Pathology Flashcards

Question

Spread of poorly differentiated neuroectodermal tumours

Answer 1

Spread within brain and spinal cord, by direct infiltration or CSF spread Rarely metastasise outside CNS

Answer 2

Supratentorial in the cerebral lobes (70%)

Answer 3

70% infratentorial Posterior fossa in midline, usually: - Cerebellum (astrocytoma, medulloblastoma) - brainstem (astrocytoma, ependymoma)

Answer 4

Protoplasmic Pilocytic Gemistocytic Fibrillary

Answer 5

1 to 4 Grade 2: Nuclear pleomorphism (astrocytoma grade 2) Grade 3: mitotic activity (anaplastic astrocytoma) Grade 4: necrosis, endothelial hyperplasia (glioblastoma multiforme)

Answer 6

Diffuse infiltration thus no clear border Cerebral astrocytoma: diffuse enlargement of region Cerebellar astrocytoma: cystic with proteinaceous fluid

Answer 7

- Variable histology - pseudo palisade - central necrosis zone surrounded by degenerate tumour with extensive cytoplasmic pleomorphism - endothelial hyperplasia

Answer 8

Grossly well differentiated with little necrosis Histo: box like cells with clear halo Well marked cell border Calcification common

Answer 9

Gross: mass protruding into ventricles, encapsulated Histo: - rosette (cuboidal tumour cells around central lumen) - pseudo rosette (pink Fibrillary halo around vessels) - spindle cells - blepharoplasts

Answer 10

Good radiotherapy response Histo: - small cells - densely stained ovoid nuclei - little cytoplasm - rosette formation with Central Fibrillary extension

Answer 11

Well circumscribed and lobulated Histo: - cellular whorls - psammoma bodies Site: parasagittal, fall cerebri, base of skull, inner surface of calvaria

Answer 12

Most commonly cranial nerve roots: - Vestibulocochlear nerve - Trigeminal nerve Can be in spinal nerve root or peripheral nerve

Answer 13

Antoni type A & B (Read)

Answer 14

Def: USF reduce by 50% Cause: 1) water or electrolyte loss 2) damage to salivary gland 3）interference with neural transmission

Answer 15

Allergic rhinitis Infectious rhinitis Occupational rhinitis Drug induced rhinitis

Answer 16

X Ray: -air fluid level -sinus opacification

Answer 17

Extension of infection to: Orbital cellulitis Orbital abscess Cavernous sinus thrombosis

Answer 18

Anatomical or functional obstruction of normal mucociliary clearance of sinuses -\> Fluid accumulation in sinus or ostemeatal complex -\> Infection

Answer 19

Ear canal skin inflammation Swelling blocking rapid cell turnover More dead skin produced, which allow germ breed Pus filled ear canal Tympanic membrane bulge outwards, leading to pain, fever, hearing loss (AOM) Tympanic membrane bursts and perforation, discharge of pus (active CSOM) Perforation persists, discharge stops (inactive CSOM)

Answer 20

TM rupture with pus discharge Mastoid abscess if pus moves in Facial nerve palsy or CN VI Brain abscess

Answer 21

Viral or bacteria (S pneumoniae, HI)

Answer 22

Bacterial: s pyogenes, Staphylococci, S pneumoniae, HI Viral: rhinovirus, adenovirus, EBV Others: diphtheria, syphilis, TB, candida

Answer 23

Fever Sore throat Odynophagia Otalgia Trismus Red swollen tonsils Throat redness Swollen uvula Gary furry tongue Whitish spots ALWAYS BILATERAL

Answer 24

1) ascending duct infection related to dehydration and debilitation e.g. Old age --\> thicker more mucous salvia that stuck in ducts --\> infection OR 2) secondary to ductal obstruction e.g. Stones (submandibular duct most likely)

Answer 25

Viral: Mumps Coxsackievirus HIV Echovirus Bacterial: Staphylococcus TB Syphilis No infectious: Sjogren's

Answer 26

Children 2-4 yo Fever Severe sore throat Stridor Dysphonia Drooling Laryngoscopy: cherry red epiglottis XR neck: thumb sign Blood culture: HIB

Answer 27

Gram negative Beta lacamase producing Coccibacilli Factor V and X for growth Type a to f, b most invasive

Answer 28

Airway protection Antibiotic (amoxiclav) Rifampicin prophylaxis HIB vaccination

Answer 29

Adolescents and young adults Low grade fever Severe sore throat Stridor (if bilateral) Dysphagia Medial deviation of tonsils

Answer 30

GAS (strep pyogenes) Mixed oropharyngeal organisms: anaerobes, viridans streptococcus

Answer 31

Beta hemolytic Lancefield group A Bacitracin sensitive

Answer 32

Alpha hemolytic Optochin sensitive Bile soluble

Answer 33

Young children of 3 months to 3 yo Fever Barking cough Tripod position Hoarseness Stridor XR neck: subglottic swelling - hourglass or steeple sign Nasopharyngeal aspirated (NPA) - viral antigens

Answer 34

Airway protection Antibiotic Abscess drainage

Answer 35

Viral mainly: Parainfluenza Influenza Respiratory syncytial Adenovirus Rhinovirus Mycoplasma

Answer 36

Airway protection Racemic adrenaline +\- steroid

Answer 37

1) submandibular and sublingual space (Ludwig's agina) 2) lateral pharyngeal space 3) retropharyngeal space

Answer 38

Board like floor swelling High fever Systemic toxicity Dysphagia Often with dental root abscess

Answer 39

Airway protection Antibiotic Soft tissue decompression Dental assessment

Answer 40

Fever Sore throat Dysphagia Neck stiffness Jaw angle swelling Great pain and trismus (if ant) Great dyspnea (if post) CT/MRI to see extension Blood culture Pus culture

Answer 41

Jugular venous thrombophlebitis Carotid artery erosion

Answer 42

Airway protection Antibiotic Surgical drainage (if abscess) Treat primary infective focus

Answer 43

Extrinsic and common pathway -\> I, II, V VII X

Answer 44

Activated partial thromboplastin time Intrinsic and common pathway -\> all factors except VII and XIII

Answer 45

Fibrinogen deficiency or dysfunction Thrombin inhibition e.g by heparin

Answer 46

PT APTT TT fibrinogen level Platelet tests -\> platelet count, platelet function test by aggregometry, skin bleeding time

Answer 47

All present with mucocutaneous bleeding Autoimmune thrombocytopenia Alloimmune thrombocytopenia -neonatal allo TP -post transfusion purpura -platelet refactoriness Inherited -Bernard-soulier syndrome -grey platelet syndrome -storage pool disease -glanzmann's thrombasthenia DIC dilutional (eg after massive transfusion)

Answer 48

Long arm of X chromosome -\> x linked Maternal side 1/3 are due to spontaneous mutation

Answer 49

Haemarthrosis -\> recurrent bleeding in major joints leading to progressive joint deformity Inhibitor to infused factor concentrate -\> replacement therapy less effective High cost of treatment Transfusion transmitted infection (esp viral HIV HBV HCV) Carrier female detection

Answer 50

Short arm of chromosome 12

Answer 51

Increased APTT Increased bleeding time VWF antigen assay Ristocetin assay Collagen binding assay Factor VIII assay

Answer 52

Deficiency of VII XII X fibrinogen Autosomal recessive

Answer 53

Obstructive jaundice Malabsorption Post oral broad spectrum antibiotics that killed intestinal flora

Answer 54

Immature liver that cannot perform K dependent post translation gamma carboxylate on of glutamic acid on II VII IX X C S sterile gut with no intestinal flora for K production Low vit K in breast milk

Answer 55

International normalised ratio INR = (PT/ mean normal PT)^ ISI ISI is international sensitivity index Used for monitoring oral anticoagulant so no vitamin K antagonism occur

Answer 56

Result of oral anticoagulant usage Competitive inhibitor of vitamin K epoxide reductase needed for recycling vitamin k during gamma carboxylation

Answer 57

Reduced hepatic synthesis of clotting factors and inhibitors (except VIII and VWF) Reduced vit K absorption due to cholestasis -\> further decrease clotting factor production Failure of reticuloendothelial cells to clear activated products and intermediates of coagulation and fibrinolysis -\> interfere with platelet function and fibrin formation Portal hypertension -\> hypersplenism -\> platelet sequestration Acquired dysfibrinogenaemia -\> abnormal fibrinogen synthesis

Answer 58

Parenteral vit K replacement Clotting factor replacement via FFP

Answer 59

Defect in platelet function (inhibition by nitric oxide) Low haematocrit -\> Platelet-vessel wall interaction

Answer 60

Increase haematocrit by red cell transfusion erythropoietin therapy Peritoneal or haemodialysis DDA VP administration Cryoprecipitate transfusion

Answer 61

Entry of tissue thromboplastin into blood stream Direct activation of coagulation Severe endothelial injury Direct activation of platelet Thrombin activation which convert fibrinogen to fibrin, activating secondary fibrinolysis Widespread coagulation ---\> intravascular fibrin formation ---\> micro thrombotic occlusion of small vessels ---\> tissue ischaemia and multi organ dysfunction Widespread coagulation and fibrinolysis depletes clotting factors, platelets and coagulation inhibitors ---\> severe bleeding

Answer 62

Infection (septicaemia and viral infection) Trauma (serious tissue injury, fat embolism, extensive burns) Cancers (acute promyelochtic leukemia, metastatic carcinoma) Obstetric condition (septic abortion, amniotic fluid embolism, abruptio placentiae) Immunological (haemolytic blood transfusion reaction eg ABO incompat; organ transplant rejection)

Answer 63

Underlying related condition Increase PT APTT TT Reduced fibrinogen level, low antithrombin Thrombocytopenia Increase fibrin degradation product namely D-dimers from secondary fibrinolysis Microangiopathic change in blood film as RBC damaged when passing through clots

Answer 64

Platelet transfusion FFP to replenish clotting factors Anticoagulants (to overt thromboembolism or extensive fibrin deposition) Antithrombin concentrate \*\*\* treat precipitating trigger first!!

Answer 65

Autoimmune disease X linked single gene deletion Immune dysfunction Polyendocrinopathy Enteropathy X linked Deletion in foxp3 transcription regulator -\> loss of Treg cells (Cd4 Cd25 foxp3)

Answer 66

Lack of Treg cells (IPEX) Release of sequestrated antigens (sympathetic ophthalmia, vasectomy) Induction of MHC II antigen on non-APC (interferon gamma on thyroid epithelial cells) Cross reaction between microbial antigen and similar autoantigen (rheumatic heart disease)

Answer 67

Genetic Hormonal Environmental (infective, drug)

Answer 68

Demonstrates familial clustering and higher concordance rate in identical twins No clear mandelian traits Multiple genes involve with low penetrance Genetic heterogeneity MHC gene esp associated -\> HLA-DR4 and rheumatoid arthritis; HLA-DR3/4 and IDDM

Answer 69

Sex preponderance in many SLE female:male = 9:1 (admin of male sex hormone and female castration helps with SLE in mice)

Answer 70

IDDM and rubella or enterovirus infection

Answer 71

SLE - hydrallazine, penicillamine Hemolytic anaemia - methyldopa

Answer 72

Drug, infection SLE -\> Sun exposure

Answer 73

1) infection (bacterial fungal) 2) Acute inflammation 3) tissue damage/ infarction 4) MPN 5) drugs eg corticosteroids

Answer 74

Infection (neonate) Leukemia, metastases Aplastic anaemia Drugs Myelofibrosis Cyclical

Answer 75

HIV AIDS Drugs eg corticosteroid

Answer 76

Children: Viral infection (CMV), sometimes bacterial (pertussis) Adolescent: Viral (EBV) Adult: Chronic lymphocytic leukemia, acute stress

