue
58
What medication helps pee out uric acid?
Probenecid
59
E
- tumor lysis syndrome
60
Chondrosarcoma
61
Describe Endochondral ossification (bone formation)
62
Describe Membranous ossification:
63
Isolated increase Alkaline Phosphatase in an elderly male, whats the dx
Paget disease of the bone
- ALP represents bone turnover
64
What inhibits RANK-L from binding to RANK?
Osteoprotegerin
- high OPG/RANK-L ratio protects the bone
65
How do bone get nutrients for growth?
Volkmann and Haversian canals, they have capillaries for nutrient transport.
66
Colles Fracture
- Radius is dorsally shifted
67
FOOSH, extended wrist, dx?
Colles fx
68
FOOSH, flexed wrist?
Smith fracture
69
FOOSH, pain in anatomical snuffbox?
Scaphoid fx, prone for avascular necrosis
70
What is the suffix for bisphosphonates?
-dronate
71
Which structure is mainly responsible for preventing excessive posterior motion of the tibia relative to the femur?
PCL- post cruciate ligament
72
What is the area of injury if a "locking" or "catching" sensation of the knee is described?
Meniscus tear
73
Weakening of the what structure results in Nersemaid's elbow?
Annular ligament, results in subluxation of the radial head.
*Common extensor tendon is at lateral epicondyle.
74
What tendon is at the medial epicondyle?
Common flexor tendon
75
What is tennis elbow vs golfer's elbow:
tennis = lateral epicondylitis, affecting the common extensor tendon
golfer = medial epicondylitis, affecting the common flexor tendon
76
Sandpaper like rash and strawberry tongue, whats the toxin?
Erythrogenic toxin from streptococcus, this is scarlet fever
77
Rheumatic fever, whats the toxin?
M protein from strep
78
What is seen in labs to infer PSGN?
low C3 levels
79
Why does fibromuscular dysplasia present with HTN?
Upregulation of RAAS
RAAS -> AT2 -> aldosterone
Increase Na and H2O, excrete K and H+
80
A 50 yo F presents with unilateral RAS,
What medication inhibits renin?
Aliskiren and Beta-blockers
81
A 50 yo F presents with unilateral RAS,
What medication inhibits pulmonary endothelial cells and thus aldosterone?
ACEi's
82
A 50 yo F presents with unilateral RAS
What medication inhibits ENac channels?
Amiloride, Triamterine
83
A 50 yo F presents with unilateral RAS
Which medication counteracts RAAS and increases concentrations of ANP and BNP?
Sacubitril (inhibits Neprilysin therefore increases ANP and BNP)
84
E
85
What skin rash is associated with cholesterol embolization syndrome?
Livedo reticular, a net like rash
86
A 30 yo M has dyspnea on exertion. Albuterol does not relieve his symptoms. On exam, head a nosebleed. An S3 gallop is heard. What is the likely diagnosis?
Osler Wever Rendu (Hereditary Hemorrhagic Telangtisias)
87
Where is the MC anatomic location for nose bleed?
Kiesselbach plexus
88
A 30 yo M has dyspnea on exertion. Albuterol does not relieve his symptoms. On exam, head a nosebleed. An S3 gallop is heard. A BNP is elevated. What is the likely etiology?
High output cardiac failure due to Arterial venous malformation.
89
What is the effect of arteriovenous malformation on preload, stroke volume, and cardiac output?
Increases all three
90
What is the term know as when a patient has chest pain worse on inspiration?
What kind of scenarios is it seen in?
Pleuritic
- seen in PE, pericarditis, Rib fracture, pneumonia, serosal lining in the thorax is inflamed
91
Infarction of the posteromedial papillary muscle. What blood vessel supplies the inferior wall of the heart?
Posterior descending artery (usually from RCA)
- supplied the diaphragmatic portion of the heart ie the posterior inter ventricular septum.
92
What EKG leads does II, III, and avF correspond to:
RCA (PDA)
93
ST segment depression, negative troponins, whats the dx?
Unstable angina
94
ST segment depression, positive troponins, whats the dx?
NSTEMI
95
what is the MCOD after MI by CAD?
VF- arrhythmia- MC prehospital cause of death in MI
96
After an MI you discover papillary rupture, what murmur can you expect?
Mitral Regurgitation (holostystolic murmur heard at the apex)
97
Sudden death after an MI, whats the cause?
free wall rupture
98
A
99
Describe S3 heart sound:
- rapid filling of increased volume into a dilated ventricle
- seen in cardiomyopathy, CHF, pregnancy, and MR
- "Kentucky"
100
Describe S4 heart sound:
- Atrial contraction into a stiff ventricle
- seen in ventricular hypertrophy
101
What is the triad for Aortic Stenosis?
