Uw April 11, 2012

Front 1

543:

PC: Infant. Carpopedal spasm. No thymic shadow on X-ray. Narrow aortic arch on angiography.

What is DX and what failed to developed?

Back 1

543:

PT have DiGeorge Syndrome, which the 3RD PHARYNGEAL POUH fails to develop, leading to lack of thymus.

** T-cell immunodeficiency.
** Chr-22 deletion

Front 2

543-A:

What are these embryonic structure?

a. Second branchial cleft
b. Third branchial arch
c. Fourth branchial arch
d. Septum transversum

Back 2

543-A:

a. 2nd branchial cleft (parhygeal grooves) -- branchial cleft cyst at mandibular angle.
b. 3rd branchial arch - tissue innervated by CN9, glossopharyngeal, the posterior 1/3 tongue.
c. 4th branchil arch - tissues of CN10, vagus, posterior 1/3 of tongue
d. Septum transversum - form diaphragm.

Front 3

315:

PC: New born male. continuous "machine-like" murmur with systolic accentuation, loudest at LEFT infraclavicular region. PT Dx with PDA.

What is PDA a remnant of?
What keeps PDA open in embryo?
What Rx to closes it after birth?

Back 3

315:

PGE-1 maintains PDA (6th aortic arch)

Indomethacin and NSAIDS closes. (by inhibit PGE-1)

Front 4

1344:

PC: 72yo male. Substernal chest pain, SOB, bilateral crackles, 3rd heart sound, distended JVP, 2+ edema of lower extremity. PT DX with MI and is in cardiogenic shock. Started on Dobutamine, Furosemide, and Nitroglycerine.

What is MOA and ACTION of Dobutamine?

Back 4

1344:

MOA: Beta-adrenergic agonist (predominantly B1-receptor). Used to Tx of acute HF associated with decrease contractility (shock).

Associated with Increase Cardiac Conduction Velocity (undesirable, lead to arrhythmia).

Front 5

1204:

Study of 200 non-diabetic (chol=195), and 180 (chol=210). Probability due to chance is 5%. There is 20% prob of false negative.

What is power of study?

Back 5

1204:

B = Type II error (false negative)

POWER = 1 - B

= 1-.20 = 0.80

Front 6

1204-A:

A statistician asks, "what is the difference between Type-I and Type-II error", and "what are the implication of each"?

Back 6

1204-A:

a. Type-I error:


b. Type-II error:

Front 7

1871:

PC: 54yo male. periodic, tight, burning substernal chest pain. Thallium stress test shows hypoperfusion to diaphragmatic side of heart.

What vessel supply this area?

Back 7

1871:

Diaphragmatic side of heart is made up mainly by the LV, which is supplied by the PDA, a branch of the Right Coronary Artery.

Front 8

1871-A:

A coronary CT angiogram is shown to a student. Describe coronary vessels and its branches.

Back 8

1871-A:

LEFT MAIN: divides into LAD and L-CX, which supply most of anterior and left lateral heart.

RIGHT MAIN: give rise to PDA (right dominant, 90%). In 10%, PDA arises from L-CX (left dominant), which supplies inferior LV.

Front 9

1871-B:

A PT has severe atherosclerosis to LAD coronary artery.

What part of myocardium is affected?

Back 9

1871-B:

Anterior 2/3 of interventricular septum (septal branches), anterior wall of left ventricle, and part of anterior papillary muscle.

Front 10

34:

PC: Newborn male. Facial dysmorphia, cleft palate, long arm Chr-22 deletion.

What is DX?

Back 10

34:

DiGeorge

- T.O.Fallot
- Interrupted aortic arch
- Missing Thymus

Front 11

34-A:

PT want you to define the following:
a. Kartagener's
b. Tuberous sclerosis
c. Friedreich's
d. Marfan
e. Down
f. Turner's

Back 11

34-A:

a. Kartagener (AR): microtubular defect, no cilia
b. TS (AD): cutaneous angiofibromas, seizure, mental retardation, visceral cyst.
c. Friedreich's (AR): spinocerebellar degeneration with spinal ataxia. Associated with facial/palatal malformation.

