A 71-year-old man was admitted to the hospital after getting very dizzy upon rising from the toilet seat. At that time his pulse was racing and he remembers that his stool looked very different than usual. Over the last 4 or 5 weeks before the incident, the patient self-medicated with high-dose ibuprofen three times a day to control some pain in his hips. What is the mechanism of action for nonsteroidal anti-inflammatory drugs (NSAIDs) to cause gastrointestinal (GI) bleeding?
Answer(s): C
NSAIDs inhibit cyclooxygenase and consequently inhibit (not promote, choice E) synthesis of prostaglandins. In the stomach, prostaglandins have a cytoprotective effect through inhibition of acid secretion, enhancement of mucosal blood flow, and stimulation of bicarbonate and mucus secretion.Inhibiting these processes can cause stomach ulcers and bleeding such as described in the case.Arachidonic acid (choice A) is not directly affected by NSAIDs--it is turned into prostaglandin bythe action of cyclooxygenases. NSAIDs do not regulate bradykinin and histamine synthesis (choices B and D).
A 52-year-old man has a history of anginal pain that until recently was responsive to nitrates. He is now evaluated for possible angioplasty. The graph in below figure shows the ECG of this patient. Blood flow across the mitral valve is largest around which indicated point in this ECG tracing?
Answer(s): E
The most rapid filling of the ventricles occurs in early diastole, immediately after opening of the atrioventricular valves. This happens after the repolarization phase (T wave) and resulting relaxation of the cardiac ventricular muscle. Excitation of the atria (choice A) also results in increased blood flow into the ventricles, occurring around choice B. However, the flow at that time is less than during early diastole.Ventricular contraction begins with the QRS complex (choice C) and lasts until the end of the T wave (choice D). During this time, the mitral and tricuspid valves are closed.
The graph in below figure shows the pressurevolume curve of the left ventricle of this patient (shaded area). The pressurevolume curve of a normal subject is shown for comparison (broken lines). Compared to normal, which term best describes this patient's heart?
Answer(s): D
Note that the end-diastolic volume of this patient is the same as that of a normal subject. Because the patient's stroke volume is larger than that of a normal subject, the force of contraction must also be larger.This could be due to increased sympathetic tone or to the fact that the patient took inotropic medications.The volume remaining after the ventricular contraction is correspondingly smaller compared to normal.Preload (choices B and E) equals end-diastolic volume and is the same in the patient and normal subjects.Afterload (choice A) is equal to arterial pressure. Both afterload and stroke volume (choice C) are larger in this patient compared to normal.
The graph in below figure shows the jugular vein pressure curve of this patient. If the first heart sound occurs between letters C and D, which part of the curve represents the atrial contraction?
Answer(s): B
below figure shows the jugular vein pressure curve. Pressure in the jugular vein reflects atrial pressure and is highest during the atrial contraction (named the "a wave"). The "v wave" (choice A) represents the rise in atrial pressure before the tricuspid valve opens during diastole. The "y notch" (choice D) is due to the fall in atrial pressure during the ventricular filling phase. The "c wave" (choice C) is due to the rise in atrial pressure produced by the bulging of the tricuspid valve during isovolumetric contraction of the right ventricle. The "x notch" (choice E) coincides with the ventricular ejection phase.
A 14-year-old boy presents with weight loss and diarrhea. His tongue becomes sore and blistery after eating oatmeal or rye bread, which leads to the diagnosis of celiac disease. The boy and his parents are advised to be sensitive to symptoms of tetany and paresthesias, since they can occur as a consequence of malabsorption of which of the following?
Answer(s): A
In patients with celiac disease the protein gluten, which is found in bread, oats, and many other foods containing wheat, barley, or rye, triggers an autoimmune response that causes damage to the small intestine leading to widespread manifestations of malabsorption. Calcium is difficult to absorb, so patients frequently experience symptoms of hypocalcemia such as muscle cramping, titanic contractions, numbness, and tingling sensations. For sensory and motor nerves, calcium is a critical second messenger involved in normal cell function, neural transmission, and cell membrane stability. The nerves respond to a lack of calcium with hyperexcitability. The inability to absorb nutrients such as carbohydrates (choice B) leads to weight loss as experienced by the boy. Fat malabsorption (choice C) is not uncommon in patients with celiac disease as a consequence of greatly diminished absorptive surface. It would manifest in steatorrhea. Iron (choice D), like calcium, is difficult to absorb and may lead to anemia. The general decrease in electrolyte absorption leads to decreased water absorption (choice E). The increased osmotic load in the GI lumen accounts for the boy's diarrhea.
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