Answer 77

Allergy Parasitic infection Drug hypersensitivity Autoimmune Neoplasm

Answer 78

Chronic myelogenous leukemia (CML) Acute leukemia

Answer 79

Chronic infection eg TB chronic inflammation Neoplasm: CML, other MPN MDS

Answer 80

AML -\> presence of blast cells; auer rods ALL -\> blast cells CML -\> basophilia, mature and immature CLL -\> abnormal mature looking lymphoid cells MDS -\> funny looking white and red cells; abnormal nucleus shape

Answer 81

Lazy leukocyte syndrome -\> defect in chemotaxis Opsonin deficient -\> defect in phagocytosis Chronic granulomatous disease, myeloperoxidase deficiency -\> defect in killing or digestion

Answer 82

1) PBS, CBC 2) Bone marrow - BMA or - touch imprints - trephine biopsy 3) cytochemistry staining - non specific esterase (AML) - myeloperoxidase (AML) - PAS (ALL) 4) flow cytometry 5) lymph node / other tissue biopsy 6) cytogenetic karyotypin 7) FISH 8) PCR

Answer 83

B cell - X linked agammaglobulinaemia - severe combined immunodeficiency T cells - DiGeorge syndrome - MHC class II deficiency

Answer 84

Plasma cell neoplasm Present as: Anaemia Bone pain Recurrent infection Renal failure PBS-\> rouleaux formation; no abnormal white cells Bone marrow-\> plasma cells 30% and clinal Urine/ serum -\> monoclonal protein

Answer 85

Assessment of BM cellularity and differential counts Identification of abnormal cells Stain with Wright-Giemsa stain

Answer 86

Assess BM cellularity Identification of abnormal cells Assess architecture and topographic relationship of cells in BM staging of lymphoma

Answer 87

There might be no metaphase cells

Answer 88

Malignancy arising from haematopoietic system or lymphpoietic system

Answer 89

Clonal malignancy of lymphoid system (ie from lineage B cells T cells NK cells)

Answer 90

Increase with age Related to viral infection - EBV, HIV HTLV human T cell lymphoproliferative virus

Answer 91

1) enlargement of nodal (lymph node) or extranodal tissues 2) A symptoms -\> asymptomatic 3) B symptoms -\> systemic, eg Fever, night sweats, loss of body weight

Answer 92

Hodgkin lymphoma B cell lymphoma T cell lymphoma NK cell lymphoma

Answer 93

Via lymphatics (Hodgkin) Hematogenous spread in other types of lymphoma Local infiltration to different organs

Answer 94

1) R-CHOP chemotherapy + targeted therapy Rituximab anti CD20 cyclophosphamide, hydroxydaunorubicin, vincristine [Oncovin], prednisone (Purine analogue containing regimen for low grade; mab for maintenance treatment) 2) HSCT autologous HSCT for relapses lymphoma (Source from peripheral blood, BM) If there is BM involvement, then allogenic HSCT

Answer 95

1) chemotherapy with/wo radiotherapy 2) Mab against CD30 for relapse 3) autologous HSCT for relapse

Answer 96

1) chemotherapy, esp L-asparaginase containing regimen 2) otherwise similar to B cell

Answer 97

Similar to B cell lymphoma 1) early use of autologous HSCT may be useful

Answer 98

Less common in Chinese Good prognosis; most patients curable

Answer 99

Found mainly in Asians (ninja!) Nose affected as main site EBV related Highly aggressive with poor prognosis

Answer 100

Uncommon Variable prognosis Related to HTLV-1 (Japan and TW)

Answer 101

1) International prognostic index -tumour stage - serum LDH - extranodal sites - age -performance 2) Histology types -lineage - high/low grade 3) chemotherapy intensity

Answer 102

-adults -myelosuppresion -\> anaemia and thrombocytopenia -leucocytosis with \>20% blasts in BM and blood -associated with toxic exposure, toxic drugs and antecedent myelodysplastic syndrome - Auer rods

Answer 103

Induction of remission Consolidation of remission with high doses of chemotherapy Maintenance of remission usually not given HSCT for relapse or high risk cases All trans retinoids acid and arsenic trioxide for acute promyelocytic leukemia

Answer 104

-mainly adults, sometimes children - leucocytosis -myelosuppresion -\> anaemia and thrombocytopenia -enlargement of lymph nodes, liver and spleen as lymphoblastic cells return to origin - CNS involvement -not obviously associated with toxic exposure B cell origin?

Answer 105

Induction of remission Consolidation chemotherapy Maintenance treatment for 2 years CNS prophylaxis HCST transplant in relapse or high risk

Answer 106

-adults; incidence increase with age -leucocytosis with mature and immature cells, basophilia -enlarged liver and spleen -associated with irradiation exposure eg atomic bomb -triphasic if untreated: 1) chronic 3-4y 2) acceleration \<6m 3) blastic crisis 1-2 months -Philadelphia gene - BCR-ABL 9-22 translocation (cytogenetic karyotyping or FISH or PCR)

Answer 107

Chemotherapy ineffective Targeted therapy with tyrosine kinase inhibitors (eg imatinib dasatinib bosutinib I'm da boss) Hydroxyurea for symptomatic treatment HSCT for blastic transformation patient or not responding to TKI

Answer 108

-elderly, never in childhood -uncommon in Chinese -late stage myelosuppresion -\> anaemia and thrombocytopenia -lymph node enlargement, late stage liver and spleen enlargement -leucocytosis with mature cells -associated with toxic exposure, toxic drugs and antecedent myelodysplastic syndrome

Answer 109

No early stage treatment Chemotherapy with Purine analogue (oral alkylation agent not preferred in \<50

Answer 110

Pancytopenia Hyper cellular BM Myelodysplastic blood cells in blood or BM BM abnormal karyotyping Increased blasts Progress to AML Associated with previous chemotherapy irradiation or toxic exposure

Answer 111

Refractory cytopenia with unilineage dysplasia Refractory cytopenia with multilineage dysplasia Refractory anaemia with ringed sideroblasts Refractory anaemia with excess blasts MDS with 5q- Childhood MDS

Answer 112

PBS CBC -\> pancytopenia BMA -\> hypercellularity Cytogenetic -\> monosomy 5 or 7, deletion of long arm of 5 or 7 5q- 7q-

Answer 113

1) risk stratification 2) supportive, transfusion for most - erythropoietin for anaemia - iron chelation for chronic transfusion 3) allogeneic HSCT in younger patients for RAMD RAEB 4) lenalidomide for 5q- syndrome 5) demethylating agents (eg azacytidine decitabine)

Answer 114

Incurable except in young patients after HSCT May transform to AML, especially in RAEB

Answer 115

Clonal disease of pluripotent HSC 1) increased circulating cells of all haematopoietic lineages 2) hypercellularity in BM 3) absence of muelodysplastic features Pre-leukemia

Answer 116

CML -\> myeloid Polycythaemia Vera -\> erythroid Primary myelofibrosis -\> fibrous tissue Essential thrombocythaemia -\> megakaryocytic

Answer 117

CML -\> BCR-ABL1 PV -\> JAK2 MF -\> 50% JAK2; 40% CALR ET -\> 50% JAK2; 40% CALR CALR = calreticulin gene

Answer 118

MPN \*) pruritus 1) high Hb -\> facial plethora 2) leucocytosis thrombocytosis 3) splenomegaly 4) suppressed serum erythropoietin diagnosis by exclusion JAK2 mutation

Answer 119

Venesection -\> replace venesected blood with normal saline Cytoreduction with hydroxyurea Avoid secondary leukemia inducing agents eg alkylating agents or radioactive phosphorus Thrombosis prophylaxis eg aspirin

Answer 120

- Hepatosplenomegaly; Extramedullary hematopoiesis, which is non functional Leuco-erythroblastic picture with tear drop RBC JAK2, CALR mutation Diffuse fibrosis of BM -\> megakaryocytic proliferation Terminally present with hepatic fibrosus -\> variceal bleeding and portal hypertension CELLULAR PHASE (prefibrotic) -anaemia -leucocytosis -thrombocytosis FIBROTIC PHASE -pancytopenia

Answer 121

1) supportive 2) early splenectomy helps to decrease blood transfusion requirement 3) alligeneic HSCT in younger patient 4) JAK2 inhibitor for high risk 5) Cytoreduction with hydroxyurea 6) avoid secondary leukemia inducing agents eg alkylating agents or radioactive phosphorus

Answer 122

Sustained thrombocytosis (must exclude chronic inflammatory disorder, infection, neoplasm) JAK2 CALR mutation

Answer 123

Treatment not required in young patient Prophylactic anti thrombotic agents eg aspirin esp in elderly Cytoreduction with hydroxyurea Anagrelide to reduce platelet count Avoid leukarmogenic agents eg alkylating agents or radioactive phosphorus

Answer 124

Increased circulating cells Hypercellularity of BM Myelodysplastic features of blood cells

Answer 125

Chronic myelomonocytic leukemia (CMML) atypical chronic myeloid leukemia (aCML)

Answer 126

Elderly Monocytic lineage proliferation High monocyte count No Philadelphia chromosome

Answer 127

Contralateral loss of discriminative touch and position sense; thermoception and nociception relatively unaffected

Answer 128

Tactile agnosia - inability to recognise object despite sensation Constructional apraxia - deficit in ability to relate extra personal space Neglect syndrome (contralateral) Spatial orientation difficulty eg map reading, driving

Answer 129

Supportive in elderly patients Allogeneic HSCT in children Tyrosine kinase inhibitor for some CMML

Answer 130

Lesions in the Ventral Posterior nuclei of thalamus (VPM, VPL) Analgesia followed by paraesthesia and hyperalgesia or even severe spontaneous pain; associated with exaggerated affective response

Answer 131

Interferes with motor proficiency and manual dexterity Independent control of fingers may be lost (corticospinal tract)

Answer 132

Paresis or weakness of axial and proximal muscles (medial descending system) Interfere with choreography of complex movement (complex movement possible but slow execution) Severely affects visually guided movement

Answer 133

Interferes with goal-directed behaviours that require planning and execution of complex motor sequence e.g. circumventing a transparent screen deficit in bimanual coordination

Answer 134

No symptoms for CN III IV V VI upper face (VII) IX X XI Contralateral symptoms for lower face VII (e.g. lower face paralysis, sagging mouth corner obicularis oris) and XII (tongue deviate to contralateral side of lesion)

Answer 135

Ipsilateral LMN symptoms for cranial nuclei III-XIII except VIII

Answer 136

UMN lesion of corticobulbar tract Contralateral lower face paralysis (sagging mouth corner - orbicularis oris)

Answer 137

LMN lesion of corticobulbar tract Ipsilateral upper and lower face paralysis (incomplete closure of eyelid - obicularis oculi; sagging mouth corner - orbicularis oris)

Answer 138

Leads to capsular infarction/ haemorrhage -\> internal capsule function affected UMN paralysis of contralateral limbs and lower face

Answer 139

Lentico-striate artery occlusion -\> capsular infarction MCA infarction Pontine infarction Corona radiata tumour etc.

