NBME Step 1

"The two of you seem to have a very important relationship. Of course you may stay together."

"The two of you seem to have a very important relationship. Of course you may stay together." OR "Visiting hours are posted outside. You are welcome during any of those times. I'm sorry, but an exception cannot be made in your case."

-*↑Fasting insulin* -> b/c of insulin resistance -*↑Testosterone* -> (d/t increased androgens) -*↑LH* → PCOS Classically presents w/ *LH:FSH ratio of 3:1* -Positive progestin challenge results *Normal 17-OH progesterone level*

-Fasting insulin -Testosterone -LH

2.0 -The normal recommended amount of water is *2.0L* b/c 450 + 450 + 900 + 100 = 1900 so need *2000 or 2.0*

1.5 OR 2.0

21-Hydroxylase -Most common deficiency → responsible for *aldosterone & cortisol synthesis* so will have -↑ACTH -↓Aldosterone -↓Cortisol -↑Androgens -*Increased 17-hydroxyprogesterone* -> b/c more progesterone is shunted toward Zona Fasciculata & Reticularis Labs -Hyponatremia *salt wasting* -Hyperkalemia -Excess androgen Clinical -Hypotension -Ambiguous (female) -Precocious (male) 11-OH deficiency -Presents similarly to 21-hydroxylase def but Clinical -*only difference → HTN* 17α-Hydroxylase -Responsible for *Androgen & Cortisol* production Labs 1-Hypernatremia (↑ aldosterone → HTN) 2-Hypokalemia (↑aldosterone) 3-Decreased androgens

17α-Hydroxylase OR 21-Hydroxylase OR 11-OH deficiency

1:4 -The most likely place to find and HLA match is among siblings with the same mother & father → you have a 1/4 *25%* chance of having an *HLA-identical match* [identical twins are not more similar than other siblings from different pregnancies (from the same parents)

1:2 OR 1:4

50% -Familial adenomatous polyposis is inherited via an AD mutation → this means the pt will have a 50% chance of passing this gene to her offspring 100% -The pt herself, has 100% chance of developing colorectal cancer *[but question is asking the chance her offspring will be affected]*

50% OR 100%

50% in females but near 0 in males -B/c it is fatal in males, so they would not be expected to be *live-born*

50% in females but near 0 in males OR 50% regardless of the sex in the child

500 men from a list of pts scheduled to be examined by a urologist

500 men from a list of pts scheduled to be examined by a urologist OR 500 men from a list of pts undergoing routine health screening at a local shopping center

Cannot be determined from the data -Prevalence cannot be calculated from a case-control study -Case control can only give you the odds ratio of a risk factor

80% OR Cannot be determined from the data

C-posterior code -Pt presents w/: 1-Tingling & dorsum of his right hand 2-weak ext of the right hand at the wrist 3-Difficulty raising arm above the shoulder Lesions of the posterior cord -Cause of Saturday night palsy *pt has been using crutches* -Wrist drop (extensors) -Difficulty raising arm above shoulder *axillary* -Loss of sensation over: --Posterior arm --forearm --dorsal hand *Radial* A -Musculocutaneous -Loss of forearm flexion & supination -Sensation of lateral forearm

A OR C

Labile cells -Defined as *cells that divide actively throughout life to replace lost cells* → Epidermal cells are labile cells Transitional cells -these cells are found in the kidney

A 10B, sustains an abrasion on his left knee. One week after the injury, epidermal cells cover many areas of the abraded skin. This stage of wound healing is best explained by the fact that epidermal cells belong to which of the following classes fo proliferative activity? (Labile cells OR Transitional cells)

Medial (internal) rotation -Subscapularis does internal rotation Extension -Performed by coracobrachialis, pec major, and anterior delta

A 65M, is scheduled for PT 3 days following a right shoulder operation. As part of a regimen to strengthen his right rotator cuff muscles, he begins therapy to strengthen the subscapularis muscle. Which of the following mvmt of the arm should this pt perform against resistance? (Extension OR Medial (internal rotation)

0.05<p<1.0 -At a CI of 95%, P is always 0.05<p<1.0

A cohort study is done to evaluate the association between the use of video display terminals (VDT's) by women & the risk for CHD in their offspring. The relative risk (risk ratio) of CHD in newborns born to women who work for 6 or more hrs daily using a VDT is 1.1 (95% CI 0.8-1.4) compared w/ women who are not exposed to VDT's. Which of the following is the p-value calculated from Chi square test? (0<p<0.01 OR 0.05<p<1.0)

1/150 -Female pt has 2/3 chance of passing gene (b/c she has an affected sibling) -The person she marries has a 1/25 chance of being a carrier -Together they have a 1/4 chance of having an affected child -(2/3)(1/4)(1/25)=*1/150*

A couple presents to the physician for counseling prior to conception. The man has two siblings w/CF. Assuming that the carrier frequency for this disorder in the general population is 1/25, which of the following best approximates there recurrence risk that the individual identified by the arrow in the pedigree shown will have a child w/CF? (1/150 OR 1/200)

Increased Angio II conc -ARB stands for *angio II receptor blocker*

A person is started on Losartan tmt. Which of the following is most likely to occur in this pt? (Increased aldosterone conc OR Increased Angio II conc)

Phase 2 -Small number of pts *w/ disease* of interest Phase 3 -Large no. of pt's *randomly assigned* either to the tmt under investigation or the best available tmt (or placebo)

A study is conducted to examine the effectiveness of a newly developed drug (drug X). Subjects to be enrolled in the study must have moderate systemic HTN; approximately 100-200 subjects will be tested. Drug X is most likely in which of the following phases of drug development? (Phase 2 OR Phase 3)

99% -3.8 is the mean -If you add 3.8 +1.8 (1 std) = 5.6 -Add 5.6 +1.8 (2 std) = 7.4 -Add 7.4 + 1.8 (3 std) = 9.2 (closest) -3 std deviations = 99.7%

A study was conducted to investigate the mean age of onset in one type of muscular dystrophy. Based on a mental eval, pts were divided into groups: Normal intelligence & sub-normal intelligence. Results are given on table. If age of onset has a normal (gaussian) distribution, the percentage of children w/normal intelligence who will have onset of the disease at less than 9 years is closest to which of the following? (90% OR 99%)

Abnormal brain development -*Increased TSH levels* especially early in pregnancy *can lead to abnormal brain development* Thyroid gland enlargement -Would not be seen w/ increased TSH levels in mom

Abnormal brain development OR Thyroid gland enlargement

Fatty change -Acute liver (alcoholic& Non-alcoholic) includes: 1-*Steatosis AKA fatty change w/ ballooning degeneration of hepatocytes* → the steatosis in ASH/NASH is *panlobular, microvesicular, & Macrovesicular* 2-Mallory-Denk bodies → ubiquitinated cytokeratin intermediate filaments in hepatocytes in alcoholic liver disease → appear as *eosinophilic inclusions bodies in cytosol of hepatocytes* 3-Neutro's around degenerating hepatocytes 4-Fibrosis which eventually lead to cirrhosis

Acute cellular swelling OR Fatty change

Rectus femoris

Adductor brevis OR Rectus femoris

Alteration of thermostatic set point -The hypothalamus is the main regulator of temperature → a transection of the spinal cord would affect this set point in times when it is needed such as an infection Cutaneous vasoconstriction -Can be elicited via whole body or localized skin cooling → not mediated by thalamus -However in infection, the the SVR would be decreased *vasodilation* is seen not vasoconstriction

Alteration on thermostatic set point OR Cutaneous vasoconstriction

AZ -Pregnant females w/ Chlamydia are treated 1--*AZ* -Non-pregnant 2--Doxy -Co-infection w/nesseria 3-Ceftriaxone -Neonatal conjunctivitis & pneumonia 4--Oral erythromycin Ampicillin -Used to treat syphilis Chloramphenicol -Not used to treat chlamydia → rarely used in US -Treats --RMSF --Meningitis (H.flu, Nesseria, S.pneumo)

Ampicillin OR AZ OR Chloramphenicol

Angiogenesis -Growth of new blood vessels from existing blood vessels → *occurs in normal physiology during wound healing or granulation tissue formation* → includes: 1-PDGF 2-VEGF 3-FGF 4-TGF-β 5-MMP -Area of may be erythematous & slightly warm d/t ↑BF Lymphocytic infiltration -seen in various disorder but not associated w/ wound healing

Angiogenesis OR Lymphocytic infiltration

Superior to the superior nasal concha

Anterior to the nasolacrimal duct OR Superior to the superior concha

Antibody, Complement C5-C9 -Pt presents w/ an *acute transfusion rxn* → most common causes are: 1-*Antibody's* against ABO groups through activation of the *complement* system Circulating IC's, complement 5a, & neutrophils -Seen in auto-immune disease like SLE, RA etc

Antibody, complement C5-C9 OR Circulating IC's, & complement 5a, neutrophils

Anticholinergic -The question say *cyclic antidepressant use* → this implies *TCA* use → AE's include: 1-Anticholinergic *Most common* 2-Anti-adrenergic (orthostatic hypotension & arrhythmias) 3-Anti-histaminic (wt gain & sedation)

Anticholinergic OR Sympathomimetic

Arrhythmia -The pt was described to have chest pain for 3 weeks and then was found dead → However the fact that he was found in is bed means the pt probably had an MI *evident by the myocardial softening & mottling involving the anterolateral wall* & then an arrhythmia right after which caused *sudden cardiac death* -> which caused him to die in his sleep→ *SCD by ventricular arrhythmia is the MCD immediately following an MI* Myocardial rupture -This would be correct if the pt made it to the hospital, was treated, and then died *3-14 days post MI*

Arrhythmia OR Myocardial rupture

Arterial laceration -Pt presents after a trauma (fall from ladder) which most likely caused an arterial laceration when she struck her head -Additionally, edema is present over the area where she struck her head Cavernous sinus thrombosis -Usually caused by: 1-*Infections* of the skin, sinuses, orbit 2-Sellar mass (pituitary adenoma) 3-Carotid cavernous fistula

Arterial laceration OR Cavernous sinus thrombosis

Hyperplasia -The pt will not receive negative feedback from the ovaries → this will cause the pituitary and hypothalamus to continue to produce more FSH & LH resulting in *hyperplasia (enlargement of organ or ↑ production of organ)*

Atrophy OR Hyperplasia

CD4+ T lymphocytes -The paracortex is the site where the antigen is presented (by APC's) to the *T-cells* -CD4+ t-cells have functions *mainly activation of cells* from the innate immune system, including: --B-lymphocytes --Cytotoxic T-cells --Non-immune cells B lymphocytes -T-cells must activate these cells first

B lymphocytes OR CD4+ T lymphocytes

Naloxone -Pt has taken loperamide → which is a agonist at µ-opioid receptors -AE --Constipation (girl presents w/*Marked abd distention* --Nausea -Pt also presents w/*↓RR* indicating opioid toxicity TMT -Naloxone (DOC for opioid toxicity

Bethanechol OR Naloxone

DECREASES THE LUMINAL PERMEABILITY OF Na+ IN THE COLLECTING DUCT Furosemide MOA -> Blocks NKCC symporter in the THaL → this *decreases the luminal permeability to Na+ in the CD d/t a downstream effect* → b/c it will cause↑Na+ in the collecting duct Blocks basolateral K+ channels in the CD -This the MOA of a K+ spring diuretic [Furosemide works in THaL] [Furosemide does not directly block K+ channels]

Blocks basolateral K+ channels in the CD OR Decreases the luminal permeability to Na+ in the collecting duct

Dysplastic nevus -AKA Atypical mole AKA Melanocytic nevus -Can be found *anywhere* --Men → trunk --Women → calves -Pt has FHx of melanoma w/ *large pigmented skin lesions* Blue nevi -Blue color is caused by being located deeper in the skin → characterized by a steel blue papule or nodule

Blue nevi OR Dysplastic nevi

Bronchogenic carcinoma -Presents w/: 1-RF → smoking (not a major RF) 2-More common in women Associated w/paraneoplastic syndromes: 1-*Hypertrophic osteoarthropathy* → a form of digital clubbing *(pt has swelling of fingers)* 2-DIC 3-Thrombophlebitis 4-Microangiopathic anemia 5-Dermatomyositis Systemic sclerosis -Characterized by: 1-Widespread microvascular damage 2-Excessive interstitial & perivascular collagen deposits *(fibrosis/sclerosis)* Affects multiple organ systems, including: *1-Skin* -Hard, swollen, & tight appearing skin w/few wrinkles 2-Mask-like faces 3-Claw like hands 4-Cutaneous ulceration of fingers & toes *2-GI* -Esophageal hypo mobility (w/Concomitant incompetence of the LES)

Bronchogenic carcinoma OR Systemic sclerosis (scleroderma)

C3a -Associated in anaphylaxis → *triggers mast degranulation* -Also C4a & C5a C1 -Associated w/ esterase inhibitor deficiency C4 -splits to: -C4a → anaphylaxis rxn -C4b →combines w/C2a to form C3 convertase which converts C3-to-C3a

C1 OR C3a Or C4

C8 1-tricep extension (C6, C7, C8) 2-Pectoralis (C6, C7, C8) 3- *Dominant → finger flexors* (C7, C8, T1) C7 2-*Dominant → Tricep ext* C6 -Dominant → Wrist extension

C7 OR C8 OR C6

Rate of infusion = CL X CSS -When infusing a drug you want to know how much you need and how fast it leaves the body

CL x CSS OR CL/CSS

Calcium -Pt presents w/signs and symptoms of hypoparathyroidism → ↓PTH which will cause *↓Ca+* → presents w/: 1-*Tingling* or burning (paresthesias) in *fingertips, toes and lips* -Mucsle aches or cramps in legs, feet abd, face -Twitching or spasms of muscles, particularly in around mouth, but also in hands, arms, throat → *Pt has involuntary contractions* 1-Fatigue or weakness 2-Painful menstruation 3-Patchy hair loss 4-Dry coats skin 5-Brittel nails 6-Depression or anxiety 7-Ca+ deposits in brain leading to *seizures* 8-Cataracts hypernatremia -Main symptoms are *neurologic* (altered mental status, weakness, twitching, seizures, coma) [no pins & needles sensation]

Calcium OR Sodium

Chi square -Used to test outcome measures that are not quantitative, but are nominal -Used to determine if a value is *statistically significant* Paired t-test -Compares *means* of the same group -Ex→ comparing the difference in employees fitness levels (the same group) before and after taking part in a company exercise program Independent t-test -Compares *means* of one group with a different group

Chi square OR Paired T-test OR Independent T-test

Lung & common carotid -These two structures are closest to the internal jugular vein

Common carotid & pulmonary artery OR Lung & common carotid

C7-T1 foraminal stenosis -This would cause compression of the *C8 nerve root* → compression of the C8 nerve root would present w/: 1-*Weakness w/handgrip (specific to entrapment)* 2-*Numbness, Tingling, & Pain that radiates down the left arm to the little finger* Compression of the ulnar nerve -This would present with loss of sensation over the medial 1 & 1/2 fingers including hypothenar eminence *[no weakness with handgrip]*

Compression of the ulnar nerve in the carpal tunnel OR C7-T1 foraminal stenosis

Cortisol -This pt presents w/*addisons disease* → which presents w/: 1-*Hyperpigmentation* 2-*Hypotension → d/t Hyponatremia* 3-*Hyperkalemia* 4-Metabolic acidosis 5-Non-specific symptoms (fatigue, malaise, wt loss, diarrhea, anorexia) Key decreased hormones 1-*↓ Cortisol* 2-↓ Aldosterone 3-↓ Androgens

Cortisol OR Glucagon

Cortisol -this pt is in a state of stress b/c he has not been eating → and it is so severe he has lost weight and has muscle weakness -Cortisol is synthesized in response to: 1-stress 2-Regulates blood sugar by metabolism of fat, protein, carbs → it is activated in the fasting state *(for GNG)* 3-Fight infections T3 -This would need to be *decreased* for the pt to have muscle weakness -However, pt would presents other symptoms (inability to concentrate, ↑ sensitivity to cold) if this was decreased

Cortisol OR T3

Crackles -Heard in increase fluid Egophony -increased resonance sounds often caused by: -Lung consolidation -Fibrosis Whispered pectoriloquy -increased loudness in whispering of sounds → heard in *lung consolidation* (pneumonia)

Crackles OR Egophony OR Whispered pectoriloquy

Increased PTH -The pt presents w/ *Secondary hyper-PTH d/t CKD* → Which presents w/ *PTH hyperplasia* d/t *↓Ca+ &/or ↑PO4* [pt has both] -In chronic renal failure you see --Hypocalcemia --Hyperphosphatemia --↑ALP --*↑PTH* Decreased 25- hydroxycholecalciferol -This is inactivated Vit.D → Pt wold be expected have increase levels of this because they have inability to convert Vit. D to active 1,25-Vit D form (d/t CKD)

Decreased 25- hydroxycholecalciferol OR Increased PTH

Decreased arterial PCO2 -Pt has Diarrhea → which is causing a metabolic alkalosis → this will lead to a respiratory compensation of Hyperventilation to get rid of excess CO2 Increased serum anion gap -Pt does not have any of the conditions in *MUDPILES* (Diarrhea is not associated with mudpiles

Decreased Arterial PCO2 OR Increased serum anion gap

Increased TPR & Decreased CO -Propranolol will have two main effects: 1-block Beta 1 receptors -> leading to decreased CO 2-Block beta 2 receptors -> leading to *increased TPR* (beta-2 receptors on smooth muscle cells cause vasodilation)

Decreased TPR & decreased CO OR Increased TPR & decreased CO

Decreased synthesis of interleukins -Cyclosporine preferentially *binds to cyclophilin* to form a complex that *inhibits calcineurin* (calcineurin is a phosphatase for transcription factor NFAT that *upon dephosphorylation, increases the activity of genes coding for IL-2 & related cytokines*) → *in this way cyclophilin inhibits phosphatase induction & decreases synthesis of interleukins (IL-2)*

Decreased synthesis of interleukins OR Induction of calcineurin phosphatase

Decreasing VLDL -Pt presents w/*Dyslipidemia Type V* → Familial hypertriglyceridemia → which presents w/: 1-Pancreatitis → d/t high fat levels Labs 1-↑VLDL 2-*↑Chylomicrons* TMT -Aimed at decreasing VLDL's Increasing Chylomicrons -No tmt should aim at increasing chylomicrons (this is what they are presenting with!)

Decreasing VLDL OR Increasing chylomicrons

Polycsytin -Associated w/Polycystic disease Desmocollin-1 -Associated w/ pemphigus vulgaris P-selectin -Target of Parvo-B19

Desmocollin-1a OR p-selectin OR Polycystin

Dihydrotestosterone -Pt has *5-α reductase deficiency* → which presents w/: 1-*46,XY karyotype* 2-*Internal male genitalia normal* *however, at birth female genitalia is predominant* --The SRY gene is present → so normal levels (in boys) of testosterone are produced leading to normal development of the wolffian structures (internal male genitalia) and regression of the Mullerian duct structures (no internal female genitalia) Sex-determining region of the Y chromosome (SRY) gene -*The SRY gene is absent in AIS* → AIS would present w/: 1-46,XY karyotype 2-Externa female genitalia w/ *scant pubic hair & rudimentary vagina* 3-Absent uterus & Fallopian tube 4-*would not have internal male genitalia*

Dihydrotestosterone OR Sex-determining region of the Y chromosome (SRY) protein

The primary component is surfactant is *lecithin* (phosphatidylglycerol & Phosphatidylcholine) Phosphatidylserine -Component of the cell membrane

Diplmitoyl lecithin OR Phophatidylserine

Do not proceed with transfusion

Do not proceed w/ transfusion OR Obtain consent from the pt's husband

Shigella Sonnei -Pt w/Shigella infection present w/: 1-Present early w/non-bloody, voluminous diarrhea 2-Dysentery occurs w/in hours-to-days & involves frequent, small, bloody, mucoid stools w/abd cramps & tenesmus 3-Children under 5 are the most likely to get a shigella infection (especially if in the same, small area - ie daycare) E.coli -This would present w/HUS

E.coli OR Shigella sonnei

Heart rate

Electrical stimulation of the stellate ganglion is most likely to result in an increase in which of the following? (Heart rate OR Vasodilation in the skin of the upper extremity)

Embolectomy -The pt presents w/*acute arterial limb ischemia* → tmt includes (in order of importance) 1-Anticoagulation w/IV heparin 2-Surgery w/Fogarty balloon catheter *embolectomy* 3-Fasciotomy to prevent compartment syndrome

Embolectomy OR Fasciotomy

Splenomegaly -The pt presents w/ a Hx of *viral infection (1 month Hx of joint pain, frequent headaches, & fatigue)* → a viral infection is a known RF for *warm hemolytic anemia (IgG)* → warm homiletic anemia commonly results in *extravascular hemolysis by splenic M∅'s → leading to splenomegaly* Other RF's for warm hemolytic anemia are: 1-Viral infection 2-SLE 3-CLL 4-Immune deficiency syndromes (CVID) TMT incudes: 1-Glucocorticoids 2-Splenectomy (for severe or resistant disease) 3-Cytotoxic agents (for this who can't undergo splenectomy or have remain symptomatic after splenectomy) [splenectomy not typically effective in Cold hemolytic anemia]

Enlarged liver OR Splenomegaly

Schistosoma

Entamoeba OR Schistosoma

Enterococcus faecalis -Non-hemolytic -Grown in chains & pairs -All strep is catalase neg Staph epidermidis -All staph is catalase positive -No hemolysis -Novobiocin sensitive -Grows in clusters

Enterococcus faecalis OR Staph epidermidis

Euthyroid sick syndrome -This is where pts have low thyroid but no systemic hypothyroid symptoms -T3 &/or T4 levels may be abnormal *T3 is low* → but the thyroid gland is functional *shown by ↑TSH after administration of TRH* -Most common patter is --*↓T3* --*↔T4* --*↔TSH* → which is responsive to TRH --↑rT3 -Often seen in --Starvation --Critical illness (ICU) [pt has recurrent pneumonia & is 70 years old] Hypothalamic abnormality -TSH would not elevate with TRH if there was an abnormality in the hypothalamus

Euthyroid sick syndrome OR Hypothalamic abnormality

Exercise induced asthma -Signs & symptoms only present when he is engaging in activity Mitral valve prolapse -Associated w/: 1-Anxiety & panic disorders 2-Connective tissue disorders (Marfan's, Ehler's Danlos, OI) 3-Majority are asymptomatic → some may have palpitations & chest pain *pt does not present w/these symtpoms* 4-Auscultation → mid-to-late systolic click OR soft late systolic regurg murmur [pt does have midsystolic click - But other signs & symptoms best fit with exercise induced asthma

Exercise induced asthma OR Mitral valve prolapse

The XR is left ankle in AP view → facing anteriorly --Tibia is on the left (Medial) --Fibula is on the right (lateral) --XR shows overlap on the fibula side which is consistent w/ an eversion Spain

Explain

External carotid -The blood supply to the thyroid includes: --*External carotid* → superior thyroid --Thyrocervical trunk → inferior thyroid Deep cervical -Supplies the deep muscle of the spinal cord in the cervical neck region

External carotid OR Deep cervical

Hemoglobin -Testosterone increases Hemoglobin, RBC count, & Hct -This question is asking specifically what the affects of an ↑ testosterone level would be FSH -Would be decreased d/t increased testosterone levels

FSH OR Hemoglobin

Incomplete formation of the pleuroperitoneal membrane -the pt presents w/a *congenital diaphragmatic hernia*→ which presents w/: 1-Absence of stomach below the diaphragm *absence of bowel gas* 2-*Abd content in left hemothorax* (the nasogastric tube is seen here) 3-Displaced lungs 4-Fluid filled stomach behind atrium 5-*Displaced mediastinum to opposite side* Failure of migration of the epimere -This is describes somite migration → associated w/severe malformations of the spine

Failure of migration of the epimere OR Incomplete formation of the pleuroperitoneal membrane

Feed by whatever means necessary to maintain comfort

Feed by whatever means necessary to maintain comfort OR Give foods according to normal caloric requirement

Fibromuscular hyperplasia -This pt probably has *Atherosclerosis* which is characterized by *fibromuscular hyperplasia* Multiple wedge shaped infarcts -Would present w/acute kidney injury or CKD [Pt does not present w/any of these symptoms or labs] -RF's include --Nephrotic syndrome --Primary hypercoagulability disorders --Malignant renal tumors --extrinsic compression --Trauma --IBD (rare) *[HTH is not a RF]*

Fibromuscular hyperplasia OR Multiple wedge shaped infarcts

Fibularis (peroneus) brevis -Immediately above the level of the ankle *over lateral malleolus* -Assists in *flexion & Eversion* Fibularis tertius -Weak dorsiflexion & eversion -However, it is located more superiorly [pt has injury over lateral Malleolus]

Fibularis (peroneus) brevis OR Fibularis (peroneus) Tertius

Flagellin -Flagellin is a protein → it is shown to *dramatically increase titers of IgG* LOS -this is a polysaccharide → May induce IgG titers but the response is more dramatic when against flagellin

Flagellin OR LOS

Focal pulmonary fibrosis -Associated w/ many conditions of the lung, including: 1-*Infection* 2-Environmental inhalants 3-Hypersensitivity pneumonia 4-Sarcoidosis, Granulomatosis w/polyangitis 5-Autoimmune (RA, SLE, Scleroderma)

Focal pulmonary fibrosis OR Normal pulmonary parenchyma

Vagus -The pt is being tested for the pharyngeal reflex (GAG reflex) → the GAG reflex arc consists of 1-*Afferent* → Glossopharyngeal 2-*Efferent* → Vagus -*The image shows that the uvula is pulling to one side → this indicates a vagus nerve deficiency*

Glossopharyngeal OR Vagus

Lysine -Characteristics of elastin → *Cross links between lysine residues forms a tertiary structure that is essential to its elastic properties* Glycine -Important for synthesis of collagen *(preprocollagen- α-chains)* → repeating sequence of glycine-proline-proline/lysine

Glycine OR Lysine

Granuloma -The pt recently had stitches so she would be more likely to form a granuloma around the foreign substances (stitches)

