TEST 5

"Finger drop" > weakness during thumb and finger extension > due to .... damaging ... nerve ...

Subluxation of the radial head > injury to deep branch of radial nerve

Tubular network located at the junction of the A and I bands in the striated mm > they are open to the extracell space to facilitate the spread of the AP >

T- tubule system T= transverse

N 4. A metanalysis investigates the effect of a substance intake on SBP > Mean SBP in the substance intake group - mean SBP in control group [95% confidence interval] is -2.3 [-2.8,-1.3]

The 95% confidence interval [-2.8,-1.3] does not include the null value of 0 > the result is statistically significant and the substance is associated with a statistically significant reduction of BP.

Shiga toxin mechanism ...

Inactivation 60 S ribosomal unit > halting cellular protein synthesis.

Normal secretory proteins of pancreatic beta cells > cytotoxic deposit in type 2 DM ...

Islet amyloid polypeptide

N 12. 7 months old boy with developmental delay, failure to thrive, episodic seizures, ophthalmoplegia, hypotonia, elevated serum lactate levels. Reduced pyruvate dehydrogenase activity. Which of the following AA in the diet will help generating energy without further elevating lactate levels ?

LYSINE and LEUCINE (exclusively ketogenic AA). PYRUVATE DEHYDROGENASE DEFICIENCY > inherited inborn error of the metabolism > pts unable to convert pyruvate to Acetyl-CoA > shunting of pyruvate to lactic acid > LACTIC ACIDOSIS and NEUROLOGIC DEFICITS. T. KETOGENIC DIET (high fat, low carb, moderate protein diet) > production of energy in the form of ketones bodies (precursor of Acetyl-CoA) from fat and AA catabolism > near absence of glucose in diet > decreases amount of pyruvate generated.

Apolipoprotein E with epsilon 4 allele > increased RF ...

Late onset Alzheimer disease

Paroxysmal fever, non specific symptoms, TACHYCARDIA (DD with Typhoid fever that has relative bradycardia), peripheral blood smear: parasites (pic) and/or RBC hemolysis.

MALARIA > transmission: bite of Anopheles mosquito

Omphalomesenteric duct partial failure at obliterating ... > ...

MECKEL'S DIVERTICULUM > painless GI bleeding with no emesis.

Group results of several studies to increase statistical power and provides an overall pooled effect estimate >

METANALYSIS

Homonymous hemianopia with macular involvement, contralateral motor and sensory deficit (+++ upper limbs) ... >

MIDDLE CEREBRAL ARTERY OCCLUSION

Most common site of injury of the ulnar nerve ...

1. ++++ Elbow 2. ++ Guyon canal at the hook of the hamate

M.o. proliferating in the mesenteric LN > ...

1. Salmonella typhi > thyphoid fever. 2. Yersinia enterocolitica > inflammation and enlargement of LN around the appendix > pseudo appendicitis > DD appendicitis.

+++ drug with anticholinergic effects > to avoid in the elderly > RF: sedation, delirium, falls

1. TCA (Amitriptyline) 2. Diphenhydramine (Antihistamine)

N 16. 43 y.o. trisomy 21 pt with mild cognitive impairment, he was working in a library, but lost his job bc of a cognitive decline > now completely dependent on a caregiver for daily activities. What's increased in this pt ?

AMYLOID PRECURSOR PROTEIN > early onset Alzheimer disease (before 65 y.o., but some features around 40 y.o.) Amyloid precursor protein is on chromosome 21 > the extra chromosome 21 > accelerates the process.

Amyloid beta plaques associated with ...

Alzheimer disease > accumulation of these insoluble plaques.

Neurofibrillary tangles associated with ...

Alzheimer disease > composed by TAU protein (component of MT).

+++ immunocompromised pts > septate hyphae with acute angle V-shaped branches ... (not dimorphic) > ...

Aspergillus fumigatus

+++ drug to avoid in the elderly > increased RF of: cognitive impairment, delirium, falls/fractures, car accident ...

