UWorld 4/15
A 49-year-old man comes to the office due to 4 months of cough and weight loss. His medical history is otherwise unremarkable and he takes no medications. The patient is a farmer who lives in Mississippi. He does not use tobacco, alcohol, or illicit drugs. His temperature is 37.9 C (100.2 F). Examination shows right lobe crackles. Chest x-ray reveals a pulmonary infiltrate in the right upper lobe. Bronchoscopy with transbronchial biopsy shows granulomatous inflammation. HIV testing is negative. Which of the following is most likely causing this patient's symptoms? A. Blastomyces dermatitidis (%) B. Candida albicans (%) C. Mucor species (%) D. Penicillium marneffei (%) E. Pneumocystis jiroveci (%)
A. Blastomyces dermatitidis (%) Blastomyces dermatitidis is a dimorphic fungus that can cause pulmonary infections in immunocompetent people and should be considered in individuals from an endemic area (states adjacent to and east of the Mississippi and Ohio river valleys; some overlap with Histoplasmosis). The fungus exists in the environment in mold form and is found in soil, organic matter, and many animals (eg, dogs, horses). It is transmitted by the respiratory route, entering the lungs and transforming into yeast form (thermal dimorphism). B dermatitidis infection can be asymptomatic or it can mimic community-acquired pneumonia (resolves spontaneously) or chronic pneumonia (may be indistinguishable from tuberculosis, other fungal infections, or cancer). Pulmonary blastomycosis is characterized by granuloma formation. Extrapulmonary disease (skin, bone, and genitourinary system) occurs in immunocompromised patients. Examination of tissues or respiratory fluids shows round yeast with thick walls and broad-based budding. Itraconazole is the preferred treatment for blastomycosis
A 65-year-old man comes to the emergency department due to sudden-onset headache. The patient has had no recent falls or head trauma. Medical history includes hypertension and lung adenocarcinoma with abdominal metastasis. Initial noncontrast CT scan of the head reveals a small temporal lobe hemorrhage. Over the next 24 hours, the patient becomes progressively obtunded and develops generalized tonic-clonic seizures. Blood pressure is 190/96 mm Hg, pulse is 38/min, and respirations are 10/min with brief episodes of apnea. A repeat noncontrast CT scan of the head reveals acute hemorrhage expansion with brain herniation. Which of the following findings is most likely to be observed on this patient's repeat neurologic examination? A. Dilated pupil (%) B. Horner syndrome (%) C. Hyperreflexia (%) D. Nystagmus (%) E. Upward gaze palsy (%)
A. Dilated pupil (%)
A 65-year-old man is being evaluated in the hospital. The patient was admitted 5 days ago for increasing lower extremity edema and dyspnea. Medical history is significant for obesity hypoventilation syndrome, pulmonary hypertension, and chronic lower extremity edema. Current temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 16/min. BMI is 50 kg/m2. Laboratory results are as follows: Admission Today (5th day) Hemoglobin 13.1 g/dL 14.5 g/dL Blood glucose 98 mg/dL 90 mg/dL Blood urea nitrogen 24 mg/dL 64 mg/dL Serum creatinine 1.2 mg/dL 2.1 mg/dL Urinalysis negative for protein, red blood cells, white blood cells, and casts Urine sodium 10 mEq/L Which of the following is the most likely cause of the laboratory abnormalities in this patient? A. Diuretic therapy (42%) B. Interstitial nephritis (8%) C. Osmotic diuresis (7%) D. Renal artery stenosis (20%) E. Tubular necrosis (13%) F. Ureteral compression (7%)
A. Diuretic therapy (42%) This patient has volume overload due to right-sided heart failure from pulmonary hypertension; he was most likely treated with diuretics to improve his volume status. However, laboratory results on day 5 demonstrate an abrupt decrease in renal function with low urine sodium and an elevated BUN/creatinine ratio (prerenal azotemia). In association with a normal urinalysis, this presentation suggests volume depletion from the excessive use of diuretics. Excessive diuresis can cause renal hypoperfusion and activation of the renin-angiotensin-aldosterone system (RAAS), which increases solute and water reabsorption by the kidney in an attempt to restore intravascular volume. As a result, laboratory studies will show low urine sodium (<20 mEq/L) and low fractional excretion of sodium (FENa <1%). Urea reabsorption is also increased in the collecting ducts, resulting in an increased BUN/creatinine ratio (>20:1). Elevated urine osmolality (>450 mOsm/kg) and urine specific gravity (>1.015) reflect concentrated urine. Evidence of hemoconcentration (eg, increased hemoglobin, albumin, uric acid levels) is also common in volume depleted patients