Granulation tissue OR Granuloma

Granulomas containing stellate micro abscesses -LN biopsy of cat-scratch disease shows: --Stellate granulomas micro abscesses --No organisms in immunocompromised on *Warthin-Starry silver stain*

Granulomas containing stellate micro abscesses OR Serous inflammation w/abundant intravascular fibrin & few inflammatory cells

Greater mucosal surface area

Greater mucosal surface area OR Less circular & longitudinal smooth muscle

Hematopoietic stem cells -This is the first thing to form when making a baby is a *cluster of a few cells* Cytotrophoblast -Forms second after cells Synctiotrophoblast -Forms last (between mom & baby)

Hematopoietic stem cells OR Synctiotrophoblast OR Cytotrophoblast

Obstruction of the bile duct -The pt presents w/Jaundice & an increased serum bilirubin conc + positive urine bilirubin test -This would only be seen in an obstruction Hemolysis -The pt would be expected to have an elevated LDH level & schistocytes on PBS [he has neither]

Hemolysis OR Obstruction of the bile duct

Heterozygous mutation in the ankyrin gene -Hereditary spherocytosis is an *AD trait* → this indicates that only one allele is needed to show mutation *75% of cases occur this way* -Membranes that can be affected are: --Spectrin --Ankyrin --Band 3 --Protein 4.2

Heterozygous mutation in the ankyrin gene OR Homozygous mutation in the ankyrin gene

Higher than normal left ventricular cardiac output -Blood flows from Aorta to Pulmonary artery which would cause an ↑ blood flow to the lungs -> then to left atrium -> then to left ventricle causing an *↑CO*

Higher than normal LV cardiac output OR Lower than normal systemic arterial PO2

Histamine -Morphine cause cause vasodilation via histamine release

Histamine OR Serotonin

Hydrocephalus ex vacuo -Risk factors include --*Alzheimers* --Advanced HIV --Pick disease --Huntingtons Normal pressure hydrocephalus -Presents w/: 1-Idiopathic (not associated w/any disease 2-Wet, wobbly, wacky presentation [pt doesn't present w/ these symptoms]

Hydrocephalus ex vacuo OR Normal pressure hydrocephalus

Hydrochlorothiazide -Pt presents w/*Nephrogenic DI* → tmt *focused on treating the underlying issue* → includes: 1-*Hydrochlorothiazide* → If pt presents w/ *Hyponatremia* 2-Indomethacin → Functions similar to a hydrochlorothiazide 3-Amiloride → for lithium induced DI Desmopressin - key tmt for *Central DI* → however, pt has ↑ ADH so central DI is not the cause

Hydrochlorothiazide OR Desmopressin

Hydrochlorothiazide -AE's incude: 1-HYPER-GLUC and: 2-*Hypokalemia* 3-Hyponatremia 4-Hypomagnesium 5-Metabolic alkalosis 6-Sexual dysfunction 7-Sleep disturbance 8-CI in sulfa allergy Lisinopril -AE's include: 1-CI in bilateral renal artery stenosis 2-Cough 3-Angioedema 4-Teratogen 5-↑Creatinine (↓GFR) 6-*Hyperkalemia* [pt has hypokalemia] 7-Hypotension

Hydrochlorothiazide OR Lisinopril

Hydroxylation of proline -This pt presents w/*scurvy* → which presents w/: 1-Classic cutaneous manifestations *follicular hyperkeratosis & hemorrhage* 2-Pt has nutritional deficiency *[eats only an occasional sandwich]* *vit C is a co-factor for Hydroxylation of proline & lysine residues in Collagen formation* Other symptoms include: 1-Swollen, spongy, purplish gums that bleed often 2-Bruising 3-Petechiae 4-Loose teeth 5-Proptosis 6-Anemia 7-Dry, brittle (corkscrew hair) 8-Slow wound healing 9-Hemathrosis Synthesis of porphyrin -Associated w/*Porphyria cutanea tarda* → which presents w/: 1-Chronic blistering of lesions on sun exposed areas of the body *(most commonly on the back of the hands)* 2-Hyperpigmented skin 3-Blisters, bullae & increased fragility 4-Hirsutism (especially on cheeks & forearm) 5-Hepatic manifestations --Mild elevations in ALT & AST --Advanced liver disease in older pts w/recurrent disease --Increased risk of cirrhosis & HCC

Hydroxylation of proline OR Synthesis of porphyrin

Conjugation -Allows for transfer of DNA *high frequency transfer* via: 1-direct cell-to-cell contact 2-via a bridge-like connection *pilus* between two cells -*Classically E.coli* allows antibiotic resistance transfer to another species Transduction -Transfer of genetic material via a bacterial phage → Lytic page infects a bacterium, leading to cleavage of bacterial DNA → Parts of bacterial chromosomal DNA then b/c packaged in capsid → *phage infects another bacteria*

In a study of antibiotic resistance, a strain of E.coli resistant to ampicillin but sensitive to streptomycin is cultured w/a strain of salmonella enteritidis sensitive to ampicillin but resistant to streptomycin. After 4 hrs of co-cultivation. the broth is plated onto a solid medium containing both ampicillin & streptomycin. S.enteritidis bacteria that are resistant to both antibiotics grow at a frequency rate of 1 per 100 cells. Which of the following is the most likely mechanism of the acquisition of ampicillin resistance by S.enteritidis? (Conjugation OR Transduction)

G2 -DNA *synthesis* & *mitosis* G1 -Cells increase in size & get ready for DNA replication -Retinoblastoma & osteosarcoma affect here S -DNA replication occurs

In which of the following stages of the cell cycle are mitotic cyclins synthesized? (S OR G2 OR G1)

Increase in cAMP -*Albuterol is a beta agonist* -> Stimulation of B2 receptors causes an increase in cAMP B2 → GS →Adenylyl cyclase →↑cAMP → Protein Kinase A → 1--Heart [Ca2+] 2--Myosin light-chain kinase (smooth muscle)

Increase in cAMP OR Decrease in cAMP

Increase in width -Going from 10 measurements to 4 measurements means you will be less confident (b/c you have less measurements)

Increase in width OR Decrease in width

Partial oxidation of Fatty acids -Glucagon is known to stimulate the activity of HSL in adipocytes → resulting in an increase of non-esterified Fa's in the circulation -Oxidation of exogenous oleate was also increased by glucagon Increased activity of acetyl-CoA carboxylase -This provides malonyl-CoA needed for FA syntheses -B/c FA are being oxidized by glucagon it doesn't make sense to also be synthesizing them

Increased activity of acetyl- CoA carboxylase OR Partial oxidation of FA's

Inferior rectus & inferior oblique -The question specifically asks what muscles are "entrapped" the two muscles located at the inferior eye are the inferior rectus & the inferior oblique -Entrapment of the inferior oblique would impair upward gaze Medial rectus & inferior oblique -The medial rectus is not located on the inferior portion of the eye so it would be entrapped by a lesion at that location

Inferior rectus & inferior oblique OR Medial rectus & inferior oblique

Missense mutations -Missense mutations do not necessarily lead to a non-functional protein *[whereas insertion & frameshift mutations do]* -Missense mutations are associated w/e.coli Insertion -This results in a frameshift mutation → which would likely create a dysfunctional protein -This often happens in microsatellite regions d/t the DNA polymerase slipping → *trinucleotide repeats are insertion mutations* -not utilized by E.coli

Insertion OR Missense

Internal iliac -The blood supply of the uterus includes: --*Internal iliac artery* → uterine artery → anastomoses with vaginal & ovarian arteries

Internal iliac OR External iliac

↑Intracellular Na+ ↑Intracellular Ca+ ↓Intracellular K+ Normally there is ↑Na+ outside of cell and ↑K+ inside of cell → if cells are damages then the app would be true -In dysfunctional myocardial cells, there would be *↑intracellular Ca+* → this can lead to reperfusion injury which causes damage caused by intracellular Ca+ release

Intracellular NA+ Intracellular CA+ Intracellular K+

Negative strand RNA Also:*P*a*R*a*MM*yxovirus 1-Mumps & Measles 2-Parainfluenza 3-RSV

Is Rubeola (measles) virus a (Negative strand RNA OR Postive strand RNA)

L3-L4 -L3 --Medial thigh --Medial Knee L4 --Medial calf --Medial side of foot L1-L2 -L1 --Right underneath glutei -L2 --Posterior upper thigh

L1-L2 OR L3-L4

Cleft lip *Think M & M* -> Maxillary & medial nasal prominences -Also the fusion of the medial nasal prominences forms *the intermaxillary segment* -*Unilateral cleft lips are most common congenital abnormality* Cleft palate -Occurs when failure of fusion of: 1-Lateral palatine shelves 2-Nasal septum 3-Median palatine shelves Anterior cleft palat → anterior to incisive foramen -Occurs when lateral palatine shelves fail to fuse w/primary palate Posterior cleft palate -Posterior to incisive foramen -Occurs when the lateral palatine shelves fail to fuse w/each other and nasal septum Anteroposterior cleft palate → combo of both

Lateral nasal & medial nasal prominences OR Maxillary & medial nasal prominences

Linoleic acid -Theses are *Omega 6 Essential FA's* → it *must be obtained via diet* Oleic acid -this is Omega 9 FA's but is found naturally in many oils - *not essential*

Linoleic acid OR Oleic acid

Liposarcoma -Large, bulky tumors w/multiple satellites extending beyond the primary tumor -Arise in fat cells in deep soft tissue (deep in thigh or retroperitoneum) -Signet sell is hallmark *irregular vacuolated cells & clear cells w/frequent mitoses* Lipoma -Associated w/*HMG I-C gene (obesity)* -Lipoma would have normal adipose cells

Lipoma OR Liposarcoma

Loading dose -Pts have similar wt (70kg) -GFR is different -Age is different Loading dose would sat stay the same b/c eq is Ld=Cs x Vd (pts have same wt) Time to steady state is based on Clearance -The pt's have different GFR's which would make the time to steady state different for each pt

Loading dose OR Time to steady state

Lung -Lung is the most common cause of Osteosarcoma MET's Liver -METs Colon>>stomach>pancreas go to liver

Lung OR Liver

Ulnar & tibial -ulnar → *Ulnar claw on finger ext* --abduction & adduction of interosseous muscles Tibial → Plantar flexion Median & tibial Median → *ape hand & popes blessing presentation* --Wrist flexion --flexion of lateral fingers --Thumb opposition --Lumbricals pf 2nd & 3rd digits --Loss of sensation over thenar eminence & dorsal & palmar aspects of lateral 3&1/2 fingers w/proximal lesion

Median & tibial OR Ulnar & tibial

Meningioma -*Most common benign neoplasms* -Commonly located parasagittally (near falx cerebri) or near convextities of cerebral hemisphere *[pt presents lesion in the interhemispheric fissure in the central sulcus (centrally located)]* -May present w/Seizures -Histological → whorled pattern of spindle cells w/psammoma bodies (laminated calcifications) Oligodendroglioma -Presents in the frontal lobes of the cerebrum

Meningioma OR Oligodendroglioma

Praziquantel -Image shows *schistosomiasis (flask-shaped w/prominent lateral spine)* -Presents w/: 1-Acute onset fever 2-Myalgias, malaise 3-*Abd pain* 4-*Vomiting blood* 4-*Hepatosplenomegaly* 5-Headache 6-Urticaria 7-Cough 8-Diarrhea, potentially bloody 9-*Abd ascites* metronidazole -Used to treat giardia -which presents w/ malabsorption syndrome

Metronidazole OR Praziquantel

Bicarbonate -RKD or acute kidney failure results in: -↑K+ -↑Mg+ -↑creatinine -↑Phosphate -↑BUN -*↓Bicarb* b/c: 1-This is reabsorbed in the kidney 2-Pt is in metabolic acidosis so it will be used up

Mg+ OR Bicarbonate

Sensation from the anterior surface of the scrotom -The *ilioinguinal nerve lies on the anterior surface of the spermatic cord* → has diff functions based on gender --Males → Anterior scrotal nerve → skin over the root of penis & *upper part of scrotum* --Female → Anterior label nerve → skin covering the mons pubis & labia majora Motor innervation to lower portion of the rectus abdominis -supplied by the thoracic-abd nerves (T7-T11) & subcostal (T12)

Motor innervation to the lower portion of the rectus abdominis muscle OR Sensation from the anterior surface or the scrotom

Naloxone -The pt has an implant for pain mgmt - the implant functions like an option analgesic → Naloxone is an opioid antagonist → so naloxone would reverse the effects resulting in increased pain to the pt

Naloxone OR Beta endorphin

Nortriptyline -The pt present w/a nerve pain presentation *similar to fibromyalgia* -Nortriptyline is a TCA & is a *secondary amine* (should be used w/caution in elderly) -Indications for TCA use include: 1-MDD 2-Enuresis *imipramine* 3-OCD *clomipramine* 4-Fibromyalgia *nortriptyline, but any will work (d/t inhibition of fast Na+ channels)* 5-Migraine prophylaxis 6-Tension headache prophylaxis

Naproxen OR Nortriptyline

Ribonucleotide reductase -Excess dATP inhibits ribonucleotide reductase & DNA synthesis → resulting in decreased lymphocytes

Nuceloside monophosphate kinase OR Ribonucleotide reductase

Starchy foods -Starchy foods can form a paste that may block the stoma

Nuts OR Starchy foods

O Rh- -The best blood type to use in transfusions is O Rh- b/c will be the least likely to cause AE's

O Rh- OR O Rh+

Open label clinical trial -Type of clinical trial in which both the researchers & participants know which tmt is being administered -May be *uncontrolled - no placebo* Observational cohort study -Begins with people without disease then used to look for development of disease after *an exposure*

Observational cohort study OR Open-label clinical trail

Obstruction of the right interventricular foramen (Monro) -Connects the third and lateral ventricles -the question states that the Right ventricle is affected → we could infer this means the right *Lateral* ventricle b/c otherwise the question would say *the right ventricle & the third ventricle are affected* Obstruction of the right aperture of the 4th ventricle (Luschka)

Obstruction of the right aperture of the 4th ventricle (Luschka) OR Obstruction of the right interventricular foramen (Monro)

Odds ratio -The subjects were chosen based on the presence or absence of disease -> this describes a case-control study Relative risk -Subjects would be chosen based on exposure not disease

Odds ratio OR Relative Risk

Thyroid hormone-binding globulin deficiency -Pt presents w/*congenital thyroid binding globulin deficiency* → which presents w/: 1-*↓T3 & ↓T4* 2-*↔Free T4* 3-*↔TSH* Organification defect in T3 & T4 -Organification is performed by *Thyroid peroxidase* → TPO may be inhibited by drugs such as: 1-PTU, MTU 2-Insufficient iodine intake 3-Hashimotos (anti-TPO antibodies)

Organification defect in T3 & T4 synthesis OR Thyroid hormone-binding globulin deficiency

Ovaries -Pt presents w/*Mullerian Agenesis* → which presents with 1-No uterus 2-Rudimentary vagina 3-Absent cervix 4-*Normal ovaries* 5-Normal lab values *(FSH, LH, testosterone, & Estradiol) -*Ovaries are not part of the mullerian duct*

Ovaries OR Ductus deferens

Phase 4 -This drug is *recently marketed*

Phase 3 OR Phase 4

Phosphoinositide hydrolysis -Oxytocin uses IP3 → other hormones that use IP3 are *GOAT HAG* *G* → GnRH *O* → oxytocin *A* → ADH (V1) *T* → TRH *H* → Histamine (H1) *A* → Angiotensin II *G* → Gastrin Tyrosine phosphorylation -Used by *Growth factors* *Insulin* *IGF-1* *FGF* *PDGF* *EGF*

Phosphoinositide hydrolysis OR Tyrosine phosphorylation

Prostaglandin E2 -Both drugs reduce inflammation by inhibiting the break down of Arachidonic acid into: 1-COX-1 2-COX-2 3-PG's *Prostaglandins* 4-TXA's IL-1 or IL-6 -These would be targeted by mono-clonal antibodies

Prostaglandin E2 OR IL-1 OR IL-6

TP53 -Associated w/ *Li-Fraumeni syndrome* → which has a *tp53 (LFS)* marker → these tumors presents in: 1-Breast 2-Brain *(Bother → brain glioma)* *(Sister → Choroid plexus tumor)* 3-sarcomas 4-Adrenal glands (mostly women & girls) *Paternal cousin → adrenal gland tumor* 5-Young age RB1 -Retinoblastoma gene → associated with osteosarcomas and with retinoblastoma at an early age (infancy)

RB1 OR TP53

Smoking -RCC arises from adenocarcinoma derived from *renal tubular cells* → RF's include: 1-*Male sex* 2-*Smoking* 3-Obesity 4-Chronic analgesic use (acetaminophen) 5-VHL 6-PCKD 7-Heavy metal exposure *(mercury, cadmium)*

Radiation exposure OR smoking

Reactive granulocytosis -This is simply an increased number of granulocytes in the blood *seen in image* → can be caused by: 1-Infection (bacterial) 2-Malignancy (CML) 3-Autoimmune disease Reactive lymphocytosis -Increased number of lymphocytes in the blood

Reactive granulocytosis OR Reactive lymphocytosis

Release of CCK -The Duodenum has: 1 G-cells → gastric acid but mostly in Antrum of stomach 2 *I-cells → CCK* 3 S-cells → secretin 4- K-cells → GIP Secretion of VIP -Source is PS ganglia in sphincters, gallbladder, SI

Release of CCK OR Secretion of VIP

Psychogenic polydipsia -Pt presents w/ labs: 1-Serum Na+ 120 2-Urine sodium 8 *N = 40-220* 3-Urine osmolality 80 *-N = 300-900 -After 24hrs water restriction, should not exceed 850* causes of low urine osmolality are: 1-Excess fluid intake or over-hydration 2-Hyponatremia 3-SIADH Resistance to the antidiuretic action of vasopressin -This would be caused by lithium → however, lithium is used in *Bipolar disorder* [pt has schizophrenia]

Resistance to the antidiuretic action of vasopressin OR Psychogenic polydipsia

Metabolic acidosis & respiratory acidosis -Pt has *↑PCO2* → respiratory acidosis -Pt also have *↓HCO3* → metabolic acidosis -This not compensated b/c we it is an *acute setting* → if it was compensated we would expect the HCO3 levels to be increased to near normal

Respiratory acidosis only OR Metabolic acidosis & respiratory acidosis

Retrograde transport thru nerves -Pt presents w/*Rabies* → route of transmission includes → 1-Infection & replication occurs w/in the striated muscles from initial entry via nAchRs → virions cross the synaptic cleft & bind to NCAMs & enter motor & sensory neurons → *retrograde axonal transport (thru nerves)* leads to rabies in the CNS

Retrograde transport thru the nerves OR Transport via bloodstream

Rhabdomyoma -Pt most likely has tuberous sclerosis which presents w/*HAMARTOMASSSS* *H* → Hamartomas in CNS & skin *A* → angiofibromas of face w/*butterfly distribution* *M* → Mitral regurg *A* → Ash leaf spots *(hypo-pigmented spots* best defined w/wood lamp) *R* → *cardiac rhabdomyoma* *T* → Tuberous sclerosis *O* → Autosomal dominant *M* → *Mental retardation* *A* → Angiomyolipomas of kidney *S* → seizures *S* → Shagreen patches *S* → *Subependymal giant cell astrocytomas* *S* → Subungual or periungual fibromas

Rhabdomyoma OR Glycogen storage disorder

Short gastric -The gastric fundus is supplied by the short gastric arteries which run left after branching from the splenic artery Left gastroepiploic -This runs along the front body of the stomach (near the fundus) -The right gastroepiploic runs off the common hepatic & is located more along the duodenum Left gastric - Is a branch off of the splenic but runs long the posterior portion of the stomach (near the aorta)

Right gastroepiploic OR Short gastric OR Left gastric

Single strand (+) -Virus that have RNA-dependent DNA polymerase are viruses that have *reverse transcriptase* → these viruses are *retrovirsuses* --HTLC → Icosahedral → (T-cell leukemia) --HIV → conical & complex No RNA (-) strand viruses have reverse transcriptase

Single strand (-) OR Single strand (+)

Squamous cell carcinoma -Is associated w/ *C's b/c its Central* -*C* → Central -*C* → hyperCalcemia (PTHrP) -*C* → Cigarettes -*C* → Cavitation - Hilar mass arising from *Bronchus*

Small cell carcinoma OR Squamous cell carcinoma

Sphingomyelin degradation -Pt has Niemann Picks, which presents w/: 1-*foam cells* lipid laden macrophages 2-Cherry red spot on macula 3-Hepatosplenomegaly 4-Progressive neurodegeneration CHYLOMICRON TRANSPORT -Associated w/ Two Familial Dyslipidemias 1-Type I - Hyperchylomicronemia 2-Type III - Dysbetalipoproteinemia Hyperchylomicronemia -presents w/ Hepatosplenomegaly -> but pt would also have pancreatitis, eruptive/pruritic xanthomas Dysbetalipoproteinemia -No hepatosplenomegaly -Pt woud have palmar xanthomas & tuberoeruptive xanthomas

Sphingomyelin degradation OR Chylomicron transport

Splenic vein

Splenic vien OR Body of pancreas

Surgical procedure = 400 Medical mgmt = 400 -Intention to treat analysis *ignores non-compliance, protocol deviations, withdrawal, & anything else that happens after randomization*

Surgical procedure = 400 Medical mgmt = 400 OR Surgical procedure = 325 Medical mgmt = 350

Testicle/estradiol -β-hCG binds to the receptors in the testicle → causing the synthesis of estradiol

Testicle/estradiol OR Pituitary gland/prolactin

DM I -Schizophrenia is more closely related to DM than to CF → pts with schizo are 2-3 times more likely to develop DM

The pedigrees of pts w/schizophrenia most closely resemble those of pts with which of the following? (CF OR DM I)

Case-control -Selects a 2 samples *starts w/ disease* --1 → disease present --2 → disease absent Then tests exposure In this example: 1-Pts w/ disease (702 pts w/hemorrhagic stoke) 2-Pts w/out disease (1376 w/out hemorrhagic stroke) Test for risk of developing disease from exposure *Drug x* -Case control gives odds ratio which gives the proportion of people w/a particularly *risk factor* who have a disease to the proportion of people w/ the same *risk factor* who do not have the disease Cross sectional -gives data of a disease's prevalence

The risk for hemorrhagic stroke from drug X is investigated by utilizing a questionnaire about drug use in 702 pts w/ hemorrhagic stoke & in 1376 control subjects contacted by random-digit dialing. Which of the following best describes this study design? (Case-control OR Cross-sectional)

Thymic lymphocytes produced before thymectomy are long lived -The thymus is the major site of T-cell development → this is the site for *positive & negative selection* -The earliest thymocytes found in the thymus are CD4-CD8- T-cells → from here all T-cells originate in the bone marrow Thymic nerve cells sequestered in the LN's replace the need for thymic lymphocytes -There are no nerve cells in the LN's

Thymic lymphocytes produced before thymectomy are long lived OR Thymic nerve cells sequestered in LN's replace the need for thymic lymphocytes

Mistakes in transcription are not transmitted to progeny -Mutations would only be transmitted to progeny if they were d/t *DNA polymerase* → RNA polymerase makes proteins and this mutations would not affect progeny

Unlike the DNA polymerase found in E.coli, RNA polymerase from this bacterium lacks proofreading activity. Which of the following is the most likely reason that the lack of proofreading ability in the RNA polymerase does not compromise the survival of the species? (Mistakes in transcription are not transmitted to progeny OR DNA polymerase is more efficient then RNA polymerase)

Uroporphyrinogen decarboxylase Uroporphyrinogen synthase -Not associated w/any conditions

Uroporphyrinogen decarboxylase OR Uroporphyrinogen synthase

Decreased -Tactile fremitus --*↓ air* --↑ liquid

What are the expected findings (for tactile fremitus) in emphysema?

high altitude sickness causes acidosis, so acetazolamide has 1-↑Blood volume & ↑Blood flow 2-↑HCO3- 3-↑pH

What are the expected levels of -pH -HCO3 -Volume

pKa 6.0 -A lower pKa means the drug is more soluble → A major characteristic of renal elimination is that they be soluble

pKa 6.0 OR pKa 10.0

25% -Question is just asking what is the likelihood of her sister being affected with an apparent AR disease -Pt is homozygous for alleles which suggests an *AR disorder* -Sister would have a 25% to be affected based on the inheritance pattern of an AR disease 0% -Never guess zero

25% OR 0%

Schizophrenia stats: -1% → general population -6.5% → first degree relatives -40% -50%→ twins

25% OR 50%

46,XY -Pt presents w/*male pseudohermaphroditism* most commonly cause by *AIS - testicular feminization* → which presents w/: 1-Karyotype 46,XY 2-*Testes present* in labia majora 3-*External genitalia are female* or ambiguous 4-*Presence of uterus and Fallopian tubes*

46,XX OR 46,XY

5' CCGG -The section must match with the sequence 5' TA*CCGG*..3' → the new sequence is read from 5' to 3' so it must be *5' CCGG*

5' CCGG OR 5' GGCC

Adenosine -Potent vasodilator at the organ level Prostacyclin (PGI2) -Involved in homeostasis → *inhibits platelet activation* Prostaglandin F2 -*Carboprost* → used as abortifacient to induce labor

A 28M, has a BP cuff placed around his left arm; the cuff in inflated to totally occlude the arterial blood flow for 2 mins & is then removed. BF in the left arm increases by 50% during the next 3 mins & then decreases to control values. Which of the following humoral substances is most likely involved? (Adenosine OR PGI2)

Lipoprotein lipase -Pt presents w/*Hyperchylomicronemia - Familial dyslipidemia I* (most common)→ which presents w/: 1-*Hepatosplenomegaly* 2-*Eruptive/pruritic xanthomas* (yellowish-white papules on back) 3-Chylomicron induced *pancreatitis* (abd pain) Labs 1-Chylomicrons 2-Cholesterol 3-Triglycerides Deficiency -AR 1-*LPL* 2-APO-CII LDL-cholesterol receptor -Would be familial type II *familial hypercholesterolemia* would present w/: -Tendon xanthomas *on heel* or elbow -Corneal Arcus -Accelerated atherosclerosis (MI < 20years) Labs -↑ LDL -↑ cholesterol

