1. Movements of Thumb. They asked about extension of thumb when hand is pronated: pg.

436
• Dermatome C6.
• Median nerve responsible for thumb for thumb opposition.
• Adduction of thumb → Ulnar nerve.
• Extension of thumb when pronated: Extensor pollicis longus (big one), Abductor
pollicis longus, Extensor pollicis brevis → all supplied by Radial nerve.

2. Brachial plexus—musculocutaneous nerve. Be able to pick this out in the picture: pg. 438

3. Testes lymphatic drainage: pg. 606

• Para-aortic also known as lumbar

4. Prostate Blood supply:

• Inferior vesical artery, branch of internal iliac
5. Prolonged epistaxis—where is the origin of the bleed?
• Posterior bleeds are prolonged and more difficult to control.
• Posterior bleeds arise from Woodruff’s plexus.
• Anterior ethmoidal, sphenopalatine, and superior labial arteries anastomose

6. Cancer of anal canal with keratin pearls. What is the lymphatic drainage: pg. 360
• Superficial inguinal nodes.
• This is squamous cell carcinoma, present below the dentate line.

Anal canal above the dentate line (adenocarcinoma) → Internal iliac nodes, inferior
mesenteric nodes.
Anal canal below the dentate line (squamous cell) → Superficial inguinal nodes.
7. Nerve supply Flexor Digitorum Profundus: pg. 436
Dual: Median nerve (radial/lateral half) AND Ulnar nerve (ulnar half).

8. Intractable hiccups—nerve to dissect

• Phrenic nerve dissection

9. Arterial access of brachial artery

• Low brachial artery access is a safe alternative approach when femoral artery cannot
be done.
• Obstacles: Median nerve, tendon of biceps, total blood flow to the forearm.
• It lies above the biceps tendon and lateral to the median nerve.
• Left brachial artery is preferred over the right because of origin of common carotid
artery on the right side.
10. Tracheal deviation on imaging—what lymph nodes are likely involved?
• Subcarinal lymph nodes—solitary LN located in lungs in the carina.
• Present at bifurcation of trachea, when it enlarges → deviation of trachea
• Risk of injury to the thoracic duct (drains the left side of the body)
11. Blood sample is collected from cubital area and needle gets accidentally inserted medial
to the biceps tendon—what structure is involved?
• Brachial artery tear
• Deep brachial (profunda brachii) is a branch of the brachial artery, located in the
cubital fossa.
• Courses posteriorly along the mid-humerus with the radial nerve, dividing into the
radial collateral, and middle collateral
Midshaft fracture: Radial nerve and deep brachial artery.
Supracondylar fracture: Median nerve and brachial artery.
• FAT PAD sign seen on X-ray
• Additional info in acute ischemia of the limb: Volkmanns ischemic contracture (a
flexion deformity) due to ischemia causing muscle fibrosis. Treat by stretching and
lengthening the FDP and FPL

12. Structure damaged during hernia repair, CT scan shows increase in rectus sheath
diameter: pg. 364
• Inferior epigastric artery most likely damaged.
13. Patient presents with an abscess of the right kidney, which neuronal body of pain fibers is
involved?
• Ans: Dorsal Root Ganglion
• Sensory nerve ending (Aδ and C fibers) → bypass pseudounipolar cell body in dorsal
root ganglion → enter spinal cord

14. Sphingomyelinase deficiency (be sure to know all of these diseases): pg. 88
• Niemann-Pick disease—progressive neurodegeneration, hepatosplenomegaly, foam
cells (lipid-laden macrophages), “cherry-red” spot on macula.
• Deficient enzyme is sphingomyelinase, accumulation of sphingomyelin.

15. Cell levels after exposure to p21: pg. 46

• p21 is pro-apoptotic and is a major target of p53. Result is decreased cell levels.
• p21 arrests the cell cycle in G1 and S phases.
1. Inhibits CDK’s
2. Interacts with PCNA (Proliferating cell nuclear antigen) to halt DNA
replication.
16. I-cell disease: pg. 47
• Golgi is the defective organelle.
• Defect in N-acetylglucosaminyl-1-phosphotransferase → failure of the Golgi to
phosphorylate mannose residues (↓ mannose-6-phosphate) on glycoproteins →
proteins are secreted extracellularly rather than delivered to lysosomes.
• Results in coarse facial features, gingival hyperplasia, clouded corneas, restricted joint
movements, claw hand deformities, kyphoscoliosis, and high plasma levels of
lysosomal enzymes.
17. Blue sclera cause in Osteogenesis Imperfecta: pg. 51
• Due to the translucent connective tissue over choroidal veins.
• Also presents with multiple fractures, opalescent teeth that wear easily due to lack of
dentin, and hearing loss (abnormal ossicles).
18. Essential fatty acids: pg. 470
• Linolenic and linoleic acid are the two important essential fatty acids.
• These are important in membrane phospholipids to maintain normal fluidity of cell
membranes essential for many functions.
• Arachidonic acid is formed from linoleic acid. Arachidonic acid is an important
precursor for prostaglandins, thromboxanes, and leutoktrienes.

19. Biotin dependent enzymes—carboxylases: pg. 68

• Cofactor for carboxylation enzymes that add a 1-carbon group
• Pyruvate carboxylase: pyruvate (3C) → oxaloacetate (4C)
• Acetyl-CoA carboxylase: acetyl-CoA (2C) → malonyl-CoA (3C)
• Propionyl-CoA carboxylase: propionyl-CoA (3C) → methylmalonyl-CoA (4C)
20. Cystic Fibrosis patient—sweat vs mucous (ion levels): pg. 60
• Diagnosis of CF is based on elevated sweat chloride concentrations
• However, patients with mild mutations of the CF transmembrane conductance
regulator (CFTR) gene may have normal sweat testing. In these cases, it is useful to
do nasal transepithelial potential difference.

Mucous: ↑ Cl-, ↓ Na+.

 • In intestinal and respiratory epithelia, the CFTR channel secretes chloride ions into the
lumen and also has a tonic inhibitory effect on the opening of the epithelial sodium
channel (ENaC), which decreases sodium reabsorption into the cell. This luminal salt
content helps retain water in the lumen, forming well-hydrated mucus.
• Because patients with CF have increased sodium absorption via the ENaC, sodium is
absorbed intracellularly but chloride in the saline solution is retained in the lumen.
• The higher relative amount of negatively charged chloride on the epithelial surface
result in a more negative transepithelial voltage difference.

