Uw April 10, 2012

Front 1

568:

PC: 15yo Male. Severe cardiomyopathy post infative myocarditis from COXSACKIE virus. 2 weeks post op -- exp dyspnea on exertion.

What process is occurring in PT and what would be seen on biopsy?

Back 1

568:

PT is experiencing ACUTE graft-vs-host reaction (<4wks) via cell-mediated pathway.

Biopsy would shows dense interstitial lymphocytic infiltrate, primarily T-cells.

** This is the aim of immunosuppressive Tx.

Front 2

1332:

PC: 8yo male. Chest pain, diagnosed with AMI, and lab work reveals increased serum METHIONINE level.

What is the essential AA in this PT? (i.e. what is needed to create methionine)

Back 2

1332:

CYSTEINE

Front 3

1976:

PC: 67yo male. Syncopal episode, bradycardic, regular rhythm, nor,al QRS, but no P-wave.

What is the most likely site of ectopic pacemaker?

Back 3

1976:

AV node

** note that all part of the conduction pathway has pacemaker activity, but the SA node has the shortest repol time, thus depol before everyone else's.

Front 4

458:

PC: Child. Vascular lesion. Skin biopsy shows **IgA** and C3 complement deposition.

What is DX, and most likely associated presentation?

Back 4

458:

DX = HSP (Henoch-Schonlein Purpura)

Presentation = rashes from buttock down, abdominal pain due to leukocytoclastic angiitis of small vessels.

IgA vasculitis = HSP, Alports (deafness/cataract), Burger's

Front 5

1506:

PC: 50yo male. Use anti-arrhythmic for recurrent AF. Arrhythmia resolved but now have mild BRADYCARDIA and QT prolongation.

What drug was used? Mechanism?

Back 5

1506:

Class III anti-arrhythmic, SOTALOL.

Bradycardia = due to beta-blocking effect.
QT prolongation = K-channel blocking effect.

** Other Class III drugs: metoprolol, propranolol, and carvedilol.

Front 6

568-A:

List probably explanation for these graft CT findings:

1. Concentric coronary atherosclerosis
2. Perivascular infiltrate with abundant eosinophils
3. Patchy necrosis with granulation tissue
4. Scant inflammation cells and interstitial fibrosis.

Back 6

568-A:

1. Atherosclerosis = pre-existing condition
2. Perivasc infiltrate/ eosinophils = hypersen myocarditis, most likely due to new Rx.
3. Patchy necrosis/ granulation = ischemic damage.
4. Scant inflam/ fibrosis = chronic rejection.

Front 7

458-A:

PC: Saddle-nose with Oliguria

What is DX?

Back 7

458-A:

Saddle nose = nasal mucosal ulceration
Oliguria = glomerulonephritis

** DX = Granulomatosis with polyangiitis (WEGENER'S), associated with C-ANCA.

Front 8

458-B:

PC: PT diagnosed with vasculitis. Weak upper extremity pulses. Histological findings resembles giant cells arteritis.

What is DX?

Back 8

458-B:

DX = TAKAYASU arteritis, a vasculitis affecting large-vessels.

Front 9

458-C:

PC: 68yo female PT previously Dx with vasculitis (unknown type). Now have headache and blurred visions.

What is type of previously DX vasculitis?

Back 9

458-C:

DX = Giant Cell Arteritis (GCA), commonly seen in elderly PT's.

Front 10

458-D:

PC: 40yo male with vasculitis has symptoms of exertional calf pain and toe ulcers. Called to ask what is the name of his disease.

What is the name of this vasculitis?

Back 10

458-D:

Significant finding = distal lower extremily claudication and ulceration.

** DX = THROMBO-ANGIITIS OBLITERANS.

Smoking is a risk factor.

Front 11

1506-A:

What are the class and action of VERAPAPIL and DILIAZEM? What are the side effects of Verapamil?

Back 11

1506-A:

Class: Class-IV anti-arrhythmic
Action: Calcium-channel blockers

Verapamil is most cardioselective, but both will work peripherally to decrease BP. Verapamil is known to cause gingival hyperplasia and constipation.

** Note that only SA node (atrium) uses Ca++ to depol.

Front 12

1616:

Parallel circuit has 4 branches, each with resistance = 2. What is the total resistance of the 4 circuits?

Back 12

1616:

PARALLEL:
1/R(t) = 1/R1 + 1/R2 + 1/R3 + 1/R(n)
1/R(t) = 1/2 + 1/2 + 1/2 + 1/2
1/R(t) = 4/2
R(total) = 2/4 = 1/2

Front 13

1765:

Using example of a target, differentiate between ACCURACY (VALIDITY) and PRECISION (RELIABILITY).