A 2B, presents to the ED b/c of severe abd pain & vomiting for 3 hours. He has also had episodes of abd pain during the last year. PE shows yellowish white papules on the back, generalized abd tenderness, & hepatosplenomegaly. Serum studies show an increased amylase activity & increased conc of total cholesterol, triglycerides, & chylomicrons. This pt most likely has a deficiency in the activity of which of the following proteins? (LDL-cholesterol receptor OR Lipoprotein lipase)

NMDA -Glutamate receptor that allows *cations* in (non-selective; any cations allowed in) GABA-A receptor -Selective for *Cl* → Target of benzos

A 2F, presents d/t being cross-eyed. PE shows moderate strabismus. If not treated, she will most likely have deficits in depth perception d/t lack of appropriate competitive interactions in the visual cortex. Calcium entry thru which of the following receptors mediates the outcome of this competitive process? (GABA-A OR NDMA)

GnG -Pt has an issue making glucose via the GnG pathway → we know this b/c when given Glycerol or Fructose his blood sugar is not elevated (which if should be he could make glucose) -However, when galactose is given his blood sugar rises (galactose is basically converted to glucose almost immediately)

A 3-month-old B, presents to the ED d/t SOB & listlessness for 3 hrs. He has had an upper RTI & has eaten poorly for the past 3 days. Temp is 98.6F, & RR are 30/min. PE shows lethargy & mild hepatomegaly. Labs show hypoglycemia, lactic acidemia, ketonemia, & metabolic acidosis. Following administration of glycerol or fructose on different days, his serum glucose conc do not increase. However, they do increase normally after the IV administration of galactose. A defect in which of the following liver metabolic pathways is the most likely cause of these findings? (FA oxidation OR GnG)

Peroxisomes -The pt presents w/ Very-long chain acyl-CoA DH deficiency → this is an enzyme deficiency *of protein* → *proteins are broken down by peroxisomes* Lysosomes -Used via MHC II -> They Digest: 1-Dysfunctional or worn out organelles 2-Food particles 3-Engulfed viruses or bacteria

A 3-month-old presents d/t of yellowing of eyes & skin & weakness since birth. PE shows jaundice, large fontanels, a flat mid facial area, hypotonia, & hepatomegaly. Serum studies show: -Total bilirubin----↑ -AST------------↑ -ALT------------↑ -VLFA-----------↑ A liver biopsy shows foamy, lipid-filled hepatocytes, necrosis, & absence of a specific organelle. This organelle is most likely which of the following? (Lysosomes OR Peroxisomes)

The pt has another mutation that was not included in the previous analysis -For a pt to exhibit symptoms in CF they must have *two dysfunctional alleles*, which must be on the *same gene* The pt has a mutation in another gene for a protein that interacts w/ CFTR -CF is a AR disorder so two non-functional mutations are needed to see symptoms -If the pt has a mutation in a different gene she would not have symptoms

A 3-week-old F newborn, presents for a follow-up exam after the results of a newborn screening showed an increase serum conc of immunoreactive trypsin. CF is suspected. At 4-months, her sweat chloride conc is >60mmol/L (N<40). Molecular analysis that includes a panel pf the 70 most common CF transmembrane gene mutations is done. Results shows a mutation in one allele. Which of the following best explains the findings in this pt? (The pt has another mutation that was not included in the previous analysis OR The pt has a mutation in another gene for a protein that interacts w/ CFTR)

Decreased afferent arteriolar resistance -Question is basically asking what achieves auto-regulation in the kidney → auto-regulation is achieved via the *afferent arterioles* & tubuloglomerular feed back mediated by the myogenic response

A 30F, presents b/c of a 2-wks Hx of right flank pain. BP is 168/98. PE shows a 7-cm mass that is palpated in the right side of the abdomen. A CT shows a mass in the retroperitoneal space on the right side that is compressing the renal artery. If the perfusion pressure to the affected kidney is decreased, but GFR & RPF remain unchanged, which of the following mechanisms mediates the auto-regulation in the renal arterioles in this pt? (Decreased afferent & efferent arteriolar resistance OR Decreased afferent arteriolar resistance)

Glycine & succinyl CoA

A 30F, presents for a follow-up tmt of chronic renal failure & normocytic, normochromic anemia. Following the administration of recombinant human EPO, her Hb conc increases in part d/t increased activity of 5-ALA synthase in RBC's. This enzyme regulates the rxn involving the condensation of which of the following compounds? (Glycine & succinyl CoA OR Lysine & δ-ALA (5-ALA)

Lunate -Scaphoid is most common to be fractured by fall on outstretched hand → however, if not an option then lunate is second best (seen as the bone closest to radius) Hammate -Located at top of bones (near index finger) *So Long To Pinky, Here Comes The Thumb*

A 34F, presents to the ED 45 mins after slipping on an icy sidewalk & landing on her outstretched right hand. Exam of the RUE shows an exquisitely tender, swollen wrist w/a palpable hard mass located immediately proximal to the wrist joint anteriorly. XR of the right wrist show are shown. Which of the following bones is most likely dislocated in this pt? (Lunate OR Hammate)

Ureter -Courses retroperitoneal suspensory ligament → at risk for both 1-Ligation of ovarian vessels 2-Ligation of uterine vessels during hysterectomy Uterine artery -Seen in the cardinal ligament (cervix to the wall of pelvis) [Ureter still at risk here]

A 35F, undergoes a left oophrectomy b/c of a 5x5-cm ovarian mass. During this procedure, which of the following structures is at greatest risk for injury when dividing the suspensory ligament? (Ureter OR Uterine artery)

Infiltration of lymphocytes & monocytes -Histoplasmosis is a *fungal infection* which affects AID's pts → B/c it is a fungal infection we would expect to see *lymphocytes* Neutrophilic infiltrate -Seen in bacteria

A 35F, w/a long standing Hx of asthma treated w/corticosteroids dies of complications of histoplasmosis. Exam at autopsy shows that the lungs are 1.5 times the normal wt. Extensive focal areas of fibrosis & 2-5-mm nodules are seen throughout both lungs. Exam of biopsy specimen of the nodules is most likely to show which of the following findings? (Infiltration of lymphocytes & monocytes OR Neutrophilic infiltrates)

Catecholamine mediated intracellular shifts of K+ -Alcohol withdrawal causes an acute shift of K+ into cells - causing Hypokalemia

A 35M, presents to the ED b/c he is disoriented & hallucinating. He has a 20-year Hx of alcoholism. On admission, he has a seizure. BP is 180/100. Serum K+ is 2.5, & urine K+ is 40mEq/L. Alcohol withdrawal is suspected. Which of the following is the most likely cause of the hypokalemia? (Catecholamine-mediated intracellular shifts of K+ OR Decreased release of renin)

B -Toxicity in the kidney most often effect the PCT → doesn't matter what causes the toxicity

A 35M, w/quadriplegia develops a UTI. He was admitted to the neurology unit 7 months ago. He had had an intermittent catheter during this entire period. A culture grows an organism that is susceptible only to aminoglycosides. Gentamicin is administered. If nephrotoxicity occurs in this pt, it is most likely to originate in which part? (B OR D)

1/50 -Must use hardy Weinberg -1/10000 is q → must take √q = √1/10000 = 1/100 -2pq (remove p b/c not necessary) so 2q = 2(1/100) = 2/100 = *1/50*

A 36F, nulligravid, & her 40 year old husband present for genetic counseling prior to conception. They have no FHx of genetic syndromes. They have been reading about certain inherited diseases & ask about their risk for being carriers of an AR disease that occurs in 1/10000. Which of the following best represents the carrier frequency of this condition? (1/50 OR 1/100)

Synaptobrevin -Pt presents w/*Tetanus (lockjaw)* → presents w/ 1-Spasms of Jaw that then progress to the entire body (Chest, neck, back, *Abd muscles*, buttocks - may all be affected) 2-Fever, headache, sweating 3-Trouble swallowing 4-HTN 5-Tachycardia Pathophysio -Toxin blocks inhibitory neurotransmitters *glycine & GABA* across the synoptic cleft → nerve impulses are not inhibited so spasms occur → *Toxin cleaves Synaptobrevin II* & prevents the release of neurotransmitters Acetocholinesterase -Botulism binds to nerves which use ACh (not esterase) → toxin cleaves *SNARE* proteins [not synaptobrevin]

A 37M, farmworker presents to the ED b/c of a 12-hrs Hx of severe pain in his abdomen & legs & painful spasms of the jaw. PE shows marked spasms of the maseter & abd musculature. During the exam, a loud noise in the exam room triggers a painful spasm & respiratory compromise requiring intubation. Administration of antitoxin prevents further symptoms, but the pt continues to require sedation & ventilatory support for the next 3-wks. This pt most likely has a syndrome that involves binding a toxin to which of the following? (Acetocholinesterase OR Synaptobrevin)

Autoimmune adrenalitis (Addisons) -AKA Primary adrenal insufficiency AKA Hypocortisolism → presents w/: 1-*Hyperpigmentation* of the skin 2-*Low cortisol* 3-Fatigue, muscle weakness 4-*Anorexia, wt loss* 5-*Hypotension* Adrenocortical carcinoma -Can present w/ Conn/cushings syndrome *pt would probably have HTN (Conns) & wt gain (Cushings)* *[would not present w/ skin hyperpigmentation -> b/c there would be negative feedback in the pituitary from increased production of hormones at the level of the adrenal gland]* -Often mets -Bimodal distribution (children <5 & adults 30-40)

A 37M, is admitted to the hospital b/c a gradually progressive weakness, anorexia, & wt loss over the past 6 months. BP is 74/40, & his skin is hyperpigmented. Morning serum cortisol conc is 2 ug/dL. Which of the following is the most likely Dx? (Adrenocortical carcinoma OR Autoimmune adrenalitis)

Finasteride -DOC for male pattern baldness Stanozolol -This is an anabolic → it will decrease his hair growth

A 40M, presents for a routine exam. He has an active lifestyle that includes swimming & cycling. PE is normal. He is concerned that his male-pattern baldness is affecting both his professional image & his ability to attract sexual partners. Which of the following tmts is the most appropriate recommendation for this pt? (Stanozolol OR Finasteride)

Demeclocycline -Originally used as a antibacterial for Lyme disease -Tetracycline antibiotic but used off label as a tmt for *hyponatremia*

A 40M, w/ terminal small cell carcinoma becomes anorectic & lethargic. Fluid restriction is initiated b/c of a serum Na+ conc of 120 mEq/L, but there is not clinical improvement after 3 days. Which of the following is the next most appropriate therapy? (Demeclocycline OR Indomethacin)

Metastatic carcionoma -More than one nodule is present → so most likely metastatic cancer Malignant mesothelioma -Would be seen in the lining of lung not on lung itself → may present w/: 1-*SOB* 2-Swollen abdomen 3-Chest pain 4-*cough* 5-Fatigue 6-*Wt loss* 7-Peural effusions [pt has no Hx of exposure]

A 43F, presents b/c of a non-productive cough for 3 wks. She has had a 15lbs wt loss during the past 3 months. A CXR shows three 0.3-1-cm nodules in the right lung. Cytologic exam of FNA from the largest nodule strongly suggests a malignant neoplasm. A photo representative of the findings in this pt's lungs is shown. Which of the following is the most likely Dx? (Malignant mesothelioma OR Metastatic carcinoma)

C -That is CN VIII B -Cranial nerve VII D -Cranial nerve XI

A 48M, has complete loss of hearing is his right ear. Which of the following labeled cranial nerves on the ventral surface is most likely to be damaged? (C OR D)

108-118 -Correct b/c both are 5 numbers apart from mean 108-114 -This is better answer but doesn't make sense b/c both sides should be the same number apart from the mean (108-113 = 5) (114-113 = 1) 112.5-113.5 -This represents *decreased confidence* → b/c there is less margin of error

A 48M, is referred for eval of possible HTN. On the basis of four measurements, the pt's average diastolic BP was 113, w/ a 95% CI of 110-116. Which of the following most likely represents the 99% CI for these data? (112.5 - 113.5 OR 108-118 OR 108-114)

Proliferative glomerulonephritis -Pt presents w/Glomerulonephritis and does not have the symptoms for TN Tubulointerstitial nephritis -Presents w/Fever, rash, hematuria, & CVA tenderness (but can be asymptomatic) -*Pyruia w/eosinophils* -Caued by 5 P's 1P→ pee (diuretics) 2P→ Pain-free (NSAIDS) 3P→ penicillins/cephalosporins 4P→PPI's 5P→ rifamPin 6→ systemic infections (SLE, Sjogren, Sarcoidosis)

A 4B, presents to the ED 6 hrs after she noticed that his urine was red. He is otherwise feeling well. Fifteen days ago, the pt had sore throat, fever, & cough. His mother thought he had a flu & treated him symptomatically w/rest & analgesics, & his status improved until now. Temp is 101.3F, Pulse is 110/min, RR is 22/min, BP is 100/50. PE shows normal breath & cardiac sounds, no organomegaly, & 1+ LE edema, bilaterally. Labs show: -BUN------40 -Creat-----2 -Albumin--3.6 Urine -Color-Red/brown -Bood-----3+ -Protein---2+ -Ketones--neg -RBC-----30-50 -RBC casts-few Which of the following is the most likely Dx? (Proliferative glomerulonephritis OR Tubulointerstitial nephritis)

Scar formation -OI usually affects type I collagen → type I collagen is seen in scar tissue Granulation tissue -Type III collagen → highly vascular tissue made up of small blood vessels, fibroblasts, & myofibroblasts - first phase of would repair

A 4F, with OI has impaired wound healing. Which of the following components of wound healing is most likely to be affected as a direct result of her underlying disease? (Granulation tissue deposition OR Scar formation)

Zidovudine -AE BM suppression (all NRTI's) & Anemia -All NRTI's→ 1-Lactic acidosis 2-Peripheral neuropathy 3-Pancreatitis (didanosine) Pentamidine -Anti-fungal med for p.jirovecii 1-Liver toxicity 2-Cough 3-Upset stomach, nausea, diarrhea, vomiting 4-Dizziness, headache 5-Burning in throat 6-Unusual taste/dryness in mouth Nelfinavir -Protease inhibitor → AE's include 1-Hyperglycemia, *lipodystrophy* 2-Nephropathy, hematuria, Thromocytopenia *(Indinavir specific)* Azithromycin - Also Clarithromycin & erythromycin → AE includes *MACRO* *M* → GI *M*otility issues *A* → Arrhythmia (Prolonged QT) *C* → Cholestatic hepatits *R* → Rash *O* → e*O*sinophilia

A 50F, with HIV presents for a follow-up. For the past 6-months, she has been receiving antiretroviral meds that includes the zidovudine, lamivudine, as well as the protease inhibitor nelfinavir. She is also receiving prophylaxis w/pentamidine for pneumocystosis & AZ for MAC. Her leukocyte count 2-wks ago was 1200 (50% seg neutro's). Her plasma HIV viral load remains undetectable. Drug-induced BM suppression is suspected. Which of the following drugs is the most likely cause? (Nelfinavir OR AZ OR Pentamidine OR Zidovudine)

Babesia microti & B.burdorferi -Vector in anaplasmosis is a *Ixodes tick* → both babesia & B.burdorferi are transmitted via tick R.rickettsii -Transmitted via *wood tick* or *dog tick*

A 50M, who lives in eastern Minnesota comes presents d/t a 3-day Hx of fever, & malaise. Temp is 102.9F, pulse is 84/min, RR is 14/min, BP is 100/70. PE shows no abnormalities. Labs show a Hb of 13.6, Leuko's 35K, Plts of 90K. The results of a PCR test for Anaplasma Phagocytophilum is positive. The causal organism in this pt is transmitted via the same vector as which of the pairs of pathogens? (Babesia microti & B.burgdorferi OR B.Burdorferi & R.rickettsii)

CMV infection -CMV is associated w/immunocompromised pts -CMV can affect different organ systems, including: 1-Pulmonary --Manifestations of CMV include *Interstitial (atypical) pneumonia* 2-Renal --Progressive renal failure *(shown w/↑BUN & ↑Creatinine)* 3-GI *(usually in HIV pts w/ CD4+ <50)* --Esophagitis (HIV) --Colitis --Hepatitis 4-Adrenal glands --Primary renal insufficiency Atypical mycobacterial infection -Can infect lungs but pt would present w/ similar symptoms to normal TB infection

A 51M, has the acute onset of fever & respiratory failure 6 weeks after a cadaveric renal transplant. He currently takes cyclosporine, prednisone, & TMP-SMX. Vitals are: -Temp----101F -Pulse----120 -RR-------40 -BP-------110/60 He has no rash. Diffuse inspiratory & expiratory crackles are heard; there is no gallop or murmur. Labs show: -Leuko's----4K -BUN------24 -Creat-----2.1 -WBC----0-1 -RBc-----0-1 Which of the following is the most likely cause of the CXR? (Atypical mycobacterium infection OR CMV infection)

Intercostal -Cells follow the path of least resistance

A 52F, presents b/c of severe pain in her mid back for 2 weeks. She has a Hx of left breast cancer treated w/mastectomy & chemo. PE shows tenderness to palpation over the thoracic spine. An MRI of the back shows mets in thoracic vertebral bodies. Which of the following veins is the most likely path for tumor cells in the breast to obtain access to the vertebral bodies? (Axillary OR Intercostal)

Granulation tissue -Pic shows granulation tissue -Also, 18 days after MI we would expect to see granulation tissue not granulomas

A 52M, is admitted to the hospital for tmt of a massive acute MI. Tmt w/O2, β-blockers, aspirin, & reperfusion therapy is initiated. 18 days later, he develops v-fib, from which he cannot be resuscitated. A photomicrograph of cardiac tissue from the site of infarct obtained at autopsy is shown. Which of the following best describes the appearance of this pt's heart? (Granulation tissue OR Granuloma)

Supraspinatus -Participates in Abduction of the arm over head Subscapularis -Rotates the humerus medially *internal rotation & adducts it*

A 54F, present b/c of a 1-wk Hx of pain in the right shoulder. The pain is more severe when she lifts objects over her head, & it is affecting her work at a retail store. She also has diff sleeping at night b/c of increased pain when she lies on her right side. She has no sig PMHx. PE shows tenderness to the right deltoid region. There is full passive ROM but decreased active ROM to abduction. Abduction & passive shoulder flexion over the head produce pain. During strength testing, the pt has pain & weakness w/abduction, particularly w/simultaneous shoulder internal rotation. Which of the following muscles is most likely affected in this pt? (Subscapularis OR Supraspinatus)

Lower motor neurons -Pt presents w/ all the classic lower motor neuron signs & symptoms Internal capsule -Cant be internal capsules b/c pt would present w/*UMN syndrome* → she would not have fasciculations, atrophy, and weakness

A 55F, presents d/t a 3-month Hx of difficulty using her hands & a 3-wks Hx of muscle cramps. She has had a 20-lbs wt loss during the past 5-wks. Neuro exam, shows tongue fasciculations & LE weakness & atrophy. Sensory exam is normal. A lesion at which of the following sites is the most likely cause of these findings? (Internal capsule OR Lower motor neurons)

↑Free T4 (thyroxine) → this is pt's med so expected to go up ↑T3 (triiodothyronine) → made from T4 so if T4 is up so will T3 ↓Tyroidal iodine uptake → would be decreased b/c pt now has too much active thyroid so doesn't need to uptake & store any more

A 55M, presents d/t a 2-wks Hx of palpitations & anxiety. He has primary hypothyroidism treated w/Levothyroxine. He says that he has been taking twice the prescribed dose for the past 2 months. Pulse is 104/min, BP is 146/88, PE shows a fine resting tremor. Which of the following sets of labs is most likely seen in this pt? (Free T4-thyroxine(↑/↓) Free T3-triiodothyronine (↑/↓) Tyroidal iodine uptake (↑/↓)

↓CO → b/c pt had an MI ↑SVR → b/c it is almost always the response ↑PCWP → b/c pt has elevated JVP (cab be either ↑/↓)

A 55M, presents to the ED b/c of a 1-hr Hx of severe chest pain, nausea, & vomiting. He is agitated, clammy, & sweating profusely. Temp is 98F, pulse is 130/min, RR is 36/min, BP is 85/45. JVP is 12 & crackles are heard in the lung bases bilaterally. Which of the following is most likely in this pt? (PCWP(↑/↓), CO(↑/↓), SVR(↑/↓)

Presenilin -Early onset AZ is associated w/: 1-Presenilin-1 gene on Ch14 2-Presenilin-2 gene on Ch1 -Presenilin is associated w/*degrading Amyloid-β proteins* Amyloid A & β2 microglobulin -Early onset AZ is associated w/ Amyloid β precursor protein (AβPP) gene on chromosome 21 [Not Amyloid A or β2 micro globulin]

A 56 year old pt dies from complications associated w/ Alzheimers. This disorder most likely indicates a mutation in a gene encoding for which of the following proteins? (β2 microglobulin OR Presenilin OR Amyloid A)

Presynaptic release of ACh -Pt presents w/*Lambert eaton* → which presents w/: 1-Usually para-neoplastic associated with *small cell carcinoma* 2-Initial *proximal limb weakness* (especially proximal leg - leading to diff climbing stairs & rising from seated position) 3-*Weakness alleviated my muscle use* Pathophysio -*Presynaptic release of ACh*→ via presynaptic PQ-type voltage gates Ca+ channels DIRECT DEPOLARIZATION OF MUSCLE FIBERS BY Ca+ -Neither lambert eaton or myasthenia involves inhibition of direct stimulation of muscle fibers by Ca+

A 56F, presents b/c of 3-wks of Hx of increasing weakness of her arms & legs. She has smoked 1 pack of ciggs daily for 30 years. PE shows pronounced weakness of the hip girdle muscles & lesser weakness of the shoulder girdle muscles, both of which improve w/ repetitive testing. A CXR shows a hilar lung mass. Electromyography is compatible w/a malfunction of the neuromuscular junction. Impairment of which of the following is the most likely cause of these findings? (Direct depolarization of muscle fibers by Ca+ OR Pre-synaptic release of ACh)

Microbial oncoprotein that interferes w/ tumor suppressor genes -HPV 16 & HPV 18 have two *Viral (microbial) oncoproteins* E6 → inhibits p53 E7 → inhibits Rb Both of these are tumor suppressor genes

A 56F, presents for a well exam. PE shows no abnormalities. Results of a Pap shows epithelial cell abnormalities, including HSINL. Which of the following mechanisms is the most likely underlying cause of the lesions in this pt? (Microbial oncoprotein that interferes w/ Tumor Suppressor genes OR Integration of a microbial genome into the host genome to induce a cellular proto-oncogene)

Subacromial bursitis -Inflammation of the bursa that separates the superior surface of the supraspinatus tendon from overlying coraco-acromial ligament -Affects the supraspinatus tendon most and presents w/ impingement like symptoms *affects the arms being lifted overhead) Adhesive capsulitis -AKA *Frozen shoulder* → pt would present with greatly restricted motion [this pt can move her shoulder]

A 60F, w/DM II presents b/c of a 6-wks Hx of right shoulder pain. The pain occurs when she attempts to raise her arm & when lying on her right side. She has not had weakness, tingling, or numbness. PE shows tenderness to palpation in the region of the right deltoid just lateral to the acromioclavicular joint. While sitting upright, she is able to adjust her arm to nearly 90°, but additional abduction is prevented by pain. Muscle strength is 5/5 in the RUE, sensation is intact & there is no impingement sign. Which of the following is the most likely Dx? (Subacromial bursitis OR Adhesive capsulitis)

Budd chiari -Defined as any thrombotic or obstructive process that inhibits the outflow of blood w/in the hepatic venous system → *Polycythemia vera* is most common cause → other etiologies include (HCC, Hyper-Coagulable states (OCP, inherited), pregnancy & post-partum -Presentation includes: 1-*Ascites* 2-*Hepatomegaly* & *splenomegaly* 3-RUQ abd pain 4-*Jaundice* (possible nutmeg appearance on gross exam) 5-Varices -Differentiate from RHF from *absence of JVD* Portal vein thrombosis -pt would present w/RUQ pain, *nausea, vomiting, bleeding* & splenomegaly, ascites -Can present similar to liver cirrhosis

A 61M, presents to the ED b/c of severe abd pain for 1 hr. He has polycythemia vera & has frequently missed appointments to have his Hct monitored. His most recent exam 2 months ago showed no abnormalities. PE shows mild scleral icterus. Abd exam shows a tender, enlarged liver, a moderately enlarged spleen, & ascites. Which of the following is the most likely Dx? (Budd chiari OR Portal vein thrombosis)

Artery of ductus deferens -Supplies blood to testis and epididymis -Arises from *Internal iliac* -> *superior vesicle artery* -> *Artery of ductus deferens* Inferior vesical artery -Supplies the inferior base of the bladder, seminal glands, & prostate

A 64M, undergoes surgical repair of an abd aortic aneurysm. During repair, the left testicular artery is ligated. Anastomotic supply from which of the following arteries will maintain adequate supply to the left testis? (Artery of ductus deferens OR Inferior vesical artery)

Atherosclerosis -Pt is older, so atherosclerosis is more common cause of HTN -MRI would show stenosis and thats it Fibromuscular dysplasia -Would be associated w/Bruits -Would be seen in *pre-menopausal* women -Pt would have symptoms: 1-may effects the abd arteries so may present w/abd pain after eating, unintended wt loss 2-HTN 3-*String of beads appearance* on MR aortography

A 65F, w/ well-controlled DM II presents for a follow-up. At her last office visit 1-yr ago, PE & labs showed no abnormalities. Temp is 99F, Pulse is 82/min, RR is 18/min, BP is 135/80. PE shows no other abnormalities. Labs show: -Hb------11.2 -Hct-----33% -BUN-----30 -Creat----2.1 Abd US shows a decreased size of both kidneys. MR aortography shows bilateral proximal renal artery stenoses. Which of the following is the most likely Dx? (Atherosclerosis OR Fibromuscular dysplasia)

Right cerebellar hemisphere

A 65M, develops a progressive ataxia w/gait unsteadiness. There is an intention tremor on the right side. The most likely cause us damage to which of the following areas of the brain? (Left cerebellar hemisphere OR Right cerebellar hemisphere)

SVR(↑), PVR(↓), PCWP (↑) -In cardiogenic shock the: 1-*SVR is always increased* 2-*PVR always decreased* (d/t vasodilation) 3-PCWP → can be either (↑/↓)

A 65M, present to ED 30 mins after sudden onset of SOB & chest discomfort in his chest. He says he feels weak & apprehensive. His pulse is 110/min, RR is 22/min, BP is 100/80. PE shows diaphoresis. An ECG shows ST elevation in the anterior leads. Compared w/a healthy man of the same age, which of the following sets of cardiopulmonary changes is most likely in the pt? (SVR(↑), PVR(↓), PCWP(↑) OR SVR(↑), PVR(↑), PCWP(↓)

A-a PO2 difference -Pt present w/ restrictive lung disease → this causes an *↑A-a gradient* FVC -FVC is decreased in both Obstructive & restrictive lung disease -Pt presents w/restrictive lung disease → FVC will be decreased but *FEV1:FVC ratio will be increased or normal*

A 70M, presents b/c of a 1-yr Hx of progressive SOB & non-productive cough. He is now unable to tolerate even mild activity. PE shows clubbing of the fingers. Inspiratory crackles are heard at both lung bases. A CT shows patchy sub-pleural reticular opacities. Biopsy of lung shows a heterogeneous pattern w/alternating areas of normal lung w/pulmonary fibrosis. Which of the following pulmonary function tests in this pt will most likely show a result greater than the predicted range? (A-a PO2 difference OR FVC)

-Pt has pre-renal azotemia, criteria is: 1-Urine osmol (>500) 2-*Urine Na+ (<20)* 3-FeNa+ (1%) 4- *Serum BUN:creatinine (>20:1)* -Causesd by 1-Volume depletion (hypotension) w/ ↓GFR 2-Hyaline casts may be seen 3-↑BUN/creatinine ratio (BUN is reabsorbed, creatine is not) Serum urea (BUN) (40) Serum Creatinine (2) Urine Na+ (5) Specificity (1.025) Serum Urea BUN (40) → filtering is decreased (b/c urine is decreased) Creatinine (2) → b/c the pt has not had dysfunctional kidneys for that long Urine Na+ (5) → the pts urine output is decreased, which means he is retaining water, Na+ will follow the water [he will not be excreting Na+]

A 70M, w/severe CHF has had progressive orthopnea for the past 4-wks. He has not been taking his meds. During this time, his urine output has progressively decreased to 300mL/day. Which of the following sets of lab findings is most likely? (serum urea BUN (20/40) Serum creatine (2/4) Urine Na+ (5/40) Specificity (1.025)

Otosclerosis -Common form of *Bilateral* conductive hearing loss in adults Acoustic schwannoma -Does not present w/bilateral conductive hearing loss

A 78M, has had progressive loss of hearing in his right ear over the past year. BC > AC in both ears. Which of the following is the most likely cause of the hearing loss? (Acoustic neuroma (schwannoma) OR Otosclerosis)

B -Renal tubular acidosis *both type 2 (Proximal renal tubular acidosis) & Type 4 (Hyperkalemic renal tubular acidosis)* *occur in the PCT* -both have ↓pH E Type II (distal renal tubular acidosis) occurs here (α-intercalated cells) → *would have Alkalosis (↑pH)*

A 7B, has metabolic acidosis & persistent phosphaturia. This pt most likely has a primary defect in which of the following labeled sites?

