UWORLD Notes April 29 2016 (Usmle Grassroots)

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Question

Id Main Division Sub Division Notes

6 Pathology Miscellaneous _{(Multisystem)}

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

[Angiomyolipoma, associ with Tuberous Sclerosis] 7 Pathology Renal, Urinary Systems & _Electrolytes

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

[Goodpasture disease, Anti-GBM antibody]

8 Histology Renal, Urinary Systems & _Electrolytes In PSGN there is deposition of IgG, IgM, an *C3*, thus producing _{a star-sky appearance on immunolfourescent microscopy.} 10 Pathology Renal, Urinary Systems & _Electrolytes

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

11 Pathology Renal, Urinary Systems & _Electrolytes

PSGN:

1)Enlarged, hypercellular glomeruli on light microsc 2) Lumpy-Bumpy granular deposits of IgG & C3 on immunofluorescence

3) Electron dense deposits (Humps)on epithelial side of the basal membrane on electron micros

12 Pathology Renal, Urinary Systems & _Electrolytes In post-strep Glomerular Nephritis there is *DECREASED SERUM _C3* 14 Pathology Nervous System

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

20 Histology Nervous System

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

*MICROGLIA* and the lipids are from breakdown prduucts that were phagocytosed.

28 Pathology Renal, Urinary Systems & _Electrolytes Pt with signs of Nephrotic syndrome would a seconday change of _{*Increased Live Lipoprotein Synthesis*} 33 PathophysiologyCardiovascular System Bicsupid aortic valve can lead to *aortic stenosis by 50 years old. *

35 Embryology Cardiovascular System

Cyanosis in transposition of the great vessels is classic. This condition is due to failure of Septation. Failure of the

aorticopulmonary septum to spiral. It can be conducive to life only if accomanied by another condition that allows mixing of blood. E.g Patent ductus arteriosus which presents with machine like murmur.

38 Pharmacology Cardiovascular System

Pt with episodic and transient anginal chest pain, occuring during night time hours and accompanied by temporary ST-segment elevations. Pt chest pain would be provoked by *Ergonovine* [Prinzmetal Angina]

[Ergonovine is an egot alkaloid that constricts vascular smooth muscle by stimulating both adrenergic and serotonergic receptors, low doses inudce coronary spasm in pts with prinzmetal angina]

39 Pathology Cardiovascular System

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

(arterial collaterals have developed around point of occlusion) 41 Pathology Cardiovascular System Light Microscopic changes of ischemic myocyte after 12 days is _{*Granulation tissue with neovascularization*}

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

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

Myocardium*

[Due to chronic ischemia

45 Microbiology Infectious Diseases

A population that is universally vaccinated with recombinent HBsAg. The disease that would almost entirely disappear is *Delta Agent Infection*

{Hep D causes infection only when encapsulated with HBsAg, it is a replication-defective RNA virus]

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

54 Pathology Gastrointestinal & Nutrition A cavernous Hemangioma is the MC benign liver tumor. Typically _{in adults 30-50 years.} 56 Pathology Gastrointestinal & Nutrition Pt with chronic hepatitis C, a large hepatic mass and multiple satelite lesions has hepatocellular carcinoma. The marker for

recurrenc is *ALPHA FETOPROTEIN* 57 Pathology Gastrointestinal & Nutrition

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

58 Pathology Hematology & Oncology

Pt dies from liver disease. Both changed and unchanged

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

62 Microbiology Gastrointestinal & Nutrition

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

63 Pathology Nervous System

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

64 Biochemistry Nervous System

Pt presents for exertional dysnpnea and fatigability. On P.E her gait is unstable when her eyes are closed and tehre is impaired vibratory sensation in the lower extremities. There is marked Pallor in conjunctiva, nail beds, and palms. The lab test that would

confirm Dx is *Serum Methylmalonic acid* [Vit B12 Def]

67 Biochemistry Gastrointestinal & Nutrition Gallstones caused by the use of fibrates for dyslipidemia are _{caasued by decreased activity of 7-lpha-hydroxylase.} 68 PathophysiologyPregnancy, Childbirth & _Puerperium

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

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MI in the setting of normal coronary arteries. Mitral valve

thickening with vegetations is noted. Pt cardiac condition is most likely associated with *SLE*

(Libman-sacks endocarditis (verucous endocarditis) occurs in 25& of sle pts. SlE may cause acute coronary syndrome at young age even with normal coronary arteries)

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

[Carcinoid Sydnrome]

78 PathophysiologyGastrointestinal & NutritionPt with cholestrol gall stones would have *High cholestrol, low bile _{salts and low Poshatidylcholine* in the gallbladder.}

79 Pathology Gastrointestinal & Nutrition

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

80 PathophysiologyGastrointestinal & NutritionThe diagnostic test most specific fro acute cholecystitis is *Failed _{gallbladder visualization on radionuclide billary scan*} 82 Pathology Cardiovascular System MCC of sudden cardiac deaths in young persons is *Hypertrophic _{cardiomyopathy*}