Syncope, Angina, and dyspnea
102
What maneuver will make Aortic stenosis murmur louder?
Squatting and raising legs
103
How does gonadal dysgenesis occur in turner syndrome?
Nondisjunction
104
C
Atrial myxoma
105
Why is there a SVT in Wolf parkinson white syndrome?
Electrical pulse enters bundle of Kent instead of normal route.
106
Whats the rhythm?
Afib
107
Whats the rhythm?
Supraventricular Tachycardia
108
Whats the rhythm?
VFib
109
Whats the rhythm?
A-flutter
110
Whats the rhythm?
Torsades de Pointes
111
Whats the rhythm?
V-Tach
*shockable if pVT
112
Whats the rhythm?
Second Degree AV block: Mobitz Type 1 Wenckebach
113
Whats the rhythm?
Second Degree AV Block: Mobitz Type 2
114
Whats the rhythm?
Third Degree AV Block
115
B
Cardiac Tamponade
Becks Triad
116
What do you look for in bundle branch block?
Abnormal QRS in precordial leads (V1-V6)
117
Why's is Lupus a mixed Type 2 and 3 hypersensitivity reaction?
- type 2 results in pancytopenia and Antiphospholipid syndrome because it's mediated through autoantibodies
- type 3 is immune complex deposition resulting in decreased C3 (compliment levels)
118
What are the skin manifestation of SLE?
119
What are the vascular, hematologic, and serosal surface manifestations of SLE?
*Keep in mind Libman Sacks endocarditis presents on both sides of the valve vs Infective endocarditis in on the topside and associated with IVDA
120
What organisms are pts prone to get infected with if they have Chronic granulomatous disease?
- catalase positive disease
- Staph, Serratia, Pseudomonas, and Candida
121
What are some infectious etiologies for granuloma formation?
TB (HY), Histoplasmosis, Cryptococcus, Bartonella (Stellate shaped), Listeria
122
What are some inflammatory etiologies causing granulomas?
Sarcoidosis, Crohn's disease, GPA, Eo-GPA
123
Pt has granulomas and works as a aerospace engineer, whats the causing agent?
Berylliosis
124
What is the MOA of Cisplatin?
Crosslinks DNA inducing apoptosis of cancer
125
What kind of toxicity is associated with Cisplatin and Vincristine?
Neurotoxic, presents with burning pain
126
Travelled to Mexico, high AST and ALT, genome shows positive mRNA virus from the Picorna virus, what is the transmission?
Fecal oral
- this is Hep A, image shows councilman bodies
127
What us the nature of the vaccine for HAV?
Killed (like flu, Rabies, and Salk)
128
What is the MOA for 5-FU?
Antimetabolite, forms 5-FdUMP, inhibiting thymidylate synthase decreasing dTMP
- Useful in chemotherapy
129
A 64 yo man with painful blisters. PE reveals severe bull that are tense. Blisters do not disappear with the finger. What is the mechanism behind the dx?
Type 2 HS against hemidesmosomes (Bullous pemphigoid)
130
Pemphigus vulargis has what involvement and what is affected?
Mucosal involvement and is associated to desmosomes (ie supra basal keratinocytes)
131
A 12 yo F presents with a rash that has become more itchy. She has had the rash on her back for a week, now spreading. PE shows a scaly rim patches on the back. Whats the dx?
What is the likely initial rash distribution know as?
Dx: Pityriasis rosea
- Herald patch
132
DRESS syndrome
Illness script = trigger + rash + lymphadenopathy + eosinophilia
133
What If you have trigger + rash + lymphadenopathy + eosinophilia WITH mucosal lesions?
Steven Johnson syndrome
Illness script = Blister, sloughing of dermal epidermal junction WITH DRESS syndrome script)
134
What do eosinophils have to inhibit helminth infections?
Major Basin Protien
135
What is the mechanism behind a hydrocele?
Persistence of the processes vaginalis
136
What normally separates the peritoneum from the scrotum?
Tunica vaginalis
137
Translucent testicular mass illuminating at the top of the testicle, there is a collection of sperm within the epididymis, whats the dx?
Spermatocele
138
What is the mechanism behind Varicocele?
Dilation of the pampiniform plexus
139
What does Varicocele present with left sided scrotal pain?
What is associated with?
Testicular vein drainage backs back to the left renal vein
*Associated with infertility
140
Where does the right testicular vein drain into?
IVC
141
C
FSGS is a hint to a hyper coagulable state, nephrotic syndrome. Loss of AT3, thrombus in the splenic vein and renal vein
142
What does heparin typically bind to?
Antithrombin 3
143
Where do nitrates typically help in ED? What is the MOA?
Inhibits PDE-5 to induce vasodilation via cGMP leading to decreased venous outflow. Acts in the Corpora cavernosa of the penis.
