NBME - NEW TESTS LATEST UPDATED 2022 QUESTIONS AND ANSWERS. Test Bank

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NBME - NEW TESTS LATEST UPDATED 2022 QUESTIONS AND ANSWERS 62 year old woman - osteoporosis - a bisphosphonate is prescribed. The expected beneficial effect of the drug is due to which of the follo... wing? Correct Answer-Decreased Osteoclast Activity Cohot Study of elderly women - relative risk ratio for hip fractures among those who exercise regularly is 1.2 (95% confidence interval of 1.1 to 1.8). Which of the following is the conclusion about the effect of exercise on the risk of hip fracture? Correct Answer-Statistically Significant Overall Increase Risk 52 year old man goes to ER with chest pain radiating to his jaw while shoveling snow. Pulse is 80/min and blood pressure is 130/70. The most immediate treatment mechanism of action? Correct AnswerIncreased nitric oxide concentration 24 year old woman - spilled hot grease on her left leg while working at a fast-food restaurant. Exam of leg shows 7cm pink, soft, granular, edematous wound. The formation of this tissue was most likely caused by increased activity of which? Correct Answer-a. Vascular Endothelial Growth Factor VEGF - stimulates angiogenesiss. TYPE III Collagen = Blood Vessels - early wound repair 27 year old man- MVC - skull x-ray shows a linear, nondepressed basal skull fracture - increased serum osm and decreased urin osm. Following desmopressin urine osm increases. Desmopressin's effect is due to the activation of which of the following? Correct Answer-a. Adenylyl CyclaseAdenylate Cyclase - ATP - CAMP -- PROTEKINASE A -- Ca v2 A 10 month old boy - 4 day history of fever and cough. He attends day care center. Chest exam shows intercostal retractions along with bilateral, diffuse wheezes and expiratory rhonchi. The infectious agent most likely has which of the following properties? Correct Answer-Mediation of Cell Entry via a fusion protein A 17 year old girl in ED - 15 minutes after being stung by a bee. Mild light headedness but no difficulty swallowing- Bilateral wheezing - Which is most appropriate pharmacotherapy for this patient? Correct Answer-B2- Agonist 14 year old boy - 2 day history of sore throat and fever that peaks in late afternoon. 1 week of fatigue. He recentaly had sex with one partner. Physical exam show cervical lymphadenopathy and pharyngeal erythema with a creamy exudate. DX? Correct Answer-Infectious Mononucleosis 57 year old man - radiation therapy for squamous cell carcinoma of the lung. Despite therapy, tumor increases in size and he dies 6 months later. The progressive tumor growth is due to a defect in cell cycle arrest in which of the following phases of cell cycle? Correct Answer-G1 28 year old - lived in sub-Saharan Africa - until he came to the US. Temp of 100.4 - imaging shows bilateral hydroureter and hydronephrosis. Biopsy shows marked fibrosis and scattered granulomas. DX? Correct Answer-SchistosomiasisA couple with a family history of a-thalassemia. Woman has one gene deletion and man has two gene deletion. If the two gene is trans - what percentage of offspring will have a two gene deletion? Correct Answer-50% previously healthy 40 year brought to emergency department by her husband - 2 day history of fever, lethargy, confusion. PE shows scattered petechiae and ecchymoses over the lower extremities - 3+ polychromasia and 3+ schistocytes and Low platelets Dx? Correct Answer-Thrombotic Thrombocytopenia Purpura 16 year old boy - is admitted to the ER because of a knife wound to the left side of his chest. An X-ray of the chest shows an air-fluid level in the left side of the chest, partial collapse of the left lung, and the elevation of the stomach bubble. The mediastinum is midline. DX? Correct AnswerHemopneumpothorax under tension 49 year old woman - coronary artery disease - BP 140/90 - High Cholesterol, High LDL (190), High triglycerides (350) - TX with atorvastatin and losartan. What are the effects on HDL and Triglycerides? Correct Answer-HDL increased Triglycerides Decreased 73 yeare old - diffuse weakness and tingling of her arms and legs. Sensation and vibration and position is decreased in all extremities. What vitamin deficiency? Correct Answer-Vitamin B12 - (cyanocobalamin) Tea and Toast - low B12 in diet15 year old girl - 3 month history of acne - which is the underlying cause of the patients acne? Correct Answer-Stimulation of Sebaceous Glands by androgens b. ACNE = Propionibacterium ACNE 4 year old from Brazil - PE shows single 12x10cm lesion in the right side of jaw with diffuse regular edges. Photomicrographs of an incisional biopsy (looks like Burkitts Lymphoma/ Starry night) - which of the processes most likely to occur in the region indicated by the arrow? Correct Answer-Apoptosis b. Endemic Burkitt lymphoma can happen in Brazil as well as Africa (jaw lesion, puffy face). 51 year old - lump on tongue - 1 pack smoking history for 30 years. 1.5 cm mass on apex of tongue. It is most appropriate to evaluate which lymph nodes first for evidence of metastasis? Correct AnswerSubmental 15 year old boy - ER - 2 hour history of confusion and agitation - fever, headache, stiff neck, and vomiting - since returned from summer camp - patient is hallucinating - lumbar puncture - shows cysts and trophozoites- most likely pathogen? Correct Answer-a. Olfactory Nerve Naegleria fowleri 17 year old - ED - 30 minutes after being found with a blank stare. Physical exam shows rigidity. During exam he becomes hostile and assaults physician - Pt ingested which drug? Correct Answer-PCPPlacebo controlled clinical trial - 5000 pts with essential hypertension. 2500 patients receive new drug and 2500 patients receive placebo. If alpha is set at 0.01 instead of 0.05, which of the following is most likely result? Correct Answer-Significant findings can be reported with greater confidence 17 year old - gymnast - comes to hospital because of lack of menstrual period for 6 months. BMI 15 Which is the cause of the amenorrhea? Correct Answer-Hypogonadotropic Hypogonadism A male stillborn is delivered at 32 weeks - Oligohydramnios - absence of a urethral opening. Which is most likely finding? Correct Answer-Pulmonary Hypoplasia A 6 day old - breast fed boy in ED - poor weight gain and irritability since delivery - Physical exam shows jaundice and hepatomegaly. The concentration of which of the following metabolites is most likely increased? Correct Answer-a. Galactose - 1 - phosphate b. Congenital intolerance to breast milk A 25-year-old man - comes to ED - severe muscle pain, diffuse, painful swelling of his neck, underarms, and groin after camping in New Mexico Generalized scattered black maculae. Examination of the right upper extremity shows erythematous, solid, tender mass. Mass is draining blood and necrotic material. The most effective antibiotic for patient disorder will interfere with which of the following processes? Correct Answer-a. Ribosomal Assembly b. Yersenia Pestis 45 year old - progressive weakness - muscle fasciculations of the upper extremities and weakness of the lower extremity - What additional findings? Correct Answer-Atrophyb. ALS = Lou Gherig A new severe respiratory illness - Why use a killed vaccine vs a live vaccine? Correct Answer-Avoids Concerns of reversion to virulence b. Killed vaccines - avoids reversion to virulence c. live vaccines - can (but rarely do) cause the disease they're designed to prevent A 33 year old - keratinizing squamous cell carcinoma of cervix. Which of the following describes pathogenesis of this patient's disease? Correct Answer-Inactivation of Cellular P53 b. p53 protein = tumor suppressor (it activates apoptosis) - most human cancer A 54 year old - 40 year history of T1DM - receiving hemodialysis for end stage renal disease while awaiting a kidney transplant. Receives a drug that induces reticulocyte release from bone marrow and stimulates a cytokine receptor that signals Jak/Stat pathway? Correct Answer-Erythropoietin Jak Stat - erythropoietin During a clinical study examining the effects of exercise. The average pulse is 175/min. Compared with measurement before the session, which is most likely decreased? Correct Answer-Total Peripheral Resistance An 8-year-old boy - 3-day history of fever, sore throat, and itchy eyes. Returned from week long summer camp that includes hiking trips and swimming - PE shows conjunctival injection and oropharyngealedema - Outbreak among other campers. Which is most likely cause of this patient's symptoms? Correct Answer-Adenovirus Fever+ Sore Throat + Itchy Eyes transmitted via swimming pools Conjunctivitis Viral = adenovirus 44-year-old woman - 10 month history of wide red streaks over her lower trunk (striae) and weight gain in face (moonface). Which additional findings? Correct Answer-Hypertension and muscle weakness b. Cushing - hypertension and muscle weakness 12 year old boy - pain below left knee -unable to play soccer - An x-ray shown - Which structures attached to the abnormal anterior tibial area? Correct Answer-patellar ligament b. Osgood-Schlatter A 65-year-old health maintenance exams - He lives is a single-family home with his cat and dog. He spend much of his time in his basement woodworking shop. This patient is increased risk for lung cancer due to which of the following environmental exposures? Correct Answer-Radon 54-year-old man - intense overwhelming fear. Which portion of brain stimulated? Correct AnswerAmygdala b. Fear = amygdala30 year old woman - recurrent URI - Sweat is Salty- Genetic testing for 36 most common mutations shows detectable G551D in one allele of CFTR - What is patients clinical phenotype? Correct Answer-The Second CFTR Gene was not detected by the testing obtained 74 year old - COPD - "I enjoy coming to see you because you remind me of my daughter. She died 35 years ago". Which is most appropriate response by physician? Correct Answer-You must miss your daughter very much. Tell me about her. b. PT = Transference 9 month old boy - awakens and cries at least once nightly and settles back to sleep after drinking a bottle of formula - Explanation for patient's sleep pattern? Correct Answer-Normal Development Pubertal gynecomastia in males is norma A 32 year old - abnormal movement in hands and worse when he feels angry - Unable to fix his gaze on one point or protrude his tongue for more than 30 sec - Pt most likely has anatomic abnormalities in which of the following locations? Correct Answer-Basal Ganglia A 14-year-old boy - recurrent otitis media since infancy - underwent tonsillectomy for obstructive sleep apnea - Cardiac auscultation exam listen - shows S3 - which is most likely finding? Correct AnswerNormal Findings b. normal physiologic splitting37 year old woman - right lower extremity edema - sudden SOB+, If present on physical exam which sign would be the most specific indicator or pulmonary arterial hypertension? Correct Answer-P2 louder than A2 b. Pulmonary Hypertension - Split S2 43 year old - with t2DM - ER - nausea and vomiting - after drinking champagne. Treated for Trichomonas Vaginalis Infection - TX with metronidazole. What is cause of nausea and vomiting? Correct AnswerAccumulation of Acetaldehyde b. Metronidazole - disulfiram reaction 45 year old man - right shoulder pain - patient unable to externally rotate the shoulder against resistance - Which of the following tendons is inflamed? Correct Answer-Infraspinatus b. SITS Muscles c. Teres Minor and Infraspinatus external rotation d. Innervated by Suprascapular Nerve A 44 year old man - 6 week feet numbness - chemotherapy with vincristine - MOA of Vincristine? Correct Answer-Depolymerization of Microtubules 10 year old - 95th percent height and 25th weight - Nurse thinks she has marfans - Molecular testing for FBN1 Gene shows single nucleotide change does not change amino acid at the locus - Explain the single nucleotide change in the patient and the mother? Correct Answer-It is a polymorphism26 year old woman - ED - 2 day history of runny nose - Patient has to wait 6 hours before she is seen. In addition to apologizing, which of the following is the most appropriate remark? Correct Answer-Thank you for waiting. How can I help you today? A 26 year old man - ER -m 30 minutes after being shot in the leg - Pulse is 120/min, respirations are 16 /min - blood pressure is 80/60. Findings compared with healthy adult? Correct Answer-Baroreceptor Firing decreased SVR increased Pulmonary Vascular Resistance Increased Absorption Increased e. BARORECPTOR - stretch receptors - mirror BP - decreased in hemorrhagic shock A 36 year old man - fluid is presenting adbomen in which of the following areas