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nbme 17 Review

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67 yo has urinary urgency after placement of urinary catheter during transurethral resection of prostate, most appropriate therapy?
inhibition of muscarinic receptors
Female pt w/ mt breast cancer, transferred to an hospice. Only family member are allowed to stay after visiting hours. Most appropriate response by the physician?
You seem very important to each other, you can stay...
male with 3 month history of gynecomastia, is taking injections of beta hCG, what is the most likely binding site and action of b-hCG causing development of gynecomastia?
Testicle---Estradiol production.
hCG has the same alpha unit as LH, FSH, TSH. Increase in hCG -> increase in LH -> more testosterone (via Leydig cells) -> more estrogen (via aromatase in adipose tissue and testis) -> gynecomastia
reviously healthy 72 year old man with weakness and fatigue. His Hb 9.2 g/dL, leukocyte count is 5400/mm3, and platelet count is 350,000/mm3. A peripheral blood smear is shown (many small RBCs with various shape andd big central palor, one WBC and its size is bigger than the RBC shown). Which of the following is the most likely cause of these findings??
GI BLOOD LOSS---CLASSIC presentation for right sided colon cancer.smear sounds classic for a microcytic anemia, so iron deficiency from GI blood loss is definitely correct
63-year-old man comes to the physician because of a 6-month history of exertional chest pain that is relieved by rest. He has smoked 1 pack of cigarettes daily for 45 years. He has mild hypertension, but he takes no medications. Which of the following types of lesions in the left anterior descending coronary artery is the most likely cause of his condition

100% vasospasm=one aneurysm, dec's from there
<50% stenosis=plaque--MI
Calcified 80% stenosis...on exertion = stable angina.
occlusion of more than 70-75%

Variant/Printzmetal--@ rest and nighttime, 2* to Vasospasm, ST elev, Tobacco, cocaine, triptans/ younger pt

