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Study Pg 502 anesthetic

o Low solubility in BLOOD = RAPID induction


o High LIPID solubility = increased potency
XXY = defect in X & Y separation = occurs in Meiosis I
o Meosis 1 = primary spermatocyte to secondary spermatocyte
Renal artery stenosis = decreased blood flow to kidneys = increased renin,
increased TPR, increased aldosterone
1. 60-year-old man for routine health examination. Has had normal blood pressure
measurements. BP today 170/95mmHg. Physical examination shows no other abnormalities.
Serum show hypokalemia and metabolic alkalosis. Plasma renin activity and serum aldosterone
concentrations are increased. Following the administration of captopril, there is a marked
increase in plasma renin activity. Which of the following is the most likely cause of the findings in
this patient?
- Renal artery stenosis
45. 52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. He
had played tennis all day and he does not remember how much fluid he had consumed. His
temperature is 36.7 oC, pulse 122min, respirations 28min and BP 90/50 mmHg. PE shows dry
skin and decreased capillary refill. An ECG and evaluation of cardiac enzymes show no
abnormalities. Which of the following findings in the nephron best describes the tubular
osmolarity, compared with serum in this patient?
PT //macula densa //medullary collection duct
- Isotonic, hypotonic, hypertonic (?)
23. 25-year-old woman with polycystic kidneys and 3-month history of weakness, fatigue,
headaches, hypertension, loss of appetite and itching. Cr 4. Labs?
- bicarb (HCO3-) decreased, inorganic phosphorous (PO4) increased, parathyroid hormone
increased

Look over anatomy

6. 35-year-old woman with 3-month progressive shortness of breath with exertion. RR 26.
Physical shows jvd and prominent a wave. Lungs clear. Cardiac exam shows loud
pulmonic component of S2 and right-sided S4 gallop. Increased pulmonary expression of
what?
- Endothelin-1
45. 45 yr old man with SOB on exertion x 6 months, nosebleeds since adolescence, 2 pics:
clubbing + hemorrhagic lesions in tongue, inhaled albuterol doesn't improve his symptoms.
Cause of symptoms?
- Pulmonary AV shunting
Disease is osler weber rendu
26. A 70-year-old woman comes to the physician for a routine pelvic examination. During
speculum examination of the vagina and cervix, the Valsalva maneuver causes a bulge of the
anterior vaginal wall. Which of the following is the most likely cause of this finding?
- Cystocelea

Leukemoid reaction is just an acute inflammatory reaction= WBC count and


neutrophils, also leukocyte alkaline phosphatase
Hemochromatosis = greatest risk for HCC
Myelin Basic Protein = MS
Bacterial crap on liver = fibrin
Common Metastases pg 233
o PB/KTL
Atelectasis from contraction (secondary to radiation)
Irregular raised, dark lesions on sunlight exposed area. Biposy shows
malignant pigmented cells = melanoma = most unfavorable prognosis if in
SUBCUTANEOUS TISSUE
V/Q = 0 = pulmonary shunt (no ventilation)
11. After operation, 65-year-old patient has lung region that is underventilated but well perfused.
Which increases?
- Physiologic shunt

Subacute granulomatous thyroiditis can be hyperthyroid acutely


Prednisone start for RA while DMARD becomes effective
Liver metastasis - Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal
Aspirin overdose = 12 hr later = metabolic acidosis
Diaphragmatic Hernia = defect in left pleuroperitoneal membrane
Pseudocholinesterase deficiency is a condition in which a person's body is abnormally
slow at breaking down a certain class of drugs used for surgical anesthesia. Pt has slow
recovery from paralysis

24. An 85-year-old woman is diagnosed with a fracture of the right femur and begins treatment with
morphine by patient-controlled analgesic pump. Three days later, her respirations are 6/min. Physical
examination shows pinpoint pupils. Her serum creatinine concentration is 1.8 mg/dL. Which of the
following best explains this patient's clinical deterioration after the initiation of morphine therapy?
- Morphine is metabolized to active metabolites that accumulate

21. 35-year-old F with intermittent sharp chest pain exacerbated by deep breathing, and can be
decreased by leaning forward. 2-month hx of pain and swelling in her hands and knees accompanied by

morning stiffness that lasts 1 hour. Pulsus paradoxus less than 10 mm Hg. Harsh scratchy sound present
in systole and diastole. Warmth, swelling, and tenderness of the metacarphophalangeal joints and knees.
Cause?
- Pericarditis

