AMBOSS, UWORLD, COMBANK Incorrects

A 40-year-old female is diagnosed by her primary care physician with severe peptic ulcer disease and ultimately undergoes gastrectomy. She returns to the clinic five years later with spasticity in her lower extremities as well as a diminished sense of vibration and touch. pt 1: Schilling test? pt 2: This patient's complications are due to the absence of a substance secreted by

1: administering porcine instrinsic factor to the patient will fix vitamin B12 deficiency 2: parietal cells

A 28-year-old woman presents in labor and delivers a healthy infant via normal spontaneous vaginal delivery. Upon successful delivery, the umbilical cord is clamped and cut. Three vessels are seen in the cut edge of the umbilical cord. These vessels are

2 umbilical arteries arising from the internal iliac artery and 1 vein

A 22-year-old man comes to the emergency department because of several episodes of blood in his urine and decreased urine output for 5 days. His blood pressure is 158/94 mm Hg. Examination shows bilateral lower extremity edema. Urinalysis shows 3+ protein and red blood cell casts. Mass spectrometry analysis of the urinary protein detects albumin, transferrin, and IgG. Which of the following best describes this type of proteinuria?

Nonselective glomerular

A 55-year-old man comes to the physician for evaluation prior to parathyroidectomy. A Tc99m-sestamibi scan shows two spots of increased uptake in the superior mediastinum. These spots represent structures that are most likely derived from which of the following embryological precursors?

3rd branchial pouch - pouches: ear (1), tonsils (2), bottom (3 - inferior parathyroids) to (3- thymus) top (4 - superior parathyroids)

A previously healthy 18-year-old woman comes to the emergency department for evaluation of intractable vomiting and uterine cramping. Her last menstrual period was 7 weeks ago. Serum β-human chorionic gonadotropin concentration is 170,000 mIU/mL. A transvaginal ultrasound shows a complex intrauterine mass with numerous anechoic spaces and multiple ovarian cysts. The patient undergoes dilation and curettage, which shows hydropic villi with diffuse, circumferential trophoblastic proliferation. Karyotype analysis of the specimen is most likely to show which of the following?

46XX of paternal origin only A complete hydatidiform mole results from the fertilization of an "empty" oocyte (i.e., one that does not carry any chromosomes) by a sperm. The haploid set of chromosomes from the sperm then doubles (paternal disomy) to yield a karyotype of either 46,XX (∼ 90% of cases) or 46,XY (∼ 10% of cases). Risk factors for molar pregnancy include previous molar pregnancies and very young or very old age (due to increased risk of oocyte abnormalities). As in this patient, there is often severe and intractable vomiting because of extremely elevated serum beta hCG levels. The excessive amount of beta hCG also stimulates the development of ovarian theca lutein cysts, which are seen on this patient's ultrasound. triploid -> partial mole

A 3175-g (7-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old primigravid woman following a spontaneous vaginal delivery. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. Cardiac examination in the delivery room shows a continuous machine-like murmur. An echocardiogram shows a structure with blood flow between the pulmonary artery and the aorta. This structure is most likely a derivate of which of the following? (which aortic arch?)

6th aortic arch (1st and 2nd deteriorate, 3rd - carotids, 4th - parts of aorta and subclavian on right, 5th- deteriorates, 6th- pulmonary artery on right, ductus arteriosus on left)

Two researchers are investigating the prevalence of hypertension in a metropolitan city. The first researcher measured the blood pressure from 1032 inpatients at a tertiary care hospital in the city (study A). The second researcher performed community blood pressure screening on 1003 people (study B) through nursing health fairs. Both studies are conducted using calibrated sphygmomanometers from the same manufacturer. Compared to study A, the result of study B is most likely to have which of the following properties?

A study's accuracy (validity) depends on systematic errors and bias. The two forms of validity are internal and external. Internal validity is likely unaffected by the blood pressure measurement, as both studies use calibrated sphygmomanometers from the same manufacturer. External validity refers to how applicable the study is to the general population; study B is more likely to exhibit higher external validity compared to study A, which involves Berkson bias. In study A, the actual prevalence of hypertension in the general population is less likely to be accurately reflected due to this bias. Therefore, study B is expected to have higher accuracy.

Two hours after undergoing open cholecystectomy for complicated cholecystitis, a 48-year-old woman develops dizziness, lethargy, abdominal pain, nausea, and vomiting. She has systemic lupus erythematosus and hypertension. Prior to hospitalization, her medications included nifedipine and prednisolone. Her pulse is 102/min and blood pressure is 111/78 mm Hg. Physical examination shows central obesity. The abdomen is soft and nontender, and the laparoscopic incisions have no discharge. Her serum cortisol and serum ACTH concentrations are decreased. Which of the following additional findings is most likely in this patient?

Adrenal insufficiency related to corticosteroid use is associated with hyponatremia due to increased antidiuretic hormone (ADH) secretion. Cortisol directly inhibits ADH secretion; loss of cortisol therefore leads to an increase in ADH, causing free water retention and dilutional hyponatremia. Symptoms that accompany hypocortisolism, e.g., nausea and vomiting, can also trigger ADH release. Hyponatremia from corticosteroid-related adrenal insufficiency is often not as pronounced as the hyponatremia seen in primary adrenal insufficiency. This is because aldosterone secretion from the zona glomerulosa remains intact.

A 66-year-old man comes to the emergency department because of shortness of breath. His temperature is 37.2°C (99°F) and pulse is 105/min. When the blood pressure cuff is inflated to 140 mm Hg, the patient's pulse is audible and regular. However, upon inspiration, the pulse disappears and does not reappear until expiration. Only when the blood pressure cuff is inflated to 125 mm Hg is the pulse audible throughout the entire respiratory cycle. Which of the following underlying conditions is most likely responsible for this patient's physical examination findings?

Asthma (pulsus paradoxus) Pulsus paradoxus most commonly occurs in patients with constrictive cardiac disease (e.g., cardiac tamponade, constrictive pericarditis, tension pneumothorax) or severe obstructive lung disease (e.g., COPD, asthma). During inspiration, there is increased systemic venous return and increased volume in the right heart, which is compensated for by expansion into the pericardial space in a healthy heart. However, in a pathologically constricted heart, this increase in right ventricle volume causes bowing of the RV free wall into the left ventricle, resulting in decreased LV filling, decreased cardiac output, and subsequent drop in systolic blood pressure. Pulsus paradoxus in patients with obstructive lung disease (e.g., asthma), on the other hand, occurs due to the amplification of intrathoracic pressure variation during respiration, which is then transmitted to the distal arteries.

A 53-year-old man is brought to the emergency department because of wheezing and shortness of breath that began 1 hour after he took a new medication. Earlier in the day he was diagnosed with stable angina pectoris and prescribed a drug that irreversibly inhibits cyclooxygenase-1 and 2. He has chronic rhinosinusitis and asthma treated with inhaled β-adrenergic agonists and corticosteroids. His respirations are 26/min. Examination shows multiple small, erythematous nasal mucosal lesions. After the patient is stabilized, therapy for primary prevention of coronary artery disease should be switched to a drug with which of the following mechanisms of action?

Blockage of P2Y12 component of ADP receptors (clopidogrol) - pt had asthma attack symptoms after ASA. Samter's triad (asthma, sinus inflammation with recurring nasal polyps, and sensitivity to aspirin and some other NSAIDs)

A patient presents with multiple infections and it is determined that they have a defective complement protein required for neutrophil chemotaxis. Which of the following is most associated with this condition?

C5a Bottom Line: C3a and C5a function primarily to attract neutrophils to the site of injury; thus they are known as inflammatory mediators.

A 6-year-old male is presented to his pediatrician with a 3-day history of fever of 38.9° C (102° F), bilateral neck swellings, and loss of appetite. The patient, a recent immigrant from India, is the child of first-degree consanguineous parents and has a history of recurrent pyogenic bacterial infections. Physical examination reveals pallor, silvery gray hair, and oculocutaneous albinism; generalized lymphadenopathy and hepatosplenomegaly are also noted. A complete blood count is ordered and shows a hemoglobin of 8.6 g/dL (reference range: 14.0-18.0), white blood count of 22.1 × 103/uL (reference range: 4.8-10.8), with lymphocytes showing single, large, round-to-oval, purple-colored intracytoplasmic granules. Blood cultures reveal a preponderance of staphylococci and streptococci. Which of the following immune deficiencies does this patient most likely have?