Answer 140

CNS vs CNS/PNS Involve cortex, corticospinal or corticobulbar tract vs alpha motor neuron, motor fibres of cranial or spinal nerves Distribute to groups of muscles vs segmental muscles Spastic paralysis (antigravity muscle, clasp-knife rigidity) vs flaccid paralysis Hyperreflexia vs hyporeflexia Mild disuse atrophy of muscle vs pronounced atrophy Babinski's sign vs no Babinski's sign

Answer 141

Decorticate posturing: Rubrospinal cord intact, therefore UL flexion (elbow and wrist flexed) - wrist flexed - leg extended - plantar flexion

Answer 142

Decerebrate posturing/rigidity Unopposed pontine reticular nucleus and vestibular nuclrus -\> extensor activities --\> UL extension (extension of elbow, pronation) - wrist flexed - leg extended - plantar flexion

Answer 143

Monocular amaurosis (ipsilateral) e.g. in optic neuritis

Answer 144

Bitemporal hemianopia e.g. pituitary macroadenoma

Answer 145

Homonymous hemianopia (contralateral side of visual field busted in both eyes) e.g. craniopharyngioma

Answer 146

Temporal: homonymous upper quadrantic hemianopia Parietal: homonymous lower quadrantic hemianopia

Answer 147

Dense homonymous hemianopia with macular sparing

Answer 148

- primitive reflex(grasp, snout, suck, rooting) - high distractibility - lack of foresight/insight - inability to switch tasks - lack of ambition/ responsibility - lack of social propriety and self-monitoring

Answer 149

- Amnesia - Flat emotion/ affect - Akinetic mutism

Answer 150

Expressive (Broca's) non-fluent Receptive (Wernicke's) fluent Global

Answer 151

2 SDs less than mean intelligence; never had a normal IQ

Answer 152

loss of previously acquired intelligence

Answer 153

1) Primary neurodegenerative dementia - alzheimer's - Lewy bodies 2) Vascular dementia - infarct --------uncommon--- 3) Infective dementia - e.g. syphilis, AIDS, CJD 4) Intracranial pathology - tumour - hydrocephalus - subdural hematoma 5) Chronic alcoholism etc.

Answer 154

History of stroke Abrupt decline Focal neurological signs Management: Stroke prevention

Answer 155

1) Neuronal and glial cell death (1º & 2º) - reduce cell death with methylprednisolone - block death receptor activation to reduce 2º injury - Stem cell transplant to replace neurons 2) Axontomy and intrinsic changes of injured neurons - Enhance regeneration by modifying intrinsic environment e.g. increase cAMP, inhibit PKC 3) Demyelination - Oligodendrocyte or Schwann cell transplant 4) Glial Scars 5) Inhibit molecules 6) Poor blood supply - reduce glial scar and inhibit molecules by enzymes, antibodies

Answer 156

may be found anywhere along the path of descent of the thyroid gland. It is commonly found in the base of the tongue or with the lateral cervical lymph nodes.

Answer 157

found anywhere along the path of descent of the thyroid gland, but always in the midline of the neck Sometimes connected to the outside by a canal, a thyroglossal fistula

Answer 158

persist along the path of migration (may be as low as aortic arch) Can be visualised by Parathyroid scintigraphy dual phase planar imaging

Answer 159

Patients are injected with tracer (Tc99m, Technetium -99m) and imaged at 5 min and images repeated at 2h. This radiotracer is taken up by the thyroid gland, but cleared from the thyroid with a half-life of 30 min. It is usually retained by abnormal parathyroid tissue

Answer 160

(normally supplies all laryngeal muscles except cricothyroid; especially important as it innervates superior cricoarytenoid muscle, the only abductor of vocal cords) Unilateral: Hoarseness, dysphagia, partial (abductor) paralysis of the vocal cord Bilateral: Bilateral (abductor) paralysis of vocal cord, airway obstruction, which may leads to death

Answer 161

1) By size: Macroadenoma 1cm+; microadenoma 1cm - 2) - Functional (hormone overproduction with clinical manifestation) or - silent (hormone overproduction without clinical manifestation) or - hormone negative

Answer 162

Monotonous pinkish secretory cells - uniform polygonal cells in sheets/cord Rare mitosis, little pleomorphism Increased vascularity

Answer 163

PRIMARY: 1) pituitary adenoma (acidophil cell tumour) SECONDARY: 1) Hypothalamic tumour releasing GHRH 2) Ectopic GH or GHRH from lung cancer or pancreatic cancer

Answer 164

Gigantism in children; Acromegaly in adults Symptoms: 1) outgrowth of all organs, bones, joints and soft tissues (excessive height in gigantism; skeletal overgrowth with large nose feet hands on acromegaly) 2) hyperglycaemia (osmotic diuresis?)

Answer 165

PRIMARY: 1) idiopathic in childhood 2) Pituitary tumours e.g. Silent or hormone negative pituitary adenoma; carniopharyngioma

Answer 166

Pituitary dwarfism in children Symptoms: 1) delayed physical maturation 2) short stature 3) reduced skeleton and muscular mass - affected walking jumping and standing 4) sparse hair growth and frontal recession

Answer 167

1) Blood test for GH or IGF-1 - difficult as t1/2 is short 2a) Functional test - stimulation test - insulin tolerance test - arginine infusion test 2b) functional test - suppression test - glucose tolerance test

Answer 168

Arginine infusion test and insulin resistance test Arginine and insulin normally reduces plasma glucose, thus increasing GH secretion -\> if GH not increased, GH hyposecretion

Answer 169

Suppression test (glucose tolerance test) Increased glucose normally lead to reduction of GH secretion If GH level not decreased, then GH hypersecretion

Answer 170

PRIMARY: 1) prolactinoma (a pituitary adenoma) SECONDARY: 1) pregnancy 2) psychiatric medications

Answer 171

Men: loss of libido, impotency, low sperm count, gynaecomastia Women: menstrual disturbances (amenorrhea), galactorrhea, loss of libido, infertility

Answer 172

Cause: pituitary adenoma Pathology: Cushing's disease (secondary hypercortisolaemia) - ACTH and Cortisol increased - symptoms: Cushing's syndrome

Answer 173

Hypercortisolaemia (Cushing's syndrome) caused by increased ACTH production due to pituitary adenoma

Answer 174

Causes: inefficient pituitary production; or use of exogenous steroids Pathology: secondary hypocortisolism (secondary adrenal insufficiency) - reduced ACTH and cortisol - Nausea, vomiting - fatigue, weakness, hypotension - hyperpigmentation and hyperkalemia NOT SEEN

Answer 175

Cause: pituitary adenoma Pathology: secondary hyperthyroidism - increase TSH and TH

Answer 176

Secondary hypothyroidism - decrease TSH and decrease TH

Answer 177

Hypogonadotropic hypogonadism female: - breast atrophy - vaginal dryness - reduced libido Male: - reduced libido - impotency

Answer 178

Where all pituitary hormones are insufficient GH, Prolactin, FLAT

Answer 179

1) post surgery or radiation 2) trauma 3) infection/ inflammation 4) pituitary tumour (silent/ hormone negative) 5) Sheehan syndrome

Answer 180

Aka postpartum hypopituitarism - caused by ischaemia necrosis of pituitary gland due to blood loss during or after childbirth

Answer 181

- Neurogenic diabetes insipidus (polyuria, polydipsia) - hypernatremia

Answer 182

1) Neurogenic DI (decreased ADH release due to hypopituitarism) 2) nephrogenic DI (inability of kidney to respond to ADH) 3) Dipsogenic (defect in hypothalamic thirst mechanism) 4) Gestational (placenta produce vasopressinase that cleaves ADH)

Answer 183

A. FUNCTIONAL: 1) insulinoma (beta cells) 2) gastrinoma (G cells) 3) glucagonoma (alpha cells) 4) VIP-oma (VIP cells) B. NON-FUNCTIONAL

Answer 184

Hypoglycaemia Triad: 1) recurrent hypoglycaemic attack 2) CNS symptoms (confusion, loss of consciousness) 3) Attack promptly relieved by glucose administration

Answer 185

Excess gastrin over stimulated H+ production by gastric parietal cells: Severe peptic ulcer - Zollinger-Ellison Syndrome

Answer 186

Secondary diabetes with hyperglycaemia

Answer 187

Increased digestive motility -\> watery diarrhoea

Answer 188

In ribbons and anastomosing trabeculae Richly vascularised Round nuclei with fine chromatin Eosinophilic cytoplasm

Answer 189

PRIMARY (both aldosterone and cortisol deficient) 1) acute primary (Waterhouse-friderichsen syndrome) 2) chronic primary (addison's disease) SECONDARY (only cortisol deficient) 1) reduced ACTH secretion due to hypopituitarism

Answer 190

Acute primary adrenal insufficiency Due to overwhelming bacterial infection -\> hypotension and shock -\> DIC -\> adrenocortical insuffiency -\> massive adrenal haemorrhage - reduce cortisol and aldosterone

Answer 191

Autoimmune adrenalitia, amyloidosis TB, infections Metastasis

Answer 192

Primary vs secondary Reduction in cortisol and aldosterone vs reduction in cortisol ACTH increase vs ACTH decrease Hyperpigmentation vs none Hyperkalemia vs none

Answer 193

- reduce cortisol and aldosterone - Nausea, vomiting - fatigue, weakness, hypotension (due to hyponatremic volume contraction) - hyperpigmentation - hyperkalemia

Answer 194

Reduced cortisol leads to negative feedback increase in pituitary ACTH secretion, which will lead to concomitant MSH secretion as ACTH is the precursor

Answer 195

1) Primary hyperaldosteronism (Conn's syndrome) 2) primary hypercortisolaemia (Adrenal Cushing's syndrome) 3) Primary androgen hypersecretion (Androgenital syndrome or virilism)

Answer 196

Congenital Adrenal Hyperplasia Cortical adenoma

Answer 197

PRIMARY (hyperadrenalism) 1) adrenal hyperplasia 2) cortical adenoma ---- SECONDARY (renal perception of low intravascular volume -\> overreaction of renin-angiotensin system) 1) renal artery stenosis 2) CHF 3) chronic renal failure 4) cirrhosis

Answer 198

Conn's: HypoK, HyperNa, alkalosis, ↑ plasma & urinary aldosterone - muscle weakness (due to hypokalemia) - tetany (metabolic alkalosis, hypokalemia) - hypertension (hypernatremia) - decrease plasma renin

Answer 199

Low plasma renin VS High plasma renin

Answer 200

1) iatrogenic/ exogenous glucocorticoid 2) Cushing's disease (secondary to pituitary ACTH hypersecretion from adenoma) 3) ectopic ACTH (from SCLC or pancreatic cancer) 4) Adrenal adenoma, carcinoma or hyperplasia (PRIMARY) 5) hypothalamic CRH hypersecretion

Answer 201

1) CVS - hypertension (hypernatremia, water retention) - left ventricular hypertrophy - capillary weakness 2) GI - peptic ulcer 3) U - sodium and water retention - hypokalemia - hypercalciuria -\> ureteric calculus - polyuria sometimes 4) G - increased androgen with clitoral hypertrophy, virilism, hirsutism, and amenorrhea 5) MSS - muscle weakness (hypokalemia) - osteoporosis - decrease bone mass -\> fractured - thin limbs 6) Skin - truncal obesity - buffalo hump - moon face - abdominal striae 7) CNS - irritability 8) Immune - poor wound healing - immunosuppresion 9) endocrine - hyperglycemia - diabetic

Answer 202

Adult adrenal medullary tumour - pressure (hypertension) - pain (headache) - perspiration - palpitation, tachycardia - pallor - tremor, sense of apprehension Complication: --\> MI due to vasoconstriction Increase urine catecholamine and vanillylmandelic acid

Answer 203

10% extra-adrenal 10% bilateral 10% malignant 10% without hypertension

Answer 204

Adrenal medullary neoplasm of children less than age of 3 Often metastasise Soft and lobulated (small blue round cells)

Answer 205

(Oral flora): Odontitis Pharynx perforation Quinsy (Staph aureus): Cervical vertebral osteomyelitis

Answer 206

Fever Dysphagia Neck stiffness Sore throat

Answer 207

Spread of infection -\> mediastinitis

Answer 208

Neck XR: prevertebral soft tissue swelling CT to check involvement extent Blood and pus culture

Answer 209

Airway protection Antibiotic Surgical drainage

Answer 210

Epi vs croup 2-4 yo VS 3 m - 3yo Toxic and unwell VS well looking Abrupt onset VS viral prodrome High fever VS moderate Fever More sever stridor vs less Minimal cough VS barking cough Dysphonia vs hoaseness Drooling and Dysphagia vs intact swallow