BENZODIAZEPINES

N 3. 30 y.o. low grade fever, malaise, cough > just returned from a trip in the Grand lakes > KOH preparation analysis of an exudate specimen > yeast with single buds > in a medium at 24C > multicellular structure with branching and tubular cells grows. PMH: tonsillectomy and tympanostomy tube placement. D ?

Blastomyces dermatitis. 5 clinically relevant fungal species (see Tab) have different morphology in different environments > DIMORPHIC: 1. Molds with hyphae at 25-30 degree Celsius 2. Yeasts (single cells) at body temperature

N 9. 44 y.o obese woman, epigastric pain with tenderness in the right subcostal area after an heavy meal, similar milder episodes after fatty food consumption. Which hormone provoked the attack ?

CHOLECYSTOKININ Produced by the I-cells of the duodenum and jejunum after fat-rich chime enters the duodenum. Fx: 1. GB contraction 2. Decrease gastric emptying 3. Increase pancreatic enzyme secretion

Gives a range of plausible values for an unknown parameter > if the ... does not include the null value the results are STATISTICALLY SIGNIFICANT > if the .... crosses the null value the results are NOT STATISTICALLY SIGNIFICANT > ...

CONFIDENCE INTERVAL (CI)

N 8. 65 y.o. worsening dyspnea on exertion > hype-resonant lungs on percussion, diffuse wheezing on auscultation. CXR: flattened diaphragm, narrow mediastinum and decreased bronchovascular markings at the periphery. Which Lung/volume pattern will be present in this pt ?

COPD > airflow obstruction and hyperinflation (air trapping) > increased residual volume (RV) and total lung capacity (TLC); decrease of FVC (forced vital capacity) and FEV 1 with decrease of FEV1/FVC. See pic.

Polymorphic m.o > budding yeast or pseudohyphae ( true hyphae only in immunocompromised in later stages of infection)

Candida albicans

Pain/paresthesia in the first 3 and 1/2 digits, hypotonia of thenar eminence, weakness of thumb abduction/opposition, RF > pregnancy or hypothyroidism > reduction of the ... tunnel ... damage at the ... nerve

Carpal tunnel syndrome > damage of the median nerve.

Sudden, painless and complete visual loss in the affected eye ... >

Central retinal artery occlusion

Anterior cerebral artery occlusion >

Contralateral weakness +++ lower extremities

Encapsulated m.o. existing only as yeast (India ink) > meningitidis in AIDS pts

Cryptococcus neoformans

Teenage onset > intact duration and quality of sleep, but shifted to later bedtime and wake time.

DELAYED-SLEEP WAKE PHASE DISORDER

Distention of stomach and duodenum at the abd XR > absent distal intestinal gas in newborn ... > .... etio mech ?

DUODENAL ATRESIA due to FAILURE OF GUT RECANILIZATION.

N 17. EEG patterns associated with sleep walking ?

Delta waves Nighttime ambulation associated with incomplete sleep arousal and amnesia for the event > sleepwalking. +++ 8-12 yrs.

Enteric bacteremia is common with ...

E coli, Proteus, Klebsiella and Salmonella typhi.

Used to identify Ab or Ag in a fluid ...

ELISA (Enzyme Linked Immunosorbent Assay)

Increase of FVC and TLC with normal RV > ...

ELITE ATHLETES Graph C in the picture.

S.e. of commonly used drugs in the elderly ... >

Elderly > increased RF s.e. > see Tab.

Evaluates surface markers on cells (e.g., CD5+) (not chromosome abnormalities) ...

FLOW CYTOMETRY

N 7. Which lab technique to use to assess if pts with CLL with trisomy of chromosome 12 have more indolent course than other pts with different genetic alterations ?

FLUORESCENSCE IN SITU HYBRIDIZATION (FISH) > chromosomal duplications, large deletion and translocations. Probes > single stranded DNA segments that anneal to complementary region of the cell chromosome. More sensitive than karyotyping. Used for D of BCR-ABL > CML !!! It does not identify small chromosomal insertions/deletions.

