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1

An adult trauma patient begins to experience shortness of breath on day 3 of his hospital stay. The patient had an open reduction internal fixation of a right femur fracture. You are concerned the patient’s shortness of breath might be attributed to an embolus. What type of embolus is this patient at risk of getting? What are the different types of emboli? (FA15 p609) (FA16 p617)

at risk for thromboemboli due to stasis
also risk for fat emboli due to long bone (also pelvic) fracture

"An embolus moves like a FAT BAT."
Types: Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor

2

How can a skull fracture at the base of the brain lead to pulsating exophthalmos (protrusion of the eye)?

skull fracture-->torn ICA in cavernous sinus-->^BP in sinus-->blood fills ophthalmic vein and orbital tissue-->exophthalmos (which pulses)

3

What is the site of action of each of the following diuretics? (FA15 p552) (FA16 p556) (SU p148, 164)
 Thiazide diuretics-
 Loop diuretics-
 Carbonic anhydrase inhibitors-
 Osmotic diuretics-
 Potassium-sparing diuretics-

 Thiazide diuretics- DCT
 Loop diuretics- thick ascending loop of Henle
 Carbonic anhydrase inhibitors- PCT
 Osmotic diuretics- PCT (also thin descending loop of Henle and collecting duct (mannitol))
 Potassium-sparing diuretics- Collecting duct

4

In patients with a prolactinoma, what pharmacologic agent can be used to inhibit the release of prolactin? In normal physiology, how is prolactin secretion regulated? (FA15 p316) (FA16 p310)

*bromocriptine (D2 agonist), cabergoline

PRL secretion from ant pit is tonically inhibited by dopamine from hypothalamus.
PRL in turn inhibits its own secretion by ^􏰄dopamine synthesis and secretion from hypothalamus.
TRH ^ 􏰄PRL secretion (e.g., in 1° or 2° hypothyroidism).

Dopamine ANTagonists (e.g., most antipsychotics) and estrogens (e.g., OCPs, pregnancy) stimulate PRL secretion.

5

The different hereditary hyperbilirubinemias can all present with jaundice and scleral icterus. What is the underlying cause in the following hyperbilirubinemias, and what form of bilirubin is elevated in the serum in each disease? (FA15 p372) (FA16 p370)
Gilbert syndrome
Crigler-Najjar syndrome, type I
Dubin-Johnson syndrome

Gilbert syndrome: Mildly decreased 􏰅UDP-glucuronosyltransferase (UGT) conjugation and impaired bilirubin uptake, ^UC bilirubin
Crigler-Najjar syndrome, type I: absent UDP-glucuronosyltransferase (UGT)-->inhibited conjugation, ^UC bili
Dubin-Johnson syndrome: inhibited transport out (defective liver excretion), ^C bili (Rotor syndrome is similar)

6

What is the cause of hypertrophic cardiomyopathy (HCM)? (FA15 p296) (FA16 p291)

60–70% of cases are familial, autosomal dominant, variable penetrance (commonly a β-myosin heavy-chain mutation (sarcomuric proteins)) Can be associated with Friedreich ataxia.

myocyte hypertrophy-->massively hypertrophied LV-->decreased compliance-->impaired diastolic filling and decrease SV

7

What are the Jones criteria for the diagnosis of acute rheumatic fever? (FA15 p129) (FA16 p120)

Evidence of strep infection + 2 major criteria OR 1 major + 2 minor
JONES: major criteria
J: joints- polyarthritis
O: pancarditis
N: nodules (subQ)
E: erythema marginatum
S: sydenham chorea

minor: fever, arthralgias, ^ESR, ^PR interval

8

During fetal development what structure traps the inferior poles of the kidney resulting in a horseshoe kidney? Do patients with horseshoe kidneys have abnormal renal function? (FA15 p527) (FA16 p531)

Inferior mesenteric artery (IMA)
have normal renal function

9

What is the mechanism of action of the following cholinergic agents? (FA15 p250-251) (FA16 p244-245)
pralidoxime
neostigmine
bethanechol
hexamethonium
atropine
carbachol

pralidoxime: regenerates AChE (antimuscarinic)
neostigmine: AChE inhibitor (muscarinic)
bethanechol: muscarinic agonist
hexamethonium: Nicotinic ACh receptor antagonist
atropine: antimuscarinic (competitive inhibitor of ACh)
carbachol: muscarinic agonist (muscarinic and nicotinic)

10

A 25-year-old man is evaluated in the clinic for red, swollen, and painful right wrist and left knee joint. During the exam, the patient brags about his sexual conquests. What sexually-transmitted organism can cause osteomyelitis as well as this patient’s septic arthritis? (FA15 p173) (FA16 p163)

N. gonorrhoeae

11

From where does the amygdala receive inputs? To where does it send output?

