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Pathophysiology

UWORLD Round 1 2021

QuestionAnswer
How are Paradoxical embolisms developed? Occurs when a thrombus from the venous system crosses into the arterial circulation via an abnormal connection between the right and left cardiac chambers
What are common Right to Left shunts? PFO, ASD, and VSD
What is a key auscultation feature of Atrial Left-to-Right shunts? Wide and fixed splitting of S2
What type of shunts are seen with wide and fixed split of S2? Atrial Left to Right shunts
What do atrial L-->R shunts create greater risk Paradoxical embolism? Periods of transient shunt reversal during straining or coughing
What actions can temporarily reverse atrial left to right shunts? Straining and coughing
How is Hypertrophic cardiomyopathy (HCM) characterized? Asymmetric ventricular septal hypertrophy and dynamic Left-ventricular outflow tract (LVOT) obstruction
What type of cardiomyopathy is characterized with a dynamic LVOT obstruction? Hypertrophic cardiomyopathy (HCM)
Do a decrease in Left Ventricular volume worses or betters LVOT obstruction ? Worsens LVOT obstruction
What are some maneuvers that can decrease Preload? Abrupt standing and Valsalva strain phase
What hemodynamic changes can help to intensify HCM murmur? 1. Decrease in LV volume 2. Decrease in Preload 3. Decrease in Afterload
Why does a decrease in LV volume, preload, and afterload lead to an intensified HCM murmur? The LVOT obstruction worsens
What is Alveolar consolidation? Alveoli become filled with fluid
What type of fluid is seen in Alveolar consolidation due to an bacterial infection? Inflammatory exudate
What causes the increase bronchophony, tactile fremitus and breaths sounds in areas affected with alveolar consolidation? The increased compactness of the alveolar fluid (compared to air) causes sound to travel faster and more efficiently, leading to increased or better sound resolution
In alveolar consolidation physical exam, the auscultation sounds will present more clearly in the affected or unaffected area? Affected lung areas (lobes)
What auscultation findings are increased with Alveolar consolidation? 1. Bronchophony, 2. Dullness to percussion 3. Tactile fremitus 4. Intensity of breath sounds
What condition is often seen along with Aortic stenosis due to coronary artery narrowing? Angina
Which type of murmur (cardiac condition) is often seen with Angina? Aortic stenosis
What conditions lead to development of Angina? Increased myocardial oxygen demand due to an increase in Left Ventricular mass (concentric hypertrophy) and ventricular wall stress
Description of a VSD: Harsh, holosystolic murmur of the lower sternal border, that causes a Left to right shunting of oxygenated blood from the Left Ventricle of the the Right Ventricle
What is a L---> R shunt that "sends" oxygenated blood from the LV to the RV? VSD
What type of blood is shunted from the LV to the RV in a VSD? Oxygenated blood
Harsh, holosystolic murmur best heard at the Lower Sternal border VSD
In which area is a VSD best heard? Lower sternal border
The shunting of blood in a VSD cause? The Right ventricular oxygen saturation to be increased
Which murmur is to be suspected if the right ventricular oxygen saturation is higher or elevated form normal? VSD
What is Preeclampsia? New-onset hypertension at >or equal 20 weeks of gestation plus proteinuria and/ or signs of end-organ damage
What causes Preeclampsia? Widespread maternal endothelial cell damage due to release of antiangiogenic factors from an ischemic placenta
What is the result of widespread anti angiogenic factors from ischemic placenta that result in Preeclampsia? 1. Widespread capillary leakage ( proteinuria, edema) 2. Vasospasm (hypertension, end-organ hypoperfusion [renal failure])
What receptors are downregulated in chronic alcohol abuse? Inhibitory GABA receptors
What receptors are upregulated in chronic alcohol abuse? Excitatory NMDA glutamate receptors
Chronic alcoholism lead to a downregulation of GABA receptors or NMDA glutamate receptors? Inhibitory GABA receptors
