Download NBME CBSE ACTUAL TEST BANK-with 100% verified solutions 2024-2025 and more Exams Nursing in PDF only on Docsity! NBME CBSE ACTUAL TEST B A N K - w i t h 1 0 0 % v e r i f i e d s o l u t i o n s 2 0 2 4 - 2 0 2 5 62 year old woman - osteoporosis - a bisphosphonate is prescribed. The expected beneficial effect of the drug is due to which of the following? - 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? -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? -Answer- Increased 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? -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? - Answer- a. Adenylyl Cyclase Adenylate 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? -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? -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? -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? -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? -Answer- Schistosomiasis A 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? -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? -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? -Answer- Hemopneumpothorax 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? -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? -Answer- Vitamin B12 - (cyanocobalamin) Tea and Toast - low B12 in diet 15 year old girl - 3 month history of acne - which is the underlying cause of the patients acne? -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? -Answer- Apoptosis b. Endemic Burkitt lymphoma can happen in Brazil as well as Africa (jaw lesion, puffy face). 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? -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? -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? - 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 oropharyngeal edema - Outbreak among other campers. Which is most likely cause of this patient's symptoms? -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? -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? - 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? - Answer- Radon 54- year-old man - intense overwhelming fear. Which portion of brain stimulated? - Answer- Amygdala b. Fear = amygdala 30 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? -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? - 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? -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? -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? -Answer- Normal Findings b. normal physiologic splitting 37 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? -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? -Answer- Accumulation 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? -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? -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? -Answer- It is a polymorphism 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? - 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? -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? - Answer- DNA Virus Herpetic Whitlow Herpetic Whitlow -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? -Answer- Ingestion of Soil b. Ascaris - fecal oral transmission 23 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? - 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? -Answer- The 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? - 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? -Answer- Membranous a. Pelvic fracture - MVC b. Pelvic Straddle injury = Bulbar (spongy) urethera A 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? -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? -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? -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? -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? -Answer- Superficial Inguinal 1 cm mass below dentate line 24 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? -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? -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? -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? -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? -Answer- ACE Inhibitors A 65 year old - bilateral wheezing - accumulation of which of the following? - Answer- Leukotrienes 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? -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? -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? -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" -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? -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? -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 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 -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? -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? -Answer- Hypercoagulability of advanced malignancy A 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? -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? -Answer- Separation 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? -Answer- Upward Gaze Parinaud Syndrome due to compression of tectum- vertical 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? -Answer- Atrial Fibrillation Wedge Shaped renal infarct -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? -Answer- Hair Follicle b. Hot Tub Folliculitis = Pseudomonas 45-year-old - picture of H. Pylori - epigastric heartburn and weight loss - Which process likely involved? -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? -Answer- Common Fibular Nerve (peroneal nerve) Which is most appropriate initial response? -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? -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? -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? - 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? -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? -Answer- a. 0.2 . 