Chediak-Higashi syndrome Bottom Line: Chédiak-Higashi syndrome is a rare autosomal recessive disorder with defective lysosomal trafficking in targeting of granules in neutrophils, monocytes, and lymphocytes. Symptoms are recurrent bacterial infections of the skin, mouth, and respiratory tract; partial albinism; and peripheral neuropathy. Cytoplasmic granules are seen in the peripheral blood smear.

A 2500-g (5-lb 8-oz) female newborn delivered at 37 weeks' gestation develops rapid breathing, grunting, and subcostal retractions shortly after birth. Despite appropriate lifesaving measures, the newborn dies 2 hours later. Autopsy shows bilateral renal agenesis. Which of the following is the most likely underlying cause of this newborn's respiratory distress?

Decreased amniotic fluid ingestion in utero due to oligohydramnios can lead to pulmonary hypoplasia, which can cause respiratory insufficiency and death in the newborn. Lung development in utero is stimulated by the stretch caused by amniotic fluid flowing through the lungs. This results in increased pro-angiogenic and pro-alveolar growth factor release, while the repetitive stretch from fluid influx matures the alveolar cells and increases distal lung surface area. Since by approx. 11 weeks of gestation fetal urine is the primary source of amniotic fluid, bilateral renal agenesis invariably results in oligohydramnios.

common AE of bile acid resins

GI upset and impaired absorption, hypertriglyceridemia due to hepatic production

A group of investigators is studying the association between a fire retardant chemical used on furniture and interstitial lung disease. They use hospital records to identify 50 people who have been diagnosed with interstitial lung disease. They also identify a group of 50 people without interstitial lung disease who are matched in age and geographic location to those with the disease. The participants' exposure to the chemical is assessed by surveys and home visits. Which of the following best describes this study design?

In case-control studies, researchers select patients with (cases) and without the outcome of interest (control group). In this study, the outcome of interest is interstitial lung disease. This study design allows odds ratios to be determined, i.e. the odds of developing interstitial lung disease dependent on exposure to the fire retardant chemical. Case-control studies are retrospective studies and are prone to recall bias.

A 29-year-old male presents to his primary care physician with complaints of chronic rhinosinusitis, fatigue, and headache. Although this has been a reoccurring issue throughout his childhood and adolescent years, it continues to progressively worsen and occurs with increased frequency. Recently, he was seen by his pulmonologist who ordered a CT scan of his chest and diagnosed him with bronchiectasis. Although he has copious amounts of sputum in the morning, nebulized bronchodilator treatments and chest physiotherapy have been effective. Vital signs today are remarkable for a temperature of 38.4°C (101.1ºF). Physical examination reveals frontal sinus tenderness to palpation. Fine crackles are auscultated throughout his lung fields without wheeze. A chest radiograph and abdominal CT scan are obtained as shown in the exhibit. The most likely diagnosis of this patient's underlying condition is

Kartagener's situs inversus (heart on right, gas bubble on right-stomach) Kartagener syndrome is characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis. It is a subcategory of primary ciliary dyskinesia, leading to impaired respiratory cilia, thereby causing poor respiratory mucus clearance. The embryonic nodal cilia cells that determine organ asymmetry are also affected, leading to situs inversus in 50% of cases. Treatment is supportive, with most patients enjoying a normal life expectancy.

A 55-year-old male presents to the emergency department with a crushing chest pain that radiates to the left shoulder. The pain started 1 hour before, while he was watching TV. Osteopathic examination reveals palpable nodules between the 2nd and 3rd ribs at the left parasternal border. The electrocardiogram reveals ST-segment elevations in V1, V2, and V3. Which coronary artery is supplying blood to the region of the heart that is most closely associated with these ST-segment elevations?

LAD (septal leads)

A 51-year-old man comes to the emergency department because of a 3-day history of shortness of breath, fever, and chills. He has no history of serious illness. His temperature is 39.5°C (103.1°F). Physical examination shows a grade 4/6, holosystolic, blowing murmur over the apex that radiates to the axilla. Crackles are heard in both lower lung fields. Examination of the extremities shows several nontender, nonblanching, erythematous macules on the palms and soles. Histopathologic examination of these macules is most likely to show which of the following?

Microabscesses with neutrophil infiltration of capillaries Microabscesses with neutrophil infiltration of capillaries and areas of hemorrhage are characteristic of the Janeway lesions seen in patients with infective endocarditis. They are thought to be caused by septic microemboli from valve vegetations and, among other vascular phenomena, constitute a minor clinical criterion for the modified Duke criteria in infective endocarditis. Janeway lesions are more common in acute endocarditis than in subacute endocarditis.

A 45-year-old woman with hypothyroidism comes to the physician because of progressive fatigue, lethargy, and epigastric pain after eating. Physical examination shows pale conjunctivae. Laboratory studies show decreased serum hemoglobin levels and increased serum gastrin levels. Esophagogastroduodenoscopy shows inflammation of the gastric body and fundus. A photomicrograph of a biopsy specimen taken from the gastric antrum is shown (G cell hyperplasia). Which of the following is the most likely cause of this patient's symptoms?

Parietal cell destruction Parietal cell destruction in the gastric fundus is seen in autoimmune-mediated atrophic gastritis (AMAG), which results in reduced gastric acid production. The reduced acid production in AMAG leads to loss of negative feedback on G cells, which subsequently causes G cell hyperplasia in the gastric antrum and hypergastrinemia. Parietal cell destruction also impairs intrinsic factor production and causes decreased vitamin B12 absorption in the ileum, leading to vitamin B12 deficiency anemia (pernicious anemia). However, iron deficiency anemia may be present earlier in the disease course, due to the decreased solubility of iron in the setting of hypochlorhydria.

A 1-year-old girl is brought to the physician by her parents for a well-child examination. She is scheduled to receive vaccinations against hepatitis A, measles, mumps, rubella, and varicella. She does not have a fever or a history of serious illness. At the previous well-child visit, the parents had agreed to all the vaccinations except the vaccination against varicella. When asked about the reasons for refusing varicella vaccination, the father had said, "It has nothing to do with the cost of the vaccine. We simply believe that the vaccine is unnecessary. We both had chickenpox as children and had no problems from the infection. We also plan to homeschool her." The physician informed the parents of the risks of not vaccinating their daughter against chickenpox, including the sequelae of chickenpox infection in adults. At the current visit, the parents still refuse the varicella vaccination. Which of the following is the most appropriate action by the physician at this time?

Recommend resources on varicella vaccination and ask the parents about administering the vaccination at the next visit.

SBP, DBP, PP changes during exercise

SBP: increased DBP: unchanged PP: increased

An infant presents with recurrent episodes of oral thrush and a recent infection with Pneumocystis jirovecii. The mother also notes that the infant has had chronic diarrhea and does not seem to be gaining weight. The infant's weight, height, and head circumference are at less than the third percentile. Past medical history includes recurrent ear infections and seborrheic dermatitis. Chest x-ray indicates the absence of thymus shadow. Flow cytometry shows reduced levels of B and T lymphocytes and natural killer cell lymphocytes. Laboratory analysis demonstrates elevated deoxyadenosine in the urine. Which of the following is the most likely mechanism responsible for this patient's presentation?

SCID - lack of adenosine deaminase (involved in purine salvage system)

A 57-year-old man comes to the physician for a follow-up evaluation of chronic, retrosternal chest pain. The pain is worse at night and after heavy meals. He has taken oral pantoprazole for several months without any relief of his symptoms. Upper endoscopy shows ulcerations in the distal esophagus and a proximally dislocated Z-line. A biopsy of the distal esophagus shows mature columnar epithelium with goblet cells. Which of the following microscopic findings underlies the same pathomechanism as the cellular changes seen in this patient?

Squamous epithelium in the bladder

A 64-year-old female presents to the emergency department with abdominal pain and fever. The abdominal pain is cramping but constant in nature, localized to the left lower quadrant. She has never experienced this before. She admits to loose stools, with no noticeable blood. She denies a history of tobacco or alcohol abuse. She has well-controlled hypertension for which she receives lisinopril daily. She denies recent travel. Vital signs reveal a temperature of 38.7°C (101.7°F), a blood pressure of 120/73 mmHg, and a heart rate of 85/min. Physical examination reveals tenderness to moderate palpation in the lower abdomen, with rebound tenderness in the left lower quadrant and minimal voluntary guarding. No rigidity is present. Bowel sounds are present, without any palpable masses. You note a tender nodule anterior to proximal iliotibial band on the left thigh. The white blood cell count is elevated, with a normal lactic acid level. The most likely associated finding upon structural examination related to a sympathetic viscerosomatic reflex would be located at

T12-L2

A 66-year-old male with a past medical history of hyperlipidemia presents with acute onset of chest discomfort while mowing his lawn with a push mower. The pain lasted for approximately 5 minutes, radiated to the jaw, and was relieved with rest. The fastest pharmacological relief for the patient's chest pain acts to

activate myosin light chain phosphatase (NTG) Bottom Line: Nitroglycerin is used for the acute treatment of angina pectoris. Nitroglycerin increases coronary blood flow and oxygenation through vasodilation of the vascular smooth muscle and peripheral veins and arteries.