as indicated by the arrow? Correct Answer-Omental Bursa (lesser sac) What is the positive predictive value (refer to chart)? Correct Answer-.67 Probability that a patient with a positive test has a disease A/(A+B)A 75 year old woman with T2DM and HTN - Emigrated from Argentina - Which of the following is the most appropriate person to serve as an interpreter for this patient encounter? Correct AnswerTelephone Interpreter During a study of renal glomeruli - if efferent arteriole is constricted - which starling forces are likely to change in the glomeruli? Correct Answer-Increased Hydrostatic Pressure 2 year old with neurocognitive dysfunction - fine during birth - both parents have learning disabilities - maternal uncle with cognitive disabilities - Irritable making eye contact with flapping his hands? Correct Answer-Trinucleotide Repeat Expansion b. Fragile X - intellectual disability - trinucleotide repeat in FMR1 gene A 33 year old man - undergoes radical thyroidectomy - postop serum calcium is 7.5 and albumin concentration of 4g/dl - PTH concentration of 200 - damage to which vessel causes finding? Correct Answer-Branch of Thyrocervical Trunk b. inferior thyroid arteries, which arise from the thyrocervical trunk. c. External carotid - superior thyroid 46 year old woman - 2 month history of fatigue and muscle weakness - 10 year history of hypertension - treated with thiazide diurectics - measured hypokalemia, hypotension and decreased BP- brisk reflexes. Likely cause? Correct Answer-Adverse Drug Effect b. Treated with a thiazide diuretic for HTN with measured hypokalemia, hypotension and decreased Hg55-year old man - nice to nurses - mean to youngest child- Which is the most likely explanation of patient's behavior? Correct Answer-Splitting b. Cluster B - borderline personality (BANH) A Study designed to evaluate the feasibility of acupuncture in children with chronic headache - 60 children recruited - In addition to their usual therapy - all children are treated with acupuncture three times per week for 2 months - Describe findings? Correct Answer-Case-Series 6 year old girl - 1 week history - lots of infections -raised neutrophil count- but cells show a delay in bactericidal activity against Staph Aureus- Most likely cause? Correct Answer-Myeloperoxidase 2 year old boy - severe pain, swelling, and redness of his left thumb (image). PE shows oral vesicle, cervical lymphadenopathy - infectious agent causing findings in thumb? Correct Answer-DNA Virus Herpetic Whitlow Herpetic Whitlow Correct Answer-vesicles on fingers 7 year old - lives in Kentucky - 2 week history of cramping abdominal pain and diarrhea - mother looked in underpants and saw earthworm - no travel history- Transmission via? Correct Answer-Ingestion of Soil b. Ascaris - fecal oral transmission23 year old man with multiple sex partners - dysuria and yellow urethral exudate - Gram Stain - numerous neutrophils - many contain gram negative diplococci. He had 3 episodes over the past 2 years. Which property of the organism - explains reinfection? Correct Answer-Antigenic Variation b. Gram negative Diplococci c. N. gonorrhea can change its pilus, 23 year old woman - genetic counseling - brother and maternal uncle had Duchene Muscular Dystrophy - Serum CK of 120 - and mother serum CK 300- What is assessment of carrier status? Correct AnswerThe patients DMD carrier status is uncertain because of random X Inactivation b. Barr Body c. DMD is X-linked. 20 year old woman - heavy bleeding - Platelet Aggregation is normal - PTT elevated - no easy bruising - Which hemorrhagic disorder cause of patients menorrhagia? Correct Answer-Von Willebrand Disease B. Platelet aggregation time being normal, ok fine I can see that. 32 year old man - ER - for MVC - urethral injury - blood noted at the uretheral meatus. Which portion of the urethra would be at greatest risk of injury? Correct Answer-Membranous a. Pelvic fracture - MVC b. Pelvic Straddle injury = Bulbar (spongy) uretheraA 63 year old - ED - unresponsive - Crackles heard over left upper and entire right lung. Pt dies. Photograph of section of right lung obtain - Which is likely cause of the position indicated by the arrow? Correct Answer-C5a Complement system calls in neutrophils C5a = neutrophil chemotaxis A 22 year old woman - 6 months sever lower backpain - endometrial biopsy shows abundant mitotic figures in the endometrial glands and stroma. Which protein or enzymes regulate the progression of this phase of the menstrual cycle? Correct Answer-Cyclin Dependent Kinase. 29 year old woman - prescribed carbamazepine for trigeminal neuralgia- family history of osteoarthritis - the most likely reason for this recommendation is that carbamazepine may affect which of the following processes? Correct Answer-Metabolism An 18 year old woman - fever, dizziness, weakness, and vomiting (toxic shock) - using synthethic pads and tampons - Physical exam shows injected conjunctiva and rash- Pts use of which increased risk? Correct Answer-Tampons A 53 year old man - - 6 month history of blood in stool - 1 cm anal mass - If mass is malignant, evaluate which lymph nodes? Correct Answer-Superficial Inguinal 1 cm mass below dentate line24 year old - brought to ED - MVC - face struck steering wheel - facial pain and double vision - Exam of left eye shows infraorbital edema - ocular movement restricted vertically - CT scan shown. Which of the following impaired on left side? Correct Answer-Sensation over the upper lip V2 = maxillary nerve 23 year old - collapsed at finish line - no loss of consciousness Associated with prolonged use of vaginal tampons or nasal packing She is placed on a cot - feet elevated - 30 minutes later her blood pressure is 110/70 mm Hg. Which described patients condition? Correct Answer-Orthostatic Hypotension .decrease in systolic blood pressure of 20 mm Hg (110-85) e. decrease in diastolic blood pressure of 10 mm Hg. (70-50) 27 year old - ER - pain in navel - nausea and one episode of vomiting 1 hour ago - underwent appendectomy 2 years ago- CT scan of abdomen shows fat stranding in small bowel with areas of inflammation in terminal illeum - 2 cm bulge on antimesenteric border of the inflamed segment. Histological specimen - most likely to show which of the following? Correct Answer-Gastric Mucosa b. Crohns with the multiple episodes over the last year, fat stranding, terminal ileum involvement 14 year old girl -parents divorced - starts acting sullen, defiant, and truant at school, sexual intercourse with new partners and no condoms, previously honor studenty- which defense mechanisms? Correct Answer-Acting Out 38 year old - pregnant woman - ultrasound shows oligohydramnios and a full term fetus with a large kidney and empty right renal fossa. Need history on maternal use of which during pregnancy? Correct Answer-ACE InhibitorsA 65 year old - bilateral wheezing - accumulation of which of the following? Correct AnswerLeukotrienes 19 year old - with asthma - comes to ER multiple times for acute asthma exacerbations - "All doctors don'g understand me" - they keep prescribing steroid inhalers. What is the most appropriate statement by the physician? Correct Answer-Tell me more about what you know about steroid inhalers and how are they supposed to work? A healthy 22 year old man - in study for glucose metabolism - He consumes an 800 calories meal consisting - 12 hours later serum glucose is within reference range - Which is involved in maintaining serum glucose? Correct Answer-Glycogenolysis of Liver 30 year old man - 6 week history of colicky abdominal pain and diarrhea with occasional blood - on autopsy - small bowel is seen in the wall of a thickend loop of small intestine - Photomicrographs (granulomas)- DX? Correct Answer-Crohns Disease A 3 month old boy - 2 hour respiratory distress - Physical exam shows cyanosis - blood sample appears brown - most likely cause of patients condition" Correct Answer-Decreased activity in the enzyme that reduced Fe3+ to Fe 2 a. the hypoxia and the "blood sample appears brown" should point you towards methemoglobinemia. b. if you want a fun video from "9-1-1" that actually explains a lot of it: c. methemoglobinemia = cyanosis and chocolate colored blood.68 year old - 1 day history of fever and swelling in left leg - cellulitis - gram stain - gram positive, catalase negative cocci - clear zones of blood agar - Which species of Streptococcus? Correct Answer-Strep Pyogenes 67 year old woman - bicuspid aortic valve - admitted to the hospital - 2 day history of fever and chills. Blood culture grows viridans streptococci - In addition to penicillin, which other drug is administered to shorten the duration of treatment? Correct Answer-Binding to 30S protein 12-year-old girl - 2 month history of intermittent yellowing of the eyes and skin - PE - no abnormalities except jaundice. Total bilirubin 3mg/dl unconjugated bilirubin > Direct - Findings in patient? Correct Answer-Decreased activity of UDP glucoronylytransferase During an experiment, drug X is added to a muscle bath containing a strip of guinea pig intestinal smooth muscle. Agonists are added to the bath, and the resultant effects on muscle tension are shown in table. Acetylcholine increased. Which of the following drugs most likely to produce effects most similar to those of drug X? Correct Answer-Cholinesterase Inhibitor 30 year old women - 28 week gestation - Fetal ultrasound normal - Father's blood group in B, Rh Positive - Physician recommends administration of Rh0D immune globulin - This treatment is most likely to prevent? Correct Answer-Formation of antibodies to RhD 55- year -old -man - hypertension and chronic kidney disease - ECG shows low voltage with electrical alternans. Physical exam is most likely to show which of the following? Correct Answer-BP 85/60Pulse 120 JVP Increased Pulse Paradoxus Increased a. Electrical Alternans = Cardiac Tamponade = pleural effusion b. Beck Triad - Hypotension, JVP, muffled heart sounds 52-year-old - newly diagnosed with Type 2 diabetes mellitus. Four weeks later, her hepatic glucose out is decreased and target tissue glucose uptake are increased. Which agent? Correct Answer-Metformin An asymptomatic 44-year-old man - with HIV infection during routine screening to donating blood. A complete blood count- platelets are low - which of the following finds are most likely? Correct AnswerPetechiae Platelet problem Correct Answer-epistaxis, ecchymoses, petechia, bleeding from superficial scratches Coagulation problem Correct Answer-late re-bleed, Menorrhagia, GI bleeds, hemarthroses 23 year old - bone marrow failure - given a large dose of rabbit antimyocyte globulin - 10 days later - develops fever, lymphadenopathy, arthralgias, and erythema on her hands and feet. Which is the most likely cause of these symptoms? Correct Answer-Immune complex deposition in tissues b. Serum sickness - TYPE 3 hypersensitivity42 year old - gunshot wound - 36 hours post-operatively she is receiving morphine. she needs morphine - she has expressed concern she is becoming addicted. Which of the following initial actions by the physician is most appropriate? Correct Answer-Reassure the patient has a miniscule chance of becoming addicted to narcotics A 22 y/o woman -- itchy, red rash on her arm - new hair dye - picture (contact dermatitis) - Which ligand pairs play a role in the proliferation of the T Lymphocytes Correct Answer-CD28 on T Lymphocytes and CD80 on epidermal Langerhans cells 6 healthy subjects in a study of muscle metabolism - Increased malonyl-CoA directly inhibits which of the following processes in these subjects Correct Answer-Fatty Acid Oxidation b. Malonyl-CoA inhibits the rate limiting step in beta-oxidation of fatty acid. Over 1 year - study is conducted to assess the antileukemic activity of a new tyrosine kinase inhibitorwith CML in blast crisis - All patients in the study had SML and are informed that they would be treated with tyrosinase inhibitor. What type of study design? Correct Answer-Open Label Clinical Trial A 63 year old man - 4 day history of increasingly severe left leg pain and swelling on his left calf - CT scan shows no abnormalities - A CT scan of the abdomen shows a 3 cm mass in the body of pancreas - Ultrasound shows a femoropopliteal venous clot - Which of the following is the most likely cause? Correct Answer-Hypercoagulability of advanced malignancyA 40 year - comes to physician because of 6-month history of facial hair growth - temporal balding and coarse hair on the upper lip chin - ultrasound shows a 12 cm ovarian mass - Describe mass? Correct Answer-Sertoli - Leydig Cell Tumor 35 year old man - pain and swelling in right arm when