GOER

At 16 yo with type one diabetes presents to the ER dehydration, hyperglycemia, fruity breath, polyuria, pH of 7.15, HCO3- 12. Obviously in DKA. What levels of hormones best match those in DKA due to T1 DM? A. ↓insulin, ↑ cortisol, ↑ glucagon B. ↑insulin, ↑ cortisol, ↓ glucagon C. ↓insulin, ↑ cortisol, ↓ glucagon D. ↓insulin, ↓ cortisol, ↓ glucagon

A. ↓insulin, ↑ cortisol, ↑ glucagon

A 26-year-old male comes to the emergency department complaining of severe epigastric pain for 1 year. He states that the pain is in the mid upper quadrant and seems to be worst after eating. The pain seem to be localized in that area and last for 40 minutes on average. He has had no previous illness. The patient tried the tablet Tums, an antacid which helps. The patient had an endoscopy which showed Corpus fundus restricted atrophic gastritis. What is the most likely cause of the patient's gastritis? A. Autoimmune gastritis B. H-pylori Gastritis C. Eating smoked foods D. Gastric tumor E. NSAIDs

A. Autoimmune gastritis

A 59-year-old man comes to the physician because of a 3-week history of bone pain, polyuria, polydipsia and dyspepsia. He was diagnosed with multiple myeloma 6-months ago. Laboratory studies show hypercalcemia, hypercalciuria and low serum PTH. Which of the following organs most likely have the PTH receptors responsible for calcium homeostasis in human beings? (you may choose more than 1 options) A. Bone B. Parathyroid gland C. Kidney D. Intestine E. Heart F. Skeletal muscles

A&C

A 46-year-old man comes to the physician because of a 4-month history of fatigue, cold intolerance, erectile dysfunction, nausea and vomiting, decreased appetite, cold intolerance and loss of pubic hair and facial hair. He had head trauma with fracture of skull base 8 months ago. His pulse is 46/min and blood pressure is 100/62 mm Hg. Physical examination shows mild dehydration, dry skin, pallor and facial puffiness. Which of the following diagnostic test/s is/are most appropriate to further evaluate this patient? (you may select one or more options) A. Serum electrolytes B. Electrocardiogram C. PPD skin test D. Hormonal assay E. Chest x-ray F. Insulin Tolerance Test G. Semen study

A B D F G

A 48-year-old woman comes to the physician because of a 4-week history of frequent micturition and epigastric pain. She was diagnosed with lung cancer 2 months ago. Laboratory studies show high serum and urinary calcium, but serum PTH is undetectable. Which of the following additional clinical features are most likely to be present in this patient? (you may choose more than one option) A. Kidney stones B. Parathyroid gland hyperplasia C. Intestinal obstruction D. Diarrhea E. Short QT interval in ECG F. Pancreatitis G. Hyperreflexia

A E F

A 53-year-old woman comes to the physician because of a 4-day history of diarrhea and lower abdominal pain. She says that she tried various home remedies to relieve her symptoms, but there is no improvement. There is no history of recent travel. Stool studies show positive blood and mucus, and stool culture is positive for flagellated, curved, oxidase-positive, Gram-negative rods. Which of the following is the most likely causal agent? A. Campylobacter jejuni B. Yersinia enterocolitica C. Samonela Typhi D. Shigella sonnei E. Vibrio cholerae

A. Campylobacter jejuni

40-year-old woman comes to the clinic because of intermittent diarrhea and abdominal bloating for 6 months. Diarrhea is usually exacerbated by consumption of wheat. She also complains of fatigue. There is no history weight loss. What is the most likely diagnosis? A. Coeliac disease B. Ulcerative colitis C. Crohn's disease D. Giardiasis E. Malabsorption

A. Coeliac disease

A 35-year-old man comes to the physician because of an 8-month history of fatigue and gradually worsening skin pruritus over his palms and soles. The pruritus is worse at night and impairs sleep. He was recently diagnosed with an inflammatory bowel disease. His laboratory results are shown below. ERCP shows areas of narrowing and dilation of the hepatic and common bile ducts. Which of the following additional findings is most consistent with this patient's condition? A. Concentric layers of connective tissue surrounding small bile ducts B. Florid, granulomatous lesions affecting small bile ducts C. PAS-positive, diastase-resistant globules in the periphery of the hepatic lobule D. Macrovesicular fat accumulation with perivenular fibrosis E. Lymphoplasmacytic infiltrate in the portal area

A. Concentric layers of connective tissue surrounding small bile ducts Onion skin fibrosis

A 36-year-old man came to the Emergency Department with a history of vomiting for two days. He describes it as coffee-ground emesis associated with black stool for the last three days. He complains that his heart is racing and that he feels lightheaded. His physical examination reveals an ill-looking young man lying in the supine position, pale but moist mucous membrane. His pulse was thready but fast. He has mild epigastric tenderness. Vitals Signs: BP 90/70mmHg, Pulse 120/mins, RR 23/min. Which of the following is the most important investigation for this patient? A. Endoscopy B. Complete blood count C. Liver function test D. H. Pylori stool antigen E. Kidney Function test.

A. Endoscopy

A 27-year-old female complaints of abdominal pain in the epigastric area. Physical examination reveals hyper-active bowel sound and tenderness in the epigastric area. Patient only significant history is terrible chronic back pain from a motor vehicular accident 3 years ago. An upper endoscopy reveals an ulcer near the gastric antrum. Stool is negative for occult blood. Culture of the specimen reveals no organisms or neutrophils.Which following is the best diagnosis? A. Gastropathy B. Steroids induced Gastritis C. Acute Gastritis D. Chronic Gastritis E. Gastric Polyp

A. Gastropathy

A 7-month-old male child is brought to the emergency by his mother because of a 3-day history of difficulty breathing, cough and runny nose. He has a history of 7 hospital admissions in last 3 months for treatment of severe fungal and viral infections. There is also a history of similar findings in other male kids in the family. His temperature is 36.5°C (97.7°F), pulse is 170/min, respirations are 40/min and shallow, rhonchi and crackles are heard on auscultation. Laboratory studies show low overall lymphocyte counts with an absence of T cells and NK cells but normal numbers of B cells. Which of the following gene mutations is most likely the cause of his repeated infections? (multiple correct choices) A. IL2 RG mutation B. JAK 3 mutation C. IL7Rα mutation D. ADA gene mutation E. BTK gene mutation

A. IL2 RG mutation

A 38-year-old West Indian man reports moderate abdominal pain for the last 2 weeks. He states the pain is not relieved by meals. His symptoms does not respond to cimetidine and antacids. He takes no other medications. Urea testing for Helicobacter pylori is positive. Which of the following, would most likely influence a worsening of his likely disorder? A. Tobacco use B. Low-fiber diet C. Excessive nitrate intake D. Gastroesophageal reflux disease E. Consumption of highly spiced foods

A. Tobacco use

A 50-year-old woman is brought to the ED by her husband because of sudden onset, severe epigastric pain radiating to the back, nausea, and vomiting. She has a history of cholelithiasis awaiting elective laparoscopic cholecystectomy. Her temperature is 36.7°C (98°F), pulse 105/min, respirations 22/min, and blood pressure 100/70 mmHg. Abdominal examination shows epigastric tenderness on palpation with periumbilical discoloration. She is advised NPO and started on IV fluids and pain medication. Which of the following investigations will be most helpful in diagnosing this patient? A. Markedly elevated lipase B. Increased AST C. Markedly decreased LDH D. Increased cholecystokinin levels E. Normal bilirubin levels

