USMLErx 2016

The designers of a COPD study organize subjects into smokers and nonsmokers and
note who gets COPD. What kind of study is this? Cohort (impact of exposure on
disease development); prospective (in whom will disease develop?) "<img
src=""7260 (1).png"">" Behavioral-Science epidemiology-and-biostatistics
observational-studies
"A doctor studies connections between smoking and lung cancer in a study asking,
""Who got sick?"" Into what two groups are subjects divided?" "Smokers and
nonsmokers; this observational, retrospective cohort study looks at prior smoking
exposure and asks, ""Who got the disease?""" "<img src=""7260 (1).png"">"
Behavioral-Science epidemiology-and-biostatistics observational-studies
A twin concordance study is conducted. What aspect of risk for development of
disease can be assessed with this kind of study? Heritability of a disease and
influence of environmental factors (nature vs. nurture) "<img src=""7260
(1).png"">" Behavioral-Science epidemiology-and-biostatistics observational-studies
A study compares the frequency with which siblings raised in different homes
develop a trait or disease. What does this study type measure? This is an
adoption study; it measures the influence of genes and environment on the
development of traits and diseases "<img src=""7260 (1).png"">" Behavioral-Science
epidemiology-and-biostatistics observational-studies
A study determined the prevalence of COPD in the United States in 2010. What type
of study was conducted? Cross-sectional study "<img src=""7260 (1).png"">"
A study compares the frequency of bipolar disorder in monozygotic and dizygotic
twins. What type of study is this? Twin concordance study "<img src=""7260
A researcher studies the relationship between smoking and lung cancer in a case-
control study. Into which two groups are subjects divided? Cases: patients with
lung cancer; controls: patients without lung cancer "<img src=""7260 (1).png"">"
A study shows that patients with diabetes are more likely to have a history of
obesity. What type of study is this? Case-control study "<img src=""7260
A study finds that ibuprofen use increases the relative risk of gastric bleeding.
What type of study is this? Cohort study "<img src=""7260 (1).png"">"
A study assesses the frequency of diabetes and related risk factors among 40- to
60-year-old women in 2014. What type of study is this? Cross-sectional study
"<img src=""7260 (1).png"">" Behavioral-Science epidemiology-and-
biostatistics observational-studies
Which type of study classifies subjects on the basis of their exposure to a given
risk factor? Cohort study "<img src=""7260 (1).png"">" Behavioral-Science
epidemiology-and-biostatistics observational-studies
Name the outcome measures of the following study designs: cross-sectional, case-
control, and cohort. Prevalence, odds ratio, and relative risk "<img src=""7260
A study evaluates different chemotherapy agents. What kind of study compares
different treatments or treatments and placebo in humans? Clinical trial "<img
src=""7261.png"">" Behavioral-Science clinical-trial epidemiology-and-
biostatistics
A researcher conducts a phase I clinical trial. Why is it performed? On whom is it
performed? "To establish the safety, toxicity, and pharmacokinetics of a new
treatment; a small number of healthy volunteers (""is it safe?#34;)" "<img
biostatistics
A researcher conducts a phase II clinical trial. Why is it performed? On whom is it
performed? "To assess optimal dosing, treatment efficacy, and adverse effects; a
small number of pts with the disease (""does it work?"")" "<img src=""7261.png"">"
Behavioral-Science clinical-trial epidemiology-and-biostatistics
A researcher conducts a phase III clinical trial on a large group of people. What
is the purpose of this type of study? "To compare the new treatment with the
current standard of care (existing treatments or placebo)""is it as good or
better?"")" "<img src=""7261.png"">" Behavioral-Science clinical-trial
epidemiology-and-biostatistics
A researcher wants to assess the rare or long-term adverse effects of a drug. Which
phase of clinical trial is best for this? "Phase IV (postmarketing)""can it
stay?""" "<img src=""7261.png"">" Behavioral-Science clinical-trial
"A clinical trial of a new drug is ""triple-blinded."" What does this mean?" The
patient, doctor, and researchers analyzing the data are blinded to which group each
subject has been assigned to "<img src=""7261.png"">" Behavioral-Science
clinical-trial epidemiology-and-biostatistics
A researcher designs a clinical trial. In what three ways can the quality of the
trial be enhanced? Randomizing, controlling, and double-blinding "<img
biostatistics
In a clinical trial, diseased patients are randomly assigned to two groups to test
the new drug against the placebo. In what phase is this? Phase III "<img
biostatistics
A recently approved drug is discontinued after being found to be a rare cause of
sudden cardiac death. How was this adverse effect detected?Postmarketing
surveillance of pts; phase IV of a clinical trial "<img src=""7261.png"">"
Behavioral-Science clinical-trial epidemiology-and-biostatistics
A researcher knows the specificity of a test for diabetes. How is the false-
positive rate calculated? False-positive rate = 1/specificity "<img
src=""7262.png"">" Behavioral-Science epidemiology-and-biostatistics
evaluation-of-diagnostic-tests
A pt asks about her probability of cervical cancer with a positive Pap smear. What
is this epidemiologic measurement called? Positive predictive value "<img
A pt wants to know her probability of being disease-free with a negative Pap smear.
What is this epidemiologic measurement called? Negative predictive value "<img
A revolutionary new HIV test has a negative predictive value of 100%. From this,
what can be inferred about the sensitivity of the test? It must be 100% also
(because FN = 0); all pts who have HIV will be correctly identified by the test
"<img src=""7262.png"">" Behavioral-Science epidemiology-and-
biostatistics evaluation-of-diagnostic-tests
A study of an HIV screening test is conducted. How is the sensitivity of a test
determined? Sensitivity: number of cases correctly identified by test (TP) divided
by total number with disease (TP + FN); sensitivity = TP/(TP + FN) "<img
A man is tested with the use of ELISA, which is a screening test with high
sensitivity. Why is it the best test for ruling out a diagnosis? Tests with high
sensitivity have low false-negative rates, meaning that most negatives are true
negatives (SN-N-OUT = Highly SeNsitive test, when Negative, rules OUT disease)
A Western blot is being done in a woman who tested positive on HIV ELISA. Why is
the Western blot used to follow up an ELISA screening test?Tests with high
specificity (eg, Western blot) confirm a diagnosis (SP-P-IN = Highly Secific test,
when Ppositive, rules IN disease) "<img src=""7262.png"">" Behavioral-Science
epidemiology-and-biostatistics evaluation-of-diagnostic-tests
An HIV test with 100% specificity has a positive result. Is there any chance (>0%)
that the result is a false positive? No: 100% specificity means that the
false-positive rate is 0, so all positives are true-positive results (specificity =
TN/[TN + FP]) "<img src=""7262.png"">" Behavioral-Science epidemiology-
and-biostatistics evaluation-of-diagnostic-tests
A screening test for cancer has 100% specificity. What should the value of the
false-negative rate equal? Not enough information (specificity = TN/[TN + FP])
false-negative results don't matter in calculation of specificity (only
sensitivity) "<img src=""7262.png"">" Behavioral-Science epidemiology-
Two groups are given the same screening test; in one group the positive predictive
value of the test is higher. Why? One group has a higher prevalence of the
disease being tested; the positive predictive value of a test varies with
prevalence "<img src=""7262.png"">" Behavioral-Science epidemiology-and-
A diabetes test has 40 true-positive and 10 false-positive results. What is the
positive predictive value (PPV), and how is it determined? PPV is the number of
true-positive results divided by the total number of positive resultsPPV = TP/(TP
+ FP), so 40/(40 + 10) = 0.8, or 80% "<img src=""7262.png"">" Behavioral-
Science epidemiology-and-biostatistics evaluation-of-diagnostic-tests
Study population A has a higher prevalence of HIV than population B. How do their
negative predictive values (NPVs) compare? Negative predictive value is
inversely related to prevalence, so population A has a lower NPV than population B
A diabetes test has 30 true negatives and 10 false negatives. What is the negative
predictive value (NPV), and how is it determined? NPV is the number of true-
negatives divided by the total number of negatives; NPV = TN/(TN + FN), so 30/(30 +
10) = 0.75 or 75% "<img src=""7262.png"">" Behavioral-Science epidemiology-
A diagnostic test has 100% sensitivity. What is the value of the false-negative
rate? The value of the false-negative rate should be equal to 0 because all cases
of the disease are detected by the test "<img src=""7262.png"">" Behavioral-
Sensitivity of an HBV test is 85%. What percentage of HBV-positive patients test
negative? 15%, which is the false-negative rate; sensitivity = TP/(TP + FN)
Specificity of an HIV test is 75%. What percentage of pts tested false positive?
25%; specificity = TN/(TN + FP) or 1-false-positive rate "<img
In HIV testing, ELISAs are sensitive. Describe the false-positive rate and
threshold as either high or low. High false-positive; low threshold "<img
In HIV testing, Western blots are specific. Describe the false-positive rate and
threshold as either high or low. Low false-positive rate; high threshold "<img
A researcher wants to know the probability of a positive test when a person has the
disease. What is this called? Sensitivity "<img src=""7262.png"">" Behavioral-
You want to know the specificity of a test for diabetes. How is specificity of a
test determined? Specificity = TN/(TN + FP) "<img src=""7262.png"">"
Behavioral-Science epidemiology-and-biostatistics evaluation-of-diagnostic-
tests
You want to know the probability of a negative test when a person does not have the
disease. What is this called? Specificity "<img src=""7262.png"">" Behavioral-
In a population there are 100 new hypertension cases per year and the disease lasts
30 years. What is the approximate prevalence? Prevalence = incidence rate
average disease durationtherefore 100 cases/year 30 years = 300 cases "<img
incidence-vs-prevalence
A study calculates the prevalence of diabetes. Is the prevalence greater than, less
than, or equal to the incidence? Prevalence is much greater than annual
incidence because of the long duration of the disease (chronic disease states)
biostatistics incidence-vs-prevalence
A study calculates the prevalence of the common cold. Is the prevalence greater
than, less than, or equal to the incidence? Incidence and prevalence are
approximately equal for diseases of short duration (acute disease states) "<img
You want to know the number of new cases of flu in the total population at risk for
the year 2015. What is measured incidence/prevalence? Incidence (incidence is new
incidents and prevalence describes all current cases) "<img src=""7263.png"">"
Behavioral-Science epidemiology-and-biostatistics incidence-vs-prevalence
You want to calculate the incidence of lead poisoning in children less than 5
years. What is the equation for calculating incidence rate?Number of new cases in a
specified time period/population at risk during the same time period "<img
You want to calculate the prevalence of hypertension in women over 70. What is the
equation for calculating prevalence? Number of existing cases/population at
risk "<img src=""7263.png"">" Behavioral-Science epidemiology-and-
biostatistics incidence-vs-prevalence
What type of study typically calculates and uses an odds ratio (OR)? What about
relative risk (RR)? Are they the same? No. OR is used in case-control studies
and RR is used in cohort studies; however, if prevalence is low, OR and RR are
interchangeable "<img src=""7264.png"">" Behavioral-Science epidemiology-
and-biostatistics quantifying-risk
Flu develops in 2% of study subjects who received vaccine vs. 8% of those who were
unvaccinated. What is the absolute risk reduction (ARR)? ARR = The difference in
risk attributable to the intervention vs. the control; in this case, ARR = 8%-2% =
6%, or 0.06 "<img src=""7264.png"">" Behavioral-Science epidemiology-and-
biostatistics quantifying-risk
A study finds that lung cancer develops in 17% of smokers vs. 0.5% of nonsmokers.
What is the relative risk (RR)? RR = Risk of disease in the exposed group/risk
of disease in the unexposed group; in this case, RR = 17/0.5 = 34 "<img
quantifying-risk
A study finds that lung cancer develops in 21% of smokers, vs. 1% of nonsmokers.
What is the attributable risk (AR)? AR = Proportion of disease attributable to
exposure; 20% (or 0.20) of the 21% overall risk of lung cancer is attributable to
smoking "<img src=""7264.png"">" Behavioral-Science epidemiology-and-
In a cohort study, 20% of 100 patients who ate sugar and 10% of 100 who did no, get
DM. What's the number needed to harm (NNH)? NNH = 1/AR; AR in this case = 20% -
10% = 10% = 0.1, so NNH = 1/0.1 = 10 "<img src=""7264.png"">" Behavioral-
Science epidemiology-and-biostatistics quantifying-risk
You are studying smoking and lung cancer. What term describes the proportion of
disease caused by exposure to the risk factor being studied? Attributable risk
You want to decide the number of pts who need to be treated with a new medication
for one pt to benefit. How is this calculated? Number Needed to Treat
(NNT)=1/absolute risk reduction (1/ARR) "<img src=""7264.png"">" Behavioral-
Science epidemiology-and-biostatistics quantifying-risk
You want to know how smoking is related to the risk of lung cancer. How is the
number needed to harm calculated? Number Needed to Harm (NNH)=1/attributable risk
(1/AR) "<img src=""7264.png"">" Behavioral-Science epidemiology-and-
A study shows that four people's taking up smoking leads to one new case of
disease. What is the attributable risk of smoking in this case? 25%: In this case,
four is the number needed to harm, so 4 = (1/attributable risk)attributable risk =
(1/4) = 0.25 = 25% "<img src=""7264.png"">" Behavioral-Science
epidemiology-and-biostatistics quantifying-risk
Flu develops in 1% of vaccinated patients and in 8% of unvaccinated ones. Calculate
the relative risk reduction (RRR). RRR (the proportion of risk reduction
attributable to an intervention) = 1-RR = 1-(1/8) = 0.875 "<img src=""7264.png"">"
Behavioral-Science epidemiology-and-biostatistics quantifying-risk
A study on hyperlipidemia is conducted in a large population, and the standard
deviations (SDs) are low. How are precision and SD related?Inverse relationship:
Increased precision means decreased standard deviation "<img src=""7265.png"">"
Behavioral-Science epidemiology-and-biostatistics precision-vs-accuracy
What describes the consistency and reproducibility of a test? Precision "<img
precision-vs-accuracy
What kind of error reduces a test's accuracy? Systemic "<img src=""7265.png"">"
Behavioral-Science epidemiology-and-biostatistics precision-vs-accuracy
A researcher wants to conduct a study with greater precision. What happens to
statistical power when precision increases? Statistical power (1-) increases
biostatistics precision-vs-accuracy
A study asks women with cervical cancer how many sexual partners they had in the
last 15 years. What type of bias might this introduce? Recall bias (awareness
of disorder is likely to alter recall by subjects) "<img src=""7266.png"">"
Behavioral-Science bias-and-study-errors epidemiology-and-biostatistics
In a smoking-cessation study, subjects either receive a medication or nothing at
all. How could bias be reduced in this study? This study is subject to procedure
bias because subjects aren't treated equally; blinding/placebos can reduce
procedure bias "<img src=""7266.png"">" Behavioral-Science bias-and-study-
errors epidemiology-and-biostatistics
In an epidemiologic study, early detection of breast cancer is confused with
increased survival. What type of bias is this? Lead-time bias "<img
src=""7266.png"">" Behavioral-Science bias-and-study-errors epidemiology-and-
biostatistics
A treatment group has access to free wellness classes, but the control group does
not have access. What kind of bias might this introduce? Procedure bias (the
treatment group may have more incentive to remain adherent)"<img src=""7266.png"">"
Behavioral-Science bias-and-study-errors epidemiology-and-biostatistics
A subject is given 3 months of placebo, 2 months of washout, then 3 months of
treatment. What is the advantage of this design? A crossover study limits
confounding bias, because each subject acts as his or her own control "<img
biostatistics
A screening test detects a disease earlier than the onset of symptoms, but the age
at death is unchanged. What type of bias is this? Lead-time bias (early
detection gives a perceived increase in survival time, when it actually has no
effect on the outcome) "<img src=""7266.png"">" Behavioral-Science bias-and-
study-errors epidemiology-and-biostatistics
The expectations of a researcher cause her to unconsciously influence a trial's
outcome (Pygmalion effect). How can this effect be limited?This is observer-
expectancy bias, which occurs when the beliefs of the researcher affect the
outcome; double-blinding can limit it "<img src=""7266.png"">" Behavioral-
Science bias-and-study-errors epidemiology-and-biostatistics
A study shows that PSA testing detects disease before symptom onset but age at
death is unchanged. How can this bias be reduced? "To reduce lead-time bias,
measure ""back-end"" survival (adjusted according to disease severity at the time
of diagnosis)" "<img src=""7266.png"">" Behavioral-Science bias-and-study-
errors epidemiology-and-biostatistics
In a diet and weight loss study, a miscalibrated scale is used to measure subjects'
weight. How can this bias be reduced? This describes measurement bias, which
can be reduced with the use of a standardized data collection method "<img
biostatistics
A study only examines hospitalized patients. What specific kind of bias is this,
and how can it be reduced? This is Berkson bias, a type of selection bias; it
can be reduced with the use of randomization and appropriate sample population
choice "<img src=""7266.png"">" Behavioral-Science bias-and-study-errors
A study surveys only healthy volunteers and has a 30% response rate. Name two
specific types of selection bias that may be present. Healthy worker effect (using
only a healthy study population); Non-response bias (nonresponders differ from
participating subjects) "<img src=""7266.png"">" Behavioral-Science bias-and-
Subjects with gastric cancer are asked to recall their prior food intake in a
study. How can you reduce bias in this study? Decreasing time from exposure to
follow-up (recall bias) "<img src=""7266.png"">" Behavioral-Science bias-and-
A researcher studying the average daily caloric intake of a city holds a survey at
one restaurant. What kind of bias might this introduce? Selection bias (the
daily caloric intake of patrons at one restaurant is unlikely to represent the
population of the whole city) "<img src=""7266.png"">" Behavioral-Science bias-
and-study-errors epidemiology-and-biostatistics
A coach studying college athletes adds all of his basketball players to only the
control group. What kind of bias might this introduce? Selection bias
(basketball players were nonrandomly assigned to one group over the other) "<img
biostatistics
A researcher designs a crossover study to reduce confounding bias. How is it
designed? The subject acts as his or her own control and is subjected to both
treatment and placebo at different times "<img src=""7266.png"">" Behavioral-
Science bias-and-study-errors epidemiology-and-biostatistics
A study shows that pulmonary disease is more common in coal workers. Coal workers
smoke more than the general population. What bias is this? Confounding bias (the
causal relationship is better explained by a variable other than the one being
studied) "<img src=""7266.png"">" Behavioral-Science bias-and-study-errors
The age at onset of Hodgkin lymphoma has a bimodal distribution. Describe the shape
of the curve depicting this data. The curve has two peaks, often suggestive of
two different populations "<img src=""7267.png"">" Behavioral-Science
epidemiology-and-biostatistics statistical-distribution
The results of a study have a positive skew. What is the relationship among the
mean, median, and mode in this distribution? Asymmetrical curve with peak to the
left and longer tail on the right; typically, mean > median > mode "<img
statistical-distribution
The results of a study have a negative skew. What is the relationship among the
mean, median, and mode in this distribution? Asymmetrical curve with peak to the
right and longer tail on the lefttypically, mean < median < mode "<img
A study has a standard deviation (SD) of 5. What is the definition of SD? The
amount of variability from the mean in a given set of values "<img
A study of colon cancer has a large sample size (n). Define the standard error of
the mean (SEM), and how it is related to n. SEM = how much variability exists
between the sample mean and the true population mean; SEM decreases as n increases
biostatistics statistical-distribution
A study reports the mean, median, and mode. What are mean, median, and mode? Mean =
average; median = middle value (or average of the 2 middle values) in list sorted
from least to greatest; mode = most common value "<img src=""7267.png"">"
Behavioral-Science epidemiology-and-biostatistics statistical-distribution
Which characteristic is least affected by outliers: mean, median, or mode? Mode
biostatistics statistical-distribution
A research study rejects the hypothesis that there is no difference between the
groups being compared. Name the hypothesis. Null hypothesis (H0) "<img
statistical-hypotheses
A research study accepts a hypothesis proposing a difference between the groups
being compared. Name the hypothesis. Alternative hypothesis (H1) "<img
statistical-hypotheses
A research study's results indicate a difference that was not truly there. What
type of error is this? Type I, -error "<img src=""7268.png"">" Behavioral-
Science epidemiology-and-biostatistics statistical-hypotheses
A research study's results indicate no difference when there truly was one. What
type of error is this? Type II, -error "<img src=""7268.png"">" Behavioral-
Science epidemiology-and-biostatistics statistical-hypotheses
A study hypothesizing differences between adult and child sleep habits finds that p
= .03. How do you interpret this value? This is a statistically significant
difference (p < .05), and there is a 3% chance of the null hypothesis being true
biostatistics outcomes-of-statistical-hypothesis-testing
A new study has a -value of .2. In light of this knowledge, what interpretation of
the experimental design can be made? There is a 20% chance that the null
hypothesis will be accepted when, in fact, it should be rejected (type II error)
A study's null hypothesis is not rejected when it should have been. What type of
statistical error is this? In type II error (), the study concludes that there
is no association between variables (blinded [] when a difference really existed)
A study's experimental hypothesis is mistakenly accepted and the null hypothesis is
rejected. What type of statistical error is this? Type I error ()you saw ()
a difference that did not really exist "<img src=""7269.png"">" Behavioral-
Science epidemiology-and-biostatistics outcomes-of-statistical-hypothesis-testing
A study is proposed to investigate smoking. How can the scientist increase the
study's power? By increasing study sample size (there is power in numbers),
expected effect size, and precision of measurement "<img src=""7269.png"">"
Behavioral-Science epidemiology-and-biostatistics outcomes-of-statistical-
hypothesis-testing
A study reports a p value of 0.05. In statistical calculations, the p value is
equal to the probability of what type of error? Type I (), or false-positive
error, occurs when it is incorrectly concluded that an association is present
The p value is often judged against the probability () of type I error. What is
the usual standard level of significance for ? <0.05 "<img src=""7269.png"">"
hypothesis-testing
A study reports a value of 0.5. In statistical calculations, the value is equal
to the probability of what type of error? Type II (), or false-negative, error
What statistical term refers to the probability of rejecting the null hypothesis
when it is in fact false? Power (or 1 - ) "<img src=""7269.png"">"
hypothesis-testing
The 95% confidence interval for a mean difference between two variables in a
smoking study includes 0. Is the null hypothesis rejected? The null hypothesis is
not rejected, because there is no significant difference between the two variables
"<img src=""7270.png"">" Behavioral-Science confidence-interval
A study reports a 99% confidence interval. What is the value of Z, and what p value
corresponds with it? Z = 2.58; p = .01 "<img src=""7270.png"">" Behavioral-
Science confidence-interval epidemiology-and-biostatistics
The confidence intervals of two groups in a study overlap. Is there a significant
difference between groups? No; only if they do not overlap can we say that those
two groups are significantly different and that our null hypothesis can be rejected
A research paper reports a 95% confidence interval of 2.53.5. What does this say
about the findings? There is a 95% chance that if the experiment were repeated,
the mean would fall between 2.5 and 3.5 "<img src=""7270.png"">" Behavioral-
In biostatistics, how is the confidence interval calculated when the mean, the Z
score, and the standard error of the mean are known? Confidence interval = range
from (mean - Z [SEM]) to (mean + Z [SEM]) "<img src=""7270.png"">" Behavioral-
A paper reports a 95% confidence interval. What is the value of Z, and what p value
corresponds with it? Z = 1.96; p = .05 "<img src=""7270.png"">" Behavioral-
In a research study the confidence interval between two groups does not overlap.
Are these groups significantly different? Yes "<img src=""7270.png"">"
Behavioral-Science confidence-interval epidemiology-and-biostatistics
If the 95% confidence interval for an odds ratio or relative risk calculation
includes 1, is the null hypothesis rejected? The null hypothesis is not
rejected, because there is no significant difference between the two groups studied
In a study on diabetes, four groups are tested. Which statistical test should be
used to check for a difference? ANalysis Of VAriance (ANOVA)is used to check
for differences among the means of three or more groups "<img src=""7271.png"">"
Behavioral-Science common-statistical-tests epidemiology-and-biostatistics
In a study on smoking, exposure and nonexposure groups are tested. Which
statistical test is used to check for a difference? "The t-test (""Tea is meant
for 2"") is used to check for a difference between the means of two groups" "<img
src=""7271.png"">" Behavioral-Science common-statistical-tests epidemiology-
and-biostatistics
A study compares the percentages of subjects in three age groups who have essential
hypertension. Which statistical test is used? Chi-tegorical (categorical); used
to check differences in percentages or proportions of categorical outcomes (not
means) in 2 groups "<img src=""7271.png"">" Behavioral-Science common-
statistical-tests epidemiology-and-biostatistics
What is the numeric range of r (Pearson correlation coefficient)? -1 (negative
correlation) to +1 (positive correlation) "<img src=""7272.png"">" Behavioral-
Science epidemiology-and-biostatistics pearson-correlation-coefficient-(r)
Which statistical term's absolute value indicates the strength of the correlation
between two variables? When is the correlation stronger? Correlation coefficient
(r); it gets stronger the closer the absolute value of r gets to 1 "<img
src=""7272.png"">" Behavioral-Science epidemiology-and-biostatistics pearson-
correlation-coefficient-(r)
A study reports an r&178; of 0.99. What does this figure represent? The
coefficient of determination: An r&178; of 0.99 indicates a strong correlation
between the two variables "<img src=""7272.png"">" Behavioral-Science
epidemiology-and-biostatistics pearson-correlation-coefficient-(r)
A study reveals a perfect linear negative correlation between two variables. What
is the correlation coefficient? -1 "<img src=""7272.png"">" Behavioral-
Science epidemiology-and-biostatistics pearson-correlation-coefficient-(r)
In biostatistics, how is the coefficient of determination calculated from the
correlation coefficient? Coefficient of determination = rthis is the value
usually reported to convey the strength of a relationship between two variables
biostatistics pearson-correlation-coefficient-(r)
What are the four core ethical principles of medicine? Autonomy, beneficence,
nonmaleficence, and justice "<img src=""7273.png"">" Behavioral-Science core-
ethical-principles ethics
What ethics term is defined as an obligation to respect patients as individuals and
to honor their preferences in medical care? Autonomy "<img src=""7273.png"">"
Behavioral-Science core-ethical-principles ethics
A cancer patient with decision-making capacity refuses life-prolonging treatment.
Which principle allows her to do this? Autonomy "<img src=""7273.png"">"
Behavioral-Science core-ethical-principles ethics
Which core ethical principle of medicine dictates that all pts must be treated
fairly? Does this also mean they are treated equally? Justice; not necessarily,
because pts sometimes need to be triaged according to disease severity "<img
src=""7273.png"">" Behavioral-Science core-ethical-principles ethics
A physician acts in her pt's best interest in providing treatment choices. What
ethical responsibility is being displayed? Beneficence; the physician has a
fiduciary duty to the pt "<img src=""7273.png"">" Behavioral-Science core-
"What ethics term can be described by the principle of ""do no harm?"""
Nonmaleficence "<img src=""7273.png"">" Behavioral-Science core-
A pt has surgery and is aware that some permanent neurological disability may
result. What ethical principle was willingly compromised? Nonmaleficence
(treatment may harm the pt but is almost always outweighed by the benefits) "<img
src=""7273.png"">" Behavioral-Science core-ethical-principles ethics
You are obtaining informed consent from a patient. What must be understood by the
patient to properly do this? The risks and benefits of the proposed intervention
and risks and benefits of the alternatives (including doing nothing) "<img
src=""7274.png"">" Behavioral-Science ethics informed-consent
You are obtaining informed consent from a patient. What are the four requirements
of informed consent? Disclosure of pertinent information, and patient must
understand plan (assess), be mentally competent (legal), and be free of coercion
"<img src=""7274.png"">" Behavioral-Science ethics informed-consent
A patient on the OR table suddenly screams that he wants to cancel the surgery. The
surgeon complies. Is this allowed? Yes; patients may revoke written consent (even
orally) at any time "<img src=""7274.png"">" Behavioral-Science ethics
informed-consent
A pt does not have informed consent for an emergency procedure. What are the four
exceptions to informed consent? Pt lacks decision-making capacity; emergency
situation; information disclosure severely harms pt; pt waives informed consent
"<img src=""7274.png"">" Behavioral-Science ethics informed-consent
A 17 yo sees you in your clinic for STD care. He plans to join the army but has not
yet done so. Must you obtain parental consent? No; although he is not yet in the
military, he is not required to have parental consent for STD treatment "<img
src=""7275.png"">" Behavioral-Science consent-for-minors ethics
A 14 yo urgently needs a blood transfusion. Her parents are opposed on religious
grounds. May the physicians provide treatment? Yes. Parental consent is not
required in the case of emergency treatment "<img src=""7275.png"">"
Behavioral-Science consent-for-minors ethics
A 14 yo doesn't want his parents to know about his HIV treatment. Under what
special circumstances is parental notification not required? Emergency
situations; STD treatment, pregnancy, contraceptive use; drug addiction care (sex,
drugs, and rock and roll) "<img src=""7275.png"">" Behavioral-Science
consent-for-minors ethics
A minor patient, not the patient's parents, provides informed consent. Which minors
may provide informed consent? Legally emancipated minors, including those who are
married, self-supporting, in the military, or have children"<img src=""7275.png"">"
Behavioral-Science consent-for-minors ethics
A 16 yo girl has a baby. Her parents never knew about the pregnancy. Must you tell
the parents about the baby to provide care? No; parental consent is not
required if a minor has children "<img src=""7275.png"">" Behavioral-Science
consent-for-minors ethics
You treat an 18-year-old patient. Besides his age, name four criteria for
determining whether he has decision-making capacity. He must make an informed
choice; the decision must be stable with time, consistent with goals, and not a
result of altered mental state "<img src=""7276.png"">" Behavioral-Science
decision-making-capacity ethics
A lucid elderly man leaves an oral do-not-resuscitate advance directive. What are
four factors that give his oral consent more validity? The patient was
informed, the directive was specific, the patient made a choice, and the decision
was repeated over time "<img src=""7277.png"">" Behavioral-Science advance-
directives ethics
A man wants to draft an advance directive. Name the three ways in which pts can
establish advance directives. Oral advance directive, living will (written advance
directive), and medical power of attorney "<img src=""7277.png"">" Behavioral-
Science advance-directives ethics
A pt says that his daughter has medical power of attorney. What is medical power of
attorney? Designation of someone by the pt as legally authorized to make medical
decisions if the pt loses decision-making capacity "<img src=""7277.png"">"
Behavioral-Science advance-directives ethics
You are deciding between advance directives. Which offers more flexibility, a
living will or medical power of attorney? Medical power of attorney, which may be
revoked regardless of competence and allows the pt to specify certain clinical
decisions "<img src=""7277.png"">" Behavioral-Science advance-directives
ethics
The daughter of a pt with Alzheimer dementia is the designated surrogate. When does
a designated surrogate lose his or her power? If the pt revokes the power of the
surrogate, even if the pt is mentally incompetent "<img src=""7277.png"">"
A patient decides to make an advance directive. What is an advance directive?
Instructions given by a patient in anticipation of a need to make important
medical decisions. May be oral or written. "<img src=""7277.png"">"
A pt has a living will. What is a living will (also known as a written advance
directive)? A legal document indicating which treatments a pt gets or does not get
after becoming incapacitated or unable to communicate "<img src=""7277.png"">"
A pt with cancer has a living will. A living will commonly dictates care that will
be given in what situations? Those in which life-sustaining treatment is required
because the pt has a terminal disease or has entered a persistent vegetative state
"<img src=""7277.png"">" Behavioral-Science advance-directives ethics
A pt after a car crash is found to be brain-dead. He did not prepare an advance
directive. Who becomes the decision-maker for him? Surrogates (individuals who
know the pt and can determine what the pt would have done if he/she were competent)
"<img src=""7278.png"">" Behavioral-Science ethics surrogate-decision-
maker
A pt is in a coma but has no advance directive. What is the priority ranking of
surrogates, starting from highest to lowest? Spouse, adult children, parents,
adult siblings, other relatives "<img src=""7278.png"">" Behavioral-Science
ethics surrogate-decision-maker
List four exceptions to confidentiality. Serious imminent harm to others is
likely; potential for self-harm; no other way to protect those at risk; physician's
act can prevent harm "<img src=""7279.png"">" Behavioral-Science
confidentiality ethics
Which standard should be used to determine the amount of medical information to
disclose to a pt's family and friends? Guided by what the pt would want, or
professional judgment of pt's best interest if pt is not present or incapacitated
"<img src=""7279.png"">" Behavioral-Science confidentiality ethics
Five people get sick on a cruise ship. In cases of infectious disease, which groups
of people may a physician break confidentiality to warn? Public officials and
identifiable people who may be at risk (i.e., reportable diseases: STDs,
tuberculosis, hepatitis, food poisoning, etc.) "<img src=""7279.png"">"
Behavioral-Science confidentiality ethics
Which ethics term refers to respecting a pt's privacy and autonomy?
Confidentiality "<img src=""7279.png"">" Behavioral-Science
confidentiality ethics
The mother of a boy with many bruises of varying ages does not want the authorities
informed. Must the physician maintain confidentiality? No, in fact, a physician
can and must break confidentiality to report the abuse of a child or an elder
A woman tells her physician that she will end her life but that no one else may
know. Does the physician respect her nondisclosure request?No, a physician can and
must break confidentiality to report a suicidal or homicidal pt "<img
src=""7279.png"">" Behavioral-Science confidentiality ethics
A pt states that he intends to kill his brother. Is the physician obligated to
violate the pt's privacy to protect the brother? Yes, the physician can and
must break confidentiality (i.e., contact the police) to protect the pt's brother
A pt in your office is intoxicated. He arrived driving his own car. Must you break
confidentiality regarding his impaired status? Yesa physician must break
confidentiality to report an impaired driver that is likely to endanger others
Name five examples of exceptions to pt confidentiality. Reportable diseases,
child/elder abuse, impaired drivers, suicidal/homicidal pts, protection of
potential victims from harm (Tarasoff) "<img src=""7279.png"">" Behavioral-
Science confidentiality ethics
The wife of one of your pts wants details on his prognosis. You do not have consent
to release this information. How do you proceed? Unless permission is given by
the pt, information should not be given to family members "<img src=""7280.png"">"
Behavioral-Science ethical-situations ethics
A pregnant 17-year-old Alabama girl requests an abortion. What is the appropriate
response? In Alabama and various other states, a minor must obtain consent from
one or both parents to undergo elective abortion "<img src=""7280.png"">"
A patient with terminal pancreatic cancer wants to be euthanized by a physician.
How do you respond to this request? In most states, refusal is the answer;
physicians may, however, give certain analgesics that happen to shorten the life of
the patient "<img src=""7280.png"">" Behavioral-Science ethical-situations
ethics
During a routine appointment, a pt flirts with you and asks you out on a date. What
is an appropriate response? Romantic relationships with pts are never
appropriate; use a chaperone, and ask direct, closed-ended questions to avoid
issues "<img src=""7280.png"">" Behavioral-Science ethical-situations
ethics
"A healthy 20 yo pt wants a full-body CT scan done to ""look for hidden cancer.""
What is an appropriate response to this pt?" Understand his rationale for the CT
scans; address concernsdo no unnecessary procedures, and do not refer/refuse to
see the pt "<img src=""7280.png"">" Behavioral-Science ethical-situations
ethics
A pt is angry about the amount of time that he spent in the waiting room. What is
an appropriate response for this pt? Apologize for any inconvenience that the
delay caused but avoid explaining why it happened "<img src=""7280.png"">"
A pt reveals to you in confidence that he is upset with the way that he was treated
by another doctor. How do you respond to this? Advise the pt to talk directly to
that physicianif the problem is with a staff member in your office, speak to that
person "<img src=""7280.png"">" Behavioral-Science ethical-situations
ethics
A child wishes to know more about his severe, life-threatening illness. The parents
are outside in the waiting room. What is your next step? Ask the parents what
they have told the child about the illness; parents decide what information the
child receives "<img src=""7280.png"">" Behavioral-Science ethical-
situations ethics
One of your pts continually misses appointments and refuses to take medications.
How can you help this pt? Find out why the pt is noncompliant, assess his/her
willingness to change behavior/be treated, and avoid coercion and referrals "<img
src=""7280.png"">" Behavioral-Science ethical-situations ethics
Bob always forgets to take his medications. What are some appropriate interventions
for Bob that will make him more likely to take them? Write down instructions for
Bob; simplify the regimen as much as possible; use the teach-back method to ensure
patient comprehension "<img src=""7280.png"">" Behavioral-Science ethical-
situations ethics
A patient's son asks you not to disclose test results if the prognosis is poor,
saying his mom won't be able to handle it. Your response? Explore his reasoning;
explain that as long as she has capacity and has not stated otherwise,
communication of her care cannot be withheld "<img src=""7280.png"">"
A woman is suicidal and the threat is serious. She refuses hospitalization and
insists on leaving. Do you hospitalize her involuntarily? Yes, as pts who are
suicidal and wish to leave may be hospitalized involuntarily if the threat is
serious "<img src=""7280.png"">" Behavioral-Science ethical-situations
ethics
A man who recently had an orchiectomy complains that women find him ugly when he
undresses. What is an appropriate response? Find out more about why the pt
feels this way without offering falsely reassuring statements "<img
src=""7280.png"">" Behavioral-Science ethical-situations ethics
A physician orders an endoscopy on the wrong pt. What should the physician do?
Regardless of the severity of the error, a physician is obligated to tell the
pt "<img src=""7280.png"">" Behavioral-Science ethical-situations ethics
The parents of a pregnant 15-year-old girl want the baby to be adopted, but the
girl wants to keep it. What is the appropriate response? The girl determines the
fate of the baby. Physicians should discuss baby care and adoption as needed and
encourage open family discussion "<img src=""7280.png"">" Behavioral-Science
ethical-situations ethics
A 7-year-old feels responsible for his older sister's death from leukemia. What is
the best approach to management? At ages 57, kids start to understand that
death is permanent, so speak concretely, avoid euphemisms, and provide reassurance
"<img src=""7280.png"">" Behavioral-Science ethical-situations ethics
A pt needs a CT scan for diagnosis, but it is not covered by her insurance. What do
you do? Do not limit treatment because of financial or time constraints, and
discuss all possibilities "<img src=""7280.png"">" Behavioral-Science
ethical-situations ethics
An infant has recently started to be afraid of strangers and does not want the
doctor to examine her. Does she use a toy with both hands? Yes; she is 6 months old
(stranger anxiety) and can pass a toy from hand to hand "<img src=""7281.png"">"
Behavioral-Science development-and-aging early-developmental-milestones
An infant has begun to crawl. How old is she? 8 months "<img src=""7281.png"">"
An infant turns when her name is called and cries when her mother leaves the room.
In 1 month, will she be able to speak? "Yes; she is 9 months old (separation
anxiety and orients to name and gestures); at 10 months she'll say ""Mama"" and
""Dada""" "<img src=""7281.png"">" Behavioral-Science development-and-aging
early-developmental-milestones
A child comfortably spends part of the day away from the mother. What vehicle is
the child now old enough to use? The child is 3 years old and can ride a
tricycle (rides 3-cycle [tricycle] at age 3) "<img src=""7281.png"">"
A child can hop on one foot. What is speech like? At 4 years, she should use
prepositions and complete sentences and tell detailed stories "<img
src=""7281.png"">" Behavioral-Science development-and-aging early-
developmental-milestones
A baby has started to roll and sits with some support. Does he react well to
strangers? No, this scenario describes a 6-month-old, who will experience stranger
anxiety "<img src=""7281.png"">" Behavioral-Science development-and-aging
A child speaks in two-word sentences. How does she eat? She can feed herself
with a fork and spoon (2024 months) "<img src=""7281.png"">" Behavioral-
Science development-and-aging early-developmental-milestones
A child builds a tower of blocks with another child. What is her speech like?
Can tell detailed stories and use prepositions and full sentences; 4 years
(cooperative play) "<img src=""7281.png"">" Behavioral-Science
development-and-aging early-developmental-milestones
A child says that she's friends with a unicorn named Maria. What kinds of pictures
can she draw? Can draw stick figures and copy lines or circles (4 years old,
imaginary friends) "<img src=""7281.png"">" Behavioral-Science
An infant is noted to have a rooting reflex and orients to its mother's voice. In 2
months, which primitive reflex will develop? The baby is 4 months or younger; in
2 months (around age 6 months), the palmar reflex develops "<img src=""7281.png"">"
"A young girl says, ""There is a flower in the garden,"" and hops on one foot. What
kinds of shapes can she draw?" A child uses complete sentences with
prepositions at 3 to 4 years; can also copy lines, circles, and stick figures
"<img src=""7281.png"">" Behavioral-Science development-and-aging early-
An infant has just started to hold his head up prone. How old is he? 1 month
"<img src=""7281.png"">" Behavioral-Science development-and-aging early-
An infant is anxious when separated from his mother. What kinds of stimuli will
children at his age respond to? Names and gestures (separation anxiety
developed by 9 months) "<img src=""7281.png"">" Behavioral-Science
A child can draw a stick figure and copy a line and circle. How old is she? 4
years (simple drawing) "<img src=""7281.png"">" Behavioral-Science
A child can stack nine blocks. How old is she? 3 years (number of blocks stacked =
age in years 3) "<img src=""7281.png"">" Behavioral-Science development-and-
aging early-developmental-milestones
A baby doesn't abduct and adduct his arms when he is gently dropped. At what age
does this reflex disappear? 3 months (Moro reflex) "<img src=""7281.png"">"
An infant has just begun to walk and point to objects. Which reflex has recently
disappeared? Babinski reflex (disappears at 12 months); walking begins between
12 and 18 months "<img src=""7281.png"">" Behavioral-Science development-and-
A toddler can climb stairs. Approximately how old is he? 18 months "<img
An infant smiles back at you. What is the youngest he can be? 2 months (social
smile) "<img src=""7281.png"">" Behavioral-Science development-and-aging
A child builds a tower with another child and tells her a story about a princess
who lives inside the castle. How old is she? 4 years (tells legends, engages in
cooperative play) "<img src=""7281.png"">" Behavioral-Science development-and-
A child is able to kick a ball. What is her speech like? 200-word vocabulary and
two-word sentences (2 years) "<img src=""7281.png"">" Behavioral-Science
A child has a 1000-word vocabulary. How many cubes can she stack? Can stack
nine cubes (age 3); 3 years (three zeros in 1000) "<img src=""7281.png"">"
A child continues to search for a toy that you have put behind your back.
Approximately how old is he? 9 months (object permanence) "<img src=""7281.png"">"
What is the approximate age at which an infant will turn toward a voice? What about
toward its name and gestures? 4 months; 9 months "<img src=""7281.png"">"
What is rapprochement and at what age does it develop? When a child is
comfortable moving away and then returning to his/her motherby 24 months "<img
A child can self-groom, button buttons, zip zippers, and brush his own teeth. For
how long has he been able to tell legendary stories? The child is 5 years old and
has been telling such stories for at least 1 year (detailed storytelling begins at
age 4) "<img src=""7281.png"">" Behavioral-Science development-and-aging
A toddler plays alongside, but not with, another toddler. How old is she? 24 to
36 months (parallel play) "<img src=""7281.png"">" Behavioral-Science
A toddler can kick a ball and eats with a fork and spoon. How old is she? 24
months; can eat with fork and spoon at 20 months "<img src=""7281.png"">"
A toddler identifies as a girl. At approximately what age is core gender identity
formed? 36 months "<img src=""7281.png"">" Behavioral-Science
An infant has just started to pass a toy from hand to hand. What is his posture
like? 6 months; can roll and sit "<img src=""7281.png"">" Behavioral-Science
An infant has just started to use a pincer grasp to pick up food. What is her
speech like? "10 months; can say ""mama"" and ""dada""" "<img
An infant has just started to point to cereal in the grocery store. Approximately
how old is he? 12 months "<img src=""7281.png"">" Behavioral-Science
A toddler has just started to comfortably spend a day away from his mother.
Approximately how old is he? 3 years "<img src=""7281.png"">" Behavioral-
Science development-and-aging early-developmental-milestones
At what ages do these four primitive reflexes (Moro, rooting, palmar, Babinski)
disappear? Moro by 3 months; rooting by 4 months; palmar by 6 months; & Babinski
by 12 months "<img src=""7281.png"">" Behavioral-Science development-and-
A patient cannot hear high-pitched noises. Where in the ear is hearing still
preserved? This describes presbycusis, in which hair cells that transmit low-
frequency sounds at the cochlear apex are preserved. "<img src=""7282.png"">"
Behavioral-Science changes-in-the-elderly development-and-aging
Does the suicide rate increase or decrease among the elderly? Increase "<img
src=""7282.png"">" Behavioral-Science changes-in-the-elderly development-and-
aging
A healthy middle-aged man is worried that with increasing age his sexual interest
will decrease. Do you refute or support his concerns? Refute them; sexual interest
does not decrease solely because of normal aging "<img src=""7282.png"">"
An elderly pt complains of increased nocturnal awakenings. She is in good health
otherwise. Are you concerned about any pathology? No, as the number of
awakenings during the night normally increases with aging "<img src=""7282.png"">"
A 70-year-old man is concerned about how his sex life will change as he ages. What
is the most appropriate response? Slower erection/ejaculation, longer refractory
period "<img src=""7282.png"">" Behavioral-Science changes-in-the-elderly
development-and-aging
A 70-year-old woman is concerned about how her sex life will change as she ages.
What is the most appropriate response? Vaginal shortening, thinning, dryness
"<img src=""7282.png"">" Behavioral-Science changes-in-the-elderly
An 80 yo sleeps 7 hours nightly. What changes in slow-wave sleep, REM sleep, and
sleep latency occur with aging? Decreased slow-wave sleep; decreased REM sleep;
increased sleep latency "<img src=""7282.png"">" Behavioral-Science changes-
in-the-elderly development-and-aging
Which of the following functions doesn't decline with aging: bladder, vision,
hearing, renal, pulm, GI, immune function, and intelligence? Intelligence
"<img src=""7282.png"">" Behavioral-Science changes-in-the-elderly
An elderly athlete is training for a race. What happens to muscle mass and fat with
aging? Muscle mass decreases; fat increases "<img src=""7282.png"">"
A child is not vaccinated on religious grounds. Which form of prevention is this
child forgoing? Primary (PP = Primary Prevents) "<img src=""7283.png"">"
Behavioral-Science disease-prevention public-health
A pt found to have diabetes is instructed to monitor blood sugar. What kind of
prevention does this home testing provide? Tertiary (RR = teRtiary Reduces
disability) "<img src=""7283.png"">" Behavioral-Science disease-prevention
public-health
A middle-aged woman with a family history of colon cancer sees her
gastroenterologist for a colonoscopy. What kind of prevention is this? Secondary
(SS = Secondary Screens) "<img src=""7283.png"">" Behavioral-Science
disease-prevention public-health
A doctor does not prescribe antibiotics for a viral upper respiratory infection.
What kind of prevention is this? Quaternary; protects pts from the harm of an
unnecessary intervention "<img src=""7283.png"">" Behavioral-Science
disease-prevention public-health
A 67-year-old with Medicare gets all of her health care at a private HMO. What part
of Medicare does she have? People with Medicare Part C get their hospital care
and basic medical treatment from approved private companies"<img src=""7284.png"">"
Behavioral-Science medicare-and-medicaid public-health
A 45-year-old unemployed homeless man with diabetes asks what insurance he can get.
What is the most appropriate response? Medicaid is for people of very low
income; it is funded by the state and federal governments "<img src=""7284.png"">"
A 45-year-old woman with ERSD has Medicare and is hospitalized for pneumonia. Which
part of Medicare covers her hospitalization? Part A: hospitAl insurance; the
other parts are B: Basic medical bills, C: delivery of parts A+B by private
Companies, D: prescription Drugs "<img src=""7284.png"">" Behavioral-Science
medicare-and-medicaid public-health
Which part of Medicare covers prescription drugs? Part D "<img
src=""7284.png"">" Behavioral-Science medicare-and-medicaid public-health
A 71-year-old comes to you for his 3-month diabetes checkup. What part of Medicare
covers this visit? Medicare Part B covers basic medical bills such as doctor's
fees and diagnostic testing "<img src=""7284.png"">" Behavioral-Science
An 83-year-old is hospitalized with a COPD exacerbation. What part of Medicare
covers his hospitalization? Medicare Part A covers hospitalizations "<img
A 73-year-old uninsured man comes to your clinic with low back pain. For what type
of health insurance is he eligible? MedicarE is for the Elderly, those under 65
with certain disabilities, and those with end-stage renal disease "<img
Name the type of insurance that developed from amendments to the Social Security
Act that is available to a 70-year-old woman. Medicare "<img src=""7284.png"">"
A homeless man with no income comes to your clinic for swelling of his right foot.
For what type of health insurance is he eligible? He is eligible for Medicaid
(MedicaiD is for the Destitute) "<img src=""7284.png"">" Behavioral-Science
For which type of government-funded insurance are patients undergoing dialysis
eligible? Medicare is for people 65 or older and for people with certain
disabilities, such as end-stage renal disease "<img src=""7284.png"">"
What are the names of two federally funded healthcare programs that originated from
amendments to the Social Security Act? Medicare and Medicaid "<img
What are the top three causes of death in children &60;1 year of age? Congenital
malformations, preterm birth, and sudden infant death syndrome (SIDS) "<img
src=""7285.png"">" Behavioral-Science common-causes-of-death-(us)-by-age
public-health
What are the top three causes of death in children aged 1 to 14 years?
Unintentional injury, cancer, and congenital malformations "<img
src=""7285.png"">" Behavioral-Science common-causes-of-death-(us)-by-age
public-health
What are the top three causes of death in people ages 15 to 34 years?
Unintentional injury, suicide, and homicide "<img src=""7285.png"">"
Behavioral-Science common-causes-of-death-(us)-by-age public-health
What are the top three causes of death in people aged 35 to 44 years?
Unintentional injury, cancer, and heart disease "<img src=""7285.png"">"
What are the top three causes of death in people aged 45 to 64 years? Cancer,
heart disease, and unintentional injury "<img src=""7285.png"">" Behavioral-
Science common-causes-of-death-(us)-by-age public-health
What are the top three causes of death in people >65 years of age? Heart
disease, cancer, and chronic respiratory disease "<img src=""7285.png"">"
A patient is admitted for wound infection 7 days after being discharged from
laparoscopic cholecystectomy. Is this considered a readmission? Yes; readmission
is when someone is rehospitalized for any reason within 30 days of the original
admission "<img src=""7286.png"">" Behavioral-Science hospitalized-
conditions-with-frequent-readmissions public-health
Name the three most common reasons for readmission among patients with Medicare.
1, Congestive heart failure; 2, septicemia; 3, pneumonia "<img
src=""7286.png"">" Behavioral-Science hospitalized-conditions-with-frequent-
readmissions public-health
What is the second most common reason for readmission among patients with Medicaid?
Schizophrenia/psychotic disorders (mood disorders are the most common reason
for admission among people with Medicaid) "<img src=""7286.png"">" Behavioral-
Science hospitalized-conditions-with-frequent-readmissions public-health
In which populations are alcohol-related disorders the second most common reason
for admission? As with patients with Medicaid, mood disorders ares the most
common reason for admission among uninsured people "<img src=""7286.png"">"
Behavioral-Science hospitalized-conditions-with-frequent-readmissions public-
health
What are the three most common reasons for hospital readmission among people with
private insurance? 1, Maintenance of chemo/radiotherapy; 2, mood disorders; 3,
complications of surgical procedures or medical care "<img src=""7286.png"">"
Behavioral-Science hospitalized-conditions-with-frequent-readmissions public-
health
An MS-1 sees a resident placing a Foley catheter in a patient without using sterile
gloves. Is she allowed to report this issue? Yes; anyone of any rank should
bring up safety concerns without fear of censure so errors can be identified and
corrected "<img src=""7287.png"">" Behavioral-Science public-health safety-
culture
In which system are data on errors collected for internal and external monitoring?
Event reporting systems "<img src=""7287.png"">" Behavioral-Science
public-health safety-culture
What is the benefit of a forcing function? Forcing functions are the most
effective intervention for preventing undesirable actions "<img src=""7288.png"">"
Behavioral-Science human-factors-design public-health
An office gives each patient a form on which to note any symptoms they've had over
the past 2 weeks. Of what is this an example? Standardization, which improves
process reliability "<img src=""7288.png"">" Behavioral-Science human-
factors-design public-health
Two neighboring hospitals decide to use the same electronic medical record to
improve continuity of care. Of what is this an example? Simplification, intended
to reduce wasteful activities "<img src=""7288.png"">" Behavioral-Science
human-factors-design public-health
Name the four parts of the PDSA cycle. Plan; do; study; act "<img
src=""7289.png"">" Behavioral-Science pdsa-cycle public-health
A doctor finds her homeless patients' HbA1c values are much worse than others' and
wants to intervene. What stage of the PDSA cycle is this? Plan: In the planning
stage, the problem and solution are defined "<img src=""7289.png"">"
Behavioral-Science pdsa-cycle public-health
Which quality measure assesses impact on patients? Outcome "<img
src=""7290.png"">" Behavioral-Science public-health quality-measurements
Which quality measure assesses the performance of the system as planned?
Process "<img src=""7290.png"">" Behavioral-Science public-health
quality-measurements
Which quality measure assesses the incidence of side effects and/or impact on other
systems? Balancing "<img src=""7290.png"">" Behavioral-Science public-
health quality-measurements
"What is the ""Swiss cheese model""?" When flaws in processes and systems of
complex organizations align, resulting in patient harm "<img src=""7291.png"">"
Behavioral-Science public-health swiss-cheese-model
Give examples of the pitfalls of complex organizations that can align to cause
patients harm. Organizational factors; unsafe supervision; preconditions; unsafe
acts "<img src=""7291.png"">" Behavioral-Science public-health swiss-cheese-
model
Which type of error has an immediate impact, active or latent? Explain. An
active error, which occurs at the level of a frontline operator "<img
src=""7292.png"">" Behavioral-Science public-health types-of-medical-errors
Which type of error is an accident waiting to happen, active or latent? Explain.
A latent error, which occurs in processes indirect from the frontline
operator but can affect patient care "<img src=""7292.png"">" Behavioral-
Science public-health types-of-medical-errors
Name some examples of medical errors. Incorrectly identifying a patient or his
diagnosis; nosocomial infection; administering incorrect medications "<img
src=""7292.png"">" Behavioral-Science public-health types-of-medical-errors
In which type of analysis is inductive reasoning used to identify all the ways in
which a process could fail? Failure mode and effects analysis, which is forward-
looking and applied before process implementation to prevent errors "<img
src=""7293.png"">" Behavioral-Science medical-error-analysis public-health
Many providers explore how a patient admitted for SBO got sepsis by examining
environment, materials, and providers. What analysis is this? Root cause
analysis, a retrospective analysis in which records and interviews are used to
identify all possible problems leading to an error "<img src=""7293.png"">"
Behavioral-Science medical-error-analysis public-health
Which type of analysis is plotted on a fishbone diagram? Root cause analyses are
plotted with the use of Ishikawa (cause-and-effect) diagrams "<img
src=""7293.png"">" Behavioral-Science medical-error-analysis public-health
A researcher adds DNA to a solution with positively and negatively charged ions.
With which of the ions does the DNA precipitate (bind to)? The positively charged
ions (DNA is negatively charged.) "<img src=""7294.png"">" biochemistry
chromatin-structure duplicate molecular
How many subunits make up a nucleosome core? What are the subunits? Eight; two
of each of four histone types (H2A, H2B, H3, and H4) "<img src=""7294.png"">"
biochemistry chromatin-structure duplicate molecular
A lab researcher induces Barr body (inactive X chromosome) formation. It is
transcriptionally inactive. How does this DNA appear on EM?It appears darker and
more condensed on EM. (This is HeteroChromatin, which is Highly Condensed.) "<img
src=""7294.png"">" biochemistry chromatin-structure duplicate molecular
What is transcriptionally active DNA called? Euchromatin: It is less condensed
and is accessible to replication enzymes "<img src=""7294.png"">" biochemistry
How many times does DNA loop around each nucleosome core? Two times "<img
Which nucleotides on the template strand are methylated in DNA replication?
Cytosine and adenine "<img src=""7294.png"">" biochemistry chromatin-
structure duplicate molecular
What is the charge of the histone octamers? Positive, giving the histones
affinity for negatively charged DNA "<img src=""7294.png"">" biochemistry
What action to CpG islands inactivates transcription of DNA? Methylation (CpG
Methylation makes DNA Mute.) "<img src=""7294.png"">" biochemistry chromatin-
structure duplicate molecular
Predominance of which two amino acids gives histones a positive charge? Lysine
and arginine "<img src=""7294.png"">" biochemistry chromatin-structure
duplicate molecular
What process relaxes DNA coiling, allowing transcription? Acetylation (Histone
Acetylation makes DNA Active.) "<img src=""7294.png"">" biochemistry
An experiment is done to tie nucleosome beads together in a string to stabilize
chromatin. Which protein facilitates this process? Histone H1 "<img
What allows mismatch repair enzymes to distinguish between old and new DNA strands?
Methylation of the template strand's cytosine and adenine during DNA
replication "<img src=""7294.png"">" biochemistry chromatin-structure
duplicate molecular
What process usually reversibly suppresses DNA transcription but can activate it in
some cases, depending on the location of the process? Histone methylation "<img
How many hydrogen bonds are there between adenine and thymine? Two "<img
src=""7295.png"">" biochemistry duplicate molecular nucleotides
Which two nucleotides are purines? Adenine and guanine (PURines [A,G]: PURe As
Gold) "<img src=""7295.png"">" biochemistry duplicate molecular nucleotides
DNA1 has 60% G-C bonds, while DNA2 has 70% A-T bonds. Which DNA has a higher
melting point? DNA1 has more G-C bonds, which have three H bonds, and is thus
stronger with a higher melting point. (A-T bonds have only two H bonds.) "<img
What are the three pyrimidines? Cytosine, Uracil, and Thymine (PYrimidines:
(C,U,T): CUT the PY [pie]) "<img src=""7295.png"">" biochemistry duplicate
molecular nucleotides
What molecule does deamination of cytosine yield? Uracil "<img
What are the components of a nucleoside? Base + (deoxy)ribose "<img
In which type of nucleic acid is uracil found? RNA "<img src=""7295.png"">"
biochemistry duplicate molecular nucleotides
Which type of bond links nucleotides? 35 Phosphodiester bond "<img
In which type of nucleic acid is thymine found? DNA "<img src=""7295.png"">"
biochemistry duplicate molecular nucleotides
Which amino acids are necessary for purine synthesis? Glycine, Aspartate, Glutamine
(GAG) "<img src=""7295.png"">" biochemistry duplicate molecular nucleotides
In de novo nucleotide synthesis, which nucleotides are made from IMP precursors?
Purines "<img src=""7296.png"">" biochemistry de-novo-pyrimidine-
and-purine-synthesis duplicate molecular
In de novo nucleotide synthesis, which nucleotides are made from orotate
precursors, with PRPP added later? Pyrimidines "<img src=""7296.png"">"
biochemistry de-novo-pyrimidine-and-purine-synthesis duplicate molecular
A pt with cancer is treated with 5-fluorouracil and methotrexate. Which parts of
the pyrimidine synthesis pathway do these inhibit? Thymidylate synthase and
human dihydrofolate reductase (DHFR), respectively, both of which decrease
dihydrofolate reductase availability "<img src=""7296.png"">" biochemistry
de-novo-pyrimidine-and-purine-synthesis duplicate molecular
Trimethoprim (TMP) is a commonly used antibiotic. What is its mechanism of action?
It inhibits bacterial dihydrofolate reductase (DHFR) "<img src=""7296.png"">"
What enzyme converts the ribonucleotide UDP to the deoxyribonucleotide dUDP?
Ribonucleotide reductase "<img src=""7296.png"">" biochemistry de-
novo-pyrimidine-and-purine-synthesis duplicate molecular
Deoxyuridine monophosphate (dUMP) is converted to deoxythymidine monophosphate
(dTMP) by which enzyme? Thymidylate synthase "<img src=""7296.png"">"
Which enzyme does hydroxyurea inhibit? Ribonucleotide reductase "<img
src=""7296.png"">" biochemistry de-novo-pyrimidine-and-purine-synthesis
duplicate molecular
What is the cofactor in the thymidylate synthase reaction (dUMP to dTMP)?
Methylene tetrahydrofolate (methylene THF) "<img src=""7296.png"">"
What cofactor is needed to convert carbamoyl phosphate to orotic acid? Aspartate
"<img src=""7296.png"">" biochemistry de-novo-pyrimidine-and-purine-
synthesis duplicate molecular
A pt takes 6-mercaptopurine (6-MP) for treatment of her cancer. What is the
mechanism of action? It blocks de novo purine synthesis by blocking conversion
of PRPP to IMP "<img src=""7296.png"">" biochemistry de-novo-pyrimidine-
Three pharmacologic treatments decrease deoxythymidine monophosphate (dTMP) through
different mechanisms. What are they? 5-Fluorouracil (5-FU) blocks dUMP dTMP;
methotrexate (MTX) and trimethoprim (TMP) both block DHF THF by inhibiting DHFR
"<img src=""7296.png"">" biochemistry de-novo-pyrimidine-and-purine-
synthesis duplicate molecular
Dihydrofolic acid (DHF) is converted to tetrahydrofolic acid (THF) by which enzyme?
Dihydrofolate reductase (DHFR) "<img src=""7296.png"">" biochemistry
de-novo-pyrimidine-and-purine-synthesis duplicate molecular
A pt with colon cancer begins chemotherapy that blocks thymidylate synthase. What
drug is used? How will it affect dihydrofolate (DHF)? 5-Fluorouracil; it inhibits
thymidylate synthase, reducing conversion of dUMP to dTMP and N5N10-methylene THF
to DHF = less DHF "<img src=""7296.png"">" biochemistry de-novo-pyrimidine-
What is the end product of guanosine and adenosine degradation? What happens to it?
Uric acid; it is renally excreted eventually "<img src=""7297.png"">"
biochemistry duplicate molecular purine-salvage-deficiencies
Which enzyme catalyzes the conversions of both guanine to guanylic acid (GMP) and
hypoxanthine to inosinic acid (IMP)? Hypoxanthine guanine
phosphoribosyltransferase (HGPRT) "<img src=""7297.png"">" biochemistry
duplicate molecular purine-salvage-deficiencies
Which enzyme in the purine salvage pathway catalyzes both the conversions of
hypoxanthine into xanthine and xanthine into uric acid? Xanthine oxidase "<img
src=""7297.png"">" biochemistry duplicate molecular purine-salvage-
deficiencies
Lesch-Nyhan syndrome is the result of an absence of what enzyme? HGPRT
(Hyperuricemia, Gout, Pissed off (aggression, self-mutilation) Retardation
(intellectual disability), DysTonia) "<img src=""7297.png"">" biochemistry
duplicate molecular purine-salvage-deficiencies
Which enzyme catalyzes the formation of adenosine monophosphate (AMP) from adenine
and phosphoribosyl pyrophosphate? Adenine phosphoribosyltransferase (APRT) "<img
deficiencies
What type of inheritance does phosphoribosyltransferase deficiency demonstrate?
X-linked recessive "<img src=""7297.png"">" biochemistry duplicate
molecular purine-salvage-deficiencies
A deficiency in which purine salvage enzyme may result in severe combined
immunodeficiency (SCID)? What is the inheritance pattern? Adenosine deaminase
(ADA), which converts adenosine into inosine; autosomal recessive "<img
deficiencies
A child with intellectual disability, gout, and choreoathetosis self-mutilates. How
would you treat him? With allopurinol or febuxostat (second line), as he has
Lesch-Nyhan syndrome "<img src=""7297.png"">" biochemistry duplicate
A pt with intellectual disability, gout, and choreoathetosis self-mutilates.
Activity of which two enzymatic pathways is increased? Uric acid production
(xanthine oxidase) and de novo purine synthesis (phosphoribosyl-pyrophosphate)
"<img src=""7297.png"">" biochemistry duplicate molecular purine-
salvage-deficiencies
What is the classic presentation of Lesch-Nyhan syndrome? HGPRT: Hyperuricemia,
Gout, Pissed off, (aggression, self-mutilation), Retardation (intellectual
disability), dysTonia "<img src=""7297.png"">" biochemistry duplicate
What is the mechanism of action of allopurinol? It blocks xanthine oxidase (XO),
thereby inhibiting conversion of hypoxanthine to xanthine "<img src=""7297.png"">"
biochemistry duplicate molecular purine-salvage-deficiencies
What are the only codons that code for tryptophan and methionine? UGG
(tryptophan) and AUG (methionine) "<img src=""7298.png"">" biochemistry
duplicate genetic-code-features molecular
How is the genetic code unambiguous and yet redundant? Although each codon
specifies a single amino acid (unambiguous), an amino acid can be coded for by
multiple codons (redundant) "<img src=""7298.png"">" biochemistry duplicate
genetic-code-features molecular
What does a commaless, nonoverlapping genetic code entail? The entire genome is
read from a fixed starting point as a continuous string of bases "<img
src=""7298.png"">" biochemistry duplicate genetic-code-features molecular
Typically, the genetic code is considered universal (ie, conserved throughout
evolution). What is one noteworthy exception to this rule? Human mitochondrial DNA,
which is not conserved "<img src=""7298.png"">" biochemistry duplicate
genetic-code-features molecular
What is the purpose of DNA topoisomerase's creation of a break in the DNA helix?
It relaxes supercoils, which helps unwind DNA for proper replication "<img
src=""7299.png"">" biochemistry dna-replication duplicate molecular
In DNA replication, how many origins of replication do prokaryotes and eukaryotes
have? Prokaryotes have one origin of replication, and eukaryotes have multiple
origins of replication "<img src=""7299.png"">" biochemistry dna-replication
duplicate molecular
Which enzyme has 3-to-5 exonuclease activity in prokaryotic DNA replication?
"DNA polymerase III has 3to5 exonuclease activity for ""proofreading"""
"<img src=""7299.png"">" biochemistry dna-replication duplicate
molecular
Which enzyme elongates the leading strand of DNA synthesis by building on an RNA
primer? DNA polymerase III "<img src=""7299.png"">" biochemistry dna-
replication duplicate molecular
What does DNA polymerase III require to initiate replication? An RNA primer,
created by primase "<img src=""7299.png"">" biochemistry dna-replication
duplicate molecular
Which enzyme degrades the RNA primer and replaces it with DNA during prokaryotic
DNA replication? DNA polymerase I "<img src=""7299.png"">" biochemistry dna-
To which end of the newly synthesized DNA molecule does DNA polymerase III add the
next deoxynucleotide? The 3 end; this is 5to3 synthesis "<img
When does DNA polymerase III stop adding deoxynucleotides to the 3 end? When
it reaches the primer of the preceding fragment "<img src=""7299.png"">"
biochemistry dna-replication duplicate molecular
A pt is treated with an antibiotic that inhibits DNA gyrase (prokaryotic
topoisomerase II). Which antibiotic is this? Fluoroquinolone "<img
Pts with progeria lack telomerase. What would be seen in their cells after
replication? Loss of genetic material with each replication from the 3 ends
of the chromosomes "<img src=""7299.png"">" biochemistry dna-replication
duplicate molecular
What are the discontinuous DNA segments formed on the lagging strand called? What
later joins them together? Okazaki fragments; DNA ligase, which creates a
phosphodiester bond within a strand of double-stranded DNA "<img src=""7299.png"">"
biochemistry dna-replication duplicate molecular
DNA polymerases I and III are enzymes found in what organisms? Prokaryotes "<img
The Y-shaped region where leading and lagging strands are synthesized is called
what? The replication fork "<img src=""7299.png"">" biochemistry dna-
Which enzyme unwinds the DNA template at the replication fork? Helicase "<img
A pt has a condition in which DNA strands reanneal too quickly during replication.
Which proteins is he likely missing? Single-stranded binding proteins "<img
In a test, an enzyme is used to add DNA to chromosomal 3 ends to prevent loss of
genetic material with duplication. Name the enzyme. Telomerase "<img
A pt tests positive for a hemoglobin-related disease caused by a missense mutation.
What is the disease? Sickle cell disease "<img src=""7300.png"">"
biochemistry duplicate molecular mutations-in-dna
Rank the following types of mutations from most to least severe: missense,
frameshift, silent, and nonsense. Frameshift &62; nonsense (a stop codon) &62;
missense &62; silent "<img src=""7300.png"">" biochemistry duplicate
molecular mutations-in-dna
Which type of mutation results in a retained intron in the mRNA? Splice site.
Splice site mutations can be rare causes of cancers, dementia, or epilepsy. "<img
src=""7300.png"">" biochemistry duplicate molecular mutations-in-dna
Which type of DNA mutation results in no change to the amino acid that is being
coded for? Silent mutation "<img src=""7300.png"">" biochemistry duplicate
molecular mutations-in-dna
Silent mutations are often the result of changes in what position of a codon?
The third position (due to tRNA wobble) "<img src=""7300.png"">"
Which type of DNA mutation yields a single changed amino acid? Missense mutation;
the severity of the mutation depends on the location of the change "<img
Which type of DNA mutation results in the misreading of all downstream nucleotides?
Why does this happen? Frameshift mutation; deletion or insertion of a number of
nucleotides not divisible by 3 shifts the reading frame "<img src=""7300.png"">"
Which kind of protein usually results from a frameshift mutation? Give an example
of a disease resulting from this type of mutation. A truncated and nonfunctional
protein; Duchenne muscular dystrophy "<img src=""7300.png"">" biochemistry
duplicate molecular mutations-in-dna
A lab detects a mutation: ACTCCTGAGGAG to ACTCCTGTGGAG. Protein size is unchanged;
the protein is nonfunctional. Identify the mutation type. This is likely a
missense mutation (GAG to GTG = glutamate to valine) "<img src=""7300.png"">"
A mutation causes a guanine to replace an adenine. Is this a transition or
transversion? Transition (purine to purine or pyrimidine to pyrimidine) "<img
A mutation causes a guanine to replace a thymine. Is this a transition or
transversion? Transversion (purine to pyrimidine or vice versa) "<img
What happens to Escherichia coli in the absence of glucose and the presence of
lactose? The lac operon is activated, and a switch to lactose metabolism occurs
"<img src=""7301.png"">" biochemistry duplicate lac-operon molecular
Escherichia coli is grown in the lab. Are lac operon genes strongly or weakly
expressed in case of low glucose and available lactose? Strongly expressed
Are lac operon genes strongly expressed or not expressed in case of low glucose and
low lactose? How about high glucose and low lactose? Not expressed; not expressed.
During nucleotide excision DNA repair, which enzyme removes the damaged DNA?
Endonuclease "<img src=""7302.png"">" biochemistry dna-repair
duplicate molecular
A 2-year-old child must stay inside during the day because sunlight causes dry skin
and sunburn. By what mechanism does this disease work? A defect in nucleotide
excision repair that prevents repair of thymidine dimers (This is xeroderma
pigmentosum.) "<img src=""7302.png"">" biochemistry dna-repair duplicate
molecular
What is the first step in the base excision repair of damaged DNA? Base-
specific glycosylases recognize and remove a single damaged base "<img
src=""7302.png"">" biochemistry dna-repair duplicate molecular
In base excision repair, what do the apurinic/apyrimidinic endonucleases do? They
nick the 5' end of the apurinic or apyrimidinic site "<img src=""7302.png"">"
biochemistry dna-repair duplicate molecular
In single-strand DNA repair, how do nucleotide excision and base excision repair
differ? Nucleotide excision removes the entire nucleotide structure, and base
excision repair removes bases without disturbing the DNA backbone "<img
A pt has a defect in his mismatch repair system. For which type of malignancy does
this significantly increase his risk? The mismatch repair system is defective
in hereditary nonpolyposis colorectal cancer (HNPCC), increasing the risk for colon
cancer "<img src=""7302.png"">" biochemistry dna-repair duplicate
molecular
Which type of DNA repair is important in spontaneous/toxic deamination? Base
excision repair "<img src=""7302.png"">" biochemistry dna-repair duplicate
molecular
A pt lacks the ability to carry out nonhomologous end joining in DNA. What disease
does the pt have? Ataxia telangiectasia, a failure of nonhomologous end joining
(bringing together of DNA fragment ends to repair double-stranded breaks) "<img
Which method of DNA repair repairs double-stranded breaks? Which two conditions are
associated with defects in this process? Nonhomologous end joining; ataxia
telangiectasia and Fanconi anemia "<img src=""7302.png"">" biochemistry dna-
repair duplicate molecular
A pt has Lynch syndrome/hereditary nonpolyposis colorectal cancer (HNPCC). Which
process is defective? How does this process occur normally?Mismatch repair; normal
process: recognition of newly synthesized strand, removal of mismatched
nucleotides, filling & resealing of the gap "<img src=""7302.png"">"
A pt has xeroderma pigmentosum. Which process is defective? How does this process
occur normally? Nucleotide excision repair; normal process: specific
endonucleases release damaged bases; DNA polymerase and ligase fill and reseal the
gap "<img src=""7302.png"">" biochemistry dna-repair duplicate molecular
How does the process of repair of spontaneous/toxic deamination work normally?
Nucleotide removal (5 end cleaved), lyase cleaving of 3 end, gap filling
with DNA polymerase-, sealing with DNA ligase "<img src=""7302.png"">"
In what direction does protein synthesis proceed? From N-terminus to C-terminus
"<img src=""7303.png"">" biochemistry dna/rna/protein-synthesis-
direction duplicate molecular
In what direction are DNA and RNA synthesized and read? DNA and RNA are both
synthesized and read from 5 to 3 "<img src=""7303.png"">" biochemistry
dna/rna/protein-synthesis-direction duplicate molecular
A new drug that blocks DNA replication has been given to a pt. What is most likely
modified in the chemical structure of the drug? 3 OH, preventing the addition of
the next nucleotide (chain termination) by way of the triphosphate bond "<img
src=""7303.png"">" biochemistry dna/rna/protein-synthesis-direction duplicate
molecular
For which amino acid does the initial AUG code in prokaryotes? What about in
eukaryotes? N-formylmethionine in prokaryotes; methionine in eukaryotes"<img
src=""7304.png"">" biochemistry duplicate molecular start-and-stop-codons
Which codon is the mRNA start codon? Which amino acid does it code for? AUG
(or rarely, GUG); methionine (AUG inAUGurates protein synthesis.) "<img
src=""7304.png"">" biochemistry duplicate molecular start-and-stop-codons
What are the three stop codons? UGA, UAA, and UAG (UGA = U Go Away, UAA = U Are
Away, and UAG = U Are Gone) "<img src=""7304.png"">" biochemistry duplicate
molecular start-and-stop-codons
An experimental new drug blocks the removal of methionine before translation has
finished in eukaryotic cells. Could this cause problems? Yes, because methionine
is sometimes removed from the developing protein before translation is completed
"<img src=""7304.png"">" biochemistry duplicate molecular start-and-
stop-codons
List the sites in order from the 3 end to the 5 end of a template strand:
termination signals, promoter, enhancer, transcribed regionEnhancer, promoter,
transcribed region, termination signals; the order is opposite for the coding
strand "<img src=""7305.png"">" biochemistry duplicate functional-
organization-of-a-eukaryotic-gene molecular
Where is the TATA box found? In the promoter region "<img src=""7305.png"">"
biochemistry duplicate functional-organization-of-a-eukaryotic-gene molecular
What does the transcribed region consist of? Introns and exons "<img
src=""7305.png"">" biochemistry duplicate functional-organization-of-a-
eukaryotic-gene molecular
What is the name of the DNA site at which RNA polymerase and transcription factors
bind? Promoter "<img src=""7306.png"">" biochemistry duplicate molecular
regulation-of-gene-expression
Which elements make up the promoter region? An AT-rich sequence with TATA and
CAAT boxes "<img src=""7306.png"">" biochemistry duplicate molecular
Is the promoter upstream or downstream of its gene locus? Upstream "<img
src=""7306.png"">" biochemistry duplicate molecular regulation-of-gene-
expression
What is the name for a DNA site where negative regulators (repressors) bind?
Silencer "<img src=""7306.png"">" biochemistry duplicate molecular
A pt has a mutation within a promoter for a gene producing hair pigment. What is
the clinical effect? There will be a significant decrease in gene transcription,
so the hair will lack pigment "<img src=""7306.png"">" biochemistry duplicate
molecular regulation-of-gene-expression
What is the name for a stretch of DNA that alters gene expression by binding
transcription factors? Enhancer "<img src=""7306.png"">" biochemistry
duplicate molecular regulation-of-gene-expression
Where might enhancers and silencers be located relative to the gene being
regulated? Far from, close to, or within the gene itself "<img src=""7306.png"">"
biochemistry duplicate molecular regulation-of-gene-expression
A man has a mutation within a silencer region of a growth hormone gene; negative
regulators bind more often. What is the clinical effect? A significant decrease
in growth hormone synthesis and effect, possibly resulting in short stature and
shortened limbs "<img src=""7306.png"">" biochemistry duplicate molecular
RNA polymerases have no proofreading function in which type of organism?
Eukaryotes "<img src=""7307.png"">" biochemistry duplicate molecular
rna-polymerases
A gardener finds a cap mushroom and decides to eat it. Later, liver failure
develops. How did this happen? The mushroom likely contained -amanitin, which
inhibits RNA polymerase II and causes severe hepatotoxicity"<img src=""7307.png"">"
biochemistry duplicate molecular rna-polymerases
In eukaryotes, which polymerase makes tRNA, mRNA, and rRNA, respectively? RNA
polymerase III, II, and I "<img src=""7307.png"">" biochemistry duplicate
molecular rna-polymerases
Of the RNA types, which is the largest RNA, the most abundant RNA, and the smallest
RNA, respectively? mRNA; rRNA; tRNA (massive, rampant, and tiny, respectively)
"<img src=""7307.png"">" biochemistry duplicate molecular rna-
polymerases
In prokaryotes, which enzyme makes rRNA, mRNA, and tRNA? RNA polymerase (a single
multisubunit complex) "<img src=""7307.png"">" biochemistry duplicate
molecular rna-polymerases
Where does RNA polymerase II open DNA? At the promoter site "<img
src=""7307.png"">" biochemistry duplicate molecular rna-polymerases
What is rifampin's mechanism of action? Inhibition of RNA polymerase in
prokaryotes "<img src=""7307.png"">" biochemistry duplicate molecular rna-
polymerases
What is actinomycin D's mechanism of action? Inhibition of RNA polymerase in
both prokaryotes and eukaryotes "<img src=""7307.png"">" biochemistry
duplicate molecular rna-polymerases
Where does eukaryotic RNA processing occur? In the nucleus "<img
src=""7308.png"">" biochemistry duplicate molecular rna-processing-
(eukaryotes)
Which three modifications take place during eukaryotic RNA processing? Capping of
the 5 end, polyadenylation of the 3 end, and splicing out of introns "<img
src=""7308.png"">" biochemistry duplicate molecular rna-processing-
(eukaryotes)
Approximately how many adenosine monophosphates are added to the 3 end of mRNA
during polyadenylation? 200 "<img src=""7308.png"">" biochemistry duplicate
molecular rna-processing-(eukaryotes)
What is the term for the initial (unprocessed) RNA transcript in eukaryotes?
Heterogeneous nuclear RNA (hnRNA) "<img src=""7308.png"">" biochemistry
duplicate molecular rna-processing-(eukaryotes)
What is the role of cytoplasmic P-bodies in RNA processing?Location of mRNA quality
control, which is accomplished using exonucleases, decapping enzymes, and micro-
RNAs "<img src=""7308.png"">" biochemistry duplicate molecular rna-
processing-(eukaryotes)
What function does the sequence AAUAAA serve in eukaryotes?Polyadenylation signal
Does poly-A polymerase require a template? No "<img src=""7308.png"">"
biochemistry duplicate molecular rna-processing-(eukaryotes)
A science experiment is done to add the 7-methylguanosine cap to hnRNA. Where does
this occur in the cell? In the nucleus; it is added to the 5 end of the hnRNA
What binds to a primary mRNA transcript and forms a spliceosome? Small nuclear
ribonucleoprotein particles (snRNPs) and other proteins "<img src=""7309.png"">"
biochemistry duplicate molecular splicing-of-pre-mrna
snRNPs form a lariat-shaped loop in order to do what? Isolate an intron for removal
"<img src=""7309.png"">" biochemistry duplicate molecular splicing-of-
pre-mrna
Release of a lariat in splicing allows what to occur? Removal of the intron and
joining of the two bordering exons "<img src=""7309.png"">" biochemistry
duplicate molecular splicing-of-pre-mrna
"A pt presents with a malar ""butterfly"" rash and renal disease. Which antibodies
does her disease make?" Spliceosomal snRNP (anti-Smith) antibodies, associated with
lupus; anti-U1 RNP antibodies are present in mixed connective tissue disease "<img
src=""7309.png"">" biochemistry duplicate molecular splicing-of-pre-mrna
Which portions of DNA contain the genetic information to code for proteinintrons
or exons? Exons (Exons exit and are expressed.) "<img src=""7310.png"">"
biochemistry duplicate introns-vs-exons molecular
What is the name for the intervening noncoding segments of DNA within a gene?
Introns (Introns are intervening sequences and stay in the nucleus.) "<img
src=""7310.png"">" biochemistry duplicate introns-vs-exons molecular
What mechanism allows the same gene to encode for multiple proteins? Alternative
splicing "<img src=""7310.png"">" biochemistry duplicate introns-vs-exons
molecular
A pt's cancer cells undergo genetic analysis. Which splicing-related phenomenon may
be implicated in the tumor's initial oncogenesis? Abnormal splicing variants
"<img src=""7310.png"">" biochemistry duplicate introns-vs-exons
molecular
What is a small mRNA molecule that regulates protein expression after
transcription? microRNA "<img src=""7311.png"">" biochemistry duplicate
micrornas molecular
Can microRNA be found in introns or exons? Introns "<img src=""7311.png"">"
biochemistry duplicate micrornas molecular
How many nucleotides make up the structure of an average tRNA? Approximately 75
to 90 "<img src=""7312.png"">" biochemistry duplicate molecular trna
Which part of a tRNA lies opposite its 3 aminoacyl end? The anticodon end "<img
src=""7312.png"">" biochemistry duplicate molecular trna
Which three-nucleotide sequence do all eukaryotic and prokaryotic tRNAs have at
their 3 ends? CCA (Can Carry Amino acids) "<img src=""7312.png"">"
biochemistry duplicate molecular trna
Where on a tRNA does the amino acid that will be incorporated into the protein
bind? The 3 end "<img src=""7312.png"">" biochemistry duplicate molecular
trna
Does charging a tRNA molecule with an amino acid require energy? Yes, as ATP is
hydrolyzed in the process "<img src=""7312.png"">" biochemistry duplicate
molecular trna
If a tRNA had a methionine bound to it, what would the sequence of the codon it
binds read, in 5to3 order? And the anticodon? Codon = AUG; anticodon = CAU
"<img src=""7312.png"">" biochemistry duplicate molecular trna
What are the three substrates of the reaction that is catalyzed by aminoacyl-tRNA
synthetase (the matchmaker)? The uncharged tRNA, the appropriate amino acid,
and ATP "<img src=""7312.png"">" biochemistry duplicate molecular trna
What does aminoacyl-tRNA synthetase do? It scrutinizes the amino acid before and
after it binds to tRNA, hydrolyzing the bond if an incorrect amino acid is present
"<img src=""7312.png"">" biochemistry duplicate molecular trna
Which sequence is necessary for tRNA-ribosome binding? Where is it found on the
tRNA? Ribothymidine, pseudouridine, cytidine (TC), found on the T-arm "<img
What is the purpose of the D-arm? It ensures identification by the correct
aminoacyl-tRNA synthetase "<img src=""7312.png"">" biochemistry duplicate
molecular trna
Which hypothesis states that only the first two positions of a triplet codon on
mRNA have a precise pairing with the tRNA anticodon? Wobble hypothesis "<img
Generally, accurate base pairing is usually only needed in which portion of the
mRNA codon? The first two nucleotide positions "<img src=""7312.png"">"
biochemistry duplicate molecular trna
The wobble hypothesis primarily explains which property of the genetic code?
Degeneracy "<img src=""7312.png"">" biochemistry duplicate molecular
trna
What are the two subunits of the eukaryotic ribosome called? The 60S subunit
and the 40S subunit; 40S + 60S leads to 80S (Eukaryotic = Even) "<img
src=""7313.png"">" biochemistry duplicate molecular protein-synthesis
Which organisms have ribosomes with 50S and 30S subunits? Prokaryotes; 30S + 50S
leads to 70S (prOkaryotes are Odd.) "<img src=""7313.png"">" biochemistry
duplicate molecular protein-synthesis
A scientist studying protein synthesis wants to block initiator methionine tRNA. He
makes an inhibitor blocking the A site. Will this work? No, as initiator
methionine tRNA does not bind at the A site (It is the sole exception; all other
aminoacyl-tRNA combinations bind there.) "<img src=""7313.png"">" biochemistry
At the start of protein synthesis, what process occurs at the same time as the
hydrolysis of methionine's bond with its tRNA? The formation of a peptide bond
between methionine and the second amino acid in the polypeptide "<img
"In reference to the ""P site"" of a ribosome, what does the ""P"" stand for?"
Peptide: The P site accommodates the growing polypeptide chain "<img
Which molecules are responsible for assembling the 40S subunit with the initiator
tRNA? Eukaryotic initiation factors (IFs) "<img src=""7313.png"">" biochemistry
In which direction relative to the mRNA does the ribosome shift after the formation
of a peptidyl bond? Toward the 3 end "<img src=""7313.png"">" biochemistry
Which molecule provides the energy for the translocation of the ribosome along the
mRNA? Guanosine triphosphate (GTP tRNAGripping and Going places)"<img
When the ribosome shifts after the formation of a peptidyl bond, to which position
does the tRNA with the growing peptide chain go? The P site (translocation)
"<img src=""7313.png"">" biochemistry duplicate molecular protein-
synthesis
Which molecule provides the energy for the charging of tRNA? ATP (ATPtRNA
Activation) "<img src=""7313.png"">" biochemistry duplicate molecular protein-
synthesis
Which molecule provides the energy for the binding of tRNA to the ribosome/mRNA
complex? Guanosine triphosphate (GTP tRNAGripping and Going places)"<img
When the ribosome shifts after the formation of a peptidyl bond, where is the
uncharged tRNA found? In the E site (holds Empty tRNA as it Exits) "<img
What is the order of the positions of the ribosome that the tRNA occupies during
translation? "A site, P site, E site (Think of ""going APE."")" "<img
In protein synthesis, what are the three steps of protein elongation? Aminoacyl-
tRNA binding to A site, transfer of growing peptide chain to amino acid at the A
site by the ribosome, and translocation "<img src=""7313.png"">" biochemistry
A pt takes an antibiotic that blocks the prokaryotic 30S subunit from assembling.
How does it interfere with protein synthesis? It inhibits formation of the
initiation complex, causing misreading of mRNA "<img src=""7313.png"">"
biochemistry duplicate molecular protein-synthesis
A pt with a MRSA infection takes an antibiotic that inhibits translocation by
binding the 50S subunit. Does this affect human cells? No. The 50S subunit is
prokaryotic, so human cells are minimally targeted by this drug "<img
In termination, what recognizes the stop codon and frees the completed protein from
the ribosome? Release factor "<img src=""7313.png"">" biochemistry
What is an example of protein trimming after translation? Removal of N- or C-
terminal propeptides from a proenzyme to yield a mature protein (eg, conversion of
trypsinogen to trypsin) "<img src=""7314.png"">" biochemistry duplicate
molecular posttranslational-modifications
What is a chaperone protein? An intracellular protein that is involved in
facilitating and/or maintaining protein folding "<img src=""7314.png"">"
biochemistry duplicate molecular posttranslational-modifications
A scientist wants to write about covalent alterations of proteins. Name six kinds
of posttranslational protein modifications. Phosphorylation, glycosylation,
hydroxylation, methylation, acetylation, and ubiquitination"<img src=""7314.png"">"
biochemistry duplicate molecular posttranslational-modifications
A scientist studies Hsp60, a protein expressed in yeast to prevent misfolding at
high temperatures. How are these proteins classified? Heat shock proteinschaperone
proteins that facilitate and maintain proper protein folding "<img
src=""7314.png"">" biochemistry duplicate molecular posttranslational-
modifications
List the five main phases of mitosis, in order. Prophase, prometaphase, metaphase,
anaphase, and telophase "<img src=""7316.png"">" biochemistry cell-cycle-
phases cellular duplicate
When does mitosis occur in the cell cycle? Mitosis occurs after G2 and before
G1 in the cell cycle "<img src=""7316.png"">" biochemistry cell-cycle-
When does DNA synthesis occur in the cell cycle? In S phase, which is after G1
and before G2 in the cell cycle "<img src=""7316.png"">" biochemistry cell-
cycle-phases cellular duplicate
From which phase of the cell cycle can a cell enter G0? G1, a subset of
interphase "<img src=""7316.png"">" biochemistry cell-cycle-phases cellular
duplicate
Which phase of the cell cycle is usually the shortest? The M phase "<img
src=""7316.png"">" biochemistry cell-cycle-phases cellular duplicate
Which phase of the cell cycle is shortened in rapidly dividing cells? G1 "<img
What is the relationship between cyclin-dependent kinases (CDKs) and cyclins?
Cyclins are regulatory proteins that activate CDKs (enzymes) at appropriate
times in the cell cycle "<img src=""7316.png"">" biochemistry cell-cycle-
Cells such as neurons, red blood cells, and skeletal and cardiac muscle cells
remain in which phase of the cell cycle? In the G0 phase; the cells described are
permanent cells "<img src=""7316.png"">" biochemistry cell-cycle-phases
cellular duplicate
Which type of cells, such as hepatocytes and lymphocytes, enter G1 from G0 when
stimulated? Stable (quiescent) cells "<img src=""7316.png"">" biochemistry
cell-cycle-phases cellular duplicate
Which type of cells, such as gastric epithelial cells, divide rapidly with a short
G1 and never go to G0? Labile cells "<img src=""7316.png"">" biochemistry
cell-cycle-phases cellular duplicate
A pt undergoing chemotherapy is prone to disturbances of bone marrow, gut
epithelium, germ cells, skin, and hair follicles. Why? These are examples of
labile cells, which are affected most heavily by chemotherapy "<img
List the three components of interphase. G1, S phase, and G2 "<img
Pts with Li-Fraumeni syndrome have unrestrained cell division and increased risk
for malignancy. Which cell cycle transition is inhibited? Transition from G1 to S-
phase; these pts are deficient in the p53 tumor suppressor protein, which prohibits
this transition "<img src=""7316.png"">" biochemistry cell-cycle-phases
cellular duplicate
What are the main functions of the rough endoplasmic reticulum? Synthesis of
secretory (exported) proteins and the addition of N-linked oligosaccharides to
proteins "<img src=""7317.png"">" biochemistry cellular duplicate rough-
endoplasmic-reticulum
A researcher studying the rough endoplasmic reticulum (RER) starts taking cells
from lab rats. Which two cell types would be most useful? Goblet cells, which
secrete mucus, and plasma cells, which secrete antibodies; both are rich in RER
"<img src=""7317.png"">" biochemistry cellular duplicate rough-
What is the histologic term for rough endoplasmic reticulum in neurons? Which
substances are synthesized there? Nissl bodies; peptide neurotransmitters and
enzymes (such as ChAT) "<img src=""7317.png"">" biochemistry cellular
duplicate rough-endoplasmic-reticulum
Which type of ribosomes synthesize cytosolic and organellar proteins? Free
ribosomes "<img src=""7317.png"">" biochemistry cellular duplicate rough-
Which type of ribosomes synthesize secretory proteins? Attached ribosomes
"<img src=""7317.png"">" biochemistry cellular duplicate rough-
What makes the smooth endoplasmic reticulum so smooth? It lacks surface
ribosomes "<img src=""7318.png"">" biochemistry cellular duplicate smooth-
List two functions of the smooth endoplasmic reticulum. Steroid synthesis;
detoxification of drugs and poisons "<img src=""7318.png"">" biochemistry
cellular duplicate smooth-endoplasmic-reticulum
A researcher wants to study cells that are rich in smooth endoplasmic reticulum
(SER). Name two types of cells suitable for this. Steroid hormoneproducing
cells of the adrenal cortex and hepatocytes "<img src=""7318.png"">"
biochemistry cellular duplicate smooth-endoplasmic-reticulum
The Golgi apparatus functions as the distribution center for what? Proteins and
lipids from the endoplasmic reticulum "<img src=""7319.png"">" biochemistry
cell-trafficking cellular duplicate
List three places to which the Golgi apparatus sends proteins and lipids. The
plasma membrane, lysosomes, and secretory vesicles "<img src=""7319.png"">"
biochemistry cell-trafficking cellular duplicate
Clathrin is a protein that transports vesicles from the trans face of the Golgi
apparatus to where? Clathrin directs vesicles from the trans face of the Golgi
apparatus to lysosomes and from the plasma membrane to endosomes "<img
src=""7319.png"">" biochemistry cell-trafficking cellular duplicate
Which type of protein-bound saccharides are modified in the Golgi apparatus? N-
oligosaccharides (on asparagine) "<img src=""7319.png"">" biochemistry cell-
trafficking cellular duplicate
What is the enzyme defect in I-cell disease and what happens to phosphorylation of
mannose residues on glycoproteins? A defect in N-acetylglucosaminyl-1-
phosphotransferase; phosphorylation decreases. "<img src=""7319.png"">"
What clinical signs may be seen if a pt's proteins are excreted extracellularly
instead of being delivered to lysosomes? Coarse facies, clouded corneas, and
restricted joints, which are signs of I-cell disease "<img src=""7319.png"">"
A child has coarse facies, clouded corneas, restricted joints, and increased plasma
lysosomal enzymes. Diagnosis and prognosis? I-cell disease, usually fatal in
childhood "<img src=""7319.png"">" biochemistry cell-trafficking cellular
duplicate
How are serine and threonine residues modified in the Golgi? O-oligosaccharides
are added "<img src=""7319.png"">" biochemistry cell-trafficking cellular
duplicate
What is the role of COPII in vesicular trafficking? Anterograde transport from
rough endoplasmic reticulum to the cis-Golgi "<img src=""7319.png"">"
Addition of which marker to proteins in the Golgi targets them to lysosomes?
Mannose-6-phosphate "<img src=""7319.png"">" biochemistry cell-
trafficking cellular duplicate
What is the role of COPI in vesicular trafficking? Retrograde movement from the
Golgi apparatus to the endoplasmic reticulum "<img src=""7319.png"">"
In a pt with abnormally low LDL receptor levels, which vesicular trafficking
protein might have a defect? Clathrin "<img src=""7319.png"">" biochemistry
cell-trafficking cellular duplicate
What is the process by which clathrin transports vesicles from outside to inside
the cell through fusion of the two lipid-based membranes? Receptor-mediated
endocytosis "<img src=""7319.png"">" biochemistry cell-trafficking cellular
duplicate
Endosomes are sorting centers for material from outside the cell or from the Golgi.
Which routes can material take from the endosome? Back to the membrane or Golgi
for further use or to lysosomes for degradation "<img src=""7319.png"">"
A pt is found to have dysfunctional signal recognition particles (SRPs) in his
cells. What does this lead to? Absent or dysfunctional SRPs lead to the
accumulation of proteins in the cytosol that cannot be trafficked to the RER "<img
src=""7319.png"">" biochemistry cell-trafficking cellular duplicate
Which organelle is involved in the catabolism of very-long-chain fatty acids
through -oxidation? What is this organelle enclosed in? Peroxisome; it is
enclosed in membrane "<img src=""7320.png"">" biochemistry cellular
duplicate peroxisome
List all substrates that undergo catabolism in the peroxisome. Very-long-chain
fatty acids, branched-chain fatty acids, ethanol, and amino acids "<img
src=""7320.png"">" biochemistry cellular duplicate peroxisome
Which barrel-shaped protein complex degrades damaged or unnecessary proteins tagged
for destruction? Proteasome "<img src=""7321.png"">" biochemistry cellular
duplicate proteasome
A man with Parkinson disease lacks protein complexes that destroy other proteins.
Proteins tagged with what marker fail to be recognized? Proteins tagged with
ubiquitin fail to be recognized by proteasomes, which may be the pathophysiology
behind some cases of Parkinson disease "<img src=""7321.png"">" biochemistry
cellular duplicate proteasome
What purposes do cilia, flagella, mitotic spindles, centrioles, and axonal
trafficking serve? What cytoskeletal element do they all require? Movement and
cell division; microtubules "<img src=""7322.png"">" biochemistry cellular
cytoskeletal-elements duplicate
Name six structures that are composed of intermediate filaments. Vimentin, desmin,
cytokeratin, lamins, glial fibrillary acid proteins (GFAP), neurofilaments "<img
src=""7322.png"">" biochemistry cellular cytoskeletal-elements duplicate
What is the major function of intermediate filaments? Maintenance of cell structure
"<img src=""7322.png"">" biochemistry cellular cytoskeletal-elements
duplicate
Name two structures that are composed of microfilaments. Actin and microvilli
"<img src=""7322.png"">" biochemistry cellular cytoskeletal-elements
duplicate
Vimentin stains identify which type of cells? Mesenchymal tissue (eg,
fibroblasts, endothelial cells, macrophages) "<img src=""7323.png"">"
biochemistry cellular duplicate immunohistochemical-stains-for-intermediate-
filaments
A pt is diagnosed with fibrosarcoma. Which stain can be used to identify the tumor
cells? Vimentin (stains well for mesenchymal tumors) "<img src=""7323.png"">"
biochemistry cellular duplicate immunohistochemical-stains-for-intermediate-
filaments
What kind of tumors can be identified with vimentin stain? Mesenchymal tumors (eg,
sarcomas, endometrial carcinoma, renal cell carcinoma, meningiomas) "<img
src=""7323.png"">" biochemistry cellular duplicate immunohistochemical-stains-
for-intermediate-filaments
Which type of cells do desmin stains identify? Muscle (Muscle is stained by
DesMin.) "<img src=""7323.png"">" biochemistry cellular duplicate
immunohistochemical-stains-for-intermediate-filaments
Epithelial tumor cells, such as squamous cell carcinoma, can be identified by which
stain? Cytokeratin "<img src=""7323.png"">" biochemistry cellular
duplicate immunohistochemical-stains-for-intermediate-filaments
Neurofilament stains identify which type of cells? Neurons "<img
src=""7323.png"">" biochemistry cellular duplicate immunohistochemical-stains-
for-intermediate-filaments
Neuroglia can be identified by what type of stain? Glial fibrillary acid protein
(GFAP stain identifies neuroGlia.) "<img src=""7323.png"">" biochemistry
cellular duplicate immunohistochemical-stains-for-intermediate-filaments
Astrocytomas and glioblastomas can be identified with what type of stain? Glial
fibrillary acid protein (GFAP) stain "<img src=""7323.png"">" biochemistry
cellular duplicate immunohistochemical-stains-for-intermediate-filaments
Microtubules are involved in what type of transport in the neurons? Slow
axoplasmic transport "<img src=""7324.png"">" biochemistry cellular
duplicate microtubule
Compare and contrast the rates of growth and collapse, respectively, for
microtubule filaments. They grow slowly and collapse quickly "<img
src=""7324.png"">" biochemistry cellular duplicate microtubule
A man has recurrent attacks of acute inflammatory arthritis with a swollen big toe.
What microtubule medication can abort an acute attack? Colchicine, as this is
gout "<img src=""7324.png"">" biochemistry cellular duplicate microtubule
What is the mechanism of action of the anticancer drugs vincristine, vinblastine,
and paclitaxel? Interference with microtubule polymerization "<img
A pt has a fungal infection. You are asked to prescribe an antifungal agent that
targets microtubules. What could you prescribe? Griseofulvin "<img
Which antihelminthic drug targets the microtubules? Mebendazole "<img
In the microtubule, what motor protein is involved in anterograde transport? What
protein is involved in retrograde transport? Anterograde transport: kinesin
(negativetopositive end); retrograde transport: dynein (positivetonegative end)
"<img src=""7324.png"">" biochemistry cellular duplicate microtubule
Name the two protein constituents of the heterodimer building block for
microtubules. How many GTPs are bound to each dimer? - and -tubulin; each dimer
has two GTPs bound "<img src=""7324.png"">" biochemistry cellular
duplicate microtubule
What protein causes the movement of the cilia? How does it work? Axonemal dynein is
an ATPase that links the nine peripheral doublets and causes cilia bending by
differential sliding of doublets "<img src=""7325.png"">" biochemistry
cellular cilia-structure duplicate
Which diagnosis should you consider in a male pt with infertility, bronchiectasis,
and recurrent sinusitis? Kartagener syndrome (primary ciliary dyskinesia)
"<img src=""7325.png"">" biochemistry cellular cilia-structure duplicate
A woman with Kartagener syndrome has infertility. What is the mechanism?
Dysfunctional fallopian tube cilia "<img src=""7325.png"">" biochemistry
A woman has a history of recurrent pneumonia; chest x-ray reveals dextrocardia. If
she tries to get pregnant, what is she at risk for? She is at risk for ectopic
pregnancy; she has Kartagener syndrome, in which fallopian tube cilia are
dysfunctional "<img src=""7325.png"">" biochemistry cellular cilia-
structure duplicate
What does the basal body consist of? Nine microtubule triplets with no central
microtubules; it is the base of a cilium "<img src=""7325.png"">" biochemistry
Describe the structure of the plasma membrane of a cell. Asymmetric lipid bilayer
"<img src=""7326.png"">" biochemistry cellular duplicate plasma-
membrane-composition
Name five components of plasma membranes. Phospholipids, cholesterol,
sphingolipids, glycolipids, and proteins "<img src=""7326.png"">" biochemistry
cellular duplicate plasma-membrane-composition
An antifungal agent that damages membranes without harming human cells is
discovered. What component does it likely target for degradation? Ergosterol
"<img src=""7326.png"">" biochemistry cellular duplicate plasma-
membrane-composition
How many ATPs are consumed in one cycle of the Na+-K+ pump?One "<img
src=""7327.png"">" biochemistry cellular duplicate sodium-potassium-pump
A man takes a drug that boosts cardiac contractility by indirectly raising
intracellular Ca2+ levels. Blockade of which pump is responsible? The sodium-
potassium pump; the drug is a cardiac glycoside "<img src=""7327.png"">"
biochemistry cellular duplicate sodium-potassium-pump
Where does ouabain bind to Na+-K+ ATPase? What does it do to the pump? At the K+
binding site; it inhibits the pump "<img src=""7327.png"">" biochemistry
cellular duplicate sodium-potassium-pump
The ATP binding site of Na+-K+ ATPase is located on which side of the plasma
membrane? Cytosolic "<img src=""7327.png"">" biochemistry cellular
duplicate sodium-potassium-pump
Sodium-potassium pumps transport how many Na+ and K+ ions (and in which direction)
for each ATP consumed? Three Na+ ions out and two K+ ions in "<img
Name two examples of cardiac glycosides. How do they affect cardiac contractility?
Digoxin and digitoxin; they increase cardiac contractility "<img
A pt has autoantibodies attacking his glomerular basement membranes. What type of
collagen is most likely being targeted? Type IV collagen (The disease is
Goodpasture syndrome.) "<img src=""7328.png"">" biochemistry cellular
collagen duplicate
Which type of collagen is deficient in the vascular type of Ehlers-Danlos syndrome?
Type III, which is deficient in the uncommon, vascular type of Ehlers-Danlos
syndrome (ThreE D) "<img src=""7328.png"">" biochemistry cellular
collagen duplicate
A man takes a drug that interferes with posttranslational modification. How will
this affect his bone, skin, and tendon production? It affects collagen synthesis
(including type I) and interferes with production; collagen undergoes extensive
posttranslational modification "<img src=""7328.png"">" biochemistry
cellular collagen duplicate
What is the most abundant protein in the human body and what is its function?
Collagen; it strengthens and organizes the extracellular matrix "<img
src=""7328.png"">" biochemistry cellular collagen duplicate
In what structures can type IV collagen be found? The basement membrane (type
IV: under the floor), basal lamina, and lens "<img src=""7328.png"">"
biochemistry cellular collagen duplicate
In what structures can type III collagen be found? The vitreous body, nucleus
pulposus, hyaline cartilage (type II: cartwolage), and articular surface of joints
"<img src=""7328.png"">" biochemistry cellular collagen duplicate
What is another name for type III collagen? In what structures can type III
collagen be found? Reticulin; it can be found in skin, blood vessels, uterus,
granulation tissue, and fetal tissue "<img src=""7328.png"">" biochemistry
cellular collagen duplicate
What is the most common type of collagen? In what structures can it be found?
Type I collagen (90%); it can be found in bone, skin, dentin, tendon, fascia,
and cornea; it is involved in late wound repair "<img src=""7328.png"">"
A baby is born with multiple fractures, loose joints, and blue sclerae. What is the
pathophysiology of the disease? Insufficient production of type I collagen (The
disease is osteogenesis imperfecta type I.) "<img src=""7328.png"">"
A 13-year-old boy presents with hearing loss, hematuria, and end-stage kidney
disease. What type of collagen is most likely defective? Type IV (The disease is
Alport syndrome.) "<img src=""7328.png"">" biochemistry cellular collagen
duplicate
What form of collagen is exocytosed from the cell into the extracellular space?
Procollagen "<img src=""7329.png"">" biochemistry cellular collagen-
synthesis-and-structure duplicate
Which two amino acid residues undergo hydroxylation in collagen synthesis?
Proline and lysine "<img src=""7329.png"">" biochemistry cellular
collagen-synthesis-and-structure duplicate
Which amino acid residue is glycosylated in collagen synthesis? Hydroxylysine
"<img src=""7329.png"">" biochemistry cellular collagen-synthesis-and-
structure duplicate
What is the structure of procollagen? Triple helix formation "<img
src=""7329.png"">" biochemistry cellular collagen-synthesis-and-structure
duplicate
A collagen chain during collagen synthesis is referred to as what?
Preprocollagen "<img src=""7329.png"">" biochemistry cellular
Many staggered tropocollagen molecules with covalent lysine-hydroxylysine cross-
links are referred to as what? Collagen fibrils "<img src=""7329.png"">"
biochemistry cellular collagen-synthesis-and-structure duplicate
Where does collagen synthesis mainly occur inside the cell?In the rough endoplasmic
reticulum (RER) "<img src=""7329.png"">" biochemistry cellular collagen-
How does the formation of tropocollagen from the cleavage of procollagen change the
solubility? It decreases the solubility (Tropocollagen is insoluble.) "<img
duplicate
Where does the formation of tropocollagen occur? Extracellular space "<img
duplicate
Historically, British sailors commonly presented with an inability to hydroxylate
proline and lysine residues, Why were limes prescribed? "They had scurvy, and
limes supplied the vitamin C that they needed (earning them the nickname
""limeys"")" "<img src=""7329.png"">" biochemistry cellular collagen-
Name the amino acids that predominate in collagen. Glycine, proline, lysine,
hydroxyproline, and hydroxylysine "<img src=""7329.png"">" biochemistry
cellular collagen-synthesis-and-structure duplicate
Which vitamin is required for the hydroxylation of proline and lysine residues in
collagen? Vitamin C "<img src=""7329.png"">" biochemistry cellular
A triple helix that is composed of three collagen chains with the terminal
disulfide-rich regions cleaved off is referred to as what? Tropocollagen "<img
duplicate
Which enzyme covalently cross-links lysine residues to hydroxylysine residues to
make collagen fibrils? Which two diseases do defects cause?Lysyl oxidase
(containing copper); Menkes disease and Ehlers-Danlos syndrome "<img
duplicate
The content of which amino acid best reflects collagen synthesis? Glycine, as
collagen is one third glycine "<img src=""7329.png"">" biochemistry cellular
A man presents with easy bruising and ecchymoses. You find that he has defective
cross-linking of tropocollagen. What disease does he have? Ehlers-Danlos syndrome
"<img src=""7329.png"">" biochemistry cellular collagen-synthesis-and-
structure duplicate
Generally speaking, what is the pathophysiology behind osteogenesis imperfecta?
Defects in the formation of the collagen triple helix"<img src=""7329.png"">"
biochemistry cellular collagen-synthesis-and-structure duplicate
What type of inheritance does the most common variant of osteogenesis imperfecta
demonstrate? Autosomal dominant "<img src=""7330.png"">" biochemistry
cellular duplicate osteogenesis-imperfecta
What process is defective in osteogenesis imperfecta? Collagen production "<img
src=""7330.png"">" biochemistry cellular duplicate osteogenesis-imperfecta
What is the pathophysiology behind the dental imperfections found in osteogenesis
imperfecta? What is the pathology called? Lack of dentin causes opalescent teeth
that wear quickly; this is called dentinogenesis imperfecta"<img src=""7330.png"">"
biochemistry cellular duplicate osteogenesis-imperfecta
A young woman with blue sclerae also has hearing loss. What is the pathophysiology
of her hearing loss? Abnormal ossicles (This is osteogenesis imperfecta.) "<img
src=""7330.png"">" biochemistry cellular duplicate osteogenesis-imperfecta
Ehlers-Danlos syndrome is a defect of what process? Collagen synthesis "<img
src=""7331.png"">" biochemistry cellular duplicate ehlers-danlos-syndrome
Like polycystic kidney disease, Ehlers-Danlos syndrome is associated with what
defects of the brain vasculature? Berry aneurysms (also associated with aortic
aneurysms) "<img src=""7331.png"">" biochemistry cellular duplicate ehlers-
danlos-syndrome
Ehlers-Danlos syndrome is transmitted through what inheritance pattern(s)? Can be
either autosomal dominant or autosomal recessive "<img src=""7331.png"">"
biochemistry cellular duplicate ehlers-danlos-syndrome
A pt has the most common type of Ehlers-Danlos syndrome. What finding would be
expected in this pt? Joint instability (seen in the hypermobility type) "<img
src=""7331.png"">" biochemistry cellular duplicate ehlers-danlos-syndrome
Autopsy of a 50-year-old with recurrent joint dislocations reveals death from
splenic rupture. What mechanism of action led to his death?Poor type III collagen
synthesis resulting in weak connective tissue, seen in the vascular type of Ehlers-
Danlos syndrome "<img src=""7331.png"">" biochemistry cellular duplicate
ehlers-danlos-syndrome
"A pt presents with brittle, ""kinky"" hair; growth retardation; and hypotonia.
What gene mutation is responsible?" A defect in the Menkes protein (ATP7A) (This is
Menkes disease.) "<img src=""7332.png"">" biochemistry cellular duplicate
menkes-disease
Impaired copper absorption and transport could result in which connective tissue
disease? Menkes disease "<img src=""7332.png"">" biochemistry cellular
duplicate menkes-disease
Why is copper a critical factor in the development of Menkes disease? Copper is a
required cofactor for lysyl oxidase, an enzyme that makes collagen fibrils from
tropocollagen "<img src=""7332.png"">" biochemistry cellular duplicate
menkes-disease
What pattern of inheritance does Menkes disease follow? X-linked recessive
"<img src=""7332.png"">" biochemistry cellular duplicate menkes-disease
What enzyme is inhibited by 1-antitrypsin? Elastase, which degrades elastin
"<img src=""7333.png"">" biochemistry cellular duplicate elastin
A man has long, slender limbs, fingers, & toes. He has an inherited defect in a
glycoprotein that forms a sheath around elastin. Diagnosis?Marfan syndrome (The
glycoprotein described is fibrillin.) "<img src=""7333.png"">" biochemistry
cellular duplicate elastin
What is the function of fibrillin? It acts as a scaffold for tropoelastin "<img
src=""7333.png"">" biochemistry cellular duplicate elastin
A man with no smoking history presents with emphysema. He was also found to have
excess elastase activity. What deficiency might he have? 1-Antitrypsin
deficiency "<img src=""7333.png"">" biochemistry cellular duplicate elastin
Elastin is rich in which amino acids? Are they hydroxylated or nonhydroxylated?
Proline, glycine, and lysine; they are nonhydroxylated "<img
Name six locations in the body where elastin may be found. Skin, lungs, large
arteries, elastic ligaments, vocal cords, ligamenta flava (connect vertebrae with
relaxed and stretched conformations) "<img src=""7333.png"">" biochemistry
cellular duplicate elastin
A pt is distraught about her aging and wants to know why her skin is becoming more
wrinkled. What is a good explanation to give her? As we age, we have decreased
collagen and elastin production, which leads to wrinkle formation "<img
What is the purpose of using the DNA polymerase chain reaction? To amplify the
number of copies of a specific DNA fragment; also useful as a diagnostic tool (eg,
for neonatal HIV or herpes encephalitis) "<img src=""7334.png"">" biochemistry
duplicate laboratory-techniques polymerase-chain-reaction
A man presents with herpes infection. You want to know whether he has HSV-1 or -2.
What molecular test can you use to differentiate the two? DNA polymerase chain
reaction "<img src=""7334.png"">" biochemistry duplicate laboratory-
techniques polymerase-chain-reaction
How is DNA separated into two strands during the polymerase chain reaction? By
heating (denaturation) "<img src=""7334.png"">" biochemistry duplicate
laboratory-techniques polymerase-chain-reaction
In the polymerase chain reaction, what is used to recognize and anneal to the DNA
fragment that needs to be amplified? DNA primers "<img src=""7334.png"">"
biochemistry duplicate laboratory-techniques polymerase-chain-reaction
What enzyme is used in the polymerase chain reaction to amplify DNA? Heat-stable
DNA polymerase "<img src=""7334.png"">" biochemistry duplicate laboratory-
techniques polymerase-chain-reaction
What are the three steps of the DNA polymerase chain reaction in order?
Denaturation, annealing, and elongation; these steps are repeated multiple
times to amplify a DNA sequence "<img src=""7334.png"">" biochemistry
How does the temperature differ for the three main steps of PCR? Denaturation: 95
C; annealing: 55 C; elongation: 72 C "<img src=""7334.png"">" biochemistry
What blot technique is used to separate and identify proteins? Western blot
"<img src=""7335.png"">" biochemistry blotting-procedures duplicate
laboratory-techniques
What blot technique detects specific sequences of DNA? Southern blot (SNoW
DRoP: Southern = DNA, Northern = RNA, Western = Protein) "<img src=""7335.png"">"
biochemistry blotting-procedures duplicate laboratory-techniques
What is the difference between a Southern blot and a Northern blot? A Southern
blot involves a radiolabeled DNA probe binding to DNA, whereas a Northern blot
involves a radiolabeled DNA probe binding to RNA "<img src=""7335.png"">"
How is the DNA sample separated in a Southern blot? Via gel electrophoresis; the
isolated DNA fragments are then transferred to a filter "<img src=""7335.png"">"
A researcher wants to identify a novel transcription factor from an ovarian cancer
cell. What blotting technique can be used? Southwestern (useful for
identifying DNA-binding proteins such as transcription factors) "<img
src=""7335.png"">" biochemistry blotting-procedures duplicate laboratory-
techniques
Which blotting procedure is useful for studying the level of gene expression in a
sample? Northern blotting (can identify mRNA, which is indicative of gene
expression) "<img src=""7335.png"">" biochemistry blotting-procedures
duplicate laboratory-techniques
A pt undergoes HIV testing. Labeled antibody binds to relevant HIV proteins. After
what screening test was this confirmatory test done? An ELISA, which is done to
screen for HIV; in the case of this positive test result, it was followed with
Western blot for confirmation "<img src=""7335.png"">" biochemistry blotting-
procedures duplicate laboratory-techniques
How is the DNA of interest tagged for visualization in a Southern blot? By
exposing the filter to a radiolabeled DNA probe that recognizes and anneals to its
complementary strand "<img src=""7335.png"">" biochemistry blotting-
How is the labeled piece of DNA on the filter visualized in a Southern blot? By
exposing the filter to a film "<img src=""7335.png"">" biochemistry blotting-
What technique can be used to determine the immunophenotype of individual cells in
a sample? Flow cytometry "<img src=""7336.png"">" biochemistry duplicate
flow-cytometry laboratory-techniques
What technique can be used to determine CD4 counts in a pt with HIV? Flow
cytometry "<img src=""7336.png"">" biochemistry duplicate flow-cytometry
In a scatter plot obtained from flow cytometry, with x-axis=CD8, y-axis=CD4, double
positive T cells would be represented in which quadrant? Right upper quadrant
"<img src=""7336.png"">" biochemistry duplicate flow-cytometry
How are the tagged cell samples analyzed in flow cytometry?By focusing a laser on
each cell and measuring both the light scatter and intensity of fluorescence "<img
src=""7336.png"">" biochemistry duplicate flow-cytometry laboratory-techniques
Which assay would allow you to detect single nucleotide polymorphisms or copy
number variations to assess predisposition to a disease? A microarrayalso
applicable for genotyping, clinical genetic testing, forensic analysis, cancer
mutations, genetic linkage analysis "<img src=""7337.png"">" biochemistry
duplicate laboratory-techniques microarrays
How can a microarray profile gene expression levels? The microarray scanner can
quantify relative amounts of complementary binding to DNA or RNA probes "<img
src=""7337.png"">" biochemistry duplicate laboratory-techniques microarrays
Describe the steps by which a microarray is used to detect gene expression levels.
Nucleic acid sequences are placed in grids; DNA/RNA probes are hybridized to
the chip; a scanner detects amounts of complementary binding "<img
src=""7337.png"">" biochemistry duplicate laboratory-techniques microarrays
A doctor orders a test that detects single nucleotide polymorphisms and copy number
variations. What technique is used for this? Microarray "<img src=""7337.png"">"
biochemistry duplicate laboratory-techniques microarrays
What is the purpose of the enzyme-linked immunosorbent assay (ELISA)? Detection of
specific antigens or antibodies within a blood sample "<img src=""7338.png"">"
biochemistry duplicate enzyme-linked-immunosorbent-assay laboratory-
techniques
What information would an enzyme-linked immunosorbent assay (ELISA) using a primary
antibody coupled to a color-generating enzyme give you? It would tell you
whether a certain antigen is present in the pt's blood "<img src=""7338.png"">"
biochemistry duplicate enzyme-linked-immunosorbent-assay laboratory-
techniques
What does positive color indicate in ELISA testing? How can the results be
quantified? Presence of antigen or antibody of interest; by measuring the intensity
of the color "<img src=""7338.png"">" biochemistry duplicate enzyme-
linked-immunosorbent-assay laboratory-techniques
Describe the sensitivity and specificity of an ELISA. Both are generally very high
"<img src=""7338.png"">" biochemistry duplicate enzyme-linked-
immunosorbent-assay laboratory-techniques
You add an anti-HIV antibody coupled to a color-generating enzyme to a pt's serum;
you see color changes. What type of assay is this? Direct ELISA; a primary
antibody coupled to a color-changing enzyme demonstrates the presence of HIV
antigens "<img src=""7338.png"">" biochemistry duplicate enzyme-linked-
You add antibodies linked to color-changing enzymes to serum w/HIV virions bound by
anti-HIV antibodies; the color changes. Name the assay. Indirect ELISA; a
secondary antibody coupled to a color-changing enzyme demonstrates the presence of
HIV antigen-antibody complexes "<img src=""7338.png"">" biochemistry
duplicate enzyme-linked-immunosorbent-assay laboratory-techniques
If you want to identify an antigen of interest with an enzyme-linked immunosorbent
assay (ELISA), how do you set up your experiment? Wash a detection (primary)
antibody over the antigen's surface; the antibody adheres to the antigen's surface
"<img src=""7338.png"">" biochemistry duplicate enzyme-linked-
If you want to identify an antibody of interest with an enzyme-linked immunosorbent
assay (ELISA), how do you set up your experiment? Mix the antibody with its
antigen so that they adhere to one another, then add a detection (primary) antibody
that targets the antigen "<img src=""7338.png"">" biochemistry duplicate
enzyme-linked-immunosorbent-assay laboratory-techniques
A geneticist wants to test for chromosomal imbalances. What test can be ordered?
Karyotyping "<img src=""7339.png"">" biochemistry duplicate karyotyping
When a karyotype analysis is performed, in what phase of mitosis are the
chromosomes? Metaphase "<img src=""7339.png"">" biochemistry duplicate
karyotyping laboratory-techniques
What is karyotyping? In what way(s) can it be used to organize chromosomal data?
Karyotyping is a genetic analysis that compares chromosomes microscopically
based on morphology, size, arm-length ratio, and banding pattern "<img
src=""7339.png"">" biochemistry duplicate karyotyping laboratory-techniques
Name two types of chromosomal imbalances that can be seen on a karyotype.
Autosomal trisomies and sex chromosome disorders "<img src=""7339.png"">"
biochemistry duplicate karyotyping laboratory-techniques
A doctor wants to order a karyotype. What types of tissue samples can be considered
for karyotyping? Blood, bone marrow, placental tissue, amniotic fluid "<img
src=""7339.png"">" biochemistry duplicate karyotyping laboratory-techniques
Fluorescence in situ hybridization analysis of chromosome 22 in a boy with DiGeorge
syndrome will show what type of fluorescence pattern? Because DiGeorge syndrome is
caused by microdeletions at 22q11, there will be a lack of fluorescence on that
part of the chromosome "<img src=""7340.png"">" biochemistry duplicate
fluorescence-in-situ-hybridization laboratory-techniques
Fluorescence in situ hybridization analysis of the Philadelphia chromosome will
show what fluorescence pattern? Fluorescence outside of the original chromosome
(suggestive of translocation) "<img src=""7340.png"">" biochemistry duplicate
A genetic disease is attributed to duplication of a gene. What fluorescence pattern
will be observed on fluorescence in situ hybridization? An extra site of
fluorescence on the affected chromosome (suggestive of duplication) "<img
src=""7340.png"">" biochemistry duplicate fluorescence-in-situ-hybridization
A doctor wants to know the advantage of a fluorescence in situ hybridization
analysis over karyotyping. How do you respond? It allows researchers to localize
anomalies at a molecular level, including deletions that are too small to be seen
on a karyotype "<img src=""7340.png"">" biochemistry duplicate
What allows fluorescence in situ hybridization analysis to detect deletions that
are too small to be visualized through karyotyping? The fluorescent DNA or RNA
probes can bind specific gene sites and indicate presence or absence of genetic
material at the molecular level "<img src=""7340.png"">" biochemistry
duplicate fluorescence-in-situ-hybridization laboratory-techniques
Lack of expected fluorescence at a chromosome site in a fluorescence in situ
hybridization analysis indicates what genetic abnormalities? Microdeletion,
translocation, or duplication "<img src=""7340.png"">" biochemistry duplicate
In cloning, why is DNA that is to be replicated inserted into plasmids containing
antibiotic-resistance genes? This technique selects for replication of the
plasmid-containing genes for antibiotic resistance as well as the DNA of interest
"<img src=""7341.png"">" biochemistry cloning-methods duplicate
What is cloning? It is a molecular technique in which there is self-perpetuating
production of recombinant DNA molecules "<img src=""7341.png"">" biochemistry
cloning-methods duplicate laboratory-techniques
In cloning, how is the eukaryotic mRNA used to produce cDNA? By using reverse
transcriptase "<img src=""7341.png"">" biochemistry cloning-methods
duplicate laboratory-techniques
In cloning, why are cDNA fragments inserted into bacterial plasmids containing
antibiotic resistance genes and transformed into bacteria? Permits selective
replication of plasmids that carry the cDNA of interest in surviving bacteria when
plated on appropriate antibiotic medium "<img src=""7341.png"">" biochemistry
mRNA is exposed to reverse transcriptase in the lab. What type of genetic material
is created by this exposure? cDNA, which lacks introns "<img src=""7341.png"">"
biochemistry cloning-methods duplicate laboratory-techniques
A doctor asks you what distinguishes cDNA from most nuclear DNA. How do you
respond? cDNA lacks introns "<img src=""7341.png"">" biochemistry
Targeted insertion or deletion of a gene into the genome of a mouse occurs through
which genetic process? Homologous recombination "<img src=""7342.png"">"
biochemistry duplicate gene-expression-modifications laboratory-techniques
You suspect that a gene is necessary for early embryonic development. What system
can you use to delete this gene at a specific time point? Cre-lox system, which
allows manipulation (such as deletion) of genes at specific developmental points
"<img src=""7342.png"">" biochemistry duplicate gene-expression-
modifications laboratory-techniques
"What is meant by ""knock-out"" and ""knock-in"" in mice?" Knock-out is the removal
(taking out) of a gene from a host genome, and knock-in refers to the insertion of
a gene into a host genome "<img src=""7342.png"">" biochemistry duplicate
gene-expression-modifications laboratory-techniques
A researcher's model system allows genes to be manipulated at specific
developmental points via an inducible system. What is the system? Cre-lox
system "<img src=""7342.png"">" biochemistry duplicate gene-expression-
modifications laboratory-techniques
In RNA interference, a dsRNA complementary to the mRNA sequence of interest is
made. What happens when this dsRNA is transfected into cells? It separates and
binds to the target mRNA, thereby promoting degradation of the target mRNA and
knocking down gene expression "<img src=""7342.png"">" biochemistry duplicate
gene-expression-modifications laboratory-techniques
What term describes the phenomenon in which the phenotype of a disease varies among
people with the same genotype? Give an example. Variable expressivity; pts with
neurofibromatosis type I (NF1) exhibit varying disease severity "<img
src=""7343.png"">" biochemistry duplicate genetic-terms genetics
A child receives two copies of a chromosome from one parent and no copies from the
other. What is this called? Uniparental disomy "<img src=""7343.png"">"
biochemistry duplicate genetic-terms genetics
It has been shown that not all individuals w/the BRCA1 mutation develop breast or
ovarian cancer. This is an example of what phenomenon? Incomplete dominance
"<img src=""7343.png"">" biochemistry duplicate genetic-terms genetics
Prader-Willi and Angelman syndromes sometimes result from uniparental disomies. How
does this mutation manifest in chromosome number? Uniparental is eUploid
(correct number of chromosomes) rather than aneuploid; imprinting pattern is simply
skewed toward one parent "<img src=""7343.png"">" biochemistry duplicate
genetic-terms genetics
What cellular process is affected in McCune-Albright syndrome? G-protein
signaling "<img src=""7343.png"">" biochemistry duplicate genetic-terms
genetics
What term describes the situation in which genetically distinct cell lines are
present in the same individual? Mosaicism, which arises from mitotic errors
after fertilization "<img src=""7343.png"">" biochemistry duplicate
A pt has unilateral caf-au-lait spots, polyostotic fibrous dysplasia, precocious
puberty, and endocrine abnormalities. Diagnosis? McCune-Albright syndrome
In uniparental disomy, heterodisomy indicates an error in which round of meiosis?
Meiosis I "<img src=""7343.png"">" biochemistry duplicate genetic-
terms genetics
A pt found to have McCune-Albright syndrome wants to know whether the condition is
lethal. What do you tell him? It is lethal if mutation occurs before fertilization
(affecting all cells), but pts with mosaicism can survive "<img src=""7343.png"">"
In uniparental disomy, isodisomy indicates what potential errors? Error in
meiosis II or postzygotic chromosomal duplication of one chromosome within a pair
and loss of the other chromosome in that pair "<img src=""7343.png"">"
What is the name of the phenomenon in which a genetic disease has an earlier onset
or worsening severity in each subsequent generation? Anticipation; trinucleotide
repeat diseases are examples "<img src=""7343.png"">" biochemistry duplicate
A pt has genetically distinct cells present in multiple tissues. What form of
mosaicism is this? Somatic mosaicism "<img src=""7343.png"">" biochemistry
duplicate genetic-terms genetics
A pt has mental retardation, light skin, and musty body odor, all resulting from a
single gene deficiency. Describe this phenomenon. Pleiotropy: One gene has more
than one effect on an individual's phenotype (This pt has phenylketonuria [PKU].)
How do most cases of uniparental disomy present? They have a normal phenotype
A pt inherits a mutation in a tumor suppressor gene. What must occur for the pt to
develop cancer? Loss of heterozygosity: The pt was previously a heterozygote for
the tumor suppressor gene; both alleles must be lost for oncogenesis "<img
Is heterodisomy homozygous or heterozygous? Is isodisomy homozygous or
heterozygous? Heterozygous; homozygous "<img src=""7343.png"">"
Do oncogenes require deletions or mutations of the complementary allele to cause
cancer? No. Unlike tumor suppressor genes, oncogenes do not require a deletion
or mutation of the complementary allele. "<img src=""7343.png"">" biochemistry
A genetic disease, such as albinism, can have mutations at different loci but
produce a similar phenotype. What is this known as? Locus heterogeneity "<img
What is an example of a genetic disease that displays anticipation? Huntington
disease "<img src=""7343.png"">" biochemistry duplicate genetic-terms
genetics
Describe a dominant negative mutation. A nonfunctional altered protein that also
prevents the gene product of the normal allele from functioning "<img
What is heteroplasmy? The presence of both mutated and normal mitochondrial DNA,
causing variable expression in mitochondrially inherited diseases "<img
Name at least one disease whose pathogenesis involves loss of heterozygosity.
Retinoblastoma, Lynch syndrome (HNPCC), Li-Fraumeni syndrome "<img
What is linkage disequilibrium? The tendency for certain alleles at two linked
loci to be inherited together more or less often than expected by chance "<img
Linkage disequilibrium is measured in what type of group? A population rather than
a family (It often varies in different populations.) "<img src=""7343.png"">"
What is the term for the phenomenon in which both alleles contribute to a phenotype
of a heterozygote? Give an example. Codominance; some examples: blood groups A, B,
and AB; 1-antitrypsin deficiency "<img src=""7343.png"">" biochemistry
What is the term for the phenomenon in which different mutations in the same locus
produce the same phenotype? Give an example. Allelic heterogeneity; -
thalassemia "<img src=""7343.png"">" biochemistry duplicate genetic-terms
genetics
A newborn develops a retinoblastoma. The tumor cells undergo genetic analysis.
Which hypothesis is likely to be proven by the testing? "The ""two-hit
hypothesis"" (Both tumor suppressor genes that block oncogenesis of the
retinoblastoma will be mutated or deleted.)" "<img src=""7343.png"">"
In Hardy-Weinberg population genetics, what do p and q represent? Frequencies
of separate alleles of a gene "<img src=""7344.png"">" biochemistry duplicate
genetics hardy-weinberg-population-genetics
What is the heterozygote frequency in a population that is in Hardy-Weinberg
equilibrium? (Remember, p2 + 2pq + q2 = 1, and p + q = 1.) 2pq "<img
src=""7344.png"">" biochemistry duplicate genetics hardy-weinberg-population-
genetics
What are the four assumptions of the Hardy-Weinberg equation? No mutation
occurring at the gene locus, no natural selection, random mating, and no net
migration "<img src=""7344.png"">" biochemistry duplicate genetics hardy-
weinberg-population-genetics
The prevalence of which type of genetic disease is indicated by q in male and q2 in
female subjects in Hardy-Weinberg genetics? X-linked recessive diseases "<img
src=""7344.png"">" biochemistry duplicate genetics hardy-weinberg-population-
genetics
What value represents the carrier frequency for an autosomal recessive disease?
2pq "<img src=""7344.png"">" biochemistry duplicate genetics hardy-
weinberg-population-genetics
For a population in Hardy-Weinberg equilibrium, with two traits (p and q), what is
the frequency of homozygosity for each of the two traits? The frequencies are p2
and q2, respectively "<img src=""7344.png"">" biochemistry duplicate
genetics hardy-weinberg-population-genetics
A boy exhibits hyperphagia, obesity, intellectual disability, hypogonadism, and
hypotonia from birth. How is this condition inherited? Prader-Willi syndrome is
due to deletion or mutation of Paternal gene on chromosome 15; 25% of cases are due
to maternal uniparental disomy "<img src=""7345.png"">" biochemistry
duplicate genetics imprinting
"In genetics, what does the term ""imprinting"" refer to?" When at a single locus,
one allele is inactivated by methylation and one allele is not (Disease is due to
the loss of the active allele.) "<img src=""7345.png"">" biochemistry
duplicate genetics imprinting
A girl exhibits inappropriate laughter like a happy puppet, seizures, ataxia, and
intellectual disability. How is the condition inherited? AngelMan syndrome is due
to deletion or mutation of Maternal gene on chromosome 15; 5% of cases are due to
paternal uniparental disomy "<img src=""7345.png"">" biochemistry duplicate
genetics imprinting
What is a uniparental disomy? When offspring receive two copies of a chromosome
from one parent and no copies of a chromosome from the other parent "<img
src=""7345.png"">" biochemistry duplicate genetics imprinting
Defects in structural genes are generally associated with what type of inheritance?
Autosomal dominant "<img src=""7346.png"">" biochemistry duplicate
genetics modes-of-inheritance
A woman with an X-linked dominant disease wants to know whether she can pass on the
gene to her child. What would you tell her? She will transmit the gene to 50%
of her daughters and sons. "<img src=""7346.png"">" biochemistry duplicate
What is the mode of inheritance of a disease present in many generations that
affects both sexes in roughly equal proportions? Autosomal dominant "<img
src=""7346.png"">" biochemistry duplicate genetics modes-of-inheritance
Diseases that are caused by defects in enzymes generally follow what pattern of
inheritance? Autosomal recessive "<img src=""7346.png"">" biochemistry
duplicate genetics modes-of-inheritance
A mother may pass a disease with a mitochondrial pattern of inheritance to which of
her children? Her daughters and sons equally; all offspring of an affected
mother may show signs of disease "<img src=""7346.png"">" biochemistry
Disorders with which mode of inheritance are often prominent in childhood?
Autosomal recessive "<img src=""7346.png"">" biochemistry duplicate
A girl has proximal tubule phosphate wasting. All of her sisters, but no brothers,
have this issue. Did this come from her mother or father? She has hypophosphatemic
rickets, an X-linked dominant disorder; it was inherited from her father, as no
sons are affected "<img src=""7346.png"">" biochemistry duplicate genetics
modes-of-inheritance
Variable expression of mitochondrial diseases in a population or within a family
can be accounted for by what phenomenon? Heteroplasmy "<img src=""7346.png"">"
biochemistry duplicate genetics modes-of-inheritance
What is another name for hypophosphatemic rickets? Vitamin Dresistant rickets
"<img src=""7346.png"">" biochemistry duplicate genetics modes-of-
inheritance
In general, are autosomal dominant or autosomal recessive disorders more severe?
Autosomal recessive disorders "<img src=""7346.png"">" biochemistry
What percentage of sons of a carrier mother can be expected to inherit an X-linked
recessive disease? 0.5 "<img src=""7346.png"">" biochemistry duplicate
Are X-linked recessive diseases generally more severe in men or women? Men "<img
To what percentage of children does a father with an X-linked dominant disease pass
the disease? Fathers transmit to all of the daughters (100%) but none of sons
(0%) "<img src=""7346.png"">" biochemistry duplicate genetics modes-of-
inheritance
Ms J has a disease, but her family history is otherwise unremarkable. Her parents
were first cousins. What might be the mode of inheritance? Autosomal recessive
inheritance
What is the chance that two heterozygous carriers for an autosomal recessive
disorder will produce an offspring with the disorder? 0.25 "<img src=""7346.png"">"
Offspring in consanguineous families have an increased risk for disorders with what
mode of inheritance? Autosomal recessive "<img src=""7346.png"">"
Disorders of which inheritance pattern are often pleiotropic? Autosomal dominant
inheritance
Disorders of which inheritance pattern have no male-to-male transmission? X-
linked recessive "<img src=""7346.png"">" biochemistry duplicate genetics
modes-of-inheritance
A boy presents with CNS disease, myopathy, and lactic acidosis. His mother has the
same disorder. What will a muscle biopsy likely show? """Ragged red fibers"" (He
has mitochondrial myopathy, a rare mitochondrial disorder caused by oxidative
phosphorylation failure.)" "<img src=""7346.png"">" biochemistry duplicate
Rett syndrome, fragile X syndrome, and Alport syndrome follow what mode of
inheritance? X-linked dominant "<img src=""7346.png"">" biochemistry
What is MELAS syndrome? What kind of disorder is it? Mitochondrial encephalopathy,
lactic acidosis, and stroke-like episodes; it is a mitochondrial myopathy "<img
A 30-year-old woman is diagnosed with Li- Fraumeni syndrome. What gene is
defective? TP53 (resulting in multiple malignancies at an early age) "<img
src=""7347.png"">" autosomal-dominant-diseases biochemistry duplicate genetics
A pt has numerous benign and malignant tumors. Other family members exhibit similar
tumors. The defect is found on which chromosome? Chromosome 3p (von Hippel
Lindau = 3 words for chromosome 3) "<img src=""7347.png"">" autosomal-
dominant-diseases biochemistry duplicate genetics
How is von Hippel-Lindau disease characterized? Numerous benign and malignant
tumors "<img src=""7347.png"">" autosomal-dominant-diseases biochemistry
duplicate genetics
What is the pathophysiology of von Hippel-Lindau disease? Deletion of VHL, a tumor
suppressor gene "<img src=""7347.png"">" autosomal-dominant-diseases
biochemistry duplicate genetics
By what other name is Li-Fraumeni syndrome known? SBLA cancer syndrome
(sarcoma, breast, leukemia, adrenal gland) "<img src=""7347.png"">"
autosomal-dominant-diseases biochemistry duplicate genetics
Achondroplasia is associated with a mutation in the FGFR3 gene. What does FGFR3
stand for? What is the result of the mutation? Fibroblast growth factor receptor
3; inhibition of chondrocyte proliferation "<img src=""7347.png"">"
A newborn presents with short limbs and a relatively large head. This runs in the
family. What is the likely mutation causing this disease? A mutation in the FGFR-3
gene; this is achondroplasia "<img src=""7347.png"">" autosomal-dominant-
diseases biochemistry duplicate genetics
Mutations in the LDL receptor are associated with familial hypercholesterolemia.
This leads to what abnormality in the lipid profile? Elevation in LDL levels "<img
A 25-year-old man is diagnosed with Marfan syndrome. What is the pathophysiology of
the disease? An FBN1 mutation leads to defective fibrillin (scaffold for
elastin), resulting in a connective tissue disorder affecting muscles and eyes
"<img src=""7347.png"">" autosomal-dominant-diseases biochemistry
duplicate genetics
What is the characteristic finding in tuberous sclerosis? Numerous benign
hamartomas "<img src=""7347.png"">" autosomal-dominant-diseases biochemistry
duplicate genetics
Most cases of autosomal dominant polycystic kidney disease (ADPKD) are associated
with a mutation in which gene? PKD1 on chromosome 16 (85% of cases) "<img
A 50-year-old man is found to have multiple large cysts on both kidneys. What is
the most likely diagnosis? Autosomal dominant polycystic kidney disease (ADPKD)
duplicate genetics
Approximately 15% of autosomal dominant polycystic kidney disease (ADPKD) cases are
associated with a mutation in which gene? PKD2 on chromosome 4 "<img
A pt has adenomatous polyps in her colon; the condition runs in her family. What is
the most likely diagnosis? Familial adenomatous polyposis "<img
What is the major complication of familial adenomatous polyposis? Colon cancer
(treatment: colon resection) "<img src=""7347.png"">" autosomal-dominant-
A defect in which gene leads to familial adenomatous polyposis? The gene is present
on which chromosome? "The APC gene; chromosome 5q (5 letters in ""polyp"")"
duplicate genetics
Familial hypercholesterolemia is the result of a defect in or absence of what
receptor? Low-density lipoprotein (LDL) receptor "<img src=""7347.png"">"
A 40-year-old woman had a myocardial infarction 20 years ago and has xanthomas on
her Achilles tendon. What will be a likely ocular finding? Corneal arcus (She has
familial hypercholesterolemia.) "<img src=""7347.png"">" autosomal-
What is another name for Osler-Weber-Rendu syndrome? Hereditary hemorrhagic
telangiectasia, an autosomal dominant disorder of blood vessels "<img
A pt has multiple telangiectasias and skin discolorations and notes recurrent
epistaxis. What other findings might be expected? Arteriovenous malformations
(AVMs), GI bleeding, hematuria; this constellation of symptoms is seen in
hereditary hemorrhagic telangiectasia "<img src=""7347.png"">" autosomal-
A pt has hemolytic anemia, increased MCHC and RDW, and spheroid erythrocytes.
Treatment? Treatment is splenectomy; this is hereditary spherocytosis.
(Inheritance pattern is autosomal dominant.) "<img src=""7347.png"">"
A pt is diagnosed with hereditary spherocytosis. The abnormal spheroid erythrocytes
are caused by a defect in what? Spectrin or ankyrin "<img src=""7347.png"">"
A young man has depression, worsening dementia, and involuntary dance-like
movements. What genetic mutation would you expect to find? "Trinucleotide repeats
of CAGn on chromosome 4 (Huntington disease): ""hunting 4 CAGs""" "<img
You are performing an autopsy on a man who had Huntington disease. What would you
find on inspection of the brain? Caudate atrophy "<img src=""7347.png"">"
What neurotransmitter changes would you expect to find in a pt with Huntington
disease? A decrease in GABA and ACh levels and an increase in dopamine levels
duplicate genetics
In families with a history of Huntington disease, an increase in trinucleotide
repeats of CAG is associated with what phenomenon? Younger age at onset
(anticipation) "<img src=""7347.png"">" autosomal-dominant-diseases
Marfan syndrome is the result of a mutation in which gene? FBN1 gene on chromosome
15 "<img src=""7347.png"">" autosomal-dominant-diseases biochemistry
duplicate genetics
A very tall man has long extremities, pectus excavatum, and hypermobile joints. In
what direction would his lenses be dislocated? Likely upward and temporal, as he
has Marfan syndrome "<img src=""7347.png"">" autosomal-dominant-diseases
What are some of the cardiac abnormalities associated with Marfan syndrome? Floppy
mitral valve; cystic medial necrosis of the aorta, which leads to aortic
incompetence and dissecting aortic aneurysm "<img src=""7347.png"">"
What is arachnodactyly? The long, tapering fingers and toes seen in pts with Marfan
syndrome "<img src=""7347.png"">" autosomal-dominant-diseases biochemistry
duplicate genetics
What are the syndromes that are part of multiple endocrine neoplasias (MEN)? What
is the inheritance pattern? MEN 1, MEN 2A, and MEN 2B; all are autosomal dominant
duplicate genetics
Name five endocrine glands that develop tumors in the multiple endocrine neoplasia
(MEN) syndromes. Pancreas, parathyroid, pituitary, thyroid, and adrenal medulla
duplicate genetics
Mutations in what gene cause multiple endocrine neoplasias 2A (MEN 2A) and 2B (MEN
2B)? The RET gene "<img src=""7347.png"">" autosomal-dominant-diseases
A pt presents with neurofibromas and Lisch nodules. What gene is mutated in this
disease? "The NF1 gene on chromosome 17 (This is neurofibromatosis type 1 [17
letters in ""von Recklinghausen""].)" "<img src=""7347.png"">" autosomal-
A man has caf-au-lait spots and skin neurofibromas. There is a family history of
similar findings. What endocrine tumor might be present? A pheochromocytoma, as
he has neurofibromatosis type 1 (von Recklinghausen disease) "<img
A pt is found to have neurofibromatosis type 2. Which gene and chromosome are
affected? The NF2 gene and chromosome 22 (Think type 2 = 22.) "<img
A pt presents with acoustic schwannomas bilaterally, juvenile cataracts,
meningiomas, and ependymomas. What is the diagnosis? Neurofibromatosis type 2
duplicate genetics
A pt has numerous benign hamartomas all over his body. Other close relatives are
affected. What is the most likely diagnosis? Tuberous sclerosis "<img
What is the genetic phenomenon exhibited by tuberous sclerosis? Variable
expressivity "<img src=""7347.png"">" autosomal-dominant-diseases
What is the mode of inheritance of albinism? Autosomal recessive "<img
src=""7348.png"">" autosomal-recessive-diseases biochemistry duplicate
genetics
What is the mode of inheritance of ARPKD, which was formerly called infantile
polycystic kidney disease? Autosomal recessive "<img src=""7348.png"">"
autosomal-recessive-diseases biochemistry duplicate genetics
What is the mode of inheritance of hemochromatosis and cystic fibrosis?
Autosomal recessive "<img src=""7348.png"">" autosomal-recessive-
Glycogen storage diseases typically have what mode of inheritance? Autosomal
recessive "<img src=""7348.png"">" autosomal-recessive-diseases biochemistry
duplicate genetics
Kartagener syndrome is inherited in what fashion? Autosomal recessive "<img
genetics
Which one of the mucopolysaccharidoses is not an autosomal recessive disease?
Hunter syndrome "<img src=""7348.png"">" autosomal-recessive-diseases
What is the mode of inheritance of phenylketonuria? Autosomal recessive "<img
genetics
What is the mode of inheritance of the thalassemias and sickle cell disease?
Autosomal recessive "<img src=""7348.png"">" autosomal-recessive-
Which one of the sphingolipidoses does not exhibit autosomal recessive inheritance?
Fabry disease "<img src=""7348.png"">" autosomal-recessive-diseases
How is Wilson disease inherited? Autosomal recessive "<img src=""7348.png"">"
autosomal-recessive-diseases biochemistry duplicate genetics
A Caucasian man has recurrent pneumonia with pseudomonas, chronic bronchitis, and
pancreatic insufficiency. What gene is likely mutated? The CFTR gene on
chromosome 7 (This is cystic fibrosis.) "<img src=""7349.png"">" biochemistry
cystic-fibrosis duplicate genetics
What is the most common type of mutation in pts with cystic fibrosis? Deletion of
Phe508 "<img src=""7349.png"">" biochemistry cystic-fibrosis duplicate
genetics
A pt is found to have a CFTR gene mutation. Which ion channel does this gene
affect? The ATP-gated Cl channel (This is cystic fibrosis.) "<img
src=""7349.png"">" biochemistry cystic-fibrosis duplicate genetics
What is the function of the ATP-gated Cl channel, which is defective in cystic
fibrosis? Secretes Cl in lungs and GI tract and reabsorbs Cl in sweat glands
"<img src=""7349.png"">" biochemistry cystic-fibrosis duplicate genetics
In cystic fibrosis, a mutation to CFTR causes misfolded proteins. How does this
lead to thick mucus in the lungs and GI tract? Misfolded proteins remain in RER
instead of being transported to cell membranes; less Cl and H2O are secreted; Na+
is reabsorbed with H2O "<img src=""7349.png"">" biochemistry cystic-fibrosis
duplicate genetics
What happens to the transepithelial potential difference with increased Na+
reabsorption in pts with cystic fibrosis? It becomes more negative "<img
A Caucasian child has steatorrhea, nasal polyps, and bronchiectasis. What might be
the diagnostic finding in the sweat? High concentrations of Cl ions (>60
mEq/L) (This is cystic fibrosis.) "<img src=""7349.png"">" biochemistry
cystic-fibrosis duplicate genetics
What metabolic disorders might be present in pts with cystic fibrosis? Contraction
alkalosis and hypokalemia (from ECF H2O/Na+ loss and renal K+/H+ wasting) "<img
A pt with cystic fibrosis has recurrent pulmonary infections, chronic bronchitis,
and clubbing. What might be seen on a chest x-ray? A reticulonodular pattern
What is the most common pathogen causing pneumonia in children with cystic
fibrosis? In adolescents? S aureus in children; P aeruginosa in adolescents
A Caucasian newborn presents with meconium ileus. What is the most appropriate
screening test for the suspected disease? Immunoreactive trypsinogen (increased in
cystic fibrosis) "<img src=""7349.png"">" biochemistry cystic-fibrosis
duplicate genetics
What common GI complications are involved in cystic fibrosis? Pancreatic
insufficiency, malabsorption, steatorrhea, biliary cirrhosis, and liver disease
Male pts with cystic fibrosis are infertile. What is the mechanism? Absence of
the vas deferens (Spermatogenesis may be unaffected.) "<img src=""7349.png"">"
biochemistry cystic-fibrosis duplicate genetics
A pt with cystic fibrosis presents with steatorrhea and malabsorption. What would
you prescribe for this pt? Pancreatic enzyme replacement "<img src=""7349.png"">"
A female pt with cystic fibrosis asks whether she will be able to have children.
What is your response? Not likely because female pts with cystic fibrosis are
subject to subfertility (amenorrhea, abnormally thick cervical mucus) "<img
A pt with cystic fibrosis is at increased risk for the deficiency of what four
vitamins? Vitamins A, D, E, and Kall of which are fat soluble "<img
In a pt with cystic fibrosis, what treatment options can be used to provide relief
from the respiratory symptoms? Chest physiotherapy, albuterol, aerosolized
dornase alfa (DNAse), and hypertonic salineall of which facilitate mucus clearance
What is the benefit of prescribing azithromycin for pts with cystic fibrosis?
Azithromycin has anti-inflammatory activity "<img src=""7349.png"">"
Which two muscular dystrophies are transmitted through X-linked recessive
inheritance? Duchenne and Becker muscular dystrophy "<img src=""7350.png"">"
biochemistry duplicate genetics x-linked-recessive-disorders
What is the pattern of inheritance of hemophilia A and B, glucose-6-phosphate
dehydrogenase deficiency, and Lesch-Nyhan syndrome? X-linked recessive "<img
src=""7350.png"">" biochemistry duplicate genetics x-linked-recessive-
disorders
What is the pattern of inheritance of Fabry disease, Hunter syndrome, and ornithine
transcarbamylase deficiency? X-linked recessive "<img src=""7350.png"">"
What is the pattern of inheritance of Bruton agammaglobulinemia, ocular albinism,
and Wiskott-Aldrich syndrome? X-linked recessive "<img src=""7350.png"">"
A female patient asks you why female carriers of X-linked recessive disorders are
variably affected. What is your response? Incidence varies with the percentage
inactivation of the X chromosome that carries the mutant vs the normal gene "<img
src=""7350.png"">" biochemistry duplicate genetics x-linked-recessive-
disorders
What type of mutation causes loss of dystrophin in Duchenne muscular dystrophy?
A frameshift or nonsense mutation, which leads to truncated dystrophin
protein and accelerated breakdown of muscle "<img src=""7351.png"">"
biochemistry duplicate genetics muscular-dystrophies
A 3-year-old boy exhibits weakness of the pelvic girdle muscles that progresses up
his body. What gene is most likely defective? The dystrophin (DMD) gene, as he
likely has Duchenne muscular dystrophy (Duchenne = deleted dystrophin) "<img
src=""7351.png"">" biochemistry duplicate genetics muscular-dystrophies
In what group of muscles does weakness normally begin in pts with Duchenne muscular
dystrophy? The pelvic girdle muscles "<img src=""7351.png"">" biochemistry
duplicate genetics muscular-dystrophies
What unique characteristic of the dystrophin gene makes it particularly susceptible
to mutation? The dystrophin gene (DMD) is the largest known human gene, which
allows for a high rate of spontaneous mutation "<img src=""7351.png"">"
biochemistry duplicate genetics muscular-dystrophies
What is the pathophysiology of Duchenne muscular dystrophy?Dystrophin anchors
muscle fibers in the myocyte membrane, and lack of this protein accelerates muscle
breakdown "<img src=""7351.png"">" biochemistry duplicate genetics muscular-
dystrophies
How does dystrophin normally anchor muscle fibers? It connects the intracellular
cytoskeleton actin to transmembrane - and -dystroglycan, which connect to the
extracellular matrix "<img src=""7351.png"">" biochemistry duplicate
genetics muscular-dystrophies
What is the most common cause of death in pts with Duchenne muscular dystrophy?
Dilated cardiomyopathy "<img src=""7351.png"">" biochemistry duplicate
At what ages do Becker and Duchenne muscular dystrophies typically present?
Duchenne presents before 5 years of age, and Becker presents in adolescence
or early adulthood "<img src=""7351.png"">" biochemistry duplicate
A 4-year-old boy uses his upper extremities to push against his legs to stand up.
What is the name of this maneuver? The Gower maneuver, seen in pts with Duchenne
muscular dystrophy "<img src=""7351.png"">" biochemistry duplicate
A 3-year-old child has pseudohypertrophy of the calves, proximal muscle weakness,
and waddling gait. What might be elevated in his serum? CK and aldolase "<img
What are the confirmation tests for diagnosis of Duchenne muscular dystrophy?
Western blot and muscle biopsy "<img src=""7351.png"">" biochemistry
How does the severity differ between Duchenne and Becker muscular dystrophies?
Becker muscular dystrophy is less severe (also presents later in life) "<img
What type of mutation causes loss of dystrophin in Becker muscular dystrophy?
A non-frameshift mutation, resulting in a partially functional protein
instead of a truncated one "<img src=""7351.png"">" biochemistry duplicate
What is the inheritance pattern of myotonic dystrophy type 1? Autosomal dominant
"<img src=""7351.png"">" biochemistry duplicate genetics muscular-
dystrophies
A man with muscle wasting and frontal balding also has myotonia, cataracts,
testicular atrophy, and arrhythmias. What gene is mutated? The DMPK gene (This is
myotonic dystrophy type 1.) "<img src=""7351.png"">" biochemistry duplicate
What causes the abnormal expression of myotonin-protein kinase that results in
myotonic dystrophy type 1? CTG trinucleotide repeat expansion in the DMPK gene
"<img src=""7351.png"">" biochemistry duplicate genetics muscular-
dystrophies
What mnemonic can you use to remember the typical findings seen in myotonic
dystrophy type 1? My Tonia,My Testicles (testicular atrophy), My Toupee (frontal
balding), My Ticker (arrhythmia) "<img src=""7351.png"">" biochemistry
Fragile X syndrome is caused by a defect in which gene? The FMR1 gene (The
defect is a trinucleotide repeat that affects its methylation and decreases its
expression.) "<img src=""7352.png"">" biochemistry duplicate fragile-x-
syndrome genetics
What are the two most common genetic causes of intellectual disability? Down
syndrome is most common, followed by fragile X syndrome "<img src=""7352.png"">"
biochemistry duplicate fragile-x-syndrome genetics
A male pt has a long face, a large jaw, large everted ears, autism, and
macroorchidism. What type of mutation causes this disease? A trinucleotide repeat:
(CGG)n (This is fragile X syndrome [fragile X = eXtra large testes, jaw, ears].)
"<img src=""7352.png"">" biochemistry duplicate fragile-x-syndrome
genetics
A pt with a large jaw and ears presents with a late systolic murmur and midsystolic
click. What produces this murmur? Mitral valve prolapse, which is part of fragile
X syndrome "<img src=""7352.png"">" biochemistry duplicate fragile-x-syndrome
genetics
What does anticipation refer to in genetic disease? Anticipation involves an
increase in disease severity and an earlier age at onset in successive generations
"<img src=""7353.png"">" biochemistry duplicate genetics trinucleotide-
repeat-expansion-diseases
Name four diseases that result from trinucleotide repeat expansion. Huntington
disease, myotonic dystrophy, Friedreich ataxia, fragile X syndrome (Try
[trinucleotide] hunting for my fried eggs [X].) "<img src=""7353.png"">"
biochemistry duplicate genetics trinucleotide-repeat-expansion-diseases
Myotonic dystrophy is associated with which trinucleotide repeats? How about
fragile X syndrome? CTG; CGG (X-Girlfriend's First Aid Helped Ace My Test.)
"<img src=""7353.png"">" biochemistry duplicate genetics trinucleotide-
repeat-expansion-diseases
A doctor asks you to explain the difference in trinucleotide repeats between
Huntington disease and Friedreich ataxia. What do you tell him? CAG in Huntington;
GAA in Friedreich (X-Girlfriend's First Aid Helped Ace My Test.) "<img
src=""7353.png"">" biochemistry duplicate genetics trinucleotide-repeat-
expansion-diseases
A newborn with Down syndrome is vomiting large amounts of bilious material. What is
the likely cause? Duodenal atresia "<img src=""7354.png"">" autosomal-
trisomies biochemistry duplicate genetics
What type of congenital heart defect is most common in pts with Down syndrome?
Atrioventricular septal defects "<img src=""7354.png"">" autosomal-
What is the most common viable chromosomal disorder? Down syndrome "<img
src=""7354.png"">" autosomal-trisomies biochemistry duplicate genetics
Pts with Down syndrome older than 35 years have an increased risk of what
neurodegenerative disease? Why? Alzheimer disease; chromosome 21 codes for
amyloid precursor protein "<img src=""7354.png"">" autosomal-trisomies
Pts with Down syndrome have an increased risk of which type(s) of cancer? ALL
and AML "<img src=""7354.png"">" autosomal-trisomies biochemistry
duplicate genetics
What is the likelihood of a 19-year-old woman having a baby with Down syndrome? A
48-year-old woman? 1:1500; 1:25 "<img src=""7354.png"">" autosomal-
What findings in the prenatal quad screen indicate possible Down syndrome?
Decreased -fetoprotein and estriol, increased -hCG and inhibin A "<img
What is the other name for Down syndrome? Trisomy 21 (for Down syndrome, Drinking
age = 21) "<img src=""7354.png"">" autosomal-trisomies biochemistry
duplicate genetics
Which trisomy is the most common: 13, 18, or 21? Which is the least common? 21
(1:700); 13 (1:15,000) "<img src=""7354.png"">" autosomal-trisomies
What is another name for trisomy 18? Edwards syndrome (Election age = 18)
"<img src=""7354.png"">" autosomal-trisomies biochemistry duplicate
genetics
What is the other name for Patau syndrome? Trisomy 13 (for Patau syndrome,
Puberty = 13) "<img src=""7354.png"">" autosomal-trisomies biochemistry
duplicate genetics
What is the life expectancy of newborns with trisomy 13 and trisomy 18? 1 year
genetics
A pregnant woman undergoes first-trimester screening; the results show decreased
PAPP-A and increased -hCG. What is seen on ultrasound? Increased nuchal
translucency and a hypoplastic nasal bone (This is Down syndrome.) "<img
How are the quad screen results different in Edwards syndrome compared with Down
syndrome? Decreased -hCG (rather than increased as in Down syndrome) and normal
or decreased inhibin A (rather than increased as in Down syndrome) "<img
You suspect a fetus has Patau syndrome (trisomy 13). What findings on first-
trimester screening might increase your suspicion? Decreased free -hCG and
PAPP-A "<img src=""7354.png"">" autosomal-trisomies biochemistry
duplicate genetics
A 1-year-old has a gap between his first two toes and intellectual disability. What
is the likely cause of a murmur noted during his exam? Atrioventricular septal
defect (He has Down syndrome.) "<img src=""7354.png"">" autosomal-
A newborn diagnosed with Down syndrome has failed to pass meconium. What is the
cause? Hirschsprung disease "<img src=""7354.png"">" autosomal-
A baby with low PAPP-A and low free -hCG in the 1st trimester has clenched hands
and rocker-bottom feet. What other findings are expected? Intellectual disability,
micrognathia, low-set ears, prominent occiput, congenital heart disease (This is
trisomy 18.) "<img src=""7354.png"">" autosomal-trisomies biochemistry
duplicate genetics
Which two trisomies present with severe intellectual disability, rocker-bottom
feet, and congenital heart disease? Edwards syndrome (trisomy 18) and Patau
syndrome (trisomy 13) "<img src=""7354.png"">" autosomal-trisomies
There are four P's that will help you remember some manifestations of Patau
syndrome. What are they? Cleft liP/Palate, holoProsencephaly, and Polydactyly
genetics
If nondisjunction occurs in meiosis I, how many normal gametes are produced in the
end? What gets separated in meiosis I? None; homologous chromosomes "<img
If nondisjunction occurs in meiosis II, how many normal gametes are produced in the
end? What gets separated in meiosis II? Two; sister chromatids "<img
Which chromosome carries the mutation for von Hippel-Lindau disease? 3 "<img
src=""7355.png"">" biochemistry duplicate genetic-disorders-by-chromosome
genetics
Which chromosome carries the mutation for Prader-Willi syndrome? 15 "<img
genetics
Which chromosome carries the mutation for Edwards syndrome?18 "<img
genetics
Which chromosome carries the mutation for DiGeorge syndrome? 22q11 "<img
genetics
A pt has a defect on chromosome 16 that results in large cystic kidneys. Which gene
is implicated? ADPKD is due to a mutation in PKD1 on chromosome 16 "<img
genetics
Which chromosome carries the mutation for Down syndrome? 21 "<img
genetics
Which chromosome carries the mutation for neurofibromatosis type 1? 17 "<img
genetics
Which chromosome carries the mutation for neurofibromatosis type 2? 22 "<img
genetics
A man is found to have ADPKD. Analysis reveals that chromosome 16 is normal. What
gene mutation is likely to blame for the man's condition? Some cases of ADPKD are
due to a mutation in PKD2 on chromosome 4 "<img src=""7355.png"">" biochemistry
duplicate genetic-disorders-by-chromosome genetics
Which chromosome carries the mutation for Angelman syndrome? 15 "<img
genetics
Which chromosome carries the mutation for Wilson disease? 13 "<img
genetics
Which chromosome carries the mutation that predisposes the affected person to Wilms
tumor? 11 "<img src=""7355.png"">" biochemistry duplicate genetic-
disorders-by-chromosome genetics
Which chromosome carries the mutation for Friedreich ataxia? 9 "<img
genetics
Which chromosome carries the mutation for Klinefelter syndrome? X "<img
genetics
Which chromosome carries the mutation for fragile X syndrome? X "<img
genetics
A pt has agammaglobulinemia. The mutation shares a chromosome with the gene
responsible for fragile X syndrome. Which chromosome is it?X (This is X-linked
agammaglobulinemia.) "<img src=""7355.png"">" biochemistry duplicate
genetic-disorders-by-chromosome genetics
Which chromosome carries the mutation for Patau syndrome? 13 "<img
genetics
Which chromosome carries the mutation for cystic fibrosis? 7 "<img
genetics
Which chromosome carries the mutation for cri-du-chat syndrome? 5 "<img
genetics
Which chromosome carries the mutation for familial adenomatous polyposis? 5
"<img src=""7355.png"">" biochemistry duplicate genetic-disorders-by-
chromosome genetics
Which chromosome carries the mutation that predisposes the affected person to renal
cell carcinomas? 3 "<img src=""7355.png"">" biochemistry duplicate
Which chromosome carries the mutation for Huntington disease? 4 "<img
genetics
Which chromosome carries the mutation for achondroplasia? 4 "<img
genetics
Which chromosome carries the mutation for hemochromatosis? What gene is implicated?
6; the HFE gene "<img src=""7355.png"">" biochemistry duplicate
A pt is concerned about breast cancer and wants to have BRCA testing done. Which
chromosomes would be analyzed for the testing? BRCA1 on chromosome 17 and BRCA2 on
chromosome 13 "<img src=""7355.png"">" biochemistry duplicate genetic-
Which chromosome carries the mutation for Marfan syndrome? 15 "<img
genetics
Which chromosome carries the mutation for -thalassemia (and other -globin gene
defects)? 16 "<img src=""7355.png"">" biochemistry duplicate genetic-
Which chromosome carries the mutation for -globin defects? Name two examples of
diseases caused by such defects. 11; sickle cell disease and -thalassemia "<img
genetics
Which chromosome carries the mutation for Williams syndrome? 7 "<img
genetics
Which chromosome carries the mutation for retinoblastoma? Which gene is implicated?
13; the RB1 gene "<img src=""7355.png"">" biochemistry duplicate
What is a Robertsonian translocation? A nonreciprocal translocation of
chromosome pairs, such that chromosomes carry genetic information in an uneven
manner "<img src=""7356.png"">" biochemistry duplicate genetics
robertsonian-translocation
What makes chromosomes 13, 14, 15, 21, and 22 candidates for Robertsonian
translocations? They are acrocentric chromosomes. (The centromere is located near
one end rather than in the middle.) "<img src=""7356.png"">" biochemistry
duplicate genetics robertsonian-translocation
How do two acrosomal chromosomes align to create a Robertsonian translocation?
The long arms match up and fuse at the centromere, losing the short arms of
the chromosomes "<img src=""7356.png"">" biochemistry duplicate genetics
robertsonian-translocation
On karyotype, a man is found to have a balanced translocation affecting chromosome
21 and 14. How will this affect his phenotype? Normal phenotype (no abnormality)
"<img src=""7356.png"">" biochemistry duplicate genetics robertsonian-
translocation
What type of translocation can result in miscarriage, stillbirth, Down syndrome, or
Patau syndrome? Unbalanced translocation "<img src=""7356.png"">"
biochemistry duplicate genetics robertsonian-translocation
A newborn with microcephaly, epicanthal folds, and a VSD produces a high-pitched
cry with a mewing sound. What genetic defect is to blame? "A microdeletion on
chromosome 5 (46XX or XY, 5p) this is Cri-du-chat (""cry of the cat"") syndrome"
"<img src=""7357.png"">" biochemistry cri-du-chat-syndrome duplicate
genetics
Cri-du-chat syndrome is caused by what type of mutation? Which chromosome is
affected? Microdeletion of short arm of chromosome 5 (46XX or XY, 5p) "<img
src=""7357.png"">" biochemistry cri-du-chat-syndrome duplicate genetics
What disease is caused by a microdeletion of the long arm of chromosome 7?
Williams syndrome "<img src=""7358.png"">" biochemistry duplicate
genetics williams-syndrome
Among others, what connective tissue gene is deleted in Williams syndrome? The
elastin gene "<img src=""7358.png"">" biochemistry duplicate genetics
williams-syndrome
A pt with elfin facies, intellectual disability, and cardiovascular disease is
friendly with strangers. What is the diagnosis? Williams syndrome "<img
src=""7358.png"">" biochemistry duplicate genetics williams-syndrome
A pt with Williams syndrome may have hypersensitivity to which vitamin? What is its
metabolic consequence? Vitamin D; hypercalcemia "<img src=""7358.png"">"
biochemistry duplicate genetics williams-syndrome
In spite of their mental retardation, in which cognitive area are pts with Williams
syndrome typically advanced? Verbal skills "<img src=""7358.png"">"
biochemistry duplicate genetics williams-syndrome
Why do 22q11 syndromes exhibit a T-cell deficiency? They result from thymic
aplasia "<img src=""7359.png"">" 22q11-deletion-syndromes biochemistry
duplicate genetics
What disease is caused by microdeletions at 22q11 and involves defects of the
thymus, the parathyroid, and the heart? DiGeorge syndrome "<img src=""7359.png"">"
22q11-deletion-syndromes biochemistry duplicate genetics
What disease is caused by microdeletions at 22q11 and involves defects of the
palate, the face, and the heart? Velocardiofacial syndrome "<img
src=""7359.png"">" 22q11-deletion-syndromes biochemistry duplicate genetics
22q11 syndromes are associated with what metabolic disorder? Hypocalcemia (due
to parathyroid aplasia) "<img src=""7359.png"" />" biochemistry
biochemistry22q11-deletion-syndromes duplicate genetics
Name five findings associated with 22q11 deletion syndromes. Cleft palate,
Abnormal facies, Thymic aplasia, Cardiac defects, and Hypocalcemia (CATCH-22)
"<img src=""7359.png"">" 22q11-deletion-syndromes biochemistry duplicate
genetics
Abnormal development of what embryonic structures results in 22q11 syndromes?
Third and fourth branchial pouches "<img src=""7359.png"" />"
Biochemistry::22q11-deletion-syndromes biochemistry duplicate genetics
What is characteristic about the phenotypic presentation in 22q11 deletion
syndromes? The presentations are variable from person to person. "<img
src=""7359.png"">" 22q11-deletion-syndromes biochemistry duplicate genetics
What are the fat-soluble vitamins? A, D, E, and K "<img src=""7360.png"">"
biochemistry duplicate nutrition vitamins:-fat-soluble
A pt with cystic fibrosis who is underweight and complains of foul-smelling stool
has a deficiency in what vitamins? Vitamins A, D, E, and K, which are fat soluble
"<img src=""7360.png"">" biochemistry duplicate nutrition vitamins:-fat-
soluble
Is accumulation of fat- or water-soluble vitamins more likely to cause toxicity?
Why? Fat-soluble vitamins; because they accumulate in fat "<img src=""7360.png"">"
biochemistry duplicate nutrition vitamins:-fat-soluble
A pt has been ingesting mineral oil. What might you find on stool analysis?
Increased fat (steatorrhea), as well as increased levels of vitamins A, D, E,
and K because of malabsorption "<img src=""7360.png"">" biochemistry
duplicate nutrition vitamins:-fat-soluble
Name some pathologic conditions that can predispose someone to fat-soluble vitamin
deficiencies. Malabsorption syndromes with steatorrhea such as cystic fibrosis
or sprue "<img src=""7360.png"">" biochemistry duplicate nutrition
vitamins:-fat-soluble
Which vitamins are water soluble? The B vitamins (B1, B2, B3, B5, B6, B7, B9, and
B12) and vitamin C "<img src=""7361.png"">" biochemistry duplicate
nutrition vitamins:-water-soluble
All of the water-soluble vitamins easily wash out from the body, except for which
two? Vitamin B12 and B9 (folate), which are stored in the liver "<img
src=""7361.png"">" biochemistry duplicate nutrition vitamins:-water-soluble
A pt complains of watery stool, itchy and erythematous skin, and soreness of the
tongue. What is a likely deficiency? A B-complex deficiency, which typically
results in diarrhea, dermatitis, and glossitis "<img src=""7361.png"">"
biochemistry duplicate nutrition vitamins:-water-soluble
Give all of the alternative names for these vitamins: B1, B2, B3, B5, B6, B7, B9,
B12, C. B1: thiamine, B2: riboflavin, B3: niacin, B5: pantothenic acid, B6:
pyridoxine, B7: biotin, B9: folate, B12: cobalamin, C: ascorbic acid "<img
src=""7361.png"">" biochemistry duplicate nutrition vitamins:-water-soluble
Identify any important molecules for which these vitamins are required: B1, B2, B3,
B5, B6, B7, B9, B12, C. B1: TPP, B2: FAD and FMN, B3: NAD+, B5: CoA, B6: PLP, B7:
none, B9: none, B12: none, C: none "<img src=""7361.png"">" biochemistry
duplicate nutrition vitamins:-water-soluble
How long are vitamins B12 and B9 (folate) stored in the liver, respectively? 3 to 4
years; 3 to 4 months. "<img src=""7361.png"">" biochemistry duplicate
nutrition vitamins:-water-soluble
What is the function of vitamins in certain enzymatic reactions? They act as
coenzymes (eg, vitamin C [ascorbic acid]) or precursors to organic cofactors (eg,
FAD, NAD+) "<img src=""7361.png"">" biochemistry duplicate nutrition
vitamins:-water-soluble
What is another name for vitamin A? Retinol (Retinol is vitamin A, so think retin-
A, a topical drug for Acne and wrinkles.) "<img src=""7362.png"">" biochemistry
duplicate nutrition vitamin-a-(retinol)
A female pt complains of night blindness and dry, scaly skin. What would you tell
her to increase consumption of in her diet? Liver and leafy vegetables "<img
src=""7362.png"">" biochemistry duplicate nutrition vitamin-a-(retinol)
Vitamin A is a constituent of what visual pigment? Retinal "<img
A pt who has been eating liver and spinach for a long time exhibits hair loss,
joint pain, and hepatomegaly. What vitamin is in excess? Vitamin A: These
symptoms are evidence of chronic toxicity "<img src=""7362.png"">" biochemistry
A 16-year-old is admitted with nausea, vomiting, vertigo, and blurred vision. She
overdosed on one of her medications. What might it be? Isotretinoin (prescribed
for severe cystic acne), leading to the signs and symptoms of vitamin A toxicity
"<img src=""7362.png"">" biochemistry duplicate nutrition vitamin-a-
(retinol)
Name two topical uses of vitamin A. It can be used topically for wrinkles and acne
(retinol)
A pregnant woman on an unusual diet ingests a large dose of a vitamin A supplement
each day. What consequence might it have for her child? It could cause cleft
palate and cardiac abnormalities. (Vitamin A is a teratogen.) "<img
A woman sees a doctor for severe acne, and he wants to prescribe isotretinoin. What
requirements must be met before treatment starts? The woman must have a
negative pregnancy test result and two forms of contraception to avoid
teratogenicity "<img src=""7362.png"">" biochemistry duplicate nutrition
vitamin-a-(retinol)
Which vitamin prevents squamous metaplasia and is used to treat measles and AML
subtype M3? Vitamin A (retinol) "<img src=""7362.png"">" biochemistry
What is the treatment for acute promyelocytic leukemia? All-trans retinoic acid
(retinol)
Which vitamin is essential for differentiation of epithelial cells into specialized
tissue (eg, pancreatic cells and mucus-secreting cells)? Vitamin A (retinol)
(retinol)
A man with a recurrent cold-like illness has hair loss and dry skin. Exam shows
keratomalacia. What else might be present on an ocular exam? Bitot spots on the
conjunctiva (This is vitamin A deficiency.) "<img src=""7362.png"">"
biochemistry duplicate nutrition vitamin-a-(retinol)
A man presents with a severe headache, dizziness, and visual problems. He has been
taking a vitamin A supplement for many years. Diagnosis? Pseudotumor cerebri (due
to vitamin A toxicity) "<img src=""7362.png"">" biochemistry duplicate
nutrition vitamin-a-(retinol)
What is another name for vitamin B1? Thiamine "<img src=""7363.png"">"
biochemistry duplicate nutrition vitamin-b1-(thiamine)
Deficiency of which vitamin causes beriberi? Vitamin B1 (thiamine) (Spell
beriberi as Ber1Ber1 to remember vitamin B1.) "<img src=""7363.png"">"
biochemistry duplicate nutrition vitamin-b1-(thiamine)
A man with chronic alcoholism exhibits confusion, ophthalmoplegia, and ataxia. In
what vitamin is he deficient? Vitamin B1 (thiamine); this is likely Wernicke-
Korsakoff syndrome "<img src=""7363.png"">" biochemistry duplicate
nutrition vitamin-b1-(thiamine)
Vitamin B1 is the precursor to what metabolic cofactor involved in dehydrogenase
enzyme reactions? Thiamine pyrophosphate (TPP) (ATP: -ketoglutarate dehydrogenase,
Transketolase,Pyruvate dehydrogenase) "<img src=""7363.png"">" biochemistry
duplicate nutrition vitamin-b1-(thiamine)
What is the role of thiamine in the tricarboxylic acid cycle? It is a cofactor
for -ketoglutarate dehydrogenase "<img src=""7363.png"">" biochemistry
Both pyruvate dehydrogenase and transketolase require which vitamin as a cofactor?
Vitamin B1 (thiamine) "<img src=""7363.png"">" biochemistry duplicate
What vitamin is needed as a cofactor for branched-chain ketoacid dehydrogenase?
Vitamin B1 (thiamine) "<img src=""7363.png"">" biochemistry duplicate
What is a major complication of wet beriberi? High-output cardiac failure "<img
src=""7363.png"">" biochemistry duplicate nutrition vitamin-b1-(thiamine)
A 55-year-old pt complains of difficulty walking and muscle wasting. He is vitamin
deficient. Diagnosis? Dry beriberi, characterized by polyneuritis and muscle
wasting "<img src=""7363.png"">" biochemistry duplicate nutrition vitamin-
b1-(thiamine)
A 55-year-old with bilateral pedal edema complains of fatigue. Chest x-ray reveals
an enlarged heart. He is vitamin deficient. Diagnosis? Wet beriberi from
thiamine deficiency (findings: dilated cardiomyopathy and edema) "<img
Why are alcoholics prone to beriberi and Wernicke-Korsakoff syndrome? Excessive
alcohol consumption can cause malnutrition and malabsorption, leading to thiamine
deficiency "<img src=""7363.png"">" biochemistry duplicate nutrition vitamin-
b1-(thiamine)
An alcoholic has ophthalmoplegia, confusion, and ataxia. His son reports
personality changes, memory loss, and confabulation. Diagnosis? Wernicke-Korsakoff
syndrome due to thiamine deficiency "<img src=""7363.png"">" biochemistry
Why are the brain and heart particularly susceptible to injury in thiamine
deficiency? Highly aerobic cells are damaged first because they cannot generate ATP
without thiamine "<img src=""7363.png"">" biochemistry duplicate nutrition
vitamin-b1-(thiamine)
A pt with malnutrition presents with confusion, ophthalmoplegia, ataxia, and
amnesia. Where are the lesions in her brain? Mammillary bodies and medial dorsal
nucleus of the thalamus (The pt has Wernicke-Korsakoff syndrome due to thiamine
deficiency.) "<img src=""7363.png"">" biochemistry duplicate nutrition
vitamin-b1-(thiamine)
What enzyme involved in the HMP shunt utilizes thiamine as a cofactor?
Transketolase (The cofactor is thiamine pyrophosphate.) "<img
An alcoholic in the ED asks for a drink and is given orange juice. He is later
found obtunded. What is the cause of the change in status? In thiamine deficiency,
impaired glucose breakdown leads to ATP depletion that is exacerbated by glucose
infusion. (Give thiamine first!) "<img src=""7363.png"">" biochemistry
After vitamin B1 is administered, a pt's RBC transketolase activity increases. Does
a finding of polyneuropathy on exam surprise you? No; this finding is
consistent with thiamine deficiency, and, if dry beriberi develops as a result,
polyneuropathy will arise "<img src=""7363.png"">" biochemistry duplicate
What is another name for vitamin B2? Riboflavin "<img src=""7364.png"">"
biochemistry duplicate nutrition vitamin-b2-(riboflavin)
A 42-year-old presents with photophobia, inflamed lips and fissures at the sides of
her mouth. Which TCA cycle cofactors are deficient? FAD and FMN (This is vitamin
B2 deficiency.) "<img src=""7364.png"">" biochemistry duplicate nutrition
vitamin-b2-(riboflavin)
What is cheilosis? Inflammation of the lips, with scaling and fissures at the
corners of the mouth; this is seen in vitamin B2 deficiency"<img src=""7364.png"">"
biochemistry duplicate nutrition vitamin-b2-(riboflavin)
What are the two signs/ symptoms of vitamin B2 (riboflavin) deficiency?
Cheilosis and Corneal vascularization (the 2 C's of B2) "<img
src=""7364.png"">" biochemistry duplicate nutrition vitamin-b2-(riboflavin)
What is another name for vitamin B3? Niacin "<img src=""7365.png"">"
biochemistry duplicate nutrition vitamin-b3-(niacin)
How does Hartnup disease lead to pellagra? Through impaired absorption of
tryptophan, which is used to synthesize niacin "<img src=""7365.png"">"
How does malignant carcinoid syndrome cause pellagra? Through increased metabolism
of tryptophan, which is used to synthesize niacin "<img src=""7365.png"">"
A pt is diagnosed with TB and begins treatment. She then notes numbness in her
hands and pellagra-like symptoms. Why? Isoniazid depletes vitamin B6, required
for niacin synthesis; B6 & niacin deficiencies cause peripheral neuropathy &
pellagra, respectively "<img src=""7365.png"">" biochemistry duplicate
nutrition vitamin-b3-(niacin)
A pt comes in with diarrhea, a new rash, and dementia. What is your diagnosis?
Pellagra (Diarrhea, Dermatitis, and Dementia = the 3 D's of B3) "<img
src=""7365.png"">" biochemistry duplicate nutrition vitamin-b3-(niacin)
A 29-y/o immigrant from Asia has an 11-mm induration on Mantoux test. She starts
taking isoniazid. What should be given with the isoniazid? Vitamin B6 (pyridoxine);
isoniazid can induce a depletion in vitamin B6, which is required for niacin
synthesis "<img src=""7365.png"">" biochemistry duplicate nutrition vitamin-
b3-(niacin)
A pt with hyperlipidemia complains of facial flushing after taking his lipid-
lowering medication. How could this have been prevented? By taking aspirin along
with the medication (niacin) because the flushing is caused by prostaglandins
"<img src=""7365.png"">" biochemistry duplicate nutrition vitamin-b3-
(niacin)
What vitamin is the precursor of NAD+ and NADP+? Vitamin B3 (niacin) (NAD
derived from Niacin [B3 3 ATP]) "<img src=""7365.png"">" biochemistry
duplicate nutrition vitamin-b3-(niacin)
Niacin is derived from which amino acid? Niacin synthesis also requires which two
vitamins? Tryptophan; B2 and B6 "<img src=""7365.png"">" biochemistry
A 58-year-old complains of new marked facial redness after taking niacin for
cholesterol control. Will antihistamine drugs be of use here? No; vitamin B3
excess causes facial flushing because of prostaglandins, not histamine "<img
src=""7365.png"">" biochemistry duplicate nutrition vitamin-b3-(niacin)
Pts with diabetes may be discouraged from taking niacin. Why? Niacin can cause
hyperglycemia as a side effect "<img src=""7365.png"">" biochemistry
A pt presents with diarrhea, rash, and hallucinations. His urinalysis shows a
neutral aminoaciduria. Treatment? High protein diet and nicotinic acid (This is
Hartnup disease causing pellagra-like symptoms.) "<img src=""7365.png"">"
A man with a history of gout presents with podagra. He was recently diagnosed with
dyslipidemia. What medication might be the culprit? Niacin (which causes
hyperuricemia); niacin can be used to treat dyslipidemia "<img src=""7365.png"">"
What is the pathophysiology of Hartnup disease? It is a deficiency of neutral amino
acid transporters in enterocytes and proximal tubular cells, causing low tryptophan
levels in the body "<img src=""7365.png"">" biochemistry duplicate
nutrition vitamin-b3-(niacin)
What is another name for vitamin B5? "Pantothenic acid (Vitamin B5 is
""pento""thenic acid.)" "<img src=""7366.png"">" biochemistry duplicate
nutrition vitamin-b5-(pantothenic-acid)
A 30-year-old presents with adrenal insufficiency, hair loss, dermatitis, and
diarrhea. Which two enzymes are likely malfunctioning? Coenzyme A (cofactor for
acyl transfers) and fatty acid synthase are impaired, as this is pantothenic acid
(vitamin B5) deficiency "<img src=""7366.png"">" biochemistry duplicate
nutrition vitamin-b5-(pantothenic-acid)
What is another name for vitamin B6? Pyridoxine "<img src=""7367.png"">"
biochemistry duplicate nutrition vitamin-b6-(pyridoxine)
Isoniazid and oral contraceptive pills can induce a deficiency in which vitamin?
Vitamin B6 (pyridoxine) "<img src=""7367.png"">" biochemistry duplicate
nutrition vitamin-b6-(pyridoxine)
A 32-year-old begins taking isoniazid after a TB diagnosis. Later, she has numbness
and tingling in her extremities. What is the cause? Vitamin B6 (pyridoxine)
deficiency, which can be induced by isoniazid and oral contraceptives (One symptom
is neuropathy.) "<img src=""7367.png"" />" biochemistry dunutrition vitamin-
b6-(pyridoxine)
Vitamin B6 is the precursor to which cofactor? Pyridoxal phosphate (PLP) "<img
src=""7367.png"">" biochemistry duplicate nutrition vitamin-b6-(pyridoxine)
Name two transaminating enzymes for which vitamin B6 serves as a cofactor.
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) "<img
src=""7367.png"">" biochemistry duplicate nutrition vitamin-b6-(pyridoxine)
Which vitamin is needed for decarboxylation reactions and is also a cofactor for
glycogen phosphorylase? Vitamin B6 (pyridoxine) "<img src=""7367.png"">"
A man complains of fatigue, convulsions, hyperirritability, and peripheral
neuropathy. Why is he experiencing fatigue? He has sideroblastic anemia caused
by a vitamin B6 deficiency "<img src=""7367.png"">" biochemistry duplicate
nutrition vitamin-b6-(pyridoxine)
Vitamin B6 (pyridoxine) is required for the synthesis of what important molecules?
Cystathionine, heme, niacin, histamine, and neurotransmitters (serotonin,
epinephrine, norepinephrine, dopamine, GABA) "<img src=""7367.png"">"
A pt who eats many raw egg whites presents with dermatitis, alopecia, and
enteritis. With what reactions does his body have difficulty? Carboxylation
reactions are impaired, as this is vitamin B7 (biotin) deficiency "<img
src=""7368.png"">" biochemistry duplicate nutrition vitamin-b7-(biotin)
Biotin and pyruvate carboxylase catalyze what reaction? Conversion of pyruvate
(3C) to oxaloacetate (4C) "<img src=""7368.png"">" biochemistry duplicate
nutrition vitamin-b7-(biotin)
Biotin is bound by what molecule found in egg whites? Avidin (Avidin in egg whites
avidly binds biotin.) "<img src=""7368.png"">" biochemistry duplicate
A deficiency in vitamin B7 is relatively rare. What are the presenting symptoms?
Dermatitis, alopecia, enteritis "<img src=""7368.png"">" biochemistry
duplicate nutrition vitamin-b7-(biotin)
Biotin and acetyl-CoA carboxylase catalyze what reaction? Conversion of acetyl-CoA
(2C) to malonyl-CoA (3C) "<img src=""7368.png"">" biochemistry duplicate
Biotin and propionyl-CoA carboxylase catalyze what reaction? Conversion of
propionyl-CoA (3C) to methylmalonyl-CoA (4C) "<img src=""7368.png"">"
biochemistry duplicate nutrition vitamin-b7-(biotin)
What disorder(s) result(s) from folate deficiency? Macrocytic anemia,
megaloblastic anemia, and glossitis "<img src=""7369.png"">" biochemistry
duplicate nutrition vitamin-b9-(folate)
What is the function of tetrahydrofolic acid (THF)? What vitamin is required for
its synthesis? It is a coenzyme of 1-carbon transfer/methylation reactions,
needed for nitrogenous base synthesis in RNA/DNA; vitamin B9 (folic acid) "<img
src=""7369.png"">" biochemistry duplicate nutrition vitamin-b9-(folate)
A pt with folate deficiency complains of fatigue. What should he increase intake of
in his diet? Leafy greens (folate from foliage) "<img src=""7369.png"">"
biochemistry duplicate nutrition vitamin-b9-(folate)
A man undergoes a jejunal resection. Within a few months, he develops anemia. What
is the most likely cause of his anemia? Folate deficiency due to jejunal
resection; folate is absorbed in the jejunum "<img src=""7369.png"">"
How long does it take for symptoms of folic acid deficiency to develop in cases of
dietary insufficiency? A few months; folate has a small reserve pool, primarily in
the liver "<img src=""7369.png"">" biochemistry duplicate nutrition vitamin-
b9-(folate)
A pregnant mother is concerned about her child having spina bifida occulta. What
can she take to reduce the risk? A folic acid supplement "<img src=""7369.png"">"
Name three drugs that cause folate deficiency. Methotrexate, phenytoin, and
sulfonamides "<img src=""7369.png"">" biochemistry duplicate nutrition
vitamin-b9-(folate)
How can you differentiate between vitamin B12 and folate deficiency? There are no
neurologic symptoms and no elevation of methylmalonic acid in folate deficiency
(folate)
A blood smear from an alcoholic shows macrocytosis. Lab tests show elevation of
homocysteine but not methylmalonic acid. Diagnosis? Folate deficiency "<img
src=""7369.png"">" biochemistry duplicate nutrition vitamin-b9-(folate)
A pt with cancer and seizures takes methotrexate and phenytoin. She starts taking
TMP-SMX for a UTI. Later, she is anemic. What happened? Drug-induced vitamin B9
(folate) deficiency occurred; all of the drugs she was taking can induce folate
deficiency "<img src=""7369.png"">" biochemistry duplicate nutrition vitamin-
b9-(folate)
What is another name for vitamin B12? Cobalamin "<img src=""7370.png"">"
biochemistry duplicate nutrition vitamin-b12-(cobalamin)
In which organ is vitamin B12 primarily stored? The liver "<img src=""7370.png"">"
A man presents with fatigue and paresthesias. Smear shows hypersegmented PMNs and
macrocytosis. What dietary recommendation would you give? Increase intake of
animal products (He has vitamin B12 deficiency.) "<img src=""7370.png"">"
How does pernicious anemia lead to vitamin B12 deficiency? Autoantibodies form
against intrinsic factor, decreasing its levels; intrinsic factor is necessary for
vitamin B12 absorption in the gut "<img src=""7370.png"">" biochemistry
duplicate nutrition vitamin-b12-(cobalamin)
A pt is infected with D latum. He exhibits anemia and foot paresthesias. What might
a spinal cord MRI show? It might show subacute combined degeneration (dorsal
column, lateral corticospinal and spinocerebellar tracts) (vitamin B12 deficiency)
(cobalamin)
A pt with Crohn disease undergoes resection of her terminal ileum. A macrocytic
anemia develops. What vitamin is she likely lacking? Vitamin B12 (cobalamin) "<img
src=""7370.png"">" biochemistry duplicate nutrition vitamin-b12-(cobalamin)
A strict vegan is found to have anemia and paresthesias. What is the mechanism of
the condition that is most likely causing her symptoms? Vitamin B12 deficiency
as a result of insufficient intake (One must consume animal products to get it.)
(cobalamin)
What is the pathophysiology of the neurologic signs and symptoms of vitamin B12
deficiency? Abnormal myelin synthesis, with paresthesias & subacute combined
degeneration (dorsal column, lateral corticospinal/spinocerebellar tracts) "<img
A 42-year-old with a history of gastric bypass has numbness and tingling in her
feet and macrocytic anemia. How long ago was her surgery? Likely many years ago;
vitamin B12 has a large reserve pool and takes many years to be depleted "<img
A 50-year-old has been a strict vegan her whole life. She has severe paresthesias
and anemia. Can her neurologic symptoms be reversed? No; a prolonged deficiency of
cobalamin (vitamin B12) leads to irreversible nervous system damage "<img
Methylmalonyl-CoA mutase is blocked in rats. Heme synthesis decreases. Levels of
which fatty and amino acids will increase? Fatty acids w/odd numbers of
carbons & branched-chain amino acids (They become methylmalonyl-CoA, which the
enzyme converts to succinyl-CoA.) "<img src=""7370.png"">" biochemistry
Vitamin B12 deficiency is induced in rats. What will measurements of TCA cycle
activity and heme synthesis show, respectively? Both will decrease; succinyl-CoA,
which requires vitamin B12, is an important precursor to both processes "<img
Vitamin B12deficient rats have decreased methionine synthase activity. What
changes to homocysteine and methionine will be detected? Homocysteine will be
increased, and methionine will be decreased (Conversion of methionine to
homocysteine via the enzyme requires B12.) "<img src=""7370.png"">"
Decreased levels of SAM are detected in the blood of a vitamin B12deficient man.
Why? With low methionine synthase activity, less methionine is synthesized, and
thus less SAM can be made (SAM is derived from methionine.)"<img src=""7370.png"">"
In vitamin B12deficient rats with low methionine synthase activity, far less CH3
is available for anabolism. Why? CH3 for anabolism is generated from SAM, which
is derived from methionine (synthesized from homocysteine via methionine synthase)
(cobalamin)
What is the test of choice for diagnosing pernicious anemia? Anti-intrinsic
factor antibody test "<img src=""7370.png"">" biochemistry duplicate
nutrition vitamin-b12-(cobalamin)
Although found in animal products, cobalamin can only be synthesized by what?
Microorganisms "<img src=""7370.png"">" biochemistry duplicate
Name some causes of vitamin B12 deficiency. Low intake, malabsorption
(sprue/enteritis/D latum), no intrinsic factor (pernicious anemia/bypass surgery),
no terminal ileum "<img src=""7370.png"">" biochemistry duplicate nutrition
vitamin-b12-(cobalamin)
Homocysteine and methylmalonic acid are elevated in vitamin B12 deficiency.
Blockade of which two reactions is the cause of the increase? Conversions of
methylmalonyl-CoA to succinyl CoA (via methylmalonyl-CoA mutase) and homocysteine
to methionine (via methionine synthase) "<img src=""7370.png"">" biochemistry
An anemic man is B12 deficient. He is replenished, yet stays anemic. Succinyl-CoA
levels are high. Do you still suspect a hypovitaminosis? Yes; he may have low
levels of vitamin B6, which are required to covert succinyl-CoA into heme "<img
A man with elevated homocysteine due to methionine synthase deficiency is given a
vitamin B6 supplement. How does this treat him? Vitamin B6 is needed for the
conversion of homocysteine to cysteine "<img src=""7370.png"">" biochemistry
A vitamin B12deficient man has elevated THF-CH3 levels. What effect will
supplementation have on his methionine levels? They will rise; increased
methionine synthase activity converts more THF-CH3 and homocysteine into THF and
methionine, respectively "<img src=""7370.png"">" biochemistry duplicate
A man presents with scurvy due to vitamin C deficiency. What is the pathophysiology
behind his disease? Vitamin C deficiency causes sCurvy due to a Collagen
synthesis defect "<img src=""7371.png"">" biochemistry duplicate nutrition
vitamin-c-(ascorbic-acid)
"A pt presents with swollen gums, bruising, anemia, poor wound healing, recurrent
infections, and ""corkscrew hair."" Cause?" Vitamin C deficiency (scurvy) "<img
src=""7371.png"">" biochemistry duplicate nutrition vitamin-c-(ascorbic-acid)
A pt with scurvy due to vitamin C deficiency would be at risk for what type of
hemorrhages? Perifollicular and subperiosteal hemorrhages "<img
What is the role of vitamin C in collagen synthesis? Hydroxylation of lysine and
proline residues "<img src=""7371.png"">" biochemistry duplicate nutrition
Vitamin C promotes the absorption of which essential mineral? How? Iron; by
reducing Fe3+ to Fe2+ "<img src=""7371.png"">" biochemistry duplicate
nutrition vitamin-c-(ascorbic-acid)
Vitamin C is required for synthesis of which neurotransmitter? Norepinephrine
"<img src=""7371.png"">" biochemistry duplicate nutrition vitamin-c-
(ascorbic-acid)
What are dietary sources of vitamin C? "Fruits and vegetables (British sailors
carried limes to prevent scurvy [origin of the word ""limey""])" "<img
What enzyme uses ascorbic acid to convert dopamine to norepinephrine? Dopamine -
hydroxylase "<img src=""7371.png"">" biochemistry duplicate nutrition vitamin-
c-(ascorbic-acid)
A pt who ingested TMP-SMX and nitrates is now short of breath. His blood is brown.
What vitamin can be used to treat his condition? Vitamin C can treat this pt's
methemoglobinemia by reducing Fe3+ to Fe2+ "<img src=""7371.png"">"
biochemistry duplicate nutrition vitamin-c-(ascorbic-acid)
A pt has calcium oxalate stones. Of which vitamin does she have an excess?
Vitamin C "<img src=""7371.png"">" biochemistry duplicate nutrition
What is another name for vitamin C? Ascorbic acid "<img src=""7371.png"">"
biochemistry duplicate nutrition vitamin-c-(ascorbic-acid)
A pt with hemochromatosis starts taking vitamin supplements. He later experiences
symptoms of iron toxicity. What happened? Vitamin C precipitated iron toxicity;
this can occur in predisposed individuals (eg, those with hereditary
hemochromatosis) "<img src=""7371.png"">" biochemistry duplicate nutrition
"A health nut encourages people to drink orange juice to ""boost their immune
systems."" Is there any merit to this claim?" Some; vitamin C deficiency does
weaken the immune system, so this supplementation may have a benefit "<img
What is/are the source(s) of vitamin D2? Ingestion from plants "<img
src=""7372.png"">" biochemistry duplicate nutrition vitamin-d
What is another name for vitamin D2? Ergocalciferol "<img src=""7372.png"">"
biochemistry duplicate nutrition vitamin-d
What is/are the source(s) of vitamin D3? Milk consumption, skin exposure to sun
(via the stratum basale) "<img src=""7372.png"">" biochemistry duplicate
nutrition vitamin-d
When drinking a glass of milk, what type of vitamin D are you absorbing?
Vitamin D3 (Drinking milk [fortified with vitamin D] is good for bones.)
"<img src=""7372.png"">" biochemistry duplicate nutrition vitamin-d
What is another name for vitamin D3? Cholecalciferol "<img src=""7372.png"">"
What is the storage form of vitamin D? What is the active form of vitamin D? 25-OH
D3; 1,25-(OH)2 D3 (calcitriol) "<img src=""7372.png"">" biochemistry
duplicate nutrition vitamin-d
A deficiency of vitamin D may lead to what electrolyte abnormality? What muscle
disorder might be present as a result? Hypocalcemia; tetany "<img
What is the function of vitamin D in the intestines? Increased intestinal
absorption of calcium and phosphate "<img src=""7372.png"">" biochemistry
duplicate nutrition vitamin-d
What is the effect of vitamin D on the bones? Vitamin D increases bone
mineralization at low levels and increases bone resorption at high levels "<img
A pt presents with hypercalcemia, hypercalciuria, appetite loss, and stupor. An
excess of what vitamin may be responsible? Vitamin D "<img src=""7372.png"">"
In what disease do epithelioid macrophages convert vitamin D into its active form
in excess, leading to hypercalcemia? Granulomatous diseases (eg, sarcoidosis)
An adult presents to your practice with bone pain and muscle weakness. What vitamin
is likely deficient in this adult? Vitamin D (The condition is osteomalacia.)
A newborn being breastfed is found to have a low vitamin D level. What should be
done to prevent the sequelae of deficiency later in life? Oral vitamin D
supplementation "<img src=""7372.png"">" biochemistry duplicate nutrition
vitamin-d
Name some conditions that can exacerbate vitamin D deficiency. Low sun exposure,
pigmented skin, prematurity "<img src=""7372.png"">" biochemistry duplicate
nutrition vitamin-d
A pt taking an oral anticoagulant starts taking a vitamin supplement. Shortly
afterward, he experiences excessive bleeding. What happened? He took vitamin E,
which can enhance the anticoagulant effects of warfarin (which he was likely
taking), increasing the risk of bleeding "<img src=""7373.png"">" biochemistry
duplicate nutrition vitamin-e-(tocopherol/tocotrienol)
How can one distinguish between vitamin E deficiency and vitamin B12 deficiency
when neurologic symptoms are present? Vitamin E deficiency presents without
megaloblastic anemia, hypersegmented neutrophils, or a high serum methylmalonic
acid level "<img src=""7373.png"">" biochemistry duplicate nutrition vitamin-
e-(tocopherol/tocotrienol)
What vitamin protects erythrocytes and membranes from free radical damage?
Vitamin E, which functions as an antioxidant "<img src=""7373.png"">"
biochemistry duplicate nutrition vitamin-e-(tocopherol/tocotrienol)
A pt presents with hemolytic anemia and vague neurologic symptoms. On a blood
smear, acanthocytes are seen. Diagnosis? Vitamin E deficiency "<img
src=""7373.png"">" biochemistry duplicate nutrition vitamin-e-
(tocopherol/tocotrienol)
A pt who avoids fat intake has weakness, reduced vibratory sensation, and
uncoordinated gait. What will a spinal cord MRI show? Posterior column and
spinocerebellar tract demyelination (Vitamin E deficiency can mimic vitamin B12
deficiency.) "<img src=""7373.png"">" biochemistry duplicate nutrition
vitamin-e-(tocopherol/tocotrienol)
What changes might be seen in PT, aPTT, and bleeding time in vitamin K deficiency?
Increased PT, increased aPTT, and normal bleeding time (K is for
Koagulation.) "<img src=""7374.png"">" biochemistry duplicate nutrition
vitamin-k-(phytomenadione,-phylloquinone,-phytonadione)
A newborn has a bleeding diathesis. What injection at birth could have prevented
this problem? Injection of vitamin K (not found in breast milk); neonates are
given vitamin K at birth to prevent bleeding diatheses "<img src=""7374.png"">"
biochemistry duplicate nutrition vitamin-k-(phytomenadione,-phylloquinone,-
phytonadione)
Which clotting factors and proteins depend on vitamin K? Factors II, VII, IX, and
X and proteins C and S "<img src=""7374.png"">" biochemistry duplicate
nutrition vitamin-k-(phytomenadione,-phylloquinone,-phytonadione)
What is the source of vitamin K in humans? Vitamin K is synthesized by
intestinal bacteria "<img src=""7374.png"">" biochemistry duplicate
An elderly patient has been taking meropenem for a few weeks for infection. She
later develops ecchymoses and hemarthrosis. Likely cause? Destruction of
intestinal bacteria, which synthesize vitamin K (which is necessary for clotting
factors II, VII, IX, and X) "<img src=""7374.png"">" biochemistry duplicate
What drug is a vitamin K antagonist? Warfarin (Coumadin) "<img
src=""7374.png"">" biochemistry duplicate nutrition vitamin-k-
(phytomenadione,-phylloquinone,-phytonadione)
By what biochemical mechanism does vitamin K promote synthesis of clotting factors
II, VII, IX, and X? Vitamin K is a cofactor for the -carboxylation of glutamic
acid residues on the clotting factors "<img src=""7374.png"">" biochemistry
duplicate nutrition vitamin-k-(phytomenadione,-phylloquinone,-phytonadione)
Neonates are born with sterile intestines. Is breastfeeding sufficient to treat the
bleeding diathesis that may arise as a result of this? No; vitamin K is not
found in breast milk, and therefore injection of vitamin K at birth is necessary
"<img src=""7374.png"">" biochemistry duplicate nutrition vitamin-k-
(phytomenadione,-phylloquinone,-phytonadione)
A man has delayed wound healing, hypogonadism, and reduced adult hair due to a
nutritional deficiency. What other symptoms might you see? Dysgeusia, anosmia, and
acrodermatitis enteropathica (He has zinc deficiency.) "<img src=""7375.png"">"
biochemistry:: nutrition::zinc
Cirrhosis is diagnosed in an alcoholic with many vitamin deficiencies. Which
mineral deficiency might have predisposed him to this? Zinc deficiency "<img
src=""7375.png"">" biochemistry duplicate nutrition zinc
What is the importance of zinc fingers? Zinc fingers (motifs) allow transcription
factors and other molecules to interact with DNA "<img src=""7375.png"">"
biochemistry duplicate nutrition zinc
Kwashiorkor is the result of a deficiency of what macromolecule in the diet?
Protein "<img src=""7376.png"">" biochemistry duplicate malnutrition
nutrition
A malnourished child also has anemia, edema, and increased liver function
parameters. What is the diagnosis? Kwashiorkor (results from a protein-deficient =
Malnutrition, Edema, Anemia, Liver [fatty]) "<img src=""7376.png"">"
biochemistry duplicate malnutrition nutrition
Marasmus is the result of what deficiency in the diet? Total calories (energy)
"<img src=""7376.png"">" biochemistry duplicate malnutrition nutrition
A child presents with tissue and muscle wasting with loss of subcutaneous fat. Is
she more likely to have kwashiorkor or marasmus? Marasmus (Marasmus results in
Muscle wasting.) "<img src=""7376.png"">" biochemistry duplicate malnutrition
nutrition
A child has kwashiorkor. What will biopsy of his liver show? Why does this finding
appear? Fatty change due to decreased apolipoprotein synthesis (secondary to
protein malnutrition) "<img src=""7376.png"">" biochemistry duplicate
malnutrition nutrition
A chronic alcoholic presents with fasting hypoglycemia. What is the mechanism?
Ethanol metabolism increases the NADH/NAD+ ratio, shunting oxaloacetate to
malate and preventing gluconeogenesis "<img src=""7377.png"">" biochemistry
duplicate ethanol-metabolism nutrition
The high NADH/NAD+ ratio after ethanol ingestion is responsible for shunting of
metabolites toward which biochemical processes? Pyruvatelactate (acidosis),
oxaloacetatemalate (gluconeogenesis), dihydroxyacetone phosphateglycerol-3-
phosphate (hepatosteatosis) "<img src=""7377.png"">" biochemistry duplicate
ethanol-metabolism nutrition
A pt presents with hypoglycemia and hepatocellular steatosis. What substance does
he chronically abuse? Alcohol "<img src=""7377.png"">" biochemistry
In ethanol toxicity, the overproduction of lactic acid causes what metabolic
disorder? Metabolic acidosis with increased anion gap "<img src=""7377.png"">"
biochemistry duplicate ethanol-metabolism nutrition
In ethanol toxicity, ketoacidosis is often observed. What is the mechanism?
Increase in the NADH/NAD+ ratio decreases TCA activity and increases acetyl-
CoA utilization for ketogenesis, leading to ketoacidosis "<img src=""7377.png"">"
In rats, a scientist uses genetic engineering to block catalase. Ethanol is given
to the rats. What happens to alcohol's rate of metabolism? It will decrease;
catalase (in peroxisomes) converts ethanol into acetaldehyde, so the rate of
conversion can be expected to decrease "<img src=""7377.png"">" biochemistry
A mutation increases CYP2E1 activity in a rat. Ethanol is administered to this rat.
What will measurements of ROS and NADP+ levels show? Both will increase;
microsomes can convert ethanol into acetaldehyde via CYP2E1, creating ROS and NADP+
(from NADPH) as byproducts "<img src=""7377.png"">" biochemistry duplicate
In the cytosol, ethanol is converted to what product? This product is then
converted to what molecule in the mitochondria? Acetaldehyde; acetate "<img
src=""7377.png"">" biochemistry duplicate ethanol-metabolism nutrition
The breakdown of ethanol into acetate results in the generation of how many
molecules of NADH (from NAD+)? Two "<img src=""7377.png"">" biochemistry
How many enzymes can participate in the direct metabolism of ethanol? Where are
each of these enzymes found? Three: CYP2E1 (microsomes), alcohol dehydrogenase
(cytosol), catalase (peroxisomes) "<img src=""7377.png"">" biochemistry
Where does fomepizole act to inhibit ethanol metabolism? What about disulfiram?
Fomepizole inhibits alcohol dehydrogenase in the cytosol; disulfiram inhibits
acetaldehyde dehydrogenase in the mitochondria "<img src=""7377.png"">"
What is the limiting reagent in alcohol metabolism? NAD+ "<img src=""7377.png"">"
A man drinks antifreeze and requires medical care. The physician administers a
medication as a means of treatment to block which process? Action of alcohol
dehydrogenase (ethanol to acetaldehyde in cytosol) to allow excretion of ethylene
glycol (The medication is fomepizole.) "<img src=""7377.png"">" biochemistry
A pt treated for C difficile infection drinks alcohol and becomes excessively
flushed. What is happening? Metronidazole causes a disulfiram-like effect,
inhibiting acetaldehyde dehydrogenase in the mitochondria (acetaldehyde to acetate)
"<img src=""7377.png"">" biochemistry duplicate ethanol-metabolism
nutrition
What happens to the rate of ethanol metabolism by alcohol dehydrogenase as more
ethanol is consumed? There is no change in the rate, as this reaction proceeds
by zero-order kinetics "<img src=""7377.png"">" biochemistry duplicate
An alcoholic takes disulfiram and wakes up hungover. The accumulation of what
molecule in ethanol metabolism contributes to his symptoms?Acetaldehyde "<img
src=""7377.png"">" biochemistry duplicate ethanol-metabolism nutrition
How does the cellular compartmentalization differ between fatty acid oxidation and
fatty acid synthesis? Fatty acid oxidation occurs in mitochondria, whereas fatty
acid synthesis occurs in the cytoplasm "<img src=""7378.png"">" biochemistry
duplicate metabolism metabolism-sites
The whole process of aerobic cellular respiration occurs where in the cell? In
both the cytoplasm and the mitochondria "<img src=""7378.png"">" biochemistry
duplicate metabolism metabolism-sites
Where in the cell are the enzymes of the HMP shunt located?In the cytoplasm "<img
src=""7378.png"">" biochemistry duplicate metabolism metabolism-sites
Where in the cell does acetyl-CoA production occur? In the mitochondria "<img
Where does protein synthesis occur in the cell? Where does steroid synthesis occur
in the cell? Rough endoplasmic reticulum (RER) and free ribosomes; smooth
endoplasmic reticulum (SER) "<img src=""7378.png"">" biochemistry duplicate
metabolism metabolism-sites
A new drug slows transport between the cytoplasm and mitochondria in cells. Which
three intracellular processes are most affected? Heme synthesis, Urea cycle,
and Gluconeogenesis (HUGs take two [ie, both mitochondria and cytoplasm].) "<img
Where in the cell does cholesterol synthesis occur? In the cytoplasm "<img
Where in the cell does oxidative phosphorylation occur? In the mitochondria
"<img src=""7378.png"">" biochemistry duplicate metabolism metabolism-
sites
Where in the cell does ketogenesis occur? In the mitochondria "<img
Name five pathways that occur exclusively in the mitochondria. Fatty acid
oxidation (-oxidation), acetyl-CoA production, TCA cycle, oxidative
phosphorylation, ketogenesis "<img src=""7378.png"">" biochemistry duplicate
Name seven pathways that occur exclusively in the cytoplasm. Glycolysis, HMP
shunt, synthesis of proteins (ribosomes, RER), steroids (SER), fatty acids,
cholesterols, nucleotides "<img src=""7378.png"">" biochemistry duplicate
Discuss how enzymes are named. Enzyme names often describe function (eg,
glucokinase phosphorylates glucose using a molecule of ATP)"<img src=""7379.png"">"
biochemistry duplicate enzyme-terminology metabolism
Which enzyme category catalyzes the transfer of a phosphate group from a high-
energy molecule (eg, ATP) to a substrate? Kinases (eg, phosphofructokinase) "<img
src=""7379.png"">" biochemistry duplicate enzyme-terminology metabolism
Which enzyme category adds inorganic phosphate onto a substrate without the use of
ATP? Phosphorylases (eg, glycogen phosphorylase) "<img src=""7379.png"">"
Which enzyme category removes a phosphate group from a substrate? Phosphatases
(eg, fructose-1,6-bisphosphatase) "<img src=""7379.png"">" biochemistry
duplicate enzyme-terminology metabolism
Which enzyme category catalyzes oxidation-reduction reactions? Dehydrogenases
(eg, pyruvate dehydrogenase) "<img src=""7379.png"">" biochemistry duplicate
enzyme-terminology metabolism
Which enzyme category transfers carbon dioxide groups using biotin as a cofactor?
Carboxylases (eg, pyruvate carboxylase) "<img src=""7379.png"">"
Which enzyme category relocates a functional group within a molecule? Mutases (eg,
vitamin B12dependent methylmalonyl-CoA mutase) "<img src=""7379.png"">"
What enzyme category adds a hydroxyl group (OH) to a substrate? Hydroxylases (eg,
tyrosine hydroxylase) "<img src=""7379.png"">" biochemistry duplicate
enzyme-terminology metabolism
What is the rate-limiting enzyme of de novo pyrimidine synthesis? What are the
important reaction upregulators and downregulators? Carbamoyl phosphate
synthetase II; ATP and PRPP promote; UTP inhibits "<img src=""7380.png"">"
biochemistry duplicate metabolism rate-determining-enzymes-of-metabolic-
processes
What is the rate-limiting enzyme of de novo purine synthesis? What are the
important reaction upregulators and downregulators? Glutamine-
phosphoribosylpyrophosphate (PRPP) amidotransferase; AMP, inosine monophosphate
(IMP), and GMP all inhibit "<img src=""7380.png"">" biochemistry duplicate
metabolism rate-determining-enzymes-of-metabolic-processes
What is the rate-limiting enzyme of glycolysis? What are the important reaction
upregulators and downregulators? Phosphofructokinase-1; AMP and fructose-2,6-
bisphosphate promote; ATP and citrate inhibit "<img src=""7380.png"">"
processes
What is the rate-limiting enzyme of gluconeogenesis? What are the important
reaction upregulators and downregulators? Fructose-1,6-bisphosphatase; AMP and
fructose-2,6-bisphosphate inhibit "<img src=""7380.png"">" biochemistry
duplicate metabolism rate-determining-enzymes-of-metabolic-processes
What is the rate-limiting enzyme of the tricarboxylic acid (TCA) cycle? What are
the important reaction upregulators and downregulators? Isocitrate
dehydrogenase; ADP promotes; ATP and NADH inhibit "<img src=""7380.png"">"
processes
What is the rate-limiting enzyme of glycogenesis? What are the important reaction
upregulators and downregulators? Glycogen synthase; glucose-6-phosphate,
insulin, and cortisol promote; epinephrine and glucagon inhibit "<img
src=""7380.png"">" biochemistry duplicate metabolism rate-determining-enzymes-
of-metabolic-processes
What is the rate-limiting enzyme of glycogenolysis? What are the important reaction
upregulators and downregulators? Glycogen phosphorylase; AMP, epinephrine, and
glucagon promote; glucose-6-phosphate, insulin, and ATP inhibit "<img
What is the rate-limiting enzyme of the HMP shunt? What are the important reaction
upregulators and downregulators? Glucose-6-phosphate dehydrogenase (G6PD); NADP+
promotes; NADPH inhibits "<img src=""7380.png"">" biochemistry duplicate
What is the rate-limiting enzyme of fatty acid synthesis? What are the important
reaction upregulators and downregulators? Acetyl-CoA carboxylase (ACC); insulin and
citrate promote; glucagon and palmitoyl-CoA inhibit "<img src=""7380.png"">"
processes
What is the rate-limiting enzyme of fatty acid oxidation? What are the important
reaction upregulators and downregulators? Carnitine acyltransferase I; malonyl-CoA
inhibits "<img src=""7380.png"">" biochemistry duplicate metabolism rate-
determining-enzymes-of-metabolic-processes
What is the rate-limiting enzyme of ketogenesis? HMG-CoA synthase "<img
What is the rate-limiting enzyme of cholesterol synthesis? What are the important
reaction upregulators and downregulators? HMG-CoA reductase; insulin and thyroxine
promote; glucagon and cholesterol inhibit "<img src=""7380.png"">" biochemistry
duplicate metabolism rate-determining-enzymes-of-metabolic-processes
What is the rate-limiting enzyme of the urea cycle? What are the important reaction
upregulators and downregulators? Carbamoyl phosphate synthetase I; N-
acetylglutamate promotes "<img src=""7380.png"">" biochemistry duplicate
What is the effect of cortisol on glycogen synthase? Glycogen phosphorylase?
Cortisol positively regulates glycogen synthase, promoting glycogenesis in an
unfed state; it has no direct effect on glycogen phosphorylase "<img
How is acetyl-CoA ultimately converted into fatty acids? What important cofactor is
required to initiate this process? Acetyl-CoA malonyl CoA (step requires biotin
cofactor) fatty acids "<img src=""7381.png"">" biochemistry duplicate
metabolism summary-of-pathways
How is acetyl-CoA ultimately converted into -hydroxybutyrate? Acetyl-CoA
acetoacetyl-CoA HMG-CoA acetoacetate -hydroxybutyrate "<img src=""7381.png"">"
biochemistry duplicate metabolism summary-of-pathways
How is acetyl-CoA ultimately converted into cholesterol? Acetyl-CoA
acetoacetyl-CoA HMG-CoA mevalonate (via HMG-CoA reductase) cholesterol "<img
src=""7381.png"">" biochemistry duplicate metabolism summary-of-pathways
Starting with acetyl-CoA, outline all of the steps within the TCA cycle. Acetyl
CoA and oxaloacetate citrate isocitrate -ketoglutarate succinyl-CoA
succinate fumarate malate oxaloacetate "<img src=""7381.png"">"
Which steps of the TCA cycle are considered important, irreversible points of
regulation? Isocitrate -ketoglutarate, -ketoglutarate succinyl-CoA, acetyl-
CoA (and oxaloacetate) citrate "<img src=""7381.png"">" biochemistry
duplicate metabolism summary-of-pathways
Name the three potential fates of pyruvate. Which of them are important,
irreversible points of regulation? Lactate (reversible), acetyl-CoA via pyruvate
dehydrogenase (irreversible), oxaloacetate via pyruvate carboxylase (irreversible)
"<img src=""7381.png"">" biochemistry duplicate metabolism summary-of-
pathways
Outline the steps in the conversion of pyruvate into phosphoenolpyruvate (PEP).
Which ones are important, irreversible points of regulation? Pyruvate
oxaloacetate via pyruvate carboxylase (irreversible), oxaloacetate
phosphoenolpyruvate via PEP carboxykinase (irreversible) "<img src=""7381.png"">"
What are the two fates of oxaloacetate after it is generated? It enters either
the TCA cycle (becoming citrate after combining with acetyl-CoA) or gluconeogenesis
(converted into phosphoenolpyruvate ) "<img src=""7381.png"">" biochemistry
Outline the steps that ultimately convert pyruvate into glyceraldehyde-3-P in
gluconeogenesis. Pyruvate oxaloacetate phosphoenolpyruvate 2-
phosphoglycerate 3-phosphoglycerate 1,3-bis-phosphoglycerate glyceraldehyde-
3-P "<img src=""7381.png"">" biochemistry duplicate metabolism summary-of-
pathways
Outline the steps that ultimately convert glyceraldehyde-3-P into pyruvate in
glycolysis. Glyceraldehyde-3-P 1,3-bis-phosphoglycerate 3-phosphoglycerate 2-
phosphoglycerate phosphoenolpyruvate pyruvate "<img src=""7381.png"">"
Fructose can enter glycolysis by two pathways. Outline them. Fructose
fructose-1-phosphate (via fructokinase) either DHAP or glyceraldehyde
glyceraldehyde-3-P (both via aldolase B) "<img src=""7381.png"">" biochemistry
A current theory is that too much fructose intake is hepatotoxic because it
bypasses a key regulatory glycolysis step. Which step is this? The conversion of
fructose-6-phosphate to fructose-1,6-bisphosphate via phosphofructokinase-1 "<img
"Fructose-6-phosphate is considered an important ""gateway molecule"" into
glycolysis. Why is this?" Conversion of fructose-6-phosphate into fructose-1,6-
bisphosphate via phosphofructokinase-1 is an irreversible, important point of
regulation "<img src=""7381.png"">" biochemistry duplicate metabolism
summary-of-pathways
Glucose-6-phosphate must undergo a reaction before export from the cell. What is
the reaction? In what disease is this reaction impaired? Dephosphorylation via
glucose-6-phosphatase into glucose; von Gierke disease "<img src=""7381.png"">"
Aside from conversion into glucose, what are the three fates of glucose-6-phosphate
in the cell? HMP shunt (becomes 6-phosphogluconolactone), glycolysis (becomes
fructose-6-phosphate), glycogenesis (becomes glucose-1-phosphate) "<img
Which two enzymes are responsible for ultimately converting galactose into glucose-
1-phosphate? Galactose galactose-1-phosphate via galactokinase; galactose-1-
phosphate glucose-1-phosphate via galactose-1-phosphate uridyltransferase "<img
Outline the steps by which glucose-6-phosphate may be converted into glycogen.
Glucose-6-phosphate glucose-1-phosphate UDP-glucose glycogen "<img
The two enzymes for converting galactose into glucose-1-phosphate may be impaired.
What two diseases are these, and which is more severe? Galactokinase deficiency
(1st step): mild galactosemia; galactose-1-phosphate uridyltransferase deficiency
(2nd step): severe galactosemia "<img src=""7381.png"">" biochemistry
The two enzymes for converting fructose into DHAP/glyceraldehyde may be impaired.
What two diseases are these, and which is more severe? Fructokinase deficiency
(1st step): essential fructosuria (mild); aldolase B (2nd step): fructose
intolerance (severe) "<img src=""7381.png"">" biochemistry duplicate
Triglyceride metabolism byproducts can ultimately reenter the glycolysis pathway.
How does this happen? Triglyceride metabolism releases glycerol, which is
converted into DHAP that becomes either glyceraldehyde-3-P or fructose-1,6-
bisphosphate "<img src=""7381.png"">" biochemistry duplicate metabolism
summary-of-pathways
A new anti-lipid agent secondarily increases both HMG-CoA and -hydroxybutyrate
levels. What enzyme might this novel agent inhibit? HMG-CoA reductase (The
substrate is HMG-CoA, and this substrate is more likely to be shunted toward -
hydroxybutyrate production.) "<img src=""7381.png"">" biochemistry duplicate
What enzyme drives glucose-6-phosphate into the HMP shunt by converting it into 6-
phosphogluconolactone? Glucose-6-phosphate dehydrogenase (G6PD) "<img
What enzyme converts glucose into glucose-6-phosphate? What enzyme reverses this
reaction? Hexokinase or glucokinase; glucose-6-phosphatase "<img
What enzyme converts fructose-6-phosphate into fructose-1,6-bisphosphate. What
enzyme reverses this reaction? Phosphofructokinase-1; fructose-1,6,-
bisphosphatase "<img src=""7381.png"">" biochemistry duplicate metabolism
summary-of-pathways
Which enzyme is responsible for converting pyruvate into acetyl-CoA? What cofactor
is required? Pyruvate dehydrogenase; thiamine (TPP) "<img src=""7381.png"">"
Which enzyme is responsible for converting phosphoenolpyruvate (PEP) to pyruvate in
glycolysis? Pyruvate kinase "<img src=""7381.png"">" biochemistry duplicate
Which enzyme is responsible for converting oxaloacetate into phosphoenolpyruvate
(PEP) in gluconeogenesis? What cofactor is required? PEP carboxykinase; biotin
"<img src=""7381.png"">" biochemistry duplicate metabolism summary-of-
pathways
Which enzyme is responsible for converting oxaloacetate into citrate in the citric
acid cycle? Citrate synthase "<img src=""7381.png"">" biochemistry duplicate
Which enzyme is responsible for converting -ketoglutarate into succinyl-CoA in the
citric acid cycle? What cofactor is required? -ketoglutarate dehydrogenase;
thiamine (TPP) "<img src=""7381.png"">" biochemistry duplicate metabolism
summary-of-pathways
Which enzyme is responsible for converting isocitrate into -ketoglutarate in the
citric acid cycle? Isocitrate dehydrogenase "<img src=""7381.png"">"
Which enzyme is responsible for converting ribulose-5-phosphate into fructose-6-
phosphate in the HMP shunt? Which cofactor is required? Transketolase; thiamine
(TPP) "<img src=""7381.png"">" biochemistry duplicate metabolism summary-of-
pathways
Which enzyme is responsible for the conversion of fructose-1,6-bisphosphate to DHAP
in the liver? What about in muscle? Aldolase B; aldolase A "<img src=""7381.png"">"
Which enzyme is responsible for converting ornithine to citrulline in the urea
cycle? Ornithine transcarbamylase "<img src=""7381.png"">" biochemistry
An enzyme sequesters CO2 and NH3 within a cell. Production of citrulline drops.
Why? The conversion of ornithine to citrulline requires carbamoyl phosphate, which
is synthesized from CO2 and NH3 "<img src=""7381.png"">" biochemistry
The conversion of arginine to ornithine in the urea cycle requires what additional
molecule? What molecule is produced as a byproduct? H2O; urea "<img
The conversion of citrulline into argininosuccinate in the urea cycle requires what
additional molecule? Aspartate "<img src=""7381.png"">" biochemistry
Argininosuccinate is converted into two different products in the urea cycle. What
are they? What is each molecule's fate? Fumarate (enters the TCA cycle) and
arginine (remains in the urea cycle) "<img src=""7381.png"">" biochemistry
Starting with CO2 and NH3, outline all of the steps within the urea cycle. CO2
and NH3 carbamoyl phosphate citrulline (requires ornithine) argininosuccinate
arginine (and fumarate) ornithine (+H2O urea) "<img src=""7381.png"">"
Which enzyme is responsible for converting propionyl-CoA into methylmalonyl-CoA?
What cofactor is required? Propionyl-CoA carboxylase; biotin "<img
Which enzyme is responsible for converting methylmalonyl-CoA into succinyl-CoA?
What cofactor is required? Propionyl-CoA carboxylase; vitamin B12 "<img
Propionyl-CoA can be synthesized from what molecules? Odd-chain fatty acids,
branched-chain amino acids, methionine, and threonine "<img src=""7381.png"">"
Which enzyme is responsible for converting HMG-CoA into mevalonate in cholesterol
synthesis? HMG-CoA reductase "<img src=""7381.png"">" biochemistry duplicate
How many ATP molecules are produced from the aerobic metabolism of glucose via the
malate-aspartate shuttle? Where does this occur? 32; this occurs in the heart
and liver "<img src=""7382.png"">" atp-production biochemistry duplicate
metabolism
How many ATP molecules are produced from the aerobic metabolism of glucose via the
glycerol-3-phosphate shuttle? Where does this occur? 30; this occurs in muscle
"<img src=""7382.png"">" atp-production biochemistry duplicate
metabolism
What supplies the energy to turn substrate into product in energetically
unfavorable reactions? ATP hydrolysis (often coupled with energetically
unfavorable reactions to produce sufficient net energy) "<img src=""7382.png"">"
atp-production biochemistry duplicate metabolism
A man with garlic breath is noted to have arsenic poisoning from ground water. How
many ATP will this pt produce through glycolysis? Arsenic causes glycolysis to
produce 0 net ATP "<img src=""7382.png"">" atp-production biochemistry
duplicate metabolism
What is the net gain in ATP molecules after a molecule of glucose has participated
in anaerobic glycolysis? 2, as the NADH created cannot be used to generate
energy without oxygen "<img src=""7382.png"">" atp-production biochemistry
In which two organs is ATP produced from the aerobic metabolism of glucose via the
malate-aspartate shuttle? Heart and liver "<img src=""7382.png"">" atp-
production biochemistry duplicate metabolism
A 25-year-old runner is exercising to the point of requiring anaerobic glycolysis.
How many ATP per glucose molecule does he produce? As a result of anaerobic
glycolysis, he produces 2 ATP per glucose molecule "<img src=""7382.png"">"
atp-production biochemistry duplicate metabolism
Name the three activated carriers of electrons. NADH, NADPH, and FADH2 "<img
src=""7383.png"">" activated-carriers biochemistry duplicate metabolism
What is the activated carrier for phosphoryl groups? ATP "<img src=""7383.png"">"
activated-carriers biochemistry duplicate metabolism
What molecule donates methyl (CH3) groups? S-adenosylmethionine (SAM, the
methyl donor man) "<img src=""7383.png"">" activated-carriers biochemistry
Which activated carrier molecule donates aldehyde groups? Thiamine pyrophosphate
(TPP) "<img src=""7383.png"">" activated-carriers biochemistry duplicate
metabolism
Acyl groups are transported using which two activated carriers? Coenzyme A and
lipoamide "<img src=""7383.png"">" activated-carriers biochemistry duplicate
metabolism
What compounds are used as single-carbon donors in various reactions?
Tetrahydrofolates "<img src=""7383.png"">" activated-carriers
biochemistry duplicate metabolism
When in the activated form, ATP carries phosphoryl groups. What chemical compounds
do coenzyme A, lipoamide, biotin, SAM, and TPP carry? Coenzyme A and lipoamide
carry acyl groups; biotin carries CO2; SAM carries CH3 groups; TPP carries
aldehydes "<img src=""7383.png"">" activated-carriers biochemistry duplicate
metabolism
Of the following, which carry electrons and which carry 1-carbon units when
activated: tetrahydrofolate, NADH, NADPH, and FADH2? NADH, NADPH, and FADH2 carry
electron groups; and tetrahydrofolate carries 1-carbon units "<img
src=""7383.png"">" activated-carriers biochemistry duplicate metabolism
What pathway produces NADPH? The HMP shunt "<img src=""7384.png"">"
biochemistry duplicate metabolism universal-electron-acceptors
In which four metabolic processes is NADPH consumed? Anabolic processes (eg,
steroid and fatty acid synthesis), respiratory burst, cytochrome P-450 system, and
glutathione reductase "<img src=""7384.png"">" biochemistry duplicate
metabolism universal-electron-acceptors
Catabolic processes use which electron acceptor to carry reducing equivalents?
Anabolic processes use which one? NAD+; NADPH "<img src=""7384.png"">"
In anabolic processes, what is the biochemical role of NADPH? Serves as a supply
of reducing equivalents "<img src=""7384.png"">" biochemistry duplicate
metabolism universal-electron-acceptors
In catabolic processes, what is the biochemical role of NAD+? NAD+ is used to
carry reducing equivalents away as NADH "<img src=""7384.png"">" biochemistry
duplicate metabolism universal-electron-acceptors
What class of universal electron acceptor is NAD+, and from which vitamin is it
derived? What about FAD+? NAD+ is a nicotinamide derived from vitamin B3; FAD+
is a flavin nucleotide derived from vitamin B2 "<img src=""7384.png"">"
What enzymatic reaction is catalyzed by the enzymes hexokinase and glucokinase?
Both phosphorylate glucose to form glucose-6-phosphate as the first committed
step of glycolysis and of glycogen synthesis in the liver "<img src=""7385.png"">"
biochemistry duplicate hexokinase-vs-glucokinase metabolism
In which location(s) is glucokinase found? Hexokinase? Glucokinase is found in
liver and cells of the pancreas; hexokinase is found elsewhere in tissue but not
liver or cells of the pancreas "<img src=""7385.png"">" biochemistry
duplicate hexokinase-vs-glucokinase metabolism
Which enzyme has a higher Km: glucokinase or hexokinase? Vmax? Glucokinase has a
higher Km (low affinity) and higher Vmax (high capacity) "<img src=""7385.png"">"
biochemistry duplicate hexokinase-vs-glucokinase metabolism
Which enzyme is feedback-inhibited by glucose-6-phosphate? Hexokinase "<img
src=""7385.png"">" biochemistry duplicate hexokinase-vs-glucokinase metabolism
Which enzyme has a greater capacity to convert glucose to glucose-6-phosphate:
glucokinase or hexokinase? Glucokinase (high Vmax) (Glucokinase is a glutton.)
"<img src=""7385.png"">" biochemistry duplicate hexokinase-vs-
glucokinase metabolism
A 65-year-old man with type 2 diabetes injects insulin before his lunch. How does
insulin affect the action of hexokinase and glucokinase? It induces glucokinase
but not hexokinase "<img src=""7385.png"">" biochemistry duplicate
hexokinase-vs-glucokinase metabolism
A 20-y/o man with type 1 diabetes has a blood glucose of 50. Where in the body is
his glucose sequestered? What if the level were 300 mg/dL? At low concentrations,
glucose is sequestered by hexokinase in tissue; at high concentrations, the excess
glucose is stored in the liver "<img src=""7385.png"">" biochemistry
duplicate hexokinase-vs-glucokinase metabolism
A pt is diagnosed with maturity-onset diabetes of the young (MODY). Which enzyme
has a gene mutation associated with this condition? Glucokinase; hexokinase is
not associated with MODY "<img src=""7385.png"">" biochemistry duplicate
hexokinase-vs-glucokinase metabolism
Where in the cell does glycolysis occur? Cytoplasm "<img src=""7386.png"">"
biochemistry duplicate glycolysis-regulation,-key-enzymes metabolism
What are the net products of glycolysis? Glucose + 2 Pi + 2 ADP + 2 NAD+ = 2
pyruvate + 2 ATP + 2 NADH + 2 H+ + 2 H2O "<img src=""7386.png"">" biochemistry
duplicate glycolysis-regulation,-key-enzymes metabolism
In glycolysis, which reactions require ATP? Glucose to glucose-6-phosphate;
fructose-6-phosphate to fructose-1,6-bisphosphate "<img src=""7386.png"">"
Which is the rate-limiting step in glycolysis? Fructose-6-phosphate to fructose-
1,6-bisphosphate via phosphofructokinase-1 "<img src=""7386.png"">"
In glycolysis, what enzyme catalyzes conversion of glucose to glucose-6-phosphate?
What compounds inhibit the conversion? Catalysts: glucokinase (liver) and
hexokinase (in all other tissue); glucose-6-P inhibits hexokinase and fructose-6-P
inhibits glucokinase "<img src=""7386.png"">" biochemistry duplicate
glycolysis-regulation,-key-enzymes metabolism
Phosphofructokinase-1 catalyzes which step in glycolysis? Conversion of fructose-
6-phosphate to fructose-1,6-bisphosphate "<img src=""7386.png"">" biochemistry
duplicate glycolysis-regulation,-key-enzymes metabolism
Which compounds inhibit the reaction catalyzed by pyruvate kinase? Which induce it?
ATP and alanine inhibit the reaction; fructose-1,6-bisphosphate induces it
"<img src=""7386.png"">" biochemistry duplicate glycolysis-regulation,-
key-enzymes metabolism
What compounds inhibit the reaction catalyzed by phosphofructokinase-1? Which
compounds induce it? ATP and citrate inhibit the reaction; AMP and fructose-2,6-
biphosphate induce it "<img src=""7386.png"">" biochemistry duplicate
In glycolysis, which reaction is reversible and produces ATP? Which enzyme
catalyzes it? Conversion of 1,3-bisphosphoglycerate (1,3-BPG) to 3-
phosphoglycerate (3-PG); phosphoglycerate kinase "<img src=""7386.png"">"
In glycolysis, the conversion of phosphoenolpyruvate to pyruvate is catalyzed by
which enzyme? Is this step reversible? Pyruvate kinase; it is not reversible
In glycolysis, which reactions generate ATP? Conversions of 1,3-
bisphosphoglycerate to 3-phosphoglycerate and phosphoenolpyruvate to pyruvate
A new drug blocks ATP delivery to various enzymes involved in glycolysis. Which
enzymes would be inhibited? Hexokinase, glucokinase, and phosphofructokinase-1
(All require ATP.) "<img src=""7386.png"">" biochemistry duplicate
What two enzymes involved in fructose-2,6-bisphosphate regulation make up the same
bifunctional complex? How is their activity regulated? Fructose bisphosphatase-
2 (FBPase-2) and phosphofructokinase-2 (PFK-2); activity is reversed by
phosphorylation by protein kinase A "<img src=""7387.png"">" biochemistry
duplicate metabolism regulation-by-fructose-2,6-bisphosphate
The enzyme phosphofructokinase-2 (PFK-2) catalyzes which reaction? The
conversion of fructose-6-phosphate to fructose-2,6-bisphosphate "<img
src=""7387.png"">" biochemistry duplicate metabolism regulation-by-fructose-
2,6-bisphosphate
What enzyme converts fructose-1,6-bisphosphate (F1,6BP) to fructose-6-phosphate
during gluconeogenesis? Fructose bisphosphatase-1 (FBPase-1) "<img
2,6-bisphosphate
What reaction is catalyzed by fructose bisphosphatase-2 (FBPase-2)? Conversion
of fructose-2,6-bisphosphate to fructose-6-phosphate "<img src=""7387.png"">"
biochemistry duplicate metabolism regulation-by-fructose-2,6-bisphosphate
Which enzyme catalyzes the conversion of fructose-6-phosphate to fructose-1,6-
bisphosphate (F1,6BP)? What compound induces this reaction?Phosphofructokinase-1
(PFK-1); fructose-2,6-bisphosphate "<img src=""7387.png"">" biochemistry
Which enzyme regulating the level of fructose-2,6-bisphosphate is active in the fed
state? Phosphofructokinase-2 (PFK-2), which increases glycolysis and thus ATP
creation for anabolic processes "<img src=""7387.png"">" biochemistry
Which enzyme regulating the level of fructose-2,6-bisphosphate is active in the
fasting state? Fructose bisphosphatase-2 (FBPase-2), which increases
gluconeogenesis (& decreases glycolysis) when glucose is needed for catabolic
processes "<img src=""7387.png"">" biochemistry duplicate metabolism
regulation-by-fructose-2,6-bisphosphate
A 20-year-old with type 1 diabetes injects insulin right before eating lunch. How
does this affect the action of FBPase-2 and PFK-2? Increases insulin, reducing
cAMP, PKA, and FBPase-2 and increasing PFK-2 action, which promotes glycolysis and
inhibits gluconeogenesis "<img src=""7387.png"">" biochemistry duplicate
metabolism regulation-by-fructose-2,6-bisphosphate
A hardworking medical student on her surgery clerkship skips lunch to go to the OR.
How does this affect the action of FBPase-2 and PFK-2? In fasting, increased
glucagon raises cAMP/PKA, raising FBPase-2 and lowering PFK-2, which inhibits
glycolysis and promotes gluconeogenesis "<img src=""7387.png"">" biochemistry
Hepatocytes with low intracellular levels of fructose 2,6-bisphosphate will mostly
have what kind of energy metabolism? Catabolism; these cells will break down
glycogen, protein, and fatty acids to synthesize glucose and gain energy "<img
2,6-bisphosphate
Which reaction is catalyzed by the pyruvate dehydrogenase complex? Pyruvate +
NAD+ + CoA to acetyl-CoA + CO2 + NADH "<img src=""7388.png"">" biochemistry
duplicate metabolism pyruvate-dehydrogenase-complex
How many enzymes and cofactors make up the pyruvate dehydrogenase complex? Where is
the complex found? Three enzymes that require five cofactors; it is found in
mitochondria "<img src=""7388.png"">" biochemistry duplicate metabolism
pyruvate-dehydrogenase-complex
An exercising man has increased pyruvate dehydrogenase complex activity. What
biochemical changes resulting from exercise induced this? Exercise activates the
complex as a result of increases in the NAD+/NADH ratio, ADP level, and Ca2+ level
"<img src=""7388.png"">" biochemistry duplicate metabolism pyruvate-
dehydrogenase-complex
A pt has rice-water stools, vomiting, and garlic breath. What will measurements of
his pyruvate dehydrogenase complex activity show? This pt has arsenic
poisoning, which inhibits lipoic acid, so the pyruvate dehydrogenase complex
activity level will be reduced "<img src=""7388.png"">" biochemistry
duplicate metabolism pyruvate-dehydrogenase-complex
Which cofactors are required for the pyruvate dehydrogenase complex? Which B
vitamins do they each include? Thiamine pyrophosphate (B1), ipoic acid, CoA
(B5, pantothenic acid), FAD (B2, riboflavin), NAD (B3, niacin) (TLC For Nancy)
Which TCA cycle enzyme is similar to the pyruvate dehydrogenase complex (same
cofactors, similar substrate)? What reaction does it catalyze? The -
ketoglutarate dehydrogenase complex, which converts -ketoglutarate to succinyl-CoA
Is pyruvate dehydrogenase active in the fasting or fed state? The fed state (It
is differentially regulated.) "<img src=""7388.png"">" biochemistry duplicate
metabolism pyruvate-dehydrogenase-complex
A pt has an enzyme deficiency causing a backup of pyruvate and alanine. How is he
treated? To treat pyruvate dehydrogenase complex deficiency, increase ketogenic
nutrient intake (eg, high fat) or increase lysine and leucine "<img
src=""7389.png"">" biochemistry duplicate metabolism pyruvate-dehydrogenase-
complex-deficiency
A pt presents with too much pyruvate being shunted to lactate via LDH. What are
some findings you would expect during your workup? Neurologic deficits, lactic
acidosis, an increase in serum alanine starting in infancy (This is pyruvate
dehydrogenase complex deficiency.) "<img src=""7389.png"">" biochemistry
duplicate metabolism pyruvate-dehydrogenase-complex-deficiency
A 2-year-old child is started on a highly ketogenic diet. His enzyme deficiency is
most likely due to what genetic mutation? Most cases of pyruvate dehydrogenase
complex deficiency are due to a mutation on the X chromosome "<img
src=""7389.png"">" biochemistry duplicate metabolism pyruvate-dehydrogenase-
complex-deficiency
In PDC deficiency, the excess pyruvate is shunted to which two enzymes that lead to
the production of lactate and alanine, respectively? Lactate dehydrogenase (LDH)
and alanine aminotransferase (ALT) "<img src=""7389.png"">" biochemistry
duplicate metabolism pyruvate-dehydrogenase-complex-deficiency
You are a nutritionist counseling a pt with pyruvate dehydrogenase deficiency. What
amino acids do you emphasize in the diet? Lysine and Leucine (the onLy pureLy
ketogenic amino acids) "<img src=""7389.png"">" biochemistry duplicate
metabolism pyruvate-dehydrogenase-complex-deficiency
Lactic dehydrogenase (LDH), a part of anaerobic glycolysis, is found in which cells
and organs? RBCs, WBCs, kidney medulla, testes, lens, cornea "<img
src=""7390.png"">" biochemistry duplicate metabolism pyruvate-metabolism
There are four primary pathways for pyruvate. What products are ultimately produced
from each pathway? Alanine, oxaloacetate, acetyl-CoA, and lactate "<img
Which amino acid carries amino groups from muscle to liver?Alanine "<img
A 4-year-old boy has a genetic defect inhibiting his ability to produce alanine
from pyruvate. Which enzyme is affected? Alanine aminotransferase "<img
What end product of the pyruvate carboxylase pathway can be used to replenish the
TCA cycle and can participate in gluconeogenesis? Oxaloacetate "<img
Of the four pyruvate metabolic pathways, which requires ATP? NADH? NAD+?
Pyruvate dehydrogenase requires ATP (and CO2); lactate dehydrogenase requires
NADH; pyruvate dehydrogenase requires NAD+ "<img src=""7390.png"">"
biochemistry duplicate metabolism pyruvate-metabolism
In anaerobic glycolysis, pyruvate is converted to lactate by which enzyme? This is
a major pathway in which tissues? Lactic acid dehydrogenase; RBCs, leukocytes,
kidney medulla, lens, testes, cornea "<img src=""7390.png"">" biochemistry
duplicate metabolism pyruvate-metabolism
Pyruvate is converted into which two molecules that can enter the tricarboxylic
acid cycle? Acetyl-CoA and oxaloacetate "<img src=""7390.png"">" biochemistry
Which pyruvate metabolism pathway produces CO2? Which consumes it? Pyruvate
dehydrogenase produces CO2; pyruvate carboxylase consumes CO2 "<img
A pt is found to have B6 deficiency. What will an assay of alanine aminotransferase
activity show? What about lactate dehydrogenase? Alanine aminotransferase
activity will decrease, as B6 is an important cofactor; lactate dehydrogenase
requires B3 and will not be affected "<img src=""7390.png"">" biochemistry
What five cofactors does pyruvate dehydrogenase require to function properly?
B1, B2, B3, B5, and lipoic acid "<img src=""7390.png"">" biochemistry
Of the four pyruvate metabolic pathways, which ones occur in the mitochondria? In
the cytosol? Pyruvate dehydrogenase and pyruvate carboxylase in the
mitochondria; alanine aminotransferase and lactic acid dehydrogenase in the cytosol
metabolism
Count carbons in these molecules: pyruvate, acetyl-CoA, citrate, isocitrate, -KG,
succinyl-CoA, succinate, fumarate, malate, oxaloacetate Pyruvate = 3; acetyl-CoA
= 2; citrate & isocitrate = 6 each; -KG = 5; succinyl-CoA, succinate, fumarate,
malate, & oxaloacetate = 4 each "<img src=""7391.png"">" biochemistry
duplicate metabolism tca-cycle-(krebs-cycle)
Which enzymes in the TCA cycle are irreversible? Citrate synthase, isocitrate
dehydrogenase, and -ketoglutarate dehydrogenase "<img src=""7391.png"">"
biochemistry duplicate metabolism tca-cycle-(krebs-cycle)
How many NADH molecules are produced during one turn of the citric acid cycle? How
many FADH2? Carbon dioxide? GTP? 3 NADH, 1 FADH2, 2 CO2, 1 GTP "<img
src=""7391.png"">" biochemistry duplicate metabolism tca-cycle-(krebs-cycle)
In the citric acid cycle, which compounds inhibit and which activate isocitrate
dehydrogenase? ATP and NADH inhibit isocitrate dehydrogenase, and ADP activates
it "<img src=""7391.png"">" biochemistry duplicate metabolism tca-cycle-
(krebs-cycle)
How many ATP molecules are produced during one turn of the citric acid cycle? From
one glucose molecule? 10 ATP for each acetyl-CoA (2.5 per NADH, 1.5 per FADH2,
and 1.0 per GTP); 20 (2 times everything per glucose) "<img src=""7391.png"">"
In the tricarboxylic acid cycle, which steps produce CO2? Isocitrate to -
ketoglutarate via isocitrate dehydrogenase and -ketoglutarate to succinyl-CoA via
-ketoglutarate dehydrogenase produce CO2 "<img src=""7391.png"">" biochemistry
In the tricarboxylic acid cycle, ATP inhibits which enzymes? Citrate synthase,
isocitrate dehydrogenase, and -ketoglutarate dehydrogenase"<img src=""7391.png"">"
At which steps in the Krebs cycle are NADH, GTP, and FADH2 produced? NADH:
isocitrate to -KG, -KG to succinyl-CoA, malate to oxaloacetate; GTP: succinyl-CoA
to succinate; FADH2: succinate to fumarate "<img src=""7391.png"">"
Which enzyme in the TCA cycle requires the same cofactors as the pyruvate
dehydrogenase complex? What cofactors are required? -Ketoglutarate
dehydrogenase; B1, B2, B3, B5, and lipoic acid "<img src=""7391.png"">"
What intermediate of the tricarboxylic acid cycle provides negative feedback to -
ketoglutarate dehydrogenase to inhibit its function? Succinyl-CoA "<img
src=""7391.png"">" biochemistry duplicate metabolism tca-cycle-(krebs-cycle)
Where in the cell does the tricarboxylic acid cycle take place? The mitochondria
"<img src=""7391.png"">" biochemistry duplicate metabolism tca-cycle-
(krebs-cycle)
Pyruvate is acted on by PDH; the product enters the TCA cycle. Identify the PDH
product. What is the PDH product converted to next? Acetyl-CoA; citrate (Citrate
Is Krebs' Starting Substrate For Making Oxaloacetate.) "<img src=""7391.png"">"
You are citrate. You enter the TCA cycle and become a product that inhibits -KG
dehydrogenase. Name this product and all intermediates. Citrate, cis-aconitate,
isocitrate, -KG, succinyl-CoA (final) (Citrate Is Krebs Starting Substrate For
Making Oxaloacetate.) "<img src=""7391.png"">" biochemistry duplicate
metabolism tca-cycle-(krebs-cycle)
You are succinyl-CoA. You enter the TCA cycle and become a product that reacts
w/citrate synthase. Name this product and all intermediates. Succinyl-CoA,
succinate, fumarate, malate, oxaloacetate (final) (Citrate Is Krebs Starting
Substrate For Making Oxaloacetate.) "<img src=""7391.png"">" biochemistry
Electrons carried by NADH created in glycolysis and the tricarboxylic acid cycle
may enter the mitochondria via which two shuttles? NADH is transferred to
complex I via the malate-aspartate shuttle or the glycerol-3-phosphate shuttle
"<img src=""7392.png"">" biochemistry duplicate electron-transport-
chain-and-oxidative-phosphorylation metabolism
How many ATP molecules can be produced from one NADH molecule during oxidative
phosphorylation? How many from one FADH2 molecule? 2.5 per NADH and 1.5 per
FADH2) "<img src=""7392.png"">" biochemistry duplicate electron-
transport-chain-and-oxidative-phosphorylation metabolism
Why does FADH2 produce fewer molecules of ATP than NADH? It enters the electron
transport chain at a lower energy level (on complex II) "<img src=""7392.png"">"
biochemistry duplicate electron-transport-chain-and-oxidative-phosphorylation
metabolism
How does the passage of electrons from NADH and FAD2 produce ATP? The passage
of electrons results in the formation of a proton gradient, which produces ATP when
coupled to oxidative phosphorylation "<img src=""7392.png"">" biochemistry
duplicate electron-transport-chain-and-oxidative-phosphorylation metabolism
A 4-year-old girl swallows some cyanide-containing rat poison found under the sink.
How does this affect her ATP production? Cyanide directly inhibits electron
transport (complex IV) and thus decreases the proton gradient and blocks ATP
synthesis "<img src=""7392.png"">" biochemistry duplicate electron-
Name the four direct electron transport inhibitors. Rotenone, antimycin A,
cyanide, and CO "<img src=""7392.png"">" biochemistry duplicate electron-
A chemist is working on a substance with a structure similar to azithromycin. How
would ingesting the substance affect ATP production? It (oligomycin) would inhibit
mitochondrial ATP synthase, which increases the proton gradient, stopping electron
transport & ATP production "<img src=""7392.png"">" biochemistry duplicate
electron-transport-chain-and-oxidative-phosphorylation metabolism
How do 2,4-dinitrophenol, aspirin, and thermogenin in brown fat affect ATP
production? Uncoupling agents increase membrane permeability, decrease the proton
gradient, and increase O2 consumption, which stops ATP synthesis "<img
src=""7392.png"">" biochemistry duplicate electron-transport-chain-and-
oxidative-phosphorylation metabolism
A 30-year-old man overdoses on an uncoupling agent that causes Reye syndrome in
children. What vital sign abnormality would he have? Why? Fever; aspirin is an
uncoupling agent, so ATP synthesis stops, but electron transport continues and
produces heat "<img src=""7392.png"">" biochemistry duplicate electron-
A newborn has a high concentration of brown fat. How does this affect his oxygen
use, ATP production, and heat generation? Brown fat has thermogenin, which
increases oxygen consumption and heat generation; ATP production is decreased
"<img src=""7392.png"">" biochemistry duplicate electron-transport-
chain-and-oxidative-phosphorylation metabolism
Give at least one example of an inhibitor for each part of the electron transport
chain: complex I, complex III, complex IV, and complex V. "Complex ONE: rotenONE;
complex 3: ""an-3-mycin"" (antimycin) A; complex 4: CO/CN (4 letters); complex V:
oligomycin" "<img src=""7392.png"">" biochemistry duplicate electron-
A man, wanting to lose weight, begins taking 2,4-dinitrophenol. He is later
hospitalized with life-threatening hyperthermia. What happened? 2,4-Dinitrophenol
lets H+ leak back into the matrix, making ATP production inefficient; ATP
generation thus accelerates, creating more heat "<img src=""7392.png"">"
biochemistry duplicate electron-transport-chain-and-oxidative-phosphorylation
metabolism
A 43-year-old man has a disorder in which he cannot convert pyruvate to
oxaloacetate. In which organelle is the defective enzyme found? The mitochondria;
this is due to a defect with pyruvate carboxylase "<img src=""7393.png"">"
biochemistry duplicate gluconeogenesis,-irreversible-enzymes metabolism
The step of gluconeogenesis that occurs in the mitochondria requires which
cofactors? What activates the reaction? Cofactors are biotin and ATP; acetyl-CoA
activates the reaction "<img src=""7393.png"">" biochemistry duplicate
gluconeogenesis,-irreversible-enzymes metabolism
Which steps of gluconeogenesis occur in the cytosol? Oxaloacetate to
phosphoenolpyruvate (phosphoenolpyruvate carboxykinase) & fructose-1,6-BP to
fructose-6-P (fructose-1,6-bisphosphatase) "<img src=""7393.png"">"
In gluconeogenesis, which enzyme reaction requires GTP? The conversion of
oxaloacetate to phosphoenolpyruvate via phosphoenolpyruvate carboxykinase "<img
src=""7393.png"">" biochemistry duplicate gluconeogenesis,-irreversible-
enzymes metabolism
In gluconeogenesis, which enzyme reaction is activated by acetyl-CoA? The
conversion of pyruvate to oxaloacetate via pyruvate carboxylase (occurs in
mitochondria) "<img src=""7393.png"">" biochemistry duplicate
In gluconeogenesis, the final creation of glucose occurs via which enzyme in which
cellular structure? Glucose-6-phosphate is converted to glucose via glucose-6-
phosphatase in the endoplasmic reticulum of the liver "<img src=""7393.png"">"
In which organ does gluconeogenesis primarily occur? Why is muscle unable to
participate in gluconeogenesis? The liver; muscle lacks glucose-6-phosphatase
"<img src=""7393.png"">" biochemistry duplicate gluconeogenesis,-
irreversible-enzymes metabolism
A 3-year-old boy has a genetic deficiency in phosphoenolpyruvate carboxykinase.
What is his primary symptom? Hypoglycemia (A deficiency in any key gluconeogenic
enzyme will cause it.) "<img src=""7393.png"">" biochemistry duplicate
What other tissues contain gluconeogenic enzymes apart from the liver? Kidney and
intestinal epithelium "<img src=""7393.png"">" biochemistry duplicate
What is the role of odd-chain fatty acids in gluconeogenesis? Metabolism of odd-
chain fatty acids produces one propionyl-CoA, which can enter the TCA cycle as
succinyl-CoA and undergo gluconeogenesis "<img src=""7393.png"">" biochemistry
duplicate gluconeogenesis,-irreversible-enzymes metabolism
Why are even-chain fatty acids unable to produce new glucose? Because their
metabolism yields only acetyl-CoA equivalents "<img src=""7393.png"">"
Name four enzymes in gluconeogenesis whose actions are irreversible. Pyruvate
carboxylase, Phosphoenolpyruvate carboxykinase, Fructose-1,6-bisphosphatase,
Glucose-6-phosphatase (Pathway Produces Fresh Glucose) "<img src=""7393.png"">"
Name an activator of fructose-1,6-bisphosphatase. Name an inhibitor. Citrate;
fructose-2,6-bisphosphate "<img src=""7393.png"">" biochemistry duplicate
What is the starting substrate of the oxidative reaction in the HMP shunt?
Glucose-6-phosphate "<img src=""7394.png"">" biochemistry duplicate
hmp-shunt-(pentose-phosphate-pathway) metabolism
What are the two phases of the HMP shunt (pentose phosphate pathway)? Where does
each occur? Irreversible oxidative phase and reversible nonoxidative phase; both
occur in the cytoplasm "<img src=""7394.png"">" biochemistry duplicate hmp-
shunt-(pentose-phosphate-pathway) metabolism
What four products are formed after both phases of the HMP shunt? What are they
used for? NADPH (reductive reactions), ribose-5-Pi (nucleotide synthesis), and
glucose-3-P & fructose-6-P (both intermediates of glycolysis pathway) "<img
src=""7394.png"">" biochemistry duplicate hmp-shunt-(pentose-phosphate-
pathway) metabolism
A 2-year-old girl was born with a glucose-6-phosphate dehydrogenase deficiency.
This interferes with which step of the HMP shunt? The irreversible oxidative
reaction converting glucose-6-phosphate to CO2, 2 NADPH, and ribulose-5-phosphate
"<img src=""7394.png"">" biochemistry duplicate hmp-shunt-(pentose-
phosphate-pathway) metabolism
A 2-year-old girl was born with a defect in the nonoxidative (reversible) step of
the HMP shunt. What enzyme(s) may be deficient? Phosphopentose isomerase or
transketolases "<img src=""7394.png"">" biochemistry duplicate hmp-shunt-
(pentose-phosphate-pathway) metabolism
How many ATP molecules are used and produced by the HMP shunt (pentose phosphate
pathway)? Zero "<img src=""7394.png"">" biochemistry duplicate hmp-shunt-
What vitamin is required as a cofactor in the HMP shunt? In which phase is it used?
Vitamin B1 (thiamine) is required in the nonoxidative phase"<img
pathway) metabolism
What is the rate-limiting step in the HMP shunt (pentose phosphate pathway)? The
irreversible oxidative reaction converting glucose-6-phosphate to CO2, 2 NADPH, and
ribulose-5-phosphate "<img src=""7394.png"">" biochemistry duplicate hmp-
What is the function of NADPH in the erythrocyte? It reduces glutathione "<img
pathway) metabolism
Name three sites of fatty acid or steroid synthesis that show high pentose
phosphate pathway (HMP shunt) activity. Lactating mammary glands, liver, and
adrenal cortex "<img src=""7394.png"">" biochemistry duplicate hmp-shunt-
A pt is taking primaquine and dapsone, and both increase oxidative stress. Where
will HMP shunt activity increase to compensate? In the red blood cells; the
reducing equivalents (NADPH) formed are necessary to neutralize oxidative radicals
produced by the drugs "<img src=""7394.png"">" biochemistry duplicate hmp-
You are using a fluorescent antibody to stain phosphopentose isomerase. In which
cellular compartment will you find it? Cytoplasm; all HMP shunt reactions are
cytoplasmic (Remember that RBCs, which lack nuclei and organelles, rely heavily on
the HMP shunt.) "<img src=""7394.png"">" biochemistry duplicate hmp-shunt-
What enzyme catalyzes the rate-limiting step of HMP shunt (pentose phosphate
pathway)? Name an inhibitor of the enzyme. Glucose-6-phosphate dehydrogenase;
NADPH "<img src=""7394.png"">" biochemistry duplicate hmp-shunt-(pentose-
phosphate-pathway) metabolism
What substance detoxifies free radicals and peroxides in the cell? Glutathione
"<img src=""7395.png"">" biochemistry duplicate glucose-6-phosphate-
dehydrogenase-deficiency metabolism
A 25-year-old African-American man develops anemia after being treated with a
sulfonamide. What enzyme deficiency does he have? Glucose-6-phosphate
dehydrogenase deficiency; hemolytic anemia develops after exposure to an oxidizing
agent (eg, a sulfonamide) "<img src=""7395.png"">" biochemistry duplicate
glucose-6-phosphate-dehydrogenase-deficiency metabolism
A pt with G6PD deficiency is being treated for tuberculosis. Soon he develops
anemia. What is the mechanism? Glucose-6-phosphate dehydrogenase is needed to
replenish NADPH; NADPH keeps glutathione, which is used to detoxify free radicals,
reduced "<img src=""7395.png"">" biochemistry duplicate glucose-6-
phosphate-dehydrogenase-deficiency metabolism
A 30-year-old man with the most common human enzyme deficiency eats fava beans.
What might you see on a peripheral blood smear? Heinz bodies (RBCs with oxidized
Hemoglobin precipitated inside) and bite cells (because splenic macrophages try to
remove the Heinz bodies) "<img src=""7395.png"">" biochemistry duplicate
Glucose-6-phosphate dehydrogenase deficiency shows what form of inheritance? X-
linked recessive (therefore, symptoms are largely seen in male pts) "<img
src=""7395.png"">" biochemistry duplicate glucose-6-phosphate-dehydrogenase-
deficiency metabolism
Blacks living in areas with a high prevalence of malaria are noted to have
increased resistance to the disease. Why? Those with glucose-6-phosphate
dehydrogenase (G6PD) deficiency are more resistant to malaria; G6PD deficiency is
more prevalent in blacks "<img src=""7395.png"">" biochemistry duplicate
What feature do fava beans, sulfonamides, primaquine, and anti-TB drugs share that
causes hemolytic anemia in persons with G6PD deficiency? They are all oxidizing
agents and cause oxidative stress to erythrocytes "<img src=""7395.png"">"
biochemistry duplicate glucose-6-phosphate-dehydrogenase-deficiency
metabolism
A 24-year-old man with glucose-6-phosphate dehydrogenase deficiency is sick with
the flu. How may this affect his hemoglobin? Hemolytic anemia may develop from
infection (inflammatory response makes free radicals that can enter RBCs, causing
oxidative damage) "<img src=""7395.png"">" biochemistry duplicate glucose-6-
phosphate-dehydrogenase-deficiency metabolism
Glucose-6-phosphate dehydrogenase changes glucose-6-phosphate into what substrate?
6-Phosphogluconate "<img src=""7395.png"">" biochemistry duplicate
A pt with G6PD deficiency undergoes a splenectomy. Aside from more Howell-Jolly
bodies, how might the appearance of his blood smear change?More Heinz bodies, fewer
bite cells (less phagocytic removal of bite cells by splenic macrophages) = Bite
into some Heinz ketchup. "<img src=""7395.png"">" biochemistry duplicate
What enzyme catalyzes the conversion of peroxide to water? What cofactor is needed
to carry out this reaction? Glutathione peroxidase; reduced form of glutathione
"<img src=""7395.png"">" biochemistry duplicate glucose-6-phosphate-
dehydrogenase-deficiency metabolism
What is the most common cause of hemolysis in pts with glucose-6-phosphate
dehydrogenase deficiency? Infection "<img src=""7395.png"">" biochemistry
duplicate glucose-6-phosphate-dehydrogenase-deficiency metabolism
A pt presents with fructose in the blood and urine. What autosomal recessive
disease may this pt have? What enzyme is defective? Essential fructosuria;
fructokinase "<img src=""7396.png"">" biochemistry disorders-of-fructose-
metabolism duplicate metabolism
Which causes milder symptomsdisorders of fructose metabolism or analogous
disorders of galactose metabolism? Disorders of fructose metabolism "<img
src=""7396.png"">" biochemistry disorders-of-fructose-metabolism duplicate
metabolism
Is essential fructosuria or fructose intolerance more clinically significant? Why?
Fructose intolerance; fructose-1-P accumulates in the cell, reducing
available phosphate, which inhibits glycogenolysis and gluconeogenesis "<img
metabolism
A pt has hypoglycemia, jaundice, and cirrhosis and vomits after eating honey. What
enzyme is likely deficient? Aldolase B (This is fructose intolerance.) "<img
metabolism
In fructose metabolism, the conversion of fructose-1-phosphate to dihydroxyacetone-
P plus glyceraldehyde is catalyzed by what enzyme? Aldolase B; the resulting
molecules can enter glycolysis "<img src=""7396.png"">" biochemistry
disorders-of-fructose-metabolism duplicate metabolism
How can fructose enter glycolysis quickly? Via aldolase B, as fructose skips
the rate-limiting step of phosphofructokinase "<img src=""7396.png"">"
biochemistry disorders-of-fructose-metabolism duplicate metabolism
A pt has a hereditary deficiency of aldolase B. What is the treatment for this
disorder? Decreased intake of fructose and sucrose (glucose + fructose) (The pt
has fructose intolerance.) "<img src=""7396.png"">" biochemistry disorders-
of-fructose-metabolism duplicate metabolism
A pt has a hereditary deficiency of aldolase B. What substrate accumulates, causing
a decrease in available phosphate? Fructose-1-phosphate accumulates because the pt
has fructose intolerance "<img src=""7396.png"">" biochemistry disorders-
A child gorges on honey, starts vomiting, and has an altered mental status. Urine
dipstick is negative for glucose. What is going on? The child has hypoglycemia;
glycogenolysis and gluconeogenesis are inhibited by phosphate depletion secondary
to fructose-1-P accumulation "<img src=""7396.png"">" biochemistry disorders-
Can any urine tests be used to definitively diagnose hereditary fructose
intolerance? No; reducing sugars are detected by a nonspecific test for inborn
errors of carbohydrate metabolism, and urine dipstick detects only glucose "<img
metabolism
A pt has a rare deficiency of triose kinase. What can you speculate about how
quickly fructose enters glycolysis in this pt? It will occur at a lower rate;
triose kinase uses ATP to convert glyceraldehyde into glyceraldehyde-3-phosphate
(which can enter glycolysis) "<img src=""7396.png"">" biochemistry disorders-
After fructose enters a cell, what are the first two reactions that it undergoes?
Fructose fructose-1-P via fructokinase; fructose-1-P dihydroxyacetone-P
and glyceraldehyde via aldolase B "<img src=""7396.png"">" biochemistry
disorders-of-fructose-metabolism duplicate metabolism
Which has milder symptomsclassic galactosemia or galactokinase deficiency?
Galactokinase deficiency "<img src=""7397.png"">" biochemistry
disorders-of-galactose-metabolism duplicate metabolism
An infant with infantile cataracts, failure to develop a social smile, and
galactose in the blood and urine has a deficiency in what enzyme?
Galactokinase "<img src=""7397.png"">" biochemistry disorders-of-
galactose-metabolism duplicate metabolism
In galactosemia, the buildup of which substance causes damage to organs, especially
the lens of the eye? Galactitol "<img src=""7397.png"">" biochemistry
What is the inheritance pattern of galactokinase deficiency and galactosemia?
Autosomal recessive "<img src=""7397.png"">" biochemistry disorders-
of-galactose-metabolism duplicate metabolism
In galactose metabolism, galactose-1-phosphate is converted to glucose-1-phosphate
by which enzyme? Which disease results from a deficiency? Galactose-1-phosphate
uridyltransferase; classic galactosemia results from a deficiency of this enzyme
"<img src=""7397.png"">" biochemistry disorders-of-galactose-metabolism
In galactose metabolism, a block in the conversion of galactose to galactose-1-
phosphate is caused by what disease? Galactokinase deficiency "<img
src=""7397.png"">" biochemistry disorders-of-galactose-metabolism duplicate
metabolism
A toddler with an enzyme deficiency has failure to thrive, jaundice, hepatomegaly,
infantile cataracts, and mental retardation. Treatment? Exclusion of galactose
and lactose (glucose and galactose) from the diet (The child has classic
galactosemia.) "<img src=""7397.png"">" biochemistry disorders-of-
galactose-metabolism duplicate metabolism
A neonate has classic galactosemia. What is the most feared systemic complication
in this pt? E coli sepsis "<img src=""7397.png"">" biochemistry disorders-
of-galactose-metabolism duplicate metabolism
One of the more serious side effects of severe galactose-1-phosphate
uridyltransferase deficiency is depletion of which mineral?PO43 "<img
src=""7397.png"">" biochemistry disorders-of-galactose-metabolism duplicate
metabolism
When galactose-1-P is converted into glucose-1-P, what important cofactor is
required? Which enzyme regenerates this cofactor? UDP-glucose, which becomes
UDP-galactose after conversion; 4-epimerase regenerates UDP-glucose from UDP-
galactose "<img src=""7397.png"">" biochemistry disorders-of-galactose-
After galactose is converted into glucose-1-phosphate, what two key metabolic
processes can glucose-1-phosphate be allocated to? Glycolysis or glycogenesis
"<img src=""7397.png"">" biochemistry disorders-of-galactose-metabolism
A pediatrician examines a toddler with recently diagnosed galactokinase deficiency.
What milestone abnormalities might be present? Failure to track objects and
failure to develop a social smile "<img src=""7397.png"">" biochemistry
Infantile cataracts seen in disorders of galactose metabolism are due to
accumulation of galactitol. What enzyme catalyzes its production? Aldose
reductase "<img src=""7397.png"">" biochemistry disorders-of-galactose-
A newborn begins feeding and suddenly develops failure to thrive. Shortly
afterward, E coli bacteremia is diagnosed. What happened? He likely has an
undiagnosed galactosemia, which manifests when feeding with lactose begins and
predisposes neonates to E coli sepsis "<img src=""7397.png"">" biochemistry
Describe how sorbitol is involved in trapping glucose in a cell. Glucose is
converted to sorbitol, its alcohol counterpart, via aldose reductase and thus is
trapped in the cell "<img src=""7398.png"">" biochemistry duplicate
metabolism sorbitol
How is sorbitol cleared from cells in some tissues? Sorbitol dehydrogenase (found
in liver, lens [to a small extent], ovaries, and seminal vesicles) converts
sorbitol to fructose "<img src=""7398.png"">" biochemistry duplicate
metabolism sorbitol
Excess blood glucose damages the eyes, nerves, and kidneys but not other organs
such as the liver, ovaries, and seminal vesicles. Why? The retina, kidneys, and
nerves lack sorbitol dehydrogenase (sorbitol fructose), so trapped sorbitol
builds up, causing osmotic damage "<img src=""7398.png"">" biochemistry
duplicate metabolism sorbitol
A man with poorly controlled type 2 diabetes has poor vision and tingling/burning
in his feet. How may sorbitol be at fault? Chronic hyperglycemia causes
sorbitol accumulation & osmotic damage in cells lacking sorbitol dehydrogenase
(Schwann cells, retina, kidney) "<img src=""7398.png"">" biochemistry
duplicate metabolism sorbitol
Identify the cofactor(s) used by the enzymes aldose reductase and sorbitol
dehydrogenase. Aldose reductase uses NADPH, and sorbitol dehydrogenase uses NAD+
"<img src=""7398.png"">" biochemistry duplicate metabolism sorbitol
Besides sorbitol, what other sugar is also converted to its respective osmotically
active alcohol form via aldose reductase? Galactose (converted to galactitol) "<img
src=""7398.png"">" biochemistry duplicate metabolism sorbitol
Which populations tend to be lactase deficient in adulthood due to an absence of a
lactase-persistent allele? Asian, African, and Native American populations "<img
src=""7399.png"">" biochemistry duplicate lactase-deficiency metabolism
A woman has bloating, cramps, and diarrhea after consuming milk and ice cream.
Where in her GI tract is the likely enzyme deficiency found? In the brush
border (She has lactase deficiency.) "<img src=""7399.png"">" biochemistry
duplicate lactase-deficiency metabolism
What is the treatment for lactase deficiency? Lactase pills or dietary avoidance
of lactose (eg, consumption of lactose-free milk) "<img src=""7399.png"">"
biochemistry duplicate lactase-deficiency metabolism
Lactase deficiency causes what type of diarrhea when lactose is consumed?
Osmotic diarrhea due to undigested sugars that are not absorbed in the small
intestine "<img src=""7399.png"">" biochemistry duplicate lactase-deficiency
metabolism
In a pt with hereditary lactose intolerance, what would an intestinal biopsy show?
Normal mucosa "<img src=""7399.png"">" biochemistry duplicate
lactase-deficiency metabolism
A newborn is found to be lactose intolerant. What is the most likely cause? A
defective gene (a very rare cause of congenital lactose intolerance) "<img
A pt with rotavirus gastroenteritis no longer tolerates milk. Why? Which stool and
breath results would confirm the likely diagnosis? Lactose intolerance from
intestinal brush border loss can occur in gastroenteritis, resulting in lowered
stool pH, increased breath hydrogen "<img src=""7399.png"">" biochemistry
duplicate lactase-deficiency metabolism
A teenager has frequent diarrhea. His stool pH is decreased, and his breath
demonstrates increased hydrogen content. Treatment? Avoidance of dietary lactose
and/or lactase supplementation (This teenager has lactase deficiency.) "<img
Which form of amino acid is found in proteins in the human body? L-amino acids
"<img src=""7400.png"">" amino-acids biochemistry duplicate metabolism
Name nine amino acids that must be consumed in the diet. Phenylalanine, Valine,
Threonine, Tryptophan, Isoleucine, Methionine, Histidine, Leucine, Lysine (PVT TIM
HaLL) "<img src=""7400.png"">" amino-acids biochemistry duplicate metabolism
Name the two purely ketogenic amino acids. Leucine and lysine "<img
src=""7400.png"">" amino-acids biochemistry duplicate metabolism
A starving pt is able to convert certain amino acids into glucose via
gluconeogenesis. These amino acids are not ketogenic. Name them. Methionine,
valine, and histidine "<img src=""7400.png"">" amino-acids biochemistry
A 13-year-old boy grew 6 inches in the past year. Which usually nonessential amino
acids are now more essential for him? Arginine and histidine, which become more
essential during periods of rapid growth "<img src=""7400.png"">" amino-acids
Which two amino acids are increased in histones? Why? Arginine and lysine; these
basic amino acids bind to the negatively charged DNA "<img src=""7400.png"">"
amino-acids biochemistry duplicate metabolism
Name the two acidic amino acids. What is their charge at the body's pH?
Aspartic acid and glutamic acid; negative "<img src=""7400.png"">" amino-
acids biochemistry duplicate metabolism
Name the amino acids that are basic. Arginine, lysine, and histidine "<img
src=""7400.png"">" amino-acids biochemistry duplicate metabolism
Name the four essential amino acids that are both glucogenic and ketogenic.
Isoleucine, phenylalanine, threonine, and tryptophan "<img src=""7400.png"">"
Which amino acid has no charge at body pH? Histidine "<img src=""7400.png"">"
Which regions of a transmembrane protein would you expect to be rich in aspartate,
arginine, and other polar amino acids? Why? Intracellular and extracellular
domains; the lipid bilayer is hydrophobic, so transmembrane domains are rich in
nonpolar amino acids "<img src=""7400.png"">" amino-acids biochemistry
What are the two end products of the urea cycle? What are their respective fates?
Urea, which is excreted through the kidneys, and fumarate, which can enter
the TCA cycle "<img src=""7401.png"">" biochemistry duplicate metabolism
urea-cycle
What precursors are converted by argininosuccinate synthetase into
argininosuccinate? Citrulline and aspartate "<img src=""7401.png"">"
biochemistry duplicate metabolism urea-cycle
The urea cycle excretes an excess of which molecule generated by amino acid
catabolism? Nitrogen "<img src=""7401.png"">" biochemistry duplicate
metabolism urea-cycle
What is the rate-limiting step in the urea cycle, and where does it occur? Is there
a required cofactor? CO2 + NH3 to carbamoyl phosphate via carbamoyl phosphate
synthetase I; in the mitochondria; yes, & it is N-acetylglutamate "<img
src=""7401.png"">" biochemistry duplicate metabolism urea-cycle
Which are the two energy-requiring steps in the urea cycle?CO2 + NH3 to carbamoyl
phosphate via carbamoyl phosphate synthetase I (2 ATP) and aspartate + citrulline
to argininosuccinate (1 ATP) "<img src=""7401.png"">" biochemistry duplicate
In what organ does the urea cycle occur? Does the urea cycle occur in the
mitochondria, in the cytosol, or both? The liver; the urea cycle occurs in both
the mitochondria and the cytosol "<img src=""7401.png"">" biochemistry
duplicate metabolism urea-cycle
You are argininosuccinate. In the urea cycle, you react with argininosuccinase.
What happens? Is ATP required? Argininosuccinate becomes Arginine and Fumarate
(Ordinarily, Careless Crappers Are Also Frivolous About Urination); no "<img
A pt has renal failure. Although the urea cycle does not occur in the kidneys, you
still worry about nitrogen-related toxicity. Why? Excess nitrogen (NH3) is
excreted via the kidneys as urea; renal failure allows urea to build up in the
blood to a toxic level (uremia) "<img src=""7401.png"">" biochemistry
duplicate metabolism urea-cycle
You are ornithine. In the urea cycle, you react with ornithine transcarbamylase.
What happens? Is ATP required? Ornithine combines with Carbamoyl phosphate to
form Citrulline (Ordinarily, Careless Crappers Are Also Frivolous About Urination);
no "<img src=""7401.png"">" biochemistry duplicate metabolism urea-cycle
You are citrulline. In the urea cycle, you react with argininosuccinate synthetase.
What happens? Is ATP required? Citrulline combines with Aspartate to form
Argininosuccinate (Ordinarily, Careless Crappers Are Also Frivolous About
Urination); yes, 1 ATP "<img src=""7401.png"">" biochemistry duplicate
You are arginine. In the urea cycle, you react with arginase. What happens? Is ATP
required? Arginine and H2O become Urea and ornithine (Ordinarily, Careless
Crappers Are Also Frivolous About Urination); no "<img src=""7401.png"">"
Urea has two amino groups and a central carbon double-bonded to oxygen. Where did
the amino groups come from? What about the carbon/oxygen? One amino group is from
NH3, and the other is from aspartate; the carbon and oxygen are from CO2 "<img
Which enzyme(s) in the urea cycle is/are found in the mitochondria? Carbamoyl
phosphate synthetase I and ornithine transcarbamylase "<img src=""7401.png"">"
What is the fate of alanine in the liver after it donates its ammonia group to the
urea cycle? It becomes pyruvate and goes through gluconeogenesis; in muscle, it
undergoes glycolysis and is converted back to alanine (Cahill cycle) "<img
src=""7402.png"">" biochemistry duplicate metabolism transport-of-ammonia-by-
alanine-and-glutamate
How are alanine and glutamate involved in the transport of ammonium? Alanine NH3
group is transferred to glutamate in the liver then enters urea cycle (alanine
[NH3] + -KG to pyruvate + glutamate [NH3]) "<img src=""7402.png"">"
biochemistry duplicate metabolism transport-of-ammonia-by-alanine-and-
glutamate
Pyruvate cannot transfer directly from liver to muscle and vice versa. Which cycle
helps pyruvate move between these tissues? The Cori cycle; pyruvate becomes
glucose to move from liver to muscle; it becomes lactate to move from muscle to
liver. "<img src=""7402.png"">" biochemistry duplicate metabolism
transport-of-ammonia-by-alanine-and-glutamate
Identify the reaction that links the Cori cycle to the Cahill cycle and allows
ammonia to enter the Cahill cycle. The conversion of pyruvate into alanine in
muscles, reacting with glutamate (carries the ammonia, becomes -ketoglutarate)
"<img src=""7402.png"">" biochemistry duplicate metabolism transport-of-
ammonia-by-alanine-and-glutamate
How is excess NH3 in muscles transferred to the Cahill cycle for urea cycle
processing in the liver? -Ketoglutarate reacts w/amino acids to form
glutamate and -ketoacids; glutamate reacts w/pyruvate to form -ketoglutarate and
alanine "<img src=""7402.png"">" biochemistry duplicate metabolism
transport-of-ammonia-by-alanine-and-glutamate
A muscle excretes a single unit of NH3. Trace its path from an amino acid in the
muscle to urea in the liver. Amino acid (muscle) to glutamate (muscle) to alanine
(muscle) to alanine (liver) to glutamate (liver) to urea (liver) "<img
src=""7402.png"">" biochemistry duplicate metabolism transport-of-ammonia-by-
alanine-and-glutamate
An experimental drug blocks the conversion of alanine to pyruvate. What happens to
gluconeogenesis activity as a result? It will decrease, because there is less
pyruvate available to be converted into glucose "<img src=""7402.png"">"
biochemistry duplicate metabolism transport-of-ammonia-by-alanine-and-
glutamate
A pt has had liver failure for years. Would you expect his ammonia level to be high
or low? High "<img src=""7403.png"">" biochemistry duplicate
hyperammonemia metabolism
A pt has urea cycle enzyme deficiencies. Would you expect his ammonia level to be
high or low? High "<img src=""7403.png"">" biochemistry duplicate
In hyperammonemia, how does the presence of excess ammonia result in inhibition of
the TCA cycle? Excess ammonia depletes -ketoglutarate "<img src=""7403.png"">"
biochemistry duplicate hyperammonemia metabolism
A 40-year-old alcoholic woman develops slurred speech and asterixis. What is the
best long-term management? Limit protein in the diet "<img src=""7403.png"">"
biochemistry duplicate hyperammonemia metabolism
A 40-year-old alcoholic woman exhibits slurred speech and asterixis. What can be
given to reduce ammonia levels by increasing its excretion?Lactulose (acidifies GI
tract/traps NH4+) and benzoate or phenylacetate (binds to NH4+) (She has
hyperammonemia.) "<img src=""7403.png"">" biochemistry duplicate
A 40-year-old alcoholic woman exhibits slurred speech and asterixis. She is given
rifaximin. How does this help decrease her symptoms? It reduces colonic
ammoniagenic bacteria (She has hyperammonemia from liver toxicity.) "<img
src=""7403.png"">" biochemistry duplicate hyperammonemia metabolism
Why does a deficiency of N-acetylglutamate lead to hyperammonemia? N-
acetylglutamate is a required cofactor for carbamoyl phosphate synthetase I, and
its deficiency inhibits the urea cycle "<img src=""7404.png"">" biochemistry
duplicate metabolism n-acetylglutamate-deficiency
A baby has poor respiration/temperature regulation, poor feeding, and developmental
delay. Name two possible urea cyclerelated diagnoses. N-acetylglutamate
deficiency or carbamoyl phosphate synthetase I deficiency (The two present
similarly.) "<img src=""7404.png"">" biochemistry duplicate metabolism n-
acetylglutamate-deficiency
Ornithine transcarbamylase deficiency interferes with the body's ability to do
what? Eliminate ammonia "<img src=""7405.png"">" biochemistry duplicate
metabolism ornithine-transcarbamylase-deficiency
You see a pt with a urea cycle enzyme deficiency but rule out ornithine
transcarbamylase deficiency. What is the inheritance pattern? Autosomal
recessive (All urea cycle enzyme deficiencies except ornithine transcarbamylase
deficiency have this inheritance pattern.) "<img src=""7405.png"">"
biochemistry duplicate metabolism ornithine-transcarbamylase-deficiency
A lethargic neonate with a low BUN is found to have the most common urea cycle
disorder. What substance do you find increased in his blood? Orotic acid
(created by excess carbamoyl phosphate) "<img src=""7405.png"">" biochemistry
duplicate metabolism ornithine-transcarbamylase-deficiency
When would you most likely detect an ornithine transcarbamylase deficiency in a pt?
Typically, this is evident in the first days of life, but onset may be later
"<img src=""7405.png"">" biochemistry duplicate metabolism ornithine-
transcarbamylase-deficiency
A pt with hyperammonemia has decreased ornithine transcarbamylase activity. Do you
expect any form of anemia on a routine blood smear? No, as ornithine
transcarbamylase deficiency is not associated with megaloblastic anemia, unlike the
closely related orotic aciduria "<img src=""7405.png"">" biochemistry
duplicate metabolism ornithine-transcarbamylase-deficiency
Arginine can be converted into which three derivatives? Which one requires BH4?
Creatinine, urea, and nitric oxide; nitric oxide requires BH4 "<img
src=""7406.png"">" amino-acid-derivatives biochemistry duplicate metabolism
A pt has a deficiency of vitamin B6. Will his body's processing of glutamate be
changed? Will any glutamate reactions be unaffected? Yes, the conversion of
glutamate to GABA requires vitamin B6; yes, the conversion of glutamate to
glutathione is unaffected "<img src=""7406.png"">" amino-acid-derivatives
How is heme produced from amino acids? Describe the reaction in detail.
Glycine is converted to porphyrin (requires vitamin B6), after which
porphyrin is converted into heme "<img src=""7406.png"">" amino-acid-
derivatives biochemistry duplicate metabolism
A pt has severe allergies. A high level of histamine is to blame. Which amino acid
and vitamin produce all of this histamine? The amino acid histidine (with the
help of vitamin B6) is the precursor to histamine production "<img
A man eats a large serving of tryptophan-rich turkey on Thanksgiving. He falls
asleep soon after. What happened? The tryptophan was converted into serotonin
(via vitamin B6 and BH4); the serotonin was then converted into melatonin "<img
The nicotinamides (NAD+ and NADP+) are derived from an amino acid. Which one? Are
any cofactors involved? They are derived from tryptophan; yes, vitamins B2 and B6
are required cofactors "<img src=""7406.png"">" amino-acid-derivatives
Phenylalanine is converted into dopamine via the intermediate products tyrosine and
dopa. All three products have fates. What are they? Tyrosine becomes thyroxine,
dopa becomes melanin, and dopamine enters the catecholamine synthesis pathway
(norepinephrine and epinephrine) "<img src=""7406.png"">" amino-acid-
derivatives biochemistry duplicate metabolism
Phenylalanine to tyrosine to dopa to dopamine to norepinephrine to epinephrine.
Each reaction step requires a cofactor. Identify each one. Phenylalanine to
tyrosine: BH4; tyrosine to dopa: BH4; dopa to dopamine: B6; dopamine to NE: vitamin
C; NE to epinephrine: SAM "<img src=""7406.png"">" amino-acid-derivatives
A pt with scurvy is noted to have a slightly reduced blood pressure. What
biochemical anomaly might explain this finding? Decreased catecholamine synthesis
due to vitamin C deficiency (Vitamin C is required to convert dopamine into
norepinephrine.) "<img src=""7406.png"">" amino-acid-derivatives biochemistry
What enzyme catalyzes the breakdown of norepinephrine to normetanephrine?
Catechol-O-methyltransferase (COMT) "<img src=""7407.png"">" biochemistry
catecholamine-synthesis/tyrosine-catabolism duplicate metabolism
What waste product is dopamine broken down into for excretion? Homovanillic acid
(HVA) "<img src=""7407.png"">" biochemistry catecholamine-synthesis/tyrosine-
catabolism duplicate metabolism
A pt cannot convert tyrosine into homogentisic acid. A below-normal level of which
TCA cycle intermediate would confirm this deficiency? Fumarate (tyrosine
homogentisic acid maleylacetoacetic acid fumarate TCA cycle) "<img
src=""7407.png"">" biochemistry catecholamine-synthesis/tyrosine-catabolism
A pt with Cushing disease has hypertension. The serum metanephrine level is
elevated. What causes this abnormal finding? Cortisol promotes
phenylethanolamine-N-methyltransferase (norepinephrine epinephrine); epinephrine
breaks down into metanephrine "<img src=""7407.png"">" biochemistry
Which three reactions in the catecholamine synthesis pathway, starting with DOPA,
require cofactors? What are they? DOPA to dopamine requires B6; dopamine to
norepinephrine requires vitamin C; norepinephrine to epinephrine requires SAM
"<img src=""7407.png"">" biochemistry catecholamine-synthesis/tyrosine-
A pt with Parkinson disease is prescribed a medication to decrease the peripheral
breakdown of levodopa. What enzyme does this drug inhibit? DOPA decarboxylase (The
pt is prescribed carbidopa along with levodopa.) "<img src=""7407.png"">"
biochemistry catecholamine-synthesis/tyrosine-catabolism duplicate metabolism
Which two reactions in catecholamine synthesis require BH4?Phenylalanine
hydroxylase (phenylalanine to tyrosine) and tyrosine hydroxylase (tyrosine to DOPA)
"<img src=""7407.png"">" biochemistry catecholamine-synthesis/tyrosine-
A pt presents with albinism. The melanin level is abnormally low. Which enzyme is
likely deficient or defective? Tyrosinase, which converts DOPA
(dihydroxyphenylalanine) into melanin "<img src=""7407.png"">" biochemistry
In alkaptonuria, which pathway is defective? What reaction is blocked by the
disease's hallmark enzyme deficiency? The breakdown of tyrosine for use in the
TCA cycle; conversion of homogentisic acid to maleylacetoacetic acid by
homogentisate oxidase "<img src=""7407.png"">" biochemistry catecholamine-
synthesis/tyrosine-catabolism duplicate metabolism
A newborn is found to have phenylketonuria. Dietary phenylalanine must be
restricted. Why? Phenylalanine hydroxylase does not function, so phenylalanine
cannot be converted into tyrosine and builds up (leading to toxicity) "<img
src=""7407.png"">" biochemistry catecholamine-synthesis/tyrosine-catabolism
A baby with phenylketonuria has normal phenylalanine hydroxylase activity, but
dopamine levels are abnormally low. What might be the cause? There may be a
defect in tetrahydrobiopterin (BH4), needed to convert phenylalanine to tyrosine
and tyrosine to DOPA "<img src=""7407.png"">" biochemistry catecholamine-
In pheochromocytoma, norepinephrine and epinephrine levels are high. It is
diagnosed by measuring their breakdown products. Name them.For norepinephrine,
normetanephrine and vanillylmandelic acid; for epinephrine, metanephrine and
vanillylmandelic acid "<img src=""7407.png"">" biochemistry catecholamine-
What cofactor is required for the conversion of dopamine to norepinephrine?
Vitamin C "<img src=""7407.png"">" biochemistry catecholamine-
Phenylketonuria exhibits what pattern of inheritance? And what is the incidence
rate? Autosomal recessive; 1:10,000 "<img src=""7408.png"">" biochemistry
duplicate metabolism phenylketonuria
Which amino acid, usually nonessential, is essential in pts with phenylketonuria?
Tyrosine "<img src=""7408.png"">" biochemistry duplicate metabolism
phenylketonuria
A short 4-year-old boy (who never had newborn screening) has developmental delay,
seizures, fair skin, and musty body odor. Treatment? Decreased dietary
phenylalanine (found in aspartame), increased dietary tyrosine and
tetrahydrobiopterin supplementation "<img src=""7408.png"">" biochemistry
A woman with phenylketonuria (PKU) learns she is pregnant. What is her baby at risk
for if she does not adhere to a phenylketonuric diet? Infants of mothers with
uncontrolled PKU are at risk for microcephaly, mental retardation, growth
retardation, and congenital heart defects "<img src=""7408.png"">" biochemistry
All newborns are screened for phenylketonuria at 2 to 3 days of age. Why not
earlier? The test result is always normal at birth, because the maternal enzymes
are present during fetal life "<img src=""7408.png"">" biochemistry duplicate
metabolism phenylketonuria
A pt with phenylketonuria is told he should avoid most artificial sweeteners. Why?
He has to avoid phenylalanine, which is found in aspartame (an ingredient in
many artificial sweeteners) "<img src=""7408.png"">" biochemistry duplicate
A pt with a disorder in aromatic amino acid metabolism presents with a musty body
odor. What disease does he most likely have? Phenylketonuria "<img
src=""7408.png"">" biochemistry duplicate metabolism phenylketonuria
A newborn with PKU has decreased tetrahydrobiopterin cofactor. Compared with
phenylalanine hydroxylase deficiency, what is the prognosis? Worse, as PKU due
to tetrahydrobiopterin cofactor deficiency is considered more malignant "<img
src=""7408.png"">" biochemistry duplicate metabolism phenylketonuria
A 3-day-old infant has high urinary phenylacetate, phenyllactate, and
phenylpyruvate levels. Name two possible enzyme defects. Decreased phenylalanine
hydroxylase activity or decreased tetrahydrobiopterin cofactor activity (The infant
has phenylketonuria.) "<img src=""7408.png"">" biochemistry duplicate
A newborn with phenylketonuria has a musty body odor. What is causing this? The
breakdown products of phenylalanine accumulate in the sweat (This disorder of
aromatic amino acid metabolism causes a musty body odor.) "<img src=""7408.png"">"
biochemistry duplicate metabolism phenylketonuria
A young boy has CNS defects and intellectual deficiency. -Ketoacid dehydrogenase
activity is low. Which amino acids cannot be degraded? Branched-chain amino
acidsIsoleucine, Leucine, and Valine: I Love Vermont maple syrup. (He has maple
syrup urine disease.) "<img src=""7409.png"">" biochemistry duplicate maple-
syrup-urine-disease metabolism
You see an infant with an enzyme deficiency and sweet-smelling urine. What is the
most likely inheritance pattern? Autosomal recessive (This is maple syrup urine
disease.) "<img src=""7409.png"">" biochemistry duplicate maple-syrup-urine-
disease metabolism
An infant is given a vitamin to treat her maple syrup urine disease. Which vitamin
was given and why? How else can you treat this condition? Thiamine; it is a
cofactor for the deficient enzyme -ketoacid dehydrogenase; can also restrict
leucine, isoleucine, and valine in the diet "<img src=""7409.png"">"
biochemistry duplicate maple-syrup-urine-disease metabolism
A neonate presents with vomiting, poor feeding, and urine that smells like burnt
sugar. What might be present in high levels in the blood? -Ketoacids, especially
those derived from leucine (This is maple syrup urine disease.) "<img
src=""7409.png"">" biochemistry duplicate maple-syrup-urine-disease metabolism
The enzyme deficient in maple syrup urine disease is dependent on which B vitamin
to function? Thiamine (B1); maple trees have B1ranches "<img src=""7409.png"">"
biochemistry duplicate maple-syrup-urine-disease metabolism
A pt submits a urine sample for routine urinalysis. The urine turns black on
standing. What is your treatment? None, as alkaptonuria is a benign condition
"<img src=""7410.png"">" alkaptonuria biochemistry duplicate metabolism
A 10-year-old pt has a benign enzyme deficiency (autosomal recessive) affecting the
degradation of tyrosine. What findings may you see? Dark connective tissues,
brown pigmented sclera, urine that turns black when exposed to air, and arthralgias
(He has alkaptonuria.) "<img src=""7410.png"">" alkaptonuria biochemistry
A 20-year-old pt with alkaptonuria has persistent joint pain. What is the
pathophysiology of this pain? Deficiency of homogentisate oxidase causes buildup of
homogentisic acid, which is toxic to cartilage and can thus lead to arthralgias
"<img src=""7410.png"">" alkaptonuria biochemistry duplicate metabolism
A pt has elevated urine homocysteine. Risks for stroke and MI are increased. What
are the three possible causes of his homocystinuria? Low cystathionine synthase,
cystathionine synthase affinity for pyridoxal phosphate, or methionine synthase
(homocysteine methyltransferase) "<img src=""7411.png"">" biochemistry
duplicate homocystinuria metabolism
Which amino acid, usually nonessential, becomes essential in pts with
homocystinuria? Cysteine "<img src=""7411.png"">" biochemistry duplicate
homocystinuria metabolism
A pt has homocystinuria caused by a decreased affinity of cystathionine synthase
for pyridoxal phosphate. How do you treat him? Increased dietary cysteine and
greatly increased dietary vitamin B6 "<img src=""7411.png"">" biochemistry
A newborn is diagnosed with cystathionine synthase deficiency. If left untreated,
what findings would develop? Elevated urine homocysteine, mental retardation,
osteoporosis, tall build, kyphosis, lens subluxation (down/in), thrombosis,
atherosclerosis "<img src=""7411.png"">" biochemistry duplicate
What enzyme converts homocysteine to methionine? What cofactor is needed for the
reaction to occur? Methionine synthase; vitamin B12 "<img src=""7411.png"">"
biochemistry duplicate homocystinuria metabolism
What enzyme converts homocysteine to cystathionine? What cofactor is needed for the
reaction to occur? Cystathionine synthase; vitamin B6 "<img src=""7411.png"">"
What are the inheritance patterns for the most common forms of homocystinuria?
All are autosomal recessive "<img src=""7411.png"">" biochemistry
A pt who had gastric bypass surgery presents with megaloblastic anemia and
peripheral neuropathy. Why is her serum homocysteine elevated? B12 is the
cofactor for homocysteine methyltransferase, which converts homocysteine to
methionine (B12 absorption was affected by surgery.) "<img src=""7411.png"">"
A marfanoid boy with osteoporosis and kyphosis takes methionine for methionine
synthase deficiency. In what direction are his eyes subluxed? Downward and
inward (He has homocystinuria.) "<img src=""7411.png"">" biochemistry
A pt has excess homocysteine. A defect is found in cystathione synthase. What is
the treatment? Increase cysteine, vitamin B12, and folate intake; decrease
methionine intake "<img src=""7411.png"">" biochemistry duplicate
A pt has excess homocysteine. A defect is found in methionine synthase. What is the
treatment? Increase methionine in the diet "<img src=""7411.png"">"
Which amino acids does the amino acid transporter affected in cystinuria usually
transport? Where is it located? Cysteine, Ornithine, Lysine, and Arginine
(COLA); it is found in the proximal convoluted tubules in the kidneys and in the
intestines "<img src=""7412.png"">" biochemistry cystinuria duplicate
metabolism
A 30-year-old woman with a renal tubular amino acid transporter defect has a
precipitation of urinary cystine stones. What is the treatment? Hydration, urinary
alkalinization (eg, potassium citrate, acetazolamide), and chelation with agents
that increase stone solubility "<img src=""7412.png"">" biochemistry
cystinuria duplicate metabolism
You analyze the kidney stones passed by a pt with cystinuria who presented with
severe pain. What do you see? The stones you see are made of two cysteines
connected by a disulfide bond "<img src=""7412.png"">" biochemistry cystinuria
What is the prevalence of cystinuria? 1:7000 (It is common.) "<img
src=""7412.png"">" biochemistry cystinuria duplicate metabolism
What is the inheritance pattern of cystinuria? Autosomal recessive "<img
src=""7412.png"">" biochemistry cystinuria duplicate metabolism
A man has a history of recurring kidney stones. Urine microscopy shows hexagonal
crystals. What diagnostic test would you order? A urinary cyanide-nitroprusside
test (This is cystinuria.) "<img src=""7412.png"">" biochemistry cystinuria
What two factors in muscle, by activating glycogen phosphorylase kinase, ensure
that glycogenolysis is coordinated with muscle activity? Calcium and calmodulin
"<img src=""7413.png"">" biochemistry duplicate glycogen-regulation-by-
insulin-and-glucagon/epinephrine metabolism
Glycogen is made from glucose by what enzyme? Glucose is made from glycogen by what
enzyme? Glycogen synthase; glycogen phosphorylase "<img src=""7413.png"">"
biochemistry duplicate glycogen-regulation-by-insulin-and-
glucagon/epinephrine metabolism
What receptor does insulin bind to in liver and muscle cells? Which enzyme does it
directly stimulate to promote glycogen synthesis? Tyrosine kinase dimer
receptor; insulin directly stimulates glycogen synthase to promote glycogen
synthesis from glucose "<img src=""7413.png"">" biochemistry duplicate
glycogen-regulation-by-insulin-and-glucagon/epinephrine metabolism
A pt under stress releases epinephrine, which binds to -receptors. How does this
help muscles contract more effectively? Calcium exits the endoplasmic reticulum,
inducing glycogen phosphorylase kinase (for glucose) and calcium-calmodulin (helps
w/contractions) "<img src=""7413.png"">" biochemistry duplicate glycogen-
regulation-by-insulin-and-glucagon/epinephrine metabolism
Calcium and the calcium-calmodulin complex both stimulate the conversion of
glycogen to glucose. Biochemically, how does this occur? Both induce glycogen
phosphorylase kinase, which in turn activates glycogen phosphorylase to break down
more glycogen into glucose "<img src=""7413.png"">" biochemistry duplicate
Glucagon stimulates the breakdown of glycogen. Where does it act? Which second
messenger system does it use? Glucagon acts solely on the liver; it acts via a cAMP
second messenger system (creates cAMP from ATP via adenylate cyclase) "<img
src=""7413.png"">" biochemistry duplicate glycogen-regulation-by-insulin-and-
A fasting man needs to break down glycogen; cAMP levels rise in liver cells to
signal this. How does cAMP act to induce more glycogenolysis? cAMP induces
protein kinase A, which induces glycogen phosphorylase kinase, which induces
glycogen phosphorylase to promote glycogenolysis "<img src=""7413.png"">"
Epinephrine can encourage glycogen breakdown by way of two pathways. What are they?