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

Young pt with an episode of syncope that was not provoked by any activity. No significant past medical history and no medications. ECG shows QT-interval prolongation. Assuming this is an inherited condition, the relevant mutations likely affects *Membrane

Potassium channel proteins*

[sudden cardiac arrhythmia, QT interval reflects cardiac myocyte action potential duration which is determined in part by K+ current] 88 Pathology Gastrointestinal & Nutrition

Pt with a mass obstructing the iliocecal valve with a high cholestrol content. A radiographic finding conistent with this presentation would be *Air in the billary tree*

(Gallstone ileus, gallstone penetrated intestine and lodged) 91 Pathology Cardiovascular System

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

94 Pathology Cardiovascular System Localized amyloid in the atria of heart is amyloid derived from _{Naturiretic peptide.} 96 PathophysiologyCardiovascular System

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

Acute-onset, mid-chest pleuritic pain that decreases on sitting up and leaning forward is characteristic of acute pericarditis.

Fibrinous or serofibrinous pericarditis is the most common form. Pericardial *Friction Rub* is the most striking physical finding.

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Pt died. Autopsy is done. Gross inspection of heart shows shows dense thick fibrous tissue in the pericardial space between

bisceral and paretal pericardium. The most likely sign that would ve been detected during physical exam is *Kussmaul Sign*

[Constrictive Pericarditis] 104 Pathology Dermatology

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

[Pityriasis versicolor] 106 Microbiology Infectious Diseases

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

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

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

112 Immunology Infectious Diseases

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

Note: Superificial Candida Infection is contributed to by a "Low T-lymphocyte count"

113 Microbiology Nervous System

HIV pt infected with organism stained with india ink in CSF

showing spherical yeast with thick capsules (C.neoformans). Most likely primary foucs is *Lungs*

[found in pigeon droppings and soil, enters thru resp route] 116 Microbiology Nervous System

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

117 Microbiology Pulmonary & Critical Care An organism's capsule that stains red on Mucicarmine staining is _{the capusle of *Cryptococcus Neoformans*}

118 Microbiology Nervous System

Pt with Hx of viral encephalitis and pneumocystis pneumonia most likey has HIV and if they present with signs of meningitis with latex agglutination positive for soluble polysaccharide antigen probably has Cryptococcal meningitis and you should expect *Budding yeast* on light microscopy.

120 Microbiology Pulmonary & Critical Care

Pt with flue like symptoms and lung symtoms of crackles and pulmonary infiltrate who works a capenter and suptum KOH preparation shows "Broad Based-Bud" most likey has *Blastomyces Dermatitidis*

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

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127 Histology Female Reproductive _{System & Breast}

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

129 Anatomy Gastrointestinal & Nutrition

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

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

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

133 PathophysiologyGastrointestinal & NutritionLactase deficeiency causes osmotic diarhea and *Acidification of _stool* 135 Pathology Gastrointestinal & Nutrition The NF-kB factor pathway stimulates *Cytokine Production* 136 Pharmacology Cardiovascular System

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

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

138 Pharmacology Cardiovascular System Sublingual nitreates *Decrease left Ventricular Volume*_{[Thru venodilation and hence decreasing preload]} 140 Pharmacology Cardiovascular System Adverse affect of nitrates is *HEADACHE* !!

Pt with signs of hypertrophic cardiomyopathy (family history of premature sudden death, systolic mumur). Due to the left

ventricular outflow obstruction, avoid drugs that reduce ventricular volume such as vasodilators and diuretics. An example of a vasodilator is *Isosorbide dinitrate*

142 Pharmacology Cardiovascular System Pts taking daily nitrates need to have a nitrate free period to _{prevent tolerance to the drug} 144 Physiology Cardiovascular System

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

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

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

151 Pharmacology Renal, Urinary Systems & _Electrolytes

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

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166 Pharmacology Endocrine, Diabetes & _Metabolism A drug that can massively decrease Triglycerides is *Fenobirate* 167 Pharmacology Endocrine, Diabetes & _Metabolism Acute falre of gouty arthritis (-ve birefringent crystals) can be due _{to Tx with *NIACIN*} 168 Pharmacology Pulmonary & Critical Care

Pt on glucocorticoids for asthma should be advised to perform *Oral Rinsing* to avoid side effects of medication.