A. Markedly elevated lipase

A 33-year-old woman comes to the physician because of a 4-months history of epigastric pain, weight loss, and loose stools. Endoscopy reveals several ulcers in the stomach and early duodenum. CT of the abdomen shows a pancreatic mass. The tumor is causing hypersecretion of a substance. Which cell normally provides gastroprotection? A. Mucus Cells B. D Cells C. G Cells D. I Cells E. Chief Cells

A. Mucus Cells

Your patient who is now diagnosed with obesity wants to know about obesity and its link to diabetes. Which of the following statements regarding insulin resistance, diabetes and metabolic syndrome is TRUE? A. Obesity contributes to the development of insulin resistance B. All patients at a specific BMI have approximately the same risk of developing type 2 diabetes C. Metabolic syndrome is a cluster of symptoms to specifically determine the patient's risk of type 2 diabetes D. The diagnosis of metabolic syndrome is an effective at determining a patients overall risk

A. Obesity contributes to the development of insulin resistance

A 60-year-old is brought to the physician by his daughter for a routine examination. He feels well other than knee pain from injuries as a navy officer 20 years ago. He has been drinking six to eight cans of beer every night in the past year. His vital signs are within normal limits. Physical examination shows an overweight man with tender hepatomegaly. Bilateral bony hypertrophy of the knees is noted. Laboratory studies show ALT 200 U/L (N: 8-20) and AST 420 U/L (N: 8-20). Based on the presumptive diagnosis, which of the following liver biopsy findings is most likely in this patient? A. Perivenular fibrosis with ballooned hepatocytes B. Clusters of blood-filled cavities feeding from the hepatic artery C. Hyperplastic hepatocytes surrounding a central stellate scar D. Concentric layers of connective tissue surrounding small bile ducts E. Florid, granulomatous lesions affecting small bile ducts

A. Perivenular fibrosis with ballooned hepatocytes Chicken wire fibrosis = alcoholic liver disease

A 70-year-old woman comes to the physician because of a 6-month history of constipation. She has no other complaints and denies other medical conditions. Her vital signs are WNL. PE is unremarkable. Colonoscopy shows multiple polyps in her colon. Which of the following factors would most likely affect the prognosis in her case? A. Polyp morphology B. Female gender C. Race D. Number of polyps E. Location of polyps

A. Polyp morphology

A 25 year old female admitted to surgical ward for adrenalectomy. Laboratory evaluation shows an elevated urine free cortisol and lack of suppression of serum cortisol following a low-dose overnight dexamethasone suppression test. Subsequent testing revealed a suppressed adrenocorticotropic hormone level. A contrast-enhanced adrenal CT scan revealed a well-circumscribed 3.7-cm right adrenal mass . What is the most appropriate perioperative management? Session ID: aokogun A. Postoperative hydrocortisone B. Postoperative morphine C. Postoperative norepinephrine D. Preoperative phenoxybenzamine (alpha blocker)

A. Postoperative hydrocortisone

A 25-year-old man comes to the physician because of a 1-week history of bloody diarrhea and abdominal pain and a 3-week history of low-grade fever and joint pain in his ankles and wrists, and red eyes. The abdominal pain is cramping, intermittent, 7/10 in intensity, and localized to the left lower quadrant. Physical examination shows conjunctival congestion. Colonoscopy shows friable rectal mucosa that bleeds easily. Which of the following additional physical findings is most likely in this patient? A. Reddish, painful, tender lumps over anterior shins B. Hyperpigmented thickening of skin C. Scaly erythematous plaques over body D. Tender blisters E. Umbilicated papules

A. Reddish, painful, tender lumps over anterior shins

A 16-year-old girl is brought to the physician by her mother because she is yet to initiate menstruation. Physical examination shows a tall, well-developed young woman with scanty pubic and axillary hair. Pelvic examination shows palpable, mobile masses in the labia majora and a shallow vagina. Her blood chemistry reveals male-specific androgen levels. Which of the following embryological events is most likely responsible for her shallow vagina? A. The paramesonephric part of vagina is absent B. The mesonephric duct forms upper part of vagina C. Gonadal dysgenesis D. Renal agenesis E. Adrenal cortical hyperplasia

A. The paramesonephric part of vagina is absent

A 40-year-old woman comes to the physician because of a 5-year history of recurrent sinusitis requiring prolonged antibiotic treatments. She also has 10-year history of "on and off" diarrhea, abdominal pain, weight loss, and fatigue. She has had two hospitalizations within the past 2 or 3 years for bacterial pneumonia. Laboratory tests show significantly decreased level of IgG and a mildly decreased level of IgA, low plasma cells and normal B-cell numbers. Stool examination shows Giardia lamblia. Which of the following are true about this disease?(multiple correct options) A. Poor or absent antibody response to immunization B. Increased risk of lymphoreticular malignancies C. Autoimmune cytopenias are common D. Immunoglobulin replacement therapy is therapeutic intervention E. Failure of b-cell differentiation

ABCDE

A 10-year-old girl is brought to the physician because of a recurrent episodes of muscle cramps, hand spasms and paresthesia. She had two episodes of seizures recently. Her vital signs are within normal limit. Physical examination shows short stature, obesity, developmental delay, bilateral cataract and dental hypoplasia, positive Chvostek sign and Trousseau sign. Which of the following are most likely differentials? (chose multiple responses) A. PTH receptor defect B. Primary hyperparathyroidism C. Secondary hyperparathyroidism D. Decreased vit D intake E. Acute myeloblastic leukemia F. DiGeorge syndrome G. Tertiary hyperparathyroidism

ACDF

A 30-year-old man comes to the emergency department because of a 2-day cramping abdominal pain, and profuse, bloody diarrhea. He has had more than 10 bowel movements in the past 24 hours. He returned from a camping trip from Mexico 2 days ago, during which he ate grilled chicken and drank water from a stream. Temperature is 38.9°C (102.1°F). Abdominal examination reveals diffuse tenderness. Which of the following bacteria would most likely cause bloody diarrhea? A. Enterotoxigenic E. coli B. Shigella C. Enterohemorrhagic E. coli D. Salmonella E. Campylobacter F. Yersinia enterocolitica G. C. difficile H. C. perfringens I. B. cereus J. Listeria

B through F

A 65-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever and left lower quadrant abdominal pain. She has had multiple episodes of abdominal pain without fever and one episode of rectal bleeding in the past 6 months. Her diet contains low-fiber and high-fat. Her temperature is 38.5°C (101.3°F), pulse is 105/min, respirations are 19/min, and blood pressure is 160/90 mmHg. Physical examination shows abdominal tenderness in the left lower quadrant. Laboratory studies show leukocytosis. Which of the following test is the best to diagnose this patient? A. Colonoscopy B. Abdominal CT C. Antibiotics D. Barium enema E. Sigmoidoscopy

B. Abdominal CT

A 42-year-old woman is brought to the emergency department because of a 6-hour history of intense right upper quadrant abdominal pain, nausea, and vomiting after a high-fat meal. She denies bowel changes or recent travel. Her temperature is 38.2°C (100.7°F); other vital signs are within normal limits. Physical examination shows an obese woman in painful distress and right upper quadrant abdominal tenderness. An ultrasound of the abdomen shows multiple echogenic foci within the gallbladder with pericholecystic fluid. Laboratory tests show leukocytosis with normal liver enzymes. Which of the following conditions has this patient most likely developed? A. Gallstone pancreatitis B. Acute cholecystitis C. Acute cholangitis D. Gallbladder cancer E. Choledocholithiasis