Sweat: ↑ Cl-, ↑ Na+.

• CFTR channel functioning is reversed in sweat ducts compared with that in
respiratory and intestinal glands. CFTR reduces the salt content of sweat by
reabsorbing luminal chloride and stimulating ENaC to increase sodium absorption from
the lumen into the cells. CFTR mutations therefore result in the production of sweat
with high chloride and sodium content.
• Nasal Transepithelial potential difference: CFTR protein reduces chloride
secretion and increases sodium absorption by the respiratory epithelia, resulting in
dehydrated mucus. When saline is applied to the nasal mucosa, the increased sodium
absorption in patients with CF cause a more negative transepithelial potential
difference—this is used to diagnose CF.

21. Pleiotropy: pg. 56

• One gene contributes to multiple phenotypic effects.
• Untreated phenylketonuria (PKU) manifests with light skin, intellectual disability, and
musty body odor.
22. Mitochondrial inheritance: pg. 59
• Mitochondrial diseases are transmitted only through the mother. All offspring of
affected females may show signs of disease. Heteroplasmy → variable expression in a
population (even within family).
• Mitochondrial myopathies—rare disorders; Often present with myopathy, lactic
acidosis, and CNS disease, eg, MELAS syndrome (mitochondrial encephalomyopathy,
lactic acidosis, and stroke-like episodes). 2° to failure in oxidative phosphorylation.
Muscle biopsy often shows “ragged-red fibers” (due to accumulation of diseased
mitochondria).
• Leber hereditary optic neuropathy—cell death in optic nerve neurons subacute
bilateral vision loss in teens/young adults, 90% males. Usually permanent.
• What happens in mitochondria? Fatty acid oxidation (β-oxidation), acetyl-CoA
production, TCA cycle, oxidative phosphorylation, ketogenesis.
23. Pompe—PAS+ slide and heart failure: pg. 87
• Lysosomal enzyme α-1,4-glucosidase
• Cardiomegaly, hypertrophic cardiomyopathy, hypotonia, exercise intolerance, and
systemic findings lead to early death.
24. Down syndrome (trisomy 21): pg. 63
• 95% of cases due to meiotic nondisjunction (↑ with advanced maternal age).
• 4% of cases due to unbalanced Robertsonian translocation, most typically between
chromosomes 14 and 21.
• Only 1% of cases are due to postfertilization mitotic error.
• The 5 A’s of Down syndrome: Advanced maternal age, Atresia (duodenal),
Atrioventricular septal defect, Alzheimer disease (early onset), AML/ALL.
25. Tyrosinase deficiency—albinism: pg. 83, 463
• Tyrosinase normally converts DOPA to Melanin.
• Albinism: normal melanocyte number with ↓ melanin production due to ↓ tyrosinase
activity or defective tyrosine transport. ↑ risk of skin cancer.
26. Reactivation of Zoster—anterograde via kinesin: pg. 48
• During reactivation from latency, the herpes simplex virus (HSV) enters its lytic cycle,
and uses anterograde transport to migrate from dorsal root ganglia neurons to the
skin or mucosa.
27. Rett Syndrome: pg. 61
• XLD mutation in MECP2, seen in girls only
• Symptoms appear between ages 1–4 and are characterized by regression (Retturn) in
motor, verbal, and cognitive abilities; ataxia; seizures; growth failure; and stereotyped
handwringing.
28. Patient with staph abscess on foot was given antibiotics but 2 days later he develops
osteomyelitis of the spine. What is the next step in management?
• MRI Spine.
29. PG in fever: pg. 211
• PGE2, TNF-α, IL-1, IL-6
30. Displacement: pg. 538
• Redirection of emotions or impulses to a neutral person or object (vs projection).
31. Sublimation: pg. 539
• Replacing an unacceptable wish with a course of action that is similar to the wish but
socially acceptable (vs reaction formation).
32. Antisocial: pg. 549
• Disregard for and violation of rights of others with lack of remorse, criminality,
impulsivity; males > females; must be ≥ 18 years old and have history of conduct
disorder before age 15. Conduct disorder if < 18 years old.
33. Treatment of schizophrenia: pg. 557
• Atypical antipsychotics are first-line for schizophrenia.
• These treat both the positive and negative symptoms
Adverse effects:
• Prolonged QT interval, fewer EPS and anticholinergic side effects than typical
antipsychotics.
 • “-pines”—metabolic syndrome (weight gain, diabetes, hyperlipidemia).
• Clozapine—agranulocytosis (monitor WBCs frequently) and seizures (dose related).
• Risperidone—hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia).
• Typical antipsychotics treat the primary positive symptoms. They are used less
frequently now but are accompanied by an array of side effects:

34. Pregnant patient receives epidural and has itching reaction—IgE independent mast cell
degranulation:
• This is most likely medication-induced IgE-independent mast cell activation. A number
of medications, including opioids, vancomycin, radiocontrast agents, atracurium, can
induce mast cell degranulation by activation of protein kinase A and PI3 kinase.
• This results in release of several mediatiors, including histamine, bradykinin, heparin,
and a number of enzymes and chemotactic factors.
• Common symptoms include diffuse itching and pain, bronchospasm, and localized
swelling (urticaria)
35. Another IgE-independent vignette—involving drug atracurium.
36. Virus remains in nucleus, but does not enter DNA: pg. 162, 167
• Orthomyxovirus is an RNA virus that replicates in the nucleus.
• This is because the machinery of orthomyxo viruses cannot make their own mRNAs.
They use cellular RNAs as primers for initiating the viral mRNA synthesis (known as
cap stealing).
• This makes it unique of all the RNA viruses.
37. Recurrent genital infection with different stages of crop healing—herpes simplex: pg. 164
• HSV-2 – cause herpes genitalis.
• It is characterized by painful, recurrent vesicular eruptions of the mucocutaneous
surfaces.
• Contraction/transmission occurs via direct contact with active lesions after which the
virus resides in the dorsal root ganglia of local nerves
• Intrahost viral spread occurs via epidermal cells causing them to fuse into giant cells
38. Thalamic Stroke—what arteries are involved: pg. 499
• PCA gives off branches to thalamus (artery of Percheron).
• The thalamus is a major sensory relay center, thus thalamic strokes present as
sensory loss.
• Thalamic pain syndrome can result (post-stroke). These are initial parasthesias
followed in weeks to months by allodynia (ordinarily painless stimuli cause pain) and
dysesthesia (unpleasant sensation to touch) on the contralateral side. Occurs in 10%
of stroke patients.
• PCA strokes often present with contralateral hemianopia with macular sparing in
addition to thalamic symptoms.
• PCA also supplies hippocampus.