Via -receptors (which stimulate ER release of calcium) or -receptors (which
act via the cAMP second messenger system) "<img src=""7413.png"">" biochemistry
duplicate glycogen-regulation-by-insulin-and-glucagon/epinephrine metabolism
A man receives an &945;-blocker and epinephrine. Glycogen breakdown increases
significantly, but muscle contractility only increases mildly. Why? -Receptor
binding (blocked) promotes both muscle contraction and glycogenolysis; -receptor
binding (open) only promotes glycogenolysis "<img src=""7413.png"">"
Via what two pathways does an activated insulin receptor trigger glycogenesis?
Direct glycogen synthase stimulation and indirect stimulation via protein
phosphatase activation "<img src=""7413.png"">" biochemistry duplicate
What type of bond is found at glycogen branch points? What type of bond is found at
side-by-side linkages of glucose in glycogen? An -1,6 bond; an -1,4 bond "<img
src=""7414.png"">" biochemistry duplicate glycogen metabolism
A pt is exercising heavily. He needs to tap stores of glycogen. In what organ does
glycogen undergo rapid glycogenolysis? Skeletal muscle "<img src=""7414.png"">"
biochemistry duplicate glycogen metabolism
In which organ do both glycogen storage and glycogenolysis occur to maintain
appropriate blood sugar levels? The liver "<img src=""7414.png"">"
A baby has defects in both debranching enzyme and glycogen phosphorylase.
Nonetheless, small amounts of glycogen are still broken down. Why? A small
amount of glycogen is broken down by lysosomes, via -1,4-glucosidase (acid
maltase) "<img src=""7414.png"">" biochemistry duplicate glycogen
metabolism
What molecule is the end product of glycogenolysis? Glucose-6-phosphate "<img
src=""7414.png"">" biochemistry duplicate glycogen metabolism
What must occur for the glucose-1-phosphate produced during glycogenolysis to be
converted to glucose? Glucose-1-phosphate must be converted to glucose-6-
phosphate, which can then be converted to glucose "<img src=""7414.png"">"
What is a limit dextrin? It is one to four residues remaining on a glycogen
branch after glycogen phosphorylase has shortened it "<img src=""7414.png"">"
Glycogen phosphorylase breaks down glycogen. What is the product of a single
reaction? Glucose-1-phosphate "<img src=""7414.png"">" biochemistry
duplicate glycogen metabolism
A glycogen molecule branch undergoing glycogenolysis only has limit dextrins
remaining. What happens next? 4--D-Glucanotransferase (a debranching enzyme) moves
3 of the 4 remaining limit dextrins (glucose-1-Ps) from the branch to the linkage
"<img src=""7414.png"">" biochemistry duplicate glycogen metabolism
4--D-Glucanotransferase has had its fun with a branch containing only limit
dextrins. What happens next? -1,6-Glucosidase (a debranching enzyme) cleaves off
the last remaining limit dextrin (glucose-1-P) from the linkage; the branch is now
gone "<img src=""7414.png"">" biochemistry duplicate glycogen metabolism
Most of the glucose released from glycogenolysis is in the form of glucose-1-P, but
a small amount of free glucose is still produced. How? Cleavage of the last
residue of limit dextrin by -1,6-glucosidase (a debranching enzyme) yields free
glucose "<img src=""7414.png"">" biochemistry duplicate glycogen
metabolism
How many glycogen storage diseases are there? What do they all have in common?
Twelve; abnormal glycogen metabolism, which causes glycogen to accumulate in
cells (Many types are also autosomal recessive.) "<img src=""7415.png"">"
biochemistry duplicate glycogen-storage-diseases metabolism
A 4-year-old boy with a known glycogen storage disease has cardiomegaly. What is
his prognosis? His prognosis is poor, as he has Pompe disease (type II);
cardiomyopathy and liver/skeletal muscle damage can cause early death "<img
src=""7415.png"">" biochemistry duplicate glycogen-storage-diseases metabolism
A newborn is deficient in -1,6-glucosidase. This deficiency is most similar to
what glycogen storage disease? How is it different? Von Gierke disease (type I):
The newborn has a milder formCori disease (type III); gluconeogenesis is intact
and blood lactate is normal "<img src=""7415.png"">" biochemistry duplicate
glycogen-storage-diseases metabolism
A boy has painful muscle cramps & red urine after exercise. What genetic defect is
likely to blame? McArdle disease (type V) is due to a deficiency of glycogen
phosphorylase in skeletal Muscle "<img src=""7415.png"">" biochemistry
duplicate glycogen-storage-diseases metabolism
A boy has painful muscle cramps & red urine after walking several blocks. What
would you expect to see on muscle biopsy & in his urine? In McArdle disease (type
V), skeletal Muscle; biopsy shows increased glycogen & the urine has myoglobin
"<img src=""7415.png"">" biochemistry duplicate glycogen-storage-
diseases metabolism
What is another name for lysosomal -1,4-glucosidase? Acid maltase "<img
A man has severe fasting hypoglycemia, high blood lactate, and hepatomegaly. He has
a glycogen storage disease. What enzyme does he lack? Glucose-6-phosphatase (This
is Von Gierke disease.) "<img src=""7415.png"">" biochemistry duplicate
What is another name for -1,6-glucosidase? Debranching enzyme "<img
A pt lacks myophosphorylase. Is this disease process autosomal recessive, autosomal
dominant, X-linked recessive, or X-linked dominant? Autosomal recessive, because
this pt has McArdle disease (type V) "<img src=""7415.png"">" biochemistry
A pt with hepatomegaly is informed he lacks glucose-6-phosphatase. What is the
treatment for his condition? Frequent consumption of glucose and cornstarch and
avoidance of fructose and galactose (He has Von Gierke disease.) "<img
A pt with Pompe disease has a grim prognosis. Which three organ systems are most
likely to be affected? Heart, liver, and muscle (Pompe trashes the Pump.) "<img
A boy with myophosphorylase deficiency has ventricular tachycardia during exercise.
He also has red urine and muscle cramps. What happened? McArdle disease (type V)
predisposes to electrolyte abnormalities, which can cause arrhythmias, and urine is
red because of myoglobinuria "<img src=""7415.png"">" biochemistry duplicate
Identify the four most important metabolic storage diseases. What useful mnemonic
can help you remember them? Von Gierke disease (type I), Pompe disease (type II),
Cori disease (type III), McArdle disease (type V); Very Poor Carbohydrate
Metabolism "<img src=""7415.png"">" biochemistry duplicate glycogen-storage-
diseases metabolism
What stain can be used to identify glycogen storage diseases? Periodic acid
Schiff stain "<img src=""7415.png"">" biochemistry duplicate glycogen-
storage-diseases metabolism
A pt is found to have limit dextrinlike structures in the cytosol of his cells.
Which glycogen storage disease would you suspect? Cori disease (type III) "<img
A child presents with cardiomegaly, hypertrophic cardiomyopathy, and exercise
intolerance. Which enzyme is likely deficient in this pt? Lysosomal -1,4-
glucosidase with -1,6-glucosidase activity (acid maltase) (This is Pompe disease.)
"<img src=""7415.png"">" biochemistry duplicate glycogen-storage-
diseases metabolism
A man has painful muscle cramps with intense exercise and reports a second-wind
phenomenon. What would blood sugar testing show? His blood glucose levels
should be normal; this is McArdle disease "<img src=""7415.png"">" biochemistry
A pt with Von Gierke disease presents with fasting hypoglycemia. What other changes
might be seen in her blood work? Increased blood lactate, triglyceride, and uric
acid levels "<img src=""7415.png"">" biochemistry duplicate glycogen-storage-
diseases metabolism
What is the second-wind phenomenon seen in pts with McArdle disease? After
profound weakness, it is a sudden boost of energy arising due to drastically
increased muscular blood flow "<img src=""7415.png"">" biochemistry duplicate
In general, what is the defect seen in the various lysosomal storage diseases? What
happens as a consequence? Each one is due to a deficiency in one of the many
lysosomal enzymes; abnormal metabolic products accumulate, causing disease "<img
src=""7416.png"">" biochemistry duplicate lysosomal-storage-diseases
metabolism
A pt has developmental delay, gargoylism, airway narrowing, and corneal clouding.
Name the deficient enzyme and accumulated substrate(s). -L-Iduronidase is the
deficient enzyme, and heparan sulfate and dermatan sulfate are accumulated. (The pt
has Hurler syndrome.) "<img src=""7416.png"">" biochemistry duplicate
lysosomal-storage-diseases metabolism
A pt has peripheral neuropathy, developmental delay, optic atrophy, and globoid
cells. Name the deficient enzyme(s) and excess substrate(s).
Galactocerebrosidase is the deficient enzyme, and galactocerebroside and
psychosine accumulate. (The pt has Krabbe disease.) "<img src=""7416.png"">"
biochemistry duplicate lysosomal-storage-diseases metabolism
A pt is diagnosed with Niemann-Pick disease. What are the deficient enzyme,
accumulated substrate, and inheritance pattern? Sphingomyelinase, sphingomyelin (no
man picks [Niemann-Pick] his nose with his sphinger), and autosomal recessive
"<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
A man has hepatosplenomegaly, pancytopenia, a history of aseptic femur necrosis,
and recurrent bone crises. What does a blood smear show? Macrophages that look
like crumpled tissue paper, or Gaucher cells. (The man has Gaucher disease.) "<img
metabolism
A pt is diagnosed with Gaucher disease. Name the deficient enzyme, accumulated
substrate, and inheritance pattern. How common is it? Glucocerebrosidase (-
glucosidase), glucocerebroside, and autosomal recessive; it is the most common of
the lysosomal storage diseases "<img src=""7416.png"">" biochemistry
duplicate lysosomal-storage-diseases metabolism
A boy has neurodegeneration, cherry-red macula, onion skin lysosomes, and a normal
liver. Name the deficient enzyme and excess substrate. Hexosaminidase A is the
deficient enzyme, and GM2 ganglioside is the excess substrate. (He has Tay-Sachs
disease.) "<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
A pt has mild symptoms similar to those of Hurler syndrome but no corneal clouding.
What behavior is expected? Aggression; this is Hunter syndrome, an X-linked
recessive mucopolysaccharidosis. (Hunters see clearly and aggressively aim for the
X.) "<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
Name the lysosomal storage disorders for which Ashkenazi Jews have an increased
risk. Tay-Sachs, Niemann-Pick, and some forms of Gaucher disease "<img
metabolism
A boy has central & peripheral demyelination with ataxia & dementia. Name the
deficient enzyme, accumulated substrate, & inheritance pattern. Arylsulfatase A,
cerebroside sulfate, and autosomal recessive (He has metachromatic leukodystrophy.)
"<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
Name the lysosomal storage diseases that may present with a cherry-red spot on the
macula. Niemann-Pick disease and Tay-Sachs disease "<img src=""7416.png"">"
A 2-year-old boy is diagnosed with Hunter syndrome. Name the deficient enzyme,
accumulated substrate(s), and inheritance pattern. Iduronate sulfatase, heparan
sulfate and dermatan sulfate, and X-linked recessive "<img src=""7416.png"">"
Name the inheritance pattern of each of the following lysosomal storage diseases:
Tay-Sachs, Krabbe, Hurler. All are autosomal recessive "<img src=""7416.png"">"
Hurler syndrome is due to what enzyme deficiency? What substances accumulate as a
result? -L-Iduronidase deficiency; heparan sulfate and dermatan sulfate
accumulate "<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
Hunter syndrome is due to what enzyme deficiency? What substances accumulate as a
result? Iduronate sulfatase deficiency; heparan sulfate and dermatan sulfate
accumulate "<img src=""7416.png"">" biochemistry duplicate lysosomal-storage-
diseases metabolism
A boy has ataxia and dementia. Tests show that cerebroside sulfate is accumulating.
What disease does he have, and what enzyme does he lack? He has metachromatic
leukodystrophy and lacks arylsulfatase A "<img src=""7416.png"">" biochemistry
duplicate lysosomal-storage-diseases metabolism
Which two lysosomal storage diseases have an X-linked recessive inheritance
pattern? Fabry disease and Hunter syndrome "<img src=""7416.png"">"
"Where does fatty acid synthesis occur in the cell? By which biochemical
""shuttle"" do the building blocks get there?" In the cell cytoplasm; via the
citrate shuttle (SYtrate [citrate] = SYnthesis) "<img src=""7417.png"">"
biochemistry duplicate fatty-acid-metabolism metabolism
Where does fatty acid degradation occur? Where are the products of degradation
consumed? Both fatty acid degradation and the consumption of the degradation
products occur in the mitochondria "<img src=""7417.png"">" biochemistry
duplicate fatty-acid-metabolism metabolism
A malnourished pt has a biotin deficiency. Which step of fatty acid synthesis is
most likely impaired? The conversion of acetyl-CoA to malonyl-CoA, which requires
biotin (Biotin donates a necessary CO2 group.) "<img src=""7417.png"">"
biochemistry duplicate fatty-acid-metabolism metabolism
A pt with an enzyme deficiency has weakness, hypotonia, and hypoketotic
hypoglycemia. What is the pathophysiology of these symptoms? Systemic primary
carnitine deficiency inhibits transport of long-chain fatty acids (LCFAs) into
mitochondria, causing toxic accumulation "<img src=""7417.png"">" biochemistry
In fatty acid synthesis, what is the main fatty acid produced? It has a total of
how many carbon atoms? Palmitate; 16 "<img src=""7417.png"">" biochemistry
A fasting pt's fatty acids begin to be broken down. What is the first reaction that
a fatty acid undergoes? Where does this occur? The fatty acid combines with CoA to
form fatty acyl-CoA via fatty acid CoA synthetase; this occurs in the cytoplasm
"<img src=""7417.png"">" biochemistry duplicate fatty-acid-metabolism
metabolism
Fatty acyl-CoA must enter mitochondria to be degraded. Via what biochemical shuttle
does it get there? Does anything inhibit this shuttle? Via the carnitine
shuttle (CARnitine = CARnage of fatty acids); yes, it is inhibited by malonyl-CoA
metabolism
Name the process that fatty acyl-CoA undergoes in a mitochondrion to be converted
into acyl-CoA. What is the newly made acyl-CoA used for? -Oxidation via acyl-CoA
dehydrogenases; it may enter the TCA cycle or be converted into ketone bodies
metabolism
Where does fatty acid synthesis predominantly occur in the body? It predominantly
occurs in the liver, lactating mammary glands, and adipose tissue "<img
src=""7417.png"">" biochemistry duplicate fatty-acid-metabolism metabolism
A toddler has lethargy and seizures; 8- to 10-carbon fatty acyl carnitines are
found in blood. What is his condition's inheritance pattern? Autosomal
recessive, as he has medium-chain acyl-CoA dehydrogenase deficiency "<img
src=""7418.png"">" biochemistry duplicate medium-chain-acyl-coa-dehydrogenase-
deficiency metabolism
A boy with medium-chain acyl-CoA dehydrogenase deficiency fasts, contracts
pneumonia, and dies 1 day later. Are his liver labs normal?No; medium-chain acyl-
CoA dehydrogenase deficiency can cause liver dysfunction, so the labs are likely
abnormal "<img src=""7418.png"">" biochemistry duplicate medium-chain-acyl-
coa-dehydrogenase-deficiency metabolism
What is the primary enzymatic defect in medium-chain acyl-CoA dehydrogenase
deficiency? Fatty acids cannot be broken down into acetyl-CoA (8- to 10-carbon
fatty acyl carnitines build up) "<img src=""7418.png"">" biochemistry
duplicate medium-chain-acyl-coa-dehydrogenase-deficiency metabolism
What is the treatment for medium-chain acyl-CoA dehydrogenase deficiency?
Avoidance of fasting "<img src=""7418.png"">" biochemistry duplicate
medium-chain-acyl-coa-dehydrogenase-deficiency metabolism
Name three ketone bodies found in pts with prolonged starvation or diabetic
ketoacidosis. Which does not appear on a standard urinalysis? Acetone,
acetoacetate, and -hydroxybutyrate; -hydroxybutyrate is not detected by the
standard urine test for ketones "<img src=""7419.png"">" biochemistry
duplicate ketone-bodies metabolism
A pt with a history of alcoholism has ketones in his urine. Why? In alcoholism,
excess NADH shunts oxaloacetate to malate, causing acetyl-CoA to build up and
promoting ketone production "<img src=""7419.png"">" biochemistry duplicate
ketone-bodies metabolism
An 18-year-old man with type 1 diabetes refuses insulin for a full day, and fruity-
smelling breath and urine ketones develop. Why? DKA depletes oxaloacetate (for
gluconeogenesis), causing acetyl-CoA buildup and shunting glucose/free fatty acids
to ketone production "<img src=""7419.png"">" biochemistry duplicate
In which organs are fatty acids and amino acids metabolized to acetoacetate and -
hydroxybutyrate? Where are these ketones used for energy? The liver; they are used
in muscle and brain "<img src=""7419.png"">" biochemistry duplicate
What are the main priorities of the human body in terms of metabolism and fuel use?
To supply glucose to the brain and red blood cells and to preserve protein
"<img src=""7420.png"">" biochemistry duplicate metabolic-fuel-use
metabolism
1 gram of protein or carbohydrate is how many kilocalories? 1 gram of fat? 1 gram
of alcohol? 4 kcal; 9 kcal; 7 kcal "<img src=""7420.png"">" biochemistry
duplicate metabolic-fuel-use metabolism
During the first 3 days of fasting, which four processes maintain blood glucose
levels? Hepatic glycogenolysis, adipose free fatty acid release, muscle and
liver free fatty acid use (over glucose), and hepatic gluconeogenesis "<img
src=""7420.png"">" biochemistry duplicate metabolic-fuel-use metabolism
During the first 3 days of fasting, what are the sources of hepatic
gluconeogenesis? Lactate and alanine from the peripheral tissues, glycerol and
propionyl-CoA from adipose tissue (Only odd-chain free fatty acids are used.)
"<img src=""7420.png"">" biochemistry duplicate metabolic-fuel-use
metabolism
A healthy 20-year-old man has just eaten lunch. What metabolic processes are used
for fuel? How does insulin respond? Glycolysis and aerobic respiration; insulin
stimulates storage of lipids, proteins, and glycogen "<img src=""7420.png"">"
biochemistry duplicate metabolic-fuel-use metabolism
A healthy 20-year-old man ate lunch 4 hours ago. What metabolic processes are used
for fuel? How are glucagon and adrenaline involved? Major source: hepatic
glycogenolysis, minor sources: hepatic gluconeogenesis/adipose tissue release of
FFA; stimulate use of fuel reserves "<img src=""7420.png"">" biochemistry
A lost hiker ran out of food 4 days ago. What fuel source is used? What happens
when it is depleted? What determines survival time? Ketones from adipose tissue
supply brain/heart; vital protein degradation accelerates, causing organ
failure/death; excess adipose stores "<img src=""7420.png"">" biochemistry
A mountain climber is starving and has no access to food. How long will her
glycogen reserves last? Approximately 1 day "<img src=""7420.png"">"
biochemistry duplicate metabolic-fuel-use metabolism
Which tissue cannot use ketone bodies as a fuel source? Why? Red blood cells;
because they lack mitochondria "<img src=""7420.png"">" biochemistry
Between meals, which two hormones help stimulate the use of fuel reserves?
Glucagon and adrenaline "<img src=""7420.png"">" biochemistry duplicate
metabolic-fuel-use metabolism
What is the rate-limiting step of cholesterol synthesis? Does anything induce this
particular step of cholesterol synthesis? HMG-CoA reductase converting HMG-CoA to
mevalonate; yes, insulin induces this step "<img src=""7421.png"">"
biochemistry cholesterol-synthesis duplicate metabolism
A 45-y/o with high cholesterol takes medications that inhibit the rate-limiting
step of cholesterol synthesis. What enzyme do they inhibit?HMG-CoA reductase, which
catalyzes the conversion of HMG-CoA to mevalonate (The medications are statins.)
"<img src=""7421.png"">" biochemistry cholesterol-synthesis duplicate
metabolism
What is the ultimate fate of two thirds of plasma cholesterol? It is esterified
by lecithin-cholesterol acyltransferase (LCAT) "<img src=""7421.png"">"
biochemistry cholesterol-synthesis duplicate metabolism
A pt takes atorvastatin for high LDL cholesterol. Describe this drug's inhibitory
effect on HMG-CoA reductase. Statins such as atorvastatin competitively and
reversibly inhibit HMG-CoA reductase "<img src=""7421.png"">" biochemistry
cholesterol-synthesis duplicate metabolism
A pt has a reduced ability to synthesize cholesterol. Which processes in the human
body will this impair? Maintenance of cell membrane integrity and synthesis of
bile acids, steroids, and vitamin D "<img src=""7421.png"">" biochemistry
cholesterol-synthesis duplicate metabolism
Which enzyme degrades triglycerides that are circulating as chylomicrons and very-
low-density lipoprotein (VLDL)? Where is it found? Lipoprotein lipase; it is
found on the vascular endothelial surface "<img src=""7422.png"">" biochemistry
duplicate lipid-transport,-key-enzymes metabolism
Which organs take up low-density lipoproteins (LDL cholesterol) from the
circulation? What receptors are used? The liver and peripheral tissues; low-
density lipoprotein (LDL) receptors "<img src=""7422.png"">" biochemistry
Describe the function of these enzymes in lipid transport: pancreatic lipase,
hepatic TG lipase (HL), and hormone-sensitive lipase. Pancreatic lipase degrades
dietary small intestinal TG; HL degrades TG remaining in IDL; hormone-sensitive
lipase degrades TG in adipocytes "<img src=""7422.png"">" biochemistry
Name three lipoproteins that receive cholesterol esters from high-density
lipoprotein via cholesterol ester transfer protein (CETP). Very-low-density
lipoprotein (VLDL), intermediate-density lipoprotein (IDL), and low-density
lipoprotein (LDL) "<img src=""7422.png"">" biochemistry duplicate lipid-
transport,-key-enzymes metabolism
If a pt's body is not able to change nascent HDL to mature HDL, what enzyme is
lacking? Lecithin-cholesterol acyltransferase (LCAT ) "<img src=""7422.png"">"
biochemistry duplicate lipid-transport,-key-enzymes metabolism
If the body is not able to transfer HDL-bound cholesterol esters to other
lipoprotein types, what protein (enzyme) is lacking? Cholesterol ester transfer
protein (CETP) "<img src=""7422.png"">" biochemistry duplicate lipid-
transport,-key-enzymes metabolism
A pt has high HDL cholesterol levels. Where does HDL originate in the body? What is
a nickname for this type of cholesterol? "It originates from the liver and
intestines; it is nicknamed ""good cholesterol""" "<img src=""7422.png"">"
A pt eats a large, fatty, cholesterol-rich meal. Via what particles are the fats
and cholesterol esters taken up from the intestines? Chylomicrons "<img
src=""7422.png"">" biochemistry duplicate lipid-transport,-key-enzymes
metabolism
A pt eats a large, fatty, cholesterol-rich meal, which is digested via
chylomicrons. Which enzyme acts first on these chylomicrons? Lipoprotein lipase
(LPL), breaking cholesterol down into free fatty acids (FFAs) "<img
src=""7422.png"">" biochemistry duplicate lipid-transport,-key-enzymes
metabolism
What happens to chylomicron remnants after processing of free fatty acids (FFAs) by
lipoprotein lipase (LPL)? Further triglyceride degradation by LPL and HL,
followed by uptake of remnants by liver receptors "<img src=""7422.png"">"
Bile is tagged with a radiolabeled tracer. You monitor bile flow in a test subject.
Between which two organs does the bile circulate? The liver and intestines
"<img src=""7422.png"">" biochemistry duplicate lipid-transport,-key-
enzymes metabolism
Which apolipoprotein is present in all cholesterol forms except low-density
lipoprotein (LDL) cholesterol? Apolipoprotein E "<img src=""7423.png"">"
biochemistry duplicate major-apolipoproteins metabolism
In which cholesterol forms is apolipoprotein B-48 found? B-100? C-II? B-48:
chylomicrons, chylomicron remnants; B-100: VLDL, IDL, LDL; C-II: chylomicrons,
VLDL, HDL "<img src=""7423.png"">" biochemistry duplicate major-
apolipoproteins metabolism
Which apolipoprotein is found only in high-density lipoproteins (HDLs)? What is its
function? Apolipoprotein A-I; it activates lecithin-cholesterol acyltransferase
(LCAT) "<img src=""7423.png"">" biochemistry duplicate major-
apolipoproteins metabolism
Which apolipoprotein helps cholesterol bind to LDL receptors? B-100 "<img
src=""7423.png"">" biochemistry duplicate major-apolipoproteins metabolism
Which apolipoprotein mediates remnant uptake? E "<img src=""7423.png"">"
Which apolipoprotein helps activate LCAT? A-I "<img src=""7423.png"">"
Which apolipoprotein functions as a lipoprotein lipase cofactor? C-II "<img
src=""7423.png"">" biochemistry duplicate major-apolipoproteins metabolism
Which apolipoprotein's main function is to mediate chylomicron secretion? B-48
"<img src=""7423.png"">" biochemistry duplicate major-apolipoproteins
metabolism
What are lipoproteins composed of? Which lipoproteins carry the most cholesterol?
Varying amounts of cholesterol, triglycerides, and phospholipids; low- and
high-density lipoproteins carry the most cholesterol "<img src=""7424.png"">"
biochemistry duplicate lipoprotein-functions metabolism
"A healthy 50-y/o woman is told she has high ""healthy"" cholesterol. What is the
function of this good cholesterol? Of ""lousy"" cholesterol?" HDL is Healthy and
transports cholesterol from the periphery to the liver; LDL is Lousy and transports
it from the liver to tissues "<img src=""7424.png"">" biochemistry duplicate
lipoprotein-functions metabolism
Which lipoprotein, formed in the degradation of very-low-density lipoprotein
(VLDL), delivers triglycerides (TGs) and cholesterol to liver? Intermediate-
density lipoprotein (IDL) "<img src=""7424.png"">" biochemistry duplicate
How do chylomicrons aid in the delivery of cholesterol and triglycerides (TGs)?
They deliver dietary TGs to peripheral tissue, become chylomicron remnants
once triacylglycerols are depleted, & deliver cholesterol to liver "<img
src=""7424.png"">" biochemistry duplicate lipoprotein-functions metabolism
From which tissue is the lipoprotein that delivers hepatic triglycerides (TGs) to
peripheral tissue secreted? The liver secretes very-low-density lipoprotein
(VLDL) "<img src=""7424.png"">" biochemistry duplicate lipoprotein-
functions metabolism
One lipoprotein is secreted by both the liver and intestines. Which apolipoproteins
does this lipoprotein carry? What are they used for? High-density lipoprotein
(from liver/intestines) carries apoC/apoE; used in chylomicron/very-low-density
lipoprotein (VLDL) metabolism "<img src=""7424.png"">" biochemistry duplicate
One lipoprotein enters target cells via receptor-mediated endocytosis. In which
tissue and by which process is this lipoprotein formed? Low-density lipoprotein
(LDL) forms in liver/peripheral tissues by modification of intermediate-density
lipoprotein (IDL) via hepatic lipase "<img src=""7424.png"">" biochemistry
duplicate lipoprotein-functions metabolism
Which two lipoproteins are secreted by the intestines? Chylomicrons and high-
density lipoprotein (HDL) "<img src=""7424.png"">" biochemistry duplicate
An alcoholic pt has unusually high levels of HDL cholesterol; his sober identical
twin has normal levels. Why might this be? Alcohol stimulates HDL synthesis,
likely raising the alcoholic pt's serum levels "<img src=""7424.png"">"
biochemistry duplicate lipoprotein-functions metabolism
A man has pancreatitis, hepatosplenomegaly, and pruritic xanthomas. Name the
causative cholesterol defects. Risk for what is not increased? Lipoprotein lipase
or apolipoprotein C-II deficiency; atherosclerosis (He has type I familial
dyslipidemia [hyperchylomicronemia].) "<img src=""7425.png"">" biochemistry
duplicate familial-dyslipidemias metabolism
A young man has hyperchylomicronemia. What is the inheritance pattern for his
disease? What do you see in his lipid panel? Inheritance pattern is autosomal
recessive; lipid panel shows increased chylomicrons, triglycerides, and cholesterol
"<img src=""7425.png"">" biochemistry duplicate familial-dyslipidemias
metabolism
A 20-y/o man with an autosomal dominant familial dyslipidemia has an MI. On exam,
he has an Achilles xanthoma and corneal arcus. Diagnosis? The pt has type IIa
familial dyslipidemia (familial hypercholesterolemia) and has no or defective LDL
receptors "<img src=""7425.png"">" biochemistry duplicate familial-
dyslipidemias metabolism
A 25-year-old man with an autosomal dominant familial dyslipidemia has
pancreatitis. Which disease does he likely have? He probably has type IV
familial dyslipidemia (hypertriglyceridemia) caused by hepatic overproduction of
VLDL "<img src=""7425.png"">" biochemistry duplicate familial-dyslipidemias
metabolism
A pt has absent LDL receptors; lipid panel shows markedly elevated LDL and
cholesterol. What's the inheritance pattern for his disease? Autosomal
dominant; the pt has type IIa familial dyslipidemia (familial hypercholesterolemia)
metabolism
Compare and contrast the abnormal lipid panel findings for these three familial
dyslipidemias: type I, type IIa, type IV. Type I: increased chylomicrons, TG, &
cholesterol; type IIa: increased LDL &: cholesterol; type IV: increased VLDL & TG
metabolism
A familial hypercholesterolemia heterozygote has what average cholesterol level?
What about a homozygote? 300 mg/dL; 700 mg/dL "<img src=""7425.png"">"
biochemistry duplicate familial-dyslipidemias metabolism
How common are familial hypercholesterolemia heterozygotes in the general
population? Homozygotes? What are both groups at high risk for? Heterozygotes are
1:500; homozygotes are very rare; both are at increased risk for myocardial
infarctions (MIs) before age 20 years "<img src=""7425.png"">" biochemistry
duplicate familial-dyslipidemias metabolism
A pt has severe abdominal pain. His triglyceride level is 1200 mg/dL. What is the
inheritance pattern of the likely causative disorder? Autosomal dominant; this is
type IV familial dyslipidemia (hypertriglyceridemia); triglycerides > 1000 mg/dL
can cause acute pancreatitis "<img src=""7425.png"">" biochemistry duplicate
familial-dyslipidemias metabolism
Identify the chemical composition and the two main functions of the peptidoglycan
layer in bacteria. It has a sugar backbone with cross-linked peptide side
chains, and it provides rigid support and protection against osmotic damage "<img
src=""7426.png"">" Microbiology bacterial-structures basic-bacteriology
duplicate
Bacteria A are able to respond to change in osmotic pressure. What characteristic
of the structure of the cell envelope gives rigid support? The cell wall is
composed of peptidoglycans that provide rigid support "<img src=""7426.png"">"
Microbiology bacterial-structures basic-bacteriology duplicate
You isolate gram-negative bacteria on a culture plate. What components of the cell
envelope are found only in gram-negative bacteria? Outer membrane, periplasm
"<img src=""7426.png"">" Microbiology bacterial-structures basic-
bacteriology duplicate
What component of the cell envelope induces TNF on gram-negative bacteria? Lipid
A (also induces IL-1) "<img src=""7426.png"">" Microbiology bacterial-
structures basic-bacteriology duplicate
What component of the cell envelope extends from the membrane to the exterior and
induces TNF and IL-1 on gram-positive bacteria? Lipoteichoic acid "<img
duplicate
Where is endotoxin (lipopolysaccharide) located in gram-negative bacteria? Which
component serves as the antigen? Outer membrane; O polysaccharide "<img
duplicate
What is the chemical composition of the bacterial cytoplasmic membrane, and what
are the membrane's two main enzymatic functions? The membrane comprises a
phospholipid bilayer with embedded proteins; it is the site of both oxidative and
transport enzymes "<img src=""7426.png"">" Microbiology bacterial-structures
basic-bacteriology duplicate
A company makes a drug that impedes bacterial protein synthesis. What subunits of
the bacterial structure does the drug likely target? 30S and 50S subunits of
ribosomes "<img src=""7426.png"">" Microbiology bacterial-structures basic-
A drug company wishes to target the bacterial structure that contains hydrolytic
enzymes. Where in the bacteria would this be? In the periplasm, the space between
the cytoplasmic membrane and the outer membrane in gram-negative bacteria "<img
duplicate
Drug X is known to target polysaccharides from the bacterial capsule. What function
of the bacterial capsule is most likely impacted? Protection from phagocytosis
"<img src=""7426.png"">" Microbiology bacterial-structures basic-
What is a plasmid, and what information does it carry? A segment of bacterial
DNA; contains genes for antibiotic resistance, enzymes, or toxin production "<img
duplicate
A painless black ulcer develops on a 56-year-old goat herder's arm. What unique
molecule does the capsule of the bacterium contain? B anthracis is the only
bacterium with a capsule containing poly D-glutamate "<img src=""7426.png"">"
A man has a catheter for a week and develops sepsis. Bacteria are found on the
catheter. Which bacterial structure lets them adhere there?Glycocalyx, made up of
polysaccharide "<img src=""7426.png"">" Microbiology bacterial-structures
What glycoprotein-derived structure allows bacteria to adhere to the cell surface?
The fimbria (pilus) "<img src=""7426.png"">" Microbiology bacterial-
What glycoprotein-derived bacterial structure is known to help form attachment
between two bacteria during conjugation? Sex pilus "<img src=""7426.png"">"
What bacterial structural appendage composed of protein is known to help provide
motility? Flagellum "<img src=""7426.png"">" Microbiology bacterial-
In the periplasmic space, what type of components tends to accumulate? Components
exiting gram-negative cells such as hydrolytic enzymes (eg, -lactamases) "<img
duplicate
What component of the outer membrane is antigenic? O polysaccharide component
and most OMPs (outer membrane proteins) "<img src=""7426.png"">" Microbiology
bacterial-structures basic-bacteriology duplicate
In a gram-positive bacterium you identify a specialized structure composed of
dipicolinic acid and peptidoglycan. What is it? Likely a spore "<img
duplicate
A gram-positive bacterium produces offspring with a special keratin-like coat. How
do these offspring survive? Spores survive by resisting dehydration, heat, and
chemicals "<img src=""7426.png"">" Microbiology bacterial-structures basic-
A drug company wishes to target the component of cell envelopes where oxidative and
transport enzymes lie. What location is chosen? Cytoplasmic membrane "<img
duplicate
Of what is the cytoplasmic membrane typically composed in gram-negative bacteria?
Phospholipid bilayers with embedded proteins and enzymes; only in gram-
positive bacteria does lipoteichoic acid extend into the interior "<img
duplicate
A hospitalized 86-year-old has S pneumoniae. His roommate has an E coli UTI. What
structures do these bacteria have in common? Gram-positives (eg, S pneumoniae)
and negatives (eg, E coli) both have flagella, pili, capsules, peptidoglycans, and
cytoplasmic membranes "<img src=""7427.png"">" Microbiology basic-
bacteriology cell-walls duplicate
Name a structure that is unique to gram-positive bacteria, then name some
structures unique to gram-negative bacteria. Gram-positives: lipoteichoic acid;
gram-negatives: porins, periplasmic space, and an outer membrane formed by
endotoxins/lipopolysaccharides "<img src=""7427.png"">" Microbiology
basic-bacteriology cell-walls duplicate
S aureus and E coli are found to grow in a patient's blood cultures. How are their
respective cell walls different? S aureus is gram-positive and has lipoteichoic
acid; E coli is gram-negative and has porins, endotoxin, LPS, and a periplasmic
space "<img src=""7427.png"">" Microbiology basic-bacteriology cell-walls
duplicate
E coli is identified in your lab. Where in the cell wall would you localize the -
lactamases? The periplasmic space, because these bacteria are gram-negative "<img
src=""7427.png"">" Microbiology basic-bacteriology cell-walls duplicate
A medical student is looking at a bacterial culture with gram-positive cocci. What
are the two most likely strains growing before his eyes? Staphylococcus and
Streptococcus "<img src=""7428.png"">" Microbiology bacterial-taxonomy
A medical student finds a gram-positive spherical bacteria that appears in
clusters. What is the most likely strain growing before his eyes?
Staphylococcus "<img src=""7428.png"">" Microbiology bacterial-
taxonomy basic-bacteriology duplicate
As a medical student, you are told that a culture has gram-negative cocci. What are
your best guesses at the specific bacterial strains? Neisseria and Moraxella
catarrhalis "<img src=""7428.png"">" Microbiology bacterial-taxonomy basic-
You examine bacteria under a microscope and notice a positive Gram stain with a
bacillus shape. List the eight most likely possibilities. Gardnerella (gram
variable); Mycobacterium(acid fast), Bacillus, Listeria, Clostridium,
Propionibacterium, Corynebacterium, and Lactobacillus "<img src=""7428.png"">"
Microbiology bacterial-taxonomy basic-bacteriology duplicate
A 6-year-old has abdominal pain and intense vomiting. You suspect a gram-negative
enteric bacterium. Name the 13 possibilities. Bacteroides/Campylobacter/E
coli/Enterobacter/Helicobacter/Klebsiella/Proteus/Pseudomonas/Salmonella/Serratia/S
higella/Vibrio/Yersinia "<img src=""7428.png"">" Microbiology bacterial-
High fever and pneumonia develop after hotel guests contract Legionella. What are
the Gram stain and shape of the bacteria? Legionella, a gram-negative bacillus
"<img src=""7428.png"">" Microbiology bacterial-taxonomy basic-
A 7-year-old girl has cough with whooping on inspiration for 2 months from
pertussis. What is the Gram stain/shape of the causative agent? Bordetella, a
gram-negative bacillus "<img src=""7428.png"">" Microbiology bacterial-
A farmer has fever, weakness, and myalgias after drinking unpasteurized milk with
Brucella. What is the Gram stain/shape of the bacterium? Brucella is a gram-
negative bacillus (he likely has brucellosis) "<img src=""7428.png"">"
A girl has pain, redness & swelling after a cat bite. Zoonotic bacteria are
cultured. What is the Gram stain/shape of the causative agent? She likely has
cellulitis caused by P multocida, a common pathogen in cats; Pasteurella is a gram-
negative bacillus "<img src=""7428.png"">" Microbiology bacterial-taxonomy
A patient with symptoms of tularemia (Francisella) arrives in your ED. What are the
Gram stain and shape of the causative bacterium? Gram-negative bacillus "<img
src=""7428.png"">" Microbiology bacterial-taxonomy basic-bacteriology
duplicate
A boy has swelling on his arm near where his new cat scratched him. What are the
Gram stain and shape of the causative zoonotic bacterium? Likely a gram-negative
bacillus (Bartonella) "<img src=""7428.png"">" Microbiology bacterial-
A woman has a foul-smelling white vaginal discharge. The Gram stain varies but is
ultimately deemed positive. What is the organism's shape? Gardnerella vaginalis is
a gram-positive (gram-variable) bacillus (this is likely bacterial vaginosis caused
by ) "<img src=""7428.png"">" Microbiology bacterial-taxonomy basic-
Which of the following is not an enteric bacillus: E coli, Vibrio, Bordetella,
Helicobacter, Serratia, Enterobacter? Bordetella, which is a respiratory gram-
negative bacillus "<img src=""7428.png"">" Microbiology bacterial-taxonomy
Which of the following is not an enteric bacillus: Pasteurella, Shigella,
Pseudomonas, Yersinia, Proteus, Bacteroides? Pasteurella, which is a zoonotic
gram-negative bacillus "<img src=""7428.png"">" Microbiology bacterial-
A 28-year-old man has a headache, cough, and fever. Bacteria with no cell wall are
identified as the cause. What will a Gram stain show? This is atypical pneumonia
caused by Mycoplasma; this bacterium has no cell well and does not Gram stain
You observe gram-positive, branching, filamentous bacteria. What are the two causes
that can be identified with acid-fast staining? Actinomyces and NocardiaNocardia
is weakly acid fast "<img src=""7428.png"">" Microbiology bacterial-
Name three types of spirochetes that can be identified with the use of a Giemsa
stain. Borrelia, Leptospira, and Treponema "<img src=""7428.png"">"
While working in a microbiology lab, you notice highly pleomorphic gram-negative
bacteria on a Giemsa stain. What bacteria might this be? Chlamydia or Rickettsia
A patient has a Haemophilus infection. By what route was it likely acquired? Name
an interesting trait of this bacterium's shape/size. Acquired through the
respiratory tract; it is pleomorphic "<img src=""7428.png"">" Microbiology
bacterial-taxonomy basic-bacteriology duplicate
A patient has a urinary tract infection. The bacteria are unable to be Gram stained
due to there being no cell wall. Why? This is likely infection with Ureaplasma,
a bacterium with sterols that do not Gram stain "<img src=""7428.png"">"
B cepacia is grown in the sputum of a patient with cystic fibrosis. What is seen on
Gram staining? A gram-negative rod "<img src=""7428.png"">" Microbiology
A patient has a cough and grows a gram-negative rod that exhibits a positive silver
stain. What is the pathogen? Legionella "<img src=""7428.png"">" Microbiology
Which of these organisms is not a gram-negative bacillus: Pasteurella, Listeria,
Salmonella, Legionella, Yersinia, Klebsiella? Listeria, a gram-positive rod, is
commonly mistaken for a gram-negative bacterium "<img src=""7428.png"">"
Which of these organisms is not a gram-positive bacillus: Lactobacillus,
Propionibacterium, Serratia, Listeria, Clostridium? Serratia, a gram-negative
bacillus "<img src=""7428.png"">" Microbiology bacterial-taxonomy basic-
Which of these organisms is not a respiratory bacillus: Bordetella, Pseudomonas,
Burkholderia, Haemophilus, Legionella? Pseudomonas, an enteric bacillus "<img
src=""7428.png"">" Microbiology bacterial-taxonomy basic-bacteriology
duplicate
A 24-year-old has atypical walking pneumonia. The bacteria have no cell wall.
Identify the causative agent. This is Mycoplasma, which has no cell wall;
Ureaplasma also lacks a cell wall "<img src=""7429.png"">" Microbiology
basic-bacteriology duplicate stains
What are the two distinguishing components in the outer layer of Mycobacteria?
Mycolic acid and high lipid content "<img src=""7429.png"">" Microbiology
List organisms that do not Gram stain well. Chlamydia, Ureaplasma, Ehrlichia,
Leptospira, Treponema, Mycobacterium, Bartonella, Anaplasma, Mycoplasma,
Legionella, Rickettsia "<img src=""7429.png"">" Microbiology basic-
bacteriology duplicate stains
A 30-year-old has a painless syphilitic penile chancre. Why doesn't the causative
organism Gram stain? What two methods can reveal it? Treponema is too thin to be
visualized on Gram staining; can be seen on dark-field microscopy or fluorescent
antibody staining "<img src=""7429.png"">" Microbiology basic-bacteriology
duplicate stains
Name seven intracellular bacteria that do not Gram stain well. Which lacks muramic
acid in its cell wall? Which is seen with silver stain? Anaplasma, Bartonella,
Chlamydia, Ehrlichia, Legionella, Rickettsia; Chlamydia lacks muramic acid;
Legionella is seen on silver stain "<img src=""7429.png"">" Microbiology
What characteristic of Mycobacterium makes it visible on Ziehl-Neelsen staining?
Mycolic acid in the cell wall is detected by the carbol fuchsin in the Ziehl-
Neelsen stain "<img src=""7429.png"">" Microbiology basic-bacteriology
duplicate stains
A 20-year-old military recruit has a headache and cough caused by Mycoplasma. Why
does this bacterium not Gram stain well? Mycoplasma does not have a cell wall and
therefore does not Gram stain well "<img src=""7429.png"">" Microbiology
Which five organisms can be visualized on Giemsa stain? Chlamydia, Borrelia,
Ricketsia, Trypanosoma, and Plasmodiumremember, certain bugs really try my
patience "<img src=""7429.png"">" Microbiology basic-bacteriology duplicate
stains
A man with Cryptosporidium oocysts asks about the cheapest way to visualize the
oocysts. What would you suggest? Are there disadvantages? Auramine-rhodamine
stain; the test is more sensitive but less specific "<img src=""7429.png"">"
Microbiology basic-bacteriology duplicate stains
What pathogen can India ink and mucicarmine be used to visualize? What part of the
organism does it stain? What color is mucicarmine? Cryptococcus neoformans;
mucicarmine stains the thick polysaccharide capsule; red "<img src=""7429.png"">"
Your advisor in the microbiology lab tells you that he wishes to use a special
silver stain. What organisms is he looking for? Legionella, Helicobacter pylori,
and Fungi (eg, Coccidioides E, Pneumocystis jirovecii) "<img src=""7429.png"">"
A patient presents with the symptoms of Whipple disease. What stain can be used to
confirm the diagnosis? PAS (period acidSchiff) stain, which stains glycogen and
mucopolysaccharides (PaSs the sugar) "<img src=""7429.png"">" Microbiology
Your mentor uses a fluorescent antibody stain. In what scenario is this typically
used? To identify many bacteria and viruses (eg, FTA-ABS for confirming syphilis)
"<img src=""7429.png"">" Microbiology basic-bacteriology duplicate
stains
In the ID lab, your attending uses Thayer-Martin agar to test for Neisseria. What
type of medium is Thayer-Martin, and how does it work? Selective medium;
contains antibiotics that permit selective growth of Neisseria by preventing the
growth of other organisms "<img src=""7430.png"">" Microbiology basic-
bacteriology duplicate properties-of-growth-media
When Escherichia coli is grown in MacConkey agar, there is a color change. Describe
the medium and how it works. MacConkey agar is a pH indicator medium; E coli is
able to convert lactose to acidic metabolites, causing a color change "<img
src=""7430.png"">" Microbiology basic-bacteriology duplicate properties-of-
growth-media
How does an indicator (differential) medium work? Give an example of such a medium.
Changes color in response to some organisms' metabolites; MacConkey agar
changes on exposure to acidic metabolites of lactose from E coli "<img
src=""7430.png"">" Microbiology basic-bacteriology duplicate properties-of-
growth-media
How does a selective medium work? Give an example of such a medium. Selective
media favor the growth of one organism over others; Thayer-Martin agar selecting
for Neisseria by inhibiting other organisms "<img src=""7430.png"">"
Microbiology basic-bacteriology duplicate properties-of-growth-media
An unimmunized 1-year-old is irritable and sluggish and has a stiff neck. How do
you culture the causative agent, Haemophilus influenzae? On chocolate agar with
factors V (NAD+) and X (hematin) (the child likely has H influenzae meningitis)
special-culture-requirements
A 25-year-old man with many sexual partners has purulent penile discharge from N.
gonorrhoeae. How is the causative organism cultured? Why? N gonorrhoeae grows on
VTCN (Vancomycin kills gram-positives, Trimethoprim and Colistin kill gram-
negatives except Neisseria, Nystatin kills fungi) "<img src=""7431.png"">"
Microbiology basic-bacteriology duplicate special-culture-requirements
A 10-year-old girl is found to have whooping cough caused by Bordetella pertussis.
How can this organism be cultured? B pertussis grows on Bordet-Gengou (potato)
agar (Bordet for Bordetella) and Regan-Lowe medium (charcoal, blood, and
antibiotic) "<img src=""7431.png"">" Microbiology basic-bacteriology duplicate
An unimmunized 7-year-old has a sore throat and fever. Exam reveals gray
pseudomembranes in his throat. What type of culture must be done? The child
likely has C diphtheriae, which grows on a tellurite plate with Lffler medium
A homeless man is febrile, coughing up blood. X-ray shows a cavitary lesion. You
consider TB. How should you culture the causative organism?The causative organism
grows on Lwenstein-Jensen agar (he likely has M tuberculosis) "<img
src=""7431.png"">" Microbiology basic-bacteriology duplicate special-culture-
requirements
Unlabeled bacterial colonies with a pink hue are noted to be acidic. What kind of
bacteria are they? What medium was used to identify them? Lactose-fermenting
enterics (eg, E coli); MacConkey agar "<img src=""7431.png"">" Microbiology
basic-bacteriology duplicate special-culture-requirements
High fever and pneumonia from Legionella develop in many guests in a hotel with
central AC. How will you culture the causative organism? Legionella grows on
charcoal yeast extract agar buffered with cysteine and iron"<img src=""7431.png"">"
In the microbiology lab, you notice that some Sabouraud agar is growing pathogens.
What is likely growing? Fungi (Sabs a fun guy) "<img src=""7431.png"">"
When an anticoagulated tube of a febrile man's blood cools, precipitate forms. M
pneumoniae is found. What medium was used? Eaton agar; M pneumoniae requires
cholesterol "<img src=""7431.png"">" Microbiology basic-bacteriology duplicate
Two plates grow the same lactose-fermenting bacteria. One is pink; the other has a
green metallic sheen. What's the bacterium? The medium? E coli, which turns
MacConkey agar pink and grows colonies with a green metallic sheen on eosin
methylene (EMB) agar "<img src=""7431.png"">" Microbiology basic-
bacteriology duplicate special-culture-requirements
Name three aerobes. Nocardia, Pseudomonas aeruginosa, and Mycobacterium
tuberculosis (Nagging Pests Must Breathe) "<img src=""7432.png"">" Microbiology
aerobes basic-bacteriology duplicate
A chest x-ray in a patient with reactivated tuberculosis shows apical infiltrates
in both lungs. Explain the location of these findings. The lung apices have the
highest partial pressure of oxygen; M tuberculosis (and all obligate aerobes)
require oxygen to make ATP "<img src=""7432.png"">" Microbiology aerobes
A man with a history of TB begins using a TNF- inhibitor. He now has a cough with
dyspnea. Where in the lung is the reactivated TB? Why? Reactivated M
tuberculosis has a predilection for the apices of the lung; this area has the
highest PO2 and lowest perfusion "<img src=""7432.png"">" Microbiology
aerobes basic-bacteriology duplicate
Clostridium, Bacteroides, Fusobacterium, and Actinomyces have increased
susceptibility to oxidative damage. Why? They lack enzymes such as catalase and
superoxide dismutase and are susceptible to oxidative damage (anaerobes Can't
Breathe Fresh Air) "<img src=""7433.png"">" Microbiology anaerobes basic-
You find anaerobic bacteria that smell bad and are difficult to culture and produce
CO2 and H2 in tissue. What causes the foul smell? Short-chain fatty acids "<img
src=""7433.png"">" Microbiology anaerobes basic-bacteriology duplicate
Where are anaerobes part of the normal flora? Where are they pathogenic? They
are normal flora in the gastrointestinal tract; typically pathogenic in all other
tissues "<img src=""7433.png"">" Microbiology anaerobes basic-bacteriology
duplicate
A 56-year-old diabetic man has a foul-smelling foot ulcer with palpable crepitus.
Which antibiotic must you not use to treat it? Why? AminoglycO2sides, which
require O2 to enter a bacterial cell; ineffective against anaerobes (he likely has
an anaerobic skin infection) "<img src=""7433.png"">" Microbiology anaerobes
You find an intracellular organism that can use both oxygen and anaerobic energy
sources. Which bacteria should you consider treating for? Salmonella, Neisseria,
Brucella, Mycobacterium, Listeria, Francisella, Legionella, Yersinia pestis (Some
Nasty Bugs May Live FacultativeLY) "<img src=""7434.png"">" Microbiology
basic-bacteriology duplicate intracellular-bugs
Coxiella is considered an obligate intracellular pathogen. Name other obligate
intracellular pathogens? How do they get energy? Rickettsia, Chlamydia, and
COxiella are intracellular; get ATP from their hosts (stay inside [cells] when it
is Really CHilly and COld) "<img src=""7434.png"">" Microbiology basic-
bacteriology duplicate intracellular-bugs
Which bacteria are facultative intracellular organisms? Salmonella, Neisseria,
Brucella, Mycobacterium, Listeria, Francisella, Legionella, Yersinia pestis (Some
Nasty Bugs May Live FacultativeLY) "<img src=""7434.png"">" Microbiology
basic-bacteriology duplicate intracellular-bugs
A 30-year-old man recently underwent splenectomy and then required several
specialized vaccines. What is the antigen in the vaccines? Bacterial capsule
conjugated to a protein serves as the antigen; strains to vaccinate against are S
pneumoniae, H influenzae, N meningitidis "<img src=""7435.png"">" Microbiology
basic-bacteriology duplicate encapsulated-bacteria
A 20-year-old man recently had a splenectomy. Explain why he should receive S
pneumoniae, H influenzae, and N meningitis vaccines. Encapsulated bacteria are
opsonized then cleared by the spleenasplenics have decreased opsonizing ability
and are at risk for infection "<img src=""7435.png"">" Microbiology basic-
bacteriology duplicate encapsulated-bacteria
A patient receives a pneumococcal conjugate vaccine (PCV). How does a PCV work to
promote a T cell response? In encapsulated bacteria vaccines, protein and
polysaccharide are conjugated to promote a T cell response and class switching as a
result "<img src=""7436.png"">" Microbiology basic-bacteriology duplicate
encapsulated-bacteria-vaccines
A splenectomy patient is at risk for infection with encapsulated bacteria. Name 4
vaccines prepared to protect this patient. Pneumococcal (PCV [Prevnar] with
conjugate, PPSV [Pneumovax] without); H influenzae type B (conjugate); and
meningococcal (conjugate) vaccines "<img src=""7436.png"">" Microbiology
basic-bacteriology duplicate encapsulated-bacteria-vaccines
An elderly woman is vaccinated only against polysaccharide antigens. Why is this
patient at greater risk for infection even with vaccines? Polysaccharide antigens
alone are not recognized/presented by T cells and hence prompt a weaker immune
response "<img src=""7436.png"">" Microbiology basic-bacteriology duplicate
encapsulated-bacteria-vaccines
In lab, you have an unmarked bacterial plate. You notice that it is producing
urease. What bacteria could be growing on the plate? Proteus, Cryptococcus, H
pylori, Ureaplasma, Nocardia,Klebsiella, S epidermidis, S saprophyticus (Pee
CHUNKSS) "<img src=""7437.png"">" Microbiology basic-bacteriology duplicate
urease-positive-organisms
Proteus and Klebsiella are both urease-positive organisms. How do these bacteria
increase pH? Urease hydrolyzes the urea, resulting in release of ammonia and
CO2 "<img src=""7437.png"">" Microbiology basic-bacteriology duplicate
urease-positive-organisms
A patient presents with struvite stones. What is the underlying biochemical
reaction that leads to the formation of such stones? Urease hydrolyzes urea, with
release of ammonia and CO2; increased urine pH makes ammonium magnesium phosphate
stone formation possible "<img src=""7437.png"">" Microbiology basic-
bacteriology duplicate urease-positive-organisms
A 16-year-old girl has recurrent S aureus, Pseudomonas, and Candida infections.
What enzyme deficiency is responsible? NADPH oxidase deficiency (chronic
granulomatous disease)these bugs are catalase positive, and they degrade the
limited H2O2 "<img src=""7438.png"">" Microbiology basic-bacteriology
catalase-positive-organisms duplicate
Catalase degrades H2O2 before conversion to microbicidal products by
myeloperoxidase (enzyme). Name seven catalase-positive organisms. Nocardia,
Pseudomonas, Listeria, Aspergillus, Candida, E coli, Staph, Serratia, B cepacia, H
pylori; Cats Need PLACESS to Belch Hairballs "<img src=""7438.png"">"
Microbiology basic-bacteriology catalase-positive-organisms duplicate
In patients with Pseudomonas infections, how does the organism's catalase make the
bacterium more pathogenic? Catalase degrades H2O2 into H2O and O2 before
myeloperoxidase converts it to microbicidal products "<img src=""7438.png"">"
Microbiology basic-bacteriology catalase-positive-organisms duplicate
Which four bacteria produce pigment? What color pigment does each one produce?
Actinomyces and S aureus = yellow (gold), P aeruginosa = blue-green (aerugula
= green), S marcescens = red maraschino cherries "<img src=""7439.png"">"
Microbiology basic-bacteriology duplicate pigment-producing-bacteria
"In microbiology lab you find bacteria that produce yellow ""sulfur granules""
(sand). What are the granules made of?" "Actinomyces israelii (Israel has yellow
sand)yellow ""sulfur granules"" are composed of bacterial filaments" "<img
src=""7439.png"">" Microbiology basic-bacteriology duplicate pigment-
producing-bacteria
In microbiology lab you find bacteria that produce blue-green pigment. What
bacterial strain is this? P aeruginosa "<img src=""7439.png"">"
Microbiology basic-bacteriology duplicate pigment-producing-bacteria
In microbiology lab you find bacteria that produce red pigment. What bacterial
strain is this? Serratia marcescens "<img src=""7439.png"">" Microbiology
basic-bacteriology duplicate pigment-producing-bacteria
A man has a catheter that is harboring biofilm-producing bacteria. What type of
bacterium is this, and where else can it be found? It is likely S epidermidis;
found in catheters and prosthetic devices and causes endocarditis in IV drug users
"<img src=""7440.png"">" Microbiology basic-bacteriology duplicate in-
vivo-biofilm-producing-bacteria
What biofilm-producing bacterial strain is associated with dental plaque and
infective endocarditis? Viridans streptococci (S mutans, S sanguinis) "<img
src=""7440.png"">" Microbiology basic-bacteriology duplicate in-vivo-biofilm-
producing-bacteria
A patient with cystic fibrosis has a chronic cough and confirmed biofilm-producing
bacterial growth. What bacterial strain is this? P aeruginosa "<img
src=""7440.png"">" Microbiology basic-bacteriology duplicate in-vivo-biofilm-
producing-bacteria
What biofilm-producing bacterium is most likely responsible for a patient's otitis
media? Nontypeable (unencapsulated) H influenzae "<img src=""7440.png"">"
Microbiology basic-bacteriology duplicate in-vivo-biofilm-producing-bacteria
A patient comes in with contact lensassociated keratitis. What biofilm-producing
bacterium is the cause? P aeruginosa "<img src=""7440.png"">" Microbiology
basic-bacteriology duplicate in-vivo-biofilm-producing-bacteria
A 16-year-old boy has a foot infection with bacteria that avoid opsonization and
phagocytosis. What protein promotes this virulence? Protein A prevents
opsonization and phagocytosis of S aureus by binding the Fc region of
immunoglobulins "<img src=""7441.png"">" Microbiology bacterial-virulence-
factors basic-bacteriology duplicate
Immunoglobulin A protease is secreted by which three bacterial species to help them
colonize which part of the body? How does it work? S pneumoniae, H influenzae
type B, Neisseria (SHiN) colonize the respiratory mucosa; IgA protease cleaves IgA
"<img src=""7441.png"">" Microbiology bacterial-virulence-factors basic-
In a patient with strep throat, what protein from group A Streptococcus prevents
phagocytosis by the body's immune cells? M protein "<img src=""7441.png"">"
Microbiology bacterial-virulence-factors basic-bacteriology duplicate
In patient with acute rheumatic fever, what bacterial virulence factor may be
responsible for the autoimmune response? M protein; it shares similar epitopes
with human cellular proteins, a phenomenon known as molecular mimicry "<img
src=""7441.png"">" Microbiology bacterial-virulence-factors basic-bacteriology
duplicate
You find bacteria with a protein able to directly deliver toxins to the eukaryotic
host cell. What other bacteria have this injectisome? Gram-negative bacteria such
as Pseudomonas, Salmonella, Shigella, and E coli have this system (also known as a
type III secretion system) "<img src=""7442.png"">" Microbiology basic-
bacteriology duplicate type-iii-secretion-system
In some gram-negative bacteria, there is a means of facilitating direct delivery of
toxins to eukaryotic host cells. What is it? An injectisome, a needle-like
protein appendage "<img src=""7442.png"">" Microbiology basic-bacteriology
duplicate type-iii-secretion-system
A bacterium transfers plasmids from one bacterium to another. What is this transfer
of information called? Conjugation or transduction "<img src=""7443.png"">"
Microbiology bacterial-genetics basic-bacteriology duplicate
Prokaryotes tend to transfer DNA by way of phage-mediated mechanisms. What is this
process called? Transduction "<img src=""7443.png"">" Microbiology
bacterial-genetics basic-bacteriology duplicate
Deoxyribonuclease is added to a petri dish growing Neisseria. What DNA is prevented
from being transferred: chromosomal, plasmid, or both? Both (the addition of
deoxyribonuclease to the environment means that all naked DNA will be degraded,
resulting in no transformation) "<img src=""7443.png"">" Microbiology
bacterial-genetics basic-bacteriology duplicate
Some bacteria can take up naked DNA from the environment. What is the process
called, and which three bacteria do it most often? Transformation (competence);
SHiN = Streptococcus pneumoniae, Haemophilus influenzae, Neisseria "<img
src=""7443.png"">" Microbiology bacterial-genetics basic-bacteriology
duplicate
What type of conjugation process does not involve the transfer of chromosomes, and
how does it work? In F+ to F conjugation, plasmids are transferred from the F+
cell through a mating bridge; no chromosomal DNA is transferred "<img
src=""7443.png"">" Microbiology bacterial-genetics basic-bacteriology
duplicate
You're conducting an experiment in which DNA segments are transferred between
chromosomes and plasmids in the same cell. Name the process. Transposition
"<img src=""7443.png"">" Microbiology bacterial-genetics basic-
Transposition is done between a plasmid and vancomycin-resistant Enterococcus & S
aureus. How does S aureus become vancomycin resistant? Flanking chromosomal DNA
is incorporated into plasmid and incorporated into another bacterium (eg, the vanA
gene to S aureus) "<img src=""7443.png"">" Microbiology bacterial-genetics
In an experiment, you see a cell incorporating an F+ plasmid into its own
chromosomes. Name the result of this bacterial genetics process. High-frequency
recombination (Hfr) cell "<img src=""7443.png"">" Microbiology bacterial-
genetics basic-bacteriology duplicate
Describe generalized transduction. Lytic phage infects bacteria, cleaves bacterial
DNA/makes viral DNA, and repackages bacterial DNA in viral capsids to infect other
bacteria "<img src=""7443.png"">" Microbiology bacterial-genetics basic-
You are performing an experiment with cholera toxin encoded in a phage. Describe
how the phage helps the toxin undergo transduction. Lysogenic phage infects
bacteria, inserts viral DNA into chromosomesviral (and bacterial) DNA excised into
capsid infects other bacteria "<img src=""7443.png"">" Microbiology bacterial-
genetics basic-bacteriology duplicate
During what bacterial genetic process is chromosomal DNA is not transferred? F+
F conjugation "<img src=""7443.png"">" Microbiology bacterial-genetics
Describe the process and specify how DNA is transferred in bacteria that engage in
specialized transduction. Lysogenic phage infected by bacterium; viral DNA
incorporated into chromosomal DNA; DNA packaged in phage viral capsules; capsules
released "<img src=""7443.png"">" Microbiology bacterial-genetics basic-
Name five bacterial toxins coded for in a lysogenic phage. Group Astrep
erythrogenic toxin, Botulinum toxin, Cholera toxin, Diphtheria toxin, Shiga toxin
(ABCD'S) "<img src=""7443.png"">" Microbiology bacterial-genetics basic-
In the OR, you explain to your peers that it is critical to autoclave surgical
equipment for what purpose? How long? At what temperature? To kill bacterial
spores; 15 minutes; 121C "<img src=""7444.png"">" Microbiology basic-
bacteriology duplicate spore-forming-bacteria
Spores can be formed by bacteria when nutrients are limited. What is typically
found at the spore core? Dipicolinic acid "<img src=""7444.png"">"
Microbiology basic-bacteriology duplicate spore-forming-bacteria
What disease does a patient with B anthracis have? Anthrax "<img
src=""7444.png"">" Microbiology basic-bacteriology duplicate spore-forming-
bacteria
What disease does a patient with B cereus have? Food poisoning "<img
bacteria
What disease does a patient with C botulinum have? Botulism "<img
bacteria
What disease does a patient with C difficile infection have? Pseudomembranous
colitis "<img src=""7444.png"">" Microbiology basic-bacteriology duplicate
spore-forming-bacteria
What disease does a patient with C perfringens infection have? Gas gangrene
spore-forming-bacteria
What disease does a patient with C tetani infection have? Tetanus "<img
bacteria
Where are endotoxins typically found? Where are exotoxins typically found?
Endotoxins are found in most gram-negative bacteria (outer membrane); both
gram-positive and gram-negative bacteria can have exotoxins"<img src=""7445.png"">"
Microbiology basic-bacteriology duplicate main-features-of-exotoxins-and-
endotoxins
What type of toxin does a gram-negative bacterium's outer cell membrane secrete?
How fatal is the dose? Endotoxin; low (hundreds of micrograms needed to cause
death) "<img src=""7445.png"">" Microbiology basic-bacteriology duplicate
main-features-of-exotoxins-and-endotoxins
What type of toxin does a staphylococcal bacterium secrete? How fatal is the dose?
Exotoxin; very toxic (1 g can be fatal) "<img src=""7445.png"">"
endotoxins
If the plasmid/bacteriophage is destroyed, which toxin's genes are destroyed?
Exotoxin "<img src=""7445.png"">" Microbiology basic-bacteriology
duplicate main-features-of-exotoxins-and-endotoxins
A febrile man with septic shock has bacteria with poorly antigenic toxins in his
blood. Which cytokine's induction caused this condition? Endotoxin induction of
TNF, IL-1, and IL-6 "<img src=""7445.png"">" Microbiology basic-
bacteriology duplicate main-features-of-exotoxins-and-endotoxins
Where are endotoxin genes located? Bacterial chromosome "<img src=""7445.png"">"
endotoxins
What are exotoxins are composed of? Polypeptides "<img src=""7445.png"">"
endotoxins
What are endotoxins composed of? The lipid A component of LPS (a bacterium's
structural part)lysis releases it "<img src=""7445.png"">" Microbiology
basic-bacteriology duplicate main-features-of-exotoxins-and-endotoxins
Which bacterial toxin (endotoxin or exotoxin) can be used to produce a vaccine?
Against which antigen are antibodies formed? Exotoxin toxoid is used as a
vaccine against exotoxin-producing organisms (antibodies called antitoxins are
formed against antigens) "<img src=""7445.png"">" Microbiology basic-
bacteriology duplicate main-features-of-exotoxins-and-endotoxins
What type of toxin is typically heat stable? Endotoxins are stable at 100C for
1 hour "<img src=""7445.png"">" Microbiology basic-bacteriology duplicate
main-features-of-exotoxins-and-endotoxins
Which type of toxin is typically destroyed at 60C? Exotoxins (rapid destruction
at 60C); staphylococcal enterotoxin is one exception "<img src=""7445.png"">"
endotoxins
What type of toxin causes tetanus, botulism, and diphtheria? Exotoxin "<img
src=""7445.png"">" Microbiology basic-bacteriology duplicate main-features-of-
exotoxins-and-endotoxins
What type of toxin causes sepsis and meningococcemia? Endotoxin "<img
src=""7445.png"">" Microbiology basic-bacteriology duplicate main-features-of-
exotoxins-and-endotoxins
Name the 10 organisms with ADP-ribosylating A-B toxins. C diphtheriae, P
aeruginosa, Shigella spp, E coli (EHEC & ETEC), B anthracis, V cholerae, B
pertussis, C tetani, C botulinum "<img src=""7446.png"">" Microbiology
basic-bacteriology bugs-with-exotoxins duplicate
A 16-year-old with shock is admitted with S aureus infection. Name three toxins
produced by this bug. The respective associated symptoms? Toxic shock syndrome
toxin (TSST-1), exfoliative toxin, enterotoxin; associated with fever, and rash
scalded skin syndrome& food poisoning "<img src=""7446.png"">" Microbiology
A patient has an ADP-ribosylating A-B toxin whose primary action is overactivation
of adenylate cyclase. Name three possible toxins. V cholerae, enterotoxigenic E
coli (ETEC), and B pertussis "<img src=""7446.png"">" Microbiology basic-
bacteriology bugs-with-exotoxins duplicate
A patient with scarlet fever has erythrogenic toxins in her blood. What toxin is to
blame for her symptoms? Exotoxin A, which causes toxic shock syndrome (fever, rash,
shock; this is S pyogenes) "<img src=""7446.png"">" Microbiology basic-
A boy with pharyngitis has a pseudomembrane in his throat. A toxin is to blame.
What is the toxin's mechanism of action? This toxin ADP-ribosylates elongation
factor 2 to inactivate it (this is C diphtheriae) "<img src=""7446.png"">"
Microbiology basic-bacteriology bugs-with-exotoxins duplicate
In a patient with toxic shock, where do the superantigens bind? What is
subsequently released to cause the symptoms of shock? Superantigens bind MHC II
molecules and TCR; overwhelming release of IFN-, IL-2, IL-1, and TNF- eventually
causes shock "<img src=""7446.png"">" Microbiology basic-bacteriology
bugs-with-exotoxins duplicate
A girl has rice-water diarrhea and is dehydrated. A toxin is to blame. What is its
mechanism of action? A-B toxin activates Gs protein and stimulates adenylate
cyclase, increasing Cl (and thus water) secreted in gut (this is V cholerae)
"<img src=""7446.png"">" Microbiology basic-bacteriology bugs-with-
exotoxins duplicate
A patient has a fever and rash and goes into shock. What are the two most likely
causative bacteria and their associated toxins? S aureus (toxic shock syndrome
toxin [TSST-1]) and S pyogenes (exotoxin A) "<img src=""7446.png"">"
What are the mechanisms of the heat-labile and heat-stable toxins of
enterotoxigenic E coli (ETEC)? Heat-labile overactivates adenylate cyclase
(more Cl, H2O secretion); heat-stable activates guanylate cyclase (less NaCl, H2O
resorption) "<img src=""7446.png"">" Microbiology basic-bacteriology bugs-
with-exotoxins duplicate
A trauma victim has foul-smelling necrotic skin lesions w/ myonecrosis; crepitus is
seen. How does the infecting agent appear on blood agar? C perfringens alpha
toxin (causing gas gangrene through phospholipid degradation) forms a double zone
of hemolysis on blood agar "<img src=""7446.png"">" Microbiology basic-
A 10-year-old girl has 2 months of coughing fits, after which she fights to catch
her breath. What is the mechanism of the offending toxin? B pertussis disables the
Gi protein (overactivates adenylate cyclase), which impairs phagocytosis, allowing
bacterial survival "<img src=""7446.png"">" Microbiology basic-
A man presents with a new heart murmur after a recent bout of pharyngitis. Name a
diagnostic test to confirm the most likely diagnosis. Look for the presence of
antistreptolysin O (ASO) antibodies (this is likely rheumatic fever) "<img
src=""7446.png"">" Microbiology basic-bacteriology bugs-with-exotoxins
duplicate
A patient tests positive for tetanospasmin. What symptoms does he have, and low
levels of what neurotransmitters are to blame? Spastic paralysis (risus sardonicus
or lockjaw); tetanus toxin blocks inhibitory neurotransmitter release (glycine,
GABA) by cleaving SNARE "<img src=""7446.png"">" Microbiology basic-
A man recovering from trauma has a foul-smelling, necrotic skin lesion and
crepitus. Explain the mechanism of action of the causative toxin. C
perfringens -toxin is a phospholipase that degrades phospholipid C, causing tissue
and cell membrane necrosis (myonecrosis) "<img src=""7446.png"">" Microbiology
A boy with a sweet tooth exhibits flaccid paralysis, mainly facial. What food did
he likely ingest? What is the disease mechanism? C botulinum in honey (or
canned food); inhibits release of stimulatory Ach at neuromuscular junction by
cleaving SNARE "<img src=""7446.png"">" Microbiology basic-bacteriology
A toddler has rheumatic fever. ASO titers are positive. Name the offending toxin.
Explain its mechanism. With what can ASO be confused? Streptolysin O; degrades cell
membranes and lyses RBCs, causing -hemolysis; can be confused w/ immune complexes
of strep glomerulonephritis "<img src=""7446.png"">" Microbiology basic-
Shigella and EHEC share a mechanism for causing GI mucosal damage and dysentery.
What is it? Both Shiga toxin and Shiga-like toxin cleave host cell rRNA,
inactivating the 60S ribosomal subunit by removing adenine from rRNA "<img
src=""7446.png"">" Microbiology basic-bacteriology bugs-with-exotoxins
duplicate
A 56-year-old goat herder discovers a painless black ulcer on his arm. What
organism is responsible? What is the mechanism of its toxin? B anthracis causes
anthrax; edema factor toxin mimics adenylate cyclase (increases cAMP), causing
edematous borders of black eschar "<img src=""7446.png"">" Microbiology
A 16-year-old with shock is admitted with S aureus infection. Name three toxins
produced by this bug. The respective associated symptoms? Toxic shock syndrome
toxin (TSST-1), exfoliative toxin, enterotoxin; associated with fever, and rash
scalded skin syndrome& food poisoning "<img src=""7446.png"">" Microbiology
At a cookout, a girl becomes ill. Labs show increased cytokine levels secondary to
a toxin. What is the toxin's mechanism of action? Causes enhanced cytokine
release (this is hemolytic-uremic syndrome [HUS] due to Shiga toxin) (note that
Shiga-like toxin also causes HUS) "<img src=""7446.png"">" Microbiology
blame for her symptoms? Exotoxin A, which causes toxic shock syndrome (fever, rash,
shock) (this is S pyogenes) "<img src=""7446.png"">" Microbiology basic-
A 16-year-old with shock is admitted with S aureus. Name three toxins produced by
this bug and respective associated symptoms. Toxic shock syndrome toxin (TSST-
1), exfoliative toxin, enterotoxin; associated with fever, and rashscalded skin
syndrome& food poisoning "<img src=""7446.png"">" Microbiology basic-
Certain bacteria, such as C diphtheriae, have ADP-ribosylating A-B toxins. Name the
functions of the A and B components. B component Binds and triggers
endocytosis; A component (taken up) is Active (eg, ADP ribosyltransferases and
other enzymatic activities) "<img src=""7446.png"">" Microbiology basic-
blame for her symptoms? Exotoxin A, causing toxic shock syndrome (fever, rash,
shock) (this is S pyogenes) "<img src=""7446.png"">" Microbiology basic-
A terrified patient presents with risus sardonicus, spasticity, and lockjaw. What
is the likely mechanism of the causative exotoxin? Tetanospasmin is a protease
that cleaves soluble NSF attachment protein receptor (SNARE), needed for
neurotransmitter release "<img src=""7446.png"">" Microbiology basic-
An Oregon trail traveler has dysentery. You suspect it is likely from EHEC. What is
the difference between EHEC and Shigella manifestations? EHEC does not invade
host cells but has Shiga-like toxin, which inactivates 60S ribosomes and causes
cytokine release, causing HUS/dysentery "<img src=""7446.png"">" Microbiology
A patient has ETEC, as well as overactivated guanylate cyclase. What toxin is
responsible? How does it cause diarrhea? Heat-stable toxin is responsible; it
decreases reabsorption of NaCl and water in the gut "<img src=""7446.png"">"
A man is infected with bacteria that produce exotoxin A, which induces host cell
death. Identify the pathogen and the exotoxin mechanism. This is P aeruginosa
infection; exotoxin A works by inactivating elongation factor (EF-2) to trigger
host cell death "<img src=""7446.png"">" Microbiology basic-bacteriology
A man has had a cough for 3 months. He is a teacher and has many pupils who were
never vaccinated. Identify the exotoxin involved. "He has B pertussis
infection, which produces the pertussis toxin that overactivates adenylate cyclase
(causes a ""100-day cough"" in adults)" "<img src=""7446.png"">" Microbiology
What is the chemical composition of endotoxin? Where is it found?
Lipopolysaccharide (LPS); cell walls of gram-negatives (endotoxin is an
integral part of the cell wall of gram-negative bacteria) "<img src=""7447.png"">"
Microbiology basic-bacteriology duplicate endotoxin
What is the primary toxic component of an endotoxin? Which components of the immune
response does this agent directly activate? Lipid A; macrophages (via TLR4),
complements (C3a and C5a), tissue factor "<img src=""7447.png"">" Microbiology
basic-bacteriology duplicate endotoxin
In endotoxin-based complement activation, which complement(s) cause(s)
hypotension/edema and histamine release? Neutrophil chemotaxis? C3a and C5a; C5a
endotoxin
What factor causes endotoxins to activate the coagulation cascade? What condition
can result from excessive stimulation of this pathway? Tissue factor;
disseminated intravascular coagulation (DIC) "<img src=""7447.png"">"
Microbiology basic-bacteriology duplicate endotoxin
Endotoxin activation of macrophages causes release of three cytokines. Name the
cytokines. What sign(s)/symptom(s) does each cause? IL-1 and IL-6 cause fever,
TNF- causes both fever and hypotension, and nitric oxide causes hypotension "<img
src=""7447.png"">" Microbiology basic-bacteriology duplicate endotoxin
What is the mnemonic used to recall the effects and characteristics of endotoxins?
ENDOTOXINS: Edema, NO, DIC/Death , Outer membrane, TNF-, O-antigen,
eXtremely heat stable, IL-1/IL-6, Neutrophil chemotaxis, Shock "<img
src=""7447.png"">" Microbiology basic-bacteriology duplicate endotoxin
A man has E coli that has caused significant fever, hypotension, and edema. What
component of the bacteria is responsible for his symptoms? LPS in the outer
membranes of gram-negative bacteria (eg, E coli) activates macrophages, complement
& tissue factor to cause symptoms "<img src=""7447.png"">" Microbiology
basic-bacteriology duplicate endotoxin
A company would like to target the E coli endotoxin with a new antibiotic. Where is
this endotoxin found? The outer membranes of gram-negative bacteria (both cocci
and rods) "<img src=""7447.png"">" Microbiology basic-bacteriology duplicate
endotoxin
What is LPS composed of? O antigen, lipid A (the toxic component), and core
polysaccharide "<img src=""7447.png"">" Microbiology basic-bacteriology
duplicate endotoxin
You are studying the effects of the lipid A component in LPS. How does this
endotoxin differ from exotoxin? Endotoxin is released on cell lysis or by
living cells; blebs detach from the outer surface membrane; exotoxins are actively
secreted "<img src=""7447.png"">" Microbiology basic-bacteriology duplicate
endotoxin
What are the three main effects of endotoxins? The three main effects are tissue
factor activation, macrophage activation (by way of TLR4), and complement
activation "<img src=""7447.png"">" Microbiology basic-bacteriology duplicate
endotoxin
You culture a cellulitis sample, suspecting a Staphylococcus species as the cause.
How can you differentiate the three main species? S aureus is coagulase
positive; of the coagulase-negative species, S epidermidis is novobiocin sensitive
and S saprophyticus is resistant "<img src=""7448.png"">" Microbiology
clinical-bacteriology duplicate gram-positive-lab-algorithm
You find gram-positive bacilli in a specimen. Of the four possible gram-positive
rods, which one is anaerobic? Clostridium, Listeria, Bacillus, and Corynebacterium;
Clostridium is anaerobic "<img src=""7448.png"">" Microbiology clinical-
bacteriology duplicate gram-positive-lab-algorithm
You note an aerobic, gram-positive, acid-fast branching filament. What bacterium is
most often confused with the one you see on the plate? Nocardia is growing on
the plate; Actinomyces is commonly confused with Nocardia but is neither aerobic
nor acid-fast stainable "<img src=""7448.png"">" Microbiology clinical-
bacteriology duplicate gram-positive-lab-algorithm
You culture a sputum sample, suspecting either Staphylococcus or Streptococcus.
With which two methods can you differentiate the bacteria? Staphylococcus is
catalase positive/grows in clusters, and Streptococcus is catalase negative/grows
in chains (both are gram-positive cocci) "<img src=""7448.png"">" Microbiology
clinical-bacteriology duplicate gram-positive-lab-algorithm
Chest x-ray of a 70-year-old man with a cough shows left lower lobe pneumonia. What
hemolysis pattern does the most likely pathogen exhibit? It exhibits green
partial (-) hemolysis (S pneumoniae is the most common cause of pneumonia) "<img
src=""7448.png"">" Microbiology clinical-bacteriology duplicate gram-positive-
lab-algorithm
On agar, what type of hemolysis is partial (green) hemolysis? What about complete
(clear) hemolysis? What about absent hemolysis? ; ; "<img src=""7448.png"">"
Microbiology clinical-bacteriology duplicate gram-positive-lab-algorithm
A Streptococcus culture exhibits partial (, green) hemolysis. How will you further
categorize the species? Viridans streptococci: no capsule, optochin resistant/bile
insoluble; S pneumoniae: has capsule, optochin sensitive/bile soluble "<img
lab-algorithm
An aerobic catalase-negative culture of cocci in chains exhibits complete
hemolysis. How will you further categorize the species? These are Streptococci
exhibiting -hemolysis: S pyogenes is bacitracin sensitive and S agalactiae is
resistant "<img src=""7448.png"">" Microbiology clinical-bacteriology
duplicate gram-positive-lab-algorithm
You have a culture of gram-positive, catalase-negative cocci that are -hemolytic
and fail to grow in 6.5% NaCl. Do they grow in bile? Yes; these are
nonenterococcus bacteria (eg, S bovis), which will grow in bile "<img
lab-algorithm
Your culture of gram-positive, catalase-negative cocci exhibits no hemolysis. How
will you further identify the species? Nonenterococci species (eg, S bovis) will
grow in bile but not in 6.5% NaCl; enterococci are the opposite "<img
lab-algorithm
Some -hemolytic cocci are bile soluble. Name the bug. What is bile doing to the
organism? Is any -hemolytic bug not bile soluble? The bug is S pneumoniae; the
bile is lysing the bacteria; viridans streptococci (also -hemolytic) are not lysed
by bile "<img src=""7448.png"">" Microbiology clinical-bacteriology
Which organism may be either -hemolytic or -hemolytic? Enterococcus "<img
lab-algorithm
Your sick patient's blood cultures are now growing coagulase-negative
Staphylococcus. Are you worried about S aureus infection? No; S aureus is
coagulase positive (coagulase-negative strains are common contaminants in blood
cultures) "<img src=""7448.png"">" Microbiology clinical-bacteriology
A urine culture from your patient is growing a catalase-positive organism. Does
this increase your suspicion of S saprophyticus? Yes; S saprophyticus is
catalase positive (as are all Staphylococcus strains) "<img src=""7448.png"">"
Microbiology clinical-bacteriology duplicate gram-positive-lab-algorithm
In the lab you have a coagulase-negative Staphylococcus bacterium. You notice that
it is novobiocin negative. Identify it. "Saprophyticus is Resistant; Epidermidis
is Sensitive NO StRESs on the office ""staph"" retreat)" "<img src=""7449.png"">"
Microbiology clinical-bacteriology duplicate gram-positive-cocci-antibiotic-
tests
In the lab, you have a coagulase-negative Staphylococcus bacterium. You notice that
it is novobiocin positive. Identify it. "Saprophyticus is Resistant; Epidermidis
is Sensitive (NO StRESs on the office ""staph"" retreat)" "<img src=""7449.png"">"
tests
In the lab, you identify a -hemolytic strain of Streptococcus. It is found to be
bacitracin-resistant. Identify the strain. To Bacitracin, Group B streptococci
are Resistant; group A streptococci are Sensitive (B-BRAS) "<img src=""7449.png"">"
tests
In the lab, you identify a -hemolytic strain of Streptococcus and find that it's
bacitracin sensitive. Identify the strain. To Bacitracin, Group B streptococci
are Resistant; group A streptococci are Sensitive (B-BRAS) "<img src=""7449.png"">"
tests
In the lab you see a strain of Streptococcus showing partial hemolysis. If the
bacteria is optochin resistant, what is the specific strain? Optochin; S
Viridans is Resistant, but S Pneumoniae is Sensitive (OVRPS (overpass) "<img
cocci-antibiotic-tests
A patient presents with a strain of bacteria that is novobiocin sensitive and
coagulase negative. Identify the specific strain. S epidermidis "<img
cocci-antibiotic-tests
In the lab, you see a strain of Streptococcus with partial hemolysis. If the
bacteria is optochin sensitive, what is the specific strain? Optochin: Viridans
is Resistant, Pneumoniae is Sensitive (OVRPS [overpass]) "<img src=""7449.png"">"
tests
You culture two different -hemolytic species. What is the catalase and optochin
status of each? S pneumoniae is optochin sensitive, and viridans streptococci are
resistant; all are catalase negative "<img src=""7450.png"">" Microbiology
a-hemolytic-bacteria clinical-bacteriology duplicate
A patient has the blood agar finding shown in the image. Name two examples of
bacteria that would appear like this. S pneumoniae and viridans streptococci
(one sees brownish/greenish rings around colonies because of partial reduction on
blood agar) "<img src=""7450.png"">" Microbiology a-hemolytic-bacteria
clinical-bacteriology duplicate
A newborn has meningitis. His mother's antenatal vaginal swab grew catalase-
negative, bacitracin-resistant gram-positive cocci. Diagnosis? S agalactiae
(group B strep) meningitis "<img src=""7451.png"">" Microbiology::clinical-
bacteriology::-hemolytic-bacteria
In microbiology lab, you identify a -hemolytic organism that is both catalase and
coagulase positive. What organism did you find? S aureus "<img src=""7451.png"">"
Microbiology clinical-bacteriology duplicate -hemolytic-bacteria
Blood agar grows both S pyogenes and S agalactiae. What makes them both different
from S aureus? Both are catalase-negative, unlike S aureus, which is catalase
positive "<img src=""7451.png"">" Microbiology clinical-bacteriology::-
hemolytic-bacteria
Name six inflammatory diseases that can result from infection with S aureus. Skin
infection, organ abscess, pneumonia (often after influenza virus infection),
endocarditis, septic arthritis, and osteomyelitis "<img src=""7452.png"">"
Microbiology clinical-bacteriology duplicate staphylococcus-aureus
What is the mechanism of action of S aureus protein A (virulence factor)? It
binds the Fc region of immunoglobulin G (Fc-IgG), inhibiting complement activation
and phagocytosis "<img src=""7452.png"">" Microbiology clinical-bacteriology
duplicate staphylococcus-aureus
One man has toxic shock syndrome, another scalded skin syndrome, yet another rapid-
onset food poisoning. Can a single organism be to blame? Yes; all are caused by
toxins released by S aureus (TSST-1, exfoliative toxin, and preformed enterotoxin,
respectively) "<img src=""7452.png"">" Microbiology clinical-bacteriology
duplicate staphylococcus-aureus
A woman leaves her tampon in for too long and develops an infection that leads to
shock. What bacterial toxin is likely responsible? TSST-1 produced by S aureus
(this can also happen with nasal tampons) "<img src=""7452.png"">" Microbiology
clinical-bacteriology duplicate staphylococcus-aureus
A teen with nasal packing presents with fever, vomiting, rash, desquamation, and
shock. Explain the pathogenesis of the causative toxin. Toxic shock syndrome
caused by TSST-1, a superantigen that binds MHC II and T-cell receptors, resulting
in polyclonal T-cell activation "<img src=""7452.png"">" Microbiology
A man has nonbloody diarrhea and emesis after eating food contaminated with S
aureus. What is the causative toxin's incubation period? Preformed S aureus
enterotoxins that cause food poisoning have a short incubation period, 26 hours
"<img src=""7452.png"">" Microbiology clinical-bacteriology duplicate
staphylococcus-aureus
A patient has MRSA. What protein is altered in MRSA that grants resistance to -
lactams? Name two drugs that are useless against MRSA. Penicillin-binding
protein; methicillin and nafcillin "<img src=""7452.png"">" Microbiology
A patient is found to have S aureus. Describe the clinical significance of the
organism's being coagulase positive. It allows the organism to form a fibrin
clot around itself, permitting abscess formation "<img src=""7452.png"">"
Microbiology clinical-bacteriology duplicate staphylococcus-aureus
You are terrified of S aureus food poisoning and overcook your food. Does this
help? No; the enterotoxin is heat stable and not destroyed by cooking "<img
src=""7452.png"">" Microbiology clinical-bacteriology duplicate
How do you distinguish S aureus from streptococci in the lab? Staph makes
catalase; strep does not (staph makes catalase because it has more staff) "<img
A scientist working on MRSA knocks out the bacteria's penicillinases but finds that
the bug is still resistant to several penicillins. Why? MRSA alters its
penicillin-binding proteins to resist killing by penicillinase-stable penicillins
(eg, methicillin, oxacillin, nafcillin) "<img src=""7452.png"">" Microbiology
A patient has TSS. How would the presentation be different if the patient had S
aureus TSS versus S pyogenes TSS? S aureus TSS = fever, vomiting, rash,
desquamation, shock, and end-organ failure; S pyogenes TSS = painful skin infection
A teenager leaves her tampon in too long and presents with fever, vomiting, and
shock. What notable findings will the labs reveal? High AST, ALT, and bilirubin
S aureus most commonly colonizes which part of the body? The nares "<img
What novobiocin-sensitive bacterium found in normal skin flora commonly
contaminates blood cultures and infects prosthetics and catheters? S
epidermidis "<img src=""7453.png"">" Microbiology clinical-bacteriology
duplicate staphylococcus-epidermidis
What property of S epidermidis allows it to infect prosthetic devices (eg, hip
implants, heart valves) and IV catheters with ease? It produces an adherent
biofilm "<img src=""7453.png"">" Microbiology clinical-bacteriology
duplicate staphylococcus-epidermidis
A woman has a nonE coli UTI with the second most common UTI organism for her
demographic. Is it novobiocin sensitive? No, it is resistant (this is S
saprophyticus, the second most common cause of uncomplicated UTIs in young women
after E coli) "<img src=""7454.png"">" Microbiology clinical-bacteriology
duplicate staphylococcus-saprophyticus
A woman has a UTI with gram-positive, catalase-positive, urease-positive cocci in
clusters. What would you find if you tested for coagulase? S saprophyticus: gram-
positive, catalase-positive, coagulase-negative, urease-positive cocci in clusters
staphylococcus-saprophyticus
A plate in the microbiology lab grows novobiocin-sensitive gram-positive cocci in
clusters. Where is this bacterium considered normal flora? The patient likely has S
saprophyticus, which is considered part of the normal flora of the female genital
tract and perineum "<img src=""7454.png"">" Microbiology clinical-
bacteriology duplicate staphylococcus-saprophyticus
A culture grows gram-positive lancet-shaped diplococci. Name the four illnesses
most commonly caused by infection with this bacteria. Meningitis, otitis media (in
children), pneumonia, sinusitis "<img src=""7455.png"">" Microbiology
clinical-bacteriology duplicate streptococcus-pneumoniae
You are told that a patient has S pneumoniae sepsis. In what two patient
populations does this occur at a higher rate? People with sickle cell disease and
asplenic patients "<img src=""7455.png"">" Microbiology clinical-bacteriology
duplicate streptococcus-pneumoniae
Name two ways in which S pneumoniae evades the immune system. Immunoglobulin A
(IgA) protease and encapsulation "<img src=""7455.png"">" Microbiology
clinical-bacteriology duplicate streptococcus-pneumoniae
A man presents with dental caries. What bacteria, part of the normal oropharyngeal
flora, likely caused the patient's infection? S mutans and S mitis "<img
src=""7456.png"">" Microbiology clinical-bacteriology duplicate viridans-
group-streptococci
In the lab, you discover a bacterium that is -hemolytic. Which test distinguishes
S pneumoniae from S viridans? Optochin sensitivity test (S viridans lives in the
mouth, unafraid of the chin [op-to-chin resistant]) "<img src=""7456.png"">"
Microbiology clinical-bacteriology duplicate viridans-group-streptococci
A man has bacterial endocarditis caused by a viridans group streptococcus. What
allows the bacteria to damage his heart? S sanguinis makes dextrans that bind to
fibrin-platelet aggregates on damaged heart valves (sanguinis = blood, in the
heart) "<img src=""7456.png"">" Microbiology clinical-bacteriology
duplicate viridans-group-streptococci
A 4-year-old boy with recent pharyngitis has tea-colored urine. Name the illness
and causative agent. What other illness(es) may arise? Acute
glomerulonephritis; S pyogenes; rheumatic fever & pharyngitis (pharyngitis can
cause rheumatic phever & glomerulonephritis) "<img src=""7457.png"">"
Microbiology clinical-bacteriology duplicate streptococcus-pyogenes-(group-a-
streptococci)
S pyogenes can produce toxigenic exotoxins that can cause which three conditions?
Scarlet fever, toxic shocklike syndrome, and necrotizing fasciitis "<img
src=""7457.png"">" Microbiology clinical-bacteriology duplicate streptococcus-
pyogenes-(group-a-streptococci)
A patient recently had S pyogenes infection. You test for antibodies to M protein
to assess the patient's risk of what condition? Rheumatic feverantibodies to M
protein enhance host defense against S pyogenes but can result in rheumatic fever
streptococcus-pyogenes-(group-a-streptococci)
You suspect that your patient has had a recent S pyogenes infection. What blood
test do you order? Antistreptolysin O titer "<img src=""7457.png"">"
streptococci)
A colleague tells you that a patient in the ED meets the Jones criteria. Explain
the criteria. Name the diagnosis. JNES: Joints (polyarthritis), (carditis),
Nodules (subcutaneous), Erythema marginatum, Sydenham chorea; rheumatic fever
streptococcus-pyogenes-(group-a-streptococci)
A girl presents with a strawberry tongue, circumoral pallor, sore throat, fever,
and sandpaper-like body rash. Name the causative agent. S pyogenes (this is
scarlet fever caused by the erythrogenic toxin) "<img src=""7457.png"">"
streptococci)
A 4-year-old boy presents with a puffy face and tea-colored urine. Evidence of what
recent skin infection is noted on examination? Impetigo, caused by S pyogenes,
which more commonly precedes glomerulonephritis than pharyngitis "<img
A patient presents with impetigo. To which topical antibiotic is the most likely
causative organism sensitive? Bacitracin (impetigo is caused by S pyogenes) "<img
A patient has cellulitis from a pyrrolidonyl arylamidase (PYR)positive bug. Name
two immunologic disorders caused by this pathogen. Rheumatic fever,
glomerulonephritis (this is S pyogenes infection) "<img src=""7457.png"">"
streptococci)
A newborn has meningitis. Mom did not receive penicillin prophylaxis. What
bacterium is responsible, and what hemolysis pattern is seen? It is likely S
agalactiae, which is -hemolytic "<img src=""7458.png"">" Microbiology
clinical-bacteriology duplicate streptococcus-agalactiae-(group-b-streptococci)
In what population does group B S agalactiae cause pneumonia, meningitis, and
sepsis? Babies (group B for Babies) "<img src=""7458.png"">" Microbiology
clinical-bacteriology duplicate streptococcus-agalactiae-(group-b-streptococci)
You add S agalactiae to a culture of S aureus to generate an enlarged area of
hemolysis. Name the causative factor for this finding. CAMP factor made by S
agalactiae (CAMP stands for the authors of the test, not cyclic AMP) "<img
agalactiae-(group-b-streptococci)
A 25-year-old woman presents at week 36 of gestation. For what bacterium should you
screen at this time? S agalactiae, which colonizes the vagina and can be
transmitted to the neonate during deliveryscreen at 3537 weeks "<img
Hippurate test is positive in a 37 weeks' pregnant woman. Cultures show bacitracin
resistance and -hemolytic bacteria. What prophylaxis? Intrapartum penicillin
prophylaxis for S agalactiae infection to prevent neonatal meningitis, pneumonia,
and sepsis "<img src=""7458.png"">" Microbiology clinical-bacteriology
duplicate streptococcus-agalactiae-(group-b-streptococci)
A 38 weeks' pregnant woman has gram-positive cocci and PYR-negative bacteria
growing on culture. What is baby at risk for without treatment? Group B
streptococcal infection causes pneumonia, meningitis, and sepsis in Babies "<img
A patient contracts a serious S bovis infection. What two complications are
possible? Bacteremia and subacute endocarditis "<img src=""7459.png"">"
Microbiology clinical-bacteriology duplicate streptococcus-bovis
A 25-year-old patient with S bovis infection should be counseled on an increased
risk of what type of cancer? Colon cancer (Bovis in the Blood = Cancer in the
Colon) "<img src=""7459.png"">" Microbiology clinical-bacteriology
duplicate streptococcus-bovis
Typically, what part of the body does S bovis colonize? The gut "<img
bovis
What subtype of S bovis is most strongly associated with colon cancer? S
gallolyticus, biotype 1 of S bovis) "<img src=""7459.png"">" Microbiology
clinical-bacteriology duplicate streptococcus-bovis
A patient has an enterococcal biliary tract infection. What lab test can
differentiate these bacteria from nonenterococcal group D bacteria? Enterococci
grow in 6.5% sodium chloride and bile; nonenterococcal group D bacteria cannot
enterococci
What type of hemolysis is induced by Enterococcus species? Enterococcus species
exhibit variable hemolysis "<img src=""7460.png"">" Microbiology clinical-
bacteriology duplicate enterococci
A patient contracts a nosocomial infection that is notably resistant to vancomycin
therapy. What is the most likely causative organism? Vancomycin-resistant
enterococci (VRE; a major cause of nosocomial infections) "<img src=""7460.png"">"
Microbiology clinical-bacteriology duplicate enterococci
Subacute endocarditis develops after a patient undergoes gastric bypass surgery.
What is the likely causative organism? Enterococci; patients are prone to such
infections after gastrointestinal and genitourinary procedures "<img
src=""7460.png"">" Microbiology clinical-bacteriology duplicate enterococci
In a man with confirmed E faecium infection, what should you look for besides UTIs
and subacute endocarditis? Biliary tract infection "<img src=""7460.png"">"
A young woman presents to your office with a UTI caused by E faecalis. To what
antibiotic is this bacterium resistant? Penicillin G "<img src=""7460.png"">"
A man has gram-positive cocci that grow normally in the colon and resistant
penicillin G. What is the result of PYR and catalase testing? Enterococci are
catalase negative and PYR positive "<img src=""7460.png"">" Microbiology
clinical-bacteriology duplicate enterococci
In a patient with B anthracis, what are the two modes of inoculation? Cutaneous
exposure and inhalation "<img src=""7461.png"">" Microbiology bacillus-
anthracis clinical-bacteriology duplicate
A sheep farmer inhales B anthracis spores. What sort of symptoms do you expect to
arise? Flu-like symptoms, rapidly progressing to fever, mediastinitis,
pulmonary hemorrhage, and shock "<img src=""7461.png"">" Microbiology
bacillus-anthracis clinical-bacteriology duplicate
Your patient is found to have B anthracis. What is unique about the bacterium's
microscopic cellular structure? B anthracis synthesizes a polypeptide capsule
(contains D-glutamate) "<img src=""7461.png"">" Microbiology bacillus-
A man has a boil-like ulcerating lesion with a black eschar. His culture shows
gram-positive spore-forming organisms. What is the organism? B anthracis (gram-
positive spore-forming rods) "<img src=""7461.png"">" Microbiology bacillus-
A shepherd is told that he has woolsorter's disease. He has a painless papule
surrounded by vesicles. What is the organism? B anthracis (gram-positive spore-
forming rods) "<img src=""7461.png"">" Microbiology bacillus-anthracis
A patient tells you that he started vomiting about an hour after eating reheated
rice. What is the most likely causative toxin? B cereusinduced reheated rice
syndrome (caused by the preformed toxin cereulide) "<img src=""7462.png"">"
Microbiology bacilllus-cereus clinical-bacteriology duplicate
What are the two different types of presentations with B cereus infection? Emetic
type and diarrheal type "<img src=""7462.png"">" Microbiology bacilllus-cereus
A patient presents with the emetic type of B cereus infection. What foods did the
patient likely ingest to cause this? Consumption of rice or and pasta
contaminated with B cereus can cause nausea and vomiting within 15 hours "<img
src=""7462.png"">" Microbiology bacilllus-cereus clinical-bacteriology
duplicate
What symptoms are associated with the diarrheal type of B cereus infection? How
long does it take for symptoms to arise? Nonbloody watery diarrhea and GI pain
(within 818 hours) "<img src=""7462.png"">" Microbiology bacilllus-cereus
A man comes in with watery nonbloody diarrhea after eating reheated rice 9 hours
earlier. Explain how the likely infection survived heating.This is likely B cereus
infection; spores survive cooking, and rewarming the rice promotes spore
germination and enterotoxin formation "<img src=""7462.png"">" Microbiology
bacilllus-cereus clinical-bacteriology duplicate
A baby who was recently fed honey now shows signs of floppy baby syndrome. What
caused these symptoms, and what did the baby ingest? Ingestion of C botulinum
spores, classically found in honey, causes this disorder in babies "<img
src=""7463.png"">" Microbiology clinical-bacteriology clostridia-(with-
exotoxins) duplicate
Name the common treatment for the following conditions caused by C botulinum: focal
dystonia, achalasia, and muscle spasm. Local botulinum toxin injections "<img
Under the microscope, you observe gram-positive, spore-forming obligate anaerobic
bacilli. Can these organisms produce exotoxins? Very likely, because these are
Clostridium spp. "<img src=""7463.png"">" Microbiology clinical-bacteriology
clostridia-(with-exotoxins) duplicate
Name four Clostridium species that produce exotoxins. C perfringens, C botulinum, C
tetani, and C difficile "<img src=""7463.png"">" Microbiology clinical-
bacteriology clostridia-(with-exotoxins) duplicate
A 27-year-old man has spastic paralysis. Renshaw cell neurotransmitter release is
inhibited. Name the toxin. Explain how it works. Tetanospasmin exotoxin from C
tetani; blocks glycine and GABA (inhibitory neurotransmitter) release from spinal
cord Renshaw cells "<img src=""7463.png"">" Microbiology clinical-
A colleague tells you that your next patient has confirmed tetanus toxin in his
system. What symptoms do you expect this patient to exhibit? "Spastic
paralysis, trismus (lockjaw), and risus sardonicus (sustained spasm of facial
muscles resulting in a ""permanent grin"")" "<img src=""7463.png"">"
Microbiology clinical-bacteriology clostridia-(with-exotoxins) duplicate
A 25-year-old woman with lockjaw and muscle spasms presents to your practice. How
are these symptoms treated? Wound debridement, antitoxin, vaccine booster,
diazepam for the muscle spasms (this is tetanus:TETanus is TETanic paralysis)
"<img src=""7463.png"">" Microbiology clinical-bacteriology clostridia-
(with-exotoxins) duplicate
"A patient with trismus and risus sardonicus comes to your office. He asks, ""What
could I have done to prevent this?""" "You respond: ""You could have gotten a
tetanus vaccine""" "<img src=""7463.png"">" Microbiology clinical-
Flaccid paralysis develops after a man eats food from a poorly sealed can. Describe
the characteristics of the toxin that is to blame. Preformed heat-labile toxin
that inhibits neuromuscular junction ACh release, causing botulism (this is C
botulinum) "<img src=""7463.png"">" Microbiology clinical-bacteriology
clostridia-(with-exotoxins) duplicate
How does the toxin produced by C botulinum cause flaccid paralysis? Inhibits ACh
release at the neuromuscular junction "<img src=""7463.png"">" Microbiology
clinical-bacteriology clostridia-(with-exotoxins) duplicate
An adult patient presents with the symptoms of botulism. What did the individual
ingest to cause them? In adults, botulism results from ingestion of preformed
toxin from bad bottles or cans of food, juice, or honey "<img src=""7463.png"">"
A patient has severe diarrhea. Exam reveals pseudomembranous colitis. Culture shows
gram-positive spore-forming bacilli. Treatment? Metronidazole or oral vancomycin
(this is infection with C difficile [difficile causes diarrhea]) "<img
A man who just had ampicillin therapy now has diarrhea. Which toxin produced by the
causative bacteria binds the brush border of the gut? Toxin A, which is an
enterotoxin produced by C difficile "<img src=""7463.png"">" Microbiology
clinical-bacteriology clostridia-(with-exotoxins) duplicate
A 30-year-old man has a C difficile infection. What cellular changes are caused by
toxin B (cytotoxin) in his gut? Destruction of cell cytoskeletal organization
by way of actin depolymerization; causes pseudomembranous colitis and diarrhea
"<img src=""7463.png"">" Microbiology clinical-bacteriology clostridia-
(with-exotoxins) duplicate
How do you diagnose disease in a patient with suspected C difficile infection
(marked by diarrhea after antibiotic use)? On the basis of the presence of
toxin A (enterotoxin) and/or toxin B (cytotoxin) in stool, using PCR "<img
Your patient has recurring C difficile infections. What treatments would you
recommend that could prevent relapse? Repeat courses of metronidazole, oral
vancomycin or fidaxomicin, fecal transplant "<img src=""7463.png"">"
A patient with pseudomembranous pharyngitis and arrhythmias has diphtheria. What is
the toxin? How does it inhibit protein synthesis? Exotoxin (encoded on a -
prophage); by the ADP ribosylation of elongation factor 2 (EF-2) "<img
src=""7464.png"">" Microbiology clinical-bacteriology corynebacterium-
diphtheriae duplicate
A child has pseudomembranous pharyngitis and diffuse lymphadenopathy. What should
be used to culture the suspected infectious agent? Cystine-tellurite agar, on
which C diphtheriae grows black colonies "<img src=""7464.png"">" Microbiology
clinical-bacteriology corynebacterium-diphtheriae duplicate
You counsel your patients that they can prevent diphtheria by receiving what?
A toxoid vaccine, usually coadministered with a tetanus vaccine "<img
src=""7464.png"">" Microbiology clinical-bacteriology corynebacterium-
diphtheriae duplicate
The mnemonic ABCDEFG is useful for remembering key information about C diphtheriae.
Explain this mnemonic. ADP ribosylation; Beta-(-)prophage; Corynebacterium
Diphtheriae; Elongation Factor 2; Granules "<img src=""7464.png"">"
Microbiology clinical-bacteriology corynebacterium-diphtheriae duplicate
A pregnant woman is infected with a facultative intracellular microbe acquired from
cold deli meats. Current and future complications? This is Listeria; present =
amnionitis, septicemia, abortion; future = granulomatosis infantiseptica, neonatal
meningitis, gastroenteritis "<img src=""7465.png"">" Microbiology clinical-
bacteriology duplicate listeria-monocytogenes
In which two populations can L monocytogenes infection lead to meningitis? What is
the empiric treatment of meningitis for them? Neonates and the immunocompromised;
ampicillin is the empiric treatment "<img src=""7465.png"">" Microbiology
clinical-bacteriology duplicate listeria-monocytogenes
A pregnant patient wants to know how to avoid contracting L monocytogenes. How do
you counsel her? Avoid ingestion of unpasteurized milk/cheese and cold deli meats
listeria-monocytogenes
An infant has L monocytogenes infection. What are the common routes of transmission
through which she acquired the disease? Transplacental, or vaginal transmission
during birth "<img src=""7465.png"">" Microbiology clinical-bacteriology
duplicate listeria-monocytogenes
"A healthy man with L monocytogenes infection asks you, ""How did this bug avoid
the attack of my immune system?""" "They form ""rocket tails"" via actin
polymerization that allow transport through the cytoplasm and into cell membranes
(avoid host antibodies)" "<img src=""7465.png"">" Microbiology clinical-
bacteriology duplicate listeria-monocytogenes
What characteristic finding can you see while examining L monocytogenes under the
microscope in broth? Tumbling motility (L monocytogenes is also the only gram-
positive organism that produces LPS) "<img src=""7465.png"">" Microbiology
clinical-bacteriology duplicate listeria-monocytogenes
Which is an anaerobe: Actinomyces or Nocardia? Actinomyces (Nocardia is an aerobe)
nocardia-vs-actinomyces
A patient has a weakly acid-fast aerobe, usually found in soil. Which bacteria is
it likely to be: Actinomyces or Nocardia? Nocardia "<img src=""7466.png"">"
Microbiology clinical-bacteriology duplicate nocardia-vs-actinomyces
You are told that a patient has an Actinomyces infection. How would you describe
the lesions generated by the bacteria? "Oral/facial abscesses that may drain
through sinus tractsforms yellow ""sulfur granules""" "<img src=""7466.png"">"
You have a gram-positive branching filamentous bacterium growing in culture. It is
typically found in soil. Identify it. Nocardia "<img src=""7466.png"">"
One patient has an Actinomyces infection; another has a Nocardia infection. How do
you treat each patient? Sulfonamides can treat Nocardia, and Actinomyces is treated
with Penicillin (treatment is a SNAP) "<img src=""7466.png"">" Microbiology
clinical-bacteriology duplicate nocardia-vs-actinomyces
"An abscess, draining via the sinuses, contains fluid and yellow ""sulfur
granules."" Is the organism part of the normal oral flora?"Yes; this is Actinomyces
infection "<img src=""7466.png"">" Microbiology clinical-bacteriology
duplicate nocardia-vs-actinomyces
A female patient has a confirmed Actinomyces infection. For what is she at risk if
she also has an IUD? Actinomyces can cause PID in people with IUDs "<img
src=""7466.png"">" Microbiology clinical-bacteriology duplicate nocardia-vs-
actinomyces
Your immunocompromised patient has a pulmonary infection. PPD test is negative; he
has unusual cutaneous lesions. Could TMP-SMX benefit him? Yes; he may have a
severe Nocardia infection, which can mimic TB (with negative PPD findings) and
cause cutaneous infections "<img src=""7466.png"">" Microbiology clinical-
bacteriology duplicate nocardia-vs-actinomyces
In a nonimmune host (eg, a child), what kind of infection occurs after exposure to
M tuberculosis? Primary tuberculosis "<img src=""7467.png"">" Microbiology
clinical-bacteriology duplicate primary-and-secondary-tuberculosis
In a partially immune, hypersensitized host, what kind of infection occurs after
exposure to M tuberculosis? Secondary tuberculosis "<img src=""7467.png"">"
Microbiology clinical-bacteriology duplicate primary-and-secondary-
tuberculosis
A patient with known primary (not secondary) tuberculosis presents to your office.
What specific chest x-ray finding confirms primary TB? Ghon complex (Ghon
focus, typically in mid/lower lobes of the lung, with hilar node involvement)
primary-and-secondary-tuberculosis
What type of lesion is seen on x-ray of the lung fields of a patient with secondary
tuberculosis? A fibrocaseous cavitary lesion in the upper lobe "<img
src=""7467.png"">" Microbiology clinical-bacteriology duplicate primary-and-
secondary-tuberculosis
A patient is given the diagnosis of primary tuberculosis. What two outcomes could
occur in this patient after the primary infection? 90%: recovery (fibrous
healing/calcification, tuberculin test positivity); <10%: progressive primary
disease (seen in AIDS or malnutrition) "<img src=""7467.png"">" Microbiology
A young boy with primary tuberculosis develops severe bacteremia. What type of
tuberculosis might he develop subsequently? Miliary tuberculosis, characterized
by small granulomas in multiple organs "<img src=""7467.png"">" Microbiology
Name seven common sites of extrapulmonary tuberculosis. Infection at which site is
Pott disease? Meninges, lymph nodes, liver, spleen, adrenal glands, joints/long
bones, vertebral bodies; infection of vertebral bodies is Pott disease "<img
A man with sarcoidosis has a negative PPD test result, but you still suspect active
infection. Justify your thinking. A patient with sarcoidosis may have a negative
result on PPD despite active infection "<img src=""7467.png"">" Microbiology
A patient's central nervous system is invaded by tuberculosis. What two conditions
should be high on your differential as the cause? Meningitis, Pott disease
(infection of vertebrae) "<img src=""7467.png"">" Microbiology clinical-
bacteriology duplicate primary-and-secondary-tuberculosis
Progressive lung disease develops in a patient with confirmed tuberculosis. In what
populations is this most likely to occur? HIV-positive and malnourished individuals
A patient has a positive PPD test. Name three possible explanations for this
result. Current tuberculosis infection, previous exposure, and BCG vaccination
A patient who has had the BCG vaccine undergoes evaluation for tuberculosis. What
is the most appropriate test to order? Interferon- release assay (IGRA), a more
specific test that yields fewer false-positive results from BCG vaccination "<img
A patient has primary tuberculosis. What percentage of patients with primary
tuberculosis will heal with fibrosis and calcification? >90% of patients "<img
Name four clinically important mycobacteria. What staining property do all
mycobacteria have in common? M tuberculosis, M scrofulaceum, M avium-
intracellulare, and M marinum; all are acid-fast organisms "<img src=""7468.png"">"
Microbiology clinical-bacteriology duplicate mycobacteria
A patient is infected with mycobacteria that are resistant to multiple drugs. What
two mycobacterial species are the likely culprits? M tuberculosis and M avium
intracellulare "<img src=""7468.png"">" Microbiology clinical-bacteriology
duplicate mycobacteria
An AIDS patient has disseminated M aviumintracellulare infection. What drug could
likely have prevented this? Azithromycin, which is used for prophylaxis,
particularly in patients with AIDS when the CD4+ count is <50 cells/mm3 "<img
src=""7468.png"">" Microbiology clinical-bacteriology duplicate mycobacteria
In a patient with virulent M tuberculosis infection, what causes inhibition of
macrophage maturation? What inhibits phagolysosome fusion? Cord factor causes
serpentine cord appearance and inhibits macrophage maturation; phagolysosomes
inhibited by sulfatides (surface glycolipids) "<img src=""7468.png"">"
Your hospital is in a midst of a tuberculosis epidemic. What are the symptoms of
tuberculosis that you should be looking out for? Night sweats, weight loss,
fever, hemoptysis, cough (productive or nonproductive) "<img src=""7468.png"">"
A patient presents with a mycobacterial infection on his hand. What is his likely
occupation? Aquarium handler (this is probably M marinum infection of the hand
mycobacteria
What component of virulent M tuberculosis induces release of TNF-? Cord factor
mycobacteria
A child presents with acid-fast organisms in his blood and cervical lymphadenitis.
What is the likely cause, if TB is ruled out? M scrofulaceum infection "<img
src=""7468.png"">" Microbiology clinical-bacteriology duplicate mycobacteria
What is another name for leprosy? Hansen disease "<img src=""7469.png"">"
Microbiology clinical-bacteriology duplicate leprosy-(hansen-disease)
A United States resident (not traveled recently) has a diagnosis of M leprae. What
is the likely animal reservoir for this patient? Armadillos "<img
src=""7469.png"">" Microbiology clinical-bacteriology duplicate leprosy-
(hansen-disease)
Because M leprae likes cool temperatures, what areas of the body does it tend to
infect? The skin and superficial nerves, causing glove-and-stocking loss of
sensation "<img src=""7469.png"">" Microbiology clinical-bacteriology
duplicate leprosy-(hansen-disease)
A patient presents with nasal collapse, loss of eyebrows, and lumpy skin. What
medications do you treat him with? This patient has the lepromatous form of Hansen
disease/leprosy; treat with dapsone, rifampin, and clofazimine "<img
(hansen-disease)
What are the two forms of Hansen disease? Lepromatous and tuberculoid "<img
(hansen-disease)
A patient has a form of leprosy that causes cell-mediated immunity to fail and
tends to have a worse prognosis. What form is this? Lepromatous can be lethal
leprosy-(hansen-disease)
You suspect M leprae infection in your patient. What characteristic of M leprae
complicates your diagnostic testing options? M leprae cannot be grown in vitro
leprosy-(hansen-disease)
A patient presents with diffuse, communicable skin lesions and a leonine facies.
What form of Hansen disease is this? Lepromatous "<img src=""7469.png"">"
A man has an intact T-cell response (cell-mediated immunity) and only a few
hypoesthetic, hairless skin nodules. How do you treat him? Treat with dapsone and
rifampin (this is the tuberculoid form of leprosy) "<img src=""7469.png"">"
Into what four shapes can gram-negative organisms be classified ? Diplococci,
coccobacilli, bacilli, and comma-shaped rods "<img src=""7470.png"">"
Microbiology clinical-bacteriology duplicate gram-negative-lab-algorithm
Name five organisms that are gram-negative coccobacilli. Which requires factors V
and X? H influenzae (requires factors V and X), B pertussis, F tularensis,
Pasteurella, and Brucella "<img src=""7470.png"">" Microbiology clinical-
bacteriology duplicate gram-negative-lab-algorithm
In lab you find an oxidase-positive, comma-shaped, gram-negative bacterium that is
able to produce urease. What's the likely culprit? H pylori produces urease
gram-negative-lab-algorithm
Name two Neisseria gram-negative diplococci and explain how to differentiate them.
N meningitidis, which ferments maltose, and N gonorrhoeae, which does not
ferment maltose "<img src=""7470.png"">" Microbiology clinical-bacteriology
duplicate gram-negative-lab-algorithm
You are given a group of gram-negative bacilli. They are differentiated by their
ability to ferment what substance? Lactose "<img src=""7470.png"">"
You identify a fast lactose-fermenting gram-negative bacillus growing on your
plate. What are the three possibilities? Klebsiella, E coli, and Enterobacter
gram-negative-lab-algorithm
In microbiology lab, you identify a slow lactose-fermenting, gram-negative
bacillus. What are the two possibilities? Citrobacter and Serratia "<img
src=""7470.png"">" Microbiology clinical-bacteriology duplicate gram-negative-
lab-algorithm
In lab, you discover an oxidase-positive, comma-shaped, gram-negative organism that
grows in alkaline media. Identify this bacterium. V cholerae "<img
lab-algorithm
In the lab, you have a group of lactose-nonfermenting, gram-negative bacilli that
are also oxidase positive. What is the likely bacterium? Pseudomonas "<img
lab-algorithm
Among lactose nonfermenters, which gram-negative bacilli are oxidase negative?
Shigella, Salmonella, Proteus, Yersinia "<img src=""7470.png"">"
In lab, you discover an oxidase-positive, comma-shaped, gram-negative bacterium
that grows at 42 C. Identify it. C jejuni "<img src=""7470.png"">"
You find oxidase-negative, gram-negative, lactose-nonfermenting bacilli that do not
produce H2S. On what agar do these bacteria grow? TSI agar (you are growing
either Shigella or Yersinia) "<img src=""7470.png"">" Microbiology clinical-
bacteriology duplicate gram-negative-lab-algorithm
In lab, you grow gram-negative aerobic diplococci. They do not use maltose. PCR for
Neisseria DNA is negative. What organism did you isolate? Moraxella "<img
lab-algorithm
What types of bacteria grow pink colonies on MacConkey agar? Lactose-fermenting
enteric: Klebsiella, E coli, Enterobacter, Serratia (weak fermenter) (MacConKEE's;
MacConKEY agarlactose is key "<img src=""7471.png"">" Microbiology clinical-
bacteriology duplicate lactose-fermenting-enteric-bacteria
You plate lactose-fermenting enteric bacteria on EMB agar. What color do colonies
take on? What color arises if the bacteria are E coli? Purple or black colonies
for lactose fermenters; E coli produce colonies with a green sheen "<img
src=""7471.png"">" Microbiology clinical-bacteriology duplicate lactose-
fermenting-enteric-bacteria
Name the enzyme produced by E coli that breaks down lactose into glucose and
galactose. -galactosidase "<img src=""7471.png"">" Microbiology clinical-
In lab, you notice purple and black colonies on an EMB agar plate. You also see a
green sheen. What enzyme do the cultured bacteria produce? -galactosidase, which
breaks down lactose into glucose and galactose (this is E coli) "<img
src=""7471.png"">" Microbiology clinical-bacteriology duplicate lactose-
fermenting-enteric-bacteria
You suspect that a patient has a Klebsiella infection. EMB agar is not available.
What other agar can you use to confirm the diagnosis? How? MacConkey agar; you will
observe pink colonies "<img src=""7471.png"">" Microbiology clinical-
A patient is infected with a species of Neisseria with a polysaccharide capsule.
What species is it? N meningitidis "<img src=""7472.png"">" Microbiology
clinical-bacteriology duplicate neisseria
For which Neisseria species is a vaccine available? Why does the other strain of
Neisseria not have a vaccine? N meningitidis has a type B vaccine that is not
widely available; N gonorrhoeae has no vaccine because of pilus protein antigenic
variation "<img src=""7472.png"">" Microbiology clinical-bacteriology
duplicate neisseria
N meningitidis and N gonorrhoeae both ferment what type of sugar and produce which
type of immunoglobulin protease? Both ferment glucose and produce IgA protease
neisseria
In lab, you notice a gram-negative diplococcus that ferments glucose. It also
ferments maltose. What is the likely bacterium? N meningitidis ferments maltose,
but N gonorrhoeae does not "<img src=""7472.png"">" Microbiology clinical-
bacteriology duplicate neisseria
A patient has an infection with N gonorrhoeae. What five disease state
presentations might this patient have? Gonorrhea, pelvic inflammatory disease
(PID), septic arthritis, Fitz-HughCurtis syndrome, and neonatal conjunctivitis
neisseria
A woman with PID develops severe RUQ pain from liver capsule inflammation. What
complication of her infection is this? Fitz-HughCurtis syndrome resulting from
N gonorrhoeae infection (PID) "<img src=""7472.png"">" Microbiology clinical-
A patient is exposed to N meningitidis. As her physician, what three clinical
conditions should you look out for? Meningococcemia, meningitis, and Waterhouse-
Friderichsen syndrome "<img src=""7472.png"">" Microbiology clinical-
Acute hypotension, petechiae, toe gangrene, and bilateral adrenal hemorrhages
develop in a patient with meningococcemia. Treatment? Ceftriaxone or penicillin G
(this is Waterhouse-Friderichsen syndrome, caused by meningococci) "<img
src=""7472.png"">" Microbiology clinical-bacteriology duplicate neisseria
A male patient comes in with a diagnosis of N gonorrhoeae infection. He wants to
know how it is transmitted and how can it be prevented. N gonorrhoeae is
transmitted during sex or birth; condoms prevent sexual transmission, and
erythromycin ointment prevents neonatal blindness "<img src=""7472.png"">"
Microbiology clinical-bacteriology duplicate neisseria
A patient with confirmed N meningitidis infection wants to know how the disease is
transmitted. What the modes of transmission? Respiratory and oral secretions
neisseria
"A 22-year-old patient comes in with gonorrhea and asks, ""Why is it not possible
to make a vaccine against this bug?""" N gonorrhoeae is known for rapid
antigenic variation of the pilus proteins "<img src=""7472.png"">" Microbiology
clinical-bacteriology duplicate neisseria
A healthcare worker may have been exposed to N meningitidis. What prophylaxis
should be offered? Rifampin, ciprofloxacin, or ceftriaxone "<img
src=""7472.png"">" Microbiology clinical-bacteriology duplicate neisseria
A patient has confirmed H influenzae infection. Name four diseases that can be
caused by the bacteria. Epiglottitis, Meningitis, Otitis media, and Pneumonia
(these are caused by HaEMOPhilus) "<img src=""7473.png"">" Microbiology
clinical-bacteriology duplicate haemophilus-influenzae
A patient has confirmed H influenzae infection. What is the likely method of
transmission? Aerosol "<img src=""7473.png"">" Microbiology clinical-
bacteriology duplicate haemophilus-influenzae
Which type of H influenzae causes the most invasive disease? Capsular type B
haemophilus-influenzae
What kind of virulence factor is produced by H influenzae? Immunoglobulin A (IgA)
protease "<img src=""7473.png"">" Microbiology clinical-bacteriology
duplicate haemophilus-influenzae
You suspect that a patient has H influenzae infection. What medium should you use
to grow the bacteria? Chocolate agar with factors V (NAD+) and X (hematin)can
also be grown with S aureus (providing factor V by way of RBC hemolysis) "<img
src=""7473.png"">" Microbiology clinical-bacteriology duplicate haemophilus-
influenzae
You are giving shots at the pediatrician's office. Typically the H influenzae
vaccine is given to which age group? Infants 218 months of age "<img
influenzae
An unvaccinated boy contracts meningitis. Bacteria grow on chocolate agar
containing factors V and X. Treatment plan? Treatment is ceftriaxoneclose
contacts should receive rifampin prophylaxis (this is H influenzae meningitis)
A 2-year-old boy, unvaccinated against H influenzae, has the flu. Can H influenzae
be the cause? No, because the influenza virus, not H influenzae, causes the
flu. "<img src=""7473.png"">" Microbiology clinical-bacteriology duplicate
A concerned dad at your doctor's office is asking how vaccines work. Describe the
vaccine used against H influenzae. It consists of a type b capsular polysaccharide
(polyribosylribitol phosphate [PRP]) conjugated to diphtheria toxoid or another
protein "<img src=""7473.png"">" Microbiology clinical-bacteriology
duplicate haemophilus-influenzae
Name three types of infections caused by nontypeable strains of H influenzae.
Otitis media, conjunctivitis, and bronchitis (all mucosal infections) "<img
influenzae
An 8-year-old presents with whooping cough. What are the virulence factors that
facilitate this infection? Tracheal cytotoxin and pertussis toxin (which
disables Gi) are virulence factors for B pertussis "<img src=""7474.png"">"
Microbiology bordetella-pertussis clinical-bacteriology duplicate
What vaccinations could have prevented a 12-year-old boy's infection with a gram-
negative aerobic coccobacillus? The Tdap or Dtap vaccine would have covered B
pertussis "<img src=""7474.png"">" Microbiology bordetella-pertussis
Why might bacterial infection in a patient with whooping cough be mistaken for a
viral infection? B pertussis can be mistaken for a viral infection because the
immune response generates a lymphocytic infiltrate "<img src=""7474.png"">"
Microbiology bordetella-pertussis clinical-bacteriology duplicate
Why is a silver stain normally used to view L pneumophila? Because it Gram stains
poorly "<img src=""7475.png"">" Microbiology clinical-bacteriology
duplicate legionella-pneumophila
An elderly veteran with chronic lung disease has Legionnaires' disease. How was the
disease likely transmitted? Aerosol transmission from an environmental source of
water such as air conditioning or a hot water tank (no person-to-person
transmission) "<img src=""7475.png"">" Microbiology clinical-bacteriology
A patient presents with pneumonia, GI, and CNS symptoms. Labs show hyponatremia.
What medium should be used to grow the causative organism? Use charcoal yeast
extract culture with iron and cysteine (this is L pneumophila infection) "<img
src=""7475.png"">" Microbiology clinical-bacteriology duplicate legionella-
pneumophila
A 75-year-old smoker has mild flu-like symptoms. Labs show hyponatremia. The
causative organism's antigen is detected in the urine. Treatment? Treat with
macrolides or quinolones (the patient likely has Pontiac fever caused by L
pneumophila) "<img src=""7475.png"">" Microbiology clinical-bacteriology
You isolate a bacterium that grows on charcoal yeast extract culture. What are two
clinical syndromes caused by this organism? Legionnaires' disease and Pontiac
fever "<img src=""7475.png"">" Microbiology clinical-bacteriology duplicate
legionella-pneumophila
Differentiate Legionnaires' disease from Pontiac fever. Legionnaires' disease is
marked by severe pneumonia with fever, GI, and CNS symptoms; Pontiac fever is a
mild flu-like syndrome "<img src=""7475.png"">" Microbiology clinical-
bacteriology duplicate legionella-pneumophila
Two smokers in their 60s, staying in a hotel, experience fever, cough, and dyspnea.
What test do you order to detect the likely culprit? Urine Legionella antigen
legionella-pneumophila
You are teaching medical students about Legionnaires' disease. What is a good story
to help them remember the basics of the disease? A French Legionnaire
(soldier) with his silver helmet, sitting around a campfire (charcoal) with his
iron daggerhe is no sissy (cysteine) "<img src=""7475.png"">" Microbiology
clinical-bacteriology duplicate legionella-pneumophila
What product of Pseudomonas causes degradation of cell membranes?
Phospholipase C "<img src=""7476.png"">" Microbiology clinical-
bacteriology duplicate pseudomonas-aeruginosa
A burn victim's skin grows slender gram-negative rods. You consider treatment with
cefepime but not cefazolin. Why? P aeruginosa is sensitive to third- and fourth-
generation cephalosporins but not others (cefazolin is a first-generation
cephalosporin) "<img src=""7476.png"">" Microbiology clinical-bacteriology
duplicate pseudomonas-aeruginosa
A patient coughs up blue-green sputum. This pathogen has an exotoxin with the same
mechanism as which pseudomembrane-forming pathogen? 's exotoxin A and C
diphtheriae's diphtheria toxin both inhibit EF-2 "<img src=""7476.png"">"
Microbiology clinical-bacteriology duplicate pseudomonas-aeruginosa
A teenager with cystic fibrosis has chronic pneumonia. Explain what property of
Pseudomonas may contribute to the chronic pneumonia. The mucoid polysaccharide
capsule causes the chronic pneumonia as a result of biofilm formation "<img
src=""7476.png"">" Microbiology clinical-bacteriology duplicate pseudomonas-
aeruginosa
Name two polymyxin antibiotics that can be used to treat P aeruginosa infection.
Polymyxin B, colistin "<img src=""7476.png"">" Microbiology clinical-
Name two third/fourth-generation cephalosporins that can be used to treat P
aeruginosa infection. Ceftazidime, cefepime "<img src=""7476.png"">"
What are the various treatment options for P aeruginosa infection? Hint: CAMPFIRE.
Carbapenems, Aminoglycosides, Monobactams, Polymyxins, Fluoroquinolones,
thIRd/fourth-gen cephalosporins, Extended-spectrum penicillins "<img
aeruginosa
A culture is growing a nonlactose-fermenting, gram-negative rod that is commonly
associated with wound and burn infections. Identify it. P aeruginosa "<img
aeruginosa
A patient has recently returned from vacation with a P aeruginosa infection. What
are common infection sources? Water, such as that implicated in swimmer's ear and
hot tub folliculitis "<img src=""7476.png"">" Microbiology clinical-
A diabetic patient presents with fever and hypotension indicative of Pseudomonas
sepsis. What type of toxin produces these symptoms? Endotoxin "<img
aeruginosa
A man has hot tub folliculitis. Exotoxin A produced by the causative bacteria
inactivates what human enzyme used in protein synthesis? Elongation factor 2 (EF-
2); this is P aeruginosa infection "<img src=""7476.png"">" Microbiology
clinical-bacteriology duplicate pseudomonas-aeruginosa
A child with cystic fibrosis has pneumonia and coughs up blue-green sputum. Is the
causative organism oxidase positive or negative? Oxidase positive (this is P
aeruginosa) "<img src=""7476.png"">" Microbiology clinical-bacteriology
Name seven syndromes caused by infection with Pseudomonas. PSEUDOmonas: Pneumonia,
Sepsis, otitis Externa (swimmers), UTIs, Drugs/Diabeties, Osteomyelitis (puncture
wounds), hot tub folliculitis "<img src=""7476.png"">" Microbiology clinical-
A diabetic patient has a fever. You discover that he has osteomyelitis and a recent
puncture wound. What is the likely causative organism? P aeruginosa "<img
aeruginosa
A burn victim exhibits black lesions on his skin. You order treatment with
aminoglycosides and piperacillin to eradicate which bacterium? P aeruginosa
(commonly causes infection in burn victims) "<img src=""7476.png"">"
A cystic fibrosis patient frequently coughs up blue-green sputum. Name two
extended-spectrum penicillins that can be used to treat him. Piperacillin,
ticarcillin "<img src=""7476.png"">" Microbiology clinical-bacteriology
Cystitis and pyelonephritis develop in a 73-year-old woman as a result of infection
with E coli. What virulence factor is responsible? Fimbriae (P-pili for
pyelonephritis) "<img src=""7477.png"">" Microbiology clinical-bacteriology
duplicate e-coli
Pneumonia and meningitis develop in a neonate as a result of infection with E coli.
What virulence factor is responsible? K capsule "<img src=""7477.png"">"
Microbiology clinical-bacteriology duplicate e-coli
Complications caused by lipopolysaccharide (LPS) endotoxin develop in a man with E
coli infection. What complication is it? Septic shock "<img src=""7477.png"">"
A patient presents with E coliinduced dysentery. No toxins are detected. How does
the responsible pathogen cause bloody diarrhea? EnteroInvasive E coli (EIEC)
Invades the mucosa of the intestine, causing necrosis and inflammation, which
results in dysentery "<img src=""7477.png"">" Microbiology clinical-
bacteriology duplicate e-coli
A patient is told that she has traveler's diarrhea. What toxins are responsible for
this diarrhea? Do they cause watery or bloody diarrhea? Labile and stable
enteroToxins of enterotoxic E coli (ETEC) cause Traveler's diarrhea; watery "<img
src=""7477.png"">" Microbiology clinical-bacteriology duplicate e-coli
What three types of E coli do not invade the intestinal mucosa? Enterohemorrhagic
(EHEC), enterotoxigenic (ETEC), and enteropathogenic (EPEC)only the enteroinvasive
(EIEC) type invades intestinal mucosa "<img src=""7477.png"">" Microbiology
clinical-bacteriology duplicate e-coli
How does enteropathogenic E coli (EPEC) cause diarrhea? It adheres to the apical
surface and flattens villi, decreasing absorption "<img src=""7477.png"">"
Does enteropathogenic E coli (EPEC) directly cause damage or act via a toxin?
EPEC does not produce a toxinit is directly pathogenic "<img
You are told that a patient has diarrhea from enteropathogenic E coli (EPEC)
infection. What population typically gets this type of infection? Children
(EPEC = Pediatrics) "<img src=""7477.png"">" Microbiology clinical-
A 7-year-old boy eats an undercooked hamburger and then experiences diarrhea and
oliguria. What lab abnormalities do you see? Low RBC/platelet counts, acute
kidney injury (this is Hemolytic-uremic syndrome due to enteroHemorrhagic E coli
[EHEC] from Hamburgers) "<img src=""7477.png"">" Microbiology clinical-
A 10-year-old has E coli serotype O157:H7. How are thrombocytopenia, anemia, and
acute renal failure induced in this patient? The Shiga-like toxin damages
endothelium; microthrombi then form, leading to hemolysis, low renal blood flow,
and platelet consumption (HUS) "<img src=""7477.png"">" Microbiology
clinical-bacteriology duplicate e-coli
What are the differences between dysentery caused by enterohemorrhagic E coli
(EHEC) and by enteroinvasive E coli (EIEC)? EHEC produces Shiga-like toxin,
causing necrosis and inflammation, and EIEC directly invades the mucosa, causing
necrosis and inflammation "<img src=""7477.png"">" Microbiology clinical-
You are concerned that a patient has EHEC. How can you distinguish EHEC from other
types of E coli, using a culture dish? EHEC does not ferment sorbitol "<img
Many patients come to the ED after ingesting spinach salad at a picnic. They have
anemia and thrombocytopenia. What toxin is responsible? The patients likely have
EHEC from the raw leafy vegetable; the toxin is the Shiga-like toxin "<img
An alcoholic passes out and aspirates his own vomit. A lung abscess that
subsequently develops is most likely caused by what pathogen? Klebsiella
infection (4 A's = Aspiration pneumonia, Abscess in lungs and liver, Alcoholics,
diAbetics) "<img src=""7478.png"">" Microbiology clinical-bacteriology
duplicate klebsiella
"What property of Klebsiella gives it the description of ""mucoid""?"
Polysaccharide capsule "<img src=""7478.png"">" Microbiology clinical-
bacteriology duplicate klebsiella
"A diabetic patient with pneumonia has red ""currant jelly"" sputum. What other
type of infection does the most likely pathogen cause?" The pneumonia pathogen
is most likely Klebsiella, which also causes nosocomial urinary tract infections
klebsiella
A 5-year-old boy eats raw beef and then has bloody diarrhea. Two weeks later, he
cannot move his legs and has hyporeflexia. What happened? He likely has Guillain-
Barr syndrome triggered by C jejuni infection (bloody diarrhea) "<img
src=""7479.png"">" Microbiology campylobacter-jejuni clinical-bacteriology
duplicate
A 9-year-old boy has ascending weakness. If this is related to an infection, what
did he most likely eat to cause it? Poultry, meat, and unpasteurized milk can
harbor C jejuni, which can cause Guillain-Barrsyndrome "<img src=""7479.png"">"
Microbiology campylobacter-jejuni clinical-bacteriology duplicate
What findings (eg, labs, morphology, growth temperature) help identify C jejuni as
a cause of infection? It is comma- or S-shaped, has polar flagella, is oxidase
positive, and grows at 42C "<img src=""7479.png"">" Microbiology
campylobacter-jejuni clinical-bacteriology duplicate
A 20-year-old pig farmer has bloody diarrhea. He later complains of dysuria and
sore red knees. What happened? How did he get infected? He has reactive
arthritis from C jejuni infection, most likely contracted from infected pigs (it is
also acquired from dogs and cats) "<img src=""7479.png"">" Microbiology
campylobacter-jejuni clinical-bacteriology duplicate
A patient has Salmonella infection. He asks about whether he should be receiving
antibiotics and what type. What do you say? Salmonellosis should not be treated
with antibiotics, as doing so can prolong symptoms "<img src=""7480.png"">"
Microbiology clinical-bacteriology duplicate salmonella-vs-shigella
Which of the following has flagella: Salmonella or Shigella? What is the pathologic
significance? "Salmonella (""salmon swim""); flagella enable hematogenous
dissemination" "<img src=""7480.png"">" Microbiology clinical-bacteriology
duplicate salmonella-vs-shigella
Are humans and primates the only reservoirs for Shigella and Salmonella? Yes
for both S typhi and Shigella; all other strains of Salmonella have animal
reservoirs "<img src=""7480.png"">" Microbiology clinical-bacteriology
How does the pathogenicity of Salmonella differ from that of Shigella? Salmonella
spreads hematogenously, whereas Shigella spreads from cell to cell without
hematogenous spread "<img src=""7480.png"">" Microbiology clinical-
bacteriology duplicate salmonella-vs-shigella
Clinically, how do patients with Salmonella and Shigella present? Both
Salmonella and Shigella often cause bloody diarrheanote that S typhi diarrhea is
often preceded by constipation "<img src=""7480.png"">" Microbiology
clinical-bacteriology duplicate salmonella-vs-shigella
A patient complains of fever, headache, and diarrhea. Physical exam reveals rose
spots on his abdomen. What is the treatment for infection? Treat with ceftriaxone
or fluoroquinolones (this is typhoid fever caused byS typhi) "<img
src=""7480.png"">" Microbiology clinical-bacteriology duplicate salmonella-vs-
shigella
A patient wonders whether she has typhoid fever. What symptoms do you look for?
What causes the symptoms? Fever, headache, and constipation followed by
diarrhea and abdominal rose spots; caused by S typhi "<img src=""7480.png"">"
A traveler who becomes ill with typhoid fever can transmit it to others, because
the pathogen can remain in what organ? The gallbladder "<img src=""7480.png"">"
A boy with a new pet turtle has gastroenteritis and bloody diarrhea. What is the
most likely cause? What are other sources? Salmonella spp; eggs, poultry,
turtles, and other pets are sources "<img src=""7480.png"">" Microbiology
clinical-bacteriology duplicate salmonella-vs-shigella
Which of the following bugs is likely to produce the least Shiga toxin: S boydii, S
sonnei, S dysenteriae, or S flexneri? The most? From most to least, they are S
dysenteriae, S flexneri, S boydii, and S sonnei "<img src=""7480.png"">"
A man with constipation and rose spots on his abdomen asks if there is a
vaccination to give to his daughter. What options are available? For S tyyphi,
there is an oral vaccine with live S typhi or an IM vaccine with Vi capsular
polysaccharide "<img src=""7480.png"">" Microbiology clinical-bacteriology
What are four modes by which Shigella can spread? The Four F's = Fingers,
Flies, Food, and Feces "<img src=""7480.png"">" Microbiology clinical-
bacteriology duplicate salmonella-vs-shigella
How can the leukocyte differential help you determine if a patient's bloody
diarrhea is due to Salmonella or Shigella? Both Salmonella and Shigella have a
primarily PMN response, except S typhi, which has a monocytic response "<img
src=""7480.png"">" Microbiology clinical-bacteriology duplicate salmonella-vs-
shigella
Compare and contrast the infectivity (hint: ID50) of Salmonella and Shigella.
Salmonella's is high (large inoculum needed; bug is inactivated by gastric
acid); Shigella's is low (resistant to gastric acid) "<img src=""7480.png"">"
A girl has abdominal pain and rose spots on her abdomen. The causative agent
produces H2S. What are the causative agent's virulence factors? This is S typhi,
which has endotoxin and Vi capsule virulence factors "<img src=""7480.png"">"
How do antibiotics affect fecal excretion in patients with Salmonella and Shigella
infections? Antibiotics prolongs the duration of fecal excretion for patients with
Salmonella; they shorten duration in Shigella patients "<img src=""7480.png"">"
A traveler to a developing country experiences rice-water diarrhea after being
infected with a pathogen that acts by what mechanism? V cholerae releases a toxin
that activates Gs and increases cAMP "<img src=""7481.png"">" Microbiology
clinical-bacteriology duplicate vibrio-cholerae
A patient on PPI therapy wants to travel to a developing country. Why is the
patient at higher risk of V cholerae infection at low inoculum? PPIs decrease
gastric acidity; typically V cholerae requires a large inoculum because it is
sensitive to stomach acid "<img src=""7481.png"">" Microbiology clinical-
bacteriology duplicate vibrio-cholerae
A patient with Y enterocolitica infection experiences acute diarrhea. What are the
possible modes of transmission for this disease? Pet feces (eg, from puppies)
and contaminated milk or pork "<img src=""7482.png"">" Microbiology clinical-
bacteriology duplicate yersinia-enterocolitica
A man has right lower abdominal pain. Crohn disease and appendicitis are ruled out.
Cultures are positive for Y enterocolitica. Diagnosis? Mesenteric adenitis
(pseudoappendicitis) and/or terminal ileitis "<img src=""7482.png"">"
Microbiology clinical-bacteriology duplicate yersinia-enterocolitica
A man with a chronic peptic ulcer has a positive result on urease breath testing.
What is the first-line treatment? Triple therapy: Amoxicillin (metronidazole if
penicillin allergic), Clarithromycin, Proton pump inhibitor (Antibiotics Cure H
Pylori "<img src=""7483.png"">" Microbiology clinical-bacteriology
duplicate helicobacter-pylori
A patient has a positive result on urea breath testing. What two pathologies in the
GI tract are caused by the causative agent? Gastritis and peptic ulcers
(especially duodenal); the patient is infected with H pylori "<img
src=""7483.png"">" Microbiology clinical-bacteriology duplicate helicobacter-
pylori
In a patient with peptic ulcers caused by H pylori, how is the bacterium able to
thrive as a pathogen in the stomach? It produces an alkaline environment by
way of the ammonia produced by urease "<img src=""7483.png"">" Microbiology
clinical-bacteriology duplicate helicobacter-pylori
In a patient with H pylori, what two cancers is the patient at increased risk for?
Gastric adenocarcinoma and MALT lymphoma "<img src=""7483.png"">"
Microbiology clinical-bacteriology duplicate helicobacter-pylori
A patient is diagnosed with duodenal ulcers caused by a curved gram-negative rod.
What three enzymes is this bacterium positive for? Catalase, oxidase, and urease
(this is H pylori) "<img src=""7483.png"">" Microbiology clinical-
bacteriology duplicate helicobacter-pylori
In a patient who is triple positive for catalase, oxidase, and urease enzymes, what
are the typical first-line diagnostic tests? The patient likely has H pylori;
the diagnostic tests available are the urea breath test and fecal antigen test
helicobacter-pylori
For what three enzymes is H pylori triple positive? Catalase, oxidase, and urease
helicobacter-pylori
What are the three spirochete species that most commonly infect humans?
Borrelia, Leptospira, and Treponema (BLT) "<img src=""7484.png"">"
Microbiology clinical-bacteriology duplicate spirochetes
You find a spirochete that is visualized on light microscopy with aniline dyes
(Wright or Giemsa stain). What is it? Borrelia (it is Big) "<img
src=""7484.png"">" Microbiology clinical-bacteriology duplicate spirochetes
You want to test for Treponema but lack a dark-field microscope. What other form of
visualization can you use? Direct fluorescent antibody (DFA) microscopy "<img
src=""7484.png"">" Microbiology clinical-bacteriology duplicate spirochetes
A man who swims in a cove has fever, fatigue, body aches, photophobia, and
conjunctival suffusion. What is the water contaminated with? Animal urine
contaminated with L interrogans, which causes leptospirosis"<img src=""7485.png"">"
Microbiology clinical-bacteriology duplicate leptospira-interrogans
A surfer in Hawaii is found to have leptospirosis on the basis of what signs and
symptoms found during the history and physical? Flu-like symptoms, myalgias of the
calves, jaundice, and photophobia with conjunctival suffusion all suggest
leptospirosis "<img src=""7485.png"">" Microbiology clinical-bacteriology
duplicate leptospira-interrogans
A patient has a severe form of leptospirosis with elevated bilirubin and
creatinine, fever, hemorrhage, and low hemoglobin. Diagnosis? Weil disease
(icterohemorrhagic leptospirosis) "<img src=""7485.png"">" Microbiology
clinical-bacteriology duplicate leptospira-interrogans
What bacterium causes Lyme disease? B burgdorferi "<img src=""7486.png"">"
Microbiology clinical-bacteriology duplicate lyme-disease
The vector of the organism that causes Lyme disease relies on what animal as part
of its life cycle? Mice play an important role in the life cycle of Ixodes
ticks and serve as a natural reservoir "<img src=""7486.png"">" Microbiology
clinical-bacteriology duplicate lyme-disease
In what region of the United States is Lyme disease common?The northeastern United
States "<img src=""7486.png"">" Microbiology clinical-bacteriology
duplicate lyme-disease
What symptoms characterize the first stage of Lyme disease?This is early localized
disease, marked by erythema chronicum migrans (expanding red bullseye rash) and
flu-like symptoms "<img src=""7486.png"">" Microbiology clinical-bacteriology
duplicate lyme-disease
A patient with a history of bullseye rash, arthritis of one knee, and facial nerve
palsy presents to your office. What is the treatment? Doxycycline, ceftriaxone
(this is Lyme disease) "<img src=""7486.png"">" Microbiology clinical-
bacteriology duplicate lyme-disease
A key Lyme [lime] pie to the FACE is a way to remember key signs/symptoms of Lyme
disease. What does FACE stand for? Facial nerve palsy, Arthritis, Cardiac block,
Erythema chronicum migrans "<img src=""7486.png"">" Microbiology clinical-
What symptoms would you see in a patient in the second (early disseminated) stage
of Lyme disease? AV block, facial nerve (Bell) palsy, migratory myalgias/transient
arthritis, carditis "<img src=""7486.png"">" Microbiology clinical-
Where can treponemes be found during primary and secondary syphilis? What do you
use to visualize them? In chancres during primary syphilis and in condylomata lata
during secondary syphilis; use dark-field microscopy to see treponemes "<img
src=""7487.png"">" Microbiology clinical-bacteriology duplicate syphilis
What is latent syphilis and when does it happen? Latent syphilis is
characterized by positive serology but no symptoms; it follows secondary syphilis
syphilis
A 42-year-old man presents with broad-based gait, the Romberg sign, and Argyll
Robertson pupils. How do you test for neurosyphilis? Test spinal fluid by means of
VDRL, FTA-ABS, and PCR "<img src=""7487.png"">" Microbiology clinical-
bacteriology duplicate syphilis
You determine that the destruction of a patient's vasa vasorum is the result of an
infection. What is the likely causative agent? T pallidum, which causes syphilis
(this is aortitis) "<img src=""7487.png"">" Microbiology clinical-
bacteriology duplicate syphilis
A 1-year-old child presents with several abnormalities; you diagnose congenital
syphilis. What could these abnormalities include? Saber shins, saddle nose,
cranial nerve VIII deafness, Hutchinson teeth, mulberry molars, rhagades, snuffles,
short maxilla "<img src=""7487.png"">" Microbiology clinical-bacteriology
duplicate syphilis
A 31-year-old man complains of an ulcer on his penis. He tests positive on VDRL/RPR
and confirmatory FTA-ABS. What is treatment of choice? Penicillin G (this is
syphilis) "<img src=""7487.png"">" Microbiology clinical-bacteriology
duplicate syphilis
In what stage of syphilis would a patient note lymphadenopathy and patchy hair
loss? Secondary "<img src=""7487.png"">" Microbiology clinical-bacteriology
duplicate syphilis
A child has linear scars at the angles of his mouth. He has mulberry molars and a
saddle nose. What are these linear scars known as? This child has congenital
syphilis; the lines are also known as rhagades "<img src=""7487.png"">"
Microbiology clinical-bacteriology duplicate syphilis
A positive Venereal Disease Research Laboratory (VDRL) test indicates that
antibodies have formed against what molecule? Beef cardiolipin "<img
src=""7488.png"">" Microbiology clinical-bacteriology duplicate vdrl-false-
positives
Is VDRL considered a more specific or more sensitive test? VDRL is considered
sensitive but not specific "<img src=""7488.png"">" Microbiology clinical-
bacteriology duplicate vdrl-false-positives
A patient's serum reacts with beef cardiolipin antibodies. What is the significance
of this (including causes of false-positive results)? False positives can be due to
Viral infection, Drugs, Rheumatic fever, Lupus or leprosy (VRDL) (this is the VDRL
test for syphilis) "<img src=""7488.png"">" Microbiology clinical-
bacteriology duplicate vdrl-false-positives
A patient comes in with a positive VDRL test. Why do you confirm the results with a
FTA-ABS test? FTA-ABS is more specific for syphiIisVDRL is more sensitive than
specific, so it is more likely to yield a false-positive result "<img
src=""7488.png"">" Microbiology clinical-bacteriology duplicate vdrl-false-
positives
A man receives intramuscular penicillin for spirochetes and later has fevers,
chills, a headache, and myalgias. What caused this phenomenon? The Jarisch-
Herxheimer reaction, a flu-like syndrome after antibiotics that occurs when killed
bacteria (here, syphilis) release toxins "<img src=""7489.png"">" Microbiology
clinical-bacteriology duplicate jarisch-herxheimer-reaction
An immunocompromised man gets a Bartonella infection. What are two diseases that
are associated with this infection? Bacillary angiomatosis and cat scratch disease
zoonotic-bacteria
How is anaplasmosis transmitted? Ixodes ticks that dwell on deer and mice "<img
src=""7490.png"">" Microbiology clinical-bacteriology duplicate zoonotic-
bacteria
A patient develops cat scratch fever after being clawed by her kitten. What is the
causative pathogen? Bartonella spp. "<img src=""7490.png"">" Microbiology
clinical-bacteriology duplicate zoonotic-bacteria
What is the vector for the pathogen that causes Lyme disease? Ixodes ticks that
dwell on deer and mice "<img src=""7490.png"">" Microbiology clinical-
bacteriology duplicate zoonotic-bacteria
A patient is bitten by a louse and develops a recurrent fever. What bacterium is
likely responsible? Borrelia recurrentis; recurrentis = relapsing fever "<img
bacteria
A patient has had a recurrent fever, with a diagnosis of B recurrentis. What is
responsible for the recurrent nature of the fever? Variable bacterial surface
antigens "<img src=""7490.png"">" Microbiology clinical-bacteriology
duplicate zoonotic-bacteria
A dairy farmer presents with 1 week of waxing and waning fever. He may have drunk
unpasteurized milk. What bacterium is causing the fevers? Brucella spp. from
unpasteurized dairy, which causes undulant fever "<img src=""7490.png"">"
Microbiology clinical-bacteriology duplicate zoonotic-bacteria
A 32-year-old man complains of bloody diarrhea, which results indicate were caused
by Campylobacter. How is this transmitted? Feces from infected animals,
especially pets; contaminated food (including meat) or hands "<img
src=""7490.png"">" Microbiology::clinical-bacteriology::duplicate zoonotic-
bacteria
A patient is found to have pneumonia. He reports having recently bought a pet
parrot. What is the likely causative agent? C psittaci, which causes
psittacosis; sources are parrots and other birds "<img src=""7490.png"">"
A patient contracts ehrlichiosis after being in the woods. How is ehrlichiosis
transmitted? Through what bacterium? Bite of the Lone Star tick (Amblyomma,
carrying E chaffeensis "<img src=""7490.png"">" Microbiology clinical-
A patient contracts tularemia from F tularensis. How is this pathogen transmitted?
Rabbits, deer flies, and ticks "<img src=""7490.png"">" Microbiology
After a devastating storm, town officials worry that what bacterium, found in
animal urine, might contaminate water supplies? Leptospira spp. "<img
bacteria
A patient has leprosy. What are sources of the pathogen that caused his disease?
Armadillos (rare) and humans with lepromatous leprosy"<img src=""7490.png"">"
How is P multocida transmitted? Animal bites (eg, cats, dogs) "<img
bacteria
A patient develops cellulitis and osteomyelitis around the site of a dog bite. What
is the likely pathogen? P multocida "<img src=""7490.png"">" Microbiology
What disease does R prowazekii cause, and what is its vector? Epidemic typhus;
body lice "<img src=""7490.png"">" Microbiology clinical-bacteriology
A patient has confirmed Rocky Mountain fever. What is the vector for his pathogen?
Dermacentor tick bites transmit R rickettsii, which causes Rocky Mountain
spotted fever "<img src=""7490.png"">" Microbiology clinical-bacteriology
A patient comes in with endemic typhus. What is the vector for his pathogen? Fleas
are the vectors for R typhi "<img src=""7490.png"">" Microbiology clinical-
A patient who has bubonic plague wishes to know the source of his disease. What do
you tell him? Fleas (with rats and prairie dogs as reservoirs) harbor Y pestis
zoonotic-bacteria
Patients contract the bubonic plague after being bitten by a flea containing what
bacterium? Y pestis "<img src=""7490.png"">" Microbiology clinical-
A child has diarrhea, vomiting, fever, and abdominal cramps for a day. What are the
possible sources of Salmonella infection for him? Reptiles, poultry "<img
bacteria
A 26-year-old female has vaginosis caused by G vaginalis. What kind of vaginal
discharge will you note on physical exam? Gray discharge with a fishy odor "<img
src=""7491.png"">" Microbiology clinical-bacteriology duplicate gardnerella-
vaginalis
Is G vaginalis considered a sexually transmitted disease? Nohowever, it is
associated with sexual activity "<img src=""7491.png"">" Microbiology
clinical-bacteriology duplicate gardnerella-vaginalis
You suspect bacterial vaginosis in a patient. What do you expect to see in a wet
prep of her vaginal discharge? Classically, clue cells or vaginal epithelial
cells covered with bacteria (stippled appearance along outer margins); this is G
vaginalis "<img src=""7491.png"">" Microbiology clinical-bacteriology
duplicate gardnerella-vaginalis
A woman diagnosed with bacterial vaginosis is prescribed metronidazole but cannot
tolerate it. What second medication may be given instead? A reasonable second-line
treatment is clindamycin (overgrowth of vaginal anaerobic bacteria characterize
bacterial vaginosis) "<img src=""7491.png"">" Microbiology clinical-
bacteriology duplicate gardnerella-vaginalis
A young woman presents with nonpainful gray vaginal discharge. You suspect
Gardnerella. What outcome do you expect on an amine whiff test? Amine whiff test
for G vaginalis: Mixing the discharge with 10% KOH solution enhances the fishy odor
gardnerella-vaginalis
What type of bacteria overgrows in the vagina in bacterial vaginosis? Anaerobic
bacteria "<img src=""7491.png"">" Microbiology clinical-bacteriology
duplicate gardnerella-vaginalis
A patient is bitten by a flea and contracts endemic typhus. What bacterium is
responsible for this disease? R typhi "<img src=""7492.png"">" Microbiology
clinical-bacteriology duplicate rickettsial-diseases-and-vector-borne-illness
A camper presents with a headache, fever, and rash that started on the wrists and
ankles. What will happen to the rash next? The rash will spread to the trunk,
palms, and soles (this is Rocky Mountain spotted fever, caused by R rickettsii)
rickettsial-diseases-and-vector-borne-illness
What is the classic triad of symptoms caused by a Rocky Mountain spotted fever
infection? Fever, headache, and rash (vasculitis) "<img src=""7492.png"">"
Microbiology clinical-bacteriology duplicate rickettsial-diseases-and-vector-
borne-illness
What three diseases start with a rash on the palms and soles? Coxsackievirus A,
Rocky Mountain spotted fever, and Syphilis (to drive CARS, you use your palms and
soles) "<img src=""7492.png"">" Microbiology clinical-bacteriology
duplicate rickettsial-diseases-and-vector-borne-illness
A boy is bitten by a human body louse and develops a rash that spreads from his
trunk outward. Will it reach the palms and soles? No; this is epidemic typhus
(think Typhus on the Trunk), caused by R prowazekii "<img src=""7492.png"">"
borne-illness
Differentiate anaplasmosis and ehrlichiosis in terms of what accompanies the
morulae. Monocytes with morulae in cytoplasm for Ehrlichiosis; Granulocytes with
morulae in cytoplasm for Anaplasma (MEGA berry) "<img src=""7492.png"">"
borne-illness
A patient has Q fever. How did the patient acquire the disease? What is it caused
by? C burnetii, transmitted by spores from tick feces and cattle placenta inhaled
as aerosols "<img src=""7492.png"">" Microbiology clinical-bacteriology
A man helps deliver a baby lamb while visiting his sister on a farm. He becomes ill
but has no rash. Describe his most likely symptoms. Q fever and pneumonia (this
is likely C burnetii; Q fever is Queer, with no rash/vector, and C burnetii
survives outside in endospore form) "<img src=""7492.png"">" Microbiology
What differentiates Q fever from the diseases of the Rickettsia genus, to which it
is closely related? What is the pathogen? C burnetii is the pathogen; it can
survive outside in its endospore form, and there is no rash or vector "<img
src=""7492.png"">" Microbiology clinical-bacteriology duplicate rickettsial-
diseases-and-vector-borne-illness
A camper from North Carolina presents with fever and a rash around the wrists and
ankles. What is the treatment? Doxycycline (this is Rocky Mountain spotted
fever) "<img src=""7492.png"">" Microbiology clinical-bacteriology
A sheep farmer has pneumonia and chest pain. Work-up reveals culture-negative
endocarditis as well. How is his disease transmitted? Spores inhaled as aerosols
from cattle/sheep amniotic fluid (this is likely C burnetii infection) "<img
What rickettsial disease is the most common cause of culture-negative endocarditis?
Q fever, caused by C burnetii "<img src=""7492.png"">" Microbiology
What is the treatment of choice for all rickettsial infections? Doxycycline "<img
Rickettsiae are transmitted by way of what vector? Arthropods (except Coxiella,
which is transmitted in aerosols) "<img src=""7492.png"">" Microbiology
In hospital A, there has been an outbreak of Rocky Mountain spotted fever, which is
endemic to the area. Where might hospital A be located? One of the South
Atlantic states, especially North Carolina "<img src=""7492.png"">"
borne-illness
During its life cycle, which form of chlamydia is infectious? "The Elementary
body (small and dense), which is ""Enfectious"" and Enters the cell by means of
Endocytosis" "<img src=""7493.png"">" Microbiology chlamydiae clinical-
During its life cycle, which form of chlamydia replicates by fission in the cell?
The Reticulate body Replicates by means of fission and Reorganizes into
elementary bodies "<img src=""7493.png"">" Microbiology chlamydiae clinical-
Which two chlamydial species cause atypical pneumonia, and how are they
transmitted? C pneumoniae and C psittaci; aerosol transmission "<img
src=""7493.png"">" Microbiology chlamydiae clinical-bacteriology duplicate
A bird trader who experiences fever and dyspnea is found to have an atypical
pneumonia. What pathogen is the most likely cause? C Psittaci, which has an
avian reservoir (Parrots) and causes atypical Pneumonia "<img src=""7493.png"">"
Microbiology chlamydiae clinical-bacteriology duplicate
A sexually active woman has PID. If it is caused by C trachomatis, what do you see
on microscopy? How do you treat her? Cytoplasmic inclusions on Giemsa or
fluorescent antibody staining; treatment is azithromycin (one-time treatment) or
doxycycline "<img src=""7493.png"">" Microbiology chlamydiae clinical-
What makes the cell wall of chlamydia unique? The cell wall lacks classic
peptidoglycans because there is less muramic acid "<img src=""7493.png"">"
Microbiology chlamydiae clinical-bacteriology duplicate
Why are Chlamydia species intracellular organisms? Because they cannot make
their own ATP "<img src=""7493.png"">" Microbiology chlamydiae clinical-
In a patient with Chlamydia, why are -lactam antibiotics less effective? The
cell wall of Chlamydia lacks classic peptidoglycans secondary because of less
muramic acid "<img src=""7493.png"">" Microbiology chlamydiae clinical-
In patients with Chlamydia infection, why is azithromycin the favored treatment?
It is a one-time treatment (in contrast with doxycycline, which requires
several doses) "<img src=""7493.png"">" Microbiology chlamydiae clinical-
Where, geographically speaking, are C trachomatis serotypes A, B, and C found? What
pathologies do they cause? ABC: they are found in Africa, cause Blindness, and
result in Chronic infection "<img src=""7494.png"">" Microbiology chlamydia-
trachomatis-serotypes clinical-bacteriology duplicate
Which C trachomatis serotypes cause urethritis, PID, ectopic pregnancy, neonatal
pneumonia with eosinophilia, and neonatal conjunctivitis? Types DK (= everything
else) "<img src=""7494.png"">" Microbiology chlamydia-trachomatis-serotypes
A patient has lymphogranuloma venereum. Which C trachomatis serotypes may be the
cause? Types L1, L2, and L3 cause Lymphogranuloma venereum "<img
src=""7494.png"">" Microbiology chlamydia-trachomatis-serotypes clinical-
A newborn is found to have neonatal chlamydia. How was this disease acquired?
As the infant passed through an infected birth canal "<img src=""7494.png"">"
Microbiology chlamydia-trachomatis-serotypes clinical-bacteriology duplicate
A 35-year-old man complains of pain and swelling along the inguinal lymph nodes,
which have begun to ulcerate (forming buboes). Treatment? Treat with doxycycline
(C trachomatis types L1, L2, and L3 cause Lymphogranuloma venereum) "<img
src=""7494.png"">" Microbiology chlamydia-trachomatis-serotypes clinical-
A newborn comes to the NICU with a staccato cough and eye discharge. You notice
significant eosinophilia on lab studies. What is the cause?C trachomatis Types DK
(= everything else) "<img src=""7494.png"">" Microbiology chlamydia-
trachomatis-serotypes clinical-bacteriology duplicate
"A patient presents with the symptoms of ""walking"" pneumonia. What bacterium is
most commonly implicated?" M pneumoniae "<img src=""7495.png"">"
Microbiology clinical-bacteriology duplicate mycoplasma-pneumoniae
"A man presents with ""walking"" pneumonia. Bacteria grow on Eaton agar. Why do you
not treat his infection with penicillins?" Treatment for M pneumoniae consists
of macrolides, doxycycline, or fluoroquinolones; it is resistant to penicillin,
having no cell wall "<img src=""7495.png"">" Microbiology clinical-
bacteriology duplicate mycoplasma-pneumoniae
What are the symptoms of M pneumoniae pneumonia? "Insidious onset (""walking""
pneumonia) with headache, nonproductive cough, and diffuse interstitial infiltrates
on chest x-ray" "<img src=""7495.png"">" Microbiology clinical-bacteriology
duplicate mycoplasma-pneumoniae
A patient presents with a nonproductive cough and headache. What hematologic
finding may help confirm M pneumoniae infection? A high titer of cold
agglutinins (IgM)they can agglutinate or lyse RBCs (Mycoplasma gets cold without a
coat) "<img src=""7495.png"">" Microbiology clinical-bacteriology duplicate
mycoplasma-pneumoniae
A patient has a nonproductive cough and a high titer of cold agglutinins. What
medium should you use to confirm your diagnosis? Eaton agar (used to grow M
pneumoniae) "<img src=""7495.png"">" Microbiology clinical-bacteriology
In a patient with M pneumoniae, why are you unable to observe bacteria on Gram
stain? M pneumoniae has no cell wall "<img src=""7495.png"">" Microbiology
clinical-bacteriology duplicate mycoplasma-pneumoniae
A coughing man has patchy interstitial infiltrates on x-ray. Cold agglutinin titer
is high. What stabilizes the causative bug's membrane? The patient has M
pneumoniae infection; the bacterial membranes contain sterols for stability "<img
src=""7495.png"">" Microbiology clinical-bacteriology duplicate mycoplasma-
pneumoniae
There is an M pneumoniae outbreak. What age group is most commonly affected? In
what settings do outbreaks typically occur? Individuals <30 years of age are
more commonly infected; outbreaks often occur among military recruits and in
prisons "<img src=""7495.png"">" Microbiology clinical-bacteriology
A patient presents with nonproductive cough and headache. Eaton agar grows bacteria
on culture. Are these bacteria pleomorphic? "Yes; this is atypical ""walking""
pneumonia caused by M pneumoniae)" "<img src=""7495.png"">" Microbiology
clinical-bacteriology duplicate mycoplasma-pneumoniae
What do histoplasmosis, paracoccidioidomycosis, and blastomycosis have in common?
All are systemic mycoses caused by dimorphic fungi (metamorphosing into mold
in cold [20C] and into yeast in heat [37C]) "<img src=""7496.png"">"
Microbiology duplicate mycology systemic-mycoses
A previously healthy woman develops pneumonia after inhaling bird droppings. Where
did this unfortunate event likely occur? The Ohio and Mississippi River valleys
(endemic) (this is histoplasmosis, which is spread by bird or bat droppings) "<img
src=""7496.png"">" Microbiology duplicate mycology systemic-mycoses
A 40-year-old man from Central America presents with inflammatory lung disease.
Skin and bone involvement is detected. Diagnosis? Blastomycosis "<img
While examining infected tissue under a microscope, how would you distinguish
coccidioidomycosis from all other dimorphic fungi? It is a spherule in tissue,
not a yeast "<img src=""7496.png"">" Microbiology duplicate mycology systemic-
mycoses
Coccidioidomycosis, found in the Southwestern US (including California) has a
notable presentation named for the area. What is it? Coccidioidomycosis causes
(San Joaquin) Valley fever and presents as desert bumps (erythema nodosum) and
desert rheumatism (arthralgias) "<img src=""7496.png"">" Microbiology
duplicate mycology systemic-mycoses
There is a spike in pneumonia and meningitis cases after an earthquake in Southern
California. What is the likely cause? Coccidioidomycosis (spores in disturbed
dust are thrown into the air and inhaled, allowing spherules to enter the lung and
cause infection) "<img src=""7496.png"">" Microbiology duplicate mycology
systemic-mycoses
A patient is found to have paracoccidioidomycosis. In what areas of the world is
this disease typically endemic? Latin America (PARAcoccidio PARAsails with the
captains wheel all the way to Latin America) "<img src=""7496.png"">"
A recent immigrant from Guatemala presents with fungal pneumonia. How would you
treat this patient? Treatment is fluconazole or itraconazole, because it is a
local infection (this is paracoccidioidomycosis, endemic in Latin America) "<img
A previously healthy immigrant from Panama has granulomas related to a fungus all
over her body. What is it? How do you treat it? Paracoccidioidomycosis; treatment
is amphotericin B, because this is a systemic infection (may mimic tuberculosis)
"<img src=""7496.png"">" Microbiology duplicate mycology systemic-
mycoses
All systemic mycoses can primarily cause what type of illness? Pneumonia "<img
In addition to pneumonia, in a patient with coccidioidomycosis, what other
illnesses should one be wary of? Meningitis (one can also see dissemination to
skin and bone) "<img src=""7496.png"">" Microbiology duplicate mycology
systemic-mycoses
What are the sizes of histoplasmosis, blastomycosis, coccidioidomycosis, and
paracoccidioidomycosis, respectively, relative to that of an RBC? Histoplasma
are smaller; blastomycosis organisms are the same size; coccidioidomycosis and
paracoccidioidomycosis organisms are larger "<img src=""7496.png"">"
How can systemic mycoses mimic tuberculosis pathologically? How is transmission
different? Both have granulomas; only tuberculosis has person-to-person
transmission "<img src=""7496.png"">" Microbiology duplicate mycology
systemic-mycoses
A 37-year-old man has pneumonia and meningitis. History reveals a recent trip to
California. What is the likely diagnosis? Coccidioidomycosis, which is endemic to
the southwestern United States, including California "<img src=""7496.png"">"
A patient presents with granulomatous nodules and inflammatory lung disease from
blastomycosis. Where might the patient hail from? The eastern United States or
Central America "<img src=""7496.png"">" Microbiology duplicate mycology
systemic-mycoses
An athlete has hypopigmented and hyperpigmented macules on her back after intensive
summer training. How do you treat her? Treatment is topical and/or oral
antifungal medications and selenium sulfide (Selsun) (this is tinea versicolor)
"<img src=""7497.png"">" Microbiology cutaneous-mycoses duplicate
mycology
In patients with tinea infections (eg, capitis), what are the characteristic
lesions seen after KOH preparation of a blue fungal stain? Branching septate hyphae
"<img src=""7497.png"">" Microbiology cutaneous-mycoses duplicate
mycology
What organisms cause tinea pedis, cruris, corporis, capitis, and unguium?
Dermatophytes (eg, Microsporum, Trichophyton, Epidermophyton) "<img
src=""7497.png"">" Microbiology cutaneous-mycoses duplicate mycology
A man has multiple erythematous scaling rings with central clearing. Where are
these rings typically found? He likely has tinea corporis infection, which occurs
on the torso "<img src=""7497.png"">" Microbiology cutaneous-mycoses
duplicate mycology
What opportunistic fungus is a cause of endocarditis in intravenous drug users?
C albicans "<img src=""7498.png"">" Microbiology duplicate mycology
opportunistic-fungal-infections
Where are the abscesses in Mucor and Rhizopus infections most commonly found?
Rhinocerebral and frontal lobe abscesses "<img src=""7498.png"">"
Microbiology duplicate mycology opportunistic-fungal-infections
A diabetic man is at risk for oral/esophageal thrush from a white fungal infection.
What three other populations are at risk? Neonates, steroid users, and AIDS
patients are also at increased risk for candidiasis "<img src=""7498.png"">"
What are the treatments for vagina, oral, and systemic Candida infections,
respectively? Topical azoles for vaginal; nystatin, fluconazole, caspofungin
for oral/esophageal; fluconazole, caspofungin, amphotericin B for systemic "<img
src=""7498.png"">" Microbiology duplicate mycology opportunistic-fungal-
infections
A patient's specimen grows C neoformans on Sabouraud agar. For what two diseases
should you be looking? Cryptococcosis and cryptococcal meningitis "<img
infections
A 37-year-old man has an infection by a heavily encapsulated yeast that is not
dimorphic. What tests are ordered to confirm the diagnosis?The India ink stain and
latex agglutination test (detects polysaccharide capsular antigens and is more
specific for Cryptococcus) "<img src=""7498.png"">" Microbiology duplicate
mycology opportunistic-fungal-infections
"An immunocompromised patient presents with ""soap bubble"" lesions in his brain.
How did the likely infectious culprit get there?" C neoformans spreads to the
CNS (usually meninges) through hematogenous dissemination after inhalation "<img
infections
A patient presents with invasive aspergillosis. This is especially likely in what
population of patients? Patients who are immunocompromised or have chronic
granulomatous disease "<img src=""7498.png"">" Microbiology duplicate
How do Mucor and Rhizopus proliferate in the body? They enter ketone/glucose-
rich blood vessel walls, penetrate the cribriform plate, and enter the brain "<img
infections
An HIV-positive patient develops disseminated candidiasis. How do you treat her?
Amphotericin B, fluconazole, or caspofungin, as the infection is systemic
"<img src=""7498.png"">" Microbiology duplicate mycology opportunistic-
fungal-infections
A neonate exhibits oral thrush. What is the likely responsible organism, and how do
you treat it? C albicans; treatment is topical azoles, because the lesion is
superficial "<img src=""7498.png"">" Microbiology duplicate mycology
Is C neoformans a mold, a yeast, or dimorphic? Yeast (not dimorphic) "<img
infections
Through what structure must Mucor and Rhizopus penetrate to invade the brain? How
are patients treated? The cribriform plate; treat with surgical debridement and
amphotericin B "<img src=""7498.png"">" Microbiology duplicate mycology
A diabetic man has a headache, facial pain, a black necrotic facial eschar, and
cranial nerve palsies. Could this patient have a thrombosis? Yes (this is
likely mucormycosis, which can cause cavernous sinus thromboses) "<img
infections
A woman has a fungal infection that produces aflatoxins. With what cancer are the
toxins associated? For what should patient be monitored? Aspergillus infection;
monitor for hepatocellular carcinoma (HCC); Aflatoxins are associated with this
malignancy "<img src=""7498.png"">" Microbiology duplicate mycology
A patient has tuberculosis. About what fungal infection, which often forms in lung
cavities after TB, should he be counseled? A fumigatus infection may cause
aspergillomas "<img src=""7498.png"">" Microbiology duplicate mycology
Patients with which chronic diseases typically acquire allergic bronchopulmonary
aspergillosis? Patients with asthma or cystic fibrosis "<img src=""7498.png"">"
A type I diabetic has a black necrotic facial eschar, fever, headaches, and eye
pain. What are two treatment options? Surgical debridement or amphotericin B
(this is mucormycosis) "<img src=""7498.png"">" Microbiology duplicate
A homeless man who lives with pigeons comes in with signs of fungal infection. What
is the most specific test to confirm diagnosis? Latex agglutination test to detect
the polysaccharide capsular antigen in C neoformans "<img src=""7498.png"">"
Is P jirovecii a protozoan or a yeast? A yeast (it was originally classified as
a protozoan) "<img src=""7499.png"">" Microbiology duplicate mycology
pneumocystis-jirovecii
A man has an infection with disk-shaped yeast seen on a methenamine silver stain of
lung tissue. Which group of hosts would be symptomatic? Immunocompromised
patients (eg, AIDS patients) (this is Pneumocystis pneumonia [PCP]) "<img
src=""7499.png"">" Microbiology duplicate mycology pneumocystis-jirovecii
How is Pneumocystis pneumonia diagnosed? From a sample obtained on lung biopsy or
lavage and stained with methenamine silver "<img src=""7499.png"">"
Microbiology duplicate mycology pneumocystis-jirovecii
An HIV patient is worried about Pneumocystis pneumonia. At what CD4 count should
the patient begin to receive prophylaxis against disease? &60; 200 cells/mm (use
trimethoprim-sulfamethoxazole [TMP-SMX], dapsone, pentamidine, or atovaquone for
prophylaxis) "<img src=""7499.png"">" Microbiology duplicate mycology
pneumocystis-jirovecii
What is the appearance of Pneumocystis pneumonia on a chest x-ray? Diffuse
bilateral ground-glass opacities "<img src=""7499.png"">" Microbiology
duplicate mycology pneumocystis-jirovecii
What is the mode of transmission of sporotrichosis? "Traumatic introduction into
the skin, classically by a thorn (""rose gardener's disease"")" "<img
src=""7500.png"">" Microbiology duplicate mycology sporothrix-schenckii
A gardener presents with a pustule on her forearm, with lesions tracing upward
toward her axilla. Likely diagnosis? "Sporotrichosis, or ""rose gardener's""
disease" "<img src=""7500.png"">" Microbiology duplicate mycology
sporothrix-schenckii
Is S schenckii a mold, a yeast, or dimorphic? Dimorphic "<img src=""7500.png"">"
Microbiology duplicate mycology sporothrix-schenckii
A patient presents with disseminated disease from S schenckii. What are you also
concerned about in this patient? Immunocompromised status (only those who are
immunocompromised have disseminated disease) "<img src=""7500.png"">"
Microbiology duplicate mycology sporothrix-schenckii
A man has cigar-shaped budding yeast growing in branching hyphae with rosettes of
conidia. How was the patient infected with this yeast? He has sporotrichosis;
traumatic introduction into the skin causes a local pustule or ulcer to form, with
nodules along draining lymphatics "<img src=""7500.png"">" Microbiology
duplicate mycology sporothrix-schenckii
A patient with diarrhea has oocysts in his stool that acid-fast stain. What is the
treatment of choice for the disease? Primary prevention is filtering of water
supplynitazoxanide can be used in immunocompromised hosts (this is
Cryptosporidium) "<img src=""7501.png"">" Microbiology duplicate parasitology
protozoagi-infections
An immunocompetent patient is infected with Cryptosporidium. What is the most
likely clinical presentation? Mild, watery diarrhea "<img src=""7501.png"">"
Microbiology duplicate parasitology protozoagi-infections
In an AIDS patient with severe diarrhea who can be safely treated with
nitazoxanide, what is the mode of transmission of the pathogen? Oocysts in water;
the patient has Cryptosporidium infection "<img src=""7501.png"">" Microbiology
duplicate parasitology protozoagi-infections
A man presents with bloody diarrhea, RUQ pain, and flask-shaped ulcers. What is the
causative agent's mode of transmission? Cysts in water; the patient has E
histolytica infection "<img src=""7501.png"">" Microbiology duplicate
parasitology protozoagi-infections
A woman has the following pathology: flask-shaped ulcers and liver abscesses with
anchovy-paste exudate. What is the treatment? This is E histolytica, which causes
amebiasis; treat with metronidazole; iodoquinol is used for asymptomatic cyst
passers "<img src=""7501.png"">" Microbiology duplicate parasitology
protozoagi-infections
A patient has confirmed E histolytica infection. What methods of diagnosis were
used? Serology and/or visualization of trophozoites (with engulfed RBCs in the
cytoplasm) or cysts (up to four nuclei each) in the stool "<img src=""7501.png"">"
Microbiology duplicate parasitology protozoagi-infections
Toxoplasma causes disease in what two patient populations? AIDS patients and
neonates (congenital toxoplasmosis) "<img src=""7502.png"">" Microbiology
duplicate parasitology protozoacns-infections
A neonate has chorioretinitis, intracranial calcifications, and hydrocephalus. What
is the treatment of choice for the causative infection? Sulfadiazine with
pyrimethamine (this is congenital toxoplasmosis) "<img src=""7502.png"">"
Microbiology duplicate parasitology protozoacns-infections
A boy gets a protozoal infection that causes rapidly fatal meningoencephalitis
after he swims in a lake. How do you confirm the diagnosis?Test for amebas in the
cerebrospinal fluid (this is N fowleri) "<img src=""7502.png"">" Microbiology
duplicate parasitology protozoacns-infections
A newly pregnant woman is advised by her doctor to avoid cats and their feces. Why
does she need to follow the doctor's directions? Toxoplasma can cross the
placenta, causing birth defects (Toxoplasma leaves cysts in cat meat and oocysts in
cat feces) "<img src=""7502.png"">" Microbiology duplicate parasitology
protozoacns-infections
What is the classic triad of congenital toxoplasmosis? Chorioretinitis,
hydrocephalus, and intracranial calcifications "<img src=""7502.png"">"
A patient who recently went swimming now has N fowleri infection. Describe the
process of infection. It is usually acquired from freshwater lakes and enters
through the cribriform plate "<img src=""7502.png"">" Microbiology duplicate
parasitology protozoacns-infections
What is the treatment of choice for bloodborne African sleeping sickness?
Suramin (it sure is nice to go to sleep) "<img src=""7502.png"">"
What treatment of choice for African sleeping sickness affects the central nervous
system? Melarsoprol (melatonin helps with sleep) "<img src=""7502.png"">"
A man bitten by mosquitoes has a 48-hour cyclic fever, headache, anemia, and
splenomegaly. Where is the infectious agent dormant? Its dormant form (hypnozoite)
resides in the liver (this is malaria, likely caused by P vivax/ovale) "<img
src=""7503.png"">" Microbiology duplicate parasitology protozoahematologic-
infections
What is the mode of transmission of the Plasmodium species that cause malaria?
Anopheles mosquitoes "<img src=""7503.png"">" Microbiology duplicate
parasitology protozoahematologic-infections
A malaria patient has severe irregular fever cycles; his RBCs are occluding the
brain, kidney, and lungs. What organism is responsible? P falciparum "<img
infections
A malaria patient has fever cycles, with fever occurring every other day. What
organism is likely causing this? P vivax/ovale "<img src=""7503.png"">"
Microbiology duplicate parasitology protozoahematologic-infections
A patient who was recently bitten by Anopheles mosquitoes has fever, anemia, and
splenomegaly. How do you diagnose his infection? Look on a blood smear for
trophozoite ring forms and red blood cell schizonts with merozoites (this is
malaria) "<img src=""7503.png"">" Microbiology duplicate parasitology
protozoahematologic-infections
A man with P falciparum malaria has life-threatening liver failure. What lab test
should be sent before treatment is started? He needs intravenous quinidine or
artesunatetest for G6PD deficiency before administering "<img src=""7503.png"">"
Which two species of Plasmodium form dormant hypnozoites in the liver, leading to
relapsing malaria? P vivax and P ovale "<img src=""7503.png"">"
Red blood cells with P falciparum infection tend to occlude capillaries in what
three organs? Kidney, lungs, and brain (cerebral malaria) "<img
infections
In a patient with babesiosis, what other disease might you be concerned about
because of its similar mode of transmission? Lyme diseaseboth are transmitted
by Ixodes ticks "<img src=""7503.png"">" Microbiology duplicate parasitology
In what region of the world is Babesia infection most common? The northeastern
United States "<img src=""7503.png"">" Microbiology duplicate parasitology
What group of people are at particular risk for severe babesiosis? What are the
three ways to diagnosis the disease? "Asplenia increases the risk of severe
disease; diagnosis is made with a blood smear (look for ""Maltese cross"" or ring
forms) or PCR" "<img src=""7503.png"">" Microbiology duplicate parasitology
A P falciparum patient wishes to start artesunate. What test must be done before
treatment? What other malaria drugs require this test? G6PD deficiency test;
this test must also be performed on patients taking primaquine for P vivax/ovale
"<img src=""7503.png"">" Microbiology duplicate parasitology protozoa
hematologic-infections
You suspect that a female patient has T vaginalis. How is the diagnosis officially
made? "Motile trophozoites on wet mount and/or ""strawberry cervix"" on exam"
"<img src=""7504.png"">" Microbiology duplicate parasitology protozoa
others
A patient exhibits cardiomyopathy, megacolon, and megaesophagus. He remembers being
bitten by a bug in Brazil. Treatment? Treat with benznidazole or nifurtimox;
this is Chagas disease from T cruzi (cruzing in my Benz, with a fur coat on) "<img
src=""7504.png"">" Microbiology duplicate parasitology protozoaothers
A man is bitten by a sandfly and develops spiking fevers, hepatosplenomegaly, and
pancytopenia. What is the treatment? Amphotericin B with sodium stibogluconate
(this is visceral leishmaniasis) "<img src=""7504.png"">" Microbiology
duplicate parasitology protozoaothers
In a patient with confirmed visceral leishmaniasis, how was the diagnosis made?
Evidence of macrophages containing amastigotes "<img src=""7504.png"">"
Microbiology duplicate parasitology protozoaothers
A patient has foul-smelling, itching, burning vaginitis with green discharge, and
trophozoites on wet mount. Diagnosis? T vaginalis infection "<img
src=""7504.png"">" Microbiology duplicate parasitology protozoaothers
How is T vaginalis transmitted? Sexually (it cannot exist outside the human
body, because it would not be able to form cysts) "<img src=""7504.png"">"
Microbiology duplicate parasitology protozoaothers
A patient has skin ulcers from a protozoa transmitted by a sandfly. What is the
best treatment? The patient has cutaneous leishmaniasis; treatment is
amphotericin B and sodium stibogluconate "<img src=""7504.png"">" Microbiology
duplicate parasitology protozoaothers
Which nematodes are transmitted by ingestion of contaminated food? Enterobius,
Ascaris, Toxocara, Trichinella (you'll get sick if you EATT these) "<img
src=""7505.png"">" Microbiology duplicate nematode-routes-of-infection
parasitology
Which nematodes are transmitted through bites? Loa loa, Onchocerca volvulus,
Wuchereria bancrofti (lay LOW to avoid getting bitten) "<img src=""7505.png"">"
Microbiology duplicate nematode-routes-of-infection parasitology
Which nematodes are transmitted cutaneously? Strongyloides, Ancylostoma, Necator
(they get into your feet from the SANd) "<img src=""7505.png"">" Microbiology
duplicate nematode-routes-of-infection parasitology
A patient is infected with Ascaris. Name three other nematodes that can be acquired
by way of the same route. Ascaris is acquired through ingestion; the other
three nematodes are Enterobius, Toxocara, and Trichinella "<img src=""7505.png"">"
A patient has confirmed Strongyloides infection. Name two other nematodes that can
be acquired by way of the same route of infection. Strongyloides is acquired by
way of the cutaneous route; the other two nematodes are Ancylostoma and Necator
"<img src=""7505.png"">" Microbiology duplicate nematode-routes-of-
infection parasitology
A patient has confirmed loa loa infection. What are two other nematodes that can be
acquired by way of a similar route? Loa loa is acquired by way of bites; O volvulus
and W bancrofti have the same mode of transmission "<img src=""7505.png"">"
What is the type I response of eosinophils against helminths? Neutralization of
histamine and leukotrienes "<img src=""7506.png"">" Microbiology duplicate
immune-response-to-helminths parasitology
What is the type II response of eosinophils against helminths? Eosinophils adhere
to the surfaces of helminth by means of IgE and release cytotoxins (eg, major basic
protein) found in their granules "<img src=""7506.png"">" Microbiology
duplicate immune-response-to-helminths parasitology
What is the common name for E vermicularis? Pinworm "<img src=""7507.png"">"
Microbiology duplicate nematodes-(roundworms) parasitology
E vermicularis causes infection of what organ? The intestines (although it
typically manifests as anal pruritus) "<img src=""7507.png"">" Microbiology
duplicate nematodes-(roundworms) parasitology
A patient experiences anal pruritus after eating contaminated food. Why do you
perform the tape test in this patient? To confirm E vermicularis (pinworm)
infection, look for eggs stuck to the tape "<img src=""7507.png"">"
What is the common name for A lumbricoides? Giant roundworm "<img
src=""7507.png"">" Microbiology duplicate nematodes-(roundworms) parasitology
In a patient with A lumbricoides, what organ is affected by the infestation? What
part of this organ is at risk for a dangerous blockage? The intestines; the
ileocecal valve is at risk for obstruction "<img src=""7507.png"">"
How is A lumbricoides transmitted, and what is the treatment? Fecal-oral (eggs
are visible in feces under a microscope); treat with bendazoles "<img
How is S stercoralis transmitted? What are the common symptoms? As soil larvae
that penetrate the skin; they infect the intestines, causing vomiting, diarrhea,
and epigastric pain (mimic peptic ulcers) "<img src=""7507.png"">" Microbiology
A patient experiences vomiting, diarrhea and epigastric pain with likely S
stercoralis infestation. What is the treatment? Ivermectin or bendazoles "<img
What is the common name for A duodenale and N americanus? Hookworms "<img
How are A duodenale and N americanus transmitted? What is the treatment of choice?
Larvae penetrate the skin; treat with bendazoles or pyrantel pamoate "<img
A patient is concerned that she has a hookworm infection. What organ is likely
affected? The intestines "<img src=""7507.png"">" Microbiology duplicate
nematodes-(roundworms) parasitology
A patient with a hookworm infestation (A duodenale or N americanus) has signs of
anemia. What is causing the anemia? Worms suck blood through the intestinal walls,
resulting in anemia "<img src=""7507.png"">" Microbiology duplicate
A man bitten by a female blackfly experiences skin hyperpigmentation and blindness.
What do you treat him with? "Treat with ivermectin; this is O volvulus infection
(blackflies, black skin nodules, ""black sight"")" "<img src=""7507.png"">"
A patient has river blindness caused by O volvulus. Anaphylaxis develops as a
result of exposure to what? Microfilaria "<img src=""7507.png"">"
A woman has skin swellings and conjunctival worms. She receives treatment with
diethylcarbamazine. How is this nematode transmitted? By way of deer, horse, and
mango flies (this is loa loa) "<img src=""7507.png"">" Microbiology duplicate
A patient exhibits visceral larva migrans after eating food contaminated with eggs.
Treatment? Use bendazoles (this is T canis infection) "<img src=""7507.png"">"
A woman bitten by a deerfly exhibits skin swelling. You see worms in the
conjunctiva. Treatment? Use diethylcarbamazine (this is loa loa infection) "<img
A man bitten by a mosquito exhibits elephantiasis 9 to 12 months later because of
lymphatic invasion and blockage. What is the diagnosis? W bancrofti infection
"<img src=""7507.png"">" Microbiology duplicate nematodes-(roundworms)
parasitology
How is T canis transmitted? Fecal-oral route, by way of food contaminated with
eggs "<img src=""7507.png"">" Microbiology duplicate nematodes-(roundworms)
parasitology
How does a nematode cause inflammation of muscle in a patient with confirmed T
spiralis? What is the best treatment? Larvae enter the bloodstream and are
encysted in striated muscle cells, leading to inflammation of the muscle; the
treatment is bendazoles "<img src=""7507.png"">" Microbiology duplicate
A recent visitor to Mexico who loves pork tacos has fever, vomiting, periorbital
edema, and muscle pain. Most likely route of infection? Ingestion of T spiralis
nematodes in undercooked pork "<img src=""7507.png"">" Microbiology duplicate
A rural boy runs around barefoot on beaches. He notices pruritic papules and
serpiginous rashes on his feet. Name the infection route. This is N americanus
infection; the nematode is transmitted cutaneously, penetrating the skin of the
feet; this is cutaneous larva migrans "<img src=""7507.png"">" Microbiology
In a patient with confirmed T canis infection, what organs tend to be infected most
often? Heart (leading to myocarditis), liver, and CNS (leading to seizures
and/or coma) "<img src=""7507.png"">" Microbiology duplicate nematodes-
(roundworms) parasitology
In a patient with an infection transmitted by a female blackfly and subsequent
river blindness, what other symptoms might you observe? Skin changes due to loss
of elastic fibers and allergic reactions to microfilariae are also possible (this
is O volvulus infection) "<img src=""7507.png"">" Microbiology duplicate
T solium, D latum, and E granulosus are examples of what type of organism?
Cestodes (tapeworms) "<img src=""7508.png"">" Microbiology cestodes-
(tapeworms) duplicate parasitology
What is the mode of transmission of T solium? Consumption of undercooked pork
containing encysted larvae "<img src=""7508.png"">" Microbiology cestodes-
(tapeworms) duplicate parasitology
What is the treatment of choice for T solium infection? Praziquantel for
intestinal infection and albendazole for neurocysticercosis"<img src=""7508.png"">"
Microbiology cestodes-(tapeworms) duplicate parasitology
After eating undercooked freshwater fish, a man exhibits vitamin B12 deficiency and
anemia. What is the best treatment? Treat with praziquantel (this is D latum
infection) "<img src=""7508.png"">" Microbiology cestodes-(tapeworms)
duplicate parasitology
What is the mode of transmission of D latum? Ingestion of larvae in uncooked
freshwater fish "<img src=""7508.png"">" Microbiology cestodes-(tapeworms)
duplicate parasitology
A patient has a chronic infection that leads to squamous cell carcinoma of the
bladder. What is the infecting helminth's host? This is Schistosoma infection
(Schistosoma uses the snail as a host) "<img src=""7509.png"">" Microbiology
duplicate parasitology trematodes-(flukes)
How is Schistosoma transmitted to humans? Through cercariae penetration of the skin
"<img src=""7509.png"">" Microbiology duplicate parasitology trematodes-
(flukes)
A 24-year-old man has had cercariae penetrate his skin. Years later, he develops
painless hematuria. What is the treatment of choice? Praziquantel (this is
schistosomiasis that may be causing squamous cell carcinoma of the bladder) "<img
src=""7509.png"">" Microbiology duplicate parasitology trematodes-(flukes)
Which fluke is transmitted in undercooked fish? C sinensis "<img src=""7509.png"">"
Microbiology duplicate parasitology trematodes-(flukes)
A 27-year-old woman infected by a fluke is found to have pigmented gallstones and
cholangiocarcinoma. Name the treatment of choice. Praziquantel (this is C
sinensis infection) "<img src=""7509.png"">" Microbiology duplicate
parasitology trematodes-(flukes)
Which fluke causes biliary tract inflammation and pigmented gallstones? This
is C sinensis infection "<img src=""7509.png"">" Microbiology duplicate
parasitology trematodes-(flukes)
A patient has a parasite that causes myalgias and periorbital edema. Identify it.
T spiralis "<img src=""7510.png"">" Microbiology duplicate parasite-
hints parasitology
An adult patient of yours has brain cysts and seizures. Which parasite is the most
likely cause? T solium (this is neurocysticercosis) "<img src=""7510.png"">"
Microbiology duplicate parasite-hints parasitology
Hydatid liver cysts develop in a 17-year-old boy. With which helminth is he
infected? E granulosus "<img src=""7510.png"">" Microbiology duplicate
parasite-hints parasitology
A 55-year-old male swimmer experiences hematuria, and bladder cancer is discovered.
With what organism might he be infected? S haematobium "<img src=""7510.png"">"
A 60-year-old woman is infected with a helminth and has vitamin B12 deficiency.
With which helminth is she infected? D latum "<img src=""7510.png"">"
A patient presents with a helminth that causes biliary tract disease and is
associated with cholangiocarcinoma. Identify it. C sinensis "<img
src=""7510.png"">" Microbiology duplicate parasite-hints parasitology
A patient has a helminth that causes portal hypertension. Identify it. S mansoni or
S japonicum "<img src=""7510.png"">" Microbiology duplicate parasite-hints
parasitology
Name the helminth(s) that classically cause(s) microcytic anemia. Ancylostoma
and Necator "<img src=""7510.png"">" Microbiology duplicate parasite-hints
parasitology
A patient has constant itching in her perianal area. Name the helminth that is
causing this pruritus. Enterobius "<img src=""7510.png"">" Microbiology
duplicate parasite-hints parasitology
A prisoner has itchy hands and serpiginous burrows in the webs of his fingers.
What's causing the itching? The patient has scabies (S scabiei infection); mites
burrow into the stratum corneum, which causes the pruritus "<img src=""7511.png"">"
Microbiology duplicate ectoparasites parasitology
A patient has serpiginous burrows on her feet and associated itching. In what
populations is this finding common? The patient has scabies (S scabiei infection);
it is most frequent in children, crowded jail populations, and nursing homes "<img
src=""7511.png"">" Microbiology duplicate ectoparasites parasitology
In a patient with lice, where do the insects prefer to live? Clothing "<img
src=""7511.png"">" Microbiology duplicate ectoparasites parasitology
What infections can the blood-sucking insects known as lice transmit to humans?
The insects can transmit R prowazekii (typhus), B recurrentis (relapsing
fever), and B quintana (trench fever) "<img src=""7511.png"">" Microbiology
duplicate ectoparasites parasitology
A child who lives in crowded public housing presents with serpiginous burrows in
his hands and feet. What are your treatment options? The child likely has scabies;
manage with permethrin cream, washing/drying of all clothing/bedding, and treatment
of close contacts "<img src=""7511.png"">" Microbiology duplicate
ectoparasites parasitology
Structurally, what are the three main classes of viruses? Naked icosahedral with
icosahedral capsid, enveloped virus with icosahedral capsid, and enveloped virus
with helical capsid "<img src=""7512.png"">" Microbiology duplicate viral-
structuregeneral-features virology
What is the definition of viral genetic recombination? The exchange of genes
between two chromosomes by crossing over within regions of significant base
sequence homology "<img src=""7513.png"">" Microbiology duplicate viral-
genetics virology
In viral genetics, what is the definition of reassortment? The exchange of genetic
material among viruses with segmented genomes (eg, influenza virus) "<img
src=""7513.png"">" Microbiology duplicate viral-genetics virology
In 2009, the H1N1 influenza A pandemic was caused by complex viral genetic event.
What was the event? Reassortment (viruses with segmented genomes exchange
segments); in this case, complex reassortments between human, swine, and avian
viruses "<img src=""7513.png"">" Microbiology duplicate viral-genetics
virology
Two viruses coinfect a cell. Virus A is coated with virus B proteins. Progeny
viruses have the type A genome and coat. What is this called? Phenotypic mixing
"<img src=""7513.png"">" Microbiology duplicate viral-genetics virology
What type of viral genomic structure is necessary for viral genome reassortment?
A segmented genome "<img src=""7513.png"">" Microbiology duplicate
viral-genetics virology
Viruses A and B infect a cell. A mutates and becomes nonfunctional; B makes a
protein that functions for both A and B. What is this called? Complementation
What is a pseudovirion? The genetic material of one virus coated by the surface
proteins of a different virus "<img src=""7513.png"">" Microbiology duplicate
viral-genetics virology
Hepatitis D virus (HDV) infection needs coinfection with hepatitis B to supply the
envelope protein for HDV. What is this called? Complementation "<img
src=""7513.png"">" Microbiology duplicate viral-genetics virology
The genome of virus A is coated with surface proteins from virus B. Whose genetic
material will the progeny of this infection have? A virus A coat with virus A
genetic material; this is phenotypic mixing "<img src=""7513.png"">"
Microbiology duplicate viral-genetics virology
In phenotypic mixing of virus A and virus B with providing surface protein, which
virus determines infectivity of the hybrid virus? The virus B protein coat
"With reassortment, there is the potential for what kind of ""shift"" to occur?"
Antigenic shift "<img src=""7513.png"">" Microbiology duplicate viral-
genetics virology
An adult patient receives a viral vaccine that induces both humoral and cell-
mediated immunity. What type of vaccine is this? Live attenuated "<img
src=""7514.png"">" Microbiology duplicate viral-vaccines virology
An adult patient receives a viral vaccine, but only humoral immunity is induced.
What type of vaccine is this? Killed virus "<img src=""7514.png"">"
Microbiology duplicate viral-vaccines virology
A patient is given a viral vaccine and it reverts to virulence (a rare occurrence).
What type of vaccine was it? Live attenuated "<img src=""7514.png"">"
To encourage vaccinations, your local city plans to give out live vaccines. In what
populations should live vaccinations be discouraged? Immunocompromised patients;
close contacts may be given live vaccines, except for live polio or influenza
"<img src=""7514.png"">" Microbiology duplicate viral-vaccines virology
Name six live attenuated vaccines. Yellow fever, MMR, rotavirus, chickenpox (VZV),
smallpox, Sabin polio virus, influenza (intranasal) "<img src=""7514.png"">"
Name four killed virus vaccines. Rabies, Influenza, Salk Polio, and hepatitis A
virus (RIP AlwaysSalK = Killed) "<img src=""7514.png"">" Microbiology
duplicate viral-vaccines virology
A child is administered the hepatitis B vaccine. Which antigen is present in the
vaccine? Recombinant hepatitis B surface antigen (HBsAg) "<img src=""7514.png"">"
Which human papillomavirus (HPV) types does the HPV vaccine protect against? What
kind of vaccine is it? HPV types 6, 11, 16, and 18 (the types most likely to cause
cervical cancer and genital warts); subunit vaccine "<img src=""7514.png"">"
In HIV patients who do not have signs of immunodeficiency, what live attenuated
vaccines can be given safely? Measles,Mumps, Rubella (MMR) "<img src=""7514.png"">"
What mnemonic can help you remember all of the live vaccines? Live! One night
only! See small yellow rotating chickens being vaccinated with Sabin and MMR! Its
incredible! "<img src=""7514.png"">" Microbiology duplicate viral-vaccines
virology
Does a patient who receives the MMR vaccine require a booster? No, live
attenuated vaccines do not require a booster "<img src=""7514.png"">"
Which family of DNA viruses do not contain double-strand DNA? Parvoviridae,
which has single-stranded DNA (parvovirus is part-of-a-virus) "<img
src=""7515.png"">" Microbiology dna-viral-genomes duplicate virology
Which three DNA virus families contain nonlinear DNA? Papillomaviruses,
polyomaviruses, and hepadnaviruses (circular) "<img src=""7515.png"">"
Microbiology dna-viral-genomes duplicate virology
Which family of RNA viruses are not single-strand RNA? "The Reoviridae family
(all are single-stranded RNA except ""repeatovirus"" [reovirus], which is double-
stranded [ds] RNA)" "<img src=""7516.png"">" Microbiology duplicate rna-
viral-genomes virology
Name the seven positive-strand RNA viruses. Retrovirus, togavirus, flavivirus,
coronavirus, calicivirus, hepevirus, and picornavirus "<img src=""7516.png"">"
Microbiology duplicate rna-viral-genomes virology
What mnemonic can help you to remember the seven positive-strand RNA viruses?
I went to a retro toga party, where I drank flavored Corona and ate hippy
California pickles "<img src=""7516.png"">" Microbiology duplicate rna-
viral-genomes virology
Why are naked nucleic acids of negative-strand ssRNA and dsRNA viruses not
infectious? They require polymerases found in the complete virion to become
infectious "<img src=""7517.png"">" Microbiology duplicate naked-viral-
genome-infectivity virology
Purified nucleic acids of certain dsDNA and positive-strand ssRNA viruses are
infectious. Why? The dsDNA and ssRNA can utilize host cell machinery (eg, ssRNA
mimics mRNA) "<img src=""7517.png"">" Microbiology duplicate naked-viral-
What two dsDNA viruses' purified nucleic acids are not considered infectious?
Poxvirus and hepatitis B virus (they require nonhuman enzymes for
replication) "<img src=""7517.png"">" Microbiology duplicate naked-viral-
You determine that a patient is infected with a DNA virus that does not replicate
in the nucleus. Which DNA virus is it? Poxvirus "<img src=""7518.png"">"
Microbiology duplicate viral-replication virology
With one exception, all DNA viruses replicate in what part of the host cell?
Nucleus "<img src=""7518.png"">" Microbiology duplicate viral-
replication virology
Where do most RNA viruses replicate in the host cell? Cytoplasm "<img
src=""7518.png"">" Microbiology duplicate viral-replication virology
Which two RNA viruses do not replicate in the cytoplasm? The influenza virus and
retroviruses "<img src=""7518.png"">" Microbiology duplicate viral-
replication virology
Name eight naked (nonenveloped) viruses. Parvovirus, Adenovirus, Papillomavirus,
Polyomavirus, Calicivirus, Picornavirus, Reovirus, and Hepevirus (PAPP smears/CPR
for naked hippies) "<img src=""7519.png"">" Microbiology duplicate viral-
envelopes virology
From what cellular structure do enveloped viruses generally get their envelopes?
From the plasma membrane as they leave the cell "<img src=""7519.png"">"
Microbiology duplicate viral-envelopes virology
What cellular structure in their hosts do the herpesviruses acquire their envelopes
from? Nuclear membrane "<img src=""7519.png"">" Microbiology duplicate viral-
envelopes virology
A 3-year-old boy contracted a virus that gave him a slapped-cheek appearance. Is
the causative virus enveloped or naked? Naked, meaning nonenveloped (the virus
here is parvovirus) "<img src=""7519.png"">" Microbiology duplicate viral-
envelopes virology
What three DNA viruses are not linear? Hepadnavirus (circular, incomplete),
papillomavirus (circular, supercoiled), and polyomavirus (circular, supercoiled)
"<img src=""7520.png"">" Microbiology dna-virus-characteristics
duplicate virology
Name seven DNA viruses. Hepadnavirus, Herpesvirus, Adenovirus, Poxvirus,
Parvovirus, Papillomavirus, andPolyomavirus (HHAPPPPy viruses) "<img
src=""7520.png"">" Microbiology dna-virus-characteristics duplicate virology
You determine that your patient is infected with a DNA virus that is not
icosahedral. What is it? Poxvirus (it is complex) "<img src=""7520.png"">"
Microbiology dna-virus-characteristics duplicate virology
You identify a DNA virus that does not replicate in the nucleus because it can
replicate without nuclear enzymes. Identify it. Poxvirus (it has a DNA-dependent
RNA polymerase and can replicate without nuclear enzymes) "<img src=""7520.png"">"
"A 3-year-old boy contracts a DNA virus that has given him a ""slapped face""
appearance. Is the causative virus single or double stranded?" Single-stranded
all DNA viruses are double stranded, except for parvovirus "<img src=""7520.png"">"
You determine that your patient is infected with a DNA virus that is circular and
incompletely coiled. What virus is it? Hepadnavirus "<img src=""7520.png"">"
A boy presents with flesh-colored, dimpled, dome-shaped lesions on his legs and
face. What type of virus is causing these symptoms? Caused by a poxvirus (this is
molluscum contagiosum, marked by flesh-colored papules with a central umbilication)
"<img src=""7521.png"">" Microbiology dna-viruses duplicate virology
A patient has a poxvirus that causes milkmaid blisters. Identify the causative
virus. Cowpox "<img src=""7521.png"">" Microbiology dna-viruses
duplicate virology
Which DNA virus is the only hepatitis-causing virus? Hepatitis B virus
(hepadnavirus) "<img src=""7521.png"">" Microbiology dna-viruses duplicate
virology
An adult man presents with red blood cell aplasia and rheumatoid arthritislike
symptoms. What viral infection does he have? Parvovirus B19 "<img
src=""7521.png"">" Microbiology dna-viruses duplicate virology
A kidney transplant recipient has renal dysfunction; tests show a virus with
circular double-stranded DNA. Does the virus have an envelope? No; this is BK
(Bad Kidney) virus infection, which is a type of polyomavirus "<img
src=""7521.png"">" Microbiology dna-viruses duplicate virology
A kindergarten teacher has conjunctivitis and a sore throat. The causative virus is
double stranded and linear. What virus is it? Adenovirus "<img src=""7521.png"">"
Microbiology dna-viruses duplicate virology
A patient presents with a new diagnosis of cervical cancer. What HPV serotypes are
associated with this malignancy? 16 and 18 "<img src=""7521.png"">"
What is the DNA structure of herpesviruses? Does the virion have an envelope?
Double-stranded and linear; yes "<img src=""7521.png"">" Microbiology
dna-viruses duplicate virology
To what viral family does hepatitis B virus belong? What DNA structure does it
have? Does it have an envelope? Hepadnaviridae; partially double-stranded and
circular; yes "<img src=""7521.png"">" Microbiology dna-viruses duplicate
virology
Retroviruses and the hepatitis B virus tend to share a common enzyme. Name the
enzyme. Reverse transcriptase "<img src=""7521.png"">" Microbiology dna-
viruses duplicate virology
A patient has febrile pharyngitis, pneumonia, and conjunctivitis. What is the viral
DNA structure of the virus most likely responsible? Double-stranded and linear
(this is an adenovirus) "<img src=""7521.png"">" Microbiology dna-viruses
duplicate virology
A patient presents with acute hemorrhagic cystitis. A virus is to blame. Does the
virus have an envelope? No, the causative virus (adenovirus) does not have an
envelope "<img src=""7521.png"">" Microbiology dna-viruses duplicate
virology
You believe you have isolated the smallest of the DNA viruses in your lab. What is
its DNA structure? Single-stranded and linear negative (this is parvovirus)
A child presents with erythema infectiosum (fifth disease or slapped-cheeks rash).
What virus is responsible? Parvovirus B19 "<img src=""7521.png"">"
A patient with sickle cell disease presents with an aplastic crisis. What virus is
most likely responsible? Parvovirus B19 "<img src=""7521.png"">"
A pregnant woman is exposed to parvovirus B19. What complication might be seen in
her fetus? Hydrops fetalis (due to red blood cell destruction) and possibly death
A patient presents with joint pain. Blood work shows a low RBC count. If a virus is
to blame, does it have an envelope? No (this is parvovirus infection, which has no
envelopeit causes pure RBC aplasia and rheumatoid arthritislike symptoms in
adults) "<img src=""7521.png"">" Microbiology dna-viruses duplicate
virology
A patient has cervical cancer. Is the virus that she's infected with circular or
linear? Single or double stranded? Enveloped? Circular; double-stranded; not
enveloped (this is the papillomavirus known as HPV) "<img src=""7521.png"">"
A patient presents with warts that are likely from HPV infection. Which HPV
serotypes are associated with warts? 1, 2, 6, and 11 "<img src=""7521.png"">"
An HIV-positive patient presents with progressive multifocal leukoencephalopathy.
With what virus do you suspect a coinfection? John Cunningham virus (JCV) (Junky
Cerebrum), a polyomavirus "<img src=""7521.png"">" Microbiology dna-viruses
duplicate virology
Which viral family is responsible for smallpox, cowpox, and molluscum contagiosum?
Poxviridae "<img src=""7521.png"">" Microbiology dna-viruses duplicate
virology
In lab, you believe that you have isolated the largest of the DNA viruses. What is
its DNA structure? Does it have an envelope? Double-stranded and linear; yes
(this is poxvirus) "<img src=""7521.png"">" Microbiology dna-viruses
duplicate virology
Which disease caused by a poxvirus has been eradicated through the use of a live
attenuated vaccine? Smallpox "<img src=""7521.png"">" Microbiology dna-
viruses duplicate virology
A patient is diagnosed with herpes encephalitis. Which lobe of the brain is most
likely affected? The temporal lobe "<img src=""7522.png"">" Microbiology
duplicate herpesviruses virology
Which herpesvirus is the most common cause of sporadic encephalitis in the United
States? Herpes simplex virus-1 "<img src=""7522.png"">" Microbiology
Where does the herpes simplex virus-2 lie latent? In the sacral ganglia "<img
src=""7522.png"">" Microbiology duplicate herpesviruses virology
Which herpesviruses are transmitted in respiratory secretions? Which are
transmitted by way of sexual contact? HSV-1, EBV, and VZV are transmitted in
respiratory secretions; HSV-2, CMV, and HHV-8 are transmitted by way of sexual
contact "<img src=""7522.png"">" Microbiology duplicate herpesviruses
virology
What herpes virus commonly causes herpes genitalis and neonatal herpes? Herpes
simplex virus-2 "<img src=""7522.png"">" Microbiology duplicate
herpesviruses virology
What herpesvirus can cause shingles, encephalitis, and pneumonia? Varicella
zoster virus (HHV-3) "<img src=""7522.png"">" Microbiology duplicate
A teenager with general malaise has a positive Monospot test result. What is the
Monospot test? What virus is associated with this test result? The Monospot test
detects heterophile antibodies by means of the agglutination of sheep or horse
RBCs; used for EBV/HHV-4 "<img src=""7522.png"">" Microbiology duplicate
What kind of presentations can cytomegalovirus have? Congenital infection,
mononucleosis, retinitis, and pneumonia "<img src=""7522.png"">" Microbiology
What virus causes a mononucleosis that's Monospot negative?Cytomegalovirus (human
herpesvirus type 5) "<img src=""7522.png"">" Microbiology duplicate
A patient has herpes simplex virus (HSV)-2 infection. She wonders how transmission
for HSV-1 and HSV-2 differs. What do you tell her? HSV-1 is spread mainly in
respiratory secretions and saliva, whereas HSV-2 is spread by means of sexual
contact and perinatally "<img src=""7522.png"">" Microbiology duplicate
Your patient has confirmed cytomegalovirus infection. How is this virus is
typically transmitted? Sexual contact, congenital, transfusion, urine, saliva,
organ transplants "<img src=""7522.png"">" Microbiology duplicate
Where does the Epstein-Barr virus establish latency? What about cytomegalovirus?
EBV establishes latency in B cells; CMV establishes latency in mononuclear
cells "<img src=""7522.png"">" Microbiology duplicate herpesviruses virology
Describe the rash of Kaposi sarcoma. Where can it be found?Dark, violaceous, flat
plaques or nodules that are endothelial growths; seen on the skin or, rarely, in
the GI tract or lungs "<img src=""7522.png"">" Microbiology duplicate
A 17-year-old athlete is found to have mononucleosis. What herpesvirus is the most
common cause of his infection? What should the boy avoid? Epstein-Barr virus
(human herpesvirus-4); he should be avoiding contact sports because of the risk of
splenic rupture "<img src=""7522.png"">" Microbiology duplicate
In what patient population do you typically see Epstein-Barr virus infection?
Teenagers and young adults "<img src=""7522.png"">" Microbiology
What lab test detects heterophile antibodies via agglutination of sheep red blood
cells? Monospot testheterophile antibodies detected by agglutination of sheep
red blood cells "<img src=""7522.png"">" Microbiology duplicate
A patient has fever and pharyngitis. Prominent anterior cervical lymphadenopathy is
seen. Does this increase or decrease suspicion of EBV? Decrease (EBV infection
is more strongly associated with posterior, not anterior, cervical adenopathy);
consider strep throat in this case "<img src=""7522.png"">" Microbiology
By way of what surface marker does EBV/HHV-4 infect B cells? CD21 "<img
src=""7522.png"">" Microbiology duplicate herpesviruses virology
What virus is a less common cause of roseola? HHV-7 "<img src=""7522.png"">"
Microbiology duplicate herpesviruses virology
What are the differences in CMV infection between immunocompetent and
immunosuppressed hosts? Immunocompetent hosts typically have a mononucleosis-type
illness; immunocompromised hosts have more serious infections, such as pneumonia
"<img src=""7522.png"">" Microbiology duplicate herpesviruses virology
Which herpes simplex virus is more likely to cause viral meningitis? Viral
meningitis is more common with HSV-2 than it is with HSV-1 "<img src=""7522.png"">"
Microbiology duplicate herpesviruses virology
What is the Tzanck test? A test to detect multinucleated giant cells in opened
skin vesicles in HSV-1, HSV-2, and VZV (Tzanck [thank] heavens I do not have
herpes) "<img src=""7523.png"">" Microbiology duplicate hsv-identification
virology
You suspect your patient of having HSV encephalitis. What lab test can you perform
to confirm this diagnosis? Cerebrospinal fluid PCR for HSV "<img
src=""7523.png"">" Microbiology duplicate hsv-identification virology
In patients with skin and genitalia findings that suggest HSV, what is the typical
identification test? Viral culture for skin/genitalia "<img src=""7523.png"">"
Microbiology duplicate hsv-identification virology
What is the viral receptor for rabies? Nicotinic AChR "<img src=""7524.png"">"
Microbiology duplicate receptors-used-by-viruses virology
If the receptor ICAM-1 is blocked, what virus will have difficulty infecting cells?
Rhinovirus "<img src=""7524.png"">" Microbiology duplicate receptors-
used-by-viruses virology
If the receptor CD21 is blocked, what virus will have difficulty infecting cells?
EBV "<img src=""7524.png"">" Microbiology duplicate receptors-used-by-
viruses virology
What are the viral receptors for HIV? CD4, CXCR4, and CCR5 "<img
src=""7524.png"">" Microbiology duplicate receptors-used-by-viruses virology
What are the viral receptors for CMV? Integrins (heparan sulfate) "<img
src=""7524.png"">" Microbiology duplicate receptors-used-by-viruses virology
Which two picornaviruses commonly cause aseptic meningitis?Echovirus and
coxsackievirus "<img src=""7525.png"">" Microbiology duplicate rna-viruses
virology
A patient presents with a runny nose and cough, likely caused by the common cold.
Which two RNA viruses could be the culprit? Rhinovirus and coronavirus "<img
src=""7525.png"">" Microbiology duplicate rna-viruses virology
What picornavirus can cause aseptic meningitis, pericarditis, herpangina (mouth
blisters/fever), myocarditis, and hand/foot/mouth disease? Coxsackievirus "<img
A patient comes to a cruise ship doctor with vomiting and diarrhea. The doctor
tells him he has likely contracted a calicivirus. Which one? Norovirus "<img
A 1-year-old presents with severe diarrhea. He is infected with a reovirus. With
which virus in that family is he most likely infected? Rotavirus "<img
A patient contracts Colorado tick fever. What is the structure of the RNA virus
that is most likely responsible? The virus is nonenveloped, with RNA that is DS
linear and, in 1012 segments, double icosahedral capsid (this is coltivirus)
"<img src=""7525.png"">" Microbiology duplicate rna-viruses virology
How is the reovirus genome unique among RNA viruses? It has double-stranded RNA
all other RNA viruses are single stranded "<img src=""7525.png"">" Microbiology
duplicate rna-viruses virology
Name the four RNA viruses that have segmented genomes, and name the number of
segments in the genome. Reovirus (1012 segments), arenavirus (2 segments),
orthomyxovirus (8 segments), and bunyavirus (3 segments) "<img src=""7525.png"">"
Microbiology duplicate rna-viruses virology
What family of RNA viruses causes hepatitis C, yellow fever, dengue, St. Louis
encephalitis, and West Nile disease? Flaviviruses "<img src=""7525.png"">"
A patient has symptoms of rubella (German measles) virus infection. What other
viruses are part of the same RNA virus family? Eastern equine encephalitis and
Western equine encephalitis (all are togaviruses, similar to rubella) "<img
Name two retroviruses that have reverse transcriptase. HIV and HTLV "<img
A patient has a virally induced T-cell leukemia. To which RNA virus family does the
virus associated with his disease belong? Retroviruses (this is HTLV) "<img
A patient has a confirmed coronavirus infection. These viruses are the causative
agents of what three diseases? The common cold, MERS, and SARS "<img
To which RNA virus family does the influenza virus belong? Orthomyxoviruses "<img
Name four medically important paramyxoviruses. Parainfluenza virus, RSV (Rx with
ribavirin), Mumps, and Measles (PaRaMyxovirus) "<img src=""7525.png"">"
A child is up to date on his measles and mumps vaccinations. To which RNA viral
family do the measles and mumps viruses belong? Paramyxoviruses "<img
A toddler exhibits a barking cough. Which RNA virus caused this illness?
Parainfluenza (the patient has croup, which is classically associated with a
barking cough) "<img src=""7525.png"">" Microbiology duplicate rna-viruses
virology
To which RNA virus family does Ebola hemorrhagic fever belong? Filoviruses "<img
What is the structure of the RNA virus family that the Marburg virus belongs to?
Negative, single-stranded, linear, and helical (filoviruses) "<img
A patient has a confirmed arenavirus infection. Which two diseases are you
concerned about? Lymphocytic choriomeningitis (from LCMV) and Lassa fever
encephalitis (spread by rodents) "<img src=""7525.png"">" Microbiology
What RNA viral family has California encephalitis, sandfly/Rift Valley fevers,
Crimean-Congo hemorrhagic fever, and hantavirus fever? Bunyaviruses "<img
A warehouse worker in Arizona has pneumonia and dyspnea; rodents tested near his
worksite were infected with an RNA virus. Diagnosis? Hantavirus, a rodent-borne
bunyavirus that in the United States causes a pulmonary syndrome "<img
Which viral family has the hepatitis D virus? Delta viruses "<img
Name seven viral families that are single-strand, positive-sense, linear RNA
viruses with icosahedral capsids. Picornavirus, hepevirus, calicivirus,
flavivirus, togavirus, coronavirus, and retrovirus (HTLV only) "<img
Name the viral family that is made up of double-stranded RNA viruses with double
icosahedral capsids. Reoviruses "<img src=""7525.png"">" Microbiology
What type of capsid shape do most negative-sense RNA viruses have? Which family of
these viruses is of uncertain type? Helical; delta viruses "<img src=""7525.png"">"
Arenaviruses have a unique RNA structure. What other two families have similar RNA
structures? Bunyavirus and delta viruses also have circular RNA "<img
What is the only positive-sense RNA virus with a helical capsid? Coronavirus "<img
Which diseases are caused by arboviruses (RNA viruses transmitted by arthropods)?
Yellow & dengue fevers, encephalites (St. Louis, Eastern & Western equine,
California), Crimean-Congo hemorrhagic fever, West Nile fever "<img
How are arboviruses transmitted? By arthropods (mosquitoes, ticks) (arbovirus,
arthropod borne) "<img src=""7525.png"">" Microbiology duplicate rna-viruses
virology
Name the four families of RNA viruses that have no envelope. Reoviruses,
picornaviruses, hepeviruses, and caliciviruses "<img src=""7525.png"">"
A human bitten by a dog exhibits partial paralysis, insomnia, agitation, and
delirium. What RNA virus family is responsible for his illness? Rhabdoviruses
(this patient has rabies) "<img src=""7525.png"">" Microbiology duplicate
rna-viruses virology
There is an outbreak of paramyxovirus, and many infants present to the ED. What
clinical presentation do they share? Treatment? Bronchiolitis caused by RSV; treat
it with ribavirin (Rx) "<img src=""7525.png"">" Microbiology duplicate rna-
viruses virology
A 2-year-old child dies after a case of diarrhea. What virus is the primary viral
cause? What is the virus' structure? Rotavirus; DS linear structure "<img
What are the five viruses of the picornaviruses family? Poliovirus, Echovirus,
Rhinovirus, Coxsackievirus, HAV (PERCH) "<img src=""7525.png"">" Microbiology
Name the virus that requires HBV coinfection to be transmitted. What is the
structure of this dependent virus's RNA? Delta viruses (this is hepatitis D); the
structure is single stranded, negative sense, and circular "<img src=""7525.png"">"
What is the capsid symmetry of the hepatitis D virus (a delta virus)? Uncertain
(recall that this is a defective virus that requires HBV coinfection) "<img
What RNA family contains the hepatitis E virus? Hepevirus "<img src=""7525.png"">"
A man has a common cold because of a single-stranded linear RNA virus that has an
envelope. Name other viruses in the same family. This patient's cold is caused
by a coronavirus; other diseases caused by viruses in the family are SARS and MERS
A resident of Colorado presents with fever caused by a reovirus. What other virus
is found in the same family? He has Colorado tick fever from coltivirus; the other
member of this family is rotavirus, which causes diarrhea (especially in children)
Which family of viruses have single-stranded circular RNA that is either positive
sense or negative sense? Arenaviruses "<img src=""7525.png"">"
Why do negative-stranded DNA viruses carry RNA-dependent RNA polymerase? To
transcribe the negative strand to a positive strand in the host cell in order to
replicate "<img src=""7526.png"">" Microbiology duplicate negative-stranded-
viruses virology
Name the six negative-stranded viral families. Arenaviruses, Bunyaviruses,
Paramyxoviruses, Orthomyxoviruses, Filoviruses, Rhabdoviruses (Always Bring
Polymerase Or Fail Replication) "<img src=""7526.png"">" Microbiology
duplicate negative-stranded-viruses virology
All segmented viruses have what type of viral genome? RNA "<img src=""7527.png"">"
Microbiology duplicate segmented-viruses virology
Name four segmented RNA viruses. Bunyaviruses, Orthomyxoviruses (influenza),
Arenaviruses, Reoviruses (BOAR) "<img src=""7527.png"">" Microbiology
duplicate segmented-viruses virology
What five RNA viruses are picornaviruses? Poliovirus, Echovirus, Rhinovirus,
Coxsackievirus, Hepatitis A virus (PERCH on a peak [picornavirus]) "<img
src=""7528.png"">" Microbiology duplicate picornavirus virology
Describe the translation and posttranslation modification of picornaviruses. The
RNA is translated into a single polypeptide, which is then cleaved by proteases
into functional viral proteins "<img src=""7528.png"">" Microbiology
duplicate picornavirus virology
What condition in humans is caused by picornaviruses (except rhinovirus and
hepatitis A)? All, except rhinovirus, are spread by what route? Aseptic
meningitis; fecal-oral route (they are enteroviruses) "<img src=""7528.png"">"
Microbiology duplicate picornavirus virology
Are picornaviruses small RNA or DNA viruses? Small RNA viruses (picornavirus =
small RNA virus) "<img src=""7528.png"">" Microbiology duplicate picornavirus
virology
What type of virus is rhinovirus? A nonenveloped RNA virus that belongs to the
picornavirus family "<img src=""7529.png"">" Microbiology duplicate
rhinovirus virology
A patient has a rhinovirus infection. What type of infection does this virus cause?
Why is it so common? The common cold; there are more than 100 serologic types
(rhino has a runny nose) "<img src=""7529.png"">" Microbiology duplicate
rhinovirus virology
Unlike the other picornaviruses, what type of infection does rhinovirus not cause?
Why? Gastrointestinal tract infections; it is acid labile and therefore destroyed
by stomach acid "<img src=""7529.png"">" Microbiology duplicate rhinovirus
virology
A man presents to the ED with a high fever, black vomitus, and jaundice. How is
this virus transmitted? What is its reservoir? Yellow fever is transmitted by the
Aedes mosquito; the virus can have a monkey or human reservoir "<img
src=""7530.png"">" Microbiology duplicate virology yellow-fever-virus
A female presents with fever and jaundice. Liver biopsy has Councilman bodies. To
which viral family does the virus belong? "Flavivirus (also an arbovirus)""flavi""
means yellow or jaundiced" "<img src=""7530.png"">" Microbiology duplicate
virology yellow-fever-virus
An infant has diarrhea, and you diagnose him with the most important global cause
of infantile gastroenteritis. What is the viral structure? Rotavirus is a segmented
dsRNA virus (a reovirus)rotavirus = Right Out The Anus "<img src=""7531.png"">"
Microbiology duplicate rotavirus virology
What population is at particularly high risk for rotavirus? How is infection
prevented? Infants and young children, especially in day care centers and
kindergartens; the CDC recommends vaccination of all infants "<img
src=""7531.png"">" Microbiology duplicate rotavirus virology
A patient is found to be infected with the orthomyxovirus influenza virus. How
would you describe its structure? Enveloped, negatively single-stranded RNA,
eight segments "<img src=""7532.png"">" Microbiology duplicate influenza-
viruses virology
Name the two major antigens of the influenza virus and the role they play in
infection. Hemagglutinin promotes viral entry; neuraminidase promotes virion
release "<img src=""7532.png"">" Microbiology duplicate influenza-viruses
virology
A patient refuses the flu vaccine. What is the most likely fatal effect of the flu?
A fatal bacterial superinfection pneumonia from S aureus, S pneumoniae, and H
influenzae "<img src=""7532.png"">" Microbiology duplicate influenza-viruses
virology
A patient who recently received his flu shot is wondering how it works. What viral
strains are found in the flu shot? It is a reformulated vaccine (there is quick
genetic change) that contains viral strains that are most likely to appear during a
flu season "<img src=""7532.png"">" Microbiology duplicate influenza-viruses
virology
Random mutations in hemagglutinin or neuraminidase genes that lead to minor genetic
changes in the influenza virus are an example of what? Genetic/antigenic drift
"<img src=""7532.png"">" Microbiology duplicate influenza-viruses
virology
A woman gets an injectable flu vaccine, but her 5-year-old daughter gets a nasal
spray. How are these vaccines different? Injection contains killed virus; nasal
spray has live mutant virus that is temperature sensitive and replicates in the
nose (not the lungs) "<img src=""7532.png"">" Microbiology duplicate
influenza-viruses virology
What causes pandemics versus epidemics? Genetic/antigenic shifts cause pandemics;
genetic/antigenic drift causes epidemics (sudden shift is more deadly than gradual
drift) "<img src=""7532.png"">" Microbiology duplicate influenza-viruses
virology
The recombination of human flu A virus with swine flu A virus is an example of
what? Genetic/antigenic shift (reassortment of viral genome) "<img
src=""7532.png"">" Microbiology duplicate influenza-viruses virology
An unvaccinated boy has fever, lymphadenopathy, arthralgias, and truncal rash for 3
days. Which viral family causes this viral infection? Rubella (a togavirus), also
known as German measles or 3-day measles "<img src=""7533.png"">" Microbiology
duplicate rubella-virus virology
Rubella is a relatively benign illness in most cases. When can serious sequelae
result? When it infects fetuses (it is a ToRCHeS infection) "<img
src=""7533.png"">" Microbiology duplicate rubella-virus virology
What diseases are caused by paramyxoviruses? In what age group do these diseases
predominate? Parainfluenza, mumps, measles, and respiratory syncytial virus
(bronchiolitis/pneumonia); infants/children "<img src=""7534.png"">"
Microbiology duplicate paramyxoviruses virology
A 3-year-old presents with barking cough. He is found to have croup. To what group
does the causative agent belong? Croup is caused by parainfluenza, a type of
paramyxovirus "<img src=""7534.png"">" Microbiology duplicate
paramyxoviruses virology
What surface protein is common to all paramyxoviruses? What is its role?
Surface F (fusion) protein; it causes respiratory epithelial cells to fuse
and become multinucleated "<img src=""7534.png"">" Microbiology duplicate
A preterm infant receives a monoclonal antibody to prevent a common respiratory
infection. Name the antibody. Name the infection. Palivizumab is a monoclonal
antibody against the surface F protein; pneumonia caused by the respiratory
syncytial virus "<img src=""7534.png"">" Microbiology duplicate
A boy has inspiratory stridor and a barking cough. If he had a severe version of
the illness, what outcome may occur due to obstruction? Severe croup can result
in pulsus paradoxus from the upper airway obstruction "<img src=""7535.png"">"
Microbiology croup-(acute-laryngotracheobronchitis) duplicate virology
What are the 3 C's of measles, used in addition to Koplik spots and a descending
rash, that can help a clinician diagnose measles? Cough, coryza, and
conjunctivitis (caused by measles or rubeola virus, a paramyxovirus) "<img
src=""7536.png"">" Microbiology duplicate measles-(rubeola)-virus virology
A young child has Koplik spots and a descending maculopapular rash. What are
possible sequelae of the patient's condition in the future?Sequelae include SSPE
(years later), encephalitis, and giant cell pneumonia (the patient has measles)
"<img src=""7536.png"">" Microbiology duplicate measles-(rubeola)-virus
virology
A 9 year-old has coryza and lymphadenitis. Biopsy shows fused lymphocytes with
paracortical hyperplasia. What is the cause of this finding? This child has
measles; fused lymphocytes are Warthin-Finkeldey giant cells "<img
src=""7536.png"">" Microbiology duplicate measles-(rubeola)-virus virology
What are the symptoms of mumps? Parotitis, Orchitis, aseptic Meningitis,
Pancreatitis (in mumps, your testes and parotid glands are as big as POM-P-oms)
"<img src=""7537.png"">" Microbiology duplicate mumps-virus virology
A 12-year-old is bitten by a raccoon while playing outside. How should he be
treated to avoid rabies infection? The wound should be cleaned; then he should
receive killed rabies vaccination with rabies immune globulin (passive-active
immunity) "<img src=""7538.png"">" Microbiology duplicate rabies-virus
virology
A bat researcher develops fever, malaise, photophobia, and coma. He soon dies.
Describe the pathophysiology. Rabies migrates retrogradely up nerve axons to the
CNS after it binds to ACh receptors "<img src=""7538.png"">" Microbiology
duplicate rabies-virus virology
A young girl was recently bitten by a skunk. Describe the progression of symptoms
in a possible rabies infection. Fever and malaise leading to agitation,
photophobia, hydrophobia, hypersalivation, then paralysis, coma, and death (takes
weeks to months) "<img src=""7538.png"">" Microbiology duplicate rabies-virus
virology
Which animal bites are most likely to result in rabies infection in the United
States? Bat, raccoon, skunk (all more common than dog) "<img src=""7538.png"">"
Microbiology duplicate rabies-virus virology
A 45-year-old woman has sudden high fever, diarrhea, and myalgias. Ebola is
diagnosed. How is this virus transmitted? Through body fluid contact, fomites
(bodies of infected deceased), infected bats/primates (apes/monkeys); nosocomial
infection is common "<img src=""7539.png"">" Microbiology duplicate ebola-
virus virology
A nurse with flu-like symptoms, diarrhea, and pyrexia is found to have Ebola. To
what severe clinical scenarios can Ebola progress? DIC, diffuse hemorrhage,
shock, death (high mortality rate) "<img src=""7539.png"">" Microbiology
duplicate ebola-virus virology
A 38-year-old woman who recently went on safari has flu-like symptoms and diarrhea
for 2 days. You suspect a filovirus. How do you diagnose? This is Ebola; use RT-
PCR to diagnose within 48 hours of the start of symptoms "<img src=""7539.png"">"
Microbiology duplicate ebola-virus virology
A nurse has flu-like symptoms, diarrhea, and high fever. Ebola is diagnosed. What
is the next step in management? No definitive treatment; supportive care,
strict isolation, barrier practices for health care workers"<img src=""7539.png"">"
Microbiology duplicate ebola-virus virology
A patient is found to have hepatitis A. What would you see on liver biopsy? What
are the modes of transmission? Swollen cells, monocytes, eosinophilic
apoptotic globules (Councilman bodies); transmission by way of shellfish, travel,
daycare centers "<img src=""7540.png"">" Microbiology duplicate hepatitis-
viruses virology
A patient is found to have HCV. What characteristic allows it to outsmart host
antibodies? Lack of 3-5-exonuclease activity leads to different HCV envelope
antigen structures and new mutant strains of the virus "<img src=""7540.png"">"
Microbiology duplicate hepatitis-viruses virology
Name the family of each of the hepatitis viruses (HAV, HBV, HCV, HDV, HEV). HAV is
an RNA picornavirus; HBV is a DNA hepadnavirus; HCV is an RNA flavivirus; HDV is an
RNA deltavirus; HEV is an RNA hepevirus "<img src=""7540.png"">" Microbiology
duplicate hepatitis-viruses virology
Which other hepatitis virus is transmitted via the same route as the hepatitis E
virus? How do the viruses differ? Hepatitis A (fecal-oral) (HAV = usually
Asymptomatic, Acute, Alone (no carriers); HEV = high mortality in pregnancy,
waterborne epidemics "<img src=""7540.png"">" Microbiology duplicate
hepatitis-viruses virology
Which of the hepatitis viruses have short incubation periods? Long incubation
periods? Which can have either? Hepatitis A and E: short (weeks); B and C: long
(months); D: short when superinfection (HDV after HBV), long when coinfection (HDV
with HBV) "<img src=""7540.png"">" Microbiology duplicate hepatitis-viruses
virology
A patient has confirmed hepatitis B. How did he acquire the virus? What other virus
is transmitted the same way? Parenteral, sexual, or maternal-fetal routes (this is
hepatitis B = Blood, Baby making, Birthing); hepatitis D virus "<img
src=""7540.png"">" Microbiology duplicate hepatitis-viruses virology
A patient who has received many blood transfusions is diagnosed with hepatitis C.
How else is it transmitted? Hepatitis C is primarily transmitted by blood
exposures, but also by intravenous drug use "<img src=""7540.png"">"
A hemophiliac who received multiple blood transfusions in the 1980s has cirrhosis
and hepatocellular carcinoma. Which virus is responsible? Hepatitis C = Chronic,
Cirrhosis, Carcinoma, Carrierhepatitis B, while less likely, can also present this
way "<img src=""7540.png"">" Microbiology duplicate hepatitis-viruses
virology
Which hepatitis types are blood borne, have chronic carriers, and cause chronic
active hepatitis, cirrhosis, and hepatocellular carcinoma? Hepatitis B and C "<img
An IV drug user has arthralgia and rash. Liver biopsy specimen looks like ground
glass. What mediates these changes? This patient has hepatitis B; the granular
eosinophilic appearance is caused by cytotoxic T-cell damage "<img
An IV drug user is found to have hepatitis C. What are its characteristic liver
biopsy findings? Lymphoid aggregates, focal macrovesicular steatosis "<img
A patient has hepatitis D. What other hepatitis virus must he have? How does the
timing of the other infection affect his prognosis? Hepatitis B virus; prognosis
is better with coinfection (HBV and HDV) than superinfection (new HDV atop chronic
HBV infection) "<img src=""7540.png"">" Microbiology duplicate hepatitis-
viruses virology
You diagnose a patient as a hepatitis carrier. Which types of hepatitis could he
have? Hepatitis B, C, or D (only these types have a carrier state) "<img
A patient is found to be infected with a hepatitis virus. Which hepatitis virus is
defective and depends on HBV for successful infection? Hepatitis D "<img
Which hepatitis virus, common in epidemics and spread via the gut, has a high
mortality rate in pregnant woman? Hepatitis E (Enteric, Expectant mothers,
Epidemic) "<img src=""7540.png"">" Microbiology duplicate hepatitis-viruses
virology
What signs and symptoms are characteristic of all hepatitis viruses? All
hepatitis viruses have fever, jaundice, and elevated levels of alanine
aminotransferase and aspartate aminotransferase "<img src=""7540.png"">"
Why are the hepatitis B, C, and D viruses unable to spread via the fecal-oral
route? Unlike naked viruses (eg, HAV and HEV = the vowels hit your bowels),
enveloped viruses are killed in the gut "<img src=""7540.png"">" Microbiology
duplicate hepatitis-viruses virology
Describe hepatitis B virus replication. DNA polymerase makes dsDNA; host RNA
polymerase uses mRNA from viral DNA for viral proteins; DNA polymerase converts RNA
to DNA for progeny "<img src=""7540.png"">" Microbiology duplicate
hepatitis-viruses virology
How would you detect active viral infection in a patient with suspected hepatitis
A? Test for immunoglobulin M hepatitis A virus antibody (antiHAV IgM) "<img
src=""7541.png"">" Microbiology duplicate hepatitis-serologic-markers virology
Which serologic marker indicates prior infection (or vaccination) and protects
against reinfection with hepatitis A? Immunoglobulin G antihepatitis A virus
antibody (antiHAV IgG) "<img src=""7541.png"">" Microbiology duplicate
hepatitis-serologic-markers virology
A patient has a continued presence of hepatitis B surface antigen in his serum.
What does this mean? This patient has active hepatitis B infection "<img
Which antibody is protective against hepatitis B infection?Hepatitis B surface
antibody (anti-HBs) "<img src=""7541.png"">" Microbiology duplicate
hepatitis-serologic-markers virology
What antigen is associated with the core of HBV? HBcAg "<img src=""7541.png"">"
Microbiology duplicate hepatitis-serologic-markers virology
What is the significance of immunoglobulin M vs. immunoglobulin G hepatitis B core
antibodies? IgM is a marker for acute or recent disease, and IgG is a marker for
prior exposure or chronic infection "<img src=""7541.png"">" Microbiology
duplicate hepatitis-serologic-markers virology
Which hepatitis serologic marker is found during the window period? IgM anti-HBc
"<img src=""7541.png"">" Microbiology duplicate hepatitis-serologic-
markers virology
A hepatitis B patient tests positive for HBeAg. Another tests positive for anti-
HBe. How is their transmissibility different? HBeAg indicates active viral
replication (high transmissibility); anti-HBe indicates low transmissibility "<img
A Chinese immigrant tests positive for HBsAg, HBeAg, and anti-HBc IgM. What stage
of hepatitis B infection is he in? Acute stage of infection "<img
A Chinese immigrant tests positive only for anti-HBe and anti-HBc IgM. What stage
of hepatitis B infection is he in? Window period "<img src=""7541.png"">"
Microbiology duplicate hepatitis-serologic-markers virology
A Chinese immigrant tests positive for HBsAg, HBeAg, and anti-HBc IgG. What stage
of hepatitis B infection is he in? Chronic HBV (high infectivity) "<img
A Chinese immigrant tests positive for HBsAg, anti-HBe, and anti-HBc IgG. What
stage of hepatitis B infection is he in? Chronic HBV (low infectivity) "<img
A Chinese immigrant tests positive for anti-HBs, anti-HBe, and anti-HBc IgG. In
what stage of hepatitis B infection is he? Recovery stage "<img
A Chinese immigrant is immunized against hepatitis B. What serologic marker
findings would confirm this? Anti-HBs, with all other hepatitis B markers being
negative "<img src=""7541.png"">" Microbiology duplicate hepatitis-
serologic-markers virology
Name the proteins for which each of these HIV genes codes: env, gag, pol. env:
gp120 and gp41; gag: p24 and p17; pol: reverse transcriptase, aspartate protease,
integrase "<img src=""7542.png"">" Microbiology duplicate hiv virology
What is the ploidy of the HIV genome? Is it an RNA or DNA virus? It is diploid; RNA
virus "<img src=""7542.png"">" Microbiology duplicate hiv virology
Which HIV proteins are located in the envelope, matrix, and capsid, respectively?
Envelope: gp120 and gp41; matrix: p17; capsid: p24 "<img src=""7542.png"">"
Microbiology duplicate hiv virology
You are trying to develop a drug that targets the HIV envelope proteins. How are
these proteins formed? env gene encodes a gp160 precursor that is cleaved into
gp120 and gp4, which are acquired through budding from the host's plasma membrane
"<img src=""7542.png"">" Microbiology duplicate hiv virology
You are trying to develop a drug that targets the HIV envelope proteins. What is
the function of these two proteins? gp120 helps HIV adhere to CD4+ T cells; gp41
facilitates HIV fusion/entry "<img src=""7542.png"">" Microbiology duplicate
hiv virology
A patient presents with low-grade fever and fatigue for weeks, with risk for HIV.
How does this virus integrate its genome into host DNA? Reverse transcriptase
converts HIV viral RNA to double-stranded DNA, which is then integrated into the
host DNA "<img src=""7542.png"">" Microbiology duplicate hiv virology
You prescribe a patient an inhibitor that prevents HIV from binding to CD4 and two
other receptors. What other proteins should it target? T-cell CXCR4 for late
infection and macrophage CCR5 for early infection "<img src=""7542.png"">"
Microbiology duplicate hiv virology
You find that a woman is immune to HIV. Which homozygous gene mutation does she
have? What would happen if she had a heterozygous mutation?CCR5 (which aids HIV
binding on macrophages); heterozygous mutations cause a slower disease course
"<img src=""7542.png"">" Microbiology duplicate hiv virology
An intravenous drug user tests positive for HIV. What are the chances that this is
a false positive? What test do you do next? Why? ELISA is sensitive, with a
high false-positive rate; Western blot (to confirm) is specific, with a low false-
positive rate "<img src=""7543.png"">" Microbiology duplicate hiv-
diagnosis virology
A patient has a negative HIV test. At which point during an actual HIV infection
could this be a false negative? Why? ELISA/Western blot may be falsely
negative in the first 12 months of infection "<img src=""7543.png"">"
Microbiology duplicate hiv-diagnosis virology
A patient has a positive HIV test. Who is at risk for false-positive tests? Why?
Babies born to infected moms; anti-gp120 antibodies cross the placenta "<img
src=""7543.png"">" Microbiology duplicate hiv-diagnosis virology
A patient comes into the HIV clinic for follow-up care after starting
antiretroviral meds. How do you evaluate his response to treatment? Test the
amount of viral RNA in plasma; high viral load indicates poor prognosis "<img
src=""7543.png"">" Microbiology duplicate hiv-diagnosis virology
A patient is HIV positive. What criteria are used to diagnose AIDS? CD4+ count
<200 cells/mm (normal 5001500 cells/mm), AIDS-defining illness (eg, PCP
pneumonia), or CD4<14% "<img src=""7543.png"">" Microbiology duplicate hiv-
diagnosis virology
A man has positive Western and ELISA tests for HIV. His CD4 count is 150 cells/mm
with no Pneumocystis pneumonia. Is this considered AIDS? Yes, as the patient has
a CD4+ count that is <200 cells/mm "<img src=""7543.png"">" Microbiology
duplicate hiv-diagnosis virology
During which phase of HIV infection does the CD4+ cell count drop most steeply?
What else happens in this phase? Acute phase (first 12 months); wide
dissemination of virus, seeding of lymphoid organs "<img src=""7544.png"">"
Microbiology duplicate time-course-of-untreated-hiv-infection virology
A man tests positive for HIV. How do you describe to him the four stages and
associated symptoms of this disease? Flu-like, acute; Feeling fine,
latency;Falling count, constitutional; Final crisis, opportunistic infections
"<img src=""7544.png"">" Microbiology duplicate time-course-of-
untreated-hiv-infection virology
Where does the HIV virus replicate during the latent phase?In the lymph nodes
"<img src=""7544.png"">" Microbiology duplicate time-course-of-
untreated-hiv-infection virology
In an HIV patient, what is the definition of moderately immunocompromised? CD4+
count <400 cells/mm "<img src=""7544.png"">" Microbiology duplicate time-
course-of-untreated-hiv-infection virology
A patient has just been found to have HIV. At what CD4+ count are AIDS-defining
illnesses expected to emerge? <200 cells/mm "<img src=""7544.png"">"
Microbiology duplicate time-course-of-untreated-hiv-infection virology
A man presents with fever, fatigue, and lymphadenopathy. What is he specifically at
risk for as his CD4+ cell count drops? Reactivation of past infections (eg, TB,
HSV, shingles), dissemination of bacterial/fungal infections, non-Hodgkin lymphoma
(this is HIV) "<img src=""7545.png"">" Microbiology common-diseases-of-
hiv-positive-adults duplicate virology
An HIV-positive man has white oral plaques and pseudohyphae on microscopy. What is
his maximum CD4+ count? What if lesions were esophageal? Candida albicans causes
oral infection if CD4+ count falls to <500 cells/mm; esophagitis if <100 cells/mm
"<img src=""7545.png"">" Microbiology common-diseases-of-hiv-positive-
adults duplicate virology
An HIV-positive man complains of white patches on his tongue that cannot be scraped
off. A test shows the presence of EBV. Diagnosis? This is oral hairy
leukoplakia (found on the lateral part of the tongue) "<img src=""7545.png"">"
Microbiology common-diseases-of-hiv-positive-adults duplicate virology
An HIV-positive patient has bacillary angiomatosis. What do you see on biopsy?
Neutrophilic inflammation caused by Bartonella henselae "<img
src=""7545.png"">" Microbiology common-diseases-of-hiv-positive-adults
duplicate virology
An HIV-positive patient has Kaposi sarcoma. What would you see on biopsy?
Lymphocytic inflammation (this is human herpesvirus 8) "<img
duplicate virology
An HIV-positive patient presents with chronic watery diarrhea. Which stain should
you use to make the diagnosis? Requires an acid-fast stain (this is
Cryptosporidium infection, which presents with acid-fast cysts in the stool) "<img
duplicate virology
An HIV-positive homosexual man contracts HPV. Which malignancy will he likely
develop? Where will a woman likely develop it? Squamous cell carcinoma of the
anus; cervix "<img src=""7545.png"">" Microbiology common-diseases-of-
An HIV-positive patient has pleuritic chest pain, hemoptysis, CD4+ count 85
cells/mm. Likely causative agent? Imaging finding? Aspergillus fumigatus;
cavitation or infiltrates "<img src=""7545.png"">" Microbiology common-
diseases-of-hiv-positive-adults duplicate virology
An HIV-positive woman is becoming more and more forgetful. Why? HIV is directly
associated with dementia (although she could also have dementia from other causes)
An HIV-positive 38-year-old has progressive multifocal leukoencephalopathy from
reactivation of the JC virus. What will you find on MRI? Nonenhancing ares of
demyelination "<img src=""7545.png"">" Microbiology common-diseases-of-
An HIV-positive 33-year-old with a CD4+ count <200 cells/mm has pneumonia. What
pathogen do you suspect? Chest x-ray finding? "Pneumocystis jiroveci; CXR would
show ""ground glass"" opacities" "<img src=""7545.png"">" Microbiology
common-diseases-of-hiv-positive-adults duplicate virology
An HIV-positive adult has invasive Aspergillus fumigatus infection. How would this
infection present? With pleuritic chest pain, hemoptysis, and
cavitation/infiltrates on chest x-ray "<img src=""7545.png"">" Microbiology
A 29-year-old HIV-positive patient presents with a stiff neck, headache, and fever.
You suspect a fungal infection. How do you diagnose it? Use India ink stain to
reveal yeast with a large capsule (this is Cryptococcus neoformans infection)
An HIV-positive patient has odynophagia and CD4+ of count 80 cells/mm. White
plaques are seen on endoscopy. Diagnosis? Biopsy findings? Esophagitis from Candida
albicans; biopsy will show yeast and pseudohyphae "<img src=""7545.png"">"
"You examine an HIV-positive patient and see ""cotton wool"" spots on funduscopic
exam. What other symptoms might this infection cause?" CMV can cause colitis,
encephalitis, pneumonitis, esophagitis, and retinitis "<img src=""7545.png"">"
An HIV-positive patient has pneumonia, which you suspect to be caused by
cytomegalovirus. What do you see on biopsy? "Cells with intranuclear inclusion
bodies (""owl eye"")" "<img src=""7545.png"">" Microbiology common-diseases-
of-hiv-positive-adults duplicate virology
An HIV-positive patient develops large cell non-Hodgkin lymphoma. What virus may
have caused it? Epstein-Barr virus "<img src=""7545.png"">" Microbiology
A patient with HIV has CNS lymphoma. How does this differ from Toxoplasma gondii
infection? Ring-enhancing lesion may be singular, compared with the multiple
lesions that may be found in Toxoplasma gondii infection "<img src=""7545.png"">"
An HIV-positive patient tests positive for Epstein-Barr virus. For which three
cancers is he at risk? Oral hairy leukoplakia, non-Hodgkin lymphoma, central
nervous system lymphoma "<img src=""7545.png"">" Microbiology common-diseases-
An HIV-positive man has fever, cough, and weight loss. Macrophages have oval yeast
cells. Causative organism? Histoplasma capsulatum "<img src=""7545.png"">"
An HIV-positive patient with a tuberculosis-like disease has a CD4+ count of 50
cells/mm and lymphadenitis. Diagnosis? Mycobacterium avium-intracellulare/M
avium complex infection "<img src=""7545.png"">" Microbiology common-diseases-
An HIV-positive man with a cat has fevers, headaches, and ring-enhancing brain
lesions. What is the highest CD4+ count he can have? 100 cells/mm (this is T
gondii infection) "<img src=""7545.png"">" Microbiology common-diseases-of-
A patient has a CD4+ count < 200 cells/mm. For what infections is she at risk?
JC virus reactivation, Pneumocystis jirovecii infection "<img
duplicate virology
Which infections are possible when the CD4+ count is < 100 cells/mm? A fumigatus,
C neoformans, C albicans, H capsulatum, T gondii, M avium-intracellulare, M avium
complex, CMV, EBV "<img src=""7545.png"">" Microbiology common-diseases-of-
An HIV-positive man has a worsening headache. Brain MRI shows multiple ring-
enhancing lesions. Are you worried about CNS lymphoma? No, as CNS lymphoma
typically presents as a solitary ring-enhancing lesionthink Toxoplasma in this
patient "<img src=""7545.png"">" Microbiology common-diseases-of-hiv-
positive-adults duplicate virology
A patient is found to have Creutzfeldt-Jakob disease. What are its causes? Normal
CNS prion protein (PrPc) becomes a -pleated form (PrPsc) that is transmissible,
resists degradation, converts more prions "<img src=""7546.png"">" Microbiology
duplicate prions virology
What clinical manifestations does prion PrPsc accumulation cause? Spongiform
encephalopathy, ataxia, dementia, death "<img src=""7546.png"">" Microbiology
A woman with rapid progression of dementia dies. Misfolded proteins are found in
the CNS. It is determined to be a sporadic case. Diagnosis?Creutzfeldt-Jakob
disease; there are some familial cases "<img src=""7546.png"">" Microbiology
A patient with ataxia and rapidly progressing dementia dies. He loved to eat beef
every day. What is the most likely diagnosis? Bovine spongiform encephalopathy
(BSE), an prion disorder also known as mad cow disease "<img src=""7546.png"">"
Microbiology duplicate prions virology
A patient presents with ataxia and delirium. He was a cannibal. If a prion is to
blame, what is the most likely diagnosis? Kuru, an acquired prion disease that was
discovered in tribes that practiced cannibalism "<img src=""7546.png"">"
Microbiology duplicate prions virology
S epidermidis is part of the normal flora of what two parts of the body? The
skin and the nose "<img src=""7547.png"">" Microbiology duplicate normal-
flora:-dominant systems
What part of the body does S aureus normally colonize? The nose "<img
src=""7547.png"">" Microbiology duplicate normal-flora:-dominant systems
In which part of the body are viridans streptococci considered normal flora? The
oropharynx "<img src=""7547.png"">" Microbiology duplicate normal-flora:-
dominant systems
A 25-year-old man has not been to the dentist in a while. What bacterium would you
find on his teeth? S mutans, found in dental plaque "<img src=""7547.png"">"
Microbiology duplicate normal-flora:-dominant systems
A patient wishes to have a bacterial culture of his colon. Which two bacteria are
considered part of the normal dominant flora of this area? B fragilis and, to a
lesser extent, E coli "<img src=""7547.png"">" Microbiology duplicate
normal-flora:-dominant systems
A woman is experiencing some vaginal discharge. Which three bacteria are considered
dominant flora in the vagina? Lactobacillus, E coli, group B strep "<img
src=""7547.png"">" Microbiology duplicate normal-flora:-dominant systems
You deliver a newborn via cesarean section. What bacteria is he colonized with?
None, as neonates delivered by cesarean section are born without any flora
but are colonized quickly after birth "<img src=""7547.png"">" Microbiology
duplicate normal-flora:-dominant systems
A girl experiences food poisoning after eating reheated fried rice. What is the
infectious agent? "B cereus: ""Food poisoning from reheated rice? Be serious!"""
"<img src=""7548.png"">" Microbiology bugs-causing-food-poisoning
duplicate systems
A patient has a bout of food poisoning that only lasts a few hours. Which two bugs
could be responsible for this brief illness? Both S aureus and B cereus cause
food poisoning that is quick to start and brief in duration"<img src=""7548.png"">"
Microbiology bugs-causing-food-poisoning duplicate systems
A patient experiences food poisoning after consuming food from a bulging can. What
is the infectious agent? C botulinum; can also be contracted from raw honey
duplicate systems
A patient experiences food poisoning after eating reheated hot dogs. What is the
most likely infectious agent? C perfringens "<img src=""7548.png"">"
A man becomes very ill after eating a hamburger cooked medium rare. What is the
most likely cause? E coli O157:H7 "<img src=""7548.png"">" Microbiology
bugs-causing-food-poisoning duplicate systems
While cooking, a chef improperly handles raw chicken and eggs. He contaminates
various kitchen surfaces and many patrons become ill. Why? Salmonella is associated
mostly with contaminated poultry, eggs, and meat (this is Salmonella poisoning)
duplicate systems
A barbecue guest starts vomiting an hour after eating vanilla custard pie. What is
the most likely cause? Preformed toxins produced by S aureus "<img
src=""7548.png"">" Microbiology bugs-causing-food-poisoning duplicate systems
What foods may harbor S aureus preformed toxins? Mayonnaise, meat, custard
duplicate systems
A patient eats seafood and experiences food poisoning. Which two organisms are most
likely responsible? V parahaemolyticus and V vulnificus "<img src=""7548.png"">"
A would infection develops after a woman handles contaminated water and shellfish.
What is the infectious agent? V vulnificus "<img src=""7548.png"">"
Which three viruses are responsible for causing watery diarrhea? Rotavirus,
adenovirus, and norovirus "<img src=""7549.png"">" Microbiology bugs-
causing-diarrhea duplicate systems
A man presents with watery diarrhea. If the organism is identified to be a
protozoa, which two protozoans are the most likely culprits? Giardia and
Cryptosporidium are the two protozoans that cause watery diarrhea "<img
src=""7549.png"">" Microbiology bugs-causing-diarrhea duplicate systems
"A man has watery diarrhea characterized by ""rice water"" stools in which you see
comma-shaped organisms. Diagnosis?" V cholerae infection "<img src=""7549.png"">"
Microbiology bugs-causing-diarrhea duplicate systems
A patient complains of watery diarrhea shortly after eating oysters from a local
seafood shack. What is the causative organism? V cholerae from infected seafood
"<img src=""7549.png"">" Microbiology bugs-causing-diarrhea duplicate
systems
Name seven organisms that can cause bloody diarrhea. Campylobacter, E histolytica,
enterohemorrhagic & enteroinvasive E coli, Salmonella, Shigella, Y enterocolitica
systems
A woman presents with bloody diarrhea. Tests show a comma- or S-shaped bug that
grows at 42C. Diagnosis? Campylobacter "<img src=""7549.png"">"
A missionary returns from Mexico with liver abscesses and bloody diarrhea. What
type of organism is responsible for the infection? A protozoan (E histolytica)
that causes amebic dysentery "<img src=""7549.png"">" Microbiology bugs-
A patient has bloody diarrhea and hemolytic-uremic syndrome. Which property of the
infectious organism causes these outcomes? Shiga-like toxin; produced by
enterohemorrhagic E coli O157:H7 "<img src=""7549.png"">" Microbiology bugs-
A man presents with bloody diarrhea. He is diagnosed with enteroinvasive E coli.
How does it cause the diarrhea? By the invasion of the colonic mucosa "<img
A patient develops diarrhea caused by a lactose-negative, motile organism. Does the
patient have bloody or watery diarrhea? Bloody, as the organism is Salmonella
systems
A patient with bloody diarrhea is found to be infected with Salmonella. How does
this organism move? What might he have eaten to get it? Salmonella has flagella
that allow it to move; animal reservoirs exist (particularly within poultry and
eggs) "<img src=""7549.png"">" Microbiology bugs-causing-diarrhea duplicate
systems
A man has diarrhea caused by a lactose-negative organism with low ID50. Does he
have bloody or watery diarrhea? Bloody (the organism is Shigella) "<img
A patient is diagnosed with bacillary dysentery from Shigella. Identify its
reservoir and the substance it produces to cause this illness. Reservoir is
humans; produces Shiga toxin "<img src=""7549.png"">" Microbiology bugs-
A 5-yo is rushed to the ED with abdominal pain and is found to have
pseudoappendicitis. What is the most likely causative agent? Y. enterocolitica
systems
Several kids in daycare have diarrhea and pseudoappendicitis. Is the diarrhea most
likely watery or bloody? Bloody, because the organism most likely responsible
is Y enterocolitica, which is associated with daycare outbreaks "<img
Name nine organisms (bacteria, protozoa, and viruses) that can cause watery
diarrhea. C difficile, C perfringens, enterotoxigenic E coli, Giardia,
Cryptosporidium, V cholerae, rotavirus, norovirus, adenovirus "<img
Pseudomembranous colitis develops while a patient is in the hospital. Will she most
likely have watery or bloody diarrhea? C difficile is the causative organism and
will likely cause watery diarrhea, but it can sometimes cause bloody diarrhea as
well "<img src=""7549.png"">" Microbiology bugs-causing-diarrhea duplicate
systems
A patient has abdominal pain and watery diarrhea. History reveals a recent
prescription for clindamycin. What is the causative organism? C difficile "<img
A patient with gas gangrene also has watery diarrhea. What organism is responsible?
C perfringens "<img src=""7549.png"">" Microbiology bugs-causing-
diarrhea duplicate systems
A traveler to India develops watery diarrhea after eating street food. Which two
toxins are produced by the pathogen causing the diarrhea? LT (heat-labile) and ST
(heat-stable) toxins produced by enterotoxigenic E coli "<img src=""7549.png"">"
A neonate in the ICU is suffering from pneumonia. Which two infectious agents are
the most likely causes? Group B streptococci and E coli infections are most likely
in newborns younger than 4 weeks "<img src=""7550.png"">" Microbiology
common-causes-of-pneumonia duplicate systems
Name the most common causes of pneumonia in patients 4 weeks18 years of age
Viruses (RSV), Mycoplasma,C trachomatis, C pneumoniae, S pneumoniae (Runts
May Cough Chunky Sputum) "<img src=""7550.png"">" Microbiology common-
causes-of-pneumonia duplicate systems
Which organism causes pneumonia in children younger than 3 years? In school-aged
children? C trachomatis in children younger than 3 years; C pneumoniae in school-
aged children "<img src=""7550.png"">" Microbiology common-causes-of-
pneumonia duplicate systems
Name the most common causes of pneumonia in adults 1840 years of age. Mycoplasma,
C pneumoniae, S pneumoniae, viruses such as influenza "<img src=""7550.png"">"
Microbiology common-causes-of-pneumonia duplicate systems
Name the most common causes of pneumonia in adults 4065 years of age. S
pneumoniae, H influenzae, Mycoplasma, anaerobes, viruses "<img src=""7550.png"">"
An elderly woman presents with fever and productive cough. What are the five most
likely pathogens? Causes of pneumonia in the elderly are S pneumoniae, H
influenzae, the influenza virus, anaerobes, and gram-negative rods "<img
src=""7550.png"">" Microbiology common-causes-of-pneumonia duplicate systems
A man with a history of excessive alcohol use presents with a fever and productive
cough. What are the most likely pathogens? Klebsiella and anaerobes (eg,
Fusobacterium, Peptostreptococcus, , Prevotella, Bacteroides) "<img
A patient with history of IV drug use is found to have pneumonia. What are the most
likely causative agents? S pneumoniae, S aureus "<img src=""7550.png"">"
A patient aspirates his stomach contents and contracts pneumonia. What type of
organism caused this? Anaerobes "<img src=""7550.png"">" Microbiology
common-causes-of-pneumonia duplicate systems
A teen has had 2 weeks of low-grade fever, fatigue, and dry cough. Atypical
pneumonia is diagnosed. Which 3 pathogens often cause this?Mycoplasma, Legionella,
and Chlamydia "<img src=""7550.png"">" Microbiology common-causes-of-
pneumonia duplicate systems
A child with cystic fibrosis contracts pneumonia. What infectious agents likely
caused this? Pseudomonas, B cepacia, S aureus, S pneumoniae "<img
Which infectious agents are the most common causes of pneumonia in the
immunocompromised? S aureus, P jirovecii (with HIV), enteric gram-negative
rods, fungi, and viruses "<img src=""7550.png"">" Microbiology common-
causes-of-pneumonia duplicate systems
An HIV-positive patient presents with pneumonia. What is the most likely causative
organism? P jirovecii "<img src=""7550.png"">" Microbiology common-causes-
of-pneumonia duplicate systems
A patient presents with nosocomial pneumonia. What are the most common causes of
this? S aureus, Pseudomonas, enteric gram-negative rods "<img src=""7550.png"">"
A woman with a recent viral infection contracts pneumonia. What are possible
causative organisms? S aureus, H influenzae, S pneumoniae "<img
A newborn presents with meningitis. What are the most likely causative agents?
The most common causes of meningitis in newborns up to 6 months old are group
B streptococci, E coli, and Listeria "<img src=""7551.png"">" Microbiology
common-causes-of-meningitis duplicate systems
A 4-year-old girl presents with fever, stiff neck, and headache. Which organisms
are the likely causes of her disease? Children 6 months6 years of age are
likely infected with S pneumoniae, N meningitidis, H influenzae type B, and
enteroviruses "<img src=""7551.png"">" Microbiology common-causes-of-
meningitis duplicate systems
A 16 yo girl presents with vomiting, headache, and a purple rash on her legs. Which
organism is the most likely cause of her disease? N meningitidis is the primary
cause of meningitis in teenagers "<img src=""7551.png"">" Microbiology
A 30-year-old man presents with a headache and stiff neck. Which infectious agents
are likely responsible for this presentation? S pneumoniae, N meningitidis,
enteroviruses, and HSV are the most common causes of meningitis in patients 660
years of age "<img src=""7551.png"">" Microbiology common-causes-of-
meningitis duplicate systems
A 65 yo man presents with vomiting, fever, and neck stiffness. Which infectious
agents are likely responsible for his presentation? S pneumoniae, Listeria and
gram-negative rods are the most common causes of meningitis in patients older than
60 years "<img src=""7551.png"">" Microbiology common-causes-of-meningitis
duplicate systems
A 70-year-old man presents with fever, neck stiffness, and headache. How do you
empirically treat this patient? Administer ceftriaxone and vancomycin
empirically; if Listeria is suspected, add ampicillin "<img src=""7551.png"">"
Microbiology common-causes-of-meningitis duplicate systems
Name five viral causes of meningitis. Enteroviruses (particularly
coxsackievirus), HSV-2, HIV, West Nile virus (which also results in encephalitis),
VZV "<img src=""7551.png"">" Microbiology common-causes-of-meningitis
duplicate systems
An HIV-positive man presents with fever and neck stiffness. What is the likely
causative agent? Cryptococcus spp. "<img src=""7551.png"">" Microbiology
How has the incidence of meningitis caused by H influenzae changed in the last 10
15 years? Decreased as a result of vaccination; cases involve unimmunized
children "<img src=""7551.png"">" Microbiology common-causes-of-meningitis
duplicate systems
A pt's CSF has normal pressure, protein, a lymphocyte predominance, and normal
glucose. Is his infection viral, bacterial, or fungal? Viral infection "<img
src=""7552.png"">" Microbiology csf-findings-in-meningitis duplicate systems
A pt's CSF has pressure, protein, a PMN predominance, and glucose. Is his
infection likely viral, bacterial, or fungal? Bacteria "<img src=""7552.png"">"
Microbiology csf-findings-in-meningitis duplicate systems
A pt's CSF has pressure, protein, a lymphocyte predominance, and glucose. Is
his infection likely viral, bacterial, or fungal? Fungi/tuberculosis "<img
What are the CSF opening pressure levels in bacterial, fungal, and viral
meningitis, respectively? Increased, increased, normal to increased "<img
What are the CSF glucose levels in bacterial, fungal, and viral meningitis,
respectively? Decreased, decreased, normal "<img src=""7552.png"">"
What are the CSF protein levels in bacterial, fungal, and viral meningitis,
respectively? Increased, increased, normal to increased "<img src=""7552.png"">"
Which white blood cell type predominates in the CSF in bacterial, fungal, and viral
meningitis, respectively? PMNs, lymphocytes, lymphocytes "<img
Infection by which two organisms is most commonly linked with brain abscesses?
Viridans streptococcus and S aureus "<img src=""7553.png"">" Microbiology
duplicate infections-causing-brain-abscess systems
A man presents after a seizure. He suffered headaches and vomiting after a tooth
extraction. What is the likely culprit and imaging finding?The patient likely has a
brain abscess, most likely from oral anaerobes, from the infection/extraction
"<img src=""7553.png"">" Microbiology duplicate infections-causing-
brain-abscess systems
Where do brain abscesses in the temporal lobe and cerebellum arise from? In the
frontal lobe? In cases of multiple abscesses? Otitis media, mastoiditis to the
temporal lobe and cerebellum; sinusitis, dental infection to the frontal lobe;
bacteremia to multiple sites "<img src=""7553.png"">" Microbiology duplicate
infections-causing-brain-abscess systems
What do you consider when finding a brain abscess in a patient diagnosed with AIDS?
Reactivation of a Toxoplasma infection "<img src=""7553.png"">"
Microbiology duplicate infections-causing-brain-abscess systems
In general, what is the most common cause of osteomyelitis?S aureus (assume this
cause if information is limited) "<img src=""7554.png"">" Microbiology
duplicate osteomyelitis systems
In sexually active people, which pathogen can rarely cause osteomyelitis and, more
commonly, septic arthritis? N gonorrhoeae "<img src=""7554.png"">"
Microbiology duplicate osteomyelitis systems
A child with sickle cell disease is found to have osteomyelitis. What are the two
likely causes in this patient? Salmonella and S aureus "<img src=""7554.png"">"
Microbiology duplicate osteomyelitis systems
A patient has a prosthetic replacement. Which two organisms could cause
osteomyelitis in this patient? S aureus and S epidermidis "<img
src=""7554.png"">" Microbiology duplicate osteomyelitis systems
A patient has vertebral osteomyelitis caused by tuberculosis. What is this called?
Pott disease "<img src=""7554.png"">" Microbiology duplicate
osteomyelitis systems
A patient is found to have osteomyelitis. If the vertebra are involved, which
organisms are likely to be found? S aureus and M tuberculosis "<img
A woman is bitten by her dog and develops osteomyelitis at the wound site. Which
infectious agent is the likely cause? P multocida is the cause of osteomyelitis
from cat and dog bites "<img src=""7554.png"">" Microbiology duplicate
A patient with a history of drug addiction is found to have osteomyelitis. What are
the most likely infectious organisms? Pseudomonas, Candida, S aureus "<img
You suspect a patient has osteomyelitis. Which type(s) of imaging would you obtain?
MRI (for acute infections and detailing sites that are involved), radiographs
(for chronic infections) "<img src=""7554.png"">" Microbiology duplicate
A patient presents with dysuria, frequency, urgency, and suprapubic pain. WBCs (not
casts) are found in the urine. Diagnosis? Cystitis "<img src=""7555.png"">"
Microbiology duplicate systems urinary-tract-infections
What is the most common route of urinary tract infection acquisition? Ascent of
bacteria from the urethra to the bladder "<img src=""7555.png"">" Microbiology
duplicate systems urinary-tract-infections
Males with what conditions are more prone to urinary tract infections?
Vesicoureteral reflux and other congenital anomalies of the urinary tract
"<img src=""7555.png"">" Microbiology duplicate systems urinary-tract-
infections
Elderly men with what condition are predisposed to urinary tract infections?
Enlarged prostate "<img src=""7555.png"">" Microbiology duplicate
systems urinary-tract-infections
A pt has fever, flank pain, costovertebral angle tenderness. Urinalysis shows WBC
casts and hematuria. What is the mechanism of disease? This patient has
pyelonephritis due to the ascension of bacteria to the kidneys "<img
src=""7555.png"">" Microbiology duplicate systems urinary-tract-infections
Why are urinary tract infection 10 times more likely to occur in women than in men?
Women have a short urethra that can be colonized by fecal flora "<img
src=""7555.png"">" Microbiology duplicate systems urinary-tract-infections
A patient presents with 5 days of burning pain while urinating and increased
frequency. Name eight predisposing factors for UTI. Congenital defects,
vesicoureteral reflux, enlarged prostate, flow obstruction, kidney surgery,
catheterization, diabetes, pregnancy "<img src=""7555.png"">" Microbiology
duplicate systems urinary-tract-infections
A patient complains of dysuria and frequency. What is the leading cause of this
infection? Escherichia coli is the primary cause of urinary tract infections
"<img src=""7556.png"">" Microbiology duplicate systems uti-bugs
You culture a urinary tract infection specimen on eosin methylene blue agar and the
colonies show a green metallic sheen. Diagnosis? Escherichia coli infection
"<img src=""7556.png"">" Microbiology duplicate systems uti-bugs
A sexually active woman comes in with dysuria and frequency. E coli is ruled out.
What is the most likely causative organism? S saprophyticus (second most common
cause of UTIs in sexually active women) "<img src=""7556.png"">" Microbiology
duplicate systems uti-bugs
A urine sample is cultured from a pt with struvite stones. Swarming on agar is
noticed. Which bacterial enzyme leads to stone formation? Urease (Proteus
mirabilis produces urease, promoting struvite stone formation) "<img
src=""7556.png"">" Microbiology duplicate systems uti-bugs
A man is infected by the third leading cause of UTIs (large mucoid capsule, viscous
colonies). Is the urease test positive or negative? Positive (the organism is
Klebsiella pneumoniae, which is a urease-producing organism) "<img
A patient develops a urinary tract infection while in the hospital. It is drug
resistant and produces a red pigment. Organism? Serratia marcescens "<img
A patient is found to have Enterococcus infection while hospitalized. Is this easy
to treat? No; it is a drug-resistant organism "<img src=""7556.png"">"
Microbiology duplicate systems uti-bugs
You culture a urine sample with a fruity odor and blue-green tint. Does this
organism usually cause a nosocomial or community-acquired UTI? Nosocomial UTI
(the organism is Pseudomonas, which is also drug resistant)"<img src=""7556.png"">"
Microbiology duplicate systems uti-bugs
What does a positive leukocyte esterase on labs indicate? Positive nitrite test?
Positive leukocyte esterase indicates WBC activity; positive nitrite test
indicates nitrate reduction in urine by bacteria such as E coli "<img
What is the urease test? How can it aid identification of the organisms behind
UTIs? In the urease test, production of urease by a bug is a positive result; it
will identify Proteus and Klebsiella "<img src=""7556.png"">" Microbiology
duplicate systems uti-bugs
How does obtaining a pH measurement help in diagnosing the cause of a vaginal
infection? The pH is normal (4.04.5) in candidal infections but is altered (>4.5)
in trichomoniasis and bacterial vaginosis "<img src=""7557.png"">" Microbiology
common-vaginal-infections duplicate systems
What is the definition of a ToRCHeS infection? A microbe that can pass from mother
to fetus, and transmission is usually transplacental, although it can also be via
delivery (eg, HSV-2) "<img src=""7558.png"">" Microbiology duplicate
systems torches-infections
Which neonatal physical exam findings are common to most ToRCHeS infections?
Jaundice, hepatosplenomegaly, growth retardation, thrombocytopenia "<img
src=""7558.png"">" Microbiology duplicate systems torches-infections
Name four important non-ToRCHeS congenital infections. Group B strep (S
agalactiae), E coli, and L monocytogenes (all also cause neonatal meningitis), and
parvovirus B19 (causes hydrops fetalis) "<img src=""7558.png"">" Microbiology
duplicate systems torches-infections
Name the six organisms/agents that cause the ToRCHeS infections. Toxoplasma gondii,
Rubella, CMV, HIV, Herpes simplex virus type 2, Syphilis "<img src=""7558.png"">"
Microbiology duplicate systems torches-infections
A baby is born with hydrocephalus, chorioretinitis, and intracranial
calcifications. How did his mom most likely catch the infectious agent?
Toxoplasma gondii is usually transmitted through cat feces or ingestion of
undercooked meat. "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
A baby is diagnosed with Toxoplasma gondii infection. On top of the classic triad
of manifestations, which physical sign may be seen? """Blueberry muffin"" rash
(the triad of hydrocephalus, chorioretinitis, and intracranial calcifications may
be accompanied by this rash)" "<img src=""7558.png"">" Microbiology duplicate
How might the mother of an infant diagnosed with Toxoplasma gondii infection
present? The mother is usually asymptomatic, with lymphadenopathy in rare
circumstances "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
A pregnant 32-yo F has a rash, arthritis, and lymphadenopathy. Which infection is
her baby at risk for? What is its mode of transmission? Congenital rubella; the
mother contracted it through respiratory droplets "<img src=""7558.png"">"
A neonate is born with a patent ductus arteriosus. Which of the ToRCHeS infections
is the most likely cause? "Rubella (triad of PDA, cataracts, and deafness); may
have ""blueberry muffin"" rash (I [eye] ruby [rubella] earrings"")" "<img
"A newborn is noted to have a ""blueberry muffin"" rash. Which three
organisms/agents constitute the differential diagnosis?" Toxoplasma gondii,
rubella, CMV "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
What are the three congenitally acquired infections in which the mother is usually
asymptomatic? Toxoplasma gondii, CMV, herpes simplex virus type 2 "<img
Which signs and symptoms are seen in a baby with a congenital CMV infection?
"Seizures, hearing loss, ""blueberry muffin"" rash, periventricular
calcifications" "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
An infant, who was found in a fit of seizures, is diagnosed with CMV infection. How
would his mother present? Mode of transmission? The mother would have
mononucleosis-like symptoms but otherwise would be asymptomatic; transmitted
through sexual contact, organ transplant "<img src=""7558.png"">" Microbiology
duplicate systems torches-infections
A neonate presents with chronic diarrhea and recurrent infections. What congenital
infection has he likely acquired? Mother's presentation? HIV; mother's
presentation varies depending on the CD4+ count "<img src=""7558.png"">"
A newborn with recurrent infections is diagnosed with congenital HIV infection.
What in the mother's history would be important to note? Sexual practice and use
of needles "<img src=""7558.png"">" Microbiology duplicate systems torches-
infections
A baby is diagnosed with encephalitis from HSV-2 infection. His mother has past
medical history of herpetic lesions. How was baby infected?Contact with skin or
mucous membranes "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
A neonate undergoing vaginal delivery comes into contact with herpetic lesions. He
must be monitored for the development of which symptoms? Encephalitis and
herpetic vesicular lesions (this is herpes simplex virus type 2 infection) "<img
A baby has notched teeth, saddle nose, and saber shins. Which disease was
transmitted, and during which maternal infection stage? Syphilis (can have short
maxilla, CN VIII deafness) transmitted through maternal 1 (chancre) and 2
(disseminated rash) syphilis "<img src=""7558.png"">" Microbiology duplicate
Which of the ToRCHeS infections can result in stillbirth or hydrops fetalis?
Syphilis "<img src=""7558.png"">" Microbiology duplicate systems
torches-infections
A patient has a head-to-toe rash. Before this he had cough, coryza, conjunctivitis,
and buccal mucosa spots. Diagnosis? Measles virus infection (rubeola) (the blue-
white spots on the buccal mucosa are known as Koplik spots)"<img src=""7559.png"">"
Microbiology duplicate red-rashes-of-childhood systems
Name seven diseases that can cause red rashes in children. Hand-foot-mouth,
roseola, rubeola, erythema infectiosum, rubella, scarlet fever, and chickenpox
"<img src=""7559.png"">" Microbiology duplicate red-rashes-of-childhood
systems
An infant has several days of high fever and a febrile seizure followed by a
macular rash all over his body. Diagnosis? Roseola (exanthem subitum) from
HHV-6 infection "<img src=""7559.png"">" Microbiology duplicate red-rashes-
of-childhood systems
What is the cutaneous manifestation of erythema infectiosum (fifth disease)? "The
classic ""slapped cheek"" rash that appears on the face" "<img src=""7559.png"">"
A 6-year-old has coalescing macules that started on the head and spread to the
body, plus postauricular lymphadenopathy. What caused this?The virus that causes
rubella (German measles); the rash eventually desquamates "<img src=""7559.png"">"
A patient has a vesicular rash that started on the trunk and spread to the face and
arms/legs. Lesions vary in stages. Causative virus? Chickenpox from varicella
zoster virus infection "<img src=""7559.png"">" Microbiology duplicate red-
rashes-of-childhood systems
A patient with which sexually transmitted infection is at risk for opportunistic
infections, Kaposi sarcoma, and lymphoma? AIDS from HIV "<img src=""7560.png"">"
Microbiology duplicate sexually-transmitted-infections systems
A man develops a chancroid, characterized by painful genital ulcers and inguinal
lymphadenopathy. What is the causative agent? """Haemophilus ducreyi (it's so
painful, you do cry)""" "<img src=""7560.png"">" Microbiology duplicate
sexually-transmitted-infections systems
A patient has a medical history of conjunctivitis, urethritis, and reactive
arthritis. Diagnosis? Chlamydia from C trachomatis (serotypes DK); could also
have PID, cervicitis "<img src=""7560.png"">" Microbiology duplicate
A patient contracts an STD, and condylomata acuminata develops. What two infectious
agents could have caused this? Clinical findings? Human papillomaviruses 6 and
11; clinical features include genital warts and koilocytes "<img src=""7560.png"">"
In addition to painful genital lesions, herpes simplex virus type 2 commonly causes
what systemic symptoms? Headaches, fevers, myalgias (HSV-1 may also cause these
symptoms but not as commonly) "<img src=""7560.png"">" Microbiology duplicate
A man has urethritis with a creamy purulent discharge, prostatitis, epididymitis,
and arthritis. Which STI is this? Other findings? Gonorrhea from N gonorrhoeae;
patients also may have cervicitis and PID "<img src=""7560.png"">" Microbiology
duplicate sexually-transmitted-infections systems
A pt develops jaundice that is secondary to a sexually transmitted infection. What
is the causative organism? Hepatitis B virus "<img src=""7560.png"">"
A patient presents with lymphogranuloma venereum. Which organisms are the possible
causes? C trachomatis serotypes L1L3 "<img src=""7560.png"">" Microbiology
duplicate sexually-transmitted-infections systems
A patient with an STI presents with painless genital ulcers and painful
lymphadenopathy. Diagnosis? Lymphogranuloma venereum (infection of the
lymphatics) caused by C trachomatis; the swollen lymph nodes are known as buboes
"<img src=""7560.png"">" Microbiology duplicate sexually-transmitted-
infections systems
Which spirochete causes a painless chancre? T pallidum, as seen in 1 syphilis
"<img src=""7560.png"">" Microbiology duplicate sexually-transmitted-
infections systems
A patient presents with secondary syphilis. In addition to fever and
lymphadenopathy, what cutaneous findings are likely? Condylomata lata, rash "<img
src=""7560.png"">" Microbiology duplicate sexually-transmitted-infections
systems
A 65-year-old has ataxia and pupils that accommodate but are unresponsive to light.
Diagnosis? Other clinical findings? Patient has tertiary syphilis. In addition to
the tabes dorsalis and Argyll Robertson pupils, he may have gummas, aortitis,
general paresis "<img src=""7560.png"">" Microbiology duplicate sexually-
transmitted-infections systems
A man complains of decreased sensation, mild paresis, and an abnormal pupil. Which
STI is the most likely cause? This is 3 syphilis from T pallidum infection "<img
src=""7560.png"">" Microbiology duplicate sexually-transmitted-infections
systems
A 22-year-old woman has vaginitis and a strawberry-colored cervix. What will be
seen on microscopy? Motile organisms; this is trichomoniasis caused by T
vaginalis "<img src=""7560.png"">" Microbiology duplicate sexually-
transmitted-infections systems
Pelvic inflammatory disease is most often caused by which two organisms? C
trachomatis and N gonorrhoeae "<img src=""7561.png"">" Microbiology duplicate
pelvic-inflammatory-disease systems
What is the most common sexually transmitted bacterial infection in the United
States? C trachomatis "<img src=""7561.png"">" Microbiology duplicate
pelvic-inflammatory-disease systems
Name four possible sequelae of pelvic inflammatory disease.Salpingitis,
endometritis, hydrosalpinx, and tubo-ovarian abscess "<img src=""7561.png"">"
Microbiology duplicate pelvic-inflammatory-disease systems
Salpingitis is a risk factor for which complications? Adhesions, ectopic pregnancy,
infertility, chronic pelvic pain "<img src=""7561.png"">" Microbiology
duplicate pelvic-inflammatory-disease systems
Which settings are associated with hepatitis B virus nosocomial infections? Renal
dialysis unit, needlesticks "<img src=""7562.png"">" Microbiology duplicate
nosocomial-infections systems
The central line on a pt undergoing plasmapheresis begins to drain. Redness and
tenderness is found on physical exam. Organisms to consider? S aureus
(including MRSA), S epidermidis (from long-term intravascular catheter use),
Enterobacter "<img src=""7562.png"">" Microbiology duplicate nosocomial-
infections systems
A hospitalized patient using a ventilator develops pneumonia. A sweet odor is noted
on exam. What is the likely infectious agent? P aeruginosa "<img
src=""7562.png"">" Microbiology duplicate nosocomial-infections systems
A hospitalized pt under endotracheal intubation begins to produce sputum. CXR shows
new infiltrates. How long has he been intubated? This is infection (from P
aeruginosa, Klebsiella, Acinetobacter, or S aureus) that occurs well after
intubation (late onset) "<img src=""7562.png"">" Microbiology duplicate
A 41 yo female with a urinary catheter complains of dysuria and flank pain. Labs
reveal leukocytosis. Which bacteria could be involved? E coli, Klebsiella, or
Proteus spp. "<img src=""7562.png"">" Microbiology duplicate nosocomial-
infections systems
A patient contracts a nosocomial infection from water aerosols. She has difficulty
breathing. Which other symptoms will develop? This is Legionella; she may have
gastrointestinal (nausea and vomiting) and neurological symptoms "<img
src=""7562.png"">" Microbiology duplicate nosocomial-infections systems
What are the two most common causes of nosocomial infections? E coli (urinary
tract infections) and S aureus (wound infections) "<img src=""7562.png"">"
Microbiology duplicate nosocomial-infections systems
A 53 yo woman complains of watery diarrhea after admission to the hospital. Labs
reveal leukocytosis. Dx? Risk factors? This patient is suffering from a
nosocomial infection by C difficile; risk factors include recent antibiotic use
"<img src=""7562.png"">" Microbiology duplicate nosocomial-infections
systems
A 67 yo with history of alcoholism has purulent malodorous sputum after aspirating
some vomit. What pathogens would you consider? Signs? Polymicrobial gram-negative
bacteria (anaerobes ofttimes); imaging may show infiltrates in the RLL (or RUL/RML
if patient is recumbent) "<img src=""7562.png"">" Microbiology duplicate
An 83-year-old in a nursing home has an erythematous and tender decubitus ulcer.
What organisms may be causing this? Other risk factors? S aureus, including
MRSA, gram-negative anaerobe (Bacteroides, Prevotella, Fusobacterium); surgical
wound, drain "<img src=""7562.png"">" Microbiology duplicate nosocomial-
infections systems
An unvaccinated girl with postauricular lymphadenopathy presents with a descending
rash. What is the likely pathogen? Rubella virus "<img src=""7563.png"">"
Microbiology bugs-affecting-unvaccinated-children duplicate systems
An unvaccinated boy has a cough, nasal congestion, conjunctivitis, a rash, and
blue-white spots in his mouth. What is the likely pathogen?Measles virus
(cough/coryza/conjunctivitis precede the rash); the spots in the mouth are Koplik
spots "<img src=""7563.png"">" Microbiology bugs-affecting-unvaccinated-
children duplicate systems
Which infectious agent resides in the nasopharynx and causes meningitis in
unvaccinated children? H influenzae type B "<img src=""7563.png"">"
An unvaccinated child contracts a virus and exhibits meningitis, myalgia, and
paralysis. What is the infectious agent? Poliovirus "<img src=""7563.png"">"
A feverish boy is drooling and has difficulty breathing and a swollen cherry-red
throat. X-ray shows a thumbprint sign. Diagnosis? Epiglottitis caused by H
influenzae type B (immunized and unimmunized children) "<img src=""7563.png"">"
An unvaccinated 4-year-old has a sore throat and gray exudate. Cardiac and
neurologic symptoms develop. Mechanism of the causative agent? Produces a toxin
that leads to necrosis in pharyngeal, cardiac, and nervous tissue (this is C
diphtheriae infection) "<img src=""7563.png"">" Microbiology bugs-affecting-
unvaccinated-children duplicate systems
An asplenic patient presents with a fulminant infection. If all else fails, which
organism is most likely the cause? Any of the encapsulated bacteria, think SHiN: S
pneumoniae H influenzae N meningitidis "<img src=""7564.png"">" Microbiology
bug-hints-(if-all-else-fails) duplicate systems
A culture of pus from an oral infection shows sulfur granules and branching rods.
What is the likely organism? Actinomyces "<img src=""7564.png"">" Microbiology
If all else fails, which organism is most likely to be involved in infection of a
patient with chronic granulomatous disease? Catalase-positive microbes,
especially S aureus "<img src=""7564.png"">" Microbiology bug-hints-(if-
all-else-fails) duplicate systems
"A man presents with an infection and ""currant jelly"" sputum. If all else fails,
what is the most likely causative organism?" Klebsiella "<img src=""7564.png"">"
Microbiology bug-hints-(if-all-else-fails) duplicate systems
A woman is bitten by her cat and develops an infection in the wound. If all else
fails, which organism do you assume is responsible? P multocida "<img
src=""7564.png"">" Microbiology bug-hints-(if-all-else-fails) duplicate
systems
A woman presents with facial nerve palsy. If all else fails, which agent do you
assume to be responsible? B burgdorferi (causes Lyme disease) "<img
systems
A diabetic man presents acutely with a fungal infection. If all else fails, what do
you assume is the most likely cause? Mucor or Rhizopus spp. (also seen in
immunocompromised patients) "<img src=""7564.png"">" Microbiology bug-hints-
(if-all-else-fails) duplicate systems
A healthcare provider suffers a needlestick injury. If all else fails, which
organism is most likely to be involved? Hepatitis B virus "<img src=""7564.png"">"
If all else fails, which organism causes disease in neutropenic patients?
Candida albicans, if systemic, or Aspergillus "<img src=""7564.png"">"
A pt develops an infection after an organ transplant. If all else fails, what is
the likely pathogen? CMV "<img src=""7564.png"">" Microbiology bug-hints-
A pt has gastrointestinal discomfort and joint pains. The organism is cultured and
is PAS positive. If all else fails, what is it? Tropheryma whipplei (Whipple
disease) "<img src=""7564.png"">" Microbiology bug-hints-(if-all-else-
fails) duplicate systems
A 2 yo child presents with epiglottitis. If all else fails, which organism is most
likely responsible? H influenzae "<img src=""7564.png"">" Microbiology
Which organism is the most likely cause of pneumonia in people with cystic
fibrosis? P aeruginosa; also likely in patients with burns "<img
systems
If all else fails, which organism is most likely responsible when pus, empyema, or
abscess formation is present? S aureus "<img src=""7564.png"">" Microbiology
A pt presents with a rash on his hands and feet. What are the three organisms that
are most likely responsible? Coxsackie A virus, T pallidum, and Rickettsia
rickettsii "<img src=""7564.png"">" Microbiology bug-hints-(if-all-else-
fails) duplicate systems
A neonate develops severe, life-threatening sepsis. If all else fails, which
organism is most likely responsible? Group B streptococcus, which should also
be suspected in a newborn with meningitis "<img src=""7564.png"">" Microbiology
You are called to consult on a pt with an infected surgical wound. If all else
fails, which organism do you assume is responsible? S aureus "<img
systems
If all else fails, which organism is most likely involved in a traumatic open wound
infection? C perfringens "<img src=""7564.png"">" Microbiology bug-hints-
What is the mechanism of action of metronidazole for its antimicrobial effect?
DNA damage involving free radicals "<img src=""7565.png"">" Microbiology
antimicrobial-therapy antimicrobials duplicate
Which process(es) do(es) sulfonamides and trimethoprim affect to exert their
antibacterial effects? Folic acid synthesis and reduction (DNA methylation);
sulfonamides inhibit conversion of PABA to DHF, trimethoprim inhibits DHF to THF
"<img src=""7565.png"">" Microbiology antimicrobial-therapy
antimicrobials duplicate
How do fluoroquinolones exert their antibacterial effects? DNA gyrase inhibition
Which process does rifampin block to exert antimicrobial effects? Bacterial
messenger RNA synthesis (RNA polymerase) "<img src=""7565.png"">" Microbiology
Name five antibiotics that work by binding to the bacterial 50S ribosomal subunits
and blocking protein synthesis. Chloramphenicol, clindamycin, streptogramins
(quinupristin/dalfopristin), linezolid, macrolides
(azithromycin/clarithromycin/erythromycin) "<img src=""7565.png"">"
Microbiology antimicrobial-therapy antimicrobials duplicate
Name two classes of antibiotics that work by binding to the bacterial 30S ribosomal
subunit. Aminoglycosides (amikacin/gentamicin/neomycin/streptomycin/tobramycin)
and tetracyclines (doxycycline/minocycline/tetracycline) "<img src=""7565.png"">"
How do penicillins, antipseudomonals, cephalosporins, carbapenems, and monobactams
work? They block cell wall synthesis by inhibiting cross-linking of peptidoglycans
Name the antibiotics that are penicillinase-sensitive. Name those that are
penicillinase-resistant. Amoxicillin, ampicillin, penicillin G/V are
penicillinase sensitive; dicloxacillin, nafcillin, oxacillin are penicillinase
resistant "<img src=""7565.png"">" Microbiology antimicrobial-therapy
Name two antipseudomonal antibiotics that interfere with peptidoglycan cross-
linking. Ticarcillin, piperacillin "<img src=""7565.png"">" Microbiology
Which antibiotics that belong to the carbapenem group? Doripenem, ertapenem,
imipenem, meropenem "<img src=""7565.png"">" Microbiology antimicrobial-
therapy antimicrobials duplicate
Name the drug that is a monobactam. Aztreonam "<img src=""7565.png"">"
Name two antibiotics that work by blocking peptidoglycan synthesis. Bacitracin
and vancomycin (glycopeptides) "<img src=""7565.png"">" Microbiology
Name a member of each generation of the cephalosporin antibiotics. 1st
generationcefazolin; 2ndcefoxitin; 3rdceftriaxone; 4thcefepime; 5thceftaroline
What are the modes of administration for penicillin G? For penicillin V?
Penicillin G is administered intravenously or intramuscularly; penicillin V
is administered orally "<img src=""7566.png"">" Microbiology antimicrobials
duplicate penicillin-g,-v
Penicillin is the prototype for which class of antibiotics?-lactams "<img
src=""7566.png"">" Microbiology antimicrobials duplicate penicillin-g,-v
Penicillin is a D-Ala-D-Ala analog. What is its mechanism of action? Binds
transpeptidases and blocks them to inhibit cross-linking of cell wall
peptidoglycan; activates enzymes that are autolytic "<img src=""7566.png"">"
Microbiology antimicrobials duplicate penicillin-g,-v
Name some specific bugs that penicillin is particularly effective against. S
pneumoniae, S pyogenes, Actinomyces, N meningitidis, T pallidum "<img
src=""7566.png"">" Microbiology antimicrobials duplicate penicillin-g,-v
Against which classes of bacteria do penicillins exhibit bactericidal activity?
Gram-positive cocci, gram-positive rods, gram-negative cocci, spirochetes
"<img src=""7566.png"">" Microbiology antimicrobials duplicate
penicillin-g,-v
You are treating a patient with a prototype -lactam antibiotic. Which side effects
might be caused by this drug? Hypersensitivity reactions, hemolytic anemia that is
direct Coombs test positive (this is penicillin) "<img src=""7566.png"">"
Microbiology antimicrobials duplicate penicillin-g,-v
How do bacteria develop resistance to penicillin? -lactamases, such as
penicillinase, cleave the -lactam ring "<img src=""7566.png"">" Microbiology
antimicrobials duplicate penicillin-g,-v
Name the penicillins that are sensitive to penicillinase. Amoxicillin and
ampicillin, of the aminopenicillin family "<img src=""7567.png"">" Microbiology
antimicrobials duplicate penicillinase-sensitive-penicillins
What is the mechanism of action for ampicillin? Same as that of penicillins
(blockage of bacterial cell wall synthesis through inhibition of peptidoglycan
cross-linking) "<img src=""7567.png"">" Microbiology antimicrobials
duplicate penicillinase-sensitive-penicillins
Which has a wider spectrum of effectiveness: ampicillin/amoxicillin or penicillin?
Ampicillin and amoxicillin have a broader spectrum of effectiveness
(AMinoPenicllins are AMPed-up penicillin) "<img src=""7567.png"">" Microbiology
Which agent, when given with amoxicillin, protects against -lactamases?
Clavulanic acid "<img src=""7567.png"">" Microbiology antimicrobials
duplicate penicillinase-sensitive-penicillins
Which has greater oral bioavailability: amoxicillin or ampicillin? Amoxicillin
(AmOxicillin has better Oral availability) "<img src=""7567.png"">"
Microbiology antimicrobials duplicate penicillinase-sensitive-penicillins
Why are ampicillin and amoxicillin called extended-spectrum penicillins? They
cover H influenzae, H pylori, E coli, Listeria monocytogenes, Proteus mirabilis,
enterococci (HHELPSS kill enterococci), Salmonella, Shigella "<img
src=""7567.png"">" Microbiology antimicrobials duplicate penicillinase-
sensitive-penicillins
What are the three major toxicities caused by ampicillin and amoxicillin? Rash,
hypersensitivity reaction, pseudomembranous colitis "<img src=""7567.png"">"
Microbiology antimicrobials duplicate penicillinase-sensitive-penicillins
What is the mechanism of resistance to ampicillin and amoxicillin? Bacteria
penicillinase cleaves the -lactam ring "<img src=""7567.png"">" Microbiology
What is the mechanism of action of dicloxacillin, nafcillin, and oxacillin?
Inhibit peptidoglycan cross-linking in bacteria cell wall, bulky R group
blocks access to -lactam ring (thus penicillinase resistant) "<img
src=""7568.png"">" Microbiology antimicrobials duplicate penicillinase-
resistant-penicillins
Against which organisms are dicloxacillin, nafcillin, and oxacillin useful? S
aureus (but not MRSA, because of change to penicillin-binding protein-binding site)
(use naf [nafcillin] for Staph) "<img src=""7568.png"">" Microbiology
antimicrobials duplicate penicillinase-resistant-penicillins
What are some side effects of penicillinase-resistant penicillins?
Hypersensitivity reaction and interstitial nephritis "<img src=""7568.png"">"
Microbiology antimicrobials duplicate penicillinase-resistant-penicillins
A patient has a Pseudomonas infection. You treat with an extended-spectrum -
lactam. What must be coadministered to prevent resistance? -Lactamase inhibitors
"<img src=""7569.png"">" Microbiology antimicrobials antipseudomonal-
penicillins duplicate
Name the penicillins that are effective against Pseudomonas spp. Piperacillin and
ticarcillin "<img src=""7569.png"">" Microbiology antimicrobials
antipseudomonal-penicillins duplicate
What is the mechanism of action of the antipseudomonal penicillins? Same as that
of penicillin (they inhibit peptidoglycan cross-linking in bacterial cell walls)
"<img src=""7569.png"">" Microbiology antimicrobials antipseudomonal-
penicillins duplicate
Which bacteria are killed by ticarcillin and piperacillin? Pseudomonas spp. and
gram-negative rods "<img src=""7569.png"">" Microbiology antimicrobials
antipseudomonal-penicillins duplicate
Which toxicity is shared by piperacillin and ticarcillin antibiotics?
Hypersensitivity reaction "<img src=""7569.png"">" Microbiology
antimicrobials antipseudomonal-penicillins duplicate
Clavulanic acid, sulbactam, and tazobactam belong to which class of antibiotics?
