UWORLD Notes April 29 2016 (Usmle Grassroots)

August 24, 2017 | Author: Bhuvana Usmle | Category: Angina Pectoris, Heart Failure, Heart, Hepatitis, Vasodilation
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Notes

Pathology

Miscellaneous (Multisystem)

A renal mass that is composed of fat, smooth musscle, and blood vessels. The pt is most likely to have additional finidng of *brain Hamartomas and ash-leaf skin pathches* [Angiomyolipoma, associ with Tuberous Sclerosis]

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Pathology

Renal, Urinary Systems & Electrolytes

Antibodies detected in the serum of a young male are found to react with teh alpha3-chain of collagen type 4. The pt is most likely to have *Hemoptyis and Oliguria* [Goodpasture disease,Anti-GBM antibody]

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Histology

Renal, Urinary Systems & Electrolytes

In PSGN there is deposition of IgG, IgM, an *C3*, thus producing a star-sky appearance on immunolfourescent microscopy.

Pathology

Renal, Urinary Systems & Electrolytes

Pt with recurrent, self-limited painless hematuria "within days" after an upper respiratory infection has Ig A nephropathy. Kidney biopsy will show *Mesangial Deposits of IgA*

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Pathology

Renal, Urinary Systems & Electrolytes

PSGN: 1)Enlarged, hypercellular glomeruli on light microsc 2) Lumpy-Bumpy granular deposits of IgG & C3 on immunofluorescence 3) Electron dense deposits (Humps)on epithelial side of the basal membrane on electron micros

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Pathology

Renal, Urinary Systems & Electrolytes

In post-strep Glomerular Nephritis there is *DECREASED SERUM C3*

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Pathology

Nervous System

HIV pt with diffuse cortical atrophy and CT scan shows enlarged ventricles. The Hydrocephalus is secondary to the cortical atrophy and hence termed *Hydrocephlus Ex Vacuo*

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Histology

Nervous System

Pt with 1 week history of hemiplegia, expressive ahagia and CT that shows hypodensity in his brain probably had an ischemic brain infarct. Histologic finding after stainling for lIPIDS would produce cells marked densely for lipids which are the *MICROGLIA* and the lipids are from breakdown prduucts that werephagocytosed.

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Pathology

Renal, Urinary Systems & Electrolytes

Pt with signs of Nephrotic syndrome would a seconday change of *Increased Live Lipoprotein Synthesis*

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PathophysiologyCardiovascular System

Bicsupid aortic valve can lead to *aortic stenosis by 50 years old. *

Embryology

Cardiovascular System

Cyanosis in transposition of the great vessels is classic. This condition is due to failure of Septation. Failure of the aorticopulmonary septum to spiral. It can be conducive to life only if accomanied by another condition that allows mixing of blood. E.g Patent ductus arteriosus which presents with machine like murmur.

Cardiovascular System

Pt with episodic and transient anginal chest pain, occuring during night time hours and accompanied by temporary ST-segment elevations. Pt chest pain would be provoked by *Ergonovine* [Prinzmetal Angina] [Ergonovine is an egot alkaloid that constricts vascular smooth muscle by stimulating both adrenergic and serotonergic receptors, low doses inudce coronary spasm in pts with prinzmetal angina]

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Pharmacology

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Pathology

Cardiovascular System

Pt with chest pt shows near-toal-occlusion of LAD artery. The absence of myocardial necrosis and scarring despite vessel occlusion in this pt is explained by the *Slow Growth Rate* of the occluding plaque. (arterial collaterals have developed around point of occlusion)

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Pathology

Cardiovascular System

Light Microscopic changes of ischemic myocyte after 12 days is *Granulationtissuewithneovascularization*

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PathophysiologyCardiovascular System

In myocardial ischemia, the depletion of ATP in critical cellular areas results in loss of contractility within about *60 seconds* of total myocardia ischemia.

Pathology

Cardiovascular System

Pt with dyspnea and chronic exertional angina is evaluated for coronary revascularization. His Echho shows Hypokinesia of the anterior wall of the left ventricle and a left ventricular ejection fraction (LVEF) of 35%. The pt undergoes coronary artery bypass grafting. Repeat eccho 10 days later shows that hypokinesia is no longer evident and LVEF increased to 50%. The best explanation for the changes in cardiac contractility is *Hibernating Myocardium* [Due to chronic ischemia

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Microbiology

Infectious Diseases

A population that is universally vaccinated with recombinent HBsAg. The disease that would almost entirely disappear is *Delta Agent Infection* {Hep D causes infection only when encapsulated with HBsAg, it is a replication-defective RNA virus]

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Microbiology

Infectious Diseases

Hepatitis that causes high incidence of fulminant hepatitis in pregnant women with high mortality (20%) is hep E which is an *unenveloped RNA virus* spread thru fecal oral route.

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Pathology

Gastrointestinal & Nutrition

A cavernous Hemangioma is the MC benign liver tumor. Typically in adults 30-50 years.

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Pathology

Pt with chronic hepatitis C, a large hepatic mass and multiple Gastrointestinal & Nutrition satelite lesions has hepatocellular carcinoma. The marker for recurrenc is *ALPHA FETOPROTEIN*

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Pathology

Moldy grains from asia that cause specific G-to-T mutation in gene Gastrointestinal & Nutrition p53. This is aflatoxin exposure, the mutation of which can increase risk for developing *Hepatocellular Carcinoma*

Pathology

Hematology & Oncology

Pt dies from liver disease. Both changed and unchanged hepatocytes domonstrate foreign DNA Fragments integrated into their genome. These fragments likely belong to *Hep B virus* [Hep C is RNA virus and has no reverse transciptatse and does not integrate into host genome]

Microbiology

The prsence of a fluid-filled cavity in liver in conjuction with fever, chills and RUQ pain. Microorganism/route combinations that is Gastrointestinal & Nutrition most likely cause is *Staph Aureus via Hematogenous route* [Hepatic Abscess caused by staph]

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Pathology

Nervous System

In Wernicke-Korsakoff syndrome, when thiamin infusion is started, the nuerologic deficit that most likely to persist despite treatment is *Memory Loss*

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Biochemistry

Nervous System

Pt presents for exertional dysnpnea and fatigability. On P.E her gait is unstable when her eyes are closed and tehre is impaired vibratory sensation in the lower extremities. There is marked Pallor in conjunctiva, nail beds, and palms. The lab test that would confirm Dx is *Serum Methylmalonic acid* [Vit B12 Def]

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Biochemistry

Gastrointestinal & Nutrition

Gallstones caused by the use of fibrates for dyslipidemia are caasued by decreased activity of 7-lpha-hydroxylase.

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Pathophysiology

Pregnancy, Childbirth & Puerperium

Pregnant woman who develops Cholelithiasis is due to *Estrogen-induced Cholestrol hypersecretion & Progestrone-inducedgallbladderhypomotility*

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Pathology

Gastrointestinal & Nutrition

Pt with slow and incomplete gallbladder emptying (gallbladder hypomotility) is at risk of developing a *Billiary Sludge*

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Pathology

Cardiovascular System

MI in the setting of normal coronary arteries. Mitral valve thickening with vegetations is noted. Pt cardiac condition is most likely associated with *SLE* (Libman-sacks endocarditis (verucous endocarditis) occurs in 25& of sle pts. SlE may cause acute coronary syndrome at young age even with normal coronary arteries)

Cardiovascular System

Pt comes in with fatigue and shortness of breat. Recently he noticed bilateral leg swelling and abdominal distention. Pt dies despite Tx. Autopsy shows significant endocardial thickening with dense fibrous deposits around the tricuspid and pulmonary valves as well as moderate pulmonary valve stenosis. The left sided cardiac chambers and valves are normal. Measuring levels of *Urinary 5-hydroxyindoleacetic acid* would ve helped in diagnosing pt [Carcinoid Sydnrome]

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Pathology

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PathophysiologyGastrointestinal & Nutrition

Pt with cholestrol gall stones would have *High cholestrol, low bile salts and low Poshatidylcholine* in the gallbladder.

Pt with severe right upper quadrant tenderness and laprascopic surgery that reveals an erythematous, distended gallbladder with Gastrointestinal & Nutrition patchy necrosis probably has acute calculous cholecystitis which usuallu results from a *Gallbladder outflow obstruction* due to gallstone obstruction of cystic duct.

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Pathology

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PathophysiologyGastrointestinal & Nutrition

The diagnostic test most specific fro acute cholecystitis is *Failed gallbladder visualization on radionuclide billary scan*

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Pathology

Cardiovascular System

MCC of sudden cardiac deaths in young persons is *Hypertrophic cardiomyopathy*

Cardiovascular System

Presentation of "Sudden Cardiac Death" in young pt with family history of SCD and autopsy finding of septal hypertrophy suggest Hypertrophic CardioMyopathy which is Autosomal Dominant in whcih there are mutations in sarcomere genes. These include *Beta-Myosin Heavy Chain* and Myosin-binding protein C.

Pathology

Cardiovascular System

Young pt with an episode of syncope that was not provoked by any activity. No significant past medical history and no medications. ECG shows QT-interval prolongation. Assuming this is an inherited condition, the relevant mutations likely affects *Membrane Potassiumchannelproteins* [sudden cardiac arrhythmia, QT interval reflects cardiac myocyte action potential duration which is determined in part by K+ current]

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Pathology

Pt with a mass obstructing the iliocecal valve with a high cholestrol content. A radiographic finding conistent with this presentation Gastrointestinal & Nutrition would be *Air in the billary tree* (Gallstone ileus, gallstone penetrated intestine and lodged)

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Pathology

Cardiovascular System

6 year old pt with Long QT interval and with family histo of sudden death probably has congenital long QT syndrome and can have an associated*Neurosensorydeafness*

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Pathology

Cardiovascular System

Localized amyloid in the atria of heart is amyloid derived from Naturiretic peptide.

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PathophysiologyCardiovascular System

Pt with Hypotension, tachycardia, Jugular venous distension with clear lungs and Pulsus Paradoxus (loss of palpable pulse during inspiration) is consistent with *Cardiac Tamponade*

Pathology

Acute-onset, mid-chest pleuritic pain that decreases on sitting up and leaning forward is characteristic of acute pericarditis. Fibrinous or serofibrinous pericarditis is the most common form. Pericardial *Friction Rub* is the most striking physical finding.

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Pathology

Cardiovascular System

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Pathology

Pathology

Microbiology

Microbiology

Microbiology

Immunology

Microbiology

Cardiovascular System

Pt died. Autopsy is done. Gross inspection of heart shows shows dense thick fibrous tissue in the pericardial space between bisceral and paretal pericardium. The most likely sign that would ve been detected during physical exam is *Kussmaul Sign* [Constrictive Pericarditis]

Dermatology

Pt with skin rash. He noticed it while in beach resort. He is works in hot humid areas. Skin finding is shown (image). Most likely cause is *Malassezia globoss* [Pityriasis versicolor]

Infectious Diseases

Mucormycosis is an opportunistic infection caused by Rhizopus, Mucor, and Absidia. Clinical picture is paranasal involvememnt in diabetic or immunocompromised patient. Fungi form broad nonseptate hyphae at 90 degree angles!!

Infectious Diseases

Pt with signs of diabetic ketoacidosis together with Black Necrotic Escha on nasal cavity examination, facial pain, & headache probably has "Mucormycosis" and Diagnosis can be made with *Mucosal Biopsy* to see borad-ribbon-like nonseptate hyphae with right-angle branching.

Infectious Diseases

Oral thrush (can be scaped off) in an otherwise healthy pt is suggestive of immunosuppression and HIV should be suspected. Therefore, Medical history can be focused on *Sexual Practices*

Infectious Diseases

Pt with HIV history whose "bood" cultures grow psuedohyphae producing yeast species with ability to form germtubes. This pt probably has "Cadidemia" (disseminated candida infection). Development of Candidemia is directly contributed by a *Low Neutrophil Count* Note: Superificial Candida Infection is contributed to by a "Low T-lymphocyte count"

Nervous System

HIV pt infected with organism stained with india ink in CSF showing spherical yeast with thick capsules (C.neoformans). Most likely primary foucs is *Lungs* [found in pigeon droppings and soil, enters thru resp route]

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Microbiology

Nervous System

Pts with headache and fever. CSF has low glucose and high protein. Microscopy shows transparent capsules on india ink is suggestive of Cryptococcal meningeoencephalitis. Tx with Amphoterain B. `

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Microbiology

Pulmonary & Critical Care

An organism's capsule that stains red on Mucicarmine staining is the capusle of *Cryptococcus Neoformans*

Nervous System

Pt with Hx of viral encephalitis and pneumocystis pneumonia most likey has HIV and if they present with signs of meningitis with latex agglutination positive for soluble polysaccharide antigen probably has Cryptococcal meningitis and you should expect *Budding yeast* on light microscopy. Pt with flue like symptoms and lung symtoms of crackles and pulmonary infiltrate who works a capenter and suptum KOH preparation shows "Broad Based-Bud" most likey has *Blastomyces Dermatitidis*

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Microbiology

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Microbiology

Pulmonary & Critical Care

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Pathology

Pt who is in shock and Hb level drops from 14 to 12. Nasogastric Gastrointestinal & Nutrition suctioning reveals bright red blood. Pt's bleeding is most likely a result of *Physiologic strss*

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Physiology

Gastrointestinal & Nutrition

*Intestinal Influences* help Down-Regulate gastric secretions after a meal.

Tumor of cells heavely loaded with mucus that has metastasized to the ovaries suggests adenocarcinoma of the *Stomach* Classicly they are mucin-producing signet-ring neoplastic cells in ovarian stroma. (Krukenberg tumor)

Histology

FemaleReproductive System & Breast

Anatomy

submucosal glands that have alkaline secretions in Gi endoscopy probably are the Submucosal (Brunner) glands which can be Gastrointestinal & Nutrition found at the *First part Duodenum* (ampulla of vater) and the Pylorus.

Pathology

Pt presents with abdominal discomfort, greasy stool, and weight loss. He has been treated for joint pain with Ibupropfen. Intestinal biopsy shows multiple macrophages loaded with PAS-positive Gastrointestinal & Nutrition granules in the lamina propria. This pt shud be Tx with *Antibiotics* [Wipple disease caused by g+ve actinomycete Tropheryma whippelii]

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Pathology

The *Glycoprotein* in cell walls of actinomycete Tropheryma whippeli colors magenta with PAS and is diastase-resistant, Gastrointestinal & Nutrition making this stain an excellent choice for evaluating tissue for whippledisease.

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PathophysiologyGastrointestinal & Nutrition

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Pathology

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Pharmacology

Lactase deficeiency causes osmotic diarhea and *Acidification of stool*

Gastrointestinal & Nutrition The NF-kB factor pathway stimulates *Cytokine Production* Cardiovascular System

Nitrates activate guanyl cyclase and increase levels of intracellular cGMP which leads to *dephosphorylation of myosin light chain* leading to relaxaton and hence vasodilation of vessel.

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Pharmacology

Cardiovascular System

At low doses, Nitroglyerin acts as a VENO-DILATOR, *Large Veins* are the most Susceptible. Vasodilation causes decreasd preload becuase blood collects in the venous system.

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Pharmacology

Cardiovascular System

Sublingual nitreates *Decrease left Ventricular Volume* [Thru venodilation and hence decreasing preload]

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Pharmacology

Cardiovascular System

Adverse affect of nitrates is *HEADACHE* !!

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Pharmacology

Cardiovascular System

Pt with signs of hypertrophic cardiomyopathy (family history of premature sudden death, systolic mumur). Due to the left ventricular outflow obstruction, avoid drugs that reduce ventricular volume such as vasodilators and diuretics. An example of a vasodilator is *Isosorbide dinitrate*

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Pharmacology

Cardiovascular System

Pts taking daily nitrates need to have a nitrate free period to prevent tolerance to the drug

Cardiovascular System

The reason why Verapamil has no effect on skeletal muscle contractility is because skeletl muscle has *No dependence on extracellular Ca influx*

Cardiovascular System

Pt with A fib and CHF that is on multiple medications and develops nausea, decreased appetitte and "Vison difficulties" and lab finding of "Hyperkalemia" probably is on *DIGOXIN*

Pharmacology

Cardiovascular System

Milrinone is a phosphodiesterase-3 inhibitor that leads to an increase intracellular cAMP which promotes intracell Ca influx and increase cardiac contractility. An increase in cAMP in vascular smooth muscle cells cause systemic *Vasodilation*

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Pharmacology

Renal, Urinary Systems & Electrolytes

With with Diabetes showing peripheral neuropathy and increased urinary albumin excretion. He has high BP. Best Pharm therapy for HTN for hypergylcemic pt with microalbuminurea is ACE and Arbs. E.g: *Lisinopril*

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Pharmacology

Cardiovascular System

A major complication of digoxin tox is Life threatenig *Arrhythmias*.

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Physiology

Pharmacology

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Pharmacology

Endocrine, Diabetes & Metabolism

A drug that can massively decrease Triglycerides is *Fenobirate*

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Pharmacology

Endocrine, Diabetes & Metabolism

Acute falre of gouty arthritis (-ve birefringent crystals) can be due to Tx with *NIACIN*

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Pharmacology

Pulmonary & Critical Care

Pt on glucocorticoids for asthma should be advised to perform *Oral Rinsing* to avoid side effects of medication. (if drug lodges in oral mucosa, it can candiasis)

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Pharmacology

Pulmonary & Critical Care

Drug that revereses irritant induced brochoconstriction but does not work in vagectomized animals (meaning drug has effect on vagus nerve) is probably *IpraTROPium* which is a muscurinic antagonist. It combats the release of Ach due to vagus nerve stimulation.

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Pharmacology

Pulmonary & Critical Care

Inhaled Cromolyn is used in Asthma. It *Inhibits Mast cell degranulation*

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Pharmacology

Poisoning&Environmental Theophylline toxicity leads to *Seizures and Tachyarrhythmias* Exposure

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Pathology

Cardiovascular System

*Mitochondrial Vacuolization* indicates irreversible cell injury.

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Pathology

Cardiovascular System

Pt wih increased thickness of left ventricular wall and decreased left ventricular cavity size have concentric cardiac hypertrophy. This is associated with *Long standing HTN*

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Physiology

Cardiovascular System

During Systole, there is decreased blood flow to the *Left Ventricular Myocardium*

Cardiovascular System

Pt with lungs that reveal macrophages containing golden cytoplasmic granules that turn dark blue with Prussian blue staining. Prussian blue detects intracellular Fe. This is consistent with hemosiderin laden macrophages (heart failure cells). This presenc indiacates chronic elevation of hydrostatic pressure most commonly as a result of *Left Ventricular Dysfuction* (i.e left-sided heart failure)

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Pathology

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PathophysiologyCardiovascular System

In isolated diastolic heart failure there is *Increased LV end-diastolic pressure, normal LV end-diastolic volume, and Normal LV ejection fraction*

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PathophysiologyCardiovascular System

Pt with VSD would also have a *Holosystolic murmur over the left sternal border*

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Pathology

Cardiovascular System

ASD is assocated with *Down Syndrome*

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Pathology

Endocrine, Diabetes & Metabolism

Pt with xanthelsama (xanthomas on medial eyelids). Best next step is *Serum lipids and glucose*

Cardiovascular System

Pt with occlusion of "right" coronary artery causes acute MI. This could lead to Sudden Cardiac Death, the most common mechanism of death here is *Ventricular Fibrillation*

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Physiology

PathophysiologyCardiovascular System

PT dies due to MI. Autopsy show slit-like tear in infarcted myocardoum. This *typically occurs within 5-14 days after an acute MI* [Free wall rupture]

PathophysiologyCardiovascular System

12 year old with a wide, fixed splitting of second heart sound on routine physical exam. The congenital heart disease in this pt may require surgical repair to prevent irreversible changes in *Pulmonary Vessels* (ASD, Pulmonary artery develop laminated medial hypertrophy, irreversible)

Embryology

Pt with signs of a stroke and echocardiogram shows bubbles on left heart when agitated saline is inserted has an Patent Foramen Ovale due to *Incomplete fusion of atrial septum primum and secundum*

Cardiovascular System

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Physiology

Pharmacology

FemaleReproductive System & Breast

Pulsatile (every 90 mins 4e.g) adminstration of GnRh is indicated in Infertility (e.g Anovulation)

Endocrine, Diabetes & Metabolism

Leuprolide is GnRh Analog and can be used in treatment of prostate cancer. (metastasizes to vertebrae) On initial therapy with Leuprolide *Testestrone and DHT rise then fall with continued use*

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Pathophysiology

Endocrine, Diabetes & Metabolism

Primary (psychogenic) polydipsia is a psychological disorder characterized by increased intake of free water leading to hyponatremia and production of large volume of dilute urine. *Water restriction* will correct the serum Na levels and leads to increse in urine osmolality.

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Pharmacology

Hematology & Oncology

In

Pathology

Endocrine, Diabetes & Metabolism

Post delivery woman who presents with signs of panhypopituitarism with failure of lactation, central hypothyroidism, and adrenal insufficiency. Most likley represents *Ischemic necrosis* of pituitray gland (Sheehan Syndrome).

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Antipsychotics such resperidone block dopamine and can therefore allow prolactin release which can cause amenorrhea. Therefore, persons on respiridone can develop *Drug Induced Amenorrhea*. Breast tenderness is also seen here.

Endocrine, Diabetes & Metabolism

50 yr old man with sudden, severe headache. He complains of mild headaches and decreased libido. P.E shows bilateral deficits involving temporal visual fields and impaired extraoccular eye movements. Shortly after admittance he becomes hypotensive and dies. Mostlikely finding in autopsy is *pituitary hemorrhage* [Pituitart apoplexy]

Endocrine, Diabetes & Metabolism

Signs of Hyponatremia (altered mental status, headache, weakness, seizures) plus a lung mass suggest SIADH casued by small cell carcinoma. An additional finding would be *normal extraceullar fluid volume*. Regulatory mechanism in the body deal with the hyponatremia resulting a Euvolemic hyponatremia.

Cardiovascular System

Pt is fatigued. P.E shows lesions involving nail beds. Further evaluation would reveal additional abnormality during *Cardiac Auscultation* [Infective endocarditis reveals a mitral regurg murmur]

Cardiovascular System

Autopsy finding of platelet-rich thrombi attached to mitral valve leaflet. Most likely associated condition is *Advanced Malignancy* [nonbacterial thrombotic endocarditis, associated with advanced malignancy, especially mucinous adenocarcinoma]

Cardiovascular System

42 year old. Pt dies from stroke.SHe had history of diastolic murmur. Autopsy of left atrium shows diffuse fibrous thickening and distortion of the mitral valve laflets, commissural fusion at the leaflet edges and narrowing of the mitral valve orifice. The finding is most likely the restult of *Rheumatic fever*

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Pathology

Pathophysiology

Pathology

Pathology

Pathology

PathophysiologyCardiovascular System

The best indicator for mitral stenosis severity is *A2-to-opening snapp time interval* (shorter when more severe) (atrial pressure builds up causing more forceful opening of valve "snap")

PathophysiologyCardiovascular System

Mitral valve stenosis with *Increased left ventricular diastolic pressure* suggests that the mitral stenosis is acoompanied by an aoirtic valve problem such as stenosis or regurgitation. Both of which can increase LV diastolic press.

PathophysiologyCardiovascular System

The opening snap in mitral stenosis occurs shortly after the mitral valve opens when *the left ventricular pressure drops below the left atrial pressure*

PathophysiologyCardiovascular System

Head poudning and bobbing are associated with *Widening of pulsepressure*

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Pathology

Cardiovascular System

10 yr old boy presents with restlessness and involuntary kerking of face, arms & legs 3 months after a sore throat. Pt is at greatest risk fro developing *Valvular Heart Disease* [Sydenham chorea as part of Acute Rheumatic Fever after Group A strep infection]

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Pathology

Cardiovascular System

*Calcific Degenration* of trileaflet aortic valve is the most common cause of Aortic Stenosis in Developed Nations.

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PathophysiologyCardiovascular System

PT with aoric stenosis can develop pulmonary edema due to *Sudden decrease in LV preload* due to loss of atrial contraction that is due to atrial fib. `

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Behavioral science

Psychiatric/Behavioral & Substance Abuse

Buspirone is an nonbenzodiazepine anxiolytic used to treat Generalized Anxiety disorder. It has a SLOW ONSET. It lacks muscle relaxant or anticonvulsant properyes and carries no risk of dependence. It is a partial agonist of 5HT (1a)

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Behavioral science

Psychiatric/Behavioral & Substance Abuse

SSRI's & SNRI's are first line medication in generalized anxiety disorder. Benzos should be limited to short term use and for pts who respond poorly to antidepressants.

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Embryology

Miscellaneous (Multisystem)

Fetus that has closely set eyes, middline mass cosistent with a proboscis, fused cerebral hemispheres, and an absent forebrain fissure has Holoprosencephaly whicha type of *Malformation*

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Pathology

Pt with sharp pain and bright red rectal bleeding on defecation Gastrointestinal & Nutrition suggest an Anal Fissure. Which is at the *Posterior midline Distal to the Dentate line*

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Genetics

FemaleReproductive System & Breast

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Pathology

65 yr old man with iron def anemia. He has weight loss and anorexia. He has no change in bower habits. Rectal exam shows guaiac-positive brown stool. A 3cm mass is found on colonoscopy. Biopsy shows pleomorphic cells with large, dark nuclei forming Gastrointestinal & Nutrition irregular, crowded glands, some of which contain mucus. Studis show multiple mass lesions in the liver and lungs. Pt's neoplasm most likely originated from *Ascending colon* [Right sided colon Cancer]

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Pharmacology

Nervous System

Long treatment of Parkinsons with Levidopa renders *DRUG RESPONSEUNPREDICTABLE*

Nervous System

Entacapone *Increases the quantity of levodopa entering the brain* [It inhibits Catechol-O-Methly transferase, and hence prevents it degradation]

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Pharmacology

Pt with signs of Turner Syndrome is likey to have *Bicuspid Aortic Valve*

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Microbiology

Pulmonary & Critical Care

Pt returning from cave exploation i central USA develop fever, cough and malaise. Pulmonary infiltrates and hilar adenopathy are present on x-ray. Lung tissue specimen will show *Ovoid cells withinMacrophages* (Histoplasma Capsulatum)

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Microbiology

Pulmonary & Critical Care

Hiv pt with cough, fever, hepatosplenomegaly (sysetmic symptoms) and a bone marrow aspirate that shows small ovoid bodues wuthun a macrophage is caused by *HISTOPLASMA Capsulatum*

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Microbiology

Pulmonary & Critical Care

Exam of lung tissue that shows spherules oacked with endospores. Pt history will most likely reveal *Recent travel to Arizona* [Coccidoides Immitis][Southern and central California, Arizona, New Mexico, & Western Texas]

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Pharmacology

Infectious Diseases

*Nystatin* bind Ergosterol in fungal cell membranes

Pharmacology

Infectious Diseases

Adminstering Amphoteracin B (binds to ergosterol) has a risk of Renal Toxicity that could result in Severe hypokalemia and hypomagnesemia due to increased tubular permeability. Therefore, *Serum K & Mg levels* should be monitored.

Pharmacology

Renal, Urinary Systems & Electrolytes

The most dangerous adverse effect of Amhoteracin B is Nephrotoxicity which can be called *Renal Tubular Dysfunction* [pt presents with ECG finding of frequent premature ventricular beats, a finding due to kidney damage induced hypokalemia]

Pharmacology

Infectious Diseases

Fungus with mutations in genes coding for Cellwall enzyme would be resistant to *Capsofungin*, an antifungal that targets cellwall glucansynthesis.

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Microbiology

Dysphagia for liquids and difficulty belching in association with a diated esophagus and absent peristalsis in the smooth portion is Gastrointestinal & Nutrition diagnostic of Achalasia. If pt is from south america or central america suspect *T. Cruzi*

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PathophysiologyGastrointestinal & Nutrition Zenker Diverticulum is due to *Cricopharyngeal motor dysfunction*

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Pathology

Alcoholic male presents with hematemesis. Endoscopy shows longitudinal mucosal tears at the gastroesophageal junction. This pt Gastrointestinal & Nutrition condition is most likely related to *Intraabdominal pressure* [Mallory-Weiss syndrome]

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Pathology

Pt presents with anatcid resistant severe Heart Burn. P.E shows scattered Telangiectasias on face, several ulcers at tip of fingers, and small Ca deposits on hands and elbows. Most likely cause of pt heart burn is *Fibrous Replacement of the muscularis in the Gastrointestinal & Nutrition loweresophagus* [CREST syndrome, Calcinossi, Raynaud Phenomenon, Esophagealdysmotility,Sclerodactly,Telangiectasia] [Esophageal dysmoti is result of atrophy and "Fibrous replacement" of muscularis in lower esoph]

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Pathology

Gastrointestinal & Nutrition

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Anatomy

A peptic ulcer localized PROXimally on the lesser curvature Gastrointestinal & Nutrition probably penetrated the *Left gastric Artery* which is a branch of the celiac trunk.

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Immunology

Rheumatology/Orthopedics & Sports

Erosions are defined as mucosal defects that do not fully extend thru the *Muscularis Mucosa*

Pts with Lymphocytes with mutated Fas gene product (i.e Fas receptor) would have an impaired *Activation-Induced T Lymhocyte Death* Fas ligand that binds to Fas receptor on t cells activates Fas assoc death domian (FADD) which activates caspases leading to Apoptosis.

Physiology

FemaleReproductive System & Breast

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Anatomy

Laparotomy shows decreased angle between superior mesenteric artery and aorta. The structure most likley obstructed is Gastrointestinal & Nutrition *Transverse portion of duodenum* [Superior mesenteric artery syndrome]

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Pathology

Pt with paraital cell hyperplasia (Zollinger-Ellison) causing visible Gastrointestinal & Nutrition enlargement of gastric folds. The stimuli that caused this probably *Gastrin*

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Progestron withdrawal leads to menses (i.e bleeding) which is a result of *Apoptosis*

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Pathology

A pt with distal ulcer and high-normal gastrin levels that rise in response to secretin adminstration are suggestive of Zollinger-Ellison Syndrome. The is caused by gastrin-secreting Gastrointestinal & Nutrition tumors (Gastrinomas) which is a *Neoplasia* Usually secretin inhibits gastrin production.

306

Pt with systemic signs and rash with skin biopsy showing large clusters of mast cells positive for KIT probably has Systemic PathophysiologyGastrointestinal & Nutrition Mastocytosis and an additional finding will be *Gastric Hypersecretion*

308

PathophysiologyEar, Nose & Throat (ENT)

Symptoms of recurrent vertigo together with unilateral hearing loss is characteristic of Meniere's disease which there is *Increased pressure and volume of endolymph*

320

Embryology

Gastrointestinal & Nutrition

Pt with Imperforate Ausu often have *Urinary tract Abnormalities* accompanying the condition.

321

Embryology

Gastrointestinal & Nutrition Meckels diverticulum is an example of ECTOPY.

326

Pathology

Gastrointestinal & Nutrition Celiac disease is diagnosed with *Small intestine Biopsy*

327

Pathology

Infant with poor weight gain since birth. He has bulky and greasy stools. Jejunal Biopsy (Image) shows foamy or clear cytoplasm of Gastrointestinal & Nutrition enterocytes with normal mucosal structure. Dx is *Abetalipoproteinemia*

330

Embryology

Gastrointestinal & Nutrition

If neural crest migation to the intestine is interrupted by the final week (12 week) of migration, The *Rectum* would be affected.

Pathology

FemaleReproductive System & Breast

Woman comes for infertility evaluation. She complains of dyspareunia. Menstrual cycles are accompanied by moderate to sevee lower abdominal pain. Pelvic exam shows a normal-sized, retroverted uterus. The post vaginal fornix is very tender to palpitation. Pt's condition most likely involves *Ectopic Endometrial Tissue* [Endometriosis][Adhesions interfere with ovulation=infetolity][imaplantsandadhesionsinvolvinguterosacral ligament result in retroverted uterus, ligament]

337

Embryology

Pregnancy, Childbirth & Puerperium

Pregnant pt on anti-convulsants who presents with polyhydroamnios, fetus probably has *Anencephaly* due to antiepileptic medication whic is a risk factor for neural tube defects.

340

Pathology

Pt with recurrent nonpitting edema of hands, raynaud phen, and Rheumatology/Orthopedics retrosternal burning has CREST syndrome which would find & Sports *Anti-centromere* Antobodoes.

341

Pathology

Hematology & Oncology

Backpain that is constant (i.e not relieved by rest or positional changes) and that is worst at night is suggestive of *Neoplasm* as in spinal metastasis.