Unstable--Thrombosis with incomplete artery occlusion. any chest pain at rest, no exertion. st depression or t-wave inversion
56 year old Woman comes to the physician for a follow up examination after recovering from Pneumococcal Pneumonia, X-ray shows no abnormalities. What allowed for full resolution:
metaplasia of mesenchymal cells----type 2 pneumocytes proliferate in damage... shouldn't be fibroblasts and shouldn't be BM integrity (think this references invasion of cells)
54 y/o female h/o htn and bilateral renal a stenosis, starts using nsaids for back pain. over next week her s.creatinine increases from 1.0 to 5.0mg/dl. most likely cause is drugs ability to inhibit
vasodilating PGs at afferent arteriole
RCT study of 2000 patients with insomnia, conducted to evaluate the efficacy of new medicine to treat the condition. subjects in treatment group are able to fall asleep on avg of 5 mins faster than subjects in control group. difference is stat. significant p=0.001. subjects in neither group report improvement in quality of life. investigators conclude new medication is efficacious for insomnia. which type of error
failure to distinguish btw statistical and clinical significanc
55 y/o man with sepsis gets confused and anxious. Treated with vanco/ceftriaxone. Temp 104, BP 84/50. Warm flushed skin. Give what solution?
0.9% saline <--- boost the BP asap, so 0.9% normal saline; 3% too hypertonic, don't need the sugar
3% saline (not this
10 year old boy has had anemia since birth. His spleen is five time times normal size. Splenectomy is indicated if the anemia is caused by which of the following disorders?
Glucose 6 phosphate dehydrogenase deficiency----patients are able to live with spherocytes. its the extravascular hemolysis which is causing the problem and symptoms. so if remove the source of the hemolysis, we can help the patient.
38 year old man comes to the physician because of a 1 week history of watery, itchy eyes and a runny nose. He works as a crane operator. Physical examination shows inflamed nasal mucosa. There is no congestion in the lower lung. Which of the following is the most appropriate pharmacotherapy
Loratadine, 1st generation has antimuscarinic effect and it wouldn't hel him since his job is a crane operator and Ranitidine is for peptic ulcer disease
atient is 30 y/o 22 weeks gestation. One day history of fever, chills, and muscle aches. Fever, high pulse, and low BP. Uterus size is consistent with gestation. Fetal heart sounds present. Leukocyte count 12,000. Blood cultures show gram positive rods What the organism that causes this?
(In pregnant if you see a vignette like this one always link it with L. monocytogenes).
Patient is 9 y/o with poor growth and weight. Bitemporal hemianopsia. Labs show GH deficiency. MRI shows calcified cystic mass in suprasellar region. Tumor is derived from which of the following?
Diverticulum of the roof of the embryonic oral cavity, Ependymal layer of the median eminence, Hypophyseal cartilage, Neural crest cells of the rhombencephalon, Neuroectoderm of the diencephalon. (Craniopharyngioma given her age).
44-year-old woman comes to the physician for a follow-up examination after two separate Pap smears showed atypical squamous cells of undetermined significance. Results of a molecular diagnostic test show the presence of the viral E6 protein of human papillomavirus. This protein is known to promote cell growth and malignancy by causing cellular p53 protein degradation. This degradation most likely begins when the p53 protein is targeted to which of the following types of cellular enzymes?
Ubiquitin ligase protein degradation
42-yo amek is brought to the ED by his wife because of a 5hr history of fever, chills, and severe pain and swelling of his left arm. His wife says he scratched his arm on a nail while repairing a fence in the yard yesterday. He appears confused. His temperature is 40C/104F, pulse 140, resps 25, and BP 71/38mmHg. PE of the left upper extremity shows edema and erythema in the area of the scratch. Lab studies. pt's symptoms are most likely directly attributable to systemic release of which of the following cytokines
IL-1 for fever (thus acute phase), so that eliminates d-f. IFN-alpha is released by virus-infected cells, and TNF-alpha is involved in making granulomas, leaving b) as the answer