Front 12

726:

A group of researchers want to use early empiric penicillin to treat bacterial pharyngitis.

- What is most common causative organism?
- What will bact. pharyngitis lead to?
- What would be decrease due to Tx?

Back 12

726:

- Streptococcal pharyngitis is MC.

- Could lead to Rheumatic Fever (RF)

- Decrease cases of Cardiac Surgery due to RF.

Front 13

1200:

PC: 68yo male. Heart palpitation, irregularly irregular EKG, absent P-wave. Started on empirical Warfarin.

What should be monitored in this PT?

Back 13

1200:

Prothrombin time (PT)

Warfarin inhibits gamma-carboxylation of vit-K dependent coag factor "1.9.7.2."

Front 14

1200-A:

Your attending asks, "when you would follows..."

a. Bleeding Time
b. aPTT
c. Fibrinogen level/ split product

Back 14

1200-A:

a. Bleeding time: platelet dysfunction. Thrombocytopenis, vWF disease, defect of platelet aggregation, DIC, ASA treatment.
b. aPTT: heparin use
c. D-dimer: DIC

Front 15

1661:

PC: 46yo female. Murmur, bounding femoral pulses, carotid pulsation, head-bobbing.

What is most likely DX?

Back 15

1661:

Aortic regurgitation, note that bounding pulses ("water-hammer") is indication of high difference in pulse pressure.

Front 16

2055:

PC: 56yo male. Tachycardia and irregular rhythm. Report binge drinking previous night.

What do you expect to find on EKG finding?

Back 16

2055:

New onset palpitation post binge drinking indicated AFIB ("holiday heart syndrome"), which shows as Absent of P-wave on EKG.

Front 17

205:

PC: A patient with TOF claims that she feels better squatting down when experiencing TET-spells.

What is the physio behind squatting?

Back 17

205:

Increase systemic vascular resistance (TPR) leads to less shunting and allow greater fraction of total Cardiac Output to pass through lungs, improving arterial oxygenation.

Front 18

145:

PC: 60yo male. Hx of HTN and Tx with max dose HCTZ and ramipril. Now have BP=160/100, HR=65. PT need another anti-HTN but need to watch out for prolonged AV-conduction.

Which anti-HTN drug has the LEAST affect on AV conduction?

Back 18

145:

NIFEDIPINE, minimal affect on AV conduction, and causes peripheral vasodilation, which might result on reflex tachycardia.

** Best to Tx HTN with bradycardia.

Front 19

445:

PC: 40yo dies of MVA. Smoker, drinker, obese. Extensive FHx of MI and stroke.

What are the pattern of Atherosclerotic plaques? Which vessels are most likely?

Back 19

445:

Atherosclerosis most likely affect LARGE vessels (i.e. aorta, carotids) and muscular arteries (i.e. coronary, popliteal)

Aorta > coronary > popliteal > internal carotic > circle of willis.

Front 20

2108:

PC: 71yo male. Hx of progressive exertional dyspnea and difficulty sleeping.

Without listening to heart sound, what are the most likely DX and pathophysiology?

Back 20

2108:

MCC oth dyspnea and nocturnal dyspnea is congestive heart failure (CHF), characterized by increase LV EDV (heart fluid overload).

Front 21

1652:

PC: 45yo male. 2 days Hx of dyspnea, orthopnea, and ankle swelling. Doctor prescribe NITROPRUSSIDE and asks what is its mechanism.

What is you answer?

Back 21

1652:

NITROPRUSSIDE is a short-acting BALANCED Venous and Arterial VASODILATOR, which decreases both preload and afterload, therefore decreases the volume (preload) and pressure (afterload) of the LV.