A 9-year-old boy is brought to the pediatrician due to poor school performance and difficulty making friends. His parents say he always had "very high energy," but they noticed that this got worse after they moved 8 months ago, which they attributed to a normal adjustment period. Over the past several months, however, the parents have received repeated phone calls from his teachers, reporting that he does not listen in class, has difficulty staying in his seat, turns in assignments late without his name, and frequently disrupts the class by talking out of turn. At home the boy forgets to do his daily chores, regularly loses his books and homework, and delays the family by taking too long getting ready for school in the morning. When his older brother teases him about this, the patient becomes irritable, and on a few occasions has shouted profanities and tried to hit his brother. Which of the following is the most likely explanation for this patient's behavior? A. Adjustment disorder (%) B. Attention-deficit hyperactivity disorder (%) C. Conduct disorder (%) D. Social anxiety disorder (%) E. Oppositional defiant disorder (%)
B. Attention-deficit hyperactivity disorder (%) Attention-deficit hyperactivity disorder (ADHD) is a common behavioral disorder characterized by a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning in ≥2 settings (eg, school, home). Diagnosis requires the presence of symptoms before age 12 with ≥6 inattentive and/or hyperactive/impulsive symptoms for ≥6 months. This patient's combination of inattentive symptoms (ie, forgetful, disorganized, loses things) and hyperactive/impulsive symptoms (ie, difficulty staying seated, interrupts others) is characteristic of the combined subtype. ADHD is more common in boys; girls are more likely to have the inattentive subtype
A 62-year-old man comes to the office with his wife due to behavioral changes. The patient has become increasingly impulsive and irritable over the past 1-2 years. He recently lost his job after making inappropriate comments and touching female coworkers. The patient has also lost interest in his hobbies and appears withdrawn during social gatherings. His other medical problems are hypertension and hyperlipidemia. A thorough neuropsychological assessment is conducted. Inability to perform which of the following tasks would be most indicative of frontal lobe dysfunction? A. Comprehending the meaning of a sentence (%) B. Describing similarities between a watch and a ruler (%) C. Differentiating between right and left (%) D. Identifying which finger is touched (%) E. Recognizing familiar faces (%)
B. Describing similarities between a watch and a ruler (%) The frontal lobes are involved in a wide array of functions, including personality, language, motor functions, and executive functions. Executive functions include abstraction, planning, impulse inhibition, attention, and working memory. Abstraction may be tested by asking a patient to describe the similarities between two objects (eg, a watch and ruler both measure things). Patients with frontal lobe damage may be unable to provide an answer or may provide concrete answers such as "they both have numbers." Because of its role in personality and impulse inhibition, processes that damage the frontal lobe (eg, traumatic brain injury, frontotemporal dementia) may lead to significant changes in behavior. Behavior change is more likely with bilateral, rather than unilateral, injury. Patients with frontal lobe injury may be disinhibited, socially inappropriate, irritable, and impulsive. (Choice A) Impaired language comprehension (ie, Wernicke aphasia) results from lesions in the dominant superior temporal gyrus. (Choices C and D) Patients with lesions in the dominant angular and supramarginal gyri (located in the parietal lobe) may have right-left disorientation and finger agnosia (ie, inability to recognize fingers). When these symptoms are accompanied by agraphia (ie, inability to write) and acalculia (ie, inability to perform arithmetic), it is known as Gerstmann syndrome. (Choice E) The inability to recognize a familiar face (ie, prosopagnosia) may result from lesions in the fusiform gyrus (located in the temporal and occipital lobes)
A 44-year-old woman comes to the office due to increasing right hip pain for the past several days. The pain is exacerbated by walking and by sitting with the right leg crossed over the left leg. The patient has a history of plantar fasciitis. Vital signs are within normal limits. BMI is 30 kg/m2. On examination, right hip abduction and internal rotation against resistance when the hip is flexed reproduce the pain. The cause of this patient's symptoms is suspected to be pathology at a tendon insertion site. The tendon of which of the following muscles is most likely involved? A. Adductor brevis (%) B. Gluteus medius (%) C. Obturator externus (%) D. Quadratus femoris (%) E. Vastus lateralis (%)