24-year-old man with a history of intravenous drug use is brought to the emergency department by his roommate 30 minutes after he could not be aroused. The friend reports that the patient injected himself with a drug approximately 6 hours ago. Laboratory studies show a serum drug concentration of 0.30 mg/L. Assuming the drug exhibits first-order one-compartment kinetics, has a half-life of2 hours, and a volume of distribution of 200 L in this patient, which of the following is the most likely approximate quantity of the drug (in mg) injected?
480 (6hrs post injection. So 3 half lives by now. Which means initial concentration of drug in the plasma was (0.3*222). Multiply that with 200 (Volume of distribution to get amount of drug that was in the body in mg)
newborn delivered at 38 weeks gestation, weighs 1800 grams, shows petechial rash, microcephaly, HPSM, serologic testing shows, mother= CMV-IgG +, CMV-IgM -
baby is CMV-IgG+, CMV-IgG+, most likely explanation??
PASSIVE transfer of maternal CMV IgG and IgM antibodies through the breastmilj. congenital CMV infection that was transmitted transplacentally during the first or second trimester of pregnancy. In contrast, the infant with acquired CMV infection after birth resulting in illness several weeks later. Perinatally, CMV can be transmitted through breast milk or vaginal secretions. Premature infants however, are particularly susceptible to transmission through transfusion of blood products
30y/0 female training for marathon, running 20 miles/d. she says as long as she takes adequate calories, she feesl well on long distance runs of 20 miles. p/e normal. serum glucose 60 mg/dl. after her glucose stores have been depleted which organ in addition to liver is likely to release newly produced glucose in this pt.
kidney
17y/o healthy girl in ER due to 1 day h/o SOB, weakness and muscle tenderness. she completed triathalon the previous day. she appears restless. she is 163 cm tall and weighs 110 lbs bmi is 19 kg/m2. temp is 110.4*F, resp 20/min , BP 150/90 mmhg. bilateral crackles in lower lung lobes. P/E show muscle tenderness . s. creatinine is 4 mg/dl. urinalysis show +3 protein and +4 hb. most likely cause of pt. condition is increased release of
myoglobin
6 week old girl is brought to the physician by her mother because of 6 day history of vomitting a small amount of milk 2-3 times daily. She appears well. She is at the 50th percentile for length and weight. Physical examination shows now abnormalities. Which of the following is most likely cause of the patient's findings
Immature lower esophageal sphincter
40 yo woman has a mole on her back that has increased in size during the past 4 mo. PE shows Raise irregular lesion with variegated black-tan pigmentation and ill-defined margins. Examination of tissue from the tissue shows pleomorphic, hyperchromatic cells within clear islands that tend to coalesce and are present at all levels of the epidermis, with extension into the paipillar dermis. What is it?
melanoma. Border irregularity, Variegated black-tan color, Evolution over time are 3/5 cardinal characteristics of melanoma grossly. Histology describes melanoma.
Old man with 2 year history of decrased force of his urinary stream and increase frequency. BUN is 55 and Creatinine is 5. Ultrasound of Urinary tract shows bilateral hydronephrosis and dilated ureters. What is the mechanism of this patient's renal failure?
Increased hydrostatic pressure in Bowman space. Pressure from BPH outlet obstruction is backed up all the way to the collecting system of the kidney. GFR is increased by increased hydrostatic pressure in the glomerulus (pushing filtrate thru membrane) or by increased oncotic pressure in bowman's space (filtrate is attracted to higher solute concentration across membrane). GFR is decreased by increased hydrostatic pressure in bowman's space (due to pressure increase traveling all the way up from prostate, which resists filtrate from crossing membrane) and by increased oncotic pressure in glomerulus (attracts filtrate to state in glomerulus
45 year old lady diagnosed with invasive ductal cell CA breast. She was started on tamoxifen and serum analysis showed decreased conc. of enoxifen the active metabolite of prodrug tamoxifen. Genetic analysis showed homozygous presence of CYP450 2D6*4 alleles. WHich of following best represents the likelihood that this patient sister has same alleles?
25%, which would be the case if each parent is a heterozygous carrier (more likely than each parent being homozygote) of the autosomal recessive allele.
A 12 yo boy is swimming in a mountain stream. he is immersed up to his neck n 60F water for 20 mins. which of the following sets of physiologic changes is most likely to occur in this boy?