15/50 - 5/50 = .2 34 - 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? - 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? -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)? -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? -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? -Answer- Graft vs Host Disease 1 -Answer- 1. 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 receptor- alfa/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? -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? - 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? - Answer- Adenosine 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)? -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? -Answer- Predictive value of a positive test result ]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? -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? -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? -Answer- Area labeled D 24-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? -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? -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? -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 achalasia 45-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? -Answer- a. Gilbert Stress related - Mild jaundice with increased unconjugated in an older fellow is decreased UDP-glucuronyltransferase 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? -Answer- Prerenal azotemia After the addition of furosemide, her BUN/Cr ratio went up to 38 and Fraction Excretion of Na < 1 33-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel. Mechanism? - 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? - 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? -Answer- Hypertension b. concentric ventricular hypertrophy = increased afterload c. eccentric ventricular hypertrophy = increased preload d. chronic HTN, Friedreich ataxia 23-year-old woman g1p1, not felt well since delivery 2 weeks ago; ongoing fatigue, inability to breast-feed, 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, 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? -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? -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- -Answer- pH 7.32 pCO2 15 HCO3 8 aspirin 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? -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? -Answer- Cyclosporine 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? -Answer- Initiate the procedure and treatment without consent Implied 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? -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? -Answer- Randomized 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? - 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? -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? -Answer- Complement 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 IgG 67-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. 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 about 10% 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? -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? -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? -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 inhibitor 18-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? -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? -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. 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? -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 past-pointing on a finger-nose test. Broad-based gait. MRI shows brain lesions in white matter of cerebellum. Pathogenesis? -Answer- CD4+ T lymphocytes are activated by myelin basic protein Multiple Sclerosis increased IgG level and myelin basic protein in CSF Oligoclonal 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? -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)? -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? -Answer- Contact the patient to discuss the situation Reach out to patient 4-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? -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 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? -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? -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? -Answer- Angiodysplasia Hematochezia is the passage of fresh blood per anus Tortuous dilation of vessels hematochezia 24-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? -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? - 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? -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 of the following is the most likely cause of the findings in this patient? -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? -Answer- Physiologic shunt - Mismatching of ventilation and perfusio - insufficient ventilation to provide the oxygen needed to oxygenate the blood Physiologic shunt -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 -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 and sizes, nucleated erythrocytes and myelocytes. Aspiration of bone marrow dry tap. Biopsy shows thickened bony trabeculae with increased