An investigator is studying the effect of antihypertensive drugs on cardiac output and renal blood flow. For comparison, a healthy volunteer is given a placebo and a continuous infusion of para-aminohippuric acid (PAH) to achieve a plasma concentration of 0.02 mg/ml. His urinary flow rate is 1.5 ml/min and the urinary concentration of PAH is measured to be 8 mg/ml. His hematocrit is 50%. Which of the following values best estimates cardiac output in this volunteer?

To calculate cardiac output, the renal plasma flow (RPF) and renal blood flow (RBF) will first need to be determined. RPF = (UPAH x Urine flow rate)/PPAH, where UPAH = urine concentration of para-aminohippuric acid (PAH) and PPAH = plasma concentration of PAH. Thus, RPF = 8 x 1.5/0.02 = 600 ml/min. Next, RBF = RPF/(1 - Hct); RBF = 600/(1 - 0.5) = 1.2 L/min. Finally, the kidneys receive 20-25% of cardiac output, so that this person's CO is 4.8-6.0 L/min (1.2 L/min/0.25 or 1.2/0.20 = 4.8 or 6.0 L/min, respectively).

A 43-year-old female presents to her primary care physician with complaints of xerostomia and xerophthalmia. Palpable enlarged parotid glands are found on physical examination. The patient complains that she constantly is carrying a bottle of water with her to stop her tongue from sticking to her soft palate. Further questioning reveals that her last dental visit uncovered numerous dental caries, which the patient is scheduled to have fixed. Which of the following antibodies is most closely associated with this patient's disease process?

anti-SS-A antibodies Bottom Line: Sjögren syndrome is an autoimmune disorder affecting the lacrimal and salivary glands. It is associated with antibodies to SS-A and SS-B (Ro and La) antigens.

A 65-year-old previously healthy male presents with diarrhea and steatorrhea for 2 weeks, with associated intermittent diffuse abdominal pain and cramping. He also reports that he has experienced joint pain for approximately 6 months, with a recent workup for rheumatoid arthritis being negative. He denies any recent travel, new medications, or sick contacts. He denies any association with food. History is negative for alcohol use. He works as a manager in the sewage waste department plant and admits to compliance with all safety gear. Vital signs are unremarkable. Bowel sounds are present in all quadrants, although hyperactive. Murphy's test is negative, complete metabolic panel is unremarkable, and HIV test is negative. Stool fat is consistent with steatorrhea. What is the most likely condition of this patient?

Whipple disease bug found in sewage, common in older men, causes the joint pain in the patient (celiac would not have joint pain, also would be associated with food intake)

A 29-year-old female stockbroker presents to the emergency department with palpitations and chest discomfort. She states that she had a stressful day but that this was not uncommon given her line of work. She admits to shortness of breath and chest pain, but denies lightheadedness or syncope. An electrocardiogram, seen in the exhibit, reveals a narrow complex tachycardia at approximately 150/min and inverted P waves immediately after the QRS complex, best observed in lead V1, without any acute ST or T wave abnormalities. Her laboratory values are within normal limits. She is administered a medication and soon after, experiences facial flushing and difficulty breathing. Which of the following drugs most likely induced this reaction?

adenosine - bronchoconstriction. she is in paroxysmal SVT (narrow complex tachy with inverted p waves)

A 34-year-old male with no significant past medical history presents to his physician's office for a pre-employment physical examination. His review of systems is negative and his physical exam is unremarkable. At the end of the visit he presents the doctor with a form that must be completed. The form requests the results of a number of genetic tests that the company requires for all potential salaried employees. The most appropriate course of action is for the physician to

advise the patient this could be a violation of GINA (Genetic information nondiscrimination act)

A 55-year-old male is brought to the emergency department following a mugging where he suffers gunshot wounds to the abdomen. The patient is intubated and brought urgently to the operating room. His family is notified and is en route to the hospital. Which of the following is the most appropriate course of action for the physician?

alert law enforcement of the injury Most states require physicians to alert law-enforcement authorities of any violence-related injury. Specific state laws should be consulted, but in general violence-related injuries should be reported.

A 67-year-old male with a history of asthma and benign prostatic hypertrophy presents to the emergency department with chest tightness. In addition, the patient complains of not being able to urinate for the past 10 hours and a feeling of fullness in the bladder area. He does admit to using an autoinjector after being stung by a bee early this morning while working in the garden. He has a history of anaphylaxis to wasps and prophylactically used this and diphenhydramine to prevent any allergic response. He had no allergy or anaphylactic symptoms afterwards. Vital signs reveal a heart rate of 94/min and a blood pressure of 182/94 mmHg. Which of the following receptor actions is the most likely cause of his presentation? (alpha 1 agonist, alpha 2 agonist, beta 1 agonist, beta 1 antagonist, beta 2 antagonist)

alpha 1 agonist -- epinephrine is agonist at alpha 1,2 and beta 1,2 This patient, after using his epinephrine autoinjector earlier in the morning, is now presenting with elevated blood pressure, chest pain, and urinary retention and is experiencing findings consistent with alpha-1 agonist receptor activation. Activation of this receptor causes arterial vasoconstriction, leading to increased blood pressure (and in this case, a hypertensive emergency as evidenced by chest pain) as well as urinary retention (causing the opposite mechanism of tamsulosin, an alpha-1 antagonist).

A 4-month-old male presents to the emergency department with acute on chronic findings of severe generalized hypotonia, muscle weakness, respiratory distress, and failure to thrive. He has been followed by his pediatrician who has ordered a referral to a specialist, but these appointments have not yet occurred. Physical exam reveals a cachectic infant with profound muscle atrophy. A chest radiograph shows cardiomegaly and an electrocardiogram reveals a short PR interval with giant QRS complexes in all leads, suggesting biventricular hypertrophy. Laboratory tests show increased serum creatine kinase, lactate dehydrogenase, and aspartate aminotransferase. No acidosis or hypoglycemia is detected. Given these findings, what is the most likely causative enzyme deficiency in this infant?

alpha-1,4-glucosidase (acid maltase deficiency, Pompe disease) The infantile form of alpha-1,4-glucosidase deficiency (GSD type II, acid maltase deficiency, Pompe disease) results in myopathy affecting multiple organ systems. Key clinical features include severe generalized hypotonia, muscle weakness, respiratory distress, failure to thrive, and cardiomegaly with presentation early in childhood.

A 16-year-old male presents to the physician's office for an annual sports physical. He has no current complaints and states he feels healthy. In review of systems, he does mention that his eyes are more yellow-appearing than others his age, but he denies vision changes. He has no significant medical history and takes no medications. Immunizations are up to date. Family and surgical history are unremarkable. Vital signs are normal. Physical exam reveals scleral icterus without associated jaundice. All other physical exam findings are normal. Laboratory values reveal normal liver enzymes, direct serum bilirubin of 2.5 mg/dL (reference range: 0.0-0.4 mg/dL), total serum bilirubin of 2.9 mg/dL (reference range: 0.2-1.2 mg/dL), and normal lactic acid dehydrogenase with markedly elevated urinary coproporphyrin I. Which of the following is the most likely mechanism that explains this patient's findings?

altered ability to transport bilirubin glucuronides into bile canaliculi Rotor syndrome - elevated coproporphyrin points to Rotor

A 42-year-old homeless male presents to the Emergency Department with very dark, reddish-brown emesis. He also complains of having multiple dark black "sticky-looking" stools in the past several weeks. On exam you note a tender nodule in the 6th intercostal space at the left midclavicular line. A complete blood count is obtained and reveals the following:

at the level of T5-9 sympathetic innervation This man is suffering from an upper gastrointestinal (GI) bleed, for hematemesis and melena suggest a source proximal to the ligament of Treitz, which is associated with the sympathetic levels of T5-T9. The ligament of Treitz is the demarcation between the upper and lower GI bleeds. It arises from the connective tissue around the celiac trunk and superior mesenteric artery and inserts into the third and fourth portions of the duodenum. Furthermore, the tender nodule in the left 6th ICS at the midclavicular line represents an anterior Chapman point for the stomach. Knowing this point can be helpful for diagnosing GI bleeds and other pathology in the stomach.