333

347

Pathology

Nervous System

1 month old infant brought due to difficulty awakening. Mother says he rolled off the bed. P.E shows lethargic biy with large full ant fontanlle. Bilateral retinal hemorrhages are seen on funduscopic exam. You should suspect *Abusive heard trauma* [Shaken baby sybcrome]

348

Pharmacology

Nervous System

Elderly pt with insomnia should be given *Ramelteon* which is a melatonin agonist. It is safe and effective. Avoid bezos, antihistaminesandsedatingantidepressants

349

Pharmacology

Nervous System

Benzo for insomnia with a lower rsik of tolerance and dependence is*Zolpidem*

350

Pharmacology

Psychiatric/Behavioral & Substance Abuse

First line therapy for pyschomotor agitation in Alcohol withdrawal is *Chlordiazepoxide* [Long acting benzo]

351

Pharmacology

Nervous System

Phenytoin is metablized by the P45O oxidase liver sysetm and therefore drugs that induce this sysetm will decrease levels of phenytoin. Such drugs include: Barbiturates, *RIFAMPIN*, carbamezapine, grieseifulvin, and chronic alcoho.

352

Pharmacology

Nervous System

Do not use DIazepam with CNS depressants such as *Chlorpheniramine* which is a 1st gen anti-histamine.

Nervous System

Pt with sudden episodes of severe, right-sided (Unilateral)facial pain (knife stabbing my face) that lasts several seconds (instigated by a meal or teeth brushing) with no other symptoms probably has Trigeminal Neuralgia. The DOC for Tx is *Carbamezapine*.Works like phenytoin by inhibiting high frequency firing by reducing the ability of Na channels to recover from inactivation. (Reduces pain). Side effects: aplastic anemia (check cbc) and drug interactions (p450 inducer)

354

Pharmacology

360

PathophysiologyOphthalmology

361

Biochemistry

363

*Absent Liver Conjugation enzymes* as seen in Criggler-najjar PathophysiologyGastrointestinal & Nutrition syndrome type 1 (UGT enzyme def) can cause Neurlogic abnormalities due to accumulation of unconjugated billirubin.

Acute and painless monocular vision loss is characteristic of *Central retinal artery occlusion* Fundoscopic findings include a pale retina with a "Cherry-Red Macula".

Rheumatology/Orthopedics SnRNA has the function of *removal of introns from RNA & Sports transcripts*

Pathology

Pt who recently travelled to south america. His liver biopsy shows spotty hepatocyte necrosis and inflammatory cell infiltration. Most likely clinical presentation of this pt is *Fever, Anorexia, and Gastrointestinal & Nutrition dar-colored urine* [Acute Hep A infection] [Dark color urine is due to increased conjugated bilirubin levels]

Histology

*Hep B* infection causes hepatocellular cytoplasm to to fill wih surface hep b antigen. The inclusions are (finely Gastrointestinal & Nutrition granular,homogenous, pale pink), dull eosnophilic,ground glass apearance. Commonly transmitted sexually or in "IV drug users"

368

Pathology

Pt dies from profuse upper gastrointestinal hemorrhage and gross examination of liver is shown after autopsy. This resulted from Gastrointestinal & Nutrition *Fibrosis and Nodular parenchymal regenration* of the liver. Pt probably died from Liver Cirhosis that led to portal HTN and eventualGIhemorrhage.

369

Pt who presents with nausea, fatigue, anorexia who recently had surgery. Pt is weak and incteric and later dies. Liver biopsy shows PathophysiologyGastrointestinal & Nutrition shrunken liver. Pt probably had Anesthetic Induced Hepatotoxicity due to Haloethane use during surgery. You would expect to also find a *Prolonged Prothrombin Time*

370

Pathology

Gastrointestinal & Nutrition

Immunology

Imigrant pt who is otherwise healthy and labfinding yiled Positive Anti-Hepatiitis A IgG. He was never vaccinated against hep A. Gastrointestinal & Nutrition Thi slab finidng suggest him having an *Anicteric viral infection as a toddler*

366

367

373

Alcohol induced hepatic steatosis is due to *Decreased Free fatty acidOxidation*

376

378

379

Microbiology

Immunology

Immunology

Infectious Diseases

Pt has fever and joint pain. He has abnormal lynphocytes on blood smear. Condition is caused by an enveloped virus containing partially-double stranded circular DNA. An enzyme packed in its virion has RNA-dependent DNA-polymerase activity. Pt is most likely infected with *Hep B virus*

Infectious Diseases

Presence of HBeAg (marker for viral replication and increased infectivity) in pregnant women with hep B infection increases the risk of vertical transmision to child.

Infectious Diseases

If HBeAg persists for several months and host ant-HBeAg remain at low or undetectable levels, suspect *Chronic Hep B with high infectivity*

382

Pathology

Renal, Urinary Systems & Electrolytes

Pt with colon cancer who has Nephrotic Syndrome (edema+proteinurea)with biopsyshowingglomerular cappillarywall thickening without increase in cellularity. When sample is stained with silver, irregular spikes from the GBM are seen. Pt has *MembranousGlomerulopathy*

385

Pathology

Renal, Urinary Systems & Electrolytes

Child with signs of nephrotic syndrome. Pathologic change that causes protein loss is *Glomerular podocyte damage* [Effacement of podyctes im Minimal Change Disease]

390

Pathology

Infectious Diseases

The most common outcome in HBV-Infected adults is acute hepatitis with mild or subclinical symptoms that eventually *completely resolve*

391

63 yr old woman died of congestive heart failure. Autopsy shows a dilated heart and brownish pigmentation of the myocardium. Light microscopy of liver after prussian blue is shown. The pt's brother PathophysiologyGastrointestinal & Nutrition died of upper GI beed at age 43. Assuming this pts condition is hereditary, what contributed to her delayed onset of symptoms is *Premenaupasual menstrual bleed* [Hemochromatosis]

394

397

Pathology

55 yr old caucasian male who is recently diagnosed with cardiac arrhythmias is found to have mild hepatomegaly. He also complains of a dark tan despite avoiding sun exposure. Pt most Gastrointestinal & Nutrition likely suffers from *Hemochromatosis* [Bronze diabetes, the triad of skin hyperpigmentation, DM, and pigmnet cirrhosis with hepatomegaly] 21 yr old man comes with impared balance, tremor, and diffculty speaking. Symptoms developed slowly over several months. Pt is found to have elevated serum transaminases. Viral Hep serologies are negative. His cousin was Dx at young age with progressive neuro disease. The Dx study most beneficial during work up is *Slit Lamp Exam* [Wilson Diseae]{Tx with D-penicilamine]

Pathology

Nervous System

401

Pathology

*Primary Biliary Cirrhosis is a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts and Gastrointestinal & Nutrition cholestasis (elevated alkaline phosphatase). The condition is most common in middle-aged women, with severe pruritis (especially at night) one of the first symptoms reported.

402

Pt with generalized pruritus and high alkaline phosphatase along with high titers of Antimitochondrial antibodies have Primary Billary PathophysiologyGastrointestinal & Nutrition Cirrhosis. Liver autopsy would morphologically resemble *Graft-vs-host disease*

403

Pathology

Liver biospy showing extensive lymphocyte infiltration and granulamatous destruction of interlobular bile ductis. Biopsy was Gastrointestinal & Nutrition most likely taken from a *45 yr old woman with a long history of pruritis and fatigue who has pale stools and xanthelasma* [Primary Billary Cirrhosis}

405

Pathology

Pt with abdominal pain, diarhea and heme-positive stools. Stool Gastrointestinal & Nutrition cultures are negative. Biopsy of colonic mucosa reveals non-caseating granuloma. Pt most likely has *Crohn's Disease*

406

Pathology

Gastrointestinal & Nutrition

Pathology

A finding most suggestive of Ulcerative colitis is *Continous Mucosalinvolvement* Gastrointestinal & Nutrition [Transnural inflam, rectal sparing, perianal fistula and noncaseating granuloma are all suggestive of crohn's disease]

410

Pathology

Pt with Ulcerative Colitis who comes due to worsening pain and bloody diarrhea. He has been non compliant with his medication. He has hypotension and tachycardia. Pt is lethargic and has dry mucus membranes. There is marked abdominal distention and Gastrointestinal & Nutrition tenderness without rebound or guarding. Rectal exam shows guaiac-positive, maroon-colored, liquid stool. Best next step in pt's workup is *Plain abdominal x-ray* [Toxic Megacolon assoc with UC]

411

Pathology

A differenc bewteen sporadic colorectal carcinoma and Gastrointestinal & Nutrition colitis-associated carcinoma is that colitis associated carcinoma is *Multifical in Nature*

413

Pathology

Pt with abdominal pain and bloody diarrhea following a complicated surgical procedure likely has acute nonocclusive Gastrointestinal & Nutrition ischemic colitis. Primary areas affected are the Splenic flexure and the *Rectosigmoid Junction*.

419

Embryology

MaleReproductiveSystem

Pathology

In the Adenoma-to-Carcinoma sequence in colon cancer, The increase in the size if the polyps that mediates the late adenoma Gastrointestinal & Nutrition part of thes sequence is a result of mutation of *K-ras* protooncogene. [APC > K-ras > p53]

407

421

423

Pathology

Hematology & Oncology

inflamed and swollen terminal ilieum is probably crohns disease in which there is involvement of TH1 helper t cells.

A patent processus vaginalis causes a communicating hydrocele. It can also cause an *Indirect Inguinal Hernia*

55 year caucasian male is found on colonoscopy to have a solitary mass in his sigmoid colon. Biopsy shows colon cancer. The feature that carries the worst prognosis is *Tumor Penetration into the Muscularis Propria* (Tumor staging, more imp than grade) Pt with skin flushing, diarhea and cramping. P.E shows purple vascular lesions surrounding her nose (Telangiectasias). Urinary excretion of 5-HIAA is increased over 24 hrs. Imagings shows tumor in small intestine. Most likely resposnible for condition is *Metastatic Carcinoid*

425

PathophysiologyHematology & Oncology

426

Pathology

Gastrointestinal & Nutrition The initiating factor in acute appendicitis is *Lumen Obstruction*

427

Pathology

A pathologic finding in a polp that is associated with greatest risk Gastrointestinal & Nutrition of malignant transformation includes a *2-cm villous adenomatous polyp*

Pathology

38 year old man with colonoscopy showing ulcerative colon mass with no polyps and biopsy showing adenocarcnoma. Gene Gastrointestinal & Nutrition mutation responsible is most likely *MSH2* (Hereditary Nonpolyposis Colorectal Canceer HNPCC)

Pathology

Pt is found to have colon adenocarcinoma in the asceding colon. Pt most likely initially presented wuth *Weight loss and progressive fatigue* Gastrointestinal & Nutrition [Ascedning colon is wide and would prevent obstruction, pt usually develop anemia due to occult blood loss and non specific symptoms also occur]

429

432

434

Pathology

Pt has acute pancreatitis with normal gallbladder and common bile duct (hence due alcohol). He has a >2 AST:ALT ratio. An additional lab finding that is likely to be associated with the Gastrointestinal & Nutrition underlying cause of this pt's pancreatitis is *Mean Corpuscular Volume of 108 fl* [Alchol causes Macrocytosis (MCV >100)likely due to poor nutrition (folate def))

435

Pathology

Gastrointestinal & Nutrition

436

Pathology

65 yr old man comes due to weight loss, Jaundice and anorexia. He notes his urine has been dark and his stools pale. P.E shows enlarged but nontender gallbladder. Most important risk factor Gastrointestinal & Nutrition predisposing of his condition is *Smoking* [Adneocarcinoma of the head of pancreas, Palpable nontender gall bladder + weight loss + obstructive jaubdice (assoc with priritis, dark urine, and pale stools). Smoking doubles the risk.]

437

Embryology

Gastrointestinal & Nutrition

440

Pathology

23 year old is hospitalized with acute pancreatitis that resolves rapidly with fasting. Pt does not consume alcohol. One of the tests that sould be considered during the workup is *Serum Gastrointestinal & Nutrition Triglycerides* [Hypertriglyceridemia can cause acute pancreatitis] [Two main causes however are gallstones and alcoholism]

441

PathophysiologyGastrointestinal & Nutrition

Acute pancreatitis is nitiated by the inappropriate activation of *Trypsinogen*

445

Pathology

An athersclerotic plaque is likely t occur at the *ABDOMINAL AORTA*

446

447

Cardiovascular System

A pancreatic psuedocyst is lined by *Fibrous and Granulation Tissue*

The ventral pancreatic primordium gives rise to the *Main ppancreatic duct*

PathophysiologyCardiovascular System

In the pathogenesis of athersclerotic plaques, release of platelet-derived growth factor (PDGF) by locally adherent *PLATELETS*, endothelial cells, and macrophages promotes the migration of smooth muscle cells (cellualr component of plaques) from the media into the intima and their subsequent proliferation. Platelets also release trnsforming growth factor Beta (TGF-Beta) which is chemotactic for SMC'S

Pathology

Cardiovascular System

Plaque stability is reduced by macrophage release of *Metalloprotinases* that degrade collagen. likelihood of plaque rupture (and hence casuing acute coronary syndrome) depends on plaque stability not size.

451

Pathology

Cardiovascular System

30 year old asian male presents with exertional calf pain and painful foot ulcers. He demonstrates hypersensitivity o intradermally injected tobacco extract. The process responsible for his condition is *Segmental vasculitis extending into contiguous veins and nerves* [Buerger's disease]

452

Pathology

Cardiovascular System

The morphologic changes observed in the arteries of a pt with Giant cell arteritis are most similar to *Takasu Arteritis*

Cardiovascular System

Old Pt with severe drug resistant HTN who dies and autopsy shows shrunken right kidney probably has unilateral renal artey stenosis due to atheromatous plaque at origin of renal artery. Stenosis eventually leads to renal atrophy due to *O2 and nutrient deprivation*

453

Pathology

454

456

457

458

Endocrine, Diabetes & Metabolism

Adrenal Tumor that is functionally similar to the outermost layer of the adrenal cortex (Glomerulosa) would have primary hyperaldostrnism due to Aldostrone-producing Adenoma (Conn Syndrome)and would therefore have *Sweating & Tremulousness* as an added symptom.

Physiology

Cardiovascular System

Really old pt with BP 180/70 at one visit then 175/68. The age related changes that best explains his BP reading are *Aortic Stiffening* [Isolated systolic HTN, Aortic stiffening decreases comppliance of aorta and elevates pressure during systole]

Pathology

Pt with multi system systems and history IV drug use. His muscle biopsy shows transmural inflammation of mid-sized arteries with areas of homogeneous, eosinophilic arterial wall necrosis (i.e Rheumatology/Orthopedics fibrinoid necrosis). Areas of internal elastic lamina disruption are & Sports also present. Most likely predisposing factor to this pt's current condition is *Viral Hepatitis* [Polyarteritis Nodosa]

Pathology

Allergy & Immunology

Skin biopsy from thigh of a child shows vascular lesions with IgA and C3 deposition. The most likely clinical presentation is *Skin rash and abdominal pain* [Henoch-Schonlein Purpura]

Pathophysiology

459

Pathology

Allergy & Immunology

Pt is hospitalized with recent onset oliguria and a high serum creatinine level. He has been seen in clinic several times for an untranasal ulcer that has failed to heal. The pt's condition is most likely assoc with antibodies against *Neutrophils* [Wegner's Granulamatosis with polyangiitis, Cytoplasmic staining Antinuetrohil cytoplasm antibodies (c-ANCA) is pathognomonic]

460

Pathology

Cardiovascular System

In Polyarteritis Nodosa. The arteries spared are usually the *Pulmonary* Arteries.

461

Pathology

Pt with persistent headache and pain in the jaw when chewing Rheumatology/Orthopedics food. Artery biopsy shows multinuclear giant cells and internal elastuc membrane "fragmentation". Pt has Giant cell arteritis and & Sports treatment reduces risk of *Ischemic optic Neuropathy*

462

Pathology

Cardiovascular System

Myxomatous degeneration with pooling of proteoglycans in the media layer of arteries is associated with *Aortic Aneurysm* [assoc w/ Marfan synd]

466

Pathology

Cardiovascular System

Baby with strawberry-type hemangiomas (bening vascular tumor) in his buttocks. These *First Increase in size then Regress*

Dermatology

Pt with small bluish lesion under the nail of her right index finger. It is extremely tender to touch. If the lesion is a tumor, its cells of origin are likely to have a function of *Thermoregulation* [This could be a glomangioma or a melanoma, since pigmentation is not in answer choice, it must be a glomangioma][A glomangioma is a tumor of modified smooth muscle cells of a glomus body. Glomus bodies are involved in thermoregulation]

Nervous System

MRI of head of young t shows an angiomatous lesion involving the cerebellum. There is also a cystic mass in the right kideny on abdominal ultrasound. The differentail Dx must include *Von-Hippel-Lindau disease*

Cardiovascular System

Pt with recurent severe nosebleed and with pink spider-like lesions on his oral and nasal mucosa, face and arms. This pt probably has *Osler-Weber-Rendu Syndrome* also called hereditary hemorrhagictelangiectasia.

467

468

469

Pathology

Pathology

Pathology

470

Pathology

Cardiovascular System

Female with history of breast cancer treated by radical mastectomy and radiation years ago. She now presents with persistent right arm swelling. This pt is at increased risk of developing*Lymphangiosarcoma* [Persistent lymphedema predisposes to lymphangiosarcoma, a rare malignant neoplasm of endothelial lining of lymphatic channels]`

471

Pathology

Cardiovascular System

A vascular tumor that is associated with Arsenic and Polyvinylchloride. The tumor is also postive for CD31. This is *LiverAngiosarcoma*

Infectious Diseases

Pt with aortic regurg murmur (diastolic) in the presence of mediastinal widening. FTA-ABS psotive (syphilus). The pathologic process responsible starts at *Vasa Vasoum Obliteration* [Teriary Syphilus causing aortic aneyrysm, which beigns with vasa vasorum endarteritis and obliteration resulting in inflam, ischemia and weakening of adventitia.]

472

Pathology

474

Pathology

Cardiovascular System

Pt with dilated and tortuous superficial veins in her lower legs. Pts condition is most likely to be complicated by *Skin Ulcerations* [Varciose Veins][Rarely to they lead to pulmonary embolism since they are superficial]

478

Histology

Pulmonary & Critical Care

*Type 2 Pneumocytes* have the ability to proliferate in response to cell injury. They can regenerate!

Pulmonary & Critical Care

The epithelium of the bronchi is psuedostratified ciliated epithelium with goblet cells and submucosal mucoserous glands and cartilage. Bronchioles, terminal bronchiols and respiratory bronchioles lack goblet cells, glands, & cartilage. The terminal brocnhioles have ciliated simple cubioidal. So CILIA is last to disappear moving distally.

480

Histology

481

Physiology

Pulmonary & Critical Care

The resistance in the airways starts high from the begining and jumps up more at medium sized bronchioles due to highly turbulent flow. The resistance then decreases going towards subsequent generations till reaching the terminal bronchioles due increased surface area allowing low resistance laminar flow.

483

Histology

Infectious Diseases

The *True vocal cords* have stratified squamous epithelium. These can be affected by HPV which is a DNA virus casuing warty growth (papillomas) on the true vocal cords.

Pulmonary & Critical Care

Pt hospitalized for abdominal pain. Lab show elevation of serum amylase and lipase. He has Hx of alcohol abuse. His condition worsens and develops severe resp distress. He dies to resp failure. Most likely finding on autopsy is *Alveolar hyaline membrane* [Pancreatitis led to ARDS][Enzymes and inflam cytokines leak into cirulation leading to infiltration of neutrophils in lung interstitium and alveolar space. Injury leads to edema & fibrin depos leading hyalinized alveoli]

485

Pathology

486

Pathology

Pulmonary & Critical Care

Pt who history of heavy alcohol use and was admitted before for acute pancreatitis. He presents with nausea vomitting and severe abdominal pain. On 2nd day he develops dyspnea, and hypoxemia. The parameter that is most likely normal in this pt is *Pulmonary Capillary Wedge pressure* [signs suggest ARDS for whch pancreatitis is major risk factor, pulmonary edema with normal PCWP]

488

Histology

Pulmonary & Critical Care

smoking induced emphysema is contributed to by neutrophils.

Nervous System

Light microscopy of bran tissue that shows neurons with shrunken nuclei, no detectable nissle substance and intensely eosinophilic cytoplasm. These findings indicate *Irreversible cell injury*

492

Pathology

494

Pathology

Nervous System

Cell body rounding, peripheral displacement of the nuclei and dispersion of Nissl substance to the periphery of the cells. These findings described indicate *Axonal Reaction*

495

Pathology

Nervous System

Pt (who is right handed) presents with acute onset headache and difficulty with vision. She passes out en route to hospital. CT scan shows an acute hemorrhage in left temporal lobe and compression of the ant medial temporal against the free margin of the the tentorium cerebelli. The CN most likely compromised is *Oculomotor*

496

Embryology

Nervous System

Vitamine supplementation prevents neural tube defects in pregant women. For exampel those defects involving the pos neural folds such as meningocele and meningomyelocele.

Nervous System

Sudden onset severe headache with no other abnormalities with subarachnoid hemorhhage on ct is likey caused by a *Saccular Anyeurysm*

497

Pathology

499

Pathology

Nervous System

Elderly with Lobar Hemorrhage in occipital and parietal areas with history of frontal lobe hemorrhage. Probably he has *Cerebral AmyloidAngioplasty*

502

Embryology

Nervous System

Acetylcholinestrase in the amniotic fluid indicates a neural tube defect in which there is a *Failure of Fusion*

Nervous System

Youn woman who presents with episodic headaches, dizziness and gait disturbance. MRI of brain shows low lying cerebellar tonisls extending into vertebral canal. Cause of this is a *CongenitalMalformation* (Chiari type 1)

504

Pathology

505

Pathology

Nervous System

Pt involved in motor vehicle accident who sustains fracture of temporal bone. Bloody most likely accumulates between *Bone and Dura Mater* [Epidural Hematoma]

507

Pharmacology

Pregnancy, Childbirth & Puerperium

Valproate increases risk of neural tube defects in pregnant women such as *Meningocele*

Nervous System

Drug interaction 2-3 weeks after New medication (e.g phenytoin)that presents with cutaneous and systemic symptoms such as diffuse erythema, generalized lymphadenopathy and facial swelling arise from DRESS (drug reaction with Eosinophila & systemic Symptoms) as the name suggests, lab finding would be *EOSINOPHILIA*

508

Pharmacology

513

Anatomy

Nervous System

Pt that presents with amenorrhea and notes that her breasts have become engorged. She is taking an antipyschotic drug. She probably has galactorhea in which the dopaminergic athway disturbance responsible is the the *Tuberoinfundibular*. It connects the Hypothalamus to ant pit and is responsible for dopamine-dependent prolactin tonic inhibition. The drug she is on blocks dopain in that pathway.

519

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Drug interactions with lithium include Thiazide diuretics. Symptoms of toxicity include resting tremor, balance issues (ataxia).

Psychiatric/Behavioral & Substance Abuse

Pt has been receiving treatment for mood swings and sleep problems. Now the pt has constipation, dry skin, and hair loss. Also she has weight gain despite regular diet. BP is 110/70. Pt appears tired but exam is otherwise normal. Most likely responsible drug is *Lithium* [Hypothyroidism due to lithium used in bipolar disorder]

520

Behavioral science

524

Histology

Pulmonary & Critical Care

Pt with tickened bronchial walls, lymphocytic infiltration, mucous gland enlargement, and patchy squamous metaplasia of bronchial wall mucosa are features of Chronic Bronchitis. Smoking is a leading cause of that. Smoking is *Behavioral contributor*

527

PathophysiologyPulmonary & Critical Care

Young pt with paroxysmal episdoes of breathlessness and wheezing unrelated to anything. Sputum microscopy shows many granule containing cells and crystalloid masses. The sputum finding suggest the role of *IL-5* in this pts condition. [granule containing cells are eosinophils and crystalloid bodies are charocot-leyden crystalsl, a response to IL-5 released by allergen activated TH2 cells]

528

PathophysiologyPulmonary & Critical Care

Hypocapniaimplies*alveolahyperventilation*

Pathology

Pulmonary & Critical Care

t dies from pulmonary infection. Autopsy shows a right lower lung lobe that is pale, firm and airless. Histologically, the alveoli are filled with "exudate containing neutrophils, fibrin, and some fragmented RBC's". This pt died during the *Grat Hepatization* phase of his disease.

Infectious Diseases

Pt presents due to fever, night sweats, weight loss and productive cough. He says his sputum is greenish and foul smelling. Chest X-ray shows a cavitary lesion in the middle lobe of right lung with air-fluid levels. Most likley cause of this cavitary lesion is *Aspiration of oropharyngeal contents* [Lung Abscess]

531

532

Microbiology

533

Pathology

Pulmonary & Critical Care

Pt with Peptosreptococcus and Fusobacterium in his lung. Predisposing factor to his condition is *Seizure disorder* [Lung abscess, caused by Oropharyngeal aspiration which can occur due to seizures (loss of consciousness)]

536

Physiology

Pulmonary & Critical Care

Dust particles smaller than 2 micrometres are eliminated by macrophagesthroughphagocytosis.

Immunology

Hematology & Oncology

Male Infant with eczema, recuurent infections and thrombocytopenia has *Wiskot-Aldrich Syndrome* [X-linked][Combined B and T cell disorder][Tx with Bone marrow transplant]

538

Immunology

2 year old with recurrent skin and mucosal infections. Skin infection drainage grows Staph aureus with no purulence. Lab test Rheumatology/Orthopedics reveals absent CD18 antigens on leukocytes. Pt is at greatest risk & Sports for *Persistent Leukocytosis* (Leukocyte Adhesion Deficiency type 1)

543

Embryology

Endocrine, Diabetes & Metabolism

Pt with absent thymic shadow and narrowing of aortic arch on xray probably has DiFeorge syndrome and lacks a thymus due to failure of *Third pharyngeal Pouch* to develop.

545

Immunology

Hematology & Oncology

ErthroblastosisFetalis(Jaundice,hepatosplenomegaly,edema, low Hb, nucleated erythrocytes, extramedullary hematopoiesis) is caused by *RBC opsonization by maternal antibodies*

548

Pharmacology

Endocrine, Diabetes & Metabolism

Glucucorticoids such as Prednisone cause Increased LIVER gluconeogenesis, therby activation *LIVER Protien Synthesis*

549

Pharmacology

Endocrine, Diabetes & Metabolism

High-dose Prednison (Corticosteroid) would elevate *Neutrophil* levels.

550

Embryology

Endocrine, Diabetes & Metabolism

*Cortisol* has the greatest effect on lecithin to sphingmyelin ratio (greater than 1.9 indicates mature lung)

552

Pathology

Pulmonary & Critical Care

Hamartomas are the most common benign lung tumors. They are composed of disorganized *Cartilage, fibrous, and adipose tissue*

537

554

555

556

558

560

565

566

569

Pulmonary & Critical Care

55 yr old woman present due to cough and recent weight loss. She doesnt smoke. P.E shows decreased breath sounds and dullness to percussion at the left lung base. Image studies show an irregular mass in the lower lobe of her left lung and left-sides pleural effusion. It malignancy is diagnosed it is most likley *Adenocarcinoma* [Most common lung cancer in general populattion]

Pulmonary & Critical Care

65 yr old presents due to nonproductive cough with anorexia and weight loss. He has a 50 pack year smoking history. Exam show enlarged supraclavilcular lymph node. Imaging shows a large mediastinalmasscausingtrachealdeviation.Immunohostochemical staining of mass is positive for chromogranin. Pt most likely suffers from *Small cell carcinoma*

Allergy & Immunology

Pt stung by a bee displaying edematous and erythematous plaque with evanescent borders and mild central pallor. This is a local allergic reaction (type 1 hypersensitivity) leading to the release of *HISTAMINE*, heparin, leukotrienes, and prostaglandins that are responisble for the increased vascular permeability leading to the presentation.

Hematology & Oncology

During the process of T-lymphocyte maturation, T cell receptors of many lymphocytes demonstrate a very high-affinity interaction with MHC molecules expressed on thymic medullary epithelial and dendritic cells. At this time, lymphocyte undergo *Negative Selection*

Infectious Diseases

Sexually active pt presents with fevers and arthralgias (arthritis). She has several postules on her arm (Dematitis). Her wrist and ankle are tender on palpation (Tensosynovitis). Pt blood shows G-ve bacteria that produces an ezyme that splits IgA at the hinge regions. Most imp role of this bacterial enzyme is *Mucosal adherence of bacteria* [Disseminated Gonorrheal Infection, produce IgA proteases]

Pulmonary & Critical Care

Pt presents with cough and headaches and dyspnea. He complains of a puffy face. P.E shows facial swelling and conjunctival edema. Dilated vessels are seen over his neck and upper trunk. The pts condition is most likely caused by a *Mediastinal Mass* [Superior Venecava syndrome]

Anatomy

Nervous System

Pancoast tumors are non-small cell lung cancers that arise near the superior sulcus. Pts may develop ipsilateral shoulder pain, upper limb parethesias and areflexic arm weakness due to involv of brachial plexus. Horner syndrome (ipsilateral partial ptosos, miosis, anhydrosis) can occur due to invlove of cervical sympathetic *Autnomic Ganglia*

Immunology

Renal, Urinary Systems & Electrolytes

Hyperacute renal transplant recjection is an *Antibody-mediated hypersensitivity* (preformed Ab's against graft)

Pathology

Pathology

Immunology

Immunology

Immunology

Pathology

574

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Following amitriptyline overdose (TCA). There is QRS widening and QTc prolongation. And Death occurs. Deat is related to *Sodium Chanel inhibition* [Fast Na chanel inhibition resulting in conduction defects and arrythmias]

582

Pathophysiology

Endocrine, Diabetes & Metabolism

Pt with Klinefelters have azospermia. That mean sperm count is *None* Ofcourse together with low LH, FSH and Testestrone.

584

Pharmacology

Endocrine, Diabetes & Metabolism

Anastrozole is used to treat estrogen receptor positive breast tumors. It *Decreases Androgen Aromatization*

585

589

Pt with a pianful rash involving groin and perineum, DM and exam that shows coalescing erythematous lesions with crushing and scaling and central areas of bronze-colored induration and biopsy of lesions shows superifical necrosis has a GLUCAGONOMA, He shouldhave*ElevetaedGlucagonLevels*

Pathology

Endocrine, Diabetes & Metabolism

Immunology

Secretory IgA exists as a dimer with J chain in the middle and a secretory piece that kind of cross links the dimer, it functions to Gastrointestinal & Nutrition prevent IgA dimer degradation in mucosal membranes. Secretory IgA is present in mucus, tear, and *Colostrum*. (Note: the serum form is a monomer)

591

Genetics

Nervous System

Young man who is aysmptomatic and found to be homozygous for the apolipoprotein E-4 allele. In the future he most likely to suffer from*Alzheimer'sdementia* [Late onset familial Alzheimer's disease] [Eary onset is assoc with 1) Amyloid precursor protein on chrom 21. 2) Presenilin 1 gene on chrom 14. 3) Presenilin 2 gene on chrom 1.]

593

Pathology

Nervous System

In alzheimer's disease, there is *Decreased acetycholine activity in the nucelus basalis*

Nervous System

Homeless man who is hospitalized and then develops acute confusion, nystagmus, abducens palsy and opthalmoplegia probably has Chronic Thiamine Deficiency due to liver dysfunction. Thiamine is needed for Glucose metabolism and therefore *Glucose Infusion* can percipitate Wernicke Encephalopathy.

Biochemistry

Nervous System

Wernicke syndrome manifests with opthalmoplegia, ataxia, & confusion. There is foci of hemorrhage and necrosis in the "mamillary bodies" and periaqueductal gray matter om autopsy. Diagnosis involves measuring *Eythrocyte Transketolase activity* It occurs due to chronic Thiamine (B1) def commonly in alcoholics.

Pharmacology

Endocrine, Diabetes & Metabolism

Pt with diabetic ketoacidosis is treated with regular insulin that has no aminoacid modification Regular insulin which has a short half life ,longer than lispro however.

597

598

600

Pathology

602

Biochemistry

Endocrine, Diabetes & Metabolism

Pituitary resection decreases ACTH which decreases Cortisol, decrease in cortisol decreases expression of *PHENYLETHANOL-N-METHYLTRANSFERASE* which the enzyme that converts Norepi into Epi. Therefore, putituwary resection leads to decreased EPI production.