144
What history feature would make a dx of erectile dysfunction psychogenic in nature?
Preserved morning erections
145
Hx of smoking, HTN, dyslipidemia, DM, TIA, stroke, MI, or CABG should get you thinking of what?
Atherosclerosis
146
What is an example. MOA, and use of a PDE-5 inhibitor?
Sildenafil
- increase cGMP to induce vasodilation
- useful in pulmonary HTN and erectile dysfunction
147
What is an example. MOA, and use of a PDE-4 inhibitor?
Roflumilast
- smooth muscle relaxation in COPD
148
What is an example. MOA, and use of a PDE-3 inhibitor?
Cilostazol and Milrinone
- increase vasodilation for claudication, increase ionotropy, reduce after load, and increase lusitropy (compliance for diastole) via increase in cAMP
149
What is an example. MOA, and use of a nonspecific phosphodiesterase inhibitor?
Theophylline
- mild bronchiolar dilation
- reduction in inflammation
- use in Asthma
150
What nerve is responsible for holding in the pee via the external urethral sphincter?
Somatic pudenal
151
What nerve is responsible for an erection?
Parasympathetic- S2-S4 pelvic splanchnic nerves
152
What nerve is responsible for emission of sperm?
Sympathetics T11-L2 (hypogastric nerve)
153
What nerve is responsible for expulsion/ejaculation of sperm?
Somatic Pudendal
154
What hormone causes male pattern baldness?
DHT Dihydrotestosterone
155
What enzyme is responsible for converting Testosterone to DHT?
5 alpha reductase
156
What enzyme is responsible for turning Testosterone to Estrogen?
Aromatase
157
What is the treatment for male pattern baldness?
Finasteride (inhibits DHT)
158
What medication inhibits aromatase?
Anastrozol
159
Autoimmune destruction of melanocytes?
Vitilligo
160
A patient presents with pancreatitis and is suddenly intubated with a a prolonged cause in the ICU. He required increased O2 and has new bilateral infiltrates on CXR. PCWP is normal. What is the likely dx?
ARDS (exudative infiltrate), PCWP is normal because etiology in pulmonary in nature.
vs CHF with abnormal echo and elevated PCWP.
Illness script = trigger + acute progressive hypoxemia
161
A 50 yo M presents with progressive SOB for the past 2 years. He has smoked marijuana from college to age 30. PFTs show low FEV1 and los DLCO. AST and ALT are elevated. What would CXR show?
Hyperinflation (alpha-1-anti-trypsin deficiency)
162
What is the illness script of Panacinar emphysema?
decrease alpha 1 antitrypsin -> inhibited elastase in alveoli -> decrease elastic tissue -> Pan E.
163
Wha is the genetic inheritance of alpha 1 antitrypsin deficiency?
Co-dominance
164
C
This the Panacinar Emphysema.
D and E are restrictive lung diseases.
165
CXR shows honeycombing and there is a decrease DLCO, whats the dx?
Pulmonary fibrosis
166
A 30 yo M presents with respiratory distress. He is 6 ft 2 in. Hx of ophthalmology exam for lens dislocation. Examination shows supaclavicular crepitus and decreased breath sounds on L. CXR is shown. What is the likely dx?
Spontaneous pneumothorax
167
How can you differentiate spontaneous pneumothorax from tension pneumothorax?
Tracheal deviation away from the lesion and Hemodynamic instability seen in tension pneumothorax.
168
When you hear crackles on PE, what should you think of?
Fluid or fibrosis
169
What is the morphology of community acquired pneumonia (PNA)?
Gram positive diplococci (Strep. Pneumoniae)
170
What component of S. Pneumonia is the PPSV 23 vaccine made of?
What is the result?
Casular polysaccharide, generates a B-cell mediated humoral response.
171
What component of S. Pneumonia is the PCV 13 vaccine made of?
Polysaccharide and protein conjugate, generates a Tcell mediated cellular response. (better for memory B cells too)
172
What is the significance of Tactile fremitus?
Solid mediums cause increased vibrations
173
Decreased breath sounds are decreased in what cases?
PTX, PNA, effusion
174
How does cryptococcus neoformans infect?
Lung inhalation -> blood -> CSF
175
What is the viral makeup of CMV?
dsDNA (HHV-5)
176
A patient with hx of AIDs is noted to have drooling and difficulty swallowing (ondoxnyphagia). Exam shows fever. CMV quantitative load is high. What would upper endoscopy show?
Linear ulcers.
This is CMV esophagitis vs HSV esophagitis which will have punched out ulcers.
177
What are the CD markers for Reed Steinburg cells in Hodgkin Lymphoma?
CD15 and CD30 (owl eye appearance)
178
What to look for in CMV pneumonia?
