Tommyk 1601-1680

[halli2468]

1601. Your attending adds daunorubicin to the drug regimen. What are the MOAs and reasons NOT to give them?

a) Daunorubicin is a Top II inhibitor, (intercalates DNA), it can be dangerous to serious CHF patients. Ask them...



1602. Pt, 25 yr old female has bone marrow transplantation for acute leukemia. Three weeks later, she has marrow engraftment and her hemoglobin and WBC count are returning to normal. Problem is now a skin rash over her trunk and upper extremities. Why? (Hard question…but common..in this procedure)

The rash is typical for graft versus host disease. The donor lymphocytes engraft and attack host tissues, causing apoptotic necrosis.



1603. Pt is college female, bothered by a rash involving her cheeks and nose every time she spends more than a few minutes outdoors on a sunny day. A biopsy of the skin involved with the rash shows deposition of IgG along the basement membrane by immunofluorescence microscopy, but uninvolved skin does not demonstrate this IgG deposition. Her antinuclear antibody test is negative. HINT: There is NO muscle weakness. Her renal function tests are normal. What does she have? (Very hard)

a) Discoid Lupus. This patient has the classic malar rash of lupus, but without a positive ANA or other findings, discoid lupus limited to the skin is the most likely diagnosis. Some patients with DLE (particularly those with a positive ANA) may go on to develop SLE. Watch for distractors. Sometimes, the MOST COMMON DX is the MOST OFTEN WRONG ANSWER CHOICE PICKED.



1604. Why wasn’t the answer Dermatomyositis to the previous case?

Dermatomyositis is an idiopathic inflammatory myopathy with characteristic cutaneous findings. It is a systemic disorder that frequently affects the esophagus and the lungs and, less commonly, the heart. There was no muscle or positive ANA test found in da previous case.



1605. For people with CREST or SLE, or Dermatomyositis, often Boards knows steroids are the first line. But you HAVE TO KNOW THE BAD SIDE EFFECTS of long term steroid use. (Recall CUSHING’s). It is important to remember that the most common cause of Cushing syndrome is use of exogenous glucocorticoids. Exogenous steroids may cause suppression of the hypothalamic-pituitary-adrenal (HPA) axis that can last for up to a year after stopping steroid treatment. An individual with HPA axis suppression is not able to increase steroid production appropriately during a medical illness and needs to receive stress doses of steroids to avoid an adrenal crisis. Thus, in the ED, the potential for adrenal insufficiency should be considered in any patient with a cushingoid appearance.

The pt asks for a diff drug, so you give a drug called Azathioprine instead. What is the MOA?

a) This is a NON-steroid ( purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity. ) In the same class as Methotrexate.



1606. Pt is bothered by episodes of nasal congestion accompanied by sneezing and watery eyes. He has no cough. On physical examination he is afebrile. There is swelling of his nasal passageways, but no other findings. His problems are most likely produced by release of chemical mediators from what cell type (CD3+, CD4+ or CD8+ or Mast Cells)?

a) Mast Cells



1607. What is seen in the neuritic plaques in the cerebral cortex of persons with Alzheimer disease? (VERY hard) (3 words, please)

a) amyloid precursor protein



1608. If you are given a case with a child with a poststrep infection, followed by renal lesions, what type hypersensitivity is this?

a) TYPE III (they'll give type I, II, III, IV as choices) You KNOW the dx right?



1609. If the Boards presents a patient with any of the reported following: Some catastrophic medical crises that occur in (common medicine) excess states are perforated viscera and opportunistic fungal infections, hypertension, obesity, osteoporosis, fractures, impaired immune function, impaired wound healing, glucose intolerance, and psychosis and that adrenal crisis I mentioned a while back, what med are they on that is SO COMMON that you are guaranteed to get it?

a) Cortico steroids. (Primary pituitary ACTH making tumor is most common). But just check to make sure they are not trying to trick you with a new form of the question, so look for adrenal ACTH and/or small cell carcinoma ACTH choices if correct.)



1610. At a fancy restaurant, your 29 year old male date had a sudden onset of fever, cough, and dyspnea. He has lost about 10% of his normal body weight over the past 6 months, along with a chronic, watery diarrhea. Right there beside the restaurant is a clinic, and so you do a bronchoalveolar lavage, and cysts of Pneumocystis carinii are seen in the fluid.

On you next date, he say he develops pain and decreased vision on the right, you think he has cytomegalovirus retinitis.

On your third date, he say he develops tan-yellow plaques on his tongue with Candida albicans. Which of the following laboratory test findings is most likely to be present in this man? (Pick Serum IgA of 10 mg/dL OR CD4 lymphocyte count of 100/microliter)

a) CD4 100/microliter. He may have AIDS, so please abstain from any "dangerous" practices...



1611. Your aunt complains of dry mouth and dry eyes that have become almost constant during the past 2 years, regardless of her fluid intake or the weather. However, her fingers do not turn blue or painful upon exposure to cold. She is found serologically to have autoantibodies to the nuclear antigen SS-A, along with a positive antinuclear antibody test. WHAT is most likely to be the worst long term complication of her underlying disease? (Pick intestinal malabsorption OR Monoclonal B-lymphocyte proliferation/lymphoma)

a) As in other autoimmune diseases, but particularly with Sjogren's syndrome, malignancy is more common, and lymphoma in particular.



