NBME 11

BLOCK 1 1.FF since TB is a reportable disease

10/24/2011 5:38:00 PM

2.CC When blood sugar is low, glucagon signals the adipocytes to activate hormone-sensitive lipase, and to convert triglycerides into free fatty acids 3.EE Ninety percent of patients with gout develop excess urate stores due to an inability to excrete sufficient amounts of normally produced uric acid in the urine (underexcretion). The remaining patients either overconsume purines or produce excessive amounts of uric acid endogenously (overproduction). In rare cases, overproduction of uric acid is primary, due to a genetic disorder. These disorders include hypoxanthine-guanine phosphoribosyltransferase deficiency (Lesch-Nyhan syndrome), glucose-6phosphatase deficiency (von Gierke disease), fructose 1-phosphate aldolase deficiency, and PP-ribose-P synthetase variants. Overproduction of uric acid may also occur in disorders that cause high cell turnover with release of purines, such as meat intake and seafood intake. These disorders include myeloproliferative and lymphoproliferative disorders, psoriasis, chemotherapy (tissue lysis), hemolytic anemias, pernicious anemia, ineffective erythropoiesis (as in B-12 deficiency), excessive exercise, and obesity. Overproduction of uric acid can occur from overconsumption of foods high in purines. Common causes of secondary gout due to underexcretion of uric acid include renal insufficiency, lead nephropathy (saturnine gout), starvation or dehydration, hypothyroidism, hyperparathyroidism, drugs (including loop and thiazide diuretics and cyclosporine A), low-dose aspirin, and chronic ethanol (especially beer and hard liquor) abuse. These disorders should be identified and corrected, if possible.

Comorbidities, including hypertension, diabetes, renal insufficiency, hypertriglyceridemia, hypercholesterolemia, diabetes, obesity, and early menopause, are associated with a higher incidence of gout. Consumption of fructose-rich foods and beverages are associated with an increased risk of gout in both men and women Because of no clinical symptoms or history we should think about risk factors that can cause Gout... ....gender...Men more than women .......................age.....elderly more than younger 4.CC Gardenella vaginalis....gram variable rod...cause vaginosis white/gray vaginal discharge Whiff test...add KOH...fishy smell non painful anaerobe overgrowth of bacteria in vagina Clue cells or vaginal epithelial cell covered with bacteria treatment....Metronidazole 5.AA Check 1904 Q in UW 6.CC Lovastatin....-statins HMG-CoA reductase inhibitors...dec.LDL.. Bad cholestrol...mild effect on HDL and triglycerides...inc. mechanism of action.... 1.inhibit cholesterol precursor , mevalonate 2.synthesizing LDL receptors

7.CC

2-Naphthylamine is an aromatic amine. It is used to make azo dyes. It is a known human carcinogen. Aniline dyes...aromatic amines 2-Naphthylamine is found in cigarette smoke and suspected to contribute to the development of transitional cell carcinoma of urinary tract system (It is activated in the liver but quickly deactivated by conjugation to glucuronic acid. In the bladder, glucuronidase re-activates it by deconjugation, which leads to the development of bladder cancer.) 8.DD Presentation Pin-point pupils, severe respiratory depression/cyanosis and coma. BP may be low but is often surprisingly well maintained and with pentazocine overdose actually increases.

Although some opiates, e.g. dextropropoxyphene and pethidine, increase muscle tone and cause fits, in general opiates cause marked hypotonia. 9.CC

Mesothelioma....It is usually caused by exposure to asbestos. Asbestosis...Ferruginous bodies...Asbestos bodies with prussian blue iron stain in the lung.

10.DD plasmid transfer between bacterias needs cell to cell contact through conjugation. And E coli is notorious for that. Bacterial transformation may be referred to as a stable genetic change brought about by the uptake of naked DNA (DNA without associated cells or proteins) and competence refers to the state of being able to take up exogenous DNA from the environment. Two forms of competence exist: natural and artificial. 11.CC

Candida albicans....oral and esophageal thrush in immunocompromised...neonates,steroides,diabetes,AIDS and Vulvaginitis.....high PH diabetes,use of antibiotics Diaper rash and endocarditis in IV drug users, disseminated candidiasis to

any organ,chronic mucocutaneous candidiasis Treatment....Nystatin for superficial infection( swish and swallow) Amphtericin B..for serious systemic infection 12.CC The palmar branch of the median nerve is a branch which arises at the lower part of the forearm. It pierces the palmar carpal ligament, and divides into a lateral and a medial branch; The lateral branch supplies the skin over the ball of the thumb, and communicates with the volar branch of the lateral antibrachial cutaneous nerve. The medial branch supplies the skin of the palm and communicates with the palmar cutaneous branch of the ulnar. Unlike most of the median nerve innervation of the hand, the palmar branch travels superficial to the Flexor retinaculum of the hand. Therefore, this portion of the median nerve usually remains functioning during carpal tunnel syndrome.

13.CC 2,3-Bisphosphoglycerate: It binds with greater affinity to deoxygenated hemoglobin (e.g. when the red cell is near respiring tissue) than it does to oxygenated hemoglobin 14.AA Acute coronary syndrome (ACS) is usually one of three diseases involving the coronary arteries: ST elevation myocardial infarction (30%), non ST elevation myocardial infarction (25%), or unstable angina (38%) The cardinal sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with diabetes). Some may report palpitations, anxiety or a sense of impending doom and a feeling of being acutely ill. 15.AA Albuterol....Beta2 agonist...relaxes bronchial smooth muscle ....used during acute exacerbation ...............................................Gs........................................................ .............. Beta1,Beta2,D1,H2,V2 receptors..........Adenyl cyclase.....ATP..> inc.cAMP.....>inc.Protein Kinase A 16 AA 17 CC CMV has a unique method of escaping immune response it dec. the expression of MHC 1 and also expresses a decoy molecule. The normal for the MHC 1 molecule is that its made in the RER and then transported to the Cell membrane. If it get translocated to the cytosol, its likely to be degraded.

Ref Kaplan Immuno Chap 8[pg 99] viral strategies for evasion of the CMI response 18.GG

Pupillary reflex: The oculomotor nerve also controls the constriction of the pupils and thickening of the lens of the eye. This can be tested in two main ways. By moving a finger toward a person's face to induce accommodation, as well as his going cross-eyed, his pupils should constrict. Shining a light into one eye should result in equal constriction of the other eye. The neurons in the optic nerve decussate in the optic chiasm with some crossing to the contralateral optic nerve tract. This is the basis of the "swinging-flashlight test".

19 DD 20.CC

Kernicterus is damage to the brain centers of infants caused by increased levels of unconjugated bilirubin 21.BB http://www.helpguide.org/elder/lewy_body_disease.htm http://www.alz.org/alzheimers_disease_dementia_with_lewy_bodies.asp Lewy bodies are abnormal aggregates of protein that develop inside nerve cells in Parkinson's disease (PD) and Alzheimer's disease (AD) and some other disorders. They are identified under the microscope when histology is performed on the brain. Parkinson's disease....degenerative disorder of CNS associated with lewy bodies and depigmentation of the substantia nigra,loss of dopaminergic

neurons rare cases have been linked with ilicit street drug...heroin 22.EE Hypothyroidism is a condition leading to the deficiency in the production of thyroid hormone. Subclinical hypothyroidism is a state of normal thyroid hormone levels, thyroxine (T4) and triiodothyronine (T3), with mild elevation of thyrotropin, thyroid-stimulating hormone (TSH). With higher TSH levels and low free T4 levels, symptoms become more readily apparent in clinical (or overt) hypothyroidism. Early.... Poor muscle tone (muscle hypotonia) Fatigue Any form of menstrual irregularity and fertility problems Hyperprolactinemia and galactorrhea Elevated serum cholesterol Cold intolerance, increased sensitivity to cold Constipation Rapid thoughts Depression Muscle cramps and joint pain Thin, brittle fingernails Coarse hair Paleness Decreased sweating Dry, itchy skin Weight gain and water retention Bradycardia Late......

Goiter Slow speech and a hoarse, breaking voice deepening of the voice can also be noticed, ma. Dry puffy skin, especially on the face Thinning of the outer third of the eyebrows Abnormal menstrual cycles Low basal body temperature Thyroid-Related Depression Uncommon......... Impaired memory Impaired cognitive function (brain fog) and inattentiveness. A slow heart rate with ECG changes including low voltage signals. Diminished cardiac output and decreased contractility Reactive (or post-prandial) hypoglycemia Sluggish reflexes Hair loss Anemia caused by impaired haemoglobin synthesis (decreased EPO levels), impaired intestinal iron and folate absorption or B12 deficiency Difficulty swallowing Shortness of breath with a shallow and slow respiratory pattern Increased need for sleep Irritability and mood instability Yellowing of the skin due to impaired conversion of beta-carotene to vitamin A Impaired renal function with decreased glomerular filtration rate Acute psychosis (myxedema madness) (a rare presentation of hypothyroidism) Decreased libido in men due to impairment of testicular testosterone synthesis Decreased sense of taste and smell (anosmia) Puffy face, hands and feet (late, less common symptoms) Gynecomastia Deafness

23.DD The palmaris longus is seen as a small tendon between the flexor carpi radialis and the flexor carpi ulnaris, although it is not always present. The muscle is absent in about 14 percent of the population Absence of palmaris does not have any known effect on grip strength 24.AA Pertusis toxin inhibits Gi, so causes increase in cAMP -Lymphocytosis promotion -Hypoglycemia due to release of insulin. Pertusis Toxin interferes with the early chemokine production and the inhibition of the neutrophil chemotaxis. Chemokines are signaling molecules produced by infected cells and attract neutrophils and macrophages. 25.EE Barrier dysfunction is present in patients with Crohn's disease as well as some of their healthy first degree relatives. It has therefore been suggested that increased tight junction permeability (reduced barrier function) is a risk factor for development of Crohn's disease. 26.AA Narrowing renal artery inc. Renin-Angiotensin-Aldosteron system....... 27.DD irreversible cell injury Plasma membrane damage lysosomal rupture Calcium ion influx....oxidative phosphorylation, nuclear pycnosis,karyolysis, Mitochondrial pemeability....vacualization and phospholipid-containing amorphous density 28.BB The addictive potential of codeine encouraged the marketing of dextromethorphan in a variety of cough and cold preparations. Although dextromethorphan is chemically derived from the opiates, it has no analgesic

or addictive properties. The cough suppression potency of dextromethorphan in adults is nearly equal to that of codeine.2 The drug, like codeine, acts on the central nervous system to elevate the threshold for coughing. 29.EE Bone marrow transplant has been shown to induce tolerance following organ transplant. 30.AA The patient is too tall and thin with scoliosis.....Marfan's....cystic medial necrosis Aortic dissection..present with tearing chest pain radiating to the back.... CXR.. mediastinal widening 31.DD adult cell type is replaced by another...often secondary to irritation/or environmental exposure Barrett's esophagous....Glandular metaplasia...replacement of non keratinized squamous epithelium with intestinal/columnar epithelium in the distal esophagous due to chronic acid reflux. .GERD

32. E Brain Lymphoma (PCNSL), also known as micro glioma and primary brain lymphoma, is a primary intracranial tumor appearing mostly in patients with severe immunosuppression (typically patients with AIDS). PCNSLs represent around 20% of all cases of lymphomas in HIV infections (other types are Burkitt's lymphomas and immunoblastic lymphomas). is highly associated with Epstein-Barr virus (EBV) infection (> 90%) in immunodeficient patients (such as those with AIDS and those iatrogenically immunosuppressed), and does not have a predilection for any particular age group.

usually presents with seizure, headache, cranial nerve findings, altered mental status, or other focal neurological deficits typical of a mass effect Systemic symptoms may include fever, night sweats, or weight loss. Other symptoms include diplopia dysphagia vertigo monocular vision loss progressive dementia or stupor in patients with a non focal neurologic exam and minimal abnormalities on MRI (more common in AIDS patients) facial hypoesthesia The definitive diagnosis is arrived at from tissue, i.e. a biopsy, by a pathologist. MRI or contrast enhanced CT classically shows multiple ring-enhancing lesions in the deep white matter. The major differential diagnosis (based on imaging) is cerebral toxoplasmosis, which is also prevalent in AIDS patients and also presents with a ring-enhanced lesion, although toxoplasmosis generally presents with more lesions and the contrast enhancement is typically more pronounced. imaging techniques cannot distinguish the two conditions with certainty, and cannot exclude other diagnoses. Thus, patients undergo a brain biopsy 33. C The patients treated with the new drug the duration of the outbreak was 1 week, instead that the duration of the patients treated with the placebo was 2 week. It mean that the prevalence in the group treated with the new drug by half.

34. D

Hemorrhoids -- vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their physiological state they act as a cushion composed of arteriovenous channels and connective tissue that aid the passage of stool. The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids present with pain in the area of the anus. Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration, NSAID analgesics, sitz baths, and rest. Surgery is reserved for those who fail to improve following these measures. 35. B Metoclopramide -- antiemetic and gastroprokinetic agent. Thus it is primarily used to treat nausea and vomiting, and to facilitate gastric emptying in patients with gastroparesis.