-lactamase inhibitors (Clavulanic Acid, Sulbactam, Tazobactam = CAST) "<img
src=""7570.png"">" Microbiology::antimicrobials::-lactamase-inhibitors
Which drug class is added to penicillin antibiotics to protect them from
penicillinases? -lactamase inhibitors (Clavulanic Acid, Sulbactam, Tazobactam =
CAST) "<img src=""7570.png"">" Microbiology::antimicrobials::-lactamase-
inhibitors
To which drug class do cephalosporins belong? -lactams (inhibit cell wall
synthesis) "<img src=""7571.png"">" Microbiology antimicrobials
cephalosporins-(generations-i-v) duplicate
Are cephalosporins more or less susceptible to penicillinase than other -lactams?
Less susceptible "<img src=""7571.png"">" Microbiology antimicrobials
Which organisms are typically not covered by cephalosporins in the first four
generations? LAME: Listeria, Atypicals (Chlamydia, Mycoplasma), MRSA (except
ceftaroline), Enterococci "<img src=""7571.png"">" Microbiology
antimicrobials cephalosporins-(generations-i-v) duplicate
Name two examples of first-generation cephalosporins. Cefazolin and cephalexin
"<img src=""7571.png"">" Microbiology antimicrobials cephalosporins-
(generations-i-v) duplicate
A patient receives a first-generation cephalosporin to protect against S aureus
wound infection. Which other organisms does this drug cover? Proteus mirabilis,
E coli, Klebsiella pneumoniae (PEcK), gram-positive cocci (this is cefazolin)
"<img src=""7571.png"">" Microbiology antimicrobials cephalosporins-
(generations-i-v) duplicate
Name three examples of second-generation cephalosporins. Cefoxitin, cefaclor, and
cefuroxime "<img src=""7571.png"">" Microbiology antimicrobials
Which organisms do second-generation cephalosporins cover? Gram-positive cocci, H
influenzae, Enterobacter aerogenes,Neisseria spp., Serratia marascens, Proteus
mirabilis,E coli,Klebsiella (HEN PEcKS) "<img src=""7571.png"">" Microbiology
Name three examples of third-generation cephalosporins. Ceftriaxone, cefotaxime,
and ceftazidime "<img src=""7571.png"">" Microbiology antimicrobials
Your pt has a serious gram-negative infection that has been resistant to other -
lactams. What do you prescribe? A third-generation cephalosporin (ceftriaxone,
cefotaxime, or ceftazidime) "<img src=""7571.png"">" Microbiology
Which -lactam drug do you prescribe for meningitis, disseminated Lyme disease, and
gonorrhea? Ceftriaxone "<img src=""7571.png"">" Microbiology antimicrobials
A child with cystic fibrosis contracts Pseudomonas pneumonia. Which third-
generation cephalosporin might you prescribe? Ceftazidime "<img src=""7571.png"">"
Microbiology antimicrobials cephalosporins-(generations-i-v) duplicate
Name one example of a fourth-generation cephalosporin. Cefepime "<img
src=""7571.png"">" Microbiology antimicrobials cephalosporins-(generations-i-
v) duplicate
Fourth-generation cephalosporins have increased activity against which organisms?
Pseudomonas and gram-positive organisms "<img src=""7571.png"">"
Ceftaroline, a fifth-generation cephalosporin, is active against which organisms?
Gram positives and gram-negatives including MRSA, but no coverage for
Pseudomonas "<img src=""7571.png"">" Microbiology antimicrobials
Which toxicity do cephalosporins share with penicillin antibiotics?
Hypersensitivity reactions "<img src=""7571.png"">" Microbiology
A pt taking a -lactam drug with reduced penicillinase susceptibility has a
prolonged prothrombin time. Why? Cephalosporin use can lead to vitamin K
deficiency, decreasing clotting factors "<img src=""7571.png"">" Microbiology
What are the signs of toxicity with cephalosporin use? Hypersensitivity
reaction, disulfiram-like reaction, autoimmune hemolytic anemia, vitamin K
deficiency "<img src=""7571.png"">" Microbiology antimicrobials
A pt with a penicillin allergy is given a cephalosporin. Why might this be
problematic? There is some cross-reactivity with penicillins, so there is a
small chance the pt will also be allergic to cephalosporins"<img src=""7571.png"">"
A pt treated with an aminoglycoside has worsening renal function after receiving an
additional drug. Which drug was added? A cephalosporin (when combined with
aminoglycosides, cephalosporins increase the potential for asynchronicity) "<img
src=""7571.png"">" Microbiology antimicrobials cephalosporins-(generations-i-
v) duplicate
What is the mechanism of resistance to cephalosporins? Changing the structure
of the penicillin-binding proteins (transpeptidases) "<img src=""7571.png"">"
Name the four carbapenem antibiotics. Imipenem, meropenem, ertapenem, and
doripenem "<img src=""7572.png"">" Microbiology antimicrobials carbapenems
duplicate
Name the carbapenem that is resistant to -lactamase and is prescribed with
cilastatin so it won't be inactivated in the kidneys. "Imipenem, a broad-spectrum
antibiotic (""the kill is lastin' with cilastatin"")" "<img src=""7572.png"">"
Microbiology antimicrobials carbapenems duplicate
Name the two new carbapenems. Ertapenem (which has limited coverage against
Pseudomonas) and doripenem "<img src=""7572.png"">" Microbiology
antimicrobials carbapenems duplicate
Which kinds of infections is imipenem used to treat? Gram-positive cocci, gram-
negative rods, and anaerobic infections "<img src=""7572.png"">" Microbiology
At what point during disease progression is imipenem or meropenem considered a
treatment option? Why? Only when other medications have failed or in life-
threatening infections; significant adverse effects "<img src=""7572.png"">"
Microbiology antimicrobials carbapenems duplicate
A man with a mutation increasing dehydropeptidase I activity takes a carbapenem
that resists the mutation. Does his seizure risk increase? No, as he was likely
given meropenem, which is not only stable to dehydropeptidase I but has a lower
risk of causing seizures "<img src=""7572.png"">" Microbiology
A man starts taking a carbapenem antibiotic. What are the side effects? Which
carbapenem has a reduced risk of the most concerning one? Carbapenems can cause
seizures at high plasma levels, GI problems, and skin rash; meropenem has a reduced
risk of seizures "<img src=""7572.png"">" Microbiology antimicrobials
carbapenems duplicate
Aztreonam is an example of what subclass of -lactam drugs?Monobactams, which are
less susceptible to -lactamases "<img src=""7573.png"">" Microbiology
antimicrobials duplicate monobactams
Aztreonam inhibits peptidoglycan cross-linking by binding to which substance?
Penicillin-binding protein 3 "<img src=""7573.png"">" Microbiology
A pt has a severe gram-negative organism infection. You choose to treat with
aminoglycosides and a monobactam. Why? Aztreonam, a monobactam, is synergistic
with aminoglycosides "<img src=""7573.png"">" Microbiology antimicrobials
duplicate monobactams
A penicillin-allergic pt with a severe infection receives penicillin. He needs a
second antibiotic. Are monobactams a good choice? Yes, as aztreonam, which has
no cross-sensitivity to penicillins/aminoglycosides and is usually nontoxic, is a
reasonable choice "<img src=""7573.png"">" Microbiology antimicrobials
duplicate monobactams
Aztreonam is active against which organisms? Gram-negative rods only "<img
src=""7573.png"">" Microbiology antimicrobials duplicate monobactams
Aztreonam is usually well-tolerated, but which side effect occasionally affects
pts? Gastrointestinal upset "<img src=""7573.png"">" Microbiology
How does vancomycin work? It binds the D-ala D-ala of cell wall precursors,
thereby inhibiting the formation of cell wall peptidoglycan"<img src=""7574.png"">"
Microbiology antimicrobials duplicate vancomycin
Vancomycin is bactericidal, with what exception? Is it resistant to -lactamases?
C difficile (it is bacteriostatic against it); resistant to -lactamases
vancomycin
Which types of organisms are treated with vancomycin? Gram-positive onlyMRSA, S
epidermidis, Enterococcus, C difficile (oral dosing for pseudomembranous colitis)
vancomycin
What types of toxicity are possible with vancomycin treatment? Nephrotoxicity,
Ototoxicity, Thrombophlebitis (NOT trouble free), diffuse flushing (red man
syndrome) "<img src=""7574.png"">" Microbiology antimicrobials duplicate
vancomycin
A 40 yo man with MRSA cellulitis is treated for a week with an antibiotic and
notices reduced hearing in both ears. Name the etiology. Vancomycin is associated
with ototoxicity "<img src=""7574.png"">" Microbiology antimicrobials
duplicate vancomycin
How do bacteria develop resistance to vancomycin? Conversion of D-ala D-ala to
D-ala D-lac (pay back 2 D-alas [dollars] for vandalizing [vancomycin]) "<img
src=""7574.png"">" Microbiology antimicrobials duplicate vancomycin
Why do protein synthesis inhibitors generally not cause harm to human cells? They
target bacterial ribosome 70S, which is smaller than the 80S of humans, which is
left unaffected "<img src=""7575.png"">" Microbiology antimicrobials
duplicate protein-synthesis-inhibitors
What is the mnemonic to remember which protein synthesis inhibitors affect which
bacterial ribosome subunits? Buy AT 30, CCEL (sell) at 50: Aminoglycosides,
Tetracyclines (30S); Cloramphenicol, b>Clindamycin, Erythromycin, Linezolid (50S)
"<img src=""7575.png"">" Microbiology antimicrobials duplicate protein-
synthesis-inhibitors
Which protein synthesis-inhibiting antibiotics are bactericidal? Aminoglycosides
(note that linezolid is variable [bacteriostatic and bactericidal]) "<img
src=""7575.png"">" Microbiology antimicrobials duplicate protein-synthesis-
inhibitors
Which protein synthesis-inhibiting antibiotics are bacteriostatic?
Tetracyclines, chloramphenicol, clindamycin, erythromycin (linezolid is
variable [bacteriostatic and bactericidal]) "<img src=""7575.png"">"
Microbiology antimicrobials duplicate protein-synthesis-inhibitors
To bacteria translating mRNA with ribosomes, a both bacteriostatic and bactericidal
antibiotic is added. Which ribosomal subunit is blocked? 50S ribosomal subunit
(blocked by linezolid) "<img src=""7575.png"">" Microbiology antimicrobials
Addition of a specific bactericidal antibiotic is noted to cause misreading of
mRNA. Inhibition of which ribosomal subunit is to blame? 30S ribosomal unit
(blocked by aminoglycosides and can cause misreading of mRNA) "<img
src=""7575.png"">" Microbiology antimicrobials duplicate protein-synthesis-
inhibitors
Bacteria given a certain 50S-inhibiting antibiotic have low peptidyl transferase
activity. Is the antibiotic bacteriostatic or bactericidal?Bacteriostatic (this is
chloramphenicol) "<img src=""7575.png"">" Microbiology antimicrobials
You add bacteriostatic antibiotics to bacteria and they have reduced A-site tRNA
binding. Inhibition of which ribosomal subunit is to blame?30S (these are
tetracycline antibiotics) "<img src=""7575.png"">" Microbiology
antimicrobials duplicate protein-synthesis-inhibitors
Antibiotics are given when bacteria inhibit translocation. A ribosomal activity
assay is performed. Is a decrease in 30S activity seen? No, as the antibiotics
that act on translocation all inhibit the 50S subunit (eg, macrolides, clindamycin)
"<img src=""7575.png"">" Microbiology antimicrobials duplicate protein-
synthesis-inhibitors
Name five antibiotics that belong to the aminoglycoside class of antibiotics.
"""Mean"" (aminoglycoside) GNATSGentamicin, Neomycin, Amikacin, Tobramycin,
Streptomycin" "<img src=""7576.png"">" Microbiology aminoglycosides
What is the mechanism of action of aminoglycosides? Bactericidal: they inhibit
the initiation complex by binding 30S, blocking translocation and causing
misreading of mRNA "<img src=""7576.png"">" Microbiology aminoglycosides
Why are aminoglycosides ineffective against anaerobes? "They require oxygen
(""Mean"" (aminoglycoside) GNATS caNNOT kill anaerobes"")" "<img src=""7576.png"">"
Microbiology aminoglycosides antimicrobials duplicate
Against what organisms are aminoglycosides used? Gram-negative rods "<img
src=""7576.png"">" Microbiology aminoglycosides antimicrobials duplicate
Aminoglycosides are synergistic with which class of antibiotics? -Lactams "<img
Your pt is being treated for an infection with an aminoglycoside, but the bacteria
develop resistance. How was this mediated? Mediated by transferase enzymes,
which inactivate the drug by acetylation, phosphorylation, or adenylation "<img
A pt is scheduled to have bowel surgery. Which antibiotic is administered before
the surgery? Neomycin "<img src=""7576.png"">" Microbiology
aminoglycosides antimicrobials duplicate
Which toxicities are associated with aminoglycosides, and what is a mnemonic for
remembering them? "Nephrotoxicity, Neuromuscular blockade, Ototoxicity,
Teratogenicity (""Mean"" (aminoglycoside) GNATS caNNOT kill anaerobes""" "<img
A man is taking an aminoglycoside; an additional medication is prescribed and he
develops severe ototoxicity. Which drug was added? Likely a loop diuretic, which
increases the ototoxic potential of aminoglycosides "<img src=""7576.png"">"
Microbiology aminoglycosides antimicrobials duplicate
A pt who had recently undergone bowel surgery is now complaining of hearing loss.
Which medications would you look for on history? Neomycin, an aminoglycoside
(used for bowel surgery)toxicity includes ototoxicity, particularly when alongside
loop diuretic use "<img src=""7576.png"">" Microbiology aminoglycosides
Name three antibiotics that belong to the tetracycline class of antibiotics.
Tetracycline, doxycycline, and minocycline "<img src=""7577.png"">"
Microbiology antimicrobials duplicate tetracyclines
What is the mechanism of action of tetracyclines? They are bacteriostatic,
binding 30S and preventing the attachment of aminoacyl-tRNA"<img src=""7577.png"">"
A pt develops severe meningitis. Lyme disease is to blame. Do you treat with a
tetracycline antibiotic? No, as tetracyclines have limited central nervous
system penetration and would thus not be effective "<img src=""7577.png"">"
A pt with renal failure needs a tetracycline-class drug for a M. pneumoniae
infection. What do you prescribe and why? Doxycycline; it is fecally eliminated and
can therefore be used by pts with renal failure "<img src=""7577.png"">"
A 35-year-old hiker from Connecticut has a bullseye rash on his arm. You prescribe
an antibiotic and caution him against consuming what? Milk, antacids, and iron-
containing products; divalent cations inhibit the absorption of tetracyclines
tetracyclines
Tetracyclines are used to treat infections with which two organisms that are
transmitted by ticks? B burgdorferi and Rickettsia "<img src=""7577.png"">"
Name five uses for tetracyclines M pneumoniae, Chlamydia, B burgdorferi, and
Rickettsia infections and acne "<img src=""7577.png"">" Microbiology
antimicrobials duplicate tetracyclines
Which feature of tetracyclines makes them effective against Rickettsia and
Chlamydia infections? Their ability to accumulate intracellularly "<img
src=""7577.png"">" Microbiology antimicrobials duplicate tetracyclines
A child presents with discolored teeth, inhibited bone growth, and GI distress
secondary to an antibiotic he is on. What is the antibiotic? A tetracycline,
which should be avoided in children because of these side effects "<img
src=""7577.png"">" Microbiology antimicrobials duplicate tetracyclines
What dermatologic adverse effect results from use of tetracyclines?
Photosensitivity "<img src=""7577.png"">" Microbiology antimicrobials
duplicate tetracyclines
Can pregnant women take tetracyclines? No, as tetracyclines are contraindicated
in pregnancy because they inhibit bone growth "<img src=""7577.png"">"
A pt's infection is no longer susceptible to tetracycline treatment. What mechanism
mediated this resistance? Decreased uptake into bacterial cells or increased
efflux out of cells by plasmid-encoded transport pumps "<img src=""7577.png"">"
A 21-year-old has Chlamydia. He also has acne. Why is your antibiotic of choice a
tetracycline? How does it work? Tetracyclines treat both Chlamydia and acne,
binding 30S and preventing aminoacyl-tRNA attachment "<img src=""7577.png"">"
A man has meningitis and is given a bacteriostatic antibiotic that is cheap and
highly toxic. Via what mechanism does this antibiotic work?Works by blocking
peptidyl transferase on the 50S ribosomal subunit (the drug administered was
chloramphenicol) "<img src=""7578.png"">" Microbiology antimicrobials
chloramphenicol duplicate
What are the most common uses for chloramphenicol? Treating meningitis (H
influenzae, N meningitidis, S pneumoniae) and Rocky Mountain spotted fever (R
ricketsii) "<img src=""7578.png"">" Microbiology antimicrobials
A pt from the developing world is given chloramphenicol, and you notice his
hemoglobin is dropping. Why? Chloramphenicol can cause a dose-dependent
suppression of red blood cell production, resulting in anemia "<img
src=""7578.png"">" Microbiology antimicrobials chloramphenicol duplicate
A man is given chloramphenicol, and you notice that he is pancytopenic. Will
lowering his dose stave off this side effect? No, as aplastic anemia is a dose-
independent adverse reaction of chloramphenicol "<img src=""7578.png"">"
Microbiology antimicrobials chloramphenicol duplicate
A premature baby from a developing country has grayish skin after he is given
antibiotics. Name the mechanism of action of the drug. The drug administered
was chloramphenicol, which works by blocking peptidyl transferase on the ribosome
subunit 50S "<img src=""7578.png"">" Microbiology antimicrobials
A premature infant in a developing country is given an antibiotic and takes on a
gray appearance. Deficiency of which enzyme is to blame? Premature infants lack
UDPglucuronyl transferase (this infant has gray baby syndrome from chloramphenicol
treatment) "<img src=""7578.png"">" Microbiology antimicrobials
A pt's infection becomes resistant to the chloramphenicol she is taking. By what
mechanism did this happen? Acquisition of a plasmid-encoded acetyltransferase
that inactivated the drug "<img src=""7578.png"">" Microbiology
antimicrobials chloramphenicol duplicate
At the 50S ribosomal subunit, clindamycin inhibits protein synthesis by blocking
what? Translocation; it is a bacteriostatic antibiotic "<img src=""7579.png"">"
Microbiology antimicrobials clindamycin duplicate
Against which organisms does clindamycin work? Anaerobes in oral infections,
aspiration pneumonia, lung abscesses (C perfringens, Bacteroides spp.), invasive
group A strep "<img src=""7579.png"">" Microbiology antimicrobials
clindamycin duplicate
A patient is found to have an anaerobic infection. When would you consider using
clindamycin vs metronidazole? Clindamycin is useful for anaerobic infections above
the diaphragm, metronidazole for those below it "<img src=""7579.png"">"
Pseudomembranous colitis develops in a patient treated for aspiration pneumonia.
Mechanism of action of the most likely antibiotic used? Blocks peptide transfer
at the ribosome subunit 50S (this is clindamycin) "<img src=""7579.png"">"
A pt is being treated with clindamycin and develops pseudomembranous colitis. How
did this happen? Clindamycin kills normal flora and allows overgrowth of C
difficile "<img src=""7579.png"">" Microbiology antimicrobials clindamycin
duplicate
Which antibiotic belongs to the oxazolidinone class? Linezolid "<img
src=""7580.png"">" Microbiology antimicrobials duplicate oxazolidinones
Against which organisms would you consider using linezolid?Gram-positive organisms
(including MRSA, VRE) "<img src=""7580.png"">" Microbiology antimicrobials
duplicate oxazolidinones
A pt on an oxazolidinone for MRSA complains of headache and rapid heart rate. On
exam he is shivering. Other toxicities of this drug? Peripheral neuropathy, bone
marrow suppression (especially thrombocytopenia) from linezolid toxicity (serotonin
syndrome described here) "<img src=""7580.png"">" Microbiology
antimicrobials duplicate oxazolidinones
A man receives an antibiotic for VRE. He notes tingling and decreased sensation in
his hands. What is the antibiotic's mechanism of action? Binds to the 50S subunit
and stops protein synthesis as well as initiation complex formation (this is
peripheral neuropathy from linezolid) "<img src=""7580.png"">" Microbiology
How would an organism become resistant to linezolid? Acquiring a point mutation of
ribosomal RNA "<img src=""7580.png"">" Microbiology antimicrobials
duplicate oxazolidinones
A pt with well-treated depression has a MRSA infection, which you treat with
linezolid. Which serious side effect might you worry about?Serotonin syndrome,
which may be precipitated by linezolid and is more likely to occur if the pt is
concomitantly taking an SSRI "<img src=""7580.png"">" Microbiology
Name three examples of macrolide antibiotics. Erythromycin, azithromycin, and
clarithromycin "<img src=""7581.png"">" Microbiology antimicrobials
duplicate macrolides
Describe the mechanism of action of the bacteriostatic macrolide antibiotics.
They bind 23S rRNA of 50S subunit and prevent translocation (macroslides
macrolides
Macrolides are used to treat infection with which organisms? Gram-positive
cocci, Mycoplasma, Legionella, Chlamydia for atypical pneumonia, Chlamydia for
STIs, B pertussis "<img src=""7581.png"">" Microbiology antimicrobials
Which types of infections are treated with macrolides? STIs, atypical
pneumonia, gram-positive cocci (streptococcal infections in patients with
penicillin allergy), B pertussis "<img src=""7581.png"">" Microbiology
antimicrobials duplicate macrolides
A pt with strep throat is allergic to penicillin. Which part of protein synthesis
is inhibited by the antibiotic that he gets instead? Translocation (he was likely
given a macrolide antibioticthink macroslides) "<img src=""7581.png"">"
Microbiology antimicrobials duplicate macrolides
What are the five toxicities caused by macrolides? MACRO: Motility issues,
Arrhythmia (prolonged QT), acute Cholestatic hepatitis, Rash, eOsinophilia "<img
src=""7581.png"">" Microbiology antimicrobials duplicate macrolides
A pt on erythromycin develops an electrical cardiac abnormality. What is it?
Prolonged QT interval "<img src=""7581.png"">" Microbiology
A man taking theophylline has an increased serum concentration of the drug. Which
antibiotic was likely recently prescribed? A macrolide; also happens with oral
anticoagulants "<img src=""7581.png"">" Microbiology antimicrobials
Which of the macrolide antibiotics inhibits cytochrome P450 enzymes?
Erythromycin, clarithromycin "<img src=""7581.png"">" Microbiology
A pt's infection becomes resistant to the macrolide antibiotic he is taking. By
what mechanism did this occur? Methylation of the 23S ribosomal RNA binding
site "<img src=""7581.png"">" Microbiology antimicrobials duplicate
macrolides
Name the drugs that belong to the sulfonamide class. Sulfamethoxazole (SMX),
sulfadiazine, sulfisoxazole "<img src=""7582.png"">" Microbiology
antimicrobials duplicate sulfonamides
How do sulfonamides work? They stop the activity of dihydropteroate synthase,
preventing folate synthesis "<img src=""7582.png"">" Microbiology
How are sulfonamides and dapsone similar? They both inhibit folate synthesis by
blocking dihydropteroate synthase "<img src=""7582.png"">" Microbiology
Are sulfonamides bacteriostatic or bactericidal? What if used with trimethoprim?
Bacteriostatic; if used with trimethoprim, they are bactericidal "<img
src=""7582.png"">" Microbiology antimicrobials duplicate sulfonamides
Sulfonamides are active against which organisms? Gram-positives, gram-
negatives, Nocardia, and Chlamydia; for simple UTIs, use a triple sulfa or
sulfamethoxazole (SMX) "<img src=""7582.png"">" Microbiology antimicrobials
duplicate sulfonamides
A man is prescribed a sulfonamide. His hemoglobin is soon after found to be low.
Which underlying enzyme deficiency does he likely have? G6PD deficiency, causing
hemolytic anemia "<img src=""7582.png"">" Microbiology antimicrobials
duplicate sulfonamides
A pt is prescribed a sulfonamide but develops renal toxicity. What specific renal
pathology is associated with these drugs? Tubulointerstitial nephritis "<img
A pt taking a sulfonamide develops a skin condition due to the medication. Is the
antibiotic to blame? Yes, as sulfonamides can cause photosensitivity "<img
What neurologic injury can sulfonamides cause in infants? Kernicterus "<img
A man on warfarin is given a sulfonamide for an infection. He soon after notes that
he bleeds much more readily. What happened? The plasma concentration of
warfarin and other drugs is raised by displacement from albumin by sulfonamides
sulfonamides
A pt is taking a sulfonamide for an infection, but the bacteria become resistant to
it. By which mechanism did this occur? Altered bacterial dihydropteroate
synthase, decreased uptake, or increased PABA synthesis "<img src=""7582.png"">"
Microbiology antimicrobials duplicate sulfonamides
Which enzyme does dapsone affect? Which other class of antibiotics has a similar
mechanism of action? Dihydropteroate synthase; sulfonamides inhibit the same
enzyme "<img src=""7583.png"">" Microbiology antimicrobials dapsone
duplicate
A patient is found to have leprosy. What do you prescribe? Dapsone, used for
lepromatous and tuberculoid forms of leprosy "<img src=""7583.png"">"
Microbiology antimicrobials dapsone duplicate
A patient is given dapsone as a precaution after being exposed to P jiroveci. Soon
after, he has a hemolytic crisis. Why? Dapsone causes hemolysis in people who
are G6PD deficient "<img src=""7583.png"">" Microbiology antimicrobials
dapsone duplicate
Describe the mechanism of action of trimethoprim. It blocks dihydrofolate
reductase (like pyrimethamine); bacteriostatic "<img src=""7584.png"">"
Microbiology antimicrobials duplicate trimethoprim
Why are trimethoprim and sulfamethoxazole used in combination? To cause the
sequential block of folate synthesis and synergistic inhibition of DNA synthesis
trimethoprim
Trimethoprim and sulfamethoxazole are used in combination in which scenarios?
UTIs, toxoplasmosis prophylaxis, Shigella, Salmonella, Pneumocystis jirovecii
pneumonia treatment and prophylaxis "<img src=""7584.png"">" Microbiology
antimicrobials duplicate trimethoprim
Trimethoprim-sulfamethoxazole is used to treat which pulmonary infection of HIV-
positive pts? Pneumocystis jirovecii pneumonia "<img src=""7584.png"">"
Microbiology antimicrobials duplicate trimethoprim
A patient taking trimethoprim-sulfamethoxazole (TMP-SMX) is having problems with
his blood. How do you treat him? Treat with folinic acid; TMP-SMX causes
megaloblastic anemia, leukopenia, granulocytopenia (TMP Treats Marrow Poorly)
trimethoprim
Name seven fluoroquinolones (hint: most end in -floxacin). Cipro-, nor-, levo-, o-,
moxi-, gemi-, and also enoxacin "<img src=""7585.png"">" Microbiology
antimicrobials duplicate fluoroquinolones
What is the mechanism of action of fluoroquinolones? Bacteriostatic or
bactericidal? Inhibition of topoisomerase II and IV, thereby making them
bactericidal "<img src=""7585.png"">" Microbiology antimicrobials
duplicate fluoroquinolones
Which class of GI drugs should not be taken with fluoroquinolones? Antacids
fluoroquinolones
Which organisms are targeted by fluoroquinolones? Gram-negative rods in the
urinary and GI tracts (including Pseudomonas), Neisseria, some gram-positives
fluoroquinolones
What is the common GI side effect of fluoroquinolones? GI upset "<img
src=""7585.png"">" Microbiology antimicrobials duplicate fluoroquinolones
What is the common dermatological side effect of fluoroquinolones? Rash "<img
What are the common CNS side effects of fluoroquinolones? Headaches, dizziness
fluoroquinolones
What are the MSK side effects of fluoroquinolones? Leg cramps, myalgia "<img
Why are fluoroquinolones contraindicated in pregnant and nursing women and patients
younger than 18 years? Possibility of cartilage damage (Fluoroquinolones hurt the
attachments to your bones) "<img src=""7585.png"">" Microbiology
antimicrobials duplicate fluoroquinolones
Which ECG change may manifest after fluoroquinolone use? Prolonged QT interval
fluoroquinolones
A 65-year-old man says that ciprofloxacin worked well for previous bouts of
traveler's diarrhea. Why should another class be used this time around?
Fluoroquinolones may cause tendinitis/tendon rupture in people older than 60
years (Fluoroquinolones hurt attachments to your bones) "<img src=""7585.png"">"
Microbiology antimicrobials duplicate fluoroquinolones
A pt on prednisone is given an antibiotic and suffers tendon rupture. What abnormal
finding might you see on this pt's ECG? Fluoroquinolones can prolong the QT
interval (prednisone with fluoroquinolone may cause tendon rupture) "<img
A man has been taking a fluoroquinolone for an infection, but the bacteria have
become resistant. By what mechanism did this occur? Chromosome-encoded mutation
in the bacterial DNA gyrase, efflux pumps, or resistance mediated by plasmid "<img
What is the mechanism of action of daptomycin? Disruption of gram-positive cocci
cell membrane "<img src=""7586.png"">" Microbiology antimicrobials
daptomycin duplicate
A patient is found to have endocarditis and prescribed daptomycin. When else would
you consider using this drug? VRE, bacteremia, skin infections by S aureus
(especially MRSA) "<img src=""7586.png"">" Microbiology antimicrobials
daptomycin duplicate
Why is daptomycin not used to treat pneumonia? It binds to and is inactivated by
surfactant "<img src=""7586.png"">" Microbiology antimicrobials daptomycin
duplicate
A patient is given daptomycin. What signs of toxicity do you watch out for?
Rhabdomyolysis, myopathy "<img src=""7586.png"">" Microbiology
antimicrobials daptomycin duplicate
What is the mechanism of action of metronidazole? Formation of free radical
toxic metabolites that damage bacterial DNA; bactericidal "<img src=""7587.png"">"
Microbiology antimicrobials duplicate metronidazole
List the organisms that can be treated with metronidazole. (GET GAP on Metro with
Metronidazole.) Giardia Entamoeba, Trichomonas, G vaginalis, Anaerobes
[Bacteroides, C difficile], H Pylori "<img src=""7587.png"">" Microbiology
antimicrobials duplicate metronidazole
A pt with H pylori infection is prescribed a triple-therapy regimen. Which drugs
are included? Metronidazole, a proton pump inhibitor, and clarithromycin "<img
src=""7587.png"">" Microbiology antimicrobials duplicate metronidazole
Clindamycin is used to treat anaerobic infections above the diaphragm. Which
antimicrobial is used to treat them below the diaphragm? Metronidazole "<img
What is the GI side effect of metronidazole? Metallic taste "<img
What is the CNS side effect of metronidazole? Headache "<img src=""7587.png"">"
Microbiology antimicrobials duplicate metronidazole
You prescribe metronidazole and advise the patient to avoid alcohol use. Why?
Disulfiram-like reaction (severe flushing, tachycardia, hypotension) "<img
A patient taking an antibiotic for giardiasis and notices a metallic taste. Which
antibiotic is it? Metronidazole "<img src=""7587.png"">" Microbiology
A 21-y/o with vaginal itching and malodorous discharge is given an antibiotic and
told to avoid alcohol. What is the mechanism of action? Forms free radical
metabolites that damage bacteria DNA (the patient has contracted Trichomonas and
been prescribed metronidazole) "<img src=""7587.png"">" Microbiology
Which antibiotic is used as prophylaxis against M tuberculosis? Isoniazid "<img
src=""7588.png"">" Microbiology antimicrobials antimycobacterial-drugs
duplicate
A woman's husband contracts tuberculosis; you prescribe a medication to prevent her
from being infected. What is its mechanism of action? Inhibits the synthesis of
mycolic acid (isoniazid is given as prophylaxis against M tuberculosis) "<img
duplicate
Which drugs are used as prophylaxis against M avium-intracellulare? Azithromycin
and rifabutin "<img src=""7588.png"">" Microbiology antimicrobials
antimycobacterial-drugs duplicate
Which drug regimen is commonly used to treat M avium-intracellulare infection?
Azithromycin or clarithromycin plus ethambutol; rifabutin or ciprofloxacin
may be added "<img src=""7588.png"">" Microbiology antimicrobials
antimycobacterial-drugs duplicate
What is the prophylactic agent against M leprae? There is no prophylaxis "<img
duplicate
A patient is found to have tuberculoid leprosy. What is the treatment? Long-term
regimen of dapsone and rifampin "<img src=""7588.png"">" Microbiology
antimicrobials antimycobacterial-drugs duplicate
A patient is found to have lepromatous leprosy. What is the treatment? Long-term
regimen of dapsone, rifampin, and clofazimine "<img src=""7588.png"">"
Microbiology antimicrobials antimycobacterial-drugs duplicate
A patient is treated for the lepromatous form of M leprae. How does his regimen
differ from that for a patient with the tuberculoid form? Clofazimine is added to
the regimen of dapsone and rifampin, which are commonly used for the tuberculoid
form "<img src=""7588.png"">" Microbiology antimicrobials antimycobacterial-
drugs duplicate
Name the two drugs that belong to the rifamycin class of antibiotics. Rifampin and
rifabutin "<img src=""7589.png"">" Microbiology antimicrobials duplicate
rifamycins
What is the mechanism of action of rifamycins (rifampin, rifabutin)? Inhibition
of DNA-dependent RNA polymerase "<img src=""7589.png"">" Microbiology
antimicrobials duplicate rifamycins
A patient is given rifampin for tuberculosis. In which other mycobacterial
infection is rifampin used? M leprae (it delays resistance to dapsone) "<img
src=""7589.png"">" Microbiology antimicrobials duplicate rifamycins
A high-risk patient asks you for prophylaxis against meningococcal meningitis.
Which antimycobacterial agent should you consider? Rifampin "<img
An unvaccinated child contracts H influenzae type B. Which antimycobacterial agent
may be used as prophylaxis for the child's contacts? Rifampin "<img
What are the 4 R's of rifampin? RNA polymerase inhibitor, Ramps up microsomal
cytochrome P-450, Red/orange body fluids, Rapid resistance when used alone "<img
A patient is being treated for leprosy. Why is rifampin used with dapsone in this
case? It delays the development of resistance to dapsone "<img src=""7589.png"">"
Microbiology antimicrobials duplicate rifamycins
A man taking an antimycobacterial agent has increased LFTs and many drug
interactions. What is the mechanism by which this occurs? Increase of cytochrome
P-450 activity by rifampin "<img src=""7589.png"">" Microbiology
antimicrobials duplicate rifamycins
After a patient starts therapy for active TB, he notices that his shirt is stained
with orange sweat. Which drug is responsible? Rifampin "<img src=""7589.png"">"
An HIV-positive patient contracts tuberculosis. Why is rifabutin favored over
rifampin in this case? Less P-450 stimulation (rifampin ramps up cytochrome P-450,
but rifabutin doesn't) "<img src=""7589.png"">" Microbiology antimicrobials
duplicate rifamycins
A patient is only given rifampin for tuberculoid leprosy and is now becoming
resistant to it. Why? Mutations that decrease rifampin's binding to RNA
polymerase; monotherapy rapidly results in resistance "<img src=""7589.png"">"
A pt exposed to M tuberculosis is given prophylactic medication. Which bacterial
enzyme is needed for it to become active? KatG (catalase-peroxidase, a bacterial
enzyme) converts this prophylactic to the active metabolite (this is isoniazid)
"<img src=""7590.png"">" Microbiology antimicrobials duplicate isoniazid
A patient requests prophylaxis against M tuberculosis before travel. What is the
one drug that can be used as solo prophylaxis? Isoniazid "<img src=""7590.png"">"
Microbiology antimicrobials duplicate isoniazid
Two pts of the same sex, weight, height, and build require different doses of
isoniazid. Why? People are either fast or slow acetylators, and the half-life of
isoniazid differs depending on the individual rate of acetylation "<img
src=""7590.png"">" Microbiology antimicrobials duplicate isoniazid
What are the major toxicities associated with isoniazid? INH = Injures Neurons
and Hepatocytes (neurotoxicity and hepatotoxicity) "<img src=""7590.png"">"
Your patient being treated for TB experiences paresthesias in her arms and legs.
How could you have prevented this side effect? By coadministering pyridoxine
(vitamin B6) to prevent neurotoxicity induced by isoniazid "<img src=""7590.png"">"
A patient being treated for TB presents with symptoms of anemia. Peripheral smear
shows ringed sideroblasts. What is the most likely cause? Isoniazid-induced
pyridoxine (vitamin B6) deficiency "<img src=""7590.png"">" Microbiology
antimicrobials duplicate isoniazid
A patient is found to have drug-induced SLE after completing an antimycobacterial
regimen for TB. Which drug is the most likely cause? Isoniazid "<img
src=""7590.png"">" Microbiology antimicrobials duplicate isoniazid
A patient exposed to TB is deemed resistant to the prophylactic agent of choice.
How does this resistance manifest? Underexpression of KatG resulting from
mutations "<img src=""7590.png"">" Microbiology antimicrobials duplicate
isoniazid
What is the mechanism of action of pyrazinamide? Unknown, but it is converted
to its active form, pyrazinoic acid "<img src=""7591.png"">" Microbiology
antimicrobials duplicate pyrazinamide
The big toe of a patient being treated for TB becomes red, swollen, and painful.
Which antimycobacterial agent is the most likely cause? Pyrazinamide-induced
hyperuricemia "<img src=""7591.png"">" Microbiology antimicrobials
duplicate pyrazinamide
A 39-year-old has an acid-fast bacillus infection. After starting therapy, he
cannot see red-green colors. How does the offending drug work? Inhibition of
arabinosyltransferase (the red-green color blindness signals ethambutol toxicity)
ethambutol
What is the primary toxicity of ethambutol? Optic neuropathy, commonly
manifesting as red-green color blindness (think eyethambutol) "<img
src=""7592.png"">" Microbiology antimicrobials duplicate ethambutol
A patient is given streptomycin as part of a TB regimen. What is the mechanism of
action of this drug? Blockage of the 30S ribosomal subunit "<img
src=""7593.png"">" Microbiology antimicrobials duplicate streptomycin
A patient being treated for TB experiences tinnitus, vertigo, and ataxia. Which
antimycobacterial agent is the most likely cause? Streptomycin "<img
src=""7593.png"">" Microbiology antimicrobials duplicate streptomycin
A pt at high risk for endocarditis is prepared for a dental procedure. What
antibiotic prophylaxis do you prescribe? Amoxicillin (also given if undergoing
surgery) "<img src=""7594.png"">" Microbiology antimicrobial-prophylaxis
A pt complains of dysuria, penile discharge, and a painful swollen knee. What do
you give to his wife as prophylaxis? His wife should be given ceftriaxone as
prophylaxis (this pt has gonorrhea) "<img src=""7594.png"">" Microbiology
antimicrobial-prophylaxis antimicrobials duplicate
A patient has recurrent dysuria, urgency, and frequency. What do you prescribe as
prophylaxis? TMP-SMX for patients with recurrent UTIs "<img src=""7594.png"">"
Microbiology antimicrobial-prophylaxis antimicrobials duplicate
A patient falls ill with meningococcal meningitis. What do you give to the
patient's close contacts for prophylaxis? Ceftriaxone, ciprofloxacin, or rifampin
"<img src=""7594.png"">" Microbiology antimicrobial-prophylaxis
A pregnant woman tests positive for group B Streptococcus. What should be given as
prophylaxis? Intrapartum penicillin G or ampicillin "<img src=""7594.png"">"
Which antibiotic is given to newborns as prophylaxis against gonococcal
conjunctivitis? Erythromycin ointment applied to the eyes "<img src=""7594.png"">"
A patient undergoes cholecystectomy. What prophylaxis is used to prevent
postsurgical S aureus infection? Cefazolin "<img src=""7594.png"">"
A child had rheumatic fever in his past. What prophylaxis do you give to prevent
streptococcal pharyngitis? Oral penicillin V or benzathine penicillin G "<img
src=""7594.png"">" Microbiology antimicrobial-prophylaxis antimicrobials
duplicate
A patient presents with a painless chancre; dark-field microscopy reveals a
spirochete. What should be given to his wife prophylactically? Benzathine
penicillin G (for syphilis) "<img src=""7594.png"">" Microbiology
antimicrobial-prophylaxis antimicrobials duplicate
An HIV patient has a CD4+ count < 200 cells/mm. Prophylaxis with TMP-SMX is
started. Against what infection is the patient being protected? Pneumocystis
pneumonia "<img src=""7595.png"">" Microbiology antimicrobials duplicate
prophylaxis-in-hiv-patients
An HIV patient has a CD4+ count < 100 cells/mm. Prophylaxis with TMP-SMX is
started. Against what infection is the patient being protected? Pneumocystis
pneumonia (if CD4+ < 200) and toxoplasmosis (if CD4 < 100) "<img src=""7595.png"">"
Microbiology antimicrobials duplicate prophylaxis-in-hiv-patients
An HIV patient is found to have a CD4+ count < 50 cells/mm. Aside from TMP-SMX,
what other prophylactic therapy should be started? Azithromycin or
clarithromycin for Mycobacterium avium complex "<img src=""7595.png"">"
Microbiology antimicrobials duplicate prophylaxis-in-hiv-patients
Name some antibiotics that can be used to treat methicillin-resistant S aureus
(MRSA). Vancomycin, daptomycin, linezolid, tigecycline, ceftaroline"<img
src=""7596.png"">" Microbiology antimicrobials duplicate treatment-of-highly-
resistant-bacteria
Which two antibiotics can be used to treat vancomycin-resistant enterococci (VRE)?
Linezolid and streptogramins (quinupristin/dalfopristin) "<img
src=""7596.png"">" Microbiology antimicrobials duplicate treatment-of-highly-
resistant-bacteria
Name two antibiotics that can be used against multidrug-resistant P aeruginosa and
Acinetobacter baumannii. Polymyxins B and E (colistin) "<img src=""7596.png"">"
Microbiology antimicrobials duplicate treatment-of-highly-resistant-bacteria
What antifungal drug class works by inhibiting ergosterol synthesis? Azoles
(clotrimazole, fluconazole, itraconazole, ketoconazole, miconazole, and
voriconazole) "<img src=""7597.png"">" Microbiology antifungal-therapy
Amphotericin is used to treat which specific fungal infections? Serious systemic
mycoses such as Cryptococcus, Blastomyces, Coccidioides, Histoplasma, Candida,
Mucor "<img src=""7598.png"">" Microbiology amphotericin-b antimicrobials
duplicate
Meningitis develops as a complication in a man with a systemic cryptococcal
infection. How must you change the regimen of amphotericin B? Give it
intrathecally (can be given with flucytosine) "<img src=""7598.png"">"
Microbiology amphotericin-b antimicrobials duplicate
A patient is receiving amphotericin B for cryptococcal meningitis. Which
electrolytes must be supplemented in this patient? Potassium and magnesium
(because of altered renal tubule permeability) "<img src=""7598.png"">"
Microbiology amphotericin-b antimicrobials duplicate
What are two ways to reduce the toxicity of amphotericin B?Using the liposomal
formulation of the drug and hydrating the patient to prevent nephrotoxicity "<img
src=""7598.png"">" Microbiology amphotericin-b antimicrobials duplicate
Amphotericin B is added to a fungal culture. The electrolyte content of the culture
media is noted to increase. What happened? "Amphotericin B binds ergosterol
(unique to fungi) and forms membrane pores (""tears"" holes), allowing leakage of
electrolytes" "<img src=""7598.png"">" Microbiology amphotericin-b
A man takes an antifungal drug that causes fever, chills, hypotension, and
arrhythmias. Supplementation of which electrolytes is necessary? K+ and Mg2+,
because of altered renal tubule permeability (this is amphotericine
[amphoterrible]) "<img src=""7598.png"">" Microbiology amphotericin-b
IV phlebitis develops in a patient being treated for cryptococcal meningitis. Which
antifungal agent is the most likely cause? Amphotericin B "<img
src=""7598.png"">" Microbiology amphotericin-b antimicrobials duplicate
Which antifungal agent acts similarly to amphotericin B but is only available in
topical formulations because of systemic toxicity? Nystatin (same mechanism as
amphotericin B) "<img src=""7599.png"">" Microbiology antimicrobials
duplicate nystatin
A woman is found to have vaginal candidiasis. Which topical antifungal may you
prescribe? Topical nystatin "<img src=""7599.png"">" Microbiology
antimicrobials duplicate nystatin
An infant has a diaper rash that you determine is a fungal infection. You prescribe
a topical medication. What is its mechanism of action? It forms membrane pores
on fungi, allowing electrolytes to leak (this is topical nystatin) "<img
src=""7599.png"">" Microbiology antimicrobials duplicate nystatin
An HIV-positive man contracts oral candidiasis (thrush). What medication do you
prescribe? Nystatin (swish and swallow) "<img src=""7599.png"">" Microbiology
antimicrobials duplicate nystatin
With which drug is flucytosine frequently paired to treat systemic fungal
infections? Amphotericin B (especially in cryptococcal meningitis) "<img
src=""7600.png"">" Microbiology antimicrobials duplicate flucytosine
What is the mechanism of action of flucytosine? Inhibition of DNA and RNA
synthesis; converted to 5-fluorouracil by cytosine deaminase "<img
What is the most serious side effect of flucytosine? Bone marrow suppression "<img
Name six specific agents that are azoles. Clotrimazole, fluconazole, itraconazole,
ketoconazole, miconazole, voriconazole "<img src=""7601.png"">" Microbiology
antimicrobials azoles duplicate
What is the mechanism of action of azoles? They inhibit fungal synthesis of
sterols (ergosterol) by preventing P-450 enzymes from converting lanosterol to
ergosterol "<img src=""7601.png"">" Microbiology antimicrobials azoles
duplicate
Generally speaking, what is the indication for treatment or prophylaxis with
azoles? For local and less serious systemic mycoses "<img src=""7601.png"">"
Microbiology antimicrobials azoles duplicate
A physician wishes to prevent cryptococcal meningitis and candidal infections (any
type) in an AIDS patient. Which azole does she choose? Fluconazole "<img
src=""7601.png"">" Microbiology antimicrobials azoles duplicate
Your patient has a fungal infection that may be Blastomyces, Coccidioides, or
Histoplasma. Which azole is the best choice? Itraconazole "<img
src=""7601.png"">" Microbiology antimicrobials azoles duplicate
What two azoles are commonly used to treat topical fungal infections? Clotrimazole
and miconazole "<img src=""7601.png"">" Microbiology antimicrobials azoles
duplicate
How do azoles influence cytochrome P450 function? They inhibit cytochrome P-450
"<img src=""7601.png"">" Microbiology antimicrobials azoles duplicate
Gynecomastia develops in a male patient being treated for systemic mycoses. By way
of which mechanism did this likely occur? Inhibition of testosterone synthesis by
ketoconazole "<img src=""7601.png"">" Microbiology antimicrobials azoles
duplicate
A patient is found to have onychomycosis. Which antifungal agent is primarily used
to treat dermatophytoses? Terbinafine "<img src=""7602.png"">" Microbiology
antimicrobials duplicate terbinafine
A patient treated for onychomycosis complains of GI upset, headache, and taste
disturbance; he also has abnormal LFTs. Most likely cause? Terbinafine "<img
src=""7602.png"">" Microbiology antimicrobials duplicate terbinafine
Name three echinocandins. Anidulafungin, caspofungin, and micafungin "<img
src=""7603.png"">" Microbiology antimicrobials duplicate echinocandins
A patient's aspergillosis worsens and is now invasive. Which class of antifungal
agents is the best option? Echinocandins (anidulafungin, caspofungin,
micafungin) "<img src=""7603.png"">" Microbiology antimicrobials duplicate
echinocandins
A patient being treated for candidiasis experiences GI upset and skin flushing.
What is the most likely cause? An echinocandin (symptoms caused by the release
of histamine) "<img src=""7603.png"">" Microbiology antimicrobials
duplicate echinocandins
What is the mechanism of action of griseofulvin? Inhibition of microtubule
function, thereby disrupting mitosis "<img src=""7604.png"">" Microbiology
antimicrobials duplicate griseofulvin
Your attending mentions an antifungal agent deposited in keratin-containing tissue,
making it strong against dermatophytes. What is it? Griseofulvin "<img
src=""7604.png"">" Microbiology antimicrobials duplicate griseofulvin
You read about an antifungal agent that acts by interfering with mitotic spindles.
For which infections is this drug used? Oral therapy for superficial infections
(griseofulvin), dermatophytoses (tinea, ringworm) "<img src=""7604.png"">"
Microbiology antimicrobials duplicate griseofulvin
A patient with atrial fibrillation taking warfarin uses griseofulvin for ringworm
and has an embolic stroke. What is the most likely cause? Griseofulvin-induced
increases in cytochrome P-450 activity and warfarin metabolism that rendered the
warfarin level subtherapeutic "<img src=""7604.png"">" Microbiology
A pregnant woman exhibits tinea corporis. What do you need to remember when
considering the antifungal griseofulvin? It is teratogenic and hence
contraindicated in pregnancy "<img src=""7604.png"">" Microbiology
A patient being treated for tinea corporis complains of headache and confusion.
What is the most likely cause? Griseofulvin side effect "<img
src=""7604.png"">" Microbiology antimicrobials duplicate griseofulvin
How does griseofulvin influence cancer risk? It is carcinogenic, so cancer risk
is increased "<img src=""7604.png"">" Microbiology antimicrobials
duplicate griseofulvin
A patient is found to have toxoplasmosis. What is the antiprotozoal agent of
choice? Pyrimethamine "<img src=""7605.png"">" Microbiology
antimicrobials antiprotozoan-therapy duplicate
A patient is found to have Trypanosoma brucei infection. What are the antiprotozoal
agents of choice? Suramin, melarsoprol "<img src=""7605.png"">" Microbiology
A patient is found to have acute Chagas disease. What is the antiprotozoal agent of
choice? Nifurtimox "<img src=""7605.png"">" Microbiology antimicrobials
antiprotozoan-therapy duplicate
A patient is found to have leishmaniasis. What is the antiprotozoal agent of
choice? Sodium stibogluconate "<img src=""7605.png"">" Microbiology
A patient is given permethrin to treat scabies. What is its mechanism of action?
Blockage of sodium channels, thereby causing neurotoxicity "<img
src=""7606.png"">" Microbiology anti-mite/louse-therapy antimicrobials
duplicate
A patient is given malathion to treat lice. What is its mechanism of action?
Inhibition of acetylcholinesterase "<img src=""7606.png"">" Microbiology
anti-mite/louse-therapy antimicrobials duplicate
A patient is given lindane to treat scabies. What is its mechanism of action?
Blockage of GABA channels, thereby causing neurotoxicity "<img
duplicate
A patient is found to have a Sarcoptes scabei infestation. Which anti-mite/louse
agents may be used? Treat PML (Pesty Mites and Lice) with PML (Permethrin,
Malathion, Lindane), because they NAG you (Na, AChE, GABA blockade). "<img
duplicate
A patient is found to have a Pthirus infestation. Which anti-mite/louse agents may
be used? Treat PML (Pesty Mites and Lice) with PML (Permethrin, Malathion,
Lindane), because they NAG you (Na, AChE, GABA blockade). "<img src=""7606.png"">"
Microbiology anti-mite/louse-therapy antimicrobials duplicate
A patient is found to have a Pediculus infestation. Which anti-mite/louse agents
can be used? Treat PML (Pesty Mites and Lice) with PML (Permethrin, Malathion,
Lindane), because they NAG you (Na, AChE, GABA blockade) "<img src=""7606.png"">"
Microbiology anti-mite/louse-therapy antimicrobials duplicate
A patient is found to have Plasmodium falciparum malaria. Why is chloroquine a poor
choice? Because the resistance rate is too high "<img src=""7607.png"">"
Microbiology antimicrobials chloroquine duplicate
A patient is fount to have non-Falciparum malaria. What is the mechanism of action
of the drug of choice? Blocks detoxification of heme into hemozoin, thereby
causing accumulation of heme, which is toxic to Plasmodium (this is chloroquine)
"<img src=""7607.png"">" Microbiology antimicrobials chloroquine
duplicate
A patient is found to have Plasmodium falciparum malaria and doesn't respond to
chloroquine therapy. Why? Resistance by way of membrane pumps that decrease
intracellular concentrations of the drug "<img src=""7607.png"">" Microbiology
antimicrobials chloroquine duplicate
A patient is found to have Plasmodium falciparum malaria. Which medications may you
prescribe to him? Artemether/lumefantrine or atovaquone/proguanil "<img
src=""7607.png"">" Microbiology antimicrobials chloroquine duplicate
A patient is quickly admitted after a diagnosis of life-threatening malaria. Which
anti-malarial agents should be started? Quinidine (in the US; quinine elsewhere)
or artesunate "<img src=""7607.png"">" Microbiology antimicrobials
chloroquine duplicate
An African American patient being treated for malaria complains of pruritus. What
is the most likely cause? Chloroquine-induced pruritus (especially in dark-
skinned individuals) "<img src=""7607.png"">" Microbiology antimicrobials
chloroquine duplicate
A patient being treated for malaria complains of a sudden bilateral vision change.
What is the most likely cause? Chloroquine-induced retinopathy (patients must
be educated on the risk, especially with long-term use) "<img src=""7607.png"">"
Microbiology antimicrobials chloroquine duplicate
A patient is found to have a helminthic infestation. Which antihelminthic agents
may be used? Mebendazole, ivermectin, pyrantel pamoate, diethylcarbamazine,
praziquantel "<img src=""7608.png"">" Microbiology antihelminthic-therapy
A patient is given mebendazole for a helminthic infestation. What is the drug's
mechanism of action? Inhibition of microtubules "<img src=""7608.png"">"
Microbiology antihelminthic-therapy antimicrobials duplicate
Name two viral DNA polymerase inhibitors and the two viruses that they are commonly
used to treat. Cidofovir and foscarnet, for HSV and CMV "<img src=""7609.png"">"
Microbiology antimicrobials antiviral-therapy duplicate
A patient has an HSV infection that does not respond to acyclovir. What drug should
you try to treat with next? Cidofovir or foscarnet, viral DNA polymerase
inhibitors that are useful for acyclovir-resistant HSV "<img src=""7609.png"">"
Adding a guanine nucleotide synthesis blocker to virus-infected cells blocks virion
assembly. What two viruses may be infecting these cells? RSV or HCV (the drug is
likely ribavirin) "<img src=""7609.png"">" Microbiology antimicrobials
antiviral-therapy duplicate
A drug is added to influenza-infected cells. Formed viral progeny become trapped
within the cell. This is due to which enzyme's inhibition? Neuraminidase (the drug
is likely a neuraminidase inhibitor, such as oseltamivir or zanamivir) "<img
src=""7609.png"">" Microbiology antimicrobials antiviral-therapy duplicate
A novel HIV antiviral drug prevents viral penetration. This ultimately blocks which
genetic process immediately downstream of penetration? Uncoating and reverse
transcription (the drug is the fusion inhibitor enfuvirtide) "<img
A drug is added to a CD4+ cell culture; HIV virions are noted to no longer attach
to the cell surface afterwards. Which drug was added? Maraviroc, a fusion inhibitor
that prevents attachment "<img src=""7609.png"">" Microbiology
antimicrobials antiviral-therapy duplicate
Name some nucleoside reverse transcriptase inhibitors (NRTIs) used to treat HIV.
Abacavir (ABC), didanosine (ddI), emtricitabine (FTC), lamivudine (3TC),
stavudine (d4T), tenofovir (TDF), zidovudine (ZDV, formerly AZT) "<img
Name some non-nucleoside reverse transcriptase inhibitors (NNRTIs) used to treat
HIV. Delavirdine, efavirenz, nevirapine "<img src=""7609.png"">" Microbiology
A drug is added to HIV-infected cells. This quickly stops the transcription of HIV
DNA by cell machinery. What category of drug was added? An integrase inhibitor
(eg, dolutegravir, elvitegravir), which blocks viral DNA integration into the host
cell genome for transcription "<img src=""7609.png"">" Microbiology
Name some protease inhibitors used to treat HIV. Atazanavir, darunavir,
fosamprenavir, indinavir, lopinavir, ritonavir, saquinavir "<img src=""7609.png"">"
A drug added to HIV-infected cells stops viral particle budding and release. HIV
proteins remain within cells. Which drug class was added? A protease inhibitor,
which blocks proteolytic processing "<img src=""7609.png"">" Microbiology
A man with a hepatitis virus infection receives a protein synthesis inhibitor. Via
what receptor does this medication likely act? The PKR receptor (the drug in
question is likely interferon-, useful for HBV and HCV) "<img src=""7609.png"">"
A drug that blocks viral uncoating is applied to influenza-infected cells. No
effect is observed. Why might this be? Drugs that inhibit influenza virus
uncoating (eg, amantadine, rimantadine) have high rates of resistance and are thus
rarely used "<img src=""7609.png"">" Microbiology antimicrobials antiviral-
therapy duplicate
A patient receives acyclovir for a viral infection that is later found to be CMV.
Should he be switched to a different drug? Yes, as acyclovir is not effective
against CMV; use ganciclovir or a viral DNA polymerase inhibitor instead "<img
What is the mechanism of action of acyclovir, and against which viruses is it an
effective agent? It is a guanosine analog, effective against HSV and VZV "<img
Influenza is suspected in a patient. Against which types of influenza are
oseltamivir and zanamivir effective? Both influenza A and B (for treatment and
prevention) "<img src=""7610.png"">" Microbiology antimicrobials duplicate
oseltamivir,-zanamivir
A patient is found to have HSV encephalitis. Which antiviral agents may be
considered for treatment? Acyclovir, valacyclovir "<img src=""7611.png"">"
Microbiology acyclovir,-famciclovir,-valacyclovir antimicrobials duplicate
Why does acyclovir interfere with viral DNA synthesis and not human DNA synthesis?
It requires monophosphorylation by the thymidine kinase of HSV/VZV and is
hence inactive in uninfected cells "<img src=""7611.png"">" Microbiology
acyclovir,-famciclovir,-valacyclovir antimicrobials duplicate
Acyclovir and valacyclovir are good therapeutic options against HSV and VZV.
Against which common herpesviruses are they not? EBV (weak activity), CMV (no
activity) "<img src=""7611.png"">" Microbiology acyclovir,-famciclovir,-
valacyclovir antimicrobials duplicate
A patient presents with both mucocutaneous and genital HSV lesions. Which antiviral
agents may be considered for treatment? Acyclovir, valacyclovir "<img
src=""7611.png"">" Microbiology acyclovir,-famciclovir,-valacyclovir
One of your patients has latent HSV, the other latent VZV. Which one, if either,
should receive acyclovir? Neither (acyclovir is ineffective against latent HSV
and VZV) "<img src=""7611.png"">" Microbiology acyclovir,-famciclovir,-
A patient is found to have genital HSV lesions and requests valacyclovir instead of
acyclovir. What advantage does the former drug have? Valacyclovir is a prodrug of
acyclovir but has better oral bioavailability "<img src=""7611.png"">"
Microbiology acyclovir,-famciclovir,-valacyclovir antimicrobials duplicate
A patient is found to have shingles (herpes zoster). Which antiviral agent is the
best therapeutic option? Famciclovir (more effective against zoster than
acyclovir/valacyclovir) "<img src=""7611.png"">" Microbiology acyclovir,-
famciclovir,-valacyclovir antimicrobials duplicate
A patient being treated for genital HSV lesions goes into acute renal failure after
a workout. What is the most likely cause? Acyclovir-induced acute renal failure (if
the patient was not adequately hydrated) "<img src=""7611.png"">" Microbiology
Obstructive crystalline nephropathy develops in a patient being treated for genital
HSV lesions. What is the most likely cause? Acyclovir-induced obstructive
crystalline nephropathy (if the patient was not adequately hydrated) "<img
src=""7611.png"">" Microbiology acyclovir,-famciclovir,-valacyclovir
A patient being treated for genital HSV lesions fails to improve. How does
resistance to this antiviral agent manifest? Mutated viral thymidine kinase
"<img src=""7611.png"">" Microbiology acyclovir,-famciclovir,-
A patient presents with painful genital lesions. A Tzanck smear is positive. What
makes the drug prescribed selective for infected cells? Acyclovir, famciclovir,
and valacyclovir require phosphorylation by viral thymidine kinase before they can
be incorporated into viral DNA "<img src=""7611.png"">" Microbiology
A patient is being treated for CMV with a drug that causes viral DNA chain
termination. What changes in the drug must occur for it to work? Formation of 5-
monophosphate by CMV kinase and a triphosphate by cellular kinases "<img
src=""7612.png"">" Microbiology antimicrobials duplicate ganciclovir
A patient is found to have CMV retinitis. What is the first-choice antiviral agent?
Ganciclovir "<img src=""7612.png"">" Microbiology antimicrobials
duplicate ganciclovir
A patient is found to have CMV retinitis, and you opt to use a prodrug of
ganciclovir. What advantage does the former have? Better oral bioavailability
(this is valganciclovir) "<img src=""7612.png"">" Microbiology
antimicrobials duplicate ganciclovir
A patient being treated for CMV retinitis exhibits leukopenia, neutropenia, and
thrombocytopenia. What is the most likely cause? Ganciclovir-induced bone
marrow suppression "<img src=""7612.png"">" Microbiology antimicrobials
A patient being treated for CMV exhibits acute crystal nephropathy. What is the
most likely cause? Ganciclovir "<img src=""7612.png"">" Microbiology
antimicrobials duplicate ganciclovir
Which antiviral drug is more toxic to host enzymes, acyclovir or ganciclovir?
Ganciclovir "<img src=""7612.png"">" Microbiology antimicrobials
A patient being treated for CMV infection doesn't respond to treatment. How may
resistance have developed? Mutated viral kinase enzymes (vs ganciclovir) "<img
src=""7612.png"">" Microbiology antimicrobials duplicate ganciclovir
A patient with CMV is found to have mutated viral kinases. Why is foscarnet still a
good treatment option? Does not require activation by viral kinases "<img
src=""7613.png"">" Microbiology antimicrobials duplicate foscarnet
An immunocompromised patient now has CMV retinitis that does not respond to
ganciclovir. Which antiviral agent should be considered? Foscarnet "<img
A patient being treated for HSV is believed to have a strain resistant to
acyclovir. Which pyrophosphate analog should be considered?Foscarnet "<img
A patient being treated for CMV retinitis suddenly has a seizure after becoming
hypokalemic. What is the most likely cause? Foscarnet-induced electrolyte
abnormalities "<img src=""7613.png"">" Microbiology antimicrobials
duplicate foscarnet
Acute tubular necrosis develops in a patient being treated for CMV retinitis. What
is the most likely cause? Foscarnet-induced nephropathy "<img src=""7613.png"">"
Microbiology antimicrobials duplicate foscarnet
In what mutation does enzyme allow cytomegalovirus or herpes simplex virus to
resist foscarnet treatment? DNA polymerase "<img src=""7613.png"">"
Microbiology antimicrobials duplicate foscarnet
A man's herpes simplex virus infection does not respond to acyclovir, and he does
not want foscarnet. What drug do you try next? Cidofovir (given for acyclovir-
resistant HSV) "<img src=""7614.png"">" Microbiology antimicrobials
cidofovir duplicate
An antiviral with a long half-life is given for HSV that did not respond to
acyclovir. Does it require phosphorylation by viral kinase?No (this is cidofovir,
which does not require activation by a viral kinase) "<img src=""7614.png"">"
Microbiology antimicrobials cidofovir duplicate
An HIV-positive man has cytomegalovirus retinitis and is treated with cidofovir.
How can the associated nephrotoxicity risk be reduced? Coadministration with
probenecid and IV saline "<img src=""7614.png"">" Microbiology
antimicrobials cidofovir duplicate
A patient found to have HIV asks when he should begin HAART. What do you tell him?
It's often started when HIV is diagnosed, viral load is high (CD4+ count <
500, or the patient presents with an AIDS-defining illness "<img src=""7615.png"">"
Microbiology antimicrobials duplicate hiv-therapy
Pancytopenia develops in a patient being treated for HIV. Which drugs should be
considered to counteract this finding? Granulocyte colonystimulating factor (G-
CSF) and erythropoietin (EPO) "<img src=""7615.png"">" Microbiology
antimicrobials duplicate hiv-therapy
A patient found to have HIV asks about HAART. What is the recommended combination
of HAART classes in HIV therapy? 2 NRTIs and 1 of the following: NNRTI, protease
inhibitor, or integrase inhibitor "<img src=""7615.png"">" Microbiology
A patient being treated for HIV is receiving an NRTI that does not require
intracellular phosphorylation. What drug is this? Tenofovir, which is already a
nucleoTide; all other NRTIs require phosphorylation "<img src=""7615.png"">"
A pregnant woman is found to be HIV-positive and asks about drug options to help
protect her child. Which NRTI may be used? Zidovudine (ZDV) can decrease the
risk of vertical transmission and is also used for general prophylaxis "<img
src=""7615.png"">" Microbiology antimicrobials duplicate hiv-therapy
A patient being treated for HIV experiences paresthesia and decreased sensation in
both legs. What is the most likely cause? NRTI-induced peripheral neuropathy "<img
Anion gap metabolic acidosis develops in a patient being treated for HIV. What is
the most likely cause? NRTI-induced lactic acidosis (nucleoside agents only) "<img
A patient being treated for HIV has upper abdominal pain radiating to the back and
Grey Turner's sign. What's the most likely cause? Didanosine-induced
pancreatitis "<img src=""7615.png"">" Microbiology antimicrobials
duplicate hiv-therapy
A patient being treated for HIV exhibits a rash and increased values on liver
function tests. What is the most likely cause? NNRTI-induced rash and
hepatotoxicity (common to all NNRTIs) "<img src=""7615.png"">" Microbiology
A patient being treated for HIV presents to your office complaining of vivid
dreams. What other side effects may be caused by this drug?CNS symptoms (this is
efavirenz) "<img src=""7615.png"">" Microbiology antimicrobials duplicate
hiv-therapy
An HIV-positive woman is found to be pregnant. She asks whether her HAART will harm
her child. Which NNRTIs should not be given to her? Delavirdine and efavirenz,
both of which are contraindicated in pregnancy "<img src=""7615.png"">"
What is the HIV-1 protease from the pol gene responsible for? Cleaving the
polypeptides made from the HIV mRNA into functional components "<img
A man with HIV finds that taking his HIV protease inhibitor makes some other meds
more potent. Inhibition of which enzyme is to blame? Cytochrome P-450 inhibition
by ritonavir "<img src=""7615.png"">" Microbiology antimicrobials
A patient taking meds for HIV has nausea, diarrhea, lipodystrophy, and episodes of
hyperglycemia. Which class of drug is she likely taking? An HIV protease
inhibitor "<img src=""7615.png"">" Microbiology antimicrobials duplicate
hiv-therapy
A patient in renal failure needs to start HAART for newly diagnosed HIV. Which
protease inhibitor should not be given to him? Indinavir, which can cause
nephropathy and hematuria "<img src=""7615.png"">" Microbiology
A patient with active TB is found to be HIV positive. How must his treatment
regimen for either diagnosis be modified? Rifampin is contraindicated with HIV
protease inhibitors because of potent CYP/UGT induction (and decreased protease
inhibitor levels) "<img src=""7615.png"">" Microbiology antimicrobials
A patient being treated for HIV is noted to have an increased creatine kinase
level. What is the most likely cause? Raltegravir-induced kinase increase "<img
A patient with newly diagnosed multiple sclerosis inquires about interferons. What
are they? Glycoproteins made by virally infected cells that have a wide range of
antiviral and antitumoral properties "<img src=""7616.png"">" Microbiology
antimicrobials duplicate interferons
Which class of interferon may be used to treat chronic hepatitis C, hepatitis B,
and Kaposi sarcoma? IFN- "<img src=""7616.png"">" Microbiology
antimicrobials duplicate interferons
Which class of interferons may be used against hairy cell leukemia, condyloma
acuminata, renal cell carcinoma, and malignant melanoma? IFN- "<img
src=""7616.png"">" Microbiology antimicrobials duplicate interferons
A patient recently found to have multiple sclerosis asks about interferon therapy.
Which class of interferons may be used for her condition? IFN- "<img
A patient recently found to have chronic granulomatous disease asks about
interferon therapy. Which class of interferons may be used?IFN- "<img
A patient begins taking a glycoprotein for her multiple sclerosis. For which major
side effects should she be monitored? Neutropenia and myopathy (common to all
interferons) "<img src=""7616.png"">" Microbiology antimicrobials
duplicate interferons
A patient is found to have chronic HCV and started on ribavirin. What is the
mechanism of action of this drug? Competitive inhibition of inosine monophosphate
dehydrogenase, thereby inhibiting synthesis of guanine nucleotides "<img
src=""7617.png"">" Microbiology antimicrobials duplicate hepatitis-c-therapy
A young woman has RSV and chronic hepatitis C. What are the side effects of the
antiviral agent that can be used to treat both disorders? Hemolytic anemia and
severe teratogenicity (this is ribavirin) "<img src=""7617.png"">" Microbiology
antimicrobials duplicate hepatitis-c-therapy
A pregnant woman with chronic HCV asks whether antiviral therapy will affect her
child. Which anti-HCV agent should not be given? Ribavirin (because of its
severe teratogenicity) "<img src=""7617.png"">" Microbiology antimicrobials
duplicate hepatitis-c-therapy
A patient being treated for HCV has simeprevir added to her treatment regimen. What
is the mechanism of action of this drug? Inhibition of HCV protease, thereby
preventing viral replication "<img src=""7617.png"">" Microbiology
antimicrobials duplicate hepatitis-c-therapy
A patient is found to have HCV, and therapy with a an HCV protease inhibitor is
started. May it be taken as monotherapy? No (this is simeprevir, which ideally is
combined with ribavirin and peginterferon alfa) "<img src=""7617.png"">"
Microbiology antimicrobials duplicate hepatitis-c-therapy
A patient being treated for chronic HCV has photosensitivity and a rash on her
trunk. What is the most likely cause? Simeprevir-induced photosensitivity and
rash "<img src=""7617.png"">" Microbiology antimicrobials duplicate
hepatitis-c-therapy
A patient with HCV is given a drug that inhibits HCV RNAdependent RNA polymerase.
What is this drug? Sofosbuvir (causes viral RNA chain termination) "<img
src=""7617.png"">" Microbiology antimicrobials duplicate hepatitis-c-therapy
A patient treated for HCV has fatigue, headaches, and nausea. Which drugs are
likely being taken in combination with the causative agent?Ribavirin
peginterferon alfa is commonly given along with sofosbuvir for chronic HCV
infection (sofosbuvir is not used as a monotherapy) "<img src=""7617.png"">"
Microbiology antimicrobials duplicate hepatitis-c-therapy
Which infection-control technique involves the use of pressurized steam at
temperatures > 120C and may be sporicidal? Autoclaving "<img src=""7618.png"">"
Microbiology antimicrobials duplicate infection-control-techniques
What is the difference between disinfection and sterilization? Disinfection
reduces the number of pathogenic organisms to a safe level; sterilization
inactivates biologic entities that multiply "<img src=""7618.png"">"
Microbiology antimicrobials duplicate infection-control-techniques
List two infection-control agents that are not sporicidal and work by denaturing
proteins and disrupting cell membranes. Alcohols and chlorhexidine "<img
src=""7618.png"">" Microbiology antimicrobials duplicate infection-control-
techniques
How does hydrogen peroxide work in disinfection/infection control? Is it
sporicidal? Induction of free radical oxidation; it is sporicidal "<img
src=""7618.png"">" Microbiology antimicrobials duplicate infection-control-
techniques
How do iodine and iodophors work to control infection? Halogenation of
proteins, RNA, and DNA; may be sporicidal "<img src=""7618.png"">" Microbiology
antimicrobials duplicate infection-control-techniques
A neonate has severe jaundice and no startle (Moro) reflex. Which antibiotic might
his mother have been taking during pregnancy? A sulfonamide, which can cause
kernicterus in the newborn "<img src=""7619.png"">" Microbiology
antimicrobials antimicrobials-to-avoid-in-pregnancy duplicate
A woman is prescribed an antibiotic during pregnancy. Her baby has hearing
abnormalities as a result. Which class of drug was it? An aminoglycoside "<img
src=""7619.png"">" Microbiology antimicrobials antimicrobials-to-avoid-in-
pregnancy duplicate
A woman is given an antibiotic during pregnancy, and her baby has cartilage damage
as a result. Which class of drug was it? A fluoroquinolone "<img src=""7619.png"">"
Microbiology antimicrobials antimicrobials-to-avoid-in-pregnancy duplicate
A pregnant woman is prescribed clarithromycin for an infection. Is this a wise
choice? No, because clarithromycin is embryotoxic "<img src=""7619.png"">"
Microbiology antimicrobials antimicrobials-to-avoid-in-pregnancy duplicate
Which class of antibiotics should pregnant women avoid if they do not want a baby
with discolored teeth and abnormal bone growth? Tetracyclines "<img
pregnancy duplicate
Citing concern for her baby, a pregnant woman refuses to take either ribavirin or
griseofulvin. Are her worries justified? Yes, both are teratogenic "<img
pregnancy duplicate
What antibiotic classically causes gray baby syndrome if taken by a pregnant woman?
Chloramphenicol "<img src=""7619.png"">" Microbiology antimicrobials
antimicrobials-to-avoid-in-pregnancy duplicate
What drugs are included in the following mnemonic for antibiotics to avoid in
pregnancy: SAFe Children Take Really Good Care? Sulfonamides, Aminoglycosides,
Fluoroquinolones, Clarithromycin, Tetracyclines, Ribavirin, Griseofulvin,
Chloramphenicol "<img src=""7619.png"">" Microbiology antimicrobials
antimicrobials-to-avoid-in-pregnancy duplicate
A patient presents to your office with painful cervical lymphadenopathy. He asks
you what lymph nodes do. What are their 3 functions? Nonspecific filtration of
lymph by macrophages, B-cell and T-cell storage, and activation of immune responses
"<img src=""7620.png"">" duplicate immunology lymph-node lymphoid-
structures
A patient is diagnosed with pharyngitis. To which lymph node cluster would drainage
flow? Cervical (head and neck) "<img src=""7621.png"">" duplicate
immunology lymph-drainage lymphoid-structures
A patient is diagnosed with bilateral multilobar pneumonia. To which lymph node
cluster would drainage flow? Hilar (lungs) "<img src=""7621.png"">"
duplicate immunology lymph-drainage lymphoid-structures
Into which lymph node cluster do the trachea and esophagus drain? Mediastinal
"<img src=""7621.png"">" duplicate immunology lymph-drainage lymphoid-
structures
Into which lymph node cluster do the upper limbs and skin above the umbilicus
drain? Axillary "<img src=""7621.png"">" duplicate immunology lymph-
drainage lymphoid-structures
A patient is diagnosed with breast cancer and you aim to determine the severity.
Which lymph node cluster should be examined? Axillary "<img src=""7621.png"">"
Into which lymph node cluster do the stomach, liver, spleen, and pancreas drain?
Celiac "<img src=""7621.png"">" duplicate immunology lymph-drainage
lymphoid-structures
The bladder, middle third of the vagina, the prostate, and the lower rectum drain
into which group of lymph nodes? Internal Iliac "<img src=""7621.png"">"
Into which lymph node cluster do the lower duodenum, jejunum, and ileum drain?
Superior mesenteric "<img src=""7621.png"">" duplicate immunology
lymph-drainage lymphoid-structures
A patient is diagnosed with colon cancer at the transverse colon. To which lymph
node cluster would drainage flow? Superior mesenteric (colon to splenic flexure)
"<img src=""7621.png"">" duplicate immunology lymph-drainage lymphoid-
structures
A patient is diagnosed with colon cancer at the sigmoid colon. To which lymph node
cluster would drainage flow? Inferior mesenteric (colon from splenic flexure to
upper rectum) "<img src=""7621.png"">" duplicate immunology lymph-drainage
lymphoid-structures
A patient is diagnosed with colorectal carcinoma at the upper rectum. To which
lymph node cluster would drainage flow? Inferior mesenteric (colon from splenic
flexure to the upper rectum) "<img src=""7621.png"">" duplicate immunology
Into which lymph node cluster do the testes, ovaries, and uterus drain? Para-
aortic "<img src=""7621.png"">" duplicate immunology lymph-drainage
lymphoid-structures
A patient is diagnosed with pyelonephritis. To which lymph node cluster would
drainage flow? Para-aortic "<img src=""7621.png"">" duplicate immunology
Where does the thoracic duct drain? The junction of the left internal jugular vein
and the left subclavian vein "<img src=""7621.png"">" duplicate immunology
A screening CT scan of a man's abdomen and pelvis shows enlarged superficial
inguinal lymph nodes. Is a genital exam warranted? Yes, superficial inguinal
lymph nodes drain the scrotum; the anal canal and subumbilical skin should also be
examined "<img src=""7621.png"">" duplicate immunology lymph-drainage
lymphoid-structures
A diabetic pt develops cellulitis w/an abscess at the dorsolateral area of his
right foot. Which lymph node cluster will collect drainage?Popliteal (posterior
calf and dorsolateral foot) "<img src=""7621.png"">" duplicate immunology
On endoscopy, a patient is noted to have a duodenal tumor. Is screening of more
than one lymph node territory required? Yes, because celiac lymph nodes drain
upper duodenum and superior mesenteric lymph nodes drain lower duodenum, both
should be investigated "<img src=""7621.png"">" duplicate immunology lymph-
A patient has thrombosis at the junction of the left subclavian and internal
jugular veins. Where do you expect to see edema? Entire body except for right
half above the diaphragm (drained by right lymphatic duct), as flow in the thoracic
duct is likely impaired "<img src=""7621.png"">" duplicate immunology lymph-
A patient is diagnosed with right-sided mastitis. Which major lymphatic duct will
carry drainage into venous circulation? Right lymphatic duct (drains the right
side of the body above the diaphragm) "<img src=""7621.png"">" duplicate
immunology lymph-drainage lymphoid-structures
A CBC reveals thrombocytosis & lymphocytosis. Peripheral blood smear reveals
nuclear remnants & target cells. What is the most likely cause? Splenectomy;
nuclear remnants are likely Howell-Jolly bodies; thrombocytosis & lymphocytosis are
due to loss of sequestration at the spleen "<img src=""7622.png"">"
duplicate immunology lymphoid-structures sinusoids-of-spleen
A patient with sickle cell disease becomes susceptible to meningococcemia. What is
the most likely cause? Splenic dysfunction; decreased IgM, complement activation,
& C3b opsonization lead to increased susceptibility to encapsulated organisms
"<img src=""7622.png"">" duplicate immunology lymphoid-structures
sinusoids-of-spleen
A patient undergoes splenectomy after an MVA and subsequent splenic laceration. To
which bacteria is this patient most susceptible? Encapsulated organisms (refer
to Please SHiNE my SKiS mnemonic) "<img src=""7622.png"">" duplicate
immunology lymphoid-structures sinusoids-of-spleen
A patient is diagnosed with Streptococcus pneumoniae. Which immune cells in the
spleen work to remove streptococci? Macrophages near the sinusoids of the spleen
eliminate encapsulated bacteria "<img src=""7622.png"">" duplicate
immunology lymphoid-structures sinusoids-of-spleen
A baby w/DiGeorge syndrome has a hypoplastic encapsulated organ in the anterior
superior mediastinum. Which pharyngeal pouch is affected? Third (the thymus,
primary site of T-cell differentiation and maturation) "<img src=""7623.png"">"
duplicate immunology lymphoid-structures thymus
The thymus is the site of T-cell differentiation and maturation. Which histologic
section of the organ holds immature T cells? Cortex (dense with immature T
cells) "<img src=""7623.png"">" duplicate immunology lymphoid-structures
thymus
The thymus is the site of T-cell maturation. Which histologic section of the organ
holds mature T cells and epithelial reticular cells? Medulla (pale with Hassall
corpuscles containing epithelial reticular cells) "<img src=""7623.png"">"
duplicate immunology lymphoid-structures thymus
An infant is found to have a hypoplastic thymus. Which immunodeficiencies are the
most likely causes? DiGeorge syndrome and severe combined immunodeficiency
(SCID) "<img src=""7623.png"">" duplicate immunology lymphoid-structures
thymus
A 35-y/o woman has progressive weakness of the ocular muscles and extremities,
especially at night. Which mediastinal organ may be enlarged? Thymus (can be
enlarged in myasthenia gravis) "<img src=""7623.png"">" duplicate
immunology lymphoid-structures thymus
A boy's innate immune system responds to a virus. Which receptors are activated,
and which molecular patterns do they look for? TLRs are activated and they look
for viral pathogen-associated molecular patterns (PAMPs), such as ssRNA "<img
src=""7624.png"">" duplicate immunology innate-vs-adaptive-immunity
lymphocytes
A girl's innate immune system responds to bacteria. Which receptors are activated,
and which molecular patterns do they look for? TLRs are activated and look for
bacterial pathogen-associated molecular patterns (PAMPs) such as LPS and flagellin
"<img src=""7624.png"">" duplicate immunology innate-vs-adaptive-
immunity lymphocytes
Which six components/cell types are responsible for innate immunity? Neutrophils,
macrophages, dendritic cells, natural killer cells (lymphoid origin), monocytes,
and the complement system "<img src=""7624.png"">" duplicate immunology
innate-vs-adaptive-immunity lymphocytes
What is the benefit of the germline-encoded target antigen recognition system by
the innate immune system? It allows innate immunity to be both fast and
nonspecific; however, resistance is heritable "<img src=""7624.png"">"
duplicate immunology innate-vs-adaptive-immunity lymphocytes
On the first day of a viral infection, a girl has increased neutrophils and fever
due to what property of this arm of the immune response? The innate immune system
is responsible for the initial response to a pathogen; its cell receptors are
germline encoded and nonspecific "<img src=""7624.png"">" duplicate
immunology innate-vs-adaptive-immunity lymphocytes
What are the three components responsible for adaptive immunity? T cells, B cells,
and circulating antibodies "<img src=""7624.png"">" duplicate immunology
innate-vs-adaptive-immunity lymphocytes
How does the adaptive immune response differ during first and second exposures to
an antigen? Adaptive immunity is slow to develop on first exposure but fast on any
subsequent exposures "<img src=""7624.png"">" duplicate immunology innate-
vs-adaptive-immunity lymphocytes
Through which mechanism does the adaptive immune system develop a highly specific
defense against pathogens? V(D)J recombination during lymphocyte development
results in variation; hence, microbial resistance is not inherited "<img
lymphocytes
A patient has elevated lysozymes, complement, CRP, and defensins. Which arm of the
immune system is likely involved? Innate immunity "<img src=""7624.png"">"
duplicate immunology innate-vs-adaptive-immunity lymphocytes
A man who had childhood measles develops no disease despite repeat exposure. How
does this response work? Memory B and T cells are activated in the adaptive
immune response and release immunoglobulins targeting the measles virus "<img
lymphocytes
How does the innate immune system recognize pathogens? By toll-like receptors
(pattern recognition receptors that recognize pathogen-associated molecular
patterns [PAMPs]) "<img src=""7624.png"">" duplicate immunology innate-vs-
adaptive-immunity lymphocytes
A boy has an infection. What are the physical barriers to infection employed by the
innate immune system? Epithelial tight junctions and mucus "<img
lymphocytes
On which cells is major histocompatibility complex (MHC) I expressed? All
nucleated cells; not RBCs "<img src=""7625.png"">" duplicate immunology
lymphocytes mhc-i-and-ii
Which three HLA loci encode for MHC class I in all nucleated cells? HLA-A, HLA-
B, HLA-C (MHC-I = 1 letter) "<img src=""7625.png"">" duplicate immunology
lymphocytes mhc-i-and-ii
A patient has a viral infection that has resolved after symptomatic Tx. Which MHC
class was involved in this patient's immune response? MHC I (presents endogenously
synthesized antigens [eg, viral, cytosolic proteins] to CD8+ cytotoxic T cells)
"<img src=""7625.png"">" duplicate immunology lymphocytes mhc-i-and-ii
All MHC receptors are encoded by HLA genes and act to present antigens to T cells.
To which receptor do all MHC molecules bind on T cells? T-cell receptors (TCRs)
(CD4 or CD8 involvement depends on MHC class.) "<img src=""7625.png"">"
duplicate immunology lymphocytes mhc-i-and-ii
Which cells express major histocompatibility complex (MHC) II? Antigen-presenting
cells "<img src=""7625.png"">" duplicate immunology lymphocytes mhc-i-and-ii
Which three HLA loci encode for MHC class II in antigen-presenting cells? HLA-
DP, HLA-DQ, HLA-DR (MHC-II = 2 letters) "<img src=""7625.png"">" duplicate
immunology lymphocytes mhc-i-and-ii
A patient has bilateral S pneumoniae pneumonia. Which MHC class is involved in this
patient's immune response? MHC II (presents exogenously synthesized antigens
[eg, bacterial proteins] to CD4+ helper T cells) "<img src=""7625.png"">"
duplicate immunology lymphocytes mhc-i-and-ii
A patient has a viral infection. How are viral antigens loaded onto the MHC
molecules associated with this patient's immune response? Viral antigens are
loaded onto MHC I in the RER via TAP (transporter associated with antigen
processing) "<img src=""7625.png"">" duplicate immunology lymphocytes mhc-i-
and-ii
A patient has a bacterial infection. How are bacterial antigens loaded onto MHC
molecules associated with this patient's immune response? Bacterial antigens are
loaded onto MHC II following the release of an invariant chain in an acidified
endosome "<img src=""7625.png"">" duplicate immunology lymphocytes mhc-i-
and-ii
A patient is found to have HLA subtype B27. Which four autoimmune-related
conditions are associated with this? Psoriasis, Ankylosing spondylitis,
Inflammatory bowel disease, and Reactive arthritis (formerly Reiter syndrome)
(PAIR) "<img src=""7626.png"">" duplicate hla-subtypes-associated-with-
diseases immunology lymphocytes
A woman has tachycardia, irritability, and exophthalmos. Which HLA subtype is
associated with her disease? HLA-DR3 (Graves disease) "<img src=""7626.png"">"
duplicate hla-subtypes-associated-with-diseases immunology lymphocytes
A man has HLA subtype DR2. Which four autoimmune-related conditions are associated
with this? Multiple sclerosis, hay fever, systemic lupus erythematosus, and
Goodpasture syndrome "<img src=""7626.png"">" duplicate hla-subtypes-
associated-with-diseases immunology lymphocytes
A 7-y/o has polyuria, polydipsia, and high blood sugar. Which two HLA subtypes are
associated with this? HLA-DR3 and HLA-DR4 (type 1 diabetes mellitus) "<img
src=""7626.png"">" duplicate hla-subtypes-associated-with-diseases immunology
lymphocytes
A man has symmetric swollen metacarpal joints and elbow nodules. Which HLA subtype
is associated with his disease? "HLA-DR4 (rheumatoid arthritis; there are 4
walls in a rheum"" [room])" "<img src=""7626.png"">" duplicate hla-subtypes-
associated-with-diseases immunology lymphocytes
A patient is found to have megaloblastic anemia secondary to a lack of intrinsic
factor. Which HLA subtype is associated with her disease? HLA-DR5 (pernicious
anemia leading to vitamin B12 deficiency) "<img src=""7626.png"">" duplicate
hla-subtypes-associated-with-diseases immunology lymphocytes
A patient has weight gain, fatigue, cold intolerance, and anti-TPO antibodies.
Which HLA subtypes are associated with this disease? HLA-DR3 and HLADR5 (Hashimoto
thyroiditis) "<img src=""7626.png"">" duplicate hla-subtypes-associated-
with-diseases immunology lymphocytes
A patient has bronze skin, a hematocrit of 60%, and high iron levels. Which HLA
subtype is associated with his disease? HLA-A3 (hemochromatosis) "<img
lymphocytes
A man with chronic diarrhea becomes asymptomatic after starting a gluten-free diet.
Which HLA subtypes are associated with this disease? HLA-DQ2/DQ8 (celiac disease;
I ate [8] too [2] much gluten at Dairy Queen.) "<img src=""7626.png"">"
A woman has a malar rash, joint pain, proteinuria, and anemia. Which HLA subtypes
are associated with her autoimmune disease? HLA-DR2, HLA-DR3 (SLE) "<img
lymphocytes
A patient presents with diffuse joint pain, rashes of unclear etiology, and
negative serum studies. Which HLA subtype should be considered? HLA-B27 (The
patient may have one of the seronegative arthropathies.) "<img src=""7626.png"">"
Which four cytokines enhance activity of natural killer cells? IL-2, IL-12, IFN-
, and IFN- "<img src=""7627.png"">" duplicate immunology lymphocytes
natural-killer-cells
Natural killer cells induce apoptosis of virally infected cells and tumor cells.
Which two enzymes are integral to this process? Perforin (perforates the target
cell membrane) and granzymes "<img src=""7627.png"">" duplicate immunology
lymphocytes natural-killer-cells
Which two signals induce natural killer cell killing activity? Exposure to
nonspecific activation signal on infected target cells and absence of MHC I on
target cell surface "<img src=""7627.png"">" duplicate immunology
lymphocytes natural-killer-cells
What is the only lymphocyte member of the innate immune system? Natural killer
cell "<img src=""7627.png"">" duplicate immunology lymphocytes natural-
killer-cells
Natural killer cells are able to kill via antibody-dependent cell-mediated
cytotoxicity. Which receptors are involved in this phenomenon? NK cell is
activated when CD16 binds to the Fc region of bound immunoglobulin "<img
src=""7627.png"">" duplicate immunology lymphocytes natural-killer-cells
Which types of organ graft rejections are mediated by T cells? Acute and chronic
cellular organ rejection "<img src=""7628.png"">" duplicate immunology
lymphocytes major-functions-of-b-and-t-cells
What are the primary functions of CD4+ helper T cells? Induction of B cells to
make antibodies and cytokines to activate macrophages "<img src=""7628.png"">"
duplicate immunology lymphocytes major-functions-of-b-and-t-cells
What are the primary functions of CD8+ cytotoxic T cells? Killing virus-infected
cells "<img src=""7628.png"">" duplicate immunology lymphocytes major-
functions-of-b-and-t-cells
Name three functions of B cells. Antigen recognition (somatic hypermutation),
antibody production (plasma cell differentiation, Ig secretion), and immunologic
memory "<img src=""7628.png"">" duplicate immunology lymphocytes major-
functions-of-b-and-t-cells
What is the rule of 8 regarding T cells and MHC molecule binding? MHC II CD4
= 8; MHC I CD8 = 8 "<img src=""7628.png"">" duplicate immunology
lymphocytes major-functions-of-b-and-t-cells
A man has significant induration 2 days after an intradermal injection of
tuberculin from a PPD test. Which immune cells mediate this? T cells (type IV
delayed cell-mediated hypersensitivity) "<img src=""7628.png"">" duplicate
immunology lymphocytes major-functions-of-b-and-t-cells
Certain vaccines involve memory B cells. What is the purpose of memory B cells?
To accelerate the future immune response to antigens "<img src=""7628.png"">"
duplicate immunology lymphocytes major-functions-of-b-and-t-cells
Which transcription factor involved with negative T-cell selection is deficient in
a patient with autoimmune polyendocrine syndrome-1? Autoimmune regulator (AIRE)
"<img src=""7629.png"">" differentiation-of-t-cells duplicate immunology
lymphocytes
Differentiating T cells undergo positive selection at the thymic cortex. How does
this selection occur? Identification of T cells that recognize self-MHCs on
cortical epithelial cells via the TCR "<img src=""7629.png"">"
differentiation-of-t-cells duplicate immunology lymphocytes
Differentiating T cells undergo negative selection at the thymic medulla. How does
this selection occur? Identification of T cells that have a high affinity for
self-antigens; these T cells undergo apoptosis "<img src=""7629.png"">"
To a culture of T-cell precursors, you add an inhibitor that blocks CD8 expression.
Will these cells be able to stave off viruses? Not likely, as CD8+ cytotoxic T
cells are required to kill virus-infected cells "<img src=""7629.png"">"
Th1 cells activate macrophages and cytotoxic T cells. Which cytokine allows them to
do so? IFN- "<img src=""7630.png"">" duplicate helper-t-cells immunology
lymphocytes
Which cytokines work to activate Th1 cells? IFN-&3947; and IL-12 "<img
src=""7630.png"">" duplicate helper-t-cells immunology lymphocytes
A pt with a viral infection recovers after 1 week of symptoms. Which immune cells
activated by Th1 cells helped in the pt's immune response? Cytotoxic T cells (Th1
also activated macrophages) "<img src=""7630.png"">" duplicate helper-t-cells
immunology lymphocytes
Th2 cells activate eosinophils and B cells. Which cytokines allow them to do so?
IL-4, IL-5, IL-10, and IL-13 "<img src=""7630.png"">" duplicate helper-
t-cells immunology lymphocytes
Th1 and Th2 cells often act to inhibit each other. Which cytokine from Th1 cells
inhibits Th2-cell action? IFN- "<img src=""7630.png"">" duplicate helper-
t-cells immunology lymphocytes
Th1 and Th2 cells often act to inhibit each other. Which cytokines from Th2 cells
inhibit Th1-cell action? IL-4 and IL-10 "<img src=""7630.png"">"
duplicate helper-t-cells immunology lymphocytes
The macrophage-lymphocyte interaction causes T-cell differentiation to Th1 cells.
Which cytokine released by macrophages & APCs causes this? IL-12 "<img
Which cytokine works to activate Th2 cells? IL-4 "<img src=""7630.png"">"
duplicate helper-t-cells immunology lymphocytes
A patient has a parasitic infection. An experimental recombinant form of IL-4 is
administered. Will this benefit the patient? In theory, yes, as IL-4 stimulates
Th2 cells, which in turn recruit eosinophils for parasite defense "<img
Cytotoxic T cells work to kill virus-infected, neoplastic, and donor graft cells.
Which cell-mediated process allows them to do so? Apoptosis "<img
src=""7631.png"">" cytotoxic-t-cells duplicate immunology lymphocytes
Cytotoxic T cells induce apoptosis in their targets following the release of
cytotoxic granules. What do these granules contain? Perforin and granzyme B "<img
src=""7631.png"">" cytotoxic-t-cells duplicate immunology lymphocytes
Cancer cells are noted to have nonfunctional apoptosis mechanisms. Will promoting a
CD8+ cell response be of value here? Unlikely, as cytotoxic T cells work by
inducing apoptosis; if apoptosis mechanisms are nonfunctional, they will be unable
to kill tumor cells "<img src=""7631.png"">" cytotoxic-t-cells duplicate
How do regulatory T cells maintain specific immune tolerance? They suppress CD4+
and CD8+ T-cell effector responses "<img src=""7632.png"">" duplicate
immunology lymphocytes regulatory-t-cells
A T cell expresses CD3, CD4, and CD25 and the transcription factor FOXP3. What type
of T cell is it? Regulatory T cell "<img src=""7632.png"">" duplicate
immunology lymphocytes regulatory-t-cells
Regulatory T cells secrete anti-inflammatory cytokines to regulate immune function.
Which cytokines are involved in this process? IL-10 and TGF- "<img
src=""7632.png"">" duplicate immunology lymphocytes regulatory-t-cells
Naive T-cell activation begins with APCs after they have processed an antigen. Name
three APCs that guide T-cell activation. Macrophages, B cells, and dendritic cells
"<img src=""7633.png"">" duplicate immunology lymphocytes t--and-b-cell-
activation
In the process of B-cell activation, what occurs immediately following B cell
receptormediated endocytosis of an antigen? Antigen presentation on MHC II
toward the TCR on T helper cells. "<img src=""7633.png"">" duplicate
immunology lymphocytes t--and-b-cell-activation
What are the four Cs to remember about the Fc fragment of an antibody? Constant
region, Carboxy terminal, Complement binding, Carbohydrate side chains "<img
src=""7634.png"">" antibody-structure-and-function duplicate immunology
lymphocytes
A boy develops hives when he eats a peanut butter sandwich. The activation of which
two cell types is most likely to blame? Mast cells and basophils due to IgE
activation and cross-linking "<img src=""7635.png"">" duplicate
immunoglobulin-isotypes immunology lymphocytes
What is the function of IgD, and where can it be found? Function is unclear; it
can be found on the surface of many B cells and in serum "<img src=""7635.png"">"
duplicate immunoglobulin-isotypes immunology lymphocytes
Which antibody isotype has the lowest serum concentrations?IgE "<img
src=""7635.png"">" duplicate immunoglobulin-isotypes immunology lymphocytes
Mast cells play a major role in immediate, type I hypersensitivity. Which antibody
isotype facilitates this phenomenon? IgE (cross-links when exposed to an
allergen and mediates the release of inflammatory mediators) "<img
A patient has a worm infection. In a tissue biopsy, eosinophils are seen attacking
the worms due to signaling by which immunoglobulin? IgE "<img src=""7635.png"">"
A pregnant woman in her third trimester is exposed to a virus. Which immunoglobulin
provides the fetus with passive immunity? Maternal IgG, which crosses the placenta
(IgM does not.) "<img src=""7635.png"">" duplicate immunoglobulin-isotypes
Mature B cells express IgM and IgD on their surfaces. With gene rearrangement and
CD40L action, which isotypes can the B cell switch to? IgA, IgG, and IgE "<img
Which immunoglobulin isotypes are expressed on the surface of mature B cells prior
to class switching? IgM and IgD "<img src=""7635.png"">" duplicate
immunoglobulin-isotypes immunology lymphocytes
Which antibody isotype is the main antibody in the secondary, delayed response to
an antigen? IgG "<img src=""7635.png"">" duplicate immunoglobulin-isotypes
Which antibody isotype is the most abundant in serum? IgG "<img src=""7635.png"">"
A patient's circulating IgG levels are found to be low following serum studies.
What are the main functions of IgG? Fixation of complement; opsonization of
bacteria; neutralization of bacterial toxins and viruses; passive immunity in
infants via placenta "<img src=""7635.png"">" duplicate immunoglobulin-
isotypes immunology lymphocytes
A patient asks how the body is able to protect all of its mucous membranes from
invading pathogens. Which antibody isotype achieves this? IgA "<img
A patient has a bacterial infection. Which antibody isotype is produced in the
primary, immediate response to an antigen? IgM "<img src=""7635.png"">"
Both IgM and IgG are involved with the fixation of complement proteins. Which of
the two is known to cross the placenta? IgG "<img src=""7635.png"">"
Thymus-independent antigens are weakly or entirely nonimmunogenic. Why is this the
case? They lack a peptide component; therefore MHC-mediated presentation to T cells
cannot occur "<img src=""7636.png"">" antigen-type-and-memory duplicate
Thymus-dependent antigens are often strongly immunogenic as they contain a peptide
component. Which two immunologic phenomena do they cause? Class switching and
immunologic memory formation due to resultant B and T helper cell interaction
"<img src=""7636.png"">" antigen-type-and-memory duplicate immunology
lymphocytes
Name two examples of a thymus-independent antigen. Lipopolysaccharides from the
cell envelope of gram-negative bacteria and polysaccharide capsular antigens "<img
src=""7636.png"">" antigen-type-and-memory duplicate immunology lymphocytes
A booster shot for the pneumococcal polysaccharide vaccine is often given after 5
years. What type of antigen is in this vaccine? A thymus-independent antigen, which
lacks a peptide component and is not presented to T cells by the MHC "<img
src=""7636.png"">" antigen-type-and-memory duplicate immunology lymphocytes
A baby receives a diphtheria vaccine containing a protein component. What kind of
antigen is in the vaccine? Thymus-dependent antigen "<img src=""7636.png"">"
antigen-type-and-memory duplicate immunology lymphocytes
A rheumatoid arthritis pt has bacteremia. Your attending asks how C-reactive
protein levels change. In which organ is this made? All acute-phase reactants are
made in the liver in both acute and chronic inflammatory states "<img
src=""7637.png"">" acute-phase-reactants duplicate immune-responses immunology
A patient with sepsis has increased levels of acute-phase reactants. Which cytokine
is known to induce APR production in the liver? IL-6 "<img src=""7637.png"">"
acute-phase-reactants duplicate immune-responses immunology
A patient develops an acute infection. Which acute-phase reactants are upregulated?
Which are downregulated? Upregulated: amyloid A, C-reactive protein, ferritin,
fibrinogen, hepcidin; downregulated: albumin, transferrin "<img src=""7637.png"">"
Lab work for a patient with sepsis reveals elevated levels of C-reactive protein.
How does CRP aid in this patient's immune response? Strong opsonin, thereby fixes
complement and facilitates phagocytosis "<img src=""7637.png"">" acute-phase-
reactants duplicate immune-responses immunology
A patient recovering from sepsis is having routine C-reactive protein levels
checked. How does CRP help us clinically? The presence of CRP is a sign of ongoing
inflammation "<img src=""7637.png"">" acute-phase-reactants duplicate
immune-responses immunology
A patient is diagnosed w/anemia of chronic disease and has elevated ferritin
levels. How does ferritin function as an acute-phase reactant? It binds and
sequesters iron to inhibit microbial iron scavenging "<img src=""7637.png"">"
A woman with severe lupus has chronic anemia. What is the function of the acute-
phase reactant that is most likely responsible? Hepcidin upregulates and prevents
release of ferritin-bound iron, resulting in anemia of chronic disease with
inflammation "<img src=""7637.png"">" acute-phase-reactants duplicate
A patient with SLE inquires about her risk of developing amyloidosis. Which acute-
phase reactant can increase this risk? Serum amyloid A (Prolonged elevation can
result in amyloidosis.) "<img src=""7637.png"">" acute-phase-reactants
duplicate immune-responses immunology
A patient with rheumatoid arthritis has elevated ESR. Which acute-phase reactant is
expected to show correlated levels? Fibrinogen "<img src=""7637.png"">" acute-
phase-reactants duplicate immune-responses immunology
Which coagulation factor increases during inflammation, aids in endothelial repair,
and correlates with erythrocyte sedimentation rate? Fibrinogen "<img
A patient with severe sepsis is found to have decreased levels of albumin while in
the ICU. Why is this acute-phase reactant downregulated? To conserve amino acids
for the positive reactants "<img src=""7637.png"">" acute-phase-reactants
A patient w/rheumatoid arthritis is found to have decreased levels of a protein
that sequesters iron in macrophages. What is this protein? Transferrin "<img
A patient has hives, diaphoresis, and SOB after eating peanuts. Which complement
proteins are involved in this patient's condition? C3a, C4a, C5aanaphylaxis
"<img src=""7638.png"">" complement duplicate immune-responses
immunology
A diabetic patient develops cellulitis. Which complement protein is responsible for
attracting neutrophils to the site of infection? C5a "<img src=""7638.png"">"
complement duplicate immune-responses immunology
In the complement system, the membrane attack complex mediates cytolysis. Which
complement proteins combine to form the MAC? C5b, C6, C7, C8, and C9 "<img
src=""7638.png"">" complement duplicate immune-responses immunology
A patient does not develop disease after being exposed to bacteria. What are the
two primary opsonins used to defend against bacteria? C3b and IgG "<img
src=""7638.png"">" complement duplicate immune-responses immunology
Complement proteins are always found circulating in plasma. What two components
prevent complement activation on self cells? Decay-accelerating factor (DAF,
also known as CD55) and C1 esterase inhibitor "<img src=""7638.png"">"
complement duplicate immune-responses immunology
A patient is diagnosed with C3 deficiency. To which hypersensitivity reaction is
this patient more susceptible? Type III (Remember that C3b helps clear immune
complexes.) "<img src=""7639.png"">" complement-disorders duplicate immune-
responses immunology
A patient with no PMH or meds presents w/angioedema. His father had the same. Which
complement disorder should be considered as the cause? C1 esterase inhibitor
deficiency (Unregulated activation of kallikrein causes elevated bradykinin levels
and subsequent angioedema.) "<img src=""7639.png"">" complement-disorders
A patient has hypertension with a history of C1 esterase inhibitor deficiency.
Which class of antihypertensive is contraindicated? ACE inhibitors (due to the
elevated levels of bradykinin) "<img src=""7639.png"">" complement-
disorders duplicate immune-responses immunology
A patient has severe, recurrent pyogenic sinus/respiratory tract infections. Which
complement disorder should be considered as the cause? C3 deficiency "<img
src=""7639.png"">" complement-disorders duplicate immune-responses immunology
A patient has a history of recurrent Neisseria bacteremia. Which complement
disorder should be considered as the cause? C5-C9 deficiency (Remember that C5-
C9 is required to form the MAC.) "<img src=""7639.png"">" complement-
disorders duplicate immune-responses immunology
A pt has bloody urine in the morning. A peripheral blood smear reveals lysed RBCs.
Which complement system regulatory protein is deficient? DAF, a GPI-anchored
enzyme that protects self cells from MAC-mediated cytolysis (This is paroxysmal
nocturnal hemoglobinuria.) "<img src=""7639.png"">" complement-disorders
What is the function of IL-1? It causes fever/acute inflammation, activates
endothelium to express adhesion molecules, and induces chemokine secretion to
recruit WBCs "<img src=""7640.png"">" duplicate immune-responses
immunology important-cytokines
What is another name for IL-1? Osteoclast-activating factor "<img
src=""7640.png"">" duplicate immune-responses immunology important-cytokines
Which type of cells secrete IL-1? Macrophages "<img src=""7640.png"">"
duplicate immune-responses immunology important-cytokines
What is the function of IL-2? It stimulates growth of helper T cells, cytotoxic T
cells, regulatory T cells, and NK cells "<img src=""7640.png"">" duplicate
immune-responses immunology important-cytokines
Which type of cells secrete IL-2? All T cells "<img src=""7640.png"">"
What is the function of IL-3? Growth and differentiation of stem cells in the bone
marrow; functions similar to GM-CSF "<img src=""7640.png"">" duplicate immune-
responses immunology important-cytokines
Which type of cells secrete IL-3? All T cells "<img src=""7640.png"">"
What is the function of IL-4? It induces differentiation of T cells into Th2 cells
and promotes growth of B cells "<img src=""7640.png"">" duplicate immune-
Which type of cells secrete IL-4? Th2 cells "<img src=""7640.png"">"
T helper cells are involved in B-cell class switching. Which cytokine from Th2
cells enhances switching to IgE and IgG? IL-4 "<img src=""7640.png"">"
What is the function of IL-5? Promotes differentiation of B cells and stimulates
growth/differentiation of eosinophils "<img src=""7640.png"">" duplicate
Which type of cells secrete IL-5? Th2 cells "<img src=""7640.png"">"
T helper cells are involved in B-cell class switching. Which cytokine from Th2
cells enhances switching to IgA? IL-5 "<img src=""7640.png"">" duplicate
What is the function of IL-6? Causes fever and stimulates production of acute-phase
reactants "<img src=""7640.png"">" duplicate immune-responses immunology
important-cytokines
What is the function of IL-8? Chemotaxis for neutrophils (Clean up on aisle 8)
"<img src=""7640.png"">" duplicate immune-responses immunology
important-cytokines
What is the function of IL-10? Modulates inflammation with TGF-; decreases
MHC class II/Th1 cytokine expression; inhibits active macrophages/dendritic cells
important-cytokines
Which type of cells secrete IL-10? Th2 cells and regulatory T cells "<img
What is the function of IL-12? Induces differentiation of T cells into Th1
cells; activates NK cells; induces interferon- secretion "<img src=""7640.png"">"
What is the function of interferon-? Triggers macrophages to kill; induces NK
cells to kill virus-infected cells; promotes MHC expression/antigen presentation by
all cells "<img src=""7640.png"">" duplicate immune-responses immunology
important-cytokines
Which type of cells secrete interferon-? Th1 cells and NK cells "<img
Macrophages secrete IL-12 to activate and recruit Th1 and NK cells. Which cytokine
do Th1 and NK cells secrete in response? Interferon- "<img src=""7640.png"">"
What is the function of TNF-? Mediates septic shock; activates endothelium;
causes WBC recruitment and vascular leak "<img src=""7640.png"">" duplicate
A patient with cancer is found to be weak and has muscle wasting. Which cytokine is
known to promote this process? TNF- (promotes cachexia in malignancy) "<img
Which type of cells secrete TNF-? Macrophages "<img src=""7640.png"">"
Summarize the stimulatory effects of IL-1, IL-2, IL-3, IL-4, IL-5, and IL-6. IL-1 =
fever (Hot), IL-2 = T cells, IL-3 = bone marrow, IL-4 = IgE, IL-5 = IgA, IL-6 =
aKute-phase proteins (Hot T-bone stEAK) "<img src=""7640.png"">" duplicate
A woman has a fever. Which two cytokines secreted by macrophages likely contribute
to this? IL-1 and IL-6 "<img src=""7640.png"">" duplicate immune-
TGF- has the same attenuating effect on the immune system as which cytokine?
IL-10 (TGF- and IL-10 both attenuate the immune response.)"<img
Iron is an essential nutrient for microbes. Which protein found in secretory fluids
& neutrophils counteracts microbes via iron chelation? Lactoferrin "<img
src=""7641.png"">" duplicate immune-responses immunology respiratory-burst-
(oxidative-burst)
Name two cells that utilize NADPH for an oxidative burst. Neutrophils and
macrophages "<img src=""7641.png"">" duplicate immune-responses immunology
respiratory-burst-(oxidative-burst)
Why do cells like neutrophils and macrophages have high concentrations of NADPH
oxidase? To aid in the immune response by rapidly releasing reactive oxygen
species that kill bacteria "<img src=""7641.png"">" duplicate immune-
responses immunology respiratory-burst-(oxidative-burst)
A patient w/bronchitis produces green sputum when he coughs. Which pigment in
neutrophils is giving this patient's sputum its color? Myeloperoxidase (blue-
green, heme-containing pigment) "<img src=""7641.png"">" duplicate immune-
responses immunology respiratory-burst-(oxidative-burst)
P aeruginosa cultures can kill off competing bacteria with high levels of reactive
oxygen species. How does this occur? These bacteria produce pyocyanin, which
can generate reactive oxygen species to kill competing microbes "<img
src=""7641.png"">" duplicate immune-responses immunology respiratory-burst-
(oxidative-burst)
Interferon- and - are both part of the innate immune system. Against which type
of viruses are they effective? RNA and DNA "<img src=""7642.png"">"
duplicate immune-responses immunology interferon-a-and--
Which cells produce and secrete interferon- and -? Virally infected cells "<img
src=""7642.png"">" duplicate immune-responses immunology interferon-a-and--
A patient has influenza. How do interferons interfere with viruses? "When a
virus infects a cell ""primed"" by interferons, enzymes selectively degrade viral
nucleic acids/proteins; apoptosis ultimately occurs" "<img src=""7642.png"">"
duplicate immune-responses immunology interferon-a-and--
What is the end point in the action of interferons- and -? Priming of
uninfected cells, resulting in apoptosis and hindering viral amplification "<img
src=""7642.png"">" duplicate immune-responses immunology interferon-a-and--
Immune cells have unique cell surface proteins to aid the immune response. Which
cell surface proteins are common to all T cells? TCR, CD3 (with TCR), CD28,
and CXCR4/CCR5 "<img src=""7643.png"">" cell-surface-proteins duplicate
cell surface proteins are unique to T helper cells? CD4 and CD40L "<img
src=""7643.png"">" cell-surface-proteins duplicate immune-responses immunology
cell surface proteins are unique to cytotoxic T cells? CD8 "<img
cell surface proteins are unique to regulatory T cells? CD4 and CD25 "<img
cell surface proteins are common to all B cells? Immunoglobulin (Ig), CD19,
CD20, CD21, CD40, MHC II, B7 "<img src=""7643.png"">" cell-surface-proteins
Patients with Epstein-Barr virus (EBV) are more likely to have a B-cell lymphoma.
How does EBV enter B cells to make this possible? On B cells, EBV binds to CD21
(You can drink Beer at the Bar when you're 21.) "<img src=""7643.png"">" cell-
surface-proteins duplicate immune-responses immunology
cell surface proteins are found on macrophages? MHC II, B7, CD40, CD14, receptors
for Fc and C3b "<img src=""7643.png"">" cell-surface-proteins duplicate
Which cell surface proteins are found on NK cells and bind to the Fc region of IgG?
CD16 "<img src=""7643.png"">" cell-surface-proteins duplicate immune-
cell surface proteins are unique to NK cells? CD56 (a unique marker for NK cells)
"<img src=""7643.png"">" cell-surface-proteins duplicate immune-
Do all human cells have major histocompatibility complex I (MHC I)? No, mature
RBCs do not; all nucleated cells do "<img src=""7643.png"">" cell-surface-
proteins duplicate immune-responses immunology
Which cell surface protein on B cells binds antigen? Immunoglobulin "<img
A woman receives a bone marrow transplant. Afterward, detection of which cell
surface protein indicates a successful procedure? CD34 (indicative of
hematopoietic stem cells) "<img src=""7643.png"">" cell-surface-proteins
Describe the process of T-cell anergy. Self-reactive T cells become nonreactive
when they do not receive a costimulatory signal on exposure to an antigen "<img
src=""7644.png"">" anergy duplicate immune-responses immunology
Anergy is best described as a mechanism for what process? Self-tolerance "<img
src=""7644.png"">" anergy duplicate immune-responses immunology
S pyogenes and S aureus are known to produce superantigens. Cross-linking of which
immune receptors causes massive cytokine release? The region of TCR and MHC
II on APCs; this results in widespread CD4+ T-cell activation and cytokine storm
"<img src=""7645.png"">" duplicate effects-of-bacterial-toxins immune-
Superantigens can cause massive release of cytokines by cross-linking immune
receptors. Which two bacteria are known for superantigens? Streptococcus pyogenes
and Staphylococcus aureus "<img src=""7645.png"">" duplicate effects-of-
bacterial-toxins immune-responses immunology
Gram-negative bacteria release endotoxins/LPS that directly stimulate macrophages.
Which receptors mediate this process? CD14 (TLR4) "<img src=""7645.png"">"
duplicate effects-of-bacterial-toxins immune-responses immunology
Macrophages respond directly to bacterial endotoxins/LPS and do not require T
helper cells. How do the causative bacteria gram stain? Gram-negative "<img
src=""7645.png"">" duplicate effects-of-bacterial-toxins immune-responses
immunology
In what way does Salmonella exhibit antigenic variation? Via two flagellar
variants "<img src=""7646.png"">" antigenic-variation duplicate immune-
In what way does Neisseria gonorrhoeae exhibit antigenic variation? Via pilus
protein variation "<img src=""7646.png"">" antigenic-variation duplicate
In what way does Borrelia recurrentis exhibit antigenic variation? Via
relapsing fever "<img src=""7646.png"">" antigenic-variation duplicate
A patient is diagnosed with influenza. In what way does this disease demonstrate
antigenic variation? Via RNA segment reassortment (major = shift; minor = drift)
"<img src=""7646.png"">" antigenic-variation duplicate immune-responses
immunology
Which type of parasite is able to exhibit classic antigenic variation? Trypanosomes
"<img src=""7646.png"">" antigenic-variation duplicate immune-responses
immunology
Which viruses are able to exhibit classic antigenic variation? Influenza, HIV,
HCV "<img src=""7646.png"">" antigenic-variation duplicate immune-responses
immunology
A patient is bitten by a raccoon & receives anti-rabies virus antibodies. In which
5 diseases are preformed antibodies given after exposure? Tetanus toxin, Botulinum
toxin, HBV, Varicella, and Rabies virus (To Be Healed Very Rapidly) "<img
src=""7647.png"">" duplicate immune-responses immunology passive-vs-active-
immunity
A mother asks about the immune function of her newborn. You explain that her baby
is protected via passive immunity. How is this acquired? By obtaining preformed
antibodies (in this case, through breast milk) "<img src=""7647.png"">"
duplicate immune-responses immunology passive-vs-active-immunity
A patient agrees to vaccination and asks how this will help his immunity. What is
the duration of the type of immunity vaccines offer? Long (due to memory formation
following antigen exposure) "<img src=""7647.png"">" duplicate immune-
responses immunology passive-vs-active-immunity
What are two immunizations that use both passive and active immunity on viral
exposure? Hepatitis B and rabies "<img src=""7647.png"">" duplicate immune-
responses immunology passive-vs-active-immunity
Live attenuated vaccines often induce strong, lifelong immunity. What type of
active immune response is triggered? Cellular and humeral response; pathogen
lacks pathogenicity but retains capacity for growth in the host "<img
src=""7648.png"">" duplicate immune-responses immunology vaccination
A patient agrees to receive an MMR vaccine. What are the cons of this type of
vaccination? Because it is a live attenuated vaccine, the microorganism may
revert to a virulent form "<img src=""7648.png"">" duplicate immune-
responses immunology vaccination
A patient newly diagnosed with HIV asks about his condition. What is the only live
attenuated vaccine that can be given to this patient? MMR "<img src=""7648.png"">"
duplicate immune-responses immunology vaccination
Inactivated/killed vaccines are often safer, but weaker, than live ones. What type
of active immune response is triggered? Humoral response only; the pathogen is
inactivated by heat/chemicals; surface antigens drive immune response "<img
A patient agrees to receive the annual, injected influenza vaccine. What are the
cons of this type of vaccination? Because it is an inactivated vaccine, the
immune response is weaker, and booster shots are often required "<img
Name four examples of killed vaccines. Rabies, Influenza (injected), Polio
(Salk), and hepatitis A (RIP Always) "<img src=""7648.png"">" duplicate
immune-responses immunology vaccination
Name eight examples of live vaccines. Measles, mumps, rubella, polio (Sabin),
influenza (intranasal), varicella, BCG, and yellow fever "<img src=""7648.png"">"
duplicate immune-responses immunology vaccination
Which type of vaccine (live or inactivated) is generally contraindicated in
pregnant patients or patients with immune deficiencies? Live attenuated vaccine
vaccination
A patient has fever, joint pain, lymphadenopathy, hives, & proteinuria. He started
a new drug 7 days ago. Type of hypersensitivity reaction? Serum sickness (type III
hypersensitivity reaction) "<img src=""7649.png"">" duplicate
hypersensitivity-types immune-responses immunology
Guillain-Barr syndrome is what type of hypersensitivity reaction? Type II
"<img src=""7649.png"">" duplicate hypersensitivity-types immune-
What is the most common cause of serum sickness? Drugs acting as haptens that
cause subsequent immune complex formation "<img src=""7649.png"">" duplicate
Polyarteritis nodosa is what type of hypersensitivity reaction? Type III "<img
src=""7649.png"">" duplicate hypersensitivity-types immune-responses
immunology
Contact dermatitis (eg, poison ivy, nickel allergy) is what type of
hypersensitivity reaction? Type IV "<img src=""7649.png"">" duplicate
The Coombs' tests both gauge the presence of type II hypersensitivity. Describe the
difference between a direct and indirect Coombs' test. Direct test detects
antibodies that are already bound to RBCs; indirect test detects serum antibodies
that can bind to RBCs "<img src=""7649.png"">" duplicate hypersensitivity-
types immune-responses immunology
Poststreptococcal glomerulonephritis is what type of hypersensitivity reaction?
Type III "<img src=""7649.png"">" duplicate hypersensitivity-types
A mother is Rh- and her infant may be Rh+. Which Coombs' test should each of them
receive? Test the mother for Rh+ antibodies w/the indirect Coombs' test and test
the infant for antibodies adhered to RBCs w/the direct Coombs' test "<img
immunology
Idiopathic thrombocytopenic purpura is what type of hypersensitivity reaction?
Type II "<img src=""7649.png"">" duplicate hypersensitivity-types
A patient has a type II hypersensitivity reaction. The complement system is
activated. How does it destroy the patient's cells? Antibody and complement lead
to formation of the membrane attack complex (MAC) (Type II is cy-2-toxic.) "<img
immunology
Myasthenia gravis is what type of hypersensitivity reaction? Type II "<img
immunology
Graft-versus-host disease is what type of hypersensitivity reaction? Type IV
Multiple sclerosis is what type of hypersensitivity reaction? Type IV "<img
immunology
Serum sickness is what type of hypersensitivity reaction? Type III "<img
immunology
Pemphigus vulgaris is what type of hypersensitivity reaction? Type II "<img
immunology
Injection of a PPD (a test for M tuberculosis) is what type of hypersensitivity
reaction? Type IV "<img src=""7649.png"">" duplicate hypersensitivity-
Pernicious anemia is what type of hypersensitivity reaction? Type II "<img
immunology
Rheumatic fever is what type of hypersensitivity reaction? Type II "<img
immunology
Erythroblastosis fetalis is what type of hypersensitivity reaction? Type II
What are the four types of hypersensitivity reactions? Anaphylactic and atopic,
Cytotoxic, Immune complex, and Delayed (ACID "<img src=""7649.png"">"
duplicate hypersensitivity-types immune-responses immunology
What is unique about the type IV hypersensitivity reaction as compared with the
other types? The response is delayed and does not involve antibodies "<img
immunology
An acute hemolytic transfusion reaction is what type of hypersensitivity reaction?
Type II "<img src=""7649.png"">" duplicate hypersensitivity-types
An anaphylactic, type I hypersensitivity reaction develops rapidly due to preformed
IgE. What drives the delayed response in anaphylaxis? Arachidonic acid metabolites
(eg, leukotrienes) "<img src=""7649.png"">" duplicate hypersensitivity-
Autoimmune hemolytic anemia is what type of hypersensitivity reaction? Type II
What is serum sickness? An immune complex disease; antibodies to foreign proteins
are made and deposited in tissues, where they fix complement and cause damage
Bullous pemphigoid is what type of hypersensitivity reaction? Type II "<img
immunology
The Arthus reaction is a local subacute antibody-mediated hypersensitivity
reaction. What are the common clinical findings of this reaction? Edema and
necrosis due to immune complex formation at the skin and subsequent complement
activation "<img src=""7649.png"">" duplicate hypersensitivity-types immune-
Allergic and atopic disorders (eg, rhinitis, hay fever, eczema, hives, asthma) are
what type of hypersensitivity reaction? Type I "<img src=""7649.png"">"
Which type of hypersensitivity does not involve antibodies?Delayed, type IV
hypersensitivity; hence, it cannot be transferred via serum"<img src=""7649.png"">"
Anaphylaxis (eg, bee sting, some food/drug allergies) is what type of
hypersensitivity reaction? Type I "<img src=""7649.png"">" duplicate
What are the 4 T's associated with type IV hypersensitivity reactions? T cells,
Transplant rejections, TB skin tests, and Touching (contact dermatitis) "<img
immunology
The Arthus reaction (eg, swelling and inflammation following tetanus vaccine) is
what type of hypersensitivity reaction? Type III "<img src=""7649.png"">"
What are the three mechanisms by which antibody deposition in a type II
hypersensitivity reaction leads to cell death or dysfunction? Opsonization
(complement/phagocytosis), complement-mediated lysis, and antibody-dependent, cell-
mediated cytotoxicity (NK cells/macrophages) "<img src=""7649.png"">"
Systemic lupus erythematosus is what type of hypersensitivity reaction? Type
III "<img src=""7649.png"">" duplicate hypersensitivity-types immune-
The Arthus reaction occurs after intradermal injection of antigen into a
presensitized patient. How do you test for this reaction? Immunofluorescence
staining "<img src=""7649.png"">" duplicate hypersensitivity-types immune-
Goodpasture syndrome is what type of hypersensitivity reaction? Type II "<img
immunology
Graves disease is what type of hypersensitivity reaction? Type II "<img
immunology
A girl wheezes and develops hives when she eats peanuts. How would you test for the
responsible hypersensitivity reaction? Use a skin test for specific IgE (This is
a type I hypersensitivity reaction.) "<img src=""7649.png"">" duplicate
A patient develops urticaria, pruritus, wheezing, and fever following blood
transfusion. What is the best treatment? The best treatment for a type I
hypersensitivity reaction to plasma proteins in transfused blood is antihistamines
"<img src=""7650.png"">" blood-transfusion-reactions duplicate immune-
A patient with IgA deficiency develops dyspnea, hypotension, and respiratory arrest
after blood transfusion. What is the most likely cause? An immune response to
IgA in donor blood; patients with IgA deficiency must receive IgA-deficient blood
to prevent this reaction "<img src=""7650.png"">" blood-transfusion-
reactions duplicate immune-responses immunology
A patient develops fever, headache, flushing, and chills after a blood transfusion.
What antibody-cell reaction is causing these symptoms? This is a febrile
nonhemolytic transfusion reaction, a type II hypersensitivity reaction due to
antibodies against donor HLA antigens/WBCs "<img src=""7650.png"">" blood-
transfusion-reactions duplicate immune-responses immunology
After a blood transfusion, a patient develops fever, hypotension, and jaundice.
What type of hypersensitivity reaction is this? Acute hemolytic transfusion
reaction (type II hypersensitivity); antibodies to donor RBC surface antigens cause
extravascular hemolysis "<img src=""7650.png"">" blood-transfusion-reactions
After a blood transfusion, a patient develops fever, hypotension, and
hemoglobinuria. What type of hypersensitivity reaction is this? Acute hemolytic
transfusion reaction (type II hypersensitivity); ABO incompatibility causes
intravascular hemolysis "<img src=""7650.png"">" blood-transfusion-reactions
Anti-ACh receptor autoantibodies are associated with which disorder? Myasthenia
gravis "<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-basement membrane autoantibodies are associated with which disorder?
Goodpasture syndrome "<img src=""7651.png"">" autoantibodies duplicate
Anticardiolipin autoantibodies and the lupus anticoagulant are associated with
which disorders? Systemic lupus erythematosus and antiphospholipid syndrome "<img
src=""7651.png"">" autoantibodies duplicate immune-responses immunology
Anticentromere autoantibodies are associated with which disorder? CREST
syndrome (limited scleroderma) "<img src=""7651.png"">" autoantibodies
Anti-desmosome (anti-desmoglein) autoantibodies are associated with which disorder?
Pemphigus vulgaris "<img src=""7651.png"">" autoantibodies duplicate
"A patient complaining of ""colorful vision"" is found to have a digoxin overdose.
Which antibody can be used to treat him?" Digoxin immune Fab "<img
Anti-dsDNA and anti-Smith autoantibodies are associated with which disorder?
Systemic lupus erythematosus "<img src=""7651.png"">" autoantibodies
Anti-glutamic acid decarboxylase (GAD-65) autoantibodies are associated with which
disorder? Diabetes mellitus type 1 "<img src=""7651.png"">"
autoantibodies duplicate immune-responses immunology
Antihemidesmosome autoantibodies are associated with which disorder? Bullous
pemphigoid "<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-histone autoantibodies are associated with which disorder? Drug-induced lupus
"<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-Jo-1, anti-SRP, and anti-Mi-2 autoantibodies are associated with which
disorders? Dermatomyositis and polymyositis "<img src=""7651.png"">"
Antinuclear antibody autoantibodies are associated with which disorder?
Systemic lupus erythematosus (nonspecific) "<img src=""7651.png"">"
Antimicrosomal and antithyroglobulin autoantibodies are associated with which
disorder? Hashimoto thyroiditis "<img src=""7651.png"">" autoantibodies
Antimitochondrial autoantibodies are associated with which disorder? Primary
biliary cirrhosis "<img src=""7651.png"">" autoantibodies duplicate immune-
Antiparietal cell autoantibodies are associated with which disorder? Pernicious
anemia "<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-Scl-70 (anti-DNA topoisomerase I) autoantibodies are associated with which
disorder? Scleroderma (diffuse type) "<img src=""7651.png"">"
Anti-smooth muscle autoantibodies are associated with which disorder? Autoimmune
hepatitis "<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-SSA and anti-SSB (anti-Ro and anti-La) autoantibodies are associated with
which disorder? Sjgren syndrome "<img src=""7651.png"">" autoantibodies
Anti-TSH receptor autoantibodies are associated with which disorder? Graves
disease "<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
Anti-U1 RNP (ribonucleoprotein) autoantibodies are associated with which disorder?
Mixed connective tissue disease "<img src=""7651.png"">"
IgA anti-endomysial and IgA anti-tissue transglutaminase autoantibodies are
associated with which disorder? Celiac disease/disorder "<img src=""7651.png"">"
MPO-ANCA/p-ANCA autoantibodies are associated with which disorders? Microscopic
polyangiitis nodosa and Churg-Strauss syndrome (eosinophilic granulomatosis with
polyangiitis) "<img src=""7651.png"">" autoantibodies duplicate immune-
PR3-ANCA/c-ANCA autoantibodies are associated with which disorder?
Granulomatosis with polyangiitis (Wegener) "<img src=""7651.png"">"
Anti-CCP autoantibodies are associated with which disorder?Rheumatoid arthritis
"<img src=""7651.png"">" autoantibodies duplicate immune-responses
immunology
A man has diffuse joint pains and aches. Rheumatoid factor autoantibodies are
positive. Which more specific test can confirm the diagnosis? Test for anti-CCP
autoantibodies, which are more specific for rheumatoid arthritis "<img
Which disorder is associated with voltage-gated calcium channel autoantibodies?
Lambert-Eaton syndrome "<img src=""7651.png"">" autoantibodies duplicate
A pt has recurrent, noninvasive skin and mucous membrane Candida infections due to
T-cell dysfunction. Which immunodeficiency is this? Chronic mucocutaneous
candidiasis (many causes) "<img src=""7652.png"">" duplicate immune-
responses immunodeficiencies immunology
What is the pathogenesis of chronic granulomatous disease? Neutrophils have reduced
microbicidal capability due to a lack of NADPH oxidase, increasing susceptibility
to catalase-positive organisms "<img src=""7652.png"">" duplicate immune-
A boy has recurrent abscesses, elevated IgE, and decreased IFN-. Which immune
cells are dysfunctional? Neutrophils "<img src=""7652.png"">" duplicate
immune-responses immunodeficiencies immunology
A boy has recurrent S aureus, E coli, and Aspergillus infections. Results of which
two tests confirm his diagnosis? Negative NBT test and abnormal flow cytometry
dihydrorhodamine test (decreased green fluorescence); these are tests for CGD
"<img src=""7652.png"">" duplicate immune-responses immunodeficiencies
immunology
What are two possible causes of severe combined immunodeficiency and their modes of
inheritance? Adenosine deaminase deficiency (autosomal recessive) and
defective IL-2R gamma chain (X-linked most common) "<img src=""7652.png"">"
duplicate immune-responses immunodeficiencies immunology
What is the most common primary immunodeficiency? What are the symptoms?
Selective IgA deficiency; Airway/GI infections, Autoimmune disease,Atopy,
Anaphylaxis to IgA-containing products but most often Asympomatic "<img
src=""7652.png"">" duplicate immune-responses immunodeficiencies immunology
A boy has recurrent infections (viral, bacterial, protozoal), faulty IL-2
receptors, and no germinal centers in lymph nodes. Tx of choice? This is SCID,
treated with bone marrow transplantation; there is no worry for graft rejection
immunology
Which immune deficiency disease presents with normal numbers of circulating B cells
but a decreased number of plasma cells? Common variable immunodeficiency (CVID)
immunology
A boy has SCID. What findings will be noted on chest x-ray, flow cytometry, and
lymph node biopsy? No thymic shadow on chest x-ray, no T cells on flow
cytometry, and no germinal centers in lymph nodes "<img src=""7652.png"">"
CVID can be acquired in the 20s and 30s. Which noninfectious conditions are such
patients at risk for developing? Autoimmune disease, bronchiectasis, lymphoma,
and sinopulmonary infections "<img src=""7652.png"">" duplicate immune-
The umbilical cord of a neonate with neutrophilia fails to separate within 30 days.
What is the most likely Dx and pathophysiology? Leukocyte adhesion deficiency type
1; lack of phagocyte LFA-1 integrin (CD18) leads to impaired migration and
chemotaxis "<img src=""7652.png"">" duplicate immune-responses
immunodeficiencies immunology
A 30-year-old patient is newly diagnosed with CVID. Which type of infection is he
at most risk of acquiring? Sinopulmonary infection "<img src=""7652.png"">"
A 2-y/o child has recurrent severe pyogenic bacterial infections, high IgM, and low
levels of all other immunoglobulins. Pathophysiology? Defective CD40L on Th cells,
which is the necessary second signal for B-cell class switching (This is hyper-IgM
syndrome.) "<img src=""7652.png"">" duplicate immune-responses
A girl has recurrent bacterial skin infections. No pus comes out of her wounds.
Characterize the number and localization of neutrophils. Neutrophil levels
increase; there are no neutrophils at infection sites due to impaired chemotaxis in
type 1 leukocyte adhesion deficiency "<img src=""7652.png"">" duplicate
An asymptomatic man is found to have selective IgA deficiency. What levels of IgA,
IgM, and IgG would you find? Decreased IgA with normal IgG and IgM levels "<img
A 5-month-old child with high IgM and very low IgG, IgA, and IgE has a severe
Pneumocystis infection. What is defective? CD40L on Th cells is abnormal,
leading to a class switching defect (hyper-IgM syndrome, X-linked recessive) "<img
A 25-year-old has frequent sinus infections and defective B-cell differentiation.
How do plasma cell and immunoglobulin levels change? Plasma cell and
immunoglobulin levels decrease (This describes common variable immunodeficiency.)
immunology
A boy has defective NADPH oxidase; his neutrophils produce fewer reactive oxygen
species. Which organism(s) is he most susceptible to? Catalase-positive bugs:
Nocardia,Pseudomonas,Listeria,Aspergillus,Candida,E.coli,Staphylococcus
aureus,Serratia (Need PLACESS); this is CGD "<img src=""7652.png"">"
A man has many oral yeast infections. Would he have a cutaneous reaction to Candida
antigens? No, he has chronic mucocutaneous candidiasis, with T-cell dysfunction
and recurrent Candida infections of skin and mucous membranes "<img
A man has many oral and skin Candida infections. Would his T cells respond in vitro
to Candida? No, he has chronic mucocutaneous candidiasis, with T-cell dysfunction
and recurrent Candida infections of skin and mucous membranes "<img
Bruton agammaglobulinemia, selective IgA deficiency, and common variable
immunodeficiency are disorders of which type of cell? B cells "<img
Name four inherited immunodeficiencies that are more common in boys. Why is this
the case? Hyper-IgM syndrome, Wiskott-Aldrich syndrome, chronic granulomatous
disease, and Bruton agammaglobulinemia; all are X-linked recessive "<img
DiGeorge syndrome, IL-12 receptor deficiency, Job syndrome, and chronic
mucocutaneous candidiasis feature dysfunction of which cell type? T cells
immunology
A boy's disorder leads to recurrent DNA double-strand breaks due to a defect in the
ATM gene. What triad of signs/Sx is commonly seen? Ataxia-telangiectasia;
Ataxia, spider Angiomas, decreased IgA "<img src=""7652.png"">" duplicate
Patients with hyper-IgM syndrome are more susceptible to infection by which
opportunistic organisms? Pneumocystis, Cryptosporidium, CMV "<img
A new mother states that she has an FMH of immunodeficiency and asks for her 4-
month-old boy to be tested. Why may it be too early? Maternal IgG depletion occurs
after 6 months "<img src=""7652.png"">" duplicate immune-responses
A woman has ataxia, web-like angiomas, low IgA levels, elevated AFP, and cerebellar
atrophy on imaging. Which gene is defective? The ATM gene: ataxia-telangiectasia
is due to ATM gene defects encoding DNA repair enzymes "<img src=""7652.png"">"
Bruton agammaglobulinemia is an XLR disorder that involves a lack of B-cell
maturation. Which gene/enzyme is affected? BTK, Bruton tyrosine kinase (Bruton
in Boys) "<img src=""7652.png"">" duplicate immune-responses
A man (like his maternal grandfather) has thrombocytopenia, recurrent infections,
and eczema. What lab findings do you expect to see? Decreased/normal IgG/IgM,
elevated IgE/IgA, thrombocytopenia with smaller platelets (Wiskott-Aldrich
syndrome) "<img src=""7652.png"">" duplicate immune-responses
A 9-m/o boy has a normal CD19+ B-cell count, no B cells in peripheral blood, low
immunoglobulins, and scanty tonsils. What's the likely Dx? Bruton
agammaglobulinemia "<img src=""7652.png"">" duplicate immune-responses
A boy has an X-linked recessive WAS gene mutation. What triad of symptoms may he
experience? Wiskott-Aldrich: Thrombocytopenia, Eczema, Recurrent infections (WATER)
immunology
A boy w/recurrent viral illnesses, ASD, and tetany has low Ca and PTH. Chest x-ray
shows no thymic shadow. What test confirms diagnosis? FISH for 22q11 deletion
(DiGeorge syndrome with thymic aplasia [lack of thymus/parathyroid glands from
third/fourth pharyngeal pouches]) "<img src=""7652.png"">" duplicate immune-
A boy has thrombocytopenic purpura, eczema, and recurrent infections. What gene is
affected? For which conditions is he at higher risk? The WAS gene (X-linked
recessive); he has an increased risk for cancer and autoimmune disease (Wiskott-
Aldrich syndrome) "<img src=""7652.png"">" duplicate immune-responses
A 5-y/o patient has disseminated mycobacterial infections after receiving the BCG
vaccine. What is the genetic inheritance of the likely Dx? Autosomal recessive;
this is IL-12 receptor deficiency (decreased activation of Th1 cells from decreased
interferon-) "<img src=""7652.png"">" duplicate immune-responses
IL-12 receptor deficiency is an AR disorder that involves disseminated
mycobacterial/fungal infections. Which immune cells are affected? Th1 cells,
resulting in decreased IFN- release; remember, IL12 activates Th1 cells "<img
A boy has retained primary teeth, eczema, and recurrent abscesses; labs show
elevated IgE and eosinophilia. What is the diagnosis and cause? Hyper-IgE (Job)
syndrome; autosomal dominant STAT3 mutation causes Th17 deficiency and abnormal
neutrophil recruitment "<img src=""7652.png"">" duplicate immune-responses
A pale, blond patient has recurrent staphylococcal infections, progressive
neurodegeneration, and infiltrative lymphohistiocytosis. Dx? Chdiak-Higashi
syndrome, AR; pancytopenia, mild coagulation defects, and giant granules in
platelets/neutrophils are also seen "<img src=""7652.png"">" duplicate immune-
List the symptoms of hyper-IgE (Job) syndrome using the mnemonic FATED. Coarse
Facies, noninflamed staphylococcal Abscesses, retained primary Teeth, high IgE,
Dermatologic problems "<img src=""7652.png"">" duplicate immune-responses
A patient with odynophagia and thrush is likely to have a deficiency of what type
of immune cell? T cells or granulocytes, as this patient has Candida esophagitis
causing painful swallowing "<img src=""7653.png"">" duplicate immune-
responses immunology infections-in-immunodeficiency
A patient has a T-cell deficiency. What types of viral infections is he at risk
for? Cytomegalovirus, Epstein-Barr virus, JCV, varicella zoster virus, and chronic
respiratory and gastrointestinal viral infections "<img src=""7653.png"">"
duplicate immune-responses immunology infections-in-immunodeficiency
A patient with pneumonia and ground-glass appearance on chest x-ray is likely to
have deficiency in what type of immune cell? T cells (This isPneumocystis
carinii pneumonia, a fungal infection common in T cellimmunodeficient states.)
infections-in-immunodeficiency
What effect can a T-cell deficiency have on a bacterial infection? Easy
dissemination (sepsis) "<img src=""7653.png"">" duplicate immune-responses
immunology infections-in-immunodeficiency
What is the difference between T-cell and B-cell deficiencies? T-cell
deficiencies tend to produce recurrent viral/fungal infections, and B-cell
deficiencies tend to produce recurrent bacterial infections"<img src=""7653.png"">"
A patient has a B-cell deficiency. What types of recurrent bacterial infections is
he most susceptible to? Encapsulated: P aeruginosa, Streptococcus pneumoniae, H
influenzae, N meningitidis, E coli, Salmonella, Klebsiella pneumoniae, group B
Strep "<img src=""7653.png"">" duplicate immune-responses immunology
A child has a B-cell deficiency. What type of poliovirus vaccine is
contraindicated? Sabin oral (live, attenuated polio vaccine) "<img
src=""7653.png"">" duplicate immune-responses immunology infections-in-
immunodeficiency
A child with an immunodeficiency has greasy, foul-smelling stools. What
immunodeficiency is likely? B-cell deficiency with no immunoglobulin A
(giardiasis), leading to lack of mucosal immunity "<img src=""7653.png"">"
A child has dysfunctional granulocytes. To what types of microbes is she most
susceptible? Fungi (Candida, Aspergillus) and bacteria (Staphylococcus,
Nocardia, Serratia, Burkholderia cepacia) "<img src=""7653.png"">" duplicate
immune-responses immunology infections-in-immunodeficiency
A boy has an absence of B cells. To which types of viruses is he most susceptible?
Poliovirus, enterovirus (enteroviral encephalitis) "<img src=""7653.png"">"
A boy with C8 complement deficiency requires a vaccine. Which vaccine does he need?
To which bacteria is he most susceptible and why? Meningococcal vaccine;
Neisseria, as there is no formation of membrane attack complex (late complement
deficiency) "<img src=""7653.png"">" duplicate immune-responses immunology
A patient has recurrent infections with encapsulated organisms. His B-cell counts
are normal. What other defect may be to blame? Early complement deficiencies "<img
src=""7653.png"">" duplicate immune-responses immunology infections-in-
immunodeficiency
A pt s/p ACL injury receives a bone-patellar tendon-bone graft from the affected
leg in reconstruction surgery. What type of graft is this? Autograft "<img
src=""7654.png"">" duplicate grafts immune-responses immunology
A patient receives a syngeneic graft (isograft) from a donor. What is the genetic
relationship between the donor and the recipient? Identical twin or clone
(definition of syngeneic graft) "<img src=""7654.png"">" duplicate grafts
In 1984, a newborn patient received a heart transplant from a baboon. What type of
graft is this? Xenograft "<img src=""7654.png"">" duplicate grafts immune-
A patient with hypertrophic obstructive cardiomyopathy receives a heart transplant.
What type of graft is this? Allograft "<img src=""7654.png"">" duplicate
grafts immune-responses immunology
Hyperacute graft rejection occurs within minutes and the graft must be removed.
What is the pathogenesis of this phenomenon? Pre-existing recipient antibodies
vs donor antigens; type II hypersensitivity causing thrombosis of graft vessels and
resultant necrosis "<img src=""7655.png"">" duplicate immune-responses
immunology transplant-rejection
A transplant patient experiences graft rejection. Biopsy reveals vasculitis of
graft vessels w/lymphocytic infiltrate. Type of rejection? Acute rejection; CD8+ T
cells react vs foreign MHCs and Ig development via humoral response; Tx with
immunosuppressants "<img src=""7655.png"">" duplicate immune-responses
Acute graft rejection occurs in weeks to months. How can this be prevented or
reversed? Use of immunosuppressants "<img src=""7655.png"">" duplicate
immune-responses immunology transplant-rejection
Chronic graft rejection occurs in months to years. What is the pathogenesis of this
phenomenon? Antibody- and T-cellmediated cell death; host T cells secrete
cytokines that drive fibrosis, atherosclerosis, and parenchymal atrophy "<img
src=""7655.png"">" duplicate immune-responses immunology transplant-rejection
A patient is diagnosed with vanishing bile duct syndrome. What organ did he or she
likely receive? Liver "<img src=""7655.png"">" duplicate immune-responses
A transplantation pt has a maculopapular rash, jaundice, hepatosplenomegaly, and
diarrhea. He likely received which type of transplantation?Bone marrow or liver
(lymphocyte-rich tissue, initiating graft-versus-host disease) "<img
Graft-versus-host disease has a variable time of onset. What underlying
pathogenesis drives this phenomenon? Grafted immunocompetent T cells in the
immunocompromised host reject cells with foreign proteins, causing severe organ
dysfunction "<img src=""7655.png"">" duplicate immune-responses immunology
transplant-rejection
Years after a kidney transplant, a patient develops glomerulopathy. What is the
mechanism for this rejection? Is it reversible? T cells and antibodies react
against donor antigens in chronic rejection; it is not reversible "<img
A patient w/leukemia receives a bone marrow transplant. Graft-versus-host disease
arises. Why did it develop? Is it beneficial? Grafts rich in lymphocytes (bone
marrow, liver) predispose to the disease; yes, it may be beneficial against
leukemia (graft versus tumor) "<img src=""7655.png"">" duplicate immune-
responses immunology transplant-rejection
Cyclosporine has a number of adverse effects. Which one is both the most common and
most concerning? Nephrotoxicity; others include hypertension, hyperlipidemia,
neurotoxicity, gingival hyperplasia, and hirsutism "<img src=""7656.png"">"
duplicate immunology immunosuppressants
Immunosuppressants work to block lymphocyte activation and proliferation. Is there
benefit to combining these agents? Yes, combining them increases efficacy/reduces
toxicity and can greatly reduce acute transplant rejection by suppressing cellular
immunity "<img src=""7656.png"">" duplicate immunology immunosuppressants
A pt receives cyclosporine for rheumatoid arthritis. Long-term use of drugs such as
cyclosporine increases the risk of which conditions? Long-term use increases risk
of cancers and infection; immunosuppressants such as cyclosporine disrupt
lymphocyte activation and growth "<img src=""7656.png"">" duplicate
immunology immunosuppressants
What are the clinical uses of cyclosporine? Minimization of organ rejection
after transplantation (prophylaxis) and treatment of autoimmune disorders
(psoriasis, rheumatoid arthritis) "<img src=""7656.png"">" duplicate
A patient with a liver transplant develops drug-induced kidney failure. Name two
drugs that could cause this effect and their mechanism. Cyclosporine and
tacrolimus are nephrotoxic immunosuppressants for transplant rejection prevention;
both inhibit calcineurin "<img src=""7656.png"">" duplicate immunology
immunosuppressants
A pt awaiting kidney transplantation is given a drug that inhibits the
immunomodulator calcineurin. What is the most likely side effect?
Nephrotoxicity; all calcineurin inhibitors (cyclosporine, tacrolimus) are
highly nephrotoxic "<img src=""7656.png"">" duplicate immunology
immunosuppressants
What is the primary clinical use of tacrolimus? Prophylaxis against transplant
rejection "<img src=""7656.png"">" duplicate immunology immunosuppressants
A pt taking a drug that prevents transplant rejection by inhibiting calcineurin has
gingival hyperplasia and hirsutism. What is she taking? Cyclosporine (Tacrolimus
has the same toxicity as cyclosporine but does not cause gingival hyperplasia and
hirsutism.) "<img src=""7656.png"">" duplicate immunology immunosuppressants
A patient w/diabetic neuropathy receives a kidney transplant. Which calcineurin
inhibitor is the best choice for immunosuppression? Cyclosporine, as tacrolimus
is associated with increased risk of both diabetes and neurotoxicity, making it a
poor choice for this patient "<img src=""7656.png"">" duplicate immunology
immunosuppressants
A patient receives a kidney transplant. What drugs can be used together to prevent
transplant rejection and lower toxicity? "Cyclosporine and sirolimus (rapamycin);
unlike cyclosporine, sirolimus is not nephrotoxic (The kidney ""sir-vives."")"
"<img src=""7656.png"">" duplicate immunology immunosuppressants
A man with a kidney transplant is taking sirolimus (rapamycin). Which three
toxicities do you warn him about? "Pancytopenia, insulin resistance, and
hyperlipidemia; Sirolimus causes ""pansirtopenia""" "<img src=""7656.png"">"
A patient admitted to Cardiology receives a drug-eluting stent. Which
immunosuppressant is often found in these stents? Sirolimus (rapamycin) "<img
src=""7656.png"">" duplicate immunology immunosuppressants
Azathioprine inhibits lymphocyte proliferation by blocking nucleotide synthesis.
For which metabolite is azathioprine a precursor? 6-mercaptopurine;
azathioprine interferes with nucleic acid synthesis (toxic to proliferating
lymphocytes) "<img src=""7656.png"">" duplicate immunology
immunosuppressants
A man is taking azathioprine. What are the clinical indications for its use?
Immunosuppression during transplantations and for autoimmune disorders such
as rheumatoid arthritis, glomerulonephritis, and Crohn disease "<img
A man taking allopurinol for gout starts taking an immunosuppressive agent for
Crohn disease. Pancytopenia develops rapidly. What happened? Azathioprine's
metabolite 6-MP is metabolized by xanthine oxidase; allopurinol inhibits xanthine
oxidase, resulting in toxic levels of 6-MP "<img src=""7656.png"">"
A patient scheduled for kidney transplantation receives a monoclonal antibody for
immunosuppression. Which side effects should be monitored? Edema, HTN, tremor
(basilixumab, daclizumab) "<img src=""7656.png"">" duplicate immunology
immunosuppressants
A liver transplant pt develops hyperglycemia, central obesity, and acne. Which drug
class may cause such symptoms? What syndrome is this? Glucocorticoids; iatrogenic
Cushing syndrome "<img src=""7656.png"">" duplicate immunology
immunosuppressants
A patient takes steroids for chronic eczema. NF-B is inhibited. How does this lead
to immune system suppression? NF-B inhibition leads to a decrease in cytokine
transcription/production, and this suppresses both B and T cells "<img
A patient takes glucocorticoids for autoimmune hemolytic anemia. What are some side
effects you should warn the patient about? Hyperglycemia, osteoporosis,
central obesity, muscle breakdown, psychosis, acne, hypertension, cataracts,
femoral head avascular necrosis "<img src=""7656.png"">" duplicate
A woman with coronary artery disease receives a drug-eluting stent with an
immunosuppressive agent. Is nephrotoxicity a concern? No, as the agent being eluted
from the stent is likely sirolimus, which is not nephrotoxic "<img
Which two monoclonal antibodies, used for transplant rejection prophylaxis, work by
blocking IL-2R? Daclizumab and basiliximab "<img src=""7656.png"">"
A patient with lupus develops lupus nephritis. Which immunosuppressant can be used
to treat this new development? Mycophenolate mofetil "<img src=""7656.png"">"
A patient taking an immunosuppressant that inhibits IMP dehydrogenase in
lymphocytes has an invasive CMV infection. Which drug is he taking?
Mycophenolate mofetil "<img src=""7656.png"">" duplicate immunology
immunosuppressants
With which CD markers is the T-cell receptor associated, and which downstream
messenger is activated to signal IL-2 activity? Associated with CD3 and CD4;
activates calcineurin, which converts NFAT-P to NFAT; NFAT enters nucleus and
promotes IL-2 transcription "<img src=""7657.png"">" duplicate immunology
immunosuppressants immunosuppression-targets
A patient lacks NADPH oxidase and has recurrent bacterial infections. Which
cytokine may be used for the treatment of his condition? "IFN- (used in chronic
""gammalomatous"" disease [CGD])" "<img src=""7658.png"">" duplicate
immunology immunosuppressants recombinant-cytokines-and-clinical-uses
A patient with neutropenia from chemotherapy is receiving a drug to recover part of
her bone marrow. Which two drugs could have been used? Filgrastim (G-CSF) and
sargramostim (GM-CSF), as both are recombinant colony-stimulating factors "<img
src=""7658.png"">" duplicate immunology immunosuppressants recombinant-
cytokines-and-clinical-uses
A man is taking interferon-. Name three clinical uses for this cytokine.
Chronic hepatitis B and C, Kaposi sarcoma, and malignant melanoma "<img
src=""7658.png"">" duplicate immunology immunosuppressants recombinant-
cytokines-and-clinical-uses
A patient has sudden loss of vision and pain in one eye. Brain MRI shows
periventricular plaques. Which cytokine can be used as treatment? The patient
likely has multiple sclerosis and can be treated with IFN-"<img src=""7658.png"">"
duplicate immunology immunosuppressants recombinant-cytokines-and-clinical-
uses
A patient presents w/petechiae and is found to have thrombocytopenia. Which
recombinant cytokines can be useful? Oprelvekin (recombinant interleukin 11);
romiplostim, eltrombopag (thrombopoietin receptor agonists)"<img src=""7658.png"">"
duplicate immunology immunosuppressants recombinant-cytokines-and-clinical-
uses
A woman with jaundice and abdominal pain is positive for hepatitis B markers. Which
recombinant cytokine could be used to help treat her? Interferon- (also useful for
hepatitis C) "<img src=""7658.png"">" duplicate immunology
immunosuppressants recombinant-cytokines-and-clinical-uses
A man with anemia and hematuria is found to have renal cell carcinoma. Which
recombinant cytokine is used to treat this condition? Aldesleukin (interleukin 2)
recombinant-cytokines-and-clinical-uses
A man with cancer is taking aldesleukin. Which cytokine is this, and what are its
indications? Recombinant interleukin 2; treatment of metastatic melanoma and
renal cell carcinoma "<img src=""7658.png"">" duplicate immunology
immunosuppressants recombinant-cytokines-and-clinical-uses
A man with end-stage renal disease presents with anemia and an MCV of 80 fL. What
can be used for treatment? Epoetin alfa (erythropoietin); this patient has
normocytic anemia due to low endogenous erythropoietin caused by renal disease
recombinant-cytokines-and-clinical-uses
Therapeutic antibodies targeting soluble TNF- help treat some
autoimmune/inflammatory diseases. What three antibodies have been developed?
Infliximab, adalimumab, certolizumab (most commonly used for IBD, rheumatoid
arthritis, psoriasis, ankylosing spondylitis) "<img src=""7659.png"">"
duplicate immunology immunosuppressants therapeutic-antibodies
What is the target of abciximab? For which two conditions is it indicated?
Glycoproteins IIb/IIIa (IIb IIIa = absiximab); prevents ischemic events in
patients undergoing percutaneous coronary intervention "<img src=""7659.png"">"
A woman is found to have breast cancer that is HER2/neu+. Which monoclonal antibody
can be used in treatment? "Trastuzumab (HER2""tras2zumab"")" "<img
src=""7659.png"">" duplicate immunology immunosuppressants therapeutic-
antibodies
A 60-y/o man is diagnosed with chronic lymphocytic leukemia. What is the target of
the therapeutic antibody given for this disease? Alemtuzumab; targets CD52
(alymtuzumab for chronic lymphocytic leukemia) "<img src=""7659.png"">"
A premature infant has chronic lung disease. What is the target of the antibody
that would you give to prevent RSV infection? Palivizumab (paliVIzumabVIrus),
targeting the RSV F protein "<img src=""7659.png"">" duplicate immunology
immunosuppressants therapeutic-antibodies
A pt w/Burkitt lymphoma is treated with an antibody that targets CD20. What is this
agent, and for which group of lymphomas is it indicated? Rituximab; B-cell non-
Hodgkin lymphomas "<img src=""7659.png"">" duplicate immunology
A boy has severe asthma and a history of allergies. Which therapeutic antibody can
you prescribe, and what does it target? Omalizumab; immunoglobulin E (prevents
IgE from binding to FcRI) "<img src=""7659.png"">" duplicate immunology
A woman has a DEXA score of -3. Which therapeutic antibody would help, and what is
its target? Denosumab (denosumab affects osteoclasts); targets RANKL, disrupting
osteoclast maturation (similar to osteoprotegerin) "<img src=""7659.png"">"
A patient presents with melena. Barium enema reveals the apple core sign. Which
antibody can be used as therapy, and what is its target? Bevacizumab, which is
used to treat colorectal cancer, targets VEGF; cetuximab is used for stage IV
colorectal cancer "<img src=""7659.png"">" duplicate immunology
A man has stage IV colorectal cancer. Which antibody can be used, what is its
target, and what other condition can it be used for? Cetuximab; EGFR; head and
neck cancer "<img src=""7659.png"">" duplicate immunology immunosuppressants
therapeutic-antibodies
A woman with optic neuritis and paresthesias has worse symptoms in warmer weather.
Name the antibody for treatment and its target. Natalizumab, which is used to treat
multiple sclerosis; its target is 4-integrin, which affects leukocyte adhesion
therapeutic-antibodies
A pt w/Crohn disease experiences worsening weakness and paralysis due to JC virus
infection. Which immunosuppressive agent is he receiving? Natalizumab, as it
targets 4-integrin and increases risk of progressive multifocal
leukoencephalopathy (also used for multiple sclerosis) "<img src=""7659.png"">"
A man has age-related macular degeneration. Fundoscopic exam shows
neovascularization. Using antibodies to inhibit which target may help? VEGF with
the therapeutic antibodies ranibizumab or bevacizumab "<img src=""7659.png"">"
A patient with anemia and hemolysis is diagnosed with paroxysmal nocturnal
hemoglobinuria. What therapeutic antibody may help this patient? Eculizumab, an
inhibitor of complement protein C5 "<img src=""7659.png"">" duplicate
immunology immunosuppressants therapeutic-antibodies
A fetus has improper development of the bulbus cordis. Which structures will have
defects as a result? The smooth parts (outflow tract) of the left and right
ventricles "<img src=""7732.png"">" cardiovascular embryology heart-
embryology
A fetus has improper development of the truncus arteriosus. Which structures will
have defects as a result? The ascending aorta and the pulmonary trunk "<img
src=""7732.png"">" cardiovascular embryology heart-embryology
A fetus has improper development of the endocardial cushion. Which structures will
have defects as a result? The atrial septum, membranous interventricular
septum, and AV and semilunar valves "<img src=""7732.png"">" cardiovascular
embryology heart-embryology
A fetus has improper development of the primitive atrium. Which structures will
have defects as a result? The trabeculated part of the left and right atria
"<img src=""7732.png"">" cardiovascular embryology heart-embryology
A fetus has improper development of the primitive ventricle. Which structures will
have defects as a result? The trabeculated part of the left and right
ventricles "<img src=""7732.png"">" cardiovascular embryology heart-
embryology
A fetus has improper development of the primitive pulmonary vein. Which structure
will have defects as a result? The smooth part of the left atrium "<img
A fetus has improper development of the left horn of the sinus venosus. Which
structure will have defects as a result? The coronary sinus "<img
A fetus has improper development of the right horn of the sinus venosus. Which
structure will have defects as a result? The smooth part of the right atrium
(sinus venarum) "<img src=""7732.png"">" cardiovascular embryology heart-
embryology
A fetus has improper development of the right common cardinal/right anterior
cardinal veins. Which structure will have defects as a result? The superior vena
cava "<img src=""7732.png"">" cardiovascular embryology heart-embryology
An ultrasound shows dysfunction of a human embryo's first functional organ. What is
it? When does this organ start to function? The heart; spontaneous beats are
seen by 4 weeks of development "<img src=""7733.png"">" cardiovascular
embryology heart-morphogenesis
A baby has defects in neural crest and endocardial cell migration. Which two
cardiac structures will be affected? The ascending aorta and pulmonary trunk,
which are created from the truncus arteriosus "<img src=""7733.png"">"
cardiovascular embryology heart-morphogenesis
A pt has dextrocardia and chronic sinusitis. What syndrome is likely responsible?
Kartagener syndrome (primary ciliary dyskinesia), causing a defect in left-
right dynein, which leads to aberrant cardiac looping "<img src=""7733.png"">"
A toxin interferes with the first step of septation of the heart chambers. What
structures are affected as a result? Septum primum & foramen primum (In normal
development, the septum primum grows toward endocardial cushions, & the foramen
primum narrows.) "<img src=""7733.png"">" cardiovascular embryology heart-
morphogenesis
During the second step of septation of the chambers, what foramen develops? What
foramen disappears as a result? The foramen secundum forms in the septum
primum; the foramen primum disappears "<img src=""7733.png"">"
During the third step of septation of the chambers, what foramen is essential to
the embryo's hemodynamics? The foramen secundum, which maintains a right-to-left
shunt "<img src=""7733.png"">" cardiovascular embryology heart-morphogenesis
In a developing fetus, the septum secundum expands over the foramen secundum. What
structure remains? The foramen ovale "<img src=""7733.png"">"
During the fifth step of septation of the chambers, what structure is altered to
become an important part of the fetal circulation? The remaining portion of the
septum primum, which forms the valve of the foramen ovale "<img src=""7733.png"">"
How is the atrial septum formed? The septum secundum and septum primum fuse
"<img src=""7733.png"">" cardiovascular embryology heart-morphogenesis
What is the final event in the septation of the atrial chambers? The foramen ovale
usually closes soon after birth because of increased left atrial pressure "<img
src=""7733.png"">" cardiovascular embryology heart-morphogenesis
You see an unfused opening between the septum primum and septum secundum in a man.
Why does this opening usually close? The unfused opening is a patent foramen
ovale, which usually closes (after birth) from increased left atrial pressure
A pt is incidentally found to have a patent foramen ovale on echocardiogram. Is it
necessary to schedule cardiac surgery right away? No, as the majority of patent
foramen ovales do not require treatment "<img src=""7733.png"">"
You detect a paradoxical embolus in a pt, and it has caused a stroke. Which heart
structure is likely defective in this pt? The atrial septum is likely defective,
allowing venous emboli to enter systemic arterial circulation. (Patent foramen
ovale can cause this.) "<img src=""7733.png"">" cardiovascular embryology
heart-morphogenesis
A pt has failure of neural crest cell migration during embryonic heart development.
Name three conditions she might have. Transposition of great vessels, tetralogy
of Fallot, and persistent truncus arteriosus "<img src=""7733.png"">"
A toxic exposure interferes with the division of the truncus arteriosus into the
aortic and pulmonary trunks. What structure is affected? Aorticopulmonary septum
A fetus has stenosis of the opening in the early muscular ventricular septum. What
structure is affected? Interventricular foramen "<img src=""7733.png"">"
A toxic exposure interferes with rotation of the aorticopulmonary septum. What
structure's formation is affected? The membranous interventricular septum; the
interventricular foramen will also not close properly "<img src=""7733.png"">"
An embryo lacks growth of the structure that separates the two atria from the
ventricles. What structures will fail to form as a result? The membranous
interventricular septum (as the structure failing to grow is the endocardial
cushion); atrial septation is also affected "<img src=""7733.png"">"
What is the most common congenital cardiac anomaly? Where is the defect in this
condition usually found? Ventricular septal defect (VSD); it most commonly
occurs in the membranous septum "<img src=""7733.png"">" cardiovascular
Which two heart valves are derived from the endocardial cushions of the outflow
tract? The aortic and pulmonic valves "<img src=""7733.png"">"
Which two heart valves are derived from fused endocardial cushions of the AV canal?
The mitral and tricuspid valves "<img src=""7733.png"">"
A boy is born with an Ebstein anomaly. What is the valvular pathology in this
disease? A displaced valve "<img src=""7733.png"">" cardiovascular
In a newborn the endocardial cushions in the AV canal have failed to properly form
valves. This may lead to which valvular anomalies? Mitral and/or tricuspid
atresia "<img src=""7733.png"">" cardiovascular embryology heart-
morphogenesis
The truncal and bulbar ridges are formed from what cellular precursors? Neural
crest and endocardial cells "<img src=""7733.png"">" cardiovascular
Name three disorders associated with conotruncal abnormalities that arise due to
failed neural crest cell migration. Transposition of great vessels, tetralogy of
Fallot, and persistent truncus arteriosus "<img src=""7733.png"">"
What broad classifications of valvular anomalies are often seen in congenital heart
disease? Stenotic, regurgitant, atretic (eg, tricuspid atresia), or displaced
(eg, Ebstein anomaly) "<img src=""7733.png"">" cardiovascular embryology
heart-morphogenesis
What is the O2 and PO2 in the blood from the placenta in the umbilical vein? 80%
and approximately 30 mm Hg; umbilical arteries have low O2 saturation "<img
src=""7734.png"">" cardiovascular embryology fetal-circulation
Fetal heart chamber pressures are studied. Are pressures higher in the right or
left atrium before birth? How does pressure change after? Pressure in the right
atrium is higher in fetal life; at birth (after the neonate takes a breath), the
pressure in the left atrium is higher "<img src=""7734.png"">"
cardiovascular embryology fetal-circulation
A neonate takes his first breath. What happens to pulmonary vasculature resistance
and oxygen saturation? Pulmonary vasculature resistance decreases, and pulmonary
oxygen saturation increases "<img src=""7734.png"">" cardiovascular
embryology fetal-circulation
Shortly after birth, a boy's foramen ovale and ductus arteriosus close. What two
changes are responsible for these findings? Increased left atrial pressure
closes the foramen ovale; increase in O2 & decrease in prostaglandins cause the
ductus arteriosus to close "<img src=""7734.png"">" cardiovascular
A premature infant has a patent ductus arteriosus but no symptoms. What is the
treatment? Indomethacin "<img src=""7734.png"">" cardiovascular
The closure of the ductus venosus is delayed in a premature infant. What is the
purpose of the ductus venosus in fetal circulation? It transports blood from the
umbilical vein to the IVC, bypassing the liver "<img src=""7734.png"">"
Describe the path of oxygen-rich blood from the umbilical vein to systemic
circulation in the fetus. Umbilical vein, ductus venosus, IVC, right atrium,
foramen ovale, left atrium, left ventricle, aorta "<img src=""7734.png"">"
Describe the pathway by which deoxygenated blood travels from the SVC to the
placenta. Don't forget the shunt(s). SVC, right atrium, right ventricle,
pulmonary artery, ductus arteriosus, descending aorta, internal iliac artery,
umbilical artery, placenta "<img src=""7734.png"">" cardiovascular
Fetal pulmonary artery resistance is high. How does this affect fetal circulation?
What structure accommodates this? Blood entering the main pulmonary artery,
instead of entering the pulmonary vessels, goes to the descending aorta via the
ductus arteriosus "<img src=""7734.png"">" cardiovascular embryology fetal-
circulation
Blood entering the main pulmonary arteries in a fetus is preferentially shunted
through the ductus arteriosus. What drives this finding? Low blood O2 tension
"<img src=""7734.png"">" cardiovascular embryology fetal-circulation
An infant is found to have a PDA and tetralogy of Fallot at birth. What treatment
would you recommend until surgery is possible? Prostaglandins (PGE1 and PGE2 kEEp
the PDA open.) "<img src=""7734.png"">" cardiovascular embryology fetal-
circulation
What does the ductus arteriosus usually become after birth?Ligamentum arteriosum
"<img src=""7735.png"">" cardiovascular embryology fetal-postnatal-
derivatives
A surgeon identifies the median umbilical ligament when performing a hernia repair.
What is the prenatal precursor of this structure? AllaNtois (urachus) is the
precursor of the mediaN umbilical ligament "<img src=""7735.png"">"
cardiovascular embryology fetal-postnatal-derivatives
A neonate has urine leaking from his umbilicus. An umbilical connection to the
bladder is seen. What duct likely had defective development? The allantoic duct
(of which the urachus is a part) "<img src=""7735.png"">" cardiovascular
embryology fetal-postnatal-derivatives
A surgeon identifies the ligamentum teres hepatis. What is the prenatal precursor
of this structure? In which structure is it contained? Umbilical vein;
falciform ligament "<img src=""7735.png"">" cardiovascular embryology
fetal-postnatal-derivatives
A surgeon identifies the medial umbilical ligament when performing hernia repair.
From what prenatal structure is it derived? The umbiLical artery (MediaL
umbilical ligament) "<img src=""7735.png"">" cardiovascular embryology
An autopsy of an infant's spine shows a fully formed nucleus pulposus. What was the
prenatal precursor of this structure? The notochord (The Notochord becomes the
Nucleus pulposus.) "<img src=""7735.png"">" cardiovascular embryology
After birth, a pt's foramen ovale closes. What structure does it become? Fossa
ovalis "<img src=""7735.png"">" cardiovascular embryology fetal-
postnatal-derivatives
What does the ductus venosus usually become after birth? Ligamentum venosum
"<img src=""7735.png"">" cardiovascular embryology fetal-postnatal-
derivatives
The most posterior heart chamber of an older man with hypertension is enlarged.
Which chamber is it? What noncardiac symptoms may he have? Left atrium; dysphagia
(due to compression of esophagus) or hoarseness (due to compression of left
recurrent laryngeal nerve [vagus branch]) "<img src=""7736.png"">" anatomy
cardiovascular coronary-artery-anatomy
Occlusion is most common in which coronary artery? What does that artery supply?
The left anterior descending artery; the anterior 2/3 of interventricular
septum, anterolateral papillary muscle, anterior left ventricle "<img
src=""7736.png"">" anatomy cardiovascular coronary-artery-anatomy
When does peak coronary artery blood flow occur? Early diastole "<img
A pt has bradycardia after a myocardial infarction. Which coronary artery is most
likely affected? Why? The RCA; it usually supplies the
sinoatrial/atrioventricular nodes (Infarct causes nodal dysfunction bradycardia
or heart block.) "<img src=""7736.png"">" anatomy cardiovascular coronary-
artery-anatomy
A man has an infarct of the posterior descending artery. In the majority of the
population, from which structure does this arise? The right coronary artery
"<img src=""7736.png"">" anatomy cardiovascular coronary-artery-anatomy
A man has a clot in the left circumflex coronary artery. Which portions of the
heart would be affected? Lateral and posterior walls of the left ventricle, as
well as the anterolateral papillary muscle "<img src=""7736.png"">"
anatomy cardiovascular coronary-artery-anatomy
A pt has isolated dysfunction of the right ventricle after an MI. Which coronary
artery was likely affected? The right (acute) marginal artery "<img
What percentage of people have left dominant, right dominant, and codominant
coronary circulation, respectively? Define these terms. 8% = left (PDA arises
from LCX.); 85% = right (PDA arises from RCA.); and 7% = codominant (PDA arises
from both LCX and RCA.) "<img src=""7736.png"">" anatomy cardiovascular
coronary-artery-anatomy
A heart autopsy shows necrosis of the posterior ventricular walls. Which artery was
likely occluded? Where else would you expect necrosis? Posterior
descending/interventricular artery (PDA); the posterior third of the
interventricular septum and posteromedial papillary muscle "<img src=""7736.png"">"
anatomy cardiovascular coronary-artery-anatomy
What are the three layers of the pericardium, from outermost to innermost?
Fibrous pericardium, parietal serous pericardium, visceral serous pericardium
"<img src=""7736.png"">" anatomy cardiovascular coronary-artery-anatomy
A man has an infection of the pericardial cavity. What layers of the pericardium
are most immediately affected? The parietal serous pericardium and visceral
serous pericardium (The pericardial cavity lies between them.) "<img
A woman has bradycardia with heart block after blockage of a single coronary
vessel. What vessel is most likely affected? The right coronary artery "<img
Your pt has a heart rate (HR) of 80 beats/min with a stroke volume (SV) of 62.5
mL/beat. What is her cardiac output (CO)? 5 L/min, as CO = SV HR "<img
src=""7737.png"">" cardiac-output cardiovascular physiology
State the Fick principle/equation. Cardiac output = Rate of oxygen consumption
Arterial oxygen content Venous oxygen content "<img src=""7737.png"">"
cardiac-output cardiovascular physiology
What are the two ways/equations for measuring mean arterial pressure? MAP = CO
total peripheral resistance (TPR); MAP = 1/3 systolic pressure + 2/3 diastolic
pressure "<img src=""7737.png"">" cardiac-output cardiovascular physiology
How is pulse pressure calculated? To what is it proportional? Systolic pressure
Diastolic pressure; it is proportional to stroke volume (and inversely
proportional to arterial compliance) "<img src=""7737.png"">" cardiac-
output cardiovascular physiology
A marathoner has an increased stroke volume while running. What are the two parts
of the equation for stroke volume (SV)? SV = Cardiac output Heart rate = End-
diastolic volume End-systolic volume "<img src=""7737.png"">" cardiac-
A man exercises. What two factors maintain cardiac output in the early stages and
what maintains cardiac output after prolonged exercise? Stroke volume and heart
rate; heart rate only (since stroke volume plateaus) "<img src=""7737.png"">"
cardiac-output cardiovascular physiology
A man runs on a treadmill for an hour. What factor would increase his cardiac
output? Increased heart rate "<img src=""7737.png"">" cardiac-output
cardiovascular physiology
On physical exam, a pt's pulse pressure is found to be decreased. Name four
conditions that may have caused this finding. Aortic stenosis, cardiogenic shock,
tamponade, and advanced heart failure "<img src=""7737.png"">" cardiac-
A pt with ventricular tachycardia experiences syncope. How do the two symptoms
relate to each other? At high heart rates, the ventricles are unable to fill
completely during diastole (preferentially shortened), causing CO and syncope
"<img src=""7737.png"">" cardiac-output cardiovascular physiology
A pt's pulse pressure is found to be increased. Name five conditions that can cause
this finding. Hyperthyroidism, aortic regurgitation, aortic stiffening
(elderly), obstructive sleep apnea ( sympathetic tone), and exercise (transient)
"<img src=""7737.png"">" cardiac-output cardiovascular physiology
A pt has ventricular tachycardia. Why is cardiac output decreased? The
increased heart rate shortens diastole, and thus, filling time "<img
src=""7737.png"">" cardiac-output cardiovascular physiology
A pt has decreased stroke volume. What three variables affect stroke volume? Stroke
Volume is affected by Contractility, Afterload, and Preload (SV CAP) "<img
src=""7738.png"">" cardiac-output-variables cardiovascular physiology
A drug decreases extracellular sodium. How does this affect stroke volume? It
decreases the activity of the sodium/calcium ion exchanger, thereby increasing
contractility and SV "<img src=""7738.png"">" cardiac-output-variables
You create a drug to increase stroke volume (SV). What three general mechanisms
might this drug exploit to increase the SV? Increased contractility, decreased
afterload, and increased preload "<img src=""7738.png"">" cardiac-output-
variables cardiovascular physiology
A novel cardiac drug mimics catecholamines. What is its mechanism of action for
increasing stroke volume and contractility? It inhibits phospholamban,
promoting Ca2+ entry into the sarcoplasmic reticulum, leading to Ca2+-induced Ca2+
release "<img src=""7738.png"">" cardiac-output-variables cardiovascular
physiology
How would a drug that increases intracellular calcium affect the stroke volume and
contractility of the heart? It would increase both contractility and stroke
volume "<img src=""7738.png"">" cardiac-output-variables cardiovascular
physiology
A pt who is taking digitalis wants to know how his medicine works and how it
affects his heart. Explain. It blocks the sodium/potassium pump, increasing
intracellular sodium, which increases intracellular calcium and contractility
"<img src=""7738.png"">" cardiac-output-variables cardiovascular
physiology
A drug blocks 1-receptors. How does this affect contractility and stroke volume?
1-Blockade decreases cAMP, which decreases contractility and stroke volume
physiology
A pt presents with a history of congestive heart failure. How does systolic
dysfunction affect contractility? It decreases contractility "<img
A pt with congestive heart failure has confusion and shortness of breath. Lactate
levels are elevated. What is causing his symptoms? Metabolic acidosis, which
decreases contractility and causes volume overload "<img src=""7738.png"">"
cardiac-output-variables cardiovascular physiology
A woman with known COPD is admitted for pneumonia. Her O2 saturation is 81%. How is
her cardiac output affected? Hypoxia and hypercapnia cause a decrease in both
contractility and stroke volume "<img src=""7738.png"">" cardiac-output-
A pt takes a non-dihydropyridine calcium channel blocker. How does this affect
contractility and stroke volume? It decreases intracellular calcium, which
decreases contractility and stroke volume "<img src=""7738.png"">" cardiac-
output-variables cardiovascular physiology
A pt with type 1 diabetes presents with fruity breath and confusion. How does this
affect contractility and stroke volume? Both contractility and SV are decreased
by the metabolic acidosis (The pt most likely has diabetic ketoacidosis.) "<img
A pt has a disease resulting in increased myocardial oxygen demand. What four
variables could be increased? MyoCARDial = Contractility, Afterload (proportional
to arterial pressure), heart Rate, Diameter of ventricle (increased wall tension)
physiology
A pt has decreased afterload. The myocardium responds by increasing its thickness.
Explain this compensatory response. Thicker myocardium decreases wall tension,
which is with elevated afterload. (Wall tension = Pressure Radius 2 Wall
thickness) "<img src=""7738.png"">" cardiac-output-variables cardiovascular
physiology
You want to measure preload and afterload in a pt. What two measurements best
approximate these terms? Ventricular end-diastolic volume (preload) and mean
arterial pressure (afterload) "<img src=""7738.png"">" cardiac-output-variables
Would you expect nitroglycerin to decrease preload or afterload? By what mechanism?
What about these questions for hydralazine? PrEload via vEnodilation; Afterload
via vAsodilation (hydrAlAzine) "<img src=""7738.png"">" cardiac-output-
A 60-year-old man mistakenly receives triple the maintenance level of IV fluids for
24 hours. Will his preload increase or decrease? It will increase because of
increased blood volume "<img src=""7738.png"">" cardiac-output-variables
A pt has chronic hypertension. How will his left ventricle compensate? LV will
hypertrophy to wall tension (Pressure Radius 2 Wall thickness) ( MAP will
afterload, thereby pressure & wall tension) "<img src=""7738.png"">"
A pt with congestive heart failure takes a drug that decreases both preload and
afterload. What class of drug is he most likely using? ACE inhibitors or ARBs
physiology
A pt does not have heart failure. What is the normal value for EF? Greater than
or equal to 55% "<img src=""7738.png"">" cardiac-output-variables
You measure the ejection fraction in a pt with heart failure. Name two equations
for your calculation. EF = Stroke volume End-diastolic volume and End-diastolic
volume End-systolic volume End-diastolic volume "<img src=""7738.png"">"
How is ejection fraction affected in systolic heart failure and diastolic heart
failure? EF decreases in systolic heart failure, whereas it remains normal in
diastolic heart failure "<img src=""7738.png"">" cardiac-output-variables
A pt has decreased ejection fraction. Which cardiac parameter does this indicate?
Contractility "<img src=""7738.png"">" cardiac-output-variables
A pt is anxious about not exercising; therefore, he exercises. How does all of this
affect his stroke volume? Both anxiety and exercise increase the stroke volume
physiology
A 25-year-old woman is in her first trimester of pregnancy. What can you surmise
about her stroke volume? It is likely increased, secondary to an increased
preload, which commonly occurs early in pregnancy "<img src=""7738.png"">"
A pt has decreased contractility of the heart. Name four conditions that could
cause this. MI, -blocker use, non-dihydropyridine calcium channel blocker use,
dilated cardiomyopathy "<img src=""7739.png"">" cardiovascular physiology
starling-curve
A drug stimulates the sympathetic nervous system. How does this affect the
contractility of the heart? It increases contractility "<img src=""7739.png"">"
cardiovascular physiology starling-curve
A pt takes digoxin. How does this affect contractile strength? It increases
contractility, similar to the effect of catecholamines "<img src=""7739.png"">"
cardiovascular physiology starling-curve
A pt has an MI and develops dilated cardiomyopathy years later. How does all of
this affect contractility of the heart? Both MIs and dilated cardiomyopathies
decrease cardiac contractility "<img src=""7739.png"">" cardiovascular
physiology starling-curve
A pt has heart failure and severe hypertension. Do you treat the hypertension with
a non-dihydropyridine calcium channel blocker? No, as this will further reduce
contractility and likely worsen the symptoms of heart failure "<img
src=""7739.png"">" cardiovascular physiology starling-curve
A man with HF enters atrial fibrillation. He is treated with digoxin instead of a
non-dihydropyridine calcium channel blocker. Why? Digoxin is a positive
inotrope: it will help to increase cardiac contractility and will treat the
arrhythmia via AV node inhibition "<img src=""7739.png"">" cardiovascular
physiology starling-curve
What is the relationship between net changes in pressure, resistance, and flow?
Driving pressure (P) = flow (Q) resistance (R), which is similar to Ohm's
law (V = I R) "<img src=""7740.png"">" cardiovascular physiology
resistance,-pressure,-flow
What is the equation for blood vessel resistance that incorporates variables of
viscosity, length, and radius? Resistance = (8 viscosity length) (
r4) "<img src=""7740.png"">" cardiovascular physiology resistance,-
pressure,-flow
In cardiology, by what factor does resistance increase in a vessel whose size is
reduced by half? 16 times (Resistance is inversely proportional to the radius to
the fourth power.) "<img src=""7740.png"">" cardiovascular physiology
What is the equation for the total resistance of blood vessels in series? RT =
R1 + R2 + R3 and so on "<img src=""7740.png"">" cardiovascular physiology
What is the equation for the total resistance of blood vessels in parallel? 1 RT
= 1 R1 + 1 R2 + 1 R3 and so on "<img src=""7740.png"">"
cardiovascular physiology resistance,-pressure,-flow
What parameter does the viscosity of blood mostly depend on? What disease states
increase the viscosity of blood? Primarily hematocrit; polycythemia, multiple
myeloma, or other hypoproteinemic states (By this logic, viscosity decreases in
anemia.) "<img src=""7740.png"">" cardiovascular physiology resistance,-
pressure,-flow
How does a pressure gradient drive blood flow? Blood flows from high pressure to
low pressure "<img src=""7740.png"">" cardiovascular physiology
You study blood flow in a rat's capillaries. You find that arteriolar dilators
change the TPR and thus capillary blood flow. Why is this? Arterioles regulate
capillary flow and account for most of TPR "<img src=""7740.png"">"
How is volumetric flow rate (Q) related to flow velocity (v) and cross-sectional
area (A)? Q = v A, as capillaries have the highest total cross-sectional area
in the body, and hence, the lowest flow velocity "<img src=""7740.png"">"
A pt undergoes nephrectomy. How will the pt's cardiac output be affected?
Cardiac output will decrease, as removal of organs in parallel arrangements
results in increased TPR, thereby decreasing cardiac output"<img src=""7740.png"">"
Which type of blood vessel provides most of the blood storage capacity? Veins
"<img src=""7740.png"">" cardiovascular physiology resistance,-
pressure,-flow
A pt has anemia. How does viscosity compare with normal values? It is decreased
"<img src=""7740.png"">" cardiovascular physiology resistance,-
pressure,-flow
Which blood vessels have the lowest flow velocity? Capillaries "<img
src=""7740.png"">" cardiovascular physiology resistance,-pressure,-flow
A pt is running on a treadmill. How does her cardiac output change? Why? CO
increases; this is due to increased heart rate and decreased total peripheral
resistance "<img src=""7741.png"">" cardiac-and-vascular-function-curves
A man overdoses on narcotics. How is cardiac output affected for a particular end-
diastolic volume? It is decreased, as inotropy (and therefore contractility)
decreases "<img src=""7741.png"">" cardiac-and-vascular-function-curves
A drug increases sympathetic activity. How does this affect right atrial pressure
for a given cardiac output? It increases right atrial pressure "<img
src=""7741.png"">" cardiac-and-vascular-function-curves cardiovascular
physiology
How do catecholamines or digoxin cause increased cardiac output (CO)? They
increase contractility, so CO increases for a given right atrial pressure "<img
src=""7741.png"">" cardiac-and-vascular-function-curves cardiovascular
physiology
What phase of the cardiac cycle corresponds with the period between the closing of
the aortic valve and the opening of the mitral valve? Isovolumetric relaxation
"<img src=""7742.png"">" cardiovascular physiology pressure-volume-
loops-and-cardiac-cycle
What phase of the cardiac cycle corresponds with the period just before mitral
valve closure? Reduced filling "<img src=""7742.png"">" cardiovascular
physiology pressure-volume-loops-and-cardiac-cycle
What does S1 correspond to? In which area is S1 loudest? Mitral and tricuspid
valve closure; the mitral area (ie, the midclavicular line in the fifth intercostal
space) "<img src=""7742.png"">" cardiovascular physiology pressure-
volume-loops-and-cardiac-cycle
What does the S2 sound correspond to? In which area is it loudest? Closure of
the aortic and pulmonary valves; aortic area in right upper sternal border "<img
src=""7742.png"">" cardiovascular physiology pressure-volume-loops-and-
cardiac-cycle
You hear an abnormal heart sound occurring during rapid ventricular filling. What
is it? What structural heart changes is it related to? S3; dilated ventricles
(eg, from increased filling pressures associated with mitral regurgitation and
congestive heart failure) "<img src=""7742.png"">" cardiovascular
physiology pressure-volume-loops-and-cardiac-cycle
During a well-child check, you hear an S3 sound in a boy with no significant
medical issues. Does this indicate a cardiac defect? No, as an S3 sound can be a
normal finding in children and pregnant women "<img src=""7742.png"">"
cardiovascular physiology pressure-volume-loops-and-cardiac-cycle
What causes the S4 heart sound, or atrial kick? The left atrium pushing blood
against a stiff left ventricular wall in a pt with ventricular hypertrophy "<img
src=""7742.png"">" cardiovascular physiology pressure-volume-loops-and-
cardiac-cycle
You hear a late diastole sound, best heard at the apex in the left lateral
decubitus position. Do you expect a high or low atrial pressure? High atrial
pressure (The sound described here is the S4 heart sound.) "<img src=""7742.png"">"
During which phase of the cardiac cycle is ventricular volume the highest? The
lowest? Atrial systole; isovolumetric relaxation "<img src=""7742.png"">"
In tricuspid regurgitation, which portion of the jugular venous pulse is absent?
X descent "<img src=""7742.png"">" cardiovascular physiology pressure-
The a, c, and v waves of the jugular venous pulse are associated with which
physiologic events, respectively? a wave: atrial contraction, c wave: right
ventricular contraction, and v wave: filling against a closed tricuspid valve
"<img src=""7742.png"">" cardiovascular physiology pressure-volume-
loops-and-cardiac-cycle
The y descent on the jugular venous pulse represents what? The x descent? y =
flow of blood from right atrium to right ventricle; x = atrial relaxation &
displacement of tricuspid during ventricular contraction "<img src=""7742.png"">"
In which condition is the a wave of the jugular venous pulse absent? Atrial
fibrillation "<img src=""7742.png"">" cardiovascular physiology pressure-
You measure O2 consumption of a heart during the period between mitral valve
closing and aortic valve opening. High or low O2 consumption? High, as the
period described is the isovolumetric contraction period, which has the highest
oxygen consumption of all cardiac cycle phases "<img src=""7742.png"">"
During which phase of the breathing cycle is S2 splitting normally increased?
Inspiration, as inspiration increased venous return increased RV filling,
stroke volume, and ejection time delayed pulmonic valve closure "<img
src=""7743.png"">" cardiovascular physiology splitting
On auscultation of a pt with a ventricular septal defect, does the splitting of P2
and A2 widen during inspiration? Yes, as fixed splitting is only in atrial (not
ventricular) septal defects, due to constant RA/RV volumes & flow through the
pulmonic valve "<img src=""7743.png"">" cardiovascular physiology splitting
Which valvular stenosis is associated with wide splitting of the S2 heart sound?
Pulmonic stenosis, which causes delayed RV emptying & therefore a delayed
pulmonic sound (S2 is also present in right bundle branch block.) "<img
src=""7743.png"">" cardiovascular physiology splitting
What is the name of the phenomenon that occurs when P2 (pulmonic valve) precedes A2
(aortic valve) in the heart sound S2? What causes it? Paradoxic splitting, as
observed in aortic stenosis or left bundle branch block; it is due to delayed
aortic valve closure "<img src=""7743.png"">" cardiovascular physiology
splitting
During auscultation of a pt with aortic stenosis, does the time between pulmonic
and aortic valvular closure change during inspiration? Yes, it decreases, and
P2 precedes A2 (paradoxical splitting) (On inspiration, splitting could also be
eliminated as P2 moves closer to A2.) "<img src=""7743.png"">"
cardiovascular physiology splitting
How does normal inspiration affect intrathoracic pressure and pulmonary blood flow?
Inspiration intrathoracic pressure and pulmonary impedance, which
pulmonary blood flow and delays closure of pulmonic valve "<img src=""7743.png"">"
cardiovascular physiology splitting
What type of splitting is seen in conditions that slow right ventricle emptying
(eg, pulmonic stenosis and right bundle branch block)? Wide splitting, as the
delayed right ventricular emptying causes delayed pulmonic sound, regardless of
breath "<img src=""7743.png"">" cardiovascular physiology splitting
You examine a pt with a cardiac defect and hear a fixed split. What defect does the
pt have? Why is there a fixed split? Atrial septal defect (causes left-right
shunt, increasing flow through pulmonic valve); regardless of breathing, pulmonic
closure is delayed "<img src=""7743.png"">" cardiovascular physiology
splitting
A pt performs the hand-grip maneuver. What happens to the heart's afterload? It
increases "<img src=""7744.png"">" auscultation-of-the-heart cardiovascular
physiology
A man has a systolic murmur. You are not sure if it is aortic stenosis (AS) or
hypertrophic cardiomyopathy (HCM). How do you differentiate? Have the pt
perform the Valsalva maneuver (HCM intensifies; AS softens.) or squat rapidly (HCM
softens; AS intensifies.) "<img src=""7744.png"">" auscultation-of-the-
heart cardiovascular physiology
Which phase of the Valsalva maneuver is used to detect murmur changes? Phase II
"<img src=""7744.png"">" auscultation-of-the-heart cardiovascular
physiology
A pt squats rapidly. What happens to preload and venous return of the heart?
Preload and venous return both increase "<img src=""7744.png"">"
auscultation-of-the-heart cardiovascular physiology
A pt performs the Valsalva maneuver. Phase II is reached, and the pt is standing.
What happens to the heart's preload? It decreases "<img src=""7744.png"">"
In what areas are the murmurs of aortic stenosis and aortic regurgitation best
heard? Aortic stenosis: aortic area (ie, right sternal border and second
intercostal space); aortic regurgitation: left sternal border "<img
src=""7744.png"">" auscultation-of-the-heart cardiovascular physiology
In what areas are the murmurs of pulmonic stenosis and pulmonic regurgitation best
heard? Pulmonic stenosis: pulmonic area (ie, left sternal border at second
intercostal space); pulmonic regurgitation: left sternal border "<img
A 60-year-old man has tricuspid stenosis. Where can you best hear the murmur? Would
the murmur be louder on inspiration or expiration? Tricuspid area (left of
sternal border, 5th intercostal space); inspiration (Right heart sounds are louder
on inspiration.) "<img src=""7744.png"">" auscultation-of-the-heart
Which murmurs are heard during systole? Aortic/pulmonic stenosis, flow murmurs,
aortic valve sclerosis, mitral/tricuspid regurgitation, hypertrophic
cardiomyopathy, VSD, MVP "<img src=""7744.png"">" auscultation-of-the-
heart cardiovascular physiology
Which five murmurs are heard during diastole? Aortic/pulmonic regurgitation,
mitral stenosis, tricuspid stenosis, and ASD "<img src=""7744.png"">"
A 65-year-old man has mitral regurgitation. Would his murmur be expected to
increase or decrease with the hand-grip maneuver? Increase (Hand grip increases
systemic vascular resistance and afterload.) "<img src=""7744.png"">"
Which murmur increases in intensity with the Valsalva strain? What maneuvers
decrease this murmur's intensity? Hypertrophic cardiomyopathy; rapid squatting
and hand grip "<img src=""7744.png"">" auscultation-of-the-heart
An increase in afterload will cause which three murmurs to increase in intensity?
Mitral regurgitation, aortic regurgitation, and ventricular septal defect
physiology
A pt with a mitral valve prolapse squats down suddenly. What will happen to the
timing of the pt's murmur? The onset of the click/murmur will be later "<img
A pt with a mitral valve prolapse performs a Valsalva maneuver. What will happen to
the timing of the pt's murmur? The onset of the click/murmur will be earlier
physiology
A pt with a mitral valve prolapse clenches his fists. What will happen to the
timing of the pt's murmur? The onset of the click/murmur will be later "<img
A pt has a systolic murmur that intensifies with Valsalva and decreases with hand
grip. Does it increase or decrease with rapid squatting? It decreases. (The
murmur described here is the murmur of hypertrophic cardiomyopathy.) "<img
Which heart murmurs are described as holosystolic, high-pitched, and blowing?
Mitral and tricuspid regurgitation "<img src=""7745.png"">"
cardiovascular heart-murmurs physiology
You hear a murmur that is loudest at the apex and radiates toward the axilla. What
maneuver increases the volume of this murmur? The hand-grip maneuver, which
increases afterload, increasing murmur intensity (The murmur described is the
mitral regurgitation murmur.) "<img src=""7745.png"">" cardiovascular heart-
murmurs physiology
What type of murmur is loudest at the left sternal border at the fifth intercostal
space and radiates to the right sternal border? Tricuspid regurgitation "<img
src=""7745.png"">" cardiovascular heart-murmurs physiology
Describe the pressures in the left ventricle (LV) and aorta in a pt with aortic
stenosis (AS) vs those in a healthy pt. In AS, pressure in LV is much higher than
in aorta, as LV squeezes blood past a stenotic valve; this results in a greater
pressure gradient "<img src=""7745.png"">" cardiovascular heart-murmurs
physiology
What does the term pulsus parvus et tardus mean? Pulses are weak compared with
the heart sounds, and the strongest part of the peripheral pulse occurs late after
S1 is heard "<img src=""7745.png"">" cardiovascular heart-murmurs physiology
Which heart valve disease process is often due to age-related calcification and can
be associated with syncope? Aortic stenosis, which on exertion can present as
Syncope, Angina, Dyspnea (SAD) "<img src=""7745.png"">" cardiovascular
heart-murmurs physiology
What is the most common valvular lesion that causes a murmur? Mitral valve
prolapse "<img src=""7745.png"">" cardiovascular heart-murmurs physiology
Which heart murmur is usually benign but can predispose pts to infective
endocarditis? Mitral valve prolapse "<img src=""7745.png"">"
cardiovascular heart-murmurs physiology
What are four examples of pathologic processes that can cause aortic regurgitation?
Aortic root dilation, bicuspid aortic valve, rheumatic fever, and
endocarditis "<img src=""7745.png"">" cardiovascular heart-murmurs
physiology
An 80-y/o woman reports that her mother told her she had rheumatic fever as a
child. Which valvular abnormalities might she have? Mitral stenosis, aortic
regurgitation, mitral valve prolapse, mitral regurgitation, tricuspid regurgitation
"<img src=""7745.png"">" cardiovascular heart-murmurs physiology
In mitral stenosis, how does the interval between the S2 and the opening snap
sounds correlate with severity? Increased interval correlates with increased
severity of mitral stenosis "<img src=""7745.png"">" cardiovascular heart-
murmurs physiology
Describe the relationship between left atrial pressure and left ventricular
pressure during diastole for a pt with mitral stenosis. In mitral stenosis, left
atrial pressure greatly exceeds left ventricular pressure during diastole "<img
src=""7745.png"">" cardiovascular heart-murmurs physiology
During which phase of the cardiac myocyte action potential does extracellular
calcium enter the cell? What is the effect of this calcium?The plateau phase;
causes calcium release from sarcoplasmic reticulum (calcium-induced calcium
release) and then muscle myocyte contraction "<img src=""7746.png"">"
cardiovascular myocardial-action-potential physiology
What do the cardiac nodal cells do during diastole? They spontaneously
depolarize, as this automaticity is due to the If (funny current) channels that
create slow, mixed Na+/K+ inward current "<img src=""7746.png"">"
cardiovascular myocardial-action-potential physiology
What cellular adaptation allows cardiac myocytes to be electrically coupled? Gap
junctions "<img src=""7746.png"">" cardiovascular myocardial-action-
potential physiology
What is the voltage value of the resting potential of a ventricular myocyte? How is
that resting potential maintained? 85 mV; the value is maintained by high K+
permeability through K+ channels "<img src=""7746.png"">" cardiovascular
myocardial-action-potential physiology
Name the phases of the myocardial action potential, in order. Rapid
upstroke/depolarization, initial repolarization, plateau, rapid repolarization,
resting potential "<img src=""7746.png"">" cardiovascular myocardial-action-
At each phase of the myocardial action potential, list the ions that enter and exit
cells through the cellular membranes. Phase 0 = Na+ in, 1 = Na+ in (tapering
off), K+ out, 2 = Ca2+ in, K+ out, 3 = Ca2+ in (tapering off), K+ out, 4 = K+ out
"<img src=""7746.png"">" cardiovascular myocardial-action-potential
physiology
What are some key features that distinguish cardiac muscle action potentials from
skeletal muscle action potentials? Ca2+/K+-mediated plateau, Ca2+-induced Ca2+
release from sarcoplasmic reticulum, If (funny current) channels, gap junctions for
coupling "<img src=""7746.png"">" cardiovascular myocardial-action-
Cardiac myocytes in which locations have pacemaker action potentials? The
sinoatrial and atrioventricular nodes "<img src=""7747.png"">"
cardiovascular pacemaker-action-potential physiology
What effect does the resting voltage of the pacemaker cell have on the speed of
conduction? Permanent inactivation of voltage-gated Na+ channels slows conduction
(how the AV node prolongs transmission from atria to ventricles) "<img
src=""7747.png"">" cardiovascular pacemaker-action-potential physiology
Compared with the myocardial action potential, which phases are absent from the
pacemaker action potential? Phases 1 and 2 (initial repolarization and plateau
phases) "<img src=""7747.png"">" cardiovascular pacemaker-action-potential
physiology
During which phase(s) of the cardiac action potential are K+ channels open? Phase
3 (leading to K+ efflux and repolarization) "<img src=""7747.png"">"
The slope of which phase in the sinoatrial node determines the heart rate? What
neurotransmitters increase and decrease the heart rate? Phase 4; catecholamines
increase heart rate by increasing the rate of depolarization; ACh and adenosine
decrease depolarization & heart rate "<img src=""7747.png"">"
Which phase of the cardiac action potential accounts for the automaticity of the
pacemaker nodes? How? "Phase 4; the If (""funny current"") channels conduct Na+
and K+, which causes spontaneous depolarization" "<img src=""7747.png"">"
"What does sympathetic stimulation do to the likelihood that If (""funny current"")
channels are open?" Increases it (As a result, the pacemaker cell depolarizes
more frequently, and the heart rate increases.) "<img src=""7747.png"">"
Name the phases of the pacemaker action potential, in order. Phase 0 =
upstroke, phase 3 = inactivation of Ca2+ channels/activation of K+ channels, phase
4 = slow spontaneous diastolic depolarization "<img src=""7747.png"">"
Which part of the electrocardiogram represents atrial repolarization? Atrial
repolarization is masked within the QRS complex "<img src=""7748.png"">"
cardiovascular electrocardiogram physiology
A 67-y/o man has U waves on his electrocardiogram in the ED. He has a normal heart
rate. What is the treatment? Replenish potassium (U waves are caused by
hypokalemia or bradycardia, the latter of which this pt does not have.) "<img
src=""7748.png"">" cardiovascular electrocardiogram physiology
What is the physiologic benefit of the atrioventricular delay? How long is it?
It allows time for ventricular filling; 100 msec "<img src=""7748.png"">"
Order the following pacemakers from fastest to slowest heart rate: His-Purkinje
system/ventricles, SA node, AV node SA node, AV node, His-Purkinje
system/ventricles "<img src=""7748.png"">" cardiovascular electrocardiogram
physiology
Order the following structures from fastest to slowest conduction: AV node, atria,
Purkinje fibers, ventricles Purkinje fibers, atria, ventricles, AV node "<img
Outline the conduction pathway starting from the SA node and ending with the
ventricles. SA node, atria, AV node, common bundle, bundle branches, fascicles,
Purkinje fibers, ventricles "<img src=""7748.png"">" cardiovascular
electrocardiogram physiology
How long is a normal PR interval? QRS complex? &60; 200 msec; &60; 20 msec "<img
A pt has a prolonged QT interval. What does this interval on the electrocardiogram
measure? Ventricular depolarization, mechanical contraction of the ventricles,
ventricular repolarization "<img src=""7748.png"">" cardiovascular
A man had chest pain recently. Inverted T waves are seen on his electrocardiogram.
What happened? What does this wave usually represent? He had a myocardial
infarction (MI), causing cardiac ischemia; inverted T waves (ventricular
repolarization) usually indicate a recent MI "<img src=""7748.png"">"
A man is given a drug that slows AV nodal conduction. Which segment of the
electrocardiogram do you expect to change as a result? The PR interval, which
represents the time from start of atrial depolarization to start of ventricular
depolarization (AV node conduction) "<img src=""7748.png"">" cardiovascular
On a pt's electrocardiogram, you note oddly enlarged P waves. This may indicate
pathology in which part of the heart? The atrium (P waves represent atrial
depolarization.) "<img src=""7748.png"">" cardiovascular electrocardiogram
physiology
A pt has an MI and loses the SA node pacemaker. The heart, however, still beats.
What is happening? The AV node (located in the posteroinferior part of the
interatrial septum) can take over if the SA node (inherent dominance) is knocked
out "<img src=""7748.png"">" cardiovascular electrocardiogram physiology
On a man's ECG, at the end of the QRS complex, before the ST segment begins, you
note a small sharp point. Are you worried about pathology? No, as this is likely
the J point, which is a normal finding "<img src=""7748.png"">"
Define torsades de pointes. Ventricular tachycardia, characterized by a
polymorphic sinusoidal pattern on electrocardiogram "<img src=""7749.png"">"
cardiovascular physiology torsades-de-pointes
What are the most dangerous sequelae of torsades de pointes? Ventricular
fibrillation and death "<img src=""7749.png"">" cardiovascular physiology
torsades-de-pointes
A 25-year-old man has a congenital long QT syndrome. What is the most likely cause
of the condition? What is he at risk for? Ion channel defects that disrupt
myocardial repolarization; torsades de pointes and sudden cardiac death "<img
src=""7749.png"">" cardiovascular physiology torsades-de-pointes
A 25-year-old man has a congenital long QT syndrome. Which genetic condition(s) may
he also have? Sensorineural deafness (Jervell and Lange-Nielsen syndrome,
autosomal recessive) (Romano-Ward syndrome [autosomal dominant] is pure cardiac)
"<img src=""7749.png"">" cardiovascular physiology torsades-de-pointes
Name five classes of medications that can prolong the QT interval.
"AntiArrhythmics (IA,III), antiBiotics (macrolides), anti""C""ychotics
(haloperidol), antiDepressants (TCAs), antiEmetics (ondansetron) (ABCDE)" "<img
src=""7749.png"">" cardiovascular physiology torsades-de-pointes
An Asian man's ECG shows a pseudo-right bundle branch block and ST elevations in
V1-V3. You suspect which inherited disorder? Brugada syndrome, which is an
autosomal dominant disorder most common in Asian male subjects "<img
src=""7750.png"">" brugada-syndrome cardiovascular physiology
An Asian man has Brugada syndrome. What is he at risk for? What preventive measure
should you take to help this pt? Ventricular tachyarrhythmias and sudden cardiac
death; these conditions can be prevented with an implantable cardioverter-
defibrillator "<img src=""7750.png"">" brugada-syndrome cardiovascular
physiology
What is Wolff-Parkinson-White syndrome? A disorder with an abnormal fast
accessory conduction pathway from the atria to the ventricles, leading to early
ventricular depolarization "<img src=""7751.png"">" cardiovascular
physiology wolff-parkinson-white-syndrome
In the lab, you study the heart of a pt with Wolff-Parkinson-White syndrome. You
note a pathway bypassing the AV node. What is it? This is likely the accessory
pathway (bundle of Kent) giving rise to the disorder "<img src=""7751.png"">"
cardiovascular physiology wolff-parkinson-white-syndrome
An 18-year-old woman presents with a targetoid rash after hiking in the woods.
Without treatment, she is at risk for what heart condition?Third-degree (complete)
atrioventricular block from Lyme disease "<img src=""7752.png"">"
cardiovascular ecg-tracings physiology
Why are pts with atrial fibrillation at increased risk for stroke? How is it
treated? It causes atrial stasis, which can lead to cardioembolic events; it is
treated w/rate/rhythm control, antithrombotics, and/or cardioversion "<img
src=""7752.png"">" cardiovascular ecg-tracings physiology
A pt has electrocardiographic findings consistent with third-degree heart block.
What are they? What is the treatment? P waves and QRS complexes are present but
have no relation with one another because atria and ventricles beat independently;
a pacemaker "<img src=""7752.png"">" cardiovascular ecg-tracings physiology
Why does atrial flutter present with sawtooth waves on electrocardiogram? How is it
treated? Rapid sequence of identical back-to-back atrial depolarization waves;
rate control, anticoagulation, cardioversion, or ablation (definitive) "<img
src=""7752.png"">" cardiovascular ecg-tracings physiology
A pt has a PR interval of 250 msec that does not change in length. What type of
atrioventricular block is this? First-degree AV block (Pts are generally free
of symptoms.) It is benign, and no treatment is required "<img src=""7752.png"">"
cardiovascular ecg-tracings physiology
Does progressive lengthening of the PR interval occur in Mobitz type I, type II, or
both? Which is more likely to progress to third-degree? Mobitz type I only;
Mobitz type II "<img src=""7752.png"">" cardiovascular ecg-tracings
physiology
One can use rate or rhythm control for the treatment of atrial fibrillation. Which
drug classes are commonly used for each approach? Rate control = -blockers,
non-dihydropyridine Ca2+ channel blockers, digoxin; rhythm control = class IC or
III antiarrhythmics "<img src=""7752.png"">" cardiovascular ecg-tracings
physiology
During a stroke workup, it is common to perform both an ECG and echocardiogram.
Certain findings may prompt treatment with warfarin. Why? Atrial fibrillation can
predispose a pt to cardioembolic events, which can be prevented with
antithrombotics such as warfarin "<img src=""7752.png"">" cardiovascular
ecg-tracings physiology
Which renal arterioles does atrial natriuretic peptide (ANP) constrict?
Efferent. ANP dilates afferent arterioles and constricts efferent arterioles,
resulting in increased GFR and diuresis through cGMP "<img src=""7753.png"">"
atrial-natriuretic-peptide cardiovascular physiology
A 75-year-old man with exacerbated congestive heart failure has pitting edema. How
is atrial natriuretic peptide affected? Atrial natriuretic peptide increases due
to increased blood volume and increased atrial pressure and counteracts the effects
of aldosterone "<img src=""7753.png"">" atrial-natriuretic-peptide
"How is the ""aldosterone escape"" mechanism mediated by atrial natriuretic
peptide?" cGMP-mediated afferent arteriole dilation and efferent arteriole
constriction promote diuresis and counteract the effects of aldosterone "<img
src=""7753.png"">" atrial-natriuretic-peptide cardiovascular physiology
What is the effect of atrial natriuretic peptide on the renal collecting tubule?
ANP, released from atrial myocytes, promotes vasodilation and decreases the
reabsorption of Na+ at the renal collecting tubule "<img src=""7753.png"">"
atrial-natriuretic-peptide cardiovascular physiology
Which myocytes release BNP? Ventricular myocytes release it in response to
increased tension. (BNP functions similarly to ANP but with a longer half-life.)
"<img src=""7754.png"">" b-type-(brain)-natriuretic-peptide
A 45-year-old man comes in and is concerned about heart failure. BNP is normal. Why
is this important? BNP has a good negative predictive value, so the pt likely
does not have heart failure "<img src=""7754.png"">" b-type-(brain)-
natriuretic-peptide cardiovascular physiology
A pt presents with shortness of breath. Heart failure is diagnosed, and nesiritide
is administered. What does this drug do? Nesiritide is a recombinant form of B-
type (brain) natriuretic peptide (BNP) acting similarly to BNP/ANP and useful in
treatment of HF "<img src=""7754.png"">" b-type-(brain)-natriuretic-peptide
Describe how blood pressure is related to the transmission of impulses from the
aortic arch receptors to the medulla. Aortic arch baroreceptor afferents travel
via the vagus nerve to the solitary nucleus of the medulla in response to or
blood pressure "<img src=""7755.png"">" baroreceptors-and-chemoreceptors
Describe how blood pressure relates to the transmission of signals from carotid
sinus receptors to the solitary nucleus of the medulla. Baroreceptor afferents
near dilated regions at the carotid bifurcations travel via the glossopharyngeal
nerves to the medulla ( or BP) "<img src=""7755.png"">" baroreceptors-and-
chemoreceptors cardiovascular physiology
Changes in which two parameters of brain interstitial fluid affect the response of
central chemoreceptors? pH and PCO2, which are influenced by arterial CO2 (Central
chemoreceptors do not directly respond to PO2.) "<img src=""7755.png"">"
baroreceptors-and-chemoreceptors cardiovascular physiology
A 30-year-old man falls and hits his head. Pulse = 43, BP = 150/100, RR = 8.
Identify the reaction that explains these findings. Cushing reaction (Increased
ICP constricts arterioles, causing cerebral ischemia, reflex hypertension, and
reflex bradycardia.) "<img src=""7755.png"">" baroreceptors-and-
Are peripheral or central baroreceptors responsible for the Cushing reaction?
Central baroreceptors "<img src=""7755.png"">" baroreceptors-and-
A man is shot in the abdomen and bleeds heavily. Which type of receptor is most
important in causing the body's response to the hemorrhage?Baroreceptors (These are
most implicated in the body's response to hypotension.) "<img src=""7755.png"">"
A 50-year-old man presents to the ED after fainting while tying his neck tie. What
is the mechanism of his syncope? Carotid sinus massage while tying the tie
baroreceptor firing AV node refractory period HR and CO "<img
src=""7755.png"">" baroreceptors-and-chemoreceptors cardiovascular physiology
Describe the body's response after baroreceptors sense hypotension. Decreased
arterial pressure/stretch, less baroreceptor firing, sympathetic tone,
parasympathetic tone, resulting in HR/BP/contractility "<img src=""7755.png"">"
What chemical changes in the blood elicit a response from peripheral
chemoreceptors? How do central chemoreceptors differ? Low PO2 (< 60 mm Hg), high
PCO2, and low blood pH; central chemoreceptors are not sensitive to O2 "<img
src=""7755.png"">" baroreceptors-and-chemoreceptors cardiovascular physiology
What is the normal pressure for the right atrium? The left atrium? &60; 5 mm
Hg; &60; 12 mm Hg "<img src=""7756.png"">" cardiovascular normal-cardiac-
pressures physiology
A woman is brought to the ICU for hypotension. What instrument can estimate her
left atrial pressure? What does it actually measure? A Swan-Ganz catheter
(pulmonary artery catheter); pulmonary capillary wedge pressure "<img
src=""7756.png"">" cardiovascular normal-cardiac-pressures physiology
What is the normal pressure for the right ventricle during systole and diastole?
The left ventricle? 25/5 mm Hg; 130/10 mm Hg "<img src=""7756.png"">"
cardiovascular normal-cardiac-pressures physiology
What is the normal pressure for the pulmonary artery during systole and diastole?
The aorta? 25/10 mm Hg; 130/90 mm Hg "<img src=""7756.png"">"
cardiovascular normal-cardiac-pressures physiology
A man has mitral stenosis. What would you expect his pulmonary capillary wedge
pressure to be compared with his LV diastolic pressure? PCWP &62; left
ventricular diastolic pressure "<img src=""7756.png"">" cardiovascular
normal-cardiac-pressures physiology
In which organ does hypoxia cause vasoconstriction? Lungs. This ensures that only
well-ventilated areas are perfused "<img src=""7757.png"">" autoregulation
Which local metabolites govern autoregulation of perfusion of the heart? The brain?
What specific change do they cause in the vasculature? Carbon dioxide,
adenosine, nitric oxide (NO), or decreased O2; carbon dioxide (pH); vasodilation
"<img src=""7757.png"">" autoregulation cardiovascular physiology
What factors govern autoregulation of perfusion of the kidneys? Myogenic and
tubuloglomerular feedback "<img src=""7757.png"">" autoregulation
Which factors govern autoregulation of perfusion of the skeletal muscles during
exercise? At rest? During exercise = local metabolites such as lactate,
adenosine, potassium, protons, carbon dioxide; at rest = sympathetic tone "<img
src=""7757.png"">" autoregulation cardiovascular physiology
Which factor governs autoregulation of perfusion of the skin? What is the effect on
homeostasis? Sympathetic stimulation; temperature control "<img
What is meant by autoregulation of blood flow? The method by which blood flow to
an organ remains constant over a wide range of perfusion pressures "<img
Baseline arterial O2 saturation is 87% in an 85-y/o man with COPD. How does this
affect pulmonary vessels? How does it benefit him? Hypoxia causes
vasoconstriction, which allows for only well-ventilated areas to remain perfused;
it optimizes gas exchange "<img src=""7757.png"">" autoregulation
How is net fluid flow (Jv) related to different pressures? Capillary permeability
to fluid (Kf)? Capillary permeability to protein ()? Jv = Kf ([Capillary
pressure Interstitial fluid pressure] [Plasma colloid pressure
Interstitial fluid colloid pressure]) "<img src=""7758.png"">" capillary-
fluid-exchange cardiovascular physiology
A 70-year-old woman has lower-extremity pitting edema. Name four common changes in
the net fluid flow equation that can cause edema. Capillary pressure,
capillary permeability, interstitial colloid osmotic pressure, or plasma
protein content "<img src=""7758.png"">" capillary-fluid-exchange
Which pressures, when increased, have a tendency to cause fluid to move from
capillaries into tissues? From the tissue into capillaries?Capillary fluid pressure
and interstitial fluid colloid osmotic pressure; interstitial fluid pressure and
plasma colloid osmotic pressure "<img src=""7758.png"">" capillary-fluid-
exchange cardiovascular physiology
An 80-year-old man with a history of right-sided heart failure has ankle edema. In
terms of capillary pressure, how did he develop edema? Heart failure increased
capillary pressure, which drove the fluid to move out of the capillaries and into
the interstitium "<img src=""7758.png"">" capillary-fluid-exchange
A 55-year-old man with alcoholic cirrhosis presents with pedal edema and ascites.
In terms of capillary pressure, how did he develop edema? Liver failure decreased
plasma protein content, decreasing plasma oncotic pressure and causing fluid to
move into the interstitium "<img src=""7758.png"">" capillary-fluid-exchange
A 5-year-old boy presents with proteinuria and periorbital edema. In terms of
capillary pressure, how did he develop edema? He probably has minimal change
disease (nephrotic syndrome), causing loss of plasma proteins and decreased colloid
pressure, promoting edema "<img src=""7758.png"">" capillary-fluid-exchange
What is the mechanism by which toxins, infections, and burns can cause edema?
Increased capillary permeability causes an increase in the filtration
constant (Kf), leading to leakage into the interstitium "<img src=""7758.png"">"
capillary-fluid-exchange cardiovascular physiology
A 50-year-old African man presents with bilateral leg and scrotal edema due to
elephantiasis. How did he develop edema? Lymphatic obstruction caused increased
interstitial colloid osmotic pressure, which caused fluid to move into the
interstitium "<img src=""7758.png"">" capillary-fluid-exchange
You deliver a baby whose skin remains bluish even hours after delivery. You suspect
a persistent truncus arteriosus. Define this disorder. Lack of aorticopulmonary
septum causes failure of truncus arteriosus to divide into pulmonary trunk and
aorta; most pts also have VSD "<img src=""7759.png"">" Pathology cardiovascular
congenital-heart-diseases
Do right-to-left shunts cause early or late cyanosis? Early, as deoxygenated blood
from the right heart enters the left heart/systemic circulation (Right-to-Left
shunts: eaRLy cyanosis) "<img src=""7759.png"">" Pathology cardiovascular
What are the five congenital cyanotic heart diseases? (Hint: 5 Ts) Tetralogy of
Fallot,Transposition of great vessels,Truncus arteriosus.Tricuspid atresia,Total
anomalous pulmonary venous return (TAPVR) "<img src=""7759.png"">" Pathology
cardiovascular congenital-heart-diseases
A 5-year-old boy is newly diagnosed with a cyanotic heart defect. What are the
three possible causes, from most to least likely? Ventricular septal defect,
atrial septal defect, and patent ductus arteriosus "<img src=""7759.png"">"
Pathology cardiovascular congenital-heart-diseases
What are the heart sounds associated with atrial septal defects? A loud S1, a wide
fixed split S2 "<img src=""7759.png"">" Pathology cardiovascular
A cyanotic newborn boy is diagnosed with tricuspid atresia. In order to survive,
what other heart defects must this child have? He must have both an atrial and a
ventricular septal defect to survive (This baby has no tricuspid valve and a
hypoplastic right ventricle.) "<img src=""7759.png"">" Pathology cardiovascular
Which congenital heart diseases (if uncorrected) can eventually result in
Eisenmenger syndrome? How do they cause it? ASD/VSD/PDA; left-to-right shunts
pulmonary flow, triggering pulmonary vasculature changes/arterial hypertension
RVH right-to-left shunt "<img src=""7759.png"">" Pathology cardiovascular
Cardiac MRI is performed on a pt with dyspnea, and total anomalous pulmonary venous
return is diagnosed. What is this anomaly? Pulmonary veins drain into the
right heart circulation (eg, SVC or carotid sinus) instead of the left (seen with
ASD and sometimes PDA) "<img src=""7759.png"">" Pathology cardiovascular
Tetralogy of Fallot is caused by the displacement of which structure during
embryogenesis? In which direction(s) is it displaced? The infundibular septum; it
is displaced anteriorly and superiorly "<img src=""7759.png"">" Pathology
A 60-y/o man has hypertension in the upper extremities and weak pulses in the lower
extremities. Diagnosis? Other physical exam findings? Coarctation of the aorta
(aortic narrowing near ductus arteriosus insertion); notched ribs on x-ray due to
collateral arteries eroding ribs "<img src=""7759.png"">" Pathology
A pt is diagnosed with tetralogy of Fallot. The severity of which structural
abnormality is the most important determinant for prognosis? Pulmonary
infundibular stenosis "<img src=""7759.png"">" Pathology cardiovascular
Which congenital or genetic diseases are associated with coarctation of the aorta?
Bicuspid aortic valve, Turner syndrome, and other heart defects "<img
src=""7759.png"">" Pathology cardiovascular congenital-heart-diseases
In tetralogy of Fallot, why does right-to-left shunting occur? " Pressure in
right ventricle (pulmonary stenosis) causes blood to be shunted through the VSD;
results in early cyanotic ""tet spells"" & RVH" "<img src=""7759.png"">"
Pathology cardiovascular congenital-heart-diseases
What is the direction of blood flow across the ductus arteriosus before and after
birth? How is the patency of this shunt maintained? Before = right to left; after
= left to right (due to lung resistance); maintained by prostaglandin E synthesis
and low O2 tension "<img src=""7759.png"">" Pathology cardiovascular
The face, lips, and tongue of a 2-year-old child turn blue whenever he cries. If he
squats, color returns to normal. Why? Squatting increases SVR, decreases right-
to-left shunting, and reduces cyanosis. (This child has tetralogy of Fallot.)
"<img src=""7759.png"">" Pathology cardiovascular congenital-heart-
diseases
A newborn has a continuous machine-like murmur and is also diagnosed with
transposition of the great vessels. What drug does she need? Prostaglandin E,
which is used to maintain a patent ductus arteriosus until transposition is
corrected (PGE keeps ductus Going.) "<img src=""7759.png"">" Pathology
Name the four congenital heart defects that comprise tetralogy of Fallot.
Pulmoary stenosis, Right ventricular hypertrophy (boot-shaped heart on chest
x-ray), Overriding aorta, and VSD (PROVe) "<img src=""7759.png"">" Pathology
A pt with anterosuperior displacement of the infundibular septum has episodes of
cyanosis. What urgent treatment does he need? Early surgical correction (The pt
has tetralogy of Fallot.) "<img src=""7759.png"">" Pathology cardiovascular
A 2-year-old child is noted to have feet that are always blue. Her hands appear
normal. What is this called? Why might she have it? Differential cyanosis; it may
be a result of a patent ductus arteriosus, which can be closed by administering
indomethacin "<img src=""7759.png"">" Pathology cardiovascular
What is the prognosis for infants with D-transposition of great vessels? They
die within the first few months of life if their condition is not surgically
corrected by addition of a shunt "<img src=""7759.png"">" Pathology
A pt has late cyanosis, clubbing, and polycythemia. He was also found to have an
asymptomatic ventricular septal defect. Diagnosis? Eisenmenger syndrome, which
results from uncorrected left-to-right shunts (Age at onset varies.) "<img
Large ventricular septal defects may lead to which harmful conditions? Left
ventricular overload, heart failure "<img src=""7759.png"">" Pathology
Describe the pathophysiology of D-transposition of great vessels.
Aorticopulmonary septum fails to spiral exiting of aorta from RV/pulmonary
trunk from LV separation of systemic/pulmonary circulations "<img
Which type of atrial septal defect, primum or secundum, can result in symptoms
ranging from none to heart failure? Secundum (most common and usually isolated)
(Ostium primum defects are rarer but usually accompanied by other cardiac
anomalies.) "<img src=""7759.png"">" Pathology cardiovascular congenital-
heart-diseases
What is the most common cause of early cyanotic heart disease? Tetralogy of
Fallot "<img src=""7759.png"">" Pathology cardiovascular congenital-
heart-diseases
Do left-to-right shunts cause early or late cyanosis? "Late, as cyanosis does not
occur until increased pulmonary pressure becomes significant (""blue kids"") (Left-
to-Right shunts: LateR cyanosis)" "<img src=""7759.png"">" Pathology
A newborn has a right-to-left cardiac shunt. Do you expect it to cause cyanosis
early or late in life? Early, as blood bypasses the lungs & is not oxygenated
(blue babies); usually requires urgent surgical correction and/or maintenance of a
PDA "<img src=""7759.png"">" Pathology cardiovascular congenital-heart-
diseases
A short 16-year-old girl has a webbed neck and primary amenorrhea. What heart
defect(s) may she have? Coarctation of aorta, bicuspid aortic valve (This girl has
Turner syndrome.) "<img src=""7760.png"">" Pathology cardiovascular
congenital-cardiac-defect-associations
Genetic testing of a newborn shows a 22q11 deletion. What cardiac defect(s) might
you find on further workup? Truncus arteriosus, tetralogy of Fallot "<img
src=""7760.png"">" Pathology cardiovascular congenital-cardiac-defect-
associations
A newborn boy has epicanthal folds, a flattened nasal bridge, and a single
transverse palmar crease. What heart defects may he have? Atrial, ventricular, and
atrioventricular septal defects (endocardial cushion defects) (The newborn has Down
syndrome.) "<img src=""7760.png"">" Pathology cardiovascular congenital-
cardiac-defect-associations
"A newborn with a ""blueberry muffin rash"" is diagnosed with congenital rubella.
What cardiac defect(s) might you find on further workup?" Septal defects, patent
ductus arteriosus, pulmonary artery stenosis "<img src=""7760.png"">"
Pathology cardiovascular congenital-cardiac-defect-associations
A pt is diagnosed with Marfan syndrome. You immediately perform an echocardiogram
to look for which cardiovascular complication(s)? Mitral valve prolapse, aortic
regurgitation, and thoracic aortic aneurysm and dissection "<img src=""7760.png"">"
A mother has poorly controlled diabetes. The offspring of this diabetic mother are
at increased risk of what congenital cardiac defect(s)? Transposition of great
vessels "<img src=""7760.png"">" Pathology cardiovascular congenital-
cardiac-defect-associations
An alcoholic woman drank heavily during her pregnancy. Which congenital heart
defect(s) are associated with fetal alcohol syndrome? Ventricular/atrial septal
defects, patent ductus arteriosus, tetralogy of Fallot "<img src=""7760.png"">"
A pt who is currently being treated for bipolar disorder is planning on pregnancy.
Which drug should not be given? Why? Lithium should not be given; it is
associated with the Ebstein anomaly, a congenital cardiac defect "<img
src=""7760.png"">" Pathology cardiovascular congenital-cardiac-defect-
associations
"A pt has ""elfin"" facial characteristics and exhibits an unusually cheerful
demeanor. What congenital cardiac defect(s) may be present?" Supravalvular
aortic stenosis (This is Williams syndrome.) "<img src=""7760.png"">"
What is the definition of hypertension in an adult? Persistent blood pressure of
140/90 mm Hg or above (Hypertensive urgency is observed when pressures are >1
80/120 mm Hg.) "<img src=""7761.png"">" Pathology cardiovascular
hypertension
Which racial group(s) has(ve) the greatest risk of developing hypertension: blacks,
whites, or Asians? Blacks, then whites, then Asians "<img src=""7761.png"">"
Pathology cardiovascular hypertension
Secondary hypertension is most commonly secondary to disease(s) in which organ(s)?
The kidneys (eg, fibromuscular dysplasia, usually in younger women), the
adrenal glands (eg, primary hyperaldosteronism) "<img src=""7761.png"">"
What are some risk factors for hypertension? Increased age, obesity, diabetes,
excess salt or alcohol intake, family history, physical inactivity "<img
src=""7761.png"">" Pathology cardiovascular hypertension
A pt has a blood pressure of 150/105 mm Hg. Regardless of age, sex, and history,
what is the most likely cause of the hypertension? Increased cardiac output or
total peripheral resistance (this is essential, or primary, hypertensionthe cause
of 90% of cases) "<img src=""7761.png"">" Pathology cardiovascular
hypertension
What are some cardiac conditions to which individuals with hypertension are
predisposed? Coronary artery disease, left ventricular hypertrophy, heart
failure, stroke, aortic dissection/aneurysm, atrial fibrillation "<img
src=""7761.png"">" Pathology cardiovascular hypertension
What are some noncardiac conditions to which individuals with hypertension are
predisposed? Chronic kidney disease (hypertensive nephropathy), retinopathy
"<img src=""7761.png"">" Pathology cardiovascular hypertension
What is the difference between hypertensive urgency and hypertensive emergency in
the context of severe hypertension (BP =180/=120 mm Hg)? Hypertensive urgency:
acute end-organ damage is absent; hypertensive emergency: acute end-organ damage is
present "<img src=""7761.png"">" Pathology cardiovascular hypertension
Give some examples of acute end-organ damage seen in hypertensive emergencies.
Encephalopathy, stroke, HF, papilledema, retinal hemorrhages/exudates, aortic
dissection, nephropathy, eclampsia, hemolytic anemia "<img src=""7761.png"">"
An 80-year-old woman notices a light ring around her iris. What is the most likely
underlying cause? Hyperlipidemia (She has a corneal lipid deposit [corneal arcus],
which is common in the elderly [arcus senilis].) "<img src=""7762.png"">"
Pathology cardiovascular hyperlipidemia-signs
A 65-year-old man has diabetes and essential hypertension. What disease process do
you suspect in his small arteries and arterioles? Hyaline arteriolosclerosis
(thickening of the small artery vessel walls in essential hypertension or diabetes
mellitus) "<img src=""7763.png"">" Pathology arteriosclerosis cardiovascular
What is another name for Mnckeberg arteriosclerosis? Medial calcific sclerosis
"<img src=""7763.png"">" Pathology arteriosclerosis cardiovascular
What is atherosclerosis? Which types of arteries are susceptible to
atherosclerosis? It is a form of arteriosclerosis caused by cholesterol plaque
buildup; elastic arteries as well as large- and medium-sized muscular arteries
"<img src=""7764.png"">" Pathology atherosclerosis cardiovascular
A 75-year-old woman has a long history of hypertension and has developed
atherosclerosis. Name six possible complications of this disease. Aneurysms,
ischemia, infarcts, peripheral vascular disease, thrombus, emboli "<img
src=""7764.png"">" Pathology atherosclerosis cardiovascular
What are two symptoms of ischemia resulting from atherosclerosis? Angina and
claudication, although many pts may have no symptoms "<img src=""7764.png"">"
Pathology atherosclerosis cardiovascular
Name four modifiable and three nonmodifiable risk factors for atherosclerosis.
Modifiable: smoking, hypertension, diabetes mellitus, hyperlipidemia;
nonmodifiable: age, gender, family history "<img src=""7764.png"">"
Pathology atherosclerosis cardiovascular
List the four most common locations for atherosclerosis to occur in order of
prevalence. Abdominal aorta, coronary artery, popliteal artery, and carotid artery
"<img src=""7764.png"">" Pathology atherosclerosis cardiovascular
Fatty streaks are a precursor of atherosclerotic plaques. How are fatty streaks
formed? Endothelial cell dysfunction with macrophage and LDL accumulation leads
to foam cell formation, which leads to formation of fatty streaks "<img
src=""7764.png"">" Pathology atherosclerosis cardiovascular
In addition to hypertension and connective tissue disease (eg, Marfan syndrome),
what conditions are linked with thoracic aortic aneurysm? Cystic medial
degeneration, bicuspid aortic valve, tertiary syphilis (obliterative endarteritis
of vasa vasorum) "<img src=""7765.png"">" Pathology aortic-aneurysm
cardiovascular
A pt has a localized, pathologic dilatation of the aorta. What symptoms exhibited
by this pt will require immediate attention? Back and/or abdominal pain, which
indicates leaking, dissection, or imminent rupture (The pt has an aortic aneurysm.)
"<img src=""7765.png"">" Pathology aortic-aneurysm cardiovascular
What causes aortic rupture? Trauma and/or deceleration injury "<img
src=""7766.png"">" Pathology cardiovascular traumatic-aortic-rupture
What is the most common portion of the aorta to rupture during traumatic injury?
The aortic isthmus (proximal descending aorta) "<img src=""7766.png"">"
Pathology cardiovascular traumatic-aortic-rupture
A very tall, double-jointed 25-y/o man presents for an annual exam. He is from a
tall family. For what vascular lesion is he most at risk? Aortic dissection,
because he likely has Marfan syndrome; aortic dissection is also associated with
hypertension and a bicuspid aortic valve "<img src=""7767.png"">" Pathology
aortic-dissection cardiovascular
Define the two types of aortic dissection: Stanford type A and Stanford type B.
A: proximal, involves ascending aorta, may extend to aortic arch/descending
aorta; B: distal, involves aortic arch and/or descending aorta "<img
src=""7767.png"">" Pathology aortic-dissection cardiovascular
A pt is found to have an aortic dissection that is located only at the descending
aorta. What is the treatment for his condition? Administration of -blockers, then
vasodilators (This is Stanford type B aortic dissection.) "<img src=""7767.png"">"
Pathology aortic-dissection cardiovascular
A pt is found to have an aortic dissection that is located only at the ascending
aorta. What is the treatment for his condition? Surgery (The pt has Stanford type A
aortic dissection.) "<img src=""7767.png"">" Pathology aortic-dissection
cardiovascular
What are the characteristics of stable angina? Chest pain occurring with exertion
and improving with rest, ST depressions often seen on ECG, usually secondary to
atherosclerosis "<img src=""7768.png"">" Pathology cardiovascular ischemic-
heart-disease-manifestations
How does the etiology of Prinzmetal (variant) angina differ from that of other
forms of angina? It is 2 to coronary artery spasm at rest with transient ST
elevations on ECG; triggers are tobacco, cocaine, triptans (but often unknown)
"<img src=""7768.png"">" Pathology cardiovascular ischemic-heart-
disease-manifestations
How do the symptoms of unstable angina differ from those of stable angina? Chest
pain can occur without exertion. (Unstable angina is a result of incomplete
coronary artery occlusion due to thrombosis.) "<img src=""7768.png"">"
Pathology cardiovascular ischemic-heart-disease-manifestations
A 55-year-old man with angina takes a vasodilator. How may this actually aggravate
his ischemia? A vasodilator causes blood to be shunted to areas of higher
perfusion, away from stenotic/ischemic regions (coronary steal syndrome) "<img
src=""7768.png"">" Pathology cardiovascular ischemic-heart-disease-
manifestations
At what point is ischemic heart disease given the term myocardial infarction rather
than unstable angina? When acute thrombosis due to coronary artery
atherosclerosis results in myocyte necrosis with an elevation in cardiac biomarkers
What are the five possible manifestations of ischemic heart disease? Angina,
coronary steal syndrome, myocardial infarction, sudden cardiac death, and chronic
ischemic heart disease "<img src=""7768.png"">" Pathology cardiovascular
ischemic-heart-disease-manifestations
A 45-y/o man develops severe chest pain and shortness of breath and then dies 45
minutes later. What is the most likely cause of death? Lethal arrhythmias, such
as ventricular fibrillation. Sudden cardiac death happens within 1 hour of onset of
symptoms "<img src=""7768.png"">" Pathology cardiovascular ischemic-heart-
What is chronic ischemic heart disease? Progression to congestive heart failure
over many years due to chronic ischemic damage from coronary atherosclerosis "<img
manifestations
What electrocardiographic change are you likely to see with stable angina during an
exercise stress test? With Prinzmetal angina? ST depressions; ST elevations "<img
manifestations
You suspect that your pt has unstable angina. What ECG changes may be seen with
unstable angina? Would biomarkers help with diagnosis? Possible ST depression
and/or T-wave inversion; cardiac biomarkers are uninformative (but are useful for
diagnosis of myocardial infarction) "<img src=""7768.png"">" Pathology
cardiovascular ischemic-heart-disease-manifestations
What test would you perform to determine whether a myocardial infarction is
transmural or subendocardial? ECG (Transmural infarcts may show ST elevations;
subendocardial infarcts may show ST depressions.) "<img src=""7768.png"">"
Your pt is a heavy smoker who complains of chest pain at rest. His ECG shows
transient ST elevations. What is appropriate treatment? Calcium channel
blockers, nitrates, and smoking cessation (He most likely has Prinzmetal angina.)
What is the underlying mechanism of most myocardial infarctions? Acute thrombosis
from ruptured coronary artery atherosclerotic plaques "<img src=""7768.png"">"
Which diseases and conditions can lead to the fatal arrhythmias that are associated
with sudden cardiac death? CAD (up to 70% of cases), hypertrophic/dilated
cardiomyopathies, hereditary ion channelopathies (eg, Brugada and long QT
syndromes) "<img src=""7768.png"">" Pathology cardiovascular ischemic-heart-
A 60-y/o man has crushing chest pain that radiates to his left arm. Which coronary
arteries may be occluded (most to least likely)? Left anterior descending,
right coronary artery, circumflex "<img src=""7769.png"">" Pathology
cardiovascular evolution-of-myocardial-infarction
A 65-year-old man comes to the ED, because he thinks he is having a heart attack.
What symptoms may he have? Diaphoresis, nausea, vomiting, severe retrosternal
pain, left arm/jaw pain, dyspnea (shortness of breath), fatigue "<img
src=""7769.png"">" Pathology cardiovascular evolution-of-myocardial-infarction
At which time interval after a myocardial infarction will the infarcted myocardium
show extensive coagulative necrosis? 1 to 3 days "<img src=""7769.png"">"
Pathology cardiovascular evolution-of-myocardial-infarction
During which time interval after a myocardial infarction is there the greatest risk
for ventricular pseudoaneurysm formation? From 3 to 14 days after a myocardial
infarction "<img src=""7769.png"">" Pathology cardiovascular evolution-of-
myocardial-infarction
How long after an MI does the infarcted myocardium appear normal both grossly and
on light microscopy? Can complications occur at this time? For the first 4 hours;
yes, as there is still risk for arrhythmias, heart failure, or cardiogenic shock
"<img src=""7769.png"">" Pathology cardiovascular evolution-of-
How long after a myocardial infarction does early coagulative necrosis begin? What
changes are seen on light microscopy at this time? After 4 hours; edema,
hemorrhages, and neutrophils are seen; and wavy fibers begin to appear "<img
src=""7769.png"">" Pathology cardiovascular evolution-of-myocardial-infarction
A pt has a myocardial infarction and is stabilized. A day later, the cardiologist
is still worried about the pt. Why? The pt is still at risk for arrhythmias, heart
failure, and cardiogenic shock for up to 1 day after the myocardial infarction
occurs "<img src=""7769.png"">" Pathology cardiovascular evolution-of-
Describe the appearance and coloring of the affected myocardium 2 months after a
myocardial infarction. The myocardium appears gray-white, demonstrating a
completely contracted scar "<img src=""7769.png"">" Pathology cardiovascular
evolution-of-myocardial-infarction
At the cellular level, what happens to the infarcted myocardium on the first day of
a myocardial infarction? Intracellular contents of necrotic cells are released
into the blood, and neutrophil migration starts "<img src=""7769.png"">"
Pathology cardiovascular evolution-of-myocardial-infarction
As a result of macrophage-mediated structural degeneration, what are some possible
dangerous sequelae of an MI 3 to 14 days after it occurs? Free wall rupture,
tamponade, papillary muscle rupture, mitral regurgitation, LV pseudoaneurysm,
interventricular septal rupture "<img src=""7769.png"">" Pathology
A man with severe CAD suddenly drops dead. Cardiac biopsy is performed an hour
later. Is a normal appearance on light microscopy surprising? No, as there are
often no abnormal light microscopy findings for up to 4 hours after an MI has
occurred "<img src=""7769.png"">" Pathology cardiovascular evolution-of-
Two weeks after experiencing a heart attack, a pt suddenly drops dead. What was the
most likely cause of sudden death? Free wall rupture causing cardiac tamponade,
occurring 314 days after an MI "<img src=""7769.png"">" Pathology
A 65-y/o man presents to the ED with 1 hour of crushing retrosternal pain radiating
to his jaw. What is the diagnostic gold standard? Electrocardiography is the
gold standard diagnostic test for MI within 6 hours of onset of symptoms "<img
src=""7770.png"">" Pathology cardiovascular diagnosis-of-myocardial-infarction
A 50-y/o man with MI symptoms has ST depressions on electrocardiogram and positive
troponins. How much of his ventricular wall is necrotic? His ECG suggests a
subendocardial infarct, where >50% of the ventricular wall is necrotic
(Subendocardium is highly vulnerable to ischemia.) "<img src=""7770.png"">"
Pathology cardiovascular diagnosis-of-myocardial-infarction
A pt presents w/1 hr of retrosternal pain radiating to her jaw. During which time
interval will cardiac troponin I be elevated in her case? Troponin I rises 4 hours
after a myocardial infarction and is elevated for 7 to 10 days (more specific than
other protein markers) "<img src=""7770.png"">" Pathology cardiovascular
diagnosis-of-myocardial-infarction
A 50-year-old man has a transmural myocardial infarction. What does his
electrocardiogram show? How much of the cardiac wall is affected? ST
elevations and Q waves; the entire wall is affected "<img src=""7770.png"">"
Pathology cardiovascular diagnosis-of-myocardial-infarction
Which protein marker is the most specific during the early stages of myocardial
infarction? Troponin I "<img src=""7770.png"">" Pathology cardiovascular
In which tissue other than the myocardium is CK-MB found? What is it useful for
diagnosing? Skeletal muscle; it is useful for diagnosing reinfarction on top of
acute myocardial infarction, as levels return to normal in 48 hours "<img
src=""7770.png"">" Pathology cardiovascular diagnosis-of-myocardial-infarction
ST-segment elevations on ECG indicate what type of damage to the myocardium? An ST
depression? Pathologic Q waves? Poor R-wave progression? Transmural infarct
(STEMI); subendocardial infarct (NSTEMI); evolving or old transmural infarct;
evolving or old transmural infarct "<img src=""7770.png"">" Pathology
cardiovascular diagnosis-of-myocardial-infarction
Hyperacute (peaked) T waves, inverted T waves, or a new left bundle branch block on
an ECG could all indicate which type of infarct? Transmural infarct (evolving
or old) "<img src=""7770.png"">" Pathology cardiovascular diagnosis-of-
Describe the period of CK-MB elevation after acute myocardial infarction. CK-MB
rises 6 to 12 hours after a myocardial infarction and returns to normal after 48
hours (unless there is reinfarction) "<img src=""7770.png"">" Pathology
cardiovascular diagnosis-of-myocardial-infarction
A pt with crushing substernal chest pain has ST elevation on ECG. Worried, you
immediately order blood work. Which tests are ordered? Measurement of troponin
I, which is a specific marker for myocardial infarction; measurement of CK-MB
should also be considered "<img src=""7770.png"">" Pathology cardiovascular
A 43-y/o woman comes to the ED with chest pain. Electrocardiogram shows ST
elevations in leads II, III, and aVF. Which vessel is occluded? The right coronary
artery, as the infarct is in the inFerior wall, given the involvement of leads II,
III, and aVF "<img src=""7771.png"">" Pathology cardiovascular ecg-
localization-of-stemi
elevations in leads V1 and V2. Where is the infarct located? In the
anteroseptal region, as a result of occlusion of the left anterior descending
artery "<img src=""7771.png"">" Pathology cardiovascular ecg-
localization-of-stemi
elevations in V5 and V6. What territory is occluded? Left circumflex artery or
left anterior descending artery, as the infarct is in the anterolateral region
"<img src=""7771.png"">" Pathology cardiovascular ecg-localization-of-
stemi
elevations in V3 and V4. What vessel is occluded? Left anterior descending
artery in the distal segments, causing an anteroapical infarction "<img
src=""7771.png"">" Pathology cardiovascular ecg-localization-of-stemi
elevations in leads I and aVL. Where is the infarct? In the left circumflex
artery, causing a lateral wall infarction "<img src=""7771.png"">" Pathology
cardiovascular ecg-localization-of-stemi
Which three complications can result from ventricular pseudoaneurysm formation
after a myocardial infarction? Mural thrombus embolization, arrhythmia, and
decreased cardiac output (Greatest risk is 314 days after a myocardial
infarction.) "<img src=""7772.png"">" Pathology cardiovascular
myocardial-infarction-complications
A pt with substernal chest pain is en route to the hospital. You are concerned that
the pt may die. Why? Cardiac arrhythmia is a major cause of death in pts w/MI
before they reach the hospital & is also common in the first few days after an MI
"<img src=""7772.png"">" Pathology cardiovascular myocardial-infarction-
complications
What complication of myocardial infarction can result in cardiac tamponade?
Ventricular free wall rupture "<img src=""7772.png"">" Pathology
cardiovascular myocardial-infarction-complications
What is the cause of the friction rub that can be heard 1 to 3 days after a
myocardial infarction? Postinfarction fibrinous pericarditis "<img
src=""7772.png"">" Pathology cardiovascular myocardial-infarction-
complications
What is Dressler syndrome? An autoimmune syndrome resulting in fibrinous
pericarditis several weeks after myocardial infarction "<img src=""7772.png"">"
Pathology cardiovascular myocardial-infarction-complications
An 83-y/o man with recent myocardial infarction has worsening dyspnea. He has
bibasilar rales and jugular venous distention. Diagnosis? Pulmonary edema due to
left ventricular failure as a complication of recent myocardial infarction "<img
complications
An 80-y/o man with sudden-onset chest pain and ST elevation on electrocardiogram
has hypotension and tachycardia. Diagnosis? Cardiogenic shock (high risk of
mortality due to a large infarct) "<img src=""7772.png"">" Pathology
A ventricular septal defect can result from which post-MI complication? When is the
period of greatest risk for this complication? Interventricular septal rupture;
like all other ruptures, greatest risk is 3 to 14 days after MI "<img
complications
Which post-MI complication is associated with fibrosis and causes a dyskinetic,
outward bulge during contraction? True ventricular aneurysm, which could arise 2
weeks to several months after MI "<img src=""7772.png"">" Pathology
What are the standard treatments for unstable angina and non-ST-segmentelevation
myocardial infarction? Anticoagulation (eg, heparin), antiplatelet therapy (eg,
aspirin + clopidogrel), -blockers, statins, ACE inhibitors"<img src=""7773.png"">"
Pathology acute-coronary-syndrome-treatments cardiovascular
You suspect that a pt has unstable angina. What medications could you provide for
symptom control? Nitroglycerin, morphine "<img src=""7773.png"">" Pathology
acute-coronary-syndrome-treatments cardiovascular
A pt was diagnosed with a transmural MI 30 minutes after arrival at the ED. What is
the most appropriate next step in management? Reperfusion therapy is the most
important therapy for a STEMI, as percutaneous coronary interventions are preferred
over fibrinolysis "<img src=""7773.png"">" Pathology acute-coronary-syndrome-
treatments cardiovascular
A woman w/an STEMI is rushed to the cardiac catheterization lab. On her return to
the unit, do you initiate therapies typical for NSTEMIs? Yes, as such pts, in
addition to reperfusion, benefit from these (anticoagulation, antiplatelets, -
blockers, ACE inhibitors, statins) "<img src=""7773.png"">" Pathology acute-
coronary-syndrome-treatments cardiovascular
What is the most common type of cardiomyopathy? Dilated cardiomyopathy, which
accounts for approximately 90% of cases (often idiopathic or familial) "<img
src=""7774.png"">" Pathology cardiomyopathies cardiovascular
A pt receiving chemotherapy has dyspnea. Echocardiogram shows dilated
cardiomyopathy. Which chemotherapeutic agent is likely responsible? Doxorubicin
"<img src=""7774.png"">" Pathology cardiomyopathies cardiovascular
Which type of cardiomyopathy is peripartum cardiomyopathy? Name some treatments.
Dilated; Na+ restriction, ACE inhibitor, diuretic, -blockers, digoxin,
implantable cardioverter-defibrillator, heart transplant "<img src=""7774.png"">"
Pathology cardiomyopathies cardiovascular
Which hematologic disorder can cause both dilated cardiomyopathy and
restrictive/obliterative cardiomyopathy? Hemochromatosis "<img src=""7774.png"">"
Which septum becomes hypertrophied in hypertrophic cardiomyopathy? What is the
pathophysiology of obstructive hypertrophic cardiomyopathy?The intraventricular
septum; the hypertrophied septum obstructs the outflow tract, because it is too
close to the mitral valve leaflet "<img src=""7774.png"">" Pathology
cardiomyopathies cardiovascular
Several members of an athletic family die at young ages. If the etiology is
cardiac, what is the most likely diagnosis? Hypertrophic cardiomyopathy, as 60%
to 70% of cases are familial (autosomal dominant) "<img src=""7774.png"">"
A young athlete had syncope during practice. He has an S4 heart sound, systolic
murmur, and mitral regurgitation. Name two drug treatments.-Blockers or non-
dihydropyridine Ca2+ channel blockers (eg, verapamil) (This is hypertrophic
cardiomyopathy.) "<img src=""7774.png"">" Pathology cardiomyopathies
cardiovascular
Name the etiologies of dilated cardiomyopathy. Alcohol, wet Beriberi, Coxsackie B,
Cocaine, Chagas disease, Doxorubicin, hemochromatosis, sarcoidosis, peripartum
cardiomyopathy (ABCCCD) "<img src=""7774.png"">" Pathology cardiomyopathies
cardiovascular
Which extra heart sounds are present in dilated cardiomyopathy? S3 and systolic
regurgitant murmur (The heart will also appear dilated on echocardiogram or have a
balloon appearance on chest x-ray.) "<img src=""7774.png"">" Pathology
Describe endocardial fibroelastosis. Thick fibroelastic tissue found in the
endocardium of affected children, which can lead to restrictive cardiomyopathy
"<img src=""7774.png"">" Pathology cardiomyopathies cardiovascular
Which cardiomyopathies present with diastolic dysfunction? With systolic
dysfunction? Restrictive/infiltrative and hypertrophic cardiomyopathies;
dilated cardiomyopathies "<img src=""7774.png"">" Pathology
A boy has frequent falls and slurred speech. Exam shows nystagmus, ataxia, and no
deep tendon reflexes. Which cardiomyopathy may he have? Hypertrophic
cardiomyopathy (The child has Friedreich ataxia.) "<img src=""7774.png"">"
What are six major causes of restrictive cardiomyopathy? Sarcoidosis,
amyloidosis, radiation fibrosis, endocardial fibroelastosis, Lffler syndrome, and
hemochromatosis "<img src=""7774.png"">" Pathology cardiomyopathies
cardiovascular
What is Lffler syndrome? Endomyocardial fibrosis with a prominent eosinophilic
infiltrate that can lead to restrictive cardiomyopathy "<img src=""7774.png"">"
A pt's ECG shows low-voltage tracings despite imaging evidence of a thick
myocardium. Heart biopsy shows amyloid deposits. Diagnosis?Restrictive/infiltrative
cardiomyopathy due to amyloidosis "<img src=""7774.png"">" Pathology
What is the difference between the myocardial cellular structures in dilated
cardiomyopathy and those in hypertrophic cardiomyopathy? Dilated cardiomyopathy:
sarcomeres added in series (eccentric hypertrophy); hypertrophic: myofibrillar
disarray with fibrosis "<img src=""7774.png"">" Pathology cardiomyopathies
cardiovascular
What is the inheritance pattern of familial hypertrophic cardiomyopathy?
Autosomal dominant (commonly, a -myosin heavy-chain mutation) "<img
src=""7774.png"">" Pathology cardiomyopathies cardiovascular
A 16-y/o soccer player has syncope during practice. Exam shows systolic murmur and
S4 sound. His uncle died suddenly at age 18. Diagnosis? Hypertrophic
cardiomyopathy, which can cause dyspnea/syncope and even sudden death (due to
ventricular arrhythmia) during exercise "<img src=""7774.png"">" Pathology
If there is a failure of left ventricular output to increase during exercise, what
is the physical symptom that emerges? Dyspnea on exertion "<img
src=""7775.png"">" Pathology cardiovascular heart-failure
A pt presents with dyspnea and is diagnosed with systolic heart failure. His heart
is dilated. What is the cause of this dilation? Increased ventricular end-diastolic
volume "<img src=""7775.png"">" Pathology cardiovascular heart-failure
A 70-y/o man with CHF starts sleeping on three pillows (vs lying flat), which
relieves his dyspnea. What is the mechanism of the dyspnea?Increased venous return
in the supine position due to gravity, which exacerbates pulmonary vascular
congestion (He has orthopnea.) "<img src=""7775.png"">" Pathology
cardiovascular heart-failure
How does the blood pressure on the right side of the heart affect portal venous
blood flow? As the pressure in the right heart (and central venous system)
increases, resistance increases for portal flow, and portal flow decreases "<img
Increased right-sided heart pressure can lead to what finding on abdominal physical
exam? Hepatomegaly (nutmeg liver on pathology) and, rarely, cardiac cirrhosis
"<img src=""7775.png"">" Pathology cardiovascular heart-failure
What are heart failure cells? Hemosiderin-laden macrophages in the lungs due
to microhemorrhages from increased pulmonary capillary pressure (left heart
failure) "<img src=""7775.png"">" Pathology cardiovascular heart-failure
Define heart failure. List its symptoms. It is a syndrome of cardiac pump
dysfunction that results in congestion and low perfusion; symptoms include dyspnea,
orthopnea, fatigue "<img src=""7775.png"">" Pathology cardiovascular
heart-failure
An 85-y/o woman is known to have right-sided heart failure. What signs may she
have? Why? Ankle edema, jugular venous distention, hepatomegaly; all signs are due
to increased venous pressure "<img src=""7775.png"">" Pathology cardiovascular
heart-failure
What is the most common cause of right-sided heart failure?Left-sided heart failure
"<img src=""7775.png"">" Pathology cardiovascular heart-failure
What is the most common cause of right-sided heart failure in the absence of left-
sided heart failure? Cor pulmonale due to COPD, in which the right ventricle
fails because of increased pulmonary arterial pressure "<img src=""7775.png"">"
Pathology cardiovascular heart-failure
What is a basic treatment paradigm for pts with heart failure? ACE inhibitors or
angiotensin II receptor antagonists, -blockers (except in acute decompensated HF),
spironolactone (All reduce mortality.) "<img src=""7775.png"">" Pathology
cardiovascular heart-failure
A man with heart failure describes awakening with difficulty catching his breath.
What is this? What is the underlying pathophysiology? Paroxysmal nocturnal dyspnea;
it is caused by increased venous return due to redistribution of blood and
reabsorption of edema "<img src=""7775.png"">" Pathology cardiovascular
heart-failure
What is the underlying pathophysiology of pulmonary edema in pts with heart
failure? Increased pulmonary venous pressure leads to pulmonary venous
distention, then fluid transudation into the lungs "<img src=""7775.png"">"
How do ejection fraction and end-diastolic volume change in the setting of systolic
dysfunction? EF decreases and EDV increases due to a decrease in contractility
that is often secondary to ischemia, MI, or dilated cardiomyopathy "<img
How do ejection fraction and end-diastolic volume change in the setting of
diastolic dysfunction? EF is preserved and EDV is normal due to a decrease in
compliance, often secondary to myocardial hypertrophy "<img src=""7775.png"">"
How does the renin-angiotensin-aldosterone system affect peripheral edema and
cardiac output in the setting of heart failure? RAS increases Na+ and water
reabsorption by the kidneys systemic venous pressure edema, preload, and
cardiac output (compensation) "<img src=""7775.png"">" Pathology cardiovascular
heart-failure
A pt with HF has rales and complains of dyspnea and fatigue. Which treatment may
relieve symptoms and lower the risk of mortality? Hydralazine with nitrate
therapy reduces the risk of mortality and relieves symptoms in selected pts with
heart failure "<img src=""7775.png"">" Pathology cardiovascular heart-
failure
Which subtypes of shock give rise to cold, clammy skin? Which type gives rise to
warm, dry skin? Hypovolemic, cardiogenic, and obstructive shock give rise to
cold, clammy skin; distributive shock gives rise to warm, dry skin "<img
src=""7776.png"">" Pathology cardiovascular shock
A hemorrhaging pt is in shock and has cold, clammy skin. What is the primary insult
in this case that gives rise to the shock? The primary insult is significantly
decreased preload due to blood loss. (He has hypovolemic shock.) "<img
A man who recently took a long plane trip develops sudden-onset dyspnea and chest
pain. He now has cold, clammy skin. What is the treatment? Obstruction relief to
increase cardiac output (He has obstructive shock from pulmonary embolism.) "<img
How do preload, afterload, and cardiac output change in the setting of obstructive
shock? Preload and afterload increase, and cardiac output (primary insult)
decreases; common causes: cardiac tamponade and pulmonary embolism "<img
A toddler who accidentally ingested peanuts now has airway constriction and low
blood pressure. What is the treatment? Pressors and IV fluids (He has
distributive shock from anaphylaxis. Other causes of this type of shock include
sepsis and CNS injury.) "<img src=""7776.png"">" Pathology cardiovascular
shock
How do preload, afterload, and cardiac output change in the setting of cardiogenic
shock? Preload & afterload increase; cardiac output (primary insult)
decreases; common causes: acute MI, HF, valvular dysfunction, arrhythmias "<img
How do preload, afterload, and cardiac output change in the setting of hypovolemic
shock? Preload and cardiac output both decrease, and afterload increases
(primary insult) "<img src=""7776.png"">" Pathology cardiovascular shock
How do preload, afterload, and cardiac output change in the setting of distributive
shock? Preload and afterload both decrease, and cardiac output increases. (The
primary insult is decreased afterload.) "<img src=""7776.png"">" Pathology
cardiovascular shock
In the ED, a pt with burns develops cold, clammy skin. What is the best treatment
for this pt's shock? IV fluids (The pt is most likely experiencing hypovolemic
shock.) "<img src=""7776.png"">" Pathology cardiovascular shock
A pt with acute myocardial infarction develops cold, clammy skin. What is the
treatment of choice for this pt's shock? Inotropes and diuresis (The pt is most
likely experiencing cardiogenic shock.) "<img src=""7776.png"">" Pathology
cardiovascular shock
What is the most commonly seen first sign of shock? Left untreated, what is the end
result of shock? The most common first sign of shock is tachycardia; the end
result of untreated shock is multiple organ dysfunction syndrome "<img
A pt who has endocarditis is noted to have round white spots on the retina
surrounded by hemorrhage. What is this sign called? Roth spots "<img
src=""7777.png"">" Pathology bacterial-endocarditis cardiovascular
Small, painless erythematous lesions are seen on the palms and soles of a pt with
endocarditis. What is this sign called? Janeway lesions "<img src=""7777.png"">"
Pathology bacterial-endocarditis cardiovascular
Is Staphylococcus aureus bacterial endocarditis rapid or insidious in onset? Rapid
(It has high virulence and results in large vegetations on previously normal
valves.) "<img src=""7777.png"">" Pathology bacterial-endocarditis
cardiovascular
Is Streptococcus viridans bacterial endocarditis rapid or gradual in onset? What
predisposes a pt to this type of endocarditis? Gradual (Smaller vegetations appear
on congenitally abnormal or diseased valves.); it arises as a sequela of dental
procedures "<img src=""7777.png"">" Pathology bacterial-endocarditis
cardiovascular
Which type of endocarditis is associated with dental procedures: acute or subacute
bacterial endocarditis? Subacute (usually seen only with previously abnormal or
diseased valves) "<img src=""7777.png"">" Pathology bacterial-endocarditis
cardiovascular
A pt presents with aseptic endocarditis. Name three potential causes. Malignancy,
hypercoagulable states, and lupus (marantic/thrombotic endocarditis) "<img
A man has fever, glomerulonephritis, and tender raised finger-pad lesions. What is
the most likely source of infection in this pt? The presence of fever,
glomerulonephritis, and Osler nodes suggests bacterial endocarditis, and the most
likely source is the mitral valve "<img src=""7777.png"">" Pathology
bacterial-endocarditis cardiovascular
A pt has bacterial endocarditis with tricuspid valve involvement. Which lifestyle
factor, and which organisms, may be responsible? IV drug abuse (don't tri
drugs with tricuspid valve endocarditis); S. aureus, Pseudomonas, Candida "<img
What symptoms and signs do the letters in the mnemonic FROM JANE represent in
bacterial endocarditis? Fever, Roth spots, Osler nodes, Murmur, Janeway lesions,
Anemia, Nail-bed hemorrhage, Emboli "<img src=""7777.png"">" Pathology
bacterial-endocarditis cardiovascular
A 60-year-old man with colon cancer presents with fever, new systolic murmur, and
Roth spots. What is the most likely causative organism? Streptococcus bovis
(gallolyticus) "<img src=""7777.png"">" Pathology bacterial-endocarditis
cardiovascular
A 55-year-old pt with a bovine valve presents with fever and small red lines on his
nails. What is the most likely causative organism? Staphylococcus epidermidis
"<img src=""7777.png"">" Pathology bacterial-endocarditis cardiovascular
Multiple blood cultures are necessary for a bacterial endocarditis diagnosis. Name
a few causative bacteria that are not culturable. Coxiella burnetii, Bartonella
spp, HACEK (Haemophilus, Actinobacillus,Cardiobacterium,Eikenella,Kingella) "<img
A boy had a sore throat caused by group A -hemolytic streptococci. If he becomes
ill again, what symptoms suggest rheumatic fever? Joint pain (polyarthritis),
(carditis), Nodules in skin (subcutaneous), Erythema marginatum, Sydenham chorea
(JNES) "<img src=""7778.png"">" Pathology cardiovascular rheumatic-fever
What laboratory findings are associated with rheumatic heart disease? What is the
treatment/prophylaxis? Elevated antistreptolysin O titers; penicillin is
prescribed for treatment and prophylaxis "<img src=""7778.png"">" Pathology
cardiovascular rheumatic-fever
A 70-year-old man had rheumatic fever as a child. What are the most likely
locations of valvular disease (from most to least likely)? Mitral, aortic,
tricuspid (higher pressure valves affected most) "<img src=""7778.png"">"
Pathology cardiovascular rheumatic-fever
A 5-y/o w/pharyngitis has a new diastolic murmur and moves limbs in a dance-like
fashion. What is the causative hypersensitivity reaction? Type II (Antibodies to M
protein can cross-react with self-antigens [an example of molecular mimicry].)
"<img src=""7778.png"">" Pathology cardiovascular rheumatic-fever
A pt survives a bout of rheumatic fever. He has a blowing, regurgitant murmur.
Decades from now, do you expect the murmur to change? Yes, as early rheumatic fever
is associated with mitral regurgitation, but over time, can convert to mitral
stenosis "<img src=""7778.png"">" Pathology cardiovascular rheumatic-fever
A 50-year-old man thinks he is having an MI. He has sharp pain, worse on
inspiration and relieved by sitting up/leaning forward. Diagnosis? Acute
pericarditis "<img src=""7779.png"">" Pathology acute-pericarditis
cardiovascular
A woman receiving radiation therapy for cancer has chest pain. ECG shows diffuse PR
depressions. What maneuvers worsen and reduce her pain? Pain worsens on
inspiration and is reduced on sitting up and/or leaning forward. (This is
radiation-induced acute pericarditis.) "<img src=""7779.png"">" Pathology
acute-pericarditis cardiovascular
ECG of a 23-year-old man with chest pain shows diffuse ST elevation. What is the
most likely cause of his condition? Idiopathic (presumed viral) pericarditis "<img
src=""7779.png"">" Pathology acute-pericarditis cardiovascular
What are some known causes of acute pericarditis? Infection (Coxsackie virus),
neoplasia, uremia, radiation, autoimmune (SLE, rheumatoid arthritis), cardiac
(acute STEMI, Dressler syndrome) "<img src=""7779.png"">" Pathology acute-
pericarditis cardiovascular
A woman comes to the ED with severe chest pain. ECG shows diffuse ST elevations.
Auscultation reveals a friction rub. Do you diagnose an MI?No, as the ECG finding
of diffuse ST elevations and the presence of a friction rub are more suggestive of
acute pericarditis "<img src=""7779.png"">" Pathology acute-pericarditis
cardiovascular
What is cardiac tamponade? Compression of the heart by fluid in pericardial
space, such as blood or effusions, that leads to decreased cardiac output "<img
src=""7780.png"">" Pathology cardiac-tamponade cardiovascular
What is pulsus paradoxus? What causes it? Systolic blood pressure by more than 10
mm Hg during inspiration; cardiac tamponade, asthma, obstructive sleep apnea,
pericarditis, croup "<img src=""7780.png"">" Pathology cardiac-tamponade
cardiovascular
A 66-year-old man had a myocardial infarction 1 week ago and is now presenting with
cardiac tamponade. What symptoms may he have? Beck triad (hypotension, distended
neck veins, distant heart sounds), increased heart rate, pulsus paradoxus "<img
src=""7780.png"">" Pathology cardiac-tamponade cardiovascular
A pt with a heart injury has pulsus paradoxus, hypotension, and distant heart
sounds. What abnormalities may be seen on her ECG? ECG may show low-voltage QRS
and electrical alternans (due to swinging motion of the heart) (History & symptoms
suggest cardiac tamponade.) "<img src=""7780.png"">" Pathology cardiac-
tamponade cardiovascular
Tertiary syphilis disrupts the vasa vasorum. What are some of the complications?
Dilation of aorta/valve ring (due to vessel wall atrophy) aneurysm of
ascending aorta or aortic arch and/or aortic valve insufficiency "<img
src=""7781.png"">" Pathology cardiovascular syphilitic-heart-disease
Calcification takes place in which two structures in pts with syphilitic heart
disease? The aortic root and the ascending aortic arch "<img src=""7781.png"">"
Pathology cardiovascular syphilitic-heart-disease
In tertiary syphilis, what is the characteristic appearance of the aortic root on
gross pathology? It is described as having a tree-bark appearance "<img
src=""7781.png"">" Pathology cardiovascular syphilitic-heart-disease
A 70-year-old veteran has chest pain and a positive RPR test. Echocardiogram shows
aortic regurgitation and dilated aortic root. Diagnosis? Aortic aneurysm and
aortic valve insufficiency due to tertiary syphilis "<img src=""7781.png"">"
Pathology cardiovascular syphilitic-heart-disease
What is the most common heart tumor? A metastasis "<img src=""7782.png"">"
Pathology cardiac-tumors cardiovascular
Where in the heart do most myxomas tend to occur? 90% occur in the atria
(mostly in the left atrium) "<img src=""7782.png"">" Pathology cardiac-tumors
cardiovascular
What is the most common primary heart tumor in children? With which genetic disease
is it associated? Rhabdomyoma; tuberous sclerosis "<img src=""7782.png"">"
Pathology cardiac-tumors cardiovascular
A pt presents with new murmur and multiple syncopal episodes. Which cardiac tumor
is the most likely cause? "A myxoma, as syncope occurs with ball-valve
obstruction of the mitral valve in left atrium; may also hear early diastolic
""tumor plop"" sound" "<img src=""7782.png"">" Pathology cardiac-tumors
cardiovascular
What is the Kussmaul sign? An increase in jugular venous pressure on inspiration
(instead of the normal decrease) "<img src=""7783.png"">" Pathology
cardiovascular kussmaul-sign
A pt has impaired filling of the right ventricle. This may lead to what clinical
findings on exam? Kussmaul sign, JVD (due to blood backing up into venae cavae)
"<img src=""7783.png"">" Pathology cardiovascular kussmaul-sign
Name four causes of the Kussmaul sign. Constrictive pericarditis, restrictive
cardiomyopathies, right atrial tumors, right ventricular tumors "<img
src=""7783.png"">" Pathology cardiovascular kussmaul-sign
What are the symptoms of Takayasu arteritis? What is the most affected demographic?
Fever, night sweats, arthritis, weak upper-extremity pulses, myalgias, skin
nodules, ocular disturbances; Asian women younger than 40 "<img src=""7784.png"">"
Pathology cardiovascular vasculitides
A 7-year-old girl has arthralgias, abdominal pain, and purpura on her legs after an
upper respiratory tract infection. Pathophysiology? Associated with IgA
nephropathy (She has Henoch-Schnlein purpura, a small-vessel vasculitis 2 to IgA
immune complex deposition.) "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
What is the triad of Henoch-Schnlein purpura? Palpable purpura on the buttocks
and legs, arthralgias, and abdominal pain "<img src=""7784.png"">" Pathology
cardiovascular vasculitides
Takayasu arteritis is associated with what laboratory finding? What histologic
findings are seen on biopsy of affected vessels? An elevated erythrocyte
sedimentation rate; granulomatous thickening and narrowing of affected vessels are
seen "<img src=""7784.png"">" Pathology cardiovascular vasculitides
What is polyarteritis nodosa? Immune complexinduced necrosis of medium-sized
arteries, typically involving the renal and visceral vessels (but not pulmonary
arteries) "<img src=""7784.png"">" Pathology cardiovascular vasculitides
Name 10 clinical findings associated with polyarteritis nodosa. Fever, weight
loss, malaise, abdominal pain, melena, headache, hypertension, neurologic
dysfunction, cutaneous eruption, renal damage "<img src=""7784.png"">"
Polyarteritis nodosa is strongly associated with which infectious disease?
Hepatitis B (30% of patients are seropositive.) "<img src=""7784.png"">"
Polyarteritis nodosa most commonly affects which age group? Describe its histologic
appearance. Young adults; transmural inflammation of arterial wall with fibrinoid
necrosis due to immune complex deposition "<img src=""7784.png"">" Pathology
Fever and which five clinical findings are associated with Kawasaki disease?
Conjunctival injection, Rash, cervical Adenopathy, Strawberry tongue,
Hand/foot changes (edema/erythema), & fever (CRASH & burn) "<img src=""7784.png"">"
What is Buerger disease? A thrombosing vasculitis affecting the medium-sized
peripheral arteries and veins of heavy smokers (usually men &62; 40 years of age)
"<img src=""7784.png"">" Pathology cardiovascular vasculitides
Buerger disease goes by what other name? Thromboangiitis obliterans "<img
src=""7784.png"">" Pathology cardiovascular vasculitides
What are three clinical findings associated with Buerger disease? What would a
biopsy of an affected artery show? Intermittent claudication, superficial nodular
phlebitis, and Raynaud phenomenon; histology would show segmental thrombosing
vasculitis "<img src=""7784.png"">" Pathology cardiovascular vasculitides
What are the main presentations of microscopic polyangiitis? Treatment? Pauci-
immune glomerulonephritis and palpable purpura; treatment: cyclophosphamide and
corticosteroids "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
What is granulomatosis with polyangiitis (Wegener granulomatosis)? A small-
vessel vasculitis characterized by focal necrotizing vasculitis, granulomas in the
lungs and upper airway, and glomerulonephritis "<img src=""7784.png"">"
A pt with Wegener granulomatosis may have which upper respiratory tract symptoms?
Lower respiratory tract symptoms? Renal symptoms? Perforation of nasal septum,
chronic sinusitis, otitis media, mastoiditis; cough, dyspnea, hemoptysis; hematuria
with red blood cell casts "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
A pt has hematuria and is diagnosed with Wegener granulomatosis. What finding may
be seen on chest x-ray? Large nodular densities "<img src=""7784.png"">"
Wegener granulomatosis and microscopic polyangiitis have similar presentations. How
can you differentiate between the two? Wegener granulomatosis has nasopharyngeal
involvement and necrotizing granulomas, whereas microscopic polyangiitis has
neither "<img src=""7784.png"">" Pathology cardiovascular vasculitides
Name three clinical findings commonly associated with temporal (giant cell)
arteritis. Unilateral headache (temporal artery), jaw claudication, and impaired
vision/irreversible blindness "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
Which MPO-ANCA/p-ANCA7#8211;positive vasculitis is a granulomatous vasculitis with
eosinophilia? Churg-Strauss syndrome (also called eosinophilic granulomatosis
with polyangiitis) "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
A 60-y/o woman with polymyalgia rheumatica has a unilateral headache and jaw
claudication. What disease process may cause a loss of vision? She is most likely
experiencing temporal arteritis, in which occlusion of the ophthalmic artery can
result in irreversible blindness "<img src=""7784.png"">" Pathology
Pts with temporal arteritis may also have which rheumatologic condition? What
population is the most commonly affected? Polymyalgia rheumatica; elderly women
"<img src=""7784.png"">" Pathology cardiovascular vasculitides
In Churg-Strauss syndrome, which ANCA will be positive in the serum? p-ANCA (MPO-
ANCA)usually has an elevated IgE level "<img src=""7784.png"">" Pathology
Temporal arteritis is associated with what laboratory test results? What is the
treatment? Elevated erythrocyte sedimentation rate; high-dose steroids before
biopsy to prevent blindness "<img src=""7784.png"">" Pathology cardiovascular
vasculitides
All ANCA-positive vasculitides affect which sized vessels? Small "<img
A 78-y/o woman with polymyalgia rheumatica presents with an intense temporal
headache. What types of arteries are likely affected? Large arteries, usually
branches of the carotid artery (She has temporal arteritis.) "<img
What is the most common childhood systemic vasculitis? It often presents after what
disease? Henoch-Schnlein purpura; typically follows upper respiratory tract
infections "<img src=""7784.png"">" Pathology cardiovascular vasculitides
A man's BP is chronically >140/90. All secondary causes of HTN have been ruled out.
Which medications are indicated for his condition? For primary (essential)
hypertension: thiazide diuretics, ACE inhibitors, ARBs, dihydropyridine Ca2+
channel blockers "<img src=""7785.png"">" cardiovascular hypertension-
treatment pharmacology
A man with HTN and HF presents with dyspnea. He says this happens whenever he runs
out of his medications. Which ones is he taking? Loop diuretics, ACE
inhibitors/ARBs, -blockers, and aldosterone antagonists "<img src=""7785.png"">"
cardiovascular hypertension-treatment pharmacology
A man with an HF exacerbation now has an EF of 20%. Which antihypertensive class
should be used with caution? -Blockers "<img src=""7785.png"">"
cardiovascular hypertension-treatment pharmacology
A pt with diabetes has a new diagnosis of hypertension. Which antihypertensive
medications are first-line for her? ACE inhibitor or ARBs, for renal protection
"<img src=""7785.png"">" cardiovascular hypertension-treatment
pharmacology
A pregnant woman at 26 weeks' gestation had a BP of 150/90 at her last 2 visits.
What medications can safely treat her hypertension? Hydralazine, labetalol,
methyldopa, nifedipine "<img src=""7785.png"">" cardiovascular hypertension-
treatment pharmacology
Which Ca2+ channel blockers will lower a pt's BP without affecting the cardiac
output or rhythm? "Dihydropyridines (""-dipines"" such as amlodipine, nimodipine,
nicardipine, clevidipine)" "<img src=""7786.png"">" calcium-channel-blockers
cardiovascular pharmacology
A pt with lupus and hypertension complains that her hands often blanch painfully.
What is the best pharmacotherapy? Dihydropyridine Ca2+ channel blockers (She has
Raynaud phenomenon.) "<img src=""7786.png"">" calcium-channel-blockers
A pt with SLE first treated with amlodipine returns with swallowing complaints.
What side effect do you expect to see in her mouth? Gingival hyperplasia (a side
effect of dihydropyridine Ca2+ channel blockers) "<img src=""7786.png"">"
calcium-channel-blockers cardiovascular pharmacology
A pt comes in with an irregularly irregular pulse and BP of 160/90. Which Ca2+
channel blockers will treat the rhythm and pressure? Diltiazem or verapamil "<img
src=""7786.png"">" calcium-channel-blockers cardiovascular pharmacology
A pt begins taking nifedipine for hypertension. What is the mechanism of action?
It blocks L-type Ca2+ channels in cardiac and smooth muscle"<img
Which Ca2+ channel blocker is used for hypertensive urgency or emergency?
Clevidipine "<img src=""7786.png"">" calcium-channel-blockers
A man taking ion channel blockers for hypertension has swollen ankles and flushing.
What specific class of medication was he prescribed? Dihydropyridine Ca2+ channel
blockers (Side effects are peripheral edema and flushing.) "<img src=""7786.png"">"
calcium-channel-blockers cardiovascular pharmacology
What are the clinical indications for the use of non-dihydropyridine Ca2+ channel
blockers? Hypertension, angina, atrial fibrillation/flutter "<img
A man hits his head on concrete. A head CT shows a subarachnoid hemorrhage. Why do
you give a Ca2+ channel blocker? Nimodipine can decrease the risk of cerebral
vasospasms "<img src=""7786.png"">" calcium-channel-blockers cardiovascular
pharmacology
Rank the relative activity of the following Ca2+ channel blockers on vascular
smooth muscle: verapamil, nifedipine, amlodipine, diltiazemAmlodipine = nifedipine
&62; diltiazem &62; verapamil "<img src=""7786.png"">" calcium-channel-blockers
Which Ca2+ channel blocker affects cardiac muscle more than vascular smooth muscle:
diltiazem or nifedipine? Diltiazem "<img src=""7786.png"">" calcium-
channel-blockers cardiovascular pharmacology
A man goes into atrial fibrillation. HR is 150 and BP is 80/60. Why are you
cautious about starting a diltiazem drip? It will reduce both cardiac output and
blood pressure "<img src=""7786.png"">" calcium-channel-blockers
What is the unexpected endocrine-related side effect of verapamil?
Hyperprolactinemia "<img src=""7786.png"">" calcium-channel-blockers
A man starts taking verapamil for atrial fibrillation. You encourage him to drink
prune juice and eat more fiber. Why? Non-dihydropyridine Ca2+ channel blockers
can cause constipation as a side effect "<img src=""7786.png"">" calcium-
channel-blockers cardiovascular pharmacology
Which does hydralazine reduce: afterload or preload? Afterload "<img
src=""7787.png"">" cardiovascular hydralazine pharmacology
Hydralazine relaxes smooth muscles by increasing which substance in endothelial
cells? cGMP "<img src=""7787.png"">" cardiovascular hydralazine
pharmacology
A man taking aspirin, hydralazine, and atorvastatin develops fevers, painful
nodules, papules, and a malar rash. Which drug is the culprit? Hydralazine, which
causes drug-induced lupus "<img src=""7787.png"">" cardiovascular
hydralazine pharmacology
A man with HTN and CAD takes his wife's hydralazine for his BP without asking his
doctor. He ends up in the ER with an NSTEMI. Mechanism? The compensatory
tachycardia of hydralazine on top of severe CAD overloaded the heart "<img
A pregnant woman complains of headaches. Her BP is 220/100. She has a history of
severe asthma. What is the best fast-acting drug? Hydralazine "<img
How can you prevent the compensatory tachycardia that is associated with
hydralazine? Co-administer a -blocker "<img src=""7787.png"">"
cardiovascular hydralazine pharmacology
What are the clinical indications for hydralazine? Severe hypertension
(particularly acute), hypertension in pregnancy, heart failure (administer with
organic nitrate) "<img src=""7787.png"">" cardiovascular hydralazine
pharmacology
A man w/HTN receiving IV nitroprusside after surgery doesn't regain consciousness.
What direct adverse effect of nitroprusside is to blame? Cyanide toxicity "<img
src=""7788.png"">" cardiovascular hypertensive-emergency pharmacology
What substance increases in the smooth muscle cell as a result of nitrates breaking
down into nitric oxide? cGMP "<img src=""7788.png"">" cardiovascular
hypertensive-emergency pharmacology
A young woman with fibromuscular dysplasia comes in with a hypertensive crisis.
What medication would address her HTN immediately? Fenoldopam, which is a
coronary, peripheral, renal, and splanchnic vasodilator "<img src=""7788.png"">"
cardiovascular hypertensive-emergency pharmacology
A man has a hypertensive emergency. You give a short-acting drug that raises cGMP
levels via NO. Why do you monitor oxygenation closely? Pts should be monitored
closely after nitroprusside is given, as it can cause cyanide toxicity (deprives
cells of ability to use O2) "<img src=""7788.png"">" cardiovascular
hypertensive-emergency pharmacology
After a lengthy surgical procedure, a pt is administered fenoldopam. For what side
effects should he be closely monitored? Hypotension and tachycardia "<img
src=""7788.png"">" cardiovascular hypertensive-emergency pharmacology
A man develops severe chest pain after walking up a hill. He was told to take
nitroglycerin. How does it work? It breaks down into NO in smooth muscle,
vasodilating veins more than arteries and decreasing preload, all of which reduce
cardiac strain "<img src=""7789.png"">" cardiovascular nitrates
pharmacology
What are three main indications for the use of nitrates (nitroglycerin, isosorbide
dinitrate, isosorbide mononitrate)? Angina, acute coronary syndrome, pulmonary
edema "<img src=""7789.png"">" cardiovascular nitrates pharmacology
A man recreationally huffs nitrous oxide at parties. What are side effects of
nitrates and nitrous oxide that he may experience? Reflex tachycardia,
hypotension, flushing, and headache "<img src=""7789.png"">" cardiovascular
nitrates pharmacology
A man at a fertilizer factory has headaches and lightheadedness every Monday after
a weekend off. How is this related to nitrous oxide? He adjusts to NO exposure
throughout the week and loses tolerance at home during the weekend; symptoms return
Monday after reexposure "<img src=""7789.png"">" cardiovascular nitrates
pharmacology
A man who began taking sublingual nitroglycerin experiences palpitations. What are
other side effects of nitrous medications? Other side effects include flushing
and headaches (The man is experiencing reflex tachycardia from the hypotensive
effect of nitroglycerin.) "<img src=""7789.png"">" cardiovascular nitrates
pharmacology
A man who began taking sublingual nitroglycerin experiences palpitations. What
medication can counter the tachycardia? -Blockers "<img src=""7789.png"">"
cardiovascular nitrates pharmacology
Which -blockers are contraindicated in angina? Partial -agonists (pindolol and
acebutolol) because they can act like epinephrine and increase HR and BP at high
doses "<img src=""7790.png"">" antianginal-therapy cardiovascular pharmacology
Which calcium channel blocker acts most like a -blocker? Verapamil "<img
src=""7790.png"">" antianginal-therapy cardiovascular pharmacology
What are the effects of -blockers, nitrates, and both combined on end-diastolic
volume (EDV), respectively? -Blockers either have no effect on or decrease EDV;
nitrates decrease EDV; a combination of the two either has no effect or decreases
EDV "<img src=""7790.png"">" antianginal-therapy cardiovascular pharmacology
What do nitrates do to end-diastolic volume (EDV)? To BP? Ejection time? To
myocardial oxygen use? They decrease all of these factors "<img src=""7790.png"">"
antianginal-therapy cardiovascular pharmacology
What do nitrates to do heart contractility? Nothing "<img src=""7790.png"">"
What do -blockers do to end-diastolic volume (EDV)? To BP? Contractility? Ejection
time? To myocardial oxygen use? They decrease EDV, BP, contractility, and
myocardial oxygen use; they increase ejection time "<img src=""7790.png"">"
What does ranolazine do to HR and contractility? Nothing "<img
src=""7791.png"">" cardiovascular pharmacology ranolazine
How does ranolazine work? It inhibits the late phase of Na+ current in
myocardium and ultimately decreases O2 consumption "<img src=""7791.png"">"
cardiovascular pharmacology ranolazine
An elderly man taking ranolazine becomes psychotic overnight. What should you check
before giving him IM haloperidol? Why? An ECG; ranolazine and haloperidol will
each increase the QT interval "<img src=""7791.png"">" cardiovascular
pharmacology ranolazine
For what conditions is ranolazine used? Angina refractory to all other
medications "<img src=""7791.png"">" cardiovascular pharmacology ranolazine
What are the side effects of ranolazine? Dizziness, headache, constipation,
nausea, QT prolongation. "<img src=""7791.png"">" cardiovascular
pharmacology ranolazine
A man has a low-density lipoprotein level of 200 mg/dL. Which drug class will lower
his LDL the most? HMG-CoA reductase inhibitors (statins) "<img src=""7792.png"">"
cardiovascular lipid-lowering-agents pharmacology
What product formation is directly inhibited by HMG CoA reductase inhibitors?
Mevalonate "<img src=""7792.png"">" cardiovascular lipid-lowering-
agents pharmacology
A pt with osteopenia wants to avoid getting osteoporosis. Which cholesterol-
lowering agents should you avoid? Bile acid resins (eg, cholestyramine,
colestipol) because they interfere with absorption of vitamins A, D, E, and K
"<img src=""7792.png"">" cardiovascular lipid-lowering-agents
pharmacology
A pt who is taking atorvastatin, cholestyramine, ezetimibe, and fenofibrate has
uncontrollable diarrhea. Which medication is the culprit? Ezetimibe "<img
src=""7792.png"">" cardiovascular lipid-lowering-agents pharmacology
A pt who is taking atorvastatin, cholestyramine, and fenofibrate has constipation.
Which medication is the culprit? Cholestyramine "<img src=""7792.png"">"
Which lipid-lowering agent inhibits lipolysis, preventing free fatty acids from
entering circulation? How does it accomplish this? Niacin; via inhibition of
hormone-sensitive lipase; hepatic VLDL synthesis is decreased "<img
src=""7792.png"">" cardiovascular lipid-lowering-agents pharmacology
A pt treated for hypertriglyceridemia has muscle pain and gallstones. What is the
mechanism of action of the drug being taken? A fibrate (eg, fenofibrate)
upregulates lipoprotein lipase and increases triglyceride clearance; it also
increases HDL by activating PPAR- "<img src=""7792.png"">" cardiovascular
lipid-lowering-agents pharmacology
Which category of lipid-lowering drugs works by inhibiting the formation of the
cholesterol precursor mevalonic acid? HMG-CoA reductase inhibitors (statins)
inhibit conversion of HMG-CoA to mevalonate. (Statins reduce mortality in pts with
CAD.) "<img src=""7792.png"">" cardiovascular lipid-lowering-agents
pharmacology
Which class of lipid-lowering drugs prevents intestinal reabsorption of bile acids,
causing the liver to synthesize more from cholesterol? Bile acid resins (eg,
cholestyramine, colestipol, colesevelam) "<img src=""7792.png"">"
Which lipid-lowering agent works by preventing cholesterol reabsorption at the
small intestinal brush border? Ezetimibe "<img src=""7792.png"">"
A pt who has begun taking lovastatin complains of RUQ pain. Which lab test should
be ordered at once? A liver function test because hepatotoxicity may result
from taking either fibrates or niacin "<img src=""7792.png"">"
By what mechanism does digoxin treat heart failure? It inhibits the Na+/K+ ATPase
pump, and ultimately Na+/Ca2+ exchange, increasing intracellular Ca2+ to increase
inotropy "<img src=""7793.png"">" cardiac-glycosides cardiovascular
pharmacology
How does digoxin prescribed for atrial fibrillation work on the heart? It slows AV
node conduction and increases the refractory period, slowing the ventricular rate
"<img src=""7793.png"">" cardiac-glycosides cardiovascular pharmacology
What vision complaint can occur with digoxin use? Blurry yellow vision (think
van Gogh) "<img src=""7793.png"">" cardiac-glycosides cardiovascular
pharmacology
Which medications displace digoxin from its tissue-binding sites and decrease
digoxin clearance (increasing the risk of digoxin toxicity)? Verapamil,
quinidine, amiodarone "<img src=""7793.png"">" cardiac-glycosides
A pt with atrial fibrillation taking digoxin comes in with nausea and vomiting. An
ECG shows AV blockade. What is the antidote? Slow normalization of K+ levels, a
cardiac pacer, anti-digoxin Fab fragments, and Mg2+ (He has digoxin toxicity.)
"<img src=""7793.png"">" cardiac-glycosides cardiovascular pharmacology
How does hypokalemia increase the toxicities of digoxin? Potassium competes with
digoxin for the same binding site on Na+/K+ ATPases, so hypokalemia increases
digoxin binding and toxicity "<img src=""7793.png"">" cardiac-glycosides
The attending on your internal medicine rotation asks about the mechanism of
digoxin. Explain it to him. It directly inhibits the Na+/K+ ATPase, indirectly
inhibiting the Na+/Ca2+ exchanger, resulting in [Ca2+]i and
inotropy/contractility "<img src=""7793.png"">" cardiac-glycosides
Which ion channel is targeted by class I antiarrhythmics? Na+ "<img
src=""7794.png"">" antiarrhythmicssodium-channel-blockers-(class-i)
A pt taking procainamide for an arrhythmia develops a facial rash and joint pains.
What antibody may be present in her serum? Anti-histone (This is likely a
reversible SLE-like syndrome.) "<img src=""7794.png"">" antiarrhythmics
sodium-channel-blockers-(class-i) cardiovascular pharmacology
A pt w/atrial fibrillation has tinnitus and headache. What does the med he is
likely taking do to action potential and refractory period?The pt is taking
quinidine, a class Ia antiarrhythmic that causes cinchonism; it increases both the
AP and refractory period times "<img src=""7794.png"">" antiarrhythmics
sodium-channel-blockers-(class-i) cardiovascular pharmacology
A pt takes flecainide for supraventricular tachycardia. What effect does this class
of drug have on action potential duration? Class IC antiarrhythmics have
minimal effect on action potential duration "<img src=""7794.png"">"
antiarrhythmicssodium-channel-blockers-(class-i) cardiovascular pharmacology
A pt takes propafenone for atrial fibrillation. Where does it act to prolong the
effective refractory period? In the AV node and other accessory bypass tracts
"<img src=""7794.png"">" antiarrhythmicssodium-channel-blockers-(class-
i) cardiovascular pharmacology
What do mexiletine and lidocaine do to a cardiac action potential (prolong vs
shorten)? Shorten "<img src=""7794.png"">" antiarrhythmicssodium-
channel-blockers-(class-i) cardiovascular pharmacology
A drug from which Na+ channelblocking antiarrhythmic class can be given for
ventricular tachycardia after MI? Class IB (eg, lidocaine or mexiletine) (IB is
Best post-MI.) "<img src=""7794.png"">" antiarrhythmicssodium-channel-
blockers-(class-i) cardiovascular pharmacology
Which Na+ channelblocking antiarrhythmic class is contraindicated after MI? Class
IC is Contraindicated in structural and ischemic heart disease "<img
Explain why Na+ channel blocker antiarrhythmics are described as state dependent.
With faster HRs, the Na+ block effect increases, while at lower HRs, the Na+
block effect decreases "<img src=""7794.png"">" antiarrhythmicssodium-
A man takes disopyramide for an arrhythmia. What type of arrhythmia may he have?
An atrial or ventricular arrhythmia (Class IA agents are especially
prescribed for re-entrant or ectopic SVT or VT.) "<img src=""7794.png"">"
A pt takes mexiletine for an arrhythmia. On which cardiac tissue does mexiletine
act? As a class IB antiarrhythmic, it preferentially acts on ischemic or
depolarized Purkinje/ventricular tissue "<img src=""7794.png"">"
A man starts taking lidocaine. What type of arrhythmia may he have? An acute
ventricular or digitalis-induced arrhythmia (Class IB antiarrhythmics [eg,
lidocaine] are used to treat these arrhythmias.) "<img src=""7794.png"">"
A 45-year-old pt takes a class IB antiarrhythmic. What are the adverse effects of
this class of drug? Class IB antiarrhythmics can cause central nervous system
stimulation/depression and cardiovascular depression "<img src=""7794.png"">"
A 45-year-old pt starts taking propafenone. What conditions may he have?
Supraventricular tachycardia, atrial fibrillation, or refractory VT (Class IC
agents [eg, propafenone] are used to treat these conditions.) "<img
Which antiarrhythmics belong to class IC? Flecainide, Propafenone (Can [class IC] I
have Fries, Please) "<img src=""7794.png"">" antiarrhythmicssodium-
Class IC antiarrhythmics have no effect on the effective refractory period in which
two types of tissues? Purkinje and ventricular tissues "<img src=""7794.png"">"
Name the possible side effects of the class IA antiarrhythmics: quinidine,
procainamide, and disopyramide. Cinchonism (quinidine), SLE-like syndrome
(procainamide), HF (disopyramide), thrombocytopenia, torsades de pointes ( QT
interval) "<img src=""7794.png"">" antiarrhythmicssodium-channel-blockers-
(class-i) cardiovascular pharmacology
Which -blocker should be avoided in pts with Prinzmetal angina? Propranolol should
not be given; it can exacerbate vasospasms "<img src=""7795.png"">"
antiarrhythmics-blockers-(class-ii) cardiovascular pharmacology
A pt with elevated HR, BP, and dilated pupils has white powder in his nostrils. Why
is it safe to give him labetalol but not metoprolol?? Labetalol is nonselective
(blocks both - and -receptors); metoprolol only blocks -receptors, which is
unsafe for cocaine users "<img src=""7795.png"">" antiarrhythmics-
blockers-(class-ii) cardiovascular pharmacology
Why is labetalol, but not metoprolol, safe for symptomatic pheochromocytomas?
Labetalol is nonselective (blocks both - and -receptors); metoprolol only
blocks -receptors, which is unsafe for pts with pheochromocytomas "<img
src=""7795.png"">" antiarrhythmics-blockers-(class-ii) cardiovascular
pharmacology
A pt with stage fright takes a medication to stop palpitations. That evening he has
erectile dysfunction. What medication was it? Propranolol, which like other -
blockers, can cause erectile dysfunction "<img src=""7795.png"">"
Which -blocker is the shortest acting? Esmolol "<img src=""7795.png"">"
What do -blockers do to SA and AV node firing? They decrease frequency "<img
pharmacology
A pt takes metoprolol for atrial fibrillation. What does metoprolol do to the PR
interval? It increases it "<img src=""7795.png"">" antiarrhythmics-
blockers-(class-ii) cardiovascular pharmacology
A pt takes metoprolol for atrial fibrillation. Which cardiac node is more sensitive
to metoprolol: SA or AV? The AV node "<img src=""7795.png"">"
What pulmonary side effects are associated with -blockers?COPD and asthma
exacerbations "<img src=""7795.png"">" antiarrhythmics-blockers-(class-
ii) cardiovascular pharmacology
What common CNS side effects do -blockers have? Depression, lethargy "<img
pharmacology
A pt starts taking a -blocker. A year later, triglycerides are increased and HDL
is decreased. Which -blocker may be the culprit? Metoprolol "<img
pharmacology
How can -blockers be risky for someone who takes insulin? They mask signs of
hypoglycemia (eg, tachycardia, palpitations) "<img src=""7795.png"">"
A pt taking amiodarone is frustrated by the need for many routine blood draws. What
must be monitored in this pt? Pulmonary function, liver function, and thyroid
function must be checked regularly in pts taking amiodarone"<img src=""7796.png"">"
antiarrhythmicspotassium-channel-blockers-(class-iii) cardiovascular
pharmacology
Which ion is blocked by class III antiarrhythmics? Name some drugs in this class.
K+; Potassium channel blockers; Amiodarone, Ibutilide, Dofetilide, Sotalol
(AIDS) "<img src=""7796.png"">" antiarrhythmicspotassium-channel-
blockers-(class-iii) cardiovascular pharmacology
Which of the class III antiarrhythmics does not cause torsades de points (TdP)?
Amiodarone; it prolongs QT like class III antiarrhythmics but it is not
associated with TdP "<img src=""7796.png"">" antiarrhythmicspotassium-
channel-blockers-(class-iii) cardiovascular pharmacology
A man takes a medication for atrial fibrillation. He has gray smears on his
forehead, which cannot be washed away. Which drug caused this? Amiodarone causes
photodermatitis "<img src=""7796.png"">" antiarrhythmicspotassium-channel-
Which antiarrhythmic drug is lipophilic and has the effects of classes I, II, III,
and IV? Amiodarone "<img src=""7796.png"">" antiarrhythmicspotassium-
channel-blockers-(class-iii) cardiovascular pharmacology
A man takes amiodarone for atrial fibrillation. Why must his thyroid function be
monitored regularly? Amiodarone has an iodine component and can cause hypo- or
hyperthyroidism "<img src=""7796.png"">" antiarrhythmicspotassium-channel-
A pt taking an antiarrhythmic develops corneal/skin deposits and photodermatitis.
Which arrhythmias may he have? Atrial fibrillation/flutter or ventricular
tachycardia (The side effects suggest that he is taking amiodarone [class III].)
"<img src=""7796.png"">" antiarrhythmicspotassium-channel-blockers-
(class-iii) cardiovascular pharmacology
How do verapamil and diltiazem help in treating atrial fibrillation? They help
control the heart rate by slowing conduction through the AV node "<img
src=""7797.png"">" antiarrhythmicscalcium-channel-blockers-(class-iv)
A pt develops an adverse reaction to verapamil. What would you expect to discover
in the pt's history? Constipation, flushing, edema, signs of cardiovascular
abnormalities such as heart failure, atrioventricular block, sinus node depression
"<img src=""7797.png"">" antiarrhythmicscalcium-channel-blockers-
(class-iv) cardiovascular pharmacology
A pt has palpitations. ECG shows tachycardia from above the ventricles. Carotid
massage fails to stop it. Which medication is the next step? Adenosine (This is
SVT.) "<img src=""7798.png"">" cardiovascular other-antiarrhythmics
pharmacology
Which ion is infused for the treatment of torsades de pointes and digoxin toxicity?
Mg2+ "<img src=""7798.png"">" cardiovascular other-antiarrhythmics
pharmacology
A pt is being infused with adenosine for SVT. How much time does this buy if it
doesn't abort the SVT? Very little time because adenosine is a short-acting (about
15 seconds) drug "<img src=""7798.png"">" cardiovascular other-
antiarrhythmics pharmacology
What does adenosine do intracellularly? It increases K+ outflow, leading to
hyperpolarization of the cell and decreased intracellular Ca2+ (ICa) "<img
src=""7798.png"">" cardiovascular other-antiarrhythmics pharmacology
A man with SVT receives adenosine pushes with no effect. His breath reeks of
coffee. Why may adenosine not have worked? Caffeine and theophylline are both
adenosine receptor blockers and blunt the effects of adenosine "<img
src=""7798.png"">" cardiovascular other-antiarrhythmics pharmacology
What is the embryologic origin of the thyroid gland? The floor of the primitive
pharynx (it descends into the neck from there) "<img src=""Screen Shot 2016-03-09
at 5.37.11 PM.png"" />" embryology endocrine thyroid-development
A girl presents with an anterior midline neck mass that moves with swallowing.
Differential diagnosis? Thyroglossal duct cyst vs branchial cleft cyst "<img
src=""Screen Shot 2016-03-09 at 5.37.11 PM.png"" />" embryology endocrine thyroid-
development
What is the most common location of ectopic thyroid tissue? What is a complication
of removing such tissue? The tongue is the most common location; removal may
result in hypothyroidism if it is the only thyroid tissue present "<img
development
How can thyroglossal duct cysts be differentiated from branchial cleft cysts on
physical examination? Thyroglossal duct cysts are anterior and move with
swallowing; branchial cleft cysts are in the lateral neck and do not move with
swallowing "<img src=""Screen Shot 2016-03-09 at 5.37.11 PM.png"" />" embryology
endocrine thyroid-development
Why would someone have three lobes in his or her thyroid gland? The pyramidal lobe
of the thyroid can be a persisting remnant of the thyroglossal duct "<img
development
What is the foramen cecum? The foramen cecum is a normal remnant of the
thyroglossal duct "<img src=""Screen Shot 2016-03-09 at 5.37.11 PM.png"" />"
embryology endocrine thyroid-development
Are all cell types in the thyroid derived from the same embryologic tissue? No,
thyroid tissue is derived from endoderm, whereas parafollicular cells (ie, C cells)
are derived from neural crest "<img src=""Screen Shot 2016-03-09 at 5.37.11
PM.png"" />" embryology endocrine thyroid-development
What are the three zones of the adrenal cortex, from outermost to innermost? Zona
Glomerulosa, zona Fasciculata, zona Reticularis (GFR corresponds with Salt [Na+],
Sugar [glucocorticoids], and Sex [androgens]) "<img src=""Screen Shot 2016-03-09
at 5.38.07 PM.png"" />" adrenal-cortex-and-medulla anatomy endocrine
Which part of the adrenal gland is derived from the same cells as melanocytes?
Chromaffin cells of the adrenal medulla are also derived from neural crest
"<img src=""Screen Shot 2016-03-09 at 5.38.07 PM.png"" />" adrenal-cortex-
and-medulla anatomy endocrine
Which hormonal system controls levels of aldosterone? The renin-angiotensin axis
A patient has congenital aplasia of her adrenal cortex. From what embryologic
tissue did this dysfunction arise? The adrenal cortex is derived from mesoderm
Cortisol and androgens in the zona reticularis are regulated by which hormones?