1612. Your baby cousin 2 years old has had numerous bacterial infections, including respiratory infections with Hemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. He develops a polyarthritis that clears with immunoglobulin therapy. A lymph node biopsy is performed, and microscopically the germinal centers of his nodes are rudimentary. During the 3rd decade of his life he develops systemic lupus erythematosus. He demonstrates skin test positivity to Candida antigen. Laboratory studies show that his serum IgG is 110 mg/dL (hint). His total WBC count is 7650/microliter with differential count of 65 segs, 4 bands, 22 lymphs. Does he have SCID, NADPH oxidase def.or something else?

He has features of X-linked agammaglobulinemia of Bruton. In this condition, B-cell maturation stops after the rearrangement of heavy-chain genes, and light chains are not produced. Thus, complete immunoglobulin molecules with both heavy and light chains are not assembled and transported to the cell membrane. The lack of immunoglobulins predisposes the child to recurrent bacterial infections. Since T-cell function remains intact, viral, fungal, and protozoal infections are not common.



1613. Your uncle asks you at a family get together that he has decreasing mobility of his spine, and he becomes more hunched over during the past 5 years. He has hip pain bilaterally. On physical examination he has loss of lumbar lordosis and diminished range of motion at the hips. A radiograph of the pelvis shows ankylosis with sacroilitis of the sacroiliac joints bilaterally. No other joints appear to be affected. His antinuclear antibody test is negative. He has no other significant medical problems. What is the most common labs you will see?

a) HLA-B27…. However, not every person with HLA B27 present will develop ankylosing spondylitis, one of the spondyloarthropathies.



1614. Your father has been plagued by mild chronic diarrhea and increased numbers of minor respiratory tract infections for most of his life. Following a motor vehicle accident with multiple lacerations to the lower leg, he has a significant blood loss requiring transfusion of blood products. During the transfusion, you are the doctor and you note an anaphylactic transfusion reaction. Which of the following diseases is he most likely to have? (Pick Graft versus host disease OR Selective IgA deficiency?)

a) Tell your dad he has Selective IgA deficiency, he CAN lead a normal life…but he has to be careful… GVHD takes LONGER to be seen. Watch out, the Boards uses TIME FRAMES to confuse you! Take good care of daddy!



1615. Q) Clinical hallmarks of this Board favorite disease are development of retinal and central nervous system (CNS) hemangioblastomas, pheochromocytomas, multiple cysts of the pancreas and kidneys, and a high potential for malignant transformation of renal cysts into carcinoma. This is too hard, so I will tell you the dx name is Von-Hippel Lindau dx. What is the inheritance pattern if asked?

a) AD



1616. Your girlfriend, about 30 yrs old, asks you for help. Basically, she is having difficulty swallowing food. On physical examination her blood pressure is 210/110 mm Hg. Laboratory testing reveals a positive antinuclear antibody test with a nucleolar pattern on immunofluorescence. Her serum complement levels are normal. Which of the following lesions is most likely to be seen in her kidneys with renal biopsy?

a) Hyperplastic arteriolosclerosis. Beware malignant HTN.



1617. Your younger brother has just had a positive tuberculin skin test, with a firm 15 mm diameter dark red firm area of induration on the forearm, appearing 60 hours following injection of the PPD. This finding is most likely to be which type of hypersensitivity?

a) Type IV hypersensitivity...know the dx??



1618. Your grandpa, with end stage renal disease from long-standing diabetes mellitus receives a renal transplant from you. A month later, he has increasing malaise. His urine output decreases. Laboratory studies show a rising serum urea nitrogen and creatinine. The allograft is biopsied and seen microscopically to be undergoing destruction by cells which are recognizing graft cells expressing class I HLA antigens. What cell is mediating this response? Pick either CD8 T cells or NK cells…

a) CD8 T cells… These are cytotoxic lymphocytes that participate in acute cellular rejection of solid organ transplants. NK, or Natural killer cells can recognize Fc receptors as well as lyse IgG coated cells as part of an antibody-dependent cell mediated cytotoxicity reaction.



1619. Your twin brother, 35, has experienced myalgias, red skin rashes over his face, and arthralgias for the past 9 months. On physical examination there are no joint deformities, and his motor strength is fine. Laboratory studies show a positive antinuclear antibody test with a speckled pattern. Additionally, he has high titers of autoantibodies to ribonucleoprotein (RNP antibodies). A serum creatine kinase is 661 U/L. He has no evidence of renal disease. Which of the following conditions is he most likely to have? Pick Mixed connective tissue disease/MCTD OR SLE or CREST syndrome…

a) MCTD…Note that there are NO renal dx and no joint deformities.



1620. Your patient is a college student with a serum IgA of 22 mg/dL, IgG of 175 mg/dL, and IgM of 40 mg/dL and has had a high fever with cough productive of yellowish sputum for the past two days. Auscultation of the chest reveals a few crackles in both lung bases. A chest radiograph reveals bilateral patchy pulmonary infiltrates. Name the inflammatory cell type you will see…Macrophages or Neutrophils?

a) Neutrophils! The signs and symptoms are suggestive of an acute bacterial pneumonia. The decreased serum immunoglobulins at his age suggest common variable immunodeficiency, which puts him at risk for bacterial infections. Such infections promote an acute inflammatory response dominated by neutrophils, which gives the sputum the yellowish, purulent appearance.