Central Blood volume / ADH / ANP
f he's in cold water, his peripheral arterioles are going to intensely vasoconstrict, leading to increased central blood volume. As a result of this increased central blood volume, ADH is likely to be decreased (owing to the relative blood volume increase, i.e. your body thinks it has enough volume), and by the same logic, ANP would also be increased owing to the relatively hypervolemic state (atria thinks it has more fluid).
A healthy 70-year-old woman has participated in a longitudinal study of the effects of aging on performance during pulmonary function tests for the past 50 years. She has undergone a complete set of tests, including arterial blood gas analysis, every 5 years. Which of the following sets of changes represents this woman now compared with her results at the age of 20 years?
Residual volume: up, down, or no change
RV- UP
Arterial PO2- Down
Alv-Art PO2 Diff- UP
rash on arms and legs after camping trip in woods, edematous, erythematous rash with linear vesicles, activation of what cells?
T-cell lymphoctyes---poison ivy..Dealayed T cell mediated type, Mactrophage activation.
38 year old man, allergy symptoms, crane operator, most approprate tx?
Loratadine--2nd gen--less sedating
ld woman with DVT. Platelet dropped significantly after a week of tx. Drug of action?
Potentiates the action of antithrombin iii (Heparin induced Thrombocytopenia HIT)
40 yof 6 month hx of episodic sinusitis now comes with 2wk hx of intermittent headaches fatigue gen. pain worsening cough now productive blood tinged sputum rx with antibiotics decongestans nasal corticosteroids didnt improve her sinus related prbs
p/e shows nasal mucosa erythema with small ulcerations auscultation lungs show scat. crackles x ray reveals pathchy opacities B/L labs
Hb 13
ESR 70
WBC 10500
serum ANCA increased
dx?
WEGENERS granulamotassis
A pregnant women with abd pain for 12 hrs and upper quadrant pain. her labs show decreased platelets and hemoglobin and elevated liver enzymes. what would you expect on peripheral blood smear?
HEELP--schistocytes because of Low platelet count. which is haemolytic ,elevated liver enzymes, low platelet
52-year-old man is brought to the physician by a social worker because his neighbors have reported that he has been confused and not taking care of himself. He has a 4-month history of diarrhea. Physical examination shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. The patient is mildly disoriented and has poor long-term memory and paranoid ideation. Which of the following is the most likely diagnosis?
Pellagra (niacin def- triple d)
A 42-year-old woman comes to the physician because of a 1-month history of abdominal pain, especially after eating fatty meals. She is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lb); BMI is 31 kg/m2. Physical examination shows jaundice and tenderness of the right upper quadrant of the abdomen. An increase in which of the following liver functions is most likely in this patient?
Cholesterol synthesis (increased cholesterol/bile acid =cholesterol stone)
B
83 yr old man found bedridden and confused, no hx of meds. temp: 35.6, pulse 100, BP 85/50... bp unchanged from IV saline 1L; pulmonary artery catheder shows following: cardiac output - high, PCWP- low, systemic vasc resistance- low. which of the following is cause of hypotension?
early septic shock---CO is high because afterload is decreased from the low systemic resistance. Fever isn't required.
4 year old boy is brought to the physician because he has had 2 bacterial urinary tract infections during the past year. physical examination shows no abnormalities. radiologic studies of the urinary tract show marked dilation of the left ureter and renal pelvis and minimal left side renal function. a left nephrectomy is performed. which of the following is most likely cause of the renal disease in the patient?
congenital ureteral obstruction
20 year old man is brought to the physician because of a 6 hour history of difficulty breathing and vomiting. he has a 10 year history of type 1 DM currently treated with insulin twice daily. pluse is 90/min, resp are 30/min and deep and bp is 90/60. physical exam shows dehydration. ollowing compounds most likely stimulated hormone sensitive lipase in adipocytes that resulted in the accumulation of metabolites causing the acidosis?
labs
serum
Na 130mEq/L
K 6.5mEq/L
HCO3 5mEq/L
glucose 500 mg/dL
blood gas
pH 7.2
PCO2 25mm Hg
epepinephrine
65 yr old woman progressive vulvar itching over past 2 months treatment miconazole is not effective. examination show atrophy of labia minora n thin , parchment of skin of vulva n around anus. what is the diagnosis?
lichen sclerosis-skin disorder that causes the skin to become thin, whitened, wrinkled, and can cause itching and pain. LS usually occurs in postmenopausal women, although men, children, and premenopausal women may be affected. It can develop on any skin surface, but in women it most commonly occurs near the clitoris, on the labia (the inner and outer genital lips), and in the anal region
70 year old man is admitted to the hospital for recent loss of mental function. He has low sodium and Chloride, anemia.
A) adrenal carcinoma
pulmonary neoplasm
5 year old man comes to the physician because of intermittent bloody diarrhea and abdominal pain during the past month. Sigmoidoscopy and rectal biopsy specimens show inflammatory bowel disease. A trial of a monoclonal antibody preparation is begun. the antibody in the preparation is most likely to be directed against which of the following components?
tnf
most predivtive of clonal lymphoid proliferation
Surface kappa:surface lambda ratio
80-year-old woman comes to the emergency department because of a 2-day history of "feeling funny." She says, "I have lost my pep." She has never been admitted to the hospital, but she has a history of poorly controlled hypertension. She just started a medication 2 weeks ago but does not recall the name. Her blood pressure is 130/85 mm Hg. Physical examination shows no abnormalities. Her serum potassium concentration is 3 mEq/L. Which of the following drugs is the most likely cause of this patient's condition?
hctz
mva in 27 yo, markeed edema and tenderness of jaw, what additional finding/ cause?
inferior alveolar nerve
occlusion of marginal branch? increased CK after stent placement?
Recanalization -> reperfusion injury via ROS -> membrane lipid peroxidation --> spill **** out of cell
Dissecting Aneurysm and cocaine
Diminished pulses in left upper extremity