It is also a primary treatment for migraine headaches. 36. E NNRTI: Nevirapine, Efavirenz, Delavirdine: Mechanism of action: Preferentially inhibit reverse transcriptase of HIV, prevent incorporation of DNA copy of viral genome into the host DNA. ( FA 2010 page 195) 37. C Congenital hearing loss --hearing loss present at birth. Can be hereditary or due to other factors present either in utero (prenatal) or at the time of birth. Treatment: A child with a congenital hearing loss should begin receiving treatment before 6 months of age. Studies suggest that children treated this early are usually able to develop communication skills (using spoken or sign language) that are as good as those of hearing peers. In the United States of America, because of a Federal law (the Individuals with Disabilities Education Act), children with a hearing loss between birth and 3 years of age have the right to receive interdisciplinary assessment and early intervention services at little or no cost. After age 3, early intervention and special education programs are provided through the public school system. 38. B Acidosis Respiratory: PO2, PH , CO2 39. A The formation of granulation tissue in an open wound allows the re epithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment.Basal keratinocytes from the wound edges and dermal appendages such as hair follicles, sweat glands and sebacious (oil) glands are the main cells responsible for the epithelialization phase of wound healing.

They advance in a sheet across the wound site and proliferate at its edges, ceasing movement when they meet in the middle. Keratinocytes migrate without first proliferating.Migration can begin as early as a few hours after wounding. However, epithelial cells require viable tissue to migrate across, so if the wound is deep it must first be filled with granulation tissue.Thus the time of onset of migration is variable and may occur about one day after wounding.Cells on the wound margins proliferate on the second and third day post-wounding in order to provide more cells for migration. 40. D Ropinirole -- non-ergoline dopamine agonist. -- acts as a D2, D3, and D4 dopamine receptor agonist with highest affinity for D3. It is weakly active at the 5-HT2, and 2 receptors and is said to have virtually no affinity for the 5-HT1, benzodiazepine, GABA, muscarinic, 1, and -adrenoreceptors. Ropinirole is metabolized primarily by cytochrome P450 CYP1A2, and at doses higher than clinical, is also metabolized by CYP3A4. At doses greater than 24 mg, CYP2D6 may be inhibited, although this has only been tested in vitro. 41. B

The uterine artery usually arises from the anterior division of the internal iliac artery Uterine artery embolization (UAE) is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. If the procedure is done for the treatment of uterine fibroids it is also called uterine fibroid embolization (UFE). Under local anesthesia a catheter is introduced into the femoral artery at the groin and advanced under radiographic control into the uterine arterty. 42 EE CMI is an immune response that does not involve antibodies or complement but rather involves the activation of macrophages, natural killer cells (NK), antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen. immune system separated into two branches: humoral immunity, for which the protective function of immunization could be found in the humor (cellfree bodily fluid or serum) and cellular immunity, for which the protective function of immunization was associated with cells. CD4 cells or helper T cells provide protection against different pathogens. T cells cause death by apoptosis without using cytokines, therefore in cell mediated immunity cytokines are not always present. Cellular immunity protects the body by: 1. activating antigen-specific cytotoxic T-lymphocytes that are able to induce apoptosis in body cells displaying epitopes of foreign antigen on their surface, such as virus-infected cells, cells with intracellular bacteria, and cancer cells displaying tumor antigens;

2. activating macrophages and natural killer cells, enabling them to destroy pathogens; and 3. stimulating cells to secrete a variety of cytokines that influence the function of other cells involved in adaptive immune responses and innate immune responses. 43. C Schizophrenia: Periods of psychosis and disturbed behavior with a decline in functioning lasting > 6 months. Associated with dopaminergic activity, dendritic branching. Marijuana use is a risk factor for schizophrenia in teens. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. 44. A Glibenclamide (INN), also known as glyburide (USAN), antidiabetic sulfonylureas, closely related to sulfa drugs. Mechanism of action: works by inhibiting ATP-sensitive potassium channels in pancreatic beta cells.--inhibition causes cell membrane depolarization, -voltage-dependent calcium channels to open, -- an increase in intracellular calcium in the beta cell, which stimulates insulin release. 45. A Plasmodium vivax -- protozoal parasite ,a human pathogen. The most frequent and widely distributed cause of recurring (tertian) malaria one of the four species of malarial parasite that commonly infect humans. less virulent than Plasmodium falciparum, which is the deadliest of the four, and is seldom fatal. carried by the female Anopheles mosquito, Chloroquine remains the treatment of choice for vivax malaria 32 to 100% of patients will relapse following successful treatment of P. vivax infection if a radical cure (eradication of liver stages) is not given Eradication of the liver stages is achieved by giving primaquine, after checking the patients G6PD status to reduce the risk of haemolysis. However, in severe G6PD deficiency, primaquine is contraindicated and should not be used

46.EE vincristine.....M-phase specific alkaloides that bind to tubulin and block polymerization of microtubules...so that mitotic spindle can not form s/e...neurotoxicity....areflexia, peripheral neurities paralytic ileus Cyclophosphamide....alkylating agent..covalantly x-link DNA at guanine N-7, require bio activation by liver s/e...myelosuppression,hemorrhagic cystitis..can be prevented by mesna Doxorubicin: .....generate free radicals and noncovalantly intercalate in DNA s/e...Cardiotoxicity,myelosuppression and marked alopesia,toxic extravasation Rituximab: General side effects have included fever (49%), chills (32%), asthenia (16%), headache (14%), and abdominal pain (6%). 47.CC Perfusion pressure....the gradient between arterial blood pressure and venous pressure in a comparable location in the vascular tree....in this case the perfusion pressure is the pressure gradient between renal artery and renal vein...... relationship between flow(Q) ,Resistance(R),and Perfusion pressure(P1P2).... According to Poiseuille Equation P1-P2(Perfusion pressure)= R multiplied by Q..... P1= Renal artery pressure P2=Renal Vein pressure This patient has Hypotension Secondary to Severe Dehydration ....this

causes the activation of the Sympathetic Nervous System ....and the RAA system ....both work independently even if the end result is the same ..... Sympathetic Nervous System causes Vasoconstriction of arteriolar beds including the renal arterioles ..... the sympathetic nervous system increases the resistance and decreases the flow (Q)....Therby decreasing perfusion pressure ( the difference between arterial presuure and venous pressure).... The RAA system ....AT II is a potent vasoconstrictor throughout the body ....including the afferent and efferent arterioles .....even if more on efferent ......When there is vasoconstriction of the afferent arterioles there will be a decrease in flow (Q)....which further decreases the perfusion pressure according to Poiseuille equation .... 48.AA immunologically compromised, esp those with HIV and low CD4 T cell counts, frequently show negative results from the PPD test. This is because the immune system needs to be functional to mount a response to the protein derivative injected under the skin. With the change from 10mm to 5 mm....there are more people can be identified with positive tuberculin test.... so incidence and prevalance will be higher The results of this test must be interpreted carefully. The person's medical risk factors determine at which increment (5 mm, 10 mm, or 15 mm) of induration the result is considered positive. A positive result indicates TB exposure. 5 mm or more is positive in HIV-positive person Recent contacts of TB case Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB Patients with organ transplants and other immunosuppressed patients

10 mm or more is positive in Recent arrivals (less than 5 years) from high-prevalence countries Injection drug users Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.) Mycobacteriology lab personnel Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.) Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories 49.CC The child has less opportunity to use her/his gross muscle for movement and development....so delayed gross motor development could be occurred 50.AA Hb electrophoresis---measures the different types of the oxygen-carrying protein (hemoglobin) in the blood. Many different types of hemoglobin (Hb) exist. The most common ones are HbA, HbA2, HbF, HbS, HbC, Hb H, and Hb M. Healthy adults only have significant levels of HbA and HbA2. Some people may also have small amounts of HbF (which is the main type of hemoglobin in an unborn baby's body). Certain diseases are associated with high HbF levels (when HbF is more than 2% of the total hemoglobin). HbS is an abnormal form of hemoglobin associated with sickle cell anemia. In people with this condition, the red blood cells sometimes have a crescent or sickle shape. The cells easily break down, or can block small blood vessels. HbC is an abnormal form of hemoglobin associated with hemolytic anemia. The symptoms are much milder than they are in sickle cell anemia.

Other, less common, abnormal Hb molecules cause anemias.

Normal Results In adults, these hemoglobin molecules make up the following percentages of total hemoglobin: Hb A: 95% to 98% Hb A2: 2% to 3% Hb F: 0.8% to 2% Hb S: 0% Hb C: 0% In infants and children, these hemoglobin molecules make up the following percentages of total hemoglobin: Hb F (newborn): 50% to 80% Hb F (6 months): 8% Hb F (over 6 months): 1% to 2% The presence of significant levels of abnormal hemoglobins may indicate: Hemoglobin C disease Rare hemoglobinopathy Sickle cell anemia Thalassemia BLOCK 2 1.CC Aspirin accetylates and irreversibaly inhibits cyclooxygenase..both coc1 and cox2 to prevent the conversion of arachidonic acid to thromoxane A2....inc. bleeding time ,no effect on PT and PTT.

2.FF Levofloxacin is a broad-spectrum antibiotic that is active against both Grampositive and Gram-negative bacteria. It functions by inhibiting DNA gyrase, a type II topoisomerase, and topoisomerase iv which is an enzyme necessary to separate replicated DNA, thereby inhibiting cell division. 3.AA The deltoid is innervated by the axillary nerve. The axillary nerve originates from the ventral rami of the C5 and C6 cervical nerves, via the superior trunk, posterior division of the superior trunk, and the posterior cord of the brachial plexus.

Axillary nerve lesion ***Sensory supply over deltoid ***Sensory loss small area over deltoid ***Area of pain across shoulder tip ***Motor deficit second 90 of shoulder abduction (deltoid) (teres minor cannot be evaluated) ***Causative lesions # neck of humerus, dislocated shoulder deep IM injection 4.BB Statistical significance= Is determined by P value.....and as see the p value is less than .05....hence for sure there is a difference between the two interventions (NOT BY CHANCE ALONE).....If the P Value is greater than .05 u can SAY the difference in the two interventions is due to CHANCE ALONE

.....So A is out -Practical Importance means CLINICAL SIGNIFICANCE not Statistical....and clinical significance MUST ANSWER THE QUESTION ...how effective is the intervention or treatment in the CLINICAL SETTING....And the doctor made the CALL in this case not the researcher....And the way u measure CLINICAL SIGNIFICANCE IS by some of the following methods...EFFECT SIZE ,Number Needed to treat,and Preventive fraction.....

-Already in the question u stated the magnitude of the difference was so small....How do they know ? They calculated NNT.... as u know NNT= 1/49%-45 %=1/4%=25.....Taking Program A as a control (as u know control groups can get placebo or as in this case STANDARD CARE).... -This means if the health official decided to change Program B as a STANDARD of CARE .....to treat HYPERCHOLSTEROLEMIA in 1 patient 25 should be INVOLVED ..... ---NNT=25 is not clinical significant.....hence choice B......

about the other choices....