Interstitial PNA presenting with hemoptysis (diffuse alveolar hemorrhage)
179
Relapse (hynozoites in liver not being killed by chloroquine) is characteristic of what parasite?
Plasmodium vivax, this represents the dormant phase
180
What is the MOA of chloroquine?
Blocks detoxification of heme into hemozoin (erythrocyte phase)
181
What do Tetracyclines and Chloroquine have in common?
Resistance via efflux pumps (P. Falciparum)
182
Periodic fevers in a traveler, what should you think about?
Malaria or TB
183
Describe the cycle of malaria:
184
What do you want to check before starting a medication like infliximab?
TB, you want to see a negative PPD test before starting TNF-alpha inhibitors to prevent disseminated TB.
185
What are the acute phase cytokines?
TNF-alpha, IL-1, IL-6
186
What activate the macrophage in making a granuloma?
IGN-gamma
187
What type of hypersensitivity is a PPD test?
type 4 you fuck
188
Medication inhibiting TNF-alpha?
Infliximab, Etanercept blocks the receptor
189
Medication inhibiting IL-1?
Anakinra
190
Medication inhibiting IL-6?
Tocilizumab
191
What maintains the granuloma?
TNF-Alpha
192
A Middle Ages male with pyelonephritis who has persistent fevers. Found to have abscess on muscle near R kidney. What is the likely diagnosis?
Psoas abscess
193
What is the actions of the Psoas muscle?
Flexion of the hip
194
What muscle group does extension of the hip?
Gluteus, hamstrings (semimembranosus, semitendonisosus, biceps femoris)
195
E
196
Wrist drop
Radial Nerve
197
Foot Drop
Perineal nerve
- everts and dorsiflexes
198
TIP-PED
(TIPPED)
Tibial inverts the foot
Peroneal everts the foot
199
Taxi cab injury
Fibular neck fracture can lead to common peroneal nerve injury
200
How does proponyl CoA turn into succinyl Coa in the context of odd chain fatty acids?
P-CoA turns into Melanyl Coa via Melonyls Coa Mutase which needs Vitamin B12 Cobalimin
201
A pt presents with fever and a murmur 2 weeks after a dental visit. He has a hx of RHD. Exam notes a holosystolic murmur at the apex. The pt undergoes a CT of the heart. What is the likely dx? What is the causal organism?
Mitral valve endocarditis.
Caused by Strep viridian (gram positive cocci in chains, alpha-hemolysis green zone on agar)
*Fever + murmur = endocarditis. Less than 2 wks, think acute. > 2 wks + dental procedure, think subacute.
202
What is the difference between cryptococcus and cryptosporidium?
Cryptococuss causes meningitis, cryptosporidium causes watery profuse diarrhea.
203
What stain is seen with Cryptosporidium?
Ziel Nielsen and acid fast stain (*TB is also acid fast)
204
What acid base abnormality would be noted when a patient has profuse diarrhea?
Hypokalemic, metabolic acidosis. This is a Non anion gap metabolic acidosis, CO2 is low because of compensation.
205
What acid base anomaly results from vomiting?
Metabolic alkalosis
206
Urease positive organisms?
Proteus, S. Saphrophyticus, Klabsiella
All responsible for staghorn calucilis
207
A 1 yo M presents with fever for last four days. On day four he has a tonic clonic jerking oh his upper extremities for 2 min. Temo is 101.5. No nuchal righty. What is the likely dx?
Febrile seizure
208
A 1 yo M presents with fever for last four days. On day four he has a tonic clonic jerking oh his upper extremities for 2 min. Temo is 101.5. No nuchal righty. On day four, he becomes afebrile and has a rash shown. What is the likely etiology?
HHV-6 (Roseola) exanthema submitim - Roseola rash
209
Young child with 5 days of fever?
Kawasaki disease
210
A young child presents with his mother to urgent care for itchiness. The family recently move onto a homeless shelter. There is interdigital erythema with intermittent spots on trunk. Excoriation is noted. Whats the likely dx?
Scabies
If you see interdigital rash, think scabies.
211
What is the treatment for scabies?
Permethrin, an anti-laos agent that inhibits Na channels in parasite nerve.
212
How does IgM make IgA, what is the mechanism called?
Class switching: Needs CD40L and CD40
- IL-5 = IgM to IgA
213
What two organs do you think about when you suspect malabsorption?
Duodenum and pancreas
214
What cytokine is responsible for turning IgM to IgE?
IL-4
215
What cytokine is responsible for turning IgM to IgG?
IL-4
216
How do Tcells activate Bcells to make antibodies?
- Signal 1: MHC 2 on the B cell interacts with the CD4+ T cell receptor on helper T cells.
- Signal 2: CD40 on the B cell interacts with the CD40L on the Tcell.
217
What cases can you see exocrine pancreatic insufficiency?