Sensory loss over the lateral upper arm > paralysis of teres minor and deltoid ... due to ... damage of ... nerve ...

Fracture of surgical neck of the humerus > axillary nerve injury

Produced in the stomach after stomach distension, peptides and vagal stimulation > fx: stimulation gastric secretion and motility

GASTRIN

Abdominal distension, bilious emesis, an delayed passage of meconium > Etio: failure of neural crest cells migrating into the bowel > aganglionic colon/rectum > bowel unable to relax > bowel narrow and obstructive

HIRSCHSPRUNG DISEASE

Persistent daytime sleepiness, not feeling refreshed after naps with excessive daytime sleepiness not explicable by other causes ...

HYDIOPATHIC HYPERSOMNIA.

Expansion of CAG trinucleotide repeats ... >

Huntington disease > abnormal movements (chorea), psychiatric symptoms, and dementia.

N 14. 45 y.o. just back from a vacation in south-East Asia > fever, pulse-temperature dissociation (relative bradycardia), headache, abdominal discomfort, HSM, constipation/loose stools, faint erythematous macular rash on trunk/abdomen. Lab: normochromic/normocytic anemia, leukopenia with left shift. Route of transmission ?

INGESTION OF FOOD or WATER CONTAMINATED BY HUMAN FECES. Etio: Salmonella typhi or paratyphi. Route: fecal-oral (FOOD or WATER CONTAMINATED BY HUMAN FECES) > infects enterocytes and via capsular antigen Vi escapes macrophages mediated destruction. Features: rising fever, relative bradycardia > abd pain and rose spots on trunk/abd > HSM, intestinal bleeding/perforation. T. Abi therapy.

N 6. 70 being treated in hospital (corticosteroids and bronchodilators) for COPD exacerbation > injected with i.m. viral inactivated vaccine which he normally receives annually > several weeks later he comes into contact with the same virus contained in the vaccine > what would happen ?

INHIBITION OF VIRAL ENTRY INTO THE CELL. Influenza vaccinations: 1. Inactivated > injection > humoral immune response (neutralizing Ab) against extra-cell viral Ag > preventing viral entry into the cell. (not processed by MCHI and do not stimulate Cd8+) 2. Live attenuated > nasal spray > cell-mediated immune response (processed by MCHI and stimulate CD8+) > killing of infected cells (in addition to humoral immunity). Influenza vaccine has 3 or 4 strains of influenza A and B > needs to be repeated annually bc circulating strains change.

N 2. 4 days old boy > bilious emesis, poor feeding, lethargy, tachypneic, tachycardic, distended abd, dehydration > laparotomy: fibrous bands from cecum/right colon and retroperitoneum > extrinsic compression of the duodenum. Which embryologic process failed ?

MIDGUT ROTATION AROUND THE SMA At 6 weeks gestation > midgut rotates around SMA > then is fixed on the posterior abdomen on a wide based mesentery. Incomplete MIDGUT ROTATION AROUND THE SMA > MIDGUT MALROTATION with cecum in the RUQ with 1. Ladd's fibrous bands compressing the duodenum > intestinal obstruction. 2. Mesenteric base is abnormally narrow > increased RF of mesentery twisting around the SMA axis > MIDGUT VOLVULUS (pic).

Prodiuced in the small intestine > promotes intestinal motility

MOTILIN

Microvilli do not contain ...

MT

N 15. 3 y.o. decreased appetite, abd. cramps, watery > bloody diarrhea, dehydration, stools with positive leukocytes and occult blood > non lactose fermenting Gram + rods on MacConkey agar, do not generate hydrogen sulfides, and cannot replicate at refrigeration temperature. Most important bacterial pathogenetic factor ?