Choice D....once you find the difference is STATISTICALLY SIGNIFICANT ...the sample size should be assumed LARGE and Enough...Only question sample size if the STUDY is not STATISTICALLY SIGNIFICANT....i.e When Calculated P Value is greater than .05..... Choice C....Many times the investigator will report the lowest COMPUTED P Value ....In general the smaller the p the BETTER...... And I remember a question on NBME 7 where the computed P value was

greater than .05.....and the answer was ....Due to chance alone....but the scenario was almost the same as this question..... 5.BB HSV-1 is the more common cause of adult encephalitis. HSV-2 is the more common cause of newborn encephalitis. The encephalitis affects the temporal lobes of the brain in most cases 6.BB Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms,[4] and the later symptoms are usually nonspecific and varied.[4] Therefore, pancreatic cancer is often not diagnosed until it is advanced. Painless jaundice (yellow tint to whites of eyes and/or yellowish skin in serious cases, possibly in combination with darkened urine) when a cancer of the head of the pancreas (about 60% of cases) obstructs the common bile duct as it runs through the pancreas. This may also cause pale-colored stool and steatorrhea. The jaundice may be associated with itching as the salt from excess bile can cause skin irritation. 7-D Secretin is a hormone that controls the secretions into the duodenum, and also separately, water homeostasis throughout the body. It is produced in the S cells of the duodenum in the crypts of Lieberkhn.[1] Its effect is to regulate the pH of the duodenal contents via the control of gastric acid secretion and buffering with bicarbonate from the centroacinar cells of the pancreas as well as intercalated ducts. It is notable for being the first hormone to be identified. In humans, the secretin peptide is encoded by the SCT 8-E Opioids withdrawal produce, anxiety, insomnia, anorexia, sweating dilated pupils, piloerection (cold turkey), fever, rhinorrhea, nausea, stomach cramps, diarrhea (flulike symtoms) and yawning

9-D Raynaud's phenomenon is an exaggeration of vasomotor responses to cold or emotional stress. More specifically, it is a hyperactivation of the sympathetic system causing extreme vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia Nefedipine vasodilate by releasing nitric oxide in smooth muscle, causing increased in cGMP and smooth muscle relaxation,. dilate veins more than arteries and dicreased the preload 10.C An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood. In the case of blood: it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells. Transudate Exudate Main causes Increased hydrostatic pressure, Decreased colloid osmotic pressure Inflammation Appearance Clear Cloudy Specific gravity < 1.012 > 1.020 Protein content < 2 g/dL > 2.9 g/dL fluid protein serum protein < 0.5 > 0.5 Difference of albumin content with blood albumin > 1.2 g/dL < 1.2 g/dL fluid LDH upper limit for serum < 0.6 or < > 0.6[5] or > Cholesterol content < 45 mg/dL > 45 mg/dL[5 Exudate...An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells

protein rich....specific gravity >1020 ***Types*** Purulent or suppurative exudate consists of plasma with both active and dead neutrophils, fibrinogen, and necrotic parenchymal cells. This kind of exudate is consistent with more severe infections, and is commonly referred to as pus. Fibrinous exudate is composed mainly of fibrinogen and fibrin. It is characteristic of rheumatic carditis, but is seen in all severe injuries such as strep throat and bacterial pneumonia. Fibrinous inflammation is often difficult to resolve due to the fact that blood vessels grow into the exudate and fill the space that was occupied by fibrin. Often, large amounts of antibiotics are necessary for resolution. Catarrhal exudate is seen in the nose and throat and is characterized by a high content of mucus. Serous exudate (sometimes classified as serous transudate) is usually seen in mild inflammation, with little protein content. Its consistency resembles that of serum, and can usually be seen in certain disease states like tuberculosis. (See below for difference between transudate and exudate) Malignant (or cancerous) pleural effusion is effusion where cancer cells are present. It is usually classified as exudate. Trasudate versus Exudate Hypocellular, Protein poor Specific gravity 11.DD Rigt heart failure....Jugular venous distantion and bilateral Ankle,sacral edema ..due to inc venous pressure

12.FF The dissociation curve shifts to the right when carbon dioxide or hydrogen ion concentration is increased. This facilitates increased oxygen dumping. This mechanism allows for the body to adapt the problem of supplying more oxygen to tissues that need it the most. The general equation for the Haldane Effect is: H+ + HbO2 H+Hb + O2 .It has asked the effect of shift of the O2 dissociation curve to the right due to an increase of H+... The answer should definitely be F,i.e., release of oxygen in tissue capillaries. That's what happens when pH falls and the curve shifts to the right.The unloading of O2 becomes easier in tissue capillaries.They have not mentioned anything regarding hypoxia in the question which u mentioned here. Rise in 2,3 BPG will also have the same effect, but the rise in 2,3 DPG is not solely due to rise in H+... 2,3-Bisphosphoglyceric acid ....interacts with deoxygenated hemoglobin beta subunits by decreasing their affinity for oxygen, so it allosterically promotes the release of the remaining oxygen molecules bound to the hemoglobin, thus enhancing the ability of RBCs to release oxygen near tissues that need it most.

13.CC

A fat embolism is a type of embolism that is often (but not always) caused by physical trauma like fracture of long bones, soft tissue trauma and burns. Fat emboli occur in almost 90% of all patients with severe injuries to bones, although only 10% of these are symptomatic. The risk of fat embolism syndrome is thought to be reduced by early immobilization of fractures and especially by early operative correction. There is also some evidence that steroid prophylaxis of high-risk patients reduces the incidence. The mortality rate of fat-embolism syndrome is approximately 10-20%. The pathogenesis occurs due to both mechanical obstruction and biochemical injury. The microemboli cause pulmonary and cerebral microvasculature occlusion. It is aggravated by local platelet and erythrocyte aggregation. The release of free fatty acids from the fat globules causes local toxic injury to endothelium. The vascular damage is aggravated by platelet activation and recruitment of granulocytes. http://library.med.utah.edu/WebPath/HISTHTML/STAINS/STAIN011.html 14.AA

http://www.google.com/imgres?imgurl=http://missinglink.ucsf.edu/lm/ids_1 04_ce...0CEAQ9QEwAw 15.BB Coccidioidmycosis....mold in soil.....Southwestern US,California...causes pneumonia and meningitis(very rare). Can disseminate to bone and skin Culture...25degree...Hyphe with doubly reflective wall Biopsy Thick -wall spherules filled with endospores 16.AA In statistics, analysis of variance (ANOVA) is a collection of statistical models, and their associated procedures, in which the observed variance in a

particular variable is partitioned into components attributable to different sources of variation. In its simplest form ANOVA provides a statistical test of whether or not the means of several groups are all equal, and therefore generalizes t-test to more than two groups. ANOVAs are helpful because they possess an advantage over a two-sample t-test. Doing multiple twosample t-tests would result in an increased chance of committing a type I error. For this reason, ANOVAs are useful in comparing two, three or more means. 1-"Interval variable" (values from where we can drive their "Mean") e.g. measurements of B.P, Weight, Cholesterol levels etc 2-"Nominal variable" ( different categories or "GROUPS") e.g. *Gender ---is a Nominal that has Two Groups (Male and Female) *AGE-------is a Nominal that we can have either TWO groups (Elderly and Middle age) or THREE Groups(Elderly, Middle-age and Children) etc *Race------a Nominal that can have many groups Two groups (African Americans and Latino) Three groups(African Americans, Latino and Asian) and so forth e.g. *"GENDER"(Men and Women)....................................................(Single Nominal) *"GENDER"(Men and Women) n "RACE"(Caucasian and African)....(Two Nominals )

e.g we compare Blood Pressure measurements *INTERVAL variable ("MEANS" of B.P measurements)

*NOMINAL variable ("GROUPS" ) so to compare MEANS of B.P. b/w two are more groups we do these tests t-Test: 1 Interval (Blood pressure Means) 1 Nominal with "ONLY TWO GROUPS" e.g. comparing the BP means b/w (Latinos) and (African Americans) *for a t-Test it will be a wrong statement to say e.g comparing B.P means b/w (Latinos), (African Americans) and (Asians)....*got 3 groups Now what's the difference B/W t-Test and ANOVA t-Test------>ONLY TWO Groups comparison ANOVA------------>TWO Groups or more than Two Groups comparison NOTE:these two will give u the Identical results if comparing "TWO Groups" t-Test................... 1 Interval and 1 Nominal with TWO Groups One-way ANOVA.....1 Interval and 1 Nominal with TWO Groups and for the above reason they rather use One-way ANOVA when more than two groups are there to be compared e.g as above comparing B.P means b/w (Latinos), (African Americans) and (Asians).......3 groups

Two-way ANOVA: 1 Interval 2 Nominal e.g. Gender (Men and Women) *AND Race (Caucasians and African Americans)

---->we do these tests to see If there is a Difference b/w groups ? t-statistics (t-Test) and f-statistics(ANOVA) will be compared to get a pvalue If p-value = 0.05 or less -----it is said to be "Statistically Significant' and we say that there is a Difference in these Groups.

Chi-square: we compare b/w "TWO NOMINAL" (with ANY # of GROUPS) (Note; we are not using any Interval variable here , just the NOMINAL data) best example...."Testing Drug Efficacy" First Nominal........(New drug group) and (Placebo group) Second Nominal ...(Recovered group) and(Not recovered group)

***I think this is all u have to do is recognize what kind of data is presented , how many Nominals, How many groups and If Interval variable is used or not? 1 Interval and 1 Nominal (Two Groups).......................t-Test or One-way ANOVA 1 Interval and 1 Nominal (More than Two groups)........One-way ANOVA 1 Interval and *2 Nominal (many groups)....................Two-way ANOVA .....................*2 Nominal (any# of Groups).................Chi-square 17.DD Post-infectiousPost-infectious glomerulonephritis can occur after essentially any infection, but classically occurs after infection with Streptococcus pyogenes. It typically occurs 1014 days after a skin or pharyngeal infection with this bacterium.

Patients present with signs and symptoms of glomerulonephritis. Diagnosis is made based on these findings in an individual with a history of recent streptococcal infection. Streptococcal titers in the blood (antistreptolysin O titers) may support the diagnosis causes Nephritic syndrome...LM..glumeruli enlarged and hypercelullar Neutrophiles..Lumpy -Bumpy appereance Em...Subepithelial IC humps..IgM,IgG,C3 IF...granular resolve spontaneously 18.EE The thymus, is the principal organ responsible for the T cell's maturation. All T cells originate from haematopoietic stem cells in the bone marrow. Haematopoietic progenitors derived from haematopoietic stem cells populate the thymus and expand by cell division to generate a large population of immature thymocytes. The earliest thymocytes express neither CD4 nor CD8, and are therefore classed as double-negative (CD4-CD8-) cells. As they progress through their development they become double-positive thymocytes (CD4+CD8+), and finally mature to single-positive (CD4+CD8or CD4-CD8+) thymocytes that are then released from the thymus to peripheral tissues. About 98% of thymocytes die during the development processes in the thymus by failing either positive selection or negative selection, whereas the other 2% survive and leave the thymus to become mature immunocompetent T cells. Positive selection "selects for" T-cells capable of interacting with MHC. Negative selection removes thymocytes that are capable of strongly binding with "self" peptides presented by MHC.

19. The answer should be B as they have asked which drug is to be given for 6 months after initiating therapy with heparin. Typically, before initiating warfarin therapy we start heparin to obtain immediate anticoagulation as warfarin takes time for it action. Immadiate anticoagulation for pulmonary embolism,stroke ,acute coronary syndrome Toxicity...bleeding Thrombocytopenis...HIT,osteoparosis,drug-drug interactions For rapid reversalof heparinization....PROTAMINE SULFATE ****Newer low molecular weight heparin...Enoxaparin act more on Xa have better bioavilibility without laboratory monitoring 20-E "Drug Y alone no effect" ( partial agonist are incapable of eliciting a maximal response and are less efecctive than the full agonist D-Noncompetitive Antagonist This is the case on the concept of "Spare Receptors" Assume ...100% receptor occupancy required by an Agonist to exert Maximum Effect (Emax) /Optimal effect. and now consider, if Emax is achieved with result *Efficacy of Drug X decreases *5 of the spare receptors are still Unoccupied Now if we raise the drug "X" dosage.....it will bind to the remaining unoccupied spare receptors and brings it Efficacy back to to the Emax. there for "No Change in Efficacy" , only "Potency decreases"(as needed higher dose of Drug X)

---------------------------------Graph on the Right--------------------------

But at "High Dose" of of NCA (Drug Y), it will bind to e.g all the 10 spare receptors---->result *Efficacy(Emax) of Drug X decreases *there are non of the spare receptors left unoccupied since there are no extra receptors left, even if we raise the Drug "X" dosage, it won't be able to increase it's Efficacy back to Emax. 21-E In treating hepatic encephalopathy, lactulose helps "draw out" ammonia (NH3) from the body.[5] Lactulose is metabolized in the colon by bacterial flora to short chain fatty acids including the production of the lactic acid and acetic acid. This partially dissociates, acidifying the colonic contents (increasing the H+ concentration in the gut).[6] This favors the formation of the nonabsorbable NH4+ from NH3, trapping NH3 in the colon and effectively reducing plasma NH3 concentrations. The effectiveness of lactulose in treating hepatic encephalopathy is somewhat controversial.[ Lactulose for hepatic encephalopathy generally requires oral dosage three or four times a day with diarrhea almost a certain side effect. 22-E A pheochromocytoma or phaeochromocytoma (PCC) is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to involute after birth [1] and secretes excessive amounts of catecholamines, usually noradrenaline (norepinephrine), and adrenaline (epinephrine) to a lesser extent TO ADD; The signs and symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, including: Skin sensations Flank pain Elevated heart rate

Elevated blood pressure, including paroxysmal (sporadic, episodic) high blood pressure, which sometimes can be more difficult to detect; another clue to the presence of pheochromocytoma is orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in diastolic blood pressure greater than 10 mmHg on making the patient stand) Palpitations Anxiety often resembling that of a panic attack Diaphoresis (excessive sweating) Headaches Pallor Weight loss Localized amyloid deposits found microscopically Elevated blood glucose level (due primarily to catecholamine stimulation of lipolysis (breakdown of stored fat) leading to high levels of free fatty acids and the subsequent inhibition of glucose uptake by muscle cells. Further, stimulation of beta-adrenergic receptors leads to glycogenolysis and gluconeogenesis and thus elevation of blood glucose levels). A pheochromocytoma can also cause resistant arterial hypertension. A pheochromocytoma can be fatal if it causes malignant hypertension, or severely high blood pressure. This hypertension is not well controlled with standard blood pressure medications