B. Gluteus medius (%) This patient has greater trochanteric pain syndrome (GTPS) characterized by lateral hip pain. GTPS is an overuse tendinopathy of the gluteus medius and gluteus minimus at their insertion on the greater trochanter of the femur. It is often referred to as trochanteric bursitis, although bursal involvement varies and is not likely the primary pathology. Risk factors include obesity, plantar fasciitis, and altered gait mechanics (eg, osteoarthritis). The gluteus medius and gluteus minimus originate from the upper and lower gluteal surfaces of the ilium, respectively, and insert onto the greater trochanter. Their primary functions include: Hip abduction Hip external rotation (internal rotation when the hip is flexed [eg, leg crossing]) Horizontal stabilization of the pelvis during ambulation
A 15-year-old boy is brought to the office by his mother due to difficulty with movement. The patient enjoys playing high school basketball but had to leave the team this year due to his progressively worsening symptoms. On examination, he is found to have significant kyphoscoliosis and a high plantar arch. His older brother suffered from a neurologic disorder and died of heart failure at age 25. This patient most likely has which of the following neuropathologic findings? A. Atrophy of the caudate nucleus (%) B. Cerebral cortex atrophy (%) C. Degeneration of the spinocerebellar tracts (%) D. Demyelination of peripheral nerves (%) E. Loss of neurons in the anterior horn of the spinal cord (%) F. Loss of neurons in the substantia nigra (%)
C. Degeneration of the spinocerebellar tracts (%) Friedreich ataxia is an autosomal recessive disorder caused by mutation of the frataxin (FXN) gene. This gene codes for an essential mitochondrial protein involved in the assembly of iron-sulfur enzymes. An increased number of trinucleotide repeats (GAA) is present in the mutated gene, causing decreased FXN expression. This leads to decreased mitochondrial energy production and increased oxidative stress, resulting in degeneration of neural tracts and peripheral nerves. The following sites of involvement are characteristic: Spinocerebellar and lateral corticospinal tract degeneration causes gait ataxia and spastic muscle weakness, respectively. Degeneration of the dorsal columns and dorsal root ganglia causes loss of position and vibration sensation. Kyphoscoliosis and foot abnormalities (pes cavus) are characteristic skeletal deformities. Heart involvement includes hypertrophic cardiomyopathy and congestive heart failure. Diabetes mellitus develops in about 10% of patients with Friedreich ataxia. (Choice D) Charcot-Marie-Tooth disease is an autosomal dominant disorder associated with demyelination of peripheral nerves. Typical findings include distal leg weakness/atrophy with sensory deficits, pes cavus, and kyphoscoliosis; cardiomyopathy is not characteristic.
A 2-day-old newborn develops lethargy and respiratory distress. Blood cultures grow beta-hemolytic Gram-positive cocci in chains that are bacitracin-resistant. Which of the following measures could have prevented this patient's condition most effectively? A. Penicillin at 30 weeks gestation (%) B. Maternal vaccination (%) C. Intrapartum ampicillin (%) D. Postnatal immunoglobulin (%) E. Breast feeding restriction (%)
C. Intrapartum ampicillin (%) The finding of Gram-positive cocci in chains indicates Streptococcus as Staphylococci classically form clusters. Group A Streptococci and Group B Streptococci are beta-hemolytic, but bacitracin resistance excludes S. pyogenes (GAS) and indicates S. agalactiae (GBS). The 2002 guidelines for perinatal group B strep prevention recommend universal prenatal screening for group B streptococcal colonization by maternal vaginal and rectal culture at 35-37 weeks gestation. In women who culture positive for GBS or in women who have had an infant affected by GBS in the past, intrapartum antibiotic prophylaxis is indicated to prevent neonatal GBS sepsis, pneumonia and meningitis. The incidence of group B streptococcal disease in babies less than a week old is declining due to these recommendations. Penicillin remains the first line agent for intrapartum antibiotic prophylaxis, with ampicillin an acceptable alternative. Choice A) Use of penicillin G at 30 weeks gestation would serve to eliminate GBS at that time and likely for the next few weeks in the expecting mother. However, after approximately 4 weeks depending on the dose administered, she is again vulnerable to colonization with GBS. Treatment with antibiotics this early in pregnancy is ineffective for GBS prophylaxis.