Answer 211

Foreign body aspirations Tumour Goitre Bilateral vocal cord palsy

Answer 212

V: juvenile angiofibroma I: nasal polyps N: Nasal papilloma, squamous carcinoma, malignant melanoma, adenocarcinoma D: / I: TB, leprosy, Scleroma, aspergillosis, candidiasis C: cleft palate, choanal atresia or stenosis A: Wegener's granulomatosis, lethal midline granuloma T: wood dust associated adenocarcinoma E: allergic nasal polyps

Answer 213

V I: aphthous ulcer N: squamous cell carcinoma D I C A: lichen planus T: ulcer E

Answer 214

V I: sialadenitis N: pleomorphic adenoma, warthin's tumour, mucoepidermoid carcinoma, adenoid cyst, lymphoepithelioma-like- carcinoma D I: viral mumps C A: Sjögren's syndrome T E

Answer 215

V I: vocal polyps (singer's nodule) N: squamous papilloma, carcinoma in situ, invasive squamous cell carcinoma D I: viral (influenza, adenovirus, chicken pox) Acute laryngitis, acute epiglottitis, croup, TB C: laryngeal web A: laryngeal edema T E

Answer 216

May be due to HSV infection

Answer 217

Commonest oral cavity neoplasm Risks: - smoking!! - alcohol abuse - HSV HPV infection - sunlight - poor dentition

Answer 218

Mucocele - obstruction of minor salivary gland

Answer 219

1) pleomorphic adenoma 2) Warthin's tumour ---MALIGNANT 3) mucoepidermoid carcinoma 4) adenoid cyst 5) lymphoepithelioma like carcinoma

Answer 220

Autoimmune destruction of salivary glands; Lymphocyte, fibrous tissue in glands -\> dry mouth -\> tooth decay -\> dry eye

Answer 221

Most commonly in parotid gland (ensure facial nerve preservation in excision!) Pleomorphic histology 1) Epithelium forming small ducts and myoepithelial cells 2) Myxoid (shiny surface) or chondroid stroma

Answer 222

Mostly in parotid gland, bilaterally Aka cystadenoma lymphomatosum papilliferum

Answer 223

Malignant salivary gland tumour Combination of glandular and squamous epithelium

Answer 224

Common in submandibular and sublingual glands Locally invasive Mixture of glandular cells and myoepithelial cells

Answer 225

Salivary gland tumour Common in Chinese Resembles NPC and associated with EBV Metastasise to lungs and lymph nodes

Answer 226

Chronic laryngitis due to mechanical injury to vocal folds eg voice misuse - squamous metaplasia - localised stromal edema - degeneration

Answer 227

Autoimmune or traumatic eg when patient is allergic to bee sting or medication Massive swelling of larynx -\> obstruct inlet -\> death due to respiratory distress

Answer 228

JUVENILE - multiple - wide area - high recurrence ADULT - single - from vocal cord exclusively - rare recurrence

Answer 229

Occurs on true vocal cords

Answer 230

- history of chronic laryngitis - heavy smoking - hoarseness, pain - dysphagia - haemoptysis Supraglottic - metastatic to lymph nodes, lungs Glottic - commonest, beat prognosis - confined to larynx Subglottic - rare, worst prognosis - metastatic to lymph nodes, lungs

Answer 231

Thin and translucent membrane between vocal folds near anterior commisure (congenital)

Answer 232

Common in southern Chinese Male more common than female Middle aged

Answer 233

1) Genetics - combination of HLA A2 and BW 46 (not found in western populations) 2) Diet - dimethylnitrosamines in salted fish and phorbol ester in plant and oil are mutagenic compounds 3) EBV - IgA component of Viral Capsid Antigen for EBV found in patient serology; may due to proliferators effect on epithelial cells

Answer 234

Fossa of Rosenmuller of nasopharynx - clinically obscure area therefore will be clinically silent until widespread metastases occur Local spread to parapharyngeal space -\> base of skull -\> cranium via foramina Distal spread -\> usually by lymphatics to H&N lymph nodes - may be hemat spread to organs

Answer 235

1) deafness and tinnitus - blockage of Eustachian tube 2) Bleeding - postnasal drip bleeding 3) headache and facial pains - trigeminal nerve compression - test for corneal reflex - temporal headache 4) neck nodes - upper jugular group at posterior triangle apex - contralateral most common; sometimes bilateral

Answer 236

Squamous cell carcinoma (-\> squamous cells) Nonkeratinising carcinoma (-\> transitional cells) Undifferentiated carcinoma

Answer 237

Undifferentiated carcinoma (95%)

Answer 238

Sheets of polygonal cells or spindle cells Prominent lymphoid infiltrate (only reactive)

Answer 239

Radiotherapy (best for undifferentiated carcinoma, SCC least) with adjuvant chemotherapy Routine follow up - High recurrence in first 2 year and after 10 years Use of plasma EBV tests to determine relapse COMPLICATION: - sarcomas after radiotherapy

Answer 240

1) GI lymphoma 2) malignant nasal lymphoma

Answer 241

- second most frequent extranodal lymphoma in Chinese - T cell lymphoma mostly - associated with EBV - polymorphic reticulosis - early biopsy may be mistaken for benign lesion

Answer 242

BENIGN 1) squamous papilloma 2) transitional papilloma MALIGNANT 1) squamous cell carcinoma 2) malignant melanoma 3) Adenocarcinoma (from mucosal glands; associated with wood dust)

Answer 243

Young boys nasal vascular lesion; develop around puberty and regress afterwards 1) nasal obstruction 2) epistaxis - due to malformation of nasal erectile tissue

Answer 244

Covered by respiratory epithelium with goblet cell hyperplasia Inflammation, allergy cystic fibrosis

Answer 245

Chronic bacterial infection (in form of granulomatous disease) beginning in the nose and extend progressively to nasopharynx, orophaynx and larynx

Answer 246

Autoimmune nasal pathology - necrotising giant cell granulomas (histiocytes, multinucleated giant cells) - will spread to trachea and lungs - death in a year from renal failure due to: 1) renal arteritis 2) necrotising glomerulitis

Answer 247

Non inflammatory destructive lesion of URT - Wegener's granulomatosis - conventional malignant lymphoma - polymorphic reticulosis

Answer 248

TYPICAL OF NASAL MALIGNANT LYMPHOMA Small number of lymphoma cell presented intermixed with reactive cells (plasma, immuneblast, histiocytes, neutrophil, eosinophil), forming a polymorphic mixture

Answer 249

Vasogenic vs cytotoxic vs hydrocephalic 1) due to increased capillary permeability and filtration pressure VS disturbed cellular osmoregulation from metabolic derangement VS increased CSF accumulation 2) white matter VS Gray and White matter VS periventricular white 3) Edema formed by plasma filtrate with plasma protein VS intercellular Na and water VS CSF 4) ECF increased vs Decreased vs increased

Answer 250

A clinical term for rapid onset of focal cerebral dysfunction of presumed vascular origin, of more than 24 hours with structural brain damage

Answer 251

A fully reversible neurological deficit, lasting less than 24 hours with no structural brain damage

Answer 252

HK: Ischaemic stroke (70%) common than haemorrhagic stroke (30%) Western: Ischaemic stroke (85%) vs haemorrhagic stroke (15%)

Answer 253

1) atherosclerosis or lipohyalinosis causing occlusion 2) Emboli 3) Hypotension eg boundary zone infarct 4) vasculitis eg TB/ HI meningitis 5) vascular complication of raised ICP 6) vasospasm in subarachnoid haemorrhage 7) venous occlusion

Answer 254

Pale vs haemorrhagic PALE - swollen and softened - cracking and liquefaction in 5 days - resorption with replacement by fluid filled cavity in weeks Ischaemic necrosis in 6 hours Macrophage in 6-12h In a week heavy macrophage infiltration with astrocytic proliferation

Answer 255

Intracranial artery or extracranial artery like vertebral artery or \*\*internal carotid artery at carotid bifurcation

Answer 256

Caucasian: more extracranial African, Asian: more intracranial

Answer 257

Atheroma plaque in carotid bifurcation Mural thrombi in the heart (chronic rheumatic heart disease)

Answer 258

Lipohyalinosis of deep penetrating arteries leading to thalamus, basal ganglia and pons - hyalinization - fibrinoid degeneration - lipid deposition - foamy macrophage accumulation Severe in hypertension Lead to lacunar infarct

Answer 259

Small infarct that lie deep in cerebral cortex or brainstem, usually due to small vessel disease or lipohyalinosis Significant neurological deficit

Answer 260

Endarteritis obliterans in TB meningitis or haemophilia influenzae meningitis

Answer 261

Border between ACA and MCA

Answer 262

Cause: diffuse intracranial atherosclerosis with drop in systemic blood pressure or congestive heart failure -\> zone between 2 arterial beds becomes maximally deficient in blood supply and progressively ischaemia and necrosis May not have clear neurological signs

Answer 263

1) Intracerebral 2) subarachnoid 3) Epidural and subdural

Answer 264

1) blood vessel abnormality - hypertension with small vessel disease and microaneurysm - saccular aneurysm - angioma - congophilic angiopathy - arteritis 2) blood disorder - thrombocytopenia - coagulopathy - anti-coagulants 3) brain tissue abnormality - infarct, tumour 4) traumatic 5) drugs, alcohol 6) idiopathic

Answer 265

Amyloid deposition in pial and intracortical arterioles Incidence increase with age Cause lobar Intracerebral haemorrhage

Answer 266

Multifocal, lobar

Answer 267

Congenital malformation of vessels 1) arteriovenous malformation AVM (most aggressive) 2) venous angioma (most common) 3) capillary angioma 4) cavernous angioma

Answer 268

Rupture with massive haemorrhage Mass effect Steal (adjacent tissue deprived of blood supply), leading to epilepsy and neurological deficit

Answer 269

1) rupture of saccular aneurysm (65%) 2) rupture of AVM (5%) 3) idiopathic (20%)

Answer 270

Arterial bifurcations, 90% in anterior circulation: 1) middle cerebral artery's first main branch in Sylvian fissure 2) anterior communicating artery's origin from anterior cerebral artery 3) internal carotid artery's terminal bifurcation and origin of posterior communicating artery

Answer 271

All ages post puberty

Answer 272

Adult polycyclic kidneys Aorta coarctation

Answer 273

Rupture: 5mm to 10mm Mass effect: \> 3cm

Answer 274

1) Spontaneous closure 2) rebleeding 3) cerebral ischaemia and infarction due to vasospasm of artery harbouring ruptured aneurysm 4) expanding haematoma 5) progressive hydrocephalus due to subarachnoid space occlusion by haematoma 6) epilepsy

Answer 275

1) neurons don't regenerate - permanent neurological dysfunction 2) little space in cranium -\> mass effect prominent 3) meninges damage will lead to hydrocephalus

Answer 276

1) meningeal irritation 2) encephalopathic signs (seizures or altered consciousness) 3) raised ICP presentation 4) Focal neurological sign -\> paralysis, anaesthesia, endocrine, focal epilepsy 5) primary or metastatic foci of infection: skin rashes, pneumonia, endocarditis l, sinusitis 6) systemic signs: Fever, leucocytosis

Answer 277

1) pus is subarachnoid space, may infiltrate ventricles and choroid plexus, posterior spinal cord 2) petechia haemorrhages and focal infarction 3) small abscess in white matter 4) subarachnoid space filled with neutrophils then lymphocytes, plasma cells and macrophage

Answer 278

1) Organization of inflammatory exudate -\> fibrosis, thickening of meninges and obliteration of subarachnoid space 2) hydrocephalus 3) cranial nerve palsy due to entrapment by fibrosis - CN 2 and 6 7 8 4) septic thrombosis of cerebral vessels may lead to cerebral infarction 5) if parenchyma involved by infection or infarction, then epilepsy, mental retardation and focal neurological sign