23.DD we need to cut 2lb=7000 cal (3500*2) 1 hr walk/d will cut 3500 cal In the meanwhile she is also getting 1800*7 calories=12600 in a week decrease intake for 500 cal /d * 7 days=3500 cal so 3500+3500=7000 It is a mathematic calculation... She is asked to loss 2 pounds weight weekly...each pounds=3500 cal and brisk walking consums 500cal per hour so........................................................... 2 pounds=7000cal she needs to loss 1000 cal per day......if she walked 2 hours per day....she

could lose 1000 calories but between choices there is no 2 hours.so if she decreases 500 cal in her diet and gets 1 hour brisk walking then she will loss 1000 cal/day.......and 7000/week 24. C Systemic lupus erythematosus often abbreviated to SLE or lupus, is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage.[1] It is a Type III hypersensitivity reaction caused by antibody-immune complex formation. SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. In SLE, the body's immune system produces antibodies against itself, particularly against proteins in the cell nucleus. SLE is triggered by environmental factors that are unknown. "All the key components of the immune system are involved in the underlying mechanisms [of SLE]" according to Rahman, and SLE is the prototypical autoimmune disease. The immune system must have a balance (homeostasis) between being sensitive enough to protect against infection, and being too sensitive and attacking the body's own proteins (autoimmunity). From an evolutionary perspective, according to Crow, the population must have enough genetic diversity to protect itself against a wide range of possible infection; some genetic combinations result in autoimmunity. The likely environmental triggers include ultraviolet light, drugs, and viruses. These stimuli cause the destruction of cells and expose their DNA, histones, and other proteins, particularly parts of the cell nucleus. Because of genetic variations in different components of the immune system, in some people the immune system attacks these nuclear-related proteins and produces antibodies against them. In the end, these antibody complexes damage blood vessels in critical areas of the body, such as the glomeruli of the kidney; these antibody attacks are the cause of SLE. Researchers are now identifying the individual genes, the proteins they produce, and their role in the immune system. Each protein is a link on the

autoimmune chain, and researchers are trying to find drugs to break each of those links. Renal Painless hematuria or proteinuria may often be the only presenting renal symptom. Acute or chronic renal impairment may develop with lupus nephritis, leading to acute or end-stage renal failure. Because of early recognition and management of SLE, end-stage renal failure occurs in less than 5% of cases. A histological hallmark of SLE is membranous glomerulonephritis with "wire loop" abnormalities.[16] This finding is due to immune complex deposition along the glomerular basement membrane, leading to a typical granular appearance in immunofluorescence testing. Lupus nephritis is an inflammation of the kidney caused by systemic lupus erythematosus (SLE), a disease of the immune system. Apart from the kidneys, SLE can also damage the skin, joints, nervous system and virtually any organ or system in the body. Histologically a wire-loop lesion will be present. The wire loop lesion is a glomerular capillary loop with subendothelial immune complex deposition that is circumferential around the loop. 25. E Kwashiorkor (pronounced /kwirkr/) is an acute form of childhood protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. The presence of edema caused by poor nutrition defines kwashiorkor.[1] Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus. More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory. Cases in the developed world are rare. The defining sign of kwashiorkor in a malnourished child is pedal edema (swelling of the feet). Other signs include a distended abdomen, an enlarged liver with fatty infiltrates, thinning hair, loss of teeth, skin depigmentation and dermatitis. Children with kwashiorkor often develop irritability and anorexia.

Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency. A child with marasmus looks emaciated. Body weight may be reduced to less than 80% of the average weight that corresponds to the height .[citation needed] Marasmus occurrence increases prior to age 1, whereas kwashiorkor occurrence increases after 18 months. It can be distinguished from kwashiorkor in that kwashiorkor is protein wasting with the presence of edema. The malnutrition associated with marasmus leads to extensive tissue and muscle wasting, as well as variable edema. Other common characteristics include dry skin, loose skin folds hanging over the glutei, axillae, etc. There is also drastic loss of adipose tissue from normal areas of fat deposits like buttocks and thighs. The afflicted are often fretful, irritable, and voraciously hungry. The word marasmus comes from a Greek word meaning starvation. Marasmus is generally known as the gradual wasting away of the body due to severe malnutrition or inadequate absorption of food. Marasmus is a form of severe protein deficiency and is one of the forms of proteinenergy malfunction (PEM). It is a severe form of malnutrition caused by inadequate intake of proteins and calories. 26. C Primary polydipsia or psychogenic polydipsia is a special form of polydipsia.[1] It is usually associated with a patient's increasing fluid intake due to the sensation of having a dry mouth. When the term "psychogenic polydipsia" is used, it implies that the condition is caused by mental disorders. However, the dry mouth is often due to phenothiazine medications used in some mental disorders, rather than the underlying condition The patient drinks large amounts of water, which dilutes the extracellular fluid, decreasing its osmotic pressure. The body responds to this by decreasing the level of vasopressin (antidiuretic hormone), with a resultant increased production of urine (polyuria). This urine will have a low electrolyte concentration. Clinical presentation Patients have been known to seek fluids from any source possible. In extreme episodes, the patient's kidneys will be unable to deal with the

fluid overload, and weight gain will be noted. Primary polydipsia can be life threatening as serum sodium is diluted to an extent that seizures and cardiac arrest can occur. 27. A Kawasaki disease: Acute, self-limiting necrotizing vasculitis in infants/ children. Association with Asia ethnicity. Fever, conjuntivitis, changes in lips/ oral mucosa (strawberry tongue), lymphadenitis, desquamative skin rash. May develop coronary aneurysms. 28. D In genetic medicine, a mosaic or mosaicism denotes the presence of two populations of cells with different genotypes in one individual who has developed from a single fertilized egg.[1] Mosaicism may result from a mutation during development which is propagated to only a subset of the adult cells. Somatic mosaicism Somatic mosaicism occurs when the somatic cells of the body are of more than one genotype. In the more common mosaics, different genotypes arise from only a single fertilized egg cell, due to mitotic errors at first cleavage. Another form of somatic mosaicism is chimerism, where two or more genotypes arise from the fusion of more than one fertilized zygote in the early stages of embryonal development. In rare cases, intersex conditions can be caused by mosaicism where some cells in the body have XX and others XY chromosomes.[2][3] The most common form of mosaicism found through prenatal diagnosis involves trisomies. Although most forms of trisomy are due to problems in meiosis and affect all cells of the organism, there are cases where the trisomy occurs in only a selection of the cells. This may be caused by a nondisjunction event in an early mitosis, resulting in a loss of a chromosome from some trisomic cells.[4] Generally this leads to a milder phenotype than in non-mosaic patients with the same disorder. An example of this is one of the milder forms of Klinefelter's syndrome, called 46/47 XY/XXY mosaic wherein some of the patient's cells contain XY chromosomes, and some contain XXY chromosomes. The 46/47 annotation indicates that the XY cells have the normal number of 46 total

chromosomes, and the XXY cells have 47 total chromosomes. Around 30% of Turner's syndrome cases demonstrate mosaicism, while complete monosomy (45 XO) occurs in about 5060% of cases. True mosaicism should not be mistaken for the phenomenon of Xinactivation, where all cells in an organism have the same genotype, but a different copy of the X chromosome is expressed in different cells, such as in calico cats. 29.C PaCO2=metabolic CO2 production/Va So if Ventilation increases to match up with CO2 production, PCO2 remains the same 30-F The classic triad for congenital rubella syndrome is: Sensorineural deafness (58% of patients) Eye abnormalitiesespecially cataract and microphthalmia (43% of patients) Congenital heart diseaseespecially patent ductus arteriosus (50% of patients) Other manifestations of CRS may include: Spleen, liver or bone marrow problems (some of which may disappear shortly after birth) Mental retardation Small head size (microcephaly) Eye defects Low birth weight Thrombocytopenic purpura (presents as a characteristic blueberry muffin rash) Hepatomegaly Micrognathia Children who have been exposed to rubella in the womb should also be watched closely as they age for any indication of the following: Developmental delay

Autism spectrum disorders[1] Schizophrenia[2] Growth retardation Learning disabilities Diabetes Glaucoma Note:NO a congenital cytomegalovirus Generalized infection may occur in the infant, and can cause complications such as low birth weight, microcephaly, seizures, petechial rash similar to the "blueberry muffin" rash of congenital rubella syndrome, and moderate hepatosplenomegaly (with jaundice). 31. C Pityriasis or tia versicolor caused by malassezia furfur. Degradation of lipids produces acids that damage melanocytes and cause hypopigmented patches. Occurs in hot humid weather. Yeast clusters & and short curved septate hyphae KOH scaping shows spaghetti and meatballs. Malassezia (formerly known as Pityrosporum) is a genus of fungi. Malassezia is naturally found on the skin surfaces of many animals, including humans. In occasional opportunistic infections, some species can cause hypopigmentation on the trunk and other locations in humans. T: Topical Miconazole, selenium sulfide. 32. A N. meningitidis: Gram neg. kidney bean shaped diploccoci, large capsule; latex particule agluttination ( or Counter immunoelectrophoresis ( CIE) to identify N. meningitidis capsular antigen in CSF. Reservorio: Human nasopharynx Transmision: Respiratory droplets; oropharyngeal colonization, spread to meninges via blood stream. Pathogenesis: Important virulent factor: Polysacharide capsule: antiphagocytic, antigenic, 5 common serogrups : B is not strongly immunogenic( sialid acid), B strain is most common strain in

US. (Kaplan Microbiology book page 257) 33. D As a medical term, precocious puberty describes puberty occurring at an unusually early age. In most of these children, the process is normal in every respect except the unusually early age, and simply represents a variation of normal development. In a minority of children, the early development is triggered by a disease such as a tumor or injury of the brain. Even in instances where there is no disease, unusually early puberty can have adverse effects on social behavior and psychological development, can reduce adult height potential, and may shift some life-long health risks. Central precocious puberty can be treated by suppressing the pituitary hormones that induce sex steroid production. The term is used with several slightly different meanings that are usually apparent from the context. In its broadest sense, and often simplified as early puberty, "precocious puberty" sometimes refers to any physical sex hormone effect, due to any cause, occurring earlier than the usual age, especially when it is being considered as a medical problem. Stricter definitions of "precocity" may refer only to central puberty starting before a statistically specified age based on percentile in the population (e.g., 2.5 standard deviations below the population mean),[1] on expert recommendations of ages at which there is more than a negligible chance of discovering an abnormal cause, or based on opinion as to the age at which early puberty may have adverse effects. A common definition for medical purposes is onset before 8 years in girls or 9 years in boys. One possible treatment is with anastrozole. Histrelin acetate (Supprelin LA), Triptorelin or Leuprolide, any GnRH agonists, may also be used. GnRH agonists stimulate the pituitary to release Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). However, when used regularly, GnRH agonists cause a decreased release of FSH and LH. GnRH produced by the hypothalamus is pulsatile, allowing for a physiologic release of FSH and LH. 34-B Inhibitory synapses The neurotransmitter at inhibitory synapses hyperpolarizes the postsynaptic membrane.

Example: gamma aminobutyric acid (GABA) at certain synapses in the brain. The GABAA receptor is a ligand-gated chloride channel. Binding of GABA to the receptors increases the influx of chloride (Cl) ions into the postsynaptic cell raising its membrane potential and thus inhibiting it. This is a fast response taking only about 1 millisecond. Binding of GABA to GABAB receptors activates an internal G protein and a "second messenger" that leads to the opening of nearby potassium (K+) channels. As you might expect, this is a slower response, taking as long as 1 second. In both cases, the resulting facilitated diffusion of ions (chloride IN; potassium OUT) increases the membrane potential (to as much as 80 mv). This increased membrane potential is called an inhibitory postsynaptic potential (IPSP) because it counteracts any excitatory signals that may arrive at that neuron. A hyperpolarized neuron appears to have an increased threshold. Actually, the threshold voltage (about 50 mv) has not changed. It is simply a question of whether the depolarization produced by excitatory synapses on the cell minus the hyperpolarizing effect of inhibitory synapses can reach this value or not. Mutation of the GABA, (no receptor) secundary to the mutation DECREASED THE influx of Cl35-F ADH is secreted in response to increased plasma osmolarity and dicreased blood volume, binds to receptors on principal cells, causing increased number of water channels and increased water reabsortion in the collecting tube. FA pag 396 The main effector organ for fluid homeostasis is the kidney. ADH acts by increasing water permeability in the collecting ducts and distal convoluted tubules, specifically it acts on proteins called aquaporins which open to allow water into the collecting duct cells. This increase in permeability allows for reabsorption of water into the bloodstream, thus concentrating the urine. Diabetes insipidus (DI) is a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine, with reduction of fluid