scraped a tree branch - Temp 101F- Examination of the right arm shows edema around a lesion - primary mechanism of edema? Correct AnswerSeparation of endothelial Junction 12-year-old - 2 month history of headaches - 6 day history of nausea and vomiting - bilateral papilledema - broad based gait An MRI - shows tumor in pineal region. Pt most likely oculuomotor impairment? Correct Answer-Upward Gaze Parinaud Syndrome due to compression of tectumvertical gaze palsy occurs with pineolmas 52 year old man - 1 day history of nausea, vomiting, and right sided abdominal pain - radiates to his back - CT scan - shows enlarged right kidney and wedge shaped areas of hypodensity - no nephrolithiasis - strongest predisposing factor? Correct Answer-Atrial Fibrillation Wedge Shaped renal infarct Correct Answer-coagulative necrosis 24 year old - rash from hot tub- the infectious agent causing these findings most likely began to proliferate in which of the following locations? Correct Answer-Hair Follicle b. Hot Tub Folliculitis = Pseudomonas45-year-old - picture of H. Pylori - epigastric heartburn and weight loss - Which process likely involved? Correct Answer-Elaboration of proteases and urease with local support tissue A 14-year-old - hit with baseball bat - unable to dorsiflex his foot. Which of the following nerves is most likely injured? Correct Answer-Common Fibular Nerve (peroneal nerve) 26 year old woman - brought to ED - 8 hour history - severe back and abdominal pain - persistent vaginal bleeding - Ultrasonography shows 2 cm ectopic pregnancy in the ampulla - Ampulla ruptured into surrounding tissue. Fluid will most likely be found in the following locations? Correct Answer-Pouch of Douglas 46 year od with ankylosing spondylitis - treated with NSAIDs drugs - Sulfasalazine treatment has not resulted in improvement - most appropriate next step in treatment is administration of a drug that inhibits which of the following? Correct Answer-Tumor Necrosis Factor 55-year-old with blisters that do not break easily, and no oral lesions - these blisters are most likely the result of adhesions failure of which of the following? Correct Answer-Basement Membrane 47-year-old with organophosphate poisoning - blurred vision, difficult breathing, diarrhea, muscle weakness, fatigue - Most appropriate immediate pharmacotherapy? Correct Answer-Atropine b. Organophosphate poisoning - DUMMBELLS c. Crosses blood brain barrier - reverses muscarinic effects in CNS72 year old - difficulty swallowing, chest pain, and cough- tachypnea and equal pulses bilaterallypercussion shows dullness over right lung - chest X-ray shows area of opacification in the lower region of the right lower region of lung - Which is most likely cause of patients condition? Correct AnswerAspiration 62 year old man -abdominal pain - interviewed by physician - used single word and sarcastic answers. No eye contact - FROWNS - tells physician third time he has been asked question- Appropriate response? Correct Answer-You Sound Upset. Tell me a little more about that. 54-year-old - ECG shows P wave and R wave no relation between the two. Which is the most likely diagnosis? Correct Answer-Third Degree AV Block 42 year old - constipation, abdominal discomfort, mild fatigue, CA increased, P04 decreased, treated for renal calculus - PE shows now abnormalities - Most likely cause of patients condition is a small well defined nodule in which location? Correct Answer-Parathyroid Gland 72 year old - ER - stroke symptoms - slurred speech and difficulty walking - left sided hemiparesis - Tongue deviates to right when protruded - proprioception and sensation to light touch are absent over the left upper and lower extremity - Which site in brain stem is damaged Correct Answer-=Area Labeled C 68 year old woman - end stage renal disease - initially she did well - within 3 months she has been admitted for fluid overload - poor adherence to fluid and salt restrictions - Which is most appropriateinitial response? Correct Answer-It is tough to change your diet and fluid intake, but what sorts of things were you doing first when you were following recommendations During an experiment - southern blot analysis - Figure showed resulting pattern with DNA samples isolated from different organs. Southern blot demonstrates? Correct Answer-Gene rearrangement 17 year old girl - physical exam shows normal female body habitus - normal breast development - refuses to have a pelvic or rectal examination.- no axillary or pubic hair - most likely clinical presentation? Correct Answer-Androgen Insensitivity 16 year old boy - 3 day abdominal pain and vomiting - CT scan shows perforated appendix - Exam of peritoneal fluid shows which organism? Correct Answer-Escherichia Coli 45 year old woman 6 month history of hot flashes, night sweats, and insomnia- Physician informed consent on new treatment - most appropriate next step? Correct Answer-Could you tell me the results of the hormone treatment options we have discussed? A randomized control trial - assess risk of GI adverse risk using azithromycin compared to erythromycin in the pertussis - 100 children with pertussis enrolled - 50 azithromycin and 50 erythromycin - vomiting among 5 pts in azithromycin group and 15 patients in erythromycin group - Which represents absolute risk reduction? Correct Answer-a. 0.2 . 15/50 - 5/50 = .234 - year -old woman with a 10 year history of Hep C - progressive fatigue - vitals normal. - liver biopsy shows hepatocellular injury - infiltration and early fibrosis - which mechanism is most likely to cause hepatocyte injury? Correct Answer-Foreign Peptides bound to Class I MHC Molecules are recognized by CD8+ T Lymphocytes A 50 year old - high blood pressure - If left untreated, which of the following is most likely to decrease in this patient? Correct Answer-Baroreceptor Firing A 62-year-old with interstitial pneumonitis - compared with a healthy man, analysis of this patients biopsy is most likely to show the following patterns in the cell population (Type 1, Type II, and Fibroblast)? Correct Answer-Type I pneumocytes decreased Type II pneumocytes increased Fibroblasts increased 31 year old - with T2DM - comes to physician because of an oozing, foul smelling wound - patient has crepitant bullae - Gram Statin shows gram-positive rods - The causal organism has which of the following virulence factors? Correct Answer-A -toxin 4 month year old with SCID received a bone marrow transplant. - six days later - he develops a widespread, erythematous, maculopapular rash - Exam of skin shows diffuse degeneration of basal epidermal cells with mononuclear inflammatory cell infiltrate- Which is cause of rash? Correct AnswerGraft vs Host Disease 1 Correct Answer1. 36-year-old F with 2 week history of fatigue, bleeding of the gums, and bone pain. Physical examination shows pallor, hepatosplenomegaly, and ecchymotic lesions over extremities. Labs:Hb 8g/dlHt 25%Leukocytes: 36,000segm neutr 4%eosinophils 4%lymph 6%mono 6% promyelo 80%platelets 25,000Polymerase chain reaction test shows an mRNA corresponding to the retinoic acid receptoralfa/promyelocytic leukemia fusion gene resulting from a reciprocal translocation of chromosomes 15 and 17. Treatment w/ all-trans retinoic acid is started. In response to the therapy, the fusion protein will most likely attract which of the following proteins to form a pre-transcriptional complex? Correct Answer-a. Histone acetylase b. Histone acetylation allows for relaxation of the DNA e. Histone Acetylation makes DNA Active f. Histone Methylation Mostly Makes DNA Mute. 68-year-old man with 3 days of increasingly severe chest pain, shortness of breath, stridor, hoarseness, difficulty swallowing and nonproductive cough. Long-standing hx of hypertension. Smokes 2 packs of cigarettes for 45 years. T 99 F, pulse 80, rr 15, bp 160/94. PE shows visible pulsation above the manubrium of the sternum and displacement of the trachea to the right. Murmur second right intercostal space. Dx? Correct Answer-Aortic aneurysm male smoker with HTN + deep chest pain and pulsatile mass = AA all day long 1. 35-year old man w several episodes of squeezing chest pain gets angiogram... gets IV NE. Question shows a graph of coronary blood flow with a drop after the NE and then a rise.Which substance causes increased total coronary blood flow 1-2 mins after NE? Correct AnswerAdenosine Adenosine and Nitric oxide (NO) increases coronary blood flow 4. Man comes to doc for cast removal. Fracture of left humerus that required open reduction, internal fixation, cast immobilization. Muscle strength is 2/5 with extension of elbow and 1/5 with extension of wrist and fingers. Patient most likely sustained a fracture at (which location in humerus)? Correct Answer-Radial groove (radial N. is the extensors of arm, wrist and fingers) Prevalence of high-grade cervical intraepithelial neoplasia in unscreened population is 5%. Prevalence in population with negative Pap smear results is as high 0.2%. Prevalence decreases, which also decreases? Correct Answer-Predictive value of a positive test result Higher prevalence - higher predictive vales - positive, predictive, prevalance 45-year-old woman with joint pain due to rheumatoid arthritis comes for infective treatment with overthe-counter agents. Initiate disease-modifying antirheumatic drug (DMARD). Delayed onset of action of DMARD, so physician prescribes another until DMARD is effective. Drug? Correct Answer-Prednisone You can use three classes of medication to treat RA: NSAIDs, corticosteroids, and DMARDs. NSAIDs and corticosteroids have a short onset of action, while DMARDs take a while to take effect. 28-year-old man infertility, weight lifter and takes anabolic steroids. Mechanism of infertility? Correct Answer-Suppression of GonadotropinsAnabolic steroid use suppresses the Hypothalamic-Pituitary-Gonadal axis which will down regulate GnRH. FA 2020 p636 62-year-old woman with 3-day hx of fever, shaking chills, and left flank pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after, sudden onset watery diarrhea and lower abdominal cramps. T 100.9 F, pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower quadrants especially on right and increased bowel sounds. Stool is brown and occult blood negative. Next step? Correct Answer-Test of the stool for Clostridium difficile toxin b. Pseudomembranous colitis c. Couple days after Ciprofloxin 72-year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. She appears alert and well nourished. Physical examination shows extensive wrinkling, scaly erythematous patches on the face, and irregularly shaped brown macules on the face and forearms. There are ecchymoses in various stages of healing on both forearms; the ecchymoses are more numerous on the right side.Laboratory studies, including a complete blood count and coagulation studies, are within the reference ranges. S he has noticed no bleeding from her gums after brushing her teeth. Which of the following is the most likely cause of the ecchymoses in this patient? Correct Answer-Extensive solar elastosis Actinic elastosis, also known as solar elastosis, is an accumulation of abnormal elastin (elastic tissue) in the dermis of the skin, or in the conjunctiva of the eye, which occurs as a result of the cumulative effects of prolonged and excessive sun exposure, a process known as photo=aging ]21-year-old woman with 2-days history of urinary frequency and pain with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram-negative bacteria. Virulence factor for adherence to bladder? Correct Answer-Fimbriae Ecoli 73-year-old man has poor appetite and lost 25 lb over 4 months. Labs show normochromatic normocytic anemia. Xray of chest shows 2-cm perihilar mass. Biopsy shows small cell carcinoma of lung. Which is responsible for weight loss? Correct Answer-Cytokine effect Cachexia = increased pro-inflammatory cytokines Mediated by TNF-α, IFN-γ, IL-1, and IL-6 34-year-old man with herniated lumbar intervertebral disc. Laminectomy and removal of hernia scheduled. CT scan of vertebrae shown, which is surgical entrance location into neural canal? Correct Answer-Area labeled D24-year-old woman overdose on drug X and has serum concentration of 32. Drug X follows first-order kinetics. 6 hours later, the serum concentration is 16. Cannot be moved from intensive care unit until concentration 1.1 or lower. Which is minimum number of hours from first blood sample (32) that patient must remain in icu? Correct Answer-30 hours (5 half lives) b. First Order - Constant Fraction c. Zero Order - Constant Amount 45-year-old woman dx with cholelithiasis. She asks why abdominal pain is intermittent and not constant. Pain is produced when gallbladder contracts against gallstone obstructing cystic duct. Where is hormone released from that causes gallbladder contraction? Correct Answer-Enteroendocrine cells of the small intestine (CCK) CCK = produced by the I cells in the duodenum and jejunum in response to fatty acids and amino acids. CCK - cause gallbladder to contract . 