Questions and Answers
Deficiency of which vitamin is associated with a high rate of complications from this patient's condition?
What is the most likely cause of the patient's findings of cough, breathlessness, and chest pain?
Intravenous dextrose is administered; how does it affect this patient's condition?
What blood gas values are most likely to be present in a patient experiencing sudden-onset dyspnea?
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What factors most likely contributed to the formation of gallstones in this patient during pregnancy?
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What type of bacteria is most likely responsible for a turbid pericardial effusion with neutrophils?
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What is most likely responsible for the patient's recent change in behavior related to gambling?
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What most likely prompted the addition of acetazolamide to the treatment regimen?
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Which hormone's profile likely shows peaks around meal times in normal individuals?
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Destruction of which of the following gastric layers is most likely responsible for this patient's symptoms?
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Injury to which of the following structures is the most likely cause of this patient's current symptoms?
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Which of the following has most likely increased as the result of the therapy?
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If a liver biopsy is performed, which of the following histologic findings would most likely be present in this patient?
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Compared to a healthy nonpregnant woman, which of the following parameters is most likely to be decreased in this patient?
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Which of the following is most likely to be observed with use of the antibody fragments compared to the intact immunoglobulin?
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Which of the following is most likely occurring in the tumor microenvironment as a result of this interaction?
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Which of the following findings is most likely to be present in this patient?
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Tension from which of the following muscles is most likely responsible for displacement of the distal bone fragment?
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Doppler ultrasound interrogation of the fistula will most likely reveal which of the following blood flow patterns?
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Which of the following cells have the same embryological origin as the tissue responsible for this patient's current condition?
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Nutritional restriction of which of the following substances can improve this patient's condition?
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What is likely the diagnosis of the unvaccinated 20-month-old girl brought to the emergency department with a rash?
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Study Notes
Card 1: Pernicious Anemia
- A 65-year-old woman presents with fatigue and lower-extremity paresthesias, suggesting possible vitamin B12 deficiency.
- Laboratory findings show macrocytic anemia, characterized by a mean corpuscular volume of 112 fL.
- Upper GI endoscopy reveals atrophic mucosa in the gastric body and fundus, likely due to autoimmune destruction of parietal cells in the upper glandular layer.
- This destruction leads to reduced hydrochloric acid and intrinsic factor secretion, resulting in megaloblastic anemia and neurologic symptoms.
Card 2: Common Fibular Nerve Injury
- A 69-year-old woman exhibits right foot weakness following left hip surgery in a lateral decubitus position.
- Physical exam reveals inability to dorsiflex or evert foot, indicating common fibular nerve injury.
- This nerve, a branch of the sciatic nerve, is vulnerable to compression due to its location around the fibula.
- Symptoms include foot drop, characterized by weakness in foot dorsiflexion and sensory loss on the dorsal foot.
Card 3: Statin Therapy Effects
- A 45-year-old man experiences an ST-elevation myocardial infarction and is started on high-intensity atorvastatin.
- His total cholesterol decreased from 200 mg/dL to 140 mg/dL in 4 weeks.
- Statins reduce hepatic cholesterol synthesis, leading to increased LDL receptor density on hepatocytes for enhanced LDL uptake.
Card 4: Chronic Hepatitis C
- A 36-year-old man has positive anti-hepatitis C virus and hepatitis C RNA results, indicating chronic infection.
- Histological evaluation of a liver biopsy would likely reveal lymphocytic infiltration of portal tracts.
- Chronic hepatitis C can progress to cirrhosis with characteristic histology of liver fibrosis and hepatocyte injury.
Card 5: Pregnancy Hemodynamics
- A 38-year-old pregnant woman at 34 weeks gestation presents with significant peripheral edema.
- In pregnancy, systemic vascular resistance (SVR) decreases due to vasodilators and increased uteroplacental blood flow.
- This physiological adjustment optimizes blood flow to the fetus and reduces SVR, contributing to edema.
Card 6: Monoclonal Antibody Pharmacokinetics
- Researchers develop an antibody targeting VEGF for age-related macular degeneration treatment.
- Using antibody fragments (Fab) rather than intact immunoglobulins improves tissue penetration due to their smaller size.
- Enhanced pharmacokinetics with Fab fragments can lead to more effective therapies with potentially reduced side effects.
Card 7: Tumor Immune Evasion Mechanisms
- A 58-year-old woman with high-grade serous carcinoma exhibits significant T-cell presence in tumor stroma.
- The tumor's expression of PD-1 ligands interacts with T-cell PD-1 receptors, leading to reduced IL-2 production and T-cell exhaustion.
- This interaction is a mechanism by which tumors evade immune detection and promote their survival.
Card 8: Stimulant Withdrawal Symptoms
- A 19-year-old male experiences new fatigue and hypersomnia after doubling his dextroamphetamine dose.
- Abrupt withdrawal from stimulants can lead to symptoms opposite to those experienced during use, such as fatigue and hyperphagia.
- Withdrawal may also include dysphoric mood, which can complicate recovery.
Card 9: Clavicle Fracture Dynamics
- A 3-year-old boy sustains a clavicle fracture, likely due to falling with an outstretched arm.