B. Acute cholecystitis

A 2-year-old boy is brought to the physician by his mother because of a 2-day history of fever, bilateral ear pain and failure to thrive. His mother says he has a 1-year history of recurrent pneumonias, otitis media, impetigo and diarrhea. Organisms cultured from these infections include Hemophilus influenzae, Streptococcoccus pneumoniae, Staphylococcus aureus and Giardia lamblia. There is history of similar condition in older brother. The boy's two sisters and both parents are not affected. His temperature is 39.5° C (102.7° F), pulse is 120/min and respirations are 27/min. Which of the following laboratory findings would most likely be seen in this boy? A. Hypocalcemia B. Agammaglobulinemia C. Decreased complement C3 D. High titer of HIV-1 RNA E. Positive ANA test result

B. Agammaglobulinemia

A 55-year-old woman comes to the physician because of an 18-month history of progressive dysphagia to both liquids and solids, heartburn and regurgitation of food. Physical examination shows shiny tight skin over the dorsum hands and telangiectasias on lips. Barium swallow study shows a dilated tubular esophagus with patulous lower esophageal sphincter (LES). Which of the following is the most likely cause for her condition? A. A. Defective meissner's plexus in LES B. B. Defective myenteric plexus in LES C. C. Defective vagal nerve function D. D. Laxity of phrenoesophageal membrane E. E. Fibrosis and vascular injury

B. B. Defective myenteric plexus in LES

A 11-month-old girl child is brought to the emergency with a 1-week history of right ear pain and discharge. She has a history of multiple infections since birth, including pneumonia with Pseudomonas aeruginosa, Adenovirus, and Aspergillus fumigatus; diarrhea with Isospora belli; otitis media with Hemophilus influenzae; and urinary tract infection with Candida albicans. Laboratory studies show lymphopenia and a proportionate decrease in all serum immunoglobulin type. X-Ray of the chest shows absent thymic shadow. Lymph node biopsy shows lack of germinal centers. The most likely prospect for permanent restoration of normal immunity for this patient would be? A. An antibiotic "cocktail" given at regular intervals. B. Bone marrow transplantation. C. Exogenous immunoglobulins administered periodically. D. Isolation to an antiseptic environment. E. Thymic hormones given throughout his life.

B. Bone marrow transplantation.

A 24-year-old woman presents to the physician with epigastric abdominal pain, fatigue, but no weight gain or loss over the past month. The abdominal pain sometimes wakes her at night, and the pain is worst with meals. She has a long-standing history of osteoarthritis and smoked one pack of cigarettes daily for 20 years. Physical examination reveals epigastric and right upper quadrant tenderness to deep palpation. Which of the following is the most influential pathogenesis of her ulcers due to NSAID? A. H. Pylori induction B. COX 1 inhibition C. COX 2 inhibition D. Hypoxemia E. Reduced mucin and bicarbonate

B. COX 1 inhibition

A 12 -year-old boy presents to his physician because of abdominal pain and yellowing the skin over the past several days, which started after attending a birthday party. His mother states he has complained of shortness of breath and fatigue over the past two months. He denies fever, recent travel, or blood transfusion. Laboratory investigation reveals elevated AST 1300 U/L (N: 8-20), ALT 700 U/L (N: 8-20), and Hb 9g/dL (N: 13.5-17.5). Genetic testing shows an H1069Q mutation of the ATP7B gene. Based on the presumptive diagnosis, which of the following is the underlying mechanism of this patient's disease process? A. Periductal fibrosis & chronic inflammation of intrahepatic and extrahepatic bile ducts B. Defective hepatocytes transport of copper into bile C. Inherited deficiency of a serine protease inhibitor D. Unregulated GI iron absorption E. Virus-induced apoptosis of hepatocytes

B. Defective hepatocytes transport of copper into bile

A 30-year-old man comes to his physician because of three days history of explosive watery diarrhea with blood and mucus which started after eating undercooked chicken. Qualitative analysis of his tool shows curved roads in the fecal smear along with red blood cells and leukocytes. Which of the following laboratory tests is most appropriate to differentiate the pathogen responsible for these findings from other organisms A. Growth at 40C (39.20F) B. Growth at 420C (107.60F) C. Growth on Mac Conkey methylene blue agar D. Growth on Mac Conkey E. Growth on Sorbitol Mac Conkey

B. Growth at 420C (107.60F)

A 59-year-old woman comes to the emergency department because of a 1-hour history of colicky right upper abdominal pain, nausea, and vomiting. She has a 3-year history of similar intermittent pain after a high-fat meal. She has a history of dyslipidemia and is non-compliant to her statin regimen. She does not smoke or use illicit drugs. Physical examination shows right upper quadrant abdominal tenderness. Ultrasound of the abdomen shows several mobile echogenic foci within the gallbladder. Which of the following factors most likely contributed to the development of this patient's condition? A. Decreased cholesterol 7-hydroxylase levels B. Increased biliary secretion of cholesterol C. Loss of function mutation of the hepatic cholesterol transporter D. Decreased HMG-CoA reductase activity E. Mutation of the hepatic phospholipid export pump

B. Increased biliary secretion of cholesterol

What is the most influential risk factor for chronic Gastritis and Peptic Ulcer disease? A. Drinking coffee B. Infection with H- pylori C. Taking a large amount of paracetamol D. GERD

B. Infection with H- pylori

A 38-year-old woman comes to the physician because of an 8-week history of headache and muscle weakness. Her pulse is 78/min and blood pressure is 176/110 mmHg. Physical examination shows no abnormalities. Laboratory studies show high serum sodium, low serum potassium and high serum bicarbonate and elevated serum aldosterone. Which of the following additional laboratory findings is most likely in this patient? A. Hyperglycemia B. Low serum renin C. High serum gastrin D. Low serum ACTH E. Elevated urinary normetanephrine

B. Low serum renin

A 35-year-old man was brought into the emergency department because of malaise, yellowing of the skin, and somnolence. Three days ago, he complained of nausea and vomiting, after ingesting medication for a headache. He denies illicit drug use but admits to consuming at least 6 drinks per day for the past month. His temperature is 37.1°C (98.8°F), pulse is 100/min, respirations are 25/min, and blood pressure is 125/76 mm Hg. Physical examination shows hepatomegaly. Laboratory studies show aminotransferase of 5300 IU/L and total bilirubin of 5.2 mg/dL(0.1-1.0 mg/dL). Based on the presumptive diagnosis, which of the following mechanism is responsible for this patient's condition? A. Accumulation of acetaldehyde in the liver B. N-acetyl-p-benzoquinone imine accumulation C. Unrestricted release of iron from enterocytes D. Increase production of mercapturic acid E. Increase mitochondrial ATP-synthase damage

B. N-acetyl-p-benzoquinone imine accumulation E is a result of B

A 59-year-old man came to the Emergency Department with a history of progressive abdominal distention associated with shortness of breath for the last two days. His physical examination reveals pale, mildly icteric and moist mucous membranes. He also has gynecomastia; decreased breath sounds bilaterally in the lower lobes of the lung, positive shifting dullness and positive fluid wave. Which of the following was most likely also found on his examination? A. Janeway lesions B. Palmar Erythema C. Osler Nodes D. Roth Spots E. Splinter Hemorrhages

B. Palmar Erythema

Patient is febrile (100.90F), pulse of 110/minute Reduced skin turgor, mild abdominal tenderness with rose colored spots at the periumbilical areaHct 44%, wbc 24,000, bun 29 mg/dl, cr 1.3. There was blood in the stool with a few fecal leukocytes.WHAT IS THE MOST LIKELY CAUSE OF THE PATIENT'S DIARRHEA? A. Shigella B. Salmonella C. Campylobacter D. Vibrio E. Yersinia enterocolitica F. Enterohemorrhagic E. coli