604

Pharmacology

Endocrine, Diabetes & Metabolism

You should monitor *BUN & Creatinine* when admistring Canagliflozin which is a SGLT2 inhibitor that decreases renal abasorption of glucose used in type 2 diabetes

605

Pharmacology

Endocrine, Diabetes & Metabolism

Pioglitazone which is Thiazolidinedione antidiabetic dryg targets *intracellular nucelar receptor* [Binds peroxisome proliferator activated receptor gamma]

606

Pharmacology

Endocrine, Diabetes & Metabolism

Meglitinides (repaglinide, nateglinide) are short acting glucose lowering medications. They are functionally similar to sulfonylureas and act by binding and closing ATP-dependent K+ chanel in pancreatic beta cell membrane, inducing depolarization and L-type Ca channel opening. The increased Ca2+ influx stimulates beta cells insulin release. They therefore, *Target membrane ion channels* Check Table

608

Pathophysiology

Endocrine, Diabetes & Metabolism

Adminstration of Metyrapone will cause a decrease in cortisol synthesis via inhibition of 11-beta-hydroxylase. In pts with an intact hypothalamic pituitary axis, this will cause a reactive increase in ACTH, 11-Deoxycortisol, and "urinary 17-hydroxycorticosteroid levels"

611

Pathophysiology

Endocrine, Diabetes & Metabolism

11-hydroxylase deficiency in congenitl adrenal hyperplasia causes high PB and Hirstutism (Big clit)

Hematology & Oncology

Child who presents with headaches and gait instability. MRI shows tumor in the cerebellum wtih both cystic and solid components (white and dark). Most likely Dx is *Pilocytic Astrocytoma* (Medulloblastoma is only solid, ie dark)

615

Pathology

622

Pharmacology

Endocrine, Diabetes & Metabolism

Pt with signs of Hyperthryroidism with eye involvement (bilateral redness,proptosis(exopthalmos))wasgivenmedicationthat reduced her proptosis. The drug did that by affecting *Inflammatory infiltration* [Glucorticoids to treat exopthalmos in Grave disease pts]

623

Pathophysiology

Endocrine, Diabetes & Metabolism

Peritibial myxedema and exopthalmos are specific features of hyperthyroidsim due to Grave's disease. Peritibial myxedema is *Lower Leg Skin thickening and induration*

624

Pathology

Pt presents with a painless scrotal nass. He also has increased sweating and heat intolerance. P.E shows an enlarged nontender right testicle. Lab shows increased serum T4 and T3. The constellation of findings seen in this pt most likley suggest an MaleReproductiveSystem elevation of serum *hCG* [Testicular malignancy releases hCG which has a similar structure to TSH and can bind and activate thyroid to produce ParaneoplasticHyperthyroidism.]

625

Pharmacology

Endocrine, Diabetes & Metabolism

*TSH levels* should be monitored in pts receiving Amiodorone therapy!

626

Pharmacology

Endocrine, Diabetes & Metabolism

Methimazole inhibits *Coupling of iodotyrosines* in the thyroid gland.

635

Anatomy

Nervous System

Old pt with long standing HTN who presents for involuntary movements, "Threw remote control across the room" P,E shows Large amplitude flinging movements affecting proximal muscles of upper extremity. Pt most likely has injury to *Subthalamic Nucleus*

636

Pathology

Nervous System

Friedreich ataxia is associated with *Cardiomyopathy*

638

Physiology

Rheumatology/Orthopedics The marker that reflects the activity of osteoblasts is *Serum Level & Sports of bone-specific Alkaline Phosphatase*

639

Physiology

Pt with pain and deformity of long bones with hearing loss (due to bony deformity of the skull). The pathologists identifies Rheumatology/Orthopedics multinuncleated cells containing over a 100 nuclei. The factor that & Sports is essential for the differentiation of these cells is *Receptor Activator of Nuclear factor Kappa-B ligand (RANK-L)* (Pagets disease of bone, Osteoclasts)

645

Microbiology

Cardiovascular System

646

Microbiology

*Staph Aureus* is the most commin cause of Acute Hematogenous Rheumatology/Orthopedics osteomeylitis in children (10 year old for eg) characterized by pain over long bones (tibia, femur)with high fever and chills. Possible & Sports soft tissue swelling. Vague symptoms.

647

Pathology

Nervous System

Coagulase-negative streptococci such as staph epi are methicilin reistant and should be treated with *Vancomysin*

Lung cancer irritating the phrenic nerve can cause dyspnea, hiccups and referred ppain to shoulder. Phrenic Neve arise from *C3-C4*

648

Pathology

Pulmonary & Critical Care

Pt with shoulder pain (pain under scapula and in right arm). Pain is associ with numbness on his right forearm and tips of fingers. He has Hemoptysis. He smoked 2 packs/day for 40 years. Most likey cause is *Superior Sulcus Tumor* (Pancoast Tumor)

649

Pathology

Pulmonary & Critical Care

Histopathology reveals lung tumor cells with numerous, long slender microvilli and abudnant tonofilaments. This is *MESOTHELIOMA*

651

Pathology

Infectious Diseases

Tertiary Syphilus genital lesions are called *Gummas*

652

Embryology

Renal, Urinary Systems & Electrolytes

urine discharge from the umbilicus is caused by a persistent allantois remnant.

654

Anatomy

Cardiovascular System

A laterally directed chest wall stab wound at the fifth intercostal space along the midclavicular line. The structure injured would be the *Left Lung*

656

Pathophysiology

Endocrine, Diabetes & Metabolism

Oral conraceptives decrease hirsutism by suppressing LH secretion and thereby *Decreasing ovarian androgen production*

Endocrine, Diabetes & Metabolism

Pt with difficulty urinating and dribbling affecting quality of life probably has BPH, treatment with Finasteride can cause releif but also cause increase hair growth over scalp. That's becuse Finasteride is a *5-alpha-reductase inhibitor*. This is the enzyme that converts testestrone into its active metaboloite DHT.

Nervous System

Inahled anesthetic with a vey large atriovenous conc gradient shortly after begining inhalation would have a *Slow Onset of Action* (high atriovenous conc gradient means increased peripheral tissue solubility which negatively affects brain saturation)

658

Pharmacology

660

Pharmacology

661

PathophysiologyPulmonary & Critical Care

664

665

667

668

671

Pathology

Only *Leucotrienes* and acetycholine produce asthma that is relieved by pharmacologic antagonists.

Male comes for infertility evaluation. Semen analysis shows normal sperm count but completely immobile sperm due to abnormal tail MaleReproductiveSystem function. The finding most likely associated with this condition is *Persistent bronchial dilation* [Primary cilary dyskinesia, auto recessive] Pt presents with recurrent transient pulmonary infiltrates. She has a history of bronchial asthma. He takes albuterol and inhaled glucocorticoids. CBC shows Eosinophilia. Chest CT shows proximal bronchiectsais. This pt has colonization of *Aspergilus Fumigatus*

Microbiology

Pulmonary & Critical Care

Pathology

Eosiniphilic granulomatosis with polyangiitis (Churg-Strauss) is a small to medium vessel vasculitis characterized by late-onset Rheumatology/Orthopedics asthma, rhinosinusitis, and eosinophilia. Mononueritis multiplex due & Sports to involvement of the epineural vessels of peripheral nerve is common. The finidning of antibodies against neutrophil myeloperoxidase is also common.

Pathology

Pathology

Pulmonary & Critical Care

Bronchoscopy with transbronchial biopsy of a calcified node is done. Polarized microscopy shows birefringent particles surrounded by dense collagen fibers. Pt most likely had exposure to *Silica*

Nervous System

PT with gait instability, dysmetria, and dysarthria. MRI shows degenration of Post columns and spinocerebellar tracts. The condition that has clinical manifestation that closely resemble this pt disease is *Vit E deficiency* [this pt has Friederich's Ataxia][vit E defi results in oxidative damage and mimic F ataxia]

673

Immunology

Nervous System

4 year old Pt with ataxia, repeated respiratory infections, and cultured cells that show high rate of genetic mutations probably has Ataxia-telangiectasia and has *Cerebellar Atrophy*

674

Pathology

Nervous System

Pt with a lesion involving teh corticospinal tract would have an additional finidng of *Hyperactive deep tendon reflex* (Hyperreflexia in UMN signs)

676

Immunology

Infectious Diseases

Symptoms of Fever, Vomiting, Diarrhea, Muscle pain, low BP and Erthroderma Indicate Toxic shock syndrome mostly caused by Staph Aureus toxic syndrome toxin which acts a superantigen that activates many *T Cells & Macrophages* leading to production of cytokins that cause capillary leakage, circulatory collapse, hypotension, fever, shock, and multiorgan failure.

678

Microbiology

Infectious Diseases

Youn woman with UTI. Sexually active. Culture shows catalase +ve, g+ve cocci. Organism responsible is *Novobiocin resistant* [Staph Saprophyticus UTI]

679

Microbiology

Cardiovascular System

Staph epi is differentiated from staph aureus by the coagulase test. Staph epi is coagulase negative while staph aureus is positive.

Microbiology

Dermatology

Infant with diffuse skin erythema, and epidemris comes off easily with gentle pressure. This is caused by *Exotoxin-mediated skin damage* (SSSS by staph exofoliatin exotoxin)

681

Pharmacology

Renal, Urinary Systems & Electrolytes

Pt with dyspnea, orthopnea, elevated JVP, lower extrem edema, and lung crackles have acute decomensated heart failure and should be treated with IV loop diuretics. Which work on *Thick ascending limb of loop of henle*

685

Pharmacology

Renal, Urinary Systems & Electrolytes

Loop diuretics such as *Furosemide* can cause Ototoxicity.

689

Pharmacology

Cardiovascular System

*FENOLDOPAM* is a selective D1 agonist that is used in hypertesnive emergencies.

699

Pharmacology

Rheumatology/Orthopedics Bisphosphanates (e,g alendronate) have similar structure to & Sports *Pyrophosphate*

680

Husband short with a large head and prominent forehead. Wife is normal. They are concerned about unborn child's height. Best response is *Rsik of short stature in child is 50%* (Achondrolasia is autosomal dominant, father must heterozygous (otherwise be dead), mom is unaffected therefore 50%)

Genetics

Miscellaneous (Multisystem)

702

Pathology

Pt with blue sclera and easily fractured bones probably has Rheumatology/Orthopedics osteogenesis imperfecta due to defect in type 1 collagen which is the primary collagen in bone. Therefore, the primary impairement & Sports is *Bone Matrix Formation*

704

Pharmacology

Psychiatric/Behavioral & Substance Abuse

A side effect of Buprion (Norepi and Dop reup inhib) (used in depression, no sex probs or weight gain) is Seizures.

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Pt on depression medication that is casuing him sexual dysfunction (SSRI's) can be switched to BUPROPION which doesnt cause sexual dysfunction.

Psychiatric/Behavioral & Substance Abuse

Pt with painful erection for more than 4 hours. Past med history is sig for treatment-resistent depression, OCD, and insomnia. Drug most likley used is *Trazadone* [Priapism, rare side effect of trazadone]

701

706

707

Behavioral science

710

Pathology

Hematology & Oncology

Neoborn with no postnatal care or medication. He has Cystic Fibrosis. He develops Intracranial Hemorrhage. Cause is *Impared gammacarboxylation* (Neonatal Vit K deficiency) (CF more suscepptible due to fat (ADEK) malabsorption)

711

Pharmacology

Cardiovascular System

Tx with statins causes increased *LDL receptor density* Elderely pt that comes with sudden-onset right arm weakness and difficulty speaking that resolve within 20 minutes, and who also has a history of HTN and hypercholestrolimia most likely had a Transient Ischemic Attack and Aspirin should be indiacted. Being an NSAID aspirin can cause *GI BLEEDING*

713

Pharmacology

Cardiovascular System

718

Pharmacology

Rheumatology/Orthopedics *Methotrexate* which is used in RA can cause GI ulcers such as & Sports "painful mouth ulcers*. It also causes Liver Tox (high liver enzymes)

Pharmacology

Etanercept is TNF-alpha inhibitor used in RA for failed methotrexate therapy. It is not an Ab but a decoy receptor for TNF-alpha. Inhibition of TNF-alpha leads to impaired cell-mediated Rheumatology/Orthopedics immunity particularly for control of mycobacteria within & Sports granulomas and therefore inhibition can result in reactivation of TB and hence beofore adminstration a *Tuberculin Skin Test* should be made.

Pathology

Child with fever and malaise. He parents say he refrains from using his right leg. Passive range of motion does not elicit pain and Rheumatology/Orthopedics no joint effusion is seen. However, the pt refuses to bear weight & Sports with his right lower extremity. Scintigraphy is most likely to reveal increased focal radiotracer uptake in the *Long Bone Metaphysis* [Hematogenous Osteomyelitis]

720

721

722

Microbiology

Infectious Diseases

Strep pyogenes (Group A)(G+ve cocci)(Beta hemolytic) (Catalse -ve) (can cuse PSGN, Acute rehumatic fever, scarlet fever, pharyngitis, & impetigo) is *Pyrrolidony Arylamidase Positive (PYR +)* and Also Bacitracin sensitive.

726

Pharmacology

Biostatistics & Epidemiology

Early penicilin Tx of Group A strep pharyngitis is important 4 prevention of Acute Rheumatic Fever which a major cause of CVS death in many developing nations. ARF affect mainly heart and CNS. Chronic cardiac inflammation can progres sto rheumatic heart disease, esp valvualr. (Mitral valve)and would need *Heart Surgery* Therefore, early Tx lowers need 4 Heart surgey!!

728

Microbiology

Infectious Diseases

*Intravascular devices* contriubute to increase in staph bactremia thru the nation

730

Microbiology

Pulmonary & Critical Care

Virulence factor of Strep Pneumoo (g+ve diplococci, alpha hemolytic) is *Polysaccharide Capsule*

731

Microbiology

Pulmonary & Critical Care

G+ve lancet shaped cocci in pairs is Strep Pneumo which is *Bile Soluble*

Hematology & Oncology

PT dies from Strep Pneumo infection. He has history of motor vehicle accident that required laparatomy. The mechanism that contributed to the severeity of this pt's infection is *Systemic Bacterial Clearance* [Pt most likely had part his spleen removed after accident and became suscptible to encapsulated bacteria due to inability to clear them]

732

Microbiology

733

735

737

738

741

742

Cardiovascular System

Old pt presents with low-grade fever and fatigue. Exam shows a diastolic murmur at left sternal border. He has nontender erythematous macules on his hands and feet. Blood cultures grow g+ve cocci that are catalase-ve and grow in hypertonic saline and bile. Pt medical history is likley to inculde *Cytoscopy* within the past month [Entercoccal Endocarditis, colonizes genitourinary tract] [Viridans are bile insoluble and dont grow on hypertonic saline]

Nervous System

Adult pt with signs of meningitis. CSF analysis shows elevated opening pressure, increased neutrophils (10%), decreased glucose and elevated protein. Pt most likely has Strep Pneumo Meningitis and gram stain of csf would reveal *Lancet-Shaped, Gram positive cocci in pairs*

Nervous System

Pt with CSF sample with bean-shaped g-ve cocci in pairs probably has Neisseria Meningitidis which reaches the meninges via *Pharynx--> blood---> choroid plexus-->Meninges* This means that neisseria meningitidis is transmitted via respiratory droplets.

Microbiology

Nervous System

Autopsy of 14 yr old male died of septic shock. Shows extensive hyperemia and infarcts of internal organs. Purpuric cutaneous lesions and hemorrhagic destruction of both adrenals are also present. The organism responsible for death more commonly causes*Meningitis* [N. Meningitidis]

Immunology

Pt who is given infliximab for Crohn Disease. Ten days later he develops a pruritic skin rash. Skin biopsy shows scattered areas of Rheumatology/Orthopedics Fibrinoid necrosis and neutrohil infiltration involving his small vessels. The finding most likely to accompany this condition is & Sports *Decreased Serum C3 level* (Serum Sickness, Type 3 (immune-complex) hypersensitivity)

Microbiology

Microbiology

Microbiology

Immunology

Renal, Urinary Systems & Electrolytes

Female Pt with glomerulinephritis, photosensitive skin rash and arthralgias together witha positive trepnemal RPR but with -ve T.pallidum enzyme ummunoassay and also prolonged aPTT probably has SLE with Antiphospholiid antibody syndrome and is therefor at risk of *Recurrent Miscarriages* The classic triad of Urethritis, Conjunctivitis, and Mono- or Oligoarticular arthritis indicates "Reactive Arthritis" which is a seronegative (RF -ve) spondyloarthropathy (HLA-B27). Symptoms usually present 1-4 weeks after a primary infection causing urethritis (dysurea). Skin finding include a vesicular rash on palms & soles, circinate balanitis, and *SACROiLiiTiS* (inflammation of sacroiliac joint)

743

Immunology

Allergy & Immunology

745

Immunology

Gastrointestinal & Nutrition NK cells kill cells that do not express MHC class 1 antigen.

747

Immunology

Renal, Urinary Systems & Electrolytes

Pt who received emergency blood transfusion who quickly develops dyspnea, chills, chest/back pain, and hemoglobinurea probably has acute hemolytic transfusion reaction. This is a type 2 hypersensity and therefore can be due to *Complement mediated cell lysis*

750

Immunology

Renal, Urinary Systems & Electrolytes

When it comes to handling parasites, eosinophile do it via the *Antigen-Dependent-Cell-Mediated Cytotoxicity (ADCC)*

751

Pathology

Cardiovascular System

A substance that is secreted by the vascular endothelium and inhibits platelet aggregation is *Prostacyclin*

753

34 yr old man comes due to lower bk pain for several years. He has stiffness and pain that are worst in the morning but gradually improve during the day. Ibuprofen provides some relief. Lab shows Rheumatology/Orthopedics a positive HLA-B27 antigen. X-ray shows fusion of sacroiliac Pathophysiology & Sports joints. Most helpful in monitoring progression of pt's disease is *ChestExpansion* [Ankylosing Spondylitis]

754

Immunology

Pt with sign of RA. Pt serum most likely has IgM antibodies that Rheumatology/Orthopedics react with *Fc portion of Human IgG* & Sports (Rheumatoid Factor)

756

Embryology

Rheumatology/Orthopedics Both the thymus and *Inferior parathyroid* originate from the 3rd & Sports pharyngeal pouch.

759

Immunology

Rheumatology/Orthopedics IL-4 & 5 are respnsible for antibody class switching. & Sports

761

PathophysiologyAllergy & Immunology

23 yr old Female with migratory arthritis and skin rash exacerbated by skin exposure. Urinalysis shows moderate proteinuria and RBC casts. Serum Ab with specificity for this pts condition react with *Double stranded DNA* [SLE]

762

Immunology

Pulmonary & Critical Care

Pt wih T cells that lack IL-12 receptor would be unable to release *IFN-Gamma* and supplementation would be needed to improve pt's recurrent respiratory infections.

764

Pathophysiology

Endocrine, Diabetes & Metabolism

Pt with fatigue, bradycardia, weight gain, constipation, and delayed relaxation of deep tendon reflexes has Hypothyroidism, the most sensitive marker for Dx is *Serum TSH*

765

Endocrine, Diabetes & Pathophysiology Metabolism

Signs of fatigue, weight gain and lumps rising from surface of skeletal muscle following percussion with reflex hammer (MYOEDEMA) combined with Elevated CK level indicate HYPOTHYROID MYOPATHY and *TSH levels* should be checked.

766

Endocrine, Diabetes & Pathophysiology Metabolism

Pt being scheduled to be treated for hyperthryoidism usning radioactive iodine therapy. Pretreatment with *Potassium perchlorate* would decrease the effects of radiotherapy thru competitive inhibition of iodine transport.

768

Pathology

Endocrine, Diabetes & Metabolism

Pt with signs hyperthyroid symptoms together with painful thyroid enlargememt. Thyroid scan reveals decrease in radioactive iodine uptake. ESR is elevated. Biopsy of thyroid will most likely reveal *Mixed, cellular infiltration with occasional multinucelated giant cells* [Sabacutegranulomatousthyroiditis]

770

Physiology

Endocrine, Diabetes & Metabolism

Thyroid peroxidase enzyme is involved in *Thyroglobin Iodination* also in oxidation of iodide, and coupling of 2 iodized tyrosine residues.

772

Pathophysiology

Endocrine, Diabetes & Metabolism

An increase in estrogen activity leads to an increase in levels of thyroxine-binding globulin. This leads to an *Increased Total T4 pool*

Nervous System

The agent that can perciptate opoid wthdrawal in an opioid tolerant pt is *Buprenorphine* [An opiod partial agonist that can act as antagonis in presence of other opioid medications]

Nervous System

A pentapeptide with strong affinity to delta and mu receptors produced after application of noxious stimuli. This substance most likely has a common molecular origin with *ACTH* (POMC us cleaved into beta endorphins, ACTH & MSH)

774

775

Pharmacology

Physiology

776

Physiology

Nervous System

The most likely postsynaptic action of low-dose morphine on the spinal level (epidural) of a pt who has severe back pain due to metastatic Ca is *Increasing K efflux out of cells* [Upon binding to Mu receptors, morphine causes G-protein coupled activation of K channels to increase K efflux. Increase K efflux leads to Hyperpolarization of postsynaptic neurons and termination of pain transmission]

780

Pharmacology

Cardiovascular System

Before giving statins check *Liver transaminases*

Cardiovascular System

Pt with reduced plasma lipoprotein activity. If condition is untreated he may develop *Acute Pancreatitis* (Familial chylomicronemia type1)

782

Pathology

787

Physiology

Hematology & Oncology

*The Hepatic Parenchymal Cells* secrete Hepcidin which is a substance that controls the storage and release of iron through its binding to ferroportin. Once bound to ferroportin it inactivates it thus prevents iron intestinal absorption into blood and also prevents its release from macrophages.

790

Biochemistry

Gastrointestinal & Nutrition

Under normal cirumstances the Ras protein is activated only when boud to *GTP*

794

Pathology

Nervous System

Atrophy in Alzheimer's disease involves the *Hippocampus* [Identify on MRI]

795

Pathology

Pulmonary & Critical Care

African american female with Dry cough, pulmonary infiltrates, hilar adenopathy, biopsy shows Non-caseating granuloma ==> *SARCOIDOSIS*

796

Immunology

Pulmonary & Critical Care

African American woman presents with exertional dyspnea and dry cough. Chest xray shows bilateral hilar adenopathy and reticular pulmonary infiltrates. Serum ACE & Ca levels are elevated. PPD test is negative. Bronchoscopy is arranged. The cell type that is most likely to predominate in the lavage is *CD4+ cells* (Sarcoidosis)

799

Pathology

Pulmonary & Critical Care

Retinal vascularization in premature neonate was most likey due *NeonatalO2supplementation*

Pulmonary & Critical Care

Newborn with Abdominal distention with normal rectal tone. Pt has severl episodes if green emesis (hence billous). Laparotomy shows inspissated green fecal mass obstructing distal ileum. Most likely cause of mortality for this pt will be *Pneumonia* This pt has meconium ileus (inspissated meconium at "Ilius") due to "Cystic Fibrosis" and hence at risk for Pneumonia.

803

Pathology

PathophysiologyPulmonary & Critical Care

In pts with Cystic Fibrosis, nasal muccosal basleine potential difference is more negative becuase of Increased Sodium reabsorption due to blocked Chloride channels due to CFTR protein defect. Therefore the respiratory mucosa of the pt demonstrates*Increasedsodiumreabsorption*

806

Pathology

Pulmonary & Critical Care

Pancreatic squamous metaplasia of the pancreas in a pt with CF (recurrent pulmonary infections, finger clubbing)is due to deficiency in *Vit A* [vit A is needed for maintenance of orderly differentiation of specialized epithelia]

807

Genetics

Recurrent pneumonia, Azoospermia, Digital clubbing, No vas MaleReproductiveSystem deferens are signs of Cystic Fibrosis. It can be diagnosed with measuring *Chloride level in the sweat*

808

Pharmacology

Gastrointestinal & Nutrition

804

Pt with cystic fibrosis can be helped with *Pancreatic enzyme supplementation* to aid absorption.

809

Pathology

Cardiovascular System

Pt with flank pain, hemturia, elevated lactate dehydrogenase (cell necrosis) and a wedge-shaped right kidney on CT likely has renal infarction most commonly due to thromboembolism. Systemic thromboembolism commonly is due to *Atrial Fibrillation*

Renal, Urinary Systems & Electrolytes

Pt with urgency, frquency, a weak urinary stream and straining on micturition. He notes noturia, and Oliguri alternating with polyurea. Pts kidneys most likely will demonstrate *Parenchymal pressure atrophy* (BPH)

811

Pathology

813

Renal, Urinary Systems & Pathophysiology Electrolytes

814

Pathology

Renal, Urinary Systems & Electrolytes

Pt with hexagonal crystals on urinalysis has cystinuria which *AMinoAcidUrea*

817

Pathophysiology

Renal, Urinary Systems & Electrolytes

*Increased citrate saturation* helps prevent claculi formation.

819

Pharmacology

Infectious Diseases

An HIV drug that can cause Hyperglycemia is *Atazanavir* {Protease Inhibitors cause hyperglycemia, lipodystrophy, and dyslipidemia]

820

Pathology

Rheumatology/Orthopedics Digital Clubbing can be caused by Lung Disease. E.g: & Sports Bronchiectasis

821

Physiology

Endocrine, Diabetes & Metabolism

822

PathophysiologyInfectious Diseases

In HBV caused hepatocellular carcinoma, the *Viral DNA integration into Host Genome* us the cause of neoplastic change.

823

Pharmacology

Cardiovascular System

Pt wirg ST segemnt MI who is given a fibrinolytic and becomes camatose with asymmetrical pupils and irregular breathing probably has *Intracerebral Hemorrhage* as an adverse affect of fibrinolytic therapy.

824

Physiology

Rheumatology/Orthopedics Lack of Tubules in muscle fibers will result in *Uncoordinated & Sports contraction of myofibrils*

829

Pathology

Hematology & Oncology

Pt has had an aortic valve replacement. His peripheral bloods smear shows fragmented RBC's (Shistocytes or helmet cells) will have *Decreased Serum Haptogloboin*

831

Pathophysiology

Renal, Urinary Systems & Electrolytes

*vesicouretral urine reflux* predisposes a woman who had frequent bladder infections to pyelonephritis because the the vesicouretral junction is weakened.

Pathology

Renal, Urinary Systems & Electrolytes

Pt with multiple risk factors for athersclerosis including age, HTN, hyperlipidemia and smoking. He presents with post prandial abdominal pain accompanied by weight loss. He has one large kidney on CT. This characteristic of *Renal Artery Stenosis*

834

Pathology

Renal, Urinary Systems & Electrolytes

Acute onset Gross hamturia in an otherwise healthy pt with family history of sickle cell disease suggests *Renal Papillary Necrosis* and an underlyin sicke cell trait.

836

Pharmacology

Dermatology

Terbinafine*inhibitssqualeneepooxidase*

837

Embryology

Renal, Urinary Systems & Electrolytes

The mcc of unilateral fetal hydronephrosis is inadequate canalization of *UretroPelvic Junction*

838

Anatomy

Gastrointestinal & Nutrition Head and Body of Pancreas are Retroperitoneal.

832

Stones in the ureter suggests calcium stones. The most common risk factor for calcium stone is *Hypercalciurea* that is usually idiopathic. Patients however have *Normocalcemia* due to Ca regulation by vitD.

tan-Fat containing tissue found around the kidneys and adrenals of a newborn is Brown Fat that helps to prevent *Hypothermia* by producig heat.

Anatomy

Pelvic fracture in a male can result in urethral injury leading to inability to void despite full bladder sensation. The most commonly MaleReproductiveSystem injured site is the *membraneous urthera* which is right after the prostatic urethra. Both membranoeous and prostatic are part of the post urethra.

841

Pharmacology

Pt who attempts suicide using an insecticide. She presents with nausea, vomiting, abdominal pain and copious diarhea. Her breath Gastrointestinal & Nutrition has a garlic odor. This most likely Arsenic Poisoning and *Dimercaprol* should be adminstered immediately.

843

PathophysiologyCardiovascular System

845

Microbiology

839

In CHF there is a compensatory *Increase in Arterial Resistance*

Rheumatology/Orthopedics rash with slapped cheek appearance is of Erythema infectiosum & Sports caused by parvo virus B19, disease is also called Fifth disease.

847

Biochemistry

Endocrine, Diabetes & Metabolism

Cells that express more glucose transporters as insulin levels increase are *skeletal muscle cells* and adipocytes. Cell that have constant glucose transporter expression even as insulin level increases are *Renal tunular cells* also brain, intestine, RBC, and Liver

848

Pathology

Endocrine, Diabetes & Metabolism

Pt with Type 2 Diabetes. Most likely assoc with his condition is *Pancreatic islet amyloid deposition*

851

Pharmacology

Nervous System

The parameter that correlates to the potency of an inhaled anesthetic is *Minimal Alveolar Concentration*

852

Pharmacology

Nervous System

Thioepntal is a short acting barbiturate used for anesthesia induction. After equilibrium in the brain, rapidly redistributes into SKELETAL MUSCLE and adipose tissue. It mechanism is increasing the inhibitory effects of GABA receptors in the CNS.

854

Pharmacology

Nervous System

Anesthesia with isoflurane would increase *Cerebral blood flow*

855

Pharmacology

Nervous System

Pt with fever and muscle rigidity soon after surgey. He has high BP and high HR. P.E shows muscle stiffness and cyanotic skin mottling. Most approprate treatments affects *Intracell Ca release in skeletal Muscles* (Pt has Malignant Hyperthermia, Treated with Dantrolene, a muscle relaxant that acts on ryandoine receptor and prevents further release of Ca)

856

Pharmacology

Nervous System

The cause of rapid plasma decay of thiopental was not metabolism of the drug but rather *redistribution of the drug to other tissues* throughout the body.

859

Pharmacology

Colchicine has side effects of ABdominal pain, nausea and Rheumatology/Orthopedics diarhea. It binfs to tubulin and therefore affects the cell & Sports *Cytoskeleton*

863

Pathology

Ophthalmology

Pharmacology

Treatment with osmotic laxatives such as polyethylene glycol represents the same mechanism of *lactase deficiency* in which Gastrointestinal & Nutrition there is a nonabsorbable osmotic substance that causes increase in water and electrolyte secretion leading to diarrhea.

865

Nervous System

Infant with white pupillary reflex and father has had a retinal neoplasm during childhood most likely has Familial Retinoblastoma. He is at greastest risk for developing *Osteosarcoma*

Child with High fever and seizures has febrile seizures and shud be given *Acetominophen* (Antipyretic, never give aspirin to a child)

866

Pharmacology

867

Pt with persistent shoulder and back pain and easy fatigability. She has pain and stiffness in all her muscles.She has difficulty Rheumatology/Orthopedics concentrating. There is normal range of motion and 5/5 muscle Pathophysiology & Sports strength. Soft tissue tenderness is present at several locatons. Most likely DX is *Fibromyalgia*

868

Biochemistry

Hematology & Oncology

A new born baby has fetal HB prdominantly (alpha 2 gamma 2) which changes to adult Hb (alpha 2 Beta 2) within the next six months.

869

Pathophysiology

FemaleReproductive System & Breast

Cervical Intraepithelial neoplasia can be caused by HPV infection which can result from sexual infection due to *Lack of barrier contraception*.

871

Pathology

Nervous System

Ischemic injury to the brain results liquefactive necrosis in which there *Lysosomal Digestion of (necrotic) Tissue*

873

Pathology

Hematology & Oncology

Alcoholic with hypersegmented neutrophils in blood smear likely has *Folate Def*

876

Pathology

Dermatology

3 year old presents with recurrent skin rashes. He develops erythematous itching rash on his cheeks, trunk, and arms abut 5 or 6 times a year. Mother says eruptions seem to be related to consumption of certain foods. The pt's condition is most likely associated with *Astham* [Atopic Dermatitis or Eczema]

877

Pathology

Pulmonary & Critical Care

Black woman Pt with malaise, cough and rash wityh X-ray revealing bilateral hilar lymphadenopathy and transbronchial autopsy showing non-caseating granuloma has *SARCOIDOSIS*

Pathology

6 yr old is brough tdue to confusion and intractable vomiting. Mother says he had a febrile illness two dasy ago and she gave him "Some over-the-counter pills and it helped his fever. While you Gastrointestinal & Nutrition talk to mother, the boy lapses into a coma. Light microscopy of his liver will reval *Microvesicular steatosis* [Rye Sydnrome, hepatic encephalopathy due to aspirin intake after a viral illness in kids]

881

882

Genetics

Cardiovascular System

Majority of Down syndrome have trisomy 21 that happens as a result of *Chromosomal nondisjunction* during the 1st meitic division of the ovum. Incidence increases with maternal age. Only about 4 percent of down syndroem is caused by Robertsonian Translocation.

886

Pathology

Renal, Urinary Systems & Electrolytes

In acute Tubular necrosis. The most important complication during the Recovery Phase is *Hypokalemia*

888

Pathology

Renal, Urinary Systems & Electrolytes

Pt with UTI. Most specific finding for a Dx of Pyelonephritis is *White blood Cell casts*

889

Histology

Hematology & Oncology

Hemolytic anemia signs with blood smear showing spherocytes (no cetral pallor) indicates spherocytosis which is *RBC cell memberanecytoskeletonabnormality*

PathophysiologyHematology & Oncology

Pt with anemia, reticulocytosis and increased indirect bilirubin. Blood smear shows RBC without central pallor. Pt is most likely to have *Increased mean corpuscular Hb concentration* {HereditarySpherocytosis]

893

Pharmacology

Hematology & Oncology

Dapsone when used as prophylactic Tx for pneumocystis jiroveci in the setting of allergy to TMP-SMX (Drug of choice)in HIV infected patients can trigger GDPD anemia, which is an *Ezyme deficiency Anemia*. Symptoms include red cell fragments, microspherocytes, and bite cells.