39. ROC Curve

• A receiver operating curve shows the tradeoff between sensitivity and specificity which
is made when choosing a cutoff value for positive and negative test results.
• The area under the curve represents accuracy (TP+TN/All).
• An accurate test has AOC close to 1.0 (rectangular/curve A).
• A test with no predictive value has AOC close to 0.5 (curve B).

40. Carbonic anhydrase inhibitors—metabolic disturbance: pg. 577, 590

• ↓ pH, ↑ PCO2, ↓ [HCO3-]
• Causes self-limited NaHCO3 diuresis and ↓ total body HCO3− stores.
 • CAI can cause RTA type 2 defect in PCT HCO3 reabsorption → excretion of HCO3- in
urine → metabolic acidosis.
• Urine can be acidified by α-intercalated cells in collecting duct, but not enough to
overcome the increased excretion of HCO3 → metabolic acidosis.
41. Giant cell arteritis: pg. 308
• Usually elderly females. Unilateral headache (temporal artery), jaw claudication. May
lead to irreversible blindness due to ophthalmic artery occlusion.
• Associated with polymyalgia rheumatica.
• The inflammatory infiltrate in affected vessels is composed of lymphocytes
(predominately CD4+) and macrophages and frequently contains multinucleated giant
cells. Cytokines, particularly IL-6, closely correlate with severity of disease.
• RX: Tocilizumab, monoclonal antibody against IL-6.
42. Trichomonas RX: pg. 158, 195
• Metronidazole: Forms toxic free radical metabolites in the bacterial cell that damage
DNA.
• Partner is also treated for prophylaxis.
43. Patient presents with oral thrush and repeated infections—next step:
• Check HIV status: HIV Immunoassay
44. Tinea capitis Rx: pg. 199, 200, 152
• Oral Terbinafine OR Griseofulvin
• Terbinafine inhibits squalene epoxidase. Adr: Hepatotoxic.
• Griseofulvin is a microtubule inhibitor. Adr: Disulfiram, P450 inducer.
45. Phototoxicity – Doxycycline
• Drugs causing phototoxicity are FoToS
• Fluoroquinolones, Tetracyclines, Sulfonamides, Amiodarone, 5FU
• Described as RASH on SUN exposed areas; avoid the sun
• Most common with Doxycycline

46. Gross adrenal gland with hypertension where do Catecholamines act?: pg. 320
• Adrenal medulla
• Cut section below shows outer cortex which is slightly yellowish and medulla which is
dark.
• Adrenal medulla produces catecholamines.

47. Urachal cyst: pg. 600

• Allantois remnant.
• Partial failure of urachus to obliterate; fluid-filled cavity lined with uroepithelium,
between umbilicus and bladder. Clear yellow fluid.
48. Lynch syndrome vignette: pg. 382
• Defective genes: MSH2, MLH1
• Autosomal dominant mutation of DNA mismatch repair genes with subsequent
microsatellite instability. ∼80% progress to colorectal carcinoma. Proximal colon is
always involved. Associated with endometrial, ovarian, and skin cancers.
49. Klinefelter hormone levels? Increased LH and FSH. pg. 620
• Dysgenesis of seminiferous tubules → ↓ inhibin B → ↑ FSH.
• Abnormal Leydig cell function → ↓ testosterone → ↑ LH → ↑ estrogen.
50. What drug is given as prophylaxis for rheumatic fever in a pharyngitis patient:
• If rapid antigen detection test is positive for group A streptococcus infection, prompt
treatment with penicillin V is done.
• Penicillin G is for prophylaxis
• If left untreated, can result in rheumatic heart disease.
51. Risk factor for pancreatic cancer—smoking
• About 1/3 of cases of pancreatic cancer are attributable to cigarette smoking.
52. Tenofovir: pg. 203
• Only nucleotide analog of the NRTI’s.
• Requires phosphorylation from thymidine kinase, however needs to be phosphorylated
2 times as opposed to 3 times in case of nucleoside analogs.
• Mechanisms of resistance:
Reverse transcriptase mutation.
Decreased incorporation of the nucleotide analogue into the viral DNA and
increased excision of the nucleotide from the viral DNA.
• Causes Fanconi syndrome.
Absorptive defect of the PCT, which loses the ability to reabsorb amino acids
(aminoaciduria), glucose (hypoglycemia), HCO3- (RTA type II, hypokalemia), and
phosphate (hypophosphatemic rickets).
53. Junctional Nevus: pg. 464
• Characterized by aggregates of nevus cells limited to the dermoepidermal junction.
• Flat black/brown macules with dark centers.
• Melanocytic nevi are benign neoplasms composed of round, uniform (nevus cells) that
are mitotically quiescent. These nevus cells lack dendrites.
• These typically progress from junctional → compound → intradermal.
54. Scleroderma patient—presents with pulmonary fibrosis, hypertension: pg. 460
• Develops due to ↑ collagen in tissues.
• Pathophysiology: T-cells secrete cytokines (such as TGF-beta) which ↑ collagen and
extracellular matrix proteins by fibroblasts.
• Earliest damage is seen in small arterioles and capillaries. Microvascular injury of
pulmonary arterioles leads to narrowing of the lumen and ↑ pressure in pulmonary
circulation.
• This leads to hypertrophy of the right ventricle, and subsequent development of right-
sided congestive heart failure.
• Findings: Accentuated P2 of S2 and signs of right heart failure due to cor pulmonale.