35-year-old with Chagas disease and 2-hour history of moderate chest pain. 4.4 lb weight loss in 2 months. Vitals stable. Barium swallow shows dilated esophagus with beak-like narrowing at lower esophageal sphincter (LES). Biopsy shows? Correct Answer-Loss of neurons in myenteric plexus failure of LES relaxation, causing distal stenosis of the LES ("bird's beak" sign) proximal dilation indicative or achalasia45-year-old man comes to physician for follow up after appendectomy. There is mild scleral icterus and well healing surgical incision. Lab values show Total bilirubin 3.2 Direct: 0.2 Indirect 3 mg/dL Dx? Correct Answer-a. Gilbert Stress related - Mild jaundice with increased unconjugated in an older fellow is decreased UDPglucuronyltransferase activity. 35yo F has congestive cardiomyopathy and pitting edema. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl. Furosemide therapy is started. After 5 days, labs show: Na 130K 4.5Cl 90HCO 30 BUN 85 Creatinine 2.2 Albumin 3Urine specific gravity 1.023, rbc 0 wbc0 sediment none Urinary fractional excretion of sodium is less than 1%. Explanation? Correct Answer-Prerenal azotemia After the addition of furosemide, her BUN/Cr ratio went up to 38 and Fraction Excretion of Na < 133-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel. Mechanism? Correct Answer-a. Inhibits microtubule disassembly "taxes STABILIZE the economy" 4-year-old boy with fatigue and irritability for 2 months. Family visited rural Louisiana 5 months ago and ran around barefoot. Conjunctivae are pale. Labs shows normal wbc with 15% eosinophils. Stool prep shows parasite egg (picture). Cause of fatigue? Correct Answer-Microcytic anemia Necator or Ancylostoma = running around barefoot (entrance site for laravae hookworms suck blood from the intestines leading to iron deficiency anemia. Parasite in US - unable to absorb nutrient like iron Heart of 76-year-old woman shows concentric enlargement of left ventricle. Micro exam shows enlarged myocardial cells with large nuclei. Dx that causes this cardiac enlargement? Correct AnswerHypertension b. concentric ventricular hypertrophy = increased afterload c. eccentric ventricular hypertrophy = increased preload d. chronic HTN, Friedreich ataxia23-year-old woman g1p1, not felt well since delivery 2 weeks ago; ongoing fatigue, inability to breastfeed, light-headedness in upright position. Pregnancy complicated by preeclampsia and required cesarean delivery, after she required blood transfusions because of hypotension. PE appears lethargic. HR 80, BP 100/50, HR standing 85, BP standing 86/44. Hb 11.6, hct 36%. Serum hormone concentrations? Correct Answer-Prolactin decreased ACTH decreased TSH decreased Aldosterone increased Sheehan syndrome c. severe bleeding requiring transfusions + inability to breastfeed (decreased prolactin d. All hormones from pituitary - destroyed 50-year-old man with pulmonary embolus. Treated with intravenous heparin. 24 hours later, warfarin added. Day 2, partial thromboplastin time is 52 seconds (control 26 sec), and prothrombin time is 12 seconds (control 12.1 sec; INR = 1). Best explanation for normal prothrombin time and INR? Correct Answer-Long half-life of factor II (prothrombin) Factor II (prothrombin) has the longest half-life Warfarin acts on Factor II, VII, IX, XHeparin = factor IIa inhibited by ATIII - thus low PTT is prolonged 8-year-old boy with persistent disruptive behavior. Teacher says he's in "constant motion" and never completes assignments. Treated in ER several times because of skateboarding injuries. Tx? Correct Answer-Methylphenidate sxs in 2+ settings--> school, and ER for skateboarding injuries Tx= methylphenidate MOA = stimulates NE and DA 65-year-old man with cancer of cecum found to have metastatic lesion to right lobe liver. Venous route of mets? Correct Answer-Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal right lobe of the liver = all drain into the Superior Mesenteric Vein. left sided structures drain into the Inferior Mesenteric Vein. 48yo man with possible hypertension. based on 20 measurements, his average diastolic pressure is 94mmHg, SD is 8mmHg. If only four measurements were made rather than 20, which of the followingstatements would best describe the width of the 95% CI with regard the mean blood pressure Correct Answer-Larger Width of confidence interval larger with fewer cases Width will become smaller - with more cases 98-year-old woman who lives with daughter and grandson comes for routine exam with type 2 diabetes and hypertension but no complaints. She has had 14-lb weight loss since last visit 3 months ago. BMI 15. PE shows multiple ecchymoses in various stages of healing upper extremities and torso. Physician should ask? Correct Answer-Are you safe at home? A transcription factor that activates expression of HMG coA reductase is identified, this TF is initially synthetized as a large precursor protein, with 2 membrane spanning domains. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. The precursor protein is most likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte? Correct Answer-Area labeled F Endoplasmic Reticulum 18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?pH/pCO2/HCO3- Correct Answer-pH 7.32 pCO2 15 HCO3 8aspirin overdose (early) = Resp Alkalosis aspirin overdose (Later) = Metabolic acidosis HCO3- should also be less than normal (22-28) 12 hours = Late Stages 10-day-old male newborn 1-day history red eyes with discharge. Pregnancy uncomplicated but no prenatal care in third trimester. PE bilateral conjunctival injection with water discharge. Cause? Correct Answer-Chlamydia trachomatis b. chlamydia occurs 1-2 weeks after birth c. conjunctivitis from gonorrhea occurs 2-5 days after birth 54-year-old man with normal renal functions gets a heart transplantation. One year later, bp 170/110 and serum creatinine 2.1. Which immunosuppressive drug caused these findings? Correct AnswerCyclosporine ADR: hypertension and nephrotoxicity 2-year-old girl with febrile seizure. PE shows nuchal rigidity and bacterial meningitis suspected. LP and immediate abx therapy planned, but parents unavailable for consent. Next step? Correct Answer-Initiate the procedure and treatment without consentImplied consent in emergency 14-year-old girl with 4 months of heavy menstrual flow. Menarche at 13 with regular intervals. History of frequent nosebleeds and easy bruisability. Father has problems with nosebleeds and clotting. PE shows mild gum bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000, bleeding time 10, PT 14 (INR 1.5), PTT 60. Dx? Correct Answer-von Willebrand disease prolonged bleeding time + prolonged PTT = A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure to manage single-vessel coronary artery disease. A total of 1000 patients are enrolled. Through a chance process, 500 are assigned to undergo the operative procedure, 250 are assigned to undergo one type of angioplasty, and 250 are assigned to undergo a second type of angioplasty. All patients are followed for 3 years to determine the incidence of myocardial infarction. Which of the following best describes this study design? Correct AnswerRandomized clinical trial Study design with randomly assigned experimental and control groups is still a randomized clinical trial In cohort study, you don't assign the exposure, you just simply follow them (risk factors). 51-year-old with Graves disease develops ulcerating pharyngitis after 6 months of propylthiouracil. What's the underlying cause of ulcerative pharyngeal disease? Correct Answer-Agranulocytosis(rare side effect of PTU) commonly presents with acute pharyngitis. . 22-year-old nulligravid woman has menses that occur at irregular 26- to 32-day intervals. Height 5 ft 4 in and weighs 187 lb. BMI 32. PE shows mild hirsutism and velvety brown, thickened skin at the base of the neck and around axillae. Patient has which condition? Correct Answer-Hyperinsulinemia b. PCOS c. Acanthosis Nigrans 3-year-old boy 7 days after dx with severe chronic diarrhea due to Giardia. Immunological studies show peripheral leukocytes that express both CD3 and CD4 and fail to express CD40 ligand. Based on this, the immunoglobulin isotype that predominates has which biological properties? Correct AnswerComplement activation Hyper IgM syndrome; without CD40 ligand, T cells are unable to provide the secondary signal to activate B cell class switching. prevents IgM from switching into IgD, G, E and A, and thus an accumulation of IgM - hence the name "hyper IgM" - and deficiency in the rest Complement activation= IgM and IgG67-year-old woman comes to the physician because of a 1-month history of low back pain. She has hypertension well controlled with a thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm Hg. Physical examination shows tenderness to palpation over the L2-3 vertebrae. Laboratory studies show:Hemoglobin 13.5 g/dLHematocrit 41%Leukocyte count 10,500/mm3Segmented neutrophils 65%Eosinophils 1%Basophils 1%Lymphocytes 30%Monocytes 3%Platelet count 250,000/mm3 Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. An x-ray of the spine shows a lytic lesion. Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. A photomicrograph of a specimen obtained on myocardial biopsy is shown. Which of the following is the most likely cause of the cardiac findings in this patient? Correct Answer-Amyloid infiltration Multiple Myleoma = monoclonal IgG kappa (light chain) spike on electrophoresis, lytic bone lesions in the spine, cardiomegaly all point to multiple myeloma. Amyloid infiltration- Causes a primary amyloidosis that can deposit in multiple tissues, Investigator studying immune response to fungi. Fungi express beta-glucans on cell surface and that triggers innate immune response. Which tx decreases glucan expression? Correct Answer-Caspofungin Inhibit cell wall synthesis by inhibiting synthesis of β-glucan6-year-old boy with 5-day history of intermittent vomiting and 3-month hx of progressive clumsiness. Can no longer ride bicycle and difficulty getting out of car. Funduscopic exam shows bilateral papilledema. Neuro exam shows impaired upward gaze and pupil response to light. Walks shuffling gait. CT shows enlarged lateral and third ventricles and a 2-cm mass. Location of mass? Correct AnswerPineal gland Pinealoma Parinaud syndrome (compression of the tectum --> vertical gaze palsy) Obstructive Hydrocephalus .34-year-old man burned hands firing pots 3 months ago. He has no pain during or after burn. PE shows mild atrophy of arms and hands, absence of deep tendon reflexes in upper extremities, and decreased pain and temperature sensations in C4 to T1 dermatomes. Touch is preserved. Dx? Correct AnswerSyringomyelia Cape like distribution of loss of pain and temperature Touch preserved - lack of degeneration in the DCML. 57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess cavities filled with purulent exudate on autopsy. Pattern of necrosis in lung tissue? Correct Answer-Liquefaction Abscess (proteolytic enzymes from neutrophils liquify tissue An investigator conducts a meta-analysis of three genome-wide association studies of Crohn Disease. The studies encompassed 3200 cases and 4800 controls, all of European descent. The initial studies identified 11 significant loci with odds ratios above 1.3 and 1.5; the combined meta-analysis identified an additional 21 loci with odd ratio of 1.1 to 1.3. It is estimated that the 32 loci identified explain about10% of the variance in disease risk with 2 loci accounting for 2% of the variance. Previous studies of twins indicated a 50% heritability rate for Crohn's disease. Which of the following best explains these results? Correct Answer-The identified loci account for a relatively small part of the variance 5-year-old girls with severe leg pain 1 day after fell off sled. Immigrate to USA from Iceland. Has had three bone fractures since birth. Parents are vegan and don't give dairy products. PE shows tenderness, swelling, and limited range of motion of left lower extremity. Xray shows fracture of fibula. Pt has vitamin deficiency that affects which of the following? Correct Answer-Intestinal calcium absorption Vegan vitamin D deficiency 36-year-old woman diagnosed with HIV. Two months ago, started antiretroviral therapy with efavirenz, emtricitabine, and tenofovir. Labs: CD4 352 and undetectable HIV viral load. Two months ago, CD4 count was 158 and plasma HIV viral load was 5500. Next step? Correct Answer-Continue efavirenz, emtricitabine, and tenofovir with no changes If it ain't broke don't fix it. Typical antiretroviral HIV therapy regime is: 3 NRTIs OR 2 NRTIs AND 1 NNRTI OR 1 Protease inhibitor OR 1 Integrase inhibitor18-year-old woman get general anesthesia for wisdom teeth extraction. After 5 minutes, gets hypertonicity of skeletal muscles and increased body temperature. The treatment is a drug that decreases? Correct Answer-Sarcoplasmic Ca release Malignant hyperthermia- rare, life-threatening condition in which inhaled anesthetics or succinylcholine induce severe muscle contractions and hyperthermia Dantrolene - TX- Prevents release of Ca2+from sarcoplasmic reticulum of skeletal muscle by inhibiting the ryanodine receptor 48. 