(if drug lodges in oral mucosa, it can candiasis)

170 Pharmacology Pulmonary & Critical Care

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

171 Pharmacology Pulmonary & Critical Care Inhaled Cromolyn is used in Asthma. It *Inhibits Mast cell _{degranulation*} 172 Pharmacology Poisoning & Environmental _Exposure Theophylline toxicity leads to *Seizures and Tachyarrhythmias* 176 Pathology Cardiovascular System *Mitochondrial Vacuolization* indicates irreversible cell injury. 181 Pathology Cardiovascular System

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

183 Physiology Cardiovascular System During Systole, there is decreased blood flow to the *Left _{Ventricular Myocardium*}

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

186 PathophysiologyCardiovascular System

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

187 PathophysiologyCardiovascular System Pt with VSD would also have a *Holosystolic murmur over the left _{sternal border*} 188 Pathology Cardiovascular System ASD is assocated with *Down Syndrome*

191 Pathology Endocrine, Diabetes & _Metabolism Pt with xanthelsama (xanthomas on medial eyelids). Best next step _{is *Serum lipids and glucose*} 192 Physiology Cardiovascular System

Pt with occlusion of "right" coronary artery causes acute MI. This could lead to Sudden Cardiac Death, the most common

mechanism of death here is *Ventricular Fibrillation* 193 PathophysiologyCardiovascular System

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

[Free wall rupture]

12 year old with a wide, fixed splitting of second heart sound on routine physical exam. The congenital heart disease in this pt may require surgical repair to prevent irreversible changes in

*Pulmonary Vessels*

(ASD, Pulmonary artery develop laminated medial hypertrophy, irreversible)

202 Embryology Cardiovascular System

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

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208 Physiology Female Reproductive _{System & Breast} Pulsatile (every 90 mins 4e.g) adminstration of GnRh is indicated _{in Infertility (e.g Anovulation)}

209 Pharmacology Endocrine, Diabetes & _Metabolism

Leuprolide is GnRh Analog and can be used in treatment of prostate cancer. (metastasizes to vertebrae)

On initial therapy with Leuprolide *Testestrone and DHT rise then fall with continued use*

212 PathophysiologyEndocrine, Diabetes & _Metabolism

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

219 Pharmacology Hematology & Oncology In 220 Pathology Endocrine, Diabetes & _Metabolism

Post delivery woman who presents with signs of

panhypopituitarism with failure of lactation, central hypothyroidism, and adrenal insufficiency. Most likley represents *Ischemic

necrosis* of pituitray gland (Sheehan Syndrome). 222 Pharmacology Psychiatric/Behavioral & _{Substance Abuse}

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

225 Pathology Endocrine, Diabetes & _Metabolism

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

[Pituitart apoplexy]

Signs of Hyponatremia (altered mental status, headache,

weakness, seizures) plus a lung mass suggest SIADH casued by small cell carcinoma. An additional finding would be *normal extraceullar fluid volume*. Regulatory mechanism in the body deal with the hyponatremia resulting a Euvolemic hyponatremia. 228 Pathology Cardiovascular System

Pt is fatigued. P.E shows lesions involving nail beds. Further evaluation would reveal additional abnormality during *Cardiac Auscultation*

[Infective endocarditis reveals a mitral regurg murmur] 231 Pathology Cardiovascular System

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

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

The best indicator for mitral stenosis severity is *A2-to-opening snapp time interval*

(shorter when more severe) (atrial pressure builds up causing more forceful opening of valve "snap")

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

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

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238 PathophysiologyCardiovascular System Head poudning and bobbing are associated with *Widening of _{pulse pressure*}

10 yr old boy presents with restlessness and involuntary kerking of face, arms & legs 3 months after a sore throat. Pt is at greatest risk fro developing *Valvular Heart Disease*

[Sydenham chorea as part of Acute Rheumatic Fever after Group A strep infection]

242 Pathology Cardiovascular System *Calcific Degenration* of trileaflet aortic valve is the most common _{cause of Aortic Stenosis in Developed Nations.} 244 PathophysiologyCardiovascular System

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

247 Behavioral _science Psychiatric/Behavioral & _{Substance Abuse}

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

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

252 Embryology Miscellaneous _{(Multisystem)}

Fetus that has closely set eyes, middline mass cosistent with a proboscis, fused cerebral hemispheres, and an absent forebrain fissure has Holoprosencephaly whicha type of *Malformation* 255 Pathology Gastrointestinal & Nutrition Pt with sharp pain and bright red rectal bleeding on defecation suggest an Anal Fissure. Which is at the *Posterior midline Distal

to the Dentate line*

256 Genetics Female Reproductive _{System & Breast} Pt with signs of Turner Syndrome is likey to have *Bicuspid Aortic _Valve*

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

[Right sided colon Cancer]

264 Pharmacology Nervous System Long treatment of Parkinsons with Levidopa renders *DRUG _RESPONSE_{UNPREDICTABLE*} 265 Pharmacology Nervous System

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

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

(Histoplasma Capsulatum) 267 Microbiology Pulmonary & Critical Care

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

Exam of lung tissue that shows spherules oacked with endospores. Pt history will most likely reveal *Recent travel to Arizona*

[Coccidoides Immitis][Southern and central California, Arizona, New Mexico, & Western Texas]

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274 Pharmacology Infectious Diseases