1621. Your patient, a graduate student in video gaming, incurs an injury in a video arcade building, with a steel H-beam striking the right side of his face, crushing the zygomatic arch and damaging the globe of the right eye. He undergoes plastic repair of bone and soft tissues and an attempt is made to salvage the eye. A month later, he has decreased visual acuity in both eyes, with choroidal thickening seen on funduscopic examination. The right eye is enucleated and shows prominent CD4 lymphocyte and macrophage infiltration of the uvea. What was the MOA? (Very hard question)

a) Sympathetic ophthalmia, with released of antigens that incite a granulomatous response, even in the opposite eye, can occur by this mechanism.



1622. Your pt.a college senior, develops marked right lower quadrant abdominal pain over the past day. On physical examination there is rebound tenderness on palpation over the right lower quadrant. Laparoscopic surgery is performed, and the appendix is swollen, erythematous, and partly covered by a yellowish exudate. The PAIN experienced by this patient is the result of the formation of what chemical mediators? (TNF-a, IL-1, bradykinin, prostaglandins?)...

a) bradykinin and prostaglandins. The other two options are responsible for fever and other things...



1623. Many reported that the NBME/Boards asked radiograph questions that would be easy IF you quickly reviewed them. There are many sources on the WEB and in atlases and they are EASY points if you memorize them shortly before the test. It is VERY high yield. Such as, given a gross or CT scan of the cervical region, can you point to the sternocleidomastoid muscle?
They asked things like: Point to the cricothyroid muscle and arch of the aorta typically on CROSS SECTIONAL radiographs. The thorax and abdomen were stressed: around L2 and/or T10. Cervical and lumbar cross sections were less stressed. Therefore, please please please review a quick radiology atlas with an emphasis on cross sections. For example, one CONCEPT was that you had a patient with Horner's Syndrome, but the SECONDARY was to point to it on a cross section (it was not enough just to say sympathetic cervical ganglion), via a,b,c,d,e, with arrows.



1624. A couple of students said that the Boards asked them about a male college student traveler to Mexico, ate refried rice, drank BOTTLED WATER and came back to the U.S. with a BLOODY DIARRHEA. Everyone in the class said E-coli 0157:H7, Shigella, Salmonella, but NONE of those were on the choices. B-cereus, was among the choices, but I believe it is associated with vomiting, not bloody diarrhea. Vibro was among the choices too, but that usually involves NON-bloody poop. And so was Giardia and E. histolytica, but the question said he drank BOTTLED water brought from U.S. What is your guess on this Board concept? My personal guess is:

a) C. jejuni. Anyone else have a better guess?



1625. Everyone...and I mean everyone in my review class got at least ONE pedigree question where you were shown a Pedigree chart tree with the squares and circles. You had to know the concept of how AD, AR, XR, XD, mitochondrial inheritance, etc. looks like because all are part of the answer choices in this crucial concept.



1626. OK, here is another great high yielder... Remember that I said about 90% of my class said they got a question on Congential Adrenal Hyperplasia. If you can, remember from complete memory, the 11B hydroxylase def, 21 B hydroxylase def, and 17 B hydroxylase def chart, you can get a whole bunch of questions correct.

They will show possibly a picture for you ambiguous genitalia for a neonate. Then you need to know the dx., it is likely 17B hydroxylase def since 17 hydroxypregnenolone is BLOCKED, so the products of androstenedione, DHEA, and thus Estradiol, Estrone, Testosterone are BLOCKED.

1 The questions here are, which is first, cholesterol, pregnenolone, or progesterone is this case of ambiguous genitalia?

2 Also, tell me enzyme that makes PREGNENOLONE...

Sincerely,

Tommy (Oh, look below, but GUESS FIRST!)

A) KNOW its goes Cholesterol, then Pregnenolone, then progesterone, then the 11-ketos, then ALDOSTERONE. (KNOW also that Angiotension II revves up Aldosterone synthase here).

A2) KNOW that DESMOLASE catalyzes PREGNENOLONE from Cholesterol. (First crucial step)



1627. What is the difference (both will be amongst the answer choices.. you WILL SEE THIS) between 21B hydroxylase def and 11B hydroxlase def. since both have similar properties? (e.g. more androgen formation)

A) KNOW that in both you will have LOWERED cholesterol, LOWERED Aldosterone (think of consequences logically), & more androgens. BUT, the key is that in 11-Beta hydroxylase def. you have mild HYPERTENSION but in 21 B. hydroxylase def, you have HYPOTENSION due to lowered Aldosterone because in 11 B. def, you can still make 11-deoxycorticosterone, which is a mineralocorticoid like Aldosterone (which will retain water). KEY KEY concept....



1628. Woman pt is pregnant, so PROLACTIN levels are up, does prolactin inhibit or elevate dopamine?

a) ELEVATED!!! Confusing, but KNOW that prolactin does a positive feedback on dopamine at the hypothalamus (can you point to the hypothalamus on a sagittal CT scan of the brain???) KNOW also that prolactin blocks GnRH so that it is a natural birth control pill for breast feeding moms initially...

KNOW that at the pituitary, dopamine goes on to BLOCK more prolactin secretion.... VERY CONFUSING. IF you need, draw yourself a picture in your mind.



1629. What is the INITIAL Amino Acid precursor for DOPAMINE?

a) Phenylalanine, ...then Tyrosine then Dopamine...