Back 13

1765:

Accuracy = hit bull-eyes all the time
Precision = hit a different spot all the time.

** To measure height, a scale is reliable but is not accurate.

Front 14

186:

PC: 65yo male. Exertional dyspnea and fatigue. Smokes 1-pack/day, drinks 10 beers/week. BP = 170/90, P=80. Also significant for bilateral lungs crackles.

What is DX and expected LV cavity, EF, and EDV?

Back 14

186:

DX: most likely to be DIASTOLIC HEART FAILURE, either not enough CO to meet tissue demand, or can only do so in elevated vent filling.

Cavity = normal
EF = normal
EDV = increased

Front 15

1174:

Calculate NNT:

Back 15

1174:

NNT = 1/ARR = 1/Placebo ratio = 1/Tx ratio

Front 16

143:

PC: 50yo male. Dizziness and confusion. Experienced chest pain and took Nitroglycerin. Also take Aspirin (prevention), and Tadalafil (Cialis). BP = 50/20, HR = 120.

What biochem process is responsible for symptoms? What is the MOA?

Back 16

143:

Accumulation of c-GMP, due to Phospho-diesterase (PDE) inhibition of c-GMP.

** All the "-Fils" = Sildenafil (viagra), Vardenfil (levitra), and Tadatafil (cialis)

Front 17

159:

New RX developed to treat arrhythmia. Has high affinity for activated and inactivated SODIUM channels. Don't affect resting channels. Noted to dissociate quickly from non-resting channels.

What class of drug should this one be under?

Back 17

159:

Class-I anti-arrhythmic

Class-1B has shortest dissociation time (shorten AP phase 3 repol but not phase 0)

Ex = LIDOCAINE, mexiletine, tocainide

Front 18

1931:

What mechanism rapidly decrease cytoplasmic Ca++ in cardiac muscles prior to relaxation?

Back 18

1931:

Na/Ca++ exchange mechanism, which "sucks up" all cytoplasmic Ca+ to prevent another contraction.

Front 19

1303:

What is the significance of P-value. Why?

Back 19

1303:

Significance, P<0.05

P>0.05 means the sample size is too small

Front 20

1303-A:

What is Berkson's bias in clinical research?

Back 20

1303-A:

selection bias that can be created by selecting HOSPITAL patients as control group.

Front 21

949:

PC: 59yo female. Facial swelling and difficulty breathing. Dx with HTN and Tx with CAPTOPRIL.

What is mechanism of Captopril's SE?

Back 21

949:

Captopril (ACE-I) increase serum BRADYKININ level, which causes cough and angioedema (1%).

Front 22

949-A:

Which drugs causes non-immune mediated mast cell degranulation?

Back 22

949-A:

In non-immune mediated mast cell degranulation, actional of mast cells are due to other stim., NOT IgE.

Caused by Vancomycin & Opiates -- pseudoallergic RXN.

Front 23

900:

PC: 49yo female. Squeezing chest pain and profuse sweating. EKG shows ST-elevation. Cardiac Troponin high. No have V-Tach and consider Tx with anti-arrhythmia.

Which Rx is highest selectivity for Ischemic Myocardium compare to normal heart tissue?

Back 23

900:

LIDOCAINE (1B anti-arrhythmic) preferentially select ischemic tissue. But Amidarone is 1st line for V-Tach.

Front 24

900-A:

What is the CLASS and ACTION of Procainamide?

Back 24

900-A:

Procainamide is a Class-1A anti-arrhythmic, which is similar to QUINIDINE, more specific for suppressing arrhythmia from CENTER of normal automaticity.

Front 25

900-B:

What is the CLASS and ACTION of Verapamil?

Back 25

900-B:

Class-IV anti-arrhythmic used primarily to treat A-Tach because it slows conduction through the AV node. Not useful in ischemic tissue.

** Prolonged use in VT could lead to VF and death.

Front 26

900-C:

What is the ACTION of Adenosine?

Back 26

900-C:

Adenosine is indicated for Tx of acute Paroxysmal Supra-Ventricular Tachycardia (PSVT).

Front 27

900-D:

Besides increasing contractility, what is the ACTION of off-labeled usage of Digoxin as an anti-arrhythmic?

Back 27

900-D:

Digoxin also has the ability to slow down AV node conduction, used in Tx of A-FIB.