Adminstering Amphoteracin B (binds to ergosterol) has a risk of Renal Toxicity that could result in Severe hypokalemia and hypomagnesemia due to increased tubular permeability. Therefore, *Serum K & Mg levels* should be monitored. 275 Pharmacology Renal, Urinary Systems & _Electrolytes

The most dangerous adverse effect of Amhoteracin B is

Nephrotoxicity which can be called *Renal Tubular Dysfunction* [pt presents with ECG finding of frequent premature ventricular beats, a finding due to kidney damage induced hypokalemia] 277 Pharmacology Infectious Diseases

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

278 Microbiology Gastrointestinal & Nutrition

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

279 PathophysiologyGastrointestinal & Nutrition Zenker Diverticulum is due to *Cricopharyngeal motor dysfunction* 281 Pathology Gastrointestinal & Nutrition

Alcoholic male presents with hematemesis. Endoscopy shows longitudinal mucosal tears at the gastroesophageal junction. This pt condition is most likely related to *Intraabdominal pressure*

[Mallory-Weiss syndrome]

Pt presents with anatcid resistant severe Heart Burn. P.E shows scattered Telangiectasias on face, several ulcers at tip of fingers, and small Ca deposits on hands and elbows. Most likely cause of pt heart burn is *Fibrous Replacement of the muscularis in the lower esophagus*

[CREST syndrome, Calcinossi, Raynaud Phenomenon, Esophageal dysmotility, Sclerodactly, Telangiectasia] [Esophageal dysmoti is result of atrophy and "Fibrous replacement" of muscularis in lower esoph]

290 Pathology Gastrointestinal & Nutrition Erosions are defined as mucosal defects that do not fully extend _{thru the *Muscularis Mucosa*} 292 Anatomy Gastrointestinal & Nutrition

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

298 Immunology Rheumatology/Orthopedics _{& Sports}

Pts with Lymphocytes with mutated Fas gene product (i.e Fas receptor) would have an impaired *Activation-Induced T Lymhocyte Death*

Fas ligand that binds to Fas receptor on t cells activates Fas assoc death domian (FADD) which activates caspases leading to

Apoptosis.

299 Physiology Female Reproductive _{System & Breast} Progestron withdrawal leads to menses (i.e bleeding) which is a _{result of *Apoptosis*}

303 Anatomy Gastrointestinal & Nutrition

Laparotomy shows decreased angle between superior mesenteric artery and aorta. The structure most likley obstructed is

*Transverse portion of duodenum* [Superior mesenteric artery syndrome] 304 Pathology Gastrointestinal & Nutrition

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

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A pt with distal ulcer and high-normal gastrin levels that rise in response to secretin adminstration are suggestive of

Zollinger-Ellison Syndrome. The is caused by gastrin-secreting tumors (Gastrinomas) which is a *Neoplasia*

Usually secretin inhibits gastrin production. 306 PathophysiologyGastrointestinal & Nutrition

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

308 PathophysiologyEar, Nose & Throat (ENT)

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

320 Embryology Gastrointestinal & Nutrition Pt with Imperforate Ausu often have *Urinary tract Abnormalities* _{accompanying the condition.} 321 Embryology Gastrointestinal & Nutrition Meckels diverticulum is an example of ECTOPY.

326 Pathology Gastrointestinal & Nutrition Celiac disease is diagnosed with *Small intestine Biopsy* 327 Pathology Gastrointestinal & Nutrition

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

*Abetalipoproteinemia*

330 Embryology Gastrointestinal & Nutrition If neural crest migation to the intestine is interrupted by the final _{week (12 week) of migration, The *Rectum* would be affected.}

333 Pathology Female Reproductive _{System & Breast}

Woman comes for infertility evaluation. She complains of

dyspareunia. Menstrual cycles are accompanied by moderate to sevee lower abdominal pain. Pelvic exam shows a normal-sized, retroverted uterus. The post vaginal fornix is very tender to

palpitation. Pt's condition most likely involves *Ectopic Endometrial Tissue*

[Endometriosis][Adhesions interfere with

ovulation=infetolity][imaplants and adhesions involving uterosacral ligament result in retroverted uterus, ligament]

337 Embryology Pregnancy, Childbirth & _Puerperium

Pregnant pt on anti-convulsants who presents with

polyhydroamnios, fetus probably has *Anencephaly* due to antiepileptic medication whic is a risk factor for neural tube defects.

340 Pathology Rheumatology/Orthopedics _{& Sports}

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

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

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

[Shaken baby sybcrome] 348 Pharmacology Nervous System

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

antihistamines and sedating antidepressants

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350 Pharmacology Psychiatric/Behavioral & _{Substance Abuse} First line therapy for pyschomotor agitation in Alcohol withdrawal is *Chlordiazepoxide* [Long acting benzo]

351 Pharmacology Nervous System

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

352 Pharmacology Nervous System Do not use DIazepam with CNS depressants such as _{*Chlorpheniramine* which is a 1st gen anti-histamine.}

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

360 PathophysiologyOphthalmology

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

361 Biochemistry Rheumatology/Orthopedics _{& Sports} SnRNA has the function of *removal of introns from RNA _transcripts* 363 PathophysiologyGastrointestinal & Nutrition*Absent Liver Conjugation enzymes* as seen in Criggler-najjar syndrome type 1 (UGT enzyme def) can cause Neurlogic

abnormalities due to accumulation of unconjugated billirubin.