ACTH, CRH "<img src=""Screen Shot 2016-03-09 at 5.38.07 PM.png"" />"
adrenal-cortex-and-medulla anatomy endocrine
A man has hypertension, low potassium, and high sodium. Renin levels are low. Which
part of the adrenal gland is causing this pathology? The zona glomerulosa of the
adrenal cortex secreting aldosterone; the patient's presentation is consistent with
hyperaldosteronism "<img src=""Screen Shot 2016-03-09 at 5.38.07 PM.png"" />"
adrenal-cortex-and-medulla anatomy endocrine
What is the primary regulator of chromaffin cells in the adrenal medulla? What are
the secretory products? Preganglionic sympathetic fibers; catecholamines
(epinephrine, norepinephrine) "<img src=""Screen Shot 2016-03-09 at 5.38.07
PM.png"" />" adrenal-cortex-and-medulla anatomy endocrine
What are the embryologic origins of the anterior and posterior pituitary?
Anterior: oral ectoderm (Rathke pouch); posterior: neuroectoderm "<img
src=""Screen Shot 2016-03-09 at 5.38.51 PM.png"" />" anatomy endocrine pituitary-
gland
What hormones does the posterior pituitary secrete? Where are these hormones made,
and how are they transported? Vasopressin (ADH) and oxytocin; made in hypothalamus
and carried via neurophysins to posterior pituitary "<img src=""Screen Shot 2016-
03-09 at 5.38.51 PM.png"" />" anatomy endocrine pituitary-gland
Which pituitary hormones have a common subunit? What is the significance of the
subunit? Thyroid-stimulating, luteinizing, follicle-stimulating, human chorionic
gonadotropin hormones; it determines hormone specificity "<img src=""Screen Shot
2016-03-09 at 5.38.51 PM.png"" />" anatomy endocrine pituitary-gland
In a patient with a nonsecreting anterior pituitary adenoma, production of which
hormones could still be affected? FSH, LH), ACTH,TSH, Prolactin, GH (FLAT PiG)
"<img src=""Screen Shot 2016-03-09 at 5.38.51 PM.png"" />" anatomy endocrine
pituitary-gland
A man craving salty food is very tan. An MRI reveals adrenal atrophy. What is the
precursor to the molecule responsible for the tanning? POMC is the precursor to
ACTH and MSH, both of which are likely increased (He has primary adrenal
insufficiency.) "<img src=""Screen Shot 2016-03-09 at 5.38.51 PM.png"" />"
anatomy endocrine pituitary-gland
Which parts of the hypothalamus produce ADH and oxytocin? Paraventricular and
supraoptic nuclei of the hypothalamus "<img src=""Screen Shot 2016-03-09 at
5.38.51 PM.png"" />" anatomy endocrine pituitary-gland
Which hormones secreted by the pituitary gland are basophils? B-FLAT: Basophils
FSH, LH, ACTH, TSH "<img src=""Screen Shot 2016-03-09 at 5.38.51 PM.png"" />"
anatomy endocrine pituitary-gland
Which hormones secreted by the pituitary gland are acidophils? GH, prolactin
"<img src=""Screen Shot 2016-03-09 at 5.38.51 PM.png"" />" anatomy endocrine
pituitary-gland
What do , , and endocrine cells of the pancreas produce, respectively? Where
are these cell types found in the typical islet? cells (periphery):
glucagon; cells (central): insulin (found inside); cells (interspersed):
somatostatin "<img src=""Screen Shot 2016-03-09 at 5.40.01 PM.png"" />"
anatomy endocrine endocrine-pancreas-cell-types
A depressed woman overdoses on a sulfonylurea. Blood work is done in the ED. What
do you expect her insulin and C-peptide levels to be? Both insulin and C-peptide
levels will be high (Sulfonylureas promote endogenous insulin release.) "<img
src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine insulin physiology
A depressed man who self-injects various drugs has a glucose of 50. What do you
expect his insulin and C-peptide levels to be? Insulin will be high; C-peptide
will be low (He is likely self-injecting insulin.) "<img src=""Screen Shot 2016-
03-09 at 5.40.32 PM.png"" />" endocrine insulin physiology
A nurse is hypoglycemic. Insulin/C-peptide levels are high; a sulfonylurea screen
is negative. Why do you perform an abdominal CT scan? To look for evidence of an
insulinoma, which could be secreting excess endogenous insulin (and causing her
hypoglycemia) "<img src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />"
endocrine insulin physiology
How does preproinsulin become insulin? Preproinsulin forms in RER, cleaved to
form proinsulin (stored in granules), then cleaved into C-peptide and insulin
(released into blood) "<img src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />"
endocrine insulin physiology
Which organs/tissues can take up glucose without insulin?
Brain,RBCs,Intestine,Cornea,Kidney,Liver<div>(BRICK L) have insulin-
independent glucose uptake</div> "<img src=""Screen Shot 2016-03-09 at 5.40.32
PM.png"" />" endocrine insulin physiology
How does the intake of glucose stimulate insulin release? <div>Glucose enters
cells to make ATP, which closes K+ channels, depolarizes the cell, allows Ca2+
influx, and lastly causes insulin exocytosis</div> "<img src=""Screen Shot 2016-
<div>A man both injects insulin and has endogenous synthesis. Are his C-peptide
levels greater than, equal to, or less than his insulin levels?</div><div><br
/></div> <div>Less than; while endogenous insulin does lead to a rise in C-
peptide levels, exogenous insulin does not</div> "<img src=""Screen Shot 2016-
<div><div>Which GLUT receptor is used by cells, the liver, kidneys, and small
intestine?</div></div><div><br /></div> <div>GLUT-2</div> "<img src=""Screen Shot
2016-03-09 at 5.40.32 PM.png"" />" endocrine insulin physiology
Which GLUT receptor requires insulin for transport and where is it expressed?
<div>GLUT-4; adipose tissue and skeletal muscles</div><div><br /></div>
"<img src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine insulin
physiology
<div>What GLUT receptors are present in the placenta? In the brain?
</div><div><br /></div> <div>GLUT-1 and GLUT-3 are found in both the brain and the
placenta</div><div><br /></div> "<img src=""Screen Shot 2016-03-09 at 5.40.32
<div>What is the effect of insulin on electrolyte (Na+, K+) and amino acid
transport?</div><div><br /></div> <div>It increases Na+ retention by the kidneys
and shifts both K+ and amino acids into cells (cellular uptake)</div><div><br
/></div> "<img src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine
insulin physiology
<div>How does insulin affect these processes: lipolysis, glucagon synthesis and
release, triglyceride synthesis, muscle protein synthesis?</div><div><br /></div>
<div>Decreases lipolysis, increases glucagon synthesis, decreases glucagon
release, increases both triglyceride and muscle protein synthesis</div><div><br
/></div> "<img src=""Screen Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine
insulin physiology
<div>A pregnant woman with type 1 diabetes mellitus injects insulin before a meal.
How does this insulin affect her fetus?</div><div><br /></div> <div>Insulin does
not cross the placenta, but it indirectly lowers the fetus's blood glucose levels
by lowering the mother's blood glucose level</div><div><br /></div> "<img
<div>What effect would a drug that keeps K+ channels open have on insulin release
in islet cells?</div><div><br /></div> <div>It would decrease insulin release
(as the cells could not depolarize)</div><div><br /></div> "<img src=""Screen
Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine insulin physiology
<div>A student studies for 24 consecutive hours without eating. What fuel does his
brain use during starvation? Why can't RBCs do the same?</div><div><br /></div>
<div>The brain uses ketone bodies during starvation; RBCs cannot do this
because they lack mitochondria for aerobic metabolism</div><div><br /></div> "<img
<div>In patient A, you give 50 g of oral glucose. In patient B, you inject it
instead. Patient A's blood sugar is much lower after 2 hours. Why?</div><div><br
/></div> <div>The insulin response to oral glucose is superior due to incretins
(eg, GLP-1) that only act with oral glucose</div><div><br /></div> "<img
<div>A patient eats fruit after exercise. He says that muscles take up energy quite
well during this time. Via what mechanism does this occur?</div><div><br /></div>
<div>GLUT-4 receptor expression on striated muscle and adipose tissue
increases after exercise, so glucose is taken into cells more
efficiently</div><div><br /></div> "<img src=""Screen Shot 2016-03-09 at 5.40.32
<div>A cognitively impaired newborn has a congenital decrease in GLUT-3 transporter
activity. What tissue type will be most affected by this?</div><div><br /></div>
<div>The brain; GLUT-3 is an insulin-independent transporter of glucose there
(The placenta also uses this transporter.)</div><div><br /></div> "<img
<div>Do spermatocytes use GLUT-5 for insulin-independent glucose transport?
</div><div><br /></div> <div>No, spermatocytes do use GLUT-5, but for fructose
transport rather than glucose transport</div><div><br /></div> "<img src=""Screen
Shot 2016-03-09 at 5.40.32 PM.png"" />" endocrine insulin physiology
<div><div>You are 20 hours without food. Hypoglycemia induces which cells to
produce glucagon? Which hormones inhibit glucagon production?
</div></div><div><br /></div> <div><div>The cells of the pancreas release
glucagon; insulin and somatostatin both inhibit glucagon
production</div></div><div><br /></div> "<img src=""Screen Shot 2016-03-09 at
5.42.29 PM.png"" />" endocrine glucagon physiology
In general, glucagon is a catabolic hormone. As such, which metabolic pathways does
it induce? Glycogenolysis, gluconeogenesis, lipolysis, ketone production "<img
src=""Screen Shot 2016-03-09 at 5.42.29 PM.png"" />" endocrine glucagon physiology
A patient is taking octreotide (somatostatin analog) for acromegaly. What effect
will this drug have on glucagon? It will inhibit glucagon secretion "<img
src=""Screen Shot 2016-03-09 at 5.42.29 PM.png"" />" endocrine glucagon physiology
A patient eats a large meal. The blood sugar rises and insulin is secreted. What
will blood measurements of glucagon activity show? Glucagon activity will be
low, as it is inhibited by both hyperglycemia and insulin "<img src=""Screen Shot
2016-03-09 at 5.42.29 PM.png"" />" endocrine glucagon physiology
What is the effect of TRH on TSH and prolactin? It stimulates TSH and prolactin
secretion "<img src=""7805 (1).png"" />" endocrine hypothalamic-pituitary-
hormones physiology
A woman with visual defects is found to have a prolactinoma. Why did she stop
menstruating? Prolactin blocks GnRH; LH and FSH secretion are reduced "<img
src=""7805 (1).png"" />" endocrine hypothalamic-pituitary-hormones physiology
What is the effect of CRH on pituitary hormone secretion? Stimulates secretion of
ACTH, MSH, and -endorphin "<img src=""7805 (1).png"">" endocrine hypothalamic-
pituitary-hormones physiology
A 10-year-old boy, short for his age, is found to have GH deficiency. High/low
levels of which hormone(s) may cause this? Low growth hormonereleasing
hormone (GHRH) or high somatostatin levels decrease the level of GH "<img
src=""7805 (1).png"">" endocrine hypothalamic-pituitary-hormones physiology
A man is found to have a somatostatin-secreting tumor. How does this affect
pituitary hormone secretion? Excess somatostatin inhibits GH and TSH secretion
"<img src=""7805 (1).png"">" endocrine hypothalamic-pituitary-hormones
physiology
A woman with paranoid schizophrenia thinks she is pregnant because of galactorrhea
and a lack of menses. Why did she get these symptoms? She is likely on
antipsychotic medications (dopamine receptor antagonists), which block dopamine
activity and thus elevate prolactin levels "<img src=""7805 (1).png"">"
endocrine hypothalamic-pituitary-hormones physiology
A woman has trouble getting pregnant. She is given pulse doses of GnRH. What does
this do? It elevates FSH and LH, thus increasing her fertility "<img src=""7805
(1).png"">" endocrine hypothalamic-pituitary-hormones physiology
A patient with AIDS receiving HAART has a slender face/arms/legs, but a big gut.
What intrinsic hormone analog can be used to treat him? He has HIV-associated
lipodystrophy from HAART, which is treated with tesamorelin, a GHRH analog "<img
src=""7805 (1).png"">" endocrine hypothalamic-pituitary-hormones physiology
A 20-y/o woman has had no menses for 3 months but has a white discharge from her
nipples. What two hormone levels do you want to check? -hCG (for pregnancy)
and prolactin (for possible prolactinoma) "<img src=""7805 (1).png"">" endocrine
hypothalamic-pituitary-hormones physiology
A man with temporal arteritis runs out of prednisone. Which hormone had primarily
been suppressed by long-term steroid use? CRH is decreased with long-term steroid
use "<img src=""7805 (1).png"">" endocrine hypothalamic-pituitary-hormones
physiology
"A man with schizophrenia complains he ""can't get it up for the ladies"" anymore.
What medication caused this, and how?" Antipsychotics block dopamine activity,
increasing prolactin levels; this inhibits GnRH, causing erectile dysfunction and
decreased libido "<img src=""7806 (1).png"">" endocrine physiology prolactin
Why are women less likely to become pregnant when breastfeeding? Prolactin
(necessary for milk production) inhibits ovulation via the inhibition GnRH "<img
src=""7806 (1).png"">" endocrine physiology prolactin
A woman with Graves disease undergoes thyroid irradiation and now complains of
amenorrhea. What is the treatment? Hypothyroidism increases TRH, which induces
prolactin secretion; this inhibits GnRH, and therefore ovulation; thyroid
replacement therapy "<img src=""7806 (1).png"">" endocrine physiology
prolactin
What reproductive complication is possible with high prolactin levels in men? From
where is it released? Decreased spermatogenesis by inhibition of GnRH synthesis
and release; the anterior pituitary "<img src=""7806 (1).png"">" endocrine
physiology prolactin
A woman presents with vision changes and galactorrhea. How do you treat her? A
prolactinoma (causing visual changes by impinging optic chiasm) is treated with
dopamine agonists (eg, bromocriptine) to lower prolactin "<img src=""7806
(1).png"">" endocrine physiology prolactin
What inhibits prolactin release and what stimulates it? Dopamine agonists;
dopamine antagonists, estrogens, and TRH "<img src=""7806 (1).png"">" endocrine
physiology prolactin
A man reports impaired peripheral vision and decreased libido. What single cause
could account for both of these changes? A prolactinoma compressing the optic
chiasm, leading to bitemporal hemianopsia, and secretion of excess prolactin,
decreasing libido "<img src=""7806 (1).png"">" endocrine physiology prolactin
By what mechanism could a patient with SLE and ESRD experience elevated prolactin
levels? Renal failure can reduce prolactin elimination, leading to elevated
prolactin levels "<img src=""7806 (1).png"">" endocrine physiology prolactin
In addition to medications, what are two physical methods by which dopamine levels
can be reduced? Nipple stimulation and chest wall injury (via ANS) "<img
Prolactin is structurally homologous to which other pituitary hormone? GH "<img
TRH is known to increase prolactin secretion. Negative feedback from which two
hormones helps to keep this in check? Plasma T3 and T4 "<img src=""7806
(1).png"">" endocrine physiology prolactin
A mother sees and hears her baby crying. Shortly afterwards she has a desire to
nurse the baby. What is driving her to do this? The sight and cry of her baby
stimulate the higher cortical centers, which inhibit hypothalamic dopamine, thus
increasing prolactin levels "<img src=""7806 (1).png"">" endocrine physiology
prolactin
A very tall teenage boy is found to have GH excess. How does GH mediate growth?
What other disease is he at risk for? GH increases IGF-1 and somatomedin C
secretion, which increases linear growth and muscle mass; diabetes (GH increases
insulin resistance.) "<img src=""7807 (1).png"">" endocrine growth-hormone-
(somatotropin) physiology
A very tall man has coarse facial features and visual defects. What tumor does he
have? What hormone normally inhibits his condition? A pituitary adenoma causing
acromegaly; somatostatin "<img src=""7807 (1).png"">" endocrine growth-
hormone-(somatotropin) physiology
A mom wants her child to grow taller. What lifestyle changes can optimize GH
release in her child? Deep sleep, exercise "<img src=""7807 (1).png"">"
endocrine growth-hormone-(somatotropin) physiology
A diabetic injects too much insulin and becomes hypoglycemic. What is the role of
GH in response to his low blood sugar? Its secretion increases, as it helps to
increase insulin resistance "<img src=""7807 (1).png"">" endocrine growth-
What is the difference between gigantism and acromegaly? Gigantism is GH excess
in children before growth plates close; acromegaly is GH excess in adults after
growth plates close "<img src=""7807 (1).png"" />" endocrine growth-
Why do patients have an increased appetite when they are sleep deprived? Sleep
loss increases ghrelin and decreases leptin, stimulating hunger (Ghrelin makes you
hunghre, leptin keeps you thin.) "<img src=""7808 (1).png"" /><img src=""Screen
Shot 2016-03-09 at 5.25.46 PM.png"" />" appetite-regulation endocrine physiology
What is the function of ghrelin? What key hormone is released in response to
ghrelin activity? Ghrelin stimulates hunger (orexigenic effectghrelin makes you
hunghre) and GH release via a GH secretagogue receptor "<img src=""Screen Shot
2016-03-09 at 5.25.46 PM.png"" /><img src=""7808 (1).png"" />" appetite-
regulation endocrine physiology
A patient does not feel full no matter how much she eats. Dysfunction of what
hormone could account for this? A lack of leptin, normally produced by adipose
tissue "<img src=""Screen Shot 2016-03-09 at 5.25.46 PM.png"" />" appetite-
regulation endocrine physiology
How does marijuana act to increase appetite? Endocannabinoids stimulate
receptors in the hypothalamus and nucleus accumbens, increasing desire for high-fat
foods (the munchies) "<img src=""Screen Shot 2016-03-09 at 5.25.46 PM.png"" />"
appetite-regulation endocrine physiology
Patients with Prader-Willi syndrome are known for insatiable appetite. Increased
production of which hormone accounts for this? Ghrelin (Ghrelin makes you hunghre)
"<img src=""Screen Shot 2016-03-09 at 5.25.46 PM.png"" /><img src=""7808
(1).png"" />" appetite-regulation endocrine physiology
Patients w/ Prader-Willi syndrome are overweight, with significantly increased
appetites. An excess of which signaling molecule is to blame? Overproduction of
ghrelin, which stimulates hunger "<img src=""Screen Shot 2016-03-09 at 5.25.46
PM.png"" />" appetite-regulation endocrine physiology
Arising at 4 AM each day for a surgery clerkship, you find yourself snacking more
often than usual. Is there a biochemical reason for this? Yes, sleep deprivation
both increases ghrelin production and decreases leptin production; the net effect
is increased appetite "<img src=""Screen Shot 2016-03-09 at 5.25.46 PM.png"" />"
appetite-regulation endocrine physiology
An intoxicated man is found down in the park. In the ED, he has massive urine
output and hypernatremia. What might be the cause? A lack of ADH production due
to pituitary trauma, causing central diabetes insipidus "<img src=""Screen Shot
2016-03-09 at 5.22.49 PM.png"" /><img src=""7809 (1).png"" />" antidiuretic-
hormone endocrine physiology
What receptors are involved in ADH's function? V1-receptors regulate blood
pressure; V2-receptors regulate serum osmolarity (The latter is ADH's primary
function.) "<img src=""Screen Shot 2016-03-09 at 5.22.49 PM.png"" /><img
src=""7809 (1).png"" />" antidiuretic-hormone endocrine physiology
What is the site of action of ADH in the kidney? What channel is involved?
Principal cells of the renal collecting duct; aquaporin channels "<img
src=""Screen Shot 2016-03-09 at 5.22.49 PM.png"" /><img src=""7809 (1).png"" />"
antidiuretic-hormone endocrine physiology
What is the serum ADH level in nephrogenic diabetes insipidus? Central diabetes
insipidus? Levels are elevated in nephrogenic diabetes insipidus and depressed in
central diabetes insipidus "<img src=""Screen Shot 2016-03-09 at 5.22.49
PM.png"" /><img src=""7809 (1).png"" />" antidiuretic-hormone endocrine physiology
A patient has SIADH as a result of lung cancer. What changes would you expect in
his serum and urine osmolarity? Decrease in serum osmolarity, increase in urine
osmolarity (urine more concentrated because free water is reabsorbed back into
blood) "<img src=""Screen Shot 2016-03-09 at 5.22.49 PM.png"" /><img
src=""7809 (1).png"" />" antidiuretic-hormone endocrine physiology
Parents are adamant that their 6-year-old son be given pharmacotherapy for his bed-
wetting. Is there a role for a hormone analog here? Yes, desmopressin acetate (an
ADH analog) is a first-line pharmacotherapy for nocturnal enuresis "<img
Where is antidiuretic hormone synthesized, stored, and secreted? It is synthesized
in the hypothalamus (supraoptic nuclei) and both stored in and secreted by the
posterior pituitary "<img src=""Screen Shot 2016-03-09 at 5.22.49 PM.png""
/><img src=""7809 (1).png"" />" antidiuretic-hormone endocrine physiology
What two systems are responsible for regulating antidiuretic hormone?
Osmoreceptors in the hypothalamus and receptors detecting hypovolemia "<img
A boy has 17-hydroxylase deficiency. What levels of aldosterone, cortisol, and K+
do you expect? Are blood pressures affected? High aldosterone, low cortisol, and
low K+; yes, blood pressures are elevated "<img src=""7810 (1).png"">" adrenal-
steroids-and-congenital-adrenal-hyperplasias endocrine physiology
In subjects with 17-hydroxylase deficiency, do XY subjects have male or female
internal anatomy? XY subjects have ambiguous external genitalia and undescended
testes "<img src=""7810 (1).png"">" adrenal-steroids-and-congenital-adrenal-
hyperplasias endocrine physiology
In subjects with 17-hydroxylase deficiency, do XX subjects have male or female
internal anatomy? XX subjects have both internal and external female anatomy but no
secondary sexual development "<img src=""7810 (1).png"">" adrenal-steroids-and-
congenital-adrenal-hyperplasias endocrine physiology
An XX infant has the most common form of congenital adrenal hyperplasia. She is
hypotensive with elevated K+. Name the genital phenotype. XX infants with 21-
hydroxylase deficiency have ambiguous genitalia (pseudohermaphroditism) because
high androgens cause virilization "<img src=""7810 (1).png"">" adrenal-steroids-
and-congenital-adrenal-hyperplasias endocrine physiology
Why do patients with a deficiency in 11-hydroxylase have hypertension despite
having hypoaldosteronism? They have an increase in 11-deoxycorticosterone,
which has mineralocorticoid properties and therefore causes hypertension "<img
src=""7810 (1).png"">" adrenal-steroids-and-congenital-adrenal-hyperplasias
endocrine physiology
What does aromatase convert androstenedione into? The product is then converted
into what other hormone in peripheral tissue? Aromatase converts androstenedione
into estrone; in peripheral tissue, estrone is converted into estradiol "<img
A woman taking long-term high-dose ketoconazole for a fungal infection exhibits
hypotension and a reduction in breast size. Why? Ketoconazole inhibits
cholesterol desmolase, reducing the conversion of cholesterol to pregnenolone (a
precursor for all adrenal hormones) "<img src=""7810 (1).png"">" adrenal-steroids-
While on service, you see a newborn with ambiguous genitalia. What lab findings
would support a diagnosis of 17-hydroxylase deficiency? Increased
mineralocorticoids, decreased cortisol, decreased sex hormones, decreased K+,
decreased androstenedione "<img src=""7810 (1).png"">" adrenal-steroids-and-
21-Hydroxylase deficiency can present either in infancy or childhood. How do these
two presentations typically differ? Infants typically present with salt wasting,
whereas children typically present with precocious puberty; XX subjects experience
virilization "<img src=""7810 (1).png"">" adrenal-steroids-and-congenital-
adrenal-hyperplasias endocrine physiology
Researchers design a chemical to block the 21-hydroxylase enzyme. What lab findings
show that this drug is having the proper effect? Decreased mineralocorticoids,
decreased cortisol, increased sex hormones, increased K+, increased renin,
increased 17-hydroxyprogesterone "<img src=""7810 (1).png"">" adrenal-steroids-
After cholesterol becomes pregnenolone, it can be acted on by one of two enzymes.
What are they? What are their respective products? 17-hydroxylase can convert
it into 17-hydroxypregnenolone, or 3-hydroxysteroid dehydrogenase can convert it
into progesterone "<img src=""7810 (1).png"">" adrenal-steroids-and-congenital-
adrenal-hyperplasias endocrine physiology
Progesterone can be acted on by one of two enzymes in the adrenal cortex. What are
they? What are their respective products? 17-hydroxylase can convert it into 17-
hydroxyprogesterone, or 21-hydroxylase can convert it into 11-deoxycorticosterone
"<img src=""7810 (1).png"">" adrenal-steroids-and-congenital-adrenal-
Is blood pressure elevated or decreased in subjects with deficiencies of 17-
hydroxylase, 21-hydroxylase, and 11-hydroxylase, respectively? Increased;
decreased; increased "<img src=""7810 (1).png"">" adrenal-steroids-and-
A novel blood pressure agent works by inhibiting 11-hydroxylase. Unfortunately,
subjects taking the new agent are still hypertensive. Why? Although aldosterone
synthesis is decreased, 11-deoxycorticosterone can still elevate the blood pressure
due to mineralocorticoid activity "<img src=""7810 (1).png"">" adrenal-steroids-
To lower estrogen levels, a new drug acts by inhibiting 17-hydroxyprogesterone.
Unfortunately, bilateral adrenal enlargement is seen. Why? Inhibiting 17-
hydroxyprogesterone will block cortisol synthesis, which will secondarily increase
ACTH levels and cause adrenal enlargement "<img src=""7810 (1).png"">" adrenal-
steroids-and-congenital-adrenal-hyperplasias endocrine physiology
"A licorice ""addict"" presents with hypertension. Excess cortisol activity in the
kidneys is to blame. What enzyme is responsible for this?" Glycyrrhetic acid (in
licorice), inhibiting cortisol conversion into cortisone (This is syndrome of
apparent mineralocorticoid excess.) "<img src=""7810 (1).png"">" adrenal-steroids-
What two reactions catalyze the transformation of pregnenolone into DHEA?
Pregnenolone to 17-hydroxypregnenolone via 17-hydroxylase, 17-
hydroxypregnenolone to DHEA via 17,20-lyase "<img src=""7810 (1).png"">"
adrenal-steroids-and-congenital-adrenal-hyperplasias endocrine physiology
What two reactions catalyze the transformation of progesterone into
androstenedione? Progesterone to 17-hydroxyprogesterone via 17-hydroxylase, 17-
hydroxyprogesterone to androstenedione via 17,20-lyase "<img src=""7810
(1).png"">" adrenal-steroids-and-congenital-adrenal-hyperplasias endocrine
physiology
A woman with estrogen receptor-positive breast cancer is prescribed aromatase
inhibitors. How do they help treat her cancer? They (anastrozole/exemestane) block
the conversion of androstenedione to estrone and testosterone to estradiol,
lowering estrogen levels "<img src=""7810 (1).png"">" adrenal-steroids-and-
Biopsy of a man's prostate cancer shows that it grows in response to DHT. How might
finasteride help to treat him? Finasteride inhibits 5-reductase, which
converts testosterone into DHT; this reduces the levels of DHT in the peripheral
tissues "<img src=""7810 (1).png"">" adrenal-steroids-and-congenital-adrenal-
What two reactions catalyze the transformation of progesterone into corticosterone?
Progesterone to 11-deoxycorticosterone via 21-hydroxylase, 11-
deoxycorticosterone to corticosterone via 11-hydroxylase "<img src=""7810
(1).png"">" adrenal-steroids-and-congenital-adrenal-hyperplasias endocrine
physiology
What two reactions catalyze the transformation of 17-hydroxyprogesterone into
cortisol? 17-hydroxyprogesterone to 11-deoxycortisol via 21-hydroxylase, 11-
deoxycortisol to cortisol via 11-hydroxylase "<img src=""7810 (1).png"">"
What enzyme converts corticosterone into aldosterone? What molecule stimulates this
enzyme? Where in the adrenal cortex does this occur? Aldosterone synthase;
angiotensin II; the zona glomerulosa (site of mineralocorticoid production) "<img
Where in the adrenal cortex does cortisol synthesis occur? The zona fasciculata
(site of glucocorticoid production) "<img src=""7810 (1).png"">" adrenal-steroids-
What two reactions catalyze the transformation of DHEA into testosterone? DHEA
to androstenedione via 3-hydroxysteroid dehydrogenase, androstenedione to
testosterone via 21-hydroxylase "<img src=""7810 (1).png"">" adrenal-steroids-
Where in the adrenal cortex do the enzymes aromatase and 5-reductase act? The
zona reticularis (site of androgen production) "<img src=""7810 (1).png"">"
Which enzyme is responsible for converting cholesterol to pregnenolone?
Cholesterol desmolase "<img src=""7810 (1).png"">" adrenal-steroids-and-
Which enzyme catalyzes the conversion of testosterone to dihydrotestosterone?
5-reductase "<img src=""7810 (1).png"">" adrenal-steroids-and-
What is ACTH's effect on cholesterol desmolase? What about ketoconazole?
Stimulatory; inhibitory "<img src=""7810 (1).png"">" adrenal-steroids-and-
Which congenital adrenal enzyme deficiencies are characterized by bilaterally
enlarged adrenal glands? All of them, because decreased cortisol production
increases ACTH levels, leading to adrenal enlargement "<img src=""7810 (1).png"">"
What stimulates aldosterone synthase to convert corticosterone into aldosterone?
Angiotensin II "<img src=""7810 (1).png"">" adrenal-steroids-and-
How is cortisol found in the bloodstream? It is bound to corticosteroid-binding
globulin "<img src=""7811 (1).png"">" cortisol endocrine physiology
What are the main effects of cortisol? Raises BP, Insulin resistance,
Gluconeogenesis; decreases Fibroblast activity, Inflammatory/Immune responses, Bone
formation (BIG FIB) "<img src=""7811 (1).png"">" cortisol endocrine physiology
A man taking high-dose steroids for ulcerative colitis has diffuse striae. A
decrease of activity in which cells is to blame? Fibroblasts, since cortisol
depresses fibroblast activity "<img src=""7811 (1).png"">" cortisol endocrine
physiology
How do steroids help people with cat allergies? With inflammation? They
decrease leukotriene and prostaglandin production, reduce eosinophil counts, and
block mast cell histamine output "<img src=""7811 (1).png"">" cortisol endocrine
physiology
A man needs steroids for a multiple sclerosis flare. He is otherwise healthy.
Inpatient labs show hyperglycemia. Do you diagnose diabetes? No, you prescribed
steroids, which increase insulin resistance (diabetogenic); this will subside once
the steroids are discontinued "<img src=""7811 (1).png"">" cortisol endocrine
physiology
A patient needs high-dose steroids for a long period. Why do you provide a
calcium/vitamin D supplement as well? Steroids suppress osteoblast activity,
resulting in decreased bone formation and increased risk for osteoporosis "<img
src=""7811 (1).png"">" cortisol endocrine physiology
A patient takes excessive corticosteroids. How does this affect the natural
mechanism for cortisol regulation? Excess cortisol decreases CRH, ACTH, and
endogenous cortisol secretion "<img src=""7811 (1).png"">" cortisol endocrine
physiology
A patient presents w/a 4th case of pneumonia in a year. He reports chronic stress.
ROS: only positive for weight gain. What could this be? Chronic stress can lead
to an increased cortisol level, thereby blunting the immune response and increasing
the risk for infection "<img src=""7811 (1).png"">" cortisol endocrine physiology
A patient is taking high-dose prednisone for her lupus. On a regular lab checkup,
you notice hypokalemia and hypernatremia. Why? At high concentrations, cortisol
can bind to and act as an agonist on aldosterone receptors, thus mimicking
hyperaldosteronism "<img src=""7811 (1).png"">" cortisol endocrine physiology
Before a patient begins receiving an oral corticosteroid, a PPD should be
performed. Why? Exogenous corticosteroids are immunosuppressive; TB or
candidiasis reactivation can occur due to decreased IL-2 production "<img
src=""7811 (1).png"">" cortisol endocrine physiology
Inhibition of which cytokine by corticosteroids causes reactivation of TB or
candidiasis? IL-2 "<img src=""7811 (1).png"">" cortisol endocrine physiology
Via what pathway is cortisol production regulated? Where in the body is cortisol
produced? Hypothalamic CRH stimulates pituitary ACTH release, which stimulates
cortisol production in the adrenal zona fasciculata "<img src=""7811 (1).png"">"
cortisol endocrine physiology
A surgery resident who is always angry is noted to have elevated cortisol levels.
What cortisol regulation derangement is likely to blame? Chronic stress (as seen
in a surgical residency) can induce prolonged secretion of CRH, thus increasing
ACTH levels and cortisol production "<img src=""7811 (1).png"">" cortisol endocrine
physiology
A patient with lupus receives steroids. Days later, she has a severe leukocytosis
but reports feeling better. Do you treat for an infection? No, steroids inhibit WBC
adhesion and thus cause a neutrophilia; it is unlikely that she has an infection
requiring treatment "<img src=""7811 (1).png"">" cortisol endocrine physiology
In what three forms is Ca2+ found in plasma? Which is the most common? The least
common? Ionized, bound to albumin, and bound to anions; ionized is the most
common form, and Ca2+ bound to anions is the least common "<img src=""7812
(1).png"">" calcium-homeostasis endocrine physiology
What are the clinical manifestations of a respiratory alkalosis, specifically in
regard to Ca2+? Increased pH allows more albumin to bind Ca2+, causing clinical
hypocalcemia (cramps, pain, paresthesias, carpopedal spasms) "<img src=""7812
(1).png"">" calcium-homeostasis endocrine physiology
What are the two sources of the precursors for activated vitamin D? Plants,
fungi, and yeasts for D2; fish, plants, and skin sun exposure for D3 "<img
src=""7813 (1).png"">" endocrine physiology vitamin-d-(cholecalciferol)
A boy living in Minnesota has bowed legs. You suspect that a vitamin deficiency is
to blame. How do you treat him? This is likely rickets; treat with vitamin D
supplementation "<img src=""7813 (1).png"">" endocrine physiology vitamin-d-
(cholecalciferol)
Patients on dialysis often develop osteomalacia. Why? These patients with no kidney
function cannot convert inactive vitamin D into the active form: 1,25-(OH)2 "<img
src=""7813 (1).png"">" endocrine physiology vitamin-d-(cholecalciferol)
PTH increases Ca2+ and decreases serum PO43. How are these effects different from
1,25-(OH)2 vitamin D's effects? 1,25-(OH)2 vitamin D increases Ca2+ and
phosphate levels from gut absorption and bone resorption "<img src=""7813
(1).png"">" endocrine physiology vitamin-d-(cholecalciferol)
24,25-(OH)2 D3 is an inactive form of vitamin D. What stimulates production of
(active) 1,25-(OH)2 vitamin D? High PTH, low Ca2+, and low PO43 increase
production of active vitamin D (1,25-(OH)2) "<img src=""7813 (1).png"">"
endocrine physiology vitamin-d-(cholecalciferol)
How are inactive forms of vitamin D converted to the active form? D3 and D2
are converted to 25-OH in the liver, then to 1,25-(OH)2 (active form) in the
kidneys "<img src=""7813 (1).png"">" endocrine physiology vitamin-d-
(cholecalciferol)
What is the difference between rickets and osteomalacia? Rickets: vitamin D
deficiency in kids (abnormally formed bone); osteomalacia: vitamin D deficiency in
adults (poor bone mineralization) "<img src=""7813 (1).png"">" endocrine
physiology vitamin-d-(cholecalciferol)
What are the two main functions of active vitamin D? Increased gut absorption of
dietary Ca2+, and PO43, enhanced bone mineralization "<img src=""7813 (1).png"">"
What form of vitamin D is able to regulate its own production? Active vitamin D
(1,25-(OH)2) is able to inhibit its own production "<img src=""7813 (1).png"">"
Which cells normally produce PTH? Chief cells of the parathyroid glands "<img
src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
A man has high PTH levels. What serum and urinary findings do you see in a patient
with primary hyperparathyroidism? High serum Ca2+, low serum PO43, and high
urine PO43 and cAMP "<img src=""7814 (1).png"">" endocrine parathyroid-hormone
physiology
How does PTH affect Ca2+ absorption in the intestines? It stimulates renal
proximal convoluted tubule 1-hydroxylase, increasing 1,25-(OH)2D3 levels; this
promotes intestinal Ca2+ absorption "<img src=""7814 (1).png"">" endocrine
parathyroid-hormone physiology
A woman on dialysis is found to have osteoporosis. Her PTH level is normal. What
enzyme might she be deficient in? 1-Hydroxylase (from the renal proximal
convoluted tubule) increases 1,25-(OH)2 D3 and therefore Ca2+ absorption from the
gut "<img src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
What electrolyte changes induce PTH secretion? Decreased serum Ca2+ and mildly to
moderately decreased Mg2+ both increase PTH secretion "<img src=""7814 (1).png"">"
endocrine parathyroid-hormone physiology
An alcoholic, hypertensive man with diarrhea recently started taking gentamicin.
How could this affect PTH secretion? Alcohol abuse, diarrhea, aminoglycosides,
& diuretics lower Mg2+; mildly/moderately low Mg2+ boosts PTH, while severely low
Mg2+ lowers it "<img src=""7814 (1).png"">" endocrine parathyroid-hormone
physiology
Almost counterintuitively, PTH can also be given to patients with osteoporosis to
help form bone. In what fashion must PTH be given? Intermittently administered
(eg, once-daily injection) PTH can stimulate bone formation"<img src=""7814
(1).png"">" endocrine parathyroid-hormone physiology
In lab rats, adding a RANK-L (receptor activator of NF-B ligand) inhibitor lowers
the serum Ca2+ level. Why might this be? PTH causes osteoblasts/osteocytes to make
RANK-L, which binds osteoclasts/osteoclast precursor RANK, stimulating
osteoclasts/increasing Ca2+ "<img src=""7814 (1).png"">" endocrine parathyroid-
hormone physiology
A patient with advanced squamous cell lung cancer has a very low serum phosphate
level. Why might this be? Some cancers secrete PTH-related peptide, which
mimics PTH; PTH causes reduced PO43 reabsorption (PTH = Phosphate Trashing
Hormone) "<img src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
With which lab findings would a patient who has parathyroid hyperplasia leading to
excessive PTH secretion present? High serum Ca2+, low serum PO43, and high
urine PO43 and cAMP "<img src=""7814 (1).png"">" endocrine parathyroid-hormone
physiology
PTH works on two organ systems: bones and kidneys. How does it affect Ca2+/PO43
processing in each? Bone: Ca2+/PO43 release; kidneys: more 1,25-(OH)2D3 via
PCT 1-hydroxylase and more DCT Ca2+ reabsorption, less PCT PO43 reabsorption
"<img src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
A patient with ESRD has severe hypomagnesemia. What would you expect from a lab
assay for serum PTH levels? Decreased PTH; while moderately low Mg2+ can increase
PTH secretion, a severe hypomagnesemic state can actually decrease PTH secretion
"<img src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
What two stimuli can promote the production of active vitamin D? Via what enzyme
does this occur, and in which organ? Increased PTH and low PO43 both
stimulate 1-hydroxylase to produce active vitamin D (1,25-(OH)2 D3) in the PCT of
the kidneys "<img src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
Which stimuli will inhibit PTH synthesis via direct feedback? Increased 1,25-
(OH)2 D3, increased Ca2+, or decreased PO43 "<img src=""7814 (1).png"">"
Which three stimuli will promote PTH synthesis via direct stimulation? Decreased
ionized Ca2+, increased PO43, or decreased 1,25-(OH)2 D3 "<img src=""7814
Name two malignancies that commonly increase the secretion of PTHrP. Squamous
cell carcinoma of the lung and renal cell carcinoma "<img src=""7814 (1).png"">"
How many parathyroid glands are there? Four "<img src=""7814 (1).png"">"
1,25(OH)2D 3 works on three organ systems: the bones, intestines, and kidneys. How
does it affect Ca2+/PO43 processing in each? Bone: more Ca2+/PO43 release;
intestines and kidneys: more Ca2+ and PO43 absorption "<img src=""7814
What three changes are seen in the urine secondary to increased PTH activity?
Decreased urine Ca2+, increased urine PO43, increased urine cAMP "<img
src=""7814 (1).png"">" endocrine parathyroid-hormone physiology
1-Hydroxylase catalyzes what reaction pertaining to vitamin D? The conversion of
25-OH D3 into 1,25(OH)2 D3 (active vitamin D) "<img src=""7814 (1).png"">"
How is calcitonin involved in Ca2+ homeostasis? It opposes PTH's actions but is not
important in normal Ca2+ homeostasis (calcitonin tones down Ca2+ levels) "<img
src=""7815 (1).png"">" calcitonin endocrine physiology
A person with medullary thyroid cancer (cancer of thyroid parafollicular [C] cells)
is expected to have an increase in what hormone? Calcitonin: parafollicular
(C) cells secrete calcitonin, lowering bone resorption and thus serum Ca2+ levels
"<img src=""7815 (1).png"">" calcitonin endocrine physiology
What stimulates the secretion of calcitonin? Increased serum Ca2+ levels "<img
src=""7815 (1).png"">" calcitonin endocrine physiology
What plasma protein binds T3/T4 in blood? Is bound thyroid hormone active? What
increases or decreases levels of the binding protein? TBG; only free hormone is
active; liver failure/steroids decrease TBG; estrogen (pregnancy/OCP use) increases
TBG "<img src=""7816 (1).png"">" endocrine physiology thyroid-hormones-(t3/t4)
Where are T3 and T4 produced? What element is required for their production? What
is their main function? T4 and some T3 are formed in thyroid follicles, but most T3
is formed in target tissues; iodine; they control the body's metabolic rate "<img
src=""7816 (1).png"">" endocrine physiology thyroid-hormones-(t3/t4)
By what mechanism do T3 and T4 affect the basal metabolic rate? They increase
basal metabolic rate by stimulating Na+/K+-ATPase activity, which increases O2
consumption, RR, and body temperature "<img src=""7816 (1).png"">" endocrine
physiology thyroid-hormones-(t3/t4)
What are the four main functions of T3? 4 B's =Brain maturation, Bone growth, -
adrenergic effects in heart (increased CO, HR, SV, contractility), Basal metabolic
rate increased "<img src=""7816 (1).png"">" endocrine physiology thyroid-
hormones-(t3/t4)
What are the catabolic effects of thyroid hormones? Increased glycogenolysis,
gluconeogenesis, lipolysis "<img src=""7816 (1).png"">" endocrine physiology
thyroid-hormones-(t3/t4)
Routine neonatal screening shows low thyroid hormone levels. What organ system's
development are you concerned about? The CNS because thyroid hormones are
needed for CNS maturation "<img src=""7816 (1).png"">" endocrine physiology
The hypothalamus releases what hormone to upregulate the thyroid axis? This
directly increases hormone production within which gland? TRH; TSH within the
pituitary gland "<img src=""7816 (1).png"">" endocrine physiology thyroid-
hormones-(t3/t4)
From which large precursor protein is thyroid hormone derived? TG "<img
A 50-year-old woman has fatigue, cold intolerance, and weight gain. She has been
adding iodized salt to food. Explain the pathophysiology. Wolff-Chaikoff effect:
temporary inhibition of thyroid peroxidase by extra iodine, reducing iodine
organification and T3/T4 production "<img src=""7816 (1).png"">" endocrine
What is the major hormone product of the thyroid gland? T4 (T3 is a lesser
product; the majority of T3 is created peripherally via 5-deiodinase.) "<img
Both propylthiouracil and methimazole decrease formation of monoiodotyrosine and
diiodotyrosine via what mechanism? How do the drugs differ?Both inhibit thyroid
peroxidase, but propylthiouracil also inhibits 5-deiodinase (which converts T4 to
T3 in peripheral tissue) "<img src=""7816 (1).png"">" endocrine physiology
A 30-year-old woman complains of weight loss, hair loss, and protruding eyes. What
autoimmune process may be at work? She likely has Graves disease due to TSI, which
stimulates follicular cells similar to TSH "<img src=""7816 (1).png"">"
endocrine physiology thyroid-hormones-(t3/t4)
A pregnant woman's lab studies show an increase in total T4 levels. Should she be
alarmed? Not necessarily; total T4 level increases in pregnancy because of
increased circulating TBG, but free T4 should remain normal"<img src=""7816
(1).png"">" endocrine physiology thyroid-hormones-(t3/t4)
Where do T3 and T4 bind to exert their effects? Which of the two has greater
affinity? Nuclear receptors; T3 "<img src=""7816 (1).png"">" endocrine
What combinations of MIT and diiodotyrosine DIT are needed to make T3 and T4,
respectively? MIT + DIT = T3; DIT + DIT = T4 "<img src=""7816 (1).png"">"
Where do free T3 and T4 exert negative feedback? The hypothalamus and anterior
pituitary "<img src=""7816 (1).png"">" endocrine physiology thyroid-hormones-
(t3/t4)
What are the two main functions of thyroid peroxidase? The oxidation and
organification of iodine; the coupling of MIT and DIT (MIT + DIT = T3, DIT + DIT =
T4) "<img src=""7816 (1).png"">" endocrine physiology thyroid-hormones-(t3/t4)
A new toxin inhibits various co-transporters that depend on Na+. How might this
induce hypothyroidism? Iodine (I) is taken up from the blood by the thyroid via
an I/Na+ co-transporter; inhibiting this co-transporter causes hypothyroidism
"<img src=""7816 (1).png"">" endocrine physiology thyroid-hormones-(t3/t4)
Explain how iodine is transported from the peripheral blood to the thyroid
follicular lumen for use in thyroid hormone (T3/T4) production. I enters the
thyroid via I/Na+ cotransporters; it is then oxidized (I to I2) & exported to
the follicular lumen via thyroid peroxidase "<img src=""7816 (1).png"">"
Where does the coupling of thyroid hormones take place? What important transporter
molecule is required to make this happen? Thyroid follicular epithelial cells; TG,
carrying organified I2 as MIT and DIT, assists with endocytosis "<img src=""7816
"What is the ""cycle"" of TG in the thyroid, and how does this assist with thyroid
hormone production?" Lumen TG binds/helps endocytose MIT/DIT into follicular
cells; in cells, deiodinase/coupling remove DIT/MIT from TG; TG then reenters
lumens "<img src=""7816 (1).png"">" endocrine physiology thyroid-hormones-
(t3/t4)
Oxidized I2 in the follicular lumen is organified into which two molecules? What
enzyme facilitates this process? MIT and DIT; thyroid peroxidase "<img
In the thyroid follicular epithelial cells, not all MIT and DIT is used to produce
thyroid hormones. What happens to these excess molecules? They detach from TG and
are converted back into inorganic iodine (I) and tyrosine via deiodinase "<img
"MIT and DIT are ""coupled"" into what hormones within the thyroid follicular
epithelial cells? What enzyme is responsible for this?" Thyroid hormones (T4 and
T3); thyroid peroxidase "<img src=""7816 (1).png"">" endocrine physiology thyroid-
hormones-(t3/t4)
Tyrosine, freed from MIT/DIT via deiodinase in thyroid follicular epithelial cells,
reenters follicular lumens with what carrier protein? TG "<img src=""7816
Which of the two thyroid hormones is more active (promotes more downstream thyroid
function)? Which enzyme generates this active form? T3; 5-deiodinase "<img
How do thyroid hormones exerting negative feedback on the anterior pituitary reduce
the production of TSH? They decrease the sensitivity of the anterior pituitary to
TRH (produced by the hypothalamus) "<img src=""7816 (1).png"">" endocrine
A toxin causes hyperthyroidism by blocking anterior pituitary T3/T4 negative
feedback. An analog of what hormone may act as an antidote?Somatostatin (inhibits
TSH production in the anterior pituitary) "<img src=""7816 (1).png"">" endocrine
A woman's IP3 signaling pathway is malfunctioning; do you expect her to be unable
to menstruate or unable to have uterine contractions? She would likely be unable to
have uterine contractions because oxytocin uses the IP3 pathway "<img src=""7817
(1).png"">" endocrine physiology signaling-pathways-of-endocrine-hormones
What are the major differences in signaling between insulin and glucagon?
Insulin uses an intrinsic tyrosine kinase pathway, whereas glucagon increases
the cAMP concentration in the cell after binding its receptor "<img src=""7817
Name the hormones that use the cAMP signaling pathway. FSH, LH, ACTH, TSH, CRH,
hCG, ADH (V2-receptor) MSH, PTH, calcitonin, GHRH, glucagon (FLAT ChAMP) "<img
src=""7817 (1).png"">" endocrine physiology signaling-pathways-of-endocrine-
hormones
A boy's receptor-associated tyrosine kinase pathway is defective. Do you note
decreased Ca2+ levels, a lack of insulin, or impaired growth? Decreased growth;
GH uses this signaling pathway "<img src=""7817 (1).png"">" endocrine
physiology signaling-pathways-of-endocrine-hormones
You are seeing a patient with malignant hypertension in the ED. Medications acting
on which signaling pathway would be most helpful here? cGMP; hormones using
this pathway tend to vasodilate (ANP, BNP, and EDRF [NO]) "<img src=""7817
What hormones use a nonreceptor tyrosine kinase? Which tyrosine kinase pathway do
they use? Prolactin, Immunomodulators (eg, cytokines IL-2/IL-6/IFN), GH, G-CSF,
Erythropoietin, Thrombopoietin (PIGGLET); JAK/STAT pathway "<img src=""7817
Antidiuretic hormone can bind the V1- or V2 The V1-receptor uses the IP3
pathway, and the V2 receptor uses cAMP "<img src=""7817 (1).png"">" endocrine
Broadly speaking, signaling molecules that utilize the nonreceptor tyrosine kinase
pathway fall into which two broad categories? Acidophils and cytokines "<img
src=""7817 (1).png"">" endocrine physiology signaling-pathways-of-endocrine-
hormones
What hormones use a receptor tyrosine kinase/MAP kinase pathway? Insulin, IGF-1,
FGF, PDGF, EGF (think growth factors) "<img src=""7817 (1).png"">" endocrine
What hormones use cGMP as a signaling molecule? BNP, ANP, EDRF (NO); with cGMP,
think vasodilators (BAD GraMPa) "<img src=""7817 (1).png"">" endocrine
A drug causes dysfunction in the cAMP pathway. Which anterior pituitary hormones
would, theoretically, continue to function normally? GH and prolactin (These use a
nonreceptor tyrosine kinase signaling pathway.) "<img src=""7817 (1).png"">"
endocrine physiology signaling-pathways-of-endocrine-hormones
Which hormones use intracellular receptors in their signaling pathways?
Progesterone, Estrogen, Testosterone, Cortisol, Aldosterone, T3/T4 Vitamin D
(PET CAT on TV) "<img src=""7817 (1).png"">" endocrine physiology signaling-
pathways-of-endocrine-hormones
What hormones use the IP3 signaling pathway? GnRH, Oxytocin, ADH (V1 receptor),
TRH, Histamine (H1 receptor), Angiotensin II, Gastrin (GOAT HAG) "<img src=""7817
A patient asks if the prednisone she was prescribed will work within seconds. What
is the most appropriate response? Steroid hormones have a delayed response; time
is required for gene transcription and protein synthesis to be affected "<img
src=""7818 (1).png"">" endocrine physiology signaling-pathway-of-steroid-hormones
Why do steroid hormones circulate bound to specific binding globulins? Steroid
hormones are lipophilic, and specific binding globulins increase their solubility
"<img src=""7818 (1).png"">" endocrine physiology signaling-pathway-of-
steroid-hormones
As SHBG increases in men, what change would you expect in free testosterone
(assuming no compensatory mechanism)? As SHBG increases in men, free
testosterone decreases, leading to gynecomastia "<img src=""7818 (1).png"">"
endocrine physiology signaling-pathway-of-steroid-hormones
A 31-year-old woman presents with facial hair. Lab values show low SHBG. What do
you expect her free testosterone to be? Increased (because she has hirsutism)
"<img src=""7818 (1).png"">" endocrine physiology signaling-pathway-of-
steroid-hormones
A 35-year-old woman is 7 months pregnant. How does pregnancy affect her SHBG level?
Pregnancy (and OCPs) increase SHBG, though the free estrogen level remains
unchanged "<img src=""7818 (1).png"">" endocrine physiology signaling-pathway-
of-steroid-hormones
A bodybuilder takes pure testosterone, thinking that it will help him build muscle.
Where will this hormone bind to its receptor? Steroid hormones bind their
receptors in either the cytoplasm or nucleus "<img src=""7818 (1).png"">"
endocrine physiology signaling-pathway-of-steroid-hormones
Which elicit a response faster: steroid hormones or peptide hormones? Peptide
hormones, as steroid hormones must act at a transcriptional level to evoke cellular
changes "<img src=""7818 (1).png"">" endocrine physiology signaling-pathway-
of-steroid-hormones
A steroid hormone acts on a cell. Outline the steps needed for gene expression to
be modified. Hormone enters cell and binds receptor (nucleus or cytoplasm),
DNA exposed, hormone binds to enhancer, transcription/translation, response "<img
src=""7818 (1).png"">" endocrine physiology signaling-pathway-of-steroid-hormones
A man has ACTH-dependent Cushing syndrome. A high-dose dexamethasone suppression
test does not lower ACTH. What will administering CRH do? The negative suppression
result suggests ectopic ACTH release, so CRH stimulation testing will not increase
ACTH "<img src=""7819 (1).png"">" Pathology cushing-syndrome endocrine
"A man has a ""buffalo hump"" and elevated ACTH. You suspect Cushing disease. How
does a high-dose dexamethasone suppression test support this?" Suppression of
ACTH is expected with high-dose (but not low-dose) dexamethasone suppression
testing "<img src=""7819 (1).png"">" Pathology cushing-syndrome endocrine
A patient has moon facies and low ACTH levels. He does not take steroids. What
diagnostic test should you order next? MRI to confirm presence of an adrenal
tumor causing an ACTH-independent Cushing syndrome (ectopic cortisol production)
"<img src=""7819 (1).png"">" Pathology cushing-syndrome endocrine
A Cushing patient's ACTH level is elevated. Brain MRI shows a pituitary mass. What
will high-dose dexamethasone suppression testing show? If the mass is secreting
ACTH (Cushing disease), there will be adequate suppression of ACTH release by high-
dose dexamethasone "<img src=""7819 (1).png"">" Pathology cushing-syndrome
endocrine
A woman has ACTH-dependent Cushing syndrome. A CRH stimulation test promotes
additional ACTH release. Do you perform a brain MRI? Yes, a positive result on CRH
stimulation testing suggests Cushing disease (ACTH-secreting pituitary tumor), so
brain MRI is indicated "<img src=""7819 (1).png"">" Pathology cushing-syndrome
endocrine
Insulin resistance and truncal obesity develop in a patient on long-term anti-
inflammatory medications. What will an adrenal biopsy show?Bilateral adrenal
atrophy; this is Cushing syndrome due to long-term corticosteroid use "<img
src=""7819 (1).png"">" Pathology cushing-syndrome endocrine
A man has low ACTH levels with suspected Cushing syndrome and denies taking
steroids. What diagnostic test confirms the diagnosis? MRI to confirm the
presence of an adrenal tumor "<img src=""7819 (1).png"">" Pathology cushing-
syndrome endocrine
What is the difference between Cushing syndrome and Cushing disease? Cushing
syndrome: high cortisol level from any cause; Cushing disease: high cortisol level
caused by an ACTH-producing pituitary adenoma "<img src=""7819 (1).png"">"
Pathology cushing-syndrome endocrine
A man with Cushing syndrome has increased ACTH. What are two possible mechanisms of
his increased ACTH level? ACTH-producing pituitary adenoma (Cushing disease),
ectopic ACTH production (eg, small cell lung cancer, bronchial carcinoid) "<img
A patient with Cushing syndrome has decreased ACTH. What are two mechanisms of
increased cortisol production with a low ACTH level? Exogenous steroids (primary
cause) and adrenal overproduction of cortisol (eg, adrenal adenoma, carcinoma,
nodular adrenal hyperplasia) "<img src=""7819 (1).png"">" Pathology cushing-
syndrome endocrine
You administer a low dose of dexamethasone to a patient and his cortisol levels
decrease. What do you expect to see after a high dose? A decrease in cortisol
levels; if low doses suppress cortisol release, then high doses will as well (the
patient has a normal HPA axis) "<img src=""7819 (1).png"">" Pathology cushing-
syndrome endocrine
A patient's cortisol level remains high after a low dose of dexamethasone but is
suppressed with a high dose. Diagnosis? An ACTH-producing pituitary tumor
(Cushing disease) "<img src=""7819 (1).png"">" Pathology cushing-syndrome
endocrine
What does dexamethasone testing before removal of a pituitary adenoma from a man
with central obesity, abdominal striae, and diabetes show? High cortisol with low
dosing and reduced cortisol with high dosing because this is a cortisol-producing
pituitary tumor (Cushing disease) "<img src=""7819 (1).png"">" Pathology cushing-
syndrome endocrine
A man has Cushing syndrome. ACTH is elevated, and cortisol remains high after both
low and high dexamethasone doses. What is the diagnosis? An ectopic ACTH-
producing tumor (fully resistant to negative feedback by dexamethasone) "<img
A CRH stimulation test is ordered for a patient with excess cortisol and elevated
ACTH, and the ACTH level does not change. Why? Because the patient has ectopic
ACTH production (often seen in paraneoplastic syndromes); this is not affected by
CRH administration "<img src=""7819 (1).png"">" Pathology cushing-syndrome
endocrine
A patient is thought to have adrenal insufficiency. What symptoms do you expect him
to report? What lab tests would you order? Weakness, hypotension, fatigue,
muscle aches, weight loss, sugar and/or salt cravings; morning/random cortisol,
serum electrolytes, and ACTH "<img src=""7820 (1).png"">" Pathology adrenal-
insufficiency endocrine
You are asked to order a metyrapone stimulation test on a patient with suspected
primary adrenal insufficiency (AI). How does this help you?In primary AI, ACTH
rises and 11-deoxycortisol & cortisol remain low; in the absence of AI, ACTH & 11-
deoxycortisol rise, and cortisol drops "<img src=""7820 (1).png"">" Pathology
adrenal-insufficiency endocrine
A man from Mexico has TB-related adrenal insufficiency. In addition to treating his
TB, what hormones must be iatrogenically replaced? Both glucocorticoid and
mineralocorticoid (fludrocortisone) must be replaced, as TB causes primary adrenal
insufficiency "<img src=""7820 (1).png"">" Pathology adrenal-insufficiency
endocrine
A young boy with septicemia, petechiae, hypotension, and hyperkalemia experiences
DIC and endotoxic shock. What is the treatment for this? In Waterhouse-
Friderichsen syndrome (acute primary adrenal insufficiency), use antibiotics (for N
meningitidis) and support (for DIC/shock) "<img src=""7820 (1).png"">" Pathology
adrenal-insufficiency endocrine
A woman with lupus would like to discontinue her medications, which include
steroids. Why do you taper the steroids slowly? Abrupt discontinuation can lead to
adrenal insufficiency (Tertiary from Treatment) "<img src=""7820 (1).png"">"
Pathology adrenal-insufficiency endocrine
Why is primary adrenal insufficiency marked by skin and mucosal findings?
Increased melanocyte-stimulating hormone (a byproduct of increased ACTH) from
POMC causes pigmentation "<img src=""7820 (1).png"">" Pathology adrenal-
One of your patients has Addison disease. What would a pathologic study of his
adrenal gland show? Adrenal atrophy and the absence of hormone production
involving all three layers of the adrenal cortex; the medulla is spared "<img
src=""7820 (1).png"">" Pathology adrenal-insufficiency endocrine
What acid-base status is expected in a young man with primary adrenal
insufficiency? Patients with Addison disease are acidotic (metabolic);
autoimmune disease is the most common cause of primary adrenal insufficiency "<img
A woman with meningococcal septicemia becomes hypotensive, with DIC. What is the
likely diagnosis? Waterhouse-Friderichsen syndrome, or acute primary adrenal
insufficiency caused by adrenal hemorrhages "<img src=""7820 (1).png"">"
Pathology adrenal-insufficiency endocrine
What is, by far, the most common cause of tertiary adrenal insufficiency? Abrupt
discontinuation of long-term treatment with corticosteroids (Tertiary from
Treatment) "<img src=""7820 (1).png"">" Pathology adrenal-insufficiency endocrine
A man with SLE exhibits skin and mucosal hyperpigmentation. Labs show high K+ and a
metabolic acidosis. Most likely disease mechanism? In light of the history of
SLE and exam findings, this is likely chronic autoimmune destruction of his adrenal
glands (Addison disease) "<img src=""7820 (1).png"">" Pathology adrenal-
A man from Africa has night sweats and fevers. He is hypotensive and craves salt.
Administering metyrapone does not raise ACTH. Diagnosis? Secondary or tertiary
adrenal insufficiency (if primary, metyrapone stimulation testing would have
increased his ACTH level) "<img src=""7820 (1).png"">" Pathology adrenal-
Why does secondary adrenal insufficiency (AI) not cause hyperkalemia, whereas
primary AI does? Secondary AI is due to decreased pituitary ACTH production with
intact adrenal glands; therefore aldosterone synthesis is preserved "<img
A man with diffuse skin and mucosal pigmentation has an elevated ACTH level and a
low cortisol level. Diagnosis? Primary adrenal insufficiency (Primary Pigments
the skin/mucosa) "<img src=""7820 (1).png"">" Pathology adrenal-insufficiency
endocrine
A man has orthostasis and salt cravings. Morning ACTH and cortisol levels are both
low. What will metyrapone stimulation testing reveal? Metyrapone decreases cortisol
levels w/no effect on ACTH or 11-deoxycortisol levels (This is secondary or
tertiary adrenal insufficiency.) "<img src=""7820 (1).png"">" Pathology adrenal-
A man has hypotension and craves potato chips. Morning ACTH is elevated; cortisol
is low. What will metyrapone stimulation testing reveal? Metyrapone will decrease
cortisol levels and increase both ACTH and 11-deoxycortisol levels (This is primary
adrenal insufficiency.) "<img src=""7820 (1).png"">" Pathology adrenal-
How does the metyrapone stimulation test work? It blocks the last step of cortisol
synthesis (11-deoxycortisol to cortisol); the responses of both ACTH and 11-
deoxycortisol are measured "<img src=""7820 (1).png"">" Pathology adrenal-
A young lady w/hypertension not responsive to multiple medications has increased
aldosterone and increased renin. What mechanism is at play?Secondary
hyperaldosteronism, or independent activation of the renin-angiotensin-aldosterone
system "<img src=""7821 (1).png"">" Pathology endocrine hyperaldosteronism
What metabolic abnormalities would you expect in a patient with hyperaldosteronism?
In addition to hypertension, the patient can have normal K+ levels or
hypokalemia with a metabolic alkalosis "<img src=""7821 (1).png"">" Pathology
endocrine hyperaldosteronism
In primary hyperaldosteronism, how would you expect the renin-aldosterone ratio to
change? Decreased renin, increased aldosterone (therefore, decreased ratio)
"<img src=""7821 (1).png"">" Pathology endocrine hyperaldosteronism
What are two causes of primary hyperaldosteronism? An adrenal adenoma (Conn
syndrome) or idiopathic adrenal hyperplasia "<img src=""7821 (1).png"">"
Pathology endocrine hyperaldosteronism
What are two causes of secondary hyperaldosteronism? Renovascular hypertension and
juxtaglomerular cell tumor with ectopic renin secretion "<img src=""7821
(1).png"">" Pathology endocrine hyperaldosteronism
Which cell types are the embryologic derivatives for all neuroendocrine tumors
(NETs)? NETs are a group of neoplasms originating from Kulchitsky and
enterochromaffin-like cells "<img src=""7822 (1).png"">" Pathology endocrine
neuroendocrine-tumors
What enzyme is common to all neuroendocrine tumors (eg, medullary carcinoma of the
thyroid, pheochromocytoma, islet cell tumors, etc)? Amine precursor uptake
decarboxylase (APUD) "<img src=""7822 (1).png"">" Pathology endocrine
neuroendocrine-tumors
Are the most common tumors of the adrenal medulla different in children and adults?
Yes, pheochromocytoma is most common in adults, and neuroblastoma is most
common in children "<img src=""7823 (1).png"">" Pathology endocrine
neuroblastoma
Where in the body can a neuroblastoma develop? Anywhere along the sympathetic
chain, usually as a firm, irregular mass that can cross the midline (unlike smooth,
unilateral Wilms tumors) "<img src=""7823 (1).png"">" Pathology endocrine
neuroblastoma
What oncogene is commonly overexpressed in neuroblastomas? The N-myc oncogene
"<img src=""7823 (1).png"">" Pathology endocrine neuroblastoma
Which two markers do neuroblastomas typically stain positive for? Bombesin and
neuron-specific enolase (NSE) "<img src=""7823 (1).png"">" Pathology endocrine
neuroblastoma
A 6-month-old boy with bizarre eye movements and lower-extremity muscle jerking is
found to have an abdominal mass. Most likely diagnosis? "Neuroblastoma
presenting with opsoclonus-myoclonus syndrome (""dancing eyesdancing feet"")"
From which embryonic cell line do neuroblastomas originate?Neural crest cells
A child newly diagnosed with a neuroblastoma is normotensive. Does this surprise
you? No, patients with neuroblastoma are less likely to develop hypertension than
those with pheochromocytomas "<img src=""7823 (1).png"">" Pathology endocrine
neuroblastoma
On the basis of a history suggesting a chromaffin cellderived adrenal tumor, you
order serum/urine tests. What do you expect to find? Increased catecholamines and
metanephrines in both urine and plasma resulting from the presence of
pheochromocytoma "<img src=""7824 (1).png"">" Pathology endocrine
pheochromocytoma
List three germline mutations that are associated with pheochromocytomas. What
percentage of cases have such mutations? NF-1, VHL, RET (MEN 2A, 2B); up to 25% of
cases "<img src=""7824 (1).png"">" Pathology endocrine pheochromocytoma
A 40-year-old woman presents with spells of high blood pressure, headache,
sweating, palpitations, and pale skin. Treatment? Irreversible -antagonists
(phenoxybenzamine), followed by -blockade, and then, tumor removal (required
treatment for a pheochromocytoma) "<img src=""7824 (1).png"">" Pathology
endocrine pheochromocytoma
What are five common symptoms associated with pheochromocytoma? 5 P's:
Pressure(high BP), Pain (headache), Perspiration, Palpitations (tachycardia), and
Pallor "<img src=""7824 (1).png"">" Pathology endocrine pheochromocytoma
List the five components of the pheochromocytoma rule of 10's. 10% malignant, 10%
bilateral, 10% extra-adrenal, 10% calcify, 10% kids "<img src=""7824 (1).png"">"
Pathology endocrine pheochromocytoma
What characteristic of a pheochromocytoma distinguishes it from chronic, poorly
controlled hypertension? "Pheochromocytomas secrete epinephrine,
norepinephrine, and dopamine, which cause relapsing and remitting symptom
""spells""" "<img src=""7824 (1).png"">" Pathology endocrine pheochromocytoma
A patient has this adrenal medulla mass removed and does well. Before surgery, what
hormone(s) was the mass likely secreting? Treatment? Likely epinephrine,
norepinephrine, and/or dopamine (This is a pheochromocytoma.); treatment is
surgical excision "<img src=""7824 (1).png"">" Pathology endocrine
pheochromocytoma
What is the best irreversible -antagonist to use for pheochromocytoma management?
Phenoxybenzamine (16 letters) is given for pheochromocytoma (also 16 letters)
"<img src=""7824 (1).png"">" Pathology endocrine pheochromocytoma
How do you distinguish hypothyroid myopathy from thyrotoxic myopathy, given that
both present with proximal muscle weakness? Hypothyroid myopathy: increased TSH
(if primary), increased CK; thyrotoxic myopathy: decreased TSH (if primary), normal
CK "<img src=""7825 (1).png"">" Pathology endocrine hypothyroidism-vs-
hyperthyroidism
A woman with a known thyroid condition is hyperactive, with hyperreflexia, and has
swelling on her shins. She has a hand tremor. Diagnosis? Pretibial myxedema due
to Graves disease (hyperthyroidism) "<img src=""7825 (1).png"">" Pathology
endocrine hypothyroidism-vs-hyperthyroidism
How do hypothyroidism and hyperthyroidism each affect the skin? The hair?
Hypothyroidism causes dry, cool skin and coarse, brittle hair; whereas
hyperthyroidism causes warm, moist skin and fine hair "<img src=""7825 (1).png"">"
Pathology endocrine hypothyroidism-vs-hyperthyroidism
What are the mechanisms by which hyperthyroidism leads to hypocholesterolemia and
hypothyroidism leads to hypercholesterolemia? Hyperthyroidism increases LDL
receptor expression, whereas hypothyroidism decreases LDL receptor expression
"<img src=""7825 (1).png"">" Pathology endocrine hypothyroidism-vs-
hyperthyroidism
Your patient states that she has been constipated, cold, and gaining weight despite
decreased appetite. What is the most likely diagnosis? Hypothyroidism "<img
src=""7825 (1).png"">" Pathology endocrine hypothyroidism-vs-hyperthyroidism
A postmenopausal woman has heat intolerance, weight loss, palpitations, and
diarrhea. What lab findings do you expect to see? Low TSH (if primary disease)
and high free or total T3/T4 (She likely has hyperthyroidism.) "<img src=""7825
(1).png"">" Pathology endocrine hypothyroidism-vs-hyperthyroidism
A woman has weight gain, lethargy, cool dry skin, and brittle hair; she exhibits
hyporeflexia on exam. What lab findings do you expect? Increased TSH (sensitive
for primary disease) and low free T3/T4 (She likely has hypothyroidism.) "<img
What cardiac symptoms can hyperthyroidism cause? What can hypothyroidism cause?
Hyperthyroidism: chest pain, palpitations, arrhythmia from increased -
adrenergic receptors; hypothyroidism: bradycardia, dyspnea on exertion "<img
A patient with a known thyroid condition is lethargic, with swelling in the face
and periorbital region. Diagnosis? Myxedema resulting from hypothyroidism "<img
A patient has symmetrical, smooth, diffuse enlargement of her thyroid gland. Is a
thyroid adenoma on your differential diagnosis? No, consider Graves disease,
Hashimoto thyroiditis, iodine deficiency, or TSH-secreting pituitary adenomas (for
a smooth/diffuse goiter) "<img src=""7826 (1).png"">" Pathology causes-of-
goiter endocrine
A patient has an enlarged thyroid gland. RAIU shows focal uptake in the left
anterolateral portion of the gland. Differential diagnosis?Toxic multinodular
goiter, thyroid adenoma, thyroid cancer, thyroid cyst (for a nodular goiter) "<img
src=""7826 (1).png"">" Pathology causes-of-goiter endocrine
How would physical exam findings help you differentiate a thyroid adenoma from
Graves disease? Graves disease presents with smooth/diffuse thyroid enlargement,
whereas thyroid adenomas are nodular "<img src=""7826 (1).png"">" Pathology
causes-of-goiter endocrine
You are doing a pediatrics rotation in an area with dietary iodine deficiency. What
symptoms suggest cretinism in a newborn? 6 P's: Pot-bellied, Pale, Puffy-faced,
Protruding umbilicus, Protuberant tongue, Ppoor brain development "<img
src=""7827 (1).png"">" Pathology endocrine hypothyroidism
A man presents with weight gain, decreased appetite, and a moderately enlarged,
nontender thyroid. What is the most likely pathophysiology?Hashimoto thyroiditis
(most common hypothyroidism cause); autoimmune disorder due to anti-thyroglobulin
antibodies, associated with HLA-DR5 "<img src=""7827 (1).png"">" Pathology
endocrine hypothyroidism
A man with a recent cold presents with jaw pain and a tender thyroid. His
erythrocyte sedimentation rate is high. Treatment? None, as subacute
granulomatous thyroiditis (de Quervain) is a self-limited hypothyroidism that may
be hyperthyroid early in its course "<img src=""7827 (1).png"">" Pathology
A patient has a thyroid biopsy showing Hrthle cells and lymphocytes with germinal
centers. What other disease is she at risk for? Non-Hodgkin lymphoma (typically of
B-cell origin), the risk of which is increased by Hashimoto thyroiditis "<img
src=""7827 (1).png"">" Pathology endocrine hypothyroidism
Following a cold, a man briefly has symptoms of hyperthyroidism, followed by self-
limited hypothyroidism. What do you see on thyroid biopsy? Granulomatous
inflammation with giant cells, as he has subacute granulomatous thyroiditis (de
Quervain) "<img src=""7827 (1).png"">" Pathology endocrine hypothyroidism
A man with possible thyroid anaplastic carcinoma has fibrosis in the airway and
thyroid. Name 3 systemic diseases with similar pathology. Autoimmune pancreatitis,
retroperitoneal fibrosis, noninfectious aortitis (Riedel thyroiditis); all due to
IgG4-related systemic disease) "<img src=""7827 (1).png"">" Pathology
A patient has weight gain, constipation, and cold intolerance. On exam, his thyroid
is hard and painless. Describe the pathophysiology. Riedel thyroiditis is caused
when the thyroid is replaced by fibrous tissues (a manifestation of IgG4-related
systemic disease) "<img src=""7827 (1).png"">" Pathology endocrine hypothyroidism
Hashimoto thyroiditis, cretinism, subacute thyroiditis, and Riedel thyroiditis all
cause hypothyroidism. Name three other causes. Iodine deficiency, goitrogens (eg,
amiodarone, lithium), and the Wolff-Chaikoff effect "<img src=""7827 (1).png"">"
Pathology endocrine hypothyroidism
A woman cannot tolerate heat after having the flu. A week later, she reports cold
intolerance but notes that it is improving. Diagnosis? Subacute granulomatous
thyroiditis (de Quervain): self-limited hypothyroidism following a flu-like illness
with hyperthyroidism early on "<img src=""7827 (1).png"">" Pathology endocrine
hypothyroidism
You biopsy a thyroid and diagnose anaplastic carcinoma. Later, you find that it is
really due to IgG4-related systemic disease. Diagnosis? Riedel thyroiditis (can
be mistaken for anaplastic carcinoma of the thyroid) "<img src=""7827 (1).png"">"
Pathology endocrine hypothyroidism
A patient presents with a painful thyroid gland. Labs show elevated ESR; physical
exam shows jaw pain. What will thyroid biopsy show? Granulomatous inflammation
(as this is subacute granulomatous thyroiditis [de Quervain]) "<img src=""7827
(1).png"">" Pathology endocrine hypothyroidism
A woman with bipolar disorder notes an enlarging mass over her anterior neck and
the signs/symptoms of hypothyroidism. Most likely cause? Certain drugs are
goitrogens (eg, lithium, amiodarone); in her case, this is likely a side effect of
lithium "<img src=""7827 (1).png"">" Pathology endocrine hypothyroidism
What antibodies are commonly implicated in Hashimoto thyroiditis? Antithyroid
peroxidase (antimicrosomal) and antithyroglobulin antibodies "<img src=""7827
(1).png"">" Pathology endocrine hypothyroidism
A woman has exophthalmos, a diffuse goiter, and pretibial myxedema. When does this
disease most often present? During times of stress (eg, pregnancy) "<img
src=""7828 (1).png"">" Pathology endocrine hyperthyroidism
A woman with Graves disease has syncope and palpitations. What lab finding might
you see in this serious complication of hyperthyroidism? Thyroid storm (a stress-
induced catecholamine surge) may present with an increase in LFTs "<img
src=""7828 (1).png"">" Pathology endocrine hyperthyroidism
What is the Jod-Basedow phenomenon? Thyrotoxicosis due to iodine repletion in
patients with iodine-deficiency goiters and partially autonomous thyroid tissue
"<img src=""7828 (1).png"">" Pathology endocrine hyperthyroidism
Name four causes of hyperthyroidism. What is the most common cause of
hyperthyroidism in the United States? Graves disease, toxic multinodular
goiter, thyroid storm, Jod-Basedow phenomenon; Graves disease is the most common
cause in the US "<img src=""7828 (1).png"">" Pathology endocrine hyperthyroidism
A woman with Graves disease is agitated, feverish, and delirious. An EKG shows
atrial fibrillation; her LFTs are elevated. Treatment? Thyroid storm 4 P's: -
blockers (eg, Propranolol), Propylthiouracil, corticosteroids (eg, Prednisolone),
Potassium iodide (Lugol iodine) "<img src=""7828 (1).png"">" Pathology
endocrine hyperthyroidism
A man has hyperthyroidism resulting from IgG autoantibodies stimulating his TSH
receptors. List three locations of affected TSH receptors. Thyroid
(hyperthyroidism), retroorbital fibroblasts (proptosis/exophthalmos), dermal
fibroblasts (pretibial myxedema); he has Graves disease "<img src=""7828
(1).png"">" Pathology endocrine hyperthyroidism
A patient has orange peeltextured skin on his lower legs and protrusion with
limited mobility of his eyes. Which autoantibody causes this? Thyroid-
stimulating IgGs against TSH receptors (The hallmarks of Graves disease are
exophthalmos, proptosis, and pretibial myxedema.) "<img src=""7828 (1).png"">"
Pathology endocrine hyperthyroidism
How is the autoimmune reaction of Graves disease mechanistically different from the
reaction after contact with poison ivy? Graves disease: thyroid-stimulating
immunoglobulins cause type II hypersensitivity; delayed contact dermatitis is type
IV hypersensitivity "<img src=""7828 (1).png"">" Pathology endocrine
hyperthyroidism
Gross examination of the retroorbital space in a patient with Graves disease would
likely show what? Osmotic muscle swelling, muscle inflammation, and increased
adipocyte count "<img src=""7828 (1).png"">" Pathology endocrine hyperthyroidism
In Graves disease, what are the biochemical causes of exophthalmos (osmotic muscle
swelling, muscle inflammation, increased adipocytes)? Retroorbital space
infiltration by activated T-cells secreting cytokines (eg, TNF-, IFN-) and
fibroblast secretion of hydrophilic GAGs "<img src=""7828 (1).png"">" Pathology
endocrine hyperthyroidism
A pathologist asks you to differentiate histology of thyroid follicular adenoma
from that of follicular carcinoma. What is your response? Same histology, except
follicular carcinoma will demonstrate the presence of capsular or vascular invasion
"<img src=""7829 (1).png"">" Pathology endocrine thyroid-adenoma
A woman with biopsy-proven thyroid adenoma asks if she should take medications for
thyroid function moving forward. What is your response? "No, most adenomas are
nonfunctional (""cold""); they rarely cause hyperthyroidism via autonomous thyroid
hormone production (hot or toxic)" "<img src=""7829 (1).png"">" Pathology
endocrine thyroid-adenoma
You diagnose thyroid cancer in a patient. What is the prognosis of the most common
type of thyroid cancer? Papillary carcinoma, the most common type of thyroid
cancer, has an excellent prognosis "<img src=""7830 (1).png"">" Pathology
endocrine thyroid-cancer
Place the following thyroid cancers in order from best to worst prognosis:
follicular, undifferentiated/anaplastic, and papillary. Papillary, follicular,
undifferentiated/anaplastic "<img src=""7830 (1).png"">" Pathology endocrine
thyroid-cancer
A biopsy of a thyroid nodule shows sheets of cells with amyloid (image). Where does
the cancer originate, and how does it usually spread? In parafollicular C cells
that produce calcitonin; it spreads hematogenously (This is medullary thyroid
cancer.) "<img src=""7830 (1).png"">" Pathology endocrine thyroid-cancer
A man has episodic headaches, palpitations, an adrenal mass, and a thyroid nodule.
What type of thyroid cancer could he have? Medullary thyroid carcinoma; the
symptoms and mass suggest pheochromocytoma (Combined, these two cancers are
associated with MEN 2A/2B.) "<img src=""7830 (1).png"">" Pathology endocrine
thyroid-cancer
An 85-year-old with a history of Hashimoto thyroiditis has a new thyroid mass.
Which two thyroid cancers do you worry about? Undifferentiated/anaplastic
carcinoma (most common in older patients) and lymphoma (associated with Hashimoto
thyroiditis) "<img src=""7830 (1).png"">" Pathology endocrine thyroid-cancer
A 50-year-old woman with thyroid cancer opts for thyroidectomy. Weeks later,
paresthesias and hyperreflexia develop. What happened? Inadvertent removal of
all the parathyroid glands with the thyroid, with resultant hypocalcemia
(paresthesias, hyperactive reflexes) "<img src=""7830 (1).png"">" Pathology
endocrine thyroid-cancer
A surgeon injures a nerve during ligation of the inferior thyroid artery in a
thyroidectomy. What nerve is affected, and what is the result? Recurrent
laryngeal nerve; hoarseness "<img src=""7830 (1).png"">" Pathology endocrine
thyroid-cancer
A patient has paralysis of the cricothyroid muscle after a thyroidectomy. Which
nerve was affected? Superior laryngeal nerve (injured during ligation of the
superior laryngeal artery) "<img src=""7830 (1).png"">" Pathology endocrine
thyroid-cancer
A patient discovers a thyroid mass. Biopsy shows uniform follicles. How does the
pathologist know whether this mass is benign or malignant? Invasion of the thyroid
capsule suggests a more malignant follicular carcinoma; no invasion suggests a more
benign thyroid adenoma "<img src=""7830 (1).png"">" Pathology endocrine thyroid-
cancer
FNA of a thyroid nodule shows cells with large empty-appearing nuclei and
intranuclear inclusion bodies. Name three risk factors for this. Risk factors for
papillary carcinoma of the thyroid include childhood irradiation, RET mutations,
and BRAF mutations "<img src=""7830 (1).png"">" Pathology endocrine thyroid-
cancer
A drug is developed that causes constitutive activation of the RAS pathway. Which
thyroid cancer is more likely to develop? Follicular carcinoma is associated with
RAS mutations "<img src=""7830 (1).png"">" Pathology endocrine thyroid-cancer
A patient has low levels of both PTH and Ca2+. What are two possible causes of
these lab findings? Surgical resection and autoimmune parathyroid gland
destruction; findings are consistent with primary hypoparathyroidism "<img
src=""7831 (1).png"">" Pathology diagnosis-of-parathyroid-disease endocrine
A patient has a low level of PTH, yet a high level of Ca2+. What are two possible
causes of these lab findings? Excessive Ca2+ intake and malignancy (eg, PTHrP);
findings are consistent with PTH-independent hypercalcemia "<img src=""7831
(1).png"">" Pathology diagnosis-of-parathyroid-disease endocrine
A patient has high levels of both PTH and Ca2+. What are three possible causes of
these lab findings? Parathyroid hyperplasia, adenoma, and/or carcinoma;
findings are consistent with primary hyperparathyroidism; "<img src=""7831
A patient has a high level of PTH, yet a low level of Ca2+. What are two possible
causes of these lab findings? Vitamin D deficiency and chronic renal failure;
findings are consistent with secondary hyperparathyroidism "<img src=""7831
A man with DiGeorge syndrome exhibits Chvostek and Trousseau signs. What is the
difference between these signs? Chvostek: facial muscle (Cheek) contraction
with facial nerve tap; Trousseau: carpal spasm with BP cuff brachial artery
occlusion (Triceps) "<img src=""7832 (1).png"">" Pathology endocrine
hypoparathyroidism
List three causes of hypoparathyroidism. Accidental surgical excision (thyroid
surgery), autoimmune destruction, and DiGeorge syndrome "<img src=""7832
(1).png"">" Pathology endocrine hypoparathyroidism
A short 27-year-old man has hypocalcemia and shortened 4th and 5th digits. What
caused his electrolyte abnormality? How is this inherited? pseudohypoparathyroidism
1A (Albright hereditary osteodystrophy), with no kidney responsiveness to PTH
(causes low Ca2+); autosomal dominant "<img src=""7832 (1).png"">" Pathology
endocrine hypoparathyroidism
In pseudohypoparathyroidism, would you expect high or low PTH? High or low Ca2+?
What is the cause? High PTH with low Ca2+ levels due to unresponsiveness of
the kidney to PTH "<img src=""7832 (1).png"">" Pathology endocrine
hypoparathyroidism
What are the classic findings in hypoparathyroidism? Tetany (eg, Chvostek and
Trousseau signs), hypocalcemia, hyperphosphatemia "<img src=""7832 (1).png"">"
Pathology endocrine hypoparathyroidism
What is the genetic defect that leads to pseudohypoparathyroidism type 1A? From
whom must this disorder be inherited? A defective Gs protein -subunit causing
end-organ PTH resistance; the mother, due to imprinting "<img src=""7832
(1).png"">" Pathology endocrine hypoparathyroidism
A boy has shortened 4th and 5th digits and short stature. His father has similar
physical findings. Does he have electrolyte abnormalities? No, he has
pseudopseudohypoparathyroidism, with physical exam features of Albright hereditary
osteodystrophy but no end-organ PTH resistance "<img src=""7832 (1).png"">"
What is the genetic defect that leads to pseudopseudohypoparathyroidism? From whom
must this disorder be inherited? A defective Gs protein -subunit, but without
end-organ resistance to PTH in this case; the father "<img src=""7832 (1).png"">"
A man has hypercalcemia, high PTH, and hypocalciuria. What is the cause of this
disorder? A defective Ca2+-sensing receptor (CaSR) on parathyroid cells does not
properly suppress PTH (This is familial hypocalciuric hypercalcemia.) "<img
src=""7833 (1).png"">" Pathology endocrine familial-hypocalciuric-hypercalcemia
A woman has familial hypocalciuric hypercalcemia. What do you expect from the lab
findings regarding Ca2+ and PTH levels in this patient? Mild hypercalcemia and
normal to high PTH levels "<img src=""7833 (1).png"">" Pathology endocrine
familial-hypocalciuric-hypercalcemia
A patient with chronic renal failure has secondary hyperparathyroidism. What are
the lab findings and how do they differ in normal kidneys? Hypocalcemia,
hyperphosphatemia, high alkaline phosphatase, and high PTH; hypophosphatemia if not
due to chronic renal failure "<img src=""7834 (1).png"">" Pathology endocrine
hyperparathyroidism
A man on dialysis with recently diagnosed secondary hyperparathyroidism has new
bone pain, abdominal pain, and high Ca2+. Pathophysiology? Hyperplastic parathyroid
cells can become autonomous, resulting in very high PTH and high Ca2+ (This is
tertiary hyperparathyroidism.) "<img src=""7834 (1).png"">" Pathology
endocrine hyperparathyroidism
A patient has primary hyperparathyroidism. What lab findings do you expect in
regard to PTH and Ca2+ levels in this patient? Hypercalcemia and high PTH "<img
src=""7834 (1).png"">" Pathology endocrine hyperparathyroidism
A patient has secondary hyperparathyroidism. What lab findings do you expect in
regard to PTH and Ca2+ levels in this patient? Hypocalcemia and high PTH "<img
src=""7834 (1).png"">" Pathology endocrine hyperparathyroidism
What are the classic signs and symptoms of hyperparathyroidism? Stones (renal
stones), bones (cystic bone spaces), groans (constipation), and psychiatric
overtones (depression) "<img src=""7834 (1).png"">" Pathology endocrine
hyperparathyroidism
A man with a longstanding parathyroid adenoma has pain in his thigh and gets a
biopsy of a painful area. What do you expect in the biopsy?"Osteitis fibrosa
cystica, a ""brown tumor"" with brown fibrous tissuefilled spaces (osteoclasts and
hemosiderin secondary to hemorrhages)" "<img src=""7834 (1).png"">" Pathology
endocrine hyperparathyroidism
A patient has hypercalcemia, hypercalciuria, hypophosphatemia, and high PTH. What
are two likely causes? What other lab values do you see? Parathyroid adenoma and
parathyroid hyperplasia; high serum ALP and high urine cAMP (This is primary
hyperparathyroidism.) "<img src=""7834 (1).png"">" Pathology endocrine
hyperparathyroidism
A man has intense dysuria and flank pain, constipation, weakness, and bone pain.
What is the likely diagnosis? What causes the bone pain? Primary
hyperparathyroidism; osteitis fibrosa cystica (brown fibrous tissue filling cystic
bone spaces) "<img src=""7834 (1).png"">" Pathology endocrine
hyperparathyroidism
What is the mechanism by which a patient develops secondary hyperparathyroidism?
Decreased Ca2+ absorption from the gut and increased levels of phosphate
causing secondary hyperplasia of the parathyroid gland "<img src=""7834
(1).png"">" Pathology endocrine hyperparathyroidism
What is the most common cause of secondary hyperparathyroidism? Chronic renal
disease, which causes hypovitaminosis D and thus decreased Ca2+ absorption from the
gut "<img src=""7834 (1).png"">" Pathology endocrine hyperparathyroidism
A 36-year-old woman has visual field defects and headaches. Where in her field of
vision is she most likely experiencing vision loss? Pituitary adenomas, most
commonly prolactinomas, can compress the optic chiasm, causing a bitemporal
hemianopia "<img src=""7835 (1).png"">" Pathology endocrine pituitary-adenoma
A 36-year-old nonpregnant woman has amenorrhea, low libido, and white discharge
from her nipples. How do you treat her? Treat prolactinomas with ergot alkaloid
dopamine agonists (bromocriptine, cabergoline) to shrink the tumor or
transsphenoidal resection "<img src=""7835 (1).png"">" Pathology endocrine
pituitary-adenoma
A 25-year-old woman has had trouble getting pregnant and now complains of
peripheral vision loss. What is the cause of her infertility? She likely has a
prolactinoma (decreased GnRH, amenorrhea, infertility) "<img src=""7835
(1).png"">" Pathology endocrine pituitary-adenoma
A 35-year-old man has bitemporal visual field defects and finds that his shoes do
not fit anymore. What lab abnormality will be seen? High growth hormone, secreted
by a somatotropic pituitary adenoma and resulting in acromegaly "<img src=""7835
(1).png"">" Pathology endocrine pituitary-adenoma
Following bilateral adrenalectomy, MRI shows that a patient's pituitary gland is
enlarging. What treatment options do you consider? Pituitary irradiation or
surgical resection as this is due to Nelson syndrome "<img src=""7836 (1).png"">"
Pathology endocrine nelson-syndrome
What is the complication seen if both adrenal glands are excised in a case of
refractory Cushing disease? Nelson syndrome: enlargement of an existing ACTH-
secreting pituitary adenoma due to removal of the cortisol feedback mechanism
"<img src=""7836 (1).png"">" Pathology endocrine nelson-syndrome
What is the most common presenting symptom of Nelson syndrome? Hyperpigmentation
(due to excess production of ACTH) "<img src=""7836 (1).png"">" Pathology
endocrine nelson-syndrome
How does excess growth hormone affect children and adults? What is the most common
cause of death in both groups with this condition? In children, increased linear
bone growth and gigantism, and, in adults, acromegaly; heart failure is the most
common cause of death "<img src=""7837 (1).png"">" Pathology acromegaly
endocrine
A 50-year-old man recently had to resize his wedding ring; he has frontal bossing
and diaphoresis. How do you diagnose his condition? Acromegaly is diagnosed with
high serum IGF-1, failure to suppress serum GH after oral glucose tolerance tests,
and a pituitary mass on MRI "<img src=""7837 (1).png"">" Pathology acromegaly
endocrine
A short boy has a saddle nose with a large forehead, small genitals, and a small
head. Receptors to which hormone could be deficient? GH, as this is Laron syndrome
(dwarfism) "<img src=""7838 (1).png"">" Pathology endocrine laron-syndrome-
(dwarfism)
A boy is diagnosed with dwarfism. What lab findings would help support this
diagnosis? Laron syndrome is a clinical diagnosis, but one would expect an
increase in GH and a decrease in IGF-1 "<img src=""7838 (1).png"">" Pathology
endocrine laron-syndrome-(dwarfism)
A man has intense thirst, polyuria, and diluted urine. Diabetes mellitus test is
negative. What endocrine disorder is on your differential? Diabetes insipidus
"<img src=""7839 (1).png"">" Pathology diabetes-insipidus endocrine
A man has low ADH and diluted urine. A significant increase in urine osmolality
occurs after he takes an ADH analog. List 6 possible causes. Pituitary tumor,
trauma, surgery, ischemic encephalopathy, autoimmune, idiopathic; this is central
diabetes insipidus "<img src=""7839 (1).png"">" Pathology diabetes-insipidus
endocrine
A man has normal ADH, diluted urine, and no change in urine osmolality after taking
an ADH analog. List 4 possible causes. Hereditary (ADH receptor defect),
hypercalcemia, hypokalemia, lithium, demeclocycline (ADH blocker); this is
nephrogenic diabetes insipidus "<img src=""7839 (1).png"">" Pathology
diabetes-insipidus endocrine
In a patient with diabetes insipidus, you expect to see what abnormalities in the
urine-specific gravity? In the serum osmolality? Low (often &60; 1.006); high
(often &62; 290 mOsm/kg) "<img src=""7839 (1).png"">" Pathology diabetes-
insipidus endocrine
A woman on lithium reports increased thirst, polyuria, and diluted urine. What is
the first test to be ordered for your suspected diagnosis? Water deprivation for 2
to 3 hours; in diabetes insipidus, urine osmolality does not increase, even with
low fluid intake "<img src=""7839 (1).png"">" Pathology diabetes-insipidus
endocrine
A woman with polydipsia and polyuria continues to have diluted urine after a water
deprivation test. What is the next step in your workup? Administer desmopressin
(ADH analog); urine concentrates if the patient has central diabetes insipidus but
stays dilute if nephrogenic "<img src=""7839 (1).png"">" Pathology diabetes-
insipidus endocrine
What lifestyle change can be used to manage both central and nephrogenic diabetes
insipidus (DI)? Otherwise, how do treatments differ? Hydration; central DI is
treated with desmopressin acetate, nephrogenic DI with offending agent removal and
HCTZ, indomethacin, or amiloride "<img src=""7839 (1).png"">" Pathology
After a traumatic brain injury from a bike accident, a man cannot concentrate his
urine. Is his serum osmolarity 150, 250, or 350 mOsm/kg? 350 mOsm/kg (which is
high); head trauma can cause central diabetes insipidus "<img src=""7839
(1).png"">" Pathology diabetes-insipidus endocrine
A man has diabetes insipidus. What is the underlying defect in this condition? What
are the two main categories of causes? Inability to concentrate urine; central
(lack of ADH production) and nephrogenic (inability to respond to ADH) "<img
src=""7839 (1).png"">" Pathology diabetes-insipidus endocrine
What are common findings in central and nephrogenic diabetes insipidus? Urine
specific gravity &60; 1.006, serum osmolality &62; 290 mOsm/kg, hyperosmotic volume
contraction "<img src=""7839 (1).png"">" Pathology diabetes-insipidus endocrine
A woman with bipolar disorder receiving drug therapy experiences polyuria and poor
skin turgor. What is the next step in management? Discontinue lithium, which
can cause nephrogenic diabetes insipidus "<img src=""7839 (1).png"">" Pathology
A patient with congenital dysfunction of her V2 receptors has a history of frequent
urination. What treatments can you prescribe her? HCTZ, indomethacin, or
amiloride (generally used to treat nephrogenic diabetes insipidus caused by
hereditary V2 receptor mutations) "<img src=""7839 (1).png"">" Pathology
A patient with COPD is found to have hyponatremia, with high urine osmolarity and
low serum osmolarity. What is the likely diagnosis? SIADH, or syndrome of
inappropriate antidiuretic hormone secretion, which can be caused by small cell
lung cancer "<img src=""7840 (1).png"">" Pathology endocrine syndrome-of-
inappropriate-antidiuretic-hormone-secretion
A patient with recently diagnosed small cell lung cancer retains fluid. How do his
serum and urine osmolarities compare? Pathophysiology? Urine &62; serum
osmolarity; SIADH (ectopic ADH from small cell lung cancer) causes low aldosterone
to maintain near-normal volume status "<img src=""7840 (1).png"">" Pathology
endocrine syndrome-of-inappropriate-antidiuretic-hormone-secretion
A patient is diagnosed with SIADH. Physical exam is negative for peripheral edema,
JVD, or pulmonary edema. Why is this? In SIADH, the body responds to water
retention by decreasing aldosterone (causing hyponatremia) to maintain near-normal
volume status "<img src=""7840 (1).png"">" Pathology endocrine syndrome-of-
A patient with hyponatremia and fluid retention has SIADH (syndrome of
inappropriate antidiuretic hormone secretion). Possible causes? Ectopic ADH
production (eg, small cell lung cancer), certain drugs (eg, cyclophosphamide), CNS
disease or head trauma, pulmonary disease "<img src=""7840 (1).png"">" Pathology
endocrine syndrome-of-inappropriate-antidiuretic-hormone-secretion
Name some treatment options for SIADH. Fluid restriction; hypertonic saline;
conivaptan, tolvaptan, or demeclocycline; slow hyponatremia correction to avoid
osmotic demyelination "<img src=""7840 (1).png"">" Pathology endocrine syndrome-
of-inappropriate-antidiuretic-hormone-secretion
An 80-year-old smoker with COPD has hyponatremia; his urine specific gravity is
1.040. What is the likely ectopic source of his ADH? Small cell lung cancer
(paraneoplastic syndrome); the patient is predisposed to this cancer because he
smokes "<img src=""7840 (1).png"">" Pathology endocrine syndrome-of-
A patient with head trauma has SIADH. What are three characteristic features of his
condition? Free water retention, urinary sodium excretion with euvolemic
hyponatremia, urine osmolality &62; serum osmolality "<img src=""7840 (1).png"">"
Pathology endocrine syndrome-of-inappropriate-antidiuretic-hormone-secretion
It is known that in SIADH, the body responds to excess ADH by decreasing
aldosterone secretion. What happens to ANP and BNP levels? Both ANP and BNP
increase to counteract progressive hyponatremia "<img src=""7840 (1).png"">"
Pathology endocrine syndrome-of-inappropriate-antidiuretic-hormone-secretion
A man on cyclophosphamide is given IV fluids at a high rate to prevent drug-induced
cystitis. Why do you check labs on him before starting? Cyclophosphamide can
cause SIADH; if he has this condition, rapid correction of Na+ may cause an osmotic
demyelination syndrome "<img src=""7840 (1).png"">" Pathology endocrine syndrome-
of-inappropriate-antidiuretic-hormone-secretion
Osmotic demyelination syndrome formerly went by what name? Central pontine
myelinolysis "<img src=""7840 (1).png"">" Pathology endocrine syndrome-of-
A woman who had a severe hemorrhage during her recent delivery cannot breastfeed
her newborn and feels cold all the time. Pathophysiology? Sheehan syndrome (an
ischemic infarction of the pituitary after postpartum bleeding that causes
hypopituitarism) "<img src=""7841 (1).png"">" Pathology endocrine hypopituitarism
An obese woman spontaneously develops central hypothyroidism and amenorrhea. What
is the cause of her hormone deficiencies? Hypopituitarism, most likely from empty
sella syndrome caused by idiopathic atrophy or compression of the pituitary (common
in obese women) "<img src=""7841 (1).png"">" Pathology endocrine hypopituitarism
Name seven causes of hypopituitarism. Nonsecreting pituitary adenoma,
craniopharyngioma, Sheehan syndrome, empty sella syndrome, brain injury or
hemorrhage (apoplexy), radiation "<img src=""7841 (1).png"">" Pathology
endocrine hypopituitarism
After head trauma, a woman has sudden-onset cold intolerance, amenorrhea, low blood
pressure, and fatigue. How can you treat her? Hormone replacement therapy:
corticosteroids, thyroxine, sex steroids, and human growth hormone (This is
hypopituitarism.) "<img src=""7841 (1).png"">" Pathology endocrine hypopituitarism
A woman with bitemporal hemianopsia is suddenly hypotensive and hypoglycemic. What
is the cause of her condition? Pituitary apoplexy (sudden hemorrhage of the
pituitary gland) resulting in hypopituitarism, often in the setting of a pituitary
adenoma "<img src=""7841 (1).png"">" Pathology endocrine hypopituitarism
"A patient with a known pituitary adenoma has a pupil that is ""down and out""
along with a headache. He reports double vision. Diagnosis?" Pituitary apoplexy
(can sometimes present with CN III palsies) "<img src=""7841 (1).png"">"
Pathology endocrine hypopituitarism
A man with a radiation-treated glioblastoma multiforme always feels cold. Exam is
notable for poor skin turgor and thin hair. Diagnosis? Hypopituitarism, likely
secondary to radiation to the brain "<img src=""7841 (1).png"">" Pathology
endocrine hypopituitarism
Why are pregnant women more predisposed to Sheehan syndrome? Pregnancy-induced
pituitary growth increases susceptibility to hypoperfusion (eg, during hypotensive
episodes) "<img src=""7841 (1).png"">" Pathology endocrine hypopituitarism
A patient with hyperglycemia and metabolic acidosis has ketones in her urine and
blood. What causes this ketonemia and ketonuria? Increased lipolysis with
insulin deficiency (Increased plasma free fatty acids are utilized for
ketogenesis.) "<img src=""7842 (1).png"">" Pathology diabetes-mellitus
endocrine
What two disease states can osmotic damage cause in patients with chronic diabetes?
What is the pathophysiology? Neuropathy and cataracts; sorbitol builds up in
organs with aldose reductase and low/absent sorbitol dehydrogenase, causing osmotic
damage "<img src=""7842 (1).png"">" Pathology diabetes-mellitus endocrine
Does diabetic neuropathy affect the motor, sensory, and/or autonomic nervous
systems? "It can affect all three systems, with a classic ""glove and stocking""
distribution of sensory loss" "<img src=""7842 (1).png"">" Pathology diabetes-
mellitus endocrine
What three glucose-related tests are diagnostically useful for diabetes? Oral
glucose tolerance test, fasting serum glucose, glycosylated hemoglobin (HbA1c) test
(reflecting average blood glucose over 3 months) "<img src=""7842 (1).png"">"
Pathology diabetes-mellitus endocrine
A patient has had poorly controlled diabetes for 20 years. For what large vessel
diseases is he at risk? What is the pathophysiology? Atherosclerosis, CAD,
peripheral vascular occlusive disease, gangrene (limb loss), cerebrovascular
disease; nonenzymatic vessel glycation "<img src=""7842 (1).png"">" Pathology
diabetes-mellitus endocrine
A patient has diabetes. What is the most common cause of death among people with
this condition? Myocardial infarction "<img src=""7842 (1).png"">" Pathology
For a diagnosis of diabetes mellitus, what three lab values can be reported for a
positive result? An HbA1c of more than 6.5%, a fasting plasma glucose of more than
126 mg/dL, or a 2-hour oral glucose tolerance test of more than 200 mg/dL "<img
src=""7842 (1).png"">" Pathology diabetes-mellitus endocrine
Describe how the oral glucose tolerance test works and what the diagnostic cutoff
for diabetes mellitus is. A patient consumes 75 g of glucose in water, and
blood sugar is checked 2 hours later; a result &62; 200 mg/dL is diagnostic "<img
A patient is scheduled to have a fasting plasma glucose test. What instructions do
you give the patient in preparation for the test? The patient should fast for
at least 8 hours before the test is done "<img src=""7842 (1).png"">" Pathology
What is the pathophysiology behind diabetic nephropathy? Describe the progression
of disease. Nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) arises
w/progressive proteinuria (starts as microalbuminuria) and arteriolosclerosis
"<img src=""7842 (1).png"">" Pathology diabetes-mellitus endocrine
In diabetic patients, which antihypertensive agent can you administer to help
protect the kidneys from progressive proteinuria? ACE inhibitors, which are
renoprotective "<img src=""7842 (1).png"">" Pathology diabetes-mellitus
endocrine
By what mechanism does hyperglycemia lead to upregulation of the thirst mechanism?
Excess glycosuria increases the plasma osmolarity, which promotes thirst
"<img src=""7842 (1).png"">" Pathology diabetes-mellitus endocrine
By what mechanism does hyperglycemia, left untreated, ultimately lead to coma and
death? Osmotic diuresis leads to H2O, Na+, and K+ loss; hypovolemia ensues,
with circulation failure, poor tissue perfusion, and finally coma/death "<img
Severely ill diabetic patients may present with an anion gap metabolic acidosis.
What two processes lead to this acid-base disorder? Increased ketogenesis and
increased serum lactate due to hypovolemia from osmotic diuresis (circulation
failure/poor tissue perfusion) "<img src=""7842 (1).png"">" Pathology
Some ill diabetic patients are noted to hyperventilate. What is the pathophysiology
behind this finding? Usually an anion gap metabolic acidosis, secondary to both
ketogenesis and elevated serum lactate "<img src=""7842 (1).png"">" Pathology
Name some acute manifestations that may be seen in type 1 and type 2 diabetes
mellitus. Name two other causes of these symptoms. Polyphagia, polydipsia,
polyuria, weight loss; glucocorticoids (steroid diabetes), unopposed secretion of
GH or epinephrine (rare) "<img src=""7842 (1).png"">" Pathology diabetes-
mellitus endocrine
Classically, diabetic ketoacidosis is an acute sign of which type of diabetes? What
about hyperosmolar coma? Type 1; type 2 "<img src=""7842 (1).png"">"
Pathology diabetes-mellitus endocrine
What three direct effects on cellular metabolism can a diabetic insulin deficiency
create? Decreased glucose uptake (compounded by increased glycogenolysis and
gluconeogenesis), increased protein catabolism, and increased lipolysis "<img
Describe the underlying mechanism of dehydration in diabetic patients. Insulin
deficiency causes decreased glucose uptake and thus glycosuria, which causes
osmotic diuresis and dehydration "<img src=""7842 (1).png"">" Pathology
Your friend w/type 1 diabetes has breath that smells like fruit; he does not chew
gum or eat sweets. Mechanistically, how is this possible? Insulin deficiency leads
to increased ketogenesis (ketonemia, ketonuria); exhaled ketones in the breath have
a fruity odor "<img src=""7842 (1).png"">" Pathology diabetes-mellitus
endocrine
"A man with years of diabetes mellitus has a funduscopic exam with ""cotton-wool
spots."" What do his retinal vessels look like on histology?" Diffuse basement
membrane thickening, which causes retinal hemorrhage, vessel proliferation,
microaneurysms, and exudate "<img src=""7842 (1).png"">" Pathology diabetes-
mellitus endocrine
A patient has chronic insulin insensitivity. List three pathologic processes caused
by small vessel disease in patients with this condition. Retinopathy, glaucoma,
neuropathy, nephropathy "<img src=""7842 (1).png"">" Pathology diabetes-mellitus
endocrine
A woman with poorly controlled diabetes has hypertension. What two diabetes-related
pathologic processes contribute to her hypertension? Nonenzymatic glycation
causing small vessel arteriosclerosis in the kidney (nephropathy) and large vessel
atherosclerosis "<img src=""7842 (1).png"">" Pathology diabetes-mellitus
endocrine
What is the underlying etiology of type 1 diabetes mellitus? Type 2? Autoimmune
-cell destruction (eg, glutamic acid decarboxylase antibodies); increased insulin
resistance, progressing to -cell failure "<img src=""7843 (1).png"">" Pathology
endocrine type-1-vs-type-2-diabetes-mellitus
Contrast the typical type 1 and 2 diabetes mellitus populations in terms of age,
association with obesity, and genetic predisposition. Type 1: &60; 30 yr, nonobese,
weak genetic link (50% twin concordance); type 2: &62; 40 yr, obese, stronger
genetic link (90% twin concordance) "<img src=""7843 (1).png"">" Pathology
Contrast types 1 and 2 diabetes mellitus in terms of the need for insulin therapy,
insulin sensitivity, and serum insulin level. Type 1: always needs insulin, high
sensitivity, low serum insulin; type 2: may need insulin, low sensitivity, variable
serum insulin "<img src=""7843 (1).png"">" Pathology endocrine type-1-vs-type-
2-diabetes-mellitus
Contrast type 1 and type 2 diabetes mellitus in terms of glucose intolerance and
the risk of ketoacidosis. Type 1: severe glucose intolerance, ketoacidosis
common; type 2: mild-moderate glucose intolerance, rare ketoacidosis "<img
src=""7843 (1).png"">" Pathology endocrine type-1-vs-type-2-diabetes-mellitus
Which type of diabetes mellitus is associated with the human leukocyte antigen
(HLA) system? With which HLA types is it associated? Type 1: associated with HLA-
DR3 and HLA-DR4; type 2: not associated with the HLA system"<img src=""7843
(1).png"">" Pathology endocrine type-1-vs-type-2-diabetes-mellitus
Contrast type 1 and type 2 diabetes mellitus in terms of the number of cells in
the pancreatic islets and histology of the islets. Type 1 islets: leukocytic
infiltrates and fewer cells; type 2 islets: islet amyloid polypeptide (IAPP)
deposits and varying numbers of cells "<img src=""7843 (1).png"">" Pathology
A patient presents with polyuria, polydipsia, polyphagia, and weight loss. Is type
1 or 2 diabetes mellitus more likely? Type 1, as all four symptoms are more
commonly seen in this type of diabetes "<img src=""7843 (1).png"">" Pathology
What autoantibodies are commonly implicated in type 1 diabetes mellitus?
Glutamic acid decarboxylase autoantibodies are the most common autoantibodies
seen in type 1 diabetes mellitus "<img src=""7843 (1).png"">" Pathology
Is the genetic predisposition to type 1 diabetes mellitus considered to be
monogenic or polygenic? What about type 2 diabetes mellitus? Both are
considered to be polygenic "<img src=""7843 (1).png"">" Pathology endocrine
type-1-vs-type-2-diabetes-mellitus
A man with type 1 diabetes has fruity breath. Why does his breath smell this way?
He is exhaling acetone; he has diabetic ketoacidosis "<img src=""7844
(1).png"">" Pathology diabetic-ketoacidosis endocrine
A diabetic man is in the ED vomiting, delirious, and breathing deeply/rapidly; his
breath has a fruity odor. What is the pathophysiology? Diabetic ketoacidosis;
increased insulin requirements (eg, stressors) cause excess lipolysis/ketogenesis,
with resultant ketone bodies "<img src=""7844 (1).png"">" Pathology diabetic-
ketoacidosis endocrine
A diabetic with diabetic ketoacidosis (DKA) has high serum ketone bodies. Which
ketone bodies, specifically, are measured in his serum? -Hydroxybutyrate and
acetoacetate are the two main ketone bodies found in DKA (-hydroxybutyrate level
&62; acetoacetate level) "<img src=""7844 (1).png"">" Pathology diabetic-
Describe Kussmaul respirations. In what state are they are commonly seen? Deep,
rapid respirations and air hunger; characteristic of diabetic ketoacidosis "<img
src=""7844 (1).png"">" Pathology diabetic-ketoacidosis endocrine
You suspect diabetic ketoacidosis in a patient. What are his glucose, pH,
bicarbonate, and WBC levels? What is his acid-base status? Increased glucose, low
pH (increased H+), decreased bicarbonate (anion gap metabolic acidosis), increased
WBC count (leukocytosis) "<img src=""7844 (1).png"">" Pathology diabetic-
A man with diabetic ketoacidosis has a potassium level of 5.3 mEq/L, but the
attending orders intravenous potassium repletion. Why? The lab value is falsely
high (total and intracellular K+ stores are low); acidosis and low insulin shift K+
into the extracellular space "<img src=""7844 (1).png"">" Pathology diabetic-
A man with a recent episode of diabetic ketoacidosis presents with an infection
over his sinuses. What infection are you worried about? Mucormycosis infection
(eg, Rhizopus fungus), which can be life threatening "<img src=""7844 (1).png"">"
Pathology diabetic-ketoacidosis endocrine
What is a common intracranial complication of diabetic ketoacidosis? Cerebral
edema "<img src=""7844 (1).png"">" Pathology diabetic-ketoacidosis endocrine
What are two common cardiovascular complications of diabetic ketoacidosis?
Arrhythmias and heart failure "<img src=""7844 (1).png"">" Pathology
diabetic-ketoacidosis endocrine
A patient presents with hyperglycemia, abdominal pain, vomiting, and fruity breath.
List the core components of your treatment plan. Intravenous insulin, fluids,
and potassium; and, in some cases, glucose to prevent hypoglycemia "<img
A patient has DKA. When would it make sense to give glucose? When the glucose
level has normalized, but IV insulin is still necessary to aid in potassium
correction (to drive K+ back into cells) "<img src=""7844 (1).png"">" Pathology
diabetic-ketoacidosis endocrine
A girl has abdominal pain, hyperglycemia, anion gap metabolic acidosis, and
ketonuria. Why is her state more common in type 1 diabetes?Lipolysis is usually
prevented by the presence of endogenous insulin in type 2 diabetes "<img
A type 2 diabetic is brought in by EMS after having a seizure. If glucose levels
are over 600 mg/dL, what treatments do you recommend? This is likely HHNS due to
limited PO intake and excessive osmotic diuresis from hyperglycemia; treat with
aggressive IV fluids and insulin "<img src=""7845 (1).png"">" Pathology
endocrine hyperosmolar-hyperglycemia-nonketotic-syndrome
With regard to plasma glucose levels, what is an easy way to differentiate HHNS
from DKA? The glucose in HHNS is usually over 600 mg/dL, whereas in DKA, glucose
levels are lower "<img src=""7845 (1).png"">" Pathology endocrine hyperosmolar-
hyperglycemia-nonketotic-syndrome
What is the difference between HHNS and DKA with regard to acid-base status? In
HHNS there is no acidosis; in DKA, the patient is in an acidotic state due to
ketone bodies in the blood "<img src=""7845 (1).png"">" Pathology endocrine
hyperosmolar-hyperglycemia-nonketotic-syndrome
An elderly diabetic has a blood glucose of 700 and serum osmolarity of 340 mOsm/kg,
yet the pH is only 7.35. Why does this not surprise you? This is likely HHNS in a
type 2 diabetic; ketone production (and thus an acidosis) is suppressed by the
presence of insulin "<img src=""7845 (1).png"">" Pathology endocrine
hyperosmolar-hyperglycemia-nonketotic-syndrome
Why is HHNS more common in elderly, nursing homebound diabetic patients?
Because they are less able to sustain PO intake in the setting of
hyperglycemia/osmotic diuresis, leading to the signs/symptoms of HHNS "<img
src=""7845 (1).png"">" Pathology endocrine hyperosmolar-hyperglycemia-nonketotic-
syndrome
What is the sequence of events that typically leads to HHNS? Hyperglycemia with
excessive osmotic diuresis leading to dehydration (compounded by poor PO intake)
"<img src=""7845 (1).png"">" Pathology endocrine hyperosmolar-hyperglycemia-
nonketotic-syndrome
A man has necrolytic migratory erythema, diabetes, and a DVT. He is depressed and
has lost more than 25 lb. Treatment? This is a glucagonoma, a tumor of
pancreatic cells; treat with octreotide and/or surgery "<img src=""7846
(1).png"">" Pathology endocrine glucagonoma
A patient has a tumor of pancreatic cells. What five symptoms might she
experience? Dermatitis (necrolytic migratory erythema), Diabetes, DVT, Declining
weight, and Depression (glucagonoma) "<img src=""7846 (1).png"">" Pathology
endocrine glucagonoma
A patient presents with lethargy and diplopia followed by syncope. Her blood
glucose is low with an elevated C-peptide level. Diagnosis?Insulinoma "<img
src=""7847 (1).png"">" Pathology endocrine insulinoma
Insulinoma is a tumor of which cells of the pancreas? cells "<img src=""7847
(1).png"">" Pathology endocrine insulinoma
A nurse presents with lethargy, syncope, and diplopia. Serum insulin is high and C-
peptide is low. Does she need surgery? No, with low C-peptide, her presentation
is more consistent with exogenous insulin overdose (or abuse); surgery is reserved
for insulinomas "<img src=""7847 (1).png"">" Pathology endocrine insulinoma
A patient with a pancreatic mass has lethargy, syncope, and diplopia. What is this
condition called, and how do you treat it? Hypoglycemia (seen with
insulinomas); surgical resection "<img src=""7847 (1).png"">" Pathology
endocrine insulinoma
Explain the Whipple triad of insulinomas. Low blood glucose, hypoglycemia symptoms
(eg, lethargy, syncope, diplopia), and resolution of symptoms after glucose
normalization "<img src=""7847 (1).png"">" Pathology endocrine insulinoma
Some insulinomas are associated with which genetic syndrome? What percentage of
cases are implicated? MEN 1; 10% "<img src=""7847 (1).png"">" Pathology
endocrine insulinoma
A woman with frequent GI issues undergoes a pancreatic biopsy and is found to have
neoplasia of her pancreatic cells. Diagnosis? Somatostatinoma "<img src=""7848
(1).png"">" Pathology endocrine somatostatinoma
A man with an abdominal mass has low levels of secretin, cholecystokinin, glucagon,
insulin, and gastrin. How do you treat him? With surgery and/or octreotide for
symptom control; he has a somatostatinoma (Excess somatostatin inhibits many GI
hormones.) "<img src=""7848 (1).png"">" Pathology endocrine somatostatinoma
A man is newly diagnosed with diabetes. He has fatty stools and occasional biliary
colic. Why do you order an abdominal CT scan? All of these symptoms
(diabetes/glucose intolerance, steatorrhea, gallstones) could be explained by an
underlying somatostatinoma "<img src=""7848 (1).png"">" Pathology endocrine
somatostatinoma
A patient has diarrhea, flushing, wheezing, pellagra, and increased 5-HIAA in his
urine. What causes this syndrome? Carcinoid tumors (especially metastatic small
bowel tumors) that secrete high levels of serotonin (carcinoid syndrome) "<img
src=""7849 (1).png"">" Pathology carcinoid-syndrome endocrine
A man with a tumor thought to be limited to the gastrointestinal tract suddenly
experiences wheezing, flushing, and diarrhea. Why? Hepatic metastases (When GI
tractlimited tumors secrete 5-HT, it is metabolized in the liver but can only
enter system after metastasis.) "<img src=""7849 (1).png"">" Pathology
carcinoid-syndrome endocrine
A man experiences diarrhea, flushing, and wheezing, and you suspect carcinoid
syndrome. What complication might a cardiac workup reveal? Tricuspid regurgitation
or pulmonic stenosis due to right-sided valvular disease "<img src=""7849
(1).png"">" Pathology carcinoid-syndrome endocrine
A man with a small bowel tumor experiences labored breathing, diarrhea, and a
flushed face. What serum and urinary findings do you expect? Niacin deficiency
and elevated urine 5-hydroxyindoleacetic acid (5-HIAA); this is carcinoid syndrome
"<img src=""7849 (1).png"">" Pathology carcinoid-syndrome endocrine
A man with a small bowel tumor has asthmatic-sounding wheezing and diarrhea.
Cardiac auscultation reveals a regurgitant murmur. Treatment? Carcinoid syndrome
(from a carcinoid tumor) is treated with resection and/or somatostatin analogs (eg,
octreotide) "<img src=""7849 (1).png"">" Pathology carcinoid-syndrome endocrine
A patient with carcinoid tumor asks you about the likelihood of metastases. How do
you respond? There is a 33% chance (rule of 1/3's = 1/3 metastasize, 1/3
present with second malignancy, 1/3 are multiple) "<img src=""7849 (1).png"">"
Pathology carcinoid-syndrome endocrine
Zollinger-Ellison syndrome is the result of a tumor that secretes what substance?
Where is the tumor usually located? Gastrin; the pancreas or duodenum "<img
src=""7850 (1).png"">" Pathology endocrine zollinger-ellison-syndrome
A patient has had no response to several PPIs. On endoscopy, he has jejunal ulcers
and thickened gastric rugae. What malignancy is possible? Zollinger-Ellison
syndrome caused by a gastrin-secreting tumor "<img src=""7850 (1).png"">"
Pathology endocrine zollinger-ellison-syndrome
A patient has jejunal ulcers, diarrhea, and increased gastrin. What genetic
syndrome is associated with this? Multiple endocrine neoplasia (MEN) type I
(gastrinoma of Zollinger-Ellison syndrome) "<img src=""7850 (1).png"">"
Pathology endocrine zollinger-ellison-syndrome
A patient has abdominal pain, diarrhea, and recurrent duodenal ulcers. What test is
positive in this syndrome? Positive secretin stimulation test: high gastrin
after administration of secretin (usually inhibits gastrin release) suggests
gastrinoma "<img src=""7850 (1).png"">" Pathology endocrine zollinger-ellison-
syndrome
A man has abdominal pain. EGD shows multiple gastric and duodenal ulcers. What
diagnostic test can verify the suspected syndrome? A secretin stimulation test;
a positive test is elevated gastrin levels after secretin administration, which
normally blocks gastrin release "<img src=""7850 (1).png"">"
Pathology::endocrine::zollinger-ellison-syndrome
Multiple endocrine neoplasia (MEN) type 1 is associated with tumors in what three
locations? Pituitary, Pancreas, and Parathyroid (MEN 1 = 3 P's) "<img src=""7851
(1).png"">" Pathology endocrine multiple-endocrine-neoplasias
Name four pancreatic endocrine tumors seen in multiple endocrine neoplasia (MEN)
type 1. Insulinoma, Zollinger-Ellison syndrome (gastrinoma), vasoactive
intestinal peptide tumor (VIPoma), and, rarely, glucagonoma"<img src=""7851
A man presents with recurrent ulcers and kidney stones. What multiple endocrine
neoplasia (MEN) does he have, and what mutation is involved? MEN 1 (Elevated
PTH can cause renal stones, and ulcers are associated with gastrinoma.); MEN1
(menin, a tumor suppressor on chromosome 11) "<img src=""7851 (1).png"">"
Pathology endocrine multiple-endocrine-neoplasias
What three abnormalities are associated with multiple endocrine neoplasia (MEN)
type 2A, or Sipple syndrome? Medullary thyroid carcinoma, Pheochromocytoma, and
Parathyroid hyperplasia (MEN 2A = 2 P's) "<img src=""7851 (1).png"">" Pathology
endocrine multiple-endocrine-neoplasias
A man with an autosomal dominant disorder has elevated calcitonin and
catecholamines. Which MEN syndromes/mutations present with these labs? MEN 2A, MEN
2B (medullary thyroid cancer); RET gene mutation (codes for receptor tyrosine
kinase) in cells of neural crest origin "<img src=""7851 (1).png"">" Pathology
What three tumors are associated with multiple endocrine neoplasia (MEN) type 2B?
Medullary thyroid carcinoma, Pheochromocytoma, and oral or intestinal
ganglioneuromas (MEN 2B = 1 P) "<img src=""7851 (1).png"">" Pathology
A man has a marfanoid habitus. Which variant of multiple endocrine neoplasia (MEN)
causes this? What other conditions might he have? MEN 2B; pheochromocytoma,
medullary thyroid carcinoma, mucosal neuromas (oral, intestinal) "<img src=""7851
A man has multiple endocrine neoplasia (MEN) type 1. His wife does not have it.
What is the likelihood that his child will have the disease? "50%; all MEN
syndromes have autosomal dominant inheritance (""All MEN are dominant"" [or so they
think.])" "<img src=""7851 (1).png"">" Pathology endocrine multiple-endocrine-
neoplasias
What gene mutation is seen in multiple endocrine neoplasia (MEN) types 2A and 2B,
and what does it code for? A mutation in the RET gene within cells of neural
crest origin; receptor tyrosine kinase "<img src=""7851 (1).png"">" Pathology
A man with a history of prolactinoma and insulinoma has hypercalcemia. A mutation
on what chromosome is to blame? MEN1 syndrome is associated with mutation in
the MEN1 gene (codes for menin, a tumor suppressor on chromosome 11) "<img
src=""7851 (1).png"">" Pathology endocrine multiple-endocrine-neoplasias
Which multiple endocrine neoplasia (MEN) is associated with parathyroid tumors, and
which is associated with parathyroid hyperplasia? MEN 1 is associated with
parathyroid tumor, whereas MEN 2A is associated with parathyroid hyperplasia "<img
A patient with recurrent gastric ulcers experiences bitemporal visual defects. What
third gland is at risk for abnormalities? Parathyroid gland; this is MEN 1,
associated with tumors of the parathyroid, pituitary, and pancreas "<img
FNA of a thyroid nodule shows nests of Congo redpositive cells. History includes a
parent and sister who had pheochromocytoma. Gene defect? A RET gene mutation;
this is MEN 2A or 2B (both associated with medullary thyroid cancers, hence Congo
red staining for amyloid) "<img src=""7851 (1).png"">" Pathology endocrine
multiple-endocrine-neoplasias
Name two meglitinides. Which population of diabetics are they indicated for?
Nateglinide, repaglinide; monotherapy or in combination with metformin for
patients with type 2 diabetes "<img src=""7852.png"">" diabetes-mellitus-drugs
endocrine pharmacology
A 68-year-old diabetic man with chronic renal disease has acidosis. What medication
do you immediately look for on his medication list? Metformin; if metformin
cannot be excreted, as in patients with renal impairment, buildup may lead to a
severe lactic acidosis "<img src=""7852.png"">" diabetes-mellitus-drugs
What is the mechanism of action of the meglitinides? They stimulate postprandial
insulin release by binding to K+ channels on -cell membranes (site differs from
sulfonylureas) "<img src=""7852.png"">" diabetes-mellitus-drugs endocrine
pharmacology
A newly diagnosed type 2 diabetic is prescribed the first-line oral agent for his
condition. What common side effect do you warn him about? GI upset, because the
first-line oral agent for type 2 diabetics is metformin "<img src=""7852.png"">"
diabetes-mellitus-drugs endocrine pharmacology
A man takes a long-acting insulin at night before going to bed. What is the purpose
of this drug? Name two drugs that this could be. Basal glucose control;
glargine, detemir "<img src=""7852.png"">" diabetes-mellitus-drugs endocrine
pharmacology
Name two adverse effects of the meglitinides. Which pathology can increase the risk
of these adverse effects? Hypoglycemia and weight gain; renal failure can
increase the risk of these adverse effects "<img src=""7852.png"">"
Which category of insulin preparations is most commonly used for postprandial
glucose control? Rapid-acting insulins (eg, Lispro, Aspart, Glulisine [no LAG])
"<img src=""7852.png"">" diabetes-mellitus-drugs endocrine pharmacology
For patients considering insulin therapy to treat their diabetes, which three
risks/concerns do you counsel them about? Hypoglycemia, lipodystrophy, and rare
hypersensitivity reactions "<img src=""7852.png"">" diabetes-mellitus-drugs
Name two first-generation sulfonylureas. Name three second-generation
sulfonylureas. Tolbutamide and chlorpropamide; glyburide, glimepiride, and
glipizide "<img src=""7852.png"">" diabetes-mellitus-drugs endocrine
pharmacology
A man with type 2 diabetes mellitus vomits and has facial redness after consuming
alcohol. What class of diabetic drug is he likely taking? First-generation
sulfonylureas, which cause a disulfiram-like reaction with alcohol ingestion "<img
src=""7852.png"">" diabetes-mellitus-drugs endocrine pharmacology
What is the mechanism of action of sulfonylureas? Sulfonylureas trigger
endogenous insulin output by closing -cell membrane K+ channels (causes
depolarization, Ca2+ influx, insulin output) "<img src=""7852.png"">"
Will sulfonylureas work in type 1 diabetes mellitus? Why or why not? No, these
drugs require islet cell function and the ability to secrete endogenous insulin
(defective in type 1 diabetes) "<img src=""7852.png"">" diabetes-mellitus-
drugs endocrine pharmacology
Sulfonylureas work best for which type of diabetes? Type 2 diabetes "<img
A man has DKA. Which insulin preparation is he given, and how? Regular insulin
(short-acting) is given via IV for DKA "<img src=""7852.png"">" diabetes-
mellitus-drugs endocrine pharmacology
What are the main side effects of sulfonylureas? In which generation of these drugs
is it more of a concern? Increased risk of hypoglycemia in renal failure and
weight gain; hypoglycemia is more of a concern with the second-generation agents
A woman has hyperkalemia due to insufficient insulin. What treatment is she given
to correct the electrolyte abnormality? Regular insulin (short-acting) and
glucose "<img src=""7852.png"">" diabetes-mellitus-drugs endocrine
pharmacology
A patient is prescribed pioglitazone. What class does it belong to? Are there any
other members of this drug class? Glitazones/thiazolidinediones; rosiglitazone
also belongs to this class "<img src=""7852.png"">" diabetes-mellitus-drugs
What is the function of genes activated by PPAR-? The genes regulate fatty acid
storage and glucose metabolism; their activation increases both insulin sensitivity
and adiponectin levels "<img src=""7852.png"">" diabetes-mellitus-drugs
For what type of diabetes are glitazones/thiazolidinediones prescribed? What are
the main side effects of these drugs? Type 2 diabetes mellitus (as monotherapy
or in combination with other agents); weight gain, edema, hepatotoxicity, heart
failure, fractures "<img src=""7852.png"">" diabetes-mellitus-drugs
Your diabetic patient is developing renal failure from diabetic nephropathy. Is it
still safe to prescribe a drug that binds to PPAR-? Yes,
glitazones/thiazolidinediones are safe to use in patients with renal impairment
Where do glitazones/thiazolidinediones bind to exert their effects? What is the
outcome of their receptor being bound? The PPAR- nuclear transcription
regulator; peripheral tissue insulin sensitivity is increased "<img
What is the basic treatment strategy for type 1 diabetes mellitus? Low-
carbohydrate diet, insulin replacement "<img src=""7852.png"">" diabetes-
Name two -glucosidase inhibitors. What is their mechanism of action? Acarbose,
miglitol; reduce postprandial hyperglycemia (inhibit brush border -glucosidase,
delaying carbohydrate hydrolysis/glucose uptake) "<img src=""7852.png"">"
What is the basic treatment strategy for type 2 diabetes mellitus? Dietary
modification and exercise for weight loss, oral agents, non-insulin injectables,
insulin replacement "<img src=""7852.png"">" diabetes-mellitus-drugs
In what population are -glucosidase inhibitors used? What is their principal
toxicity? Patients with type 2 diabetes mellitus; gastrointestinal disturbances
What is the basic treatment strategy for gestational diabetes mellitus?
Dietary modifications, exercise, insulin replacement if lifestyle
modification fails "<img src=""7852.png"">" diabetes-mellitus-drugs
A diabetic patient uses a drug that decreases both gastric emptying and glucagon
levels. Name three of the drug's side effects. This is pramlintide; side effects
include hypoglycemia (in the setting of mistimed prandial insulin), diarrhea, and
nausea "<img src=""7852.png"">" diabetes-mellitus-drugs endocrine
pharmacology
Classify each insulin as rapid-, short-, intermediate-, or long-acting: NPH,
glulisine, regular, lispro, glargine, aspart, detemir. Rapid-acting: Lispro,
Aspart, Glulisine (no LAG); short-acting: regular; intermediate-acting: NPH; long-
acting: glargine, detemir "<img src=""7852.png"">" diabetes-mellitus-drugs
How does amylin work? What drug is an analog of this hormone? How is it given, and
in which type(s) of diabetes is it indicated? It reduces gastric emptying and
inhibits glucagon release; pramlintide, administered as a subcutaneous injection;
type 1 and type 2 diabetes "<img src=""7852.png"">" diabetes-mellitus-drugs
Insulin binds insulin receptors, which utilize which signaling pathway?
Tyrosine kinase "<img src=""7852.png"">" diabetes-mellitus-drugs
Give two examples of glucagon-like peptide-1 (GLP-1) analogs. What is the mechanism
of action? Exenatide, liraglutide; increase glucose-dependent insulin output,
promote satiety, and decrease both glucagon output and gastric emptying "<img
What function does insulin have in each of these tissues: liver, muscle, fat?
Liver: increases glucose storage as glycogen; muscle: increases
glycogen/protein synthesis and K+ uptake; fat: increases triglyceride stores "<img
The GLP-1 analogs and DPP-4 inhibitors have similar actions. How do their side
effect profiles differ? GLP-1 analogs: nausea, vomiting, pancreatitis, weight loss;
DPP-4 inhibitors: mild urinary or respiratory tract infections "<img
For which conditions is insulin generally an appropriate treatment? Type 1, type
2, and gestational diabetes; DKA (administer via IV); hyperkalemia (administer with
glucose); stress hyperglycemia "<img src=""7852.png"">" diabetes-mellitus-
A new drug increases insulin levels and decreases glucagon levels. What drug
classes can it belong to? In which population are they used? GLP-1 analogs
(exenatide, liraglutide) and DPP-4 inhibitors (linagliptin, saxagliptin,
sitagliptin); patients with type 2 diabetes mellitus "<img src=""7852.png"">"
A nondiabetic patient in the ICU is noted to have a blood glucose of 225 mg/dL.
What medication is appropriate for this condition? Insulin, which is effective
in treating stress-induced hyperglycemia "<img src=""7852.png"">" diabetes-
A woman uses an SGLT-2 inhibitor. Name three members of this drug class. What is
its mechanism of action, and what population is it used in?Canagliflozin,
dapagliflozin, empagliflozin block glucose reabsorption in the proximal convoluted
tubule; patients with type 2 DM "<img src=""7852.png"">" diabetes-mellitus-
A patient with newly diagnosed type 2 diabetes mellitus is prescribed a biguanide.
Name the drug, and identify its mechanism of action. Metformin (exact mechanism
unknown); it blocks gluconeogenesis & promotes both glycolysis & peripheral glucose
uptake (insulin sensitizer) "<img src=""7852.png"">" diabetes-mellitus-drugs
What are the adverse effects of the sodium-glucose co-transporter 2 (SGLT-2)
inhibitors? Glucosuria, UTIs, vaginal yeast infections, hyperkalemia, dehydration
(orthostatic hypotension) "<img src=""7852.png"">" diabetes-mellitus-drugs
A diabetic patient has no islet cell function. Which oral diabetic medication can
still be given to him? Name two side effects. Metformin; GI upset and lactic
acidosis (most serious adverse effect) "<img src=""7852.png"">" diabetes-
Name two GLP-1 analogs. Which one is administered subcutaneously? Exenatide,
liraglutide; liraglutide is administered subcutaneously "<img src=""7852.png"">"
What process do methimazole and propylthiouracil both inhibit? Thyroid hormone
synthesis (by blocking peroxidase, which inhibits the organification [coupling] of
iodine) "<img src=""7853.png"">" endocrine pharmacology thionamides
You are deciding how to treat a patient with a goiter, tachycardia, and weight
loss. Why might you choose propylthiouracil over methimazole? Besides blocking
thyroid hormone synthesis, propylthiouracil blocks 5-deiodinase and peripheral T4-
to-T3 conversion "<img src=""7853.png"">" endocrine pharmacology thionamides
You start a patient on medication for hyperthyroidism. What lab test should be
ordered to avoid a rare but devastating adverse effect? Complete blood count to
check for aplastic anemia or agranulocytosis (seen with use of propylthiouracil and
methimazole) "<img src=""7853.png"">" endocrine pharmacology thionamides
What are the known adverse effects of methimazole and propylthiouracil? Rash,
aplastic anemia, agranulocytosis (rare), hepatotoxicity, teratogenicity
(methimazole only [can cause aplasia cutis]) "<img src=""7853.png"">"
endocrine pharmacology thionamides
A newborn is missing a layer of epidermis on his scalp. His mother has
hyperthyroidism. What happened? How could you have prevented this? Aplastic
cutis occurs in those exposed to methimazole in utero (given to mother for
hyperthyroidism); use propylthiouracil in pregnancy "<img src=""7853.png"">"
What are the 2 P's of propylthiouracil that help you remember the characteristics
that make it different from methimazole? Propylthiouracil (PTU) blocks Peripheral
conversion [of T4 to T3] and can be used in Pregnancy "<img src=""7853.png"">"
What pharmacotherapies are used as thyroxine replacements in hypothyroidism and
myxedema? What is an off-label use? Levothyroxine (T4), triiodothyronine (T3);
weight loss supplement "<img src=""7854.png"">" endocrine levothyroxine-
(t4),-triiodothyronine-(t3) pharmacology
A patient begins taking thyroid hormone replacement therapy. What complications
must you carefully monitor the patient for? Tachycardia, heat intolerance,
tremors, arrhythmias (symptoms of hyperthyroidism) "<img src=""7854.png"">"
endocrine levothyroxine-(t4),-triiodothyronine-(t3) pharmacology
What are two medical indications for use of growth hormone?Growth hormone (GH)
deficiency and Turner syndrome "<img src=""7855.png"">" endocrine
hypothalamic/pituitary-drugs pharmacology
List five indications for the use of octreotide. Which hormone is it an analog of?
Gastrinoma, acromegaly, glucagonoma, carcinoid tumor, esophageal varices;
somatostatin "<img src=""7855.png"">" endocrine hypothalamic/pituitary-
drugs pharmacology
List three processes that can be stimulated with the use of exogenous oxytocin.
Labor, uterine contractions, milk let-down "<img src=""7855.png"">"
endocrine hypothalamic/pituitary-drugs pharmacology
After delivery, a woman continues to have uterine bleeding. What normally
endogenous substance can be given to stop the blood loss? Oxytocin "<img
src=""7855.png"">" endocrine hypothalamic/pituitary-drugs pharmacology
A woman is given desmopressin acetate. Can desmopressin be used in the treatment of
nephrogenic diabetes insipidus (DI)? No, desmopressin is an antidiuretic
hormone analog that requires a renal response and therefore is effective only in
central DI "<img src=""7855.png"">" endocrine hypothalamic/pituitary-drugs
pharmacology
A drug blocks ADH at the V2 receptor. What condition is this drug used to treat?
Name two drugs in this class. SIADH; ADH antagonists include conivaptan and
tolvaptan "<img src=""7855.png"">" endocrine hypothalamic/pituitary-drugs
pharmacology
A man notices coarsening facial features and enlarging hands. What medication can
be given to initially halt disease progression? Octreotide can be given for
acromegaly "<img src=""7855.png"">" endocrine hypothalamic/pituitary-drugs
pharmacology
A woman has hyponatremia with low serum osmolarity and high urine osmolarity. What
antibiotic works by antagonizing the defective pathway? Demeclocycline
(antidiuretic hormone antagonist, in tetracycline family), used to treat SIADH
"<img src=""7856.png"">" demeclocycline endocrine pharmacology
A woman uses an ADH antagonist that is a member of the tetracycline family. What
are the adverse effects of this drug? Demeclocycline causes nephrogenic
diabetes insipidus (antagonizes ADH), photosensitivity, abnormalities of
bones/teeth (It's a tetracycline.) "<img src=""7856.png"">" demeclocycline
A patient with asthma uses glucocorticoids. Generally speaking, what is the
mechanism of action of these drugs? Metabolic, catabolic, anti-inflammatory, and
immunosuppressive effects, mediated by interaction with glucocorticoid response
elements "<img src=""7857.png"">" endocrine glucocorticoids pharmacology
List six examples of glucocorticoid drugs. Beclomethasone, dexamethasone,
hydrocortisone, methylprednisolone, prednisone, triamcinolone "<img
src=""7857.png"">" endocrine glucocorticoids pharmacology
Name six side effects of glucocorticoids. Iatrogenic Cushing syndrome,
adrenocortical atrophy, peptic ulcers, steroid diabetes, steroid psychosis,
cataracts "<img src=""7857.png"">" endocrine glucocorticoids pharmacology
What medication can be injected into a joint to treat the inflammation associated
with degenerative arthritis? Glucocorticoids, which are potent anti-inflammatory
agents "<img src=""7857.png"">" endocrine glucocorticoids pharmacology
Give an example of a common pediatric pulmonary disease that can be treated with
glucocorticoids. Asthma "<img src=""7857.png"">" endocrine
glucocorticoids pharmacology
A man with rheumatoid arthritis has a buffalo hump, truncal obesity, muscle
wasting, and hyperglycemia. What is the cause of his symptoms? Iatrogenic Cushing
syndrome caused by glucocorticoid use (for immune suppression in the setting of an
autoimmune disease) "<img src=""7857.png"">" endocrine glucocorticoids
pharmacology
What is the effect of long-term glucocorticoid use on fat distribution?
Truncal obesity, buffalo hump, moon facies "<img src=""7857.png"">"
endocrine glucocorticoids pharmacology
What effect does long-term glucocorticoid use have on the musculoskeletal and
gastrointestinal systems? It can cause muscle wasting, osteoporosis, and peptic
ulcers "<img src=""7857.png"">" endocrine glucocorticoids pharmacology
What effect can glucocorticoid toxicity have on the skin? Skin thinning, striae,
and easy bruisability "<img src=""7857.png"">" endocrine glucocorticoids
pharmacology
A patient receiving long-term glucocorticoid therapy runs out of his medication
while on vacation and becomes hypotensive. Why? Long-term glucocorticoid therapy
may lead to adrenocortical atrophy, causing adrenal insufficiency if the drug is
stopped abruptly "<img src=""7857.png"">" endocrine glucocorticoids
pharmacology
What effect can glucocorticoid toxicity have on menses? It can cause amenorrhea
"<img src=""7857.png"">" endocrine glucocorticoids pharmacology
A patient is admitted for an asthma flare. IV methylprednisolone is given and he
improves, but he later becomes psychotic. What happened? Probably steroid
psychosis; methylprednisolone is an IV glucocorticoid "<img src=""7857.png"">"
endocrine glucocorticoids pharmacology
Name two targets inhibited by glucocorticoids that promote its various effects on
the body. Phospholipase A2, transcription factors such as NF-B "<img
src=""7857.png"">" endocrine glucocorticoids pharmacology
A patient recovering from WaterhouseFriderichsen syndrome will be given what drug
to replace hormonal insufficiency? Fludrocortisone is a mineralocorticoid
replacement used in primary adrenal insufficiency "<img src=""7858.png"">"
endocrine fludrocortisone pharmacology
What are the side effects of the drug given for hormonal replacement in Addison
disease? Fludrocortisone has side effects similar to those of glucocorticoids;
also edema, heart failure exacerbation, hyperpigmentation "<img src=""7858.png"">"
endocrine fludrocortisone pharmacology
How much of a glucocorticoid effect does fludrocortisone have? Very little,
although it does share some adverse effects with glucocorticoids "<img
src=""7858.png"">" endocrine fludrocortisone pharmacology
A patient takes cinacalcet. What condition is this prescribed for, and what is the
mechanism of action? Primary or secondary hyperparathyroidism; it sensitizes the
calcium-sensing receptor (CaSR) in parathyroid tissue to decrease PTH output "<img
src=""7859.png"">" cinacalcet endocrine pharmacology
A patient with kidney stones and osteitis fibrosa cystica has hypercalcemia. What
medication should she take, and what is its toxicity? Cinacalcet; hypocalcemia
"<img src=""7859.png"">" cinacalcet endocrine pharmacology
How does cinacalcet's sensitization of the calcium-sensing receptor (CaSR) help in
the treatment of hypercalcemia? Increases the CaSR's sensitivity to circulating
Ca2+, thus improving negative feedback inhibition of PTH release "<img
src=""7859.png"">" cinacalcet endocrine pharmacology
A pt has a malformed gastrointestinal tract from pharynx to duodenum. What part of
the embryo had impaired development? The foregut "<img src=""7860.png"">"
Gastrointestinal embryology normal-gastrointestinal-embryology
In a pt with a hiatal hernia, the herniated structure was originally derived from
what part of the embryo? The foregut (herniation of the proximal stomach
through the diaphragm) "<img src=""7860.png"">" Gastrointestinal embryology
normal-gastrointestinal-embryology
A developing embryo has a malfunction of the midgut. Which region of the
gastrointestinal tract will be affected? Duodenum to the transverse colon "<img
src=""7860.png"">" Gastrointestinal embryology normal-gastrointestinal-
embryology
The part of the colon supplied by both the hepatic and splenic flexures is derived
from what part of the embryo? The midgut (The transverse colon is supplied by both
the hepatic and splenic flexures.) "<img src=""7860.png"">" Gastrointestinal
embryology normal-gastrointestinal-embryology
A developing embryo has damage to the hindgut. As an adult, what structures of the
GI tract will be affected? The distal transverse colon to the rectum "<img
src=""7860.png"">" Gastrointestinal embryology normal-gastrointestinal-
embryology
A pt has ulcerative colitis (UC) with involvement of the rectum, which derives from
what part of the embryo? The hindgut (UC always affects the rectum and may
affect more proximal regions.) "<img src=""7860.png"">" Gastrointestinal
embryology normal-gastrointestinal-embryology
In the sixth week, what developmental event occurs with the physiologic midgut?
Herniation through the umbilical ring "<img src=""7860.png"">"
In the tenth week, what developmental event occurs with the physiologic midgut?
It returns to the abdominal cavity and rotates around the superior mesenteric
artery (SMA), a total of 270 degrees counterclockwise "<img src=""7860.png"">"
An extrusion of abdominal contents not covered by peritoneum is found on a newborn.
Where is this seen relative to the umbilicus? This is gastroschisis, typically
found to the right of the umbilicus "<img src=""7861.png"">" Gastrointestinal
embryology ventral-wall-defects
A baby with bladder exstrophy presents to the clinic. What type of folds failed to
close properly during embryologic development? Caudal folds "<img
src=""7861.png"">" Gastrointestinal embryology ventral-wall-defects
A baby presents with sternal defects. Failure of what type of folds to close
properly caused this clinical scenario? Rostral folds "<img src=""7861.png"">"
Gastrointestinal embryology ventral-wall-defects
An extrusion of abdominal contents into the umbilical cord is covered by the
peritoneum on a newborn having surgery. Name this diagnosis. Omphalocele
(sealed by peritoneum) "<img src=""7861.png"">" Gastrointestinal embryology
ventral-wall-defects
A baby presents with gastroschisis. Failure of what type of folds to close properly
caused this clinical scenario? Lateral folds "<img src=""7861.png"">"
Gastrointestinal embryology ventral-wall-defects
A pt's chest x-ray shows an airway stricture. He is drooling excessively. How do
you confirm your suspected diagnosis? Attempt to pass a nasogastric tube (In a
tracheoesophageal fistula, the tube will not reach the stomach.) "<img
src=""7862.png"">" Gastrointestinal embryology tracheoesophageal-anomalies
A newborn chokes and vomits with the first feeding, and she reportedly had
polyhydramnios in utero. Why might this baby become cyanotic? The newborn may
develop cyanosis from laryngospasm (to avoid reflux-related aspiration); this is a
tracheoesophageal fistula "<img src=""7862.png"">" Gastrointestinal
embryology tracheoesophageal-anomalies
A baby with esophageal atresia has a chest x-ray revealing a gasless abdomen. What
type of esophageal atresia is this? Pure esophageal atresia (may also be due to
stenosis) "<img src=""7862.png"">" Gastrointestinal embryology
tracheoesophageal-anomalies
What is the most common subtype of tracheoesophageal fistula? Esophageal atresia
with a distal tracheoesophageal fistula (a blind-pouch upper esophagus with the
lower esophagus connected to the trachea) "<img src=""7862.png"">"
Gastrointestinal embryology tracheoesophageal-anomalies
What are some symptoms seen with the most common subtype of tracheoesophageal
fistula? Cyanosis, choking, and vomiting with feeding; gastric air bubbles on x-
rays of the chest; polyhydramnios (if still in utero) "<img src=""7862.png"">"
Gastrointestinal embryology tracheoesophageal-anomalies
A baby is born with trisomy 21 and diagnosed with duodenal atresia. How would you
explain this GI tract malformation to the parents? Failure of the duodenum to
recanalize properly, associated with Down syndrome "<img src=""7863.png"">"
Gastrointestinal embryology intestinal-atresia
In a pt with congenital pyloric stenosis, hypertrophy of the pylorus leads to what
problem? Gastric outlet obstruction "<img src=""7864.png"">"
Gastrointestinal embryology hypertrophic-pyloric-stenosis
An infant with projectile vomiting has a palpable, epigastric, olive-sized mass on
exam. Did the mother receive antibiotics before birth? Possibly, since
congenital pyloric stenosis is associated with macrolide exposure "<img
src=""7864.png"">" Gastrointestinal embryology hypertrophic-pyloric-stenosis
In a baby with suspected congenital pyloric stenosis, what type of vomit would rule
out the disorder? Bilious (Bilious vomit originates distal to the pyloric
sphincter.) "<img src=""7864.png"">" Gastrointestinal embryology hypertrophic-
pyloric-stenosis
The mother of a newborn says her previous child had developed projectile vomiting.
When would this most likely occur in this newborn? 2 to 6 weeks of age "<img
A 3-week-old baby has projectile nonbilious vomiting and normal findings on
physical exam. What treatment will likely be indicated? "Surgical pyloromyotomy
(With pyloric stenosis, the classic ""olive mass"" is often not palpable.)" "<img
Congenital pyloric stenosis often occurs in what demographic group? Firstborn
male infants "<img src=""7864.png"">" Gastrointestinal embryology
hypertrophic-pyloric-stenosis
A woman taking clarithromycin for acne gives birth to her first baby. He repeatedly
vomits after feeds. Is the baby male or female? Male; this is likely hypertrophic
pyloric stenosis, which is associated with prenatal macrolide exposure and
firstborn males "<img src=""7864.png"">" Gastrointestinal embryology
hypertrophic-pyloric-stenosis
A pt is diagnosed with pancreas divisum, and she asks how this developed. What do
you tell her? It arises due to failure of the ventral and dorsal pancreatic
buds to fuse during embryologic development "<img src=""7865.png"">"
Gastrointestinal embryology pancreas-and-spleen-embryology
The pancreas is derived from which part of the embryo? The foregut "<img
src=""7865.png"">" Gastrointestinal embryology pancreas-and-spleen-embryology
What malformation results when the ventral pancreatic bud encircles the second part
of the duodenum? Annular pancreas "<img src=""7865.png"">" Gastrointestinal
embryology pancreas-and-spleen-embryology
From which embryologic derivative (germ cell layer) does the spleen arise?
Mesoderm "<img src=""7865.png"">" Gastrointestinal embryology
pancreas-and-spleen-embryology
The spleen receives blood from vasculature originating from which part of the
embryo? The foregut (specifically, the celiac artery), even though the spleen
is of mesodermal origin "<img src=""7865.png"">" Gastrointestinal embryology
pancreas-and-spleen-embryology
A pt has a malformed accessory pancreatic duct. What pancreatic bud did not form
correctly? The dorsal pancreatic bud "<img src=""7865.png"">"
Gastrointestinal embryology pancreas-and-spleen-embryology
Ventral pancreatic buds contribute to the formation of these three pancreatic
structures. Pancreatic head, main pancreatic duct, and uncinate process"<img
src=""7865.png"">" Gastrointestinal embryology pancreas-and-spleen-embryology
A child has malformed mesentery of the foregut. What mesodermal organ that is
supplied by the celiac artery are you concerned about? The spleen (supplied by
the foregut-derived celiac artery) "<img src=""7865.png"">" Gastrointestinal
embryology pancreas-and-spleen-embryology
A pt has congenital malformation of the dorsal pancreatic bud. Which structures
will ultimately be malformed? The body, tail, isthmus, and accessory pancreatic
duct "<img src=""7865.png"">" Gastrointestinal embryology pancreas-and-
spleen-embryology
Which parts of the duodenum are retroperitoneal? The second, third, and fourth
parts "<img src=""7866.png"">" Gastrointestinal anatomy retroperitoneal-
structures
What qualities define the retroperitoneal structures? Gastrointestinal structures
lacking a mesentery and non-GI structures that are behind the peritoneum "<img
src=""7866.png"">" Gastrointestinal anatomy retroperitoneal-structures
Name all the structures or parts of structures that are retroperitoneal structures
(SAD PUCKER mnemonic) Suprarenal glands, Aorta/IVC, Duodenum (2nd4th parts),
Pancreas (not tail), Ureters, Colon, Kidneys, Esophagus (thoracic), Rectum (part)
"<img src=""7866.png"">" Gastrointestinal anatomy retroperitoneal-
structures
Which two structures are completely retroperitoneal? Kidneys and adrenal glands
structures
What part of the pancreas is not found in the retroperitoneal space? The tail
structures
Which two parts of the urinary system are retroperitoneal? The kidney and ureters
structures
Which portion(s) of the colon is/are retroperitoneal? The ascending and descending
colon "<img src=""7866.png"">" Gastrointestinal anatomy retroperitoneal-
structures
A man presents to the ED with injury to his retroperitoneal organs. What is likely
to accumulate in the retroperitoneal space? Blood, gas "<img src=""7866.png"">"
Gastrointestinal anatomy retroperitoneal-structures
A man develops back pain as a result of a ruptured abdominal aortic aneurysm. Why
back pain and not chest or epigastric pain? The aorta in the abdomen is
retroperitoneal, so pain is referred to the dorsal side of the body "<img
src=""7866.png"">" Gastrointestinal anatomy retroperitoneal-structures
A researcher dissects the falciform ligament. He finds vein remnants inside. What
has he uncovered? The ligamentum teres hepatis (derivative of fetal umbilical vein)
"<img src=""7867.png"">" Gastrointestinal anatomy important-
gastrointestinal-ligaments
A surgeon accidentally cuts into the hepatoduodenal ligament and notes bile-tinged
bleeding. What specific structure(s) has he cut into? The portal triad: proper
hepatic artery, portal vein, common bile duct "<img src=""7867.png"">"
Gastrointestinal anatomy important-gastrointestinal-ligaments
A surgeon carefully cuts into a ligament separating the greater curvature and
spleen. He aims to avoid bleeding from which specific vessels? Short gastrics and
left gastroepiploic vessels (This is the gastrosplenic ligament.) "<img
src=""7867.png"">" Gastrointestinal anatomy important-gastrointestinal-
ligaments
The falciform ligament connects which two structures? The liver and the anterior
abdominal wall "<img src=""7867.png"">" Gastrointestinal anatomy important-
In the gastrointestinal tract, the gastrohepatic ligament connects which two
structures? The liver and the lesser curvature of the stomach "<img
src=""7867.png"">" Gastrointestinal anatomy important-gastrointestinal-
ligaments
In the gastrointestinal tract, if the gastrocolic ligament were damaged, which of
the pt's two structures would be disconnected? The transverse colon and the
greater curvature of the stomach "<img src=""7867.png"">" Gastrointestinal
anatomy important-gastrointestinal-ligaments
In the gastrointestinal tract, if the splenorenal ligament were damaged, which of
the pt's two structures would be disconnected? The spleen and the posterior
abdominal wall "<img src=""7867.png"">" Gastrointestinal anatomy important-
The hepatoduodenal ligament connects which two structures? The liver and duodenum
The falciform ligament contains what structure? The ligamentum teres hepatis
(derived from the fetal umbilical vein) "<img src=""7867.png"">"
During surgery, the gastrohepatic ligament is severed. Blood flow to which organ is
impaired? The stomach (gastric arteries) "<img src=""7867.png"">"
The gastrocolic ligament contains what structures? The gastroepiploic arteries
What vessels are contained within the gastrosplenic ligament? Short gastrics,
left gastroepiploic vessels "<img src=""7867.png"">" Gastrointestinal anatomy
important-gastrointestinal-ligaments
The splenorenal ligament contains what structures? The splenic artery and vein,
tail of pancreas "<img src=""7867.png"">" Gastrointestinal anatomy important-
Intraoperatively, the portal triad is noted to be bleeding. Through which opening
can it be compressed to achieve hemostasis? The omental foramen may be accessed
to compress the hepatoduodenal ligament. (Compression is called the Pringle
maneuver.) "<img src=""7867.png"">" Gastrointestinal anatomy important-
The surgeon needs to access the lesser sac during surgery. Which of the pt's
gastrointestinal ligaments can be cut to do this? The gastrohepatic ligament
What ligaments are part of the greater omentum? The gastrocolic and gastrosplenic
ligaments "<img src=""7867.png"">" Gastrointestinal anatomy important-
The ligament that separates the right greater and lesser sacs connects the liver to
which structure? The lesser curvature of the stomach (gastrohepatic ligament,
containing the gastric arteries) "<img src=""7867.png"">" Gastrointestinal
anatomy important-gastrointestinal-ligaments
What ligament is a derivative of the ventral mesentery? The falciform ligament
Which layer of the muscularis externa is closer to the gut lumen? The circular
layer "<img src=""7868.png"">" Gastrointestinal anatomy digestive-tract-
anatomy
List the three components of the gut wall mucosa. Epithelium, lamina propria,
and muscularis mucosa "<img src=""7868.png"">" Gastrointestinal anatomy
digestive-tract-anatomy
If a pt is missing his submucosal nerve plexus, which gut function would be
impaired? Secretory activity (The Submucosa contains the Submucosal nerve plexus,
also known as the Meissner plexus.) "<img src=""7868.png"">" Gastrointestinal
anatomy digestive-tract-anatomy
Which nerve plexus lies between the inner circular and outer longitudinal layers of
the muscularis externa? The Muscularis externa contains the Myenteric nerve plexus
(also known as the Auerbach plexus), responsible for Motility "<img
src=""7868.png"">" Gastrointestinal anatomy digestive-tract-anatomy
List the four main layers of the gut wall, starting from the lumen. Mucosa,
Submucosa, Muscularis externa, and Serosa (MSMS) "<img src=""7868.png"">"
Gastrointestinal anatomy digestive-tract-anatomy
List the basal electrical rhythms (frequencies) of the stomach, duodenum, and
ileum. Stomach: 3 waves/min; duodenum: 12 waves/min; ileum: 89 waves/min
"<img src=""7868.png"">" Gastrointestinal anatomy digestive-tract-
anatomy
Into what layer(s) can ulcers extend? Submucosa, inner or outer muscular layer
anatomy
What is the outermost layer of the gut called when retroperitoneal? Adventitia
(The tunica serosa exists only in the peritoneal cavity.) "<img src=""7868.png"">"
What is the outermost layer of the gut called when intraperitoneal? Tunica
serosa (The GI adventitia exists only retroperitoneally.) "<img src=""7868.png"">"
In which layer of the gut are erosions typically found? Mucosa only "<img
src=""7868.png"">" Gastrointestinal anatomy digestive-tract-anatomy
What type of epithelial cells normally line the esophagus? Nonkeratinized
stratified squamous epithelium "<img src=""7869.png"">" Gastrointestinal
anatomy digestive-tract-histology
A man with celiac disease has loss of villi and microvilli on small intestinal
biopsy. Which part of the small intestine is most affected?The duodenum (Villi and
microvilli increase the surface area of the epithelium to maximize absorption.)
histology
What submucosal structures are unique to the duodenum? What is their function?
Brunner glands; they secrete bicarbonate "<img src=""7869.png"">"
Gastrointestinal anatomy digestive-tract-histology
Which epithelial glands are found throughout the small intestine? Crypts of
Lieberkhn "<img src=""7869.png"">" Gastrointestinal anatomy digestive-tract-
histology
Goblet cells are most highly concentrated in this area of the small intestine.
Ileum "<img src=""7869.png"">" Gastrointestinal anatomy digestive-tract-
histology
Gastric glands are found in this part of the digestive tract. Stomach "<img
src=""7869.png"">" Gastrointestinal anatomy digestive-tract-histology
Which immunologic structures are unique to the ileum? Peyer patches "<img
src=""7869.png"">" Gastrointestinal anatomy digestive-tract-histology
A pt undergoes a bowel biopsy, which later reveals crypts of Lieberkhn but no
villi. Which segment was biopsied? Colon (Crypts of Lieberkhn are also present
throughout the small intestine, which also contains villi.)"<img src=""7869.png"">"
What two segments of the small intestine have plicae circulares? Jejunum and ileum
histology
A pt with Crohn disease has destruction of his ileal lamina propria and submucosa.
What structures are affected by this? Peyer patches "<img src=""7869.png"">"
Which branch(es) of the aorta come(s) off at the level of L1? The superior
mesenteric artery and renal arteries "<img src=""7870.png"">"
Gastrointestinal abdominal-aorta-and-branches anatomy
The paired arteries feeding the gonads (testicles/ovaries) originate from the
abdominal aorta at which level? Below L1/above L2 "<img src=""7870.png"">"
At what level does the abdominal aorta bifurcate? "L4 (""bifourcation"" of
abdominal aorta)" "<img src=""7870.png"">" Gastrointestinal abdominal-aorta-
and-branches anatomy
Which three arteries does the aorta become after the bifurcation? Left and
right common iliac arteries, median sacral artery "<img src=""7870.png"">"
Arteries supplying GI structures branch out which way from the aorta? This is in
contrast to which direction applying to non-GI structures? Anteriorly; laterally
and posteriorly "<img src=""7870.png"">" Gastrointestinal abdominal-aorta-
A vascular surgeon accidentally cuts into a branch of the aorta originating at the
T12 level. Name an artery that may be compromised. The celiac trunk or middle
suprarenal artery "<img src=""7870.png"">" Gastrointestinal abdominal-aorta-
The common iliac arteries further bifurcate into which two major arteries? The
internal and external iliac arteries "<img src=""7870.png"">"
A pt undergoes surgery for an L3 abdominal aortic aneurysm. Blood supply to which
organ system is most at risk? The intestines (The inferior mesenteric artery,
originating at the L3 level, may be compromised by the surgery.) "<img
src=""7870.png"">" Gastrointestinal abdominal-aorta-and-branches anatomy
Where is the IVC found relative to the aorta? To the right "<img
src=""7870.png"">" Gastrointestinal abdominal-aorta-and-branches anatomy
Which portion of the duodenum is susceptible to compression between the superior
mesenteric artery and the aorta? The third (transverse) portion of the duodenum
(This is superior mesenteric artery syndrome.) "<img src=""7871.png"">"
Gastrointestinal anatomy superior-mesenteric-artery-syndrome
A woman presents with a portion of her duodenum entrapped between the SMA and
aorta. What do you want to know about in her medical history? Conditions
associated with diminished mesenteric fat (eg, low body weight/malnutrition); this
is superior mesenteric artery (SMA) syndrome "<img src=""7871.png"">"
Gastrointestinal anatomy superior-mesenteric-artery-syndrome
A man with severe abdominal pain has an exploratory laparotomy revealing necrosis
of foregut structures. Which artery was likely affected? The celiac artery "<img
src=""7872.png"">" Gastrointestinal anatomy gastrointestinal-blood-supply-and-
innervation
An 80-year-old has a colonoscopy revealing necrotic mucosa at the splenic flexure.
Which arteries branching from the aorta supply this area? The superior and
inferior mesenteric arteries (The splenic flexure is the watershed area between
them.) "<img src=""7872.png"">" Gastrointestinal anatomy
gastrointestinal-blood-supply-and-innervation
What are the three embryologic divisions of the gastrointestinal tract? The
foregut, midgut, and hindgut "<img src=""7872.png"">" Gastrointestinal anatomy
A man presents with severe abdominal pain. Exploratory laparotomy shows necrosis of
midgut structures. Which artery was likely compromised? The superior mesenteric
artery "<img src=""7872.png"">" Gastrointestinal anatomy
After an abdominal aortic aneurysm repair, a pt is found to have necrotic sigmoid
colon. Which artery was likely compromised? The inferior mesenteric artery
"<img src=""7872.png"">" Gastrointestinal anatomy gastrointestinal-
blood-supply-and-innervation
The foregut and midgut get their parasympathetic innervation from this nerve.
Vagus nerve "<img src=""7872.png"">" Gastrointestinal anatomy
The hindgut gets its parasympathetic innervation from this nerve. Pelvic nerve
What portion of the gastrointestinal tract is derived from the embryonic midgut?
The distal duodenum to the proximal two thirds of the transverse colon "<img
innervation
What portion of the gastrointestinal tract is derived from the embryonic hindgut?
The distal third of the transverse colon to the upper rectum "<img
innervation
What organ supplied by the celiac trunk is not an embryonic gut derivative? The
spleen "<img src=""7872.png"">" Gastrointestinal anatomy
A pt recently underwent a vagotomy. Which segments of her GI tract would be
expected to lack parasympathetic innervation? The foregut and midgut (pharynx to
proximal two thirds of the transverse colon) "<img src=""7872.png"">"
Gastrointestinal anatomy gastrointestinal-blood-supply-and-innervation
A trauma pt is hoarse and complains of dysphagia from vagal nerve damage. What part
of the gut still has parasympathetic innervation? Hindgut (The vagus nerve
innervates the foregut and midgut, while the pelvic nerve innervates the hindgut.)
The stomach receives its main blood supply from branches of what structure? The
celiac trunk "<img src=""7873.png"">" Gastrointestinal anatomy celiac-
trunk
Name the three main branches of the celiac trunk. Common hepatic artery,
splenic artery, and left gastric artery "<img src=""7873.png"">"
Gastrointestinal anatomy celiac-trunk
A pt's splenic artery is occluded by a clot. What artery, related to the stomach,
can likely serve as an anastomosis? The gastroepiploic artery (right to left) "<img
src=""7873.png"">" Gastrointestinal anatomy celiac-trunk
What are the three main branches of the common hepatic artery? The right gastric
artery, gastroduodenal artery, and proper hepatic artery "<img src=""7873.png"">"
What are the three branches of the gastroduodenal artery? The anterior superior
pancreaticoduodenal, posterior superior pancreaticoduodenal, and right
gastroepiploic arteries "<img src=""7873.png"">" Gastrointestinal anatomy
celiac-trunk
While operating on a pt, a surgeon cuts the right and left gastroepiploic arteries.
What part of the stomach is lacking vasculature? Greater curvature of the
stomach "<img src=""7873.png"">" Gastrointestinal anatomy celiac-trunk
After surgery, a man is found to have impaired circulation to the lesser curvature
of the stomach. Which vessels may have been cut? Right and left gastric
arteries "<img src=""7873.png"">" Gastrointestinal anatomy celiac-trunk
Strong anastomoses exist between what arteries that come off the celiac trunk?
Left and right gastroepiploic arteries and left and right gastric arteries
"<img src=""7873.png"">" Gastrointestinal anatomy celiac-trunk
Which arteries branch from the splenic artery to supply the stomach? The short
gastric arteries and the left gastroepiploic artery "<img src=""7873.png"">"
Name three clinical signs of portal hypertension, detectable on physical exam.
Esophageal (esophagus) varices, anorectal varices, and caput medusae (gut,
butt, and caput) "<img src=""7874.png"">" Gastrointestinal anatomy
portosystemic-anastomoses
A chronic alcoholic man presents with mental status changes, tense ascites, and
hematemesis. What is a likely cause of this presentation? Bleeding esophageal
varices secondary to portal hypertension from his cirrhosis (as evidenced by his
ascites) "<img src=""7874.png"">" Gastrointestinal anatomy portosystemic-
anastomoses
A pt with portal hypertension has rectal bleeding from prolapsed, dilated veins
around the anus. How did this result? Portosystemic anastomoses between the
superior and middle rectal arteries created anorectal varices "<img
src=""7874.png"">" Gastrointestinal anatomy portosystemic-anastomoses
What clinical finding results from portosystemic anastomoses when it involves the
inferior epigastric and superior epigastric veins? Caput medusae in the abdomen
"<img src=""7874.png"">" Gastrointestinal anatomy portosystemic-
anastomoses
An alcoholic pt has refractory gastrointestinal bleeding secondary to cirrhosis.
What surgical procedure can be used to stabilize him? Transjugular intrahepatic
portosystemic shunt (TIPS) moves blood from the portal to hepatic veins, shunting
blood to systemic circulation "<img src=""7874.png"">" Gastrointestinal anatomy
Via what pathway does blood leave the anus to enter the systemic circulation?
Middle and inferior rectal veins to iliac veins to inferior vena cava "<img
Via what pathway does blood leave the anus to enter the portal circulation?
Superior rectal vein (superior hemorrhoidal vein) to inferior mesenteric vein
to splenic vein to portal vein "<img src=""7874.png"">" Gastrointestinal
anatomy portosystemic-anastomoses
Via what pathway does blood leave the esophagus to enter the systemic circulation?
Esophageal veins to azygos vein "<img src=""7874.png"">"
Gastrointestinal anatomy portosystemic-anastomoses
An alcoholic has hematemesis. EGD is positive for esophageal varices. This is due
to interplay between which two veins? The left gastric and azygos veins "<img
Via what pathway does blood leave the esophagus to enter the portal circulation?
Esophageal veins to left gastric vein (coronary vein) to portal vein "<img
Via what pathway does blood leave the umbilicus to enter the systemic circulation?
Small epigastric veins to iliac veins to inferior vena cava"<img
Via what pathway does blood leave the umbilicus to enter the portal circulation?
Paraumbilical vein to portal vein "<img src=""7874.png"">"
"A pt with advanced hepatitis C reports that his belly button looks like a
""starfish."" This is due to interplay between which two veins?" The paraumbilical
and epigastric veins "<img src=""7874.png"">" Gastrointestinal anatomy
Anorectal varices are due to interplay between which two veins? Superior rectal
(superior hemorrhoidal) and middle/inferior rectal veins "<img src=""7874.png"">"
The pectinate line is formed where which two embryologic derivatives meet?
Endoderm (hindgut) and ectoderm "<img src=""7875.png"">"
Gastrointestinal anatomy pectinate-(dentate)-line
What type of hemorrhoids occur above the pectinate line? Below the pectinate line?
Internal hemorrhoids; external hemorrhoids "<img src=""7875.png"">"
A pt presents with pain on defecation. On exam, you find that he has somatically
innervated swollen masses. What nerve innervates them? Somatic nerves (pudendal
nerve inferior rectal branch); these are external hemorrhoids and are thus painful
(unlike internal hemorrhoids) "<img src=""7875.png"">" Gastrointestinal anatomy
pectinate-(dentate)-line
A pt is diagnosed with cancer occurring above the pectinate line. What kind is it?
What would it be if it were below the pectinate line? Adenocarcinoma (endodermal
derivation); squamous cell carcinoma (ectodermal derivation) "<img
src=""7875.png"">" Gastrointestinal anatomy pectinate-(dentate)-line
Above the pectinate line, lymphatic drainage is to what nodes? Deep nodes "<img
src=""7875.png"">" Gastrointestinal anatomy pectinate-(dentate)-line
Below the pectinate line, lymphatic drainage is to what nodes? Superficial
inguinal nodes "<img src=""7875.png"">" Gastrointestinal anatomy pectinate-
(dentate)-line
Above the pectinate line, the blood supply comes from what artery? The superior
rectal artery (branch of the inferior mesenteric artery) "<img src=""7875.png"">"
The superior rectal artery is a branch of what artery that comes off the aorta?
The inferior mesenteric artery "<img src=""7875.png"">"
Is innervation below the pectinate line somatic or visceral? Somatic
(Hemorrhoids there are painful.) "<img src=""7875.png"">" Gastrointestinal
anatomy pectinate-(dentate)-line
Below the pectinate line, the arterial supply is from what artery? The inferior
rectal artery "<img src=""7875.png"">" Gastrointestinal anatomy pectinate-
(dentate)-line
The inferior rectal artery is a branch of what artery? The internal pudendal
artery "<img src=""7875.png"">" Gastrointestinal anatomy pectinate-
(dentate)-line
A 52-year-old man has rectal bleeding and a painful mass that flares up during
defecation. Which nerve is involved? Inferior rectal branch of the pudendal
nerve (This is most likely an external hemorrhoid, which receives somatic
innervation.) "<img src=""7875.png"">" Gastrointestinal anatomy pectinate-
(dentate)-line
A pt has a tear in the anal mucosa below the pectinate line. What is this called?
Where is it most likely found on the anus? Anal fissure; below Pectinate line,
Pain on Pooping, blood on Paper, located Posteriorly where it is Poorly Perfused)
"<img src=""7875.png"">" Gastrointestinal anatomy pectinate-(dentate)-
line
A pt with cirrhosis has internal hemorrhoids. Describe the pathway for venous
drainage to the portal system, which is likely impaired. Superior rectal vein to
inferior mesenteric vein to portal system "<img src=""7875.png"">"
What are some risk factors for developing anal fissures? Low-fiber diets and
constipation "<img src=""7875.png"">" Gastrointestinal anatomy pectinate-
(dentate)-line
In liver anatomy, which part of hepatocytes face the bile canaliculi? The
sinusoids? The apical surfaces of hepatocytes face the bile canaliculi;
basolateral surfaces face the sinusoids "<img src=""7876.png"">"
Gastrointestinal anatomy liver-tissue-architecture
In a pt with viral hepatitis, what zone of the liver is first affected? Zone
I, the periportal zone "<img src=""7876.png"">" Gastrointestinal anatomy
liver-tissue-architecture
A teenaged cocaine addict presents with elevated liver enzymes. What zone of the
liver is cocaine most likely affecting? Zone I, the periportal zone "<img
src=""7876.png"">" Gastrointestinal anatomy liver-tissue-architecture
A man from South Africa has worsening fever, hematemesis, and jaundice and
unfortunately dies. A postmortem liver biopsy would reveal what? Hepatic necrosis
in the intermediate zone II (Pt had yellow fever.) "<img src=""7876.png"">"
A pt experiences septic shock and becomes hypotensive. Which zone of the liver is
first to suffer necrosis? Zone III, the pericentral vein zone, or centrilobular
zone "<img src=""7876.png"">" Gastrointestinal anatomy liver-tissue-
architecture
Drugs metabolized by the P-450 system are most likely to be found in which zone of
the liver? Zone III, the pericentral vein zone, or centrilobular zone "<img
src=""7876.png"">" Gastrointestinal anatomy liver-tissue-architecture
Which zone of the liver is most sensitive to metabolic toxins? Zone III, the
pericentral vein zone, or centrilobular zone "<img src=""7876.png"">"
A pt with chronic alcoholism presents with elevated liver enzyme levels. The zone
of damage is located closest to which blood vessel? The central vein (zone III)
"<img src=""7876.png"">" Gastrointestinal anatomy liver-tissue-
architecture
Lymph drains from the liver via which histologic structure?The space of Disse
"<img src=""7876.png"">" Gastrointestinal anatomy liver-tissue-
architecture
What do hepatic stellate cells store? What do they produce? Where are they found?
They store vitamin A; they release extracellular matrix; they are found in
the space of Disse "<img src=""7876.png"">" Gastrointestinal anatomy
liver-tissue-architecture
A pt has RUQ abdominal pain and a stone obstructing the common bile duct (CBD).
Which two biliary ducts drain directly into the CBD? The cystic duct and common
hepatic duct "<img src=""7877.png"">" Gastrointestinal anatomy biliary-
structures
A pt has colicky abdominal pain with elevated amylase, lipase, and alkaline
phosphatase. What structure has become involved? Ampulla of Vater (The pt has
a gallstone that is now obstructing both biliary and pancreatic ducts.) "<img
src=""7877.png"">" Gastrointestinal anatomy biliary-structures
Bile passes through this sphincter to enter the duodenum. The sphincter of Oddi
"<img src=""7877.png"">" Gastrointestinal anatomy biliary-structures
An elderly man presents with jaundice and weight loss. Where might a pancreatic
tumor be located? Head of the pancreas (A tumor in this area, usually ductal
adenocarcinoma, can present with jaundice, if it obstructs the common bile duct.)
"<img src=""7877.png"">" Gastrointestinal anatomy biliary-structures
Which structure forms the superior border of the femoral triangle? The inguinal
ligament "<img src=""7878.png"">" Gastrointestinal anatomy femoral-region
Which structure forms the lateral border of the femoral triangle? The
sartorius muscle "<img src=""7878.png"">" Gastrointestinal anatomy femoral-
region
Which structure forms the medial border of the femoral triangle? The adductor
longus muscle "<img src=""7878.png"">" Gastrointestinal anatomy femoral-
region
Name, from lateral to medial, the organization of vasculature, lymphatics, and
nerves in the femoral region. Nerve, Artery, Vein, and Lymphatics (Go from lateral
to medial to find your NAVeL.) "<img src=""7878.png"">" Gastrointestinal
anatomy femoral-region
Which of the following is most medial: femoral artery, femoral vein, or femoral
nerve? Femoral vein (Venous near the penis, in the sense that they are both
medial) "<img src=""7878.png"">" Gastrointestinal anatomy femoral-region
What three main structures are contained within the femoral sheath? Femoral
artery, femoral vein, and femoral canal "<img src=""7878.png"">"
Gastrointestinal anatomy femoral-region
What femoral triangle structure lies outside of the femoral sheath? The femoral
nerve "<img src=""7878.png"">" Gastrointestinal anatomy femoral-region
A man is stabbed. The femoral triangle is punctured, but the femoral sheath is
intact. What part of the femoral triangle may be damaged? The femoral nerve "<img
src=""7878.png"">" Gastrointestinal anatomy femoral-region
A pt has an indirect hernia. Through which structure does this hernia protrude?
The internal inguinal ring "<img src=""7879.png"">" Gastrointestinal
anatomy inguinal-canal
Name the layers that comprise the spermatic cord, from the most superficial to the
deepest layer. External spermatic fascia, cremasteric muscle and fascia,
internal spermatic fascia "<img src=""7879.png"">" Gastrointestinal anatomy
inguinal-canal
What are the layers that comprise the spermatic cord (from the innermost layer to
the most superficial layer)? ICE tie: Int spermatic fascia (transversalis fascia),
Cremasteric muscle & fascia (int oblique), Ext spermatic fascia (ext oblique)
"<img src=""7879.png"">" Gastrointestinal anatomy inguinal-canal
From the most superficial layer to the deepest, what are the three muscles that
cover the internal (deep) inguinal ring? External oblique, internal oblique, and
transversus abdominis "<img src=""7879.png"">" Gastrointestinal anatomy
inguinal-canal
A male pt has a direct inguinal hernia. Through what structure does the hernia
protrude? Abdominal wall "<img src=""7879.png"">" Gastrointestinal anatomy
inguinal-canal
From which muscle layer does the internal spermatic fascia derive?
Transversalis fascia "<img src=""7879.png"">" Gastrointestinal anatomy
inguinal-canal
A pt has a damaged cremasteric muscle in the spermatic cord. From which muscle
layer does the cremasteric muscle originate? Internal oblique "<img
src=""7879.png"">" Gastrointestinal anatomy inguinal-canal
A surgeon cuts the external spermatic fascia of the spermatic cord. From which
muscle layer does this layer originate? External oblique "<img src=""7879.png"">"
Gastrointestinal anatomy inguinal-canal
A male pt has a direct inguinal hernia. Between which two structures do you
typically find a direct inguinal hernia? The inferior epigastric vessels and the
rectus abdominis "<img src=""7879.png"">" Gastrointestinal anatomy inguinal-
canal
A pt is found to have an incarcerated bowel due to a hernia. What is the pt's most
likely gender? Female, as this is a femoral hernia (most likely cause of bowel
incarceration), and femoral hernia is more common in females "<img
src=""7880.png"">" Gastrointestinal anatomy hernias
An elderly man presents with a hernia through the inguinal triangle. How many
layers of spermatic fascia cover this hernia? One: only the external spermatic
fascia covers a direct inguinal hernia "<img src=""7880.png"">"
Gastrointestinal anatomy hernias
How many layers of the spermatic fascia cover the sac of an indirect hernia? A
direct hernia? Indirect hernia = all three layers; direct hernia = one, only the
external spermatic fascia "<img src=""7880.png"">" Gastrointestinal anatomy
hernias
Relative to the pubic tubercle, where is a femoral hernia typically located?
Lateral to the pubic tubercle (through the femoral canal) "<img
Which type of hiatal hernia is associated with gastroesophageal reflux disease
refractory to medical treatment? Sliding hernias (hourglass stomach) result in
a displaced gastroesophageal junction, increasing risk for gastroesophageal reflux
disease "<img src=""7880.png"">" Gastrointestinal anatomy hernias
What is a hernia? Protrusion of peritoneum through an opening, usually at a site of
weakness "<img src=""7880.png"">" Gastrointestinal anatomy hernias
A pt presents with a hernia. Name possible risks. Incarceration and
strangulation "<img src=""7880.png"">" Gastrointestinal anatomy hernias
A pt is diagnosed with a diaphragmatic hernia. Which side of the chest is expected
to be affected and why? The left side, as the liver protects the right side of the
chest "<img src=""7880.png"">" Gastrointestinal anatomy hernias
How do sliding hernias and paraesophageal hernias each affect the gastroesophageal
junction? "Sliding hernias displace the junction upward (""hourglass stomach"");
paraesophageal hernias have normal junction (Fundus pushes into thorax.)" "<img
A pt complains of heartburn. Further investigation reveals that his stomach
herniated through the esophageal hiatus. Diagnosis? Hiatal hernia, the most
common form of diaphragmatic hernia "<img src=""7880.png"">" Gastrointestinal
anatomy hernias
What structures are displaced in a paraesophageal hernia? The fundus of the
stomach is displaced into the thorax, but the gastroesophageal junction is
unaffected "<img src=""7880.png"">" Gastrointestinal anatomy hernias
You examine a boy with an indirect inguinal hernia. Given the affected
developmental structure, what complication is possible? Hydrocele (Indirect
inguinal hernia is caused by incomplete closure of the processus vaginalis.) "<img
Through which structure do both direct and indirect hernias pass? The external
(superficial) inguinal ring "<img src=""7880.png"">" Gastrointestinal anatomy
hernias
What structure is a useful landmark for differentiating direct inguinal hernias
from indirect inguinal hernias? Inferior epigastric artery: Medial to inferior
epigastric = Direct, Lateral Inferior epigastric = Indirect (MDs don't LIe.) "<img
If an elderly man presents to your clinic with an inguinal hernia, what type of
hernia is most likely observed? Direct inguinal hernia "<img src=""7880.png"">"
Gastrointestinal anatomy hernias
An elderly man has an inguinal hernia. Name the structures through which the hernia
travels. A direct inguinal hernia goes through the Hesselbach triangle,
abdominal wall medial to inferior epigastric artery, external inguinal ring "<img
The G cells produce which hormone? Where are these cells found? Gastrin; in the
antrum of the stomach and duodenum "<img src=""7881.png"">" Gastrointestinal
gastrointestinal-regulatory-substances physiology
What functions would be impaired in a gastrointestinal tract without G cells?
Acid secretion, growth of the gastric mucosa, gastric motility "<img
src=""7881.png"">" Gastrointestinal gastrointestinal-regulatory-substances
physiology
Name at least two stimuli for the release of gastrin. Distention, amino acids,
vagal stimulation through GRP, peptides, alkalinization "<img src=""7881.png"">"
Gastrointestinal gastrointestinal-regulatory-substances physiology
What serves as negative feedback for gastrin release? Acid secretion (a pH <1.5
will inhibit gastrin secretion) "<img src=""7881.png"">" Gastrointestinal
A pt with PUD refractory to medical treatment has multiple gastric ulcers. Gastrin
level is elevated. Diagnosis? Zollinger-Ellison syndrome due to ectopic production
of gastrin "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
regulatory-substances physiology
A pt receiving long-term PPI therapy might have increased levels of which gastric
hormone due to lack of negative feedback? Gastrin "<img src=""7881.png"">"
A pt has excess gastric acid, increased gallbladder contraction, and excess insulin
and glucagon release. What hormone does he lack? Somatostatin "<img
physiology
The overarching inhibitory hormone of the gastrointestinal system is made by which
cells? Where are these cells found? Somatostatin is made by D cells found in
pancreatic islets and GI mucosa "<img src=""7881.png"">" Gastrointestinal
A pt is given somatostatin. How does this affect pepsinogen secretion? Decreases it
"<img src=""7881.png"">" Gastrointestinal gastrointestinal-regulatory-
substances physiology
A pt is given somatostatin. How does this affect gastric acid secretion?
Decreases it "<img src=""7881.png"">" Gastrointestinal
A pt is given somatostatin. How does this affect pancreatic fluid secretion?
Decreases it "<img src=""7881.png"">" Gastrointestinal
A pt is given somatostatin. How does this affect fluid secretion in the small
intestine? Decreases it "<img src=""7881.png"">" Gastrointestinal
What effect does somatostatin have on the gallbladder? It decreases gallbladder
contraction "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
The presence of what substance in the gut lumen causes increases in somatostatin
release? Acid "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
What inhibits somatostatin release? Vagal stimulation "<img src=""7881.png"">"
A man is diagnosed with acromegaly. He is treated with a somatostatin analog, which
can also be used to treat what other illnesses? Octreotide, which is used for
acromegaly, can also be used to treat carcinoid syndrome and variceal bleeding
A man does not produce a hormone that increases gallbladder contraction. He is
status post small bowel resection. What happened? Due to resection of the
duodenum and jejunum, he has no I cells, which are responsible for synthesizing
cholecystokinin "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
What are the actions of cholecystokinin? Stimulation of gallbladder contraction,
pancreatic secretion, and sphincter of Oddi relaxation; slowing of gastric emptying
The presence of which substances causes an increase in I cell secretion of
cholecystokinin? Fatty acids and amino acids "<img src=""7881.png"">"
In a pt with cholelithiasis, pain worsens after the ingestion of what types of
foods? Fatty foods (from stimulation of cholecystokinin release, which causes
gallbladder contraction) "<img src=""7881.png"">" Gastrointestinal
What does CCK act on that results in pancreatic secretion? The neuronal muscarinic
pathway "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
A pt has a genetic defect in her neural muscarinic pathways. Will her pancreatic
activity be affected? Yes, as cholecystokinin uses those pathways to stimulate
pancreatic secretions "<img src=""7881.png"">" Gastrointestinal
Secretin is produced by which cells? What stimulates this hormone's release? S
cells of the duodenum; acids and fatty acids "<img src=""7881.png"">"
What are the actions of secretin? Increases both pancreatic bicarbonate secretion
and bile acid secretion; decreases gastric acid secretion "<img src=""7881.png"">"
A pt has S cell dysfunction. What kinds of substances is he unable to digest well
in his duodenum? Why? Fatty acids; without secretin, the pt cannot alkalinize
duodenal gastric acid, and pancreatic enzymes will not function properly "<img
physiology
Secretin acts to increase pancreatic bicarbonate secretion. What is the function of
bicarbonate? Where does it work? Bicarbonate neutralizes gastric acid so that
enzymes from the pancreas can function; it works in the duodenum "<img
physiology
What is the endocrine regulatory effect of glucose-dependent insulinotropic
peptide? Increases release of insulin "<img src=""7881.png"">"
A pt who is unable to produce secretin would have difficulty with the activity of
enzymes from which organ? The pancreas (Its enzymes would be denatured and
nonfunctional in the acidic environment created by gastric acid.) "<img
physiology
Glucose-dependent insulinotropic peptide is made by which cells? Where are these
cells found? What is another name for this hormone? It is made by K cells of the
duodenum and jejunum; it is also known as gastric inhibitory peptide (GIP) "<img
physiology
What is the exocrine regulatory effect of glucose-dependent insulinotropic peptide?
Decreases secretion of gastric acid "<img src=""7881.png"">"
A pt eats a meal with a large amount of fatty acids, amino acids, and glucose. What
happens to activity levels of K cells? They increase. (All of these stimulate
glucose-dependent insulinotropic peptide release.) "<img src=""7881.png"">"
Why is an oral glucose load used more rapidly by the body than an equivalent load
that is given intravenously? Oral (but not intravenous) glucose stimulates
glucose-dependent insulinotropic peptide, which stimulates insulin release "<img
physiology
What is the function of motilin? Production of migrating motor complexes (MMCs)
in the small intestine to promote peristalsis "<img src=""7881.png"">"
What hormone is produced by the small intestine, increases during fasting, and is
associated with intestinal peristalsis? Motilin "<img src=""7881.png"">"
A man takes erythromycin for a bacterial infection. He develops diarrhea not due to
gut flora depletion. Are his MMCs to blame? Yes. Erythromycin is a potent
stimulator of motilin receptors, which increase intestinal peristalsis, likely
causing the man's diarrhea "<img src=""7881.png"">" Gastrointestinal
Where is vasoactive intestinal polypeptide (VIP) secreted within the GI tract?
Parasympathetic ganglia in sphincters, gallbladder, and small intestine
What effect does vasoactive intestinal peptide (VIP) have on secretion of water and
electrolytes in the intestines? Increases their secretion "<img
physiology
What effect does vasoactive intestinal peptide (VIP) have on smooth muscle and
sphincters in the intestines? Relaxation of these structures "<img
physiology
Which stimuli increase the secretion of vasoactive intestinal peptide (VIP)?
Distention and vagal stimulation "<img src=""7881.png"">"
Which stimuli decrease the secretion of vasoactive intestinal peptide (VIP)?
Adrenergic input "<img src=""7881.png"">" Gastrointestinal
A pt presents with watery diarrhea, hypokalemia, and achlorhydria. What is the most
likely tumor causing this syndrome? VIPoma, a non-, non- islet cell pancreatic
tumor that releases vasoactive intestinal peptide "<img src=""7881.png"">"
A pt has profuse watery diarrhea. CT shows a pancreatic mass; labs show hypokalemia
and achlorhydria. Diagnosis? This is a VIPoma causing WDHA syndrome (Watery
Diarrhea, Hypokalemia, and Achlorhydria) "<img src=""7881.png"">"
Which molecule causes an increase in smooth muscle relaxation in the gut,
particularly in the lower esophageal sphincter? Nitric oxide "<img
physiology
A man with dysphagia has uncoordinated esophageal peristalsis and increased lower
esophageal sphincter tone. What is the pathophysiology? Achalasia causing
increased lower esophageal sphincter tone secondary to decreased nitric oxide
secretion "<img src=""7881.png"">" Gastrointestinal gastrointestinal-
This hormone is released in the fasting state and increases one's appetite.
Consumption of food decreases its release. Where is it produced? This is ghrelin,
released from the stomach "<img src=""7881.png"">" Gastrointestinal
A pt with Prader-Willi syndrome will have an increase in this hormone, which
increases his appetite. Ghrelin "<img src=""7881.png"">" Gastrointestinal
A pt is status post gastric bypass surgery. He has no desire to eat and has lost
weight since. What hormone was affected? Ghrelin, which is produced in the stomach
A pt is diagnosed with anemia. Which vitamin is he deficient in? B12; destruction
of parietal cells leads to decreased intrinsic factor, which is needed for its
uptake in the terminal ileum "<img src=""7882.png"">" Gastrointestinal
gastrointestinal-secretory-products physiology
A pt has vitamin B12 deficiency. What part of the GI system could be damaged?
Parietal cells of the stomach (source of intrinsic factor) or terminal ileum
(where B12 is absorbed with intrinsic factor) "<img src=""7882.png"">"
Gastrointestinal gastrointestinal-secretory-products physiology
How does autoimmune destruction of the stomach's parietal cells manifest? As
chronic gastritis and pernicious anemia "<img src=""7882.png"">"
Increased levels of which substances cause parietal cells to release gastric acid?
Acetylcholine, histamine, gastrin "<img src=""7882.png"">"
Decreased levels of which substances cause parietal cells to secrete gastric acid?
Somatostatin, GIP, prostaglandin, secretin "<img src=""7882.png"">"
Describe how pepsin is activated. In the presence of acid, the proenzyme
pepsinogen autocatalyzes its cleavage to the active pepsin "<img src=""7882.png"">"
What is the primary role of pepsin? What cells secrete it, and where are these
cells found? Functions in protein digestion; it is secreted by chief cells in
the stomach "<img src=""7882.png"">" Gastrointestinal gastrointestinal-
secretory-products physiology
High levels of secretin increase the secretion of this molecule, whose main purpose
is to neutralize acid. Bicarbonate "<img src=""7882.png"">" Gastrointestinal
Where are bicarbonate-secreting mucosal cells located? What about bicarbonate-
secreting Brunner glands? In the salivary glands, stomach, duodenum, and
pancreas; in the duodenum "<img src=""7882.png"">" Gastrointestinal
Where is bicarbonate usually trapped in the GI system? In the mucus that covers
gastric epithelium "<img src=""7882.png"">" Gastrointestinal
A pt has vitamin B12 deficiency. What part of the GI system could be damaged,
affecting vitamin B12 levels? Parietal cells of the stomach or the terminal ileum
(The latter is where vitamin B12 is absorbed as a complex with intrinsic factor.)
"<img src=""7882.png"">" Gastrointestinal gastrointestinal-secretory-
products physiology
Decreased levels of which hormones will cause parietal cells to secrete gastric
acid? Somatostatin, GIP, prostaglandin, secretin "<img src=""7882.png"">"
HCl and intrinsic factor are released by which cells? In what part of the stomach
are these cells located? HCl and intrinsic factor are released by parietal
cells; the body of the stomach "<img src=""7883.png"">" Gastrointestinal
locations-of-gastrointestinal-secretory-cells physiology
Which cells produce pepsinogen? In what part of the stomach are these cells
located? Chief cells release pepsinogen; the body of the stomach "<img
src=""7883.png"">" Gastrointestinal locations-of-gastrointestinal-secretory-
cells physiology
Gastrin stimulates the production of which two substances? Histamine (which leads
to acid secretion) and intrinsic factor "<img src=""7883.png"">"
Gastrointestinal locations-of-gastrointestinal-secretory-cells physiology
Name five substances that are secreted directly into the lumen of the stomach
Mucus, somatostatin, pepsinogen, intrinsic factor, and HCl "<img
src=""7883.png"">" Gastrointestinal locations-of-gastrointestinal-secretory-
cells physiology
Does gastrin stimulate the basal or apical surface of the parietal cells? Basal
surface (It is secreted into circulation to stimulate enterochromaffin-like and
parietal cells.) "<img src=""7883.png"">" Gastrointestinal locations-of-
gastrointestinal-secretory-cells physiology
On which cells does gastrin act to increase acid secretion through histamine
release? Enterochromaffin-like (ECL) cells "<img src=""7883.png"">"
Which cells release somatostatin? From which part of the stomach? D cells
release somatostatin; from the antrum of the stomach "<img src=""7883.png"">"
Name three types of secretory cells found in the duodenum and their associated
products. I cells: cholecystokinin; K cells: glucose-dependent insulinotropic
peptide (GIP); S cells: secretin "<img src=""7883.png"">" Gastrointestinal
locations-of-gastrointestinal-secretory-cells physiology
Are pancreatic secretions hypotonic, isotonic, or hypertonic? Isotonic "<img
src=""7884.png"">" Gastrointestinal pancreatic-secretions physiology
For the pancreas, what is affected when there is low flow of secretions? When there
is high flow of secretions? High levels of Cl result when there is low flow of
secretion; high levels of HCO3 result when there is high flow "<img
A pt with decreased -amylase may have impaired digestion of what type of food
material? Starch "<img src=""7884.png"">" Gastrointestinal pancreatic-
secretions physiology
A man eats a large amount of popcorn at a movie. What critical enzyme is released
in its active form to digest this? -Amylase "<img src=""7884.png"">"
Gastrointestinal pancreatic-secretions physiology
Are -amylases secreted in active or inactive forms? Active forms "<img
Lipases function in what digestive process? Fat digestion "<img
Proteases help digest protein. Name the major proteases secreted by the pancreas.
Trypsin, chymotrypsin, elastase, and carboxypeptidase"<img src=""7884.png"">"
Gastrointestinal pancreatic-secretions physiology
Are proteases secreted in active or inactive forms? Inactive forms (called
proenzymes or zymogens) "<img src=""7884.png"">" Gastrointestinal pancreatic-
secretions physiology
Which pancreatic enzyme converts trypsinogen to trypsin?
Enterokinase/enteropeptidase (on the duodenal and jejunal brush border)
"<img src=""7884.png"">" Gastrointestinal pancreatic-secretions
physiology
After being converted to its active form, what does trypsin do? It activates other
proenzymes as well as more trypsin molecules (positive feedback) "<img
Which of these sugars is/are not absorbed by enterocytes: glucose, galactose,
fructose, sucrose? Sucrose, a disaccharide (Only monosaccharides are absorbed
by enterocytes.) "<img src=""7885.png"">" Gastrointestinal carbohydrate-
absorption physiology
Glucose and galactose are taken up by this transporter, which is dependent on this
ion. Sodium-glucose linked transporter (SGLT1), dependent on sodium ion "<img
src=""7885.png"">" Gastrointestinal carbohydrate-absorption physiology
Describe how fructose is absorbed. By facilitated diffusion by GLUT-5 "<img
src=""7885.png"">" Gastrointestinal carbohydrate-absorption physiology
All monosaccharides are transported from the enterocytes to the blood by what
transporter? Glucose transporter 2 (GLUT-2) "<img src=""7885.png"">"
Gastrointestinal carbohydrate-absorption physiology
A pt with carbohydrate malabsorption might undergo which test to distinguish GI
mucosal damage from other causes of malabsorption? D-xylose absorption test
"<img src=""7885.png"">" Gastrointestinal carbohydrate-absorption
physiology
Iron is absorbed as this ionized form mainly in this part of the small intestine.
Fe2+ is absorbed in the duodenum "<img src=""7886.png"">"
Gastrointestinal physiology vitamin/mineral-absorption
In which part of the GI is folate absorbed? Small bowel "<img src=""7886.png"">"
A pt has resection of the ileum as part of surgery for Crohn disease. For which
vitamin deficiency might he be at risk? Vitamin B12 deficiency (B12 is absorbed
with bile salts in the ileum while bound to intrinsic factor.) "<img
src=""7886.png"">" Gastrointestinal physiology vitamin/mineral-absorption
A pt has severe Crohn disease requiring an extensive colectomy. For which
vitamin/mineral deficiencies is he at risk? Iron, Folate, and vitamin B12
(absorbed in the small bowel; think Iron Fist, Bro) "<img src=""7886.png"">"
Peyer patches are made of which type of tissue: mucosal, lymphoid, or muscularis?
Lymphoid (Peyer patches are made of unencapsulated lymphoid tissue.) "<img
src=""7887.png"">" Gastrointestinal peyer-patches physiology
What is the main action of M cells? M cells take up antigens from the gut lumen for
presentation to B cells and eventual creation of immunoglobulin A (IgA) antibodies
"<img src=""7887.png"">" Gastrointestinal peyer-patches physiology
After stimulated B cells from Peyer patches have differentiated into plasma cells,
what do they secrete? Immunoglobulin A (IgA, the Intragut Antibody) "<img
After being secreted, immunoglobulin A (IgA) functions to bind what? Intraluminal
antigens (think IgA, the Intragut Antibody) "<img src=""7887.png"">"
Gastrointestinal peyer-patches physiology
What must IgA receive before it can be transported through the epithelium and into
the gut to deal with antigens? Protective secretory component "<img
Which amino acids must bind to bile acids to make them water soluble? Glycine or
taurine "<img src=""7888.png"">" Gastrointestinal bile physiology
What are the six components of bile? Bile salts, phospholipids, cholesterol,
bilirubin, water, and ions "<img src=""7888.png"">" Gastrointestinal bile
physiology
A pt has defective cholesterol -hydroxylase activity. Does this affect his ability
to absorb vitamins in any way? Yes, as this impairs the rate-limiting step of
bile synthesis (One of bile's functions is to assist with vitamin digestion and
absorption.) "<img src=""7888.png"">" Gastrointestinal bile physiology
In a pt who is unable to produce bile, what physiologic functions would be
impaired? Excretion of cholesterol, digestion and uptake of lipids and fat-
soluble vitamins, and antimicrobial activity "<img src=""7888.png"">"
Gastrointestinal bile physiology
What is the only means of cholesterol excretion from the body? Via bile "<img
src=""7888.png"">" Gastrointestinal bile physiology
In an experiment, bacteria within a Petri dish exposed to gallbladder secretions
are noted to perish quickly. What is going on? Bile, which has antimicrobial
activity via bacterial membrane disruption, is present in the gallbladder
secretions "<img src=""7888.png"">" Gastrointestinal bile physiology
Describe how heme becomes bilirubin. Heme oxygenase metabolizes heme to
biliverdin, which is reduced to bilirubin "<img src=""7889.png"">"
Gastrointestinal bilirubin physiology
How is unconjugated bilirubin removed from blood? It is conjugated with
glucuronate in the liver and leaves in bile "<img src=""7889.png"">"
A pt has hemolytic anemia. What would liver function tests show? Unconjugated
hyperbilirubinemia (Bilirubin is a breakdown product of heme.) "<img
src=""7889.png"">" Gastrointestinal bilirubin physiology
What is the essential structural difference between direct and indirect bilirubin?
Direct bilirubin is conjugated with glucuronic acid and is water soluble;
indirect bilirubin is not conjugated and is water insoluble"<img src=""7889.png"">"
How is bilirubin excreted from the body? Bilirubin is excreted in bile (It is
excreted in urine as urobilin and in stool as stercobilin.)"<img src=""7889.png"">"
What type of bilirubin is water soluble: direct or indirect? What type is water
insoluble? Direct bilirubin is water soluble; indirect bilirubin is water
insoluble "<img src=""7889.png"">" Gastrointestinal bilirubin physiology
As bilirubin travels through the circulation, what is it bound to? Albumin, as
unconjugated bilirubin-albumin complex "<img src=""7889.png"">"
A pt has impaired bile acid conjugation. What would liver function tests show?
Unconjugated (indirect) hyperbilirubinemia "<img src=""7889.png"">"
What gives urine its yellow color? Urobilin, one of the forms in which bile is
excreted from the body "<img src=""7889.png"">" Gastrointestinal bilirubin
physiology
If exposed to conjugated bilirubin, colonic bacteria will produce what?
Urobilinogen "<img src=""7889.png"">" Gastrointestinal bilirubin
physiology
A pt taking antibiotics has his gut flora wiped out. His urine is noted to be paler
than usual. Why? Bilirubin conversion into urobilinogen is impaired, and
conversion into urobilin, which gives urine its yellow color, is impaired "<img
How much of urobilinogen is excreted as stercobilin in feces? 80% as
stercobilin, giving stool its brown color "<img src=""7889.png"">"
20% of urobilinogen goes to the kidneys and liver. How much enters the
enterohepatic circulation? How much is excreted renally? 90% enters the
enterohepatic circulation; 10% is excreted as urobilin (which gives urine its
yellow color) through the kidneys "<img src=""7889.png"">" Gastrointestinal
bilirubin physiology
A pt with an obstruction in stercobilin deposition will have what characteristic
change in excretion? Pale stools (obstruction inhibits stercobilin's ability to
be deposited in the gastrointestinal lumen, leading to pale stools) "<img
In what form is urobilinogen excreted in feces? In a healthy pt, what color is the
stool? It is excreted in feces as stercobilin, which causes the brown color of
normal stool "<img src=""7889.png"">" Gastrointestinal bilirubin
physiology
In an experiment, tagged urobilinogen in the gut can be expected to be later found
in which organ? The liver, via enterohepatic circulation "<img src=""7889.png"">"
Which enzyme catalyzes bilirubin conjugation? UDP-glucuronosyltransferase "<img
A pt has a benign tumor made of heterotopic salivary gland tissue trapped in a
lymph node, surrounded by lymphatic tissue. Diagnosis? Warthin tumor (papillary
cystadenoma lymphomatosum), which is a benign cystic tumor with germinal centers
"<img src=""7890.png"">" Gastrointestinal Pathology salivary-gland-
tumors
A pt had a salivary gland tumor removed. Which gland was likely involved?
Parotid gland "<img src=""7890.png"">" Gastrointestinal Pathology
salivary-gland-tumors
Pleomorphic adenomas typically consist of what two types of connective tissue?
Chondromyxoid stroma and epithelium "<img src=""7890.png"">"
Gastrointestinal Pathology salivary-gland-tumors
A pt had a salivary gland tumor rupture intraoperatively. The tumor recurs a few
weeks later. Type of salivary gland tumor? Pleomorphic adenoma "<img
src=""7890.png"">" Gastrointestinal Pathology salivary-gland-tumors
A pt presents with a painless, slow-growing mass and is found to have the most
common type of malignant salivary tumor. What is it? Mucoepidermoid carcinoma
tumors
A pt has a painless mass in the parotid area. Histologic exam of the lesion reveals
mucinous and squamous components. What do you suspect? Mucoepidermoid carcinoma
tumors
A pt has a benign cystic tumor in the salivary gland, and it has germinal centers.
Diagnosis? Warthin tumor (papillary cystadenoma lymphomatosum) "<img
src=""7890.png"">" Gastrointestinal Pathology salivary-gland-tumors
What is another name for papillary cystadenoma lymphomatosum? Warthin tumor
tumors
What is the most common presenting symptom of achalasia? Progressive dysphagia to
both solids and liquids (vs obstruction, which presents as dysphagia to solids
only) "<img src=""7891.png"">" Gastrointestinal Pathology achalasia
Achalasia results from the failure of what process to occur? Relaxation of the
lower esophageal sphincter "<img src=""7891.png"">" Gastrointestinal
Pathology achalasia
In a man with high lower esophageal sphincter resting pressure/uncoordinated
peristalsis, you see innervation loss from which plexus? The myenteric (Auerbach)
plexus, which innervates the LES "<img src=""7891.png"">" Gastrointestinal
Pathology achalasia
After you diagnose a man with achalasia, you should advise him that he has
increased risk for what malignancy? Esophageal squamous cell carcinoma "<img
src=""7891.png"">" Gastrointestinal Pathology achalasia
A man is diagnosed with new achalasia. He recently traveled to South America. What
parasitic disease did he likely contract while there? Chagas disease (associated
with secondary achalasia) from T cruzi infection "<img src=""7891.png"">"
Gastrointestinal Pathology achalasia
What is the etymology of the word achalasia? A = absence of and chalasia =
relaxation "<img src=""7891.png"">" Gastrointestinal Pathology achalasia
Name secondary causes of achalasia. Chagas disease from T cruzi infection and
extraesophageal malignancies that cause mass effect or are paraneoplastic "<img
src=""7891.png"">" Gastrointestinal Pathology achalasia
A pt has a food allergy that causes dysphagia and impaction of food. Does it
respond to GERD therapy? No, as this is eosinophilic esophagitis, which does
not respond to GERD therapies "<img src=""7892.png"">" Gastrointestinal
Pathology esophageal-pathologies
A pt has numerous allergies and GERD unresponsive to therapy. What will esophageal
biopsy likely show? Eosinophilic infiltration on biopsy; rings and linear
furrows on endoscopy "<img src=""7892.png"">" Gastrointestinal Pathology
esophageal-pathologies
A pt is diagnosed with esophageal strictures. What is this associated with?
Ingestion of caustic compounds and acid reflux "<img src=""7892.png"">"
Gastrointestinal Pathology esophageal-pathologies
Esophagitis is commonly found along with what conditions? Reflux, infection,
chemical ingestion, medications "<img src=""7892.png"">" Gastrointestinal
A pt is diagnosed with esophagitis. Name three infectious agents that are
associated with esophagitis. Candida, HSV-1, and CMV "<img src=""7892.png"">"
A pt is diagnosed with esophagitis. White pseudomembranes are found on mucosa.
Diagnosis? Candida esophagitis "<img src=""7892.png"">" Gastrointestinal
In pts with esophagitis, how do you differentiate ulcers caused by HSV-1 from those
caused by CMV? HSV-1 causes punched-out ulcers; CMV causes linear ulcers "<img
src=""7892.png"">" Gastrointestinal Pathology esophageal-pathologies
A pt complains of cough, heartburn, difficulty swallowing, and regurgitation of
food. Diagnosis? Gastroesophageal reflux disease "<img src=""7892.png"">"
A pt with asthma and chronic cough has recent complaints of hoarseness. What may
have caused this? Laryngopharyngeal reflux "<img src=""7892.png"">"
A pt has GERD. What would be an expected finding with manometry? Transient
decreases in tone in the lower esophageal sphincter "<img src=""7892.png"">"
A 45-year-old known alcoholic comes to the ED with painful vomiting. She has blood
in her vomitus. What is the cause of her hematemesis? Mallory-Weiss tears, which
often result from vomiting associated with alcoholism and bulimia "<img
Plummer-Vinson syndrome has what symptom triad? "Dysphagia, Iron deficiency anemia,
Esophageal webs (""Plumbers"" DIE.)" "<img src=""7892.png"">"
A pt has dysphagia, iron deficiency anemia, and esophageal webs. He is at increased
risk for what type of cancer? Squamous cell carcinoma of the esophagus "<img
What is the underlying pathophysiology of dysphagia associated with CREST syndrome?
Esophageal dysmotility and low pressure at the lower esophageal sphincter
"<img src=""7892.png"">" Gastrointestinal Pathology esophageal-
pathologies
A man has Barrett esophagus. Workup shows esophageal smooth muscle atrophy, low LES
pressure, and reflux. Diagnosis? Sclerodermal esophageal dysmotility (part of
CREST syndrome) "<img src=""7892.png"">" Gastrointestinal Pathology
esophageal-pathologies
A pt with numerous allergies and GERD unresponsive to therapy has an esophageal
biopsy. What is it likely to show? Eosinophilic infiltration (This is eosinophilic
esophagitis, common in pts with atopy.) "<img src=""7892.png"">"
Is Barrett esophagus an example of dysplasia, hyperplasia, neoplasia, or
metaplasia? Metaplasia "<img src=""7893.png"">" Gastrointestinal Pathology
barrett-esophagus
What causes Barrett esophagus? Chronic acid reflux resulting in glandular
metaplasia "<img src=""7893.png"">" Gastrointestinal Pathology barrett-
esophagus
What specific malignancy is associated with Barrett esophagus? Adenocarcinoma of
the esophagus "<img src=""7893.png"">" Gastrointestinal Pathology barrett-
esophagus
A Mexican woman with dysphagia of solids now has difficulty with liquids as well.
She also smokes. Which part of her esophagus is affected? Likely the upper two
thirds of her esophagus, as this is squamous cell carcinoma"<img src=""7894.png"">"
Gastrointestinal Pathology esophageal-cancer
Worldwide, which type of esophageal cancer is most common? Esophageal squamous cell
carcinoma "<img src=""7894.png"">" Gastrointestinal Pathology esophageal-
cancer
An alcoholic with a Zenker diverticulum has dysphagia with hot liquids. For which
type of esophageal cancer is he at high risk? Esophageal squamous cell cancer
"<img src=""7894.png"">" Gastrointestinal Pathology esophageal-cancer
A smoker presents with progressive dysphagia and weight loss in the past few
months. What is his likely diagnosis? Esophageal squamous cell cancer or
esophageal adenocarcinoma "<img src=""7894.png"">" Gastrointestinal
Pathology esophageal-cancer
A pt with esophageal strictures from consuming caustic substances is at increased
risk for what type of cancer? Squamous cell carcinoma of the esophagus "<img
src=""7894.png"">" Gastrointestinal Pathology esophageal-cancer
An obese pt with a very long history of GERD has started to have dysphagia to
liquids. What finding is likely on esophageal biopsy? Esophageal adenocarcinoma
"<img src=""7894.png"">" Gastrointestinal Pathology esophageal-cancer
A pt has esophageal dysmotility and increased LES tone. He is at increased risk for
which types of cancer? Both squamous cell carcinoma and adenocarcinoma of the
esophagus, since he has achalasia "<img src=""7894.png"">" Gastrointestinal
Pathology esophageal-cancer
A pt with a history of Barrett esophagus has dysphagia for solids and liquids and
weight loss. What is the likely diagnosis? Esophageal adenocarcinoma "<img
A pt (native of the United States) presents with esophageal cancer. Which part of
the esophagus is it most likely to affect? The lower third, as this is
esophageal Adenocarcinoma, which is more common than squamous cell esophageal
cancers in America "<img src=""7894.png"">" Gastrointestinal Pathology
esophageal-cancer
A pt with Hirschsprung disease has progressive dysphagia and other symptoms of
achalasia. For what type of cancer is he at high risk? Esophageal cancer "<img
A pt who has used NSAIDs for a long time is diagnosed with gastritis. How would you
differentiate acute and chronic gastritis? Acute is erosive; chronic is not
"<img src=""7895.png"">" Gastrointestinal Pathology gastritis
Name some causes of acute gastritis. NSAIDs, alcohol, burns, brain injury
In acute gastritis, disruption of what type of barrier occurs? Disruption of the
mucosal barrier "<img src=""7895.png"">" Gastrointestinal Pathology
gastritis
A pt with rheumatoid arthritis, compliant with his medications, has nausea and
abdominal pain. What type of gastritis are you considering?Acute gastritis (The pt
is likely taking NSAIDs daily.) "<img src=""7895.png"">" Gastrointestinal
Pathology gastritis
A pt with severe burns develops which complication of acute gastritis? Curling
ulcer (Burned by the Curling iron) "<img src=""7895.png"">" Gastrointestinal
Pathology gastritis
By which mechanism do severe burns cause acute gastritis? Curling ulcers are
caused by a decrease in plasma volume, leading to mucosal ischemia "<img
src=""7895.png"">" Gastrointestinal Pathology gastritis
A man with brain injury develops acute, raw, burning epigastric pain. He should be
treated to prevent which complication? Cushing ulcers (Always Cushion the
brain.) "<img src=""7895.png"">" Gastrointestinal Pathology gastritis
How can brain injury cause acute gastritis? Cushing ulcers are caused by
increased vagal stimulation, which increases acetylcholine and, in turn, acid
production "<img src=""7895.png"">" Gastrointestinal Pathology gastritis
Chronic gastritis carries an increased risk for what kind of gastric carcinoma(s)?
MALT lymphoma and gastric cancers "<img src=""7895.png"">"
Gastrointestinal Pathology gastritis
In a pt with chronic gastritis, mucosal inflammation leads to atrophy and
metaplasia. Which hormone would increase from the atrophy? Gastrin would increase
as a result of hypochlorhydria "<img src=""7895.png"">" Gastrointestinal
Pathology gastritis
In a pt with chronic gastritis, mucosal inflammation leads to atrophy and
metaplasia. Metaplasia increases his risk for what? Gastric cancer "<img
A pt with H pylori infection is diagnosed with gastritis. For what else is he at
increased risk? Peptic ulcer disease and MALT lymphoma "<img src=""7895.png"">"
What is the most common cause of chronic gastritis? Which part of the stomach does
it affect? H pylori; it affects the antrum of the stomach initially and spreads to
the body of the stomach "<img src=""7895.png"">" Gastrointestinal Pathology
gastritis
A pt with chronic gastritis also has anemia. Why? Which part of the stomach is
affected? He has antibodies against parietal cells and intrinsic factor, which
lead to anemia; the body and fundus of the stomach are affected "<img
A pt receiving long-term NSAID therapy complains of stomach pain and is found to be
anemic. What is the pathophysiology of his condition? NSAIDs reduce prostaglandin
E2, causing erosive gastritis, which causes occult blood loss and mild anemia
A woman w/Graves disease is anemic with a high MCV despite taking iron. She has bad
abdominal pain. Which part of her stomach is affected? Fundus/body (This is
chronic gastritis of the stomach, with pernicious anemia, associated with other
autoimmunity such as Graves disease.) "<img src=""7895.png"">"
A pt has thickened gastric lining with increased mucous cells and parietal cell
atrophy on fluoroscopy. Is this disease precancerous? Yes (This pt has
Mn#233;trier disease, which is precancerous.) "<img src=""7896.png"">"
Gastrointestinal Pathology mntrier-disease
What is the most common histologic type of stomach cancer? Adenocarcinoma; others
are lymphoma, stromal tumor, carcinoid "<img src=""7897.png"">"
Gastrointestinal Pathology gastric-cancer
A pt has dark leathery patches on the nape of his neck and in the axillae. It is
from malignancy. What might you see on his umbilicus? Sister Mary Joseph nodules
(subcutaneous periumbilical metastasis) (Pt has acanthosis nigricans, suggesting
stomach cancer.) "<img src=""7897.png"">" Gastrointestinal Pathology gastric-
cancer
A pt has experienced weight loss and early satiety and has numerous pigmented skin
lesions. Diagnosis? Gastric cancer; skin manifestations are called Leser-Trlat
sign "<img src=""7897.png"">" Gastrointestinal Pathology gastric-cancer
Where are intestinal stomach cancers most commonly located in the stomach? What do
they look like? Lesser curvature; they look like ulcers with raised sides "<img
src=""7897.png"">" Gastrointestinal Pathology gastric-cancer
Name at least three risk factors for stomach cancer. Nitrosamines (from smoked
foods), achlorhydria, chronic gastritis, smoking, H pylori infection "<img
What is meant when stomach cancer is termed linitis plastica? Diffuse gastric
cancer in which the sides of the stomach have thickened and become leathery "<img
A man has 1 month of fatigue, weight loss, and early satiety. If he has palpable
lymph nodes from metastases, where are they likely found? Left-sided
supraclavicular nodes, also called Virchow nodes (metastasis from stomach cancer)
"<img src=""7897.png"">" Gastrointestinal Pathology gastric-cancer
A 65-year-old man has a growing periumbilical mass and abdominal fullness. What
umbilical finding might be present on exam? Sister Mary Joseph nodules "<img
A woman has bilateral ovarian cancer with abundant mucus and signet ring cells.
Could this cancer in fact be a metastasis? Yes, as this could represent
metastasis from the stomach to both ovaries, known as a Krukenberg tumor "<img
Describe the appearance of a Krukenberg tumor. This metastatic gastric carcinoma
has mucin-secreting signet ring cells whose nuclei are at the periphery "<img
What is the Sister Mary Joseph nodule, and where is it located? It is a metastasis
of gastric cancer found in the subcutaneous periumbilical area "<img
Which two regions of the gastrointestinal tract are affected by peptic ulcer
disease? The stomach (gastric ulcers) and the duodenum (duodenal ulcers) "<img
src=""7898.png"">" Gastrointestinal Pathology peptic-ulcer-disease
A pt has significant weight loss and abdominal pain after eating. Endoscopy shows
ulcers. What kind of ulcers are they likely to be? Gastric ulcers, which
generally result in increased pain after meals (Gastric ulcer pain is Greater with
meals.) "<img src=""7898.png"">" Gastrointestinal Pathology peptic-ulcer-
disease
Which etiologic factor is associated with 70% of gastric ulcers? Helicobacter
pylori infection "<img src=""7898.png"">" Gastrointestinal Pathology peptic-
ulcer-disease
A pt taking NSAIDs for back pain presents with abdominal pain exacerbated by meals.
What is the most likely cause of his abdominal pain? Long-term use of NSAIDs
leading to gastric ulcers "<img src=""7898.png"">" Gastrointestinal
Pathology peptic-ulcer-disease
What is the pathophysiology of gastric ulcers? Decreased mucus production leading
to destruction of tissue by gastric acid due to decreased protection "<img
Does the pain associated with duodenal ulcers increase, decrease, or remain the
same with food? Decrease (Duodenal ulcer pain is Decreased with food.) "<img
Which type of gastrointestinal ulcer is more likely to be associated with weight
gain? Duodenal ulcer (The pain associated with duodenal ulcers decreases with
meals, thereby resulting in weight gain.) "<img src=""7898.png"">"
Gastrointestinal Pathology peptic-ulcer-disease
Pts with duodenal ulcers tend to have hypertrophy of which glands? Brunner
glands "<img src=""7898.png"">" Gastrointestinal Pathology peptic-ulcer-
disease
A pt has Zollinger-Ellison syndrome. For which type of ulcer is the pt at risk?
Duodenal ulcer (Zollinger-Ellison syndrome is associated with increased
gastric secretions, resulting in ulcer formation.) "<img src=""7898.png"">"
Gastrointestinal Pathology peptic-ulcer-disease
An elderly pt takes high-dose NSAIDs. For which type of ulcer is he at increased
risk? Gastric ulcer "<img src=""7898.png"">" Gastrointestinal Pathology
peptic-ulcer-disease
What is the pathology of duodenal ulcers? Decrease in mucosal protection or
increase in gastric acid secretion "<img src=""7898.png"">" Gastrointestinal
Which type of peptic ulcer disease puts the pt at greater risk for development of a
carcinoma? Gastric ulcer "<img src=""7898.png"">" Gastrointestinal
On endoscopy, a man with stomach pain is found to have a lesion with irregular,
raised margins. Is it more likely an ulcer or a malignancy?Malignancy (carcinoma).
Peptic ulcers have clean margins and a punched-out appearance. "<img
Which artery is most likely to hemorrhage with a ruptured gastric ulcer on the
lesser curvature of the stomach? Left gastric artery "<img src=""7899.png"">"
Gastrointestinal Pathology ulcer-complications
Which artery is most likely to hemorrhage secondary to a ruptured duodenal ulcer on
the posterior wall of the duodenum? Gastroduodenal artery "<img src=""7899.png"">"
If an ulcer hemorrhages, is it likely to occur anteriorly or posteriorly? What
about perforation? Hemorrhages are more likely to occur posteriorly;
perforations are more likely to occur anteriorly "<img src=""7899.png"">"
Where are obstructions due to peptic ulcers likely to occur? Pyloric channel
and duodenum "<img src=""7899.png"">" Gastrointestinal Pathology ulcer-
complications
Where do perforations from ulcers typically occur? The duodenum "<img
src=""7899.png"">" Gastrointestinal Pathology ulcer-complications
A pt has diarrhea, steatorrhea, weight loss, weakness, and vitamin/mineral
deficiencies. She likely has what type of illness? A malabsorption syndrome
"<img src=""7900.png"">" Gastrointestinal Pathology malabsorption-
syndromes
A pt complains of diarrhea and weight loss. If a malabsorption syndrome is
suspected, what do you screen for? Fecal fat "<img src=""7900.png"">"
Gastrointestinal Pathology malabsorption-syndromes
A child develops greasy stools and failure to thrive after the addition of wheat to
her diet. She has autoantibodies to which substance? Gluten (gliadin), suggesting
celiac disease "<img src=""7900.png"">" Gastrointestinal Pathology
malabsorption-syndromes
A pt is said to have autoimmune damage to the small bowel caused by gluten
sensitivity. Which illness is described? Celiac disease "<img src=""7900.png"">"
A child has diarrhea and a rash on the extensor surfaces that resolves with dietary
modification. It is associated with which GI pathology? Associated with celiac
disease, as this is dermatitis herpetiformis "<img src=""7900.png"">"
A pt has celiac disease. For which malignancy would the pt be at increased risk?
T-cell lymphoma "<img src=""7900.png"">" Gastrointestinal Pathology
A pt with diarrhea that occurs on a wheat-containing diet undergoes colonoscopy.
What histologic findings are expected? Blunting of villi, crypt hyperplasia, and
intraepithelial lymphocytes, as this is celiac disease "<img src=""7900.png"">"
A pt is found to have gluten sensitivity. What is the pathophysiology of his
disease? Antibodies destroy villi (primarily in the distal duodenum and proximal
jejunum), thereby decreasing mucosal absorption and causing diarrhea "<img
src=""7900.png"">" Gastrointestinal Pathology malabsorption-syndromes
A pt has anti-endomysial, anti-tissue transglutaminase, and anti-gliadin
antibodies. What serotypes are associated with this syndrome? HLA-DQ2, HLA-DQ8
"<img src=""7900.png"">" Gastrointestinal Pathology malabsorption-
syndromes
A pt with chronic pancreatitis is given the D-xylose test. What would you expect
the result to be? Normal (The D-xylose test has normal results in cases of
pancreatic insufficiency.) "<img src=""7900.png"">" Gastrointestinal
Pathology malabsorption-syndromes
Celiac disease primarily affects what part(s) of the bowel?Distal duodenum and/or
proximal jejunum "<img src=""7900.png"">" Gastrointestinal Pathology
A pt presents with extremely itchy rashes on her knees and elbows.
Immunofluorescence shows IgA deposits at dermal papillae. Treatment? A gluten-
free diet will resolve the skin lesions. (This is dermatitis herpetiformis, which
is a finding in celiac disease.) "<img src=""7900.png"">" Gastrointestinal
Explain how the D-xylose test works. D-xylose is absorbed in the intestine and
excreted in urine; a decreased level in blood/urine means defect in mucosa or too
much bacteria "<img src=""7900.png"">" Gastrointestinal Pathology
A boy has diarrhea any time he eats dairy products. If he were to have an
intestinal biopsy, what is the expected appearance of the villi? The villi will
appear normal, unless the lactase deficiency is caused by injury to the villi (eg,
viral enteritis) "<img src=""7900.png"">" Gastrointestinal Pathology
A pt with lactase deficiency ingests a dairy-containing meal and develops diarrhea.
Stool studies will show an excess of which sugar? Lactose (The inability to
cleave lactose via lactase causes osmotic diarrhea.) "<img src=""7900.png"">"
A pt with lactase deficiency undergoes a lactose tolerance test. Following the
administration of lactose, what do you expect to see? Osmotic diarrhea and an
increase in breath hydrogen level &62; 20 ppm "<img src=""7900.png"">"
A pt is diagnosed with lactase deficiency. Why would his stool pH be acidic after
consumption of lactose? Bacteria in the colon ferment the lactose that is not
absorbed "<img src=""7900.png"">" Gastrointestinal Pathology malabsorption-
syndromes
A 15-year-old boy with chronic respiratory infections due to Pseudomonas has fatty
stools. What is the most likely pathophysiology? Pancreatic insufficiency due
to sludging of pancreatic secretions, as a result of cystic fibrosis "<img
A pt is diagnosed with ampullary cancer. What do you expect to see on stool
studies? Low pH: Obstructive cancers of the pancreatic head lead to pancreatic
insufficiency causing low pH in the duodenum and fecal elastase "<img
Pancreatic insufficiency causes the malabsorption of which macronutrient(s)? Fat,
the fat-soluble vitamins (A, D, E, and K), and sometimes vitamin B12 "<img
A pt with pancreatic insufficiency is given the D-xylose absorption test. What
results do you observe? Normal urinary excretion (If decreased excretion is seen,
the pathology is due to intestinal mucosa defects or bacterial overgrowth.) "<img
Unlike a pt with celiac disease, a pt with tropical sprue can be treated with which
class of drugs? Antibiotics "<img src=""7900.png"">" Gastrointestinal
A pt with tropical sprue has a colonoscopy with biopsy. Which sections of the GI
tract are likely to be affected? The entire small bowel "<img src=""7900.png"">"
A man returns from the Bahamas with complaints of diarrhea and decreased mucosal
absorption. Will this pt respond to antibiotics? Yes, the pt has tropical
sprue and will respond to antibiotics "<img src=""7900.png"">"
A pt returns from Ecuador and complains of weakness and steatorrhea. Blood tests
would reveal what sort of anemia? Megaloblastic anemia from folate and vitamin
B12 deficiency, as this pt has tropical sprue "<img src=""7900.png"">"
An 80-year-old man presents with Whipple disease. A Gram stain of the causative
organism would show what? Gram-positive rods (Tropheryma whipplei) "<img
A pt with suspected Whipple disease has a biopsy with PAS staining. Where would you
look to confirm foamy macrophages? Intestinal lamina propria, mesenteric lymph
nodes "<img src=""7900.png"">" Gastrointestinal Pathology malabsorption-
syndromes
A woman is diagnosed with Whipple disease and wants to know about potential
complications. What non-GI symptoms might also occur? Cardiac symptoms,
Arthralgias, Neurologic symptoms (most common in older men); think Foamy Whipped
cream in a CAN "<img src=""7900.png"">" Gastrointestinal Pathology
A 70-year-old man with arthralgias and cardiac and neurologic symptoms undergoes
duodenal biopsy. What is likely to be found with PAS stain?Foamy macrophages (This
is Whipple disease; remember Foamy Whipped cream in a CAN.)"<img src=""7900.png"">"
Which abnormal antibodies may be found in pts with Celiac disease? IgA anti-
tissue transglutaminase, anti-deamidated gliadin peptide antibody, anti-endomysial
antibody "<img src=""7900.png"">" Gastrointestinal Pathology malabsorption-
syndromes
Name at least two complications of ulcerative colitis.
Malnutrition/malabsorption, toxic megacolon, colorectal carcinoma (worse with
pancolitis), fulminant colitis, perforation "<img src=""7901.png"">"
Gastrointestinal Pathology inflammatory-bowel-diseases
"In ulcerative colitis, inflammation, pseudopolyps, and freely hanging mesentery
are seen. What causes the ""lead pipe"" appearance?" Loss of haustra "<img
src=""7901.png"">" Gastrointestinal Pathology inflammatory-bowel-diseases
A man has transmural colonic inflammation with noncaseating granulomas and lymphoid
aggregates. Diagnosis? Crohn disease "<img src=""7901.png"">"
A man with bloody diarrhea has a colon biopsy showing crypt abscesses and ulcers.
Does it show granulomas? No, as this is ulcerative colitis, which does not
include granulomas "<img src=""7901.png"">" Gastrointestinal Pathology
inflammatory-bowel-diseases
Name at least two extraintestinal manifestations that are common to ulcerative
colitis and Crohn disease. Pyoderma gangrenosum, erythema nodosum, aphthous
stomatitis, uveitis, episcleritis, arthritis "<img src=""7901.png"">"
Name at least two complications of Crohn disease. Malnutrition/malabsorption,
colorectal carcinoma, fistulas, phlegmon, abscess, strictures, perianal disease
"<img src=""7901.png"">" Gastrointestinal Pathology inflammatory-bowel-
diseases
A 20-year-old pt has recurrent diarrhea that is sometimes bloody, weight loss, oral
ulcers, and perianal fistulas. Likely diagnosis? Crohn disease "<img
Is perianal disease mainly a complication of Crohn disease, ulcerative colitis, or
both? Crohn disease "<img src=""7901.png"">" Gastrointestinal Pathology
Is toxic megacolon mainly a complication of Crohn disease, ulcerative colitis, or
both? Ulcerative colitis "<img src=""7901.png"">" Gastrointestinal
Pathology inflammatory-bowel-diseases
Are strictures mainly a complication of Crohn disease, ulcerative colitis, or both?
Crohn disease (Strictures can lead to obstruction.) "<img src=""7901.png"">"
A pt has primary sclerosing cholangitis. Which inflammatory bowel disease might she
also have? Ulcerative colitis "<img src=""7901.png"">" Gastrointestinal
A pt has bloody diarrhea, a rash, and primary sclerosing cholangitis. Would this pt
be p-ANCA or c-ANCA positive? p-ANCA positive; pt has ulcerative colitis "<img
A pt has calcium oxalate kidney stones. Would this association be linked to Crohn
disease or ulcerative colitis? Crohn disease; gallstones may also be seen with
Crohn disease "<img src=""7901.png"">" Gastrointestinal Pathology
A 23-year-old woman with bloody diarrhea has mucosal inflammation and pseudopolyps
of the rectum. What are some treatments? 5-Aminosalicyclic preparations, 6-
mercaptopurine, infliximab, and colectomy (This is ulcerative colitis.) "<img
A malnourished 20-year-old man has pyoderma gangrenosum, crypt abscesses on biopsy,
and bloody diarrhea. What are some treatments? ASA preparations (mesalamine), 6-
mercaptopurine, infliximab, or colectomy (Diagnosis is ulcerative colitis.) "<img
What mnemonic can help you to remember the basics of Crohn disease? For Crohn,
think of a fat granny and an old crone skipping down a cobblestone road away from
the wreck (rectal sparing) "<img src=""7901.png"">" Gastrointestinal
What mnemonic can help you to remember the basics of ulcerative colitis?
ULCCCERS = Ulcers, Large bowel, Continuous, Colorectal carcinoma, Crypt
abscesses, Extends proximally, Red diarrhea, Sclerosing cholangitis "<img
A 26-year-old man with abdominal pain and mucus in the stool has transmural
inflammation of the ileum. What complications may occur? Migratory polyarthritis,
erythema nodosum, pyoderma gangrenosum, ankylosing spondylitis, aphthous ulcers,
uveitis (This is Crohn disease.) "<img src=""7901.png"">" Gastrointestinal
Name the inflammatory bowel disease that can affect any part of the GI tract.
Crohn disease (usually affects the terminal ileum and colon) "<img
Which type of inflammatory bowel disease tends to show skip lesions (noncontiguous
areas of mucosal involvement)? Crohn disease "<img src=""7901.png"">"
A pt has a continuous segment of friable colonic mucosa that abruptly stops in the
mid-transverse colon. Treatment? Aminosalicylates, 6-mercaptopurine, infliximab,
colectomy; pt has ulcerative colitis, which always affects the rectum "<img
Describe the gross morphology typically found in Crohn disease. Cobblestone
mucosa, creeping fat, bowel wall thickening (string sign on x-ray), linear ulcers,
fissures, fistulas, transmural inflammation "<img src=""7901.png"">"
Describe the gross morphology typically found in ulcerative colitis. "Mucosal and
submucosal inflammation, friable mucosa with freely hanging mesentery, loss of
haustra causing ""lead-pipe"" appearance on images" "<img src=""7901.png"">"
Involvement of what part of the gastrointestinal tract favors a diagnosis of
ulcerative colitis over Crohn disease? Rectum "<img src=""7901.png"">"
A 45-year-old woman has recurrent abdominal pain. List the other criteria that must
be present to diagnose irritable bowel syndrome. Pain that improves with
defecation, change in stool frequency or appearance (At least two of these must
also be present.) "<img src=""7902.png"">" Gastrointestinal Pathology
irritable-bowel-syndrome
A 40-year-old woman has irregular bowel movements and recurrent abdominal pain that
eases after defecation. Will her symptoms be chronic? Yes, she has irritable bowel
syndrome, which has chronic symptoms that may be mostly diarrhea or constipation or
a mix of both "<img src=""7902.png"">" Gastrointestinal Pathology
irritable-bowel-syndrome
A 13-y/o boy has nausea, fever, sharp pain that started at the umbilicus then
migrated to the right. What is the name of this area of pain? McBurney point,
located one third of the way from a line drawn from the right anterior superior
iliac spine to the umbilicus "<img src=""7903.png"">" Gastrointestinal
Pathology appendicitis
A boy has 2 days of fever, vomiting, and abdominal pain. Workup reveals psoas,
obturator, and Rovsing signs. What is the treatment? Surgery (appendectomy for
appendicitis) "<img src=""7903.png"">" Gastrointestinal Pathology
appendicitis
In elderly pts, what condition must be included in the differential diagnosis of
acute abdominal pain (in addition to appendicitis)? Diverticulitis "<img
src=""7903.png"">" Gastrointestinal Pathology appendicitis
A 21-year-old woman presents with diffuse periumbilical pain and nausea. Other than
appendicitis, what condition should be ruled out? Ectopic pregnancy (ruled out
by a -human chorionic gonadotropin test) "<img src=""7903.png"">"
Gastrointestinal Pathology appendicitis
A 7-year-old boy is transferred to your ED because appendicitis is suspected. What
signs would you check for on physical exam? Psoas, obturator, and Rovsing
signs; pain at the McBurney point; guarding; and rebound tenderness "<img
src=""7903.png"">" Gastrointestinal Pathology appendicitis
In children, what causes appendicitis? Obstruction by lymphoid hyperplasia (as
opposed to fecaliths in adults) "<img src=""7903.png"">" Gastrointestinal
Pathology appendicitis
What is a diverticulum? A blind pouch leading off of the alimentary tract that
communicates with the lumen of the tract "<img src=""7904.png"">"
Gastrointestinal Pathology diverticula-of-the-gi-tract
What is the difference between a true diverticulum and a false diverticulum? A true
diverticulum contains 3 layers (mucosa, submucosa, serosa), whereas a false
diverticulum contains only 2 layers (mucosa, submucosa) "<img src=""7904.png"">"
Are most diverticula of the GI tract true or false? Most are false "<img
src=""7904.png"">" Gastrointestinal Pathology diverticula-of-the-gi-tract
A 62-year-old man with known diverticulosis has a screening colonoscopy. Where
would you most expect to observe a diverticulum? The sigmoid colon "<img
A pt's vasa recta perforate the muscularis externa. What is the diagnosis?
Pseudodiverticulum or false diverticulum "<img src=""7904.png"">"
What is the etiology of diverticulosis? Increased intraluminal pressure combined
with focal weakness of the colonic wall "<img src=""7904.png"">"
A pt is concerned about her likelihood of developing diverticulosis. What dietary
change do you suggest? Increase the amount of dietary fiber "<img
A 57-year-old woman presents with vague abdominal discomfort and painless rectal
bleeding. What is the most likely diagnosis? Diverticulosis "<img
An 80-year-old woman has vague GI discomfort and hematochezia, as do many people
her age. She will most likely receive what diagnosis? Diverticulosis "<img
A 67-y/o man with history of abdominal discomfort is diagnosed with diverticulosis.
Where in the GI tract are diverticula most likely found? Sigmoid colon "<img
Diverticulitis classically causes pain in what region of the abdomen? The left
lower quadrant "<img src=""7904.png"">" Gastrointestinal Pathology
diverticula-of-the-gi-tract
A man with fevers and rectal bleeding is found to have diverticulitis. What are the
four most common potential complications? Perforation, abscess formation, fistula,
and obstruction "<img src=""7904.png"">" Gastrointestinal Pathology
diverticula-of-the-gi-tract
A 73-y/o man admitted for LLQ pain and rectal bleeding develops pneumaturia on day
4 of hospitalization. What complication has occurred? Colovesical fistula (one of
the more common complications of diverticulitis) "<img src=""7904.png"">"
After being diagnosed with diverticulitis, your pt asks about the mainstay of
treatment. What do you respond? Administration of antibiotics is the mainstay
of treatment, although percutaneous drainage or surgery may be required "<img
A pt has symptoms similar to those of appendicitis, but the pain is on the left
side. What is the most likely diagnosis? Diverticulitis "<img src=""7904.png"">"
What is a Zenker diverticulum? Herniation of mucosal tissue at Killian
triangle, between the thyropharyngeal & cricopharyngeal parts of the inferior
pharyngeal constrictor "<img src=""7905.png"">" Gastrointestinal Pathology
zenker-diverticulum
Is Zenker diverticulum a true or false diverticulum? False diverticulum "<img
src=""7905.png"">" Gastrointestinal Pathology zenker-diverticulum
A pt presents with halitosis and decreased oral intake due to discomfort on
swallowing. What is the most likely diagnosis? Zenker diverticulum "<img
In what age and gender group is Zenker diverticulum most common? Elderly men "<img
What is the mnemonic to remember important characteristics of Zenker diverticulum?
Elder MIKE has bad breath: Elderly, Males, Inferior pharyngeal constrictor,
Killian triangle, Esophageal dysmotility, Halitosis "<img src=""7905.png"">"
Gastrointestinal Pathology zenker-diverticulum
A 15-month-old has persistence of the vitelline duct. Does this result in a true or
false diverticulum? This pt has Meckel diverticulum, a true diverticulum "<img
src=""7906.png"">" Gastrointestinal Pathology meckel-diverticulum
A 16-month-old girl has had melena for the past 7 weeks; she sometimes clutches her
RLQ. What test can confirm the most likely diagnosis? Pertechnetate uptake by
ectopic gastric mucosa to confirm Meckel diverticulum "<img src=""7906.png"">"
Gastrointestinal Pathology meckel-diverticulum
A pt with a Meckel diverticulum has significant pain. What is most likely causing
it? Gastric acid secretion from ectopic tissue growth (gastric and/or pancreatic
tissue) "<img src=""7906.png"">" Gastrointestinal Pathology meckel-
diverticulum
A newborn has a cystic dilation of the vitelline duct found on exam. Do you need to
perform a pertechnetate study? No, as this finding is more consistent with an
omphalomesenteric cyst rather than a Meckel diverticulum "<img src=""7906.png"">"
Approximately what size is a typical Meckel diverticulum? 2 in (six 2's: 2 as
likely in males; 2 in long, 2 ft from ileocecal valve, 2% of population, first 2 yr
of life, 2 epithelial types) "<img src=""7906.png"">" Gastrointestinal
Pathology meckel-diverticulum
How far are Meckel diverticula typically located from the ileocecal valve? 2 ft
(six 2's: 2 as likely in males; 2 in long, 2 ft from ileocecal valve, 2% of
population, first 2 yr of life, 2 epithelial types) "<img src=""7906.png"">"
In approximately what percentage of the population can Meckel diverticula be found?
2% (six 2's: 2 as likely in males; 2 in long, 2 ft from ileocecal valve, 2%
of population, first 2 yr of life, 2 epithelial types) "<img src=""7906.png"">"
When in life do Meckel diverticula typically present? First 2 yr (six 2's: 2 as
likely in males; 2 in long, 2 ft from ileocecal valve, 2% of population, first 2 yr
of life, 2 epithelial types) "<img src=""7906.png"">" Gastrointestinal
Is Meckel diverticulum more common in male or female pts? Twice as common in male
pts (the six 2's) "<img src=""7906.png"">" Gastrointestinal Pathology meckel-
diverticulum
How many types of epithelia are found in Meckel diverticula? Two, gastric
and/or pancreatic (the six 2's) "<img src=""7906.png"">" Gastrointestinal
What is the most common congenital anomaly of the gastrointestinal tract? Meckel
diverticulum "<img src=""7906.png"">" Gastrointestinal Pathology meckel-
diverticulum
A 19-month-old boy has a congenital anomaly causing melena and RLQ pain. What are
some potential complications? Intussusception, volvulus, colonic obstruction (This
is a Meckel diverticulum.) "<img src=""7906.png"">" Gastrointestinal
A woman who heard about a condition called Hirschsprung disease wonders if her baby
may have it. What symptoms would you ask about? Inability to pass meconium within 2
days after birth or chronic constipation in a child, bilious emesis, abdominal
distention "<img src=""7907.png"">" Gastrointestinal Pathology hirschsprung-
disease
What would a rectal biopsy from a pt with Hirschsprung disease likely show? Lack
of ganglionic cells/enteric nervous plexuses, called Auerbach and Meissner
plexuses, which allow relaxation of the affected bowel "<img src=""7907.png"">"
Gastrointestinal Pathology hirschsprung-disease
Hirschsprung disease results from the failure of which process? Neural crest cell
migration "<img src=""7907.png"">" Gastrointestinal Pathology hirschsprung-
disease
At birth, a baby presents with an aganglionic segment of the colon, preventing
passage of meconium. Could genetic screening be of value? Yes, as this is
Hirschsprung disease, which is associated with RET gene mutations (Risk is also
increased in pts with Down syndrome.) "<img src=""7907.png"">"
A 2-day-old child does not pass meconium. Anal manometry shows increased resting
tone. If abnormal, what is the most likely karyotype? Trisomy 21 (or Down syndrome,
which increases the risk for Hirschsprung disease) "<img src=""7907.png"">"
A newborn has bilious emesis and fails to pass meconium after 48 hours. What is the
treatment for this disease? How is it diagnosed? Treated with resection;
diagnosed by rectal suction biopsy, as this is Hirschsprung disease "<img
src=""7907.png"">" Gastrointestinal Pathology hirschsprung-disease
Colonoscopy is performed on a newborn with Hirschsprung disease. What will be found
proximal to the diseased segment of bowel? A transition zone, or dilated
portion of bowel; think of Hirschsprung as a giant spring that has sprung in the
colon "<img src=""7907.png"">" Gastrointestinal Pathology hirschsprung-disease
In a pt with Hirschsprung disease, where is the dilated segment of the colon
relative to the aganglionic segment? Proximal "<img src=""7907.png"">"
Does Hirschsprung disease involve the rectum? Yes "<img src=""7907.png"">"
Malrotation of the gut is due to improper rotation of what fetal structure during
development? The midgut "<img src=""7908.png"">" Gastrointestinal
Pathology malrotation
An infant has twisting of a portion of the bowel around its mesentery. Where is
this twisting likely to occur? Midgut (This is volvulus.) "<img
src=""7909.png"">" Gastrointestinal Pathology volvulus
A 3-year-old presents with loose stools and severe but intermittent lower abdominal
pain. What section of the GI tract is likely affected? "The ileocecal junction
(This is intussusception, which often presents with classic ""currant jelly""
stools.)" "<img src=""7910.png"">" Gastrointestinal Pathology
intussusception
Is intussusception found more commonly in adults or children? Children "<img
src=""7910.png"">" Gastrointestinal Pathology intussusception
An adult has telescoping bowel on imaging. He should receive a colonoscopy for what
associated condition? Colon cancer, as this is intussusception, which may be a
presenting sign of colon cancer in adults "<img src=""7910.png"">"
Gastrointestinal Pathology intussusception
A young child presents with abdominal pain. Abdominal ultrasound shows a bull's-eye
appearance to a loop of bowel. Do you consult Surgery? Yes, as this finding is
classically associated with intussusception, which is an abdominal emergency "<img
src=""7910.png"">" Gastrointestinal Pathology intussusception
A child is diagnosed with intussusception. What pathologies lead to this? It is
usually idiopathic, but Peyer patch hypertrophy from adenovirus infection and
Meckel diverticulum (most common) can act as lead points "<img src=""7910.png"">"
Gastrointestinal Pathology intussusception
A man with a history of heart disease has abdominal pain and red currant jelly
stools. Do you limit your differential to intussusception? No, as acute mesenteric
ischemia may also present with red currant jelly stools "<img src=""7911.png"">"
Gastrointestinal Pathology other-intestinal-disorders
Which artery is often blocked in pts with acute mesenteric ischemia? The superior
mesenteric artery (SMA); occlusion of the SMA leads to blocked intestinal blood
flow and bowel necrosis "<img src=""7911.png"">" Gastrointestinal Pathology
other-intestinal-disorders
An 80-year-old man with CAD has 6 months of weight loss due to pain after eating.
What do you suspect is the source of the pain? "Celiac artery, SMA, or IMA
atherosclerosis; hypoperfusion causes postprandial pain; this is chronic mesenteric
ischemia, ""intestinal angina""" "<img src=""7911.png"">" Gastrointestinal
Pathology other-intestinal-disorders
Where does colonic ischemia commonly occur? Which population is typically affected?
The splenic flexure and distal colon (watershed areas between arterial
territories that therefore have tenuous blood flow); elderly "<img
src=""7911.png"">" Gastrointestinal Pathology other-intestinal-disorders
What is a common complaint of pts with colonic ischemia? Crampy abdominal pain
then hematochezia (Increased metabolic demand in intestines and inability to supply
blood leads to an ischemic state.) "<img src=""7911.png"">" Gastrointestinal
An elderly pt has painless hematochezia. After colonoscopy fails to detect any
neoplasms, what test can confirm the most likely cause? Angiography, as the most
likely cause of the painless bleeding is angiodysplasia "<img src=""7911.png"">"
Where is angiodysplasia typically found in the gastrointestinal tract? Cecum,
terminal ileum, ascending colon "<img src=""7911.png"">" Gastrointestinal
A 70-year-old complains of bright red blood per rectum. Angiography shows tortuous
dilation of vessels at the bleeding site. Diagnosis? Angiodysplasia "<img
A pt with angiodysplasia will typically complain of what symptoms?
Hematochezia, due to bleeding from tortuous dilation of vessels "<img
Is angiodysplasia more common in children, young adults, or the elderly? The
elderly "<img src=""7911.png"">" Gastrointestinal Pathology other-
intestinal-disorders
What is the most common cause of small bowel obstruction? Adhesions, which are
fibrous bands of scar tissue that form after surgery "<img src=""7911.png"">"
A 35-year-old with history of appendectomy complains of pain in the RLQ. What would
be high on your differential for a cause of obstruction? Adhesions, which are the
most common cause of small bowel obstruction "<img src=""7911.png"">"
What medical conditions are associated with ileus? Abdominal surgeries, use of
opiates, hypokalemia, sepsis "<img src=""7911.png"">" Gastrointestinal
A recent abdominal surgery pt has stomach pain and vomiting. Laparotomy reveals
adhesions. What might you see on gross examination? Well-demarcated necrotic
zones, demonstrated by symptomatic adhesions "<img src=""7911.png"">"
A 48-year-old man with many past abdominal surgeries has a distended abdomen with
decreased bowel sounds. What does this pt likely have? Ileus, or intestinal
hypomotility without obstruction "<img src=""7911.png"">" Gastrointestinal
An opiate abuser complains of increased constipation and decreased flatus. On CT,
no obstructions are noted. What does he have? Ileus (intestinal hypomotility
without obstruction) "<img src=""7911.png"">" Gastrointestinal Pathology
other-intestinal-disorders
A pt with sepsis is diagnosed with intestinal hypomotility without obstruction.
What treatment options may be of use for this pt? Bowel rest, electrolyte
correction, and cholinergic drugs to stimulate intestinal motility (This is ileus.)
"<img src=""7911.png"">" Gastrointestinal Pathology other-intestinal-
disorders
A newborn fails to pass meconium. Results of rectal exam and manometry are normal.
His older brother died of pneumonia. Diagnosis? Meconium ileus due to cystic
fibrosis; a plug obstructs the intestine and blocks the passage of stool "<img
Which pts are most at risk for necrotizing enterocolitis? Premature neonates and
neonates who are formula fed (decreased immunity) "<img src=""7911.png"">"
A premature infant develops feeding intolerance; he has a distended abdomen and
pneumatosis on x-ray. He has no bilious vomiting. Diagnosis? Necrotizing
enterocolitis "<img src=""7911.png"">" Gastrointestinal Pathology other-
intestinal-disorders
A premature newborn may have necrotizing enterocolitis. Urgent abdominal imaging is
performed. What findings would confirm your diagnosis? Signs of perforation
including pneumatosis intestinalis, free air in the abdomen, portal venous gas
"<img src=""7911.png"">" Gastrointestinal Pathology other-intestinal-
disorders
"A newborn presents with early bilious vomiting and a ""double bubble"" on x-ray.
Which chromosomal abnormality is associated with his disease?" Trisomy 21 (Down
syndrome) (This newborn likely has duodenal atresia, which is associated with this
chromosomal abnormality.) "<img src=""7911.png"">" Gastrointestinal
Name the different types of polyps, and identify which are neoplastic. Hyperplastic
(non-neoplastic), hamartomatous (non-neoplastic generally), adenomatous
(neoplastic), serrated (premalignant) "<img src=""7912.png"">"
Gastrointestinal Pathology colonic-polyps
Your 50-year-old pt has a history of hyperplastic polyps. On colonoscopy, where do
you most expect to find new hyperplastic polyps? In the rectosigmoid area
"<img src=""7912.png"">" Gastrointestinal Pathology colonic-polyps
A child with rectal discomfort has a single rectal juvenile polyp found on
colonoscopy. He is otherwise well. Should it be urgently removed? No, as there
is no malignant potential if it is truly the only juvenile polyp "<img
src=""7912.png"">" Gastrointestinal Pathology colonic-polyps
Hamartomatous colonic polyps are associated with which two polyposis syndromes?
Peutz-Jeghers syndrome and juvenile polyposis; these polyps are made of
normal tissue with distorted architecture "<img src=""7912.png"">"
What type of polyp is considered a precursor for colorectal cancer? Adenomatous
List the three adenomatous polyp subtypes in order of their potential for malignant
transformation, from lowest to highest. Tubular adenomas, tubulovillous adenoma,
villous adenomas "<img src=""7912.png"">" Gastrointestinal Pathology colonic-
polyps
On colonoscopy, a pt has several polyps, but whether they have malignant potential
is unclear. Testing of which genes may be helpful? APC and KRAS, which are
commonly mutated via the chromosomal instability pathway in neoplastic polyps
"A pt has a colonoscopy. Polyps are biopsied, and ""saw tooth"" crypts are seen. Is
there a risk for progression to colorectal cancer?" Yes, as the biopsy
description is consistent with serrated polyps, which are premalignant (up to 20%
of sporadic colorectal cancer cases) "<img src=""7912.png"">"
Which genetic mutations are associated with serrated polyps? The CpG
hypermethylation phenotype pathway with microsatellite instability, and mutations
in BRAF "<img src=""7912.png"">" Gastrointestinal Pathology colonic-polyps
A pt has multiple GI tract hamartomas and hyperpigmented hands, mouth, lips, and
genitalia. For which cancers is he at increased risk? Colorectal, breast, stomach,
small bowel, pancreatic cancers (The pt has Peutz-Jeghers syndrome.) "<img
src=""7913.png"">" Gastrointestinal Pathology polyposis-syndromes
A 12-year-old boy is found to have several polyps in his colon, stomach, and small
bowel. For what cancer is he at risk? Adenocarcinoma (This is likely juvenile
polyposis syndrome.) "<img src=""7913.png"">" Gastrointestinal Pathology
polyposis-syndromes
What is the inheritance pattern of juvenile polyposis syndrome? At what age does it
typically present? Autosomal dominant; before 5 years of age "<img
A pt inherits a mutation of the APC gene on chromosome 5q. He asks about his risk
for colorectal cancer. What do you tell him? The pt has familial adenomatous
polyposis syndrome; 100% of cases progress to colorectal cancer if the colon is not
removed "<img src=""7913.png"">" Gastrointestinal Pathology polyposis-
syndromes
A 28-year-old man has familial adenomatous polyposis. What is the chance his
newborn son will be affected? 50% (autosomal dominant inheritance) "<img
You are going to perform a colonoscopy on a pt with familial adenomatous polyposis.
What do you expect to find? Is the rectum involved? Thousands of polyps
(pancolonic involvement); the rectum is always involved "<img src=""7913.png"">"
Gastrointestinal Pathology polyposis-syndromes
A pt with bone and soft tissue tumors is found to have thousands of polyps on
colonoscopy. Which syndrome is suspected? Gardner syndrome "<img src=""7913.png"">"
Why might you want to perform a colonoscopy on a young pt with extra teeth and
abnormally pigmented retinas? These are Gardner syndrome traits (FAP, osseous/soft
tissue tumors, hypertrophy of retinal pigment epithelium, impacted/supernumerary
teeth) "<img src=""7913.png"">" Gastrointestinal Pathology polyposis-
syndromes
A young pt with a history of a brain tumor has GI bleeding. For which syndrome
might you want to urgently screen him? Turcot syndrome (FAP + malignant CNS
tumor) (Turcot = Turban) "<img src=""7913.png"">" Gastrointestinal
Pathology polyposis-syndromes
A man has GI tract hamartomas and dark patches around his mouth and palms. What is
the chance his son will have the same disorder? The probability is 50% (This pt has
Peutz-Jeghers syndrome, an autosomal dominant disorder.) "<img src=""7913.png"">"
A woman is diagnosed with endometrial cancer and has multiple relatives with skin
and colorectal cancer. What syndrome do you suspect? Lynch syndrome, or hereditary
nonpolyposis colorectal cancer (HNPCC) "<img src=""7914.png"">"
Gastrointestinal Pathology lynch-syndrome
Describe the inheritance pattern and pathophysiology of Lynch syndrome.
Autosomal dominant inheritance in which DNA mismatch repair genes are mutated
and result in microsatellite instability "<img src=""7914.png"">"
If you are working up a pt for HNPCC, which part of the bowel do you biopsy? The
proximal colon, which is always involved "<img src=""7914.png"">"
In what percentage of pts will HNPCC progress to colorectal cancer?
Approximately 80% "<img src=""7914.png"">" Gastrointestinal Pathology
lynch-syndrome
How likely is it for a pt with colorectal cancer to have a family history? 0.25
"<img src=""7915.png"">" Gastrointestinal Pathology colorectal-cancer
Name at least three risk factors for colorectal cancer. Adenomatous and serrated
polyps, familial cancer syndromes, IBD, tobacco use, diet rich in processed meat
and low in fiber "<img src=""7915.png"">" Gastrointestinal Pathology
colorectal-cancer
Put in order (from most to least common) where colorectal cancer presents:
descending colon, ascending colon, rectosigmoid junction. Rectosigmoid junction,
ascending colon, descending colon "<img src=""7915.png"">" Gastrointestinal
Pathology colorectal-cancer
A pt is diagnosed with right-sided colon cancer. What type of symptoms were
observed in this pt to reach this diagnosis? An exophytic mass, iron deficiency
anemia, weight loss "<img src=""7915.png"">" Gastrointestinal Pathology
colorectal-cancer
A pt is diagnosed with cancer of the descending colon. What symptoms would you
observe in this pt? Colicky pain, presence of infiltrating mass, partial
obstruction, and hematochezia "<img src=""7915.png"">" Gastrointestinal
Pathology colorectal-cancer
A man has fevers, hypotension, and a new murmur. Blood cultures grow a
streptococcal species. Why might you want to perform a colonoscopy? Although
rare, colorectal cancer can be associated with Streptococcus bovis bacteremia (This
pt may need a colonoscopy once stabilized.) "<img src=""7915.png"">"
Gastrointestinal Pathology colorectal-cancer
A male pt with iron deficiency anemia is concerned about colon cancer risk. Should
he be concerned? Who else should be concerned? Yes, as iron deficiency anemia can
be a presenting sign of colorectal cancer in men, especially those older than 50;
postmenopausal women "<img src=""7915.png"">" Gastrointestinal Pathology
colorectal-cancer
How do you screen for colorectal cancer? Colonoscopy, flexible sigmoidoscopy,
stool occult blood testing, or stool DNA testing "<img src=""7915.png"">"
Gastrointestinal Pathology colorectal-cancer
A pt with a history of colorectal cancer is constantly monitored for recurrence.
Which nonspecific serum tumor marker is used? Carcinoembryonic antigen (CEA)
"<img src=""7915.png"">" Gastrointestinal Pathology colorectal-cancer
"A man is worried about colon cancer. He wants a screening CEA test done, because
he is ""scared of colonoscopies."" What do you tell him?" CEA levels cannot be
used for screening; they can be used only to monitor for recurrence in pts with a
previous diagnosis "<img src=""7915.png"">" Gastrointestinal Pathology
colorectal-cancer
Describe the sequence of events that leads to most forms of sporadic colorectal
cancer. Loss of APC gene, KRAS mutation, loss of tumor suppressor gene (p53)
(Order of events is AK-53.) "<img src=""7916.png"">" Gastrointestinal
Pathology molecular-pathogenesis-of-colorectal-cancer
A pt with hundreds of colonic polyps is found to have colorectal cancer. The loss
of which gene triggered this pathologic process? The APC gene (Loss of
function causes increased proliferation and decreased intracellular adhesion.)
"<img src=""7916.png"">" Gastrointestinal Pathology molecular-
pathogenesis-of-colorectal-cancer
Unregulated intracellular signaling promotes adenoma formation. Which gene mutation
is responsible for this? KRAS mutation "<img src=""7916.png"">"
Gastrointestinal Pathology molecular-pathogenesis-of-colorectal-cancer
Loss of function of which tumor suppressor genes is the last step in malignant
transformation of colonic epithelial cells? p53 and DCC "<img src=""7916.png"">"
Mutations/methylation of mismatch repair genes reflects which pathway in the
pathogenesis of colorectal cancer? Microsatellite instability pathway "<img
src=""7916.png"">" Gastrointestinal Pathology molecular-pathogenesis-of-
colorectal-cancer
Lynch syndrome is an autosomal dominant disorder with a high risk of CRC. Which
gene mutations are frequently implicated in this disease? MSH2 and MLH1 mutations
"<img src=""7916.png"">" Gastrointestinal Pathology molecular-
pathogenesis-of-colorectal-cancer
In the CRC chromosomal instability pathway, indicate whether each gene in the
sequence is a tumor suppressor or a proto-oncogene. APC is a tumor suppressor;
KRAS is a proto-oncogene; p53 and DCC are tumor suppressors"<img src=""7916.png"">"
What is the most common etiology of liver cirrhosis in the United States?
Alcohol (responsible for 60% to 70% of cases) "<img src=""7917.png"">"
Gastrointestinal Pathology cirrhosis-and-portal-hypertension
Disruption of normal liver architecture in cirrhosis is defined by what pathology?
Diffuse bridging fibrosis leading to a shrunken liver and regenerative
nodules "<img src=""7917.png"">" Gastrointestinal Pathology cirrhosis-and-
portal-hypertension
What cells usually cause the bridging fibrosis in cirrhosis? Stellate cells
"<img src=""7917.png"">" Gastrointestinal Pathology cirrhosis-and-
portal-hypertension
Name as many causes of liver cirrhosis as you can. Alcohol, nonalcoholic
steatohepatitis, chronic viral hepatitis, autoimmune hepatitis, biliary disease,
genetic/metabolic disorders "<img src=""7917.png"">" Gastrointestinal
Pathology cirrhosis-and-portal-hypertension
Cirrhosis increases the risk for which type of carcinoma? Hepatocellular carcinoma
(HCC) "<img src=""7917.png"">" Gastrointestinal Pathology cirrhosis-and-
portal-hypertension
An alcoholic has cirrhosis with hyperbilirubinemia. What do you expect to find on
eye exam? Scleral icterus "<img src=""7917.png"">" Gastrointestinal
Pathology cirrhosis-and-portal-hypertension
Name three causes of portal hypertension (increased pressure in venous system).
Cirrhosis (most common in Western countries), venous obstruction (Budd-Chiari
syndrome, portal vein thrombosis), schistosomiasis "<img src=""7917.png"">"
Name at least three direct effects of portal hypertension. Splenomegaly; caput
medusae; ascites; esophageal, gastric, and anorectal varices "<img
src=""7917.png"">" Gastrointestinal Pathology cirrhosis-and-portal-
hypertension
A man with cirrhosis presents with confusion, a flapping tremor, and an elevated
ammonia level. What complication causes these symptoms? Hepatic encephalopathy
portal-hypertension
While examining a pt with known cirrhosis, you cannot help but notice his musty
breath. What is this called? Fetor hepaticus "<img src=""7917.png"">"
Visible dilated capillary proliferation within the skin secondary to the effects of
liver failure and cirrhosis is called what? Spider nevi "<img src=""7917.png"">"
Gynecomastia, testicular atrophy, and amenorrhea can be sequelae of cirrhosis
secondary to what? Hyperestrogenemia "<img src=""7917.png"">"
A pt with cirrhosis has a coarse, flapping tremor of the hands. What is this
called? Asterixis "<img src=""7917.png"">" Gastrointestinal Pathology
cirrhosis-and-portal-hypertension
Coagulopathy secondary to intrinsic synthetic dysfunction from the liver is
secondary to what? Inability to produce coagulation factors causing elevation
in prothrombin time "<img src=""7917.png"">" Gastrointestinal Pathology
cirrhosis-and-portal-hypertension
Thrombocytopenia and anemia are commonly encountered in cirrhosis. What is the
pathogenesis? Splenomegaly (splenic sequestration) and bone marrow suppression.
portal-hypertension
Is the ankle edema of cirrhosis considered an effect of portal hypertension or an
effect of liver cell synthetic failure? Liver cell synthetic failure (due to the
inability to synthesize albumin, resulting in lack of oncotic pressure) "<img
src=""7917.png"">" Gastrointestinal Pathology cirrhosis-and-portal-
hypertension
What two hepatic enzymes are elevated in injury to hepatocytes? Alanine
aminotransferase and aspartate aminotransferase "<img src=""7918.png"">"
Gastrointestinal Pathology serum-markers-of-liver-pathology
Describe a pattern of transaminitis consistent with most liver diseases. ALT
&62; AST "<img src=""7918.png"">" Gastrointestinal Pathology serum-markers-
of-liver-pathology
Describe a pattern of transaminitis consistent with alcoholic liver disease. AST
&62; ALT (&62; 2:1 ratio) "<img src=""7918.png"">" Gastrointestinal
Pathology serum-markers-of-liver-pathology
What does AST &62; ALT in nonalcoholic liver disease suggest? Progression to
advanced fibrosis (cirrhosis) "<img src=""7918.png"">" Gastrointestinal
Pathology serum-markers-of-liver-pathology
What causes an elevation in alkaline phosphatase? Biliary obstruction causing
cholestasis, infiltrative biliary disorders, bone disease "<img src=""7918.png"">"
What test is appropriate to order for a pt with unspecified elevation in alkaline
phosphatase? Why? Measurement of -glutamyl transpeptidase; it is increased in
various liver and biliary conditions but not associated with bone pathology "<img
src=""7918.png"">" Gastrointestinal Pathology serum-markers-of-liver-pathology
Alkaline phosphatase, in addition to being a marker of liver disease, is also a
marker of what other kind of disease? Bone disease "<img src=""7918.png"">"
A 5-year-old with seasonal flu was given aspirin for fever. He developed
encephalopathy, elevated LFTs and died. Diagnosis? Reye syndrome "<img
src=""7919.png"">" Gastrointestinal Pathology reye-syndrome
What pathologic liver changes are associated with Reye syndrome? Microvesicular
fatty changes, hepatomegaly, and mitochondrial abnormalities "<img
Which two viruses, when treated with aspirin in children, are typically associated
with the development of Reye syndrome? VZV and influenza "<img src=""7919.png"">"
Gastrointestinal Pathology reye-syndrome
Describe the proposed mechanism for aspirin toxicity in Reye syndrome. Aspirin
metabolites decrease -oxidation by reversible inhibition of mitochondrial enzymes
"<img src=""7919.png"">" Gastrointestinal Pathology reye-syndrome
Name one disease for which aspirin is used as treatment in children. Kawasaki
disease: Aspirin is needed to treat inflammation and prevent clot formation "<img
A 35-year-old alcoholic has a liver ultrasound that shows fatty liver disease. What
pathology would be seen if a biopsy were performed? Macrovesicular fatty change
"<img src=""7920.png"">" Gastrointestinal Pathology alcoholic-liver-
disease
At what stage is alcoholic liver disease reversible? Hepatic steatosis "<img
src=""7920.png"">" Gastrointestinal Pathology alcoholic-liver-disease
A known alcoholic presents with RUQ dull pain and hepatomegaly. Describe the
pathology seen if the pt has a liver biopsy performed. Mallory bodies and
necrotic hepatocytes with neutrophil infiltrate "<img src=""7920.png"">"
Gastrointestinal Pathology alcoholic-liver-disease
"An alcoholic pt has jaundice, a ""hobnail"" liver, and hypoalbuminemia. If the pt
quits drinking, will these symptoms go away?" No, this describes a micronodular,
shrunken liver, indicating alcoholic cirrhosis, which is irreversible "<img
src=""7920.png"">" Gastrointestinal Pathology alcoholic-liver-disease
An obese female with metabolic syndrome has an RUQ ultrasound that shows fatty
liver changes. She is asymptomatic. Name her condition. Non-alcoholic fatty
liver disease "<img src=""7921.png"">" Gastrointestinal Pathology non-
alcoholic-fatty-liver-disease
What LFT abnormality would one expect to see in NASH? ALT &62; AST "<img
src=""7921.png"">" Gastrointestinal Pathology non-alcoholic-fatty-liver-
disease
A pt with NASH fails to change her lifestyle. NASH progresses to liver cirrhosis.
She should be screened for what malignancy? HCC "<img src=""7921.png"">"
Gastrointestinal Pathology non-alcoholic-fatty-liver-disease
A known alcoholic pt with cirrhosis presents with obtundation and is found to be
guaiac positive. Mechanism of his encephalopathy? Increased ammonia production
and absorption in the setting of a GI bleed "<img src=""7922.png"">"
Gastrointestinal Pathology hepatic-encephalopathy
Rifaximin is generally used in refractory hepatic encephalopathy. What is its
mechanism of action? It decreases NH4+-producing gut bacteria "<img
src=""7922.png"">" Gastrointestinal Pathology hepatic-encephalopathy
A pt with cirrhosis undergoes TIPS. Two weeks later, she is found confused and
disoriented at home. What condition does she have? Hepatic encephalopathy "<img
src=""7922.png"">" Gastrointestinal Pathology hepatic-encephalopathy
Name as many triggers for hepatic encephalopathy as you can. GI bleed,
constipation, infection, renal failure, diuretics, TIPS, portal vein thrombosis
"<img src=""7922.png"">" Gastrointestinal Pathology hepatic-
encephalopathy
An alcoholic with an ammonia level of 500 mol/L is comatose. How do you treat him
emergently, and what is the mechanism of this tmt? Administer lactulose, which
increases ammonium generation "<img src=""7922.png"">" Gastrointestinal
Pathology hepatic-encephalopathy
A pt with cirrhosis is noncompliant with his lactulose. How does lactulose prevent
hepatic encephalopathy? It increases ammonia production in the GI tract and
elimination via feces "<img src=""7922.png"">" Gastrointestinal Pathology
hepatic-encephalopathy
What two viral diseases are associated with an increased incidence of
hepatocellular carcinoma? Hepatitis B and C "<img src=""7923.png"">"
Gastrointestinal Pathology hepatocellular-carcinoma/hepatoma
Excessive exposure to what two substances is associated with an increased incidence
of hepatocellular carcinoma? Alcohol (alcoholic cirrhosis) and carcinogens such as
aflatoxin "<img src=""7923.png"">" Gastrointestinal Pathology
hepatocellular-carcinoma/hepatoma
A 52-year-old man who comes in with RUQ abdominal pain is convinced that he has
liver cancer. What signs/symptoms could you check for? Jaundice, tender
hepatomegaly, ascites, polycythemia, anorexia "<img src=""7923.png"">"
A pt is diagnosed w/hepatocellular carcinoma. His friend asks what factors might
increase his risk for this disease. What do you tell him? Hepatitis B and C, all
causes of cirrhosis, specific carcinogens (aflatoxin from Aspergillus) "<img
src=""7923.png"">" Gastrointestinal Pathology hepatocellular-
carcinoma/hepatoma
A doctor suspects hepatocellular carcinoma in a pt. What serologic marker does she
expect to be elevated? -Fetoprotein "<img src=""7923.png"">"
What imaging tool is used as a screening tool for hepatocellular carcinoma (HCC)?
Liver ultrasound "<img src=""7923.png"">" Gastrointestinal Pathology
hepatocellular-carcinoma/hepatoma
What imaging tools are used to categorize a lesion seen on liver ultrasound that is
suggestive of hepatocellular carcinoma? Contrast CT and MRI "<img
carcinoma/hepatoma
What is the gold standard test for diagnosis of hepatocellular carcinoma? Liver
biopsy and evaluation by a pathologist "<img src=""7923.png"">"
How might a hepatocellular carcinoma predispose a pt to Budd-Chiari syndrome?
Via polycythemia (a hypercoagulable state leading to thrombosis in the
hepatic vein) or by direct compression of the hepatic vein "<img src=""7923.png"">"
Name three hereditary conditions that predispose to cirrhosis, and therefore, HCC.
Wilson disease, hemochromatosis, -antitrypsin deficiency "<img
carcinoma/hepatoma
In what circumstances would a liver biopsy be contraindicated for a pt with a liver
tumor ? If the tumor is thought to be a cavernous hemangioma because of the
risk of hemorrhage; this tumor is extremely vascular "<img src=""7924.png"">"
Gastrointestinal Pathology other-liver-tumors
A pt taking oral contraceptives is discovered to have a benign liver tumor. What
tumor does she most likely have? Hepatic adenoma "<img src=""7924.png"">"
What medications predispose a pt to develop hepatic adenomas? Oral
contraceptives; anabolic steroids "<img src=""7924.png"">" Gastrointestinal
Pathology other-liver-tumors
Hepatic adenomas are benign; they most commonly regress. However, in rare cases,
they can cause death. How? Spontaneous rupture leading to and hemorrhagic shock
"<img src=""7924.png"">" Gastrointestinal Pathology other-liver-tumors
A pt from Russia worked with arsenic and polyvinyl chloride. She is found to have a
malignant liver tumor. What liver tumor do you suspect? Angiosarcoma "<img
src=""7924.png"">" Gastrointestinal Pathology other-liver-tumors
A pt has an abdominal CT that shows multiple hepatic masses suggestive of
metastasis. Where might the primary tumor be? In the GI, lung, or breast
(Metastases are the most common liver tumors.) "<img src=""7924.png"">"
A pt has rapid development of abdominal pain, ascites, hepatomegaly, jaundice, and
renal failure. What condition do you suspect? Budd-Chiari syndrome "<img
src=""7925.png"">" Gastrointestinal Pathology budd-chiari-syndrome
Budd-Chiari syndrome is caused by what pathophysiology? Thrombosis or
compression of hepatic veins "<img src=""7925.png"">" Gastrointestinal
Pathology budd-chiari-syndrome
A pt lacks JVD and hepatojugular reflex. He does have transaminitis and congestive
hepatopathy. What condition do you suspect? Budd-Chiari syndrome "<img
src=""7925.png"">" Gastrointestinal Pathology budd-chiari-syndrome
What liver region becomes congested and necrotic in Budd-Chiari syndrome? The
centrilobular region (nutmeg liver) "<img src=""7925.png"">" Gastrointestinal
What medical conditions are often associated with Budd-Chiari syndrome?
Polycythemia vera, pregnancy (postpartum state), hypercoagulable states,
hepatocellular carcinoma "<img src=""7925.png"">" Gastrointestinal
A pt has panacinar emphysema, and an RUQ ultrasound shows a nodular liver. Explain
the mechanism of his cirrhosis. Misfolded gene product protein aggregates in
hepatocellular ER lead to inflammation and cirrhosis "<img src=""7926.png"">"
Gastrointestinal Pathology a1-antitrypsin-deficiency
1-Antitrypsin deficiency is a devastating condition in the lungs due to
disinhibition of what enzyme? Elastase "<img src=""7926.png"">"
Gastrointestinal Pathology a1-antitrypsin-deficiency
A 50-year-old pt who has never smoked presents with dyspnea. CT scan of the chest
shows emphysema. What serologic test must you order? 1-Antitrypsin level "<img
src=""7926.png"">" Gastrointestinal Pathology a1-antitrypsin-deficiency
Is the hyperbilirubinemia of an intrahepatic process (such as hepatitis or
cirrhosis) conjugated, unconjugated, or mixed? It is mixed (direct and indirect)
hyperbilirubinemia "<img src=""7927.png"">" Gastrointestinal Pathology
jaundice
A 5-day-old infant has persistent hyperbilirubinemia despite phototherapy. Is it
likely conjugated, unconjugated, or mixed? It is likely unconjugated
(indirect) hyperbilirubinemia, likely due to hemolysis "<img src=""7927.png"">"
Gastrointestinal Pathology jaundice
Lab results show high direct and indirect bilirubin levels. Is this pt's
hyperbilirubinemia conjugated, unconjugated, or mixed? This is mixed (direct
and indirect) hyperbilirubinemia "<img src=""7927.png"">" Gastrointestinal
Pathology jaundice
Is the hyperbilirubinemia of biliary tract obstruction conjugated, unconjugated, or
mixed? It is conjugated (direct) hyperbilirubinemia "<img src=""7927.png"">"
Gastrointestinal Pathology jaundice
Lab results show high direct bilirubin and normal indirect bilirubin levels. What
type of biliary disease process might cause this? An obstructive process such
as gallstones, primary sclerosing cholangitis, or biliary cirrhosis "<img
src=""7927.png"">" Gastrointestinal Pathology jaundice
Lab results show high indirect bilirubin levels. Does this represent a conjugated,
unconjugated, or mixed hyperbilirubinemia? Unconjugated (indirect)
hyperbilirubinemia "<img src=""7927.png"">" Gastrointestinal Pathology
jaundice
A pt with Dubin-Johnson syndrome comes in to your office. What type of
hyperbilirubinemia does she have? Conjugated (direct) (Dubin-Johnson is a defect
of bile excretion.) "<img src=""7927.png"">" Gastrointestinal Pathology
jaundice
A pt presents with Crigler-Najjar syndrome. What sort of hyperbilirubinemia does
she have? Unconjugated (indirect) (Crigler-Najjar is a defect of conjugation.)
"<img src=""7927.png"">" Gastrointestinal Pathology jaundice
Name some causes of an unconjugated (indirect) hyperbilirubinemia. Hemolysis,
physiologic (in newborns), Crigler-Najjar syndrome, Gilbert syndrome "<img
Name some causes of a conjugated (direct) hyperbilirubinemia associated with
biliary tract obstruction. Gallstones, cholangiocarcinoma, pancreatic or liver
cancer, liver flukes "<img src=""7927.png"">" Gastrointestinal Pathology
jaundice
Name some causes of a conjugated (direct) hyperbilirubinemia that are due to
biliary tract disease but are not obstructive. Primary sclerosing cholangitis,
primary biliary cirrhosis "<img src=""7927.png"">" Gastrointestinal
Pathology jaundice
Name some causes of a conjugated (direct) hyperbilirubinemia that are due to bile
excretion defects. Dubin-Johnson syndrome, Rotor syndrome "<img
A newborn's skin has a yellowish hue for 12 hours after birth. The doctor says it
is a benign condition. What is its molecular basis? Immature UDP-
glucuronosyltransferase in the infant, leading to increased unconjugated bilirubin
levels and jaundice "<img src=""7928.png"">" Gastrointestinal Pathology
physiologic-neonatal-jaundice
A newborn's skin appears yellow for 10 hours after birth. The doctor says it is due
to immature UDP-glucuronosyltransferase. Treatment? Phototherapy, which converts
the unconjugated bilirubin into a water-soluble form that can be excreted in urine
"<img src=""7928.png"">" Gastrointestinal Pathology physiologic-
neonatal-jaundice
"A newborn has severe physiologic neonatal jaundice. A doctor wants to start
phototherapy to ""protect the brain."" What does he mean by this?" Untreated
unconjugated hyperbilirubinemia can cause kernicterus (bilirubin deposition in the
brain, particularly in the basal ganglia) "<img src=""7928.png"">"
Gastrointestinal Pathology physiologic-neonatal-jaundice
A pt has disease symptoms similar to those of Dubin-Johnson syndrome, but you do
not find a grossly black liver. Does the prognosis change? No, as this is Rotor
syndrome, which is a milder form of Dubin-Johnson syndrome "<img src=""7929.png"">"
Gastrointestinal Pathology hereditary-hyperbilirubinemias
What physiologic process is defective in pts with Dubin-Johnson syndrome?
Excretion of bilirubin from hepatocytes "<img src=""7929.png"">"
A pt has defective excretion of direct bilirubin. Gross pathology shows a black
liver. Diagnosis? Dubin-Johnson syndrome, in which the liver appears black on gross
examination "<img src=""7929.png"">" Gastrointestinal Pathology hereditary-
hyperbilirubinemias
You diagnose Dubin-Johnson syndrome in a neonate with conjugated
hyperbilirubinemia. How do you explain the prognosis to the parents? There are no
clinical consequences, as this condition is benign "<img src=""7929.png"">"
A 22-year-old pt new to your practice has a history of benign unconjugated
hyperbilirubinemia. Which hepatic enzyme is likely affected?
Glucuronosyltransferase (specifically UDP-glucuronosyltransferase in the case
of Gilbert syndrome) "<img src=""7929.png"">" Gastrointestinal Pathology
hereditary-hyperbilirubinemias
Unconjugated bilirubin is formed from what substance? Hemoglobin "<img
src=""7929.png"">" Gastrointestinal Pathology hereditary-hyperbilirubinemias
What cells within the liver are part of the mononuclear phagocyte system, aiding in
the conversion of hemoglobin to unconjugated bilirubin? Kupffer cells "<img
Describe the properties of circulating bilirubin in healthy individuals. What
allows it to be transported through the bloodstream? Circulating bilirubin is
unconjugated and water-insoluble; it must be bound to albumin for transport "<img
To enter hepatocytes for processing, through what two spaces must circulating
bilirubin pass? Junctions between endothelial cells in the hepatic sinusoid,
followed by the space of Disse "<img src=""7929.png"">" Gastrointestinal
Pathology hereditary-hyperbilirubinemias
A man has a rare mutation that slightly inhibits passage of bilirubin through the
space of Disse. This presents similarly to what syndrome? Gilbert syndrome (can
consider this to be a form of impaired bilirubin uptake) "<img src=""7929.png"">"
Within hepatocytes, what enzyme converts unconjugated bilirubin to conjugated
bilirubin? What function does it have? UDP-glucuronosyltransferase; it
conjugates the bilirubin "<img src=""7929.png"">" Gastrointestinal
After being acted on by UDP-glucuronosyltransferase, how does bilirubin differ from
a previously circulating form? It is now conjugated (bilirubin diglucuronide)
and is more water soluble "<img src=""7929.png"">" Gastrointestinal
Conjugated bilirubin is secreted into what structure so that it may become a part
of bile? The lumen of the bile canaliculus "<img src=""7929.png"">"
A pt has jaundice and RUQ pain. A common bile duct gallstone is detected. This most
directly impairs what step of bilirubin metabolism? Secretion of conjugated
bilirubin into the lumen of the bile canaliculus due to obstruction/stasis "<img
A college student with no prior medical history presents with scleral icterus
during final exams. What is the likely diagnosis? Gilbert syndrome, likely
precipitated by fasting or stress from studying "<img src=""7929.png"">"
The parents of a child with Gilbert syndrome want to know what complications to
expect. What do you tell them? Gilbert syndrome has no clinical consequences
other than jaundice "<img src=""7929.png"">" Gastrointestinal Pathology
A woman occasionally has jaundice caused by stress, which goes away without
treatment. What is the pathogenesis of this benign condition? Slightly decreased
UDP-glucuronosyltransferase activity or decreased bilirubin uptake by hepatocytes
(This is Gilbert syndrome.) "<img src=""7929.png"">" Gastrointestinal
Which levels are elevated in Gilbert syndrome: conjugated bilirubin, unconjugated
bilirubin, or both? Unconjugated bilirubin, since UDP-glucuronosyltransferase
activity is decreased "<img src=""7929.png"">" Gastrointestinal Pathology
A 1-y/o girl has a new unconjugated hyperbilirubinemia with no lab indications of
hemolysis. What asymptomatic condition is likely? Gilbert syndrome, which can
be triggered by fasting and stress in predisposed individuals "<img
A newborn has defective activity of UDP-glucuronosyltransferase, usually resulting
in death within a few years of birth. Diagnosis? Crigler-Najjar syndrome type
I "<img src=""7929.png"">" Gastrointestinal Pathology hereditary-
hyperbilirubinemias
A 2-week-old boy is diagnosed with Crigler-Najjar syndrome type I. What do you tell
the parents about the prognosis? Death occurs in childhood "<img
A pt has jaundice, kernicterus, and high unconjugated bilirubin levels. He dies at
age 3 years. What enzyme is missing in his disease? UDP-glucuronosyltransferase
(The pt had Crigler-Najjar syndrome type I.) "<img src=""7929.png"">"
The parents of a jaundiced newborn are concerned that he has Crigler-Najjar
syndrome. What type of bilirubinemia would rule this out? Conjugated
hyperbilirubinemia, as Crigler-Najjar syndrome causes impaired conjugation, leading
to an unconjugated hyperbilirubinemia "<img src=""7929.png"">"
What is kernicterus? Bilirubin deposition in the brain "<img src=""7929.png"">"
What would a neonate with absent UDP-glucuronosyltransferase and cerebral palsy be
treated with? Plasmapheresis and phototherapy (for Crigler-Najjar syndrome)
"<img src=""7929.png"">" Gastrointestinal Pathology hereditary-
hyperbilirubinemias
A baby has hyperbilirubinemia from low UDP-glucuronosyltransferase. What drug can
be administered to help you determine the prognosis? Phenobarbital, as it enhances
enzyme synthesis in Crigler-Najjar syndrome type II (less severe/better prognosis)
but has no effect in type I "<img src=""7929.png"">" Gastrointestinal
A newborn has persistent hyperbilirubinemia despite phototherapy. What type of
bilirubinemia supports a diagnosis of Dubin-Johnson syndrome? Conjugated
hyperbilirubinemia (Dubin-Johnson syndrome is a defect of hepatic excretion of
bile.) "<img src=""7929.png"">" Gastrointestinal Pathology hereditary-
hyperbilirubinemias
Name the gene and chromosome associated with Wilson disease. ATP7B gene,
chromosome 13 "<img src=""7930.png"">" Gastrointestinal Pathology wilson-
disease-(hepatolenticular-degeneration)
What is Wilson disease? What is the mode of inheritance? Decreased copper
excretion into bile and blood; recessive mutations in hepatocyte copper-
transporting ATPase "<img src=""7930.png"">" Gastrointestinal Pathology
wilson-disease-(hepatolenticular-degeneration)
A pt has golden-brown corneal rings and hemolytic anemia. What is the cause of his
rare condition? Wilson disease, caused by inadequate hepatic copper excretion and
failure of copper to enter circulation as ceruloplasmin "<img src=""7930.png"">"
Gastrointestinal Pathology wilson-disease-(hepatolenticular-degeneration)
Copper normally enters the blood circulation in what form? As ceruloplasmin "<img
src=""7930.png"">" Gastrointestinal Pathology wilson-disease-
(hepatolenticular-degeneration)
Wilson disease is a systemic condition that affects which organs? Liver,
brain, corneas, kidneys, and joints "<img src=""7930.png"">" Gastrointestinal
Pathology wilson-disease-(hepatolenticular-degeneration)
A man with a defective ATP7B gene is seen by a neurologist for parkinsonian
symptoms. What portion of the brain is most likely affected? The basal ganglia
(due to copper deposition from Wilson disease) "<img src=""7930.png"">"
You evaluate a 25-year-old woman experiencing confusion. You notice a brown ring on
the edge of her iris. What tests would you order? Measurements of serum
ceruloplasmin (which you can expect to be low) and urine copper (which you can
expect to be high) "<img src=""7930.png"">" Gastrointestinal Pathology
What is the name for the copper deposits in the eye of a pt with Wilson disease?
Kayser-Fleischer rings "<img src=""7930.png"">" Gastrointestinal
An ICU pt has fulminant liver failure. You suspect Wilson disease. Which agents
could you use for therapy? Penicillamine or trientine as a chelator, oral zinc.
"<img src=""7930.png"">" Gastrointestinal Pathology wilson-disease-
What cancer is associated with Wilson disease? Hepatocellular carcinoma "<img
A pt with Wilson disease presents with choreiform movements. This is due to copper
deposition in which area of the brain? The basal ganglia "<img src=""7930.png"">"
A pt has hemolytic anemia, asterixis, progressing dementia, and dysarthria. What is
the treatment for this rare condition? Chelation therapy with penicillamine or
trientine, oral zinc (The pt has Wilson disease.) "<img src=""7930.png"">"
The parents of a child with Wilson disease ask about the chances of future children
having the disease. How do you respond? There is a 25% chance, as Wilson disease
has autosomal recessive inheritance "<img src=""7930.png"">" Gastrointestinal
What type of anemia is associated with Wilson disease? Hemolytic anemia "<img
A 30-year-old pt has new-onset dementia, elevated liver function tests, and
discolored rings around his irises. Diagnosis? Wilson disease "<img
A pt with Wilson disease affecting the kidneys will present with what syndrome?
Fanconi syndrome "<img src=""7930.png"">" Gastrointestinal Pathology
Hemochromatosis presents later in women than in men. What is the reason for this?
Monthly blood loss via menses is protective and forestalls iron deposition in
organs "<img src=""7931.png"">" Gastrointestinal Pathology
hemochromatosis
A 40-year-old man is diagnosed with constrictive cardiomyopathy. His father died of
hepatic failure at 45. What condition do you suspect? Hemochromatosis "<img
src=""7931.png"">" Gastrointestinal Pathology hemochromatosis
A pt recently diagnosed with IDDM has pigmented skin and elevated liver function
tests. What stain do you order on liver biopsy? Prussian blue stain for iron (this
is hemochromatosis) "<img src=""7931.png"">" Gastrointestinal Pathology
hemochromatosis
What imaging study is specific for hemochromatosis? Why? MRI because it can
identify hemosiderin "<img src=""7931.png"">" Gastrointestinal Pathology
hemochromatosis
Hemochromatosis causes which three classic symptoms in which three organs?
"Micronodular cirrhosis (liver), pigmentation (skin), and diabetes (pancreas)
the triad of symptoms referred to as ""bronze diabetes""" "<img src=""7931.png"">"
Gastrointestinal Pathology hemochromatosis
What is the pattern of inheritance of primary hemochromatosis? Autosomal
recessive "<img src=""7931.png"">" Gastrointestinal Pathology
hemochromatosis
Primary hemochromatosis is due to which mutations of the HFE gene on chromosome 6?
C282Y, H63D "<img src=""7931.png"">" Gastrointestinal Pathology
hemochromatosis
A pt has a C282Y mutation on the HFE gene that causes symptoms. What are some of
his treatment options? Repeated phlebotomy, chelation with deferasirox or
deferoxamine, oral deferiprone (This is hereditary hemochromatosis.) "<img
src=""7931.png"">" Gastrointestinal Pathology hemochromatosis
Describe ferritin levels, iron levels, TIBC, and transferrin saturation in pts with
hemochromatosis. High, high, low, high "<img src=""7931.png"">"
Gastrointestinal Pathology hemochromatosis
What is an example of secondary hemochromatosis? Long-term transfusion
therapy, which can occur in the setting of disorders such as -thalassemia major
"<img src=""7931.png"">" Gastrointestinal Pathology hemochromatosis
A pt with asymptomatic ulcerative colitis has jaundice, dark urine, and pale
stools. Labs reveal cholestatic hyperbilirubinemia. Diagnosis? Primary sclerosing
cholangitis (PSC) "<img src=""7932.png"">" Gastrointestinal Pathology biliary-
tract-disease
What is the underlying pathology in primary sclerosing cholangitis? "Concentric
""onion skin"" fibrosis of unknown cause (leading to alternating strictures and
dilation of intra-/extrahepatic ducts)" "<img src=""7932.png"">"
Gastrointestinal Pathology biliary-tract-disease
MRCP of a pt with jaundice reveals alternating intra-/extrahepatic bile duct
dilatation. What condition does this suggest? Primary sclerosing cholangitis
"<img src=""7932.png"">" Gastrointestinal Pathology biliary-tract-
disease
P- ANCApositive ulcerative colitis is commonly associated with which biliary tract
disease? Primary sclerosing cholangitis "<img src=""7932.png"">"
A 70-y/o man has never seen a physician and presents with cirrhosis. Diagnosis is
PSC. For what malignancies is he at increased risk? Cholangiocarcinoma and
gallbladder carcinoma "<img src=""7932.png"">" Gastrointestinal Pathology
biliary-tract-disease
Name two imaging techniques that can be used to diagnose primary sclerosis
cholangitis. ERCP and MRCP "<img src=""7932.png"">" Gastrointestinal
Pathology biliary-tract-disease
A 39-y/o woman has a liver biopsy performed. What findings would suggest a
diagnosis of primary biliary cirrhosis? Lymphocytic infiltrate, granulomas,
destruction of intralobular bile ducts "<img src=""7932.png"">"
Which antibody abnormalities are classically seen in pts with primary biliary
cirrhosis? Positive anti-mitochondrial antibodies, elevated IgM antibodies "<img
src=""7932.png"">" Gastrointestinal Pathology biliary-tract-disease
A pt has secondary biliary cirrhosis. What do you expect his conjugated bilirubin,
cholesterol, and alkaline phosphatase levels to be? All increased (a cholestatic
pattern) "<img src=""7932.png"">" Gastrointestinal Pathology biliary-tract-
disease
A pt with CREST syndrome and celiac disease presents with jaundice. What biliary
tract disease does she most likely have? Primary biliary cirrhosis (classically
associated with other autoimmune conditions) "<img src=""7932.png"">"
Which immunoglobulin is elevated in primary sclerosing cholangitis and primary
biliary cirrhosis? Immunoglobulin M "<img src=""7932.png"">"
A pt with secondary biliary cirrhosis presents with fever, abdominal pain, and
severe sepsis. What complication must now be considered? Ascending cholangitis,
which is a bacterial infection facilitated by biliary stasis "<img
src=""7932.png"">" Gastrointestinal Pathology biliary-tract-disease
Name some disease states associated with primary biliary cirrhosis. Autoimmune
conditions such as CREST syndrome, Sgren syndrome, rheumatoid arthritis, and
celiac disease "<img src=""7932.png"">" Gastrointestinal Pathology biliary-
tract-disease
A man with primary sclerosing cholangitis presents with a RUQ mass. After HCC, what
is the next most concerning etiology? Cholangiocarcinoma, a potential
complication of primary sclerosing cholangitis "<img src=""7932.png"">"
A postmenopausal Native American woman receiving HRT is found to have gallstones.
What is the composition of the stones? Cholesterol "<img src=""7933.png"">"
Gastrointestinal Pathology gallstones-(cholelithiasis)
A woman with a history of obesity, OCP use, and multiple pregnancies has
cholelithiasis. Describe the appearance of the stones. Radiolucent (The pt
likely has cholesterol gallstones.) "<img src=""7933.png"">" Gastrointestinal
Pathology gallstones-(cholelithiasis)
A pt w/Crohn disease undergoes small bowel resection. While receiving TPN, he has
fever and RUQ pain; US shows a gallstone. Type of stone? Pigment stone "<img
src=""7933.png"">" Gastrointestinal Pathology gallstones-(cholelithiasis)
Name some conditions associated with pigmented gallstones. Crohn disease, chronic
hemolysis, alcoholic cirrhosis, advanced age, biliary infections, TPN "<img
Approximately what percentage of cholesterol stones are radiopaque? 1020% (due
to calcification) "<img src=""7933.png"">" Gastrointestinal Pathology
gallstones-(cholelithiasis)
A pt with known cholelithiasis presents with RUQ pain after eating a fatty meal.
Name the hormone responsible for gallbladder contraction. Cholecystokinin (CCK)
"<img src=""7933.png"">" Gastrointestinal Pathology gallstones-
(cholelithiasis)
A 40-year-old obese pt presents with dull periumbilical pain. Her lipase level is
elevated. What is likely causing her acute pancreatitis? Cholelithiasis "<img
Why does Crohn disease predispose pts to gallstones? Because of the inability of
the diseased terminal ileum to absorb bile salts "<img src=""7933.png"">"
Name four risk factors for development of cholelithiasis. The 4 F's: Female, Fat,
Fertile (pregnant), Forty "<img src=""7933.png"">" Gastrointestinal
List at least four common risk factors for the formation of cholesterol stones.
Obesity, Crohn disease, cystic fibrosis, advanced age, clofibrate, estrogens,
multiparity, rapid weight loss, Native American origin "<img src=""7933.png"">"
What percentage of gallstones are cholesterol stones? 80% of all gallstones "<img
An alcoholic with a history of cirrhosis and biliary infections will most likely
have what kind of gallstones (radiolucent or radiopaque)? Radiopaque (The pt
likely has pigment gallstones.) "<img src=""7933.png"">" Gastrointestinal
A pt has RUQ pain, jaundice, and fever. Ultrasound shows gallstones, and labs show
elevated WBC count. What is the diagnosis? Acute cholangitis (Charcot triad =
RUQ pain, jaundice, and fever) "<img src=""7933.png"">" Gastrointestinal
A pt presents with nausea, vomiting, and abdominal distention. Abdominal CT reveals
air in the biliary tree. What caused her condition? Gallstone ileus due to a
fistula between the gallbladder and the GI tract. She now has an obstruction of the
IC valve. Pneumobilia is seen. "<img src=""7933.png"">" Gastrointestinal
Name three conditions in which pneumobilia is seen. Gallstone ileus, necrotizing
ascending cholangitis, after ERCP "<img src=""7933.png"">" Gastrointestinal
A 39-year-old overweight woman presents with jaundice and RUQ pain. How would you
diagnose her condition, and what is the treatment? Ultrasound would be used to
identify a distended gallbladder with stones; cholecystectomy "<img
Name at least two major complications of gallstones. Ascending cholangitis, acute
pancreatitis, bile stasis, cholecystitis "<img src=""7933.png"">"
Ultrasound shows an 8-mm stone in the cystic duct of a long-time diabetic man.
Despite this, he had no complaint of significant pain. Why?Diabetic pts might have
neuropathy, which can reduce the sensation of pain from gallstones "<img
A pt has jaundice, fever, and RUQ pain. Likely diagnosis? These symptoms are
classic for the Charcot triad, which indicates cholangitis "<img src=""7933.png"">"
A pt has cholecystitis. What pattern of LFTs would you typically expect?