Answer 279

1) asymptomatic colonisation of nasopharyngeal mucosa (usu via fimbriae) 2) bacteria pass mucosal barrier and enter blood stream via phagocytic vacuole 3) bacterial capsule evade phagocytosis and complement pathway 4) sustained high grade bacteraemia 5) bacteria attach to laminin receptor on brain microvascular endothelium 6) meningeal invasion -\> breakdown of epithelial tight junction or cross BBB by endocytosis 7) uncontrolled replication of bacteria in subarachnoid space (defenceless due to low complement, antibody and WBC) 8) bacterial release endotoxins and components that activate endothelial and macrophage Toll like receptor -\> release of pro inflammatory cytokines 9) inflammation of subarachnoid space, increased permeability of BBB and endothelium

Answer 280

E coli (K1) Streptococcus agalactiae Listeria monocytogenes (unpasteurised milk) Enterobacteriaceae eg salmonella

Answer 281

HIB Neisseria meningitidis Streptococcus pneumoniae

Answer 282

Neisseria meningitidis Streptococcus pneumoniae

Answer 283

Neisseria meningitidis Streptococcus pneumoniae Aerobic gram neg (Klebsiella, Escherichia, salmonella)

Answer 284

Neisseria meningitidis Streptococcus pneumoniae Aerobic gram neg (Klebsiella, Escherichia, salmonella) Listeria monocytogenes Pseudomonas aeruginosa

Answer 285

Streptococcus suis

Answer 286

Nagleria fowleri Other amoeba

Answer 287

Angiostrongylus cantonensis (eosinophilia meningitis)

Answer 288

Staphylococcus aureus Staphylococcus epidermidis Aerobic gram neg (Klebsiella, Escherichia, salmonella) Aspergillus

Answer 289

Staphylococcus aureus Staphylococcus epidermidis Aerobic gram neg (Klebsiella, Escherichia, salmonella) Proprionibacterium acne

Answer 290

1) LP for CSF gram smear and culture and antigen detection, after exclusion of SOL by CT/MRI 2) empirical IV high dose antibiotic that crosses BBB eg penicillin G, ceftriaxone 3) adjunctive dexamethasone before/with first dose of antibiotics to decrease inflammatory complications in HIB or strep pneumoniae 4) elevation of head by 30 degrees and anticonvulsant for ICP symptoms relief 5) chemoprophylaxis with rifampicin before HIB or Neisseria meningitidis contact 6) active immunisation eg HIB vaccination, meningococcus/ pneumococcal vaccination

Answer 291

1) mycobacterium tuberculosis 2) cryptococcus neoformans 3) Treponema pallidum (syphilis) 4) Lyme's disease - ticks 5) nocardia 6) candida,

Answer 292

1) granulomatous inflammation - granuloma - central caseous necrosis bordered by epithelioid histiocytes - Langhan's giant cells with fibrosis in periphery 2) thick gelatinous exudate around granuloma

Answer 293

0) chronic inflammation causes intimal proliferation and luminal narrowing of cerebral arteries (endarteritis obliteran) -\> superficial infarct 1) Organization of inflammatory exudate -\> fibrosis, thickening of meninges and obliteration of subarachnoid space 2) hydrocephalus 3) cranial nerve palsy due to entrapment by fibrosis - CN 2 and 6 7 8 4) septic thrombosis of cerebral vessels may lead to cerebral infarction 5) if parenchyma involved by infection or infarction, then epilepsy, mental retardation and focal neurological sign

Answer 294

1) CSF lymphocytosis and monocytosis 2) CSF high protein low sugar 3) CSF and sputum LJ medium culture positive 4) CSF ZN stain positive 5) CSF TB PCR positive 6) CXR may reveal concomitant pulmonary TB

Answer 295

PIER Pyrazinamise Isoniazid Ethambutol Rifampicin Steroid for reducing inflammatory complication

Answer 296

Underlying immunodeficiency - malignant lymphoma, AIDS, post transplant - positive CSF Indian ink - CSF high protein low glucose - serum or CSF cryptococcal antigen - positive fungal culture

Answer 297

Thickened opalescent meninges Contains mucoid exudate Small cysts Granuloma

Answer 298

Fluconazole Amphotericin B

Answer 299

A spread from contiguous suppurating focus, hematogenous spread from distant focus, direct inoculation for trauma 1) bacteria crosses BBB and enter brain parenchyma 2) acute inflammation -\> early cerebritis, late cerebritis 3) early capsule formation with tissue necrosis and collagen fiber encapsulation 4) late capsule formation

Answer 300

Multiple sites Toxoplasma gondii Aspergillosis Mucomycosis Nocardia

Answer 301

Temporal or cerebellar Streptococcus viridans Bacteroides Peptostreptococcus

Answer 302

Frontal, temporal Streptococcus viridans Peptostreptococcus Bacteroides

Answer 303

Frontal Streptococcus viridans Peptostreptococcus Bacteroides

Answer 304

Multiple sites Viridans strep Peptostreptococcus Bacteroides Enterobacteriaceae

Answer 305

Multiple sites Staphylococcus aureus Streps

Answer 306

Related to wound Staphylococcus aureus Streps

Answer 307

1) acute inflammation with pus, tissue necrosis and neutrophilia (cerebritis) 2) capsule formation and collagen fibre encapsulation 3) gliosis 4) may cause cerebral herniation 5) epilepsy

Answer 308

1) contrast CT or MRI shows focal lesion with hypodense centre with perilesional ring 2) surgical aspiration yield pus for gram smear, aerobic culture 3) empirical high dose IV antibiotic that crosses BBB

Answer 309

Neck stiffness Headache Photophobia Kernig's sign (when hip and knee bent at 90 degree in supine patient, extension of knee is painful) Brudzinski's sign (forced flexion of neck of supine patient will lead to flexion of hips)

Answer 310

Turbid vs clear or sl turbid vs clear or sl turbid Cell count \>500 VS \<500 Neutrophil vs lymphcyte vs lymphcyte Low glucose vs normal vs low High protein vs high vs high

Answer 311

1) direct invasion of CNS -cytoplasmic effect of virus replication in CNS 2) post infection syndrome - cross reacting immunological response to myelin -\> dysmyelination of CNS

Answer 312

Follow vaccination measles VZ, influenza - wide spread perivascular demyelination, with lymphocytic cuffing - astrocytic proliferation and perivascular gliosis at later stage ----- Same + neurophagia by microglia

Answer 313

1) cell line culture from CSF (good isolation rate in meningitis, poor in encephalitis esp post infection; enterovirus subtypes are often inculturable) 2) cell culture from other sites Eg throat swab (mumps, enterovirus) Stool (enterovirus) 3) serology - paired titre with raising - IgM antibody for EBV JE CMV - intrathecal antibody detection - enterovirus seri types got no common antigen 4) brain biopsy 5) PCR RT-PCR of CSF

Answer 314

1) enterovirus (echovirus, coxsackie A, B, EV71) 2) HSV 2 (recurrent genital herpes) ----- 3) mumps 4) LCM 5) HIV

Answer 315

1) HSV 1 2) Enterovirus (echovirus, EV71) 3) VZV ------ 4) Japanese encephalitis 5) Febrile exanthems (measles, rubella) 6) rabies

Answer 316

Enterovirus (polio, EV71) HSV 2 VZV Mumps Exanthems JE EBV CMV

Answer 317

Picornavirus RNA, single strand Non encapsulated Summer seasonality

Answer 318

HSV type 2 (usu recurrent genital lesion) Self limiting (may not require acyclovir) Winter seasonality

Answer 319

HSV 1 (in neonate is type 2) Entry to CNS via - blood; - or spread along olfactory nerve from nasopharynx -\> frontal lobe - reactivation from trigeminal ganglion -\> pia mater Often affects temporal lobe or orbital surface of frontal lobe

Answer 320

May be reactivation of latent virus unconnected with CNS Approximately 1% of population have HSV isolated from mouth

Answer 321

Treatment with acyclovir upon clinical suspicion -\> mortality is 70% if untreated

Answer 322

- arbovirus - common is South China or SE Asia but not HK (check travel history) - mostly asymptomatic - water birds and pigs as reservoir, mosquito as vector; no human to human infection - vaccine

Answer 323

Especially prominent in immunocompromised (reactivation in AIDS) - latent infection in dorsal root ganglion - skin lesion may precede (shingles) - skin lesion may absent (zoster sine herpete)

Answer 324

Rhabdovirus Zoonosis -\> animal reservoir dogs and other mammals Animal saliva infectious when introduced on mucosal surface Human human transmission not known Replicates in striated muscles, enter nerve endings via acetylcholine receptor -\> carried via axon to brain/ spinal cord -\> replication in brain -\> travels to salivary gland, skin, muscles via peripheral nerves Incubation in face bite is shorter due to shorter travel distance

Answer 325

Viral antigen via immunofluorescence Negri bodies

Answer 326

Prodrome: itching at bite wound Furious rabies: hydrophobia, aerophobia, meningo-encephalitis Paralytic rabies: paralysis of bitten limb and spread

Answer 327

1) wound toilet; clean with soap and water with good debridment 2) assess rabies risk by observing animal and area ------ Prevention: 1) control/ vaccination of dogs 2) passive immunisation - human rabies globulin - infiltrate wound and inject IM 3) active immunisation - 6 doses of killed vaccine

Answer 328

Relatively resistant to heat, UV, ionising radiation, formalin Protease resistant protein Isoform of normal cell prion-related protein PrPc Accumulation leads to disease

Answer 329

Accumulation of PrPsc in brain Loss of neuron -\> spongiform vacuolation Lack of inflammatory or immune response Long incubation time -\> rapidly progressive dementia -\> loss of memory -\> intellect loss -\> personality change -\> clumsiness

Answer 330

Human: 1) Kuru (cannibalism) 2) Creutzfeldt-Jakob disease - classical sporadic - familial - new variant CJD (BSE in human) Sheep: Scrapie Cattle: Bovine SE (BSE)

Answer 331

Implantation of contaminated graft (dura mater, cornea) Human GH Human pituitary gonadotropin Contaminated surgical equipment

Answer 332

Inform relevant department Use disposable equipments in contact with CSF blood or tissues Avoid aerosol generating procedures in high risk tissues eg high speed drill Special sterilisation (chlorine, NaOH, enzymatic detergents, autoclave)

Answer 333

FORM AND FUNCTION 1) Form - H&N not covered - treatment will affect external appearance - psychosocial well being 2) Function

Answer 334

Left supraclavicular node adenopathy; indicates infraclavicular lesion or infra diaphragmatic lesion from thoracic duct eg pelvic cancer or gastric cancer

Answer 335

Removal of neck lymphatic that harbours cancer metastasis - Level I to V nodes - sternocleidomastoid muscle - internal jugular vein - Accessary nerve - Cervical plexus

Answer 336

Removal of level I-V neck lymphatics - cervical plexus With preservation of one or more: - sternocleidomastoid muscle - internal jugular vein - accessory nerve

Answer 337

Removal of areas of lymphatics with highest chance of occult nodal metastasis, for those with no clinical evidence of nodal metastases but high chance of occult nodal metastases - supraomohyoid neck dissection (I, II, III for oral tongue cancer) - central compartment dissection (bilateral VI) for thyroid cancer

Answer 338

Complete removal of larynx - loss of speech - loss filter function of the nose - loss of humidification - ineffective cough

Answer 339

Cleaves synaptobrevin (V-SNARE)

Answer 340

B, D, F, G cleaves synaptobrevin (V-SNARE) C cleaves syntaxin (T-SNARE) A, E cleaves SNAP-25 (T-SNARE)

Answer 341

Venom of female black widow spider Causes CA independent discharge of synaptic vesicles - Binds neurexin, bypass Ca dependent requirement for triggering vesicle fusion - Blinds CL1 and activate intracellular signal transduction cascade for Ca independent action

Answer 342

Decreased production or release of Ach Syndromes: - episodic apnea - weakness of eye muscles (diplopia) - weakness of throat and mouth muscles (dysphagia, cannot chew)