Include the outcome for each participant in the group to which he or she was randomized -the question specifically asks about the pt's that were not adherent → these pts still provide valuable data to the study b/c they were assigned to only one group and were only taking *one med* → this can tell the investigators what happens if the pts stops taking the meds (do they still have an effect on BP)

A prospective study is done to assess the relative efficacy of two different anti-HTN meds, both of which were shown to be efficacious in placebo-controlled trials. In the study, pt's w/HTN were randomly assigned to receive one of two meds. At the conclusion of the study, some participants reported inconsistent adherence to their med regime, while others reported discontinuing their study med altogether before the primary outcome (BP measurement after 30 days) was obtained. A few of these pts who discontinued their study med were prescribed the other group's study med by their primary care physician & were taking it at the time of the primary outcome measurement. In their primary analysis, which of the following methods should the investigators use to analyze data from the pt's who were not adherent to the med regime? (Exclude the outcome for only those who inadvertently switched to the other study med OR Exclude the outcome for only those who reported stopping the med altogether OR Include the outcome for each participant in the group to which he or she was randomized)

CD8+ lymphos

A pt presents w/ EBV infection. The atypical lymphocytes in this pt are most likely which of the following cell types? (CD 4+ lymphos OR CD8+ lymphos)

TGF-β -*Wound healing* -Stimulates angiogenesis & fibrosis *(fibroblast migration & proliferation)* - resolution of the inflammatory response TNF-α -Causes cachexia in malignancy -Maintains granulomas -Activates endothelium, causes WBC recruitment, vascular leak

A pt presents w/a subcutaneous nodule. Micro exam of the nodule shows fibrous CT, M∅, multinucleated giant cells, fibroblasts, a few lymphocytes, & scattered fragments of polarizable foreign material. Which of the following substances that promotes fibroblast migration & proliferation most likely led to this lesion? (TGF-β OR TNF-α)

Impaired release of glucagon -After insulin wears off then glucagon should take effect which keeps blood sugar levels stabilized → this pts prolonged hypoglycemia is evidence that glucagon is not taking affect when it should

A pt w/ a 20-year Hx of DM I has episodes of prolonged hypoglycemia following injections on insulin. Which of the following is the most likely cause of the prolonged hypoglycemia? (decreased number of hepatic catecholamine receptors OR Impaired release of glucagon)

Regular exercise -Prevents disease in healthy people → other primary preventions are: 1-Legislation to ban use of hazardous products (asbestos) or to mandate safe practices (seat belts, helmets) 2-Education about health & safe habits (eating well, exercise, not smoking) 3-Immunization Annual mammography -This is used to detect breast cancer *only detects after it has already occurred* → so *secondary prevention* → other examples include 1-Daily, low-dose aspirin OR diet and exercise programs after a stroke to prevent future strokes) 2-Modified work so injured of ill workers can return safely to job Tertiary 1-Cardiac or stroke rehab programs, chronic disease mgmt programs (DM, arthritis, depression) 2-Support groups 3-Vocational rehab programs to retrain workers

A public health consultant is contacted by a HMO for recommendations about a primary health prevention techniques for a population of women ages 30-40 years. Which of the following is most appropriate primary preventative recommendation for this group? (Regular exercise OR Annual mammography)

Case control Cohort -Would not be time efficient as you would have to follow subjects over time

A researcher hypothesizes that exposure to more than 50ug/L arsenic in drinking water is associated w/an increased risk for development of a common cancer compared w/persons whose drinking water contains less than 5ug/L. Which of the following is the most time-efficient experimental design to investigate this hypothesis? (Case-control OR Cohort study)

Prevalence: above standard Incidence: above standard

A researcher is asked to prospectively investigate the incidence of decubitus ulcers in the 100 residents of a nursing care facility during a 2-year period. At the beginning of the study, 10 residents are found to have decubitus ulcers. During the first year, five additional residents develop decubitus ulcers, & another 10 residents develop decubitus ulcers during the second year. Three of the previously noted ulcers have completely healed by the end of the 2-year period. National standards for the nursing care facilities mandate that the prevalence of decubitus ulcers should be less than 20% of the total residents in the facility, & the incidence of new decubitus ulcers should be less than 50/1000 pt years. Which of the following is the most appropriate conclusion regarding the prevalence & incidence of decubitus ulcers in this population at the end of the 2-years period? (Prevalence: Above standard Incidence:above standard OR Prevalence below standard Incidence below standard)

PICA -Pt present w/ *Wallenberg Syndrome AKA lateral medullary syndrome* → presents w/: 1-Sensory deficits contralateral to lesion (pt has left side) 2-Sensory deficits on face ipsilateral to lesion (pt has right side lesion) 3-Cranial nerves ipsilateral to lesion [pt has Horner's on right side] AICA -Would result in lateral pontine syndrome

AICA OR PICA

Inability of vaccine to elicit secretory antibody at the epithelial surface -A killed vaccine [described in stem] would not be able to produce antibodies to the epithelial surface Ability of V.cholera to produce multiple antigenic types of enterotoxins -Most Bacteria cannot produce multiple antigenic types of enterotoxins

Ability of V.cholera to produce multiple antigenic types of enterotoxins OR Inability of the vaccine to elicit secretory antibody to the epithelial surface

Formic acid -Methanol breaks down to formic acid

Acetaldehyde OR Formic acid

Furosemide -Loop diuretics are safe to use in: 1-HF w/ sig fluid overload 2-*Advanced kidney failure*

Acetazolamide OR Furosemide

Alanine -Pt has normal blood glucose after fasting → this can be accomlished by two methods: 1-Cahill cycle *alanine* → where glucose-alanine are transported from muscle to liver Acetoacetate -This is not necessarily a "precursor" it is a Ketone body (as is β-Hydroxybutyrate) -*This would not raise glucose and pt would be in acidosis*

Acetoacetate OR Alanine

Autoantibodies against plts glycoproteins -Pt presents w/*Immune thrombocytopenia* → which is an *acquired thrombocytopenia* - caused by auto antibodies that target plts antigens/glycoprotein *(GIIb/IIIa)* -Etiologies include: 1-Young women (30-40) 2-Older men (>70) 3-*Petechiae, purpura* 4-Epistaxis *pt has bleeding gums* 5-Fatigue 6-*Decreased plts* 7-↔/↑Megakaryocytes Splenomegaly EXCLUDES ITP Acquired antibodies against platelet antigen P1A1 -Associated w/ transfusion rxns

Acquired antibodies against platelet antigen P1A1 OR Autoantibodies against plts glycoproteins

Actinic keratosis -Cutaneous lesion that typically presents d/t sun exposure → presents as scaling macules or papules that have potential to become malignant 1-Most present as scaling macules that occur primarily in the face, balding scalp, & *dorsal aspect of the hands* 2-*Usually dry and pale in color* (can also present as hyperpigmented) Seborrheic keratosis -AKA basal cell papilloma → non-cancerous benign growth that originates in keratinocytes → presents as: 1-People in older age 2-Flat & greasy 3-Variable tan & brown pigment 4-Round or oval shape 5-Diameter ranges from small to > 2.5 cm -*Leser-Trelat sign is an acute & rapid onset of multiple seborrheic keratoses*

Actinic keratosis OR Seborrheic keratosis

Nephrolithiasis -Presents w/: 1-Hematuria 2-Abd exam → Dull Pain/ mild tenderness in abd, flank, groin --Flat w/hypoactive bowel sounds 3-Occasional *severe abd pain w/ nausea & vomiting* Hypernephroma -Most common type of kidney cancer [pt would have chronic presentation vs. acute] Acute papillary necrosis -Presents with 1-Gross hematuria *[pt has]* 2-Gross proteinuria 3-Flank pain *[pt has]* [pt presents w/no proteinuria and has vomiting associated w/ the pain -> nephrolithiasis is more likely]

Acute papillary necrosis OR Hypernephroma OR Nephrolithiasis

Decreased gluconeogenesis (GnG) -Baby will have Hypoglycemia d/t ↑insulin response to ↑maternal blood glucose levels -Increased insulin will block GnG b/c insulin opposes glucagon Increased serum insulin growth factor -This is a mediator for GH

An 18-hour-old newborn is 24 inches long & weighs 12-lbs. His mom has DM I. His serum glucose conc is 20mg/dL. Which of the following fetal conditions immediately prior to birth most likely precipitated the newborn's postnatal hypoglycemia? (Decreased Gluconeogenesis OR Increased serum insulin like growth factor)

Decreased sodium bicarbonate reabsorption in the proximal tubule -Pt has *Fanconi's syndrome* → which presents w/: 1-Wasting a variable amounts of phosphate, glucose, amino acids, & bicarbonate by the Proximal renal tubule *Defects are associated w/reduced ATP & Na+/K+ ATPase activity* Serum findings 1-*Hypokalemia* 2-*Hypophosphatemia* 3-*Metabolic acidosis* Causes of fanconi syndrome 1-Inborn errors of metabolism (cystinosis, galactosemia, fructosemia, tyrinosemia (most common) *[Pt probably has galactosemia (dehydration, decreased muscle tone]* 2-X-linked syndromes (Lowe syndrome, Dent's disease) 3-Metals (Wilson's, heavy metal tox) *pt has crystals in slit lamp exam which indicates Wilson's* 4-Meds (chemo, immunosuppressants, gentamicin, tenofovir, expired tetracyclines) Signs & symptoms 1-*Polyuria* 2-Polydipsia 3-Dehydration 4-Bone deformities *pt has bowing of legs* 5-Impaired growth Dx -made by finding in urine: 1-↑Glucose 2-↑AA's 3-↑Electrolytes *DECREASED H+ ION SECRETION IN PROXIMAL TUBULE * -Seen in *renal tubular acidosis type I* -Renal tubular acidosis is associated with a defect in the ability of the alpha intercalated cells to secrete H+ -> this would cause an *increased pH* [pt has decreased pH*

An 18-month-old F, presents b/c of failure of thrive & frequent wet diapers. She is at the 3rd percentile for length & wt. PE shows dehydration, decreased muscle tone, & bowing of legs. Slit lamp exam shows crystals in the corneas. Serum studies show hypophosphatemia, hypokalemia, & a non-anion gap metabolic acidosis. Urine studies show a pH of 5, glucosuria, phosphaturia, & generalized aminoaciduria. Which of the following is the most likely cause of the metabolic acidosis in this pt? (Decreased H+ ion secretion in the proximal tubule OR Decreased Na+ bicarbonate resorption in the proximal tubule)

*↓Max O2 consumption (VO2 max)* -Myasthenia presents as *restrictive lung disease* -Decreased b/c she is not able able to not able to get in enough O2 (d/t weakness in resp. muscles) *↑ Venous blood lactate* -Increased b/c she is not getting enough O2 (d/t restrictive type malfunction) *Increased Energy production of glycolysis* -This is increased in Myasthenia gravis

An 18F, presents b/c of a 6-month Hx of progressive muscle weakness, poor exercise tolerance, & SOB w/exertion. She also has had difficulty following moving objects w/her eyes, especially when she is tired. Pulse is 110/min, RR is 22/min, BP is 105/85. PE shows bilateral ptosis. Muscle strength is 3/5 to 4/5 in all extremities. Exam of a muscle biopsy shows abnormal accumulations of mitochondria in the sub-sarcolemmal regions. Which of the following additional sets of findings is most likely in this pt? (Max O2 consumption (VO2 max) (↑/↓) Venous blood lactate (↑/↓) Energy production by glycolysis (↑/↓)

Respiratory acidosis -Can be caused by any condition that interferes w/normal effective ventilation → causes include: 1-URTI 2-Pneumonia 3-*Pneumothorax* → pt presents w/ a pneumothorax 4-COPD ARDS -caused by inflammation → in particular cytokine secretion, neutrophil infiltration, & increased alveolar capillary permeability → damage leads to pulm edema, atelectasis, pulm vascular obliteration Etiology includes : 1-Aspiration 2-Near drowning 3-DIC 4-Air embolism 5-Sepsis *no.1* 6-Smoke inhalation [not trauma]

An 18F, presents d/t sharp chest pain & SOB 1 hr after receiving a non-penetrating injury during a rugby game.RR are 22/min. PE shows decreased breath sounds & increased tympany to percussion on the right. CXR is shown. This pt is at greatest risk for developing which of the following complications? (Diffuse alveolar damage OR Respiratory acidosis)

20 -Vd is calculated two ways 1-t1/2 = (0.7xVd)/CL OR VD=(C-initial)/Plasma conc We use the second eq so VD = 80mg/(4ug/mL) -but we must convert 4ug to mg so Vd = 80mg/(.004mg/mL) = 20,000mL -then convert to Liters 20,000mL/(1L/1000mL) = *20L*

An 80M is admitted to the hospital b/c of a 2 wks Hx of severe, persistent UTI. An 80-mg dose of Drug X is administered IV. Thirty mins after the infusion is complete, his serum conc of Drug X is 4ug/mL. Assuming a distribution t1/2 life of 3 mins & an elimination t1/2 of 24 hrs, the volume of distribution of this drug (in L) in the peripheral compartment is closest to which of the following? (2 OR 20)

Decreased function of the puborectalis muscle -The puborectalis is the medial part of the levator ani & forms a sling around the distal end o fat anorectal junction that helps to maintain fecal incontinence Hypertonicity of the Internal anal sphincter -This would be true if it was the *External* anal sphincter

An 82F, presents d/t fecal incontinence for 2-months. PE shows no abnormalities. Which of the following is the most likely underlying mechanism of this pts condition? (Decreased function of the puborectalis muscle OR Hypertonicity of the internal sphincter)

Antitoxoplasma IgM antibody concentrations -The fetus is able to produce IgM antibodies against the toxoplasmosis infection → *IgM antibodies are the first to be produced in utero*

Antitoxoplasma IgG antibody concentrations OR Antitoxoplasma IgM antibody concentrations

Aortic -The image shows a *Mercedes Benz sign* with indicates the *aortic valve* -Additionally, the image shows LVH, which would indicate a problem with the aortic heart causing LV hypertrophy

Aortic OR Mitral

Doxy -MOA → bind the 30s subunit & prevent attachment of amino-acyl tRNA -AE of doxycycline include: 1-*Photosensitivity* 2-Teeth discoloration 3-Teratogen Azithromycin -MOA → *binds the 50s subunit & blocks amino-acyl transpeptidation & translocation* -AE's include *MACRO* → *M* → GI Motility *A* → Arrhythmia (QT prolongation) *C* → Cholestatic hepatitis (jaundice - erythromycin) *R* → Rash *O* → esinOphilia Erythromycin -Cholestatic jaundice -Pyloric stenosis

Azithromycin OR Doxy

Non-Hodgkin Lymphoma -EBV can present as primary non-Hodgkins lymphoma in HIV pts → it is the second most common cause of mass lesions in the brain (after Toxo) → Appears as Mass lesion on MRI, similar to Toxo → must be differentiated by CSF analysis & biopsy *[pt was treated for Toxo but the mass only grew in size → indicates that it is not Toxo infection* Bacterial abscess -The head lesion would be seen as purulent liquefactive necrosis -Pt would have Hx of previous infection from: --Sinusitis (strep) --Trauma (S.aureus) --Chronic otitis media (Anaerobes)

Bacterial abscess OR Non-Hodgkin lymphoma

C1 inhibitor -Pt presents w/Hereditary angioedema AKA *C1 esterase deficiency* → which presents w/: 1-episodic attacks of angioedema *(beginning in childhood)*in one of the following areas --*Sub-Q tissue* →visible swelling of affected body part *(pt has swelling of face & extremities)* --Abd organs → *most common in childhood* (presents as vomiting, diarrhea, colicky pain mimicking a surgical emergency) --Upper airway edema & swelling → (laryngeal edema & upper airway swelling)\ --Non-pitting cutaneous edema → most common reported symtpom TMT Acute --Plasma derived C1 inhibitor concentrations --Recombinant C1 inhibitor --Bradykinin receptor 2 antagonist *(icatibant)* --Kallikrein inhibitor *(ecallantide)* Long term --*Androgens → Danazol* (post-pubertal males) --Antifibrinolytics (tranexamic acid) → growing children --Regular infusions of plasma-derived C1 inhibitor (pregnant women)

C1 inhibitor OR IgA

COPD -We know this pt has *↑Hemoglobin* → this indicates *erythrocytosis* -The pt's PBS shows a more or less normal PBS w/: --Erythrocytosis --Neutrophils -COPD causes erythrocytosis b/c the pt has long standing hypoxemia Myelodysplastic syndrome -The PBS would show: --Pseudo-Pegler-Huet cells *(Neutrophils w/only two nuclear lobes)* [the pt's PBS shows neutrophils w/ 3 lobes] --Ringed sideroblasts Additional findings --Pt would have Hx of cancer ± chemo therapy --Pt would have decreased reticulocytes (erythrocytes) *[pt has erythrocytosis]*

COPD OR Myelodysplastic syndrome

Yersinia -Yersinia enterocolitica causes: 1-Acute diarrhea & pseudoappendicitis 2-Acquired via --Consumption of undercooked pork --*Contaminated milk* (pt had unpasteurized milk) --Pet feces 3-*grows at cold temps*

Campylobacter OR Yersinia

Glucose → G6P→F6P +*glutamine* → Glucosamine Carbamoyl phosphate - is used in urea cycle

Carbamoyl phosphate OR Glutamine

Carcinoma of the breast -*Invasive ductal carcinoma is the most common post menopausal breast carcinoma -DCIS does not usually produce a mass, but is often detected *as calcification* on mammography *pt has an extremely radiodense mass w/irregular margins & clustered micro-calcifications* Fibroadenoma -Most common in women *under 30* [pt is 62] -Presents as solitary, non-tender, solid, mobile mass w/well defined edges →Usually bilateral [no calcifications & not extremely radio-dense]

Carcinoma of the breast OR Fibroadenoma

CEREBRAL BLOOD FLOW Brain response to CO2 levels are: 1-*Hypocapnia ↓ blood flow* 2-Hypercapnia ↑ Blood flow -Pt presents with *Hypocapnia* Cerebral tissue pH -this would be increased b/c there would be less CO2 meaning it would be less acidotic

Cerebral blood flow OR Cerebral tissue pH

t-test -Used to compare the *mean* of a *group* of the *same* people Chi-test -Compares categorical data → in this example they are specifically asking about *comparing the mean of the two groups* Sign test -Would compare a sample of *randomly selected people*

Chi Square OR t-Test OR Sign test

Cholecalciferol -There are two type of Vit. D --D2 (ergocalciferol) → from plants --D3 (Cholecalciferol) → steps to D3 synthesis are: 1-7- Dehydrocholesterol (always present in the skin) 2-Cholecalciferol is synthesized by the body from 7-Dehydrocholesterol during UVB radiation exposure 3-25-OH D3 *storage from Vit. D* 4-1,25 Vit.D *active form of Vit. D*

Cholecalciferol OR 7-dehydrocholesterol

Chondroblasts → form cartilage Osteoblasts → form bone Osteoblasts -The pt most likely presents w/*Cleidocranial dysostosis/dysplasia* → which is a *congenital defect (CBFA-1 mutation)* → that affects mostly: 1-*bones & teeth* 2-Collar bone are either poorly developed or absent →*allowing the shoulders to be brought close together*

Chondroblasts OR Osteoblasts

Chondrosarcoma -Malignant transformation of an osteochrondroma → *most common benign tumor* -Usually occur in long bone metaphysis (most commonly in distal femur, proximal tibia, or proximal humerus -Usually in aged 10-30 years -Presents as *hard painless mass that has been present & unchanging for years* -Microscopy Would show *calcification - illustrating malignant transformation & a glistening mass w/ cysts* Echondroma -Commonly found in the inter-medullary (Diaphyseal) portion of bone -Most common in 20-50yrs -Benign cartilaginous tumor Multilobulated bone cyst -Would present as simple and filled w/serosanguineous fluid

Chondrosarcoma OR Echondroma OR Multilobulated bone cyst

Obstructive uropathy -presents w/: --Back pain --Fever --Leukocytosis (seen in image) --CVA tenderness --*RF → pregnancy* Chorioamnionititis -Presents w/ *maternal fever + one of the following* 1-Fetal tachycardia 2-Maternal leukocytosis 3-Purulent amniotic fluid *[pt has severe back pain + CVA tenderness → this fits more with obstructive uropathy]*

Chorioamnionitis OR Obstructive uropathy

Cluster headache -Characterized by: 1-*unilateral & brief* 2-*Peri-orbital pain* 3-*ipsilateral autonomic symptoms* (lacrimation, rhinorrhea, sweating, miosis, ptosis - "Horner like" 4-*Repeat in clusters of 3-6 wks* → followed by month or year long absences [pt had similar episodes 2 years ago] TMT 1-Triptans 2- Verapamil *prophylaxis* Sinus headache -Pressure headache -Pt would have Hx of URT or allergies & would present w/: 1-Purulent nasal discharge 2-Nasal congestion 3-Facial pain over the sinuses worsened by bending down or applying pressure

Cluster headache OR Sinus headache

Coarctation of the aorta -Would cause *LVH (systemic overload)* -Common causes of a left axis deviation are: 1-*LVH* 1-Left anterior block 2-MI 3-Obesity 4-WPW 5-ASD Right atrial hypertrophy -RAH or RHV would show a right axis deviation

Coarctation of the aorta OR Right atrial hypertrophy

Unrearranged immunoglobulin gene -T-cells immunoglobulin rearrangement involves the joining of up *1-6 segments* B-cell immunoglobulin rearrangement involves the joining of 1 segment to another The fact that a 6-kb band (6-segments) is left over points to T-cell rearrangement of immunoglobulin Constant region gene rearrangement -this is constant, & would not rearrange

Constant region gene rearrangement OR Un-rearranged immunoglobulin gene

Countertransference -Doctor projects feelings about formative or other important persons onto pt -Ex: "Pt reminds physician of younger sibling" Transference -same as above but Ex: "Doc reminds pt of parent" Conversion -Seen in conversion disorder only

Conversion OR Countertransference OR Transference

Disruption of normal splicing by creation of a new splice site -The image shows an exon & an intron: -*IN*trons are *IN*tervening & are removed -*EX*ons are *EX*pressed Introns typical have a -*GU at 5' end* -*AG at 3' end* The mutation in the stem shows that a *new AG site* will be created before the normal *AG* which will result in abnormal splicing Creation of a missense mutation that leads to the synthesis of a defective β-globulin gene -A missense mutation here would not matter b/c it would be in an intron → which would be spliced out

Creation of a missense mutation that leads to the synthesis of a defective β-globulin OR Disruption of normal splicing by creation of a new splice site

DNA fragmentation Bromodeoxyuridine staining -Replaces thymidine in staining

DNA fragmentation OR Bromodeoxyuridine staining

Recombinant double stranded DNA repair break -This pt presents w/a *BRCA* mutation → BRCA is associated w/Recombinant double stranded DNA breaks -Cancers associated --*Breast cancer* --*Ovarian cancer* DNA mismatch repair -Describes Lynch syndrome -Associated cancers include: --Colorectal cancer --Endometrial --Ovaires --Sebaceous glands