A 4-month-old boy is brought to the cardiology clinic by his parents for continued follow-up of tetralogy of Fallot. The diagnosis was made during routine antenatal sonography, and the pregnancy and delivery were otherwise uncomplicated. The infant has been seen frequently in the clinic and has not had any cyanosis, respiratory distress, or difficulty feeding. The parents become concerned when their son's surgical plan is discussed because he does not have the clinical signs that other children with tetralogy of Fallot demonstrate. Which of the following is the major determinant of symptom severity in this condition? A. Aortic valve insufficiency (%) B. Associated pulmonary malformations (%) C. Right ventricular outflow tract obstruction (%) D. Tricuspid valve insufficiency (%) E. Ventricular septal defect (%)
C. Right ventricular outflow tract obstruction (%) Tetralogy of Fallot (TOF) is characterized by ventricular septal defect (VSD), overriding aorta, right ventricular outflow tract (RVOT) obstruction, and right ventricular hypertrophy. The VSD generally is large, which allows for equal pressure in the right and left ventricles. Therefore, it is the amount of RVOT obstruction that determines how much deoxygenated blood is delivered to the systemic circulation. Infants with significant RVOT obstruction shunt more deoxygenated blood across the VSD to the aorta and are more cyanotic. Infants with no or minimal RVOT obstruction, such as this patient, deliver more deoxygenated blood to the lungs and appear acyanotic. The degree of RVOT obstruction is dynamic and can increase suddenly, leading to profound cyanosis ("tet spells"). These can be caused by dehydration or hyperventilation but are usually idiopathic
Scientists studying the kidney's response to hypoperfusion apply a clip to a pig's right renal artery that reduces blood flow to the kidney by about 70%. After 6 months, they perform a right nephrectomy and examine the glomeruli and tubules microscopically. Which of the following cell types would be most likely to undergo hyperplasia as a result of the clip placement? A. Cuboidal epithelial cells of the proximal tubules (%) B. Endothelial cells of the efferent arteriole (%) C. Intraglomerular mesangial cells (%) D. Modified smooth muscle cells of the afferent arteriole (%) E. Squamous epithelial cells of the thick ascending limb of the loop of Henle (%)
D. Modified smooth muscle cells of the afferent arteriole (%) Renal artery stenosis causing significant renal hypoperfusion will result in a decreased glomerular filtration rate and activation of the renin-angiotensin-aldosterone system. This leads to increased renin release by modified smooth muscle (juxtaglomerular) cells in the walls of afferent glomerular arterioles. Chronic renal hypoperfusion can cause hyperplasia of the juxtaglomerular apparatus
A 4-year-old girl is brought to the clinic due to an inward deviated right eye. Examination shows a pale red reflex in the right eye relative to the left eye. Dilated funduscopic examination reveals a well-circumscribed white mass within the retina. Genetic analysis shows a germline mutation in the patient's cells leading to development of the mass. Which of the following is the most likely function of the protein affected by this patient's gene mutation? A. Activation of receptor tyrosine kinase (%) B. Conversion of GTP to GDP (%) C. Opposition of p53 activity (%) D. Prevention of the G1/S cell cycle transition (%) E. Repair of damaged DNA (%)
D. Prevention of the G1/S cell cycle transition (%) This patient's pale red reflex and well-circumscribed white mass within the retina are indicative of retinoblastoma. Retinoblastoma is an intraocular tumor caused by inactivating mutations affecting the RB1tumor suppressor gene with subsequent dysregulation of the cell cycle. The cell cycle consists of the following stages: Gap phase 0 (G0 phase) is a resting stage in which the cell cycle is suspended. Interphase is the stage in which the cell prepares for division. Interphase is subdivided into the G1 phase (synthesis of RNA, protein, lipid, and carbohydrate), S phase (DNA replication), and the G2 phase (ATP synthesis). Mitosis (M) is the stage in which the cell divides into two daughter cells. Checkpoints occur at the G1/S and G2/M transitions, allowing the cell cycle to be stopped if damaged DNA is detected by cyclins