Answer 343

Autosomal recessive (usually missense) - loss of function of choline acetyltransferase - defective ACH resynthesis and packaging Treatment: - Acetylcholine esterase inhibitors

Answer 344

- Serum IgG against presynaptic voltage-gated calcium channels - P\>Q\>N - Reduced presynaptic voltage based calcium influx and calcium-dependent quantal exocytosis of Ach

Answer 345

- Enzyme dificiency in heme synthesis - autosomal dominant - intermediates of heme excreted in urine (uro, copro) or faeces (copro, proto)

Answer 346

Acute intermittent porphyria

Answer 347

- most prevalent porphyria affecting liver - lack of porphobilinogen deaminase - accumulation of ALA and porphobilinogen I Symptoms: - sever abdominal pain - neurological dysfunction

Answer 348

- prematurely destroys RBC - insufficient co-enzymes - excess uroporphyrinogen I produced - accumulation of uroporphyrin I, coproporphyrin I Symptoms: - port wine urine - red fluorescent teeth under UV - light sensitivity of skin

Answer 349

porphyrins under sunlight will produce Oxygen free radicals (those from less water soluble ones will attack organelle targets) -\> inflammation

Answer 350

1) Over absorption - thalassemia, alcoholic cirrhosis 2) Defect in iron absorption - hereditary hemochromatosis

Answer 351

High plasma iron: increased ferritin, decreased transferrin Low plasma iron: increased transferrin, decreased ferritin

Answer 352

The Fenton reaction is catalysed by ferric and ferrous irons: O2-\*(superoxide) + H2O2 =\> O2 + OH- + OH\* Which produces highly reactive hydroxyl radicals that damage polysaccharides, proteins, lipids, DNA

Answer 353

Caused by hydroxyl radicals 1) Lipid peroxidation - lysosome, mitochondria, and microsome damage 2) Fibrosis - stimulate collagen synthesis (stimulate prolyl hydroxylase) - Fibrosis and lipid peroxidation tgt =\> liver cirrhosis 3) Ascorbic acid depletion - iron overload =\> excretion of oxalic acid - scurvy - reduce iron for erythropoiesis - osteoporosis

Answer 354

- Iron mainly stored as hemosiderin - large amount of iron in spleen, BM, liver, thyroid, pancreas, heart - accumulation takes many years -\> symptoms not present until middle aged - increased ferritin, decreased transferrin, increased transferrin saturation Symptoms: - skin pigmentation - Hepatomegaly and cirrhosis - diabetes - hypogonadism (reduce libido) - arthritis, osteoporosis - diabetes - Heart failure

Answer 355

2 possible HFE gene mutations on chromosome 6: 1) C282Y (cysteine to tyrosine) - mutant HFE protein does not bind Beta2-microglobulin, preventing its transport to cell surface - decreased affinity of transferrin receptor for transferrin =\> iron accumulation 2) H63D (histidine to aspartic acid) - prevent HFE protein from interacting with cell surface proteins that detect iron concentration =\> failed iron absorption regulation, thus accumulation

Answer 356

1) Phlebotomy until all excess of iron is removed (monitor Hb level to prevent anaemia) 2) Stop phlebotomy when ferritin level normalised 3) continuous monitoring of ferritin level and periodic phlebotomy to prevent iron reaccumulation 4) Iron chelators (Removal of iron before irreversible pathologies improve prognosis)

Answer 357

- Defect in G6PD gene (Xq28) - X-linked - Heterogenous (No single mutation, large insertion or deletion) - Never complete absence of G6PD - Most common enzymopathy

Answer 358

Food: fava bean Drugs: primaquine, pamaquine (malaria), sulfamethoxazole, chloramphenicol, trimethoprim, aspirin, Vitamin K Chinese herbal medicine (especially breast feed!) Others: Mothballs

Answer 359

With offending agent: 1) Cells have lowered reduced glutathione dur to lack of G6PD 2) Offending agent generates peroxides 3) Glutathione peroxidase cannot reduce peroxides due to absence of reduced glutathione 4) Oxidative attacks lead to homeless Without offending agent: 1) Cells have lowered reduced glutathione due to lack of G6PD 2) sulfhydryl groups of Hb cannot maintain in reduced form without G6PD 3) Hb crosslink to form Heinz body 4) RBC membrane more prone to oxidative stress -\> haemolysis

Answer 360

1) Infective (poliomyelitis, HIV) 2) Toxic 3) Immunological (multifocal motor neuropathy) 4) Degenerative (sporadic e.g. ALS; or genetic e.g. familial ALS)

Answer 361

Both UMN and LMN damage: UMN: - spastic paralysis - fasciculation (twitching) - clonus (shaking) LMN: - profound muscle atrophy - muscle weakness

Answer 362

- more common (75%) - progressive weight loss - 6 months of progressive weakness of hand grip - loss of ambulation within 1 year - death from respiratory failure after 40 months - fasciculation of muscle in affected limbs - cramps and spasms

Answer 363

- less common (25%); usu elderly women - profound progressive weight loss - 9 months of progressive dysphonia and dysphagia - ambulation maintained to death - death from respiratory failure after 12 months - inappropriate laughing or crying - apnoea when lying flat

Answer 364

- Spinal muscular atrophy - spondylotic myelopathy - conductive block neuropathy

Answer 365

- Myasthenia Gravis - progressive supranuclear palsy

Answer 366

\*\*Deposition of neurofilament - Bunina bodies in motor neurone - "skeins" in anterior horn cells (rare glial inclusions) - Hyaline bodies in anterior horn cells - Dystrophic neurites in anterior horn \*\*AXONAL SWELLING \*\*increased anterograde and decreased retrograde axonal transport \*\*decreased mitochondrial transport

Answer 367

1) SOD1 dismutase mutation (AD) 2) Dynactin gene point mutation (AD)

Answer 368

-\> impaired dismutase activity; Gain of toxic function 1) Aberrant redox chemistry; change in conformation of SOD1 dismutase that allow channel to accept larger molecules 2) Protein instability and SOD1 aggregation

Answer 369

1st Alzheimer's disease 2nd Parkinson's disease

Answer 370

1) Increase with age 2) men more common than women

Answer 371

6 1) Resting tremor (pill-rolling) 2) Bradykinesia/ Akinesia 3) Cogwheel rigidity 4) Flexed posture of neck, trunk, limb 5) Loss of postural reflexes 6) Freezing phenomenon

Answer 372

- Intracellular eosinophilic masses made up of alpha-synuclein - pathologic landmark of PD, but not specific

Answer 373

1) Dopamine depletion in SN and nigrostriatal pathway to caudate and putamen -\> increased inhibition of thalamus and reduced excitatory input to motor cortex 2) Depigmentation (loss of neuromelanin) in SNpc and LC (neuromelanin is derived from oxidised dopamine) 3) Presence of Lewy bodies, and increased glial cells in SNpc and LC 4) Loss of monoaminergic neurons in SNpc and LC leading to decreased monoamine level at site and nerve terminals

Answer 374

PARK1 -\> alpha-synuclein mutation (AD) PARK2 -\> parkin (ubiquitin ligase) mutation (AR)

Answer 375

Parkinson's disease alpha-synuclein mutation (AD) Alpha-synuclein aggregate to large fibrillar forms, and form Lewy body with ubiquitin Alpha-synuclein and Abeta peptides, also form calcium channels at plasma surface -\> calcium overload -\> mitochondrial dysfunction -\> cell death

Answer 376

Parkinson's disease Parkin (E3 ubiquitin ligase) mutation (AR) Inactivation -\> accumulation of parkin substrate in neutrons -\> selective toxicity to DA neurons

Answer 377

1) Age on onset - early: 65yo 2) Family history - familial - sporadic

Answer 378

1) Age (increase) 2) Down's syndrome 3) severe head injury 4) Family history of dementia (esp early onset)

Answer 379

1) Amyloid plague -\> amyloid proteins and other associated proteins 2) Neurofibrillary tangles -\> abnormal microtubules associated with protein tau 3) Macroscopically wide spread cortical atrophy (deepening of sulcus)

Answer 380

1) Deficits in 2 or more areas of cognition 2) MMSE score \<24, with neuropsychological test evaluation 3) progressive worsening of cognitive function

Answer 381

1) Memory - impaired anterograde episodic memory - delayed recall of stories - Sparring working memory - Poor word list learning (12 words memorise after 3 readings) 2) Attention and execution - poor concentration - selective attention - problem with complex tasks - Wisconsin card sorting test (ability to display flexibility in changing schedules) 3) Language and knowledge - impaired semantics - word definition poor - word finding poor - later phonological and syntactic deficits 4) Visuospatial and perceptual abilities - impaired drawing esp 3D - Conceptual apraxia

Answer 382

- Apathy - Anxiety - agitation and destructive behaviour later - Depression - Delusions in late stage - Theft of items or paranoia - phantom lodger

Answer 383

50% of early onset AD APP gene PSEN1 gene PSEN2 gene (ApoE4 allele increases AD risk and reduce onset age) (MAPT gene in tau hypothesis)

Answer 384

1) Amyloid hypothesis - amyloid precursor protein (APP gene) is broken down by secretases - a non-soluble fragment of APP, Aβ-42, accumulates and deposit outside cell - Aβ-42 helps other protein fragments (e.g. apoE) to gather into plagues - plagues cause neuronal death - PSEN1 and PSEN2 gene -\> gamma secretase subunits 2) Tau hypothesis (less favourable) - microtubule associated protein tau (MAPT gene) is associated with microtubule responsible for axonal transport - accumulation of phosphate on tau causes "Paired Helical Filaments) and form neurofibrillary tangles - impaired axonal transport cause neuronal death

Answer 385

Risk factor for AD - for transport of plasma lipids within tissues - mechanism is associated with Aβ clearance and neuronal repair ApoE2 allele - protective for AD, risk for cardiovascular disease ApoE3 allele - normal ApoE4 allele - risk allele for AD (increase risk and earlier onset age)

Answer 386

HbH (β4) - 3 gene deletion α thal Hb Bart (γ4) - 4 gene deletion α thal HbF (α2γ2) - β thal major Inviable tetramer (α4) - precipitate immediately - β thal major

Answer 387

(- -) α-thal-1 (i.e. α0-thal) means both α-globin genes deleted in the chromosome (α -) α-thal-2 (i.e. α+-thal) means only one α-globin gene deleted in the chromosome

Answer 388

(αα/αα) = normal (αα/α-) = silent carrier (clinically and haematologically silent) (αα/- -) cis OR (α-/α-) trans = α thalassemia trait or α thalassemia minor -\> considered carrier (α-/- -) = HbH disease (- -/- -) = Hydrops fetalis: could not survive and die shortly after birth due to lethal haemolytic anaemia from Hb Bart precipitation

Answer 389

α thalassemia major: sever and transfusion dependent α thalassemia intermediate: between major and minor α thalassemia minor (asymptomatic carrier state, trait) silent carrier: clinically and haematologically silent

Answer 390

cis 2-gene deletion more common in Asians. Most common single gene disorder in the world

Answer 391

Unequal crossover of chromosome 16 during meiosis 1) Two homologous sister chromatids of chromosome 16 align side by side and form chiasma 2) if misaligned, then the DNA crossover recombination may remove α-globin gene (gene deletion) from one of the chromosome

Answer 392

β0: mutation that produce little or no β chain β+: mutation that produce detectable β chain level β++: mild β chain production defect

Answer 393

β thalassemia major (Cooley's anemia) - severe anaemia - require lifelong regular transfusion starting in infancy - severe iron overload - splenomegaly and bone disease common β thalassemia intermedia - mild to moderate anaemia, may be asymptomatic - relatively independent from transfusion - variable iron overload - splenomegaly and bone deformity common β thalassemia minor (trait) - mild or no anaemia - microcytosis - no splenomegaly no bone deformities