55. Osteoporosis—PTH, Ca levels in the blood: pg. 449, 451

• In primary osteoporosis (not caused by a medical disorder) serum Ca2+, PTH, ALP are
normal.
56. In chronic kidney disease—electrolyte levels: pg. 586
• CKD causes renal osteodystrophy.
• ↓ EPO
• ↓ Ca2+, ↑ PO43- (because of ↓ vitamin D)
• ↑ PTH (due to secondary hyperparathyroidism)
57. After unilateral nephrectomy, what changes occur in the remaining kidney?
• Glomerular hypertrophy and hyperfiltration will occur as a part of compensation.
 • However, after some time, focal segmental glomerulosclerosis (FSGN) begins to
develop. This is known as hyperfiltration injury.
• FSGN by nature progresses to ESRD.
• Unilateral renal agenesis has the same effect.
58. Test before starting on TNF-α therapy: pg. 472
• PPD test.
• TNF-α normally forms and maintains granulomas. Inhibition will break down
granuloma and cause disseminated TB.
• TNF-α drugs include infliximab, adalimumab, certolizumab, golimumab, and
etanercept.
59. Parameters in CHF: pg. 291
• ↑ ANP, ↑ BNP → ⊖ Renin → ↓ Angiotensin, ↓ Aldosterone
• ↑ ANP, ↑ BNP result due to volume overload state in heart failure which causes
increased stretch sensed by atrial myocytes.
• NP’s stimulate natriuresis/diuresis and improve GFR and filtration fraction.
• Also, NP’s inhibit renin, thus decreasing levels of Angiotensin II and Aldosterone.
• Nesiritide: BNP analogue.
• Sacubitril: Neprilysin inhibitor. Neprilysin is the enzyme that normally degrades ANP,
BNP.

60. Exogenous androgen use in a thirteen year old patient—what are the effects? pg. 617
• Short stature. Excess testosterone gets converted to estrogen which is responsible
for closure of epiphyseal plates.
61. Mechanism by which heart rate increases when a patient stands:
• Standing results in pooling of blood in the veins which triggers the baroreceptor reflex
to increase sympathetic outflow, which in turn increases heart rate.

62. p53 mutation pg. 222, 56

• Causes unrestrained cell division → Li-Fraumeni syndrome (AD inheritance)
• Also known as SBLA cancer syndrome—Sarcoma (OS/RMS), of Breast, Brain,
Leukemia, Adrenal Cortex.
• Li-Fraumeni is an example of ‘Loss of heterozygosity.’ If a patient inherits or
develops a mutation in a tumor suppressor gene, the complementary allele must be
deleted/mutated before cancer develops. This is not true of oncogenes.
63. Tender granulomatous thyroid—de Quervain: pg. 336
• Self-limited, often follows flu-like illness. Hyperthyroid early in course, followed by
hypothyroidism.
• Histology: Mixed lymphocytic infiltrate—multinucleated giant cells and macrophages
• ↑ ESR, jaw pain, tender thyroid
64. Hepatitis B—what do would you see in a recently resolved infection: pg. 174
• Anti-Hbs, Anti-Hbe, Anti-Hbc (IgG)

65. Hep C infection treatment—Ribavarin + IFN-α: pg. 204

• Ribavirin ⊖’s IMP dehydrogenase → ⊖’s guanine nucleotide synthesis and duplication
of viral genetic material.
• Given in Hep C in combination with Sofosbuvir (which inhibits RNA-dependent RNA
polymerase) or IFN-α.
• Ribavirin may also be used in RSV in severe cases (prefer Palivizumab), Lassa fever,
Hanta virus
• Adverse effects: Hemolytic anemia, BM suppression, airway irritation, teratogen.
66. Mother is positive for Hepatitis B and negative for HIV. Hepatitis B vaccine and hepatitis
antibodies are given. What is the next management step?
• No intervention because vaccine and antibodies are sufficient for protection of the
fetus.
• Interferon alpha is contraindicated in pregnant women
• Treatment with antiviral agents is suggested if HBV DNA levels are high. Discontinue
treatment at delivery if breastfeeding is chosen.
• Hepatitis B Vaccine—recombinant surface protein subunit vaccine. Contains HBsAg.
Prevents vertical transmission (neonatal Hep B). All pregnant women should be
screened for HBV. Administer Hep B immune globulin followed by active immunization
with recombinant vaccine in newborns of actively infected mothers.
67. ESR due to increased fibrinogen: pg. 211, 212
• Inflammation → ↑ IL-1, IL-6, TNF-α → ↑ Fibrinogen → ↑ ESR
• Fibrinogen (and other products of inflammation) coat RBC’s and cause aggregation.
The denser RBC aggregates fall at a faster rate within a pipette tube → ↑ ESR
(Rouleaux formation)
68. Partial agonist activity: pg. 230
• Acts at same site as full agonist, but with lower maximal effect (↓ efficacy). Potency is
an independent variable.
• Morphine (full agonist) vs buprenorphine (partial agonist) at opioid μ-receptors.
69. Patient with urge continence is given antihistaminics—mechanism for relief of symptoms?
• Antihistaminics have anticholinergic activity, inhibit M3 on bladder and cause relief
of urge incontinence. It causes detrusor relaxation and constriction of the sphincter.
Antihistaminics have receptor blocking activity in addition to Histamine receptors:
• Cholinergic/muscarinic—blurry vision, exacerbation of glaucoma, urine
retention, delirium, constipation.
• Alpha-adrenergic—postural dizziness, falls.
• Serotonergic—appetite stimulation, weight gain.
• Rx for urge incontinence specifically: oxybutynin, tolterodine, and solifenacin.
70. Cocaine induces coronary artery spasm: pg. 299
• Drugs causing coronary vasospasm: Cocaine, Amphetamines, Sumatriptan, Ergot
alkaloids (CASE).
• Caution when giving β-blockers if cocaine intoxication is suspected as it can lead to
unopposed α1 activation, activation extreme hypertension, coronary vasospasm.
• Rx: CCB’s, nitrates, and smoking cessation (if applicable).
• Specific antidote for cocaine toxicity is phentolamine.
71. Left ventricular failure + S4. History of hypertension is present and ECG is shown
• The three major causes of valvular aortic stenosis are:
▪ A calcified normal valve (most common in the US)
▪ Congenitally abnormal, bicuspid valve with calcification (AD)
▪ Rheumatic heart disease
• Symptoms: Syncope, Angina, Dyspnea (SAD)
• S4 indicates stiff walls. Due to ↑ pressure of the hypertrophic myocardium.
• S2 is diminished due to reduced mobility of the aortic leaflets.
• Auscultation: Crescendo-decrescendo systolic ejection murmur heard best in the
right second intercostal space with radiation to the carotids.
• Aortic stenosis causes concentric hypertrophy.
• Concentric hypertrophy is characterized by uniform thickening of the ventricular wall
with the outer dimension of the ventricle remaining almost unchanged, resulting in a
narrowed ventricular cavity size.
• It is due to chronic ↑ of ventricular pressures during systole, which is usually caused
by long-standing hypertension or aortic stenosis (increased LV afterload).
• Patients may develop diastolic dysfunction with LA enlargement and congestive heart
failure due to impaired ventricular compliance and filling.
• QRS complex is increased in amplitude (R waves)
72. Statins increase LDL receptors pg. 313
• Statins inhibit the rate-limiting enzyme in hepatic cholesterol synthesis.
• In response to these changes, hepatocytes increase their surface expression of the
LDL receptor to increase uptake of circulating LDL.