894

Pathology

Hematology & Oncology

G6PD has an *X-linked recessive* mode of inheritance.

Hematology & Oncology

infant with Hb electrophoresis showing: HbF=70%, HbA=20% & HbS=10%. Mother has sick cell trait. Pt hasn no pallor or splenomegaly. Most likely true abt this pt is that *She has relative protection from Plasmodium Falciparum* [Sickle cell trait]

890

895

Pathology

896

Pathology

Hematology & Oncology

African Am woman with sickle cell disease is admitted cuz of fever, chills, and malaise. She has a hight WBC count and neutrophilia. She becomes hypotensive and dies. Her blood cultures are most likely to grow *Step Pneumo* [Sicle Cell pts eventually become "functionally asplenic" and at risk with encapsulated bacteria infection. Strep Pneumo is the most commob. H flu is the second] [Salmonella is MMC of osteomyelitis in children]

897

PathophysiologyHematology & Oncology

Pt with sign of abdominal pain, ascites, anemia, thombocytopenia, hypercoagulability (e.g hepatic vein thrombosis) and a flow cytometry that shows CD55 & CD59 Deficiency has Paraoxysmal nocturnal hemoglobinuria whcih results in a hemolytic anemia due to*ComplementActivation*

899

Pharmacology

Cardiovascular System

Amiodarone (class 3 antarrythmic) tho it prolongs QT interval (like other class 3's and 1A's) it does not increase risk of torsades.

900

Pharmacology

Cardiovascular System

An antiarrhythmic agent that binds perferentially to rapidly depolarizing and ischemic ventricular myocardial fibers and has minimal effect on normal ventricular myocardium is *Lidocaine* It is effective in inhibiting ischemia-induced ventricular arrhythmias.

901

Pharmacology

Cardiovascular System

Know that Dofetilide is a class 3 anti-arrhythmic medication (K channel blocker)

Nervous System

Pt been acting strange, not seeming to care about family (flat affect), aggressivness, periodic random jerky movements (Choreiform). Pts probably has Huntington's disease. There is Def of *GABA* neurotransmitter.

Pharmacology

Pulmonary & Critical Care

Pt presents with dyspnea and weakness. Mother had similar symptoms and died at age 42. Lung biopsy shows medial hypertrophy, intimal fibrosis and decreased intraluminal diameter if small branches of pulmonary artery. Pt is scheduled for lung transplantation. The medication indicated for management during the waiting period is *Bosentan* [Pt has idiopathic pulmonary a hypertension][Bosentan is endothelin-receptor antagonist, it blocks vasoconstricting affects of endothelin]

Genetics

Renal, Urinary Systems & Electrolytes

Pt with painless hematuria, right sided renal mass, cytoology of malignant cells with chromosome 3p deletion. No significant family history. Findings indicate Sporadic Renal cell carcinoma which is due to deletion of VHL gene on chromosome 3.

902

903

904

906

Pathology

Pathology

Nervous System

Sensory ataxia and argyll robertson pupils are characteristic of tabes dorsalis which a manisfestation of tertiary syphils caused by treponemapallidum*Spirochete*. The argyll roberston pupils are casued by spirochete inavading the midbrain tectum.

907

Signs of encephalities (fever, headache, aphasia, mental alteration) with temporal lobe lesions indicate *HSV ENCEPHALITIES*

Microbiology

Infectious Diseases

914

Pathology

Elderly woman with jaw pain during chewing (Jaw claudication), Rheumatology/Orthopedics An episode of vision loss in one eye that resolved (amaurosis & Sports fugax). Best initial test is *Erythrocyte Sed Rate* [Giant cell Arteritis][C-reactive protein is also indicated]

915

Pathology

Nervous System

Rapid correction of Hyponatremia results in *Osmotic Demyelination Syndrome*

920

Pharmacology

Endocrine, Diabetes & Metabolism

A drug that activates peroxisome-proliferator activated receptor-y (a nuclear receptor and transcription factor) (such drugs are the -glitazones) results in *Decreased Insulin Resistance*

921

Pathophysiology

Endocrine, Diabetes & Metabolism

To diagnose Type diabetes melitus use *Fasting blood glucose level*, random glucose, or HbA1c.

922

Pathophysiology

Endocrine, Diabetes & Metabolism

A fetus born to a mother who had gestational diabetes would have hypoglycemia due to *Beta cell hyperplasia* [Pancreas is used to a lot of glucose from mother. After delivery, glucose suddenly stops but beta cells are still high in number and secreting insulin, resulting in hypoglycemia]

925

Pathophysiology

Endocrine, Diabetes & Metabolism

Amenorhea in pt involved in strenous excersie and low body wieght is caused by *HYpothalamic Suppression*

Endocrine, Diabetes & Metabolism

Pt with history of SLE dies at home. At her last P.E, her BP was 150/90. Clinical records show progressive truncal obesity, facial plethora, and proximal muscle weakness. Lab showed mild hyperglycemia. Evaluation of her adrenal galnds will most likely show *Bilateral cortical atrophy* [Iatrogenic cushing syndrome due to prolonged glucucorticoid use, leads to supression of of hypothalamic oituitary axis]

Endocrine, Diabetes & Metabolism

Pt with HTN at young age together with weakness and paresthesias (electrolye or acid-base disturbance) and low Renin levels is consisent with Primary Hyperaldostronism. His Serum level of *Na is normal, K is low, HCO3 is High* (Na is normal due to aldostrone escape)

Endocrine, Diabetes & Metabolism

An infant boy with recurrent vomitting (salt wasting) and poor feeding and P.E shows dehydration (salt wasting) and hypotension with labs showing low sodium (wasting) and hyperkalemia. Pt probably has Congenital Adrenal Hyperplasia - 21-hyrdoxylase deficiency. There would be low cortisol, low aldo, high ACTH, and *High 17-hydroxyprogestrone* which is a precuror to cortisol synthesis.

928

929

Pathophysiology

Pathophysiology

930

Pathophysiology

933

Endocrine, Diabetes & Pathophysiology Metabolism

934

Biochemistry

Symptoms of Headache, tachycardia, diaphoresis and severe HTN. THese resolve before Tx is given. Same thing happened a month ago. This is pheochromocytoma and there is *Elevated catecholamine release*

Endocrine, Diabetes & Metabolism

Sorbitol produced by aldolase reductase is normally metabolized to *Fructose*

937

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Pt that is Dx with panic disorder and is given a drug that relieves symptoms within an hour. Drug is prbably Benzodiazepine which *Binds Allosterically to GABA receptor* Barbiturates work on a different allosteric site and prolong duration of channel opening in response to GABA.

939

Pathology

Cardiovascular System

Most common cause of aortic stenosis in the elderly is *Valvular Calcification*

PathophysiologyCardiovascular System

Presence of a holosystolic heart murmur indicates Mitral valve Regurgitation. Its severity can be indicated by the presence of an *S3 gallop* which indiactes severe disease and indicates rapid ventricular filling due to large volume of regurgitant blood re-entering the ventricle during mid-diastole.

947

Pathology

Cardiovascular System

Pt with midsystolic click followed by short late-systolic murmur at apex. Murmur disappears with squating. Pt's condition is related to *Connective Tissue* [Pt has Mitral valve prolapse with mitral regurgitation]

949

Pharmacology

Cardiovascular System

A side of ACE inhibitors is cough and Angioedema (elnlarged lip) tat is caused by *Bradykinin accumulation*

944

951

Physiology

Cardiovascular System

The most significant factor limiting coronary blood supply during an exercise test is *Duration of Diastole* (Myocardial Perfusion happens during Diastole)

953

Immunology

Hematology & Oncology

CCR5 protien plays a role in HIV entry into CD4+ Cells. Blocking of CCR5 receptor blocks entry of HIV into cells.

955

Genetics

Pregnancy, Childbirth & Puerperium

Pt with Clitromegally and High Androgen levels with Maternal Virilization probably has *Aromatase Deficiency*

956

Renal, Urinary Systems & Pathophysiology Electrolytes

Pt with Metablic Alkalosis (pH > 7.45 & pCO2 >24). Lab study most useful in diagnosing pt is *Urine Chloride* Note: Volume status and urine chloride are important in the workup of metablic alkalosis.

Microbiology

Pulmonary & Critical Care

Pt with persistent cough and pulmonary infiltrate. Pt's blood shows clumping in ice but not in warm water. Organism causing condition? => *Mycoplasma Pneumonia* -(ColdAgglutinin)

Pulmonary & Critical Care

Heavy smoker with fever, confusion, headache, watery diarrhea and mildy productive cough. Sputum gram stain show numerous neutrophils but no bacteria. Most likely cause is *Legionella Pneumophila* [Triad of atypical pneumonia, diarrhea, and hyponatremia][poor gram stain][long smoking Hx]

Pulmonary & Critical Care

Microogranism causing pneumonia is isolated and demonstrates slow growth on Buffered Carcoal Yeast Extract that is supplemented with L-cystein and Fe. It is visualized with a silver stain. Most likely cause of increased incidence of nosocomial punemonias in his hospital is *Colonization of the hospital water sysetm* (Legionella)

958

960

961

Microbiology

Microbiology

962

Microbiology

Pulmonary & Critical Care

5 yr old boy has hugh serum level of antibodies against Polyribitol ribose phosphate(PRP). The antibodies would most likely carry protectionagainst*Epiglottitis* [Anti H. Influenza capsule antibodies]

964

Microbiology

Pulmonary & Critical Care

H. influenza requires a blood agar supplemented with hematic and NAD+. Pathogenicity is related to *Capsule* Virulence factor [H.INFLU type B (HiB)]

965

Immunology

Allergy & Immunology

We conjugate the H. Influenza capsular polysaccharide together with diptheria toxoid in the vaccine because this combination *IncreasesImmunogenicity*.

966

PathophysiologyNervous System

In tetanus, release of *Glycine* neurotransmitter is inhibited.

968

Microbiology

Infectious Diseases

Neoborn presents with inability to open mouth and hands are clenched all day. P.E shows increased muscle tone, arching of the back, and dorsiflexed feet. This could ve been prevented with *Vaccination of pregnant woman* (Neonatal tetanus)

969

Pathology

Nervous System

Pt with suspected tetanus who sustained a minor lower extremity wound 1 week ago should have *History and Physical exam* as the most important in making a Dx.

Infectious Diseases

Ulcer with central black eschar surrounded by edema suggest Bacillus Anthracis. Helping in making a diagnosis would be *Occupation* [exposure to animal or animal products, if no risk of occupational exposure then there is potential of bioterrorism]

971

Microbiology

974

Microbiology

Pt who has recently been to a resort presents with ithcy rash. Exam shows diffuse, pruritic, papuloppustular rash on trunk and Rheumatology/Orthopedics extremities. Analysis of fluid shows oxidase +ve grame -ve rods that prodcuces a pigment on culture medium. Most likely source of & Sports this infection is *Pool water* (Psuedomonas hot tub folliculitis)

976

Microbiology

V Cholera is oxidase positive, g-ve, commam shaped rod that can Gastrointestinal & Nutrition grow on alkaline media. Stool microscopy reveals *Mucous and some sloughed epithelial cells* with No fecal leukocytes or RBC's.

978

Pathophysiology

Pt with lung mass and Hypercalcemia but with no bone focal lytic Rheumatology/Orthopedics lesions probably has Malignancy-associated hypercalcemia that is & Sports characterized by elevated *Parathyroid hormone-related protein* Pt with celiac disease will also develop vit D deficiency due to defective mucosal absorption, presenting as bone pain and weakness (Adult). Lab test would reveal *low Ca, Low PO4-, High PTH* [No vit D decreases absorption of Ca AND PO4- from GI tract]

981

Pathophysiology

Endocrine, Diabetes & Metabolism

982

Pathophysiology

Rheumatology/Orthopedics In primary osteoporosis, serum Ca and PTH levels are typically & Sports *Normal in range*

984

Pathology

Pt with non-caseating granuloma, lymphadenopathy, and hypercalcemia could have sarcoidosis. The elevated Ca level is Rheumatology/Orthopedics due to *Activated Macrophages* how? There is increased & Sports expression of 1-alpha hydroxylase in activated macrophages which causes PTH-independent production of 1,25-dihydroxyvitD leading to increase intest abs of ca and hence hypercalcemia.

985

Pathophysiology

Endocrine, Diabetes & Metabolism

In DKA there is *Increased (or normal) extracell K & Decreased Intracell K**

Pathology

Endocrine, Diabetes & Metabolism

Pt with elevated serum gastrin levels. Multi organ disease is suspected. Pt should be asked for a history of *MEN type 1* (MEN Type 1 has primary hyperparathyroidism, pituitary tumors, and pacnreatic tumors (esp "Gastrinomas"))

Physiology

Biopsy of a pt shows haphazardly oriented segments of lamellar Rheumatology/Orthopedics bone with prominent cement lines. The pathogenesis of the condition initially involves increases activity of *Osteoclasts* & Sports (Osteolytic phase of paget disease of bone)

986

987

990

Physiology

Endocrine, Diabetes & Metabolism

Aching bones and insdeous pain in back, pelvis and lower extremities, combined with reduced sunlight exposure suggests Vit D deficiency. UV light from the sun converts *7-dehydrocholesterol* into *Cholecalciferol (Vit D3)*. Vit D3 is then converted into 25-hydroxycholecalciferol by 25-hydroxylase. 25-hydroxycholecalcifrol is then converted to 1,25-dihydroxycholecalciferol (active vitD) by 1-alpha-hydroxylase. This is the enzyme in the kidney acted on by PTH (+) and Ca2+ (-).

992

Physiology

Endocrine, Diabetes & Metabolism

Pt with mild hypercalcemia, borderline high PTH levels and urinary Ca that is very low and normal 25-hydroxyvit D pobably has a mutation in *Membrane-bound receptor coupled with a G-protein*

995

Biochemistry

GeneralPrinciples

After a ligand binds to a G protein-coupled receptor that activates phopholipase C, membrane phospholipids are broken down to DAG and IP3. *Protein Kinase C* is subsequently activated by DAG and Ca.

996

Biochemistry

GeneralPrinciples

If lactic acid is accumulatimg that means there is increased activity of Lactate dehydrogensae and DECREASED activity of *Pyruvate Dehydrogensae*

997

Biochemistry

Endocrine, Diabetes & Metabolism

Oxaloacetate-----> Phosphoenolpyruvate (catalyzed byPEP carboxykinase) is the 2nd commited step in gluconeogenesis which predominates in starvation states.

998

Biochemistry

Endocrine, Diabetes & Metabolism

Pts with pyruvate dehydrogenase deficiency should be on a ketogenic diet. Soley Ketogenic aminoacids include *lysine* and leucine.

999

Microbiology

Pulmonary & Critical Care

A newborn who develops lethargy and respiratory distress. Blood cultures shows beta-hemolytic gram+ve cocci in chains that are bacitracin-resistant. The measure that could have prevented this patients condition is *Intrapartum ampicilin* [Strep Agalactiae, ie. Group B strep]

1000

Pharmacology

Infectious Diseases

Bcteria that produce an enzyme (Aminoglycoside-modifying enzyme) transfer an acetyl group to exogenous substance can gain resistanc to *Gentamicin*.

1001

Microbiology

Cardiovascular System

Pt with Strep Gallolytics (S.Bovis) infection. Additional workup should focus on *Colonic Neoplasia*

1003

Microbiology

Cardiovascular System

Viridans Steptococci are normal inhabitants if the oral cavity and are a cause of transient bactremia after dental procedures in healthy and diseased individuals. In pts with pre-existing valvular lesions, viridans streptococci can adhere to *Fibrin-Platelet Aggregates* and establish infection that leads to endocarditis.

1004

Pharmacology

Infectious Diseases

Management of household contacts of Meningococcl infection sis *Prophylactic Rifampin*

1005

Microbiology

Nervous System

Neisseria meningitidis uses pilus roteins to attach to *Nasopharynx epithelial cells*

1006

Microbiology

Nervous System

Pt with signs of meningitis and blood culture showing g-ve kidney bean-shaped diplococci, the microbial component causing morbidity is *Outer membrane LipoOligosaccaride*

Infectious Diseases

Pt with asymmetric polyarthritis (knee, elbow, wrist)with synovial fluid analysis showing neutrophilic predominanc and intracellular organisms most likey has "Neusseria Gonorrhoeae". *Condom use could ve prevented it*

Endocrine, Diabetes & Metabolism

Insuline resistance by the pancreatic cells i sstimulated by increased ATP production. *Glucokinase* functions as a glucose sensor in pancreatic beta cells by controlling the rate of glucose entry into the glycolytic pathway. Mutations in the *glucokinase* gene are a cause of maturity-onset diabetes of the young.

Cardiovascular System

The anthracyclines (daunorubicin, doxorubicin, epirubicin, and idarubicin) are chemotherapeutic agents associated with severe Cardiotoxiity thru generation of free radicals. They cause *Dilated Cardiomyopathy* Hypovolemia reduces RPF and hence *GFR*. This activates a compensatory mechanism that systemical vasocnstricts leading to further *reduction in RPF*. However, another reflux is increased angiotensin 2 release due to decreased GFR that would vasoconstrct efferent arteriole and help maintain GFR. As *RPF is lower than GFR*. *FF Rises*.

1007

1010

1014

Microbiology

Biochemistry

Pharmacology

1016

Pathology

Renal, Urinary Systems & Electrolytes

1018

Physiology

Gastrointestinal & Nutrition Lipid absorption occurs in the Jejunum.

1019

Biochemistry

Endocrine, Diabetes & Metabolism

Pt has absent lactate dehydrogenase activity in muscles. In this pt, strenuous exercise leads to inhibition of glycolysis in skeletal muscles due to intracellular depletion of *NAD+*

1021

Biochemistry

Endocrine, Diabetes & Metabolism

Homeless pt with signs of wernicke encephalopathy after admin of glucose without thiamine supplemenation would have an impaired *Alpha ketoglutarate to Succinly CoA reaction* [Thiamine is needed for alpha ketogluyerate dehydrogenase][Also needed for other dehydrogenases and transketolase]

1022

Biochemistry

Endocrine, Diabetes & Metabolism

A direct source of energy in the TCA cycle is in the conversion of succinylcoA into Succinate thus yeilding GTP.

1026

Microbiology

Infectious Diseases

Tx of Neisseria Gonorrhea does not appear to provide lasting protective immunity due to *High variability of microbial antigenic structure* and hence recurrent infections occur.

FemaleReproductive System & Breast

Pt presents to fertility clinic. Attempting to concieve for past year, no success. She used OCP for 15 years. 7 years ago she got ceftriaxone for fever, abdominal pain, and vaginal discharge. Major contributing factor to her inability to conceive is *Insufficient antibiotic use* [PID was treated only for gonorhea, azithro was not used for coverage of chlamidya, this led to subclinical continous infection that led to scaring of fallopian tubes and subsequent infertility]

GeneralPrinciples

The rate of glycogenolysis within myocytes increases several x100 during active skeletal muscle contraction. The substance that synchronizes these two processes is *Ca2+*

Endocrine, Diabetes & Metabolism

Increasing fructose-2,6-bisphosphate promotes glycoloysis (insulin like effect) and inhibits Gluconeogensis. Inhibiting Gluconeogenesis means less alanine and other glucuneogenic substrates are converted to glucos.

1027

1028

1031

Microbiology

Biochemistry

Biochemistry

1034

Biochemistry

Endocrine, Diabetes & Metabolism

During fasting, maintenance of pt blood glucise is facilitated by hepatic conversion of pyruvate into glucose. The substance that is an allosteric activator of the first step of this process is *Acetyl-CoA* [Gluconeogenesis]

1035

Biochemistry

Hematology & Oncology

Synthesis of ribose from fructose-6phosphate can be done using *Transketolase*.

1036

Biochemistry

Hematology & Oncology

G6PDconvertsglucose-6-phosphateto6-phosphogluconate

Nervous System

3 month old infant with Hydrocephalus, Intracranial Calcifications and Chorioretinitis has "Congenital Toxoplasmosis" which is tansmitted transplacentally and the cause is therefore *In-Utero-Infection*

Cardiovascular System

Pt with chest pain that radiates to left shoulder. Pain increases with inspiration and partially relieved by sitting up and leaning forward. She was seen for a facial rash 6 month ago. She is also being evaluated for proteinurea. Cause of this pt's chest pain is *Pericardial Inflammation* (Manifestation of SLE)

Dermatology

In shingles, affected are would have *Multinucleated cells with Intranuclear inclusions* [VZV]

Infectious Diseases

An unvaccinated infant is brought with a rash. Three days ago, she developed fever, along with cough, congestion, and red eyes. Rash appeared on face and spread to trunk and arms. The def assoc with increased complications from this pt condition is *Vit A* [Measles virus]

1038

1040

1042

1045

Microbiology

Pathology

Pathology

Pathology

1049

Pathology

Renal, Urinary Systems & Electrolytes

Pt with chronic lower back pain who has been using over the counter NSAIDS ever since pain started 8 years ago. He has elevated BP, trace lower extremity edema. High BUN. High Creatinine. 1+ protein and 3-4 WBC in urine. Renal ultra sound shows bilateral shrunken and irregular kidneys with few papillary calcifications. Most likley cause of renal dysfunction is *Crhonic Interstitial Nephritis* [NSAID associated chronic renal injury]

1050

Pathophysiology

Renal, Urinary Systems & Electrolytes

Uric acid would percipitates in *Collecting duct and distal tubule due to low urine pH*

Pathology

In klinefelters syndrome there is *Increased FSH* due to loss of feedback Inhibition due to decrease in Inhibin levels (from sertoli MaleReproductiveSystem cells. There is also decreased testestrone (damage to leydig cells) that is from primary hypogonadism.

Pathology

FemaleReproductive System & Breast

Asymptomatic pt's mamogram reveals microcalcifications. Biopsy shows ducts distended by pleomorphic cells with prominent central necrosis. Origin of this lesion is the *Breast Duct* [Ductal Ca in Situ]

Nervous System

Ascending paralysis after upper resp tract infection. Condition most likely associated with *Endoneural inflammatory infiltration* [GBS after C.jejuni infection]

Hematology & Oncology

Intracranial Hemorrhage and its associated signs without signs of trauma in a newborn that didnt receive vaccines is most likely due to *Impaired clotting facotor carboxylation* as in vit K deficiency.

Endocrine, Diabetes & Metabolism

Pt presents with myalgias, anorexia, and skin rash. He has been consuming raw white eggs for several months. P.E shows macular dermatitis of extremities. A water soluble vit def is suspected. The biochemical conversions that most likely uses the def vit as a cofactor are *Pyruvate to Oxaloacetate* [Vit B7 (Biotin) needed as a cofactor for Carboxylases]

Dermatology

Pallegra which is due to niacin (ViB3, precursor to NAD) deficiency is characterized by Dermatitis (skin rash on sun exposed), Diarrhea, and Dementia (irritable, hostile, dioriented). Niacin is obtained from diet or synthesized in body from *Tryptophan*. Therefore, Tryptophan is the precursor for the compensatory pathway for NAD synthesis.

1055

1057

1058

1062

1063

1064

Pathology

Physiology

Biochemistry

Biochemistry

1065

Physiology

Endocrine, Diabetes & Metabolism

Pt presents with progressve lethargy. For past 3 weeks she had loss of appetite, constipation, muscle weakness, polyuria and polydipsia. She has been taking large doses of vitamins. Exam shows she is stuporous and has dry mucus membranes. The metabolic abnormality in this pt can also be found in *Sarcoidosis* [Hypercalcemia]

1068

Biochemistry

Gastrointestinal & Nutrition

The substance with the fastest rate of metablosim in the glycotic pathwayis*Fructose-1-phosphate*

1070

Biochemistry

Endocrine, Diabetes & Metabolism

Pt with hereditary defect in fructose metabolism. He is asymtomatic however. This pt is still able to metabolize fructose due to compensatory activity of *Hexokinase* [Essential fructose uea]

1072

Biochemistry

Gastrointestinal & Nutrition

Lactose intolerance is due to absence of enzyme lactase which convertsGalactosyl-B-1,4-glucose(LACTOSE)intoGalactose.

1073

Biochemistry

Endocrine, Diabetes & Metabolism

In Aldolase deficiency, remove *Sucrose* from Diet.

1077

Pharmacology

Hematology & Oncology

A medication that is a low molecular weight fraction of a negatively charged chemical stored in mast cell granules. Its mechanism of action is *Binding to antithrombin 3* [LMW Heparin]

1079

Pharmacology

Hematology & Oncology

A platelet surface glycoprotein receptor that normally binds fibrinogen to support platelet agreggation is Gp2b/3a. This is targeted by *Abciximab*

1080

Pharmacology

Cardiovascular System

A drug given in periheral artery disease that provides symptomatic improvement due to direct dilation of arteries and inhibition of platlet aggregation is *Cilostazol* [Phosphodiesterase Inhibitor]

1082

Physiology

Hematology & Oncology

Fibrinolytics are used in ST segment elevation MI. They may cause reperfusion arrythmias on arterial re-opening. These are usually benign. An example is *tPA* [Tissue plasminogen activator]

1083

Pathology

Hematology & Oncology

BRCA1/2 (breats and ovarian cancer) is responsible for *DNA repair*

Hematology & Oncology

Previously healthy woman comes due to fever and sore throat. P.E shows tonsillar exudate and nontender cervical lymph nodes measuring 3.5cn. Antibiotics are started. A week later, pt says symptoms resolved but the cervical lymph decreased lil bit inside. On follow ups, the node fluctuates in size but doesnt disappear. Most likely seen on biposy is *Follicular Lymphoma]

Hematology & Oncology

For Heparin Overdose give *Protamine* (Not Fresh frozen plasma) (For warfarin overdose give FFP before vitK, protamine ineffective for warfarin overdose)

Cardiovascular System

Emigrant child with unknown history of vaccination who presents with fever, throat pain, an dyspnea. There is coalescing gray pharyngeal exudate and cervical adenopathy. He later dies of Myocarditis and HF. Pt most likely has Diptheria and could have been prevented by DTP vaccine which has diptheria toxoid which provides *IgG against circulating proteins*

Infectious Diseases

6 year old of recently immigrant family comes due to sore throat and fever. Exam shows mild tonsilar erythema with exudates. Microscopy shows clumped, gram +ve bacteria with polar granules that stain deeply with aniline dyes. The pathogenicity of the organism likely causing this condition is *Impairment of protein Synthesis* (Diptheia toxin, ADP-ribosylation of EF-2)

Infectious Diseases

6 yr old with fever and sore throat. Non immunized. P.E shows a grey pharyngeal exudate and gram stains shows g+ve organisms. The culture type that facilitate teh growth of this organism is *Cystein-tellurite agar* [C.DIPTHERIA] [Bordet-Gengou medium is for pertusis, thayer martin for gonorrhea, mcConkey is for enterics]

1086

1087

1092

1093

1095

Pathology

Pharmacology

Microbiology

Microbiology

Microbiology

1097

Microbiology

Hematology & Oncology

Pt with somnolence, lethargy, and oliguria with bloody diarrhea. He has high urea, BUN and creatinine. Blood smear reveals fragmented erythrocytes, Pt has HUS which is related to the consumption of *Undercooked Beef*

1100

Microbiology

Gastrointestinal & Nutrition

The toxin of EHEC *Inactivates ribosomal subunits* [Just like shigella toxin]

1101

Microbiology

Pt present with sore on his right hand. He is in Wool business. Was recently in Asia. P.E shows an ulcer with black eschar and siginificant surrounding edema. The toxin causing the edema Rheumatology/Orthopedics around the ulcer has a MOA similar to a toxin produced by & Sports *Bordetella Pertussis* (Bacillus Anthracis, anthrax exotoxin edema factor similar to adenylate cyclase toxin of bordetella pertusis)

1104

Pharmacology

Infectious Diseases

Trimethoprim has the same inracellular target as *Methotrexate*

Dermatology

Pt with inflamatory acne. The glands involved release secretions by *Holocrine* manner. [Sebacious glands]

Dermatology

Pt comes for routine check up and you notice several subcutaneous bumps attached to Achilles tendons. Best initial test is *Blood Cholestrol* Pt has tendinous xanthomas (yellow nodules composed of "lipid" laiden histiocytes in the dermis) -Associatedwith(FamilialHypercholestrolemia)

1106

1108

Anatomy

Pathology

1111

Pathology

Dermatology

Pt presents with pruritic skin rash over elbows and knees. He also has prolonged abdominal discomfort, faltulence and voluminous greasy stools. The finding most likely to be seen in this pt is *IncreasedIntestinalintraepitheliallymphocytes* [Pt has Dematitis Herpetiform which is associated with celiac disease that has increased intraepithelial lymphocytes]

1113

Pathology

Dermatology

Highest risk of metastasis in a malignant melanoma is *Active Vertical Growth*

1114

Pathology

Dermatology

Biopsy of Urticaria would show *Dermal Edema*

Dermatology

Pt with bilateral skin lesions over his elbows. Biopsy shows very thing stratum granulosum and prominent parakeratoic startum corneum with occasional foci of neutrophil accumulation. Most likely Dx is *Psoriasis*.

1117

Pathology

1118

Pharmacology

Cardiovascular System

Phosphodiesterase inhibitors such as Sildenafil lead to rise in intracellular cGMP and result in vasodilation. This signaling pathway is most similar to *Brain (and Atrial) Natriuretic Peptide* which bind to transmembrane receptors linked to guanyl cyclase that increases cGMP which activates cGMP-dependent kinase leadingtovasodilation.

1119

Biochemistry

Endocrine, Diabetes & Metabolism

Reactions of the pentos phosphate pathway (HMP shunt) occur in the cytoplasm. Therefore this includes activity of enzyme *Transketolase*

1121

Biochemistry

Endocrine, Diabetes & Metabolism

Insulin increases intracellular glycogen stores and decreases hepatic glucose release into blood (gluconeogenesis), it does so by activating *Protein Phosphatase-1*

Immunology

Dermatology

Pt presents with highly Pruritic (itchy) erythematous rash consisting of papules, vesicle and bulla following exposure to wilderness (Elctrician working in unmaintained woody area). Cells responsible for tissue damage are *T cells* [Poison IVY dermatitis, type 4 hypersen]

Microbiology

Depending on age and condition of host and the species of Shigella, as few as 10-500 cells can cause infection. *Shigella Gastrointestinal & Nutrition flexneru* [others include Entamoeba Histolytica, Giardia and C. jejuni]

1133

1136

1137

1138

1139

1140

Microbiology

Pathology

Microbiology

Microbiology

Infectious Diseases

AfricAmer womann with fev, malaise, and intense pain over right thigh. She has long history of frequent presentation to hospital with painful crises that respond to supplemental O2 & IV narcotics. The new episode is diff cuz is Febrile with exquisite thigh pain & abnormal MRI finding. Blood grows nonlactose-ferment, oxidase -ve, motile organism. Virulence mechanism is *Resistance to Opsonization* [Salmonella osteomyelitis in Sickle cell pt, encapsulated, functional asplenia]

Infectious Diseases

Pt recently went to south america presents with fever, headache, abdominal pain and 1 week history of watery diarrhea that has recently become bloody. He is febrile and P.E shows hepatosplenomegalyandseveralfainterythematousmaculopapular lesions on chest and abdomen. Most likely cause is *Salmonella Typhi* [Typhoid Fever]

Infectious Diseases

E.coli which shows green metalic sheen on EMB agar, hemolysis on blood agar, and lactos fermentation (pink) on McKonkey agar causes UTI's thru use of *Fimbrial antigen* which allows adhesion toUrothelium

Nervous System

Infant with meningitis and culture grows gram -ve rods that form pink colonies on McConkey agar has E.coli neonatal meningitis and the bacterial virulence factor is *Capsule* (K1 capsular polysaccharide)

1141

PathophysiologyInfectious Diseases

Pt with fever, skin flushing and altered level of consciousness. Low BP and blood culture positive for E. coli. They most likey have Septic shocks due to *Lipid A* which is part of E.Coli LPS which is released during either bacteriolysis and/or cell division.