DNA mismatch repair OR Recombinant double stranded DNA repair break

Damage to the anal sphincter -The pt recently had a vaginal delivery → vaginal deliveries are associated w/an increased risk for *anal fissures which would affect the anal sphincter* → RF's for primary anal fissures are: 1-Constipation. diarrhea 2-*Vaginal delivery* 3-Anal sex Spastic contraction of the puborectalis muscle -The puborectalis forms sling around the distal end of the anorectal junction & helps to maintain fecal continence → dysfunction *(spastic contraction of puborectalis AKA Anismus)* → this had an *unknown cause* & is usually treated w/ dietary changes *[not associated w/vaginal delivery]* Pubococcygeus -Target for Kegel exercises for urinary incontinence

Damage to the anal sphincter OR Spastic contraction of the puborectalis muscle OR Pubococcygeus

Decreased alveolar PO2 -This pt will present with *hypoxemia* → and be in 1-Respiratory alkalosis →b/c hyperventilating 2-*↓PaO2* → b/c high altitude causes hypoxemia 3-↓PaCO2 → b/c hyperventilating 4-↑HR 5-↓SV Increased SNS activity -Hypoxemia causes a reflexive drop on BP

Decreased alveolar PO2 OR Increased SNS activity

Decreased binding of RNA polymerase -TATA binding protein (TBP), box is a transcription factor → Eukaryotic RNA polymerases require transcription factors

Decreased binding of RNA polymerase OR Decreased binding of DNA polymerase

Increased blood HCO3- -Pt presents w/COPD →will have metabolic Acidosis → kidney will compensate w/*↑HCO3* Increased urinary excretion of HCO3 -B/c he has acidosis the kidney will try to keep HCO3 Decreased blood PCO2 -No → b/c pt has COPD → will have ↑PCO2 (will be acidotic) since can't get air out

Decreased blood PCO2 OR Increased blood HCO3 OR Increased urinary excretion of HCO3-

Increased osteoclasts maturation & activity Pt presents w/ *primary Hyper-PTH* Pathology Begins with *↑PTH* → which stimulate osteoblasts (leading to increase production of of RANK-L & M-CSF) → RANK-L on osteoblasts bind RANK receptors on osteoclasts which *stimulates osteoclasts to resorb bone & increase Ca+ levels* -Prolonged bone absorption from chronically elevated PTH levels can lead to cystic bone lesions which may be brown *(called osteitis fibrosa cystica)* *[this pt does not present with this]* Labs include: 1-*↑PTH* 2-*↑ALP* 3-*↑Ca+* 4-*↓Phosphate* Symptoms of Primary Hyper-PTH include: 1-Renal symptoms --*Polyuria* --Nephrolithiasis 2-GI symptoms --Constipation --Anorexia --Vomiting --Occasional signs of pancreatitis 3-Neurologic --Weakness, fatigue, confusion, stupor, even coma Decreased Ca+ reabsorption by the renal tubules -This would be caused by end organ resistance → the pt would have a Hx of CKD -We would also see Hypocalcemia b/c the kidney would not be able to absorb it

Decreased calcium absorption by the renal tubules OR Increased osteoclast maturation & activity

Disruption of the secondary structure of the collagen molecules -OI is caused by a *↓ production of collagen* caused by a mutation in the *COL1A1 & COL1A2 genes* Pathophysio -*The substitution of glycine to bulkier AA's in the collagen triple helix creates steric hinderance that creates a bulge in the collagen complex (secondary structure)* Decreased hydrogen-bonding formation between collagen molecules -Hydrogen bonding is formed between he AA's not the collagen (secondary structures)

Decreased hydrogen-bond formation between collagen molecules OR Disruption of the secondary structure of the collagen molecules

Prolonged PT time -Dicoumarol is an anticoagulant that depletes Vit. K (similar to warfarin) → Vit.K affects PT time [Aspirin does not affect PT time] Decreased plts count -Neither drug would effect plts count

Decreased plts count OR Prolonged PT time

Their are two treatments for acne → including are: 1-Isotretinoin → *(which decreases sebaceous gland activity & normalize follicular keratinization)* 2-Oral/Topical antibiotics → *(used to decrease bacterial growth)* So the effect of this drug from binding to its receptor is: *Teratogenic effects in embryo (b/c its the only answer choice that correctly identifies the effects of the isotretinoin* Decreased propionibacterium acnes proliferation -This is achieved by antibiotics

Decreased propionibacterium acnes production OR Teratogenic effects in embryo

Decreased slope of diastolic depolarization -β-blockers decrease the slope of diastolic depolarization & decrease AV conduction velocity Increased Ca+ influx during the late phase of slow depolarization -This would increase HR [beta blocker decrease HR]

Decreased slope of diastolic depolarization OR Increased Ca+ influx during the late phase of slow depolarization

Increasing cGMP -This pt presents w/*severe HTN* → the DOC for severe HTN are 1-Hydralazine 2-Nitroprusside 3-Nitrates (more used for angina) -all of these drugs have MOA of *↑cGMP* Decreasing cAMP -This the MOA of β-blockers → they are used in tmt of HTN but not for HTN emergencies

Decreasing cAMP OR Increasing cGMP

Deep branch of the ulnar nerve at the hook of the hamate bone -The pts main symptoms are --Abduction & adduction of the fingers *(Ulnar nerve)* --Froment sign (flexion of the thumb *adductor pollicus - Ulnar* Recurrent branch of the median -Supplies the thumb -(opponens pollicis) -(Abductor pollicis brevis) -Superficial part of the flexor pollicis brevis

Deep branch of the ulnar nerve at the hook of the hamate bone OR Recurrent branch of the median nerve in the palm

Deletion of a hydrophobic amino acid sequence from the N terminus -Synthesis of all proteins begins in the *cytosol* → they then get targeted to enter the ER → this targeting relies on a targeting signal encoded in the *N-terminal portion of the protein* → this is recognized by a specific receptor on the ER which then allows it into the ER

Deletion of a hydrophobic amino acid sequence from the N terminus OR Premature termination of the polypeptide chain near the C terminus

Pick disease -MRI → disproportional atrophy (focal degeneration)of the *frontal* or temporal lobes -Microscopic findings → Microvacuolation & neuronal loss --Swollen neurons --Decreased myelin --Astrocytic gliosis Symptoms -Characterized by disturbances in: --*Dementia* --Behavior *(wandering, pacing, Compulsive buying, vulgar language, disinhibition) --Personality --Language Dementia Az type -Characteristics include --Aphasia --Agnosia (inability to recognize or identify objects despite intact sensory function) --Apraxia (inability to execute voluntary motor activities despite intact ability to comprehend the task & intact sensorimotor function) --Disturbances in executive functioning (planning, organizing) MRI findings -Diffuse cortical atrophy *(parietal & prefrontal)* -Narrowed gyri w/ widened sulci -*Hippocampal atrophy w/granulovacuolar degeneration - (most characteristic)*

Dementia, Az type OR Pick disease

Descending colon -Retroperitoneal organs → these include *SAD PUCKER* → the ones that have individual parts are: -Duodenum (2nd thru 4th parts) -Colon *ascending & descending* -Esophagus (thoracic portion) -Rectum (partial)

Descending colon OR Transverse colon

Interruption of erythrocyte production -Parvo-B19 *infects erythroid progenitors* b/c these cells express high levels of its cellular receptor *P-antigen AKA globoside* → causing apoptosis of infected cells

Destruction of erythrocytes in the peripheral circulation by an infectious agent OR Interruption of erythrocyte production

Dextromethorphan -This has morophine like effects → MOA includes: 1-Non-selective serotonin reuptake inhibitor 2-sigma-1 receptor agonist AE's include -*Constipation* Guaifenesin -Expectorant → used to cough out phlegm → AE's include: 1-Dizziness 2-Sleepiness 3-Skin rash 4-Nausea, vomiting 5-Formation of kidney stones *[no constipation]*

Dextromethorphan OR Guaifenesin

Diarrhea -Orlistat is a GI lipase inhibitor → blocks absorption of 25% of fat in meals

Diarrhea OR Increased BP

Didanosine -Causes pancreatitis Zidovudine -Anemia Abacavir -CI in HLA-B 5701 mutations But both cause 1-BM suppression 2-peripheral neuropathy 3-lactic acidosis

Didanosine OR Zidovudine

Antidepressant therapy -The pt has a Hx of MDD & has had a recent MI → recent events (like MI) are RF for depression in older pts Diet high in omega-3 FA's -Normal/acceptable LDL levels are in the 100-129 range → the pts levels are in the normal range

Diet high in omega-3 FA's OR Antidepressant therapy

Usual interstitial pneumonitis -A from of lung disease characterized by progressive scarring *fibrosis* of lungs → the fibrosis involves the *interstitium* → *most common form of *interstitial fibrosis* Diffuse alveolar damage -Would been seen in ARDS (acute setting)

Diffuse alveolar damage OR Usual interstitial pneumonitis

Dilated rough ER OR Large lysosomes

Dilated rough ER -Pt presents with Cranio-Lenticulo-sutural dysplasia AKA Boyadjiev-Jabs syndrome *This is a rare AR skeletal dysplasia* → a disorder of *COP II* → causes a *significant dilation of the ER in fibroblasts* → d/t the dilation, export of proteins such as collagen *which would effect endochondral bone formation* is disrupted -the production of SEC23A protein is involved in the pathway of exporting collagen COP II Large Lysosomes -Would be correct if this was I-cell disease - this is part of the lysosomal storage disorders -*Inclusion cells would be seen in microscopy → containing Oligosaccharides, GAG's, Lipids that cannot be broken down to to deficient lysosomal enzymes → these products will get released outside of cell where they also build up

Dilution of serum Na+ d/t ADH secretion -Pt presents w/*CHF* symptoms → this could cause a *compensatory increase in RAAS* → part of the compensation is *↑ ADH* [ANP would not be elevated b/c pt does not have increased intravascular volume] Increase urinary Na+ excretion of Na+ d/t secretion of ANP -Released from atria in response to *atrial stretch often secondary to ↑ vascular volume* -ANP counteracts the RAAS system by *increasing GFR & Na+ filtration* w/no compensatory Na+ reabsorption in distal nephron → results in loss of both Na+ & water

Dilution of serum Na+ d/t ADH secretion OR Increased urinary Na+ excretion d/t secretion of ANP

Direct antigobulin test -The test *detects IgM antibody* specific for *human IgG or Human complement C3* → IgG is a *warm hemolytic anemia* -This test is used primarily to diagnose *Immune mediated hemolytic anemia* -Pt presents w/: 1-Jaundice 2-Afebrile w/no evidence of infection 3-Anemia 4-Reticulocytosis The initial tests for hemolytic anemia include: 1-CBC 2-PBS 3-Reticulocyte Ct 4-LDH & Haptoglobin 5-LFT's 6-Autoimmune studies *(Coombs testing)* 7-Serum & urine free Hb & urinary hemosiderin Hemoglobin electrophoresis -Not on the initial tests for hemolytic anemia -Also, PBS only shows anemia & reticulocytosis

Direct antiglobulin test OR Hemoglobin electrophoresis

Direct transition from wakefulness to REM sleep -The pt suffers from *Narcolepsy* → which presents w/: 1-*Uncontrollable sleepiness* 2-*Characterized by REM sleep*

Direct transition from wakefulness to REM sleep OR Gradual transition from wakefulness to stage 1 sleep

Displacement -Redirection of emotions or impulses to a neutral person or object "a teacher is yelled at by the principal. Instead of confronting the principal directly, the teacher goes home & criticizes her husbands dinner" Suppression -*intentionally* withholding an idea or feeling from conscious awareness "Choosing to not worry about the big game until it is time to play" Sublimation (not an answer choice) -Replacing an unacceptable wish w/a course off action that is similar to the wish but *is acceptable* does not conflict w/one's value system "Teenagers regression toward his father is redirected to perform well in sports"

Displacement OR Suppression OR Sublimation (not an answer choice)

Dissecting aneurysm -Has a classical presentation of: 1-Abrupt-onset chest, back, abd pain *described as sharp, tearing, ripping* --Anterior chest pain → if ascending --Inter-scapular back pain → descending 2-*Pulse or BP variation* (SBP variation >20 between arms) [pt has diminished pulses in left arm] 3-*Mediastinal widening* 4-RF --*HTN* --*Cocaine use* Pseudoaneurysm -Would present as painful, tender, pulsatile mass -Can present in heart chamber after a procedure but *widened mediastinum* is not common

Dissecting aneurysm OR Pseudoaneurysm

Diuretics -Present w/: 1-Metabolic alkalosis 1-*↓Na+* 2-↓K+ 3-↓Cl- 4-↑Urinary Na+ 5-↑urinary K+ 6-*Hypotension* 7-*No pooping* Laxatives -Laxatives cause metabolic alkalosis *but would not effect Na+ levels* Labs -*↓K+* (b/c of loss of K+ in stool) -Hypochloremia → ↓K+ impairs Cl reabsorption causing *↓Cl* -↓Cl decreases the activity of the Cl-HCO3- exchange leading to *↑HCO3*

Diuretics OR Laxatives

Diverticulitis -Presents w/: 1-Older adults [pt is 65 years old] 2-*LLQ pain* 3-*Low grade fever, chills* 4-Leukocytosis 5-Nausea 6-Altered bowel habits *constipation> diarrhea* 7-Urinary frequency, urgency, dysuria 8-Gross exam → *three separate, poorly delimited regions of narrowing of the lumen* Ulcerative colitis -Would appear in young adult women -Would have IBS symptoms -Would have toxic megacolon

Diverticulitis OR Ulcerative colitis

Diverticulum of the roof of the embryonic oral cavity -Presents as *suprasellar neoplasm* -May be cystic (develops from nests of epithelium derived from Rathke's pouch -Formed from *surface ectoderm* → *epithelial lining (diverticulum) of the roof of the oral cavity* Neuroectoderm -Structures formed from neuroectoderm (neural tube) are: 1-Brain (neurophysin, CNS neurons, oligodendrocytes, astrocytes, ependymal cells, pineal gland) 2-Retina 3-Spinal cord

Diverticulum of the roof the embryonic oral cavity OR Neuroectoderm of the diencephalon

Drug effect -Thiazide AE's include: 1-*Hyper GLUC* 2-Hypokalemia 3-Hyponatremia 4-Hypomagnesium 5-Metabolic acidosis 6-Sexual disturbance (impotence, breast discharge - Breast discharge caused by the kidney's inability to get rid of prolactin) 7-Sleep disturbances Systemic mastocytosis -Mastocytosis *this is an allergic rxn* presents w/ 1-Itching 2-Hives 3-Anaphylactic 4-shock

Drug effect OR Systemic mactocytosis

Substance P Enkephalin This is an endogenous neuropeptide agonist for the δ (delta) opioid receptor -Found mostly in the brain & adrenal medulla → not associated with the burning pain this pt presents with

Enkephalin OR Substance P

Gemfibrozil -Pt presents w/*myopathy/ rhabdomyolysis* → which presents when pts use a *statin & Fibrate* -MOA fibrates → activation of nuclear transcription factor PPAR-α receptor leading to *up-regulation of LPL* Ezetimibe -Inhibits dietary cholesterol enterocyte absorption by inhibiting NPC1L1 at brush border -AE's include --Hepatotoxicity (manifests as ↑LFT's) --Diarrhea

Ezetimibe OR Gemfibrozil

Failure of the Na+-K+ pump -Pt would most likely present w/*acute tubular necrosis* → d/t ischemia (pre-renal failure) → ischemia causes intra-renal vasoconstriction by 2 different mechanisms→ --1-Loss of tubule cell polarity → redistribution of Na+-K+ ATPase to luminal tubular cell surface → ↑ Na+ delivery to detail tubule → intra-renal vasoconstriction --2-Endothelial damage → ↑vasoconstrictors (endothelin) & ↓vasodilators (NO,PGI2) → intra-renal vasoconstriction Etiology includes: 1-Effects on circulating blood volume -(Hypovolemia) -(Systemic vasodilation) -(Cirrhosis) 2-*↓ Cardiac output* -*(CHF)* 3-NSAIDs

Failure of the Na+-K+ pump OR Increased intracellular H+ concentration

Reduviid bug -PBS shows Trypanosoma Cruzi → pts would have *Chagas* → presents w/: Acute 1-Chagoma → inflammation at the bite site 2-Roamana's sign → inflammation & *swelling around eyelids* (when organisms enter conjunctiva) Chronic 1-Dilated cardiomyopathy w/apical atrophy *chest pain that radiates to the left arm* 2-Cardiac arrhthmias 3-Megacolon 4-Megaesophagus 5-Achalasia 6-*SOB* 7-*Muscle & joint pains* 8-*fever* Flea bite -Pt would present w/*bubonic plague* which presents w/: 1-Sudden onset of fever, chills, weakness Followed by 2-Intense pain & swelling in Lymph nodes *buboes* → some may have eschars, pustules, or necrotic lesions Sand fly -Transmits Leishmania donovani *leishmaniasis* → presents -intermittent spiking fever w/ weakness (secondary to anemia) 2-Splenomegaly ± hepatomegaly 3-Pancytopenia 4-Kala-Azar (skin hyperpigmentation in fair-skinned pts) 5-Skin boil erythematous papule at sandfly bite

Flea OR Reduviid bug OR Sand fly

Mammillary bodies -Pt most likely presents w/*schizophrenia* schizophrenia can affect two pathways in the Brain: 1-Positive symptoms → *Mesolimbic* → Of which *mammillary bodies are an important part* 2-Negative symptoms → mesocortical → connects ventral tegmentum to the pre-frontal cortex Hippocampus -Associated w/memory → affected in Az

Hippocampus OR Mammillary bodies

Increased vascular permeability -Pt present w/*Gout* → *Neutrophils* are the most commonly associated w/damage inflammation of acute gout → they do damage by *increasing vascular permeability* Histamine release -Produced by *basophils & mast cells* [Not neutrophils] -Mainly causes *itching*

Histamine release OR Increased vascular permeability

Lack of choroidal pigment deposition in the macula -The enzyme shows that there would be a decreased in black pigment *eumelanin* with the mutation described in the stem → black pigment in general would be a protective color against UV and is responsible for the dark pigment deposits in the eye Increased photo protection of the prevalent melanin form -Black is the prevalent melanin form, so this is incorrect

Increased photo protection of the prevalent melanin form OR Lack of choroidal pigment deposition in the macula

Stabilization of mast cell membranes -H1 receptors are used to treat allergic rxns → they target histamine which is mainly stored in *mast cells & basophils* → the are antagonists for H1 receptors so they will *stabilize the cell membranes* preventing the release of histamine Inhibition of H2 receptors -H2 receptors are in the gastric parietal cells

Inhibition of H2 receptors OR Stabilization of mast cell membranes

-Strength of association (improvement) -Temporal relationship (time) -Dose-dependent gradient (no of sessions) These three factors would most support the relationship Consistency of other studies -Would not support the relationship as well as others (above)

Investigators conduct a prospective, community-based study to assess the effectiveness of an intervention to promote early language acquisition among children during the first 3 years of life. Delivered over 6-months across five day-care centers, the intervention consisted of providing monthly classes to a cohort of mothers, beginning when each child was 2 years old. Each child's language skills were assessed independently at the age of 2 & 3 years; scores were normalized for age. The results are summarized on the table. Which of the following set of characteristics of this study best supports the relationship between the intervention & child language scores? (Strength of association, dose-response gradient, consistency of other studies OR Strength of association, temporal relationship, dose-response gradient)

Key Mneumonic *MD*'s dont *LI*e *MD* → medial/Direct *LI* → lateral/indirect Lateral to the inferior epigastric artery & superior to the inguinal ligament -Pt presents w/an *indirect hernia* → which presents w/: 1-Seen in infants 2-Reducible 3-*Lie lateral to the inferior epigastric vessels* → indirect inguinal hernias enter the inguinal canal at the *deep inguinal ring* & pass *inferomedially to emerge via the superficial ring* → if large enough, it can extend into scrotom → usually d/t to *patent processus vaginalis* → increased risk for *hydrocele* Medial to the inferior epigastric vessels -Presents in Older men → *punch thru* the floor of the inguinal canal thru the external superficial inguinal ring* AKA the transversalis fascia *(posterior wall of the inguinal canal)* thru Hesselbach's triangle

Lateral to the inferior epigastric artery & superior to the inguinal ligament OR Medial to the inferior epigastric artery & superior to the inguinal ligament

Right Kidney -The thoracic duct runs from T12 to the root of the neck → the right kidney is located in this area (T12-L3) → both kidneys drain into the thoracic duct as only specific areas of the body drain into the right lymphatic duct Left Breast -The breast drains into the axillary LN's → which then drain into the right lymphatic duct which drains: 1-The right upper limb 2-Right side of the thorax 3-Right side of halves of the head and neck Left upper extremity, Right lung, heart -The thoracic duct is damaged near the level of the posterior mediastinum → organs that are located at this level would most likely be unaffected *[the kidneys lie below this level and their drainage would most likely be affected]*

Left Breast OR Right kidney OR Heart OR Left upper extremity OR Right lung

Left parietal lobe -Pts vision loss *right lower quadrantanopia* is on the right side →this specific lesion is caused by lesion in the *parietal lobe to the MCA* Left temporal lobe -Pt would have *right upper quadrantanopia* caused by a lesion in the *temporal lobe to MCA*

Left parietal lobe OR Left temporal lobe

Libido → Decreased Nocturnal erections → normal All pts with physiologic ED experience normal nocturnal erections → b/c they are *spontaneous*

Libido (Increased/decreased/normal) OR Nocturnal erections (increased/decreased/normal)

Main point is: -Sensitivity → used for screening -Specificity → used to confirm *Low sensitivity* -Used to look for false negatives (rule out disease) -A test that has low sensitivity would have many false negative (cannot rule out disease)→ this would meant the doctor would miss a case Low specificity -Used to check for false positives (rule in disease) -Low specificity would mean many people would be false positive

Low sensitivity OR Low specificity

Ubiquitin ligase -Attached to a lysine -Ubiquitination by E3 ligase mediates many activates including: --Cell trafficking --DNA repair --Signaling --They can target proteins to proteasomes for destruction -Monoubiqutination can regulate cytosolic protein localization → the E3 ligase ubiquitylates p53 either for degradation or for nuclear export (monoubiquitlyation) Lysosomal protease -This is a different system for cell waste disposal → it is associated w/*mannose-6-phosphate* & lysosomal storage diseases

Lysosomal protease OR Ubiquitin ligase

MDD -Even tho not all symptoms of MDD are there, this still fits better then sleep apnea -Pt does have anhedonia & poor concentration tho Sleep apnea -Usually caused by obstructive or central sleep apnea Obstructive 1-Obesity 2-Anatomical abnormalities 3-FHx 4-Sedatives 5-Hypothyroid 6-Smoking Central 1-Stroke 2-Arnold-chiari 3-Opioids 4-CHF 5-Any condition affecting brain stem

MDD OR Sleep apnea

Spironolactone -Ascites tmt approach includes: 1-Sodium restriction 2-Diuretics --*Furosemide* --*Spironolactone* --*Beta blockers* (to lower portal pressure in cirrhotic pts) Metolazone -This is a thiazide diuretic → not indicated in tmt for massive ascites

Metolazone OR Spironolactone

Mixed venous oxygen tension -this is normally 40mmHg → It can be either decreased or increased w/ associated diseases Decreased *increased O2 consumption* 1-Fever 2-Exercise 3-Shivering 4-Malignant hyperthermia 5-Thyroid storm Decreased O2 delivery 1-Hypoxia 2-*Low CO - Pt has MI* 3-high hemoglobin Increased (decreased O2 consumption) 1-Hypothermia 2-Left-to-right shunt 3-High cardiac out put Impaired tissue uptake 1-Cyanide tox 2-Sepsis 3-Wedged PA catheter Pulmonary vascular resistance -can be increased or decreased

Mixed venous oxygen tension OR Pulmonary vascular resistance

X-chromosome linked isoenzymes

Monoclonality of neoplastic cells in endometrial cancer can be best determined by analysis of which of the following? (Laminin receptor density OR X-chromosome linked isoenzymes)

Negative nitrogen balance -The pt has been Breaking down muscle, so he will be in negative nitrogen balance

Negative nitrogen balance OR Positive nitrogen balance

Interstitial inflammation -Pt presents w/ hydronephrosis → RF's are 1-*Recurrent UTI's - interstitial inflammation* 2-Pregnancy 3-Enlarged prostate 4-Tumor 5-Scarring of tissue 6-Blood clot 7-Congenital blockage 8-Kidney stone Nephroblastomatosis -Presence of multiple embryonic rests of tissue w/in kidney → may give rise to wilm's tumor

Nephroblastomatosis OR Interstitial inflammation

Phase variation -A method for bacteria to deal w/rapidly varying environments w/out requiring random mutations → involves the variation of protein expression, *frequently in an on-off fashion* w/in diff parts of a bacterial population Transposon mutagenesis -Segment of DNA (transposon) that can "jump" *excision & re-integration* from one location to another → can transfer genes from plasmid to chromosome & vice versa -*vanA gene from vancomycin-resistant enterococcus to S.aureus*

Phase variation OR Transposon mutagenesis

Essential thrombocythemia Criteria 1-*Sustained Plts count >450K* 2-*BM biopsy showing proliferation of mainly megakaryocytic lineage* -Characterized by over production of plts -Most people are asymptomatic -Bleeding (d/t dysfunctional plts -Blood clots (DVT, PE) -Headache, nausea, vomiting, abd pain -Visual disturbances -Dizziness, fainting -*Numbness in extremities* -splenomegaly Labs -↓RBC count -↑WBC count -Maegakaryocytic hyperplasia Reactive thrombocytosis -D/t to other causes → pt presents w/*no sig Hx of chronic diseases* -Pt would most likely have a Hx of *myeloproliferative Dx* -Chronic inflammation -Malignancy Polycythemia vera -Associated w/ *Budd chiari* → presents w/: 1-Aquagenic pruritus (itching following exposure to warm water) 2-Erythromelalgia (episodic blockage of blood vessels followed by *pain in extremities w/ erythema & cyanosis* 3-Symptomatic gout 4-Splenomegaly 5-Blurry vision/headache 6-Facial plethora Labs 1-*Thrombocytosis* 2-Leukocytosis 3-↓ EPO levels