73. ADH Antagonists: pg. 350

• These are used in SIADH.
• Conivaptan, tolvaptan block action of ADH at V2-receptor.
• Demeclocycline (a tetracycline). Adverse effects: nephrogenic DI, photosensitivity,
abnormalities of bone and teeth.
74. Biliary atresia
 • Biliary atresia is a progressive, complete or partial obstruction of extrahepatic bile
ducts. The biliary tree is normal at birth and subsequently undergoes destruction that
is thought to be immune-related or viral-induced.
• Infants may appear healthy at birth. Jaundice presents within the first 2 months of
life, along with dark urine (↑ renal excretion of bilirubin) and pale stools (due to lack
of intestinal bile).
• Physical examination: Hepatomegaly due to inflammation.
• Lab findings: ↑ direct bilirubin, ↑ GGT.
• Liver biopsy is diagnostic. It shows intrahepatic bile duct proliferation, portal tract
edema, and fibrosis.
• Urgent surgical intervention is required, as lack of intervention can lead to death (due
to cirrhosis) usually within 2 years.

75. Lab findings of DKA: pg. 345

• ↓ pH, ↑ H+, ↑ ketone levels, ↓ HCO3-, ↑ K+, ↑ glucose
• ↓ HCO3- (<15) → used up to buffer ketoacids.
• ↓ PaCO2 levels → due to hyperventilation. Kussmaul’s breathing pattern leads to
compensatory respiratory alkalosis.
Hyperkalemia but total body K+ depletion:
• ↑ K+ in blood but depleted intracellular K+ due to transcellular shift from ↓ insulin
and exchange with H+.
• Osmotic diuresis → ↑ K+ loss in urine → total body K+ depletion.

76. BPH resulting in bladder trabeculations—obstructive uropathy: pg. 635

• Obstructive uropathy is the most common complication of BPH.
• It can result in prominent trabeculations seen on the bladder. This trabeculated
appearance is due to hyperplasia and hypertrophy of smooth muscle.
 • Other consequences of obstructive uropathy:
-The stasis from obstruction predisposes to infection.
-The obstruction can lead to bilateral hydroureter and hydronephrosis.
-Bladder diverticula can develop.
• BPH presents with frequency of urination, nocturia, difficulty starting and stopping
urine stream, dysuria. ↑ PSA.
• Rx: α1-antagonists, 5α-reductase inhibitors, PDE-5 inhibitors.

77. Which is the best study for a small sample size?

• Crossover study. Crossover designs effectively double the sample size (placebos and
those receiving drug are switched after a washout period).

78. Confidence interval: pg. 258

• Range of values within which the true mean of the population is expected to fall, with
a specified probability.
• CI for sample mean = x ± Z(SE)
• The 95% CI (corresponding to α = .05) is often used.
• For the 95% CI, Z = 1.96.
• For the 99% CI, Z = 2.58.
• If the 95% CI for a mean difference between 2 variables includes 0, then there is no
significant difference and H0 is not rejected.
• If the 95% CI for odds ratio or relative risk includes 1, H0 is not rejected.
• If the CI’s between 2 groups do not overlap → statistically significant difference exists.
If the CI’s between 2 groups overlap → usually no significant difference exists.
79. Incidence: pg. 255

80. Positive Skew: pg. 257

• Mean>Median>Mode
 • Asymmetry with longer tail on left.

81. Population Pyramid—be familiar with developed vs developing nations. Developing

countries will have more death in old age, especially in poor income families, thus will
have a triangular shape.
• Expansive: Expansive population pyramids are used to describe populations that are
young and growing. They are often characterized by their typical ‘pyramid’ shape,
which has a broad base and narrow top. Expansive population pyramids show a larger
percentage of the population in the younger age cohorts, usually with each age cohort
smaller in size than the one below it. These types of populations are typically
representative of developing nations, whose populations often have high fertility
rates and lower than average life expectancies.
• Stationary: Stationary, or near stationary, population pyramids are used to describe
populations that are not growing. They are characterized by their rectangular shape,
displaying somewhat equal percentages across age cohorts that taper off toward the
top. These pyramids are often characteristic of developed nations, where birth
rates are low and overall quality of life is high.
• Constrictive: Constrictive population pyramids are used to describe populations that
are elderly and shrinking. Constrictive pyramids can often look like beehives and
typically have an inverted shape with the graph tapering in at the bottom. Constrictive
pyramids have smaller percentages of people in the younger age cohorts and are
typically characteristic of countries with higher levels of social and economic
development, where access to quality education and health care is available
to a large portion of the population.

82. Randomized Control Trial: pg. 252

• A type of scientific experiment which aims to reduce bias when testing a new
treatment. The people participating in the trial are randomly allocated to either the
group receiving the treatment under investigation or to a group receiving standard
treatment (or placebo treatment) as the control.
 • Randomization minimizes selection bias and the different comparison groups allow the
researchers to determine any effects of the treatment when compared with the no
treatment (control) group, while other variables are kept constant. The RCT is often
considered the gold standard for a clinical trial.
83. Relative Risk: pg. 254
• Typically used in cohort studies. Risk of developing disease in the exposed group
divided by risk in the unexposed group. For rare diseases (low prevalence, <10%),
OR approximates RR.
• RR = 1 → no association between exposure and disease.
• RR > 1 → exposure associated with ↑ disease occurrence.
• RR < 1 → exposure associated with ↓ disease occurrence.