Usually normal alkaline phosphatase, transaminase and bilirubin levels;
however, increased ALP may suggest involvement of the bile duct "<img
src=""7934.png"">" Gastrointestinal Pathology cholecystitis
A pt presents with abdominal pain. On deep palpation of the RUQ, she appears to
hold her breath. Name this finding. Positive Murphy sign (inspiratory arrest on
deep palpation) indicative of cholecystitis "<img src=""7934.png"">"
Gastrointestinal Pathology cholecystitis
Name three possible causes of cholecystitis. Gallstones (most common),
infection, cytomegalovirus (uncommon), and ischemia "<img src=""7934.png"">"
If the bile duct becomes involved in a pt with cholecystitis, what lab value would
you observe to be increased? Alkaline phosphatase (ALP) "<img src=""7934.png"">"
A pt whom you believe has chronic inflammation of the gallbladder should be
diagnosed using what method? Ultrasound or HIDA scan "<img src=""7934.png"">"
How is porcelain gallbladder usually treated and why? Prophylactic cholecystectomy
due to risk of gallbladder carcinoma "<img src=""7935.png"">"
Gastrointestinal Pathology porcelain-gallbladder
Chronic cholecystitis leads to high rates of gallbladder carcinoma. What is the
most common pathologic carcinoma seen? Adenocarcinoma "<img src=""7935.png"">"
Gastrointestinal Pathology porcelain-gallbladder
Define the pathophysiology of acute pancreatitis. Pancreatic enzymes become
activated, leading to autodigestion of the pancreas "<img src=""7936.png"">"
Gastrointestinal Pathology acute-pancreatitis
List at least five causes of acute pancreatitis. Idiopathic, Gallstones,
Ethanol, Trauma, Steroids, Mumps, Autoimmunity, Scorpions, Hypercalcemia/HTG, ERCP,
Drugs (I GET SMASHED.) "<img src=""7936.png"">" Gastrointestinal Pathology
acute-pancreatitis
You become concerned about acute pancreatitis when an alcoholic man complains of
severe abdominal pain that radiates where? To the back "<img src=""7936.png"">"
A pt has acute epigastric pain radiating to the back. What two values will be
elevated, characterizing his disorder? Amylase and lipase levels will likely be
elevated. (The pt has acute pancreatitis.) "<img src=""7936.png"">"
Which has higher specificity for acute pancreatitis: amylase or lipase? Lipase
(Amylase levels can be elevated in other disorders, such as mumps.) "<img
src=""7936.png"">" Gastrointestinal Pathology acute-pancreatitis
A 67-year-old woman is admitted with acute pancreatitis. What major complications
should you look out for? DIC, ARDS, hypocalcemia, diffuse fat necrosis,
pseudocyst formation, hemorrhage, infection, multisystem organ failure "<img
src=""7936.png"">" Gastrointestinal Pathology acute-pancreatitis
How does acute pancreatitis lead to hypocalcemia? Ca2+ collects in pancreatic
soap deposits, causing hypocalcemia "<img src=""7936.png"">" Gastrointestinal
Pathology acute-pancreatitis
An alcoholic has night blindness and diarrhea. His diarrhea is described as foul
smelling and fatty. Which condition do you suspect? Chronic pancreatitis "<img
src=""7937.png"">" Gastrointestinal Pathology chronic-pancreatitis
Chronic calcifying pancreatitis is strongly associated with what etiology? What is
another common cause? Idiopathic; alcoholism "<img src=""7937.png"">"
Gastrointestinal Pathology chronic-pancreatitis
In an alcoholic woman with chronic pancreatitis, what symptoms would lead you to
suspect pancreatic insufficiency? Steatorrhea, fat-soluble vitamin deficiency,
diabetes mellitus "<img src=""7937.png"">" Gastrointestinal Pathology chronic-
pancreatitis
Describe the pathophysiology of chronic pancreatitis. Chronic inflammation,
atrophy, calcification of the pancreas "<img src=""7937.png"">"
A pt has multiple bouts of alcoholic pancreatitis. When counseling your pt, you
tell him he is at risk for which condition? Pancreatic insufficiency (chronic
pancreatitis) "<img src=""7937.png"">" Gastrointestinal Pathology chronic-
pancreatitis
Which fat-soluble vitamins are not absorbed in a pt with pancreatic insufficiency
secondary to chronic pancreatitis? Vitamins A, D, E, and K "<img src=""7937.png"">"
A severe alcoholic has a CT scan that shows no cirrhosis but diffuse calcification
of his pancreas. What might blood work show? Amylase and lipase levels may or
may not be elevated "<img src=""7937.png"">" Gastrointestinal Pathology
chronic-pancreatitis
An increased risk of pancreatic cancer is associated with which kind of
pancreatitis (acute or chronic)? Chronic "<img src=""7937.png"">"
A pt with a symptomatic CFTR mutation complains of greasy, foul-smelling stools. Is
screening for diabetes merited? Yes, since the pt has cystic fibrosis and may
be developing steatorrhea from pancreatic insufficiency, screening for diabetes is
reasonable "<img src=""7937.png"">" Gastrointestinal Pathology chronic-
pancreatitis
You diagnose a woman with pancreatic adenocarcinoma. What is the prognosis for this
disease? The prognosis is poor with an average survival of 1 year after
diagnosis, as it has typically already metastasized at the time of diagnosis "<img
src=""7938.png"">" Gastrointestinal Pathology pancreatic-adenocarcinoma
A pt presents with weight loss, night sweats, and painless jaundice. Where is the
tumor most likely located? The pancreatic head (Jaundice with a nontender,
palpable gallbladder is the Courvoisier sign, associated with pancreatic
adenocarcinoma.) "<img src=""7938.png"">" Gastrointestinal Pathology
pancreatic-adenocarcinoma
A mass is found on the head of a pt's pancreas. What abnormal lab findings would be
expected? Increased alkaline phosphatase and direct bilirubin levels, indicating
obstructive jaundice "<img src=""7938.png"">" Gastrointestinal Pathology
Obstructive jaundice with a palpable, nontender gallbladder on abdominal exam is
known as what? Courvoisier sign (associated with pancreatic adenocarcinoma but
also possibly due to other acute distal bile duct obstructions) "<img
src=""7938.png"">" Gastrointestinal Pathology pancreatic-adenocarcinoma
You find redness and tenderness on palpation of the extremities in a pt with
pancreatic adenocarcinoma. What is this sign called? Trousseau syndrome, or
migratory thrombophlebitis "<img src=""7938.png"">" Gastrointestinal
Pathology pancreatic-adenocarcinoma
What two ethnic groups have an increased risk for pancreatic cancer? Jewish and
African-American men "<img src=""7938.png"">" Gastrointestinal Pathology
Which two tumor markers are commonly associated with pancreatic cancer? Which is
more specific for the disease? CA 19-9 (more specific) and carcinoembryonic
antigen (CEA) "<img src=""7938.png"">" Gastrointestinal Pathology
Which is most likely to be a risk factor for pancreatic cancer: alcohol, tobacco,
or sulfa drugs? Tobacco "<img src=""7938.png"">" Gastrointestinal
Pathology pancreatic-adenocarcinoma
Proton pump inhibitors work on pumps that exchange which two ions? Hydrogen and
potassium "<img src=""7939.png"">" Gastrointestinal acid-suppression-therapy
pharmacology
H2 blockers work on which stomach cell type? Parietal cells "<img
src=""7939.png"">" Gastrointestinal acid-suppression-therapy pharmacology
Muscarinic antagonists work on which two cell types in the stomach?
Enterochromaffin-like cells (with M1 receptors) and parietal cells (with M3
receptors) "<img src=""7939.png"">" Gastrointestinal acid-suppression-therapy
pharmacology
Why are misoprostol, sucralfate, and bismuth useful in treating gastric ulcers?
These drugs have a protective effect on the mucosa underlying the ulcers
"<img src=""7939.png"">" Gastrointestinal acid-suppression-therapy
pharmacology
Where does somatostatin act? Somatostatin acts on enterochromaffin-like cells via
ST2 receptors "<img src=""7939.png"">" Gastrointestinal acid-suppression-
therapy pharmacology
A surgeon damages the vagus nerve while operating. What type of GI receptors would
be directly affected? Muscarinic antagonists, because the vagus nerve stimulates
the M1 and M3 receptors "<img src=""7939.png"">" Gastrointestinal acid-
suppression-therapy pharmacology
A man has been taking an antacid for GERD pain. What is the mechanism of action for
this drug, and what does it target? Antacids work in the stomach lumen and block
the secretion of acid, or H+ "<img src=""7939.png"">" Gastrointestinal acid-
What type of cell in the antrum is stimulated by food? What hormone is stimulated
by food to promote gastric acid secretion? G cell; gastrin "<img
If a pt is deficient in gastrin, which cells and receptors will be understimulated
in the fundus? Parietal cells and ECLs (Both have G [CCK-B] receptors that are
stimulated by gastrin.) "<img src=""7939.png"">" Gastrointestinal acid-
A pt has a gastric ulcer causing severe pain. Name at least two medications that
can be given to help with ulcer healing. Misoprostol, sucralfate, bismuth "<img
You study stomach gastrin activity. You administer food to rats and take several
biopsies. Which stomach area will show the most activity? The antrum "<img
Most gastric acid secretion (and the actions of medications that inhibit it) can be
found in which area of the stomach? The fundus "<img src=""7939.png"">"
Gastrointestinal acid-suppression-therapy pharmacology
A 50-y/o man w/gastritis starts taking a medication that inhibits cytochrome P-450.
What adverse effects of this drug are seen in men? Prolactin release,
gynecomastia, impotence, decreased libido (Cimetidine is a P-450 inhibitor and has
antiandrogenic effects.) "<img src=""7940.png"">" Gastrointestinal h2-
blockers pharmacology
Name at least two clinical uses of H2 blockers. Treatment of peptic ulcers,
gastritis, mild esophageal reflux "<img src=""7940.png"">" Gastrointestinal
h2-blockers pharmacology
A pt takes more than 10 medications for various reasons. You are worried about drug
interactions. Which H2 blocker should you avoid? Cimetidine, as it causes
inhibition of cytochrome P-450 and may alter the metabolism of other drugs "<img
src=""7940.png"">" Gastrointestinal h2-blockers pharmacology
Which two H2 blockers can decrease the renal excretion of creatinine? Ranitidine
and cimetidine "<img src=""7940.png"">" Gastrointestinal h2-blockers
pharmacology
A 47-year-old woman has developed confusion, dizziness, and headaches since she
began taking an H2 blocker. What is happening? Cimetidine (able to cross the
blood-brain barrier, unlike other H2 blockers) can cause confusion, dizziness, and
headaches "<img src=""7940.png"">" Gastrointestinal h2-blockers pharmacology
A woman taking a specific H2 blocker wants to get pregnant. Her doctor says she
needs to stop taking the H2 blocker. Why? Cimetidine, the H2 blocker she is likely
taking, is dangerous to the fetus, because it can cross the placenta "<img
A woman has unexpected galactorrhea; medications include sertraline, pantoprazole,
cimetidine, aspirin, & simvastatin. Is a drug to blame? Yes, as cimetidine can
increase prolactin levels, which may cause galactorrhea "<img src=""7940.png"">"
Gastrointestinal h2-blockers pharmacology
Give at least two examples of H2 blockers. "Cimetidine, ranitidine,
famotidine, nizatidine (Take H2 blockers before you dine. Think ""table for 2"" to
remember H2.)" "<img src=""7940.png"">" Gastrointestinal h2-blockers
pharmacology
What substance is the endogenous agonist of the H2 receptor? Histamine "<img
What is the effect of H2 blockers on parietal cells? Reversible decrease of
hydrogen ion secretion "<img src=""7940.png"">" Gastrointestinal h2-blockers
pharmacology
A 34-y/o woman reports ranitidine doesn't relieve her epigastric pain; stool is
negative for H pylori antigens. What drug should be added? Omeprazole,
esomeprazole, pantoprazole, lansoprazole, or dexlansoprazole (proton pump
inhibitors) "<img src=""7941.png"">" Gastrointestinal pharmacology proton-
pump-inhibitors
Proton pump inhibitors work by irreversibly inhibiting this protein in stomach
parietal cells. H+/K+ ATPase "<img src=""7941.png"">" Gastrointestinal
pharmacology proton-pump-inhibitors
Name at least two conditions that are treated with proton pump inhibitors. Peptic
ulcers, gastritis, esophageal reflux, Zollinger-Ellison syndrome "<img
src=""7941.png"">" Gastrointestinal pharmacology proton-pump-inhibitors
A pt has been using proton pump inhibitors for a long time. His level of which
divalent electrolyte is likely decreased? Magnesium "<img src=""7941.png"">"
Gastrointestinal pharmacology proton-pump-inhibitors
A pt in the ICU is intubated and begins receiving a PPI for GI prophylaxis. Later
he develops severe, foul-smelling diarrhea. Diagnosis? Clostridium difficile
colitis (Treatment with a PPI is a risk factor for its development.) "<img
src=""7941.png"">" Gastrointestinal pharmacology proton-pump-inhibitors
A 54-y/o woman being treated for CHF and hypothyroidism has started taking daily
antacids. How might this affect her other medications? It might interfere with
absorption, bioavailability, and urinary excretion by altering gastric and urinary
pH and delaying gastric emptying "<img src=""7942.png"">" Gastrointestinal
antacid-use pharmacology
Name at least two compounds commonly used as antacids. Aluminum hydroxide,
calcium carbonate, magnesium hydroxide "<img src=""7942.png"">"
Gastrointestinal antacid-use pharmacology
A pt presents with constipation, proximal muscle weakness, and seizures. What
antacid is he likely using? Aluminum hydroxide "<img src=""7942.png"">"
Diarrhea, hyporeflexia, hypotension, cardiac arrest, and hypokalemia are side
effects of which antacid? Magnesium hydroxide "<img src=""7942.png"">"
A young pt is overusing the antacid calcium carbonate. What adverse effects does
this cause? Hypercalcemia (milk-alkali syndrome), rebound acid increase"<img
src=""7942.png"">" Gastrointestinal antacid-use pharmacology
All antacids cause what electrolyte abnormality if they are overused? Hypokalemia
"<img src=""7942.png"">" Gastrointestinal antacid-use pharmacology
A pt who heavily self-medicates for GERD complains of dizziness and diarrhea. Which
antacid is she likely overusing? Magnesium hydroxide, as it can cause diarrhea
and hypotension "<img src=""7942.png"">" Gastrointestinal antacid-use
pharmacology
A pt has hypophosphatemia and osteodystrophy. What medication is he likely
overusing to treat his GERD? Aluminum hydroxide "<img src=""7942.png"">"
A pt with GERD needs to take tetracycline for an infection. Why should you check
the medication list before starting treatment? Calcium carbonate antacids can
chelate and reduce the effectiveness of certain other oral medications, such as
tetracycline "<img src=""7942.png"">" Gastrointestinal antacid-use
pharmacology
What is the mechanism of action of bismuth and sucralfate? They bind to ulcer
bases, providing physical protection and allowing bicarbonate secretion to
reestablish a pH gradient in the mucous layer "<img src=""7943.png"">"
Gastrointestinal bismuth,-sucralfate pharmacology
A man presents with traveler's diarrhea. What two drugs might you choose to help
reestablish the pH gradient in the mucous layer? Bismuth and sucralfate "<img
src=""7943.png"">" Gastrointestinal bismuth,-sucralfate pharmacology
How does misoprostol act? As a synthetic prostaglandin E1 analog, it increases
production and secretion of gastric mucus and decreases acid production "<img
src=""7944.png"">" Gastrointestinal misoprostol pharmacology
How does misoprostol affect gastric mucus and acid? It increases the production
and secretion of gastric mucus and decreases the production of acid. "<img
A pt with rheumatoid arthritis starts taking misoprostol because she was unable to
tolerate her prior treatment. What was the complication? Peptic ulcers induced by
NSAIDs (Misoprostol increases gastric mucus production and decreases acid
production.) "<img src=""7944.png"">" Gastrointestinal misoprostol
pharmacology
A neonate is noted to be cyanotic on the third day of life. What medication should
be ordered immediately? Misoprostol, which maintains a patent ductus arteriosus,
allowing pulmonary and systemic circulations to mix in cases of heart disease
"<img src=""7944.png"">" Gastrointestinal misoprostol pharmacology
A woman is given misoprostol at 42 weeks' gestation. Why? To induce labor "<img
Within what population is misoprostol contraindicated? Women of childbearing
potential because it is an abortifacient "<img src=""7944.png"">"
Gastrointestinal misoprostol pharmacology
A 22-year-old woman requests a chemical abortion of her pregnancy. She receives a
PGE1 analog. What side effect should she expect? Diarrhea, as she has likely
been given misoprostol "<img src=""7944.png"">" Gastrointestinal misoprostol
pharmacology
A pt receiving drug therapy for a VIPoma experiences nausea, cramps, and
steatorrhea. What medication is she likely receiving? Octreotide "<img
src=""7945.png"">" Gastrointestinal octreotide pharmacology
A pt presents with bleeding esophageal varices. Name a drug that can quickly help
stop the bleeding and describe its mechanism of action. Octreotide, a long-
acting somatostatin analog, inhibits secretion of many splanchnic vasodilatory
hormones "<img src=""7945.png"">" Gastrointestinal octreotide pharmacology
A man with recent onset of excessive growth hormone secretion and a woman with a
carcinoid tumor could both benefit from what drug? Octreotide "<img
src=""7945.png"">" Gastrointestinal octreotide pharmacology
A pt who has both constipation and hepatic encephalopathy should be given which
medication? Lactulose, since it addresses both problems "<img src=""7946.png"">"
Gastrointestinal osmotic-laxatives pharmacology
A pt with a history of bulimia is found to be dehydrated. Abuse of what GI
medication could contribute to this finding? Osmotic laxatives "<img
src=""7946.png"">" Gastrointestinal osmotic-laxatives pharmacology
Magnesium hydroxide, magnesium citrate, polyethylene glycol, and lactulose all
belong to which class of medication? Osmotic laxatives "<img src=""7946.png"">"
Gastrointestinal osmotic-laxatives pharmacology
For a 24-year-old man with ulcerative colitis, you prescribe a medication that is a
combination of two drugs. What are these? Sulfapyridine and 5-aminosalicylic acid
(The medicine is sulfasalazine.) "<img src=""7947.png"">" Gastrointestinal
pharmacology sulfasalazine
What is the function of sulfapyridine? It is an antibiotic "<img
src=""7947.png"">" Gastrointestinal pharmacology sulfasalazine
What activates sulfasalazine in the gut? Be specific. Colonic bacteria activate
sulfasalazine "<img src=""7947.png"">" Gastrointestinal pharmacology
sulfasalazine
A 30-year-old man starts taking a drug composed of sulfapyridine and 5-
aminosalicylic acid for Crohn disease. What are the side effects? Reversible
oligospermia, malaise, nausea, sulfonamide toxicity (The drug is sulfasalazine.)
"<img src=""7947.png"">" Gastrointestinal pharmacology sulfasalazine
A pt is found to have Crohn ileitis and asks if he can begin taking sulfasalazine.
What is the appropriate response? Sulfasalazine would be ineffective, because it
is activated by colonic bacteria and thus has no effect proximal to the colon
"<img src=""7947.png"">" Gastrointestinal pharmacology sulfasalazine
What component of sulfasalazine is known to be anti-inflammatory? 5-
Aminosalicylic acid "<img src=""7947.png"">" Gastrointestinal pharmacology
sulfasalazine
A pt receiving chemotherapy has frequent diarrhea relieved by loperamide. What is
loperamide's mechanism of action? As an agonist at -opioid receptors, loperamide
slows gut motility "<img src=""7948.png"">" Gastrointestinal loperamide
pharmacology
What is the addictive profile of loperamide? Low "<img src=""7948.png"">"
Gastrointestinal loperamide pharmacology
Does loperamide cross the blood-brain barrier? No "<img src=""7948.png"">"
Gastrointestinal loperamide pharmacology
Ondansetron is an antagonist of what receptor type? 5-Hydroxytryptamine3 "<img
src=""7949.png"">" Gastrointestinal ondansetron pharmacology
Ondansetron is used to control vomiting primarily in which two settings? After
surgery and in conjunction with cancer chemotherapy (At a party but feeling queasy?
Keep on dancing with ondansetron!) "<img src=""7949.png"">" Gastrointestinal
ondansetron pharmacology
You give a 47-y/o woman a 5-HT3 antagonist for her nausea during chemotherapy. What
two main adverse effects should you expect? Headache and constipation, as the
5-HT3 antagonist is ondansetron "<img src=""7949.png"">" Gastrointestinal
ondansetron pharmacology
What is the mechanism of action of ondansetron? It binds 5-HT3 receptors and
antagonizes them, decreasing vagal stimulation "<img src=""7949.png"">"
Gastrointestinal ondansetron pharmacology
In the ED, you see a pt receiving a 5-HT3 antagonist for nausea and are told to
recheck her ECG. Why? The pt is receiving ondansetron, which decreases vagal
stimulation and may cause QT prolongation "<img src=""7949.png"">"
Gastrointestinal ondansetron pharmacology
What is the mechanism of action of metoclopramide? It is a dopamine receptor
antagonist (specifically the D2 receptor) "<img src=""7950.png"">"
Gastrointestinal metoclopramide pharmacology
Metoclopramide is contraindicated in pts with what serious gastrointestinal
disorder? Small bowel obstruction; it is prokinetic and thus can cause bowel
perforation "<img src=""7950.png"">" Gastrointestinal metoclopramide
pharmacology
On which parts of the gastrointestinal tract does metoclopramide act? Lower
esophageal sphincter (increases tone and contractility), stomach, small bowel
(increases motility); it has no effect on the colon "<img src=""7950.png"">"
Give at least two clinical uses of metoclopramide. Diabetic gastroparesis,
postsurgical gastroparesis, antiemesis "<img src=""7950.png"">"
A pt with Parkinson disease and profuse vomiting asks for metoclopramide. Why does
the doctor disagree with this choice? Metoclopramide, a D2 receptor antagonist,
can cross-react with and block D1 receptors, exacerbating parkinsonian symptoms
"<img src=""7950.png"">" Gastrointestinal metoclopramide pharmacology
A 74-y/o woman has hypovolemia due to gastroenteritis. Would you first prescribe
ondansetron or metoclopramide for her nausea? Ondansetron because metoclopramide
is useful in GI-based nausea but has a greater risk of adverse effects in the
elderly "<img src=""7950.png"">" Gastrointestinal metoclopramide
pharmacology
A man wants a refill of a medication a previous doctor prescribed for weight loss.
He says it gives him greasy stools. What drug is it? Orlistat (inhibits gastric
and pancreatic lipase) "<img src=""7951.png"">" Gastrointestinal orlistat
pharmacology
A pt asks about a weight loss drug she saw on TV, which has greasy stools and
vitamin deficiencies as side effects. How does the drug work? It inhibits
gastric and pancreatic lipase (The drug is orlistat.) "<img src=""7951.png"">"
Gastrointestinal orlistat pharmacology
A pt with asymptomatic gallstones is given what medication to dissolve them?
Ursodiol (ursodeoxycholic acid) "<img src=""7952.png"">"
Gastrointestinal pharmacology ursodiol-(ursodeoxycholic-acid)
What is the mechanism of action of ursodiol (ursodeoxycholic acid)? It increases
bile secretion and decreases cholesterol secretion and reabsorption "<img
src=""7952.png"">" Gastrointestinal pharmacology ursodiol-(ursodeoxycholic-
acid)
Name two clinical indications for prescribing ursodiol (ursodeoxycholic acid).
Primary biliary cirrhosis and gallstone prevention/dissolution "<img
src=""7952.png"">" Gastrointestinal pharmacology ursodiol-(ursodeoxycholic-
acid)
Describe the basic function of an erythrocyte. To carry O2 from the lungs to
peripheral tissues and return CO2 from peripheral tissues to the lungs for
elimination "<img src=""7953.png"">" Hematology-and-Oncology anatomy
erythrocyte
Describe the molecular constitution of an RBC. Biconcave structure with large
surface-to-volume ratio for gas exchange, anucleate and lacking organelles "<img
src=""7953.png"">" Hematology-and-Oncology anatomy erythrocyte
What exchange transporter helps RBCs carry CO2? Cl/HCO3 antiporter on the membrane
"<img src=""7953.png"">" Hematology-and-Oncology anatomy erythrocyte
On what molecule do erythrocytes depend exclusively for energy? Glucose "<img
How would you describe a peripheral blood smear showing RBCs of varying sizes and
shapes? The smear exhibits anisocytosis (varying sizes) and poikilocytosis
(varying shapes) "<img src=""7953.png"">" Hematology-and-Oncology anatomy
erythrocyte
How long is the life span of an erythrocyte? 120 days "<img src=""7953.png"">"
Hematology-and-Oncology anatomy erythrocyte
Reticulocytes contain RNA. What stain would you use to evaluate RNA, and what color
would it appear? Wright-Giemsa stain; blue "<img src=""7953.png"">"
Hematology-and-Oncology anatomy erythrocyte
A blood smear from a patient with severe anemia contains immature RBC forms. What
does this mean? Immature RBCs, or reticulocytes, reflect erythroid proliferation
(an attempt by the patient's bone marrow to replenish the lost RBCs) "<img
On a routine complete blood count, a patient's hematocrit is noted to be high. What
does this suggest about the patient's RBC count? That it is increased (this is
called erythrocytosis, or polycythemia) "<img src=""7953.png"">" Hematology-
and-Oncology anatomy erythrocyte
How do mature platelets form from megakaryocyte precursors?Small portions of
cytoplasm break off from the megakaryocyte "<img src=""7954.png"">"
Hematology-and-Oncology anatomy thrombocyte-(platelet)
What is the life span of a platelet? 8-10 days "<img src=""7954.png"">"
Hematology-and-Oncology anatomy thrombocyte-(platelet)
Describe the process of platelet aggregation to form a platelet plug. When
activated by endothelial injury, they aggregate with other platelets and interact
with fibrinogen to from a platelet plug "<img src=""7954.png"">" Hematology-
and-Oncology anatomy thrombocyte-(platelet)
What two types of granules do platelets contain? Dense granules and alpha
granules "<img src=""7954.png"">" Hematology-and-Oncology anatomy
thrombocyte-(platelet)
What are the contents of the dense granules of platelets? Adenosine diphosphate,
calcium "<img src=""7954.png"">" Hematology-and-Oncology anatomy
What are the contents of the -granules of platelets? Von Willebrand factor,
fibrinogen, fibronectin "<img src=""7954.png"">" Hematology-and-Oncology
anatomy thrombocyte-(platelet)
About what percentage of platelets does the spleen store? 0.33 "<img
src=""7954.png"">" Hematology-and-Oncology anatomy thrombocyte-(platelet)
What skin finding is typically noted in thrombocytopenic patients? Petechiae
"<img src=""7954.png"">" Hematology-and-Oncology anatomy thrombocyte-
(platelet)
In primary hemostasis, von Willebrand factor must be released and bind to what
platelet receptor? Glycoprotein Ib "<img src=""7954.png"">" Hematology-
and-Oncology anatomy thrombocyte-(platelet)
In the formation of a stable thrombus, fibrinogen binds platelets together via what
receptor? Glycoprotein IIb/IIIa "<img src=""7954.png"">" Hematology-and-
Oncology anatomy thrombocyte-(platelet)
A woman taking aspirin is undergoing surgery. How long before surgery must she
discontinue aspirin? At least 810 days before surgery (this is the lifespan of
a platelet) "<img src=""7954.png"">" Hematology-and-Oncology anatomy
A patient undergoes splenectomy. Blood loss is minimal. After surgery, platelet
count has increased by more than 25%. What happened? Approximately a third of the
platelet pool is normally stored in the spleenthese platelets were released into
circulation during surgery "<img src=""7954.png"">" Hematology-and-Oncology
anatomy thrombocyte-(platelet)
On the skin of a pt, you see small red lesions that do not blanch with pressure.
Name two possible etiologies of these lesions. These are petechiae, which can be
caused by a low platelet count (thrombocytopenia) or dysfunctional platelets "<img
src=""7954.png"">" Hematology-and-Oncology anatomy thrombocyte-(platelet)
Granulocytes and mononuclear cells are what kind of blood cells? Leukocytes (leuk =
white and cyte = cell) "<img src=""7955.png"">" Hematology-and-Oncology
anatomy leukocyte
Name three types of granulocytes. Basophils, eosinophils, and neutrophils "<img
src=""7955.png"">" Hematology-and-Oncology anatomy leukocyte
Name two types of mononuclear cells. Lymphocytes and monocytes "<img
What is the main function of leukocytes? To defend against infection "<img
How many leukocytes are normally found per cubic milliliter (cells/mm3) of blood?
4000 to 10,000 cells/mm3 "<img src=""7955.png"">" Hematology-and-
Oncology anatomy leukocyte
In a test, you separate all granulocytes from all mononuclear cells. Which of the
two groups will likely have a higher number of cells? Granulocytes, making up 55-
65.75% of all leukocytes (mononuclear cells are the remaining 34.25-45%) "<img
Patients taking clozapine require weekly blood draws to screen for agranulocytosis.
What cell types are most affected? Granulocytesnamely, neutrophils, eosinophils,
and basophils "<img src=""7955.png"">" Hematology-and-Oncology anatomy
leukocyte
Which type of leukocyte mediates acute inflammatory responses? Neutrophil "<img
src=""7956.png"">" Hematology-and-Oncology anatomy neutrophil
An increase in number of neutrophils indicates what type of infection? Bacterial
"<img src=""7956.png"">" Hematology-and-Oncology anatomy neutrophil
A peripheral smear reveals increased bands (immature neutrophils). What does this
reflect? State of increased myeloid proliferation (bacterial infection, CML)
"<img src=""7956.png"">" Hematology-and-Oncology anatomy neutrophil
What do specific granules in neutrophils contain? Leukocyte alkaline
phosphatase, lactoferrin, lysozyme, collagenase "<img src=""7956.png"">"
Hematology-and-Oncology anatomy neutrophil
What structure contains proteinases, acid phosphatase, myeloperoxidase, and B-
glucuronidase? Lysosomes (azurophilic granules) "<img src=""7956.png"">"
What are hypersegmented neutrophils? In which nutrient deficiency are they seen?
Nucleus with 6-plus lobes; seen in vitamin B12/folate deficiency "<img
src=""7956.png"">" Hematology-and-Oncology anatomy neutrophil
Name some neutrophilic chemotactic agents. C5a, LTB4, IL-8, platelet-
activating factor, kallikrein "<img src=""7956.png"">" Hematology-and-Oncology
anatomy neutrophil
What are the contents of small granules in neutrophils? ALP, collagenase,
lysozyme, lactoferrin "<img src=""7956.png"">" Hematology-and-Oncology
anatomy neutrophil
A patient is seen for a red, swollen, painful fifth finger. Blood smear reveals
increased WBCs with multilobed nuclei. What are they? Neutrophils, which respond to
acute inflammation "<img src=""7956.png"">" Hematology-and-Oncology
anatomy neutrophil
A 78-year-old woman has depression, weakness, and leg paresthesias. Blood smear
shows hypersegmented neutrophils. A possible diagnosis? Vitamin B12 deficiency
(folate deficiency can cause similar blood smear findings, but only B12 causes
neurologic symptoms) "<img src=""7956.png"">" Hematology-and-Oncology
anatomy neutrophil
A 65-year-old woman with CML has her blood drawn. What do you expect to see on the
complete blood count report? A high number of band cells (immature neutrophils),
reflecting increased myeloid proliferation "<img src=""7956.png"">"
"You are rounding with your team. The attending says to you, ""Your patient has a
bunch of bands in his blood."" What does that mean?" Bands are immature
neutrophils, usually seen during states of increased myeloid proliferation such as
bacterial infection or CML "<img src=""7956.png"">" Hematology-and-Oncology
anatomy neutrophil
Under the microscope in your lab, you note a neutrophil with several azurophilic
granules. What is contained within these granules? These granules (also known as
lysosomes) contain proteinases, acid phosphatase, myeloperoxidase, and -
glucuronidase "<img src=""7956.png"">" Hematology-and-Oncology anatomy
neutrophil
A peripheral blood smear shows multiple neutrophils (nuclei of six, seven, or even
eight lobes). Lab tests needed to diagnose the cause? Vitamin B12 and folate tests
(hypersegmented polys [neutrophils] with five or more lobes are present in
deficiencies of either vitamin) "<img src=""7956.png"">" Hematology-and-
Oncology anatomy neutrophil
A man has a bacterial infection. Leukocyte counts are high. You send serum for
studies of chemotactic agents. Which ones will be high? All neutrophil
chemotactic agents, which include C5a, IL-8, LTB4, kallikrein, and platelet-
activating factor "<img src=""7956.png"">" Hematology-and-Oncology anatomy
neutrophil
Describe the identifying features of a monocyte. Monocytes have large, kidney-
shaped nuclei and extensive frosted-glass cytoplasm "<img src=""7957.png"">"
Hematology-and-Oncology anatomy monocyte
What cells differentiate into macrophages in tissue? Mono = one (nucleus); cyte =
cell "<img src=""7957.png"">" Hematology-and-Oncology anatomy monocyte
What role do macrophages play in the immunologic response to extracellular
pathogens? They function as antigen-presenting cells by way of major
histocompatibility complex class II molecules "<img src=""7958.png"">"
Hematology-and-Oncology anatomy macrophage
What are the function of macrophages? Phagocytoses bacteria, cellular debris,
and senescent RBCs "<img src=""7958.png"">" Hematology-and-Oncology
anatomy macrophage
What substance activates macrophages? Interferon- "<img src=""7958.png"">"
Hematology-and-Oncology anatomy macrophage
A patient with TB has numerous granulomas on bronchoscopy. The leukocyte important
to their formation was activated from which precursor? Monocytes differentiate
into macrophages within the tissuesmacrophages are important in granuloma
formation "<img src=""7958.png"">" Hematology-and-Oncology anatomy
macrophage
A patient is in septic shock. Lab studies show increased bacterial LPS. How is this
contributing to the patient's pathology? The lipid A component of bacterial LPS
binds to CD14 on macrophages, which can trigger septic shock "<img
src=""7958.png"">" Hematology-and-Oncology anatomy macrophage
Eosinophils are phagocytic cells, particularly in the presence of what?
Antigen-antibody complexes "<img src=""7959.png"">" Hematology-and-
Oncology anatomy eosinophil
Name five diagnoses to consider in a patient found to have eosinophilia.
Neoplasm, Asthma, Allergic reaction, Chronic adrenal insufficiency, Parasites
(invasive)(NAACP) "<img src=""7959.png"">" Hematology-and-Oncology anatomy
eosinophil
What is the function of eosinophils? Defends against helminthic infections
(major basic protein) "<img src=""7959.png"">" Hematology-and-Oncology
anatomy eosinophil
What enzymes are produced by eosinophils? Histaminase and major basic protein (a
helminthotoxin) "<img src=""7959.png"">" Hematology-and-Oncology anatomy
eosinophil
A boy has anal pruritus because of a helminth infection. Which granulocyte enzyme
is important in the body's defense against this parasite? Major basic protein (a
helminthotoxin), which is secreted by eosinophils "<img src=""7959.png"">"
Hematology-and-Oncology anatomy eosinophil
A man's blood smear shows numerous cells with bilobate nuclei and large
eosinophilic uniform-sized granules. What diagnoses do you consider? Eosinophilia
in Neoplasia, Asthma, Allergic reaction, Collagen vascular disease, Parasites
(NAACP) "<img src=""7959.png"">" Hematology-and-Oncology anatomy
eosinophil
A healthy man has no need for leukotriene output. If you isolate his basophils and
study the intracellular contents, are leukotrienes found? Noleukotrienes are both
synthesized and released on demand by basophils, and therefore none will be found
if they are not needed "<img src=""7960.png"">" Hematology-and-Oncology
anatomy basophil
What molecules are released during basophil degranulation? What stain is best for
identifying basophils? Heparin (anticoagulant), histamine (causes vasodilation),
and leukotrienes are released; basophils stain best with basic stains "<img
src=""7960.png"">" Hematology-and-Oncology anatomy basophil
What is the function of basophils? They mediate allergic reaction "<img
src=""7960.png"">" Hematology-and-Oncology anatomy basophil
In which type of hypersensitivity reactions are mast cells involved? Type I
reactions (mast cells mediate allergic reactions in local tissues) "<img
src=""7961.png"">" Hematology-and-Oncology anatomy mast-cell
What stimulus causes degranulation of mast cells? Antigen binding to IgE-Fc
receptor complexes on the surfaces of mast cells "<img src=""7961.png"">"
Hematology-and-Oncology anatomy mast-cell
What medication could prevent exacerbation of asthma (by preventing the release of
inflammatory compounds from mast cells)? Cromolyn sodium, which stabilizes mast
cell membranes and prevents degranulation "<img src=""7961.png"">" Hematology-
and-Oncology anatomy mast-cell
What other cell type do mast cells resemble, both structurally and functionally?
Basophils "<img src=""7961.png"">" Hematology-and-Oncology anatomy
mast-cell
Describe the process of mast cell degranulation, starting with antibody binding.
Fc portion of IgE binds to the mast cell membrane, IgE cross-links on antigen
stimulation, degranulation occurs "<img src=""7961.png"">" Hematology-and-
Oncology anatomy mast-cell
What is the function of dendritic cell? Dendritic cells are phagocytes and
antigen-presenting cells "<img src=""7962.png"">" Hematology-and-Oncology
anatomy dendritic-cell
What are dendritic cells in the skin called? Langerhans cells "<img
src=""7962.png"">" Hematology-and-Oncology anatomy dendritic-cell
What are the three types of lymphocytes? B cells, T cells (B and T cells mediate
adaptive immunity), and NK cells (part of the innate immune response) "<img
src=""7963.png"">" Hematology-and-Oncology anatomy lymphocyte
After maturation, where do B lymphocytes migrate to from the bone marrow?
Peripheral lymphoid tissue (lymph node follicles, white pulp of spleen, other
unencapsulated lymphoid tissue) "<img src=""7964.png"">" Hematology-and-
Oncology anatomy b-cell
What is the response of a B cell after encountering an antigen? B cells
differentiate into plasma cells (secrete antibodies) and memory cells "<img
src=""7964.png"">" Hematology-and-Oncology anatomy b-cell
What major histocompatibility complex do B cells possess on the cell surface?
MHC II, which allows B cells to act as antigen-presenting cells "<img
src=""7964.png"">" Hematology-and-Oncology anatomy b-cell
Name the three types of mature cells into which T cells differentiate. Cytotoxic T
cells, helper T cells, and regulatory T cells "<img src=""7965.png"">"
Hematology-and-Oncology anatomy t-cell
Which major histocompatibility complex and CD molecules are expressed by cytotoxic
T cells? MHC I and CD8 (MHC 1 CD8 = 8 "<img src=""7965.png"">"
Which MHC and CD molecules are expressed by helper T cells?MHC II and CD4 (MHC 2
CD 4 = 8) "<img src=""7965.png"">" Hematology-and-Oncology anatomy t-cell
T lymphocytes mediate which type of immune response? Cellular "<img
src=""7965.png"">" Hematology-and-Oncology anatomy t-cell
What costimulatory molecule present on B cells is required to activate T cells?
CD28 "<img src=""7965.png"">" Hematology-and-Oncology anatomy t-cell
What is the predominant type of lymphocyte found in the circulation? T cells,
which make up approximately 80% of circulating lymphocytes "<img src=""7965.png"">"
What is the primary cellular target of HIV? CD4+ helper T cells "<img
src=""7965.png"">" Hematology-and-Oncology anatomy t-cell
What is the main role of plasma cells? To produce large amounts of antibody
specific to a particular antigen "<img src=""7966.png"">" Hematology-and-
Oncology anatomy plasma-cell
What are the characteristic features of plasma cells? "Plasma cells have eccentric
nuclei with ""clock-face"" chromatin, abundant RER, and well-developed Golgi
apparatus" "<img src=""7966.png"">" Hematology-and-Oncology anatomy plasma-
cell
Where are plasma cells found? Bone marrow "<img src=""7966.png"">" Hematology-
and-Oncology anatomy plasma-cell
What cancer results from plasma cells? Multiple myeloma "<img src=""7966.png"">"
Hematology-and-Oncology anatomy plasma-cell
You note that a pt's bone marrow shows a monoclonal proliferation of plasma cells.
What is the diagnosis? Multiple myeloma "<img src=""7966.png"">" Hematology-
and-Oncology anatomy plasma-cell
During weeks 38 of embryogenesis, where does erythropoiesis occur? Yolk sac
"<img src=""7967.png"">" Hematology-and-Oncology fetal-erythropoiesis
physiology
Describe the constitution of fetal hemoglobin. Two -globulins, two -globulins
physiology
From week 6 of embryogenesis until birth, where does erythropoiesis occur? Liver
physiology
Describe the constitution of adult hemoglobin. Two -globulins, two -globulins
physiology
During weeks 1028 of embryogenesis, where does erythropoiesis occur? Spleen
physiology
How does fetal hemoglobin extract oxygen from maternal hemoglobin? Fetal Hb has
higher affinity for oxygen, allowing it to extract oxygen from maternal Hb across
the placenta "<img src=""7967.png"">" Hematology-and-Oncology fetal-
erythropoiesis physiology
From week 18 of embryogenesis until adulthood, where does erythropoiesis occur?
Bone marrow "<img src=""7967.png"">" Hematology-and-Oncology fetal-
erythropoiesis physiology
Which molecule binds less avidly to fetal hemoglobin, giving it a higher affinity
to oxygen? 2,3-BPG "<img src=""7967.png"">" Hematology-and-Oncology
fetal-erythropoiesis physiology
A man is in a car accident and requires a blood transfusion. His blood type is AB+.
Which blood groups can the patient receive safely? All blood types (A+, B+, AB+,
O) "<img src=""7968.png"">" Hematology-and-Oncology blood-groups physiology
Which circulating antibodies can be found in the plasma of a patient with the A+
blood type? Anti-B IgM "<img src=""7968.png"">" Hematology-and-Oncology
blood-groups physiology
Which circulating antibodies can be found in the plasma of a patient with the B+
blood type? Anti-A IgM "<img src=""7968.png"">" Hematology-and-Oncology
Which circulating antibodies can be found in the plasma of a patient with an O
blood type? Anti-A IgM and anti-B IgM "<img src=""7968.png"">" Hematology-
and-Oncology blood-groups physiology
A man's blood has both A and B antigens. A transfusion is needed, but only type AB
blood is available. Can it be given without hemolysis? Yes; people with AB
blood are universal recipients of RBCs and can be given any ABO blood type without
hemolysis "<img src=""7968.png"">" Hematology-and-Oncology blood-groups
physiology
A doctor mistakenly administers AB+ blood to a patient with B+ blood. What reaction
will be seen? Why? Hemolytic reaction; the patient has anti-A IgM antibodies
in plasma "<img src=""7968.png"">" Hematology-and-Oncology blood-groups
physiology
A patient's blood is found to contain the A antigen. Transfusion of blood with
which two ABO antigen groups produces a hemolytic reaction?Types B and AB "<img
src=""7968.png"">" Hematology-and-Oncology blood-groups physiology
A patient's blood is found to contain the B antigen. Transfusion of blood with
which two ABO antigen groups produces a hemolytic reaction?Types A and AB "<img
src=""7968.png"">" Hematology-and-Oncology blood-groups physiology
A man's blood has neither A nor B antigens. A plasma transfusion is required. Is
the risk of ABO-related hemolysis high? No; the man has type O blood and is a
universal recipient of plasma (no risk of transfused anti-A or anti-B antibodies'
binding to his RBCs) "<img src=""7968.png"">" Hematology-and-Oncology
A pregnant woman is hemorrhaging, and there is no time to cross and match for a
blood transfusion. What blood type do you give? Why? O-negative; exposure to Rh-
positive blood stimulates the formation of anti-Rh IgG antibodies, which may
complicate future pregnancies "<img src=""7968.png"">" Hematology-and-Oncology
A woman is blood type O and her fetus is blood type B. Will the fetus be at risk
for hemolytic disease of the newborn? No; antibodies against ABO blood groups
are IgM class and do not cross the placenta "<img src=""7968.png"">"
Hematology-and-Oncology blood-groups physiology
A woman who is hemorrhaging urgently needs plasma. There is no time for a type and
screen. Plasma from which ABO donor should be given? "A donor with type AB blood
plasma does not have anti-A or anti-B antibodies, making it ""universal donor""
plasma" "<img src=""7968.png"">" Hematology-and-Oncology blood-groups
physiology
A patient with type O blood requires a blood transfusion. Do you give her type A,
B, or AB blood? None of these, because a type O patient who receives a blood type
other than O will experience a hemolytic reaction "<img src=""7968.png"">"
Hematology-and-Oncology blood-groups physiology
An Rh-negative mother gives birth to an Rh-positive baby. What immune globulin must
you administer to the mother during her next pregnancy? Anti-D IgG (RhoGAM)
"<img src=""7969.png"">" Hematology-and-Oncology physiology rh-
hemolytic-disease-of-the-newborn
During which trimester is RhoGAM administered? Third trimester "<img
src=""7969.png"">" Hematology-and-Oncology physiology rh-hemolytic-disease-of-
the-newborn
Rh-negative mothers exposed to Rh-positive blood during delivery make anti-D IgG
antibodies. Is this important in subsequent pregnancies? YesIgG crosses the
placenta, leading to hemolytic disease of the newborn in an Rh-positive fetus
"<img src=""7969.png"">" Hematology-and-Oncology physiology rh-
hemolytic-disease-of-the-newborn
An O+ woman gives birth to an A+ baby. The baby requires phototherapy for jaundice
on day 3 after birth. Mechanism of the jaundice? Mother's IgG antibodies
against the A antigen in the baby's blood cross the placenta, causing hemolysis
(ABO hemolytic disease of newborn) "<img src=""7970.png"">" Hematology-and-
Oncology abo-hemolytic-disease-of-the-newborn physiology
An O+ woman has an A+ baby who has ABO hemolytic disease of the newborn. Will
disease severity change in future pregnancies? NoABO hemolytic disease of the
newborn does not worsen with future pregnancies "<img src=""7970.png"">"
Hematology-and-Oncology abo-hemolytic-disease-of-the-newborn physiology
Hemoglobin molecules travel from cathode (-) to anode (+). Which Hb molecule
travels farthest? HbA "<img src=""7971.png"">" Hematology-and-Oncology
hemoglobin-electrophoresis physiology
What type of mutation causes a change from HgA to HgS and HgC? Missense mutation
"<img src=""7971.png"">" Hematology-and-Oncology hemoglobin-
electrophoresis physiology
What change in molecule results in HgS from HgA? Glutamic acid to valine "<img
src=""7971.png"">" Hematology-and-Oncology hemoglobin-electrophoresis
physiology
What change in molecule results in HgC from HgA? Glutamic acid to lysine "<img
src=""7971.png"">" Hematology-and-Oncology hemoglobin-electrophoresis
physiology
List the order in which Hg molecules move from cathode to anode. A, F, S, C (A Fat
Santa Claus) "<img src=""7971.png"">" Hematology-and-Oncology hemoglobin-
electrophoresis physiology
What part of the fibrinolytic system also activates the complement cascade by
cleaving C3 to C3a? Plasmin "<img src=""7972.png"">" Hematology-and-
Oncology coagulation-and-kinin-pathways physiology
Name two reactions initiated by high-molecular-weight kininogen. HMWK is the
initial reagent in the kinin cascade and stimulates the coagulation cascade by
interacting with factor XII (activates to XIIa) "<img src=""7972.png"">"
Hematology-and-Oncology coagulation-and-kinin-pathways physiology
What does plasmin produce when it interacts with fibrin clots? Fibrin degradation
products "<img src=""7972.png"">" Hematology-and-Oncology coagulation-and-
kinin-pathways physiology
Once high-molecular-weight kininogen (HMWK) cleaves to form bradykinin, what are
the effects of the kinin cascade? Increased vasodilation, vascular permeability,
and pain (all bradykinin mediated) "<img src=""7972.png"">" Hematology-and-
What factor converts prekallikrein to kallikrein and factor XI to XIa? Factor XIIa
(it is involved in both the kinin cascade and the coagulation cascade) "<img
src=""7972.png"">" Hematology-and-Oncology coagulation-and-kinin-pathways
physiology
Which coagulation factors are specific to the intrinsic coagulation pathway? Factor
XII, factor XI, factor IX, factor VIII "<img src=""7972.png"">" Hematology-
and-Oncology coagulation-and-kinin-pathways physiology
Which coagulation factors are specific to the extrinsic coagulation pathway? Factor
VII, thromboplastin (tissue factor) "<img src=""7972.png"">" Hematology-and-
Which coagulation factors are common to both the intrinsic and extrinsic
coagulation pathways (part of the common pathway)? Factors X, V, II
(prothrombin), I (fibrinogen), XIII "<img src=""7972.png"">" Hematology-and-
What is the end result of the coagulation cascade? The conversion of fibrinogen
into fibrin to form a fibrin mesh that will stabilize the platelet plug "<img
physiology
Which four reactions in the coagulation cascade require both Ca2+ and a
phospholipid surface as cofactors? The conversion of VII to VIIa via tissue
factor, or X to Xa via either VIIa or IXa, or II to IIa via Va "<img
physiology
Name two initiators of the intrinsic coagulation pathway. Factor XII is converted
to XIIa in the presence of HMWK (kinin cascade), collagen, the basement membrane,
and activated platelets "<img src=""7972.png"">" Hematology-and-Oncology
coagulation-and-kinin-pathways physiology
What are two stimuli for the conversion of factor X to factor Xa? Factor VIIa
(extrinsic) or factor IXa w/factor VIIIa as a cofactor (intrinsic), as this is
where intrinsic and extrinsic pathways converge "<img src=""7972.png"">"
What ion does factor XIII require to stabilize the fibrin mesh? Ca2+ "<img
physiology
A man starting a new antihypertensive has facial swelling from vasodilation and
coughing. Bradykinin activity is increased. What happened? He took ACE inhibitors
(ACE blocks bradykinin, but when inhibited, kallikrein predominates and bradykinin
levels rise, causing his symptoms) "<img src=""7972.png"">" Hematology-and-
A child has hemarthroses. Intrinsic pathway activity is low, but factor VIII and IX
activity is normal. Inheritance pattern of the disorder? Autosomal recessive
(this is likely hemophilia C, which is due to a deficiency of factor XI in the
intrinsic pathway) "<img src=""7972.png"">" Hematology-and-Oncology
A young man has abnormal bleeding. A factor XI assay is normal, but his intrinsic
pathway is sluggish. Inheritance pattern of his disorder? X-linked recessive (he
has either hemophilia A or hemophilia B, which are deficiencies of factors VIII and
IX, respectively) "<img src=""7972.png"">" Hematology-and-Oncology
A man has a high clotting risk; your preceptor asks you to order an anticoagulant
that acts on factor IIa (thrombin). What are your options? Heparin (greatest
efficacy), LMWH (dalteparin, enoxaparin), and direct thrombin inhibitors
(bivalirudin, argatroban, dabigatran) "<img src=""7972.png"">" Hematology-
and-Oncology coagulation-and-kinin-pathways physiology
It is known that giving alteplase within 3 to 4.5 hours of an ischemic stroke helps
to preserve brain function. How does it work? It activates tissue plasminogen
activator, generating more plasmin, which breaks down fibrin meshes into fibrin
degradation products "<img src=""7972.png"">" Hematology-and-Oncology
Name some thrombolytics that can be utilized to convert plasminogen into plasmin.
Alteplase, reteplase, streptokinase, tenecteplase "<img src=""7972.png"">"
A pt requires rapid reversal of alteplase initially given for a stroke. The
reversal agent of choice works by inhibiting what reaction?Aminocaproic acid works
by inhibiting tPA, which converts plasminogen into plasmin (plasmin promotes the
lysis of fibrin) "<img src=""7972.png"">" Hematology-and-Oncology
A pt initiates argatroban therapy for thrombosis prevention. What will an assay
measuring factor XIIIa activity show? Low activity, as argatroban blocks IIa
(thrombin), reducing fibrin monomer (Ia) formation from fibrinogen (I) and XIIIa
activation from XIII "<img src=""7972.png"">" Hematology-and-Oncology
Name some agents that can be given to block factor Xa in the coagulation cascade.
Which agent(s) is(are) the most effective? LMWHs such as dalteparin or
enoxaparin (greatest efficacy), heparin, direct Xa inhibitors (apixaban,
rivaroxaban), fondaparinux "<img src=""7972.png"">" Hematology-and-Oncology
Which two cofactors in the coagulation cascade are considered cofactors for other
reactions? In which pathway(s) are they found? Factors Va and VIIIa; Va is found
in the combined pathway and VIIIa is found in the intrinsic pathway "<img
physiology
By what three routes does factor IIa (thrombin) exert positive feedback on the
coagulation cascade, to promote more thrombosis? It promotes the conversion of
factors V to Va, VIII to VIIIa, and XIII to XIIIa "<img src=""7972.png"">"
A man taking heparin is hemorrhaging from his head after a minor fall. What
reaction(s) account(s) for the effects of heparin? Enhancement of antithrombin,
resulting in inhibition of activated factors II (principal target), VII, IX, X
(principal target), XI, and XII "<img src=""7973.png"">" Hematology-and-
Oncology coagulation-cascade-components physiology
What enzyme is involved in vitamin K activation? What specific reaction does this
enzyme carry out on vitamin K? Epoxide reductase (reduction of oxidized
vitamin K to reduced vitamin K) "<img src=""7973.png"">" Hematology-and-
Oncology coagulation-cascade-components physiology
"A pt on warfarin asks you how it helps ""thin his blood."" Your response?" It
inhibits epoxide reductase, thereby inhibiting the activation of vitamin K "<img
src=""7973.png"">" Hematology-and-Oncology coagulation-cascade-components
physiology
Why do neonates receive an injection of vitamin K soon after birth? Prevents
hemorrhagic disease of the newborn (lack of enteric bacteria ultimately leads to
deficiency of vitamin Kdependent factors) "<img src=""7973.png"">"
Hematology-and-Oncology coagulation-cascade-components physiology
Name the endogenous factors that initiate anticoagulation. Antithrombin III,
protein C, plasminogen "<img src=""7973.png"">" Hematology-and-Oncology
coagulation-cascade-components physiology
What is the role of protein S in anticoagulation? Protein S is a cofactor for
protein C activation, which inactivates factors Va and VIIIa, reducing the tendency
to clot "<img src=""7973.png"">" Hematology-and-Oncology coagulation-
cascade-components physiology
How does plasminogen act as an anticoagulant? Plasminogen is activated by tissue
plasminogen activator to plasmin, which cleaves the fibrin mesh and destroys
coagulation factors "<img src=""7973.png"">" Hematology-and-Oncology
What is tissue plasminogen activator used for clinically? tPA is used as a
thrombolytic, and it activates plasminogen to plasmin "<img src=""7973.png"">"
A rapid-sequence MRI shows an acute thrombotic stroke. What medication given within
3 to 4.5 hours of stroke onset may reduce brain damage? Tissue plasminogen
activator, a thrombolytic "<img src=""7973.png"">" Hematology-and-Oncology
A pt presents with a DVT due to a factor V Leiden mutation. What anomaly in the
coagulation cascade caused this presentation? The factor V Leiden mutation
produces a factor V that is resistant to activated protein C inhibition, leading to
a hypercoagulable state "<img src=""7973.png"">" Hematology-and-Oncology
An 80-year-old alcoholic with chronic hepatitis is severely deficient in vitamin K.
Which coagulation factors will be affected? Factors II, VII, IX, and X, and
proteins C and S, all of which will be decreased "<img src=""7973.png"">"
What happens during the activation phase of platelet plug formation? On ADP
activation of the platelet, glycoprotein IIa/IIIb is expressed on the platelet
surface "<img src=""7974.png"">" Hematology-and-Oncology physiology
platelet-plug-formation-(primary-hemostasis)
What happens during the injury phase of platelet plug formation? Transient
vasoconstriction by way of both the neural stimulation reflex and endothelin
release from damaged cells "<img src=""7974.png"">" Hematology-and-Oncology
physiology platelet-plug-formation-(primary-hemostasis)
What happens during the exposure phase of platelet plug formation? Von
Willebrand factor (from endothelial Weibel-Palade bodies and platelet -granules)
binds to exposed collagen "<img src=""7974.png"">" Hematology-and-Oncology
What happens during the adhesion phase of platelet plug formation? Platelets
bind vWF via GpIb receptors and undergo conformational changes, releasing ADP, Ca2+
(both for coagulation cascade), and TXA2 "<img src=""7974.png"">" Hematology-
and-Oncology physiology platelet-plug-formation-(primary-hemostasis)
What happens during the aggregation phase of platelet plug formation? Fibrinogen
binds GpIIb/IIIa receptors and links platelets together "<img src=""7974.png"">"
Hematology-and-Oncology physiology platelet-plug-formation-(primary-
hemostasis)
Generally speaking, what is it that determines how effectively platelets aggregate
(as opposed to the platelets' all separating)? A balance between pro-aggregation
and anti-aggregation factors at the site of aggregation "<img src=""7974.png"">"
hemostasis)
What pro-aggregation factor decreases blood flow and increases platelet
aggregation? TXA2 "<img src=""7974.png"">" Hematology-and-Oncology
What two anti-aggregation factors are released by endothelial cells that increase
blood flow and decrease platelet aggregation? PGI2 and NO "<img src=""7974.png"">"
hemostasis)
A patient has a congenital deficiency of GpIIb. Which stage of platelet plug
formation does this impair, increasing the tendency to bleed? Platelets cannot
bind to vWF during the adhesion phase in Glanzmann thrombasthenia (lack of GpIIb),
increasing bleeding tendency "<img src=""7974.png"">" Hematology-and-Oncology
A patient takes clopidogrel, which inhibits the platelet ADP receptor. Which phase
of platelet plug formation will be most impaired? AdhesionADP (released from
platelets) helps platelets adhere to the endothelium after the platelet vWFinduced
conformational change "<img src=""7974.png"">" Hematology-and-Oncology
A patient takes aspirin, which inhibits TXA2 synthesis. What happens to the
stability of the platelet plug as a result? It will be destabilized, because
TXA2 is a pro-aggregation factorwithout it, anti-aggregation factors predominate,
destabilizing the plug "<img src=""7974.png"">" Hematology-and-Oncology
After a stable platelet plug forms and stops bleeding, what step in hemostasis
begins to ensure stability of the plug? The coagulation cascade (secondary
hemostasis) "<img src=""7974.png"">" Hematology-and-Oncology physiology
platelet-plug-formation-(primary-hemostasis)
How do the functions of glycoprotein Ib and glycoprotein IIb/IIIa on the platelet
surface differ? Glycoprotein Ib binds von Willebrand factor on damaged
endothelial surface, and IIa/IIIb binds fibrinogen attached to other platelets
"<img src=""7975.png"">" Hematology-and-Oncology physiology
thrombogenesis
A patient takes aspirin. What is its mechanism of action in the prevention of clot
formation? Aspirin irreversibly inhibits cyclooxygenase within the platelets,
thereby preventing TXA2 formation and thus the aggregation of platelets "<img
src=""7975.png"">" Hematology-and-Oncology physiology thrombogenesis
Which stage of platelet plug formation is affected by clopidogrel, prasugrel, and
ticlopidine? These drugs inhibit the adenosine diphosphateinduced expression
of glycoprotein IIa/IIIb "<img src=""7975.png"">" Hematology-and-Oncology
physiology thrombogenesis
A patient takes abciximab. What other drugs act in the same manner? Eptifibatide
and tirofiban also act on glycoprotein IIb/IIIa "<img src=""7975.png"">"
Hematology-and-Oncology physiology thrombogenesis
Name four mediators of thrombus formation or degradation that are found in the
vascular endothelial cell. Von Willebrand factor/factor VIII, thromboplastin,
tissue plasminogen activator (tPA), and prostaglandin I2 "<img src=""7975.png"">"
Which molecule, found on the surface of vascular endothelial cells, is a cofactor
in the activation of protein C, an anticoagulant? Thrombomodulin, which is
located on the surface of vascular endothelial cells "<img src=""7975.png"">"
A patient has Bernard-Soulier syndrome. What receptor is deficient in this disease?
Glycoprotein Ib "<img src=""7975.png"">" Hematology-and-Oncology
physiology thrombogenesis
A patient has Glanzmann thrombasthenia. What is the general pathophysiology of this
disease? When glycoprotein IIb/IIIa is deficient, platelets cannot aggregate
"<img src=""7975.png"">" Hematology-and-Oncology physiology
thrombogenesis
A ristocetin assay shows no agglutination, signifying no reaction of vWF with GpIb.
What two disorders are associated with this finding? Von Willebrand disease (a
deficiency of vWF) and Bernard-Soulier syndrome (a deficiency of GpIb) "<img
src=""7975.png"">" Hematology-and-Oncology physiology thrombogenesis
A man has a deficiency of GpIIb/IIIa receptors. You perform a test that promotes
vWF activation. Will this help you with your diagnosis? Nothis is the
ristocetin assay, which promotes GpIb binding to vWF; results are not abnormal in
people with GpIIb/IIIa deficiency "<img src=""7975.png"">" Hematology-and-
Oncology physiology thrombogenesis
How do you distinguish an echinocyte from an acanthocyte? Echinocyte projections
are smaller and more uniform "<img src=""7976.png"">" Hematology-and-Oncology
Pathology pathologic-rbc-forms
"What is the pathophysiology behind the unusual shape assumed by ""teardrop cells""
(dacryocytes)?" """Teardrop cells"" are RBCs that ""shed a tear"" on being
mechanically squeezed from the bone marrow" "<img src=""7976.png"">"
Hematology-and-Oncology Pathology pathologic-rbc-forms
A G6PD patient eats fava beans and feels weak for several days. A smear taken 1
week later shows bite cells. What occured? Hb -SH groups were oxidized to -S
S- by beans to form precipitations (Heinz bodies), causing RBC membrane phagocytic
damage (bite cells) "<img src=""7977.png"">" Hematology-and-Oncology
Pathology other-rbc-abnormalities
What does the mean corpuscular volume (MCV) help diagnose in an anemia workup?
MCV <80 fL is microcytic anemia, MCV >100 fL is macrocytic anemia, and MCV
between those values (80100 fL) is normocytic anemia "<img src=""7978.png"">"
Hematology-and-Oncology Pathology anemias
What are the two types of normocytic anemia? Nonhemolytic and hemolytic "<img
src=""7978.png"">" Hematology-and-Oncology Pathology anemias
How are normocytic, normochromic hemolytic anemias further classified? Intrinsic
vs. extrinsic to the red blood cell "<img src=""7978.png"">" Hematology-and-
Oncology Pathology anemias
Name six causes of hemolytic normocytic anemia intrinsic to the red blood cell.
Hereditary spherocytosis (membrane), G6PD/pyruvate kinase deficiency
(enzymes), HbC, paroxysmal nocturnal hemoglobinuria, sickle cell anemia "<img
What are the two types of macrocytic anemia? Megaloblastic and nonmegaloblastic
"<img src=""7978.png"">" Hematology-and-Oncology Pathology anemias
Name five causes of microcytic anemia. Iron deficiency (late), anemia of chronic
disease (late), thalassemias, lead poisoning, and sideroblastic anemias "<img
Name four causes of nonhemolytic normocytic anemia. Anemia of chronic disease
(early), aplastic anemia, chronic kidney disease, and iron deficiency (early)
Name four causes of hemolytic normocytic anemia extrinsic to the red blood cell
(red blood cell is not defective). Autoimmune hemolytic anemia, microangiopathic
hemolytic anemia, macroangiopathic hemolytic anemia, and infections "<img
Name three causes of nonmegaloblastic macrocytic anemia. Alcoholism, liver
disease, and Diamond-Blackfan anemia "<img src=""7978.png"">" Hematology-
and-Oncology Pathology anemias
Name three causes of megaloblastic macrocytic anemia. Folate deficiency, B12
deficiency, and orotic aciduria "<img src=""7978.png"">" Hematology-and-
Oncology Pathology anemias
A patient has a severe copper deficiency. What MCV do you expect on a complete
blood count? The MCV will likely be <80 fL, because copper deficiency can
cause sideroblastic anemia, which is a microcytic anemia "<img src=""7978.png"">"
Which two disease states may first appear as normocytic anemias but then progress
to become microcytic anemias? Anemia of chronic disease and iron deficiency anemia
What important lab value is used to distinguish hemolytic and nonhemolytic
normocytic anemias? The reticulocyte count (increased in hemolytic anemias,
normal or decreased in nonhemolytic anemias) "<img src=""7978.png"">"
A patient has iron-deficiency anemia. Name three causes of this disease and its
effect on red blood cells. Chronic bleeding, malnutrition/poor absorption, and
high demand (eg, pregnancy); iron deficiency slows heme synthesis (impairs final
step) "<img src=""7979.png"">" Hematology-and-Oncology Pathology microcytic-
(mcv-<-80-fl),-hypochromic-anemia
An Italian man has a point mutation in his -hemoglobin chain gene. Diagnosis?
-Thalassemia (these mutations are at splicing sites and promoter regions,
leading to decreased synthesis of -globin) "<img src=""7979.png"">"
Hematology-and-Oncology Pathology microcytic-(mcv-<-80-fl),-hypochromic-
anemia
In -thalassemia, what is the difference in the deletion pattern between Asian and
African populations with the disease? It is a cis deletion in Asian populations
and a trans deletions in African populations "<img src=""7979.png"">"
anemia
A patient has -thalassemia minor. What is the associated mutation? There is a
mutation in one gene (heterozygote) in a promoter or splice site, causing
underproduction of -globin "<img src=""7979.png"">" Hematology-and-Oncology
Pathology microcytic-(mcv-<-80-fl),-hypochromic-anemia
A fetus has deletions of all four -globin genes. What condition will this result
in? Hemoglobin Barts (4, no -globins), a lethal condition that results in
hydrops fetalis "<img src=""7979.png"">" Hematology-and-Oncology Pathology
microcytic-(mcv-<-80-fl),-hypochromic-anemia
A patient has -thalassemia major. What physical exam and X-ray findings do you
expect on exam? """Crew cut"" appearance on skull X-ray (marrow expansion leading
to skeletal deformities), ""chipmunk"" facies, hepatosplenomegaly" "<img
src=""7979.png"">" Hematology-and-Oncology Pathology microcytic-(mcv-<-80-
fl),-hypochromic-anemia
A girl has a deletion of three of the four -globin genes. What disease do you
expect to see? Hemoglobin H disease with very little -globin and excess -
globin formation (4, or HbH) "<img src=""7979.png"">" Hematology-and-Oncology
A boy has a father homozygous for hemoglobin S (HbS) and a mother with -
thalassemia major. What disease do you expect in the boy? Mild-to-moderate sickle
cell anemia, varying with the level of -chain production (he'll be an HbS/-
thalassemia heterozygote) "<img src=""7979.png"">" Hematology-and-Oncology
A man complains of changes in his bowel habits and bright-red blood in his stools.
His MCV is 68 fL. What is the most likely diagnosis? Iron-deficiency anemia
(microcytic anemia); this patient may have a chronic bleed in his colon "<img
What is the cause of basophilic stippling associated with lead poisoning? Lead
disrupts the degradation of rRNA, which builds up as aggregates and stains with
basic dyes in RBCs "<img src=""7979.png"">" Hematology-and-Oncology
A woman presents with tongue inflammation and atrophy, dysphagia with solids, and a
hemoglobin of 9 g/dL. What is the cause of her anemia? Iron deficiency (this is
Plummer-Vinson syndrome, marked by the triad of esophageal webs, dysphagia, and
iron-deficiency anemia) "<img src=""7979.png"">" Hematology-and-Oncology
A new patient says that he has been found to have lead poisoning. What commonly
associated signs and symptoms might he report? LEAD = Lead Lines (gingivae/long
bone metaphyses), Encephalopathy/Erythrocyte stippling, Abdomen pain/sideroblastic
Anemia, wrist/foot Drop "<img src=""7979.png"">" Hematology-and-Oncology
What is the cause of hereditary sideroblastic anemia? What is its inheritance
pattern? A defect in the -aminolevulinic acid gene; X-linked "<img
A fetus undergoes amniocentesis and is found to have deletions of all four -globin
genes. What is the likely outcome? Hydrops fetalis (deletion of four genes is
incompatible with life in -thalassemia) "<img src=""7979.png"">" Hematology-
and-Oncology Pathology microcytic-(mcv-<-80-fl),-hypochromic-anemia
A patient has a mutation in -ALA synthase. Treatment? Pyridoxine (vitamin B6),
a cofactor for -ALA synthase, can be used to treat genetic sideroblastic anemia
"<img src=""7979.png"">" Hematology-and-Oncology Pathology microcytic-
A child is found to have deletions of two -globin genes. What symptoms will likely
manifest? Deletion of two -globin genes is associated with less clinically
significant anemia in -thalassemia "<img src=""7979.png"">" Hematology-and-
Oncology Pathology microcytic-(mcv-<-80-fl),-hypochromic-anemia
"In lead poisoning, where do ""lines"" of lead, readily be detected on exam or with
imaging, tend to be deposited?" Burton lines, also known as Lead Lines, appear
on both the gingivae and the metaphyses of long bones (visible on x-ray) "<img
Name some reversible causes of sideroblastic anemia. Of these causes, which is the
most common? Alcohol use (most common), lead poisoning, vitamin B6 deficiency,
copper deficiency, isoniazid use "<img src=""7979.png"">" Hematology-and-
Oncology Pathology microcytic-(mcv-<-80-fl),-hypochromic-anemia
A child has a deletion of one -globin gene. What symptoms will likely manifest?
Deletion of one -globin gene is typically clinically silent (no anemia) in
-thalassemia "<img src=""7979.png"">" Hematology-and-Oncology Pathology
In sideroblastic anemia, the synthesis of which substance is impaired? Heme "<img
A 6-month-old presents with severe anemia. Electrophoresis shows increased fetal
hemoglobin. Why is he symptomatic at this age? This is -thalassemia major; HbF
(22) is protective in newborns, so infants become symptomatic only after 6 months
of age "<img src=""7979.png"">" Hematology-and-Oncology Pathology
A girl's growth is declining. You suspect ferrochelatase and ALA dehydratase
inhibition. To what two defects in RBCs does this lead? A decrease in the
synthesis of heme and an increase in RBC protoporphyrin (this is lead poisoning)
"<img src=""7979.png"">" Hematology-and-Oncology Pathology microcytic-
You see basophilic stippling on the blood smear of a child who has been eating
paint chips. What treatment is indicated? Succimer is used for chelation in kids
with lead poisoning (it sucks to be a kid who eats lead) "<img src=""7979.png"">"
anemia
A patient with -thalassemia major has an increased risk of aplastic crisis due to
what infectious cause? Parvovirus B19 infection "<img src=""7979.png"">"
anemia
A man who restores old houses presents with memory loss, abdominal pain, and foot
drop. What is the likely cause of his symptoms? Exposure to lead-based paint
(encephalopathy, abdominal pain, and peripheral neuropathy are signs of lead
poisoning) "<img src=""7979.png"">" Hematology-and-Oncology Pathology
A patient has -thalassemia minor. What symptoms and laboratory findings will you
find? This condition is usually asymptomatic and is diagnosed on the basis of an
increased HbA2 fraction (>3.5%) on electrophoresis "<img src=""7979.png"">"
anemia
A patient is homozygous for a mutation in the -globin gene. What are the possible
long-term effects of treatment? The treatment is multiple blood transfusions,
which may result in secondary hemochromatosis "<img src=""7979.png"">"
anemia
Why is mean corpuscular volume increased in megaloblastic macrocytic anemias?
A defect in DNA synthesis causes the nucleus to take longer to mature than
the cytoplasm, resulting in excess cytoplasm and a megaloblast "<img
src=""7980.png"">" Hematology-and-Oncology Pathology macrocytic-(mcv->-100-
fl)-anemia
A patient has a congenital deficiency of pyrimidine synthesis. In what disease
process does this result? Orotic aciduria, which in turn results in macrocytic
anemia "<img src=""7980.png"">" Hematology-and-Oncology Pathology
macrocytic-(mcv->-100-fl)-anemia
How do homocysteine levels compare in vitamin B12 and folate deficiency? Both
conditions are marked by an increase in homocysteine "<img src=""7980.png"">"
Hematology-and-Oncology Pathology macrocytic-(mcv->-100-fl)-anemia
Name two conditions in which an increased demand for folate can result in a
macrocytic anemia. Pregnancy (folate is needed for fetal neural tube
development) and hemolytic anemia (folate is needed to replenish hemolyzed blood)
"<img src=""7980.png"">" Hematology-and-Oncology Pathology macrocytic-
(mcv->-100-fl)-anemia
What autoimmune disorder can result in a macrocytic anemia?Pernicious anemia, from
autoimmune gastritis that secondarily leads to vitamin B12 deficiency "<img
fl)-anemia
A man deficient in vitamin B12 has high homocysteine and methylmalonic acid. In
what specific neurological derangement does this result? Deficiency causes
subacute combined degeneration (spinocerebellar tract, lateral corticospinal tract,
and dorsal column dysfunction) "<img src=""7980.png"">" Hematology-and-
Oncology Pathology macrocytic-(mcv->-100-fl)-anemia
How does nonmegaloblastic anemia differ from megaloblastic anemia?
Nonmegaloblastic macrocytic anemias do not involve impaired DNA synthesis,
whereas in megaloblastic anemias DNA synthesis is impaired "<img src=""7980.png"">"
Deficiencies in what enzyme will result in failure to convert orotic acid to
uridine monophosphate? Uridine monophosphate synthase (this is seen in orotic
aciduria) "<img src=""7980.png"">" Hematology-and-Oncology Pathology
Which synthetic pathway utilizes the conversion of orotic acid to uridine
monophosphate? The de novo pyrimidine synthesis pathway "<img src=""7980.png"">"
What is the inheritance pattern of orotic aciduria? Autosomal recessive "<img
fl)-anemia
A child has megaloblastic anemia that is unresponsive to B12 or folate
supplementation, as well asa normal ammonia level. Diagnosis? Orotic aciduria
A child exhibits megaloblastic anemia, failure to thrive, and developmental delay.
What treatment do you consider? Uridine monophosphate supplementation to bypass
the mutated UMP synthase enzyme (this is orotic aciduria) "<img src=""7980.png"">"
Name two causes of nonmegaloblastic macrocytic anemia. Alcoholism and liver
disease "<img src=""7980.png"">" Hematology-and-Oncology Pathology
A 50-year-old man adopts a vegan diet. Years later, he has difficulty walking, and
physical exam reveals poor vibration sense. Diagnosis? Veganism can result in
insufficient intake of vitamin B12, resulting in deficiency"<img src=""7980.png"">"
An anemic man's MCV is 110 fL. His homocysteine is high. Name two causes of these
findings and a lab test with which to differentiate them. Vitamin B12 (cobalamin)
or folate deficiency; test for methylmalonic acid, which is high only in vitamin
B12 deficiency "<img src=""7980.png"">" Hematology-and-Oncology Pathology
A man who loves the new sushi bar in town presents with weight loss and fatigue.
Labs show macrocytic anemia. What is the likely cause? Eating raw fish may lead
to infection with D latum, a tapeworm found in fish/sushi that absorbs vitamin B12
A 30-year-old man with Crohn disease presents with chronic low energy and gait
ataxia. Why is he susceptible to macrocytic anemia? Crohn disease often affects
the terminal ileum, where vitamin B12 is absorbed "<img src=""7980.png"">"
You note that a woman's MCV is <100 fL because of a medication. What agents could
be to blame? Is this megaloblastic or nonmegaloblastic? Methotrexate,
trimethoprim, or phenytoin; all interfere with folate metabolism and cause
megaloblastic anemia "<img src=""7980.png"">" Hematology-and-Oncology
Pathology macrocytic-(mcv->-100-fl)-anemia
A student is forgetful and lethargic a few months after becoming a vegan. What
vitamin deficiency could be causing her symptoms? Vitamin B12 deficiency
(common in veganism) causes megaloblastic anemia and neurologic symptoms "<img
fl)-anemia
An alcoholic with cirrhosis is fatigued. His hemoglobin is 9 g/dL and MCV 125 fL.
What is the most likely cause and mechanism of his anemia? Nonmegaloblastic
macrocytic anemia caused by liver disease or direct alcohol-induced bone marrow
toxicity "<img src=""7980.png"">" Hematology-and-Oncology Pathology
A patient presents with a macrocytic anemia years after a Roux-en-Y procedure. What
is the likely cause? What will be seen on physical exam? Gastrectomy, leading to
B12 deficiency; examination reveals fatigue and neurologic symptoms "<img
fl)-anemia
An 85-year-old cachectic woman presents to ED after a fall. She has megaloblastic
anemia. What two vitamin deficiencies can explain this? Vitamin B12 and folate
deficiency both cause megaloblastic anemia (only vitamin B12 deficiency causes
neurologic symptoms [the fall]) "<img src=""7980.png"">" Hematology-and-
An infant presents with vomiting and confusion; serum shows hyperammonemia and
increased urine orotic acid. What is a likely diagnosis? Ornithine
transcarbamylase deficiency (orotic aciduria does not have hyperammonemia) "<img
fl)-anemia
For what was the Schilling test historically used? Generally speaking, how did the
test work? This four-stage test was used to find the cause of vitamin B12
deficiency, distinguishing dietary insufficiency from malabsorption "<img
fl)-anemia
A 1-year-old with congenital face defects suddenly becomes pale and weak. Blood
counts are low. What will hemoglobin electrophoresis show? Rapid onset of anemia at
this age and craniofacial abnormalities suggest Diamond-Blackfan anemia;
electrophoresis shows increased HbF "<img src=""7980.png"">" Hematology-and-
A toddler is short, with a deformed face and triple phalanx thumbs. He is anemic.
How does a bone marrow biopsy aid your diagnosis? These findings are suggestive
of Diamond-Blackfan anemia; biopsy isolates erythroid progenitor cells, which
likely carry intrinsic defects "<img src=""7980.png"">" Hematology-and-
In patients with Diamond-Blackfan anemia, how often can physical exam findings be
used to aid in the diagnosis? Physical exam abnormalities (eg, craniofacial
abnormalities, triphalangeal thumbs, short stature) are seen in up to 50% of cases
How are normocytic, normochromic hemolytic anemias classified? First by cause
(intrinsic vs. extrinsic to the RBC), then by location (intravascular vs.
extravascular) "<img src=""7981.png"">" Hematology-and-Oncology Pathology
normocytic,-normochromic-anemia
What lab findings in the blood and urine are seen in a patient with an
intravascular hemolytic process? Low haptoglobin, high LDH, and both
schistocytes and reticulocytes on blood smear, plus hemoglobin, hemosiderin, and
urobilinogen in urine "<img src=""7981.png"">" Hematology-and-Oncology
Pathology normocytic,-normochromic-anemia
What lab findings in the blood and urine are seen in a patient with an
extravascular hemolytic process? Increased LDH and unconjugated bilirubin; no
hemoglobin or hemosiderin in the urine "<img src=""7981.png"">" Hematology-
and-Oncology Pathology normocytic,-normochromic-anemia
A blood smear shows schistocytes and increased reticulocytes. Labs show low
haptoglobin, high LDH, and urine urobilinogen. Possible causes? PNH, mechanical
destruction (eg, aortic stenosis or a prosthetic valve), microangiopathic hemolysis
(patient has intravascular hemolysis) "<img src=""7981.png"">" Hematology-
and-Oncology Pathology normocytic,-normochromic-anemia
A patient has jaundice. A peripheral smear shows schistocytes. LDH is increased and
unconjugated bilirubin is high. What is the cause? Extravascular hemolysis (eg,
hereditary spherocytosis), in which RBCs are cleared by macrophages in the spleen
"<img src=""7981.png"">" Hematology-and-Oncology Pathology normocytic,-
normochromic-anemia
How are normocytic, normochromic anemias classified? As hemolytic vs. nonhemolytic
"<img src=""7981.png"">" Hematology-and-Oncology Pathology normocytic,-
normochromic-anemia
A 47-year-old woman with a recent infection reports malaise and mucosal bleeding.
On exam, she is pale, with diffuse petechiae. Diagnosis? Aplastic anemia, likely
due to a viral agent (eg, parvovirus B19, EBV, HIV, hepatitis viruses) "<img
src=""7982.png"">" Hematology-and-Oncology Pathology nonhemolytic,-normocytic-
anemia
"You order bone marrow aspiration in a woman with fatigue, pallor, and mucosal
bleeding. A ""dry tap"" returns. Why does this concern you?" "Aplastic anemia
is marked by hypocellular bone marrow with fatty infiltration, resulting in ""dry
taps""" "<img src=""7982.png"">" Hematology-and-Oncology Pathology
nonhemolytic,-normocytic-anemia
How do chronic inflammatory processes cause anemia? Hepcidin (liver) increases,
inhibiting macrophage and intestinal ferroportin and blocking macrophage iron
release/intestinal iron absorption "<img src=""7982.png"">" Hematology-and-
Oncology Pathology nonhemolytic,-normocytic-anemia
What are the iron and ferritin levels and total iron-binding capacity (TIBC) in a
patient with anemia of chronic disease? Decreased iron and TIBC, increased
ferritin "<img src=""7982.png"">" Hematology-and-Oncology Pathology
What are four general etiologies of aplastic anemia? Radiation/drugs, viral
infections, Fanconi anemia, or idiopathic aplastic anemia "<img src=""7982.png"">"
Hematology-and-Oncology Pathology nonhemolytic,-normocytic-anemia
A man with a prosthetic heart valve has chronic fatigue. What will blood testing
for LDH and haptoglobin levels show? Increased LDH and decreased haptoglobin
(prosthetic valves cause mechanical destruction of RBCs and intravascular hemolytic
anemia) "<img src=""7982.png"">" Hematology-and-Oncology Pathology
Other than withdrawal of offending agents (eg, drugs) or immunosuppressive
regimens, what three treatments for aplastic anemia are there? Immunosuppression
(eg, cyclosporine, antithymocyte globulin), bone marrow allograft, transfusions,
bone marrow stimulation (eg, GM-CSF) "<img src=""7982.png"">" Hematology-
and-Oncology Pathology nonhemolytic,-normocytic-anemia
Name four drugs that can result in aplastic anemia. Benzene, chloramphenicol,
alkylating agents, and antimetabolites "<img src=""7982.png"">" Hematology-
What four viral infections can cause aplastic anemia? Epstein-Barr virus (EBV),
parvovirus B19, HIV, and the hepatitis viruses "<img src=""7982.png"">"
Hematology-and-Oncology Pathology nonhemolytic,-normocytic-anemia
What are two possible explanations for aplastic anemia that is considered
idiopathic? An immune-mediated 1 stem cell defect and a consequence of acute
hepatitis "<img src=""7982.png"">" Hematology-and-Oncology Pathology
Why do patients with chronic kidney disease have normocytic, normochromic anemias?
The kidneys produce erythropoietinin renal failure, the loss of
erythropoietin causes anemia "<img src=""7982.png"">" Hematology-and-Oncology
Pathology nonhemolytic,-normocytic-anemia
A patient has rheumatoid arthritis. How will her MCV change through the course of
her disease? It will initially be normocytic but may progress to become
microcytic after some time "<img src=""7982.png"">" Hematology-and-Oncology
A woman is on a chemotherapy regimen with alkylating agents. What type of anemia is
she predisposed to? Aplastic anemia "<img src=""7982.png"">" Hematology-
You suspect that a patient has aplastic anemia due to an autoimmune process. What
treatment can you pursue? Immunosuppression using drugs such as antithymocyte
globulin or cyclosporine "<img src=""7982.png"">" Hematology-and-Oncology
A pancytopenic boy is short and has caf-au-lait spots all over his body. He has
odd-looking hands. What malignancies do you screen him for?"Numerous tumors and
leukemia; he most likely has Fanconi anemia (his ""odd-looking hands"" are due to
thumb/radial defects)" "<img src=""7982.png"">" Hematology-and-Oncology
What is the molecular defect underlying Fanconi syndrome? A DNA repair defect
leading to bone marrow failure "<img src=""7982.png"">" Hematology-and-
Oncology Pathology nonhemolytic,-normocytic-anemia
A patient has hereditary spherocytosis. What organ is responsible for anemia in
this disease? The spleen; the inflexible membrane causes the spleen to remove
affected red blood cells prematurely "<img src=""7983.png"">" Hematology-
and-Oncology Pathology intrinsic-hemolytic-anemia
A patient has spherocytes on a peripheral blood smear and splenomegaly on exam.
What additional lab do you order to confirm the diagnosis? Osmotic fragility test
to look for hereditary spherocytosis; you may also see a normal to low MCV with an
abundance of RBCs "<img src=""7983.png"">" Hematology-and-Oncology Pathology
intrinsic-hemolytic-anemia
What mutations are responsible for the red blood cell morphology seen in hereditary
spherocytosis? Defects in ankyrin, band 3, protein 4.2, or spectrin (these
proteins interact with the RBC skeleton/plasma membrane to preserve biconcavity)
"<img src=""7983.png"">" Hematology-and-Oncology Pathology intrinsic-
hemolytic-anemia
What are the RBC indices that define hereditary spherocytosis? Increased MCHC,
normal-to-low MCV, increased RBC count "<img src=""7983.png"">" Hematology-
A smear from a Scandinavian man shows small, round RBCs without central pallor and
a positive osmotic fragility test. What is the treatment? Treat with splenectomy
(this patient has hereditary spherocytosis) "<img src=""7983.png"">"
Hematology-and-Oncology Pathology intrinsic-hemolytic-anemia
Do defects in the RBC membrane proteins ankyrin, band 3 protein 4.2, or spectrin
cause intravascular or extravascular hemolytic anemia? Extravascular hemolytic
anemia "<img src=""7983.png"">" Hematology-and-Oncology Pathology
In G6PD deficiency, what is the underlying pathophysiology behind the resultant
anemia? The depletion of glutathione increases susceptibility to oxidant
stressors, leading to a hemolytic anemia on exposure to them "<img
src=""7983.png"">" Hematology-and-Oncology Pathology intrinsic-hemolytic-
anemia
What is the most common enzymatic disorder of RBCs? Its mode of inheritance? G6PD
deficiency; X-linked recessive "<img src=""7983.png"">" Hematology-and-
Oncology Pathology intrinsic-hemolytic-anemia
A patient is found to have G6PD deficiency after hemolysis develops. What clues
would his blood smear contain that could aid diagnosis? "Heinz bodies and bite
cells (from oxidant stress [eg, fava beans]think ""stress makes me eat bites of
fava beans with Heinz ketchup"")" "<img src=""7983.png"">" Hematology-and-
You prescribe primaquine for malaria; soon the patient experiences back pain,
jaundice, and hemoglobinuria. What did you overlook? A diagnosis of G6PD
deficiency (sulfa drugs, some antimalarials, fava beans, and infections can cause
oxidant stress, trigger hemolysis) "<img src=""7983.png"">" Hematology-and-
What kind of hemolytic anemia occurs in patients with G6PD deficiency exposed to
oxidants? Both extravascular and intravascular hemolysis "<img src=""7983.png"">"
A boy has an X-linked recessive disorder of RBCs causing both intravascular and
extravascular hemolytic anemia. Diagnosis? G6PD deficiency "<img
anemia
How does pyruvate kinase deficiency most often present? As hemolytic anemia in a
newborn "<img src=""7983.png"">" Hematology-and-Oncology Pathology
A newborn has extravascular hemolysis; RBC analyses show very high rigidity. What
is the pattern of inheritance for the likely diagnosis? Autosomal recessive
(pyruvate kinase deficiency causes low ATP in RBCs, leading to rigidity of the
membranes and destruction by the spleen) "<img src=""7983.png"">" Hematology-
What mutation produces hemoglobin C, and what type of anemia does it cause? A -
globin chain position 6 point mutation substituting glutamic acid with lysine;
intrinsic normocytic extravascular hemolytic anemia "<img src=""7983.png"">"
A patient has a combined hemoglobin S and hemoglobin C mutation. How will this
affect her disease course? Patients with hemoglobin S and C mutations have
milder sickle cell anemia than do homozygotes with hemoglobin SS "<img
anemia
A boy with a homozygous -globin point mutation (glutamic acid to lysine) presents
with fatigue. He is anemic. What will a blood smear show? In homozygotes with
hemoglobin C disease, blood smear shows hemoglobin crystals inside RBCs and target
cells "<img src=""7983.png"">" Hematology-and-Oncology Pathology intrinsic-
hemolytic-anemia
A patient is found to have a DVT. Labs show pancytopenia and Coombs-negative
hemolysis. What treatment do you offer this patient? Eculizumab, a terminal
complement inhibitor, is effective in patients with paroxysmal nocturnal
hemoglobinuria "<img src=""7983.png"">" Hematology-and-Oncology Pathology
What is the mechanism of hemolysis in paroxysmal nocturnal hemoglobinuria?
Intravascular hemolysis due to a defective GPI anchor for decay-accelerating
factor (normally prevents complement-mediated RBC destruction) "<img
anemia
What is the triad associated with paroxysmal nocturnal hemoglobinuria? Coombs test
negative hemolytic anemia, pancytopenia, and venous thrombosis "<img
anemia
A woman complains of dark urine on waking. Flow cytometry shows no CD55 or CD59
markers on her RBCs. What condition is likely? She has paroxysmal nocturnal
hemoglobinuria, an acquired mutation of hematopoietic stem cells with a higher
incidence of acute leukemias "<img src=""7983.png"">" Hematology-and-Oncology
Pathology intrinsic-hemolytic-anemia
A newborn with sickle cell anemia is initially asymptomatic. Why? The newborn
still has a high level of hemoglobin F and will be asymptomatic until his
hemoglobin F is replaced by hemoglobin S "<img src=""7983.png"">" Hematology-
What mutation causes sickle cell anemia? A point mutation at position 6 of the -
globin chain substituting glutamic acid with valine "<img src=""7983.png"">"
What is the pathogenesis of sickle cell anemia? Low oxygen, high altitude, or
acidosis causes hemoglobin S to polymerize (sickle), leading to anemia and vaso-
occlusive crises "<img src=""7983.png"">" Hematology-and-Oncology Pathology
What evolutionary advantage may explain the prevalence of sickle cell trait in the
African-American population? Patients with sickle cell trait (heterozygotes) are
resistant to malaria8% of African-American population carries the trait "<img
anemia
What treatment options are available for patients with sickle cell anemia?
Patients can be treated with hydroxyurea (increases hemoglobin F
concentration) adequate hydration can be therapeutic as well "<img
anemia
Name some of the painful crises with which patients with sickle cell anemia may
present. Dactylitis (painful hand/foot swelling), priapism, acute chest
syndrome, avascular necrosis, stroke "<img src=""7983.png"">" Hematology-
What manifestation of sickle cell anemia is also seen in patients with
thalassemias? "A ""crew cut"" appearance on skull X-ray, resulting from
increased erythropoiesis and bone marrow expansion" "<img src=""7983.png"">"
A 19-year-old man with sickle cell anemia has his blood drawn. What might you see
on his blood smear, considering his splenic dysfunction? Howell-Jolly bodies
(early splenic dysfunction, or autosplenectomy, occurs in childhood) "<img
anemia
A patient with known sickle cell anemia presents with femur swelling and
tenderness. You are most concerned for infection by which organism? Salmonella
(the patient likely has osteomyelitis from Salmonella infection, which occurs more
often in sickle cell anemia patients) "<img src=""7983.png"">" Hematology-
An adolescent with Howell-Jolly bodies on peripheral smear is suspected to have
sickle cell anemia. What is the diagnostic test of choice? Hemoglobin
electrophoresis "<img src=""7983.png"">" Hematology-and-Oncology Pathology
A woman with hereditary spherocytosis has a parvovirus B19 infection. Why is this
important? Parvovirus B19 can cause aplastic crises in patients with hereditary
spherocytosis "<img src=""7983.png"">" Hematology-and-Oncology Pathology
A patient who is homozygous for sickle cell anemia is found to have microhematuria.
What renal condition is the most likely culprit? Microhematuria from medullary
infarcts (renal papillary necrosis from decreased O2 in papilla may also appear)
"<img src=""7983.png"">" Hematology-and-Oncology Pathology intrinsic-
hemolytic-anemia
A teenager with sickle cell anemia presents with severe S pneumoniae meningitis.
Why was he at increased risk for this infection? Sickle cell anemia carries a
high risk for infection by encapsulated organisms because of splenic dysfunction
and eventual autosplenectomy "<img src=""7983.png"">" Hematology-and-Oncology
Pathology intrinsic-hemolytic-anemia
A patient with a mechanical aortic valve and symptoms of anemia has an abnormal
blood smear. What do you see? Why? Schistocytes; prosthetic heart valves can cause
macroangiopathic hemolytic anemias as a result of traumatic mechanical destruction
"<img src=""7984.png"">" Hematology-and-Oncology Pathology extrinsic-
hemolytic-anemia
A patient is told that her EBV infection is causing an autoimmune hemolytic anemia.
Should she believe her doctor? Yes, because mononucleosis can cause a cold
agglutinintype acute hemolytic anemia "<img src=""7984.png"">" Hematology-
and-Oncology Pathology extrinsic-hemolytic-anemia
Name three conditions associated with warm agglutinin (immunoglobulin Gmediated)
autoimmune hemolysis. IgG-mediated warm hemolysis is triggered by SLE, CLL, and
drug reactions (eg, -methyldopa) (warm weather is Great) "<img src=""7984.png"">"
Hematology-and-Oncology Pathology extrinsic-hemolytic-anemia
Name two infections that can present with hemolytic anemia resulting from cold
agglutinins. Mycoplasma pneumoniae infection and infectious Mononucleosis,
which are IgM-mediated (cold weather is MMMiserable) "<img src=""7984.png"">"
How is a direct Coombs test performed, and what constitutes a positive test result?
Anti-IgG antibody (Coombs reagent) is added to patient bloodif the RBCs are
coated with antibodies, they agglutinate (positive test) "<img src=""7984.png"">"
How is an indirect Coombs test performed, and what constitutes a positive test
result? Normal RBCs are added to patient serumthey agglutinate if anti-RBC Ig
is present after anti-Ig antibody (Coombs reagent) is later added "<img
src=""7984.png"">" Hematology-and-Oncology Pathology extrinsic-hemolytic-
anemia
You note schistocytes, or helmet cells, on a patient's peripheral blood smear. What
mechanism causes this deformity? Damage to RBCs as they pass through a narrow or
obstructed vessel lumen (seen in micro- and macroangiopathic hemolytic anemias)
hemolytic-anemia
What type of hemolytic anemia may affect a patient with aortic stenosis? A
macroangiopathic hemolytic anemia "<img src=""7984.png"">" Hematology-and-
Oncology Pathology extrinsic-hemolytic-anemia
Name four conditions that may result in helmet cells, or schistocytes, on a
peripheral blood smear as a result of microangiopathic anemia. TTP/HUS, SLE, DIC,
and malignant hypertension "<img src=""7984.png"">" Hematology-and-Oncology
Pathology extrinsic-hemolytic-anemia
A patient has hemolysis that is not associated with agglutinins. Name two
infections that result in this finding. Intracellular pathogens, such as malaria
and Babesia, can lyse erythrocytes and cause hemolytic anemia "<img
anemia
What is the cause of most both warm and cold autoimmune hemolytic anemias? Many
warm and cold autoimmune hemolytic anemias are idiopathic in etiology "<img
anemia
A woman with systemic lupus erythematosus (SLE) has fatigue; hemoglobin is 9 g/dL
and MCV is 92. What is a likely cause of her anemia? Warm agglutinin autoimmune
hemolytic anemia, a chronic anemia that is IgG-mediated (warm weather is Great)
hemolytic-anemia
What is the role of ferritin in the body? It is the primary iron storage protein of
the body "<img src=""7985.png"">" Hematology-and-Oncology Pathology lab-
values-in-anemia
What is the relationship between transferrin and total iron-binding capacity
(TIBC)? What is the transferrin saturation? TIBC is an indirect measure of
transferrin, which transports iron in the blood; transferrin saturation is the
ratio of serum iron to TIBC "<img src=""7985.png"">" Hematology-and-Oncology
Pathology lab-values-in-anemia
What is the evolutionary theory behind the origin of anemia of chronic disease?
Pathogens need circulating iron to thrive; sequestering iron in macrophages
may prevent said pathogens from acquiring iron and reproducing "<img
src=""7985.png"">" Hematology-and-Oncology Pathology lab-values-in-anemia
A woman takes oral contraceptive pills. How does this affect the body's iron
handling? What other physiologic state causes the same changes? Normal serum
iron/ferritin, high TIBC (estrogen stimulates production of binding proteins), low
transferrin saturation percentage; pregnancy "<img src=""7985.png"">"
Hematology-and-Oncology Pathology lab-values-in-anemia
An asymptomatic man with Crohn disease has a routine exam. Hemoglobin is 12 g/dL,
and MCV is 85. What will a panel of iron studies show? Serum iron, TIBC, and
transferrin are low; ferritin is high; transferrin saturation percentage is normal
(this is anemia of chronic disease) "<img src=""7985.png"">" Hematology-and-
Oncology Pathology lab-values-in-anemia
A woman with menorrhagia has fatigue and dizziness. Her hemoglobin is 10 g/dL, and
MCV is 77. What will a panel of iron studies show? Serum iron and ferritin are
low, TIBC is high, transferrin saturation percentage is very low (this is iron-
deficiency anemia from bleeding) "<img src=""7985.png"">" Hematology-and-
Oncology Pathology lab-values-in-anemia
A middle-aged man has bronze skin, diabetes, and cirrhosis. What will a panel of
iron studies show? TIBC is low and serum iron, ferritin, and transferrin
saturation percentage are high (he has hemochromatosis) "<img src=""7985.png"">"
Hematology-and-Oncology Pathology lab-values-in-anemia
A patient has an absolute neutrophil count < 1500 cells/mm3. Name some possible
causes for this finding. SLE, septic/postinfectious states, aplastic anemia,
drugs (eg, chemotherapy), radiation "<img src=""7986.png"">" Hematology-and-
Oncology Pathology leukopenias
A patient has an absolute lymphocyte count < 1500 cells/mm3. Name some possible
causes for this finding. SCID, HIV, SLE, DiGeorge syndrome, sepsis, radiation,
corticosteroids, postoperative state "<img src=""7986.png"">" Hematology-
and-Oncology Pathology leukopenias
A patient has an absolute eosinophil count < 30 cells/mm3. Name some possible
causes for this finding. Cushing syndrome and corticosteroid use "<img
src=""7986.png"">" Hematology-and-Oncology Pathology leukopenias
How do corticosteroids lead to neutrophilia, despite causing both lymphopenia and
eosinopenia? They inhibit neutrophil adhesion molecule activation, preventing
migration to sites of inflammation and trapping them in the vasculature "<img
How, mechanistically, does cortisol administration affect the eosinophil and
lymphocyte counts, respectively? Corticosteroids sequester eosinophils in lymph
nodes and trigger apoptosis of lymphocytes "<img src=""7986.png"">"
Hematology-and-Oncology Pathology leukopenias
A man with abdominal striae and moon facies is found to have Cushing syndrome. What
abnormalities in his leukocyte counts are expected? Eosinopenia, lymphopenia, and
neutrophilia "<img src=""7986.png"">" Hematology-and-Oncology Pathology
leukopenias
Neutropenic precautions are imposed for a patient. Labs are checked daily. At what
neutrophil count do you worry about severe infections? Severe infections
typically occur when the neutrophil count is < 500 cells/mm3 "<img
What is a left shift? An increase in neutrophil precursors (eg, band cells,
metamyelocytes) with or without neutrophilia, usually from infection or
inflammation "<img src=""7987.png"">" Hematology-and-Oncology Pathology
left-shift
A man with metastatic melanoma is fatigued. Neutrophil precursors and immature RBCs
are seen on blood smear. Why? He is having a leukoerythroblastic reaction, either
from severe anemia or precursors' responding to melanoma invasion of the bone
marrow "<img src=""7987.png"">" Hematology-and-Oncology Pathology left-
shift
In a left shift, what is the classic finding in the patient's peripheral WBCs?
An increase in neutrophil precursors, with or without neutrophilia (left
shift: a shift to a more immature cell in the maturation process) "<img
src=""7987.png"">" Hematology-and-Oncology Pathology left-shift
You infuse a synthetic derivative of uroporphyrinogen decarboxylase into a patient
with porphyria cutanea tarda. Will this serve as a cure? Yesthis enzyme converts
uroporphyrinogen III (which builds up in porphyria cutanea tarda) into
coproporphyrinogen III and ultimately heme "<img src=""7988.png"">"
Hematology-and-Oncology Pathology heme-synthesis,-porphyrias,-and-lead-
poisoning
You reverse a woman's porphyria cutanea tarda and note increased cytosolic
coproporphyrinogen III. How is this molecule converted into heme?
Coproporphyrinogen III enters mitochondria, is converted to protoporphyrin,
and finally becomes heme via ferrochelatase (with Fe2+ cofactor) "<img
src=""7988.png"">" Hematology-and-Oncology Pathology heme-synthesis,-
porphyrias,-and-lead-poisoning
In porphyria cutanea tarda, a defect in what enzyme leads to the buildup of what
substance in the blood? How does this affect the urine? Uroporphyrinogen
decarboxylase is defective, leading to the buildup of uroporphyrin; the urine
becomes tea-colored due to uroporphyrin "<img src=""7988.png"">" Hematology-
and-Oncology Pathology heme-synthesis,-porphyrias,-and-lead-poisoning
Lead poisoning leads to the accumulation of what two heme precursors in the blood?
Protoporphyrin and -aminolevulinic acid (-ALA) "<img src=""7988.png"">"
poisoning
An attack of acute intermittent porphyria leads to the accumulation of what three
heme precursors? Are they seen in the blood or urine? Protoporphyrin (blood), -
aminolevulinic acid (-ALA, blood), and coporphobilinogen (urine) "<img
X-linked sideroblastic anemia is due to a defect in which enzyme in heme synthesis,
facilitating which reaction? -Aminolevulinic acid synthase (the rate-limiting
step of heme synthesis); glycine and succinyl-CoA to -aminolevulinic acid
(requires B6) "<img src=""7988.png"">" Hematology-and-Oncology Pathology
heme-synthesis,-porphyrias,-and-lead-poisoning
What pathologic process occurs if there is a defect in one of the steps of heme
synthesis? Porphyria, in which heme precursors accumulate "<img src=""7988.png"">"
poisoning
What are the differences in neurologic outcomes between adults and children with
lead poisoning? Adults typically have headaches, memory loss, and demyelination,
and children suffer from mental deterioration "<img src=""7988.png"">"
poisoning
What environmental exposures are common sources of lead poisoning in adults? In
children? Adults are exposed to lead in the environment (e.g., batteries,
ammunition); children are exposed via lead paint "<img src=""7988.png"">"
poisoning
A patient has acute intermittent porphyria. What is the defective enzyme?
Porphobilinogen deaminase "<img src=""7988.png"">" Hematology-and-
Oncology Pathology heme-synthesis,-porphyrias,-and-lead-poisoning
How does heme provide feedback for its own synthesis? Heme inhibits -
aminolevulinic acid synthase, the rate-limiting step in synthesishence a low heme
level increases ALA synthase activity "<img src=""7988.png"">" Hematology-
A patient has accumulation of porphobilinogen, -ALA, and coporphobilinogen in her
urine. What enzyme is defective? Porphobilinogen deaminase (this is the
defective enzyme in acute intermittent porphyria) "<img src=""7988.png"">"
poisoning
What cofactor is necessary for the rate-limiting step in heme synthesis? Why?
Vitamin B6; needed to convert glycine and succinyl-CoA to -aminolevulinic
acid "<img src=""7988.png"">" Hematology-and-Oncology Pathology heme-
synthesis,-porphyrias,-and-lead-poisoning
Which step in heme synthesis requires iron? The final step, where
protoporphyrin is converted to heme by ferrochelatase "<img src=""7988.png"">"
poisoning
A man presents with abdominal pain and port winecolored urine. What treatments are
available for his condition? Glucose or heme, both of which inhibit ALA synthase
to decrease buildup of heme precursors (he has acute intermittent porphyria) "<img
A woman who works in an ammunition factory experiences headaches and memory loss.
What is the diagnosis? What is the mechanism of disease? Lead poisoning; lead
inhibits ferrochelatase and -aminolevulinic acid dehydratase in heme synthesis, &
thus heme precursors accumulate "<img src=""7988.png"">" Hematology-and-
A patient who recently started phenobarbital has abdominal pain, altered mental
status, and port winecolored urine. Diagnosis? Acute intermittent porphyria (5
P's: abdominal Pain, Port winecolored urine, Polyneuropathy, Psychiatric
disturbances, drug Precipitants) "<img src=""7988.png"">" Hematology-and-
What are the 5 Ps that represent the symptoms associated with acute intermittent
porphyria? Painful abdomen, Port winecolored urine, Polyneuropathy, Psychological
disturbances, Precipitation by drugs, alcohol, and starvation "<img
Name the enzyme(s), substrate(s), cofactor(s), and product(s) involved in the first
step of heme synthesis. What inhibits this step? -aminolevulinic acid
synthase (rate-limiting, converts glycine and succinyl-CoA to -ALA [needs B6]);
inhibited by glucose and heme "<img src=""7988.png"">" Hematology-and-Oncology
Pathology heme-synthesis,-porphyrias,-and-lead-poisoning
In the various porphyrias, heme synthesis is not appropriately inhibited, further
contributing to excess precursor buildup. Why? Because heme is not properly
synthesized, there is less negative feedback on -ALA synthase by heme, leading to
pathway overactivation "<img src=""7988.png"">" Hematology-and-Oncology
Pathology heme-synthesis,-porphyrias,-and-lead-poisoning
You add -aminolevulinic acid (-ALA) to cell cultures. Hours later,
porphobilinogen rises within the cells' cytoplasm. What happened? In heme
synthesis, -ALA exits the mitochondria into the cytoplasm and is converted into
porphobilinogen by -ALA dehydratase "<img src=""7988.png"">" Hematology-
Radiolabeled porphobilinogen is added to cell cytoplasm. Later, you also find
radiolabeled uroporphyrinogen III there. What happened? Normal heme synthesis
(porphobilinogen becomes hydroxymethylbilane via porphobilinogen deaminase, which
then becomes uroporphyrinogen III) "<img src=""7988.png"">" Hematology-and-
Excess iron causes problems because, mechanistically, it has what effect on cells?
Causes cell death due to the peroxidation of membrane lipids "<img
src=""7989.png"">" Hematology-and-Oncology Pathology iron-poisoning
A grandma thought her grandson was eating candy, but he now has nausea, vomiting,
lethargy, and GI bleeding. Name a possible toxin exposure. Iron poisoning "<img
src=""7989.png"">" Hematology-and-Oncology Pathology iron-poisoning
A mother finds her infant son eating iron tablets and brings him to the ED. What is
the treatment? Chelation (e.g., IV deferoxamine, oral deferasirox), and if
severe, dialysis may be required "<img src=""7989.png"">" Hematology-and-
Oncology Pathology iron-poisoning
A toddler exhibits vomiting, GI bleeding, and lethargy after eating his mother's
medication. What feared complication may require surgery? Iron poisoning can cause
GI scarring, which may lead to obstruction "<img src=""7989.png"">"
Hematology-and-Oncology Pathology iron-poisoning
You order a prothrombin time (PT) assay. What coagulation factors are evaluated?
Factors I, II, V, VII, and X (the common and extrinsic pathways) "<img
src=""7990.png"">" Hematology-and-Oncology Pathology coagulation-disorders
You order a PTT assay. What coagulation factors are evaluated? All coagulation
factors except VII and XIII (the intrinsic pathway) "<img src=""7990.png"">"
Hematology-and-Oncology Pathology coagulation-disorders
A patient sustains a hemorrhagic stroke. The warfarin level is found to be
supratherapeutic. What will a bleeding time assay show? It will be normal,
because warfarin does not affect bleeding time (you will see increases in both PT
and PTT, however) "<img src=""7990.png"">" Hematology-and-Oncology Pathology
coagulation-disorders
A patient has hemophilia A. What are the prothrombin time (PT) and partial
thromboplastin time (PTT) results? PT is normal and PTT is increased, because
hemophilia affects the intrinsic pathway "<img src=""7990.png"">" Hematology-
and-Oncology Pathology coagulation-disorders
A patient has a vitamin K deficiency . How does this affect prothrombin time (PT)
and partial thromboplastin time (PTT)? Both PT and PTT are highvitamin K is
necessary for the synthesis of factors II, VII, IX, and X and proteins C and S
"<img src=""7990.png"">" Hematology-and-Oncology Pathology coagulation-
disorders
What are the treatments for patients with hemophilia A, B, and C, respectively?
A: desmopressin and factor VIII concentrate; B: factor IX concentrate, C:
factor XI concentrate "<img src=""7990.png"">" Hematology-and-Oncology
Pathology coagulation-disorders
A boy undergoes tooth extraction and has excessive bleeding afterward. If it is due
to a hereditary condition, what will his PT and PTT be? PT will be normal and
PTT will be high (this is likely hemophilia A, B, or C) "<img src=""7990.png"">"
Hematology-and-Oncology Pathology coagulation-disorders
A man with a history of easy bruising has a large, swollen joint. Arthrocentesis
shows blood. What underlying disease is responsible? Hemophilia A, B, or C, each
of which causes spontaneous hemarthrosis, a type of macrohemorrhage "<img
Which factors' deficiencies are responsible for hemophilia A, B, and C?
Hemophilia A: factor VIII; hemophilia B: factor IX; hemophilia C: factor XI
"<img src=""7990.png"">" Hematology-and-Oncology Pathology coagulation-
disorders
What is the INR? With which coagulation parameter is it useful for monitoring?
The international normalized ratio; it is calculated from PT and commonly
used to follow patients on warfarin; 1 is normal, >1 is prolonged "<img
A patient has a problem with platelet function. What coagulation test will show
this? Bleeding time will be increased "<img src=""7991.png"">" Hematology-
and-Oncology Pathology platelet-disorders
What is the mechanism by which Bernard-Soulier syndrome causes a defect in the
interaction of platelets? A decrease in the molecule glycoprotein Ib for
platelet-to-vWF adhesion results in defective formation of platelet plugs "<img
src=""7991.png"">" Hematology-and-Oncology Pathology platelet-disorders
Glanzmann thrombasthenia causes a defect in what aspect of platelet interaction?
Poor platelet-to-platelet aggregation in platelet plug formation due to
decreased glycoprotein IIb/IIIa "<img src=""7991.png"">" Hematology-and-
Oncology Pathology platelet-disorders
A patient has immune thrombocytopenia. What antibody is produced? What will you
find increased on bone marrow biopsy? Antibodies against glycoprotein IIb/IIIa
causing platelet-antibody complex destruction by splenic macrophages;
megakaryocytes are increased "<img src=""7991.png"">" Hematology-and-Oncology
Pathology platelet-disorders
A patient has thrombotic thrombocytopenic purpura. What enzyme is deficient? ADAMTS
13, a metalloprotease that degrades von Willebrand factor multimers "<img
What is the role that von Willebrand factor multimers play in the development of
thrombotic thrombocytopenic purpura? The large vWF multimers cause increased
platelet adhesion leading to increased platelet aggregation and thrombosis "<img
A thrombocytopenic woman's bone marrow biopsy shows large and numerous
megakaryocytes. Treatment? Steroids, intravenous immunoglobulin, splenectomy for
refractory disease (this is immune thrombocytopenia) "<img src=""7991.png"">"
Hematology-and-Oncology Pathology platelet-disorders
A woman with schistocytes on blood smear and high LDH and bleeding time is found to
have inhibitory antibodies against ADAMTS 13. Treatment? Plasmapheresis, steroids
(this is thrombotic thrombocytopenic purpura) "<img src=""7991.png"">"
Hematology-and-Oncology Pathology platelet-disorders
A patient has petechiae and recurrent epistaxis. Blood smear shows no platelet
clumping. What will bleeding time and platelet count show? Bleeding time is
increased and platelet count is normal (this is Glanzmann thrombasthenia) "<img
A patient with purpura and menorrhagia has low platelets. Antiplatelet antibodies
are found. What can trigger this condition? Viral illnesses may trigger it
(this is immune thrombocytopenia involving decreased platelet survival and
increased marrow megakaryocytes) "<img src=""7991.png"">" Hematology-and-
A patient has bleeding from the gums, epistaxis, petechiae, and purpura. What is
the likely defect in coagulation? Increased bleeding time with or without a
platelet count reduction (these describe the microhemorrhages associated with
platelet disorders) "<img src=""7991.png"">" Hematology-and-Oncology
A patient comes in with fever, hallucinations, and altered mental status. Labs show
anemia, proteinuria, and thrombocytopenia. Diagnosis? Thrombotic thrombocytopenic
purpura (pentad: neurologic symptoms, renal failure, fever, thrombocytopenia,
microangiopathic hemolytic anemia) "<img src=""7991.png"">" Hematology-and-
A child comes in with bloody diarrhea and lethargy. Labs show anemia, high
creatinine, and thrombocytopenia. Treatment? Plasmapheresis; this is likely
hemolytic-uremic syndrome "<img src=""7991.png"">" Hematology-and-Oncology
What is a very common cause of hemolytic-uremic syndrome in children? Shiga toxin
producing E coli (STEC, eg, O157:H7) "<img src=""7991.png"">" Hematology-
A man has bleeding; he is hemolyzing RBCs and has thrombocytopenia and renal
failure. There is no fever or delirium. Does he have diarrhea? Unlikely; this
presentation is consistent with hemolytic-uremic syndrome, which in adults may not
present with diarrhea (STEC not required) "<img src=""7991.png"">" Hematology-
A woman has an intrinsic pathway coagulation defect. Bleeding time and PTT are
increased. Describe the mechanism of action of her treatment. Desmopressin helps
release von Willebrand factor stored in endothelium (this is von Willebrand
disease) "<img src=""7992.png"">" Hematology-and-Oncology Pathology mixed-
platelet-and-coagulation-disorders
In von Willebrand disease, how is platelet plug formation defective? There is
decreased vWF available for platelet-to-vWF adhesion "<img src=""7992.png"">"
Hematology-and-Oncology Pathology mixed-platelet-and-coagulation-disorders
What is the most common inherited bleeding disorder? Is it autosomal dominant or
recessive? How is it diagnosed and treated? von Willebrand disease; autosomal
dominant (varying severity, typically mild); positive ristocetin cofactor assay,
desmopressin (DDAVP) "<img src=""7992.png"">" Hematology-and-Oncology
Pathology mixed-platelet-and-coagulation-disorders
A mnemonic for the seven most common causes of DIC is STOP Making New Thrombi. What
does it stand for? Sepsis (gram-negative), Trauma, Obstetric complications,
acute Pancreatitis, Malignancy, Nephrotic syndrome, and Transfusions "<img
src=""7992.png"">" Hematology-and-Oncology Pathology mixed-platelet-and-
Von Willebrand factor (vWF) carries/protects what factor of the coagulation
pathway? Factor VIII "<img src=""7992.png"">" Hematology-and-Oncology
How is a bleeding state brought about in disseminated intravascular coagulation?
There is a deficiency in clotting factors from widespread activation of
clotting, resulting in a decreased ability to form future clots "<img
A patient has disseminated intravascular coagulation. Name the important lab
findings associated with this disorder. Low platelet count, fibrinogen, and
factors V/VIII; increased bleeding time, PT/PTT, fibrin degradation products (D-
dimers); schistocytes "<img src=""7992.png"">" Hematology-and-Oncology
A woman exhibits severe postpartum bleeding. Labs show increased PT, PTT, and
bleeding time and a decreased platelet count. Diagnosis? Disseminated
intravascular coagulation (likely due to obstetric complications) "<img
What is the pathogenesis of factor V Leiden? A mutation in factor V, making it
undegradable by protein C, leading to a hypercoagulable state "<img
src=""7993.png"">" Hematology-and-Oncology Pathology hereditary-thrombosis-
syndromes-leading-to-hypercoagulability
Name the most common cause of inherited hypercoagulability in whites. Factor V
Leiden "<img src=""7993.png"">" Hematology-and-Oncology Pathology
hereditary-thrombosis-syndromes-leading-to-hypercoagulability
Why does protein C or protein S deficiency lead to a hypercoagulable state?
Inability to inactivate clotting factors Va and VIIIa"<img src=""7993.png"">"
Hematology-and-Oncology Pathology hereditary-thrombosis-syndromes-leading-to-
hypercoagulability
A patient has a prothrombin gene mutation. Why are venous clots more likely to
form? Mutation in the 3 untranslated region, leading to increased prothrombin
production/level and therefore venous clot formation "<img src=""7993.png"">"
Hematology-and-Oncology Pathology hereditary-thrombosis-syndromes-leading-to-
hypercoagulability
In what states can antithrombin deficiency be acquired? In renal failure or
nephrotic syndrome, antithrombin may be lost in the urine, reducing inhibition of
factors IIa and Xa "<img src=""7993.png"">" Hematology-and-Oncology
Pathology hereditary-thrombosis-syndromes-leading-to-hypercoagulability
A woman with hypercoagulability treated with heparin continues to have a normal
PTT. What is a possible cause of her lack of a response? The mechanism of heparin
depends on antithrombin III (she has antithrombin III deficiency and will not have
the expected increase in PTT) "<img src=""7993.png"">" Hematology-and-Oncology
Pathology hereditary-thrombosis-syndromes-leading-to-hypercoagulability
A woman has purpura and bullae on her legs after taking warfarin. With this
warfarin reaction, what coagulopathy are you worried about?Protein C deficiency
(protein C Cancels Coagulation) "<img src=""7993.png"">" Hematology-and-
Oncology Pathology hereditary-thrombosis-syndromes-leading-to-hypercoagulability
What is the mutation responsible for factor V Leiden? A mutant factor V, with a G
toA DNA point mutation leading to an Arg506Gln mutation by its cleavage site
"<img src=""7993.png"">" Hematology-and-Oncology Pathology hereditary-
thrombosis-syndromes-leading-to-hypercoagulability
What are the roles of protein C and protein S? What happens when there is a
deficiency of either of them? They inactivate factors Va and VIIIa, preventing
coagulation (C Cancels, and S Stops, Coagulation); a hypercoagulable state "<img
What are the common complications seen in patients with factor V Leiden?
Cerebral vein thromboses, DVT, recurrent pregnancy loss "<img
A patient has a bleeding wound while taking a vitamin K antagonist. What two
antidotes would you want to give, and for what reason? Fresh-frozen plasma to
immediately counteract the effects of warfarin, and vitamin K to help with longer-
term reversal "<img src=""7994.png"">" Hematology-and-Oncology Pathology
blood-transfusion-therapy
A patient with an uncontrollable nosebleed is found to have a platelet count of
<15,000/mm, What blood product would be therapeutic? Platelets, the transfusion of
which increases platelet count in thrombocytopenia and in qualitative defects
"<img src=""7994.png"">" Hematology-and-Oncology Pathology blood-
transfusion-therapy
A patient with liver cirrhosis has increased bleeding after a surgical procedure.
What blood product would be therapeutic? Fresh-frozen plasma, which will increase
the coagulation factors that are deficient in cirrhosis (these are produced in the
liver) "<img src=""7994.png"">" Hematology-and-Oncology Pathology blood-
transfusion-therapy
A patient has numbness and tingling in his fingers and toes after receiving
multiple blood transfusions during surgery. What is the cause? Citrate, an
anticoagulant in stored blood, is a calcium chelator and can lead to hypocalcemia
after multiple transfusions "<img src=""7994.png"">" Hematology-and-Oncology
Pathology blood-transfusion-therapy
What transfusion therapy is used to treat fibrinogen and factor VIII deficiencies?
Why? Cryoprecipitate; it contains fibrinogen, factor VIII, factor XIII, and
fibronectin "<img src=""7994.png"">" Hematology-and-Oncology Pathology blood-
transfusion-therapy
A hemorrhaging patient undergoes a blood transfusion. Name some risks associated
with this process. Infection, transfusion reactions, hypocalcemia (due to
citrate), hyperkalemia (old RBC lysis), iron overload (secondary hemochromatosis)
"<img src=""7994.png"">" Hematology-and-Oncology Pathology blood-
transfusion-therapy
A bleeding patient with severe anemia requires the transfusion of packed RBCs. What
is the physiologic benefit of this process? It will increase hemoglobin and
therefore the O2-carrying capacity of the blood "<img src=""7994.png"">"
Hematology-and-Oncology Pathology blood-transfusion-therapy
By how much will a unit of transfused platelets increase the platelet count? 5000
platelets/mm3 "<img src=""7994.png"">" Hematology-and-Oncology Pathology
blood-transfusion-therapy
In what three conditions is the transfusion of fresh-frozen plasma warranted to
reverse a coagulopathy? DIC, cirrhosis, and situations requiring immediate reversal
of warfarin "<img src=""7994.png"">" Hematology-and-Oncology Pathology blood-
transfusion-therapy
How does tumor location differ between leukemia and lymphoma? Leukemia cells are
found in peripheral blood and bone marrow, whereas lymphoma cells are lymphoid
masses (presentation may blur definitions) "<img src=""7995.png"">"
Hematology-and-Oncology Pathology leukemia-vs-lymphoma
How do the constitutional symptoms of Hodgkin and non-Hodgkin lymphomas compare?
Hodgkin: numerous constitutional (B) signs/symptoms (eg, low-grade fever,
night sweats, weight loss); non-Hodgkin: fewer signs/symptoms "<img
src=""7996.png"">" Hematology-and-Oncology Pathology hodgkin-vs-non-hodgkin-
lymphoma
Which diseases are associated with Hodgkin and non-Hodgkin lymphomas, respectively?
Epstein-Barr virus infection is associated with Hodgkin lymphoma; HIV and
autoimmunity are associated with non-Hodgkin lymphoma "<img src=""7996.png"">"
Hematology-and-Oncology Pathology hodgkin-vs-non-hodgkin-lymphoma
What is characteristically found on biopsy to help diagnose Hodgkin lymphoma?
Reed-Sternberg cells "<img src=""7996.png"">" Hematology-and-Oncology
Pathology hodgkin-vs-non-hodgkin-lymphoma
Typically, non-Hodgkin lymphoma is a tumor derived from what type of cell? B
lymphocytes, except for the few that have T-cell origins "<img src=""7996.png"">"
How does the pattern of lymph node involvement differ between Hodgkin and non-
Hodgkin lymphomas? Hodgkin: localized (single node group), contiguous spread;
non-Hodgkin: multiple node groups, extranodal involvement, noncontiguous spread
"<img src=""7996.png"">" Hematology-and-Oncology Pathology hodgkin-vs-
non-hodgkin-lymphoma
A 57-year-old man has night sweats and weight loss. Reed-Sternberg cells are found
on microscopy. How do you predict his prognosis? Stage is the strongest
predictor of prognosis in Hodgkin lymphoma (Hodgkin lymphomas have better prognoses
than do non-Hodgkin lymphomas) "<img src=""7996.png"">" Hematology-and-
Oncology Pathology hodgkin-vs-non-hodgkin-lymphoma
How do the demographics of Hodgkin and non-Hodgkin lymphomas differ? Hodgkin:
bimodal onset (young adults, >55 years), men > women (except nodular sclerosing);
non-Hodgkin: occurs in children and adults "<img src=""7996.png"">"
A patient with night sweats, low-grade fevers, weight loss, and new palpable lymph
nodes likely has what type of lymphoma? Hodgkin (the patient has B symptoms and
localized nodal involvement, which is more consistent with Hodgkin lymphoma) "<img
src=""7996.png"">" Hematology-and-Oncology Pathology hodgkin-vs-non-hodgkin-
lymphoma
What is the CD profile of Reed-Sternberg cells? CD15+ and CD30+ (2 owl eyes [CDs]
15 = 30) "<img src=""7997.png"">" Hematology-and-Oncology Pathology reed-
sternberg-cells
A Hodgkin lymphoma patient with strong stromal or lymphocytic reactions against
Reed-Sternberg cells has what prognosis? Better "<img src=""7997.png"">"
Hematology-and-Oncology Pathology reed-sternberg-cells
A lymphoma patient undergoes biopsy; Reed-Sternberg cells are seen. Are you able to
make the diagnosis of Hodgkin lymphoma? No; though Reed-Sternberg cells are
necessary for the diagnosis, they are not sufficient, so additional testing is
needed "<img src=""7997.png"">" Hematology-and-Oncology Pathology reed-
sternberg-cells
How is the gene product of the translocation t(8;14) associated with Burkitt
lymphoma? The c-myc (8) oncogene moves next to heavy-chain immunoglobulin gene
promoter (14) and is produced in large quantities "<img src=""7998.png"">"
Hematology-and-Oncology Pathology non-hodgkin-lymphoma
What infectious cause is associated with Burkitt lymphoma? Epstein-Barr virus
"<img src=""7998.png"">" Hematology-and-Oncology Pathology non-hodgkin-
lymphoma
Name the five non-Hodgkin lymphoma subtypes that are associated with mature B
cells. Burkitt lymphoma, diffuse large B-cell lymphoma, follicular lymphoma,
mantle cell lymphoma, and primary central nervous system lymphoma "<img
src=""7998.png"">" Hematology-and-Oncology Pathology non-hodgkin-lymphoma
Name two non-Hodgkin lymphoma subtypes that are associated with mature T cells.
Adult T-cell lymphoma and mycosis fungoides/Szary syndrome"<img
A Caribbean man presents with multiple skin lesions. Viral tests reveal HTLV-1
positivity. What electrolyte abnormality might he have? This is adult T-cell
lymphoma, a neoplasm with cutaneous lesions seen in Japan, West Africa, and the
Caribbean; hypercalcemia may be seen "<img src=""7998.png"">" Hematology-
and-Oncology Pathology non-hodgkin-lymphoma
Which non-Hodgkin lymphoma of mature B-cell origin is the most common in adults?
Diffuse large B-cell lymphoma (only 20% of which are found in children)
lymphoma
A pathologist sees cells that are nodular and small with cleaved nuclei. He notes
Bcl-2 overactivity, preventing which cellular process? Follicular lymphoma has
this histologic appearance and is associated with Bcl-2 overactivity, which
inhibits apoptosis "<img src=""7998.png"">" Hematology-and-Oncology
Pathology non-hodgkin-lymphoma
Which variant of non-Hodgkin lymphoma is most commonly associated with HIV/AIDS?
Primary central nervous system lymphoma (considered an AIDS-defining illness,
in fact) "<img src=""7998.png"">" Hematology-and-Oncology Pathology non-
hodgkin-lymphoma
A man presents with an aggressive lymphoma in a later stage. What diagnosis are you
most concerned about? Mantle cell lymphoma "<img src=""7998.png"">"
A patient has itchy skin patches biopsied. Cells show cerebriform nuclei and CD4
positivity in the lab. Why do you immediately order a CBC? Mycosis fungoides (skin
patches/plaques, a cutaneous T-cell lymphoma)) can progress to Szary syndrome, a
T-cell leukemia "<img src=""7998.png"">" Hematology-and-Oncology Pathology
A patient's lymphoma profile reveals a t(11;14) translocation between cyclin D1 and
heavy-chain Ig. Identify the patient's age and sex. The patient is a man (this is
mantle cell lymphoma, a non-Hodgkin lymphoma subtype) "<img src=""7998.png"">"
A Japanese man has new skin lesions. Labwork shows hypercalcemia, and X-rays show
lytic lesions. Why is a social history important for him? Adult T-cell lymphomas
(common in Japan, caused by the HTLV virus) are associated with IV drug abuse
lymphoma
30 years after quitting heroin, a West African man has hypercalcemia, bone pain,
and skin lesions. What virus is involved in this neoplasm? Human T-lymphocyte virus
(HTLV) is associated with adult T-cell lymphomas "<img src=""7998.png"">"
What is the expected course in a patient who has follicular lymphoma? What is the
typical presentation for such a patient? Indolent; patients typically experience
(present with) waxing and waning of painless lymphadenopathy "<img
"Name the cell type(s) being described when one refers to the ""starry sky""
appearance of a Burkitt lymphoma biopsy specimen." "Sheets of lymphocytes with
interspersed ""tingible body"" macrophages" "<img src=""7998.png"">"
Which variant of non-Hodgkin lymphoma is associated with a t(8;14) translocation?
What two genes are translocated? Burkitt lymphoma; c-myc (8) and heavy-chain Ig
(14) "<img src=""7998.png"">" Hematology-and-Oncology Pathology non-hodgkin-
lymphoma
What two genes are translocated? Follicular lymphoma; heavy-chain Ig (14) and
BCL-2 (18) "<img src=""7998.png"">" Hematology-and-Oncology Pathology non-
hodgkin-lymphoma
What two genes are translocated? Mantle cell lymphoma; cyclin D1 (11) and heavy-
chain Ig (14) "<img src=""7998.png"">" Hematology-and-Oncology Pathology
In Burkitt lymphoma, what is the difference, in terms of location, in where lesions
typically appear? The endemic form in Africa typically involves a jaw lesion, and
the sporadic form typically has pelvic or abdominal involvement "<img
A patient reports waxing/waning lymphadenopathy. A biopsy shows t(14;18)
translocations and small cleaved cells. What disease grade is this? This is a
grade 1 follicular lymphoma (defined by follicular architecture with small cleaved
cells) "<img src=""7998.png"">" Hematology-and-Oncology Pathology non-
hodgkin-lymphoma
What are the three grades of follicular lymphoma? Grade 1: small cleaved cells;
grade 2: large cells; grade 3: mixture of small cleaved cells and large cells
lymphoma
A patient with headaches is found on biopsy to have a new lymphoma in his brain.
For which infectious disease do you immediately test her? HIV/AIDS; primary
central nervous system lymphoma is considered an AIDS-defining illness "<img
An AIDS patient presents with confusion, seizures, and memory loss. Brain MRI shows
several masses. What is your differential diagnosis? In an AIDS patient, consider
primary central nervous system or toxoplasmosis (additional studies, such as CSF
analysis, are required) "<img src=""7998.png"">" Hematology-and-Oncology
Pathology non-hodgkin-lymphoma
Primary central nervous system lymphoma typically affects what population?
Adults, usually ones with HIV/AIDS "<img src=""7998.png"">" Hematology-
and-Oncology Pathology non-hodgkin-lymphoma
What does MGUS stand for? What is its significance? Monoclonal gammopathy of
undetermined significance; it is a monoclonal plasma cell expansion and
asymptomatic precursor to multiple myeloma "<img src=""7999.png"">"
Hematology-and-Oncology Pathology multiple-myeloma
A patient presents with lower back pain. He has anemia, high creatinine, and high
calcium. What diagnosis do you consider? Multiple myeloma (CRAB: hyperCalcemia,
Renal insufficiency, Anemia, Bone/Back pain) "<img src=""7999.png"">"
A man's bone marrow biopsy shows proliferation of plasma cells with a fried-egg
appearance. How old is the man undergoing the biopsy? Multiple myeloma, a plasma
cell neoplasm, is the most common primary tumor arising in patients >4050 years of
age "<img src=""7999.png"">" Hematology-and-Oncology Pathology multiple-
myeloma
A 65-year-old man has an M spike on serum protein electrophoresis. He is
asymptomatic. What is the likely diagnosis? Monoclonal gammopathy of
undetermined significance (MGUS), a condition that may progress to multiple myeloma
(12% per year) "<img src=""7999.png"">" Hematology-and-Oncology Pathology
multiple-myeloma
A patient presents with Raynaud phenomenon and a positive M spike on serum protein
electrophoresis. His vision is blurry. Diagnosis? This is likely Waldenstrm
macroglobulinemia with hyperviscosity (eg, Raynaud phenomenon, blurry vision)] &
absence of CRAB findings "<img src=""7999.png"">" Hematology-and-Oncology
Pathology multiple-myeloma
A patient with multiple myeloma presents with a fever. Why is this significant?
Multiple myeloma produces nonfunctional immunoglobulins, increasing the
possibility of infection resulting from immunocompromise "<img src=""7999.png"">"
What is the difference between the immunoglobulins (Igs) involved in Waldenstrm
macroglobulinemia and those in multiple myeloma? Waldenstrm
macroglobulinemia: overproduction of IgM (M spike); multiple myeloma: increased IgG
(55%) or IgA (25%) "<img src=""7999.png"">" Hematology-and-Oncology
What is the classic gross appearance of the monoclonal plasma cells seen in
multiple myeloma? "A ""fried egg"" appearance with ""clock face"" chromatin and
intracytoplasmic inclusions containing immunoglobulin" "<img src=""7999.png"">"
What noninvasive tests are ordered in a patient in whom multiple myeloma is
suspected? Serum and urine protein electrophoresis, peripheral blood smear,
radiographs "<img src=""7999.png"">" Hematology-and-Oncology Pathology
multiple-myeloma
Waldenstrm macroglobulinemia and multiple myeloma each have an M spike on protein
electrophoresis. How do their presentations differ? Hyperviscosity symptoms are
more common in Waldenstrm macroglobulinemia, whereas CRAB findings are more common
in multiple myeloma "<img src=""7999.png"">" Hematology-and-Oncology
Myelodysplastic syndromes involve what type of cells, resulting in improper
maturation of all cells in what lineage? Stem cells, leading to cell maturation
defects in all nonlymphoid lineages "<img src=""8000.png"">" Hematology-and-
Oncology Pathology myelodysplastic-syndromes
A woman found to have breast cancer undergoes chemotherapy and radiation.
Hematologically, for what is she now at risk? A myelodysplastic syndrome
(ineffective hematopoiesis) resulting from environmental exposures (in this case,
radiation and chemotherapy) "<img src=""8000.png"">" Hematology-and-Oncology
Pathology myelodysplastic-syndromes
A patient finishes his final round of chemotherapy. Blood smear shows neutrophils
with two nuclei connected by chromatin. What is this? The pseudoPelger-Huet
anomaly, commonly seen after a patient finishes a round of chemotherapy "<img
src=""8000.png"">" Hematology-and-Oncology Pathology myelodysplastic-syndromes
Name some events/exposures that increase one's risk of myelodysplastic syndrome.
De novo mutations and environmental exposures (eg, radiation, benzene,
chemotherapy) "<img src=""8000.png"">" Hematology-and-Oncology Pathology
myelodysplastic-syndromes
For what serious complication must patients with myelodysplastic syndromes be
monitored closely? Transformation to AML "<img src=""8000.png"">"
Hematology-and-Oncology Pathology myelodysplastic-syndromes
What is the difference between small lymphocytic lymphoma (SLL) and chronic
lymphocytic leukemia (CLL)? CLL has increased peripheral blood lymphocytosis, or
bone marrow involvement; SLL does not "<img src=""8001.png"">" Hematology-
and-Oncology Pathology leukemias
A 63-year-old man has just been found to have a B-cell neoplasm that is CD20+ and
CD5+. How does this neoplasm typically present? Asymptomatic, slow progression,
possibly with autoimmune hemolytic anemia (this is small lymphocytic
lymphoma/chronic lymphocytic leukemia) "<img src=""8001.png"">" Hematology-
A patient is found to have a mature B-cell tumor that is TRAP-stain positive. If
bone marrow aspiration is ordered, what will be found? "Bone marrow fibrosis
and, often, a ""dry tap"" on aspiration (the patient has hairy cell leukemia)"
"<img src=""8001.png"">" Hematology-and-Oncology Pathology leukemias
What are the common sites of metastases in acute lymphoblastic leukemia/lymphoma?
Central nervous system and testes "<img src=""8001.png"">" Hematology-
Which of the leukemias is most responsive to treatment? What are some cell markers
that can be used to identify it? Acute lymphoblastic leukemia/lymphoma; cells
may be TdT+ (a marker of pre-T and pre-B cells) and CD10+ (a marker of pre-B cells)
What diagnosis is confirmed by the presence of the Philadelphia chromosome?
Identify the specific mutation and the gene directly affected. Chronic
myelogenous leukemia; the mutation is a t[9;22] translocation, resulting in an
oncogenic BCR-ABL gene "<img src=""8001.png"">" Hematology-and-Oncology
Pathology leukemias
What helps distinguish chronic myelogenous leukemia (CML) and a leukemoid reaction
in patients with increased WBCs/immature forms? Leukocyte alkaline phosphatase will
be low in CML and high in leukemoid reactions because of the maturity of the cells
involved "<img src=""8001.png"">" Hematology-and-Oncology Pathology
leukemias
What drug is effective against chronic myelogenous leukemia? What is its mechanism
of action? Inhibitors of the BCR-ABL tyrosine kinase (eg, imatinib) "<img
src=""8001.png"">" Hematology-and-Oncology Pathology leukemias
How does the epidemiology of acute myelogenous leukemia (AML) differ from that of
chronic myelogenous leukemia (CML)? The median age at AML onset is 65 years; CML
occurs across the age spectrum, with a median age of 64 and a range between ages 45
and 85 "<img src=""8001.png"">" Hematology-and-Oncology Pathology
leukemias
What are Auer rods? Myeloperoxidase-positive cytoplasmic inclusions seen mostly
in APL (formerly M3 AML) "<img src=""8001.png"">" Hematology-and-Oncology
Pathology leukemias
A patient has unregulated leukocyte growth in the bone marrow, anemia, and
thrombocytopenia. What is the likely diagnosis? Leukemia (patients have marrow
failure and variable amounts of WBCs and RBCs in the blood, leading to anemia,
infections, and low platelets) "<img src=""8001.png"">" Hematology-and-
Oncology Pathology leukemias
An adolescent male with a mediastinal mass has TdT+ and CD10+ cells on bone marrow
immunohistochemistry. Where else do you look for disease? The CNS and testes (this
is likely acute lymphoblastic leukemia/lymphoma) "<img src=""8001.png"">"
Hematology-and-Oncology Pathology leukemias
A woman with chronic myelogenous leukemia suddenly becomes severely ill. How has
her disease course changed? CML can accelerate and transform to acute
lymphoblastic leukemia/lymphoma or acute myelogenous leukemia in a blast crisis
A patient's blood smear is notable for blasts. Leukemia is diagnosed. Was an
increased WBC count part of the diagnosis? Likely, but in rare cases the WBC
count is normal or even decreased "<img src=""8001.png"">" Hematology-and-
Which organs do leukemic cell infiltrates most commonly affect? Liver, spleen,
lymph nodes, skin (leukemia cutis) "<img src=""8001.png"">" Hematology-and-
What are risk factors for developing acute myelogenous leukemia? Alkylating
chemotherapy, radiation, myeloproliferative disorders, Down syndrome "<img
What translocation is associated with the acute myelogenous leukemia APL subtype?
What therapy does it respond to? t(15;17); it responds to all-trans retinoic
acid (vitamin A) by inducing promyelocyte differentiation "<img src=""8001.png"">"
Although hairy cell leukemia can be diagnosed with a positive TRAP stain, what
diagnostic modality has by a large replaced this? Flow cytometry "<img
In which population is acute lymphoblastic leukemia/lymphoma most common?
Children "<img src=""8001.png"">" Hematology-and-Oncology Pathology
leukemias
An adult patient is given a new diagnosis of acute lymphoblastic leukemia/lymphoma.
Why are you suddenly more concerned about this patient? Acute lymphoblastic
leukemia/lymphoma, though rarer in adults, carries a worse prognosis in them as
well "<img src=""8001.png"">" Hematology-and-Oncology Pathology leukemias
A boy recently found to have mediastinal acute lymphoblastic leukemia/lymphoma is
suddenly dyspneic and has facial edema. What happened? The boy's mediastinal
mass may now be compressing the superior vena cava (SVC), leading to an SVC-like
syndrome "<img src=""8001.png"">" Hematology-and-Oncology Pathology
leukemias
A SLL/CLL patient suddenly becomes gravely ill, with diffuse bulky lymphadenopathy.
Biopsy of a node will most likely show what malignancy? Diffuse large B-cell
lymphoma (DLBCL); the patient has undergone a Richter transformation, with SLL/CLL
becoming a more aggressive lymphoma "<img src=""8001.png"">" Hematology-and-
What is the classic finding on the peripheral smear of a patient with chronic
lymphocytic leukemia/small lymphocytic lymphoma? Smudge cells (Crushed Little
Lymphocytes in CLL) "<img src=""8001.png"">" Hematology-and-Oncology
Pathology leukemias
In which population is hairy cell leukemia most likely to appear? Adult men
Hairy cell leukemia is a neoplasm of which cell line? Are the cells generally
mature or immature? It is a neoplasm of mature B cells "<img src=""8001.png"">"
"Why is hairy cell leukemia described with the word ""hairy"" on pathology?" The
cells have filamentous hair-like projections that appear fuzzy on light microscopy
What are some types of mature/maturing granulocytes likely to appear on the
peripheral smear of a patient with chronic myelogenous leukemia? Neutrophils,
metamyelocytes, myelocytes, basophils "<img src=""8001.png"">" Hematology-
Name the abnormal gene and the chromosomal translocation that are associated with
follicular lymphoma. t(14;18), with activation of BCL2 "<img src=""8002.png"">"
Hematology-and-Oncology Pathology chromosomal-translocations
chronic myelogenous leukemia. t(9;22), with activation of BCR-ABL (also known as
the Philadelphia chromosome [Philadelphia CreaML cheese]) "<img src=""8002.png"">"
Name the abnormal gene that is associated with subtype APL (M3) of acute
myelogenous leukemia. t(15;17) "<img src=""8002.png"">" Hematology-and-
Oncology Pathology chromosomal-translocations
mantle cell lymphoma. t(11;14), with activation of cyclin D1 "<img
src=""8002.png"">" Hematology-and-Oncology Pathology chromosomal-
translocations
Burkitt lymphoma. t(8;14), with activation of c-myc "<img src=""8002.png"">"
In a patient with an acute myeloid leukemia (AML) with a crossing-over event
between chromosomes 15 and 17, what treatment should be given? The APL (M3)
subtype of AML responds to all-trans retinoic acid "<img src=""8002.png"">"
Various malignancies are potentiated by certain genes' being translocated next to
the Ig heavy chain gene on chromosome 14. Why? The Ig heavy chain gene is
constitutively expressed, soother genes translocated next to the heavy chain region
are overexpressed as well "<img src=""8002.png"">" Hematology-and-Oncology
Pathology chromosomal-translocations
In Langerhans cell histiocytosis, dysplastic immature cells are unable to
effectively stimulate which other cells via antigen presentation? Primary T
cells "<img src=""8003.png"">" Hematology-and-Oncology Pathology langerhans-
cell-histiocytosis
What surface proteins do the cells that cause Langerhans cell histiocytosis
express? S-100 and CD1a "<img src=""8003.png"">" Hematology-and-Oncology
Pathology langerhans-cell-histiocytosis
Name some signs/symptoms that can be seen in the presentation of a patient with
Langerhans cell histiocytosis. Lytic bone lesions, skin rashes, or recurrent
otitis media with a mass involving the mastoid bone "<img src=""8003.png"">"
Hematology-and-Oncology Pathology langerhans-cell-histiocytosis
What abnormality is the core cause of secondary polycythemia vera? Natural or
artificial increases in EPO levels "<img src=""8004.png"">" Hematology-and-
Oncology Pathology chronic-myeloproliferative-disorders
What is the hematologic profile for polycythemia vera in terms of RBC, WBC, and
platelet counts? All three (RBC, WBC, platelet) are increased "<img
src=""8004.png"">" Hematology-and-Oncology Pathology chronic-
myeloproliferative-disorders
Which chronic myeloproliferative disorder is commonly associated with massive
splenomegaly? Myelofibrosis "<img src=""8004.png"">" Hematology-and-
A woman has intense pruritus after hot showers. Her EPO level is high. Abnormal
increases of which leukocyte are to blame for the pruritus?Basophils (this is
likely polycythemia vera) "<img src=""8004.png"">" Hematology-and-Oncology
Pathology chronic-myeloproliferative-disorders
Not including EPO levels, what is the defining laboratory abnormality in a patient
with polycythemia vera? Increased hematocrit "<img src=""8004.png"">"
Hematology-and-Oncology Pathology chronic-myeloproliferative-disorders
A patient's CBC reveals low RBCs, high WBCs, and high platelets. What test can help
differentiate the two most likely diagnoses? CML is Philadelphia chromosome
positive, whereas myelofibrosis 30%50% of the time has associated JAK2 mutation
positivity "<img src=""8004.png"">" Hematology-and-Oncology Pathology
chronic-myeloproliferative-disorders
What three myeloproliferative disorders are associated with the JAK2 mutation
(involved in hematopoietic signaling)? Polycythemia vera, essential
thrombocytosis (30%50% of cases), and myelofibrosis (30%50% of cases) "<img
Which myeloproliferative disorder does not involve hematopoietic growth factor
signaling due to a JAK2 mutation? What is its mechanism? Chronic myelogenous
leukemia, for which the Philadelphia chromosome increases cell division and
inhibits apoptosis "<img src=""8004.png"">" Hematology-and-Oncology
Pathology chronic-myeloproliferative-disorders
Which gene mutation is commonly associated with chronic myeloproliferative
disorders? The V617F JAK2 mutation "<img src=""8004.png"">" Hematology-and-
Name the four common chronic myeloproliferative disorders. Polycythemia vera,
essential thrombocythemia, myelofibrosis, chronic myelogenous leukemia "<img
Is polycythemia vera associated with a JAK2 mutation considered a primary or
secondary form of polycythemia? Primary "<img src=""8004.png"">"
Hematology-and-Oncology Pathology chronic-myeloproliferative-disorders
What peripheral blood and bone marrow findings are consistent with a diagnosis of
essential thrombocythemia? Massive proliferation of megakaryocytes and platelets
"<img src=""8004.png"">" Hematology-and-Oncology Pathology chronic-
A 55-year-old man has bone pain. Fibrotic obliteration of the bone marrow and
teardrop cells on his peripheral smear are noted. Diagnosis? Myelofibrosis, a
fibrotic dysplasia of the bone marrow leading to teardrop cells (bone marrow is
crying because its fibrosed/a dry tap) "<img src=""8004.png"">" Hematology-
and-Oncology Pathology chronic-myeloproliferative-disorders
What changes in plasma volume, RBC mass, O2 saturation, and EPO would be expected
in a patient with severe diffuse burns? Decreased plasma volume only; the
perceived RBC mass rise is due to reduced plasma volume from dehydration/burns
(relative polycythemia) "<img src=""8005.png"">" Hematology-and-Oncology
Pathology polycythemia
A patient has polycythemia vera. What changes in plasma volume, RBC mass, O2
saturation, and EPO level do you expect? Increased plasma volume, greatly
increased RBC mass, normal O2 saturation, decreased EPO (negative feedback inhibits
EPO production) "<img src=""8005.png"">" Hematology-and-Oncology Pathology
polycythemia
You are told that a man's plasma volume is increased, RBC mass is increased, and
EPO is low. What condition is most likely to blame? Polycythemia vera, with EPO
production decreased because negative feedback is suppressing renal EPO production
"<img src=""8005.png"">" Hematology-and-Oncology Pathology polycythemia
In what condition(s) do you expect to see appropriate absolute polycythemia? Lung
disease, congenital heart disease, high altitude "<img src=""8005.png"">"
Hematology-and-Oncology Pathology polycythemia
In what condition(s) do you expect to see inappropriate absolute polycythemia?
Hydronephrosis, malignancy (eg, renal cell carcinoma, hepatocellular
carcinoma)all pathologies trigger ectopic erythropoietin secretion "<img
src=""8005.png"">" Hematology-and-Oncology Pathology polycythemia
A patient moves to Denver. What changes in plasma volume, RBC mass, O2 saturation,
and EPO do you note within a few weeks? No change in plasma volume, increased RBC
mass and EPO, decreased O2 saturation (appropriate absolute polycythemia due to
altitude) "<img src=""8005.png"">" Hematology-and-Oncology Pathology
polycythemia
A man with renal cell carcinoma has polycythemia. What changes in plasma volume,
RBC mass, O2 saturation, and EPO do you expect? Normal plasma volume, increased RBC
mass and EPO, normal O2 saturation (inappropriate polycythemia from ectopic
erythropoietin) "<img src=""8005.png"">" Hematology-and-Oncology Pathology
polycythemia
By what mechanism does heparin anticoagulate? Does it prolong prothrombin time,
partial thromboplastin time, both, or neither? It is the cofactor for antithrombin
activation and reduces both thrombin and factor Xa; PTT is increased "<img
src=""8006.png"">" Hematology-and-Oncology heparin pharmacology
Name four adverse effects of heparin. Thrombocytopenia (heparin-induced
thrombocytopenia), osteoporosis, bleeding, and drug-drug interactions "<img
During pregnancy, is heparin or warfarin the preferred method of anticoagulation?
Heparinunlike warfarin, which is a teratogen, heparin does not cross the
placenta and so can be used safely during pregnancy "<img src=""8006.png"">"
Hematology-and-Oncology heparin pharmacology
Name four clinical uses for heparin. Immediate anticoagulation for acute
coronary syndrome, myocardial infarction, deep venous thrombosis, and pulmonary
embolism "<img src=""8006.png"">" Hematology-and-Oncology heparin
pharmacology
What are the clinical advantages of the low-molecular-weight heparins (eg,
enoxaparin, dalteparin) and fondaparinux compared with heparin? More factor Xa
activity, better bioavailability, 24 times longer half-life, subcutaneous dosing,
and no need for laboratory monitoring "<img src=""8006.png"">" Hematology-
and-Oncology heparin pharmacology
Disseminated intravascular coagulation develops while a man is taking heparin; he
bleeds profusely. What is the antidote for rapid reversal? Protamine sulfate, a
positively charged molecule; it binds negatively charged heparin "<img
What complex is formed that promotes thrombosis and thrombocytopenia in heparin-
induced thrombocytopenia (HIT)? IgG antibodies form a complex with heparin
bound to platelet factor 4 (PF4), activating platelets and causing
thrombosis/thrombocytopenia "<img src=""8006.png"">" Hematology-and-Oncology
heparin pharmacology
What are possible disadvantages of using low-molecular-weight heparins and
fondaparinux as opposed to traditional heparin? They have longer half-lives and are
not easily reversible "<img src=""8006.png"">" Hematology-and-Oncology
heparin pharmacology
What is the mechanism of action of bivalirudin? From what natural source is it
derived? It is a direct thrombin inhibitor that directly inhibits free and clot-
associated thrombin; hirudin, the anticoagulant used by leeches "<img
src=""8007.png"">" Hematology-and-Oncology direct-thrombin-inhibitors
pharmacology
Heparin-induced thrombocytopenia develops in a patient who was started on heparin
therapy. How do you change his anticoagulation regimen? Use a direct thrombin
inhibitor (eg, bivalirudin) instead of heparin "<img src=""8007.png"">"
Hematology-and-Oncology direct-thrombin-inhibitors pharmacology
What are the clinical indications for bivalirudin? Venous thromboembolism,
atrial fibrillation, HIT "<img src=""8007.png"">" Hematology-and-Oncology
direct-thrombin-inhibitors pharmacology
Does the use of direct thrombin inhibitors require lab monitoring? No "<img
src=""8007.png"">" Hematology-and-Oncology direct-thrombin-inhibitors
pharmacology
A patient taking bivalirudin bleeds profusely. There is no specific reversal agent,
but what therapies may provide some benefit? Activated prothrombin complex
concentrates (PCCs) and/or fibrinolytics (eg, tranexamic acid) may help reverse
bivalirudin "<img src=""8007.png"">" Hematology-and-Oncology direct-thrombin-
inhibitors pharmacology
A man on long-term anticoagulation for atrial fibrillation stroke prevention needs
weekly blood testing. Which medication does he take? Warfarin (eg, for venous
thromboembolism prophylaxis), which requires PT/INR checks on a regular basis
"<img src=""8008.png"">" Hematology-and-Oncology pharmacology warfarin
Name four adverse effect of warfarin. Teratogenic effects (crosses placenta and
is contraindicated in pregnancy), drug-drug interactions, bleeding, and skin/tissue
necrosis "<img src=""8008.png"">" Hematology-and-Oncology pharmacology
warfarin
How is warfarin metabolized? Metabolism is affected by polymorphisms in the
vitamin K epoxide reductase gene (VKORC1) "<img src=""8008.png"">" Hematology-
and-Oncology pharmacology warfarin
A patient is taking warfarin for VTE prophylaxis. What labs indicate that it is in
the therapeutic range? PT/INR, both increased, because warfarin affects the
EXtrinsic pathway (the EX PresidenT went to war) "<img src=""8008.png"">"
Hematology-and-Oncology pharmacology warfarin
A patient has a new DVT. What drugs should you start treatment with, and how should
you dose them? "Begin heparin and warfarin togethera heparin ""bridge"" is
needed for the initial transient hypercoagulable state caused by warfarin" "<img
src=""8008.png"">" Hematology-and-Oncology pharmacology warfarin
A man on warfarin has sudden GI bleeding. Labs show a supratherapeutic PT/INR. What
two treatments can you offer this patient for reversal? Give fresh-frozen plasma
(rapid reversal) and vitamin K (slower reversal) "<img src=""8008.png"">"
Hematology-and-Oncology pharmacology warfarin
A 50-year-old man with a new mechanical valve requires long-term anticoagulation.
What's the mechanism of action of the preferred treatment? Warfarin, which inhibits
normal synthesis and -carboxylation of the vitamin Kdependent factors (II, VII,
IX, X, C, S) "<img src=""8008.png"">" Hematology-and-Oncology
pharmacology warfarin
What is the pathophysiology behind skin/tissue necrosis seen during the first few
days of high-dose warfarin therapy? Proteins C and S have shorter half-lives than
do factors II, VII, IX, and X; depletion leads to a hypercoagulable state/necrosis
"<img src=""8008.png"">" Hematology-and-Oncology pharmacology warfarin
What is the difference in the onset of action between heparin and warfarin?
Heparin acts within seconds, whereas warfarin has a slow onset dependent on
the half-lives of the normal clotting factors "<img src=""8009.png"">"
Hematology-and-Oncology heparin-vs-warfarin pharmacology
Compare the labs monitored for heparin and for warfarin. What about antidotes for
overdose? PTT (intrinsic) is monitored for heparin, protamine sulfate given for
overdose; PT/INR (extrinsic) for warfarin, vitamin K/FFP for overdose "<img
src=""8009.png"">" Hematology-and-Oncology heparin-vs-warfarin pharmacology
Compare the mechanisms of action of heparin and warfarin. Heparin activates
antithrombin, decreasing IIa (thrombin) & Xa activity; warfarin impairs vitamin K
dependent factors II, VII, IX, X, C, S "<img src=""8009.png"">" Hematology-
and-Oncology heparin-vs-warfarin pharmacology
What is the difference in administration between heparin and warfarin? Heparin is
administered parenterally (intravenously or subcutaneously), whereas warfarin is
given orally "<img src=""8009.png"">" Hematology-and-Oncology heparin-vs-
warfarin pharmacology
Where is the site of action of warfarin? Heparin? Liver; blood "<img
Compare and contrast the molecular structures of heparin and warfarin. Heparin is a
large anionic, acidic polymer, whereas warfarin is a small amphipathic molecule
"<img src=""8009.png"">" Hematology-and-Oncology heparin-vs-warfarin
pharmacology
Compare the duration of action between warfarin and heparin. Warfarin lasts for
days (chronic), whereas heparin lasts for hours (acute) "<img src=""8009.png"">"
Hematology-and-Oncology heparin-vs-warfarin pharmacology
Explain how it makes sense that heparin inhibits coagulation in vitro (e.g., in a
laboratory blood specimen), whereas warfarin does not. Heparin acts directly in
the blood, whereas warfarin acts distantly and slowly at the site of coagulation
factor synthesis (the liver) "<img src=""8009.png"">" Hematology-and-Oncology
heparin-vs-warfarin pharmacology
A pregnant woman must be anticoagulated. Which anticoagulant is teratogenic and
should not be administered? Warfarin (don't send pregnant women to war) "<img
What is the mechanism of action for the anticoagulants apixaban and rivaroxaban?
ApiXaban and rivaroXaban bind and inhibit factor Xa directly "<img
src=""8010.png"">" Hematology-and-Oncology direct-factor-xa-inhibitors
pharmacology
A patient with recurrent DVTs is administered a direct factor Xa inhibitor to
prevent future pulmonary emboli. What is prescribed? Rivaroxaban "<img
src=""8010.png"">" Hematology-and-Oncology direct-factor-xa-inhibitors
pharmacology
A man with atrial fibrillation takes an oral anticoagulant that does not require
monitoring. Name the drug class and main adverse effects. Apixaban or rivaroxaban,
both of which are direct factor Xa inhibitors; bleeding is a possible side effect
"<img src=""8010.png"">" Hematology-and-Oncology direct-factor-xa-
inhibitors pharmacology
Emergency physicians are terrified that patients will present with hemorrhage while
taking direct factor Xa inhibitors. Why? There is no reversal agent/antidote for
bleeding caused by direct factor Xa inhibitor use "<img src=""8010.png"">"
Hematology-and-Oncology direct-factor-xa-inhibitors pharmacology
What is the mechanism of action of thrombolytics? They aid in the conversion of
plasminogen to plasmin to cleave thrombin and fibrin clots "<img src=""8011.png"">"
Hematology-and-Oncology pharmacology thrombolytics
What treatment option potentially can reverse the pathology of an early myocardial
infarction or ischemic stroke? Prompt administration of thrombolytics "<img
src=""8011.png"">" Hematology-and-Oncology pharmacology thrombolytics
What major complication can be seen from the administration of thrombolytics?
Bleeding "<img src=""8011.png"">" Hematology-and-Oncology
pharmacology thrombolytics
Name five contraindications for thrombolytics that are related to an increased risk
of bleeding. Active bleeding, a history of intracranial bleeding, recent
surgery, known bleeding diatheses, and severe hypertension "<img src=""8011.png"">"
What is the pharmacologic treatment regimen of choice for thrombolytic (e.g., tPA)
reversal? Aminocaproic acid (an inhibitor of fibrinolysis), and fresh-frozen
plasma & cryoprecipitate to correct factor deficiencies "<img src=""8011.png"">"
What is the primary enzymatic reaction that thrombolytics act on? They
directly or indirectly promote the conversion of plasminogen to plasmin, which
initiates fibrinolysis "<img src=""8011.png"">" Hematology-and-Oncology
Name three drugs/drug combinations that can be used to lyse an existing thrombus.
Streptokinase, alteplase (tPA), reteplase (rPA), tenecteplase (TNK-tPA)
"<img src=""8011.png"">" Hematology-and-Oncology pharmacology
thrombolytics
How do thrombolytics affect the prothrombin time (PT), partial thromboplastin time
(PTT), and platelet count? PT and PTT increase due to deactivation of thrombin,
and there is no effect on the platelet count "<img src=""8011.png"">"
A truck driver has sudden shortness of breath, tachypnea, and tachycardia. His BP
is 85/60 mmHg. What drug would likely help this patient? Thrombolytics are
administered in severe cases of pulmonary embolism with hemodynamic instability, as
is the case with this patient "<img src=""8011.png"">" Hematology-and-Oncology
Name at least one potentially life-threatening toxicity of the antiplatelet drug
ticlopidine. Neutropenia (ticlopidine only); TTP may arise as a side effect of
any ADP receptor inhibitor (clopidogrel/prasugrel/ticagrelor/ticlopidine) "<img
src=""8012.png"">" Hematology-and-Oncology adp-receptor-inhibitors
pharmacology
What are three common clinical uses of clopidogrel, ticlopidine, prasugrel, and
ticagrelor? Acute coronary syndromes, antiplatelet therapy in coronary stenting,
and reducing the incidence or recurrence of thrombotic stroke "<img
src=""8012.png"">" Hematology-and-Oncology adp-receptor-inhibitors
pharmacology
A 55-year-old patient has a coronary stent placed and is started on an ADP
receptorblocking drug after the procedure. Mechanism of action? Clopidogrel,
prasugrel, ticagrelor, and ticlopidine block ADP receptors, preventing glycoprotein
IIb/IIIa expression on platelet surfaces "<img src=""8012.png"">" Hematology-
and-Oncology adp-receptor-inhibitors pharmacology
ADP receptor blockers are generally irreversible, except for which specific agent?
Ticagrelor "<img src=""8012.png"">" Hematology-and-Oncology adp-
receptor-inhibitors pharmacology
What is the mechanism of action of cilostazol and dipyridamole? These drugs are
phosphodiesterase III inhibitors that cause vasodilation and increase cAMP in
platelets, which inhibits platelet aggregation "<img src=""8013.png"">"
Hematology-and-Oncology cilostazol,-dipyridamole pharmacology
What are the toxicities of cilostazol and dipyridamole? Nausea, headache, facial
flushing, hypotension, abdominal pain "<img src=""8013.png"">" Hematology-
and-Oncology cilostazol,-dipyridamole pharmacology
What are the clinical uses of cilostazol and dipyridamole? Coronary vasodilation,
intermittent claudication, prevention of stroke or TIA (combined with aspirin),
angina prophylaxis "<img src=""8013.png"">" Hematology-and-Oncology
cilostazol,-dipyridamole pharmacology
A patient has had both strokes and TIAs in the past. With which drug could
cilostazol and dipyridamole be combined to aid prevention? Aspirin "<img
src=""8013.png"">" Hematology-and-Oncology cilostazol,-dipyridamole
pharmacology
A 68-year-old man has burning pain in both feet when he walks and sometimes awakens
at night in pain. What drug(s) do you recommend? Cilostazol or dipyridamole
(this patient has intermittent claudication) "<img src=""8013.png"">"
Hematology-and-Oncology cilostazol,-dipyridamole pharmacology
What is the mechanism of action of abciximab, eptifibatide, and tirofiban? They
bind the glycoprotein IIb/IIIa receptor on activated platelets and prevent
aggregation "<img src=""8014.png"">" Hematology-and-Oncology glycoprotein-
iib/iiia-inhibitors pharmacology
What are clinical uses of abciximab, eptifibatide, and tirofiban? Unstable
angina or during percutaneous transluminal coronary angioplasty "<img
src=""8014.png"">" Hematology-and-Oncology glycoprotein-iib/iiia-inhibitors
pharmacology
Name three specific glycoprotein IIb/IIIa inhibitors. Abciximab, eptifibatide, and
tirofiban "<img src=""8014.png"">" Hematology-and-Oncology glycoprotein-
iib/iiia-inhibitors pharmacology
What is the glycoprotein IIb/IIIa inhibitor abciximab made of? Monoclonal
antibody Fab fragments "<img src=""8014.png"">" Hematology-and-Oncology
glycoprotein-iib/iiia-inhibitors pharmacology
A patient with low platelets needs a stent, and you want to start a glycoprotein
IIb/IIIa receptor blocker. What makes this treatment risky?Bleeding and
thrombocytopenia are side effects of this medication "<img src=""8014.png"">"
Hematology-and-Oncology glycoprotein-iib/iiia-inhibitors pharmacology
What alternative path can a cell take from the G1 stage of the cell cycle, aside
from stage S? What happens during G1? G0 (resting); duplication of cellular
content "<img src=""8015.png"">" Hematology-and-Oncology cancer-drugs
cell-cycle pharmacology
Which cancer drugs act only on stage M of the cell cycle? Microtubule inhibitors
(paclitaxel, vinblastine, vincristine) "<img src=""8015.png"">" Hematology-
and-Oncology cancer-drugscell-cycle pharmacology
Which cancer drug acts only on stage G2 of the cell cycle? Bleomycin "<img
src=""8015.png"">" Hematology-and-Oncology cancer-drugscell-cycle
pharmacology
Which cancer drugs act only on stage S of the cell cycle? Antimetabolites
(azathioprine, cladribine, cytarabine, 5-fluorouracil, hydroxyurea, methotrexate,
6-mercaptopurine) "<img src=""8015.png"">" Hematology-and-Oncology cancer-
drugscell-cycle pharmacology
Which cancer drug(s) act(s) on both stage S and stage G2 of the cell cycle?
Topoisomerase inhibitors (etoposide, irinotecan, teniposide, topotecan)
"<img src=""8015.png"">" Hematology-and-Oncology cancer-drugscell-
cycle pharmacology
Which cancer drugs act independent of the cell cycle? Platinum agents (eg,
cisplatin), alkylating agents (busulfan, cyclophosphamide, ifosfamide, nitrosoureas
[eg, carmustine]) "<img src=""8015.png"">" Hematology-and-Oncology cancer-
What important phase of cellular replication occurs between mitosis and the G1
phase of the cell cycle? Cytokinesis "<img src=""8015.png"">" Hematology-
and-Oncology cancer-drugscell-cycle pharmacology
Cells regulate themselves through the cell cycle. What helps regulate the G1 to S
transition? Rb and p53 modulate the G1 restriction point and this transition
(dysfunction in these proteins increases the likelihood for cancer) "<img
pharmacology
What is the primary purpose of the G1 phase of the cell cycle? Duplication of
cellular contents "<img src=""8015.png"">" Hematology-and-Oncology cancer-
What is the primary purpose of the S phase of the cell cycle? DNA synthesis
"<img src=""8015.png"">" Hematology-and-Oncology cancer-drugscell-
cycle pharmacology
What is the primary purpose of the G2 phase of the cell cycle? Double-checking
and repair "<img src=""8015.png"">" Hematology-and-Oncology cancer-drugs
cell-cycle pharmacology
What is the primary purpose of the M phase of the cell cycle? Mitosis "<img
pharmacology
Interphase comprises which phase(s) of the cell cycle? G1, S, G2 "<img
pharmacology
Which antineoplastic agents interfere with nucleotide synthesis? What are their
mechanisms of action? Methotrexate and 5-FU decrease thymidine synthesis, 6-MP
decreases de novo purine synthesis, hydroxyurea inhibits ribonucleotide reductase
"<img src=""8016.png"">" Hematology-and-Oncology cancer-drugstargets
pharmacology
Which antineoplastic agents interfere with DNA by causing direct damage to it? What
are their mechanisms of action? Alkylating agents/cisplatin cross-link DNA,
bleomycin causes DNA strand breaks, dactinomycin and doxorubicin intercalate DNA
"<img src=""8016.png"">" Hematology-and-Oncology cancer-drugstargets
pharmacology
Which antineoplastic agents interfere with DNA by inhibiting enzymes that act on
it? What are their mechanisms of action? Etoposide inhibits topoisomerase II,
irinotecan inhibits topoisomerase I "<img src=""8016.png"">" Hematology-and-
Oncology cancer-drugstargets pharmacology
Which antineoplastic agents interfere with cellular division? What are their
mechanisms of action? Vinca alkaloids inhibit microtubule formation, paclitaxel
inhibits microtubule disassembly "<img src=""8016.png"">" Hematology-and-
Oncology cancer-drugstargets pharmacology
A patient takes both 5-fluorouracil and paclitaxel for a tumor. Is DNA synthesis
directly impaired? DNA synthesis is not directly impaired by either: 5-FU
blocks thymidine synthesis; paclitaxel blocks cell division (microtubule
disassembly) "<img src=""8016.png"">" Hematology-and-Oncology cancer-
drugstargets pharmacology
An oncology patient take a folic acid analog that inhibits dihydrofolate reductase.
How does this drug help treat malignancies? Methotrexate (inhibiting
dihydrofolate reductase) results in less deoxythymidine monophosphate (dTMP) needed
for DNA and protein synthesis "<img src=""8017.png"">" Hematology-and-Oncology
antimetabolites pharmacology
Name four cancers that methotrexate can be used to treat. Leukemias (ALL),
lymphomas, choriocarcinomas, and sarcomas "<img src=""8017.png"">" Hematology-
and-Oncology antimetabolites pharmacology
Name at least two non-neoplastic conditions for which methotrexate can be used.
Vasculitis, ectopic pregnancy, medical abortion (with misoprostol), IBD,
rheumatoid arthritis, psoriasis "<img src=""8017.png"">" Hematology-and-
Oncology antimetabolites pharmacology
How does 5-fluorouracil (5-FU), a pyrimidine analog, interact with folic acid?
It is converted to 5F-dUMP, which covalently binds folic acid, forming a
complex that inhibits thymidylate synthase "<img src=""8017.png"">"
Hematology-and-Oncology antimetabolites pharmacology
A man's IBD has been controlled by steroids but becomes refractory to treatment.
Name 2 drugs that could be used to wean him from steroids. Azathioprine and 6-
mercaptopurine "<img src=""8017.png"">" Hematology-and-Oncology
antimetabolites pharmacology
What enzyme is inhibited by the 5-FdUMP/folic acid complex?Thymidylate synthase,
which is needed to form deoxythymidine monophosphate (dTMP) for DNA and protein
synthesis "<img src=""8017.png"">" Hematology-and-Oncology antimetabolites
pharmacology
What is the mechanism by which azathioprine and 6-mercaptopurine (6-MP) exert an
antineoplastic effect? These are purine (thiol) analogs, which inhibit de novo
purine synthesis (activated by HGPRT) "<img src=""8017.png"">" Hematology-
Azathioprine and 6-mercaptopurine are used in the prevention/treatment of what
conditions? Organ rejection prevention, rheumatoid arthritis, IBD, SLE, weaning
from steroids in chronic diseases, steroid-refractory conditions "<img
src=""8017.png"">" Hematology-and-Oncology antimetabolites pharmacology
Which organs are affected in patients with toxicities from 6-mercaptopurine or
azathioprine? Bone marrow (myelosuppression), GI tract, liver "<img
How does cytarabine (arabinofuranosyl cytidine) exert its antineoplastic effect?
It is a pyrimidine analog that inhibits DNA polymerase "<img
Name the adverse effects of cytarabine (arabinofuranosyl cytidine).
Myelosuppression with megaloblastic anemia (CYTarabine causes panCYTopenia)
"<img src=""8017.png"">" Hematology-and-Oncology antimetabolites
pharmacology
What agent is administered to reverse myelosuppression associated with methotrexate
(MTX) use? Leucovorin (folinic acid) is used to rescue the bone marrow"<img
What toxicities are associated with methotrexate other than myelosuppression?
Hepatotoxicity, mucositis (eg, mouth ulcers), pulmonary fibrosis "<img
What cancers are commonly treated with cytarabine (arabinofuranosyl cytidine)?
Leukemias (AML) and lymphomas "<img src=""8017.png"">" Hematology-and-
What are the clinical uses for 5-fluorouracil (5-FU)? Colon cancer, pancreatic
cancer, basal cell carcinoma (topical) "<img src=""8017.png"">" Hematology-
A patient with a history of gout has a cancer that requires either azathioprine or
6-MP. What do you worry about in a patient like this? Coadministering azathioprine
or 6-MP (metabolized by xanthine oxidase) & allopurinol or febuxostat (inhibit
xanthine oxidase) can be toxic "<img src=""8017.png"">" Hematology-and-
All the antimetabolites interfere with which phase of DNA synthesis? S phase
pharmacology
An old man is given cladribine for a leukemia. What is its mechanism of action?
It is a purine analog with multiple mechanisms (eg, inhibition of DNA
polymerase leading to DNA strand breaks) "<img src=""8017.png"">" Hematology-
A pathologist believes that blood smear findings are consistent with hairy cell
leukemia. What drug can help with this condition? Cladribine, a purine analog
pharmacology
A patient is given an excessive dose of 5-fluorouracil (5-FU). Can leucovorin be
administered to the patient to reduce toxicity? No; myelosuppression in this case
is worsened with leucovorin (which, in fact, is given to enhance 5-FU activity)
pharmacology
In a patient with TRAP-positive bone marrow cells and a dry tap on aspiration, what
side effects does the chemotherapy drug of choice cause? Myelosuppression,
nephrotoxicity, neurotoxicity (hairy cell leukemia is treated with cladribine)
pharmacology
Name three neoplasms against which dactinomycin (actinomycin D) is commonly used?
Ewing sarcoma, Wilms tumor, and rhabdomyosarcoma (in childhood tumors,
actinomycin D because children act out) "<img src=""8018.png"">" Hematology-
and-Oncology antitumor-antibiotics pharmacology
Which of the antitumor antibiotics has the least myelosuppression as an adverse
effect? Bleomycin (myelosuppression is a common adverse effect of all other
antitumor antibiotics) "<img src=""8018.png"">" Hematology-and-Oncology
antitumor-antibiotics pharmacology
What common mechanism is seen in the antineoplastic drugs bleomycin, daunorubicin,
and doxorubicin? They damage/interfere with DNA, inhibiting cell replication"<img
src=""8018.png"">" Hematology-and-Oncology antitumor-antibiotics pharmacology
Which malignancies are treated commonly with doxorubicin or daunorubicin? Solid
tumors, leukemias, lymphomas "<img src=""8018.png"">" Hematology-and-Oncology
Name two neoplasms commonly treated with bleomycin. Testicular cancer and Hodgkin
lymphoma "<img src=""8018.png"">" Hematology-and-Oncology antitumor-
antibiotics pharmacology
A patient with breast cancer is about to start neoadjuvant daunorubicin. What other
drug should be given to prevent a major side effect? Dexrazoxane (iron-chelating
agent) is used to prevent cardiotoxicity (dilated cardiomyopathy) "<img
A man starts an antitumor antibiotic for treating testicular cancer. Later he
requires frequent follow-up with a pulmonologist. Why? A significant side
effect of bleomycin, an antitumor antibiotic used for testicular cancer, is
pulmonary fibrosis "<img src=""8018.png"">" Hematology-and-Oncology
A combination of doxorubicin and bleomycin is given to a woman for lymphoma. About
what cosmetic side effects should she be counseled? Alopecia (a side effect of
doxorubicin) and skin hyperpigmentation (a side effect of bleomycin) "<img
A man on chemotherapy for leukemia presents with hematuria. What chemotherapeutic
agent can cause this side effect? How is it prevented? Cyclophosphamide (or
ifosfamide) can cause hemorrhagic cystitis; this can be prevented with mesna or N-
acetylcysteine "<img src=""8019.png"">" Hematology-and-Oncology alkylating-
agents pharmacology
What toxicities are seen in busulfan? Severe myelosuppression (in almost all
cases), pulmonary fibrosis, skin hyperpigmentation "<img src=""8019.png"">"
Hematology-and-Oncology alkylating-agents pharmacology
Which alkylating agents are used especially in treating central nervous system
neoplasms? Nitrosoureas cross the blood-brain barrier and are used for brain
tumors (eg, glioblastoma multiforme) "<img src=""8019.png"">" Hematology-
and-Oncology alkylating-agents pharmacology
What is the major adverse effect of the nitrosourea chemotherapeutic agents? CNS
toxicity (convulsions, dizziness, ataxia) "<img src=""8019.png"">" Hematology-
Why might a patient being administered busulfan want to invest in high-quality
cosmetics? Busulfan can cause hyperpigmentation as a side effect "<img
src=""8019.png"">" Hematology-and-Oncology alkylating-agents pharmacology
In addition to ablation of bone marrow for transplantation, what malignancy can
busulfan be used to be treat? CML "<img src=""8019.png"">" Hematology-and-
Oncology alkylating-agents pharmacology
Which alkylating agent(s) require(s) activation by the liver and might not be
effective in a pt with liver failure? Cyclophosphamide and ifosfamide cause DNA
cross-links at guanine N-7both require bioactivation by the liver "<img
src=""8019.png"">" Hematology-and-Oncology alkylating-agents pharmacology
Which alkylating agents are able to penetrate the blood-brain barrier to access the
central nervous system? Do they require bioactivation? Nitrosoureas, including
carmustine, lomustine, semustine, and streptozotocin; yes, they require
bioactivation "<img src=""8019.png"">" Hematology-and-Oncology alkylating-
agents pharmacology
Which malignancies are cyclophosphamide and ifosfamide commonly used to treat?
Solid tumors, leukemia, lymphomas "<img src=""8019.png"">" Hematology-
Which alkylating agent would you choose for a patient about to undergo
hematopoietic stem cell transplantation? Busulfan, which will ablate the host's
bone marrow before transplantation "<img src=""8019.png"">" Hematology-and-
Oncology alkylating-agents pharmacology
Which neoplasms are commonly treated with the use of taxols (eg, paclitaxel)?
Ovarian and breast carcinomas "<img src=""8020.png"">" Hematology-and-
Oncology microtubule-inhibitors pharmacology
What neoplasms are commonly treated with a vinca alkaloid (vincristine or
vinblastine)? Solid tumors, leukemias, Hodgkin lymphoma (vinblastine), non-
Hodgkin lymphoma (vincristine) "<img src=""8020.png"">" Hematology-and-
Oncology microtubule-inhibitors pharmacology
What toxicities are associated with vincristine treatment? Neurotoxicity, including
areflexia, peripheral neuritis, and paralytic ileus "<img src=""8020.png"">"
Hematology-and-Oncology microtubule-inhibitors pharmacology
What antineoplastic drug functions by hyperstabilizing the mitotic spindle so tumor
cells are unable to complete anaphase? Paclitaxel and other taxols "<img
src=""8020.png"">" Hematology-and-Oncology microtubule-inhibitors pharmacology
A woman on chemotherapy for non-Hodgkin lymphoma reports new-onset abdominal pain
and painful fingertips. What drug is likely responsible? Vincristine; this drug
is neurotoxic (causing areflexia, peripheral neuritis) and causes constipation
(including paralytic ileus) "<img src=""8020.png"">" Hematology-and-Oncology
microtubule-inhibitors pharmacology
What are the clinical uses of cisplatin and carboplatin? What is the mechanism of
action? Testicular, bladder, ovary, lung carcinomas; they cross-link DNA "<img
src=""8021.png"">" Hematology-and-Oncology cisplatin,-carboplatin pharmacology
Name three major toxicities of cisplatin and carboplatin. Nephrotoxicity,
peripheral neuropathy, and ototoxicity "<img src=""8021.png"">" Hematology-
and-Oncology cisplatin,-carboplatin pharmacology
A man on standard chemotherapy, including cisplatin, for testicular cancer
experiences kidney damage. How might this have been prevented? Nephrotoxicity can
be prevented with amifostine (free radical scavenger) and chloride (saline)
diuresis "<img src=""8021.png"">" Hematology-and-Oncology cisplatin,-
carboplatin pharmacology
What are the clinical uses for etoposide and teniposide? What is the mechanism of
action? Solid tumors (eg, testicular and small cell lung cancer), leukemias,
lymphomas; etoposide blocks topoisomerase II, causing DNA degradation "<img
src=""8022.png"">" Hematology-and-Oncology etoposide,-teniposide pharmacology
What are two side effects of therapy with etoposide and teniposide?
Myelosuppression, alopecia "<img src=""8022.png"">" Hematology-and-
Oncology etoposide,-teniposide pharmacology
A man begins chemotherapy for colon cancer with an agent that inhibits DNA
unwinding and replication. What side effects might he experience? He is
receiving one of the topoisomerase I inhibitors (irinotecan or topotecan); side
effects include severe myelosuppression and diarrhea "<img src=""8023.png"">"
Hematology-and-Oncology irinotecan,-topotecan pharmacology
While you are getting coffee, a stranger asks why his uncle is taking irinotecan.
What is one common indication for this medication? Irinotecan is often used
against colon cancer "<img src=""8023.png"">" Hematology-and-Oncology
irinotecan,-topotecan pharmacology
While you are getting coffee, a stranger asks why her aunt is taking topotecan.
What are two common indications for this medication? Topotecan is often used
against ovarian and small cell lung cancers "<img src=""8023.png"">"
Hematology-and-Oncology irinotecan,-topotecan pharmacology
Which drug inhibits ribonucleotide reductase, acting during the S phase to decrease
DNA synthesis? Hydroxyurea (blocks DNA Synthesis and is S-phase specific) "<img
src=""8024.png"">" Hematology-and-Oncology hydroxyurea pharmacology
What are the three clinical uses for hydroxyurea? Chronic myelogenous leukemia
(CML), melanoma, and sickle cell anemia (hydroxyurea increases the concentration of
hemoglobin F) "<img src=""8024.png"">" Hematology-and-Oncology hydroxyurea
pharmacology
A boy with sickle cell anemia was recently prescribed hydroxyurea. How does it help
him? What are two major toxicities of this medication? Hydroxyurea increases
concentration of hemoglobin F; bone marrow suppression and gastrointestinal upset
"<img src=""8024.png"">" Hematology-and-Oncology hydroxyurea
pharmacology
What are the most commonly used glucocorticoids in cancer chemotherapy?
Prednisone and prednisolone "<img src=""8025.png"">" Hematology-and-
Oncology pharmacology prednisone,-prednisolone
What are the clinical uses of prednisone and prednisolone? Combination chemotherapy
(eg, chronic lymphocytic leukemia, non-Hodgkin lymphoma) and immunosuppression (eg,
autoimmune diseases) "<img src=""8025.png"">" Hematology-and-Oncology
pharmacology prednisone,-prednisolone
How is prednisone thought to exert an antineoplastic effect? Via various
mechanisms, such as binding of intracytoplasmic steroid receptors and alteration of
gene transcription "<img src=""8025.png"">" Hematology-and-Oncology
pharmacology prednisone,-prednisolone
Where is the binding site for medications commonly used as immunosuppressants or as
glucocorticoids located? Intracytoplasmic steroid receptors are bound in order
to alter gene expression by prednisone/prednisolone "<img src=""8025.png"">"
Hematology-and-Oncology pharmacology prednisone,-prednisolone
What are the major side effects of prednisone or prednisolone therapy? Cushing-
like: weight gain, central obesity, muscle breakdown, cataracts, acne,
osteoporosis, HTN, peptic ulcers, hyperglycemia, psychosis "<img src=""8025.png"">"
Hematology-and-Oncology pharmacology prednisone,-prednisolone
What are the clinical uses of bevacizumab? What is the drug's mechanism of action?
Solid tumors (colorectal cancer, renal cell carcinoma), mAb against vascular
endothelial growth factor (VEGF), inhibits angiogenesis "<img src=""8026.png"">"
Hematology-and-Oncology bevacizumab pharmacology
What are the major side effects of bevacizumab therapy? Hemorrhages, blood
clots, impaired wound healing "<img src=""8026.png"">" Hematology-and-Oncology
bevacizumab pharmacology
What is the mechanism of action of erlotinib? Which malignancy is it useful
against? What is its major side effect? It is an EGFR tyrosine kinase inhibitor;
useful against nonsmall cell lung cancer; rash "<img src=""8027.png"">"
Hematology-and-Oncology erlotinib pharmacology
What is the mechanism of action of cetuximab? Which malignancies is it useful
against? Monoclonal antibody that targets EGFR; useful against stage IV
colorectal cancer with wild-type KRAS and head and neck cancers "<img
src=""8028.png"">" Hematology-and-Oncology cetuximab pharmacology
What are the major side effects of cetuximab therapy? Rashes, diarrhea, increased
LFTs "<img src=""8028.png"">" Hematology-and-Oncology cetuximab pharmacology
What is the major side effect of imatinib therapy? Fluid retention "<img
src=""8029.png"">" Hematology-and-Oncology imatinib pharmacology
What is the mechanism of action of imatinib? Inhibits the tyrosine kinase formed
by the BCR-ABL translocation (Philadelphia chromosome) in CML and by c-kit in GI
stromal tumors "<img src=""8029.png"">" Hematology-and-Oncology imatinib
pharmacology
What are the clinical uses of imatinib? Chronic myelogenous leukemia (CML) and GI
stromal tumors "<img src=""8029.png"">" Hematology-and-Oncology imatinib
pharmacology
What are the clinical uses of rituximab? Non-Hodgkin lymphoma, chronic
lymphoblastic leukemia (CLL), idiopathic thrombocytopenic purpura (ITP), rheumatoid
arthritis "<img src=""8030.png"">" Hematology-and-Oncology pharmacology
rituximab
What is the mechanism of action of rituximab? What major side effect must be
closely monitored for? It is a monoclonal antibody against CD20 (found in most B-
cell neoplasms); progressive multifocal leukoencephalopathy"<img src=""8030.png"">"
Hematology-and-Oncology pharmacology rituximab
What is the primary mechanism of action of tamoxifen and raloxifene? They are
selective estrogen receptor modulators (SERMs) that the block binding of estrogen
to estrogen receptorpositive breast cancer cells "<img src=""8031.png"">"
Hematology-and-Oncology pharmacology tamoxifen,-raloxifene
Why is raloxifene not associated with an increased risk of endometrial carcinoma,
whereas tamoxifen is? Raloxifene acts as an antagonist at the level of
endometrium, but tamoxifen acts as a partial agonist, increasing endometrial cancer
risk "<img src=""8031.png"">" Hematology-and-Oncology pharmacology
tamoxifen,-raloxifene
The presence of what tumor marker would prompt you to use tamoxifen in the
treatment of breast cancer? The tumor must be estrogen receptor positive
(selective estrogen receptor modulators [SERMs], like tamoxifen, act on the
estrogen receptor) "<img src=""8031.png"">" Hematology-and-Oncology
pharmacology tamoxifen,-raloxifene
What is the major side effect of therapy with tamoxifen or raloxifene that the
patient must be monitored for? Thromboembolic events (eg, DVTs, PEs) "<img
src=""8031.png"">" Hematology-and-Oncology pharmacology tamoxifen,-raloxifene
Are tamoxifen and raloxifene agonists or antagonists in breast tissue? What about
bone? Endometrial tissue? Antagonists in breast tissue, agonists in bone;
tamoxifen is a partial agonist in endometrial tissue, whereas raloxifene is an
antagonist "<img src=""8031.png"">" Hematology-and-Oncology pharmacology
tamoxifen,-raloxifene
What treatment option is available in a pt who has metastatic breast cancer that is
HER-2 (c-erbB2) positive? Trastuzumab, a monoclonal antibody against HER-2 c-
erbB2, a tyrosine kinase receptor "<img src=""8032.png"">" Hematology-and-
Oncology pharmacology trastuzumab-(herceptin)
What is the proposed mechanism of action of trastuzumab? Tras2zumab helps kill
breast cancer cells by inhibiting cellular signals initiated by HER-2 and via
antibody-dependent cytotoxicity "<img src=""8032.png"">" Hematology-and-
Oncology pharmacology trastuzumab-(herceptin)
What organ should be monitored closely for adverse effects in a pt taking
trastuzumab (Herceptin)? The heart (an adverse effect of trastuzumab therapy
is cardiotoxicity [heartceptin damages the heart]) "<img src=""8032.png"">"
Hematology-and-Oncology pharmacology trastuzumab-(herceptin)
What is the clinical use of vemurafenib? What is its mechanism of action?
Metastatic melanoma; it is a small molecule inhibitor of BRAF oncogene
positive melanoma (VEmuRAF-enib for V600E-mutated BRAF inhibition) "<img
src=""8033.png"">" Hematology-and-Oncology pharmacology vemurafenib
What are the toxicities of cisplatin/carboplatin? Nephrotoxicity, ototoxicity
"<img src=""8034.png"">" Hematology-and-Oncology common-chemotoxicities
pharmacology
What is a major toxicity of vincristine? Peripheral neuropathy "<img
src=""8034.png"">" Hematology-and-Oncology common-chemotoxicities pharmacology
What is a major toxicity of busulfan? Pulmonary fibrosis "<img
What is a major toxicity of bleomycin? Pulmonary fibrosis "<img
What is a major toxicity of doxorubicin? Cardiotoxicity "<img src=""8034.png"">"
Hematology-and-Oncology common-chemotoxicities pharmacology
What is a major toxicity of trastuzumab? Cardiotoxicity "<img src=""8034.png"">"
Hematology-and-Oncology common-chemotoxicities pharmacology
What is the major toxicity of methotrexate? Myelosuppression "<img
What is the major toxicity of 5-fluorouracil (5-FU)? Myelosuppression "<img
What is the major toxicity of 6-mercaptopurine (6-MP)? Myelosuppression "<img
What is the major toxicity of cyclophosphamide? Hemorrhagic cystitis "<img
"A patient has knee pain. While patient is supine, a ""pop"" is elicited on
internal rotation of the knee. Where is the patient's injury?" The lateral
meniscus (This is the McMurray test.) "<img src=""8035.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology knee-exam
On physical exam, a patient has a positive anterior drawer sign. This indicates
that which ligament is torn? The anterior cruciate ligament (ACL) "<img
src=""8035.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-
physiology knee-exam
A patient has abnormal passive adduction (laxity on application of varus stress).
Which ligament is torn? The lateral collateral ligament "<img src=""8035.png"">"
"A patient has knee pain. While patient is supine, a ""pop"" is elicited on
external rotation of the knee. Where is the patient's injury?" The medial
meniscus (This is the McMurray test.) "<img src=""8035.png"">"
A supine man, with his knee at a 30-degree angle, has lateral tibial space widening
when a varus force is applied. Site of injury? The lateral collateral ligament
(Varus force is medial.) "<img src=""8035.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology knee-exam
A supine man with his knees at a 90-degree angle has an increase in anterior tibial
gliding without other knee findings. Injury location? This is likely an anterior
cruciate ligament (ACL) injury "<img src=""8035.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology knee-exam
A supine man with his knees at a 90-degree angle has an increase in posterior
tibial gliding without other knee findings. Injury location? This is likely a
posterior cruciate ligament (PCL) injury "<img src=""8035.png"">"
Regarding the cruciate ligaments, the terms anterior and posterior refer to
attachments at what site? The tibia "<img src=""8035.png"">"
A man with a knee injury has medial meniscus damage and a positive anterior drawer
sign. From which side was force applied to the knee? This is likely the unhappy
triad with ACL, MCL, and medial meniscus damage, due to lateral force being applied
to a planted leg "<img src=""8036.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology common-knee-conditions
The knee of a young soccer player is struck laterally, and now the tibia can be
displaced anteriorly. Which knee structures were injured? The ACL, MCL, and medial
meniscus (This is the unhappy triad.) "<img src=""8036.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology common-
knee-conditions
A cleaner is constantly scrubbing floors on her hands and knees. She has knee pain.
What is the most likely cause of the pain? Prepatellar bursitis, which can be
caused by pressure from frequent kneeling or repeated trauma "<img
physiology common-knee-conditions
A patient abducts his arm. Which two muscles help him to do so, and how do they
work together to facilitate abduction? The supraspinatus and deltoid muscles;
the supraspinatus mediates initial arm abduction; the deltoid takes over the
further the arm abducts "<img src=""8037.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology rotator-cuff-muscles
What is the action of the teres minor? Which nerve(s) innervate(s) this muscle?
Adducts and laterally rotates the arm; axillary nerve"<img src=""8037.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology rotator-
cuff-muscles
Which rotator cuff muscle adducts and medially rotates the arm? Which nerve(s)
innervate(s) this muscle? Subscapularis; upper and lower subscapular nerves
"<img src=""8037.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
anatomy-and-physiology rotator-cuff-muscles
Which muscle of the rotator cuff is found on the superior aspect of the humerus?
Which nerve(s) innervate(s) this muscle? Supraspinatus; suprascapular nerve "<img
physiology rotator-cuff-muscles
You suspect your 18-year-old patient has injured his rotator cuff in the most
common way. What test can help confirm this injury? The empty/full-can test,
which suggests supraspinatus injury "<img src=""8037.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology rotator-cuff-muscles
A patient who cannot move his shoulder after a traumatic accident has likely
injured nerves at what spinal levels? C5C6 "<img src=""8037.png"">"
cuff-muscles
A patient has a positive empty/full-can test result. The deltoid muscle functions
normally. An injury to which nerve may be to blame? The suprascapular nerve,
which innervates the supraspinatus muscle (assessed with the empty-/full-can test)
anatomy-and-physiology rotator-cuff-muscles
What muscles comprise the rotator cuff? Supraspinatus, Infraspinatus, teres
minor, Subscapularis (SItS [small t for teres minor]) "<img src=""8037.png"">"
cuff-muscles
A pitcher presents with shoulder pain. What nerve innervates the muscle that is
most likely to be injured in this particular patient? The suprascapular nerve
(innervates the infraspinatus muscle, which is commonly injured in pitchers) "<img
physiology rotator-cuff-muscles
A golfer has chronic pain on the medial side of his right elbow. What arm motion
done in excess likely led to this condition? Repetitive flexion (forehand
shots), causing medial epicondylitis (golfer's elbow) "<img src=""8038.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology overuse-
injuries-of-the-elbow
A tennis player has chronic pain on the lateral side of her right elbow. What arm
motion done in excess likely led to this condition? Repetitive extension
(backhand shots), causing lateral epicondylitis (tennis elbow) "<img
physiology overuse-injuries-of-the-elbow
While commonly associated with sports such as golf and tennis, can medial or
lateral epicondylitis arise from other causes? Yes, either may arise
idiopathically "<img src=""8038.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology overuse-injuries-of-the-elbow
A typist is diagnosed with carpal tunnel syndrome. Exam shows spared thenar
eminence sensation, despite significant thenar atrophy. Why? The palmar
cutaneous branch of the median nerve, which innervates the thenar eminence, enters
the hand external to the carpal tunnel "<img src=""8039.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology wrist-
bones
Name the carpal bones of the wrist. (This does not include related bones of the
radius and ulna.) Scaphoid, Lunate, Triquetrum, Pisiform, Hamate, Capitate,
Trapezoid, Trapezium (So Long To Pinky, Here Comes The Thumb) "<img
physiology wrist-bones
Which carpal bone is most prone to avascular necrosis? Why?Scaphoid; because of
retrograde blood supply "<img src=""8039.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology wrist-bones
A man slips and hurts his wrist. He then notes paresthesias over the lateral aspect
of his hand. Which nerve was likely injured? The median nerve (due to
dislocation of the lunate), causing an acute carpal tunnel syndrome "<img
physiology wrist-bones
A pianist complains of pain and occasional numbness in his thumbs and index
fingers, a problem likely caused by what? Carpal tunnel syndrome (entrapment of the
median nerve in the carpal tunnel) "<img src=""8039.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology wrist-bones
A bicyclist complains of paresthesias and decreased pinch strength in his pinky.
What syndrome do you suspect? Guyon canal syndrome, causing ulnar nerve injury
anatomy-and-physiology wrist-bones
Name some conditions that can predispose a patient to carpal tunnel syndrome.
Pregnancy, rheumatoid arthritis, hypothyroidism, diabetes, dialysis-related
amyloidosis, repetitive use "<img src=""8039.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology wrist-bones
A man falls on his outstretched hand and experiences sensory deficits in his 4th
and 5th digits. Which bone in the wrist was likely damaged?The hook of the hamate,
leading to ulnar nerve injury "<img src=""8039.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology wrist-bones
A 22-year-old man fractures his arm through the midshaft of the humerus. A nerve
that spans which nerve roots was likely injured? The radial nerve (C5T1)
anatomy-and-physiology upper-extremity-nerves
A man fractures his arm through the surgical neck of the humerus. What other arm
insult damages the same nerve likely injured in this man? Anterior dislocation of
humerus (Both this and fracture of the surgical neck of the humerus can damage the
axillary nerve [C5C6].) "<img src=""8040.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology upper-extremity-nerves
A woman with a cervical disk herniation has weakness the finger and wrist extensors
and a weak grip. What nerve roots are likely impaired? C5T1 (the radial nerve)
Days after a shoulder injection, a man has persistent pain. He cannot abduct his
shoulder past 15. Does he have sensation loss? Yes, as he has likely injured his
axillary nerve (C5C6) and will have sensation loss over the deltoid muscle and
lateral arm "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology upper-extremity-nerves
A man lacerates the medial aspect of his hand at the thumb base and severs a nerve.
What type of motor deficit do you expect? Loss of thumb
opposition/abduction/flexion (ape hand), due to recurrent damage to branch of the
median nerve (C5T1) "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology upper-extremity-nerves
A patient with an ankle cast has been on crutches for 6 weeks. He is now having
problems with wrist extension. What might be the cause? Radial nerve injury
secondary to improper crutch use "<img src=""8040.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology upper-extremity-nerves
"A boy fractures his humerus ""funny bone"" and compresses a nerve. What deficits
will be seen in his wrist as a result?" Radial deviation of the wrist on flexion
(seen with proximal lesions such as this) (He has injured his ulnar nerve.) "<img
physiology upper-extremity-nerves
"A patient thinks he has fractured his humerus ""funny bone"" after banging his
elbow on a table. What part of the bone was affected?" The medial epicondyle of
the humerus "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-Connective-
A girl loses lateral forearm sensation. She has trouble flexing and supinating her
forearm. Where is the lesion causing her symptoms? Her upper trunk in the
brachial plexus is likely compressed, leading to musculoskeletal nerve (C5C7)
dysfunction "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-Connective-
A man falls down the stairs and lands on the heels of his hands with his hands
outstretched. He is at risk for injury to what nerve? Ulnar nerve (C8T1) "<img
A radiologist tells you that your patient has fractured his hook of the hamate.
Will the patient have radial deviation on wrist flexion? No, as this is a distal
ulnar nerve (C8T1) lesion (Proximal ulnar muscles will not be affected, and wrist
flexion should be normal.) "<img src=""8040.png"">" Musculoskeletal,-Skin,-
A patient has no sensation over her deltoid muscle and lateral arm. Her deltoid
muscle appears flattened. What will a shoulder exam reveal?Impaired abduction past
15 degrees (The findings suggest axillary nerve [C5C6] dysfunction.) "<img
The palmar surface of the first three digits is innervated by which main upper
extremity nerve? Median nerve "<img src=""8040.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology upper-extremity-nerves
The thenar muscles are innervated by what branch of the median nerve? The
recurrent branch (C5T1) "<img src=""8040.png"">" Musculoskeletal,-Skin,-
Cutaneous sensation on the lateral dorsum of the hand is provided by what nerve?
Radial nerve (superficial branch) "<img src=""8040.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology upper-
extremity-nerves
A chef places his index and middle fingers on a burner, senses the heat and quickly
jerks away, thanks to sensation by which nerve? Median nerve (C5T1) "<img
A patient loses the ability to flex and supinate the forearm following a car
accident. What nerve was likely damaged? Musculocutaneous nerve (C5C7) "<img
A Pope's-blessing palsy can result from damage to what part of the brachial plexus?
The median nerve distribution (C5T1) "<img src=""8040.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology upper-
extremity-nerves
After falling from a tree, a woman has no sensation over her shoulder and cannot
abduct her arm. What could the lesion be? She likely has a fractured surgical neck
of the humerus or a humeral head dislocation, damaging the axillary nerve (C5C6)
A patient suffers a midshaft humerus fracture damaging the extensor compartment. He
has a wrist drop. What sensory deficit is expected? Deficit over the posterior
arm, dorsal hand, dorsal thumb (This is radial nerve [C5T1] dysfunction.) "<img
A man using crutches for 3 months can no longer extend his wrist due to nerve
compression. What other muscles might be affected? Elbow, wrist, and finger
extensors, including grip strength (This is radial nerve [C5T1] dysfunction.)
A patient has a supracondylar fracture of the humerus with nerve injury. What motor
deficits do you expect on arm exam? Lost sensation over thenar eminence and dorsal
and palmar aspects of lateral 3 fingers (damage to median nerve proximally) "<img
Pt presents w/supracondylar humerus fracture and is insensate over dorsal aspect of
lateral hand. The damaged nerve arises from which roots? Median nerve arises from
the C5T1 roots "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-
A typist has tingling in his thenar eminence. Percussing his wrist makes the
tingling more intense. What nerve is likely impaired? Median nerve (C5T1) (This is
a positive Tinel sign, suggestive of carpal tunnel syndrome.) "<img
A patient fractures the medial epicondyle of the humerus. What sensory and motor
deficits are expected on physical exam? Paresthesia of medial 1 fingers,
inability to flex medial fingers/wrist, radial deviation of wrist (This is an ulnar
nerve injury.) "<img src=""8040.png"">" Musculoskeletal,-Skin,-and-
A man loses sensation over medial 1 fingers and hypothenar eminence after a wrist
injury. Findings on hand motor exam? Interosseous and medial 2 lumbrical
weakness, ulnar claw on digit extension (This is an ulnar nerve injury.) "<img
A man has wrist drop with loss of elbow, wrist, and finger extension. He slept with
his arm draped over a couch. Is there sensory loss? Yes; this is Saturday night
palsy affecting the radial nerve (C5T1; he will have posterior arm/forearm &
dorsal hand sensory loss "<img src=""8040.png"">" Musculoskeletal,-Skin,-
A man has a palmar laceration. A hand surgeon notes a transected recurrent branch
of the median nerve. What exam findings do you expect? """Ape hand"" with
preserved sensation (loss of opposition, abduction, and flexion of thumb)" "<img
Over months, a lung cancer patient develops atrophy, pain, and edema in his right
hand. Where is his tumor most likely invading? Compressing the lower trunk of the
brachial plexus and the subclavian vessels (The patient likely has a right-sided
Pancoast tumor.) "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology brachial-plexus-lesions
A falling climber grabs a tree branch as he falls. Afterward, he can no longer flex
his hand's MCP joints. What nerve roots were injured? C8T1 (He likely experienced
traction of or tore the lower brachial plexus trunk as he fell, suggestive of a
Klumpke palsy.) "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-
A man has problems abducting and laterally rotating his shoulders and
flexing/supinating at his elbows. Where is the nerve injury? "C5C6, with
deltoid, supraspinatus, infraspinatus, & biceps brachii deficits due to upper
brachial trunk lesion (Erb palsy = ""Erb-er"" trunk)" "<img src=""8041.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology brachial-
plexus-lesions
A patient presents with a waiter's-tip deformity after being thrown from a
motorcycle. What cervical roots are now impaired? C5, C6 (upper trunk of
brachial plexus) (known as Erb palsy) "<img src=""8041.png"">"
plexus-lesions
An adult has his left arm by his side, shoulders internally rotated, arms extended
and pronated. He cannot change this position. Diagnosis? This is an Erb palsy
(C57#8211;C6) injury (also known as a waiter's tip) "<img src=""8041.png"">"
plexus-lesions
A patient presents with wrist drop after getting drunk and sleeping on a couch all
of Saturday night. What nerve was most likely injured? The radial nerve (This
is a classic Saturday night palsy presentation.) "<img src=""8041.png"">"
plexus-lesions
Your attending tells you to examine a patient who suffered damage to his
musculocutaneous nerve. What deficits do you uncover on exam? Difficulty flexing
the elbow, variable sensory loss over the arm "<img src=""8041.png"">"
plexus-lesions
A lesion to the lower trunk of the brachial plexus produces what deficit? Describe
the expected findings on exam. Impaired MCP joint flexion and DIP/PIP joint
extension from impaired lumbrical, interosseous, thenar, and hypothenar muscles
(Klumpke palsy) "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-
Claw hand (Klumpke palsy) can result from damage to what part of the brachial
plexus? Lower trunk (C8T1 nerve roots) "<img src=""8041.png"">"
plexus-lesions
A newborn's delivery was complicated by excessive lateral neck traction. Now her
arm hangs limply and is medially rotated. What happened? She developed an Erb
palsy due to traction on or damage to the upper trunk of the brachial plexus (C5C6
nerve roots) "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-
A man has atrophy of his lumbricals with ischemia, pain, and edema from vascular
compression. He has supernumerary cervical ribs. Diagnosis?Thoracic outlet syndrome
secondary to the supernumerary cervical rib causing compression "<img
physiology brachial-plexus-lesions
A conman is stabbed. He cannot abduct his arm past 90, and his scapulas appear
asymmetric. What muscle is impaired? Serratus anterior (causing a winged
scapula due to a long thoracic nerve injury) "<img src=""8041.png"">"
plexus-lesions
A man has posterior cord damage from trauma. Two nerves exiting from this cord are
impaired. What two major findings will you see on exam? Deltoid paralysis (due
to axillary nerve impairment) and wrist drop (due to radial nerve impairment)
anatomy-and-physiology brachial-plexus-lesions
A trauma patient has proximal median nerve damage. When he recovers, you examine
his ipsilateral hand. What motor deficits will you uncover?Decreased thumb function
and a Pope's-blessing deformity "<img src=""8041.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology brachial-plexus-lesions
A trauma patient has proximal ulnar nerve damage. When he recovers, you examine his
ipsilateral hand. What motor deficits will you uncover? Decreased function of
the intrinsic muscles of the hand with a claw-hand deformity "<img
physiology brachial-plexus-lesions
Moving proximally to distally, what are the five major distributions of the
brachial plexus? Roots, Trunks, Divisions, Cords, Branches (Randy Travis Drinks
Cold Beer) "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology brachial-plexus-lesions
A woman undergoing a mastectomy has her long thoracic nerve severed. What is the
function of the muscle innervated by the LTN? The serratus anterior attaches the
scapula to the posterior wall of the thoracic cage and allows for abduction above
the horizontal position "<img src=""8041.png"">" Musculoskeletal,-Skin,-and-
A patient has a proximal median nerve lesion. How do you expect this to affect his
thumb? It causes thenar atrophy with an impaired ability to abduct the thumb,
leading to an ape-hand distortion "<img src=""8042.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology distortions-of-the-hand
You notice a patient has wasting of the thenar eminence. What nerve is likely
damaged? Median nerve "<img src=""8042.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology distortions-of-the-hand
A patient with a proximal ulnar nerve lesion attempts to make a fist. What type of
hand gesture do you expect them to make? An OK gesture with digits 13 flexed
(similar to the claw hand of distal median nerve lesions) "<img src=""8042.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology
distortions-of-the-hand
Name the function of the lumbrical muscles of the hand. The lumbricals flex the
MCP joints and extend both the DIP and PIP joints "<img src=""8042.png"">"
distortions-of-the-hand
How does a Pope's-blessing distortion arise? A proximal median nerve lesion
causes loss of lateral finger flexion and thumb oppositiondistortion arises on
trying to make a fist "<img src=""8042.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology distortions-of-the-hand
A man injures the recurrent branch of his median nerve. Which muscles become
denervated? Opponens pollicis, Abductor pollicis, Flexor pollicis brevis (Oppose,
Abduct, and Flex = OAF) "<img src=""8043.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology hand-muscles
What three muscles comprise the hypothenar eminence? The thenar muscles = Opponens
pollicis, Abductor pollicis, Flexor pollicis brevis (Oppose, Abduct, and Flex =
OAF) "<img src=""8043.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
anatomy-and-physiology hand-muscles
A patient completely loses his ability to adduct his fingers. What group of muscles
is not working properly? Palmar interossei muscles (PAD = Palmars ADduct)
A patient completely loses his ability to abduct his fingers. What group of muscles
is not working properly? Dorsal interossei muscles (DAB = Dorsals ABduct)
What is the function of the lumbrical muscles? To flex at the MCP joint and extend
PIP and DIP joints "<img src=""8043.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology hand-muscles
A man can no longer adduct his thigh and has a sensory deficit of his medial thigh.
What type of intervention may be responsible for this? Pelvic surgery,
associated with lesions of the obturator nerve (L2L4) "<img src=""8044.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology lower-
extremity-nerves
A man cannot flex his thigh, extend his leg, or feel his anterior thigh/medial leg.
What is the likely injury that is causing his symptoms? A pelvic fracture
affecting the femoral nerve (L2L4) "<img src=""8044.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology lower-extremity-nerves
A 26-year-old man injures his lateral leg and cannot dorsiflex his toes or feel his
dorsal foot. The injury causes what sensory deficit? Anterolateral leg and dorsal
foot paresthesias due to injury of the common peroneal nerve (L4S2) "<img
physiology lower-extremity-nerves
A man injures his knee and can no longer invert and plantarflex his foot. Where on
his foot do you expect him to have sensory loss? The sole of the foot (He
likely had knee trauma with secondary damage to his tibial nerve.) "<img
A man with a fibular neck fracture cannot evert or dorsiflex his foot. He has a
steppage gait. What spinal nerve roots are impaired? L4S2 (common peroneal
nerve), causing foot drop (Peroneal Everts and Dorsiflexes = injured foot dropped)
anatomy-and-physiology lower-extremity-nerves
The knee of a 30-year-old man is struck, and he cannot invert or plantarflex his
foot/toes. What are the spinal roots of the injured nerve? L4S3 (tibial nerve)
(TIP = Tibial Inverts and Plantarflexes; if injured, cant stand on TIPtoes) "<img
A patient has trauma to his knee and damages his tibial nerve. What motor deficits
are expected on physical exam? Inability to invert, plantarflex (TIP = Tibial
Inverts and Plantarflexes; if injured, cant stand on TIPtoes) "<img
A man who receives an injection to the upper medial gluteal region later
demonstrates a Trendelenburg gait. It has what characteristics? Contralateral hip
drops when standing on leg ipsilateral to site of injury (His superior gluteal
nerve [L4S1] was likely injured.) "<img src=""8044.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology lower-extremity-nerves
A man's hip dislocates posteriorly. He cannot jump, rise from a seat, or climb
stairs. What are the spinal roots of the injured nerve? L5S2 (inferior gluteal
nerve), with impairment of the gluteus maximus muscle "<img src=""8044.png"">"
extremity-nerves
Inability to evert the foot is due to damage to what nerve? What about foot
inversion? Common peroneal (L4S2); tibial (L4S3) "<img src=""8044.png"">"
extremity-nerves
The ability to dorsiflex the foot is due to damage to what nerve? What about
plantarflexion? Common peroneal (L4S2); tibial (L4S3) "<img src=""8044.png"">"
extremity-nerves
In patients with foot drop, which nerve is damaged? Common peroneal (L4S2) "<img
What does the sciatic nerve (L4S3) split into? The common peroneal and tibial
nerves "<img src=""8044.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology lower-extremity-nerves
A woman undergoing childbirth receives a pudendal nerve block. What landmark does
the anesthesiologist use to locate the site of the block? The ischial spine "<img
What nerve roots make up the pudendal nerve? What region does this nerve innervate?
S2S4; the perineum "<img src=""8044.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology lower-extremity-nerves
A pharmacist is giving an IM injection to the buttocks of a patient. Afterwards,
the patient experiences difficulty walking. What happened? Iatrogenic injury to the
superior gluteal nerve; this is because the injection was likely given to the upper
medial region of the buttocks "<img src=""8044.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology lower-extremity-nerves
In patients unable to stand on their tiptoes, which nerve is damaged? Tibial (L4
S3) "<img src=""8044.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
anatomy-and-physiology lower-extremity-nerves
What are hallmark signs and symptoms of a radiculopathy? Paresthesias and
weakness in distribution of specific lumbar or sacral spinal nerves "<img
physiology signs-of-lumbosacral-radiculopathy
What is the most common cause of a radiculopathy? Intervertebral disc
herniation in which the nerve associated with the inferior vertebral body is
impinged "<img src=""8045.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology signs-of-lumbosacral-radiculopathy
A back pain patient has dorsiflexion weakness. Lumbosacral MRI shows a disc
herniation. On exam, what type of gait will be impaired in him? Heel walking
(Dorsiflexion weakness suggests an impaired L5 nerve root from an L4L5 disc
herniation.) "<img src=""8045.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology signs-of-lumbosacral-radiculopathy
A patient suffers an L3L4 disc herniation. Which nerve roots are impaired by this
lesion? The L4 nerve roots (In the lumbar spine, the nerve roots are found
inferior to their associated vertebral body.) "<img src=""8045.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology signs-of-
lumbosacral-radiculopathy
A man with back pain has weak left hip flexion and left patellar hyporeflexia.
Herniation at which level, in which direction, is to blame?Left posterolateral
herniation of the L3L4 intervertebral disc, impinging on the left L4 nerve root
anatomy-and-physiology signs-of-lumbosacral-radiculopathy
Why are disc herniations more likely to occur posterolaterally as opposed to
anteriorly? Due to the thin posterior longitudinal ligament and thicker anterior
longitudinal ligament along the midline of the vertebral bodies "<img
physiology signs-of-lumbosacral-radiculopathy
A back pain patient has difficulty with plantarflexion and toe walking. What reflex
do you check to confirm your suspected diagnosis? The Achilles reflex (impaired
in S1 radiculopathies secondary to L5S1 disc herniations) "<img src=""8045.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology signs-of-
lumbosacral-radiculopathy
A patient fractures the midshaft of his humerus and damages his radial nerve. What
artery was likely injured? Deep brachial artery "<img src=""8046.png"">"
neurovascular-pairing
A patient lacerates his posterior tibial artery by dropping a table saw. What nerve
will be impaired? Tibial nerve (L4S3) "<img src=""8046.png"">"
The median nerve runs alongside which artery, through which fossa? The brachial
artery, the distal humerus/cubital fossa "<img src=""8046.png"">"
Which nerve and artery would you expect to see injured with a fracture at the
surgical neck of the humerus? The axillary nerve and the posterior circumflex
artery "<img src=""8046.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology neurovascular-pairing
A man is struck from behind by a thrown javelin; it lands in his popliteal fossa.
What major nerve and artery are at risk of being damaged? The tibial nerve and the
popliteal artery "<img src=""8046.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology neurovascular-pairing
A patient suffers a fracture of the medial malleolus. What nerve and artery may be
damaged secondary to this insult? The tibial nerve and the posterior tibial
artery "<img src=""8046.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology neurovascular-pairing
A man has a humerus fracture. He has no sensation overlying the deltoid. An
expanding hematoma is likely due to leakage from which vessel? The posterior
circumflex artery; it and the axillary nerve are at risk for damage due to
compromise of the surgical neck of the humerus "<img src=""8046.png"">"
At the synapse of a neuromuscular junction, which ion influx into the axon triggers
the release of neurotransmitters? Ca2+, through voltage-gated channels "<img
physiology muscle-conduction-to-contraction
After presynaptic neuron neurotransmitter release, postsynaptic ligand binding
leads to the depolarization of which membrane? The motor end plate of the muscle
cell (postsynaptic membrane) "<img src=""8047.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology muscle-conduction-to-contraction
As an action potential travels along a muscle cell, it goes down into invaginations
in the membrane called what? T-tubules "<img src=""8047.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology muscle-
conduction-to-contraction
A new drug inhibits the ryanodine receptor. What ion will not be released from the
sarcoplasmic reticulum as a result? Ca2+ "<img src=""8047.png"">"
During skeletal muscle contraction, what is the result of Ca2+ binding to troponin
C? A conformational change that allows tropomyosin out of the myosin-binding
groove on actin filaments "<img src=""8047.png"">" Musculoskeletal,-Skin,-
During skeletal muscle contraction, which bands of the sarcomere shorten in length?
H band and I band between the Z lines (HIZ shrinkage)"<img src=""8047.png"">"
Ryanodine receptors are located where? They couple with which receptors on the cell
membrane? Ryanodine receptors are located on the sarcoplasmic reticulum; they
couple with dihydropyridine receptors on the cell membrane "<img src=""8047.png"">"
The M line and Z line serve as sites of attachment for actin and myosin. State if
each of these lines are attached to actin and/or myosin. The M line is attached
to myosin; the Z line is attached to actin "<img src=""8047.png"">"
What happens during the power stroke in a myocyte? Myosin releases ADP and
inorganic POi and is displaced on the actin filament "<img src=""8047.png"">"
A poison affects the release of certain molecules, such that myosin cannot be
displaced on the actin filament. What molecules are these? ADP and inorganic POi
anatomy-and-physiology muscle-conduction-to-contraction
In a sarcomere, why does the A band remain the same length during contraction?
The A band represents myosin, which is fixed relative to sarcomere
contraction between the Z lines "<img src=""8047.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology muscle-conduction-to-contraction
What happens when ATP binds to a myosin head that is attached to the actin
filament? It triggers its release; subsequent hydrolysis of the ATP to ADP places
myosin in a cocked position for the next contraction cycle "<img src=""8047.png"">"
What are T-tubules, and what is their relation to the muscle? T-tubules are
extensions of plasma membrane juxtaposed with terminal cisternae and are part of
the sarcoplasmic reticulum "<img src=""8047.png"">" Musculoskeletal,-Skin,-
What are the differences between skeletal muscle T-tubules and cardiac muscle T-
tubules? Skeletal muscle T-tubules = 1 T-tubule & 2 terminal cisternae (triad),
cardiac muscle T-tubules = 1 T-tubule & 1 terminal cisterna (dyad) "<img
physiology muscle-conduction-to-contraction
What is the role of troponin C in muscle contraction? It binds intracellular Ca2+,
which leads to the conformational change that moves tropomyosin out of the myosin-
binding groove on actin "<img src=""8047.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology muscle-conduction-to-contraction
Explain how type 1 muscle fibers utilize oxidative phosphorylation. They have a
relative increase in oxidative phosphorylation in order to provide sustained muscle
contractions "<img src=""8048.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology types-of-muscle-fibers
Sprinters tend to predominantly have which muscle fiber type compared with marathon
runners? Sprinters tend to have type 2 (fast twitch) muscle fibers, whereas
marathon runners have more slow twitch (type 1) fibers "<img src=""8048.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology types-of-
muscle-fibers
Why are type 1 muscle fibers red? They have high concentrations of mitochondria
and myoglobin for sustained contraction "<img src=""8048.png"">"
muscle-fibers
Why are type 2 muscle fibers white? They have low concentrations of mitochondria
and myoglobin "<img src=""8048.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology types-of-muscle-fibers
What type of muscle fiber creates a sustained contractiontype 1 or type 2? Why?
Type 1, red, slow twitch; due to increased oxidative phosphorylation (1 slow
red ox) "<img src=""8048.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology types-of-muscle-fibers
A weight trainer benches on a daily basis. His wife tells him that he is in fact
inducing hypertrophy of which type of muscle fiber? Type 2 muscle fibers, which
are white fast twitch fibers "<img src=""8048.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology types-of-muscle-fibers
Explain how type 2 muscle fibers utilize anaerobic glycolysis. There is a
relative increase in anaerobic glycolysis "<img src=""8048.png"">"
muscle-fibers
In smooth muscle, Ca2+ binds to which molecule after entering the cell to initiate
contraction? Calmodulin "<img src=""8049.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology smooth-muscle-contraction
What are the steps in smooth muscle contraction following calmodulin binding Ca2+?
MLCK is activated, phosphorylating myosin and leading to contraction
(Relaxation involves MLCP and dephosphorylation of myosin.)"<img src=""8049.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology smooth-
muscle-contraction
What are the steps to relax smooth muscle after contraction? NO enters cell,
guanylate cyclase increases cGMP levels, cGMP activates MLCP, myosin/actin complex
dephosphorylated, unbinding/relaxation "<img src=""8049.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology smooth-
muscle-contraction
How does smooth muscle respond to intracellular Ca2+ versus nitric oxide?
Contraction (Ca2+ = Contraction); relaxation (nitric oxide = relaxation)
anatomy-and-physiology smooth-muscle-contraction
An action potential reaching a smooth muscle cell must activate what type of
channel to promote Ca2+ influx into the cell? L-type voltage-gated Ca2+ channels
anatomy-and-physiology smooth-muscle-contraction
What is the difference in function of myosin-light-chain kinase (MLCK) versus
myosin-light-chain phosphatase (MLCP)? MLCK causes muscle contraction, whereas
MLCP leads to relaxation "<img src=""8049.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue anatomy-and-physiology smooth-muscle-contraction
Nitric oxide (NO) in smooth muscle cells is derived from which amino acid generated
where? L-arginine within endothelial cells (via L-arginine's conversion to NO
via NO synthase) "<img src=""8049.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology smooth-muscle-contraction
A drug is synthesized to prevent calcium binding to NO synthase. What effect would
this have on smooth muscle function? It would prevent relaxation of smooth
muscle "<img src=""8049.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue anatomy-and-physiology smooth-muscle-contraction
How do molecules such as acetylcholine and bradykinin induce smooth muscle cell
relaxation? They bind endothelial cell receptors, increasing Ca2+, which activates
NO synthase; NO then diffuses into smooth muscle cells to relax them "<img
physiology smooth-muscle-contraction
In bone formation, which type of ossification is responsible for long bone growth?
Which type is responsible for flat bone growth? Endochondral; membranous "<img
physiology bone-formation
In membranous ossification, how does woven bone formation differ from lamellar bone
formation with regard to cartilage content? Woven bone is formed directly
without cartilage; it is later remodelled to lamellar bone "<img src=""8050.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology bone-
formation
What role do osteoclasts and osteoblasts play in endochondral ossification? They
replace the cartilaginous model with woven bone and later remodel it into lamellar
bone "<img src=""8050.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
anatomy-and-physiology bone-formation
A man fractures his femur, which initially heals with what type of bone? Woven
bone "<img src=""8050.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
Which bones are formed by endochondral ossification? Bones of the axial and
appendicular skeleton, as well as the base of the skull "<img src=""8050.png"">"
formation
Which bones are formed by membranous ossification? Bones of calvarium and face
A patient is diagnosed with Paget disease of bone. Histologically, what bone type
will be seen on biopsy of a pathologic lesion? Woven bone "<img src=""8050.png"">"
formation
In achondroplasia, which type of ossification is defective?Endochondral
ossification "<img src=""8050.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue anatomy-and-physiology bone-formation
What is the source of osteoblasts, and how do they build bone? Mesenchymal stem
cells in the periosteum differentiate into osteoblasts, which secrete collagen and
catalyze mineralization via ALP "<img src=""8051.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue anatomy-and-physiology cell-biology-of-bone
What secretions of osteoclasts effectively dissolve bone? H+ and collagenases
anatomy-and-physiology cell-biology-of-bone
A doctor gives his rival a drug so that his body can no longer break down old bone
cells. Which enzyme does this drug most likely inhibit? Collagenase, as
osteoclasts release H+ and collagenases to dissolve old bone "<img
physiology cell-biology-of-bone
The cells that dissolve bone are derived from what precursor cells? Osteoclasts
are derived from a fusion of monocyte and macrophage lineage precursors "<img
How is parathyroid hormone involved in normal bone physiology? At low,
intermittent levels, it exerts anabolic (bone-building) effects by activating
osteoblasts directly and osteoclasts indirectly "<img src=""8051.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue anatomy-and-physiology cell-
biology-of-bone
A patient has osteitis fibrosa cystica. Which hormone is likely chronically
elevated in him? Parathyroid hormone, leading to excess bone catabolism; the
patient may have 1 hyperparathyroidism) "<img src=""8051.png"">"
biology-of-bone
How does estrogen exert its effects on bone? It inhibits apoptosis in bone-
forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts "<img
How does estrogen deficiency (eg, due to surgery, or after menopause) lead to
osteoporosis? Excess remodeling cycles and bone resorption occur without the
protective effects of estrogen, leading to osteoporosis "<img src=""8051.png"">"
biology-of-bone
A scientist cultures osteoblasts and notes active mineralization. What will pH
measurements of this cell culture show? An alkaline environment (Osteoblasts
secrete ALP to create this environment and catalyze mineralization.) "<img
Achondroplasia is inherited in what fashion? Are most cases caused by this genetic
error? Autosomal dominant; no, as the majority of cases are sporadic "<img
src=""8052.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue Pathology
achondroplasia
You see a 4-year-old boy with achondroplasia and note he has short limbs. Why is
this seen in patients with achondroplasia? The underlying problem in patients
with achondroplasia is failure of long bone growth (endochondral ossification)
Pathology achondroplasia
You see a 4-year-old boy with achondroplasia and note that he has short limbs but
an appropriate head circumference. How is this possible? Patients with
achondroplasia have defects in endochondral, not membranous, ossificationthe skull
and axial bones are unaffected "<img src=""8052.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology achondroplasia
What is the result of a fibroblast growth factor receptor 3 (FGFR3) mutation in
patients with achondroplasia? The gene is constitutively active, inhibiting
chondrocyte proliferation and therefore longitudinal bone growth (endochondral
ossification) "<img src=""8052.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology achondroplasia
You meet a boy with a large head and short limbs whose PTH levels are normal. What
protein is consistently activated? Fibroblast growth factor receptor (FGFR3); this
boy has achondroplasia, the most common cause of dwarfism "<img src=""8052.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology achondroplasia
What types of bone are affected in osteoporosis? How does mineralization change?
Trabecular (spongy) and cortical bone; mineralization does not change "<img
osteoporosis
A 75-y/o woman has compression fractures. She has no known gene disorders. Relative
to normal, what are her serum Ca2+ and PO43- levels? Normal (Ca2+ and PO43- serum
levels are not affected by osteoporosis) "<img src=""8053.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteoporosis
You perform a bone scan on a patient with osteoporosis. What kind of fractures do
you expect to see? Vertebral compression fractures, femoral neck fractures,
and Colles fractures of the distal radius are all commonly seen "<img
osteoporosis
A 77-year-old man with kyphosis presents with severe back pain. What could have
been used as prophylaxis for the most likely etiology? Regular weight-bearing
exercise and adequate intake of both Ca2+ and vitamin D throughout adulthood help
to prevent osteoporosis "<img src=""8053.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology osteoporosis
A patient with a history of osteoporosis is told that she must be careful using
certain types of medications. What are they? Steroids, alcohol, anticonvulsants,
anticoagulants, and thyroid replacement therapy, all of which can increase
osteoporosis risk/severity "<img src=""8053.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology osteoporosis
A 71-year-old woman is prescribed denosumab. What cell type will it act on, and
what is the underlying condition being treated? Denosumab is a monoclonal antibody
that inhibits RANKL; the underlying condition is osteoporosis "<img
osteoporosis
A woman w/a fracture of her humerus after a car accident asks if this is due to
osteoporosis. Which fractures would indicate osteoporosis? Fragility fractures of
the hip or vertebra "<img src=""8053.png"">" Musculoskeletal,-Skin,-and-
A 68-year-old woman at her PCP's office has a DEXA T-score of 2 standard deviations
below average. Does she have osteoporosis? No, the DEXA bone mineral density
T-score must be below -2.5 "<img src=""8053.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology osteoporosis
A woman with a history of DVTs taking levothyroxine, warfarin, and phenytoin
develops osteoporosis at age 45. What likely contributed? Most likely her
anticonvulsant, anticoagulation, and thyroid replacement therapy rather than a low
estrogen level "<img src=""8053.png"">" Musculoskeletal,-Skin,-and-
A patient has been told he has dense bones, yet he is frequently fracturing them.
What might he have? Osteopetrosis (marble bone disease) "<img src=""8054.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteopetrosis-(marble-
bone-disease)
In osteopetrosis, bone resorption is impaired as a result of abnormal function by
which cell type? Osteoclasts "<img src=""8054.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology osteopetrosis-(marble-bone-disease)
What hematologic complications may arise from osteopetrosis? Pancytopenia (due
to bone filling the marrow space), increased extramedullary hematopoiesis "<img
osteopetrosis-(marble-bone-disease)
What neurologic lesions may result from osteopetrosis? Why?Cranial nerve palsies
due to narrowed foramina in the skull "<img src=""8054.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteopetrosis-(marble-
bone-disease)
A 12-year-old boy who frequently fractures his bones is diagnosed with
osteopetrosis. How would a bone marrow transplant cure him?Transplanting normal
cells may cure him because osteopetrosis is due to defective osteoclasts, which are
derived from bone marrow monocytes "<img src=""8054.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology osteopetrosis-(marble-bone-disease)
Which of the following diseases are essentially the same: osteoporosis,
osteomalacia, osteopetrosis, rickets? Osteomalacia and rickets are the same
disease, but rickets is the term for the childhood form "<img src=""8055.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteomalacia/rickets
A child with xeroderma pigmentosum should receive a supplement with which fat-
soluble vitamin to prevent which disease? Vitamin D to prevent rickets "<img
osteomalacia/rickets
What disorder is caused by defective mineralization of osteoid leading to soft
bones? Osteomalacia/rickets "<img src=""8055.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology osteomalacia/rickets
A 2-year/old boy has bowing of his legs. His labs show elevated PTH levels but
decreased Ca2+ levels. What is the primary deficiency? Vitamin D (This child
has rickets.) "<img src=""8055.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology osteomalacia/rickets
A patient is diagnosed with osteomalacia. What is the pathophysiology of this
condition? Low vitamin D leads to low serum Ca2+ levels, increasing PTH levels and
secondarily lowering PO43- levels "<img src=""8055.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology osteomalacia/rickets
Parathyroid hormone is increased in osteomalacia, which activates what type of cell
to produce what enzyme? Osteoblasts are stimulated to make alkaline phosphatase
(ALP), because they require an alkaline environment to function properly "<img
osteomalacia/rickets
A man with an increasing hat size and progressive hearing loss suffers a long bone
fracture. What enzyme do you expect to be elevated? Alkaline phosphatase (ALP);
this patient has Paget disease of bone (osteitis deformans)"<img src=""8056.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology paget-disease-of-bone-
(osteitis-deformans)
A patient has increased osteoblastic and osteoclastic activity with normal Ca2+,
PO43-, and PTH levels. What disease stage is this? This is the mixed stage of
Paget disease of bone (osteitis deformans), with increases in both osteoblast and
osteoclast activity "<img src=""8056.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology paget-disease-of-bone-(osteitis-deformans)
A man with high-output cardiac failure has a long bone fracture. His serum ALP
level is increased. What caused the heart failure? Increased blood flow through
arteriovenous shunts arising secondary to pathologic remodeling of Paget disease of
bone (osteitis deformans) "<img src=""8056.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology paget-disease-of-bone-(osteitis-deformans)
If a man complains of worsening hearing, increased hat size, and heart failure all
due to the same disease, he is at risk of what cancer? Osteogenic sarcoma, the
risk for which is higher in Paget disease of bone (osteitis deformans) "<img
paget-disease-of-bone-(osteitis-deformans)
What happens to levels of Ca2+, PO43-, PTH, and ALP in Paget disease of bone?
Ca2+, PO43-, and PTH levels are all normal; ALP levels are increased "<img
paget-disease-of-bone-(osteitis-deformans)
What are the four main stages of Paget disease of bone (osteitis deformans) and the
defining characteristic of each one? Lytic (osteoclasts only), mixed
(osteoclasts/osteoblasts), sclerotic (osteoblasts only), and quiescent (low
osteoblast/osteoclast activity) "<img src=""8056.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology paget-disease-of-bone-(osteitis-deformans)
What is the most common cause of death in advanced osteitis deformans? High-output
heart failure is the most common cause of death in osteitis deformans (Paget
disease of bone) "<img src=""8056.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology paget-disease-of-bone-(osteitis-deformans)
What are some common causes of avascular necrosis? CAST Bent LEGS:
Corticosteroids, Alcoholism, Sickle cell, Trauma, the Bends, LEgg-Calv-Perthes,
Gaucher, Slipped capital femoral epiphysis "<img src=""8057.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteonecrosis-
(avascular-necrosis)
What bone density disease has no laboratory abnormalities? Osteoporosis, which has
a decrease in bone mass "<img src=""8058.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology lab-values-in-bone-disorders
In osteitis fibrosa cystica due to primary hyperparathyroidism, what happens to
Ca2+, PO43-, ALP, and PTH levels? Ca2+, ALP, and PTH levels are increased,
whereas the PO43- level is decreased "<img src=""8058.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology lab-values-in-bone-
disorders
What lab value is elevated in Paget disease of bone? What type of bony architecture
is seen? "Alkaline phosphatase is elevated; abnormal ""mosaic"" bone
architecture is seen" "<img src=""8058.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology lab-values-in-bone-disorders
Describe a distinguishing characteristic of the bones of patients with long-term
osteitis fibrosa cystica. They have brown tumors (due to fibrous replacement of
bone) or subperiosteal thinning "<img src=""8058.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology lab-values-in-bone-disorders
What is the difference between osteoporosis and osteopetrosis? Osteoporosis has
low bone mass; osteopetrosis has dense, brittle bones; may see decreased Ca2+ in
severe, malignant osteopetrosis "<img src=""8058.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology lab-values-in-bone-disorders
In which disease do you see overly soft bones? In which do you see brown tumors?
Osteomalacia/rickets; osteitis fibrosa cystica "<img src=""8058.png"">"
disorders
A patient has increased serum Ca2+ and PO43- with decreased PTH. What condition can
lead to this lab profile? Hypervitaminosis D, due to oversupplementation or
granulomatous diseases such as sarcoidosis "<img src=""8058.png"">"
disorders
What is the difference between primary and secondary hyperparathyroidism in terms
of causative pathologies? Primary is due to PTH secretion (eg, from a tumor),
whereas secondary is a response to renal failure with concomitant vitamin D
deficiency "<img src=""8058.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology lab-values-in-bone-disorders
What are some causes of primary hyperparathyroidism? Parathyroid hyperplasia, a
parathyroid adenoma, a parathyroid carcinoma, or idiopathic"<img src=""8058.png"">"
disorders
What is the lab profile for Ca2+, PO43-, PTH, and ALP in a patient with primary
hyperparathyroidism? High Ca2+, low PO43-, high ALP, high PTH "<img
src=""8058.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue Pathology lab-
values-in-bone-disorders
What is the lab profile for Ca2+, PO43-, PTH, and ALP in a patient with secondary
hyperparathyroidism? Low Ca2+, high PO43-, high ALP, high PTH "<img
src=""8058.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue Pathology lab-
values-in-bone-disorders
Giant cell tumors have a peak incidence in patients in what age range and occur at
what anatomic location? 2040 years of age; epiphyseal end of long bones, often
around the knee "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology primary-bone-tumors
At what age do men usually develop osteochondromas? At ages younger than 25 years
Pathology primary-bone-tumors
Osteochondromas rarely transform into which type of malignancy? Chondrosarcoma
Pathology primary-bone-tumors
What is the second most common primary malignant bone tumor after multiple myeloma?
Osteosarcoma "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-
At what ages do osteosarcomas peak? 1020 years old (primary), &62; 65 years of age
(secondary) (bimodal distribution) "<img src=""8059.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology primary-bone-tumors
Where in the body are osteosarcomas most commonly found? In the metaphysis of the
long bones, especially around the knee "<img src=""8059.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology primary-bone-tumors
What is the prognosis of patients with untreated Ewing sarcoma? How does their
prognosis change with treatment? Ewing sarcoma is an aggressive cancer with
early metastases, yet it responds well to chemotherapy "<img src=""8059.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology primary-bone-tumors
Name some predisposing factors for osteosarcoma. Paget disease of bone, bone
infarcts, radiation, familial retinoblastoma, Li-Fraumeni syndrome (germline p53
mutation) "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology primary-bone-tumors
A 15-year-old boy has a bone tumor with sunburst pattern on x-ray due to periosteal
elevation. What is the finding called? What tumor is it? Codman triangle;
osteosarcoma "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-
Patients of what sex and age are predisposed to Ewing sarcoma? Boys younger than
15 years of age "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-
"A boy with an aggressive bone tumor has an x-ray that shows periosteal ""onion
skinning."" What will genetic analysis of the tumor show?" t(11;22) translocation
causing fusion protein EWS-FLI 1 (11 + 22 = 33, Patrick Ewing's jersey number)
(seen in Ewing sarcoma) "<img src=""8059.png"">" Musculoskeletal,-Skin,-and-
Where is Ewing sarcoma most commonly found? The diaphysis of long bones,
pelvis, scapula, and ribs "<img src=""8059.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology primary-bone-tumors
A 77-year-old woman has pain in her hands at the end of the day. By what mechanism
has her arthritis developed? "Mechanical wear and tear on articular cartilage
(""degenerative joint disease""); this is osteoarthritis" "<img src=""8060.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology osteoarthritis-and-
rheumatoid-arthritis
Are systemic symptoms absent or present in osteoarthritis? Is it an inflammatory or
noninflammatory arthritis? Absent (Osteoarthritis is not associated with
systemic symptoms.); noninflammatory "<img src=""8060.png"">"
A 70-year-old woman has DIP and PIP joint pain without MCP involvement. She has no
morning stiffness. Name 4 risk factors for her condition. Age, female sex,
obesity, and joint trauma (This is osteoarthritis.) "<img src=""8060.png"">"
Why is the presentation of osteoarthritis sometimes described as bowleggedness?
Because cartilage loss typically begins at the medial aspect of the knees
Pathology osteoarthritis-and-rheumatoid-arthritis
Is eburnation (a polished, ivory-like appearance of bone) found in osteoarthritis,
rheumatoid arthritis, or both? Osteoarthritis, due to the mechanical rubbing
of bone on bone "<img src=""8060.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology osteoarthritis-and-rheumatoid-arthritis
A man w/ joint pains is positive for anti-cyclic citrullinated peptide antibodies.
Name some systemic symptoms associated with his disease. Fever, fatigue, weight
loss (He has rheumatoid arthritis.) "<img src=""8060.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology osteoarthritis-and-rheumatoid-arthritis
What is the difference between the etiologies of osteoarthritis and rheumatoid
arthritis? Osteoarthritis is mechanical erosion of the articular cartilage,
whereas rheumatoid arthritis is autoimmune, inflammatory joint destruction "<img
osteoarthritis-and-rheumatoid-arthritis
Is rheumatoid arthritis more prevalent in the male or female population? Female
population "<img src=""8060.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology osteoarthritis-and-rheumatoid-arthritis
Eighty percent of patients with rheumatoid arthritis have what serologic finding?
Rheumatoid factor (anti-IgG antibodies) "<img src=""8060.png"">"
What time of day is the stiffness of rheumatoid arthritis most intense. How long
does it usually last? Morning; usually more than 1 hour, improving with use "<img
Is the joint involvement in rheumatoid arthritis unilateral or symmetric?
Inflammatory or noninflammatory? Symmetric; inflammatory "<img src=""8060.png"">"
What type of arthritis tends to improve with use but often manifests with systemic
symptoms? Rheumatoid arthritis "<img src=""8060.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology osteoarthritis-and-rheumatoid-arthritis
What are some classic findings seen externally on the hands of patients with
rheumatoid arthritis? Subluxation, fingers with ulnar deviation, swan neck
deformity, and boutonniere deformity "<img src=""8060.png"">"
Rheumatoid arthritis has a strong association with which human leukocyte antigen
(HLA) complex? HLA-DR4 "<img src=""8060.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology osteoarthritis-and-rheumatoid-arthritis
Name the finger joints usually spared in rheumatoid arthritis and osteoarthritis,
respectively. DIP joint and MCP joint "<img src=""8060.png"">"
What is the eponymous cyst that is associated with rheumatoid arthritis and is
found behind the knee? A Baker cyst "<img src=""8060.png"">"
Despite a positive rheumatoid factor, the attending is not convinced that a patient
has rheumatoid arthritis. What other test do you order? Anti-cyclic
citrullinated peptide antibody test (more specific) "<img src=""8060.png"">"
In rheumatoid arthritis, would you expect to see a change to the amount of synovial
fluid in the joint space? Yes, you would expect increased synovial fluid "<img
A man has joint pain, a swan neck deformity, and fevers. NSAIDs and COX-2
inhibitors do not work. What other treatment options can you try?
Glucocorticoids, disease-modifying agents (eg, methotrexate, sulfasalazine),
biologics (eg, TNF- inhibitors) (for rheumatoid arthritis)"<img src=""8060.png"">"
A 77-year-old woman has pain in her knees at the end of the day. What medical
treatments might be considered? Acetaminophen, NSAIDs, and intra-articular
glucocorticoids (for osteoarthritis) "<img src=""8060.png"">"
What are rheumatoid nodules? Areas of fibrinoid necrosis with palisading
histiocytes, found in subcutaneous tissues; seen in the lung with Caplan syndrome
Pathology osteoarthritis-and-rheumatoid-arthritis
A patient with joint pains/deformities is short of breath. A biopsy shows AA
amyloidosis. What specific lab test confirms the diagnosis?Anti-cyclic
citrullinated peptide antibodies (specific for rheumatoid arthritis); he has Caplan
syndrome (pneumoconiosis/rheumatoid nodules) "<img src=""8060.png"">"
Which disease-modifying agents can be used in the treatment of rheumatoid
arthritis? Methotrexate, sulfasalazine, hydroxychloroquine, leflunomide "<img
A patient has dry mouth and dry eyes. His joints are swollen and painful. Blood
work shows anemia of chronic disease. Diagnosis? Likely rheumatoid arthritis
complicated by Sjgren syndrome (the latter is a common extraarticular
manifestation of the former) "<img src=""8060.png"">" Musculoskeletal,-Skin,-
How is the synovial fluid aspirate different in rheumatoid arthritis as opposed to
osteoarthritis (OA)? In OA, the fluid is noninflammatory (WBC &60; 2000 mm3); in
RA, the fluid is inflammatory (WBC &62; 2000 mm3) "<img src=""8060.png"">"
Your patient with rheumatoid arthritis has neutropenia. Exam shows splenomegaly.
Diagnosis? Felty syndrome "<img src=""8060.png"">" Musculoskeletal,-Skin,-
If your patient with carpal tunnel syndrome has joint inflammation in his
interphalangeal joints, do you suspect rheumatoid arthritis? Yes; carpal tunnel
syndrome may be an extraarticular manifestation of rheumatoid arthritis "<img
Gout occurs from the precipitation of this crystal in joint spaces. Monosodium
urate "<img src=""8061.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
Pathology gout
A 56-year-old man with a history of gout is given a new antihypertensive agent,
which causes a gout attack. What drug was likely started? A thiazide diuretic
(blocks excretion of uric acid and increases the likelihood of having a gout flare)
Pathology gout
A patient has swollen, red, painful joints. They appear to be associated with gout.
Will they appear in a symmetric or asymmetric pattern? Asymmetric "<img
src=""8061.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue Pathology gout
Describe what gout crystals look like under polarized light. Negatively
birefringent, needle shaped, appearing yellow under parallel light "<img
Is gout more common in men or women? Men "<img src=""8061.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology gout
Alcohol use and large meals can exacerbate what joint disease? Why? Gout;
alcohol and other metabolites from the meal compete with uric acid for excretion
sites in kidney, causing reduced secretion "<img src=""8061.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology gout
A 55yo man who drinks alcohol on a daily basis presents with a red, swollen toe.
What is the acute management of this patient's disease? NSAIDs (eg,
indomethacin), glucocorticoids, or colchicine (this patient has gout) "<img
Name four metabolic diseases/conditions that predispose a patient to gout due to
uric acid overproduction. Lesch-Nyhan syndrome, PRPP excess, increased cell
turnover (eg, in tumor lysis syndrome), and von Gierke disease "<img
Gout is a problem of uric acid buildup. Do the majority of cases involve
overproduction or underexcretion? 90% involve underexcretion, and 10 involve
overproduction "<img src=""8061.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology gout
What is podagra? A painful, swollen MTP joint of the big toe, classically seen in
acute gout flares "<img src=""8061.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology gout
Calcium pyrophosphate deposition disease is caused by the deposition of what type
of crystals within the joint space? Calcium pyrophosphate "<img src=""8062.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology calcium-pyrophosphate-
deposition-disease
Joint aspiration shows basophilic, rhomboid crystals that are weakly birefringent
and blue under parallel light. What does the patient have? Calcium pyrophosphate
deposition disease "<img src=""8062.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology calcium-pyrophosphate-deposition-disease
People of what age and sex are predisposed to calcium pyrophosphate deposition
disease? Men and women older than 50 years of age (both sexes affected equally)
Pathology calcium-pyrophosphate-deposition-disease
In gout, crystals are which color under parallel light? What about crystals in
calcium pyrophosphate deposition disease? Yellow; blue "<img src=""8062.png"">"
deposition-disease
A patient with a severe, acute flare of calcium pyrophosphate deposition disease
benefit by taking which medications early? NSAIDs, colchicine, glucocorticoids
(All may be used for acute treatment.) "<img src=""8062.png"">"
deposition-disease
What are some pathologic conditions associated with calcium pyrophosphate
deposition disease? Hemochromatosis, hyperparathyroidism, joint trauma "<img
calcium-pyrophosphate-deposition-disease
A patient has clear chondrocalcinosis on a knee x-ray. In simple terms, what does
this mean? Cartilage calcification, likely due to calcium pyrophosphate deposition
disease "<img src=""8062.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology calcium-pyrophosphate-deposition-disease
In calcium pyrophosphate deposition disease, what is a term for pain and swelling
with acute inflammation? Chronic degeneration? Pseudogout; pseudoosteoarthritis
Pathology calcium-pyrophosphate-deposition-disease
A tanned, diabetic patient with liver disease has had pain in his left knee for
years. Is this likely osteoarthritis? It is likely pseudo-osteoarthritis due to
calcium pyrophosphate deposition disease in the knee joint, secondary to
hemochromatosis "<img src=""8062.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology calcium-pyrophosphate-deposition-disease
A patient has dry eyes, dry mouth, and bilateral parotid gland swelling. Name some
complications that he is at risk for. Dental caries, mucosa-associated lymphoid
tissue (MALT) lymphoma (This patient has Sjgren syndrome.)"<img src=""8063.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology sjgren-syndrome
A 50-year-old woman with dry eyes, dry mouth, trouble swallowing, and joint pain
may have an increased risk of what type of cancer? MALT lymphoma (This patient
has Sjgren syndrome.) "<img src=""8063.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology sjgren-syndrome
Which serologic findings are characteristic of Sjgren syndrome? Antinuclear
antibodies, SS-A (anti-Ro), and/or SS-B (anti-La) "<img src=""8063.png"">"
A woman's serum is positive for antibodies ANA, SS-A, and SS-B. Would you be
surprised to see deformities in her hands? You would not be surprised, as
Sjgren syndrome often presents with other autoimmune diseases such as rheumatoid
arthritis "<img src=""8063.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology sjgren-syndrome
Individuals with Sjgren syndrome are at increased risk for which dental condition,
due in part to enlargement of what gland? Caries, due to decreased production of
saliva (xerostomia) from the parotid "<img src=""8063.png"">"
A 50-year-old woman has an autoimmune disorder involving dry mouth, joint pain, and
parotid swelling. Does she have visual complaints? Yes; this is Sjgren
syndrome, which may present with keratoconjunctivitis sicca (decreased tear
production with subsequent corneal damage) "<img src=""8063.png"">"
A patient with known osteoarthritis (OA) has a fever and worsening swelling in her
knees. How do you differentiate OA from septic arthritis? Septic arthritis
synovial fluid is purulent with a WBC count &62; 50,000 mm3, whereas OA has
noninflammatory synovial fluid "<img src=""8064.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology septic-arthritis
Name the three organisms that most commonly cause septic arthritis. S aureus,
Streptococcus, and N gonorrhoeae "<img src=""8064.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology septic-arthritis
What signs and symptoms are classically associated with gonococcal arthritis?
Either purulent arthritis (eg, of the knee) or a triad of polyarthralgias,
tenosynovitis (eg, of the hand), dermatitis (eg, pustules) "<img src=""8064.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology septic-arthritis
What does it mean when it is said that a spondyloarthropathy is seronegative?
Serology for rheumatoid factor (anti-IgG antibody) is negative "<img
seronegative-spondyloarthropathies
In seronegative spondyloarthropathies, there is a strong association with which
human leukocyte antigen? HLA-B27 (MHC class I serotype) "<img
What are the major seronegative spondyloarthropathies? Psoriatic arthritis,
Ankylosing spondylitis, Inflammatory bowel disease, Reactive arthritis (Reiter
syndrome) (PAIR) "<img src=""8065.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology seronegative-spondyloarthropathies
A man presents with red eyes, dysuria, and pain in his left knee for 2 days. Four
weeks ago, he had bloody diarrhea. What is the diagnosis? Reactive arthritis with
conjunctivitis, urethritis, and arthritis (can't see, can't pee, can't bend my
knee) "<img src=""8065.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
Pathology seronegative-spondyloarthropathies
What are two triggers for reactive arthritis (Reiter syndrome)? Gastrointestinal
(Shigella, Salmonella, Yersinia, Campylobacter) and Chlamydia infections "<img
Patients with inflammatory bowel disease are most likely to have which form of
arthritis? Ankylosing spondylitis or peripheral arthritis (both seronegative
spondyloarthropathies) "<img src=""8065.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology seronegative-spondyloarthropathies
A patient receiving immunosuppressive therapy for diarrhea now has pain in his
lower back. Is this new finding related to his diarrhea? Yes, he likely has IBD
(Crohn disease, ulcerative colitis) with an extragastrointestinal manifestation, in
this case, spondyloarthritis "<img src=""8065.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology seronegative-spondyloarthropathies
A young woman presents with a history of seizures and psychotic episodes. Is lupus
on your differential diagnosis? Yes, as systemic lupus erythematosus may
present with neurologic abnormalities such as seizures and psychosis "<img
systemic-lupus-erythematosus
Use the mnemonic RASH OR PAIN to list the classic findings seen in patients with
systemic lupus erythematosus. Rash, Arthritis, Serositis, Hematologic disorders,
Oral/nasopharyngeal ulcers, Renal, Photosensitivity, ANA, Immunologic, Neurologic
Pathology systemic-lupus-erythematosus
A pt w/Wolff-Parkinson-White syndrome develops a malar rash after starting
treatment. What lab finding is sensitive for this condition? Antihistone
antibodies are sensitive for drug-induced lupus (Procainamide is commonly
implicated with this condition.) "<img src=""8066.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology systemic-lupus-erythematosus
A patient presents with a malar rash, mouth ulcers, and arthritis. She is about to
go on vacation to Hawaii. What do you tell her? She has systemic lupus
erythematosus and therefore could be photosensitive; she should protect against sun
exposure "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology systemic-lupus-erythematosus
Which serologic findings (antibodies) can be positive in patients with lupus?
Antinuclear, anti-double-stranded DNA, and anti-Smith antibodies (antihistone
antibodies in cases of drug-induced lupus) "<img src=""8066.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology systemic-lupus-
erythematosus
A man taking procainamide develops arthritis, fatigue, and pericarditis. His serum
might reveal the presence of which antibody? Antihistone antibodies, sensitive
for drug-induced lupus "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology systemic-lupus-erythematosus
What are possible mucocutaneous manifestations of systemic lupus erythematosus?
Malar or discoid rashes, mucositis (oropharyngeal ulcers), serositis,
photosensitivity "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-
Which antibody are specific for lupus but are not prognostic? What do they target?
Anti-Smith antibodies; snRNPs "<img src=""8066.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology systemic-lupus-erythematosus
Which antibodies are specific for lupus and predict a poor prognosis? What organ
system is often affected when these antibodies are present?Anti-dsDNA antibodies;
the kidneys "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-Connective-
Which antibodies are sensitive but not specific for lupus and are used as a primary
screening test? Antinuclear antibodies (ANA) "<img src=""8066.png"">"
erythematosus
A young woman has leukopenia and oropharyngeal ulcers. She also has diffuse joint
pains and a facial rash. What treatments can be offered? NSAIDs, steroids,
immunosuppressants, and/or hydroxychloroquine (This is likely systemic lupus
erythematosus.) "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-
Renal biopsy of a patient with lupus shows immune complex deposition. Which lab
findings would support the formation of these complexes? Decreased C3, C4, and
CH50 levels "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-Connective-
What demographic is most commonly affected by lupus? Women of reproductive age and
African-American descent "<img src=""8066.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology systemic-lupus-erythematosus
A patient with lupus dies of complications of renal disease. Autopsy of her heart
valves may show what pathology? Nonbacterial verrucous endocarditis (Libman-
Sacks Endocarditis) with vegetations on the mitral or aortic valve (LSE in SLE)
Pathology systemic-lupus-erythematosus
A man has glomerulonephritis, a malar rash, photosensitivity, and serositis. What
antibodies are specific for this disease? Anti-dsDNA and anti-Smith antibodies (the
patient likely has systemic lupus erythematosus) "<img src=""8066.png"">"
erythematosus
A 19-year-old woman with a malar rash is noted to have pancytopenia on routine
blood work. What condition does she likely have? Systemic lupus erythematosus
(associated with hematologic disorders) "<img src=""8066.png"">"
erythematosus
A 27-year-old woman with a history of lupus develops hematuria. What histologic
finding(s) do you expect on renal biopsy? Evidence of diffuse proliferative
glomerulonephritis (a common cause of severe nephritic or nephrotic syndrome in
patients with lupus) "<img src=""8066.png"">" Musculoskeletal,-Skin,-and-
A patient with lupus has nephrotic syndrome. What type of glomerulonephropathy do
you expect her to have? Diffuse proliferative "<img src=""8066.png"">"
erythematosus
A patient with lupus develops a pulmonary embolism. What laboratory findings would
you expect? Anticardiolipin, lupus anticoagulant, anti-&946;2 glycoprotein
antibodies (this is antiphospholipid syndrome) "<img src=""8067.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology antiphospholipid-
syndrome
A patient tests positive for both anticardiolipin antibodies and the lupus
anticoagulant. What do you expect on VDRL/RPR and PTT testing? VDRL/RPR might be
falsely positive and the PTT might be prolonged (The patient has antiphospholipid
syndrome.) "<img src=""8067.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology antiphospholipid-syndrome
A patient with a malar rash tests positive for anticardiolipin antibodies. She
becomes pregnant. What is her risk of a spontaneous abortion? Higher than the
general population, as the patient has antiphospholipid syndrome "<img
antiphospholipid-syndrome
In addition to laboratory data, what is used to make the diagnosis of
antiphospholipid syndrome? Clinical criteria including a history of thromboses
(arterial or venous) and/or spontaneous abortions "<img src=""8067.png"">"
syndrome
A woman is still in the hospital after her third spontaneous abortion. Lab values
show a prolonged PTT. What treatment is recommended? Systemic anticoagulation due
to a likely diagnosis of antiphospholipid syndrome "<img src=""8067.png"">"
syndrome
A patient has a malar rash, muscle aches, and fingertip ulcers. What lab finding
could account for all of these findings? Anti-U1 RNP antibodies (speckled ANA) for
mixed connective tissue disease (has features of lupus, systemic sclerosis, and/or
polymyositis) "<img src=""8068.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology mixed-connective-tissue-disease
A woman has indurated purple lesions on her cheeks. She also has a Bell palsy. Her
serum ACE level is high. Do you diagnose lupus in her? No; these findings are
more consistent with sarcoidosis (The skin lesions are likely lupus pernio.) "<img
sarcoidosis
What population is most affected by sarcoidosis? Black women "<img
sarcoidosis
What kind of process is sarcoidosis? What is the characteristic systemic pathologic
finding? Immune-mediated process; widespread noncaseating granulomas"<img
sarcoidosis
A patient with sarcoidosis has progressive dyspnea on exertion. What kind of
pattern would you expect to see on pulmonary function testing? A restrictive
pattern, as patients with sarcoidosis can develop interstitial fibrosis "<img
sarcoidosis
What type of skin pathology is associated with sarcoidosis?Erythema nodosum "<img
sarcoidosis
What two histopathologic findings are seen in the epithelioid granulomas of
sarcoidosis? Schaumann bodies and asteroid bodies "<img src=""8069.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology sarcoidosis
A 29-year-old black woman has uveitis, lupus pernio, Bell palsy, and bilateral
hilar adenopathy. How do you treat her? Steroids (for sarcoidosis) "<img
sarcoidosis
An African-American woman has tender painful nodules over her anterior shins. She
reports some dyspnea. What imaging study do you order? Erythema nodosum likely
represents the skin findings of sarcoidosis; a chest x-ray should be obtained to
look for pulmonary involvement "<img src=""8069.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue Pathology sarcoidosis
A 60-year-old patient has sore, stiff hips and shoulders, fever, malaise, and
weight loss. She has normal strength. Diagnosis? Polymyalgia rheumatica "<img
polymyalgia-rheumatica
A patient has polymyalgia rheumatica. What do you expect the ESR, CRP, and CK
levels to be? ESR and CRP will be elevated, and the CK will be normal "<img
polymyalgia-rheumatica
Polymyalgia rheumatica occurs most commonly in which age group? Patients &62; 50
years of age "<img src=""8070.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology polymyalgia-rheumatica
A patient with painful, stiff shoulders, malaise, and fever develops a headache
that is worse in the temples. What are you concerned about?Temporal (giant cell)
arteritis, which is associated with polymyalgia rheumatica "<img src=""8070.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology polymyalgia-rheumatica
A patient with painful, stiff shoulders, malaise, and fever quickly feels better
after taking her new medication. What is the medication? Low-dose corticosteroids
(for polymyalgia rheumatica) "<img src=""8070.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology polymyalgia-rheumatica
What demographic is most commonly affected by fibromyalgia?Women 2050 years of age
Pathology fibromyalgia
A 40-year-old woman has diffuse musculoskeletal pain/stiffness, paresthesias, poor
sleep, and fatigue. How do you treat her? Regular exercise, antidepressants (TCAs,
SNRIs), or anticonvulsants (The patient likely has fibromyalgia.) "<img
fibromyalgia
"What is the ""fibro fog"" that is seen in patients with fibromyalgia?"
Cognitive disturbances "<img src=""8071.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology fibromyalgia
Polymyositis involves progressive muscle weakness, generally of which muscle
groups? Proximal muscle groups, often the shoulders "<img src=""8072.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology
polymyositis/dermatomyositis
What is the pathophysiology of the disease polymyositis? CD8+ T cells cause
endomysial inflammation of skeletal myofibers "<img src=""8072.png"">"
Which lab results would you expect to be abnormal in polymyositis/dermatomyositis?
Elevated CK and positive ANA, anti-Jo-1, anti-SRP, and anti-Mi-2 antibodies
Pathology polymyositis/dermatomyositis
A man with a heliotrope rash has a muscle biopsy performed. What sort of
inflammation do you observe? Which cell type is involved? Perimysial inflammation
with an influx of CD4+ T cells (This is dermatomyositis.) "<img src=""8072.png"">"
What cutaneous findings would support a diagnosis of dermatomyositis over
polymyositis? "Malar rash, Gottron papules, heliotrope (erythematous
periorbital) rash, ""shawl and face"" rash, mechanic's hands" "<img
A young female patient has ptosis, diplopia, and weakness that worsens with muscle
use. What is the root cause of her symptoms? Autoantibodies to postsynaptic
acetylcholine receptors (The patient likely has myasthenia gravis.) "<img
neuromuscular-junction-diseases
Repetitive muscle activity affects patients with myasthenia gravis in what way?
What about those with Lambert-Eaton myasthenic syndrome? Strength worsens with
muscle use; strength improves with muscle use "<img src=""8073.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology neuromuscular-
junction-diseases
Name the two ophthalmic manifestations of myasthenia gravis. Ptosis and
diplopia "<img src=""8073.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology neuromuscular-junction-diseases
A young woman has ptosis, diplopia, and weakness that worsens with muscle use. Why
do you want to order a chest x-ray for her? Because of its strong association
with myasthenia gravis, patients with this diagnosis should be screened for a
thymoma "<img src=""8073.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology neuromuscular-junction-diseases
A patient has dry mouth and proximal muscle weakness that improves with muscle use.
What is the root cause of her symptoms? Autoantibodies to presynaptic Ca2+
channels, causing decreased acetylcholine release (The patient has Lambert-Eaton
myasthenic syndrome.) "<img src=""8073.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology neuromuscular-junction-diseases
Lambert-Eaton myasthenic syndrome leads predominantly to muscle weakness in which
muscle groups? Proximal "<img src=""8073.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology neuromuscular-junction-diseases
A man has autoantibodies against presynaptic Ca2+ channels, causing weakness. What
malignancy is his disease classically associated with? Small cell lung cancer
(He has Lambert-Eaton myasthenic syndrome.) "<img src=""8073.png"">"
junction-diseases
Do myasthenia gravis and Lambert-Eaton syndrome both improve with
acetylcholinesterase inhibitor use? No, only myasthenia gravis reverses with the
use of AChE inhibitors. "<img src=""8073.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology neuromuscular-junction-diseases
A smoker has proximal muscle weakness, dry mouth, and impotence. AChE inhibitors
have no effect. What underlying malignancy is to blame? This is Lambert-Eaton
myasthenic syndrome, likely secondary to small cell lung cancer "<img
neuromuscular-junction-diseases
You believe a patient has myasthenia gravis. What drug would you give to diagnose
the condition? To treat it? Acetylcholinesterase inhibitors for both: edrophonium
to diagnose, pyridostigmine to treat "<img src=""8073.png"">"
junction-diseases
A man develops a firm lump over bone following muscular trauma. It is not
neoplastic. What is the most common location for this condition? The upper or lower
extremities (This patient likely has myositis ossificans.) "<img src=""8074.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology myositis-ossificans
What condition involves excessive fibrosis and collagen deposition, most commonly
under the skin? What other systems can be involved? Scleroderma; the
gastrointestinal, renal, pulmonary, and cardiovascular systems can also be involved
Pathology scleroderma-(systemic-sclerosis)
What are the classic symptoms of diffuse scleroderma? Widespread skin involvement,
rapid progression, early visceral involvement "<img src=""8075.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology scleroderma-(systemic-
sclerosis)
What are the two types of scleroderma? Which has a more benign clinical course?
Diffuse scleroderma and CREST syndrome; CREST is more benign "<img
scleroderma-(systemic-sclerosis)
You suspect a 58-year-old woman has diffuse scleroderma. What antibody test can you
order to help support this diagnosis? Anti-Scl-70 (anti-DNA topoisomerase I)
antibody titers "<img src=""8075.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue Pathology scleroderma-(systemic-sclerosis)
What does CREST stand for? Is it a limited or diffuse form of scleroderma?
Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly,
Telangiectasia; limited "<img src=""8075.png"">" Musculoskeletal,-Skin,-and-
A patient with Raynaud phenomenon tests positive for anticentromere antibodies. In
what two body areas does he likely have skin findings? The fingers and face
(This patient has limited scleroderma.) "<img src=""8075.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology scleroderma-(systemic-
sclerosis)
A patient has skin telangiectasias, Raynaud phenomenon, heartburn, and calcinosis
on x-ray. What test do you order to confirm the diagnosis? Anti-centromere antibody
titers "<img src=""8075.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology scleroderma-(systemic-sclerosis)
A patient has Raynaud phenomenon and heartburn. What serum marker would be positive
if she had the diffuse form of this disease? Anti-Scl-70 (anti-DNA topoisomerase
I) antibodies are seen in diffuse scleroderma (anti-centromere antibodies in
limited scleroderma) "<img src=""8075.png"">" Musculoskeletal,-Skin,-and-
What is the classic triad for a patient presenting with scleroderma?
Autoimmunity, noninflammatory vasculopathy, and collagen deposition with
fibrosis. "<img src=""8075.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue Pathology scleroderma-(systemic-sclerosis)
Raynaud disease occurs most often in which parts of the body? Fingers and toes
Pathology raynaud-phenomenon
When would you diagnose a patient as having Raynaud syndrome instead of Raynaud
disease? If symptoms are secondary to an underlying disorder (not idiopathic)
such as mixed connective tissue disease, SLE, or CREST syndrome "<img
raynaud-phenomenon
Describe the sequence of skin color changes in Raynaud phenomenon. White
(ischemia) to blue (hypoxia) to red (reperfusion) "<img src=""8076.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue Pathology raynaud-phenomenon
"A woman with CREST syndrome has numerous ulcerations on her hands. She says that
her hands were ""red, white, and blue"" yesterday. Diagnosis?" This is likely
digital ulceration (critical ischemia) due to Raynaud syndrome, likely arising
secondary to CREST syndrome "<img src=""8076.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue Pathology raynaud-phenomenon
Which layer of the epidermis contains desmosomes? Stratum spinosum "<img
src=""8077.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue dermatology
skin-layers
Which layer of the epidermis contains keratin? Stratum corneum "<img
skin-layers
Which layer of the epidermis contains stem cells? Stratum basale "<img
skin-layers
What are the three main layers of skin, from superficial to deep? Epidermis,
dermis, and subcutaneous fat (hypodermis, subcutis) "<img src=""8077.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology skin-layers
Which epithelial cell junction is made of actin and cadherins? Adherens junctions
(belt desmosome, zona adherens) "<img src=""8078.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue dermatology epithelial-cell-junctions
Which type of junction prevents the paracellular movement of solutes? Tight
junctions (zona occludens) "<img src=""8078.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue dermatology epithelial-cell-junctions
What does the loss of E-cadherin do in neoplastic cells? Promotes metastatic
dissemination "<img src=""8078.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology epithelial-cell-junctions
Cadherin-actin proteins depend on what ion to form an adherens junction? Ca2+
(CADherins = Ca-dependent adhesion proteins) "<img src=""8078.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology epithelial-cell-
junctions
What junction provides structural support using desmoplakin and cytokeratin?
Desmosomes (spot desmosome, macula adherens) "<img src=""8078.png"">"
junctions
What protein do gap junctions utilize to allow electric and chemical communication
between cells? Connexons, which are transmembrane channel proteins with a
central pore through which communication occurs "<img src=""8078.png"">"
junctions
Which epithelial cell junction anchors cells to the basement membrane?
Hemidesmosomes "<img src=""8078.png"">" Musculoskeletal,-Skin,-and-
What do integrins anchor a cell to? On which membrane are they found? Collagen and
laminin in the basement membrane (integrins maintain integrity); the basolateral
membrane "<img src=""8078.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue dermatology epithelial-cell-junctions
In pemphigus vulgaris, autoantibodies are directed against what epithelial cell
junction? Desmosomes, found between 2 adjacent cells (It's vulgarto spread your
legs apart.) "<img src=""8078.png"">" Musculoskeletal,-Skin,-and-
A skin biopsy of bullous pemphigoid is done. It will show a gap between what two
structures? "The basolateral wall of the cell and basement membrane (in bullous
pemphigoid, hemidesmosomes down ""bullow"" are targeted)" "<img src=""8078.png"">"
junctions
Which junctions are attacked in bullous pemphigoid? Hemidesmosomes (Think of hemi
as a half circle or bubble.) "<img src=""8078.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue dermatology epithelial-cell-junctions
How does an adherens junction connect one cell to another cell? What protein is
unique to an adherens junction? Via transmembrane cadherins on each cell face;
an adherens junction must be linked to the actin-cytoskeleton of its two respective
cells "<img src=""8078.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
dermatology epithelial-cell-junctions
In a desmosome, which proteins link cell membranes to each other? Which
cytoskeletal protein links to the membrane protein? Desmoplakins in each membrane
connect to each other; cytokeratin binds to desmoplakin inside the cell "<img
epithelial-cell-junctions
What's the difference between a macule and patch? Macule is &60; 1 cm; patch is
&62; 1 cm "<img src=""8079.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue dermatologic-macroscopic-terms-(morphology) dermatology
What's the difference between a macule and papule? Macule is flat and papule is
raised up "<img src=""8079.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue dermatologic-macroscopic-terms-(morphology) dermatology
What is the difference between a papule and plaque? Papule is &60; 1 cm; plaque
is &62; 1 cm "<img src=""8079.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatologic-macroscopic-terms-(morphology) dermatology
What is the medical term for Cindy Crawford's beauty mark, also known as a mole?
Papule "<img src=""8079.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatologic-macroscopic-terms-(morphology) dermatology
What is the difference between vesicles and bullae? Both are fluid-filled
blisters; vesicles are &60; 1 cm and bullae are &62; 1 cm "<img src=""8079.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatologic-macroscopic-terms-
(morphology) dermatology
What microscopic terms define the epidermis in psoriasis? A thickened stratum
corneum (hyperkeratosis) with retention of nuclei (parakeratosis) "<img
src=""8080.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue dermatologic-
microscopic-terms dermatology
A patient presents with palmar calluses. What is the medical term for this?
Hyperkeratosis "<img src=""8080.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatologic-microscopic-terms dermatology
A patient presents with palmar calluses. What layer of epidermis is affected?
The stratum corneum (This is a form of hyperkeratosis.) "<img
What epidermal layer is thickened in lichen planus? The stratum granulosum (This
is a form of hypergranulosis.) "<img src=""8080.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue dermatologic-microscopic-terms dermatology
What is the term for a collection of fluid in the epidermis of a patient with
eczematous dermatitis? Spongiosis "<img src=""8080.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue dermatologic-microscopic-terms dermatology
A man with pemphigus vulgaris complains that his skin splits open at the slightest
touches. What is the microscopic term for this finding? Acantholysis (separation
of epidermal cells) "<img src=""8080.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatologic-microscopic-terms dermatology
A diabetic has a dark velvety skin lesion behind his neck. What is the diagnosis?
What epidermal layer is involved? This is acanthosis nigricans, or epidermal
hyperplasia with increased thickness of the stratum spinosum "<img
A girl has albinism; her sister does not. How does her melanocyte count compare
with her sister's? How does melanin production compare? Those with albinism have
the same number of melanocytes as those without; it is melanin production that is
decreased "<img src=""8081.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue dermatology pigmented-skin-disorders
Benign seborrheic keratoses are most likely to arise on which areas of the body?
The head, trunk, and extremities "<img src=""8082.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue common-skin-disorders
dermatology
Urticaria arises secondary to which pathologic changes within the skin secondary to
an allergic stimulus? Mast cell degranulation leading to wheal formation,
characterized by superficial edema and lymphatic channel dilation "<img
src=""8082.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue common-skin-
disorders dermatology
A patient status post radiation and mastectomy for breast cancer is diagnosed with
angiosarcoma. Where does it usually appear on the body? Head, neck, and breasts
(sun-exposed areas) "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology vascular-tumors
An elderly patient is diagnosed with angiosarcoma. What is the prognosis? Poor;
angiosarcoma has a very high tendency for metastasis via lymphatics and blood
vessels "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue dermatology vascular-tumors
An unlucky man who works with polyvinyl chloride (PVC) and arsenic loses 20 lb and
has no appetite. Which vascular tumor may be to blame? Hepatic angiosarcoma,
which is associated with long-term PVC and arsenic exposure"<img src=""8083.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology vascular-tumors
What is the prognosis for a patient diagnosed with angiosarcoma? What makes this
malignancy so difficult to treat? Poor; this malignancy is invariably fatal; it
is aggressive and difficult to resect, often due to a delay in diagnosis "<img
vascular-tumors
What viruses are associated with the development of Kaposi sarcoma? HHV-8 and
HIV "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue
dermatology vascular-tumors
A woman notices that her nail is warped due to a painful red-blue spot under her
nail bed. What is the diagnosis and cause? Glomus tumor, a benign
proliferation arising from modified smooth muscle cells of the thermoregulatory
glomus body "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-Connective-
An HIV-positive man develops purple spots over his skin. Biopsy shows a lymphocytic
infiltrate. Where else could these lesions arise? This is Kaposi sarcoma, which
most commonly arises on the skin, but is also seen in the mouth, GI tract, and
respiratory epithelium "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology vascular-tumors
An HIV-positive man develops bubbly purple spots over his shins. How do you
differentiate his condition from bacillary angiomatosis? Kaposi sarcoma has a
lymphocytic infiltrate on biopsy, whereas bacillary angiomatosis has a neutrophilic
infiltrate "<img src=""8083.png"">" Musculoskeletal,-Skin,-and-Connective-
A postmastectomy breast cancer survivor develops lymphedema. Knowing this, why do
you insist on evaluating her no less than once per year? She is at increased risk
for angiosarcoma, a highly aggressive rare blood vessel malignancy associated with
postmastectomy lymphedema "<img src=""8083.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue dermatology vascular-tumors
What skin conditions are caused by HSV1 and HSV2? Herpes labialis, herpes
genitalis, and herpetic whitlow are caused by herpesviruses"<img src=""8084.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology skin-infections
A man has a painful rash on his torso that follows a dermatome. What infection did
he have as a child that predisposed him to this new rash? Varicella (chickenpox),
predisposing him to zoster (shingles) later in life "<img src=""8084.png"">"
A woman on immunosuppressants has a generalized vesicular rash all over her body
after an illness. Vesicles grow VZV on PCR. Diagnosis? Disseminated zoster;
patients usually present with dermatomal vesicles in reactivation, but they can be
diffuse in the immunocompromised "<img src=""8084.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue dermatology skin-infections
A man develops a painful vesicular skin rash on his back that follows a dermatome.
What virus is responsible? What did he have as a child? The varicella zoster
virus causing shingles; shingles is a reactivation of prior varicella zoster
infection (He had chickenpox as a child.) "<img src=""8084.png"">"
A 45-year-old sexually active patient develops hairy leukoplakia on his tongue.
What test must be done immediately? An HIV screening test "<img src=""8084.png"">"
A patient has a white, painless plaque on his tongue. How can you ensure this is
hairy leukoplakia and not thrush? Leukoplakia cannot be scraped off, whereas
thrush can be "<img src=""8084.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology skin-infections
An immunocompromised smoker has white plaque on his tongue that can't be scraped
off. Are these lesions tender? Hairy leukoplakia is generally painless "<img
skin-infections
What groups of patients are most susceptible to hairy leukoplakia? HIV-positive
patients and organ transplant recipients "<img src=""8084.png"">"
Is hairy leukoplakia a precancerous lesion? No (in contrast to leukoplakia)
dermatology skin-infections
What populations are at risk for staphylococcal scalded skin syndrome? Newborns,
children, and adults with renal disease "<img src=""8084.png"">"
How can staphylococcal scalded skin syndrome be distinguished from toxic epidermal
necrosis on biopsy? Staphylococcal scalded skin syndrome: loss of stratum
granulosum desmosomes; toxic epidermal necrosis: loss of epidermal-dermal adhesions
dermatology skin-infections
What antibody is involved in bullous pemphigoid? In pemphigus vulgaris?
Hemidesmosomes (the epidermal basement membrane; are bullow the epidermis);
desmoglein (a component of desmosomes) "<img src=""8085.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue blistering-skin-disorders
dermatology
A patient has large, flaccid bullae with epidermal separation on stroking of the
lesion. What is this sign called? Nikolsky sign (positive); this is pemphigus
vulgaris (In comparison, bullous pemphigus is Nikolsky negative.) "<img
src=""8085.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue blistering-
skin-disorders dermatology
Why might doctors admit a patient with pemphigus vulgaris to the ICU, whereas a
patient with bullous pemphigus is managed as an outpatient?Pemphigus vulgaris is
potentially fatal (mucosa and infection risk), whereas bullous pemphigoid doesn't
involve mucosa "<img src=""8085.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue blistering-skin-disorders dermatology
A man with diarrhea has pruritic papules, vesicles, and bullae on his skin. How
does a biopsy appear on immunofluorescence? Immunoglobulin A (IgA) deposits are
seem at the tips of dermal papillae (This is dermatitis herpetiformis, associated
with celiac disease.) "<img src=""8085.png"">" Musculoskeletal,-Skin,-and-
List some common causes of erythema multiforme. Infections (eg, M pneumoniae, HSV),
drugs (eg, sulfa drugs, -lactams, phenytoin), cancers, autoimmune diseases "<img
src=""8085.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue blistering-
skin-disorders dermatology
A patient takes phenytoin. She is later febrile with bullae and areas of necrosis
scattered all over her body. What is the histopathology? Dermal-epidermal
junction cell sloughing (This patient likely has a Stevens-Johnson syndrome/toxic
epidermal necrolysis spectrum disorder.) "<img src=""8085.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue blistering-skin-disorders
dermatology
What term describes bullae, necrosis, and skin sloughing covering between 10% and
30% of the body? Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS-TEN)
blistering-skin-disorders dermatology
In a patient with the classic targetoid lesions of erythema multiforme, it is
important not to miss which important, more severe diagnosis? Stevens-Johnson
syndrome and/or toxic epidermal necrolysis, which may present with similar
targetoid lesions "<img src=""8085.png"">" Musculoskeletal,-Skin,-and-
A patient with lichen planus has white reticular lines on her oral mucosa. What is
this finding called? Wickham striae (a term for any mucosal involvement of
lichen planus) "<img src=""8086.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology miscellaneous-skin-disorders
What causes a sunburn? What are some of the risks of having too many sunburns?
Excess UV radiation; too many sunburns can lead to impetigo and skin cancers
(basal cell carcinoma, squamous cell carcinoma, melanoma) "<img src=""8086.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology miscellaneous-skin-
disorders
What does UV irradiation do at a cellular level? It causes DNA mutations and
can induce apoptosis of keratinocytes "<img src=""8086.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology miscellaneous-skin-
disorders
What type of ultraviolet radiation predominantly causes tanning? What type
predominantly causes sunburns? UVA is dominant in tanning and photoAging; UVB
is dominant in sunBurns "<img src=""8086.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology miscellaneous-skin-disorders
What is the most common skin cancer? Where is it most commonly found? How does it
spread? Basal cell carcinoma, found most commonly on sun-exposed areas of the
body; it spreads locally but rarely metastasizes "<img src=""8087.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue dermatology skin-cancer
What is the second most common skin cancer? Squamous cell carcinoma "<img
skin-cancer
How does squamous cell carcinoma spread? Invades locally surrounding tissues and
can spread to lymph nodes; it rarely metastasizes "<img src=""8087.png"">"
What are the ABCDEs of melanoma? Asymmetry, Border irregularity, Color
variation, Diameter over 6 mm, Evolution over time "<img src=""8087.png"">"
Genetic testing in a man with metastatic melanoma as shown reveals the BRAF V600E
mutation. What medical treatment do you recommend? Metastatic or unresectable
melanoma in patients with a BRAF V600E mutation may benefit from vemurafenib, a
BRAF kinase inhibitor "<img src=""8087.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue dermatology skin-cancer
Which skin cancer subtype is most likely to metastasize? Melanoma "<img
skin-cancer
What does the 5-lipoxygenase pathway of the arachidonic acid pathway yield?
Leukotrienes (via 5-HPETE) "<img src=""8088.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue arachidonic-acid-pathway pharmacology
Which leukotriene is a neutrophil chemotactic agent? Leukotriene B4 (LTB4)
(neutrophils arrive B4 others) "<img src=""8088.png"">" Musculoskeletal,-
What effect do leukotrienes C4, D4, and E4 have on the bronchi and the bronchioles?
They increase bronchial tone "<img src=""8088.png"">" Musculoskeletal,-
What are two effects exerted by prostacyclin (PGI2)? Inhibition of platelet
aggregation (PGI2 is a Platelet-Gathering Inhibitor) and vasodilation (decreases
vascular tone) "<img src=""8088.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue arachidonic-acid-pathway pharmacology
A pregnant woman begins to feel contractions. What prostaglandins are responsible
for this? Prostaglandin E2 and F2 (both increase uterine tone) "<img
src=""8088.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue arachidonic-
acid-pathway pharmacology
An asthmatic patient's symptoms are due to increased bronchial tone. What
leukotriene-targeting medications can help him to feel better? Montelukast and
zafirlukast (antagonize leukotriene receptors) and zileuton (5-lipoxygenase
inhibitor blocking leukotriene synthesis) "<img src=""8088.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue arachidonic-acid-pathway
pharmacology
What mechanism of action do corticosteroids have on the arachidonic acid pathway?
They specifically inhibit phospholipase A2 (synthesis of arachidonic acid
from membrane phospholipids) "<img src=""8088.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue arachidonic-acid-pathway pharmacology
What two drugs inhibit leukotrienes from increasing bronchial tone? Zafirlukast
and montelukast "<img src=""8088.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue arachidonic-acid-pathway pharmacology
In the arachidonic acid pathway, NSAIDs prevent the formation of what immediate
products and, subsequently, what downstream products? NSAIDs inhibit COX-1 and COX-
2, blocking cyclic endoperoxide formation and downstream prostacyclin,
prostaglandin, and thromboxane synthesis "<img src=""8088.png"">"
pharmacology
What product of the arachidonic acid cascade promotes platelet aggregation and
increases vascular tone? Thromboxane A2 "<img src=""8088.png"">"
pharmacology
What painkillers work on the COX enzymes to reduce pain and inflammation?
NSAIDs, acetaminophen, aspirin, COX-2 inhibitors (celecoxib) "<img
Which NSAIDs inhibit only COX-2? Celecoxib (All other NSAIDs inhibit both COX-1
and COX-2.) "<img src=""8088.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue arachidonic-acid-pathway pharmacology
Aspirin is used as an antiplatelet agent to reduce the risk of strokes or
myocardial infarctions. What is the mechanism? It inhibits the production of
thromboxane by reducing cyclic endoperoxide synthesis, reducing both platelet
aggregation and vascular tone "<img src=""8088.png"">" Musculoskeletal,-Skin,-
What specific reaction is catalyzed by 5-lipoxygenase? The conversion of
arachidonic acid into 5-HPETE, a leukotriene precursor "<img src=""8088.png"">"
pharmacology
Cyclic endoperoxides are derived from what precursor molecule? Arachidonic acid,
via the cyclooxygenase enzymes (COX-1 and COX-2) "<img src=""8088.png"">"
pharmacology
Why is epoprostenol sometimes used in the treatment of pulmonary hypertension?
It is a PGI2 analog, which acts to reduce vascular tone (vasodilate) and
inhibit platelet aggregation "<img src=""8088.png"">" Musculoskeletal,-Skin,-
Alprostadil is a synthetic variant of which prostaglandin? What does it do? PGE1;
it decreases vascular tone "<img src=""8088.png"">" Musculoskeletal,-Skin,-
Dinoprostone is a synthetic variant of which prostaglandin? What does it do? PGE2;
it increases uterine tone "<img src=""8088.png"">" Musculoskeletal,-Skin,-
Carboprost is a synthetic variant of which prostaglandin? What does it do? PGF2;
it increases uterine tone "<img src=""8088.png"">" Musculoskeletal,-Skin,-
In contrast to the other COX-1 and COX-2 inhibitors, what is unique about aspirin
in how it interacts with the enzymes? Its inhibition is irreversible "<img
A patient takes acetaminophen for a headache. What is the mechanism of action by
which it treats the pain? Acetaminophen reversibly inhibits cyclooxygenase,
mainly in the central nervous system (It is inactivated peripherally.) "<img
src=""8089.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue acetaminophen
pharmacology
Acetaminophen has antipyretic and analgesic effects, but lacks what other property
that is common to NSAIDs? Anti-inflammatory properties "<img src=""8089.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue acetaminophen pharmacology
A man overdoses on acetaminophen as a suicide attempt. What is a result of
acetaminophen toxicity? What is the mechanism? Hepatic necrosis; its metabolite
NAPQI depletes glutathione and forms toxic byproducts in the liver "<img
src=""8089.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue acetaminophen
pharmacology
A man overdoses on acetaminophen as a suicide attempt. What is the treatment?
Treat with N-acetylcysteine (regenerates glutathione)"<img src=""8089.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue acetaminophen pharmacology
Your patient wants to take aspirin for anti-inflammatory purposes. What dose do you
recommend? A high dose, or about 24004000 mg/day "<img src=""8090.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue aspirin pharmacology
Aspirin decreases synthesis of which two products? Thromboxane A2 (TXA2) and
prostaglandins "<img src=""8090.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue aspirin pharmacology
What effect does aspirin have on prothrombin time (PT), partial prothrombin time
(PTT), and bleeding time? Aspirin has no effect on PT or PTT, but increases
bleeding time until new platelets are produced "<img src=""8090.png"">"
Your patient with a history of two heart attacks requires long-term aspirin
therapy. What dose do you prescribe? A low dose, or less than 300 mg/day (all
that is necessary for adequate inhibition of platelet aggregation) "<img
src=""8090.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue aspirin
pharmacology
A 25-year-old man has a bothersome headache and a fever. What dose of aspirin can
you prescribe to help relieve his fever and pain? An intermediate dose, about
3002400 mg/d (for analgesic or antipyretic effects) "<img src=""8090.png"">"
A man develops acute renal failure, interstitial nephritis, gastric ulcers and
bleeding. What painkiller might he be taking? Aspirin (All are side effects
associated with long-term use.) "<img src=""8090.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue aspirin pharmacology
Your pediatrician warns you not to give your 4-year-old son aspirin for fevers
while he has chickenpox. Why? What can you use instead? Aspirin administered to
children can cause Reye syndrome; acetaminophen can be used instead "<img
src=""8090.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue aspirin
pharmacology
In a suicide attempt, a man overdoses on a medication. He has tinnitus, dyspnea,
and metabolic acidosis. What did he take? Aspirin "<img src=""8090.png"">"
A man overdoses on aspirin and develops tinnitus. What neurologic damage is
responsible for this? Damage to CN VIII "<img src=""8090.png"">"
What is aspirin's mechanism of action? Irreversible inhibition of cyclooxygenase
(both COX-1 and COX-2) via covalent acetylation "<img src=""8090.png"">"
In early overdose of aspirin, what is the first acid-base abnormality seen? What
does it transition to? Respiratory alkalosis; it becomes a mixed respiratory
alkalosis and metabolic acidosis later on "<img src=""8090.png"">"
How does celecoxib differ from other NSAIDs? It reversibly inhibits COX-2 in
inflammatory cells and blood vessels, has less affinity for COX-1 (fewer GI and
platelet effects) "<img src=""8091.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue celecoxib pharmacology
For which diseases are COX-2 inhibitors indicated? Rheumatoid arthritis and
osteoarthritis "<img src=""8091.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue celecoxib pharmacology
What common allergy precludes patients from using cyclooxygenase 2 (COX-2)
inhibitors? Sulfa allergy "<img src=""8091.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue celecoxib pharmacology
A patient is concerned about the long-term use of selective cyclooxygenase 2 (COX-
2) inhibitors. Why is this? COX-2 inhibitors increase the risk of thrombosis
(They do not inhibit platelet function, as TXA2 production depends on COX-1.)
celecoxib pharmacology
To which class of drugs do ibuprofen, naproxen, indomethacin, ketorolac,
diclofenac, meloxicam, and piroxicam belong? What are their uses? NSAIDs,
which are antipyretic, antiinflammatory, and analgesic drugs "<img
src=""8092.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue NSAIDs
pharmacology
What is an NSAID's mechanism of action? An NSAID causes reversible inhibition of
cyclooxygenase (both COX-1 and COX-2), blocking prostaglandin synthesis "<img
src=""8092.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue NSAIDs
pharmacology
In a newborn, on day 3 of life, a machine-like murmur is heard on auscultation.
What NSAID should be administered to eliminate the murmur? Indomethacin, an NSAID
that closes a patent ductus arteriosus "<img src=""8092.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue NSAIDs pharmacology
What are the side effects of NSAIDs? Interstitial nephritis, gastric ulcers
(Prostaglandins protect gastric mucosa.); renal ischemia (Prostaglandins dilate
afferent arterioles.) "<img src=""8092.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue NSAIDs pharmacology
What enzyme does leflunomide reversibly inhibit? Dihydroorotate dehydrogenase
leflunomide pharmacology
A patient with rheumatoid arthritis takes a medication that inhibits dihydroorotate
dehydrogenase. How does this help to treat his disease? Inhibition of this
enzyme decreases pyrimidine synthesis, limiting cell proliferation (specifically of
T cells); the drug is leflunomide "<img src=""8093.png"">" Musculoskeletal,-
Skin,-and-Connective-Tissue leflunomide pharmacology
For what diseases is leflunomide indicated? Psoriatic arthritis, rheumatoid
arthritis "<img src=""8093.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue leflunomide pharmacology
What are some of the side effects of leflunomide? Teratogenicity,
hepatotoxicity, diarrhea, hypertension "<img src=""8093.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue leflunomide pharmacology
By what mechanism do ibandronate, alendronate, risedronate, and zoledronate work?
They are pyrophosphate analogs that bind hydroxyapatite in bone and inhibit
the activity of osteoclasts "<img src=""8094.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue bisphosphonates pharmacology
Aside from osteoporosis, what are other clinical indications for use of
bisphosphonates? Hypercalcemia, Paget disease of bone, metastatic bone disease,
and osteogenesis imperfecta "<img src=""8094.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue bisphosphonates pharmacology
What are the side effects of bisphosphonates? Corrosive esophagitis, jaw
osteonecrosis, and atypical stress fractures "<img src=""8094.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue bisphosphonates pharmacology
An Asian woman takes alendronate (an oral bisphosphonate) for osteoporosis but
develops esophagitis. How can this be avoided? By taking it with lots of water and
staying upright for at least 30 minutes afterward "<img src=""8094.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue bisphosphonates pharmacology
A patient with osteoporosis receives a PTH analog that promotes bone growth
subcutaneously each day. What cells are stimulated by this drug? Osteoblasts
(Teriparatide increases osteoblast activity.) "<img src=""8095.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue pharmacology teriparatide
A patient with osteoporosis takes a PTH analog that promotes bone growth. This may
increase her risk of which electrolyte derangement? Transient hypercalcemia (The
drug is teriparatide.) "<img src=""8095.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue pharmacology teriparatide
How does the efficacy of teriparatide compare with that of other antiresorptive
therapies? Teriparatide more effectively promotes bone growth than other
antiresorptive therapies (such as bisphosphonates) "<img src=""8095.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue pharmacology teriparatide
A patient has a fourth gout flare. He takes low-dose aspirin to relieve the pain.
How does aspirin contribute to gout? Low-dose aspirin decreases uric acid
clearance and thus increases the risk of gout flares; high-dose aspirin inhibits
uric acid reabsorption "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue gout-drugs pharmacology
A patient has an acute attack of gout. What medications provide rapid pain relief?
NSAIDS (naproxen or indomethacin), glucocorticoids (oral, intra-articular, or
parenteral), colchicine "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
What is the mechanism of action of colchicine? It stabilizes tubulin and stops
microtubules from polymerizing, thus preventing leukocyte chemotaxis and
degranulation "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
What are the side effects of colchicine? GI upset "<img src=""8096.png"">"
Musculoskeletal,-Skin,-and-Connective-Tissue gout-drugs pharmacology
A patient with lymphoma starts chemotherapy. Why might it be helpful to also give
this patient allopurinol? Chemotherapy invokes tumor lysis, releasing purines
and causing urate nephropathy; allopurinol prevents this by blocking urate
production "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue gout-drugs pharmacology
What is the mechanism of action of pegloticase? How is it used in the treatment of
gout? It is a recombinant uricase that catalyzes the metabolism of uric acid to
allantoin (more water-soluble); it is used to prevent gout "<img src=""8096.png"">"
Allopurinol increases serum levels of which drugs if taken concurrently?
Azathioprine and 6-MP (both metabolized by xanthine oxidase, which is
inhibited by allopurinol) "<img src=""8096.png"">" Musculoskeletal,-Skin,-
and-Connective-Tissue gout-drugs pharmacology
What is the mechanism of action of allopurinol? What medication works the same way?
It is a competitive xanthine oxidase inhibitor, decreasing the conversion of
hypoxanthine and xanthine into urate; febuxostat "<img src=""8096.png"">"
A man with chronic gout who is taking probenecid gets a kidney stone. How might
this have happened? Probenecid blocks the reabsorption of uric acid in the
proximal convoluted tubule, predisposing him to urate stones "<img
src=""8096.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue gout-drugs
pharmacology
A man with chronic gout who is taking probenecid has strep throat. How do you
administer penicillin differently? The penicillin dose should be lowered, as
probenecid inhibits the secretion of penicillin by the kidney "<img
src=""8096.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue gout-drugs
pharmacology
A man with gastritis presents with a painful big toe. Joint fluid analysis shows
needle-shaped negatively birefringent crystals. Treatment? Corticosteroids or
colchicine for his acute gout flare; avoid NSAIDs in patients such as this one with
gastric upset "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
A patient with a history of renal stones and hyperuricemia develops chronic gout.
Which class(es) of drugs best prevent(s) gouty attacks? Xanthine oxidase
inhibitors (eg, allopurinol, febuxostat); avoid uricosuric agents such as
probenecid and aspirin "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
While NSAIDs can be used to treat acute gout flares, salicylates such as aspirin
are typically avoided. Why? All but the highest doses depress uric acid
clearance, and even high doses (in the range of 56 g/day) have only minor
uricosuric activity "<img src=""8096.png"">" Musculoskeletal,-Skin,-and-
What is etanercept, and what is its mechanism of action? A fusion protein (TNF-,
receptor + IgG1 Fc) produced by recombinant DNA and acting as a tumor necrosis
factor decoy receptor "<img src=""8097.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue pharmacology tnf-a-inhibitors
What is etanercept used for? Rheumatoid arthritis, psoriasis, ankylosing
spondylitis "<img src=""8097.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue pharmacology tnf-a-inhibitors
What are infliximab and adalimumab? Anti-tumor necrosis factor- monoclonal
antibodies "<img src=""8097.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue pharmacology tnf-a-inhibitors
What diseases are managed with infliximab and adalimumab? Inflammatory bowel
disease, rheumatoid arthritis, ankylosing spondylitis, psoriasis "<img
src=""8097.png"">" Musculoskeletal,-Skin,-and-Connective-Tissue pharmacology
tnf-a-inhibitors
How do tumor necrosis factor- inhibitors reactivate latent tuberculosis
infections? Inhibiting TNF will stop granulomas from stabilizing and enclosing TB
pharmacology tnf-a-inhibitors
An immigrant has hemoptysis after having been given a TNF- inhibitor. What is your
first concern for this patient? Inhibition of TNF may have reactivated a latent
TB infection "<img src=""8097.png"">" Musculoskeletal,-Skin,-and-
Connective-Tissue pharmacology tnf-a-inhibitors
What test should every patient receiving a TNF- inhibitor have before starting it?
Purified protein derivative test to check for latent TB "<img
tnf-a-inhibitors
A man receiving chemotherapy has renal failure. Urinalysis shows urate
precipitates. A recombinant form of which enzyme can help treat him? Uricase
(Rasburicase is the recombinant form of this enzyme.); this patient has tumor lysis
syndrome "<img src=""8098.png"">" Musculoskeletal,-Skin,-and-Connective-
Tissue pharmacology rasburicase
What is the mechanism of action of rasburicase? It is a recombinant form of
uricase, which catalyzes the metabolism of uric acid to allantoin "<img
rasburicase
The notochord induces overlying ectoderm to differentiate into what line of cells?
These cells then go on to form what structure? Neuroectoderm; the neural plate
"<img src=""8099.png"">" embryology neural-development neurology
The neural plate gives rise to the neural tube and what line of cells? Neural crest
cells "<img src=""8099.png"">" embryology neural-development neurology
Is the alar plate dorsal or ventral? Does it contain motor or sensory neurons?
Dorsal; sensory "<img src=""8099.png"">" embryology neural-development
neurology
Is the basal plate dorsal or ventral? Does it contain motor or sensory neurons?
Ventral; motor "<img src=""8099.png"">" embryology neural-development
neurology
The nucleus pulposus of the intervertebral disc in adults is derived from what
structure? Notochord "<img src=""8099.png"">" embryology neural-development
neurology
When in fetal development does ectoderm differentiate into the neural tube and
neural crest cells and establish the dorsal-ventral axis? The first trimester,
days 18 to 21 "<img src=""8099.png"">" embryology neural-development
neurology
Name the three primary vesicles of the developing brain. Prosencephalon
(forebrain), mesencephalon (midbrain), rhombencephalon (hindbrain) "<img
src=""8100.png"">" embryology neurology regional-specification-of-developing-
brain
What does the prosencephalon split into? Telencephalon (cerebral hemispheres) and
diencephalon (thalamus, hypothalamus) "<img src=""8100.png"">" embryology
neurology regional-specification-of-developing-brain
What are the adult derivatives of the diencephalon in the developing brain? Specify
the walls and cavities. Thalamus and hypothalamus (walls) and the third ventricle
(cavities) "<img src=""8100.png"">" embryology neurology regional-
specification-of-developing-brain
What does the mesencephalon split into? What does it eventually become in the adult
brain? Nothing; it eventually becomes the midbrain and cerebral aqueduct
"<img src=""8100.png"">" embryology neurology regional-specification-of-
developing-brain
What does the rhombencephalon split into? What does it eventually become in the
adult brain? It splits into the metencephalon (eventually becoming the pons
and cerebellum) and myelencephalon (eventually becoming the medulla) "<img
brain
What does the telencephalon become in the adult brain? Specify the walls and
cavities. Cerebral hemispheres (walls) and lateral ventricles (cavities) "<img
brain
What does the mesencephalon become in the adult brain? Specify the walls and
cavities. Midbrain (walls) and aqueduct (cavities) "<img src=""8100.png"">"
embryology neurology regional-specification-of-developing-brain
What does the metencephalon become in the developing brain? Specify the walls and
cavities. Pons and cerebellum (walls) and upper part of the fourth ventricle
What does the myelencephalon become in the developing brain? Specify the walls and
cavities. The medulla (walls) and the lower part of the fourth ventricle
A fetus' myelencephalon fails to grow. Communication with what structure distal to
it will likely be affected? The spinal cord "<img src=""8100.png"">"
embryology neurology regional-specification-of-developing-brain
To which four cell types does the neuroectoderm give rise? CNS neurons, ependymal
cells, oligodendroglia, astrocytes "<img src=""8101.png"">" cns/pns-origins
embryology neurology
What cells make up the inner lining of the ventricles? Ependymal cells "<img
src=""8101.png"">" cns/pns-origins embryology neurology
From which embryonic layer do microglia originate? The mesoderm (Microglia, like
Macrophages, originate from Mesoderm.) "<img src=""8101.png"">" cns/pns-
origins embryology neurology
What is the function of ependymal cells? Ependymal cells make cerebrospinal fluid
"<img src=""8101.png"">" cns/pns-origins embryology neurology
Which two types of cells of the nervous system are derived from neural crest cells?
Schwann cells and peripheral nervous system neurons "<img src=""8101.png"">"
cns/pns-origins embryology neurology
Central nervous system neurons derive from what embryologic structure? What about
peripheral nerves? Neuroectoderm; neural crest "<img src=""8101.png"">"
A pt has a CNS injury with gliosis. What is the embryonal origin of the cell
involved? Mesoderm (Microglia are involved.) "<img src=""8101.png"">"
When must the neuropore fuse to avoid neural tube defects? If fusion fails,
generally speaking, what type of defect remains? By the 4th week of gestation;
if fusion fails, there will be a persistent hole between the spinal canal and
amniotic cavity "<img src=""8102.png"">" embryology neural-tube-defects
neurology
How can a mother reduce the risk of neural tube defect formation in her fetus?