- Muscle tension from the deltoid contributes to the displacement of the bone fragments in the fracture site.
- Tension dynamics from adjacent muscles create a risk for nonunion of the fractured bone.
Card 10: Aortic Fistula Flow Patterns
- A 32-year-old man presents with endocarditis and an intracardiac fistula between the aortic root and right ventricle.
- Doppler ultrasound will show continuous blood flow from the aortic root to the right ventricle, indicative of a left-to-right shunt.
- This continuous flow pattern correlates with pressure differences between aorta and right ventricle during the cardiac cycle.
Card 11: Pheochromocytoma Associations
- A 33-year-old man exhibits symptoms consistent with pheochromocytoma, a catecholamine-secreting adrenal tumor.
- These tumors arise from chromaffin cells, which share an embryonic origin with melanin-producing cells from neural crest tissue.
- Family history suggestive of multiple endocrine neoplasia (MEN) type 2 may also be relevant.
Card 12: Urea Cycle Disorders
- A 4-day-old boy shows signs of an inherited urea cycle disorder, specifically ornithine translocase deficiency.
- Poor feeding and lethargy indicate ammonia accumulation, causing severe symptoms in infancy.
- Nutritional management focuses on protein restriction to limit ammonia production while providing essential amino acids.
Card 13: Measles Complications and Vitamin A
- An unvaccinated 20-month-old girl presents with measles, characterized by a maculopapular rash and respiratory symptoms.
- Vitamin A deficiency increases complication risks during measles, notably keratitis and pneumonia.
- Supplementation is essential for preventing ocular complications and improving recovery outcomes in measles patients.
Card 14: Pneumonia Presentation
- A 68-year-old man exhibits cough, breathlessness, and chest pain, with findings consistent with bacterial pneumonia.
- Dullness to percussion and bronchial breath sounds indicate fluid-filled alveoli due to neutrophil-rich exudate.
- This consolidation is a hallmark of pneumonia, leading to significant respiratory symptoms and clinical findings.### Alveolar Consolidation
- Alveolar consolidation causes sound transmission to be more efficient in fluid-filled alveoli than in air-filled ones.
- Breath sounds and tactile fremitus are more pronounced in areas of consolidation due to increased sound intensity.
- Bronchophony occurs when spoken words are heard more clearly over consolidated lung areas compared to normal lung sound.
- Percussion over consolidated areas yields relative dullness, contrasting the resonant sound of air-filled alveoli.
Acute Intermittent Porphyria (AIP)
- AIP is an autosomal dominant disorder caused by porphobilinogen (PBG) deaminase deficiency.
- Symptoms include abdominal pain, vomiting, neuropathy, and neuropsychiatric issues, alongside reddish urine that darkens upon standing.
- Treatment involves inhibiting ALA synthase to reduce toxic intermediate accumulations through intravenous heme and glucose administration.
- AIP is characterized by neurovisceral symptoms, typically linked to early steps of porphyrin synthesis.
Pulmonary Embolism (PE)
- Sudden-onset shortness of breath and calf swelling suggest PE, commonly arising from deep venous thrombosis.
- PE leads to impaired blood flow and increased ventilation/perfusion (V/Q) mismatch, causing hypoxemia.
- Hyperventilation can induce respiratory alkalosis and hypocapnia (low PaCO2) without improving arterial oxygenation.
- PaO2 levels may be low due to the impaired gas exchange caused by PE.
Gallstone Formation in Pregnancy
- Gallstones can develop in 5-12% of pregnant women due to hormonal changes.
- Estrogen increases cholesterol secretion in bile, leading to supersaturation.
- Progesterone reduces gallbladder motility, resulting in stone formation when cholesterol exceeds bile salts.
Pericarditis
- Turbid pericardial effusion with neutrophils hints towards purulent pericarditis commonly caused by bacteria or fungi.
- Staphylococcus aureus, a cluster-forming gram-positive cocci, is most frequently isolated in such cases.
- Pericarditis can arise from hematologic spread or complications from chest injuries and surgeries.
Impulse Control Disorders in Parkinson's Disease
- Dopamine agonists can cause impulse control disorders such as pathological gambling in Parkinson's disease patients.
- These medications enhance dopamine activity in the ventral striatum associated with reward pathways.
- Monitoring for behavioral changes is critical in patients receiving dopamine treatments.
Loop Diuretic Therapy and Metabolic Alkalosis
- Loop diuretics lead to metabolic alkalosis via renal excretion of H+ and K+ and bicarbonate retention.
- Acetazolamide can be used to counter metabolic alkalosis by inhibiting NaHCO3 reabsorption in the proximal tubule.
- This results in increased bicarbonate loss and helps normalize pH.
Ghrelin and Weight Loss Post-Gastrectomy
- After gastrectomy, patients show altered ghrelin secretion patterns, leading to reduced appetite stimulation.
- Ghrelin, primarily secreted in the stomach, peaks before meals and declines after eating.
- Removal of ghrelin-secreting cells during bariatric surgeries contributes to significant weight loss in these patients.
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