Crackles heard over all lung fields

Chest x-ray w/ widened aortic arch
MLF Syndrome (intranuclear opthalmoplegia)
Common in MS
- Convergence intact bc cortex sends signal directly to CN III nuclei
- MLF syndrome causes ipsilateral eye to not adduct
Inhaled glue toxicity
14 y/o boy
Bilateral aching in the temple
forgetting names, dates, and places
Clumsy w/ frequent falls
Broad Based Ataxic Gate
Stroke Findings in Parietal Temporal Lobe
Sensory loss with agraphesthesia
Familial Hypercholesterolemia
heterozygotes- 30omg/dL
homozygotes 700 mg/dL
Pacemaker indications
Mobitz II and 3rd degree heart block
Poison Oak
Woods+Linear Vessicles

Type IV Hypersensitivity- T Lymphocytes
Difference between distributive shock and cardiogenic/hypovolemic shock?
Distributive shock is high output failure, while hypovolemic/cardiogenic shock is low output failure.

High output means high return and low resistance. PCWP (which measures pulmonary vascular resistance) is also low because of massive vasodilation. All this vasodilation makes the skin warm and dry, and it cannot be fixed with fluids because the increased permeability still persists. Examples include septic, neurogenic and anaphylactic shock.

In low output failure (hypovolemic/cardiogenic), all of these parameters are reversed.
Cause of sudden death in left ventricular hypertrophy?
aortic stenosis (anterior valve leaflet gets in the way)
Exertional Rhabdomyolysis
Due to poor hydration during activity
Post triathlon event--> releasing myoglobin--> heme+ fe-> inc oxidative stress (Inc ROS)--> Renal damage
Histological appearance of a myxoma?
Pathologically, myxomas are gelatinous structures that consist of myxoma cells embedded in a stroma rich in glycosaminoglycans.
Tubular Adenoma
Smooth discreet surfaces

Lesions are common in adults

Generally a symptomatic!

(Do not confuse with Inflammatory Pseudopoly w/ UC)
Aldosterone Tumor
Check Plasma Renin

Isotonic Sodium Increase therefore serum sodium will not increased!
Lesion of CN X?
uvula deviates away
Difference between avoidant and schizoid personality disorders?
avoidant: desires relationships with others
schizoid: content with isolation
Increased expiratory flow rate in pulmonary fibrosis patient?
increased radial traction on airways
Nerve damage during repair of internal carotid aneurysm location?
Cranial Nerve III Damage after repair of aneurysm in right internal carotid artery

Right pupil larger than left pupil, sympathetic fibers on the outside of the nerve is damaged
A fib
Antithrombic therapy, rate control, cardiac conversion
A flutter
Same as A fib + CATHETER ABLATION
V fib
CPR + Defib
1st degree HB
No treatment Reqd
Early Septic Shock
Hypotension (inc vasodilation) with Inc CO
Puberty stages: Males and Females
Male:
Testicular growth --> Adrenarche (Axillary and pubic hair) --> Growth --> Spermarche

Females:
Thelarche (Breast development) --> adrenarche --> Growth Acceleration --> Menarche
P450 Inducers
Chronic Alcoholic Mona Steals Phen-Phen and Never Refuses Greasy Carbs