Take folate supplements to avoid low levels both before conception and during
pregnancy "<img src=""8102.png"">" embryology neural-tube-defects neurology
Why is acetylcholinesterase (AchE) elevated in amniotic fluid of a fetus with a
meningomyelocele? Fetal AchE will flow out of the pore from the spinal cord into
the amniotic fluid "<img src=""8102.png"">" embryology neural-tube-
defects neurology
What is the most common neural tube defect? Spina bifida occulta "<img
src=""8102.png"">" embryology neural-tube-defects neurology
What lab abnormalities would you expect in the maternal serum and amniotic fluid of
a woman carrying a fetus with a meningocele? Increased AFP in amniotic fluid and
maternal serum; increased acetylcholinesterase in amniotic fluid "<img
A mother sees a tuft of hair over the lower vertebrae of her newborn. What is
associated with this? Spina bifida occulta and skin dimples are associated with
this "<img src=""8102.png"">" embryology neural-tube-defects neurology
In a pt with spina bifida occulta, what is the maternal serum level and amniotic
level of AFP? Why? Normal; the meninges closed over the spinal cord within the
canal, thus cutting off the spinal canal from the amniotic fluid "<img
A 43-year-old pregnant woman is found to have high serum -fetoprotein. What other
test do you order to confirm the diagnosis? Measurement of AChE in amniotic
fluid because a high level indicates a neural tube defect "<img src=""8102.png"">"
embryology neural-tube-defects neurology
What is the relation of the meninges and spinal cord in a meningomyelocele? In a
meningomyelocele, both the spinal cord and meninges extrude from the bony defect
"<img src=""8102.png"">" embryology neural-tube-defects neurology
What is the relation of the meninges and spinal cord in a meningocele? In a
meningocele, the spinal cord is within the bony canal, but the meninges extrude
through the bony defect "<img src=""8102.png"">" embryology neural-tube-
defects neurology
An infant has cyclopia. What pathway is responsible for this finding? What is the
clinically milder presentation of this mutation? The sonic hedgehog signaling
pathway; cleft lip and palate "<img src=""8103.png"">" embryology forebrain-
anomalies neurology
An infant has a semilobar brain and a cleft palate. What conditions are associated
with these findings? Patau syndrome, fetal alcohol syndrome "<img
src=""8103.png"">" embryology forebrain-anomalies neurology
A baby has a malformation of the anterior neural tube causing agenesis of the
forebrain and calvarium. What condition is this? Anencephaly "<img
A fetus lacks a forebrain. Which molecule is increased in the amniotic fluid?
-Fetoprotein "<img src=""8103.png"">" embryology forebrain-
anomalies neurology
A fetus with anencephaly has polyhydramnios. Why? Amniotic fluid has
accumulated due to a lack of brain function that allows the fetus to swallow the
fluid "<img src=""8103.png"">" embryology forebrain-anomalies neurology
What maternal complications are associated with anencephaly? Is there anything the
mother can do to reduce her fetus' risk of this? Maternal type 1 diabetes, low
folate levels; yes, she can take folate supplements to lower the risk "<img
A baby is born with one midline eye. What is the diagnosis?Holoprosencephaly "<img
An infant has cyclopia. At what time should the brain have split into two separate
hemispheres? Cerebral hemispheric separation should have occurred during weeks
5 and 6 "<img src=""8103.png"">" embryology forebrain-anomalies neurology
An infant with hydrocephalus is found, on MRI, to have low-lying cerebellar tonsils
and aqueductal stenosis. Where else should you scan? Thoracic and lumbar areas
should be scanned to rule out myelomeningocele. (This patient has a Chiari II
malformation.) "<img src=""8104.png"">" embryology neurology posterior-
fossa-malformations
An infant has agenesis of the cerebellar vermis with cystic enlargement of the
fourth ventricle. Diagnosis? Dandy-Walker malformation "<img src=""8104.png"">"
embryology neurology posterior-fossa-malformations
An infant with hydrocephalus, cerebellar tonsil herniation, and aqueductal stenosis
has lower limb weakness. What is the diagnosis? Chiari II malformation: An
associated lumbosacral meningomyelocele can cause weakness/sensory loss at and
below the level of the lesion "<img src=""8104.png"">" embryology neurology
posterior-fossa-malformations
An infant has a Dandy-Walker malformation. What other associated malformations
might you find? Hydrocephalus, spina bifida "<img src=""8104.png"">"
embryology neurology posterior-fossa-malformations
A pt has loss of pain and temperature sensation in both arms. What tracts are
affected in syringomyelia? Fibers that cross the anterior white commissure of
the spinothalamic tract "<img src=""8105.png"">" embryology neurology
syringomyelia
A pt has loss of pain and temperature sensation in both arms. Why is light touch
preserved in syringomyelia? The spinothalamic tract is affected first; the dorsal
columns are typically preserved "<img src=""8105.png"">" embryology
neurology syringomyelia
A pt has progressive bilateral arm numbness, headaches, and ataxia. What is the
diagnosis? Chiari I malformation with syrinx "<img src=""8105.png"">"
embryology neurology syringomyelia
You see a pt in whom pain and temperature sensation in the hands have been lost,
but the sense of touch is intact. Where is the lesion? The lesion is most
commonly found at C8T1 (The cape-like distribution of syringomyelia is described.)
"<img src=""8105.png"">" embryology neurology syringomyelia
What neurologic malformation is commonly associated with syringomyelia? Chiari
type I malformation (cerebellar tonsillar ectopia of greater than 3 to 5 mm) "<img
src=""8105.png"">" embryology neurology syringomyelia
How do most children with Chiari I malformations typically present? Most are
free of symptoms, although they sometimes have headaches and cerebellar symptoms
"<img src=""8105.png"">" embryology neurology syringomyelia
What cranial nerve (CN) mediates taste in the anterior two thirds of tongue? The
posterior third? CN VII mediates taste in the anterior two thirds of the tongue;
CN IX mediates taste in the posterior third "<img src=""8106.png"">"
embryology neurology tongue-development
What cranial nerve (CN) mediates sensation in the anterior two thirds of the
tongue? The posterior third? CN V3 mediates sensation in the anterior two thirds
of the tongue; CN IX mediates sensation in the posterior third "<img
src=""8106.png"">" embryology neurology tongue-development
Which cranial nerve(s) supply(ies) motor innervation to the tongue? Cranial
nerves X and XII "<img src=""8106.png"">" embryology neurology tongue-
development
What muscles make up the tongue and what cranial nerves (CN) supply them? The
palatoglossus muscle is supplied by CN X; the hyoglossus, genioglossus, and
styloglossus muscles are supplied by CN XII "<img src=""8106.png"">"
Which cranial nerve(s) mediate(s) the sense of taste? Which brain stem nucleus
moderates the nerve(s)? Cranial nerves VII, IX, and X mediate taste; the solitary
nucleus moderates the nerves "<img src=""8106.png"">" embryology neurology
tongue-development
Which cranial nerve(s) mediate(s) the sense of pain in the tongue? Cranial
nerves V3, IX, and X "<img src=""8106.png"">" embryology neurology tongue-
development
Which muscle retracts and depresses the tongue? Which cranial nerve (CN) innervates
this muscle? Hyoglossus muscle; CN XII "<img src=""8106.png"">"
A boy is amazed that his friend can roll his tongue into a U shape. Which muscle
allows him to do this? Which nerve innervates this muscle? Styloglossus muscle
(draws the sides of the tongue up to form a trough to hold food to be swallowed);
CN XII "<img src=""8106.png"">" embryology neurology tongue-development
A pt sticks out her tongue to show you her new tongue piercing. Which nerve and
muscle are involved in this action? CN XII and the genioglossus muscle, which
protrudes the tongue "<img src=""8106.png"">" embryology neurology tongue-
development
Which muscle of the tongue is the only one NOT innervated by cranial nerve (CN)
XII? Which CN innervates it? Function? The palatoglossus muscle, which is
innervated by CN X, elevates the posterior tongue in swallowing "<img
What part of the tongue is formed by the first and second branchial arches? By the
third and fourth branchial arches? Anterior two thirds; posterior third "<img
Are neurons permanent or labile? Do they divide in adulthood? Permanent; they do
not divide "<img src=""8107.png"">" anatomy-and-physiology neurology neurons
What part of a neuron receives input? What part sends output? Dendrites; axons
"<img src=""8107.png"">" anatomy-and-physiology neurology neurons
Describe Wallerian degeneration. Is axon regeneration possible in the peripheral
nervous system (PNS)? In the central nervous system (CNS)? An axon degenerates
distally to an injury and retracts proximally; axonal regeneration is possible in
the PNS but not in the CNS "<img src=""8107.png"">" anatomy-and-physiology
neurology neurons
A neuron is stained with Nissl stain. What parts of the neuron are stained and
unstained? Why? Cell bodies and dendrites are stained; axons are not stained
because they lack RER "<img src=""8107.png"">" anatomy-and-physiology
neurology neurons
A brain specimen shows neural injury and GFAP-staining cells. What is this
response, and which cells are involved? Reactive gliosis; astrocytes "<img
src=""8108.png"">" anatomy-and-physiology astrocytes neurology
What are the many responsibilities of an astrocyte? Physical support, repair, K+
metabolism, excess neurotransmitter removal, part of blood-brain barrier, glycogen
reserve buffer "<img src=""8108.png"">" anatomy-and-physiology astrocytes
neurology
A biopsy specimen of a brain tumor stains positive for GFAP. What type of tumor is
it? From what germinal layer did it arise? Astrocytoma; neuroectoderm "<img
src=""8108.png"">" anatomy-and-physiology astrocytes neurology
What is the histologic appearance of microglia? They have small, irregular nuclei
and relatively little cytoplasm; they are not readily discernible by Nissl staining
"<img src=""8109.png"">" anatomy-and-physiology microglia neurology
A man with AIDS has multinucleated giant cells detected on brain biopsy. What kind
of cells are these? Microglia "<img src=""8109.png"">" anatomy-and-
physiology microglia neurology
A boy develops bacterial meningitis. Which cells of the brain react? What is their
embryologic origin? Microglia become large phagocytic cells; mesoderm "<img
src=""8109.png"">" anatomy-and-physiology microglia neurology
What does myelin do to an axon's space constant? To its conduction velocity? Myelin
wraps around an axon and increases both the space constant and conduction velocity
"<img src=""8110.png"">" anatomy-and-physiology myelin neurology
How do signals travel along an axon? An action potential travels through the
axon via saltatory conduction, jumping across nodes of Ranvier, which are Na+
channel rich "<img src=""8110.png"">" anatomy-and-physiology myelin
neurology
In demyelinating disease of the central nervous system, what cell type is involved,
and what is the functional deficit? Oligodendrocytes; conduction velocity of
signals decreases with myelin loss "<img src=""8110.png"">" anatomy-and-
physiology myelin neurology
What type of cells myelinate axons of the peripheral nervous system? How many axons
do each of these myelinate? Schwann cells; each cell wraps around one axon "<img
src=""8111.png"">" anatomy-and-physiology neurology schwann-cells
A man with hearing loss has a mass in the internal acoustic meatus. From which cell
type is it derived? What nerve is involved? Diagnosis? Schwann cells; CN VIII;
acoustic (vestibular) schwannoma "<img src=""8111.png"">" anatomy-and-
physiology neurology schwann-cells
In Guillain Barr syndrome, what cells are injured, and what is the functional
deficit? Schwann cells; axonal conduction velocity decreases with demyelination
of peripheral axons "<img src=""8111.png"">" anatomy-and-physiology
neurology schwann-cells
What cell type is important in axonal regeneration in peripheral nerves? From what
embryologic structure is it derived? Schwann cell; neural crest cells "<img
src=""8111.png"">" anatomy-and-physiology neurology schwann-cells
A 42-year-old woman is diagnosed with multiple sclerosis. Which cells are
specifically damaged in this disease? Oligodendrocytes (These cells are
attacked in an autoimmune process resulting in demyelination.) "<img
src=""8112.png"">" anatomy-and-physiology neurology oligodendroglia
A man has progressive multifocal leukoencephalopathy (PML). What do the cells look
like histologically? "Oligodendrocytes have a ""fried egg"" appearance, with
small nuclei, dark chromatin, and little cytoplasm" "<img src=""8112.png"">"
anatomy-and-physiology neurology oligodendroglia
How many axons does each oligodendrocyte myelinate? About 30 "<img
src=""8112.png"">" anatomy-and-physiology neurology oligodendroglia
An infant boy develops leukodystrophy. What is the embryologic origin of the cells
that are affected in this disease? Oligodendrocytes originate from neuroectoderm
"<img src=""8112.png"">" anatomy-and-physiology neurology
oligodendroglia
A man has progressive multifocal leukoencephalopathy (PML). How prevalent are the
implicated cells in white matter? Oligodendrocytes make up the majority of cells
in white matter "<img src=""8112.png"">" anatomy-and-physiology neurology
oligodendroglia
What are the five receptor types in sensory corpuscles? Free nerve endings,
Meissner corpuscles, Pacinian corpuscles, Merkel discs, and Ruffini corpuscles
"<img src=""8113.png"">" anatomy-and-physiology neurology sensory-
receptors
What receptor type is involved in fine/light touch? What kind of fibers carry their
signals? Meissner corpuscles (also sense position and dynamic touch); fibers are
large, myelinated, and fast adapting "<img src=""8113.png"">" Neurology
anatomy-and-physiology sensory-receptors
What receptor type dominates glabrous (hairless) skin? The Meissner corpuscle
(Glabrous skin includes the lips and fingertips.) "<img src=""8113.png"">"
Neurology anatomy-and-physiology sensory-receptors
Where are pacinian corpuscles found? What do they sense? Pacinian corpuscles are
found in deep skin layers, ligaments, and joint capsules; they sense vibration and
pressure "<img src=""8113.png"">" Neurology anatomy-and-physiology sensory-
receptors
Describe the key features of the sensory neurons that innervate pacinian
corpuscles. They are fast-adapting, large, myelinated fibers "<img
src=""8113.png"">" Neurology anatomy-and-physiology sensory-receptors
Which skin receptors detect the edge of a knife or table? What features do the
sensory neurons that innervate them have? Merkel discsinnervated by large,
myelinated, slowly adapting fibers. (It is evolutionarily disadvantageous to adapt
to a blade edge!) "<img src=""8113.png"">" Neurology anatomy-and-physiology
sensory-receptors
Merkel discs are large, slowly adapting myelinated fibers that respond to what
three senses? Deep static touch (eg, shapes, edges, textures), pressure, and
position "<img src=""8113.png"">" Neurology anatomy-and-physiology sensory-
receptors
A man burns his hand on a stove. He first feels burning, then a steady pain. What
type of sensory neurons transmit these sensations? Free nerve endings for A
(fast and myelinated) and C (slow and unmyelinated) sensory neuron fibers "<img
src=""8113.png"">" Neurology anatomy-and-physiology sensory-receptors
Of the sensory corpuscles, name the only receptor type that is unmyelinated. C
fibers of free nerve endings "<img src=""8113.png"">" Neurology anatomy-and-
physiology sensory-receptors
What type of sensory corpuscle can be found throughout the skin (as well as some
viscera), and what does it sense? Free nerve endings (for C and A sensory neuron
fibers); pain and temperature "<img src=""8113.png"">" Neurology anatomy-and-
A woman puts her hand on an active stove. Which fibers sense the heat from the
stove? C and A fibers (for free nerve endings) "<img src=""8113.png"">"
Neurology anatomy-and-physiology sensory-receptors
A man goes rock climbing. What are the traits of Ruffini's corpuscles that help him
grip? Where are they? What do they detect? Slow adapting dendritic fibers in
the finger tips and joints; they detect pressure, slippage of objects, and finger
joint angle changes "<img src=""8113.png"">" Neurology anatomy-and-
A woman recovers from Guillain Barr syndrome. What part of her nerves were damaged
by this disorder? The peripheral nerve endoneurium (which wraps around a single
nerve fiber) developed an inflammatory infiltrate and impaired nerve function
"<img src=""8114.png"">" Neurology anatomy-and-physiology peripheral-
nerve
A surgeon rejoins peripheral nerve endings in limb reattachment surgery.
Microsurgery is needed to reconnect which nerve component? Perineurium (or
Permeability barrier), which surrounds the fascicles of nerve fibers "<img
src=""8114.png"">" Neurology anatomy-and-physiology peripheral-nerve
What is the connective tissue that surrounds the entire peripheral nerve, including
the fascicles and blood supply? The epineurium, which is dense connective
tissue "<img src=""8114.png"">" Neurology anatomy-and-physiology
peripheral-nerve
Where in the brain is dopamine synthesized? The ventral tegmentum and
substantia nigra pars compacta (SNpc) "<img src=""8115.png"">" Neurology
anatomy-and-physiology neurotransmitters
A man is stressed and anxious. What center in the brain is associated with this
response? What neurotransmitter is synthesized there? The locus coeruleus;
norepinephrine "<img src=""8115.png"">" Neurology anatomy-and-physiology
neurotransmitters
Where in the brain is serotonin synthesized? The raphe nucleus "<img
src=""8115.png"">" Neurology anatomy-and-physiology neurotransmitters
Where in the brain is acetylcholine synthesized? The basal nucleus of Meynert
"<img src=""8115.png"">" Neurology anatomy-and-physiology
neurotransmitters
Which neurotransmitters are modulated in anxiety? Norepinephrine increases
(sympathetic response); serotonin and GABA decrease "<img src=""8115.png"">"
Neurology anatomy-and-physiology neurotransmitters
Which neurotransmitters are modulated in depression? Norepinephrine, dopamine, and
serotonin all decrease; there are no changes in GABA or acetylcholine "<img
A pt and his family have early-onset chorea and dementia. What happens to dopamine,
GABA, and acetylcholine levels in this condition? Dopamine levels increase, and
GABA and acetylcholine levels decrease. (This is Huntington disease.) "<img
A man with progressive dementia has Alzheimer disease. Which important
neurotransmitter is decreased in this condition? Acetylcholine "<img
A pt has Parkinson disease. A decrease in which neurotransmitter is involved in the
pathogenesis of this condition? Dopamine "<img src=""8115.png"">"
Neurology anatomy-and-physiology neurotransmitters
A man exhibits shaking, dementia, and bradykinesia. He cannot taste or smell. Which
neurotransmitters are increased and decreased? Serotonin and acetylcholine are
increased, and dopamine is decreased. (He has Parkinson disease.) "<img
What neurotransmitter is elevated in pts with schizophrenia? Dopamine "<img
Where is GABA synthesized? In what two conditions is it decreased? Nucleus
accumbens; anxiety and Huntington disease "<img src=""8115.png"">" Neurology
anatomy-and-physiology neurotransmitters
What two substances slowly cross the blood-brain barrier by a carrier-mediated
transport mechanism? Glucose and amino acids "<img src=""8116.png"">"
Neurology anatomy-and-physiology blood-brain-barrier
A man needs a drug that can penetrate the blood-brain barrier (BBB). The drug must
have what properties to diffuse rapidly across the BBB? The drug must be
nonpolar and lipid soluble "<img src=""8116.png"">" Neurology anatomy-and-
physiology blood-brain-barrier
Name the three blood-tissue barriers found in the body. The blood-brain barrier,
the blood-testis barrier, and the maternal-fetal blood barrier of the placenta
"<img src=""8116.png"">" Neurology anatomy-and-physiology blood-brain-
barrier
Name three specialized brain regions with fenestrated capillaries and no blood-
brain barrier. Identify each region's role. Area postrema (triggers emesis),
organum vasculosum of lamina terminalis (senses osmolarity), and neurohypophysis
(releases ADH into blood) "<img src=""8116.png"">" Neurology anatomy-and-
physiology blood-brain-barrier
Name two scenarios that result in the destruction of blood-brain barrier
endothelial tight junctions and cause vasogenic edema in the brain. Infarction
and/or neoplasm "<img src=""8116.png"">" Neurology anatomy-and-physiology
blood-brain-barrier
A pt vomits after chemotherapy. Which brain structure contributes to this response?
The area postrema, which has fenestrated capillaries and no blood-brain
barrier "<img src=""8116.png"">" Neurology anatomy-and-physiology blood-
brain-barrier
A man is thirsty. A brain region senses this, and his posterior pituitary secretes
ADH. What is the sensor? How does ADH enter circulation? OVLT (osmotic sensor);
the neurohypophysis has fenestrated capillaries and lacks a BBB, so secretory
products can reach the circulation "<img src=""8116.png"">" Neurology anatomy-
and-physiology blood-brain-barrier
You are concerned that a toxin may be able to cross the blood-brain barrier. Would
testing the CSF for this toxin be of any value? Yes, because CSF bathes the brain,
and toxins permeating the blood-brain barrier would likely appear in the CSF "<img
src=""8116.png"">" Neurology anatomy-and-physiology blood-brain-barrier
A boy is very thirsty. Central control for thirst and water balance is found in
what part of the brain? Which hormone is involved? The supraoptic nucleus of the
hypothalamus; ADH "<img src=""8117.png"">" Neurology anatomy-and-physiology
hypothalamus
A woman has severe anorexia. What area of her hypothalamus is abnormal? What does
it normally do? The lateral area (If you zap your lateral area, you shrink
laterally.); normally, the lateral area stimulates appetite"<img src=""8117.png"">"
Neurology anatomy-and-physiology hypothalamus
"A boy has ""the munchies."" What part of his hypothalamus is being stimulated?
What hormones stimulate and inhibit this area?" The lateral area; it is stimulated
by ghrelin and inhibited by leptin "<img src=""8117.png"">" Neurology anatomy-
and-physiology hypothalamus
A woman with severe anorexia is found to have abnormal lateral hypothalamic nuclei
on fMRI. Who else may have this pathology? Infants with failure to thrive
"<img src=""8117.png"">" Neurology anatomy-and-physiology hypothalamus
A child feels full after a meal. What area of the hypothalamus is activated to
trigger this sensation? By what hormone? The ventromedial area; leptin "<img
src=""8117.png"">" Neurology anatomy-and-physiology hypothalamus
Which part of the hypothalamus regulates sympathetic activity and allows you to
feel warm? The posterior hypothalamus (If you zap your posterior hypothalamus, you
become a poikilotherm [cold-blooded, like a snake].) "<img src=""8117.png"">"
A pt with brain damage has difficulty staying warm in cold temperatures. What area
of the brain is affected? The posterior hypothalamus (If you zap your posterior
hypothalamus, you become a poikilotherm [cold-blooded, like a snake].) "<img
A boy develops gradual hyperphagia. MRI shows a mass in his hypothalamus. What
nucleus is being affected? What is the underlying diagnosis? The ventromedial
area (If you zap your ventromedial area, you grow ventrally and medially.); likely
a craniopharyngioma "<img src=""8117.png"">" Neurology anatomy-and-
physiology hypothalamus
A pt has brain damage affecting his circadian rhythms. Which part of the
hypothalamus is affected? Suprachiasmatic nucleus (You need sleep to be
charismatic [chiasmatic].) "<img src=""8117.png"">" Neurology anatomy-and-
physiology hypothalamus
Which part of the hypothalamus regulates parasympathetic activity and allows you to
cool off? The anterior hypothalamus (Anterior nucleus = cool off [cooling,
pArasympathetic]; A/C = anterior cooling.) "<img src=""8117.png"">"
A pt with brain damage has difficulty staying cool in hot temperatures. What area
of the brain is affected? The anterior hypothalamus (Anterior nucleus = cool
off [cooling, pArasympathetic]; A/C = anterior cooling.) "<img src=""8117.png"">"
How does the mnemonic TAN HATS help you remember the major functions of the
hypothalamus? Thirst/water, Adenohypophysis, Neurohypophysis, Hunger,
Autonomics, Temperature, Sexual urges "<img src=""8117.png"">" Neurology
anatomy-and-physiology hypothalamus
A pt eats a large meal. Leptin levels rise in his blood. How does leptin affect the
ventromedial and lateral areas of the hypothalamus? Leptin stimulates the
ventromedial area, promoting a feeling of satiety, and inhibits the lateral area,
blocking the sensation of hunger "<img src=""8117.png"">" Neurology anatomy-
From where are the chemicals ADH and oxytocin released? Both are made in the
hypothalamus; they are carried by neurophysins down axons to the posterior
pituitary, where they are stored/released "<img src=""8117.png"">" Neurology
anatomy-and-physiology hypothalamus
The posterior pituitary receives axonal projections from which two nuclei? Which
chemicals originate from each of these nuclei? Supraoptic nucleus (ADH) and
paraventricular nucleus (oxytocin) "<img src=""8117.png"">" Neurology anatomy-
Where in the central nervous system is the area postrema found? The medulla "<img
A girl is dreaming. How often do REM sleep cycles occur? What is the duration
through the night? What neurotransmitter is elevated in REM? Every 90 minutes;
the duration increases with each cycle; acetylcholine "<img src=""8118.png"">"
Neurology anatomy-and-physiology sleep-physiology
Identify the EEG waveforms for the awake states (eyes open, eyes closed), N1, N2,
N3, and REM sleep, respectively. Beta, Alpha, Theta, Sleep spindles/K complexes,
Delta, Beta (At night, BATS Drink Blood.) "<img src=""8118.png"">" Neurology
anatomy-and-physiology sleep-physiology
Assuming a 20-year-old has perfect sleep habits, what percentage of time is spent
in light sleep? Deeper sleep? Delta sleep? REM sleep? Light sleep (N1): 5%; deeper
sleep (N2): 45%; delta (deepest) sleep (N3): 25%; REM sleep: 25% "<img
src=""8118.png"">" Neurology anatomy-and-physiology sleep-physiology
A 23-year-old grinds her teeth while sleeping. Name the stage, characteristic
waves, and percentage of sleep spent in this stage. Stage N2 (deeper non-REM
sleep); K complexes and sleep spindles; 45% "<img src=""8118.png"">"
A 16-year-old pt sleepwalks. Name the stage, characteristic waves, and percentage
of sleep spent in this stage. Stage N3 (deepest non-REM sleep); delta waves (lowest
frequency, highest amplitude); 25% "<img src=""8118.png"">" Neurology anatomy-
and-physiology sleep-physiology
A 21-year-old pt dreams and loses motor tone. Name the stage, characteristic waves,
and percentage of sleep spent in this stage. REM sleep; beta waves; 25% "<img
A man is awake and alert, and his eyes are open. What EEG waveform would you expect
to see? Beta (highest frequency, lowest amplitude) "<img src=""8118.png"">"
A man is awake, but now his eyes are closed. What EEG waveform would you expect to
see? Alpha waves "<img src=""8118.png"">" Neurology anatomy-and-physiology
sleep-physiology
Which waves have the highest frequency and lowest amplitude? Beta waves "<img
Which waves have the lowest frequency and highest amplitude? Delta waves "<img
You tell a man having trouble sleeping to avoid alcohol, benzodiazepines, and
barbiturates. How do these substances interfere with sleep?By decreasing REM sleep
and non-REM delta wave deep sleep "<img src=""8118.png"">" Neurology anatomy-
and-physiology sleep-physiology
How does norepinephrine affect REM sleep? It decreases REM sleep "<img
Which brain area is responsible for the rapid eye movements of REM sleep?
Paramedian pontine reticular formation/conjugate gaze center "<img
A child wakes up screaming repeatedly during the night. Diagnosis? In what stage of
sleep does this typically happen? Possible treatment? The child has night terrors,
which typically occur during stage N3. Benzodiazepines can reduce the duration of
slow-wave sleep "<img src=""8118.png"">" Neurology anatomy-and-physiology
sleep-physiology
A 10-year-old boy frequently wets the bed. Which drug is used to treat enuresis?
What is its mechanism of action? Oral desmopressin acetate (DDAVP) is the
preferred treatment (vs imipramine, which has more adverse effects); DDAVP
functions like ADH "<img src=""8118.png"">" Neurology anatomy-and-
physiology sleep-physiology
A man is sleeping and enters an REM state. What physiologic changes are likely to
be seen as this occurs? Increased pulse and blood pressure (variable), increased
brain O2 use, penile tumescence, possible memory processing functions "<img
Which nucleus of the hypothalamus drives the circadian rhythm? What environmental
stimulus regulates this nucleus? The suprachiasmatic nucleus; light "<img
The release of which hormones or neurotransmitters is dictated by circadian
rhythms? Adrenocorticotropic hormone (ACTH), prolactin, melatonin, nocturnal
norepinephrine "<img src=""8118.png"">" Neurology anatomy-and-physiology
sleep-physiology
Melatonin release from the pineal gland is triggered by the release of which
neurotransmitter from the suprachiasmatic nucleus? Norepinephrine "<img
A woman has a stroke affecting the lateral geniculate nucleus (LGN). What deficits
will she have? Name this area's input and projections. Visual (Lateral =
Light); input: CN II, output: calcarine sulcus "<img src=""8119.png"">"
Neurology anatomy-and-physiology thalamus
The thalamus relays all ascending sensory information to the cortex except for
what? Olfaction "<img src=""8119.png"">" Neurology anatomy-and-physiology
thalamus
A woman has a stroke affecting the medial geniculate nucleus (MGN). What deficits
will she have? Name this area's input and projections. Auditory (Medial =
Music); input: superior olive and inferior colliculus, output: auditory cortex of
temporal lobe "<img src=""8119.png"">" Neurology anatomy-and-physiology
thalamus
A man has a stroke in the ventral posterolateral (VPL) thalamic nucleus. What are
his expected symptoms? All modalities of skin sensationpain, temperature,
vibration, proprioception, pressure, and light touchwill be impaired "<img
src=""8119.png"">" Neurology anatomy-and-physiology thalamus
A pt has a stroke in the ventral posterolateral thalamic (VPL) nucleus. What tracts
are now blocked from providing input? The spinothalamic tract and dorsal
columns/medial lemniscus "<img src=""8119.png"">" Neurology anatomy-and-
physiology thalamus
A man has a stroke in the ventral posterior nucleus (VPM) of the thalamus. What
deficits will he have as a result? Hemifacial sensory loss and some loss of taste
from his VPM stroke (Makeup goes on the face.) "<img src=""8119.png"">"
A man has a stroke in the ventral posterior nucleus (VPM) of the thalamus. Name
this area's input and projection. Input: trigeminal and gustatory pathways,
output: somatosensory cortex "<img src=""8119.png"">" Neurology anatomy-and-
physiology thalamus
A man has hemimotor weakness from a thalamic stroke. Which area of the thalamus may
be affected? Name the area's input and output. The ventral lateral (VL) nucleus;
input: basal ganglia and cerebellum, output: motor cortex "<img src=""8119.png"">"
What is the ventral posterior (VP) nucleus' thalamic output? What is the ventral
lateral (VL) nucleus' thalamic output? The VP nucleus goes to the primary
somatosensory cortex; the VL nucleus goes to the motor cortex "<img
src=""8119.png"">" Neurology anatomy-and-physiology thalamus
In the thalamus, to what parts of the brain do the lateral geniculate nucleus (LGN)
and medial geniculate nucleus (MGN) relay information? The LGN relays light to
the calcarine sulcus, and the MGN relays sound to the auditory cortex of the
temporal lobe "<img src=""8119.png"">" Neurology anatomy-and-physiology
thalamus
What five structures make up the limbic system? Amygdala, HIPPOcampus, FORnix,
Mammillary BODies, CINGulate Gyrus (A HIPPO FORked My BODy in a CINGle Gesture)
"<img src=""8120.png"">" Neurology anatomy-and-physiology limbic-system
What are the five functions of the limbic system? Feeding, Fighting, Fleeing,
Feeling, and Sex = the famous 5 F's "<img src=""8120.png"">" Neurology anatomy-
and-physiology limbic-system
A pt with schizophrenia has a flat affect and paucity of speech. Decreased activity
of what dopaminergic pathway is responsible? "Mesocortical (These are
""negative"" symptoms.)" "<img src=""8121.png"">" Neurology anatomy-and-
physiology dopaminergic-pathways
A pt with schizophrenia has delusions and hallucinations. Increased activity of
what dopaminergic pathway is responsible? "Mesolimbic (These are ""positive""
symptoms.)" "<img src=""8121.png"">" anatomy-and-physiology dopaminergic-
pathways neurology
What dopaminergic pathway is the primary therapeutic target of antipsychotic drugs?
What is the desired effect of these drugs? "Mesolimbic; inhibition of the
pathway to block ""positive"" symptoms" "<img src=""8121.png"">" anatomy-and-
physiology dopaminergic-pathways neurology
What dopaminergic pathway is most resistant to antipsychotic drugs? Which symptoms
of schizophrenia are most refractory to antipsychotics? "Mesocortical;
""negative"" symptoms, such as flat affect and paucity of speech" "<img
src=""8121.png"">" anatomy-and-physiology dopaminergic-pathways neurology
A pt has dystonia, akathisia, and parkinsonism. Decreased activity of what
dopaminergic pathway is responsible for these symptoms? Nigrostriatal "<img
A schizophrenic woman has low libido and galactorrhea. Prolactin levels are
elevated. What medication is she likely taking? Antipsychotics (dopamine
antagonists), which may be inhibiting the tuberoinfundibular pathway "<img
What is the major dopaminergic pathway in the brain? Nigrostriatal "<img
What cosmetic side effect should men taking antipsychotic medications watch out
for? Inhibition of what pathway is to blame? Gynecomastia; inhibition of the
tuberoinfundibular pathway causes this "<img src=""8121.png"">" anatomy-and-
physiology dopaminergic-pathways neurology
What are the output neurons of the cerebellum? Purkinje cells "<img
src=""8122.png"">" anatomy-and-physiology cerebellum neurology
A man throws a baseball with his right arm. How does the cerebellum receive input
from this motor activity? Right arm information is relayed from the
contralateral (left) motor cortex into the right cerebellum via the middle
cerebellar peduncle "<img src=""8122.png"">" anatomy-and-physiology
cerebellum neurology
A man throws a baseball with his right arm. How will the cerebellum modulate the
motor cortex signals that stimulate the force exerted? Right-sided Purkinje
cells, to deep cerebellar nuclei, to contralateral (left) motor cortex via the
superior cerebellar peduncle "<img src=""8122.png"">" anatomy-and-physiology
cerebellum neurology
A man stands on his right leg for a yoga pose. How does the cerebellum receive
input about his proprioception to maintain this stance? Right leg proprioception
will be relayed via the right dorsal column and enter the right cerebellum via
right inferior cerebellar peduncle "<img src=""8122.png"">" anatomy-and-
physiology cerebellum neurology
The cerebellum receives contralateral input from the cortex via which structure?
Middle cerebellar peduncle "<img src=""8122.png"">" anatomy-and-
A man with a cerebellar stroke keeps falling to the left. Where in the cerebellum
is the lesion? Left lateral cerebellum "<img src=""8122.png"">" anatomy-and-
A man has truncal ataxia, head tilting, wide gait, and nystagmus. Where in the
cerebellum is the lesion? In the middle: Damage to the vermis, fastigial
nuclei, and/or flocculonodular lobe causes bilateral truncal motor deficits "<img
From lateral to medial, name the four deep nuclei of the cerebellum. "Dentate,
Emboliform, Globose, Fastigial (""Don't Eat Greasy Foods."")" "<img
Ipsilateral proprioceptive information from the body reaches the cerebellum via
which structure? Inferior cerebellar peduncle "<img src=""8122.png"">"
anatomy-and-physiology cerebellum neurology
The cerebellum provides stimulatory feedback to the contralateral cortex via which
structure? Superior cerebellar peduncle "<img src=""8122.png"">" anatomy-and-
Which brain area is most involved in voluntary movements and postural adjustments?
The basal ganglia "<img src=""8123.png"">" anatomy-and-physiology basal-
ganglia neurology
A pt presents with cogwheel rigidity and bradykinesia. Abnormal function in which
part of the midbrain is responsible? The substantia nigra pars compacta, when
unable to produce dopamine, causes parkinsonian symptoms "<img src=""8123.png"">"
anatomy-and-physiology basal-ganglia neurology
You come to a halt while running. How does the substantia nigra pars compacta
modulate the direct and indirect pathways to stop movements? Dopamine release
decreases. Less D1binding decreases direct pathway activity, and less D2 binding
disinhibits the indirect pathway "<img src=""8123.png"">" anatomy-and-
physiology basal-ganglia neurology
You want to cross the street. How does the cortex modulate your direct dopaminergic
pathway to initiate movements? The cortex stimulates the striatum to inhibit
GPi, which can no longer inhibit the thalamus; the cortex can now generate movement
"<img src=""8123.png"">" anatomy-and-physiology basal-ganglia neurology
You come to a halt while running. How does your cortex modulate the indirect
pathway to stop your movements? The cortex stimulates the striatum and GABA
inhibits the GPe; the GPe no longer inhibits the STN, which inhibits the GPi and
stops movement "<img src=""8123.png"">" anatomy-and-physiology basal-
ganglia neurology
The substantia nigra in the midbrain sends dopamine to the putamen. Which receptors
does it bind to modulate movement? Binding D1 receptors promotes movement via the
direct pathway, and binding D2receptors inhibits the indirect pathway, allowing
movement "<img src=""8123.png"">" anatomy-and-physiology basal-ganglia
neurology
What do the caudate and putamen make up? How is each responsible for motor
functions? The striatum; the caudate is involved in the cognitive aspects of
motion; and the putamen guides motor learning, performance, and sequences "<img
src=""8123.png"">" anatomy-and-physiology basal-ganglia neurology
What do the putamen and globus pallidus make up? The lentiform nucleus "<img
You start running. How does the substantia nigra pars compacta modulate the direct
and indirect pathway to begin movements? The SNc stimulates the direct pathway
(D1) and inhibits the indirect pathway (D2) "<img src=""8123.png"">"
Dopamine from which area binds D1 receptors? Does this stimulate or inhibit
movement? Where are these D1 receptors located? Substantia nigra pars compacta
(SNc); this stimulates movement (via the direct pathway); in the putamen "<img
Dopamine from which area binds D2 receptors? Does this stimulate or inhibit
movement? Where are these D2 receptors located? Substantia nigra pars compacta
(SNc); this stimulates movement (via indirect pathway inhibition); in the putamen
"<img src=""8123.png"">" anatomy-and-physiology basal-ganglia neurology
If the globus pallidus internus (GPi) is stimulated, what happens to the thalamus
and cortex? What happens to movement? The GPi will inhibit the thalamus and
cortex, preventing movement "<img src=""8123.png"">" anatomy-and-physiology
basal-ganglia neurology
If the globus pallidus externus (GPe) is stimulated, what happens to the thalamus
and cortex? What happens to movement? An active GPe will inhibit the STN, which
in turn inhibits the GPi; this inhibits the thalamus and cortex, preventing
movement "<img src=""8123.png"">" anatomy-and-physiology basal-ganglia
neurology
If the subthalamic nucleus (STN) is stimulated, what happens to the thalamus and
cortex? What happens to movement? An active STN inhibits the GPi, which in turns
inhibits the thalamus and cortex, preventing movement "<img src=""8123.png"">"
Dopamine binds to D1 receptors in the striatum. What happens downstream in the
direct pathway to promote movement? The striatum releases GABA to inhibit the GPi;
the GPi no longer inhibits the thalamus, which then stimulates the cortex to
promote movement "<img src=""8123.png"">" anatomy-and-physiology basal-
ganglia neurology
Dopamine binds to D2 receptors in the striatum. What happens downstream in the
indirect pathway to promote movement? The GPe is less inhibited and inhibits
the STN; the inhibited STN cannot stimulate the GPi, disinhibiting the
thalamus/promoting movement "<img src=""8123.png"">" anatomy-and-physiology
Dopamine unbinds D1 receptors in the striatum. Describe the sequence of direct
pathway events downstream leading to less motion. The GPi is less inhibited by
D1; hence, the thalamusand thus the cortexare more inhibited by the GPi, and
movement decreases "<img src=""8123.png"">" anatomy-and-physiology basal-
ganglia neurology
Dopamine unbinds D2 receptors in the striatum. Describe the sequence of indirect
pathway events downstream leading to less motion. The GPe is more inhibited,
disinhibiting the STN; the disinhibited STN can stimulate the GPi, inhibiting the
thalamus/decreasing movement "<img src=""8123.png"">" anatomy-and-physiology
An active (disinhibited) GPi will directly inhibit which structure? Does this
ultimately promote or decrease movement? The thalamus; this reduces stimulatory
output to the cortex, decreasing movement "<img src=""8123.png"">" anatomy-and-
An active (disinhibited) GPe will directly inhibit which structure? Does this
ultimately promote or decrease movement? The STN; this reduces stimulatory output
to the GPi, disinhibiting the thalamus and promoting movement "<img
An active (disinhibited) STN will directly stimulate which structure? Does this
ultimately promote or decrease movement? The GPi; this increases inhibitory output
to the thalamus, decreasing movement "<img src=""8123.png"">" anatomy-and-
The right arm and leg of a man in the ED are flailing wildly. What characteristic
lesion on imaging will confirm the causative pathology? A contralateral
subthalamic nucleus lesion caused by a lacunar stroke (The finding is
hemiballismus.) "<img src=""8124.png"">" anatomy-and-physiology movement-
disorders neurology
A woman experiences sudden flailing of her right arm and right leg. What is this?
What is the characteristic associated lesion? "Hemiballismus (""Half-of-body
ballistic.""); a lesion in the contralateral subthalamic nucleus (eg, from a
lacunar stroke)" "<img src=""8124.png"">" anatomy-and-physiology movement-
disorders neurology
Sudden, jerky, purposeless movements or slow, writhing movements are characteristic
of lesions in which part of the brain? Basal ganglia (The movements are chorea
and athetosis, respectively.) "<img src=""8124.png"">" anatomy-and-physiology
movement-disorders neurology
A man with Huntington disease makes jerky, purposeless movements. What is this
movement called, and where is the associated brain lesion? Chorea; basal ganglia
"<img src=""8124.png"">" anatomy-and-physiology movement-disorders
neurology
A man with Huntington disease has slow, writhing, snake-like movement in his
fingers. What brain lesion is associated with this finding?A lesion of the basal
ganglia, as this is athetosis "<img src=""8124.png"">" anatomy-and-physiology
A man with kidney failure has sustained hiccups for days. What movement is a
hiccup? Myoclonus, a sudden brief muscle contraction (more common with
metabolic derangements such as renal and liver failure) "<img src=""8124.png"">"
anatomy-and-physiology movement-disorders neurology
A man with kidney failure has sustained hiccups for days. Why may he have hiccups?
Myoclonic movements, such as hiccups, are commonly seen in pts with metabolic
abnormalities of the liver and kidneys "<img src=""8124.png"">" anatomy-and-
physiology movement-disorders neurology
A man taking haloperidol has sustained muscle contraction of his neck, with
significant contortions. Of what disorder is this an example? Dystonia
(Blepharospasm and writer's cramp are also examples of this pathology.) "<img
src=""8124.png"">" anatomy-and-physiology movement-disorders neurology
A pt with a tremor that worsens with sustained postures self-medicates with
alcohol. Explain how alcohol affects his tremor. Alcohol decreases essential
tremor amplitude, so affected individuals often use it to self-medicate "<img
A man with a head injury has an intention tremor. What is an intention tremor and
what causes it? A slow, zigzag motion when pointing or extending toward a target;
it is caused by cerebellar dysfunction "<img src=""8124.png"">" anatomy-and-
physiology movement-disorders neurology
A pt complains of a chronic tremor of her hands, worse with pouring water or
writing and when she is anxious. What are some treatments? A -blocker (eg,
propranolol) or primidone can be used to treat essential tremor "<img
A man's thumb is constantly pill rolling. The movement stops with focus on the hand
or with voluntary movement. What disease may he have? Parkinson disease (This is a
classic resting tremor.) "<img src=""8124.png"">" anatomy-and-physiology
A pt complains of a chronic tremor of her hands, worse with pouring water or
writing. Why is taking a family history helpful? This is essential tremor,
which often has a genetic predisposition and may run in families "<img
A man's thumb constantly circles his index finger at rest. The movement stops with
focus on the hand or with movement. What is the tremor? Resting tremor "<img
A man has a resting tremor, cogwheel rigidity, bradykinesia, shuffling gait, and
postural instability. What is his likely diagnosis? Parkinson disease TRAPS your
body (Tremor, Rigidity (cogwheel),Akinesia, Postural instability, Shuffling gait)
"<img src=""8125.png"">" anatomy-and-physiology neurology parkinson-
disease
An autopsy is performed on a woman with Parkinson disease. Which region of the
brain is likely depigmented? Which cells? Substantia nigra pars compacta;
dopaminergic neurons "<img src=""8125.png"">" anatomy-and-physiology
neurology parkinson-disease
A 72-year-old man complains of a resting tremor, slow movement, and loss of
balance. Which neurons are lost, and where are they located? Dopaminergic
neurons in the substantia nigra pars compacta (He has Parkinson disease.) "<img
src=""8125.png"">" anatomy-and-physiology neurology parkinson-disease
A girl's father dies of Huntington disease at age 43 years. How is the disease
inherited? At what age would symptoms manifest? Inheritance is autosomal dominant;
symptoms typically begin to appear between the ages of 20 and 50 years "<img
src=""8126.png"">" anatomy-and-physiology huntington-disease neurology
A pt is diagnosed with Huntington disease. In this disease, what mechanisms are
responsible for neuronal cell death? NMDA receptor (NMDA-R) binding, causing
glutamate excitotoxicity "<img src=""8126.png"">" anatomy-and-physiology
huntington-disease neurology
A man with dementia has Huntington disease. Which two neurotransmitter levels
decline secondary to atrophy of the caudate nucleus? Caudate loses ACH and GABA.
(Huntington disease is a CAG repeat disorder.) "<img src=""8126.png"">"
anatomy-and-physiology huntington-disease neurology
A woman with depression and choreiform movements has Huntington disease. What
finding(s) do you see on imaging? "Atrophy of the caudate nuclei (""box car""
ventricles)" "<img src=""8126.png"">" anatomy-and-physiology huntington-
disease neurology
A man with a CAG repeat disorder has chorea, depression, aggression, and
progressive dementia. What can this disorder be mistaken for? Chorea,
depression, aggression, and progressive dementia all suggest Huntington disease but
may be mistaken for substance abuse "<img src=""8126.png"">" anatomy-and-
physiology huntington-disease neurology
Which lobes are separated by the central sulcus? Which lobes are separated by the
Sylvian fissure? Frontal lobe and parietal lobe; frontal lobe and temporal lobe
"<img src=""8127.png"">" anatomy-and-physiology cerebral-cortex-
functions neurology
What frontal lobe cortex is found directly anterior to the primary motor cortex?
The premotor cortex "<img src=""8127.png"">" anatomy-and-physiology
cerebral-cortex-functions neurology
Identify the lobes with the principal visual cortex, primary auditory cortex,
primary sensory cortex, and frontal eye fields, respectively. Occipital lobe;
temporal lobe; parietal lobe; frontal lobe "<img src=""8127.png"">"
anatomy-and-physiology cerebral-cortex-functions neurology
Identify the lobes with the motor speech cortex, premotor cortex. Primary motor
cortex, frontal eye fields and Broca area, respectively. All are found in the
frontal lobe "<img src=""8127.png"">" anatomy-and-physiology cerebral-
cortex-functions neurology
Which two cortical areas are connected by the arcuate fasciculus? What are their
functions? "The Wernicke (temporal lobe) and Broca (frontal lobe) areas; Wernicke
(""What?"") is for language content; Broca is for speech production" "<img
src=""8127.png"">" anatomy-and-physiology cerebral-cortex-functions neurology
What parietal lobe cortex is found directly posterior to the primary somatosensory
cortex? The somatosensory association cortex "<img src=""8127.png"">"
What frontal lobe cortex is important for helping the motor cortices control eye
movements? The frontal eye fields "<img src=""8127.png"">" anatomy-and-
physiology cerebral-cortex-functions neurology
What brain region, found in the anterior part of the frontal lobe, plays a role in
executive function? The prefrontal association area "<img src=""8127.png"">"
"What ""gap"" separates the frontal lobe from the temporal lobe?" The Sylvian
fissure "<img src=""8127.png"">" anatomy-and-physiology cerebral-cortex-
functions neurology
Why might a stroke affecting only the primary motor and somatosensory cortices lead
to aphasia? The arcuate fasciculus (linking the Wernicke and Broca areas) passes
through these two cortices "<img src=""8127.png"">" anatomy-and-physiology
A stroke affecting the most anterior part of the temporal lobe will lead to
dysfunction in which area? The limbic association area "<img src=""8127.png"">"
Where is the primary auditory cortex found? This area is appropriately found
adjacent to which area important in language processing? The superior temporal
lobe; Wernicke area "<img src=""8127.png"">" anatomy-and-physiology
Where in the brain is the primary visual cortex found? The occipital lobe
functions neurology
The Broca area moderates the mechanical production of speech. Why is it important
that this area be found in the frontal lobe? So that it may be adjacent to the
motor areas (eg, primary motor cortex, premotor cortex) to help generate speech
functions neurology
A pt follows commands and repeats phrases but cannot initiate fluent speech. What
type of aphasia is this? What is affected? Transcortical motor aphasia
(nonfluent with intact comprehension and repetition); frontal areas near (not
including) the Broca area "<img src=""8128.png"">" anatomy-and-physiology
aphasia neurology
"A pt fails to repeat the phrase ""no ifs, ands, or buts""; speech is otherwise
normal. What type of aphasia is this? Where is the lesion?"Conduction aphasia; the
arcuate fasciculus "<img src=""8128.png"">" anatomy-and-physiology
aphasia neurology
A man doesn't understand anything you say and responds irrelevantly. He can repeat
words well. Type of aphasia? Location of lesion? Transcortical sensory aphasia
(fluent with impaired comprehension/intact repetition); temporal areas near (not
including) the Wernicke area "<img src=""8128.png"">" anatomy-and-physiology
aphasia neurology
A man with nonfluent speech cannot comprehend commands. Surprisingly, he can repeat
one-word phrases. What type of aphasia is this? Mixed transcortical aphasia
(nonfluent, with impaired comprehension), in which only repetition is spared "<img
src=""8128.png"">" anatomy-and-physiology aphasia neurology
A man has nonfluent speech, cannot comprehend commands, but can repeat words. What
type of stroke is likely causing these findings? A watershed stroke: A mixed
transcortical aphasia affects both the Wernicke and Broca areas while sparing the
arcuate fasciculus "<img src=""8128.png"">" anatomy-and-physiology
aphasia neurology
After a stroke, a woman can understand speech but cannot repeat it or talk
fluently. What type of aphasia does she have? Broca (Broca = Broken Boca [mouth
in Spanish]), a nonfluent aphasia with intact comprehension and impaired repetition
"<img src=""8128.png"">" anatomy-and-physiology aphasia neurology
After a stroke, a woman can understand speech but cannot repeat it or talk
fluently. Which gyrus is affected? The inferior frontal gyrus of the frontal lobe
(Broca area) "<img src=""8128.png"">" anatomy-and-physiology aphasia
neurology
After a stroke, a woman responds to anything spoken to her with fluent but totally
unrelated phrases. What aphasia is this? Wernicke (Wernicke is Wordy but makes no
sense.); this is a fluent aphasia with impaired comprehension and impaired
repetition "<img src=""8128.png"">" anatomy-and-physiology aphasia neurology
After a stroke, a woman responds to anything spoken to her with fluent but totally
unrelated phrases. Which gyrus is affected? The superior temporal gyrus of the
temporal lobe (Wernicke area) "<img src=""8128.png"">" anatomy-and-physiology
aphasia neurology
Post stroke, a man has fluent but unrelated responses to questions. How do you tell
if he has a Wernicke or a transcortical sensory aphasia? See if he can repeat
one-word phrases; if he can repeat them, he has transcortical sensory aphasia; if
he cannot, he has Wernicke aphasia "<img src=""8128.png"">" anatomy-and-
physiology aphasia neurology
A man is struck on the left side of his head. He cannot follow commands or say
anything sensible. What aphasia is this? What was damaged? Global aphasia
(nonfluent with impaired comprehension and repetition); the arcuate fasciculus and
Wernicke and Broca areas are impaired "<img src=""8128.png"">" anatomy-and-
physiology aphasia neurology
An alcoholic man is confused, ataxic, and confabulating. What area of his brain is
damaged? What can unmask this disease in the hospital? The mammillary bodies,
as this is Wernicke-Korsakoff syndrome; giving dextrose in the setting of low
thiamine may precipitate this syndrome "<img src=""8129.png"">" anatomy-and-
physiology common-brain-lesions neurology
A woman arrives with hair/makeup half done and a sock/shoe on only the left foot.
She can only draw half a clock. Where is her brain lesion? Probably in her right
(nondominant) parietal lobe; this pt is exhibiting signs of hemispatial neglect
syndrome "<img src=""8129.png"">" anatomy-and-physiology common-brain-
lesions neurology
A man with left-right disorientation has trouble writing, doing math, and
distinguishing fingers. Where is the lesion? Dominant parietal cortex (This is
Gerstmann syndrome.) "<img src=""8129.png"">" anatomy-and-physiology
common-brain-lesions neurology
A man with a head injury is in a coma and has reduced levels of arousal and
wakefulness. Where is the lesion? The reticular-activating system in the midbrain
"<img src=""8129.png"">" anatomy-and-physiology common-brain-lesions
neurology
A woman with Parkinson disease has a resting tremor, chorea, and athetosis. Where
is the lesion? Basal ganglia "<img src=""8129.png"">" anatomy-and-
physiology common-brain-lesions neurology
An alcoholic woman has an intentional tremor and limb ataxia. Where is the brain
lesion likely to be found? The cerebellar hemispheres (Cerebellar hemispheres
are laterally located and affect lateral limbs.); they atrophy with chronic alcohol
use "<img src=""8129.png"">" anatomy-and-physiology common-brain-lesions
neurology
A man has a tumor in his right cerebellum. If it grows, on which side of his body
will deficits be observed? Which way would he fall? Right side (ipsilateral
deficits); he would fall toward the lesionin this case, to the right "<img
src=""8129.png"">" anatomy-and-physiology common-brain-lesions neurology
A pt walks with a wide-based gait, and his speech is slurred and difficult to
understand. What part of the brain is damaged? The cerebellar vermis (Vermis is
centrally located, affecting the central body.); damage to the vermis results in
truncal ataxia, dysarthria "<img src=""8129.png"">" anatomy-and-physiology
A man repetitively flails his left arm and leg when he tries to move either of
them. Where is the lesion? In the right subthalamic nucleus (This is
hemiballismus, contralateral to the deficits.) "<img src=""8129.png"">"
anatomy-and-physiology common-brain-lesions neurology
A woman loses the ability to make new memories. Where is the brain lesion? On
both sides of the hippocampus, as this is anterograde amnesia "<img
A man has a lesion of the left frontal eye field (FEF). Where do his eyes look in
relation to the lesion? Toward the left (The FEF activates the eyes to look to the
opposite side, so if the left is damaged, the right FEF will be unopposed.) "<img
A pt has a left-sided paramedian pontine reticular formation (PPRF) lesion. Where
do the eyes look in relation to the lesion? Away from the lesion (toward the
right) "<img src=""8129.png"">" anatomy-and-physiology common-brain-
lesions neurology
A pt with cerebellar damage has difficulty pronouncing words (dysarthria). What
other major finding will he have on exam? Truncal ataxia (He likely has damage to
the cerebellar vermis.) "<img src=""8129.png"">" anatomy-and-physiology
A homeless alcoholic confabulates responses, has nystagmus, and cannot walk
properly. A deficiency of what has led to these findings? Vitamin B1 (thiamine),
as this is Wernicke-Korsakoff syndrome (Wernicke problems come in a CAN of beer:
Confusion, Ataxia, Nystagmus) "<img src=""8129.png"">" anatomy-and-physiology
A shy man is suddenly hyperoral, hypersexual, and disinhibited. His CSF has HSV-1
PCR positivity. A lesion in what area is likely to blame? The amygdala, as this is
Klver-Bucy syndrome (associated with HSV-1 encephalitis) "<img src=""8129.png"">"
anatomy-and-physiology common-brain-lesions neurology
A man with new frontal headaches, hostility, and poor decision making and
concentration now has primitive reflexes. Where is the lesion? The frontal lobe
"<img src=""8129.png"">" anatomy-and-physiology common-brain-lesions
neurology
What is the homunculus? Topographic representation of the motor and sensory areas
in the cerebral cortex "<img src=""8130.png"">" anatomy-and-physiology
homunculus neurology
Which body regions have the greatest motor and sensory cortical representation?
Why? The hands, face, and tongue have larger representations because they are more
densely innervated "<img src=""8130.png"">" anatomy-and-physiology
homunculus neurology
A stroke affects the most medial part of the motor cortex. Which region of the body
will most likely be affected? On this map, the toes and lower extremities;
representations lie in the region of the medial motor cortex (ACA territory) "<img
src=""8130.png"">" anatomy-and-physiology homunculus neurology
A stroke affects the most lateral part of the motor cortex. Which region of the
body will most likely be affected? The tongue and face "<img src=""8130.png"">"
anatomy-and-physiology homunculus neurology
A pt has a watershed stroke between the MCA and ACA territories. Which parts of the
body will likely have sensory and motor deficits? The hands and possibly some
of the face "<img src=""8130.png"">" anatomy-and-physiology homunculus
neurology
How is cerebral perfusion primarily regulated? How does this change with severe
hypoxia? Cerebral perfusion is primarily regulated by the partial pressure of
CO2; in severe hypoxia, the partial pressure of O2 regulates perfusion "<img
src=""8131.png"">" anatomy-and-physiology cerebral-perfusion neurology
A pt with cerebral edema after a stroke is therapeutically hyperventilated. What
effect does this have on intracranial pressure (ICP)? Hyperventilation lowers the
ICP (High respiratory rate lowers PCO2, decreasing cerebral perfusion through
vasoconstriction.) "<img src=""8131.png"">" Neurology anatomy-and-
physiology cerebral-perfusion
A pt has hypoxemia from cardiac arrest. At what partial pressure of oxygen does
cerebral blood flow start increasing to compensate? At less than 50 mm Hg
(Normally, the partial pressure of oxygen is approximately 100 mm Hg.) "<img
src=""8131.png"">" Neurology anatomy-and-physiology cerebral-perfusion
A pt develops hypercarbic respiratory failure. At what partial pressure of carbon
dioxide does cerebral blood flow stop increasing? A partial pressure greater
than 90 mm Hg results in the plateauing of cerebral blood flow. (A normal pressure
is 40 mm Hg.) "<img src=""8131.png"">" Neurology anatomy-and-physiology
cerebral-perfusion
A pt develops an epidural hematoma. If his mean arterial blood pressure remains
constant, what will his cerebral perfusion pressure be? Decreased; Mean arterial
pressure (MAP) Intracranial pressure (ICP, in this case elevated) = Cerebral
perfusion pressure (CPP) "<img src=""8131.png"">" Neurology anatomy-and-
A pt has a cardiac arrest without return of circulation. What will his cerebral
perfusion pressure (CPP) be? Zero; MAP (0) ICP (will be elevated from edema) =
CPP (which will be 0) "<img src=""8131.png"">" Neurology anatomy-and-
If a pt's cerebral perfusion pressure (CPP) is 0, what is the person's brain
function? It indicates brain death; no cerebral perfusion is occurring "<img
src=""8131.png"">" Neurology anatomy-and-physiology cerebral-perfusion
A man has severe hypotension. Which two areas of the brain are at greatest risk for
ischemia during such an event? The areas between the anterior cerebral/middle
cerebral and posterior cerebral/middle cerebral arteries (watershed zones) "<img
src=""8132.png"">" Neurology anatomy-and-physiology cerebral-arteries
cortical-distribution
Severe hypotension causes ischemia in the watershed zones of the brain in a 90-
year-old man. What two symptoms might he exhibit? Upper leg and upper arm
weakness with defects in higher-order visual processing "<img src=""8132.png"">"
anatomy-and-physiology cerebral-arteriescortical-distribution neurology
Name four arteries that stem off the internal carotid artery (ICA) at its most
distal end (within the brain). The anterior cerebral (ACA), middle cerebral
(MCA), posterior communicating (PCom), and anterior choroidal arteries "<img
src=""8133.png"">" anatomy-and-physiology circle-of-willis neurology
Cerebral angiography in a man with vision loss shows an anterior communicating
artery (ACom) aneurysm. How does the aneurysm impair vision? Because the ACom
is directly atop the optic chiasm, an ACom aneurysm could directly compress the
optic chiasm, causing vision loss "<img src=""8133.png"">" anatomy-and-
physiology circle-of-willis neurology
What arteries are connected to the most distal portion of the basilar artery?
The posterior inferior cerebellar artery (PICA) and vertebral arteries "<img
Which arteries comprise the anterior circulation of the brain? ICA, ACA, ACom,
MCA, anterior choroidal, lenticulostriate "<img src=""8133.png"">" anatomy-and-
Which arteries comprise the posterior circulation of the brain? VA, BA, PCA, SCA,
AICA, PICA, pontine perforators "<img src=""8133.png"">" anatomy-and-
Which artery links the anterior and posterior circulations of the brain? The
PCom "<img src=""8133.png"">" anatomy-and-physiology circle-of-willis
neurology
What arteries of the cerebral circulation supply the cerebellum? Where does each
originate? The SICA and AICA, which originate in the basilar artery, and the PICA,
which originates in the vertebral artery "<img src=""8133.png"">" anatomy-and-
Where does the anterior spinal artery originate? The anterior spinal artery
originates from the superior vertebral arteries "<img src=""8133.png"">"
anatomy-and-physiology circle-of-willis neurology
A massive embolus occludes the proximal MCA. Which vessels originating near this
area are now likely compromised? The anterior choroidal and lenticulostriate
arteries originate from the proximal MCA and could be compromised "<img
A basilar artery thrombosis causes pontine ischemia. Which arteries off the basilar
artery are directly compromised? The pontine perforators, which originate from
the basilar artery over the pons "<img src=""8133.png"">" anatomy-and-
What are the three major branches of the aortic arch? Brachiocephalic artery,
common carotid artery, subclavian artery "<img src=""8133.png"">" anatomy-and-
The topmost part of the basilar artery is infarcted in a stroke, but there is no
vision loss. Why might this be? Collateral circulation through the PComs can
provide blood flow to the PCAs in the event that the basilar artery is compromised
"<img src=""8133.png"">" anatomy-and-physiology circle-of-willis
neurology
What vessels do the AICA, PICA, and SCA stem from, respectively? AICA: basilar
artery; PICA: vertebral arteries; SCA: basilar artery "<img src=""8133.png"">"
From which major vessel(s) in the upper thorax do the vertebral arteries originate?
The subclavian arteries "<img src=""8133.png"">" anatomy-and-physiology
circle-of-willis neurology
From which major vessel(s) in the upper thorax do the common carotid arteries
(CCAs) originate? The left CCA originates directly from the aortic arch; the right
CCA originates from the brachiocephalic artery "<img src=""8133.png"">"
A man loses sensation and strength in his left arm and face. He seems to neglect
the left side as well. Where is the stroke located? The right middle cerebral
artery (MCA); damage to the nondominant (usually right) parietal lobe causes
hemineglect "<img src=""8134.png"">" anatomy-and-physiology effects-of-strokes
neurology
A man with a history of berry aneurysms now complains of sudden-onset vision loss.
What's going on? He likely has an anterior communicating artery berry aneurysm
that is impinging on the optic chiasm "<img src=""8134.png"">" anatomy-and-
physiology effects-of-strokes neurology
A man loses sensation and strength in his right arm and face. He has broken speech
and is visibly frustrated. Where is the stroke located? The left middle cerebral
artery (MCA) causing a Broca, or expressive, aphasia "<img src=""8134.png"">"
anatomy-and-physiology effects-of-strokes neurology
A pt is found to have a saccular aneurysm of the posterior communicating artery.
What symptom(s) do you expect to see on exam? A cranial nerve III palsy (the eye
is down and out) with ptosis and mydriasis "<img src=""8134.png"">"
A woman suddenly loses strength and sensation in her left leg. If this is the
result of a stroke, where is the stroke most likely located? Right anterior
cerebral artery (ACA) "<img src=""8134.png"">" anatomy-and-physiology
effects-of-strokes neurology
A man presents with sudden-onset cranial nerve III palsy. CT angiography shows a
PCom lesion. Is it a stroke? Unlikely, since PCom lesions are typically aneurysms,
not strokes "<img src=""8134.png"">" anatomy-and-physiology effects-of-strokes
neurology
A man with hypertension sustains a lacunar infarct. What part of the brain is
likely affected, and what presentation do you see? The striatum or internal
capsule, due to lenticulostriate artery infarction; you see contralateral loss of
sensation and/or motor function "<img src=""8134.png"">" anatomy-and-
Which parts of the brain are most commonly involved in a lacunar infarct? The
striatum and internal capsule "<img src=""8134.png"">" anatomy-and-physiology
A pt has right-sided weakness, right proprioceptive loss, and a left-deviating
tongue. Where is the lesion? Which artery is involved? Left caudal medulla;
anterior spinal artery (lateral corticospinal tract, medial lemniscus, and caudal
medulla [hypoglossal nerve] damage) "<img src=""8134.png"">" anatomy-and-
A man has impaired proprioception and strength in his right arm and leg. His tongue
deviates to the left. Name the syndrome and its cause. Medial medullary
syndrome, due to infarction of the paramedian branches of the anterior spinal
artery (ASA) and/or vertebral arteries (VA) "<img src=""8134.png"">"
A woman with an anteroinferior cerebellar artery (AICA) stroke has lateral pontine
syndrome. What brain areas are affected? Lateral pons (vestibular nuclei, facial
nucleus, trigeminal nucleus, cochlear nuclei, sympathetics), middle/inferior
cerebellar peduncles "<img src=""8134.png"">" anatomy-and-physiology
A pt has posteroinferior cerebellar artery (PICA) stroke. Which brain areas are
affected? Lateral medulla: vestibular nuclei, lateral spinothalamic tract, CN V
nucleus, nucleus ambiguus, sympathetics, inferior cerebellar peduncle "<img
src=""8134.png"">" anatomy-and-physiology effects-of-strokes neurology
A pt has a posteroinferior cerebellar artery (PICA) stroke. What symptoms do you
expect to see? Vertigo, vomiting, lost limb/face pain/heat/cold sensation,
nystagmus, dysphagia/hoarseness, gag loss, ipsilateral Horner, ataxia, dysmetria
"<img src=""8134.png"">" anatomy-and-physiology effects-of-strokes
neurology
A woman with a recent stroke has hoarseness and trouble swallowing. These symptoms
are specific for damage to which brain-stem region? "Nucleus ambiguus (""Don't
pick a [PICA] horse [hoarseness] that can't eat [dysphagia].); she has a PICA
stroke" "<img src=""8134.png"">" anatomy-and-physiology effects-of-strokes
neurology
A woman has an anteroinferior cerebellar artery (AICA) stroke. What symptoms do you
expect to see? Vomiting/vertigo/nystagmus, decreased tears/saliva/taste,
ipsilateral face pain/temp and contralateral body pain/temp loss, ataxia/dysmetria
neurology
A man has facial droop from an anteroinferior cerebellar artery (AICA) stroke.
Damage to which brain-stem area is specific for this stroke? "The facial
nucleus (""Facial droop means AICA's pooped."")" "<img src=""8134.png"">"
A pt suddenly loses the right visual field of each eye but retains some of the
center field. What artery was affected? The posterior cerebral artery (PCA),
resulting in damage to the occipital cortex and visual cortex with macular sparing
neurology
A man presumed to be brain dead makes vertical eye movements and blinks a lot.
There are no other voluntary movements. Diagnosis? Locked-in syndrome, with
basilar artery occlusion "<img src=""8134.png"">" anatomy-and-physiology
What artery is occluded in locked-in syndrome? The basilar artery "<img
src=""8134.png"">" anatomy-and-physiology effects-of-strokes neurology
A man suddenly develops a basilar artery thrombosis. What brain structures are
involved in such a stroke? Pons, medulla, lower midbrain, corticospinal and
corticobulbar tracts, ocular cranial nerve nuclei, paramedian pontine reticular
formation "<img src=""8134.png"">" anatomy-and-physiology effects-of-strokes
neurology
Paralysis of the left arm and leg occur in a man with severe hypertension. Other
exam findings are normal. An MRI will show a stroke where? The right
striatum/internal capsule; this is a lacunar infarct caused by hypertension and
resulting in contralateral hemiparesis/hemiplegia "<img src=""8134.png"">"
A man has left face and arm motor and sensory loss. You detect no neglect or
aphasia on exam. Vision is normal. What stroke type is this? A lacunar infarct;
a large-vessel stroke (eg, of the MCA) is unlikely due to the absence of cortical
signs (neglect, aphasia, vision loss) "<img src=""8134.png"">" anatomy-and-
A man is noted to have an incidental aneurysm on CT angiogram. Where is it likely
to be found? If it grows, what are the risks? Between the ACom and ACA in the
circle of Willis; rupture, causing subarachnoid hemorrhage or hemorrhagic stroke
"<img src=""8135.png"">" anatomy-and-physiology aneurysms neurology
A man with Ehlers-Danlos syndrome has an unruptured cerebral aneurysm. What are the
neurologic sequelae? "No symptoms until it ruptures; then hemorrhagic stroke,
subarachnoid hemorrhage (""worst headache of his life"")" "<img src=""8135.png"">"
anatomy-and-physiology aneurysms neurology
A man with gradual visual loss is diagnosed with a large compressing aneurysm at
the ACA-ACom junction. What were his presenting symptoms? Bitemporal hemianopia
secondary to the aneurysm's compression of the optic chiasm"<img src=""8135.png"">"
anatomy-and-physiology aneurysms neurology
A man with chronic hypertension has Charcot-Bouchard microaneurysms. Where are
these usually found? Are they visible on an angiogram? They are often found in
the small vessels of the basal ganglia and thalamus; they are not visible on an
angiogram "<img src=""8135.png"">" anatomy-and-physiology aneurysms
neurology
Which congenital diseases are associated with cerebral aneurysms? Autosomal
dominant polycystic kidney disease (ADPKD) and Ehlers-Danlos syndrome "<img
src=""8135.png"">" anatomy-and-physiology aneurysms neurology
What are four important risk factors for aneurysm formation, aside from congenital
disorders? Smoking, hypertension, advanced age, and race (Blacks have a higher
risk.) "<img src=""8135.png"">" anatomy-and-physiology aneurysms
neurology
A man experienced sudden rupture of an anterior communicating artery aneurysm. What
were his symptoms? Contralateral leg weakness and sensory loss due to anterior
cerebral artery (ACA) compromise "<img src=""8136.png"">" anatomy-and-
physiology effects-of-saccular-aneurysms neurology
A man develops a full third nerve palsy with evidence of a symptomatic cerebral
aneurysm. What are his symptoms, and where is the aneurysm?"Mydriasis, mild ptosis,
with a ""down and out"" eye; his CN III is being compressed by a PCom aneurysm"
"<img src=""8136.png"">" Neurology anatomy-and-physiology effects-of-
saccular-aneurysms
A woman with polycystic kidneys has a right MCA aneurysm near the circle of Willis.
What would her symptoms be should it rupture? Left-sided face and arm weakness
and sensory loss (a right MCA syndrome) "<img src=""8136.png"">" Neurology
anatomy-and-physiology effects-of-saccular-aneurysms
After a stroke, a man experiences tingling of his arm and leg. Years later, the
slightest touch there feels painful. What is the diagnosis?Central post-stroke pain
syndrome caused by thalamic lesions "<img src=""8137.png"">" Neurology anatomy-
and-physiology central-post-stroke-pain-syndrome
After a stroke, a man feels tingling of his arm and leg. Months later, the
slightest touch feels like a burn. Where was his stroke? Thalamus (He has a
central post-stroke pain syndrome.) "<img src=""8137.png"">" Neurology anatomy-
and-physiology central-post-stroke-pain-syndrome
What percentage of stroke pts go on to develop a central post-stroke pain syndrome?
~10% of stroke pts "<img src=""8137.png"">" Neurology anatomy-and-
physiology central-post-stroke-pain-syndrome
What kind of intracranial hematoma crosses suture lines but not the falx? What kind
crosses the falx but not suture lines? Subdural hematoma; epidural hematoma
"<img src=""8138.png"">" Neurology anatomy-and-physiology intracranial-
hemorrhage
An old pt has two individual lobar hemorrhages in different lobes. What do you
suspect is the underlying cause? Amyloid angiopathy (leads to recurrent lobar
hemorrhagic stroke in the elderly) "<img src=""8138.png"">" Neurology anatomy-
and-physiology intracranial-hemorrhage
A baby is shaken by an assailant. What type of hematoma would you expect to see on
head CT? A subdural hematoma "<img src=""8138.png"">" Neurology anatomy-
and-physiology intracranial-hemorrhage
A man is hospitalized after a subarachnoid bleed. What may occur in the first 410
days after hemorrhage? What medication prevents this? Vasospasm due to blood
breakdown, which can alter blood flow and lead to ischemic infarcts; nimodipine is
given to prevent vasospasm "<img src=""8138.png"">" Neurology anatomy-and-
physiology intracranial-hemorrhage
A man is hospitalized after a subarachnoid bleed. For what kind of hydrocephalus is
he at risk? Obstructive hydrocephalus (if blood clogs a foramen) and communicating
hydrocephalus (if arachnoid granulations are obstructed) "<img src=""8138.png"">"
Neurology anatomy-and-physiology intracranial-hemorrhage
A pt presents with the worst headache of her life. Spinal tap shows xanthochromia.
What is the diagnosis? Subarachnoid hemorrhage "<img src=""8138.png"">"
Neurology anatomy-and-physiology intracranial-hemorrhage
A pt develops pulseless electrical activity (PEA). How many minutes into PEA is he
likely to develop irreversible brain damage? 5 minutes (With no cardiac output,
he has diffuse cerebral hypoxia.) "<img src=""8139.png"">" Neurology anatomy-
and-physiology ischemic-brain-disease/stroke
A woman undergoing cardiovascular surgery has severe hypotension. Name the regions
of her brain that are most vulnerable in such situations. The hippocampus,
neocortex, cerebellum, and watershed areas "<img src=""8139.png"">"
Neurology anatomy-and-physiology ischemic-brain-disease/stroke
The brain tissue of a man shows reactive gliosis and vascular proliferation. What
type of stroke did he have? How long ago did it occur? An ischemic stroke
(results in liquefactive necrosis); about 12 weeks ago, as reactive gliosis is
seen 12 weeks after the ischemic event "<img src=""8139.png"">" Neurology
anatomy-and-physiology ischemic-brain-disease/stroke
A man had an ischemic stroke 72 hours ago. What histologic changes are likely
present in the lesion? From 1248 hours after ischemia: red neurons; from 2472
hours: presence of necrosis, neutrophils "<img src=""8139.png"">" Neurology
A man is 1 month out from an ischemic stroke. Describe the time course of
histologic changes from 3 to 5 days out to the present. 3 to 5 days: macrophages
(microglia); 1 to 2 weeks: reactive gliosis and vascular proliferation; 2 weeks and
beyond: glial scar formation "<img src=""8139.png"">" Neurology anatomy-and-
physiology ischemic-brain-disease/stroke
A pathologist determines that an older man died 1248 hours after an ischemic
stroke. What did the pathologist see on histologic exam? Red neurons
(Irreversible neuron injury has a predictable time course: red neurons appear 1248
hours after ischemia.) "<img src=""8139.png"">" Neurology anatomy-and-
A man has hemiplegia that began 30 minutes ago. Which type of brain imaging would
best detect an infarct at this point? MRI: A brightness can be seen on
diffusion-weighted MRI within the first 3 to 30 minutes of a stroke "<img
src=""8139.png"">" Neurology anatomy-and-physiology ischemic-brain-
disease/stroke
A man has hemiplegia that began 10 hours ago. Will the stroke be visible on a CT
scan? What about an MRI? It will likely be visible on both CT and MRI; MRI
detects strokes within the first 3 to 30 minutes, and CT shows ischemia 6 to 24
hours out "<img src=""8139.png"">" Neurology anatomy-and-physiology
ischemic-brain-disease/stroke
A pt with atrial fibrillation has a stroke affecting multiple vascular territories.
Describe the likely cause of this stroke. An embolism (eg, from the heart) traveled
up the cerebral vessels and fragmented "<img src=""8139.png"">" Neurology
What are the three most common subtypes of ischemic stroke?Embolic, thrombotic, and
hypoxic "<img src=""8139.png"">" Neurology anatomy-and-physiology
A man develops a right facial palsy. Function returns 10 minutes later while he is
waiting in the ED. Most likely cause of this event? A TIA, a brief (<15 minute)
reversible period of neurologic dysfunction from focal ischemia with no MRI
findings "<img src=""8139.png"">" Neurology anatomy-and-physiology
An old man with 2 hours of hemiparesis and no hemorrhage risk comes to the ED.
Results of head CT are completely normal. Treatment? Tissue plasminogen activator
(tPA); if the stroke occurred in the past 4.5 hours, he can be given tPA as he has
no contraindications "<img src=""8139.png"">" Neurology anatomy-and-
An old man with recent ischemic stroke comes in for follow-up. How can you decrease
his future stroke risk? With medication (eg, aspirin); treatment of disorders that
increase risk (eg, atrial fibrillation); and control of BP, blood sugar, lipids
"<img src=""8139.png"">" Neurology anatomy-and-physiology ischemic-
brain-disease/stroke
A man develops hypotension while undergoing cardiac surgery. For what type of
stroke is he at risk? Hypoxic ischemic stroke in a watershed distribution "<img
disease/stroke
A pt with a history of DVTs has a new ischemic stroke. Why do you decide to perform
an echocardiogram? Given the DVT history, you want to rule out a patent
foramen ovale (through which an embolized DVT could travel to the brain) "<img
disease/stroke
What are the two major vascular structures that communicate with the cavernous
sinus? The superior ophthalmic vein and the sphenoparietal sinus "<img
src=""8140.png"">" Neurology anatomy-and-physiology dural-venous-sinuses
The straight sinus, which drains into the confluence of sinuses, receives drainage
from which two key vascular structures? The inferior sagittal sinus and the great
cerebral vein of Galen "<img src=""8140.png"">" Neurology anatomy-and-
physiology dural-venous-sinuses
Which sinus is the primary site of CSF return? What structures facilitate the
return of CSF to this sinus? The superior sagittal sinus; arachnoid granulations
"<img src=""8140.png"">" Neurology anatomy-and-physiology dural-venous-
sinuses
Via which opening in the skull does blood leave the skull to enter the internal
jugular veins? The jugular foramen "<img src=""8140.png"">" Neurology
anatomy-and-physiology dural-venous-sinuses
How do venous blood and CSF drain out of the brain? Blood from cerebral veins and
CSF from the arachnoid granulations enter the dural venous sinuses, then drain into
the internal jugular veins "<img src=""8140.png"">" Neurology anatomy-and-
physiology dural-venous-sinuses
A dehydrated, pregnant woman develops a severe, insidious headache that worsens
with position changes. She has papilledema. Diagnosis? Dural venous sinus
thrombosis "<img src=""8140.png"">" Neurology anatomy-and-physiology dural-
venous-sinuses
What risk factors might predispose a young woman to develop a dural venous sinus
thrombosis? What are complications of this condition? Hypercoagulability (eg,
pregnancy, factor V Leiden, oral contraceptive use); headaches, seizures,
hemorrhages, focal neurologic deficits "<img src=""8140.png"">" Neurology
anatomy-and-physiology dural-venous-sinuses
What path does the superior sagittal sinus follow to reach and drain into the
superior vena cava? Superior sagittal sinus, to confluence of sinuses, to
transverse sinus, to sigmoid sinus, to internal jugular vein, to superior vena cava
"<img src=""8140.png"">" Neurology anatomy-and-physiology dural-venous-
sinuses
Which three sinuses drain into the confluence of sinuses? What sinus directly
serves as the outflow back into the systemic circulation? The superior sagittal
sinus, the straight sinus, and the occipital sinus; the transverse sinus "<img
src=""8140.png"">" Neurology anatomy-and-physiology dural-venous-sinuses
An infant has hydrocephalus with severely widened lateral ventricles. All other
openings are narrow thereafter. Where is the occlusion? The lateral ventricles
cannot drain due to an obstruction within the interventricular foramina of Monro
"<img src=""8141.png"">" Neurology anatomy-and-physiology ventricular-
system
An infant has huge lateral ventricles, foramina of Monro, and third ventricle. All
other openings are normal. Where is the occlusion? In the cerebral aqueduct (of
Sylvius); communication between the third and fourth ventricles is blocked "<img
src=""8141.png"">" Neurology anatomy-and-physiology ventricular-system
How does CSF drain from the fourth ventricle into the subarachnoid space? The
fourth ventricle communicates with the subarachnoid space via the foramina of
Luschka (Laterally) and the foramen of Magendie (Medially) "<img src=""8141.png"">"
Neurology anatomy-and-physiology ventricular-system
In a healthy person, what produces CSF, what reabsorbs it, and how is it drained
from the brain? Ependymal cells in the choroid plexus produce CSF; arachnoid
granulations reabsorb it; and the dural venous sinuses drain it "<img
src=""8141.png"">" Neurology anatomy-and-physiology ventricular-system
A woman with pseudotumor cerebri gets diplopia after she stops taking her
medications. Brain MRI is normal. Why does she have double vision? CSF pressure
likely increased again, compressing CN VI and causing a palsy that leads to
diplopia "<img src=""8142.png"">" Neurology anatomy-and-physiology
idiopathic-intracranial-hypertension-(pseudotumor-cerebri)
A woman has diplopia and headaches. Her mental status is normal, as are brain
imaging results. What will lumbar puncture likely demonstrate? Increased opening
pressure and relief of the headache (This is idiopathic intracranial hypertension
[pseudotumor cerebri].) "<img src=""8142.png"">" anatomy-and-physiology
idiopathic-intracranial-hypertension-(pseudotumor-cerebri) neurology
A woman has headaches and diplopia. Brain imaging shows hydrocephalus with CSF
outflow obstruction. Is this pseudotumor cerebri? No, pseudotumor cerebri
typically shows normal results on brain imaging; another cause of increased ICP in
this pt should be suspected "<img src=""8142.png"">" anatomy-and-physiology
idiopathic-intracranial-hypertension-(pseudotumor-cerebri) neurology
What are risk factors for idiopathic intracranial hypertension (pseudotumor
cerebri)? Being a woman of childbearing age, vitamin A excess, danazol use,
tetracycline use "<img src=""8142.png"">" anatomy-and-physiology idiopathic-
intracranial-hypertension-(pseudotumor-cerebri) neurology
Name some treatment options for pts with idiopathic intracranial hypertension
(pseudotumor cerebri). Weight loss, acetazolamide, topiramate, and, if refractory,
procedures (eg, repeat lumbar punctures, CSF shunt, optic nerve fenestration)
"<img src=""8142.png"">" anatomy-and-physiology idiopathic-intracranial-
hypertension-(pseudotumor-cerebri) neurology
An infant in the clinic has an enlarging head after being hospitalized for
meningitis. Diagnosis? How did meningitis cause his condition? Communicating
hydrocephalus; arachnoid scarring after meningitis limited CSF absorption at the
arachnoid granulations "<img src=""8143.png"">" anatomy-and-physiology
hydrocephalus neurology
A pt with normal pressure hydrocephalus has urinary incontinence, cognitive
dysfunction, and ataxia. What findings are seen on head CT?Ventricle expansion
distorts the fibers of the corona radiata, with no increased subarachnoid space
volume (wet, wobbly, and wacky) "<img src=""8143.png"">" anatomy-and-
physiology hydrocephalus neurology
The MRI of a man with Alzheimer disease demonstrates abnormally large ventricles,
but he has no symptoms. What is going on? This is ex vacuo ventriculomegaly; the
true finding is brain atrophy with less neural tissue and an appearance of
increased CSF "<img src=""8143.png"">" anatomy-and-physiology
A pt has normal pressure hydrocephalus. How does the ventricle size change? Is
opening pressure high, low, or normal? Ventricle size is enlarged; opening
pressure of CSF is normal "<img src=""8143.png"">" anatomy-and-physiology
An infant is brought in because of an unusually large head. Imaging shows stenosis
of the aqueduct of Sylvius. Diagnosis? Noncommunicating hydrocephalus, caused by
a structural blockage of CSF circulation (in this case, stenosis) "<img
src=""8143.png"">" anatomy-and-physiology hydrocephalus neurology
A man has ex vacuo ventriculomegaly. How does this affect intracranial pressure?
With what conditions is it associated? Intracranial pressure is normal; it is
seen in atrophic disorders such as Alzheimer disease, Pick disease, and advanced
HIV infection "<img src=""8143.png"">" anatomy-and-physiology
An obstructive colloid cyst is noted on brain MRI of a pt with papilledema. Which
intracranial structure is likely blocked? The interventricular foramen of Monro,
which can be blocked by such cysts, causing a noncommunicating hydrocephalus "<img
What is the classic gait seen in a pt with enlarged ventricles on brain imaging,
urinary incontinence, and cognitive impairments? A magnetic gait in which feet
appear to be stuck to the floor (This is normal pressure hydrocephalus.) "<img
An older man is found to have lower back pain caused by vertebral disc herniation.
What are the most common locations of this herniation? L4L5 or L5S1 "<img
src=""8144.png"">" anatomy-and-physiology neurology spinal-nerves
An older man is found to have lower back pain caused by vertebral disc herniation.
What parts of the vertebral disc herniate? The nucleus pulposus (soft central
disc) pushes out through the annulus fibrosus (outer ring) posterolaterally "<img
An old man with back pain has all reflexes intact except for loss at the left
ankle. What nerve root level is affected? The left S1 nerve root "<img
How many pairs of cervical, thoracic, lumbar, sacral, and coccygeal spinal nerves
are there (each and total)? 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1
coccygeal (31 total) "<img src=""8144.png"">" anatomy-and-physiology
neurology spinal-nerves
Which nerves exit the intervertebral foramina above the corresponding vertebrae?
C1C7 "<img src=""8144.png"">" anatomy-and-physiology neurology spinal-
nerves
Which nerves exit the intervertebral foramina below the correspondingly named
vertebrae? T1 and below (Note that C8 exits below C7 and above T1.) "<img
At what vertebral level does the spinal cord end in adults? Where does the
subarachnoid space extend? Between the L1 and L2 vertebral bodies; the
subarachnoid space extends down to the lower border of S2 "<img src=""8145.png"">"
anatomy-and-physiology neurology spinal-cordlower-extent
When a lumbar puncture is performed, between which two spinous process levels
should the needle enter? Why is it risky to enter higher? Between L3 and L4 or L4
and L5 (level of the cauda equina); entering higher will risk shearing the actual
spinal cord "<img src=""8145.png"">" Neurology anatomy-and-physiology spinal-
cordlower-extent
A woman with a spinal cord lesion has diminished senses of crude touch and
pressure. What tract is affected? The anterior spinothalamic tract, an ascending
pathway "<img src=""8146.png"">" Neurology anatomy-and-physiology spinal-
cord-and-associated-tracts
A man with a spinal cord lesion has diminished pain and temperature sensation in
his legs. What tract is affected? The lateral part of the lateral spinothalamic
tract (Legs are Lateral), an ascending pathway "<img src=""8146.png"">"
Neurology anatomy-and-physiology spinal-cord-and-associated-tracts
A man with spinal cord lesions has diminished senses of pressure, vibration, touch,
and proprioception in his arms. What tract is affected? The lateral dorsal
columnfasciculus cuneatus (The dorsal column is organized as you are, with hands
at sides, arms outside, legs inside.) "<img src=""8146.png"">" Neurology
anatomy-and-physiology spinal-cord-and-associated-tracts
A man with spinal cord lesions has diminished senses of pressure, vibration, touch,
and proprioception in his legs. What tract is affected? The medial dorsal column
fasciculus gracilis (The dorsal column is organized as you are, with hands at
sides, arms outside, legs inside.) "<img src=""8146.png"">" Neurology anatomy-
and-physiology spinal-cord-and-associated-tracts
What is the function of the intermediate lateral horn in the spinal cord? At which
levels is it present? The intermediate horn carries sympathetic system axons from
the brain and preganglionic neurons; it is present from T1L2/L3 "<img
src=""8146.png"">" Neurology anatomy-and-physiology spinal-cord-and-
associated-tracts
A man with a spinal cord lesion has diminished pain and temperature sensation in
his arms. What tract is affected? The medial part of the lateral spinothalamic
tract (Legs are Lateral in the Lateral corticospinal and spinothalamic tracts.)
"<img src=""8146.png"">" Neurology anatomy-and-physiology spinal-cord-
and-associated-tracts
A man with a spinal cord lesion cannot move his left leg. Everything else is
normal. Which tracts of the spinal cord may be involved? The lateral part of the
lateral corticospinal tract (Legs are Lateral in Lateral corticospinal,
spinothalamic tracts.) "<img src=""8146.png"">" Neurology anatomy-and-
physiology spinal-cord-and-associated-tracts
A woman with a spinal cord lesion has diminished voluntary movement in her arms.
Which tracts may be affected? The medial part of the lateral corticospinal tract or
anterior corticospinal tract "<img src=""8146.png"">" Neurology anatomy-and-
physiology spinal-cord-and-associated-tracts
Which tracts synapse first, then cross? Ascending tracts "<img src=""8147.png"">"
Neurology anatomy-and-physiology spinal-tract-anatomy-and-functions
A woman cannot feel pressure, vibration, or touch; and proprioceptive sensation is
absent. Which pathway in the spinal cord is impaired? The dorsal column pathway
"<img src=""8147.png"">" Neurology anatomy-and-physiology spinal-tract-
anatomy-and-functions
In which part(s) of the spinal cord do vibratory axons from the dorsal root
ganglion travel to ascend? Posterior columns (the ipsilateral fasciculus
cuneatus and gracilis) "<img src=""8147.png"">" Neurology anatomy-and-
physiology spinal-tract-anatomy-and-functions
Where do axons from the fasciculus gracilis and cuneatus synapse? Ipsilateral
nucleus cuneatus and gracilis of the medulla "<img src=""8147.png"">"
Where does the dorsal column pathway decussate before arriving at the ventral
posterolateral nucleus of the thalamus? Fibers from the nucleus gracilis and
cuneatus decussate, then ascend through the medial lemniscus in the medulla "<img
src=""8147.png"">" Neurology anatomy-and-physiology spinal-tract-anatomy-and-
functions
Where do the dorsal column pathways go from the ventral posterolateral nucleus
thalamus to relay information? The sensory cortex "<img src=""8147.png"">"
Where do A and C fibers synapse in the spinothalamic tract? Sensory fibers of
the dorsal root ganglia will enter the spinal cord and synapse on neurons of
ipsilateral gray matter "<img src=""8147.png"">" Neurology anatomy-and-
In the spinothalamic tract, do neurons in the spinal cord ascend ipsilaterally or
contralaterally to where they initially entered? Fibers decussate in the
anterior white commissure at the same spinal level and ascend via the contralateral
spinothalamic tract "<img src=""8147.png"">" Neurology anatomy-and-
Where do fibers from the spinothalamic tract decussate? At the anterior
commissure near the same level at which they entered the spinal cord "<img
functions
The spinothalamic tract synapses in what area of the thalamus before reaching the
sensory cortex? The ventral posterolateral (VPL) nucleus of the thalamus "<img
functions
Where do third-order neurons of the spinothalamic tract and dorsal column pathway
originate and terminate? They originate in the ventral posterolateral (VPL)
nucleus of the thalamus and terminate in the sensory cortex"<img src=""8147.png"">"
Which order neuron (first or second) of the spinothalamic tract decussates at the
anterior white commissure? Second "<img src=""8147.png"">" Neurology
anatomy-and-physiology spinal-tract-anatomy-and-functions
Which structure contains the cell bodies of the first-order neurons of the
spinothalamic and dorsal column tracts? Dorsal root ganglia "<img
functions
Which spinal cord tract conveys voluntary movement stimuli to the limbs? Which
tract is affected if a person reports left-sided weakness? The lateral
corticospinal tract; the right lateral corticospinal tract would be affected in a
case of left-sided weakness "<img src=""8147.png"">" Neurology anatomy-and-
Where does the lateral corticospinal tract decussate? The axon of the motor cortex
neuron descends ipsilaterally through the internal capsule and decussates at the
pyramids in the medulla "<img src=""8147.png"">" Neurology anatomy-and-
Where do upper motor neurons synapse with lower motor neurons in the corticospinal
tract? The anterior horn cell bodies of the spinal cord "<img
functions
Where does the second synapse of the lateral corticospinal tract occur? The
neuromuscular junction "<img src=""8147.png"">" Neurology anatomy-and-
A man has weakness and increased tone in his legs and positive Babinski signs. Do
you expect his legs to be hyporeflexic or hyperreflexic? Hyperreflexic: This is a
lesion of the upper motor neurons "<img src=""8148.png"">" Neurology anatomy-
and-physiology motor-neuron-signs
What findings do you expect in a pt with an upper motor neuron lesion? Weakness,
positive Babinski signs, spastic paralysis, clasp knife spasticity, increased
reflexes/tone (Upper motor neuron = everything up) "<img src=""8148.png"">"
Neurology anatomy-and-physiology motor-neuron-signs
What findings do you expect in a pt with a lower motor neuron lesion? Weakness,
atrophy, flaccid paralysis, fasciculations, decreased reflex/tone (Lower motor
neuron = everything lowered) "<img src=""8148.png"">" Neurology anatomy-and-
physiology motor-neuron-signs
In what type of pt is a Babinski sign (upward-moving toes) normal? An infant
"<img src=""8148.png"">" Neurology anatomy-and-physiology motor-neuron-
signs
A man has weakness, atrophy, fasciculations, and diminished reflexes. What will you
find when you assess his muscle tone? It will be decreased, as he has a lower
motor neuron lesion "<img src=""8148.png"">" Neurology anatomy-and-
physiology motor-neuron-signs
A pt's exam findings are notable for fasciculations. What does this mean? Which
lesion is associated with this finding? A fasciculation (muscle twitching) may
indicate a lower motor neuron lesion "<img src=""8148.png"">" Neurology
anatomy-and-physiology motor-neuron-signs
"Compare the types of paralysis seen in upper and lower motor neuron disease. Which
one has a ""clasp knife"" quality?" Upper motor neuron disease involves spastic
paralysis (eg, clasp knife spasticity); lower motor neuron disease involves flaccid
paralysis "<img src=""8148.png"">" Neurology anatomy-and-physiology motor-
neuron-signs
On exam, a neonate has hypotonia. Karyotyping rules out Down syndrome. The infant
later shows tongue fasciculations. Inheritance pattern? Autosomal recessive
(This is likely Werdnig-Hoffmann disease.) "<img src=""8149.png"">"
Neurology anatomy-and-physiology spinal-cord-lesions
"On exam, a neonate has hypotonia and tongue fasciculations. His mother describes
him as ""floppy"" with symmetric weakness. Life expectancy?" He has a median
life expectancy of 7 months, as this is Werdnig-Hoffmann disease "<img
src=""8149.png"">" Neurology anatomy-and-physiology spinal-cord-lesions
In an infant with Werdnig-Hoffmann disease, which neurons are affected? Where is
the damage? Only lower motor neurons of the anterior horn of the spinal cord, with
death of lower motor neurons (This is a genetic disorder.) "<img src=""8149.png"">"
A man has fasciculations, asymmetric weakness, and muscle atrophy. He is superoxide
dismutase 1 deficient. What may extend his lifespan? Riluzole, which modestly
increases survival by decreasing presynaptic glutamate release (He has amyotrophic
lateral sclerosis.) "<img src=""8149.png"">" Neurology anatomy-and-
physiology spinal-cord-lesions
Stephen Hawking is well known to have amyotrophic lateral sclerosis (ALS). His
cognition is of what key feature of this disease? Cognitive, sensory, and
oculomotor abilities are not affected by ALS, or Lou Gehrig disease "<img
src=""8149.png"">" Neurology anatomy-and-physiology spinal-cord-lesions
What features of the nervous system are spared from amyotrophic lateral sclerosis
(ALS)? ALS does not affect cognition, sensation, or bowel/bladder function
"<img src=""8149.png"">" Neurology anatomy-and-physiology spinal-cord-
lesions
A man gets sudden bilateral leg paralysis, areflexia, and pain/temperature loss
from T4 down. Surprisingly, he senses vibration. Diagnosis?Occlusion of the
anterior spinal artery at the T2 level, sparing the dorsal columns because they are
supplied by the posterior spinal artery "<img src=""8149.png"">" Neurology
anatomy-and-physiology spinal-cord-lesions
A man with syphilis has numb legs, a positive Romberg sign, loss of leg reflexes,
and an ataxic gait. What spinal cord parts are affected? Demyelination of dorsal
columns and dorsal roots has taken place (This is tabes dorsalis caused by tertiary
syphilis.) "<img src=""8149.png"">" Neurology anatomy-and-physiology spinal-
cord-lesions
A pt presents with pupils reactive to accommodation but not to light and a
dislocation in the midfoot. Diagnose these findings. Argyll Robertson pupils and
Charcot joints (associated with tertiary syphilis) with tabes dorsalis
(demyelination of dorsal columns/roots) "<img src=""8149.png"">" Neurology
anatomy-and-physiology spinal-cord-lesions
A strict vegan woman has mildly low B12 levels on routine blood tests. What
symptoms would she develop with more severe B12 deficiency?Paresthesias, ataxic
gait, and poor vibration and position sense. "<img src=""8149.png"">"
A pt with a Chiari I malformation doesn't feel pain and temperature along her arms
and back. Are other sensory modalities at risk? Yes, with time, syringomyelia will
expand beyond the second-order neurons of the anterior white commissure to other
tracts "<img src=""8149.png"">" Neurology anatomy-and-physiology spinal-
cord-lesions
A man with syphilis has progressive sensory ataxia (poor proprioception) and
shooting pains. What other physical exam findings may one see? Argyll Robertson
pupils, Charcot joints, Romberg sign, and absence of DTRs (This is tabes dorsalis
from tertiary syphilis.) "<img src=""8149.png"">" Neurology anatomy-and-
physiology spinal-cord-lesions
What weakness pattern would be displayed by a pt with Werdnig-Hoffman disease? By a
pt with poliomyelitis? A pt with Werdnig-Hoffman would have symmetric weakness; a
pt with poliomyelitis would have asymmetric weakness "<img src=""8149.png"">"
How is polio transmitted? Where does it replicate in the human body? Via the
fecal-oral route; it replicates in the oropharynx and small intestine before
entering the CNS from the bloodstream "<img src=""8150.png"">" Neurology
anatomy-and-physiology poliomyelitis
A boy with headaches, nausea, fever, malaise, and weakness is diagnosed with polio.
What part of the spinal cord is affected? The anterior horn, causing lower motor
neuron signs (eg, flaccid paralysis) "<img src=""8150.png"">" Neurology
What are the general (ie, nonneurologic) signs and symptoms of a polio infection?
Malaise, headaches, fever, nausea "<img src=""8150.png"">" Neurology
A boy with malaise and nausea is diagnosed with polio. He reports severe weakness.
What clinical findings do you expect to see in his legs? Muscle atrophy,
fasciculations, weakness, and loss of reflexes and muscle tone (lower motor neuron
signs due to anterior horn damage) "<img src=""8150.png"">" Neurology anatomy-
and-physiology poliomyelitis
A boy is suspected of having acute poliomyelitis. What tests would you order, and
what would the studies you order show? Lumbar puncture (increased WBCs, protein
in CSF with no change in glucose) and stool/throat swabs (can recover virus) "<img
src=""8150.png"">" Neurology anatomy-and-physiology poliomyelitis
On lumbar puncture of a pt with polio, is CSF protein increased, decreased, or
unchanged? What about glucose? WBCs? CSF protein is slightly increased;
glucose is unchanged; WBCs are increased "<img src=""8150.png"">" Neurology
A child with kyphosis has frequent falls & a staggering gait. What mode of
inheritance has caused this? What chromosome is the mutation on? Autosomal
recessive; chromosome 9 (This is Friedreich ataxia.) "<img src=""8151.png"">"
Neurology anatomy-and-physiology friedreich-ataxia
A boy has nystagmus and dysarthria. He falls often and is diabetic. He also has
heart failure. What is abnormal on his genetic analysis? Two copies of the gene
encoding frataxin will both have increased trinucleotide repeats (GAA). (This is
Friedreich ataxia.) "<img src=""8151.png"">" Neurology anatomy-and-
physiology friedreich-ataxia
Which part of the nervous system is affected in Friedreich ataxia? Spinal cord
tracts: Loss of myelinated fibers in multiple tracts leads to weakness, DTR loss,
and impaired vibration and proprioception "<img src=""8151.png"">" Neurology
anatomy-and-physiology friedreich-ataxia
A boy suddenly faints. On exam, he has diffuse muscle atrophy, no reflexes, Romberg
positivity, and nystagmus. Why did he faint? His syncope is most likely the
result of hypertrophic cardiomyopathy. (This is Friedreich ataxia.) "<img
src=""8151.png"">" Neurology anatomy-and-physiology friedreich-ataxia
For what cardiac complication should a pt with Friedreich's ataxia be monitored?
Why is frequent follow-up important? Hypertrophic cardiomyopathy; because it
is a common cause of death in these pts "<img src=""8151.png"">" Neurology
anatomy-and-physiology friedreich-ataxia
A 10-year-old child is suspected of having Friedreich ataxia. What is the first
clinical sign most commonly seen in children? Kyphoscoliosis "<img
src=""8151.png"">" Neurology anatomy-and-physiology friedreich-ataxia
A child with kyphosis and frequent falls, nystagmus, dysarthria, and pes cavus
needs monitoring for what endocrine disease? Diabetes mellitus; the child has
Friedreich ataxia, and diabetes mellitus is a complication that requires monitoring
"<img src=""8151.png"">" Neurology anatomy-and-physiology friedreich-
ataxia
A pt develops Brown-Squard syndrome after being stabbed. Assuming the knife went
through the left side, which tracts are severed? The left-sided corticospinal
tract, spinothalamic tract, and dorsal column (all tracts on the left, as this is
spinal cord hemisection) "<img src=""8152.png"">" Neurology anatomy-and-
physiology brown-squard-syndrome
A man loses pain/temperature sensation in his left leg and cannot find his right
leg with eyes closed. There is no T12 sensation. Diagnosis?Brown-Squard syndrome
at the level of T12 "<img src=""8152.png"">" Neurology anatomy-and-
physiology brown-squard-syndrome
A woman has hemisection of the spinal cord above T1. What facial syndrome may be
associated with her lesion? Horner syndrome (damage to the oculosympathetic
pathway) in Brown-Squard syndrome above T1 "<img src=""8152.png"">"
Neurology anatomy-and-physiology brown-squard-syndrome
A pt has Brown-Squard syndrome after being stabbed in the back. Describe the
findings contralateral to the insult on exam. No pain or temperature sense
contralaterally two levels below the level of the lesion "<img src=""8152.png"">"
A pt is stabbed in the back, and the left spinal cord half is transected. What
symptoms will you expect on the same side below the cut? LMN signs & loss of all
sensation at the level of the lesion; UMN signs & loss of
tactile/vibration/proprioception sense below the lesion "<img src=""8152.png"">"
A pt is stabbed in the back; the left spinal cord is transected. What symptoms will
you expect on the opposite side below the cut? Pain and temperature loss
(spinothalamic tract) below the lesion "<img src=""8152.png"">" Neurology
anatomy-and-physiology brown-squard-syndrome
A pt has paresthesias at the level of the inguinal ligament. Which nerve root may
be affected? L1 (L1 is IL [Inguinal Ligament].) "<img src=""8153.png"">"
Neurology anatomy-and-physiology landmark-dermatomes
A pt has loss of sensation at the level of a low-collar shirt. Which nerve root may
be affected? C4 (low-collar shirt) "<img src=""8153.png"">" Neurology
anatomy-and-physiology landmark-dermatomes
You are examining dermatomes on a man. Where would you look for acute appendicitis?
What about gallbladder inflammation? T10 (the umbilicus, an early site of
referred appendicitis pain); right C3C5 (phrenic nerve, a site of referred
gallbladder pain) "<img src=""8153.png"">" Neurology anatomy-and-physiology
landmark-dermatomes
A woman complains of pain along the edge of her jaw over the mastoid and around the
back of her head. Which nerve root is affected? "C2 (posterior half of a skull
""cap"")" "<img src=""8153.png"">" Neurology anatomy-and-physiology
landmark-dermatomes
A pt presents with paresthesias on his neck in the distribution of a high
turtleneck shirt. What cervical nerve root is involved? C3 (high turtleneck
shirt) "<img src=""8153.png"">" Neurology anatomy-and-physiology
landmark-dermatomes
A pt has pain shooting down the lateral edge of her shoulder to her thumb. Which
nerve root may be affected? C6 (Thumbs up sign on left hand looks like a six for
C6.) "<img src=""8153.png"">" Neurology anatomy-and-physiology landmark-
dermatomes
A pt has impaired sensation at the level of the nipple. Which nerve root innervates
this dermatome? T4 (at the teat pore) "<img src=""8153.png"">" Neurology
anatomy-and-physiology landmark-dermatomes
A pt has impaired sensation at the level of the xiphoid process. Which nerve root
innervates this dermatome? T7 (at the xiphoid process) "<img src=""8153.png"">"
Neurology anatomy-and-physiology landmark-dermatomes
A pt is unable to have an erection and has no sensation in his penis or anus. Which
nerve roots could be involved? "S2, S3, and S4 (""S2, 3, 4 keep the penis off
the floor."")" "<img src=""8153.png"">" Neurology anatomy-and-physiology
landmark-dermatomes
A pt has early appendicitis. Pain is often referred to the distribution of which
nerve root and dermatome? T10, the umbilicus (at the belly butten) "<img
src=""8153.png"">" Neurology anatomy-and-physiology landmark-dermatomes
Which spinal nerve innervates the kneecaps? L4 (Down on ALL 4's) "<img
src=""8153.png"">" Neurology anatomy-and-physiology landmark-dermatomes
A man with cholecystitis has referred right shoulder pain. What nerve is likely
affected? What body parts may refer pain to this area? The phrenic nerve;
diaphragm or gallbladder "<img src=""8153.png"">" Neurology anatomy-and-
physiology landmark-dermatomes
A pt has 2+ bilateral biceps, triceps, patella, and Achilles reflexes. Name the
nerve roots associated with these reflexes. C5, 6pick up sticks (biceps);
C7, 8lay them straight (triceps); L3, 4kick the door (patellar); S1, 2
buckle my shoe (Achilles) "<img src=""8154.png"">" Neurology anatomy-and-
physiology clinical-reflexes
A pt with lower spinal cord injury has a diminished anal wink reflex. What nerve
roots are associated with this reflex? S3, S4winks galore (anal wink reflex)
"<img src=""8154.png"">" Neurology anatomy-and-physiology clinical-
reflexes
A man with spinal cord injury has a diminished cremaster reflex when his thigh is
stroked. What nerve roots are associated with this reflex? L1, L2testicles move
(cremaster reflex) "<img src=""8154.png"">" Neurology anatomy-and-
physiology clinical-reflexes
A man has dorsiflexion of the big toe and fanning of the other toes on plantar
stimulation. Name this clinical sign and its significance. Plantar (Babinski)
reflex, a sign of an upper motor neuron lesion "<img src=""8155.png"">"
Neurology anatomy-and-physiology primitive-reflexes
An infant is startled and extends and abducts the limbs as if hanging on for life.
What reflex is this? The Moro reflex "<img src=""8155.png"">" Neurology
anatomy-and-physiology primitive-reflexes
An infant turns toward the side of her cheek being stroked and sucks when the roof
of her mouth is stimulated. Name these reflexes. The first is the rooting
reflex (nipple seeking), and the second is the sucking reflex "<img
src=""8155.png"">" Neurology anatomy-and-physiology primitive-reflexes
You place a finger in the palm of an infant. What reflex will be elicited? The
palmar reflex; the infant will grasp a finger placed in the palm "<img
An 85-year-old pt has a sucking reflex and a palmar reflex. Lesions in what lobe of
the brain may cause primitive reflexes to reemerge? The frontal lobe (Mature
frontal lobes usually inhibit these reflexes.) "<img src=""8155.png"">"
CNS reflexes that were present in a baby are gone. When do primitive reflexes
disappear? Which part of the brain has control over this? Within the first year of
life; the frontal lobe inhibits their release "<img src=""8155.png"">"
On exam, a healthy pt shows bilateral dorsiflexion of the large toe with
stimulation. How old is this pt? This is normal only in people younger than 1
year; the plantar (Babinski) reflex in adults is an abnormality, indicating a UMN
lesion "<img src=""8155.png"">" Neurology anatomy-and-physiology
primitive-reflexes
A 1-year-old infant is held up with his face and abdomen toward the ground. What
happens when you stroke along the right of his spine? This will elicit the Galant
reflex (a primitive reflex); he will flex laterally to the right "<img
Which cranial nerves (CNs) lie medially at the brain stem? CNs III, IV, VI, and XII
(factors of 12, except 1 and 2) "<img src=""8156.png"">" Neurology anatomy-
and-physiology brain-stemventral-view
On exam, a pt shows paralysis of conjugate vertical gaze. MRI shows a pinealoma.
Name the syndrome associated with the visual sign. Parinaud syndrome; caused by
a lesion in the superior colliculi (eg, from a pineal tumor) "<img
src=""8157.png"">" anatomy-and-physiology brain-stemdorsal-view-(cerebellum-
removed) neurology
A brain pathology specimen shows intact superior and inferior colliculi. Where are
they located? In what systems are they involved? Dorsal brain stem (Superior
colliculus [conjugate vertical gaze center] is above the inferior colliculus
[auditory].) "<img src=""8157.png"">" Neurology anatomy-and-physiology
brain-stemdorsal-view-(cerebellum-removed)
Which cranial nerve nuclei are located in the midbrain? CN III, IV "<img
src=""8158.png"">" Neurology anatomy-and-physiology cranial-nerve-nuclei
Which cranial nerve nuclei are located in the pons? CN V, VI, VII, VIII "<img
Which cranial nerve nuclei are located in the medulla? CN IX, X, XII "<img
Which cranial nerve nuclei are located in the spinal cord? CN XI "<img
A pt has a midbrain lesion. The nuclei of which cranial nerves (CNs) are most
likely to be affected? CNs III and IV "<img src=""8158.png"">" Neurology
anatomy-and-physiology cranial-nerve-nuclei
A pt has a pontine lesion. The nuclei of which cranial nerves (CNs) are most likely
to be affected? CNs V, VI, VII, VIII "<img src=""8158.png"">" Neurology
A pt has a lesion in the medulla. The nuclei of which cranial nerves (CNs) are most
likely to be affected? CNs IX, X, XII "<img src=""8158.png"">" Neurology
A pt has an upper spinal cord lesion. Name the cranial nerve (CN) nucleus that is
most likely to be affected. CN XI "<img src=""8158.png"">" Neurology anatomy-
and-physiology cranial-nerve-nuclei
Sensory cranial nerves (CNs) typically originate in which part of the brain stem?
The lateral regions "<img src=""8158.png"">" Neurology anatomy-and-
physiology cranial-nerve-nuclei
Motor cranial nerves (CNs) typically originate in which part of the brain stem?
Provide the mnemonic that may help. The medial region; Lateral nuclei = sensory
(aLar plate); Medial nuclei = Motor (basal plate) "<img src=""8158.png"">"
Neurology anatomy-and-physiology cranial-nerve-nuclei
Name the longitudinal groove that separates the sensory and motor areas of the
spinal cord and brain stem. The sulcus limitans (This groove forms during
development of the alar and basal plates.) "<img src=""8158.png"">"
Where are cranial nerve nuclei generally located within the brain stem? In the
tegmentum, between the dorsal and ventral parts of the brain stem "<img
A pt has asymmetric elevation of the soft palate. Name the cranial nerve (CN) and
muscle affected. CN IX (glossopharyngeal nerve), which innervates the
stylopharyngeus muscle (elevates pharynx and larynx) "<img src=""8158.png"">"
Through which structure do cranial nerves III/IV/VI, the first trigeminal nerve
division, the ophthalmic vein, and sympathetic fibers pass?The Superior orbital
fissure (Standing room only) "<img src=""8159.png"">" Neurology anatomy-and-
physiology cranial-nerve-and-vessel-pathways
Which cranial nerves (CNs) exit the skull through holes in the middle cranial fossa
in the sphenoid bone? CNs IIVI "<img src=""8159.png"">" Neurology anatomy-
and-physiology cranial-nerve-and-vessel-pathways
Through which anatomic structure does cranial nerve I pass when entering/exiting
the skull? Cribriform plate "<img src=""8159.png"">" Neurology anatomy-and-
Where does the second division of the trigeminal nerve exit the skull? Foramen
Rotundum (standing Room only) "<img src=""8159.png"">" Neurology anatomy-and-
Where does the third division of the trigeminal nerve exit the skull? Foramen
Ovale (standing room Only) "<img src=""8159.png"">" Neurology anatomy-and-
Where does the middle meningeal artery exit the skull? Foramen spinosum "<img
src=""8159.png"">" Neurology anatomy-and-physiology cranial-nerve-and-vessel-
pathways
Which cranial nerves (CNs) exit the skull through the posterior cranial fossa? Name
the bones in this region. CNs VIIXII; temporal and occipital bones "<img
pathways
The internal auditory meatus contains which two cranial nerves (CNs)? CNs VII and
VIII "<img src=""8159.png"">" Neurology anatomy-and-physiology cranial-nerve-
and-vessel-pathways
Which foramen contains cranial nerves (CNs) IXXI and the jugular vein? The
jugular foramen "<img src=""8159.png"">" Neurology anatomy-and-physiology
cranial-nerve-and-vessel-pathways
Where does the spinal cord exit the skull? Foramen magnum "<img
pathways
The spinal roots of cranial nerve XI and the vertebral arteries exit the skull via
which opening? Foramen magnum "<img src=""8159.png"">" Neurology anatomy-
and-physiology cranial-nerve-and-vessel-pathways
Through which three holes do the three branches of the trigeminal nerve leave the
skull? V1 through Superior orbital fissure, V2 through foramen Rotundum, V3
through foramen Ovale (Standing Room Only) "<img src=""8159.png"">"
Neurology anatomy-and-physiology cranial-nerve-and-vessel-pathways
Name the canal used by the cranial nerve (CN) responsible for movement of the
tongue. Hypoglossal canal (CN XII exits the posterior cranial fossa via the
hypoglossal canal.) "<img src=""8159.png"">" Neurology anatomy-and-
A doctor places cinnamon sticks under a pt's nose. Is this sense relayed through
the thalamus? No, CN I (olfactory nerve) is the only cranial nerve that goes to
the cortex without a thalamic relay "<img src=""8160.png"">" Neurology anatomy-
and-physiology cranial-nerves
Blindness could be the result of injury to which cranial nerve (CN)? CN II (optic
nerve) "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
A pt's eyes constrict in response to light. Which cranial nerve performs this
function, and what does it innervate? CN III: SR, IR, MR, IO, levator
palpebrae, sphincter pupillae, Edinger-Westphal nucleus, muscarinic receptors
"<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
What is another name for cranial nerve III? The oculomotor nerve "<img
src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
Name the two cranial nerves (CNs) that control only eye movement (not pupil
constriction). CNs IV (trochlear nerve: superior oblique muscles) and VI
(abducens nerve: lateral rectus muscles) "<img src=""8160.png"">" Neurology
anatomy-and-physiology cranial-nerves
A pt is asked to clench her jaw and indicate whether she feels light touch on her
face. What cranial nerve (CN) is tested? CN V (trigeminal nerve) "<img
An individual loses the sense of taste on the anterior two thirds of the tongue.
Which cranial nerve is affected? CN VII (facial nerve) "<img src=""8160.png"">"
Neurology anatomy-and-physiology cranial-nerves
A pt is asked to stick out her tongue and move it from side to side. Name the
cranial nerve (CN) that controls the movement of the tongue. CN XII
(hypoglossal nerve) "<img src=""8160.png"">" Neurology anatomy-and-
physiology cranial-nerves
Name the cranial nerve (CN) that innervates the submandibular and sublingual
salivary glands. CN VII (facial nerve) "<img src=""8160.png"">" Neurology
A pt with a cranial nerve lesion is deaf and has difficulty balancing. Which
cranial nerve (CN) is affected? CN VIII (vestibulocochlear nerve) "<img
A pt loses taste in the posterior third of the tongue. Name the cranial nerve (CN)
that is responsible. CN IX (glossopharyngeal nerve) "<img src=""8160.png"">"
Name the cranial nerve (CN) that innervates the parotid gland. CN IX
(glossopharyngeal nerve) "<img src=""8160.png"">" Neurology anatomy-and-
physiology cranial-nerves
Name the cranial nerve (CN) that mediates taste in the extreme posterior
oropharynx. CN X (vagus nerve) "<img src=""8160.png"">" Neurology anatomy-
Name the cranial nerve (CN) that monitors aortic arch chemoreceptors and
baroreceptors. CN X (vagus nerve) "<img src=""8160.png"">" Neurology
Name the cranial nerve (CN) that monitors carotid body and sinus chemo- and
baroreceptors. CN IX (glossopharyngeal nerve) "<img src=""8160.png"">"
A woman has difficulty turning her head and shrugging her shoulders. Name the
cranial nerve (CN) that is affected. CN XI (accessory nerve) "<img
Name the cranial nerve (CN) that is responsible for lacrimation. CN VII (facial
nerve) "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
Name the cranial nerves (CNs) that are responsible for salivation. CN VII
(facial nerve): salivation from submandibular and sublingual glands and CN IX
(glossopharyngeal nerve): salivation from parotid gland "<img src=""8160.png"">"
Name the cranial nerve (CN) that is responsible for closing the eye (orbicularis
oculi). CN VII (facial nerve) "<img src=""8160.png"">" Neurology anatomy-
A pt has impaired sensation and movement in the tongue. Name the cranial nerves
(CNs) that are likely impaired in this pt. CN VII (facial): senses anterior
two thirds, CN IX (glossopharyngeal): senses posterior third, CN XII (hypoglossal):
movement "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
Name the cranial nerves (CNs) that are responsible for opening and closing the
eyelid. CN III (oculomotor nerve) opens the eyelid (levator palpebrae) and CN
VII (facial nerve) closes the eyelid (orbicularis oculi) "<img src=""8160.png"">"
Name the cranial nerves (CNs) that are responsible for taste. VII (facial
nerve): tongue (anterior two thirds); IX (glossopharyngeal nerve): tongue posterior
third; X (vagus nerve): epiglottic area "<img src=""8160.png"">" Neurology
Name the two cranial nerves (CNs) that are involved in swallowing. CN IX
(glossopharyngeal nerve) and CN X (vagus nerve) "<img src=""8160.png"">"
A pt with a Bell palsy has hyperacusis (heightened sensitivity to sound). What is
causing this phenomenon? CN VII (facial nerve), which innervates the stapedius
muscle in the ear, is impaired "<img src=""8160.png"">" Neurology anatomy-
What is the name of cranial nerve I? Sensory, motor, or both? Olfactory nerve;
sensory "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
What is the name of cranial nerve II? Sensory, motor, or both? Optic nerve;
sensory "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
What is the name of cranial nerve III? Sensory, motor, or both? Oculomotor nerve;
motor "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
What is the name of cranial nerve IV? Sensory, motor, or both? Trochlear nerve;
What is the name of cranial nerve V? Sensory, motor, or both? Trigeminal nerve;
both "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
What is the name of cranial nerve VI? Sensory, motor, or both? Abducens nerve;
What is the name of cranial nerve VII? Sensory, motor, or both? Facial nerve; both
What is the name of cranial nerve VIII? Sensory, motor, or both? Vestibulocochlear
nerve; sensory "<img src=""8160.png"">" Neurology anatomy-and-physiology
cranial-nerves
What is the name of cranial nerve IX? Sensory, motor, or both? Glossopharyngeal
nerve; both "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-
nerves
What is the name of cranial nerve X? Sensory, motor, or both? Vagus nerve; both
What is the name of cranial nerve XI? Sensory, motor, or both? Accessory nerve;
What is the name of cranial nerve XII? Sensory, motor, or both? Hypoglossal nerve;
Which cranial nerves (CNs) carry motor signals exclusively?CNs III, IV, VI, XI, and
XII "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
Which cranial nerves (CNs) carry sensory signals exclusively? CNs I, II, and
VIII "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
Which cranial nerves (CNs) carry both sensory and motor signals? CNs V, VII, IX,
and X "<img src=""8160.png"">" Neurology anatomy-and-physiology cranial-nerves
Which brain-stem nucleus receives visceral sensory information such as taste, gut
distention, and baroreceptor feedback? The nucleus Solitarius (Sensory) "<img
src=""8161.png"">" Neurology anatomy-and-physiology facial-nerve-palsy
Which cranial nerves (CNs) carry information to the nucleus solitarius? CNs
VII, IX, and X "<img src=""8161.png"">" anatomy-and-physiology facial-
nerve-palsy neurology
Which brain-stem nucleus provides the motor innervation of the pharynx, larynx, and
upper esophagus? The nucleus aMbiguus (Motor) "<img src=""8161.png"">"
anatomy-and-physiology facial-nerve-palsy neurology
Which nucleus sends parasympathetic fibers to the heart, lungs, and upper
gastrointestinal tract? Which cranial nerve (CN) is involved? The dorsal motor
nucleus; CN X "<img src=""8161.png"">" anatomy-and-physiology facial-
nerve-palsy neurology
A pt has difficulty swallowing because of a lesion in the nucleus ambiguus. Which
cranial nerves (CNs) are affected? CNs IX and X "<img src=""8161.png"">"
anatomy-and-physiology facial-nerve-palsy neurology
Does a lesion of cranial nerve (CN) XII result in tongue deviation toward the
ipsilateral or contralateral side of the lesion? Why? Toward the ipsilateral side;
a lesion in CN XII causes muscle weakness and an inability to balance opposing
force "<img src=""8163.png"">" anatomy-and-physiology common-cranial-nerve-
lesions neurology
A pt's jaw deviates to the right. In which cranial nerve (CN) does this indicate a
lesion? On which side? Why? In CN V on the right side; the jaw deviates toward
the same side as the lesion because of unopposed force from the opposite pterygoid
muscle "<img src=""8163.png"">" anatomy-and-physiology common-cranial-
nerve-lesions neurology
A pt opens her mouth, and the uvula is deviated to the right. Where is the lesion?
In CN X (The uvula deviates away from the lesion as the weak side collapses,
making the uvula point away.) "<img src=""8163.png"">" anatomy-and-physiology
common-cranial-nerve-lesions neurology
A man shrugs his shoulders, and the right is lower than the left. If this is a
nerve problem, in which way is he less able to turn his head? The left; the
right SCM helps turn the head to the left (right shoulder droop [trapezius] =
ipsilateral CN XI lesion) "<img src=""8163.png"">" anatomy-and-physiology
common-cranial-nerve-lesions neurology
Name the three muscles that close the jaw. "Masseter, teMporalis, and Medial
pterygoid (M's Munch) (""It takes more muscle to keep your mouth shut."")" "<img
src=""8164.png"">" anatomy-and-physiology mastication-muscles neurology
Name the muscle that opens the jaw. Lateral pterygoid (Lateral Lowers the jaw)
"<img src=""8164.png"">" anatomy-and-physiology mastication-muscles
neurology
Which cranial nerve opens the jaw? Trigeminal nerve (CN V3) "<img
src=""8164.png"">" anatomy-and-physiology mastication-muscles neurology
Is the upper motor neuron innervation of the upper face from the ipsilateral,
bilateral, or contralateral cortex? Bilateral "<img src=""8165.png"">"
anatomy-and-physiology facial-nerve-lesions neurology
A man has a facial droop on his right forehead and cheek. Is this an upper or lower
motor neuron lesion? Name the side of the lesion. Right lower motor neuron
lesion (ipsilateral lower motor neuron damage) "<img src=""8165.png"">"
Neurology anatomy-and-physiology facial-nerve-lesions
A pt has left lower facial paralysis but is able to raise his eyebrows bilaterally.
Where is the lesion? Either the motor cortex or a connection between the cortex
and the right facial nucleus (upper motor neuron lesion) "<img src=""8165.png"">"
Does Bell palsy cause facial paralysis to the ipsilateral or contralateral side of
the lesion? Ipsilateral side "<img src=""8165.png"">" Neurology anatomy-and-
physiology facial-nerve-lesions
Lyme disease, herpes simplex, herpes zoster, sarcoidosis, tumors, and diabetes can
all present with what common complication? Facial nerve palsy (It is called
Bell palsy only when the cause is idiopathic.) "<img src=""8165.png"">"
What is the common treatment for facial nerve palsy? Corticosteroids "<img
src=""8165.png"">" Neurology anatomy-and-physiology facial-nerve-lesions
What is the name of the disorder in which facial nerve palsy develops as a result
of herpes zoster infection? Ramsay Hunt syndrome "<img src=""8165.png"">"
The cavernous sinus is a collection of venous sinuses surrounding which gland?
The pituitary gland "<img src=""8166.png"">" Neurology anatomy-and-
physiology cavernous-sinus
The cavernous sinus contains venous return from which structures? What is the
drainage of the cavernous sinus? Blood from the eye and superficial cortex
drains to the cavernous sinus, then to the internal jugular vein "<img
src=""8166.png"">" Neurology anatomy-and-physiology cavernous-sinus
Which cranial nerves (CNs) traverse the cavernous sinus? CNs III, IV, V1, V2, and
VI "<img src=""8166.png"">" Neurology anatomy-and-physiology cavernous-
sinus
A pt with a brain tumor shows limited extraocular movement and reduced corneal and
maxillary sensation. Name the syndrome. Cavernous sinus syndrome (Mass [eg, a
tumor] compresses the cavernous sinus, impairing cranial nerves III, IV, V1, V2,
and VI.) "<img src=""8166.png"">" Neurology anatomy-and-physiology
cavernous-sinus
Which arteries pass through the cavernous sinus? The internal carotid arteries
"<img src=""8166.png"">" Neurology anatomy-and-physiology cavernous-
sinus
A pt sustains head trauma with diffuse bleeding. Shortly after he arrives in the
ED, an acute CN VI palsy develops. What happened? Likely injury to the internal
carotid artery, causing a carotid-cavernous fistula and leading to cavernous sinus
syndrome with a CN VI palsy "<img src=""8166.png"">" Neurology anatomy-and-
Ophthalmoplegia, lessened corneal sensation, and Horner syndrome develop in a man
with bacteremia. What will maxillary sensory testing show? Possibly diminished
sensation (from CN V impairment); these symptoms may indicate a cavernous sinus
thrombosis due to infection "<img src=""8166.png"">" Neurology anatomy-and-
A man has a pituitary mass invading the cavernous sinus. CN V is impaired, but not
in the lower part of the face. Why? Of the three CN V branches, only V1 and V2
(upper two thirds of the face) pass through the cavernous sinus; CN V3 does not and
is unaffected "<img src=""8166.png"">" Neurology anatomy-and-physiology
cavernous-sinus
What structures make up the outer ear? The pinna (visible portion), auditory
canal, and eardrum "<img src=""8167.png"">" Neurology anatomy-and-
physiology auditory-physiology
How does the outer ear transfer sound? It transfers sound by the vibration of
the eardrum "<img src=""8167.png"">" Neurology anatomy-and-physiology
auditory-physiology
What structures make up the middle ear? The air-filled space and the ossicles
(malleus, incus, and stapes) "<img src=""8167.png"">" Neurology anatomy-and-
physiology auditory-physiology
What is the function of the middle ear? The ossicles conduct and amplify sound to
the inner ear "<img src=""8167.png"">" Neurology anatomy-and-physiology
auditory-physiology
What structure makes up the inner ear? The snail-shaped, fluid-filled cochlea
(contains basilar membrane that vibrates and conducts sound to the auditory nerve)
"<img src=""8167.png"">" Neurology anatomy-and-physiology auditory-
physiology
A pt has high-frequency hearing loss. What part of the basilar membrane is damaged?
Base of the cochlea (thin and rigid) "<img src=""8167.png"">"
Neurology anatomy-and-physiology auditory-physiology
A pt has low-frequency hearing loss. What part of the basilar membrane is likely
damaged? The apex near the helicotrema (wide and flexible) "<img
src=""8167.png"">" Neurology anatomy-and-physiology auditory-physiology
A pt with a brain-stem stroke has hearing loss. Inner ear testing demonstrates a
normal cochlea. What is the cause of the hearing loss? The stroke (the auditory
nerve conducts sound from the cochlea to the brain stem) "<img src=""8167.png"">"
Neurology anatomy-and-physiology auditory-physiology
A pt has an audiogram demonstrating conductive hearing loss in the right ear. What
will the Weber and Rinne tests show? Weber test: lateralization to the
affected ear (right); Rinne test: abnormal result (bone conduction greater than air
conduction) "<img src=""8168.png"">" Neurology anatomy-and-physiology hearing-
loss
A pt has a Weber test finding localized to the left and air &62; bone conduction
bilaterally. What type of hearing loss is this? Sensorineural hearing loss on the
right "<img src=""8168.png"">" Neurology anatomy-and-physiology hearing-loss
A pt has a Weber test finding lateralized to the right and bone &62; air conduction
on the right. What type of hearing loss is this? Conductive hearing loss on
the right "<img src=""8168.png"">" Neurology anatomy-and-physiology hearing-
loss
A woman has an audiogram demonstrating sensorineural hearing loss in the right ear.
What will her Weber and Rinne tests show? Weber test: lateralization to the
unaffected ear (left); Rinne test: normal result (air conduction greater than bone
conduction) "<img src=""8168.png"">" Neurology anatomy-and-physiology hearing-
loss
A construction worker realizes he cannot hear high-frequency sounds. What damage
has occurred in his ears? Damage to the stereociliated cells in the organ of
Corti (can result from sudden extremely loud noises causing tympanic membrane
rupture) "<img src=""8168.png"">" Neurology anatomy-and-physiology hearing-
loss
A pt has overgrowth of desquamated keratin debris within the middle ear. What is
this called? What type of hearing loss do you observe? Cholesteatoma;
conductive hearing loss "<img src=""8169.png"">" Neurology anatomy-and-
physiology cholesteatoma
A pt sustains unusual cranial trauma, and the optic nerve is severed. What other
structures were also severed in this event? The central retinal artery and the
central retinal vein (Both run inside of the optic nerve.) "<img src=""8170.png"">"
neurology normal-eye ophthalmology
From outside to inside, what are the main tissue layers of the eyeball? Sclera
(outer), choroid (middle), and retina (inner) "<img src=""8170.png"">"
Neurology normal-eye ophthalmology
What is the most anterior structure of the eye? What lies directly behind it?
The cornea; the anterior chamber "<img src=""8170.png"">" Neurology
normal-eye ophthalmology
To what structure does the optic nerve, entering the eyeball, connect directly?
Name an important landmark adjacent to this structure. The optic disc; the
fovea "<img src=""8170.png"">" Neurology normal-eye ophthalmology
What structure separates the anterior chamber from the posterior chamber within the
eye? The pupil "<img src=""8170.png"">" Neurology normal-eye ophthalmology
What structure directly determines the size of the pupil? The iris "<img
src=""8170.png"">" Neurology normal-eye ophthalmology
Through what structure must light pass to reach the lens? What structure suspends
the lens in place? The pupil; the zonular fibers attached to the ciliary
bodies "<img src=""8170.png"">" Neurology normal-eye ophthalmology
Aqueous humor is produced by what structure in the posterior chamber? Where does it
drain from? What does it drain into? Ciliary epithelium; it drains from the
trabecular meshwork; it drains into the canal of Schlemm "<img src=""8171.png"">"
Neurology aqueous-humor-pathway ophthalmology
A pt starts taking the -blocker timolol. What ocular function is likely to be
affected? The production of aqueous humor from the ciliary epithelium"<img
src=""8171.png"">" Neurology aqueous-humor-pathway ophthalmology
What receptors are associated with the ciliary muscles of the eye? The ciliary
muscles have M3 receptors "<img src=""8171.png"">" Neurology aqueous-humor-
pathway ophthalmology
A man with cholinergic agonist poisoning has overactivation of the sphincter
pupillae muscles, resulting in pathologic miosis. Why? M3 receptors are found
on the sphincter pupillae muscles, which cause miosis "<img src=""8171.png"">"
Neurology aqueous-humor-pathway ophthalmology
A pt is terrified and has a surge of adrenaline. His dilator pupillae muscles
activate, and his pupils are enlarged. Why is this? Adrenaline binds to 1-
receptors of the dilator pupillae muscles, leading to mydriasis (pupil enlargement)
"<img src=""8171.png"">" Neurology aqueous-humor-pathway ophthalmology
One cause of glaucoma is the iris pushing up against the trabecular meshwork. Why
might this cause increased intraocular pressure? It prevents aqueous humor,
produced by the ciliary bodies, from draining into the canal of Schlemm, thus
increasing pressure "<img src=""8171.png"">" Neurology aqueous-humor-
pathway ophthalmology
What is hyperopia? The eye is too short for the refractive power of the cornea
and lens, so light is focused behind the retina "<img src=""8172.png"">"
Neurology ophthalmology refractive-errors
What is myopia? The eye is too long for the refractive power of the cornea and
lens, so light is focused in front of the retina "<img src=""8172.png"">"
neurology ophthalmology refractive-errors
What is astigmatism? Abnormal curvature of the cornea that causes different
refractive powers to arise at different axes "<img src=""8172.png"">"
neurology ophthalmology refractive-errors
A pt notes difficulty seeing and must wear reading glasses. Distant vision is
normal. What change in his lens is to blame? The lens has reduced elasticity
(presbyopia, which results in age-related impaired accommodation [difficulty
focusing on near objects]) "<img src=""8172.png"">" neurology ophthalmology
refractive-errors
Name the major risk factors for cataracts. Aging, smoking, alcohol, sunlight,
prolonged corticosteroid use, classic galactosemia, galactokinase deficiency,
diabetes, trauma, infection "<img src=""8173.png"">" cataract neurology
ophthalmology
An elderly diabetic pt develops bilateral cataracts. The accumulation of which
compound is most likely responsible? Sorbitol "<img src=""8173.png"">"
cataract neurology ophthalmology
A 78-year-old black woman presents with peripheral visual loss and optic disc
cupping. Do you see any atrophy on funduscopic exam? Yes, optic disc atrophy is
common in glaucoma "<img src=""8174.png"">" glaucoma neurology
ophthalmology
Increased intraocular pressure manifests as what finding on funduscopy? Optic
disc atrophy with cupping "<img src=""8174.png"">" glaucoma neurology
ophthalmology
What is the difference between the two forms of glaucoma? Open-angle glaucoma:
impaired canal of Schlemm drainage; closed-angle: angle between iris and lens
narrows & pressure increases behind iris "<img src=""8174.png"">" glaucoma
neurology ophthalmology
Why is epinephrine contraindicated in closed-angle glaucoma? Sympathetic
stimulation causes mydriasis, which exacerbates outflow obstruction "<img
src=""8174.png"">" glaucoma neurology ophthalmology
Is open-angle glaucoma painful? Is closed-angle glaucoma painful? Open-angle
glaucoma: painless; closed-angle glaucoma: painful "<img src=""8174.png"">"
glaucoma neurology ophthalmology
In which form of glaucoma is epinephrine contraindicated? Acute closed-angle
glaucoma because epinephrine has a mydriatic effect "<img src=""8174.png"">"
glaucoma neurology ophthalmology
An African-American pt presents with optic disc atrophy and cupping. Which variant
of her disease process is most likely occurring? Open-angle glaucoma (African-
American race is a risk factor.) "<img src=""8174.png"">" glaucoma neurology
ophthalmology
A woman has sudden painful vision loss and a terrible headache. She is seeing halos
around lights. You touch her eye. How does it feel? The eye will likely feel rock
hard, as this is closed- or narrow-angle glaucoma with acute closure "<img
What pathologic process underlies primary closed/narrow-angle glaucoma?
Enlargement or forward movement of lens against central iris leads to
closure; fluid accumulates behind iris, pushing it against cornea "<img
What are secondary causes of closed/narrow-angle glaucoma? Hypoxia from retinal
disease (eg, diabetes, vein occlusion) induces vasoproliferation in the iris that
contracts the angle "<img src=""8174.png"">" glaucoma neurology
ophthalmology
What is damaged with chronic closed/narrow-angle glaucoma? The optic nerve and
peripheral vision (This type of glaucoma is generally asymptomatic.) "<img
Name some causes of secondary open-angle glaucoma. Blocked trabecular meshwork
from WBCs (eg, uveitis), RBCs (eg, vitreous hemorrhage), or retinal elements (eg,
retinal detachment) "<img src=""8174.png"">" glaucoma neurology
ophthalmology
A pt presents with inflammation/redness and itchiness of both eyes. What is this
condition called and what is the likely etiology? Conjunctivitis; allergy "<img
src=""8175.png"">" conjunctivitis neurology ophthalmology
A pt presents with pus and inflammation/redness in his right eye. What is the most
likely etiology and what is the treatment? Bacteria; treatment is
administration of antibiotics "<img src=""8175.png"">" Neurology conjunctivitis
ophthalmology
What is the most common cause of conjunctivitis? What is the most likely specific
pathogen? What is the treatment? A virus; adenovirus; supportive treatment, as
it is self-resolving "<img src=""8175.png"">" Neurology conjunctivitis
ophthalmology
What is uveitis? Inflammation of the uvea: anterior (iritis), intermediate (pars
planitis), posterior (choroiditis and/or retinitis) "<img src=""8176.png"">"
Neurology ophthalmology uveitis
What kinds of conditions are typically associated with uveitis? Name some examples.
Systemic inflammatory disorders (eg, sarcoidosis, rheumatoid arthritis,
juvenile idiopathic arthritis, HLA-B27associated conditions) "<img
src=""8176.png"">" neurology ophthalmology uveitis
What is a hypopyon? An accumulation of pus in the anterior chamber of the eye
"<img src=""8176.png"">" neurology ophthalmology uveitis
What is age-related macular degeneration? Degeneration of the macula (central area
of the retina) causing distortion (metamorphopsia) and eventual loss of central
vision (scotomas) "<img src=""8177.png"">" age-related-macular-degeneration
What are the two classes of macular degeneration, and how often does each occur?
Dry (>80%) and wet (1015%) "<img src=""8177.png"">" age-related-
macular-degeneration neurology ophthalmology
A man has rapid monocular vision loss. Treatment with a VEGF inhibitor slows
symptom progression. What other treatment could work for him? Laser therapy, as
this is likely wet macular degeneration "<img src=""8177.png"">" age-related-
macular-degeneration neurology ophthalmology
What is ranibizumab, and for which form of age-related macular degeneration is it
indicated? An anti-VEGF (vascular endothelial growth factor) drug that, when
injected into the eye, slows the progression of wet macular degeneration "<img
src=""8177.png"">" age-related-macular-degeneration neurology ophthalmology
What are drusen? Deposits of yellowish extracellular material in and between the
Bruch membrane and retinal pigment epithelium in dry macular degeneration "<img
src=""8177.png"">" age-related-macular-degeneration neurology ophthalmology
How does diabetes lead to diabetic retinopathy? Retinal damage results from chronic
hyperglycemia "<img src=""8178.png"">" diabetic-retinopathy neurology
ophthalmology
A diabetic man has progressing monocular vision loss. Funduscopy shows aberrant
retinal vessels. What treatments can you offer? For proliferative diabetic
retinopathy, you may offer peripheral retinal photocoagulation or anti-VEGF agents
(eg, bevacizumab) "<img src=""8178.png"">" Neurology diabetic-retinopathy
ophthalmology
What is the pathophysiology of nonproliferative diabetic retinopathy? Capillaries
damaged by chronic hyperglycemia leak blood, and lipids and fluid seep into the
retina, leading to hemorrhages and macular edema "<img src=""8178.png"">"
Neurology diabetic-retinopathy ophthalmology
What is the pathophysiology of proliferative diabetic retinopathy? Prolonged
hypoxia from chronic hyperglycemia results in new blood vessel formation, causing
traction on the retina "<img src=""8178.png"">" Neurology diabetic-
retinopathy ophthalmology
A pt has retinal vein occlusion. What findings do you expect to see on funduscopy?
Retinal hemorrhages and venous engorgement, with edema in the affected area
"<img src=""8179.png"">" Neurology ophthalmology retinal-vein-occlusion
What is retinal detachment? Separation of the retinal neurosensory layer from the
outermost pigmented epithelium, causing photoreceptor degeneration and vision loss
"<img src=""8180.png"">" neurology ophthalmology retinal-detachment
What is the neurosensory layer of the retina? The photoreceptor layer with rods
and cones "<img src=""8180.png"">" neurology ophthalmology retinal-
detachment
What is the outermost pigmented epithelium of the retina? A supportive layer that
normally shields the retina from excess light and provides structural support
"<img src=""8180.png"">" neurology ophthalmology retinal-detachment
What are some causes of retinal detachment? Diabetic traction, retinal breaks,
inflammatory effusion "<img src=""8180.png"">" neurology ophthalmology
retinal-detachment
"A pt reports ""curtain-like"" vision loss. He has a history of diabetes. What two
studies can be used to confirm the likely diagnosis?" Funduscopy (to visualize
splaying and paucity of retinal vessels) and cross-sectional optical ultrasound to
diagnose retinal detachment "<img src=""8180.png"">" neurology ophthalmology
retinal-detachment
"What are ""flashes"" and ""floaters"" in the context of retinal detachment?"
Signs and symptoms of posterior vitreous detachment, often preceding retinal
detachment "<img src=""8180.png"">" neurology ophthalmology retinal-
detachment
At the center of what retinal structure is the fovea found?The macula "<img
src=""8181.png"">" central-retinal-artery-occlusion neurology ophthalmology
A woman has progressive, painless vision loss in both eyes. Her father had the same
issue. What will retinal examination of the macula show? Bone spiculeshaped
deposits around the macula, characteristic of retinitis pigmentosa "<img
src=""8182.png"">" Neurology ophthalmology retinitis-pigmentosa
What are the classic funduscopic findings in retinitis? Retinal edema and
necrosis leading to scar formation "<img src=""8183.png"">" neurology
ophthalmology retinitis
What is the most common physiologic cause of papilledema? Increased intracranial
pressure "<img src=""8184.png"">" Neurology ophthalmology papilledema
What eye finding correlates with a mass effect within the brain? Why? Bilateral
papilledema, which is due to an increase in intracranial pressure from the mass
effect "<img src=""8184.png"">" Neurology ophthalmology papilledema
A pupil is constricted. What is this called, and what mediates this action?
Miosis; parasympathetic pathway "<img src=""8185.png"">" Neurology
ophthalmology pupillary-control
A pupil is dilated. What is this called, and what mediates this action?
Mydriasis; sympathetic pathway "<img src=""8185.png"">" Neurology
What ciliary nerves innervate pupillary sphincter muscles? What ciliary nerves
innervate pupillary dilator muscles? Short; long "<img src=""8185.png"">"
Neurology ophthalmology pupillary-control
In rare cases, pts with apical lung cancers can present with loss of mydriasis. Why
might this be? Apical tumors may compress superior cervical ganglia of the
cervical sympathetic chain (lung apex/subclavian vessels), blocking mydriasis
"<img src=""8185.png"">" Neurology ophthalmology pupillary-control
A pt's stroke knocks out one of his Edinger-Westphal nuclei. What stops receiving
signals downstream, and what function is affected? Ciliary ganglia (via CN III)
stop receiving signals, leading to loss of miosis in the affected eye "<img
src=""8185.png"">" Neurology ophthalmology pupillary-control
What is the pathway of the pupillary light reflex? Light to CN II to pretectal
nuclei (midbrain) (activates Edinger-Westphal nuclei, and pupils contract
bilaterally [consensual reflex]) "<img src=""8185.png"">" Neurology
What paths are taken by the two neurons of the parasympathetic pathway that cause
miosis? First: Edinger-Westphal nucleus to ciliary ganglion via CN III; second:
short ciliary nerves to pupillary sphincter muscles "<img src=""8185.png"">"
Neurology ophthalmology pupillary-control
What paths are taken by the first two neurons of the sympathetic pathway that cause
mydriasis? First: hypothalamus to ciliospinal center of Budge (C8T2); second:
exit at T1 to superior cervical ganglion "<img src=""8185.png"">" Neurology
What is the path taken by the final neuron of the sympathetic pathway that causes
mydriasis, starting with the cervical sympathetic chain? Internal carotid plexus
to cavernous sinus to orbit as long ciliary nerve to pupillary dilator muscles
"<img src=""8185.png"">" Neurology ophthalmology pupillary-control
Name some structures that are innervated by the sympathetic chain. Pupillary
dilator muscles, smooth muscle of the eyelids (minor retractors) sweat glands of
the forehead and face "<img src=""8185.png"">" Neurology ophthalmology
pupillary-control
What is a Marcus Gunn pupil? Diminished bilateral pupil constriction when light is
shone in an eye with an afferent pupillary defect, relative to the unaffected eye
"<img src=""8186.png"">" Neurology marcus-gunn-pupil ophthalmology
A swinging flashlight test shows pupillary constriction if the left eye is
illuminated, dilation if the right eye is illuminated. Diagnosis? Marcus Gunn
pupil (afferent pupillary defect) of the right side, from optic nerve or retinal
damage "<img src=""8186.png"">" marcus-gunn-pupil neurology ophthalmology
A lifetime smoker has fatigue, weight loss, ptosis, and miosis. What two other
spinal cord lesions can cause the last two symptoms? He has a Pancoast tumor and
Horner syndrome. (Horner syndrome can also result from late-stage syringomyelia and
Brown-Squard syndrome.) "<img src=""8187.png"">" horner-syndrome
A pt with ptosis, anhidrosis, and miosis has Horner syndrome. Trace the three-
neuron pathway that is disrupted in this syndrome. Hypothalamus to IML in
lateral horn (first synapse) to superior cervical ganglion (second synapse) to
postganglionics in face, pupil, eyelid "<img src=""8187.png"">" horner-
syndrome neurology ophthalmology
A pt has damage to a sympathetic pathway that travels with the carotids. What is
this pathway called? What symptoms would you expect? Oculosympathetic pathway
(damaged in Horner syndrome); a facial sympathectomy with ptosis, anhidrosis, and
miosis would be expected "<img src=""8187.png"">" horner-syndrome
A pt with late-stage syringomyelia is found to have Horner syndrome. What triad is
a classic sign of the disorder on the affected side? Ptosis (eyelid droop due to
superior tarsal muscle weakness), Anhydrosis (no sweating/flushing),Miosis (pupil
constriction) (PAM is horny.) "<img src=""8187.png"">" horner-syndrome
A pt with carotid artery dissection only has an issue with lower facial sweating.
Where is the dissection most likely found? The external carotid artery, which
only carries sympathetic fibers that innervate sweat glands of the lower face
"<img src=""8187.png"">" horner-syndrome neurology ophthalmology
A man has unilateral ptosis and miosis. His forehead does not sweat, but the rest
of his face does. Where is the sympathetic chain lesion? The internal carotid
artery, after the bifurcation of the common carotid artery (The sympathetic fibers
to the lower face are spared.) "<img src=""8187.png"">" horner-syndrome
The long ciliary nerve, just before reaching the eye, travels as a part of which
cranial nerve? The ophthalmic division of the trigeminal nerve "<img
src=""8187.png"">" horner-syndrome neurology ophthalmology
In the sympathetic chain, some fibers enter the eye, whereas others travel to areas
above it. What functions does each group of fibers have? In the eye (long ciliary
nerve): pupillary dilator; above the eye: forehead sweat glands, eyelid smooth
muscles "<img src=""8187.png"">" horner-syndrome neurology ophthalmology
A pt sustains spinal cord trauma at the level of T2. Do you expect any findings on
ophthalmologic exam? No. As this lesion is just below the synapse of the first
and second sympathetic chain neurons, it will not be affected "<img
src=""8187.png"">" horner-syndrome neurology ophthalmology
Which extraocular muscle does cranial nerve IV innervate? Superior oblique "<img
src=""8188.png"">" neurology ocular-motility ophthalmology
Which extraocular muscle does cranial nerve VI innervate? Lateral rectus "<img
src=""8188.png"">" Neurology ocular-motility ophthalmology
Which muscle abducts, intorts, and depresses the eye? Superior oblique "<img
"How does the ""chemical formula"" (mnemonic) LR6SO4R3 help you remember the
innervations of the extraocular muscle?" CN VI innervates the Lateral Rectus; CN
IV innervates the Superior Oblique; CN III innervates the Rest "<img
A pt's inability to follow the examiner's finger toward the nose indicates a
weakness in which muscle? Medial rectus "<img src=""8188.png"">"
Neurology ocular-motility ophthalmology
A pt's inability to follow the examiner's finger upward and medially indicates a
weakness in which muscle? Inferior oblique (Obliques move the eye in the
Opposite direction.) "<img src=""8188.png"">" Neurology ocular-motility
ophthalmology
A pt's inability to follow the examiner's finger downward and medially indicates a
weakness in which muscle? Superior oblique (Obliques move the eye in the
Opposite direction.) "<img src=""8188.png"">" Neurology ocular-motility
ophthalmology
A pt's inability to follow the examiner's finger downward and laterally indicates a
weakness in which muscle? Inferior rectus "<img src=""8188.png"">"
A pt's inability to follow the examiner's finger toward the temple indicates a
weakness in which muscle? Lateral rectus "<img src=""8188.png"">"
A pt's inability to follow the examiner's finger upward and laterally indicates a
weakness in which muscle? Superior rectus "<img src=""8188.png"">"
How does the mnemonic IOU help you remember the test for the inferior oblique?
To test the Inferior Oblique, have the patient look Up "<img
What eye position is best for testing the function of the superior oblique muscle?
When the eye is adducted "<img src=""8188.png"">" Neurology ocular-
motility ophthalmology
A pt's right eye is stuck in a down-and-out position. Name the CN lesion and other
eye exam findings. This is a CN III lesion, with ptosis, loss of
accommodation, and mydriasis (pupil dilation) "<img src=""8189.png"">"
Neurology cn-iii,-iv,-vi-palsies ophthalmology
A pt presents with one persistently dilated pupil. What is the pathophysiology of
the lesion? A blown pupil: CN III peripheral fibers are parasympathetic, causing
unopposed sympathetic stimulation (mydriasis) when they are compressed "<img
src=""8189.png"">" cn-iii,-iv,-vi-palsies neurology ophthalmology
A pt has limited movement in one eye; the eye is directed downward and laterally.
Ptosis is seen. What is the etiology of the lesion? A CN III central motor fiber
lesion caused when vascular disease (eg, diabetes [sorbitol buildup]) decreased
oxygen to interior fibers "<img src=""8189.png"">" cn-iii,-iv,-vi-palsies
Name some specific causes of CN III lesions with primarily parasympathetic
deficits. Posterior communicating artery aneurysms, uncal herniation (Compression
affects the outer parasympathetic fibers of the nerve.) "<img src=""8189.png"">"
cn-iii,-iv,-vi-palsies neurology ophthalmology
Where does the vasculature that supplies the motor fibers of CN III reside? Along
the outside of the nerve (Thus, when compromised, deeper motor fibers farther from
the blood supply are affected first.) "<img src=""8189.png"">" cn-iii,-iv,-
vi-palsies neurology ophthalmology
What are exam findings for a pt with damage to the parasympathetic fibers of CN
III? A diminished or no pupillary light reflex and a blown pupil (often with a
down and out gaze) "<img src=""8189.png"">" cn-iii,-iv,-vi-palsies
What are the physical exam findings in a pt with unilateral cranial nerve IV
(trochlear) palsy? The eye moves upward, especially with contralateral gaze
and head tilt toward the side of the lesion "<img src=""8189.png"">" cn-
iii,-iv,-vi-palsies neurology ophthalmology
A pt has a distal left MCA stroke affecting branches to the parietal lobe. Will
visual field testing reveal any deficits? Yes, the pt may have a right lower
quadrantic anopia if the left dorsal optic radiation was affected "<img
src=""8190.png"">" neurology ophthalmology visual-field-defects
A 75-year-old pt has vision loss in the center of her left eye. What is the cause?
She has a central scotoma, likely resulting from macular degeneration in her
left eye "<img src=""8190.png"">" neurology ophthalmology visual-field-
defects
What is the pathway of the Meyer loop? Inferior retina; loops around the
inferior horn of the lateral ventricle "<img src=""8190.png"">" neurology
ophthalmology visual-field-defects
What is the pathway of the dorsal optic radiation? Superior retina; takes
shortest path via internal capsule "<img src=""8190.png"">" neurology
A pt has a distal right MCA stroke affecting branches to the temporal lobe. Will
visual field testing reveal any deficits? Yes, the pt may have a left upper
quadrantic anopia if the right Meyer loop was affected "<img src=""8190.png"">"
neurology ophthalmology visual-field-defects
Transection of the optic nerve results in what type of visual field defect?
Complete unilateral anopia "<img src=""8190.png"">" neurology
If a pt presents with a pituitary adenoma, for what visual field defect should he
or she be screened? Bitemporal hemianopia "<img src=""8190.png"">"
What is the name for the bundle of nerve fibers between the optic chiasm and the
lateral geniculate body? The optic tract "<img src=""8190.png"">"
A lesion of the right optic tract may cause what type of visual field defect?
Left homonymous hemianopia "<img src=""8190.png"">" neurology
A lesion of the left Meyer loop (optic afferents through the temporal lobe) may
result in what type of visual field defect? Right upper quadrantic anopia "<img
src=""8190.png"">" neurology ophthalmology visual-field-defects
A lesion of the right dorsal optic radiation (parietal lobe) may result in what
visual field defect? Left lower quadrantic anopia "<img src=""8190.png"">"
A lesion at the right calcarine fissure of the visual cortex may result in what
visual field defect? Left hemianopia with macular sparing (PCA infarct); the
macula has bilateral projections to the occiput "<img src=""8190.png"">"
A pt has a stroke resulting in loss of the entire left visual field. There is
macular sparing. Name the likely infarcted vessel. Right posterior cerebral
artery (PCA), which supplies the optic tract; lesions here result in a hemianopia
with macular sparing "<img src=""8190.png"">" neurology ophthalmology
visual-field-defects
A pt cannot gaze laterally with both eyes. When he looks left, the left eye has
nystagmus, but convergence is normal. Diagnosis? Medial longitudinal
fasciculus syndrome "<img src=""8191.png"">" internuclear-ophthalmoplegia
With what disease is medial longitudinal fasciculus syndrome associated?
Multiple sclerosis (MLF in MS) "<img src=""8191.png"">" Neurology
internuclear-ophthalmoplegia ophthalmology
What two structures does the right medial longitudinal fasciculus connect? Left
CN VI nucleus and right medial subnucleus of CN III "<img src=""8191.png"">"
Neurology internuclear-ophthalmoplegia ophthalmology
The medial longitudinal fasciculus coordinates lateral gaze by connecting which two
cranial nerve (CN) nuclei? The CN VI nucleus (which controls the lateral rectus)
and the medial rectus subnucleus of CN III "<img src=""8191.png"">"
Neurology internuclear-ophthalmoplegia ophthalmology
A pt has a right-side INO. He tries to look left, and horizontal nystagmus develops
in his left eye. Why? The left CN VI nucleus, unable to stimulate the right CN
III subnucleus to move the right eye medially, overfires, causing the nystagmus
"<img src=""8191.png"">" Neurology internuclear-ophthalmoplegia
ophthalmology
"A ""right"" internuclear ophthalmoplegia indicates that the lesion is on which
side, affecting the connection between which two nuclei?" The ipsilateral MLF
(communication between contralateral CN VI nucleus and ipsilateral CN III
subnucleus) is impaired "<img src=""8191.png"">" Neurology internuclear-
ophthalmoplegia ophthalmology
Can INOs present unilaterally, bilaterally, or both? With which type of
presentation is multiple sclerosis classically associated? INOs can present both
unilaterally and bilaterally; multiple sclerosis is associated with bilateral
lesions "<img src=""8191.png"">" Neurology internuclear-ophthalmoplegia
ophthalmology
What is the most common cause of dementia in the elderly? Alzheimer disease "<img
src=""8192.png"">" Neurology Pathology dementia
The proteins APP, presenilin-1, presenilin-2, and ApoE4 are associated with the
familial form of what type of dementia? Alzheimer disease "<img src=""8192.png"">"
Neurology Pathology dementia
Alzheimer disease may cause amyloid angiopathy, which can result in what serious
complication? Intracranial hemorrhage "<img src=""8192.png"">" Neurology
Pathology dementia
What is the difference between the apolipoprotein isoforms E2 and E4 in the
pathogenesis of Alzheimer disease? The E4 isoform is a genetic risk factor for
familial Alzheimer disease, and the E2 isoform protects against Alzheimer disease
"<img src=""8192.png"">" Neurology Pathology dementia
Mutations in which three proteins increase the risk for early-onset Alzheimer
dementia? APP, presenilin-1, and presenilin-2 "<img src=""8192.png"">"
What are senile plaques made of? Where are they commonly found? Extracellular -
amyloid; in the gray matter "<img src=""8192.png"">" Neurology Pathology
dementia
What is the second most common cause of dementia in the elderly after Alzheimer
disease? Vascular dementia (caused by multiple arterial infarcts) "<img
What degenerative disease of the cerebral cortex affects only the frontal and
temporal lobes? Pick disease (frontotemporal dementia) "<img src=""8192.png"">"
What pathologic findings (gross and microscopic) are characteristic of Pick disease
(frontotemporal dementia)? Pick bodies ( protein aggregates) and frontotemporal
atrophy with sparing of parietal lobe, posterior two thirds of superior temporal
gyrus "<img src=""8192.png"">" Neurology Pathology dementia
An elderly woman is increasingly socially inappropriate and inattentive and has
difficulty speaking. What is the likely diagnosis? Pick disease (frontotemporal
dementia) "<img src=""8192.png"">" Neurology Pathology dementia
What degenerative disease of the cerebral cortex is caused by an -synuclein
defect? Lewy body dementia "<img src=""8192.png"">" Neurology
Pathology dementia
A pt has a resting tremor and short-term memory loss and is having visual
hallucinations. Diagnosis and histologic findings? Lewy body dementia; an -
synuclein defect causes the formation of Lewy bodies, mainly in the cortical
regions "<img src=""8192.png"">" Neurology Pathology dementia
What degenerative disease of the cerebral cortex is associated with rapidly
progressive dementia, myoclonus, and a spongiform cortex? Creutzfeldt-Jakob
disease "<img src=""8192.png"">" Neurology Pathology dementia
A pt has a rapidly progressive dementia with startle myoclonus. Explain the
abnormal biology causing these symptoms. Prions have isoform PrPsc (instead of
PrPc), resulting in a protease-resistant -pleated sheet. (This pt has Creutzfeldt-
Jakob disease.) "<img src=""8192.png"">" Neurology Pathology dementia
An older pt has memory loss. Before she takes the first-line AChE inhibitor, what
treatable causes of her symptoms must be ruled out? Wilson disease, NPH, HIV,
syphilis, and vitamin B1, B3, or B12 deficiency "<img src=""8192.png"">"
An elderly pt has a progressive dementia, worsening after each hospital stay.
Alzheimer dementia is ruled out. Most likely diagnosis? "Vascular or ""multi-
infarct"" dementia, the second most common cause of dementia in the elderly" "<img
How is (amyloid-), which builds up in pts with Alzheimer dementia, formed?
It is synthesized by cleaving of amyloid precursor protein (APP) "<img
What histopathologic finding correlates with the severity of Alzheimer dementia?
Explain the composition of this protein. Neurofibrillary tangles; these are
intracellular, abnormally hyperphosphorylated tau proteins that form insoluble
cytoskeletal elements "<img src=""8192.png"">" Neurology Pathology dementia
What are the possible clinical manifestations of osmotic demyelination syndrome?
Loss of consciousness, dysphagia, acute paralysis, diplopia, dysarthria
"<img src=""8193.png"">" Neurology Pathology osmotic-demyelination-
syndrome-(central-pontine-myelinolysis)
What is the most feared possible complication of osmotic demyelination syndrome?
Locked-in syndrome "<img src=""8193.png"">" Pathology neurology
osmotic-demyelination-syndrome-(central-pontine-myelinolysis)
What is the most common cause of osmotic demyelination syndrome? Medical treatment;
specifically, overly rapid correction of hyponatremia "<img src=""8193.png"">"
Pathology neurology osmotic-demyelination-syndrome-(central-pontine-
myelinolysis)
What syndrome is caused by increasing the sodium level too quickly in a pt with
hyponatremia? Osmotic demyelination syndrome (From low to high, your pons will
die.) "<img src=""8193.png"">" Pathology neurology osmotic-
demyelination-syndrome-(central-pontine-myelinolysis)
A pt with hyponatremia receiving Na+ therapy exhibits acute paralysis and loss of
consciousness. Describe what you might see on MRI. Increased signal in the
central pons, indicating massive axonal demyelination in central pontine
myelinolysis "<img src=""8193.png"">" Pathology neurology osmotic-
demyelination-syndrome-(central-pontine-myelinolysis)
A pt with hyponatremia develops dysarthria, diplopia, and dysphagia after a
hospital intervention. Diagnosis? Cause? Central pontine myelinolysis; secondary
to edema and osmotic forces caused by overcorrection of serum sodium "<img
src=""8193.png"">" Pathology neurology osmotic-demyelination-syndrome-
(central-pontine-myelinolysis)
A man has hypernatremia. The doctor lowers his Na level slowly. What brain damage
would occur if serum Na were corrected too quickly? "Cerebral edema and
herniation (""From high to low, your brain will blow.)" "<img src=""8193.png"">"
Pathology neurology osmotic-demyelination-syndrome-(central-pontine-
myelinolysis)
In broad terms, what is the pathophysiology of multiple sclerosis? Autoimmune
inflammation and demyelination of the CNS (brain and spinal cord) "<img
src=""8194.png"">" Pathology multiple-sclerosis neurology
What are some of the typical presenting symptoms of multiple sclerosis? Optic
neuritis (sudden loss of vision resulting in Marcus Gunn pupil), INO, hemiparesis,
hemisensory symptoms, bladder/bowel incontinence "<img src=""8194.png"">"
Pathology multiple-sclerosis neurology
How do you diagnose multiple sclerosis? Increased IgG level and myelin basic
protein in CSF. Oligoclonal bands are diagnostic. MRI is gold standard. "<img
What is the Charcot triad of multiple sclerosis? Scanning speech, Intention
tremor (also Incontinence and INO), Nystagmus = SIN "<img src=""8194.png"">"
A female pt's lab results confirm oligoclonal bands in the cerebrospinal fluid.
What drugs can delay the course of this disease? Disease-modifying therapies
(eg, -interferon, glatiramer, natalizumab) are used to slow the progression of
multiple sclerosis "<img src=""8194.png"">" Pathology multiple-sclerosis
neurology
Which imaging modality is the gold standard for diagnosing multiple sclerosis? What
are the typical findings? MRI; periventricular plaques with destruction of
axons and multiple white matter lesions separated in space and time "<img
Multiple sclerosis causes damage to which of the following: axons, neuron cell
bodies, myelin? Myelin only "<img src=""8194.png"">" Pathology multiple-
sclerosis neurology
What demographic group (race, sex, and age) is most likely to be affected by
multiple sclerosis? White women, 2030 years of age "<img src=""8194.png"">"
What symptomatic treatment is given to pts with multiple sclerosis? Muscarinic
antagonists and catheterization (neurogenic bladder), opioids (pain), GABA agonists
(spasticity), immunosuppression (steroids) "<img src=""8194.png"">"
Is the course of multiple sclerosis usually rapidly progressive, chronic,
insidious, or relapsing and remitting? Relapsing and remitting "<img
A pt with multiple sclerosis has optic neuritis. She cannot see out of the eye.
What pupil abnormality will you see on ophthalmologic exam?A Marcus Gunn pupil
"<img src=""8194.png"">" Pathology multiple-sclerosis neurology
A woman with longstanding multiple sclerosis has bladder spasticity and muscle
spasms. What treatments can you offer for symptom relief? For a neurogenic
bladder: catheterization, muscarinic antagonists; for spasticity: baclofen, GABAB
receptor agonists "<img src=""8194.png"">" Pathology multiple-sclerosis
neurology
A 24-year-old woman has new-onset leg paralysis. It has spread to the face. ECG
findings are abnormal; CSF protein is high. Diagnosis? Acute inflammatory
demyelinating polyradiculopathy, the most common variant of Guillain-Barr syndrome
"<img src=""8195.png"">" Pathology acute-inflammatory-demyelinating-
polyradiculopathy neurology
How long does it generally take pts to recover from Guillain-Barr syndrome? Most
pts recover in weeks to months "<img src=""8195.png"">" Pathology acute-
inflammatory-demyelinating-polyradiculopathy neurology
What is the classic CSF finding in Guillain-Barr syndrome?High protein and normal
cells (This is called albuminocytologic dissociation.) "<img src=""8195.png"">"
Pathology acute-inflammatory-demyelinating-polyradiculopathy neurology
A pt with recent Campylobacter jejuni infection is found to have Guillain-Barr
syndrome. Explain the pathogenesis. Infection likely resulted in an autoimmune
attack due to molecular mimicry on the peripheral myelin (although there is no
definitive link) "<img src=""8195.png"">" Pathology acute-inflammatory-
demyelinating-polyradiculopathy neurology
What is the prognosis for pts with Guillain-Barr syndrome?Almost never fatal, with
most pts making a full recovery after weeks to months "<img src=""8195.png"">"
What ocular finding do you expect in a pt with Guillain-Barr syndrome? Why?
Papilledema; swelling of the optic disc results from increased protein levels
in the CSF "<img src=""8195.png"">" Pathology acute-inflammatory-
After an infection, a 30-year-old man experiences symmetric ascending muscle
weakness starting in the legs. How do you treat him? Plasmapheresis or IV
administration of immune globulins and respiratory support if paralysis develops
(He has Guillain-Barr syndrome.) "<img src=""8195.png"">" Pathology acute-
In Guillain-Barr syndrome, what tissue is the target of autoimmune attack?
Peripheral myelin made by Schwann cells "<img src=""8195.png"">"
Which GI bacterial infection is a common inciting event for Guillain-Barr
syndrome? What other class of pathogens has a strong link? Campylobacter jejuni;
viruses "<img src=""8195.png"">" Pathology acute-inflammatory-
Of 10 pts with Guillain-Barr syndrome, approximately how many do you expect to
have facial paralysis? 5 (50%) "<img src=""8195.png"">" Pathology acute-
A man with suspected Guillain-Barr syndrome experiences tachycardia and
alternating bouts of hypertension & hypotension. What is happening? He likely
has autonomic dysfunction, which may occur in pts with Guillain-Barr syndrome
"<img src=""8195.png"">" Pathology acute-inflammatory-demyelinating-
polyradiculopathy neurology
A pt with AIDS experiences memory loss, poor speech, and incoordination. He tests
positive for active JC virus infection. Diagnosis? Progressive multifocal
leukoencephalopathy (destruction of oligodendrocytes) due to reactivation of latent
JC viral infection "<img src=""8196.png"">" Pathology neurology other-
demyelinating-and-dysmyelinating-diseases
Which virus has been implicated in progressive multifocal leukoencephalopathy?
JC virus (Almost all individuals have evidence of infection, but the virus is
latent except in severely immunocompromised pts.) "<img src=""8196.png"">"
Pathology neurology other-demyelinating-and-dysmyelinating-diseases
After which infections may acute disseminated (postinfectious) encephalomyelitis
occur? What about vaccinations? It may occur after chickenpox or measles
infection or after rabies or smallpox vaccination "<img src=""8196.png"">"
A child with a recent measles infection has meningismus and multifocal neurologic
signs. Name this demyelinating disease. Acute disseminated (postinfectious)
encephalomyelitis "<img src=""8196.png"">" Pathology neurology other-
What is the mode of inheritance of metachromatic leukodystrophy? Autosomal
recessive "<img src=""8196.png"">" Pathology neurology other-demyelinating-
and-dysmyelinating-diseases
In metachromatic leukodystrophy, what is the consequence of sulfatide accumulation
in cells? Impaired production of the myelin sheath "<img src=""8196.png"">"
In metachromatic leukodystrophy, which enzyme is deficient? What neurologic
problems develop? Arylsulfatase A (Sulfatides impair myelin production.); central
and peripheral demyelination, ataxia, and dementia develop "<img src=""8196.png"">"
What is the enzyme deficiency in Krabbe disease? What is the mode of inheritance?
Galactocerebrosidase; autosomal recessive "<img src=""8196.png"">"
What two substances are built up in Krabbe disease resulting in destruction of
myelin sheath? Galactocerebroside and psychosine "<img src=""8196.png"">"
Which hereditary nerve disorder is marked by defective production of
structural/functional peripheral nerve or myelin sheath proteins? Charcot-
Marie-Tooth disease (a hereditary motor and sensory neuropathy [HMSN]) "<img
src=""8196.png"">" Pathology neurology other-demyelinating-and-dysmyelinating-
diseases
A boy has a neuropathy, poor development, and vision loss. Galactocerebroside and
psychosine levels are high. What will a nerve biopsy show? Globoid cells,
characteristic of Krabbe disease "<img src=""8196.png"">" Pathology
neurology other-demyelinating-and-dysmyelinating-diseases
A child has ataxia and dementia. Nerve biopsy shows peripheral demyelination and
increased sulfatides. What will brain MRI show? Central demyelination, seen in
metachromatic leukodystrophy "<img src=""8196.png"">" Pathology neurology
other-demyelinating-and-dysmyelinating-diseases
In what percentage of pts with AIDS does progressive multifocal leukoencephalopathy
develop? 24% "<img src=""8196.png"">" Pathology neurology other-
Before a pt with multiple sclerosis starts natalizumab therapy, the neurologist
performs a lumbar puncture. What is he looking for? Evidence of JC virus latency
or infection; natalizumab increases the risk of progressive multifocal
leukoencephalopathy "<img src=""8196.png"">" Pathology neurology other-
A pt taking rituximab exhibits acute delirium. Brain MRI shows diffuse
demyelination. What is the pt's prognosis? Grim; this is likely progressive
multifocal leukoencephalopathy, which is rapidly progressive and usually fatal
"<img src=""8196.png"">" Pathology neurology other-demyelinating-and-
dysmyelinating-diseases
A man has progressive motor and sensory abnormalities. He has scoliosis and high
foot arches. What is his disorder's mode of inheritance? Autosomal dominant (This
is likely Charcot-Marie-Tooth disease, a hereditary motor and sensory neuropathy
[HMSN].) "<img src=""8196.png"">" Pathology neurology other-demyelinating-
and-dysmyelinating-diseases
A boy cannot metabolize long-chain fatty acids; they build up in his nervous
system, adrenal glands, and testes. Mode of inheritance? X-linked, as this is
adrenoleukodystrophy "<img src=""8197.png"">" Pathology
adrenoleukodystrophy neurology
A boy has had adrenoleukodystrophy for several years. For what major morbidities is
he at risk? Long-term coma, adrenal gland crisis, and death "<img src=""8197.png"">"
Pathology adrenoleukodystrophy neurology
How do partial seizures differ from generalized seizures? Partial seizures affect
one area of the brain and are often preceded by an aura; generalized seizures
affect the brain diffusely "<img src=""8198.png"">" Pathology neurology
seizures
From which part of the brain do partial seizures most commonly originate? Medial
temporal lobe "<img src=""8198.png"">" Pathology neurology seizures
How does neuronal firing during a seizure differ from normal brain activity? During
a seizure, neuronal firing is synchronized and occurs at a high frequency "<img
src=""8198.png"">" Pathology neurology seizures
A woman calls 911 and reports that her husband is on the floor thrashing with
alternating stiffening movements. What is the diagnosis? Tonic-clonic (grand mal)
seizure "<img src=""8198.png"">" Pathology neurology seizures
How do complex and simple partial seizures differ? Simple: no loss of
consciousness (LOC) but with motor, sensory, autonomic, or psychic effects;
complex: consciousness is impaired "<img src=""8198.png"">" Pathology
neurology seizures
A young girl lapses into a blank stare, then begins talking as if nothing happened.
What is the characteristic frequency of this seizure? 3 Hz (the characteristic
frequency of an absence [petit mal] seizure) "<img src=""8198.png"">"
Pathology neurology seizures
What type of seizure is characterized by quick, repetitive jerks? Myoclonic
What type of seizure is associated with stiffening (as opposed to jerking)? Tonic
A young boy presents to the ED, seizing, with a fever of 105 F. Epilepsy is
immediately diagnosed. Is this diagnosis correct? Explain. No, epilepsy is a
disorder of recurrent seizures; febrile seizures are not diagnostic of epilepsy
"<img src=""8198.png"">" Pathology neurology seizures
What most commonly causes seizures in adults? In the elderly? Adults: stroke,
trauma, tumor, infection; elderly: tumor, stroke, metabolic derangement, trauma,
infection "<img src=""8198.png"">" Pathology neurology seizures
What type of seizures can be confused with syncope? Drop/atonic seizures "<img
src=""8198.png"">" Pathology neurology seizures
A paramedic reports that he is bringing in a man in status epilepticus. What does
this mean? Continuous or recurrent seizure activity lasting longer than 1030
minutes (The definition is variable.) "<img src=""8198.png"">" Pathology
neurology seizures
What are the most common causes of seizures in children? Genetic disorders,
infection (generally when febrile), trauma, congenital malformations, metabolic
derangement "<img src=""8198.png"">" Pathology neurology seizures
A pt has 72 hours of unilateral pulsating head pain with nausea and photophobia,
preceded by an aura. Name the type of headache. Migraine headache "<img
src=""8199.png"">" Pathology headaches neurology
A man presents with excruciating periorbital pain associated with his headache.
What treatments can you offer? Inhaled oxygen (100%), sumatriptan (for cluster
headaches) "<img src=""8199.png"">" Neurology Pathology headaches
A 26-year-old woman has had a pulsing headache with phonophobia for 3 hours. She
had an aura beforehand. What treatments can you offer? Abortives (eg, triptans,
NSAIDs), then propranolol, topiramate, Ca2+ channel blockers, or amitriptyline for
migraine prophylaxis "<img src=""8199.png"">" Neurology Pathology headaches
The release of which three substances may be implicated in the origin of migraine
headaches? What is it that these substances may do? Substance P, calcitonin gene
related peptide (CGRP), vasoactive peptides; they may irritate CN V, the meninges,
or blood vessels "<img src=""8199.png"">" Neurology Pathology headaches
A pt has headaches lasting 45 minutes with bilateral steady pain but no photophobia
or aura. What treatments can you offer? Analgesics (such as NSAIDs and
acetaminophen) for acute pain, amitriptyline for chronic pain (These are tension
headaches.) "<img src=""8199.png"">" Neurology Pathology headaches
A 30-year-old pt with Horner syndrome has frequent, brief headaches with unilateral
periorbital pain and rhinorrhea. Headache type? Cluster headache "<img
src=""8199.png"">" Neurology Pathology headaches
A pt has frequent, brief headaches with unilateral periorbital pain and rhinorrhea.
Is this pt more likely to be male or female? Male (Cluster headaches are more
common in the male population.) "<img src=""8199.png"">" Neurology
Pathology headaches
A pt presents with the sudden onset of the worst headache of his life. What
etiology is suggested by his complaint? Subarachnoid hemorrhage "<img
How can you differentiate a cluster headache from trigeminal neuralgia (TN)?
Duration: TN causes shooting pain in the CN V distribution lasting less than
a minute; cluster headaches last longer (15 minutes to 3 hours) "<img
You go to see a pt without a headache history who has a new-onset headache. Name
the more serious diagnoses in your differential. Subarachnoid hemorrhage,
meningitis, hydrocephalus, neoplasia, arteritis "<img src=""8199.png"">"
Neurology Pathology headaches
What is vertigo? How does it fit into the spectrum of symptoms such as dizziness
and lightheadedness? Vertigo is the sensation of spinning while actually
stationary; it is a subtype of dizziness but is distinct from lightheadedness
"<img src=""8200.png"">" Neurology Pathology vertigo
A 30-year-old woman has periodic loss of hearing and feelings that the room is
spinning. What do you expect on positional testing? Delayed horizontal nystagmus
(She has peripheral vertigo.) "<img src=""8200.png"">" Neurology Pathology
vertigo
A 35-year-old man has positional testing for vertigo; delayed horizontal nystagmus
develops. What type of vertigo is this? Possible causes? Peripheral vertigo;
possible causes: semicircular canal debris, vestibular nerve infection, or Mnire
disease "<img src=""8200.png"">" Neurology Pathology vertigo
A 40-year-old man with immediate nystagmus switches directions on position testing.
Why do you immediately order a brain MRI? To look for a central lesion; the exam
findings are consistent with central vertigo "<img src=""8200.png"">"
Neurology Pathology vertigo
You suspect that a pt has had a stroke compromising his vestibular nuclei. What
bedside exam can you do? What do you see on exam? Positional testing; if you're
correct, you see immediate nystagmus in any direction; it may even change direction
(This is central vertigo.) "<img src=""8200.png"">" Neurology Pathology
vertigo
A woman with a history of metastatic cancer has diplopia, dysmetria, and direction-
changing nystagmus. Could a metastasis be to blame? Yes. This is central vertigo,
and a metastasis to the posterior fossa may be to blame if it invades the brain
stem or cerebellum "<img src=""8200.png"">" Neurology Pathology vertigo
A father has caf-au-lait spots and neurofibromas; his son has a pheochromocytoma
and an optic glioma. Explain this variation in NF1. Neurofibromatosis type 1 is
autosomal dominant with 100% penetrance but variable expression "<img
src=""8201.png"">" Neurology Pathology neurocutaneous-disorders
What syndrome is a congenital disorder characterized by facial port-wine stains and
ipsilateral leptomeningeal angioma? Sturge-Weber syndrome "<img src=""8201.png"">"
Neurology Pathology neurocutaneous-disorders
Tuberous sclerosis is characterized by what three characteristic cutaneous
manifestations? Ash-leaf spots, shagreen patches, and angiofibromas; ungual
fibromas may also be present "<img src=""8201.png"">" Neurology Pathology
neurocutaneous-disorders
What mutation causes neurofibromatosis type 1 (von Recklinghausen disease)?
Mutation of the NF1 gene on chromosome 17 (codes for neurofibromin, a
negative regulator of RAS) "<img src=""8201.png"">" Neurology Pathology
What neurocutaneous disorder is linked with cavernous hemangioma, bilateral renal
cell carcinoma, pheochromocytoma, and hemangioblastoma? von Hippe-Lindau disease
"<img src=""8201.png"">" Neurology Pathology neurocutaneous-disorders
Sturge-Weber syndrome is best characterized as a disorder of which embryologic
derivative? How is the disorder acquired? Sturge-Weber syndrome is a congenital,
noninherited (somatic) developmental anomaly of neural crest derivatives
(mesoderm/ectoderm) "<img src=""8201.png"">" Neurology Pathology
In Sturge-Weber syndrome, what is the pathophysiology behind nevus flammeus? It is
due to defects in small (capillary-sized) blood vessels of the face (It is a
nonneoplastic port-wine stain birthmark in CN V1/V2.) "<img src=""8201.png"">"
A pt with a GNAQ gene mutation has increased intraocular pressure at a young age.
What is the pathophysiology behind this finding? Episcleral hemangiomas, which
may increase intraocular pressure and lead to early-onset glaucoma, occur in people
with Sturge-Weber syndrome "<img src=""8201.png"">" Neurology Pathology
A boy with tram-track calcifications on opposing gyri (seen via brain CT) has
intractable epilepsy. What is the pathophysiology behind this? Ipsilateral
leptomeningeal angiomas. which can cause seizures and intellectual disabilities,
develop in people with Sturge-Weber syndrome "<img src=""8201.png"">"
Identify the common characteristics of Sturge-Weber syndrome. Sporadic, port-
wine Stain, Tram track calcifications (opposing gyri), Unilateral, mental
Retardation, Glaucoma, GNAQ gene, Epilepsy "<img src=""8201.png"">"
Identify the common characteristics of tuberous sclerosis. Hamartoma Angiofibroma
Mitral regurg Ash-leaf spot Rhabdomyoma aut dOm Mental retardation renal
Angiomyolipoma Seizure Shagreen patch "<img src=""8201.png"">" Neurology
Pathology neurocutaneous-disorders
From what cell type do meningiomas arise? Where are they most commonly found?
Arachnoid cells; extra-axially (external to brain parenchyma) in convexities
of the hemispheres (near brain surface) and parasagittal region "<img
src=""8202.png"">" Neurology Pathology adult-primary-brain-tumors
What type of staining may help confirm the diagnosis of glioblastoma multiforme?
Glial fibrillary acidic protein (GFAP) staining "<img src=""8202.png"">"
Neurology Pathology adult-primary-brain-tumors
What rare and slow-growing primary brain tumor is most often found in the frontal
lobes of the brain? Oligodendroglioma "<img src=""8202.png"">" Neurology
Pathology adult-primary-brain-tumors
A pt has a prolactin-secreting tumor in her brain. What is the most likely tumor
type? If it goes untreated, what sequelae may result? Pituitary adenoma; sequelae
include bitemporal hemianopia (due to pressure on the optic chiasm) and hyper- or
hypopituitarism "<img src=""8202.png"">" Neurology Pathology adult-primary-
brain-tumors
Spindle cells in a whorled pattern with psammoma bodies are characteristic of which
primary intracranial tumor? Meningioma "<img src=""8202.png"">" Neurology
Which hormone do pituitary adenomas most commonly secrete? Prolactin (Prolactinomas
are the most common adenoma subtype.) "<img src=""8202.png"">" Neurology
A pt with retinal angiomas has a cerebellar mass. Labs show polycythemia. What will
biopsy of the cerebellar mass show? Closely arranged, thin-walled capillaries with
little intervening parenchyma (a hemangioblastoma, seen in vonHippel Lindau
syndrome) "<img src=""8202.png"">" Neurology Pathology adult-primary-brain-
tumors
A child is found to have an ependymoma obstructing the fourth ventricle. What can
this cause? Generally, what is the prognosis? Hydrocephalus; the prognosis is
generally poor "<img src=""8203.png"">" Neurology Pathology childhood-
primary-brain-tumors
A craniopharyngioma is embryologically derived from the remnants of what structure?
The Rathke pouch "<img src=""8203.png"">" Neurology Pathology
childhood-primary-brain-tumors
On gross examination, how does a medulloblastoma appear? It is a solid tumor
"<img src=""8203.png"">" Neurology Pathology childhood-primary-brain-
tumors
What benign childhood tumor is often confused with a pituitary adenoma, because it
can present with bitemporal hemianopia? Craniopharyngioma "<img src=""8203.png"">"
Neurology Pathology childhood-primary-brain-tumors
A pt presents with vertical gaze palsy, obstructive hydrocephalus, and precocious
puberty. Diagnosis? Where is the lesion? Parinaud syndrome; the tumor is in the
pineal gland "<img src=""8203.png"">" Neurology Pathology childhood-
primary-brain-tumors
The histology of a pinealoma resembles that of what other tumor type? Germ cell
tumor (eg, a testicular seminoma) "<img src=""8203.png"">" Neurology
Pathology childhood-primary-brain-tumors
Which artery can be compressed with cingulate (subfalcine) herniation under the
falx cerebri? Anterior cerebral artery "<img src=""8204.png"">"
Neurology Pathology herniation-syndromes
A pt with a massive intracranial bleed begins to have herniation through the
foramen magnum. What clinical outcomes are likely? Why? Coma and death caused by
compression of the brain stem (inhibits respiration); this is cerebellar tonsil
herniation into the foramen magnum "<img src=""8204.png"">" Neurology
Pathology herniation-syndromes
A woman has a hemorrhage that causes caudal brain stem displacement. If it is left
unchecked, what catastrophic outcome will occur? Why? This may cause rupture of her
paramedian basilar artery branches, leading to Duret hemorrhages, which are usually
fatal "<img src=""8204.png"">" Neurology Pathology herniation-syndromes
A pt has a left-sided uncal herniation. What neurologic findings are expected?
Left CN III compression causing blown pupil (down and out), left PCA
compression causing contralateral homonymous hemianopia; left paralysis "<img
src=""8204.png"">" Neurology Pathology herniation-syndromes
A man has unilateral weakness. Head CT shows left-sided uncal herniation. What is
being compressed, and on what side does it cause weakness? The right-side
(contralateral) crus cerebri at the Kernohan notch, causing left-sided weakness
(false localization sign) "<img src=""8204.png"">" Neurology Pathology
duplicate herniation-syndromes
A man has unilateral weakness. Head CT shows left-sided uncal herniation. What is
being compressed, and on what side does it cause weakness? The right-side
(contralateral) crus cerebri at the Kernohan notch, causing left-sided weakness
(false localization sign) "<img src=""8204.png"">" Neurology Pathology
duplicate herniation-syndromes
Downward transtentorial (central) herniation causes displacement of what structure?
In which direction? Displacement of the brain stem; caudal "<img
src=""8204.png"">" Neurology Pathology herniation-syndromes
How do 1-agonists (eg, epinephrine) and 2-agonists (eg, brimonidine) work to
treat glaucoma? They decrease aqueous humor synthesis "<img src=""8205.png"">"
Neurology glaucoma-drugs pharmacology
What side effects do pts have with epinephrine and brimonidine? Mydriasis (1),
blurry vision, ocular hyperemia, foreign body sensation, allergic reaction,
pruritus "<img src=""8205.png"">" Neurology glaucoma-drugs pharmacology
Which -agonist is contraindicated for closed-angle glaucoma? Epinephrine "<img
src=""8205.png"">" Neurology glaucoma-drugs pharmacology
By what mechanism do -blockers treat glaucoma? Name some examples from this drug
class. By decreasing aqueous humor synthesis; timolol, betaxolol, carteolol
"<img src=""8205.png"">" Neurology glaucoma-drugs pharmacology
How does acetazolamide treat glaucoma? It decreases aqueous humor synthesis by
inhibiting carbonic anhydrase "<img src=""8205.png"">" Neurology glaucoma-drugs
pharmacology
By what mechanism do cholinomimetics treat glaucoma? They increase outflow of
aqueous humor, contract the ciliary muscle, and open the trabecular meshwork "<img
An older woman with glaucoma begins receiving brimonidine (an 2 agonist). What
side effects might she experience? Blurry vision, ocular hyperemia, foreign body
sensation, an ocular allergic reaction, ocular pruritus "<img src=""8205.png"">"
Which prostaglandin increases the outflow of aqueous humor in glaucoma? It is an
analog of which prostaglandin? Latanoprost; prostaglandin F2 "<img
A pt's new glaucoma drug is causing browning of the iris. What is the mechanism of
the drug she is taking? It increases the flow of aqueous humor (She is probably
taking latanoprost or bimatoprost.) "<img src=""8205.png"">" Neurology
glaucoma-drugs pharmacology
Of the drugs epinephrine, timolol, and acetazolamide, which can cause pupillary or
vision changes? Epinephrine, which can cause mydriasis. Timolol and acetazolamide
have no effect on the pupil or vision "<img src=""8205.png"">" Neurology
A man has severe eye pain caused by blockage of aqueous humor outflow. Do you give
a direct or indirect cholinomimetic? Which one? Why? A direct cholinomimetic,
specifically pilocarpine, because pilocarpine is very effective in opening the
meshwork into the canal of Schlemm "<img src=""8205.png"">" Neurology
Name the two direct and two indirect cholinomimetics available to treat glaucoma.
Direct: pilocarpine, carbachol; indirect: physostigmine, echothiophate "<img
What is the main side effect of latanoprost? Darkening (browning) of the iris
"<img src=""8205.png"">" Neurology glaucoma-drugs pharmacology
What are the side effects of the cholinomimetics used to treat glaucoma? Miosis
and cyclospasm (contraction of the ciliary muscles) "<img src=""8205.png"">"
Morphine, fentanyl, codeine, loperamide, methadone, meperidine, dextromethorphan,
diphenoxylate, and pentazocine are all what type of drug? Opioid analgesics "<img
src=""8206.png"">" Neurology opioid-analgesics pharmacology
Explain the mechanism of action of opioids. They cause opening of K+
channels[ closing of Ca+ channels; and inhibition of ACh, norepinephrine, 5-HT,
glutamate, and substance P "<img src=""8206.png"">" Neurology opioid-
analgesics pharmacology
Which opioid receptors bind most avidly to -endorphin? Dynorphin? Enkephalin?
-Receptors bind to -endorphin; -receptors bind to enkephalin; -receptors
bind to dynorphin "<img src=""8206.png"">" Neurology opioid-analgesics
pharmacology
Which opioid agonist is used for cough suppression? Dextromethorphan "<img
Which two opioid agonists are used to alleviate diarrhea? Loperamide and
diphenoxylate "<img src=""8206.png"">" Neurology opioid-analgesics
pharmacology
Which opioid analgesics are used for maintenance programs for heroin addicts?
Methadone or a combination of buprenorphine and naloxone "<img
What changes in neurotransmitter release do opioid receptor agonists cause? They
inhibit the release of acetylcholine, norepinephrine, serotonin (5-HT), glutamate,
and substance P "<img src=""8206.png"">" Neurology opioid-analgesics
pharmacology
A man known to the ED presents with respiratory depression, constipation, and
miosis. Overactivity at which three receptors is to blame? Excessive binding at -,
-, and -opioid receptors, as this is opioid toxicity "<img src=""8206.png"">"
Neurology opioid-analgesics pharmacology
Despite requiring increasing doses for recreational use, which two adverse effects
of opioid use will pts not develop tolerance to? Miosis and constipation "<img
A pt who is a known drug user has pinpoint pupils and respiratory depression. What
can be given to reverse this condition? Naloxone or naltrexone (opioid receptor
antagonists), as this is opioid overdose (eg, with heroin) "<img src=""8206.png"">"
Neurology opioid-analgesics pharmacology
How does pentazocine work? It is a -opioid receptor agonist and a -opioid
receptor antagonist "<img src=""8207.png"">" Neurology pentazocine
pharmacology
What are the clinical indications for pentazocine use? What are the adverse
effects? As an analgesic for moderate to severe pain; opioid withdrawal symptoms
if taken with a full opioid (competition for opioid receptors) "<img
src=""8207.png"">" neurology pentazocine pharmacology
What is butorphanol's mechanism of action? It is a opioid receptor agonist
and a opioid receptor partial agonist "<img src=""8208.png"">" butorphanol
neurology pharmacology
What is the toxicity of butorphanol? Are the effects of overdose reversible? Causes
opioid withdrawal if the pt also takes full opioid agonists (opioid receptor
competition); naloxone does not reverse overdose well "<img src=""8208.png"">"
butorphanol neurology pharmacology
A pt with very advanced stage lung disease is offered butorphanol. Why would the
clinician treat the pt with this particular drug? Butorphanol causes less
respiratory depression than full opioid agonists "<img src=""8208.png"">"
butorphanol neurology pharmacology
In what clinical situations is butorphanol typically used? Because butorphanol
produces analgesia, it is used for severe pain (eg, migraine headache, labor)
"<img src=""8208.png"">" butorphanol neurology pharmacology
Which analgesic drug is a weak opioid agonist and inhibitor of serotonin and
norepinephrine reuptake? "Tramadol (""tram it all"" in with tramadol)" "<img
src=""8209.png"">" neurology pharmacology tramadol
A 50-year-old woman with fibromyalgia has chronic pain after surgery. Which
medication has weak opioid action and SSRI/SNRI effects? Tramadol "<img
src=""8209.png"">" neurology pharmacology tramadol
What are the side effects of tramadol? Lowers seizure threshold, induces
serotonin syndrome, causes other side effects similar to those of other opioids
"<img src=""8209.png"">" neurology pharmacology tramadol
A pt taking phenytoin develops megaloblastic anemia. Why? Phenytoin decreases
folate absorption, and folate is required for red blood cell DNA synthesis "<img
src=""8210.png"">" epilepsy-drugs neurology pharmacology
Which types of seizures are treated with levetiracetam? Simple and complex
partial seizures and tonic-clonic generalized seizures "<img src=""8210.png"">"
epilepsy-drugs neurology pharmacology
What are the side effects of valproic acid therapy? GI distress, hepatotoxicity,
neural tube defects (eg, spina bifida), tremor, weight gain"<img src=""8210.png"">"
What are the side effects of ethosuximide therapy? Ethosuximide causes Fatigue,
GI distress, Headache, Itching, and Stevens-Johnson syndrome (EFGHIJ) "<img
In light of the adverse effects of carbamazepine, which tests should you routinely
order to monitor your pts who take it? Liver function tests and complete blood
count (Carbamazepine can cause liver toxicity and blood dyscrasias.) "<img
A pt with bipolar disorder develops myoclonic seizures. The epilepsy drug of choice
for this pt inhibits channels for which ion? Na+ (The drug of choice is valproic
acid.) "<img src=""8210.png"">" epilepsy-drugs neurology pharmacology
Which types of seizures are treated with phenytoin? What is its mechanism of
action? Simple and complex partial, tonic-clonic (first-line), status
epilepticus (first-line prophylaxis); it shuts down Na+ channels "<img
For which conditions is phenytoin the first-line treatment?First-line treatment of
tonic-clonic seizures and first-line prophylaxis for status epilepticus (both
generalized seizures) "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
A pt with seizures and anticoagulation has gingival hyperplasia, lymph node
swelling, and a low INR. Which medication is she taking? Phenytoin (It may cause
gingival hyperplasia, nystagmus, diplopia, megaloblastic anemia, teratogenesis,
SLE-like syndrome, P-450 induction.) "<img src=""8210.png"">" epilepsy-
drugs neurology pharmacology
A pt is having a tonic-clonic seizure. Medication must be given by way of the
parenteral route. Which drug should be given? Fosphenytoin (Unlike phenytoin,
fosphenytoin is pH neutral, so it can be given by IV injection.) "<img
A pt has severe, shooting jaw pain. After treatment, she has agranulocytosis,
SIADH, and liver toxicity. Which medication did she use? Carbamazepine for
trigeminal neuralgia (other effects: aplastic anemia, SJS, P-450 induction) "<img
Which types of seizures are treated with carbamazepine? When is this drug first-
line treatment? What is its mechanism of action? Simple and complex partial
seizures and tonic-clonic generalized seizures (first-line for all three types); it
inactivates sodium channels "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
Which types of seizures are treated with lamotrigine? What is its mechanism of
action? Simple and complex partial seizures and tonic-clonic generalized
seizures; it blocks voltage-gated sodium channels "<img src=""8210.png"">"
What is the most serious complication of lamotrigine therapy, and how can the risk
be minimized? Lamotrigine can cause Stevens-Johnson syndrome; it must be
titrated slowly to minimize risk "<img src=""8210.png"">" epilepsy-drugs
Which types of seizures are treated with gabapentin? What is its mechanism of
seizures; inactivates voltage-activated Ca2+ channels and is a GABA analog "<img
Gabapentin has multiple uses. Name three of them. Peripheral neuropathy,
postherpetic neuralgia, seizures (simple, complex, tonic-clonic) "<img
Which types of seizures are treated with topiramate? What is its mechanism of
seizures; it inactivates sodium channels and increases GABA action "<img
Which epilepsy drug is the first-line agent used to treat neonates?
Phenobarbital "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
Which types of seizures are treated with phenobarbital? What is its mechanism of
seizures; it increases GABAA action "<img src=""8210.png"">" epilepsy-drugs
What is the first-line agent used to prevent seizures in pts with eclampsia?
Magnesium sulfate (MgSO4) "<img src=""8210.png"">" epilepsy-drugs
Which types of seizures are treated with valproic acid? When is it the first-line
treatment? Simple, complex, tonic-clonic (first line), and absence generalized
seizures "<img src=""8210.png"">" epilepsy-drugs neurology pharmacology
A pt presents with a seizure that involves one side of the body. She is
unconscious. What is the first-line treatment? Carbamazepine (first-line treatment
for simple and complex partial seizures) "<img src=""8210.png"">" epilepsy-
What is the mechanism of action of valproate? It inactivates Na+ channels and
increases GABA concentration by inhibiting GABA transaminase "<img
Which types of seizures are treated with benzodiazepines? What is their mechanism
of action? Acute status epilepticus; they increase the action of GABAA"<img
A woman at 35 weeks' gestation has eclamptic seizures. If she receives magnesium
but continues seizing, what is the next medication to use? Benzodiazepines
(diazepam, lorazepam) "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
Which types of seizures are treated with ethosuximide? What is its mechanism of
action? Absence seizures (ethosuximide: Sucks to have Silent Seizures); it
blocks thalamic T-type Ca2+ channels "<img src=""8210.png"">" epilepsy-
Which types of seizures are treated with tiagabine? What is its mechanism of
action? Simple and complex partial seizures; it increases GABA by inhibiting
GABA reuptake "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
Which types of seizures are treated with vigabatrin? What is its mechanism of
action? Simple and complex partial seizures; it irreversibly inhibits GABA
transaminase, thus increasing GABA concentration "<img src=""8210.png"">"
What is the mechanism of action of levetiracetam? Its mechanism is unknown, but
it may modulate GABA and glutamate release "<img src=""8210.png"">"
A man with epilepsy starts taking a new medication at full strength and notices a
skin lesion. What is the danger of progression? The skin lesions may progress to
epidermal necrosis and sloughing (Stevens-Johnson syndrome is the greatest
concern.) "<img src=""8210.png"">" epilepsy-drugs neurology pharmacology
A 30-y/o man receiving medical therapy for trigeminal neuralgia has a low blood
count. Which medication toxicity are you worried about? Aplastic anemia or
agranulocytosis, both of which are associated with carbamazepine use "<img
A 40-y/o woman with a history of tonic-clonic seizures develops hirsutism and
gingival hyperplasia. What drug is responsible? Phenytoin "<img src=""8210.png"">"
A 40-year-old man with a history of myoclonic seizures has elevated liver function
tests. What drug is responsible? Valproic acid, which causes acute
hepatotoxicity "<img src=""8210.png"">" epilepsy-drugs neurology
pharmacology
Women of childbearing age who are using which two antiepileptic drugs should also
use birth control because of the teratogenic risks? Valproic acid, which causes
neural tube defects (eg, spina bifida), and carbamazepine "<img src=""8210.png"">"
A pt with migraines and simple seizures is admitted for hematuria and flank pain.
Which epilepsy drug is he taking? Topiramate; it causes sedation, mental dulling,
kidney stones, and weight loss "<img src=""8210.png"">" epilepsy-drugs
An epileptic woman has hirsutism, megaloblastic anemia, ataxia, and gingival
hyperplasia. Which skin effect can also be seen with this drug? Stevens-Johnson
syndrome, a potential side effect of phenytoin "<img src=""8210.png"">"
Which four epilepsy drugs might predispose individuals to Stevens-Johnson syndrome?
Carbamazepine, phenytoin, ethosuximide, and lamotrigine "<img
A 45-year-old pt with atrial fibrillation and phenobarbital-controlled epilepsy
needs increased dosing of anticoagulants. Why? Phenobarbital induces cytochrome P-
450. Other side effects are sedation, tolerance, dependence, and cardiorespiratory
depression "<img src=""8210.png"">" epilepsy-drugs neurology pharmacology
What are the side effects of gabapentin therapy? Sedation and ataxia "<img
Which antiepileptic drug is used primarily to treat tonic-clonic seizures and has
zero-order kinetics? Phenytoin "<img src=""8210.png"">" epilepsy-drugs
A woman has nystagmus, ataxia, diplopia, and sedation after receiving a drug for
tonic-clonic seizures. Which drug did she receive? Phenytoin "<img
A woman treated with phenytoin asks about drug risks during pregnancy. She knows
about Stevens-Johnson syndrome. What do you tell her? Fetal hydantoin syndrome,
nystagmus, diplopia, ataxia, megaloblastic anemia, SLE-like syndrome, P-450
induction, lymphadenopathy, osteopenia "<img src=""8210.png"">" epilepsy-
Phenobarbital, pentobarbital, thiopental, and secobarbital are members of which
class of drugs? Barbiturates "<img src=""8211.png"">" barbiturates
What is the mechanism of action of barbiturates? Barbiturates facilitate GABAA
action by increasing the duration of Cl channel opening (barbidurates increase
duration) "<img src=""8211.png"">" barbiturates neurology pharmacology
Which class of medications commonly used to treat anxiety is contraindicated in pts
with porphyria? Barbiturates "<img src=""8211.png"">" barbiturates
A pt with a history of alcohol abuse asks for a barbiturate prescription to help
him sleep. What are you worried about? Barbiturates have an additive central
nervous system depression effect when combined with alcohol, and there is no
antidote for overdoses "<img src=""8211.png"">" barbiturates neurology
pharmacology
What is the treatment for barbiturate overdose? Supportive (that is, assisted
respiration and maintenance of blood pressure until the drug is metabolized) "<img
src=""8211.png"">" barbiturates neurology pharmacology
What are the clinical uses of barbiturates? Barbiturates are used commonly as
sedatives for treating anxiety, seizures, and insomnia and for the induction of
anesthesia (thiopental) "<img src=""8211.png"">" barbiturates neurology
pharmacology
A pt taking a fixed dose of warfarin starts taking barbiturates. What will happen
to the anticoagulative effect of his warfarin dose? Barbiturates induce
cytochrome P-450 enzymes, so the warfarin will be metabolized more quickly, and the
efficacy of his dose will decrease "<img src=""8211.png"">" barbiturates
Barbiturate overdose can be fatal because of depression of what organ system?
The cardiopulmonary system "<img src=""8211.png"">" barbiturates
Diazepam, lorazepam, triazolam, temazepam, oxazepam, midazolam, chlordiazepoxide,
and alprazolam are members of what class of drugs? Benzodiazepines "<img
src=""8212.png"">" benzodiazepines neurology pharmacology
Which benzodiazepines have short half-lives? What's the danger? Alprazolam,
Triazolam, Oxazepam, and Midazolam (ATOM); because they are short acting, they have
a higher addictive potential "<img src=""8212.png"">" benzodiazepines
A 40-y/o woman with medication-controlled anxiety is admitted because of altered
mental status and decreased respiratory drive. Antidote? Flumazenil; it is a
competitive antagonist of GABA receptors "<img src=""8212.png"">"
benzodiazepines neurology pharmacology
What are the clinical uses of benzodiazepines? Anxiety, hypnosis, night terrors
and sleepwalking, spasticity, status epilepticus, alcohol detoxification (eg, DTs),
general anesthesia "<img src=""8212.png"">" benzodiazepines neurology
pharmacology
Which benzodiazepines (short- or long-acting) have a higher addiction potential?
Short-acting "<img src=""8212.png"">" benzodiazepines neurology
pharmacology
Compare the mechanism of action by which benzodiazepines facilitate GABAA action
with that of barbiturates. Benzodiazepines increase frequency of Cl channel
opening; barbiturates increase duration of Cl channel opening "<img
src=""8212.png"">" benzodiazepines neurology pharmacology
What is the mechanism of action of benzodiazepines? "They facilitate GABAA action
by increasing the frequency of Cl channel opening (""frenzodiazepines"" increase
frequency)" "<img src=""8212.png"">" benzodiazepines neurology pharmacology
Name the nonbenzodiazepine hypnotics. Zolpidem, Zaleplon, esZopiclone (All
ZZZs put you to sleep.) "<img src=""8213.png"">" neurology
nonbenzodiazepine-hypnotics pharmacology
What is the mechanism of action of nonbenzodiazepine hypnotics? They act by way of
the benzodiazepine-1 (BZ1) subtype of the GABA receptor; like benzodiazepines, they
are reversed with flumazenil "<img src=""8213.png"">" neurology
What is the main clinical use for nonbenzodiazepine hypnotics? Treating insomnia
"<img src=""8213.png"">" neurology nonbenzodiazepine-hypnotics
pharmacology
What are the adverse effects of nonbenzodiazepine hypnotics? Ataxia, headaches,
confusion "<img src=""8213.png"">" neurology nonbenzodiazepine-hypnotics
pharmacology
Why are nonbenzodiazepine hypnotics attractive for insomnia treatment? They are
short acting, cause only modest day-after psychomotor depression and few amnestic
effects, and have a low dependence risk "<img src=""8213.png"">" neurology
Acute liver failure develops in a pt taking zolpidem. Why might you want to avoid
giving the pt any more zolpidem? Nonbenzodiazepine hypnotics such as zolpidem
are metabolized by the liver (explains short duration), so liver failure could
cause toxicity "<img src=""8213.png"">" neurology nonbenzodiazepine-
hypnotics pharmacology
How do general anesthetics get across the blood-brain barrier? They are either
lipid soluble or actively transported "<img src=""8214.png"">" anesthetics
general-principles neurology pharmacology
For general anesthetics, what is the effect of lipid solubility on the speed of
induction and recovery time? Lower lipid solubility leads to faster onset and
shorter recovery. Higher solubility increases potency "<img src=""8214.png"">"
Neurology anestheticsgeneral-principles pharmacology
In anesthesia, what does the acronym MAC stand for? What does it indicate? How does
it relate to potency? Minimal Alveolar Concentration at which 50% of the
population is anesthetized; the lower the MAC, the more potent the anesthetic
"<img src=""8214.png"">" Neurology anestheticsgeneral-principles
pharmacology
How is the potency of an anesthetic calculated? 1 divided by minimal alveolar
concentration (MAC); the potency is inversely proportional to the MAC "<img
src=""8214.png"">" Neurology anestheticsgeneral-principles pharmacology
What are four common adverse effects of inhaled anesthetics? Myocardial
depression, respiratory depression, nausea/emesis, and increased cerebral blood
flow (decreased cerebral metabolic demand) "<img src=""8215.png"">"
Neurology inhaled-anesthetics pharmacology
A pt has increased bleeding time and increased AST/ALT levels after general
anesthesia. What was the probable common agent used? Halothane, causing
hepatotoxicity "<img src=""8215.png"">" Neurology inhaled-anesthetics
pharmacology
A pt undergoes general anesthesia with an inhaled anesthetic that causes increased
BUN and Cr. What was the most likely causative agent? Methoxyflurane, causing
nephrotoxicity "<img src=""8215.png"">" Neurology inhaled-anesthetics
pharmacology
A pt has a history of seizures. Which inhaled anesthetic should be avoided?
Enflurane; it is proconvulsive "<img src=""8215.png"">" Neurology
inhaled-anesthetics pharmacology
Which anesthetic causes side effects similar to those experienced by divers
surfacing too fast? How does it cause these effects? Nitrous oxide; by expansion
of trapped gas in a body cavity "<img src=""8215.png"">" Neurology inhaled-
anesthetics pharmacology
Which class of drugs can cause malignant hyperthermia, myocardial depression, and a
decrease in cerebral metabolic demand? Inhaled anesthetics "<img
src=""8215.png"">" Neurology inhaled-anesthetics pharmacology
Name the only inhaled anesthetic that, at toxic levels, will not cause malignant
hyperthermia. What can happen instead at toxic levels? Nitrous oxide; at toxic
levels, the drug can cause expansion of gas trapped in a body cavity "<img
A pt undergoes general anesthesia. The anesthesiologist later notes fever and
severe muscle contractions. What treatment is needed? Dantrolene is needed for the
treatment of malignant hyperthermia caused by succinylcholine "<img
A pt undergoes general anesthesia with an inhaled anesthetic. How will cerebral
blood flow and cerebral metabolism be affected? Cerebral blood flow will be
increased, and metabolism will be decreased (counterintuitive, since metabolic
byproducts are vasodilators) "<img src=""8215.png"">" Neurology inhaled-
Name six drugs used as inhaled anesthetics. Halothane, enflurane, isoflurane,
sevoflurane, methoxyflurane, and nitrous oxide (N2O) "<img src=""8215.png"">"
Neurology inhaled-anesthetics pharmacology
What are three common adverse effects of midazolam? Postoperative respiratory
depression, hypotension, and anterograde amnesia "<img src=""8216.png"">"
Neurology intravenous-anesthetics pharmacology
A pt needs to be sedated for setting of a broken bone. Which phencyclidine (PCP)
analog is often used in the emergency setting? Ketamine (an arylcyclohexylamine)
"<img src=""8216.png"">" Neurology intravenous-anesthetics pharmacology
What are three common adverse effects of ketamine? Disorientation,
hallucinations, and bad dreams "<img src=""8216.png"">" Neurology
intravenous-anesthetics pharmacology
Which two opiates are commonly used with other agents during general anesthesia?
Morphine and fentanyl "<img src=""8216.png"">" Neurology intravenous-
Which common IV lipid-based anesthetic, used for rapid anesthesia induction,
results in less postoperative nausea than thiopental? Propofol "<img
src=""8216.png"">" Neurology intravenous-anesthetics pharmacology
What is the only commonly used anesthesia induction agent that does not lower blood
pressure? Ketamine (In fact, it acts as a cardiovascular stimulant.) "<img
What is the mechanism of action of propofol? In which situations is it primarily
used? Propofol potentiates GABAA; it is used for sedation in the ICU, rapid
anesthesia induction, and short procedures "<img src=""8216.png"">"
Neurology intravenous-anesthetics pharmacology
What are the common IV anesthesia agents? (Hint: There's a mnemonic.) Thiopental,
Midazolam, Ketamine, Propofol, Opioids (The Mighty King Proposes Foolishly to
Oprah.) "<img src=""8216.png"">" Neurology intravenous-anesthetics
pharmacology
After endoscopy, a man goes into respiratory distress. The CRNA realizes that she
gave too much anesthetic. Cause? Treatment? Midazolam, the drug most commonly
used during endoscopies, can cause respiratory depression; treat overdoses with
flumazenil "<img src=""8216.png"">" Neurology intravenous-anesthetics
pharmacology
What is the mechanism of action of ketamine? It blocks NMDA receptors "<img
What are the physiologic characteristics that terminate the effects of
barbiturates? Rapid redistribution into tissues (ie, skeletal muscle) and fat,
decreased cerebral blood flow "<img src=""8216.png"">" Neurology intravenous-
Why is the barbiturate thiopental an ideal choice for the induction of anesthesia
and short surgical procedures? It has high potency and high lipid solubility
and enters the brain rapidly "<img src=""8216.png"">" Neurology intravenous-
Which drug is commonly mixed with local anesthetics to enhance their action,
decrease bleeding, and decrease systemic concentration? Epinephrine (It acts
through local vasoconstriction to increase anesthesia by decreasing systemic
concentration.) "<img src=""8217.png"">" Neurology local-anesthetics
pharmacology
Explain the mechanism of action of a local anesthetic on the nerve cell membrane.
It binds to the inner surface of the Na channel; it works best in rapidly
firing nerves "<img src=""8217.png"">" Neurology local-anesthetics
pharmacology
A pt is undergoing dbridement of a warm, swollen, erythematous laceration. Why
would more anesthetic be necessary than in the fresh wound?In infected (acidic)
tissue, alkaline anesthetics are charged and cannot penetrate membrane effectively;
thus more anesthetic is needed "<img src=""8217.png"">" Neurology local-
List the order in which the following sensations are lost during nerve blockade
(first to last): pressure, pain, touch, temperature. Pain, temperature, touch,
pressure "<img src=""8217.png"">" Neurology local-anesthetics pharmacology
Which amide, used in local anesthesia, may cause severe cardiovascular toxicity?
Bupivacaine "<img src=""8217.png"">" Neurology local-anesthetics
pharmacology
Which infrequently used local anesthetic is a commonly abused street drug that may
cause cardiac arrhythmias or hypo- or hypertension? Cocaine "<img
src=""8217.png"">" Neurology local-anesthetics pharmacology
List the three esters and three amides categorized as local anesthetics.
Esters: procaine, cocaine, and tetracaine; amides: lIdocaIne, mepIvacaIne,
and bupIvacaIne (All amIdes have 2 I's in their names.) "<img src=""8217.png"">"
Neurology local-anesthetics pharmacology
A pt receives an injection of lidocaine. Which sensory nerves are blocked first:
small unmyelinated fibers or large myelinated fibers? Why? Small unmyelinated
fibers; size is more important than myelination, so small fibers are blocked first
whether or not they are myelinated. "<img src=""8217.png"">" Neurology local-
A pt undergoing a minor surgical procedure is given lidocaine. How does this amide
reach its site of action? Lidocaine (a tertiary amine) penetrates the membrane
in an uncharged form, then binds the Na+ channel in a charged form "<img
src=""8217.png"">" Neurology local-anesthetics pharmacology
A pt is allergic to tetracaine. Which local anesthetics may be used instead? Amides
(lidocaine, mepivacaine, bupivacaine), as they have allergy profiles different from
those of esters (procaine, cocaine, tetracaine) "<img src=""8217.png"">"
Neurology local-anesthetics pharmacology
Which local anesthetic may cause methemoglobinemia as a side effect? Benzocaine
"<img src=""8217.png"">" Neurology local-anesthetics pharmacology
Phase I depolarization in neuromuscular blockade is potentiated by which class of
inhibitors? Cholinesterase "<img src=""8218.png"">" Neurology neuromuscular-
blocking-drugs pharmacology
How does succinylcholine lead to paralysis? Succinylcholine causes sustained
depolarization to prevent muscle contraction "<img src=""8218.png"">"
Neurology neuromuscular-blocking-drugs pharmacology
Neuromuscular blocking drugs used for paralysis during surgery or mechanical
ventilation are selective for what type of nicotinic receptors? Motor (vs
autonomic) "<img src=""8218.png"">" Neurology neuromuscular-blocking-drugs
pharmacology
What is the antidote to phase I (prolonged depolarization) action of
succinylcholine? None; there is no antidote "<img src=""8218.png"">"
Name six nondepolarizing neuromuscular blocking drugs. Tubocurarine,
atracurium, mivacurium, pancuronium, vecuronium, and rocuronium "<img
src=""8218.png"">" Neurology neuromuscular-blocking-drugs pharmacology
Compare the receptor targets of depolarizing with those of nondepolarizing
neuromuscular drugs. Depolarizing drugs target acetylcholine; nondepolarizing
drugs target nicotinic motor receptors "<img src=""8218.png"">" Neurology
neuromuscular-blocking-drugs pharmacology
A pt is given an overdose of a nondepolarizing neuromuscular blocking drug. What is
the mechanism by which the antidote works? The antidote (neostigmine or
edrophonium) inhibits cholinesterase "<img src=""8218.png"">" Neurology
What are the complications associated with succinylcholine?Hyperkalemia,
hypercalcemia, and malignant hyperthermia "<img src=""8218.png"">" Neurology
Name a severe complication of most inhaled anesthetics and a depolarizing
neuromuscular blocking drug. Malignant hyperthermia can result from all inhaled
anesthetics (except nitrous oxide); succinylcholine "<img src=""8218.png"">"
What is the mechanism of action of the depolarizing neuromuscular blocking drug
succinylcholine? It is a strong ACh receptor agonist that produces sustained
depolarization and prevents muscle contraction "<img src=""8218.png"">"
A pt receives succinylcholine. Her temp rises to 105 F. What medication reverses
symptoms by decoupling excitation-relaxation in muscles? Dantrolene, which is
also used in neuroleptic malignant syndrome "<img src=""8219.png"">"
Neurology dantrolene pharmacology
A 42-y/o schizophrenic pt presents with hyperthermia and muscle rigidity. Name the
muscle relaxant used and its mechanism of action. Dantrolene; it prevents
release of Ca2+ from SR in muscle by antagonizing the ryanodine receptors "<img
src=""8219.png"">" Neurology dantrolene pharmacology
A 29-y/o man has back pain. What is the mechanism of action of the commonly
prescribed muscle relaxant that works at the spinal cord? Baclofen inhibits GABAB
receptors at the spinal cord level; it is used to treat muscle spasms (eg, acute
low back pain) "<img src=""8220.png"">" Neurology baclofen pharmacology
A 35-y/o pt with back pain is given a centrally acting muscle relaxant structurally
related to TCAs. Name the drug and its side effects. Cyclobenzaprine has
anticholinergic side effects: drowsiness, dry mouth, and dizziness, especially in
elderly pts "<img src=""8221.png"">" cyclobenzaprine neurology pharmacology
Name two catechol-O-methyltransferase inhibitors that prevent the breakdown of L-
dopa in the peripheral nervous system. Entacapone and tolcapone "<img
src=""8222.png"">" Neurology parkinson-disease-drugs pharmacology
Patients with parkinsonism have excess activity of what neurotransmitter?
Acetylcholine "<img src=""8222.png"">" Neurology parkinson-disease-
drugs pharmacology
Which five drugs/classes are used to treat Parkinson disease? Use the mnemonic
BALSA Bromocriptine, Amantadine, Levodopa (with carbidopa), Selegiline (and COMT
inhibitors), Antimuscarinics "<img src=""8222.png"">" Neurology parkinson-
disease-drugs pharmacology
What two symptoms characterize amantadine toxicity? Ataxia and livedo reticularis
"<img src=""8222.png"">" Neurology parkinson-disease-drugs pharmacology
What are the two subclasses of direct dopamine agonists? Which one is preferred?
The ergots (eg, bromocriptine) and non-ergots (eg, pramipexole, ropinirole);
non-ergots are preferred "<img src=""8222.png"">" Neurology parkinson-
disease-drugs pharmacology
Which selective catechol-O-methyltransferase (COMT) inhibitor prevents dopamine
breakdown into 3-MT within the central nervous system? Tolcapone "<img
How do centrally acting Parkinson drugs that prevent dopamine breakdown work?
They act centrally (post-BBB) to prevent the breakdown of dopamine and
increase its availability within the central nervous system"<img src=""8222.png"">"
Neurology parkinson-disease-drugs pharmacology
How do peripherally acting Parkinson drugs that prevent L-DOPA breakdown work?
They act peripherally (pre-BBB) to prevent the breakdown of L-DOPA and
increase the amount that passes through the BBB into the brain "<img
Levodopa (L-DOPA) and carbidopa confer two benefits when given together. What are
they? Carbidopa blocks peripheral DOPA decarboxylase L-DOPA conversion to dopamine;
also reduces dopamine toxicity (eg, nausea, vomiting). "<img src=""8222.png"">"
In the periphery, L-DOPA can be broken down into two different metabolites. What
are they, and which enzymes facilitate the reactions? Dopamine (via DOPA
decarboxylase [DDC]) and 3-O-methyldopa (via COMT) "<img src=""8222.png"">"
Increased peripheral dopamine can cause nausea and vomiting. Carbidopa
administration attenuates this effect. Why? Carbidopa inhibits DOPA
decarboxylase, thus reducing the conversion of L-DOPA into dopamine (thereby
reducing side effects) "<img src=""8222.png"">" Neurology parkinson-disease-
drugs pharmacology
What is the peripheral (ie, pre-BBB) mechanism of action of entacapone and
tolcapone? Which one also acts centrally? They prevent peripheral L-DOPA
degradation to 3-O-methyldopa (3-OMD) by inhibiting COMT; tolcapone "<img
What enzyme is inhibited by tolcapone and entacapone? Peripherally, this prevents
the breakdown of L-DOPA into which metabolite? COMT; 3-O-methyldopa "<img
How does selegiline increase available dopamine within the central nervous system?
Consider enzyme inhibition for a specific reaction. It blocks central conversion
of dopamine into DOPAC by inhibiting MAO-B "<img src=""8222.png"">"
After L-DOPA passes through the BBB, what enzyme converts it into dopamine? DOPA
decarboxylase (DDC) "<img src=""8222.png"">" Neurology parkinson-disease-
drugs pharmacology
In what specific part of the neurons in the central nervous system do centrally
acting Parkinson drugs that inhibit dopamine breakdown act?The presynaptic
terminals of the substantia nigra neurons "<img src=""8222.png"">" Neurology
parkinson-disease-drugs pharmacology
Which COMT-inhibiting drug can act centrally (ie, post-BBB)? What reaction,
facilitated by which enzyme, does it block? Tolcapone; it blocks central
conversion of dopamine into 3-MT by inhibiting COMT "<img src=""8222.png"">"
The drug amantadine increases dopamine availability within the synaptic cleft. By
what two mechanisms does it accomplish this? It promotes the release of dopamine
from the presynaptic neuron and inhibits its reuptake by the presynaptic neuron
"<img src=""8222.png"">" Neurology parkinson-disease-drugs pharmacology
What three drugs act as direct dopamine agonists? Where do they bind to exert this
effect? Bromocriptine (ergot), pramipexole (non-ergot), ropinirole (non-ergot);
they bind dopamine receptors in the striatum postsynaptic terminals "<img
Which Parkinson disease drug crosses the blood-brain barrier and is converted to
dopamine by dopa decarboxylase in the CNS? L-DOPA "<img src=""8223.png"">"
Neurology l-dopa-(levodopa)/carbidopa pharmacology
What effect may L-DOPA have on the heart? It may cause arrhythmias resulting from
increased peripheral formation of catecholamines "<img src=""8223.png"">"
Which medication is a peripheral decarboxylase inhibitor that is given with L-DOPA
to increase its effective concentration? Carbidopa "<img src=""8223.png"">"
"What is the ""on-off"" phenomenon due to long-term use of L-DOPA?" Dyskinesia
while on; akinesia while off "<img src=""8223.png"">" Neurology l-dopa-
(levodopa)/carbidopa pharmacology
What effect does selegiline have on the adverse effects of L-DOPA in pts with
parkinsonian conditions? Enhances the adverse effects by inhibiting MAO-B
metabolism of dopamine "<img src=""8224.png"">" Neurology pharmacology
selegiline,-rasagiline
Which enzyme is inhibited by the action of selegiline, and what substance is
increased after administration? MAO-B (which normally preferentially
metabolizes dopamine over norepinephrine and 5-HT); available dopamine is increased
"<img src=""8224.png"">" neurology pharmacology selegiline,-rasagiline
What is the clinical use of selegiline? Name the adverse effect of this drug.
As an adjunctive agent to L-DOPA in the treatment of Parkinson disease; may
enhance adverse effects of L-DOPA "<img src=""8224.png"">" neurology
pharmacology selegiline,-rasagiline
A 70-year-old man takes a medication affecting ACh levels to slow the progression
of Alzheimer disease. What is the mechanism of action? Inhibition of
acetylcholinesterase; the medication may be donepezil (most common), galantamine,
rivastigmine, or tacrine "<img src=""8225.png"">" alzheimer-drugs
Which drug, used for Alzheimer disease, acts as an NMDA receptor antagonist?
Memantine "<img src=""8225.png"">" alzheimer-drugs neurology
pharmacology
Memantine helps prevent what Ca2+-mediated process in Alzheimer disease?
Excitotoxicity of neurons (mediated by Ca2+) "<img src=""8225.png"">"
alzheimer-drugs neurology pharmacology
Which dopamine receptor antagonist can be used to treat Huntington disease? On
which receptor does it act? Haloperidol; it acts as an antagonist on the D2
receptor "<img src=""8226.png"">" huntington-disease-drugs neurology
pharmacology
What levels of dopamine, GABA, and acetylcholine characterize Huntington disease?
Increased dopamine, decreased GABA, and decreased acetylcholine levels "<img
src=""8226.png"">" Neurology huntington-disease-drugs pharmacology
Name two monoamine-depleting drugs used to treat Huntington disease. Name the
mechanism of action. Reserpine and tetrabenazine; they inhibit vesicular
monoamine transporter, limiting dopamine vesicle packaging and release "<img
src=""8226.png"">" Neurology huntington-disease-drugs pharmacology
What is the treatment for ALS that modestly increases survival? How does it work?
Riluzole; it decreases glutamate excitotoxicity "<img src=""8227.png"">"
Neurology pharmacology riluzole
What is the mechanism of action of sumatriptan? It is a 5-HT1B/1D agonist that
inhibits trigeminal nerve activation, prevents vasoactive peptide release, and
induces vasoconstriction "<img src=""8228.png"">" neurology pharmacology
triptans
A 30-y/o man with Horner syndrome has frequent, brief headaches with unilateral
periorbital pain and rhinorrhea. Which drug can help? Sumatriptan "<img
src=""8228.png"">" Neurology pharmacology triptans
A 50-y/o man with a history of coronary artery disease now gets migraine headaches.
What drug is contraindicated for his headaches? Why? Sumatriptan; it causes
coronary vasospasm and could worsen coronary artery disease or Prinzmetal angina
"<img src=""8228.png"">" Neurology pharmacology triptans
What are the clinical uses of sumatriptan? Acute migraine and cluster
headaches (Sumatriptan = a SUMo wrestler TRIPs ANd falls on your head.) "<img
A pt with an acute migraine is given sumatriptan. What side effect might he
experience? How is this related to the drug's action? Mild paresthesias;
sumatriptan induces vasoconstriction (hence, the paresthesias) "<img
A toddler cries when he sees someone in a white coat. His reaction is an example of
what type of conditioning? Classical conditioning: He cries because he
associates a white coat with a shot because they occurred together in the past
"<img src=""8229.png"">" classical-conditioning psychiatry psychology
You conduct Pavlov's classical conditioning experiment. When you ring a bell, a dog
salivates. What is the learned/conditioned stimulus? The bell is the stimulus: it
triggers a natural response, salivation), by virtue of having previously been
associated with food "<img src=""8229.png"">" classical-conditioning
psychiatry psychology
You conduct Pavlov's classical conditioning experiment. When you ring a bell, a dog
salivates. What is the unconditioned stimulus? Food: Salivation is an involuntary
response to it, so food counts as an unconditioned, rather than a conditioned,
stimulus "<img src=""8229.png"">" classical-conditioning psychiatry
psychology
A man feels able to block out unwanted feelings when injecting heroin. What type of
conditioning would lead to repeat behavior? Reinforcement: Target behavior
(response) is followed by removal of aversive stimulus "<img src=""8230.png"">"
operant-conditioning psychiatry psychology
What is operant conditioning? Learning in which a particular action is elicited
because it produces a punishment or reward "<img src=""8230.png"">"
operant-conditioning psychiatry psychology
A man feels euphoria when injecting heroin. What type of conditioning would lead to
repeat behavior? Positive reinforcement (operant conditioning) "<img
src=""8230.png"">" operant-conditioning psychiatry psychology
How do punishment and negative reinforcement differ in operant conditioning?
Aversive stimuli preventing behavior is punishment; aversive stimuli
eliciting behavior (to stop the stimulus) is negative reinforcement "<img
A patient takes naloxone as part of his recovery. Now opiates do not cause
euphoria, so he stops abusing them. What is this effect called? Extinction, in
which removal of positive reinforcement leads to cessation of behavior "<img
How do classical and operant conditioning differ with respect to voluntariness to
do the action involved? Classical is usually involuntary (salivating, being scared,
etc); operant is usually voluntary (but can become subconscious and habitual)
"<img src=""8230.png"">" operant-conditioning psychiatry psychology
Differentiate between transference and countertransference Transference: patient
projecting feelings onto physician; countertransference: physician projecting
feelings onto patient "<img src=""8231.png"">" psychiatry psychology
transference-and-countertransference
A patient is hostile toward her female psychiatrist. History reveals a tumultuous
past with her mother. What term describes this behavior? Transference: Patient
projects feelings about formative or other important persons onto physician "<img
src=""8231.png"">" psychiatry psychology transference-and-countertransference
A psychiatrist gets angry at a patient who abuses cats. The psychiatrist's father
also tortured cats. What term describes this anger? Countertransference: Doctor
projects feelings about formative or other important persons onto patient "<img
src=""8231.png"">" psychiatry psychology transference-and-countertransference
A 6-year-old boy throws groceries out of the cart when his mother refuses him
candy. Is his ego defense mature or immature? This is acting out (temper
tantrum), which is an immature ego defense "<img src=""8232.png"">" ego-
defenses psychiatry psychology
A woman has dissociative identity disorder (multiple personality disorder). This is
an extreme form of what type of defense mechanism? Dissociation: a drastic but
temporary change in personality/memory/behavior to avoid stressors (an immature ego
defense) "<img src=""8232.png"">" ego-defenses psychiatry psychology
A 30-y/o lawyer learns that he has an incurable brain tumor. He carries on as if
nothing has happened. Is his response immature or mature? This is denial, an
immature ego defense "<img src=""8232.png"">" ego-defenses psychiatry
psychology
Define displacement as an ego defense. Is it a mature or immature defense?
Negative feelings are targeted at an object or person unrelated to the
inciting event; immature "<img src=""8232.png"">" ego-defenses psychiatry
psychology
A mother yells at her son after her husband yells at her. What defense mechanism is
this? Is it a mature or immature ego defense? This is displacement, which is an
psychology
Define fixation as an ego defense. Is it a mature or immature defense? Fixation is
an immature ego defense wherein a person partially remains at a more childish level
of development "<img src=""8232.png"">" ego-defenses psychiatry psychology
A medical student chews on the ends of pens when he is nervous. What type of ego
defense is this? Fixation: never moving past a childish behavior (oral stage of
gratification in this case) "<img src=""8232.png"">" ego-defenses psychiatry
psychology
Differentiate between fixation and regression as ego defenses. Fixation is
remaining at a more childish level of development; regression is acting immaturely
due to stress "<img src=""8232.png"">" ego-defenses psychiatry psychology
A boy who is abused at home begins to bully other children at school. What is the
ego defense? Is it immature or mature? Identification: emulating the behavior of
a more powerful (but not necessarily admired) figure; immature "<img
src=""8232.png"">" ego-defenses psychiatry psychology
Define isolation of affect as an ego defense. Is it a mature or immature defense?
Memory of an unacceptable act is separated from the emotion associated with
it; immature "<img src=""8232.png"">" ego-defenses psychiatry psychology
A 16-y/o girl describes sexual abuse by her father in detail but shows no emotion.
What defense mechanism is this? Is it mature or immature? This is isolation of
affect, an immature ego defense "<img src=""8232.png"">" ego-defenses
After committing adultery, a man goes into detail about his poor marriage causing
divorce. Is this a mature or immature ego defense? This is rationalization, an
psychology
Define the ego defense known as reaction formation. Is it a mature or immature
defense? A negative idea or feeling is replaced by adopting a behavior that is
opposite to the original; immature "<img src=""8232.png"">" ego-defenses
A secret alcoholic publicly extolls the virtues of abstinence. What type of defense
mechanism is this? Is it mature or immature? This is reaction formation, an
psychology
A 40-y/o man becomes completely dependent on his father after his mother's death.
What defense mechanism is this? Is it mature or immature? This is regression
(returning to an earlier stage of development to deal with the world), an immature
ego defense "<img src=""8232.png"">" ego-defenses psychiatry psychology
In terms of voluntariness and maturity, how do repression and suppression differ?
Repression is involuntary and immature; suppression is voluntary and mature
"<img src=""8232.png"">" ego-defenses psychiatry psychology
A teenager does not remember that he was abused as a child. What ego defense
mechanism is this? Repression "<img src=""8232.png"">" ego-defenses
Describe the ego defense altruism. Is it considered mature or immature? In
altruism, guilty feelings are relieved through acts of unsolicited generosity
toward others; mature "<img src=""8232.png"">" ego-defenses psychiatry
psychology
A woman thinks you are the only physician who cares for her well-being and that the
rest are selfish and dumb. What ego defense is this? This is splitting, an
immature ego defense commonly associated with borderline personality disorder
A girl thinks her mother is a terrible person but believes her father is perfect.
With what personality disorder is this associated? Borderline personality
disorder "<img src=""8232.png"">" ego-defenses psychiatry psychology
A secretary dislikes her boss, so she often changes his schedule at the last
minute. Type of defense mechanism? Mature or immature? Passive aggression
indirect show of opposition by failing to meet expectations; immature "<img
A robber steals a large sum. Years later, he feels regretful and makes a donation
to an orphanage. Is this a mature or immature ego defense? This is altruism, a
mature defense mechanism "<img src=""8232.png"">" ego-defenses psychiatry
psychology
Describe humor as an ego defense. Is it a mature or immature defense? A person
using humor as a defense diffuses the pressure of an anxiety-provoking situation by
joking about it; mature "<img src=""8232.png"">" ego-defenses psychiatry
psychology
Is a nervous ice skater who feels better when she jokes about her planned
performance using a mature or immature ego defense? She is using humor, a mature
What is the ego defense known as sublimation? Is it a mature or immature defense?
A person replaces an unacceptable wish with a similar wish/action that is
more acceptable in terms of his or her value system; mature"<img src=""8232.png"">"
ego-defenses psychiatry psychology
Differentiate between sublimation and reaction formation. Sublimation: redirecting
feelings into something similar but in line with values; reaction formation:
unconsciously doing the opposite "<img src=""8232.png"">" ego-defenses
When a bully decides to stop bullying other kids and join the boxing team, is he
employing a mature or immature ego defense? This is sublimation: replacing
unacceptable desires (bullying) with something without value system conflicts
(boxing), a mature ego defense "<img src=""8232.png"">" ego-defenses
What mature ego defense is evoked when one voluntarily blocks an idea or feeling
from his/her own awareness? Suppression "<img src=""8232.png"">" ego-defenses
What are the four mature ego defenses? Sublimation, Altruism, Suppression, and
Humor (Mature adults wear a SASH.) "<img src=""8232.png"">" ego-defenses
Define the ego defense known as projection. Is it mature or immature? The
attribution of unacceptable feelings or beliefs to someone or something else;
immature "<img src=""8232.png"">" ego-defenses psychiatry psychology
A man who desires his co-worker believes that his wife is cheating on him. Which
ego defense is this? Is this mature or immature? This is projection, an
psychology
An 18-year-old patient presents with bedwetting; he was previously continent. Is
this an example of fixation or regression? Regression: He had previously
reached a developmental milestone and then reverted "<img src=""8232.png"">"
A patient often uses a passive-aggressive ego defense. What does this mean? Is it a
mature or immature defense? Performing below expectations and expressing
negativity to show opposition indirectly; immature "<img src=""8232.png"">"
A restaurant employee is constantly late to work because he dislikes his new
manager. What ego defense is this? Is it mature or immature? This is passive
aggression (performing below expectations in opposition), an immature ego defense
A man steals at work and is fired. He claims the job was not important to him
anyway. What ego defense is this? Is it mature or immature?This is rationalization,
which is an immature ego defense "<img src=""8232.png"">" ego-defenses
What is an ego defense? A mental process unconsciously used by the mind to resolve
conflict and prevent unpleasant feelings (eg, anxiety and depression) "<img
A 4-year-old can't have cookies, so he lies on the floor and screams. What ego
defense is this? Is it mature or immature? Acting out, in which unacceptable
feelings/thoughts become actions; immature "<img src=""8232.png"">" ego-
defenses psychiatry psychology
A man ignores the existence of a painful reality. What ego defense is he employing?
Is it immature or mature? This is denial, an immature ego defense "<img
An M4 intentionally refuses to stress over his residency match after submitting his
rank order list. Mature or immature ego defense? This is suppression, a mature
How does the lifetime risk for bipolar disorder and schizophrenia differ for the
general population, parent/sibling, monozygotic twins? General population
(~1%); parents/siblings (~10%); monozygotic twins (~50%) "<img src=""8233.png"">"
Pathology psychiatric-genetics psychiatry
An infant is subjected to long-term deprivation of affection. What are the four
effects of this long-term deprivation on infants? Failure to thrive, poor
language/socialization skills, lack of basic trust, reactive attachment disorder
(infant withdrawn/unresponsive) "<img src=""8234.png"">" Pathology infant-
deprivation-effects psychiatry
What are the 4 W's (mnemonic) of infant deprivation? Weak, Wordless, Wanting
(socially), and Wary "<img src=""8234.png"">" Pathology infant-deprivation-
effects psychiatry
An 8-month-old has low muscle tone, is withdrawn, and is unresponsive. He is poorly
supervised at home. Are these effects reversible? If infant affection
deprivation lasts longer than 6 months, the effects may be irreversible and can
result in death "<img src=""8234.png"">" Pathology infant-deprivation-
effects psychiatry
A child is physically abused. Who is the most likely abuser? The biological
mother "<img src=""8235.png"">" Pathology child-abuse psychiatry
Who is the usual perpetrator of sexual abuse of a child? A male figure known to
the child "<img src=""8235.png"">" Pathology child-abuse psychiatry
A 5-m/o girl is listless, and x-ray shows fractures at different stages of healing.
What eye finding would help confirm suspicion of abuse? "Retinal hemorrhages,
suggestive of ""shaken baby syndrome."" An ophthalmoscopic exam should be performed
when child abuse is suspected" "<img src=""8235.png"">" Pathology child-
abuse psychiatry
Physical child abuse accounts for what percentage of deaths in children younger
than 1 year? 0.4 "<img src=""8235.png"">" Pathology child-abuse
psychiatry
The peak incidence of sexual abuse in children occurs in what age range? 912
years "<img src=""8235.png"">" Pathology child-abuse psychiatry
A 5-year-old girl with 2 weeks of vaginal discharge tests positive for gonorrhea.
What should you suspect? Always suspect sexual abuse in pediatric cases of
STIs; urinary tract infections; and genital, anal, or oral trauma "<img
src=""8235.png"">" Pathology child-abuse psychiatry
On exam, a toddler has several spiral fractures and belt marks. Head CT shows a
subdural hematoma. Who likely caused these injuries? The biological mother is
likely responsible for these signs of physical abuse "<img src=""8235.png"">"
Pathology child-abuse psychiatry
What is the definition of child neglect? How common is neglect in comparison with
other forms of child maltreatment? Failure to provide adequate supervision,
shelter, food, education, affection, or some combination; the most common form of
maltreatment "<img src=""8236.png"">" Pathology child-neglect psychiatry
What are the signs of child neglect? To whom do you report neglect? Failure to
thrive, poor hygiene, malnutrition, withdrawal, impaired social or emotional
development; local child protective services "<img src=""8236.png"">"
Pathology child-neglect psychiatry
A child is brought in after displaying withdrawn behavior. He is thin and
malnourished and has poor hygiene. What is your next step? These are signs and
symptoms of child neglect; report your findings to local child protective services
"<img src=""8236.png"">" Pathology child-neglect psychiatry
What is vulnerable child syndrome? Parents think their child is more susceptible
to illness or injury, often following a major illness or life-threatening event
"<img src=""8237.png"">" Pathology psychiatry vulnerable-child-syndrome
What are some consequences of vulnerable child syndrome? The child may miss
school or have excessive medical visits due to parents' worry that the child is
more susceptible to illness or injury "<img src=""8237.png"">" Pathology
psychiatry vulnerable-child-syndrome
A 7-year-old girl cannot pay attention in school and at home and acts impulsively.
What is the long-term prognosis for her condition? Fifty percent of patients
will continue to have ADHD into adulthood "<img src=""8238.png"">" Pathology
childhood-and-early-onset-disorders psychiatry
A 4-year-old boy barely speaks or socializes. He flaps his arms, cannot make eye
contact, and fixates on his shoes. What is the diagnosis? Autism spectrum
disorder, which presents with language/social impairments and, sometimes, decreased
intelligence; it is more common in boys "<img src=""8238.png"">" Pathology
A 3-year-old girl loses developmental milestones, speaks less, wrings her hands,
and has developed a clumsy gait. What is the diagnosis? Rett syndrome: Symptoms
of regression characteristically present at approximately 1 to 4 years of age
"<img src=""8238.png"">" Pathology childhood-and-early-onset-disorders
psychiatry
A previously normal 3-year-old girl now speaks/understands less, wrings her hands,
and staggers. When does this disorder occur in boys? Rett syndrome is X-linked and
therefore mostly a disease of girls; affected boys generally die in utero or
shortly after birth "<img src=""8238.png"">" Pathology childhood-and-
early-onset-disorders psychiatry
What are the features of an autism spectrum disorder? Language and social
impairment, preoccupation w/objects, lower intelligence, repetitive behaviors, and
rarely, unusual abilities (savants) "<img src=""8238.png"">" Pathology
A boy is found to have autism. When does this disorder present? Is it more common
in girls or boys? Most cases present in early childhood; it is more common in boys
psychiatry
A psychiatrist sees a 14-year-old who repeatedly vandalizes public property and
beats up classmates. Treatment options? This is conduct disorder; treat with
cognitive behavioral therapy (CBT) "<img src=""8238.png"">" Pathology
A 12-year-old boy is regularly disobedient and curses at his teachers but is not
violent and does not commit crimes. What is the diagnosis? Oppositional defiant
disorder "<img src=""8238.png"">" Pathology childhood-and-early-onset-
disorders psychiatry
What differentiates conduct disorder from oppositional defiant disorder?
Conduct disorder: behavior harms people or damages property; oppositional
defiant disorder: hostile, defiant behavior without delinquency "<img
src=""8238.png"">" Pathology childhood-and-early-onset-disorders psychiatry
A child curses at her parents and teachers but has not committed any crimes. What
is the treatment for her disorder? This is oppositional defiant disorder, which is
treated with cognitive behavioral therapy (CBT) "<img src=""8238.png"">"
Pathology childhood-and-early-onset-disorders psychiatry
A 6-year-old boy with a short attention span and poor impulse control presents to a
child psychiatrist. Likely diagnosis? Attention-deficit hyperactivity disorder.
Check that it occurs in multiple settings "<img src=""8238.png"">" Pathology
You suspect that a child who does poorly in school has ADHD. When does this
disorder present? Does it affect intelligence? Onset is typically before age 12;
intelligence is normal "<img src=""8238.png"">" Pathology childhood-and-
A 7-year-old has a short attention span and poor impulse control at home and
school. What are treatments for this disorder? This is ADHD; treatments include
stimulants (eg, methylphenidate), a stimulant alternative (eg, atomoxetine), &
cognitive behavioral therapy "<img src=""8238.png"">" Pathology childhood-and-
What three traits characterize attention-deficit hyperactivity disorder?
Hyperactivity, impulsivity, and inattention in multiple settings (eg, school,
home, places of worship) "<img src=""8238.png"">" Pathology childhood-and-
A child cannot pay attention at school and home and acts impulsively. What might
neuroimaging show? Decreased frontal lobe volume and metabolism, sometimes
associated with attention-deficit hyperactivity disorder "<img src=""8238.png"">"
A boy has exhibited tics for the past 6 months. How long do symptoms need to be
present for Tourette syndrome to be diagnosed? More than 1 year; one cannot say at
this point whether he has Tourette syndrome "<img src=""8238.png"">"
A 10-year-old boy has multiple tics and involuntary profane outbursts. What are two
conditions associated with this disorder? Obsessive-compulsive disorder and ADHD
are associated with this disorder, which is Tourette syndrome "<img
A boy has Tourette syndrome. What symptoms does he have? When does this disease
present? Sudden, rapid, nonrhythmic stereotyped motor and vocal tics, present
for at least a year; before age 18 "<img src=""8238.png"">" Pathology
A boy has Tourette syndrome. What is the first-line therapy? If an intractable tic
develops, how do you treat it? Behavioral therapy and psychoeducation; high-
potency antipsychotics (eg. fluphenazine, pimozide), tetrabenazine, clonidine,
guanfacine "<img src=""8238.png"">" Pathology childhood-and-early-onset-
You suspect a 13-year-old boy has Tourette syndrome, but he does not have
coprolalia. Could he still have Tourette syndrome? Yes, only 10% to 20% of
patients with Tourette syndrome exhibit coprolalia "<img src=""8238.png"">"
A young girl complains of a headache to avoid going to school, because she is
scared to leave her mother. What is her diagnosis? Separation anxiety disorder
psychiatry
A child exhibits a disorder of overwhelming fear of separation from parents. At
what age does this most commonly present? Separation anxiety disorder most commonly
develops between the ages of 7 and 9 years "<img src=""8238.png"">"
What is the treatment for a 7-year-old boy who complains of a headache each
morning, then cries hysterically when he is sent to school?Cognitive behavioral
therapy, play therapy, family therapy (This is separation anxiety disorder.) "<img
How do you distinguish between conduct disorder and oppositional defiant disorder?
In conduct disorder, the basic rights of others are violated, but in
oppositional defiant disorder, they are not "<img src=""8238.png"">"
A young boy with a larger than average head has poor social skills and repetitive
behavior. What is his expected intelligence level? This is suggestive of autism
spectrum disorder. He will probably have lower intelligence; savant ability is rare
psychiatry
What are the predicted social, communication, and behavioral limitations of autism
spectrum disorder? Limited in all three domains. Children may also engage in
ritualized/repetitive behaviors. "<img src=""8238.png"">" Pathology
In Huntington disease what neurotransmitters are either increased or decreased?
GABA and ACh are decreased, and dopamine is increased"<img src=""8239.png"">"
Pathology neurotransmitter-changes-with-disease psychiatry
For each of the following, are dopamine levels increased or decreased: depression,
Huntington disease, schizophrenia, Parkinson disease? Decreased; increased;
increased; decreased "<img src=""8239.png"">" Pathology neurotransmitter-
changes-with-disease psychiatry
Compare levels of serotonin and norepinephrine (NE) in anxiety and depression.
Which shows decreased GABA? Which shows decreased dopamine?Both have decreased
serotonin; anxiety has increased NE and decreased GABA; depression has decreased NE
and dopamine "<img src=""8239.png"">" Pathology neurotransmitter-changes-
with-disease psychiatry
Compare the levels of ACh in Huntington disease, Alzheimer disease, and Parkinson
disease. Decreased; decreased; increased "<img src=""8239.png"">"
A patient has a mental disorder with decreased ACh and increased glutamate. What
are these findings consistent with? Alzheimer dementia "<img src=""8239.png"">"
A patient has a mental disorder with increased norepinephrine and decreased GABA
and 5-HT. What is this consistent with? Anxiety "<img src=""8239.png"">"
A patient has a mental disorder with decreased norepinephrine and decreased
dopamine and 5-HT. What are these findings consistent with?Depression "<img
src=""8239.png"">" Pathology neurotransmitter-changes-with-disease psychiatry
A patient has a mental disorder with increased dopamine and decreased GABA and ACh.
What are these findings consistent with? Huntington disease "<img
A patient has a mental disorder with decreased dopamine and increased ACh. What are
these findings consistent with? Parkinson disease "<img src=""8239.png"">"
A patient has a mental disorder with increased dopamine alone. What is this finding
consistent with? Schizophrenia "<img src=""8239.png"">" Pathology
neurotransmitter-changes-with-disease psychiatry
A patient is rapidly becoming demented. GABA and ACh levels are decreased. An
antagonist against what receptor might be helpful? Dopamine, which is increased
in patients with Huntington disease "<img src=""8239.png"">" Pathology
A man cannot sleep well. GABA is decreased, and norepinephrine is increased. A
higher level of which neurotransmitter may help? Serotonin, which is decreased
in patients with anxiety "<img src=""8239.png"">" Pathology
A man has bradykinesia and masklike facies from low dopamine. He drools
excessively. An antagonist for which neurotransmitter may help? ACh, which is
increased in patients with Parkinson disease "<img src=""8239.png"">"
A man is either anxious or depressed. Serotonin is found to be low. Measuring which
neurotransmitter can help you with the diagnosis? Norepinephrine, which is
decreased in patients with depression and increased in patients with anxiety "<img
An elderly woman has altered mental status. List the order in which a person loses
his or her components of orientation. Typically, orientation to time is lost
first, then to place, then to person "<img src=""8240.png"">" Pathology
orientation psychiatry
You are testing orientation in an elderly patient with delirium. What is
orientation? The patients ability to know who he or she is, where he or she
is, and the date and time "<img src=""8240.png"">" Pathology orientation
psychiatry
A patient does not know who she is, where she is, and what date it is. Name seven
possible causes of her state. Alcohol, drugs, fluid/electrolyte imbalances, head
trauma, hypoglycemia, infections, nutritional deficiencies "<img src=""8240.png"">"
Pathology orientation psychiatry
A man has bilateral destruction of mamillary bodies on autopsy. What syndrome did
he likely have, and how could it have been prevented? Korsakoff syndrome; since
destruction of mamillary bodies is associated with vitamin B1 (thiamine) deficiency
"<img src=""8241.png"">" Pathology amnesias psychiatry
After a car accident with CNS trauma, a patient cannot recall anything that
occurred from that day onward. What type of amnesia is this? Anterograde "<img
src=""8241.png"">" Pathology amnesias psychiatry
A 44-year-old alcoholic man comes to the ED exhibiting anterograde amnesia and
confabulation. What is the diagnosis? Korsakoff amnesia (from thiamine
deficiency and mammillary body destruction due to alcohol use; anterograde &62;
retrograde) "<img src=""8241.png"">" Pathology amnesias psychiatry
After a car accident, a man is unable to recall anything that occurred before the
incident but can still make new memories. Diagnosis? Retrograde amnesia "<img
Is Korsakoff amnesia anterograde or retrograde? Largely anterograde, but with some
retrograde memory loss "<img src=""8241.png"">" Pathology amnesias psychiatry
After the severe trauma of child abuse, a woman is unable to recall any important
personal information. What type of amnesia is this? Dissociative amnesia "<img
A man takes an abrupt trip to the other side of the country and is found wandering
on the streets there. What is the most likely diagnosis? Dissociative fugue,
which occurs during a period of dissociative amnesia, often associated with
traumatic circumstances "<img src=""8241.png"">" Pathology amnesias psychiatry
A woman has two distinct identities with different names and personalities; history
reveals childhood sexual abuse. What is the diagnosis? Dissociative identity
disorder "<img src=""8242.png"">" Pathology dissociative-disorders
psychiatry
A man often feels estranged from his surroundings and from himself, almost as if he
is merely an observer. What could this condition be?
Depersonalization/derealization disorder (estrangement/detachment from one's
own body/place in life) "<img src=""8242.png"">" Pathology dissociative-
What is the difference between depersonalization and derealization?
Depersonalization: detachment/estrangement from
body/thoughts/perceptions/actions; derealization: detachment/estrangement from
environment "<img src=""8242.png"">" Pathology dissociative-disorders
psychiatry
Is dissociative identity disorder more common in men or women? What is another
(outdated) name for this disorder? Women; multiple personality disorder "<img
src=""8242.png"">" Pathology dissociative-disorders psychiatry
A woman has two different identities, or personalities. Name seven factors with
which this disorder is associated. Depression, borderline personality, sexual
abuse, PTSD, substance abuse, somatoform conditions (This is dissociative identity
disorder.) "<img src=""8242.png"">" Pathology dissociative-disorders
psychiatry
Define delirium. Is it reversible? Acute-onset waxing/waning consciousness with
decreased attention span/arousal, often caused by illness or medication; often
reversible "<img src=""8243.png"">" Pathology delirium psychiatry
An elderly man who overdosed on amitriptyline is confused, misperceiving things,
and hallucinating. What is wrong with him? Probably medication-induced
delirium caused by the amitriptyline, a tricyclic antidepressant with
anticholinergic effects "<img src=""8243.png"">" Pathology delirium psychiatry
You suspect that your patient with altered mental status has delirium. What test
may be helpful in confirming the diagnosis? An EEG: Delirium is associated with
abnormal EEG readings "<img src=""8243.png"">" Pathology delirium psychiatry
What is the treatment for delirium? Treatment of underlying cause, oxygen and
hydration to optimize brain condition, antipsychotics (TADA = Tolerate, Anticipate,
Don't Agitate) "<img src=""8243.png"">" Pathology delirium psychiatry
A patient has altered mental status. What is the most common cause of this symptom
in the inpatient setting? What meds typically induce it? Delirium, often caused
by drugs with anticholinergic effects "<img src=""8243.png"">" Pathology
delirium psychiatry
An 80-y/o suddenly has a waning level of consciousness and falls asleep as you
speak to her. What is usually the cause of this condition? Delirium usually results
from illness (CNS disease, infection, trauma, substance abuse/withdrawal,
metabolic/electrolyte issues, bleeds) "<img src=""8243.png"">" Pathology
delirium psychiatry
An alcoholic patient is increasingly delirious. What class of medication may be
indicated for this patient's particular delirium? Benzodiazepines, because the
symptoms could be a result of alcohol withdrawal "<img src=""8243.png"">"
Pathology delirium psychiatry
An elderly woman is brought to the ED with sudden-onset restlessness and violent
outbursts. She falls asleep as you talk to her. Treatment? Address the underlying
condition, which is likely delirium and will resolve with proper treatment "<img
src=""8243.png"">" Pathology delirium psychiatry
A patient has memory deficits and changes in intellectual function. Name seven
irreversible causes of dementia. Alzheimer disease, Pick disease, Huntington
disease, cerebral infarct, Lewy body dementia, Creutzfeldt-Jakob disease, substance
abuse "<img src=""8244.png"">" Pathology dementia psychiatry
A patient has memory deficits and changes in intellectual function. Name five
reversible causes of dementia. Normal pressure hydrocephalus, vitamin B12
deficiency, hypothyroidism, depression, neurosyphilis "<img src=""8244.png"">"
Pathology dementia psychiatry
An 80-year-old has had worsening memory and behavioral changes for the past 6
months. For what conditions should you screen this patient?Depression,
hypothyroidism, and vitamin B12 "<img src=""8244.png"">" Pathology dementia
psychiatry
Define dementia. What is usually seen on EEG? Gradual decline in cognitive
function with no change in level of consciousness, increased incidence with age;
EEG is normal "<img src=""8244.png"">" Pathology dementia psychiatry
An 80-year-old man presents with sleep problems, anhedonia, and fatigue. What
psychiatric or endocrine diagnosis besides dementia is likely? Depression
(pseudodementia) and hypothyroidism often present with symptoms similar to those of
dementia in the elderly "<img src=""8244.png"">" Pathology dementia psychiatry
A 75-year-old man has had amnesia, aphasia, apraxia, agnosia, personality change,
and poor judgment for 5 months. General diagnosis? Dementia, characterized by
memory loss and worsening cognition "<img src=""8244.png"">" Pathology dementia
psychiatry
What primarily differentiates delirium from dementia? """Dememtia"" is
characterized by memory loss, whereas delirium is a problem with sensorium
(Demented pts can become delirious.)" "<img src=""8244.png"">" Pathology
dementia psychiatry
A patient has psychosis. What is this? Distorted perception of reality, marked
by delusions, hallucinations, and/or disorganized thinking "<img src=""8245.png"">"
Pathology psychiatry psychosis
A man says he has hallucinations. What are hallucinations? Perceptions in the
absence of external stimuli (eg, hearing voices that do not exist) "<img
src=""8245.png"">" Pathology psychiatry psychosis
A homicide suspect is found to be delusional. What are delusions? False
beliefs about oneself or others that persist despite the facts (eg, thinking that a
newborn is Satan) "<img src=""8245.png"">" Pathology psychiatry psychosis
"A patient answers you by saying ""I shop apples sometimes red carts it's clean to
cook."" What kind of speech is this?" Disorganized speech: words and ideas
strung together based on sounds, puns, or loose associations "<img
A patient frequently smells apple pie in the absence of any such stimulus. What is
this type of hallucination associated with? Olfactory hallucinations (rare) are
associated with brain tumors or precede psychomotor epilepsy "<img
A man hallucinates when he goes to sleep. What kind of hallucination is this:
hypnagogic or hypnopompic? Associated condition? Hypnagogic (going to sleep);
narcolepsy "<img src=""8245.png"">" Pathology psychiatry psychosis
A man has the sensation of ants crawling on his skin. What is this called? What
substance abuses is this associated with? Formication (a tactile hallucination);
cocaine abuse (cocaine crawlies), alcohol withdrawal "<img src=""8245.png"">"
Pathology psychiatry psychosis
A man hallucinates when he wakes up from sleep. What kind of hallucination is this:
hypnagogic or hypnopompic? Associated condition? Hypnopompic (pompous on
awakening); narcolepsy "<img src=""8245.png"">" Pathology psychiatry
psychosis
A man tastes apple pie when he is not eating. What condition is this hallucination
associated with? Is it common or rare? Epilepsy; gustatory hallucinations are
rare "<img src=""8245.png"">" Pathology psychiatry psychosis
For schizophrenia to be diagnosed, periods of psychosis and disturbed behavior
leading to functional decline must be present for how long?6 months or longer
"<img src=""8246.png"">" Pathology psychiatry schizophrenia
What are the symptoms of schizophrenia? How many symptoms are needed for diagnosis?
Delusions, hallucinations (mainly auditory), disorganized speech (loose
associations), disorganized/catatonic behavior, negative symptoms; 2 "<img
src=""8246.png"">" Pathology psychiatry schizophrenia
A man has delusions and hears voices. How do you know if this is a brief psychotic
disorder, a schizophreniform disorder, or schizophrenia? Duration of symptoms;
brief psychotic disorder lasts &60; 1 month, schizophreniform lasts 1 to 6 months,
schizophrenia lasts &62; 6 months "<img src=""8246.png"">" Pathology
psychiatry schizophrenia
A man has catatonic behavior and negative symptoms of schizophrenia. What are the
so-called negative symptoms of schizophrenia? Flat affect; social withdrawal;
lack of motivation, speech, or thought "<img src=""8246.png"">" Pathology
An 18-year-old patient had hallucinations and delusions that lasted for 2 weeks
during finals and then resolved. Likely diagnosis? Brief psychotic disorder
(less than 1 month, often related to stress) "<img src=""8246.png"">"
Pathology psychiatry schizophrenia
Name the four positive symptoms of schizophrenia. Delusions, hallucinations,
disorganized thought, and disorganized/catatonic behavior "<img src=""8246.png"">"
A man has psychotic symptoms for 2 weeks without symptoms of a mood disorder, but
then symptoms of a mood disorder develop. Diagnosis? Schizoaffective disorder
"<img src=""8246.png"">" Pathology psychiatry schizophrenia
Describe the epidemiology of schizophrenia in male versus female populations.
Lifetime prevalence is 1.5% for both (also for blacks and whites), but it
presents at a younger age in male patients (late teens, early 20s) "<img
src=""8246.png"">" Pathology psychiatry schizophrenia
A teen presents with symptoms of schizophrenia for the past 5 months. Diagnosis?
Schizophreniform disorder (schizophrenia symptoms that last for only 1 to 6
months) "<img src=""8246.png"">" Pathology psychiatry schizophrenia
A man has schizoaffective disorder. What mood disorders co-occur with psychosis?
Does the mood disorder occur without psychosis? Major depression or mania; mood
disorder is only present with psychosis "<img src=""8246.png"">" Pathology
Twin brothers have schizophrenia and schizoaffective disorder. Their mother asks
what predisposed them to these illnesses. You say? Genetics and environment both
contribute to the etiology of schizophrenia "<img src=""8246.png"">"
A patient has schizophrenia. Is dopamine increased or decreased? Is dendritic
branching increased or decreased? Increased; decreased "<img src=""8246.png"">"
A 19-year-old man has auditory hallucinations and disorganized speech for 9 months.
History reveals marijuana use. What is the diagnosis? Schizophrenia (Marijuana use
is a risk factor in teens.) "<img src=""8246.png"">" Pathology psychiatry
schizophrenia
A 19-year-old man has had auditory hallucinations and disorganized speech for 2
months. History reveals marijuana use. Diagnosis? Schizophreniform disorder
(Marijuana use is a risk factor in teens.) "<img src=""8246.png"">"
A 25-year-old man has had auditory hallucinations for 9 months. Can you make a
diagnosis of schizophrenia? Although auditory hallucinations are not benign, they
do not make the diagnosis of schizophrenia; at least one additional symptom is
needed "<img src=""8246.png"">" Pathology psychiatry schizophrenia
A patient has had delusions and has heard voices for the past 5 years. What is the
first-line treatment for this disorder? Atypical antipsychotics, such as
risperidone, are first-line therapies for schizophrenia "<img src=""8246.png"">"
A highly successful businessman believes his daughter is president, but she is not.
What is the diagnosis if this lasts more than 1 month? Delusional disorder
(fixed, nonbizarre belief with no functional impairment) "<img src=""8247.png"">"
Pathology delusional-disorder psychiatry
For the past year a man has believed he is the president. He has no other symptoms.
With this disorder, how do patients generally function? General function is not
impaired "<img src=""8247.png"">" Pathology delusional-disorder psychiatry
Major depressive disorder, bipolar disorder, dysthymic disorder, and cyclothymic
disorder are examples of what kind of disorder? Mood disorders (loss of control
over moods, or abnormal moods, with functional impairment; may have episodic
psychotic features) "<img src=""8248.png"">" Pathology mood-disorder
psychiatry
What are mood disorders? Disorders with an abnormal range of moods/internal
emotions, with loss of control over them; cause distress and impairment in daily
function "<img src=""8248.png"">" Pathology mood-disorder psychiatry
In 1 week a man spends his savings on a yacht, researches sailing all night without
sleeping, and talks fast. What is the diagnosis? Manic episode with
irresponsibility, goal-directed activity, decreased need for sleep, and
talkativeness "<img src=""8249.png"">" Pathology manic-episode psychiatry
To qualify for a manic episode, how many manic symptoms must be present and for how
long? At least three symptoms, lasting at least 1 week "<img src=""8249.png"">"
Pathology manic-episode psychiatry
For a week a man cannot control his thoughts, sit still, or pay attention; he is
preoccupied with his own importance. Likely diagnosis? Manic episode "<img
src=""8249.png"">" Pathology manic-episode psychiatry
What are the seven potential symptoms of a manic episode? (Hint: DIG FAST mnemonic)
Distractibility, Irresponsibility, Grandiosity, Flight of ideas,
Activity/Agitation, Sleep needs decreased, Talkativeness "<img src=""8249.png"">"
Pathology manic-episode psychiatry
Compare hypomanic and manic episodes in terms of severity. Hypomanic episodes are
less intense, do not impair function or feature psychosis, and do not require
hospitalization "<img src=""8250.png"">" Pathology hypomanic-episode
psychiatry
A businessman goes on a spending spree, sleeps less, and talks a lot for 4 days. He
continues to work normally. Diagnosis? This is hypomania; the episode has lasted
for at least 4 consecutive days and does not impair function, and there is no
psychosis "<img src=""8250.png"">" Pathology hypomanic-episode psychiatry
Can bipolar disorder be diagnosed in a patient with a history of manic episodes but
no history of depressive episodes? Yes, history of a single manic episode is
inevitably followed by a depressive episode at some point "<img src=""8251.png"">"
Pathology bipolar-disorder-(manic-depression) psychiatry
A patient with a mood disorder presents with increased manic symptoms after
starting a new drug. What medication was likely started? An antidepressant, which
can cause increased mania in patients with bipolar disorder"<img src=""8251.png"">"
How does bipolar I disorder differ from bipolar II disorder? Bipolar I is
characterized by manic episodes; bipolar II, by hypomanic episodes "<img
src=""8251.png"">" Pathology bipolar-disorder-(manic-depression) psychiatry
A man has had a week of distractibility, reduced sleep, and pressured speech. What
drugs are used most commonly to treat this disorder? Mood stabilizers (eg,
carbamazepine, lithium, valproic acid) and atypical antipsychotics, as this is
bipolar disorder "<img src=""8251.png"">" Pathology bipolar-disorder-(manic-
depression) psychiatry
A patient has mild dysthymia and has been experiencing hypomanic episodes for 3
years. What is this disorder called? Cyclothymic disorder (milder version of
bipolar disorder, lasting at least 2 years) "<img src=""8251.png"">"
Describe the mood experienced between manic or hypomanic episodes in people with
bipolar disorder. Generally returns to normal "<img src=""8251.png"">"
The risk of what catastrophic event is markedly increased in people with bipolar
disorder? Suicide "<img src=""8251.png"">" Pathology bipolar-disorder-
(manic-depression) psychiatry
How long do major depressive episodes usually last? 6 to 12 months "<img
src=""8252.png"">" Pathology major-depressive-disorder psychiatry
A woman presents after 3 years of chronic mild depression. Her psychiatrist calls
it somewhat subclinical in presentation. Diagnosis? Persistent depressive
disorder (dysthymia for at least 2 years) "<img src=""8252.png"">" Pathology
major-depressive-disorder psychiatry
A man has anhedonia, fatigue, inattention, & increased appetite/sleep. What other
finding is needed to diagnose a major depressive episode? Symptoms must have been
present for most days during the past 2 weeks "<img src=""8252.png"">"
Pathology major-depressive-disorder psychiatry
What are the features of major depressive disorder? Sleep problems, loss of
Interest, Guilt, low Energy, Concentration, Appetite changes, Psychomotor slowing,
Suicidality "<img src=""8252.png"">" Pathology major-depressive-disorder
psychiatry
A man with symptoms of poor concentration, low energy, and anhedonia complains that
his alarm clock is no longer useful. Why? He is likely depressed and experiencing
early-morning awakening (terminal insomnia), which is common in patients with
depression "<img src=""8252.png"">" Pathology major-depressive-disorder
psychiatry
A patient with depression has sleep disturbances. How is his REM sleep altered?
Decreased REM latency; increased REM early in sleep cycle; increased total
REM sleep "<img src=""8252.png"">" Pathology major-depressive-disorder
psychiatry
A patient presents with sleep changes for the past 2 months. She has repeated
nighttime and early morning awakenings. Likely diagnosis? Depression (associated
with many changes in quality of REM sleep and duration throughout the night) "<img
src=""8252.png"">" Pathology major-depressive-disorder psychiatry
A man has had anhedonia, feelings of guilt, depressed mood and appetite, and sleep
loss for a year. Name some treatments for this disorder. CBT and SSRIs are first-
line therapies for depression; other options include bupropion, SNRIs, mirtazapine,
and, in some patients, ECT "<img src=""8252.png"">" Pathology major-
depressive-disorder psychiatry
What symptoms differentiate atypical depression from classical depression?
Hypersomnia, overeating/weight gain, leaden paralysis, ability to react
positively to positive events, hypersensitivity to rejection "<img
src=""8253.png"">" Pathology depression-with-atypical-features psychiatry
A patient has the most common subtype of depression. What drugs are used to treat
this disorder? First-line treatments for atypical depression: SSRIs, CBT, and
monoamine oxidase (MAO) inhibitors (which work but are risky) "<img
src=""8253.png"">" Pathology depression-with-atypical-features psychiatry
"What are the ""reversed"" vegetative symptoms of atypical depression?"
Hypersomnia and hyperphagia "<img src=""8253.png"">" Pathology
depression-with-atypical-features psychiatry
What are three postpartum mood disturbances that female patients may experience, in
order of incidence? When after delivery are they seen? Postpartum blues (50
85%), postpartum depression (1015%), and postpartum psychosis (0.10.2%); all
within 4 weeks of delivery "<img src=""8254.png"">" Pathology postpartum-
mood-disturbances psychiatry
A 26-year-old woman who delivered a baby boy 2 days ago tells you she is depressed,
tearful, and tired. Diagnosis? Postpartum blues, usually resolved within 10
days; patient should be followed up for possible postpartum depression "<img
src=""8254.png"">" Pathology postpartum-mood-disturbances psychiatry
A 26-year-old who delivered her baby 2 months ago still feels depressed and
anxious. What is the likely diagnosis, and how do you treat her? Postpartum
depression (begins within 4 weeks of delivery); treatment is SSRIs and CBT "<img
A 26-year-old woman who delivered her baby 8 days ago reports delusions and
threatens to kill herself and the baby. Diagnosis and treatment? Likely postpartum
psychosis; admit to inpatient psychiatric unit; administer atypical antipsychotics,
ECT if drug therapy is insufficient "<img src=""8254.png"">" Pathology
postpartum-mood-disturbances psychiatry
After what period do postpartum blues often resolve? 10 days "<img
Which is the only postpartum mood disturbance that usually does not warrant
pharmacologic therapy? Postpartum blues "<img src=""8254.png"">" Pathology
postpartum-mood-disturbances psychiatry
A woman who gave birth 8 days ago reports delusions and threatens to kill herself
and the baby. Risk factors for this condition? Bipolar disorder, psychotic
disorder, first pregnancy, family history, recent discontinuation of psychotropic
medication "<img src=""8254.png"">" Pathology postpartum-mood-disturbances
psychiatry
A woman who lost her husband in a car accident has shock, denial, and guilt and
feels ill. When does her response become pathologic? When the grief is persistent
and leads to functional impairment "<img src=""8255.png"">" Pathology grief
psychiatry
A woman's husband dies. Name four characteristic components of normal bereavement.
Shock, denial, guilt, and somatic symptoms "<img src=""8255.png"">"
Pathology grief psychiatry
Since the loss of his wife 2 years ago, a man has been persistently severely
depressed. Is this grief normal? No, this is pathologic grief (excessively
intense or prolonged grief that is delayed, inhibited, or denied, lasting more than
6 months) "<img src=""8255.png"">" Pathology grief psychiatry
A boy hears his mother's voice during the year after her death. He has no
depressive or psychotic symptoms. Does he have a disorder? No, hallucinations alone
are not considered a sign of pathologic grief "<img src=""8255.png"">"
Pathology grief psychiatry
How does electroconvulsive therapy work? For which three conditions is it used?
Grand mal seizures are induced in anesthetized patients; refractory
depression, depression with psychosis, acute suicidal ideation "<img
src=""8256.png"">" Pathology electroconvulsive-therapy psychiatry
A 40-year-old depressed woman believes a UFO is after her. She tries to stab
herself but is restrained. What immediate therapy could help? Electroconvulsive
therapy (good for an immediate response [eg, acute suicidality] and in depression
with psychotic features or catatonia) "<img src=""8256.png"">" Pathology
electroconvulsive-therapy psychiatry
A man undergoes an extreme treatment for depression that induces a generalized
seizure. Name the adverse effects. Are they reversible? Disorientation and
antero-/retrograde amnesia (from electroconvulsive therapy); yes, adverse effects
are often reversible within 6 months "<img src=""8256.png"">" Pathology
A 25-year-old pregnant woman with a history of depression is acutely suicidal. Is
the immediate therapy for her condition safe in her case? Yes, electroconvulsive
therapy is safe in pregnancy "<img src=""8256.png"">" Pathology
Are men or women at greater risk for suicide completion? Men (although women
attempt suicide more frequently) "<img src=""8257.png"">" Pathology
psychiatry risk-factors-for-suicide-completion
Why does your mentor ask a depressed patient whether he has a plan for suicide or
has ever attempted it? Because a plan for suicide and a previous attempt are two
risk factors for future suicide completion "<img src=""8257.png"">"
Pathology psychiatry risk-factors-for-suicide-completion
Which sex attempts suicide more often? Which sex has more successful suicide
completions? Females are more likely to attempt suicide; males are more likely
to successfully complete suicide "<img src=""8257.png"">" Pathology
What are some risk factors for suicide completion? Sex (male), Age (teen/old),
Depression, Prior attempt, Ethanol/drugs, Rational thinking loss, Sickness,
Organized plan, No spouse/support "<img src=""8257.png"">" Pathology
What type of disorder includes OCD, PTSD, generalized anxiety disorder, panic
disorder, and phobias? Anxiety disorder "<img src=""8258.png"">" Pathology
anxiety-disorder psychiatry
How would you describe an anxiety disorder? Inappropriate fear and its physical
manifestations, considered out of proportion to the stimulus, that impair daily
function "<img src=""8258.png"">" Pathology anxiety-disorder psychiatry
A patient has an anxiety disorder. How do you treat it? Cognitive behavioral
therapy (CBT), selective serotonin reuptake inhibitors (SSRIs),
serotonin/norepinephrine reuptake inhibitors (SNRIs) "<img src=""8258.png"">"
Pathology anxiety-disorder psychiatry
A man has random episodes of intense fear that last 10 minutes with palpitations,
sweating, chest pain, and chills. What is the diagnosis? Panic disorder "<img
src=""8259.png"">" Pathology panic-disorder psychiatry
Your 30-year-old patient is pregnant. She has a history of panic disorder and fears
that her baby will have it, too. What do you tell her? There is a strong
genetic component to panic disorder, and it is possible that her baby will have
symptoms later in life "<img src=""8259.png"">" Pathology panic-disorder
psychiatry
A man has hand tingling, abdominal pain, nausea, and feelings of choking. What is
the first-line treatment? What medication is used acutely? Cognitive behavioral
therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and venlafaxine;
benzodiazepines "<img src=""8259.png"">" Pathology panic-disorder psychiatry
Besides palpitations, lightheadedness, chest pain, chills, choking, sweating, and
shaking, what are other symptoms of panic disorder? Paresthesias, Abdominal
distress, Nausea, Intense fear of dying/losing control, disConnectedness, Shortness
of breath (PANICS) "<img src=""8259.png"">" Pathology panic-disorder
psychiatry
A patient believes that he has had a panic attack. How do you diagnose it? An
attack, followed by a month w/at least one of the following responses: fear of new
attacks, worry about consequences, changed behavior "<img src=""8259.png"">"
Pathology panic-disorder psychiatry
A boy is terrified of pencils and will not sit in any classrooms. Without the use
of medication, how can specific phobias be treated? Systematic desensitization
(repeated exposure to the stimulus until the fear reaction abates) "<img
src=""8260.png"">" Pathology psychiatry specific-phobia
Do individuals with a specific phobia have insight into their condition? Yes,
patients with phobias typically realize that their fear is excessive "<img
How do pathologic specific phobias differ from normal fears? Pathologic
specific phobias interfere with normal functioning and are triggered by the
presence/thought of a specific stimulus "<img src=""8260.png"">" Pathology
psychiatry specific-phobia
A woman has a crippling fear of speaking in public or using a public restroom.
Which therapies can be used as treatment? This is social anxiety disorder, defined
as an excessive fear of embarrassment in social contexts; SSRIs or CBT can be used
"<img src=""8260.png"">" Pathology psychiatry specific-phobia
A woman is afraid of leaving home, using public transportation, and being in
crowds. She is also terrified of open spaces. Treatment? This is agoraphobia, a
type of specific phobia; treatment is CBT, SSRIs, or MAO inhibitors "<img
What is agoraphobia? An exaggerated fear of open or enclosed places, using
public transportation, being in line or in crowds, or leaving home alone "<img
What is social anxiety disorder? An exaggerated fear of embarrassment in social
situations (eg, public speaking, using public restrooms) "<img src=""8260.png"">"
Pathology psychiatry specific-phobia
Define adjustment disorder. Impairing emotional symptoms in response to an
identified stressor that last up to 6 months (> 6 months if stressor is chronic)
"<img src=""8261.png"">" Pathology generalized-anxiety-disorder
psychiatry
A man hasn't been able to sleep or concentrate for 8 months and says he worries
about everything. What treatment options can you offer? This is generalized
anxiety disorder. First-line therapy is CBT, SSRIs, SNRIs; second-line therapy is
buspirone, TCAs, benzodiazepines "<img src=""8261.png"">" Pathology
generalized-anxiety-disorder psychiatry
By definition, the symptoms of generalized anxiety disorder must last how long to
be clinically significant? More than 6 months "<img src=""8261.png"">"
Pathology generalized-anxiety-disorder psychiatry
A man worries about everything. What are some of the symptoms, aside from anxiety,
associated with generalized anxiety disorder? Sleep problems, fatigue, difficulty
concentrating, gastrointestinal disturbances "<img src=""8261.png"">"
Pathology generalized-anxiety-disorder psychiatry
A woman recently moved away from her family to a new state and has had anxiety and
depression for 6 months. How would you treat her? This is adjustment disorder;
treat with CBT and/or SSRIs "<img src=""8261.png"">" Pathology generalized-
anxiety-disorder psychiatry
A patient has obsessive-compulsive disorder with various obsessions and
compulsions. He asks you what those are. Your reply? Obsessions are intrusive,
recurring thoughts/feelings that cause severe anxiety; compulsions are repetitive
actions that provide relief "<img src=""8262.png"">" Pathology obsessive-
compulsive-disorder psychiatry
A man is disturbed by his thoughts that everything is dirty and often needs to wash
his hands. Name three first-line treatments. CBT, selective serotonin reuptake
inhibitors (SSRIs), clomipramine (a tricyclic antidepressant); this is obsessive-
compulsive disorder "<img src=""8262.png"">" Pathology obsessive-
compulsive-disorder psychiatry
Obsessive-compulsive disorder is considered ego-dystonic. Define ego-dystonic. What
personality disorder can it be differentiated from? Behavior inconsistent with
one's own beliefs and attitudes and causing distress; obsessive-compulsive
personality disorder (ego-syntonic) "<img src=""8262.png"">" Pathology
obsessive-compulsive-disorder psychiatry
A 30-year-old man compulsively locks the door and peeks out the window. He may have
had a childhood history of what disorder? Tourette syndrome, commonly associated
with obsessive-compulsive disorder "<img src=""8262.png"">" Pathology
obsessive-compulsive-disorder psychiatry
A teen complains of how ugly her nose is and requests a nose job. She has seen
other physicians about the same thing. Treatment? CBT (This is body dysmorphic
disorder.) "<img src=""8262.png"">" Pathology obsessive-compulsive-disorder
psychiatry
What is body dysmorphic disorder? A preoccupation with minor/imagined defects in
appearance that causes significant distress/functional impairment "<img
src=""8262.png"">" Pathology obsessive-compulsive-disorder psychiatry
How long must symptoms be present for PTSD to be diagnosed? What is the disorder
called before it evolves into PTSD? At least 1 month; if symptoms persist between 3
days and 1 month, it is considered acute stress disorder "<img src=""8263.png"">"
Pathology post-traumatic-stress-disorder psychiatry
Within what time frame after the traumatic incident must symptoms begin for a
diagnosis of post-traumatic stress disorder to be made? Any time, but the
disturbance must last more than 1 month "<img src=""8263.png"">" Pathology
post-traumatic-stress-disorder psychiatry
For the last 4 months a war veteran has had recurrent nightmares of his friend
being shot; he often feels helpless and scared. Treatment? CBT, selective serotonin
reuptake inhibitors, and venlafaxine are all first-line treatments for post-
traumatic stress disorder (PTSD) "<img src=""8263.png"">" Pathology post-
traumatic-stress-disorder psychiatry
A girl is raped in a theater. For many months afterward, she has recurrent
flashbacks and avoids the theater. What treatments may help her? CBT, selective
serotonin reuptake inhibitors, and venlafaxine may help manage post-traumatic
stress disorder "<img src=""8263.png"">" Pathology post-traumatic-stress-
disorder psychiatry
A soldier describes 2 weeks of recurrent nightmares of her close friend's death in
the Iraq War. What is the diagnosis? Treatment? This is acute stress disorder
(lasts between 3 days and 1 month); treatment is CBT (no pharmacotherapy indicated)
"<img src=""8263.png"">" Pathology post-traumatic-stress-disorder
psychiatry
A man was injured in an especially violent car accident. What symptoms would occur
if he had post-traumatic stress disorder? Increased arousal, avoidance of trauma-
related stimuli, intense fear, nightmares/flashbacks lasting more than 1 month
"<img src=""8263.png"">" Pathology post-traumatic-stress-disorder
psychiatry
A 10-year-old boy pretends to be sick each time he has a math test so his parents
will let him miss school. What is the diagnosis? Malingering (consciously
faking illness for secondary gain) "<img src=""8264.png"">" Pathology
malingering psychiatry
A school-hating girl suddenly loses leg function after failing a test. She takes
time off and attends all follow-up appointments. Diagnosis?Likely a somatoform
disorder (conversion disorder), as she continues to follow up and have symptoms
despite being allowed to miss school "<img src=""8264.png"">" Pathology
What is the main difference between malingering and a factitious disorder?
Malingering: chief goal is external (secondary gain); factitious disorder:
chief goal is psychologic (primary gain) "<img src=""8264.png"">" Pathology
A man fakes illness to avoid work and go see the Super Bowl. After the game, he
returns to work. If asked to see a doctor, does he go? No, this is malingering;
these patients have poor compliance with diagnostic or therapeutic medical care
"<img src=""8264.png"">" Pathology malingering psychiatry
When a patient has unexplained complaints/symptoms and you suspect a psychiatric
disorder, what should you first try to determine? If it is a conscious attempt
to deceive; if it is, suspect malingering or factitious disorders, and if not,
suspect somatoform disorders "<img src=""8264.png"">" Pathology malingering
psychiatry
A man is constantly trying to deceive others by faking illnesses. How can you
determine whether this is malingering or factitious? Determine what he gains from
it: if primary (psychologic), suspect factitious disorder, and, if secondary
(external), suspect malingering "<img src=""8264.png"">" Pathology
A mother is caught injecting feces into the IV of her 3-year-old son to keep him in
the hospital. What is the mother's disorder called? Munchausen syndrome by proxy,
which is a form of child (or even elder) abuse "<img src=""8265.png"">"
Pathology factitious-disorders psychiatry
A man in the ED seeks admission for nonspecific belly pain for the twelfth time
this year, demanding another colonoscopy. Likely diagnosis?Munchausen syndrome, a
chronic factitious disorder (many hospital admissions and a willingness to undergo
invasive procedures) "<img src=""8265.png"">" Pathology factitious-
A patient has a factitious disorder. What is the primary goal of a patient with a
factitious disorder? To get medical attention (primary [internal] gain) by way
of the sick role (in contrast to malingerers who are seeking a secondary gain)
"<img src=""8265.png"">" Pathology factitious-disorders psychiatry
A patient has Munchausen syndrome. How does it differ from malingering?
Patients with Munchausen syndrome are willing to undergo tests and
procedures, whereas malingerers often avoid treatment "<img src=""8265.png"">"
Pathology factitious-disorders psychiatry
A woman brings her mother to the hospital many times each week. Workup findings are
always normal. Do you consider calling the police? Yes, this may be Munchausen
syndrome by proxy, child/elder abuse in which caregivers cause/fabricate illness to
have the sick role by proxy "<img src=""8265.png"">" Pathology factitious-
A 27-y/o man says he cannot move his leg. Workup is negative. He does not seem
distressed. His wife died recently in a car crash. Diagnosis? Conversion
disorder (loss of sensory/motor function that follows an acute stressor but is not
distressing to the patient) "<img src=""8266.png"">" Pathology psychiatry
somatic-symptom-and-related-disorders
Identify the three groups in which conversion disorder is most common. Female
subjects, adolescents, and young adults "<img src=""8266.png"">" Pathology
psychiatry somatic-symptom-and-related-disorders
A diabetic patient is anxious about back and belly pain she has had for the past 8
months despite negative workup findings. Diagnosis? Somatic symptom disorder,
with symptoms lasting months to years and great anxiety about symptoms; may co-
occur with medical illness "<img src=""8266.png"">" Pathology psychiatry
somatic-symptom-and-related-disorders
A woman presents multiple times with a preoccupation and fear that she has cancer
despite continued reassurance. What is the diagnosis? Illness anxiety disorder
(hypochondriasis) "<img src=""8266.png"">" Pathology psychiatry somatic-
symptom-and-related-disorders
What is a somatoform disorder? Any disorder characterized by physical symptoms
with no identifiable physical cause; symptoms are not intentionally
produced/feigned "<img src=""8266.png"">" Pathology psychiatry somatic-
A woman has a somatoform disorder. How does it differ from malingering?
Malingering is a product of conscious actions, whereas a somatoform disorder
is a product of unconscious drives "<img src=""8266.png"">" Pathology
A man is fired and suddenly loses the ability to speak. He is indifferent to it at
every doctor appointment. What is this phenomenon called? This is la belle
indiffrence, seen in conversion disorder "<img src=""8266.png"">" Pathology
A 30-y/o infertile woman gains weight and has morning sickness. She tells co-
workers she is pregnant, but a pregnancy test is negative. Dx? Pseudocyesis
(false, nondelusional belief of being pregnant, often accompanied by signs and
symptoms of pregnancy) "<img src=""8266.png"">" Pathology psychiatry somatic-
What are the three clusters of personality disorders? Clusters A, B, and C can be
remembered as Weird, Wild, and Worried, respectively "<img src=""8267.png"">"
Pathology personality psychiatry
Define personality trait. A personality trait is a consistent way a person
processes his/her environment and his/her role in it "<img src=""8267.png"">"
How does a personality disorder differ from a personality trait? Disorder:
inflexible/maladaptive pattern of behavior, causing distress/impairment; trait:
enduring way of relating to self and environment "<img src=""8267.png"">"
A man has a personality disorder. Does he have insight into his condition? No,
personality disorders are ego-syntonic; the man does not see anything wrong with
his behavior "<img src=""8267.png"">" Pathology personality psychiatry
Schizophrenia develops in an 18-year-old man. Which cluster of personality
disorders is genetically associated with schizophrenia? Cluster A (paranoid,
schizoid, schizotypal) "<img src=""8268.png"">" Pathology cluster-a-
personality-disorders psychiatry
A 28-year-old woman accuses her mother of stealing her money and spying on her when
she is at work. What personality disorder is this? Paranoid personality disorder
(cluster A), characterized by distrust, suspiciousness "<img src=""8268.png"">"
Pathology cluster-a-personality-disorders psychiatry
A patient complains for years to you that people are conspiring against him. What
is the main ego defense mechanism he uses? He likely has paranoid personality
disorder and uses projection (accusing others of things the patient is actually
guilty of) "<img src=""8268.png"">" Pathology cluster-a-personality-disorders
psychiatry
Name the three cluster A personality disorders and their common characteristics.
Paranoid, schizoid, and schizotypal; Weird, odd, eccentric, poor social
relationships, no psychosis (Accusatory, Aloof, Awkward) "<img src=""8268.png"">"
Pathology cluster-a-personality-disorders psychiatry
A mother says that her son is acting weird. His lack of friends does not bother
him, and he stays home all day reading. Likely diagnosis? Schizoid personality
disorder (cluster A) (schizoid = distant) "<img src=""8268.png"">" Pathology
cluster-a-personality-disorders psychiatry
Compare schizoid and avoidant personality disorders. Schizoid patients do not
desire social contact, and avoidant patients desire social contact but have
difficulty achieving it "<img src=""8268.png"">" Pathology cluster-a-
A person is interpersonally awkward and often has odd beliefs or magical thinking.
Which personality disorder is this consistent with? Schizotypal personality
disorder (magical thinking) "<img src=""8268.png"">" Pathology cluster-a-
A 45-year-old patient dresses oddly and sleeps outside to absorb the full
gravitational pull of the moon. What personality disorder is this? Schizotypal
personality disorder (cluster A) "<img src=""8268.png"">" Pathology cluster-
a-personality-disorders psychiatry
Generally speaking, what characteristics do the four cluster B personality
disorders share? Name the disorders. Dramatic, emotional, or erratic behavior;
antisocial, borderline, histrionic, narcissistic "<img src=""8269.png"">"
Pathology cluster-b-personality-disorders psychiatry
A 20-year-old pt has many arrests for assault/robbery/arson. He threatens you
during the exam. Is his disorder more common in men or women? Antisocial
personality disorder (cluster B) is more common in men (antisocial = sociopath)
"<img src=""8269.png"">" Pathology cluster-b-personality-disorders
psychiatry
A 16-year-old boy has multiple arrests for assault, robbery, and arson. Should you
consider antisocial personality disorder as a diagnosis? No, antisocial
personality disorder can be diagnosed only in those older than 18 years; in pts
younger than 18 years, it's conduct disorder "<img src=""8269.png"">"
Pathology cluster-b-personality-disorders psychiatry
A woman in provocative clothes tries to seduce you, then sobs loudly when you do
not reciprocate. Diagnosis? Histrionic personality disorder (cluster B)
(preoccupied with appearance and very emotional, sexual, excitable) "<img
src=""8269.png"">" Pathology cluster-b-personality-disorders psychiatry
A pt has a group B personality disorder. What two other conditions are genetically
associated with this group? Substance abuse and mood disorder "<img
A volatile woman has many sexual relationships. She cuts her forearms and feels
empty. She thinks all doctors are quacks. How do you treat?This is borderline
personality disorder, treated with dialectical behavior therapy "<img
A man is impulsive, bored, and feels empty. Does this disorder affect men or women
more? Which major defense mechanism is at work? Women; splitting (This is
borderline personality disorder.) "<img src=""8269.png"">" Pathology cluster-
b-personality-disorders psychiatry
A man loudly demands the best room money can buy because he is the hotel's best
customer. How does he likely act in relationships? He likely demands admiration,
becomes enraged at criticism, and lacks empathy; this is narcissistic personality
disorder "<img src=""8269.png"">" Pathology cluster-b-personality-disorders
psychiatry
A 30-year-old man at a job interview says they would be foolish not to hire him, as
he is a genius. What personality disorder might he have? Narcissistic personality
disorder "<img src=""8269.png"">" Pathology cluster-b-personality-disorders
psychiatry
A 25-year-old says he doesn't fit in. He is afraid to talk; he feels he isn't funny
or interesting. What is the likely diagnosis? Avoidant personality disorder,
cluster C (hypersensitive to rejection, feelings of inadequacy, but unlike
schizoid, desires relationships) "<img src=""8270.png"">" Pathology cluster-
c-personality-disorders psychiatry
A patient has a personality disorder characterized by abnormal anxiety or fear.
Which cluster? Genetic association with which disorders? "Cluster C: ""Worried""
(Cowardly, Compulsive, Clingy); anxiety disorders" "<img src=""8270.png"">"
Pathology cluster-c-personality-disorders psychiatry
Name the three cluster C personality disorders. Avoidant, obsessive-compulsive, and
dependent "<img src=""8270.png"">" Pathology cluster-c-personality-disorders
psychiatry
A woman has a desire to keep her nails trimmed to 1 cm exactly. This does not
bother her. What personality disorder might she have? Obsessive-compulsive
personality disorder (cluster C)not OCD, because her behaviors are ego-syntonic
"<img src=""8270.png"">" Pathology cluster-c-personality-disorders
psychiatry
A woman has low self-confidence and constantly needs reassurance. What personality
disorder might she have? What is an associated risk? Dependent personality
disorder (cluster C), which has a genetic relationship with anxiety disorders;
abusive relationships "<img src=""8270.png"">" Pathology cluster-c-
A patient often tries to lose weight by taking diuretics. What disorder do you
suspect? What other agents might she be abusing? Bulimia nervosa; other
medications used to try to control weight include laxatives and emetics "<img
src=""8271.png"">" Pathology eating-disorders psychiatry
Compare the body weight profiles of patients with anorexia nervosa and bulimia
nervosa. Pts with anorexia often weigh less than their ideal body weight (BMI
<18.5 kg/m2), whereas pts with bulimia often have normal body weight "<img
A patient has bulimia nervosa. What signs or symptoms of induced vomiting may be
seen? Parotitis, erosion of tooth enamel, electrolyte disturbances, dorsal hand
calluses (Russell sign) "<img src=""8271.png"">" Pathology eating-disorders
psychiatry
A physician notes eroded tooth enamel in a teenager. She orders a CBC and a
metabolic panel. What abnormalities does she expect to see?Anemia, electrolyte
abnormalities, metabolic alkalosis, all resulting from bulimia nervosa "<img
A 16-year-old girl with a BMI of 15 kg/m2 feels overweight. What psychiatric
disorder do you screen for? Does a DEXA scan have a role here? Depression, which
is often associated with anorexia nervosa; DEXA scans screen for osteoporosis,
which can be caused by anorexia nervosa "<img src=""8271.png"">" Pathology
eating-disorders psychiatry
An underweight adolescent girl has numerous metatarsal stress fractures. List four
more signs of the disorder that you suspect. Anorexia nervosa lowers bone
density, raising the risk of fractures during exercise, and causes amenorrhea,
lanugo, anemia, and weight loss "<img src=""8271.png"">" Pathology eating-
Patients with anorexia and bulimia nervosa may or may not purge. What distinguishes
the two disorders? Anorexia nervosa: excessive dieting/exercise, body weight
less than 85% of ideal; bulimia: binge eating with or without purging "<img
A patient's chart contains a diagnosis of anorexia nervosa. Her (reliable) mother
says she eats normal-sized meals. Is this possible? Yes, anorexia nervosa can
involve excessive exercise as a means of weight reduction "<img src=""8271.png"">"
Pathology eating-disorders psychiatry
A girl with a BMI of 17 kg/m2 has amenorrhea and anemia. What is the first-line
treatment for her disorder? What may occur during treatment? Psychotherapy &
nutritional rehabilitation for anorexia nervosa; refeeding syndrome
(hypophosphatemia) may occur in the severely malnourished "<img src=""8271.png"">"
A slightly overweight boy often binge eats and self-induces vomiting. For how long
must this occur for a disorder to be diagnosed? Weekly for at least 3 months (This
is bulimia nervosa.) "<img src=""8271.png"">" Pathology eating-disorders
psychiatry
A 16-y/o girl says that some days she overeats and then exercises for hours to
compensate. Her BMI is 24 kg/m2. Other signs of this illness? Signs of bulimia
nervosa include parotitis, enamel erosion, electrolyte disturbances, alkalosis, and
dorsal hand calluses "<img src=""8271.png"">" Pathology eating-disorders
psychiatry
An obese man regularly binge eats, consuming 5000 calories at once. He never
exercises; his doctor tells him he is prediabetic. Treatment? Psychotherapy such
as CBT; SSRIs. This is binge eating disorder. "<img src=""8271.png"">"
A male patient, Pat, has identified strongly as a woman for the last 15 years. Pat
is uncomfortable using the restrooms at work. Disorder? Gender dysphoria
(strong, persistent identification with opposite sex causing distress/impairment)
"<img src=""8272.png"">" Pathology gender-dysphoria psychiatry
A female patient goes through gender reassignment surgery and androgen therapy so
she can live as man. What is this called? Transsexualism (wanting to live as the
opposite sex) "<img src=""8272.png"">" Pathology gender-dysphoria
psychiatry
A man buys and wears women's clothing daily. What is this called? Transvestism
(wearing clothes of the opposite sex, like a vest), a form of paraphilia "<img
src=""8272.png"">" Pathology gender-dysphoria psychiatry
A patient has gender dysphoria, disagreeing with the gender that was assigned at
birth. With what term may the patient identify? Transgender "<img src=""8272.png"">"
Pathology gender-dysphoria psychiatry
What are the three causes that you include in the differential diagnosis for any
sexual dysfunction disorder? Drugs, disease, and psychologic issues "<img
src=""8273.png"">" Pathology psychiatry sexual-dysfunction
A man undergoes workup for erectile dysfunction, but no organic cause can be found.
Name a nonorganic cause for his symptoms. Performance anxiety (a psychologic cause)
"<img src=""8273.png"">" Pathology psychiatry sexual-dysfunction
A man has sexual dysfunction after starting a medication. Name four classes of
drugs or substances that can cause sexual dysfunction. Antihypertensives,
neuroleptics, SSRIs, and ethanol "<img src=""8273.png"">" Pathology
psychiatry sexual-dysfunction
A man has sexual dysfunction. Name three disease states that can cause sexual
dysfunction. Depression, diabetes, and STIs "<img src=""8273.png"">"
Pathology psychiatry sexual-dysfunction
Name the four broad categories of sexual dysfunction. Desire (low desire/aversion),
arousal (erectile dysfunction), orgasmic (anorgasmia/premature ejaculation), pain
(dyspareunia/vaginismus) "<img src=""8273.png"">" Pathology psychiatry
sexual-dysfunction
A mom is concerned; her son routinely wakes up at night screaming but cannot recall
the event the next day. What prognosis do you give her? This is sleep terror
disorder and is usually self-limited; the child will likely outgrow it "<img
src=""8274.png"">" Pathology psychiatry sleep-terror-disorder
A boy screams in the middle of the night but has no memory of the dream. What
waveform is seen on EEG? How does this differ from nightmares? Slow-wave sleep
(delta waves, stage 3); this is sleep terror disorder; typical nightmares occur
during REM sleep (with memory of the dream) "<img src=""8274.png"">"
Pathology psychiatry sleep-terror-disorder
A child wakes up screaming at night and cannot recall the arousal the following
day. What may have triggered this? Fever, emotional stress during the previous
day, and lack of sleep are possible triggers of sleep terror disorder "<img
src=""8274.png"">" Pathology psychiatry sleep-terror-disorder
A man has cataplexy. Define cataplexy. Associated condition? Loss of all muscle
tone as a result of a strong emotional stimulus; this is a hallmark of narcolepsy
"<img src=""8275.png"">" Pathology narcolepsy psychiatry
When do hypnagogic hallucinations occur? When do hypnopompic hallucinations occur?
Hypnagogic: when going to sleep; hypnopompic: when awakening from sleep
A man has a genetic disorder with disordered regulation of sleep-wake cycles and
excessive daytime sleepiness. Neurochemical changes? Decreased production of
hypocretin (orexin) in the lateral hypothalamus, as this is narcolepsy "<img
src=""8275.png"">" Pathology narcolepsy psychiatry
A patient taking sodium oxybate for a sleep-related disorder suddenly falls asleep.
What sleep stage does he immediately enter? REM sleep; this is known as short
REM latency and is seen in narcolepsy "<img src=""8275.png"">" Pathology
narcolepsy psychiatry
A startled man temporarily loses all muscle tone. His father has similar episodes.