Pt who recently travelled to south america. His liver biopsy shows spotty hepatocyte necrosis and inflammatory cell infiltration. Most likely clinical presentation of this pt is *Fever, Anorexia, and dar-colored urine*

[Acute Hep A infection]

[Dark color urine is due to increased conjugated bilirubin levels] 367 Histology Gastrointestinal & Nutrition

*Hep B* infection causes hepatocellular cytoplasm to to fill wih surface hep b antigen. The inclusions are (finely

granular,homogenous, pale pink), dull eosnophilic,ground glass apearance. Commonly transmitted sexually or in "IV drug users"

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

369 PathophysiologyGastrointestinal & Nutrition

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

370 Pathology Gastrointestinal & Nutrition Alcohol induced hepatic steatosis is due to *Decreased Free fatty _{acid Oxidation*}

373 Immunology Gastrointestinal & Nutrition

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

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

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

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

Pt with colon cancer who has Nephrotic Syndrome

(edema+proteinurea)with biopsy showing glomerular cappillary wall thickening without increase in cellularity. When sample is stained with silver, irregular spikes from the GBM are seen. Pt has *Membranous Glomerulopathy*

Child with signs of nephrotic syndrome. Pathologic change that causes protein loss is *Glomerular podocyte damage*

[Effacement of podyctes im Minimal Change Disease] 390 Pathology Infectious Diseases

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

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

[Hemochromatosis]

55 yr old caucasian male who is recently diagnosed with cardiac arrhythmias is found to have mild hepatomegaly. He also

complains of a dark tan despite avoiding sun exposure. Pt most likely suffers from *Hemochromatosis*

[Bronze diabetes, the triad of skin hyperpigmentation, DM, and pigmnet cirrhosis with hepatomegaly]

21 yr old man comes with impared balance, tremor, and diffculty speaking. Symptoms developed slowly over several months. Pt is found to have elevated serum transaminases. Viral Hep serologies are negative. His cousin was Dx at young age with progressive neuro disease. The Dx study most beneficial during work up is *Slit Lamp Exam*

[Wilson Diseae]{Tx with D-penicilamine]

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

Pt with generalized pruritus and high alkaline phosphatase along with high titers of Antimitochondrial antibodies have Primary Billary Cirrhosis. Liver autopsy would morphologically resemble

*Graft-vs-host disease*

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

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405 Pathology Gastrointestinal & Nutrition Pt with abdominal pain, diarhea and heme-positive stools. Stool cultures are negative. Biopsy of colonic mucosa reveals non-caseating granuloma. Pt most likely has *Crohn's Disease* 406 Pathology Gastrointestinal & Nutrition inflamed and swollen terminal ilieum is probably crohns disease in _{which there is involvement of TH1 helper t cells.}

A finding most suggestive of Ulcerative colitis is *Continous Mucosal involvement*

[Transnural inflam, rectal sparing, perianal fistula and

noncaseating granuloma are all suggestive of crohn's disease]

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

[Toxic Megacolon assoc with UC] 411 Pathology Gastrointestinal & Nutrition

A differenc bewteen sporadic colorectal carcinoma and

colitis-associated carcinoma is that colitis associated carcinoma is *Multifical in Nature*

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

419 Embryology Male Reproductive System A patent processus vaginalis causes a communicating hydrocele. _{It can also cause an *Indirect Inguinal Hernia*}

In the Adenoma-to-Carcinoma sequence in colon cancer, The increase in the size if the polyps that mediates the late adenoma part of thes sequence is a result of mutation of *K-ras*

protooncogene. [APC > K-ras > p53]

55 year caucasian male is found on colonoscopy to have a solitary mass in his sigmoid colon. Biopsy shows colon cancer. The

feature that carries the worst prognosis is *Tumor Penetration into the Muscularis Propria*

(Tumor staging, more imp than grade)

425 PathophysiologyHematology & Oncology

Pt with skin flushing, diarhea and cramping. P.E shows purple vascular lesions surrounding her nose (Telangiectasias). Urinary excretion of 5-HIAA is increased over 24 hrs. Imagings shows tumor in small intestine. Most likely resposnible for condition is *Metastatic Carcinoid*

426 Pathology Gastrointestinal & Nutrition The initiating factor in acute appendicitis is *Lumen Obstruction* 427 Pathology Gastrointestinal & Nutrition

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

38 year old man with colonoscopy showing ulcerative colon mass with no polyps and biopsy showing adenocarcnoma. Gene mutation responsible is most likely *MSH2*

(Hereditary Nonpolyposis Colorectal Canceer HNPCC)