84. Budd Chiari—Thrombosis of Hepatic Vein. Results in liver congestion and increase in
liver enzymes. Diagnose with Hepatic Venography: pg. 386
• Thrombosis or compression of the hepatic veins with centrilobular congestion and
necrosis → congestive liver disease (“painful” hepatomegaly, ascites, varices,
abdominal pain, liver failure.)
• Absence of JVD. Associated with hyper coagulable states, polycythemia vera (most
common cause), postpartum state, HCC. May cause nutmeg liver (mottled
appearance)
• Lab: increased serum transaminases and a prolonged PT.
• Dx: ultrasonography with pulsed Doppler as a first-line test and magnetic resonance
imaging (MRI).
• Prognosis: mortality rate of 75% in the first year
85. PCOS hormone level at day 21—progesterone is low: pg. 627
• Key mechanism is ↑ LH relative to FSH (LH/FSH ratio > 3).
• ↑ LH stimulates theca cells → ↑ androgens → ↑ estrogen (via aromatase) → ↓ FSH
• Thus LH is increased out of proportion to FSH levels
• The ↓ FSH → ↓ follicular maturation → no ovulation → no progesterone surge.
• Day 21 in the cycle is normally the peak of progesterone surge. However, in case of
PCOS, lack of progesterone surge results in lower than expected levels of
progesterone.
 • Rx: Cycle regulation via weight reduction (↓ peripheral estrone formation), OCPs
(prevent endometrial hyperplasia due to unopposed estrogen); clomiphene,
metformin to induce ovulation; spironolactone, ketoconazole (antiandrogens) to treat
hirsutism.
86. Electrolyte imbalance in vomiting (metabolic alkalosis): pg. 576
• Serum: ↑ pH, ↑ PCO2, ↑ HCO3-
• Urine (1-3 days): ↑ pH, ↓ Cl-, ↑ HCO3-, ↑ Na+, and ↑ K+
• ↓ Urine Cl-—often associated with volume depletion.
• The hypokalemia seen as a result of vomiting is largely due to urinary excretion of K+
in the first 1-3 days.

87. IgA nephropathy: pg. 581

• Episodic hematuria that occurs concurrently with respiratory or GI tract infections (IgA
is secreted by mucosal linings). Renal pathology of IgA vasculitis (HSP).
• Occurs 2-3 days after infection. Don’t confuse with PSGN which occurs 2-4 weeks
after infection.
• LM—mesangial proliferation
• IF—IgA-based IC deposits in mesangium; EM—mesangial IC deposition
• There is mesangial cell and matrix increase, with mesangial deposits (dark blue).

88. Lead poisoning (older constructions) pg. 407

 • Lead poisoning occurs through occupational exposure. Symptoms include colicky
abdominal pain, constipation, Burton lead lines on the gum, peripheral neuropathy
(wrist/foot drop), and anemia.
• Lab: Microcytic anemia with normal iron studies, with basophilic stippling on PBS.
• Rx: EDTA, dimercaprol, succimer, penicillamine.
89. TTP—PBF shows schistocytes, which factor is affected?: pg.415
• TTP—inhibition or deficiency of ADAMTS 13 (vWF metalloprotease) → degradation of
vWF multimers.
• vWF increases the half life of and stabilizes factor 8
Pathogenesis: ↓ ADAMTS13 → ↑ uncleaved vWF multimers → platelet trapping
and activation.
Labs: schistocytes, ↑ LDH, ↓ haptoglobin. ↑ BT, ↓ PC. Normal coagulation
parameters.
FAT RN: Fever, Anemia (MAHA), Thrombocytopenia, Renal failure, Neurologic
symptoms
Rx: plasmapheresis (life saving), steroids.

90. Pulmonary embolism—increased dead space: pg. 654

• Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs. In
most cases, pulmonary embolism is caused by blood clots that travel to the lungs
from the legs or, rarely, other parts of the body (deep vein thrombosis).
• A V /Q mismatch is decrease in perfusion relative to ventilation. Pulmonary embolism
is an example of increased dead space. Dead space is a space at which gas exchange
does not take place. It is ventilation without perfusion.

Imaging:

• CT pulmonary angiography is imaging

test of choice for PE (look for filling
defects).

• V/Q mismatch, hypoxemia,

respiratory alkalosis. Sudden-onset
dyspnea, pleuritic chest pain,
tachypnea, tachycardia.

• Lines of Zahn are interdigitating

areas of pink (platelets, fibrin) and
red (RBCs) found only in thrombi
formed before death; help distinguish
pre- and postmortem thrombi.

91. Antiplatelet to avoid in pregnancy: Warfarin: pg. 596

• Effects of Warfarin on fetus: bone deformities, fetal hemorrhage, abortion,
ophthalmologic abnormalities.
• Other teratogenic drugs include: ACE inhibitors, Alkylating agents, Aminoglycosides,
Antiepileptic drugs, Diethylstilbestrol, Folate antagonists, Isotretinoin, Lithium,
Methimazole, Tetracycline, Thalidomide.
92. Employee angry at boss – stays at work to complete work: pg. 539
 • Sublimation—replacing an unacceptable wish with a course of action that is similar to
the wish but socially acceptable (vs reaction formation).
93. Azoreduction of Sulfasalazine: pg. 231
• Sulfasalazine is a prodrug composed of 5-ASA linked to sulfapyridine by an azo bond
• It is partially absorbed in the jejunum after oral ingestion.
• The remainder is reduced in the colon by coliform bacterial enzyme, azoreductase,
to sulfapyridine and 5-ASA.
• Azoreduction is a phase II drug metabolism process.
• In the picture below, the N=N group is called an azo group.