1630. This one concept "tripped" a whole bunch of people...

What is the initial Amino Acid to make MELANIN? (melanin is made from DOPAMINE, which we just discussed in detail)

a) Phenylalanine, NOT TYPTOPHAN (which a number of students picked wrong). Students got MELANIN confused with MELATONIN, which was also in the answer choices!!!. See, how tricky!!!! KNOW that Niacin, Serotonin, and Melatonin comes from Tryptophan! {I myself use the mneumonic, "I TRIPPED (tryp tophan) over my N.M.S. (National Medical Science) book...which was good because it was nice (NIACIN) to be done with exams, I can take now take a nap (M..Melatonin includes sleep), and I am happy to be done (S...Serotonin, which helps to keep you happy).



1631. What is the INITIAL amino acid needed in the mechanism of action of sildenafil (penis erections)?

a) ARGININE! Arginine makes Nitric Oxide which is associated with the MOA of Sildenafil/Viagra (DO NOT CONFUSE WITH NITROUS OXIDE).

KNOW Urea, Nitric Oxide, Creatinine, are all products are Arginine!!!!!!!

Think...ARRGHH! (Arginine), my sexed out UNCle, just urinated (UREA) after having erection enhanced sex (w/ Nitric Oxide in Viagra) , he is such a creature (Creatinine)! {That is the mneumonic I used, my students laughed out loud for one full minute after some of these Tommyk mneumonics. Do not worry, I personally abstain...) U.N.C.le...Arrgh!

Such risky behavior in my opinion is wrong...



1632. Shown a picture of the tongue. Where are the receptors located and what type of cells are TASTE BUDS?

a) These are modified EPITHELIAL cells and contain PRE-synaptic vesicles...arrows everywhere...



1633. I do not still know how to import a "chart" in here, but KNOW this...

You will be shown a Pressure Volume Curve of the LUNG. Just understand that if you LOSE pulmonary surfactant, and pulmonary collagen, both curves will be diverging away from each other.

Sorry, I cannot draw here, but KNOW that if you lose surfactant, Pressures go UP, and if you LOSE pulmonary collagen, Volumes go UP...



1634. You are shown a sample of urine. What is the primary part of urine which is nitrogenous??? (Uric acid, urea, creatinine, ammonium ion)

a) AMMONIUM ION!! Hard, isn't it?



1635. Your pt. is on Lithium. You are told or know it works via phosphoinositol cascade. Which is the most important intermediate made? (GMP, AMP, ADP, CDP are answer choices)? (Classic 2nd messenger question but VERY VERY VERY VERY hard)

a) CDP!!



1636. Your middle aged mom has had a chronic, non-productive cough for 4 months, & fever. She has a chest radiograph that reveals multiple small parenchymal nodules along with hilar and cervical lymphadenopathy. Biopsy shows noncaseating granulomatous inflammation. Cultures for bacterial, fungal, and mycobacterial organisms are negative. Which of the following chemical mediators is most important in the development of this inflammation? (Pick from these: Bradykinin, Interferon.gamma, or PGE2)

Interferon gamma…is part of a noncaseating granulomatous inflammation. You had to focus on the two words, noncaseating granulomatous…



1637. Shown a pic of Type II pneumocyte. It secretes surfactant. Is surfactant made mostly from (Pick from: sphingomelin, cardiolipin, dipalmitoylphosphatidylcholine)?

a) dipalmitoylphosphatidylcholine. KNOW that sphingomyelin is a lipid (fat) that usually causes the progressive development of enlargement of the liver and spleen (hepatosplenomegaly), "swollen glands" (lymphadenopathy), anemia and mental and physical deterioration. (Relation to Niemann Pick dx). Cardiolipin is used to make antigens to detect certain dxs.



1638. Your teenage cousin has had episodes of sneezing with watery eyes and runny nose for the past 2 weeks. She has red, swollen nasal mucosal surfaces. She has had similar episodes each Spring and Summer when the amount of ragweed pollen in the air is high. Her symptoms are most likely to be mediated by the release of ___________? Pick either (C3b, PAF, TNF, Histamine, IgM)

a) Histamine. Note: IgE, not IgM, is more related here.



1639. Your aunt has had mild nausea with vomiting for the past 6 weeks. She undergoes an upper GI endoscopy. The microscopic appearance of these biopsies shows mucosal infiltration by lymphocytes, macrophages, and plasma cells. What is her dx? (Pick either S. aureus infection or H. pylori infection)

a) H. pylori… lymphocytes, macrophages, and plasma are the key words/cells that point to a CHRONIC inflammation rather than ACUTE inflammation.



1640. You are looking at lymphatic channels in normal soft tissue preparations. S. aureus organisms are innoculated into the tissues and the immunologic response observed. Which of the following functions is most likely to be served by these lymphatics to produce a specific immune response? (Pick from below

1- Transportation of antigen presenting cells

2- The lymphatic channels bring lymphocytes to peripheral tissue sites

3- Provide an emigration area for neutrophils

a) Transportation of antigen presenting cells….Antigen presenting cells such as dendritic cells and macrophages which have trapped antigen can be transported to lymph nodes where they encounter specific clones of memory cells capable of responding to those specific antigens. The other two choices are wrong because: Most neutrophils marginate, roll, adhere, and diapedese through venules and capillaries. There are valves in the lymphatics (just as in veins) which result in a one-way flow of lymph from peripheral tissues to lymph nodes.