MUCOSAL INVASION > spreading to other cells via protrusions created by host-cell actin polymerization > immune response by neutrophils. Shigella (+++ sonnei) bacterial enteritis > +++ pediatric disease, homosexual men, adults in skilled nursing facilities. Transmission with only 10-100 m.o.

In KOH preparation > short hyphae and spores ("spaghetti and meatball") > cutaneous mycosis > hypopigmented patches ...

Malassezia furfur

Rapid onset petechial/purpuric rash, confusion, sepsis, hypotension. Transmission: aerosolized droplets.

Meningococcal meningitidis.

Amyloid alpha associated with ...

Multisystemic amyloidosis > reaction to chronic diseases (IBD, rheumatoid arthritis)

Sensory loss over the lateral forearm, decreased strength on forearm flexion > ... injury of ... innervation of the ... mm

Musculocutaneous nerve > innervating the CORACOBRACHIALIS MM (located deep to the biceps)

N 10. 25 y.o. falls asleep while talking, feels refreshed after a nap, sometimes hears a voice calling his name prior to falling asleep. Also, recent uncharacteristic clumsiness. D ?

NARCOLEPSY D. 1. Recurrent lapses into sleep ( at least 3 time a week for at least 3 months) 2. And one of the following: a. Cataplexy b. Low CSF hypochretin-1 c. Shortened REM sleep latency Associated features: 1. Hypnagogic or hypnopompic hallucinations 2. Sleep paralysis (inability to move after awakening)

Size-fractioning of RNA in a gel, then targets specific mRNA sequence of interest > assessing quantity and size of a specific mRNA section ...

NORTHERN BLOTTING

The .... is zero if the parameter of interest is a difference ... The ... is 1 if the parameter of interest is a ratio (e.g., OR or RR)

NULL VALUE

RER in neurons ...

Nissl substance

Most common cause of excessive daytime sleepiness, loud snoring and gasping and apnea during sleep. Etio: upper airway obstruction.

OBSTRUCTIVE SLEEP APNEA

Sialic acid analog > inhibits influenza NEUROAMINIDASE > prevents release of viral progeny ... >

OSELTAMIVIR

Asymptomatic condition due to failure of the ventral/dorsal pancreatic buds to fuse > ...

PANCREAS DIVISUM

Omphalomesenteric duct complete failure at obliterating ... > ...

PERSISTENT VILLIN DUCT > VITELLINE FISTULA

Horner's syndrome, ipsilateral deficit to CN V,VIII, IX, X and XI, and contralateral loss of pain/temperature sensation. Etio ?

PICA (Posterior Inferior Cerebellar Artery > WALLENBERG (LATERAL MEDULLARY) SYNDROME

N 13. 55 y.o. sudden onset headache and partial visual loss: contralateral homonymous hemianopia with macular sparring. PMH: 3 yrs history of AF. Etio: occlusion of which artery ?

POSTERIOR CEREBRAL ARTERY (from embolic event due to AF) > ischemic injury to ipsilateral striate cortex > contralateral homonymous hemianopia with macular sparring (macula spared bc collateral blood supply from MCA tot he occipital lobe)

N 20. 65 y.o. WOMAN dies of congestive heart failure > dilated heart with brownish pigmentation of myocardium > in her liver with Prussian blue staining: blue pigmented granules. The brother died in his 40s of GI bleeding > if the disorder is hereditary > what delayed the onset in this woman > ...

PREMENOPAUSAL MENSTRUAL BLEEDING. Hereditary Hemochromatosis > AR disorder > increased GI iron absorption > iron accumulation in the parenchymal organs (brother died bc of liver cirrhosis > esophageal bleeding) > men onset in 30s-40s , women bc of menstruations partially offset the onset. Etio: inactivating mut. HFE gene > impaired hepcidin secretion. RF: excess of Vit C ( increases iron absorption) and frequent blood transfusion. T. Therapeutic phlebotomy

N 18. 87 y.o. after an hip fracture > indwelling urinary catheter > develop UTI > what's best strategy to prevent this complication ?