RECEIVES inputs from Limbic cortex and Neocortex (Parietal, Temporal, and Occipital lobes; esp. visual and auditory association areas)

SENDs signals back to cotical areas from where it received inputs:
Hippocampus, Septum, Thalamus, Hypothalamus

12

What are some of the reasons a woman might have primary amenorrhea? (has never started menstruating)

*Turner syndrome*, imperforate hymen, androgen insensitivity syndrome, Mullerian duct agenesis (due to lack of uterine development), delayed puberty

13

The body uses both the cell-mediated and the humoral immune system to fight infection. Which T cell type regulates the humoral response? (FA15 p202) (FA16 p194)

Th2 helper T cells

-Secretes *IL-4, IL-5*, IL-10, IL-13
-Recruits eosinophils for parasite defense and promotes IgE production by B cells
-Activated by IL-4
-Inhibited by IFN-γ (from Th1 cell)

IN CONTRAST Th1 cells augment CMI by generating IL-2 and IFN-y

14

Coal miners are at an increased risk for skin cancer because of their exposure to arsenic. Which type of skin cancer is associated with this exposure? (FA15 p443) (FA16 p445)

Squamous cell carcinoma

15

What is syringomyelia? What symptoms are commonly seen in patients with syringomyelia?
(FA15 p450) (FA16 p452)

Cystic cavity (syrinx- "tube") within central canal spinal cord (C8-T1 typ.)
Crossing anterior spinal commissural fibers (AWC) are typically damaged first.
Results in a “cape- like,” bilateral loss of pain/ temp in UE (fine touch sensation is preserved, could see motor deficits). Associated with Chiari malformations, trauma, and tumors.

16

In performing a lumbar puncture to obtain a sample of CSF, what structures are pierced, starting with the most exterior?

skin/superficial fascia
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura mater
subdural space
arachnoid mater
subarachnoid space
NOT pia

17

In which phase of meiosis is a primary oocyte arrested until just prior to ovulation? In which phase of meiosis is an oocyte arrested until fertilization? (FA15 p575) (FA16 p578)

arrested in PrOphase I prior to Ovulation

arrested in Metaphase II until fertilization ("an egg Met a sperm")

18

Does the notochord become the neural tube? (FA15 p448) (FA16 p450)

No, the notochord (from mesoderm) induces overlying ectoderm to become neural plate-->neural tube
IT ITSELF becomes nucleus pulposus of the vertebral column

19

A 65-year-old woman with primary pulmonary hypertension is in severe respiratory distress, and she has cyanosis and signs of right-sided heart failure. What medications are used in the treatment of pulmonary hypertension? What are their mechanisms of action? (FA15 p620) (FA16 p627)

Endothelin receptor antagonists: (bosentan, ambrisentan): decrease PVR

PDE-5 inhibitors:(sildenafil, tadalafil) Inhibit cGMP PDE5 and prolong vasodilatory effect of NO. (tx ED also)

Prostacyclin analogs:(epoprostenol, iloprost) (PGI2) direct vasodilatory effects on pulm and syst arterial vascular beds. Inhibit platelet aggregation

Dihydropyridine CCBs (nifedipine)

*all cause vasodilation*


20

A 35-year-old man develops hallucinations just before sleep, episodes of excessive sleepiness, and cataplexy during times of laughter and sadness. Narcoleptic sleep episodes begin with what stage of sleep? What are the different stages of normal sleep? How do they differ from one another?
(FA15 p455) (FA16 p457)

narcolepsy occurs in REM
awake: Beta waves
awake, eyes closed: alpha waves
Non-REM sleep
Stage N1 (5%): light; Theta
Stage N2 (45%): deeper, bruxism; Sleep spindles and K complexes
Stage N3 (25%): deepest non-REM, sleepwalking, night terrors, bedwetting; Delta (lowest freq, highest amp)
REM sleep (25%): Loss of motor tone, ^􏰄brain O2 use, ^ 􏰄and variable PP and BP; when dreaming and penile/clitoral tumescence occur; may serve memory processing function; Beta

"at night, BATS Drink Blood"

21

Chiari I malformation

cerebellar tonsillar
ectopi less than 3–5 mm; congenital, usually asymptomatic in childhood, manifests with headaches and cerebellar symptoms.