Polycythemia vera OR Essential thrombocythemia OR Reactive thrombocytosis

Splitting lecithin to phosphorylcholine & diglyceride -C.perfringens uses tow toxins --*Alpha toxin* AKA *Phospholipase* or *lecithinase* → degrades phospholipids *phosphatidylcholine*, tissue & cell membranes --*Heat labile enterotoxin* → causes food poisoning by inducing membrane instability *pore formation*& *binding to claudins* Preventing release of inhibitory neurotransmitters -This describes tetanus toxin

Preventing release of inhibitory neurotransmitters OR Splitting lecithin to phosphorylcholine & diglyceride

Pyruvate kinase -Pt presents w/*Pyruvate kinase deficiency* → which presents w/: 1-Characterized by extravascular normocytic anemia *seen in pt as ↑ indirect bilirubin* → pts presents w/ *unexpectedly mild symptoms* 1-*↑ Reticulocytes* Reticulocytosis - pt has *22%* 2-*↑ 2,3 BPG* → which decreases the affinity of Hb for O2 → ↑ O2 unloading into tissues 3-PBS may show Burr cells Pathology -Pt has a AR mutation of PKLR gene → causes a *↓ ATP level* in RBC's → which then Decreases the Na+/K+ ATPase activity → leading to *Osmotic fragility, swelling, & hemolysis* Glyceraldehyde-3-phosphate dehydrogenase -Catalyses the 6th step in glycolysis -Associated w/ neurodegenerative diseases

Pyruvate kinase OR Glyceraldehyde-3-phosphate dehydrogenase

Secreted from cells -Pathology → deficiency in the enzyme *N-acetylglutamate-1-phosphotransferase* → which tags (phosphorylates) enzymes w/mannose-6-phosphate residues to target them for lysosomes (lysosomes need these enzymes to function properly) → however, these pts lack this enzyme so instead the dysfunctional enzymes are *secreted out of the cell* → lysosomes cannot function w/out these enzymes so the contents found in lysosomes (lipids, GAGs, oligosaccharides) build up in cells leading to *I-cells or Inclusion cells* -An example of this is Hurlers disease which present w/" 1-Corneal clouding 2-Dwarfism 3-Hepatosplenomegaly 4-Failure to thrive & developmental delays

Retained in rough ER OR Secreted from cells

Retinal cells -Pt presents with a *Sporadic form of retinoblastoma* → which presents w/: 1-Only have one allele of RB gene affected 2-Develops later in life 3-Unilateral (vs bilateral in familial form) 4-they *do not* have the same increased risk of developing future cancers Somatic cell of the child -would present much later in life (adults) do to exposure to something or some other factor

Retinal cells OR Somatic cells of the child

SMA -Pt presents with a duodenal obstruction → ligament of trietz connects to the 3rd & 4th parts of duodenum → its blood supply is the SMA

SMA OR Celiac

Serum K+ conc -Pt w/ DKA have: 1-Elevated glucose 2-Anion gap metabolic acidosis 3-↓total body K+ stores 4-*↔/↑ serum K+ conc* 5-↔ total-body Na+ 6-↓Na+ Pathophysio -When K+ moves from the intracellular fluid the the ECT → water follows → Na+ gets diluted out bu the increased water so pts will have: -*Normal total-body Na+ (but decreased serum Na+)* -*↓serum K+* Chloride levels -not affected in DKA

Serum Cl conc OR Serum K+ conc

16% -296 is 1 std deviation (68%) away from mean -100%-68% = 32% -32%/2 = 16% (32% must divide by 2 b/c 16% of the population would be found above 296 and 16% would be below 296

Serum cholesterol conc's are measured as part of a community study. The means & std are given for women by age group. Assuming serum cholesterol conc's follow a normal (gaussian) distribution, which of the following is the probability that a woman between the ages of 50-54 years has a serum cholesterol conc greater than 296? (1% OR 16%)

Shrunken eosinophilic (red) neurons -red neurons are found in the *first 12-24 hrs after an ischemic injury (stroke)*

Shrunken eosinophilic (red) neurons OR No abnormalities

Surfactant -*Type II pneumocytes* are *clustered cuboidal cells* who produce two things: 1-Contain secretory cytoplasmic inclusions called *lamellar bodies* that secrete *surfactant* 2-also act as *stem cells of alveoli* → replace damage type I & II pneumocytes Type I pneumocytes -Form 90-95% surface area but only 33% cell number -They form the tight junctions and prevent large molecules from passing Club cells are the stem cells of the lower airway including (primary, terminal, & respiratory bronchioles) Type I collagen -not used for repair in alveoli

Surfactant OR Type I collagen

Synthesis of factor X -The question asks *what coagulation process is affected* not what is deficient → This pt has hemophilia *deficiency in factor VIII* → factor VIII causes Factor X formation (Factor IXa → *Factor X*) so this process will be affected

Synthesis of factor VIII OR Synthesis of factor X

Phase I -Enroll a *small number* of *Healthy subjects* or those w/ disease of interest -Tests safety, *Pharmocokinetics, & toxicity* -Answers *Is drug safe to use* Phase II -Involve a *large no. pts *w/ disease to be treated* (usually 1K-3K) who are *randomly assigned* to 1/2 groups: --The tmt being investigated group --The best tmt currently available (or placebo) Phase III -Compare TMT being investigated to the current (gold standard tmt) -Asks "Is the drug as good or better?" -Uses *randomized* & *double-blind* & *prospective* parameters Pre-clinical studies -these are *non-clinical studies*

Ten healthy human subjects are given a new oral drug & monitored for drug effect & toxicity. Blood samples are periodically taken & analyzed to define the human pharmacokinetics of the drug for the first time. Which of the following best describes this trial? (Pre-clinical OR Phase 1 OR Phase 2 OR Phase 3)

Intestinal mucosa Lumen of the duodenum -No absorption, only mixing & bile

The breakdown of dipeptides & tripeptides to free Amino acids takes place primarily in which of the following areas of the GI tract? (Intestinal mucosa OR Lumen of the duodenum)

Broken ribs

What physical finding is associated with sub-Q crepitus?

Antiplatelet antibodies -Pt presents w/*HIT (heparin induced thrombocytopenia)* → which is an immune mediated rxn from *auto-antibodies to platelet factor 4 (PF4):heparin complex* → the auto-antibodies react w/the plts causing peripheral activation (thrombosis & thrombocytopenia)

Antiplatelet antibodies OR Heparin-induced hemodilution

Ductal ion reabsorption is more efficient at low flow rates -Substance X produces more saliva *which causes an increased flow rate* → At higher flow rates less Na+ chloride can be absorbed Citric acid decreases water absorption by the salivary ducts -The ion absorption in the salivary glands is based on flow rates

Citric acid decreases water absorption by the salivary ducts OR Ductal ion reabsorption is more efficient at low flow rates

Serum K+ conc -Pt has DKA which usually presents with ↑K+ → *insulin is a potent stimulator for hypokalemia b/c it will cause more K+ to transport into cells -> causing decreased serum K+* Urinary K+ excretion -The main effect is that insulin causes K+ transport into cells

Serum K+ conc OR Urinary K+ conc

MDMA -Presentation includes: Hallucinogenic stimulant that presents w/: 1-Euphoria 2-Disinhibition, Hyperactivity 3-Distorted sensory & time 4-Teeth clenching 5-*Confusion* Life threatening 1-*HTN* 2-*Tachycardia* 3-Hyperthermia 4-Hyponatremia 5-Serotonin syndrome LSD 1-Perceptual distortion (Visual, auditory) 2-Depersonalization 3-Anxiety 4-Paranoia 5-Psychosis 6-Possible flashbacks

A 20M, presents to the ED by his friend 8 hrs after the acute onset of confusion following an all-night dance party. Pulse is 140/min, BP is 180/110. PE shows pale, cold extremities. There is no diaphoresis. An ECG shows sinus tachycardia. This pt most likely ingested which of the following substances? (LSD OR MDMA)

Black fly -Pt present w/*Onchocerciasis* AKA *river blindness* → which present w/: 1-99% of cases from sub-Saharan Africa 2-Transmitted be female *black fly* 3-*Subcutaneous nodules* over bony prominences 4-Blindness 5-Pruritic skin rash w/subsequent elastic fiber loss & skin atrophy 6-Epilepsy 7-*Microfilariae* on microscopy Ixodes Tick -Lyme disease & babesiosis Culex mosquito -Arbovirus, West Nile, malaria

A 10B, who was adopted from the Congo 2 wks ago presents for an initial exam. He appears slim, has thin extremities, & is in no distress. Temp is 99.1F, BP is 118/68, RR is 20/min. The lungs are clear to auscultation, & heart sounds are normal. The abd is soft & nontender, & there is no hepatosplenomegaly. There are four 0.5-mm, firm, nontender nodules: two over the right iliac crest, one on the left thigh, & one on the left knee. Exam of a skin snip shows microfilariae. Which of the following is the most likely vector of this pt's infection? (Black fly OR Culex mosquito OR Ixodes tick)

Palpable RV lift -The values show that there is blood mixing between the RV & LV → this is causing the pressure in the RV to increase to match the same pressure in the LV → this would cause a *palpable RV lift* Diastolic murmur -Would only occur w/ 1-Aortic regurg 2-Mitral/tricuspid stenosis -Neither would be seen in this pt

A 10F, w/ a lifelong Hx of intermittent dyspnea presents for a follow-up. During an episode of dyspnea, she turns blue. The episode resolves after she squats. A systolic murmur was heard at birth. Today, a grade 4/6 systolic murmur is heard at the pulmonic area, radiating widely to the back & left side. Cardiac catheterization shows: -Aorta------82% -VC--------70% -Pul artery--70% -RA--------70% -LA--------95% -RV--------70% -LV--------82% Which of the following is most likely in this pt? (Diastolic murmur OR Palpable RV lift)

Inhalant abuse -Signs include: 1-*Bilateral injected conjunctivae* 2-Runny nose 3-Unusual smelling breath 4-*loss of appetite* 5-Anxiety 6-*Sores around mouth* Impetigo -Usually presents in kids aged 2-5 [pt is 12] -Would present as bullous impetigo on non-bullous impetigo (single lesion) RF include: 1-Poverty 2-Crowding 3-Poor hygiene 5-Underlying scabies infection

A 12B, presents b/c of a persistent rash around his nose & mouth for 4 months. He has also had a decreased appetite & an unintentional wt loss (10-lbs) during the past 3 months. His mother states, "The rash developed shortly after he started at his new school. I wonder if he keeps getting into something. I've tried hydrocortisone cream, but it didn't work." She adds, "And now his grades are failing, & he's not eating as much as he used to. I hope he's not depressed b/c of the rash." The rash began as mild redness & then became dry & started to flake. The pt says there is no pain or discomfort w/the rash. PE shows injection of both conjunctivae, an eczematous eruption extending inferiorly from the nasolabial fold to the upper lip, & erythematous nasal mucosa that is friable w/gold stippling. When asked, he states that his mood is fine. Which of the following is the most likely cause of this pt's condition? (Impetigo OR Inhalant abuse)

Testosterone -Cause of acne vulgaris

A 15B, presents for a well-child exam. During the interview, he asks if he will develop severe acne like his 18 brother did at his age. He says "It was awful. My parents took him to a doc, but nothing helped. Then one day it seemed to go away on it's own." PE shows mild, scattered open & closed comedones. If this pt develops severe acne vulgaris that resolves spontaneously over the next 3 years, a rapid increase in the secretion of which of the following substances will have been the most likely cause of the acne? (Adrostanediol OR Testosterone)

ER -The folding of proteins occurs in the ER → if the protein is folded correctly it leaves the ER, *if it is not folded correctly it cannot leave the ER and will accumulate in the ER*

A 15F, w/CF has a mutation in the CFTR gene, which results in deletion of p508. This mutation does not prevent synthesis of CFTR but does prevent it from folding properly. The improperly folded CFTR protein will accumulate in which of the following cellular compartments? (Endoplasmic reticulum OR Peroxisome)

Tail of pancreas -Celiac trunk → Splenic artery → pancreatic branches to pancreas Left kidney -Abd aorta → Renal artery → left kidney

A 16F, presents to the ED 30 mins after being injured in a MVC. BP is 70/40. PE shows cold, clammy skin. A CXR shows fracture of the 9th rib on the left. An exploratory operation shows a rupture of the spleen. Ligation of the blood supply to the spleen is most likely to damage which of the following additional structures? (Left kidney OR Tail of pancreas)

-Pt will present w/ either: 1-Non-anion gap metabolic acidosis (similar to chronic diarrhea) 2- Hypochloremic metabolic alkalosis (only if to is severely ill) Pt may present w/non-anion gap metabolic acidosis, so: *↓ K+ & decreases HCO3* → laxatives or diarrhea will cause hypokalemia d/t loss of K+ in stool & loss of HCO3- -*Increased serum CL* -> to make up for decreased HCO3-

A 16F, w/Bulimia nervosa presents w/a 4-month Hx of non-bloody diarrhea. Her mother is concerned that she is abusing laxatives to maintain a low body weight. Which of the following sets serum electrolyte conc is most likely in this pt? K+/ Cl-/ HCO3

δ-Aminolevulinate -1st compound in the porphyrin synthesis pathway leading to *heme synthesis* -Produced by *BM* EPO -Produced by *kidney* → stimulates BM to produce RBC's

A 17F, has sig blood loss after being injured in a MVC. Blood loss stimulates BM to synthesize which of the following hormones? (δ-Aminolevulinate OR EPO)

Polyneuropathy -May present w/: 1-Numbness, *weakness*, or burning pain 2-presents on the same areas on both sides of body 3-Usually presents in distal → proximal pattern Syringomyelia -Most common in the 3rd & 4th decades of life [pt is 19] → presents w/: 1-Firs symptom → Loss of pain & temp in cape like distribution (back & arms) 2-Flaccid paralysis 3-Decreased deep tendon reflexes 4-Fasciculations

A 19M, has had weakness of the muscles of her neck & extremities for the past week. Bladder & bowel function is normal. Position sense is impaired. Which of the following is the most likely Dx? (Polyneuropathy OR Syringomyelia)

Iris -Coloboma iridis is a cleft in the iris caused by a failure of the choroid fissure to close in wk 7 of development → *clefts w/in the iris do not affect vision* [clefts outside the iris can affect vision]

A 2-wks-old F, presents for a well-child exam. PE shows an asymmetric left pupil. Ophthalmologic exam shows a coloboma of the left eye. Incomplete closure of the embryonic fissure that is limited to which of the following structures of the left eye is most likely to spare this pt's vision? (Iris OR Optic nerve)

Phase 3 -Consists of a randomized, prospective, double-blind study on volunteers Phase 4 -Post-marketing strategies *after-approval* -Used to detect long-term AE's associated w/widespread use & can result in a drug being w/drawn from market

A 21F, w/asthma presents b/c her meds is not relieving her symptoms. The physician tells the pt about a clinical trial of a new drug for asthma. This trial is large, randomized, prospective, & double-blind study on volunteers w/asthma. This trial is most likely occurring at which of the following phases of drug development? (Phase 3 OR Phase 4)

Leishmania -Usually presents w/: 1-People that travel to Middle East 2-Intermittent/spiking fever (w/weakness secondary to anemia) 3-*Splenomegaly ± hepatomegaly* 4-Pancytopenia (anemia, leukopenia, thrombocytopenia → pts can die of hemorrhage) 5-Kala-azar (black fever) → skin hyperpigmentation (fair skinned pts) 6-Papule at bite site → which expands & ulcerates (boils) 7-Wt loss 8-Abd pain Schistosomiasis -Usually associated w/ bladder -presents w/ localized erythema, pruritic maculopapular rash -Acute onset fever, myalgias/malaise, abd pain, hepatosplenomegaly, headache, urticaria, cough, diarrhea (potentially bloody), lymphadenopathy

A 21M, presents b/c of a 1-month Hx of fever & abd pain; he also has had a 15-lbs wt loss during this period. He is a consultant to a non-governmental organization that support organic farming. He returned from a 2-months trip to the Middle East 3 wks ago. Temp is 102.2F. PE shows generalized lymphadenopathy & hepatosplenomegaly. labs show pancytopenia. The most likely cause of these findings is an organism belonging to which of the following genera? (Leishmania OR Schistosoma)

Pineal gland -Vertical gaze palsies are most commonly caused by a lesion in midbrain → the pineal gland is in close proximity to the midbrain PPRF -Would present as horizontal gaze palsy

A 22F, present b/c of nausea & vomiting for 1 wk. She has a 6-month Hx of headaches. She works as a data entry tech & has recently found it difficult to focus on the text. She also has had trouble looking up from her desk at the clock on the wall w/out moving her head. Neuro exam shows marked vertical gaze palsy & impaired accommodation. Horizontal gaze is normal. An MRI of the brain is most likely to show a tumor at which of the following locations? (Pineal gland OR PPRF)

All increased

A 22M, presents to the ED 30mins after a friend found him unconscious in on the floor. A drug OD is suspected. Pulse is 120/min, RR is 4/min w/apparent low tidal volumes, & BP is 120/100. PE shows mild cyanosis. He is intubated & mechanically ventilated w/Positive pressure ventilation (rate=12/min, Vt=7mL) using 10cm H2O PEEP. Which of the following sets of findings best describes the effects of the mechanical ventilation w/PEEP on this pt's alveolar (P-A) & intrapleural pressures (Pip)? (Peak inspiratory (P-A) (+/-) End tidal (P-A) (+/-) Peak inspiratory (Pip) (+/-) End-Tidal (Pip) (+/-)

*↓ PTH* → b/c thyroidectomy probably injured PTH gland -Decreased Ca+ b/c PTH causes a release of Ca+ from bones [pt presents with hypocalcemia] *Decreased Phosphate* → PTH increases the absorption of phosphate from the intestines -> if there is *decreased PTH, then that the phosphate levels will increase* b/c it is not being absorbed *↔/↑ 25-Vit D Levels* -> PTH d/t decreased activity pf *1-alpha-hydroxylase enzyme* (which converts 25-Vit D to active form) -> if there is decreased PTH then there will be *regular or increased levels of 25-vit. D*

A 24F, pt who has graves disease undergoes a partial thyroidectomy. Several months later, she develops muscle cramps, tetany, & hypocalcemia. Which serum lab findings do you expect? (PTH, Phosphate, 25-hydroxyvitamin D)

Increased Lymph flow -Histamine *directly stimulates lymphatic vessel contraction* which would *↑ lymph flow* Decrease in hydrostatic interstitial pressure -Histamine *↑ the permeability of capillaries* → which allows more blood to flow in leading to an *↑ in interstitial hydrostatic pressure*

A 24M, receives an injection of histamine in the brachial artery. Which of the following changes is most likely to occur in his forearm in response to the histamine? (Decreased interstitial hydrostatic pressure OR Increased Lymph flow)

Lateral pterygoid -Only muscles that assists in *depressing the mandible* (Relaxation would reduce the TMJ) Levator palatini -During swallowing it contracts, elevating the soft palate to help prevent food from entering the nasopharynx

A 29M presents to the ED b/c of a 1-hr Hx of bilateral jaw pain that began immediately after he tried to bite into a thick double cheeseburger. PE shows excessive drooling & an inability to evaluate the mandible. An XR of the skull shows bilateral anterior dislocation of the TMJ. Reduction of the TMJ is recommended. Relaxation of which of the following muscles is most likely to facilitate this procedure? (Lateral pterygoid OR Levator veli palatini)

Pulmonary capillary leakage -Pt presents w/ Shock so would have pulm capillary leakage Hypoventilation -This pt would have an increased PCO2 [however pt has decreased PCO2]

A 25F, present to the ED by her husband 30 mins after losing consciousness at home. She had been home from work for the past 5-days b/c of fever. She has a Hx of recurrent Upper UTI's. Temp is 103F, pulse is 135/min, BP is 82/48. Diffuse crackles are heard over both lung fields. ABG analysis on room air shows: -pH-------7.18 -PCO2----32 -PO2-----64 A blood culture shows Gm(-) rods. A CXR shows diffuse bilateral infiltrates. Which of the following is the most likely cause of this pt's symptoms? (Hypoventilation OR Pulmonary capillary leakage)

Germ cells -Germ cell tumors are the most common cause of testicular cancer → seminomas are the most common type Non-germ cell tumors -Made up by leydig or Sertoli cells

A 25M, has an orchiectomy for a recently detected testicular neoplasm. A biopsy is shown. Which of the following are the most likely cells of origin of this neoplasm? (Fibroblasts OR Germ cells)

1 in 4 will have 25% β-globin function & may require occasional transfusions -Use punnet square, works out to 1 in 4 will be affected -Father → A A(not functional) -Mom → A a(affected) -Heme holds 4 so all expect one would be affected

A 26M & his 25F, present for genetic counseling prior tp conception. both pts were previously found to have a microcytic anemia & an increased fraction of Hemoglobin A2. Genetic analysis shows that the man has a Hz null mutation of the β-globin gene, & the woman has a Hz mutation known to cause a 50% decrease in β-globin gene function of one allele. Which of the following best represents the β-globin function possibilities for this couple's offspring? (1 in 4 will have 25% β-globin function & may require occasional transfusions OR 1 in 2 will have 50% β-globin function w/out need for transfusions)

Angiotensin -Pt presents w/*Pseudotumor cerebri (idiopathic intracranial HTN)* → Angiotensin is a potent vasoconstrictor which would be elevated in a pt with HTN EPO -Would not be a direct cause of increased HTN

A 27F, has headaches & blurred vision. She does not drink, smoke, or use drugs. Temp is 98.6F, BP is 196/142. PE shows papilledema & bilateral CVA bruits. Which of the following serum conc is most likely to be increased? (Angiotensin OR EPO)

Injections of gonadotropins -Pt needs both 1-↑ testosterone & 2-↑ FSH (to produce mature sperm) Oral clomiphene citrate -Used to induce ovulation in women

A 27M, presents b/c he & his wife have not been able to conceive. He has poor libido & is unable to maintain an erection. He has been receiving thyroid hormone & corticosteroid replacement therapy since surgical removal of a pituitary adenoma 2 years ago. His serum test level is .05nmol/L (N 10-35). Semen analysis shows azoospermia. Which of the following is the most appropriate TMT to restore the pt's fertility? (oral clomiophene citrate OR Injections of gonadotropins)

Peptide transporter (TAP) -BLS is associated with MHC I deficiencies and TAP1, TAP2, TAPBP deficiencies FAS ligand -Associated w/ apoptosis → and diseases: 1-Autoimmune lymphoproliferative syndrome 2-Glioblastoma 3-Myelodysplastic syndromes

A 2B, presents b/c of chronic bacterial respiratory infections since birth. He is currently asymptomatic. PE shows no abnormalities. T-& B-lymphocyte counts & serum antibody conc are w/in reference ranges. NK cell count & function are normal. Analysis of cellular expression of HLA by flow cytometry shows absence of class I MHC expressing cells. A Dx of bare lymphocyte syndrome, Type I, is made. This pt most likely has mutations in the genes encoding which of the following? (Fas ligand OR Peptide transporter (TAP))

Na+ -Blocks sodium channels -Causes paraesthesia of the lips & tongue, mouth *tingling* -followed be paresthesias in the extremities, hypersalivation, sweating, bradycardia, headache, weakness

A 30M, develops tingling around the lips & mouth after consuming a small portion of fugu (puffer fish) in a Japanese restaurant. The liver of this fish contains tetrodotoxin, a substance that causes cardiac arrest when consumed in high doses. This pt's symptoms are most likely d/t the blocking action of tetrodotoxin on which of the following ion channels? (Na+ OR Ca+)

Formation of hypnozoites -Pt has *malaria* → one of the features is that it forms hypnozoites and has the PBS shown Chloroquine resistance -Can happen but it is *not a feature*

A 30M, who is a migrant farm worker presents to the ED b/c of a 1-wk Hx of fever, chills, & severe headache. He immigrated to the midwestern USA from Honduras 1 year ago. He is alert. Temp is 104F, pulse is 101/min, RR are 20/min, BP is 105/62. The lungs are clear to auscultation. Cardiac exam is normal. The abd is soft w/active bowel sounds. Neuro exam shows a supple neck; there is nu nuchal rigidity. He is oriented to person, place, & time. Labs show: -Hb---------------14 -Hct---------------42% -Leuko's----------4,6K -Neutro's----------57% -Lymph's-----------33% -Monocytes-------10% Urine -Color------clear yellow -Blood-------------1+ -Urobilinogen-----trace A pictomicrograph of a PBS is shown. This pt's overall condition is most likely caused by an infectious agent w/which of the following features? (Formation of hypnozoites OR Chloroquine resistance)

Hypoglycemia -Frequently encountered complication of facilparum malaria Adrenal insufficiency -Causes include: Adrenal atrophy or autoimmune, Granulomatous infection (TB). Infarction of adrenal gland, HIV, Waterhouse-Frederichsen, DIC)

A 31F, primigravid at 32-wks presents b/c of a 3-day Hx of fever & chills. She recently immigrated to the USA from Ghana. She appears drowsy. Temp is 103F, Pulse is 136/min, RR is 24/min, BP is 95/62. PE shows a uterus consistent in size w/32 wks. A PBS is shown. This pt is at greatest risk for which of the following complications? (Adrenal insufficiency OR Hypoglycemia)

NRTI -pt presents w/*Lactic acidosis (seen as increased liver values in this pt)*→ major AE of nucleosides → other AE include: 1-BM suppression 2-Peripheral neuropathy 3-Lactic acidosis 4-Anemia & Pancreatitis (Zidovudine) Integrase inhibitor -Kidney tox ↑creatinine kinase *pt would have decreased kidney function*

A 31F, w/HIV presents to the ED d/t a 6 hrs Hx of chest & abd pain & SOB w/exertion. She is currently receiving antiretroviral therapy. Pulse is 100/min, RR is 20/min, BP is 104/62. PE shows no abnormalities. Labs show Increased liver values. A drug from which of the following classes is the most likely cause? (Integrase inhibitor OR NRTI)