Prompt removal of the catheter when no longer indicated. Major RF for catheter related UTI is duration of the catheterization. Prevention: 1. Avoid unnecessary catheterization 2. Remove as soon as is no more indicated. 3. Sterile technique. !!! Routine replacement of an urinary catheter to prevent UTI is not associated with reduced RF.

second generation antipsychotic > +++ drug to avoid in the elderly > RF increased falls and cardiac mortality.

QUETIAPINE

N 1. Melatonin agonist with the lowest s.e. in the elderly .... ?

RAMELTEON

Acting out the content of the dreams (punching, kicking) due to loosing normal sleep paralysis during REM sleep ... >

REM SLEEP BEHAVIOR DISORDER.

TLC, RV, FVC and FEV1 all reduced, but FEV1/FVC normal or increased ... >

RESTRICTIVE LUNG DISEASE

Fracture of the midshaft of the humerus ... >

Radial nerve injury > wrist drop (hand and finger extensor mm paralysis) and sensory loss over the posterior forearm and dorsolateral hand.

Saprophytic fungi > mucormycosis in immunocompromised pts > +++ paranasal infection in diabetic ketoacidosis pts ... >

Rhizophus, Mucor and Absidia. Rhizophus, Mucor > non septate hyphae with wide angle branching.

Promotes bicarbonate secretion from pancreas ...

SECRETIN

N 5. In an animal model > toxic substance targeting the protein KINESIN > histological analysis: what will be absent ?

SECRETORY VESICLES IN NERVE TERMINAL KYNESIN > MT associated motor protein > anterograde transport > if it is blocked > impaired anterograde transport > absent SECRETORY VESICLES IN NERVE TERMINAL.

N 11. 30 y.o frequent anxiety attacks > fear that they will recur > PMH: alcohol abuse in his 20s, otherwise unremarkable. T ?

SSRI PANIC DISORDER > chronic anxiety disorder, recurrent unexpected panic attacks, anticipatory anxiety and phobic avoidance. T> SSRI/SNRI and/or CBT (maintenance) and BDZ for (acute distress). !!! BDZ have RF abuse, dependence and withdrawal > avoid in pts with PMH of substance abuse (here alcohol) MAOI > effective, but NOT 1st line > dietary restriction, avoidance of certain drugs, severe s.e. (hypertensive crisis, serotoninergic crisis) TCA > effective, but higher s.e. burden (anticholinergic effects, orthostatic hypotension, cardiac conduction delay) > replaced by SSRI

Low PH > hormone produced in pancreas, stomach, intestine, hypothalamus. Its production inhibited by vagal simulation. Fx: inhibition of GH, TSH, and also gastrin, CCK, VIP, secretin, insulin, glucagon ...

SST (SOMATOSTATIN)

Lung volumes and capacity ...

See pic.

THERMALLY DIMORPHIC FUNGI >

See tab.

Inflammation and enlargement of LN around the appendix > pseudo appendicitis > DD appendicitis.

Yersinia enterocolitica >

Branch of the medial cord of the brachial plexus (from C8-T1 ventral rami)

Ulnar nerve

N 19. 65 y.o. after falling from a bike > clumsiness sensation, reduced sensation over the 5th digit and hypotonia of eminence hypothenar ... > the nerve affected here is injured at which location > ...

Ulnar nerve > injured in the Guyon canal at the hook of the hamate

Sensory loss at the 4th-5th digit, eminence hypothenar (which can appear flattened), and weakness of wrist flexion/abduction, finger abduction/adduction, flexion of 4th/5th digit. Ulnar claw deformity during finger extension. Damage at ?

Ulnar nerve.

Produced in the pancreas > stimulation of intestinal water secretion, promotes pancreas bicarbonate secretion, counteracts gastrin >

VIP (Vasoactive Intestinal Peptide)

Size-fractioning of proteins in a gel > targets a specific protein using an Ab with a radiotracer/enzyme ... >

WESTERN BLOTTING