22

What is the mechanism of action for methylphenidate? (FA15 p520) (FA16 p524) What are the signs of intoxication of amphetamine? (FA15 p518) (FA16 p522)

indirect sympathomimetic; releases stored catecholamines-->into the synaptic cleft, especially norepinephrine and dopamine.

amphetamine intoxication: Euphoria, grandiosity, *pupillary dilation, *prolonged wakefulness and attention, hypertension, tachycardia, anorexia, paranoia, *fever, *delusions, *hallucinations
Severe: cardiac arrest, seizures.
*specific to amphetamine (vs. general stimulants)
Treatment: benzos for agitation and seizures.

23

What are the effects of stimulating the amygdala?

memory and emotion
^ and dec in arterial BP
^/dec HR
^/dec GI motility/secretion
defecation or micturition
pupillary dilation or constriction
piloerection
secretion of various ant pit hormones
movements related to eating
negative emotions
sexual responses


24

What anatomical structure is implicated in hematoma formation as a sequela of vulvar trauma?

"saddle trauma" hurdle/bike injuries, sexual trauma
bulb of vestibule: erectile tissue, highly vascular, deep to labia major, fat pad in adult females (not children)
looks similar to bartholin cyst

25

Given each of the following deficits, list the corresponding affected artery. (FA15 p464) (FA16 p467)
Loss of motor and sensation of leg and foot
Contralateral homonymous hemianopia with macular sparing
Aphasia with generalized sensory and motor dysfunction
Loss of motor and sensation of the face
Loss of motor and sensation of the arms

Loss of motor and sensation of leg and foot: ACA
Contralateral homonymous hemianopia with macular sparing: PCA
Aphasia with generalized sensory and motor dysfunction: MCA, ACA, ACom
Loss of motor and sensation of the face: MCA
Loss of motor and sensation of the arms: MCA

26

A 50-year-old roofing worker develops a cough for the past month that is now associated with hemoptysis. The patient denies a smoking history or prolonged exposure to second-hand smoke. An x- ray reveals a left-sided lower lung coin-shaped lesion. What type of lung cancer is suspected in this individual? What is the appearance of asbestos fibers in the lung? What cancers are associated with asbestosis? (FA15 p612, 617) (FA16 p620, 624)

bronchogenic adenocarcinoma (>mesothelioma-pleural)
asbestos (ferruginous) bodies are golden-brown fusiform rods resembling dumbbells found in alveolar septum sputum sample, visualized using Prussian blue stain, often obtained by bronchoalveolar lavage.

27

When performing a femoral arterial line placement or femoral venous catheter placement, it is important to palpate the femoral artery to determine where the inguinal structures are located. What structures are found under and just inferior to the inguinal ligament? List them in order from lateral to medial. (FA15 p350) (FA16 p347)

N-AVeL
femoral Nerve (not in femoral ring), femoral Artery, femoral Vein, (empty space), Lymphatics

28

What are the causes of iatrogenic Creutzfeldt-Jakob disease (CJD)? What measures can be taken to avoid iatrogenic CJD? (FA15 p171) (FA16 p161)

CNS-related tissue transplants
corneal, liver transplants, dural grafts, cadaver pituitary hormones
nose, throat sx
skin sx
-automated sx instrument washers
-autoclave and sodium hydroxide (NaOH)
-keeping sx instruments in a moist environment after use

29

Sertoli cells release a substance that acts on the paramesonephric ducts in order to prevent the formation of what structures in a normal male fetus? What other name is given to the paramesonephric ducts? (FA15 p567) (FA16 p571)

Sertoli cells secrete mullerian inhibitory factor (MIF)-->inhibits the paramesonephric (mullerian) ducts from developing into fallopian tubes, uterus, proximal vagina

-SRY gene on Y chromosome—produces testis-determining factorŽ-->testes development.

-Leydig cells secrete androgens that stimulate development of mesonephric ducts.

30

A 54-year-old man presents with a blood pressure of 200/160 mm Hg, and the examination reveals right-sided abdominal bruit suggestive of renal artery stenosis. What is the mechanism by which renal artery stenosis causes hypertension? What are some other common causes of secondary hyperaldosteronism? (FA16 p318)

kidneys perceive low intravascular volume (JG cells see less Na+ due to decreased perfusion)-->increase RAAS to raise BP

2o hyperaldo:
chronic renal failure, CHF, cirrhosis, nephrotic syndrome
- juxtaglomerular cell tumor (due to independent activation of renin-angiotensin-aldosterone system) ^aldosterone, ^renin