1143

Pathology

Gastrointestinal & Nutrition

Infection with Shigella Sonnei though food. The cells primarily responsible for uptake of bacteria are *Microfold (M) cells*

Nervous System

A child with an intracranial calcified mass. On gross exam of mass after removal, it shows cystic spaces with thick brownish-yellow fluid that is rich in cholestrol. The mass is likely derived from cell responsible for forming the *Ant pititary* [Craniopharyngioma derived from Rathke's pouch] Child with brain tumor comprised o spindle cells that have hair like glial processes and are associated with microcysts. These cells are mixed wuth Rosenthal fibers and granular eosinophilic bodies. Most likely Dx is *Pilocytic astrocytoma*

1152

Pathology

1153

Pathology

Nervous System

1156

Pharmacology

Colichy abdominal pain, constipation, irritability and headaches, Gastrointestinal & Nutrition and works at battery factor, history of iron def anemia --> Lead posinong

1159

Histology

Rheumatology/Orthopedics Osteocytes are connected to each other by *Gap Junctions* & Sports

1161

Physiology

Renal, Urinary Systems & Electrolytes

ADH acts on *Medullary segment of collecting duct*

Cardiovascular System

Blanching of a vein into which NE is being infused together with induration and pallor of surrounding tissue suggets NE extravasation which is treated with *Phentolamine*

1164

Pharmacology

Pt smoked unknown substance. He displays uncoordinated jerky movements of extremities and assualts someone. He appears immune to pain. In the ER he has visual hallucinations and alternates between agitation and sedation. He is hyptertensive and tachycardic and has vertical nystagmus. Later, he doesnt remember anything that happened. MOA of drug is *N-Methyl-D-aspartatereceptorAntagonism*(NMDAAntagonist) [This is PCP]

Behavioral science

Psychiatric/Behavioral & Substance Abuse

1168

Pharmacology

A gout drug that causes nausea, vomiting and diarhea after intake Rheumatology/Orthopedics is a drug that *Inhibits microtubule formation* & Sports [Colchicine]

1174

Biostatistics

Cardiovascular System

Number Needed to Treat is 1/Absolute Risk Reduction. (ARR is: conrol rate - Tx rate)

1175

Biostatistics

Biostatistics & Epidemiology

Absolute risk reduction = Event rate in the control group - event rate in the Tx group

1178

Biostatistics

Biostatistics & Epidemiology

Check other calculations in choices.

1187

Biostatistics

Biostatistics & Epidemiology

A trend in whoch there is a rising prevalence but stable incidence is due to prolonged duration of disease (*IMPROVED QUALITY OF CARE* for e.g)

1188

Biostatistics

Biostatistics & Epidemiology

Disproportionate loss of follow up btw exposed and control leads to attrition bias which is a form of *Selection Bias*

1189

Biostatistics

Biostatistics & Epidemiology

Matching involves grouping patients with similar characteristics in both the control and treaetment (case) group. It is done to control confounding bias.

1190

Biostatistics

GeneralPrinciples

*Negative Predictive Value* is the probability of being free of disease. Answers the question: What are the chances that I really do not have cancer?

1194

Pharmacology

Cardiovascular System

Pregnanct associated deep vein thrombosis is treated with *Enoxaparin* [Low molecular wieght heparin]

1198

Pharmacology

Infectious Diseases

A drug for Beta-lactamase producing Bacteroides species is *Pipercillin-tazobactam*

1208

Biostatistics

Rheumatology/Orthopedics Case-fatality rate is calculated by dividing the number of fatal & Sports cases by the total number of people with the disease.

1212

Pharmacology

A muscle relaxant that shows initial equal reduction in response Rheumatology/Orthopedics followed by fading away unequal response in the TOF stimulation & Sports test is a depolarizing muscle blocker like *Succinycholine*

1214

Pharmacology

Dermatology

28 yr odl pt who has history of childhood dermatitis has been routinely applying corticosteroid cream to the flexor area of his skin for many years. A punch biopsy of area subjected to this topical therapy would most likely show *Dermal Atrophy* [corticosteroids in addition to anti-inflammatory effect, cause decreased production of extracellular matrix collagen and GAGS]

1216

Microbiology

Pulmonary & Critical Care

Pt with sign of Tb and the observed bacterial growth is mycobacteria that grow in parallel chains (Serpentine cords). This growth correlates with bacterial *Virulence*

1165

1221

Pathology

Pulmonary & Critical Care

Finding of small fibrotic focus in lower lobe of right lung and a calcified lymph node in the right lung hilus. This findings are most consistent with *Primary exposure to M. tuberculosis* [Ghon foucs and Ghon complex]

1223

Pharmacology

Infectious Diseases

M. Tuberculosis with significantly decreaed activity of intracellular catalse peroxidase exhibit resistance to *Isoniazid*

1228

Pharmacology

Infectious Diseases

Pt being treated with TB that develops blurry vison (bilateral central scotomas). Likely responsible agent is *Ethambutol* (optic neuropathy)

1233

Biostatistics

Pulmonary & Critical Care

Know how to calculate Sen, Spec, PPV, NPV (QUICKLY)

1244

Biochemistry

Dermatology

Ehlers Danlos Syndrome which presents with hyperextensible skin, easy bruising, hypermobile joints is a defect in collagen synthesis.

1245

Biochemistry

Dermatology

Ehler-Danlos Synrome can be caused by procollagen peptidase deficiency which results in impaired *cleavage of terminal propeptides* Where? --> Extracellular space.

1247

Biochemistry

Dermatology

Signs of scurvy such as bleeding gums , ecchymoses and corkscrew hairs implicate vit C deficiency. Vit C is required in postranslational hydroxylation of proline and lysin residues by hydroxylases in collagen synthesis. It happens in the Rough Endoplasmic reticulum

1248

Biochemistry

GeneralPrinciples

Collagen made by fibroblasts has Glycine as every third amino acid (GLY-X-Y) it is thefefore the most abundant.

1249

Biochemistry

Pulmonary & Critical Care

The stretch and recoil property of elastin is mediated by *Interchain cross-links involving lysine* [involveslysyloxidase]

1250

Biochemistry

an elstin associated glycoprotein defecct that is abundant in the Rheumatology/Orthopedics lens, periosteium, and aortic media refers to *Marfan Syndrome* an autosomal dominant disease with a defect in FBN1 gene coding & Sports for fibrillin glycoproten that forms around elastin.

1251

Biochemistry

In the duodenum, Enteropeptidase convert Trypsinogen to the Gastrointestinal & Nutrition active form trypisn. Pt with impaired enteropeptidase will fail to form *Trypsin*

1252

Pharmacology

Cardiovascular System

1255

PathophysiologyNervous System

Medication that causes selective direct relaxation of smooth muscles of arterioles but does not affect veins would have an adverse effect of *Na and fluid retention* Newborn that is crying, has tremors, tachynea, sneezing and diarhhea and mother has history of mental illness and/or hep c infection history probably has Neonatal Abstinence Syndrome and should be treated with opoids such as *Methadone*

1258

Pharmacology

Pt is given an opioid analgesic and develops upper abdominal pain. P.E shows tenderness over RUQ. An adverse drug effect invlving *SMooth muscle cells* is responsible. Gastrointestinal & Nutrition [Admin of mu opioid analgesics can cause contraction of smooth muscle of the sphinctor of Oddi leading to spasm and increase in common bile duct pressure which can lead to increase pressure in gallbladder and billary colid formation leading to pain]

1260

Pathology

Nervous System

Pt with HIV and has mass on temporal lobe and biopsy shows cells with EBV probably has a *Primary CNS Lymphoma*

Pathology

Nervous System

Pt undergoing hemodialysis who has dminished sensation over thumb, first two fingers, and radial half of her thrid finger probably has carpal tunnel syndrome. The underlying mechanism of which is *Nerve compression within an anatomic compartment* [Median nerve compression thru deposition of Beta2-microglobulin in carpal tunnel (dialysis assocated amyloidosis)]

Pathology

Pt presents with worsening scoliosis. Pt with mutation in dystrophin Rheumatology/Orthopedics gene on x chromosome. Histopathology of pt's calf would reveal *Fibrofattymusclereplacement* & Sports (Duchene Muscular dystrophy)

1264

1266

1268

1272

Pathology

Nervous System

Myotonia dystrophy is an autosomal dominant disorder caused by trinucleatide repeats of myotonia protein kinase (CTG). Sustained contraction, frontal baldness and cataratcs along with weakness and type one fiber muscle atrophy is commonly seen. Also gonadalhypertrophy.

Biostatistics

Biostatistics & Epidemiology

Statistical power *1-Beta* represents a study's ability to detect a difference when one exists. Basically the ability to reject the null hypothesis when its truly false.

1287

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Methadone which is used in Heroin Addicts (Opiate) during withdrawal phase, it is beneficial due to *Long Half-Life* and can therefore suppress cravings and withdrawal symptoms for >24 hrs. It is a full Mu-opiod receptor agonist (not partial) The partial agonist is "Buprenorphine" also used. (Usually alone with Nalaxone which is an opoid anatagonist)

1288

Behavioral science

Psychiatric/Behavioral & Substance Abuse

PCP is a hallucinogen that causes agitation, halluciantions, violent behavior. Distinguishing factors of abuse are are Ataxia, Nystagmus, and Memory loss

1290

Pharmacology

Pt with 4 week history of mucoid diarrhea with benign findings on evaluation (intermitten mild heart burn, unpleasant tase with dairy products).Pt is started on Diphenoxylate therapy. Primary target of Gastrointestinal & Nutrition this drug is *Motility* [Pt has uncomplicated diarrhea, diphenoxylate is an opoid anti-diarrhea agent structurally related to meperidine, it binds to mu opiate receptor in gi tracts and slows motility]

1292

Pathology

Hematology & Oncology

Pt on Warfarin who develops warfarin-induced skin necrosis, most likely had *Protein C deficiency*

Hematology & Oncology

Pt end-stage renal disease. Dialysis is to be given. Before that, he develops bleeding around the catheter exit. Furtehr evaluation would show *Normal PT, aPTT, Platelet count, But Prolonged Bleeding time* {Uremic platelet dysfunction due to accumulation of toxins in blood, Bleeding time is an indication of platelet function]

1293

Pathology

1297

Pathology

Hematology & Oncology

RBC cell fragments, burr cells, and helmet cells are associated with either microangipathic hemolytic anemia or mechanical cell destruction. In pts with prosthetic valves, red blood cells are exposed to excessive shear and turbulence in the circulation, causing damage from mechanical trauma.

1301

Biostatistics

Cardiovascular System

Blinding prevents observer bias.

1303

Biostatistics

Biostatistics & Epidemiology

A study's power increases as its *Sample Size* increase. Therefore, the larger the sample size, the larger the ability of a study to detect a difference when one truly exists.

1304

Pathology

Nervous System

*Schwannoma* is S-100 positive. (indicates neural crest origin)

1307

Genetics

Nervous System

Pt with Fleshy, dome shaped lesions plus cafe-au-lait spots probably has cutaneous neurofibromas which is a hallmark of NF-1 which exhibits an inheritance pattenr of *Single Gene Autosomal Dominant* -The NF-1 gene is on chromosome 17.

1309

Microbiology

Infectious Diseases

Isoniazid inhibits mycolic acid synthesis in the treatment of TB thus making Tb cells less resistent to decoloration by acid-alcohol.

Pulmonary & Critical Care

Hiv Pt with CD4 Count of 40 and blood culture grow acid fast bacteria that grow optimally at 41 C. This could have been prevented by prophylaxis with *Azithromycin* (MACComplex)

1312

Pharmacology

1313

1314

Microbiology

Pathology

Dermatology

Pt presents with skin changes. Blotches of skin on her arms appear to be of different color. She also has a tingling sensation in her hands. Exam shows patchy area of skin anesthesia and hypopigmentation on her upper extremities. Nerve biopsy shows organisms invading Schwann cells. Hiv test is negative. Most likley cause is *Myobacterium Leprae* [Tubercolid Leprosy, TH1 response. mild form compared to Lepromatousleprosy(TH20]

Dermatology

Pt that was injected with heat killed M. Leprae and developed a large indurated nodule demostrates *Increased IL-2 & IFN-gamma in skin lesions*

1316

Microbiology

Dermatology

When pt's serum is added to a mixure of cardiolipin, lecithin, and cholestrol and extensive flocculation is observed, the next step is to evaluate for *Spirochetal Antibodies*. This is a nonspecific treponemal serologic test known as the rapid plasma reagin test.

1318

Physiology

Nervous System

In MS, *Length Constant* is decreased.

1322

Pharmacology

Nervous System

ST-Segment elevation in inferior leads tells you its Inferior MI. Inf MI is due to blockage of right coronary artery which supplies SA & AV nodes. Thus, inf MI's Often present with bradycardia. Treating bradycardia with ATROPINE thru blocking vagal influence on nodes thus increasing HR. Side effect of Atropine in the eye is GLAUCOMA. So pts complains of severe right sided eye pain.

1326

Pathophysiology

Endocrine, Diabetes & Metabolism

Upregulation of *Serine Phosphorylation* decreases insulin-mediated glucose uptake.

1327

Endocrine, Diabetes & Pathophysiology Metabolism

Insulin Resistance correlates strongly with Ecxess Visceral Fat which can be assessed using *Wasit Circumference* or waist-to hip-ratio.

1334

Biochemistry

Dermatology

12 yr old is evaluated for ataxia acompanied by episodic erythematous and puritic skin lesions and loose stools. Lab shows loss of neutral aromatic amino acids in urine. The pt symptoms would most likley respond to to supplementation with *Niacin Vit B3* [Hartnup dsiease, defective intestinal and renal absorption of tryptophan. Ttryptophan is a precursor to Nicotinic acid, serotonin, andmelatonin.] [Tryptophan, phenylalanine and tyrosine are all aromatic aa][note:Pallegra?]

1335

Biochemistry

Nervous System

Hypertonicity, muslce rigidity and sugar smelling diapers are signs for maple syrup urine disease and branched chain amino acids such as leucine, isoleucine and valine should be restricted.

Hematology & Oncology

Pt comes due to recurrent blistering on back of hands and forearms for several years. P.E shows vesicles and erosion on the dorsum of both hands. Most likely deficient enzyme in this pt is *Uroporphyrinogen Decarboxylase* [Porphria Cutaneo Tarda]

Hematology & Oncology

Pt with neurologic symptoms (tingling, difficulty concentrating) and recurrent episodes of nonspecific abdominal pain likely has acute intermitten porphyria. (PBG deaminase def) This attack is helped with infusion of heme which downregulates hepatic *ALA synthase*

1337

1338

1339

Biochemistry

Biochemistry

PathophysiologyHematology & Oncology

Pt with acute abdominal pain, nausea and confusion with reddish urine that darkens after standing for 24 hrs and her symptoms are releived by IV dextrose probably has *acute intermittent porphyria* in which there is deficient PBG Deaminase. Symptoms are exacerbated by CYP450 inducers including smoking and alcohol and relieved by glucose and heme.

1343

Pharmacology

Cardiovascular System

A drug that is a pure adrenergic agonist that causes immediate increase in BP and delayed decrease in heart rate. Admin of drug to healthy individuals would most likely result in *Decreased atrioventricular node conduction velocity* [The delayed decrease in heart rate was a reflex bradycardia, the drug affects alpha 1 receptors]

1344

Pharmacology

Cardiovascular System

Dobutamine increases *myocardial oxygen consumption*

1352

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pt who requires benzodiazepam with least imapaired judjement or daytime fatigue should be given one with a short T1/2 and least hepatic metabolismlike *Lorazepam* [LOTbenzos,lorazepam,oxazepam,temazepam][Undergodirect glucuronidation]

1356

Physiology

Nervous System

Macular lesions can result in *Central Scotomas*

1357

Physiology

Pulmonary & Critical Care

Pt with acute metabolic acidosis (Normal HCO3 with low pH and High Pco2)could most likely suffer from *Heroin Overdose* [Heroin causes respiratory depression and hypoventilation]

1358

Physiology

Gastrointestinal & Nutrition

A drug that inhibits primary active transports across cell membranesis*Omeprazole*

1360

Pharmacology

Nervous System

Receptor that when stimulated causes immediate change in transmembrane Ca, Na, and potassium secondary to opening of receptor channel is *Nicotinic Cholinergic Receptor*

1363

Pharmacology

Ophthalmology

Timolol in Tx of Glaucoma targets *Ciliary epitheliium* [Decreases aquoeus humor production]

1365

Pharmacology

Cardiovascular System

*Dopamine* at lower doses stimulates D1 receptors in the renal vasculature and tubules therey inducing an increase in renal blood flow. At somewhat higher doese, dopamine stimulates the beta-1-adrenergic receptors in the heart thereby increasing Cardiac Contractility. At still higher doess, dopamine stimulates alpha-1-receptors in the systemic vasculature thereby causing generalized systemic vasoconstriction and hence lower cardiac output due to higher after load.

1367

Pharmacology

Cardiovascular System

Noreepi therapy results in *cAMP increase in cardiace muscle cells*

Nervous System

A drug that causes less uterine contractions (i.e uterine relaxation) and Eye Midryasis is *Alpha and beta-adrenergic agonist* [B2 stimulation in uterus causes relaxation while Alpha 1 stimulation in eyes causes mydriyasis (the basis of using phenylephrine befor eye exams)]

Endocrine, Diabetes & Metabolism

*Orinithine Transcarbamoylase* deficiency is the mcc urea cycle disorder. The high NH3 causes neurologic abnormalities. Typical tell tale sign is high urine OROTIC ACID. becasue with no OTC, carbamoyl phosphate is converted to orotic acid in pyrmidine synthesis.

1368

1370

Pharmacology

Biochemistry

1371

Biochemistry

Nervous System

Infant with lethargy vomiting and seizures. Lab shows high ammonium levels. Liver biopsy suggest impaired formation of N-acetylgutamate as the cause. The reaction impaired in this pt would be *Conversion of CO2+NH3 into Carbamoyl-Phosphate* {N-acetylglutamateactivatescarbamoylphosphatesynthase1 which is th enzyme that converts co2+NH3 into Carbamoyl phosphate]

1372

Biochemistry

Nervous System

Pt with inherited condition wich imapirs transport of ornithine from cytosol to mitochondria. Restric *proteins* from diet to improve condition.

1374

Microbiology

Hematology & Oncology

Mother had still bith at 18 weeks. Autopsy shows pleural effusion, pulmonary hypoplasia, and ascites. Infection with *Non-enveloped, single stranded DNA virus* is most likely etiology. [Parvovirus causing fetal hydrops]

1377

Microbiology

Pulmonary & Critical Care

If viral paricles lose their infectivity once exposed to ether. We can conclude that the are *Enveloped* [Ether and other organic solvents can inactivate the enveloped virus]

1386

Biochemistry

Hematology & Oncology

Oxygen binding to Hb involves the release of *Protons* [H+ is released]

1388

Microbiology

Allergy & Immunology

Immigrant 6 year old who presents with dyspnea. He has Fever. Exam shows neck swelling, palatal paralysis and a gray pharyngeal exudate. His vaccination history is unknown. The intervention that will imrove his symptons is *Passive Immunization* (C.Diptheria infection, exotoxin)

1389

Microbiology

Allergy & Immunology

Non pathogenic C. Diptheria become pathogenic thru *Phage conversionpermitingexotoxinproduction*

1390

1391

1394

1396

1397

1398

1401

PathophysiologyInfectious Diseases

Pts who are migrants (unknown vaccine status) who develop severe pharyngitis with exudates and cervical lymphadenopathy (neck swelling, dysphagia) and one them dies of heart failure. These people probably has respiratory diptheria infection. The diptheria toxin works like the Exotoxin A produced by *Psuedomonas Aerugionsa*

Microbiology

Nervous System

A motile gram +ve rod that has a narrow zone of beta hemolysis, and can grow well at refrigiration temp is likely Listeria which is an Inracellular Organism and therefore requires *Cell Mediated Immunity* to eliminate.

Microbiology

Crepitus on physical and radiographic visualization of gas in Rheumatology/Orthopedics tissues esuggests Gas gangrene by C. Perfringes which also & Sports causes Transient Watery Diarrhea and Abdominal Discomfort.

Pathology

Pt presents with abdoinal pain and diarrhea. Recent trip to mexico.He is febrile. Elevated leukocytes. Sigmoidoscopy shows white/yellow plaques on colonic mucosa and biopsy shows that Gastrointestinal & Nutrition plaque are composed of fibrin and inflammatory cells. Given pt'd Dx, the element likely elicited on further Hx taking regarding mexico trip is *hospitalization and antibiotics for pnemonia* [C. Deficile Colitis]

Microbiology

Pt takes Clindamycin and develops C.diff Colitis. The causative Gastrointestinal & Nutrition agent damages the *Cytoskeleton Integrity* of intestinal mucosal cells.

Microbiology

In the absence of normal intestinal microbial flora, C.difficile can Gastrointestinal & Nutrition overgrow and produce toxins. Therefore, persons with a *Preserved Intestinal MicroBiome* may not develop an infection.

Microbiology

Nervous System

Bacterial product that when injected into muscles with relentless focal dystonia produces dramatic but temporary relief of symptoms is C. Botulinum toxin, The bacteria demonstrates *Subterminal SporeFormation*

1405

Pathology

Hematology & Oncology

The presence of rod-shaped intracytoplasmic inclusions known as Auer rods is characteristic of many forms of acute myeloblastic leukemia (AML). The M3 varian of AML, acute promyelocytic leukemia, is associated with the cytogenic abnormality *t(15:17)*

1406

Pathology

Hematology & Oncology

Auer rods which are seeen in Acute Myelogenous Leukemia stain positive for *Peroxidase*

1408

1413

Microbiology

Biochemistry

Infectious Diseases

Phospholipid composition of viral particle surface is highly similar to that of cell nucelar membrane. This is most likely *Cytomegalovirus* (Herpes viruses bud thru and acquire the lipid bilayer envelope from the host cell nuclear membrane)

Hematology & Oncology

In an experiment where scientist were able to separate hemoglobin tetramers into individual alpha and beta subunits. If a solution is created that contains only monomeric beta-hemoglobin subunits and the o2 dissociation curve is measure, it would be have a *very high affinity (P50%=1)* The beta subunit is almost identical to Myoglobin which has a stong affinity to O2 (p50%=1) vs p50%=26 of HbA.

1419

Biochemistry

Hematology & Oncology

Differences between synthesis of 2 daughter DNA strands include *The joining of DNA fragments by ligase* This is beacuse the leading strand is less affected by ligase compared to the lagging strand which has okazaki fragments that must be constantly ligated by ligase.

1421

Genetics

Nervous System

CGG Trinucleotid repeats is characteristic of Fragile X syndrome. Symptoms results from *Gene methylation* of FMR1 gene.

Microbiology

Enteric pathogen causing diarhea that can be transmitted from domestic animals to humans is *Campylobacter* extra note: Gastrointestinal & Nutrition -(Curved G-ve rod that moves in corkscrw fashion) -MCC of acute gastroenteritis in kids and adults -Assoc with GBS

1422

1424

Biochemistry

GeneralPrinciples

Certain tRNA molecules can recognize multiple different codons coding for the same amino acid, a phenomenon explained by the *Wobble hypothesis* {Genetic code is Degenerate]

1425

Pharmacology

Renal, Urinary Systems & Electrolytes

Pt on Chlorthalidone that develops muscle weakness. It is due *Hypokalemia*

1429

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Young man who says that his parents who are about to get a divorce are angry at him. His defense mechanism is *Projection*

GeneralPrinciples

E.coli with enzyme-mediated nucleotide removal in the " 5' to 3' direction " is done by *DNA polymerase 1* [Other 3 have 3' to 5' exonucelease activity][DNA p1 Removes the RNA Primer]

GeneralPrinciples

The factor that makes eukayotic DNA replication quick and effective despite large size and complexity of genome is *Multiple origins of replication*

GeneralPrinciples

A protein that has reverse transcriptase activity that functions to add TTAGGG repeat to the 3'end of chromosomes. The cell type with this protein is most likely *Epidermal Basal cells* [Temlomerase protein on stem cells]

1434

1437

1438

Biochemistry

Biochemistry

Genetics

1439

Pathology

Cardiovascular System

Pt with blunt chest and head trauma who has pulsus paradoxus (fall in systolic BP greater than 10 on inspiration), Jugular venous distention and tachy cardia. He probably has *CARDIAC TAMPONADE*

1446

Pharmacology

Pulmonary & Critical Care

Alcoholic pt with poor dentition whose chest CT shows air fluid microabscesses. best treatment option is *Clindamycin* [Oral Anaerobic bacteria causing aspiration pneumonia]

Embryology

If Leydig cells are working in a male (46xy) and Sertoli cells are not then the fetus will have female and male internal genitalia and MaleReproductiveSystem male external genitalia. Why? becuase sertoli cells produce MIF which inhibits female internal gonad differentiation.

1449

1450

Pt with recurrent acute Monoarthitis (one knee) and a history of a Rheumatology/Orthopedics myeloproliferative disorder (E.g Polycytemia Vera) has typical Pathophysiology features of "GOUT" and would therefore have *Needle Shaped, & Sports Negatively Birefringent Crystals* on needle aspiration of the joint.

1452

Symptoms of hyeracusis (high sensitivity to everday sounds) accompanied by ear pain and difficulty hearing is due to damage to the stapedius muscle wich is innervated by the stapedius nerve which a branch of the *Facial nerve*

Anatomy

Nervous System

1454

Biochemistry

Infant with language regression and anemia probably has lead Poisoning&Environmental posioning and probably has an inhoiibited *ALA Dehydratase Exposure enzyme* plus ferrochelatase inhibition.

1456

Biochemistry

Hematology & Oncology

The change in color of a bruise from blue to green is explained by activity of *Heme Oxygenase* [Biliverdin is Green, Bilirubin is yellow]

Genetics

GeneralPrinciples

The acqusition of a new viral surface rotein is often all that is necessary for a virus to infect a new type of host cell. This is an example of *Phenotype Mixing* Here there is no change in parental genome and tehrefore, subsequent progeny will revert to having only original host attacking properties.

Microbiology

Pregnancy, Childbirth & Puerperium

Infant Pt with White pupils (Cataracts), heaing loss, and Machine like murmur (PDA) probably has congenital Rubella. This could have been prevented by giving the mother the *Live attenuated* Rubella virus vaccine.

Immunology

Pulmonary & Critical Care

Pt given an inactivated viral component vaccine. On exposure to real virus, would result in *Inhibition of viral entry into cells* (Humoral immunity and not cell mediated immunity since it is not a live virus)

1467

Immunology

The live attenuated oral (Sabine) poliovirus vaccine produces stronger mucosal sectretory igA immune resposne than Salk killed Gastrointestinal & Nutrition vaccine. Secretory IgA maybe refered to as *Duodenal Luminal IgA*. Remember the route of entry of the virus is thru the intestinal epithelial cells.

1468

Immunology

Infectious Diseases

The antiviral action of interferon is *Decreased prtein synthesis by infected cells*

1462

1464

1466

1469

Genetics

GeneralPrinciples

Viruses with segmented genomes can undergo genetic shift through reassortment. Such viruses inclide orthomyxoviruses (influenza) and *RotaViruses*

1470

Biochemistry

Hematology & Oncology

Both HbS and HbC result from *Misense Mutations*

1471

Biochemistry

Infectious Diseases

Bacterial *DNA polymerase 1* removes RNA primers during DNA replication.

1474

Genetics

Hematology & Oncology

External Beam Radio therapy kills cancer cells through *Double-strand DNA breaks*

1475

Biochemistry

Pt who presents with difficulty swallowing and is found to have an mass in esophagus. He is a hunter and put sodium nitrite in his meat. Analysis of biopsy sample show Cytosin Demaination. This Gastrointestinal & Nutrition damage is usually repaired (Base Excision Repair) by this enzymatic sequence; *Glycosylase, Endonuclease, Lyase, Polymerase, Ligase*

1476

Genetics

Dermatology

Pt with xeroderma pigmentosum have a defect in *Endonucelease* enzyme.

1480

Biochemistry

Nervous System

High Arginine in plasma and CNS suggest arginase deficiency which works to convert arginine into *Urea* in the urea cycle.

1487

Biochemistry

Hematology & Oncology

Duchenne Muscular Dystrophy can also results from None-sense Mutations (premature stop codon) [Usually from deletions (frameshift) thu]

1488

Pharmacology

Infectious Diseases

Antibiotic that causes tinitis and hearing loss is most likey an aminoglycoside which affects *mRNA genetic code reading* (binds irreversibly to 30s ribosomes)

Anatomy

A gardner who comes in with knee pain with no visible erythema or Rheumatology/Orthopedics abrasions. He spends hours on on his knees while working. The & Sports bursae most likely affected in this pt is *Prepatellar* [Prepatellar Bursitis][a.ka "housemaids knee]

1491

1493

Physiology

Nervous System

Pt with cerebral edema who is on a ventilator adjusted to achieve a pCO2 level bwteen 26-30 mmHG. Most likley effect of this intervention is *Increased cerebral vascular resistance* [a dro in pCO2 causes vasoconstriction and increases resistance and hence reduces cerebral blood flow]

1498

Microbiology

Infectious Diseases

Symptoms of acute dysurea and heamturia in the setting of a day care (mostly boys) is Hemorrhagic Cystis caused by the *ADENOVIRUS* which its genomic fragments can be found in urine.

1500

Biochemistry

Nervous System

Pt with imapaired Tetrahydrobiopetrin synthesis would have phenylketonurea and would therefore have deificency of *Serotonin*

1501

Biochemistry

Endocrine, Diabetes & Metabolism

Pt with Phenylalanemia who is place on dietary requirements and supplemented with tyrosine and presents with normal phenylalanine levels but with axial hypotonia and microcephaly. Also, prolactin is elevated. The enzyme missing in this pt *Dihydrobiopterin reductase* (Involved in converting tyrosine to DOPA, hence high prolacin)

1507

Pharmacology

Cardiovascular System

*Dofetilide* is a class 3 antiarrhythmic and blocks K channels, Just like Sotalol and Amiodarone.

Cardiovascular System

A drug that depresses phase 0 ventricular depolarization (Na) and prolongs phase 3 (K) is probably a class 1A antiarrythmics which include*Disopyramide*

Cardiovascular System

Rightward extension of ventricular filling portion of graph indicates increase in ventricular preload. This can occur in any state of fluid overload (renal failure, CHF) or after infusion of *NORMAL SALINE*

1509

1511

Pharmacology

Physiology

1512

Physiology

Cardiovascular System

Pt presents with sign of hypovolemic shock who is give Normal Saline. This intervention increases *End-Diastolic Sarcomere Lenght* (Increase in preload stretches myocardium and hence the sarcomere length)

1513

Physiology

Cardiovascular System

Cardiac tissue conduction velocity is from fastest to slowest as: Purkinje system-->Atrial muscle--->Ventricular muscle---> AV node [Park AT VENTure AVenue]

1514

Physiology

Pulmonary & Critical Care

The CFTR protein is a transmembrane *ATP-gated* Chloride channel.

1515

Physiology

Cardiovascular System

Pt with sudden onset palpitation plus rapid regular tachycardia that responds to carotid massage probbly has PSVT. Carotid massage increases afferent firing which increases vagal parasympathetic tone which slows conduction thru AV node and hence *Prolongs AV node Refractory period*

1516

Physiology

Cardiovascular System

Within the zone of autoregulation of coronary blood flow. The main endogenous factor for control of coronary blood flow is *Nitric oxide*

1521

Physiology

Pulmonary & Critical Care

Pt with illness like with Obstructive Lung disease would have air trapping in lungs and hence a high *RV/TLC ratio*

1522

Physiology

Pulmonary & Critical Care

Pt with tracheal pO2 of 150, Alveolar pO2 of 145, and Alveolar pCO2 of 5 has *Pulmonary alveolar perfusion* note: tracheal pO2 is normal. Normal alveolar pO2 is 104.

1526

Physiology

Pulmonary & Critical Care

P(A)O2(Alveolar)=150-(PaCO2(Arterial)/0.8)

1528

Physiology

Cardiovascular System

The *Blood Flow Per Minute* in the pulmonary circulation closely matches the blood flow in the systemic circulation. This is true in both exercise and rest.

1529

Physiology

Cardiovascular System

Cardiac Output= Rate of O2 consumption/arteriovenous O2 content difference.

1535

Anatomy

Pulmonary & Critical Care

The *Phrenic Nerve* carries paim fibers form the Diaphragmatic and Mediastinal Pleura. Irritation of pleura at either area will produce sharp pain worsened by "inspiration" that will be referred to the c3-c5 distribution at the "base of the neck and over the shoulder".

1536

Histology

Nervous System

The Blood brain barrier has Tight Junctions (Zonula Occludens)

Pulmonary & Critical Care

The PO2 in the left atrium and ventricle is lower than that in the pulmonary capillaries due to mixing of oxygenated blood from the pulmonary veins with *Deoxygenated blood* arising from the bronchil arteries and thebesian veins.

1542

Physiology

1545

Physiology

Hematology & Oncology

CO poisoning causes *Increased CarboxyHb together with unchanged PaCo2, Methoglobin level is unchanged* [In Co poisoning, O2 contect is decreased BUT not oxygen partial pressure which is represented by PacO2]

1546

Physiology

Gastrointestinal & Nutrition

Secetin, released by the *Duodenal S cells* stimulates release of bicarbonate from the pancreas.