Answer 394

Primary modifier - β-globin gene genotype (greater production of β globin -\> better condition) Secondary modifier - α-globin gene genotype (less production of α globin -\> alleviate imbalance and reduce α4 precipitation -\> better condition) - α-hemoglobin stabilizing protein (AHSP) -\> stabilise α-harmohlobin to reduce α4 precipitation -\> better condition - γ gene (more γ chain -\> functional HbF formation -\> better condition) - BCL11A SNP (low BCL11A -\> higher HbF formation -\> better condition)

Answer 395

Excess α globin chain which leads to: - inclusion bodies - ineffective erythropoiesis - anaemia which then cause: \> Jaundice, gallstone, iron overload, bone deformity

Answer 396

α-hemoglobin stabilizing protein (AHSP) -\> stabilise α-harmohlobin to reduce α4 precipitation -\> better condition

Answer 397

BCL11A SNP (AA) -\> low BCL11A -\> higher HbF formation -\> better condition BCL11A SNP (GG) -\> high BCL11A -\> lower HbF formation -\> worse condition

Answer 398

Codon 41/42 (frameshift) Intron 2-654 (single nucleotide change that create new splice site that cause extra exon) General ------- 1) splicing mutation (SNP that activate cryptic splice sites, or create new splice site thus extra exon, or destroy normal splice site thus exon skip) 2) Missense 3) Frameshift by insertion/deletion 4) Nonsense mutation -\> premature terminated mRNA undergo nonsense-mediated decay

Answer 399

Failure of B cell signal transduction (lack of Bruton's tyrosine kinase) - Bruton's syndrome - recurrent infection - no humeral response - few or no mature B cells

Answer 400

1) mutated MHC gene on chromosome 6 leading to faulty positive and negative selection of T cells -\> active autoreactive T cells in periphery that kills B cells 2) Proinsulin gene class I VNTR leads to under expression of thymic insulin -\> faulty selection of T cells and Treg cells; class III VNTR is protective as it promotes thymic insulin expression 3) PTPN22 (specific phosphatase) 4) AIRE (autoimmune regulator for thymic epithelial cell self-antigen expression)

Answer 401

- Immune-related (T cell autoimmune) - genetically predisposed - may need virus or environmental hit (diet, trauma) - loss of beta cell mass - presence of insulitis

Answer 402

Viral Infected beta cells -\> beta cell's MHC class I display viral antigen -\> activation of Tc cells for killing -\> APC's MHC II display viral antigen -\> activate Th2 cell -\> B cell activation to make beta cell auto antibody for killing

Answer 403

Damaged B cell release B cell autoantigen that is taken up by APC, processed and presented via MHC II -\> Th1 cell activation -\> release cytokines, and activate Tc cell -\> killing

Answer 404

- Spread posteriorly to mastoid antrum - damage structures deep to the walls of tympanic cavity (e.g. internal carotid artery, IJV) - and then spread to middle or posterior cranial fossa by bone resorption, and then extend to brain!

Answer 405

Inflammation of nasal mucosa Spread to: 1) Anterior cranial fossa 2) Middle ear via auditory tube 3) Paranasal sinus 4) Lacrimal apparatus and conjunctiva

Answer 406

Caused by birth injury, congenital malformation or postnatal trauma -\> severe may obstruct breathing and need surgery

Answer 407

If extends above, may affect roof and cribriform plate of ethmoid bone May tear meninges =\> CSF rhinorrhea

Answer 408

Maxillary sinus, because the drainage site (hiatus semilunaris) of the maxillary sinus is located superior to the sinus floor Thus secretions more likely to be retained and easily infected

Answer 409

Visual symptoms: Vertical diplopia Sensory symptoms: Cheek hypothesia

Answer 410

Herniation of pharyngeal mucosa, at the region between thyropharyngeus and cricopharyngeus, the only region without constrictor overlapping

Answer 411

Shows an enlarged jugulodigastric lymph nodes -\> if chronic then perform tonsillectomy

Answer 412

Used for chronic tonsillitis - safe if the fibrous capsule is respected - large vein between tonsil and soft palate may cause bleeding during operation - CN IX (lateral wall accompanies tonsillar artery) and internal carotid artery (lateral to tonsils) may be damaged (!!)

Answer 413

1) Primary (PTH secretion without known stimuli): - parathyroid Adenoma (80%) - parathyroid Hyperplasia (15%) - parathyroid Carcinoma (5%) - MEN I, IIa 2) Secondary (chronic ↓ Ca2+ stimulates PTH secretion): - chronic renal disease (decreased phosphate excretion, which results in hyperphosphataemia. The elevated serum phosphate levels depress ionized calcium levels) - Vitamin D deficiency - Calcium deficiency in diet - Malabsorption 3) Tertiary (develops after secondary hyperparathyroidism; The glands become autonomous and do not respond to the level of calcium in blood)

Answer 414

fasting then blood test for plasma Ca2+ & PTH level. PTH high Ca high -\> primary PTH high Ca low/normal -\> secondary

Answer 415

1) Hypercalcaemia: Metastatic calcification in multiple sites e.g. stomach, lungs, myocardium, cardiac valves, blood vessels, skin, etc 2) Hypercalciuria - Urinary stones and associated infection 3) Gastrointestinal disturbances - pancreatitis, gallstones, constipation 4) hyperpolarization -\> depression of CNS/PNS, muscular weakness, cardiac arrhythmias 5) Bone disease: - Osteopenia (Prominent osteoclasts erode bone matrix and resorption) - Osteitis fibrosa cystica - Fracture - Brown tumors of hyperparathyroidism (Aggregates of osteoclasts, reactive giant cells, and hemorrhagic debris occasionally form masses that may be mistaken for neoplasm)

Answer 416

Low and normal calcium level, therefore: 1) Bone disease: - Osteopenia (Prominent osteoclasts erode bone matrix and resorption) - Osteitis fibrosa cystica - Fracture - Brown tumors of hyperparathyroidism (Aggregates of osteoclasts, reactive giant cells, and hemorrhagic debris occasionally form masses that may be mistaken for neoplasm)

Answer 417

1) Primary Hyperparathyroidism - parathyroid Adenoma (80%) - parathyroid Hyperplasia (15%) - parathyroid Carcinoma (5%) - MEN I, IIa 2) malignancy (releases PTH-related protein) - PTHrP is an essential tissue factor - It can bind to PTH receptors and acts like PTH - produced in excess by some malignant tumors e.g. squamous cell carcinoma of lung and breast cancers

Answer 418

A. Surgical removal, or iatrogenic (damage to blood supply during thyroidectomy) B. Congenital absence, as in DiGeorge syndrome. C. Autoimmune parathyroiditis, ends up in primary (idiopathic) atrophy.

Answer 419

- hypocalcaemia - enhanced neuromuscularexcitability (tetany)

Answer 420

1. Somatic mutation of MEN1 2. Relocation of cyclin D1 to near the PTH gene, leading to transcriptional activation Each of the above is found in about 20% of all sporadic parathyroid adenomas.

Answer 421

The weights of the glands are increased. The hyperplastic gland shows decreased stromal fat

Answer 422

- Fat content virtually absent in adenoma - The presence of capsule or compressed gland strongly favors adenoma

Answer 423

1) Sestamibi scan (parathyroid scintigraphy dual phase planar imaging) using Tc99m 2) Intra-operative (frozen section) diagnosis -\> Determine if the tissue is of parathyroid origin -\> look at stromal fat content, capsule, and compressed gland to Determine the nature of the lesion (Definite diagnosis depends on the examination of at least 2 glands, preferably all 4 glands) 3) Radioguided Parathyroidectomy - hyperactive parathyroid tumor is made radioactive before surgery so probe can detect

Answer 424

resistance to parathyroid hormone (PTH insensitivity in the target organs): - hypocalcaemia - elevated PTH levels - parathyroid gland hyperplasia - Type Ia, associated developmental bone defects (Albright hereditary osteodystrophy) Chromsome 20 GNAS1 mutation

Answer 425

Cortical - cortical adenoma (adult) - cortical carcinoma (children, adult) Medullary - Pheochromocytoma (adult) - Neuroblastoma (children)

Answer 426

1) Arranged in packets 2) vascularized background 3) Central regular nuclei & pale to clear cytoplasm 4) Monotonous cells

Answer 427

Grossly - Pale gray or brown - Cystic change - Haemorrhage Histo: - Finely granular basophilic or amphophilic cytoplasm (dirty blue) - Zellballen, trabecular or solid pattern - Polygonal or spindle cells in rich vascular network

Answer 428

1) Thyroid hyperplasia - Diffuse nontoxic (simple) goiter - Multinodular goitre 2) Thyroid adenoma (more than 90% of neoplasm) - Follicular adenoma 3) Thyroid carcinoma - Papillary carcinoma (\>85%) - Follicular carcinoma - Medullary carcinoma - Anaplastic carcinoma

Answer 429

Involves entire thyroid gland Two stages i) Hyperplastic stage (enlarged follicles filled with colloid) ii) Colloid involution -\> long standing ones may convert to multi nodular goitre

Answer 430

Thyroid hyperplastic - Endemic due to compensatory increase in TSH (e.g. Poor nutrition, lack of iodine in diet)

Answer 431

long-standing simple goiter convert into multi nodular goiter Symptoms: - Toxic or non-toxic - Most patients are euthyroid or with subclinical hyperthyroidism

Answer 432

Thyroid hyperplastic : Nodular hyperplasia with variably sized colloid-filled follicles

Answer 433

- forms fibrous capsule (benign) - Hurtle cell change

Answer 434

1) Papillary carcinoma (\>85%) 2) Follicular carcinoma (5% - 15%) 3) Anaplastic carcinoma 4) Medullary carcinoma

Answer 435

EXCELLENT PROGNOSIS; 25-50 yo Risk factor: ionizing radiation exposure Symptoms: - asymptomatic thyroid nodules - mass in cervical lymph nodes - hoarseness, dysphagia, cough, dyspnoea

Answer 436

- Orphan annie eye Nuclear inclusions - Nuclear grooves - Papillary structure - Psammoma bodies - multinucleated giant cells - over-lapping ground-glass nucleus

Answer 437

40-60 yo; Female: male= 3:1

Answer 438

SAME AS FOLLICULAR ADENOMA - encapsulated - Hurtle cell change - Malignancy defined by \*\*Vascular invasion and \*\*capsular invasion

Answer 439

Prone to haematogenous metastasis (bone, liver, lungs)

Answer 440

65 yo, Mortality rate approaching 100% Preceding or concurrent well-differentiated thyroid carcinoma Histologically: markedly pleormorphic cells/spindle cells/squamoid cells

Answer 441

Derived from parafollicular C cells -\> secrete calcitonin 70% sporadic and remaining as MEN syndrome (MEN 2a and 2b)

Answer 442

1) Surgical (thyroidectomy) 2) Hormone replacement 3) Radiotherapy for ablation 4) Serum thyroglobulin level for monitoring relapse

Answer 443

PRIMARY: 1) due to thyroid gland insufficiency: - congenital absence of thyroid tissue - autoimmune destruction of thyroid tissue (e.g. Hashimoto's thyroiditis, Fibrous atrophy of thyroid) - surgical removal of thyroid tissue - radio ablation of thyroid by radioactive iodine - tumour (Thyroid Follicular adenoma) 2) due to Impaired thyroid hormone synthesis: - iodine deficiency - Goitrogens (cabbage) - congenital enzymatic defects - drug mediated inhibition SECONDARY: - Insufficient secretion of TRH or TSH (e.g. hypothalamic tumour or pituitary non-functional macroadenoma, Sheehan's, etc.)