66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. Bilateral end-inspiratory crackles heard. CT chest shows diffuse reticular opacities at periphery and bases of lungs. Micro exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci and no granulomas. Dx? Correct Answer-Idiopathic pulmonary fibrosis honeycomb lung 35-year-old man with several episodes of dizziness and fainting during the past 2 months. Father and several paternal uncles died suddenly. PE and lipid studies normal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this? Correct Answer-Outward (delayed) rectifying potassium channel QT is correlated with the repolarization (Phase III), 4-month-old boy with 1-day respiratory distress. Has progressive weakness and difficulty feeding for a month. RR 50/min. PE shows enlarged tongue and generalized hypotonia. Increased lactate, pyruvate,glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle shows increased glycogen. Enzyme impaired? Correct Answer-alpha-1,4-Glucosidase Pompe Disease (Type 2) Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase) 58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. 2-year history difficulty swallowing, joint stiffness, diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity to cold weather, fingers turn white. Hx of esophageal reflux. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. PE cutaneous ulceration, clawlike flexion deformity, decreased joint mobility. At risk for which pulmonary disorder? Correct Answer-Pulmonary hypertension systemic sclerosis/CREST complications = interstitial fibrosis, pulmonary HTN CREST - Calcinosis, anti-Centromere antibody, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly Telangiectasia2-year-old woman has operation for hyperparathyroidism. Three parathyroid glands found but one does not appear in normal superior location on right side. Embryologic event that led to this? Correct AnswerAbnormal migration of endoderm from fourth pharyngeal pouch 4th pharyngeal pouch gives rise to superior parathyroid EAR Tonsils - Bottom to Top 46-year-old woman with 1-week low-grade fever and joint pain. Has chronic headaches and takes ibuprofen several times. PE diffuse maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal biopsy would show what? Correct Answer-Inflammatory infiltrates in the interstitium acute interstitial nephritis urine eosinophils + NSAID use + Rash 47-year-old woman with irregular, raised, multicolored dark lesion on left forearm with frequent sunlight exposure. Biopsy shows malignant pigmented cells. Worst prognosis with involvement of which layer? Correct Answer-Subcutaneous tissue highly vascularized and has larger blood vessels than the dermis, leading to a higher risk of metastasis and worse prognosis (TNM staging system) Deeper than basement membrane - no longer carcinoma in situ33-year-old man dx with epilepsy age 10 years. Most recent generalized tonic-clonic was 5 years ago. Medication was adjusted. Current meds include carbamazepine. He's never had any collisions while driving his motor vehicle. Patient's status with respect to driving? Correct Answer-He is medically qualified to drive most of the states a 1-2-year free seizure period is required for epileptic patients to get their license 35-year-old from group home comes for worsening behavior for 2 weeks. He believes CIA is spying on him through television set. Reports hearing voices in hall outside and that CIA now plans to kill him. Appears disheveled with unkempt hair and poor hygiene, difficulty answering questions because listening to internal stimuli. Mental status exam will show which? Correct Answer-Flattened affect Schizophrenia Positive—hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior Negative—flat or blunted affect, apathy, anhedonia, alogia, socialwithdrawal 45 yr old man with SOB on exertion x 6 months, nosebleeds since adolescence, 2 pics: clubbing + hemorrhagic lesions in tongue (IMAGE), inhaled albuterol doesn't improve his symptoms. Cause of symptoms? Correct Answer-Pulmonary AV shunting osler weber rendua hereditary hemorrhagic telangiectasia55-year-old man northern European descent with 2-month weakness, altered skin color, bilateral knee pain. Siblings have type 2 diabetes and cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of transferrin and ferritin. Liver biopsy increased iron content and cirrhosis Greatest risk? Correct Answer-Hepatocellular carcinoma hemochromatosis (bronzed skin, hepatomegaly, arthritis, increased iron content and cirrhosis) Cirrhosis -> hepatocellular carcinoma 52-year-old female with a history of breast cancer who received 4week course of radiations 6 months ago comes for follow-up. Exam shows no cancer recurrence. Respiratory Rate 26/min. CT chest shows b/l atelectasis in upper lung fields. Primary pathophysiological cause? Correct Answer-Contraction radiation therapy caused fibrosis and the myofibroblasts "contract" during fibrosis 19-year-old woman 2-day history of pain in left index finger. Injured it when catching a ball. PE shows erythema of left index finger. Unable to flex the distal phalanx when proximal interphalangeal joint metacarpophalangeal joints restrained. Xray normal. Injured structure? Correct Answer-Flexor digitorum profundus tendon profound go far - profundus to distal/furthest phalynx 21-year-old woman with 10-days difficulty walking. Two years ago had loss of vision in left eye which improved. Neuro exam shows decreased visual acuity in left eye with pallor of optic disc. Has pastpointing on a finger-nose test. Broad-based gait. MRI shows brain lesions in white matter of cerebellum. Pathogenesis? Correct Answer-CD4+ T lymphocytes are activated by myelin basic protein Multiple Sclerosis increased IgG level and myelin basic protein in CSFOligoclonal Bands 69-year-old woman with 3-week history of muscle cramps, weakness, abdominal pain, and constipation. Hypertension treated with metoprolol and hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which drug should be added? Correct Answer-Triamterene (potassium-sparing) = Keep your SEAT Spirolactone, Eplenone Amiloride, Triametrene Work in Distal Tubule Collecting Duct 82-year-old woman comes to the physician because of constant severe lower abdominal pain and fever for 24 hours. Laparoscopic examination shows severe diverticulosis and perforated diverticulitis. In spite of appropriate therapy, she dies 2 days later. Liver autopsy shown. Which of the following is the primary component of the material shown on the hepatic surface (IMAGE)? Correct Answer-Fibrin Fibrin activated - perforated - for coagulation Fibrin deposition local defense mechanism 58-year-old man comes to physician for benzodiazepine prescription for situation at work. Feels anxious and thinks he can complete last 2 years of work if anxiety decreases. Gives 1-month regimen of benzodiazepine. Wife calls, "My husband got fired! I know it was because he was taking too much of that drug you gave him. Didn't you know he had history of alcoholism?" Initial action? Correct AnswerContact the patient to discuss the situation Reach out to patient4-year-old boy (pedigree shown) has clumsy gait for past year. Exam calf hypertrophy and proximal muscle weakness. Creatine kinase increased. Muscle biopsy shows loss of muscle tissue, regenerating muscles fibers and fibrosis. Maternal uncle had similar findings and died at 15 years. Patient's sister is pregnant. Ultrasound identifies male fetus. Probability fetus has disorder? Correct Answer-¼ boy you only look at half, so the chance of him having it is 1/2.so 1/2 * 1/2= 1/4 2-year-old boy 2-day history of fever, sore throat, rash. T 101.7 F (38.7 C). Widespread, red, sandpaperlike rash on extremities. Purulent exudate over tonsils. Dx streptococcus pyogenes (group A) infection. Cause of skin findings? Correct Answer-Erythrogenic toxin causes a Toxic shock-like syndrome Fever, Rash, Shock, Scarlet Fever. Streptococcus Pyogens (group A strep) 35-year-old woman pain in left leg 2 days. PE shows deep venous thrombosis. Labs: platelet 200,000, PT 12 (INR 1), PTT 37. Heparin started. Five days later, platelet 120,000. Reason for decreased platelets? Correct Answer-Drug-related antibodies Heparin induced thrombocytopenia: IgG against platelet factor 4 FA 20201-year-old has numerous infections of skin and oral mucosa since birth. Infections slow to respond to antibiotic therapy. T 100.4F. PE multiple erythematous lesions of skin some with superficial ulceration. WBC 21,000 77% segmented neutrophils, 6% bands, 14% lymphocytes and 3% monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of lesion grows Staphylococcus aureus. Defective? Correct Answer-An integrin Leukocyte adhesion deficiency = integrin defect Neutrophils are unable to adhere and migrate to infection sites, instead accumulating in blood. A 25-year-old woman comes to the physician because of a 2-year history of intermittent, diffuse, cramping lower abdominal pain. The pain is usually associated with 2 to 6 days of loose, watery stools, and is typically relieved with defecation. Between these episodes, her stools are normal. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies, including complete blood count, metabolic panel, and thyroid function tests show no abnormalities. A drug targeting which of the following mechanisms of action is most appropriate for this patient? Correct Answer-Accentuation of μ-opioid myenteric plexus receptor Irritable Bowel Syndrome. Loperamide = opioid anti-diarrheal 35-year-old woman with infertile, receive injection of contrast material into cervix. On hysterosalpingogram (shown), contrast material (indicated by arrows) also seen in peritoneal cavity, which explain this finding? Correct Answer-Spillage of contrast which normal fallopian tubes - leak contrast - a gap between fallopian tubes and ovary.no spillage, that means there is a blockage = infertility 27-year-old primigravid woman at 18 weeks gestation comes to physician for routine prenatal examination. The uterus consistent in size with 18-week gestation. Ultrasonography shows a male fetus. The collecting system and pelvis of the left kidney is dilated and the renal cortex appears compressed. The left and right ureters are not dilated. The right kidney appears normal. Amniotic fluid volume is normal. Which causing renal finding in this fetus? Correct Answer-Incomplete recanalization of proximal ureter ureteropelvic junction, - LAST to canalize and can lead to congenital obstruction. 