and cyclin-dependent kinases. DNA repair mechanisms are activated, but if the DNA damage is too substantial, the cell undergoes apoptosis. The RB1 gene encodes the Rb protein that regulates the G1/S checkpoint. In its active form, Rb protein binds and inhibits E2F transcription factors, thereby halting the cell cycle. In contrast, when a cell is ready to divide, Rb protein is phosphorylated by cyclin-dependent kinases, allowing the cell to proceed through the G1/S checkpoint. Loss-of-function mutations affecting the Rb protein result in unrestricted progression through the G1/S checkpoint, leading to uncontrolled cell division. Inciting RB1 mutations have been linked to retinoblastoma and osteosarcoma
A 2-year-old boy is brought to the office by his parents. He is currently toilet-training during the day and at nighttime. After he urinated in the toilet last night, his parents forgot to flush the toilet and noticed that the boy's urine turned black overnight. The child has no significant past medical history and takes no medications. He can say 2-word sentences, follow 2-step directions, and jump with 2 feet off the ground. Examination shows a well-nourished child with no swelling or tenderness of any joints. Urinalysis results are as follows: Color black Specific gravity 1.022 Protein none Blood negative Glucose negative Ketones negative Leukocyte esterase negative Which of the following conversion pathways is most likely deficient in this patient? A. Leucine to acetoacetate (%) B. Phenylalanine to tyrosine (%) C. Serine to cysteine (%) D. Tyrosine to fumarate (%) E. Valine to glutamic acid (%)
D. Tyrosine to fumarate (%)
A 26-year-old woman comes to the office due to recent weight gain. She has eaten more than usual over the last 5 months, has gained 3.2 kg (7 lb), and feels guilty and depressed about it. Further questioning reveals that she consumes a large pizza and two large bags of chips in one sitting several times a week. Afterward, the patient feels ashamed about being unable to control her intake and fasts to make up for it. She is very distressed about being unable to lose weight despite exercising 2-3 hours a day. Vital signs are within normal limits. BMI is 23.7 kg/m2. Despite being told that her BMI is normal, the patient insists that she is overweight. Which of the following is the most likely diagnosis? A. Adjustment disorder with depressed mood (0%) B. Anorexia nervosa (%) C. Binge-eating disorder (%) D. Body dysmorphic disorder (%) E. Bulimia nervosa (%) F. Normal behavior (%)
E. Bulimia nervosa (%) This patient's recurrent episodes of eating large amounts of food and sense of loss of control, together with compensatory behaviors (fasting, exercising) to prevent weight gain, is consistent with bulimia nervosa (BN). Patients with BN are excessively preoccupied with their weight and body shape. Although self-induced vomiting is the most common compensatory behavior, patients may also fast and exercise excessively or misuse laxatives, enemas, diuretics, or diet pills. In DSM-5, both binges and inappropriate compensatory behaviors must occur at least once a week for 3 months for diagnosis. Patients with BN are normal weight or overweight, in contrast to individuals with anorexia nervosa. Signs of BN in patients who vomit regularly may include hypotension, tachycardia, dry skin, menstrual irregularities, erosion of dental enamel, parotid hypertrophy, calloused knuckles, and electrolyte abnormalities (eg, hypokalemia, hypochloremia, metabolic alkalosis). (Choice A) This patient's depressive and guilty feelings after a binge are characteristic of BN. (Choice B) Both BN and anorexia nervosa may be characterized by preoccupation with weight, binge eating, and compensatory behavior (there is a binge-eating/purging subtype of anorexia). Patients with anorexia nervosa have significantly low body weight (BMI <18.5 kg/m2). In BN, body weight is typically normal to increased. (Choice C) In binge-eating disorder, patients engage in recurrent episodes of binge eating but do not use inappropriate compensatory behaviors as in BN. (Choice D) Body dysmorphic disorder is characterized by intense preoccupation with a perceived defect in physical appearance leading to significant functional impairment. It is not diagnosed when weight gain is the preoccupation of an individual who meets the criteria for an eating disorder.