B. Salmonella

A 40-year-old man comes to the physician because of a 6-month history of worsening diarrhea. He says he passes watery stool about six times per day and the stool is tea color with no blood or mucus. He takes codeine and loperamide to relieve his symptoms. His pulse is 80/min, blood pressure is 120/70 mmHg, and respirations are 16/min. Physical examination shows no abnormalities. An abdominal ultrasound shows a pancreatic mass.Which of the following pharmacologic agents is most appropriate to treat this patient? A. Bromocriptine B. Somatostatin analogue C. Cholestyramine D. Codeine E. Somatropin analogue

B. Somatostatin analogue

A 69-year-old man comes to the physician because of a 7-week history of cold intolerance, hypotension, fatigue and weight gain of 4.6 kg (10 lbs.). He has a 1-year history of atrial fibrillation. Laboratory studies show low serum levels of TSH and free T4. Imaging studies of his head shows partial necrosis of anterior pituitary gland. A carotid angiogram shows a block in the artery that supplies to the anterior pituitary gland. Which of the following blood vessels is most likely blocked? A. Middle cerebral artery B. Superior hypophyseal artery C. Posterior cerebral artery D. Inferior hypophyseal artery E. Anterior communicating artery

B. Superior hypophyseal artery

A 36 year old female presents to her Physician with complaints of excessive thirst, weight loss of 2kg in 3months, frequent urination and recurrent vaginal candidiasis. Physical examination reveals a mildly dehydrated overweight female with Blood pressure of 120/80mmHg, pulse of 90/min and dark discoloration of her neck and armpits. 2+ glucose and 1+ ketones is found on Urine dipstick. What is the most likely diagnosis? A. Addison's Disease B. Type 2 Diabetes C. Hypothyroidism D. Hyperthyroidism E. Hypercalcemia

B. Type 2 Diabetes

A 23-year-old woman at 10 weeks of gestation is brought to the emergency department because of vomiting and vaginal bleeding for the past 2 days. She states the bleeding is like heavy spotting with dark purplish-colored blood and with passage of vesicles. Physical examination shows the uterus is larger than expected for gestational age. An ultrasound scan shows a snowstorm appearance of the uterus with absence of fetal parts. Which of the following karyotype is most likely observed from the collected vesicles? A. 45, XO B. 47, XXY C. 46, XX or XY D. 69, XXX or XXY E. 47, XXX

C. 46, XX or XY

The man, now age 73, is brought to the emergency department because of confusion for the past 2 days. He has a 10-year history of heavy alcohol drinking. PE shows a skinny man with scleral icterus and generalized jaundice. His abdomen is distended with spider angiomas and dilated paraumbilical veins. While at the ED, the patient vomits a large amount of blood. Rupture of which of the following is the most likely underlying cause of hematemesis in this patient? A. Anastomosis of the superior rectal vein with the middle and inferior rectal veins B. Anastomosis between the superior epigastric and paraumbilical veins C. Anastomosis between the left gastric and azygos veins D. Anastomosis between the left portal vein and the IVC E. Anastomosis of the splenic vein with the renal, adrenal, and gonadal veins

C. Anastomosis between the left gastric and azygos veins

A 50-year-old man hospitalized for community acquired pneumonia develops fever and loose stools on the fourth hospital day. He recently traveled to Brazil for vacation without taking any prophylactic antibiotics or receiving any vaccinations. Sigmoidoscopy demonstrates white/yellow membrane-like plaques on the colonic mucosa and biopsy shows that these plaques are composed of fibrin and inflammatory cells. The patient's condition is most likely associated with which of the following. A. A recent travel to Mexico B. Mixed vaccination C. Antibiotic therapy D. Gastritis prophylaxis E. Consumption of home canned foods

C. Antibiotic therapy

A 30-year-old man comes to the physician because of a 2-month history of fatigue, frequent urination, and increased fluid intake. He denies a past medical history of significance except for a decrease in his libido over the past four months and the occasional joint pain. Physical examination shows a slate-gray hue to the skin and hepatomegaly. A liver biopsy shows pronounced blue staining of hepatocytes with Prussian blue staining. Laboratory investigation shows elevated transaminases and fasting glucose of 190mg/dL (70-110 mg/dL). Based on the presumptive diagnosis, which of the following laboratory results is expected in this patient? Iron/% Saturation/TIBC/Ferritim A. A inc Dec inc Dec B. B Dec Dec Dec inc C. C inc inc Dec inc D. D Dec Dec inc Dec

C. C inc inc Dec inc

A 54-year-old man is brought to the emergency department by his wife because of a 35-min history of epigastric pain, fever, nausea, and vomiting. He is a heavy alcohol drinker for the past 20 years and went binge drinking the previous day. His temperature is 38.3°C (100.9°F), pulse is 110/min, respirations are 18/min, and blood pressure is 140/90 mmHg. Abdominal examination shows epigastric tenderness on palpation with guarding and a purplish discoloration of the flanks. Which of the following best explains the mechanism of initiation of this patient's condition? A. Erosion of the gastric mucosa B. Decreased intracellular calcium concentration in the pancreas C. Decreased trypsin inhibitor concentration in the pancreas D. Longitudinal tear in the submucosa of the lower esophagus E. Decreased protein content of the pancreatic fluid

C. Decreased trypsin inhibitor concentration in the pancreas

A 22-year-old male presents to the physician because of the yellowing of his skin and increasing fatigue for the past three months. He has a history of productive cough, wheezing, and shortness of breath. Physical examination shows scleral icterus, jaundice, and a palpable firm liver. Laboratory investigations show elevated aminotransferases. Genetic testing of this patient will reveal which of the following? A. Mutation in ATP7B gene B. Mutation of the HFE gene C. Defects in the SERPINA1 gene D. Mutations of the CFTR gene E. Pathogenic variants in the GBE1 gene

C. Defects in the SERPINA1 gene

A 2-year-old boy is brought to the physician because of a 2-day history of runny nose, cough and sore throat. He also has a 1-year history of multiple episodes of otitis media, upper respiratory infections, pneumonia, and sinusitis. Laboratory studies show decreased levels of all immunoglobulins. Which of the following is the most likely microorganism affecting this patient ? A. Mycobacteria B. Intracellular bacteria C. Extracellular bacteria D. Intracellular protozoa E. Fungi

C. Extracellular bacteria

A 28-year-old man comes to the physician because of a 2-months history of epigastric pain, weight loss, and loose stools. Endoscopy reveals several ulcers in the stomach and early duodenum. CT of the abdomen shows a pancreatic mass. The tumor is causing hypersecretion of a substance that is normally secreted from which cell type? A. I Cells B. D Cells C. G Cells D. Chief Cells E. Mucus Cells

C. G Cells

A 30-year-old woman with 34 weeks of gestation comes to the clinic for her third trimester ultrasound. Her previous pregnancy history includes 1 term birth with twins 6 years ago; one abortion at 10 weeks 4 years ago; and one fetal demise at 30 weeks 3 years ago. Which of the following obstetric formula conveys about her pregnancy history? A. G4P2A1L3 B. G4P3A1L2 C. G4P2A1L2 D. G5P2A2L2 E. G5P2A1L2