What occurs to GABA activity and glutamate activity in response to sudden cessation of alcohol in a chronic alcoholic? Decreased GABA activity and an increase in Glutamate activity, leading to CNS overexcitation
What changes at the neurotransmitter level are responsible for CNS overexcitation? Decreased GABA activity and increase glutamate activity
If labs and CSF analysis show a increase in glutamate activity and decrease in GABA receptor activity, what is a possible condition? Sudden alcohol withdrawals of a chronic alcoholic
What is used to treat infertility in PCOS? Clomiphene
What is the MOA of Clomiphene? Estrogen receptor modulator that decreases negative feedback inhibition at the hypothalamus by circulating Estrogen, thereby increasing gonadotropin production
On which gland does Clomiphene exerts its action? Negative feedback inhibition at the Hypothalamus
What is an important Estrogen receptor modulator that is used to treat infertility in PCOS patients? Clomiphene
What is the normal Ejection fraction? 55%
How is heart failure with preserved ejection fraction characterized? Diastolic dysfunction, which frequently occurs in the setting of prolonged systemic hypertension due to concentric left ventricular hypertrophy
What are consequences of prolonged systemic hypertension with respect with heart failure? Diastolic dysfunction, due to concentric left ventricular hypertrophy
What is the result of prolonged systemic hypertension causing diastolic heart dysfunction with normal EF? Concentric Left Ventricular hypertrophy
What is the best description of Tension Pneumothorax? Progressively increasing intrapleural pressure that leads to contralateral mediastinal shifting (tracheal deviation) and vena cava collapse
What pulmonary condition is often seen with Vena Cava collapse and tracheal deviation? Tension pneumothorax
What are the clinical features of Tension pneumothorax? Hypotension, tachycardia, and obstructive shock due to decreased venous return to the heart
What causes the symptoms of pneumothorax? Decreased venous return to the heart
Which type of pneumothorax is seen with tracheal deviation? Tension pneumothorax
What are findings exclusive of Tension pneumothorax? 1. Tracheal deviation 2. Contralateral mediastinal shift (on x-ray)
What is a common symptom of Endometrial hyperplasia/cancer in postmenopausal women? Postmenopausal vaginal bleeding
What is a common risk factor for postmenopausal women vaginal bleeding due to Endometrial hyperplasia/cancer? Obesity
How does obesity increase the risk of Endometrial cancer or hyperplasia? Peripheral aromatization of androgens to Estrogens in the adipose tissue
What condition is associated with unopposed and excessive estrogen exposure and uncontrolled endometrial tissue proliferation? Obesity
What is causes Hepatic Encephalopathy? Increased levels of ammonia and other neurotoxins in the circulation that lead to increased inhibitory neurotransmission and impaired excitatory neurotransmitter release
What condition is associated with blood accumulation of ammonia, most likely seen in alcoholic patients? Hepatic encephalopathy
What condition is often caused by a stressor, such as cirrhosis, infection, or GI bleed, that lead elevated serum ammonia levels? Hepatic encephalopathy
What are the Vitamin K coagulation factors? Factors II, VII, IX, and X, plus Protein C and S
Where are Vitamin K coagulation factors synthesized? Liver
Which vitamin K coagulation factor has the shortest half life? Factor VII
What can indicate possible factor VII (7) deficiency? Failure to the Prothrombin time (PT) to correct with vitamin K supplementation
A person is administered vitamin K due to a prolonged bleed, but after a while the PT still not corrected. Dx? Factor VII deficiency
What organ disease may lead to Factor VII deficiency? Liver disease
What is the most common sleep-breathing disorder? Obstructive Sleep Apnea
What is OSA? Most common sleep breathing disorder, that is characterized by recurrent obstruction of the upper airways.