What two drugs can treat his condition? Stimulants (such as amphetamines and
modafinil) and nighttime sodium oxybate (GHB) "<img src=""8275.png"">"
Pathology narcolepsy psychiatry
A man has a history of hallucinations that occur just before he falls asleep and
wakes up. CSF studies show reduced hypocretin. Treatment? Daytime stimulants
(amphetamines, modafinil) and nighttime sodium oxybate (GHB), as this is narcolepsy
What are the criteria for diagnosing substance use disorder? Two or more of the
substance abuse signs in a period of 1 year "<img src=""8276.png"">"
Pathology psychiatry substance-use-disorder
Signs of substance use disorder are tolerance, withdrawal, inability to cut down,
associated social conflicts, plus what other symptoms? Much energy spent
obtaining/using/recovering, skipping obligations due to use, use despite knowing
problems, use more/longer than desired "<img src=""8276.png"">" Pathology
psychiatry substance-use-disorder
What are some ways substance use disorder affects others, not just the abuser
him/herself? Can cause social or interpersonal conflicts related to use and
failure to fulfill obligations at school, work, or home "<img src=""8276.png"">"
Bob has often tried to cut down on drug use but always finds himself using more
than he intended despite knowing the dangers. Diagnosis? Substance use disorder
(He has three criteria, and the minimum needed is two.) "<img src=""8276.png"">"
Aside from the physical dangers, how can a substance use disorder harm a patient?
Recurrent use in physically dangerous situations and significant energy
expended on obtaining, using, or recovering from the substance "<img
src=""8276.png"">" Pathology psychiatry substance-use-disorder
A patient with alcohol addiction wants to quit drinking. What are the six stages of
overcoming substance addiction? Precontemplation, contemplation,
preparation/determination, action/willpower, maintenance, relapse "<img
src=""8277.png"">" Pathology psychiatry stages-of-change-in-overcoming-
substance-addiction
You tell a teenage patient to quit smoking. He replies that there is nothing wrong
with smoking. What stage of behavior change is he in? Precontemplation "<img
substance-addiction
You counsel a patient on smoking. He says he knows smoking is bad and would quit if
he could. What stage of behavior change is this? Contemplation "<img
substance-addiction
You speak with a man who says he is getting ready to quit smoking (eg, by buying
nicotine gum). What stage of behavior change is this? Preparation/determination
"<img src=""8277.png"">" Pathology psychiatry stages-of-change-in-
overcoming-substance-addiction
A patient you have been counseling about smoking says he has been actively cutting
down each day. What stage of behavior change is this? Action/willpower "<img
substance-addiction
Your patient proudly says that she has not smoked any cigarettes for 2 months. What
stage of behavior change is this? Maintenance "<img src=""8277.png"">"
Pathology psychiatry stages-of-change-in-overcoming-substance-addiction
Your patient comes in ashamed; he admits to breaking down and drinking after 6
months of sobriety. What stage of behavior change is this? Relapse "<img
substance-addiction
An obese man knows that his weight negatively affects his life. What stages must he
progress through before he can maintain a healthy BMI?
Preparation/determination to start changing his behavior, action/willpower to
enact changes, and maintenance to stick with these changes "<img src=""8277.png"">"
Pathology psychiatry stages-of-change-in-overcoming-substance-addiction
A man leaves a party with slurred speech, ataxia, and mood changes. GGT is high.
What is his likely AST:ALT ratio? 2:1 AST:ALT ratio (He is probably intoxicated
with alcohol.) "<img src=""8278.png"">" Pathology psychiatry psychoactive-
drug-intoxication-and-withdrawal
A college student presents with emotional lability, slurred speech, ataxia, coma,
and blackouts after a frat party. Likely diagnosis? Alcohol intoxication "<img
src=""8278.png"">" Pathology psychiatry psychoactive-drug-intoxication-and-
withdrawal
A man is undergoing alcohol withdrawal. What are the features of mild and severe
withdrawal? Mild: anxiety, tremor, insomnia, seizures (as with other depressants);
severe: autonomic hyperactivity and delirium tremens (DTs) "<img src=""8278.png"">"
Pathology psychiatry psychoactive-drug-intoxication-and-withdrawal
A patient with anxiety presents with respiratory depression. What did she take:
PCP, LSD, or barbiturates? Treatment? Barbiturates; manage symptoms, increase
blood pressure, and assist respiration "<img src=""8278.png"">" Pathology
psychiatry psychoactive-drug-intoxication-and-withdrawal
A patient overdoses on a pain medication known for causing constipation. What
should you give him as treatment? Naloxone and naltrexone, used for opioid
overdose "<img src=""8278.png"">" Pathology psychiatry psychoactive-drug-
intoxication-and-withdrawal
A 40-y/o man with mild bradypnea, ataxia, and somnolence says all he has consumed
today are anti-anxiety drugs. What does drug screen show? Benzodiazepines "<img
withdrawal
You suspect benzodiazepine overdose in a man with respiratory depression. What can
you use to treat this patient? Why is this rarely used? Flumazenil (a
competitive benzodiazepine antagonist); it is rarely used because it can
precipitate seizures "<img src=""8278.png"">" Pathology psychiatry
psychoactive-drug-intoxication-and-withdrawal
What are the symptoms of barbiturate withdrawal and benzodiazepine withdrawal?
Barbiturates: delirium, cardiovascular collapse; benzodiazepines: sleep
disturbance, depression, rebound anxiety, seizures "<img src=""8278.png"">"
A 46-year-old drug abuser presents with sweating, rhinorrhea, diarrhea, and dilated
pupils. You note goosebumps on his arms. Diagnosis? Opiate withdrawal; stopping
cold turkey can produce piloerection, or goosebumps "<img src=""8278.png"">"
A man has tremors, anxiety, seizures, and insomnia. If this is not treated, what
life-threatening condition may develop? Mortality rate? Delirium tremens (DTs),
seen in severe withdrawal, 515% mortality rate "<img src=""8278.png"">"
Which drug class has a higher safety margin: barbiturates or benzodiazepines?
Benzodiazepines, although these can still cause minor respiratory depression
(in addition to ataxia) "<img src=""8278.png"">" Pathology psychiatry
A patient w/chronic pain has sweating, mydriasis, piloerection, fever, rhinorrhea,
yawning, nausea, stomach cramps, and diarrhea. Diagnosis? Opiate withdrawal "<img
withdrawal
A college student abuses his roommate's ADHD medications. What are symptoms of
amphetamine intoxication? Euphoria, grandiosity, pupillary dilation, prolonged
wakefulness/attention, hypertension, tachycardia, anorexia, paranoia, fever "<img
withdrawal
An IV drug user comes to the ED with chest pain and has a sudden cardiac arrest.
What is used to treat overdose with the drug this man took?-Blockers and
benzodiazepines are used to treat cocaine overdose; do not use -blockers "<img
withdrawal
A paranoid man comes to the ED thinking that bugs are crawling on him. What are
other symptoms of intoxication of the drug he likely took? Impaired judgment,
pupillary dilation, hallucinations (tactile), paranoid ideation, angina, and
cardiac death may result from cocaine use "<img src=""8278.png"">" Pathology
A man drinks too much coffee and presents with restlessness, muscle twitching, and
increased urination. What withdrawal symptoms may occur? Lack of concentration
and headache, both signs of caffeine withdrawal "<img src=""8278.png"">"
A man hospitalized for 2 days is listless, sleeps excessively, feels hungry, and is
depressed. From what drug class is he withdrawing? Amphetamines "<img
withdrawal
A teen comes in with a week of irritability, anxiety, and cravings. You smell faint
traces of smoke on him. Diagnosis? Nicotine withdrawal "<img src=""8278.png"">"
Your patient quit smoking tobacco yesterday and has become anxious and irritable.
What are some good treatments with which to assist him? Nicotine patch, gum, or
lozenges; bupropion; varenicline "<img src=""8278.png"">" Pathology
A man has mood elevation, reduced anxiety, sedation, behavioral disinhibition, and
respiratory depression. Drug type? Withdrawal symptoms? A depressant; withdrawal
symptoms include anxiety, tremor, seizures, insomnia "<img src=""8278.png"">"
A man has mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias,
anxiety, and tachycardia. Drug type? Withdrawal symptoms? A stimulant; withdrawal
symptoms include depression, lethargy, headache, weight gain "<img
withdrawal
A patient with a history of drug use has dilated pupils, piloerection, and
diarrhea. How do you treat this? This is opioid withdrawal; treat with long-term
support, buprenorphine, and methadone "<img src=""8278.png"">" Pathology
A sweating, confused man likely has delirium tremens. Treatment? Which test
sensitive for his abused substance yields positive results?Benzodiazepines; serum
-glutamyltransferase (GGT) is a sensitive measure of alcohol use "<img
withdrawal
A man who drinks four cups of coffee every day complains of muscle twitches and
diuresis. What would happen if he stopped drinking coffee? These are symptoms of
caffeine intoxication; he would have withdrawal symptoms, including headache and
difficulty concentrating "<img src=""8278.png"">" Pathology psychiatry
A man has visual hallucinations and nightmare-like flashbacks of his childhood.
Assuming he is on drugs, do you expect him to be paranoid? Yes, one may see
paranoia resulting from lysergic acid diethylamide (LSD) use "<img
withdrawal
A man punches an ED nurse. You note vertical and horizontal nystagmus. If the man
is on drugs, what will his heart rate show? Tachycardia, caused by
phencyclidine (PCP) "<img src=""8278.png"">" Pathology psychiatry
A teen has been withdrawn and eating more. Her mouth is dry, and she says time is
moving slowly. If on drugs, what will her eyes show? Conjunctival injection, due
to marijuana use "<img src=""8278.png"">" Pathology psychiatry psychoactive-
drug-intoxication-and-withdrawal
A man has euphoria, paranoid delusions, and a craving for corn chips and ice cream.
For how long can the drug he took be detected in urine? This is marijuana,
detectable in the urine for up to 1 month "<img src=""8278.png"">" Pathology
A marijuana user wants to quit, but trying makes her irritable, depressed,
nauseated, and anorexic. How do you counsel her? Symptoms of marijuana
withdrawal peak in 48 hours and end after 57 days; if she gets through this
period, quitting for good is possible "<img src=""8278.png"">" Pathology
A man is belligerent, agitated, feverish, impulsive, and psychotic. What are other
symptoms of this form of intoxication? Treatment? Analgesia, nystagmus,
tachycardia, homicidality, delirium, seizures; benzodiazepines/rapid-acting
antipsychotics (PCP intoxication) "<img src=""8278.png"">" Pathology
A patient has visual and auditory perceptual distortions, depersonalization,
paranoia, psychosis, and flashbacks. Diagnosis? Lysergic acid diethylamide (LSD)
use "<img src=""8278.png"">" Pathology psychiatry psychoactive-drug-
intoxication-and-withdrawal
A man is happy and feels as if time is moving slowly. His conjunctivae are
injected. What are other symptoms produced by the drug he's on? Anxiety, paranoid
delusions, impaired judgment, social withdrawal, increased appetite, dry mouth,
hallucinations (He has used marijuana.) "<img src=""8278.png"">" Pathology
A pt comes to the ED after attacking a bouncer. His extremities jerk violently, and
he has vertical and horizontal nystagmus. Treatment? Benzodiazepines or rapid-
acting antipsychotics to reverse PCP intoxication "<img src=""8278.png"">"
A man on chemotherapy is nauseated and says that marijuana (used as a teenager)
always helped quell nausea. What can you prescribe for him?Dronabinol
(tetrahydrocannabinol isomer) is prescribable marijuana, used as an antiemetic
(chemotherapy) and an appetite stimulant (AIDS) "<img src=""8278.png"">"
A man who takes PCP regularly stops taking it suddenly. What symptoms of withdrawal
might you see? Irritability, restlessness, thought and sleep disturbances,
anergia, depression, anxiety "<img src=""8278.png"">" Pathology psychiatry
A patient intoxicated with PCP presents to the ED. What abnormalities might you
note on neuro-ophthalmologic exam? Horizontal and vertical nystagmus "<img
withdrawal
A patient brought to the ED from a rave is euphoric, disinhibited, and hyperactive.
Complications from intoxication with this drug? MDMA (ecstasy) intoxication can
have life-threatening effects including HTN, tachycardia, hyperthermia,
hyponatremia, and serotonin syndrome "<img src=""8278.png"">" Pathology
A patient brought to the ED from a rave is euphoric, disinhibited, and hyperactive.
Complications from withdrawal of this drug? MDMA (ecstasy) withdrawal can cause
depression, fatigue, appetite changes, anxiety, difficulty concentrating "<img
withdrawal
A 45-year-old heroin addict has symptoms of endocarditis. What cardiac valves do
you evaluate by echocardiogram for possible vegetations? The tricuspid and
pulmonic valves (Right-sided endocarditis is more likely in intravenous drug
users.) "<img src=""8279.png"">" Pathology heroin-addiction psychiatry
What makes naloxone plus buprenorphine a useful combination for heroin
detoxification and maintenance? The combination acts as a partial opiate
agonist that is long acting, and withdrawal symptoms occur only when naloxone is
injected "<img src=""8279.png"">" Pathology heroin-addiction psychiatry
A 28-year-old man with track marks on his arms admits to heroin abuse. To which
medical problems or complications is he predisposed? Hepatitis, abscesses, HIV,
right-sided endocarditis, bacteremia "<img src=""8279.png"">" Pathology
heroin-addiction psychiatry
A patient is addicted to heroin. What treatment has a low abuse potential and why?
Naloxone and buprenorphine; the former is not orally bioavailable, so
withdrawal symptoms occur only if it is injected "<img src=""8279.png"">"
Pathology heroin-addiction psychiatry
A heroin addict takes methadone. What makes it useful for heroin detoxification and
long-term maintenance? It is a long-acting opiate agonist "<img src=""8279.png"">"
Pathology heroin-addiction psychiatry
A heroin addict has been detoxified. Which drug is typically used for relapse
prevention? What is its mechanism of action? Naltrexone; it's a long-acting
opioid antagonist "<img src=""8279.png"">" Pathology heroin-addiction
psychiatry
An alcoholic patient wants to quit drinking. What treatments can you recommend?
Disulfiram (conditions patient to abstain), acamprosate, naltrexone, support
groups (eg, Alcoholics Anonymous), supportive care "<img src=""8280.png"">"
Pathology alcoholism psychiatry
What common origin could cirrhosis, pancreatitis, hepatitis, peripheral neuropathy,
and testicular atrophy share? All are potential complications of alcoholism "<img
src=""8280.png"">" Pathology alcoholism psychiatry
An alcoholic experiences confusion, ataxia, and then memory problems/personality
changes. What neurologic pathology is associated with this?Bilateral necrosis of
the mammillary bodies, periventricular hemorrhage (This is Wernicke-Korsakoff
syndrome.) "<img src=""8280.png"">" Pathology alcoholism psychiatry
A man vomits excessively and violently after binge drinking. His emesis is bilious
at first but later becomes bloody. What is the diagnosis? Mallory-Weiss syndrome:
prolonged vomiting/retching leads to lacerations of the esophagus (often
misdiagnosed as esophageal varices) "<img src=""8280.png"">" Pathology
alcoholism psychiatry
A man is confused; has ophthalmoplegia, ataxia, memory loss, and personality
changes. What nutritional deficiency causes this syndrome? Thiamine (vitamin B1)
deficiency, commonly seen in alcoholics who get most of their caloric intake from
alcohol "<img src=""8280.png"">" Pathology alcoholism psychiatry
An alcoholic patient has Wernicke encephalopathy. Treatment? If not treated, what
irreversible symptoms may it progress to include? IV vitamin B1 (thiamine);
irreversible memory loss, confabulation, personality changes (known as Korsakoff
psychosis) "<img src=""8280.png"">" Pathology alcoholism psychiatry
A 45-year-old alcoholic presents with confusion, ophthalmoplegia, and ataxia. Of
what disorder is this triad the hallmark? Wernicke encephalopathy, an acute
disorder resulting from alcohol abuse (low vitamin B1 [thiamine] level) "<img
src=""8280.png"">" Pathology alcoholism psychiatry
An alcoholic man vomits blood. He has had Mallory-Weiss tears in the past. Because
of this, can you rule out esophageal varices? No, ruptured esophageal varices and
Mallory-Weiss tears present similarly; thus both should remain on the differential
"<img src=""8280.png"">" Pathology alcoholism psychiatry
An alcoholic starts to have memory problems and confabulate information. Treatment?
Intravenous thiamine (vitamin B1); it should be given before any dextrose-
containing fluids (Wernicke-Korsakoff syndrome) "<img src=""8280.png"">"
Pathology alcoholism psychiatry
What is the definition of alcoholism? Physiologic tolerance/dependence on
alcohol with symptoms of withdrawal (tremors, tachycardia, HTN, malaise, nausea,
DTs) on cessation "<img src=""8280.png"">" Pathology alcoholism psychiatry
When after the last drink are DTs most likely to occur? When after the last drink
are visual hallucinations most likely to occur? DTs occur after 2 to 4 days after
the last drink; alcoholic hallucinosis occurs 12 to 48 hours after the last drink
"<img src=""8281.png"">" Pathology delirium-tremens psychiatry
Describe the classical pattern of symptoms seen in patients with DTs. Tachycardia,
tremors, anxiety, and seizures (autonomic symptoms) "<img src=""8281.png"">"
Pathology delirium-tremens psychiatry
Two days after an alcoholic man is hospitalized for pancreatitis, he begins seizing
and hearing voices. What treatment should be used? Longer-acting benzodiazepines
(eg, lorazepam, chlordiazepoxide, diazepam) should be used to treat DTs "<img
src=""8281.png"">" Pathology delirium-tremens psychiatry
A man has had episodes of mania interspersed with episodes of severe depression.
What are the three first-line drugs (all mood stabilizers)?Valproic acid, lithium,
and atypical antipsychotics (for bipolar disorder) "<img src=""8282.png"">"
pharmacology preferred-medications-for-selected-psychiatric-conditions
psychiatry
A teenage girl has eroded enamel, puffy cheeks, and calluses on the backs of her
hands. Drug class of choice? Selective serotonin reuptake inhibitors (SSRIs) for
bulimia "<img src=""8282.png"">" pharmacology preferred-medications-for-
selected-psychiatric-conditions psychiatry
A woman reports feeling anxious and restless all the time and worries about
everything. Which two first-line drug classes might you use? Selective
serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake
inhibitors (SNRIs) (for generalized anxiety disorder) "<img src=""8282.png"">"
psychiatry
A man reports having 3 weeks of anhedonia, feelings of sadness and guilt, insomnia,
and reduced appetite. What is the first-line drug class? SSRIs (for depression)
"<img src=""8282.png"">" pharmacology preferred-medications-for-
A patient is found to have panic disorder. What three drugs are typically used for
treatment? Venlafaxine, selective serotonin reuptake inhibitors (SSRIs), and
benzodiazepines "<img src=""8282.png"">" pharmacology preferred-medications-
for-selected-psychiatric-conditions psychiatry
Beth reorganizes her shoes by height each morning and always washes the dishes
exactly three times. What treatment might help her? Selective serotonin reuptake
inhibitors (SSRIs) or clomipramine (for obsessive-compulsive disorder) "<img
src=""8282.png"">" pharmacology preferred-medications-for-selected-
psychiatric-conditions psychiatry
A man complains of hallucinations and delusions; he is found to have schizophrenia.
What is the drug class of choice? Atypical antipsychotics "<img src=""8282.png"">"
psychiatry
Bob has a disorder that involves a facial tic and occasional swearing. What drugs
might help him? Antipsychotics (eg, pimozide, fluphenazine), tetrabenazine, or
clonidine (for Tourette syndrome) "<img src=""8282.png"">" pharmacology
preferred-medications-for-selected-psychiatric-conditions psychiatry
A boy presents with reports from both school and home of his inability to
concentrate, hyperactivity, and impulsivity. Drug class of choice? Stimulants
(eg, methylphenidate) are the drug class of choice for ADHD"<img src=""8282.png"">"
psychiatry
A war veteran has had flashbacks and nightmares for the past 4 years. What drug
class can be used to help manage his condition? Selective serotonin reuptake
inhibitors (SSRIs) or venlafaxine (for post-traumatic stress disorder [PTSD])
"<img src=""8282.png"">" pharmacology preferred-medications-for-
A patient's social phobia does not respond to selective serotonin reuptake
inhibitors (SSRIs). What else can be used to treat his condition? -Blockers,
benzodiazepines "<img src=""8282.png"">" pharmacology preferred-medications-
for-selected-psychiatric-conditions psychiatry
What class of medications is typically used to treat patients experiencing
withdrawal from alcohol? Longer-acting benzodiazepines (eg, chlordiazepoxide,
lorazepam, diazepam) are used to treat alcohol withdrawal "<img src=""8282.png"">"
psychiatry
A boy comes in with reports of concentration difficulties, restlessness, and
impulsivity. Name three CNS stimulants you can use for him.Methylphenidate,
dextroamphetamine, and methamphetamine (He has ADHD.) "<img src=""8283.png"">"
cns-stimulants pharmacology psychiatry
Explain the mechanism of action of methylphenidate, dextroamphetamine, and
methamphetamine. They are CNS stimulants that augment catecholamine release
(especially norepinephrine and dopamine) at the synaptic cleft "<img
src=""8283.png"">" cns-stimulants pharmacology psychiatry
Besides attention-deficit hyperactivity disorder (ADHD), what can methylphenidate,
dextroamphetamine, and methamphetamine be used to treat? Narcolepsy and appetite
(control) "<img src=""8283.png"">" cns-stimulants pharmacology psychiatry
Which antipsychotic causes corneal deposits? Which one causes retinal deposits?
ChlorpromazineCorneal deposits; ThioridazinereTinal deposits "<img
src=""8284.png"">" antipsychotics-(neuroleptics) pharmacology psychiatry
Which neuroleptics are high-potency drugs, and what side effects are more likely
with them? Trifluoperazine, Fluphenazine, Haloperidol (Try to Fly High);
neurologic side effects (extrapyramidal symptoms) "<img src=""8284.png"">"
antipsychotics-(neuroleptics) pharmacology psychiatry
Put these extrapyramidal adverse effects of neuroleptics in chronologic order:
tardive dyskinesia, akathisia, dystonia, bradykinesia. ADAPT: Acute Dystonia
(hours to days); Akathisia and Parkinsonism (days to months); Tardive dyskinesia
(months to years) "<img src=""8284.png"">" antipsychotics-(neuroleptics)
pharmacology psychiatry
In reference to neuroleptic malignant syndrome, what does the FEVER mnemonic
represent? Fever, Encephalopathy, Vitals unstable, Enzymes increased, Rigidity of
muscles "<img src=""8284.png"">" antipsychotics-(neuroleptics)
What is the reason for the long half-life of neuroleptics? They're highly lipid
soluble, so there's a large volume of distribution; therefore it takes a long time
for them to be removed from the body "<img src=""8284.png"">"
How do typical antipsychotics affect dopamine receptors, cAMP activity, muscarinic
receptors, 1 receptors, and histamine receptors? By blocking D2 receptors;
increasing cAMP (via D2 block); and blocking muscarinic, 1, and histamine
receptors "<img src=""8284.png"">" antipsychotics-(neuroleptics)
What are four clinical uses of neuroleptics? Schizophrenia (primarily for
positive symptoms), psychosis, acute mania, and Tourette syndrome "<img
A patient with schizophrenia has a prolonged QT interval on ECG. What could be
causing this? Use of typical or atypical antipsychotics "<img src=""8284.png"">"
A patient on haloperidol presents with rigidity, autonomic instability, and
hyperpyrexia. Name 4 other drugs that can cause this syndrome. Trifluoperazine,
fluphenazine, thioridazine, chlorpromazine (all typical antipsychotics); this is
neuroleptic malignant syndrome "<img src=""8284.png"">" antipsychotics-
(neuroleptics) pharmacology psychiatry
Name five typical antipsychotics (neuroleptics). "Haloperidol,
trifluoperazine, fluphenazine, thioridazine, chlorpromazine (haloperidol +
""azines"")" "<img src=""8284.png"">" antipsychotics-(neuroleptics)
A male patient with schizophrenia starts leaking milk from his nipples. What is the
pathophysiology behind this finding? He likely takes an antipsychotic, which
antagonizes dopamine receptors, causing hyperprolactinemia and galactorrhea "<img
Four hours after taking a psychiatric drug, a man has spasms and his eyes roll in
their sockets. Treatment for this reaction? This is acute dystonia (oculogyric
crisis), an extrapyramidal symptom due to neuroleptics; benztropine and
diphenhydramine treat dyskinesia "<img src=""8284.png"">" antipsychotics-
What adverse effect of neuroleptic medications is characterized by sluggishness in
initiating purposeful movements? When does it manifest? Bradykinesia
(parkinsonism); 4 weeks after the drug is taken "<img src=""8284.png"">"
What extrapyramidal adverse effect of neuroleptics is irreversible? When does it
occur? Stereotypical oral-facial movements in tardive dyskinesia; more than 4
months after taking the drug "<img src=""8284.png"">" antipsychotics-
Why does your schizophrenic patient have a dry mouth and constipation and feel
sedated? Do you expect his blood pressure to be high or low? Neuroleptics block
muscarinic receptors (dry mouth, constipation) and histamine receptors (sedation);
low (hypotension from 1-blockade) "<img src=""8284.png"">" antipsychotics-
A man has fever, rigidity, myoglobinuria, and tachycardia after taking haloperidol.
What is this, and how should it be managed? Neuroleptic malignant syndrome,
which is most often seen with haloperidol; treat with dantrolene and D2 agonists
(eg, bromocriptine) "<img src=""8284.png"">" antipsychotics-(neuroleptics)
Four days ago, a patient started taking fluphenazine. She states that she is unable
to sit still. What adverse effect is she experiencing? Akathisia (restlessness,
occurring 4 days after the start of neuroleptic therapy) "<img src=""8284.png"">"
Which neuroleptics are considered low-potency drugs? What qualifies them as such?
Chlorpromazine and Thioridazine (Cheating Thieves are low.); lower incidence
of neurologic side effects "<img src=""8284.png"">" antipsychotics-
What do olanzapine, clozapine, quetiapine, risperidone, aripiprazole, and
ziprasidone have in common? They are atypical antipsychotics "<img
src=""8285.png"">" atypical-antipsychotics pharmacology psychiatry
Which type of schizophrenia symptoms are treated with typical antipsychotics?
Atypical antipsychotics? Positive symptoms are treated with typical
antipsychotics; both positive and negative symptoms are treated with atypical
antipsychotics "<img src=""8285.png"">" atypical-antipsychotics
A 36-year-old schizophrenic patient on haloperidol experiences torticollis, tremor,
and dry mouth. What is an alternative treatment? Atypical antipsychotics,
which have a lower risk of extrapyramidal symptoms and anticholinergic side effects
"<img src=""8285.png"">" atypical-antipsychotics pharmacology psychiatry
Which receptor type(s) do atypical antipsychotics affect? 5-HT2, dopamine, and
H1 (Effects on different receptor types are varied.) "<img src=""8285.png"">"
atypical-antipsychotics pharmacology psychiatry
What are the indications for atypical antipsychotic use? Schizophrenia (positive
and negative symptoms), bipolar and obsessive-compulsive disorders, anxiety,
depression, mania, Tourette syndrome "<img src=""8285.png"">" atypical-
antipsychotics pharmacology psychiatry
You start a patient on clozapine. What blood tests do you need to order and how
regularly? Weekly CBC to monitor white blood cells, because clozapine can cause
agranulocytosis (Must watch bone marrow clozely with clozapine.) "<img
src=""8285.png"">" atypical-antipsychotics pharmacology psychiatry
A man with bipolar disorder has gained weight since starting an atypical
antipsychotic. Which specific agents are most likely to cause this? Clozapine
and olanzapine "<img src=""8285.png"">" atypical-antipsychotics
A man with schizophrenia comes in complaining of lactation and larger breasts.
Which atypical antipsychotic was he likely prescribed? Risperidone (increases
prolactin, thus causing these symptoms) "<img src=""8285.png"">" atypical-
A woman taking risperidone has menstrual and fertility issues. Endocrine blood work
is done. What abnormalities do you expect and why? Decreased GnRH, LH, and FSH
(because risperidone increases prolactin) "<img src=""8285.png"">" atypical-
A schizophrenic patient taking ziprasidone undergoes ECG, and the findings are
abnormal. What abnormality do you see and why? QT prolongation resulting from
atypical antipsychotic (ziprasidone) use "<img src=""8285.png"">" atypical-
What disorder is lithium used to treat, and what biochemical cascade might it
affect? Bipolar disorder; by way of an unclear mechanism, it may cause
inhibition of the phosphoinositol cascade "<img src=""8286.png"">" lithium
Polyuria and polydipsia develop in a man on long-term lithium therapy. You treat
with exogenous ADH, but treatment fails. Why? Nephrogenic diabetes insipidus
(caused by lithium) causes ADH function to be inhibited at the level of the kidney
(ADH resistance) "<img src=""8286.png"">" lithium pharmacology psychiatry
A neonate has a displaced tricuspid valve and an atrialized right ventricle. Which
drug did the mother take? What else can the drug cause? Lithium (as this is the
Ebstein anomaly); great vessel malformations in the fetus (Lithium is
contraindicated in pregnant women.) "<img src=""8286.png"">" lithium
A patient taking lithium complains of lethargy, constipation, and constantly
feeling cold. What lab test should be ordered? Thyroid-stimulating hormone (TSH)
test (Lithium can cause hypothyroidism.) "<img src=""8286.png"">" lithium
A patient has bipolar disorder and HTN. How is lithium reabsorbed in the kidney?
Which blood pressure medications should he avoid? It is reabsorbed at the
proximal convoluted tubule (PCT) along with sodium; thiazides because they can
increase lithium toxicity "<img src=""8286.png"">" lithium pharmacology
psychiatry
A patient has syndrome of inappropriate antidiuretic hormone secretion (SIADH).
What psychiatric drug can be used for treatment? Why? Lithium; it antagonizes ADH
receptors "<img src=""8286.png"">" lithium pharmacology psychiatry
Your patient with bipolar disorder has delirium, hyponatremia, and a tremor; he
feels both tired and cold. Why is this? He is taking lithium; Lithium side
effects: Movement (tremors), Nephrogenic diabetes insipidus, hypOthyroidism,
Pregnancy problems (LMNOP) "<img src=""8286.png"">" lithium pharmacology
psychiatry
Lithium has a narrow therapeutic window. Does this pharmacologic property affect
clinical practice in any way? Yes, it means that clinicians must check the lithium
level regularly to ensure that lithium is neither supratherapeutic nor
subtherapeutic "<img src=""8286.png"">" lithium pharmacology psychiatry
You prescribe your patient with anxiety buspirone instead of a barbiturate or
benzodiazepine. What adverse effects are avoided? Buspirone does not interact
with alcohol and does not cause sedation, addiction, or tolerance "<img
src=""8287.png"">" buspirone pharmacology psychiatry
A man with generalized anxiety disorder takes a nonsedating, nonaddictive drug with
no alcohol interaction. What is its mechanism of action? Buspirone stimulates
serotonin (specifically 5-HT1A) receptors "<img src=""8287.png"">" buspirone
What is the primary clinical indication for buspirone? Generalized anxiety
disorder (I'm always anxious if the bus will be on time, so I take buspirone.)
"<img src=""8287.png"">" buspirone pharmacology psychiatry
Which four antidepressants act by inhibiting serotonin reuptake? SSRIs, SNRIs,
TCAs, trazodone "<img src=""8288.png"">" antidepressants pharmacology
psychiatry
Which two antidepressants act by inhibiting norepinephrine reuptake? SNRIs and
TCAs "<img src=""8288.png"">" antidepressants pharmacology psychiatry
A patient starts taking an MAO inhibitor. What changes in neurotransmitter levels
are expected? MAO inhibitors block MAO, which breaks down both 5-HT and NE into
metabolites, so 5-HT and NE levels should be increased "<img src=""8288.png"">"
antidepressants pharmacology psychiatry
Studies in rats show increased NE in the synaptic cleft after mirtazapine
administration. Why does this occur? Mirtazapine inhibits the 2-adrenergic
receptor (autoreceptor), which in turn decreases the inhibition of NE release
"<img src=""8288.png"">" antidepressants pharmacology psychiatry
You prescribe bupropion for your depressed patient. This drug increases available
NE by acting in opposition to which adrenergic receptor? The 2-adrenergic
receptor (autoreceptor) "<img src=""8288.png"">" antidepressants pharmacology
psychiatry
Name four selective serotonin reuptake inhibitors (SSRIs). Fluoxetine, paroxetine,
sertraline, and citalopram (Flashbacks paralyze senior citizens.) "<img
src=""8289.png"">" pharmacology psychiatry selective-serotonin-reuptake-
inhibitors
Your patient has been taking an SSRI for 2 weeks but reports no benefit. What do
you do? Reassure her because it normally takes 4 to 8 weeks for an SSRI to show
clinical benefit "<img src=""8289.png"">" pharmacology psychiatry selective-
serotonin-reuptake-inhibitors
What are indications for using selective serotonin reuptake inhibitor (SSRI)
therapy? Depression, OCD, panic disorder, generalized anxiety disorder, bulimia,
social phobias, PTSD "<img src=""8289.png"">" pharmacology psychiatry
selective-serotonin-reuptake-inhibitors
Before prescribing fluoxetine, what common side effects should you counsel the
patient about? How do they compare with those of TCAs? GI upset, sexual
dysfunction (decreased libido and anorgasmia), and SIADH are SSRI side effects;
they have fewer side effects than TCAs "<img src=""8289.png"">" pharmacology
psychiatry selective-serotonin-reuptake-inhibitors
A patient being treated for depression presents with a temperature of 105 F,
rigidity, flushing, and diarrhea. How do you treat him? Administer
cyproheptadine, a serotonin (5-HT2) receptor antagonist (This is serotonin
syndrome.) "<img src=""8289.png"">" pharmacology psychiatry selective-
serotonin-reuptake-inhibitors
Name two serotonin-norepinephrine reuptake inhibitors (SNRIs). Venlafaxine and
duloxetine "<img src=""8290.png"">" pharmacology psychiatry serotonin-
norepinephrine-reuptake-inhibitors
A pt with depression is prescribed serotonin-norepinephrine reuptake inhibitors
(SNRIs). What is the mechanism of action of this drug class? Inhibition of
serotonin (5-HT) and norepinephrine reuptake "<img src=""8290.png"">"
pharmacology psychiatry serotonin-norepinephrine-reuptake-inhibitors
Aside from depression, what are three other indications for venlafaxine?
Generalized anxiety disorder, PTSD, and panic disorder "<img
src=""8290.png"">" pharmacology psychiatry serotonin-norepinephrine-reuptake-
inhibitors
A diabetic 60-year-old man cannot feel his toes, and his dog just died (he's
depressed). What drug may help his neuropathy and depression? Duloxetine (a
serotonin-norepinephrine reuptake inhibitor [SNRI] used for diabetic peripheral
neuropathy) "<img src=""8290.png"">" pharmacology psychiatry serotonin-
norepinephrine-reuptake-inhibitors
You prescribe a serotonin-norepinephrine reuptake inhibitor (SNRI) for your
depressed patient. What adverse effects do you warn her about? Increased blood
pressure (most common), stimulant effects, sedation, and nausea "<img
src=""8290.png"">" pharmacology psychiatry serotonin-norepinephrine-reuptake-
inhibitors
A patient takes both a selective serotonin reuptake inhibitor (SSRI) and a
monoamine oxidase (MAO) inhibitor. What syndrome may develop? Serotonin syndrome
(myoclonus, diarrhea, flushing, seizures, hyperthermia, and cardiovascular
collapse) "<img src=""8291.png"">" pharmacology psychiatry serotonin-
syndrome
A patient taking both phenelzine and fluoxetine develops hyperthermia and
hyperreflexia. What other symptoms might she have? Neuromuscular Activity
(clonus, hypertonia, tremors, seizure), Autonomic stimulation (diaphoresis,
diarrhea), Agitation (3 A's) "<img src=""8291.png"">" pharmacology psychiatry
serotonin-syndrome
A patient taking both phenelzine and fluoxetine develops hyperthermia and
hyperreflexia. What drug can reverse this? Cyproheptadine, a 5-HT2 receptor
antagonist, is used to treat serotonin syndrome "<img src=""8291.png"">"
pharmacology psychiatry serotonin-syndrome
A pt taking both phenelzine and fluoxetine develops hyperthermia and hyperreflexia.
What is the mechanism of the drug that reverses this? Serotonin syndrome is caused
by increased levels of 5-HT; it can be reversed with drugs that antagonize 5-HT2
receptors "<img src=""8291.png"">" pharmacology psychiatry serotonin-
syndrome
Name the tricyclic antidepressants (TCAs). Amitriptyline, nortriptyline,
imipramine, desipramine, clomipramine, doxepin, amoxapine "<img src=""8292.png"">"
pharmacology psychiatry tricyclic-antidepressants
A 17-year-old patient has nocturnal bedwetting. What antidepressant is a treatment
option for this patient? Imipramine, a tricyclic antidepressant (TCA) "<img
src=""8292.png"">" pharmacology psychiatry tricyclic-antidepressants
Convulsions, coma, arrhythmias, fever, and respiratory depression develop in a man
taking an antidepressant. How do you treat this? Treat tricyclic
antidepressant (TCA) toxicity with intravenous NaHCO3 to prevent cardiac
arrhythmias "<img src=""8292.png"">" pharmacology psychiatry tricyclic-
antidepressants
You prescribe a tricyclic antidepressant (TCA) for your patient with obsessive-
compulsive disorder. Which TCA do you choose? Clomipramine "<img
You consider using a tricyclic antidepressant (TCA) for your depressed patient with
epilepsy. Why might a neurologist talk you out of it? TCAs increase the risk of
seizures (Tri C's: Convulsions, Coma, CCardiotoxity) "<img src=""8292.png"">"
Tricyclic antidepressants (TCAs) block the reuptake of what two neurotransmitters?
Serotonin (5-HT) and norepinephrine "<img src=""8292.png"">" pharmacology
psychiatry tricyclic-antidepressants
What are the five major adverse effects of tricyclic antidepressant (TCA) overdose?
Tri-C's: Convulsions, Coma, Cardiotoxicity; also respiratory depression and
hyperpyrexia "<img src=""8292.png"">" pharmacology psychiatry tricyclic-
antidepressants
A man who recently started depression treatment has dry mouth, tachycardia, and
urine retention. Which specific agent did he likely take? Amitriptyline, a
tertiary TCA that has more anticholinergic properties "<img src=""8292.png"">"
Besides major depression, which four other conditions can be treated with tricyclic
antidepressants (TCAs)? Obsessive-compulsive disorder (with clomipramine),
peripheral neuropathy, chronic pain, migraine (prophylaxis)"<img src=""8292.png"">"
Which specific TCA should be avoided in the elderly and why? What alternative agent
may be used? Amitriptyline (a 3 TCA); the anticholinergic effects may cause
confusion and hallucinations; nortriptyline (a less anticholinergic 2 TCA) "<img
A man feels tired and lightheaded when he stands up, and his mouth is always dry.
What antidepressant drug class is likely the cause? Tricyclic antidepressants
(TCAs), which can cause sedation, postural hypotension (-1 blocking), and
anticholinergic side effects "<img src=""8292.png"">" pharmacology psychiatry
tricyclic-antidepressants
A depressed patient taking amitriptyline has chest pain and undergoes an ECG. What
abnormal finding would you not be surprised to see? QT prolongation, a side
effect of tricyclic antidepressant (TCA) use "<img src=""8292.png"">"
An anxious woman with atypical depression is always worried that she is dying,
despite repeatedly normal test results. How do you treat her? With monoamine
oxidase (MAO) inhibitors (They treat atypical depression, anxiety, and
hypochondriasis.) "<img src=""8293.png"">" monoamine-oxidase-inhibitors
A 32-year-old man who takes phenelzine daily goes to a wine and cheese party. What
foods should he avoid? Why? Wine and cheese, which are high in tyramine and cause
hypertensive crisis if ingested by someone taking monoamine oxidase (MAO)
inhibitors "<img src=""8293.png"">" monoamine-oxidase-inhibitors pharmacology
psychiatry
Your patient takes isocarboxazid. What other drugs do you tell her to avoid? SSRIs,
TCAs, St Johns wort, dextromethorphan, and meperidine; all can cause serotonin
syndrome when co-administered with MAO inhibitors "<img src=""8293.png"">"
monoamine-oxidase-inhibitors pharmacology psychiatry
Name the monoamine oxidase (MAO) inhibitors. Tranylcypromine, Phenelzine,
Isocarboxazid, Selegiline (selective MAO-B inhibitor) (MAOTakes Pride In Shanghai.)
"<img src=""8293.png"">" monoamine-oxidase-inhibitors pharmacology
psychiatry
A woman is prescribed a monoamine oxidase (MAO) inhibitor for her depression. What
is the mechanism of action of this agent? Inhibition of MAO prevents breakdown of
amine neurotransmitters (norepinephrine, serotonin [5-HT], dopamine) "<img
src=""8293.png"">" monoamine-oxidase-inhibitors pharmacology psychiatry
A man wants to quit smoking. What is the mechanism of action of the antidepressant
you prescribe for him? Bupropion increases norepinephrine and dopamine by way of
an unknown mechanism "<img src=""8294.png"">" atypical-antidepressants
A patient with bulimia is depressed and wants to start taking an antidepressant.
Which medication should you avoid? Why? Bupropion because it lowers the seizure
threshold and bulimia predisposes her to seizure-provoking electrolyte
abnormalities "<img src=""8294.png"">" atypical-antidepressants
A man has a painful sustained erection after taking an antidepressant for insomnia.
What is the mechanism of action of the causative agent? Trazodone, an atypical
antidepressant that can cause priapism, blocks 5-HT2; H1 receptors, and 1-
receptors "<img src=""8294.png"">" atypical-antidepressants pharmacology
psychiatry
A frail 90-year old woman cannot sleep due to her depression. Which atypical
antidepressant might be most beneficial for her? Mirtazapine, which can cause
sedation and weight gain (especially useful in elderly or anorexic patients) "<img
src=""8294.png"">" atypical-antidepressants pharmacology psychiatry
What are the adverse effects of mirtazapine? What is its mechanism of action?
Sedation, increased appetite, weight gain, dry mouth; it antagonizes 2-, 5-
HT2-, and 5-HT3-receptors "<img src=""8294.png"">" atypical-antidepressants
Is trazodone better for depression or insomnia? Why? Insomnia; very high doses are
needed for antidepressant effects "<img src=""8294.png"">" atypical-
antidepressants pharmacology psychiatry
A patient taking an atypical antidepressant experiences headaches. Of what
medication is this a side effect? Bupropion "<img src=""8294.png"">"
atypical-antidepressants pharmacology psychiatry
Your 25-year-old patient worries that taking paroxetine for depression will worsen
his sexual dysfunction. What is an alternative treatment? Bupropion "<img
A woman cannot have an orgasm since she started taking fluoxetine. What is another
option for her? What is its side effect profile? Bupropion; some stimulant
effects (tachycardia, insomnia), headache, seizures in anorexia/bulimia but no
sexual side effects "<img src=""8294.png"">" atypical-antidepressants
You prescribe a pill to a patient who wants to quit smoking. What is its mechanism
of action? Varenicline is a partial agonist at the nicotinic ACh receptor "<img
You prescribe a pill to a patient who wants to quit smoking. What is its adverse
effect? Varenicline's major adverse effect is sleep disturbance "<img
During which trimester of fetal development does a structure that eventually
contributes to the male genital system arise? During the first trimester, the
mesonephros, which later contributes to the male genital system, begins to develop
"<img src=""8295.png"">" embryology kidney-embryology renal
The kidneys of a 4-week-old human embryo are examined. The development of which
structure is expected to be seen? The pronephros "<img src=""8295.png"">"
embryology kidney-embryology renal
After week 4, what happens to the pronephros? The pronephros degenerates "<img
src=""8295.png"">" embryology kidney-embryology renal
What fetal structure functions as the interim kidney for the first trimester?
The mesonephros "<img src=""8295.png"">" embryology kidney-embryology
renal
A researcher wishes to physically block development of the ureteric bud. Where must
he stall development? The caudal end of the mesonephros "<img src=""8295.png"">"
What adult structures in the urinary tract are derived from the ureteric bud?
Collecting ducts, calyces, pelvises, and ureters "<img src=""8295.png"">"
What adult structures in the urinary tract are derived from the metanephric
mesenchyme? Structures in the kidney, from the glomerulus to the distal convoluted
tubule "<img src=""8295.png"">" embryology kidney-embryology renal
What is the most common cause of hydronephrosis in a fetus? Why? Ureteropelvic
junction obstruction; the ureteropelvic junction is the last structure to canalize
The interaction of which two structures/tissues in the developing kidney induces
proper differentiation and formation of the renal tubules? The ureteric bud and the
metanephric mesenchyme (Aberrant interaction leads to congenital malformations.)
A fetus has pulmonary hypoplasia, facial and limb deformities, and bilateral renal
agenesis. What syndrome is this? Potter sequence (syndrome) "<img
src=""8296.png"">" embryology potter-sequence-(syndrome) renal
A newborn is found to have bilateral renal agenesis, which leads to the Potter
sequence (syndrome). What else causes this sequence to occur? Autosomal
recessive polycystic kidney disease (ARPKD), obstructive uropathy (eg, posterior
urethral valves) "<img src=""8296.png"">" embryology potter-sequence-
(syndrome) renal
How does the mnemonic POTTER help you remember the characteristic features of the
Potter sequence (syndrome)? Pulmonary hypoplasia, Oligohydramnios (trigger),
Twisted face, Twisted skin, Extremity defects, Renal failure (in utero) "<img
src=""8296.png"">" embryology potter-sequence-(syndrome) renal
A 40-year-old man is incidentally found to have fused kidneys on an abdominal CT
scan. Name this anatomic abnormality. Horseshoe kidney "<img src=""8297.png"">"
embryology horseshoe-kidney renal
A horseshoe kidney gets trapped beneath which artery? Inferior mesenteric (and it
remains low in the abdomen) "<img src=""8297.png"">" embryology horseshoe-
kidney renal
A girl with a webbed neck, short stature, and a low hairline presents with
amenorrhea. What renal anomaly might be found on ultrasound? Horseshoe kidney,
as this is Turner syndrome "<img src=""8297.png"">" embryology horseshoe-
kidney renal
Name the group of congenital syndromes with which horseshoe kidney is most strongly
associated. Chromosomal aneuploidy syndromes (eg, Down, Edwards, Patau, Turner)
"<img src=""8297.png"">" embryology horseshoe-kidney renal
An ultrasound of a fetus at 20 weeks reveals only one kidney and one ureter. What
is the mechanism by which the other kidney failed to develop? Unilateral renal
agenesis, due to failure of the ureteric bud to develop and lead to differentiation
of the metanephric mesenchyme "<img src=""8298.png"">" embryology renal
unilateral-renal-agenesis
During development, an abnormal interaction between an embryo's ureteric bud and
the metanephric mesoderm occurs. Is the kidney functional? No, this interaction
results in a multicystic dysplastic kidney, a nonfunctional kidney consisting of
connective tissue and cysts "<img src=""8299.png"">" embryology multicystic-
dysplastic-kidney renal
Is multicystic dysplastic kidney usually unilateral or bilateral? What are the
symptoms and how is the condition diagnosed? Unilateral; generally asymptomatic,
with hypertrophy (compensation) by the other kidney; diagnosed prenatally with
ultrasound "<img src=""8299.png"">" embryology multicystic-dysplastic-kidney
renal
Bifurcation of the uteric bud before it enters the metanephric blastema lead leads
to an anomaly. Name the anomaly. Duplex collecting system "<img
src=""8300.png"">" duplex-collecting-system embryology renal
A 4-year-old has vesicoureteral reflux and multiple UTIs because of asynchronous
muscle contraction. What is the developmental pathogenesis?Duplex collecting system
caused by bifurcation of the ureteric bud before it enters the metanephric
blastema, resulting in a bifid ureter "<img src=""8300.png"">" duplex-
collecting-system embryology renal
A 40-year-old woman is noted to have an absent right kidney during an ultrasound
for cholecystitis. Do you worry about her left kidney? Yes, a congenital
solitary functioning kidney may have hypertrophied or have abnormalities (though
most pts are asymptomatic) "<img src=""8301.png"">" congenital-solitary-
functioning-kidney embryology renal
A pt undergoes nephrectomy to donate a kidney. The surgeon only wishes to take the
kidney from one side. Which one and why? The left kidney because it has a longer
renal vein than the right kidney "<img src=""8302.png"">" anatomy kidney-
anatomy-and-glomerular-structure renal
Starting with the renal artery and listing only arteries, trace the path of blood
as it passes through the kidney. Renal artery to segmental artery to interlobar
artery to interlobular artery to arcuate artery "<img src=""8302.png"">"
anatomy kidney-anatomy-and-glomerular-structure renal
Urine exits the kidneys into the ureters via which structure? Renal pelvis
"<img src=""8302.png"">" anatomy kidney-anatomy-and-glomerular-structure
renal
Blood enters a glomerulus through the afferent arteriole. Trace its path to the
efferent arteriole, noting the key structures it passes. Afferent arteriole to
juxtaglomerular cells to glomerulus (podocytes/mesangial cells/basement membrane)
to efferent arteriole "<img src=""8302.png"">" anatomy kidney-anatomy-and-
glomerular-structure renal
In terms of blood flow, what is the difference between the afferent and efferent
arterioles of the kidney? The afferent arteriole contains arriving blood, while
the efferent arteriole contains exiting blood "<img src=""8302.png"">"
anatomy kidney-anatomy-and-glomerular-structure renal
How do the ureters run to the uterine artery and the vas deferens? Is their course
to the bladder retro- or intraperitoneal? Water (ureters) under the bridge (uterine
artery, vas deferens); retroperitoneal "<img src=""8303.png"">" anatomy
renal ureters:-course
After a hysterectomy, a woman is found to have blood in her bladder. What is the
key anatomic relationship of the structures involved? The surgeon likely cut the
pt's ureter(s) during the ligation of the uterine vessels in the hysterectomy
(waters under the bridge) "<img src=""8303.png"">" anatomy renal ureters:-
course
What fraction of total body water is extracellular vs intracellular? What fraction
of extracellular fluid is plasma vs interstitial? Total body water = one third
extracellular, two thirds intracellular; extracellular fluid = one fourth plasma,
three fourths interstitial "<img src=""8304.png"">" fluid-compartments
physiology renal
In a person weighing 70 kg, how much mass is non-water, both in percentage and
kilograms? 40%, 28 kg "<img src=""8304.png"">" fluid-compartments physiology
renal
In an experiment, radiolabeled albumin and, later, radiolabeled inulin are infused
into a pt. Which two variables are being measured? Radiolabeled albumin may be
used to measure plasma volume, and inulin may be used to measure extracellular
volume "<img src=""8304.png"">" fluid-compartments physiology renal
What is the 60-40-20 rule (percentage of body weight) for the average person?
60% of total body weight is total body water, 40% is intracellular fluid
(ICF), and 20% is extracellular fluid (ECF) "<img src=""8304.png"">" fluid-
compartments physiology renal
A healthy pt's plasma osmolality is measured during a routine visit. It is found to
be normal. What value do you expect to see? 285295 mOsm/kg "<img
src=""8304.png"">" fluid-compartments physiology renal
Is the concentration of K+ higher intracellularly or extracellularly?
Intracellularly (HIKIN': HIgh K+ INtracellularly) "<img src=""8304.png"">"
fluid-compartments physiology renal
Of the extracellular fluid, what percentage is interstitial fluid, and what
percentage is plasma? 75%; 25% "<img src=""8304.png"">" fluid-compartments
physiology renal
Of the extracellular fluid in a 70-kg man, what are the volume and mass of
interstitial fluid, and what are the volume and mass of plasma? Interstitial
fluid: 10.5 L and 10.5 kg; plasma: 3.5 L and 3.5 kg "<img src=""8304.png"">"
fluid-compartments physiology renal
What is the volume of water contained within RBCs in the intracellular fluid of a
70-kg man? 2.8 L "<img src=""8304.png"">" fluid-compartments physiology renal
What is the total blood volume of an average 70-kg man? Of this volume, what
percentage is hematocrit (HCT)? How is HCT calculated? 6 L; 45%; HCT (%) ~
3[Hb] in g/dL "<img src=""8304.png"">" fluid-compartments physiology renal
Glomerular fenestrated capillary endothelium filters plasma by what parameter? The
fused basement membrane filters it by what parameter? Epithelium: by size; basement
membrane: by charge "<img src=""8305.png"">" glomerular-filtration-barrier
physiology renal
Which polysaccharide is contained in the renal glomerular basement membrane? How
does it filter plasma? Heparan sulfate; it filters plasma via its negative charge
(blocks albumin filtration) "<img src=""8305.png"">" glomerular-filtration-
barrier physiology renal
What are the three components of the glomerular filtration barrier? How does each
contribute to the filtration function of the glomerulus? Fenestrated capillary
endothelium (size), fused basement membrane with heparan sulfate (neg charge,
size), epithelial layer (neg charge) "<img src=""8305.png"">" glomerular-
filtration-barrier physiology renal
A pt presents with edema. Labs show albuminuria, hypoproteinemia, and
hyperlipidemia. What has happened to the pt's glomeruli? The glomeruli have lost
the charge barrier, resulting in nephrotic syndrome and loss of protein (namely
albumin) "<img src=""8305.png"">" glomerular-filtration-barrier physiology
renal
What is clearance? With what unit of measurement is it expressed? The volume
of plasma from which a substance is completely cleared per unit of time; measured
in milliliters per minute (mL/min) "<img src=""8306.png"">" physiology renal
renal-clearance
What is the formula for calculating the clearance of substance X, the volume of
plasma cleared completely of X per unit of time? Clearance of X = Urine
concentration of X (mg/mL) urine flow rate (mL/min) divided by plasma
concentration of X (mg/mL) (Cx = Ux V/Px) "<img src=""8306.png"">"
physiology renal renal-clearance
If renal clearance is less than the glomerular filtration rate of substance X, will
there be net tubular reabsorption or secretion of X? Reabsorption "<img
src=""8306.png"">" physiology renal renal-clearance
If renal clearance is greater than the glomerular filtration rate of substance X,
will there be net tubular reabsorption or secretion of X? Secretion "<img
src=""8306.png"">" physiology renal renal-clearance
X is measured in a pt. Plasma level (Px) = 100 mg/mL; urine level (Ux) = 200 mg/mL;
urine flow (V) = 1 mL/min. What is X's clearance (Cx)? 2 mL/min: Cx (mL/min) =
(Ux V)/Px = (200 mg/mL 1 mL/min)/100 mg/mL = 2 mL/min "<img src=""8306.png"">"
physiology renal renal-clearance
In a pt, Y's clearance (Cy) is 3 mL/min. He voids 3 mL/min. Plasma level (PY) is 5
mg/mL. What is the urine level of substance Y (Uy)? 5 mg/mL: Knowing CY = (UY
V)/PY: UY = (CYY "<img src=""8306.png"">" physiology renal renal-clearance
If renal clearance is equal to the glomerular filtration rate of substance X, is
there net tubular secretion or reabsorption of X? Neither. Because clearance is
equal to glomerular filtration rate, there is neither net secretion nor net
reabsorption "<img src=""8306.png"">" physiology renal renal-clearance
What is the unit of measurement for the glomerular filtration rate (GFR)? Volume
over time, usually measured in milliliters per minute (mL/min), similar to
clearance "<img src=""8307.png"">" glomerular-filtration-rate physiology
renal
Which endogenous substance and which exogenous substance are commonly used to
calculate GFR? What is a normal GFR value? Inulin (exogenous); creatinine
(endogenous, yields slight overestimate due to secretion); 100 mL/min "<img
src=""8307.png"">" glomerular-filtration-rate physiology renal
Inulin is infused into a pt to assess renal function. What can it be used to
measure and how? Inulin clearance (GFR = urine inulin concentration times urine
flow rate divided by plasma inulin concentration [Uinulin V/Pinulin]) "<img
A man receives inulin (I). Plasma level (PI) = 2 mg/mL, urine level (UI) = 250
mg/mL, urine flow (V) = 1 mL/min. Calculate his GFR (mL/min). GFR = CI (mL/min)
= (UI V)/PI = (250 mg/mL 1 mL/min)/2 mg/mL = 125 mL/min"<img src=""8307.png"">"
glomerular-filtration-rate physiology renal
Is creatinine clearance an accurate estimate of GFR? Why or why not? No, it
overestimates GFR; after filtration, some is secreted into the renal tubules "<img
Which formula calculates the glomerular filtration rate (GFR) by relating the
glomerular capillary (GC) and Bowman space (BS) pressures? GFR = Kf [(PGC PBS)
(GC BS)], where Kf = filtration constant; P = hydrostatic pressure difference;
= oncotic pressure difference "<img src=""8307.png"">" glomerular-
filtration-rate physiology renal
Do reductions or elevations in GFR define the stages of chronic kidney disease?
Reductions "<img src=""8307.png"">" glomerular-filtration-rate
physiology renal
Which substance's clearance is used to estimate renal plasma flow? Why? Para-
aminohippuric acid (PAH); 100% of PAH is actively secreted from the proximal tubule
into the urine (renal vein PAH concentration = 0) "<img src=""8308.png"">"
effective-renal-plasma-flow physiology renal
What is the formula for estimating the effective renal plasma flow (eRPF) using
para-aminohippuric acid (PAH)? eRPF = urine PAH concentration times the urine
flow rate divided by the plasma PAH concentration (UPAH V/PPAH) "<img
src=""8308.png"">" effective-renal-plasma-flow physiology renal
What is the formula for estimating renal blood flow (RBF) if renal plasma flow
(RPF) is known? RBF = RPF divided by (1 Hct) (Normally, RBF is double the RPF.)
"<img src=""8308.png"">" effective-renal-plasma-flow physiology renal
You infuse para-aminohippuric acid (PAH) into a pt. An hour later, you still detect
a trace of PAH in the pt's blood. Why? Ten percent of renal blood flow goes to
the kidney parenchyma rather than through the glomerulus; PAH in this blood is not
filtered "<img src=""8308.png"">" effective-renal-plasma-flow physiology
renal
Is effective renal plasma flow a good estimate of true renal plasma flow? Why or
why not? It underestimates true renal plasma flow by 10%, since 10% of renal
blood flow supplies the kidney parenchyma "<img src=""8308.png"">" effective-
renal-plasma-flow physiology renal
A man receives PAH. Plasma level (PPAH) = 2 mg/mL, urine level (UPAH) = 550 mg/mL,
urine flow (V) = 4 mL/min. What is his eRPF? 1100 mL/min; eRPF = CPAH (mL/min) =
(UPAH V)/PPAH = (550 4)/2 = 1100 mL/min "<img src=""8308.png"">"
effective-renal-plasma-flow physiology renal
A man receives PAH. His eRPF is estimated to be 1000 mL/min. With a hematocrit
(Hct) of 50%, what is his RBF (mL/min)? RBF = RPF/(1 Hct) = 1100 mL/min/(1
0.5) = 2200 mL/min (Remember eRPF underestimates RPF by approximately 10%.) "<img
src=""8308.png"">" effective-renal-plasma-flow physiology renal
How is the filtration fraction for a molecule determined? What is the expected
filtration fraction in a healthy individual? By determining the ratio of the
glomerular filtration rate to renal plasma flow; it is normally around 20% "<img
src=""8309.png"">" filtration physiology renal
Prostaglandins are infused into a rat's renal arteries. What effects do they have
on the glomeruli? What drug class can block them? They preferentially dilate
afferent arterioles, increasing both the GFR and the RPF to keep the filtration
fraction constant; NSAIDs "<img src=""8309.png"">" filtration physiology
renal
Angiotensin II (AT II) is infused into a rat's renal arteries. What effects does it
have on the glomeruli? What drug class can block it? AT II preferentially
constricts efferent arterioles, increasing GFR and decreasing RPF to increase
filtration fraction; ACE inhibitors "<img src=""8309.png"">" filtration
physiology renal
How do prostaglandins affect renal plasma flow, GFR, and filtration fraction?
They increase both renal plasma flow and GFR but cause no change in
filtration fraction "<img src=""8309.png"">" filtration physiology renal
In terms of filtration in the glomerulus, the filtered load is equal to the
glomerular filtration rate multiplied by what? The plasma concentration "<img
src=""8309.png"">" filtration physiology renal
How does angiotensin II affect renal plasma flow, GFR, and filtration fraction?
It decreases renal plasma flow, increases GFR, and increases filtration
fraction "<img src=""8309.png"">" filtration physiology renal
A man takes an ACE inhibitor. How does its blockage of angiotensin II (AT II)
affect the filtration factor (FF)? FF decreases; renal plasma flow increases, and
the glomerular filtration rate decreases "<img src=""8309.png"">" filtration
physiology renal
A man takes several capsules of extra-strength ibuprofen. What effect does this
have on the afferent arterioles in his kidneys? NSAIDs block prostaglandins'
dilatory effect on afferent arterioles; thus his afferent arterioles constrict,
which decreases GFR and RPF "<img src=""8309.png"">" filtration physiology
renal
A pt's GFR is 125 mL/min, and RPF is 500 mL/min. What is the filtration fraction
(FF)? FF = GFR/RPF = (125 mL/min)/(500 mL/min) = 0.25 = 25%"<img src=""8309.png"">"
filtration physiology renal
After a pt with a GFR of 125 mL/min takes a drug, a plasma concentration of 10
mg/mL is measured. What is the filtered load? Filtered load = GFR plasma
concentration = 125 mL/min 10 mg/mL = 1250 mg/min "<img src=""8309.png"">"
filtration physiology renal
The clearance of which substance can estimate GFR? RPF? GFR: creatinine; RPF:
PAH "<img src=""8309.png"">" filtration physiology renal
Describe the effects of afferent arteriole constriction on renal plasma flow,
glomerular filtration rate, and filtration fraction. Renal plasma flow decreases;
glomerular filtration rate decreases; filtration fraction does not change "<img
src=""8310.png"">" changes-in-glomerular-dynamics physiology renal
Describe the effects of efferent arteriole constriction on renal plasma flow,
glomerular filtration rate, and filtration fraction. Renal plasma flow decreases;
glomerular filtration rate increases; filtration fraction increases "<img
Describe the effects of elevated plasma protein concentration on renal plasma flow,
glomerular filtration rate, and filtration fraction. Renal plasma flow does not
change; glomerular filtration rate decreases; filtration fraction decreases "<img
Describe the effects of reduced plasma protein concentration on renal plasma flow,
glomerular filtration rate, and filtration fraction. Renal plasma flow does not
change; glomerular filtration rate increases; filtration fraction increases "<img
Describe the effects of ureter constriction on renal plasma flow, glomerular
filtration rate, and filtration fraction. Renal plasma flow does not change;
glomerular filtration rate decreases; filtration fraction decreases "<img
Describe the effects of dehydration on renal plasma flow, glomerular filtration
rate, and filtration fraction. Renal plasma flow decreases; glomerular
filtration rate decreases; filtration fraction increases "<img src=""8310.png"">"
changes-in-glomerular-dynamics physiology renal
What is the formula for filtered load? Filtered load = glomerular filtration
rate PX (PX is the plasma concentration of X.) "<img src=""8311.png"">"
calculation-of-reabsorption-and-secretion-rate physiology renal
What is the formula for excretion rate? Excretion rate = V UX, where V is the
urine flow rate and UX is the urine concentration of X "<img src=""8311.png"">"
With respect to kidney fluid dynamics, excess filtration, compared with excretion,
leads to what? Reabsorption "<img src=""8311.png"">" calculation-of-
reabsorption-and-secretion-rate physiology renal
A pt's GFR is 125 mL/min, and plasma concentration of substance X is 20 mg/mL. What
is the filtered load of X? 2500 mg/min: Filtered load = GFR plasma
concentration = 125 mL/min 20 mg/mL = 2500 mg/min "<img src=""8311.png"">"
A pt's urine flow (V) is 5 mL/min. X is found in his urine at a concentration of
1000 mg/mL (UX). Find the excretion rate. Excretion rate = V UX = 5 mL/min 1000
mg/mL = 5000 mg/min "<img src=""8311.png"">" calculation-of-reabsorption-
and-secretion-rate physiology renal
For X, a pt's filtered load is 100 mg/min, and excretion rate is 200 mg/min. Is X
reabsorbed or secreted? Secreted (secretion rate = excreted filtered = 200 mg/min
100 mg/min = 100 mg/min) "<img src=""8311.png"">" calculation-of-
For Y, a pt's filtered load is 30 mg/min, and excretion rate is 20 mg/min. Is Y
reabsorbed or secreted? Reabsorbed (reabsorption rate = filtered excreted = 30
mg/min 20 mg/min = 10 mg/min) "<img src=""8311.png"">" calculation-of-
In the nephron, what happens to glucose in the proximal tubule? Glucose is fully
reabsorbed in the proximal tubule (if serum glucose levels are less than 375 mg/dL)
via Na+/glucose cotransporters. "<img src=""8312.png"">" glucose-clearance
physiology renal
When plasma glucose levels exceed 200 mg/dL, what finding may be seen on
urinalysis? What disease process is usually suspected? Glucosuria, because
proximal tubule glucose reabsorption mechanisms cannot keep up with the elevated
glucose load; diabetes mellitus "<img src=""8312.png"">" glucose-clearance
physiology renal
A diabetic's blood sugar is 275 mg/dL; the urine is positive for glucose. Can
proximal tubule pumps handle further blood sugar increases?Yes, the glucose
threshold of 200 mg/dL has been passed, but the transporters are not fully
saturated (Tm) until the level passes 375 mg/dL "<img src=""8312.png"">"
glucose-clearance physiology renal
Glucosuria and aminoaciduria develop in a pregnant woman. Do you immediately
diagnose diabetes? No, normal pregnancy decreases reabsorption of glucose and
amino acids in the proximal tubule, resulting in glucosuria and aminoaciduria
"<img src=""8312.png"">" glucose-clearance physiology renal
What substance is secreted into the lumen of the early proximal convoluted tubule
of the kidney and acts as a buffer for hydrogen (H+) ions? Ammonia (NH3) "<img
src=""8313.png"">" nephron-physiology physiology renal
What substances are largely reabsorbed in the early proximal convoluted tubule?
All glucose and amino acids and most bicarbonate, sodium, chloride,
potassium, phosphate, and water "<img src=""8313.png"">" nephron-physiology
physiology renal
What is the tonicity of the reabsorption of glucose, amino acids, HCO3, Na+, Cl,
PO43, and H2O in the proximal tubule? Isotonic "<img src=""8313.png"">"
nephron-physiology physiology renal
In a study, radiolabeled angiotensin II (AT II) is found in high concentrations in
the early proximal convoluted tubules (PCTs). Why? AT II stimulates Na+/H+ ion
exchange, increasing sodium, water, and bicarbonate reabsorption and permitting
contraction alkalosis "<img src=""8313.png"">" nephron-physiology physiology
renal
A hiker high up on a mountain is delirious. What mechanism makes acetazolamide a
treatment? Will his urine be acidic or alkalotic? It is useful in altitude
sickness because it blocks the uptake of bicarbonate via inhibition of carbonic
anhydrase; urine will be alkalotic "<img src=""8313.png"">" nephron-physiology
physiology renal
Can Na+ be reabsorbed in the thin loop of Henle? What is the effect on urine
osmolarity? No, the thin loop is impermeable to Na+) but permeable to water, so
urine becomes hypertonic "<img src=""8313.png"">" nephron-physiology
physiology renal
Which portion of the loop of Henle is permeable to water? Which portion is
impermeable? The thin portion is permeable; the thick portion is impermeable
"<img src=""8313.png"">" nephron-physiology physiology renal
On which segment of the kidney nephron do the hormones aldosterone and antidiuretic
hormone (vasopressin) act? The collecting tubules "<img src=""8313.png"">"
What type of cell in the collecting tubule of a nephron is responsible for
sodium/potassium exchange and the reabsorption of water? The principal cell
"<img src=""8313.png"">" nephron-physiology physiology renal
A pt taking lithium loses aquaporin-linked receptor function in renal principal
cells. Which hormone normally binds to these receptors? Antidiuretic hormone
(ADH) normally binds to V2 receptors on principal cells "<img src=""8313.png"">"
Early PCT fluid tonicity is measured in a pt. He is healthy and not taking
medication. Is the fluid hypertonic, isotonic, or hypotonic? Isotonic "<img
What happens to the osmolarity of urine as it passes through the thick loop of
Henle? It becomes hypotonic (diluted) "<img src=""8313.png"">"
What happens to the osmolarity of urine as it passes through the early distal
convoluted tubule? It is diluted (becomes hypotonic) "<img src=""8313.png"">"
What is aldosterone's main action at the collecting tubules? It acts on
mineralocorticoid receptors and inserts sodium channels, thereby reabsorbing sodium
and secreting potassium and hydrogen "<img src=""8313.png"">" nephron-
physiology physiology renal
In what action does antidiuretic hormone (ADH) activity at V2 receptors result?
Insertion of aquaporin water channels on the luminal side of the collecting
tubules, resulting in increased water reabsorption "<img src=""8313.png"">"
What hormone inhibits the sodium/phosphate cotransporter in the early PCT?
Parathyroid hormone (to increase phosphate excretion)"<img src=""8313.png"">"
What indirectly induces the paracellular absorption of magnesium and calcium at the
thick ascending loop of Henle? Positive lumen potential generated by potassium
backleak "<img src=""8313.png"">" nephron-physiology physiology renal
What percentage of nephron lumen sodium is reabsorbed in the early PCT? The thick
ascending tubule? The early DCT? The collecting tubule? Early PCT: 65%80%;
thick ascending tubule: 10%20%; early DCT: 5%10%; collecting tubule: 3%5% "<img
How does aldosterone affect principal cells? It increases apical K+ conductance,
increases Na+/K+ pump activity, and increases ENaC channels, leading to lumen
negativity and K+ loss "<img src=""8313.png"">" nephron-physiology physiology
renal
How does aldosterone affect -intercalated cells? It increases H+ ATPase
activity, leading to increased HCO3/Cl exchanger activity"<img src=""8313.png"">"
A pt ingests a toxin that interferes with protein synthesis. Will the kidneys be
able to utilize aldosterone effectively? No, aldosterone binding acts by
increasing mRNA production and protein synthesis, so such a toxin would interfere
with its function "<img src=""8313.png"">" nephron-physiology physiology renal
What is the effect of PTH on the early DCT? It increases activity of the
sodium/calcium exchanger between the blood and the DCT cells, thereby promoting
calcium uptake from the lumen "<img src=""8313.png"">" nephron-physiology
physiology renal
In terms of ion processing, what is the main function of -intercalated cells?
They secrete H+ into the urine (and take up K+ from it), promoting HCO3
release into the blood (in exchange for Cl) "<img src=""8313.png"">"
In terms of ion processing, what is the main function of -intercalated cells?
-Intercalated cells secrete HCO3- into the urine (and take up Cl from it),
promoting H+ release into the blood "<img src=""8313.png"">" nephron-physiology
physiology renal
In the early DCT, which ion diffuses from the urine into the blood as a result of
transporter activity? Chloride "<img src=""8313.png"">" nephron-physiology
physiology renal
In the thick ascending tubule of Henle, which two ions diffuse from the urine into
the blood down their electrochemical gradient? Chloride and potassium "<img
In the collecting tubule, which ion diffuses from the urine into the blood
passively? Chloride "<img src=""8313.png"">" nephron-physiology physiology
renal
Which three ions are actively taken up by the thick ascending loop of Henle?
Sodium, potassium, and chloride "<img src=""8313.png"">" nephron-
How does 11-hydroxysteroid dehydrogenase in mineralocorticoid receptor-containing
cells help regulate blood pressure and electrolytes? It converts cortisol into
cortisone in these cells before the cortisol can act on the mineralocorticoid
receptors (mimics aldosterone) "<img src=""8314.png"">" physiology renal
renal-tubular-defects
What are the prominent serum and urine electrolyte abnormalities seen in Bartter
syndrome? Hypokalemia, metabolic alkalosis (blood), and hypercalciuria "<img
src=""8314.png"">" physiology renal renal-tubular-defects
What are the prominent serum electrolyte abnormalities seen in Liddle syndrome?
Hypokalemia and metabolic alkalosis "<img src=""8314.png"">" physiology
renal renal-tubular-defects
A man with a collecting tubule gain of function mutation has hypertension despite
low serum aldosterone. Too much of what ion is reabsorbed? Sodium, as this is
Liddle syndrome "<img src=""8314.png"">" physiology renal renal-tubular-
defects
A man has hypertension. Serum studies reveal hypokalemia and metabolic alkalosis.
Aldosterone is low. Could this disorder be acquired? Yes, these findings are
consistent with 11-hydroxysteroid dehydrogenase deficiency (SAME), which may be
acquired from glycyrrhetinic acid "<img src=""8314.png"">" physiology renal
A pt with Wilson disease has a low body pH. Urine studies show elevated protein and
glucose. Where in the kidney is the likely defect? A PCT reabsorptive defect
causes HCO3, PO43, amino acid, and glucose losses in urine (This is Fanconi
syndrome due to Wilson disease.) "<img src=""8314.png"">" physiology renal
A man with lymphoma received an excess of cyclophosphamide at his last chemotherapy
session and now has a metabolic acidosis. What happened? The nephrotoxic
cyclophosphamide has caused Fanconi syndrome (reabsorptive defect in the PCT that
results in metabolic acidosis) "<img src=""8314.png"">" physiology renal
A pt with an autosomal recessive disease has hypokalemia, elevated body pH, and
hypercalciuria. Where is the defect in his kidneys? In the thick ascending loop
of Henle (The pt has Bartter syndrome.) "<img src=""8314.png"">" physiology
renal renal-tubular-defects
Bartter syndrome is a reabsorptive defect in the thick ascending loop of Henle.
Which cotransporter does it affect? The Na+/K+/2Cl cotransporter "<img
src=""8314.png"">" physiology renal renal-tubular-defects
Gitelman syndrome is a defect of reabsorption of which substance in the DCT? NaCl
"<img src=""8314.png"">" physiology renal renal-tubular-defects
A man with an autosomal recessive disorder presents with hypokalemia and a high
body pH but a normal urine calcium level. Diagnosis? Gitelman syndrome (High
calcium in the urine is seen with Bartter syndrome.) "<img src=""8314.png"">"
physiology renal renal-tubular-defects
A pt with chronic HTN has low K+ levels. He has an autosomal dominant kidney
disorder affecting the collecting tubules. Treatment? Amiloride (The pt has Liddle
syndrome.) "<img src=""8314.png"">" physiology renal renal-tubular-defects
Liddle syndrome is an increase in Na+ reabsorption in which region of the nephron?
Collecting tubules "<img src=""8314.png"">" physiology renal renal-
tubular-defects
A pt has hypokalemia and a metabolic alkalosis. Aldosterone is low, and blood
pressure is high. Is this an ion channel issue? Yes, this combination of findings
is consistent with Liddle syndrome, with abnormally increased renal sodium channel
activity "<img src=""8314.png"">" physiology renal renal-tubular-defects
"A black licorice ""addict"" has HTN, low K+, and a metabolic acidosis. To what
hereditary deficiency is this condition similar?" A hereditary deficiency of
11-hydroxysteroid dehydrogenase (syndrome of apparent mineralocorticoid excess)
"<img src=""8314.png"">" physiology renal renal-tubular-defects
Name some causes of Fanconi syndrome. Wilson disease, tyrosinemia, glycogen
storage disease, cystinosis, ischemia, multiple myeloma, nephrotoxins/drugs, lead
poisoning "<img src=""8314.png"">" physiology renal renal-tubular-defects
What are the prominent serum and urine electrolyte abnormalities seen in Gitelman
syndrome? Hypokalemia, hypomagnesemia, metabolic alkalosis (blood), and
hypocalciuria (urine) "<img src=""8314.png"">" physiology renal renal-
tubular-defects
Para-aminohippuric acid (PAH), unlike inulin, is pumped into renal tubules. How
does its tubular fluid/plasma ratio compare with inulin's? Higher (Concentration of
PAH increases because of both water reabsorption and active secretion into the
tubule by proximal tubule cells.) "<img src=""8315.png"">" physiology
relative-concentrations-along-proximal-convoluted-tubules renal
The tubular fluid to plasma ratio for amino acids and glucose is less than that of
inulin. What likely happens to them in the PCT? Net reabsorption "<img
src=""8315.png"">" physiology relative-concentrations-along-proximal-
convoluted-tubules renal
The Na+ concentration along the length of the proximal tubule remains constant. Is
it being secreted, reabsorbed, or neither? Reabsorbed "<img src=""8315.png"">"
physiology relative-concentrations-along-proximal-convoluted-tubules renal
Reabsorption of which electrolyte drives water reabsorption, nearly matching total
osmolarity throughout the length of the proximal tubule? Sodium "<img
HCO3 concentration along the length of the proximal tubule decreases. Is it being
secreted, reabsorbed, or neither? Reabsorbed (HCO3 is reabsorbed more avidly
than most other ions.) "<img src=""8315.png"">" physiology relative-
concentrations-along-proximal-convoluted-tubules renal
In a mouse model, nephron inulin concentrations throughout the PCT are measured.
Distally, they rise. Is this secretion? No, inulin concentration increases as a
result of water reabsorption (concentration); the raw amount is constant "<img
In mouse nephrons, Na+ and Cl are measured throughout the PCT. Moving distally,
how do the concentrations compare? Distally, the Cl concentration plateaus and
parallels Na+; proximally, relative concentration of Cl#8722; increases vs Na+
"<img src=""8315.png"">" physiology relative-concentrations-along-
proximal-convoluted-tubules renal
Under what condition will the tubular fluid to plasma ratio (TF/P) of a solute be
greater than 1? When the solute is reabsorbed less quickly than water"<img
less than 1? When the solute is reabsorbed more quickly than water"<img
equal to 1? When the solute is reabsorbed at the same rate as water "<img
What five actions of angiotensin II increase intravascular volume and blood
pressure? Vasoconstriction, increased PCT Na+ reabsorption, adrenal cortex
aldosterone release, pituitary ADH release, thirst (drinking more water) "<img
src=""8316.png"">" physiology renal renin-angiotensin-aldosterone-system
A pt is found to have decreased renin activity. Where is the first substrate of the
RAAS pathway synthesized? The liver synthesis angiotensinogen, which is
normally converted by renin to angiotensin I "<img src=""8316.png"">"
physiology renal renin-angiotensin-aldosterone-system
What are the two main sources of angiotensin-converting enzyme (ACE)? What is their
effect on angiotensin I? Lung and kidney epithelia; they cleave angiotensin I
into angiotensin II "<img src=""8316.png"">" physiology renal renin-
angiotensin-aldosterone-system
For unknown reasons, a hospitalized pt has a high plasma renin level. An attending
asks you for causes. What four responses could you give? A decrease in blood
pressure, a decrease in distal Na+ macula densa delivery, an increase in
sympathetic tone, or a renin-secreting tumor "<img src=""8316.png"">"
physiology renal renin-angiotensin-aldosterone-system
A rat is injected with angiotensin II. This stimulates release of aldosterone from
where? The adrenal gland "<img src=""8316.png"">" physiology renal renin-
What is the influence of ADH and aldosterone on blood volume and serum osmolarity?
ADH regulates osmolarity; aldosterone regulates blood volume "<img
A pt is in hemorrhagic shock with iso-osmolar volume loss. What will serum levels
of aldosterone and ADH be? Both will be high because they rise in states of
severe volume depletion "<img src=""8316.png"">" physiology renal renin-
What hormone, released from the atria, may act as a check on the renin-angiotensin
system to prevent volume overload? Atrial natriuretic peptide (ANP) "<img
How does aldosterone secretion from the adrenal gland create favorable conditions
for salt and water retention? It increases the number of luminal sodium channels
and basolateral sodium-potassium antiporters, and water passively follows sodium
influx "<img src=""8316.png"">" physiology renal renin-angiotensin-
aldosterone-system
What is the effect of atrial natriuretic peptide (ANP) on renin secretion? It
decreases renin secretion "<img src=""8316.png"">" physiology renal renin-
An experimental drug blocks the activity of atrial natriuretic peptide (ANP). How
does this affect the glomerular filtration rate (GFR)? It decreases the GFR,
because dilation of afferent arterioles (action of ANP) is inhibited "<img
Describe how changes in serum sodium lead to renin release.Decreased Na+ delivery
to the macula densa triggers renin release from the juxtaglomerular apparatus
"<img src=""8316.png"">" physiology renal renin-angiotensin-aldosterone-
system
What hormone, released by the ventricles, acts very similarly to ANP? By way of
what second messenger system do both of these hormones act?BNP; via cGMP (which
relaxes smooth muscle) "<img src=""8316.png"">" physiology renal renin-
Which hormone in the renin-angiotensin-aldosterone system alters baroreceptor
responses to prevent reflex bradycardia? Angiotensin II (Otherwise, the increase
in blood pressure caused by angiotensin II would lead to a slower heart rate.)
"<img src=""8316.png"">" physiology renal renin-angiotensin-aldosterone-
system
A drug blocks AT II production, causing bradykinin-induced flushing. How is AT II
inhibited, and why is bradykinin increased? Via an angiotensin-converting
enzyme (ACE) inhibitor; ACE, which breaks down bradykinin, is blocked by ACE
inhibitors, so bradykinin rises "<img src=""8316.png"">" physiology renal
renin-angiotensin-aldosterone-system
How does angiotensin II (AT II) promote contraction alkalosis? It increases PCT
Na+/H+ activity, promoting reabsorption of HCO3, Na+, and water, ultimately
promoting contraction alkalosis "<img src=""8316.png"">" physiology renal
renin-angiotensin-aldosterone-system
Name the three stimuli that upregulate renin activity. Decreased BP (detected
by JG cells), decreased Na+ delivery to macula densa, increased sympathetic tone
via 1-receptors "<img src=""8316.png"">" physiology renal renin-angiotensin-
aldosterone-system
In response to a decrease in renal arterial pressure and an increase in renal
sympathetic discharge (1), which cells secrete renin? JG cells "<img
Juxtaglomerular cells in the juxtaglomerular apparatus are modified smooth muscle
cells of what arteriole of the glomerular vasculature? The afferent arteriole
"<img src=""8317.png"">" juxtaglomerular-apparatus physiology renal
What effect will decreased NaCl delivery to the DCT have on the macula densa cells
and juxtaglomerular apparatus? Decreased NaCl leads to adenosine release and
afferent arteriole vasoconstriction "<img src=""8317.png"">" juxtaglomerular-
apparatus physiology renal
Name at least two triggers of renin release by the juxtaglomerular cells.
Decrease in renal blood pressure, decrease in sodium delivery to the distal
tubule, increase in sympathetic tone (1) "<img src=""8317.png"">"
juxtaglomerular-apparatus physiology renal
What are the results of renin release by the juxtaglomerular cells? Angiotensin
II and aldosterone levels increase, leading to increased NaCl retention,
circulating volume, and blood pressure "<img src=""8317.png"">"
juxtaglomerular-apparatus physiology renal
A pt starts taking a -blocker. Later, serum levels of renin are noted to be
unusually low. Why is this the case? 1-Receptor activity stimulates renin
release, and the new -blocker is likely interfering with this "<img
src=""8317.png"">" juxtaglomerular-apparatus physiology renal
Name four key hormones/enzymes released by the kidney that contribute to its
endocrine function. Erythropoietin, 1,25-(OH)2 vitamin D, renin, and
prostaglandins "<img src=""8318.png"">" kidney-endocrine-functions
physiology renal
In mice, hypoxia is induced, and kidney hormone secretion is measured. Which
hormone has a direct effect of counterbalancing the hypoxia? Erythropoietin
(released by the endothelial cells of renal peritubular capillaries in response to
hypoxia) to increase RBC production "<img src=""8318.png"">" kidney-endocrine-
functions physiology renal
What enzyme from the kidney is activated by parathyroid hormone, and what is the
function of that enzyme? 1-Hydroxylase; it converts 25-OH vitamin D to 1,25-
(OH)2 vitamin D "<img src=""8318.png"">" kidney-endocrine-functions
physiology renal
How do prostaglandins affect the glomerular filtration rate? Which drug type can
cause acute renal failure by inhibiting prostaglandins? Prostaglandins increase
renal blood flow by dilating the afferent arterioles; NSAIDs "<img
src=""8318.png"">" kidney-endocrine-functions physiology renal
A man with chronic back pain starts taking daily NSAIDs. What is the effect of this
drug on the afferent arteriole of the kidney glomerulus? Prevention of the
vasodilation of the afferent arterioles by prostaglandins, reducing the glomerular
filtration rate "<img src=""8318.png"">" kidney-endocrine-functions
physiology renal
What are the direct and indirect effects of parathyroid hormone on the kidneys?
Direct: increased renal Ca2+ reabsorption, decreased renal phosphate
reabsorption; indirect: increased 1,25-(OH)2 vitamin D production "<img
A man with chronic renal failure presents with severe anemia. Administration of
which kidney hormone should increase red blood cell count? Erythropoietin "<img
A pt with chronic kidney disease is told to take NSAIDs. As the pt's doctor, you
stop the medication right away. Why? NSAIDs block renal-protective
prostaglandin synthesis (afferent arteriole constricts, RBF drops), which may
result in acute renal failure "<img src=""8318.png"">" kidney-endocrine-
functions physiology renal
Which nephron cells secrete dopamine? What is its effect at low doses? Higher
doses? PCT cells; it increases RBF through dilation of afferent, efferent, &
interlobular vessels at low doses; it vasoconstricts at higher doses "<img
A pt is given a drug that acts at the collecting tubules to increase water
reabsorption. What hormone does this drug mimic? The drug is desmopressin,
which mimics ADH to insert aquaporins in principal cell membranes and increase the
reabsorption of free water "<img src=""8319.png"">" hormones-acting-on-
kidney physiology renal
A pt is given a drug that antagonizes the effects of a hormone that increases
nephron water channels. On which cell type does this drug act? Principal cells;
the drug is of the vaptan class, which inhibits the effect of ADH "<img
src=""8319.png"">" hormones-acting-on-kidney physiology renal
What is the effect of atrial natriuretic peptide (ANP) on the kidney's glomerular
filtration rate (GFR) and sodium excretion? Both GFR and Na+ filtration
increase, but there is no compensatory Na+ reabsorption in the distal nephron
"<img src=""8319.png"">" hormones-acting-on-kidney physiology renal
On what segment of the nephron does aldosterone primarily exert its effects?
Collecting tubules "<img src=""8319.png"">" hormones-acting-on-
On what segments of the nephron does parathyroid hormone (PTH) exert its effects?
The proximal and distal convoluted tubules, increasing calcium reabsorption
and phosphate secretion "<img src=""8319.png"">" hormones-acting-on-kidney
physiology renal
What is a major difference between the actions of angiotensin II (AT II) and atrial
natriuretic peptide (ANP)? AT II promotes proximal and distal nephron Na+
reabsorption, whereas ANP does not "<img src=""8319.png"">" hormones-acting-
on-kidney physiology renal
What is the effect of angiotensin II (AT II) on the glomerular filtration rate
(GFR) and therefore the filtration fraction (FF)? AT II constricts the efferent
arterioles, increasing GFR and FF; there is a compensatory increase in Na+
reabsorption in the nephron "<img src=""8319.png"">" hormones-acting-on-
What are aldosterone's main effects on the kidney? It increases Na+
reabsorption, indirectly increases K+ secretion, and increases H+ secretion "<img
src=""8319.png"">" hormones-acting-on-kidney physiology renal
A pt is bleeding and hypotensive. How does angiotensin II (AT II) slow additional
volume loss while preserving kidney function? AT II constricts the efferent
arterioles, increasing GFR and FF, with compensatory Na+ reabsorption in the
proximal and distal nephrons "<img src=""8319.png"">" hormones-acting-on-
Which vitamin does parathyroid hormone (PTH) help convert to an active form, and
what is the effect of this vitamin? 1,25-(OH)2 vitamin D3, which increases both
calcium and PO43 absorption from the gut "<img src=""8319.png"">" hormones-
acting-on-kidney physiology renal
What effect does ADH exert on the number of aquaporins, and therefore water
reabsorption, in the nephron collecting tubules? Antidiuretic hormone (ADH)
increases the number of water channels (aquaporins) and thus increases water
reabsorption "<img src=""8319.png"">" hormones-acting-on-kidney
physiology renal
Name six things that can cause hyperkalemia by promoting a shift of potassium out
of cells. Digitalis, hyperOsmolarity, Lysis of cells, Acidosis, -blocker, high
blood Sugar (insulin deficiency) (DO LAS) "<img src=""8320.png"">"
physiology potassium-shifts renal
Name four things that can cause hypokalemia by promoting a shift of potassium into
cells. -Adrenergic agonists (via Na+/K+ ATPase), alkalosis, hypo-osmolarity,
and insulin (via Na+/K+ ATPase) (Insulin shifts K+ into cells.) "<img
src=""8320.png"">" physiology potassium-shifts renal
A pt overdoses on insulin. What would you expect his serum K+ level to be? Low,
because insulin drives K+ into the cell, causing hypokalemia. (Insulin shifts K+
into cells.) "<img src=""8320.png"">" physiology potassium-shifts renal
By what mechanism does insulin cause potassium shifts across cellular membranes?
Insulin stimulates Na+/K+ ATPase to pump K+ into the cell in exchange for Na+
transfer out of the cell "<img src=""8320.png"">" physiology potassium-
shifts renal
By what mechanism does stimulation of the -adrenergic system cause hypokalemia?
By stimulating the Na+/K+ ATPase to pump K+ into the cell in exchange for Na+
transfer out of the cell "<img src=""8320.png"">" physiology potassium-
shifts renal
A pt is in diabetic ketoacidosis with high serum potassium. How should you manage
his potassium after insulin has been given? Low insulin causes K+ to shift out
of cells, which is lost in urine; total K+ is low despite high serum K+, so
supplemental K+ is needed "<img src=""8320.png"">" physiology potassium-
shifts renal
A man with lung cancer has altered consciousness from SIADH. If this is due to an
electrolyte imbalance, what other symptoms might be seen? Malaise, nausea, stupor,
and coma (all from hyponatremia) "<img src=""8321.png"">" electrolyte-
disturbances physiology renal
A pt with a history of renal disease and potato chip binges is delirious and
irritated. Which electrolyte imbalance do you suspect? Hypernatremia (high
serum sodium concentration), which causes such neurologic derangements as
irritability, delirium, and coma "<img src=""8321.png"">" electrolyte-
Paralysis develops in a pt with Conn syndrome. What do you expect to find on ECG?
U waves and flattened T waves, as the pt has hypokalemia "<img
src=""8321.png"">" electrolyte-disturbances physiology renal
What are the major symptoms of hypocalcemia? Seizures, tetany, and neuromuscular
irritability "<img src=""8321.png"">" electrolyte-disturbances physiology
renal
What are the major symptoms of hypomagnesemia? Hypokalemia, tetany, and torsades
de pointes "<img src=""8321.png"">" electrolyte-disturbances physiology renal
How do the manifestations of low and high phosphate levels differ? Low level:
bone loss, osteomalacia (adults), rickets (children); high level: hypocalcemia,
metastatic calcification, renal stones "<img src=""8321.png"">" electrolyte-
A pt in kidney failure misses dialysis, and mental status is altered. Labs show
hyperkalemia. What do you expect to see on ECG? Arrhythmias, peaked T waves,
widened QRS complexes (all signs of hyperkalemia), or all three "<img
A pt has labile potassium and is both hyper- and hypokalemic at different times.
What clinical findings will persist regardless? Arrhythmias and muscle weakness are
seen in both hyper- and hypokalemia "<img src=""8321.png"">" electrolyte-
A pt has renal stones and increased urinary frequency, bone pain, abdominal pain,
and psychosis. What electrolyte imbalance is present? Hypercalcemia, which presents
with stones, bones, groans, thrones, and psychiatric overtones "<img
What are the major symptoms of hypermagnesemia? Diminished DTRs, hypotension,
lethargy, hypocalcemia, bradycardia, cardiac arrest "<img src=""8321.png"">"
electrolyte-disturbances physiology renal
A pt has Bartter syndrome. What do you expect his blood pressure, plasma renin,
aldosterone, and urine Ca++ to be? Normal blood pressure, increased plasma renin
and aldosterone, increased urine calcium "<img src=""8322.png"">" features-of-
renal-disorders physiology renal
A pt has Gitelman syndrome. What do you expect his blood pressure, plasma renin,
aldosterone, serum Mg++, and urine Ca++ to be? Normal blood pressure, increased
plasma renin and aldosterone, decreased serum magnesium, decreased urine calcium
"<img src=""8322.png"">" features-of-renal-disorders physiology renal
A pt has Liddle syndrome. What do you expect his blood pressure, plasma renin
level, and aldosterone level to be? Increased blood pressure, decreased plasma
renin and aldosterone levels "<img src=""8322.png"">" features-of-renal-
disorders physiology renal
A pt has SIADH. What do you expect his blood pressure, plasma renin level, and
aldosterone level to be? Increased blood pressure, decreased plasma renin and
aldosterone levels "<img src=""8322.png"">" features-of-renal-disorders
physiology renal
A pt has Conn syndrome (primary hyperaldosteronism). What do you expect his blood
pressure, plasma renin level, and aldosterone level to be? Increased blood
pressure, decreased plasma renin level, increased aldosterone level "<img
src=""8322.png"">" features-of-renal-disorders physiology renal
A pt has a renin-secreting tumor. What do you expect his blood pressure, plasma
renin level, and aldosterone level to be? Increased blood pressure, increased
plasma renin and aldosterone levels "<img src=""8322.png"">" features-of-renal-
disorders physiology renal
Describe the PCO2 status, HCO3 status, and compensatory response of metabolic
acidosis. Decreased HCO3 (primary disturbance) leads to immediate
hyperventilation and decreased PCO2 "<img src=""8323.png"">" acid-base-
Describe the PCO2 status, HCO3 status, and compensatory response of metabolic
alkalosis. Increased HCO3 (primary disturbance) leads to immediate
hypoventilation and increased PCO2 "<img src=""8323.png"">" acid-base-
Describe the PCO2 status, HCO3 status, and compensatory response of respiratory
acidosis. Decreased ventilation leads to increased PCO2 with delayed compensatory
renal reabsorption of HCO3 "<img src=""8323.png"">" acid-base-physiology
physiology renal
Describe the PCO2 status, HCO3 status, and compensatory response of respiratory
alkalosis. Increased ventilation leads to decreased PCO2 with delayed compensatory
renal HCO3 excretion into urine "<img src=""8323.png"">" acid-base-
What can be calculated with the Henderson-Hasselbalch equation if HCO3 and PCO2
are known? The pH, because pH = pKa + log (HCO3/[0.03] PCO2) "<img
src=""8323.png"">" acid-base-physiology physiology renal
In metabolic acidosis, a reduction in HCO3 is the main disturbance. How is the
expected compensatory change of PCO2 calculated? With the Winters formula:
PCO2 = 1.5 [HCO3] + 8 2 "<img src=""8323.png"">" acid-base-physiology
physiology renal
A pt with sepsis has an anion gap metabolic acidosis. Measured PCO2 is 30; HCO3 is
15. Is this a pure anion gap metabolic acidosis? Yes, per the Winters formula,
predicted PCO2 is 1.5 [15] + 8 2, or 30.5 (within 2 of 30) "<img
src=""8323.png"">" acid-base-physiology physiology renal
A pt has an anion gap metabolic acidosis. Measured PCO2 is 2; HCO3 is 8. Is this a
pure anion gap metabolic acidosis? No, per the Winters formula, predicted PCO2 is
1.5 [8] + 8 2, or 22) (not within 2 of 26), and a respiratory acidosis is also
present "<img src=""8323.png"">" acid-base-physiology physiology renal
What primary acid-base disturbance is present when arterial pH is less than 7.35
and PCO2 is less than 40 mm Hg? Metabolic acidosis "<img src=""8324.png"">"
acidosis/alkalosis physiology renal
A man climbing a mountain feels short of breath. He takes rapid, deep breaths.
Which acid-base abnormality would you likely see? Respiratory alkalosis:
Exposure to higher altitudes forces hyperventilation, lowering PCO2 to &60; 40 and
raising pH to &62; 7.45 "<img src=""8324.png"">" acidosis/alkalosis physiology
renal
What is the main cause of respiratory alkalosis? Name some conditions that may
provoke this acid-base derangement. Hyperventilation; causes include hysteria,
tumor, hypoxemia (eg, high altitude), pulmonary emboli, and salicylates (early)
"<img src=""8324.png"">" acidosis/alkalosis physiology renal
The body can easily compensate for metabolic acidoses and alkaloses. How does it
accomplish this? By adjusting the breathing rate to blow off (in the case of
acidosis) or retain (in the case of alkalosis) PCO2 "<img src=""8324.png"">"
What primary acid-base disturbance is present when arterial pH is less than 7.35
and PCO2 is greater than 40 mm Hg? Respiratory acidosis "<img src=""8324.png"">"
What primary acid-base disturbance is present when arterial pH is greater than 7.45
and PCO2 is less than 40 mm Hg? Respiratory alkalosis "<img src=""8324.png"">"
What is the primary acid-base disturbance when arterial pH is greater than 7.45 and
PCO2 is greater than 40 mm Hg? Metabolic alkalosis "<img src=""8324.png"">"
What is the formula for calculating the anion gap? What is considered a normal
anion gap? Anion gap = Na+ (Cl + HCO3); normal value is 812 mEq/L"<img
src=""8324.png"">" acidosis/alkalosis physiology renal
Name at least four conditions that can cause a normal anion gap metabolic acidosis.
Hyperalimentation, Addison disease, Renal tubular acidosis, Diarrhea,
Acetazolamide, Spironolactone, Saline infusion (HARD-ASS) "<img src=""8324.png"">"
What mechanisms or disease states can lead to respiratory acidosis?
Hypoventilation (eg, airway obstruction, acute or chronic lung disease,
opioids, narcotics, sedatives, weakening of respiratory muscles) "<img
src=""8324.png"">" acidosis/alkalosis physiology renal
What are the possible causes of a metabolic acidosis with an anion gap?
Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol, Iron/INH, Lactic
acidosis, Ethylene glycol, Salicylates (MUDPILES) "<img src=""8324.png"">"
If arterial pH is greater than 7.5 and PCO2 is greater than 40 mm Hg, which acid-
base compensatory mechanism is in use? Respiratory compensation (hypoventilation
to increase carbon dioxide) "<img src=""8324.png"">" acidosis/alkalosis
physiology renal
A pt overdoses on aspirin. What is the initial acid-base imbalance? What type of
acid-base imbalance develops later? Respiratory alkalosis; metabolic acidosis
(Aspirin is a salicylate.) "<img src=""8324.png"">" acidosis/alkalosis
physiology renal
Name at least two causes of metabolic alkalosis. Vomiting, loop diuretic use,
antacid use, hyperaldosteronism "<img src=""8324.png"">" acidosis/alkalosis
physiology renal
An alcoholic is confused; his labs are: pH 7.32, HCO3 15, PCO2 30, Na+ 140, Cl
105. Name the acid-base imbalance. Metabolic acidosis with an anion gap
(calculates to 20) (The likely cause in this case is ethylene glycol poisoning.)
"<img src=""8324.png"">" acidosis/alkalosis physiology renal
A child has diarrhea; his labs are: pH 7.30, HCO3 12, PCO2 25, Na+ 142, Cl 120.
What acid-base imbalance is this? Metabolic acidosis with normal anion gap
(calculates to 10) (Likely cause in this case is HCO3 loss due to excessive
diarrhea.) "<img src=""8324.png"">" acidosis/alkalosis physiology renal
A drug addict with slow, shallow breaths has pH of 7.29, HCO3 of 23, PCO2 of 50.
What acid-base imbalance is this? Respiratory acidosis due to hypoventilation
(likely from opioid intoxication) "<img src=""8324.png"">" acidosis/alkalosis
physiology renal
A pt who is vomiting due to a stomach virus has pH of 7.48, HCO3 of 36, PCO2 of
50. What is the origin of this acid-base imbalance? Metabolic alkalosis due to
vomiting (Loss of Cl leads to HCO3 retention.) "<img src=""8324.png"">"
A pt presents with hypoaldosteronism and acidosis. Why did hyperkalemia result in
an acidotic state? Ammoniagenesis decreased, which resulted in a decreased
excretion of H+ "<img src=""8325.png"">" physiology renal renal-tubular-
acidosis
What is the mechanism behind acidosis in RTA type 1? -Intercalated cells in DCT
not secreting H+; urine pH above 5.5 "<img src=""8325.png"">" physiology
renal renal-tubular-acidosis
A pt has a defect in HCO3 reabsorption at the PCT. What type of RTA does she have,
and what is her potassium derangement? RTA type 2 associated with hypokalemia
"<img src=""8325.png"">" physiology renal renal-tubular-acidosis
What are the potassium imbalances in renal tubular acidosis types 1, 2, and 4?
1 and 2: hypokalemia; 4: hyperkalemia "<img src=""8325.png"">"
physiology renal renal-tubular-acidosis
A man with a fungal infection has calcium-containing kidney stones, hypokalemia,
and alkaline urine. Which antifungal agent is to blame? This is amphotericin B
toxicity, which causes type 1 renal tubular acidosis (associated with calcium
phosphate kidney stones) "<img src=""8325.png"">" physiology renal renal-
tubular-acidosis
A man with a UTI has hyperkalemia and low aldosterone. Urinalysis shows acidic
urine and low ammonia. Which antibiotic caused this? This is type 4 renal tubular
acidosis, likely due to TMP/SMX use "<img src=""8325.png"">" physiology renal
renal-tubular-acidosis
A hiker continues to take acetazolamide after returning from a climb. What would
you expect the serum pH to be? What about urine pH? Serum pH is increased by loss
of HCO3, and the urine is still acidified by - intercalated cells (This is type 2
renal tubular acidosis.) "<img src=""8325.png"">" physiology renal renal-
tubular-acidosis
List some causes of type 1 renal tubular acidosis. Amphotericin B toxicity,
analgesic nephropathy, congenital anomalies (obstruction) of the urinary tract
"<img src=""8325.png"">" physiology renal renal-tubular-acidosis
List some causes of type 2 renal tubular acidosis. Fanconi syndrome, carbonic
anhydrase inhibitors "<img src=""8325.png"">" physiology renal renal-
tubular-acidosis
Identify the two broad categories of disorders that lead to type 4 renal tubular
acidosis. Low aldosterone production and resistance to aldosterone "<img
src=""8325.png"">" physiology renal renal-tubular-acidosis
Name some causes of aldosterone deficiency that lead to type 4 renal tubular
acidosis. Diabetic hyporeninism, ARBs, ACE inhibitors, heparin, NSAIDs, adrenal
insufficiency, and cyclosporine "<img src=""8325.png"">" physiology renal
renal-tubular-acidosis
Name some causes of aldosterone resistance that lead to type 4 renal tubular
acidosis. K+-sparing diuretics, TMP/SMX, nephropathy due to obstruction "<img
src=""8325.png"">" physiology renal renal-tubular-acidosis
Which form of renal tubular acidosis increases the risk of hypophosphatemic
rickets? Type 2 "<img src=""8325.png"">" physiology renal renal-
tubular-acidosis
A smoker has painless hematuria. Red blood cells, but no casts, are seen in his
urine. Where does this suggest that the bleeding is from? Blood in the urine
without casts suggests an extrarenal process; in a smoker, you would suspect
bladder cancer "<img src=""8326.png"">" Pathology casts-in-urine renal
In glomerulonephritis and malignant hypertension, which type of casts are most
likely to be seen on urinalysis? Red blood cell casts "<img src=""8326.png"">"
Pathology casts-in-urine renal
In tubulointerstitial disease, acute pyelonephritis, and transplant rejection,
which type of casts are most likely to be seen on urinalysis? White blood cell
casts "<img src=""8326.png"">" Pathology casts-in-urine renal
What type of casts would be seen in the urine of a pt with advanced renal disease
or chronic renal failure? Waxy casts "<img src=""8326.png"">" Pathology
casts-in-urine renal
A pt presents with hematuria, dysuria, increased frequency, and suprapubic pain.
What will the urine be positive for? Any casts? Positive for blood, leukocytes; no
casts "<img src=""8326.png"">" Pathology casts-in-urine renal
A pt has granular (muddy brown) casts. What does this suggest about the location of
his renal disease? It suggests intrarenal, acute tubular necrosis "<img
src=""8326.png"">" Pathology casts-in-urine renal
A pt has flank pain and hematuria. The urine is red, and urinalysis shows RBCs and
stones. Do you expect to see casts? No, because kidney stones are extrarenal and
generally do not present with casts "<img src=""8326.png"">" Pathology casts-
in-urine renal
A pt is found to have nephrotic syndrome. What type of casts is urine sediment
analysis most likely to show? Fatty casts (oval fat bodies) "<img src=""8326.png"">"
Pathology casts-in-urine renal
A pt presents with abdominal pain and anxiety. Workup is notable only for
concentrated urine with hyaline casts. Diagnosis? No diagnosis can be made, as
hyaline casts are a nonspecific finding that may be normal and are often seen in
concentrated urine samples "<img src=""8326.png"">" Pathology casts-in-urine
renal
A woman has a UTI. Pyuria is seen on urinalysis, but there are no WBC casts. What
does this suggest about the location of renal disease? Pyuria is extrarenal,
and casts would not be expected "<img src=""8326.png"">" Pathology casts-
in-urine renal
What percentage of glomeruli are involved in focal glomerular disease? What about
diffuse disease? Less than 50% in focal disease and greater than 50% in diffuse
disease "<img src=""8327.png"">" Pathology nomenclature-of-glomerular-
disorders renal
On microscopic examination, hypercellular glomeruli are noted. With which type of
glomerular disease is this finding consistent? Proliferative "<img
src=""8327.png"">" Pathology nomenclature-of-glomerular-disorders renal
What is the difference between primary and secondary glomerular disease?
Primary glomerular disease is a disorder of the kidneys; secondary disease is
a result of a systemic disease or other organ dysfunction "<img src=""8327.png"">"
Pathology nomenclature-of-glomerular-disorders renal
Is minimal change disease a primary or secondary glomerular disease? Primary
"<img src=""8327.png"">" Pathology nomenclature-of-glomerular-disorders
renal
Is SLE a primary or secondary cause of glomerular disease? Secondary "<img
The cutoff between a focal and a diffuse glomerular process requires what
percentage of glomeruli to be involved? 50% (focal is &60; 50%; diffuse is &62;
50%) "<img src=""8327.png"">" Pathology nomenclature-of-glomerular-disorders
renal
On microscopic examination, thickening of the glomerular basement membrane is
noted. With what glomerular disorder is this consistent? Membranous "<img
Give five examples of disorders that present largely as nephritic syndrome. Acute
poststreptococcal, rapidly progressive, and membranoproliferative
glomerulonephritis; Alport syndrome; IgA nephropathy "<img src=""8328.png"">"
Pathology glomerular-diseases renal
Give five examples of disorders that present largely as nephrotic syndrome. Focal
segmental glomerulosclerosis, membranous nephropathy, minimal change disease,
amyloidosis, and diabetic glomerulonephropathy "<img src=""8328.png"">"
Give two examples of disorders that are most likely to present as a combination of
nephritic syndrome and nephrotic syndrome. Diffuse proliferative and
membranoproliferative glomerulonephritis "<img src=""8328.png"">" Pathology
glomerular-diseases renal
A pt presents with acute poststreptococcal glomerulonephritis. This is likely a
result of disruption of which part of the glomerulus? The basement membrane
(disrupted in nephritic syndrome) "<img src=""8328.png"">" Pathology
What is the cutoff, in grams per day, for protein that differentiates nephritic
from nephrotic disease? &60; 3.5 g/day is nephritic syndrome; &62; 3.5 g/day is
nephrotic syndrome "<img src=""8328.png"">" Pathology glomerular-diseases
renal
A man has hypertension and edema. Labs: increased BUN and creatinine. Urinalysis:
hematuria and RBC casts. What will glomerular biopsy show? Glomerular basement
membrane (GBM) disruption, a hallmark of nephritic syndrome"<img src=""8328.png"">"
A man has classic nephritic syndrome findings. His 24-hour urinary protein
excretion is 4 g. Should his diagnosis be nephrotic syndrome? No. Some severe
cases of nephritic syndrome may have nephrotic range (>3.5 g) proteinuria, and
nephritic-nephrotic syndrome is also possible "<img src=""8328.png"">"
A man with IgA nephropathy has nephrotic-range proteinuria and mixed
nephritic/nephrotic syndrome signs. What do urine protein studies show? A
daily excretion of more than 3.5 g; this is a mixed nephritic-nephrotic syndrome
(may occur with any form of nephritic syndrome) "<img src=""8328.png"">"
A pt exhibits diffuse edema. He voids 4 g of protein per day and has
hypoalbuminemia and hyperlipidemia. What will glomerular biopsy show? Podocyte
disruption, a hallmark of nephrotic syndrome "<img src=""8328.png"">"
What is the difference between primary and secondary nephrotic syndromes?
Primary: due to direct podocyte damage; secondary: damage occurs in the
setting of systemic illness (eg, diabetes) "<img src=""8328.png"">"
Which two variants of nephrotic syndrome are always the result of a systemic
process? Diabetic glomerulonephropathy and amyloidosis-associated nephrotic
syndrome "<img src=""8328.png"">" Pathology glomerular-diseases renal
Focal segmental glomerulosclerosis, minimal change disease, membranous nephropathy:
primary nephropathy, secondary nephropathy, or both? All three may present as
either a primary or secondary disorder "<img src=""8328.png"">" Pathology
A pt presents with nephritic syndrome. What are some of the hallmark findings you
expect to see on workup? NephrItic syndrome is Inflammatory, causing hematuria
and RBC casts; associated with oliguria, azotemia, proteinemia, and hypertension
"<img src=""8329.png"">" Pathology nephritic-syndrome renal
What is the pattern of immunofluorescence in acute poststreptococcal
glomerulonephritis? Granular appearance due to immunoglobulin G, immunoglobulin
M, and C3 deposition along the glomerular basement membrane and mesangium "<img
src=""8329.png"">" Pathology nephritic-syndrome renal
"Identify the nephritic syndrome with these findings: LM: hypercellular glomeruli,
IF: ""lumpy bumpy,"" EM: subepithelial immune complexes" Acute poststreptococcal
glomerulonephritis "<img src=""8329.png"">" Pathology nephritic-syndrome
renal
A child exhibits hypertension, periorbital edema, and hematuria 2 weeks after
having strep throat. Describe the findings on IF and EM. "IF shows a ""lumpy
bumpy"" pattern caused by IgG, IgM, and C3 deposits in the GBM; EM shows
subepithelial immune complexes" "<img src=""8329.png"">" Pathology
nephritic-syndrome renal
A boy recently had a streptococcal skin infection. He now has cola-colored urine.
Is this a hypersensitivity reaction? Prognosis? Yes, this is acute
poststreptococcal glomerulonephritis, a type III hypersensitivity reaction; good
(almost always resolves spontaneously) "<img src=""8329.png"">" Pathology
A boy has peripheral and periorbital edema, brown urine, and hypertension. Anti-
DNase B titer is increased. What are his complement levels?Low, as this is acute
poststreptococcal glomerulonephritis "<img src=""8329.png"">" Pathology
A pt has hematuria and hemoptysis with a linear pattern on immunofluorescence. What
is the pathogenesis of this disease? Goodpasture syndrome, is a type II
hypersensitivity reaction with antibodies against GBM and alveolar basement
membrane proteins "<img src=""8329.png"">" Pathology nephritic-syndrome renal
A boy who had strep throat has hematuria and eye puffiness. His glomeruli look
lumpy and bumpy. What will electron microscopy likely show?Subepithelial immune
complex deposits (evidence of acute poststreptococcal glomerulonephritis) (This
condition will resolve spontaneously.) "<img src=""8329.png"">" Pathology
Describe the light microscopy and immunofluorescence pattern of rapidly progressive
glomerulonephritis (RPGN). Crescents of fibrin, protein (C3b), and cell
(parietal cells, monocytes, macrophages) debris "<img src=""8329.png"">"
Pathology nephritic-syndrome renal
Name some hallmarks of nephritic syndrome. Hematuria, hypertension, possible
oliguria, azotemia, proteinuria (less than 3.5 g/day), red blood cell casts in
urine "<img src=""8329.png"">" Pathology nephritic-syndrome renal
A pt has granulomatosis with polyangiitis; he is c-ANCA positive on antibody
screening. What type of nephritis is this? This is rapidly progressive
glomerulonephritis (RPGN) due to granulomatosis with polyangiitis (Wegener), which
is PR3-ANCA/c-ANCA positive "<img src=""8329.png"">" Pathology nephritic-
syndrome renal
Differentiate the key staining difference between granulomatosis with polyangiitis
(Wegener) and microscopic polyangiitis Granulomatosis with polyangiitis
(Wegener) is c-ANCA positive, whereas microscopic polyangiitis is p-ANCA positive
"A woman with a malar rash has ""wire looping"" on LM during a kidney biopsy. What
type of kidney pathology is to blame?" Diffuse proliferative glomerulonephritis
(DPGN), which is classically seen in lupus (think wire lupus [wire looping]) "<img
A young man has episodic hematuria and RBC casts after colds. Name the key EM and
IF findings in a renal specimen taken during an episode. This is Berger disease;
EM reveals mesangial deposits, shown to be IgA on IF. (The same renal pathology is
seen in Henoch-Schnlein purpura.) "<img src=""8329.png"">" Pathology
A boy has hematuria, abdominal pain, and palpable purpura on his buttocks. Where
would you expect to find immune complexes on renal biopsy? One would see IgA immune
complex deposits in the mesangium, as this is Henoch-Schnlein purpura "<img
Splitting of GBM is seen on EM of a kidney biopsy in a pt with hearing
difficulties, retinopathy, and hematuria. Inheritance pattern? "This is Alport
syndrome (""can't see, can't pee, can't hear a bee""), which is most commonly X
linked" "<img src=""8329.png"">" Pathology nephritic-syndrome renal
Differentiate the appearance of the immune complexes (ICs) of the two types of
membranoproliferative glomerulonephritis (MPGN). "Type I: subendothelial ICs
with granular IF, PAS stain ""tram-track"" appearance of GBM splitting; type II:
intramembranous (""dense"") deposits" "<img src=""8329.png"">" Pathology
A man has hepatitis B and subendothelial immune complex deposits seen on renal
biopsy. What are some of the symptoms of this kidney disease? This is MPGN, in
which one sees hematuria, hypertension, and RBC casts (may also present with
nephrotic range proteinuria and severe edema) "<img src=""8329.png"">"
A pt has signs of both nephritic and nephrotic syndrome, with intramembranous IC
deposits on kidney biopsy. What is his serum C3 level? The C3 level will be
low, as this is type II MPGN, associated with C3 nephritic factor, which stabilizes
C3 convertase and consumes C3 "<img src=""8329.png"">" Pathology nephritic-
syndrome renal
A pt presents with hematuria and hemoptysis. You suspect Goodpasture syndrome.
Which antibody would confirm your diagnosis? Antibody to glomerular and alveolar
basement membrane "<img src=""8329.png"">" Pathology nephritic-syndrome renal
A pt presents with hemoptysis and hematuria. Workup shows that a type II
hypersensitivity reaction is involved. Treatment? This is Goodpasture syndrome,
with a typical renal presentation of RPGN; treatment consists of emergency
plasmapheresis "<img src=""8329.png"">" Pathology nephritic-syndrome renal
A pt with a mild cold develops HTN and facial swelling. Hx reveals multiple
episodes of hematuria with RBC casts. Likely diagnosis? Immunoglobulin A
glomerulopathy (Berger disease), a nephritic syndrome "<img src=""8329.png"">"
Name three disease processes that result in rapidly progressive glomerulonephritis.
Goodpasture syndrome, granulomatosis with polyangiitis (Wegener), microscopic
polyangiitis "<img src=""8329.png"">" Pathology nephritic-syndrome renal
What is the underlying mechanism resulting in diffuse proliferative
glomerulonephritis due to systemic lupus erythematosus? Subendothelial (and
sometimes intramembranous) anti-DNA immune complex deposition "<img
What are the findings on light microscopy and immunofluorescence in diffuse
proliferative glomerulonephritis? Wire looping of capillaries on light microscopy
and granular immunofluorescence due to subendothelial immune complex deposition
Diffuse proliferative glomerulonephritis is the most common cause of death in which
systemic disease? Systemic lupus erythematosus (can also be related to
membranoproliferative glomerulonephritis) "<img src=""8329.png"">" Pathology
Henoch-Schnlein purpura is associated with which nephritic syndrome? Berger
disease (IgA nephropathy) "<img src=""8329.png"">" Pathology nephritic-
syndrome renal
A pt is diagnosed with microscopic polyangiitis. An autoimmune workup is done.
Which staining labs will likely return positive? MPO-ANCA/p-ANCA "<img
You study a family tree and note that many family members have Alport syndrome.
What is the typical inheritance pattern of this disorder? X-linked "<img
Which type of nephritic syndrome is most likely to copresent with nephrotic
syndrome? Membranoproliferative glomerulonephritis (MPGN) "<img src=""8329.png"">"
"On microscopy, you note subendothelial deposits and a ""tram track"" appearance
with PAS. Which infectious diseases might you check for?" Hepatitis B and C "<img
What are the characteristic findings in membranous nephropathy on electron
microscopy? A spike-and-dome appearance with subepithelial deposits "<img
src=""8330.png"">" Pathology nephrotic-syndrome renal
What are some of the hallmark findings you expect to see on workup of a pt with
nephrotic syndrome? NephrOtic syndrome: massive prOteinuria, edema, fatty
casts, and hyperlipidemia are hallmarks "<img src=""8330.png"">" Pathology
nephrotic-syndrome renal
A pt has nephrotic syndrome. Biopsy shows Kimmelstiel-Wilson lesions, mesangial
expansion, and basement membrane thickening. Diagnosis? Diabetic
glomerulonephropathy "<img src=""8330.png"">" Pathology nephrotic-syndrome
renal
Which types of nephrotic syndrome are characterized pathologically by a granular
pattern on immunofluorescence? Membranous nephropathy "<img src=""8330.png"">"
Pathology nephrotic-syndrome renal
What are the characteristic findings of focal segmental glomerulosclerosis on light
microscopy? Segmental sclerosis, hyalinosis of glomeruli "<img src=""8330.png"">"
A girl who had viral gastroenteritis now has edema and frothy urine. Her glomerular
foot processes are effaced. Treatment? This is likely minimal change disease,
treatable with corticosteroids "<img src=""8330.png"">" Pathology
Which type of nephrotic syndrome is characterized by diffuse capillary and basement
membrane thickening seen on light microscopy? Membranous nephropathy "<img
Name four causes of secondary membranous nephropathy. Autoimmune (eg, phospholipase
A2 receptor antibodies), drugs (eg, NSAIDs, penicillamine), infections (eg, HBV,
HCV), SLE, solid tumors "<img src=""8330.png"">" Pathology nephrotic-syndrome
renal
A young, healthy boy presents with minimal change disease. What is the pathogenesis
of this disorder? The effacement of glomerular podocyte foot processes disrupts the
charge barrier, causing selective loss of albumin from plasma "<img
A boy is found to have Hodgkin lymphoma. He later exhibits frothy urine and diffuse
edema before chemotherapy. What is happening? He may have minimal change disease,
associated with Hodgkin lymphoma due to cytokine-mediated damage of the kidneys
"<img src=""8330.png"">" Pathology nephrotic-syndrome renal
Focal segmental glomerulosclerosis develops in a healthy pt. You start steroids but
are not optimistic about their efficacy. Why? The primary (idiopathic) form of
this disorder responds inconsistently to steroids and may progress to chronic renal
disease "<img src=""8330.png"">" Pathology nephrotic-syndrome renal
A healthy pt develops membranous nephropathy. Steroids are started. Do you expect
them to reverse the kidney pathology? Unsure; the primary (idiopathic) form of
this disorder responds inconsistently to steroids and may progress to chronic renal
disease "<img src=""8330.png"">" Pathology nephrotic-syndrome renal
Which type of nephrotic syndrome may be caused by antibodies to phospholipase A2
receptors? Membranous nephropathy "<img src=""8330.png"">" Pathology
Name some disorders that are associated with focal segmental glomerulosclerosis.
HIV, sickle cell disease, heroin abuse, massive obesity, interferon
treatment, chronic kidney disease resulting from congenital malformation "<img
A child presents with frothy urine and edema. Labs show hypoalbuminemia. He has no
other medical issues. Do you treat with steroids? Yes, this is likely minimal
change disease, which, when primary (idiopathic), responds well to steroids "<img
What are the hallmark urinalysis findings in a pt with nephrotic syndrome?
Nephrotic-range proteinuria (>3.5 g/day), fatty casts"<img src=""8330.png"">"
What are the main differences between primary and secondary nephrotic syndrome?
Primary disease involves direct podocyte sclerosis; secondary disease is due
to podocyte damage by a systemic illness (eg, diabetes) "<img src=""8330.png"">"
Is it possible for nephrotic syndrome to copresent with nephritic syndrome? Yes,
severe forms of nephritic syndrome may present with nephrotic features (nephritic-
nephrotic syndrome) if charge barrier damage occurs "<img src=""8330.png"">"
A pt with lupus and membranous glomerulonephritis has an embolic stroke. A
hypercoagulable workup is done. Which abnormality might you see? A deficiency of
antithrombin III (AT III), which can occur as a result of nephrotic syndrome due to
AT III loss in the urine "<img src=""8330.png"">" Pathology nephrotic-
syndrome renal
A heroin abuser with focal segmental glomerulosclerosis has recurrent skin
infections that respond poorly to antibiotics. Why? Nephrotic syndrome involves
loss of immunoglobulins in the urine and soft tissue edema, both of which increase
the risk for infection "<img src=""8330.png"">" Pathology nephrotic-syndrome
renal
In diabetic glomerulonephropathy, what causes the increased permeability and
thickening of the glomerular basement membrane? Nonenzymatic glycosylation of the
glomerular basement membrane "<img src=""8330.png"">" Pathology nephrotic-
syndrome renal
A pt has nephrotic syndrome due to multiple myeloma. A glomerular biopsy is
ordered. What are the expected light microscopy findings? Amyloid takes on an
apple-green birefringence with a Congo red stain. (Amyloid deposits arise in the
kidney as a result of multiple myeloma.) "<img src=""8330.png"">" Pathology
Name at least two conditions that can predispose people to nephrotic syndrome as a
result of amyloidosis. Multiple myeloma, tuberculosis, rheumatoid arthritis "<img
In diabetic glomerulonephropathy, what causes mesangial expansion? Nonenzymatic
glycosylation of the efferent arterioles, leading to an increased glomerular
filtration rate and thus mesangial expansion "<img src=""8330.png"">"
A young boy has hematuria, and microscopy reveals a 6-sided stone. Why might you
want to order more imaging of the kidneys? He likely has cystine stones, which
are poorly soluble and increase the risk of staghorn calculi, which require
surgical removal "<img src=""8331.png"">" Pathology kidney-stones renal
How does pH affect the formation of kidney stones (calcium, ammonium-magnesium-
phosphate, uric acid, and cystine)? Ammonium-magnesium-phosphate precipitates at
high pH; uric acid and cystine, at low pH; calcium can precipitate at a high or low
pH "<img src=""8331.png"">" Pathology kidney-stones renal
An alcoholic mistakes antifreeze for liquor. Which type of kidney stones would be
expected to arise as a result? Calcium oxalate stones caused by ethylene
glycol "<img src=""8331.png"">" Pathology kidney-stones renal
A pt who abuses vitamin C supplements presents with flank pain and hematuria. What
treatments can you offer? This is a calcium oxalate stone formation due to
vitamin C excess; treatments are hydration, thiazides, and citrate "<img
src=""8331.png"">" Pathology kidney-stones renal
A pt with gout experiences flank pain and hematuria. X-rays of the abdomen are
negative. Might he still have kidney stones? Yes, these may be uric acid stones,
which are not visible on x-rays; they may be visualized with either CT or
ultrasound "<img src=""8331.png"">" Pathology kidney-stones renal
What are the hallmark symptoms of kidney stones? Unilateral flank tenderness,
colicky pain radiating to groin, and hematuria "<img src=""8331.png"">"
Pathology kidney-stones renal
What are the four most common renal stones, in descending order of frequency?
Calcium (80%), ammonium magnesium phospate (15%), uric acid (5%), and cystine
(1%) "<img src=""8331.png"">" Pathology kidney-stones renal
Which kidney stones are radiolucent? Uric acid and cystine stones (Calcium and
ammonium magnesium phosphate are radiopaque.) "<img src=""8331.png"">"
Pathology kidney-stones renal
What is hydronephrosis? Distention/dilation of renal pelvis and calyces, usually as
a result of another disease process "<img src=""8332.png"">" Pathology
hydronephrosis renal
A man with chronic unilateral ureter stenosis exhibits hydronephrosis with high
creatinine. Why is the creatinine level rising? He likely has only one kidney; with
no second kidney to compensate for the obstruction, filtration is impaired and
creatinine rises "<img src=""8332.png"">" Pathology hydronephrosis renal
Name some causes of hydronephrosis. Urinary tract obstruction (eg, renal stones,
BPH, cervical cancer, injury to ureter), retroperitoneal fibrosis, vesicoureteral
reflux "<img src=""8332.png"">" Pathology hydronephrosis renal
A pt has chronic unilateral kidney stones that are causing ipsilateral
hydronephrosis. Where will pathologic dilation be seen? The proximal ureter and
kidney; dilation always occurs proximal to the site of pathology "<img
src=""8332.png"">" Pathology hydronephrosis renal
Renal cell carcinoma (RCC) is a malignancy of which cell type? RCC develops from
PCT cells, which become filled with lipids and carbohydrates "<img
src=""8333.png"">" Pathology renal renal-cell-carcinoma
A hyperviscosity syndrome develops in a smoker with hematuria, weight loss, and a
palpable flank mass. What is the likely cause? Renal cell carcinoma producing
excess EPO, leading to polycythemia "<img src=""8333.png"">" Pathology renal
renal-cell-carcinoma
What is the mechanism of renal cell carcinoma metastasis? It invades the renal
vein and IVC, then spreads hematogenously, often metastizing to lung and bone
"<img src=""8333.png"">" Pathology renal renal-cell-carcinoma
What is the chromosomal abnormality most often implicated in renal cell carcinoma?
A gene deletion on chromosome 3, either sporadic or inherited via von Hippel-
Lindau syndrome "<img src=""8333.png"">" Pathology renal renal-cell-
carcinoma
To which two types of cancer treatment is renal cell carcinoma resistant?
Chemotherapy and radiotherapy "<img src=""8333.png"">" Pathology renal
renal-cell-carcinoma
Is a renal oncocytoma benign or malignant? Benign "<img src=""8334.png"">"
Pathology renal renal-oncocytoma
Despite being benign, all renal oncocytomas are resected. Why? It is important to
rule out other causes of renal masses, such as a renal cell carcinoma "<img
src=""8334.png"">" Pathology renal renal-oncocytoma
What is the most common renal malignancy of early childhood (ie, 2 to 4 years of
age)? Wilms tumor "<img src=""8335.png"">" Pathology renal wilms-tumor-
(nephroblastoma)
A 3-year-old boy presents with hematuria and a huge, palpable flank mass. He has
developmental delay, GU anomalies, and aniridia. Dx? WAGR complex = Wilms tumor,
Aniridia, Genitourinary malformations, and mental Retardation "<img
src=""8335.png"">" Pathology renal wilms-tumor-(nephroblastoma)
How does Wilms tumor most commonly present? As a large palpable flank mass
and/or hematuria in young children; it may be associated with genetic
hemihypertrophy syndromes "<img src=""8335.png"">" Pathology renal wilms-
tumor-(nephroblastoma)
Which malignancy contains embryonic glomerular structures and may be part of
Beckwith-Wiedemann syndrome? Wilms tumor "<img src=""8335.png"">" Pathology
renal wilms-tumor-(nephroblastoma)
A boy with this CT scan finding has macroglossia, organomegaly, and
hemihypertrophy. What type of mutation is likely to blame for the mass? A loss
of function mutation (This is likely a Wilms tumor, presenting as part of Beckwith-
Wiedemann syndrome.) "<img src=""8335.png"">" Pathology renal wilms-tumor-
(nephroblastoma)
In which four anatomic structures of the urinary tract can transitional cell
carcinoma occur? Renal calyces, renal pelvis, ureters, and bladder "<img
src=""8336.png"">" Pathology renal transitional-cell-carcinoma
A smoker presents with painless hematuria and weight loss. Urine sediment is
negative for casts. What diagnosis are you concerned about?Transitional cell
carcinoma of the bladder "<img src=""8336.png"">" Pathology renal
transitional-cell-carcinoma
Which environmental exposures are associated with transitional cell carcinoma?
Phenacetin, Smoking, Aniline dyes, and Cyclophosphamide (associated with
problems in your Pee SAC) "<img src=""8336.png"">" Pathology renal
transitional-cell-carcinoma
A Middle Eastern smoker presents with painless hematuria. What condition does he
likely have? Bladder squamous cell carcinoma (He has two risk factors: smoking
and potential exposure to Schistosoma haematobium in the Middle East.) "<img
src=""8337.png"">" Pathology renal squamous-cell-carcinoma-of-the-bladder
Chronic urinary bladder irritation can lead to squamous metaplasia, which when not
checked can eventually progress how (histologically)? It could become squamous
dysplasia, which predisposes to squamous cell carcinoma "<img src=""8337.png"">"
Pathology renal squamous-cell-carcinoma-of-the-bladder
A pt has had recurrent kidney stones all of his life. He presents with painless
hematuria. What diagnosis must you rule out? Squamous cell carcinoma of the
bladder (Chronic nephrolithiasis is a risk factor.) "<img src=""8337.png"">"
Pathology renal squamous-cell-carcinoma-of-the-bladder
A pt presents complaining of urinary leakage with sneezing. What type of
incontinence is this and how would you treat it? Stress incontinence;
treatment plan includes Kegel exercises, weight loss, and pessaries "<img
src=""8338.png"">" Pathology renal urinary-incontinence
List 3 risk factors associated with stress incontinence. Obesity, vaginal
delivery, prostate surgery "<img src=""8338.png"">" Pathology renal urinary-
incontinence
What is the mechanism behind urge incontinence? Overactive bladder/detrusor
instability "<img src=""8338.png"">" Pathology renal urinary-incontinence
A pt with BPH complains of urinary incontinence. Which type of incontinence do you
suspect, and what is the treatment? Overflow incontinence due to outlet
obstruction; BPH is treated with -blockers "<img src=""8338.png"">"
Pathology renal urinary-incontinence
A pt presents with urine incontinence with lifting along with episodes of increased
urgency. Diagnosis? Mixed incontinence, which has features of both urge and
stress incontinence "<img src=""8338.png"">" Pathology renal urinary-
incontinence
A sexually active teen has dysuria and urinary frequency. Pyuria is sterile; urine
cultures are negative. What organism(s) are responsible? Neisseria gonorrhea and
Chlamydia trachomatis (The pt has urethritis.) "<img src=""8339.png"">"
Pathology renal urinary-tract-infection-(acute-bacterial-cystitis)
As soon as a postoperative pt is able to ambulate with assistance, his indwelling
Foley catheter is removed. Why? To prevent the development of acute infectious
cystitis (Indwelling catheters are a significant risk factor.) "<img
src=""8339.png"">" Pathology renal urinary-tract-infection-(acute-bacterial-
cystitis)
A pt's urinalysis is positive for nitrites and leukocyte esterase. What is the most
likely culprit? E coli, the most common cause of acute infectious cystitis and
associated with nitrites on urinalysis "<img src=""8339.png"">" Pathology
renal urinary-tract-infection-(acute-bacterial-cystitis)
An elderly woman has urinary urgency and dysuria. Her urine has an ammonia-like
odor to it. Diagnosis? She has acute infectious cystitis caused by Proteus
mirabilis "<img src=""8339.png"">" Pathology renal urinary-tract-infection-
(acute-bacterial-cystitis)
Cystitis develops in a young woman. Urinalysis shows leukocyte esterase and no
nitrites. Urine culture shows no E. coli. Diagnosis? Staphylococcus saprophyticus
cystitis (common in young sexually active women) "<img src=""8339.png"">"
A pt presents with suprapubic pain, dysuria, urinary frequency, and urgency. You
check vital signs. Do you expect to see a fever? No, acute infectious cystitis
is not usually associated with systemic signs such as fevers and chills "<img
src=""8339.png"">" Pathology renal urinary-tract-infection-(acute-bacterial-
cystitis)
List some risk factors for acute infectious cystitis. "Female sex (short urethra),
sexual intercourse (""honeymoon cystitis""), indwelling catheters, diabetes
mellitus, impaired bladder emptying" "<img src=""8339.png"">" Pathology
renal urinary-tract-infection-(acute-bacterial-cystitis)
List some common bacterial causes of acute infectious cystitis. Escherichia coli,
Staphylococcus saprophyticus, Klebsiella, Proteus mirabilis"<img src=""8339.png"">"
What gross anatomic changes of the kidneys occur with chronic pyelonephritis? What
is required for these recurrent infections to occur? Coarse, asymmetric
corticomedullary scarring and blunted calices; a predisposition such as
vesicoureteral reflux and obstruction "<img src=""8340.png"">" Pathology
pyelonephritis renal
A woman chooses to forgo treatment for her pyelonephritis. Name at least one
complication of her poor decision. Chronic pyelonephritis, renal papillary
necrosis, perinephric abscess, urosepsis "<img src=""8340.png"">" Pathology
pyelonephritis renal
What is xanthogranulomatous pyelonephritis? A rare disorder characterized by
widespread kidney damage associated with granulomatous tissue containing
macrophages "<img src=""8340.png"">" Pathology pyelonephritis renal
In acute pyelonephritis, which parts of the kidney do neutrophils invade? Which
parts do they spare? Neutrophils invade renal interstitium but spare glomeruli
and vessels "<img src=""8340.png"">" Pathology pyelonephritis renal
What urinalysis finding suggests pyelonephritis in a febrile pt with flank
tenderness, nausea, and vomiting? Is this acute or chronic?White blood cell casts;
acute "<img src=""8340.png"">" Pathology pyelonephritis renal
A pt has had chronic pyelonephritis for many years. In this pt, what substance may
be filling the tubules of the renal nephrons? Eosinophilic casts, a
histopathologic biopsy finding known as thyroidization of the kidney "<img
src=""8340.png"">" Pathology pyelonephritis renal
Define diffuse cortical necrosis of the kidneys, and name two disease processes
that are associated with it. Acute generalized infarction of the cortices of both
kidneys; associated with obstetric problems (eg, abruptio placentae) and septic
shock "<img src=""8341.png"">" Pathology diffuse-cortical-necrosis renal
The pathology behind diffuse cortical necrosis is thought to be a combination of
which two pathologic processes? Vasospasm and DIC "<img src=""8341.png"">"
Pathology diffuse-cortical-necrosis renal
Renal osteodystrophy arises as a result of the failure of which kidney function?
Production of active vitamin D, leading to hypocalcemia and a secondary
increase in parathyroid hormone, resulting in bone loss "<img src=""8342.png"">"
Pathology renal renal-osteodystrophy
A bone scan in a pt with renal failure shows subperiosteal bone thinning; labs show
low vitamin D, hypocalcemia, and hyperphosphatemia. Dx? Renal osteodystrophy
(secondary hyperparathyroidism) "<img src=""8342.png"">" Pathology renal
renal-osteodystrophy
Renal osteodystrophy arises as a result of a failure of which step in vitamin D
processing? Vitamin D hydroxylation "<img src=""8342.png"">" Pathology renal
renal-osteodystrophy
In renal osteodystrophy, two mechanisms contribute to low serum calcium levels.
What are they? Low vitamin D reduces calcium absorption in the gut; high
phosphate sequesters serum calcium and leads to metastatic calcifications "<img
src=""8342.png"">" Pathology renal renal-osteodystrophy
What are three general categories of renal dysfunction that can lead to acute renal
injury? Prerenal (eg, hypotension and reduced renal blood flow), intrinsic (eg,
tubular necrosis), and postrenal (eg, outflow obstruction) "<img src=""8343.png"">"
Pathology acute-kidney-injury-(acute-renal-failure) renal
What is acute renal failure? A condition characterized by an abrupt decline in
renal function with elevated blood urea nitrogen and creatinine levels over several
days "<img src=""8343.png"">" Pathology acute-kidney-injury-(acute-renal-
failure) renal
How do urine osmolality and urine sodium differ in prerenal failure and intrinsic
renal failure? The kidneys are not functionally impaired in prerenal failure:
urine osmolality is higher and sodium is absorbed normally "<img src=""8343.png"">"
A bleeding man has a blood pressure of 95/65 and heart rate of 110. His BUN is 45;
creatinine is 1.5. Is there prerenal azotemia? Yes, the BUN/creatinine ratio is
&62; 20 (45/1.5 = 30) "<img src=""8343.png"">" Pathology acute-kidney-
injury-(acute-renal-failure) renal
A dehydrated man is hypotensive, and his kidneys desperately try to compensate,
promoting retention of which three substances? Sodium, water, and urea (in an
attempt to maintain blood volume) "<img src=""8343.png"">" Pathology acute-
kidney-injury-(acute-renal-failure) renal
Why does the blood urea nitrogen (BUN)/creatinine ratio increase in pts who have
low renal blood flow (RBF)? When RBF and the glomerular filtration rate are
reduced, urea is absorbed but creatinine is not (known as prerenal azotemia) "<img
src=""8343.png"">" Pathology acute-kidney-injury-(acute-renal-failure) renal
Name the main causes of acute intrinsic renal failure and the characteristic
urinary cast that suggests the presence of this condition. Acute tubular necrosis,
ischemia, toxic injury, and, rarely, acute glomerulonephritis; epithelial/granular
(muddy) casts "<img src=""8343.png"">" Pathology acute-kidney-injury-
(acute-renal-failure) renal
A pt presents with postrenal outflow obstruction that has caused acute renal
failure. What are some of the potential causes? Kidney stones, benign prostatic
hyperplasia, congenital anomalies, neoplasia (All must be bilateral unless there is
only one kidney.) "<img src=""8343.png"">" Pathology acute-kidney-injury-
(acute-renal-failure) renal
What is the BUN/Cr in intrinsic renal failure? Less than 15; kidneys not able to
absorb BUN "<img src=""8343.png"">" Pathology acute-kidney-injury-(acute-
renal-failure) renal
Urine osmolarity &62; 500, urine Na+ &60; 20, FeNa &60; 1%, BUN/creatinine ratio
&62; 20. What type of failure is this? Prerenal "<img src=""8343.png"">"
Urine osmolarity &60; 350, Na+ &62; 40, FeNa &62; 2%, BUN/creatinine ratio &62; 15.
What type of failure is this? Postrenal "<img src=""8343.png"">" Pathology
acute-kidney-injury-(acute-renal-failure) renal
Urine osmolarity &60; 350, Na+ &62; 40, FeNa &62; 2%, BUN/creatinine ratio &60; 15.
What type of failure is this? Intrinsic "<img src=""8343.png"">" Pathology
acute-kidney-injury-(acute-renal-failure) renal
How does the glomerular filtration rate (GFR) change in intrinsic renal failure?
GFR decreases as a result of fluid backflow caused by obstructing necrotic
debris in the tubules "<img src=""8343.png"">" Pathology acute-kidney-
A pt with severe BPH has an FENa of 1.2%. You check a day later, and the FENa has
risen to 2.5%. What does this tell you? This suggests progression of his
postrenal azotemia (An FENa of &62; 1% suggests mild azotemia, and an FENa of &62;
2% suggests severe azotemia.) "<img src=""8343.png"">" Pathology acute-kidney-
Define renal failure. The inability to make urine and excrete nitrogenous wastes
"<img src=""8344.png"">" Pathology consequences-of-renal-failure renal
In renal failure, what happens to K+, total body Na+, and serum pH? K+ increases
(hyperkalemia), sodium is retained, and pH is decreased (metabolic acidosis) "<img
src=""8344.png"">" Pathology consequences-of-renal-failure renal
What are the two main forms of renal failure? Acute (eg, ATN) and chronic (eg,
diabetes, hypertension, congenital anomalies) "<img src=""8344.png"">"
Pathology consequences-of-renal-failure renal
A man in chronic renal failure is found to be anemic. His iron levels are normal
and his diet balanced. What is likely causing his anemia? Impairment of
erythropoietin production by the diseased kidneys "<img src=""8344.png"">"
A man develops renal failure. Name three cardiovascular or cardiopulmonary
consequences of excess sodium and water retention in this man. Congestive heart
failure, hypertension, and pulmonary edema "<img src=""8344.png"">"
A pt who is noncompliant with dialysis presents with anorexia and pruritus. ECG
shows ST elevations in all leads. What happened? Uremia has developed as a
result of renal failure (noncompliance with dialysis); ST elevations in all leads
suggest uremic pericarditis "<img src=""8344.png"">" Pathology consequences-
of-renal-failure renal
What do renal osteodystrophy, dyslipidemia (elevated triglycerides), growth
retardation, and developmental delay have in common, renally? All are
consequences of renal failure "<img src=""8344.png"">" Pathology consequences-
of-renal-failure renal
A dialysis pt has a BUN of 120 and altered mental status. He is nauseated and
anorexic. What else do you expect to see on exam? One may also see
pericarditis, asterixis, encephalopathy, platelet dysfunction, or all four, as this
is uremia "<img src=""8344.png"">" Pathology consequences-of-renal-failure
renal
List some common consequences of renal failure. Use the mnemonic MAD HUNGER.
Metabolic Acidosis, Dyslipidemia, Hyperkalemia, Uremia, Na+/H2O retention,
slow Growth, low Erythropoietin, Renal osteodystrophy "<img src=""8344.png"">"
A woman presents with fever, rash, hematuria, and costovertebral angle tenderness.
She has taken NSAIDs for months for back pain. Diagnosis? Drug-induced
interstitial nephritis (tubulointerstitial nephritis) "<img src=""8345.png"">"
Pathology acute-interstitial-nephritis-(tubulointerstitial-nephritis) renal
How long after ingesting a substance does drug-induced interstitial nephritis
occur? Which lab findings suggest the diagnosis? Approximately 1 to 2 weeks
(but can occur months after ingestion of NSAIDs); pyuria (eosinophils), azotemia
"<img src=""8345.png"">" Pathology acute-interstitial-nephritis-
(tubulointerstitial-nephritis) renal
Name at least three types of drugs that are associated with interstitial nephritis.
Diuretics, penicillin derivatives, proton pump inhibitors, sulfonamides,
rifampin "<img src=""8345.png"">" Pathology acute-interstitial-nephritis-
(tubulointerstitial-nephritis) renal
A pt taking rifampin feels healthy. Renal biopsy, however, shows inflammation.
Could this be drug-induced interstitial nephritis? Yes, the presentation of
drug-induced interstitial nephritis (tubulointerstitial nephritis) can be
asymptomatic "<img src=""8345.png"">" Pathology acute-interstitial-
nephritis-(tubulointerstitial-nephritis) renal
What is the most common cause of acute kidney injury in hospitalized pts? What
happens if it is left untreated? Acute tubular necrosis; it is self-reversing in
some cases but can be fatal if left untreated "<img src=""8346.png"">"
Pathology acute-tubular-necrosis renal
A pt with sepsis is hypotensive. Urinalysis shows muddy brown casts and the pt has
oliguria. What is the cause of this renal pathology? Decreased renal blood flow,
causing ischemic damage to tubular cells (This is acute tubular necrosis.) "<img
src=""8346.png"">" Pathology acute-tubular-necrosis renal
What are the two broad categories of acute tubular necrosis? Ischemia resulting
from decreased blood flow and direct nephrotoxicity "<img src=""8346.png"">"
Pathology acute-tubular-necrosis renal
A normotensive ICU pt receives aminoglycosides and begins to decompensate. These
findings are noted on renal biopsy. High or low FENa? This is most likely
nephrotoxic injury caused by the aminoglycoside antibiotics, resulting in acute
tubular necrosis, so FENa is high "<img src=""8346.png"">" Pathology acute-
tubular-necrosis renal
A man with acute renal failure has hematuria, proteinuria, and muddy brown urine
casts. Death will most likely occur in which disease stage?The initial oliguric
phase (maintenance, lasting 13 weeks) if dialysis is not started (The pt has acute
tubular necrosis.) "<img src=""8346.png"">" Pathology acute-tubular-
necrosis renal
What are the three stages of acute tubular necrosis? Inciting event, maintenance
(oliguria, hyperkalemia risk), and recovery (polyuria, BUN and serum creatinine
fall, hypokalemia risk) "<img src=""8346.png"">" Pathology acute-tubular-
necrosis renal
An addict overdoses and begins seizing; hematuria develops and his creatinine rises
sharply. What type of casts do you expect on urinalysis? "Granular ""muddy
brown"" casts (The pt has acute tubular necrosis caused by myoglobinuria that
resulted from his seizure.)" "<img src=""8346.png"">" Pathology acute-tubular-
necrosis renal
What is the clinical presentation of renal papillary necrosis? Gross hematuria
and proteinuria (the result of sloughing of the renal papillae, often after an
infection or immune stimulus) "<img src=""8347.png"">" Pathology renal renal-
papillary-necrosis
Name at least two conditions associated with renal papillary necrosis. Sickle cell
disease or trait, Acute pyelonephritis, Analgesics (NSAIDs), Diabetes mellitus
(SAAD papa with papillary necrosis) "<img src=""8347.png"">" Pathology renal
renal-papillary-necrosis
Name the autosomal recessive disease that presents with multiple bilateral kidney
cysts and renal failure in infancy. Autosomal Recessive polycystic kidney disease
(ARPKD) (infantile polycystic kidney disease) "<img src=""8348.png"">"
Pathology renal renal-cyst-disorders
What is autosomal dominant polycystic kidney disease (ADPKD)? ADPKD is Autosomal
Dominant and characterized by multiple bilateral cysts that destroy the kidney
parenchyma during adulthood "<img src=""8348.png"">" Pathology renal renal-
cyst-disorders
A man has flank pain, hematuria, hypertension, and azotemia. His father and brother
have the same issues. What might brain imaging reveal? Berry aneurysms, as this
is likely Autosomal Dominant polycystic kidney disease (ADPKD) "<img
src=""8348.png"">" Pathology renal renal-cyst-disorders
A man has multiple liver and kidney cysts. Echocardiogram shows mitral valve
prolapse. Do you expect the kidney cysts to be bilateral? Yes, because autosomal
dominant polycystic kidney disease presents with bilateral renal cysts "<img
A pt presents with renal medullary cystic disease. What are the hallmark
characteristics that you expect to find on workup? Small kidneys, fibrosis,
progressive renal insufficiency, and urine-concentrating defects "<img
What cause of death is associated with autosomal dominant polycystic kidney
disease? Death is most commonly due to complications of chronic kidney disease
or hypertension (due to increased renin production) "<img src=""8348.png"">"
Which liver disease is associated with autosomal recessive polycystic kidney
disease? Congenital hepatic fibrosis leading to portal hypertension and liver
cirrhosis "<img src=""8348.png"">" Pathology renal renal-cyst-disorders
What are the complications of autosomal recessive polycystic kidney disease in
utero and after the neonatal period? In utero: renal failure leading to Potter
sequence; neonatal: hypertension, portal hypertension, progressive renal and liver
insufficiency "<img src=""8348.png"">" Pathology renal renal-cyst-
disorders
A man on dialysis is found to have multiple cortical and medullary cysts, all
anechoic on ultrasound. Are these of concern? No, these are likely to be simple
cysts that are not of clinical concern "<img src=""8348.png"">" Pathology
renal renal-cyst-disorders
An elderly pt is found to have several cortical renal cysts that are thin and
filled with ultrafiltrate. Are these lesions malignant? Unlikely; they are more
likely to be simple cysts, which are a benign, asymptomatic, incidental finding in
older adults "<img src=""8348.png"">" Pathology renal renal-cyst-
disorders
Renal biopsy of a pt with kidney failure shows tubulointerstitial fibrosis.
Ultrasound fails to visualize medullary cysts. Prognosis? The prognosis is poor,
as this is likely medullary cystic disease "<img src=""8348.png"">"
A pt's CT scan incidentally shows septated, enhancing renal cysts. He is healthy
and asymptomatic. Is follow-up imaging recommended? Yes, because these cysts have
complex features (eg, septation, enhancement, solid parts) and must be monitored
(renal cell carcinoma risk) "<img src=""8348.png"">" Pathology renal renal-
cyst-disorders
A pt starts taking a potassium-sparing diuretic. What are the main electrolytes
absorbed and secreted at the site where this drug acts? Potassium-sparing
diuretics act on the collecting tubule, where NaCl (reabsorbed), K+ (secreted), and
H+ (secreted) are exchanged "<img src=""8349.png"">" diuretics:-site-of-
action pharmacology renal
A pt takes mannitol. On which segments of the nephron does an osmotic agent such as
mannitol exert its diuretic effects? Proximal convoluted tubule and the thin
descending loop of Henle "<img src=""8349.png"">" diuretics:-site-of-
action pharmacology renal
Where are calcium and magnesium reabsorbed by the nephron? The thick ascending limb
of the loop of Henle, in the cortex "<img src=""8349.png"">" diuretics:-site-
of-action pharmacology renal
Secretion of potassium and hydrogen occurs in which part of the collecting tubule
of the nephron? The cortical part "<img src=""8349.png"">" diuretics:-site-
of-action pharmacology renal
Which part of the nephron is freely permeable to water, but not to electrolytes?
The thin descending limb of the loop of Henle "<img src=""8349.png"">"
diuretics:-site-of-action pharmacology renal
A pt takes acetazolamide for altitude sickness. What are the main electrolytes
reabsorbed at the site where this drug acts? It acts on the proximal convoluted
tubule, where sodium, sugars, amino acids and HCO3- "<img src=""8349.png"">"
A man receives loop diuretics for a heart failure flare. How permeable to water is
the site where they act? Are electrolytes absorbed there? They act on the thick
ascending loop of Henle, impermeable to water; yes, Na+, Mg2+, Ca2+, and Cl- are
reabsorbed there "<img src=""8349.png"">" diuretics:-site-of-action
pharmacology renal
A pt starts taking a thiazide diuretic for hypertension. Does it act on the
cortical or medullary part of the nephron? Thiazide diuretics act on the
distal convoluted tubule, located in the cortex "<img src=""8349.png"">"
A pt takes a diuretic for increased intracranial pressure. What is the drug and its
mechanism of action? Mannitol, an osmotic diuretic, which increases tubular
fluid osmolarity and therefore urine flow rate (also acts on intraocular pressure)
"<img src=""8350.png"">" mannitol pharmacology renal
A pt with anuria presents with heart failure. Is it safe to give this pt an osmotic
diuretic? No, osmotic diuretics such as mannitol are contraindicated in pts with
anuria and/or heart failure "<img src=""8350.png"">" mannitol pharmacology
renal
A pt takes acetazolamide. Name at least two toxicities associated with this
medication. "Proximal renal tubular acidosis (""ACID""azolamide causes ACIDosis),
paresthesias, ammonia toxicity, sulfa allergic reactions" "<img src=""8351.png"">"
acetazolamide pharmacology renal
A pt starts taking acetazolamide for mild altitude sickness. What is the mechanism
of action of this drug? It acts as a carbonic anhydrase inhibitor, causing self-
limited sodium bicarbonate diuresis and a reduction in total body bicarbonate
stores "<img src=""8351.png"">" acetazolamide pharmacology renal
Name some clinical indications for acetazolamide. Glaucoma, urinary
alkalinization, metabolic alkalosis, altitude sickness, pseudotumor cerebri "<img
src=""8351.png"">" acetazolamide pharmacology renal
What are three (general) clinical uses for loop diuretics? To treat edematous
states (congestive heart failure, cirrhosis, nephrotic syndrome, pulmonary edema),
hypertension, and hypercalcemia "<img src=""8352.png"">" loop-diuretics
pharmacology renal
What is the mechanism of action of loop diuretics? They block Na+/K+/Cl- thick
ascending limb cotransporters, abolish medullary hypertonicity, and prevent urine
concentration "<img src=""8352.png"">" loop-diuretics pharmacology renal
What is the effect of the loop diuretic furosemide on calcium handling in the
kidney nephron? Furosemide increases calcium excretion (Loops Lose Ca2+) "<img
src=""8352.png"">" loop-diuretics pharmacology renal
Name at least four toxicities associated with use of loop diuretics. Ototoxicity,
Hypokalemia, Dehydration, Allergy (sulfa)/metabolic Alkalosis, Nephritis
(interstitial), Gout (OH DANG!) "<img src=""8352.png"">" loop-diuretics
pharmacology renal
When would ethacrynic acid (a phenoxyacetic acid derivative) be a good choice for a
pt? When a loop diuretic is needed, but the pt has a sulfa drug allergy "<img
src=""8352.png"">" loop-diuretics pharmacology renal
A pt taking torsemide is noted to have dilated renal afferent arterioles. This
effect is blocked by NSAIDs. What is happening? Torsemide, a loop diuretic, dilates
the afferent arterioles by stimulating prostaglandin E (PGE) release, an effect
inhibited by NSAIDs "<img src=""8352.png"">" loop-diuretics pharmacology
renal
A pt with a sulfa allergy needs urgent loop diuretic diuresis due to heart failure.
What medication can you offer him? Ethacrynic acid, as it is a phenoxyacetic acid
derivative, not a sulfonamide, with the same mechanism of action as other loop
diuretics "<img src=""8352.png"">" loop-diuretics pharmacology renal
What is the most concerning toxicity of ethacrynic acid, especially as compared
with other agents in this drug class? Ethacrynic acid (nonsulfonamide) is much
more ototoxic than the sulfonamide loop diuretics (Loop earrings hurt your ears.)
"<img src=""8352.png"">" loop-diuretics pharmacology renal
Serum levels of which substances are increased as a result of the effects of
thiazide diuretics such as metolazone? Glucose (hyperGlycemia), lipids
(hyperLipidemia), uric acid (hyperUricemia), and calcium (hyperCalcemia)
(hyperGLUC) "<img src=""8353.png"">" pharmacology renal thiazide-diuretics
What happens to calcium when a loop diuretic is used? When a thiazide diuretic is
used? Loop diuretics cause calcium wasting, while thiazide diuretics cause
increased calcium reabsorption "<img src=""8353.png"">" pharmacology renal
thiazide-diuretics
Name some clinical uses of thiazide diuretics. To treat hypertension, congestive
heart failure, idiopathic hypercalciuria, nephrogenic diabetes insipidus, and
osteoporosis "<img src=""8353.png"">" pharmacology renal thiazide-
diuretics
What acid-base abnormality is associated with thiazide diuretic use? Hypokalemic
metabolic alkalosis "<img src=""8353.png"">" pharmacology renal thiazide-
diuretics
A pt of yours with a history of gout and diabetes wants to start taking
hydrochlorothiazide for hypertension. You refuse. Why? Hydrochlorothiazide
increases levels of both uric acid and glucose, which may worsen the pt's gout and
diabetes, respectively "<img src=""8353.png"">" pharmacology renal thiazide-
diuretics
A pt of yours starts taking chlorthalidone for hypertension and notes fewer kidney
stone attacks. Why might this be happening? Hydrochlorothiazide increases DCT
reabsorption of calcium, which reduces the likelihood of calcium-containing stones
in the urine "<img src=""8353.png"">" pharmacology renal thiazide-
diuretics
What are the mechanisms of action of spironolactone and eplerenone? What about
triamterene and amiloride? Spironolactone/eplerenone competitively antagonize
the aldosterone receptor; triamterene/amiloride block the collecting duct's Na+
channels "<img src=""8354.png"">" pharmacology potassium-sparing-diuretics
renal
Name some clinical uses of potassium-sparing diuretics. To treat
hyperaldosteronism, potassium depletion, congestive heart failure, ascites
(spironolactone), nephrogenic DI (amiloride) "<img src=""8354.png"">"
pharmacology potassium-sparing-diuretics renal
A pt begins taking a second diuretic to offset the effect of furosemide. What part
of the nephron does this second diuretic act on? The cortical collecting
tubule, as this is likely a potassium-sparing diuretic "<img src=""8354.png"">"
pharmacology potassium-sparing-diuretics renal
Your pt is starting to take a potassium-sparing diuretic and is worried about side
effects. What do you tell him? Side effects include hyperkalemia (leading to
arrhythmias) and endocrine effects w/spironolactone (eg, gynecomastia &
antiandrogen effects) "<img src=""8354.png"">" pharmacology potassium-
sparing-diuretics renal
What is the mechanism by which potassium-sparing diuretics cause acidemia?
Hyperkalemia leads to potassium entering all cells via the H+/K+ exchanger in
exchange for H+ exiting cells "<img src=""8355.png"">" diuretics:-electrolyte-
changes pharmacology renal
A pt taking a carbonic anhydrase inhibitor develops acidemia. What is the likely
cause? Acetazolamide causes the kidney to decrease HCO3 reabsoprtion, thereby
decreasing the body's pH and leading to acidemia "<img src=""8355.png"">"
diuretics:-electrolyte-changes pharmacology renal
A pt is noted to have low serum potassium and high levels of potassium in the
urine. Could a diuretic be responsible? Yes, because all except the potassium-
sparing diuretics can cause these findings "<img src=""8355.png"">"
What happens to blood pH with overuse of loop and thiazide diuretics? What about
overuse of acetazolamide? Loop diuretics and thiazides raise blood pH;
acetazolamide and K+-sparing diuretics lower blood pH "<img src=""8355.png"">"
What is the effect on urinary calcium excretion of loop diuretics and thiazide
diuretics, respectively? Loop diuretics increase it (decreased paracellular
reabsorption ); thiazides decrease it (enhanced reabsorption in distal convoluted
tubule) "<img src=""8355.png"">" diuretics:-electrolyte-changes
pharmacology renal
A pt taking a loop diuretic is noted to have elevated calcium in his urine. Is the
loop diuretic responsible? Yes, loop diuretics decrease paracellular Ca2+
reabsorption, leading to increased urinary Ca2+ levels and hypocalcemia "<img
src=""8355.png"">" diuretics:-electrolyte-changes pharmacology renal
What mechanism underlies volume contraction alkalosis? Volume contraction
increases angiotensin II activity, increasing proximal tubule H+/Na+ exchange and
HCO3- reabsorption "<img src=""8355.png"">" diuretics:-electrolyte-
In a pt taking diuretics, labs show a high urine sodium and a low serum sodium. Can
you pinpoint which diuretic(s) may be responsible? No, as all diuretics can
cause this effect (depending on the potency of the diuretic effect); this is a
nonspecific finding "<img src=""8355.png"">" diuretics:-electrolyte-
By what mechanism involving all cells does potassium loss lead to alkalemia? K+
exits all cells (to maintain a normal serum level) in exchange for H+ entering
cells (causing the alkalemia) "<img src=""8355.png"">" diuretics:-electrolyte-
How does a low potassium state lead to alkalemia and a paradoxical aciduria? H+
rather than K+ is exchanged for Na+ at the cortical collecting tubule "<img
src=""8355.png"">" diuretics:-electrolyte-changes pharmacology renal
What type of drug is lisinopril? Name some other drugs in this class. An
angiotensin-converting enzyme inhibitor; other examples are captopril, enalapril,
and ramipril (all end with -pril) "<img src=""8356.png"">" angiotensin-
converting-enzyme-inhibitors pharmacology renal
A pt taking an ACE inhibitor is noted to have a high serum renin level. Why is this
the case? Loss of feedback inhibition (reduced angiotensin II and GFR by
preventing constriction of efferent arterioles) "<img src=""8356.png"">"
angiotensin-converting-enzyme-inhibitors pharmacology renal
A pt starts taking lisinopril. Weeks later, he complains of a chronic dry cough.
What medication change would you suggest? ARBs such as losartan are less likely to
cause coughing as a side effect (they do not increase bradykinin) than are ACE
inhibitors "<img src=""8356.png"">" angiotensin-converting-enzyme-inhibitors
pharmacology renal
Angioedema develops in a man taking an ACE inhibitor. How is the medication
responsible for this? ACE inhibitors prevent the inactivation of bradykinin, a
potent vasodilator; increased bradykinin levels cause angioedema in some pts "<img
src=""8356.png"">" angiotensin-converting-enzyme-inhibitors pharmacology renal
A pt taking an ACE inhibitor develops an arrhythmia. An electrolyte abnormality is
found to be the cause. Which electrolyte is abnormal? Potassium, since ACE
inhibitors can cause hyperkalemia "<img src=""8356.png"">" angiotensin-
converting-enzyme-inhibitors pharmacology renal
Your pt is starting to take an ACE inhibitor and is worried about side effects.
What do you tell him? Side effects are Cough, Angioedema, Teratogen, Creatinine
increase (decreased GFR), Hyperkalemia, Hypotension (Captopril's CATCHH) "<img
A pt with no known renal pathologies starts taking an ACE inhibitor; soon after,
acute kidney injury develops. What condition may he have? Bilateral renal artery
stenosis (These pts are dependent on angiotensin II to maintain their glomerular
filtration rate.) "<img src=""8356.png"">" angiotensin-converting-enzyme-
inhibitors pharmacology renal
You are counseling a pt about angiotensin-converting enzyme (ACE) inhibitors. What
are some clinical uses? Decrease mortality from heart failure; treat proteinuria,
HTN, diabetic nephropathy; prevent heart remodeling resulting from chronic HTN
"<img src=""8356.png"">" angiotensin-converting-enzyme-inhibitors
pharmacology renal
You prescribe an ACE inhibitor for a woman with diabetic nephropathy. How do you
describe this drug's mechanism of action? Decreasing intraglomerular pressure with
ACE inhibitors slows glomerular basement membrane thickening "<img
A pt has C2 esterase inhibitor deficiency. What renal medication must you avoid
prescribing for him and why? Avoid ACE inhibitors due to the adverse effect of
angioedema (from inactivation of bradykinin, a potent vasodilator) "<img
A pt is switched from an ACE inhibitor to an ARB because of side effects. Why is
the ARB mechanism better for this pt? ACE inhibitors can lead to angioedema by
increasing bradykinin; ARBs do not inhibit ACE and therefore do not increase
bradykinin "<img src=""8357.png"">" angiotensin-ii-receptor-blockers
pharmacology renal
A man switches from an ACE inhibitor to an ARB. What do you expect levels of renin,
angiotensin I (AT I), and angiotensin II (AT II) to be? Renin and AT I remain
high, but now AT II is high as a result of blockage of the AT1 receptor instead of
ACE "<img src=""8357.png"">" angiotensin-ii-receptor-blockers pharmacology
renal
What are the side effects of ARBs? Hyperkalemia, decreased renal function,
hypotension; teratogenicity "<img src=""8357.png"">" angiotensin-ii-receptor-
blockers pharmacology renal
Name some clinical indications for ARBs. Hypertension, HF, proteinuria, or
diabetic nephropathy with intolerance to ACE inhibitors (eg, cough, angioedema)
"<img src=""8357.png"">" angiotensin-ii-receptor-blockers pharmacology
renal
A pt has tried ACE inhibitors, ARBs, and spironolactone. What other medication
would you suggest that acts on the RAAS? A direct renin inhibitor such as
aliskiren, which blocks conversion of angiotensinogen to angiotensin I "<img
src=""8358.png"">" aliskiren pharmacology renal
A pt was recently switched from an ACE inhibitor to aliskiren. What change would
you expect in the RAAS? Aliskiren is a direct renin inhibitor, so angiotensinogen
would increase, whereas angiotensin I would decrease "<img src=""8358.png"">"
aliskiren pharmacology renal
A diabetic man was recently switched to an ARB from an ACE inhibitor. His blood
pressure is still not ideal. Should you consider aliskiren?Probably not, as it is
relatively contraindicated in diabetic pts already taking an ACE inhibitor or ARB
"<img src=""8358.png"">" aliskiren pharmacology renal
You prescribe aliskiren for a pt. What side effects should you counsel him about?
Hyperkalemia, decreased renal function, hypotension (also relatively
contraindicated in pts already taking ACE inhibitors or ARBs) "<img
src=""8358.png"">" aliskiren pharmacology renal
What is the gene that is expressed at the base of limbs in a zone of polarizing
activity? Sonic hedgehog gene "<img src=""8359.png"">" embryology
important-genes-of-embryogenesis reproductive
Along what axis does the sonic hedgehog gene regulate patterning? In what system's
development does it play a key role? The anterior-posterior axis; the CNS
"<img src=""8359.png"">" embryology important-genes-of-embryogenesis
reproductive
For a newborn with a known sonic hedgehog gene mutation, what is the most likely
abnormal finding? Holoprosencephaly "<img src=""8359.png"">" embryology
important-genes-of-embryogenesis reproductive
Name two genes expressed at the apical ectodermal ridge (the thickened ectoderm at
the distal end of each developing limb). Wnt-7 and FGF "<img src=""8359.png"">"
embryology important-genes-of-embryogenesis reproductive
What is the gene responsible for proper organization along the dorsal-ventral axis?
Wnt-7 "<img src=""8359.png"">" embryology important-genes-of-
embryogenesis reproductive
What gene is responsible for the lengthening of limbs? FGF "<img
src=""8359.png"">" embryology important-genes-of-embryogenesis reproductive
You observe insufficient mitosis of underlying mesoderm in an embryo, and the limbs
are short. What gene could be defective? FGF, which stimulates mitosis of the
underlying mesoderm and promotes limb lengthening "<img src=""8359.png"">"
You notice defects in segmental organization in the cranial-caudal direction in an
embryo. What gene could be mutated? Homeobox (Hox) genes "<img src=""8359.png"">"
You observe an embryo that is notable for the presence of appendages in several
wrong locations. Which gene is likely mutated? Homeobox (Hox) genes "<img
src=""8359.png"">" embryology important-genes-of-embryogenesis reproductive
What is formed when a sperm fertilizes an ovum? The zygote (formation of the zygote
defined as day 0) "<img src=""8360.png"">" early-fetal-development embryology
reproductive
At what stage of development does implantation in the uterine wall occur? What
important hormone secretion also begins at this time? The blastocyst stage (it
'sticks' at day 6); hCG secretion "<img src=""8360.png"">" early-fetal-
development embryology reproductive
You observe that an embryo exists as a bilaminar disc. How many weeks old is the
embryo? 2 weeks = 2 layers (bilaminar disc consists of the epiblast and the
hypoblast) "<img src=""8360.png"">" early-fetal-development embryology
reproductive
You observe that an embryo exists as a trilaminar disc. How many weeks old is the
embryo? 3 weeks = 3 layers "<img src=""8360.png"">" early-fetal-
The neural plate of an embryo is starting to form. How many weeks old is the
embryo? 3 weeks "<img src=""8360.png"">" early-fetal-development
embryology reproductive
You note initial development of the notochord and primitive streak. How many weeks
old is the embryo? 3 weeks "<img src=""8360.png"">" early-fetal-
You are starting to see organ development in an embryo. During what weeks of
embryonic development does organogenesis occur? Weeks 38 (the embryonic period
"<img src=""8360.png"">" early-fetal-development embryology reproductive
From which germ layer does an embryo's neural tube form? At which week does the
neural tube close? Neuroectoderm; week 4 "<img src=""8360.png"">" early-
fetal-development embryology reproductive
A pregnant woman wants to know the time period during which her baby is most
susceptible to teratogens. What do you tell her? Weeks 38 "<img
src=""8360.png"">" early-fetal-development embryology reproductive
You note that the heart is beginning to beat in an embryo. In what week of
development is the embryo? Week 4 (4 heart chambers) "<img src=""8360.png"">"
early-fetal-development embryology reproductive
You note the appearance of upper and lower limb buds in an embryo. Approximately
how many weeks old is the embryo? 4 weeks (4 limbs) "<img src=""8360.png"">"
early-fetal-development embryology reproductive
When is fetal cardiac activity first visible by transvaginal ultrasound? Week 6
A patient wants to know the sex of her fetus. During which week of development can
the first male/female characteristics be distinguished? Week 10 "<img
During embryonic development, what event occurs around days 610? Implantation
in the uterine wall "<img src=""8360.png"">" early-fetal-development
You note that a zygote has divided into a morula. During what day of embryogenesis
does this event occur? Day 4 "<img src=""8360.png"">" early-fetal-development
Tests on an impregnated mouse show an embryo at day 1 of development in the
fallopian tube. What is the chromosomal makeup of the embryo? 2N4C "<img
Tests on an impregnated mouse show a zygote at day 2 of development in the
fallopian tube. What will a serum hCG measurement show? The serum hCG
measurement will be negativehCG secretion does not generally begin until the
blastocyst implants (around 6 days) "<img src=""8360.png"">" early-fetal-
Tests on an impregnated mouse show an embryo at day 7 of development in the uterus.
What will a serum hCG measurement show? The serum hCG measurement will be
positive, because hCG secretion generally begins after the blastocyst implants
(usually on day 6) "<img src=""8360.png"">" early-fetal-development
What process forms the trilaminar disc? At what week of development? How do the
three germ layers then arise? Gastrulation; week 3; the epiblast invaginates,
forming the primitive streak, which becomes the endoderm, mesoderm, and ectoderm
A patient is excited about her pregnancy and asks you when she will start to feel
fetal movement. What do you tell her? Week 8 (when there is gait) "<img
After an ovarian follicle ruptures, what structure is left behind in the ovary?
Without fertilization, what is this structure's fate? Corpus luteum; degeneration
What embryonic structure becomes the notochord? What about the neural plate? At
what week of development does all of this occur? Midline mesoderm; overlying
ectoderm; week 3 "<img src=""8360.png"">" early-fetal-development embryology
reproductive
In the ovary, what cell is released from a follicle after ovulation? What is the
chromosomal composition of this cell? Secondary oocyte; 1N1C "<img
On what day of embryogenesis does the embryo enter the uterus? In what
developmental stage is the embryo at that time? Day 4; morula "<img
What germ layer gives rise to the autonomic ganglia? Ectoderm (neural crest) "<img
src=""8361.png"">" embryologic-derivatives embryology reproductive
What germ layer gives rise to the thyroid follicular cells?Endoderm (luminal
epithelial derivatives) "<img src=""8361.png"">" embryologic-derivatives
What germ layer gives rise to the testes? Mesoderm "<img src=""8361.png"">"
embryologic-derivatives embryology reproductive
What germ layer gives rise to the mammary glands? Ectoderm (surface ectoderm)
"<img src=""8361.png"">" embryologic-derivatives embryology reproductive
What germ layer gives rise to the gut tube epithelium? Endoderm "<img
What germ layer gives rise to the chromaffin cells of the adrenal medulla?
Ectoderm (neural crest) "<img src=""8361.png"">" embryologic-derivatives
What germ layer gives rise to the gallbladder? Endoderm (a luminal epithelial
derivative) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to the sensory organs of the ear? Ectoderm (surface
ectoderm) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to the dermis? Mesoderm "<img src=""8361.png"">"
What germ layer gives rise to the spinal cord? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the parafollicular (C) cells of the thyroid?
Ectoderm (neural crest) "<img src=""8361.png"">" embryologic-derivatives
What germ layer gives rise to the lungs? Endoderm (a luminal epithelial
reproductive
What germ layer gives rise to the ovaries? Mesoderm "<img src=""8361.png"">"
A neonate is born with defects in embryogenesis involving the mesodermal germ
layer. What are some common abnormalities? VACTERL: Vertebral, Anal atresia,
Cardiac, Tracheo-Esophageal fistula, Renal, Limb (bone/muscle) (Mesoderm:
Middle/Meat layer) "<img src=""8361.png"">" embryologic-derivatives
Generally speaking, from which germ layer is the CNS derived? What about the PNS
and its nearby non-neural associated structures? Neuroectoderm; neural crest
cells "<img src=""8361.png"">" embryologic-derivatives embryology reproductive
Generally speaking, in fetal development, which germ layer gives rise to the
external and outer layers of the fetus? Ectoderm (the external/outer layer) "<img
Generally speaking, in fetal development, which germ layer gives rise to the
internal linings (eg, gut tube epithelium) of the fetus? "Entoderm (the
""enternal"" layer)" "<img src=""8361.png"">" embryologic-derivatives
What germ layer subset's formation does the notochord induce? Neuroectoderm (the
neural plate), derived from ectoderm "<img src=""8361.png"">" embryologic-
derivatives embryology reproductive
What is the only postnatal derivative to arise from the notochord? The nucleus
pulposus of the intervertebral discs "<img src=""8361.png"">" embryologic-
What germ layer gives rise to the lens of the eye? Ectoderm (surface ectoderm)
What germ layer gives rise to serous linings of body cavities such as the
peritoneum? Mesoderm "<img src=""8361.png"">" embryologic-derivatives
What germ layer gives rise to the spleen? Mesoderm (derived from foregut mesentery)
What germ layer gives rise to the aorticopulmonary septum? Ectoderm (neural crest)
What germ layer gives rise to astrocytes? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the retina? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the dorsal root ganglia? Ectoderm (neural crest)
What germ layer gives rise to the upper vagina? The lower vagina? Mesoderm;
endoderm (derived from urogenital sinus) "<img src=""8361.png"">" embryologic-
What germ layer gives rise to the eustachian tubes? Endoderm (luminal epithelial
derivatives) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to the bones of the skull? Ectoderm (neural crest) "<img
What germ layer gives rise to the endocardial cushions? Ectoderm (neural crest)
What germ layer gives rise to the thymus? Endoderm (a luminal epithelial
reproductive
Generally speaking, what germ layer gives rise to cardiovascular structures?
Mesoderm "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to most of the bones in the body? Mesoderm "<img
Generally speaking, what germ layer gives rise to luminal epithelial derivatives
such as the lungs? Endoderm "<img src=""8361.png"">" embryologic-
What germ layer gives rise to the kidneys? Mesoderm "<img src=""8361.png"">"
What germ layer gives rise to muscle? Mesoderm "<img src=""8361.png"">"
What germ layer gives rise to the pancreas? Endoderm (a luminal epithelial
reproductive
What germ layer gives rise to the brain? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the pia mater? Ectoderm (neural crest) "<img
What germ layer gives rise to most of the urethra? Endoderm (derived from
urogenital sinus) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to the epidermis? Ectoderm (surface ectoderm) "<img
What germ layer gives rise to the arachnoid mater? Ectoderm (neural crest) "<img
What germ layer gives rise to Schwann cells? Ectoderm (neural crest) "<img
What germ layer gives rise to the ependymal cells? Ectoderm (neuroectoderm)
What germ layer gives rise to the anal canal above the pectinate line? Below it?
Endoderm; ectoderm (surface ectoderm) "<img src=""8361.png"">"
What germ layer gives rise to the liver? Endoderm (a luminal epithelial
reproductive
What germ layer gives rise to the parathyroid glands? Endoderm (luminal epithelial
derivatives) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to the epithelial linings of the oral cavity?
Ectoderm (surface ectoderm) "<img src=""8361.png"">" embryologic-
What germ layer gives rise to the CNS neurons? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to oligodendrocytes? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the cranial nerves? Ectoderm (neural crest) "<img
What germ layer gives rise to the neurohypophysis? Ectoderm (neuroectoderm)
What germ layer gives rise to the olfactory epithelium? Ectoderm (surface
ectoderm) "<img src=""8361.png"">" embryologic-derivatives embryology
reproductive
What germ layer gives rise to connective tissue? Mesoderm "<img
What germ layer gives rise to the pineal gland? Ectoderm (neuroectoderm) "<img
What germ layer gives rise to the adenohypophysis? Ectoderm (surface ectoderm,
from Rathke pouch) "<img src=""8361.png"">" embryologic-derivatives
What germ layer gives rise to the sweat glands? Ectoderm (surface ectoderm) "<img
What germ layer gives rise to the parotid glands? Ectoderm (surface ectoderm)
What germ layer gives rise to the adrenal cortex? Mesoderm "<img
What germ layer gives rise to melanocytes? Ectoderm (neural crest) "<img
What germ layer gives rise to odontoblasts? Ectoderm (neural crest) "<img
An infant is born with a malformation-type error in organ morphogenesis. During
what period of development does this occur? Embryonic period (weeks 38) "<img
src=""8362.png"">" embryology reproductive types-of-errors-in-organ-
morphogenesis
You noticed structural abnormalities in a fetus due to compression by extrinsic
mechanical forces. What type of morphogenesis error is this? Deformation, which
is due to extrinsic disruption after the embryonic period "<img src=""8362.png"">"
embryology reproductive types-of-errors-in-organ-morphogenesis
You note the absence of both an organ and its primordial tissue in a fetus. What
type of morphogenesis error is this? Agenesis "<img src=""8362.png"">"
You note the total absence of an organ in a fetus even though the primordial tissue
is present. What type of morphogenesis error is this? Aplasia "<img
morphogenesis
You note incomplete development of a fetal organ in the presence of its primordial
tissue. How would you categorize this observation? Hypoplasia "<img
morphogenesis
A fetus has entrapment of normal tissues by amniotic bands, causing secondary
breakdown. What type of error in organ morphogenesis is this? Disruption (the
example given is amniotic band syndrome) "<img src=""8362.png"">" embryology
reproductive types-of-errors-in-organ-morphogenesis
A neonate presents with abnormalities that resulted from a single embryologic
event. What type of organ morphogenesis error is this? Sequence (an example is
oligohydramnios resulting in the Potter sequence) "<img src=""8362.png"">"
A 2-week-old embryo is exposed to a teratogen; what is the likely effect on
development? Before week 3, there is usually an all-or-none effect (either
embryonal demise or no abnormalities) "<img src=""8363.png"">" embryology
reproductive teratogens
What embryonic process is occurring when the fetus is most susceptible to
teratogens? Organogenesis, between the third and eighth weeks of pregnancy "<img
src=""8363.png"">" embryology reproductive teratogens
A fetus is exposed to a teratogen after 8 weeks of pregnancy; will organogenesis be
affected? No (typically after 8 weeks, growth and function are affected, but not
organogenesis) "<img src=""8363.png"">" embryology reproductive teratogens
A woman is exposed to alcohol during her pregnancy. What might you expect to see in
her child? Birth defects and intellectual disabilityfetal alcohol syndrome is
possible "<img src=""8363.png"">" embryology reproductive teratogens
A pregnant woman is taking ACE inhibitors. This can lead to damage of what organ in
the fetus? The kidney "<img src=""8363.png"">" embryology reproductive
teratogens
A 26-year-old pregnant woman regularly abuses a drug that causes vasoconstriction.
For what four complications is her fetus most at risk? This is cocaine, which
can cause low birth weight, preterm birth, IUGR, and placental abruption "<img
A fetus is exposed to a drug that increases her risk of vaginal clear cell
adenocarcinoma. For what other condition is she at risk? Diethylstilbestrol, in
addition to increased vaginal clear cell adenocarcinoma risk, can cause congenital
Mllerian anomalies "<img src=""8363.png"">" embryology reproductive
teratogens
A young woman is diagnosed with clear cell carcinoma of the vagina. This cancer is
associated with exposure to what teratogen in utero? Diethylstilbestrol "<img
A 24-year-old woman refuses to quit smoking during her pregnancy. What are the
consequences of tobacco use during pregnancy? Low birth weight (leading cause in
developed countries), preterm labor, placental problems, IUGR, SIDS "<img
A fetus is exposed to an excess of iodine in utero. Name two teratogenic effects
from this. How would iodine deficiency differ? Congenital goiter and
hypothyroidism (cretinism); iodine deficiency can cause the same two effects "<img
A 23-year-old woman takes the acne treatment isotretinoin during pregnancy. What
might result? Multiple severe birth defects (contraception is mandatory when
patients are taking isoTERATinoin) "<img src=""8363.png"">" embryology
"A boy has ""flipper"" limbs. Define this condition. What teratogen was he most
likely exposed to in utero?" The defect is known as phocomelia or micromelia;
thalidomide (limb defects with tha-limb-domide) "<img src=""8363.png"">"
embryology reproductive teratogens
An infant is born with discolored teeth. What antibiotic was the fetus exposed to
in utero? "Tetracyclines (""teethracyclines"")" "<img src=""8363.png"">"
A woman undergoes chemotherapy with alkylating agents during her pregnancy; what
fetal abnormalities are you concerned about? Multiple anomalies, including
absence of digits "<img src=""8363.png"">" embryology reproductive teratogens
An infant is exposed to aminoglycoside antibiotics in utero. What deficit should
you test for? Ototoxicity (cranial nerve VIII toxicity) from aminoglycosides (a
mean guy hit the baby in the ear) "<img src=""8363.png"">" embryology
What birth defects might occur in a pregnant woman taking antiepileptic drugs?
Neural tube defects, cardiac defects, cleft palate, skeletal abnormalities
(eg, phalanx/nail hypoplasia, facial dysmorphism) "<img src=""8363.png"">"
A 25-year-old bipolar woman gives birth to a child with a cardiac anomaly. What
medication was she taking, and what is the anomaly? Lithium; Ebstein anomaly
(apical discplacement of tricuspid valve) "<img src=""8363.png"">" embryology
A baby is born with sirenomelia. The defect is associated with what maternal
condition? Diabetes "<img src=""8363.png"">" embryology reproductive
teratogens
A mother with poorly controlled diabetes may give birth to infants with which
defects? Caudal regression syndrome (anal atresia to sirenomelia), neural tube
defects, congenital heart defects, macrosomia "<img src=""8363.png"">"
A 23-year-old woman is exposed to a teratogen that lead shielding could have
blocked. What birth defects could occur? Microcephaly and intellectual disability
(caused by exposure to X-rays) "<img src=""8363.png"">" embryology
A newborn presents with aplasia cutis congenita. What medication could cause this
defect? Methimazole (usually used to treat hyperthyroidism) "<img
A woman who smoked during pregnancy has a baby with low birth weight. What is the
proposed mechanism behind this? Nicotine causes vasoconstriction, and CO
impairs O2 deliverysmoking is the leading cause of low birth weight in developed
countries "<img src=""8363.png"">" embryology reproductive teratogens
A pregnant woman takes vitamin A in excess. What teratogenic effect does this have
on her fetus? Too much maternal vitamin A carries an extremely high risk of
spontaneous abortion and birth defects (cleft palate, cardiac anomalies) "<img
A pregnant woman does not consume enough iodine in her diet. What might you expect
in her baby? Congenital goiter or hypothyroidism (cretinism)excessive iodine
can also cause these defects "<img src=""8363.png"">" embryology reproductive
teratogens
A pregnant woman takes valproate for seizures. What medication must she be
prescribed if she continues the valproate? High-dose folate (important for all
pregnant women taking antiepileptic drugs) "<img src=""8363.png"">"
Name four antiepileptic agents that should be avoided in pregnancy because of their
teratogenicity. Valproate, carbamazepine, phenytoin, phenobarbital "<img
What risk is associated with the use of folate antagonists such as trimethoprim,
methotrexate, and antiepileptic drugs during pregnancy? Neural tube defects
"<img src=""8363.png"">" embryology reproductive teratogens
A seafood-loving mother's newborn has diffuse nerve damage. Which fish should she
have avoided while dining at seafood restaurants? Swordfish, shark, tilefish,
and king mackerel all contain high levels of neurotoxic methylmercury "<img
Why is warfarin unsafe for use during pregnancy? It can cause bone
deformities, fetal hemorrhage, abortion, and ophthalmologic abnormalities "<img
A mother must change her anticoagulation during pregnancy because of the risk of
fetal bone defects. What can she take instead? Don't wage warfare (warfarin) on
the fetus; keep it heppy with heparin (does not cross placenta) "<img
A child carries a diagnosis of fetal alcohol syndrome. What craniofacial findings
are characteristic of this disorder? Microcephaly, facial abnormalities (eg, a
smooth philtrum, thin vermillion border [upper lip], small palpebral fissures)
"<img src=""8364.png"">" embryology fetal-alcohol-syndrome reproductive
A child has a smooth philtrum and hypertelorism. A heart defect is diagnosed. What
is the mechanism of this condition? This is fetal alcohol syndrome, which is due to
a failure of cell migration "<img src=""8364.png"">" embryology fetal-
alcohol-syndrome reproductive
A newborn is found to have a heart-lung fistula and holoprosencephaly. What
substance was his mother likely abusing during pregnancy? Alcohol (these defects
are found in the most severe form of fetal alcohol syndrome) "<img
src=""8364.png"">" embryology fetal-alcohol-syndrome reproductive
A mother is told to stop drinking alcohol during her pregnancy because it could
affect her child's intelligence. Is this true? Yes, maternal alcohol use during
pregnancy can result in intellectual disability in a woman's children "<img
What limb abnormality is seen in fetal alcohol syndrome? Limb dislocation "<img
Is developmental retardation in fetal alcohol syndrome seen prenatally,
postnatally, or both prenatally and postnatally? Both pre- and postnatally
"<img src=""8364.png"">" embryology fetal-alcohol-syndrome reproductive
What conditions characterize the most severe form of fetal alcohol syndrome? Heart-
lung fistulas and holoprosencephaly "<img src=""8364.png"">" embryology fetal-
alcohol-syndrome reproductive
You observe cleavage of a zygote on day 6 after fertilization. What type of twin
pregnancy do you expect to arise? Cleavage in the morula stage (days 48) results
in monochorionic, diamniotic twins (about 75% of twin pregnancies) "<img
src=""8365.png"">" embryology reproductive twinning
pregnancy do you expect to arise? Cleavage in the 2-cell stage (days 04) results
in dichorionic, diamniotic twins (about 25% of twin pregnancies) "<img
pregnancy do you expect to arise? Cleavage in the blastocyst stage (days 812)
results in monochorionic, monoamniotic twins (a rare twin pregnancy form) "<img
pregnancy do you expect to arise? Cleavage in the formed embryonic disc stage
(>13 days) results in conjoined monochorionic, monoamniotic twins (a rare twin
pregnancy form) "<img src=""8365.png"">" embryology reproductive twinning
By means of what two mechanisms can a formed embryonic disc undergo twinning? What
type of twinning results from this? Cleavage or axis duplication; monozygotic
(identical) twins that are conjoined, monochorionic, and monoamniotic "<img
How many chorion(s) and amniotic sac(s) should be present in a patient pregnant
with conjoined twins? One chorion and one amniotic sac "<img src=""8365.png"">"
embryology reproductive twinning
A patient has dizygotic (fraternal) twins. From how many eggs and sperm do
dizygotic twins arise? Two eggs and two sperm (each egg separately fertilized by a
different sperm) "<img src=""8365.png"">" embryology reproductive twinning
A patient has monozygotic (identical) twins. From how many eggs and sperms do
monozygotic twins arise? One egg and one sperm; monozygotic twins arise from
splitting of the fertilized egg into two zygotes in early pregnancy "<img
A morula is cleaved just before becoming a blastocyst. What type of twin pregnancy
will result? Monozygotic (identical), monochorionic, diamniotic twins "<img
A patient has monozygotic (identical), dichorionic, diamniotic twins. Between what
two stages of the zygote did cleavage occur? Between the two-cell stage and
morula stage "<img src=""8365.png"">" embryology reproductive twinning
A blastocyst is cleaved just before the embryonic disc forms. What type of twin
pregnancy will result? Monozygotic (identical), monochorionic, monoamniotic twins
"<img src=""8365.png"">" embryology reproductive twinning
A woman gives birth to monozygotic (identical), monochorionic, monoamniotic
conjoined twins. Where in the growth process did cleavage occur? Cleavage or axis
duplication occurred after the embryonic disc was formed "<img src=""8365.png"">"
For monozygotic (identical) twins, what determines both the chorionicity (number of
chorions) and the amnionicity (number of amnions)? The timing of cleavage "<img
What percentage of twins are dizygotic (fraternal)? Monozygotic (identical)? 66%
(2/3); 33% (&$8765;1/3) "<img src=""8365.png"">" embryology reproductive
twinning
After a sperm fertilizes an egg, what are the major zygotic stages between
fertilization and formation of the embryonic disc? Fertilized egg, two-cell
stage, morula, blastocyst, formed embryonic disc "<img src=""8365.png"">"
Once the formed embryonic disc arises, what two cavities have developed in the
zygote? Chorionic cavity and amniotic cavity "<img src=""8365.png"">"
Between days 0 and 4 after fertilization, in what stage is the zygote? Two-cell
stage "<img src=""8365.png"">" embryology reproductive twinning
Between days 4 and 8 after fertilization, in what stage is the zygote? Morula
"<img src=""8365.png"">" embryology reproductive twinning
Between days 8 and 12 after fertilization, in what stage is the zygote?
Blastocyst "<img src=""8365.png"">" embryology reproductive twinning
Around day 12 after fertilization, what important structure forms in the zygote?
What two cavities may also now be seen? The embryonic disc; the chorionic and
amniotic cavities "<img src=""8365.png"">" embryology reproductive twinning
Which layer of the chorionic villus secretes hormones such as human chorionic
gonadotropin (hCG)? The outer layer (syncytiotrophoblast) synthesizes hormones
such as hCG "<img src=""8366.png"">" embryology placenta reproductive
Is the decidua basalis derived from the maternal or fetal component of the
placenta? Whose blood is found in its lacunae? Maternal endometrium, with maternal
blood in the lacunae "<img src=""8366.png"">" embryology placenta
reproductive
What stimulates the corpus luteum to secrete progesterone during the first
trimester of pregnancy? Where is this made? Human chorionic gonadotropin (hCG),
which is structurally similar to LH; syncytiotrophoblast (syncytiotrophoblast
synthesizes hormones) "<img src=""8366.png"">" embryology placenta
reproductive
What is the primary site of nutrient and gas exchange between the mother and fetus?
The placenta "<img src=""8366.png"">" embryology placenta
reproductive
Which layer of the chorionic villus is mitotically active? Inner layer (the
Cytotrophoblast), which makes Cells "<img src=""8366.png"">" embryology
placenta reproductive
Tests on syncytiotrophoblastic tissue show low MHC-I expression. If white blood
cells are introduced, do they show an increase in activity?Unlikely (the lack of
MHC-I expression in the syncytiotrophoblast lowers the probability of attack by the
maternal immune system) "<img src=""8366.png"">" embryology placenta
reproductive
What is the name of the structure separating the amniotic cavity from the lacunae
containing maternal blood? The chorionic plate "<img src=""8366.png"">"
embryology placenta reproductive
In the umbilical cord, what vascular structures carry blood from the fetus to the
mother? Is the blood O2 rich or O2 poor? The umbilical arteries; O2 poor "<img
src=""8366.png"">" embryology placenta reproductive
In the placental branch villi, what waste products diffuse from the fetal
circulation into the maternal circulation? CO2, H2O, hormones, urea, and other
waste products "<img src=""8366.png"">" embryology placenta reproductive
In the umbilical cord, which vascular structure carries blood from the mother to
the fetus? Is the blood O2 rich or O2 poor? The umbilical vein; O2 rich "<img
Fetal blood within arteries and veins is exposed to maternal blood in the lacunae
within what structure? Branch villus "<img src=""8366.png"">" embryology
placenta reproductive
In the maternal circulation, which vessels carry O2 rich blood to the lacunae?
Which vessels remove O2 poor blood? Endometrial arteries; endometrial veins "<img
In the placental branch villi, what is able to pass from the maternal circulation
to the fetal circulation? O2, H2O, electrolytes, nutrients, hormones, IgG,
certain drugs, and viruses "<img src=""8366.png"">" embryology placenta
reproductive
In the placenta, what is the inner layer of the chorionic villus? The outer layer?
Cytotrophoblast; syncytiotrophoblast "<img src=""8366.png"">"
embryology placenta reproductive
Do the umbilical arteries carry oxygenated or deoxygenated blood? Deoxygenated
blood "<img src=""8367.png"">" embryology reproductive umbilical-cord
The umbilical arteries shunt deoxygenated blood to the placenta out of which
arteries in the fetus? Fetal internal iliac arteries "<img src=""8367.png"">"
embryology reproductive umbilical-cord
Does the umbilical vein carry oxygenated or deoxygenated blood? Oxygenated blood
"<img src=""8367.png"">" embryology reproductive umbilical-cord
You just delivered a baby. Why should you take a good look at the cord and document
the number of umbilical arteries? A single umbilical artery (two-vessel cord) is
associated with congenital and chromosomal anomalies "<img src=""8367.png"">"
From which fetal structure are the umbilical arteries and veins derived? The
allantois "<img src=""8367.png"">" embryology reproductive umbilical-cord
The umbilical vein drains into the IVC via which structure(s)? Liver or ductus
venosus "<img src=""8367.png"">" embryology reproductive umbilical-cord
Normally, how many umbilical artery(ies) and vein(s) are present? Two
umbilical arteries and one umbilical vein "<img src=""8367.png"">" embryology
reproductive umbilical-cord
What structure connects the fetal bladder with the umbilicus and removes
nitrogenous waste from the fetal bladder? The urachus, a duct between the fetal
bladder and the umbilicus (formed from allantois) "<img src=""8367.png"">"
During the third week of fetal development, what structure forms the allantois?
Into which part of the fetus does it then extend? The yolk sac; the urogenital
sinus "<img src=""8367.png"">" embryology reproductive umbilical-cord
Which two structures are connected by the vitelline duct? The vitelline duct
(omphalomesenteric duct) connects the yolk sac to the midgut lumen "<img
src=""8367.png"">" embryology reproductive umbilical-cord
In what week of gestation does the vitelline duct obliterate? In the seventh
week "<img src=""8367.png"">" embryology reproductive umbilical-cord
A patient is found to have Meckel diverticulum. What findings and symptoms could be
present? Heterotopic gastric mucosa and/or pancreatic tissue could be present,
resulting in melena, abdominal pain, and hematochezia "<img src=""8367.png"">"
Embryologically, the first aortic arch gives rise to part of what artery? The
maxillary artery, which is a branch of the external carotid artery (the first arch
is maximal) "<img src=""8368.png"">" aortic-arch-derivatives embryology
reproductive
Embryologically, the second aortic arch gives rise to what two arteries? The
stapedial artery and the hyoid artery (Second = Stapedial) "<img src=""8368.png"">"
aortic-arch-derivatives embryology reproductive
Embryologically, the third aortic arch gives rise to which two arteries? The
Common Carotid and proximal internal Carotid (for the 3rd arch, remember that C is
the 3rd letter of the alphabet) "<img src=""8368.png"">" aortic-arch-
Embryologically, the fourth aortic arch on the left gives rise to what structure?
The aortic arch (4th arch [4 limbs] = systemic) "<img src=""8368.png"">"
Embryologically, the fourth aortic arch on the right gives rise to what structure?
The proximal part of the right subclavian artery (4th arch [4 limbs] =
systemic) "<img src=""8368.png"">" aortic-arch-derivatives embryology
reproductive
Embryologically, the fifth aortic arch gives rise to which structures? There is no
fifth arch giving rise to a significant structure "<img src=""8368.png"">"
Embryologically, the sixth aortic arch gives rise to what structure on both the
right and the left? Proximal part of the pulmonary arteries "<img
src=""8368.png"">" aortic-arch-derivatives embryology reproductive
Embryologically, the sixth aortic arch gives rise to what important systemic shunt?
On what side of the body does this occur? The ductus arteriosus; the left side only
"<img src=""8368.png"">" aortic-arch-derivatives embryology reproductive
Embryologically, what are the three components of the branchial (pharyngeal)
apparatus? Clefts, arches, and pouches "<img src=""8369.png"">" branchial-
(pharyngeal)-apparatus embryology reproductive
Embryologically speaking, from which primary germ layer are branchial clefts (also
called branchial grooves) derived? Ectoderm "<img src=""8369.png"">"
branchial-(pharyngeal)-apparatus embryology reproductive
Embryologically speaking, from which two cell populations are branchial arches
derived? Mesoderm and neural crest "<img src=""8369.png"">" branchial-
(pharyngeal)-apparatus embryology reproductive
A man has difficulty swallowing due to malformation of a pharyngeal muscle. Which
embryologic tissue is likely involved? Muscles and arteries of the branchial
arches develop from mesoderm "<img src=""8369.png"">" branchial-(pharyngeal)-
apparatus embryology reproductive
A patient presents with a malformed hyoid bone, which is part of the pharyngeal
apparatus. Which embryologic tissue is likely involved? Neural crest cells form
the bones and cartilage of the branchial arches "<img src=""8369.png"">"
Embryologically speaking, from which primary germ layer are branchial pouches
derived? Endoderm "<img src=""8369.png"">" branchial-(pharyngeal)-
apparatus embryology reproductive
What are the branchial apparatus components from outside to inside? Clefts,
Arches, Pouches (CAP covers outside to inside) "<img src=""8369.png"">"
If a branchial cleft sinus fails to be obliterated properly, what pathology may
arise? Branchial cleft cyst "<img src=""8370.png"">" branchial-cleft-
A patient has trouble with hearing. Which branchial cleft is most likely to be
involved? The external auditory meatus is derived from the first branchial cleft
malformations would result in problems with hearing "<img src=""8370.png"">"
branchial-cleft-derivatives embryology reproductive
Into what structures do the second through fourth branchial clefts develop? They
are later obliterated by the proliferation of what? Temporary cervical sinuses;
proliferating second brachial arch mesenchyme "<img src=""8370.png"">"
branchial-cleft-derivatives embryology reproductive
It is suspected that a patient has a branchial cleft cyst. Where do you expect to
find it on imaging? Does it move when he swallows? The lateral neck, anterior to
the sternocleidomastoid muscle; does not move when the affected person swallows
"<img src=""8370.png"">" branchial-cleft-derivatives embryology
reproductive
From which branchial arch subset are the muscles of mastication derived? The
first arch "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset is the posterior third of the tongue derived?
The third and fourth arches "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset is Meckel cartilage derived? The first arch
"<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset is the levator veli palatini muscle derived?
The fourth arch "<img src=""8371.png"">" branchial-arch-derivatives
From which branchial arch subset is the greater horn of the hyoid derived? The
third arch "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset are the muscles of facial expression derived?
The second arch "<img src=""8371.png"">" branchial-arch-derivatives
From which branchial arch subset is the maxilla derived? The first arch "<img
src=""8371.png"">" branchial-arch-derivatives embryology reproductive
From which branchial arch subset is the cuneiform cartilage derived? The fourth
through sixth arches "<img src=""8371.png"">" branchial-arch-derivatives
From which branchial arch subset is cranial nerve VII derived? The second arch
reproductive
From which branchial arch subset is the tensor veli palatini muscle derived? The
reproductive
From which branchial arch subset is the styloid process derived? The second arch
reproductive
From which branchial arch subset is the platysma muscle derived? The second arch
reproductive
From which branchial arch subset is the superior laryngeal branch of cranial nerve
X derived? The fourth arch "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset is the tensor tympani muscle derived? The first
arch "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset are almost all intrinsic muscles of the larynx
derived? Which muscle is the exception? The sixth arch; the cricothyroid muscle
(derived from the fourth arch) "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset are most pharyngeal constrictor muscles derived?
The fourth arch "<img src=""8371.png"">" branchial-arch-derivatives
From which branchial arch subset is the mylohyoid muscle derived? The first
reproductive
From which branchial arch subset is the incus derived? The first arch "<img
From which branchial arch subset is cranial nerve V2 derived? The first arch
reproductive
From which branchial arch subset is the cricoid cartilage derived? The fourth
From which branchial arch subset is the maxillary process derived? The first
reproductive
From which branchial arch subset is the posterior belly of the digastric muscle
derived? The second arch "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset is the medial pterygoid muscle derived? The
reproductive
From which branchial arch subset is the stapedius muscle derived? The second
reproductive
From which branchial arch subset is the recurrent laryngeal branch of cranial nerve
X derived? The sixth arch "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset is the malleus derived? The first arch "<img
From which branchial arch subset is the sphenomandibular ligament derived? The
reproductive
From which branchial arch subset is the thyroid cartilage derived? The fourth
From which branchial arch subset is Reichert cartilage derived? The second arch
reproductive
From which branchial arch subset is the lateral pterygoid muscle derived? The
reproductive
From which branchial arch subset is the arytenoid cartilage derived? The fourth
From which branchial arch subset is the cricothyroid muscle derived? The fourth
reproductive
From which branchial arch subset is the zygomatic bone derived? The first arch
reproductive
From which branchial arch subset is the temporalis muscle derived? The first
reproductive
From which branchial arch subset are the stapes derived? The second arch "<img
From which branchial arch subset is the masseter muscle derived? The first arch
reproductive
From which branchial arch subset is the anterior belly of the digastric muscle
derived? The first arch "<img src=""8371.png"">" branchial-arch-
From which branchial arch subset is the stylohyoid ligament derived? The second
reproductive
From which branchial arch subset is cranial nerve V3 derived? The first arch
reproductive
From which branchial arch subset is cranial nerve IX derived? The third arch
reproductive
From which branchial arch subset is the lesser horn of the hyoid derived? The
second arch "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset is the stylohyoid muscle derived? The second
reproductive
From which branchial arch subset is the mandibular process derived? The first
reproductive
From which branchial arch subset is the stylopharyngeus muscle derived? The
third arch "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
From which branchial arch subset is the mandible derived? The first arch "<img
A scientist alters an embryo so its fifth branchial arch does not form. Much to his
surprise, the embryo grows normally. What happened? The fifth branchial arch does
not make any major developmental contributions, so normal development would largely
be expected "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
A patient has difficulty chewing because of a problem with her mandible. Which
branchial arch is likely involved? Meckel cartilage, including the Mandible,
Malleus, incus, and sphenoMandibular ligament, is derived from the first branchial
reproductive
Which cartilages are derived from the fourth and sixth branchial arches?
Artyenoids, Cricoid, Corniculate, Cuneiform, Thyroid (used to sing and ACCCT)
reproductive
Which bones derived from the second branchial arch help with the facial expression
smile)? The Stapes, Styloid process, lesser horn of hyoid, Stylohyoid ligament
reproductive
Which muscles are derived from the second branchial arch? The muscles of facial
expression (Smile), Stapedius, Stylohyoid, platySma, posterior belly of the
digastric "<img src=""8371.png"">" branchial-arch-derivatives embryology
reproductive
What is unique about the cranial nerves derived from the branchial arches? These
are the only ones with both sensory and motor components (the exception is V2,
derived from the first arch, which is sensory only) "<img src=""8371.png"">"
branchial-arch-derivatives embryology reproductive
A child has mandibular hypoplasia and facial anomalies. Neural crest cells in his
first branchial arch failed to migrate. Diagnosis? Treacher Collins syndrome
reproductive
A child has micrognathia, glossoptosis, cleft palate, and airway obstruction
because of a defect in one of his branchial arches. Diagnosis? This is the Pierre
Robin sequence, caused by a defect in the first branchial arch "<img
Embryologically speaking, what are the cartilaginous derivatives from the second
branchial arch called? Reichert cartilage (Smile), which includes Stapes,
Stylohyoid ligament, Styloid process, and lesser horn of hyoid "<img
A patient has difficulty swallowing. An issue with the stylopharyngeus muscle is
found. A problem with which nerve is likely to blame? The glossopharyngeal nerve
(CN XI) of the third branchial arch (think of stylopharyngeus innervated by
glossopharyngeal nerve) "<img src=""8371.png"">" branchial-arch-derivatives
From which branchial pouch are endoderm-lined structures of the ear derived? The
first pouch "<img src=""8372.png"">" branchial-pouch-derivatives embryology
reproductive
From which branchial pouch is the ultimobranchial body derived? The fourth pouch
"<img src=""8372.png"">" branchial-pouch-derivatives embryology
reproductive
From which branchial pouch is the epithelial lining of the palatine tonsil derived?
The second pouch "<img src=""8372.png"">" branchial-pouch-derivatives
From which branchial pouch are the eustachian tubes derived? The first pouch
reproductive
From which branchial pouch are the parafollicular (C) cells of the thyroid derived?
The fourth pouch "<img src=""8372.png"">" branchial-pouch-derivatives
From which branchial pouch are the superior parathyroids derived? The fourth
pouch "<img src=""8372.png"">" branchial-pouch-derivatives embryology
reproductive
From which branchial pouch are the middle ear cavities derived? The first pouch
reproductive
From which branchial pouch are the mastoid air cells derived? The first pouch
reproductive
From which branchial pouch is the thymus derived? The third pouch "<img
src=""8372.png"">" branchial-pouch-derivatives embryology reproductive
From which branchial pouch are the inferior parathyroids derived? The third
pouch "<img src=""8372.png"">" branchial-pouch-derivatives embryology
reproductive
What is interesting about the final position of structures derived from the 3rd
branchial pouch? They end up below structures derived from the 4th branchial pouch
reproductive
What structures does the 3rd branchial pouch ultimately contribute to? The 3rd
pouch contributes to 3 structures: the thymus, left inferior parathyroids, and
right inferior parathyroids "<img src=""8372.png"">" branchial-pouch-
A newborn is found to have aberrant development of the third and fourth branchial
pouches. What syndrome could result from this defect? DiGeorge syndrome "<img
A newborn has cardiac defects, hypocalcemia, and frequent infections. Name the
disorder and the glands affected. DiGeorge syndrome: parathyroid and thymus
glands leading to T-lymphocyte deficiency, due to aberrant development of 3rd and
4th pouches "<img src=""8372.png"">" branchial-pouch-derivatives embryology
reproductive
A newborn is found to have thymic aplasia and lack of parathyroid development. What
cardiac defects might also be present? Conotruncal anomalies, which are
associated with DiGeorge syndrome (chromosome 22q11 deletion) "<img
In order, what are the major structures that develop from branchial pouches 1
through 4? Ear, tonsils, bottom to top: 1 ear, 2 tonsils, 3 dorsal (bottom for
inferior parathyroids), 3 ventral (to = thymus), 4 (top = superior parathyroids)
reproductive
From which branchial pouches do the dorsal wings arise? What structures do they
ultimately become? The third and fourth pouches; the inferior parathyroids
(third pouch) and superior parathyroids (fourth pouch) "<img src=""8372.png"">"
branchial-pouch-derivatives embryology reproductive
From which branchial pouches do the ventral wings arise? What structures do they
ultimately become? Third and fourth pouches; thymus (third pouch),
ultimobranchial body (fourth pouch), and parafollicular (C) cells of thyroid
(fourth pouch) "<img src=""8372.png"">" branchial-pouch-derivatives
Cleft palate can arise as a result of a three different processes' failing to occur
properly. What are these processes? Lateral palatine shelf fusion, lateral palatine
shelf/nasal septum fusion, and median palatine shelf (secondary palate) formation
"<img src=""8373.png"">" cleft-lip-and-cleft-palate embryology
reproductive
Although cleft lip and cleft palate have two distinct origins, can they occur in
the same patient? Yes, the two often occur together "<img src=""8373.png"">"
cleft-lip-and-cleft-palate embryology reproductive
What is another name for the mesonephric duct, and what four structures are derived
from it? Wolffian duct; Seminal vesicles, Epididymis, Ejaculatory duct, and
Ductus deferens (SEED) "<img src=""8374.png"">" embryology genital-embryology
reproductive
What is another name for the paramesonephric duct, and what three structures are
derived from it? Mllerian duct; the fallopian tubes, the uterus, and upper
portion of the vagina (lower portion is from the urogenital sinus) "<img
src=""8374.png"">" embryology genital-embryology reproductive
A child with an XY karyotype has both testes and a uterus. The paramesonephric duct
was not suppressed. Which hormone's failure is to blame? Mllerian inhibitory
factor (MIF), which is secreted by Sertoli cells, suppresses development of the
paramesonephric ducts "<img src=""8374.png"">" embryology genital-embryology
reproductive
What class of hormones promotes the development of the mesonephric ducts in male
subjects? Androgens, which are secreted by Leydig cells "<img src=""8374.png"">"
embryology genital-embryology reproductive
Is male or female development the default fetal development? Female (in the
absence of a Y chromosome, female reproductive organs will develop) "<img
In female development, which duct degenerates, and which duct develops? The
mesonephric duct; the paramesonephric duct "<img src=""8374.png"">"
In male development, which gene on which chromosome codes for testis-determining
factor? The SRY gene on the Y chromosome "<img src=""8374.png"">"
In male development, the mesonephric duct develops into all genitourinary internal
structures except for what? The prostate "<img src=""8374.png"">"
Which embryologic structure of the genitals degenerates in the female? What does
the remnant become? Mesonephric duct; the Gartner duct "<img src=""8374.png"">"
Which cells produce Mllerian inhibitory factor (MIF) in males? Sertoli cells
"<img src=""8374.png"">" embryology genital-embryology reproductive
Which cells produce the androgens that promote development of the mesonephric
ducts? Leydig cells "<img src=""8374.png"">" embryology genital-
What structure becomes the lower portion of the vagina? The urogenital sinus
"<img src=""8374.png"">" embryology genital-embryology reproductive
A woman with fully developed secondary sex characteristics has primary amenorrhea.
Her ovaries are functional. What abnormality is to blame? Mayer-Rokitansky-Kster-
Hauser syndrome (Mllerian agenesis); fully developed secondary sex characteristics
indicate functional ovaries "<img src=""8374.png"">" embryology genital-
In male development, what duct degenerates? What is the remnant of this duct
called? The paramesonephric (Mllerian) duct; appendix testis "<img
A male has no Sertoli cells. What internal and external genitalia will be seen
phenotypically? Both male and female internal genitalia with male external
genitaliaSertoli cells secrete Mllerian inhibitory factor"<img src=""8375.png"">"
embryology reproductive sry-gene
A male subject has 5-reductase deficiency. What internal and external genitalia
will be seen phenotypically? Male internal genitalia and ambiguous external
genitalia until pubertymasculinization from increased testosterone levels during
puberty "<img src=""8375.png"">" embryology reproductive sry-gene
A male newborn has improper degeneration of the paramesonephric (Mllerian) duct.
The absence of which hormone may be to blame? Mllerian inhibitory factor, which
is produced by Sertoli cells, promotes degeneration of the paramesonephric
(Mllerian) duct "<img src=""8375.png"">" embryology reproductive sry-gene
What is the function of 5-reductase? Converts testosterone to
dihydrotestosterone (DHT) "<img src=""8375.png"">" embryology reproductive
sry-gene
What is the function of dihydrotestosterone (DHT)? It promotes development of
the genital tubercle and urogenital sinus into the male external genitalia and
prostate "<img src=""8375.png"">" embryology reproductive sry-gene
Which chromosome is the SRY gene on? The Y chromosome "<img src=""8375.png"">"
embryology reproductive sry-gene
A male newborn has improper development of his internal genitalia (prostate
excluded). Impaired hormone release by which cells is to blame? Leydig cells,
which produce testosterone (required for differentiation of the Wolffian duct into
the male internal genitalia) "<img src=""8375.png"">" embryology reproductive
sry-gene
A male newborn has improper degeneration of the paramesonephric (Mllerian) duct.
What hormone might be absent? Mllerian inhibitory factor, which is produced by
Sertoli cells "<img src=""8375.png"">" embryology reproductive sry-gene
A teenager with the inability to convert testosterone into DHT notes that his
ambiguous genitalia are masculinizing. What is happening? He has 5-reductase
deficiencyincreased testosterone level causes masculinization at the onset of
puberty "<img src=""8375.png"">" embryology reproductive sry-gene
A newborn has deformities in his external genitalia and prostate. A deficiency of
which enzyme could explain this finding? 5-Reductase (responsible for converting
testosterone into DHT, which promotes development of the urogenital sinus and
genital tubercle) "<img src=""8375.png"">" embryology reproductive sry-gene
A newborn has both male and female internal genitalia and male external genitalia.
What two developmental anomalies can cause this finding? A lack of Sertoli cells
or of Mllerian inhibitory factor "<img src=""8375.png"">" embryology
reproductive sry-gene
An infertile woman is found to have the sequelae of incomplete fusion of her
Mllerian ducts. Name this anomaly and its complications. Bicornuate uterus, which
increases the risk of a complicated pregnancy "<img src=""8376.png"">"
embryology reproductive uterine-(mllerian-duct)-anomalies
What two structures does the urogenital sinus form under the influence of
dihydrotestosterone in the male embryo? The prostate and the bulbourethral glands
(of Cowper) "<img src=""8377.png"">" embryology male/female-genital-homologs
reproductive
What structures does the genital tubercle form under the influence of
dihydrotestosterone (DHT)? The glans penis, the corpus cavernosum, the corpus
spongiosum "<img src=""8377.png"">" embryology male/female-genital-homologs
reproductive
What two structures does the genital tubercle form under the influence of estrogen?
The glans clitoris and the vestibular bulbs "<img src=""8377.png"">"
embryology male/female-genital-homologs reproductive
What two structures does the urogenital sinus form under the influence of estrogen
in the female embryo? The greater vestibular glands (of Bartholin) and the
urethral and paraurethral glands (of Skene) "<img src=""8377.png"">"
embryology male/female-genital-homologs reproductive
What structure do the urogenital folds develop into in the male subject, and what
structure in the female subject? Hormones responsible? The ventral shaft of the
penis (penile urethra) in the male under dihydrotestosteronethe labia minora in
the female under estrogen "<img src=""8377.png"">" embryology male/female-
genital-homologs reproductive
What structure do labioscrotal swellings develop into in males? What structure in
females? What hormones are responsible? The scrotum in males under
dihydrotestosterone; the labia majora in females under estrogen "<img
src=""8377.png"">" embryology male/female-genital-homologs reproductive
A male newborn has undifferentiated genitalia. What hormone, missing or unable to
act, is critical for these structures' formation? Dihydrotestosterone "<img
A female newborn has undifferentiated genitalia. What hormone, missing or unable to
act, is critical for these structures' formation? Estrogen "<img
Which is a more common congenital penile abnormality: epispadias or hypospadias?
Hypospadias "<img src=""8378.png"">" congenital-penile-abnormalities
What is the embryologic origin of epispadias? Epispadias results from faulty
positioning of the genital tubercle "<img src=""8378.png"">" congenital-penile-
abnormalities embryology reproductive
Hypospadias refers to the abnormal opening of the penile urethra on what penile
surface? What about epispadias? Hypospadias: ventral surface (hypo is below);
epispadias: dorsal surface (when you have Epispadias, you hit your Eye when you
pEE) "<img src=""8378.png"">" congenital-penile-abnormalities embryology
reproductive
What two ligaments are formed from the gubernaculum (a band of fibrous tissue) in
females? What is the purpose of the gubernaculum in males? Ovarian ligament and
round ligament of the uterus; it anchors the testes within the scrotum "<img
src=""8379.png"">" descent-of-testes-and-ovaries embryology reproductive
Describe the process of formation of the tunica vaginalis. This testes layer is
formed from an evagination of the peritoneum (processus vaginalis) "<img
A scientist induces apoptosis of a female rat's peritoneal evagination. Do you
worry about any long-term consequences? No, because this is the processus
vaginalis, which is typically obliterated in female subjects "<img
Which gonadal vein drains to the renal vein and then to the IVC? Which gonadal vein
drains directly to the IVC? "The left gonadal vein (""Left gonadal vein takes the
Longest way""); the right gonadal vein" "<img src=""8380.png"">" anatomy
gonadal-drainage reproductive
Which lymph nodes might be biopsied for a patient with a testicular or ovarian
malignancy? The para-aortic lymph nodes, which serve as the lymphatic drainage of
the gonads "<img src=""8380.png"">" anatomy gonadal-drainage reproductive
To which lymph nodes does fluid from the distal vagina/vulva/scrotum/distal anus
drain? The superficial inguinal lymph nodes "<img src=""8380.png"">"
anatomy gonadal-drainage reproductive
A 30-year-old man has a swollen testicle that looks like a bag of worms. Is this
pathology more likely on the left or right side? Left; flow is less laminar
there (the spermatic vein enters the renal vein at 90), thus venous pressure is
increased (this is a varicocele) "<img src=""8380.png"">" anatomy gonadal-
drainage reproductive
From what reproductive organs does fluid drain to the external iliac lymph nodes?
Internal iliac lymph nodes? Body of uterus, cervix, superior bladder; prostate,
cervix, corpus cavernosum, proximal vagina "<img src=""8380.png"">"
anatomy gonadal-drainage reproductive
A man reports that his glans penis feels swollen and wants to know where fluid from
this organ drains. What do you tell him? It drains to the deep inguinal lymph
nodes "<img src=""8380.png"">" anatomy gonadal-drainage reproductive
During surgical ligation of which vessels is the ureter at risk? Ovarian and
uterine vessels "<img src=""8381.png"">" anatomy female-reproductive-anatomy
reproductive
A woman has reduced urine output after hysterectomy (removal of uterus). During
ligation of what structure was the ureter likely damaged? The uterine vessels,
which run through the cardinal ligament and require ligation during hysterectomy
"<img src=""8381.png"">" anatomy female-reproductive-anatomy
reproductive
During surgery, you notice a ligament that connects the cervix to the side wall of
the pelvis. What is this ligament? The cardinal ligament "<img src=""8381.png"">"
anatomy female-reproductive-anatomy reproductive
You perform oophorectomy (removal of ovaries). Which vessels should you ligate to
prevent bleeding? Which ligament contains the vessels? The ovarian vessels,
contained in the infundibulopelvic ligament "<img src=""8381.png"">"
What is the broad ligament? Name its three components. A fold of peritoneum;
the mesovarium, mesometrium, and mesosalpinx "<img src=""8381.png"">"
Above which artery does the round ligament travel? Artery of Sampson "<img
src=""8381.png"">" anatomy female-reproductive-anatomy reproductive
What structures are contained within the broad ligament of the uterus? The round
ligaments of the uterus, the fallopian tubes, the ovaries "<img src=""8381.png"">"
During surgery, you notice a ligament that connects the uterus, fallopian tubes,
and ovaries to the pelvic side wall. What is this ligament?The broad ligament
"<img src=""8381.png"">" anatomy female-reproductive-anatomy
reproductive
During surgery, you notice a ligament that connects the medial pole of the ovary to
the lateral uterus. What is this ligament? The ovarian ligament, which is a
derivative of the gubernaculum (ovarian Ligament Latches to Lateral uterus) "<img
During surgery, you notice a ligament that connects the uterine fundus to the labia
majora. What is this ligament? The round ligament, which runs through the
round inguinal canalfound above the artery of Sampson "<img src=""8381.png"">"
Which ligament contains the uterine vessels? The cardinal ligament "<img
During surgery, you noticed a ligament that connects the ovaries to the lateral
pelvic wall. What is this ligament? The suspensory ligament of the ovaries, also
called the infundibulopelvic ligament (contains the ovarian vessels) "<img
Which female reproductive structure is lined by ciliated simple columnar
epithelium? The fallopian tubes "<img src=""8382.png"">" anatomy female-
reproductive-epithelial-histology reproductive
A 40-year-old woman has fishy-smelling vaginal discharge. You suspect bacterial
vaginosis. What epithelium type did the organism invade? Stratified squamous
epithelium, nonkeratinized, in the vagina "<img src=""8382.png"">" anatomy
female-reproductive-epithelial-histology reproductive
The endocervix is lined by what type of epithelium? The ectocervix? Simple
columnar epithelium; stratified squamous, nonkeratinized epithelium "<img
src=""8382.png"">" anatomy female-reproductive-epithelial-histology
reproductive
What type of epithelium lines the uterus in the proliferative phase? In the
secretory phase? The ovaries (outer surface)? Simple columnar epithelium with
long tubular glands; coiled glands; simple cuboidal epithelium (germinal
epithelium) "<img src=""8382.png"">" anatomy female-reproductive-epithelial-
histology reproductive
In order, through which structures do sperm travel (from start to finish) to
complete ejaculation? Seminiferous tubules, Epididymis, Vas deferens, Ejaculatory
ducts, Nothing, Urethra, Penis (SEVEN UP) "<img src=""8383.png"">" anatomy
male-reproductive-anatomy reproductive
A 67-year-old man has difficulty urinating. On rectal exam, you find an enlarged
prostate. What is the likely cause of his voiding troubles?Pressure against the
bladder wall by the enlarged prostate "<img src=""8383.png"">" anatomy
male-reproductive-anatomy reproductive
You examine a man and see blood at the urethral meatus. What does this make you
suspect? A urethral injury "<img src=""8384.png"">" anatomy reproductive
urethral-injury
A man is leaking urine into his retropubic space. What type of injury did he
sustain? This finding is classic after posterior urethral injury "<img
src=""8384.png"">" anatomy reproductive urethral-injury
A man suffers a perineal straddle injury. Describe where urine would leak on exam.
In anterior urethral injury, urine would leak beneath the deep fascia of Buck
and into the superficial perineal space if that fascia is torn "<img
src=""8384.png"">" anatomy reproductive urethral-injury
What part of the urethra is prone to injury in pelvic fracture? The membranous
urethra (posterior urethra) "<img src=""8384.png"">" anatomy reproductive
urethral-injury
What part of the urethra is prone to injury in perineal straddle injuries? The
bulbar and penile urethra (anterior urethra) "<img src=""8384.png"">"
anatomy reproductive urethral-injury
Which nervous system mediates erections? Emission? Ejaculation? Parasympathetic
(pelvic nerve); Sympathetic (hypogastric), Somatic and visceral (pudendal) (Point,
Squeeze, and Shoot) "<img src=""8385.png"">" anatomy autonomic-
innervation-of-the-male-sexual-response reproductive
What is the role of nitric oxide (NO) in the physiology of penile erection? NO is
proerectile, causing smooth muscle relaxation and vasodilation through cGMP
production to increase blood flow to the penis "<img src=""8385.png"">"
anatomy autonomic-innervation-of-the-male-sexual-response reproductive
A man comes to you with erectile dysfunction. Name the type of drug that works by
affecting the nitric oxide (NO) pathway and explain how. PDE-5 inhibitors (eg,
sildenafil) block cGMP breakdown, causing an increase in cGMP leading to smooth
muscle relaxation and vasodilation "<img src=""8385.png"">" anatomy autonomic-
innervation-of-the-male-sexual-response reproductive
What is the effect of norepinephrine on the male sexual response?
Norepinephrine is antierectile, causing smooth muscle contraction and
vasoconstriction through Ca2+ influx, reducing blood flow to the penis "<img
src=""8385.png"">" anatomy autonomic-innervation-of-the-male-sexual-response
reproductive
Damage to which nerves interferes with emission and ejaculation? The hypogastric
nerve (sympathetic nervous system) controls emission, and the pudendal nerve
(somatic nervous system) controls ejaculation "<img src=""8385.png"">"
anatomy autonomic-innervation-of-the-male-sexual-response reproductive
Of the cells found in the seminiferous tubules, what are the germ cells called? The
non-germ cells? The endocrine cells? Spermatogonia; Sertoli cells; Leydig
cells "<img src=""8386.png"">" anatomy reproductive seminiferous-tubules
A man presents with decreased sexual function and desire. He has low testosterone.
What cells secrete testosterone? Where are they located? Leydig cells secrete
testosterone in the presence of luteinizing hormone; in the interstitium "<img
src=""8386.png"">" anatomy reproductive seminiferous-tubules
What hormones and proteins do Sertoli cells produce? They secrete inhibin B,
androgen-binding protein, and Mllerian inhibitory factor (MIF) "<img
What is the effect of inhibin B released by Sertoli cells? Of androgen-binding
protein? Inhibits follicle-stimulating hormone; maintains the high local
testosterone level required for spermatogenesis "<img src=""8386.png"">"
anatomy reproductive seminiferous-tubules
What forms the blood-testis barrier? What is their purpose?Tight junctions between
Sertoli cells; they isolate gametes from the immune system, preventing autoimmune
attack "<img src=""8386.png"">" anatomy reproductive seminiferous-tubules
A man is unable to produce primary spermatocytes and maintain a sperm pool. What
type of cell is likely defective here? Spermatogonia "<img src=""8386.png"">"
anatomy reproductive seminiferous-tubules
How do Sertoli cells and Leydig cells respond to changes in temperature?
Sertoli cells lower sperm production/inhibin B release with increased
temperature (eg, varicocele, cryptorchidism); Leydig cells unaffected "<img
What type of cell provides most of the support and nourishment for the developing
spermatozoa and regulates spermatogenesis? Sertoli cells Support Sperm
Synthesis "<img src=""8386.png"">" anatomy reproductive seminiferous-tubules
In the testes, where are spermatogonia found? Sertoli cells? Leydig cells? Both
spermatogonia and Sertoli cells line seminiferous tubules; Leydig cells are found
in the interstitium "<img src=""8386.png"">" anatomy reproductive
seminiferous-tubules
Which cells in the seminiferous tubules contain aromatase? What is the function of
this enzyme? Sertoli and Leydig cells; aromatase converts testosterone and
androstenedione to estrogen "<img src=""8386.png"">" anatomy reproductive
seminiferous-tubules
Sertoli cells are the homolog of what female cells? Leydig cells are the homolog of
what female cells? Granulosa cells; theca interna cells "<img
What hormones do Sertoli and Leydig cells respond to, respectively? How do their
negative-feedback systems work? Sertoli: FSH, with inhibin B providing negative
feedback; Leydig: LH, with testosterone providing negative feedback "<img
Name three places in the female body where estrogen can be produced. The ovaries
(17-estradiol), the placenta (estriol), and adipose tissue (estrone via
aromatization) "<img src=""8387.png"">" estrogen physiology reproductive
Rank the following three forms of estrogen in order of most to least potent:
estradiol, estriol, and estrone. Estradiol > estrone > estriol "<img
src=""8387.png"">" estrogen physiology reproductive
What major hormone is produced by the granulosa cells? By the theca cells?
Granulosa cellsestrogen via conversion of androgens by aromatase; theca
cellsandrogens via conversion of cholesterol by desmolase "<img src=""8387.png"">"
estrogen physiology reproductive
A young female patient is ovulating and thus has increased luteinizing hormone (LH)
levels. What is the effect of LH in theca cells? LH promotes the conversion of
cholesterol to androgens via the enzyme desmolase "<img src=""8387.png"">"
What effects does estrogen have on the uterus and ovaries? Estrogen stimulates
follicle growth and endometrial proliferation and increases myometrial excitability
"<img src=""8387.png"">" estrogen physiology reproductive
What is the role of estrogen in physical development during puberty? Prompts
genital and breast development and influences female fat distribution "<img
What is the effect of estrogen on proteins and fats in the body? Increased
synthesis of sex hormonebinding globulin, transport proteins, and HDL, with
decrease in LDL "<img src=""8387.png"">" estrogen physiology reproductive
What is the effect of estrogen on the plasma lipid profile?Increased HDL and
decreased LDL "<img src=""8387.png"">" estrogen physiology reproductive
How does estrogen affect follicle-stimulating hormone (FSH) and luteinizing hormone
(LH) levels? It provides negative feedback on FSH and LH secretion except near
ovulation, when estrogen provides positive feedback for the LH surge "<img
A pregnant woman has increased levels of estrogen. What is the effect of estrogen
on prolactin secretion? Estrogen increases prolactin secretion "<img
Where are estrogen receptors located? What happens once estrogen binds?
Cytoplasm; receptors translocate to the nucleus once estrogen binds "<img
An increase in which variant of estrogen is an indicator of fetal well-being during
pregnancy? Estriol (generally increases 1000-fold) "<img src=""8387.png"">"
A pregnant female notices various changes in her body. During pregnancy, what
happens to the levels of endogenous estrogens? There is a 50-fold increase in
estradiol and estrone and a 1000-fold increase in estriol "<img src=""8387.png"">"
To which three receptors is estrogen known to provide upregulation? Estrogen,
LH, and progesterone receptors "<img src=""8387.png"">" estrogen
physiology reproductive
A young woman exhibits constant GnRH secretion. Do you expect normal FSH and LH
levels? No; pulsatile GnRH stimulation is needed for have normal FSH and LH
secretion "<img src=""8387.png"">" estrogen physiology reproductive
Name the four sources of progesterone. Corpus luteum, placenta, adrenal cortex,
and testes "<img src=""8388.png"">" physiology progesterone reproductive
Progesterone causes what changes in the endometrium? Spiral artery development and
increased endometrial glandular secretions; also prevents endometrial hyperplasia
"<img src=""8388.png"">" physiology progesterone reproductive
A 21-year-old woman is worried about miscarriage. She has an adequate progesterone
level. What effect does progesterone have on pregnancy? Progesterone maintains
the pregnancy (progesterone is pro-gestation) "<img src=""8388.png"">"
physiology progesterone reproductive
How does progesterone affect myometrial excitability? What about estrogen?
Progesterone decreases myometrial excitability; estrogen increases it "<img
src=""8388.png"">" physiology progesterone reproductive
What is the effect of progesterone on cervical mucus? Progesterone thickens
cervical mucus to prevent sperm entry into the uterus "<img src=""8388.png"">"
What effect does progesterone have on uterine smooth muscle? It relaxes uterine
smooth muscle, helping prevent contractions "<img src=""8388.png"">"
What effects does progesterone have on follicle-stimulating hormone (FSH),
luteinizing hormone (LH), and estrogen? Inhibits release of FSH and LH and
decreases estrogen receptor expressivity "<img src=""8388.png"">" physiology
progesterone reproductive
Progesterone levels are monitored daily during a female's menstrual cycle. What
does the elevation in her progesterone level indicate? Progesterone elevation
indicates that ovulation has occurred "<img src=""8388.png"">" physiology
progesterone reproductive
A woman is noted to have a drop in progesterone level after delivery. What is the
significance of this phenomenon? A drop in progesterone level disinhibits
prolactin, allowing an increase in lactation (prolactin is pro-lactation) "<img
src=""8388.png"">" physiology progesterone reproductive
What effect does progesterone exert on body temperature? It increases body
temperature "<img src=""8388.png"">" physiology progesterone reproductive
When does a 1 oocyte undergo and complete meiosis I? Meiosis I begins during fetal
life and is completed just before ovulation "<img src=""8389.png"">"
oogenesis physiology reproductive
In what stage of meiosis I is a primary oocyte arrested between fetal life and
ovulation? Prophase I (meiosis I is in prOphase I until Ovulation) "<img
src=""8389.png"">" oogenesis physiology reproductive
What is the genetic makeup of a primary oocyte (in terms of chromosomal material)?
It is diploid (2N, 4C) with 46 sister chromatids "<img src=""8389.png"">"
In what stage of meiosis II is a 2 oocyte arrested between ovulation and
fertilization? Metaphase II (an egg met a sperm) "<img src=""8389.png"">"
A 16-year-old girl ovulates on day 14 of her menstrual cycle. What type of oocyte
is released, and what happens if it is not fertilized? 1 oocyte, it
degenerates if fertilization does not occur within 1 day "<img src=""8389.png"">"
What is the genetic makeup of an oogonium (in terms of chromosomal material)?
It is diploid (2N, 2C), with 46 single chromosomes "<img src=""8389.png"">"
What is the genetic makeup of a secondary oocyte (in terms of chromosomal
material)? It is haploid (1N, 2C) with 23 sister chromatids "<img
What is the genetic makeup of an ovum (in terms of chromosomal material)? It is
haploid (1N, 1C) with 23 single chromatids "<img src=""8389.png"">"
With what egg cell type(s) does meiosis I begin? What cell type(s) is present at
the end of meiosis I? A primary oocyte; both a secondary oocyte and polar body
"<img src=""8389.png"">" oogenesis physiology reproductive
What stage of oogenesis begins with an oogonium and ends with a 1 oocyte?
Replication (interphase) "<img src=""8389.png"">" oogenesis
In which stage of oogenesis does a 2 oocyte become an ovum and polar body? What
happens to the first polar body (formed after meiosis I)? Meiosis II; the first
polar body can either degenerate or give rise to two polar bodies "<img
A woman has transient abdominal pain on day 14 of her menstrual cycle. You
determine that she's just ovulated. What is this pain called? "Mittelschmerz:
Tube contraction, follicular swelling/rupture may cause peritoneal irritation and
can mimic appendicitis (""Middle hurts"")" "<img src=""8390.png"">"
ovulation physiology reproductive
What causes the luteinizing hormone surge, and what happens after the surge? The
estrogen surge causes a luteinizing hormone surge, which then causes rupture of an
ovarian follicle and ovulation "<img src=""8390.png"">" ovulation
A woman ovulates. What happens to her temperature during ovulation? Temperature
is increased due to progesterone "<img src=""8390.png"">" ovulation
In preparation for ovulation, increased estrogen leads to increased GnRH receptor
expression in which organ? Anterior pituitary "<img src=""8390.png"">"
ovulation physiology reproductive
Place in order: progesterone from corpus luteum, LH surge, menstruation, ovulation,
increase in estrogen release, progesterone levels fall Increase in estrogen
release, LH surge, ovulation, progesterone from corpus luteum, progesterone levels
fall, menstruation "<img src=""8391.png"">" menstrual-cycle physiology
reproductive
Oligomenorrhea is defined as a cycle lasting more or less than how many days? What
about polymenorrhea? Longer than 35 days; fewer than 21 days "<img
src=""8391.png"">" menstrual-cycle physiology reproductive
A 23-year-old woman has heavy and irregular menses and has to change her sanitary
pad every 2 hours. What is this condition called? Menometrorrhagia "<img
A 32-year-old woman complains of spotting and frequent menstruation. She says that
her periods are unpredictable. What is this condition? Metrorrhagia (frequent
or irregular menstruation), often called spotting or intermenstrual bleeding "<img
A 23-year-old woman has heavy, regular menses that last for more than 7 days. What
is this condition called? Menorrhagia, defined as menses with greater than 80
mL blood loss or menses that last for more than 7 days. "<img src=""8391.png"">"
menstrual-cycle physiology reproductive
A woman is at the beginning of her pregnancy. Which hormone is essential in
maintaining the endometrium and supporting implantation? Progesterone (decreased
progesterone levels lead to decreased fertility) "<img src=""8391.png"">"
During which part of the menstrual cycle is follicular growth fastest? Second week
of the proliferative phase "<img src=""8391.png"">" menstrual-cycle
A woman has severe pain with menses. What is often associated with this condition?
This is dysmenorrhea, which often is associated with endometriosis "<img
What hormone stimulates endometrial proliferation during the menstrual cycle?
Estrogen "<img src=""8391.png"">" menstrual-cycle physiology
reproductive
How long does the luteal phase of the menstrual cycle typically last? The
follicular phase? 14 days (ovulation day + 14 days = menstruation); follicular
phase can vary in length (accounts for differences in menstrual cycle lengths)
"<img src=""8391.png"">" menstrual-cycle physiology reproductive
When, relative to ovulation, does the estrogen level peak? What about the
progesterone level? Before ovulation; after ovulation "<img src=""8391.png"">"
Is the corpus luteum present during the follicular or luteal phase? Luteal phase
(the corpus luteum is formed from the ruptured follicle and produces progesterone)
"<img src=""8391.png"">" menstrual-cycle physiology reproductive
Regression of the corpus luteum leads to what event? Menstruation (when
progesterone levels decrease, the endometrial lining sloughs off due to apoptosis
of endometrial cells) "<img src=""8391.png"">" menstrual-cycle physiology
reproductive
Where does fertilization most commonly occur? In the upper end of the Fallopian
tube (the ampulla) "<img src=""8392.png"">" physiology pregnancy
reproductive
A woman who is trying to conceive wants to know when fertilization occurs in
relation to ovulation. What do you say? Fertilization occurs within 1 day of
ovulation "<img src=""8392.png"">" physiology pregnancy reproductive
A woman who is trying to conceive wants to know when implantation occurs in
relation to ovulation. What do you say? Implantation in the wall of the uterus
occurs 6 days after fertilization "<img src=""8392.png"">" physiology
pregnancy reproductive
A woman orders a pregnancy test. When is human chorionic gonadotropin (hCG) first
detectable in the blood after conception? In the urine? hCG can first be
detected in the blood 1 week after conception and in the urine 2 weeks after
conception "<img src=""8392.png"">" physiology pregnancy reproductive
What physiologic changes involving the heart do you expect in pregnancy?
Increased cardiac output (increased preload, decreased afterload); increased
heart rate to improve renal and placental perfusion "<img src=""8392.png"">"
physiology pregnancy reproductive
What is the source of hCG shortly after conception? hCG is secreted by
syncytiotrophoblasts "<img src=""8392.png"">" physiology pregnancy
reproductive
In which trimester does the hCG level peak? The first trimester, after which
the placenta becomes the source of progesterone "<img src=""8392.png"">"
physiology pregnancy reproductive
In pregnancy, when do progesterone, estrogen, and prolactin levels peak? The
levels increase throughout pregnancy "<img src=""8392.png"">" physiology
A woman with asthma asks what physiologic respiratory changes she should expect in
pregnancy. What do you tell her? She should expect to hyperventilate more (an
increased respiratory rate is needed to aid elimination of fetal CO2) "<img
src=""8392.png"">" physiology pregnancy reproductive
What physiologic changes involving the bloodstream do you expect in pregnancy?
Anemia is expected in pregnancy because the serum plasma level increases more
than the serum RBC level "<img src=""8392.png"">" physiology pregnancy
reproductive
A woman with a history of DVT wants to know how pregnancy will affect her risk of
another clot. How do you counsel her? Clotting risk (hypercoagulability)
increases; physiologically this decreases blood loss at the time of delivery "<img
A pregnant patient wants to know how to calculate gestational and embryonic ages.
What do you tell her? Gestational age is calculated from the last menstrual
period; embryonic age is from date of conception (gestational age minus 2 weeks)
"<img src=""8392.png"">" physiology pregnancy reproductive
The levels of all hormones but one generally increase throughout pregnancy. What is
it? When does this hormone's level typically peak? hCG; 8 to 10 weeks "<img
A 25-year-old woman has a positive result on a home pregnancy test. What hormone
does the pregnancy test detect, and where is it produced? The home pregnancy test
detects hCG, which is produced by the syncytiotrophoblast of the placenta "<img
src=""8393.png"">" hcg physiology reproductive
A woman has very high hCG levels for gestation. Name four scenarios that could
result in this observation. Multiple gestations, hydatidiform moles,
choriocarcinoma, and Down syndrome "<img src=""8393.png"">" hcg physiology
reproductive
A woman presents after having missed her period 2 weeks ago. What noninvasive test
can you perform to determine whether she's pregnant? Urinary hCG testing can be
used to detect early pregnancy "<img src=""8393.png"">" hcg physiology
reproductive
What is the role of human chorionic gonadotropin (hCG) in the first trimester of
pregnancy? By acting like luteinizing hormone, hCG prevents abortion and maintains
the corpus luteum, which is the source of progesterone "<img src=""8393.png"">"
hcg physiology reproductive
A woman is in her third trimester of pregnancy. What is the source of hCG, estriol,
and progesterone during this period? In the second and third trimesters, the
placenta is the source (as the corpus luteum degenerates) "<img src=""8393.png"">"
hcg physiology reproductive
You order a human chorionic gonadotropin (hCG) pregnancy test. Does this test
detect the or subunit of hCG? The unique subunit (the subunit is
structurally identical to LH, FSH, and TSH, making it less specific) "<img
A woman has low human chorionic gonadotropin levels for gestation. Name three
scenarios that could result in this observation. Ectopic/failing pregnancy,
Edwards syndrome, and Patau syndrome "<img src=""8393.png"">" hcg
A woman with stable thyroid disease becomes pregnant. How do you counsel her about
the hCG level and how it affects her thyroid status? hCG has a structure similar
to TSH's, so an increased level of hCG can cause hyperthyroidism "<img
A baby continues to have an Apgar score <4 for a prolonged period. For what is the
infant at risk? Long-term neurologic damage "<img src=""8394.png"">" apgar-
score physiology reproductive
In the Apgar scoring system, what is the highest score for each of the five
assessed areas? The maximum total score attainable? 2 points; 10 points "<img
src=""8394.png"">" apgar-score physiology reproductive
A baby is in good health after birth. What is the expected range for this healthy
infant's Apgar score? 7 to 10 "<img src=""8394.png"">" apgar-score
At how many minutes after birth is an Apgar score assigned?At both 1 minute and 5
minutes after birth "<img src=""8394.png"">" apgar-score physiology
reproductive
A baby is born with an Apgar score < 7, and it does not change at the 5-minute
mark. What is the next appropriate step? Urgent further evaluation "<img
A neonate's pulse is 110. He has active arm/leg movements. He cries strongly, pulls
away, and is pink except for the toes. Apgar score? 9 (he loses 1 point for non-
pink toes) "<img src=""8394.png"">" apgar-score physiology reproductive
A neonate's HR is 95. He has brisk arm/leg movements. He cries strongly but only
grimaces on stimulation. He is pink all over. Apgar score? 8 (he loses 1 point for
a HR < 100 and 1 point for grimacing on stimulation) "<img src=""8394.png"">"
apgar-score physiology reproductive
A neonate has no pulse and is very pale. There is no response to stimulation. Slow
breathing and flexed extremities are seen. Apgar score? 2 (he earns 1 point for
flexed extremities and 1 point for slow breathing) "<img src=""8394.png"">"
apgar-score physiology reproductive
A neonate has blue extremities and a pink torso. His HR is 115. He has a weak cry
and irregular breathing. He flexes his arms. Apgar score? 6 (he loses 1 point for
blue extremities, 1 point for a weak cry, 1 point for flexed extremities, and 1
point for irregular breathing) "<img src=""8394.png"">" apgar-score
A neonate grimaces but does not pull away. He is pink all over, and the HR is 90.
He moves actively and cries strongly. Apgar score? 8 (he loses 1 point for a HR
< 100 and 1 point for grimacing on stimulation without pulling away) "<img
A pale-blue infant has a pulse of 90. Breathing is slow. He moves actively and
pulls away on stimulation. Is further evaluation needed? The Apgar score is 6 (he
loses 2 points for being pale/blue, 1 point for HR < 100, and 1 point for slow
breaths); scores < 7 need evaluation "<img src=""8394.png"">" apgar-score
Name five problems associated with low birth weight. Impaired immune function,
impaired thermoregulation, hypoglycemia, polycythemia, and impaired
neurocognitive/emotional development "<img src=""8395.png"">" low-birth-
weight physiology reproductive
A baby has a low birth weight. What is the definition of low birth weight, and with
what is it associated? <2500 g; associated with increased risk of sudden infant
death syndrome (SIDS) and overall mortality "<img src=""8395.png"">" low-
birth-weight physiology reproductive
A baby weighs 2400 g at birth. What are the two main possible causes for his
condition? Prematurity and intrauterine growth retardation (the baby is of low
birth weight, defined as < 2500 g) "<img src=""8395.png"">" low-birth-weight
Is a low birth weight associated with emotional problems later in life? What about
physical problems? Yes to both "<img src=""8395.png"">" low-birth-weight
A 4-lb baby is born prematurely. What are five possible major complications of this
low birth weight? Neonatal respiratory distress syndrome, necrotizing
enterocolitis, infection, persistent fetal circulation, and intraventricular
hemorrhage "<img src=""8395.png"">" low-birth-weight physiology reproductive
A mother decides to breastfeed her baby because of the benefits she has read about.
What process induces lactation? When does this occur? Decreased progesterone and
estrogen levels disinhibits prolactin and induces lactation; after delivery "<img
src=""8396.png"">" lactation physiology reproductive
What are two functions of prolactin in the perinatal period? Two functions of
oxytocin? Prolactin induces/maintains milk production, decreases reproductive
function; oxytocin increases milk let0down & causes uterine contractions "<img
A mother wants to resume breastfeeding after having stopped for 1 month. Why is
suckling necessary to maintain milk production? Suckling stimulates nerves that
induce increased oxytocin and prolactin levels "<img src=""8396.png"">"
lactation physiology reproductive
A woman wants to know what is considered the ideal nutrition for infants that are
less than 6 months old. What do you tell her? Breast milk, which contains
maternal immunoglobulins (important for passive immunity, mostly IgA), macrophages,
and lymphocytes "<img src=""8396.png"">" lactation physiology reproductive
A woman wants to know the benefits of breastfeeding for her baby. What do you tell
her? It is associated with lower risk of infant infections and development of
allergies, obesity, diabetes mellitus, and asthma for the child "<img
A woman wants to know the benefits of breastfeeding for the mother. What do you
tell her? Breastfeeding is associated with a decrease in maternal risk of ovarian
and breast cancerit also facilitates mother-child bonding "<img src=""8396.png"">"
lactation physiology reproductive
A woman plans to only breastfeed her infant. What supplementation should you
provide for the infant? Vitamin D "<img src=""8396.png"">" lactation
In menopause, what happens to estrogen, LH, FSH, and GnRH levels? The estrogen
level decreases, whereas the LH, FSH, and GnRH levels all increase "<img
src=""8397.png"">" menopause physiology reproductive
After years of abnormal menses, a 50-year-old woman notes amenorrhea, dyspareunia,
and hot flashes. How do you confirm the likely diagnosis? Menopausemarked by
amenorrhea, vaginal atrophy causing dyspareunia, and hot flashesis confirmed by
increased serum FSH "<img src=""8397.png"">" menopause physiology
reproductive
What is the average age for the onset of menopause in nonsmokers? 51 years;
menopause occurs earlier in smokers "<img src=""8397.png"">" menopause
What is the main source of estrogen following menopause? The peripheral
conversion of androgens into estrone; increased androgens may cause hirsutism
"<img src=""8397.png"">" menopause physiology reproductive
A 35-year-old woman presents with amenorrhea, hot flashes, and a low bone mineral
density. What diagnosis is likely? She has symptoms of early menopause (prior to
age 40), which may indicate premature ovarian failure "<img src=""8397.png"">"
menopause physiology reproductive
A 38-year-old female who has smoked for 15 years asks when she will reach
menopause. Do you predict it will be before or after she turns 51? Before, as
she is a smoker (average age in nonsmokers is 51 years) "<img src=""8397.png"">"
You suspect that a woman is in menopause. What are the clinical and pathologic
manifestations of menopause? Hot flashes, Atrophy of the Vagina, Osteoporosis,
Coronary artery disease, Sleep disturbances (HAVOCS) "<img src=""8397.png"">"
You suspect a woman is menopausal. What is the best serum test to confirm that
menopause has occurred and why? Check for significantly increased levels of
follicle-stimulating hormone (FSH) (decreased estrogen reduces negative feedback on
FSH) "<img src=""8397.png"">" menopause physiology reproductive
You observe that women in menopause have decreased levels of estrogen. What is the
cause of this phenomenon? The age-linked decline in the number of ovarian
follicles causes a decrease in estrogen production "<img src=""8397.png"">"
You suspect that a woman is approaching menopause. What is the most tell-tale sign
of imminent menopause leading up to it? 45 years of abnormal menstrual cycles
(menopause is usually preceded by these years) "<img src=""8397.png"">"
A 50-year-old woman reports 10 months of amenorrhea. Is she in menopause? Not
technically; the definition of menopause is amenorrhea for at least 12 months
"<img src=""8397.png"">" menopause physiology reproductive
Rank these three androgens in order, from most to least potent: androstenedione,
dihydrotestosterone (DHT), and testosterone. DHT > testosterone >
androstenedione "<img src=""8398.png"">" androgens physiology reproductive
What is the major source of dihydrotestosterone and testosterone in men? Of
androstenedione? The testes; the adrenals (AnDrostenedione = ADrenal) "<img
src=""8398.png"">" androgens physiology reproductive
A man notices balding and increased sebaceous gland activity. He also has an
enlarged prostate. What hormone causes these findings? Dihydrotestosterone
(DHT, also involved in differentiation of the penis, scrotum, and prostate early in
life) "<img src=""8398.png"">" androgens physiology reproductive
A 60-year-old man with benign prostatic hyperplasia takes a medication that
inhibits 5-reductase. Name the medication and its function. Finasteride
prevents conversion of testosterone to dihydrotestosterone by inhibiting 5-
reductase "<img src=""8398.png"">" androgens physiology reproductive
Which enzyme converts testosterone and androstenedione to estrogen in men? Where is
this enzyme found? Cytochrome P-450 aromatase; adipose tissue and testes "<img
src=""8398.png"">" androgens physiology reproductive
A 14-year-old boy presents for an annual exam. He reports many changes since last
year. What effects does testosterone have during puberty? Growth spurt (penis,
seminal vesicles, sperm, muscle, RBCs), deepening of the voice, increased libido,
closure of epiphyseal plates "<img src=""8398.png"">" androgens physiology
reproductive
A 57-year-old man has difficulty urinating and notices changes in his body. What
are the late effects of dihydrotestosterone on men? Prostate growth, balding,
sebaceous gland activity "<img src=""8398.png"">" androgens physiology
reproductive
A bodybuilder comes to your office for infertility; on exam, you note small
testicles. What is a likely cause of his infertility? Azoospermia due to exogenous
testosterone use causing hypothalamic-pituitary-gonadal axis inhibition and low
intratesticular testosterone "<img src=""8398.png"">" androgens physiology
reproductive
You noticed that the epiphyseal plate of a man has closed. What hormone causes this
phenomenon? Estrogen, converted from testosterone "<img src=""8398.png"">"
androgens physiology reproductive
You notice differentiation of the epididymis, vas deferens, internal genitalia, and
seminal vesicles in a male fetus. What hormone drives these processes? Testosterone
"<img src=""8398.png"">" androgens physiology reproductive
Testosterone influences the differentiation of all aspects of internal male
genitalia except for which organ? The prostate "<img src=""8398.png"">"
androgens physiology reproductive
How long does it take for the development of a mature spermatid? Where does this
spermatogenesis occur? 2 months; in the seminiferous tubules "<img
src=""8399.png"">" physiology reproductive spermatogenesis
Put these in order from least to most developed: spermatozoon, 1 spermatocyte, 2
spermatocyte, spermatid, spermatogonium. Spermatogonium, 1 spermatocyte, 2
spermatocyte, spermatid, spermatozoon (gonium is going to be a sperm, Zoon is
Zooming to egg) "<img src=""8399.png"">" physiology reproductive
spermatogenesis
What is the genetic makeup of a spermatogonium (in terms of chromosomal material)?
It is diploid (2N, 2C) with 46 single chromosomes and a sex of X-Y "<img
What is the genetic makeup of a primary spermatocyte (in terms of chromosomal
material)? It is diploid (2N, 4C) with 46 sister chromatids and a sex of X-X/Y-Y
"<img src=""8399.png"">" physiology reproductive spermatogenesis
What is the genetic makeup of a secondary spermatocyte (in terms of chromosomal
material)? It is haploid (1N, 2C) with 23 sister chromatids and a sex of X-X or Y-
Y "<img src=""8399.png"">" physiology reproductive spermatogenesis
What is the genetic makeup of a spermatid (in terms of chromosomal material)?
It is haploid (1N, 1C) with 23 single chromatids and a sex of X or Y "<img
What is the genetic makeup of a mature spermatozoon (in terms of chromosomal
material)? It is haploid (1N, 1C) with 23 single chromatids and a sex of X or Y
"<img src=""8399.png"">" physiology reproductive spermatogenesis
Sperm transform between which two sperm subtypes during meiosis I? What about
meiosis II? Primary spermatocyte to secondary spermatocyte; secondary spermatocyte
to spermatid "<img src=""8399.png"">" physiology reproductive
spermatogenesis
A male patient is found to have impaired tail mobility of his sperm. What condition
can this lead to, and which disease can cause this? Infertility, which is seen in
ciliary dyskinesia/Kartagener syndrome "<img src=""8399.png"">" physiology
reproductive spermatogenesis
When does spermatogenesis begin? What is spermiogenesis? Begins at puberty with
spermatogonia; spermatids lose their cytoplasmic contents and gain an acrosomal cap
to form mature spermatozoon "<img src=""8399.png"">" physiology reproductive
spermatogenesis
What kind of barrier must the spermatogonia cross during the replication
(interphase) stage of spermatogenesis? Spermatogonia must cross the tight
junctions of the blood-testis barrier on the journey to becoming primary
spermatocytes "<img src=""8399.png"">" physiology reproductive
spermatogenesis
A teenage girl is not sure whether she is finished with puberty. She is at least
Tanner stage 4. How can she know whether she has finished? For females in Tanner
stage 5, the areolae are no longer raised and the pubic hair crosses both the pubis
and medial thighs "<img src=""8400.png"">" physiology reproductive tanner-
stages-of-sexual-development
On a blood smear from a male patient, you note a small dumbbell-shaped extension of
a cell nucleus (ie, Barr body). What does it represent? Inactivated X
chromosome, which is normal in women but indicates Klinefelter syndrome (XXY) in
men "<img src=""8401.png"">" Pathology reproductive sex-chromosome-disorders
You refer a 30-year-old man and his wife for an infertility work-up. You suspect
congenital hypogonadism. Diagnosis? Klinefelter syndrome (XXY) is a common cause of
congenital hypogonadism in men (incidence is 1:850) "<img src=""8401.png"">"
Pathology reproductive sex-chromosome-disorders
What happens to follicle-stimulating hormone (FSH), estrogen, testosterone, and
luteinizing hormone (LH) levels in Klinefelter syndrome? Seminiferous tubule
dysgenesis causes low inhibin B/high FSH; abnormal Leydig cell function causes low
testosterone/high LH/high estrogen "<img src=""8401.png"">" Pathology
reproductive sex-chromosome-disorders
A tall boy is noted to have testicular atrophy and long extremities. What will
intelligence testing reveal? It will likely show a developmental delay, which is
sometimes seen in people with Klinefelter syndrome "<img src=""8401.png"">"
A young female patient with Turner syndrome presents with cold legs. Her brachial
pulses are brisk. What cardiovascular anomaly is to blame? Preductal coarctation of
the aorta (femoral pulse weaker than brachial pulse, ribs notched)common in
patients with Turner syndrome) "<img src=""8401.png"">" Pathology
How many Barr bodies are seen when the cells of a patient with Turner syndrome are
examined under the microscope? None "<img src=""8401.png"">" Pathology
In women with Turner syndrome, when does menopause occur relative to menarche?
Menopause occurs before menarche "<img src=""8401.png"">" Pathology
A short teenage girl undergoes an infertility work-up. You note a shield-like chest
and webbed neck. Why do you perform a heart ultrasound? She likely has Turner
syndrome, which may include such cardiovascular anomalies as bicuspid aortic valve
or coarctation of the aorta "<img src=""8401.png"">" Pathology reproductive
sex-chromosome-disorders
A woman of short stature presents to your office. She has a webbed neck and
lymphedema. What will an ovarian biopsy show? Ovarian dysgenesis (streak ovary),
seen in Turner syndrome "<img src=""8401.png"">" Pathology reproductive sex-
chromosome-disorders
What is the most common cause of primary amenorrhea? Turner syndrome "<img
src=""8401.png"">" Pathology reproductive sex-chromosome-disorders
What are the possible genotypes of a female patient with Turner syndrome? 45,XO
(complete monosomy) or 45,XO/46,XX (mosaicism; from mitotic error) "<img
A woman with Turner syndrome wishes to get pregnant. Is this possible? If so, what
treatments can you offer her? Yes, it may be possible with IVF or with
administration of exogenous progesterone and estradiol-17 "<img src=""8401.png"">"
A phenotypically normal, very tall man with acne and learning disabilities presents
to your office. What additional disorder might he have? Double Y males (XYY), in
addition to acne and learning disabilities, may present with autism spectrum
disorders "<img src=""8401.png"">" Pathology reproductive sex-chromosome-
disorders
A woman presents to your office. You discover ovotestis, a mixture of ovarian and
testicular tissues. What is her condition? "Ovotesticular disorder (46,XX or
47,XXY), or the presence of ovotestis and ambiguous genitalia; formerly called
""true hermaphroditism""" "<img src=""8401.png"">" Pathology reproductive
sex-chromosome-disorders
What is the approximate ratio of male to female gonadal tissue in people with
ovotesticular disorder of sex development? 46,XX > 46,XY "<img
A man has the genotype XYY. What do you tell him about his fertility and the
mechanism of how this happened? Normal fertilitythis is not hereditary but
just a random nondisjunction event in paternal meiosis II "<img src=""8401.png"">"
What is the most common mechanism behind sex chromosome disorders? Aneuploidy
caused by meiotic nondisjunction "<img src=""8401.png"">" Pathology
In a patient with ovotesticular disorder of sex development, what kind of genitalia
will be seen on exam? Ambiguous genitalia "<img src=""8401.png"">"
A man has small testicles, sparse body hair, and anosmia. He has low testosterone
and luteinizing hormone. Most likely diagnosis? Hypogonadotropic hypogonadism "<img
src=""8402.png"">" Pathology diagnosing-disorders-of-sex-hormones reproductive
A man lacks secondary sex characteristics (pubic/face/underarm hair). He has low
testosterone and high luteinizing hormone. Diagnosis? Primary hypogonadism "<img
src=""8402.png"">" Pathology diagnosing-disorders-of-sex-hormones reproductive
A patient with an XY genotype has defective androgen receptors. What levels of
testosterone and luteinizing hormone (LH) will you see? Both testosterone and LH
would be elevated (congenital androgen insensitivity) "<img src=""8402.png"">"
Pathology diagnosing-disorders-of-sex-hormones reproductive
A man has high testosterone. What lab test helps distinguish a defect in the
androgen receptor from the use of exogenous testosterone? Luteinizing hormone
test, which will produce a high result with an androgen receptor defect and low
result with exogenous testosterone use "<img src=""8402.png"">" Pathology
diagnosing-disorders-of-sex-hormones reproductive
A man has high testosterone. What lab test helps distinguish a defect in the
androgen receptor from a testosterone-secreting tumor? Luteinizing hormone
test, which will produce a high result with androgen receptor defect and low result
with testosterone-secreting tumor "<img src=""8402.png"">" Pathology
diagnosing-disorders-of-sex-hormones reproductive
How do levels of testosterone and luteinizing hormone (LH) distinguish primary
hypogonadism from hypogonadotropic hypogonadism? Both have low testosterone,
but primary hypogonadism (gonadal failure) has high LH and hypogonadotropic
hypogonadism has low LH "<img src=""8402.png"">" Pathology diagnosing-
disorders-of-sex-hormones reproductive
What is the term for a mismatch between the phenotype of internal (gonadal) and
external genital structures? Pseudohermaphroditism, hermaphrodite, or intersex (a
disagreement between the phenotypic [external genitalia] and the gonadal sex)
"<img src=""8403.png"">" Pathology other-disorders-of-sex-development
reproductive
A patient has a 46,XY disorder of sexual development. What internal and external
sex organs are present? Testes are present, and the external genitalia are female
or ambiguous "<img src=""8403.png"">" Pathology other-disorders-of-sex-
development reproductive
A patient presents with a 46,XY disorder of sexual development. What is the most
common cause of this disorder? Androgen insensitivity syndrome (also known as
testicular feminization) "<img src=""8403.png"">" Pathology other-
disorders-of-sex-development reproductive
A female with a XX genotype presents with virilized external genitalia. Ultrasound
shows the presence of ovaries. What is the diagnosis? A 46,XX disorder of sexual
development "<img src=""8403.png"">" Pathology other-disorders-of-sex-
A patient presents with a 46,XX disorder of sexual development. What in utero event
can lead to this disorder? Excessive/inappropriate exposure to androgenic
steroids in early gestation (eg, congenital adrenal hyperplasia or exogenous
androgen use) "<img src=""8403.png"">" Pathology other-disorders-of-sex-
A female infant (46,XX) has masculinized genitalia and increased serum testosterone
and androstenedione. What is a possible diagnosis? Placental aromatase
deficiency, an inability to synthesize estrogens from androgens "<img
src=""8404.png"">" Pathology placental-aromatase-deficiency reproductive
A pregnant woman has evidence of virilization during her pregnancy. Fetal androgens
are detected in her blood. What is the likely diagnosis? Placental aromatase
deficiency in her fetus (fetal androgens can cross the placenta and cause maternal
virilization) "<img src=""8404.png"">" Pathology placental-aromatase-
deficiency reproductive
You observe no sexual hair in a normal-appearing woman. She has a blind-pouch
vagina with no palpable uterus or fallopian tubes. Diagnosis? Androgen
insensitivity syndrome (a mutation in the androgen receptor that leads to no
response to androgens) "<img src=""8405.png"">" Pathology androgen-
insensitivity-syndrome-(46,xy) reproductive
What hormone levels distinguish androgen insensitivity syndrome from sex chromosome
disorders? In androgen insensitivity syndrome, testosterone, estrogen, and LH
levels are all high (not the case with sex chromosome disorders) "<img
src=""8405.png"">" Pathology androgen-insensitivity-syndrome-(46,xy)
reproductive
A patient has androgen insensitivity syndrome. Are testes present? What treatment,
if any, is needed? Normally functioning testes are often found in the labia
majora; surgical removal required to prevent malignancy "<img src=""8405.png"">"
Pathology androgen-insensitivity-syndrome-(46,xy) reproductive
What is the genotype and phenotype for someone with androgen insensitivity
syndrome? The genotype is 46,XY and the phenotype externally female; internally
only a rudimentary vagina is seen, but no fallopian tubes or uterus "<img
src=""8405.png"">" Pathology androgen-insensitivity-syndrome-(46,xy)
reproductive
What is the phenotype of the external genitalia of someone with 5-reductase
deficiency? Genotype? It is ambiguous until puberty, at which point increased
testosterone causes masculinization; internal genitalia are normal "<img
src=""8406.png"">" 5a-reductase-deficiency Pathology reproductive
What are the levels of testosterone, estrogen, and luteinizing hormone in a patient
with 5-reductase deficiency? Testosterone and estrogen are normal, and LH is
normal to increased "<img src=""8406.png"">" 5a-reductase-deficiency
Pathology reproductive
What reaction is hindered in patients with 5-reductase deficiency? The
conversion of testosterone to dihydrotestosterone "<img src=""8406.png"">"
5a-reductase-deficiency Pathology reproductive
What is the inheritance pattern of 5-reductase deficiency? Does it occur in males,
females, or both? Autosomal recessive, limited to genetic males (46,XY)"<img
src=""8406.png"">" 5a-reductase-deficiency Pathology reproductive
A male lacking secondary sex characteristics and the ability to smell (anosmia)
presents for his yearly physical. What is the diagnosis? Kallmann syndrome, which
is due to defective migration of GnRH cells and formation of the olfactory bulb
"<img src=""8407.png"">" Pathology kallmann-syndrome reproductive
A young female patient failed to complete puberty and presents with amenorrhea. She
has very low GnRH levels. What is a possible diagnosis? Kallmann syndrome, which
is a form of hypogonadotropic hypogonadism "<img src=""8407.png"">"
Pathology kallmann-syndrome reproductive
A man with Kallmann syndrome has decreased synthesis of what hormone from the
hypothalamus? How does this affect his sperm count? GnRH; this decreases FSH, LH,
and testosterone, leading to a low sperm count "<img src=""8407.png"">"
A female patient has Kallmann syndrome. How do you counsel her regarding her
menstrual cycle? She will have amenorrhea and infertility "<img src=""8407.png"">"
A hydatidiform mole is a precursor of what malignancy? Which mole subtype has the
strongest association with malignancy? Choriocarcinoma; more common with
complete moles (2%) than partial moles (very rare) "<img src=""8408.png"">"
Pathology hydatidiform-mole reproductive
What are the possible karyotypes of a partial hydatidiform mole? Can it contain
fetal parts? Triploid (69,XXY; 69,XXX; 69,XYY); yes (partial = fetal parts)
"<img src=""8408.png"">" Pathology hydatidiform-mole reproductive
Is a patient with high human chorionic gonadotropin and a large uterus more likely
to have a complete or partial mole? A complete mole (partial moles typically have
milder increases in human chorionic gonadotropin and normal uterus size) "<img
src=""8408.png"">" Pathology hydatidiform-mole reproductive
What is the genotype of a complete hydatidiform mole? Can it contain fetal parts?
Diploid (46,XX or 46,XY); no "<img src=""8408.png"">" Pathology
hydatidiform-mole reproductive
What is the origin of the genetic material in a partial hydatidiform mole? This
type of mole has DNA from both mother and father due to the fertilization of one
egg by two spermit can be 69,XXX, 69,XXY, or 69,XYY "<img src=""8408.png"">"
Pathology hydatidiform-mole reproductive
How does the risk of malignancy differ between complete and partial moles?
Complete = 1520% malignant trophoblastic disease risk, 2% progress to
choriocarcinomapartial = low malignancy risk (<%), rarely progresses "<img
A woman has vaginal bleeding, enlarged uterus, pelvic pressure/pain, theca-lutein
cysts, hyperthyroidism, and hyperemesis. Diagnosis? These symptoms are classic
indications of hydatidiform mole "<img src=""8408.png"">" Pathology
hydatidiform-mole reproductive
You observe cystic swelling of chorionic villi and proliferation of trophoblasts in
the chorionic epithelium in a patient. Diagnosis? Hydatidiform mole "<img
"An 18-weeks-pregnant woman has an enlarged uterus with a ""snowstorm"" appearance
on ultrasound. What vital sign must be checked?" This is a hydatidiform mole;
watch out for early preeclampsia (onset before 20 weeks gestation) by checking her
blood pressure "<img src=""8408.png"">" Pathology hydatidiform-mole
reproductive
Describe the components that must come together to form a complete hydatidiform
mole. A single sperm with an enucleated egg, which results in duplicated paternal
DNA "<img src=""8408.png"">" Pathology hydatidiform-mole reproductive
A 4-months-pregnant woman who has not received prenatal care passes grape-like
masses in her urine. Will maternal DNA be found in the fetus? No; this is a
complete molar pregnancy, so there is no fetus, and all DNA found will be paternal
in origin "<img src=""8408.png"">" Pathology hydatidiform-mole reproductive
A woman has abnormally high hCG, shortness of breath, and multiple theca-lutein
cysts. On review of systems, might she report a cough? Yes; choriocarcinoma
tends to metastasize to the lungs and can cause hemoptysis "<img src=""8409.png"">"
Pathology choriocarcinoma reproductive
A postpartum woman has hemoptysis and dyspnea. Blood work shows high -hCG. D&C is
performed for diagnosis. Likely histologic findings? Proliferation of
cytotrophoblasts and syncytiotrophoblasts but no chorionic villi (this is a
choriocarcinoma) "<img src=""8409.png"">" Pathology choriocarcinoma
reproductive
Choriocarcinomas are malignancies that arise from what tissue? Trophoblastic
tissue "<img src=""8409.png"">" Pathology choriocarcinoma reproductive
What rare tumor associated with multiple theca-lutein cysts can occur in either the
mother or fetus during or after pregnancy? Choriocarcinoma "<img
src=""8409.png"">" Pathology choriocarcinoma reproductive
After delivery, a woman has massive bleeding and fails to complete the third stage
(delivery of the placenta). What is the likely diagnosis? Placenta accreta,
increta, or percreta "<img src=""8410.png"">" Pathology pregnancy-
complications reproductive
Name two risk factors for placenta previa. Multiparity and prior C-sections
"<img src=""8410.png"">" Pathology pregnancy-complications reproductive
Name three risk factors for placenta accreta/increta/percreta. Prior C-sections,
inflammation, placenta previa "<img src=""8410.png"">" Pathology pregnancy-
A woman with 9 weeks of amenorrhea has sudden lower abdominal pain and a lower-
than-expected rise in hCG. What diagnosis is likely? Ectopic pregnancy "<img
src=""8410.png"">" Pathology pregnancy-complications reproductive
Name five risk factors for placental abruption (abruptio placentae). Smoking,
hypertension, cocaine abuse, trauma (eg, motor vehicle crash), preeclampsia "<img
A woman is found to have an ectopic pregnancy. Name four risk factors that might
have predisposed her to this condition. Prior ectopic pregnancy, history of
infertility, salpingitis (pelvic inflammatory disease), ruptured appendix, and
prior tubal surgery "<img src=""8410.png"">" Pathology pregnancy-
A patient presents with membrane rupture, painless vaginal bleeding, and a fetal
heart rate < 110 beats/min. Treatment? Emergency C-section (this is the classic
triad of vasa previa) "<img src=""8410.png"">" Pathology pregnancy-
You suspect abruptio placentae in a pregnant woman with abrupt painful bleeding in
the third trimester. What other symptoms may be present? Disseminated
intravascular coagulation (DIC), maternal shock, fetal distress; this threatens the
lives of both mother and fetus "<img src=""8410.png"">" Pathology
pregnancy-complications reproductive
What kind of umbilical cord insertion is associated with vasa previa? Velamentous
(insertion into chorioamniotic membrane rather than placenta, so vessels travel to
placenta unprotected by Wharton jelly) "<img src=""8410.png"">" Pathology
A pregnant woman has placenta accreta. Will a biopsy of the uterine serosa near the
affected area show invading placental tissue? No, as the placenta attaches to the
myometrium with no penetration in placenta accreta; the serosa is spared "<img
A patient presents with lower-than-normal hCG level and abdominal pain. What might
her presentation easily be mistaken for? This is likely an ectopic pregnancy,
which can be clinically mistaken for appendicitis "<img src=""8410.png"">"
Pathology pregnancy-complications reproductive
A pregnant woman has placenta increta. Does the placenta penetrate into the
myometrium in this patient? Yes, the placenta penetrates into the myometrium in
placenta increta "<img src=""8410.png"">" Pathology pregnancy-complications
reproductive
A pregnant patient presents with left-sided abdominal pain and vaginal bleeding.
What imaging do you obtain? Ultrasound to confirm ectopic pregnancy "<img
A pregnant woman has placenta percreta. Is further assessment of her rectum and
bladder indicated? Yes, the placenta perforates the myometrium and into the
uterine serosa in placenta percretamay adhere to rectum and bladder) "<img
What are four causes of postpartum hemorrhage? What is the most common? 4 T's:
Tone (uterine atony, #1), Trauma (lacerations, incisions, rupture), Thrombin
(coagulopathy), Tissue (retained products of conception) "<img src=""8410.png"">"
A 35-year-old woman presents 7 days after delivery with massive painless vaginal
bleeding. What is the most likely diagnosis? Retained placental tissue (causing
postpartum hemorrhage) "<img src=""8410.png"">" Pathology pregnancy-
A 37-weeks-pregnant woman has abdominal pain but no vaginal bleeding. She goes into
shock. Fetal heart tracings show bradycardia. Diagnosis? Placental abruption,
which can present with a concealed bleedshe has gone into shock, and her fetus is
also in distress "<img src=""8410.png"">" Pathology pregnancy-complications
reproductive
If placenta accreta/increta/percreta is not detected before delivery, massive
postpartum bleeding may ensue, leading to what complication? Sheehan syndrome
"<img src=""8410.png"">" Pathology pregnancy-complications reproductive
A woman with painless third-trimester bleeding has a placenta seen < 2 cm from the
internal cervical os. Has she had a prior C-section? Likely yesthis is placenta
previa, for which prior C-section is a risk factor "<img src=""8410.png"">"
What is used to distinguish placenta accreta, increta, and percreta? The depth of
placental penetration into the uterus "<img src=""8410.png"">" Pathology
A 25-year-old woman who has not had her period for 8 weeks presents with severe LLQ
pain without vaginal bleeding. Diagnosis? Ectopic pregnancy, which is not always
accompanied by vaginal bleeding; the key is pain (with or without bleeding) and
amenorrhea "<img src=""8410.png"">" Pathology pregnancy-complications
reproductive
What fetal malformations are associated with polyhydramnios (too much amniotic
fluid)? Fetal malformations such as esophageal/duodenal atresia, and
anencephaly, leading to inability by the fetus to swallow amniotic fluid "<img
src=""8411.png"">" Pathology amniotic-fluid-abnormalities reproductive
A pregnant woman was told that she has oligohydramnios after her last ultrasound.
What process is causing this condition? Oligohydramnios (too little amniotic
fluid) is caused by an inability of the fetus to excrete urine "<img
src=""8411.png"">" Pathology amniotic-fluid-abnormalities reproductive
Name three congenital conditions that are associated with oligohydramnios.
Placental insufficiency, bilateral renal agenesis, and posterior urethral
valves (in male subjects) "<img src=""8411.png"">" Pathology amniotic-
fluid-abnormalities reproductive
What fetal syndrome is associated with severe oligohydramnios? Potter sequence
(lack of amniotic fluid leads to pulmonary hypoplasia, characteristic facies, and
other abnormalities) "<img src=""8411.png"">" Pathology amniotic-fluid-
abnormalities reproductive
What are some situations associated with polyhydramnios? Maternal diabetes, fetal
anemia, multiple gestations, fetal esophageal/duodenal atresia or anencephaly
(states impairing fetal swallowing) "<img src=""8411.png"">" Pathology
amniotic-fluid-abnormalities reproductive
Name four preexisting medical conditions that are associated with an increased risk
of developing preeclampsia. Hypertension, chronic renal disease, diabetes, and
autoimmune disorders "<img src=""8412.png"">" Pathology hypertension-in-
A woman at 25 weeks' gestation has a blood pressure of 140/90 mm Hg and protein in
her urine. Name the diagnosis and treatment. Preeclampsiaantihypertensives, IV
magnesium sulfate to prevent seizures; definitive treatment is delivery of fetus
"<img src=""8412.png"">" Pathology hypertension-in-pregnancy
reproductive
A woman with no preexisting hypertension, proteinuria, or end-organ damage has a BP
of 140/90 mmHg at week 25 of pregnancy. Diagnosis? Gestational hypertension
(pregnancy-induced hypertension) "<img src=""8412.png"">" Pathology
hypertension-in-pregnancy reproductive
A pregnant woman in the ED has a high BP, a platelet count of 90, and increased
liver function markers and indirect bilirubin. Diagnosis? This is HELLP syndrome
(Hemolysis, Elevated Liver enzymes, Low Platelet count), a severe manifestation of
preeclampsia "<img src=""8412.png"">" Pathology hypertension-in-pregnancy
reproductive
A pregnant woman is diagnosed with preeclampsia. What is thought to be the etiology
of preeclampsia? Abnormal placental spiral arteries leading to maternal
endothelial dysfunction, vasoconstriction, and ischemia "<img src=""8412.png"">"
Pathology hypertension-in-pregnancy reproductive
A pregnant woman being monitored for preeclampsia suddenly seizes. What is this
condition called? What are the treatment options? Eclampsia; IV magnesium
sulfate, antihypertensives, immediate delivery "<img src=""8412.png"">"
What are the treatment options for gestational hypertension? Antihypertensives
(Hydralazine, -Methyldopa, Labetalol, Nifedipine), delivery at 37 to 39 weeks
(Hypertensive Moms Love Nifedipine) "<img src=""8412.png"">" Pathology
hypertension-in-pregnancy reproductive
A woman at 18 weeks' gestation has separate blood pressure readings of 145/92 and
151/66 mm Hg. Do you diagnose gestational hypertension? No; a diagnosis of
gestational hypertension (pregnancy-induced hypertension) may only be made after
the 20th week of gestation "<img src=""8412.png"">" Pathology hypertension-
in-pregnancy reproductive
A woman has eclampsia. What three associated conditions may result in maternal
death? Stroke, intracranial hemorrhage, and adult respiratory distress
syndrome (ARDS) "<img src=""8412.png"">" Pathology hypertension-in-pregnancy
reproductive
What are some complications of preeclampsia? Placental abruption, renal failure,
uteroplacental insufficiency, coagulopathy, eclampsia "<img src=""8412.png"">"
At 15 weeks, a pregnant woman has new-onset proteinuria and hypertension. What is
the diagnosis? Consider a molar pregnancy, as preeclampsia usually does not
arise until at least 20 weeks of gestation "<img src=""8412.png"">"
A pregnant woman has hypertension and proteinuria, and schistocytes are seen on
blood smear. Severe hypotension suddenly develops. Why? She has preeclampsia and
HELLP syndrome, and a hepatic subcapsular hematoma has likely ruptured, leading to
severe hypotension "<img src=""8412.png"">" Pathology hypertension-in-
At 15 weeks, a pregnant woman has new-onset hypertension without proteinuria.
Diagnosis? Undiagnosed chronic hypertension, which can only be gestational
hypertension if it develops after the 20th week of gestation "<img
src=""8412.png"">" Pathology hypertension-in-pregnancy reproductive
List these cancers in order of worsening prognosis: cervical, endometrial, ovarian.
Ovarian > endometrial > cervical "<img src=""8413.png"">" Pathology
gynecologic-tumor-epidemiology reproductive
List the incidence of gynecologic tumors in the US from most to least common. Which
one is most common worldwide? US: endometrial > ovarian > cervical; worldwide:
cervical cancer is the most common because of lack of HPV screening and HPV vaccine
access "<img src=""8413.png"">" Pathology gynecologic-tumor-epidemiology
reproductive
What vaginal cancer develops secondary to cervical carcinoma? Vaginal squamous
cell carcinoma develops from cervical squamous cell carcinoma (primary vaginal
cancer is rare) "<img src=""8414.png"">" Pathology reproductive vaginal-
tumors
A female patient presents with clear cell adenocarcinoma of the vagina. What drug
was she likely exposed to in utero? Diethylstilbestrol (DES) "<img
src=""8414.png"">" Pathology reproductive vaginal-tumors
A 3-year-old girl presents with a clear grape-like polypoid mass emerging from her
vagina. Diagnosis? Sarcoma botryoides (embryonal rhabdomyosarcoma variant)
"<img src=""8414.png"">" Pathology reproductive vaginal-tumors
A toddler presents with a grape-like protrusion from her vagina. Histology shows
spindle-shaped cells and desmin positivity. Diagnosis? Sarcoma botryoides
(embryonal rhabdomyosarcoma variant) "<img src=""8414.png"">" Pathology
reproductive vaginal-tumors
On histology, where would you expect to see the initial stages of cervical
dysplasia or carcinoma in situ? Basal layer of squamocolumnar junction
(transformation zone): Dysplasia begins basally and progressively extends to the
apical surface "<img src=""8415.png"">" Pathology cervical-pathology
reproductive
A 19-year-old woman receives the HPV vaccine. It protects against which two
carcinogenic HPV strains? How do they cause cervical cancer? 16 and 18 (E6 gene
product inhibits p53 suppressor gene, E7 gene product inhibits RB suppressor gene)
"<img src=""8415.png"">" Pathology cervical-pathology reproductive
What characteristics of cervical cancer make it amenable to screening and effective
intervention? Slow development and identifiable precursor lesions, which can be
located and removed at an early stage "<img src=""8415.png"">" Pathology
cervical-pathology reproductive
Name four risk factors for cervical cancer. Which is the most common/important?
Multiple sexual partners (most common/important risk factor), early sexual
intercourse, HIV infection, and smoking "<img src=""8415.png"">" Pathology
A 40-year-old woman with a history of cervical carcinoma now has oliguria and a
creatinine of 4.0 mg/dL (high). What is the likely cause? Lateral invasion by the
carcinoma, resulting in obstruction of the ureters and subsequent renal failure
"<img src=""8415.png"">" Pathology cervical-pathology reproductive
What are the three levels of classification for cervical intraepithelial neoplasia
(CIN)? CIN I is mild dysplasia, CIN 2 is moderate dysplasia, CIN 3 is severe
dysplasia or carcinoma in situ "<img src=""8415.png"">" Pathology
A woman has invasive cervical carcinoma as a result of HPV infection. From what
line of cells did the carcinoma most likely originate? Squamous cells "<img
src=""8415.png"">" Pathology cervical-pathology reproductive
A 24-year-old woman presents with postcoital bleeding. She has a history of smoking
and several sexual partners. How do you diagnose? She is at high risk for
cervical dysplasia, which is typically asymptomatic but can present with abnormal
bleeding; do a Pap smear "<img src=""8415.png"">" Pathology cervical-
pathology reproductive
What distinguishes premature ovarian failure from menopause? Menopause occurs
after age 40; premature ovarian failure occurs before age 40 "<img
src=""8416.png"">" Pathology premature-ovarian-failure reproductive
A 40-year-old woman has hot flashes, and you suspect premature ovarian failure.
What do you expect to see on blood laboratory results? Decreased estrogen,
increased follicle-stimulating hormone and luteinizing hormone "<img
src=""8416.png"">" Pathology premature-ovarian-failure reproductive
A 39-year-old woman has hot flashes, vaginal atrophy, and irregular menses. What
would you expect to see on ovarian biopsy? Atresia of the ovarian follicles
(this is premature ovarian failure) "<img src=""8416.png"">" Pathology
premature-ovarian-failure reproductive
Name four endocrine abnormalities that can cause anovulation. Thyroid disorders,
Cushing syndrome, adrenal insufficiency, hyperprolactinemia"<img src=""8417.png"">"
Pathology most-common-causes-of-anovulation reproductive
Name two causes of anovulation, other than pregnancy, that are due to increased
levels of circulating estrogens. Polycystic ovarian syndrome and obesity "<img
src=""8417.png"">" Pathology most-common-causes-of-anovulation reproductive
What might cause anovulation in a 30-year-old woman who is experiencing hot
flashes, irregular menstrual cycles, and dyspareunia? Premature ovarian failure
"<img src=""8417.png"">" Pathology most-common-causes-of-anovulation
reproductive
Disrupting what endocrine signaling system may cause anovulation? The
hypothalamic-pituitary-ovarian (HPO) axis (such as in Kallmann syndrome, where
there is a failure of gonadotrope cells in the pituitary) "<img src=""8417.png"">"
Pathology most-common-causes-of-anovulation reproductive
What two conditions, which typically involve a great deal of weight loss or energy
consumption, can lead to anovulation? Having an eating disorder and being a
competitive athlete "<img src=""8417.png"">" Pathology most-common-causes-
of-anovulation reproductive
An obese woman has amenorrhea/oligomenorrhea and dark hair above her lips.
Pregnancy tests are negative. What is causing her infertility? Polycystic ovarian
syndrome, in which increased luteinizing hormone causes anovulation (a common cause
of subfertility in women) "<img src=""8418.png"">" Pathology polycystic-
ovarian-syndrome-(stein-leventhal-syndrome) reproductive
A woman is found to have Stein-Leventhal syndrome. What is the cause of the
increased serum testosterone level? Deranged steroid synthesis by theca cells
results in hyperandrogenism (note: this is also known as polycystic ovarian
syndrome) "<img src=""8418.png"">" Pathology polycystic-ovarian-syndrome-
(stein-leventhal-syndrome) reproductive
How does polycystic ovarian syndrome affect luteinizing hormone (LH), follicle-
stimulating hormone (FSH), and androgen levels? LH is increased; FSH is increased,
the LH:FSH ratio is increased, and androgens (such as testosterone) are increased
"<img src=""8418.png"">" Pathology polycystic-ovarian-syndrome-(stein-
leventhal-syndrome) reproductive
A woman with polycystic ovarian syndrome is at increased risk for what type of
cancer? Endometrial cancer secondary to unopposed estrogen from repeated
anovulatory cycles "<img src=""8418.png"">" Pathology polycystic-ovarian-
syndrome-(stein-leventhal-syndrome) reproductive
A woman has hirsutism, infertility, oligomenorrhea, and enlarged cystic ovaries
bilaterally. Diagnosis and treatment options? Polycystic ovarian syndrometreated
with weight loss, oral contraceptives, clomiphene citrate, ketoconazole, and
spironolactone "<img src=""8418.png"">" Pathology polycystic-ovarian-
syndrome-(stein-leventhal-syndrome) reproductive
What causes the increased luteinizing hormone (LH) found in polycystic ovarian
syndrome? Increased LH due to pituitary/hypothalamic dysfunction resulting from
hyperinsulinemia/insulin resistance "<img src=""8418.png"">" Pathology
polycystic-ovarian-syndrome-(stein-leventhal-syndrome) reproductive
A woman with endometrial hyperplasia and anovulatory cycles is found to have an
ovarian cyst. What is the most likely type? A follicular cyst, which can be
associated with endometrial hyperplasia and elevated estrogens "<img
src=""8419.png"">" Pathology ovarian-cysts reproductive
What type of cyst is most likely to form in the presence of increased
gonadotropins? A theca-lutein cyst, which responds to gonadotropins; often
multiple and bilateral "<img src=""8419.png"">" Pathology ovarian-cysts
reproductive
What type of cysts are associated with choriocarcinoma and hydatidiform moles?
Theca-lutein cysts "<img src=""8419.png"">" Pathology ovarian-cysts
reproductive
What is an ovarian cyst that consists of an unruptured, distended graafian follicle
called? A follicular cyst (most common ovarian mass in women) "<img
src=""8419.png"">" Pathology ovarian-cysts reproductive
Which malignant ovarian neoplasm can progress to pseudomyxoma peritonei?
Mucinous cystadenocarcinoma (pseudomyxoma peritonei is intraperitoneal
accumulation of mucinous material from an ovarian/appendiceal tumor) "<img
src=""8420.png"">" Pathology ovarian-neoplasms reproductive
A 25-year-old woman has an adnexal mass. Ultrasound detects a pelvic tumor. What
germ cell tumor does she most likely have? A mature cystic teratoma (dermoid
cyst), which is the most common benign ovarian tumor in women 2030 years of age
"<img src=""8420.png"">" Pathology ovarian-neoplasms reproductive
A woman has palpitations, sweating, weight loss, and a low level of thyroid-
stimulating hormone. What ovarian pathology may be responsible? Struma ovarii, in
which functional thyroid tissue within a monodermal teratoma can uncommonly cause
symptoms of hyperthyroidism "<img src=""8420.png"">" Pathology ovarian-
neoplasms reproductive
The majority of malignant ovarian neoplasms arise from which origin? The majority
(95%) are of epithelial origin, with serous cystadenocarcinoma being the most
common "<img src=""8420.png"">" Pathology ovarian-neoplasms reproductive
Which malignant ovarian neoplasm is the most common ovarian neoplasm, frequently
bilateral, and presents with psammoma bodies? Serous cystadenocarcinoma "<img
Which benign ovarian neoplasm is often bilateral and has a fallopian tubelike
epithelium? Serous cystadenoma, which is the most common ovarian neoplasm "<img
A 55-year-old woman has an ovarian malignancy removed. The pathologist sees
psammoma bodies. Is the tumor likely unilateral or bilateral? Bilateral (this is
likely a serous cystadenocarcinoma) "<img src=""8420.png"">" Pathology ovarian-
Does genetic predisposition play a role in the development of ovarian neoplasms?
What are three associated genetic mutations? Yes, there is a strong family
history and genetic component; BRCA-1, BRCA-2, and Lynch syndrome are related to
ovarian cancer "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
What is the female analog to a seminoma in a male subject? What does the histology
show? In whom does it most commonly arise? Dysgerminoma (1% of ovarian tumors,
30% of germ cell tumors); sheets of uniform cells that look like fried eggs; most
common in adolescents "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
A male infant has a testicular mass. The pathologist notes that it is aggressive
and hemorrhagic. How would the tumor appear grossly? Yellow, friable (hence the
hemorrhagic component), and solid; this is likely a yolk sac (endodermal sinus)
tumor "<img src=""8420.png"">" Pathology ovarian-neoplasms reproductive
Which germ cell tumor is very aggressive and appears as a yellow, solid, and
friable mass on gross pathology? In whom does it usually arise? An endodermal
sinus (yolk sac) tumor (most common tumor in male infants, typically appearing in
the ovaries or testes of young children "<img src=""8420.png"">" Pathology
ovarian-neoplasms reproductive
What benign ovarian neoplasm resembles bladder epithelium and has coffee bean
nuclei on H&E stain? Describe the gross appearance. "Brenner tumor (Brenner is
Benign and looks like Bladder); encapsulated, pale yellowtan, ""coffee bean""
nuclei on H&E" "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
A 50-year-old woman has an ovarian tumor removed. The neoplasm contains bundles of
spindle-shaped fibroblasts. Is it benign? Yes; this is a fibroma of the ovary,
which is a benign neoplasm "<img src=""8420.png"">" Pathology ovarian-
A 50-year-old woman presents with a unilateral pleural effusion, ascites, and an
enlarged ovary. What will ovarian biopsy show? An ovarian fibroma with bundles of
spindle-shaped fibroblasts (this is Meigs syndrome; symptoms will disappear once
the fibroma is excised) "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
Is there a difference in the prognoses of a patient with an immature teratoma and
one with a mature teratoma? Yes (immature teratomas are aggressive and commonly
diagnosed after menopause; mature teratomas are benign) "<img src=""8420.png"">"
Pathology ovarian-neoplasms reproductive
A 55-year-old woman presents with pelvic pain, dyspareunia, and dysmenorrhea.
Ultrasound shows a complex mass within the ovary. Diagnosis? "Endometrioma,
which presents as a mass from growth of ectopic endometrial tissue within ovary
with cyst formation (a ""chocolate cyst"")" "<img src=""8420.png"">"
A girl with an ovarian mass has sexual precocity, breast tenderness, and abnormal
uterine bleeding. Does her mass secrete anything? Yes; a granulosa cell tumor
may produce estrogen and/or progesterone, leading to precocious puberty/sexual
precocity "<img src=""8420.png"">" Pathology ovarian-neoplasms reproductive
Ovarian neoplasms are the adnexal masses most commonly found in women older than 55
years. From what three origins do they arise? Surface epithelium, germ cells, and
sex cord stromal tissue (may be benign or malignant) "<img src=""8420.png"">"
What histologic appearance is seen in Krukenberg tumor of the ovaries? From which
organ system does it originate from? Signet cell adenocarcinoma, which
secretes mucin; caused by a GI malignancy (often gastric cancer) that metastasizes
to the ovaries "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
An elderly woman has a pleural effusion, bowel obstruction, abdominal distention,
and an adnexal mass. How would you diagnose this patient? Diagnose surgicallyher
symptoms are common for an ovarian neoplasm "<img src=""8420.png"">"
A woman is diagnosed with a granulosa cell tumor. This tumor is predominant in
women of what age group, and can produce which two hormones? Often produces
estrogen and/or progesterone (granulosa cell tumor is predominant in women in their
50s) "<img src=""8420.png"">" Pathology ovarian-neoplasms reproductive
A woman had infertility issues, endometriosis, and polycystic ovarian syndrome. She
is at increased risk for what type of neoplasm? Ovarian neoplasms "<img
Mature teratomas are more likely to contain thyroid tissue. In contrast, what type
of tissue is more likely present in immature teratomas? Immature teratomas most
typically contain immature/embryonic-like neural tissue "<img src=""8420.png"">"
What are some factors that decrease a woman's risk for developing ovarian
neoplasms? Previous pregnancy, OCPs, tubal ligation, history of breastfeeding
A 60-year-old woman is found to have a thecoma. What hormone is produced by this
benign ovarian neoplasm? What is a common presentation? Estrogen (similar to
granulosa cell tumors); it often presents as abnormal uterine bleeding in
postmenopausal women "<img src=""8420.png"">" Pathology ovarian-neoplasms
reproductive
What serum marker would you measure in a patient with an ovarian neoplasm? Can this
same marker be used for screening? CA 125, which is a general marker for ovarian
neoplasia used to monitor disease progression (but is not good for screening)
An hour after giving birth, a woman experiences abdominal pain, fever, and uterine
tenderness. What is the likely cause of her pain? Endometritis; retained
material (products of conception or a foreign body such as IUD) promotes infection
from vagina or GI bacterial flora "<img src=""8421.png"">" Pathology
endometrial-conditions reproductive
On laparoscopy, a woman with chronic pelvic pain has many lesions that appear as
chocolate cysts in her ovaries. Does she have cancer? "Unlikely; ""chocolate
cysts"" (endometriomas) are classic for endometriosis, which is caused by cyclic
bleeding of ectopic endometrial tissue" "<img src=""8421.png"">" Pathology
A woman has been unable to conceive for several years and has severe pain during
periods and with sex. What diagnosis should you consider? Endometriosis, which is
nonneoplastic ectopic endometrial tissue (glands/stroma), most commonly found in
the peritoneum, pelvis, or ovaries "<img src=""8421.png"">" Pathology
What processes are thought to lead to the ectopic endometrial implantation in
endometriosis? Retrograde menstrual flow, transportation of endometrial tissue
via the lymphatic system, metaplastic transformation of multipotent cells "<img
src=""8421.png"">" Pathology endometrial-conditions reproductive
A 35-year-old woman has dyschezia, dysmenorrhea, and dyspareunia. Her uterus is of
normal size. How do you treat her? Treat with OCPs, NSAIDs, GnRH agonists,
progestins, danazol, laparoscopic surgery (this is endometriosis) "<img
Biopsy reveals extension of glandular endometrial tissue into a patient's uterine
myometrium. What is the underlying pathophysiology? This is adenomyosis, caused
by hyperplasia of the endometrial basalis layer "<img src=""8421.png"">"
Pathology endometrial-conditions reproductive
What is the most common gynecologic malignancy? Endometrial carcinoma "<img
A patient has dysmenorrhea and menorrhagia. She also has a soft, enlarged, and
globular uterus. How do you treat her? Treat with GnRH agonists or hysterectomy
(this is likely adenomyosis) "<img src=""8421.png"">" Pathology endometrial-
conditions reproductive
Biopsy shows a collection of endometrial tissues that is well-circumscribed within
a patient's uterine wall. What may histology show? This is an endometrial polyp,
which on histology may also contain smooth muscle cells "<img src=""8421.png"">"
A 30-year-old reports painless abnormal uterine bleeding. You find a collection of
tissue extending into the endometrial cavity. Diagnosis? An endometrial polyp
(may also be asymptomatic) "<img src=""8421.png"">" Pathology endometrial-
What are the histologic signs that can predict the risk of progression of
endometrial hyperplasia to endometrial carcinoma? The presence of nuclear
atypia is the greatest risk factor, but one may also assess for complex (vs.
simple) gland architecture "<img src=""8421.png"">" Pathology endometrial-
Name four risk factors for endometrial hyperplasia. Anovulatory cycles,
polycystic ovarian syndrome, hormone replacement therapy, granulosa cell tumor (all
increase estrogen exposure) "<img src=""8421.png"">" Pathology endometrial-
A young black woman presents with abnormal uterine bleeding. She has had several
miscarriages. What benign neoplasm could be responsible? Leiomyoma (fibroid)
"<img src=""8421.png"">" Pathology endometrial-conditions reproductive
Leiomyomas are sensitive to what hormone? What is the clinical significance?
Estrogen, meaning leiomyomas grow with pregnancy and shrink with menopause
"<img src=""8421.png"">" Pathology endometrial-conditions reproductive
A young woman has uterine bleeding and fatigues easily. She is anemic. Exam shows
multiple uterine masses. What are you worried about? Iron deficiency anemia
secondary to severe bleeding from leiomyomas "<img src=""8421.png"">"
A woman has had leiomyomas for many years. She wants screening because she is
worried that they will progress to cancer. Your reply? There is no need to
screen, because malignant transformation from leiomyosarcoma is rare "<img
Name the most common locations of each of the following: intraductal papilloma,
fibrocystic change, lobular carcinoma. Intraductal papilloma: lactiferous
sinus/major duct; fibrocystic change and lobular carcinoma: terminal duct lobular
unit "<img src=""8422.png"">" Pathology breast-pathology reproductive
Name the most common locations of each of the following: breast abscess, Paget
disease, ductal carcinoma. Breast abscess and Paget disease: lactiferous
sinus/major duct; ductal carcinoma: terminal duct lobular unit "<img
src=""8422.png"">" Pathology breast-pathology reproductive
Name the most common locations of each of the following: ductal carcinoma in situ
(DCIS), fibroadenoma, mastitis. DCIS: terminal duct lobular unit; fibroadenoma:
stroma, mastitis: lactiferous sinus/major duct "<img src=""8422.png"">"
Pathology breast-pathology reproductive
A woman complains of itchy breast skin and a bloody discharge from her nipples.
What is the most commonly affected site? The lactiferous sinus/major duct (this is
Paget disease) "<img src=""8422.png"">" Pathology breast-pathology
reproductive
Name the most common locations of each of the following: lobular carcinoma in situ
(LCIS), phyllodes tumor. LCIS: terminal duct lobular unit; phyllodes tumor:
stroma "<img src=""8422.png"">" Pathology breast-pathology reproductive
What is the most common breast tumor among women younger than 35 years?