C. G4P2A1L2

A 52-year-old man is brought to the emergency with a 7-hour history of intermittent chest pain. The pain is sharp, 7/10 in intensity, behind the sternum radiating to the neck and increases on lying down. He also has a 2-month history of dry cough and hoarseness in the mornings. Laboratory investigations are normal. ECG is normal. Which of the following is the most likely cause of the patient's symptoms? A. Myocardial infarction B. Pericarditis C. Gastroesophageal reflux D. Pulmonary embolism E. Pneumonia

C. Gastroesophageal reflux

40-year-old man comes to the physician because of a 11 day-history of watery diarrhea. He says it began 6 days after returning from his 1-month vacation in Brazil . His temperature is 37°C (98.60F), blood pressure is 120/70 mm Hg, and respirations are 18/min. Physical examination shows no abnormalities. Stool microscopy is shown in the figure. Which of the following is the most likely causative agent? A. Salmonella Typhi B. Entamoeba hisstolytica C. Giardia lamblia D. Shigella dysenteriae E. Campylobacter jejuni

C. Giardia lamblia

A-50-year-old woman comes to the clinic because of lethargy, abdominal pain, loose watery diarrhea and bloating of 1 week. She has been traveling around the world for a few months now returns to the United states. She has lost 5Lb. Physical examination shows examination having mild generalized tenderness on the abdomen. What is the most likely organism causing her symptoms? A. Campylobacter jejuni B. Staphylococcus aureus C. Giardia lamblia D. Salmonella enterica E. Shigella dysentry

C. Giardia lamblia

A 50-year-old woman comes to the physician because of intermittent bloating, abdominal pain, watery diarrhea, and flatulence for several months. The condition is often worse after meals, but sometimes eating presents no problems. The patient follows a normal diet with no restriction. Patient is not on any medication There is no family history of gastrointestinal disorders. Stool studies reveal an osmotic gap of 210 mOsm/kg.Impairment in which of the following processes is most likely affected this patient? A. Emulsification of triglycerides B. Galactose phosphorylation C. Gluten digestion D. Sucrose hydrolysis E. Hydrolysis of lactose to galactose and glucose

C. Gluten digestion

An 18-year-old woman comes to her family physician because of tremors in her hands; associated with poor memory, and difficulty focusing on tasks. Her behavior has changed in the past 6 months in that she has frequent episodes of depression, separated by episodes of bizarre behavior, including excessive drinking. Her parents have noted slight slurring of her speech. On physical examination, upper extremity tremors and incoordination involving her hands. Slit-lamp examination reveals Kayser-Fleischer rings. The main mechanism of excess copper removal in the healthy human body is: A. Glomerular filtration B. Renal tubular secretion C. Hepatic excretion into bile D. Intestinal epithelial accumulation E. Colonic active secretion

C. Hepatic excretion into bile

A 24-year-old woman comes to the physician because of difficulty becoming pregnant. She is trying to conceive a child for over a year; however, she has not been successful. Medical history is significant for type 2 diabetes mellitus and obesity. Physical examination shows acne on the face, hair on the upper lip and chin and acanthosis nigricans on the posterior neck. Blood tests shows a ratio of LH to FSH is 3. Which of the following features is most likely pathophysiological basis for the patient condition? A. Hyperaldosteronism B. Hyperthyroidism C. Hyperandrogenism D. Hypercholesteremia E. Hypercortisolism

C. Hyperandrogenism

3-year-old infant was brought to the Clinic by his mother with complaint of abdominal colic after every feed of cereal. He is also noted to have little or no growth over the last month. On physical examination he has pale mucosal membranes, weight about 18 percentiles short for age and mildly pitting pedal edema. Itchy and blistery patches of skin on knees elbows and buttocks. Which of the following tests is recommended to be used to screen this patient? A. Shilling's test B. Antigliadin IgA and IgG antibodies C. IgA tissue transglutaminase antibodies (tTG) D. Withdrawal of lactose from the diet to monitor for improvement of symptoms E. Scotch tape test

C. IgA tissue transglutaminase antibodies (tTG)

A 76-year-old man comes to the physician because of a 3-month history of lower back ache, lower abdominal discomfort and a 5-kg (11-lb) weight loss. Physical examination shows no abnormalities. Digital rectal examination shows a hard nodule in the posterior lobe of the prostate. Laboratory studies show an elevated serum prostate specific antigen. Histologic examination of a prostate biopsy shows adenocarcinoma. Metastasis to which of the following lymph nodes is most likely to occur first in this patient? A. Para-aortic nodes B. Retroperitoneal nodes C. Iliac nodes D. Superficial inguinal nodes E. Deep inguinal nodes

C. Iliac nodes

A 24-year-old woman comes to the physician because of urinary frequency and abnormal uterine bleeding. Her menstrual history is characterized by excessive bleeding at irregular intervals. Pelvic examination shows single mass in the anterior wall of the uterus and this being confirmed by ultrasonography. Which one of the following clinical terms best describes the abnormal uterine bleeding in this woman? A. Menorrhagia B. Dysmenorrhea C. Menometrorrhagia D. Oligomenorrhea E. Polymenorrhea

C. Menometrorrhagia

A 23-year-old man comes to the physician because of a 5-week history of increased urination and thirst. He states that his elder brother was diagnosed with chronic pancreatitis at the age of 30. His vital signs are within normal limits. Physical examination shows mild dehydration. Laboratory studies show serum calcium of 11.6 mg/dL (N: 8.5-10.5) and elevated serum PTH. A 24-hour urinary calcium is low. Which of the following defects best explains the laboratory findings of this patient? A. PTH receptor defect B. Malabsorption of Vitamin D C. Mutation in calcium-sensing receptors D. Mutation in Vitamin D receptor E. Defective calcium reabsorption in renal tubules

C. Mutation in calcium-sensing receptors

A 65-year-old man comes to the emergency department with a complaint of abdominal pain rated 7/10. The pain is dull and localized to the left lower quadrant with no radiation. He had one previous episode, which resolved on its own. His bowel movements are regular, and he denies nausea or vomiting. He admitted to feeling a little warmer than usual but denied chills. His medical records show he has had Diabetes Mellitus for the past 10 years and Hyperlipidemia for the last 15 years. No significant family history. Vitals signs were 100.1 F, BP 120/85mm Hg, HR 80/min, RR 16/min. Physical examination was positive for left lower quadrant tenderness, no mass. Rectal examination negative stool guaiac test.Which of the following is a proven risk factor for developing this patient diagnosis? A. Statin use B. Alcohol C. Obesity D. Seed and nuts E. Overexertion

C. Obesity

A 36-year-old man comes to the clinic because of 6-week history of burning sensation in the fingers. He also complains of feeling weak at the end of the day and having unpleasant tingling sensation in his toes for a month. He reported feeling extremely bloated in the past few weeks. Physical examination shows distended abdomen and hypersonic bowel activity. Endoscopic imaging revealed multiple areas of metaplasia and scaring in stomach. Lab values suggest increase in MCV and MCH with MCHC normal. Which of the following cells are most likely affected to cause the disease? A. Chief cells B. Interstitial cells of Cajal C. Parietal cells D. G cells E. D cells

C. Parietal cells

A 38-year-old male complaints of a 2-months history of intermittent abdominal pain that is worse about an hour after he eats. Physical examination reveals slim built man with excessively loose skin suggesting rapid weight loss. An upper endoscopy reveals an ulcer near the gastric antrum. Stool is negative for occult blood. Culture of the specimen reveals gram-negative microaerophilic organisms. Which following is H. Pylori risk factor for? A. Peptic ulcer disease only B. Peptic ulcer disease and MALT Lymphoma only C. Peptic ulcer disease ,gastric adenocarcinoma, and MALT lymphoma D. Peptic ulcer disease and gastric adenocarcinoma only E. Gastric adenocarcinoma and MALT Lymphoma only