A 55-year-old male with past medical history of chronic obstructive pulmonary disease presents to a general surgeon's office for evaluation of a right-sided indirect inguinal hernia. The operation is discussed at length, and it is decided to proceed with an elective laparoscopic right-sided indirect inguinal hernia repair. The patient consented in the office to the steps of the procedure, pros/cons, as well as possible complications, discussed at length. The patient prior to surgery has no right lower quadrant pain, nausea, vomiting, or diarrhea. During the surgery, the surgeon also removes the patient's appendix due to a suspicious cyst-like lesion. After the surgery, the man contacts a lawyer wishing to know if it was appropriate for the surgeon to remove his appendix. The lawyer correctly tells the man that he believes the surgeon is guilty of which of the following?

battery This patient has experienced battery, which is defined as the intentional and unauthorized (without consent) contact of a patient. This patient gave consent for a specific procedure (ie, inguinal hernia) and did not consent to have his appendix removed (incidental appendectomy). Unless the appendix had been an immediate risk to the patient's life, in which it may have been removed under implied consent, it should not have been removed.

A 45-year-old man comes to the emergency department because of hematuria and bilateral flank pain. He has passed urinary stones twice before and has a history of recurrent urinary tract infections. He reports no recent trauma. His father had a history of kidney failure and underwent a kidney transplant. His temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 155/98 mm Hg. Abdominal examination shows palpable, bilateral flank masses. Results of a complete blood count are within the reference range. His serum creatinine concentration is 2.9 mg/dL. Which of the following findings is most likely to be associated with this patient's condition?

berry aneurysm ADPKD is associated with cerebral saccular aneurysms, as well as liver cysts, HTN, and mitral valve prolapse

MOA of dobutamine

beta 1 agonist, Gs protein -> AC -> cAMP -> increased Ca so increased contractility

A 28-year-old female comes to the office because she is planning a hiking trip in the mountains and does not want to "feel bad" like she did previously. Upon further questioning, she states the last time she went hiking through the mountains, she had a severe throbbing headache with associated nausea and lightheadedness. These symptoms ruined her trip and she had to go back down the mountain to recover. She wants to know if you can give her something that will prevent these symptoms from occurring. You prescribe a medication that would be effective in preventing these symptoms. Which ion and nephron segment pair best explains why this medication is effective in preventing these symptoms?

bicarb; PCT Acetazolamide, a carbonic anhydrase inhibitor, can be utilized in the primary prophylaxis of altitude sickness. Carbonic anhydrase inhibitors, such as acetazolamide, are weak diuretics. They decrease the secretion of hydrogen ions in the proximal convoluted tubule, with increased loss of bicarbonate and sodium. Since acetazolamide increases the loss of bicarbonate in the urine, people will develop a mild metabolic acidosis, which can help compensate for the respiratory alkalosis, accelerating acclimatization. It can both prevent these symptoms from occurring and quicken the resolution of these symptoms once they have occurred.

A 9-year-old boy is playing outdoors when he begins gasping for air. A rash appears all over his body. Since he has had a similar reaction previously, his mother rushes him to the emergency department. On questioning, the patient's mother reports he has no previous history of asthma. The boy is having difficulty speaking due to a swollen tongue, and complains about having been stung by a bee just before he started having difficulty breathing. Which of the following best describes what happened following the bee sting to account for this patient's symptoms?

binding of antigen to antibodies on surface of cells (antigen binds to IgE on surface of mast cells -> degranulation) The patient is most likely having an anaphylactic reaction to the bee sting as evidenced by the difficulty breathing and the body rash. The fact that these symptoms occurred almost immediately after the bee sting suggests the boy had been stung previously and had produced IgE antibodies. Anaphylactic reactions are systemic type I hypersensitivity reactions that involve degranulation of mast cells and basophils. In a sensitized individual, the first step in an anaphylactic reaction is binding of the antigen to IgE antibodies. These IgE antibodies are synthesized prior to the anaphylactic reaction, and are found on the surface of mast cells and basophils, which both have Fc epsilon I receptors. These receptors bind the constant region of the IgE antibodies, allowing the antigen binding sites to be available. Antigen cross-links 2 IgE antibodies, resulting in release of histamine and other vasoactive compounds. These mediators produce the symptoms of anaphylactic response by inducing vasodilation and smooth muscle contraction. These responses occur very quickly following contact with the antigen because the antibodies are already bound to the mast cells.

An investigator compares the amount of oxygen delivered to the kidneys between healthy subjects and patients with ischemic renal injury. She measures the arterial oxygen content and estimates renal plasma flow rate by measuring para-aminohippurate (PAH) clearance. Which of the following additional measurements would suffice to accurately calculate the rate of oxygen delivery to the kidneys?

hematocrit bc: renal DO2 = RBF x CaO2 so we just need RBF, which can be calculated using: RBF = RPF(1-Hct)

A 3-year-old previously healthy female presents to the emergency department with fever for the past 2 days. Her mother reports that the child has a reduced ability to hold her neck upright. The mother gave the child ibuprofen to reduce the fever yesterday, which improved her symptoms minimally. This morning, the child wouldn't hold her own cup or stand up and is acting more confused. The patient has no allergies. Vital signs reveal: Temperature101.2°F (38.4°C) Blood pressure80/50 mmHg Heart rate150/min Respiratory rate21/min Oxygen saturation97% on room air Physical examination reveals a lethargic toddler lying in the fetal position on her father's lap and a positive Brudzinski sign. Analysis of the cerebrospinal fluid reveals gram-positive cocci, which are alpha-hemolytic on blood agar. What is the mechanism of action of the most appropriate empirical treatment?

blocks peptidoglycan synthesis pt has meningitis due to strep pneumo -- treatment is ceftriaxone + vanc, both of which block peptidoglycan synthesis

A 5-year-old Caucasian male presents to the pediatrician for a well-child examination. The physical examination is notable for an apparent mental developmental delay with well-developed verbal skills. His parents report that the boy has extreme friendliness with strangers. There is an elfin appearance to his face. An electrolyte panel reveals hypercalcemia. Chromosomal analysis is most likely to reveal a defect in

chromosome 7 Bottom Line: Elfin facies, intellectual disability, hypercalcemia, and extreme friendliness towards strangers are findings associated with William syndrome due to a deletion on chromosome 7. (angelman syndrome -- different -- microdeletion on chromosome 15)

A 3-year-old male presents to your clinic with recurrent abscesses. Vital signs reveal a temperature of 37.8°C (100°F), a pulse of 75/min, a respiration rate of 12/min, and a blood pressure of 115/85 mmHg. His father states that the patient has also had increased episodes of epistaxis and that his gums bleed after brushing his teeth. Bruising was noted on all of the patient's extremities. Both parents have brown eyes and hair. Physical examination reveals a fair-skinned, blue-eyed child with metallic blonde hair. His irises also have reduced pigmentation bilaterally. Which of the following is most likely involved in the patient's disease?

defect in phagocytic cells' phagocyte lysosome fusion (Chediak-Higashi syndrome) Chediak-Higashi syndrome is an autosomal recessive disorder characterized by recurrent pyogenic infections, oculocutaneous albinism, progressive neurologic abnormalities, and coagulation defects. It is due to an abnormal lysosomal trafficking protein that results in defective phagolysosome formation. As a result, there is impaired lysosome degranulation, and phagocytized bacteria are not destroyed by the lysosomes. Patients present in infancy or early childhood with partial albinism and recurrent pyogenic infections. Most patients have fair skin with light blond or white hair that often has a metallic sheen to it.Patients typically have light blue eyes, with a decreased pigmentation to the iris. Patients suffer from recurrent pyogenic infections such as abscesses, ulcerations, and pyoderma gangrenosum. The diagnosis can be made by examination of a peripheral smear for the pathognomonic giant cytoplasmic granules in leukocytes.

A 55-year-old male with a history of tobacco abuse presents with a dull aching pain in his left groin that is worse after long days standing at his job as a cashier. He has also noticed a lump in the area that he can push back into his abdomen, and it is relatively tender when he does so. Acetaminophen and laying down seem to improve the pain slightly. Vital signs are unremarkable. On physical exam, there is a 3-cm bulge noted on the left groin that is tender to palpation. It is easily reducible, but due to his pannus, it is difficult to delineate the anatomy and a focused ultrasound is ordered. Ultrasound reveals a hernia containing fat, which is seen just to the left of midline and above the inguinal ligament. Just lateral to the hernia, a pulsatile structure is visualized. Which of the following is the most likely diagnosis?

direct inguinal hernia A direct inguinal hernia passes through the Hesselbach triangle, lying medial to the inferior epigastric artery.