reticulum. Dx? -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 - 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 Leukocyte esterase 4+ A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis? -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? -Answer- Chloroquine 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? -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? -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 -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? - Answer- alpha1- adrenoreceptors low doses d1 = dilates renal vessels medium b1 agonist = ionotropic and chonotropic high doses a1 agonist = vasoconstriction 8-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? -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? -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? -Answer- Schedule 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 right-sided S4 gallop. Increased pulmonary expression of what? -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 mask to anesthetize this patient quickly would have which of the following characteristics? -Answer- Low 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? -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? -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? -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? -Answer- Axillary fracture of the surgical neck of the humerus. axillary nerve and the posterior circumflex humeral artery 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? - 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? -Answer- Provide 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? - Answer- PCT 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? -Answer- Single Primary Development Defect pyloric stenosis - olive shaped mass - stand-alone defect VACTERL -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? -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 receiving the 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? - 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? - 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? -Answer- Capsular polysaccharide Strep 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? -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? -Answer- Discuss treatment options and a referral for detoxification program 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? -Answer- Pleomorphic 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? - 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? -Answer- Antibodies directed against glycoprotein (Gp) IIb/IIIa complex Immune thrombocytopenia 60-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, lactose- fermenting organism. Bug? -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? -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? - 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? -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? -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 -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? - 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? -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? - 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? - Answer- Increased transcription of HMG-CoA reductase 63 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? - 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? -Answer- Endothelial nitric oxide synthase production shows small intraerythrocytic rings. Polymerase chain reaction for Plasmodium is negative. Causal organism from bite of? -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? - 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? -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? -Answer- Left pleuroperitoneal membrane Diaphragmatic 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? - 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? -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 mouth Retrospective 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? -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? -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? -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? -Answer- Bilateral stents in the ureters 34-year old man is brought to the ER semiconscious and combative. In addition to sedation, a short-acting 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? -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? -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? -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 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? -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? -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? - Answer- Red pulp Red pulp -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? -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? - 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 for pain. Best action to encourage patient to adapt to illness? -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? - 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? - 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? -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? -Answer- ACTH no change cortisol no change 71-year old woman with coronary disease and well-controlled hypertension is brought to the physician 2 hours after sudden onset of weakness of her left leg. Her BP 145/85 mmHg. Neurologic exam: weakness and decreased sensation over the left lower extremity. There are no other sensory or motor deficits. Which labeled structure is site of injury? -Answer- A (Pre/postcentral gyrus; motor/sensory cortex) 71-year-old man admitted for prostatic resection. Normal mental status. 