C. Peptic ulcer disease ,gastric adenocarcinoma, and MALT lymphoma

A 30-year-old man is brought to the emergency department because of a 2-hour history of severe abdominal pain, bloating and nausea. He says that the pain is sharp, intense, non-radiating and occurred 1 hour after eating. The pain was initially in the upper abdomen but, now has generalized to the entire abdomen. He was diagnosed to have chronic gastritis and was treated with a proton pump inhibitor one year ago. His temperature is 39.8oC (103.6°F), pulse is 108/min and blood pressure is 140/86 mm Hg. Abdominal x-ray shows free air under the diaphragm. Which of the following is the most likely diagnosis? A. Bleeding B. Obstruction C. Perforation D. Zollinger-Ellison syndrome E. Boerhaave syndrome

C. Perforation

A 48-year-old man comes to the emergency department because of a 3-hour history of nausea, vomiting, and severe epigastric pain radiating to the back. He is a chronic alcoholic who went binge drinking 12 hours ago. He has smoked one pack of cigarettes daily for the past 15 years. His temperature is 38.8°C (102°F), pulse is 116/min, respirations are 22/min, and blood pressure is 88/60 mmHg. Physical examination shows a man in painful distress with abdominal tenderness and purplish discoloration of the flanks. Abdominal CT scan shows peripancreatic fluid and punctate areas of calcification within the pancreas. Which of the following findings most likely indicates poor prognosis in this patient? A. Microcytic anemia B. Leukopenia C. Persistent hypocalcemia D. Low LDH levels E. Normoglycemia

C. Persistent hypocalcemia

Which of the following mechanisms will most likely contribute to the development of alcoholic liver disease in this man? A. Conversion of acetaldehyde to ethanol in the presence of alcohol dehydrogenase B. Activation of the microsomal ethanol-oxidizing system at low ethanol concentrations C. ROS triggering lipid peroxidation that cause hepatocellular damage D. Increased beta-oxidation of fatty acids in the liver E. Activation of catalase in peroxisomes at low hydrogen peroxide levels causing increased ethanol metabolism

C. ROS triggering lipid peroxidation that cause hepatocellular damage

A 28-year-old woman comes to the physician because of an 8-month history of crampy abdominal pain and diarrhea alternating with constipation. She likes to travel but has been unable to do so lately as she is taking a master's degree while working full-time. She has no other complaints and denies other medical conditions. PE and stool exam are unremarkable. Infection from which of the following etiologic agents is linked to post-infectious irritable bowel syndrome? A. Bifidobacterium B. Staphylococcus C. Shigella D. Lactobacillus E. Streptococcus

C. Shigella

A 45-year-old woman is brought to the emergency department because of a 1-day history of vomiting, abdominal pain, and diffuse, watery diarrhea. She was admitted to the hospital for gallbladder surgery 10 days ago. Her postoperative period was complicated with fever and she was treated with a 1-week course of broad-spectrum antibiotics. Her temperature is 39.40C (103°F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 18/min. Physical examination shows tenderness in the left lower quadrant. Fecal occult blood is negative. Which of the following laboratory tests is the best next step in the management of this patient? A. Blood culture B. Stool osmotic gap C. Stool toxin assay D. Stool for ova and parasites E. 24-hour fecal fat

C. Stool toxin assay

A 50-year-old man comes to the physician because of a 4-month history of joint pain, abdominal pain, weight loss of 6 kg (15 lbs.) and passing pale and greasy loose stools . Physical examination shows no abnormalities. Histologic examination of a small bowel biopsy shows numerous PAS-positive materials in the lamina propria as well as villous atrophy. Which of the following is the most likely diagnosis? A. Celiac sprue B. Crohn disease C. Whipple disease D. Cystic fibrosis E. Ulcerative colitis

C. Whipple disease

An 84 year old female, retired judge, presented to her Primary care physician with complaints of fatigue, difficulty concentrating, nervousness and diarrhea. She sometimes feels a fast heartbeat and thinks she is losing weight. She attributes it to being overworked. After a history and physical examination which of the following investigations will you order? A. Free T3 and FreeT4 B. Thyroid uptake scan C. Thyroid stimulating antibody D. TSH

D. TSH

A 24-year-old woman comes to the physician because of missed period. Her last menstrual period was 6 weeks ago. Urine pregnancy test is positive for β-HCG. Which of the following hormones alpha subunit is identical to alpha subunit of Human chorionic gonadotropin? A. LH B. FSH C. TSH D. All of the above

D. All of the above

A 34-year-old man comes to the physician because of a 1-day history of left-sided flank pain described as sharp, colicky, 8/10 in intensity, and radiating to the left groin. He has a 2-year history of Crohn's disease on medication. Physical examination shows a man in painful distress with left-sided CVA tenderness. Urinalysis shows RBC too numerous to count (TNTC). Renal ultrasound shows multiple renal and ureteral stones on the left. Which of the following types of stones will the patient most likely develop? A. Tyrosine B. Calcium phosphate C. Cystine D. Calcium oxalate E. Struvite

D. Calcium oxalate

A 63-year-old African American man came to the clinic complaining of 20 pounds of unintentional weight loss, chronic non-bloody diarrhea, and fatigue for two months. His physical examination shows a thin middle-aged with temporal wasting and pale skin. His abdominal examination reveals a flat, soft, non-tender abdomen with no masses felt and no organomegaly. Which of the following is the most likely diagnosis? A. Diverticulosis B. Inflammatory Bowel Disease C. Shigella Infection D. Colon Cancer E. Giardia

D. Colon Cancer

A 2-month-old male child is brought to the physician because of a 1-week history of severe diarrhea and signs and symptoms suggestive of Pneumocystis carinii pneumonia. His weight is in the 10th percentile. Physical examination shows an oral fungal infection with Candida albicans. Test results for HIV are negative by polymerase chain reaction. Which of the following is the most likely cause of these findings ? A. Grossly reduced levels of B cells. B. An X-linked inheritance of HLA genes. C. Defective isotype switching. D. Defective T-cell function. E. Selective IgA deficiency.

D. Defective T-cell function

A 45-year-old man comes to the physician with a 7-year history of regurgitation of food in the back of his throat and a constant sour taste. He has a 10-pack year history of smoking. Esophageogastroduodenoscopy (EGD) shows patchy area of epithelium resembling gastric mucosa extending 6cm proximal to esophageogastric junction. Biopsy of this epithelium shows intestinal metaplasia. The patient is likely to be at an increased risk of which of the following? A. Hiatal hernia B. Barrett's esophagus C. GERD D. Esophageal adenocarcinoma E. Achalasia

D. Esophageal adenocarcinoma

A 53-year-old man comes to the physician because of a 2-week history of frequent micturition and bone pains. He was diagnosed with Hodgkin lymphoma 3 months ago. Laboratory studies show serum calcium of 13.2 mg/dL, low serum PTH and elevated 24-hour urinary calcium. Which of the following best explains these laboratory findings in this patient? A. Parathyroid gland hyperplasia B. Secretion of ectopic PTHrP by the tumor C. Increased serum globulins D. Increased secretion of calcitriol by the tumor E. Increased bone osteolysis by tumor cells