1549

Pathophysiology

FemaleReproductive System & Breast

Symptoms of primary herpes infections include inguinal lymphadenopathy, tender vesicular lesions covering both labia majora and pernium with dysuria and itching. The infection (probably hsv-2) can lead to *Recurrent Genital Ulcers* (less sever) (HSV lies dormant in sacral dorsal root ganglia)

1550

Microbiology

Infectious Diseases

Recurrence of genital hepres can be reduced by *Continous daily valacyclovir*

Dermatology

a unilateral vesicular rash involving a single dermatome is Shingles. The pt would siffer from *Persistent local pain* in the next 6 months

Cardiovascular System

Pt that presents with with dyspnea, orthopnea, and fatigue and with a history of MI that was not revascularized due to delya in Tx. The fact that the pt also presents with a diastolic heart sound that is best heard in the left decubitus position at the apex is consistent with a decompensated HF. The physical exam finidng (i.e the heart sound) can be accentuated when *Listening at the end of expiration*

Renal, Urinary Systems & Electrolytes

In a study a volunteer is given a substance that that specifically and complete inhibits glucose transport in the proximal renal tubules. In this volunteer, glucose clearance will best approximate the clearance of *Inulin* [No tubular reabsorption or secretion, filtered amount equals excreted amount] [Note that PAH is secreted as well]

1553

1557

1559

Microbiology

Physiology

Physiology

1560

1565

1568

1573

Physiology

Pharmacology

Pharmacology

Microbiology

FemaleReproductive System & Breast

LH stimulates the theca interna cells of the ovarian follicle to produce androgens. Aromatase within the follicle's *Granulosa* cells subsequently converts these androgens to estradiol under FSH stumulation. The theca externa cells serve as connective tissue support structure for the follicle.

Cardiovascular System

In pts with HTN and chronic ischemic myocardial failure, ACE inhibitors (*Lisinopril*)are considered most effective long term treatment.

Pregnancy, Childbirth & Puerperium

Pt who has severe acne with scarring and now is interested in Isotretinoin treatmnet. Best next step in management is *Urine Beta-hCG* [ral isotrtinoin is Teratogenic]

Nervous System

Pt with presenting to ER with seizures. On exam he has oral thrush and lymphadenopathy and MRI shows multiple ring enhancing lesions (shown) probably has HIV and has acquired *Toxoplasmosis.* that explain his seizures.

Pregnancy, Childbirth & Puerperium

Pregn pt who is a migrant and develops low grade fever and maculopapular rash that spreads from face and chest to trunk and extremities over next 48 hrs. P.E shows postauricular lymphadenopathy. The mother is at immediate risk for *Polyarthralgia* while the fetus at risk *Sensineuronal Deafnes*. This pt has German measles (Rubella) and has not been vaccinated with MMR

1575

Microbiology

1578

PathophysiologyCardiovascular System

In signs for Cor Pulmonale due to COPD, moderate increase in capillary fluid transudation can be ofset by a compensatory increase in *Tissue Lymhatic Drainage*

Pathology

Pulmonary & Critical Care

Pt with fevers, hemodynamic instability, tachypnea and evidence of UTI has Urosepsis likely complicated by ARDS causing her hypoxia. Her resp symptoms are most likely due to *Fluid accummulation in alveolar spaces* [increased recruitment of neutrohils causing capillary damage and leakage*

Hematology & Oncology

Pancreatic calcification with abdominal pain and finding of low hemoglobin and high MCV suggest Macrocytic anemia. The pts probably has Chronic pancreatitis due to ethanol abuse. The anemia is due to folic acid def or b12 def and is causing impaired DNA synthesis leading to *diminished thymidine synthesis*

1579

1580

Pathology

1581

Vit A deficiency is characterized by night blindess and dry skin (hyperkeratosis). Deficiency of this fat soluble vitamin can result PathophysiologyGastrointestinal & Nutrition from Billary disorders, exocrine pancreatic insuffciency, or intestinalmalabsorption.

1584

Physiology

Pulmonary & Critical Care

Sudden-onset tachypnea and chest pain in a hospitalized pt shud raise suspicion for Pulmonary Embolism. Especially if pt is immobilized or had recent surgery. Thrombotic occlusion of pulmonary circulation leads to increased blood flow to remainder of lung causing a *Ventilation-perfusion V/Q mismatch*

1586

Physiology

Pulmonary & Critical Care

Increase in hemtocrit with normal red blood cell mass indicates *RelativeErythrocytosis*

1587

Physiology

Pulmonary & Critical Care

The tissue that would Increase vascular resistance due to low Oxygen tissue content is the *Lungs*

1588

Physiology

Renal, Urinary Systems & Electrolytes

The nephron segment that will have the lowest concentration of PAH is *Bowman's capsule*

1589

Physiology

Cardiovascular System

Increase in HR and cardiac output with no changes in PaO2 and PaCO2 indicate *Exercise*

1592

Microbiology

GeneralPrinciples

Pt with CMV postive antibody probably had a *Mononucleosis-like illness* in the past due to CMV infection, symptoms include fever, malaisse, myalgia, atypical lymphocytosis, and elevated transaminases.

1594

Microbiology

Infectious Diseases

A virus that gives B lymphocytes the ability to proliferate indefinitely and retain their bility to secrete immunoglobins is diagnosed "in vivo" using *Heterophile Antibodies" (EBV virus)

1596

Immunology

Gastrointestinal & Nutrition

Immune mechanism against Giradia involves CD4+ T helper cells and *Secretory IgA Production*

1598

Immunology

Hematology & Oncology

The surface marker for the macrophages of TB is CD14

1600

A young man with acute lower extremity artthritis and a sterile (no bacteria) joint effusion following a GI infection (diarrheal illness) Rheumatology/Orthopedics has typical symtoms of "Reactive Arthritis". It is a associated with Pathophysiology & Sports *HLA-B27* [Sponduloarthropathy assoc with HLA-B27]

1601

Campylobacter Jejuni can lead to Guillain-Barre Syndrome. GBS is a demyelinating syndrome of the peripheral nerves characterized by ascending muscle weakness and paralysis. Pt has history of self resolving diarhea. C. jejuni is a common cause of infectious diarrhea.

Microbiology

Nervous System

1602

Microbiology

Pt ingests solution containing 13C labeled urea. He then is aksed to blow into a tube and labeled carbon is detected in his breath Gastrointestinal & Nutrition samples. This is most likely part of the evaluation of *Duodenal Ulcer* (H.pylori is urease positive)

1607

Physiology

Renal, Urinary Systems & Electrolytes

In the setting of low ADH, the highest osmolality is at the *Bottom of Loop of Henle*

Renal, Urinary Systems & Electrolytes

If animal is deprived of water, ADH will be high, high ADH promotes water reabsorption. The place with the lowest urine osmloarity (highest dilution) would be the distal convoluted tubule. Why? because its impermeable to water but continues to reabsorb electrolytes. Also, the fluid just came from the ascending limb which is also impermeable to water but reabsorps electrolytes.

Cardiovascular System

Pt with lightheadedness when pressure is placed on the carotid sinus has carotid sinus hypersensitivity and the carotid sinus has AFFERENT sensory fibers to the meduula via the hering nerve which is a branch of the *Glossopharyngeal nerve*

Allergy & Immunology

Pt with decreased serum complement C4 and C1 esterase inhibitor levels. Drug that is contraindicated is *Captopril* [Hereditary angioedema][ ACE inhibitors make bradykinin accumulate in addition to already high bradykinin due to loss of inhibitory action of C1 esterase inhib on kalikrein which converts kinogen into bradykinin]

1608

1609

1612

Physiology

Physiology

Pharmacology

1613

Immunology

Dermatology

Symptoms of Maculopapular Rash (skin) and multiple intestinal ulcers (GI) after Liver transplant (or bone marrow) suggest Graft-versus-Host disease which is characterized by *Graft T cell sensitization against Host MHC antigen.*

1614

Immunology

Hematology & Oncology

B cells undergo *ISOTYPE SWITCHING* in germinal centres (round) of the cortex of lymph nodes.

1615

Physiology

Endocrine, Diabetes & Metabolism

High T3 would have negative feedback effects reducing TSH, T4 and rT3.

1616

Physiology

GeneralPrinciples

Resistance in parallel is 1/T=1/R1+1/R2+1/R3+...etc [Remeber to inverse the answer]

1620

Physiology

Pulmonary & Critical Care

Increased lung volume increases PVR in alveolar vessels and decreases PVR in extra-alveolar vessels. *PVR is lowest near FRC*

1621

Physiology

Cardiovascular System

Decrease flow by a factor of 16 decreases radium of lumen by a factor of 2 meaning *50%*

Cardiovascular System

Decreased Cardiac output with unchanged venous return suggests a problem in the contractility of the heart either due to a negative inotropic drug or due to an injury to the myocardium such as with a myocardial infarction.

1624

Physiology

1625

Physiology

Cardiovascular System

A Cardiac output and venous return curve shows the cardiac output is increased and the venous return is increased as well with a rightward shift in right atrial pressure (increased mean arterial pressure). Most likely cause is *Chronic Atriovenous Fistula* [High cardiac output with increased venous return indicates lowering of TPR. The rightward shift of right atrial pressure in the venous return curve indicates higher mean arterial pressure which indicates a chronic fistula]

1628

Pharmacology

Hematology & Oncology

Monloclonal antibody against CD20 marker is *Rituximab*

Hematology & Oncology

IV drug used with HIV infection. He comes due abdominal distention and anorexia. CT scan shows ascites and large mass surrounding small intestine. Biopsy of mass shows unifrom, round, medium-sized tumor cells with basophilic cytoplasm and proliferation fraction of >99%. Agent assoc is *EBV* [Burkitt Lymphoma, t(8:14) involving c-myc] [Kaposi sarcoma (hhv8) would shows large cells, big nuclei, and prominent nucleoli]

Anatomy

FemaleReproductive System & Breast

*The suspensory ligament of ovary* must be ligated during removal of ovaries to prevent bleeding. It carries the ovarian artery. It also known as the infundibulopelvic ligament. Note that the Cardinal Ligament (transverse cervical ligament) holds the uterine artery and needs to be ligated in a hysterectomy.

Anatomy

Pt with sensory loss over the medial 1 and 1/2 digits and Rheumatology/Orthopedics hypothenar eminence indicate ulnar nerve injury which often & Sports occurs at *Hook of Hamate*

Pharmacology

Renal, Urinary Systems & Electrolytes

Pt on Acyclovir who develops acute elevation of serum creatine levels. This could have been prevented with *Agressive IV Hydration* (Acyclovir Nephrotox)

Renal, Urinary Systems & Electrolytes

*Foscarnet* can be used in Ganciclovir resistent CMV. Being a Ca chelator it can cause hypocalcemia. Also it induces renal wasting of Mg causing hypomagnesemia. Also reduces production of PTH further contributing to Hypocalcemia.

1630

1632

1634

1642

1643

Pathology

Pharmacology

1644

Pharmacology

Infectious Diseases

Pt with HIV being treated for Colitis (most likely CMV) with IV agent that does not require intracellular activation and is known to bind in vitro with viral encoded enzymes such as DNA polymerase, RNa polymerase, and reverse transcriptase is *FOSCARNET*

1648

Pharmacology

Infectious Diseases

Oseltamivir is a neuramidase inhibitor and is useful in treatment of Influ A and B viruses. It inhibits *Virion Particle Release*

1653

Physiology

Cardiovascular System

In heart catheterization. The structure the produces a pressure changed of a max of 25 and a min of 2 is *Right Ventricle*

Hematology & Oncology

Pt who wwas in motor vehicle accident and has received several units of packed-red blood cells. He now complains of tingling sensation in his toes and fingers. Ca level is 7.2. Most likely cause of symptoms is *Ca chelation by a substancce in the transfused blood* (Citrate is added prior to storage, chelates Ca)

1654

Physiology

1655

Pharmacology

Endocrine, Diabetes & Metabolism

Pt with type 2 diabetes. Tx that would increase serum C-peptide level include *Glyburide* {Sulfonylureases like glyburide and Meglitinide increase endogenous insulin producttion and henc c-peptide]

1657

Physiology

Nervous System

A pt is being evaluated for hypoventilation. He is asked to take several deep breathe in rapid succession. Physiograph shows decreasing amplitude of cyclic intrapleural pressure changes during deep rapid breathing. Most likely site of this pts disease is *Neuromuscular Junction* [Pleural pressure changes indicate diaphragmatic contraction. Decreasing contraction with each breathe (weaker with repition) This most likely involves NJM (e.g Myasthenia Gravis or restrictive lung)

1659

Pathology

Endocrine, Diabetes & Metabolism

Medullary thyroid carcinoma would show *Nests of polygonal cells with Congo-ed positive deposits* [Amyloid stains with Congo red]

1660

Pathology

Endocrine, Diabetes & Metabolism

In Medullary Thyroid Cancer, the gene changes responsible is *Activating mutation of RET proto-oncogene*

Physiology

Cardiovascular System

Pt with a cardiac murmur and P.E reveals bouding femoral pulses and carotid pulsations that are accompanied by head-bobbing most likely suffers from *Aortic Regurgitation*

Physiology

ATP helps release *Myosin head from Actin binding site*, and thus Rheumatology/Orthopedics lack of ATP leads to persistance of myosin-actin cross bridge & Sports (Rigor mortis)

1661

1665

1666

Microbiology

Pulmonary & Critical Care

Pts olde than 65 are particularly prone to developing secondary bacterial pneumonia after influenza infection. In order, the ppathogens often most responsible for 2ndry bacterial pneumonia are Strep Pneumo, *Staph Aureus*, and H. Influenza.

1667

Microbiology

Pulmonary & Critical Care

Child with upper-respiratory tract symptoms "followed" by brassy (barking) cough and difficulty breathing probbaly has parainfluenza virus Croup which is a *Paramyxovirus*

1669

Microbiology

Dermatology

Child of immigrants with a rash that started in face and spread rapidly down the body. Exam shows a generalized, fine pinkish, maculopapular rash and tender lymphadenopathy bilateral behind the ears. Most likely cause of this disease is a *Togavirus* [Rubella is a togavirus] [Rubeola by paramyxovirus which causes measles has no post auricular lumphadenopathy usually assoc with it]

1672

Microbiology

Infectious Diseases

An HIV protein that is Glycosylated then proetolytically cleaved in 2 smaller proteins. This protein is gp160 which is cleaved into gp120 and gp41 which help in *Virion attachment to the Target Cells*

1673

Pharmacology

Endocrine, Diabetes & Metabolism

Pt with redistribution of fat from the extremities to the trunk. This is a common adverse effect of *highly-active antiretroviral therapy (HAART)*

Hematology & Oncology

An HIV antiviral drug that is structurally unrelated to nucleosides and is not phosphorylated intracellularly. The drug acts within the cytolplasm of infected cells to inhibit sunthesis of viral DNA from RNA template. The drug is *Nevirapine* [Non nucleaoside Reverse transcriptase Inhibitor, e.g nevirapine and efavirenz]

Pulmonary & Critical Care

Mycoplasma hominis is a genus that includes Ureaplasma urealyticum and those have no cell walls. They are therefore resistent to cell wall synthesis inhibitors. We tend to use anti-ribosomal agents (macrolides, tetracyclies)

1674

1677

Pharmacology

Microbiology

Pulmonary & Critical Care

Pt with persistent coughm low-grade fever and malaise. Chest xray shows pulmonary infiltrates more severe than would be expected based on clinical status. Causative agent required cholestrol enriched medium to grow. This is walking pneumonia caused by *Mycoplasma Pneumonia*

Anatomy

Renal, Urinary Systems & Electrolytes

The "proximal" part of the ureter is supplied by the *Renal Artery*. The middle part is highly variable receiving supply from the gonadal artery, the common iliac, and uterine arteries. The distal part (close to bladder) is supplied by Superior Vesical artery, which is a branch of the internal iliac.

1684

Embryology

Infant with flaccid lower extremity and absent ankle reflexes Rheumatology/Orthopedics bilaterally and with poorly developed lumbar spine and sacrum (agenesis) has Caudal Regression Syndrome which is related to & Sports mother *Uncontrolled Diabetes* during pregnancy.

1686

Anatomy

Ear, Nose & Throat (ENT)

The recurrent laryngeal nerve is in close proximity to the inferior thyroid artery and can accidently damaged during inferior thyroid artery ligation during a thyroidectomy.

1679

1680

Microbiology

1687

Anatomy

Nervous System

Pt with initial resistance to passive extension followed by sudden release has Clasp-knife Spasticity which is seen in upper motor neuron lesion due to lack of inhibition on spinal stretch reflex arch. Pts with *INTERNAL CAPSULE* stroke have pure motor weakness affecting contralateral limbs and lower face.

1688

Genetics

Pregnancy, Childbirth & Puerperium

An ovulated oocyte is at *Metaphase of Meiosis 2*

1695

Anatomy

Pulmonary & Critical Care

Stab wound immediately above the clavicle and lateral to the manubrium can puncture the *Pleura* and cause pneumothorax, tensionpneumothoraxorhemothorax.

1696

Anatomy

Nervous System

Embolism to ACA would impared ability to *Climb stairs*

1697

Anatomy

Rheumatology/Orthopedics An anterior translation of the tibia relative to the femur on stability & Sports testing indicates an inury to the *Anterior Cruciate Ligament*

1698

Anatomy

Ear, Nose & Throat (ENT)

Blunt trauma to the globe can cause orbital blowout fractures. These fractures most commonly involve the medial or inferior orbital walls due to thin bone bordering the ethmoid and *Maxillart* sinuses.

1699

Anatomy

Cardiovascular System

A puncture wound at the left sternal border in the fourth intercostal space will injure the *Right Ventricle*

1700

Anatomy

Renal, Urinary Systems & Electrolytes

A fracture of the elft 12th rib can cause laceration to *Left Kidney*

Anatomy

CHild Pt who falls on his outstretched arms and fractures his clavicle. What causes the medial fragment of the fractured bone to Rheumatology/Orthopedics be displaced superiorly is the *Sternocleidomastoid muscle* while & Sports the lateral portion would be pulled inferiorly by the wieght of the arm and the pectoralis major muscle.

1704

Anatomy

Pt who falls on his can hands and cant extend wrist. Mid humoral Rheumatology/Orthopedics shaft fracture is detected. Artery is injured is *Deep Brachial Artery (Profunda brachi)* & Sports (Runs along the radial nerve)

1705

Embryology

Cardiovascular System

Teratology of Fallor results from *Deviation of Infundibular Septum*

1710

Pharmacology

GeneralPrinciples

low Vd (3-5L) indicates highly charged/ hydrophilic drug and that it has a high molecular wieght thereby highly protein bound.

GeneralPrinciples

Graph that is bimodal in measuring the concentration of Isoniazid in plasma suggest pharmacologic polymorphism in drug metabolizing capacity. Isoniazid is metabolized by *Acetylation* and therefore you have slow and fast acetylators.

1702

1712

Pharmacology

1717

Pathology

Hematology & Oncology

Hypophosphorylated RB protein is likely to *Prevent G1/S cell cycle Transition* (hypophosphorylated is active, abnormal phosphorylation results in inactivation and proceeding of cycle unchecked)

1722

Microbiology

Hematology & Oncology

pt being Tx for HIV. Viral strains show significant increase in POL gene. This is related to *Antiretroviral chemotherapy* (Resistance to drugs)

Infectious Diseases

Pt with HIV who presents due to several months of pain and itching in perirectal area. He also has intermitten rectal bleeding. Exam shows a visible ulcerative mass. Most likely responsible pathogen is*HumanPapillomavirus* [Anal squamous cell cacinoma] [CMV causes retinits and colitis, not a mass]

1723

Microbiology

1726

Pharmacology

Dermatology

Pt with hair loss at anterior scalp and vertex has typical features of androgenetic alopecia. 5-alpha-redyctase inhibitors such as *Finasteride* help minimize progression of this disease.

1728

Genetics

GeneralPrinciples

*Classic Galactosemia* is autosomal recessive.

1730

Anatomy

Rheumatology/Orthopedics The most important structure in the Valsalva Meneuver is *Rectum & Sports Abdmonis Muscle* which can be seen anterioly on a CT scan.

1734

Histology

Rheumatology/Orthopedics Antibodeis against Actin would be against the Z-line since it & Sports contains only actin

1737

Anatomy

In a pt with BPH who is given Finasteride that acts on *The MaleReproductiveSystem prostate* (below the bladder on CT) (5-alpha reductase inhibitor)

1739

Anatomy

FemaleReproductive System & Breast

A *pudendal nerve* block is performed by injecting an anesthetic intravaginally, medial to the ischial spine, through the sacrospinous ligament. This provides anesthesia to most of the perineum.

1740

Embryology

Ear, Nose & Throat (ENT)

a uni lateral cleft lip is caused bt failure of *Fusion on the maxillary prominenceandintermaxillarysegment*

1741

Anatomy

Nervous System

Vomiting from sysetmic chemotherapy is triggered by chemoreceptor trigger zone located on the *Dorsal surfce of Medulla at the caudal end of 4th Ventricle* (Area postrema)

1742

Anatomy

Nervous System

Pt with nerve injury and prsents with foot slapping the ground with each step (steppage gait) has *Common peroneal nerve injury*

1745

Anatomy

Pulmonary & Critical Care

Pts who is supine will aspirate into the *Post segment of the upper lobe* and the Superior segment of the lower lobes of the right lung

Endocrine, Diabetes & Metabolism

A nerby nerve injury while ligating an artery entering the superior pole of the thyroid lobe(superior thyroid artery) would most likely deninnervate the *Cricothyroid Muscle* which is innevated by the external branch of the superior laryngeal neerve.

1747

Anatomy

1749

Anatomy

Nervous System

Injury to median nerve at the wrist is manfiested by diminished sensation in first 3 digits with preserved sensation along the thenar eminence. The median nerves courses between the *Flexor digitorum superficialis and Flexor digitorum Profundus*

1750

Embryology

Cardiovascular System

The common carotid artery which is palpatrd along the inner side of the sternocleidomastoid muscle is derived from the 3rd pharyngeal aortic arch.

Renal, Urinary Systems & Electrolytes

Neoborn who has tachypnea and hypoxia. He has a flattened nose and bilateral club feet. He dies one hour later. To be found during autopsy is *Renal Agenesis* [Potter sequence of pulmonary hypoplasia, falttened facies, and limb deformity due to Oligohydroamnios due urinary tract anomaly]

1752

Embryology

1754

Pathology

Hematology & Oncology

Benign lympph node enlargement in response to antigenic stimulation is associated with a Polyclonal proliferation of lymphocytes. A monoclonal lymphocytic proliferation of lymphocytes. A *Monoclonal lymphocytic proliferation* is a strong evidenc of malignancy.

1755

Pathology

Hematology & Oncology

8 year odl pt from east africa with Large tumor on Mandible with palbable regional lymphadenopathy. Biopsy shows diffuse infiltrate of lymphoid cells with numerous mitotic figures and interspersed macrophages surrounded by clear spaces (star-sky app). The gene translocated in these lymphoid cells produces a protein that is most directly responsbile for *Transcription Activation* -(Burkits lymphoma, C-myc gene, t(8:14))

1758

Pathology

Hematology & Oncology

bcl-2 gene normally inhibits *Cell death cascade* (inhibits apoptosis)

Hematology & Oncology

An example of Anaplastic tumor cells is *Brain tumor cells forming giant cells* [No resemblence to tissue of origin. Composed of pleomorphic cells with large, hyperchromatic nuclei that grow in disorganized fashion. Anaplastic tumors may also contain numerous, abdnormal mitoses and giant tumor cells]

Hematology & Oncology

Pt has cancer. Genetic study shows a single nucleotide substitution causing an "activating mutation". Gene most likely involved is *KRAS* [Activating mutation indicates a proto-oncogene, like KRAS][APC, BRCA, RB, & TP53 are tumor suppressors hence are anti-oncogenes]

Hematology & Oncology

Pt presents with skin rash. He has history of pneumocystic pneumonia and painful ulcers. He uses Ilicit drugs frequently. P.E shows a widespread rash of lesions (image shown). Most likely cause is *Human Herpes Virus 8* [Kaposi Sarcoma]

1759

1760

1761

Pathology

Pathology

Pathology

1763

Immunology

Pulmonary & Critical Care

2 yr old boy Pt with sinopulmonary infections (otitis media & pneumococal pneumonia for e.g) Together with G. lamblia gastroenteritis, failure to thrive and low Serum Imunoglobulins. Flow cytometry of pts peripheral blood would show def of cell bearing *CD19* marker [X-linedAgammaglobulinemia, Bcells]

1768

Physiology

Endocrine, Diabetes & Metabolism

Proinsuline is cleaved by beta peptidases into Insulin and C-peptide, both of which are then *Packed in Secretory Granules*

1773

Pharmacology

Prolonged use of glucocorticoids such as *Prednisone* in pts with Rheumatology/Orthopedics Rheumatoid A. can lead to osteoarthritis and cause fractures of & Sports vertebral bones for example.

1775

Pharmacology

Pregnancy, Childbirth & Puerperium

Tetracyclines (Doxycycline) that are given to treat pregnant women with Lyme disease can cause fetal *Teeth Staining*. If pregnancy is known, give Penicillin instead. If pt is on warfarin and a new drug was added and pt developed thrombotic event, then the new drug lowered efficacy of anticoagulation property of warfarin through the induction of CYP450, which is how Warfarin is metablized. One such drug is Phenobarbital.

1777

Pharmacology

Nervous System

1783

Pathology

Pt with abdominal pain, diarrhea, and tender abdomen without Gastrointestinal & Nutrition guarding. There is a draining fistula near her coccyx. Most likley Dx is *Crohn Disease*

1784

Pharmacology

Hematology & Oncology

Enoxaparin is a form of low molecular weight heparin and therefore binds to *Antithrombin 3* which once activated binds factor Xa and stops it from converting prothromin to thrombin.

1785

Pathology

Hematology & Oncology

Pt with anemia (manifesting as fatigue), thrombocytopenia (Easy bruising), and neutropenia (recent respiratory infection), with profound reticilocytopenia, morphologically normal cells line in eriheral smear and no splenomegaly. Bone marrow biopsy would most likely show *Hypocellular marrow filled with fat cells and marrow stroma* [Aplastic Anemia]

1786

Pathology

Hematology & Oncology

Calculate Corrected reticulocyte count or sth.

Hematology & Oncology

Pt with progressive fatigue and occasional palpitations. She is post menopausal. Blood Hb level is 8.5. Peripheral blood smear shows pale microcytes. WHat should be ruled out initially in this pt *Occult blood loss* [hypochromic, microcytic anemia in setting of iron deficiency] [primary mechanism of iron def is blood loss and shud be excluded first]

Hematology & Oncology

Pt with hypochromic microcytic anemia who is treated with Fe supplementation. several week later her blood smear shows numerous enlarged RBC that appear blue on Wright-Giemsa stain. The bluish color on hese RBC is explained by the presence of *rRNA* [Enhance erythropoiesis and release of mature RBC's and reticulocytes, reticulocyte lacks nucleus but retain basophilic residual rRNA that appears blue on said stain)

Hematology & Oncology

Individuals who demonstrate increased ativity of a specific intracellular enzyme are more susceptible to developing benz(o)pyrene induced lung cancer. The enzyme that is most likely overactive in these pts is *Microsomal Monooxygenase*

Anatomy

Cardiovascular System

The aorta and superior mesenteric artery can compress the left renal vein. The increase pressure in the left renal vein causes retrograde blood flow to the testes and dialtion of the pampiniform plexus ==> *VARICOCELE*

Biochemistry

Chronic alcoholic pt with angular stomatitis, cheilitis, glossitis and a "low riboflavin" probably has riboflavin (B2) deficeincy. Riboflavin can become FMN (flavin mononucleotide) then FAD (dinucleotide) Gastrointestinal & Nutrition which act as coenzymes in reactions thru acceptance of electrons (ETC (complex2)& Krebs). FAD is a component of *Succinate Dehydrogenase*

1793

1796

1797

1805

1807

Pathology

Pathology

Pathology

*Vaginal Agenesis* is characterized by short vagina and rudimentary uterus and Amenorrhea with normal 2ndry sex characteristics and normal wieght and stature. It is a.k.a Mullerian Aplasia or MRKH syndrome. It often presents with urologic issues as as unilateral renal agensis.

1809

Embryology

FemaleReproductive System & Breast

1812

Anatomy

Mastectomy with axillary lymph node removal can injur the long Rheumatology/Orthopedics thoracic nerve and henc injury seratius anterior and lead to winged & Sports scapula.

1813

1814

Anatomy

Anatomy

Cardiovascular System

A skull fracture at the junction of the frontal, pariatal, temporal and sphenoid bones (pterion) risks lacerating the middle meningeal artery and causing epidural hematoma. The MMA is a branch of *Maxillary Artery*

Ear, Nose & Throat (ENT)

Pt who faints after otoscope exam has experience vasovagal syncope due to stimulation of post ext auditory canal. *Vagus Nerve is affected*

1815 1816

Anatomy Pharmacology

Nervous System

CN IX resection would lead to loss of sensation over the *Tonsils*

Hematology & Oncology

Pt undergoing chemotherapy who presents with signs of hemorrhagic cystitis. Pt is probably undergoing Cyclophosphamide or ifosfamide. This could have been prevented with giving *MESNA*

1819

Pharmacology

Hematology & Oncology

Tumor cells become resistant to anticancer agents through expression of cell surface glycoprotein (P-glycoproetin, coded for by the human multi-drug resistance gene MDR1) which functions as an *ATP-dependent transporter*

1828

Pharmacology

Cardiovascular System

If pt cant handle aspirin and he has stable angina. Give him *Clopidogrel*

Anatomy

Nervous System

Pt who falls from tree and tries to break fall ny grabbing tree branch will likely suffer from *Lower trunk injury of Brachial Plexus*. He will be unable to perform fine finger movements with hand (Lower trunk supplies median and ulnar)

Genetics

Pregnancy, Childbirth & Puerperium

A complete mole usually results when an empty ovum is fertilized by a haploid sperm. Subsequent duplication of the paternal genetic complement (23X) results in characteristic *46,XX* genotype

1832

Anatomy

A mass in the third portion of the duodenum that is infiltrating Gastrointestinal & Nutrition beyond guy wall carrys the risk of compromising the *Superior Mesenteric Artery*

1833

Embryology

Pulmonary & Critical Care

High blood oxygen in a fetus can be found in the inferior venecava.

1844

Pathology

Endocrine, Diabetes & Metabolism

Pt with history of thyroidectomy (Medullary thyroid Cancer), flesh color nodule on lips and tongue (Mucosal Neuromas), & Marfinoid Habitus (tall, long fingers etc) probably has *MEN 2B*

1846

Anatomy

Nervous System

Occlusion to the *Middle cerebral Artery* can cause both Wernicke and Broca's aphasia.

Hematology & Oncology

In an experiment where folate is deprived. Provision of *Thymidine* would reduce erythroid precuros cell apoptosis. [Folate def inhibits formation of dTMP, Thymidine supplementation can increase dTMP and hence reduce erythroid precursor cell apotosis]

Hematology & Oncology

Pt with Atrophic Gastritis who is given cyanocobalmin (vit B12) to treat his macrocytic anemia (penicious anemia) would have a rapid rise then fall of his *Reticulocyte count* His Hemoglobin would rise steadily but less rapidly.

1829

1830

1847

1848

Biochemistry

Pathology

1850

Pathology

Renal, Urinary Systems & Electrolytes

7 yr odl with two day history of colicky abdominal pain develops bloody stools. His urine appeared red today. P.E shows palpable skin lesions on his buttocks. An additional finding consistent with his condition is *Joint Pain* [Henoch-SchonleinPurpura][Mostcommonsmallvesselvasculitis in children]

1851

Pathology

Hematology & Oncology

In HUS thee is *Elevated seum indirect bilirubin*

Nervous System

Young college stduent with headache, fever, altered metal status, nuchal rigidity, purpuric rash) has Meningococcal meningitis and could have been prevented with *Capsular Polysacharide* vaccine.

PathophysiologyNervous System

Hydrocephalus in infants presents with macrocephaly and poor feeding. Imaging studies showing enlarged ventricles are characteristic. Untreated hydrocephalus leads to spasticity due to stretching of periventricular pyramidal tracts, developmental delays, and seizures.

1853

1854

Microbiology

1855

PathophysiologyHematology & Oncology

Infant with hand and foot syndrome (Dactylitis) with family hsitory of penumococcal sepsis (encapsulated) probably has sickle cell disease and his *Serum Haptoglobin would be Reduced*

1860

PathophysiologyDermatology

Wrincles are a result of *decreased collagen fibrils production* Old pt with blood in urine. Renal biospy shows rouned/polygonal cells with abundant cytoplasm. The process that acconts for abnormal appearance of cells is *Glycogen and lipid accumulation* [C lear cell Ca of Kidney]

Pathology

Renal, Urinary Systems & Electrolytes

1863

Pathology

Pt recently went to mexico. He presents with low grade fever, anorexia, dark colored urine and RUQ tenderness. Liver biopsy Gastrointestinal & Nutrition most likely shows *Hepatocye Swelling* [Acute viral hepatitis, most likely by Hep A virus] [Hall mark is hepatocyte necrosis which characterized by swelling]

1868

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Signs of confusion, fever, flushing, dry mouth, mydriasis and decreased bowel sounds indiacte an Anticholinergic crisis which can be caused by Tricylic Antidepressants such as *Amitriptyline*

1871

Anatomy

Cardiovascular System

In most poeple with right coronary dominance, Inducible ischemia of the inferior surface of the heart would probably be due to occlusion of *Right coronary artery*

1873

Pathology

Hematology & Oncology

Angiogenesis is predominantly driven by *Fibroblast Growth Factor* and Vascular Endothelilal Growth Factor.