Pt is found to have colon adenocarcinoma in the asceding colon. Pt most likely initially presented wuth *Weight loss and progressive fatigue*

[Ascedning colon is wide and would prevent obstruction, pt usually develop anemia due to occult blood loss and non specific

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Pt has acute pancreatitis with normal gallbladder and common bile duct (hence due alcohol). He has a >2 AST:ALT ratio. An

additional lab finding that is likely to be associated with the underlying cause of this pt's pancreatitis is *Mean Corpuscular Volume of 108 fl*

[Alchol causes Macrocytosis (MCV >100)likely due to poor nutrition (folate def))

435 Pathology Gastrointestinal & Nutrition A pancreatic psuedocyst is lined by *Fibrous and Granulation _Tissue*

65 yr old man comes due to weight loss, Jaundice and anorexia. He notes his urine has been dark and his stools pale. P.E shows enlarged but nontender gallbladder. Most important risk factor predisposing of his condition is *Smoking*

[Adneocarcinoma of the head of pancreas, Palpable nontender gall bladder + weight loss + obstructive jaubdice (assoc with priritis, dark urine, and pale stools). Smoking doubles the risk.] 437 Embryology Gastrointestinal & Nutrition The ventral pancreatic primordium gives rise to the *Main _{ppancreatic duct*}

23 year old is hospitalized with acute pancreatitis that resolves rapidly with fasting. Pt does not consume alcohol. One of the tests that sould be considered during the workup is *Serum

Triglycerides*

[Hypertriglyceridemia can cause acute pancreatitis] [Two main causes however are gallstones and alcoholism] 441 PathophysiologyGastrointestinal & NutritionAcute pancreatitis is nitiated by the inappropriate activation of _{*Trypsinogen*} 445 Pathology Cardiovascular System An athersclerotic plaque is likely t occur at the *ABDOMINAL _AORTA*

In the pathogenesis of athersclerotic plaques, release of platelet-derived growth factor (PDGF) by locally adherent

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

Plaque stability is reduced by macrophage release of

*Metalloprotinases* that degrade collagen. likelihood of plaque rupture (and hence casuing acute coronary syndrome) depends on plaque stability not size.

30 year old asian male presents with exertional calf pain and painful foot ulcers. He demonstrates hypersensitivity o

intradermally injected tobacco extract. The process responsible for his condition is *Segmental vasculitis extending into contiguous veins and nerves*

[Buerger's disease]

452 Pathology Cardiovascular System The morphologic changes observed in the arteries of a pt with _{Giant cell arteritis are most similar to *Takasu Arteritis*}

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

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Adrenal Tumor that is functionally similar to the outermost layer of the adrenal cortex (Glomerulosa) would have primary

hyperaldostrnism due to Aldostrone-producing Adenoma (Conn Syndrome)and would therefore have *Sweating & Tremulousness* as an added symptom.

456 Physiology Cardiovascular System

Really old pt with BP 180/70 at one visit then 175/68. The age related changes that best explains his BP reading are *Aortic Stiffening*

[Isolated systolic HTN, Aortic stiffening decreases comppliance of aorta and elevates pressure during systole]

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

[Polyarteritis Nodosa] 458 Pathology Allergy & Immunology

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

[Henoch-Schonlein Purpura]

459 Pathology Allergy & Immunology

Pt is hospitalized with recent onset oliguria and a high serum creatinine level. He has been seen in clinic several times for an untranasal ulcer that has failed to heal. The pt's condition is most likely assoc with antibodies against *Neutrophils*

[Wegner's Granulamatosis with polyangiitis, Cytoplasmic staining Antinuetrohil cytoplasm antibodies (c-ANCA) is pathognomonic] 460 Pathology Cardiovascular System In Polyarteritis Nodosa. The arteries spared are usually the _{*Pulmonary* Arteries.}

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

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

466 Pathology Cardiovascular System Baby with strawberry-type hemangiomas (bening vascular tumor) _{in his buttocks. These *First Increase in size then Regress*}

467 Pathology Dermatology

Pt with small bluish lesion under the nail of her right index finger. It is extremely tender to touch. If the lesion is a tumor, its cells of origin are likely to have a function of *Thermoregulation*

[This could be a glomangioma or a melanoma, since pigmentation is not in answer choice, it must be a glomangioma][A glomangioma is a tumor of modified smooth muscle cells of a glomus body. Glomus bodies are involved in thermoregulation]

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

*Von-Hippel-Lindau disease* 469 Pathology Cardiovascular System

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

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Female with history of breast cancer treated by radical mastectomy and radiation years ago. She now presents with persistent right arm swelling. This pt is at increased risk of developing *Lymphangiosarcoma*

[Persistent lymphedema predisposes to lymphangiosarcoma, a rare malignant neoplasm of endothelial lining of lymphatic channels]`

A vascular tumor that is associated with Arsenic and

Polyvinylchloride. The tumor is also postive for CD31. This is *Liver Angiosarcoma*

472 Pathology Infectious Diseases

Pt with aortic regurg murmur (diastolic) in the presence of

mediastinal widening. FTA-ABS psotive (syphilus). The pathologic process responsible starts at *Vasa Vasoum Obliteration*

[Teriary Syphilus causing aortic aneyrysm, which beigns with vasa vasorum endarteritis and obliteration resulting in inflam, ischemia and weakening of adventitia.]