2 days after surgery, confused and restless. Cannot sleep and restless, seeing little men coming through window. Dx? -Answer- Delirium 2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam of stool shows viral particles with wheel-like shape. Properties of virus? Type of nucleic acid/envelop/capsid symmetry -Answer- Double- stranded RNA, segmented/no/icosahedral Double-stranded RNA, segmented/no/icosahedral "wheel-like shape" -Answer- rotavirus 62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital-associated infection. Studies show 30% of patients require admission after procedure, and 2 percent of admitted patients acquire hospital infection. Patient's risk for infection overall? - Answer- 6/1000 30% * 2% = .0006 Randomized controlled trial evaluating tx of acute otitis media. No statistically significant differences found between infants receiving the 4-year-old male with recurrent UTIs, left kidney found small and non functional; right is normal. Nephrectomy is done, and the picture shown (dilated ureter and renal calyx). Microscopic exam of kidney will show which? -Answer- Tubular atrophy tubulointerstitial fibrosis of the kidney Girl has chronic cough with thick sputum, abdominal cramps in RLQ, and frequent resp infections. Clubbing of fingers, hyperresonance on chest percussion. Diffuse crackles and scattered wheezes. On xray - diffuse hyperinflation of the right upper lobe. She has a healthy brother. What's the likelihood he is a carrier for the condition? -Answer- 2 of 3 15-year-old girl comes with lack of improvement of facial acne. Tried topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Says, "Please help me." She has never been sexually active. Tx? -Answer- Isotretinoin 40 year old brought to ER after wife found him unresponsibve- PCO2 60, PO2 50 HCO3 12 - acid base status? -Answer- Metabolic acidosis and respiratory acidosis Check pH - NONE Check Bicarb - low - metabolic acidosis Check CO2- high - respiratory acidosis (hypoventilating) 35 year old woman - undergoes flexible nasopharyngoscopy - Purulent discharge from the right sphenoethmodial recess. Location of structure? - Answer- superior to superior concha 18 year old on tennis team -after 5 hours or practicing - tenderness over lateral elbow pain -inflammation at the origin of what muscle? -Answer- Extensor Carpi Radialis Brevis 47 y/o woman patient with psoriasis - comes to physician for follow-up- previously given several topical creams used in specific sequence - no improvement of symptoms - what is appropriate way to beginning discussion of compliance? -Answer- Most people find it difficult to stick to routine. How did you do? 44 year old - severe pain and swelling in knuckles and knees - increased erythrocyte count and Rheumatoid Factor - Treatment with Ibuprofen for 2 week. Plasma after 2 weeks (Leukotriene, Arachidonic Acid, PGE2, PGH2)? - Answer- Leukotriene Increased Arachidonic acid Increased PGE2 decreased PGH2 decreased 26 year old man - HIV+ , 3 days of reddening skin involving the palms, arms, legs, and soles. RPR test is positive. Treatment to eradicate the causal organism? -Answer- Penicillin 6 year old - firm, smooth, umbilicated papules 2 to 4 mm in diameter- causal organisms? -Answer- Poxvirus 28-year-old man -struck in right eye by a baseball. He has diplopia, periorbital swelling, and enophthalmos, Upwards gaze impaired- fracture involving the orbital-floor- Entrapment of which muscles? -Answer- inferior rectus and inferior oblique fracture involving the orbital-floor Acetaminophen and nonsteroidal anti-inflammatory agents - reduce fever by decreasing the synthesis of which of the following factors in the hypothalamus? -Answer- Prostaglandin E2 75-year-old - sudden onset of partial loss of vision - Visual fields show R- lower Quadrantopia - pie on the ground - a lesion in which of the following? - Answer- Parietal Lobe - left Pie on the ground - Contralertal lesion in parietal lobe - baums loop -bombs on ground 53-year-old - GERD - dietary changes and stress reduction have no effect. What drug both relieves symptoms and promotes healing? -Answer- Omeprazole Irreversibly inhibit H+/K+ ATPASE stomach parietal p. 399-2 22yo woman, g1p1, 2-day hx of fever, severe vaginal bleeding. four days ago delivered healthy male newborn. Temp 38.1 C (100.6 F). Pelvic exam: open cervix, heavy vaginal bleeding. US shows uterus with no placental tissue or thrombi. If operation required to control bleeding, ligation of branch of which artery required? -Answer- internal iliac 42yo F with 3-year hx of an intermittent facial rash, including the forehead, eyelids, nose, and cheeks. Rash seems to be getting worse since she moved from New York to Florida last year. Spicy foods precipitate a flushing reaction that seems to exacerbate the rash. PE shows erythema over the nose and cheeks, with scattered telangiectasias and a few papules. Dx? - Answer- Rosacea 17 year old - evaluated for growth delay - X-ray shows suprasellar calcifications- most likely explanation for this condition? -Answer- Craniopharyngioma Most common childhood suprasellar tumors Remnants of Rathke Pouch - derived from oral/surface ectoderm of oral cavity 64 y/o man - bronchospastic pulmonary disease - wheezing in spite increasing on b- adrenergic agonist inhaler- hospitalized and systemic prednisone is added - which explains the action of prednisone in enhancing response on B-adrenergic agonist?? - Answer- Enhanced action of the