Buccinator -*Parotid gland pierces the buccinator* → mass can form within the salivary gland and parotid gland and pass through Masseter -Used during closing of the jaws but pierced by anything

A 32F, presents b/c of pain & swelling of her right cheek for 24 hrs. PE shows a mildly swollen & tender area overlying the parotid gland. Sialolithiasis is suspected. The calculus is most likely present in a duct that passes thru which of the following muscles to enter the oral cavity? (Buccinator OR Masseter)

Precapillary resistance -This describes the RAAS system → when HTN is sensed the RAAS system is inhibited which causes vasodilation lead to decrease pre-capillary resistance Lymphatic flow -Would have more of a contribution if albumin was greatly increased but everything in this pt is more or less normal

A 32M, has a diastolic BP that consistently ranges between 100-110. He is otherwise healthy & is not taking any meds. Serum conc of K+, Glucose, creatinine, Cholesterol, & uric acid are w/in the reference range. Urine contains only trace amounts of protein & no albumin. He is unlikely to develop peripheral tissue edema b/c of regulatory adjustments in which of the following? (Lymphatic flow OR Pre-capillary resistance)

Flexion at the DIP joint -Flexor digitorum profundus Flexion at metacarpophalangeal joint -Flexor digitorum superficialis Flexion of the PIP joint -Flexor digitorum superficialis

A 32M, presents to the ED after sustaining a deep laceration that may have injured the nerve supply to the flexor digitorum profundus muscle of the index finger. Which of the following mvmts can be used to specifically test for the function of this muscle? (Flexion at the DIP joint OR Flexion at the PIP joint OR Flexion at the metacarpophalangeal joint)

Normoblasts -An immature RBC containing Hb & a pyknotic nucleus → normally present in bone marrow but can appear in anemias Metamyelocytes -Would be seen in white blood cell disorders (like AML, CML) → they are *immature blast cells*

A 32M, who lives at sea level travels to a mountainous region for a 2-month vacation. On arrival at the mountains, he develops SOB w/exertion. At the end of his first 2 weeks of vacation, his exercise tolerance has increased. If this pt's bone marrow were examined at this time, it would most likely show increased numbers of which of the following cells? (Normoblasts OR Metamyelocytes)

Calcitriol (↓) → the active form of Ca+ would be decreased PTH (↑) → d/t low calcium levels → this has three effects in differing organs 1-Bone → increases dissolution, releasing Ca+ & phosphorus (↑Ca, ↑ phosphorus) 2-Kidney → Increase Ca+ reabsorption & phosphorus excretion (↑Ca+, ↓Phosphorus) 3-Enhanced GI absorption of Ca+ Inorganic phosphorus (↓) → phosphorus gets absorbed in GI so it would be increased

A 33F, presents for a routine follow-up exam. She has celiac sprue & fat malabsorption. PE shows asthenia. Labs show a serum Ca+ of 7.8. Which of the following additional sets of serum findings is most likely in this pt? (Inorganic phosphorus (↑/↓), PTH (↑/↓), Calcitriol (↑/↓)

Tuberculous osteomyelitis -Pt presents w/*Pott disease* → Pt has RF *infliximab use* → presents w/: 1-Usually affects back 2-Would present w/abscess (caseous necrosis, *granuloma formation* Sarcoidosis -Pt would present w/ *Granulomas* (non-caseating) & *common in females 20-60* 1-Restrictive type lung disease (cough, dyspnea) 2-Chest pain 3-Eye lesions (anterior uveitis) 4-Skin lesions (erythema nodosum) 5-Fever 6-Anorexia 7-Arthralgias 8-Parotid gland swelling

A 34F, w/ long Hx of RA refractory to tmt w/corticosteroids & MTX presents d/t a 2-wks Hx of increasingly severe low back pain, decreased appetite, & malaise. She has never had low back pain in the past. She has not had fever, LE weakness, constipation, bladder or bowel incontinence, wt loss, or sensory changes. 6-wks ago, she began tmt w/infliximab b/c of bilateral wrist, hand, & knee pain. Temp is 98,6F. PE shows mild tenderness over the L1-L2 vertebrae. Labs show: -Hb------11.3 -Hct------32% -Leuko's--7,8K -Plts------290K An MRI of the spine shows osteomyelitis of L1-L2 w/destruction of the intervertebral disc space & a 1.2-cm adjacent abscess. The abscess is debrided, & samples of the abscess & bone tissue are sent for analysis. A gram stain is neg. Pathologic exam of the bone specimen shows acute & chronic inflammation w/granuloma formation. Which of the following is the most likely cause of these findings? (Sarcoidosis OR Tuberculous ostemyelitis)

Infiltration of lymphocytes, plasma cells, & M∅ -These are the cells you would see in a setting of chronic inflammation (seen in Hep C) → *lymphocytes or lymphocyte aggregates are key* Palisading lymphocytes & giant cells -Seen in cancer or RA

A 34F, w/a 5-year Hx of Hep C presents b/c of progressive fatigue during the past month. Vitals are normal. Her liver is not palpable. Serum studies show: -Albumin------3 -Total Bili-----1.8 -ALP---------68 -AST---------33 -ALT---------38 Her serum α-fetoprotein conc is w/in reference range. A liver biopsy specimen is most likely to show which of the following? (Infiltration of lymphocytes, plasma cells, & M∅ OR Palisading lymphocytes & giant cells)

D -Pain and temp travels via the ALS → b/c the ALS crosses over and and will ascend at D

A 34M, presents to the ED for the next 30 mins after being involved in a MVC. Sensation to pain is decreased over the left lower extremity. Which of the following labeled regions is most likely damaged? (D OR C)

Palms -B/c he is black but his palms are not black so less protection

A 35, African America, presents for a routine exam. He recently read a pamphlet at a health fair on the importance of screening for skin cancer. He enjoys sailing & usually goes on on his boat every weekend when the weather is nice. He doesn't not use sunscreen, but he states that he doesn't "burn". PE shows no abnormalities. This pt is at increased risk for melanoma at which of the following locations? (Palms OR Scalp)

Parasympathomimetic stimulation -Stimulation of PSNS -During micturition → causes relaxation of bladder *indication* -In lungs (M3 - bronchoconstriction) → *Contraindication*

A 35F, has difficulty urinating 2 days post-partum. She has a long Hx of asthma. Which of the following mechanisms is both an indication & a contraindication for bethanechol in this pt? (ACh-ase action OR Parasympathomimetic stimulation)

Foramen cecum -Pt presents with Thyroglossal Duct cyst → the *foramen cecum indicates the former site of the thyroglossal duct* -D/t failure of obliteration of the thyroglossal duct Frenulum of tongue -Thin membrane on undersurface of the tongue → allows for mvmt of the tongue → if short may cause inhibition with speaking (tongue tied)

A 35F, presents b/c of a 1 year Hx of fatigue & lethargy; She also has had a 20-lbs wt gain during this period. She says that she has to wear a coat in her office b/c she is always cold. PE shows coarse skin. Exam of the neck shows no palpable thyroid gland tissue. Neuro exam shows a delayed relaxation phase of the calcanea (achilles) reflex. serum conc of T4 (thyroxine) & T3 (Triiodothyronine) are decreased. A thyroid scan shows localization of the radio-iodine in the middle of the inferior aspect of the oral cavity; no radioactivity id detected in the neck. The radio iodine is most likely localized inferior to which of the following structures? (Foramen cecum OR Frenulum of tongue)

Gemfibrozil -Triglyceride levels are above normal (N=<150) pt's levels are *350* Atorvastatin -Pt has ~ normal levels of cholesterol (N=<2000) pt has, even though LDL are above normal (N=<100, pt has 190) a statin will only minimally reduce LDL

A 39F, w/obesity & recently Dx'd hypertriglyceridemia presents for a follow-up. She started a diet 3-months ago that was recommended by the physician. She also has PUD. She has smoked 1 pack of ciggs daily for 10 years. She does not appear to be in distress. Pulse is 80/min & regular, RR is 12/min, BP is 145/92. The lungs are clear to auscultation & percussion. Cardiac exam is normal. Abd exam shows normal bowel sounds; there are no masses or organomegaly. There is mild epigastric tenderness to deep palpation. Serum studies show: -Cholesterol------210 -HDL------------20 -Triglycerides-----350 Which of the following is the most appropriate med for this pt? (Atorvastatin OR Gemfibrozil)

Ferritin -Pt presents 1-Micronodular cirrhosis of liver *hepatomegaly* 2-Diabetes 3-Bronze-colored skin pigmentation 4-Testicular atrophy (dysfunction & ↓ libido *↓testosterone*) *Caused by untreated hemochromatosis* ACTH -If pt had Addisons would present w/: 1-Hypotension 2-Hyperkalemia [pt has normal K+] 3-Metabolic acidosis 4-Hyperpigmentation 5-Malaise, fatigue, weakness, anorexia, wt loss

A 39M, presents b/c of darkening of his skin & fatigue during the past 4 months. He has 3-yrs Hx of DM I treated w/insulin. PE shows hepatomegaly & testicular atrophy. Serum studies show: -Na------------138 -K-------------4.1 -AST-----------45 -ALT-----------74 -Testosterone---7 (N=10-35) Which of the following serum conc is most likely to be abnormal in this pt? (ACTH OR Ferritin)

Annular pancreas -Occurs when the ventral pancreatic bud forms a band of pancreatic tissue around the 2nd part of duodenum → may present w/: 1-Polyhydraminos 2-*Duodenal obstruction* (epigastric pain) 3-*Recurrent Bile stained vomiting* 4-Low birth wt 5-Poor feeding Esophageal atresia -Is TEF → would present *immediately after birth* w/: 1-Mom → Hx of polyhydraminos during pregnancy 2-Inability to feed 3-Resp distress 4-Choking 5-Drooling Extra hepatic biliary atresia -Usually affect neonates -Frequently presents in the first 4-8 weeks of life w/ *jaundice*

A 3B, presents to the ED b/c of epigastric pain & bile stained vomitus. The child had been well prior to this episode & has reached all milestones normally. Which of the following is most likely to be the cause of this pt's problem? (Annular pancreas OR Esophageal atresia OR Extrahepatic biliary atresia

Pituitary gland -High dose dexamethasone suppression test: -*Adequate suppression → Cushings disease → pituriaty gland* -No suppression → ectopic secretion → adrenal or other source

A 40F, presents b/c of a 1-year Hx of progressive facial puffiness & wt gain. She also has had several URTI's during the the past 8 months. Temp is 99F, pulse is 82/min, RR is 18/min, BP is 160/95. PE shows increased fat around the neck, facial plethora, moon facies, red striae over the breasts, abd, & buttocks, & proximal muscle weakness. Serum studies show a mildly increased ACTH conc that is suppressed after an oral administration of dexamethasone for several days. The most likely cause of the findings in this pt is hypersecretion of a hormone from a tumor located in which of the following organs? (Adrenal cortex OR Pituitary gland)

Adenine -Pt presents w/*pellegra* → which presents w/: 1-Diarrhea 2-Dermatitis *classically in neck-line distribution* 3-Dementia Pathophysio -Pt has *niacin deficiency* → niacin is a precursor for NADH & NADPH co-factors → *adenine is used to make NAD*

A 40M, who recently immigrated to the USA from Kenya presents to the ED b/c of a 3-wks Hx of diarrhea. He appears disoriented & cachectic. He recalls zero of three objects after 5 mins. A photo of the head, neck, & upper chest is shown. Similar findings are seen over the dorsal aspects of the hands. The Dx of vitamin deficiency in this pt is part of a co-factor that contains which of the following components? (Adenine OR Alanine)

Spontaneous regression -Pt presents w/a *ganglion cyst* (most common mass of hand or wrist) →most are benign, may be fluid filled or hard, & will *spontaneously regress*

A 42F, presents b/c a 1-year Hx of an enlarging, painless mass on her right wrist. Exam of the right wrist shows the findings on the image. The mass is firm & non-tender & transilluminates w/the application of a pen light. Without tmt, which of the following is most likely to occur? (Paresthesias OR Spontaneous regression)

Binding of a permeable ligand to a nuclear transcription factor -Estrogen is a steroid hormone → therefore it must use an intracellular receptor *nuclear transcription factor* → others that use this are *PET CAT on TV* *P* → progesterone *E* → *estrogen* *T* → testosterone *C* →cortisol *A*→Aldosterone *T* → T3/T4 Vit. D

A 42F, presents d/t a 2-year Hx of fatigue & abnormally heavy, prolonged menses. Endometrial biopsy shows simple glandular hyperplasia w/out atypia. Which of the following best describes the pathogenesis of this pt's endometrial disorder? (Activation of G-coupled receptor by guanosine triphosphate OR Binding of a permeable ligand to nuclear transcription factor)

Sand fly -Transmit *Leishmaniasis* → which presents w/: 1-*Intermittent/spiking fever w/weakness* 2-*Splenomegaly* ± hepatomegaly 3-*Pancytopenia* 4- Kala-azar (Black fever- skin hyper-pigmentation in fair skinned pts) 5-*Erythematous papule at the sand fly bite* (which expands & ulcerates forming a boil) Black fly -Transmits *onchocerca volvulus* which causes *river blindness*

A 42M, presents b/c of a 1-month Hx of intermittent high-grade fever, dizziness, diarrhea, & fatigue; He has also had a 11-lbs wt loss. During a trip to India 3 months ago, he was bitten by an insect, & he says that a sore developed at the site of the bite. Temp is 100.4F. PE shows splenomegaly & muscle wasting. Labs show pancytopenia. Which of the following is the most likely vector in this pt's infection? (Black fly OR Sand fly)

Celiac sprue -Presents w/: GI symptoms 1-Foul-smelling diarrhea 2-Abd pain 3-*Wt loss* 4-Bloating 5-Fatigue 6-*Steatorrhea* Extra-intestinal manifestations 1-*anemia* 2-Neurologic (motor weakness, paresthesias) 3-Dermatitis herpetiformis 4-Hormonal disorders (amenorrhea/infertility -women, impotence/infertility - men) Complications of long-term include: 1-*Osteopenia*/osteoporosis 2-*Anemia* (can also be megaloblastic) 3-Bleeding diathesis 4-Severe dehydration 5-Malnutrition IBS -Characterized by *recurrent Abd pain & altered bowel habits* [pt has none of these] -Recurrent abd pain must be associated w/≥2 of the following: 1-Improves upon defecation 2-Onset associated w/change in stool frequency 3-Onset associated w/change in stool appearance

A 44F, presents b/c of steatorrhea, flatulence, & a 22-lbs wt loss over the past 6 months. Findings on PE are unremarkable. Labs show: -Hb----------9.6 -MCV--------74 -Iron---------40 -Ferritin------10 Test of the stool for occult blood is neg; stool cultures & stool exam for parasites are neg. A lateral CXR shows mild osteopenia. Which of the following is the most likely explanation for these findings? (Celiac sprue OR IBS)

4.5 -Myocardial O2 supply = Coronary Blood flow (30mL/min) X Arterial blood O2 conc (0.15) 30 x 0.15 = *4.5*

A 45F, w/CAD & anemia presents for assessment of her cardiac perfusion. Transthoracic color Doppler echo is done. Results show that blood flow in the anterior inter ventricular (LAD) branch of the coronary is 30ml/min. Arterial blood O2 conc is 0.15ml O2/mL. Which of the following most closely approximates the myocardial oxygen supply to the left ventricle in this pt? (in mL O2/min) (2.0 OR 4.5)

Fasciculus gracilis -Pt has only sensory deficits (numbness, spastic paraparesis, bilateral babinski, proprioception & sensation diminished in toes) Dorsal spinocerebellar -Only conveys proprioceptive info [pt also presents w/ numbness]

A 47F, w/MS presents d/t a 2-day Hx of bilateral LE numbness. Muscle strength is 5/5 in the UE. There is spastic paraparesis of the LE. Deep tendon reflexes are brisk in the LE, & there is sustained clonus at the ankles. Babinski sign is present bilaterally. Proprioception & sensation to vibration are diminished in the toes. Sensation to pinprick & temp are normal. When asked to stand w/her eyes closed & arms extended outward, the pt is unable to maintain balance. This pt's symptoms of abnormal sensation are most likely caused by damage to which of the following tracts? (Dorsal spinocerebellar OR Fasciculus gracilis)

Inhibition of Gastric H+-K+ ATPase -This is the *main MOA of PPI's* → the overall effect is that they block stimulation from M, H, and ACh b/c all of these stimulate the H-K ATPase Blockade of gastric Histaminergic receptors -This describes H2 antagonists

A 48F, has severe GERD. Antacids do not provide symptomatic relief. Which of the following is the mechanism of action of the most effector suppressor of acid production? (Blockade of gastric hemorrhage OR Inhibition of gastric H+-K+ ATPase)

Tongue -Pt present w/*thyroglossal cyst* (most common) → *d/t part of the thyroglossal duct failure to obliterate, leaving a cyst* -> presents as: 1-*Midline* cyst 2-Located below hyoid bone -> usually near *foramen cecum* Pharyngeal arch -*branchial cleft cysts* (accounts for 20% of neck masses) → presents in the upper part of the neck *anterior to the sternocleidomastoid* → typically d/t: 1-Failure of obliteration of the second branchial cleft 2-Failure of fusion of the 2nd & 3rd branchial arches

A 4B, has a 1-cm midline mass just inferior to the hyoid bone. The mass was present at birth & remains unchanged. The mass most likely derived from tissue that originated from which of the following structures? (Tongue OR Pharyngeal arch)

Dietary change -Pt presents w/ Vit B12 deficiency → which presents as jaundice in vegan adolescents → this requires a dietary changes Folic acid -Would not help in Vit. B12 deficiency

A 4B, presents b/c of marked yellowing of skin. He & his family do not eat meat, milk, eggs, or other foods derived from animal products. There have not been any changes in stool or urine color. He has not travelled, & no members of his family have been ill. Temp is 98.6F, pulse is 80/min, RR are 12/min, & BP is 100/60. Exam shows a yellow-tinged skin, but his sclerae are non-icteric. Which of the following interventions is most likely to improve this child's appearance? (Dietary changes OR Folic acid)

Acute lung injury -Characterized by new, acute lung injury *sudden acute resp distress w/in 6 hrs* after blood product administration [pt presents 45 min after transfusion] -Occurs in the absence of temporally-associated RF's -presents w/: 2-May have associated Fever, cyanosis, *Hypotension* 3-*Pulm crackles*, *bilateral patchy infiltrates* Serum sickness -Presents w/*allergic rxn*: 1-Rash, itching 2-Fever 3-Joint pain 4-Facial swelling 5-presents 1-3 wks after exposure to new med

A 57F, requires intubation in the ICU after developing progressive dyspnea & hypoxemia 45 mins after the initiation of a transfusion of packed RBC's. The pt has cirrhosis & was admitted to the hospital b/c of melena; the transfusion was initiated after she was found to have a Hb conc of 6.4. PMHx is sig for Hep C D'x at 41 years. She has a 25-year Hx of illicit drug use. The pt is intubated & sedated. Temp is 98.4F, pulse is 92/min, RR is 16/min, BP is 94/58. There is no JVD. Bilateral basilar crackles are heard on auscultation; there are no wheezes. PE shows spider angiomata on the chest & abd, minimal ascites, & trace bilateral pedal edema. CXR shows bilateral diffuse airspace disease w/out pleural effusions or cardiomegaly. This pt most likely developed which of the following types of transfusion rxn's? (Acute lung injury OR Serum sickness)

Neural crest cells -Vestibular schwannomas (acoustic neuromas) -S-100+ *made from neural crest cells* Glioblasts -Would be a glioblastoma

A 59F, has a 10-yrs Hx of progressive right-sided hearing loss. An MRI of the head shows a large cerebellopontine angle mass that has compressed the vestibulocochlear nn on the right. The mass most likely arose from which of the following cells types? (Glioblasts OR Neural crest cells)

Immune destruction of plts -Pt presents w/*ITP* → which presents in children as: 1-*W/in one month of viral infection* 2-*Petechiae*/purpura 3-Epistaxis 4-Fatigue 5-Dx of exclusion: *Thrombocytopenia w/out anemia* [pt has normocytic & normochromic PBS] 6-*Decreased plts* 7-*Absence of plts on PBS* 8- *ABSENCE OF SPLENOMEGALY* Consumption of plts by intravascular thrombosis -Microangiopathic anemia caused by either *TTP* or *HUS* -Pt would have schistocytes on PBS

A 5B, who has recently recovered from an upper URTI develops easy bruising. Exam shows petechiae on the LE. Labs show: -Hb------12 -Hct------36% -Leuko's--8K -Plts-----18K The erythrocytes are normochromic & normocytic. A PBS of the BM is shown. Which of the following is the most likely mechanism of thrombocytopenia? (Consumption of plts by intravascular thrombosis OR Immune destruction of plts)

Regulatory T-lymphocytes - FOXP3 (AKA scurfin) is a protein involved in immune system responses → appears to be a master regulator of the regulatory pathway in the development & function of *regulatory T-cells*

A 6-month old M, presents b/c of a 2-month Hx of failure to thrive & intractable diarrhea that is worse after he feeds. PE shows eczematous dermatitis & mild lymphadenopathy. His heel stick BG is 260 (N=60-100). Genetic testing shows a mutation in the gene encoding the transcriptional protein, FOXP3. The most likely cause of this pt's condition is a decrease in which type of the following T-lymphocyte populations? (Regulatory T-lymphocytes OR Th2 lymphocytes)

Hyporeflexia -"B" Is the dorsal root ganglion → it contains the Afferent limbs for the reflex arc → damage to these cells results in Hyporeflexia Fibrillations -would be seen if damage was to the area labeled D

A 60F, is receiving cisplatin for advanced transitional cell carcinoma. She develops paresthesias, & the med is stopped. The med likely damaged the largest cells in the region labeled "B" in the diagram. The damage to the cells would most likely lead to which of the following motor signs? (Fibrillations OR Hyporeflexia)

EPO -Pt presents w/*polycythemia vera* → defined as *abnormally high RBC count accompanied by above/normal Hb level* Pathophysio -Pt has mutation in *JAK2* causing constitutively active JAK2 *in presence of low EPO levels* TOTAL RED CELL MASS -This is an indicator of erythrocytosis and is elevated for two reasons: 1-An increased number or RBC's (polycythemia) *this would be elevated in this pt* 2-Decreased blood volume (relative polycythemia)

A 60M, presents b/c of a 1-month Hx of headache & dizziness. BP is 160/85. PE shows moderate splenomegaly. Labs show: -Hb-------20.5 -Hct------55% -Erythro's-7mil -MCV-----78 -Leuko's--18K -Neutro's-75% -Eosin---5% -Baso----5% -Mono---5% -Lympho-10% -RCDW--20% (N=13-15%) -Arterial O2 sat-N Which of the following is most likely to be decreased in this pt? (EPO OR Total red cell mass)

Pediculus capitis humanus - AKA *Head lice*→ presents w: 1-Itchy scalp 2-Hair w/*white globular protuberances* 3-Close proximity to other kids Trichophyton rubrum -Would present w/an *infection of the scalp* in young children → presents as: 1-Erythematous, scaling patch on the scalp, which slowly enlarges 2-Alopecia 3-*Black dot appearance* [pt has white, globular protuberances] 4-Boggy, elevated, tender lesion known as *kerion* often accompanied w/posterior cervical lymphadenopathy [Pt does not have this presentation]

A 6F, presents b/c of a 2-day Hx of severely itchy scalp. The mother reports that 10 children in her daughter's class also have the same symptoms. The pt has no Hx of major medical illness & receives no meds. Vitals are normal. Exam of multiple hair shafts shows 1-2-mm, white, globular protuberances. Which of the following is the most likely cause of this pt's condition? (Pediculus humanus capitis OR Tricophyton rubrum)

Serum sickness -This is a type III hypersensitivity rxn *antigen-Antibody complex depositions* -In Rheumatoid arthritis Rheumatoid factor (IgM) binds to circulating IgG to form *immune complexes* Natural killer cell killing -No immune complexes are formed Wheal & flare rxn -Type I HS

A 70F, presents d/t a 3-month Hx of increasingly severe pain of her joints. She says that her fingers have become fo stiff that she can no longer play the piano. PE shows rheumatoid nodules underneath the skin close to the joints of the elbows & hands. The immunologic mechanism of this pt's inflammation is most similar to which of the following mechanisms? (Serum sickness OR Wheel & flare rxn OR Natural killer cell killing)

Stimulation of α-receptors -α1 receptors control bladder sphincter contraction → is you stimulate the sphincters they will contract more tightly, hypothetically alleviating stress incontinence Stimulation of M receptors -M3 receptors control bladder contracting → stimulation would cause micturition

A 75F, has stress urinary incontinence w/ sphincteric incompetence. Pelvic floor muscle exercises & the use of vaginal pessary provide inadequate improvement, & the pt refuses surgical intervention. Administration of a drug w/which of the following MOA is most appropriate? (Stimulation of α-receptors OR Antagonism of α-receptors)

10% -Beta Error (Type II error) (the likelihood that you miss an association that really is there) Alpha error (Type I error) -You make an association that is not really there 90% Power = (1-Beta)

A clinical study is designed to evaluate the association of caffeine consumption & pancreatic caner. In this study, alpha is set to .05 & beta at .10. Which of the following best describes the likelihood of missing an association between caffeine consumption & pancreatic cancer in this study? (10% OR 90%)

200 -After making table: AR = 30/1000 - 30/3000 90/3000-30/3000=.02% .02x10000=*200*

A cohort study is conducted to examine the association between smoking & lug cancer in 4000 people. 1000 participants smoke cigs & 3000 do not. After 10 years of follow-up, there are 30 cases of lung cancer among the smokers & 30 cases among the non-smokers. According to these results, how many lung cancer cases are attributable to smoking would be expected to occur in a group of 10,000 smokers of the same period of time? (200 OR 300)

Rough ER -Question specifically asks *the biosynthesis...* > Rough ER Plays an essential role in the *synthesis of proteins* → the functional signal recognition particle (SRP) tags newly made proteins as they exit the ribosome → it is usually found in the *cytoplasm* by → tags proteins to get them to the *rough ER*