intake having no effect on the latter. There are several different types of DI, each with a different cause. The most common type in humans is central DI, caused by a deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH). The second common type of DI is nephrogenic diabetes insipidus, which is caused by an insensitivity of the kidneys to ADH. It can also be an iatrogenic artifact of drug use. 36.CC Subdural hematoma....rupture of bridging vein crescent -shaped hemorrhage that crosses suture lines...cn not cross falx.tentorium venous bleeding with delayed onset ,seen in elderly,alcoholics,blunt trauma,shaken baby 37 A esophageal varices liver cirrhosis -->portal hypertension -->Ascites, splenomegaly, esophageal varices, caput medusae, haemarrhoids 38 B Zona glomerulosa -->Aldosterone other options C -zona fasciculata, D -zona reticularis, E -adrenal medulla 39.BB Diabetic retinopathy is retinopathy (damage to the retina) caused by complications of diabetes mellitus, which can eventually lead to blindness. It is an ocular manifestation of systemic disease which affects up to 80% of all patients who have had diabetes for 10 years or more. Diabetic retinopathy is the result of microvascular retinal changes. Hyperglycemia-induced intramural pericyte death and thickening of the basement membrane lead to incompetence of the vascular walls. These damages change the formation of the blood-retinal barrier and also make the retinal blood vessels become more permeable. Small blood vessels such as those in the eye are especially vulnerable to poor blood sugar (blood glucose) control. An overaccumulation of glucose

and/or fructose damages the tiny blood vessels in the retina. During the initial stage, called nonproliferative diabetic retinopathy (NPDR), most people do not notice any change in their vision. Some people develop a condition called macular edema. It occurs when the damaged blood vessels leak fluid and lipids onto the macula, the part of the retina that lets us see detail. The fluid makes the macula swell, which blurs vision. 40 B chemokine receptor HIV entry requires interaction with CD4 receptors and CCR5 receptors 41 C its not A for sure 42.AA Adenocarcinoma is a type of cancer that develops in cells lining glandular types of internal organs,The World Health Organization (WHO) defines adenocarcinoma as "a malignant epithelial tumor with tubular, acinar, or papillary growth patterns, and/or mucus production by the tumor cells."Currently the WHO recognizes four categories of adenocarcinoma: acinar papillary bronchioloalveolar solid carcinoma with mucus formation The majority of adenocarcinomas occur at the periphery of the lung, and, as a resultare often asymptomatic until late in their course. They frequently lie just below the pleura, and cause pleural retraction and thickening on x-ray. Often adenocarcinomas are discovered on routine chest x-rays or in a primary search for distant metastases. Adenocarcinomas grossly present with the "three P's" - peripheral, pigmented and puckered.Commonly lesions are found near the pleural

surface (peripheral) which is retracted (puckered) over the neoplasm.The cut surface is often white . 43.DD Physiologically, phosphorylase kinase plays the important role of stimulating glycogen breakdown into free glucose by phosphorylating glycogen phosphorylase and stabilizing its active conformation. This activity is particularly important in liver and muscle cells, though for somewhat different purposes. While muscle cells generally break down glycogen to power their immediate activity, liver cells are responsible for maintaining glucose concentration in the bloodstream. Thus, the regulatory mechanisms of PhK activity vary somewhat depending on cell type. 44 A oocyte donation turners sundrome --- streak ovaries-- no germ cells bosted by nf2011 to add Genetic mosaicism (46XX/45XO) is most often implicated, alongside nondisjunction (45XO) and partial monosomy (46XX). Turner syndrome is characterized by primary amenorrhea, premature ovarian failure, streak gonads and infertility. However, technology (especially oocyte donation) provides the opportunity of pregnancy in these patients. 45 B inheritance of amplified CYP2D6 locus rule out A induction --->increased dose should induce a response C inactive alleles & D inhibitor --> small doses should do the trick E tolerance ----> initiall doses should induce a response 45 B inheritance of amplified CYP2D6 locus rule out A induction --->increased dose should induce a response C inactive alleles & D inhibitor --> small doses should do the trick

E tolerance ----> initiall doses should induce a response ************************************************************* ******************************** 46.EE Ureters paa under uterine artery and under ductus deferens. Complication in surgery...ligation the ovarian vasculature in the suspensory lig.....accidental ligationof the Ureter 47.EE Microscopic Polyangitis...like wegner but lacks granuloma....P-ANCA positive All affect small vessels 48.DD Weber's syndrome (superior alternating hemiplegia) is a form of stroke characterized by the presence of an oculomotor nerve palsy and contralateral hemiparesis or hemiplegia. This lesion is usually unilateral and affects several structures in the midbrain including: substantia nigra contralateral parkinsonism because its dopaminergic projections to the basal ganglia innervate the ipsilateral hemisphere motor field, leading to a movement disorder of the contralateral body. corticospinal fibers contralateral hemiparesis and typical upper motor neuron findings corticobulbar tract difficulty with contralateral lower facial muscles and hypoglossal nerve functions oculomotor nerve fibers ipsilateral oculomotor nerve palsy with a drooping eyelid and fixed wide pupil pointed down and out. This leads to diplopia

It is caused by midbrain infarction as a result of occlusion of the paramedian branches of the posterior cerebral artery or of basilar bifurcation perforating arteries

Thalamic syndrome (or thalamic pain syndrome)It is also known as

"Dejerine-Roussy disease" is a condition that can be associated with inadequate blood supply from the posterior cerebral artery. It is a rare neurological disorder in which the body becomes hypersensitive to pain as a result of damage to the thalamus, a part of the brain that affects sensation. The thalamus has been described as the brains sensory relay station. Primary symptoms include pain and loss of sensation, usually in the face, arms, and/or legs. Pain or discomfort may be fel after being mildly touched or even in the absence of a stimulus. The pain associated with thalamic syndrome may be made worse by exposure to heat or cold and by emotional distress. Sometimes, this may include even such emotions as those brought on by listening to music.

Gerstmann's syndrome is a cognitive impairment that results from damage to a specific area of the brain -- the left parietal lobe in the region of the angular gyrus. It may occur after a stroke or in association with damage to the parietal lobe. It is characterized by four primary symptoms: a writing disability (agraphia or dysgraphia), a lack of understanding of the rules for calculation or arithmetic (acalculia or dyscalculia), an inability to distinguish right from left, and an inability to identify fingers (finger agnosia). The disorder should not be confused with Gerstmann-Strussler-Scheinker disease, a type of transmissible spongiform encephalopathy.

Lateral medullary syndrome (also called Wallenberg syndrome and posterior inferior cerebellar artery syndrome) is a disease in which the patient has a constellation of neurologic symptoms due to injury to the lateral part of the medulla in the brain, resulting in tissue ischemia and necrosis. This syndrome is characterized by sensory deficits affecting the trunk (torso) and extremities on the opposite side of the infarction and sensory deficits

affecting the face and cranial nerves on the same side with the infarct. Specifically, there is a loss of pain and temperature sensation on the contralateral (opposite) side of the body and ipsilateral (same) side of the face. This crossed finding is diagnostic for the syndrome. Clinical symptoms include swallowing difficulty, or dysphagia, slurred speech, ataxia, facial pain, vertigo, nystagmus, Horner syndrome, diplopia, and possibly palatal myoclonus.

49 E zolpidem Zolpidem (Ambien) is a prescription medication used for the short-term treatment of insomnia, as well as some brain disorders. It is a short-acting nonbenzodiazepine hypnotic that potentiates gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, by binding to GABAA receptors at the same location as benzodiazepines. It works quickly (usually within 15 minutes) and has a short half-life (23 hours).

Zolpidem has not adequately demonstrated effectiveness in maintaining sleep, however it is effective in initiating sleep 50.BB Fragile X syndrome is a genetic disorder caused by mutation of the FMR1 gene on the X-chromosome. Expansion of the CGG repeating codon to such a degree results in a methylation of that portion of the DNA, effectively silencing the expression of the FMR1 protein.

Mutation of the FMR1 gene leads to the transcriptional silencing of the fragile X-mental retardation protein, FMRP. In normal individuals, FMRP is believed to regulate a substantial population of mRNA: FMRP plays important roles in learning and memory,

Block 3 1.EE Sucralfate and bismuth....bind to ulser base....pysical protection,and allow bicarbonate secretion to restablish PH gradient in the mucous layer Misoprostol....a PGE1 analog.....inc.production and secretion of gastric mucous barrier and dic acid production A,B..can affect absorbtion,bioavailibility or urinary excreation of other drugs

by altering gastric and urinary PHor by delaying gastric emptying Ranitidin....H2 blocker...reversible block of histamine H2 receptors.....dec H+ secretion by parietal cells 2.AA CFTR gene on chromosome 7 ..deletion of Phe 508,folding of the CFTR protein in the endoplasmic reticulum is affected by this mutation 3.BB Digoxin toxicity......inc.parasympathetic activity..nausea,vomitingdiarrhea,blurry yellow visionand arrhythmia may cause inc.PR and decQT,scooping of STad T-wave inversion Antidote...slowly normalize K+and Mg+,lidocain,anti-dig fragments... 4.CC The concept they are testing is if a disease has a high heterozygote frequency then the chances of a female carrier and a male carrier meeting are higher, and thus chances of having a child with a recessive disorder in a family where none of the grandparents had a disease are also higher. It is referring to the particular gene frequency in the population. For example, the gene frequency for cystic fibrosis is high in Caucasians. Cystic Fibrosis....AR with high heterozigot frequency, most common lethal genetic disease of caucasians.......deletion of Phe 508,folding of the CFTR protein in the endoplasmic reticulum is affected by this mutation defective Cl- chanel.......secretion abnormally thick mucous that pluge lung ,pancreas and lver.....recurent pulmonary infection,Fat-soluble vitamine deficiency....failure to thrive in infancy 5.CC Spirochete Infections: Lyme Disease and Leptospirosis Lyme disease is characterized by dermatological, neurological, cardiac, rheumatic, and ophthalmic manifestations that result from tick-borne transmission of the spirochete Borrelia burgdorferi Three chronological stages: 1.Primary or initial phaserash at the site of tick bite (erythema chronicum migrans) and flu-like symptoms.

2.Secondary or dissemination stagefurther dermatological, cardiac, and neurological manifestations. 3.Tertiary or late stagearthritis, meningoencephalitis, cranial neuropathy, peripheral neuropathy, carditis. ASSOCIATED FEATURES Conjunctivitis, most common manifestation in stage 1. Cranial nerve palsies, optic nerve inflammation can occur in stage 2. Corneal, uveal, and retinal inflammation can occur in stage 3. Leptospirosis is a zoonotic infection of worldwide distribution caused by pathogenic Leptospira species. Biphasic disease. Leptospiremic phasesevere headache, fever, myalgia. Immune phasehigh fever, meningismus, central and peripheral nervous system manifestations. Ocular manifestations occur in the majority of patients. Conjunctivitis, uveitis, subconjunctival hemorrhages. ASSOCIATED FEATURE Weils diseasesevere disease with hemorrhages, renal failure, and jaundice. 6.DD the bullet is seen inside the spleen 7.BB The lesser omentum (small omentum; gastrohepatic omentum; omentum minus) is the double layer of peritoneum that extends from the liver to the lesser curvature of the stomach and the start of the duodenum. The lesser omentum is extremely thin, and is continuous with the two layers of peritoneum which cover respectively the antero-superior and posteroinferior surfaces of the stomach and first part of the duodenum. http://en.wikipedia.org/wiki/File:Gray1104.png

8.CC The paraaortic lymph node group is divided into three subgroups: preaortic, retroaortic, and right and left lateral aortic. The preaortic group drains the abdominal part of the gastrointestinal tract above the mid-rectum. The retroaortic group drains from the lateral and preaortic glands. The lateral group drains the iliac lymph nodes, the ovaries, and other pelvic organs. The lateral group nodes are located adjacent to the aorta, anterior to the spine, extending laterally to the edge of the psoas major muscles, and superiorly to the crura of the diaphragm. 9.EE Otitis media is most commonly caused by infection with viral, bacterial, or fungal pathogens. The most common bacterial pathogen is Streptococcus pneumoniae. Others include Pseudomonas aeruginosa, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Among older adolescents and young adults, the most common cause of ear infections is Haemophilus influenzae. Viruses such as respiratory syncytial virus (RSV) and those that cause the common cold may also result in otitis media by damaging the normal defenses of the epithelial cells in the upper respiratory tract.

