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Answers 1>The Correct Answer Is A. Fascial Straps (Retinacula) And

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Answers 1>The Correct Answer Is A. Fascial Straps (Retinacula) And Answers 1>The correct answer is A. Fascial straps (retinacula) and fascial coverings of muscles or muscle groups characteristically attach to nearby bones by blending with the covering periosteum. No deep attachments are usually made by fascia. Cancellous bone (choice B) is spongy bone, which is usually found in marrow, and is not the site for fascial attachment. Fascia do not usually attach to cartilage (choice C). Fascia attaches to bony shafts, or diaphyses (choice D), superficially via the periosteum. Fascia do not penetrate the bone to reach the marrow (choice E). 2>The correct answer is D. The lesion is a malignant melanoma. Melanomas can develop either de novo or in an existing mole. Sunlight exposure is a significant risk factor and fair-skinned persons are at increased risk of developing melanoma. The most significant factor for long term prognosis is the depth of the lesion, since the superficial dermis lies about 1 mm under the skin surface, and penetration to this depth is associated with a much higher incidence of metastasis than is seen with a more superficial location. The circumference of the lesion (choice A) is much less important than depth , since one form of melanoma (superficial spreading) can still have good prognosis despite large size, if it has not extended to the depth of the superficial dermal lymphatic bed. The darkness (choice B) or degree of variation in color (choice C) do not have prognostic significance once melanoma is diagnosed. Irregularity, or fuzziness at the border (choice E) of a mole-like lesion is a good clue to potential malignancy, but does not affect prognosis once a melanoma is diagnosed. ________________________________________ 3>The correct answer is E. Beta-adrenergic blockade may blunt or prevent the premonitory signs and symptoms (e.g., tachycardia, blood pressure changes) of acute episodes of hypoglycemia. Non-selective beta-blockers, such as propranolol, may even potentiate insulin-induced hypoglycemia. Even though this effect is less likely with cardioselective agents, the use of either cardioselective or non-selective beta-blockers in diabetics is not recommended due to their "masking" effect of the normal warning signs and symptoms of hypoglycemia. None of the drugs listed in the othe r choices will blunt the premonitory signs and symptoms of hypoglycemia. Captopril (choice A) is an angiotensin-converting enzyme (ACE) inhibito r that can be safely used for the treatment of hypertension in diabetic patients. Diltiazem (choice B) is a calcium channel blocker that is also considered to be safe and effective for the treatment of hypertension in diabetic patients. Both methyldopa (choice C), a centrally acting alpha-adrenergic agonist , and prazosin (choice D), an alpha1-adrenergic antagonist, can be safely used to treat hypertension in diabetic patients. However, due to the side effect profile of these medications, they are generally used only in diabetic patients who are unresponsive to ACE inhibitors and calcium channel blockers. ________________________________________ 4>The correct answer is A. Acute pyelonephritis is an infectious disease involving the kidney parenchyma and the renal pelvis. Gram-negative bacteria, such as Escherichia coli, Proteus, Klebsiella, and Enterobacter, are the most common causative organisms in acute pyelonephritis. Laboratory evaluation will often reveal leukocytosis with a left shift, and urinalysis typically shows pyuria, varying degrees of hematuria , and white cell casts. Since bacteremia is present, the patient should be hospitalized and empirically started on IV ampicillin and gentamicin . This regimen may be need to be changed, however, once the sensitivity results are available. Erythromycin (choice B) and tetracycline (choice E) are both bacteriostatic antibiotics and would not be recommended in a patient with a severe infection, such as acute pyelonephritis with bacteremia. Vancomycin (choice C) is primarily used in the treatment of severe gram-positive infections. Phenazopyridine (choice D) is a urinary analgesic, and nitrofurantoin (choice D) is a urinary tract anti-infective. Although nitrofurantoin is indicated for the treatment of "mild" cases of pyelonephritis, as well as cystitis, this patient's condition is severe and should be treated with appropriate antibiotics. ________________________________________ 5>The correct answer is E. The patient is suffering from hyperacute rejection due to the preformed anti-B ABO blood group antibody found in all type A positive individuals. Hyperacute rejection occurs within minutes to a few hours of the time of transplantation, and is due to the destruction of the transplanted tissue