A 63-year-old man comes to the emergency department with 2 hours of chest pain and shortness of breath. The pain started as lower sternal discomfort that he attributed to indigestion, but then spread all over the anterior chest. The patient has never had similar pain before. Medical history includes hypertension, hyperlipidemia, and diet-controlled type 2 diabetes mellitus. The patient is an ex-smoker with a 20-pack-year history. On cardiac auscultation, a systolic murmur is heard. Basilar crackles are present on both sides. After initial evaluation, the patient is taken to the cardiac catheterization laboratory and is found to have a coronary artery occlusion, which is successfully revascularized. The next morning, the patient appears comfortable and wants to go home. The lungs are clear on auscultation, and no heart murmur is present. The murmur heard during initial presentation is most likely explained by a pathologic process involving which of the following structures? A. Aortic root (%) B. Aortic valve leaflets (%) C. Interventricular septum (%) D. Mitral valve chordae (%) E. Papillary muscle (%)
E. Papillary muscle (%) This patient with myocardial infarction developed a new systolic murmur that resolved following revascularization, which is consistent with mitral regurgitation (MR) due to papillary muscle dysfunction. Myocardial infarction can cause ischemia of the papillary muscle and the adjacent LV wall on which it is mounted. This results in hypokinesis and outward displacement of the papillary muscle, creating increased tension on the attached chordae tendineae and preventing complete closure of the corresponding mitral valve cusp. Timely restoration of adequate blood supply with coronary revascularization restores papillary muscle and LV wall motion, often leading to resolution of the MR. In contrast to papillary muscle dysfunction, papillary muscle rupture is a mechanical complication of MI that occurs acutely or within 3-5 days and leads to acute MR; it does not resolve with coronary revascularization and typically requires surgical repair
A 58-year-old man with a history of hypertension and hyperlipidemia comes to the emergency department due to substernal chest pain that began 6 hours ago and has gradually worsened. Blood pressure is 104/72 mm Hg and pulse is 88/min. ECG shows normal sinus rhythm with ST-segment depression and T-wave inversion, and troponin levels are elevated. The patient is diagnosed with non-ST-segment elevation myocardial infarction and admitted to the hospital for medical management, with coronary angiography scheduled the following morning. That evening, telemetry monitoring shows a new Mobitz type 1 second-degree atrioventricular block. Which of the following arteries was most likely obstructed during this patient's myocardial infarction? A. Left anterior descending (%) B. Left circumflex (%) C. Left main coronary (%) D. Ramus intermedius (%) E. Right coronary (%)
E. Right coronary (%)
scientist is interested in the mechanisms by which leukocytes traffic to sites of inflammation and infection. She finds that endothelial cells increase the expression of certain cell surface molecules in response to cytokines to allow for leukocyte trafficking. She subsequently creates a knockout mouse that has a deletion in the platelet endothelial cell adhesion molecule 1 (PECAM-1) gene. The protein product of this gene is mainly localized to specific areas on the endothelial cells. Absent expression of this gene will most likely affect which of the following neutrophil functions? A. Crawling (%) B. Margination (%) C. Rolling (%) D. Tight adhesion (%) E. Transmigration (%)
E. Transmigration (%)
A 67-year-old smoker comes to the office with a 2-week history of decreased vision in his right eye that he describes as "blurry" and "distorted." The patient has been having vision problems over the past year, and these have made it more difficult to drive and require that he use a bright light to read the newspaper. He has no history of diabetes mellitus or hypertension. The patient uses an albuterol inhaler for occasional wheezing and shortness of breath. Ophthalmologic examination of the right eye shows a grayish discoloration of the macula with areas of adjacent hemorrhage. Which of the following should be specifically targeted in treatment of this patient's condition? A. CD20 lymphocyte glycoprotein (%) B. Epidermal growth factor receptor (%) C. Interleukin-2 (%) D. Tumor necrosis factor-alpha (%) E. Vascular endothelial growth factor (%)