10.AA most human rabies cases in the United States were caused by bat bites that probably were unrecognized or undetected,Rabis is a viral disease that causes acute encephalitis . The period between infection and the first flu-like symptoms is normally two to twelve weeks, but can be as long as two years. Soon after, the symptoms expand to slight or partial paralysis, cerebral dysfunction, anxiety, insomnia, confusion, agitation, abnormal behavior, paranoia, terror, hallucinations, progressing to delirium The production of large quantities of saliva and tears coupled with an inability to speak or swallow are typical during the later stages of the disease; this can result in hydrophobia, in which the patient has difficulty swallowing because the throat and jaw become slowly paralyzed, shows panic when presented with liquids to drink, and cannot quench his or her thirst. Negri bodies are 100% diagnostic for rabies infection, but are found in only about 80% of cases 11.DD Viral vacines that living strains elicit both-cell mediated and humoral immunity,whereas killed viral vaccines elicit predominantly an antibody respond....so common features of these two types... sabin and salk ...induce humoral immunity/antibody respond.. 12.CC Albinism...Congenital deficiency of either ** Tyrosinase ....inability to syntetize melanin from tyrosine...Autosomal ressesive or ** Defective tyrosine transporter...dec.amount of tyrosin and thus melanin 13.FF

....odds of having disease in exposed group divided by odds of having disease in unexposed group 250/50/250/150......3 14.CC Decreased ATP causes decreased action of Na+ / K+ pumps in the cell membranes, leading to increased Na+ and water within the cell (cell swelling). 15.FF Individuals with passive-aggressive personality disorder appear to comply or act appropriately, but actually behave negatively and passively resist. This personality disorder is a chronic condition, meaning that it lasts throughout life. Symptoms include: Contradictory and inconsistent behaviorAn individual with passiveaggressive personality disorder may appear enthusiastic to carry out others requests, but he purposely performs in a manner that is not useful and sometimes even damaging. Intentional avoidance of responsibility. Some behaviors that may be used to avoid responsibility include: Procrastinationto delay or postpone needlessly and intentionally Deliberate inefficiencypurposefully performing in an incompetent manner Forgetfulness Feelings of resentment toward others Stubbornness Argumentative, sulky, and hostile, especially toward authority figures Easily offended Resentful of useful suggestions from others Blames others Chronically impatient Unexpressed anger or hostility

16.AA supernumerary nipples (polythelia) more than the normal number of nipples, may be on the breast or other parts of the body-found along the "milk line" from axilla to groin. These accessory nipples resemble raised nevi (commonly called "moles"). It is derived from epithelial tissue . Usually, the supernumerary nipple remains undetected or asymptomatic. Occasionally, the supernumerary nipple is noticed only when hormonal changes during adolescence, menstruation, or pregnancy cause increased pigmentation, fluctuating swelling, tenderness, or even lactation. 17.BB In people who have sarcoidosis, immune system cells cause inflammation and cluster to form lumps called granulomas. If many granulomas form in an organ, they can affect how the organ works. This can cause signs and symptoms. Signs and symptoms vary depending on which organs are affected. Many people who have sarcoidosis have no symptoms or mild symptoms. Some researchers think that sarcoidosis develops when the immune system responds to a trigger, such as bacteria, viruses, dust, or chemicals. Genetics also may play a role in sarcoidosis.

18.CC Influenza viruses...Orthomyxovirus...enveloped,single stranded..RNA viruses with segmented genome. Contain: Hemagglutinin antigen....promote viral entery and Neuroaminidase antigen..promotes progeny viral release Amantadine is DOC for prophylaxis and treatment It blocks viral penetration/uncoating, it also can release dopamine from intact nerve terminal...is used forr parkinson's disease

19.CC Oculomotor nerveIII......eye movement(SR,IR,MR,IO)...pupillary constriction ,accommodation,eyelide opening(Levator Palpebrae) 20.BB Allergic Rhinitis is defined as inflammation of the nasal membranes and is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea.The eyes, ears, sinuses, and throat can also be involved. Allergic rhinitis is the most common cause of rhinitis. Exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins. This specific IgE coats the surface of mast cells, which are present in the nasal mucosa. When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators. The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin. The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2. These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea . A pet that is isolated to one area of the house may still cause significant problems for an person with allergic rhinitis because the dander can be airborne and move to any part of the home through the ventilation system. 21.BB Most humans are exposed to CMV in their lifetime, but typically only individuals with weakened immune systems become ill from CMV infection. Usually, CMV produces no symptoms. However, serious CMV infections can occur in people with weakened immune systems due to AIDS, organ transplants, bone marrow transplant, chemotherapy, or medicines that suppress the immune system. A CMV infection may affect different parts of the body. Infections include: CMV esophagitis (infection of the esophagus) CMV gastroenteritis (infection of the stomach or intestines) CMV retinitis (infection of the eye)

CMV pneumonia (infection of the lung) Mononucleosis-like illness

22.DD ITs tricuspid Valve. The other is mitral valve. Its too low for aortic valve and you dont do pulmonary artery replacement in adults. So even by exclusion its tricuspid 23.FF A Meckel's diverticulum, a true congenital diverticulum, is a small bulge in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk), and is the most frequent malformation of the gastrointestinal tract Meckel's diverticulum is located in the distal ileum, usually within about 60100 cm (2 feet) of the ileocecal valve The most common presenting symptom is painless rectal bleeding such as melaena-like black offensive stools, followed by intestinal obstruction, volvulus and intussusception. Occasionally, Meckel's diverticulitis may

present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area. Most of the time, bleeding occurs without warning and stops spontaneously. The symptoms can be extremely painful, often mistaken as just belly pain resulting from not eating or constipation.

24.BB Because dual infection is common, patients diagnosed with either Gonorrhea or Chlamydia should receive empiric treatment for both infections, unless the other infection has been ruled out. Treatment of Chlamydia: Azithromycin Doxycycline Treatment of Gonorrhea: Ceftriaxone Cefixime 25 Steroid-induced osteoporosis (SIOP) is osteoporosis arising due to use of glucocorticoids - analogous to Cushing's syndrome and involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Some professional guidelines recommend prophylaxis in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when this is in excess of three months. Alternate day use may not prevent this complication. Mechanisms of SIOP include: Direct inhibition of osteoblast function Direct enhancement of bone resorption Inhibition of gastrointestinal calcium absorption Increased urine calcium loss Inhibition of sex steroids

26.DD Chronic exposure to relatively low levels of carbon monoxide may cause persistent headaches, lightheadedness, depression, confusion, memory loss, nausea and vomiting. It is unknown whether low-level chronic exposure may cause permanent neurological damage. Typically, upon removal from exposure to carbon monoxide, symptoms usually resolve themselves, unless there has been an

episode of severe acute poisoning 27.CC Although the kidneys receive nearly a quarter of the cardiac output and extract relatively little oxygen, there is a marked discrepancy between cortical and medullary blood flow and oxygen delivery and consumption. In the medulla, blood flow and oxygen supply are restricted by a tubulovascular anatomy specifically designed for urinary concentration. 28..Answer should be DD.. Characteristic of rapidly redistributed drug..At first the drug is rapidly redistributed so the plasma level falls suddenly. This is followed by normal elimination which causes the characteristic change in the slope.. 29.DD Classic galactosemia...due to Galactose-1-phosphate Uridyltransferase Smptos:failure of thrive,Jaundice,hepatomegaly,cataracts and mental retardation Galaktokinase deficiency....Galactitol accumulates if galactose is present in diet.....mild condition 30.CC retroviruses (HIV and HTLV) have reverse transcriptase 31.DD

http://en.wikipedia.org/wiki/File:Gray784.png 32.CC At a single locus,only 1 allele is active,the other is inactive(imprinted/inactivated by methylation)...deletion of active allele......>disease 33.CC Vascular endothelial growth factor (VEGF) is a signal protein produced by cells that stimulates vasculogenesis and angiogenesis. It is part of the system that restores the oxygen supply to tissues when blood circulation is inadequate.

34.CC AML-M3...High circulating myeloblasts on peripheral smear Auer bodies...Peroxide positive cytoplasmic inclusion in granulocytes and myeloblasts Treatment of AML M3 can release Auer rods..........>DIC 35.DD Secoundary Hypeparathyroidism.....due to chornic renal failure...causes secoundry hyperplasia of parathyroid due to dec Calcium ion absorption and inc.phosphorous HYpocalcemia,Hyperphosphatemia,high Alkaline phosphatase,high PTH 36.BB The cold agglutinins test is used to confirm the diagnosis of certain diseases that stimulate the body to produce cold agglutinins. mycoplasma pneumonia, a form of atypical bacterial pneumonia, and is related to cold agglutinin disease. This species lacks a peptidoglycan cell wall. Instead, it has a cell membrane that incorporates sterol compounds, similar to eukaryotic cells. It obtains these sterols from the host serum, allowing it to retain a simple structure. Lacking a cell wall, these organisms are resistant to the effects of penicillins and other beta-lactam antibiotics, which act by disrupting the bacterial cell wall. Antibiotics with activity against these organisms include certain macrolides (erythromycin, azithromycin, clarithromycin), fluoroquinolones and their derivatives (e.g., ciprofloxacin, levofloxacin), and tetracyclines (e.g., doxycycline). 37.CC

Persons with component deficiencies in the final common complement pathway (C3,C5-C9) are more susceptible to N. meningitidis infection than complement-satisfactory persons, and it was estimated that the risk of infection is 7000 times higher in such individuals. In addition, complement component-deficient population frequently experience frequent meningococcal disease. 38.EE Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries. It is the result of the eventual depletion of almost all of the oocytes and ovarian follicles in the ovaries. This causes an increase in circulating follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels because there are a decreased number of oocytes and follicles responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and mood changes. Long term effects may include osteoporosis and vaginal atrophy. 39.AA Alprazolam is a potent short-acting drug of the benzodiazepine class. It is primarily used to treat moderate to severe anxiety disorders (e.g., social anxiety disorder) and panic attacks, and is used as an adjunctive treatment for anxiety associated with moderate depression. 40.EE Cleft lip...failure of fusion of the maxillary and medial nasal process ...formtion of primary palate Cleft palate.....failure of fusion of the lateral palatine processes ,the nasal septum,and/or the median palatine process......formation of secoundary palate

41.DD Drug X is an alpha1 blocker NE.....alpha1>alpha2>beta1.......has high alpha1 agonist power.....after using drug X ......force dec. fom 15.1.....6.8 Isoproterenol.....is a nonselective beta agonist........after using drug X.....there is no significant change Phenylephrine.....is an alpha agonist...alpha1>alpha2......after using drug X.....there is a significant change....dec. force from 13.....to....5.5 So drug X must be an alpha 1 antagonist......between choices Prazosin is an alpha 1 antagonist 42.DD 43.DD the difference O2 saturation% between right atrium ..75%....and right ventricel... 83% shows there is a openenig/shunt between two ventricles that causes to move oxygenated blood from left to right ventricle....so VSD....Holosystolic ,harsh sounding murmur..loudest at tricuspid area 44.CC Secoundary hyperparathyroidism...look at Q35 45.DD Rheumatoid artheritis....Autoimmune inflamatory diseaseaffecting synovial joints with pannus formation in joint....MCP and PIP.......****no DIP...Osteoarthritis*** Subcutaneous rhem.nodules,ulnar deviation,subluxation Baker's cyst...Behind the knee nodules 80% have Positive Rheumatic factor...anti-antiG antibody strong association with....HLA-DR4

clinical presentation.....morning stifness improving with use,symmetric joint involvment..and systemic symptoms...tempreture,fatigue,pleuritis,pericarditis 46 E

47 B Brother, if the new born Male low threshold mean more susceptible to have the disease it's tricky Q Males are more commonly affected than females, with firstborn males affected about four times as often, and there is a genetic predisposition for the disease.[2] It is commonly associated with people of Jewish ancestry,

and has multifactorial inheritance patterns.[3] Pyloric stenosis is more common in whites than Hispanics, African Americans, or Asians. http://en.wikipedia.org/wiki/Pyloric_stenosis I think A...because the chance of geting of this abnormality in males more than females..so if this Patient is a female the chance of her brother is much more than other ones 48.EE The thymus and parathyroid, both derivatives of the 3rd pharyngeal pouches 49.CC Bosentan is a dual endothelin receptor antagonist used in the treatment of pulmonary artery hypertension (PAH). Bosentan is a competitive antagonist of endothelin-1 at the endothelin-A (ET-A) and endothelin-B (ET-B) receptors. Under normal conditions, endothelin-1 binding of ET-A or ET-B receptors causes pulmonary vasoconstriction. By blocking this interaction, bosentan decreases pulmonary vascular resistance. Bosentan has a slightly higher affinity for ET-A than ETB. 50-D Common variable hypogammaglobulinemia, unknown molecular defect, onsets in late teens, early tewnties, B cells presents in peripheral blood, immunoglobulin levels decreased with time,; increased autoimmunity, the albumin can be normal or low, but the gamma globulin always is low, this curve is the same for Lymphoproliferative disorders, inflammatory bowel disease, congenital immunodeficiencies

BLOCK 4

1.CC Antiphospholipid antibody testing may be ordered when a patient has symptoms suggestive of a thrombotic episode, such as pain and swelling in the extremities, shortness of breath, and headaches. It also may be ordered when a woman has had recurrent miscarriages and/or as a follow-up to a prolonged PTT test. Cardiolipin antibodies (IgG, IgM, and sometimes IgA) are frequently ordered as they are the most common antiphospholipids. If a patient has a prolonged PTT test, further lupus anticoagulant testing is usually indicated If the tests indicate the presence of the lupus anticoagulant and it persists when retested, then it is likely that the patient is positive for the lupus anticoagulant. Patients who have one or more antiphospholipid antibodies and those that are diagnosed with antiphospholipid syndrome have an increased risk of having recurrent thrombotic episodes, recurrent miscarriages, and thrombocytopenia. Occasionally, antiphospholipid testing may be ordered to help determine the cause of a positive VDRL/RPR test for syphilis. The reagents used to test for syphilis contain phospholipids and can cause a false positive result in patients with antiphospholipid antibodies 2.EE MAO inhibitors are contraindicated with SSRI's.. May cause serotonin syndrome due to excess synaptic serotonin.. S/S-diarrhea,flushing,muscle spasm,etc. 3.BB Cohort study by concept is prospective, the patient are follow forward in time, the population should be follow long enough for incidence to appear, according to the question there is no decresed between both group ---MI and placebo group----the study get the information in retrospective condition. C, D, E discarded to precoz, no enough time with the study to

place en practice----- A NO because cross sectional is used to determine prevalence or to establish etiology 4.DD

Syphilis is a sexually transmitted disease caused by the spirochetal bacteria Treponema pallidum subspecies pallidum. The primary route of transmission of syphilis is through sexual contact however it may also be transmitted from mother to fetus during pregnancy or at birth resulting in congenital syphilis. The signs and symptoms of syphilis vary depending on which of the four stages it presents in (primary, secondary, latent, and tertiary). The primary stage typically presents with a single chancre, secondary syphilis with a diffuse rash, latent with little to no symptoms, and tertiary with gummas, neurological, or cardiac symptoms. Diagnosis is usually via blood tests. It can be effectively treated with antibiotics, specifically intramuscular penicillin G.