25-year-old-man who has a history of facial flushing and rapid heart rate each time he consumes a small amount of alcohol participates in study of alcohol intolerance. Molecular analysis shows presence of a lysine (K487, oriental variant) for glutamate (E487, native variant) substitution in aldehyde dehydrogenase. Kinetic characteristics of the enzyme variants shown:(NAD+))E487 Km 37 KCat 180K487 Km 5600 kCat 9.5based on these findings, which of the following is the most likely cause of this man's condition? Correct Answer-Decreased catalytic efficiency of K487 Catalytic efficiency is defined as Kcat/KM 21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. Finding most likely? Correct Answer-Increased sympathetic nerve traffic to sinoatrial node 48-year-old woman with gradual onset back pain past 2 weeks. No trauma. Doesn't smoke cigarettes, drink alcohol or use drugs. Hemogram, serologic studies and urinalysis unremarkable. X-ray of spine shows two lytic lesions, in T-10 and L-1. Dx? Correct Answer-Metastatic carcinoma of the breastProstate, Breast >Kidney, Thyroid, Lung Workbench wiped down with alcohol, successfully inactivates viruses with which characteristic? Correct Answer-Enveloped virion Alcohol-based products disrupt the lipid membrane envelope 52-year-old with chronic pancreatitis is deficient in which enzymes that causes inability to digest triglycerides? Correct Answer-Colipase cofactor for pancreatic lipase, 35-year-old primigravid woman 36 weeks' gestation with 6-hour history of heavy vaginal bleeding. No prenatal care. Ultrasound shows placenta over cervical os. Can't stop bleeding and has cesarean. Dx? Correct Answer-Placenta previa Opening of Cervical OS - preview of Placement 45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No mass45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No masses palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125.Technetium-99m scan shows 1.2 cm nodule in neck. Mutation?s palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation? Correct Answer-MEN1 Pituitary, Pancreatic, Parathyroid - 3ps = MEN 1 Parathyroid tumor releasing PTH, increasing Ca and ALP. 6-year-old girl with 15-minute history of severe shortness of breath. Diagnosed with throat tumor 3 years ago. RR 32. PE nasal flaring. Laryngoscopy shows multiple raised, finger-shaped lesions from vocal cords and epiglottis. Lesions excised and shows finger-shaped fibrovascular cores lined with benign squamous epithelium. Causal virus? Correct Answer-Human papillomavirus, type 6 Laryngopapiloma A 68-year-old man comes to the physician because of a 1-month history of light-headedness and tightness in his chest with exertion. He adds that the pain is worse after arguing with his wife, and the symptoms resolve with rest. He has a past history of lower gastrointestinal bleeding; evaluation at that time was negative on upper endoscopy and colonoscopy. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 15/min, and blood pressure is 110/75 mm Hg. Physical examination shows no abnormalities. His hemoglobin concentration is 8.2 g/dL, and hematocrit is 24%. Test of the stool for occult blood is positive. An ECG shows no abnormalities. Repeat colonoscopy shows no abnormalities. Which of the following is the most likely cause of this patient's gastrointestinal symptoms? Correct Answer-Angiodysplasia Hematochezia is the passage of fresh blood per anus Tortuous dilation of vessels hematochezia24-year-old man with 3-day progressive numbness of both feet ascended to thighs. Last 24 hours, numbness and tingling of hands. PE ataxic gait. Deep tendon reflexes diminished in upper extremities and absent in knees and ankles. Vibration and joint position absent in fingertips and feet bilaterally. Mild weakness distal upper extremities ad moderate weakness of lower extremities. Structure involved? Correct Answer-Myelinated primary afferents Most common subtype of Guillain-Barré syndrome 27-year-old man for psychiatric eval sent by employer because he is "very odd." Is a computer repair specialist and lives alone, Refuses to socialize and has no friends. Extremely preoccupied with science fiction, occult, afterlife. Personality disorder? Correct Answer-Schizotypal Eccentric appearance, odd beliefs or magical thinking Cluster A 45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides 550. Which drug to prescribe? Correct Answer-Fenofibrate Triglycerides 550 MOA = Activates PPAR-αto induce HDL synthesis 60-year-old man for routine health examination. Has had normal blood pressure measurements. BP today 170/95mmHg. Physical examination shows no other abnormalities. Serum show hypokalemia and metabolic alkalosis. Plasma renin activity and serum aldosterone concentrations are increased. Following the administration of captopril, there is a marked increase in plasma renin activity. Which ofthe following is the most likely cause of the findings in this patient? Correct Answer-Renal artery stenosis Decreased renal perfusion (one or both kidneys) Increased renin Increased angiotensin ---HTN After operation, 65-year-old patient has lung region that is under ventilated but well perfused. Which increases? Correct Answer-Physiologic shunt - Mismatching of ventilation and perfusio - insufficient ventilation to provide the oxygen needed to oxygenate the blood Physiologic shunt Correct Answer--Mismatching of ventilation and perfusion with the lung -Results in insufficient ventilation to provide the oxygen needed to oxygenate the blood flowing through the alveolar capillaries Physiologic dead space Correct Answer-portion of the tracheobronchial tree that does not participate in gas exchange 63-year-old man 2-week sensation of fullness in left upper quadrant. Has lethargy and shortness of breath. 20-lb weight loss during 3 months. PE shows pallor. Spleen tip palpated. Labs: hb 9, hct 27%, wbc 4000, serum uric acid 15. Peripheral blood smear numerous erythrocytes with abnormal shapes andsizes, nucleated erythrocytes and myelocytes. Aspiration of bone marrow dry tap. Biopsy shows thickened bony trabeculae with increased reticulum. Dx? Correct Answer-Myelofibrosis "Bone marrow cries because it's fibrosed and is a dry tap" 17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states, "I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. After reassurance, Most appropriate next statement to mother Correct Answer-Tell me more about your concerns about your son's height 1-year-old boy with rash for 2 weeks. 10th percentile for height and weight. PE scaly, seborrheic eruption over scalp, palms, back, diaper region and soles of feet. Generalized lymphadenopathy and hepatosplenomegaly. Xray of skull shows osteolytic lesions. EM biopsy of skin shows tennis racketshaped bilamellar granule in cytoplasm. Immuno studies show CD1a antigen expression. Abnormal cells in patient are derived from which cell? Correct Answer-Dendritic cells Langerhans cells (LC) are tissue-resident dendritic cells of the skin, and contain organelles 2-month-old boy well child exam, mother with no concerns. 25th percentile for length and 30th percentile for weight. Cardiac exam shows blowing holosystolic murmur best heard at lower left sternal border. Cause? Correct Answer-Ventricular septal defect Blowing Holosystolic Murmur at Lower left sternal border Study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women randomly assigned to one of two groups. 48 of women receive new drug, 52 receive standard therapy.The primary purpose of this method of assigning patients to different groups is to create which of the following? Correct Answer-Two groups with similar underlying characteristics A 70-year-old woman comes to the physician for a routine pelvic examination. During speculum examination of the vagina and cervix, the Valsalva maneuver causes a bulge of the anterior vaginal wall. Which of the following is the most likely cause of this finding? Correct Answer-Cystocele prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms 32-year-old man with HIV infection follow up examination, has been treated with HAART for the past 6 years HIV plasma viral load has been undetectable. HIV viral load now increase, antiretroviral resistance suspected. HIV genotype analysis confirms that the virus has resistance mutations, which of the following most likely mutated? Correct Answer-Reverse transcriptase and protease HAART therapy = reverse transcriptase and protease enzymes. 32-year-old man with X-linked recessive disease has deafness, hematuria and progressive renal failure. Protein abnormality? Correct Answer-Type IV collagen Alport Syndrome Can't See, Can't pee, Can't hear a Bee65-year-old woman with 6 hour Hx fever and shaking chills. 4 hours ago, she took 325 mg aspirine tablets. Temp 39.4 C, pulse 96/m, respiration 18/m and blood pressure 102/60 mmHg. Physical examination shows marked tenderness bilaterally in the costovertebral areas. Lab studies show: Hb 13 g/dlHt 39% Leukocyte count 32,.000/mm3 Urine ph 6 Nitrites 4+ Leukocyte esterase 4+ A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis? Correct Answer-Leukemoid reaction 25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium vivax. His initial therapeutic response is good, but he develops recurrent parasitemia 2 months later. Which of the following best explains the recurrence? Correct AnswerChloroquine is ineffective on the exoerythrocytic malaria tissue stages P vivax/ovale, add primaquine for hypnozoite Hypnozoite = inactive dormant - only in P. Vivax and Ovale 28-year-old woman comes to the physician because of a 4-day history of palpitations, severe neck pain, fatigue, and malaise. Her pulse is 120/min and regular. Physical examination shows a diffusely tender,mildly enlarged thyroid gland. There is no exophthalmos. Serum studies show a thyroid-stimulating hormone concentration of 0.01 μU/mL. Which of the following is the most likely diagnosis? Correct Answer-Subacute granulomatous thyroiditis de quervain's = pain 68-year-old man with a 10-month history of shortness of breath and swelling of his feet, family history of cardiovascular disease. He smoked 2 packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80. PE: 3+ pitting edema of lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest. Grade 2/6 pansystolic mumur heard best at lower left sternal border, which increases on inspiration. Maximal impulse palpated in sub-xiphoid area. S1 and S2 sounds are distant. Liver span 14 cm. Diagnosis? Correct Answer-Cor pulmonale Backfilling of blood from the lungs into the R ventricle is stretching out the R side (dilation) and also remodeling the heart via hypertrophy cor pulmonale Correct Answer-right ventricular hypertrophy and heart failure due to pulmonary hypertension 17-year-old boy in septic shock unresponsive to ADH (vasopressin). Treat is discontinued, and high-dose dopamine in started. Which receptors are stimulated? Correct Answer-alpha1-adrenoreceptors low doses d1 = dilates renal vessels medium b1 agonist = ionotropic and chonotropic high doses a1 agonist = vasoconstriction8-year-old girl is brought to the physician by her mother because of a 3-week history of poor feeding chronic diarrhea and pale foul-smelling stools. Mother says the symptoms began with colicky abdominal pain following introduction of solid food to the infant's diet. History of gluten sensitivity. 60th percentile for length and 25th percentile for weight. Which cell is dysfunctional? Correct Answer-Enterocyte Celiac disease, an autoimmune intolerance to gliadin leading to enterocyte damage and subsequent malabsorption 25-year-old woman comes for counseling prior to conception. Has seizure disorder on valproic acid. Fetus at greatest risk for drug-related adverse effect during which pregnancy stage? Correct Answer-3 to 8 weeks Neural tube defects Neuropores fail to fuse (4th week) 16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. After counseling about safe sex, best next step? Correct AnswerSchedule next routine examination Normal behavior for a teen boy 35-year-old woman with 3-month progressive shortness of breath with exertion. RR 26. Physical shows jvd and prominent a wave. Lungs clear. Cardiac exam shows loud pulmonic component of S2 and rightsided S4 gallop. Increased pulmonary expression of what? Correct Answer-Endothelin-1 pulmonary hypertension = imbalance between vasodilation substances and vasoconstrictors. 7-year-old boy is about undergo an appendectomy. An intravenous catheter needs to be inserted, but the patient is fearful of being stuck with needle. The most appropriate anesthesia administered by maskto anesthetize this patient quickly would have which of the following characteristics? Correct AnswerLow blood solubility --> faster onset --> faster recovery Lipid solubility determines potency 66-year-old man dies 7 days after myocardial infarction. Gross of heart shown (perforated interventricular wall). Histology? Correct Answer-Erythrocytes, cellular debris, macrophages, and early granulation tissue 0-24 hours Dark Mottling 3-14 days - Macrophages, then granulation tissue at margins 68-year-old man with creatinine 2.3 due to chronically increased hydrostatic pressure in Bowman space. Cause? Correct Answer-Benign prostatic hyperplasia A sexually active 32-year-old woman has vaginal pain with urination. Pelvic examination show bilateral vesicoulcerative lesions of introitus. Tx? Correct Answer-Acyclovir inhibit viral DNA polymerase by chain termination 26-year-old man comes in 2 hours after injuring arm skiing. Sensation to pinprick absent over lateral aspect of shoulder. Xray of right shoulder shown (fracture of surgical neck of humerus). Nerve damaged? Correct Answer-Axillary fracture of the surgical neck of the humerus.axillary nerve and the posterior circumflex humeral artery Radial does lateral elbow musculocutaneous does lateral forearm Patient making sexual advances towards physician. Appropriate measure? Correct Answer-Have a chaperone join them for the remainder of the examination Inappropriate behavior - sexual advances towards physician A 70-year-old man comes with skin blistering for 1 week. No oral lesions. Physical shows tense bullae in joint folds of upper and lower extremities. Biopsy shows subepidermal blister formation. Immunofluorescence microscopy shows antibodies against proteins at the dermal-epidermal junction. Target by antibodies? Correct Answer-Hemidesmosome Subepidermal blister formation + Tense Bullae An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism. Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show decreased mucosal thickness and hyperplasia of enterochromaffin like cells. This resembles? Correct Answer-Chronic Gastritis mucosal inflammation leading to atrophy56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. No recent trauma or back strain. Urine is darker than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in upper portion of right kidney. Urine shows 50 erythrocytes, 6 leukocytes, no bacteria. Dx? Correct Answer-Renal Cell Carcinoma hematuria, palpable masses, 2° polycythemia, flank pain, fever, weight loss 67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain. Ex-lap shows embolus in superior mesenteric artery with complete occlusion of middle colic artery. Ischemic changes where? Correct Answer-Small intestine, ascending colon, and part of the transverse colon Midgut = major duodenal papilla (of the duodenum) to the proximal 2/3 of the transverse colon. Persons are at risk of influenza are vaccination every year because of antigenic variation, which can be drift (minor) or shift (major). Mechanism of antigenic shift? Correct Answer-Reassortment viruses with segmented genomes (eg, influenza virus) exchange genetic material. 2 viruses making a combo virus - 2 genomes 34-year-old man with a 3-month history of a progressive rash on his feet. Rash is not itchy or painful. A photograph of feet is shown = Kaposi Sarcoma. HIV+. In addition to HAART, which of the following pharmacotherapy is most appropriate? Correct Answer-Antineoplastic Endothelial malignancy most commonly affecting the skin, mouth, GI tract, respiratory tract.Associated with HHV-8 and HIV Kaposi typically presents in HIV pts earlier, under a 500 CD4 tcell count, bartonella angiomatosis presents <100 70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation, depressed mood for 3 months. He had myocardial infarction and non sustained ventricular tachycardia 2 years ago. Tx? Correct Answer-Paroxetine SSRIs are first line for depression. Avoid TCAs in elderly = anticholinergic side effects. 29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12. She is 5.3 Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment. Which of the following will ensure adherence? Correct AnswerProvide follow ups to monitor progress in attaining her goal Improve Doctor patient relationship - add next appointment 52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. He had played tennis all day and he does not remember how much fluid he had consumed. His temperature is 36.7 oC,pulse 122min, respirations 28min and BP 90/50 mmHg. PE shows dry skin and decreased capillary refill. An ECG and evaluation of cardiac enzymes show no abnormalities. Which of the following findings in the nephron best describes the tubular osmolarity, compared with serum in this patient? Correct AnswerPCT Isotonic, Macula Densa hypotonic Medullary Collecting Duct hypertonic 3-week-old male newborn with recurrent vomiting after feeding since birth, and eager to feed after vomiting. Abdominal exam shows firm, mobile mass in epigastrium to right of midline. Dx description? Correct Answer-Single Primary Development Defect pyloric stenosis - olive shaped mass - stand-alone defect VACTERL Correct Answer-vertebral defects, heart defects, renal and limb abnormalities 65-year-old with sudden onset generalized tonic-clonic seizures. Personality change last 6 months; used to be mild mannered and now verbally abusive. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through corpus callosum. Dx? Correct Answer-High-grade fibrillary astrocytoma Glioblastoma multiforme- "crosses hemisphere" GFAP + A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receivingthe new agent than in patients receiving the standard treatment. Results are shown:Recurrent Stroke Rates per 1000 Person-YearsStandard Treatment vs. New Antiplatelet Drug Women .12 .04 Men .24 .08 Overall .18. .06 Based on these results, which of the following is the relative risk reduction in women? Correct Answer- 67% .12-.04= .08 .18-.06 = .12 .08/.12 = 67% 22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse is 33/min, and blood pressure is110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular ejection fraction of 75%. Which of the following best describes the findings in this patient? Correct Answer-Eccentric Hypertrophy ECCentric - ECCpands ventricle CONcentric - CONstricts ventricle 68-year-old man with alcoholism comes for fever, chills and productive cough of purulent sputum for 3 days. Blood cultures positive. Gram stain: gram-positive, lancet-shaped diplococci. Vaccine is against which bacterial component? Correct Answer-Capsular polysaccharideStrep pneumonia Child with XXY karyotype, genetic studies showed he received the extra "x" from his father. An error of chromosome segregation occurred during anaphase at which of the following stages of spermatogenesis in the patient's father? Correct Answer-Primary Spermatocyte Most problems with cell division occur in anaphase of Meiosis I. Meiosis 1⇒ from primary to secondary spermatocyte Meiosis 2 → Secondary to spermatid' 28-year-old man with ulcerative colitis, history of partial colectomy, and improved rectal bleeding and diarrhea since then. Meds include mesalamine, hydrocodone and acetaminophen. He says, "I've been taking so much of my opiate prescription that I ran out and stole some from my job." Next step? Correct Answer-Discuss treatment options and a referral for detoxification program 67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity. Brain tissue histology shown as well as gross cross sections of midbrain both normal and diseased. Substance referred to by arrow. Which Substance? Correct Answer-Alpha-synuclein 8-year-old boy with pain on back and head since he fell off swing. Tender 2.5cm swollen mass over right occiput. CT shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Biopsy shows sheet-like infiltrate of pale eosinophilic cells with bean-shaped nuclei. Cells positive for CD1a. Electron microscopy of cells shows Birbeck granules. Abnormal cell type? Correct Answer-Langerhans cells30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick over right lateral forearm. Brachial plexus lesion? Correct Answer-E (musculocutaneous nerve) 8-year-old man comes with cracked lips and peeling sunburned skin. Works as lifeguard. PE shows desquamation of sunburned skin. Lips are dry and cracked. Petrolatum to lips may reduce lip symptoms by which of following effects of the compound? Correct Answer-Barrier During a clinical study of calcium and phosphorus metabolism, a 50-year-old man undergoes series of lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2 hours. His serum Ca concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum concentration of which of the following substances is likely to be increased at this time? Correct Answer- 24,25-Dihydroxycholecalciferol inactive metabolite preferentially synthesized when normal 30. 35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions over several years. Taking oral contraceptives for 15y. PE shows fluidfilled vesicles and bullae. Labs: AST increased, ALT increased, total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin? Correct Answer-Succinyl CoA 32-year-old woman brought in after 10-foot fall from ladder. PE suggests severe hemorrhage and shock. Xray shows fracture of left ninth and tenth ribs. Organ injured? Correct Answer-Spleen4-day-old boy with vomiting after breastfeeding. PE shows lethargy and dry mucous membranes. Labs: Na 139, Cl 90, K 7, HCO3 17, Glucose 42, BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency? Correct Answer-21-hydroxylase infancy (salt wasting) or childhood(precocious puberty 70-year-old woman comes to the physician because of increasingly severe pain in the right knee over the past 3 months. She has fallen repeatedly. She has a 10-year history of symptomatic osteitis deformans. She has bowed tibia and tenderness of the proximal right tibia. an X ray shows a fracture of the proximal tibia with elevated periosteum and sunburst pattern. an x-ray of lungs shows pulmonary nodules of various sizes. which of the following findings is most likely on biopsy? Correct AnswerPleomorphic neoplastic cells producing new woven bone Osteosarcoma histological appearance. Paget disease is one of risk factor Cholera toxin catalyzes transfer of ADP-ribose to an arginine residue in stimulatory G protein resulting in inhibition of GTPase activity. Which increases in cells as a result? Correct Answer-Concentration of cAMP 10-year-old boy with 4 days nosebleeds and easy bruising. Three weeks ago, upper respiratory tract infection. PE ecchymoses on upper and lower extremities. Labs shows hemoglobin and leukocyte count normal, and decreased platelet count. Bone marrow smear shows increased megakaryocytes. Mechanism of dz? Correct Answer-Antibodies directed against glycoprotein (Gp) IIb/IIIa complex Immune thrombocytopenia60-year-old man 1 day of fever, chills, confusion and memory loss. Returned from Gulf coast where he walked barefoot. Hx of severe cirrhosis and portal hypertension. T 39C (102.2 F), RR 22, bp 90/48. Physical shows early blister formation on right lower extremity. Blood culture: gram-negative, lactosefermenting organism. Bug? Correct Answer-Vibrio vulnificus 45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle? Correct Answer-Transcription factor c-Jun: increased beta-myosin heave chain: increased endothelin: increased Newborn is found to have a cervical rib. Transformation of seventh cervical segment to thoracic identity. Which is true of HOX gene alteration? Correct Answer-Expression of a HOX gene normally expressed only caudal to C7 30-year-old woman with a long-standing history of pelvic inflammatory disease has surgical resection of a scarred segment of a fallopian tube. Which of the following inflammatory cells is most likely to be found in the resected specimen? Correct Answer-Macrophages 39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600), urine protein 4+, urine RBC numerous. Hypersensitivity reaction? Correct Answer-Type III (immune complex-mediated)25-year-old woman with polycystic kidneys and 3-month history of weakness, fatigue, headaches, hypertension, loss of appetite and itching. Cr 4. Labs Correct Answer-HCO3- decreased - no resorption PO4 increased, PTH increased 5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of action for motion sickness? Correct Answer-Antagonist at muscarinic-3 (M3) receptors 63-year-old woman with 2-week history of daily episodes of severe, lancinating, left-sided facial pain. Pain lasts 30 to 60 seconds and shoots down ear along jawline. Precipitated by chewing or brushing teeth. Dx? Correct Answer-Trigeminal neuralgia 45-year-old homeless man found unconscious. Breath smells of alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on chest. Labs: hemoglobin 10, hematocrit 30%, MCV 110, WBC 9000, platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. Labs? Correct Answer-Methylmalonic acid: normal Homocysteine: increased 55-year-old man with elevated LDL cholesterol is prescribed lovastatin. This treatment would result in which adaptive responses at the cellular level? Correct Answer-Increased transcription of HMG-CoA reductase63 yo man with mild emphysema has smoked 1 pack for 45 years sudden headache, myalgia and rising temperature. A dry cough develops, with chill and chest pain. Examination of gram stain of sputum disclose neutrophils, but bacteria are not evident. An X-ray of the chest is consistent with severe pneumonia. A culture of sputum is negative, but culture of bronchoscopy specimen on a highly specialized bacteriologic medium yields gram negative rods. The identity of these bacteria is confirmed by staining with specific fluorescent antibodies. The patient respond therapy with macrolide Ab. Mechanism? Correct Answer-Inhalation of aerosol from an environmental source (Legionella) - Aerosol transmission 50-year-old woman with COPD comes with 3 months of progressive shortness of breath. Physical shows JVD, loud pulmonary component of S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity for carbon monoxide. Which is decreased in pulmonary vascular smooth muscle? Correct Answer-Endothelial nitric oxide synthase production 63-year-old man with abnormal blood pressure. 