Pathogenesis of OSA: Relaxation of the oropharyngeal and/or soft palate musculature during sleep results in functional collapse of the airway, producing periods of reduced/absent airflow despite continued breathing efforts
What condition is seen with periods of absent breathing during the night? Obstructive Sleep Apnea
What causes of Anemia of Chronic disease (ACD)? Chronic elevations in inflammatory cytokines, which lead to reduced iron absorption and increased retention in the reticuloendothelial system
What is a complication of impair iron availability in anemia of chronic disease? Normocytic/microcytic anemia with low serum iron and low TIBC
What is the Metyrapone stimulation test? A sensitive indicator of HPA axis integrity
What causes the administration of Metyrapone? Causes a decrease in cortisol synthesis via inhibition of 11-B-hydroxylase in the Zona Fasciculata
A Metyrapone stimulation test will cause elevation in concentration of which substances? 1. ACTH 2. 11-deoxycortisol, 3. Urinary 17-hydroxycorticosteroid
What are pleural effusions? Collection of fluid between the lung and parietal lung membrane
What are the two types of Pleural effusions? Exudative and Transudative
Which pleural effusion is characterized with a high protein or LDH content? Exudative pleural effusion
What is the main cause for Exudative effusions? Result from inflammation and consequently increased vascular membrane permeability
What are some condition that develop Exudative pleural effusions? Lung cancer, pneumonia, rheumatoid arthritis, and TB
What is the main pathogenesis of Transudative pleural effusions? Alterations in hydrostatic or oncotic pressures
What conditions are associated with Transudative effusions? Heart failure, cirrhosis, and nephrotic syndrome
What is Empyema? Infection of the pleural effusion
Infected pleural effusion is known as: Empyema
What are the findings of the aspirate of an Empyema? 1. Pus 2. Low pH 3. Decreased glucose 4. Increased LDH
What are findings on the CXR of a person with a pleural effusion? 1. Blunting of Costovertebral angle 2. Fluid in lung fissures 3. Meniscus (severe) 4. Contralateral mediastinal deviation (severe cases)
What is the cause of Wilson disease? Due to defective Copper transport within hepatocytes, which lead to impaired Biliary excretion of Copper
What is the result of the Copper accumulation in Wilson disease? Release of free copper into bloodstream and copper deposition into extrahepatic tissues, such as Basal ganglia and cornea.
What condition is associated with defective biliary excretion of Copper? Wilson disease
List of actions of Glucagon: 1. Increases serum glucose by increase in hepatic glycogenolysis and gluconeogenesis 2. Stimulates insulin secretion from the Pancreas
What is the difference between Epinephrine and Glucagon? Glucagon has an insignificant effect of glucose homeostasis in skeletal muscle, adipose tissue, and renal cortex
On which tissue or organ does glucagon stimulates glycogenolysis and gluconeogenesis? Liver
What is an Abdominal Aortic Aneurysm (AAA)? Focal dilation of abdominal aorta > 50% above the normal (>3 cm diameter)
50% increase focal dilation of the abdominal aorta. Dx? Abdominal Aortic Aneurysm
What are the most important risk factors of AAA? Age > 65, smoking, and male sex
What is the mechanism of pathogenesis of Vasospastic Angina? Hyperreactivity of Coronary artery smooth muscle
Hyperactivity of coronary artery smooth muscle Vasospastic angina
What is the typical person that suffers of Vasospastic angina? Young people under 50 years of age with no apparent risk factor for CAD
What is the clinical presentation of Vasospastic angina? Recurrent episodic chest discomfort that typically occur during rest or sleep and resolve within 15 minutes
Recurrent episodes of sudden chest pain during times or rest or sleep that quickly resolve, usually before 15 minutes since start of pain. Dx? Vasospastic angina
What is the main mediator (cytokine) involved in Anemia of Chronic disease? Hepcidin
What is Hepcidin? Peptide release from the liver that inhibits roni channel on enterocytes and reticuloendothelial cells
What occurs to iron levels and availability in Anemia of chronic disease? Reduces iron availability for erythropoiesis, which leads to normocytic anemia with a poor reticulocyte response