Chronic Alcohol
Modafenil
St. John's Wort (anti-dep)
Phenytoin
Phenobarbitol
Nevirapine
Rifampin
Griseofulvin
Carbamazepine
Antacid (omeprazole, cimetidine, ranitidine) effect
Decreases absorption of drugs that require an acidic environment to dissolve (like itraconazole)
Mechanism of hypercalcemia in SARCOIDOSIS
Increased intestinal Vitamin D (1,25-dihydroxyvitamin D)
Artery supply to female GU
Ovary/Uterus - Ovarian artery (from abdominal aorta) in suspensory ligament
Uterus/Cervix - Uterine artery (br. of hypogastric/internal iliac)
Vagina - Vaginal artery (br. of hypogastric/internal iliac)
Perineum/labia/rectum/vestibuule - pudendal artery (from internal iliac)
Tuberculosis leprae
Likes cold termperatures
Human-human transmission; armadillos
Skin lesions
Contained in macrophages (tuberculoid form)
Tx: clofazimine
Phases of clinical research
Preclinical: Testing in non-human subjects
Phase 0: Assess pharmacodynamics and pharmacokinetics
Phase 1: Testing on healthy volunteers
Phase 2: Testing on patients to asses efficacy and safety
Phase 3: testing on patients to assess efficacy, effectiveness and safety
Phase 4: long-term consequences
Incomplete formation of pleuroperitoneal membrane
Congenital diaphragmatic hernia
Treatment for DVT + side effects
Warfarin: red/brown urine, severe bleeding, joint pain, bruising
Heparin: HIT
Consequences of inhalants (Spray paints, glues, dewaxers, dry-cleaning chemical)
Slurred speech, lack of coordination, euphoria, dizziness, lightheadedness, hallucinations, delusions
Hyperthyroidism in pregnancy
End of 1st trimester, Hcg (which resembles TSH) may increase T4 transiently.

Diagnosis can be done by measuring free T4
Acute onset abd pain and tenderness
nausea
vomiting
bloody diarrhea
dark purple-red hemorrhagic small intestin
Mesenteric venous thrombosis
Leak in H+ions inward across inner mitochondria leads to what effect on oxidative phosphorylation
Increased ratio of O2 consumption to ATP generation

destroying the H+ gradient, so you get less ATP per O2 consumed
Recovery from pneumococcal pneumonia and xray shows no abnormalities
No fibrosis, nothing bad. The Basement membrane integrity was maintained
Belly button dermatome
T10
PG effect on kidney
Vasodilates the afferent arteriole
Polyarteritis nodosum
Fibromuscular dysplasia
Transmural inflammation of the arterial wall
Chronic bronchitis blood gas
Increased CO2 retention, increased blood HCO3 in response, decreased O2
Osteoarthritis produce bone spurs on vertebrae, compression in which intervertebral foraminae will cause distal ant thigh and medial leg and foot pain.
L3 and L4
what does increased radial traction on airways mean?
increased recoil
drugs used in urinary urgency
antimuscarinics:
oxybutynin, darifenacin, solifenacin
tolterodine, foestrodine, trospium
What does the pelvic splanchnic nerve do?
1. Empty urinary bladder
2. Control and closing of the internal urethral sphincter
3. Influence motility in the rectum
4. Sexual functions like erection
Hypogastric nerve
Responsible for emission (prior to ejaculation, which is instead the pudendal nerve); emission is SYMPATHETIC NS medaited
Branches of the pudendal nerve
1. Inferior rectal nerve
2. Perineal nerve
3. dorsal nerve of penis
4. dorsal nerve of clitoris
Sacral splanchnic nerves
Sympathetic nerves
Menarche vs. thelarche vs. pubarche
Pubarche: development of pubic hair
Thelarche: breast buds form
Menarche: onset of menses (usually occurs 2 years after thelarche!)
what is the first objective sign of puberty for girls?
1. Thelarche - firm, tender lump under the center of the areola of one or both breasts (10.5 yrs)
2. Pubic hair - pubarche
First objective sign of puberty in males
1. Testicular enlargement (gonardarche)
1. Nodulatiry of the uterosacral ligaments
2. Fixed retroversion of the uterus
3. Dysmenorrhea
4. Painful intercourse
ENDOMETRIOSIS
Formation of vesicles and blisters on the skin which frequently takes weeks to heal after sensitivity to sunlight
Porphyria cutanea tarda
Disorder caused by increased synthesis of compounds in the skin that are subject to excitation by visible light
Excess uroporphyrinogen close to the skin due to UROD deficiency
Cyclophosphamide MOA
Attaches the alkyl group to the guanine base of DNA, at the number 7 nitrogen atom of the imidazole ring. This interferes with DNA replication by forming intrastrand and interstrand DNA crosslinks