A female neonate is delivered at 38-wks by CS. PE shows macrocephaly & shortened proximal segments of all limbs. A Dx of achondroplasia is made. DNA sequencing shows a G→A mutation in the FGF 3 receptor gene on Ch4. The biosynthesis of this protein requires a functional signal recognition particle receptor. This receptor is most likely found in which of the following cellular locations? (mRNA OR Ribosome OR Rough ER)

Closure of the caudal neuropore -Failure causes myelomeningocele Notochord -Gives rise to nucleus pulposus & the intervertebral discs

A male has a myelomeningocele that involves the vertebral arches of L2-L5. PE shows bilateral clubfeet. Which of the following developmental processes is most likely affected in this newborn? (Closure of the caudal neuropore OR Development of the notocord

Ask the mother & sister to leave the room & inform the parents of the abnormality

A male newborn is delivered at term to a 30F. The newborn has a malformed RUE. The woman's husband, mother, & sister also are in the delivery room. Which of the following is the most appropriate initial action by the physician? (Ask the mother & sister to leave the room & inform the parents of the abnormality OR Call the hospital pediatricians to come to the delivery room immediately)

Histamine -plays a major role in the inflammatory response → causes itching (urticaria) and *vasodilation* IL-1 -Pyrogenic & helps stimulate TNF

A man accidental touches the surface of a hot stove; 20-mins later, a blister develops at the site. Biochemical analysis of the blister fluid at this time is most likely to show the presence of which of the following? (Histamine OR IL-1)

Tox Screen -Must confirm suspicion of cocaine

A previously healthy 32M, is brought to the ED by friends 45 mins after sudden onset of severe headaches, seizures, left-sided weakness, & nausea that began while they were attending a party. His friends believe there may have been drugs at the party. On arrival, he is alert & cooperative. He appears to be in pain. Pulse is 120/min, RR is 16/min, BP is 160/100. Neurologic exam shows bilateral dilated pupils, hyper-reflexia, & mild hemiparesis on the left side. He is oriented to person, place, & time. A CT of the head shows a 1.5-cm hemorrhage in the right basal ganglia. Which of the following is the most appropriate next step in Dx? (Echo OR Tox screen)

Infraspinatus -*External rotation* would be affected Supraspinatus -Pt would *not be able to abduct arm and lift overhead* if this was affected *pour out test would be positive* Subscapularis -Pt would not be able to internally rotate arm if this was hurt [pt can internally rotate]

A previously healthy 45M, presents d/t a 3-day Hx of left arm pain & weakness. Use of ibuprofen has provided no relief. He does not smoke or drink. Vitals are normal. Exam of the LUE show weakness w/external rotation of the shoulder but full strength w/elbow in extension. There is no weakness on shoulder mid-arc abduction of internal rotation. There is no pain or weakness on flexion of the shoulder at 30° against resistance w/the elbow fully extended & the arm fully supinated. The most likely cause of this pt's condition is injury to which of the following tendons? (Infraspinatus OR Supraspinatus OR Subscapularis)

Type I error (No change) Type II error (decreased) -Type II error is related to power -Power is increased with increase in sample size -An increase in sample size will *decrease* type II error -Increasing sample size makes the hypothesis more sensitive (more likely) to reject the null hypothesis when *it is in fact false* -A type II error is when you *fail to reject the null when it is false*

A study is conducted to asses the extent to cardiac valvular abnormalities in pts receiving ergot DA agonists. Group X consists of 40 pts who have been treated w/an ergot DA agonist for at least 1 yr. Group Y consists of 54 age- & gender- matched controls. It is found that pts in Group X have sig greater composite regurgitation scores (5±2.1 [mean ±std deviation {SD}]) than Group Y (3.3±2[mean ±SD]), p < 0.05. The investigators decide to double the No. of pts in each group, & keep the same criterion (p <0.05) for statistical significance. This change will most likely have which of the following effects on probability of Type I & type II error? (↑/↓/↔) for each?

Adenylyl cyclase *Gs* --β1, β2, β3 --D1 --H2 Gi -M2 -α2 -D2 Both Gs & Gi utilize *Adenylyl Cyclase* → cAMP → Protein kinase A → --Smooth muscle (myosin light chain kinase) --Heart (↑ Ca+) Phospholipase C -Gq →*Phospholipase C* → PIP2→ --DAG →Protein Kinase C --IP3 → --Smooth muscle contraction *↑Ca+* -receptors that use Gq → *HAV*e *1* *M*&*M* (H1, α1, V1, M1, M3) Gualnylyl cyclase -G protein used in signaling cascade (Gi, Gs, Gq, Gα) are all components of it

Adenylyl cyclase OR Gualnyly cyclase OR Phospholipase C

Adjustment disorder -Criteria includes: 1-Symptoms begin w/in 3 months of onset of stressor *pts symptoms began two months after tmt for Hodgkins* 2-Significant distress or impaired social or occupational functioning (absence of this indicates a normal stress response) *pt takes his temp several times a day & calls the physician* 3-Symptoms present after a psychosocial stressor *pt Dx'd and treated for Hodgkins* Somatic symptom disorder -Criteria for somatic symptom disorder are: 1 ≥1 somatic symptom that causes distress or psychosocial impairment 2-Symptoms cause excessive or persistent thoughts, feelings *(anxiety)* or behaviors (time. energy) 3-*6 month duration*

Adjustment disorder w/anxiety OR Somatic symptom disorder

Doxorubicin -Pt presents w/*dilated cardiomyopathy* → which presents w/: 1-*SOB* 2-*Dyspnea on exertion* 2-*Narrow pulse pressure, systolic regurg murmur in presence of S3* 3-*pleural effusions & edema* (Bibasilar crackles d/t fluid buildup 4-Orthopnea 5-Enlarged heart 6-Arrhythmias Bleomycin -cause of pulmonary fibrosis → which presents w/: 1-*SOB* 2-Dry cough 3-Fatigue 4-Unexplained wt loss 5-Aching muscles & joints 6-Clubbing of finger

After completing 6 courses of chemo for cancer of the breast, a 45F, has SOB, dyspnea on exertion, & orthopnea. Basilar crackles are heard bilaterally, & there is an S3 gallop. CXR shows an enlarged heart, bilateral interstitial & alveolar edema, & bilateral pleural effusions. Which of the following is the chemo drug most likely to have caused these findings? (Bleomycin OR Doxorubicin)

Agonist at γ-aminobutyric acid B (GABAb) receptors -The pt presents w/*muscle spasms & painful cramps* → the tmt approach is: 1-Cyclobenzaprine → (Locus coeruleus ↑NE release) 2-*Baclofen* → *MOA is a GABAb receptor agonist*

Agonist at γ-aminobutyric acid B (GABAb) receptors OR Antagonist at glycine receptors

Post-translational modification -Used in protein modification -Used to convert pro-hormones → hormones Alternative splicing -Used for gene expression (not protein modification) to make protein (not modify it)

An experimental study is conducted to examine the function of the pro-opiomelanocortin gene. The gene is found to encode an mRNA from which protein products are generated. This protein serves as the precursor of ACTH hormone & β-lipotropin. Which of the following processes is necessary in order to generate these hormones? (Alternative splicing OR Post-translation modification)

Basal keratinocyte: suprabasal keratinocyte

An investigator is conducting a study of a novel protein in an experimental animal model. It is found that this protein interferes w/the normal structure of desmosomes. Which of the following cell junctions in skin is most likely to be affected by the presence of this protein? (Basal keratinocyte:suprabasal keratinocyte OR Granular keratinocyte:Stratum corneum)

Enveloped -An envelope make bacteria susceptible to low heat and alcohol

An investigator is conducting a study to determine the cause of an outbreak of illness at a skilled nursing care facility. A total of 13 residents developed fever, an erythematous rash, & varying degrees of renal impairment during a 2-wks period. A previously unidentified virus is recovered from urine specimens collected from seven of these pts. Physical characterization of the virus shows that viral infectivity is essentially destroyed by heating to 60°C for 30 mins. Based on this findings, this virus most likely has which of the following characteristics? (Enveloped OR Non-enveloped)

Free radical formation -Radiation causes free radical formation Formation of pyrimidine dimers -UV light causes the formation of pyrimidine dimers

An investigator is studying a new drug for the tmt of pts undergoing adjuvant radiation therapy. The drug is designed to be administered prior to irradiation to minimize localized tissue damage at the irradiated site. This drug most likely inhibits which of the following effects of the external beam radiation? (Free radical formation OR Formation of pyrimidine dimers)

Presentation of antigens to CD8+ T-lymphocytes -Bortezomib affects two processes: 1-Protein synthesis 2-*Controls apoptosis via CD8+ cells*→ CD8+ cells activate apoptosis via the Fas/FasL pathway Perforin Released by NK cells to create holes in membranes

An investigator is studying the adverse effects of a proteasome inhibitor, bortezomib, on immune responses. Bortezomib is administered to a group of pts w/relapsed multiple myeloma, & immune responses are observed. Which of the following immunologic processes is primarily affected by this drug? (Activation of perforin OR Presentation of antigens to CD8+ T-lymphocytes)

Decreased blood volume -Bed rest leads to an elevated HR → despite an elevated HR, VO2 max is reduced from decreased SV & CO as a result from decreased VR associated w/*lower circulating blood volume*

An otherwise healthy 35M, sustains a fracture of the left pelvis in a MVC. A 3-week period of bed rest for this pt is most likely to cause which of the following physiological changes? (Decreased blood volume OR Decreased plasma sodium volume)

Atrophy of dermal collagen -Pt most likely presents w/*lichen planus* → which presents w/: 1-Pruritic 2-Purple 3-Papules & 4-Plaques which are 5-Planar topped & 6-Polygonal Histology 1-Hyperparakeratosis (retuned nuclei w/in stratum corneum w/ thickening of the granular layer) 2-Eosinophilic/colloid/hyaline bodies 3-Dermal infiltrate *(pt has atrophy of dermal collagen)* Autoimmune disease -not associated w/ autoimmune disease

Atrophy of dermal collagen OR Autoimmune disease

Autoimmune adrenalitis -AKA Addison's presents w: 1-Fatigue/malaise 2-Weakness 3-Anorexia 4-Wt loss 5-*Bilateral decreased adrenals* Labs 1-Hypotension (↓Aldosterone) 2-Hyperkalemia (↓Aldosterone) 3-Metabolic acidosis (↓Aldosterone) 4-Hyperpigmentation (↑MSH) Retroperitoneal fibrosis -AKA Ormond's disease → presents w/: 1-Lower back pain 2-Kidney failure 3-HTN 4-DVT CT findings -Confluent mass surrounding the aorta

Autoimmune adrenalitis OR Retroperitoneal fibrosis

Multifactorial -Pt presents w/ *Sjogrens syndrome* is multi-factorial

Autosomal recessive OR Multifactorial

Avascular necrosis -Presents w/: 1-*Increasingly severe Pain which may limit mvmt* Risk factors include 1-*alcoholism* 2-Extended glucocorticoid use 3-Bone fractures 4-Joint dislocations Hyperparathyroidism -Pt would present w/ many more symptoms associated w/Hypercalcemia -Pt would have Hx of --Parathyroid adenoma --Vit D deficiency --CKD

Avascular necrosis OR Hyperparathyroidism

Avulsion of hepatic veins from IVC -Pt presents w/BAT → BAT presents w/2 patterns of hepatic venous injury: 1-avulsion of trunk of the right hepatic vein from the IVC 2-Avulsion of upper branch of right hepatic vein Trauma from transection of hepatic artery -Pt would have bleeding upon entering the abd cavity

Avulsion of hepatic veins from the IVC OR Traumatic transection of the hepatic artery

Retina -Hyaline membrane AKA Infant respiratory distress syndrome disease is caused by ↓ surfactant levels in newborns → this is treated w/ mechanical ventilation → however, this tmt lead to a complication -> *retinopathy of prematurity (caused by O2 therapy tmt in a newborn)* → prevention is aimed at continuous monitoring & keeping levels between 92%-95% Choroid plexus -The tmt described above would not prevent damage to the choroid plexus

Chorioid plexus OR Retina

Encourage the family to come to a consensus based on their perceptions of the pt's wishes -The pt has declined in health and now has impaired swallowing reflex → the pt will now have to be on life support so this is a good time for the family to reach a consensus on what the pt might have wanted

Encourage the family to come to a consensus based on their perceptions of the pt's wishes OR Recommend a tube, b/c feeding will be more efficient & prevent starvation

Endodermal cells *HIT EMU BURPS* *H* → Hepatocytes *I* → inferior 2/3 of vagina *T* → Thymus & thyroid *E* → Entire GI lumen *M* → middle ear *U* → Urethra, urinary bladder (except distal male urethras derived from ectoderm) *B* → Bulbourethral glands (Cowper's) *U* → Urethral glands (Littre's) *R* → Respiratory tract *P* → *Pancreas & Parathyroid* *S* → Sublingual & submandibular glands

Endodermal cells OR Neural crest cells

Polyubiquitination

Glycogenolysis OR Polyubiquitination

Enhanced action of the agonist at β-adrenergic receptors

How does prednisone enhance the β-adrenergic response at receptors? Enhanced absorption of agonist OR Enhanced action of the agonist at β-adrenergic receptors

Hyperplastic arteriosclerosis Causes 1-Seen in *Malignant HTN* 2-Appears as *onion skinning* 3-Can be a cause of *flame hemorrhages* 4-Would present w/*severe arteriolar narrowing* Monckeberg arteriosclerosis -Type of arteriosclerosis involving dystrophic calcification of the media in small to medium sized muscular arteries *typically in radial & ulnar* -Benign & does not obstruct arterial flow *would not cause flame hemorrhages* -Classified as *pipestem* appearance in XR

Hyperplastic arteriosclerosis OR Medial arterial calcification (Monckeberg arteriosclerosis)

HYPOKALEMIA -Metabolic alkalosis -Laxative use causes 1-↓K+ → increased loss of K+ in stool 2- ↓Cl → ↓K+ impairs Cl- reabsorption 3-↑HCO3 → causes a ↓Cl causes decreased activity of the Cl-HCO3- exchanger HYPOPHOSPHATEMIA -Phosphate not affected

Hypokalemia OR Hypophosphatemia

Hypophosphatemia -Fanconi's syndrome is characterized by wasting of viable amounts of: 1-Phosphate 2-Glucose 3-Amino Acids 4-Bicarb -by the proximal renal tubule -Associated w/ reduced ATP & Na+/K+ ATPase activity Serum findings include: 1-Hypokalemia 2-Hypophosphatemia 3-Metabolic acidosis Urine findings -Elevated levels of --Glucose --Amino Acids --Electrolytes

Hyponatremia OR Hypophosphatemia

TNF-α -Pt present w/RA → *IL-1 & TNF-α* are release by mono-nuclear cells in the pannus, & are responsible for initiating the joint damage seen in RA -Also have HLA-DR4 -DIP joints are *SPARED* IL-2 -Helps to stimulates T-cells

IL-2 OR TNF-α

If the TMT really changes the mean asthma score by 0.4, there is an 80% chance that a study of this size will find a p-value of ≤.05

If the TMT really changes the mean asthma score by 0.4, there is an 80% chance that a study of this size will find a p-value ≥0.05 OR If the TMT really changes the mean asthma score by 0.4, there is an 80% chance that a study of this size will find a p-value of ≤.05

Fusion of the sclerotomes

Immediately after spontaneous vaginal delivery, a full-term male newborn is found to have a tuft of hair midline in the lumbar region. Palpation of the area shows an absence of spinous processes in that region. Imaging studies show no additional abnormalities. The most likely cause of this defect was failure of which of the following events during gestation? (Formation of the neural tube OR Fusion of the sclerotomes)

A weak pulse d/t decreased stroke volume -The bodies response to hemorrhagic shock is: 1-↑SVR → this will decrease blood to everything 2-↓↓PWP b/c less blood is returning to heart → which *will cause a ↓SV → weak pulse* also 3-↓CO d/t decreased blood return from lungs 4-↓VR Increased renal blood flow d/t sympathetic stimuation -Shock causes *systemic hypoperfusion* → which *will decrease blood flow to kidney*

Increased renal blood flow d/t sympathetic activation OR A weak pulse d/t decreased stroke volume

Squamous cell carcinoma -Central cavitary mass d/t extensive central necrosis Infarct -This would show an area of hemorrhage & necrosis *[not a central cavitary necrosis]*

Infarct OR Squamous cell carcinoma

Pelvic splanchnic -The pelvic splanchnic nerves functions are: 1-regulate the emptying of the urinary bladder 2-Control the opening of the internal urethral sphincter 3-Influence motility in the rectum *(deficiency would cause constipation)* 4-Function for erections Inferior rectal -Cutaneous innervation below the pectinate line & the external anal sphincter

Inferior rectal OR Pelvic splanchnic

Legionella -Transmitted via aerosols from environment *air conditioning & hot water tanks* (pts were recently at a retreat which probably had both of these) -Can present with two ways: 1-Legionaires disease → *severe, often lobar pneumonia* 2-Pontiac fever → flu like illness w/out respiratory symptoms Strep pneumo -Would present w/pneumonia but *[not associated with pts in groups]* *[children under 5 would be affected]* *[pts would have red/brown sputum]* *[pts would have bacteremia as a complication]* Influenza -Does not cause pneumonia

Influenza OR Legionella OR Strep pneumo

Scaphoid fractures -Most common fractures when falling on an *outstretched hand* that is radically deviated - Presents w/*point tenderness on the anatomical snuff box* Lunate -Commonly dislocated → which may cause acute carpal tunnel syndrome

Lunate OR Scaphoid

Metastatic carcinoma -Pt presents with increasingly severe back pain that is worse at night and persists regardless of activity level → this is probably d/t *Prostate carcinoma* -It has a preference for mets to back -Presents as Lytic lesions Osteitis deformans -If pt presented w/ this he would have findings such as: 1-Increased hat size 2-Headaches 3-Hearing loss 4-Loss of vision [pt has normal PE findings] X-ray → would show *thickened bone Cortex w/shaggy radiolucent lytic lesions*

Metastatic carcinoma OR Osteitis deforms (Pagets)

Methionine -The 9 essential AA's are: *H*elp *I*n *L*earning *T*hese *L*ittle *M*olecules *P*roves *T*ruly *V*aluable 1-Histidine 2-Isoleucine 3-Leucine 4-Threonine 5-Lysine 6-Methionine 7-Phenylalanine 8-Tryptophan 9-Valine

Methionine OR Alanine

Myeloma cells do not have membrane bound surface immunoglobulin -MM is a disease characterized by *↑plasma cells* → plasma cells produce *little-to-none membrane immunoglobulin* Myeloma cells are not susceptible to antibody-dependent cell-mediated cytotoxicity -They are susceptible to cell-mediated cytotoxicity

Myeloma cells are not susceptible to antibody-dependent cell-mediated cytotoxicity OR Myeloma cells do not have membrane bound surface immunoglobulin

NMDA receptors are blocked by Mg+ at the resting membrane potential -The NMDA receptors initially have Mg+ & Zn+ that are bound which blocks the passage of other ions → *Depolarization* dislodges the Mg+ & Zn+ allowing other cations (Ca+) to pass

NMDA receptors are blocked by Mg+ at the resting membrane potential OR NMDA receptors can be activated only if the cell membrane is hyper-polarized

PPV of a positive test -↑Prevalence → ↑PPV -↑prevalence → ↓ NPV

PPV of a positive test OR PPV of a negative test

Temporal lobe 1-Deja vu or jamais vu (feeling of unfamiliar) 2-Auditory, visual, *olfactory hallucinations* 3-Amnesia 4-Sudden sense of unprovoked fear & anxiety 5-Nausea 6-Dissociation or derealization 7-Synthesia Partiel lobe -would present w/language deficits -Dyphasia -Dyscalcula -Dyslexia

Parietal lobe OR Temporal lobe

Methylase -Methylation is protective → so if there is not methylation it is more likely to be digested

Physical analysis of an isolated genomic DNA from a mutant strain of E.coli shows that it can now be digested into numerous small fragments w/a restriction endonuclease that recognizes the GATC sequence. The DNA from the wild-type parental strain is resistant to digestion w/this restriction endonuclease. The mutation that causes this type of phenotype is most likely to occur in the gene encoding which of the following activities? (Gyrase OR Methylase)

Placement of the central line via the internal left jugular vein -the most common causes for a chylothorax are 1-Surgery 2-Truma -*Placement of a central line is the most common surgical case of a chylothorax*

Placement of the central line via the internal left jugular vein OR Placement of the pulmonary artery catheter via the right subclavian vein

Proteins X & Y express the same epitopes -The line is going down and meeting *[If no epitopes were shared then the line would be straight across]*

Proteins X & Y express the same epitopes OR Proteins X & Y have no epitopes in common

Release of stored of TH from a thyroid gland infiltrated by lymphocytes -Pt presents w/*Subacute lymphocytic thyroiditis* → which presents in 1-*Postpartum women* most common 2-*Enlarged, non-tender thyroid* Labs 1-*Normal/Increased serum T4* 2-*Decreased serum TSH* 3-*Decreased I-123 uptake* Release of TSH from a thyroid gland stimulated by antibodies -This is graves disease Labs -↑T4 & ↑T3 -↓TSH *(Key difference -> pt has normal TSH)* -Elevated liver enzymes

Release of stored TH from a thyroid gland infiltrated by lymphocytes OR Release of TH from a thyroid gland stimulated by antibodies

Testicular artery -this is the last artery before reaching the renal artery as you ascend the abd aorta SMA -Much higher than renal artery

SMA OR Testicular artery

Decreased interstitial oncotic pressure -Pt has CHF with would present w/*transudate fluid* → this is caused by: 1-*↑ Hydrostatic pressure* 2-*↓ oncotic pressure*

What are the expected findings for interstitial oncotic pressure for a pt with CHF?

Extra lumen in media of proximal aorta

What are the expected findings in the aorta d/t HTN?

-Classically affects the ascending aorta → manifests as a dilated aorta & aortic regurg -Pathogenesis → Proliferative endarteritis that affects the vasa vasorum leading to medial necrosis & loss of elastin fibers

What are the expected findings seen in the aorta d/t tertiary syphilis?

Stimulation of the release of biogenic neurotransmitters -*↑catecholamines in the synaptic cleft (especially DA & NE)* Also used for --Appetite control --Narcolepsy Blockade of post-synaptic AA neurotransmitter receptors -This is an SSRI

What is the mechanism of action of methylphenidate (Adderall)? Stimulation of the release of biogenic neurotransmitters OR Blockade of post-synaptic inhibitory AA neurotransmitter receptors

*Proteasome inhibitors -> Bortezomib, carflizomib, ixazomib* → lead to cell cycle arrest & apoptosis AE -Bortezomib → peripheral neuropathy

What is the tmt for multiple myeloma?

Yolk sac Gestational sac -All the black area *Anechoic* encircled by a hyper-echoic rim - Chorionic cavity -is the space surrounding the gestational sac (outermost area) *not seen in this US*

Which of the following best describes the structure pointed at by the arrow? (Yolk sac OR Chorionic cavity OR Gestational sac)

Increase in axonal capacitance -Normally Myelin decreases capacitance & increases resistance across the axonal membrane → demyelination would *increase capacitance* Fast axonal transport -Describes retrograde transport (which has not direct correlation to myelin)

Which of the following best explains impaired action potentials in the affected axons in pt's w/demyelinating disease? (Cessation of fast axonal transport OR Increase in axonal capacitance)

Only cookies -B/c odds of eating cookies and getting E.coli are (drank milk 1, Did not drink milk 6) → if milk was to blame then the OR would be ↑ in the category where pts ate no cookies

Which of the following conclusions can be drawn from these data? (Only cookies are independently associated w/E.coli OR Only milk is independently associated w/E.coli)

Proteins X & Y have no epitopes in common

Which of the following interpretations of the epitopes expressed by proteins X & Y is correct? (Proteins X & Y express the same epitopes OR Proteins X & Y have no epitopes in common)

Lomustine & Cyclophosphamide -Lomustine is an alkylating drug (like cyclophosphamide) Cytosine arabinoside & Cyclophosphamide -Cytosine arabinoside is a pyrimidine analog

Which of the following pairs of drugs interferes w/ DNA synthesis by cross linking? (Cystosine arabinoside & Cyclophosphamide OR Lomustine & cyclophosphamide

Extensive hydrophobic interactions between AA side chains of the protein & the membrane phospholipid tails

Which of the following properties of integral membrane proteins results in their becoming anchored w/in the membrane? (Formation of ionic bonds between the AA side chains & the phospholipid tails OR Extensive hydrophobic interactions between the AA side chains of the protein & the membrane phospholipid tails)

PTH (↑) Ca (↓) →hypocalcemia Serum Phos(↑) →Hyperphosphatemia → *INCREASED* PTH has different effects depending on the organ: 1-Serum -> Increased phosphate -> Increased PTH causes increased phosphate b/c it causes phosphate release from bone (also Ca+ release) 2-Kidney -> Increased phosphate would cause decreased absorption of phosphate in the kidney

Which of the following sets of serum findings is most likely in a 50M w/ recently Dx'd chronic renal failure? (PTH, Ca, Phosphate)

Lamins -Intermediate filaments, fibrous proteins that provide *structural function* & transcriptional regulation in the *cell nucleus* Tubulin -Used to make microtubules

Which of the following terms best describes the fibrous proteins that form the two-dimensional network on the inner surface of the nuclear membrane? (Lamins OR Tubulin)

Live attenuated virus -These include *M*usic & L*YRICSS* are best enjoyed *Live* *M* → MMR *Y*→yellow fever *R*→rotavirus *I*→Intranasal influenza *C*→Chicken pox *S*→smallpox *S*→sabin polio virus Inactivated virus sal*K* = killed *RIP A*lways *R*→rabies *I*→influenza (injected) *P*→Polio (Salk) *A*→H*A*V

Which of the following types of vaccine is most appropriate to prevent mumps? (Inactivated virus OR Live attenuated virus)

Decreased → in pt with a normal restriction picture Normal → in obese pts

Would the residual volume be normal or decreased?