6 months ago, bp was 135/85. Today bp 170/98. Bruit heard over left renal artery. CT angios hows left arterial stenosis. Labs? Correct Answer-Total peripheral resistance increased, Plasma renin activity increased, Serum aldosterone concentration increased renal artery stenosis.20-year-old woman at 27 weeks' gestation is admitted to the hospital because of a 12-hour history of intense uterine contractions occurring every 8 minutes. Her membranes ruptured 32 hours ago. Her temperature is 39.1°C(102.4°F), and pulse is 115/min. Physical examination shows tenderness of the uterus. Pelvic examination shows a closed cervix that is not effaced. The fetal heart rate is 210/min. Which of the following is the primary stimulus for her uterine muscle contractions? Correct AnswerInflamed maternal decidua release of prostaglandin Preterm Premature Rupture Of Membrane 30-year-old woman with 2-years of numbness, blanching, and bluish color to ears, fingers and toes after emotional upset or cold exposure. Vitals and PE normal. Avoid taking which drug? Correct AnswerPhenylephrine 18-month-old girl with 2 day progressive cough and hoarseness. T 102.2F, HR 88, RR 24, bp 100/70. Oxygen saturation 95%. PE mild erythema of oropharyngeal and laryngeal mucosa no exudate, harsh, barking cough heard. Improves within 4 days. Cause? Correct Answer-Parainfluenza Patient with orthostatic hypotension, loose stools for 1 year, and history of type 1 DM. Stool studies are normal. What is the pathophysiological mechanism of the diarrhea? Correct Answer-Motility disorder 39-year-old man with polycystic kidney disease has 6-month history intermittent blood in urine. T 98.6 F HR 100 RR 24 BP 160/90. Urea nitrogen 100, creatinine 8. UA shows blood. Arterial blood gas shows? Correct Answer-pH 7.22 pCO2. 28 HCO3- 11Uremia: part of MUDPILES Bad kidneys = Can't reabsorb HCO3 "base" > Metabolic Acidic with respiratory compensation 20-year-old woman with 2-week fever, shaking chills, headaches, fatigue, and joint and muscle pain. Spent summer workin as lifeguard in Long Island, New York. Has splenectomy for motor vehicle collision 6 years ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings. Polymerase chain reaction for Plasmodium is negative. Causal organism from bite of? Correct Answer-Tick Male newborn delivered at 28 weeks, neonatal respiratory distress syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A deficiency in which of the following most likely caused the disorder? Correct Answer-Dipalmitoylphosphatidylcholine 55-year-old woman who is a physician has fractured femur during motor vehicle collision. 2 days after admission, has tachycardia, restlessness, diaphoresis, anxiety, seeing "vague shapes" on walls. Dx? Correct Answer-Alcohol withdrawal Full-term newborn in respiratory distress. Imaging shows abdominal contents in left pleural cavity. Maldevelopment of which structure led to diaphragm defect? Correct Answer-Left pleuroperitoneal membraneDiaphragmatic hernia To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI 32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain the recommended protein intake (56g day); a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). which best describes number of calories that should be provided by fat in this its diet each day? Correct Answer-630 0.3 fat x 2000 = 600 calories (fat) (Fat 30 + Carbs 55+15 = 100) 35-year-old woman passed out while washing dishes. Began to feel weak and dizzy, husband shares with nursing staff history of bulimia nervosa, and has been binging more frequently. Suspected she has been vomiting. Labs of patient? Correct Answer-K+ decreased HCO3- increased/ Anion Gap normal pH increased' Metabolic Alkalosis > loss of HCL Anion Gap Normal = NOT a MUDPILE HCL, NA+ = out the mouthRetrospective study of incidence and outcome of subarachnoid hemorrhage. Incidence is 15 per 100,000 people, mortality is 6 per 100,000 people. Incidence remains constant, case fatality rate? Correct Answer-40% 16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to prescribe an emergency oral contraceptive. The physician on call is not the patient's regular physician and does not dispense emergency contraception for moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to state which of the following? Correct Answer-"I can have one of my colleagues call you back to further discuss your concerns" 58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Use of over-the-counter cough suppressants has not resolved his symptoms. He has smoked 2 packs of cigarettes daily for 35 years. He has no family history of lung disease. His temperature is 37°C (98.6°F), pulse is 72/min, and respirations are 18/min. Physical examination shows cyanosis. Diffuse wheezing is heard on auscultation. Which of the following pulmonary cell types is most likely to be abnormal in this patient? Correct Answer-Pseudostratified columnar epithelial cells Smoker, Cyanosis - chronic bronchitis squamous metaplasia 64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam tenderness of flanks and lower quadrants. BUN 34 and creatinine 3.8. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters. Tx to improve renal function? Correct Answer-Bilateral stents in the ureters34-year old man is brought to the ER semiconscious and combative. In addition to sedation, a shortacting neuromuscular blocking agent is administered for intubation to prevent aspiration. Within a few seconds after admin of the drug, he has transient muscle fasciculations in his face; he develops generalized paralysis within 1 minute. Forty five minutes after completion of the procedure, he is still paralyzed. A genetic abnormality of which of the following enzymes is the most likely cause of his unusually slow recovery from paralysis? Correct Answer-Pseudocholinesterase Succinycholine - Acetylcholine Agonist increased in system --> longer anesthesia recovery Gy67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3 months. PE shows cachexia and significant muscle wasting. Intracellular components increased in patient's muscle cells? Correct Answer-Autophagic vacuoles 48-year-old man 2-month increasing abdominal girth and inability to achieve an erection. Smoked 1 pack cigarettes for 20 years and drank 1 pint of liquor daily. Vitals normal. PE shows scleral icterus, spider angiomata, gynecomastia, ascites, and prominent umbilical venous pattern. Testis small. Cause of gynecomastia? Correct Answer-Failure of liver to degrade estrogen Alcoholic - cirrhosis - Liver injury Investigator studying vancomycin-resistant strain of Enterococcus faecalis. Ten generations created. Culture inoculated and resulting bacterial colonies are screened for vancomycin resistance. Vancomycinsensitive colonies observed at frequency of one per 100 cells. Mechanism of decreased vancomycin resistance? Correct Answer-Plasmid loss20-year-old woman with palpable lump in right breast 4 months, no pain, swelling or nipple discharge. Lump is smooth, firm, round, mobile, nontender, well delineated. No skin change. Dx? Correct AnswerFibroadenoma Researching new cancer drug, effective at killing rapidly dividing cells, in mice caused profound myelosuppression. In patients, most appropriate to follow which when at risk for infectious complications? Correct AnswerNeutrophil counts 35-year-old woman with fever and sharp chest pain for 3 days. T 101.3F. Friction rub heard. All causes of secondary pericarditis ruled out. Cause of primary pericarditis? Correct Answer-Virus 65-year-old woman comes to the physician because of a 1-week history of a swollen, painful left knee. Her temperature is 38°C (100.4°F), and blood pressure is 110/65 mm Hg. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. A photomicrograph of synovial fluid obtained by arthrocentesis is shown. This patient's synovial fluid most likely contains which of the following? Correct Answer-Uric acid needle shape right in the middle was a uric acid crystal17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states, "I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. After reassuring mom, Most appropriate next statement to mother? Correct Answer-"Tell me more about your concerns about your son's height." \19-year-old man with gastrointestinal bleeding. Laparotomy done and 5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm from ileocecal valve resected. 99mTc-pertechnetate scan Pathology shows? Correct Answer-Heterotopic gastric mucosa 99mTc-pertechnetate scan = Meckel Diverticula 19-year-old woman is admitted to the hospital for antibiotic treatment of meningococcal meningitis. She is stabilized. Three days later, her pulse is 120/min, and blood pressure is 60/30 mm Hg. Physical examination shows bilateral flank tenderness. Serum studies show a sodium concentration of 128 mEq/L, potassium of 5.4 mEq/L, and bicarbonate of 20 mEq/L. Which of the following is the most appropriate next step to determine the cause of this patient's hypotension? Correct AnswerAdrenocorticotropic hormone stimulation test 25-year-old woman with fatigue for 3 wks and intermittent fever for 7 days, had teeth cleaned a month ago, no abx for prophylaxis, and had rheumatic fever as child and endocarditis 4 y ago. PE shows 2/6 murmur, ultrasound shows abnormal mitral valve. Photo of growth from blood cultures shown (GP cocci in chains). Characteristic of causal organism? Correct Answer-]Greening reaction on blood agar alpha hemolysis (green)83-year-old with arteriosclerosis undergoes repair of infrarenal abdominal aortic aneurysm. Graft extends just below the renal arteries to the bifurcation of the aorta. Which organ will lose primary blood supply and rely on collateral circulation? Correct Answer-Descending colon In a 25-year-old patient who underwent splenectomy, target cells are seen on peripheral smear. These cells are seen due to loss of function of which portion of spleen? Correct Answer-Red pulp Red pulp Correct Answer-the region of the spleen composed of blood-filled venous sinuses and thin plates of splenic tissue (cords), which consist of red blood cells and various white blood cells Filter the blood of antigens, microorganisms, and defective or worn-out red blood cell 56-year-old exposed to possible chemical attack. Respirations labored, diaphoresis, excessive lacrimation, increased salivation, muscle strength 2/5, urinary and fecal incontinence. Besides atropine, another tx? Correct Answer-Pralidoxime Studying epithelial repair of small intestine in experimental animal. Wants to identify most active cell division location. Where is this cell activity found? Correct Answer-Base of the crypt 48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints. Current meds include prednisone, hydroxychloroquine, and oxycodone forpain. Best action to encourage patient to adapt to illness? Correct Answer-Encourage the patient to participate in a support group for persons with her condition A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. Three hours later, he develops tachypnea and dyspnea. Arterial blood gas analysis on room air shows a decreased Po2 and Pco2. A chest x-ray shows bilateral interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to what will preclude restoration? Correct Answer-Basement membranes 12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Left breast is slightly larger than right, nipple mildly tender. Penis slightly enlarged and pubic hair curling and beginning to darken at base. Best next step? Correct Answer-Reassure the mother that physical findings are not uncommon for his age 17-year-old boy with syncopal episode, fever, nausea, muscle aches, progressive confusion. T 103.5F, palpable bp 80. PE rash on lower extremities. WBC 26,000. Blood and CSF cultures grow oxidase positive, gram negative diplococcus. Brother with similar infection at same age. Immune disorder? Correct Answer-Late component of complement deficiency 75-year-old man comes to the physician because of an enlarging face shoulders and trunk and thinning of his arms and legs. Physical examination shows a large plethoric face, fat pad over the upper thoracic spine and purple striae on the abdomen. Serum studies show undetectable ACTH and an increased cortisol concentration. Administration of low dose dexamethasone would most likely result in which of the following sets of serum findings? Correct Answer-ACTH no chang [Show More]

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