Front 28

227:

In a Cardiac Catheterization graph, what is the main component changes that should be observed for

a. AR
b. MR
c. AS
d. MS

Back 28

227:

a. AR = aortic pressure falls below 50

b. MR =

c. AS = LV pressure super high

d. MS =

Front 29

234:

PC: 33yo Hispanic female. Comes with SOB and hemoptysis. Improves with diuretic. However, develops R-side hemiparesis soon after. DX with Isolated Mitral Stenosis.

What is the physiological result of isolated MS?

Back 29

234:

MS --> Blood backing up --> increased PWP --> tricuspid regurg --> RV dilation --> incr systolic pulmo artery pressure --> reduced pulmonary compliance.

Front 30

187:

PC: 7yo male. Hx of inter-cardiac shunting (RA/RV doesn't equal Pulmo artery). There is increase O2 going from RA to RV ("step up").

What is DX and physical finding?

Back 30

187:

DX = VSD (blood shunting L-R in ventricle)

Finding = loud HOLOsystolic murmur best heard LEFT sternal border in 3rd or 4th ICS.

** Note: P-A-T-M

Front 31

187-A:

In which abnormality is decreased femoral-to-brachial BP ratio most prominent. (i.e. differential pulses)

Back 31

187-A:

Congenital coarctation of the aorta, most commonly in Turner's syndrom (XO).

Front 32

187-B:

PT discovered to have FIXED S2 splitting on cardiac auscultation. What is most likely associated disease?

Back 32

187-B:

Wide S2 splitting most commonly present in PT Atrial Septal Defect (ASD). Lesion may produce O2 increase from vena cava to RA, but not "step up" from RA to RV.

Front 33

187-C:

PT present with cyanosis and finger-nail clubbing. What is the likely cause?

Back 33

187-C:

Cyanotic congenital disease disease

* Transposition
* Truncus Arteriosus
* Tetralogy of Fallot

Front 34

187-D:

Feeling of PT's neck reveals abnormal SPIKE-and-DOME carotid pulse upstroke. What is condition?

Back 34

187-D:

Hypertrophic Obstructive Cardiomyopathy, associated with dynamic LV outflow tract obstruction during systole.

Front 35

240:

PC: 10yo male. Dyspnea. Myocardial biopsy shows collection of mononuclear inflammatory cells, large histiocytes, and interstitial myocardial granulomas (assuming to be ASCHOFF bodies).

What is DX and original cause?

Back 35

240:

Acute Rheumatic Carditis, caused by viral infection.

Front 36

2117:

PC: 7yo boy. Cardiac auscultation finding at LEFT sternal border shows HOLOsystolic murmur. Murmur is accentuated with HANDGRIP exercise.

What is most likely DX?

Back 36

2117:

Low-pitched Holosystolic Murmur at Left Sternal Border suggests...

VSD

... which is louder with INCREASED afterload (handgrip).

Front 37

200:

PC: 63yo male. Severe dyspnea, orthopnea, and fatigue. Hx of MI 6 mos ago and non-compliant with meds. BP = 170/100, HR = 100. Auscultation shows lung base crackles, S3-gallop, and Holosystolic murmur at Apex. Improves with vasodilators.

What is most likely cause of murmur?

Back 37

200:

Functional Mitral Regurg (MR), which increases fluid in the lungs (edema), and increase LV filling rate (S3 gallop).

Untreated will lead to fluid overload, causing LV dilatation.

Front 38

1699:

PC: 23yo male. Stab wound at Left 4th ICS. CT scan was done.

What is most likely injured? What are the level for

a. Pulmonary trunk
b. Right atrium

Back 38

1699:

Most likely to injure the RV.

a. Pulmonary trunk = 2nd ICS
b. Right atrium is on the right 4th ICS.

Front 39

898:

PC; 24yo male. Sudden onset palpitation. Rapid IV injection of Drug-X instantaneously resolves arrhythmia but SE's includes flushing, burning in chest, and SOB.

What is DX and what is Drug-X most likely be?

Back 39

898:

DX is most likely PSVT, and ADENOSINE is 1st line Tx.

Adenosine is rapid acting Rx (HL<10sec) which slows conduction in AV node by hyperpolarizing nodal pacemaker and conducting cells.

Front 40

187-A:

In which abnormality is decreased femoral-to-brachial BP ratio most prominent. (i.e. differential pulses)

Back 40

187-A:

Congenital coarctation of the aorta, most commonly in Turner's syndrom (XO).

Front 41

29:

PC: 10yo male. Headache, nose bleed, and muscle weakness when going uphill. Exams shows Pulsatile vessels palpable along PT't ribs.

What is DX?

Back 41

29:

DX = coarctation or aorta, presented with rib-notching.

Front 42

187-B:

PT discovered to have FIXED S2 splitting on cardiac auscultation. What is most likely associated disease?