Front 22

144:

PC: 55yo male. HTN and cardiac disease. Attending considered adding Verapamil (Ca++ Blocker) to reduce blood pressure.

Knowing that skeletal muscles uses Calcium to depol, will this affect these muscles?

Back 22

144:

No, Verapamil will not affect skeletal muscles due to the fact that MSK muscle has its own independent Ca++ supply. Not relying on plasma.

Front 23

1505:

PC: 65yo. Fever, joint pain, body rash, serum ANA positive. Hx of CAD, CHF, and arrhythmia.

What is this patient taking? I.e. These are the side effects of what drug?

Back 23

1505:

PROCAINAMIDE (1A anti-arrhythmic)

SE:
LUPUS (fever, joint pain, body rash, serum ANA positive), arrhythmia, and psychotic disturbance.

Front 24

2107:

PC: 65yo male. Hx HTN, DM-2, smoker. Jog 3 miles per day, BMI = 28.5, FHx normal. Doctor decide to auscultate at apex.

Without listening to heart sound, what is your provisional DX?

Back 24

2107:

Apex = ventricular heaves
Left ventricular hypertrophy

Front 25

136:

PC: PT has severe retrosternal chest pain. Nitroglycerin IV relief pain and decrease BP.

What is the skeletal muscle molecular target of nitrates as a side effect to its MOA?

Back 25

136:

Nitric Oxide (NO) stimulates GUANYLATE CYCLASE to convert GTP into cGMP.

Increase cGMP concentration decrease free intracellular Ca++, whic decrease Myosin light-chain kinase activity, and finally decrease myosin light-chain dephosphoryllation?

Front 26

1047:

PC: 56yo male. Fatigue and dyspnea. Lower edema and decreased peripheral sensation. Cardiac dilation and increased CO.

What nutrient is he deficient in?

Back 26

1047:

Vitamin B1 (Thiamin)

Infant beriberi = cardiomegaly, tachy, cyanosis, dyspnea, vomiting.
Wernicke-Korsakoff = EtOh, confabulation
Adult dry = symmetrical neuropathy
Adult wet = dry + cardiac involvement

Front 27

1948:

PC: 45yo. BP 155/100 (1st) and 160/100 (2nd). HR 85. Low sodium diet, exercise regularly. You decide to prescribe Metoprolol.

What changes to do you expect to see as a result of this prescription?

Back 27

1948:

Metoprolol (selective B1-blocker, which are found in cardiac tissue and renal JG cell).

Decreased level of circulating renin

Front 28

1252:

Pharmaceutical company makes a new drug, Drug-X, that will (1) relax smooth mm. of arterioles but (2) does NOT affect veins.

What side effects would you expect to see on clinical trials?

Back 28

1252:

This drug causes arteriodilation, which will be picked up by baroceptor in Aorta and Carotid as hypovolemia.

This will trigger reflex sympathetic to increase HR, contractility, and renin release.

Front 29

1653:

PC: 46yo female undergo cardiac cath. 1st pass = 27mmHg to 2mmHg. After two inches advance, 2nd pass = 26mmHg to 10mmHg.

What is the initial location (1st pass) of the cath?

Back 29

1653:

Must be in the RIGHT VENTRICLE, since there is a higher pulse pressure.

Front 30

975:

PC: 38yo male IV drug user. High grade fever, tague, dyspnea, and died in ICU. Autopsy shows patchy lung necrosis ("wedge shape hemorrhagic infarcts").

What is this patient most likely suffered from?

Back 30

975:

Tricuspid valve endocarditis,

which is most common with STAPH AUREUS in IVDU. Staph likes to affect right-heart, and any necrosis in lung is hemorrhagic due to dual blood supply.

He likely have gotten a PE from septic emboli.

Front 31

1609:

PC: 65yo male. Loss consciousness after buttoning his collar. BP = 70/40, HR = 45.

What happened?

Back 31

1609:

He gave himself a carotid massage, which stimulates baroceptors in carotid bifurcation (CN-9).