Chronic pancreatitis and Cystic fibrosis
218
What cases will you see malabsorption from the duodenum?
Celiac disease (+TTG) (tissue transglutaminase), lactose intolerance, Crohn's intolerance, SIBO (bloating and poor motility)
*SIBO- Small intestinal bacterial overgrowth
219
Describe Whipple disease?
T. Whipplei invades and compresses the lacteal so micelles cannot be absorbed at the duodenum
- causes systemic manifestations like carditis, arthralgias, and neurological issues
- Positive PAS staining on macrophages
220
What does Vitamin E deficiency present with?
Hemolysis
221
A pregnant female present with fever + CVA tenderness. UA is notable for WBC casts. What is the likely diagnosis?
Pyelonephritis
222
What are the changes in pregnancy which predispose mothers to urinary tract disease?
- Progesterone -> ureteral dilation increase risk for VUR
- Gravid uterus compresses ureter resulting in ascending infection
223
What can chronic pyelonephritis (or recurrent) cause?
Dilated ureter, tubular atrophy, and fibrosis of interstitial
224
How can you treat pyelonephritis in non-pregnant pts?
CTX: 3rd gen (ceftriaxone) beta-lactam
Ciprofloxacin: DNA gyrase (2 and 4) inhibitor (topoisomerase)
225
B
Pt was taking exogenous thyroid hormone
*Think exogenous testosterone and glucocorticoids, T - small testes, G- Adrenal insufficiency
226
What are these, what are they related to?
Cowdry inclusion bodies, related to HSV
Genitalia = HSV2
Oral vesicular lesions = HSV1
227
STI Ulcers Painful
HSV and Chancroid (Haemophilis Ducreyi)
228
STI Ulcers Painless
Syphillis, Lymphogranuloma venereum (LGV) Chlamydia L1-L3), and Granuloma inguinale (Klabsiella)
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Describe Acyclovir:
- guanosine analog, needs Thymidine kinase for activation
- used in HSV
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Is chancroid g+ or g-?
Gram negative
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How to detect syphilis?
Dark field Microscopy
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STI painless ulcers + painful lymphadenopathy and fistulas
LGV Lymphogranuloma venereum
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What is Donovanosis?
Gram negative intracytoplasmic cysts caused by Klebsiella
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What can you give to a pt with neuropathic pain associated with VZV?
Gabapentin or Duloxetine (SSRI)
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Young F multiple sexual partners with fever + cervical motion tenderness, whats the next best step in management and whats the Dx
Obtain and Beta-HcG and think PID caused by N. gonorrhea and Chlamydia, gram negative, obligate intracellular microbe.
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What are the antibiotics disrupting ribosomes?
*Aminoglycosides are bad for the ears and kidneys, Chloramphenicol is associated with gray baby syndrome
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A 40 yo hiker presents with 3 days of fever and malaise. A source bacteria is isolated : Anaplama Phagocytophilum from the Ioxdes tick. What location of the USA may this patient be from?
Northeaster and upper Midwestern USA (Lyme disease)
- Borrelia Burgdorforia and Babesia
- rash is known as Erythema migraines, stage one of infection
- Lyme affects nerves so watch for Bell's palsy and grouped beating (heart block)
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239
B
*Keep in mind can be fecal oral too, this is St. Louis Encephalitis
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Painless Jaundice in a heavy smoker
Pancreatic cancer
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What is the likely treatment for PCP PNA?
TMP-SMX or Pentamidine
- inhibits bacterial DHFR
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What medication inhibits DHFR and useful in treat RA?
Methotrexate MTX
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Interstitial infiltrates and ground glass opacities in a immunocompromised pt?
Pneumocystis jirivecii PCP
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What lung cancer would produce hyperglycemia and hypokalemia?
Small cell lung cancer (ACTH related paraneoplastic syndrome)
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What is the vaginal pH for UTI caused by candida?
Normal pH< 4.5
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What is the MOA for fluconazole?
Inhibits alpha-demethylase resulting in inhibition of fungal sterol synthesis part of the cell membrane.
*keep in mind that -azoles also cause QT prolongation and CYP inhibition
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Pseudohyphae, budding yeasts, host defense are phagocytes, whats the organism?
Candida
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A 28 yo F presents with a jaw mass. She was recently seen at the dentist for dental caries. Examination shows a unilateral firm left jaw mass. Needle aspiration is performed. The image is shown. Anaerobic culture is needed to grow the underlying organism. What is the likely diagnosis?
Actinomyces
- not acid fast, cat neg.
- Sulfur granules
- treat with PCN
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Gram positive branching filamentous rods, what two organisms should pop up?
Nocardia and Actinomyces
- N= aerobe, cat positive, weakly acid fast. Tb like, however negative PPD. Tx is Sulfonamides
- A= not acid fast, catalase negative, "sulfurs" granules. Tx with PCN
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What class of medications are Phenelzine, Tranylcypromine, and Isocarboxazid?