Back 42

187-B:

Wide S2 splitting most commonly present in PT Atrial Septal Defect (ASD). Lesion may produce O2 increase from vena cava to RA, but not "step up" from RA to RV.

Front 43

187-C:

PT present with cyanosis and finger-nail clubbing. What is the likely cause?

Back 43

187-C:

Cyanotic congenital disease disease

* Transposition
* Truncus Arteriosus
* Tetralogy of Fallot

Front 44

187-D:

Feeling of PT's neck reveals abnormal SPIKE-and-DOME carotid pulse upstroke. What is condition?

Back 44

187-D:

Hypertrophic Obstructive Cardiomyopathy, associated with dynamic LV outflow tract obstruction during systole.

Front 45

240:

PC: 10yo male. Dyspnea. Myocardial biopsy shows collection of mononuclear inflammatory cells, large histiocytes, and interstitial myocardial granulomas (assuming to be ASCHOFF bodies).

What is DX and original cause?

Back 45

240:

Acute Rheumatic Carditis, caused by viral infection.

Front 46

2117:

PC: 7yo boy. Cardiac auscultation finding at LEFT sternal border shows HOLOsystolic murmur. Murmur is accentuated with HANDGRIP exercise.

What is most likely DX?

Back 46

2117:

Low-pitched Holosystolic Murmur at Left Sternal Border suggests...

VSD

... which is louder with INCREASED afterload (handgrip).

Front 47

200:

PC: 63yo male. Severe dyspnea, orthopnea, and fatigue. Hx of MI 6 mos ago and non-compliant with meds. BP = 170/100, HR = 100. Auscultation shows lung base crackles, S3-gallop, and Holosystolic murmur at Apex. Improves with vasodilators.

What is most likely cause of murmur?

Back 47

200:

Functional Mitral Regurg (MR), which increases fluid in the lungs (edema), and increase LV filling rate (S3 gallop).

Untreated will lead to fluid overload, causing LV dilatation.

Front 48

1699:

PC: 23yo male. Stab wound at Left 4th ICS. CT scan was done.

What is most likely injured? What are the level for

a. Pulmonary trunk
b. Right atrium

Back 48

1699:

Most likely to injure the RV.

a. Pulmonary trunk = 2nd ICS
b. Right atrium is on the right 4th ICS.

Front 49

898:

PC; 24yo male. Sudden onset palpitation. Rapid IV injection of Drug-X instantaneously resolves arrhythmia but SE's includes flushing, burning in chest, and SOB.

What is DX and what is Drug-X most likely be?

Back 49

898:

DX is most likely PSVT, and ADENOSINE is 1st line Tx.

Adenosine is rapid acting Rx (HL<10sec) which slows conduction in AV node by hyperpolarizing nodal pacemaker and conducting cells.

Front 50

29:

PC: 10yo male. Headache, nose bleed, and muscle weakness when going uphill. Exams shows Pulsatile vessels palpable along PT't ribs.

What is DX?

Back 50

29:

DX = coarctation or aorta, presented with rib-notching.

Front 51

236:

PC: 34yo Asian female. Progressive exertional dyspnea, lower extreme edema, cough. Also Hx of frequent noct SOB and hoarseness. Nil smoke or EtOH. Auscultation shows loud 1st and 2nd heart sound and Mid-Diastolic murmur at Apex.

What is the Hoarseness most likely caused by?

Back 51

236:

Nerve impingement, to the point of neurapraxia (impaired conduction).

Left Recurrent Laryngeal nerve loops behind ligamentum arteriosum, underneath and around aortic arch, and back up along side trachea to larynx.

Front 52

231:

PC: 73yo male with Hx of advanced visceral CA dies today of extensive MI. Autopsy reveals STERILE non-destructive vegetation along MITRAL leaflet edge.

What is this Vegetation, and what is it most similar to?

Back 52

231:

Vegetation is characteristic of Non-Bacterial Thrombotic Endocarditis (NBTE), resulting in hypercoagulable state.

It is most similar to TROUSSEAU syndrome, which is migratory thrombophlebitis, seen in PT with disseminated CA.

Front 53

231-A:

A PT asks you, "what is Lambert-Eaton syndrome".

Your answer should be?

Back 53

231-A:

Lambert-Eaton syndrome is an AUTOIMMUNE paraneoplastic myasthenic syndrome that affect pre-synaptic Ca++ channels, resulting in decreased ACh release.

It is associated with OAT-CELL carcinoma of the lungs.

Front 54

781:

PC: 53yo male is recovering from AMI. Exams shows obese male with with no other abnormalities. Labs shows High LDL, Low TG, and Low HDL.