94. Lab findings in iron deficiency - increase FPP pg. 406

• Labs: ↓ iron, ↑ TIBC, ↓ ferritin, ↑ free erythrocyte protoporphyrin, ↑ RDW. Microcytosis
and hypochromasia (↑ central pallor)
95. ITP: pg. 415
• ↑ BT, ↓ PC
• Anti-GpIIb/IIIa antibodies → splenic macrophage consumption of platelet-antibody
complex.
• May be 1° (idiopathic) or 2° to autoimmune disorder, viral illness, malignancy, or
drug reaction.
• Labs: ↑ megakaryocytes on bone marrow biopsy.
• Rx: Steroids, IVIG; rituximab or splenectomy for refractory ITP
96. What mutation should you check for before starting Cetuximab?: pg. 122
• KRAS mutation
• Activating mutations of KRAS gene lead to constitutive activation of EGFR pathway,
promoting increased cell proliferation and growth. Tumors harboring these mutations
are resistant to treatment with anti-EGFR drugs (eg, cetuximab, panitumumab)
97. PNH—Decay accelerating factor absent: pg. 410
• ↑ complement-mediated intravascular RBC lysis (acquired mutation in PIGA gene →
impaired synthesis of GPI anchor for decay-accelerating factor [DAF/CD55] and
membrane inhibitor of reactive lysis [MIRL/CD59] that protects RBC membrane from
complement).
• Acquired mutation in a hematopoietic stem cell. ↑ incidence of acute leukemias.
• Patients may report red or pink urine (from hemoglobinuria).
• Labs: CD55/59 ⊝ RBCs on flow cytometry. Treatment: eculizumab (inhibits terminal
complement formation).
98. Necator Americanus. Same picture from NBME 18 (hookworm): pg. 159
• Presents with anemia
• Via skin penetration

99. Effect of propranolol on epinephrine: pg. 238-240

• Epinephrine has β1 = β2 > α1
• β1 = ↑ ♡ rate and contractility which ↑ systolic BP (due to rise in cardiac output)
• β2 = Vasodilation and ↓ diastolic BP
• α1 = ↑ Peripheral resistance and ↑ diastolic BP
• At low doses → β2 mediated vasodilation predominates
• At high doses → α1 vasoconstriction predominates
• Low dose epinephrine → ↑ ♡ rate (β1) and ↓ diastolic BP (β2).
• After propranolol administration, ♡ rate fails to increase and there is a marked ↑
diastolic BP.

Summary:
• Epinephrine ↑ systolic BP (α1 + β1) and ♡ rate (β1), and either increases or decreases
diastolic blood pressure depending on the dose (either α1 or β2 predominates).
• Pretreatment with propranolol eliminates the β effects of epinephrine (vasodilation
and tachycardia), leaving only the α effect (vasoconstriction).
100. S1 radiculopathy—reflex lost: pg. 445
• Radiculopathy: Paresthesia and weakness related to specific lumbosacral spinal
nerves.
• Presents as weakness of plantar flexion, difficulty in toewalking, ↓ Achilles reflex.

101. Vincristine induced peripheral neuropathy—mechanism: pg. 429

• Vincristine—inhibits microtubule formation. Crisps the nerves (whereas Vinblastine
blasts the bone).
102. Carpal tunnel syndrome: pg. 435
• Tinel test - percussion of wrist causes tingling.
103. Patient with strep pneumonia develops pleural effusion, cause?: pg. 662
• Increased permeability.
• Pleural effusion is pathologic accumulation of fluid in the pleural space. It is often
parapneumonic (in association with pneumonia).
• In pneumonia inflammation causes increased permeability of capillaries within the
visceral pleura.
• The effusion is exudative because it is inflammatory in origin (as opposed to
transudate which is characterized by ↓ oncotic pressure/↑ hydrostatic pressure).
• Chest x-ray: Blunting of costophrenic angle, obscuration of diaphragm,
• Examination: ↓ breath sounds, ↓ fremitus, dull on percussion, tracheal deviation away
from lesion.

104. Tdt+, CD3+, malignant pre-T lymphocyte: pg. 420

• Vignette describes T-cell ALL—acute, rapidly progressive leukemia characterized by
the presence T lymphoblasts in the blood and bone marrow. Children > Adults (worse
prognosis).
• T-cell types commonly present as an anterior mediastinal mass (SVC like
syndrome) or as an acute leukemia. This differentiates it from B-cell types which
metastasize to the testicles. There is CNS involvement in both types.
• TdT+ (marker of pre-T and pre-B cells), CD3+
• t(12;21) → better prognosis.
105. Cerebellum of MRI patient having ataxia: which side involved? Ipsilateral

• Ipsilateral because fibers that go

through the cerebellum decussate
again, returning to their original side.

• Lateral lesions—affect voluntary

movement of extremities (lateral
structures); when injured, propensity
to fall toward injured (ipsilateral)
side.

• Medial lesions (eg, vermis, fastigial

nuclei, flocculonodular lobe)—truncal
ataxia (wide-based cerebellar gait),
nystagmus, head tilting. Generally
result in bilateral motor deficits
affecting axial and proximal limb
musculature (medial structures).

106. Neurotransmitter involved in craving—dopamine from nucleus accumbens

• The nucleus accumbens is a part of the basal ganglia and is the main component of
the ventral striatum. (Dorsal striatum of basal ganglia refers to caudate and
putamen).
• Dopamine is released into the nucleus accumbens following exposure to rewarding
stimuli, including recreational drugs like substituted amphetamines, cocaine, and
morphine.
• The nucleus accumbens and the ventral tegmental area (VTA) are the primary sites
where addictive drugs act. These drugs alter the neuromodulatory influence of
dopamine on the processing of reinforcement signals by prolonging the action of
dopamine in the nucleus accumbens or by stimulating the activation of neurons there
and also in the VTA.
107. Myasthenia gravis patient with increased PCO2—hypoventilation: pg. 459, 657
• Anti-ACh receptor to postsynaptic ACh receptor.
• Poor muscular effort—Polio, Myasthenia Gravis, GBS, poor breathing mechanics
(extrapulmonary, peripheral hypoventilation, normal A-a gradient).
• This is a restrictive lung disease affecting expansion and causes ↓ lung volumes ↓
FVC and TLC PFTs: ↑ FEV1/FVC ratio.
• Patient presents with dyspnea short, shallow breaths.
• Respiratory Acidosis: ↓ pH, ↑ PCO2, ↑ HCO3- (compensated)
• Myasthenia Gravis presents with ptosis, diplopia, weakness in respiratory muscle
involvement can lead to dyspnea. Worsens with muscle use. Improvement after
edrophonium (tensilon) test.
108. SCC—antibodies against calcium channels: pg. 665
• Lambert Eaton is characterized by Autoantibodies to presynaptic Ca2+ channel → ACh
release. Associated with small cell lung cancer.
• Other paraneoplastic syndromes associated with SCC include Cushing’s, SIADH, and
paraneoplastic cerebellar degeneration (Anti-Hu antibodies).
109. Colipase supplementation in chronic pancreatitis: pg. 391
• Colipase is a protein co-enzyme required for optimal activity of pancreatic lipase.
• It is secreted by the pancreas in an inactive form, pro-colipase, which is activated in
the intestinal lumen by trypsin.
• Its function is to prevent the inhibitory effect of bile salts on the lipase-catalyzed
intraduodenal hydrolysis of dietary long-chain triglycerides.
• It is used in chronic pancreatitis patients suffering from malnutrition.
• Fecal elastase (stool) is tested in chronic pancreatitis