1641. In a miolecular bio experiment, you inject into a nucleus a chemical that produces single base pair insertions and deletions. What is the effect?…is it:

1-A single AA change would occur, resulting in a nonfunctional protein.

2-A protein will be made that differs in more than one AA residue change from the normal protein.

a) 2- A protein will be made that differs in more than one AA residue change from the normal protein.



1642. You see a female pt in college who has a history of arthralgias for 2 years. There is HYPOCHROMIC, MICROCYTIC RBCs. The total RBC count is normal. Total serum iron and ferritin is normal. But, electrophoresis shows high hemoglobin A2 at 5.5%. This is typical for:

1-Anemia of chronic dx.

2-B-thalassemia minor

3-autoimmune hemolytic anemia

Pick one. (It was a difficult concept)…

a) B-thalassemia minor. Note the hypochromic microcytic RBCs. Note that Anemia of chronic disease would have an INCREASE in ferritin.



1643. A runway magazine female model pt.of yours travels to Brazil to do a swimsuit photo from the U.S. and comes back with increasingly severe diarrhea. You ask her for a stool sample (yuck!) and you see mucus and blood. The diarrhea then goes away, but then she comes back three weeks later with fever, pain in the upper right quadrant. You do ultrasound and see a 9 cm cystic mass. This is:

1- Clostridium difficle

2- Strongyloides

3- Giardia

4- Entamoeba

Pick one…

a) Entamoeba...NOTE...liver abscess..Got it? Cool...



1644. A patient of yours falls and cuts his arm. Later, a growth of new capillaries is observed to occur within the first week. A substance secreted by macrophages is found at the wound site to stimulate this capillary proliferation. Which of the following substances is most likely to have this function?

1- Platelet-derived growth factor

2- Phospholipase C

3- Fibronectin

4- Fibroblast growth factor

5- Epidermal growth factor

(The above factors HAVE to ALL be known as they are common and asked all the time.)

a) FGF, choice 4, is best. But some students liked PDGF too as an answer. FGF is more general though. PDGF is released from macrophages as well as activated platelets and can stimulate fibroblast growth for collagen synthesis. Phospholipases aid in stimulation of intracellular protein kinases that promote protein phosphorylation. Fibronectin is a component of the extracellular matrix that helps to link cells together. FGF can stimulate all aspects of angiogenesis.



1645. Your grandfather sees you with a history of ischemic heart disease and has worsening congestive heart failure. He has noted increasing dyspnea and orthopnea for the past 2 months. On physical examination there is dullness to percussion at lung bases. A chest x-*** shows bilateral pleural effusions. A left thoracentesis is performed, and a half liter is obtained. What would indicate that it is a transudate? Pick one below:

1- Cloudy appearance

2- High protein

3- High volume of effusion

4- Less than 3 g of protein per 100 ml of fluid.

a) The answer is option 4, a transudate has few cells or protein and has a clear appearance. A cloudy appearance suggests the presence of increased cells, characteristic of an exudate. Increased protein is characteristic of an exudate. Transudative ascites is defined as having less than 3 g of protein per 100 ml of fluid. It is, as its name would suggest, a result of raised hydrostatic pressure forcing fluid out of blood vessels. Causes include:cardiac failure, nephrotic syndrome, and other causes of hypoproteinaemia, e.g. hepatic failure. Is it clear to you?



1646. After you passed all the USMLE steps, you become a doctor and do research too. You have patients in your first major research project undergoing laparoscopic cholecystectomy, they are then followed to observe the post-surgical wound healing process. The small incisions are closed with sutures. Over the 4 weeks following surgery, the wounds are observed to regain tensile strength and there is re-epithelialization. Of the following substances, which is most likely found to function intracellularly in cells involved in this wound healing proccess?

1- Fibronectin (Recall these anchor cells to collagen)

2- Laminin (Recall this is a large part of basement membranes)

3- Tyrosine kinase

4- Collagen

5- Hyaluronic acid (recall this lubricates joints & is one of the proteoglycans in the extracellular matrix.)

a) 3-Tyrosine kinase. Key word in INTRAcellular for Tyrosine kinase. Cell surface growth factor receptors recruit intracellular protein kinases that begin a sequence of events leading to cell division and growth. Fibronectin acts in the extracellular matrix to bind macromolecules (such as proteoglycans) via integrin receptors to aid attachment and migration of cells. This is a BIGGIE.



1647. You get the USMLE score report envelope, open it, and you passed! But you got a bad paper cut because you were so nervous opening it. Which product, Thromboxane OR Hageman factor, is responsible for BOTH the coagulation cascade AND the pain as the blood trickles from your cut?

a) Hagenman Factor! KNOW how all the common cascades intermix. Thromboxane, a product of the cyclooxygenase pathway, promotes vasoconstriction and platelet aggregation. But Hageman factor (factor XII in the intrinsic coagulation pathway) activates both systems.