What are the steps to improves his lipid panels?

Back 54

781:

** 1st line = ALWAYS diet and exercise.

- Decrease LDL = Statin > Ezetimibe

- Decrease TG = Fibrate > Niacin

- Increase HDL = Niacin

Front 55

1365:

Med student infuses Drug-X IV over dose range and measure Renal Blood Flow and Cardiac Output.

a. Low dose Drug-X = increase flow
b. High dose Drug-X = decrease flow

What is Drug-X most likely be?

Back 55

1365:

DOPAMINE. DA is an adrenergic agonist with dose-based effect.
** Low dose = stim D1 receptor in renal, increasing GFR, blood flow, and Na-excretion.
** High dose = stim B1-adrenergic receptor in heart, increasing contractility, PP, and systolic BP.
** Higher dose = stim A1-receptor, systemic vasoconstriction, decrease CO due to increase afterload (TPR).

Front 56

2023:

PC: 35yo male with chronic cough and wt loss. CT scan shows...

a. SVC
b. Ascending Aorta
c. Pulmonary trunk
d. Esophagus
e. Descending Aorta

Back 56

2023:

a. SVC is right of the heart (Duh!) and posterior and lateral to ascending aorta.
b. Ascending aorta is slight right, and most anterior vessel.
c. Pulmo trunk is on the left side
d. Esophagus is smaller and anterior to descending aorta.
e. Descending aorta is left side of vertebrae.

Front 57

823:

PC: 76yo male. Severe chest pain and diaphoresis. Hx of DM-2, HTN, and R. Carotid stenosis. BP=120/70, HR=75. EKG shows ST elevation > 1mm. TX with streptokinase, morphine, IV fluid, and low-dose B-blocker. PT develop neurologic deficit later.

What happened?

Back 57

823:

Intercerebral hemorrhage. because breakage of clot by streptokinase. MC side effect is hemorrhage.

** Emergent cardiac catherization is the gold standard if possible.

Front 58

951:

Researchers want to measure coronary blood flow during heavy exercise. It is noted that at this time, there is the highest flow due to significant drop in vessel resistance.

What is major limiting factor?

Back 58

951:

Coronary vessels fills during diastole, thus is it the DURATION of diastole that contribute to filling.

Front 59

728:

Epidemiology shows significant increase in STAPH infection in large city hospitals over 20 years.

What is the reason?

Back 59

728:

Intravascular device

** STAPH is a skin flora

Front 60

202:

What is such a common congenital cardiac abnormality in adult that is considered a normal variant?

Back 60

202:

Patent Foramen Ovale, connecting RA and LA. This is the passage that venous clots can causes stroke (by bypassing the lungs).

Think of how common strokes are.

Front 61

202-A:

PC: 24yo male present with Endocardial Cushion Defect.

What is his likely IQ level and why?

Back 61

202-A:

IQ most likely LOW because he has DOWN syndrome.

Front 62

1836:

PC: A test patient was given Drug-X IV to see it's effect on cardiovascular system. After infusion, Cardiac Contractility increase while Vascular Resistance decreases.

What is this drug?

Back 62

1836:

ISOPROTERENOL

Causes a dose-dependent increase in cardiac contractility (B1-agonist) and systemic vascular relaxation (B2-agonist)

This drug has no effect on A-receptor.

Front 63

32:

PC: 10yo boy. Complains of exertional dyspnea and fatigue. DX with congenital heart disease (unknown) in the past. Physical finding reveals toe cyanosis and clubbing, but fingers are normal.

What is he suffering from?

Back 63

32:

PT is experiencing differential cyanosis.

Toe: get blood from abdominal aorta.
Fingers: from brachial artery.

DX = PDA, which decreases O2 sat in descending aorta.

Front 64

7791:

A unique alien race was found with human-like genetic transmission. Extraction shows NUCLEAR ENZYME that transfer a METHYL group from S-ADENOSYL-METHIONINE to a CYTOSINE residue in a DNA molecule.

This enzyme is implicated in which genetic transmission process?

Back 64

7791:

DNA imprinting, a phenomenon in which an offspring's gene are expressed in a parent-specific manner, which alter (silence) the phenotype without altering the genotype.

Front 65

85:

PC: 24yo dies suddenly after documented harsh systolic murmur. Family Hx shows extensive sudden death. Autopsy specimen found THICK interventricular septum.

What action would most likely increase the murmur sound?

Back 65

85:

PT most likely died of hypertrophic cardiomyopathy (HCM), commonly found in young athletic male.

Anything that decreases LV EDV will increases the murmue (ie strand up).