Fibroadenoma, a benign tumor "<img src=""8423.png"">" Pathology benign-
breast-disease reproductive
A 20-year-old woman has a small, mobile, firm breast mass with well-defined
borders. What is the most likely diagnosis? Fibroadenoma, the most common tumor
in women younger than 35 years "<img src=""8423.png"">" Pathology benign-
breast-disease reproductive
A 24-year-old woman notes a breast mass that grows and is more tender during
menstruation. Does she have breast cancer? Unlikely; age and description are
consistent with a fibroadenoma from increased estrogen (eg, in pregnancy or before
menstruation) "<img src=""8423.png"">" Pathology benign-breast-disease
reproductive
What neoplasm would be likely in a woman with serosanguineous discharge from her
nipple but without a palpable breast mass? Intraductal papilloma, a
lactiferous duct tumor often seen below the areola that leads to a slightly
increased risk for carcinoma (1.52) "<img src=""8423.png"">" Pathology
benign-breast-disease reproductive
A large, bulky breast mass made up of connective tissue and cysts with leaf-like
projections is taken from a 55-year-old woman. Prognosis? A phyllodes tumor is
usually considered benign, but some may become malignant "<img src=""8423.png"">"
Pathology benign-breast-disease reproductive
Name three lesion subtypes seen in fibrocystic changes of the breast. Simple cysts
(fluid-filled duct dilation with blue domes), papillary apocrine change/metaplasia,
stromal fibrosis "<img src=""8423.png"">" Pathology benign-breast-disease
reproductive
What diagnosis should you suspect in a woman who presents with a painless breast
lump following trauma to her chest? This is likely fat necrosis, a benign process
that occurs after trauma (although up to 50% of patients may not recall an injury)
"<img src=""8423.png"">" Pathology benign-breast-disease reproductive
Name six nondrug-related conditions that can cause gynecomastia as a result of
hyperestrogenism. Newborn, puberty, old age, testicular tumor, cirrhotic liver
disease, and hypogonadism (eg, Klinefelter syndrome) "<img src=""8423.png"">"
A male patient presents with abnormally enlarged breasts. What is this finding
called, and which drugs could cause this? "Gynecomastia; Spironolactone, Hormones,
Cimetidine, Ketoconazole (""Some Hormones Create Knockers"")" "<img
src=""8423.png"">" Pathology benign-breast-disease reproductive
A woman has multiple painful breast masses bilaterally that fluctuate in size
during her menstrual cycle. What is the likely diagnosis? Fibrocystic changes, the
most common cause of breast lumps in premenopausal women older than 35 years "<img
Which breast pathology has increased acini and stromal fibrosis on histology,
sometimes with calcifications? Is the cancer risk increased? Sclerosing
adenosis, associated with an increased risk (1.52) of cancer "<img
A male infant is born and you find he has slightly enlarged breasts bilaterally.
What do you do? Nothing, as this is normal (physiologic) and will resolve with
time (gynecomastia is also normal at puberty and old age) "<img src=""8423.png"">"
A breastfeeding woman has nipple tenderness, redness, and drainage. S aureus is
isolated in the fluid. Should she continue breastfeeding? Yes (this is lactational
mastitis) "<img src=""8423.png"">" Pathology benign-breast-disease
reproductive
A woman who is breastfeeding presents with an infection arising from cracks in her
nipple. How do you treat her? Treat with antibiotics and keep breastfeeding (this
is lactational mastitis) "<img src=""8423.png"">" Pathology benign-breast-
disease reproductive
A woman has a painless lump on her breast. Biopsy shows necrotic fat and giant
cells. Mammography shows a calcified oil cyst. Diagnosis? Fat necrosis "<img
A woman has the most common cause of nipple discharge. How might this discharge
appear grossly? Does it carry an increased risk of cancer? It is serous or bloody;
this is likely an intraductal papilloma, associated with a slightly (1.52)
increased risk for cancer "<img src=""8423.png"">" Pathology benign-breast-
disease reproductive
A breast biopsy shows increased cellularity of the terminal ductal and lobular
epithelium. Diagnosis? Epithelial hyperplasia "<img src=""8423.png"">"
A woman has biopsy-proven epithelial hyperplasia. For what finding suggesting
increased cancer risk must the pathologist be alert? Atypical cells "<img
What is the most common age range during which phyllodes tumors arise? The fifth
decade of life "<img src=""8423.png"">" Pathology benign-breast-disease
reproductive
From which part of the breast tissue do malignant tumors most commonly arise? When
do they most commonly arise? The terminal duct lobular unit; they most commonly
arise after menopause "<img src=""8424.png"">" Pathology malignant-breast-
tumors reproductive
For which cellular markers that affect both treatment and prognosis should you test
a patient with a new diagnosis of breast cancer? Hormone receptor expression
(estrogen, progesterone receptors) and c-erbB2 (HER-2, an epidermal growth factor
[EGF] receptor) "<img src=""8424.png"">" Pathology malignant-breast-tumors
reproductive
A woman has a malignant breast tumor that is negative for ER, PR, and Her2/Neu.
What does this suggest about tumor aggressiveness? A triple-negative genotype is
suggestive of a more aggressive tumor "<img src=""8424.png"">" Pathology
malignant-breast-tumors reproductive
What is the single most important prognostic factor in early-stage breast cancer?
Where do malignant breast cancers most often originate? Axillary lymph node
involvement; the upper outer quadrant of the breast "<img src=""8424.png"">"
Pathology malignant-breast-tumors reproductive
Name five risk factors for breast malignancies. Obesity, estrogen exposure,
total number of menstrual cycles, older age at 1st live birth, BRCA1/BRCA2
mutations, African American "<img src=""8424.png"">" Pathology malignant-
breast-tumors reproductive
Why is obesity a risk factor for breast cancer? Androstenedione is converted to
estrone in adipose tissue, which serves as a major source of estrogen in
postmenopausal women "<img src=""8424.png"">" Pathology malignant-breast-
tumors reproductive
A patient is found to have an invasive ductal carcinoma. What type of infiltration
pattern is seen grossly on pathologic analysis? A stellate pattern (considered a
classic finding) "<img src=""8424.png"">" Pathology malignant-breast-tumors
reproductive
An African-American woman is found to have a malignant breast tumor. Risk of which
breast cancer genotype is increased with her background? Tumors that are negative
for estrogen receptors, progesterone receptors, and Her2/Neu (triple negative) are
more likely to occur "<img src=""8424.png"">" Pathology malignant-breast-
tumors reproductive
Biopsy of a malignant breast tumor shows a fleshy appearance with cellular,
lymphocytic infiltrates. What is the diagnosis and prognosis? Medullary
carcinoma, which has a good prognosis "<img src=""8424.png"">" Pathology
malignant-breast-tumors reproductive
A woman with known ductal atypia undergoes mammography. What finding might you
expect? Microcalcifications, an early sign of ductal carcinoma in situ "<img
src=""8424.png"">" Pathology malignant-breast-tumors reproductive
A woman receives antibiotics for mastitis but does not improve. Why are you
worried? Inflammatory breast cancer is often mistaken for mastitis (or Paget
disease), so you should do an urgent workup for this diagnosis "<img
src=""8424.png"">" Pathology malignant-breast-tumors reproductive
A 65-year-old man used sildenafil more than 4 hours ago. He has a persistent
painful erection. What else can cause this pathology? Trazodone, trauma, and sickle
cell disease (sickled RBCs get trapped in vascular channels); this is ischemic
priapism, a >4-hour erection "<img src=""8425.png"">" Pathology penile-
pathology reproductive
A man comes in with a sustained erection for over 5 hours. Why must this be treated
right away? Name three treatment options. Immediate treatment is needed to prevent
ischemia; options are corporal aspiration, intracavernosal phenylephrine, or
surgical decompression "<img src=""8425.png"">" Pathology penile-pathology
reproductive
Name two risk factors associated with an increased rate of penile squamous cell
carcinoma. Lack of circumcision and human papillomavirus infection "<img
src=""8425.png"">" Pathology penile-pathology reproductive
Geographically, where is penile squamous cell carcinoma most common? It is most
common in South America, Asia, and Africa "<img src=""8425.png"">" Pathology
penile-pathology reproductive
What are three precursor in situ lesions for penile squamous cell carcinoma? Bowen
disease (in penile shaft, leukoplakia), Bowenoid papulosis (red papules),
erythroplasia of Queyrat (cancer of glans, erythroplakia) "<img src=""8425.png"">"
Pathology penile-pathology reproductive
A man has erectile dysfunction and pain. His penis is curved and there are fibrous
plaques within his tunica albuginea. Treatment? Consider treating surgically once
curvature stabilizes (this is Peyronie disease) "<img src=""8425.png"">"
Pathology penile-pathology reproductive
How does Peyronie disease differ from penile fracture (usually occurs during
intercourse)? Penile fracture involves corpora cavernosa rupture from forced
bending; Peyronie disease is abnormal curvature from fibrous plaques "<img
A man has pain with intercourse. He is anxious about his performance and notes
erectile dysfunction. Which pathology do you consider? Peyronie disease
(abnormal penile curvature caused by a tunica albuginea fibrous plaque) "<img
How does cryptorchidism affect inhibin B, follicle-stimulating hormone (FSH),
luteinizing hormone (LH), and testosterone? Decreased inhibin B, increased FSH,
normal LH, normal testosterone if unilateral and decreased testosterone if
bilateral "<img src=""8426.png"">" Pathology cryptorchidism reproductive
On a male newborn's exam, you fail to palpate testicles in the scrotum. Name one
risk factor and two complications of this condition. Prematurity is a risk factor
for cryptorchidism (undescended testis, one or both); risk of infertility and
testicular (germ cell) tumor "<img src=""8426.png"">" Pathology cryptorchidism
reproductive
A newborn is diagnosed with cryptorchidism. Why does this cause infertility? The
increased temperature of the testes when they are close to the body leads to
impaired spermatogenesis (sperm develop best at <37C) "<img src=""8426.png"">"
Pathology cryptorchidism reproductive
How is Leydig cell function affected in cryptorchidism? Leydig cell function is
unaffected by increased testicular temperature seen in cryptorchidism (therefore,
testosterone levels may be normal) "<img src=""8426.png"">" Pathology
cryptorchidism reproductive
A 25-year-old has painless left scrotal swelling that looks like a bag of worms
when he stands. What work-up testing do you order? Order (diagnose by)
ultrasound with Doppler (this is varicocele, the most common cause of scrotal
enlargement in men) "<img src=""8427.png"">" Pathology reproductive
varicocele
What is the pathophysiology of varicocele? How do you treat it? Increased venous
pressure causes dilation of pampiniform plexus; treatment is varicocelectomy or
embolization "<img src=""8427.png"">" Pathology reproductive varicocele
On which side is varicocele more common? Why? Left; the left gonadal vein drains
into the left renal vein, which is a path of higher resistance, thus increasing
venous pressure "<img src=""8427.png"">" Pathology reproductive varicocele
How do you diagnose varicocele on physical exam? "Perform a standing physical
exam; distension is seen on inspection and a ""bag of worms"" on palpation" "<img
src=""8427.png"">" Pathology reproductive varicocele
What are the most common locations of extragonadal germ cell tumors in adults
versus infants/children? All are midline (adults = retroperitoneum,
mediastinum, pineal, and suprasellar regions, kids = sacrococcygeal teratomas)
"<img src=""8428.png"">" Pathology extragonadal-germ-cell-tumors
reproductive
An infant is found to have a sacrococcygeal teratoma. What is the classification of
this tumor? Extragonadal germ cell tumor (most common kinds in infants and young
children) "<img src=""8428.png"">" Pathology extragonadal-germ-cell-tumors
reproductive
How can you tell if a scrotal mass is benign or malignant? Benign ones can be
transilluminated with light, whereas malignant ones are usually solid tumors "<img
src=""8429.png"">" Pathology reproductive scrotal-masses
An infant has scrotal swelling. What is the most likely mechanism? Incomplete
obliteration of processus vaginalis leading to a congenital hydrocele "<img
src=""8429.png"">" Pathology reproductive scrotal-masses
A man with groin trauma comes in complaining of a scrotal fluid collection. The
fluid is bloody. What is the diagnosis? Hematocele (versus an acquired hydrocele,
a benign scrotal fluid collection usually resulting from infection, trauma, or
tumor) "<img src=""8429.png"">" Pathology reproductive scrotal-masses
A patient has a fluctuant paratesticular nodule. What is the pathophysiology of
this nodule? A cyst resulting from dilation of an epididymal duct or rete
testis (this is likely a spermatocele) "<img src=""8429.png"">" Pathology
reproductive scrotal-masses
What type of testicular tumor is more common: germ cell tumor or nongerm cell
tumor? Germ cell tumors make up 95% of testicular tumors; nongerm cell tumors
account for the remaining 5% "<img src=""8430.png"">" Pathology reproductive
testicular-germ-cell-tumors
A man has gynecomastia and a testicular mass. Pathology shows disordered
syncytiotrophoblasts and cytotrophoblasts. Serum marker to check? Human
chorionic gonadotropin (hCG); these findings are consistent with choriocarcinoma,
and increased hCG can cause gynecomastia "<img src=""8430.png"">" Pathology
reproductive testicular-germ-cell-tumors
Are most germ cell tumors of the testicle benign or malignant? What about nongerm
cell tumors? Most germ cell tumors of the testicle are malignant, whereas most
nongerm cell tumors are benign "<img src=""8430.png"">" Pathology
A 25-year-old man has a painless testicular mass. Biopsy shows lobules of large
cells with a fried-egg appearance. Prognosis? Seminoma is malignant but has an
excellent prognosis (only metastasizes late in its course and is highly
radiosensitive) "<img src=""8430.png"">" Pathology reproductive testicular-
germ-cell-tumors
In men, are mature teratomas benign or malignant? Children? Women? They may be
malignant in men, are benign in children, and are generally benign in women "<img
src=""8430.png"">" Pathology reproductive testicular-germ-cell-tumors
What is the most common type of testicular tumor? What treatment can be used in a
patient with this tumor? Seminoma; radiation therapy "<img src=""8430.png"">"
Pathology reproductive testicular-germ-cell-tumors
What malignant painful testicular germ cell tumor typically has glandular
histopathology and can be mixed with other tumor types? Prognosis? Embryonal
carcinoma (pure embryonal carcinoma is rare); prognosis is worse than with seminoma
"<img src=""8430.png"">" Pathology reproductive testicular-germ-cell-
tumors
A patient has a hemorrhagic, necrotic testicular tumor with mixed
glandular/papillary morphology. What is the likely diagnosis? Embryonal
carcinoma, which is a type of malignant testicular germ cell tumor "<img
A 35-year-old man presents with a testicular mass. On exam, the mass does not
transilluminate. What are you worried about? Testicular cancer should be in the
differential for any testicular mass that does not transilluminate "<img
How does embryonal carcinoma affect levels of human chorionic gonadotropin (hCG)
and -fetoprotein (AFP)? hCG is increased, whereas AFP is normal in pure
embryonal carcinoma (rare), and elevated when mixed with other tumor types (most
common) "<img src=""8430.png"">" Pathology reproductive testicular-germ-
cell-tumors
Biopsy of a boy's testicular germ cell tumor shows Schiller-Duval bodies. There are
increased -fetoprotein levels. Guess the boy's age. <3 years of age (this is a
yolk sac [endodermal sinus] tumor, the most common testicular tumor in boys <3
years of age) "<img src=""8430.png"">" Pathology reproductive testicular-
germ-cell-tumors
A patient has a firm, painless swelling in his testicle. Biopsy shows a mucinous
yellow testicular germ cell tumor. Prognosis? Yolk sac (endodermal sinus) tumors
are aggressive (analogous to ovarian yolk sac tumors) and therefore have a poorer
prognosis "<img src=""8430.png"">" Pathology reproductive testicular-germ-
cell-tumors
A boy is found to have a yolk sac tumor. What tumor marker is elevated? What do you
expect to see on histology? Increased -fetoprotein; Schiller-Duval bodies
(resemble primitive glomeruli) "<img src=""8430.png"">" Pathology
A patient has a testicular mass and high human chorionic gonadotropin (hCG) and -
fetoprotein (AFP) levels. Possible diagnosis? Mixed embryonal carcinoma (pure
tumors do not have high AFP) "<img src=""8430.png"">" Pathology reproductive
Testicular germ cell tumors, which most often occur in young men, are associated
with which risk factors? Cryptorchidism and Klinefelter syndrome; can also
present as a mixed germ cell tumor "<img src=""8430.png"">" Pathology
Tumor metastases are found in the lungs and brain of a man with a testicular
neoplasm. Which testicular germ cell tumor can cause this? Choriocarcinoma (prone
to hematogenous metastasis to the lungs and brain) "<img src=""8430.png"">"
Pathology reproductive testicular-germ-cell-tumors
A man was diagnosed recently with choriocarcinoma in the testes. He has increased
hCG levels. This finding can result in what symptoms? Patients may present with
gynecomastia or symptoms of hyperthyroidism (hCG is an LH, FSH, and TSH analog)
"<img src=""8430.png"">" Pathology reproductive testicular-germ-cell-
tumors
A young man comes in with a testicular mass. How does the transillumination test
help you diagnose it? Testicular germ cell tumors do not transilluminate, but
hydroceles do "<img src=""8430.png"">" Pathology reproductive testicular-
germ-cell-tumors
A male infant has a testicular mass that does not transilluminate. Is a seminoma at
the top of your differential? Noseminomas do not occur in infancy, so consider
other testicular neoplasms "<img src=""8430.png"">" Pathology reproductive
On histology, eosinophilic cytoplasmic inclusions are found in a 10-year-old boy's
testicular mass. What symptoms might the boy exhibit? Precocious puberty and
gynecomastia (this is a Leydig cell tumor, and the inclusions are also known as
Reinke crystals) "<img src=""8431.png"">" Pathology reproductive testicular-
nongerm-cell-tumors
What symptoms would you expect to see in a child with a testicular Leydig cell
tumor? An adult? What color are these tumors grossly? This androgen or estrogen-
producing tumor will result in precocious puberty in boys and often causes
gynecomastia in adult men; golden brown "<img src=""8431.png"">" Pathology
reproductive testicular-nongerm-cell-tumors
What is the most common testicular cancer among older men? Is it aggressive or
indolent? Testicular lymphoma (it is not a primary tumor but arises when lymphoma
metastasizes to the testes); aggressive "<img src=""8431.png"">" Pathology
reproductive testicular-nongerm-cell-tumors
Where do Sertoli cell tumors derive from? Sex cord stroma (also called
androblastomas) "<img src=""8431.png"">" Pathology reproductive testicular-
nongerm-cell-tumors
Are most testicular nongerm cell tumors (5% of all testicular tumors) benign or
malignant? Benign "<img src=""8431.png"">" Pathology reproductive
testicular-nongerm-cell-tumors
A 65-year-old man presents with increased urinary frequency, nocturia, and
difficulty starting/stopping his stream. Treatment options?Treat with 1-
antagonists (eg, terazosin or tamsulosin), 5-reductase inhibitors (eg,
finasteride), tadalafil "<img src=""8432.png"">" Pathology benign-prostatic-
hyperplasia reproductive
How can 1-antagonists help to treat prostatic hyperplasia?1-antagonists such as
terazosin and tamsulosin relax prostate smooth muscle "<img src=""8432.png"">"
Pathology benign-prostatic-hyperplasia reproductive
What three serious complications can arise in a patient with benign prostatic
hyperplasia? Distension or hypertrophy of the bladder, UTI, and
hydronephrosis; note that there is no increased risk for malignancy "<img
src=""8432.png"">" Pathology benign-prostatic-hyperplasia reproductive
Free prostate-specific antigen (PSA) levels can be elevated in men with what two
conditions? Benign prostatic hyperplasia and prostate cancer "<img
src=""8432.png"">" Pathology benign-prostatic-hyperplasia reproductive
An old man has dysuria, increased urinary frequency and urgency, and lower back
pain. Diagnosis? What can you expect on rectal exam? This is prostatitis; you
would note a tender, warm, enlarged prostate "<img src=""8433.png"">"
Pathology prostatitis reproductive
What strain of bacteria is the most common cause of bacterial prostatitis? E coli
(acute prostatitis is usually bacterial) "<img src=""8433.png"">" Pathology
prostatitis reproductive
What is the main difference between acute prostatitis and chronic prostatitis?
Acute prostatitis is usually bacterial, whereas chronic prostatitis may be
bacterial or abacterial "<img src=""8433.png"">" Pathology prostatitis
reproductive
Name two useful tumor markers for prostatic adenocarcinoma.Prostatic acid
phosphatase and prostate-specific antigen (PSA) (total PSA increases, but the
fraction of free PSA decreases) "<img src=""8434.png"">" Pathology
prostatic-adenocarcinoma reproductive
Prostatic adenocarcinoma is common among men in what age group? Men older than 50
years "<img src=""8434.png"">" Pathology prostatic-adenocarcinoma reproductive
An elderly man has back pain, a hard nodule on prostate exam, and elevated PSA and
ALP levels. Why does his back most likely hurt? He likely has prostate
adenocarcinoma with bone metastases (osteoblastic lesions) to his back, causing
back pain "<img src=""8434.png"">" Pathology prostatic-adenocarcinoma
reproductive
What is the most common way of diagnosing prostatic adenocarcinoma? Measurement
of PSA followed by needle core biopsy of the prostate "<img src=""8434.png"">"
Pathology prostatic-adenocarcinoma reproductive
What hormone is synthesized and released from the hypothalamus to stimulate the
release of LH and FSH from the anterior pituitary? GnRH "<img src=""8435.png"">"
control-of-reproductive-hormones pharmacology reproductive
You prescribe a patient clomiphene. Do LH and FSH levels increase or decrease with
administration of this drug? Increase; clomiphene prevents normal feedback
inhibition on GnRH in the hypothalamus, thereby increasing GnRH production (and
thus LH/FSH) "<img src=""8435.png"">" control-of-reproductive-hormones
pharmacology reproductive
Explain how GnRH agonists can demonstrate both agonistic and antagonistic
properties. Pulsatile GnRH is required for normal function; GnRH agonists therefore
can be agonistic (pulsatile use) or antagonistic (continuous use) "<img
src=""8435.png"">" control-of-reproductive-hormones pharmacology reproductive
Oral contraceptives and danazol work at which level of which part of the
reproductive axis? The ovaries "<img src=""8435.png"">" control-of-
reproductive-hormones pharmacology reproductive
A postmenopausal woman presents with breast cancer. Name a drug that you could
prescribe to lower her estrogen levels by blocking aromatase. Anastrozole, which
is an aromatase inhibitor; blocks the conversion of testosterone to estradiol, as
well as androstenedione to estrone "<img src=""8435.png"">" control-of-
Leydig cells in the testis are stimulated by which hormone to produce testosterone?
Luteinizing hormone (LH) "<img src=""8435.png"">" control-of-
Name two drugs that block testosterone synthesis in the testes. Ketoconazole and
spironolactone "<img src=""8435.png"">" control-of-reproductive-hormones
Which hormone is important for synthesis of androgens such as testosterone and
androstenedione? Which drugs inhibit this hormone? P-450c17; ketoconazole and
danazol "<img src=""8435.png"">" control-of-reproductive-hormones
How do selective estrogen receptor modulators (SERMs) such as tamoxifen and
raloxifene modulate the effects of estrogen? They bind to estrogen receptors and
block (or, in some cases, stimulate) gene expression in estrogen-responsive cells
"<img src=""8435.png"">" control-of-reproductive-hormones pharmacology
reproductive
A patient presents with benign prostatic hyperplasia (BPH). What drug is useful in
treating BPH by decreasing dihydrotestosterone? Finasteride, which blocks 5-
reductase, an enzyme that converts testosterone to the more potent
dihydrotestosterone "<img src=""8435.png"">" control-of-reproductive-
hormones pharmacology reproductive
Name three antiandrogenic drugs that function by preventing androgens (eg,
testosterone or DHT) from binding to their specific receptors. Flutamide,
cyproterone, and spironolactone "<img src=""8435.png"">" control-of-
The drug flutamide prevents the formation of the androgen-receptor complex. This
has what effect in androgen-responsive cells? It decreases gene expression
triggered by androgens "<img src=""8435.png"">" control-of-reproductive-
hormones pharmacology reproductive
Aromatase is responsible for the generation of which two forms of estrogen? Which
third form of estrogen can arise indirectly? Estradiol and estrone; estriol
"<img src=""8435.png"">" control-of-reproductive-hormones pharmacology
reproductive
How do GnRH antagonists prevent the secretion of LH and FSH from the anterior
pituitary? They block hypothalamic GnRH from binding to receptors in the anterior
pituitary "<img src=""8435.png"">" control-of-reproductive-hormones
How do the clinical uses of leuprolide differ depending on the way in which it is
administered? Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist
when dosed in a pulsatile manner and a GnRH antagonist when dosed continuously
"<img src=""8436.png"">" leuprolide pharmacology reproductive
Name five common clinical uses for leuprolide. Uterine fibroids, prostate cancer,
endometriosis, precocious puberty, infertility "<img src=""8436.png"">"
leuprolide pharmacology reproductive
A man with prostate cancer is prescribed a GnRH analog with agonist properties.
Should it be dosed in a pulsatile or continuous manner? Dose continuously to
inhibit GnRH, which decreases circulating androgens that can stimulate prostate
adenocarcinoma (this is leuprolide) "<img src=""8436.png"">" leuprolide
When used continuously, what effect does leuprolide have on GnRH receptors? What
about with pulsatile administration? Downregulation (decreases FSH/LH);
upregulation (stimulates FSH/LH); leuprolide can be used in lieu of GnRH "<img
src=""8436.png"">" leuprolide pharmacology reproductive
What is the mechanism of action of ethinyl estradiol, diethylstilbestrol (DES), and
mestranol? They bind to estrogen receptors and act as agonists "<img
src=""8437.png"">" estrogens pharmacology reproductive
Name four conditions in women that are treated with estrogens. Estrogens also can
be used to treat which condition in elderly men? Hypogonadism, ovarian
failure, menstrual abnormalities, and postmenopausal hormone replacement therapy;
androgen-dependent prostate cancer "<img src=""8437.png"">" estrogens
What are the adverse effects of treatment with exogenous estrogens? Increased
endometrial cancer risk, abnormal uterine bleeding in postmenopausal women, vaginal
clear cell adenocarcinoma, hypercoagulability "<img src=""8437.png"">"
estrogens pharmacology reproductive
You diagnose clear cell adenocarcinoma of the vagina. What should you ask about
while taking the patient's history? In utero exposure to diethylstilbestrol (DES)
"<img src=""8437.png"">" estrogens pharmacology reproductive
Name three contraindications to estrogen therapy. Estrogen receptor (ER)
positive breast cancer, history of deep venous thromboses (DVTs), and smoking after
35 years of age "<img src=""8437.png"">" estrogens pharmacology reproductive
A female patient with a history of deep vein thrombosis (DVT) desires birth
control. What options do you recommend? Estrogen therapy can precipitate DVTs, so
you should recommend non-estrogen birth control methods (eg, progesterone only)
"<img src=""8437.png"">" estrogens pharmacology reproductive
A young, healthy woman comes to you seeking birth control. What important question
should be asked of her during the history? Whether she is a smoker; if she is
a smoker, any contraceptive option containing estrogen is contraindicated "<img
src=""8437.png"">" estrogens pharmacology reproductive
What is the main difference between tamoxifen and raloxifene? Raloxifene does
not increase risk of endometrial cancer (antagonist at uterine tissue), whereas
tamoxifen does (agonist at uterine tissue) "<img src=""8438.png"">"
pharmacology reproductive selective-estrogen-receptor-modulators
A 40-year-old woman is trying to get pregnant. How does the interaction of
clomiphene at the hypothalamus increase ovulation? High FSH and LH promote
ovulation (clomiphene is a selective estrogen receptor modulator that blocks
negative feedback on LH and FSH) "<img src=""8438.png"">" pharmacology
reproductive selective-estrogen-receptor-modulators
What is the primary clinical use for clomiphene? What are four adverse effects
associated with its use? Infertility due to anovulation (eg, PCOS); hot
flashes, ovarian enlargement, multiple simultaneous pregnancies, and visual
disturbances "<img src=""8438.png"">" pharmacology reproductive
selective-estrogen-receptor-modulators
You prescribe a patient tamoxifen for the treatment of breast cancer. How does it
work? Because it acts as an estrogen antagonist in the breast, it treats and
prevents recurrence of ER/PR-positive breast cancers "<img src=""8438.png"">"
pharmacology reproductive selective-estrogen-receptor-modulators
You order tamoxifen for a patient with breast cancer. What events may result from
the estrogenic effects of tamoxifen at other locations? Tamoxifen is associated
with endometrial cancer (acts as an estrogen receptor agonist at the uterus and
bone) and thromboembolic events "<img src=""8438.png"">" pharmacology
reproductive selective-estrogen-receptor-modulators
Which selective estrogen receptor modulator reduces the resorption of bone and is
used to treat osteoporosis? Raloxifene, which acts as an estrogen receptor
agonist in bone and reduces bone resorption (note that it still has risk of
thromboembolism) "<img src=""8438.png"">" pharmacology reproductive
selective-estrogen-receptor-modulators
What is the mechanism of action of anastrozole, letrozole, and exemestane? They
function by inhibiting aromatase, the enzyme that converts androgens to estrogens
in peripheral tissue "<img src=""8439.png"">" aromatase-inhibitors
A postmenopausal woman has a hard, immobile breast lump. What investigation should
you conduct, and how does it guide treatment options? If the lump is found to be
estrogen receptor (ER) positive, aromatase inhibitors should work well (this is
likely breast cancer) "<img src=""8439.png"">" aromatase-inhibitors
What are the indications for hormone replacement therapy? Relief/prevention of
menopausal symptoms (eg, hot flashes, vaginal atrophy) and osteoporosis caused by
decreased estrogen "<img src=""8440.png"">" hormone-replacement-therapy
Progesterone is added to a patient's hormone replacement therapy regimen. This is
because unopposed estrogen increases the risk of what? Endometrial cancer
(however, this combination may increase the risk of cardiovascular events) "<img
src=""8440.png"">" hormone-replacement-therapy pharmacology reproductive
You prescribe hormone replacement therapy for an older woman. What secondary
benefit does this have on her bones, and what is the mechanism? It increases
estrogen, which decreases osteoclast activity, thus helping prevent osteoporosis
"<img src=""8440.png"">" hormone-replacement-therapy pharmacology
reproductive
What effect do progestins have on the endometrium? They bind to progesterone
receptors, reducing endometrial lining growth while increasing its vascularization,
and thickening cervical mucus "<img src=""8441.png"">" pharmacology progestins
reproductive
Name three clinical uses of progestins (eg, levonorgestrel, medroxyprogesterone,
etonogestrel, norethindrone, megestrol). For contraception, to treat endometrial
cancer, and to treat abnormal uterine bleeding "<img src=""8441.png"">"
pharmacology progestins reproductive
You use the progestin challenge on a patient. How do you interpret a positive
result (being able to induce a withdrawal bleed)? A withdrawal bleed rules out
anatomical defects such as Asherman syndrome and chronic anovulation without
estrogen "<img src=""8441.png"">" pharmacology progestins reproductive
A patient seeks contraception. What forms of progesterone do you offer her?
Progesterone can come as a pill, implant, depot injection, or intrauterine
device (and may or may not include estrogen) "<img src=""8441.png"">"
pharmacology progestins reproductive
What is the mechanism of action of mifepristone and ulipristal? They competitively
inhibit progestins at progesterone receptors (antiprogestins) "<img
src=""8442.png"">" antiprogestins pharmacology reproductive
A woman comes in for a pregnancy termination at 6 weeks' gestation. What
combination of two medications do you offer her? Mifepristone in conjunction
with misoprostol "<img src=""8442.png"">" antiprogestins pharmacology
reproductive
A female patient comes to you after having unprotected sex yesterday. What anti-
progestin can you offer her urgently? Ulipristal, which is used for emergency
contraception "<img src=""8442.png"">" antiprogestins pharmacology
reproductive
You have prescribed combined oral contraceptive pills to a 15-year-old patient. She
asks how the pills work. Answer her. Estrogen/progestins inhibit LH and FSH,
blocking the estrogen and LH surges and thus preventing ovulation "<img
src=""8443.png"">" combined-contraception pharmacology reproductive
Aside from preventing ovulation, how else do progestins prevent pregnancy? They
thicken cervical mucus (limiting sperm access to the uterus) and inhibit
endometrial proliferation (making it less implantable) "<img src=""8443.png"">"
combined-contraception pharmacology reproductive
A patient wants you to prescribe her combined oral contraceptive pills. What
contraindications should you screen her for? Smokers >35 years old (increased
cardiovascular event risk), thromboembolism/stroke/CAD history, migraines with
aura, breast cancer "<img src=""8443.png"">" combined-contraception
A woman comes in seeking birth control. What are some forms of combined
contraception you can offer her? Progestins and ethinyl estradiol come in pill,
patch, and vaginal ring forms "<img src=""8443.png"">" combined-contraception
A girl comes in after unprotected sex. She does not believe in taking hormones for
emergency contraception. What can you offer her? The copper IUD (it is, in
fact, the most effective emergency contraception, and it serves as long-acting
reversible contraception as well) "<img src=""8444.png"">" copper-
intrauterine-device pharmacology reproductive
You've just placed a copper intrauterine device for a patient. About what side
effects do you counsel her? Longer/heavier menses, dysmenorrhea, risk of PID with
insertion "<img src=""8444.png"">" copper-intrauterine-device pharmacology
reproductive
A woman comes in for her copper intrauterine device insertion. She reports having
an active chlamydia infection. Does this alter the visit? Yes, insertion of the
copper IUD is contraindicated in cases of active pelvic infection (PID) "<img
src=""8444.png"">" copper-intrauterine-device pharmacology reproductive
A woman who does not believe in using hormones asks what else she can use for
contraception. What do you offer her? How does it work? The copper IUD is
hormone free; it produces a local inflammatory reaction toxic to sperm and ova,
preventing fertilization and implantation "<img src=""8444.png"">" copper-
intrauterine-device pharmacology reproductive
You give a woman in labor a 2-agonist. Will this help her be more comfortable?
Yes, because 2-agonists (e.g., terbutaline, ritodrine) relax the uterus and
reduce contraction frequency during labor "<img src=""8445.png"">" pharmacology
reproductive terbutaline,-ritodrine
A 30-year-old woman is taking danazol. Which two medical conditions warrant this
treatment? Endometriosis and hereditary angioedema "<img src=""8446.png"">"
danazol pharmacology reproductive
Your patient recently started taking danazol for endometriosis. She now complains
of side effects. What might they be? Weight gain, edema, acne, hirsutism,
masculinization, decreased high-density lipoprotein (HDL), hepatotoxicity "<img
src=""8446.png"">" danazol pharmacology reproductive
You counsel an endometriosis patient about a drug that may cause hirsutism. What is
the mechanism of action of this drug? Acts as a partial agonist at androgen
receptors (this is danazol, a synthetic androgen) "<img src=""8446.png"">"
danazol pharmacology reproductive
How would exogenous testosterone affect the height of a child that has not
completed puberty? This child may be shorter than expected because of
premature closure of the epiphyseal plates "<img src=""8447.png"">"
pharmacology reproductive testosterone,-methyltestosterone
Testosterone can be used to treat hormonal deficiencies. How does it work? This
androgen receptor agonist can be used in hypogonadism to help develop 2 sex
characteristics, and can cause female masculinization "<img src=""8447.png"">"
A patient comes to the ED with severe burn injuries. How is testosterone useful for
patients who have sustained burns? Testosterone stimulates anabolism, which helps
promote recovery from burns or other severe injuries "<img src=""8447.png"">"
What genital exam finding would you expect in a male patient using exogenous
testosterone? Why? Testicular atrophy; exogenous testosterone blocks LH
release, which decreases intratesticular testosterone, causing testicular atrophy
"<img src=""8447.png"">" pharmacology reproductive testosterone,-
methyltestosterone
A patient on testosterone therapy comes in for a check-up. What lab is important to
draw? What findings would you expect? Check serum lipids; you would expect
elevated low-density lipoprotein (LDL) and decreased high-density lipoprotein (HDL)
levels "<img src=""8447.png"">" pharmacology reproductive testosterone,-
methyltestosterone
A 46-year-old man is taking finasteride to prevent male pattern baldness. What is
the mechanism of action of this medication?- Blocks the conversion of
testosterone to the more potent dihydrotestosterone (DHT); finasteride is a 5-
reductase inhibitor "<img src=""8448.png"">" antiandrogens pharmacology
reproductive
A 66-year-old man has difficulty urinating, nocturia, and male-pattern baldness.
Which antiandrogen may be useful for him? Finasteride, a 5-reductase inhibitor, is
used to treat benign prostate hypertrophy (BPH) and male-pattern baldness "<img
src=""8448.png"">" antiandrogens pharmacology reproductive
What is the mechanism of action of flutamide? It is a nonsteroidal competitive
testosterone receptor antagonist "<img src=""8448.png"">" antiandrogens
Name two drugs that function as antiandrogens as an additional effect from their
interference with steroid synthesis and signaling. Ketoconazole (inhibits 17,20-
desmolase & steroid synthesis), & spironolactone (blocks steroid binding, 17,20-
desmolase, & 17-hydroxylase) "<img src=""8448.png"">" antiandrogens
What two adverse effects are common to both ketoconazole and spironolactone?
Gynecomastia and amenorrhea "<img src=""8448.png"">" antiandrogens
Which condition is flutamide used to treat? Prostate carcinoma "<img
src=""8448.png"">" antiandrogens pharmacology reproductive
Ketoconazole and spironolactone are used to prevent what conditions in women?
Hirsutism and androgenic symptoms in women with polycystic ovarian syndrome
"<img src=""8448.png"">" antiandrogens pharmacology reproductive
An elderly man with benign prostatic hyperplasia (BPH) takes a drug that inhibits
smooth muscle contraction. What drug class is this? An 1-antagonist that
inhibits smooth muscle contraction and thereby treats BPH (this is tamsulosin)
"<img src=""8449.png"">" pharmacology reproductive tamsulosin
Why does tamsulosin relax the smooth muscles of the prostate but not the systemic
vasculature? It is selective for 1A,D-receptors found on the prostate, rather
than the 1B-receptors on systemic vessels "<img src=""8449.png"">"
pharmacology reproductive tamsulosin
A patient presents with flushing, reflux, headache, and impaired blue-green vision.
What drug has he likely ingested? Sildenafil/vardenafil/tadalafil (Hot and
sweaty, but then Headache, Heartburn, Hypotension) "<img src=""8450.png"">"
pharmacology phosphodiesterase-type-5-inhibitors reproductive
A man with severe hypertension now has life-threatening hypotension after taking
sildenafil. What other medication is he likely taking? Nitrates (concomitant
use can precipitate life-threatening hypotension) "<img src=""8450.png"">"
A man with erectile dysfunction is taking sildenafil. How does this medication
increase penile blood flow and cause erection? It inhibits PDE-5, increasing cGMP
level, resulting in smooth muscle relaxation, and increasing blood flow in the
corpus cavernosum "<img src=""8450.png"">" pharmacology phosphodiesterase-
type-5-inhibitors reproductive
What is the primary clinical use of sildenafil, vardenafil, and tadalafil? To
treat erectile dysfunction and pulmonary hypertension (sildenafil, vardenafil, and
tadalafil fill the penis) "<img src=""8450.png"">" pharmacology
phosphodiesterase-type-5-inhibitors reproductive
Pilots, especially those flying at night, are not allowed to take PDE-5 inhibitors
before or during the flight. Why might this be? PDE-5 inhibitors (sildenafil,
vardenafil, tadalafil) can cause blue-green vision impairment, which may make it
harder to fly the plane "<img src=""8450.png"">" pharmacology
phosphodiesterase-type-5-inhibitors reproductive
A patient with pulmonary hypertension comes to your office. How do PDE-5 inhibitors
help him? They increase cGMP, resulting in smooth muscle relaxation in response
to NO, thereby decreasing pulmonary vascular resistance "<img src=""8450.png"">"
You prescribe a man a direct arteriolar vasodilator to treat his androgenetic
alopecia. What other disorder does this drug treat? Can also be used to treat
severe refractory hypertension (this is minoxidil, a direct arteriolar vasodilator)
"<img src=""8451.png"">" minoxidil pharmacology reproductive
Describe the general process of lung development. How many stages are there? Lung
bud develops from distal end of respiratory diverticulum; bud divides into 2
bronchial buds that branch off to form bronchi; 5 stages "<img src=""8452.png"">"
Respiratory embryology lung-development
During which week of embryonic development does lung development start? Week 4
"<img src=""8452.png"">" Respiratory embryology lung-development
Name all the stages of lung development, in order. Embryonic (weeks 47),
pseudoglandular (weeks 516), canalicular (weeks 1626), saccular (week 26birth),
and alveolar (week 328 years) "<img src=""8452.png"">" Respiratory
embryology lung-development
What happens during the embryonic stage of lung development? Which gestational
weeks does this stage encompass? Lung bud trachea mainstem bronchi
secondary (lobar) bronchi tertiary (segmental) bronchi; weeks 47 "<img
src=""8452.png"">" Respiratory embryology lung-development
What happens during the alveolar stage of lung development? Which gestational weeks
does this stage encompass? Terminal sacs become adult alveoli due to secondary
septation; week 32birth; development continues to the age of 8 years "<img
What happens during the pseudoglandular stage of lung development? Which
gestational weeks does this stage encompass? Endodermal tubules become terminal
bronchioles, which are surrounded by a modest capillary network; weeks 516 "<img
What happens during the canalicular stage of lung development? Which gestational
weeks does this stage encompass? Terminal bronchioles become respiratory
bronchioles, which become alveolar ducts, surrounded by a prominent capillary
network; weeks 1626 "<img src=""8452.png"">" Respiratory embryology lung-
development
What happens during the saccular stage of lung development? Which gestational weeks
does this stage encompass? Alveolar ducts become terminal sacs, which are
separated by primary septae, and pneumocytes develop; week 26birth "<img
Describe the difference in vascular resistance (VR) between the respiratory system
in utero and at birth. "In utero ""breathing"" occurs via aspiration/expulsion of
amniotic fluid, increasing VR; at birth, replacement of fluid with air decreases
VR" "<img src=""8452.png"">" Respiratory embryology lung-development
Give estimates of the alveoli count at birth and at full development. By what age
are lungs fully developed? At birth: 2070 million alveoli; by the age of 8
years (full development): 300400 million alveoli "<img src=""8452.png"">"
Respiratory embryology lung-development
At what gestational age does respiration become possible? Which stage of lung
development is this? Canalicular stage (25 weeks) when airways increase in
diameter; pseudoglandular stage (Before then, development is incompatible with
life.) "<img src=""8452.png"">" Respiratory embryology lung-development
A baby is born with a tracheoesophageal (TE) fistula. At what stage of lung
development did this likely arise? Which gestational weeks?The embryonic stage;
weeks 4 to 7 "<img src=""8452.png"">" Respiratory embryology lung-
development
A baby is born with Potter sequence. Name the three classic components of this
sequence. Pulmonary hypoplasia, congenital diaphragmatic hernia, and bilateral
renal agenesis "<img src=""8453.png"">" Respiratory congenital-lung-
malformations embryology
A neonate is born with pulmonary hypoplasia. What is this? Does this more commonly
affect the right or left lung? Pulmonary hypoplasia is a term for a poorly
developed bronchial tree with abnormal histology; the right lung "<img
src=""8453.png"">" Respiratory congenital-lung-malformations embryology
A newborn's chest x-ray reveals discrete, round. sharply defined, air-filled
densities. What are these and how are they formed? These are bronchogenic cysts,
which are caused by abnormal budding of the foregut and dilation of terminal or
large bronchi "<img src=""8453.png"">" Respiratory congenital-lung-
You are speaking with the parents of a baby born with bronchogenic cysts. What can
they expect in terms of infections? These cysts can cause chronic infections, since
they drain poorly "<img src=""8453.png"">" Respiratory congenital-lung-
What pneumocyte subtype makes up 97% of the alveolar surface area? Type I
pneumocytes "<img src=""8454.png"">" Respiratory embryology pneumocytes
Histologically, how do type I pneumocytes appear? What about type II pneumocytes?
Squamous and thin; cuboidal and clustered "<img src=""8454.png"">"
Respiratory embryology pneumocytes
What is the advantage of having numerous thin type I pneumocytes line the walls of
alveoli? Maximum gas exchange is permitted by thin cells (squamous morphology)
"<img src=""8454.png"">" Respiratory embryology pneumocytes
What are two important functions of type II pneumocytes? They secrete surfactant
(which prevents alveolar collapse) and serve as precursors to other pneumocytes
(both types I and II) "<img src=""8454.png"">" Respiratory embryology
pneumocytes
A pt has a pneumothorax, which damages his lungs. Which cells proliferate to repair
the lungs after they have been damaged? Type II pneumocytes (They are the
precursors of both type I and type II pneumocytes.) "<img src=""8454.png"">"
Describe club cells (histologically) and their three functions. Nonciliated
columnar/cuboidal pneumocytes w/secretory granules that secrete a surfactant
component, degrade toxins, & act as reserve cells "<img src=""8454.png"">"
Explain the law of Laplace using the equation for calculating collapsing pressure
(P). P = 2 (Surface tension) Radius; alveoli have a tendency to collapse on
expiration, because as their radius decreases, P increases "<img src=""8454.png"">"
What is dipalmitoylphosphatidylcholine? What is its function? A type of lecithin
and an important component of surfactant; surfactant decreases alveolar surface
tension and prevents atelectasis "<img src=""8454.png"">" Respiratory
embryology pneumocytes
A neonate is born at 32 weeks. Why is this neonate more likely to have respiratory
problems? Surfactant synthesis starts at 26 weeks but does not mature until 35
weeks, so this neonate is more likely to have respiratory distress "<img
src=""8454.png"">" Respiratory embryology pneumocytes
Describe the mechanism of surfactant preventing alveolar collapse. Surfactant
decreases alveolar surface tension, preventing alveolar collapse, decreasing lung
recoil, and increasing compliance "<img src=""8454.png"">" Respiratory
embryology pneumocytes
A newborn dies of neonatal respiratory distress syndrome. Lung tissue examined in
the lab will reveal a deficiency of what chemical? Surfactant "<img
src=""8455.png"">" Respiratory embryology neonatal-respiratory-distress-
syndrome
How does the lack of surfactant in neonatal respiratory distress syndrome impair
gas exchange in the lungs? Surfactant deficiency leads to an increase in surface
tension, resulting in collapse of the alveoli "<img src=""8455.png"">"
Respiratory embryology neonatal-respiratory-distress-syndrome
What is used as a measure of lung maturity in neonates? What values are expected in
neonatal respiratory distress syndrome (NRDS)? The lecithin-sphingomyelin ratio in
amniotic fluid; &62; 2 is healthy; &60; 1.5 is predictive of NRDS "<img
syndrome
What vascular pathology is associated with persistently low oxygen tension due to
neonatal respiratory distress syndrome? Patent ductus arteriosus "<img
syndrome
A premature infant born to a diabetic mother exhibits intercostal retractions and
appears hypoxic. What is the most likely diagnosis? Neonatal respiratory distress
syndrome "<img src=""8455.png"">" Respiratory embryology neonatal-
respiratory-distress-syndrome
A newborn is given oxygen with caution by a neonatologist, who also performs serial
eye exams. What is the physician worried about? Retinopathy of prematurity, a side
effect of therapeutic supplemental oxygen administration in newborns with NRDS
"<img src=""8455.png"">" Respiratory embryology neonatal-respiratory-
distress-syndrome
A newborn receives supplemental oxygen therapy for neonatal respiratory distress
syndrome. This can lead to what three complications? Retinopathy of prematurity,
Intraventricular hemorrhage, and Bronchopulmonary dysplasia (RIB) "<img
syndrome
What are three risk factors for neonatal respiratory distress syndrome?
Prematurity, maternal diabetes (due to elevated fetal insulin), and cesarean
delivery (due to decreased release of fetal glucocorticoids) "<img
syndrome
A woman at 30 weeks' gestation presents for an exam. The ratio of which 2 amniotic
fluid markers can be used to assess fetal lung maturity? Lecithin and
sphingomyelin (The lecithin-sphingomyelin ratio is a marker for surfactant
quantity.) "<img src=""8455.png"">" Respiratory embryology neonatal-
A newborn diagnosed with neonatal respiratory distress syndrome is at risk for what
complications? Metabolic acidosis, PDA, necrotizing enterocolitis "<img
syndrome
A lecithin-sphingomyelin ratio is derived for a neonate to evaluate fetal lung
maturity. What value is indicative of lung maturity? Ratio &62; 2.0 "<img
syndrome
Medical management of neonatal respiratory distress syndrome includes what
treatments for the mother and infant? Administration of steroids to the mother
before delivery and administration of artificial surfactant to the newborn "<img
syndrome
In addition to the lecithin-sphingomyelin (L/S) ratio, what are two screening tests
for neonatal respiratory distress syndrome? The foam stability index test and
the surfactant-albumin ratio "<img src=""8455.png"">" Respiratory embryology
neonatal-respiratory-distress-syndrome
Which structures make up the large airways of the conducting zone of the
respiratory tree? The small airways? Large airways: nose, pharynx, larynx,
trachea, bronchi; small airways: bronchioles, terminal bronchioles "<img
src=""8456.png"">" Respiratory anatomy respiratory-tree
Which part of the conducting zone of the respiratory tree has the least airway
resistance? The terminal bronchioles (A large number of them run in parallel.)
"<img src=""8456.png"">" Respiratory anatomy respiratory-tree
Name the three functions of the conducting zone of the respiratory tree. "The
conducting zone warms, humidifies, and filters air; it does not participate in gas
exchange (""anatomic dead space"")" "<img src=""8456.png"">" Respiratory
anatomy respiratory-tree
Which zone of the respiratory tree includes the anatomic dead space? The
conducting zone (By definition, dead space does not participate in gas exchange.)
Cartilage and goblet cells extend to the end of what part of the conducting zone?
The bronchi "<img src=""8456.png"">" Respiratory anatomy respiratory-
tree
Describe the types of epithelium in the parts of the conducting zone.
Pseudostratified ciliated columnar cells arise in bronchi/early terminal
bronchioles; cuboidal cells arise in terminal bronchioles onward "<img
src=""8456.png"">" Respiratory anatomy respiratory-tree
What type of muscle is found in the walls of the conducting airways? To which area
does it extend? Smooth muscle; it extends to the end of the terminal bronchioles
(Beyond that point, it is sparse.) "<img src=""8456.png"">" Respiratory
What anatomic area does the respiratory zone encompass? What is its major function?
The lung parenchyma: respiratory bronchioles, the alveolar ducts, and the
alveoli; its major function is gas exchange "<img src=""8456.png"">"
Respiratory anatomy respiratory-tree
What type of epithelial cell is found in respiratory bronchioles?
Predominantly cuboidal cells "<img src=""8456.png"">" Respiratory
A pt aspirates debris into his lungs. Other than cilia, what helps clear the
debris? Alveolar macrophages (They also participate in the immune response.)
How many lobes does the right lung have? How many does the left lung have? Three;
two (Left has Less Lobes [2] and Lingula.) "<img src=""8457.png"">"
Respiratory anatomy lung-relations
What structure does the left lung have that the right lung does not? The lingula,
which is the homolog of the middle lobe of the right lung "<img src=""8457.png"">"
Where is the pulmonary artery in relation to the bronchus within the right lung
hilum? Anterior (RALS = Right Anterior; Left Superior) "<img src=""8457.png"">"
Where is the pulmonary artery in relation to the bronchus within the left lung
hilum? Superior (RALS = Right Anterior; Left Superior) "<img src=""8457.png"">"
The oblique fissure divides which two lobes in the right lung? The left lung?
The middle and inferior lobes; the superior and inferior lobes "<img
src=""8457.png"">" Respiratory anatomy lung-relations
Both the right and left lungs have what type of fissure? In contrast, what type of
fissure is found in only the right lung? Oblique fissure; horizontal fissure "<img
src=""8457.png"">" Respiratory anatomy lung-relations
In the posterior aspect of both the right and left lungs, which fissure divides the
superior and inferior lobes? The oblique fissure "<img src=""8457.png"">"
What mnemonic can be used to recall the levels at which certain anatomic structures
perforate the diaphragm? I (IVC) ate (8) ten (10) eggs (esophagus) at (aorta)
twelve (12) "<img src=""8458.png"">" Respiratory anatomy diaphragm-structures
Neurons from which three nerve roots come together to form the phrenic nerve, which
innervates the diaphragm? C3, C4, C5 (C3, 4, 5 keeps the diaphragm alive.)
"<img src=""8458.png"">" Respiratory anatomy diaphragm-structures
A man with diaphragmatic trauma has no pain there. To which anatomic regions is the
pain referred? What is the innervation of these regions? The shoulder (C5) and
the trapezius ridge (C3, C4) "<img src=""8458.png"">" Respiratory anatomy
diaphragm-structures
Which tendon can be found on the inferior aspect of the diaphragm surrounding the
caval and esophageal hiatuses? The central tendon "<img src=""8458.png"">"
Respiratory anatomy diaphragm-structures
The abdominal aorta bifurcates at what level? The common carotid? The trachea?
L4; C4; T4 (All are bifourcations.) "<img src=""8458.png"">" Respiratory
anatomy diaphragm-structures
A man comes in with severe pain, and you determine that his phrenic nerve is
irritated. What are three possible clinical causes? Air, blood, or pus in his
peritoneal cavity can all irritate the diaphragm (phrenic nerve) "<img
src=""8458.png"">" Respiratory anatomy diaphragm-structures
A pt has penetrating trauma to the diaphragm at the level of T8. What vascular
structure is the trauma surgeon most concerned about? The inferior vena cava, which
passes through the diaphragm at the level of T8 (8 letters in vena cava) "<img
What two structures perforate the diaphragm at the level of T10? The esophagus and
the vagus pass through at the level of T10 (C10, two trunks) "<img
At what level does the esophagus perforate the diaphragm? T10 (10 letters in
[o]esophagus) "<img src=""8458.png"">" Respiratory anatomy diaphragm-
structures
What three structures perforate the diaphragm at the level of T12? The aorta
(red), thoracic duct (white), and azygos vein (blue) (At T-1-2, it's the red,
white, and blue.) "<img src=""8458.png"">" Respiratory anatomy diaphragm-
structures
What is the term for the volume of air in excess of tidal volume that moves into
the lung on inspiration? Inspiratory reserve volume "<img src=""8459.png"">"
Respiratory lung-volumes physiology
A man breathes calmly and quietly. He takes in a normal breath and then lets it out
without any force. What volume of air is being moved? Tidal volume, which is
approximately 500 mL "<img src=""8459.png"">" Respiratory lung-volumes
physiology
What is the term for the volume of air that can still be breathed out after a
normal expiration? Expiratory reserve volume "<img src=""8459.png"">"
What is the term for the volume of air in the lungs after maximal expiration?
Residual volume "<img src=""8459.png"">" Respiratory lung-volumes
physiology
What is unmeasurable on spirometry: inspiratory reserve volume, tidal volume,
expiratory reserve volume, residual volume? Residual volume "<img
src=""8459.png"">" Respiratory lung-volumes physiology
The inspiratory reserve volume plus the tidal volume equals what? Inspiratory
capacity "<img src=""8459.png"">" Respiratory lung-volumes physiology
The residual volume plus the expiratory reserve volume equals what? Functional
residual capacity "<img src=""8459.png"">" Respiratory lung-volumes physiology
Describe the functional residual capacity (FRC). What are its two components? Can
it be measured on spirometry? FRC = the total volume left in the lungs after normal
expiration; components: residual volume and expiratory reserve volume; no "<img
Vital capacity equals the sum of what three lung volumes? Tidal volume,
inspiratory reserve volume, and expiratory reserve volume "<img src=""8459.png"">"
What is the term for the maximum volume of air that can be inhaled and exhaled?
Vital capacity "<img src=""8459.png"">" Respiratory lung-volumes
physiology
A pt exhales as much as he can, inhales as much as he can, and then exhales as much
as he can again. What volume of air has he moved? His vital capacity (VC) "<img
Inspiratory reserve volume + tidal volume + expiratory reserve volume + residual
volume equals what? Can it be measured on spirometry? Total lung capacity; no "<img
Name the four lung volumes. Lung volumes (LITER): Inspiratory reserve, Tidal,
Expiratory reserve, Residual "<img src=""8459.png"">" Respiratory lung-volumes
physiology
What is the definition of a capacity? The sum of two or more physiologic
volumes "<img src=""8459.png"">" Respiratory lung-volumes physiology
Which three lung volumes CANNOT be measured on spirometry? Residual volume,
functional residual capacity, and total lung capacity "<img src=""8459.png"">"
What is the equation for determining the volume of dead space in the lungs, where
PaCO2 = arterial and PECO2 = expired air? VD = VT ([PaCO2 PECO2] PaCO2)
(Taco, Paco, PEco, Paco, as the order of variables) "<img src=""8460.png"">"
Respiratory determination-of-physiologic-dead-space physiology
You know a pt's physiologic dead space, expired air CO2, and arterial CO2. Can you
calculate the tidal volume (VT)? Yes, as VD = VT ([PaCO2 PECO2] PaCO2),
where PaCO2 = arterial, and PECO2 = expired air "<img src=""8460.png"">"
Respiratory determination-of-physiologic-dead-space physiology
A pt's tidal volume is 500 mL, PaCO2 is 50 mm Hg, and PECO2 is 35 mm Hg. What is
the volume of distribution? 150 mL; VD = 500 mL ([50 mm Hg 35 mm Hg] 50 mm
Hg) "<img src=""8460.png"">" Respiratory determination-of-physiologic-dead-
space physiology
Describe the parts of the airway that contribute to the physiologic dead space.
It is approximately equivalent to the anatomic dead space in normal lungs,
plus any alveolar dead space "<img src=""8460.png"">" Respiratory
determination-of-physiologic-dead-space physiology
What is pathologic dead space? When part of the respiratory zone becomes
unable to perform gas exchange (ventilation without perfusion) "<img
src=""8460.png"">" Respiratory determination-of-physiologic-dead-space
physiology
What is the volume of inspired air that does not contribute to gas exchange?
Physiologic dead space, VD "<img src=""8460.png"">" Respiratory
determination-of-physiologic-dead-space physiology
A pt has a lung disease with a V/Q defect. What can you say about his physiologic
dead space? It is likely greater than the anatomic dead space in normal lungs (In
healthy persons, these two spaces are more or less equivalent.) "<img
src=""8460.png"">" Respiratory determination-of-physiologic-dead-space
physiology
What is minute ventilation (VE)? How do you calculate it? The total volume of gas
entering the lungs each minute; VE = VT respiratory rate (RR) "<img
src=""8461.png"">" Respiratory physiology ventilation
A pt with a tidal volume of 400 mL is breathing 20 times per minute. What is his
minute ventilation? 8000 mL/min, as minute ventilation (VE) = 400 mL 20
breaths/min "<img src=""8461.png"">" Respiratory physiology ventilation
What are normal values for respiratory rate (RR), tidal volume, and physiologic
dead space? RR: 12 to 20 breaths/min; tidal volume: 500 mL/breath; physiologic dead
space: 150 mL/breath "<img src=""8461.png"">" Respiratory physiology
ventilation
What is alveolar ventilation (VA)? How do you calculate it?The volume of gas per
unit time that reaches the alveoli; VA = (VT VD) respiratory rate "<img
src=""8461.png"">" Respiratory physiology ventilation
A pt with a tidal volume of 650 mL is breathing 10 times per minute. His dead space
is 150 mL. What is his alveolar ventilation? 5000 mL/min, as alveolar
ventilation (VA) = (650 mL 150 mL) 10 breaths/min "<img src=""8461.png"">"
Respiratory physiology ventilation
A pt is breathing naturally. Describe the natural tendency of lung and chest wall
movement. The lungs tend to collapse inward, and the chest wall springs outward
"<img src=""8462.png"">" Respiratory lung-and-chest-wall physiology
At what point in the respiratory cycle is the inward pull of the lung equal to the
outward pull of the chest wall? At functional residual capacity (FRC) "<img
src=""8462.png"">" Respiratory lung-and-chest-wall physiology
At the point of functional residual capacity (FRC), what is the value of the air
pressure within the lungs? At FRC, the pressure within the lungs is equal to
atmospheric pressure "<img src=""8462.png"">" Respiratory lung-and-chest-
wall physiology
A pt takes a deep breath. What determines the combined volume of the chest wall and
lungs? Elastic properties of both "<img src=""8462.png"">" Respiratory
lung-and-chest-wall physiology
In terms of lung pressures, explain how a pneumothorax is prevented. At FRC, lung
pressures are atmospheric, and opposing forces of the lung and chest wall create
negative pressure in the intrapleural space "<img src=""8462.png"">"
Respiratory lung-and-chest-wall physiology
At what lung volume is the pulmonary vascular resistance at a minimum? At
functional residual capacity (FRC) "<img src=""8462.png"">" Respiratory lung-
and-chest-wall physiology
What is compliance? The change in lung volume for a given change in pressure,
expressed as V/P, and inversely proportional to wall stiffness "<img
A 43-year-old woman has pulmonary fibrosis. How does this affect her lung
compliance? What else would affect compliance in a similar way? Pulmonary fibrosis
decreases lung compliance; pulmonary edema and pneumonia also decrease lung
compliance "<img src=""8462.png"">" Respiratory lung-and-chest-wall
physiology
A pt is diagnosed with emphysema. What do you tell him about his lung compliance?
It is increased "<img src=""8462.png"">" Respiratory lung-and-chest-
wall physiology
A pt comes in for her annual exam. She is healthy. What do you tell her to expect
regarding her lung compliance as she ages? It increases with normal aging
"<img src=""8462.png"">" Respiratory lung-and-chest-wall physiology
Is the lung easier or harder to fill with high compliance? What about low
compliance? High compliance: easier to fill; low compliance: harder to fill "<img
What is hysteresis in relation to the pulmonary system? Lung inflation curve
follows a different curve than lung deflation curve because the surface tension
needs to be overcome during inflation "<img src=""8462.png"">" Respiratory
lung-and-chest-wall physiology
How does surfactant affect compliance? It increases it "<img src=""8462.png"">"
Respiratory lung-and-chest-wall physiology
How many polypeptide subunits make up hemoglobin? Four "<img src=""8463.png"">"
Respiratory hemoglobin physiology
What are the two conformational forms of hemoglobin? Relaxed (oxygenated) and taut
(deoxygenated) "<img src=""8463.png"">" Respiratory hemoglobin physiology
Which form of hemoglobin has the highest affinity for oxygen? The relaxed form
has 300 times more affinity for oxygen (Taut in Tissues.Relaxed in Respiratory
area.) "<img src=""8463.png"">" Respiratory hemoglobin physiology
Does hemoglobin have positive or negative cooperativity with respect to oxygen
binding and affinity? Positive "<img src=""8463.png"">" Respiratory
hemoglobin physiology
Does hemoglobin have positive or negative allostery with respect to oxygen binding
and affinity? Negative "<img src=""8463.png"">" Respiratory hemoglobin
physiology
An increase in which five factors will favor the taut form of hemoglobin over the
relaxed form and will decrease affinity for oxygen? Chloride (Cl), protons (H+),
carbon dioxide, 2,3-bisphosphoglycerate, and temperature "<img src=""8463.png"">"
A pt is exercising and generating lots of H+ and carbon dioxide at the tissue
level. Which form will hemoglobin take at these sites? Taut, as exercise
(generating CO2) favors the taut form for oxygen unloading "<img src=""8463.png"">"
What interaction with 2,3-BPG allows fetal hemoglobin to have a greater affinity
for oxygen? Decreased affinity for 2,3-BPG allows for greater affinity for oxygen
"<img src=""8463.png"">" Respiratory hemoglobin physiology
Hemoglobin can act as a buffer for which ions? H+ "<img src=""8463.png"">"
When another molecule, such as carbon monoxide, binds to hemoglobin in place of
oxygen, what are the systemic effects? CO causes a left shift in the oxygen-
hemoglobin curve, resulting in tissue hypoxia from decreased oxygen unloading
"<img src=""8464.png"">" Respiratory hemoglobin-modifications physiology
A pt has cyanide poisoning. What two treatments do you provide? Nitrites first and
then thiosulfate "<img src=""8464.png"">" Respiratory hemoglobin-
modifications physiology
A pt who spends much of his time mountaineering is cyanotic; a blood sample is
chocolate colored. What caused this? Poisoning by nitrites found in high-
altitude water "<img src=""8464.png"">" Respiratory hemoglobin-
What is the name of a form of hemoglobin in which carbon monoxide is bound instead
of oxygen? Carboxyhemoglobin "<img src=""8464.png"">" Respiratory hemoglobin-
Does carbon monoxide or oxygen have a greater affinity for hemoglobin? CO has 200
times the affinity of oxygen for hemoglobin "<img src=""8464.png"">"
Respiratory hemoglobin-modifications physiology
A man presents with a headache, nausea, and confusion. He was found in a small
unventilated room with a space heater. Treatment? 100% O2 and hyperbaric O2
(This is likely carbon monoxide poisoning.) "<img src=""8464.png"">"
Hemoglobin modifications causing decreased oxygen saturation and content may lead
to what? Hypoxia "<img src=""8464.png"">" Respiratory hemoglobin-
What is the difference between hemoglobin and methemoglobin? Iron in hemoglobin
is in reduced form (ferrous, Fe2+), while iron in methemoglobin is in oxidized form
(ferric, Fe3+) "<img src=""8464.png"">" Respiratory hemoglobin-
A man has cyanide poisoning. What property of methemoglobin makes it useful for
treatment? The ferric (Fe3+) state of methemoglobin has decreased affinity for O2
but increased affinity for cyanide "<img src=""8464.png"">" Respiratory
hemoglobin-modifications physiology
A cyanotic pt is found to have chocolate-colored blood. Treatment? Methylene
blue (This pt has methemoglobinemia.) "<img src=""8464.png"">" Respiratory
hemoglobin-modifications physiology
A child has cyanide poisoning. What is the mechanism of action of nitrites used in
the treatment? Nitrites oxidize iron to form methemoglobin, which readily binds
cyanide, restoring function to cytochrome oxidase "<img src=""8464.png"">"
What is the shape of the oxygen-hemoglobin dissociation curve? Explain.
Sigmoidal due to positive cooperativity, as Hb can bind four O2 molecules; O2
binding is easier when more O2 is bound "<img src=""8465.png"">" Respiratory
oxygen-hemoglobin-dissociation-curve physiology
How does the structure of myoglobin affect its function? It is monomeric and thus
has no positive cooperativity as seen in hemoglobin, and it lacks the sigmoidal
curve "<img src=""8465.png"">" Respiratory oxygen-hemoglobin-dissociation-
curve physiology
When the oxygen-hemoglobin dissociation curve shifts to the right, what happens to
the affinity of hemoglobin for oxygen? A right shift decreases the affinity of
hemoglobin for oxygen "<img src=""8465.png"">" Respiratory oxygen-
hemoglobin-dissociation-curve physiology
When the oxygen-hemoglobin dissociation curve shifts to the right, what happens to
the O2 saturation (%) at a PO2 of 50 mm Hg? A right shift decreases oxygen
saturation. (Higher oxygen pressure is required to saturate hemoglobin.) "<img
src=""8465.png"">" Respiratory oxygen-hemoglobin-dissociation-curve physiology
A shift of the oxygen-hemoglobin dissociation curve to the right facilitates what
process in tissue? The unloading of oxygen to tissue "<img src=""8465.png"">"
Respiratory oxygen-hemoglobin-dissociation-curve physiology
When the oxygen-hemoglobin dissociation curve shifts to the left, what happens to
the affinity of hemoglobin for oxygen? A left shift increases the affinity of
hemoglobin for oxygen "<img src=""8465.png"">" Respiratory oxygen-
Increases in the amount of which six factors cause a right shift of the oxygen-
hemoglobin dissociation curve? Right shift: ACE BATs right handed (Acid, CO2,
Exercise, 2,3-BPG, Altitude, Temperature) "<img src=""8465.png"">" Respiratory
When the oxygen-hemoglobin dissociation curve shifts to the left, what happens to
the O2 saturation (%) at a PO2 of 50 mm Hg? A left shift increases oxygen
saturation. (Less oxygen pressure is required to saturate hemoglobin.) "<img
Decreases in the amount of which factors cause a left shift of the oxygen-
hemoglobin dissociation curve? Acid (H+), CO2, exercise, 2,3-BPG, altitude,
temperature "<img src=""8465.png"">" Respiratory oxygen-hemoglobin-
dissociation-curve physiology
A fetus's oxygen-hemoglobin dissociation curve is investigated. How does it compare
to an adult's oxygen-hemoglobin dissociation curve? It is shifted to the left
(Fetal hemoglobin has higher affinity for oxygen than adult hemoglobin.) "<img
A pt in shock develops lactic acidosis. This decrease in pH causes what kind of
shift in the oxygen-hemoglobin dissociation curve? Right shift (due to increased
acid [or H+] lowering the pH) "<img src=""8465.png"">" Respiratory oxygen-
A pt's chest is injured and her partial pressure of CO2 is increased. How does this
affect her oxygen-hemoglobin dissociation curve? Shifts it to the right "<img
A pt is exercising. What effect does this have on his oxygen-hemoglobin
dissociation curve? Shifts it to the right "<img src=""8465.png"">"
The level of 2,3 BPG increases. What happens to the oxygen-hemoglobin dissociation
curve? It shifts to the right "<img src=""8465.png"">" Respiratory
A hiker scales an extremely tall mountain. High altitude induces what change in the
oxygen-hemoglobin dissociation curve? A shifts to the right "<img
A pt develops a fever. An increase in temperature causes what kind of shift in the
oxygen-hemoglobin dissociation curve? A right shift "<img src=""8465.png"">"
A woman has fatigue and pallor. What are the likely levels of her Hb, % O2
saturation of Hb, dissolved O2 (PaO2), and total O2 content? Hb is decreased, %
O2 saturation of Hb is normal, PaO2 is normal, and total O2 content is decreased
(She has anemia.) "<img src=""8466.png"">" Respiratory oxygen-content-of-blood
physiology
A man has polycythemia. What are the likely levels of his Hb, O2 saturation of Hb,
dissolved O2 (PaO2), and total O2 content? Hb is increased, % O2 saturation of
Hb is normal, PaO2 is normal, and total O2 is content increased "<img
src=""8466.png"">" Respiratory oxygen-content-of-blood physiology
What is the equation for oxygen content in the blood? O2 content = (O2 binding
capacity Percent saturation) + Dissolved O2 "<img src=""8466.png"">"
Respiratory oxygen-content-of-blood physiology
What is the normal level of hemoglobin in the blood? How many milliliters of oxygen
can it bind? Normal Hb amount = 15 g/dL; each gram can bind 1.34 mL of oxygen
"<img src=""8466.png"">" Respiratory oxygen-content-of-blood physiology
A previously healthy pt develops blue lips and fingertips. What does this say about
the value of her deoxygenated hemoglobin level? Her deoxygenated hemoglobin must be
&62; 5 g/dL (This is cyanosis.) "<img src=""8466.png"">" Respiratory
oxygen-content-of-blood physiology
What is the normal value of the O2 binding capacity? 20.1 mL O2/dL Hb "<img
src=""8466.png"">" Respiratory oxygen-content-of-blood physiology
How do you calculate oxygen delivery to the tissues? O2 delivery to tissues =
Cardiac output O2 content of blood "<img src=""8466.png"">" Respiratory
oxygen-content-of-blood physiology
A woman has CO poisoning. What are the likely levels of her Hb, % O2 saturation of
Hb, dissolved O2 (PaO22 content? Hb is normal, % O2 saturation of Hb is
decreased (CO competes with O2), PaO2 is normal, and total O2 content is decreased
"<img src=""8466.png"">" Respiratory oxygen-content-of-blood physiology
What is the resistance and compliance in pulmonary circulation? Low resistance,
high compliance "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
Within the lungs, a decrease in PAO2 causes what process to occur within the
vasculature in the area? Hypoxic vasoconstriction "<img src=""8467.png"">"
Respiratory physiology pulmonary-circulation
Within the lungs, hypoxic vasoconstriction serves what physiologic function? It
shifts blood away from the poorly ventilated areas of the lung to those that are
well ventilated "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
Name the perfusion-limited gases. Oxygen (in healthy lungs), carbon dioxide,
nitrous oxide "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
Under perfusion-limited conditions, where along the length of the pulmonary
capillary do the partial pressures of a gas equilibrate? Early (Gas exchange is
not limited by its ability to cross the membraneonly by the supply of blood.)
"<img src=""8467.png"">" Respiratory physiology pulmonary-circulation
A pt becomes hypoxic from a massive hemorrhage. Under these perfusion-limited
conditions, how can pulmonary gas exchange be increased? By increasing blood flow
"<img src=""8467.png"">" Respiratory physiology pulmonary-circulation
Name the diffusion-limited gases. Oxygen (in damaged lungsemphysema, fibrosis),
carbon monoxide "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
Under what two conditions is oxygen a diffusion-limited gas? Emphysema and
fibrosis "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
Under diffusion-limited conditions, where along the length of the pulmonary
capillary does the gas equilibrate? It does not equilibrate (The characteristics of
the gas cause it to diffuse slowly across the alveolar membrane.) "<img
src=""8467.png"">" Respiratory physiology pulmonary-circulation
A pt with untreated pulmonary hypertension presents with jugular venous distention,
edema, and hepatomegaly. What caused this? The pt is showing signs of cor
pulmonale (right heart failure), a complication of pulmonary hypertension "<img
src=""8467.png"">" Respiratory physiology pulmonary-circulation
What is the equation for diffusion of a gas across a membrane? Vgas = A Dk(P1
P2) T, where A = area, T = thickness, DkP1 P2) = difference in partial
pressures "<img src=""8467.png"">" Respiratory physiology pulmonary-
circulation
A pt has emphysema. How does this affect the diffusion capacity of oxygen?
Destruction of membranes decreases the area available for gas transfer,
causing a decrease in diffusion "<img src=""8467.png"">" Respiratory
physiology pulmonary-circulation
In the equation for gas diffusion, which variable is affected by pulmonary
fibrosis, and how? Thickness of the alveolar membrane is increased in
pulmonary fibrosis, causing a decrease in diffusion "<img src=""8467.png"">"
Respiratory physiology pulmonary-circulation
How is pulmonary vascular resistance calculated? PVR = Pressure in the
pulmonary artery Pressure in the left atrium) Cardiac output "<img
src=""8468.png"">" Respiratory physiology pulmonary-vascular-resistance
How is left atrial pressure measured? It is approximated by pulmonary wedge
pressure "<img src=""8468.png"">" Respiratory physiology pulmonary-
vascular-resistance
How do you measure pulmonary vascular resistance using flow and the difference in
pressure across it? R = P Q, where R is resistance, P is pressure, and Q is
flow "<img src=""8468.png"">" Respiratory physiology pulmonary-vascular-
resistance
How is pulmonary vascular resistance affected by vessel length and radius?
Directly prop. to length & inversely prop. to radius; R = (81) (r4),
where = viscosity of blood, 1 = vessel length, and r = vessel radius "<img
A pt's cardiac output is 5 L/min. Ppulm artery is 10 mm Hg, & PL atrium is 5 mm Hg.
What is the pulmonary vascular resistance? PVR = (Ppulm artery PL atrium)
Cardiac output = ([10 mm Hg 5 mm Hg]) 5 L/min) = 1 (mm Hg min) L "<img
A pt's pulmonary vascular resistance is 2 (mm Hg min)/L. If Ppulm artery is 20
and PL atrium is 8 mm Hg, calculate the cardiac output. CO = 6 L/min, as PVR =
(Ppulm artery PL atrium) Cardiac output = 2 (mm Hg min) L = ([20 mmHg 8
mm Hg]) Cardiac output) "<img src=""8468.png"">" Respiratory physiology
pulmonary-vascular-resistance
Define the variables of the full alveolar gas equation: PAO2 = PIO2 PaCO2/R.
PAO2 = alveolar PO2, PIO2 = PO2 in inspired air, PaCO2 = arterial PCO2, R =
respiratory quotient = CO2 produced/O2 consumed "<img src=""8469.png"">"
Respiratory alveolar-gas-equation physiology
How can the alveolar gas equation be simplified and approximated (assuming that the
pt is breathing ambient air)? PAO2 = 150 (PaCO2 0.8) "<img src=""8469.png"">"
By using the alveolar gas equation, what important measure of pulmonary function
can be determined? The alveolar-arterial gradient "<img src=""8469.png"">"
What is the normal alveolar-arterial gradient? 1015 mm Hg "<img src=""8469.png"">"
A pt's alveolar PO2 is 100 mm Hg. Air PO2 is 150 mm Hg. Assuming a respiratory
quotient of 0.8, what is the arterial CO2? 40 mm Hg, as PAO2 = PlCO2 PaCO2
R = 100 mm Hg = 150 mm Hg ( mm Hg 0.8) "<img src=""8469.png"">"
Explain why the alveolar-arterial gradient might be elevated. What three pathologic
processes can cause this? V/Q mismatches, diffusion limitations (fibrosis), and
shunting (A rise in the A-a gradient may occur in hypoxemia.) "<img
src=""8469.png"">" Respiratory alveolar-gas-equation physiology
A pt has a respiratory quotient (R) of 1.0. What does this value signify? The
respiratory quotient (R) is a ratio of carbon dioxide produced to oxygen consumed
"<img src=""8469.png"">" Respiratory alveolar-gas-equation physiology
A pt breathes air with a PO2 of 100 mm Hg. PaCO2 is 30 mm Hg. With a respiratory
quotient of 0.6, what is alveolar O2? 50 mm Hg, as PAO2 = PIO2 PaCO2 R =
100 mm Hg (30 mm Hg 0.6) "<img src=""8469.png"">" Respiratory alveolar-
gas-equation physiology
Name five processes that can lead to hypoxemia (decreased arterial oxygen). High
altitude, hypoventilation, ventilation/perfusion ratio mismatches, diffusion
limitations, and right-to-left shunting "<img src=""8470.png"">" Respiratory
oxygen-deprivation physiology
Which two processes lead to hypoxemia with a normal A-a gradient? High
altitude and hypoventilation (eg, opioid use) "<img src=""8470.png"">"
Respiratory oxygen-deprivation physiology
Which three processes can lead to hypoxemia with an increased A-a gradient?
Ventilation/perfusion ratio mismatches, diffusion limitation, and right-to-
left shunting "<img src=""8470.png"">" Respiratory oxygen-deprivation
physiology
Name four processes that can lead to hypoxia (decreased oxygen delivery to tissue).
Decreased cardiac output, hypoxemia, anemia, and carbon monoxide poisoning
"<img src=""8470.png"">" Respiratory oxygen-deprivation physiology
Name two processes that can lead to ischemia (loss of blood flow). Impeded
arterial flow and reduced venous drainage "<img src=""8470.png"">" Respiratory
oxygen-deprivation physiology
What is the difference between hypoxemia and hypoxia? Hypoxemia is decreased
arterial partial pressure of oxygen, whereas hypoxia is decreased oxygen delivery
to tissue "<img src=""8470.png"">" Respiratory oxygen-deprivation physiology
A pt appears sedated and is breathing slowly after a painful surgical procedure.
What is his likely A-a gradient? The A-a gradient would be normal, since opioid-
induced hypoventilation leads to metabolic acidosis with a normal A-a gradient
"<img src=""8470.png"">" Respiratory oxygen-deprivation physiology
A hiker is weak after rapidly ascending a mountain. What is his likely A-a
gradient? His A-a gradient is likely normal, as this is a case of hypoxemia
caused by a high altitude "<img src=""8470.png"">" Respiratory oxygen-
deprivation physiology
A pt is found to have a diffusion limitation in his lungs. How would the A-a
gradient help you show this? Diffusion limitation would lead to an increased A-a
gradient "<img src=""8470.png"">" Respiratory oxygen-deprivation physiology
A pt develops a pulmonary embolus. What is his likely A-a gradient? This is a
case of V/Q mismatch, which would cause an increased A-a gradient "<img
src=""8470.png"">" Respiratory oxygen-deprivation physiology
A pt is found to have a right-to-left shunt. How is his likely A-a gradient
affected? It is increased "<img src=""8470.png"">" Respiratory oxygen-
deprivation physiology
What is the ideal ventilation/perfusion ratio for gas exchange? 1:1 "<img
src=""8471.png"">" Respiratory physiology v/q-mismatch
Within which part of the lung does ventilation/perfusion equal approximately 3?
The apex of the lung "<img src=""8471.png"">" Respiratory physiology
v/q-mismatch
What does a V/Q ratio of 3 reveal about the apex of the lung? Ventilation is
wasted "<img src=""8471.png"">" Respiratory physiology v/q-mismatch
Within which part of the lung does ventilation/perfusion equal approximately 0.6?
The base of the lung "<img src=""8471.png"">" Respiratory physiology
v/q-mismatch
What does a V/Q ratio of .6 reveal about the base of the lung? Perfusion is being
wasted "<img src=""8471.png"">" Respiratory physiology v/q-mismatch
Is ventilation greater at the base of the lung or the apex of the lung? The
base of the lung "<img src=""8471.png"">" Respiratory physiology v/q-mismatch
Is perfusion greater at the base of the lung or the apex of the lung? The base of
the lung "<img src=""8471.png"">" Respiratory physiology v/q-mismatch
A pt exercises. The vasodilation of the apical capillaries of the lung results in
what change to the ventilation/perfusion ratio? The ventilation/perfusion ratio
approaches 1, maximizing gas exchange to meet the metabolic demands of exercise
"<img src=""8471.png"">" Respiratory physiology v/q-mismatch
A pt has tuberculosis. This and other microorganisms that thrive in high-oxygen
environments flourish in which part of the lungs? The apex "<img
A woman chokes and aspirates a peanut. What is her ventilation/perfusion ratio
likely to be? "Approaching 0, as airway obstruction creates a blood flow shunt,
which isn't part of gas exchange (0 = ""oirway"" obstruction.)" "<img
A child chokes on a peanut. This airway obstruction leads to perfusion with no
ventilation within an area of the lungs. What is this called? A shunt "<img
A man has a pulmonary embolus. What is his ventilation/perfusion ratio likely to
be? Approaching , as the pulmonary embolus is a blood flow obstruction, causing
physiologic dead space ( = blood flow obstruction) "<img src=""8471.png"">"
Respiratory physiology v/q-mismatch
Which zone of the lung is associated with wasted ventilation? Zone 1 "<img
Which zone of the lung is associated with wasted perfusion?Zone 3 "<img
A pt has hypoxia due to a suspected shunt and you begin treating with 100% oxygen.
Will the pt's condition improve? If the pt truly has a shunt, it is unlikely
that his or her condition will improve with 100% oxygen "<img src=""8471.png"">"
Respiratory physiology v/q-mismatch
A pt has hypoxia with a V/Q ratio approaching infinity. How will you treat her?
Physiologic dead space should be suspected; assuming dead space is less than
100%, oxygen should improve her condition "<img src=""8471.png"">" Respiratory
physiology v/q-mismatch
What enzyme catalyzes the conversion of carbon dioxide and water into carbonic
acid? Carbonic anhydrase "<img src=""8472.png"">" Respiratory co2-
transport physiology
In which forms is carbon dioxide transported from the tissues to the lungs? What is
the percentage of each form? 90% as bicarbonate (HCO3), 5% bound to hemoglobin as
carbaminohemoglobin (HbCO2), 5% dissolved CO2 "<img src=""8472.png"">"
Respiratory co2-transport physiology
Once inside a red blood cell, carbon dioxide combines with which molecule to
eventually become bicarbonate? Water "<img src=""8472.png"">" Respiratory
co2-transport physiology
Within a red blood cell, the carbonic acid formed from the combination of carbon
dioxide and water dissociates into what two compounds? Hydrogen and bicarbonate
ions "<img src=""8472.png"">" Respiratory co2-transport physiology
What is the fate of the bicarbonate that results from the deprotonation of carbonic
acid within a red blood cell? It leaves the red blood cell and is replaced by a
chloride molecule "<img src=""8472.png"">" Respiratory co2-transport
physiology
In the lungs, the oxygenation of hemoglobin promotes what? The dissociation of a
proton from hemoglobin and therefore a decrease in pH, which favors formation of
carbon dioxide from bicarbonate "<img src=""8472.png"">" Respiratory co2-
transport physiology
Name the effect in which oxygenation of hemoglobin in the lungs promotes H+
dissociation, causing CO2 release from RBCs. The Haldane effect "<img
src=""8472.png"">" Respiratory co2-transport physiology
A woman has lactic acidosis. How will this pH reduction in the peripheral tissues
relative to the lungs shift the oxygen dissociation curve? It will shift it to the
right, favoring dissociation of oxygen from hemoglobin "<img src=""8472.png"">"
Respiratory co2-transport physiology
In peripheral tissue, the right shift of the oxygen dissociation curve causes
oxygen unloading. What is this effect called? The Bohr effect "<img
src=""8472.png"">" Respiratory co2-transport physiology
A hiker ascends to a high altitude. What happens to his ventilation, PaO2, and
PaCO2? PaO2 and PaCO2 decrease, as ventilation is increased "<img
src=""8473.png"">" Respiratory physiology response-to-high-altitude
A pt has been living high in the mountains for years. What happens to his
erythropoietin levels? In response to high altitude, erythropoietin levels are
increased, as are hematocrit and hemoglobin "<img src=""8473.png"">"
Respiratory physiology response-to-high-altitude
A hiker ascends a mountain. What happens to his level of 2,3-bisphosphoglycerate?
In response to high altitude, the 2,3-BPG level increases "<img
What substance binds to hemoglobin so that hemoglobin releases more oxygen as a
physiologic response to high altitude? 2,3-Bisphosphoglycerate "<img
A hiker climbs up a tall mountain. Which organelle in his tissues increases in
quantity? The number of mitochondria increases in response to high altitude
"<img src=""8473.png"">" Respiratory physiology response-to-high-
altitude
A man ascends a mountain. Increased renal excretion of what substance occurs in
response? Bicarbonate, in response to respiratory alkalosis "<img
At high altitudes, renal excretion of bicarbonate increases. Why? In
compensation for the respiratory alkalosis that occurs as a result of increased
ventilation "<img src=""8473.png"">" Respiratory physiology response-to-high-
altitude
The increased renal excretion of bicarbonate that is seen in response to high
altitude can be augmented by using which drug? Acetazolamide "<img
A man decides to live in the mountains for several years. What condition develops
in response to chronic hypoxic pulmonary vasoconstriction? Right ventricular
hypertrophy "<img src=""8473.png"">" Respiratory physiology response-to-high-
altitude
A man undergoes an exercise test. What happens to carbon dioxide production in his
muscles, oxygen consumption, and rate of ventilation? They all increase "<img
src=""8474.png"">" Respiratory physiology response-to-exercise
A man undergoes an exercise test. What happens to the ventilation/perfusion ratio?
It becomes more uniform from apex to base "<img src=""8474.png"">"
Respiratory physiology response-to-exercise
A woman undergoes an exercise test. What happens to pulmonary blood flow? It
increases due to increased cardiac output "<img src=""8474.png"">" Respiratory
physiology response-to-exercise
A personal trainer performs strenuous exercise. How does the pH of the body change?
The pH decreases during strenuous exercise due to lactic acidosis "<img
What happens to PaO2 and PaCO2 in response to exercise? No change "<img
In response to exercise, what happens to the venous CO2 and venous O2 content?
Venous CO2 increases, and venous O2 decreases "<img src=""8474.png"">"
Respiratory physiology response-to-exercise
A pt is diagnosed with rhinosinusitis. Which sinuses are typically affected?
Maxillary sinuses "<img src=""8475.png"">" Pathology Respiratory
rhinosinusitis
A 53-y/o man has pain in his maxillary sinuses from obstruction of sinus drainage.
What is the most common acute cause of this condition? Viral URIs are the most
common cause "<img src=""8475.png"">" Pathology Respiratory
rhinosinusitis
A pt has epistaxis. What is the most common location of the bleeding? The anterior
segment of the nostril, also known as the Kiesselbach plexus "<img
src=""8476.png"">" Pathology Respiratory epistaxis
A pt presents with extensive nose bleeding. A posterior segment hemorrhage is
suspected. Which artery is often involved? The sphenopalatine artery (branch
of the maxillary artery) "<img src=""8476.png"">" Pathology Respiratory
epistaxis
What is field cancerization? The phenomenon of a carcinogen causing damage to a
large mucosal area, resulting in multiple tumors "<img src=""8477.png"">"
Pathology Respiratory head-and-neck-cancer
What type of cancer most often occurs in the head and neck region? Squamous
cell carcinoma "<img src=""8477.png"">" Pathology Respiratory head-and-
neck-cancer
List four risk factors for head and neck cancer. Tobacco, alcohol, HPV-16
(oropharyngeal), EBV (nasopharyngeal) "<img src=""8477.png"">" Pathology
Respiratory head-and-neck-cancer
Which three factors that promote blood coagulation are known as the Virchow triad?
Stasis, Hypercoagulability, and Endothelial damage (SHE) "<img
src=""8478.png"">" Pathology Respiratory deep-venous-thrombosis
A pt diagnosed with factor V Leiden deficiency is at risk of developing DVT. Which
element of the Virchow triad is affected? Hypercoagulability "<img
A pt presents with dyspnea and tachycardia. Chest CT shows a pulmonary embolus.
Where did the embolus most likely originate? The deep veins of the leg "<img
Describe the Homan sign. In the Homan sign, dorsiflexion of the foot results
in a tender calf muscle because of the presence of a deep venous thrombosis "<img
A pt presents with a red, swollen leg. Venous ultrasonography confirms a deep
venous thrombosis. What is your initial treatment of choice? Unfractionated
heparin or heparins of low molecular weight "<img src=""8478.png"">"
Pathology Respiratory deep-venous-thrombosis
A pt with recurrent deep venous thromboses requires long-term anticoagulation.
Which medications may be prescribed? Oral anticoagulants (eg, warfarin,
rivaroxaban) "<img src=""8478.png"">" Pathology Respiratory deep-venous-
thrombosis
How does endothelial damage lead to the formation of a clot? Exposed collagen
triggers the clotting cascade "<img src=""8478.png"">" Pathology Respiratory
deep-venous-thrombosis
A pt has sudden chest pain and difficulty breathing. If he is diagnosed with a
pulmonary embolus, what signs will you discover? Sudden-onset dyspnea, chest
pain, tachypnea, tachycardia "<img src=""8479.png"">" Pathology Respiratory
pulmonary-emboli
Name the types of emboli to the lungs. An embolus moves like a FAT BAT (Fat,
Air, Thrombus, Bacteria, Amniotic fluid, Tumor) "<img src=""8479.png"">"
Pathology Respiratory pulmonary-emboli
A pt presents with sudden-onset dyspnea 1 hour after a femur fracture occurred. He
is found to have a V/Q mismatch. What is your diagnosis? Fat embolus "<img
src=""8479.png"">" Pathology Respiratory pulmonary-emboli
A pt presents with sudden-onset dyspnea, altered mental status, and a petechial
rash after liposuction. What is the likely cause? Fat emboli (The classic
presenting triad is hypoxemia, neurologic abnormalities, and petechial rash.)
"<img src=""8479.png"">" Pathology Respiratory pulmonary-emboli
A postpartum woman has a suspected amniotic fluid embolus. This could lead to which
dangerous hematologic condition? Disseminated intravascular coagulation "<img
A diver who ascended too quickly complains of joint pain and shortness of breath.
How would you treat this pt? Administration of hyperbaric O2 (The pt has an air
embolus: nitrogen bubbles can precipitate in divers who ascend too quickly.) "<img
A pt presents with sudden chest pain, tachypnea, and dyspnea. What is the imaging
test of choice? What is being sought? Computed tomography pulmonary
angiography; filling defects are being sought "<img src=""8479.png"">"
Pathology Respiratory pulmonary-emboli
Your bed-bound pt has developed sudden-onset tachypnea and tachycardia. You suspect
a PE. What diagnostic test do you order? CT pulmonary angiography, the imaging
test of choice to detect a filling defect "<img src=""8479.png"">" Pathology
Respiratory pulmonary-emboli
What is the definition of obstructive lung disease? How does it affect lung
volumes? Obstruction to flow leading to air trapping & the collapse of airways
at high volumes; RV increases due to air trapping, & FVC decreases "<img
src=""8480.png"">" Pathology Respiratory obstructive-lung-diseases
Does residual volume increase or decrease in obstructive lung disease? How about
functional vital capacity? RV increases; FVC decreases "<img src=""8480.png"">"
Pathology Respiratory obstructive-lung-diseases
What is the hallmark pulmonary function test finding in pts with obstructive lung
disease? Decreased ratio of FEV1 to FVC (The decrease in FEV1 is greater than
FVC.) "<img src=""8480.png"">" Pathology Respiratory obstructive-lung-diseases
A pt with chronic, hypoxic vasoconstriction can have what cardiac manifestation?
Cor pulmonale "<img src=""8480.png"">" Pathology Respiratory
obstructive-lung-diseases
List four types of obstructive lung disease. Chronic bronchitis, emphysema,
asthma, and bronchiectasis "<img src=""8480.png"">" Pathology Respiratory
A pt has had a productive cough for 5 months over the course of 3 years. What
findings do you expect on pulmonary function tests? A decreased ratio of FEV1 to
FVC (The pt has classic chronic bronchitis.) "<img src=""8480.png"">"
A man has had a productive cough for 5 months over 2 years w/wheezing, crackles, &
cyanosis. What histologic changes are seen on lung biopsy? Hyperplasia of the
mucus-secreting glands in the bronchi (The pt has chronic bronchitis.) "<img
What is the Reid index? Thickness of gland layer/total thickness of bronchial wall;
a value over 50% is indicative of chronic bronchitis "<img src=""8480.png"">"
How is the Reid index calculated? Reid index = gland layer thickness/total
bronchial wall thickness "<img src=""8480.png"">" Pathology Respiratory
A pt with chronic bronchitis presents to clinic. What clinical findings are
auscultated in the lungs of this pt? Usually wheezing and crackles "<img
A pt with chronic bronchitis presents to clinic. What visible skin finding may be
noted on exam? Cyanosis (early-onset hypoxemia from shunting) "<img
A pt with chronic bronchitis presents to clinic. What causes early-onset hypoxemia
in such pts? Shunting "<img src=""8480.png"">" Pathology Respiratory
A woman has had 6 months of productive cough in 3 years, wheezing, crackles, and
cyanosis. What other findings would you expect in this pt? "Late-onset dyspnea,
secondary polycythemia, and hypercapnia (This pt has chronic bronchitis, as she is
a ""blue bloater."")" "<img src=""8480.png"">" Pathology Respiratory
In emphysemic lungs, what happens to compliance, diffusing capacity for CO, and
recoil? Compliance increases, diffusing capacity for CO decreases, and recoil
decreases "<img src=""8480.png"">" Pathology Respiratory obstructive-lung-
diseases
How will breathing through pursed lips help a pt with emphysema? This increases
airway pressure, which helps prevent airway collapse "<img src=""8480.png"">"
Name the two types of emphysema. Centriacinar and panacinar "<img
A pt is diagnosed with 1-antitrypsin deficiency. With which pattern of alveolar
damage is this condition associated? Panacinar (The pt has emphysema.) "<img
In emphysema, the loss of elastic fibers and increased lung compliance result from
increased activity of which enzyme? Elastase "<img src=""8480.png"">"
In pts with asthma, there is hyperresponsiveness of what lung segment? The bronchi
"<img src=""8480.png"">" Pathology Respiratory obstructive-lung-diseases
How is asthma differentiated from other obstructive lung diseases?
Bronchoconstriction is reversible "<img src=""8480.png"">" Pathology
Respiratory obstructive-lung-diseases
A man with cough, tachypnea, and wheezing has a drop in BP >10 mm Hg on
inspiration. What pathologic findings do you expect on lung biopsy? Curschmann
spirals, smooth muscle hypertrophy, Charcot-Leyden crystals (This is asthma, which
can exhibit pulsus paradoxus when severe.) "<img src=""8480.png"">"
What are Charcot-Leyden crystals? Eosinophilic, hexagonal, double-pointed needle-
shaped crystals, formed after the breakdown of eosinophils in sputum in asthma
Name some triggers for bronchial hyperresponsiveness in pts with asthma.
Allergens, viral URIs, stress "<img src=""8480.png"">" Pathology
Respiratory obstructive-lung-diseases
A child with cough, wheezing, dyspnea, and tachypnea has pulsus paradoxus on exam.
What is a test for his condition? Methacholine challenge (The pt has asthma.)
What finding is commonly noted on pulmonary function tests of pts with asthma?
Decreased inspiratory-expiratory ratio "<img src=""8480.png"">"
You measure the blood pressure of a pt having a severe asthma attack. What
phenomenon might you observe with inspiration? Pulsus paradoxus "<img
What is bronchiectasis? Chronic necrotizing infection of bronchi "<img
Bronchiectasis, or chronic necrotizing infection of the bronchi, can lead to what?
Permanently dilated bronchi, multiple infections, purulent sputum,
hemoptysis, digital clubbing "<img src=""8480.png"">" Pathology Respiratory
A pt with bronchiectasis feels ill and has a productive cough. His sputum is most
likely to consist of what? Blood and pus "<img src=""8480.png"">"
Recurrent infections, bronchial obstruction, and poor ciliary motility may lead to
what lung manifestation? Bronchiectasis "<img src=""8480.png"">"
Which two genetic diseases are associated with bronchiectasis? Cystic fibrosis
and Kartagener syndrome "<img src=""8480.png"">" Pathology Respiratory
A pt has Kartagener syndrome leading to permanently dilated airways. Which fungal
pulmonary infection is he prone to developing? Allergic bronchopulmonary
aspergillosis (He likely has bronchiectasis.) "<img src=""8480.png"">"
Which two lung volumes are typically decreased in pts with restrictive lung
disease? Functional vital capacity and total lung capacity "<img
src=""8481.png"">" Pathology Respiratory restrictive-lung-disease
Pts with restrictive lung disease typically have an FEV1/FVC ratio with what value?
80% or greater "<img src=""8481.png"">" Pathology Respiratory
restrictive-lung-disease
What are the two general types of restrictive lung disease?Poor breathing mechanics
and interstitial lung diseases "<img src=""8481.png"">" Pathology
Respiratory restrictive-lung-disease
Extrapulmonary causes of restrictive lung disease are generally the result of what?
Poor breathing mechanics from muscular (eg, polio, myasthenia gravis) or
structural (eg, scoliosis, morbid obesity) dysfunction "<img src=""8481.png"">"
Pathology Respiratory restrictive-lung-disease
How does the A-a gradient vary between restrictive lung disease due to poor
mechanics and interstitial lung disease? The A-a gradient is normal in poor
breathing mechanics and elevated in interstitial lung disease "<img
Which infectious disease can cause poor muscular effort and lead to extrapulmonary
restrictive lung disease and peripheral hypoventilation? Polio "<img
What disease of the neuromuscular junction can cause poor muscular effort and
thereby lead to extrapulmonary restrictive lung disease? Myasthenia gravis "<img
A 32-y/o woman with neuromuscular disease, ptosis, diplopia, and muscle weakness at
the day's end may have what pulmonary manifestation? Restrictive lung disease from
poor muscular effort (The woman likely has myasthenia gravis.) "<img
Other than scoliosis and muscle diseases, what condition can lead to extrapulmonary
restrictive lung disease? Morbid obesity "<img src=""8481.png"">"
Pulmonary causes of restrictive lung disease are generally the result of what
category of diseases? Interstitial lung diseases "<img src=""8481.png"">"
What happens to the pulmonary diffusion capacity in ARDS? It decreases "<img
A premature infant is diagnosed with hyaline membrane lung disease. What type of
restrictive lung disease is this? Interstitial type (This is neonatal respiratory
distress syndrome [NRDS], also known as hyaline membrane disease.) "<img
Which category of interstitial lung diseases has a clear association with an
environmental exposure? Pneumoconioses (eg, anthracosis, silicosis, asbestosis)
"<img src=""8481.png"">" Pathology Respiratory restrictive-lung-disease
A pt has bilateral hilar lymphadenopathy, noncaseating granulomas, and
hypercalcemia. What interstitial lung disease does she have? Sarcoidosis "<img
A pt has an autoimmune disease with hemoptysis and hematuria with renal failure.
What kind of lung disease does this pt have? Restrictive lung disease
(Goodpasture syndrome) "<img src=""8481.png"">" Pathology Respiratory
Name four drugs that can cause interstitial lung disease. Bleomycin, busulfan,
methotrexate, and amiodarone "<img src=""8481.png"">" Pathology Respiratory
Which granulomatous small-to-medium vessel vasculitis causes both
glomerulonephritis and pulmonary dysfunction? Granulomatosis with polyangiitis
(Wegener granulomatosis) "<img src=""8481.png"">" Pathology Respiratory
What disease can cause restrictive lung disease due to eosinophilic granulomas in
the lungs? Langerhans cell histiocytosis "<img src=""8481.png"">" Pathology
Respiratory restrictive-lung-disease
A pt has a cough and dyspnea at work that resolves when he leaves. What restrictive
pulmonary process is likely causing his symptoms? Hypersensitivity pneumonitis
A pt has progressive dyspnea. Serum ACE and Ca2+ levels are elevated. What will a
chest x-ray show? Bilateral hilar lymphadenopathy (This is likely sarcoidosis.)
A pt with COPD has PFTs performed. What would you expect his TLC, FRC, and RV to be
compared with normal values? In obstructive lung disease, TLC, FRC, and RV are all
increased "<img src=""8482.png"">" Pathology Respiratory flow-volume-loops
A pt with silicosis has PFTs performed. What would you expect his FEV1 and FVC to
be compared with normal values? In restrictive lung disease, both FEV1 and FVC
are reduced "<img src=""8482.png"">" Pathology Respiratory flow-volume-loops
A bird keeper develops dyspnea, cough, chest tightness, and a headache. What is the
pathophysiology of his disorder? A mixed III/IV hypersensitivity to
environmental antigens (common in farmers and those around birds) (This is
hypersensitivity pneumonitis.) "<img src=""8483.png"">" Pathology
Respiratory hypersensitivity-pneumonitis
Silicosis, coal workers' pneumoconiosis, and asbestosis are associated with
increased risk of what other conditions? Cor pulmonale, Caplan syndrome (the
combination of pneumoconiosis and rheumatoid arthritis), and cancer "<img
src=""8484.png"">" Pathology Respiratory pneumoconioses
What occupations are associated with exposure to asbestos? Shipbuilding, roofing,
and plumbing "<img src=""8484.png"">" Pathology Respiratory
pneumoconioses
Which lobes of the lungs are most affected by asbestosis? What about silicosis?
Asbestos affects lower lobes; silicosis affects upper lobes"<img
A pt presents with shortness of breath and a cough. He works for a local aerospace
manufacturing plant. Likely diagnosis? Berylliosis, as working in the aerospace
or manufacturing industries increases one's risk for beryllium exposure "<img
A pt presents with shortness of breath and a cough. He works for a local aerospace
manufacturing plant. Treatment? Steroids; granulomas arise in berylliosis, and
these may respond to steroids "<img src=""8484.png"">" Pathology Respiratory
pneumoconioses
Which lobes of the lungs are affected in a pt with berylliosis? Upper lobes "<img
Explain the pathogenesis of coal workers' pneumoconiosis (also known as black lung
disease). Prolonged exposure to coal dust results in deposition of carbon in
macrophages, which leads to inflammation and fibrosis in the lungs "<img
Which lobes of the lungs are most affected by coal miners' disease? Upper lobes
"<img src=""8484.png"">" Pathology Respiratory pneumoconioses
A pt is diagnosed with anthracosis. How does this differ from coal workers'
pneumoconiosis? Anthracosis is the result of exposure to sooty air in the city
versus coal dust in coal workers' pneumoconiosis (It is asymptomatic.) "<img
Pts with silicosis typically work in which three fields? Foundries, sandblasting,
and mining "<img src=""8484.png"">" Pathology Respiratory pneumoconioses
A foundry worker has dyspnea and cough. Chest x-ray shows calcification of his
hilar lymph nodes. What cell type is responsible? Macrophages, which respond to
silica exposure by releasing fibrogenic factors, leading to fibrosis of the lungs
(The pt has silicosis.) "<img src=""8484.png"">" Pathology Respiratory
pneumoconioses
How does silicosis increase the risk of susceptibility to tuberculosis? Silica
impairs macrophage phagolysosomes, affecting their ability to effectively kill
microbes "<img src=""8484.png"">" Pathology Respiratory pneumoconioses
A sandblaster has eggshell calcification visible on chest x-ray. What disorders
does this pt have an increased risk of developing? TB and bronchogenic carcinoma
(This pt has silicosis.) "<img src=""8484.png"">" Pathology Respiratory
pneumoconioses
A foundry worker has dyspnea and cough. Chest x-ray shows hilar lymph node
calcifications. He has an increased risk for what cancer type? Bronchogenic
carcinoma "<img src=""8484.png"">" Pathology Respiratory pneumoconioses
Which lobes of the lung are most affected by silicosis? Upper lobes "<img
What is a mnemonic that helps you remember which pneumoconiosis affects the upper
and lower lobes of the lungs? Asbestos: from roof (insulation) but affects base
(lower lobes); silica and coal: from base (earth) but affect roof (upper lobes)
"<img src=""8484.png"">" Pathology Respiratory pneumoconioses
A shipbuilder has calcified supradiaphragmatic and pleural plaques. What study
could be done to confirm the diagnosis? Bronchoalveolar lavage with Prussian blue
stain, which will demonstrate fusiform rods "<img src=""8484.png"">"
Pathology Respiratory pneumoconioses
A pt hospitalized for acute pancreatitis suddenly has difficulty breathing.
PaO2/FiO2 ratio is decreased. Diagnosis? Acute respiratory distress syndrome "<img
src=""8485.png"">" Pathology Respiratory acute-respiratory-distress-syndrome
Name eight conditions known to cause acute respiratory distress syndrome.
Sepsis, Pancreatitis, Pneumonia, Aspiration, uRemia, Trauma, Amniotic fluid
embolism, Shock (SPARTAS) "<img src=""8485.png"">" Pathology Respiratory
acute-respiratory-distress-syndrome
Despite many etiologies, what pathophysiology is seen in all cases of acute
respiratory distress syndrome? Alveolar damage leading to capillary
permeability, fluid leakage into alveoli, & pulmonary edema, resulting in thickened
(hyaline) membranes "<img src=""8485.png"">" Pathology Respiratory acute-
How does endothelial damage lead to the development of ARDS? It causes
increased capillary permeability to protein-rich fluid "<img src=""8485.png"">"
Pathology Respiratory acute-respiratory-distress-syndrome
A pt is diagnosed with dyspnea characterized by a decreased PaO2/FiO2 ratio.
Management? Mechanical ventilation with low tidal volumes and treatment of the
underlying cause (trauma, sepsis, uremia) (This is ARDS.) "<img src=""8485.png"">"
Name three molecular mechanisms that contribute to the initial damage to alveoli in
acute respiratory distress syndrome. Neutrophilic toxins, activation of the
coagulation cascade, and oxygen-derived free radicals "<img src=""8485.png"">"
An alcoholic man with acute pancreatitis and oxygen desaturation is having trouble
breathing. What put him at risk for this disorder? Pancreatitis, which triggers
acute respiratory distress syndrome "<img src=""8485.png"">" Pathology
Respiratory acute-respiratory-distress-syndrome
What obstetric complication can result in adult respiratory distress syndrome?
Amniotic fluid embolism "<img src=""8485.png"">" Pathology Respiratory
acute-respiratory-distress-syndrome
A man has daytime sleepiness, which is attributed to sleep apnea. What would you
expect his daytime PaO2 to be? Daytime PaO2 would be normal "<img
src=""8486.png"">" Pathology Respiratory sleep-apnea
A pt is diagnosed with sleep apnea. What complications may arise from the hypoxia
he experiences at night? Arrhythmias (atrial fibrillation or flutter),
systemic or pulmonary hypertension, sudden death "<img src=""8486.png"">"
Pathology Respiratory sleep-apnea
What is the difference between central and obstructive sleep apnea? Central
apnea is due to a lack of CNS-derived respiratory effort, and obstructive apnea is
due to a mechanical airway obstruction "<img src=""8486.png"">" Pathology
Respiratory sleep-apnea
An obese man complains of chronic fatigue. His wife says he is an especially loud
snorer. What treatments can you recommend? Weight loss, continuous positive
airway pressure, surgery (He has obstructive sleep apnea.) "<img src=""8486.png"">"
A child is diagnosed with obstructive sleep apnea. With what anatomic abnormality
is this associated in children? In adults? Adenotonsillar hypertrophy in
children; excess parapharyngeal tissue in adults "<img src=""8486.png"">"
Name five conditions potentially associated with sleep apnea. Obesity, loud
snoring, pulmonary/systemic hypertension, arrhythmias, and possible sudden death
"<img src=""8486.png"">" Pathology Respiratory sleep-apnea
An obese pt has daytime somnolence, disrupted sleep, and loud snoring. CBC shows
elevated hematocrit. Why is his hematocrit high? Increased erythropoietin
secondary to hypoxia "<img src=""8486.png"">" Pathology Respiratory sleep-
apnea
An obese pt snores and has disrupted sleep. His PaO2 is reduced and PaCO2 is
increased. Diagnosis? Obesity hypoventilation syndrome; he is retaining PaCO2
"<img src=""8486.png"">" Pathology Respiratory sleep-apnea
What is the normal pulmonary arterial pressure? 10&8211;14 mm Hg "<img
src=""8487.png"">" Pathology Respiratory pulmonary-hypertension
What is the cutoff value for pulmonary hypertension? 25 mm Hg during rest "<img
What three pathologic changes in the vasculature are caused by pulmonary
hypertension? Medial hypertrophy, arteriosclerosis, and intimal fibrosis of the
pulmonary arteries "<img src=""8487.png"">" Pathology Respiratory
pulmonary-hypertension
A man is diagnosed with pulmonary hypertension. What undesirable outcome is
possible when he finds himself in severe respiratory distress? Cyanosis and RVH,
followed by death from decompensated cor pulmonale "<img src=""8487.png"">"
Pathology Respiratory pulmonary-hypertension
A pt with pulmonary hypertension is lost to follow-up. Is he at risk for sequelae
from his untreated pulmonary hypertension? Yes (Sequelae are severe
respiratory distress causing RVH and cyanosis, resulting in decompensated cor
pulmonale and death.) "<img src=""8487.png"">" Pathology Respiratory
Name the five classification groups of pulmonary hypertension (PH). Pulmonary
arterial hypertension, chronic thromboembolic PH, PH from left heart disease, PH
from lung disease/hypoxia, and multifactorial "<img src=""8487.png"">"
Hereditary pulmonary arterial hypertension is caused by what? An inactivating
mutation in the BMPR2 gene, which normally inhibits vascular smooth muscle
proliferation "<img src=""8487.png"">" Pathology Respiratory pulmonary-
hypertension
What is the prognosis for a pt diagnosed with heritable pulmonary arterial
hypertension? Poor "<img src=""8487.png"">" Pathology Respiratory
Besides idiopathic and heritable pulmonary arterial hypertension, what are some
other causes of PAH? Congenital heart disease, HIV, schistosomiasis, drugs
(cocaine), connective tissue disease, portal hypertension "<img src=""8487.png"">"
A pt with narcolepsy is prescribed amphetamines. What pulmonary side effect would
you expect? Which other drug has this effect? Pulmonary arterial hypertension;
cocaine "<img src=""8487.png"">" Pathology Respiratory pulmonary-
hypertension
What are some of the potential causes of secondary pulmonary hypertension? COPD,
systolic/diastolic issues, mitral stenosis, recurrent microthrombi, sleep apnea,
high altitude, hematologic/metabolic/systemic illness "<img src=""8487.png"">"
Which heart conditions can lead to pulmonary hypertension? Systolic or diastolic
dysfunction, valvular disease (eg, mitral stenosis) "<img src=""8487.png"">"
A pt has mitral stenosis. How might this pathology ultimately cause pulmonary
hypertension? Increased resistance to flow in the left heart causes backup of
pressure from the left atrium into the pulmonary vasculature "<img
Name primary conditions of the lungs that lead to pulmonary hypertension. Lung
parenchyma destruction (eg., COPD), hypoxemic vasoconstriction (eg, living in areas
at high altitudes, sleep apnea) "<img src=""8487.png"">" Pathology
Respiratory pulmonary-hypertension
A pt has chronic obstructive pulmonary disease (COPD). How might this pathology
ultimately lead to pulmonary hypertension? By the destruction of lung
parenchyma and subsequent vasoconstriction due to hypoxia "<img src=""8487.png"">"
How does obstructive sleep apnea or living at high altitudes cause pulmonary
hypertension? Obstructive sleep apnea and living at high altitudes cause
hypoxia, which in turn causes pulmonary vasoconstriction "<img src=""8487.png"">"
A pt with cancer has recurrent microthrombi and is repeatedly hospitalized. Could
this cause him to develop pulmonary hypertension? Yes; pressures increase
because the emboli decrease the total cross-sectional area of the pulmonary
vascular bed "<img src=""8487.png"">" Pathology Respiratory pulmonary-
hypertension
A pt has decreased breath sounds on the right, dullness to percussion, and tracheal
deviation to the right. What does he have? Atelectasis (bronchial obstruction)
on the right "<img src=""8488.png"">" Pathology Respiratory lung
physical-findings
A pt has dyspnea, decreased right breath sounds, dullness to percussion, and
decreased tactile fremitus. What is the likely diagnosis? Pleural effusion "<img
src=""8488.png"">" Pathology Respiratory lungphysical-findings
A pt has crackles on the right with dullness to percussion and no tactile fremitus.
Will there be tracheal deviation? Yes; there will be deviation away from the side
of the lesion if the effusion is large (This is a pleural effusion on the right.)
"<img src=""8488.png"">" Pathology Respiratory lungphysical-findings
A postoperative pt refuses to use his incentive spirometer. What physical exam
findings might you expect? Decreased breath sounds, dullness to percussion,
decreased fremitus, tracheal deviation toward the side of the lesion "<img
A pt has dyspnea, hyperresonance, decreased breath sounds on the left, and tactile
fremitus. Is there tracheal deviation? There is no tracheal deviation, as this
pt has a simple pneumothorax "<img src=""8488.png"">" Pathology Respiratory
lungphysical-findings
A man has dyspnea, absent right breath sounds, hyperresonance, and tracheal
deviation to the left. How will fremitus be affected? Fremitus will decrease. (This
pt has a tension pneumothorax.) "<img src=""8488.png"">" Pathology
Respiratory lungphysical-findings
A pt has fever, dyspnea, right bronchial breath sounds, dullness to percussion, and
increased tactile fremitus. Likely diagnosis? Lobar pneumonia "<img
A pt has shortness of breath, severe HF, bronchial breath sounds, dullness to
percussion at bases, and increased fremitus. Diagnosis? Pulmonary edema "<img
A pt has fever, bronchial breath sounds, dullness to percussion, and increased
fremitus. Is there tracheal deviation? No; there is no tracheal deviation, as
with pulmonary edema and simple pneumothorax. (This pt has lobar pneumonia.) "<img
Toward which side would you expect the trachea to deviate in both tension
pneumothorax and pleural effusion? Toward the side opposite the lesion (Note that
lesion must be large for tracheal deviation to occur in pleural effusion.) "<img
Which way will the trachea deviate in atelectasis? Toward the side of the lesion
"<img src=""8488.png"">" Pathology Respiratory lungphysical-findings
How is the protein content in a transudate different from that in an exudate?
A transudate contains less protein than an exudate "<img src=""8489.png"">"
Pathology Respiratory pleural-effusions
Name the three types of pleural effusions. Transudative, exudative, and
lymphatic "<img src=""8489.png"">" Pathology Respiratory pleural-effusions
What changes to the hydrostatic and oncotic pressures result in a transudative
pleural effusion? Increased hydrostatic pressure and decreased oncotic pressure
"<img src=""8489.png"">" Pathology Respiratory pleural-effusions
Name four causes of exudative pulmonary effusions. Malignancy, pneumonia,
collagen vascular disease, and states of increased vascular permeability (trauma)
"<img src=""8489.png"">" Pathology Respiratory pleural-effusions
What makes an exudate cloudy? Exudates are cloudy because of their higher protein
content "<img src=""8489.png"">" Pathology Respiratory pleural-effusions
A pt develops a pleural effusion secondary to trauma. Is this more likely to be
transudative or exudative? Exudative (Trauma is a state of increased vascular
permeability.) "<img src=""8489.png"">" Pathology Respiratory pleural-
effusions
A pt with an exudative pleural effusion requires immediate drainage of the
effusion. Why is this the case? Exudates have a high infection risk "<img
src=""8489.png"">" Pathology Respiratory pleural-effusions
A woman has a pleural effusion with a high triglyceride level and a milky
appearance. What type of effusion is this? Lymphatic "<img src=""8489.png"">"
Pathology Respiratory pleural-effusions
What causes lymphatic effusions (chylothorax)? Thoracic duct injury from trauma or
malignancy "<img src=""8489.png"">" Pathology Respiratory pleural-effusions
Name four types of pneumothorax. Primary spontaneous, secondary spontaneous,
traumatic, and tension "<img src=""8490.png"">" Pathology Respiratory
pneumothorax
A tall young man has unilateral chest pain, dyspnea, and ruptured apical blebs.
Which way is his trachea deviated? Toward the affected lung (This is a spontaneous
pneumothorax.) "<img src=""8490.png"">" Pathology Respiratory pneumothorax
A tall, thin 15-y/o boy has chest pain and dyspnea. There is decreased fremitus and
hyperresonance on the left chest. What caused this? Rupture of an apical bleb or
cyst, which causes primary spontaneous pneumothorax in tall, thin boys and young
men "<img src=""8490.png"">" Pathology Respiratory pneumothorax
Name two causes of secondary spontaneous pneumothorax. Lung disease (eg,
emphysema, infections) and barotrauma from use of high pressures in mechanical
ventilation "<img src=""8490.png"">" Pathology Respiratory pneumothorax
A pt is receiving mechanical ventilation. He complains of unilateral chest pain and
dyspnea. What happened? He likely developed a pneumothorax caused by the high
pressure of the ventilator "<img src=""8490.png"">" Pathology Respiratory
pneumothorax
A man presents after falling from the top of a roof. He has chest pain, dyspnea,
diminished breath sounds, and tactile fremitus. Diagnosis? This is likely a
traumatic pneumothorax from blunt trauma (also seen in penetrating trauma [eg,
gunshot wounds]) "<img src=""8490.png"">" Pathology Respiratory pneumothorax
A pt is involved in a motor vehicle crash and has a right-sided tension
pneumothorax. How is this condition treated? Immediate needle decompression and
chest tube placement "<img src=""8490.png"">" Pathology Respiratory
pneumothorax
List three bacterial causes of interstitial pneumonia. Mycoplasma, Legionella,
and Chlamydia "<img src=""8491.png"">" Pathology Respiratory pneumonia
Which type of pneumonia is most often caused by viruses? Interstitial (atypical)
pneumonia "<img src=""8491.png"">" Pathology Respiratory pneumonia
Which category of pneumonia typically has a less acute presentation? Interstitial
pneumonia (walking pneumonia) "<img src=""8491.png"">" Pathology Respiratory
pneumonia
List four viruses that commonly cause interstitial pneumonia. Respiratory
syncytial virus, influenza virus, cytomegalovirus, and adenovirus "<img
src=""8491.png"">" Pathology Respiratory pneumonia
Interstitial pneumonia characteristically shows diffuse, patchy inflammation that
is localized to which areas of the lung? Interstitial areas at the alveolar walls
"<img src=""8491.png"">" Pathology Respiratory pneumonia
The distribution of interstitial pneumonia characteristically involves how many
lobes? Usually more than one "<img src=""8491.png"">" Pathology
Respiratory pneumonia
What is a lung abscess? A localized collection of pus within the lung parenchyma
"<img src=""8492.png"">" Pathology Respiratory lung-abscess
Name two conditions that can predispose a pt to lung abscess formation.
Bronchial obstruction (eg, tumor) or oropharyngeal content aspiration (eg,
loss of consciousness during seizures or heavy alcohol use)"<img src=""8492.png"">"
Pathology Respiratory lung-abscess
What finding on chest x-ray is suggestive of a lung abscess? Air-fluid levels
"<img src=""8492.png"">" Pathology Respiratory lung-abscess
A roofer who smokes is noted to have hemorrhagic pleural effusions and pleural
thickening. Is his smoking to blame? Not likely, as this is mesothelioma
secondary to asbestosis, for which smoking is not a risk factor "<img
src=""8493.png"">" Pathology Respiratory mesothelioma
A roofer is noted to have pleural thickening, and a biopsy of the lesion is
performed. What would it show on histologic exam? Psammoma bodies (This pt has
mesothelioma.) "<img src=""8493.png"">" Pathology Respiratory mesothelioma
A plumber has chest pain and dyspnea. Histologic exam shows psammoma bodies. What
kind of pleural effusion is associated with his condition? Exudative (This pt has
mesothelioma from asbestos exposure.) "<img src=""8493.png"">" Pathology
Respiratory mesothelioma
CT scan of the chest in a pt with dyspnea shows an apical lung mass. What
neurologic structures are at risk of being compressed? The cervical sympathetic
plexus (This is a Pancoast tumor.) "<img src=""8494.png"">" Pathology
Respiratory pancoast-tumor-(superior-sulcus-tumor)
When a Pancoast tumor disrupts the cervical sympathetic plexus, it can result in
what condition? What findings will be seen? Horner syndrome; ipsilateral
ptosis, miosis, and anhidrosis will be seen "<img src=""8494.png"">"
Pathology Respiratory pancoast-tumor-(superior-sulcus-tumor)
A pt has cough, weight loss, and malaise. Exam shows ipsilateral eyelid droop,
miosis, and no sweating. What will a chest x-ray show? Given the history, a
chest x-ray will likely show an apical opacity characteristic of a Pancoast tumor
"<img src=""8494.png"">" Pathology Respiratory pancoast-tumor-(superior-
sulcus-tumor)
A man is diagnosed with a Pancoast tumor. In addition to Horner syndrome, what
findings may you observe? Sensorimotor deficits, hoarseness, and/or obstruction
of the superior vena cava leading to SVC syndrome "<img src=""8494.png"">"
Pathology Respiratory pancoast-tumor-(superior-sulcus-tumor)
Superior vena cava syndrome is most likely caused by what? Neoplasms and thromboses
from indwelling catheters "<img src=""8495.png"">" Pathology Respiratory
superior-vena-cava-syndrome
A pt with superior vena cava syndrome develops confusion, loss of sensation, and
hemiparesis. What has likely occurred? Severe elevated cranial pressure
increased aneurysm formation and led to rupture of intracranial arteries "<img
src=""8495.png"">" Pathology Respiratory superior-vena-cava-syndrome
Superior vena cava syndrome puts a pt at risk for rupture of which arteries?
Intracranial arteries, as a result of increased intracranial pressure "<img
src=""8495.png"">" Pathology Respiratory superior-vena-cava-syndrome
A man with a left lung mass has headaches and dizziness. Brain angiography shows a
berry aneurysm. What major vessel is blocked by the mass? The superior vena cava
(This is SVC syndrome.) "<img src=""8495.png"">" Pathology Respiratory
superior-vena-cava-syndrome
What type of cancer is the leading cause of cancer death? Lung cancer "<img
src=""8496.png"">" Pathology Respiratory lung-cancer
A pt with a history of smoking has a cough and hemoptysis. Exam shows decreased
breath sounds and wheezing. What do you suspect? Lung cancer (A common
clinical presentation is cough, bronchial obstruction, hemoptysis, and wheezing.)
"<img src=""8496.png"">" Pathology Respiratory lung-cancer
What are common presenting radiologic findings in pts with lung cancer?
Pneumonic coin lesions on chest x-ray and noncalcified nodules on CT "<img
Name four common sites of metastases from primary lung cancer. Brain, bone,
liver, and adrenals "<img src=""8496.png"">" Pathology Respiratory lung-
cancer
In association with a primary lung cancer, what finding suggests bone metastases?
Pathologic fractures "<img src=""8496.png"">" Pathology Respiratory
lung-cancer
A pt is diagnosed with the leading cause of cancer death. What two findings on
physical exam might suggest liver metastases? Jaundice and hepatomegaly (This is
lung cancer.) "<img src=""8496.png"">" Pathology Respiratory lung-cancer
Is a lung mass more likely to be from metastases or a primary neoplasm?
Metastases "<img src=""8496.png"">" Pathology Respiratory lung-cancer
A pt is found to have multiple pulmonary tumors. If these are metastatic, name the
most common sites of origin. Breast, colon, prostate, bladder "<img
What are the common complications of lung cancer? SVC syndrome, Pancoast tumor,
Horner syndrome, Endocrine (paraneoplastic), Recurrent laryngeal nerve compression,
Effusions (SPHERE) "<img src=""8496.png"">" Pathology Respiratory lung-
cancer
A pt with lung cancer experiences unexpected voice changes. How is her voice
changing, and why might this be happening? It is becoming hoarse due to
compression of the recurrent laryngeal nerve "<img src=""8496.png"">"
Pathology Respiratory lung-cancer
Which potential spaces can develop effusions as a result of lung cancer?
Pleural and pericardial spaces "<img src=""8496.png"">" Pathology
Respiratory lung-cancer
List two forms of bronchogenic carcinoma that tend to arise peripherally in the
lungs. Adenocarcinoma and large cell carcinoma "<img src=""8496.png"">"
List risk factors that lead to lung cancer. Asbestos exposure, family history,
radon, smoking, secondhand smoke "<img src=""8496.png"">" Pathology
What is the treatment for small cell lung cancer? This inoperable cancer is
treated with chemotherapy "<img src=""8496.png"">" Pathology Respiratory
lung-cancer
A pt is diagnosed with an oat cell carcinoma of the lung. In which area of the
lungs does this type of cancer typically arise? The central area (Small cell [oat
cell] cancer is a very aggressive type of lung cancer.) "<img src=""8496.png"">"
Name three possible products of neoplastic neuroendocrine cells in small cell
carcinoma. ACTH, SIADH, and Antibodies against presynaptic calcium channels or
neurons "<img src=""8496.png"">" Pathology Respiratory lung-cancer
An elderly smoker with hemoptysis and known lung cancer develops muscle weakness
that improves with activity. What is the diagnosis? Lambert-Eaton syndrome (a
paraneoplastic syndrome associated with small cell carcinoma of the lung) "<img
A smoker is newly diagnosed with lung cancer, which has myc amplification and
chromogranin A positivity on histology. Treatment? Chemotherapy, as it is
usually inoperable (This pt has small cell [oat cell] cancer.) "<img
Which four lung cancers are considered non-small cell tumors? Adenocarcinoma,
squamous cell carcinoma, large cell carcinoma, and bronchial carcinoid tumor "<img
A nonsmoker is diagnosed with lung cancer. What type do you suspect and which area
of the lung is often affected? Adenocarcinoma, which is often found in the
peripheral area of the lung "<img src=""8496.png"">" Pathology Respiratory
lung-cancer
A nonsmoker is diagnosed with lung cancer. What is the most common type of lung
cancer in nonsmokers and overall? Adenocarcinoma "<img src=""8496.png"">"
What activating mutations are found in adenocarcinoma? KRAS, EGFR, ALK "<img
What lung cancer is associated with hypertrophic osteoarthropathy (clubbing)?
Adenocarcinoma "<img src=""8496.png"">" Pathology Respiratory lung-
cancer
A nonsmoker has cough, clubbing, and joint pain. Chest x-ray shows hazy
infiltrates, suggesting cancer. Where is growth most likely to be? Along
alveolar septa, giving an appearance of wall thickening (The pt has bronchoalveolar
cancer [excellent prognosis].) "<img src=""8496.png"">" Pathology
Bronchioloalveolar adenocarcinoma can present similarly to which other noncancerous
pathologic lung disease? Pneumonia "<img src=""8496.png"">" Pathology
A woman has chest pain, dyspnea, and hemoptysis. Histology shows a glandular
pattern and mucin (image). Did this woman smoke? Unlikely, as this is
adenocarcinoma, which classically arises in nonsmokers and women "<img
A pt is diagnosed with a squamous cell carcinoma of the lung. In which area of the
lungs does this cancer type typically arise? The central area "<img
A pt with lung cancer has elevated calcium. Is the causative malignancy typically
found centrally or peripherally? Centrally, as this is squamous cell cancer,
with release of parathyroid hormonerelated peptide causing hypercalcemia "<img
What are the 3Cs of squamous cell carcinoma? Cavitation, Cigarettes, and
hyperCalcemia (from parathyroid hormonerelated protein) "<img src=""8496.png"">"
A pt is diagnosed with a large cell carcinoma of the lung. In which area of the
lungs does this cancer type typically arise? The peripheral area "<img
What peripherally arising form of bronchogenic carcinoma is most anaplastic or
undifferentiated? Large cell carcinoma is highly undifferentiated and therefore
carries a poor prognosis "<img src=""8496.png"">" Pathology Respiratory
lung-cancer
What is the usual approach to the treatment of large cell carcinoma of the lung?
Surgical removal (It is poorly responsive to chemotherapy.)"<img
A pt with a lung mass has a biopsy showing pleomorphic giant cells that can secrete
-hCG. What cancer type is this? Large cell carcinoma "<img src=""8496.png"">"
What two types of lung cancer have excellent prognoses? Bronchial carcinoid and
the bronchioloalveolar subtype of adenocarcinoma "<img src=""8496.png"">"
What are the classic symptoms of carcinoid syndrome? What is the cause?
Flushing, diarrhea, and wheezing; the symptoms are caused by serotonin
secretion into the bloodstream "<img src=""8496.png"">" Pathology
A pt with dyspnea, chest pain, and chronic cough now has flushing, diarrhea, and
wheezing. What do you expect a biopsy specimen to show? Nests of neuroendocrine
cells that are chromogranin A positive (This is a bronchial carcinoid tumor.)
"<img src=""8496.png"">" Pathology Respiratory lung-cancer
Are H1 blockers reversible or irreversible inhibitors? Reversible "<img
src=""8497.png"">" Respiratory antihistamines pharmacology
What are three first-generation H1 blockers? Diphenhydramine, dimenhydrinate,
and chlorpheniramine "<img src=""8497.png"">" Respiratory antihistamines
pharmacology
Name four second-generation H1 blockers. Loratadine, fexofenadine, cetirizine, and
desloratadine "<img src=""8497.png"">" Respiratory antihistamines
pharmacology
Why are second-generation antihistamines far less sedating than first-generation
antihistamines? Second-generation antihistamines have less CNS penetration "<img
A pt has motion sickness on a flight and would like to fall asleep. What class of
medication would be useful for this pt? H1 blockers (eg, diphenhydramine), which
are useful for relief of allergy symptoms and motion sickness and as sleep aids
"<img src=""8497.png"">" Respiratory antihistamines pharmacology
A pt takes chlorpheniramine for allergies. About which side effects would you
counsel the pt? Sedation, antimuscarinic symptoms, anti--adrenergic symptoms
"<img src=""8497.png"">" Respiratory antihistamines pharmacology
What is the clinical use of second-generation H1 blockers? Allergies "<img
A truck driver has severe allergies. You want to prescribe a histamine blocker.
Would diphenhydramine work for him? No; although it treats allergies, a first-
generation antihistamine is too sedating and would pose a risk to a pt whose work
is driving "<img src=""8497.png"">" Respiratory antihistamines pharmacology
A pt with cystic fibrosis is prescribed a medication that would loosen mucus plugs.
What is the mechanism of action of this drug? It disrupts disulfide bonds (N-
acetylcysteine is a mucolytic.) "<img src=""8498.png"">" Respiratory
expectorants pharmacology
How does guaifenesin help a pt with a severe cough productive of sputum? It
thins respiratory secretions; it does not reduce the cough reflex "<img
src=""8498.png"">" Respiratory expectorants pharmacology
N-acetylcysteine is an expectorant. How does it work? It dissolves mucus plugs by
disrupting disulfide bonds (It is a mucolytic.) "<img src=""8498.png"">"
Respiratory expectorants pharmacology
Which mucolytic is also used as an antidote for acetaminophen overdose? N-
acetylcysteine "<img src=""8498.png"">" Respiratory expectorants
pharmacology
By what mechanism does dextromethorphan suppress cough? It antagonizes NMDA
glutamate receptors "<img src=""8499.png"">" Respiratory dextromethorphan
pharmacology
Dextromethorphan is a synthetic analog of what drug? Codeine "<img
src=""8499.png"">" Respiratory dextromethorphan pharmacology
Excess use of dextromethorphan can produce what side effect? Mild opioid effect
"<img src=""8499.png"">" Respiratory dextromethorphan pharmacology
A pt with a cough overdoses on an NMDA glutamate receptor antagonist. What drug can
be used to treat the overdose? Naloxone (Dextromethorphan can cause opioid-
like effects.) "<img src=""8499.png"">" Respiratory dextromethorphan
pharmacology
Why does dextromethorphan have mild abuse potential? If used in excess, it has a
mild opioid effect "<img src=""8499.png"">" Respiratory dextromethorphan
pharmacology
A pt with depression takes dextromethorphan to suppress a cough. She develops
tachycardia, diaphoresis, and tremor. Diagnosis? This is serotonin syndrome,
seen when dextromethorphan is combined with another serotonergic agent such as
certain antidepressants "<img src=""8499.png"">" Respiratory dextromethorphan
pharmacology
What is the main clinical function of pseudoephedrine and phenylephrine? By what
mechanism? Nasal decongestants via -adrenergic agonism "<img src=""8500.png"">"
Respiratory pharmacology pseudoephedrine,-phenylephrine
What are the clinical indications for pseudoephedrine and phenylephrine? Reduce
hyperemia, edema, nasal congestion; open obstructed eustachian tubes; and act as
stimulant (pseudoephedrine only, used to make meth) "<img src=""8500.png"">"
Respiratory pharmacology pseudoephedrine,-phenylephrine
A pt takes -adrenergic agonists for nasal congestion. What side effects can be
expected? Hypertension and central nervous system stimulation/anxiety"<img
src=""8500.png"">" Respiratory pharmacology pseudoephedrine,-phenylephrine
A pt with COPD has a pulmonary artery pressure of 26 mm Hg. He is prescribed an
endothelin receptor antagonist. What must you monitor? Liver enzyme levels for
hepatotoxic side effects (This pt has pulmonary hypertension from COPD, and the
medication described is bosentan.) "<img src=""8501.png"">" Respiratory
pharmacology pulmonary-hypertension-drugs
What is the mechanism of action of sildenafil? It inhibits cGMP PDE5 and prolongs
nitric oxide vasodilatory effects "<img src=""8501.png"">" Respiratory
pharmacology pulmonary-hypertension-drugs
A man with pulmonary hypertension and erectile dysfunction would benefit from which
medication? Sildenafil "<img src=""8501.png"">" Respiratory pharmacology
pulmonary-hypertension-drugs
Name two prostacyclin analog medications for pulmonary hypertension that directly
vasodilate pulmonary and systemic vascular beds. Epoprostenol and iloprost
"<img src=""8501.png"">" Respiratory pharmacology pulmonary-
hypertension-drugs
A man with elevated pulmonary artery pressure is given a PGI2 analog that also
works to inhibit platelet aggregation. Side effects? Flushing and jaw pain (He has
pulmonary artery hypertension, and the medication described is epoprostenol or
iloprost.) "<img src=""8501.png"">" Respiratory pharmacology pulmonary-
hypertension-drugs
Name the three types of drugs that are used for pulmonary hypertension.
Endothelin receptor antagonists, prostacyclin analogs, and PDE5 inhibitors
"<img src=""8501.png"">" Respiratory pharmacology pulmonary-
hypertension-drugs
Name a competitive endothelin receptor antagonist that is used to decrease
pulmonary vascular resistance for pulmonary hypertension. Bosentan "<img
src=""8501.png"">" Respiratory pharmacology pulmonary-hypertension-drugs
Bronchoconstriction is mediated by which two processes? Inflammation and
parasympathetic tone (which are targets for therapy) "<img src=""8502.png"">"
Respiratory asthma-drugs pharmacology
What is the mechanism of action of albuterol? Albuterol relaxes bronchial smooth
muscle through its agonism of 2-adrenergic receptors "<img src=""8502.png"">"
A typical pt with asthma takes a combination of drugs that targets which two
pathways mediating bronchoconstriction? Inflammation and parasympathetic tone
"<img src=""8502.png"">" Respiratory asthma-drugs pharmacology
Is albuterol used as a controller medication or for relief of symptoms during
exacerbations? For relief of symptoms in acute asthma exacerbations "<img
src=""8502.png"">" Respiratory asthma-drugs pharmacology
Name two long-acting 2-agonists. Salmeterol and formoterol "<img
List two adverse effects that a pt may experience while taking salmeterol. Tremor
and arrhythmias "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
Name two inhaled corticosteroids commonly used to treat asthma. Fluticasone and
budesonide "<img src=""8502.png"">" Respiratory asthma-drugs pharmacology
What mechanism of inhaled corticosteroids makes them useful in treating asthma?
They inhibit the synthesis of virtually all cytokines"<img src=""8502.png"">"
Inhaled corticosteroids are useful in treating asthma by inactivating what
transcription factor? Nuclear factor B "<img src=""8502.png"">" Respiratory
asthma-drugs pharmacology
Nuclear factor B induces the production of what major inflammatory agent? Tumor
necrosis factor- "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
A pt has chronic asthma. What class of drugs is considered first-line therapy for
this pt? Inhaled corticosteroids "<img src=""8502.png"">" Respiratory
asthma-drugs pharmacology
Ipratropium is an example of what class of drugs? Muscarinic antagonists "<img
A pt has both asthma and COPD. What is the mechanism of action of the drug that
would be useful in treating both of his conditions? Ipratropium, which is used to
treat both asthma and COPD, as it blocks muscarinic receptors competitively "<img
Does ipratropium cause a competitive or a noncompetitive receptor blockade?
Mechanism? Competitive; it prevents endogenous acetylcholine from inducing
bronchoconstriction "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
Ipratropium is used to treat chronic obstructive pulmonary disease, as is what
other long-acting muscarinic antagonist? Tiotropium "<img src=""8502.png"">"
Name two clinical indications for the use of ipratropium. Asthma and chronic
obstructive pulmonary disease "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
Name three examples of antileukotriene drugs. Zileuton, zafirlukast, and
montelukast "<img src=""8502.png"">" Respiratory asthma-drugs pharmacology
Zileuton is an inhibitor of what pathway? Toxicity? The 5-lipoxygenase pathway
that produces leukotrienes from arachidonic acid; it is hepatotoxic "<img
What medication is used for allergic asthma resistant to inhaled corticosteroids
and 2-agonists? How does it work? Omalizumab, a monoclonal anti-immunoglobulin E
antibody that binds unbound immunoglobulin E and blocks FcRI binding "<img
What is theophylline's mechanism of action? It likely inhibits
phosphodiesterase, leading to increased cAMP levels and bronchodilation "<img
What is the effect of increased cAMP concentration on bronchial smooth muscle?
Decreased bronchial tone (It causes bronchodilation.)"<img src=""8502.png"">"
The use of which asthma drug is limited because of its narrow therapeutic index?
Theophylline "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
A pt wants to try theophylline but is worried about side effects. What two side
effects do you discuss with the pt? Cardiotoxicity and neurotoxicity "<img
Besides phosphodiesterase, what else does theophylline inhibit? Adenosine "<img
In the pathogenesis of asthma, the binding of antigens to immunoglobulin E on mast
cells results in what? The release of mediators such as leukotrienes and histamine
from mast cells "<img src=""8502.png"">" Respiratory asthma-drugs
pharmacology
In the pathogenesis of asthma, the release of mediators from mast cells results in
what two responses? Bronchoconstriction (early) and inflammation (late) "<img
In the treatment of asthma, what drug type prevents released mast cell mediators
from inducing the late response of airway inflammation? Steroids "<img
What is the primary mechanism by which methacholine works? Bronchoconstriction via
muscarinic (M3) receptor agonism "<img src=""8503.png"">" Respiratory
methacholine pharmacology
A physician cannot determine whether a pt has asthma. What drug could be used in an
asthma challenge test for this pt? Methacholine "<img src=""8503.png"">"
Respiratory methacholine pharmacology
Which pathway(s) of apoptosis require(s) ATP? Both intrinsic and extrinsic
pathways (Apoptosis always requires energy.) "<img src=""7660.png"" />"
Inflammation Pathology apoptosis
Define pyknosis and karyorrhexis. Of what process are they parts? Pyknosis is
nuclear shrinkage; karyorrhexis is nuclear fragmentation by endonuclease action at
internucleosomal regions; stages of apoptosis "<img src=""7660.png"">"
Inflammation Pathology apoptosis
Which sensitive indicator of apoptosis is observed during DNA electrophoresis? What
causes this phenomenon? DNA laddering; this reflects endonucleases cleaving at
internucleosomal regions during karyorrhexis, yielding 180-bp fragments "<img
src=""7660.png"">" Pathology apoptosis inflammation
On histologic examination, a dying cell lacks signs of acute inflammation in its
vicinity. What type of cell death has likely occurred? Apoptosis; necrosis
involves surrounding inflammation "<img src=""7660.png"">" Pathology
apoptosis inflammation
GI bleeding develops in a man undergoing abdominal radiation therapy. Colonoscopy
with biopsy is performed. What will the biopsy show? Apoptosis of GI tissues due
to free radical formation and dsDNA breakage from radiation, to which GI cells are
very susceptible "<img src=""7660.png"">" Pathology apoptosis inflammation
How does radiation therapy cause apoptosis of tumors and surrounding tissue? Which
cell types are particularly susceptible? Free radical formation and dsDNA
breakage; rapidly dividing cells (skin, GI mucosa) are extremely susceptible "<img
src=""7660.png"">" Pathology apoptosis inflammation
Under what conditions does intrinsic apoptosis occur? Embryogenesis, hormone
induction (menstruation), atrophy (menopause), injurious stimuli (radiation,
toxins, hypoxia) "<img src=""7660.png"">" Pathology apoptosis inflammation
Resolution of an immunologic reaction leads to apoptosis of involved effector
cells. Which cytokine mediates this? Decreased IL-2 (survival signal) after a
completed immunologic RXN causes apoptosis of proliferating effector cells via
intrinsic pathway "<img src=""7660.png"">" Pathology apoptosis inflammation
The extrinsic apoptotic pathway is necessary in thymic medullary negative selection
via Fas/FasL. What is the consequence if this fails? Autoimmune
lymphoproliferative syndrome (increased number of circulating self-reacting
lymphocytes due to failure of clonal deletion) "<img src=""7660.png"">"
Pathology apoptosis inflammation
A pt w/lymphoma & splenomegaly is diagnosed with autoimmune lymphoproliferative
syndrome. Which arm of the apoptotic pathway is defective? Extrinsic; defect in
FASL/FAS (CD95) pathway at FAS, FASL, or caspase 10 "<img src=""7660.png"">"
Pathology apoptosis inflammation
Define necrosis. Enzymatic degradation/protein denaturation due to exogenous
injury; intracellular components leak; unlike apoptosis, an inflammatory process
"<img src=""7661.png"">" Pathology inflammation necrosis
What is the main difference between necrosis and apoptosis?Necrosis is associated
with inflammation, whereas apoptosis is not "<img src=""7661.png"">"
Pathology inflammation necrosis
Coagulative necrosis occurs most commonly in what organs? In tissues supplied by
end arteries (especially heart, liver, and kidneys) "<img src=""7661.png"">"
Liquefactive necrosis most commonly occurs in at the brain. Why? Does it occur
anywhere else? Largely because of the brain's high fat content; it can also
occur in bacterial abscesses "<img src=""7661.png"">" Pathology inflammation
necrosis
An alcoholic has several bouts of acute pancreatitis. If he does not stop drinking,
what will biopsy of his pancreas eventually show? Fat necrosis: outlines of
dead fat cells without peripheral nuclei; fat saponification (combined w/Ca2+),
appearing dark blue on H&E stain "<img src=""7661.png"">" Pathology
inflammation necrosis
Which type of necrosis most commonly occurs in the limbs and gastrointestinal
tract? Gangrenous necrosis due to chronic ischemia "<img src=""7661.png"">"
Which type of necrosis is typically associated with tuberculosis? Is this type of
necrosis associated with other infections? Caseous necrosis; yes, it is
associated with systemic fungal infections such as Histoplasma capsulatum and
Nocardia "<img src=""7661.png"">" Pathology inflammation necrosis
A parapneumonic effusion develops in a 50-y/o man with pneumonia. What will
analysis under the microscope in the pathology lab show? Liquefactive necrosis,
with neutrophils and cell debris seen with bacterial infection "<img
src=""7661.png"">" Pathology inflammation necrosis
Coagulative necrosis occurs after ischemia/infarction except in stroke. What is the
key difference as compared with liquefactive necrosis? Coagulative necrosis =
protein denaturation then enzymatic degradation; liquefactive is vice versa due to
enzyme release from neutrophils "<img src=""7661.png"">" Pathology
inflammation necrosis
Which aspects of cell injury are irreversible even with restoration of the oxygen
supply? Pyknosis, karyorrhexis, karyolysis, membrane damage, lysosomal rupture,
mitochondrial permeability/vacuolization, densities in mitochondria "<img
src=""7662.png"">" Pathology cell-injury inflammation
Which aspects of cell injury are reversible with restoration of the oxygen supply?
ATP depletion, swelling, nuclear chromatin clumping, decreased glycogen,
fatty change, ribosomal/polysomal detachment, membrane blebbing "<img
Regarding cell injury, is nuclear chromatin clumping reversible or irreversible?
Reversible "<img src=""7662.png"">" Pathology cell-injury inflammation
Regarding cell injury, is lysosomal rupture reversible or irreversible?
Irreversible "<img src=""7662.png"">" Pathology cell-injury
inflammation
Regarding cell injury, is ribosomal detachment reversible or irreversible? What
does this indicate? Reversible; it indicates decreased protein synthesis "<img
Regarding cell injury, is glycogen depletion reversible or irreversible?
Regarding cell injury, is increased mitochondrial permeability reversible or
irreversible? What might you see within mitochondria? Irreversible; you might see
vacuolization with phospholipid-containing amorphous densities within mitochondria
"<img src=""7662.png"">" Pathology cell-injury inflammation
Regarding cell injury, is fatty change reversible or irreversible? Reversible
"<img src=""7662.png"">" Pathology cell-injury inflammation
Describe the mechanism by which lack of ATP leads to cellular swelling. Is this
process reversible or irreversible? Without ATP, Na+/K+ ATPase pumps do not work,
thereby causing water influx and reversible swelling/blebbing "<img
Regarding cell injury, is membrane blebbing reversible or irreversible?
What is the definition of a watershed area? One with dual blood supply from the
most distal branches of two arteries; resists one vessel blockage but is
susceptible to hypoperfusion "<img src=""7663.png"">" Pathology inflammation
ischemia
The hepatic lobule is separated into three histologic zones based on oxygen supply.
Which zone is most susceptible to ischemia? Zone III (the area around the
central vein) "<img src=""7663.png"">" Inflammation Pathology ischemia
A man with atherosclerosis often has left upper quadrant pain after eating a large
meal. What watershed area is most likely affected? Splenic flexure of the colon
"<img src=""7663.png"">" Inflammation Pathology ischemia
Hypoxic ischemic encephalopathy (HIE) primarily affects which cell type(s) in the
brain? Pyramidal cells of the hippocampus and Purkinje cells of the cerebellum
What part of the heart is most susceptible to hypoxia? Why?Subendocardial tissue,
especially at the LV; it is a watershed area farthest from arterial supply "<img
src=""7663.png"">" Inflammation Pathology ischemia
Which parts of the brain are most susceptible to hypoxia? Why? Anterior, middle,
and posterior cerebral artery (ACA, MCA, PCA) boundaries; because they are
watershed areas "<img src=""7663.png"">" Inflammation Pathology ischemia
What parts of the kidney are most susceptible to hypoxia? Why? Straight segment
of proximal tubule (metabolically active) and thick ascending limb (low O2 tension)
Why can reperfusion of an organ with a red infarct lead to more damage? Injury
results from damage by free radicals (Red = reperfusion) "<img src=""7664.png"">"
Inflammation Pathology infarcts:-red-vs-pale
What are the five hallmarks of inflammation? Rubor (redness), dolor (pain),
calor (heat), tumor (swelling), and functio laesa (loss of function) "<img
src=""7665.png"">" Pathology inflammation
A man has a left lower lobe exudative effusion from bacterial pneumonia. Which
vascular aspects of the inflammatory process led to this? Increased vascular
permeability, vasodilation, and endothelial injury "<img src=""7665.png"">"
Pathology inflammation
What is the cellular component of the inflammatory process?Neutrophil extravasation
(circulation to injured tissue) to mediate phagocytosis, degranulation, and
inflammatory mediator release "<img src=""7665.png"">" Pathology inflammation
A 40-year-old man has chronic pulmonary fibrosis. Which cell type in his lungs will
predominate in causing the pathologic changes? Fibroblasts (This is chronic
inflammation.) "<img src=""7665.png"">" Inflammation Pathology
Which immune cells and proteins mediate acute inflammation?Neutrophils,
eosinophils, and antibodies "<img src=""7665.png"">" Pathology inflammation
Chronic inflammation is characterized by persistent destruction and repair with
blood vessel formation and fibrosis. Which immune cells mediate chronic
inflammation? Mononuclear cells (monocytes, macrophages, lymphocytes, plasma
cells) and fibroblasts "<img src=""7665.png"">" Pathology inflammation
What are some hallmarks of chronic inflammation? Chronic inflammation is
characterized by persistent destruction and repair with blood vessel proliferation
and fibrosis "<img src=""7665.png"">" Pathology inflammation
Granulomas form as a result of chronic inflammation. What is a granuloma?
Nodular collections of epithelioid macrophages and giant cells "<img
An abscess is collection of pus surrounded by fibrosis. In which phase of
inflammation do abscesses form? An abscess is an outcome of acute inflammation
"<img src=""7665.png"">" Pathology inflammation
What are some outcomes of prolonged chronic inflammation? Scarring and amyloidosis
"<img src=""7665.png"">" Pathology inflammation
What are the possible outcomes of an acute inflammatory episode? Complete
resolution, abscess formation, progression to chronic inflammation "<img
What is the phenomenon of axon degeneration distal to the site of injury? What is
its mechanism? Wallerian degeneration; axons degenerate distal to the injury,
and macrophages remove the debris and surrounding myelin "<img src=""7666.png"">"
Pathology chromatolysis inflammation
Differentiate between dystrophic and metastatic calcification. Dystrophic: Ca2+
deposition in abnormal tissue w/injury or necrosis; metastatic: deposition in
normal tissue in setting of hypercalcemia "<img src=""7667.png"">" Pathology
inflammation types-of-calcification
A pt has a crescendo-decrescendo murmur. ECHO reveals calcific aortic stenosis.
What is the likely serum Ca2+ abnormality in this pt? There is none (In fact, pts
usually have normal Ca2+ levels.); dystrophic calcification of the valve is
responsible for the murmur "<img src=""7667.png"">" Pathology inflammation
types-of-calcification
A pt with hypercalcemia presents with hypervitaminosis D. What mineral is over
deposited? Where does one tend to see the deposits? Ca2+; usually in interstitial
tissues of kidney, lungs, and gastric mucosa (Tissues losing acid favor Ca2+
deposition.) "<img src=""7667.png"">" Pathology inflammation types-of-
calcification
Name some disorders that lead to hypercalcemia and, therefore, metastatic
calcification. Primary hyperparathyroidism, sarcoidosis, and hypervitaminosis D
"<img src=""7667.png"">" Pathology inflammation types-of-calcification
Name some disorders that lead to a high systemic burden of calcium-phosphate
complexes and, therefore, metastatic calcification. Chronic renal failure with
hyperparathyroidism, long-term dialysis, calciphylaxis, or warfarin use "<img
src=""7667.png"">" Pathology inflammation types-of-calcification
Name the five main cytokines (released in response to bacterial products) that
guide leukocytes to the site of injury or infection. C5a, IL-8, LTB4, kallikrein,
and platelet-activating factor "<img src=""7668.png"">" Pathology
inflammation leukocyte-extravasation
An immunocompromised patient undergoes a workup. Neutrophil studies show impaired
tight-binding. A defect in which subunit is to blame? The CD18 integrin subunit,
important for tight-binding and impaired in leukocyte adhesion deficiency type 1
"<img src=""7668.png"">" Pathology inflammation leukocyte-extravasation
Free radical injury can be induced by exposure to what substances and processes?
Radiation, metabolism of drugs (phase I), transition metals, redox reactions,
nitric oxide, and leukocyte oxidative burst "<img src=""7669.png"">"
Inflammation Pathology free-radical-injury
By which three main mechanisms do free radicals damage cells? Membrane lipid
peroxidation, protein modification, and DNA breakage "<img src=""7669.png"">"
Pathology free-radical-injury inflammation
A patient undergoes thrombolysis for acute limb ischemia. What type of free radical
injury is of greatest concern? Reperfusion injury (eg, from superoxide
formation) "<img src=""7669.png"">" Pathology free-radical-injury
inflammation
Name four pathways for free radical degradation. Enzymes (catalase,
glutathione peroxidase), spontaneous decay, antioxidants (vitamins A, C, E), metal
carriers (transferrin, ceruloplasmin) "<img src=""7669.png"">" Pathology
free-radical-injury inflammation
An infant born at 22 weeks' gestation is given O2 therapy. He goes blind, and
respiratory distress develops. Why? Retinopathy of prematurity (eyes) and
bronchopulmonary dysplasia (lungs) due to O2-mediated free radical formation "<img
src=""7669.png"">" Pathology free-radical-injury inflammation
Name some enzymes that degrade free radicals. Catalase, glutathione peroxidase,
and superoxide dismutase "<img src=""7669.png"">" Pathology free-radical-
injury inflammation
Name the three vitamins with antioxidant properties involved in degrading free
radicals. Vitamins A, C, and E "<img src=""7669.png"">" Pathology free-
radical-injury inflammation
Free radical damage by carbon tetrachloride causes what pathologic change in the
human body? Fatty change in the liver "<img src=""7669.png"">" Pathology
free-radical-injury inflammation
A patient overdoses on acetaminophen. What pathologic changes will be seen in his
liver and kidneys? Fulminant hepatitis, renal papillary necrosis "<img
src=""7669.png"">" Pathology free-radical-injury inflammation
Is hemochromatosis a risk factor for free radical formation? Yes, iron overload
can lead to free radical formation "<img src=""7669.png"">" Pathology free-
radical-injury inflammation
A firefighter inhales a significant quantity of toxic fumes and carbon particles.
What are some clinical issues for which he's at high risk? Chemical
tracheobronchitis, edema, pneumonia, and ARDS "<img src=""7670.png"">"
Pathology inflammation inhalational-injury-and-sequelae
Compare hypertrophic and keloid scars with respect to collagen synthesis and
arrangement and rate of recurrence after resection. Collagen synthesis is
increased in keloids compared with hypertrophic scars; unlike hypertrophic scars,
keloids often recur after resection "<img src=""7671.png"">" Inflammation
Pathology scar-formation
Which ethnicities are at higher risk for keloid scar formation after a wound?
Ethnicities with darker skin (not solely African Americans)"<img
src=""7671.png"">" Inflammation Pathology scar-formation
Four months after a skin laceration, a pt asks if his skin can be expected to
regain tensile strength after scarring. What is your reply?Unlikely; after about 3
months, the skin has regained 70% to 80% of its tensile strength and is unlikely to
regain any additional strength "<img src=""7671.png"">" Inflammation
Pathology scar-formation
There are three phases of wound healing. What are they and how long do they
generally last? Inflammatory (up to 3 days), proliferative (3 days to weeks),
remodeling (1 week to 6+ months) "<img src=""7672.png"">" Inflammation
Pathology wound-healing
Which phase of wound healing is characterized by infiltration of platelets,
neutrophils, and macrophages at the site of injury? Inflammatory phase "<img
src=""7672.png"">" Inflammation Pathology wound-healing
Which phase of wound healing has infiltration of fibroblasts, myofibroblasts,
endothelial cells, and keratinocytes at the site of injury?Proliferative phase
"<img src=""7672.png"">" Inflammation Pathology wound-healing
Which cells are most important in mediating the remodeling process of wound
healing? Fibroblasts "<img src=""7672.png"">" Inflammation Pathology wound-
healing
A patient sustained a cut on his arm 2 days ago. What are the characteristics of
the phase of healing his wound is likely in? Clot formation, increased vessel
permeability, neutrophil migration (inflammatory phase) "<img src=""7672.png"">"
Inflammation Pathology wound-healing
Which wound healing phase has collagen deposition, angiogenesis, clot dissolution,
epithelial cell proliferation, and wound contraction? Proliferative phase "<img
A patient has her wound studied by a medical student. Biopsy of the wound shows
type III collagen. Which phase of healing is the wound in? Proliferative phase;
type III collagen is formed alongside granulation tissue "<img src=""7672.png"">"
The remodeling phase of wound healing involves the replacement of type III collagen
with type I. What benefit does this offer? Increases the tensile strength of
the tissue "<img src=""7672.png"">" Inflammation Pathology wound-healing
All aspects of angiogenesis during wound healing are stimulated by which tissue
mediator(s)? FGF, TGF-, and VEGF "<img src=""7672.png"">" Inflammation
Pathology wound-healing
What are the roles of TGF- in wound healing? Angiogenesis, fibrosis, and cell
cycle arrest "<img src=""7672.png"">" Inflammation Pathology wound-
healing
What type of tissue mediator is known to stimulate cell growth via the tyrosine
kinases? Name an example of such a tyrosine kinase. EGF; an example is EGFR, as
expressed by ErbB1 "<img src=""7672.png"">" Inflammation Pathology wound-
healing
Which tissue mediator is secreted by platelets and macrophages and stimulates
fibroblast growth for collagen synthesis during wound healing? PDGF "<img
Which tissue mediator in wound healing induces vascular remodeling and smooth
muscle cell migration? PDGF "<img src=""7672.png"">" Inflammation Pathology
wound-healing
What is the role of the tissue mediator metalloproteinase? Tissue remodeling "<img
A man taking an ErbB1-inhibitor sustains an injury. Reduced function of which
signaling molecule will impede healing? Cell growth will be impaired by a
reduction in tyrosine kinase function (in this case, EGFR) "<img src=""7672.png"">"
What is the histologic difference between granulomas seen in TB and those seen in
sarcoidosis? TB involves caseating granulomas; in sarcoidosis, granulomas are
noncaseating "<img src=""7673.png"">" Inflammation Pathology
granulomatous-diseases
Why must you test for latent tuberculosis before starting an anti-TNF medication?
Because these medications break down granulomas and can cause disseminated
disease "<img src=""7673.png"">" Inflammation Pathology granulomatous-
diseases
Name some infectious causes of granulomatous diseases. Bartonella henselae,
fungi, L monocytogenes, M leprae and M tuberculosis, Treponema pallidum,
schistosomiasis "<img src=""7673.png"">" Inflammation Pathology
Name some noninfectious causes of granulomatous diseases. Eosinophilic
granulomatosis/polyangiitis (Churg-Strauss), Crohn disease, foreign bodies,
granulomatosis/polyangiitis (Wegener), sarcoidosis "<img src=""7673.png"">"
Inflammation Pathology granulomatous-diseases
A Mexican immigrant not up to date on vaccines has caseating granulomas on liver
biopsy and a 3-month history of cough. What is the cause? Tuberculosis (miliary
type); remember, TB involves caseating granulomas "<img src=""7673.png"">"
Inflammation Pathology granulomatous-diseases
A pt has chronic cough. CXR shows hilar LAD & parenchymal infiltrates. Lung Bx
reveals noncaseating granulomas. How may Ca levels change? They will be increased;
granulomatous diseases are associated with hypercalcemia due to calcitriol
production (sarcoidosis) "<img src=""7673.png"">" Inflammation Pathology
Name three causes of transudates. Increased hydrostatic pressure (eg, HF),
decreased oncotic pressure (eg, cirrhosis), and sodium retention "<img
src=""7674.png"">" Inflammation Pathology exudate-vs-transudate
Compare exudates and transudates with respect to cellularity, protein content, and
specific gravity. Exudates: cellular, protein rich, specific gravity &62; 1.020;
transudates: hypocellular, protein poor, specific gravity &60; 1.012 "<img
src=""7674.png"">" Pathology exudate-vs-transudate inflammation
Name three pathologic processes that lead to the formation of exudates.
Lymphatic obstruction, malignancy, and inflammation "<img src=""7674.png"">"
Pathology exudate-vs-transudate inflammation
A man with severe congestive heart failure has a pleural effusion. Is the fluid's
specific gravity greater than 1.020 or less than 1.012? Specific gravity is less
than 1.012 (transudative), a result of increased hydrostatic pressure "<img
src=""7674.png"">" Pathology exudate-vs-transudate inflammation
A 40-year-old man with bacterial pneumonia has a pleural effusion on chest x-ray.
Is the fluid likely to be protein rich or protein poor? Protein rich (exudative)
because of the inflammatory process "<img src=""7674.png"">" Pathology exudate-
vs-transudate inflammation
A chronic alcoholic has extensive liver cirrhosis and ascites. Is the fluid likely
to be cellular or hypocellular? Hypocellular (transudative) due to low oncotic
pressure "<img src=""7674.png"">" Pathology exudate-vs-transudate
inflammation
What does erythrocyte sedimentation rate (ESR) measure? The rate at which RBCs
coated with products of inflammation (eg, fibrinogen) aggregate and fall within a
test tube "<img src=""7675.png"">" Pathology erythrocyte-sedimentation-rate
inflammation
Name at least two conditions that can predispose someone to a lower erythrocyte
sedimentation rate. Sickle cell anemia (altered shape), polycythemia (dilution
of inflammatory factors), CHF, microcytosis, hypofibrinogenemia "<img
src=""7675.png"">" Pathology erythrocyte-sedimentation-rate inflammation
Name at least three pathologic conditions that can cause an increase in erythrocyte
sedimentation rate. Anemia, infection, inflammation (eg, temporal arteritis),
cancer (eg, multiple myeloma), renal dz, pregnancy, autoimmune disorders (eg, SLE)
"<img src=""7675.png"">" Pathology erythrocyte-sedimentation-rate
inflammation
A medical student worries that a pregnant woman's high ESR indicates that she has
an infection. Do you agree? Why or why not? No, the ESR can be increased
naturally in pregnancy, without superimposed infection "<img src=""7675.png"">"
Pathology erythrocyte-sedimentation-rate inflammation
An elderly woman presents with headache, acute vision loss, and tenderness over her
temporal area. What would you expect her ESR to be? Increased because this is
temporal arteritis; ESR in temporal arteritis can be markedly elevated "<img
A patient with multiple myeloma has an elevated ESR. What is the pathogenesis of
this finding? Coating of RBCs by products of inflammation (eg, fibrinogen),
thereby causing aggregation; dense RBC aggregates fall at a higher rate "<img
What is the underlying pathogenesis of amyloidosis? An abnormal aggregation of
proteins (or their fragments) into -pleated sheets that leads to cell damage and
apoptosis "<img src=""7676.png"">" Pathology amyloidosis inflammation
Primary amyloidosis is characterized by the deposition of AL protein. From what
protein is this derived? AL is associated with immunoglobulin Light chains;
may occur as a plasma cell disorder or in association with multiple myeloma "<img
src=""7676.png"">" Pathology amyloidosis inflammation
Secondary amyloidosis is characterized by the deposition of AA fibrils. From which
protein are they derived? AA fibrils are composed of serum Amyloid A;
associated with inflammatory conditions (eg, RA, IBD, spondyloarthropathy, chronic
infection) "<img src=""7676.png"">" Pathology amyloidosis inflammation
Alzheimer disease is an example of organ-specific amyloidosis. Which amyloid
protein is involved and what is its precursor protein? -Amyloid; derived from
amyloid precursor protein "<img src=""7676.png"">" Pathology amyloidosis
inflammation
A pt w/ESRD on long-term dialysis has paresthesia in the first 3 digits of his
right hand. What are the amyloid fibrils made of in this pt? 2-Microglobulin;
he has dialysis-related amyloidosis, which can present as carpal tunnel syndrome
"<img src=""7676.png"">" Pathology amyloidosis inflammation
What disease can cause amyloidosis from an excess of immunoglobulin light chains?
Multiple myeloma "<img src=""7676.png"">" Pathology amyloidosis
inflammation
A pt w/restrictive cardiomyopathy has a Bx of his myocardium. Dx is senile
amyloidosis. Which proteins are found in these amyloid deposits? Wild-type
transthyretin (TTR); deposits are mainly in the ventricles; disease progression is
slower compared with AL amyloidosis "<img src=""7676.png"">" Pathology
amyloidosis inflammation
What are the renal, hematologic, gastrointestinal, and neurologic sequelae of
amyloidosis? Renal: nephrotic syndrome; hematologic: easy bruising,
splenomegaly; GI: hepatomegaly; neurologic: neuropathy "<img src=""7676.png"">"
Pathology amyloidosis inflammation
A patient has a heritable form of cardiac and neurologic amyloidosis. What mutation
is responsible? Transthyretin gene mutation "<img src=""7676.png"">"
Describe the amyloidosis seen in Alzheimer disease. Is it organ specific?
Deposition of -amyloid protein cleaved from amyloid precursor protein (APP)
into cerebral tissues; yes, it is organ specific "<img src=""7676.png"">"
Describe the amyloidosis seen in type 2 diabetes mellitus. Is it organ specific?
Deposition of islet amyloid polypeptide (IAPP, derived from amylin) in the
pancreatic islets; yes, it is organ specific "<img src=""7676.png"">"
A patient with multiple myeloma is suspected to have developed sarcoidosis as a
sequela. Which type of sarcoidosis is most likely? AL type; remember, the AL
type of amyloidosis is associated with immunoglobulin Light chains "<img
A patient with sarcoidosis develops nephrotic syndrome as a sequela. Which two
types of amyloidosis have multisystem involvement? AL type and AA type "<img
Name some tissues where lipofuscin is commonly found on autopsy. All tissues, but
especially the heart, colon, liver, kidneys, and eyes "<img src=""7677.png"">"
Pathology inflammation lipofuscin
A patient is enthusiastic about working out and inquires about muscle hypertrophy.
What is hypertrophy? An increase in cell size "<img src=""7678.png"">"
Neoplasia Pathology reactive-cellular-changes
A pt s/p traumatic injury to his R median nerve at the wrist has a diminished
thenar eminence. What reactive cellular change caused this?Atrophy secondary to
denervation "<img src=""7678.png"">" Neoplasia Pathology reactive-cellular-
changes
Reactive cellular changes occur in response to evolving stressors/triggers. What is
atrophy? Decrease in tissue mass due to decrease in cell number/size (caused by
disuse, denervation, hypoperfusion, loss of hormones, poor nutrition) "<img
src=""7678.png"">" Neoplasia Pathology reactive-cellular-changes
A pt w/epilepsy takes phenytoin to control her seizures. She is diagnosed
w/gingival hyperplasia due to phenytoin use. What is hyperplasia? An increase
in cell number; it can be a risk factor for malignancy but is not considered
premalignant "<img src=""7678.png"">" Neoplasia Pathology reactive-
cellular-changes
A patient with GERD is found to have Barrett esophagus after an EGD. What reactive
cellular change is responsible for this finding? Metaplasia, or replacement of
one cell type with another (In this case, columnar epithelium replaces squamous
epithelium.) "<img src=""7678.png"">" Neoplasia Pathology reactive-
cellular-changes
A patient with Barrett esophagus inquires about whether he can get esophageal
cancer. What do you say? Yes, metaplasia has a risk of undergoing malignant
transformation if the irritant (gastric acid in this case) is not removed "<img
src=""7678.png"">" Neoplasia Pathology reactive-cellular-changes
Neoplasia can be either malignant or benign. What is neoplasia? Uncontrolled,
clonal proliferation of cells "<img src=""7679.png"">" Neoplasia Pathology
preneoplastic-and-neoplastic-cellular-changes
Mild dysplasia is reversible, whereas severe dysplasia can become carcinoma in
situ. What is dysplasia? Disordered, non-neoplastic cell growth; typically
only used in reference to epithelial cells "<img src=""7679.png"">"
Neoplasia Pathology preneoplastic-and-neoplastic-cellular-changes
A patient dies from complications of anaplastic thyroid cancer. What is anaplasia?
Complete lack of differentiation of cells in a malignant neoplasm "<img
src=""7679.png"">" Neoplasia Pathology preneoplastic-and-neoplastic-cellular-
changes
Anaplasia is the complete lack of differentiation of cells in a malignant neoplasm.
What is differentiation? The degree to which a malignant tumor resembles its
tissue of origin; well-differentiated tumors closely resemble their tissue of
origin "<img src=""7679.png"">" Neoplasia Pathology preneoplastic-and-
neoplastic-cellular-changes
What is carcinoma in situ? Full-thickness, noninvasive neoplasia in which cells
are monoclonal with high nuclear/cytoplasmic ratios and clumped chromatin
(preinvasive) "<img src=""7680.png"">" Neoplasia Pathology neoplastic-
progression
Describe the process of hyperplasia. Cells increase in number beyond normal
tissue "<img src=""7680.png"">" Neoplasia Pathology neoplastic-
progression
Describe the process of dysplasia. Abnormal proliferation of cells with loss of
normal size, shape, and orientation "<img src=""7680.png"">" Neoplasia
Pathology neoplastic-progression
Generally speaking, how do neoplastic cells differ from normal cells? Neoplastic
cells can evade apoptosis, induce angiogenesis, replicate endlessly without growth
signals, invade tissue, and metastasize "<img src=""7680.png"">" Neoplasia
A patient's colorectal tumor biopsy shows decreased E-cadherin staining in some
regions. What is the significance of this finding? E-cadherin helps form cell-
cell connections in epithelial tissue; its inactivation is one step in the
progression to invasive carcinoma "<img src=""7680.png"">" Neoplasia
A woman with a breast mass undergoes biopsy. Analysis reveals intact E-cadherin
function. Do you expect to find metastases? No, the biopsy shows cells not yet
invading the basement membrane; combined with intact E-cadherin, this suggests
carcinoma in situ "<img src=""7680.png"">" Neoplasia Pathology neoplastic-
progression
A woman has invasive ductal carcinoma. What will enzyme analysis of the cells
indicated by the red arrows in the image likely reveal? Elevated collagenase and
hydrolase (metalloproteinase) activity (Cells have invaded the basement membrane,
suggesting invasive carcinoma.) "<img src=""7680.png"">" Neoplasia
A patient has high-grade cervical cancer. To what does the grade of a tumor refer?
The degree of cellular differentiation and mitotic activity on histology
"<img src=""7681.png"">" Neoplasia Pathology tumor-grade-vs-stage
A patient has stage IV cervical cancer. To what does the stage of a tumor refer?
The degree of localization and/or spread based on size and site of the
primary lesion, spread to lymph nodes, and the presence of metastases "<img
src=""7681.png"">" Neoplasia Pathology tumor-grade-vs-stage
Regarding tumors, which usually has more prognostic value: stage or grade? Stage
"<img src=""7681.png"">" Neoplasia Pathology tumor-grade-vs-stage
Which factors are considered in assigning stage to a tumor?The degree of
localization, the size of the primary lesion, the spread to regional lymph nodes,
and the presence of metastases "<img src=""7681.png"">" Neoplasia
Pathology tumor-grade-vs-stage
"Regarding tumor staging, what do the letters ""TNM"" refer to?" TNM is a classic
staging system: T = Tumor size; NNode involvement; M = etastases "<img
src=""7681.png"">" Neoplasia Pathology tumor-grade-vs-stage
On which two types of findings is the TNM staging system based? It is based on
clinical (c) and pathology (p) findings "<img src=""7681.png"">" Neoplasia
Pathology tumor-grade-vs-stage
The terms carcinoma and sarcoma both typically imply malignancy. What is the origin
of a carcinoma? Epithelial "<img src=""7682.png"">" Neoplasia Pathology
tumor-nomenclature
The terms carcinoma and sarcoma both typically imply malignancy. What is the origin
of a sarcoma? Mesenchymal "<img src=""7682.png"">" Neoplasia Pathology
tumor-nomenclature
Adenoma and papilloma are benign tumors of what cell type? Epithelial "<img
src=""7682.png"">" Neoplasia Pathology tumor-nomenclature
Malignancies of blood cells are called what? Leukemias and lymphomas "<img
Hemangioma is a benign tumor of what cell type? Blood vessel "<img
Leiomyoma is a benign tumor of what cell type? Smooth muscle "<img
Rhabdomyoma is a benign tumor of what cell type? Striated muscle "<img
Leiomyosarcoma is a malignant tumor of what cell type? Smooth muscle "<img
Fibroma is a benign tumor of what cell type? Connective tissue "<img
Osteoma is a benign tumor of what cell type? Bone "<img src=""7682.png"">"
Neoplasia Pathology tumor-nomenclature
Lipoma is a benign tumor of what cell type? Fat "<img src=""7682.png"">"
Rhabdomyosarcoma is a malignant tumor of what cell type? Striated muscle "<img
Osteosarcoma is a malignant tumor of what cell type? Bone "<img src=""7682.png"">"
Liposarcoma is a malignant tumor of what cell type? Fat "<img src=""7682.png"">"
What would you call a malignant tumor originating from a blood vessel? Angiosarcoma
"<img src=""7682.png"">" Neoplasia Pathology tumor-nomenclature
A 2-year-old boy has a choristoma near the ileocecal valve. What is the most common
presentation? Bleeding; choristoma is normal tissue in a foreign location, such
as gastric or pancreatic mucosa in a Meckel diverticulum "<img src=""7682.png"">"
What is a hamartoma? A disorganized overgrowth of tissues in their native
location (eg, Peutz-Jeghers polyps) "<img src=""7682.png"">" Neoplasia
Pathology tumor-nomenclature
Which type of tumor is well differentiated, has slow growth, and does not
metastasize? Benign "<img src=""7682.png"">" Neoplasia Pathology
tumor-nomenclature
Which type of tumor is poorly differentiated, has erratic growth and local
invasion, and can metastasize? Metastatic "<img src=""7682.png"">"
On endoscopy, you find a papilloma in the gastric lining. Do you expect this tumor
to be well or poorly differentiated? Well differentiated because papillomas
are benign tumors "<img src=""7682.png"">" Neoplasia Pathology tumor-
nomenclature
A 3-year-old girl has a rhabdomyosarcoma. How would the chromosomes of the
cancerous cells compare in length with those of normal cells? Rhabdomyosarcomas
are malignant tumors; telomerase activity would likely be increased, keeping
chromosomes longer than normal "<img src=""7682.png"">" Neoplasia
Pathology tumor-nomenclature
Do benign tumors exhibit necrosis? No, they do not usually undergo necrosis "<img
Name the three cancers with the highest incidence among men. Prostate, lung,
colorectal "<img src=""7683.png"">" Neoplasia Pathology cancer-epidemiology
Name the three cancers with the highest incidence among women. Breast, lung,
colorectal "<img src=""7683.png"">" Neoplasia Pathology cancer-epidemiology
Which three cancers cause the most deaths in men? Lung, prostate, colorectal
"<img src=""7683.png"">" Neoplasia Pathology cancer-epidemiology
Which three cancers cause the most deaths in women? Lung, breast, colorectal
"<img src=""7683.png"">" Neoplasia Pathology cancer-epidemiology
In the United States, where does cancer rank as a leading cause of death? Second
(Heart disease is first.) "<img src=""7683.png"">" Neoplasia Pathology
cancer-epidemiology
An epidemiologist studies cancer deaths. He notes that lung cancer incidence
differs between men and women. What difference does he see?The incidence of lung
cancer has decreased in men but has not changed significantly in women "<img
src=""7683.png"">" Neoplasia Pathology cancer-epidemiology
A patient is found to have multiple sudden-onset seborrheic keratoses. Why might
you propose a full-body CT scan for this patient? Multiple seborrheic keratoses
are associated with several neoplasms, including GI, breast, lung, and lymphoid
malignancies "<img src=""7684.png"">" Neoplasia Pathology paraneoplastic-
syndromes
A patient with small cell lung cancer feels weakness. What abnormality will
electrolyte studies at the neuromuscular junction likely reveal? Presynaptic Ca2+
channel antibodies acting at the neuromuscular junction, blocking normal conduction
(This is Lambert-Eaton syndrome.) "<img src=""7684.png"">" Neoplasia
Pathology paraneoplastic-syndromes
A velvety hyperpigmentation suddenly develops on the back of a diabetic patient's
neck. Do you consider performing endoscopy? Yes, though most commonly seen with
insulin resistance, acanthosis nigricans can be a sign of visceral malignancy (eg,
stomach cancer) "<img src=""7684.png"">" Neoplasia Pathology paraneoplastic-
syndromes
A smoker with persistent cough now has signs of Lambert-Eaton syndrome. Which
neoplasm is of the greatest concern? Small cell lung carcinoma "<img
src=""7684.png"">" Neoplasia Pathology paraneoplastic-syndromes
A patient has hyponatremia and high urine osmolarity. Screening for lung cancer is
negative. For what other neoplasm do you screen? Intracranial neoplasm (This
is SIADH.) "<img src=""7684.png"">" Neoplasia Pathology paraneoplastic-
syndromes
A patient has polycythemia of unclear origin. For which potentially causative
malignancies do you screen as part of your workup? Renal cell carcinomas,
hemangioblastomas, hepatocellular carcinoma, pheochromocytoma, leiomyoma (All can
secrete erythropoietin.) "<img src=""7684.png"">" Neoplasia Pathology
paraneoplastic-syndromes
Recent labs in a patient with squamous cell lung cancer showed elevated calcium.
What hormone is responsible? Parathyroid-hormone-related protein (PTHrP) "<img
Recent labs in a pt with Hodgkin lymphoma showed elevated calcium. What hormone is
responsible? Can any other cancers do this? 1,25-(OH)2D3 (calcitriol); yes,
some non-Hodgkin lymphomas can cause this "<img src=""7684.png"">" Neoplasia
Polycythemia is found in a patient with renal cell carcinoma. What hormone is
driving this? Erythropoietin "<img src=""7684.png"">" Neoplasia
A smoker presents with moon facies, progressive obesity, a buffalo hump, and purple
stretch marks. If there is also cough, what is going on? This is likely ectopic
ACTH secretion from small cell lung cancer (causing Cushing syndrome) "<img
Oncogenes cause cancer by what mechanism? Damage to only one allele sufficient
enough to cause gain of function "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
A man is found to have chronic myeloid leukemia. You send blood to the lab for
genetic analysis. Activity of what gene product is elevated? A tyrosine kinase
coded for by the BCR-ABL gene "<img src=""7685.png"">" Neoplasia Pathology
oncogenes
A patient has a mutation at KRAS. You recommend screening for which cancer types?
Colon, lung, and pancreatic cancers "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
A man has Burkitt lymphoma. You send a biopsy specimen to the lab for genetic
analysis. Activity of what gene product is elevated? A transcription factor coded
for by the c-MYC gene "<img src=""7685.png"">" Neoplasia Pathology oncogenes
A patient with lymphoma is found to have increased activity of an antiapoptotic
molecule. What subtype of lymphoma does he most likely have? Follicular or
diffuse large B-cell lymphoma, associated with the BCL-2 gene (codes for an
antiapoptotic molecule that inhibits apoptosis) "<img src=""7685.png"">"
Neoplasia Pathology oncogenes
A 54-year-old woman has breast cancer responsive to the monoclonal antibody
trastuzumab. What oncogene is involved in her cancer? HER2/neu (c-erbB2), a
tyrosine kinase "<img src=""7685.png"">" Neoplasia Pathology oncogenes
An infant has a mutation on the MYCN oncogene. Which tumor type is she at risk for
developing? Neuroblastoma "<img src=""7685.png"">" Neoplasia Pathology
oncogenes
A patient has a mutation at the MYCL1 oncogene. Which tumors is he at risk for?
Lung tumors "<img src=""7685.png"">" Neoplasia Pathology oncogenes
A patient is found to be positive for the RET gene encoding for a tyrosine kinase.
For which syndromes is she at risk? Multiple endocrine neoplasia (MEN) types 2A and
2B, medullary thyroid cancer "<img src=""7685.png"">" Neoplasia Pathology
oncogenes
A patient is found to have a gastrointestinal stromal tumor (GIST). On genetic
analysis, upregulation of which receptor type will be seen?Cytokine receptors, as a
result of increased c-KIT activity "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
During cancer testing, a lab error allows for only 1 of a pt's 2 alleles to be
tested for oncogenes. Is testing of the 2nd allele needed? Unlikely; only one
allele needs to be mutated for an oncogene to increase cancer risk, so both alleles
need not necessarily be tested "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
What do c-MYC, MYCL1 and MYCN all have in common? They are all oncogenes that
code for transcription factors "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
A patient presents with a skin lesion described as black with asymmetric and
irregular borders. Which oncogene may carry a mutation? BRAF, a serine/threonine
kinase "<img src=""7685.png"">" Neoplasia Pathology oncogenes
A patient is found to have medullary thyroid cancer. Increased activity of which
signaling molecule is expected on biopsy analysis? A tyrosine kinase (because of
increased RET activity) "<img src=""7685.png"">" Neoplasia Pathology oncogenes
A patient is found to have an aggressive, undifferentiated lymphoma. Are there any
specific gene mutations that may be worth testing for? Yes, undifferentiated
lymphomas can be associated with BCL-2 mutations (codes for an antiapoptotic
molecule) "<img src=""7685.png"">" Neoplasia Pathology oncogenes
Acute lymphoblastic leukemia develops in a young adult with Down syndrome.
Increased activity of which gene product is likely to blame? A tyrosine kinase
(because of a BCR-ABL gene mutation) "<img src=""7685.png"">" Neoplasia
Pathology oncogenes
Patient complains of flushing and itchiness after bathing and has erythrocytosis on
lab workup. Which oncogene may carry a mutation? JAK2 may carry a mutation, as
this is polycythemia vera, a chronic myeloproliferative disorder "<img
src=""7685.png"">" Neoplasia Pathology oncogenes
Which tumor suppressor genes are mutated in a child who presents with ash leaf
spots, seizures, and developmental delays? TSC1, which produces the hamartin
protein, and TSC2, which produces the tuberin protein "<img src=""7686.png"">"
Neoplasia Pathology tumor-suppressor-genes
A lab allows for only 1 of a patient's 2 alleles to be tested for tumor suppressor
gene mutations. Could this affect prognostication? Yes, both alleles of a tumor
suppressor gene must be mutated for cancer risk to increase, so testing of a single
allele is not conclusive "<img src=""7686.png"">" Neoplasia Pathology
tumor-suppressor-genes
A 32-year-old pt with breast cancer has an FH of adrenal tumors, leukemia, and
sarcoma. What is the normal function of the mutated gene? p53, a tumor suppressor,
normally regulates the G1/S transition, and one copy is mutated in Li-Fraumeni
syndrome "<img src=""7686.png"">" Neoplasia Pathology tumor-suppressor-
genes
A pt's family history suggests a BRCA1 or BRCA2 mutation. Why might this lead to
cancer? The BRCA genes encode DNA repair proteins; they function as tumor
suppressors "<img src=""7686.png"">" Neoplasia Pathology tumor-suppressor-
genes
A child presents with mental retardation, seizures, and facial angiofibromas. For
what three tumors is this child at risk? Astrocytoma, angiomyolipoma, and cardiac
rhabdomyoma (This is tuberous sclerosis.) "<img src=""7686.png"">" Neoplasia
Pathology tumor-suppressor-genes
A patient with renal cell carcinoma has a mutation in the inhibitor of hypoxia
inducible factor 1a. For which syndrome should you screen? Screen for von Hippel-
Lindau disease, which is associated with VHL gene mutations (The gene product
inhibits hypoxia inducible factor 1a.) "<img src=""7686.png"">" Neoplasia
A family has an inherited PTEN gene mutation. For which cancers should men and
women in the family be screened? Men: breast and prostate cancers; women: breast
and endometrial cancers "<img src=""7686.png"">" Neoplasia Pathology tumor-
suppressor-genes
A patient is noted to have a defective menin protein. For which syndrome should you
screen the patient? Multiple endocrine neoplasia (MEN) 1, associated with MEN1
gene mutations (encodes for menin) "<img src=""7686.png"">" Neoplasia
What is the role of the VHL tumor suppressor gene? Inhibition of hypoxia
inducible factor 1a "<img src=""7686.png"">" Neoplasia Pathology tumor-
suppressor-genes
A boy is noted to have a palpable flank mass. Hematuria is seen on urinalysis. If
this is malignancy, mutations in which genes are to blame? WT1 or WT2, causing a
nephroblastoma (Wilms Tumor) "<img src=""7686.png"">" Neoplasia Pathology
A boy with neurofibromatosis 1 has a mutation of the NF1 tumor suppressor gene.
What does NF1 typically produce? NF1 encodes the ras GTPase activating protein
(neurofibromin) "<img src=""7686.png"">" Neoplasia Pathology tumor-
suppressor-genes
Loss of function of the tumor suppressor gene NF2 is associated with
neurofibromatosis type 2. What does the gene typically produce? NF2 produces
Merlin (schwannomin) protein "<img src=""7686.png"">" Neoplasia Pathology
A pt presents with epigastric pain; abdominal CT reveals pancreatic mass consistent
w/cancer. Which tumor suppressor gene might be involved? DPC4/SMAD4 (DPCDeleted
in Pancreatic Cancer) "<img src=""7686.png"">" Neoplasia Pathology tumor-
suppressor-genes
A patient has a mass invading the colon. Which tumor suppressor gene could be lost?
DCC (Deleted in Colon Cancer) "<img src=""7686.png"">" Neoplasia
What is a tumor suppressor? A genetic element suppressing cellular growth; its
loss increases the risk of cancer development "<img src=""7686.png"">"
Neoplasia Pathology tumor-suppressor-genes
A 2-year-old girl has leukocoria and strabismus. A mass is palpated over her femur.
Which tumor suppressor gene is most likely involved? Rb (The patient likely has
Retinoblastoma and osteosarcoma "<img src=""7686.png"">" Neoplasia
The tumor suppressor gene associated with retinoblastoma and osteosarcoma has what
function? The Rb tumor suppressor gene inhibits E2F, blocking the G1toS phase
transition "<img src=""7686.png"">" Neoplasia Pathology tumor-suppressor-
genes
A young woman is found to have both breast and ovarian cancer. Which intracellular
process is likely impaired due to a mutation? DNA repair (due to a BRCA1 or BRCA2
mutation) "<img src=""7686.png"">" Neoplasia Pathology tumor-suppressor-
genes
A patient with Li-Fraumeni syndrome is found to have a p53 mutation. What does this
gene product normally do? p53 is a transcription factor for p21, blocking the
G1toS phase transition "<img src=""7686.png"">" Neoplasia Pathology
A woman with melanoma is confirmed to have a tumor suppressor gene mutation at
CDKN2A. What does the gene typically produce? p16, which blocks cell progression
from G1 to S phase "<img src=""7686.png"">" Neoplasia Pathology tumor-
suppressor-genes
On colonoscopy, a teenage boy is found to have rectal bleeding and thousands of
polyps. Which tumor suppressor gene is most likely involved? The APC gene is
associated with familial adenomatous polyposis (FAP) and a high risk for colorectal
cancer "<img src=""7686.png"">" Neoplasia Pathology tumor-suppressor-
genes
A patient has adult T-cell leukemia. Which oncogenic virus do you suspect? Human
T-cell leukemia virus 1 (can also cause a lymphoma) "<img src=""7687.png"">"
Neoplasia Pathology oncogenic-microbes
Which oncogenic viruses are associated with hepatocellular carcinoma? Hepatitis
viruses B and C (HBV and HCV) "<img src=""7687.png"">" Neoplasia Pathology
oncogenic-microbes
Which oncogenic virus is associated with CNS lymphoma (immunocompromised), Burkitt
lymphoma, Hodgkin lymphoma, and nasopharyngeal carcinoma? Epstein-Barr virus (EBV)
"<img src=""7687.png"">" Neoplasia Pathology oncogenic-microbes
Which oncogenic virus is associated with Kaposi sarcoma and body cavity fluid B-
cell lymphoma? Human herpesvirus type 8 (HHV-8) "<img src=""7687.png"">"
A patient has an oncogenic virus associated with penile/anal carcinoma. Where else
should you look for cancer? In the head and neck, the throat, and the cervix in
women; (HPV (especially subtypes 16 and 18) can cause cancer in these areas "<img
src=""7687.png"">" Neoplasia Pathology oncogenic-microbes
Patients with HIV are at increased risk for many cancers. For which type of cancer
is a patient with HIV and EBV at risk? Primary central nervous system lymphoma
"<img src=""7687.png"">" Neoplasia Pathology oncogenic-microbes
A patient with peptic ulcer disease has a positive urea breath test. For which two
cancers does he have an increased risk? Gastric adenocarcinoma and MALT lymphoma
(The patient has H pylori infection.) "<img src=""7687.png"">" Neoplasia
Pathology oncogenic-microbes
For which specific cancer are patients with a history of Schistosoma haematobium
exposure at increased risk? Squamous cell carcinoma of the bladder "<img
src=""7687.png"">" Neoplasia Pathology oncogenic-microbes
Name a liver fluke that can be categorized as an oncogenic microbe. What cancer
does it cause? Clonorchis sinensis; cholangiocarcinoma "<img src=""7687.png"">"
For what two malignancies is a 40-year-old man with a history of coccidioidomycosis
and Pneumocystis jirovecii at risk? Non-Hodgkin lymphoma and Kaposi sarcoma (This
patient likely has AIDS.) "<img src=""7687.png"">" Neoplasia Pathology
oncogenic-microbes
A patient with a career in the cleaning industry was exposed to carbon
tetrachloride. What will the pathology report of his liver show? Centrilobular
necrosis and fatty change in the liver "<img src=""7688.png"">" Neoplasia
Pathology carcinogens
Smoked foods often have which chemical that is associated with an increased risk of
stomach cancer? Nitrosamines "<img src=""7688.png"">" Neoplasia
Name at least four cancers that are associated with the carcinogenic effects of
cigarette smoke. Lung, laryngeal squamous cell, renal cell, cervical, bladder, and
esophageal cancers; pancreatic adenocarcinoma "<img src=""7688.png"">"
Neoplasia Pathology carcinogens
Which chemical carcinogen is associated with mesothelioma and bronchogenic
carcinoma? Which one occurs more commonly? Asbestos; bronchogenic carcinoma is
more common than mesothelioma "<img src=""7688.png"">" Neoplasia Pathology
carcinogens
Arsenic exposure is associated with which three types of carcinoma? Squamous
cell carcinoma of the skin, lung cancer, and angiosarcoma of the liver "<img
src=""7688.png"">" Neoplasia Pathology carcinogens
A patient has gross hematuria. You find a transitional cell carcinoma. What type of
chemical is classically associated with this malignancy? Aromatic amines (eg,
benzidine, 2-naphthylamine) "<img src=""7688.png"">" Neoplasia Pathology
carcinogens
A woman's breast cancer is fully treated with an alkylating agent. For which other
cancer type should lifelong screening be done? Blood cancers (leukemia), which can
arise as a result of alkylating agent use "<img src=""7688.png"">" Neoplasia
Excessive alcohol intake will increase risk for which two cancer types?
Hepatocellular carcinoma and squamous cell carcinoma of the esophagus "<img
A woman worked in a factory that made radium dial watches that emitted radon.
Exposure has increased her risk for what malignancy? Lung cancer "<img
A patient is exposed to ionizing radiation in a work accident. For which specific
malignancy does this increase his risk? Papillary thyroid carcinoma "<img
A patient with a history of aflatoxin-producing Aspergillus infection is at risk
for developing what type of carcinoma? Hepatocellular carcinoma "<img
A patient is found to have angiosarcoma of the liver. What was this patient's most
likely occupation? Chemical plant worker, specifically work involving vinyl
chloride (a risk factor for liver angiosarcoma) "<img src=""7688.png"">"
Neoplasia Pathology carcinogens
What is a psammoma body? A laminated, concentric, calcified spherule seen
histologically in a number of cancers "<img src=""7689.png"">" Neoplasia
Pathology psammoma-bodies
A man has prostate cancer that has been in remission for several months. Which
marker might be used for detecting reoccurrence? Prostate-specific antigen
(PSA) "<img src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
List at least three cancer types that may all have elevated carcinoembryonic
antigen (CEA)? Colorectal, pancreatic, gastric, breast, medullary thyroid
carcinoma "<img src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
Which tumor marker (normally made by a fetus) can also be elevated in the presence
of a yolk sac tumor? -fetoprotein "<img src=""7690.png"">" Neoplasia
Pathology serum-tumor-markers
A 45-year-old alcoholic has a mass in his right upper quadrant; you suspect
hepatocellular carcinoma. Which tumor marker can you order?-fetoprotein "<img
src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
A patient is found to have increased -human chorionic gonadotropin. Which cancers
are associated with this marker? Hydatidiform moles, Choriocarcinomas
(Gestational trophoblastic disease), testicular cancer, mixed germ cell tumors
(hCG) "<img src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
What tumor marker is associated with ovarian tumors? CA 125 "<img
What cancers/diseases are associated with an elevated alkaline phosphatase level?
Bone/liver metastases, seminoma (placental ALP), and Paget disease of bone
"<img src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
A patient being treated for cancer presents with an elevated alkaline phosphatase
level. What may have occurred? Metastases to bone or liver "<img
A patient has an abdominal mass near the pancreas. Though not diagnostic, testing
of which tumor marker may aid you in the workup? CA 19-9, which is increased
with pancreatic adenocarcinoma "<img src=""7690.png"">" Neoplasia
How are tumor markers used in clinical practice? To confirm a diagnosis, to
monitor for tumor recurrence, and to monitor response to therapy (not to diagnose)
"<img src=""7690.png"">" Neoplasia Pathology serum-tumor-markers
A 70-year-old man has increased prostate-specific antigen (PSA) and an enlarged,
painful prostate. List three differential diagnoses. Benign prostatic hyperplasia,
prostatitis, and prostate cancer "<img src=""7690.png"">" Neoplasia
Which tumor marker may be elevated in a patient with MEN 2A syndrome and a thyroid
malignancy? Calcitonin, a marker of medullary thyroid cancer "<img
A 54-year-old woman has elevated CA 15-3 and CA 27-29 markers. What type of cancer
does she most likely have? Breast cancer "<img src=""7690.png"">"
Neoplasia Pathology serum-tumor-markers
In which tumors might -fetoprotein be used to monitor recurrence or response to
therapy? Hepatocellular carcinoma, hepatoblastoma, yolk sac (endodermal sinus)
tumor, mixed germ cell tumor "<img src=""7690.png"">" Neoplasia Pathology
serum-tumor-markers
A 60-y/o smoker has a cough and cushingoid habitus. X-ray shows a lung mass. Which
neuroendocrine marker will return positive in his tumor? Chromogranin (This is
small cell carcinoma of the lung with ectopic ACTH secretion.) "<img
A young woman has an elevated serum -fetoprotein level. Before she is screened for
malignancy, what state should be ruled out? Pregnancy, which causes mild -
fetoprotein elevation; fetal neural tube/abdominal wall defects may also cause a
high -fetoprotein level "<img src=""7690.png"">" Neoplasia Pathology
serum-tumor-markers
Because of a lab error, a healthy patient's CEA level is checked. It returns high.
Do you diagnose any particular cancers in this patient? No, CEA is too
nonspecific to diagnose any specific cancers; more information is needed to
diagnose cancer, if it is even present "<img src=""7690.png"">" Neoplasia
Which substance, also called multidrug resistance protein 1 (MDR1), can increase
resistance to chemotherapy over time? How does it work? P-glycoprotein,
expressed by some cancers (eg, colon, liver); it pumps out toxins (eg,
chemotherapy), increasing resistance to treatment "<img src=""7691.png"">"
Neoplasia Pathology p-glycoprotein
A patient being treated for adrenal cell carcinoma stops responding to therapy.
Name a marker that expels chemotherapy drugs out of cells. P-glycoprotein or
multidrug resistance protein 1 "<img src=""7691.png"">" Neoplasia
Pathology p-glycoprotein
A chemo pt has decreased intracellular doxorubicin and etoposide concentrations.
What is the normal function of the protein responsible? Multidrug resistance
protein 1 (MDR1), also known as P-glycoprotein, normally pumps out toxins and
metabolites "<img src=""7691.png"">" Neoplasia Pathology p-glycoprotein
Define cachexia. The weight loss, muscle atrophy, and fatigue that occur in
chronic disease "<img src=""7692.png"">" Neoplasia Pathology cachexia
What are some common diseases that can cause cachexia? Cancer, AIDS, heart
failure, tuberculosis, COPD (Note that all of these are chronic diseases.) "<img
src=""7692.png"">" Neoplasia Pathology cachexia
A man with stage IV cancer experiences marked weight loss, muscle atrophy, and
fatigue. What inflammatory markers will be elevated in him?This is cachexia,
mediated by tumor necrosis factor (TNF; cachectin), interferon-, IL-1, and IL-6
"<img src=""7692.png"">" Neoplasia Pathology cachexia
A patient has cancer with lymph node involvement. What are the next two most common
areas of metastasis? Liver and lung (the most common sites of metastasis after
the regional lymph nodes) "<img src=""7693.png"">" Neoplasia Pathology
common-metastases
Which cancers commonly metastasize to the bone? Breast, lung, thyroid, kidney, and
prostate cancers "<img src=""7693.png"">" Neoplasia Pathology common-
metastases
Name the five primary sites of tumors that commonly metastasize to the brain, from
most to least common. Lung, breast, prostate, melanoma, and GI "<img
src=""7693.png"">" Neoplasia Pathology common-metastases
Metastasis from the lung to the bone results in what type of lesions? Mixed (lytic
and blastic) "<img src=""7693.png"">" Neoplasia Pathology common-
metastases
Metastasis from the prostate to the bone results in what type of lesions?
Blastic "<img src=""7693.png"">" Neoplasia Pathology common-
metastases
Metastasis from the breast to the bone results in what type of lesions? Mixed
(lytic and blastic) "<img src=""7693.png"">" Neoplasia Pathology common-
metastases
Name the three primary sites of tumors that commonly metastasize to the liver, from
most to least common. Colon, stomach, and pancreas "<img src=""7693.png"">"
Neoplasia Pathology common-metastases
Name the four primary sites of tumors that commonly metastasize to bone, from most
to least common. Prostate, breast, lung, thyroid, and kidney "<img
src=""7693.png"">" Neoplasia Pathology common-metastases
How do competitive inhibitors work? Competitive inhibitors resemble the substrate
and compete for the active site on an enzyme, decreasing substrate affinity "<img
src=""7694 (1).png"">" enzyme-kinetics pharmacokinetics-and-pharmacodynamics
pharmacology
Define Km. Km (the Michaelis-Menten constant) is inversely related to affinity of
an enzyme for a substrate (higher Km= less affinity for substrate) "<img
pharmacology
What does decreasing Km do to enzyme affinity? It increases enzyme affinity for
the substrate "<img src=""7694 (1).png"">" enzyme-kinetics pharmacokinetics-
and-pharmacodynamics pharmacology
How is Vmax It is directly proportional: more enzyme = higher Vmax "<img
pharmacology
When the substrate concentration increases, what happens to the rate of reaction?
It increases, then plateaus; reaction velocity increases as substrate
concentration increases and plateaus when the enzyme is saturated "<img
pharmacology
When velocity is equal to half its maximum (Vmax), the corresponding concentration
of substrate is equal to what value? Km "<img src=""7694 (1).png"">"
enzyme-kinetics pharmacokinetics-and-pharmacodynamics pharmacology
Describe the effect of each inhibitor type on Km: reversible competitive,
irreversible competitive, and noncompetitive. Reversible competitive increases
Km; irreversible competitive does not change it; noncompetitive does not change it
"<img src=""7694 (1).png"">" enzyme-kinetics pharmacokinetics-and-
pharmacodynamics pharmacology
Describe the effect of each inhibitor type on Vmax: reversible competitive,
irreversible competitive, and noncompetitive. Reversible competitive does not
change Vmax; irreversible competitive decreases it; noncompetitive decreases it
"<img src=""7694 (1).png"">" enzyme-kinetics pharmacokinetics-and-
Describe the effect of each inhibitor type on pharmacodynamics: reversible
competitive, irreversible competitive, and noncompetitive. Reversible competitive
decreases potency; irreversible competitive decreases efficacy; noncompetitive
decreases efficacy "<img src=""7694 (1).png"">" enzyme-kinetics
pharmacokinetics-and-pharmacodynamics pharmacology
Indicate whether each of these inhibitor types binds to an active site: reversible
competitive, irreversible competitive, noncompetitive. Reversible competitive
binds to an active site; irreversible competitive binds to an active site;
noncompetitive does not bind "<img src=""7694 (1).png"">" enzyme-kinetics
Indicate whether each inhibitor type can be overcome by a rise in [S]: reversible
competitive, irreversible competitive, & noncompetitive. Reversible competitive,
yes; irreversible competitive, no; noncompetitive, no "<img src=""7694 (1).png"">"
Indicate whether each inhibitor type resembles its substrate: reversible
competitive, irreversible competitive, & noncompetitive. Reversible competitive,
yes; irreversible competitive, yes; noncompetitive, no "<img src=""7694
(1).png"">" enzyme-kinetics pharmacokinetics-and-pharmacodynamics pharmacology
Hemoglobin is a protein that exhibits cooperative kinetics. What will the curve
look like with cooperative kinetics? Sigmoidal "<img src=""7694 (1).png"">"
A drug inhibitor increases Km and is overcome when the substrate concentration
increases. What type of inhibitor is it? Competitive inhibitor, reversible "<img
pharmacology
You are worried about the bioavailability, clearance, and half-life of drug A in
the body. Pharmacokinetics or pharmacodynamics? Pharmacokinetics "<img src=""7695
(1).png"">" pharmacokinetics pharmacokinetics-and-pharmacodynamics pharmacology
You give 50 mg of drug A to a pt. The initial plasma drug concentration is 2.5
mg/L. What is the volume of distribution of drug A? 20 L; Volume of distribution
= Amount of drug in the body/Plasma drug concentration "<img src=""7695
A pt takes a drug with a low volume of distribution (eg, 48 L). Where in the body
is the drug most likely to be distributed? Blood only; these drugs (usually
large/charged molecules or drugs bound to plasma protein) are not distributed
outside the plasma "<img src=""7695 (1).png"">" pharmacokinetics
A pt takes a drug with a medium volume of distribution (15 L). Where is it most
likely to be found: blood, extracellular space, or tissues?Extracellular space;
these drugs (usually small hydrophilic molecules) are distributed throughout the
total body water "<img src=""7695 (1).png"">" pharmacokinetics pharmacokinetics-
A pt takes a drug with a high volume of distribution (40 L). Where is it most
likely to be found: blood, extracellular space, or tissues?All tissues, including
fat; these drugs are usually small lipophilic molecules and may be bound to tissue
protein "<img src=""7695 (1).png"">" pharmacokinetics pharmacokinetics-and-
In a pt who weighs 75 kg, a drug has a volume of distribution of 40 L. Where can it
be expected to be found in the body? All tissues (including fat) "<img
src=""7695 (1).png"">" pharmacokinetics pharmacokinetics-and-pharmacodynamics
pharmacology
A pt has minimal change disease (MCD). Would the apparent Vd of a plasma protein
bound drug increase or decrease? Increase. Apparent Vdcan be changed by
liver/kidney disease. MCD causes loss of plasma proteins; decreased protein binding
can increase Vd "<img src=""7695 (1).png"">" pharmacokinetics pharmacokinetics-
What is the formula for calculating the clearance of a drug? Clearance = Rate
of elimination of drug/Plasma drug concentration, or Vd Ke (elimination constant)
"<img src=""7695 (1).png"">" pharmacokinetics pharmacokinetics-and-
The t of a drug is 4 hours. How long must the drug be infused at a constant rate
before only 6.25% of the drug remains? 16 hours (4 half-lives) "<img src=""7695
You have decided to administer a drug but are worried about drug clearance in your
pt. Which diseases could impair drug clearance? Diseases that cause defects in
cardiac, renal, or hepatic function "<img src=""7695 (1).png"">" pharmacokinetics
What is the definition of the half-life of a drug? The time of
elimination/constant infusion required to change the amount of drug in the body by
half; property of first-order elimination "<img src=""7695 (1).png"">"
pharmacokinetics pharmacokinetics-and-pharmacodynamics pharmacology
You administer a drug with a half-life of 2 hours to a pt by way of constant
infusion. How long will it take to reach steady state? 8 to 10 hours; a drug
infused at a constant rate reaches 90% of steady state at ~3.3 half-lives and
steady state at ~45 half-lives "<img src=""7695 (1).png"">" pharmacokinetics
You administer a drug with a Vd of 30 L and a clearance rate of 1.05 L/min. What is
the half-life of this drug? 20 minutes: Half-life = (0.693 Volume of
distribution)/Clearance "<img src=""7695 (1).png"">" pharmacokinetics
After 1 half-life, given constant intravenous infusion of a drug, how close to
steady state is the concentration of the drug? 50% of steady-state concentration
You prescribe a drug that is taken orally. The bioavailability (F) is 70%. Which
two factors likely cause F to be less than 100%? Incomplete absorption of the
drug and first-pass metabolism; bioavailability of intravenous drugs is 100% "<img
pharmacology
A drug has a bioavailability of 60%. What dosage is needed to ensure that 300 mg of
the drug reaches the systemic circulation unchanged? 500 mg: Amount of drug needed
0.6 = 300 mg, so drug needed = 300 mg/0.6 = 500 mg "<img src=""7695 (1).png"">"
A pt is given constant intravenous infusion of a drug. After 3 half-lives, what
percentage of the drug remains? 12.5% of steady-state concentration "<img
pharmacology
Drug B is made up of small hydrophilic molecules. Where is this drug typically
distributed: blood, extracellular space, or tissues? Extracellular space "<img
pharmacology
Drug C is made up of large charged molecules. Where is this drug typically
distributed: blood, extracellular space, or tissues? Blood "<img src=""7695
Drug D is composed of small lipophilic molecules. Where is this drug typically
distributed: blood, extracellular space, or tissues? All tissues, including fat
Drug E is a drug that tends to bind to tissue proteins. Where does it tend to be
distributed: blood, extracellular space, or tissues? Why? All tissues, including
fat; it has a high Vd "<img src=""7695 (1).png"">" pharmacokinetics
What is the bioavailability for a drug administered IV and how does it differ from
the same drug given orally? IV bioavailability = 100%. Oral bioavailability is
usually less than 100% due to first-pass metabolism "<img src=""7695 (1).png"">"
What is the formula for the loading dose of a drug? Loading dose = Target plasma
concentration Volume of distribution)/Bioavailability "<img src=""7696
(1).png"">" dosage-calculations pharmacokinetics-and-pharmacodynamics pharmacology
What is the formula for calculating the maintenance dose of a drug administered IV?
Maintenance dose = Target plasma concentration Clearance Dosage
interval/Bioavailability "<img src=""7696 (1).png"">" dosage-calculations
One pt has cirrhosis and another has chronic renal failure. How do you change the
loading and maintenance doses of drugs for them? In both hepatic and renal
disease, loading dose usually does not change, but maintenance dose is decreased
"<img src=""7696 (1).png"">" dosage-calculations pharmacokinetics-and-
Name the factor(s) on which time to steady state depends: t, dose, dosing
frequency. Time to steady state mainly depends on t; it is independent of dose
and dosing frequency "<img src=""7696 (1).png"">" dosage-calculations
Giving aspirin and acetaminophen together would have what kind of effect?
Additive. Effects of substance A and B will be equal to the sum of their
individual effects "<img src=""7697 (1).png"">" pharmacokinetics-and-
pharmacodynamics pharmacology types-of-drug-interactions
Drug A is required to see the full effect of Drug B. This describes what kind of
interaction? Permissive "<img src=""7697 (1).png"">" pharmacokinetics-and-
pharmacodynamics pharmacology types-of-drug-interactions
A pt undergoing coronary stenting receives dual anti-platelet therapy with
clopidogrel and aspirin. What interaction will these drugs have? Synergistic.
Effect is greater than the sum of individual parts "<img src=""7697 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology types-of-drug-interactions
A person takes multiple doses of LSD and finds that the effects decline rapidly.
What type of interaction is this? Tachyphylactic "<img src=""7697 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology types-of-drug-interactions
In zero-order elimination of drugs from the body, what is the relationship between
the rate of elimination and the drug concentration? No relationship; the rate of
elimination is constant (fixed amount of drug per unit of time), regardless of drug
concentration "<img src=""7698 (1).png"">" elimination-of-drugs
Name three drugs that exhibit zero-order elimination. "Phenytoin, Ethanol, and
Aspirin at toxic concentrations (A PEA is round, shaped like the ""0"" in zero
order.)" "<img src=""7698 (1).png"">" elimination-of-drugs pharmacokinetics-
In first-order elimination of drugs from the body, what is the relationship between
the rate of elimination and the drug concentration? Rate of elimination is
directly proportional to the drug concentration: a constant fraction (rather than a
constant amount) is eliminated "<img src=""7698 (1).png"">" elimination-of-
drugs pharmacokinetics-and-pharmacodynamics pharmacology
A 20-year-old man has been taking amphetamines. Which substance should you give to
enhance the renal clearance of this weakly basic drug? Ammonium chloride "<img
src=""7699 (1).png"">" pharmacokinetics-and-pharmacodynamics pharmacology urine-
ph-and-drug-elimination
Three hours after a boy consumes a bottle of aspirin, IV saline with bicarbonate is
started. By what mechanism does this help him? Bicarbonate alkalinizes the lumen
of nephrons, thereby trapping aspirin (a weak acid that is ionized in basic
environments) in urine "<img src=""7699 (1).png"">" pharmacokinetics-and-
pharmacodynamics pharmacology urine-ph-and-drug-elimination
A young college student has overdosed on the combination drug Adderall. How do you
treat this overdose? Overdoses of amphetamines, such as Adderall, may be treated
with ammonium chloride "<img src=""7699 (1).png"">" pharmacokinetics-and-
In which environment will a weak acid become trapped? What about a weak base?
A weak acid will become trapped in a basic environment; a weak base will
become trapped in an acidic environment "<img src=""7699 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology urine-ph-and-drug-
elimination
What substance is given to enhance the renal clearance of weakly acidic drugs such
as phenobarbital, methotrexate, TCAs, and aspirin? Bicarbonate: A basic
environment ionizes weakly acidic drugs, and ionized drugs are then trapped in
urine and cleared quickly "<img src=""7699 (1).png"">" pharmacokinetics-and-
Which three types of biochemical reactions are involved in phase I metabolism of
drugs? Reduction, oxidation, and hydrolysis "<img src=""7700 (1).png"">"
drug-metabolism pharmacokinetics-and-pharmacodynamics pharmacology
Will drugs be more or less soluble in water after phase I of drug metabolism?
More soluble: Drugs become more polar and are often still active "<img
src=""7700 (1).png"">" drug-metabolism pharmacokinetics-and-pharmacodynamics
pharmacology
Which enzyme system mediates phase I metabolism of drugs in the body? Cytochrome
P-450, usually resulting in water-soluble, slightly polar metabolites that are
often still active "<img src=""7700 (1).png"">" drug-metabolism
Which four types of conjugation reactions are involved in phase II metabolism of
drugs? Glucuronidation, acetylation, methylation and sulfation "<img
src=""7700 (1).png"">" drug-metabolism pharmacokinetics-and-pharmacodynamics
pharmacology
In a geriatric pts, which system of drug metabolism (phase I or phase II) will be
lost first? Phase I (Geriatric patients have More GAS = Methlyation,
Glucuronidation, Acetylation, and Sulfation [phase II].) "<img src=""7700
(1).png"">" drug-metabolism pharmacokinetics-and-pharmacodynamics pharmacology
What are the characteristics of drugs that have undergone phase II drug metabolism?
Very polar; inactive; renally excreted "<img src=""7700 (1).png"">" drug-
metabolism pharmacokinetics-and-pharmacodynamics pharmacology
The products of phase II metabolism of drugs are typically excreted by which organ?
Kidneys "<img src=""7700 (1).png"">" drug-metabolism pharmacokinetics-
Which phase of drug metabolism is likely to be preserved in a 98-year-old man?
Phase II (Geriatric patients have More GAS = Methlyation, Glucuronidation,
Acetylation, and Sulfation [phase II].) "<img src=""7700 (1).png"">" drug-
metabolism pharmacokinetics-and-pharmacodynamics pharmacology
A 40-year-old man is a slow acetylator. Does he have a greater or lesser side
effect burden than someone with normal acetylation? Why? He has a greater side
effect burden because of the decreased rate of metabolism "<img src=""7700
(1).png"">" drug-metabolism pharmacokinetics-and-pharmacodynamics pharmacology
What is the definition of efficacy? Maximal effect a drug can produce "<img
src=""7701 (1).png"">" efficacy-vs-potency pharmacokinetics-and-pharmacodynamics
pharmacology
What is the definition of potency? Amount of drug needed for a given effect "<img
pharmacology
If 50 mg of drug A is needed to achieve an effect but 100 mg of drug B is needed
for the same effect, what is different between the drugs? Potency: Drug A is more
potent. Both drugs have the same effect and therefore the same efficacy "<img
pharmacology
By increasing efficacy, what happens to potency? Nothing: Factors are
unrelated and independent of one another "<img src=""7701 (1).png"">" efficacy-vs-
potency pharmacokinetics-and-pharmacodynamics pharmacology
What happens to efficacy when a competitive antagonist is given? Efficacy remains
the same. A competitive antagonist is overcome with increased concentration of
agonist "<img src=""7702 (1).png"">" pharmacokinetics-and-pharmacodynamics
pharmacology receptor-binding
In pharmacodynamics, what happens to efficacy in the presence of a noncompetitive
antagonist? Efficacy is decreased and cannot be overcome by increasing the agonist
substrate concentration "<img src=""7702 (1).png"">" pharmacokinetics-and-
pharmacodynamics pharmacology receptor-binding
How does the efficacy of a partial agonist relate to the efficacy of a full agonist
of the same receptor? A partial agonist has lower maximal efficacy. (Potency is a
separate, independent variable.) "<img src=""7702 (1).png"">" pharmacokinetics-
and-pharmacodynamics pharmacology receptor-binding
How does the potency of a partial agonist relate to the potency of a full agonist
of the same receptor? A partial agonist may be more potent than, less potent
than, or just as potent as a full agonist "<img src=""7702 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology receptor-binding
A man overdoses on diazepam. An antidote acting on GABA receptors is given. In what
direction does diazepam's receptor binding curve shift? The curve shifts to the
right; potency is decreased with no change in efficacy. (He was given flumazenil, a
competitive antagonist.) "<img src=""7702 (1).png"">" pharmacokinetics-and-
pharmacodynamics pharmacology receptor-binding
Phenoxybenzamine (PB) lowers the efficacy of norepinephrine (NE) on -receptors. PB
is likely what type of antagonist to NE on -receptors? Noncompetitive "<img
src=""7702 (1).png"">" pharmacokinetics-and-pharmacodynamics pharmacology
receptor-binding
A pt is given buprenorphine instead of morphine and is in significantly more pain.
What kind of receptor binding is occurring? Partial agonist with decreased
efficacy "<img src=""7702 (1).png"">" pharmacokinetics-and-pharmacodynamics
pharmacology receptor-binding
Which property of a drug is determined by its therapeutic index? Safety: Drugs with
higher therapeutic indices are less likely to cause toxicities "<img src=""7703
(1).png"">" pharmacokinetics-and-pharmacodynamics pharmacology therapeutic-index
What is the formula that describes the therapeutic index (TI) of a drug? TI =
TD50 (median toxic dose)/ED50 (median effective dose) (TITE) "<img src=""7703
(1).png"">" pharmacokinetics-and-pharmacodynamics pharmacology therapeutic-index
Drug A has a therapeutic index of 5, whereas drug B has a therapeutic index of 30.
Which drug is safer for your patient? Drug B: Safer drugs have higher
therapeutic index values; drugs such as digoxin, lithium, theophylline, and
warfarin have lower TI values. "<img src=""7703 (1).png"">" pharmacokinetics-
and-pharmacodynamics pharmacology therapeutic-index
What property of a drug is determined by its therapeutic window? The measure of
clinical drug effectiveness for a pt "<img src=""7703 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology therapeutic-index
Median toxic dose (TD50) is often replaced by another value for animal studies.
What is it? Lethal median dose (LD50) "<img src=""7703 (1).png"">"
pharmacokinetics-and-pharmacodynamics pharmacology therapeutic-index
Which types of nerves arise from the spinal cord and directly innervate skeletal
muscle? Somatic nerves "<img src=""7704 (1).png"">" autonomic-drugs central-
and-peripheral-nervous-system pharmacology
How many neurons are involved in parasympathetic transmission from the spinal cord
to the target organ? Two "<img src=""7704 (1).png"">" autonomic-drugs central-
Which neurotransmitter receptors mediate parasympathetic tone in cardiac and smooth
muscle, as well as in gland cells? Muscarinic acetylcholine receptors "<img
src=""7704 (1).png"">" autonomic-drugs central-and-peripheral-nervous-system
pharmacology
Describe the two neurons in the parasympathetic nervous system. The preganglionic
neuron originates in the medulla and has a long axon; the postganglionic neuron is
near the organ and has a short axon "<img src=""7704 (1).png"">" autonomic-drugs
central-and-peripheral-nervous-system pharmacology
Which neurotransmitter mediates parasympathetic nervous system function?
Acetylcholine (ACh) "<img src=""7704 (1).png"">" autonomic-drugs central-
Which neurotransmitter receptors mediate parasympathetic nervous system function at
the peripheral ganglia? Nicotinic acetylcholine receptors "<img src=""7704
(1).png"">" autonomic-drugs central-and-peripheral-nervous-system pharmacology
Somatic nerves arising from the spine innervate skeletal muscle. Which
neurotransmitter receptors on skeletal muscle receive this input? Nicotinic
acetylcholine receptors "<img src=""7704 (1).png"">" autonomic-drugs central-and-
peripheral-nervous-system pharmacology
How many neurons are involved in sympathetic transmission from the spinal cord to
the target organ? Two "<img src=""7704 (1).png"">" autonomic-drugs central-and-
Where do preganglionic sympathetic neurons synapse? Paravertebral ganglia,
sympathetic chain "<img src=""7704 (1).png"">" autonomic-drugs central-and-
Which neurotransmitter is present at the paravertebral ganglia and what type of
receptor does it act on? Acetylcholine; nicotinic receptor "<img src=""7704
Which neurotransmitter mediates sympathetic nervous system function at the sweat
glands? Acetylcholine "<img src=""7704 (1).png"">" autonomic-drugs central-
Which neurotransmitter receptors mediate sympathetic nervous system function to
permit sweating? Muscarinic acetylcholine receptors "<img src=""7704 (1).png"">"
autonomic-drugs central-and-peripheral-nervous-system pharmacology
Which neurotransmitter mediates sympathetic tone in the cardiac muscle, smooth
muscle, and glandular cells? Norepinephrine "<img src=""7704 (1).png"">"
autonomic-drugs central-and-peripheral-nervous-system pharmacology
What are four cell types in which - and -adrenergic receptors mediate sympathetic
tone? Cardiac muscle, smooth muscle, glandular cells, and terminal ends of neurons
"<img src=""7704 (1).png"">" autonomic-drugs central-and-peripheral-nervous-
system pharmacology
Which neurotransmitter mediates sympathetic tone in the renal vasculature and in
smooth muscle? Dopamine "<img src=""7704 (1).png"">" autonomic-drugs central-
Which neurotransmitter receptor mediates sympathetic tone in the renal vasculature
and in smooth muscle? D1 receptor "<img src=""7704 (1).png"">" autonomic-drugs
central-and-peripheral-nervous-system pharmacology
Which two substances are released into the blood from the adrenal medulla after the
activation of the sympathetic nervous system? Epinephrine and norepinephrine
"<img src=""7704 (1).png"">" autonomic-drugs central-and-peripheral-nervous-
system pharmacology
How many synapses are involved in activation of the adrenal medulla? One "<img
src=""7704 (1).png"">" autonomic-drugs central-and-peripheral-nervous-system
pharmacology
A man has double vision and dry mouth. You suspect food poisoning with Clostridium.
Which transmitter/receptor group(s) is/are affected? All neurotransmitter/receptor
groups with ACh as the neurotransmitter (cholinergic terminals) will be affected,
as botulism is suspected "<img src=""7704 (1).png"">" autonomic-drugs central-
Which two components of the sympathetic nervous system are innervated by
cholinergic fibers? Adrenal medulla and sweat glands "<img src=""7704
Are nicotinic acetylcholine receptors ligand-gated sodium-potassium channels or G-
proteincoupled receptors? Nicotinic receptors are ligand-gated sodium-potassium
channels "<img src=""7705 (1).png"">" ach-receptors autonomic-drugs
pharmacology
Are muscarinic acetylcholine receptors ligand-gated sodium-potassium channels or G-
proteincoupled receptors? Muscarinic acetylcholine receptors are G-protein
coupled receptors that act through second messengers "<img src=""7705 (1).png"">"
ach-receptors autonomic-drugs pharmacology
What are the two subtypes of nicotinic acetylcholine receptors, and where are they
typically found? NN is found in autonomic ganglia and adrenal medulla; NM is found
at neuromuscular junctions of skeletal muscle "<img src=""7705 (1).png"">" ach-
receptors autonomic-drugs pharmacology
How many subtypes of muscarinic acetylcholine receptors are there? Five: M1,
M2, M3, M4, and M5 "<img src=""7705 (1).png"">" ach-receptors autonomic-drugs
pharmacology
To what class of G proteins are 1-, 2-, 1-, 2-, and 3-receptors linked? "G-
protein classes q, i, s, s, and s, respectively. (""After qisses [kisses], you get
a qiq [kick] out of siq [sick] sqs [super qinky sex]."")" "<img src=""7706
(1).png"">" autonomic-drugs g-proteinlinked-2nd-messengers pharmacology
To what class of G proteins are M1-, M2-, and M3-receptors linked? "G-protein
classes q, i, and q, respectively. (""After qisses [kisses], you get a qiq [kick]
out of siq [sick] sqs [super qinky sex]."")" "<img src=""7706 (1).png"">"
autonomic-drugs g-proteinlinked-2nd-messengers pharmacology
To what class of G proteins are D1-, D2-, and H1-receptors linked? "G-protein
classes s, i, and q, respectively. (""After qisses [kisses], you get a qiq [kick]
To what class of G proteins are H2-, V1-, and V2-receptors linked? "G-protein
classes s, q, and s, respectively. (""After qisses [kisses], you get a qiq [kick]
What are the major effects of 1-receptor activation? Vascular smooth muscle
contraction, pupillary dilator muscle contraction (mydriasis), intestinal and
bladder sphincter muscle contraction "<img src=""7706 (1).png"">" autonomic-
drugs g-proteinlinked-2nd-messengers pharmacology
What are the major effects of 2-receptor activation? Decreased sympathetic
(adrenergic) output, reduced lipolysis and insulin, increased platelet aggregation,
increased aqueous humor synthesis "<img src=""7706 (1).png"">" autonomic-drugs g-
proteinlinked-2nd-messengers pharmacology
What are the major functions of 1-receptor activation? Increased heart rate and
contractility, increased renin release from the kidneys, increased lipolysis "<img
src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-2nd-messengers
pharmacology
A tocolytic is administered to a pt to prevent premature labor. Which G-protein
receptor is likely activated through this medication? 2-Receptor: Activation
decreases uterine tone by way of Gs "<img src=""7706 (1).png"">" autonomic-drugs g-
A drug activates 2-receptors. How does it affect the body's vasculature? It
promotes vasodilation "<img src=""7706 (1).png"">" autonomic-drugs g-protein
linked-2nd-messengers pharmacology
A drug activates 2-receptors. How will it affect the respiratory system? It
promotes bronchodilation "<img src=""7706 (1).png"">" autonomic-drugs g-
What are the major effects of 3-receptor activation? Increased lipolysis and
increased thermogenesis in skeletal muscle "<img src=""7706 (1).png"">"
An 2-receptor agonist is given. Serum insulin and lipid levels decrease.
Intracellular ATP increases. What enzyme is being inhibited? Adenylyl cyclase,
from stimulation of Gi activity by way of increased 2-receptor activity "<img
pharmacology
A -receptor agonist is applied to an eye. Aqueous humor production increases, and
ciliary muscles relax. Via what kinase does this occur? This is likely a 2-
receptor agonist acting via the Gs pathway to increase adenylyl cyclase activity,
and thus protein kinase A activity "<img src=""7706 (1).png"">" autonomic-drugs g-
A drug targets M1-receptors. Where are these receptors located? In the central and
enteric nervous systems "<img src=""7706 (1).png"">" autonomic-drugs g-protein
A drug activates M2-receptors. How will it affect cardiac function? It will
decrease both heart rate and contractility of the atria "<img src=""7706
A parasympathetic toxin causes excess gut peristalsis and bladder contraction.
Audible wheezing is also heard. Which receptor is to blame?M3-receptors, causing
increased gut peristalsis, bladder contractions, and bronchoconstriction via Gq G-
protein activity "<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-
2nd-messengers pharmacology
A drug activates M3-receptors. What would you observe in a pt's eye after
administering this drug? Miosis (pupillary sphincter muscle contraction) and
accommodation (ciliary muscle contraction) "<img src=""7706 (1).png"">"
A drug increases exocrine gland secretion by activating a G-proteinlinked
receptor. Which enzyme is likely directly activated here? Phospholipase C, through
activation of M3-receptors; M3 activation increases lacrimal gland, salivary gland,
and gastric acid secretion "<img src=""7706 (1).png"">" autonomic-drugs g-
A pt takes a drug that activates D1-receptors. How will the renal vasculature be
affected? The drug will relax the renal vascular smooth muscle "<img src=""7706
A pt takes a drug that blocks H1-receptors. Describe at least four effects of this
medication. Decreases in pruritus, pain, nasal mucus, and bronchial mucus; dilation
of bronchioles; decreased vascular permeability "<img src=""7706 (1).png"">"
In a pt with GERD, one of the H receptors is overactivated to cause increased
gastric acid secretion. Which H-receptor subtype is to blame? The H2-receptor
"<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-2nd-messengers
pharmacology
A drug activates V1-receptors. What is its effect on vascular smooth muscle? It
increases vascular smooth muscle contraction "<img src=""7706 (1).png"">"
Activation of which G-proteincoupled receptors can increase vascular smooth muscle
contraction? Relaxation? 1 and V1 receptors promote contraction; 2 and D1
(renal only) receptors promote relaxation "<img src=""7706 (1).png"">" autonomic-
A drug activates V2-receptors. What is its effect? It increases water
permeability and reabsorption in the collecting tubules of the kidney (V2 is found
in the 2 kidneys.) "<img src=""7706 (1).png"">" autonomic-drugs g-protein
Name five types of receptors coupled with Gq proteins. H1, 1, V1, M1, and M3
(HAVe 1 M&M) "<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-
Name six types of receptors coupled with Gs proteins. 1, 2, 3, D1, H2, and V2
pharmacology
Name three types of receptors coupled with Gi proteins. M2, 2, and D2 (MAD
2's>) "<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-2nd-messengers
pharmacology
A drug is designed to activate several Gq receptors. Activity of what enzyme is
upregulated directly downstream of Gq-coupled receptors? Phospholipase C "<img
pharmacology
A drug activates Gs receptors. Which enzyme is upregulated directly downstream of
Gs-coupled receptors? Adenylyl cyclase "<img src=""7706 (1).png"">" autonomic-
A drug activates Gi receptors. Which enzyme is downregulated directly downstream of
Gi-coupled receptors? Adenylyl cyclase "<img src=""7706 (1).png"">" autonomic-
A drug upregulates adenylyl cyclase. What reaction does this enzyme catalyze?
ATP to cAMP "<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-
A drug activates Gs proteins. What is the final effector enzyme influenced in this
pathway? Is it upregulated or downregulated? Protein kinase A; it is upregulated
pharmacology
A drug activates Gi proteins. What is the final effector enzyme influenced in this
pathway? Is it upregulated or downregulated? Protein kinase A; it is
downregulated "<img src=""7706 (1).png"">" autonomic-drugs g-proteinlinked-
A drug activates phospholipase C, which catalyzes cleavage of membrane lipid PIP2.
What two molecules result from this reaction? Inositol triphosphate (IP3) and
diacylglycerol (DAG) "<img src=""7706 (1).png"">" autonomic-drugs g-protein
A 20-year-old pt has mydriasis. What is the receptor most likely associated with
this medical condition? The 1-receptor "<img src=""7706 (1).png"">" autonomic-
A drug increases inositol triphosphate (IP3). How is the intracellular
concentration of Ca2+ affected? The intracellular Ca2+ concentration is
increased, causing smooth muscle contraction "<img src=""7706 (1).png"">"
Diacylglycerol (DAG) is found in various baking products. If a pt ingests DAG, what
enzyme will be activated as a result? Protein kinase C "<img src=""7706
Ms A is given a 1-blocker. What type of receptor agonist would act on heart rate
in the same way as the pt's medication? An M2 agonist "<img src=""7706
A drug activates D2-receptors. What is the result? Increased modulation of
neurotransmitter release, especially within the brain "<img src=""7706 (1).png"">"
A drug increases aqueous humor production, decreases tocolysis, and promotes
ciliary muscle relaxation. What receptor is behind all of this? The 2-receptor
pharmacology
A pt has increased heart rate, contractility, and insulin release. She has blurry
vision. What sympathetic receptor is being activated? The 2-receptor "<img
pharmacology
A man takes a drug that activates protein kinase A (PKA). What effects does this
drug have on heart contractility and smooth muscle? PKA increases cardiac muscle
intracellular Ca2+ concentrations, boosting contractility; it inhibits smooth
muscle myosin light-chain kinase "<img src=""7706 (1).png"">" autonomic-drugs g-
Amphetamines that have gained access to neurosecretory vesicles promote
norepinephrine release into the synaptic cleft via what mechanism? They
displace NE from neurosecretory vesicles; NE builds up in presynaptic terminals;
NET expels the built-up NE into the synaptic clefts "<img src=""7707 (1).png"">"
autonomic-drugs pharmacology
A pt is taking vesamicol as an experimental medication. What is the effect of this
drug in cholinergic neurons? It prevents the uptake of ACh into presynaptic
vesicles, decreasing ACh activity (Less is released into the synapse.) "<img
src=""7707 (1).png"">" autonomic-drugs pharmacology
Researchers use hemicholinium in experiments to reduce the synthesis of
acetylcholine (ACh). How does hemicholinium achieve this effect? It reduces the
synthesis and levels of ACh by blocking the uptake of choline, a building block of
ACh, into presynaptic neurons "<img src=""7707 (1).png"">" autonomic-drugs
pharmacology
Describe the process by which amphetamines gain access to neurosecretory vesicles
in noradrenergic cells. They use NE transporters (NETs) to enter presynaptic
terminals; they use vesicular monoamine transporters (VMATs) to enter vesicles
"<img src=""7707 (1).png"">" autonomic-drugs pharmacology
Drugs that prevent choline and acetate levels from rising in cholinergic synaptic
clefts act on enzymes located on which surface? The postsynaptic membrane (The
enzyme inhibited is AChE.) "<img src=""7707 (1).png"">" autonomic-drugs
pharmacology
What enzyme is responsible for the formation of acetylcholine? What are its two
substrates? Choline acetyltransferase (ChAT); acetyl-CoA and choline "<img
A drug induces acetylcholine release into the synaptic cleft by increasing the
entry of an ion in the nerve terminal. Which ion is this? Ca2+ "<img src=""7707
(1).png"">" autonomic-drugs pharmacology
What enzyme breaks down acetylcholine in the synaptic cleft? What two products
result from this reaction? Acetylcholinesterase; choline and acetate "<img
Tyrosine transporters are located in the nerve terminals of what type of cells?
Noradrenergic cells; tyrosine is the precursor of norepinephrine "<img
Tyrosine is a precursor to the formation of which neurotransmitters? What is the
order of their synthesis? Noradrenergic neurotransmitters; tyrosine DOPA
dopamine norepinephrine "<img src=""7707 (1).png"">" autonomic-drugs
pharmacology
A new drug increases CNS levels of dopamine by increasing levels of an intermediate
precursor for dopamine synthesis. Name the intermediate. DOPA "<img src=""7707
Where in the neuron is dopamine converted into norepinephrine? Presynaptic
vesicles "<img src=""7707 (1).png"">" autonomic-drugs pharmacology
A drug induces norepinephrine release into the synaptic cleft by increasing the
entry of an ion in the nerve terminal. Which ion is this? Ca2+ "<img src=""7707
Which three mechanisms are used to clear norepinephrine from the synaptic cleft?
Diffusion, metabolism, and reuptake "<img src=""7707 (1).png"">" autonomic-
drugs pharmacology
What two receptor types modulate the presynaptic release of norepinephrine from the
noradrenergic nerve terminals? Angiotensin II (AT II) receptors (promote
release) and 2-receptors (inhibit release) "<img src=""7707 (1).png"">"
A drug activates angiotensin II receptors in presynaptic sympathetic nerve
terminals. What effect does this have on norepinephrine release? Stimulates
norepinephrine release "<img src=""7707 (1).png"">" autonomic-drugs pharmacology
What effect does the activation of 2-receptors in presynaptic sympathetic nerve
terminals exert on norepinephrine release? Inhibits norepinephrine release
Norepinephrine-mediated activation of 2-receptors on presynaptic sympathetic nerve
terminals is an example of what type of feedback? Negative feedback "<img
A drug inhibits reuptake of norepinephrine from noradrenergic nerve terminals. Name
three drugs with this mechanism of action. Cocaine, TCAs, and amphetamines
A pt in ventricular tachycardia is given bretylium. How does this affect the
noradrenergic pathway? What other drug works similarly? It blocks the release of
norepinephrine from the nerve terminals; guanethidine works similarly "<img
A pt is given reserpine as treatment for dyskinesia in Huntington disease. How does
this affect norepinephrine (NE) release? Reserpine blocks neurotransmitter
packaging into vesicles, thus lowering functional transmitter release (eg, of NE)
into the synapse "<img src=""7707 (1).png"">" autonomic-drugs pharmacology
A pt takes a drug that increases norepinephrine release from the nerve terminals.
Name two drugs with this mechanism of action. Amphetamine, ephedrine "<img
A 1-year-old boy who ate a lot of honey is lethargic and has flaccid paralysis.
Where is the toxin inhibiting his cholinergic pathways? Botulinum toxin blocks
ACh release from presynaptic vesicles "<img src=""7707 (1).png"">" autonomic-
drugs pharmacology
Pts with myasthenia gravis take drugs that inhibit AChE. How do these drugs affect
synaptic choline and acetate levels? Inhibiting AChE increases the level and
duration of ACh action, thus less is broken down into choline and acetate "<img
A pt with a pheochromocytoma starts taking metyrosine. How will this drug help the
pt? It inhibits the conversion of tyrosine into DOPA, which consequently reduces
the levels of dopamine and norepinephrine available for release "<img src=""7707
A pt takes an MAO inhibitor for depression. What substance is likely to accumulate
in this pt as a result? Tyramine: levels rise quickly in pts who take MAO
inhibitors and consume tyramine-rich food and drink (eg, cheese, wine) "<img
src=""7708 (1).png"">" autonomic-drugs pharmacology tyramine
A pt who takes an MAO inhibitor drinks a lot of wine and eats cheese. What is the
most serious consequence of this behavior? A hypertensive crisis secondary to
elevated tyramine levels "<img src=""7708 (1).png"">" autonomic-drugs
pharmacology tyramine
Why does a woman taking an MAO inhibitor have increased blood pressure after
drinking a bottle of vodka? Tyramine enters presynaptic vesicles and
displaces/leads to the release of neurotransmitters such as NE, which boost
sympathetic stimulation "<img src=""7708 (1).png"">" autonomic-drugs pharmacology
tyramine
What is the common mechanism of action for bethanechol, carbachol, pilocarpine, and
methacholine? Direct cholinergic agonism "<img src=""7709 (1).png"">"
autonomic-drugs cholinomimetic-agents pharmacology
What are the clinical indications for the use of bethanechol? "Postoperative and
neurogenic ileus, urinary retention (""Bethany, call [bethanechol] me to activate
your bowels and bladder."")" "<img src=""7709 (1).png"">" autonomic-drugs
cholinomimetic-agents pharmacology
A man takes bethanechol after surgery. What is its mechanism of action?
Activates bowel and bladder smooth muscle; is resistant to AChE "<img
src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents pharmacology
In a pt with glaucoma, what are two direct agonist cholinomimetic drugs that can be
prescribed? Carbachol (carbon copy of acetylcholine) and pilocarpine "<img
Carbachol and pilocarpine are effective for the treatment of open-angle glaucoma
because they activate what muscle? The ciliary muscle of the eye "<img src=""7709
(1).png"">" autonomic-drugs cholinomimetic-agents pharmacology
You prescribe pilocarpine for a pt with closed-angle glaucoma. Pilocarpine is
effective for this because it activates what muscle? The pupillary sphincter
(Pilocarpine is also a potent stimulator of sweat, saliva, and tears.) "<img
You suspect that your pt has asthma and plan to perform a challenge test. What is
the agent of choice, and how does it work? Methacholine; when inhaled, it
stimulates muscarinic receptors in the airways and induces bronchoconstriction
"<img src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents
pharmacology
Name seven indirect cholinergic agonists (anticholinesterases). Neostigmine,
pyridostigmine, edrophonium, physostigmine, donepezil, rivastigmine, and
galantamine "<img src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents
pharmacology
What are the clinical indications for the use of neostigmine? Postoperative and
neurogenic ileus, urinary retention, myasthenia gravis, postoperative reversal of
neuromuscular junction blockade "<img src=""7709 (1).png"">" autonomic-drugs
You administer edrophonium to a pt with myasthenia gravis. What effect will it
have, and for how long will the effect last? Transient reversal of weakness due
to increased ACh levels; effect lasts minutes "<img src=""7709 (1).png"">"
You accidentally overdose a pt with atropine. What pharmacologic agent should you
use to fix your mistake? Why? "Physostigmine; it can cross the blood-brain barrier
and reverse central and peripheral nervous system effects (""phyxes"" atropine
overdose)" "<img src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents
pharmacology
Indirect cholinergic agonists increase endogenous acetylcholine by inhibiting what
enzyme? Acetylcholinesterase "<img src=""7709 (1).png"">" autonomic-drugs
A pt with myasthenia gravis receives pyridostigmine. Why? Pyridostigmine increases
endogenous acetylcholine, and thus muscle strength, in myasthenics (gets rid of
myasthenia gravis) "<img src=""7709 (1).png"">" autonomic-drugs
A pt receives neostigmine for myasthenia gravis. What effect does this have on the
central nervous system? None: it does not penetrate the blood-brain barrier (NeoCNS
= No CNS penetration) "<img src=""7709 (1).png"">" autonomic-drugs
A pt with myasthenia gravis develops frequent asthma attacks. Which medication
could be underlying these symptoms? Cholinomimetics (eg, pyridostigmine, used to
treat myasthenia gravis), which can exacerbate asthma (as well as COPD and peptic
ulcers) "<img src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents
pharmacology
A pt takes donepezil. Which three conditions could be exacerbated by drugs of this
class? COPD, asthma, peptic ulcers "<img src=""7709 (1).png"">" autonomic-
drugs cholinomimetic-agents pharmacology
A pt with xerostomia takes an acetylcholinesterase-resistant direct cholinomimetic
agonist. What drug is this? Pilocarpine (Bethanechol is also resistant to this
enzyme but is not used to treat xerostomia.) "<img src=""7709 (1).png"">"
A patient has Alzheimer disease. What cholinomimetic agents can be prescribed for
his treatment? Donepezil, rivastigmine, or galantamine (All are
acetylcholinesterases.) "<img src=""7709 (1).png"">" autonomic-drugs
In the past, myasthenia gravis was diagnosed with the use of edrophonium. What is
the diagnostic test of choice for this disease now? Anti-AChR (acetylcholine
receptor) antibody testing "<img src=""7709 (1).png"">" autonomic-drugs
A pt with myasthenia gravis is wondering if there are any long-acting drugs to
combat the disease. What is she likely to be prescribed? Pyridostigmine (gets rid
of myasthenia gravis) "<img src=""7709 (1).png"">" autonomic-drugs
In addition to treating glaucoma, for what else is pilocarpine useful? "Pilocarpine
is useful for stimulating the release of sweat, tears, and saliva (""You cry,
drool, and sweat on your pilow."")" "<img src=""7709 (1).png"">" autonomic-drugs
A man has a postoperative neuromuscular junction blockade from anesthetics. What is
the mechanism of action of the reversal agent of choice? Acetylcholinesterase
inhibitor (neostigmine) reverses the blockade by increasing acetylcholine levels
"<img src=""7709 (1).png"">" autonomic-drugs cholinomimetic-agents
pharmacology
Carbachol is useful for which subtype(s) of glaucoma? What about pilocarpine?
Open-angle glaucoma; both open- and closed-angle glaucoma "<img src=""7709
(1).png"">" autonomic-drugs cholinomimetic-agents pharmacology
A man has dry eyes and decreased saliva production. An AChE-resistant medication
alleviates these symptoms. What is its mechanism of action?Pilocarpine, a direct
cholinergic agonist, stimulates production of sweat, tears, and saliva in pts with
xerostomia (Sjgren syndrome) "<img src=""7709 (1).png"">" autonomic-drugs
What structural component of acetylcholinesterase agents determines whether they
can act on the CNS? Quaternary amines (eg, on neostigmine or pyridostigmine)
cannot enter the CNS; tertiary amines (eg, physostigmine) can enter the CNS "<img
A pt presents with organophosphate poisoning. What symptoms may he experience?
Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation of
skeletal muscle/CNS, Lacrimation, Sweating, Salivation (DUMBBELSS) "<img
src=""7710 (1).png"">" autonomic-drugs cholinesterase-inhibitor-poisoning
pharmacology
A man ingests parathion, an organophosphate. What enzyme does this irreversibly
inhibit? Acetylcholinesterase "<img src=""7710 (1).png"">" autonomic-drugs
cholinesterase-inhibitor-poisoning pharmacology
A gardener has parathion poisoning as a result of insecticide exposure. What drugs
should be given for treatment, and how do they work? Atropine (inhibits muscarinic
ACh receptors) and pralidoxime (regenerates active AChE if given early) treat
organophosphate poisoning "<img src=""7710 (1).png"">" autonomic-drugs
cholinesterase-inhibitor-poisoning pharmacology
A man has respiratory failure from organophosphate poisoning. What antidote could
have regenerated acetylcholinesterase if given earlier? Pralidoxime "<img
src=""7710 (1).png"">" autonomic-drugs cholinesterase-inhibitor-poisoning
pharmacology
After visiting an ophthalmologist, a pt complains of mydriasis and cycloplegia.
What muscarinic antagonists caused these symptoms? Atropine, homatropine, or
tropicamide; these drugs produce mydriasis and cycloplegia by antagonizing
muscarinic receptors in the eye "<img src=""7711 (1).png"">" autonomic-drugs
muscarinic-antagonists pharmacology
An elderly pt takes benztropine but cannot remember why. What are the likely
clinical application and mechanism of action? "Benztropine, a muscarinic
antagonist, is used to ease cholinergic symptoms of Parkinson disease (""park my
Benz"") and to treat acute dystonia" "<img src=""7711 (1).png"">" autonomic-
drugs muscarinic-antagonists pharmacology
A pt's severe asthma attack is unresponsive to albuterol. What other medications
that act as muscarinic antagonists can be used? "Ipratropium and tiotropium are
muscarinic antagonists used to treat asthma and COPD (""I pray I can breathe
soon!"")" "<img src=""7711 (1).png"">" autonomic-drugs muscarinic-antagonists
pharmacology
A pt is administered glycopyrrolate parenterally before surgery. What is the effect
of this agent? It is a muscarinic antagonist used to reduce airway secretions
"<img src=""7711 (1).png"">" autonomic-drugs muscarinic-antagonists
pharmacology
A pt is taking glycopyrrolate. What is the effect of this agent when taken orally?
It is a muscarinic antagonist that, when taken orally, reduces drooling and
can be used to treat peptic ulcers "<img src=""7711 (1).png"">" autonomic-drugs
muscarinic-antagonists pharmacology
A female pt complains of urinary urgency resulting from frequent bladder spasms.
Which muscarinic antagonists can reduce this urgency? Oxybutynin, tolterodine,
solifenacin "<img src=""7711 (1).png"">" autonomic-drugs muscarinic-antagonists
pharmacology
A pt complains of motion sickness. What is the mechanism of action of scopolamine,
the agent most commonly used for treatment? It is an antimuscarinic agent that
acts in the CNS "<img src=""7711 (1).png"">" autonomic-drugs muscarinic-
antagonists pharmacology
You gave a pt haloperidol for schizophrenia, but Parkinson-like motor side effects
developed. What drug could you add to treat this? Benztropine, a muscarinic
antagonist, can be used to treat the acute dystonia described here "<img
src=""7711 (1).png"">" autonomic-drugs muscarinic-antagonists pharmacology
A pt is found to have irritable bowel syndrome. Which muscarinic antagonists can be
prescribed as antispasmodics for this pt? Hyoscyamine, dicyclomine "<img
Preoperatively, a patient is administered glycopyrrolate. How is this medication
given, and what is the desired effect after administration?It is given
parenterally; the reduction of airway secretions in the preoperative period "<img
What are the two effects of atropine on the eye? Pupil dilation and
cycloplegia "<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
What is the effect of atropine on the airway mucosa? Decreased secretions "<img
src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
What is the effect of atropine on the stomach? Decreased acid secretion "<img
What is the effect of atropine on the intestines? Decreased motility "<img
What is the effect of atropine on the bladder? Decreased urgency, especially in
cystitis "<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
A pt with atropine toxicity has a rapid pulse, cycloplegia, and disorientation.
What do you expect his body temperature to be? Increased (hot as a hare), a result
of decreased sweating "<img src=""7712 (1).png"">" atropine autonomic-drugs
pharmacology
A woman is given a drug for bradycardia. She experiences severe acute pain in her
right eye. Identify the drug and the side effect. Atropine; acute angle-closure
glaucoma "<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
A pt overdoses on atropine. How does this affect his heart rate? Increases it;
atropine counteracts DUMBBeLSS (Diarrhea, Urination, Miosis, Bronchospasm,
Bradycardia, Lacrimation, Sweating, Salivation) "<img src=""7712 (1).png"">"
atropine autonomic-drugs pharmacology
A pt has atropine toxicity. How will her skin appear? Dry and flushed (dry as a
bone, red as a beet) "<img src=""7712 (1).png"">" atropine autonomic-drugs
pharmacology
A patient has Jimson weed poisoning. Describe his orientation. Disoriented (mad
as a hatter); the plant alkaloids can also cause mydriasis (gardener's pupil)
"<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
A man has a gardener's pupil and dry mouth. On review of systems, what type of
urinary issue would you expect him to report? Urinary retention (more likely to
occur in men with prostatic hyperplasia) secondary to antimuscarinic toxicity
"<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
A novice gardener complains of a unilateral dilated pupil. Name a plant that could
cause this reaction. Jimson weed (Datura) causes gardener's pupil due to plant
alkaloids "<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
An infant being given atropine has dry mouth and is constipated. What other side
effect is most likely to arise? Hyperthermia (more common in infants) "<img
A pt with bradycardia is given too much atropine. How is skeletal muscle affected?
Not at all, as atropine does not affect nicotinic receptors in skeletal
muscle "<img src=""7712 (1).png"">" atropine autonomic-drugs pharmacology
Why might an ophthalmologist give atropine eyedrops to a patient before performing
an eye exam? It causes mydriasis and cycloplegia (blind as a bat), allowing
for easier examination of the eye (especially the retina) "<img src=""7712
(1).png"">" atropine autonomic-drugs pharmacology
Which types of receptors are activated by epinephrine? - and -receptors (
&62; ) "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
Which types of receptors are activated by norepinephrine? Put them in order, from
greatest to least affinity. 1 &62; 2 &62; 1 "<img src=""7713 (1).png"">"
autonomic-drugs pharmacology sympathomimetics
For which receptors is isoproterenol an agonist? 1- and 2-receptors equally
"<img src=""7713 (1).png"">" autonomic-drugs pharmacology sympathomimetics
Which types of receptors does dopamine activate, and how strongly does it activate
them relative to one another? D1 = D2 &62; &62; "<img src=""7713 (1).png"">"
For which receptors is dobutamine an agonist? Put them in order, from greatest to
least affinity. 1 &62; 2, "<img src=""7713 (1).png"">" autonomic-drugs
pharmacology sympathomimetics
Phenylephrine is an agonist for which receptors? 1- and 2-receptors (1 &62;
2) "<img src=""7713 (1).png"">" autonomic-drugs pharmacology sympathomimetics
For which receptors are albuterol and salmeterol agonists? 1 and 2 receptors (2
&62; 1) "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
You are giving a pt epinephrine. Name three clinical applications. Anaphylaxis,
open-angle glaucoma, asthma "<img src=""7713 (1).png"">" autonomic-drugs
You are giving a pt isoproterenol. What clinical situation is likely present?
A tachyarrhythmia; isoproterenol is used for electrophysiologic evaluation of
tachyarrhythmias (but can worsen ischemia) "<img src=""7713 (1).png"">"
How does the dopamine level affect the type of receptors it binds to (and thus the
type of effects seen)? At lower doses: -receptors, leading to inotropic and
chronotropic effects; at higher doses: -receptors, leading to vasoconstriction
You give a pt dopamine. Name three clinical situations warranting its use. Heart
failure, shock, unstable bradycardia "<img src=""7713 (1).png"">" autonomic-
drugs pharmacology sympathomimetics
You want to give a pt dobutamine. Name two clinical applications. Heart
failure (inotropic &62; chronotropic), cardiac stress testing "<img src=""7713
(1).png"">" autonomic-drugs pharmacology sympathomimetics
You prescribe phenylephrine for a pt. Name three clinical applications. Ocular
procedures (mydriatic), hypotension (vasoconstrictor), rhinitis (decongestant)
You are deciding whether to prescribe albuterol or salmeterol for a pt. What
condition does he likely have, and how would you decide? Asthma or COPD;
albuterol is better for acute attacks, and salmeterol is better for long-term
control "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
What is the general mechanism of action of amphetamine, cocaine, and ephedrine?
They are indirect sympathomimetics "<img src=""7713 (1).png"">" autonomic-
drugs pharmacology sympathomimetics
A man takes an amphetamine. Describe the mechanism of action resulting in its
sympathomimetic effects. It stimulates the release of stored catecholamines
and inhibits their reuptake "<img src=""7713 (1).png"">" autonomic-drugs
A man has daytime sleepiness, hallucinations before and after sleep, and cataplexy.
What indirect sympathomimetic do you use to treat him? Amphetamine, as he has
narcolepsy "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
By way of what mechanism does ephedrine exert its sympathomimetic effects?
Ephedrine is an indirect sympathomimetic that stimulates the release of
stored catecholamines "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
A pt abuses an indirect sympathomimetic that causes vasoconstriction and local
anesthesia. What drug class must this pt avoid? -blockers, which cause unopposed
-1 activation, and thus extreme hypertension, during states of cocaine
intoxication "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
You prescribe a sympathomimetic for a boy with ADHD. Name two other situations in
which you would you use this class of drugs. Amphetamines are the drug of choice
for ADHD, but can also be used to treat narcolepsy and obesity "<img src=""7713
A pt with heart failure receives low-dose dopamine. What are its effects at low
doses? Chronotropic and inotropic due to effects "<img src=""7713
What are three clinical applications for ephedrine? Nasal congestion, urinary
incontinence, and hypotension "<img src=""7713 (1).png"">" autonomic-drugs
You explain to a patient the effects of cocaine on the body. How does it act as a
sympathomimetic? It is an indirect general agonist for catecholamines and it
inhibits their reuptake "<img src=""7713 (1).png"">" autonomic-drugs pharmacology
sympathomimetics
A man receives fenoldopam after a postoperative hypertensive episode. What is its
mechanism of action? D1 direct agonism, which results in vasodilation (of
coronary, peripheral, renal, and splanchnic vessels) and increased natriuresis
A pt in shock receives dopamine at a high dose. What are its major effects at these
doses? Vasoconstriction due to effects "<img src=""7713 (1).png"">"
A pt would like an inhaler for long-term control of her asthma because she cannot
take albuterol PRN. What -agonist do you recommend? Salmeterol "<img src=""7713
A pt receives fenoldopam. What are two indications for this drug, and what two
adverse effects may arise? Postoperative hypertension and hypertensive crises;
hypotension and tachycardia "<img src=""7713 (1).png"">" autonomic-drugs
A drug user has extremely high blood pressure and tachycardia. What should you
consider before choosing an antihypertensive? Cocaine intoxication because giving
-blockers can lead to unopposed 1 activation and extreme hypertension "<img
src=""7713 (1).png"">" autonomic-drugs pharmacology sympathomimetics
What are two indications for norepinephrine administration?Hypotension, septic
shock "<img src=""7713 (1).png"">" autonomic-drugs pharmacology sympathomimetics
A man has postural hypotension. You prescribe a pure 1-agonist but warn him about
rapid position changes. Why? The drug is midodrine; it has the potential to
exacerbate supine hypertension "<img src=""7713 (1).png"">" autonomic-drugs
What are two indications for midodrine administration? What receptor(s) does it
primarily target? Autonomic insufficiency and postural hypotension; 1-receptors
Is the effect of isoproterenol on -receptors greater than, equal to, or less than
its effect on -receptors? Greater than "<img src=""7714 (1).png"">"
autonomic-drugs norepinephrine-vs-isoproterenol pharmacology
What are the effects of norepinephrine on systolic and diastolic blood pressure,
pulse pressure, and heart rate? It increases systolic and diastolic blood
pressures, increases pulse pressure, and reduces heart rate by way of reflex
bradycardia "<img src=""7714 (1).png"">" autonomic-drugs norepinephrine-vs-
isoproterenol pharmacology
What are the effects of isoproterenol on systolic and diastolic blood pressure,
pulse pressure, and heart rate? It decreases mean arterial pressure (2-
mediated vasodilation) and increases heart rate through 1 and reflex activity
"<img src=""7714 (1).png"">" autonomic-drugs norepinephrine-vs-isoproterenol
pharmacology
You administer isoproterenol to a patient taking an -blocker. Does the -blocker
influence the effects of isoproterenol? Yes, minimally: Isoproterenol has very
little activity "<img src=""7714 (1).png"">" autonomic-drugs norepinephrine-vs-
isoproterenol pharmacology
A 25-year-old woman at 39 weeks' gestation has two BP readings of 165/110. What
drug can you use acutely to lower her BP? -Methyldopa, which is safe for use in
pregnancy "<img src=""7715 (1).png"">" autonomic-drugs pharmacology
sympatholytics-(a2-agonists)
What are three clinical indications for the use of clonidine? ADHD, hypertensive
urgency (limited situations; doesn't reduce renal blood flow), Tourette syndrome
"<img src=""7715 (1).png"">" autonomic-drugs pharmacology sympatholytics-
(a2-agonists)
You give a pregnant patient with hypertension an -2-agonist. What side effects
would you be on the lookout for? Direct Coombs-positive hemolytic anemia or an
SLE-like syndrome, as the -2-agonist is -methyldopa "<img src=""7715 (1).png"">"
autonomic-drugs pharmacology sympatholytics-(a2-agonists)
A boy with ADHD recently began receiving an -2-agonist. For what side effects
would you monitor him? Bradycardia, hypotension, CNS depression, respiratory
depression, and miosis, as the -2-agonist is clonidine or guanfacine "<img
src=""7715 (1).png"">" autonomic-drugs pharmacology sympatholytics-(a2-agonists)
Why doesn't phenylephrine, a pressor, cause hypotension if a patient is pretreated
with an -blocker? Phenylephrine is a pure -agonist, so pretreatment with an
-blocker will cause any response to be suppressed, not reversed (no action)
"<img src=""7716 (1).png"">" a-blockers autonomic-drugs pharmacology
A few hours after your pt fills his prescription to treat his PTSD, he calls you,
saying that he is feeling dizzy. Why? Prazosin (an 1-selective blocker used
for PTSD) can cause orthostatic hypotension with the first dose "<img src=""7716
(1).png"">" a-blockers autonomic-drugs pharmacology
You prepare to remove a pt's pheochromocytoma. Would you use phenoxybenzamine or
phentolamine before the procedure? Why? Phenoxybenzamine: Its effect is
irreversible (high catecholamine levels during surgery would overcome
phentolamine's reversible -blocking) "<img src=""7716 (1).png"">" a-blockers
What are the mechanism of action and clinical application of phentolamine?
Phentolamine is a nonselective reversible -blocker given to pts taking MAO
inhibitors experiencing a tyramine-induced hypertensive crisis "<img src=""7716
(1).png"">" a-blockers autonomic-drugs pharmacology
Name two adverse effects of nonselective -blockers Orthostatic hypotension and
reflex tachycardia "<img src=""7716 (1).png"">" a-blockers autonomic-drugs
pharmacology
A man with hypertension also has BPH (leading to urinary retention). Name the side
effects of a medication used to treat both conditions. Side effects of 1-
selective blockers (prazosin, terazosin, doxazosin, tamsulosin) include orthostasis
(first dose), dizziness, and headaches "<img src=""7716 (1).png"">" a-blockers
A pt takes tamsulosin for BPH. He is found to have hypertension. Do you change his
BPH medication? Yes, because tamsulosin is not useful for hypertension; consider
use of prazosin, terazosin, or doxazosin instead "<img src=""7716 (1).png"">"
a-blockers autonomic-drugs pharmacology
What are the mechanism of action and clinical application of mirtazapine?
Mirtazapine is an 2-selective blocker used to treat depression "<img
src=""7716 (1).png"">" a-blockers autonomic-drugs pharmacology
What are three adverse effects of 2-selective blockers? Sedation, increased
serum cholesterol, and increased appetite "<img src=""7716 (1).png"">" a-blockers
Why does epinephrine, a pressor, cause hypotension if a pt is pretreated with an -
blocker? If -receptors are blocked, the 2-agonist properties of epinephrine
predominate and lower the blood pressure "<img src=""7716 (1).png"">" a-blockers
A man with SVT receives class II antiarrhythmics. What will measurements of his AV
conduction velocity show shortly afterward? A decrease (He likely received
metoprolol or esmolol, which reduce AV conduction velocity.) "<img src=""7717
(1).png"">" autonomic-drugs pharmacology -blockers
Name seven clinical applications for -blockers. Angina pectoris, myocardial
infarction (MI), supraventricular tachycardia (SVT), hypertension, heart failure
(HF), glaucoma, variceal bleeds "<img src=""7717 (1).png"">" autonomic-drugs
pharmacology -blockers
A pt presents with glaucoma. What -blocker is frequently used to treat this, and
what is its mechanism of action? Timolol, which decreases the secretion of
aqueous humor "<img src=""7717 (1).png"">" autonomic-drugs pharmacology -
blockers
A woman presents with angina pectoris. You administer drugs to reduce her
myocardial O2 consumption. How do they do this? The drugs are -blockers, which
reduce myocardial O2 consumption by decreasing heart rate and contractility "<img
src=""7717 (1).png"">" autonomic-drugs pharmacology -blockers
A 63-year-old woman is referred to you for long-term care after developing heart
failure. Is atenolol a good drug choice for her? No; pts with heart failure
should receive metoprolol, carvedilol, or bisoprolol (all -blockers) to decrease
mortality "<img src=""7717 (1).png"">" autonomic-drugs pharmacology -blockers
You prescribe a -blocker for your pt with hypertension. What is its mechanism of
action? It decreases both cardiac output and renin secretion (as a result of
1-receptor blockade on JGA cells) "<img src=""7717 (1).png"">" autonomic-drugs
You prescribe a -blocker for a pt with heart failure. What longer-term benefit
does this drug have? It decreases mortality in chronic heart failure "<img
You prescribe a -blocker for a pt with a recent myocardial infarction. What
longer-term benefit does this drug have? It decreases mortality "<img src=""7717
Name four nonselective -blockers. Nadolol, pindolol (partial agonist),
propranolol, and timolol (Nonselective antagonists usually go from N to Z.) "<img
Name five 1-selective antagonists. Acebutolol (partial agonist), atenolol,
betaxolol, esmolol, and metoprolol (Selective antagonists mostly go from A to M.)
"<img src=""7717 (1).png"">" autonomic-drugs pharmacology -blockers
What -blockers are partial agonists? Acebutolol and pindolol "<img src=""7717
What are two nonselective - and -antagonists? Carvedilol and labetalol (which
have modified suffixes instead of -olol) "<img src=""7717 (1).png"">" autonomic-
drugs pharmacology -blockers
A pt with Graves disease has angina. Heart rate = 128 beats/min; BP = 120/80 mm Hg.
What drug class treats her cardiac issues immediately? -Blockers, such as
propranolol, which reduce heart rate and consequently ease angina "<img
A suicidal pt comes in after having overdosed on his -blocker. What are some
symptoms you might expect to see? Erectile dysfunction, asthma/COPD flares,
bradycardia, AV block, heart failure, seizures, sedation, sleep changes,
dyslipidemia (metoprolol) "<img src=""7717 (1).png"">" autonomic-drugs
A 40-year-old man with hypertension is noncompliant with his antihypertensive,
because it makes him impotent. Which medication is he taking? -Blockers, which
are associated with erectile dysfunction "<img src=""7717 (1).png"">"
pharmacology::autonomic-drugs::-blockers
A 40-year-old woman has increased wheezing after taking propranolol for
hypertension. What is the cause of the increased wheezing? Nonselective -blockers
prevent bronchodilation and limit the effect of asthma medications such as
albuterol, which are -agonists "<img src=""7717 (1).png"">" autonomic-drugs
A doctor prescribes nebivolol to a pt who had persistent hypertension with his
previous #&946;-blocker. Why would this one help? It combines cardioselective
1-adrenergic blockade with 3 stimulation, activating nitric oxide synthase
(vasodilation) "<img src=""7717 (1).png"">" autonomic-drugs pharmacology -
blockers
You are debating whether to prescribe a #&946;-blocker for your diabetic patient.
What are you concerned about? Should you prescribe it? Its capacity to mask
hypoglycemia in diabetics is a concern, but the benefits likely outweigh the risks,
so it is not contraindicated "<img src=""7717 (1).png"">" autonomic-drugs
A known cocaine user is hospitalized with a heart attack. Do you give this pt
metoprolol to reduce O2 demand? With caution, because there is a risk of
unopposed -adrenergic receptor agonist activity in this pt if a -blocker is given
You prescribe a -blocker for your pt with cirrhosis and known varices. Why is this
medication important for this pt? It decreases the hepatic venous pressure
gradient and eases portal hypertension, decreasing the risk of variceal bleeding
Which two -blockers are commonly prescribed for variceal bleeding? Nadolol and
propranolol "<img src=""7717 (1).png"">" autonomic-drugs pharmacology -blockers
A Japanese patient comes in after ingesting poorly prepared pufferfish. What is the
mechanism of action of this highly potent toxin? Tetrodotoxin binds fast
voltage-gated Na+ channels in cardiac/nerve tissue and prevents depolarization
"<img src=""7718 (1).png"">" autonomic-drugs ingested-seafood-toxins
pharmacology
A man in Japan reports nausea, diarrhea, paresthesias, weakness, dizziness, and
loss of deep tendon reflexes. How do you treat him? Treatment is mainly
supportive, as this is likely tetrodotoxin poisoning "<img src=""7718 (1).png"">"
autonomic-drugs ingested-seafood-toxins pharmacology
A pt becomes ill shortly after eating moray eel. With what other type of poisoning
is this often confused? Ciguatoxin poisoning is easily confused with cholinergic
poisoning "<img src=""7718 (1).png"">" autonomic-drugs ingested-seafood-toxins
pharmacology
A woman enjoys eating pufferfish, a delicacy in Japan. If it is poorly prepared,
what symptoms would you expect to develop? Nausea, diarrhea, paresthesia,
weakness, dizziness, and loss of reflexes "<img src=""7718 (1).png"">" autonomic-
drugs ingested-seafood-toxins pharmacology
"A pt reports altered temperature sensation (""cold feels hot and hot feels cold"")
after eating snapper. Mechanism of action for this finding?" This is ciguatoxin
poisoning, which opens Na+ channels, causing depolarization (in this case,
temperature-related dysesthesia) "<img src=""7718 (1).png"">" autonomic-drugs
ingested-seafood-toxins pharmacology
A woman reports feeling odd after eating barracuda. How do you treat her?
Treatment is mainly supportive, as this is ciguatoxin poisoning, occurring
with consumption of reef fish (eg, barracuda, snapper, moray eel) "<img
src=""7718 (1).png"">" autonomic-drugs ingested-seafood-toxins pharmacology
A pt becomes ill shortly after eating mackerel. What is the likely cause of this
illness and the mechanism of action? Scombroid poisoning in which bacterial
histidine decarboxylase converts histidine to histamine "<img src=""7718
(1).png"">" autonomic-drugs ingested-seafood-toxins pharmacology
A pt comes in with bronchospasm, angioedema, and hypotension after eating mahi-
mahi. Treatment? Scombroid poisoning is treated supportively with antihistamines
and antianaphylactics (eg, bronchodilators [albuterol] and epinephrine) "<img
src=""7718 (1).png"">" autonomic-drugs ingested-seafood-toxins pharmacology
A man eats tuna that has been improperly stored at a warm temperature and becomes
ill. What symptoms do you expect him to have? Scombroid poisoning is marked by an
acute-onset burning sensation in the mouth, flushing, erythema, urticaria, and
itching "<img src=""7718 (1).png"">" autonomic-drugs ingested-seafood-toxins
pharmacology
A child becomes ill after eating sushi in a restaurant that did not store the fish
properly. What is this poisoning often misdiagnosed as? This is scombroid
poisoning (caused by spoiled dark-meat fish), and it is often misdiagnosed as an
allergy to fish "<img src=""7718 (1).png"">" autonomic-drugs ingested-seafood-
toxins pharmacology
Left untreated, what are the grave consequences of scombroid poisoning?
Bronchospasm, angioedema, and hypotension "<img src=""7718 (1).png"">"
autonomic-drugs ingested-seafood-toxins pharmacology
Which types of fish classically cause scombroid poisoning? Spoiled dark-meat fish
(eg, tuna, mahi-mahi, mackerel, bonito) "<img src=""7718 (1).png"">" autonomic-
drugs ingested-seafood-toxins pharmacology
A suicidal teenager overdoses on acetaminophen. What is the mechanism of action of
the antidote? N-acetylcysteine replenishes glutathione "<img src=""7719
(1).png"">" pharmacology specific-toxicity-treatments toxicities-and-side-effects
A pt overdoses on salicylates and presents to the ED in a panic. What antidote(s)
can be used to treat this overdose? NaHCO3 (alkalinizes urine) and dialysis if
necessary "<img src=""7719 (1).png"">" pharmacology specific-toxicity-treatments
toxicities-and-side-effects
A man overdoses on amphetamines. What is the mechanism of action of the antidote?
NH4Cl promotes urinary excretion of the drug by acidifying the urine.
(Amphetamines are basic drugs.) "<img src=""7719 (1).png"">" pharmacology
specific-toxicity-treatments toxicities-and-side-effects
A farmer comes in with suspected organophosphate toxicity. What are the two
possible antidotes? Atropine and pralidoxime (Both can also be used to treat
AChE inhibitor toxicity.) "<img src=""7719 (1).png"">" pharmacology specific-
toxicity-treatments toxicities-and-side-effects
A boy has suspected anticholinergic or antimuscarinic agent toxicity. What is the
antidote? Which vital sign is it critical to monitor? Physostigmine salicylate;
temperature should be monitored so that measures can be taken as needed to control
hyperthermia "<img src=""7719 (1).png"">" pharmacology specific-toxicity-
treatments toxicities-and-side-effects
A woman attempts suicide by overdosing on her prescribed metoprolol. What is the
antidote for this toxicity? The antidote consists of saline, atropine, and
glucagon, as this is -blocker toxicity "<img src=""7719 (1).png"">" pharmacology
A pt comes in with nausea and yellow-green vision after starting digitalis
(digoxin) therapy. What is the treatment for this toxicity?Anti-dig Fab fragments
"<img src=""7719 (1).png"">" pharmacology specific-toxicity-treatments
A pt has been receiving transfusions for years because of his thalassemia. What are
three antidotes for iron toxicity? Deferoxamine, deferasirox, deferiprone "<img
src=""7719 (1).png"">" pharmacology specific-toxicity-treatments toxicities-and-
side-effects
A child living in a very old house presents with nausea, vomiting, and abdominal
pain. What are four treatments for lead poisoning? EDTA, dimercaprol, succimer,
and penicillamine "<img src=""7719 (1).png"">" pharmacology specific-toxicity-
A miner comes in with poisoning that, you deduce, is caused by mercury. Name two
possible treatments. Dimercaprol (dimercaprol for mercury poisoning) and
succimer "<img src=""7719 (1).png"">" pharmacology specific-toxicity-treatments
A pt attempts suicide with cyanide. Antidotes? Thiosulfate + nitrite or
hydroxocobalamin "<img src=""7719 (1).png"">" pharmacology specific-toxicity-
A pt is found to have too much methemoglobin in his system. What is the treatment
for methemoglobinemia? Methylene blue (for methemeglobinemia), vitamin C "<img
side-effects
A girl comes in after a house fire in respiratory distress. What are the treatments
for carbon monoxide poisoning? 100% oxygen, hyperbaric oxygen "<img
side-effects
A child comes in after drinking a whole jug of antifreeze. The treatments of choice
are good for what other type of poisoning? Methanol poisoning. Both ethylene
glycol (antifreeze) and methanol toxicity are treated with fomepizole (preferred),
ethanol, or dialysis "<img src=""7719 (1).png"">" pharmacology specific-
A drug user overdoses on opioids. Antidote? Naloxone "<img src=""7719
A pt has overdosed on benzodiazepines. Antidote? Flumazenil "<img src=""7719
An old man has accidentally overdosed on his tricyclic antidepressant. What is the
antidote? NaHCO3 "<img src=""7719 (1).png"">" pharmacology specific-
A pt's dosage of heparin is accidentally tripled while she is in the hospital. How
can you reverse this? By administering protamine sulfate "<img src=""7719
A pt overdoses on alternative medicines containing gold. What are the antidotes?
Penicillamine, dimercaprol (BAL), succimer "<img src=""7719 (1).png"">"
pharmacology specific-toxicity-treatments toxicities-and-side-effects
A pt taking warfarin needs an urgent operation. What treatment should the pt
receive before the operation? Fresh frozen plasma for immediate reversal of the
anticoagulation effect; vitamin K for delayed reversal "<img src=""7719
A woman brings in her 3-year-old boy after finding him eating acetaminophen pills.
What drug do you give to minimize liver toxicity? N-acetylcysteine "<img
side-effects
A child has persistent vomiting and is found to have copper poisoning. What is the
antidote? Penicillamine or trientine "<img src=""7719 (1).png"">" pharmacology
A pt presents with vomiting and headaches after recent relocation. The drinking
water has high levels of arsenic. Treatment? Dimercarprol, succimer "<img
side-effects
A pt experiences cutaneous flushing after taking a new medication. What four drugs
could be responsible? Vancomycin, Adenosine, Niacin, Calcium channel blockers,
Echinocandins (VANCE) "<img src=""7720 (1).png"">" drug-reactionscardiovascular
pharmacology toxicities-and-side-effects
A pt receiving chemotherapy experiences dyspnea. Symptom progression slows with
dexrazoxane. Which chemotherapeutic agents is he receiving?Doxorubicin and
daunorubicin (anthracyclines), which can cause dilated cardiomyopathy (preventable
with dexrazoxane) "<img src=""7720 (1).png"">" drug-reactionscardiovascular
You note torsade de pointes on a patient's ECG. Which drugs can cause this?
"AntiArrhythmics (IA/II), antiBiotics (macrolides), anti""C""ychotics
(haldoperidol), antiDepressants (TCAs), antiEmetics (ondansetron) (ABCDE" "<img
src=""7720 (1).png"">" drug-reactionscardiovascular pharmacology toxicities-and-
side-effects
A pt comes in with acute-onset coronary vasospasm. What three drugs could be
responsible? Sumatriptan, cocaine, or ergot alkaloids "<img src=""7720
(1).png"">" drug-reactionscardiovascular pharmacology toxicities-and-side-effects
A pt with sarcoidosis loses the steroids he was taking daily for 3 months. What
adverse effect may occur if he abruptly stops taking them? Adrenocortical
insufficiency from long-term hypothalamic-pituitary-adrenal axis suppression; do
not discontinue steroids abruptly! "<img src=""7721 (1).png"">" drug-reactions
endocrine/reproductive pharmacology toxicities-and-side-effects
A pt with bipolar disorder has fatigue, decreased deep tendon reflexes, and high
levels of TSH. What is causing his condition? Lithium toxicity leading to
hypothyroidism. (Amiodarone and sulfonamides can also cause hypothyroidism.) "<img
src=""7721 (1).png"">" drug-reactionsendocrine/reproductive pharmacology
"A woman complains of daily ""hot flashes."" She takes several medications. Name
two drugs that could be causing these symptoms." Tamoxifen, clomiphene "<img
What drugs or drug classes should your pt with diabetes avoid because they can
cause hyperglycemia as a side effect? Tacrolimus, Protease inhibitors, Niacin,
HCTZ, Corticosteroids (Taking Pills Necessitates Having blood Checked) "<img
A pt being treated for an asthma exacerbation is noted to have elevated glucose
levels. Which drug is she likely receiving? A corticosteroid "<img src=""7721
(1).png"">" drug-reactionsendocrine/reproductive pharmacology toxicities-and-side-
effects
A new pt who recently began receiving erythromycin develops jaundice. What adverse
effect do you suspect? Acute cholestatic hepatitis "<img src=""7722 (1).png"">"
drug-reactionsgi pharmacology toxicities-and-side-effects
A pt has liver disease. Which drugs (or exposures) should he avoid because they can
cause focal to massive hepatic necrosis? "Halothane, Amanita phalloides (death cap
mushroom), Valproic acid, Acetaminophen (liver ""HAVAc"")" "<img src=""7722
(1).png"">" drug-reactionsgi pharmacology toxicities-and-side-effects
Name some drugs that cause hepatitis as a side effect. Isoniazid, rifampin,
pyrazinamide, statins, and fibrates "<img src=""7722 (1).png"">" drug-reactionsgi
A woman taking antibiotics has smelly, voluminous diarrhea. Pseudomembranous
colitis is diagnosed. Which antibiotics may have been given? Clindamycin,
ampicillin, or cephalosporins (all of which predispose to resistant C difficile
superinfection) "<img src=""7722 (1).png"">" drug-reactionsgi pharmacology
A pt receives clindamycin and ampicillin in the hospital. This could lead to the
overgrowth of which bacterium in the colon? C difficile, which leads to
pseudomembranous colitis; antibiotics increase the risk of superinfection with
resistant C difficile "<img src=""7722 (1).png"">" drug-reactionsgi
A pt is embarrassed to tell you that he has been having GI disturbances since he
started taking metformin. What is the specific problem? Diarrhea "<img
src=""7722 (1).png"">" drug-reactionsgi pharmacology toxicities-and-side-effects
A pt develops drug-related pancreatitis. Which Drugs Cause A Violent Abdominal
Distress? Didanosine, Corticosteroids, Alcohol, Valproic acid, Azathioprine, and
Diuretics (furosemide, HCTZ) can cause pancreatitis "<img src=""7722 (1).png"">"
drug-reactionsgi pharmacology toxicities-and-side-effects
A pt has pill-induced esophagitis. What three drugs may be responsible?
Bisphosphonates, potassium chloride, tetracyclines "<img src=""7722
(1).png"">" drug-reactionsgi pharmacology toxicities-and-side-effects
Name some drugs that can cause diarrhea as a side effect.
Acamprosate/acarbose/cholinesterase
inhibitors/colchicine/erythromycin/ezetimibe/metformin/misoprostol/orlistat/pramlin
tide/quinidine/SSRIs "<img src=""7722 (1).png"">" drug-reactionsgi
A pt has an impaired immune system. Name six drugs that she should avoid because
they can cause agranulocytosis as an adverse effect. Clozapine, Carbamazepine,
Propylthiouracil, Methimazole, Colchicine, Ganciclovir (Can Cause Pretty Major
Collapse of Granulocytes) "<img src=""7723 (1).png"">" drug-reactions
hematologic pharmacology toxicities-and-side-effects
A pt develops aplastic anemia after she begins taking a new medication. Name six
drugs (or exposures) with this side effect. Carbamazepine, Methimazole, NSAIDs,
Benzene, Chloramphenicol, Propylthiouracil (Cant Make New Blood Cells Properly)
"<img src=""7723 (1).png"">" drug-reactionshematologic pharmacology
A pt taking multiple drugs becomes weak and pale. Peripheral blood smear shows
megaloblastic anemia. What drugs could be responsible? Phenytoin, Methotrexate,
Sulfa drugs (having a blast with PMS) "<img src=""7723 (1).png"">" drug-
reactionshematologic pharmacology toxicities-and-side-effects
A pregnant pt has direct Coombs-positive hemolytic anemia after she begins taking a
new drug. Which drugs may be responsible? Methyldopa or penicillin "<img
src=""7723 (1).png"">" drug-reactionshematologic pharmacology toxicities-and-
side-effects
A pt takes a drug that, she was told, can cause gray baby syndrome. What drug is
it? Chloramphenicol "<img src=""7723 (1).png"">" drug-reactionshematologic
You see a patient with G6PD deficiency. Which drugs should you tell him to avoid
because they can trigger hemolytic anemia? Isoniazid, Sulfonamides, Dapsone,
Primaquine, Aspirin,Ibuprofen, Nitrofurantoin (Hemolysis IS D [the] PAIN.) "<img
src=""7723 (1).png"">" drug-reactionshematologic pharmacology toxicities-and-
side-effects
A woman has dyspnea and leg swelling after she begins taking estrogen-based OCPs.
What adverse events can these pills lead to? Thrombotic events such as deep vein
thrombosis and pulmonary embolus "<img src=""7723 (1).png"">" drug-reactions
hematologic pharmacology toxicities-and-side-effects
What commonly used drug can cause thrombocytopenia? Heparin "<img src=""7723
(1).png"">" drug-reactionshematologic pharmacology toxicities-and-side-effects
A pt who has frequent seizures (despite compliance with treatment) complains that
her mouth feels swollen. What is responsible? Phenytoin toxicity leading to
gingival hyperplasia "<img src=""7724 (1).png"">" drug-reactions
musculoskeletal/skin/connective-tissue pharmacology toxicities-and-side-effects
A pt complains of excruciating pain in his toe after he begins taking a new
medication. Which drugs could be responsible? Pyrazinamide, Thiazides,
Furosemide, Niacin, Cyclosporine (Painful Tophi and Feet Need Care); this is
hyperuricemia (gout) "<img src=""7724 (1).png"">" drug-reactions
A pt with lupus undergoing long-term oral immunosuppression has sudden-onset back
pain. What medication could have contributed to this? Long-term steroid use can
lead to osteoporosis and bone fractures "<img src=""7724 (1).png"">" drug-
reactionsmusculoskeletal/skin/connective-tissue pharmacology toxicities-and-side-
effects
A pt taking antibiotics for a bacterial infection notes that his skin is
hypersensitive to sunlight. Which antibiotics might he be taking?
Sulfonamides, Amiodarone, or Tetracyclines (SAT For Photo, where F represents
5-FU) "<img src=""7724 (1).png"">" drug-reactionsmusculoskeletal/skin/connective-
tissue pharmacology toxicities-and-side-effects
A rash that is found to be a result of Stevens-Johnson syndrome develops in a pt.
Name at least four drugs that can cause this. Antiepileptics (lamotrigine),
allopurinol, sulfa drugs, penicillin (Steven Johnson has epileptic allergy to sulfa
drugs and penicillin.) "<img src=""7724 (1).png"">" drug-reactions
A lupus-like syndrome develops in pt taking a new medication. Name at least four
drugs that could be the cause. "Sulfa drugs, Hydralazine, Isoniazid,
Procainamide, Phenytoin, Etanerecept. (Having lupus is '""SHIPP-E"")" "<img
src=""7724 (1).png"">" drug-reactionsmusculoskeletal/skin/connective-tissue
A pt is taking a drug that can cause tendinitis, tendon rupture, and cartilage
damage. What class of drugs is the likely culprit? Fluoroquinolones "<img
A 5-year-old girl's physician refuses to prescribe her a tetracycline antibiotic
for treatment of a urinary tract infection. Why? Tetracyclines can cause teeth
discoloration in children "<img src=""7724 (1).png"">" drug-reactions
A pt develops muscle pain after taking a new medication. Name some drugs that can
cause myopathy as a side effect. Fibrates, niacin, colchicine,
hydroxychloroquine, interferon-, penicillamine, statins, and glucocorticoids
"<img src=""7724 (1).png"">" drug-reactionsmusculoskeletal/skin/connective-
tissue pharmacology toxicities-and-side-effects
A pt with HIV complains that her legs have been getting skinnier and her belly
bigger since she started taking a new drug. What is the drug? In this case, fat
redistribution was caused by Protease inhibitors; it can also be caused by
Glucocorticoids (fat PiG) "<img src=""7724 (1).png"">" drug-reactions
Name some drugs that can cause gingival hyperplasia as a side effect. Phenytoin,
Ca2+ channel blockers, cyclosporine "<img src=""7724 (1).png"">" drug-reactions
Which commonly used anticoagulant increases the risk of osteoporosis with long-term
use? Heparin "<img src=""7724 (1).png"">" drug-reactions
Which chemotherapeutic agent is known to cause photosensitivity? 5-FU "<img
An older man with schizophrenia and chronic nausea frequently grimaces, blinks, and
smacks his lips. What is responsible for his condition? Long-term antipsychotic
use, which results in tardive dyskinesia; metoclopramide (an anti-emetic) can also
cause this condition "<img src=""7725 (1).png"">" drug-reactionsneurologic
A pt has cinchonism. What two drugs are likely culprits? Quinidine and quinine;
cinchonism involves headache and tinnitus "<img src=""7725 (1).png"">" drug-
reactionsneurologic pharmacology toxicities-and-side-effects
A pt recently began experiencing Parkinson-like symptoms. Name three medications or
drug classes he may have recently received. Antipsychotics, Reserpine, and
Metoclopramide (cogwheel rigidity of ARM) "<img src=""7725 (1).png"">" drug-
reactionsneurologic pharmacology toxicities-and-side-effects
A pt with prior head trauma taking multiple medications starts having seizures.
Name at least three drugs that lower the seizure threshold.Isoniazid (vitamin B6
deficiency), Bupropion, Imipenem/cilastatin, Tramadol, Enflurane, (With seizures, I
BITE my tongue.) "<img src=""7725 (1).png"">" drug-reactionsneurologic
A man with bipolar disorder constantly feels thirsty and drinks endlessly. Diabetes
insipidus is diagnosed. Which drugs may be responsible? Lithium or
demeclocycline "<img src=""7726 (1).png"">" drug-reactionsrenal/genitourinary
A pt has new-onset confusion. Labs show severe hyponatremia from SIADH. Name three
drugs that might be responsible. Carbamazepine, Cyclophosphamide, SSRIs (Cant
Concentrate Serum Sodium) "<img src=""7726 (1).png"">" drug-reactions
renal/genitourinary pharmacology toxicities-and-side-effects
A pt develops Fanconi syndrome after receiving a new medication. Which drugs are
associated with this syndrome? Tenofovir, ifosfamide "<img src=""7726
(1).png"">" drug-reactionsrenal/genitourinary pharmacology toxicities-and-side-
effects
You diagnose interstitial nephritis. What drugs could have been responsible?
Methicillin, furosemide, NSAIDs "<img src=""7726 (1).png"">" drug-
reactionsrenal/genitourinary pharmacology toxicities-and-side-effects
A pt has dysuria. Blood is detected on urinalysis. Administration of mesna stops
symptom progression. Which drugs may be to blame? Cyclophosphamide or
ifosfamide (Either can cause hemorrhagic cystitis, which can be prevented with
mesna.) "<img src=""7726 (1).png"">" drug-reactionsrenal/genitourinary
A pt has worsening dyspnea on exertion. He is found to have pulmonary fibrosis.
Name three drugs that could be responsible. Methotrexate, Nitrofurantoin,
Carmustine, Bleomycin, Busulfan, Amiodarone (My Nose Cannot Breathe Bad Air) "<img
src=""7727 (1).png"">" drug-reactionsrespiratory pharmacology toxicities-and-
side-effects
A pt starts taking a new medication for hypertension. An uncomfortable dry cough
develops soon after. What drug is the pt likely taking? An angiotensin-
converting enzyme (ACE) inhibitor "<img src=""7727 (1).png"">" drug-reactions
respiratory pharmacology toxicities-and-side-effects
An alcoholic suddenly develops an aversion to alcohol, similar to when he took
disulfiram in the past. Name some drugs that may be to blame. Metronidazole,
certain cephalosporins, griseofulvin, procarbazine, first-generation sulfonylureas
(All cause a disulfiram-like reaction.) "<img src=""7728 (1).png"">" drug-
reactionsmultiorgan pharmacology toxicities-and-side-effects
A pt taking multiple medications develops hearing loss and kidney failure. Name
three drugs associated with these effects. Aminoglycosides, vancomycin, loop
diuretics, cisplatin "<img src=""7728 (1).png"">" drug-reactionsmultiorgan
A man with an unknown drug overdose has dry mouth, urinary retention, blurry
vision, and anhidrosis. Name three drugs that may be to blame. Atropine, TCAs,
H1-blockers, antipsychotics (These findings are consistent with antimuscarinic
toxicity.) "<img src=""7728 (1).png"">" drug-reactionsmultiorgan pharmacology
Ototoxicity develops in a pt with cancer. Amifostine slows the progression of
symptoms. What other side effect is being treated? Nephrotoxicity (The pt is
likely taking cisplatin [causes ototoxicity and nephrotoxicity], and amifostine can
treat these side effects.) "<img src=""7728 (1).png"">" drug-reactions
multiorgan pharmacology toxicities-and-side-effects
Name eight drugs that induce cytochrome P-450 enzyme activity (hint: Chronic
alcoholics Steal Phen-Phen and Never Refuse Greasy Carbs.) Chronic alcohol use, St
John's wort, Phenytoin, Phenobarbital, Nevirapine, Rifampin, Griseofulvin,
Carbamazepine "<img src=""7729 (1).png"">" cytochrome-p-450-interactions-
(selected) pharmacology toxicities-and-side-effects
Name 10 things that inhibit cytochrome P-450 enzyme activity (hint: AAA RACKS IN GQ
Magazine). Acute Alcohol Abuse, Ritonavir, Amiodarone, Cimetidine/ciprofloxacin,
Ketoconazle, Sulfonamides, INH, Grapefruit, Quinidine, Macrolides "<img
src=""7729 (1).png"">" cytochrome-p-450-interactions-(selected) pharmacology
A doctor advises an alcoholic taking warfarin to avoid alcohol. He does, and his
warfarin level normalizes without a dosage change. Why? Chronic alcohol abuse
promotes cytochrome P-450 enzyme activity, which promotes the metabolism of other
drugs (eg, warfarin) "<img src=""7729 (1).png"">" cytochrome-p-450-
interactions-(selected) pharmacology toxicities-and-side-effects
A college student drinks 12 shots of vodka. How will this affect his cytochrome P-
450 system? This acute alcohol abuse will inhibit the P-450 system "<img
A man with chronic alcoholism has drunk 12 shots of vodka daily for years. How is
this affecting his cytochrome P-450 system? Chronic alcohol use induces the P-
450 system "<img src=""7729 (1).png"">" cytochrome-p-450-interactions-(selected)
Name at least four drugs (substrates) that are commonly metabolized by cytochrome
P-450 enzymes. Anti-epileptics, Theophylline, Warfarin, OCPs (Always Think When
Outdoors) "<img src=""7729 (1).png"">" cytochrome-p-450-interactions-(selected)
A pt taking warfarin decides to drink grapefruit juice. What effect will this have
on his warfarin level? Grapefruit juice will inhibit the P-450 system and reduce
warfarin metabolism, causing his level to become supratherapeutic "<img
A woman takes warfarin and multiple anti-epileptic medications. Azithromycin is
given for an infection. Are any dosage adjustments needed? No, since azithromycin
is the one macrolide that does not inhibit cytochrome P-450, no dosage adjustments
for other medications are needed "<img src=""7729 (1).png"">" cytochrome-p-450-
A pt taking warfarin begins taking ciprofloxacin for an infection. Why might you
consider temporarily reducing his daily dose of warfarin? Ciprofloxacin inhibits
the P-450 system, which may increase serum warfarin levels (and it may kill off
vitamin Kproducing gut bacteria!) "<img src=""7729 (1).png"">" cytochrome-p-450-
Which macrolide is not considered to be an inhibitor of the cytochrome P-450
system? Azithromycin "<img src=""7729 (1).png"">" cytochrome-p-450-
Name some commonly prescribed sulfa drugs. Sulfonamide antibiotics,
Sulfasalazine, Probenecid, Furosemide, Acetazolamide, Celecoxib, Thiazides,
Sulfonylureas (Scary Sulfa Pharm FACTS) "<img src=""7730 (1).png"">" pharmacology
sulfa-drugs toxicities-and-side-effects
A pt with sulfa allergy mistakenly receives furosemide and has a reaction. Name at
least four clinical manifestations of this reaction. Fever, urinary tract
infection, Stevens-Johnson syndrome, hemolytic anemia, thrombocytopenia,
agranulocytosis, urticaria (hives) "<img src=""7730 (1).png"">" pharmacology
A pt has new-onset fever and urticaria. She just switched diuretics. What is a
possible drug-related cause of her symptoms? She may be allergic to sulfa drugs
and was just switched to furosemide or a thiazide diuretic "<img src=""7730
(1).png"">" pharmacology sulfa-drugs toxicities-and-side-effects
A pt with osteoarthritis has hives after trying a new anti-inflammatory drug. What
reaction is he having? Which medication is responsible? He is having an allergic
reaction to a sulfa drug (likely celecoxib or sulfasalazine) "<img src=""7730
A pt with gout has urticaria and fever after changing medications. The uric acid
level is rising acutely. Which medication is responsible? Probenecid, as this is
an allergic reaction to a sulfa drug "<img src=""7730 (1).png"">" pharmacology
A mountain climber has a pruritic rash/urticaria after taking a medication for
altitude sickness. What medication did she take? Acetazolamide (She is having
an allergic reaction to a sulfa drug.) "<img src=""7730 (1).png"">" pharmacology
A diabetic woman developed a rash 3 days ago after a medication change. What
reaction is this and what medication is responsible? She is having an allergic
reaction to a sulfa drug; a sulfonylurea is responsible "<img src=""7730
A patient takes a drug for erectile dysfunction that inhibits PDE-5. What is the
typical suffix for this class of drug? -afil (eg, sildenafil) "<img
src=""7731.png"">" drug-names miscellaneous pharmacology
A pt takes an antibiotic that is a peptidoglycan synthesis inhibitor. What is the
typical suffix for this class of drug? -cillin (eg, ampicillin) "<img
A pt receives an inhaled general anesthetic. What is the typical suffix for this
class of drug? -ane (eg, halothane) "<img src=""7731.png"">" drug-names
miscellaneous pharmacology
A pt takes a benzodiazepine. What is the typical suffix for this class of drug?
-azepam (eg, diazepam) or -zolam (eg, alprazolam) "<img src=""7731.png"">"
drug-names miscellaneous pharmacology
A pt takes a drug for a fungal infections, which inhibits ergosterol synthesis.
What is the typical suffix for this class of drug? -azole (eg, ketoconazole)
"<img src=""7731.png"">" drug-names miscellaneous pharmacology
A pt takes an antibiotic that inhibits protein synthesis and discolors teeth. What
is the typical suffix for this class of drug? -cycline, (eg, tetracycline) "<img
A pt receives a local anesthetic. What is the typical suffix for this class of
drug? -caine (eg, lidocaine) "<img src=""7731.png"">" drug-names miscellaneous
pharmacology
A pt with HIV takes a protease inhibitor. What is the typical suffix for this class
of drug? -navir (eg, ritonavir) "<img src=""7731.png"">" drug-names
A man with CHF takes a -blocker. What is the typical suffix for this class of
drug? -olol (eg, propranolol) "<img src=""7731.png"">" drug-names miscellaneous
pharmacology
A pt with schizophrenia takes a typical antipsychotic. What is the typical suffix
for this class of drug? -azine (eg, thioridazine) "<img src=""7731.png"">"
A pt receives a barbiturate for sedation during a procedure. What is the typical
suffix for this class of drug? -barbital (eg, phenobarbital) "<img
A pt with treatment-resistant depression takes tricyclic antidepressants. What is
the typical suffix for this class of drug? -triptyline (eg, amitriptyline) or
-ipramine (eg, imipramine) "<img src=""7731.png"">" drug-names miscellaneous
pharmacology
A pt with diabetes takes an angiotensin-converting enzyme (ACE) inhibitor. What is
the typical suffix for this class of drug? -pril (eg, captopril) "<img
A pt with asthma takes a 2-agonist. What is the typical suffix for this class of
drug? -terol (eg, albuterol) "<img src=""7731.png"">" drug-names miscellaneous
pharmacology
A pt with GERD takes an H2-antagonist. What is the typical suffix for this class of
drug? -tidine (eg, cimetidine) "<img src=""7731.png"">" drug-names
A pt with growth hormone deficiency takes a pituitary hormone as therapy. What is
the typical suffix for pituitary hormones? -tropin, such as somatotropin "<img
A pt with prostate hyperplasia takes an 1-antagonist. What is the typical suffix
for this class of drug? -zosin (eg, prazosin) "<img src=""7731.png"">" drug-
names miscellaneous pharmacology
A man with hyperlipidemia takes a HMG-CoA reductase inhibitor. What is the typical
suffix for this class of drug? -statin (eg, atorvastatin) "<img
A woman with diabetes takes a PPAR- activator. What is the typical suffix for this
class of drug? -glitazone (eg, rosiglitazone) "<img src=""7731.png"">"
A woman with osteoporosis is prescribed a bisphosphonate. What is the typical
suffix for this class of drug? -dronate (eg, alendronate) "<img
A pt with GERD takes a proton pump inhibitor. What is the typical suffix for this
class of drug? -prazole (e.g., omeprazole) "<img src=""7731.png"">" drug-
A pt with glaucoma takes a prostaglandin analog. What is the typical suffix for
this class of drug? -prost (eg, latanoprost) "<img src=""7731.png"">"
A pt with a recent kidney transplant takes a chimeric monoclonal antibody. What is
the typical suffix for this class of drug? -ximab (eg, basiliximab) "<img
A pt with a recent kidney transplant takes a humanized monoclonal antibody. What is
the typical suffix for this class of drug? -zumab (eg, daclizumab) "<img
A pt with hypertension takes an angiotensin II receptor blocker. What is the
typical suffix for this class of drug? -sartan (eg, losartan) "<img
A pt with urinary retention after surgery takes a cholinergic agonist. What is the
typical suffix for this class of drug? -chol (eg, bethanechol, carbachol) "<img
A pt undergoing surgery receives a nondepolarizing paralytic. What is the typical
suffix for this class of drug? -curium (eg, atracurium) or -curonium (eg,
vecuronium) "<img src=""7731.png"">" drug-names miscellaneous pharmacology
A pt with myasthenia gravis takes an AChE inhibitor. What is the typical suffix for
this class of drug? -stigmine (eg, neostigmine) "<img src=""7731.png"">"
A pt with depression takes an SSRI. What is the typical suffix for this class of
drug? -etine (eg, fluoxetine) "<img src=""7731.png"">" drug-names miscellaneous
pharmacology
A pt with migraines takes a 5-HT1B/1D agonist. What is the typical suffix for this
class of drug? -triptan (eg, sumatriptan) "<img src=""7731.png"">" drug-
A pt with a herpes infection takes a DNA polymerase inhibitor. What is the typical
suffix for this class of drug? -ovir (eg, acyclovir) "<img src=""7731.png"">"
A pt with hypertension starts taking a dihydropyridine Ca2+ channel blocker. What
is the typical suffix for this class of drug? -dipine (eg, amlodipine) "<img
A pt with atypical pneumonia takes a macrolide antibiotic. What is the typical
suffix for this class of drug? -thromycin (eg, azithromycin) "<img
A pt with the flu receives a neuraminidase inhibitor. What is the typical suffix
for this class of drug? -ivir (eg, oseltamivir) "<img src=""7731.png"">" drug-
A pt with pinworms receives an antiparasitic/antihelminthic agent. What is the
typical suffix for this class of drug? -bendazole (eg, mebendazole) "<img
A man with atrial fibrillation starts taking a direct factor Xa inhibitor. What is
the typical suffix for this class of drug? -xaban (eg, apixaban, edoxaban,
rivaroxaban); all are Xa inhibitors "<img src=""7731.png"">" drug-names

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The designers of a COPD study organize subjects into smokers and nonsmokers and

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