1648. KNOW that while Thromboxane vasoconstricts and causes the platlets to aggregate, HISTAMINE vasodilates.



1649. Your geriatric pt. has had a fever for the past day. Her temperature is 37 C and blood pressure 90/50 mm Hg with heart rate of 106/minute. Labs show a CBC with WBC count of 12,000. A blood culture is positive for E coli. Her central line pressure falls suddenly. She goes into hypovolemic shock as a result of the widespread inappropriate release of a chemical mediator derived from macrophages. Organs start to fail…Which is the mediator? Pick from below:

1-NO

2-Bradykinin

3-Histamine

4-ProstaCYCLIN

5-C3a

a) 1-NO, Nitric oxide acts as a vasodilator. Small amounts released from endothelial cells causes vasodilation and prevents thrombosis. KNOW that Macrophages release NO to kill bacteria, but large amounts released body-wide can cause hypotension and shock. Prostacyclin is generated by the arachidonic acid pathway and it promotes vasodilation. The key here and in a lot of the Step 1 questions is noting "What is the question asking specifically?" Many of the choices also VASODILATE, but note that the question here asked about MACROPHAGE release. E.g., C3a will vasodilate, but they are not released by macrophages. This is a common mistake that has "Boards written all over it."



1650. At the USMLE testing center, you are signing in and get a piece of the wood pencil in your skin. You do not remove it, and over the next 3 days the area around the sliver becomes red, swollen, and tender. Neutrophils migrate into the injured tissue. Which of the following substances on endothelial cells is most instrumental in promoting this inflammatory reaction?

Pick from Interferon gamma, Factor XII, Lysozyme, Selectin, Prostacyclin…

a) Selectins are adhesive molecules expressed on endothelial cell surfaces and attract leukocytes, mainly neutrophils. P-selectin is expressed rapidly, while E-selectin is expressed within several hours. Recall…Interferons are produced by a variety of cells and are mainly part of inflammatory reactions involving lymphocytes. Prostacyclin is produced by endothelium to reduce platelet adhesion. Factor XII is part of coagulation.



1651. A piece of a small toothpick inside your skin for 2-4 months includes the transformation of tissue macrophages to epithelioid cells. There are also lymphocytes present. Over time, fibroblasts lay down collagen as the focus of inflammation heals. These events are most likely to occur as an inflammatory response to which of the following infectious agents? Pick from: Mycobacterium leprae, Pseudomonas, Cytomegalovirus, Giardia, Treponema pallidum…

a) Mycobacteria lead to granuloma formation.



1652. Sorry that some are having trouble getting all the posts. Especially, a lot of people are asking me to update the Tommyk posts to 1651. Again, so sorry, but I have no access to that database. All of us are part of the ValueMD family, but I have no permissions. If we can get a link going, there maybe there can be a way. I am trying to communicate with Doc (the moderator) to get this problem solved. Happy studying! Remember, don't give up, try to reward yourself after studying for a few hours, and God Bless your efforts. BTW, again, try to always guess first before looking at the answers. Simply reading them won't good much good. You are likely to just "forget them" in a few minutes and not integrate them. But if you really try to make a guess, even if it is an incorrect one, you are doing better in terms of understanding and processing...

So, here is a candy cane question...

Your peds pt has a single functional allele of a tumor suppressor gene. At his 7th birthday, the remaining normal allele is lost through a point mutation (so sad!). As a result, the ability to regulate the transition from G1 to the S phase of cell cycle is lost. Which of the following neoplasms is most likely to arise? (Pick between: BRCA1 cancer OR Retinoblastoma OR Astrocytoma OR Small cell anaplastic carcinoma of the lung)

a) Most likely Boards will say Retinoblastoma from the Rb tumor suppressor gene loss.



1653. Your college aged pt has a mass in her thyroid gland. No lymphadenopathy is noted. A chest x-*** shows no masses. A fine needle aspirate of the nodule is done by you and cytologic examination reveals cells present consistent with a papillary carcinoma of the thyroid. There are no other family members affected by this disorder. She works as a secretary for an accounting firm part time. Which of the following findings would you consider most relevant in her past history to indicate a risk factor for this neoplasm? (Pick either arsenic OR radiation)

a) Radiation therapy. Boards know that radiation therapy often causes ALL (leukemia) cancer too. Arsenic is related to SKIN CANCER.



1654. At your next family picnic, your uncle says he felt vague abdominal discomfort for the past 6 months. On physical examination he has no lymphadenopathy, and no abdominal masses or organomegaly. Bowel sounds are present. An abdominal CT scan shows a 15 cm retroperitoneal soft tissue mass on the left psoas muscle. A stool specimen tested for occult blood is negative. What cancer does he likely have? (Pick either Lymphoma OR Adenocarcinoma OR Sarcoma)

a) Sarcoma! This is no good. The other choices do not often come up in "soft" tissues. That is why you must read the question carefully. As Dr. Goljan said to me, Sarcomas are very very bad. Watch for them!



1655. KNOW the common ones like..NF-1 is a tumor suppressor gene associated with neurofibromatosis. Do you remember the CLASSIC presentation of neurofibromatosis? You WILL be asked..



1656. Oh, KNOW that Boards will ask you about how neurofibromatosis is associated often with an optic glioma. An optic glioma is a tumor of the optic nerve (the nerve which controls vision). This tumor usually appears in childhood and is first noticed because of poor or failing vision or bulging of the eye. They "may" include that they have HTN in addition to the classic skin spots & learning disabilities…they "may" describe an eye exam…



1657. Which of the following neoplasms is most likely to arise via a VIRUS? (Pick either hepatic angiosarcoma OR T-lymphocyte lymphoma)

a) KNOW HTLV virus often causes T-lymphocyte lymphoma…



1658. KNOW that Boards will ask you the details of a TERATOMA of the ovary. So common. They will show you a pic of a "chocolate cyst" with teeth, hair, etc. Tell me, do they often metastasize? (Your pt. Will be scared to death since ovarian neoplasms are so dangerous).

a) Thankfully to God, these are circumscribed and cystic and often do NOT metastasize!