agonist at B-adrenergic receptors Corticosteroids- upregulates B2 receptors + inhibit b2 Cortisol - permissive effect on catecholamines - 336-1 enfuviritide Scientists - identified the flawed gene causes 1-6 colon cancer - when gene is working - gene repairs discriminates between the template and the newly synthesized DNA strand, correcting mistakes in the newly synthesized gene? -Answer- Mismatch repair Colon Cancer - Lynch HNPCC 55 y/o- with renal artery stenosis - 50% reduction in renal blood flow - which part of kidney has the highest concentration of renin in response to reduction in arcuate pressure -Answer- Cortex Renin is produced in JG Cells - located in cortex P. 589 - located in modified smooth muscle of afferent 14 year old - 2 month history of hair loss - PT sad since grandmother died unexpectedly 3 months ago. Underlining skin is normal. Explanation for hair loss -Answer- Trichotillmania Compulsively pulling out one hair - causes significant distress despite attempts to stop - p. 563 34 year old - 6 week history pf fatigue and shortness of breath - fixed split S2 - midsystolic pulmonary ejection murmur - A congenital heart defect - patient undergoes surgical repair - greatest risk for intraoperative injury? -Answer- Atrioventricular Bundle 66 year old - pain, fever, chills, - left lower abdominal pain - severe constipation over 5 years -a barium of lower GI - 3 separate area of narrowing of the lumen of the distal sigmoid - Photograph of lesion - DX? - Answer- Diverticulitis LLQ pain, fever, leukocytosis, wall thickening p. 383-3 > 60 years old - 64 year old women - T2DM and HTN - soreness and muscle Pain in large muscles - She began rosubastatin therapy - her medicatioons include gemfibrozil, HCTZ, losrtan, and metformin, elevated serum creatine kinase - what interaction between rosuvastatin and which of the following? -Answer- Gemfibrozil Statins - 320- cause Rhabdomyolysis Myopathy when used with fibrates 48-year-old man - ER - 1-hour history of vomiting blood - Physical exam shows ascites. A surgical shunt between which of the following veins - release esophageal bleeding? - Answer- Splenic and left renal vein 37-year-old - MVC - severe, sharp, chest pain - hyperresonance- decreased tactile fremitus - adventitious sounds are absent- multiple rib fractures - pathway of chest pain? -Answer- Intercostal nerve Multiple rib fractures and pneumothorax - COPD costal and cervical pleura innervated by intercostal nerve 78 yeasr old women - paroxysomal embolus in left leg - left lower extremity cool and pale, absence pulses- ECG shows irregularly irregular rhythm - which treatment is most appropriate? -Answer- Embolectomy Originated in heart - sudden acute of pain in the leg Paroxysmal embolus 75 year old man - fever, back pain, pain on urination - long standing prostatitis- gram statin - gram positive cocci in chains - cause of illness? - Answer- Enterococcus Faecalis Gram + cocci in chains + UTI = enterococcus 65-year-old - vomiting blood - Hypovolemic shock- placement of catheter in internal jugular vein for blood transfusions - improper insertion damage to which of sets of underlying structures? -Answer- Lung and Common Carotid Artery b. Internal jugular vein - next to common carotid - and lung apex extend above 1st rib 32-year-old woman at 35 weeks' gestation - during her labor - increased oxytocin concentrations - most likely cause of finding? - Answer- Birth Canal Reflex Fergusson Reflex - positive feedback loop 75 year old woman - sudden Horner syndrome, dysphagia, difficulty speaking, which occluded? -Answer- Posterior Inferior Cerebellar Lateral medullary syndrome - nucleus ambigious (IX, X, XI) 65-year-old man in MVC - photograph of lung at autopsy (Centrally located lesion) - Dx? -Answer- Squamous Cell Carcinoma Centrally located- arising or extending into bronchus Hilar mass arising from bronchus - p. 684 Hypercalcemia - PTHrp- source from cancer 54yo man for exam. P80, R14, BP140/95. Physical exam normal. ACE inhibitor given. Where is MOA in kidney? -Answer- F - ACE preferentially vasoldiate the efferent arteriole Preserves GFR - by back pressure vasodilation of efferent 68 year old man - 1 month history of not being able to sustain an erection - wife died 2 years ago - able to masturbate - testosterone within reference range -no symptoms of depression- which pairs of finding in history? - Answer- Libido Normal Nocturnal Erection Normal A 30 year with hypothyroidism - receiving T4 - fetus at greatest risk if TSH concentrations increase? -Answer- Abnormal Brain Development 51-year-old woman - burning abdominal pain, sweats profusely, 2 cm- mass in proximal duodenum. Gastrin releasing tumor stimulates which labeled cells in picture? -Answer- B- parietal Cells Stain Eosinophilic - fried egg appearance- PINK EGGS Parietal cells - secrete gastric acid 25-year old develops shortness of breath - after moving from sea level to a mining town at 3350. At rest, pulmonary hypertension with normal cardiac output - pulmonary function tests are normal - Which explains pulmonary hypertension? -Answer- Decreased Alveolar PO2 30 year -old comes to the office - 20lb weight loss after initiating a low- carbohydrate diet - low fat diet -it is most important to counsel the patient to include which of the following to maintain a good nutrition? -Answer- Linoleic Acid Essential fatty acids - OMEGA 6 and Omega 3 Omega 6= linoleic and Omega 3 = alpha linoleic Must be obtained through diet - vegetables, oils, meats, nuts, and egg Deficiency - lead to poor growth, skin lesions, reproductive failure 44-year-old man -altered