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

478 Histology Pulmonary & Critical Care *Type 2 Pneumocytes* have the ability to proliferate in response to _{cell injury. They can regenerate!}

480 Histology Pulmonary & Critical Care

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

481 Physiology Pulmonary & Critical Care

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

483 Histology Infectious Diseases

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

485 Pathology Pulmonary & Critical Care

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

Pt who history of heavy alcohol use and was admitted before for acute pancreatitis. He presents with nausea vomitting and severe abdominal pain. On 2nd day he develops dyspnea, and

hypoxemia. The parameter that is most likely normal in this pt is *Pulmonary Capillary Wedge pressure*

[signs suggest ARDS for whch pancreatitis is major risk factor, pulmonary edema with normal PCWP]

488 Histology Pulmonary & Critical Care smoking induced emphysema is contributed to by neutrophils. 492 Pathology Nervous System

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

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

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

496 Embryology Nervous System

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

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

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

502 Embryology Nervous System Acetylcholinestrase in the amniotic fluid indicates a neural tube _{defect in which there is a *Failure of Fusion*}

Youn woman who presents with episodic headaches, dizziness and gait disturbance. MRI of brain shows low lying cerebellar tonisls extending into vertebral canal. Cause of this is a *Congenital Malformation*

(Chiari type 1) 505 Pathology Nervous System

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

[Epidural Hematoma]

507 Pharmacology Pregnancy, Childbirth & _Puerperium Valproate increases risk of neural tube defects in pregnant women _{such as *Meningocele*}

Drug interaction 2-3 weeks after New medication (e.g

phenytoin)that presents with cutaneous and systemic symptoms such as diffuse erythema, generalized lymphadenopathy and facial swelling arise from DRESS (drug reaction with Eosinophila & systemic Symptoms) as the name suggests, lab finding would be *EOSINOPHILIA*

513 Anatomy Nervous System

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

519 Pharmacology Psychiatric/Behavioral & _{Substance Abuse} Drug interactions with lithium include Thiazide diuretics. Symptoms _{of toxicity include resting tremor, balance issues (ataxia).}

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

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524 Histology Pulmonary & Critical Care

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

527 PathophysiologyPulmonary & Critical Care

Young pt with paroxysmal episdoes of breathlessness and

wheezing unrelated to anything. Sputum microscopy shows many granule containing cells and crystalloid masses. The sputum finding suggest the role of *IL-5* in this pts condition.

[granule containing cells are eosinophils and crystalloid bodies are charocot-leyden crystalsl, a response to IL-5 released by allergen activated TH2 cells]

528 PathophysiologyPulmonary & Critical Care Hypocapnia implies *alveola hyperventilation*

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

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

*Aspiration of oropharyngeal contents* [Lung Abscess]

Pt with Peptosreptococcus and Fusobacterium in his lung. Predisposing factor to his condition is *Seizure disorder*

[Lung abscess, caused by Oropharyngeal aspiration which can occur due to seizures (loss of consciousness)]

536 Physiology Pulmonary & Critical Care Dust particles smaller than 2 micrometres are eliminated by _{macrophages through phagocytosis.}

537 Immunology Hematology & Oncology

Male Infant with eczema, recuurent infections and thrombocytopenia has *Wiskot-Aldrich Syndrome*

[X-linked][Combined B and T cell disorder][Tx with Bone marrow transplant]

538 Immunology Rheumatology/Orthopedics _{& Sports}

2 year old with recurrent skin and mucosal infections. Skin

infection drainage grows Staph aureus with no purulence. Lab test reveals absent CD18 antigens on leukocytes. Pt is at greatest risk for *Persistent Leukocytosis*

(Leukocyte Adhesion Deficiency type 1) 543 Embryology Endocrine, Diabetes & _Metabolism

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

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

548 Pharmacology Endocrine, Diabetes & _Metabolism Glucucorticoids such as Prednisone cause Increased LIVER _{gluconeogenesis, therby activation *LIVER Protien Synthesis*} 549 Pharmacology Endocrine, Diabetes & _Metabolism High-dose Prednison (Corticosteroid) would elevate *Neutrophil* _levels. 550 Embryology Endocrine, Diabetes & _Metabolism *Cortisol* has the greatest effect on lecithin to sphingmyelin ratio _{(greater than 1.9 indicates mature lung)} 552 Pathology Pulmonary & Critical Care Hamartomas are the most common benign lung tumors. They are _{composed of disorganized *Cartilage, fibrous, and adipose tissue*}