Does Anemia of Chronic disease present with a poor or good reticulocyte response? Poor reticulocyte response
High levels of Hepcidin and poor reticulocyte response, due to reduced erythropoiesis and normocyte anemia. Dx? Anemia of Chronic Disease
What causes the development of Pulmonary Arterial Hypertension? Endothelial dysfunction that leads to increased in vasoconstrictive, pro-proliferative mediators, and a decrease in vasodilative and anti-proliferative mediators in the pulmonary vasculature
What are the vasoconstrictive and pro-proliferative mediators increased in PAH? Endothelin and Thromboxane-2
An increase in Endothelin and TXA2 is often seen in what pulmonary condition? Pulmonary Arterial Hypertension
What are the vasodilative and anti-proliferative endothelial mediators associated with PAH? Nitric oxide (NO) and Prostacyclin
What does the imbalance between vasodilation and vasoconstrictive mediators in PAH causes? Intimal wall-thickening with consequent increasing pulmonary vascular resistance
What are key findings in physical examination and auscultation of Pulmonary Arterial Hypertension? - Young patient with progressive dyspnea and fatigue - Loud pulmonic component of S2
Which condition is seen with a Loud component of S2? Pulmonary Arterial Hypertension
What is Narcolepsy? Chronic sleep disorders characterized by excessive daytime sleepiness, cataplexy, and REM sleep-related phenomena (hallucinations and sleep paralysis)
What sleep disorder is often associated with hallucinations? Narcolepsy
What sleep disorder is often seen with moments of cataplexy and auditory hallucinations before sleep and right after waking up? Narcolepsy
What causes Insulin resistance? Phosphorylation of Serine and Threonine residues of insulin receptor and insulin receptor substrate by Serine kinase
What enzyme phosphorylates Serine and Threonine residues of Insulin receptors? Serine Kinase
What important metabolic process is associated with Serine kinase? Insulin resistance by phosphorylating Serine and Threonine residues of insulin receptors
What are substances that precipitate the phosphorylation of Serine and Threonine of insulin receptors by Serine kinase? TNF-alpha, catecholamines, glucocorticoids, and glucagon
What is a result of Transudative effusions not caused by inflammatory processes? Result in low nucleated cell counts and normal (or high) glucose level
If serum protein or LDH level are higher ahn the pleural fluid levels of protein or LDH, it is what type of pleural effusion? Transudative effusion
What are the causes of Diabetic Mellitus type 2? Insulin resistance and relative insulin deficiency
What is an important contributory factor to insulin resistance in DM type 2? Chronic elevated free fatty acids levels, by impairing insulin-dependent glucose uptake and increasing hepatic gluconeogenesis
What is Serum Sickness? Type 3 hypersensitivity reaction to non-human proteins characterized by vasculitis result from tissue deposition of circulating immune complexes
What are clinical manifestations of Serum Sickness? Fever, pruritic skin rash, arthralgias, and low serum C3 and C4 complement levels
What type 3 hypersensitivity reaction is seen with low leves of C3 and C4 complement levels? Serum Sickness
What is common name of Myopia? Nearsightedness
What is myopia? Refractive error in which the focal point of an image fall anterior to the retina due to increased anterior-posterior diameter of the eyes
Patient has difficulty seeing objects in a long distance, but normal vision on nearby objects. Dx? Myopia
In recording visual acuity, the as the bottom number increases, it means: Worst visual acuity
Which protays better visual acuity 20/90 or 20/10? 20/10
What are clinical manifestations of Diabetic diarrhea? 1. Painless, watery diarrhea 2. Secretory-like diarrhea (persist at night and while fasting) 3. Labs usually unremarkable
What is the pathogenesis of Diabetic diarrhea? Prolonged hyperglycemia in diabetic mellitus injure PNS and SNS, resulting in Diabetic Autonomic neuropathy
What is the result of Diabetic autonomic neuropathy in relation to persistent diarrhea? Disordered small-bowel and colonic motility and increased intestinal secretion, resulting in secretory-like diarrhea (fasting bowel movements)
What is a key and uncomfortable characteristic of diabetic diarrhea? Secretory-like, and it persists during the night and at times of fasting.