1659. What's the diff between Neurofibromatosis and Tuberous Sclerosis? They have similar presentations...they will BOTH be in the answer choices in a given case...Also, what is the inheritance pattern for Tuberous Sclerosis??

a) Most commonly, it is epilepsy, along with the mental retardation, and facial angiofibromas. It is now recognized that patients with TS may present with a broad range of clinical symptoms due to variable expressivity. TS may affect many organs, most commonly the brain, skin, eyes, heart, kidneys, and lungs. It is mainly autosomal dominant inheritance…This is a MUST know…Remember, they could use other words like seizures or describe a tonic clonic movement instead of using "buzzwords".



1660. Your father noted a 15 kg weight loss with increasing fatigue over the past year. He has experienced dull abdominal pain also. He has developed abdominal distention with lack of stools in the past two days. On PE, bowel sounds are reduced. CT scan reveals a mass involving the descending colon. At laparotomy, a partial resection of the left colon is performed, with removal of an encircling mass in the descending colon found to be an adenocarcinoma. Which of the following laboratory test findings is most likely? (Pick either … Elevated alpha-fetoprotein OR Decreased lactate dehydrogenase OR Microcytic hypochromic anemia)

a) Microcytic hypochromic anemia … KNOW that the elevation of the AFP in association with neoplasia most often occurs with testicular and liver cancers. The LDH is elevated in a variety of disease conditions and never decreased. In this case, metastatic disease and tissue necrosis may have elevated the LDH. The anemia likely came from blood loss from mucosal erosion and necrosis. You have to know this one.



1661. Medscape and other sources said BRCA-1 mutation causes both breast AND ovarian cancer.

Someone asked me about this cause it was on their test, but do NOT worry. They cannot ask you to differentiate breast and ovarian cancer and BRCA-1. Sorry about the confusion.



1662. Your grandpa has a 70 pack year smoking. experiences hemoptysis. He has puffiness of the face, pedal edema, bruises of the skin, blood pressure of 165/100 mm Hg. A chest radiograph reveals a 5 cm right upper lobe lung mass. A fine needle aspirate of this mass yields cells consistent with small cell anaplastic carcinoma. A bone scan shows no metastases. Staining of the tumor cells is likely to be positive for _________? (Pick Gastrin, Insulin, or ACTH)

a) ACTH



1663. Your mother noted a lump on her left shoulder that has enlarged over the past 6 months. There is an enlarged, non-tender supraclavicular lymph node. A biopsy of the node is done and on examination there is a metastatic neoplasm. Which of the following is the most likely primary neoplasm? (Pick Breast fibroma, Gliobastoma/brain, Adenocarcinoma/colon, Papilloma/Larynx)

a) Adenocarcinoma/colon KNOW the other choices are either BENIGN so they won’t spread or are Primary and won’t spread)



1664. Your uncle, 60 yrs old, went to you for a health maintenance exam. There is a positive stool guaiac test. Laboratory studies show a CBC with Hgb 10.0 g/dL, Hct 30 & MCV 73, platelet count 300,000/microliter, and WBC count 8700. He is found on colonoscopy to have a 4 cm mass lesion arising on the mucosal surface of the transverse colon. What KIND of neoplasm is this and is it secretory?

a) This is adenocarcinoma of the colon and is NOT secretory. SQUAMOUS cell carcinomas like of the kidney and lung will e.g. make hypercalcemia.



1666. KNOW that a high S-phase, as well as aneuploidy, are features often seen in cancers. Many drugs usually are made to act in the S phase, (but not all). This is just a general rule if you have to guess...



1667. KNOW that you will get a Q on breast cancer. common. KNOW that intraductal growth and estrogen receptor + is good for prognosis (recall infiltrating is BAD), and so is aneuploidy (BAD) and POOR differentiation on biopsy(BAD).



1668. Middle age pt complains of pain in his left thigh (acute). Thigh is increased in size, compared to the right. 17 cm solid mass is seen that does not appear to arise from bone, but it does have infiltrative margins. There are highly pleomorphic spindle cells. Which marker is most likely seen? Pick (Vimentin, Lambda light chain, Alpha fetoprotein, Cytokeratin).

a) Vimentin! (an intermediate filament often found in neoplasms of mesenchymal origin.) The location and size and histologic characteristics suggest a sarcoma, not carcinoma (understand this!). Alpha fetoprotein is a marker that is found in hepatocellular carcinomas and in some testicular carcinomas.Cytokeratin is often related to carcinomas.



1669. This is crucial, define cathepsin...(this is a common answer choice in cancer questions)

a) any of various proteolytic enzymes found in animal tissue that catalyze the hydrolysis of proteins into polypeptides. If seen as a marker, it is BAD, because the neoplasm can more easily spread.



1670. Which oncogene appears to be activated by amplification and it has been associated with neuroblastomas?

a) n-myc is known......... KNOW ret is associated with ret proto-oncogene (multiple endocrine neoplasia and medullary thyroid carcinoma). This is a common answer given instead...