5.EE Type II cells are responsible for the production and secretion of surfactant (the majority of which are dipalmitoylphosphatidylcholine), a group of phospholipids that reduce the alveolar surface tension. Surfactant phospholipids are stored in Type II pneumocytes in lamellar bodies, which are specialized vesicles. Release of surfactant in lamellar bodies occurs from an infant's first breath onwards. Type II pneumocytes can replicate in the alveoli and will replicate to replace damaged Type I pneumocytes.

6.CC

Body store iron deficiency is diagnosed by diagnostic tests as a low serum ferritin, a low serum iron level, an elevated serum transferrin and a high total iron binding capacity (TIBC). A low serum ferritin is the most sensitive lab test for iron deficiency anemia Serum iron levels (i.e., iron not part of the hemoglobin in red cells) may be measured directly in the blood, but these levels increase immediately with iron supplmentation. The diagnosis of IDA requires that a patient be anemic and show laboratory evidence of iron deficiency. Red blood cells in IDA are usually described as being microcytic (i.e., mean corpuscular volume less than 80 m3 [80 fL])

and hypochromic, however the manifestation of iron deficiency occurs in several stages. 7.DD Hydrocholorothiazide ......Hypercalcemia http://courses.washington.edu/bonephys/hypercalU/opthiazide.html 8.DD IgG is the only Ig that transports through the placenta 9. C

Pneumothorax (plural pneumothoraces) is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions ("primary") as well as in those with lung disease ("secondary"), and many pneumothoraces occur after physical trauma to the chest, blast injury, or as a complication of medical treatment.[1][2] The symptoms of a pneumothorax are determined by the size of the air leak and the speed by which it occurs; they may include chest pain in most cases and shortness of breath in many. The diagnosis can be made by physical examination in severe cases but usually requires a chest X-ray or computed tomography (CT scan) in milder forms. In a small proportion, the pneumothorax leads to severe oxygen shortage and low blood pressure, progressing to cardiac arrest unless treated; this situation is termed tension pneumothorax 10. B Hypertrophic cardiomyopathy is a disease of the myocardium (the muscle of the heart) in which a portion of the myocardium is hypertrophied (thickened) without any obvious cause.[1][2][3][4][5][6] It is perhaps most well-known as a leading cause of sudden cardiac death in young athletes.[7] The occurrence of hypertrophic cardiomyopathy is a significant cause of sudden unexpected cardiac death in any age group and as a cause of disabling cardiac symptoms. Younger people are likely to have a more severe form of hypertrophic cardiomyopathy HCM is frequently asymptomatic until sudden cardiac death, and for this reason some suggest routinely screening certain populations for this disease.[8] A cardiomyopathy is a primary disease that affects the muscle of the heart. With hypertrophic cardiomyopathy (HCM), the sarcomeres (contractile elements) in the heart replicate causing heart muscle cells to increase in size, which results in the thickening of the heart muscle. In addition, the normal alignment of muscle cells is disrupted, a phenomenon known as myocardial disarray. HCM also causes disruptions of the electrical functions of the heart. HCM is most commonly due to a mutation in one of 9 sarcomeric genes that results in a mutated protein in the sarcomere, the primary component of the myocyte (the muscle cell of the heart).

Myosin heavy chain mutations are associated with development of familial hypertrophic cardiomyopathy. About 50-60% of patients with a high index of clinical suspicion for HCM will have a mutation identified in at least 1 of 9 sarcomeric genes. Approximately 45% of these mutations occur in the myosin heavy chain gene on chromosome 14 q11.2-3, while approximately 35% involve the cardiac myosin binding protein C gene. Since HCM is typically an autosomal dominant trait, children of an HCM parent have 50% chance of inheriting the disease-causing mutation. Whenever a mutation is identified through genetic testing, family-specific genetic testing can be used to identify relatives atrisk for the disease (HCM Genetic Testing Overview). In individuals without a family history of HCM, the most common cause of the disease is a de novo mutation of the gene that produces the -myosin heavy chain. 11. B Erectile dysfunction (ED, "male impotence") is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual performance. A study in 2002 found that ED can also be associated with bicycling. The number of hours on a bike and/or the pressure on the penis from the saddle of an upright bicycle is directly related to erectile dysfunction Causes Drugs (anti-depressants (SSRIs) and nicotine are most common) Neurogenic disorders (spinal cord and brain injuries, nerve disorders such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and stroke[4]) [5] Cavernosal disorders (Peyronie's disease ) Psychological causes: performance anxiety, stress, mental disorders (clinical depression, schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders or traits[6]), psychological problems, negative feelings.[7][not in citation given] Surgery (radiation therapy, surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. Prostate and bladder cancer surgery often require removing tissue and nerves surrounding a tumor, which increases the risk for impotence[8])

Ageing. It is four times higher in men in their 60s than in men in their 40s.[9] Kidney failure Diseases such as diabetes and multiple sclerosis (MS). While these two causes have not been proven theyre likely suspects as they cause issues with both the blood flow and nervous systems. Lifestyle: smoking is a key cause of erectile dysfunction.[10][11] Smoking causes impotence because it promotes arterial narrowing

12. D Type IV Hypersensitivity: Delayed type ( 48 - 72 hrs), CD4 +TH1 cells mediate, Activate macrophages, causes inflamation, common in chronic intracellular inflamation. (Kaplan micro immuno book page 158). 13. D Stage 0 Tis N0 M0 Tis: Tumor confined to mucosa; cancer-in-situ Stage I T1 N0 M0 T1: Tumor invades submucosa Stage I T2 N0 M0 T2: Tumor invades muscularis propria Stage II-A T3 N0 M0 T3: Tumor invades subserosa or beyond (without other organs involved) Stage II-B T4 N0 M0 T4: Tumor invades adjacent organs or perforates the visceral peritoneum Stage III-A T1-2 N1 M0 N1: Metastasis to 1 to 3 regional lymph nodes. T1 or T2. Stage III-B T3-4 N1 M0 N1: Metastasis to 1 to 3 regional lymph nodes. T3 or T4. Stage III-C any T, N2 M0 N2: Metastasis to 4 or more regional lymph nodes. Any T.

Stage IV any T, any N, M1 M1: Distant metastases present. Any T, any N. http://en.wikipedia.org/wiki/Colorectal_cancer#Staging 14. D Posterior urethral valve (PUV) disorder is an obstructive developmental anomaly in the urethra and genitourinary system of male newborns.[1] A posterior urethral valve is an obstructing membrane in the posterior male urethra as a result of abnormal in utero development. It is the most common cause of bladder outlet obstruction in male newborns. The disorder varies in degree, with mild cases followed conservatively. More severe cases can have renal failure and even respiratory failure from lung underdevelopment as result of low amniotic fluid volumes, requiring intensive care and close monitoring. Abdominal ultrasound is of some benefit, but not diagnostic. Features that suggest posterior urethral valves are bilateral hydronephrosis, a thickened bladder wall with thickened smooth muscle trabeculations, and bladder diverticula. 15.BB

B.....100% sensitivity

C.....most accurate D....100%specificity 16.DD Natural killer cells (or NK cells) are a type of cytotoxic lymphocyte that constitute a major component of the innate immune system. NK cells play a major role in the rejection of tumors and cells infected by viruses.

NK cells are cytotoxic; small granules in their cytoplasm contain proteins such as perforin and proteases known as granzymes. Upon release in close proximity to a cell slated for killing, perforin forms pores in the cell membrane of the target cell, creating an aqueous channel through which the granzymes and associated molecules can enter, inducing either apoptosis or osmotic cell lysis. 17.CC

Ehler-Danlos syndrome...faulty collagen synthesis causing:

Hyperextensible skin tendency to bleed hypermobile joint...may be assiciated with joint dislocation,berry aneurism and organ rupture Type III collagn is most frequently accected Can be AR or AD 18.CC Increased estrogen produces higher levels of thyroid-binding globulin, a protein that transports thyroid hormone in the blood. These normal hormonal changes can sometimes make thyroid function tests during pregnancy difficult to interpret. Low TSH levels may occur in a normal pregnancy, however, especially in the first trimester. If TSH levels are low, another blood test is performed to measure T4 and T3. Elevated levels of free T4the portion of thyroid hormone not attached to thyroid-binding proteinsconfirm the diagnosis. Rarely, free T4 levels are normal in a woman with hyperthyroidism but T3 levels are high. Because of normal pregnancy-related changes in thyroid function, test results must be interpreted with caution. 19.BB The ureter passes under the uterine artery in females and the ductus deferens in the males in the pelvis. The gonadal arteries cross the ureter in its middle 1/3 in the abdominal cavity where it overlies posas major. In pelvic surgery, particularly during hysterectomy, the ureter is at risk when the uterine artery is ligated and divided

20.AA High levels of AFP may suggest that the developing baby has a neural tube defect such as spina bifida or anencephaly. High levels of AFP may also suggest defects with the esophagus or a failure of the baby's abdomen to close.However, the most common reason for elevated AFP levels is inaccurate dating of the pregnancy. Low levels of AFP and abnormal levels of hCG and estriol may indicate that the developing baby has Trisomy 21( Down syndrome), Trisomy 18 (Edwards Syndrome) or another type of chromosome abnormality 21.CC Baclophen is an agonist for the GABAB receptors. Its beneficial effects in spasticity result from actions at spinal and supraspinal site. Baclofen is widely used for the treatment of spastic movement disorders, especially in instances of spinal cord injury, spastic diplegia cerebral palsy, multiple sclerosis, amyotrophic lateral sclerosis , peripheral neuropathy and trigeminal and glossopharyngeal neuralgias. 22.BB pleiotropy the production by a single gene of multiple phenotypic effects. The term is often used to refer to a single gene defect that is expressed as problems in multiple systems of the body, such as in osteogenesis imperfecta, where the gene causes defects in several different systems that contain collagen. 23.DD Tay-Sac Disease is caused by insufficient activity of an enzyme called hexosaminidase A that catalyzes the biodegradation of fatty acid derivatives known as gangliosides. Hexosaminidase A is a vital hydrolytic enzyme, found in the lysosomes, that breaks down phospholipids.