What kind of murmur is seen with Aortic Regurgitation (AR)? Decrescendo Diastolic murmur
When does in the cardiac cycle does AR has its maximal intensity? Immediately after closure of the Aortic valve, when the pressure gradient between aorta and left ventricle
What are characteristics in the Pressure tracing of Aortic Regurgitation (AR)? 1. Loss of the Aortic Dicrotic notch 2. Steep diastolic decline in Aortic pressure 3. High-peaking systolic pressures
What valvular disease is seen with a decrescendo diastolic murmur? Aortic Regurgitation
Pressure tracing shows a loss or absence Aortic dicrotic notch? Aortic Regurgitation
What forces or resistances determine the Left Ventricular afterload? 1. Forward flow (aortic pressure) and, 2. Regurgitant flow (Left Atrial pressure)
What is the result of a reduce SVR in Cardiac Output? Increase the ratio of forward to regurgitant flow and improves cardiac output
A decrease in SVR causes an eventual increase or decrease of cardiac output? Increase
Why does a decrease in SVR causes an increase of CO? Decrease of pressure pushing back into the heart LV, leads to an optimal increased cardiac output
Which sided heart failure promotes the development of Ascites? Right-sided heart failure
What causes the formation of Ascites in Right-side Heart Failure? Increase Central Venous Pressure (CVP), which is transmitted to the hepatic sinusoids, leading to increased capillary hydrostatic pressure
How is the Oncotic capillary pressure altered in early right-sided heart failure? Normal, at least for a few weeks
What causes Stable Angina? Results from fixed Coronary artery stenosis that limits blood flow to downstream myocardium, preventing myocardial oxygen supply for increasing during exertion
What is the use of Dobutamine? Mimics the effects of exercise and increases myocardial oxygen demand
What medication is used to mimic the effects of exercise and increase myocardial oxygen demand? Dobutamine
Why is Dobutamine used in stable angina? As it provoke areas of ischemic myocardium which can then be visualised by localized and transient decrease in contractility and reduced ejection fraction
A test that causes transient decrease in cardiac contractility, and often used in Stable angina? Dobutamine stress test
What virus is strongly associated with Anal Squamous Cell carcinoma? Human Papilloma Virus (HPV)
How is Anal Squamous cell carcinoma clinically presented? Rectal bleeding, pruritus, and/or pain
What is the gross examination of HPV-induced anal squamous cell carcinoma? Ulcerated or nodular, exophytic anal lesion
What is the histology description of HPV anal squamous cell carcinoma? Large, eosinophilic, hyperchromatic squamous cells arranged in islands with nuclear atypia and prominent keratinization
What is the possible diagnosis in new-onset odynophagia in the setting of chronic GERD? Erosive Esophagitis
List of clinical manifestations of GERD: 1. Regurgitation of acidic material in mouth 2. Heartburn 3. Odynophagia (erosive esophagitis) 4. Extraesophageal symptoms (cough, laryngitis, wheezing)
What causes Osmotic Demyelination Syndrome? Results from overly rapid correction of chronic hyponatremia
The excessively fast correction of chronic hyponatremia causes: Osmotic Demyelination Syndrome
What is the main finding of Osmotic Demyelination syndrome in a MRI? Focal demyelination of the Pons
What are the clinical manifestations of Osmotic Demyelination syndrome? Quadriplegia, Pseudobulbar palsy, and reduced level of consciousness
What are actions or events the occur during REM sleep? Dreaming, voluntary muscle paralysis, and nightmares
Which part of sleep is associated with nightmares? REM sleep
On which part of night is REM sleep associated? Final third (1/3) of the night
What part of sleep is seen in the last third of the night? REM sleep
Dreaming and Voluntary muscle paralysis is seen during which sleep phase? REM sleep
What is the difference in memory between a nightmare and a night terror? A night terror is a non-REM parasomnia, and the person does not have any recollection of the dream, while a nightmare is a REM-phenomena with some recollection of the dream
Night terror or Nightmare if the person does not remember the dream? Night terror
Nigthmare. REM or Non-REM sleep? REM sleep
Night terror or nightmare, if patient has recollection of the bad dream? Nightmare
What is the typical or classic symptomt triad associated with Salicylate intoxication? Fever, Tinnitus, and Tachypnea
What blood gas imbalance is seen first in Aspirin toxicity? Respiratory alkalosis
What is the late blood gas imbalance of salicylate toxicity? Anion gap Metabolic acidosis