110. Drug Trials—preclinical: pg. 252

• Preclinical = Animals.
• Small group of healthy volunteers = Phase I
111. Q: Study consists of survey via phone. Randomly select 1000 males/females. 25
questions in survey. P-value for entire survey is .3, but for one question the p value is
.035. What is the validity of the study?
• Answer: A meta-analysis would look at the same question across different studies,
and essentially compare the P-values. Even though it happened to be significant by
some small random chance in your study, it probably won’t be significant in other
studies that asked the same question (if there is truly no significant difference). So
when you do the meta-analysis and aggregate over all the studies, you’d likely find it
isn’t significant anymore.
112. Morphine + Buprenorphine = Precipitation of withdrawal effects due to partial
agonist action/antagonism?: pg. 534
• Buprenorphine has a very high affinity for the opioid receptor and is unlikely to be
displaced by full agonists (heroin, oxycodone, morphine).
• If a full agonist (such as morphine) is bound to the receptor and buprenorphine is
introduced, buprenorphine will displace morphine because buprenorphine has a much
higher affinity for the receptor.
• This displacement will cause a sudden drop in the receptor activation; going from full
activation to partial activation.
• The result of this partial activation is withdrawal.
• Thus, the full agonist must be completely displayed before starting buprenorphine.
• Advantages of Buprenorphine: Ceiling effect—increasing the dose does not go above
the ceiling limit. No matter how much buprenorphine is taken, the level of analgesia,
euphoria, or respiratory depression will not increase to high levels. Thus safe in
dependent patients

113. Ethics question on Elderly Abuse

• There are various forms of elderly abuse—refer to table.
 • Factitious disorder imposed on another → Also known as Munchausen syndrome by
proxy. Illness in a child or elderly patient is caused or fabricated by the caregiver.
Motivation is to assume a sick role by proxy. Form of child/elder abuse.

114. Normal development in 12 month old boy: pg. 616

115. Elderly patient after surgery has altered sensorium – delirium due to inhaled
anesthetic: pg. 242
• Delirium is a reversible acute confusional state characterized primarily by waxing and
waning mental status changes and impaired attention. Disorientation, agitation,
psychosis, and sleep disturbances may also occur. Delirium occurs secondary to an
underlying medical condition, such as UTI and therefore the primary management is
to treat the underlying cause. The elderly and those with pre-existing cognitive
disorders are at a higher risk for delirium and may present with varying degrees of
agitation.
• It is most commonly seen in elderly patients with medical illness and is often
associated with anxiety, agitation, delusions, and/or hallucinations.
 • Patients with neurologic conditions are more likely to develop delirium due to reduced
cognitive reserve.
• Rx High-potency first-generation antipsychotics (eg, haloperidol) and some second-
generation antipsychotics can be used for acute treatment of agitation and psychosis
associated with delirium. When used in low doses, haloperidol is generally well-
tolerated and causes minimal sedative, anticholinergic, hypotensive and
extrapyramidal side effects.

116. Vignette describes renal cell carcinoma with a uniform population of cancer cells.
What causes uniformity in carcinomas? – Double check this. My friend believes the
answer is A.
Options:
(a) DNA replication
(b) Asymmetrical cell division
(c) Mitochondrial division
(d) Cell cycle regulators

• The question stem presents with a group of homogenous cancer cells. The cell
uniformity is a result of uninhibited DNA replication, occurring in S phase of the cell
cycle.
• Mutations in DNA replication result in heterogeneity of cancer cells.
• The mitochondria possesses a genome of its own. It does not divide when the cell
divides—it stays on the side of the division it happens to be on during mitosis.
• CDK’s act to transition between phases of the cell cycle. They are implicated in
neoplasia but are not responsible for the homogenous characteristic of cancer cells.
• Asymmetrical cell division would result in a heterogenous population of cancer cells.

117. Patient traveled recently, has vesiculopustular lesions on chest, arms: pg.
• Not sure about this one.
118. Smoke inhalation injury to lungs, patient inhales with mouth—Parameters:
Elimination of particles more than 10mm (↓), elimination by ciliated cells (↓), and
elimination by macrophages (↓). + Cough (↑)?: pg. 658
Parameters:
• ↓ Elimination of particles >10mm: particles >5 deposit in upper airways.
• ↓ Elimination by ciliated cells: due to mucosal cilia paralysis.
• ↓ Elimination by macrophages: there is impaired alveolar macrophage function and
loss of surfactant.
• ↑ Cough reflex: the bronchospasm and increased mucus lead to reflex coughing.

Pathophysiology:
• Smoke inhalation injury causes direct toxic damage to the airway tract. Mucosal
edema results which may progress to mucosal slough. These mucus and ash plugs
predispose to bacterial pneumonia.
• Complication of smoke inhalation from fires or other noxious substances. Caused by
heat, particulates (< 1 μm diameter), or irritants (eg, NH3) → chemical
tracheobronchitis, edema, pneumonia, ARDS. Many patients present 2° to burns, CO
inhalation, cyanide poisoning, or arsenic poisoning. Singed nasal hairs common on
exam.
• Bronchoscopy shows severe edema, congestion of bronchus, and soot deposition.

119. NSAIDs: pg. 246, 587

• Interstitial nephritis
• Characterized by eosinophilia
• Remember these P’s:
Pee (diuretics), Pain-free (NSAIDs), Penicillins and cephalosporins, Proton pump
inhibitors, RifamPin, AlloPurinol, Phenytoin, AmPhotericin B
120. Question describes two inhaled anesthetics and asks why we picked this one over
the other in a shoulder repair. It asks about respiratory depression. Friend picked Nitrous
oxide. Conceptually, sevoflurane is the preferred inhaled anesthetic. Not sure.
• Answer choices: thiopentone, isoflurane, halothane, sevoflurane, nitrous oxide

121. MHC I—defect of TAP transporter: pg. 100

• Antigen peptides loaded onto MHC I in RER after delivery via TAP (transporter
associated with antigen processing