After learning in a lecture that cesarean section rates vary from < 0.5% to over 30% across countries, a medical student wants to investigate if national cesarean section rates correlate with national maternal mortality rates worldwide. For his investigation, the student obtains population data from an international registry that contains tabulated cesarean section rates and maternal mortality rates from the last 10 years for a total of 119 countries. Which of the following best describes this study design?

ecological study An ecological study is an observational study that assesses data collected at the population level for exposures and/or outcomes. It is used to investigate causal relationships between a specific factor (cesarean section in this case) and its outcome (maternal mortality rate in this case) at the population level. This student collected and studied the data for cesarean section and maternal mortality rates for many countries. As each unit of observation was an entire country (i.e., large population), this study design is an ecological study. Ecological studies cannot be employed to draw conclusions on an individual level (e.g., personal risk of maternal death in a patient with or without a cesarean section).

A 68-year-old, G4P3-0-1-3 female presents to her gynecologist after finding an unusual lump in her breast during a self-examination at home. She began noticing some breast changes about 6 months ago, include some crusting of the nipple, but she thought it was just dry skin. However, use of lotion did not significantly improve her symptoms. Vital signs include a blood pressure of 124/79 mmHg, heart rate of 93/min, a height of 162 cm (5'4"), and a body mass index of 34 kg/m2. On physical examination, there are fissures surrounding the left nipple, along with some crusted ulcerations. There is no discharge from the nipple, however, there is a nearly 2 cm mass underneath the areola on palpation. Biopsy is performed and confirms breast cancer. The patient undergoes a mastectomy followed by a treatment that targets the estrogen receptor. She is now at an increased risk for developing:

endometrial cancer tamoxifen is a SERM, is an estrogen agonist for bone (prevents osteoporosis) and the endometrium (increases risk of hyperplasia). It is an estrogen receptor antagonist and prevents breast cancer. imp: raloxifene (another SERM) is an antagonist at endometrium so does not increase risk for endometrial cancer, but is less useful in breast cancer - typically used in women with osteoporosis

A 10-year-old male is brought to the emergency department after having ingested a substance found in the basement. He appears drowsy and has trouble speaking to the physician. His parents report that he complained of blurry vision in his eyes 1 hour ago, with associated nausea and vomiting. Vital signs reveal: Temperature36.7°C (98.1°F)Blood pressure137/75 mmHgHeart rate110/min Physical examination reveals a lethargic male who responds to voice and follows commands. His speech is slurred, and he has trouble answering orientation questions. A urinalysis reveals the presence of blood, whereas microscopic examination of the urine reveals crystals. Laboratory work is significant for a lactate level of 2.7 mmol/L (reference range: 0.5-1 mmol/L). Which of the following medications should be administered to prevent progression of his condition?

fomepizole Ethylene glycol toxicity causes nausea, vomiting, an anion gap metabolic acidosis, coma, seizures, and cardiovascular depression. Fomepizole, an inhibitor of alcohol dehydrogenase, is the antidote for ethylene and methanol toxicity.

A 45-year-old female is on daily medication with nortriptyline for depression. This drug is known to have a relatively large volume of distribution (Vd) and based on this it is most appropriate to state that

for a given dose, its plasma concentration is low (because it spreads out)

A 6-month-old male infant is brought to the pediatrician's office for a well-child visit. The child's mother states she has been trying to introduce soft foods including rice cereal, apples, and peaches. However, since doing so, he has been vomiting, sweating, and fatigued. Fasting serum glucose is found to be 37 mg/dL (reference range: 74-106 mg/dL). Given his presentation, the child most likely has elevated

fructose-1-phosphate pt has hereditary fructose intolerance Fructose metabolism is a multi-step process that converts fructose into glucose that can be used for energy or stored as glycogen. The first reaction involves the conversion of fructose into fructose-1-phosphate with the assistance of adenosine triphosphate. From here, fructose-1-phosphate is split into glyceraldehyde and dihydroxyacetone phosphate (DHAP) with the use of aldolase B. Hereditary fructose intolerance is defined as a deficiency or absence of aldolase B. When aldolase B is absent, fructose-1-phosphate accumulates at the expense of glyceraldehyde-3-phosphate, normally made from glyceraldehyde and DHAP. Without this essential molecule, metabolism is impaired, causing hypoglycemia whenever fructose is ingested. Treatment with a fructose-free diet allows the patient to live a normal life.

A 72-year-old male presents to the emergency department with a complaint of abdominal pain. He states that the pain started about two days ago and has been gradually getting worse. It is described as a cramping, aching pain located in the left lower quadrant. The pain waxes and wanes but never completely resolves. Associated symptoms include subjective fever, chills, and diarrhea. He denies bright red, black, or maroon stools. (pt has diverticulitis) what would you find on OMT exam?

hard, tender 5 mm nodule along left IT band Bottom Line: The Chapman's point corresponding to the sigmoid colon would be found along the left anterior iliotibial band.

A 4-year-old girl is brought to the emergency department because of colicky abdominal pain for 1 day. She has had two similar episodes in the past. Urinalysis shows red blood cells and hexagonal-shaped crystals. Urine sodium cyanide nitroprusside test is positive. Further evaluation of this patient is most likely to show which of the following findings?

impaired intestinal ornithine reabsorption Autosomal recessive cystinuria is a hereditary defect of proximal convoluted tubule and small intestine amino acid transport proteins. These defects prevent proper reabsorption of ornithine, cystine, lysine, and arginine in the small intestine and the kidneys. This leads to the precipitation of hexagonal-shaped cystine stones in urine and a positive urine sodium cyanide nitroprusside test.

A 22-year-old man comes to the physician for the evaluation of a 2-day history of right testicular pain. At the age of 6 months, he was treated for hypospadias and cryptorchidism. Physical examination shows a rubbery, large right testicle. Orchidectomy is performed. A photomicrograph of a section of the mass is shown. Which of the following additional findings is most likely in this patient? photo shows primordial follicles and seminiferous tubules

increased glandular breast tissue Ovotesticular disorder is a rare disorder of sexual development characterized by the presence of both ovarian and testicular tissues in the same individual (true hermaphroditism). Most patients with ovotesticular disorder have a female karyotype (46,XX) but approx. 10% of cases have a male karyotype (46,XY) with a predominantly male phenotype, as seen here. The features of ovotesticular disorder in patients with a male karyotype include hypospadias and cryptorchidism at birth and Increased glandular breast tissue (gynecomastia) during puberty.

A 65-year-old man comes to the physician for a routine examination. He feels well. His pulse is 80/min and blood pressure is 140/85 mm Hg. Cardiac examination shows a holosystolic murmur in the 4th intercostal space along the left sternal border that gets louder during inspiration. The increase of this patient's murmur is best explained by which of the following hemodynamic changes?

increased right ventricular stroke volume (tricuspid regurgitation) A holosystolic murmur in the 4th intercostal space along the left sternal border that gets louder during inspiration is classic for tricuspid regurgitation. Tricuspid regurgitation, unlike other holosystolic murmurs (e.g., mitral regurgitation or ventricular septal defects), increases during inspiration. Inspiration causes a period of negative intrathoracic pressure, allowing for increased venous return to the heart, ultimately producing increased right ventricular stroke volume. This excess blood volume must be entirely ejected through the tricuspid valve, producing the increased intensity of the murmur. The left ventricle stroke volume is affected in the opposite manner with inspiration decreasing venous return from the pulmonary veins, leading to a reduction in left ventricular stroke volume. Consequently, the left-sided holosystolic murmurs of mitral regurgitation and ventricular septal defects do not augment with inspiration.

A 36-year-old male presents to the emergency department with right-sided flank pain and bloody urine. His pain began early this morning, and he describes it as coming in waves. He noted bloody urine after the onset of the pain. He denies burning with urination or penile discharge. He has had no new sexual partners and has no history of sexually transmitted diseases. His past medical history reveals hypertension that is well-controlled on lisinopril. An abdominal and pelvic ultrasound is performed and reveals bilaterally enlarged kidneys with numerous variably sized anechoic lesions within the parenchyma. Which of the following is true regarding the most likely etiology of this patient's disease process?

inherited in AD fashion (ADPKD) Bottom Line: Autosomal dominant polycystic kidney disease is due most commonly to mutations in PKD1 and PKD2. It is characterized by imaging findings of bilateral enlarged kidneys with multiple cysts.