D. Increased secretion of calcitriol by the tumor

A 49-year-old woman comes to the physician because of a 6-week history of lump in the neck. She has a 1-year history of nephrolithiasis and hypercalcemia. Physical examination shows hard non-tender mass in the right lobe of the thyroid and enlarged cervical lymph nodes on the right side. Thyroid scan shows a cold nodule in her right thyroid. Immunostaining of the cells from a biopsy of this cold nodule is positive for calcitonin. Which of the following thyroid neoplasms is most likely in this patient? A. Papillary carcinoma B. Follicular carcinoma C. Thyroid lymphoma D. Medullary carcinoma E. Anaplastic carcinoma F. Benign adenoma

D. Medullary carcinoma

A 50-year-old woman has a 6-months history of diarrhea. There are no fecal WBCs, and the stool osmotic gap is found to be 164 mOsm/Kg. The pathogenesis of her chronic diarrhea is most likely which of the following? A. Secretory B. Inflammatory C. Fictitious D. Osmotic E. Bile salt induced

D. Osmotic

A 24-year-old medical student participates in a clinical research study to assess the efficacy of a new synthetic human secretin analog. He has no medical conditions and denies intake of alcohol or illicit drugs. He is given a test load of the drug, after which fluid secretions in the duodenum are measured and evaluated. Which of the following statements best describes normal exocrine pancreatic secretion as seen in this patient? A. It has a higher chloride concentration than plasma B. It is stimulated by the presence of bicarbonate in the duodenum C. Pancreatic bicarbonate secretion is increased by somatostatin D. Pancreatic enzyme secretion is increased by cholecystokinin E. It is hypotonic

D. Pancreatic enzyme secretion is increased by cholecystokinin

Which cells in the stomach are responsible for secreting Hydrochloric acid? A. Chief cells B. Interstitial cells of Cajal C. G cells D. Parietal cells E. D cells

D. Parietal cells

A 41-year-old woman comes to the physician because of a 3-week history of nervousness, heat intolerance, diarrhea and a weight loss of 20 lbs., despite a good appetite. Physical examination shows tachycardia, irregular pulse, lid-lag and a fine tremor of her hands. Which of the following diagnostic tests is the best to determine the etiology of this patient's condition? A. Plasma free T3/T4 B. Measurement of serum glucose C. Urine metanephrine D. Plasma TSH-receptor autoantibodies E. Cervical lymph node biopsy F. Measurement of BMR

D. Plasma TSH-receptor autoantibodies

A 35-year-old woman comes to the physician for a routine examination. She is currently asymptomatic. She is a phlebotomist and had a needlestick injury 6 years ago, after which she had mild fever and jaundice for 2 months. Her vital signs are within normal limits. Physical examination shows no abnormalities. Her hepatitis serology results are shown below. Which of the following statements best explains this patient's condition? A. She has acute hepatitis B B. She has acute hepatitis B and C C. She has chronic hepatitis B with high infectivity and hepatitis C D. She has chronic hepatitis B with low infectivity and hepatitis C E. She has recovered from past hepatitis B infection

D. She has chronic hepatitis B with low infectivity and hepatitis C

A 52-year-old man is brought to the emergency department because of a 1-hour history of altered mental status and abdominal distension. He has a 15-year history of chronic alcohol use and is fully vaccinated for hepatitis B. Physical examination shows an ill-looking man with gynecomastia and palmar erythema. The abdomen is severely distended with dilated periumbilical veins, splenomegaly, and pitting bipedal. Neurologic examination shows disorientation and asterixis. Which of the following is the most likely explanation for this patient presentation? A. Misfolded protein aggregates in hepatocellular endoplasmic reticulum B. Accumulation of iron in the hepatocytes C. Ground-glass hepatocytes with cytotoxic T cells D. Thick, fibrous bands surrounding regenerating hepatocytes E. Macrovesicular lipid accumulation in hepatocytes

D. Thick, fibrous bands surrounding regenerating hepatocytes

A 2-week-old newborn girl is brought to the physician because of lethargy, hoarse cry, poor feeding, constipation and puffiness of face and limbs. Physical examination shows non-pitting edema, macroglossia, umbilical hernia, large fontanels, hypotonia, dry skin, hypothermia and goiter. Laboratory studies show low serum free T4 and elevated serum TSH. Which of the following enzymes' deficiency is the most likely cause of this patient's presentation? A. Tyrosine kinase B. Tyrosine hydroxylase C. 5-Deiodinase D. Thyroid peroxidase E. Na+-K+ ATPase

D. Thyroid peroxidase

45-year-old woman with chronic diarrhea comes to the emergency room because of nausea and vomiting for 2 days, along with severe continuous midabdominal pain. Her past history suggests presence of gall stones. She has a low-grade fever and all other vitals are stable. The ER physician finds that she has a slightly elevated WBC count (12,000) and an elevated serum amylase. The most likely diagnosis is: A. Ruptured abdominal aortic aneurysm B. Hepatitis C. Peptic ulcer disease D. Early phase of acute appendicitis E. Acute pancreatitis

E. Acute pancreatitis

A 7-month-old female child is brought to the physician because of a 2-week history severe diarrhea. She has a history of recurrent infections with multiple agents, including Cytomegalovirus, Candida albicans, Staphylococcus aureus, and Staphylococcus epidermidis. A careful family history and pedigree analysis show this to be a genetic disorder that is inherited in an autosomal recessive pattern. Which of the following laboratory studies is most likely to be useful in establishing the underlying mechanism of immunodeficiency in this infant? A. Quantitative serum immunoglobulin levels B. Enumeration of B cells in blood C. Enumeration of CD3+ cells in blood D. Tests of neutrophil function E. Adenosine deaminase levels in leukocytes

E. Adenosine deaminase levels in leukocytes

A 31-year-old woman comes to the physician because of a 2-month history of fatigue, dizziness and muscle weakness. Physical examination shows hypotension. Laboratory studies show hyponatremia, hypoglycemia, low serum ACTH and cortisol but normal serum potassium and bicarbonate. Defective functioning of which of the following zone/s of adrenal cortex is/are most likely in this patient? A. Zona glomerulosa B. Zona fasciculata C. Zona reticularis D. A and B E. B and C F. A, B and C

E. B and C

A 85-year-old woman comes to the emergency department because of a 1-month history of burning retrosternal chest pain after meals. The pain is relieved by antacids. ECG shows no abnormality. An x-ray of the chest is shown. She is advised posterior cruroplasty, and anterior gastropexy. Which of the following is a likely complication of this condition? A. Esophageal squamous cell carcinoma B. Interstitial lung disease C. Eosinophilic esophagitis D. Pseudoachalasia E. Gastric volvulus

E. Gastric volvulus

A 38-year-old woman comes to the physician because of an 8-week history of progressive weight gain, muscle weakness, headache, menstrual irregularities, and acne. Her blood pressure is 164/96 mmHg. Physical examination shows truncal obesity, round face, violaceous striae in chest and abdomen and thin extremities. Laboratory studies show low serum potassium, high serum glucose, elevated serum cortisol and ACTH. MRI of the brain shows a pituitary microadenoma. Which of the following additional physical findings is most likely in this patient? A. Dry mucus membranes B. Fine tremor of hands C. Delayed tendon reflexes D. Non-pitting edema E. Hyperpigmentation

E. Hyperpigmentation

A 25-year-old woman comes to the physician because of a 1-day history of profuse watery diarrhea with flecks of mucus that started shortly after she returned from a trip to South America. She has not had no nausea or vomiting. Pulse is 104/min and blood pressure is 105/65 mm Hg. Physical examination shows dry mucous membranes and decreased skin turgor. Stool culture shows gram-negative, comma-shaped, flagellated bacilli. Which of the following is the most likely mechanism of this patient's diarrhea? A. Decreased ability of water absorption in the colon B. Fluid and electrolyte loss due to inflammation of luminal surface epithelium C. Autonomic neuropathy D. Excessive water excretion due to osmotically active solutes in the lumen E. Hypersecretion of chloride due to overactivation of adenylate cyclase