1671. Stem of a question with a new drug being used on a carcinoma. It is observed that a response occurs that leads to DNA strand breakage and carcinoma cell death. However, after 4 months, the carcinoma is no longer regressing with this therapy. RESISTENCE! Altered expression of which of the following by the neoplastic cells has most likely resulted in LESS TUMOR CELL DEATH? (PICK: laminin mutation, OR Leukocyte common antigen OR DNA topoisomerase II) This is a CRUCIAL concept…

a) DNA topoisomerase II. The drugs that target topoisomerase II freeze the enzyme as it is cutting DNA strands. This leads to DNA strand breakage and cell death. Resistant cells in culture show alterations in the topoisomerase II protein. Relate in your mind of the other choices:

Lamin=basement membranes & Leukocyte common antigen=lymphoma,WBCs COOL! We are really learning at ValueMD!



1672. This came up just last month. Pt.,young, presents with loose stools, mother says kid has eczema (dry, flaky skin), and forgets where she put her dolls at a lot and gets confused. What is the dx and missing vitamin? (KEY) Gave list of vitamins...

a) This is classic Pellagra, ( or Niacin Def. Specifically vitamin B3). Do NOT forget!



1673. Another...you are given a vegetarian pregnant women on a diet that does NOT includes green, leafy vegetables! and baby developed a specific nutritional deficiency where a picture was shown of the fetus. It was not a benign defect. IT was a BAD BAD defect. The dx started with a "a" in the name. What is it?

a) anencephaly (NO BRAIN), just know that this IS a case of a neural crest defect. Don't just think of a "tuft" of hair coming out of the lower back spinal column.



1674. LISTEN, if you are not passing and remembering...take a YEAR OFF and just study! IT IS ABOUT TIME, NOT BRAINS! (AND organization)

I get hundreds, hundreds! of emails (PM) that say, "I have all your stuff and Goljan's and First Aid, etc...but I am still not passing." They ask me if they are stupid...

NO WAY! I personally do NOT like the test at all. It tests too many obscure stuff. One of my attendings here in the U.S. noted that I was a foreign born/student and even said he does not know why Boards asks about certain diseases that NO LONGER EXIST!

I do not know the mind of the NBME. But I want everyone to know that this is a test of TIME and WILLPOWER, not brain power. If you don't believe me, then I dare you. Take a YEAR off, study diligently. NOT simply "reading" but studying to "UNDERSTAND", and then look back. You will be SURPRISED at how SMART YOU REALLY ARE! Seriously, it is all about time. There is just so much info, so if you are a slow reader or have ADD it WILL take a year or more to pass.

But so what????? If you end up at the top of the mountain, who is gonna ask you later about the number of USMLE Step 1 attempts? So don't start feeling down and depressed. That is going to only make it THAT MUCH HARDER to get the energy to study and pass.

Please, pray and study and leave the rest to God. Love, Tommy



1675. KNOW that this came up and continues to come up…Obesity, so prevalent in the U.S., is associated with HTN, Diabetes, and Osteoarthritis.... most of you all know that. But, the NBME wanted you and wants you to know it is also associated with GALLSTONES…OK? That is a CRITICAL CONCEPT. Think of the endless cases...colicky pain...radiographs shown...etc. etc...



1676. If given an alcoholic and asked what vitamin should you give, think carefully FIRST about the case. Do NOT be foolish and JUMP too fast. Do not jump to Thiamine (Vit. B3) def. right away or Folate def. This came up...if given a case of an alcoholic with easy bruising and erythema, think VITAMIN K (Factors 2,7,9,10).



1677. If asked about diet, which is a HOT TOPIC on USMLE now, tell me which vitamin is a good source for beta carotene? (oh, also KNOW that breads have good sources of Vit. B and some calcium in addition to fiber).

a) Carrots…Like our moderator, Doc, used to say, "What's up doc?" from Bugs Bunny who ate a ton of carrots.



1678. Pt case given: A pt came in and said he ate too many vitamin A tablets. He presents with headaches, joint pain and blurry vision, red-orange skin (no discoloration in eye…key point to diff from alcohol jaundice). So, to treat the eye problems, papilledema, what is the disease MOA, and what medicine will you give and how does it work (first line tx)?

Papilledema is an optic disc swelling that is secondary to elevated intracranial pressure. Papilledema almost always presents as a bilateral phenomenon and may develop over hours to weeks. The term should not be used to describe optic disc swelling with underlying infectious, infiltrative, or inflammatory etiologies. KNOW that the subarachnoid space of the brain is continuous with the optic nerve sheath. Hence, as the cerebrospinal fluid (CSF) pressure increases, the pressure is transmitted to the optic nerve. So, treat first line with Acetazolamide! The MOA is that the conversion of carbon dioxide to bicarbonate plays a key role in the production of both aqueous humor and CSF. Carbonic anhydrase inhibitors act by inhibiting the conversion of carbon dioxide to bicarbonate, thus inhibiting the production of both aqueous humor and CSF. KNOW that acetazolamide is a sulfa drug! So watch out for allergies to sulfas! Common common common.......



1679. KNOW the faulty Bcl-2 gene is often characteristic for lymphomas. Carcinomas are composed of cells having lost control of proliferation like the p53. Key pt. DO not forget this one.



1680. KNOW that BCL-2 is a human proto-oncogene located on chromosome 18. Its product is an integral membrane protein located in the membranes of the endoplasmic reticulum (ER), nuclear envelope, and in the outer membranes of the mitochondria.

Some test taker mistaked it for a Tumor Suppressor gene…Bcl-2 is a HOT TOPIC now…