A 60-year-old male with a history of hypertension, systolic congestive heart failure, and atrial fibrillation presents to the emergency department with nausea, vomiting, and a loss of appetite. He also complains of seeing yellow around all objects, with episodes of blurriness, that started this morning. Vital signs reveal a blood pressure of 130/90 mmHg and heart rate of 50/min. Cardiac exam reveals bradycardia with an irregularly irregular rhythm. No bibasilar rales are appreciated. An electrocardiogram reveals a long PR interval and a shortened QT interval with downsloping ST depression. Laboratory values are positive for a potassium of 3.0 mEq/L (reference range: 3.5-5.1 mEq/L). An overdose of a medication is suspected. Which of the following describes the mechanism of action of this most likely drug?

inhibition of Na/K ATPase (digoxin toxicity) Digoxin inhibits Na+/K+ adenosine triphosphatase, with toxicity most commonly presenting with gastrointestinal distress; however, bradycardia and atrioventricular block are also common due to the parasympathetic effects. Visual disturbances such as yellow and blurred vision, diplopia, halos, scotomas, and photophobia can also be observed with toxicity.

A 65-year-old male presents to his primary care physician to establish continued care. His past medical history includes diabetes mellitus, hypertension, peripheral vascular disease, erectile dysfunction, and cataracts. He is currently taking metformin, glipizide, metoprolol, hydrochlorothiazide, and sildenafil. His physician asks him if he is currently experiencing any problems with his medications. His only complaint is that he has noticed a slight blue tint to his visual field. Fundoscopic exam is unremarkable for eye pathology. His change in vision is most likely due to

inhibition of phosphodiesterase (sildenafil) Sildenafil also weakly inhibits phosphodiesterase 6 (PDE6), which is required for the transformation of light into electrical signals. A major side effect seen with sildenafil is cyanopsia or blue vision.

A 27-year-old female presents to the clinic with increased urinary frequency and flank pain for the last 4 days. Vital signs reveal:Temperature38.3ºC (101ºF)Blood pressure120/80 mmHgHeart rate79/minRespiratory rate16/minA urinalysis is obtained with leukocyte esterase, nitrites, and many white blood cells observed. A pregnancy test is found to be negative. In her history, she is taking daily folate and iron supplements to correct a recent diagnosed deficiency, along with oral contraceptives. Her only allergy is to sulfa drugs. Given her most likely diagnosis, which of the following is the mechanism of action for the most appropriate antimicrobial therapy?

inhibition of topoisomerase IV pt has pyelo -- cipro and bactrim (pt cant take bactrim) so cipro -- inhibit topoisomerase (gyrase)

An investigator is studying physiological changes in the autonomic nervous system in response to different stimuli. 40 μg of epinephrine is infused in a healthy volunteer over a period of 5 minutes, and phenoxybenzamine is subsequently administered. Which of the following effects is most likely to be observed in this volunteer?

insulin secretion is inhibited by alpha-2 receptor agonism and stimulated by beta-2 receptor agonism on pancreatic cells. The alpha-adrenergic effects of epinephrine are blocked by phenoxybenzamine, which blocks both alpha-1 and alpha-2 receptors irreversibly. As a result, the beta-adrenergic effects of epinephrine on the pancreas would predominate, leading to an increase in insulin secretion.

drainage of internal hemorrhoids vs external hemorrhoids

internal: superior rectal veins -> inferior mesenteric veins external: inferior rectal veins -> internal pudendal -> internal iliac veins

A 45-year-old female presents to her primary care physician with a mass in her neck. History reveals she has worked in a nuclear power plant for over 25 years. Laboratory studies reveal a thyroid stimulating hormone level of 5.0 microU/mL (reference range: 0.4-4.2 microU/mL). Magnetic resonance imaging studies indicate a thyroid mass lesion. Biopsy reveals an irregular, cystic mass within the parenchyma as shown in the exhibit. Regarding this tumor, it is most appropriate to state that **histo question**

it is the most common thyroid malignancy (papillary carcinoma)

A 62-year-old man with gastroesophageal reflux disease and osteoarthritis is brought to the emergency department because of a 1-hour history of severe, stabbing epigastric pain. For the last 6 months, he has had progressively worsening right knee pain, for which he takes ibuprofen several times a day. He has smoked half a pack of cigarettes daily for 25 years. The lungs are clear to auscultation. An ECG shows sinus tachycardia without ST-segment elevations or depressions. This patient is most likely to have referred pain in which of the following locations?

left shoulder peptic ulcer disease - referred to left shoulder due to left hemi diaphragm irritation

A 27-year-old female presents to the office with the complaint of headaches. History reveals the headaches are across the frontal region and worsen around her period. Physical examination of the cranium with the vault hold reveals compression at the sphenobasilar synchondrosis. When using the vault hold, the physician's ring finger should be palpating the

mastoid process - look up pic of vault hold The positioning of the fingers when performing the vault hold, as well as an image of the hold, is shown below: 2nd digit: greater wings of the sphenoid 3rd digit: temporal, anterior to ear (crossing parietal bone) 4th digit: temporal (mastoid process), posterior to ear (crossing parietal bone) 5th digit: occiput medial to occipitomastoid suture

A 35-year-old female presents with general malaise and a fever of two days' duration. She reports that she has been congested with facial pain and mucus in the back of her throat. History reveals that she smokes a pack of cigarettes per day, has not consumed alcohol in five years, and is married. Her blood pressure is 130/80 mmHg, and her respiratory rate is 20/min. Osteopathic manipulative techniques were performed, beginning with decreasing lymphatic congestion in the thoracic outlet. Which of the following sinuses is most likely affected?

maxillary sinus - most commonly affected sinus in sinusitis

A 50-year-old male, who has never seen a physician as an adult, is presenting to a community clinic with complaints of fatigue, increased urination, and a 9-kg (20-lb) weight loss in the past 5 weeks. His only medication is ibuprofen, which he takes once daily for chronic back pain. His social history is negative for tobacco or alcohol use but does admit to smoking marijuana occasionally. Family history is positive for diabetes and hypertension. Vital signs reveal a blood pressure of 124/82 mmHg in both arms and body mass index of 37 kg/m2. Physical examination reveals an obese male with normal heart and lung sounds. Funduscopic examination reveals macular edema with proliferation of retinal vasculature. Laboratory data are shown in the table. renal biopsy shows Kimmelsteil-Wilson nodules aka diabetic nephropathy. underlying pathophysiology?

mesangial expansion Bottom Line: In diabetic nephropathy, the basement membranes in the glomeruli thickens becomes more permeable to protein (ie, albuminuria). As the mesangial matrix becomes more abundant, it forms distinctive mesangial nodules, called Kimmelstiel-Wilson nodules, that are seen in renal biopsy. Progression of nephropathy can be slowed by angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

A 29-year-old female complains of bowel issues of 6 months' duration. She states that, ever since moving for new employment, she has had problems with alternating constipation and diarrhea with associated abdominal cramping. Having a bowel movement will often make her feel better, and she feels that she has constipation more so than diarrhea. She denies melena, hematochezia, headaches, and nausea. A colonoscopy is negative. The most appropriate technique to alleviate this patient's symptoms involves

midline pressure over the superior mesenteric ganglion (patient has IBS) This patient is presenting with irritable bowel syndrome (IBS), a diagnosis of exclusion that often presents with alternating constipation and diarrhea, with relief upon defecation. Superior mesenteric ganglion release is a treatment that can be used to help decrease the sympathetic tone to T10-11 and treat dysfunctions from the distal duodenum to mid-transverse colon. Other viable treatments include inhibitory techniques of the iliotibial band, lumbosacral paraspinal tissues, and associated Chapman's reflex points. Contraindications to this treatment include an aortic aneurysm or nearby surgical wound.