mental status HTN (210/145)- fundoscopic exam shows papilledema and retinal hemorrhages - A drug with which of the following effects on vascular smooth muscle is likely to decrease blood pressure? -Answer- Increasing cGMP A test has been developed to screen for HPV infections - If the prevalence increases by 50%- which of the following features of the test will increase? - Answer- Predictive value of a positive test . A newborn female external genitalia - 46 XY karotype - shows male genital ducts - the most likely cause of this anomaly is a mutations resulting in the absence expression of which of the following hormones or factors? -Answer- Dihydrotestosterone 36-year-old with AIDS - tx with CCR5 receptor inhibitors - which is natural ligand for HIV co-receptor? -Answer- Chemokine Maraviroc binds to CCR5 Cysteine-Cysteine Chemokine receptors - found on surface of CD4+ 7 year old - difficulty concentrating in school - "feels tired" - hypochromic anemia - fatigue - increased serum creatinine - additional abnormal concentrations in this patient? -Answer- Increased Blood Lead Physician prescribes a recently marked drug for 20 patients - After several months, 5 patients develop increased serum AST and ALT - Physician discontinues drug and reports adverse effects to the FDA. Physician participated in what phase of clinical trial? -Answer- Phase 4 SWIM Post marketing surveillance - detects rare or long term adverse effexts 6-month-old - exaggerated reaction to loud noises- Exam shows muscle weakness, increased start reflex, cherry red spots on retina- most likely cause of this disorder is accumulation of which of the following lipids in the patients lysosomes? -Answer- GM2 Tay-Sachs - cherry red spot Gm2 gangliosides accumulate Deficiency in Hexoaminidase A 60 year old - ER -thrown from care in high speed automobile accident and struck guardrail- blood in urethral meatus and fractures of the pelvis and left femur. A Foley catheter is unable to be inserted- which is most likely explanation? -Answer- Urethral Disruption Suspect urethral injury if blood is seen at the urethral meatus 30 year old - pruritic rash on his lower back - underwent liver transplantation 1year ago and maintained on immunosuppressive drugs -PE shows vesicles containing clear fluid associated with ulcerated and crusted lesions- likely diagnosis? -Answer- Varicella- zoster virus infection 50-year-old man progressive dyspnea on exertion. Dyspnea at rest. Exam of lung tissue biopsy shows chronic inflammation and fibrous thickening of alveolar septa. Dx? - Answer- Usual Interstitial Pneumonitis 52-year-old woman admitted to hospital because of breath die to malignant ascites and pleural effuision- two gynecologists disagree about treatment -- pt comes to primary care pysician to help address conflicty - what do internal medicine physicians do to address concern? -Answer- Speak with two gynecologists to attempt to coordinate 36-year-old woman undergoes a total hysterectomy and bilateral salpingo- oophorectomy for extensive endometriosis of the pelvis. After operation, she refuses hormone therapy. Which of the following - most likely occur in gonadotrophs if this patient refuses hormone therapy -Answer- Hyperplasia Gonadotrophs are the FSH/LH producing pituitary cells. No ovaries, no hormones, no feedback inhibition. An investigator - study efficacy of capsular polysaccharides - Neisseria Meningitidis - Which of the following compounds is most likely to induce increased titers of these antibodies when conjugated to polysaccharides? -Answer- Flagellin 35-year-old woman with blistering lesions on sun-exposed area of face, arms, hands - increased AST, ALT, Total Porphyrin, Urine uroporphyrin III, deficiency in what enzyme? -Answer- Uroporphyrinogen Decarboxylase Porphyria cutanea tardia - vampire blistering lesion on sun- exposed European Vampire - hide in cardboard 53-year-old - breast cancer - taking tamoxifen - what is effect on tamoxifen on breast and Uterus? -Answer- Breast Antagonist Bone Agonist Uterus partial agonist. 26-year-old - counseling prior to conception - pedigree - fatal to males not born = which is most likely risk to live born? -Answer- 50% in females, but near 0 in males Fatal to males in utero X linked dominant - males have 50% of getting from mom 43 year old - follow-up exam -underwent cardiac valve replacement - Chest X-Ray shown - which of the following valves most likely replaced in this patient? -Answer- Aortic 30 year old - pregnant + gram positive rods - pregnant women - fever, chills, muscles aches - which causal organism? -Answer- Listeria Monocytogenes Normal appearing 17-year-old - normal appearing - vagina ends blinding - no uterus or ovaries to palpate - chromatin negative nuclei - which is likely diagnosis? -Answer- Androgen Insensitivity Syndrome 27 year-old - 34 weeks pregnant - nausea, vomiting, abdominal pain for 12 hours -HTN 164/104, Elevated Liver Enzymes. platelet count low eve what do you see on peripheral blood smear? -Answer- Schistocytes 52 year - ER - sudden chest pain - IV morphine - generalized pruritus and warmth in 1 minute - which substance most likely cause new symptoms? - Answer- Histamine Pruritus and warmth in 1 minute- Hypersensitivity 59-year-old man - 3-month history of progressive difficulty swallowing - 15lb weight loss - smoked 1 pack of cigs daily for 40 years - cachectic - mass ulcerated with elevation surrounding mucosal rim- 6 cm mass in mid esophagus - centrally located mass - examination of the biopsy specimen of the mass is likely to show neoplastic cells with which of the following? -Answer- Foci