Cardiovascular System

In the event of an interruption of blood flow secondary to arterial occlusion of left atrium. The organ that would be least vulnerable to infarction is the *LIVER* [Has dual blood supply][The exception is during liver transplant and there is hepatic artery thrombosis. This becuase during the transplant the collateral supply is severed]

1862

1875

1877

1879

Pathology

PathophysiologyHematology & Oncology

Pea d'orange is an erythematous itchy breast rash with skin texture changes analogous to an orange peel. This is the key dermatologuc presentation of inflammatory breast cancer and is caused by cancerous cells obstructing lymphatic drainage to the dermal lymphatic spaces.

Pathology

Hematology & Oncology

A pt with a single amino acid substitutiion near the protein C cleavage sit in he coagulation factor V gene products. This pt is at greatest risk for *Pulmonary thromnoembolism* [Factor V leiden, predisposes to hypercoagable state and DVT]

1880

Pathology

Hematology & Oncology

Pt with chest tightness and dyspnea, with chest CT showing a saddle pulmonary embolus. Pt has history of cancer, smoking and age (70). This places him at risk of developing a vebous thromboembolism. A factor that contrinutes to this a *Hypercoagulable state* (Virchow's triad: endothelial injury, venous stasis, and hypercoagulable state)

1882

Pathology

Cardiovascular System

Transient myocardial ischemia causes myocardial hypertrophy is due to *Inttracellular Ca2+ accumulation*

1890

Pharmacology

Hematology & Oncology

6-mercaptopurine is inactivated by *Xanthine Oxidase*

1893

Pharmacology

Hematology & Oncology

Vincristine inhibits cell synthesis at the M phase. (Microtubules)

Dermatology

Pt with animal exposure and scratch marks together with tender regional LYMPHADENOPATHY likely has Cat-Scratch Disease caused by Bartonella Henselae, a g-ve organism that also causes *Bacillary Angiomatosis* in immunocompromised pts

1898

Microbiology

PathophysiologyCardiovascular System

A normal bleeding time indicates adequate platelet function. A normal Activated partial thromboplastic time (aPTT) indicates an intact intrinisic coagulation system. A prolonged prothrombin time in the setting of a normal aPTT indicates a defect in th extrinsic coagulation systen (E.g *fACOTR 7*)

1906

Microbiology

An elderly person with Confusion and flaccid paralysis and CSF PCR shows Viral RNA. Most likey it is West Nile Virus which is transmitted by *An Insect Bite* of the Culex Mosquito.

1907

Pt who has acute pancreatitis and has a malignant mass on pancrease and undergoes subtotal pancreatectomy would have PathophysiologyGastrointestinal & Nutrition normal *IntestinalD-xyloseAbsorptioon* (xylose is simple sugar, doesnt need pancreatic enzymes for absorption)

1903

Nervous System

1910

PathophysiologyPulmonary & Critical Care

1913

Pathology

Middle aged man with new-onset fever, productive cough and a dense lobar infiltrate likely has community acquired pneumonia. Most commonly caused by Strep Pneumo. What accounts for the green color of his sputum is *Myeloperoxidase* of the neutrophil.

Renal, Urinary Systems & Electrolytes

Screening for early-stage diabetic nephropathy is done by measuring urinary concentration of *Albumin*

1915

Embryology

Renal, Urinary Systems & Electrolytes

Ultrasound of fetus with bilaterally enlarged fetal kidneys with diffuse small cysts and oligohydroamnios has Autosomal recessive polycystic kidney disease (ARPKD) and is the oligohydroamnios can lead to Potters sequence which is Flattened facies, Limb deformity, and "Pulmnary Hypoplasia" and therefore the baby can be born with *Respiratory Disress*

1922

Histology

Nervous System

Kinesin & dynein are *Microtublar* motor proteins responsible for rapid axonal transport.Kinesin acts in Anterograde transpor, Dynein in Retrograde.

1925

Pathology

Pulmonary & Critical Care

*Animal Dander should be avoided by pts with Asthma.

1927

Pathology

IV drug used wuth fever, jaundice and anorexia. Liver biopsy shows mononuclear infiltrates, hepatocyte swelling and acidophilic Gastrointestinal & Nutrition bodies. Formation of acidophilic bodies is the result of *Apoptosis* [viralhepatitis]

1928

Pathology

FemaleReproductive System & Breast

Pt's P.E reveals a large adnexal mass. Ultrasonography reveals a large ovarian cyst. She has signs of virlization togther with clitoromegaly. Most likely Dx is *Sertoli-Leydig tumor*

1929

Microbiology

FemaleReproductive System & Breast

Pt with gray white fishy vaginal discharge with no inflammation that shows clue cells is characteristic of bacteril vaginosis caused by Gardnerella vaginitis which an *Anaerobic gram variable organism*

1931

Physiology

Cardiovascular System

Ca efflux prior to myocyte relaxation is caused by use of Ca2+ATPase and *NA+/Ca+ Exchange Mechanisms*

1932

Microbiology

FemaleReproductive System & Breast

Pt with abdominal pain, bloody vaginal discharge, orthostatic HTN and a positive preganancy test. Prior infection with *N.Gonorrhoeae* is likely responsible for her current condition. [Pt has a ruptured ectopic preganncy. Primary resik factor for Ectopic preg is tubal scaring and prior infection with Chlamidya and N. gonorrhea are major predisposing factors.]

1933

Anatomy

Nervous System

Pt with diplopia and has problems walking down stairs and trouble reading probably has a lesion to the trochlear nerve which is responsible for depression of adducted eye.

1935

Genetics

Presence of ragged skeletal muscle fibers and lactic acidosis is suugestive of mitochondrial myopathy. Heteoroplasmy is Rheumatology/Orthopedics responsible for variable expressiion of mitochonndrial disease in those affected. Heteroplasmy is having both mutated and wild & Sports mitochondrial Genomes in one individual, severity of disease depends on ratio of these.

1936

Histology

Nervous System

A toxic insult that targets protein KInesin will affect *Secretory vesicles in nerve terminals* and will make them absent from tissue histological examination.

Pathology

Dermatology

54 yr old woman comes due to multiple firm violaceous nodules on her right upper arm. She was diagnosed with breast cancer and treated with radical mastectomy. And had axillary lymph node disection that shows no metastases. Post-operatively developed chronic lymphadema involving her right arm. Most likley etiology of her current skin lesions is *Angiosarcoma* [Chronic lymphedema is a risk factor for cutaneous angiosarcoma][lymph node disect is classic predisposing procedure]

1938

Physiology

Pt with secretory diarhea. Her gastric cells lack gastric acid. Somatostatin relieves her symptoms. An excess of *Vasoactive Intestinal Peptide* is responsible. Gastrointestinal & Nutrition [VIPoma, a pancreatic islet cell tumor results in watery diarhea, hypokalemia and achlorhydria. Somatostatin decrease productuon of GI hormones]

1939

PathophysiologyPulmonary & Critical Care

Pt with CF has Na loss in sweat.

1940

PathophysiologyHematology & Oncology

Target cells are seen in Beta Thallesemia. Its a condition in hwich there is impaired *mRNA formation*

PathophysiologyPulmonary & Critical Care

Chronic smoker with chronic cough who has been hospitalized before for respiratory infections and treated with antibiotics probably has COPD and therefore hypoxia and an additional finding would be *Increased Erythropoitin production* in repsonse to the hypoxia.

Pharmacology

Nervous System

Pt with a hand tremor. It is most prominent in activity such drinking from a glass. She says alcohol improves the tremor. Family Hx is significant for similar problems. Best Tx for this pt is *Propranolol* [Essential Tremor, nonselective beta blockers lessens it via CNS effects]

1937

1942

1946

1947

Pharmacology

Cardiovascular System

Norepi is an agonist for alpha 1 and Beta 2 but significantly more agonist effect for alpha1 and therefore causes vasoconstriction (B2 causes dilation). Therefore, norepi increases vascular tension (vasoconstriction). A drug that reduces this ability of norepi would have to block its alpha 1 agonist effect Irrevesibly (non-competitively), and therefore a nonselective, non-cmpetitive alpha antagonist such as *Phenoxybenzamine* can do it.

1948

Pharmacology

Cardiovascular System

Betal Blockers inhibit renin release.

1949

Microbiology

Infectious Diseases

N. Gonorrhea urethritis is treated treated with *Ceftriaxone (3rd gen Ceph) and Azithromycin (Macrolide) *

1952

Pharmacology

Infectious Diseases

Penicilins are structurally similar to *D-alanine-D-alanine* and they inhibit transpeptidases by binding to its site.

Hematology & Oncology

Hemophilia is an X-linked cogulopathy that presents with intramuscular hemorrhage, hemarthroses, delayed bleed after procedure. Lab results show prolonged Partial Thromboplastin Time.

1953

Pathology

Pt has epistaxis, ecchymoses, and marked thrombocytopenia. SHe has a normal hematocrit, leukocyte count and differential, frinogen and PT. She takes no medication, and there is no hepatosplenomegaly on P.E. These findings suggest an isolated acquired thrombocytopenia. Most likely mechanism in this pt is *Immune destruction of platelets* like "Immune thrombocytopenic purpura"

1954

Pathology

Hematology & Oncology

1956

Anatomy

Rheumatology/Orthopedics In a pt with a femoral neck fracture. The injury that would lead to osteonecrosis most likley involves the *Medial Cicrumflex* Artery. & Sports

1957

Histology

FemaleReproductive System & Breast

Pt with heavy and painful menstrual bleeding with uniformly enlarged uterus has Adenomyosis, which is *Endometrial tissue in theMyometrium*

1958

Pathology

Infectious Diseases

Bacterial Vaginosis can be Tx with *Clindamycin* or Metronidazole.

1964

Pathology

Hematology & Oncology

The finding of a high peak in gamma-globulin region on serum protein electrophoresis (SPEP) usually represents an M protein consisting of an overproduced monoclonal immunoglobin. Multiple myeloma causes an M protein peak on SPEK as well as anemia (weakness), lytic bone lesions (back pain, pathologic fractures) and renal insufficiency (related to amyloid deposition and hypercalcemia). *Multiple myeloma is *Plasma cell neoplasm**

1965

Pharmacology

Infectious Diseases

In treating Malaria by vivax (recurrent fever every 48 hrs). Primaquine is added to chloroquine in order to *Prevent disease Relapse*

1966

Microbiology

Nervous System

Child with fever, headaches, vomiting, mild pharyngeal erythema and neck stiffness. CSF analysis shows normal glucose and mildly elevated protein. Leukocyte count is 300 with lymphocytic predominance. Most likely cause is *Entervirus* (Viral meningitis (aseptic), entervirus include cosackie, polio, echovirus)

1967

Anatomy

Cardiovascular System

For graft purposes, the Great Saphenous Vein can accessed at a site *Just inferolateral to the pubic tubercle*

1970

Genetics

GeneralPrinciples

The occurence of multiple, seemingly unrelated phenotypic manifestation, often in different organs system as a result of a single genetic defect is termed *Pleiotropy* [Vignette example is Homocysteinurea, manifesting with pitting edema (from DVT), caved in chest wall (marfinoid habitus), DVT, singlegene mut in cystathionine beeta-synthase enzyme]

1971

Physiology

Gastrointestinal & Nutrition

Secretin increases concentration of *Bicarbonate* released from the pancreas.

1973

Physiology

Cardiovascular System

Calcium channel blockers as as verapamil slow *diastolic depolarization* in SA and AV node.

Cardiovascular System

Pt with irregular beat rhythm, narrow QRS complexes and Absent P waves has A fib. What determines his ventricular contraction rate is the *AV node refractory period*

Pulmonary & Critical Care

In high altitudes Po2 decreases and body responds by hyperventilation which hence decreases PCO2 causing a respiratory alkalosis (low pH). After 2 days the kidney respond to the alkalosis by excreting HCO3 and decreasing it in blood.

Pulmonary & Critical Care

Obese truck driver with history of calf swelling who presenst to ER with sudden onset dyspnea probably has PE lodged from DVT (calf swelling). In PE there is *respiratory alkalosis, low CO2, Low O2, and normal HCO3*

1977

1980

1981

Physiology

Physiology

Physiology

1984

Pharmacology

Endocrine, Diabetes & Metabolism

1985

PathophysiologyPulmonary & Critical Care

1987

Physiology

In a non medical setting, severe hypoglycemia is treated wih *IM Glucagon* An obese man who has excessive daytime sleepiness and signs of upper air way obstruction such as snoring has obstructive sleep apnea which is associated with syestemic hypertension and can also lead to Pulmonary HTN!

Pregnancy, Childbirth & Puerperium

Progestrone inhibits prolactin during getstation thereby preventing lactation.

Renal, Urinary Systems & Electrolytes

18 year old male with progressive skin rash. He has long standing history of intermittent burning sensation in his palms and soles that is exacerbated bt stres and fatigue. Burning is severe after exercise. He sweats very little. Lab test reveals undetectable levels of alpha-galactosidase A. Pt is at greatest risk for *Renal Failure* [Fabry Disease, X-linked alpha-galactosidase A def]

Biochemistry

Endocrine, Diabetes & Metabolism

An autosomal recessive diroder of Sphingomyelinase deficiency. Most consistent with this condition is *Neurodegenration and Hepatosplenomegaly* [Neiman-Pick disease. aslo foamy macrophages and cherry-red macular spot]

Pathology

FemaleReproductive System & Breast

Pt with HIV whose PAP semar shows high grae cervical dysplasia. The strongest risk factor for cervical dysplasia in this pt is *Immunosupression* [Risk factors for cervical cancer]

Pulmonary & Critical Care

Infant with recurrent otitis media and bronchiolitis. He has oral candiasis. He has a Hx of chronic Diarrhea. Serum protein electrophoresis shows very low gamma globulin level. X-ray shows absent thymic shadow. Most likley Dx is *SCID* [Recurrent viral infections, Oral thrush, Persistent Diarrhea. Absent thymic shadow is due to severe T cell def. Hypogammaglobulinema is due to low B cells. Both low humoral and cell med immunity]

Pharmacology

Nervous System

Pt that presents with chest pain and has history of HTN, Diabetesm, and asthma. Tx is given and chest pain disappears but he now develops dyspnea. Pt was most likey given beta blockers to relieve chest pain (B-1 block) and develoved bronchoconstriction (B-2 block) which caused the dyspnea. B-blockers work by *Inhibiting the neurostransmitter-receptor interaction in adrenergic synapses*

2003

Pharmacology

Renal, Urinary Systems & Electrolytes

Thiazides prevent calcium loss in urine, Thiazides keep calcium in the body. Thus, they are useful in Tx of nephrolithiasis due to calcium oxalate stones. Loop diuretics on the other hand lose calcium. Loops Lose Calcium.

2006

Pharmacology

Cardiovascular System

Beta Blockers prolong *PR interval* by decreasing AV nodal conduction.

1989

1990

1992

1995

2000

Biochemistry

Immunology

2009

Physiology

Cardiovascular System

During a study, the blood oxygen content of the aorta and several other vessels is measured at rest. The greatest difference in these measurements will most likely be between the aorta and the *Coronary Sinus* [myocardial oxygen extraction is very high]

2012

Physiology

Renal, Urinary Systems & Electrolytes

After adminstration of Desmopressin, renal clearance of *Urea* decreases.

2015

Genetics

GeneralPrinciples

The homeobox genes code for proteins that are *Transcription regulators*

2018

Pharmacology

Hematology & Oncology

Etoposide is a chemotherapeutic agent that inhibits the sealing activity of *Topoisomerase 2*

2023

Anatomy

Cardiovascular System

The Superior Venecava is derived from the common cardinal veins.

2024

Anatomy

Nervous System

jaw deviation to right on opening mouth, difficulty chewing food suggest CN V3 Injury (Mandibuar) It passes through *foramen ovale*.

2025

Genetics

GeneralPrinciples

Enhancers can be *Located upstream, downstream or within introns of the gene*

2029

Genetics

GeneralPrinciples

Releasing factor 1 recognizes stop codons.

2030

Genetics

GeneralPrinciples

Mutations in promotor regions such as TATA box can likely affect *Transcription Initiation*

2033

Genetics

GeneralPrinciples

The poly A tail at the *3' end of RNA* is not transcriped from DNA template and was a post transcription modification.

2035

Biochemistry

GeneralPrinciples

mRNA *Interaction with P bodies* occurs only in the CYtoplasm.

2036

Biochemistry

Nervous System

Pt with mutation in Protein involved in the assembly of small nuclear ribonucleoproteins (snRNP's) in motor neurons. Pt will have impaired function of *Spliceosomes*

2037

Biochemistry

Dermatology

tRNA containts chemically modified bases such as dihydrouridine, ribothymidine, and pseudouridine. It has a *CCA* sequence at the its 3'-end that is used a recognition sequence by proteins. The 3' terminal hydroxyl group of the CCA tail serves as the aa binding site.

2047

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pt with mood symptoms and history of psychotic symptoms for more than 4 weeks in absence of moods symptoms suggests *Schizoaffective Disorder*

2049

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Use SSRI'S to treat OCD.

2053

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Shifting of emotions assciated with a significant person from the past to a person in the presentis called *Transference*

2056

Pathology

FemaleReproductive System & Breast

The female reproductive structure that contains simple cuboidal epithelial cells is *Ovary*

2057

Behavioral science

Social Sciences A pregnant minor is entitled to consent to prenatal care. Not an (Ethics/Legal/Professional) electiveterminationhowever.

2066

Biochemistry

Endocrine, Diabetes & Metabolism

Pt with orotic acid urea and normal ammonia levels could have a defect of UMP synthase (hereditary orotic aciduria) Supplementation with *URIDINE* helps this pt.

2067

Biochemistry

Nervous System

In lesch-Nyhan syndrome, there is increased activity of *PRPP Amidotransferase* due to compensatory increase in Denovo Purine Synthesis.

2068

Immunology

Allergy & Immunology

Histamine and *Tryptase* are elevated in Anaphylaxis.

2069

Immunology

Allergy & Immunology

Mast cell degranulation is triggered by *Receptor aggregation* during High affinity IgE receptor activation.

Nervous System

loss of touch, temperature, and vibratory sensations indiacte damage to spinothalamic and dorsal column tracts. These two both project into the Ventral Post. Lateral Nucleus of Thalamus. Also if pt experiences diminished sensation over right side of face, then his trigeminal pathway is damaged. The trigemical pathway is also received by the thalamus at the Ventral Post. Medial Nucleus. So damage to *Venral Post Thalamus* can trigger all above sensory loss involving 3 paths.

2076

Anatomy

2077

Anatomy

Nervous System

fluid filled cavities in the deep structures of the brain arise from lacune formation due to occlsuin of small penetrating arteries that supply the structures. These lacunar infarcts are cause by LIPOHYALINOSIS (hyaline thickening of vascular wall) & Microatheromas (athersclerotic accumulation of lipid-laden macrophages on intimal layer of penetrating arteries. These predispose to *Small-Vesel Occlusion*

2078

Immunology

Dermatology

Pts with history of otitis media, chronic diarhea who on on exa have pneumocystis probably have SCID. (Otitis meedia is from bacteria and that reuires Humoral immunity) (pneumocystits requires t cells) Thefere *Combined Immune deficiency*

2082

Microbiology

Nervous System

Toxoplasmosis is Tx with *Pyrimethamine and Sulfadiazine* [If u see ring enhancing lesions in HIV , suspect toxo before lymphoma]

2084

Pathology

Hematology & Oncology

Pt with signs of sickle cell disease (african american, recurrent back pain, bony tenderness, low Hb). Histopathologic evaluation of his spleen would show *Fibrosis and Atrophy*

2087

Genetics

Hematology & Oncology

In beta thalassemia there is *Microcytosis*

Pharmacology

Nervous System

Treat serotonin syndrome with *Cyproheptadine* (a first gen. antihistamine that has nonspecific 5-HT & 5-HT2 receptor antagonism)

Biochemistry

Mutation in PRPP synthetase (enzyme in purine denova synthesis) Rheumatology/Orthopedics can lead to hyperuricemia due increased production of purines. & Sports Thus increasing the risk for Gout Which affects *Joints*

Biochemistry

Negatively Birefringent crystals under polarized light indicates Rheumatology/Orthopedics Gouty Arthritis, for which the inflamatory response is mediated by & Sports *NEUTROPHILS*

2089

2090

2091

2093

Pathology

2094

FemaleReproductive Pathophysiology System & Breast

Pt with menstrual irregularities, who is obese and has acne and hirsutism probably has Polycystic Ovarian Syndrome, and therefore has *Enlarged Ovaries*

2095

Pathophysiology

FemaleReproductive System & Breast

Pts with PCOD who desire fertility are treated with Clomiphene, *An estrogen receptor Modulator*

2099

PathophysiologyCardiovascular System

Pulsus Paradoxus can be seen in *Pericardial Disease*

PathophysiologyCardiovascular System

Pt with dyspnea, tachypnea, prolonged expiration and bilateral wheezing is suggestive of acute exacerbation of Obstructive Pulmonary Disease. This is usually treated with beta agonists which relax bronchial smooth muscles by stimulating beta-2-adrenergic receptors. The receptor is Gs coupled and activates adenylyl cyclase and *Increases intracellular cAMP concentration*

PathophysiologyCardiovascular System

Pt presents with fatigue and dyspnea. An early diastolic murmur is heard at the left sternal border. Pt most likey has *Aortic Regurgitation*

Pharmacology

During continous infusion of a drug metabolized by first order kinetics, the "stead state" is reached in *4-5 half lives* (calculate it)

2100

2105

2112

Hematology & Oncology

Breast cells that over express 185kD glycoprotein and that have intracellular tyrosine kinase activity are probably the HER2/neu oncogenes that *Accelerates Cell Proliferation*

GeneralPrinciples

2116

Pathology

2117

PathophysiologyCardiovascular System

A low pitched holosystolic murmur heard best at the left sternal border with accentuation during the handgrip exercise is characteristic of *VSD*

2127

Anatomy

Nervous System

The most common finding in *PCA* territory infarction is Contralateral Hemianopia.

2128

Immunology

Pulmonary & Critical Care

*Anti IgE Antibodies* are effective add-on-therapy to severe allergic asthma patients that are already on glucucorticoids and beta-agonists.ExamplesincludeOmalizumab.

Anatomy

Cardiovascular System

A high speed motor vehicle accident that leads to injury of aorta would most liley ruptur that ismthus (just after subclavian artery) of the aorta. Pt usually dies before reaching hospital. If they do reach they present with non specific chest and abdominal pain.

2131

Pathology

Renal, Urinary Systems & Electrolytes

Proteinurea with serum containing IgG4 antobodies to phospholipase A2 receptor (PLA2R) suggests idiopathic *Membranious Nephropathy*

2132

Pharmacology

Hematology & Oncology

Unfractionated Heparin binds to thrombin and inactivates it better than low molecular weight heparin.

2133

PathophysiologyHematology & Oncology

Antocoagulant that prolongs both PTT and PT with no effect on TT is *Direct factor Xa Ihibitor*

Pathophysiology

Renal, Urinary Systems & Electrolytes

Significant renal artery stenosis causes renal hypoperfusion and activation of the RAAS system. This leads increased release of renin by the JG cells. These cells would undergo hyperplasia and hypertrophy and they are *Modified smooth muscle cells of the afferent arteriole*

Microbiology

Culture of a "periappendiceal fluid collection" in the abdomen could reveal the anaerobic *Bacteroides Fragilis* which express Gastrointestinal & Nutrition surface polysaccharides that favor abscess formation. Others could include E.coli, enterococci, & streptococci.

Anatomy

Psoas major muscle contributes to hip flexion which is an action Rheumatology/Orthopedics taken when sitting up from a supine position without using the & Sports hand.

2130

7569

7573

7621

Pulmonary & Critical Care

Pt with long history of smoking who comes due to shortness of breath and chonic mild cough. Lung x-ray shows hemithorax opacification on the right and deviation of the trachea toward opacified side. Most likely cause is *Righ mainstem bronchus lesion* [Collapsed lung due to bronchial obstruction]

7646

Anatomy

Cardiovascular System

Left ventricular leads in biventricular pacemaker course through the coronary sinus, which resides in the *Atrioventricular Groove* on the post aspect of the heart.

7710

Pathology

Gastrointestinal & Nutrition

Pt with duodenal ulcer. H. Pylori can be found in *Prepyloric area* [Antrum of stomach]

Ophthalmology

Pt with decreased vision. Says its blurry and distorted. Exam shows a grayish discoloration of the macula with area of adjacent hemorrhage. In treatment of this condition, *Vacsular Endothelial Growth Factor* should be specifically targeted. (Age related Macular degeneration (AMD), Retinal neovascularization due to VEGF) [Txwithranibizumab,bevacizumab)

Psychiatric/Behavioral & Substance Abuse

Patients with frontal lobe injury often experience executive dysfunction and personality changes secondary to impairement of the ogranizational, restraint, and motivational systems. Changes in social behavior can manifest in variable ways with *Left* sided lesions more often associated with "Apathy" and right-sided lesions withdisinhibition.

7721

7752

Pharmacology

Behavioral science

7792

Pharmacology

Rheumatology/Orthopedics A medication that selectively binds to an IL-1 "inducible" enzyyme & Sports is probably a selective COX-2 inhibitor such as *Celecoxib*

8249

Pharmacology

Renal, Urinary Systems & Electrolytes

Pharmacologic therapy of Urge incontinence involves *Antimuscurinic Agents*

8259

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Tx Narcolepst with *Modanfil*

8262

PathophysiologyPulmonary & Critical Care

8266

Physiology

Cheyne-stokes breathing (rapid breathing followed by apnea) is associated with *Congestive Heart Failure*

Wieght lifter who raises wieght above head and then his arms Rheumatology/Orthopedics suddenly and involuntarily give away and he drops the wieght to ground. The structure that was most likley responsible for the & Sports suddent muscle relaxation is *Golgi tendon organ*

8282

Microbiology

Cardiovascular System

The action that most likely prevents intravascular catheter-related infections is *Alcohol-based hand scrub prior to beginning the procedure*

8283

Genetics

Gastrointestinal & Nutrition

Differences in halotype frequencies in a population can be as a result of *Linkage Disequilibrium*

8288

Pharmacology

Infectious Diseases

Antibiotic against MRSA (pt is allegric to vanco) that causes increassed Creaatinine Kinase and causes muscle pain. The agent used affects *Maintenance of membrane Potential* of bacteria. (Daptomycin, creates transmembrane channels that depolarize cellular membrane)

8289

Pharmacology

Cardiovascular System

Low dose Atenolol affects B1 adrenergic receptors on *cardiac cells and JGP cells but not vascular smmoth muscle*

Pathology

HIV pt with multople hemorrhagic polypoidal lesions on colonoscopy. Biopsy reveals spindle cells with surrounding blood Gastrointestinal & Nutrition vesselproliferation. Most likely cause is *Kaposi's Sarcoma* [HHV-8]

8290

8294

8296

8324

Anatomy

Pathology

Microbiology

Cardiovascular System

IV drug users can have righ sided endocarditis involving the *TriCuspid Vavle* most often due Staph Aureus infection. This often presents as an early systolic murmur best heard over the left lower sternal border due to tricuspid regurgitation.

Cardiovascular System

Pt complains of worsening dyspnea. Also low grade fever and weight loss, also syncopal episodes when lying down. Auscultation shows low-pitched mid-diastolic rumble at cardiac apex. ECG shows left atrial enlargement and echo shows large pedunclated mass attached to the left atrium. Histology of mass will likley show *Scattered cell within a mucopolysaccharide strome* [Atrial Myxoma]

Nervous System

Agitation, disorienttion, Pharyngospasm, Photophobia, COMA and Death strongly suggests Rabies Encephalitis which binds to *ACETYLCHOLINERECEPTORS*(nicotinic) Neoborn with a palpable swelling of neck. He is comfortable only when held sideways. The child favors looking toward right and cries when his head is turned to left. Most likely condition present prenatally is *Intrauterine Malposition* [Congenital torticollis, sternocleidomastoid muscle injury and fibrosis]

8325

Pathology

Pregnancy, Childbirth & Puerperium

8326

Anatomy

MaleReproductiveSystem The scrotum is drained by the superficial inguinal lymph nodes.

8327

Pharmacology

Psychiatric/Behavioral & Substance Abuse

Treating pt already on SSRI such as paroxetine with antibiotic Linezolid can ilicit Sertonin Syndrome characteized by tremor, hyperflexia, clonus, confusion, agitaton, cramps and diarrhea.

8328

Genetics

GeneralPrinciples

In Trisomy 21, chromosomal nondisjunction occurs in *Meiosis 1*

8332

Anatomy

Cardiovascular System

Pt undergoes transesophageal echocardiography. The ultrasound probe is placed in the mid-esophagus facing "anteriorly". The cardiac chamber closest to the probe is *Left Atrium*

8333

Anatomy

Cardiovascular System

Transesophageal echo probe facing posteriorly would interrogate the *Descending Aorta*

Ear, Nose & Throat (ENT)

ELderely diabetic with severe pain and discharge from ear. Touching pinea causes extreme pain. Otoscopy shows granulation tissue in left ear canal with scant amount of discharge. Tymapnic membrane is clear, and no middle ear effusion. Cultures grow a g-ve rod. Characteristic best describing infecting organism is *Motile and Oxidase +ve* [PsudemonasOtitisExterna]

8342

Microbiology

8352

PathophysiologyNervous System

Pt presenting with weakness, dizziness and paraesthesias with recent history of eating japanese food has probably a Tetrodotoxin from eating Puffer fish. These toxins block Sodium channels thereforepreventingmuscledepoolarization.

8371

Pharmacology

Hematology & Oncology

The step that Raltegravir imapirs in viral replication is *mRNA transcription*

8390

Anatomy

FemaleReproductive System & Breast

16 year old female with pelvic pain every 28 days and resolves in a day or two with fully developed 2ndry sexual characteristic. She has a palpable mass anterior to the rectum. Serum Beta-hCG is negative. Most likely Dx is *Imperforate hymen*

8424

Histology

Endocrine, Diabetes & Metabolism

The adrenam medulla is demaracted from the cortex and is composed of Chromaffin cells with a deeply basophilic (blue) cytoplasm. The medulla is stimulated by Acetycholine.

8425

Biochemistry

Gastrointestinal & Nutrition

Mutations in Leptin gene or receptor will lead to *Hyperphagia and Obesity*

8455

Pharmacology

Gastrointestinal & Nutrition

Ribavirin wich is used in Hep C infection works by *Interferring with duplication of viral genetic material*

8456

Behavioral science

GeneralPrinciples

Providing care to all company employees in exchange for a set monthly fee is *Capitation*

8458

Pathology

Cardiovascular System

Most common cause of death a lightening strike is *Cardiac Arrythmia* and Respiratory failure.

8476

Pharmacology

Nervous System

Woman who presents with a migrain who is given a medication to be used immediately during an attack. Medication most likely affect *Postsynaptic serotonin receptor stimulation* (Triptans, e.g sumatriptan, serotonin agononist 5-HT 1B & 1D)

8480

Immunology

Hematology & Oncology

PECAM-1 gene is involved in Transmigration during the inflamatory process.

Pharmacology

Quadriplegic pt who is givena a skeletal muscle relaxant before Rheumatology/Orthopedics intubation goes into cardiac arrest. He has V fib and massive Hyperkalemia. Admistration of *Succinylcholine* probably caused & Sports hissymptoms*

8482

Biochemistry

Pt with Abdominal pain who ingested mmushrooms, he is jaundiced with tender palpable liver and elevated liver enzymes and Gastrointestinal & Nutrition bilirubin most likey has Amatoxin that binds to DNA-dependent RNA polymerase type 2 and halts *mRNA synthesis*

8522

Anatomy

Nervous System

8481

The vagus and spinal accessory nerve exit through the *Jugular Foramen*

8524

Biochemistry

Nervous System

Infant with normal development in first few month then progressive neurologic deterioration. P.E shows macrocephaly and an abnormal startle reflex with acoustic stimuli. Funduscopy shows a bright red fovea centralis. (chery red macula spot)Pt most likley has accumulation of *GM2 ganglioside* [Tay-Sachs]

8530

Immunology

Renal, Urinary Systems & Electrolytes

Pt with renal cell carcinoma and given high dose IL-2. There is reduction in tumor burden. Mechanism? -> *Enhanced Activity of NK cells*

8533

Microbiology

Nervous System

Blood cultures that grow coagulase negative staph after a ventriculoperitoneal shunt placement. The most imp virulence mechanism of bacterium is *Synthesis of an extracullular polysaccharide matrix* [Staph Epidermidis releasing a biofilm]

8538

Pharmacology

Infectious Diseases

Tx of enterobius vermicularis is *Albendazole* [Scotch tape test]

8539

Immunology

The molecule involved in mediating the accumulation of pus is Gastrointestinal & Nutrition *IL-8* [Neutrophil chemotaxis]

8542

Pharmacology

Hematology & Oncology

Rasburicase converts uric acid into more soluble metabolites.