A 25-year-old female presents to her gynecologist for increased vaginal discharge. She has been noticing some yellowish discharge for the past few weeks, but is now bothered by accompanying vulvovaginal burning and itching. She admits to multiple male sexual partners in the past 6 months. She takes an oral contraceptive pill consistently and denies use of any barrier protection. The patient has no significant medical history and does not take medications. Vital signs include blood pressure of 115/78 mmHg, heart rate of 88/min, and a body mass index of 24 kg/m2. Pelvic examination reveals severe cervical inflammation and a foul-smelling, thin, frothy discharge in the vaginal vault that is a greenish-yellow color. Which of the following describes the most likely infectious agent?

motile protozoan A sexually active female with frothy, foul-smelling, greenish-yellow discharge should be suspected of having a Trichomonas vaginalis infection. The organism is a motile protozoan. NOT gardnerella bc it does not produce cervical inflammation. NOT chlamydia because discharge is not foul smelling and thin

A 45-year-old previously healthy female is referred to a gynecologist for complaints of bilateral pelvic pain, especially during intercourse. In addition, she has had mild dyspepsia for the past 2 months, complaining of early satiety and bloating. Over-the-counter antacids did not relieve her symptoms. She admits to weight loss of 5 lbs (2.3 kg) over a 3-month period, which she attributes to her dyspepsia. She takes no medications. She quit smoking 3 years ago and drinks less than 4 alcoholic drinks per week. Family history reveals a sister who was recently diagnosed with lobular carcinoma of the breast. Vital signs are unremarkable. On physical exam, the physician notes skin changes in both the axillae and groin, as shown in the exhibit. Pelvic exam shows both ovaries to be enlarged and irregularly shaped. CT scan of the pelvis reveals bilateral complex ovarian masses concerning for malignancy. Pathologic examination of the ovarian tissue will likely show which of the following?

mucin-producing signet ring cells (Krukenberg tumor) Krukenberg tumors are ovarian metastases from gastrointestinal tract primary cancers. Histologically, the tumor will show mucin-producing signet ring cells. acanthosis nigricans - can point to insulin resistance, points to mucin producing GI tumor

A 21-year-old female presents to her gynecologist due to painless lesions that she has recently noticed in her genital area. She is sexually active and "mostly" uses condoms. Her menstrual cycle is regular, and she is otherwise in good health. Her past medical history includes Neisseria gonorrheae infection for which she was successfully treated. She denies any fevers, chills, or vaginal discharge, and says the lesions are not pruritic. On examination, multiple rough, grey-colored papules are apparent on the vulva and in the vagina. There is no erythema or edema on or around the lesions, or anywhere in the vagina or on the cervix. There is no cervical motion tenderness. Which of the following is characteristic of the causative agent?

non-enveloped double-stranded circular DNA virus (HPV) q describing condyloma acuminata

Bottom Line: A Northern blot is a technique useful in identifying a sample of RNA through its binding to a radiolabeled DNA probe. The standard screening assay for detecting antibodies to HIV is an enzyme immunoassay. A confirmatory Western blot is performed if the screening test is positive in order to exclude a false-positive test.

northern blot Bottom Line: A Northern blot is a technique useful in identifying a sample of RNA through its binding to a radiolabeled DNA probe. The standard screening assay for detecting antibodies to HIV is an enzyme immunoassay. A confirmatory Western blot is performed if the screening test is positive in order to exclude a false-positive test.

A 36-year-old female presents to the emergency department with worsening dyspnea. Her dyspnea has been progressing during the past year, and she has blood-tinged sputum that has been present periodically for the past 2 months. She was adopted at 12 years of age and immigrated to the United States at that time. She does not know her childhood medical history but knows that she did not have access to medical care as a child. Physical examination reveals some lung crackles and a heart murmur. An ECG indicates that there is a sinus rhythm with a normal rate and axis. The P waves in several leads are notched; the P-wave in V1 is biphasic with a dominant negative component. The chest radiograph shows signs of pulmonary congestion and enlargement of the left atrium and pulmonary artery, but there is no evidence of enlargement of either of the ventricles. Which of the following best describes this patient's heart murmur?

opening snap with low pitched decrescendo rumbling diastolic murmur (pt has mitral stenosis) On auscultation of the heart, MS is best heard at the apex with the patient in the left lateral recumbent position. Electrical conduction of the engorged left atrium takes longer than with the right atrium, which can be manifested on the ECG as notched P-waves in the limb leads and/or a biphasic P-wave in V1. The murmur of MS begins in diastole with the opening snap of the mitral valve followed by decrescendo low-pitched rumbling that reflects the falling pressure gradient during ventricular filling.

A 41-year-old female is brought into the emergency department by paramedics after a motor vehicle accident. Upon arrival, she appears to be stable but complains of mild abdominal pain. Osteopathic examination is notable for a nodule between rib 7 and rib 8 on the right that is tender to palpation. CT scan of the abdomen reveals a retroperitoneal hematoma. Trauma of which of the following anatomic structures is most likely responsible for this finding?

pancreas key: not AA because she is relatively stable

A 25-month-old male is brought to his pediatrician because of regular vomiting, a skin rash, irritability, and failure to thrive. On physical examination, he is noted to have microcephaly, large zygomatic arches, and inadequate dental enamel. A serum phenylalanine level is found to be elevated. Both parents have no known medical conditions. The most important dietary recommendation for the child at this time is to decrease consumption of

pt has PKU, should decrease consumption of juice sweetened with aspartame bc it has phenylalanine

A 70-year-old male presents to his primary care physician with a new complaint of urinary frequency, nocturia, dysuria, and trouble starting and stopping the stream of urine. Digital rectal examination reveals an enlarged prostate gland, and lab work shows an increase in free prostate-specific antigen. The patient is diagnosed with benign prostatic hyperplasia and prescribed tamsulosin in order to help improve his symptoms. The patient's insurance is Medicare. What part of Medicare will cover his prescription for tamsulosin?

part D (d for Drugs) Medicare is a federal program that is available to patients over the age of 65. Medicare part D is for prescription drug coverage. Answer A: Medicare part A is responsible for inpatient hospital care, skilled nursing, hospice, and home health care. Answer B: Medicare part B covers outpatient care, physical therapy, and occupational therapy. Answer C: Medicare part C is called the Medicare advantage plan and is a combination of parts A and B. Answer E: Medicaid is a federal and state program of health care for people with low income.

A new thionamide drug has been developed by a major pharmaceutical company for treatment of hyperthyroidism (HTh). In this phase of the testing process for approval by the U.S. Food and Drug Administration (FDA), 40 healthy normal volunteers without HTh are given the drug at progressively greater dosages over an 8-week period, beginning with a subtherapeutic dose. The dose is increased weekly, and samples of urine and blood are obtained at the beginning and end of each week for assessments of absorption, metabolism, and excretion. Patients are monitored closely throughout the study for side effects and evidence of toxicity. The design of this study most likely conforms best to which phase in the FDA approval process?

phase 1 The purpose of phase 1 clinical trials is to examine dosing and safety in a small group of normal healthy subjects (n=20-100)

A 72-year-old female lives in a rural town with only 1 family practice physician. The next closest physician's office is 20 miles away. She has not seen a physician in more than 10 years and is concerned about her general health. Upon calling the office, she is told that he is not currently accepting new patients and is unwilling to see her. The patient becomes infuriated and threatens to sue the physician. It is most accurate to state that the

physician has no legal obligation to see or refer her (no patient physician relationship established so no need to refer)

A 55-year-old female had a right-sided mastectomy for treatment of a breast mass. Microscopic evaluation of the surgical specimen revealed invasive ductal carcinoma and further testing showed overexpression of estrogen receptors. Based on these results, the physician recommended long-term pharmacologic therapy. The patient completed her treatment without complications. There were no indications of bone density loss or joint pain upon completion of the regimen. Two years later, the patient returns to the clinic for evaluation of a new complaint. After evaluation, the physician informs the patient that her new complaint is most likely the result of an adverse event caused by the post-mastectomy pharmacologic therapy. This patient is most likely presenting with which of the following complaints?

post-menopausal bleeding pt was on tamoxifen (ER+) SERM during tx, AE: DVT,PE,HLD delayed: endometrial hyperplasia/bleeding

A 46-year-old female with a history of Hashimoto thyroiditis presents to her primary care physician with dry eyes and mouth, itching, knee pain, yellow sclera, and dark urine. She reports a family history of autoimmune disease. Vital signs are within normal limits. Physical examination reveals a painful right upper quadrant with significant hepatomegaly. Laboratory analysis reveals hypergammaglobulinemia, significantly elevated high-density lipoprotein cholesterol and total cholesterol, and an increase in alkaline phosphatase. A right upper quadrant ultrasound displays hepatosplenomegaly as well as an unremarkable gallbladder and common bile duct. A magnetic resonance cholangiopancreatography is normal. The most likely diagnosis is

primary biliary cholangitis Bottom Line: Primary biliary cholangitis is of autoimmune etiology and most commonly presents in middle-aged women. Symptoms include pruritus, jaundice, dark urine, light stools, and hepatosplenomegaly. Unlike primary sclerosing cholangitis, magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography is normal with no extrahepatic biliary involvement.

A 46-year-old female presents to the emergency department with dizziness, difficulty breathing, and a racing heart. Her blood pressure is 120/80 mmHg with a heart rate of 200/min. An EKG reveals a short PR interval and delta waves. She complains of having had these episodes rather frequently during the prior month. A diagnosis is made and cardiac ablation is recommended. However, the patient prefers to try medication because she is concerned about risks related to an ablation procedure. On follow-up 1 week later, she complains of mild, diffuse, joint discomfort and facial erythema. Her temperature is 37.8° C (100.1° F), but otherwise, all vital signs are stable. An EKG is obtained as shown in the exhibit. Her most recent symptoms are likely related to which of the following medications?

procainamide Bottom Line: Procainamide is a class Ia antiarrhythmic that blocks fast sodium channels and potassium channels. Long term use of procainamide can lead to arthralgias and a butterfly rash resembling a reversible lupus-like syndrome.