of Keratinization Squamous Cell Carcinoma occurs in upper 2/3 - Adenovrius occurs in distal 1/3 34-year-old - periorbital headaches - last 60- 90 minutes - lacrimation and nasal stuffiness - whichh of the following is most likely diagnosis? -Answer- Cluster Headache 7-year-old - lack of adequate quality protein identified as critical issue- which of the following is most critical in analysis of child's diet? -Answer- Methionine 33-year-old women - fever, malaise, burning on urination, and scant vaginal discharge extremely tender vesicles and ulcers - DX? -Answer- Genital Herpes 28-year-old - sudden onset of 30 of shortness of breath - history of cocaine abuse - diminished pulses in left upper extremity - widened aortic arch - dx? -Answer- Dissecting Aneurysm 24 year old - sickle cell disease - generalized fatigue -MCV 105- Hematocrit dropped. Which diagnostic test most likely explain the patients symptoms and decreased hematocrit? -Answer- Serum Parvovirus B19 IgM antibody test 66-year-old - 1 day history of fever - underwent transurethral resection for prostate 1 week ago - BP 70/50 Blood cultures grow, lactose-positive, gram negative rods. Which describes the initial event of hypotension in the patient? -Answer- Lipopolysaccharide stimulation of toll like receptors A photograph shows spinal cord injury after MVC - image shows damage to fasciculus gracilis? -Answer- Loss of sensation to vibration of both feet 47-year-old - aplastic anemia - TX for disseminated aspergillosis with antifungal drug binds to specific sterols in plasma membrane - which drug? - Answer- Amphotericin B 34-year-old - ER - unconscious after alcohol intoxication - which is interpretation of arterial blood gas. Ph 7.25 Pco2 23 Po2 78 - Na+ 140, Cl - 105, HCO3 10? -Answer- Primary Metabolic Acidosis with increased anion gap Ph low, Bicard low, CO2 low Na+ - (HCO3+ + Cl-) 140 - (10 + 105) = 25 18-year-old - 2-week history of fatigue - PE shows scleral icterus - Lab shows - Hemogloblin Low- high bilirubin - increased 2,3 BPG, increased reticulocytes - mostly likely deficiency in enzyme in erythrocytes? - Answer- Pyruvate Kinase 22 year old - frequent episodes of cutaneous urticaria and laryngospsm - allergic cause of his urticaria. Which of the following complement proteins is most likely deficient? - Answer- C1 esterase inhibitor (binds activated C1r, C1s) 45 year - ER - MVC - patients' ventilator - adjusted to tidal volume- application of PEEP will most likely prevent which of the following complications? -Answer- Absorption Atelectasis 35-year-old -DKA - treated with insulin - decreased plasma glucose 900mg/dl to 270. which additional lab finding will likely decreases with insulin therapy? -Answer- Serum potassium concentrations 67 year sore - fever, sore throat, difficulty swallowing- Corynebacterium diphtheria - the pathogen produced diphtheria toxin - blocks which of the following processes? -Answer- Translation myocardial softening and mottling involving the anterolateral wall - Photomicrograph of a section is shown. which is most likely mechanism of death -Answer- Arrhythmia Ventricular Arrythmia - most common after 24 hours of MI 68 year old - fever, shortness of breath - Xray shows right lower lobe infiltrates - leukocytes 38,000 - peripheral blood smear is shown- which of the following best describes blood smear? -Answer- Reactive Granulocytosis 19 year old women -1 month of abdominal pain and severe diarrhea - 5.4 KG weight loss colonoscopy shows non-bloody diarrhea and cobblestone appearance of the colonic mucosa - stricture in retroperitoneal portion of the bowel - which is the most likely location of the stricture -Answer- Descending Colon Which of the following best explain why use of anti-idiotypic antibody is inappropriate therapeutic reagent for treatment? -Answer- Myeloma Cells do not have membrane surface immunoglobulin a. Plasma cells produce secretory Ab's (aka produce Ab's) -- plasma cells do not have membrane-bound Ig (aka do not have BCR'). 9 year-old - tumor in heart - what is the diagnosis? -Answer- Rhabdomyoma Tumor heart in child = rhabdomyoma 32-year-old woman - sister recently died of melanoma - Other family members similarly affected. Which lesion is most likely on both sun exposed and nonsun exposed ares on patient skin? -Answer- Dysplastic Nevi Diastolic blood pressure obtained from two groups of 100 asymptomatic - picture of Diastolic average? -Answer- Median Group Y = Higher Mode Group Y = Higher 72 year old man - history of nonproductive cough -non hodgkin lymphoma- treated with antineoplastic drugs - chest xray shows diffuse infiltrates- which of the drugs most likely cause of patient symptoms? -Answer- Bleomycin 47 y/o - jaundice - increased serum bilirubin and positive urine bilirubin test -Which is most likely associated with the positive urine bilirubin test - Answer- Obstruction of the Bile Duct 70-year-old - persistent fever despite intravenous broad-spectrum antibiotic therapy 3 days after operative incision for cervical carcinoma. PE shows placement of central venous catheter - Blood cultures from cather grow - Gram stain colonies, 4um, elliptical, purple budding organisms- which is the causal organisms? -Answer- Candida Albicans A 74-year-old with mild dementia is admitted to the hospital because of congestive heart failure. Physician recommends coronary angiopgraphy and angioplasty. The patient states that she wants to go home. It would be appropriate to question patient capacity if? -Answer- Inability to understand the severity and prognosis of her medical condition informed consent process