8546

Physiology

Cardiovascular System

In pts with CHF, compensatory activation of of RAAS and *Sympathetic Nervous System* results in increased afterload, excess fluid retention and cardiac remodelling.

8556

Genetics

FemaleReproductive System & Breast

Turner syndrome pt can become pregnant but with oocyte donation.

8563

Physiology

Cardiovascular System

When you give Acetycholine to dilat blood vessles. The amino acid resposnible for this vasodilation is *Arginine*

8564

Anatomy

Nervous System

Premature neonate with decreased level of conscousnes and hypotonia. She is weak, has prominent scalp veins and tense fontanels. Ultrasound shows blood in the lateral ventricles. Source of ventricles is *Germinal Matrix* (This interventricular hemorrhage in a premature neonate)

8569

Pharmacology

Dermatology

In Tx of psoriasis, we use Vit D analogs such as *Calcitriene* which activates Vit D receptor, which is a *Nuclear Transcription Factor*

8587

Anatomy

Obese pt is interested in adjustable gastric band. In order to encircle the stomach, the band must pass thru the *Lesser Gastrointestinal & Nutrition Omentum* (Hepatoduodenalligamnet+hepatogastricligament)

8592

Anatomy

Nervous System

Pt with homonymous hemianopia with macular sparing could have occlusion of *PCA*

8593

Microbiology

Infectious Diseases

Isopropanol has antiseptic properties through *Disruption of cell membranes*

8594

Anatomy

Nervous System

Injury to meyer's loop in the temporal lope results in contralateral superiorquadantanopia.

Nervous System

Pt with right nasal hemianopsia who has an interal carotic artery aneurysm. Most likely portion of visual pathway that is dirupted is the *right peri chiasm* [review optic lesions]

8636

Anatomy

8671

Anatomy

Pt presents because of right lower abdominal and groin pain and difficulty walking. He is on warfarin. His abdominal CT (image) Rheumatology/Orthopedics shows retroperitoneal hematoma lying anterior to psoas muscle. Additional expected finding would be *Loss of sensation on the ant & Sports aspect of right thigh* [Femoral nerve compressed due to bleeding from warfarin use]

8702

Embryology

Nervous System

The anterior pituitary is derived from *Surface Ectoderm* (Rathke's pouch) -Check Table

8703

Anatomy

Pulmonary & Critical Care

Pt with a fish bone lodged in the left piriform recess would impair his internal laryngeal nerve which is a branch of superior laryngeal nerve (CN X) and hence would impair his *Cough Reflex*

8710

Pathology

pt comes with fever, right flank pain, and difficulty walking. He has diabetes. The pt lies supine with his right knee flexed and externally roatated. He resists extension of the leg and thigh, particularly at Rheumatology/Orthopedics the hip. The pathologic process occuring in this pt involves the & Sports *Psoas Major* Muscle. [Psoas abscess associated with diabetes as a rsik factor][Psoas sign is elicited on hip extension]

8711

Histology

Cardiovascular System

Scar tissue in the heart is Type 1 Collagen, Just like tendons, ligaments, bone and blood vessels are type 1.

Pharmacology

Pulmonary & Critical Care

*Vacrenicline* is a partial agonist of nicotinic acetycholine receptors. It can assist pts with cessation of tobacco use by reducing withdrawal cravings and attenuating teh rewarding effects of nicotine.

Biochemistry

Pt with signs of RA. Serum autoantibodies with "high specificity" Rheumatology/Orthopedics for this pt condition are most likely to react with *Citrullinated peptides* & Sports [ant-CCP]

8754

8802

8858

Microbiology

Dermatology

Burn patients are susceptibe to infection with pseudomonas aeruginosa which a gram -ve rod that is oxidase positive and non-lactos fermenting. Tx can be with 4th generation cephalosporin *CeFePiMe*

8869

Pharmacology

Cardiovascular System

*Flacainide* reduces QRS interval.

Microbiology

The finding most suggestive of Strongloides Stercoralis infection is Gastrointestinal & Nutrition *Rhabditiform Larvae in Stool* [Tx with Ivermectin]

8873

8881

Physiology

Renal, Urinary Systems & Electrolytes

When GFR is normal, relative decease in GFR results in only a small increase in serum creatinine. However, when GGFR is significantly decreased, small decrements of GFR produce large changes in serum creatinine. Young girl with a soft raise, hyperpigmented, 0.5cm nontender lesion iinferior to the right breast. Most likely cause is *Failed involution of the mammary ridge* [Accessory Nipple]

8904

PathophysiologyDermatology

8930

Pharmacology

Pt with BPH and treated with drug that reduces prostate volume is MaleReproductiveSystem probably beig treated with 5-alpha reductase inhibitors such as *Finasteride*

8954

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Majority of overdose deaths are related to *Opioids*

9814

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Access to firearms increases risks for suicide.

9920

9989

Pathology

Microbiology

Infant with abdominal distention, vomiting and blood streaked stools. She was born out of preterm delivery. Abdominal x-rays Gastrointestinal & Nutrition shows curvilinear areas of lucency that parallel the bowel wall lumen. Most likely Dx is *Necrotizing Enterocolitis* Pulmonary & Critical Care

*Klebsiella Pneumoniae* is a g -ve rod that grows pink-colored (lactose fermenting) mucoid colonies on MacConkey agar. It is encapsulated and casues community acquired pnemonia in Alcholicpateints. Scabies causes an intesnse pruritic (ITCHY) rash at the wrsit, later surface of fingers and finger webs. Pts excoriate (ITCH) Caused by Sarcoptes Scabiei. Diagnose under microscpe for egg and mite itself.

10168

Microbiology

Infectious Diseases

10290

Behavioral science

Social Sciences The requirement for hospice care referal is *Prognosis of less or (Ethics/Legal/Professional) equal to six months*

10399

Behavioral science

Social Sciences Physicians must report impaired collegues in a timely manner. (Ethics/Legal/Professional)

10401

Microbiology

C. Difficile Infection is treated with Metronidazole, Vanco or *Fidaxomicin* The first two are first line treatments but Gastrointestinal & Nutrition *Fidaxomicin* is used in recurrent CDI and is bacteriocidal with minimalsystemicabsorption.

10570

Biostatistics

Biostatistics & Epidemiology

When the unit of analysis in a study is "Populations" and not individuals, then it is an *Ecological Study*

10581

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pt with somatic symptom disorder should be *Scheduled regular outpatient office visits*

10583

Anatomy

Pt was stabbed in RUQ. He is bleeding. Brisk, n"onpulsatile" bleeding is seen emanating from behind the lover. The surgeon occludes the "hepatoduodenal ligament", but the pt continues to Gastrointestinal & Nutrition hemorrhage. Most likley source of bleeding is *Inferior Vene cava* [Pringle maneuver, hepatoduodenal ligament includes the portal triad of hepatic artery, ven and comon bile duct][the nonpulsatile nature of bleed make it not from an artery]

10785

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Stimulus conrtol therapy in Tx of insomnia involves leaving the bedroom if unable to fall asleep within 20 minutes.

10962

Anatomy

Renal, Urinary Systems & Electrolytes

Pt leaking urine with coughing (stress incontinence) is due *to Urethral sphincter dysfunction*

Renal, Urinary Systems & Electrolytes

Pt with MS who develops urge incontinence. Reason is *Uninhibited bladder contraction* [Loss of central nervous inhibition of detrusor contraction, as disease progresses the bladder can become atonic and dilated leading to overflow incontinence]

Renal, Urinary Systems & Electrolytes

Diabetic autonomic neuropathy is common in type 1 diabetes and can cause overflow incontinence due to inability to sense a full bladder and incomplete emmptying. *Postvoid Residual* testing with ultrasound or catheterization can confirm inadequate bladder emptying.

Nervous System

Pt with MS who has spastic paraparesis. Most effective monotherapy for this pts spasms is *Baclofen* (agaonist at GABA-B receptor) (Tizanidine is also effective)

Infectious Diseases

Fever and Diarhea after Antibiotic adminstration suggest C. Diff infection and precaution of wearing *Nonsterile gloves and Gown* should done.

11038

11040

11458

11459

Pathophysiology

Pathophysiology

Pharmacology

Microbiology

11462

Pathology

11464

Renal, Urinary Systems & Pathophysiology Electrolytes

Pts with MS often develop a spastic bladder a few weeks after developing an acute lesion of the spinal cord. These pt present with increased urinary frequency and urge incontinence. Urodynamic studies show the presence of *Bladder Hypertonia*

Pathology

Dermatology

*Compound Nevi* are benign proliferation of melanocytes that involve both the dermis and epidermis. They have uniiform pigmentation and symmetrical sharp borders.

11502

Nervous System

Pt with long history of parkinson disease who recently develops freezing episodes could benefit from high frequency deep brain stimulation of the *Subthalamic Nucelus* or the globus pallidus internus.

11513

Physiology

Cardiovascular System

A drug that selectively decreases heart rate but has no effect on myocardial contractility or relaxation. The ion transpoters that this medication works on are *Funny Na channels during S4* [Ivabradine]

11516

Pathophysiology

Renal, Urinary Systems & Electrolytes

Preventing UTI's from catheter can be done with *Prompt removal of catheter when no longer indicated*

11524

Microbiology

Infectious Diseases

Pt with fever and malaise. He had fever and chills which later became fatigue. He lives in easter Massachusetts. There are lung crackles and palpable splenomegaly. Peripheral blood smear shows Intraerythrocytic pleomorphic forms (Maltese Cross). Most likely source of infection is *Ixodes Tick* (Babesiosis)

11534

Behavioral science

Miscellaneous (Multisystem)

Pt with many diseases including neurocognitive disorder, in order to achieve drug adherence, you should *Involve a social worker in discharge planning* -Note: Checklist wont work since pt's cognition is impaired.

11540

Microbiology

Infectious Diseases

Pt who presents with febrile illness, bilateral infiltrates on x-ray, abnormal liver funcion tests, anemia, and (most importantly) *CROSS-SHAPED IntraErythrocytic Inclusions* has Babesiiosis by the Babesia microto which is a TICK Borne infection by the IXodes Tick which also transmits the organism *BORRELIA BURGDORFERI* that causes Lyme disease.

11547

Microbiology

Infectious Diseases

Pt bitten by his dog. Wound is warm, red and swollen after 24hrs. Wound culture grows g-ve coccobacilli and culture has mouse-like odor. Organism? => *Pasturella Multicoda*

11548

Pathology

Renal transplant pt who presents with worsening retrosternal chest pain, dysphagia, and odynophagia. An esophagogastroduodenosopyshowslinearshallowulceraionon Gastrointestinal & Nutrition lower esophagus. Likely finding on esophageal biopsy is *Enlarged cells with Intranuclear inclusions* (CMVesophagitis)

11550

Behavioral science

Miscellaneous (Multisystem)

Pt who is becoming an outpatient and has complex medication regimens should be given a *Hospital discharge checklist*

Pharmacology

Endocrine, Diabetes & Metabolism

A diabetic drug that can cause hypoglycemia is *Glyburide* [Sulfonlureas increase insulin secretion from pancrease. Glipizide is also a sulfonylurea but it is short acting (unlike Glyburide) and hence its risk of hypoglycemia is reduced]

Nervous System

HIV-Associated dementia should be suspected in AIDS pateients with progressive cognitive decline. Characteristic histopathologic finding is Microglial Nodules formed around areas of necrosis that may fuse to form multinucleated giant cells.

11565

11568

Pathology

11574

Pathology

Nervous System

Pt involved in a truama who is camatose and has a rigid extension of the upper and lower extremities. Damage to the *Pons* could explain his posturing. [Decerebrate posture, damage to brainstem at/below level of red nucleus (midbrain, tegmentum, pons). It is due to loss of descending excitation to the upper limb flexors (via rubrospinal tract) and predominance of extensors (via vestibulospinal tract)

11577

Pharmacology

Psychiatric/Behavioral & Substance Abuse

A pharmcotherapeutic agent that "reduces craving" for alcohol Naltrexons which *Blocks Mu-opoid Receptor*

11585

Pharmacology

Hematology & Oncology

Pt with Human epidermal growth factor receptor 2 tumor positivity (3+over expression). Adjuvant therapy of a monoclonal antibody is started. Target of this therapy is *Tyrosine Kinase Receptor* [Breat Ca, HER2-neu is a tyrosine kinase receptor, antibody is TrasTUzumab]

11590

Pharmacology

Infectious Diseases

Pt with HLA-B*57:01 positive results is associated with *Abacavir*

11594

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Suspicion and distrust, feeling of being exploited, together with histroy of repetitive conflict suggests *paranoid personality disorder*

11603

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Fear of Elevators is treated with *Behavioral Therapy*

11604

Microbiology

Infectious Diseases

20 yr old woman comes due to vaginal pain with sex annd dysuria. She has a new boyfriend. Exam shows multiple, painful, shallow ulcers with an erythematous base on the left labia. There is no vaginal discharge. And no cervical motion tenderness. She has bilateral inguinal lymphadenopathy. Best diagnostic test for pts condition is *PCR fro viral DNA* [Genital Herpes, Tzanck smear is also possible][Syphilus is painless chancre]

11605

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pts who has pyschotic symptoms has been staying up late for exams probably has *Substance Induced Psychotic disorder*

11627

Pathology

Nervous System

Pt with cavernous hemangioma is at greatest risk of developing *Intracerebral Hemorrhage*

11629

Behavioral science

If a hypertensive and diabetic patient is using herbs to lose weight, Gastrointestinal & Nutrition explain to them that these are poorly regulated and have potential health risks.

11632

Pathology

Nervous System

The cerebellar Vermis modulates axial/truncal posture via connections with the medial descending motor systems. Lesions on the vermis will results in TRUNCAL ATAXIA. Characterized by unsteady gait, vertigo, nystagmus. Also, HEADACHE, nausea.

11634

Pharmacology

Endocrine, Diabetes & Metabolism

An anti-hyperlipidemia drugs that inhibits cholestrol absorption at the brush border of the small intestine is *Ezetimibe*

11646

Biopsy that shows Endomysial Mononuclear inflammatory Infiltrates and Patchy Muscle Fiber Necrosis inidcates Rheumatology/Orthopedics Pathophysiology Polymyositis which present with insidious proximal muscle & Sports weakness. Usually, Autoantibodies such as antinuclear antibodies (ANA) and *Anti-histydle-tRNA-Synthetase (anti-Jo1)* are present.

11653

Pathology

Pt with who presents with pelvic pain. She has fibrous Dysplasia (multiple osteolytic-appearing lesions of the hip and pelvis), Rheumatology/Orthopedics enodocrine abnormalities (hyperthyroidism, percocious puberty) & Sports and cafe-au-lait spots. (Triad) suggest a Dx of *McCune-Albright Syndrome*

11658

Anatomy

MaleReproductiveSystem Gonadal arteries originate from the abdominal aorta!

11659

Anatomy

Rheumatology/Orthopedics pt with a comminuted patella fracture would be unable to *Extend & Sports the knee against gravity*

Postoperative HypoParaThyroidism is common after thyroidectomy. Symptoms include Tingling, Numbness, Muscle Spasms, Seizure, Trousseau and Chvostek signs ( twitching of lower face muscle on percusiion below zygomatic arch) Rifaxim is given in hepatic encephalopathy. It works by *Decreasingintraluminalammoniaproduction*

11660

Physiology

Endocrine, Diabetes & Metabolism

11661

Pharmacology

Gastrointestinal & Nutrition

11668

Behavioral science

Social Sciences a health insurance plan with low monthly premieums is *Health (Ethics/Legal/Professional) MaintenanceOrganization*

11670

11674

Microbiology

Immunology

Infectious Diseases

Pt presents with tonic-clonic seizure. He grew in rural Guatemala and immigrated to US 3 years ago. All other test are negative. MRI of brain reveals 2.5-centimetre cyst within the left sylvian fissure that has minimal enhancement and no associated edema. Most likely means of acquisition of infection is *Exposure to infected stool* [Neurocysticercosis by Taenia solium]

GeneralPrinciples

The ubiquitin proteasome pathway is essential for breakdown of intracellualr proteins, both native and foreign. Ubiquitin works as a tag for proteasome recognition. This is performed by *Ubiquitin Ligase* that catalyzes ubiquitin attachment.

11675

Pathology

Ophthalmology

Pt with pathcy vision loss and flame-shaped retinal hemorrhage on fundoscopic exam probably is due to *HTN* Poorly controlled HTN can cause acute retinal hemorrhage which presents as painless, unilateral visual disturbances ranging from mild loss of visual acuity topermanentblindnes.

11680

Pharmacology

Nervous System

Topical Capsaicin in the non-systemic Tx of post herpetic neuralgia depletes *Substance P* by over releasing it.

11682

Physiology

Nervous System

Gaba pentin Inhibits presynaptic voltage-gated Ca channels thus preventingneurostransmittervesiclerelease.

11683

Anatomy

Rheumatology/Orthopedics In Carpal Tunnel Syndroem, Incicision of the *Transverse Carpal & Sports Ligament* (Flexor retinaculum) would improve symptoms.

11708

Anatomy

Renal, Urinary Systems & Electrolytes

11727

Anatomy

Rheumatology/Orthopedics The *Piriformis muscle* passes through the greater sicatic & Sports formaen and occupies most of its volume.

11728

11739

In suprapubic cystostomy, besides the bladder, the structure most likely penetrated by the trocar and cannula is the *Anterior AbdominalAponeurosis*

A therapy for vomiting would involve blocking of *Neurokinin 1* receptors. [Part of 5 receptors involved in vomiting, others are 5-H3, H1, M1, & D2]

Pharmacology

Hematology & Oncology

Pharmacology

Pts with cholestrol gallstones who refuse cholecstectomy can be treated with Hydrophilic bile acids (ursodeoxycholic acid) that Gastrointestinal & Nutrition reduce billary cholestrol secretion and *Increase billary bile acid concentration*, which promotes gallstones dissolution by improving cholestrol solubility. Howver, gallstone recurrence may occur.

11742

Anatomy

Nervous System

Orbital floor fractures can impair the infraorbital nerve which is a continuation of the maxilaary nerve and result in numbness and paresthesia in the uppercheeck, UPPER LIP, and upper gingiva. This can also impair inferior rectus muscle amd impair superior gaze

11743

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Use clozapine in treatment resistent schizophrenia. (Agranulocytosis, seizures and metabolic syndrome are side effects)

11744

Anatomy

Nervous System

The three trunks of the brachial plexus pass between the middle and anterior scalene muscles (scalene triangle). Interscalene nerve block (anesthesia) in this arrea would also affect the Phrenic Nerve and hence affect the *Diaphragm* causing transient ipsilateral diaphragmatic paralysis. (Phrenic nerve roots pass thru the interscalene sheath)

11746

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Depression, Fatigue, Hypersomnia, Hyperphagia, and Vivid dreams are characteristic of *Cocaine Withdrawal*

11750

Pathology

Hematology & Oncology

55 yr old man with generalized weakness and easy fatigability. He has abdominal discomfort. Exam shows abdominal distention, and massive hepatomeglay with spleen crossing midline. Peripheral blood smear shows pancytopenia.Bone marrow aspiration is attempted but no marrow can be aspirated. Finding most likely to be seen in this pt is *Lymphocytes with cytoplasmic prjections* [Hairy cell luekemia, "Dry Tap" due to marrow infiltration. Splenomegaly to infiltration of red pulp]

11754

Pathology

Hematology & Oncology

Bone Metastases that is Osteoblastic (Sclerotic) on imaging can be related to *Prostate cancer* [Also small cell lung Ca and Hodgkin Lymphoma]

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pt with recurrent episodes of chest ain, ,tachycardia, shortness of breath, sweating, and tremulousness in a young otherwise healthy pt with normal ECG. Best next step in management is *Benzodiazepine* [Panic Disorder]

Anatomy

Undescended testes that can be felt medial to the mid-inguinal MaleReproductiveSystem point have to only be passed through the Superficial inguinal ring which is formed by the *External oblique muscle aponeurosis*

Anatomy

Cardiovascular System

While cannulating the Right Common Femoral artery for cardiac catherization, the physician penetrates the arterial wall above the right ingiunal ligament. Soon after pt becomes cold, and hypotensive. Bleeding is susupected. Most likely location is *Retroperitoneal Space* [CFA cannulation shud be below inguinal ligament]

Infectious Diseases

Old pt with fever and altered mental status whos urine culture grow g-ve rods that are lactos fermenting and indole-postive probably has *E. Coli* (UTI) (Indole positivity distinguishes it from Enterobacter cloacea)

11756

11762

11764

11766

Microbiology

11770

Pt with headaches, visual and muscular symptoms, an enlarged Rheumatology/Orthopedics temporal artery, an elevated ESR has Giant cell Arteritis with Pathophysiology assoc. polymyalgia rheumatica. The most imp mediator of this & Sports conditon is *IL-6* (cell mediated immunity, vasculitis)

11771

Anatomy

External Hemorrhoids originate below the dentate the line. They Gastrointestinal & Nutrition have cutanoeous (somatic) innervation from the inferior rectal nerve which is a branch of the *Pudendal Nerve*

11775

Anatomy

Gastrointestinal & Nutrition

The somatic pain in appendicitis that shifts from the umbilicus to Mcbirney point is due to *Inflammation of parietal peritoneum*

Nervous System

The Quadraceps tendon is supplied by the femoral nerve. The femoral nerve can be blocked best in the *Inguinal Crease* at the lateral borde of the femoral artery.

11777

Anatomy

11778

Anatomy

15 year old boy presents with right arm numbness. He plays baseball. He has had fluctuating tingling and numbness involving the right shoulder arm and hand. Also he felt dull pain in right little Rheumatology/Orthopedics finger and hand. He has a cervical rib. Exam shows decreased & Sports sensation over emdial 2 fingers and hypothenar eminence. The structure contributing to this pts condition is *Scalene Muscle* (Thoracid outlet syndrome, compression of brachial plexus)

11780

Anatomy

Cardiovascular System

Pulmonary capillary wedge pressure (measured via a swan-ganz catheter into the pulmonary artery) closely reflectsend-diastolic pressure in *Left Atrium* and the Left Ventricle.

11781

Anatomy

FemaleReproductive System & Breast

Pt with right sided back pain and voiding is normal after a hysterectomy probably has an injured *Ureter* during the surgery. Voiding is normal becuase other ureter is functionl.

11782

Anatomy

Gastrointestinal & Nutrition *Teniae coli* are used to locate the appendix.

11783

Anatomy

Ear, Nose & Throat (ENT)

Pt with epistaxis. Silver nitrate cautery is performed and bleeding stops. Cautery was most likely applied to *Nasal Septum* [Most bleeds happen here in Kiesselback's plexus]

11786

Immunology

Renal, Urinary Systems & Electrolytes

An immuno suppressant that inhibits lymphocyte proliferation by blocking interleukin-2-signal transduction is similar to *Sirolimus*

11798

Pathology

Rheumatology/Orthopedics Pt with sign of SLE would have *Low C3 and C4* & Sports

Embryology

New born Pt with down syndrome who has reducible midline abdominal protrusion covered by skin probably has an Gastrointestinal & Nutrition uncomplicated umblical hernia due to *Incomplete Closure of Umbilical Ring*

11803

PathophysiologyHematology & Oncology

Pt with muscle weakness. P.E shows Gotrons papules. (image) Further evaluation would likely reveal *Ovarian Adenocarcinoma* [Dermatomyositis, perimysial infiltrates. It can occur alone or as a paraneoplastic syndrome. Most commonly associated with Ovarian, lung, colorectal and non-hodkins lymphoma]

11807

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Pts who is bulimic (bulimia nervosa) (Binging, exercise, normal weight, self induced vomiting proven by pharyngeal erythema, hypokalemia, and increased amylase)can be given an SSRI such as*Fluoxetine*

11809

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Methylphenidate used in ADHD has a side effect of *Decrease Appetite and Weight loss*

11810

Behavioral science

Psychiatric/Behavioral & Substance Abuse

A child at age 2 with only 40 words of vocabularly should be *Assessed further* (Normal is 50-100 words at age 2)

11812

Microbiology

Infectious Diseases

Pt with UTI after recent cytoscopy in which urine culture shows g+ve cocci in chains most likey has Enteroccocus which shows *Gamma hemolysis on blood agar*

11817

Anatomy

Pt has mass in the middle third of the rectum extending to rectosigmoid junction. It was resected. The lymph nodes that shud be assessed are the *Internal Iliac lymph nodes* Gastrointestinal & Nutrition (lymph drianage of rectum proximal to the anal dentate line occurs via inferior mesenteric and internal iliac nodes, while distal to dentate line drain into inguinal nodes)

11818

Pathophysiology

Acute joint pain, swelling, and erythema with restricted range of Rheumatology/Orthopedics motion is consistent with synovitis. Diagnosed with *Synovial Fluid & Sports Analysis*

11805

11819

Anatomy

13 yr old boy comes with right knee pain. It started as a mild ache in lower part of knee then worsened and now causes him to limp. Pain is relieved with rest and reproduced when knee is Rheumatology/Orthopedics straightened. Evaluation reveals avulsion of 2ndry ossification center of tibia due to repetitive muscle contraction and traction of & Sports bone. Most likely insertion site of involved muscle tendon is *Tibial Tuberosity* [Osgood-Schiatter Disease]

11820

Anatomy

FemaleReproductive System & Breast

11821

Pathology

Rheumatology/Orthopedics Rheeumatoid arthritis most likely affects *Cervical Spine* & Sports

Exercise to strengthen pelvic floor targets *Levantor Ani Muscle*

11822

Microbiology

Infectious Diseases

Infant comes due to generalized seizure. She fever for past 12 hrs. Pt is discharged with no medication. Three days later, she has no fever but develops a maculopapular rash on her trunk. She is most likely infected with *Human Herpesvirus 6* [Roseola infantum, the seizure can happen with any febrile illness]

11823

Anatomy

FemaleReproductive System & Breast

To help with delivery, a vertica; midline incision is made at the post vaginal opening through the vaginal and subvaginal mucosa. The structure most likely involved in this incision is the *Perineal Body*

11835

Genetics

Biostatistics & Epidemiology

Good Question On Hardy Wieiberg analysis

11838

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Use *SRRI's* in panic disoder in pt who presents camly and normal vital signs.

11840

Anatomy

Internal hemorhoids is characterized by painless bleeding, mucosal lesnions above the dentate line on anoscopy. Constipation can lead to it. The venous component is drained into Superior Gastrointestinal & Nutrition rectal veins wich drian into The *Inferior Mesenteric Vein* which drains into the splenic vein which drains into the hepatic portal vein.

11844

Pharmacology

Cardiovascular System

Fenofibrate therapy *Rduces Hepatic VLDL production*

11845

Anatomy

Pulmonary & Critical Care

In Obstructive Sleep Apnea. Electric stimulation of *Hypoglossal nerve* help the pt

11852

Pathology

Dermatology

Allergic reaction to Morphine is *IgE- Independent mass cell Degranulation*

11854

Behavioral science

Psychiatric/Behavioral & Substance Abuse

srri's used in depression *Block Serotonin Receptor*

Pathology

FemaleReproductive System & Breast

Histopathology of High-grade cervical intraepithelial neoplasia (CIN) would show *Expansion of immature basal cells to the epithelial surface*

Infectious Diseases

Pt presents with shortness of breath, myalgias and retroorbital headaches. Pt was cleaning Animal waste at a farm. He is febrile, bronchial breath sounds are hear in right lower lung. Chest xray shows right lower and middle lobe consolidation. Lab shows thrombocytopenia and elevated liver enzymes. HIV test is negative. Most likley cause is *Coxiella Burnetii* [Q fever, has headaches and pneumonia with thrombocytopenia andelevatedthrombocytopenia]

11858

11859

Microbiology

11860

Intestinal Bacteria can produce *Folate* and vit K. PathophysiologyGastrointestinal & Nutrition (In gastric bypass surgey there is bacterial overgrowth leading to increase in these two substances)

11862

Microbiology

Nervous System

Pt with "fever", "stiff neck", altered mentation, "severe headache with photophobia" could have Bacterial Meningitis and there *CSF should be analyzed* to confirm diagnosis. Note: Migrains don't present with fever!

11866

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Dont confuse *Anxiety to due medical condition* as in Hyperthyroidsim with generalized anxiety disorder. Weightloss, tachycardia, warm moist skin, tremor along with anxiety suggest hyperthyroidism.

Microbiology

Pt who acquire staph infection thru hemodialysis catheters and Rheumatology/Orthopedics present with backpain could have developed osteomyelitis which & Sports can be evaluated using *MRI of the spine*

11868

11869

Pathology

Hematology & Oncology

Paroxysmal nocturnal hemoglobinuria is due to a gene defect that leads to uncontrolled complement-mediated hemolysis. The classic triad includes hemolytic anemoa (hemoglobinuria), pancytopenia, and thrombosis at atypical sites. Chronic hemolysis can cause deposition in the kidney(*Hemosiderosis*)

11890

Histology

FemaleReproductive System & Breast

Revisebreastneoplasia!

11899

Behavioral science

Psychiatric/Behavioral & Substance Abuse

Delirium can be treated with first gen antipsychotic such as *Haloperidol* in addition to treating the underlying cause.

11900

PathophysiologyPulmonary & Critical Care

Obesity related restritive lung disease decreases *Expiratory reserve volume, functional residual capacity, forced expiratory volume, forced vital capacity and total lung volume, Residual volume is unchanged however*

11904

Genetics

GeneralPrinciples

Spina Bifida has a *Multifactorial* Inheritance pattern

Infectious Diseases

Virus that develop a trait (due to culturing with another viruse) and their subsequent progeny continue to have the trait. Mechanism that explains this is *Reassortment* (Recombination is if progency acquires completely new trait)

FemaleReproductive System & Breast

Woman who delivers twins and has postpartum hemorrhage and surgery is started. To control her bleeding, bilateral ligation of *Internal Iliac* arteries is preformed and this would preserve her fertility due to the dual supply of the uterus from the ovarian arteries.

GeneralPrinciples

*Alternative Splicing* is a process by which a single gene can code for various unique proteins by selectively including or excluding different DNA coding regions (Exons) into mature mRNA.

11907

11908

11913

Genetics

Anatomy

Genetics

11917

Biochemistry

Endocrine, Diabetes & Metabolism

*Hormone Sensitive Lipase* is found in adipose tissue, it catalyzes the mobilization of stored triglycerides into free fatty acids and glycerol. The liver can further oxidize FFA to acetyl-coA and then further metabolized into Ketoen Bodies. This can be seen during Starvation.

11918

Biochemistry

Endocrine, Diabetes & Metabolism

In an animal that well fed with CHD's. beta-oxidation of fatty acids is inhibited via *Malonyl-coA* which inhibits carnitine acyltransferase from shuttling acyl groups into the mitochondria.

11919

Pathophysiology

Pregnancy, Childbirth & Puerperium

Woman who has a complication after c-section delivery of dyspnea, hypotension, bradycardia, hypoxia, and DIC (bleeding from incisons) and later dies most likely has Amniotic Fluid Emboism (amniotic fluid enters maternal circulation). Histology of lungs reveals *Pulmonary artery branch with swirls of fetal squmous tissue*

11939

Biochemistry

Renal, Urinary Systems & Electrolytes

Pt with anion ga metabolic acidosis would rewuire renal metabolism of *Glutamine* for maximizing acid excretion pt.

11945

Pharmacology

Renal, Urinary Systems & Electrolytes

Erythropoiesis-stimulating agents are associated with increased risk for *hYPERTENSION* and thromboembolic events.

11950

Biochemistry

Endocrine, Diabetes & Metabolism

Zinc finger mtoif are composed of chains of aminoacids bound together around a zinc atom via linkage with cystein and histidine residues. Intracellular receptors that bind steroids, *Thyroid Hormones*, and fat-soluble vitamins act directly as transcription factors and conatin zinc biding domains.

11952

Anatomy

Nervous System

Postpartumn fecal incontinence can be caused by injury to *Pedundal Nerve*

11956

Anatomy

Cardiovascular System

Radiofreqyency ablation of the AV node in a pt with arrhythmia is achieved at the *Interatrial septum near the opening of the coronary sinus*

FemaleReproductive System & Breast

Septic Abortiontypically prsents with fever, abodominal pain, uterine tenderness, and/or foul-semlling discharge after preganancy termination. Common offending pathogens inculude *Staph Aureus* and E. coil due to seeding of the uterine cavity duringinstrumentation.

11961

Microbiology

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