7. 38-year-old F undergoes laparoscopic cholecystecomy with general anesthesia. Afetr she awakens
postoperatively, she is nauseated and vomits threee times in 20 minutes. Treatment for N/V?
- Ondansetron
25. 35 y/o man with 3 yr history of enlarging nose, coarse facies, muscle weakness, increased hand/foot
size. Large fleshy nose and prognathism on exam. High IGF-1 in serum. MRI shows pituitary adenoma.
Morphologic analysis of the tumor shows a densely granulated somatotroph adenoma. Further studies
show that the G alpha-s subunit of the tumor G proteins lack GTPase activity. The tumor cells most likely
have an increased activity of which enzyme?
- Adenlyl cyclase
27. 56-year-old with palpable hard nodule on prstate has increased serum prostate-specific antigen
concentration. Fine-needle biopsy specimen shows adenocarcinoma. Patient undergoes radical
prostatectomy. Which structure is at greatest risk for injury during removal of prostate?
- Pelvic parasympathetic nerves
29. 66-year-old man surgical excision of a brain mass; photomicrograph of excised tissue shown. Smoked
1 pack daily for 50 years. Labs show polycythemia, hypercalcemia, and microscopic hematuria.
Immunostaining of the tissue is positive for epithelial membrane antigen and negative for
carcinoembryonic antigen. Site of primary neoplasm?
- Kidney b/c hypercalemia due to PTHrP (squamous cell lung carcinoma or renal cell carcinoma) but EPO
increased in renal cell carcinoma so kidney is most likely)
34. 28-year-old woman with 1-week history of fever and chills. 4.5-kg weight loss, 5-year hx of chronic
sinusitis. Mildly distressed. BMI 18. Temp is 39 C (102.2 F). Has markedly diminished nasal septa. Chest
x-ray shows multiple pulmonary nodules. Serologic studies hsow presence of antibodies against
proteinase 3. Dx?
- Wegener granulomatosis
5. 12-year-old girl with progressive fatigue and generalized weakness for 5 months. Erythematous,
maculopapular rash over elbows and proximal muscle weakness. Difficulty lifting her upper extremities.
Trouble standing from a seated position. Increased serum kinase activity; serum antinuclear antibody
assay positive. Dx?
- Dermatomyositis
51-year-old M with 3-mo hx of hepatitis B antigen-negative polyarteritis nodosa has progressive proximal
muscle weakness and myalgia. A biopsy specimen of involved muscle would show?
- Segmental ischemic necrosis
9. 62-year-old F with chronic renal disease. BMI 21, BP is 140/100. Labs show anemia. Rx with
intravenous recombinant erythropoietin is started. Measurement of which is best to monitor effectiveness
of Rx?
- Plasma hemoglobin concentration
10. 27-year-old nulligravid inability to conceive for 2 years. Menses at 3- to 4-month intervals since
menarche at 14 years Follicle-stimulating hormone, luteinizing hormone, and estrogen wnl. Most
appropriate Rx?
- Clomiphene

12. 45-year-old M has fever chills, dysuria, and a tender, enlarged prostate. Organism?
- Escherichia coli
13. 76-year-old M with a 1-month hx of pulsatile abdominal mass dx with an abdominal aortic aneurysm.
CT scan with contrast also showed incidental finding of a horseshoe kidney. Surgical approach to repair
aneurysm to be further complicated be presence of which?
- Abnormal origin of the superior mesenteric artery
15. 18-year-old M with anxiety and confusion for 6 hours. No A/V hallucinations. T 38.2 C, pulse 130/min,
BP 180/110. Diaphoresis, pupillary dilation, and muscle weakness. Substance?
- Amphetamines
17. 68-year-old M with 2-hour episode of loss of vision in his right eye 2 days ago. Underwent left femoralpopliteal bypass 3 months ago for peripheral vascular disease. Funduscopic exam shows cholesterol
emboli. Cause is embolus in which arteriers?
- Right ophthalmic
22. 24-year-old woman stung on her right thumb by a bee 30 minutes ago. Urticarial lesion at site of sting.
Six hour later, area has become indurated and firm. Explanation of the induration?
- Influx of macrophages producing interleukin-1 (IL-1), IL-6, and tumor necrosis factor-alpha
25. 55-year-old F has headache, T to 40 C, stiff neck and confusion. Spleen removed due to injury in
MVC 7 months ago. Most likely organism in cerebrospinal fluid?
- Streptococcus pneumoniae
35. 49-year-old woman with breast cancer develops increased numbness of both hands and feet between
chemotherapy doses. Sensation to pinprick and fine touch decreased over hands, wrists, ankles, and
feet. Which is most likely disrupted in this patient as a result of the chemo?
- Microtubules for axonal transport
40. 54-year-old woman who works as a nurse comes to the physician for routine tuberculosis screening. A
sample of her whole blood is incubated with a mixture of synthetic peptides representing two proteins of
the suspected pathogen. Three days later, supernatant is collected for evaluation. Measurement of which
of the following cytokine concentrations is most likely to indicate a positive result?
- Interferon gamma
41. 20-year-old F with BP 140/100. BUN 50, glucose 90. U/A shows numerous WBCs and WBC casts;
protein excretion is 3000 mg/24h. GFR is 20% of normal. Ultrasonography shows small asymmetric
kidneys with broad scars and blunted calyces, with vesicoureteral reflux. Dx?
- Bilateral hydronephrosis
43. 20-year-old M with 4-hr hx of abdominal pain, nausea, and vomiting. Had been drinking ethanol
heavily all weekend and took three doses of acetaminophen. Increased risk for liver injury because of
which factor of ethanol?
- Induction of cytochrome P450 enzymes that activate acetaminophen to a hepatotoxic metabolite
45. 45-year-old M with congestive heart failure. Two 1st degree relatives died in 40s with dilated
cardiomyopathy and cirrhosis. Has cardiac enlargement and generalized hyperpigmentation. Glucose is
320. Histologic exam of endomyocardial tissue is most likely to show an excess of?
- Iron
46. 64 y/o man with cough, dyspnea, and chest pain. CXR shows abnormal density in hilar region. Biopsy
shows round cells with little cytoplasm that are twice size of lymphocytes. Cells are arranged in
infiltrating sheets that have neither glandular nor squamous organization. Which abnormality would you
find?