When Hexosaminidase A is no longer functioning properly, the lipids accumulate in the brain and interfere with normal biological processes. GM2 Gangliosides are made and biodegraded rapidly in early life as the brain develops. Patients and carriers of TaySachs disease can be identified by a simple blood test that measures hexosaminidase A activity. 24.DD Anthrax is a disease caused by Bacillus anthracis, a spore-forming, Gram positive, rod-shaped bacterium (Fig. 1). The lethality of the disease owes itself to the bacterium's two principal virulence factors: (i) the polyglutamic acid capsule, which is anti-phagocytic, and (ii) the tripartite protein toxin, called anthrax toxin. Anthrax toxin is a mixture of three protein components: (i) protective antigen (PA), (ii) edema factor (EF), and (iii) lethal factor (LF). 25.EE Gynecomastia is overdevelopment of the male breast. The glandular tissue of the breast swells, usually in response to an excess of the female hormone estrogen or a lack of testosterone, a male hormone. It occurs in babies, teen boys, and older men. 26.AA It is Sargramostim....GM-CSF - For febrile neutropenia: Adults dosage is 510 g/kg IV or SC once daily is sufficient to support the Absolute Neutrophil Count during an episode of febrile neutropenia. - For the treatment of congenital, idiopathic, and cyclic neutropenia and hastens the recovery of marrow from neutropenia after cancer chemotherapy

27.CC Supraspinatus helps deltoid abduct arm...innervated by Axillary n. Infraspinatus ..latealyrotate arms Teres Minor.....adducts and laterally rotates arm Subscapularis..medially rotates and adducts arm 28.BB Rapid correction of hyponatremia causing Central Pontine myelinosis which is characterised by acute paralysis,dysphagia,dysarthria and loss of consciousness. Wernicke encephalopathy is a syndrome characterised by ataxia, ophthalmoplegia, confusion, and impairment of short-term memory. It is caused by lesions in the medial thalamic nuclei, mammillary bodies, periaqueductal and periventricular brainstem nuclei, and superior cerebellar vermis, often resulting from inadequate intake or absorption of thiamine (vitamin B1), especially in conjunction with carbohydrate ingestion. It is most commonly correlated with prolonged alcohol, consumption resulting in thiamine deficiency. 29.FF Reovirus family..no envelope...DS RNA ...10-12 segments ..1.Rotavirus(children diarrhea) and 2. Reovirus(colorodo tick fever) Rotavirus is number 1 cause of fetal diarrhea in children less than 2...nonbloody ,watery stool and ELISA+ 30.DD Edema is caused by... 1.inc. capillary pressure(inc.capilary pressure and heart failure) 2.low plasma proteins...(dec. plasma colloid osmotic pressure.nephrotic symdrome ,liver failure)

3. inc. capillary pemiability (toxin,infection,burns) 4.inc. interestitial fluid colloid osmotic pressure(lymphatic blockage) 31. CC

Right Phrenic nerve and i got it right.The mediastinal space which is present between the parietal layer of serous pericardium and the fibrous pericardium contains both the phrenic N and the vagus N.So it can be both phrenic and vagus which are given in the options but i guessed it and i got it right. The answer should be C Dx of this CT picture really big pericardial effusion . Breast cancer is the second most common cause of malignant pericardial effusions. Approximately one in four patients with malignant pericardial effusions has breast cancer, and autopsy findings indicate that of all patients with breast cancer, approximately one in four had malignant pericardial effusion. Hematologic malignancies such as leukemia, Hodgkin disease, and non-Hodgkin lymphoma make up the third largest group (15% of cases).

the primary. Lung cancer, the most frequent source of neoplastic pericardial disease, accounts for about one-third of cases. PLEASE check this video:http://radiographics.rsna.org/content/21/2/439.full On both sides the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.[1] Both of these nerves supply motor fibres to the diaphragm and sensory fibres to the fibrous pericardium, mediastinal pleura, and diaphragmatic peritoneum. Open to more explanations 32.AA significant factor in AD is the greatly reduced presence of acetylcholine in the cerebral cortex. Acetylcholine is necessary for cognitive function. Alzheimer's disease (AD) is an irreversible, progressive disorder in which brain cells (neurons) deteriorate, resulting in the loss of cognitive functions, primarily memory, judgment and reasoning, movement coordination, and pattern recognition. In advanced stages of the disease, all memory and mental functioning may be lost. The cerebral cortex is an extremely convoluted and complicated structure associated with the "higher" functions of the mindthought, reasoning, sensation, and motion. The hippocampus plays a crucial role in learning and in processing various forms of information as long-term memory. Damage to the hippocampus produces global amnesia 33.DD Multi-infarct dementia, is one type of vascular dementia. Vascular dementia is the second most common form of dementia after Alzheimer's disease (AD)

in older adults. Multi-infarct dementia (MID) is thought to be an irreversible form of dementia, and its onset is caused by a number of small strokes or sometimes, one large stroke preceded or followed by other strokes. Risk factors for vascular dementia include hypertension, smoking, hypercholesterolemia, diabetes mellitus, and cardiovascular and cerebrovascular disease 34.CC The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habits.There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating or abdominal distention. People with IBS more commonly than others have gastroesophageal reflux, symptoms relating to the genitourinary system, chronic fatigue syndrome, fibromyalgia, headache, backache and psychiatric symptoms such as depression and anxiety. Some studies indicate that up to 60% of persons with IBS also have a psychological disorder, typically anxiety or depression. 35.EE Myelofibrosis, also known as myeloid metaplasia, is a disorder of the bone marrow. It is currently classified as a myeloproliferative disease in which the proliferation of an abnormal type of bone marrow stem cell results in fibrosis, or the replacement of the marrow with collagenous connective tissue fibers. Abdominal fullness related to an enlarged spleen (splenomegaly). Bone pain Bruising and easy bleeding due to inadequate numbers of platelets Fatigue Increased susceptibility to infection, such as pneumonia or diarrhea Pallor and shortness of breath while doing physical work due to anemia Because of a high rate of cell turnover, hyperuricemia and gout may also

complicate the picture The bone marrow is replaced by collagen fibrosis, impairing the patient's ability to generate new blood cells resulting in a progressive pancytopenia 36. C Mitochondria have their own genetic material, and the machinery to manufacture their own RNAs and proteins.

Leigh's disease, also known as Subacute Necrotizing Encephalomyelopathy (SNEM), is a rare neurometabolic disorder that affects the central nervous system. There is another form of this disease called the X-linked Leigh's syndrome (OMIM 308930), which is a mutation in the oxidative phosphorylation enzymes (which are on both the mtDNA and the nuclear DNA). The X-linked Leigh's disease is a mutation of a gene encoding PDHA1, part of the pyruvate dehydrogenase complex, located on the X chromosome It is an inherited disorder that usually affects infants between the age of three months and two years, but, in rare cases, teenagers and adults as well. In the case of the disease, mutations in mitochondrial DNA (mtDNA) or in nuclear DNA (gene SURF1[2] and some COX assembly factors) cause degradation of motor skills and eventually death. Mitochondria are an essential organelle in eukaryotic cells. Their function is to convert the potential energy of glucose, amino acids, and fatty acids into adenosine triphosphate (ATP). Mitochondria carry their own DNA, called mitochondrial DNA [mtDNA]. The information stored in the mtDNA is used to produce several of the enzymes essential to the production of ATP. Mutations in the mtDNA that cause the mitochondria to fail, to function improperly, a person is at risk for a number of disorders, including Leigh's disease. In the case of Leigh's disease, crucial cells in the brain stem have mutated mtDNA, creating poorly functioning mitochondria. This causes a chronic lack of energy in the cells, which, in turn, affects the central nervous system and inhibits motor functions. http://en.wikipedia.org/wiki/Leigh's_disease

37. B Mebendazole or MBZ is a benzimidazole drug developed by Janssen Pharmaceutica and marketed as Vermox, Ovex, Antiox, and Pripsen. It is used to treat infestations by worms including pinworms, roundworms, tapeworms, hookworms, and whipworms Mechanism of action Mebendazole is thought to work by selectively inhibiting the synthesis of microtubules in parasitic worms, and by destroying extant cytoplasmic microtubes in their intestinal cells: thereby blocking the uptake of glucose and other nutrients, resulting in the gradual immobilization and eventual death of the helminths. The drug is a highly effective broad spectrum antihelminitic indicated for the treatment of nematode infestations, including round worm, whip worm, thread worm, and hook worm. It is poorly absorbed and has no systemic effects. 38. C 39. A

Acute pyelonephritis: Affects cortex with relative sparing of glomeruli /vessels white cells cast in urine are clssic. Present fever, CVA tenderness, nausea and vomiting. Acute pyelonephritis is characterized by neutrophilic inflitrationand abscessformation within the renal interstitium. Abscess may rupture, introduction collections of white cells to the tubular lumen. 40. A

x Middle cerebral artery syndrome is a condition whereby the blood supply from the middle cerebral artery (MCA) is restricted, leading to a reduction of the function of the portions of the brain supplied by that vessel: the lateral aspects of frontal, temporal and parietal lobes, the corona radiata, globus pallidus, caudate and putamen. The MCA is the most common site for the occurrence of ischemic stroke Signs and Symptoms 1. Hemiparesis or hemiplegia of the lower half of the contralateral face[2] 2. Hemiparesis or hemiplegia of the contralateral upper and lower extremities*[2]

3. Sensory loss of the contralateral face, arm and leg*[2] 4. Ataxia of contralateral extremities*[1] 5. Speech impairments/aphasia: Broca's, Wernicke's or Global aphasia as a result of a dominant hemisphere lesion (usually the left brain)[1][2][3] 6. Perceptual deficits: hemispatial neglect, anosognosia, apraxia, and spatial disorganization as a result of a non-dominant hemisphere lesion (usually the right brain)[1][3] 7. Visual disorders: deviation conjuge, a gaze preference towards the side of the lesion; contralateral homonymous hemianopsia. 41. B Diabetic ketoacidosis (DKA) is a potentially life-threatening complication in patients with diabetes mellitus. It happens predominantly in those with type 1 diabetes, but it can occur in those with type 2 diabetes under certain circumstances. DKA results from a shortage of insulin; in response the body switches to burning fatty acids and producing acidic ketone bodies that cause most of the symptoms and complications. Diabetes mellitus type 1 (Type 1 diabetes, IDDM, or, formerly, juvenile diabetes) is a form of diabetes mellitus that results from autoimmune destruction of insulin-producing beta cells of the pancreas.[2] The subsequent lack of insulin leads to increased blood and urine glucose. The classical symptoms are polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger), and weight loss. Pathophysiology The pathophysiology in diabetes type I is basically a destruction of beta cells in the pancreas, regardless of which risk factors or causative entities have been present. Individual risk factors can have separate pathophysiological processes to, in turn, cause this beta cell destruction. Still, a process that appears to be common to most risk factors is an autoimmune response towards beta cells, involving an expansion of autoreactive CD4+ and CD8+ T helper cells, autoantibody-producing B cells and activation of the innate immune system. 42. C In contraction, the wound is made smaller by the action of myofibroblasts, which establish a grip on the wound edges and contract themselves using a

mechanism similar to that in smooth muscle cells. When the cells' roles are close to complete, unneeded cells undergo apoptosis. If contraction continues for too long, it can lead to disfigurement and loss of function. 43. B. Anorexia nerviosa: excessive dieting +/- purging intense fear of gaining weight , body imagen distortion, and exercise , leading to body weight < 85% below ideal body weight. Associated with body density.severe weight loss, metatarsal stress fractures, amenorrhea ( GnRH, LH, FSH, estrogen), anemia, and electrolyte disturbances. Sen primarily in adolescent girls. Commonly coexist with depression. ( FA 2010 page 447) 44. D Vitamine B12 defficiency: Macrocytic , megaloblastic anemia, hypersegmented PMN, neurologic symptoms ( paresthesias, subacuted combined degeneration) due to anormal myelin. Prolonged deficiency leads to irreversible nervous system damage 45. E Standard deviation is a widely used measurement of variability or diversity used in statistics and probability theory. It shows how much variation or "dispersion" there is from the average (mean, or expected value). A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data are spread out over a large range of values. 46. A Calcitonin: Source: Parafollicular cells ( C cells ) of thyroid. Acts to bone reabsorption. Regulation: serum Ca causes calcitonin secretion. ( FA 2010 page 289) 47. A 48. D Phenylketonuria: Due to phenylalanine hydroxylase, or tetrahydrobiopterin cofactor. Thyrosine becomes essential. Findings: mental

retardation, growth retardation, seizures, fair skin, eczema, musty body odor. Treatment: phenylalanine ( contained in aspartame, eg, Nutrasweet) and thyrosine in diet. ( FA page 107) 49. D Methrotexate: mechanism of action The similar structure of dihydrofolic acid (top) and methotrexate (top) suggests that methotrexate is a competitive inhibitor Methotrexate competitively inhibits dihydrofolate reductase (DHFR), an enzyme that participates in the tetrahydrofolate synthesis.[4] The affinity of methotrexate for DHFR is about one thousand-fold that of folate. DHFR catalyses the conversion of dihydrofolate to the active tetrahydrofolate. Folic acid is needed for the de novo synthesis of the nucleoside thymidine, required for DNA synthesis. Also, folate is needed for purine base synthesis, so all purine synthesis will be inhibited. Methotrexate, therefore, inhibits the synthesis of DNA, RNA, thymidylates, and proteins. Methotrexate acts specifically during DNA and RNA synthesis, and thus it is cytotoxic during the S-phase of the cell cycle. Logically, it therefore has a greater toxic effect on rapidly dividing cells (such as malignant and myeloid cells, and gastrointestinal and oral mucosa), which replicate their DNA more frequently, and thus inhibits the growth and proliferation of these noncancerous cells, as well as causing the side effects listed below. Facing a scarcity of dTMP, rapidly dividing cancerous cells undergo cell death via thymineless death. Thymidylate synthetase (EC 2.1.1.45)[1] is the enzyme used to generate thymidine monophosphate (dTMP), which is subsequently phosphorylated to thymidine triphosphate for use in DNA synthesis and repair. 5,10-methylenetetrahydrofolate + dUMP dihydrofolate + dTMP By means of reductive methylation, deoxyuridine monophosphate (dUMP) and N5,N10-methylene tetrahydrofolate are together used to form dTMP, yielding dihydrofolate as a secondary product. 50. E Carotid Massage: afferent activity, Parasympathetic, sympathetic activity, HR, , BP

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