Front 32

2070:

PC: 34yo male. 2mo Hx of dyspnea and edema. Evil doctor asks you to interpret this JVP wave reading.

What are different part of the JVP -- A, C, X, Y, V ?

Back 32

2070:

A (1st peak) - RA contraction
C (2nd peak) - bulging tricuspid
X (1st dip) - RA relax
V (3rd peak) - inflow of venous blood
Y (2nd dip) - passive emptying (diastole)

Front 33

230:

PC: 36yo female. R-side weakness, speech difficulty. Hx of fatigue, low grade fever. PT died in hospital. Autopsy shows Mitral Valve with extensive vegetation.

What condition allows PT to have Mitral Valve infection?

Back 33

230:

Mitral Valve Prolapse,

PT seems to have Native Valve Bacterial Endocarditis (NVBE), which is complicated by embolic event.

Front 34

1977:

PC: 69yo male. Palpitation and dyspnea. EKG shows HR 120, irregular rhythm, narrow QRS, and no P-wave.

What seems to be the determinant of ventricular rhythm rate in this patient?

Back 34

1977:

AV node refractory period,

which patient is appear to experience AFIB, which is controlled only by the slow conduction of AV node.

Front 35

195:

PC: 62yo female with MI dies on day 4 of admission. Autopsy shows infarcted heart at distal LAD.

What is the cause of her death?

Back 35

195:

Profound hypotension,

because the damaged heart (LV) cannot pump blood anymore (cardiogenic shock).

Front 36

153:

PC: 70yo male with syncopal episode. Hx of severe constipation, COPD, and admited to hosp for AFIB and tachycardia. EKG shows second-degree AV block, which is believed to be a SE of his medication.

Which medication is he taking?

Back 36

153:

VERAPAMIL,

a Ca++ blocker that is preferentially used to treat AFIB because it slows down AV conduction.

Front 37

229:

PC: 23yo male with 3wks Hx of fatigue, cardiac murmur, now have have mild proteinuria and hematuria. Creatinine level is 2.3 and urine has RED CELL CAST.

Which are most likely cause of urine finding?

Back 37

229:

RBC CAST = infection,

most likely caused by Bacterial Endocarditis (BE) in this patient. The TWO FOLD in creatinine indicates 50% reduction in renal GFR.

Front 38

74:

PC: 3yo male with endocardial thickening (fibrous deposit) around tricuspid and pulmonary valve as well as pulmo valve stenosis. Left cardiac chambers and valve are normal.

What are Carcinoid Syndrome? And how is it detect in blood?

Back 38

74:

Carcinoid Syndrome = increase production of SEROTONIN by carcinoid tumors, causing FLUSHING, CRAMP, and N/V/D. Also endocardial fibrosis.

Detect via urine 5-hydroxy-indole-acetic acid.

Front 39

83:

PC: 16yo male collapsed and died while jogging. Extensive FHx of sudden death.

What is the genetic defect in this PT?

Back 39

83:

Patient most likely died of hypertrophic cardiomyopathy (HCM), which is due to a mutation in

Cardiac SARCOMERE protein,

most likely a point mutation in the beta-myosin heavy chain.

Front 40

1001:

PC: A PT with infective endocarditis found to have STEP BOVIS in his blood culture.

What condition would predispose him to higher risk of infection by STEP BOVIS?

Back 40

1001:

Anything to do with the COLON, since Strep Bovis is a normal gut flora.

Front 41

199:

PC: 35yo female with dyspnea and dizziness on exertion. She's on strict weight-reduction diet and use appetite-suppressant medication. BP 110/80, HR 90. Unfortunately, PT dies 6 mo post initial visit.

What causes this PT to die, according to her history?

Back 41

199:

Appetite-suppressant Rx has tendency to cause SECONDARY PULMONARY HYPERTENSION if used more than 3 months.

This will lead to RV hypertrophy.