- Hyponatremia: round cells with little cytoplasm = small cells; hilar region = central = either small cell or
squamous cell. They say it is negative for squamous, so small cell carcinoma of the lung. Will see SIADH
= hyponatremia
2. 24-year-old African American M with 3-mo Hx of red bumps on his face and chin, istchy and painful.
Hyperpigmented papules over the cheeks, jawline, and neck. Dx?
- Pseudofolliculitis barbae
12-year-old boy with 6-mo hx of difficulty walking and leg pain. Mild atrophy of the lower extremities and
hammer toes. High-stepping gait. Nerve biopsy will show?
- Abnormal myelin sheaths
11. Investigator studying regulation of pulmonary lymphatic flow. Catheters in femoral vein, pulmonary
artery, and main lymphatic vessel drainig the lungs in animals. Which will most likely increase the flow of
pulmonary lymph in these animals?
- Intravenous infusion of 0.9% saline for 5 minutes
12. 18-year-old M with acute lymphoblastic leukemia with 3-day hx of fever & left0sided chest pain. Taking
chemo asparaginase, disorubicin, prednisone, and vincristine. ANC less than 500. T 39.2. Lower lobe
infiltrate and a moderate pleural effusion on the left. Photomicrograph of a periodic acid-Schiff stain of
pleural fluid obtained via thoracentesis is shown. Appropriate Rx?
- Amphotericin B
23. 55yo M with constipation since starting OTC medication 2 weeks ago for a chronic, persistent cough
and sinus congestion. Which ingredients is causing new symptom?
- Dextromethorphan
24. 23-year-old F with Sjogren syndrome 6 years ago has 3/10 burning pain in her toes. Uses capsaicin
cream to help. Has decreased perception of temperature over the feet bilatearlly. Sensation to vibration,
proprioception, reflexes, muscle strength are normal. Which neurotransmitter is mediating pain?
- Substance P
25. 26yo M undergoes colonscopy for tenesmus and bloody diarrhea. Biopsy shows microabscesses
within the crypts and depletion of mucus from goblet cells. Dx?
- Ulcerative colitis
27. Newborn female dx with hypothyroidism 2 days after birth. Ultrasonography of the neck shows
absence of any thyroid gland tissue. Physical is normal. Maternal to fetal transfer of which explains
normal development?
Study of antiretroviral agents to identify which agents inhibits entry of the HIV virus into the CD4+ T
lymphocytes. Which agents is most likely to be identified?
- Enfuvirtide
30. 38yo F with 10-week hx of epigastric pain and frequent stools. Has had two episodes of renal calculi
in 2 yrs. Superficial lipomata and mild epigastric tenderness. Upper endoscopy shows two large,
nonbleeding duodenal ulcers. Gastric pH is 2.3, gastrin concentration is 2000. PPI started. Measurement
of which is next step?
- Serum calcium concentration
32.16yo boy 30 minutes after he dove into a 3-foot-deep pool at night. Unable to move right upper/lower
extremities. Damage to which labeled region of cross section of spinal cord?
-G