E. Vascular endothelial growth factor (%)
A 48-year-old woman comes to the office with a 6-month history of involuntary passage of a few drops of urine when sneezing or coughing. She has recently been leaking even more urine with minimal activity, which has been embarrassing and has caused her to limit her social activities. The patient has no weakness, numbness, or fecal incontinence. She has a history of hypertension and type 2 diabetes mellitus. She does not use tobacco, alcohol, or illicit drugs. She is married and has 4 children. Her supine blood pressure is 126/82 mm Hg and her upright blood pressure is 120/80 mm Hg. External genitalia examination shows leakage of a small amount of urine from the urethra when the patient is asked to cough. Neurological examination is within normal limits. Which of the following is the most likely cause of her condition? A. Detrusor muscle inactivity (%) B. Detrusor muscle overactivity (%) C. Diabetic autonomic neuropathy (%) D. Small frontal lobe infarct (%) E. Urethral obstruction from a tumor (%) F. Urethral sphincter dysfunction (%)
F. Urethral sphincter dysfunction (%)
A 26-year-old man comes to the emergency department due to a 10-hour history of progressively worsening right-sided scrotal pain. Clinical and radiological evaluations confirm testicular torsion with significant ischemic damage and the patient undergoes unilateral orchiectomy. Three months later, he comes to the office for follow-up. The patient is otherwise healthy and takes no medications but is worried about the risk of sexual dysfunction and infertility. Further evaluation is most likely to show which of the following sets of findings in this patient? Erectile fxn (decreased or normal) Sperm Count (decreased or normal)
Following unilateral orchiectomy, the initial drop in circulating testosterone stimulates pituitary LH secretion, leading to compensatory testosterone production and Leydig cell hyperplasia in the remaining testis. Testosterone levels are quickly restored, maintaining normal libido, erectile function, and secondary sex characteristics. Concurrently, the loss of inhibin following unilateral orchiectomy leads to increased pituitary FSH release, stimulating ABP production and facilitating spermatogenesis in the remaining testis. However, due to the loss of seminiferous tubules in the orchiectomized testis, most patients experience decreased net spermatogenesis, often with reduced fertility
raidial nerve goes with which artery?
deep brachial
Bladder emptying is mainly due to _____, while continence is maintained by ____
detrusor muscle contraction the urethral sphincters
This patient has greater trochanteric pain syndrome (GTPS) characterized by lateral hip pain. GTPS is an overuse tendinopathy of the ______ at their insertion on the greater trochanter of the femur. It is often referred to as trochanteric bursitis, although bursal involvement varies and is not likely the primary pathology. Risk factors include obesity, plantar fasciitis, and altered gait mechanics (eg, osteoarthritis
gluteus medius and gluteus minimus
What does abnormal Huntingtin protein do?
inhibits Histone acetylation= decreased transcription
A study's _____ increases as its sample size increases. Therefore, the larger the sample, the greater the ability of a study to detect a difference when one truly exists
power
Stress incontinence is the most common form of incontinence and typically presents after age 45. Patients have brief involuntary urine loss through the dysfunctional or weak urethral sphincter during activities (eg, coughing, sneezing, or vigorous effort) that increase abdominal pressure. It is almost twice as common in women because External Urethral Sphincter trauma or_____ nerve (innervates External Urethral Sphincter) injury is common during vaginal child birth.
pudendal
can't extend wrist = injury to
radial n
Myocardial infarction that causes ischemia of the papillary muscle or nearby left ventricular wall can result in acute mitral regurgitation with development of a new _____ murmur. Timely restoration of blood flow can improve papillary muscle dysfunction and lead to resolution of the regurgitation.
systolic
minute ventilation
tidal volume x respiratory rate