A 61-year-old male with a history of asthma presents for his annual physical examination. He claims to want assistance in smoking cessation because he is feeling mild chest tightness and substernal pain with physical activity that resolves with rest. Family history is positive for a brother who recently died due to end-stage congestive heart failure. Vital signs reveal his blood pressure is 160/90 mmHg with a heart rate of 110/min. An electrocardiogram reveals sinus tachycardia. His lipid panel reveals a low density lipoprotein level of 160 mg/dL (reference range: < 130 mg/dL) and a total cholesterol of 290 mg/dL (reference range: < 200 mg/dL). A medication is started to help with symptoms and an outpatient stress test is ordered. However, several days later, he is brought to the emergency department with wheezing, dry cough, and shortness of breath. Spirometry reveals a low forced expiratory volume/forced vital capacity ratio of 60% of predicted (reference range: > 80%). Which of the following is the most likely cause of this patient's presentation?

propanolol - nonselective beta blocker causing pulmonary symptoms in patients with a hx of pulmonary disease

A 65-year-old woman comes to the physician for a routine bone mineral density screening. She does not have any children. Menopause was at age 55. Her mother died of breast cancer at the age of 48 years. She has hypertension for which she takes ramipril. Dual-energy x-ray absorptiometry at the femoral neck shows a T-score of -2.7 SD. The physician considers treatment with raloxifene. This medication would put her at increased risk of developing which of the following conditions?

pulmonary embolism (Raloxifene is a SERM) Osteoporosis in postmenopausal women is most commonly due to estrogen deficiency. Estrogen physiologically prevents bone breakdown by stimulating osteoblasts and inhibiting osteoclasts. Raloxifene prevents bone resorption by acting as an agonist on estrogen receptors in the bone. At the same time, it acts as an estrogen antagonist in the breast and endometrium. The most severe adverse effects of raloxifene are thromboembolic events, such as deep venous thrombosis, pulmonary embolism, and retinal vein thrombosis. Raloxifene is therefore contraindicated in women with a history of or current venous thromboembolic disorders.

A 7-month-old male is referred to an immunologist after his pediatrician noted a history of multiple viral and fungal infections. Flow cytometry analysis reveals very low levels of CD3+ cells, normal levels of CD19+ cells, and depressed levels of serum immunoglobulins. Which of the following would be defective in the immune response of this patient?

response to peptide antigens presented by MHC I and MHC II This patient has a T-cell deficiency as indicated by the lack of CD3+ cells, which is a marker shared by both CD4+ helper T cells and CD8+ cytotoxic T cells. His cell-mediated immune response is dysregulated as evidenced by his repeated viral and fungal infections. His B cell levels are normal (CD19+ cells) but are not secreting antibody at optimal levels due to the lack of CD4+ T cell help. Because of this fact, T cell-deficient patients present with a severe combined immunodeficiency (SCID). T cells are MHC restricted and must use their T cell receptor (TCR) to bind to peptide antigens that are presented in MHC molecules.CD4+ T cells bind extracellular peptide antigens presented by antigen-presenting cells (APC) in MHC-II, while CD8+ T cells bind cytoplasmic peptide antigens presented by all nucleated cells in MHC-I. Due to the T-cell deficiency, response to peptide antigens presented by MHC-I and MHC-II will be defective in the patient.

A 2-year-old male with a history of developmental delay is brought to the pediatric emergency department by his mother who reports that her son has been having trouble breathing. A chest radiograph is performed and reveals the presence of pulmonary vascular congestion and pulmonary edema. Review of the patient's electronic medical record indicates a history of renal angiomyolipomas, which were discovered approximately 6 months ago on an abdominal ultrasound for an unrelated issue. Physical exam reveals the presence of small, nodular, soft tissue densities near the patient's nasolabial folds that are likely cutaneous angiofibromas. Further workup, including an echocardiogram, reveals the presence of an intracardiac soft tissue mass. The most likely diagnosis is

rhabdomyoma child has tuberous sclerosis-multisystem hamartomatous lesions genetics:AD, TSC1 (tuberin) or TSC2 (hamartin)

A 25-year-old man comes to the physician for a 2-month history of abdominal discomfort, fatigue, and increased urinary frequency, especially at night. He has also noticed that despite eating more often he has lost 14-lbs (6-kg). He has a congenital solitary kidney and a history of Hashimoto thyroiditis, for which he takes levothyroxine. He has smoked two packs of cigarettes daily for 10 years. BMI is 18 kg/m2. His temperature is 36.7°C (98.1°F), pulse is 80/min, and blood pressure is 110/60 mm Hg. Physical examination is unremarkable. Serum studies show an osmolality of 305 mOsm/L and bicarbonate of 17 mEq/L. Urinalysis shows clear-colored urine with no organisms. Which of the following is most likely to be helpful in establishing the diagnosis?

serum glucose test - diabetes mellitus type 1

A 65-year-old male with a history of hematuria, hypertension, and abdominal pain dies of renal failure. There is a family history of kidney failure. An autopsy is performed the kidney reveals lesions displayed in the exhibit. This condition is most associated with which of the following cerebral abnormalities?

subarachnoid hemorrhage (berry aneurysms bleed into subarachnoid space) pt has ADPKD

A 53-year-old female patient presents for pain located to the right side of her jaw after a recent dental procedure. She states that she is unable to open her mouth fully due to pain on the right side. She states that she returned to her dentist for evaluation and he did not find any clinical issue. You choose to palpate her cranium using the vault hold and notice the greater wings of the sphenoid moving in a caudad direction, while the base of the sphenoid deviates cephalad in relation to the occiput. The most likely diagnosis is

superior vertical strain A vertical strain occurs when there is cephalad or caudad movement of the base of the sphenoid in relation to the occiput. The strain is named after the direction of the base of the sphenoid. If the base of the sphenoid moves caudad in relation to the occiput, and the greater wings of the sphenoid move cephalad, it is termed an inferior vertical strain. In the case above, the base of the sphenoid moves cephalad in relation to the occiput while the greater wings of the sphenoid move caudad, which describes a superior vertical strain.

A 55-year-old male is brought to the emergency department with chest pain. An electrocardiogram reveals 3mm ST depressions in the anterior leads. The patient will be admitted for a cardiac catheterization. Which of the following requires that the patient be provided information on advance directives at the time of admission?

the patient self-determination act

A study is conducted by a Japanese research organization to determine the role of cigarette smoking on the development of chronic obstructive pulmonary disease (COPD) in Tokyo. Two thousand patients with COPD are recruited for the experimental group, and 3500 subjects without any respiratory disease are enrolled for the control group. The mean values of age, BMI, blood pressure, and blood levels of glucose and cholesterol are similar in the groups. After enrollment into the study, the subjects are asked whether or not they smoked at any point in their lives; for this study, a history of smoking of at least one pack a year is considered to be relevant to classify someone as a smoker. Which of these statements most accurately describes this study?

this is a retrospective study (do odds ratio, not relative risk)

A 3-year-old girl is brought to the emergency department because of abdominal pain and watery diarrhea for the past 2 days. This morning, her stool had a red tint. She and her parents visited a circus 1 week ago. The patient attends day care. Her immunizations are up-to-date. Her temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg. Abdominal examination shows a soft abdomen that is tender to palpation in the right lower quadrant with rebound. A stool culture grows Yersinia enterocolitica. Consumption of which of the following is most likely to cause the infection seen in this patient?

undercooked PORK

A 2-year-old male is brought to the emergency department by his father after he noticed dark red blood in the child's stool the previous night. The father states that the patient has been eating and drinking normally without vomiting, abdominal pain, constipation, or bowel straining. He takes no medications. Examination reveals a nontoxic, afebrile boy in no acute distress. His abdominal exam is benign. There are no hemorrhoids or anal fissures on the exam. A fecal occult blood test is positive. A complete blood count is normal. An abdominal radiograph shows a nonspecific bowel gas pattern with no evidence of obstruction. A radionuclide technetium-99m (Tc-99m) pertechnetate scan is performed. Besides showing radiotracer accumulation in the stomach, the Tc-99m pertechnetate scan is most likely to reveal which of the following?

uptake in RLQ - most likely location of meckel diverticulum this Q is dumb