What condition often results in a mixed acid-base disturbance with possible blood pH within normal range? Salicylate intoxication
PaCO2 and HCO3- are low or high in Mixed Acid-base imbalance due to aspirin intoxication? Low
What common AR respiratory condition is seen with developing Spontaneous pneumothorax? Cystic fibrosis
Spontaneous pneumothorax is common in Cystic fibrosis due: Involvement of alveolar rupture, leading to a loss of intrapleural negative pressure
How is Spontaneous pneumothorax clinically presented? Sudden-onset of shortness of breath, unilateral decreased breath sounds, and sometimes subcutaneous crepitus
If the pneumothorax is associated with hypotension and tachypnea, it is probably what type of pneumothorax? Tension pneumothorax
What are the two main renal changes due to Renal Artery Stenosis? 1. Decreased GFR 2. Activation of RAAS system
What cells increase release of Renin? Juxtaglomerular cells in the walls of the AFFERENT glomerular arterioles
What is the result of chronic renal hypoperfusion? Hyperplasia of the Juxtaglomerular apparatus
What can you suspect in hyperplasia of juxtaglomerular apparatus? Chronic renal hypoperfusion in RAS
What is the effect on the adrenal gland due to long-term use of supraphysiologic doses of glucocorticoids? Bilateral Adrenocortical atrophy involving the Z. Fasciculata and Z. Reticularis
What areas of the adrenal gland are atrophied in long-term use of high doses of corticosteroids? Z. Fasciculata and Z. Reticularis
What is the resulting condition of sudden cessation of the Exogenous corticosteroids? Adrenal crisis
What is a common cause of Adrenal crisis? Sudden cessation of exogenous corticosteroids
What is Preeclampsia? New-onset hypertension with proteinuria and/or signs of end-organ damage
What is an important association of Preeclampsia? Widespread maternal endothelial dysfunction, which occurs due to increased antiangiogenic factor release and decreased proangiogenic factor activity (VEFG) and placental growth factor.
What is the most common Proangiogenic factor associated with Preeclampsia? VEGF and placental growth factor
What is the result of widespread maternal endothelial dysfunction in Preeclampsia? 1. Increased anti-angiogenic factor release 2. Decreased Pro-angiogenic factor activity
What is Abruptio placentae? Detachment of the placenta for the uterus prior to fetal delivery, presents with painful vaginal bleeding
How is presented Abruptio placentae clinically? Painful vaginal bleeding; tender, firm uterus; heart rate abnormalities, and high-frequency contractions.
What are common risk factors of Abruptio placentae? Abdominal trauma, maternal hypertension, and tobacco or cocaine use
How are cataracts of characterized clinically? Progressive opacification of the lens, with chronic loss of visual acuity
Progressive opacification of the lens with chronic loss of visual acuity? Cataracts
What are two common conditions leading to cataract formation? Aging and exposure to UV light
How does UV light and normal aging induced cataract formation? Induce nuclear sclerosis, photooxidative damage to lens crystallins, and osmotic injury
What nuclear factor interaction is essential formation and differentiation of Osteoclasts? kappa B (RANK)/ RANK-Ligand (RANK-L)
RANK-L ---RANK interaction is associated with what type of cell differentiation and formation? Osteoclasts
What is commonly used to block RANK-L binding to RANK? Osteoprotegerin (OPG)
What monoclonal antibody works very similar to OPG? Denosumab
What is Denosumab? Monoclonal antibody used in treatment of postmenopausal osteoporosis
What is the result of decreased formation of Osteoclasts? Decreased bone resorption
What failed nuclear interaction leads to a decreased bone resorption? Blocking binding of RANK-L to RANK
What is creatine kinase? Enzyme, that leaks across the damaged cell membrane and into circulation, as heart, brain, and skeletal muscle are injured
What is the cause of Reperfusion injury? Secondary to oxygen free radical generation, mitochondrial damage, inflammation, and activation of the complement pathway
What enzyme is secreted by reperfusion injury in heart, brain, and skeletal muscle? Creatine kinase
What AR condition is associated with accumulation of thick, viscous secretions in ducts throughout the body? Cystic fibrosis
What causes CF-related diabetes? Progressive description of Pancreatic islet cells leads to decreased insulin production
What is a consequence of destruction of pancreatic islet cells in caused in Cystic fibrosis? CF-related diabetes
Created by: rakomi
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