Monoamine Oxidase inhibitors, these increase levels of NE, 5-HT (clonus), and dopamine.
* Wait 2 weeks for washout before starting SSRI.
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What are in the brain is serotonin synthesized?
Raphe nuclei (SSRI increase serotonin here)
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What non stimulant agent can you use to treat ADHD?
Atomoxetine (SNRI) and alpha 2 agonists (Clonidine)
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A 54 yo M with hx of Hep C noncompliant with therapy presents with joint pain and fatigue. He has hepatomegaly and rash denoted in the image. It is suspected that this is due to T3HS ten. What lab value would be low in this patient?
C3 and C4 compliment
- T3HS = Ag Ab complex immune mediated reaction
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What are the two Ab which fix complement?
IgM and IgG
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When you see Hep C, think what?
- Mixed cryoglobulinemia
- Lichen Planus (purple, polygonal, planar, and Wickham striae)
- Porphyria cutanea tarda (severe photosensitivity and blistering)
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Bilateral lymphadenopathy is suggestive of what?
Sarcoidosis
- AA female with SOB
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What can you see on Bronchiolar Alveolar lavage in a patient with sarcoidosis?
Increased CD4:CD8 ratio
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Why does a patient have hypercalcemia in the setting of sarcoidosis?
Increase activity of 1-alpha-hydroxylase in macrophages increase the activation conversion of vitamin D.
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What two factors are elevated in sarcoidosis?
ACE and Calcium
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A 55 yo F presents with a 6 month old hx of cough and dyspnea. She has cold sensitivity to her fingers. She is on an H2 blocker. Exam of the hands show cutaneous ulceration. The patient is at increased right for what Pulmonaryy disorder?
Pulmonary HTN (CREST) due to pulmonary fibrosis
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What is the Ab positive in Scleroderma?
Anti-centromere Ab
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What is the Ab positive for systemic sclerosis?
Anti-Scl-70 Ab (anti-DNA topoisomerase)
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What is the mechanism of the hypoxemia and pulmonary HTN?
Increased V/Q mismatch and Diffusion defect.
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What is the triad for Scleroderma?
- Collagen deposition of skin
- vasculopathy (180/110)
- autoimmunity
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What is the Ab for Celiac disease?
anti-TTG
Tissue Transglutaminase Antibodies (tTG)
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Blunted duodenal vili
Celiac disease
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Blunted podocytes
Minimal change disease
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What is Erythema Nodosum
Skin manifestation associated with underlying conditions, marks inflammation in the subcutaneous fat
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What genetic syndrome (3) is associated with bilateral RCC?
Von Hippel Lindau: Hemangioblastomas of cerebellum and Pheochromocytomas
- pVHL normally ubiquinates HIF (hypoxic induced factor), no pVHL gene, increase HIF -> increase VEGF leading to angiogenesis.
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What are the markers of a Pheochromocytoma?
Increased VMA and HVA
HVA, or homovanillic acid, and VMA, or vanillylmandelic acid
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Painful hematuria, think what 2 things?
RCC and Kidney stone
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Painless hematuria, think?
Bladder cancer
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PTH acts where on the kidney?
DCT
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B
- C D and E relate to type 1 DM
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What is the virulence factor which E Coli has that increases propensity to UTI's?
Fimbriae known as P-Pili, maintains adherence to transitional epithelium
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What is the mechanism by which plasmids are transferred thus mediating resistance?
Conjugation plasmid (F+ to F- via sex pillus)
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C
This phenomena is known as Transformation
Cell lysis + Naked DNA = Transfer into new genes.
Seen in S. Pneumonia, H flu, and Neisseria
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Bone pain and swelling (atraumatic) and anemia, what do you think of?
SCD
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Posterior urethral valve
- low amniotic fluid index -> low amniotic fluid -> Potter sequence
Image shows Talipes equinovarus
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Renal papillary necrosis is seen in what cases?
NSAID use, SCD, and T2DM
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What anatomical location are most predisposed to stone obstruction?
UPJ (highest spot), Pelvic brim (middle), and UVJ (lowest spot)
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Anemia + low Plt count + acute kidney injury is a illness script for what?
Hemolytic uremic syndrome
*MCV unveils a normocytic anemia
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What conditions would you see Schistocytes?
HUS, TTP, DIC, Prosthetic Heart valve
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Anemia + low Plt count + acute kidney injury + Fever + AMS is a illness script for what?
Thrombitic Thrombocytopenia Purpura (TTP)
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Is haptoglobin high or low in intravascular hemolysis?
low because haptoglobin bind to free heme
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What embryological origin is cricopharyngeal muscle (forms the UES)?