Answer 444

Primary: Low free T4 and elevated TSH (feedback), may present with goitre Secondary: Low TSH leading to low free T4, no goitre

Answer 445

1) Cretinism in Infant: delayed/incomplete physical and mental development -\> IRREVERSIBLE mental retardation and dwarfism 2) Youth: impaired physical growth 3) Adult onset: \*\* myxedema - decreased basal metabolic rate, cold intolerance, lack of energy and tiredness (decrease Na/K ATPase) - Anorexic, weight gain - bradycardia, decrease in cardiac output - slowing of mental function and motor activity (decreased catecholaimine response and Na/K ATPase) - goiter (in primary due to TSH increase) - dry skin (reduced sebaceous gland activity) - constipation (⇩GI tract motility & secretion) - menorrhagia, amenorrhea

Answer 446

Characteristic of hypothyroidism -\> due to deposition of glycosaminoglycan Mechanism: accumulation of mucopolysaccharides, hyaluronic acid and chondroitin sulphate (highly hydrophilic molecules) that retain fluid in the subcutaneous area - Facial puffiness and periorbital swelling - Peri-orbital haemorrhage is due to increased fragility of swollen dermal tissues

Answer 447

In primary hypothyroidism, thyroid hormone production decreases this results in increased TSH release (less negative feedback) TSH acts on thyroid, stimulating follicular cell proliferation and increasing colloid production (hypertrophy)

Answer 448

Middle-aged women - Diffusely enlarged thyroid -\> Progressive thyroid enlargement - (early phase of hyperthyroidism) -\> euthyroid -\> hypothyroid COMPLICATIONS: - Tracheal compression, especially when thyroid is retrosternal - Malignant lymphoma (diffuse large B cell lymphoma)

Answer 449

Cell mediated autoimmune reaction against the thyroid cells - parenchymal destruction Thyroid enlargement is a result of lymphoid infiltration and TSH-stimulated proliferation TSH is elevated due to ineffective production of thyroid hormones (Hurthle cell change) in thyroiditis

Answer 450

1) Thyroid function tests (TSH, T3, T4) 2) Antithyroid antibodies assay i) anti-thyroglobulin ii) anti-thyroid (microsomal) peroxidase antibodies

Answer 451

antibodies usually measured clinically as a confirmatory test for autoimmune thyroiditis (Grave's, Hashimoto's, and fibrous atrophy of thyroid) i) anti-thyroglobulin ii) anti-thyroid (microsomal) peroxidase antibodies

Answer 452

- Observe and wait (early period) - Replacement thyroid hormone - Surgery, to relieve pressure effects (especially for retrosternal goiter), or for cosmetic reasons

Answer 453

Enlarged thyroid follicular cells - eosinophilic, full of mitochondria, but with ineffective hormone production - e.g. in Hashimoto's thyroiditis, and Thyroid Follicular adenoma

Answer 454

Variant of Hashimoto's thyroiditis

Answer 455

autoimmune thryoiditis AKA idiopathic myxedema: - progressive shrinking of the thyroid gland - loss of epithelium and follicles; oxyphilic and squamous metaplasia of follicular cells - dense infiltration by sensitized lymphocytes and plasma cells - Chronic inflammation - final replacement of the gland by keloid tissue-like fibrous tissue (when 90% gland destroyed -\> hypothyroidism) - increased TSH, but with no hyperplastic effect - inability to respond to TSH suggests that blocking antibodies exist in this disease which compete with TSH for its receptors

Answer 456

Antibodies directed against thyroglobulin and microsomal antibodies, detectable years before the onset of hormonal failure, and cell-mediated immune mechanisms contribute to the pathogenesis

Answer 457

1) Granulomatous thyroiditis - TB, fungal infections - subacute granulomatous (De Quervain’s) thyroiditis 2) Drug induced thyroiditis 3) Radiation thyroiditis

Answer 458

aka subacute granulomatous thyroiditis Follows a viral URT infection Pain and tenderness, enlarged thyroid Self limiting

Answer 459

Invasive fibrous thyroiditis -\> IDIOPATHIC - May be mistaken clinically for malignancy because: Hard and adherent to surrounding soft tissues; and Fibrosis may compress the trachea or esophagus - May remain stable over many years, or it may progress slowly and produce hypothyroidism - May be associated with multifocal fibrosis (IgG4-related disease) - May overlap with autoimmune thyroiditis

Answer 460

1. Graves’ disease (diffuse toxic goiter, autoimmune hyperthyroidism) 2. Hashimoto’s thyroiditis 3. Fibrous atrophy of thyroid (idiopathic myxoedema)

Answer 461

1) Grave's disease 2) Toxic Adenoma 3) Toxic Multinodular Goiter 4) TSH-Secreting Pituitary Adenoma

Answer 462

- exophthalmos - increase in basal metabolic rate, heat intolerance, sweating, warm and moist skin - Tachycardia - weight loss, very hungry - tremour - diarrhoea - nervousness

Answer 463

an autoimmune disorder characterized by a variable combination of hyperthyroidism, goitre, ophthalmopathy (exophthlamos) and dermopathy (\*\*Pretibial myxoedema), DIFFUSE INVOLVEMENT OF thyroid - production of autoantibodies that bind to and activate the TSH receptor, promoting TH secretion and growth of the thyroid gland Autoantibodies: - thyrotropin receptor antibodies (TRA), - thyroid stimulating immunoglobins (TSI), and - thyroid growth stimulating immunoglobins

Answer 464

smoking, high dietary iodine intake, stress and infections.

Answer 465

Eye lid retraction and protrusion of eye balls (in Grave's Disease) - T cells and autoantibodies reactive to the extraocular eye muscles and retro-orbital tissues =\> inflammation and swelling (tissue deposit) of the extraocular muscles and orbital fat, eyelid retraction, periorbitaledema =\>swelling of soft tissues within the confines of the orbits precipitated by fibroblast growth and inflammatory cell infiltration.

Answer 466

- Keratoconjunctivitis =\> blindness - Compression of optic nerve =\> blindness

Answer 467

Pretibial myxedema: - Localized non-pitting edema of skin - Hyaluronic acid accumulates in dermis and subcutis

Answer 468

HLA-DR3 HLA-B8 (25% concordance in identical twins)

Answer 469

Positive thyrotropin receptor antibody at end of treatment predicts disease recurrence

Answer 470

solitary, autonomously functioning thyroid neoplasm (uncontrolled growth of abnormal tissue or tumor) that synthesizes and secretes excessive amounts of TH -\> hyperthyroidism

Answer 471

- composed of multiple autonomously functioning thyroid nodules that synthesize and secrete excessive TH (Like Grave's, but NODULAR FOCI) - common in old people -\> hyperthyroidism; goiter with multiple palpable thyroid nodules

Answer 472

1) TSH immunoassay (all primary are TSH suppressed; increased in secondary from TSH secreting pituitary adenoma) 2) Thyroid function test (test serum T3 T4) to check underlying cause: 3) screening for autoantibodies 4) radioactive iodine uptake assay 5) thyroid ultrasonography

Answer 473

MEN1: MEN1 encoding MENIN MEN2a, 2b: RET gene

Answer 474

A group of genetically inherited diseases resulting in proliferative lesions (hyperplasia, adenomas, and carcinomas) of multiple endocrine organs - Younger age of onset - Multiple organs - Agressive and recur

Answer 475

MEN1: - pituitary tumour, frequently prolactinoma - parathyroid hyperplasia/adenoma - pancreas endocrine tumour MEN2a: - Parathyroid hyperplasia - Pheochromocytoma - Medullary thyroid carcinoma MEN2b: - Pheochromocytoma - Medullary thyroid carcinoma - Neuromas or ganglioneuromas of the skin, oral mucosa, eyes, respiratory tract, and gastrointestinal tract

Answer 476

Prophylactic thyroidectomy is generally recommended

Answer 477

Minor depression disorder - less severe symptoms - short duration Major depression disorder - severe symptoms that interfere with function - more than 2 weeks Dysthymic disorder - less severe symptoms - more than 2 years

Answer 478

Monoamine hypothesis - caused by dysfunction or deficiency of monoamine neurotransmitters (decreased synaptic availability) Neurotrophic hypothesis - caused by dropped Brain Derived Neurotrophic Factor BDNF, leading to impaired growth of neurons -\> loss of hippocampal volume

Answer 479

Monoamine - monoamine level improve immediately with drug, but depression not immediately cured - removal of monoamine precursor does not cause depression Neurotrophic - BDNF knock out mice does not experience depression

Answer 480

1) Hallucination (5 senses perception without stimulation) 2) Delusion (believe in untrue things) 3) Confused and disturbed thoughts (rapid random constant speech, with abrupt stop and change in direction) 4) A lack of insight and self-awareness

Answer 481

1) Psychological problems - Schizophrenia - Bipolar disorder - severe depression or stress - lack of sleep 2) Medical condition - Stroke - Hyponatremia - CNS tumour - neurosyphilis - HIV encephalitis 3) alcohol or drugs - cocaine, ketamine, LSD

Answer 482

Dopamine hypothesis - Excess dopamine interrupts the mesolimbic and mesocortical pathways responsible for memory, social behaviour, emotion, self awareness

Answer 483

Gorss 1) Diffuse parenchymal goitre 2) Beefy red colour of thyroid gland Histo 1) Hyperplastic follicle (from cuboidal turned to low columnar or squamous) with papillary infolding 2) Scanty colloid content; patchy lymphocytoc infiltration 3) Increased vascularity

Answer 484

FEEDBACK: correct ongoing movement when deviate from intended movement FEEDFORWARD: modify central programs so that subsequent movement fulfil goal with few errors

Answer 485

Operation on molar teeth or mandible eg sublingual glands -\> loss of general sensation to anterior 2/3 tongue -\> loss of secretomotor and special taste to anterior 2/3 tongue IF distal to joining of chorda tympani

Answer 486

Anterior branch of middle meningeal artery, may produce haematoma and cause death due to raises ICP

Answer 487

Primary damage: sudden acceleration or deceleration, focal impact Secondary: alteration of cerebral blood flow and ICP

Answer 488

1) plain skull X-Ray -\> USELESS low diagnostic value since can only visualise skull fractures -------- Not all patient need neuroimaging, so only perform following if proper identification 2) conventional CT + more available than MRI + relatively cheaper than MRI + short time + great for bone and acute subarachnoid and parenchymal hemorrhage - still costly - image quality problems due to metal objects - miss small amt of blood - CT comes late after intracranial damage - radiation 3) MRI + greater sensitivity in chronic settings eg after surgery + better than CT for detecting axonal damage, subtle changes + better for brainstem, basal ganglia and thalamus - more costly and inaccessible

Answer 489

Based on New Orleans Criteria or Camadian Head CT rules: \*) low Glasgow Coma Scale 1) vomiting and headache (not for children) 2) amnesia esp longer and severe 3) ethanol or drug intoxication 4) Age greater than 60 or 65 5) maybe Coagulopathy/ anticoagulant use 6) sign of basal skull fracture

Answer 490

Glasgow coma score of 15/15 CT After TBI: 1) headache 2) vomit 3) age greater than 60 4) drug or alcohol intoxication 5) persistent anterograde amnesia 6) visible trauma above clavicle 7) seizure

Answer 491

1) GCS \<15 2) 65 yo 3) vomit X 2 4) signs of basal skull fracture 5) suspected open or depressed skull fracture 6) amnesia 7) dangerous impact mechanism eg fall from more than 5 stairs, ejected from motor vehicles, struck by vehicle

Answer 492

Eye opening Verbal ability Motor ability

Answer 493

- Racoon eyes - Battle's sign - Hemotympanum - CSF otorrhea or rhinorrhea

Answer 494

- incomplete eye closure (obicularis oculi) -\> exposure keratitis and ectropion - incomplete mouth closure (obicularis oris), sagging mouth corner, dribbling saliva - alteration of anterior 2/3 tongue taste (chorda tympani) - hyperacusis (stapedius)

Answer 495

Intensive pain in facial area due to vascular compression upon trigeminal nerve root -\> suicidal disease

Pathology Flashcards

(522 cards)