E. Hypersecretion of chloride due to overactivation of adenylate cyclase

Thinking of his risk factors and current presentation, which of the following findings is most consistent with a diagnosis of hepatocellular carcinoma in this patient? A. Endothelium-lined hepatic lesions with blood-filled cavities fed by the hepatic artery B. Low alpha-fetoprotein levels C. History of a glycogen storage disease in childhood D. Central stellate scar surrounded by hyperplastic hepatocytes E. Hypoattenuating lesions with hyperenhancement in the arterial phase and rapid washout in the venous phase

E. Hypoattenuating lesions with hyperenhancement in the arterial phase and rapid washout in the venous phase

A 45-year-old man presents to the clinic because of a 4-months history of intermittent abdominal pain that is worse when he eats and weight loss. Physical examination reveals severe epigastric and right upper quadrant tenderness. On auscultation, active bowel sounds are heard. An upper endoscopy reveals diffused inflammation of the gastric mucosa and 3 duodenal ulcers. An abdominal ultrasound shows a 4 cm irregular mass in the pancreatic tail.Which of the following changes in the gastric mucosa is likely to be found in this patient? A. Diffuse mucosal disruption with hemorrhage B. Diffuse signet ring cells surrounding gastric mucosal glands C. Hyperplasia of Parietal cells with hypersecretion D. Partial squamous metaplasia of gastric mucosal epithelium E. Lymphoplasmacytic infiltrate lamina propria

E. Lymphoplasmacytic infiltrate lamina propria

A 9-day-old male boy is brought to the emergency department because of a 20-minute history of multiple recurrent seizures, characterized by stiffening of the body and laryngospasm . There is no family history of any disease. He was born by a cesarean section at 38 weeks of gestation. His weight, length and APGAR score at birth was normal. Laboratory studies show serum calcium of 6.3 mg/dL(normal ≥ 8 mg/dL). An x-ray of the chest is shown. Which of the following mechanisms is most likely responsible for the clinical features seen in this infant? A. Acquisition of maternal HIV infection at delivery B. Failure of differentiation of pre-B cells into B cells C. Impaired maturation of B cells into plasma cells D. Lack of the gene encoding adenosine deaminase E. Malformation of third and fourth pharyngeal pouches

E. Malformation of third and fourth pharyngeal pouches

A 60-year-old woman comes to the physician with a 1-year history of heartburn and chest pain. It occurs more after meals and increases on lying down. She also has a 9-month history of shortness of breath. Her BMI is 30 (normal 18.5-24.9). Her vitals are normal. Esophageal pH testing shows a drop in pH to below 4.0 (normal- 7.0). Which of the following would most likely be contributing to her symptoms? A. Elevated lower esophageal sphincteric pressure B. Peptic stricture C. Increase in esophageal clearance D. Rapid gastric emptying E. Progressive laxity of the phrenoesophageal membrane leading to hiatal hernia

E. Progressive laxity of the phrenoesophageal membrane leading to hiatal hernia

A 30-year-old woman comes to the physician because of a 2-day history of fever, diarrhea and abdominal pain. She says she has had fever and chills for the past 8 days for which she took acetaminophen, but the fever did not subside. She returned from a vacation in Mexico 8 days ago. Her temperature is 38.5C (101.30F), pulse is 56/min, respirations are 16/min and blood pressure is 120/70 mmHg. Physical examination shows hepatosplenomegaly and erythematous, blanchable, nontender papules on her abdomen, trunk, and the back. Laboratory studies show leucopenia, elevated C-reactive protein, and mildly elevated serum aminotransferases. Which of the following is the most likely etiologic agent? A. Proteus mirabilis B. Vibrio cholerae C. Shigella flexneri D. Salmonella enteritidis E. Salmonella Typhi

E. Salmonella Typhi

A 62-year-old man comes to the physician because of a 5-week history of episodes of non-bloody diarrhea, abdominal pain, flushing around the face and neck. His vital signs are within normal limits. Physical examination shows flushing of the face and a holosystolic murmur heard best in the left midsternal border. An elevated level of which of the following is most likely in this patient? A. Fecal leukocyte B. Prostaglandins C. Serum vasoactive intestinal peptide D. Urinary vanillylmandelic acid E. Urinary 5-hydroxyindoleacetic acid

E. Urinary 5-hydroxyindoleacetic acid

A 25-year-old woman comes to the physician because of a 1-day history of profuse watery diarrhea with flecks of mucus that started shortly after she returned from a trip to South America. She has not had no nausea or vomiting. Pulse is 104/min and blood pressure is 105/65 mm Hg. Physical examination shows dry mucous membranes and decreased skin turgor. Stool culture shows gram-negative, comma-shaped, flagellated bacilli. Which of the following bacteria is most likely the cause of this patient's diarrhea? A. Shigella B. Enterohemorrhagic E. coli C. Salmonella D. Campylobacter E. Yersinia enterocolitica F. Vibrio cholerae

F. Vibrio cholerae

A 44-year-old female presented to the clinic with a 2 weeks history of inconsistent abdominal pain. She describes the pain as being intense and rated as being 8/10 in intensity with 10 being the worst pain she has ever experience. When asked about the location of the pain she rubs the upper part of her abdomen in the middle and right quadrant. She clarifies that pain is not consistently there and would last about 30 minutes when it occurs. The pain does not seem to radiate anywhere. She recalls the pain being aggravated after eating food at breakfast and dinner. She denies any stool changes, vomiting , constipation or diarrhea.PMHx: The patient medical history is significant for obesity, hyperlipidemia, depression and alcoholism. PSHx: NilLab: PendingBased on the history, what are the 3 best differential diagnosis that can be considered in the above case ?Based on the history, what are the 3 best differential diagnosis that can be considered in the above case?

PUD, gastritis, pancreatitis, H. pylori

A 15-year-old boy presents to the emergency room accompanied by his parents because of abdominal pain. One day ago, he had nausea, vomiting, diaphoresis, and malaise after ingesting a large amount of acetaminophen after he was being bullied at school, but he stated that these symptoms resolved. He has a history of epilepsy, for which he is being treated with carbamazepine. Physical examination shows right upper quadrant tenderness and palpable liver 5 cm below the costal margins. Laboratory investigations show serum alanine aminotransferase of 6498 units/L, total bilirubin of 5.6 mg/dL, and INR of 6.8. The anticonvulsant may worsen the outcome of this patient's intentional overdose because of induction of which of the following? a. Cytochrome P450 (CYP2E1)) b. Sulfotransferase (SULT) c. Cytochrome P450 (CYP3A4) d. UDP-glucuronosyl transferases (UGT) e. Cytochrome P450 (CYP1A2)

a. Cytochrome P450 (CYP2E1))

A 28-year-old woman comes to the physician because of fatigue, anorexia, nausea, and abdominal discomfort for the past two weeks. She has mild pruritus, and arthralgia involving the small joints. She has a history of thyroid disease. She does not smoke but consumes about seven beers per week. Physical examination is normal. Laboratory investigations show increased gamma-globulin levels, alanine aminotransferase 60 U/L (normal 10-40), aspartate aminotransferase 200 U/L( Normal 12-38 U/L). Which of the following is the most likely diagnosis? a. Viral hepatitis b. Autoimmune hepatitis c. Hemochromatosis d. Alcohol hepatitis e. Primary biliary cirrhosis

b. Autoimmune hepatitis