Fourth pharyngeal arch
- Vagus nerve- superior laryngeal branch
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What two tissues do you see in Meckel's diverticulum?
Gastric and Pancreatic
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What parts of the duodenum are retroperitoneal?
2nd 3rd and 4th (most commonly injured.
*Think: if the superior (1st) part is intraperitoneal and there is blunt trauma, the force can shear parts 2-4 if the superior part is pulled.
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Post mortem analysis of the lower third of the esophagus shows the following: basal zone hyperplasia, eosinophilic infiltrate of the squamous mucosa. What is the likely past medical history noted in this patient?
Esophageal reflux (esophagitis)
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What is the dx if histology noted columnar cells, goblet cells, and transition from NKSE?
Barret's esophagus
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Pt presents with dysphagia and eosinophils in the upper esophagus, what will endoscopy show?
Concentric rings
- this is eosinophilic esophagitis
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What are the causes of eosinophilia?
NAACP
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A 75 yo M presents with weight loss. He has iron deficiency anemia. In the office, his HgB is 6.9. What is the next best step in management?
Fecal occult stool test and colonoscopy
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What condition is noted to be associated with colon cancer without a polyp precursor?
Lynch syndrome (HNPCC)
- MSH-2 gene -> poor mismatch repair -> micro satellite instability.
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High esophageal pressure
Achalasia
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Low esophageal pressure
GERD
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What is the embryological derivative of the anus below the pectinate line?
Ectoderm, painful anal fissures because of the somatic nerve innervation.
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What is the Mc location of anal fissure tears?
Posterior midline
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Sudden onset of bilious emesis
Post-pyloric obstruction
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Whats the dx?
Intestinal volvulus
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When does the embryological gut rotate 270 degree CC?
What vessel does it rotate around?
Rotates around 10th week, rotates about the SMA.
*If this goes wrong you get intestinal volvulus.
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A 33 yo M with chronic abdominal pain and bloody diarrhea presents for colonoscopy. Biopsy is shown. The report notes friable mucosa with superficial mucosa with superficial ulcerations. Microscopy reveal crypt abscesses and no granulomas. That is the likely auto-immune lab value associated with this condition?
p-ANCA (MPO-ANCA)
Dx is Ulcerative colitis
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Pt with Ulcerative colitis presents with itching. Cholangiogram is notable for 'beading' of the intra-extrahepatic ducts. What is the likely dx?
Primary sclerosis cholangitis
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When you seen pruritic, what should you think of?
Histamine, contact, or bile acid deposition
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What is the antibody marker for primary biliary cholangitis?
anti-mitochondrial Abs
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What is the drug class of clomiphene?
SERM -> antagonists at estrogen receptor in the hypothalamus. This causes a surge of LH and FSH to induce ovulation.
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A male with end-stage prostate cancer is given a GnRH agonist. What is the likely medication?
Leuprolide (GnRH agonist) -> used in a continuous manner to down regulate LH and FSH
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A 35 yo female is interested in started combined contraception of ethinyl estradiol/progestin. What hx would be helpful to ask prior to starting this medication?
- Migraine with aura
- smoker (>35 yo)
- history of DVT
*If any of these are yes, do not give contraceptives
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What is the inheritance pattern of Peutz-Jeghers syndrome?
Autosomal dominant
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What neurological disorder has hypopigmented patches and hamartomas?
Tuberous sclerosis (angiofibromas, cortical hamartomas, etc.)
*Shagreen patches
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Lisch Nodules is associated with what?
NF-1
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A 5 yo immigrant boy presents with failure to thrive. Throughout his life overseas he received multiple transfusions. On exam, he has hepatosplenomegaly HgB decreased, MCV 52. RDW is normal. What would peripheral blood smear show?
Target cells (beta-thalassemia)
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What is the most likely etiology for beta thalassemia?
Point mutation affecting splice sites resulting in abnormal promoter sequences for transcription leading to abnormal protein.
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With IDA, is the RDW high or low?
High
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A 5 yo immigrant boy presents with failure to thrive. Throughout his life overseas he received multiple transfusions. On exam, he has hepatosplenomegaly HgB decreased, MCV 52. RDW is normal.
In pt with Beta-thalassemia, it is noted to have increase in AST and ALT. His ferritin, and transferrin saturation is elevated.
What is the likely diagnosis? What is the Tx?
Secondary hemochromatosis
- tx= Deferoxamine (iron chelator) +/- phlebotomy
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What should you think about when you see target cells?
HbC disease, Asplenia, Liver disease, Thalassemia
'HALT for the Target'
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What molecule is upregulated resulting in reduced enteric Fe reabsorption?
Hepcidin
- reduces Fe in the blood
- increases ferritin (iron storage form) in the bone marrow
* this is a evolutionary adaptation to combat bacterial infection
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Pt with RA now has itching, elevated direct bilirubin. cholecysectomy is performed showing granulomas. What autoantibody may be positive?