37. Studying bacterial virulence factors. Ferric uptake regulation protein (Fur) binds to DNA at 5' end. Fur
efficiency increases as concentration of iron increases. Fur regulates which processes?
- Transcription
42. Full-term female develops respiratory distress shortly after delivery. Cyanosis, markedly decreased
breath sounds bilatearlly, and occasional bowel sound over left hemithorax. CXR shows multiple- cysticappearing areas on the left and decreased aeration on the right. Dx?
- Congenital diaphragmatic hernia
43. 15-year-old boy BMI 21. Pulse 85 and bounding, BP 110/40. Ophthalmologic exam shows dislocation
of right lens. Pectus excavatum. 3/6 decrescendo diastolic murmur at aortic area. CXR shows wide
mediastinum. Genetic defect in production of?
- Fibrillin
44. 60-yo-M has coagulation testing prior to CABG. PR is 11.5, and activated PTT is 160 seconds. Which
inflammatory responses is most likely to be abnormal?
- Kallikrein formation
45. Study of Plasmodium infection in animal model. Animals inoculated with various species. Chloroquine
is administered. Which two Plasmodium species will stay viable?
- P. falciparum and P. vivax

Internal Laryngeal N. = cough reflex = piriform recess


Gag Reflex = CN 9 and CN 10
S4 = left ventricular hypertrophy
PPARalpha increased LPL activity AND decreases VLDL production
Fibrates and Niacin both decrease VLDL production
If all else fails, person from underdeveloped country with murmur = think RF which is associated with MR
If you have a normal A-a gradient, then low arterial O2 is directly due to low alveolar O2 and not due to
V/Q mismatch or diffusion disorders.
Mycobacterium Avium vs TB: Avium grows at higher temps, goes to reticuloendothelial organs so it will be
seen with anemia, elevated LDH and ALP.
Kussmall sign (paradoxal increase in JVP on inspiration) = CHRONIC not acute pericarditis
Pulsus Paradoxus (>10 mmHg drop during inspiration) = CHRONIC not acute pericarditis, cardiac
tamponade, cor pulmonale
Pericardial Knock = sound heard in early diastole, before S2 = seen in CHRONIC, not acute pericarditis
5 days after MI = LV free wall rupture = hypotension, PEA and death
True ventricular aneurysm = >1month
L sided HF = Pulmonary Hypertension (PH) = pulmonary venous congestion, increased endothelin,
increased vascular tone, remodeling of pulmonary vasculature, SM proliferation (medial hypertrophy) and
intimal thickening and fibrosis (collagen and elastase deposition)
PH due to hypoxia induced constriction = COPD and emphysema obliteration of pulmonary vasculature

Hemosiderin laden macrophages in lung = CHRONIC LV failure


Lowest osmolarity in high ADH or dehydration = DCT
If Lactate is not being generated, then NAD+ is not being produced, so NAD+ cant be used for glycolysis
NADH formed from HMP shunt necessary for FA synthesis
Review ethanol effects, alcohol stops gluconeogenesis, not glycogenolysis
Ketone formation + Glucose formation is due to hormone sensitive lipase which breaks down TGs into
Glycerol and FAs. FAs turn into ketones. Glycerol into glucose. HSL is activated during starvation.
rT3 formed from T4, not T3
Insulin resistance decreases effects of insulin, so you get increased lipolysis = increased FFAs
Primary Aldosteronism = NORMAL Sodium due to aldosterone escape; bicarb is also increased due to
increased H+ excretion
SIADH = euvolemic hyponatremia = NORMAL Extracellular volumes

T3/4 and Cortisol increases gluconeogenesis, lipolysis, proteolysis


Glucagon increases lipolysis, ketogenesis (opposite of insulin)

Tenderpoint for calf = muscle belly in lower popliteal margin

Inferior vertical strain = index fingers moving superiorly and 5th fingers moving
inferiorly while palpating the cranium with vault hold

Iliacus tenderpoint tx = flexion and External rotation

OA translation more symmetric in extended position = ease = OA extended

Articularotry techniques = LVLA = good for post-op pts. examples include Rib
Raising and Spencer technique

IT band syndrome tx = pt lateral recumbent and physician apply pressure


downward on the band

paraspinal inhibition = decrease sympathetics

iliacus tenderpoint = 7 cm medial to ASIS

Posterior tibia on talus (or anterior talus) = diagnosed by decreased dorsiflexion and
tenderness or anterior ankle

Myofascial release or capal tunnel = extend wrist and transverse traction to flexor
retinaculum

AC1 tender point = posterior aspect of ascending ramus of mandible. Tx: rotate
head AWAy
Treatment for radial head tenderpoint = E SUP Val; for medial epicondyle = F PRO
Add
Nursemaids eblow = Flexed, Adducted, Pronated
Bilateral sacral FLEXION = common in post-partum pt

SEX LAP = tendons of De Quervains tenosynovitis = Short Extensor pollicis


(extensor pollicis brevis), Long Abductor Pollicis (abductor pollicis longus)
PC1 = Flexion
PC3 = F Sa Ra
All other post cervical = E Sa Ra
Posterior Rib tenderpts = rotate torso toward and S away