by preformed antibodies reacting with antigens found on the transplanted tissue that activate complement and destroy the target tissue. Preformed antibodies can also be due to presensitization to a previous graft, blood transfusion, or pregnancy. Acute rejection due to antibody-mediated immunity (choice A) is incorrect because this patient suffered from hyperacute rejection (immediate) occurring within minutes to hours, rather than days. Acute rejection due to cell-mediated immunity (choice B) will not occur until several days or a week following transplantation. Acute rejection is due to type II and type IV reactions. Chronic rejection, due to the presence of cell-mediated immunity to minor HLA antigens (choice C), occurs in allograft transplantation months to even years after the transplant. Chronic rejection is generally caused by both humoral and cell-mediated immunity. An accelerated acute rejection, occurring in 3-5 days, can be caused by tissue infiltration and destruction by presensitized T lymphocytes and macrophages (choice D) and/or antibody-dependent, cell-mediated cytotoxicity (ADCC). Note that this is not a hyperacute reaction. ________________________________________ 6>The correct answer is E. Arrow E points to a smooth muscle cell in the media of the arteriole. Alpha1 agonists stimulate alpha1 receptors present on the smooth muscle, which leads to an increase in intracellular calcium via phosphatidylinositol hydrolysis. This increase in calcium is necessary for smooth muscle contraction. Arrow A indicates an endothelial cell located in the intima of the arteriole. Nitric oxide, also known as endothelial cell relaxing factor (EDRF), is produced from arginine by endothelial cells. A muscarinic agonist can lead to the evolution of NO, producing vasodilatation. Arrow B indicates a polymorphonuclear leukocyte in the bloodstream. Arrow C indicates the basal lamina underlying the endothelium. Arrow D indicates the arteriolar adventitia. ________________________________________ 7>The correct answer is B. Hyperlipidemia has been subclassified based on the lipid and lipoprotein profiles. Type 2a, which this patient has, can be seen in a hereditary form, known as familial hypercholesterolemia, and also in secondary, acquired forms related to nephritic syndrome and hyperthyroidism. The root problem appears to be a deficiency of LDL receptors, which leads to a specific elevation of cholesterol in the form of increased LDL. Heterozygotes for the hereditary form generally develop cardiovascular disease from 30 to 50 years of age. Homozygotes may have cardiovascular disease in childhood. Type 1 (choice A) is characterized by isolated elevation of chylomicrons. Type 2b (choice C) is characterized by elevations of both cholesterol and triglycerides in the form of LDL and VLDL. Type 3 (choice D) is characterized by elevations of triglycerides and cholesterol in the form of chylomicron remnants and IDL. Type 5 (choice E) is characterized by elevations of triglycerides and cholesterol in the form of VLDL and chylomicrons. ________________________________________ 8>The correct answer is D. Wernicke-Korsakoff syndrome refers to the constellation of neurologic symptoms caused by thiamine deficiency. Among these, a severe memory deficit, which the patient may attempt to cover by making up bizarre explanations (confabulation), is prominent. Anatomical damage to the mamillary bodies and periventricular structures has been postulated as the cause. In the U.S., severe thiamine deficiency is seen most commonly in chronic alcoholics. Thiamine deficiency can also damage peripheral nerves ("dry" beriberi) and the heart ("wet" beriberi). Folic acid deficiency (choice A) produces megaloblastic anemia without neurologic symptoms. Niacin deficiency (choice B) produces pellagra, characterized by depigmenting dermatitis, chronic diarrhea, and anemia. Riboflavin deficiency (choice C) produces ariboflavinosis, characterized by glossitis, corneal opacities, dermatitis, and erythroid hyperplasia. Vitamin B12 deficiency (choice E) produces megaloblastic anemia accompanied by degeneration of the posterolateral spinal cord. ________________________________________ 9>The correct answer is A. Fibrinogen is cleaved by thrombin twice as it is activated to form fibrin. The initial cleavage causes it to polymerize and the second causes it to branch. Thrombin also activates Factor XIII to XIIIa, which crosslinks the fibrin strands and strengthens the clot. HMWK (choice B) is a cofactor in the intrinsic pathway that converts Factor XI to XIa. Plasminogen (choice C) is a central proenzyme in clot lysis. When plasminogen is converted to plasmin, it digests fibrin threads, as well as a number of protein factors including Factors V, VIII, XII, and prothrombin. Thrombin (choice D) is an enzyme derived from prothrombin. It converts fibrinogen to
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