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55 yr old woman present due to cough and recent weight loss. She doesnt smoke. P.E shows decreased breath sounds and dullness to percussion at the left lung base. Image studies show an irregular mass in the lower lobe of her left lung and left-sides pleural

effusion. It malignancy is diagnosed it is most likley *Adenocarcinoma*

[Most common lung cancer in general populattion]

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

556 Immunology Allergy & Immunology

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

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

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

[Disseminated Gonorrheal Infection, produce IgA proteases]

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

[Superior Venecava syndrome]

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

569 Immunology Renal, Urinary Systems & _Electrolytes

Hyperacute renal transplant recjection is an *Antibody-mediated hypersensitivity*

(preformed Ab's against graft)

Following amitriptyline overdose (TCA). There is QRS widening and QTc prolongation. And Death occurs. Deat is related to *Sodium Chanel inhibition*

[Fast Na chanel inhibition resulting in conduction defects and arrythmias]

Pt with Klinefelters have azospermia. That mean sperm count is *None*

Ofcourse together with low LH, FSH and Testestrone.

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585 Pathology Endocrine, Diabetes & _Metabolism

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

589 Immunology Gastrointestinal & Nutrition

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

591 Genetics Nervous System

Young man who is aysmptomatic and found to be homozygous for the apolipoprotein E-4 allele. In the future he most likely to suffer from *Alzheimer's dementia*

[Late onset familial Alzheimer's disease]

[Eary onset is assoc with 1) Amyloid precursor protein on chrom 21. 2) Presenilin 1 gene on chrom 14. 3) Presenilin 2 gene on chrom 1.]

593 Pathology Nervous System In alzheimer's disease, there is *Decreased acetycholine activity _{in the nucelus basalis*}

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

598 Biochemistry Nervous System

Wernicke syndrome manifests with opthalmoplegia, ataxia, & confusion. There is foci of hemorrhage and necrosis in the "mamillary bodies" and periaqueductal gray matter om autopsy. Diagnosis involves measuring *Eythrocyte Transketolase activity* It occurs due to chronic Thiamine (B1) def commonly in alcoholics. 600 Pharmacology Endocrine, Diabetes & _Metabolism

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

602 Biochemistry Endocrine, Diabetes & _Metabolism

Pituitary resection decreases ACTH which decreases Cortisol, decrease in cortisol decreases expression of

*PHENYLETHANOL-N-METHYLTRANSFERASE* which the enzyme that converts Norepi into Epi. Therefore, putituwary resection leads to decreased EPI production.

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

Pioglitazone which is Thiazolidinedione antidiabetic dryg targets *intracellular nucelar receptor*

[Binds peroxisome proliferator activated receptor gamma]

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

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

611 PathophysiologyEndocrine, Diabetes & _Metabolism 11-hydroxylase deficiency in congenitl adrenal hyperplasia causes _{high PB and Hirstutism (Big clit)}

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

Pt with signs of Hyperthryroidism with eye involvement (bilateral redness, proptosis (exopthalmos))was given medication that reduced her proptosis. The drug did that by affecting *Inflammatory infiltration*

[Glucorticoids to treat exopthalmos in Grave disease pts] 623 PathophysiologyEndocrine, Diabetes & _Metabolism

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

624 Pathology Male Reproductive System

Pt presents with a painless scrotal nass. He also has increased sweating and heat intolerance. P.E shows an enlarged nontender right testicle. Lab shows increased serum T4 and T3. The

constellation of findings seen in this pt most likley suggest an elevation of serum *hCG*

[Testicular malignancy releases hCG which has a similar structure to TSH and can bind and activate thyroid to produce

Paraneoplastic Hyperthyroidism.]

625 Pharmacology Endocrine, Diabetes & _Metabolism *TSH levels* should be monitored in pts receiving Amiodorone _therapy! 626 Pharmacology Endocrine, Diabetes & _Metabolism Methimazole inhibits *Coupling of iodotyrosines* in the thyroid _gland.

Old pt with long standing HTN who presents for involuntary movements, "Threw remote control across the room" P,E shows Large amplitude flinging movements affecting proximal muscles of upper extremity. Pt most likely has injury to *Subthalamic Nucleus* 636 Pathology Nervous System Friedreich ataxia is associated with *Cardiomyopathy*

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

639 Physiology Rheumatology/Orthopedics _{& Sports}

Pt with pain and deformity of long bones with hearing loss (due to bony deformity of the skull). The pathologists identifies

multinuncleated cells containing over a 100 nuclei. The factor that is essential for the differentiation of these cells is *Receptor Activator of Nuclear factor Kappa-B ligand (RANK-L)* (Pagets disease of bone, Osteoclasts)

645 Microbiology Cardiovascular System Coagulase-negative streptococci such as staph epi are methicilin _{reistant and should be treated with *Vancomysin*}

646 Microbiology Rheumatology/Orthopedics _{& Sports}

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

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