Anti-mitochondrial Ab
- Primary biliary cirrhosis
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What would CBC show in chronic hypoxemia?
Elevated hematocrit (hypoxemia induced polycythemia)
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What is the signaling transduction pathway for erythropoietin?
Tyrosine kinase JAK STAT
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What is the differential dx for digital clubbing?
Bronchiectasis
Cystic fibrosis
Lung CA (Non-small cell)
Cyanotic heart defects
Pulmonary fibrosis
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What are the Tyrosine kinase associated JAK STAT signals? In other words, what fits into these receptors to trigger JAK STAT?
324
A 49 yo M presents with hyperpigmentation. Serum glucose is 240 mg/dL. He is noted to have elevations in AST and ALT. What may echocardiogram show?
Dx: Hemochromatosis
- Restrictive cardiomyopathy (classic), S4 (Tenessee)
- Dilated cardiomyopathy (reversible), S3 (Kentucky)
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A 49 yo M presents with hyperpigmentation. Serum glucose is 240 mg/dL. He is noted to have elevations in AST and ALT.
What reproductive abnormality may this patient have
Decreased testosterone
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A mutation in the HFE gene is noted, what is the downstream pathophysiologic effect?
Increased intestinal absorption
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Iron is to hemochromatosis as Cu 2+ is to Wilson's disease -> ? ->?
-> cirrhosis -> HCC
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A 44 yo M is noted to have small skin spots and a heavy nose bleed. He recovered from a viral infection 1 week ago. CBC shows decreased platelets and smear shows no blasts. A bone marry biopsy is shown noting increased immature platelets. What is the likely dx?
Immune mediated thrombocytopenia
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Where do peripheral destruction of platelets occur?
Spleen
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Problems with secondary hemostasis commonly presents with what?
- hemarthrosis
- changes in PT and PTT
330
C, also Abciximab, and Tyrofivan
GPIIb/IIIa inhibitors
330
Where is Hereditary spherocytosis associated with in the world?
Northern Europe
331
What prenatal care intervention may prevent Rh incompatibility?
When should you do it?
Administration of Anti-D Ig at 28 weeks, Rhogam
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An elderly pt with back pain, fatigue, and hypercalcemia,
What is the mechanism behind constipation and depression?
Hypercalcemia (stones, bones, groan, psychiatric overtones)
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An elderly pt with back pain, fatigue, and hypercalcemia,
What is the mechanism behind infections?
Hypogammaglobulinemia and bone marrow infiltration
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An elderly pt with back pain, fatigue, and hypercalcemia,
What would be the next step in dx?
IgG, IgA, light chains seen on M spike
335
An elderly pt with back pain, fatigue, and hypercalcemia,
What is the mechanism behind the renal insufficiency BUN: Cr 10-15:1?
Accumulation of monoclonal proteins
336
How can you differentiate Multiple Myeloma with Wondenström Macroglobulinemia?
Hyperviscosity syndrome
Neuropathy
Hepatosplenomegaly
IgM proliferation vs IgG
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Low HgB, low ferritin, and high RDW
IDA
338
In normal apoptosis, what inhibits BAX/BAK and this cytochrome C release?
Bcl-2
339
What form of NHL is associated with Bcl-2 over expression?
Follicular lymphoma (14;18 translocation)
340
What has translocations Hodgkins or nonhodgkins lymphoma?
NHL
341
A 5 yo boy presents with a skull fracture. X rays shows osteolytic lesions. A brown purple eczema like rash is on the hairline. Bx of rash is S100 positive. EM is shown. What is the likely diagnosis?
Langerhan cell histiocytosis
- clonal proliferation of APC
*Image shows Birbek granules (tennis racket shaped)
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What skin neoplasm is also S100 positive?
Melanoma (neural crest derivative)
343
What are the antigen presenting cells?
B cells, macrophages, langerhan cells
344
C
345
A patient presents with over 50 k WBC count. What test would differentiate a severe infection from a leukemia (ie CML)?
Leukocyte alkaline phosphatase score (LAP)
- positive means leukamoid reaction
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LAP score is negative, besides blasts, what cell is characteristically elevated in CML?
Basophilia
- 9;22 Ph chromosome (BCR;ABL)
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Bilateral vestibular schwannomas (neuromas) seen in?
NF-2 (merlin?) Chromosome 22
vs NF-1 chromsome 17
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Pt with MS is started on Baclofen. What is the MOA?
GABA B receptor agonist
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A patient with MS requires slow anterograde axonal transport to regenerate axons (Rate limiting step), which CNs are part of CNS and thus cannot regenerate?
CN1 and CN II
350
Describe Weber syndrome:
