T- 18
In a 25-year-old patient who underwent splenectomy, target cells are seen on peripheral smear. These cells are seen due to loss of function of which portion of spleen?
Red pulp
Retrospective study of incidence and outcome of subarachnoid hemorrhage. Incidence is 15 per 100,000 people, mortality is 6 per 100,000 people. Incidence remains constant, case fatality rate?
40%
A sexually active 32-year-old woman has vaginal pain with urination. Pelvic examination show bilateral vesicoulcerative lesions of introitus. Tx?
Acyclovir inhibit viral DNA polymerase by chain termination
28-year-old man with ulcerative colitis, history of partial colectomy, and improved rectal bleeding and diarrhea since then. Meds include mesalamine, hydrocodone and acetaminophen. He says, "I've been taking so much of my opiate prescription that I ran out and stole some from my job." Next step?
Discuss treatment options and a referral for detoxification program
2-month-old female with T 102F, vomiting, diarrhea, dehydration. Exam of stool shows viral particles with wheel-like shape. Properties of virus? Type of nucleic acid/envelop/capsid symmetry
Double-stranded RNA, segmented/no/icosahedral
35-year-old woman pain in left leg 2 days. PE shows deep venous thrombosis. Labs: platelet 200,000, PT 12 (INR 1), PTT 37. Heparin started. Five days later, platelet 120,000. Reason for decreased platelets?
Drug-related antibodies Heparin induced thrombocytopenia: IgG against platelet factor 4 FA 2020
19-year-old woman 2-day history of pain in left index finger. Injured it when catching a ball. PE shows erythema of left index finger. Unable to flex the distal phalanx when proximal interphalangeal joint metacarpophalangeal joints restrained. Xray normal. Injured structure?
Flexor digitorum profundus tendon profound go far - profundus to distal/furthest phalynx
5-year-old boy with motion sickness. Planning vacation to Australia, and wants diphenhydramine for motion sickness. Mechanism of action for motion sickness?
Antagonist at muscarinic-3 (M3) receptors
27-year-old man for psychiatric eval sent by employer because he is "very odd." Is a computer repair specialist and lives alone, Refuses to socialize and has no friends. Extremely preoccupied with science fiction, occult, afterlife. Personality disorder?
Schizotypal Eccentric appearance, odd beliefs or magical thinking Cluster A
8-year-old man comes with cracked lips and peeling sunburned skin. Works as lifeguard. PE shows desquamation of sunburned skin. Lips are dry and cracked. Petrolatum to lips may reduce lip symptoms by which of following effects of the compound?
Barrier
71-year-old man admitted for prostatic resection. Normal mental status. 2 days after surgery, confused and restless. Cannot sleep and restless, seeing little men coming through window. Dx?
Delirium
30-year-old man in bicycle collision and hits right shoulder forcefully. Unable to flex right elbow with decreased sensation to pinprick over right lateral forearm. Brachial plexus lesion?
E (musculocutaneous nerve)
Workbench wiped down with alcohol, successfully inactivates viruses with which characteristic?
Enveloped virion Alcohol-based products disrupt the lipid membrane envelope
Patient with orthostatic hypotension, loose stools for 1 year, and history of type 1 DM. Stool studies are normal. What is the pathophysiological mechanism of the diarrhea?
Motility disorder
30-year-old woman with 2-years of numbness, blanching, and bluish color to ears, fingers and toes after emotional upset or cold exposure. Vitals and PE normal. Avoid taking which drug?
Phenylephrine
14-year-old girl with type 1 diabetes mellitus and 4-hour history of lethargy, confusion, disorientation. Symptoms gradually developed and she did not take her usual insulin dose during a sleepover. HR 110, RR 24 deep and rapid, bp 95/75. Labs: glucose 450, arterial pH 7.15. ABG?
pCO decreased HCO3- decreased Anion gap increase DKA
Double-stranded RNA, segmented/no/icosahedral "wheel-like shape"
rotavirus
cor pulmonale
right ventricular hypertrophy and heart failure due to pulmonary hypertension
Red pulp
the region of the spleen composed of blood-filled venous sinuses and thin plates of splenic tissue (cords), which consist of red blood cells and various white blood cells Filter the blood of antigens, microorganisms, and defective or worn-out red blood cell
VACTERL
vertebral defects, heart defects, renal and limb abnormalities
Studying epithelial repair of small intestine in experimental animal. Wants to identify most active cell division location. Where is this cell activity found?
Base of the crypt
10-day-old male newborn 1-day history red eyes with discharge. Pregnancy uncomplicated but no prenatal care in third trimester. PE bilateral conjunctival injection with water discharge. Cause?
Chlamydia trachomatis b. chlamydia occurs 1-2 weeks after birth c. conjunctivitis from gonorrhea occurs 2-5 days after birth
Cholera toxin catalyzes transfer of ADP-ribose to an arginine residue in stimulatory G protein resulting in inhibition of GTPase activity. Which increases in cells as a result?
Concentration of cAMP
46-year-old woman with 1-week low-grade fever and joint pain. Has chronic headaches and takes ibuprofen several times. PE diffuse maculopapular rash. UA 2+ protein, 10-20 WBC and eosinophils. Renal biopsy would show what?
Inflammatory infiltrates in the interstitium acute interstitial nephritis urine eosinophils + NSAID use + Rash
16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to prescribe an emergency oral contraceptive. The physician on call is not the patient's regular physician and does not dispense emergency contraception for moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to state which of the following?
"I can have one of my colleagues call you back to further discuss your concerns"
17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states, "I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. After reassuring mom, Most appropriate next statement to mother?
"Tell me more about your concerns about your son's height."
Physiologic shunt
-Mismatching of ventilation and perfusion with the lung -Results in insufficient ventilation to provide the oxygen needed to oxygenate the blood flowing through the alveolar capillaries
Girl has chronic cough with thick sputum, abdominal cramps in RLQ, and frequent resp infections. Clubbing of fingers, hyperresonance on chest percussion. Diffuse crackles and scattered wheezes. On xray - diffuse hyperinflation of the right upper lobe. She has a healthy brother. What's the likelihood he is a carrier for the condition?
2 of 3
4-day-old boy with vomiting after breastfeeding. PE shows lethargy and dry mucous membranes. Labs: Na 139, Cl 90, K 7, HCO3 17, Glucose 42, BUN 25, Cr 0.4, 17-hydroxyprogesterone increased. Enzyme deficiency?
21-hydroxylase infancy (salt wasting) or childhood(precocious puberty
During a clinical study of calcium and phosphorus metabolism, a 50-year-old man undergoes series of lab studies. His serum Ca, PO4 and PTH are normal. He is given infusion 2 g Calcium chloride over 2 hours. His serum Ca concentration now is 11.5mg/dl. Compared with pre infusion levels, the serum concentration of which of the following substances is likely to be increased at this time?
24,25-Dihydroxycholecalciferol inactive metabolite preferentially synthesized when normal
25-year-old woman comes for counseling prior to conception. Has seizure disorder on valproic acid. Fetus at greatest risk for drug-related adverse effect during which pregnancy stage?
3 to 8 weeks Neural tube defects Neuropores fail to fuse (4th week)
24-year-old woman overdose on drug X and has serum concentration of 32. Drug X follows first-order kinetics. 6 hours later, the serum concentration is 16. Cannot be moved from intensive care unit until concentration 1.1 or lower. Which is minimum number of hours from first blood sample (32) that patient must remain in icu?
30 hours (5 half lives) b. First Order - Constant Fraction c. Zero Order - Constant Amount
62-year-old with angina pectoris is referred for cardiac catheterization. Patient worried about hospital-associated infection. Studies show 30% of patients require admission after procedure, and 2 percent of admitted patients acquire hospital infection. Patient's risk for infection overall?
6/1000 30% * 2% = .0006
To decrease risk for cv disease 24 yo man begins diet. 1.53 95 kg BMI 32, Intends to lose 16 kg by limiting caloric intake to 2000 cal. to maintain the recommended protein intake (56g day); a balanced decreased in carbs and fat is required (caloric radio of fat and carbs is 30:55). which best describes number of calories that should be provided by fat in this its diet each day?
630 0.3 fat x 2000 = 600 calories (fat) (Fat 30 + Carbs 55+15 = 100)
A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. Results are shown:Recurrent Stroke Rates per 1000 Person-YearsStandard Treatment vs. New Antiplatelet Drug Women .12 .04 Men .24 .08 Overall .18. .06 Based on these results, which of the following is the relative risk reduction in women?
67% .12-.04= .08 .18-.06 = .12 .08/.12 = 67%
71-year old woman with coronary disease and well-controlled hypertension is brought to the physician 2 hours after sudden onset of weakness of her left leg. Her BP 145/85 mmHg. Neurologic exam: weakness and decreased sensation over the left lower extremity. There are no other sensory or motor deficits. Which labeled structure is site of injury?
A (Pre/postcentral gyrus; motor/sensory cortex)
35-year-old man with severe back pain, gained 8 kg in the past 6 months, decreased peripheral vision, compression fracture spine at T10 and L1, healing left rib fracture at T6, imaging shows pituitary macroadenoma. This tumor produces which?
ACTH
75-year-old man comes to the physician because of an enlarging face shoulders and trunk and thinning of his arms and legs. Physical examination shows a large plethoric face, fat pad over the upper thoracic spine and purple striae on the abdomen. Serum studies show undetectable ACTH and an increased cortisol concentration. Administration of low dose dexamethasone would most likely result in which of the following sets of serum findings?
ACTH no change cortisol no change
65-year-old with sudden onset generalized tonic-clonic seizures. Personality change last 6 months; used to be mild mannered and now verbally abusive. CT shows single mass enhances with contrast in right frontal lobe and crosses to left hemisphere through corpus callosum. Dx?
High-grade fibrillary astrocytoma Glioblastoma multiforme- "crosses hemisphere" GFAP +
2-year-old woman has operation for hyperparathyroidism. Three parathyroid glands found but one does not appear in normal superior location on right side. Embryologic event that led to this?
Abnormal migration of endoderm from fourth pharyngeal pouch 4th pharyngeal pouch gives rise to superior parathyroid EAR Tonsils - Bottom to Top
A 25-year-old woman comes to the physician because of a 2-year history of intermittent, diffuse, cramping lower abdominal pain. The pain is usually associated with 2 to 6 days of loose, watery stools, and is typically relieved with defecation. Between these episodes, her stools are normal. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies, including complete blood count, metabolic panel, and thyroid function tests show no abnormalities. A drug targeting which of the following mechanisms of action is most appropriate for this patient?
Accentuation of μ-opioid myenteric plexus receptor Irritable Bowel Syndrome. Loperamide = opioid anti-diarrheal
1. 35-year old man w several episodes of squeezing chest pain gets angiogram... gets IV NE. Question shows a graph of coronary blood flow with a drop after the NE and then a rise. Which substance causes increased total coronary blood flow 1-2 mins after NE?
Adenosine Adenosine and Nitric oxide (NO) increases coronary blood flow
19-year-old woman is admitted to the hospital for antibiotic treatment of meningococcal meningitis. She is stabilized. Three days later, her pulse is 120/min, and blood pressure is 60/30 mm Hg. Physical examination shows bilateral flank tenderness. Serum studies show a sodium concentration of 128 mEq/L, potassium of 5.4 mEq/L, and bicarbonate of 20 mEq/L. Which of the following is the most appropriate next step to determine the cause of this patient's hypotension?
Adrenocorticotropic hormone stimulation test
51-year-old with Graves disease develops ulcerating pharyngitis after 6 months of propylthiouracil. What's the underlying cause of ulcerative pharyngeal disease?
Agranulocytosis (rare side effect of PTU) commonly presents with acute pharyngitis.
55-year-old woman who is a physician has fractured femur during motor vehicle collision. 2 days after admission, has tachycardia, restlessness, diaphoresis, anxiety, seeing "vague shapes" on walls. Dx?
Alcohol withdrawal
67-year-old man with 1 year progressive difficulty writing and walking. Pt is stooped and talks slowly. PE shows bland facial expression, fine resting tremor in both hands, no tremor when moves, walks with difficulty starting and stopping, cogwheel rigidity. Brain tissue histology shown as well as gross cross sections of midbrain both normal and diseased. Substance referred to by arrow. Which Substance?
Alpha-synuclein
67-year-old woman comes to the physician because of a 1-month history of low back pain. She has hypertension well controlled with a thiazide diuretic. Her pulse is 140/min, and blood pressure is 140/85 mm Hg. Physical examination shows tenderness to palpation over the L2-3 vertebrae. Laboratory studies show:Hemoglobin 13.5 g/dLHematocrit 41%Leukocyte count 10,500/mm3Segmented neutrophils 65%Eosinophils 1%Basophils 1%Lymphocytes 30%Monocytes 3%Platelet count 250,000/mm3 Serum electrophoresis shows a monoclonal spike of IgG kappa. A chest x-ray shows cardiomegaly with bilateral pleural and pericardial effusions. An x-ray of the spine shows a lytic lesion. Echocardiography shows an echodense thickened left ventricle and poor diastolic compliance. A photomicrograph of a specimen obtained on myocardial biopsy is shown. Which of the following is the most likely cause of the cardiac findings in this patient?
Amyloid infiltration Multiple Myleoma = monoclonal IgG kappa (light chain) spike on electrophoresis, lytic bone lesions in the spine, cardiomegaly all point to multiple myeloma. Amyloid infiltration- Causes a primary amyloidosis that can deposit in multiple tissues,
1-year-old has numerous infections of skin and oral mucosa since birth. Infections slow to respond to antibiotic therapy. T 100.4F. PE multiple erythematous lesions of skin some with superficial ulceration. WBC 21,000 77% segmented neutrophils, 6% bands, 14% lymphocytes and 3% monocytes. Biopsy shows no neutrophils in dermis or epidermis. Culture of lesion grows Staphylococcus aureus. Defective?
An integrin Leukocyte adhesion deficiency = integrin defect Neutrophils are unable to adhere and migrate to infection sites, instead accumulating in blood.
A 68-year-old man comes to the physician because of a 1-month history of light-headedness and tightness in his chest with exertion. He adds that the pain is worse after arguing with his wife, and the symptoms resolve with rest. He has a past history of lower gastrointestinal bleeding; evaluation at that time was negative on upper endoscopy and colonoscopy. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 15/min, and blood pressure is 110/75 mm Hg. Physical examination shows no abnormalities. His hemoglobin concentration is 8.2 g/dL, and hematocrit is 24%. Test of the stool for occult blood is positive. An ECG shows no abnormalities. Repeat colonoscopy shows no abnormalities. Which of the following is the most likely cause of this patient's gastrointestinal symptoms?
Angiodysplasia Hematochezia is the passage of fresh blood per anus Tortuous dilation of vessels hematochezia
48-year-old man 2-month increasing abdominal girth and inability to achieve an erection. Smoked 1 pack cigarettes for 20 years and drank 1 pint of liquor daily. Vitals normal. PE shows scleral icterus, spider angiomata, gynecomastia, ascites, and prominent umbilical venous pattern. Testis small. Cause of gynecomastia?
Failure of liver to degrade estrogen Alcoholic - cirrhosis - Liver injury
45-year-old man bmi 26, total cholesterol 200, HDL 50, triglycerides 550. Which drug to prescribe?
Fenofibrate Triglycerides 550 MOA = Activates PPAR-αto induce HDL synthesis
10-year-old boy with 4 days nosebleeds and easy bruising. Three weeks ago, upper respiratory tract infection. PE ecchymoses on upper and lower extremities. Labs shows hemoglobin and leukocyte count normal, and decreased platelet count. Bone marrow smear shows increased megakaryocytes. Mechanism of dz?
Antibodies directed against glycoprotein (Gp) IIb/IIIa complex Immune thrombocytopenia
34-year-old man with a 3-month history of a progressive rash on his feet. Rash is not itchy or painful. A photograph of feet is shown = Kaposi Sarcoma. HIV+. In addition to HAART, which of the following pharmacotherapy is most appropriate?
Antineoplastic Endothelial malignancy most commonly affecting the skin, mouth, GI tract, respiratory tract. Associated with HHV-8 and HIV Kaposi typically presents in HIV pts earlier, under a 500 CD4 tcell count, bartonella angiomatosis presents <100
38-year-old man 1-week shortness of breath with exertion, light palpation of carotid artery shows upstroke is abnormally brisk and downstroke falls precipitously. Cause of finding?
Aortic Regurgitation water hammer pulse = brisk upstroke and downstroke in the carotid
68-year-old man with 3 days of increasingly severe chest pain, shortness of breath, stridor, hoarseness, difficulty swallowing and nonproductive cough. Long-standing hx of hypertension. Smokes 2 packs of cigarettes for 45 years. T 99 F, pulse 80, rr 15, bp 160/94. PE shows visible pulsation above the manubrium of the sternum and displacement of the trachea to the right. Murmur second right intercostal space. Dx?
Aortic aneurysm male smoker with HTN + deep chest pain and pulsatile mass = AA all day long
98-year-old woman who lives with daughter and grandson comes for routine exam with type 2 diabetes and hypertension but no complaints. She has had 14-lb weight loss since last visit 3 months ago. BMI 15. PE shows multiple ecchymoses in various stages of healing upper extremities and torso. Physician should ask?
Are you safe at home?
34-year-old man with herniated lumbar intervertebral disc. Laminectomy and removal of hernia scheduled. CT scan of vertebrae shown, which is surgical entrance location into neural canal?
Area labeled D
A transcription factor that activates expression of HMG coA reductase is identified, this TF is initially synthetized as a large precursor protein, with 2 membrane spanning domains. The transcriptional domain is released by proteolysis when the membrane has a decreased cholesterol concentration. The precursor protein is most likely initially produced in which of the following labeled area on this labeled diagram of a hepatocyte?
Area labeled F Endoplasmic Reticulum
Gy67-year-old man who eight months ago dx with primary lung carcinoma involving adrenal glands, liver, and bone. Had 17.6-lb weight loss during 3 months. PE shows cachexia and significant muscle wasting. Intracellular components increased in patient's muscle cells?
Autophagic vacuoles
26-year-old man comes in 2 hours after injuring arm skiing. Sensation to pinprick absent over lateral aspect of shoulder. Xray of right shoulder shown (fracture of surgical neck of humerus). Nerve damaged?
Axillary fracture of the surgical neck of the humerus. axillary nerve and the posterior circumflex humeral artery Radial does lateral elbow musculocutaneous does lateral forearm
A 25-year-old man is admitted to the hospital because of severe crush injuries to the chest and extensive burns over 30% of his body surface area. Three hours later, he develops tachypnea and dyspnea. Arterial blood gas analysis on room air shows a decreased Po2 and Pco2. A chest x-ray shows bilateral interstitial and alveolar infiltrates. The patient is intubated and mechanically ventilated. Damage to what will preclude restoration?
Basement membranes
68-year-old man with creatinine 2.3 due to chronically increased hydrostatic pressure in Bowman space. Cause?
Benign prostatic hyperplasia
64-year-old with non-Hodgkin lymphoma and 3-day history of abdominal pain and nausea. T 99.7F, HR 100, bp 130/80. Abdominal exam tenderness of flanks and lower quadrants. BUN 34 and creatinine 3.8. CT shows bilateral hydronephrosis and lymphadenopathy compressing ureters. Tx to improve renal function?
Bilateral stents in the ureters
25-year-old man just returned from work as worker from Africa begins oral chloroquine therapy for malaria caused by Plasmodium vivax. His initial therapeutic response is good, but he develops recurrent parasitemia 2 months later. Which of the following best explains the recurrence?
Chloroquine is ineffective on the exoerythrocytic malaria tissue stages P vivax/ovale, add primaquine for hypnozoite Hypnozoite = inactive dormant - only in P. Vivax and Ovale
An experimental animal is created that has a defect in an innate gastrointestinal defense mechanism. Organism is found to have decreased HCl prod. After 2 months on biopsy gastric fundus and body show decreased mucosal thickness and hyperplasia of enterochromaffin like cells. This resembles?
Chronic Gastritis mucosal inflammation leading to atrophy
21-year-old woman with 10-days difficulty walking. Two years ago had loss of vision in left eye which improved. Neuro exam shows decreased visual acuity in left eye with pallor of optic disc. Has past-pointing on a finger-nose test. Broad-based gait. MRI shows brain lesions in white matter of cerebellum. Pathogenesis?
CD4+ T lymphocytes are activated by myelin basic protein Multiple Sclerosis increased IgG level and myelin basic protein in CSF Oligoclonal Bands
.66-year-old woman is brought to the emergency department by her daughter because of a 2-day history of fever, flank pain, pain with urination, and nausea. Ten days ago, she was admitted to the hospital for similar symptoms and was diagnosed with acute pyelonephritis. She was discharged with instructions to take oral ciprofloxacin after a 3-day course of intravenous ciprofloxacin resulted in improvement. She also has hypertension, hyperlipidemia, and osteoporosis. Current medications also include alendronate, calcium carbonate, ezetimibe, hydrochlorothiazide, and simvastatin. Her temperature is 39.1°C (102.4°F), and blood pressure is 130/80 mm Hg. The most likely cause of this patient's current condition is an interaction between her current oral antibiotic and which of the following medications?
Calcium carbonate antacid - chelate tetracyclines and fluoroquinolones
68-year-old man with alcoholism comes for fever, chills and productive cough of purulent sputum for 3 days. Blood cultures positive. Gram stain: gram-positive, lancet-shaped diplococci. Vaccine is against which bacterial component?
Capsular polysaccharide Strep pneumonia
Investigator studying immune response to fungi. Fungi express beta-glucans on cell surface and that triggers innate immune response. Which tx decreases glucan expression?
Caspofungin Inhibit cell wall synthesis by inhibiting synthesis of β-glucan
52-year-old with chronic pancreatitis is deficient in which enzymes that causes inability to digest triglycerides?
Colipase cofactor for pancreatic lipase,
3-year-old boy 7 days after dx with severe chronic diarrhea due to Giardia. Immunological studies show peripheral leukocytes that express both CD3 and CD4 and fail to express CD40 ligand. Based on this, the immunoglobulin isotype that predominates has which biological properties?
Complement activation Hyper IgM syndrome; without CD40 ligand, T cells are unable to provide the secondary signal to activate B cell class switching. prevents IgM from switching into IgD, G, E and A, and thus an accumulation of IgM - hence the name "hyper IgM" - and deficiency in the rest Complement activation= IgM and IgG
58-year-old man comes to physician for benzodiazepine prescription for situation at work. Feels anxious and thinks he can complete last 2 years of work if anxiety decreases. Gives 1-month regimen of benzodiazepine. Wife calls, "My husband got fired! I know it was because he was taking too much of that drug you gave him. Didn't you know he had history of alcoholism?" Initial action?
Contact the patient to discuss the situation Reach out to patient
36-year-old woman diagnosed with HIV. Two months ago, started antiretroviral therapy with efavirenz, emtricitabine, and tenofovir. Labs: CD4 352 and undetectable HIV viral load. Two months ago, CD4 count was 158 and plasma HIV viral load was 5500. Next step?
Continue efavirenz, emtricitabine, and tenofovir with no changes If it ain't broke don't fix it. Typical antiretroviral HIV therapy regime is: 3 NRTIs OR 2 NRTIs AND 1 NNRTI OR 1 Protease inhibitor OR 1 Integrase inhibitor
52-year-old female with a history of breast cancer who received 4week course of radiations 6 months ago comes for follow-up. Exam shows no cancer recurrence. Respiratory Rate 26/min. CT chest shows b/l atelectasis in upper lung fields. Primary pathophysiological cause?
Contraction radiation therapy caused fibrosis and the myofibroblasts "contract" during fibrosis
68-year-old man with a 10-month history of shortness of breath and swelling of his feet, family history of cardiovascular disease. He smoked 2 packs of cigarettes daily for 50 years. Pulse 80/min, rr 24/min, BP 150/80. PE: 3+ pitting edema of lower extremities. Diffuse, scattered wheezes are heard bilaterally on auscultation of the chest. Grade 2/6 pansystolic mumur heard best at lower left sternal border, which increases on inspiration. Maximal impulse palpated in sub-xiphoid area. S1 and S2 sounds are distant. Liver span 14 cm. Diagnosis?
Cor pulmonale Backfilling of blood from the lungs into the R ventricle is stretching out the R side (dilation) and also remodeling the heart via hypertrophy
54-year-old man with normal renal functions gets a heart transplantation. One year later, bp 170/110 and serum creatinine 2.1. Which immunosuppressive drug caused these findings?
Cyclosporine ADR: hypertension and nephrotoxicity
A 70-year-old woman comes to the physician for a routine pelvic examination. During speculum examination of the vagina and cervix, the Valsalva maneuver causes a bulge of the anterior vaginal wall. Which of the following is the most likely cause of this finding?
Cystocele prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms
73-year-old man has poor appetite and lost 25 lb over 4 months. Labs show normochromatic normocytic anemia. Xray of chest shows 2-cm perihilar mass. Biopsy shows small cell carcinoma of lung. Which is responsible for weight loss?
Cytokine effect Cachexia = increased pro-inflammatory cytokines Mediated by TNF-α, IFN-γ, IL-1, and IL-6
25-year-old-man who has a history of facial flushing and rapid heart rate each time he consumes a small amount of alcohol participates in study of alcohol intolerance. Molecular analysis shows presence of a lysine (K487, oriental variant) for glutamate (E487, native variant) substitution in aldehyde dehydrogenase. Kinetic characteristics of the enzyme variants shown:(NAD+))E487 Km 37 KCat 180K487 Km 5600 kCat 9.5based on these findings, which of the following is the most likely cause of this man's condition?
Decreased catalytic efficiency of K487 Catalytic efficiency is defined as Kcat/KM
56-year-old man comes with vague right-sided flank pain and 7-lb weight loss over past 6 weeks. No recent trauma or back strain. Urine is darker than usual over 2 weeks. Renal ultrasound shows 1.5-cm solid mass in upper portion of right kidney. Urine shows 50 erythrocytes, 6 leukocytes, no bacteria. Dx?
Renal Cell Carcinoma hematuria, palpable masses, 2° polycythemia, flank pain, fever, weight loss
1-year-old boy with rash for 2 weeks. 10th percentile for height and weight. PE scaly, seborrheic eruption over scalp, palms, back, diaper region and soles of feet. Generalized lymphadenopathy and hepatosplenomegaly. Xray of skull shows osteolytic lesions. EM biopsy of skin shows tennis racket-shaped bilamellar granule in cytoplasm. Immuno studies show CD1a antigen expression. Abnormal cells in patient are derived from which cell?
Dendritic cells Langerhans cells (LC) are tissue-resident dendritic cells of the skin, and contain organelles
83-year-old with arteriosclerosis undergoes repair of infrarenal abdominal aortic aneurysm. Graft extends just below the renal arteries to the bifurcation of the aorta. Which organ will lose primary blood supply and rely on collateral circulation?
Descending colon
Male newborn delivered at 28 weeks, neonatal respiratory distress syndrome, ABG shows decreased pH, decreased Po2 increased PCO2. A deficiency in which of the following most likely caused the disorder?
Dipalmitoylphosphatidylcholine
82-year-old woman comes to the physician because of constant severe lower abdominal pain and fever for 24 hours. Laparoscopic examination shows severe diverticulosis and perforated diverticulitis. In spite of appropriate therapy, she dies 2 days later. Liver autopsy shown. Which of the following is the primary component of the material shown on the hepatic surface (IMAGE)?
Fibrin Fibrin activated - perforated - for coagulation Fibrin deposition local defense mechanism
22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse is 33/min, and blood pressure is110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular ejection fraction of 75%. Which of the following best describes the findings in this patient?
Eccentric Hypertrophy ECCentric - ECCpands ventricle CONcentric - CONstricts ventricle
20-year-old woman with palpable lump in right breast 4 months, no pain, swelling or nipple discharge. Lump is smooth, firm, round, mobile, nontender, well delineated. No skin change. Dx?
Fibroadenoma
48-year-old recently diagnosed with lupus and difficulty working as schoolteacher because of severe pain and swelling of joints. Current meds include prednisone, hydroxychloroquine, and oxycodone for pain. Best action to encourage patient to adapt to illness?
Encourage the patient to participate in a support group for persons with her condition
50-year-old woman with COPD comes with 3 months of progressive shortness of breath. Physical shows JVD, loud pulmonary component of S2. Pulmonary function tests show FEV1:FVC ratio of 20% and decreased diffusing capacity for carbon monoxide. Which is decreased in pulmonary vascular smooth muscle?
Endothelial nitric oxide synthase production
35-year-old woman with 3-month progressive shortness of breath with exertion. RR 26. Physical shows jvd and prominent a wave. Lungs clear. Cardiac exam shows loud pulmonic component of S2 and right-sided S4 gallop. Increased pulmonary expression of what?
Endothelin-1 pulmonary hypertension = imbalance between vasodilation substances and vasoconstrictors.
8-year-old girl is brought to the physician by her mother because of a 3-week history of poor feeding chronic diarrhea and pale foul-smelling stools. Mother says the symptoms began with colicky abdominal pain following introduction of solid food to the infant's diet. History of gluten sensitivity. 60th percentile for length and 25th percentile for weight. Which cell is dysfunctional?
Enterocyte Celiac disease, an autoimmune intolerance to gliadin leading to enterocyte damage and subsequent malabsorption
45-year-old woman dx with cholelithiasis. She asks why abdominal pain is intermittent and not constant. Pain is produced when gallbladder contracts against gallstone obstructing cystic duct. Where is hormone released from that causes gallbladder contraction?
Enteroendocrine cells of the small intestine (CCK) CCK = produced by the I cells in the duodenum and jejunum in response to fatty acids and amino acids. CCK - cause gallbladder to contract
66-year-old man dies 7 days after myocardial infarction. Gross of heart shown (perforated interventricular wall). Histology?
Erythrocytes, cellular debris, macrophages, and early granulation tissue 0-24 hours Dark Mottling 3-14 days - Macrophages, then granulation tissue at margins
2-year-old boy 2-day history of fever, sore throat, rash. T 101.7 F (38.7 C). Widespread, red, sandpaper-like rash on extremities. Purulent exudate over tonsils. Dx streptococcus pyogenes (group A) infection. Cause of skin findings?
Erythrogenic toxin causes a Toxic shock-like syndrome Fever, Rash, Shock, Scarlet Fever. Streptococcus Pyogens (group A strep)
67-year-old man with 3 months fatigue and shortness of breath. Vitals HR 90, RR 15, bp 150/98. PE conjunctival pallor. Labs: hb 8.5, hct 26%, MCV 90, RDW 14.4% (N=13-15%), Cr 2.9, Ferritin 144, Iron 24, Transferrin saturation 23% (N=20-50%). Besides iron supplementation, most appropriate tx?
Erythropoietin
Newborn is found to have a cervical rib. Transformation of seventh cervical segment to thoracic identity. Which is true of HOX gene alteration?
Expression of a HOX gene normally expressed only caudal to C7
72-year-old woman comes to the physician because of a 6-month history of increased bruising on her forearms. She appears alert and well nourished. Physical examination shows extensive wrinkling, scaly erythematous patches on the face, and irregularly shaped brown macules on the face and forearms. There are ecchymoses in various stages of healing on both forearms; the ecchymoses are more numerous on the right side. Laboratory studies, including a complete blood count and coagulation studies, are within the reference ranges. S he has noticed no bleeding from her gums after brushing her teeth. Which of the following is the most likely cause of the ecchymoses in this patient?
Extensive solar elastosis Actinic elastosis, also known as solar elastosis, is an accumulation of abnormal elastin (elastic tissue) in the dermis of the skin, or in the conjunctiva of the eye, which occurs as a result of the cumulative effects of prolonged and excessive sun exposure, a process known as photo=aging
]21-year-old woman with 2-days history of urinary frequency and pain with urination. T 39 C (102.2 F), pulse 125, bp 96/60. Urine grows gram-negative bacteria. Virulence factor for adherence to bladder?
Fimbriae Ecoli
35-year-old from group home comes for worsening behavior for 2 weeks. He believes CIA is spying on him through television set. Reports hearing voices in hall outside and that CIA now plans to kill him. Appears disheveled with unkempt hair and poor hygiene, difficulty answering questions because listening to internal stimuli. Mental status exam will show which?
Flattened affect Schizophrenia Positive—hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior Negative—flat or blunted affect, apathy, anhedonia, alogia, socialwithdrawal
25-year-old woman with polycystic kidneys and 3-month history of weakness, fatigue, headaches, hypertension, loss of appetite and itching. Cr 4. Labs
HCO3- decreased - no resorption PO4 increased, PTH increased
Patient making sexual advances towards physician. Appropriate measure?
Have a chaperone join them for the remainder of the examination Inappropriate behavior - sexual advances towards physician
33-year-old man dx with epilepsy age 10 years. Most recent generalized tonic-clonic was 5 years ago. Medication was adjusted. Current meds include carbamazepine. He's never had any collisions while driving his motor vehicle. Patient's status with respect to driving?
He is medically qualified to drive most of the states a 1-2-year free seizure period is required for epileptic patients to get their license
A 70-year-old man comes with skin blistering for 1 week. No oral lesions. Physical shows tense bullae in joint folds of upper and lower extremities. Biopsy shows subepidermal blister formation. Immunofluorescence microscopy shows antibodies against proteins at the dermal-epidermal junction. Target by antibodies?
Hemidesmosome Subepidermal blister formation + Tense Bullae
55-year-old man northern European descent with 2-month weakness, altered skin color, bilateral knee pain. Siblings have type 2 diabetes and cirrhosis. PE bronzed skin, hepatomegaly, arthritis. Increased saturation of transferrin and ferritin. Liver biopsy increased iron content and cirrhosis Greatest risk?
Hepatocellular carcinoma hemochromatosis (bronzed skin, hepatomegaly, arthritis, increased iron content and cirrhosis) Cirrhosis -> hepatocellular carcinoma
\19-year-old man with gastrointestinal bleeding. Laparotomy done and 5-cm blind outpouching on antimesenteric side of terminal ileum 15 cm from ileocecal valve resected. 99mTc-pertechnetate scan Pathology shows?
Heterotopic gastric mucosa 99mTc-pertechnetate scan = Meckel Diverticula
6-year-old girl with 15-minute history of severe shortness of breath. Diagnosed with throat tumor 3 years ago. RR 32. PE nasal flaring. Laryngoscopy shows multiple raised, finger-shaped lesions from vocal cords and epiglottis. Lesions excised and shows finger-shaped fibrovascular cores lined with benign squamous epithelium. Causal virus?
Human papillomavirus, type 6 Laryngopapiloma
65-year-old man with 4-hour history of intermittent severe pain in flank area radiating to genital region. History of hypercalciuria and renal calculi. Drug decrease the urinary excretion of calcium?
Hydrochlorothiazide
. 22-year-old nulligravid woman has menses that occur at irregular 26- to 32-day intervals. Height 5 ft 4 in and weighs 187 lb. BMI 32. PE shows mild hirsutism and velvety brown, thickened skin at the base of the neck and around axillae. Patient has which condition?
Hyperinsulinemia b. PCOS c. Acanthosis Nigrans
Heart of 76-year-old woman shows concentric enlargement of left ventricle. Micro exam shows enlarged myocardial cells with large nuclei. Dx that causes this cardiac enlargement?
Hypertension b. concentric ventricular hypertrophy = increased afterload c. eccentric ventricular hypertrophy = increased preload d. chronic HTN, Friedreich ataxia
48. 66-year-old man with 1-month hx of nonproductive cough and 6 months shortness of breath. Bilateral end-inspiratory crackles heard. CT chest shows diffuse reticular opacities at periphery and bases of lungs. Micro exam of biopsy shows patchy interstitial fibrosis, several fibroblastic foci and no granulomas. Dx?
Idiopathic pulmonary fibrosis honeycomb lung
65-year-old man with cancer of cecum found to have metastatic lesion to right lobe liver. Venous route of mets?
Ileocolic --> superior mesenteric --> portal --> right hepatic branch of portal right lobe of the liver = all drain into the Superior Mesenteric Vein. left sided structures drain into the Inferior Mesenteric Vein.
32-year-old woman has new neuro finding while being tx for acute infection of sphenoid sinus. Imaging shows cavernous sinus thrombosis on left. Additional finding most likely?
Inability to abduct the eye
27-year-old primigravid woman at 18 weeks gestation comes to physician for routine prenatal examination. The uterus consistent in size with 18-week gestation. Ultrasonography shows a male fetus. The collecting system and pelvis of the left kidney is dilated and the renal cortex appears compressed. The left and right ureters are not dilated. The right kidney appears normal. Amniotic fluid volume is normal. Which causing renal finding in this fetus?
Incomplete recanalization of proximal ureter ureteropelvic junction, - LAST to canalize and can lead to congenital obstruction.
21-year-old man loses 15% total blood volume 2 minute after motor vehicle collision. Finding most likely?
Increased sympathetic nerve traffic to sinoatrial node
55-year-old man with elevated LDL cholesterol is prescribed lovastatin. This treatment would result in which adaptive responses at the cellular level?
Increased transcription of HMG-CoA reductase
20-year-old woman at 27 weeks' gestation is admitted to the hospital because of a 12-hour history of intense uterine contractions occurring every 8 minutes. Her membranes ruptured 32 hours ago. Her temperature is 39.1°C(102.4°F), and pulse is 115/min. Physical examination shows tenderness of the uterus. Pelvic examination shows a closed cervix that is not effaced. The fetal heart rate is 210/min. Which of the following is the primary stimulus for her uterine muscle contractions?
Inflamed maternal decidua release of prostaglandin Preterm Premature Rupture Of Membrane
63 yo man with mild emphysema has smoked 1 pack for 45 years sudden headache, myalgia and rising temperature. A dry cough develops, with chill and chest pain. Examination of gram stain of sputum disclose neutrophils, but bacteria are not evident. An X-ray of the chest is consistent with severe pneumonia. A culture of sputum is negative, but culture of bronchoscopy specimen on a highly specialized bacteriologic medium yields gram negative rods. The identity of these bacteria is confirmed by staining with specific fluorescent antibodies. The patient respond therapy with macrolide Ab. Mechanism?
Inhalation of aerosol from an environmental source (Legionella) - Aerosol transmission
2-year-old girl with febrile seizure. PE shows nuchal rigidity and bacterial meningitis suspected. LP and immediate abx therapy planned, but parents unavailable for consent. Next step?
Initiate the procedure and treatment without consent Implied consent in emergency
5-year-old girls with severe leg pain 1 day after fell off sled. Immigrate to USA from Iceland. Has had three bone fractures since birth. Parents are vegan and don't give dairy products. PE shows tenderness, swelling, and limited range of motion of left lower extremity. Xray shows fracture of fibula. Pt has vitamin deficiency that affects which of the following?
Intestinal calcium absorption Vegan vitamin D deficiency
15-year-old girl comes with lack of improvement of facial acne. Tried topical clindamycin and benzoyl peroxide PE severe acne vulgaris. Says, "Please help me." She has never been sexually active. Tx?
Isotretinoin
.34-year-old man burned hands firing pots 3 months ago. He has no pain during or after burn. PE shows mild atrophy of arms and hands, absence of deep tendon reflexes in upper extremities, and decreased pain and temperature sensations in C4 to T1 dermatomes. Touch is preserved. Dx?
Syringomyelia Cape like distribution of loss of pain and temperature Touch preserved - lack of degeneration in the DCML.
35-year-old woman passed out while washing dishes. Began to feel weak and dizzy, husband shares with nursing staff history of bulimia nervosa, and has been binging more frequently. Suspected she has been vomiting. Labs of patient?
K+ decreased HCO3- increased/ Anion Gap normal pH increased' Metabolic Alkalosis > loss of HCL Anion Gap Normal = NOT a MUDPILE HCL, NA+ = out the mouth
8-year-old boy with pain on back and head since he fell off swing. Tender 2.5cm swollen mass over right occiput. CT shows osteolytic and soft-tissue mass in skull with inward displacement of dura. Biopsy shows sheet-like infiltrate of pale eosinophilic cells with bean-shaped nuclei. Cells positive for CD1a. Electron microscopy of cells shows Birbeck granules. Abnormal cell type?
Langerhans cells
48yo man with possible hypertension. based on 20 measurements, his average diastolic pressure is 94mmHg, SD is 8mmHg. If only four measurements were made rather than 20, which of the following statements would best describe the width of the 95% CI with regard the mean blood pressure
Larger Width of confidence interval larger with fewer cases Width will become smaller - with more cases
17-year-old boy with syncopal episode, fever, nausea, muscle aches, progressive confusion. T 103.5F, palpable bp 80. PE rash on lower extremities. WBC 26,000. Blood and CSF cultures grow oxidase positive, gram negative diplococcus. Brother with similar infection at same age. Immune disorder?
Late component of complement deficiency
Full-term newborn in respiratory distress. Imaging shows abdominal contents in left pleural cavity. Maldevelopment of which structure led to diaphragm defect?
Left pleuroperitoneal membrane Diaphragmatic hernia
65-year-old woman with 6 hour Hx fever and shaking chills. 4 hours ago, she took 325 mg aspirine tablets. Temp 39.4 C, pulse 96/m, respiration 18/m and blood pressure 102/60 mmHg. Physical examination shows marked tenderness bilaterally in the costovertebral areas. Lab studies show: Hb 13 g/dlHt 39% Leukocyte count 32,.000/mm3 Urine ph 6 Nitrites 4+ Leukocyte esterase 4+ A photograph of wright stained peripheral blood smear, which the most likely cause this patient leukocytosis?
Leukemoid reaction
57-year-old man with alcoholism dies of klebsiella pneumonia. Abscess cavities filled with purulent exudate on autopsy. Pattern of necrosis in lung tissue?
Liquefaction Abscess (proteolytic enzymes from neutrophils liquify tissue
50-year-old man with pulmonary embolus. Treated with intravenous heparin. 24 hours later, warfarin added. Day 2, partial thromboplastin time is 52 seconds (control 26 sec), and prothrombin time is 12 seconds (control 12.1 sec; INR = 1). Best explanation for normal prothrombin time and INR?
Long half-life of factor II (prothrombin) Factor II (prothrombin) has the longest half-life Warfarin acts on Factor II, VII, IX, X Heparin = factor IIa inhibited by ATIII - thus low PTT is prolonged
. 35-year-old with Chagas disease and 2-hour history of moderate chest pain. 4.4 lb weight loss in 2 months. Vitals stable. Barium swallow shows dilated esophagus with beak-like narrowing at lower esophageal sphincter (LES). Biopsy shows?
Loss of neurons in myenteric plexus failure of LES relaxation, causing distal stenosis of the LES ("bird's beak" sign) proximal dilation indicative or achalasia
7-year-old boy is about undergo an appendectomy. An intravenous catheter needs to be inserted, but the patient is fearful of being stuck with needle. The most appropriate anesthesia administered by mask to anesthetize this patient quickly would have which of the following characteristics?
Low blood solubility --> faster onset --> faster recovery Lipid solubility determines potency
45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No mass45-year-old woman with 4-month joint pain, muscles aches and fatigue. Had a renal calculus 6 months ago and had cholecystectomy 1 year ago. Appears fatigue, depressed, there is mucosal pallor. No masses palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation?s palpated in neck. Labs: erythrocyte count 3 million, K+ 4, Cl- 106, Ca2+ 13, phosphorous 2.7, alk phos 125. Technetium-99m scan shows 1.2 cm nodule in neck. Mutation?
MEN1 Pituitary, Pancreatic, Parathyroid - 3ps = MEN 1 Parathyroid tumor releasing PTH, increasing Ca and ALP.
30-year-old woman with a long-standing history of pelvic inflammatory disease has surgical resection of a scarred segment of a fallopian tube. Which of the following inflammatory cells is most likely to be found in the resected specimen?
Macrophages
48-year-old woman with gradual onset back pain past 2 weeks. No trauma. Doesn't smoke cigarettes, drink alcohol or use drugs. Hemogram, serologic studies and urinalysis unremarkable. X-ray of spine shows two lytic lesions, in T-10 and L-1. Dx?
Metastatic carcinoma of the breast Prostate, Breast >Kidney, Thyroid, Lung
45-year-old homeless man found unconscious. Breath smells of alcohol. Vitals stable. PE shows bronzed skin and spider angiomata on chest. Labs: hemoglobin 10, hematocrit 30%, MCV 110, WBC 9000, platelets 160,000, ferritin 200, b12 500, folate 20. Blood smear shows hypersegmented neutrophils and 3+ oval macrocytes. Labs?
Methylmalonic acid: normal Homocysteine: increased
8-year-old boy with persistent disruptive behavior. Teacher says he's in "constant motion" and never completes assignments. Treated in ER several times because of skateboarding injuries. Tx?
Methylphenidate sxs in 2+ settings--> school, and ER for skateboarding injuries Tx= methylphenidate MOA = stimulates NE and DA
4-year-old boy with fatigue and irritability for 2 months. Family visited rural Louisiana 5 months ago and ran around barefoot. Conjunctivae are pale. Labs shows normal wbc with 15% eosinophils. Stool prep shows parasite egg (picture). Cause of fatigue?
Microcytic anemia Necator or Ancylostoma = running around barefoot (entrance site for laravae hookworms suck blood from the intestines leading to iron deficiency anemia. Parasite in US - unable to absorb nutrient like iron
24-year-old man with 3-day progressive numbness of both feet ascended to thighs. Last 24 hours, numbness and tingling of hands. PE ataxic gait. Deep tendon reflexes diminished in upper extremities and absent in knees and ankles. Vibration and joint position absent in fingertips and feet bilaterally. Mild weakness distal upper extremities ad moderate weakness of lower extremities. Structure involved?
Myelinated primary afferents Most common subtype of Guillain-Barré syndrome
63-year-old man 2-week sensation of fullness in left upper quadrant. Has lethargy and shortness of breath. 20-lb weight loss during 3 months. PE shows pallor. Spleen tip palpated. Labs: hb 9, hct 27%, wbc 4000, serum uric acid 15. Peripheral blood smear numerous erythrocytes with abnormal shapes and sizes, nucleated erythrocytes and myelocytes. Aspiration of bone marrow dry tap. Biopsy shows thickened bony trabeculae with increased reticulum. Dx?
Myelofibrosis "Bone marrow cries because it's fibrosed and is a dry tap"
A study is conducted to compare the incidence of myocardial infarction in patients undergoing two different types of angioplasty or an operative procedure to manage single-vessel coronary artery disease. A total of 1000 patients are enrolled. Through a chance process, 500 are assigned to undergo the operative procedure, 250 are assigned to undergo one type of angioplasty, and 250 are assigned to undergo a second type of angioplasty. All patients are followed for 3 years to determine the incidence of myocardial infarction. Which of the following best describes this study design?
Randomized clinical trial Study design with randomly assigned experimental and control groups is still a randomized clinical trial In cohort study, you don't assign the exposure, you just simply follow them (risk factors).
Researching new cancer drug, effective at killing rapidly dividing cells, in mice caused profound myelosuppression. In patients, most appropriate to follow which when at risk for infectious complications?
Neutrophil counts
Randomized controlled trial evaluating tx of acute otitis media. No statistically significant differences found between infants receiving the antibiotic and those with standard tx. Which aspect results in type II error?
Number of subjects in the study
35-year-old man with several episodes of dizziness and fainting during the past 2 months. Father and several paternal uncles died suddenly. PE and lipid studies normal. Angiography shows no coronary artery blockage. ECG shows prolonged QT. Decreased activity in which of following causes this?
Outward (delayed) rectifying potassium channel QT is correlated with the repolarization (Phase III),
52 yo man is brought to er 30min after the onset of chest pain and shortness of breath. He had played tennis all day and he does not remember how much fluid he had consumed. His temperature is 36.7 oC, pulse 122min, respirations 28min and BP 90/50 mmHg. PE shows dry skin and decreased capillary refill. An ECG and evaluation of cardiac enzymes show no abnormalities. Which of the following findings in the nephron best describes the tubular osmolarity, compared with serum in this patient?
PCT Isotonic, Macula Densa hypotonic Medullary Collecting Duct hypertonic
18-month-old girl with 2 day progressive cough and hoarseness. T 102.2F, HR 88, RR 24, bp 100/70. Oxygen saturation 95%. PE mild erythema of oropharyngeal and laryngeal mucosa no exudate, harsh, barking cough heard. Improves within 4 days. Cause?
Parainfluenza
70-year-old man with early morning awakening, decreased energy, difficulty concentrating, anhedonia, psychomotor retardation, depressed mood for 3 months. He had myocardial infarction and non sustained ventricular tachycardia 2 years ago. Tx?
Paroxetine SSRIs are first line for depression. Avoid TCAs in elderly = anticholinergic side effects.
After operation, 65-year-old patient has lung region that is under ventilated but well perfused. Which increases?
Physiologic shunt - Mismatching of ventilation and perfusio - insufficient ventilation to provide the oxygen needed to oxygenate the blood
6-year-old boy with 5-day history of intermittent vomiting and 3-month hx of progressive clumsiness. Can no longer ride bicycle and difficulty getting out of car. Funduscopic exam shows bilateral papilledema. Neuro exam shows impaired upward gaze and pupil response to light. Walks shuffling gait. CT shows enlarged lateral and third ventricles and a 2-cm mass. Location of mass?
Pineal gland Pinealoma Parinaud syndrome (compression of the tectum --> vertical gaze palsy) Obstructive Hydrocephalus
35-year-old primigravid woman 36 weeks' gestation with 6-hour history of heavy vaginal bleeding. No prenatal care. Ultrasound shows placenta over cervical os. Can't stop bleeding and has cesarean. Dx?
Placenta previa Opening of Cervical OS - preview of Placement
Investigator studying vancomycin-resistant strain of Enterococcus faecalis. Ten generations created. Culture inoculated and resulting bacterial colonies are screened for vancomycin resistance. Vancomycin-sensitive colonies observed at frequency of one per 100 cells. Mechanism of decreased vancomycin resistance?
Plasmid loss
70-year-old woman comes to the physician because of increasingly severe pain in the right knee over the past 3 months. She has fallen repeatedly. She has a 10-year history of symptomatic osteitis deformans. She has bowed tibia and tenderness of the proximal right tibia. an X ray shows a fracture of the proximal tibia with elevated periosteum and sunburst pattern. an x-ray of lungs shows pulmonary nodules of various sizes. which of the following findings is most likely on biopsy?
Pleomorphic neoplastic cells producing new woven bone Osteosarcoma histological appearance. Paget disease is one of risk factor
Persons are at risk of influenza are vaccination every year because of antigenic variation, which can be drift (minor) or shift (major). Mechanism of antigenic shift?
Reassortment viruses with segmented genomes (eg, influenza virus) exchange genetic material. 2 viruses making a combo virus - 2 genomes
56-year-old exposed to possible chemical attack. Respirations labored, diaphoresis, excessive lacrimation, increased salivation, muscle strength 2/5, urinary and fecal incontinence. Besides atropine, another tx?
Pralidoxime
Prevalence of high-grade cervical intraepithelial neoplasia in unscreened population is 5%. Prevalence in population with negative Pap smear results is as high 0.2%. Prevalence decreases, which also decreases?
Predictive value of a positive test result Higher prevalence - higher predictive vales - positive, predictive, prevalance
45-year-old woman with joint pain due to rheumatoid arthritis comes for infective treatment with over-the-counter agents. Initiate disease-modifying antirheumatic drug (DMARD). Delayed onset of action of DMARD, so physician prescribes another until DMARD is effective. Drug?
Prednisone You can use three classes of medication to treat RA: NSAIDs, corticosteroids, and DMARDs. NSAIDs and corticosteroids have a short onset of action, while DMARDs take a while to take effect.
35yo F has congestive cardiomyopathy and pitting edema. Her serum urea nitrogen concentration is 25mg/dl and serum creatinine is 1.8mg/dl. Furosemide therapy is started. After 5 days, labs show: Na 130K 4.5Cl 90HCO 30 BUN 85 Creatinine 2.2 Albumin 3Urine specific gravity 1.023, rbc 0 wbc0 sediment none Urinary fractional excretion of sodium is less than 1%. Explanation?
Prerenal azotemia After the addition of furosemide, her BUN/Cr ratio went up to 38 and Fraction Excretion of Na < 1
Child with XXY karyotype, genetic studies showed he received the extra "x" from his father. An error of chromosome segregation occurred during anaphase at which of the following stages of spermatogenesis in the patient's father?
Primary Spermatocyte Most problems with cell division occur in anaphase of Meiosis I. Meiosis 1⇒ from primary to secondary spermatocyte Meiosis 2 → Secondary to spermatid'
23-year-old woman g1p1, not felt well since delivery 2 weeks ago; ongoing fatigue, inability to breast-feed, light-headedness in upright position. Pregnancy complicated by preeclampsia and required cesarean delivery, after she required blood transfusions because of hypotension. PE appears lethargic. HR 80, BP 100/50, HR standing 85, BP standing 86/44. Hb 11.6, hct 36%. Serum hormone concentrations?
Prolactin decreased ACTH decreased TSH decreased Aldosterone increased Sheehan syndrome c. severe bleeding requiring transfusions + inability to breastfeed (decreased prolactin d. All hormones from pituitary - destroyed
29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12. She is 5.3 Ft and weighs 86kgs. BMI 34. She is evaluated and a diagnosis of PCOS is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment. Which of the following will ensure adherence?
Provide follow ups to monitor progress in attaining her goal Improve Doctor patient relationship - add next appointment
34-year old man is brought to the ER semiconscious and combative. In addition to sedation, a short-acting neuromuscular blocking agent is administered for intubation to prevent aspiration. Within a few seconds after admin of the drug, he has transient muscle fasciculations in his face; he develops generalized paralysis within 1 minute. Forty five minutes after completion of the procedure, he is still paralyzed. A genetic abnormality of which of the following enzymes is the most likely cause of his unusually slow recovery from paralysis?
Pseudocholinesterase Succinycholine - Acetylcholine Agonist increased in system --> longer anesthesia recovery
58-year-old man comes to the physician because of a 4-year history of recurrent cough productive of increased sputum. Use of over-the-counter cough suppressants has not resolved his symptoms. He has smoked 2 packs of cigarettes daily for 35 years. He has no family history of lung disease. His temperature is 37°C (98.6°F), pulse is 72/min, and respirations are 18/min. Physical examination shows cyanosis. Diffuse wheezing is heard on auscultation. Which of the following pulmonary cell types is most likely to be abnormal in this patient?
Pseudostratified columnar epithelial cells Smoker, Cyanosis - chronic bronchitis squamous metaplasia
45 yr old man with SOB on exertion x 6 months, nosebleeds since adolescence, 2 pics: clubbing + hemorrhagic lesions in tongue (IMAGE), inhaled albuterol doesn't improve his symptoms. Cause of symptoms?
Pulmonary AV shunting osler weber rendua hereditary hemorrhagic telangiectasia
58-year-old woman with 6-month shortness of breath and chronic nonproductive cough. 2-year history difficulty swallowing, joint stiffness, diffuse tightening of skin on face, neck, shoulders, arms, fingers. Sensitivity to cold weather, fingers turn white. Hx of esophageal reflux. Biopsy showed atrophy of epidermis and deposition of collagen throughout dermis with loss of dermal appendages. PE cutaneous ulceration, clawlike flexion deformity, decreased joint mobility. At risk for which pulmonary disorder?
Pulmonary hypertension systemic sclerosis/CREST complications = interstitial fibrosis, pulmonary HTN CREST - Calcinosis, anti-Centromere antibody, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly Telangiectasia
4. Man comes to doc for cast removal. Fracture of left humerus that required open reduction, internal fixation, cast immobilization. Muscle strength is 2/5 with extension of elbow and 1/5 with extension of wrist and fingers. Patient most likely sustained a fracture at (which location in humerus)?
Radial groove (radial N. is the extensors of arm, wrist and fingers)
12-year-old boy with mother concerned about enlarged left breast and family history of breast cancer. Left breast is slightly larger than right, nipple mildly tender. Penis slightly enlarged and pubic hair curling and beginning to darken at base. Best next step?
Reassure the mother that physical findings are not uncommon for his age
60-year-old man for routine health examination. Has had normal blood pressure measurements. BP today 170/95mmHg. Physical examination shows no other abnormalities. Serum show hypokalemia and metabolic alkalosis. Plasma renin activity and serum aldosterone concentrations are increased. Following the administration of captopril, there is a marked increase in plasma renin activity. Which of the following is the most likely cause of the findings in this patient?
Renal artery stenosis Decreased renal perfusion (one or both kidneys) Increased renin Increased angiotensin ---HTN
32-year-old man with HIV infection follow up examination, has been treated with HAART for the past 6 years HIV plasma viral load has been undetectable. HIV viral load now increase, antiretroviral resistance suspected. HIV genotype analysis confirms that the virus has resistance mutations, which of the following most likely mutated?
Reverse transcriptase and protease HAART therapy = reverse transcriptase and protease enzymes.
18-year-old woman get general anesthesia for wisdom teeth extraction. After 5 minutes, gets hypertonicity of skeletal muscles and increased body temperature. The treatment is a drug that decreases?
Sarcoplasmic Ca release Malignant hyperthermia- rare, life-threatening condition in which inhaled anesthetics or succinylcholine induce severe muscle contractions and hyperthermia Dantrolene - TX- Prevents release of Ca2+from sarcoplasmic reticulum of skeletal muscle by inhibiting the ryanodine receptor
16-year-old boy who frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. After counseling about safe sex, best next step?
Schedule next routine examination Normal behavior for a teen boy
3-week-old male newborn with recurrent vomiting after feeding since birth, and eager to feed after vomiting. Abdominal exam shows firm, mobile mass in epigastrium to right of midline. Dx description?
Single Primary Development Defect pyloric stenosis - olive shaped mass - stand-alone defect
17-year-old boy brought by mother with concern that puberty is delayed. When mother leaves room, patient states, "I'm fine. I don't know what's the matter with her. She wants me to be tall like my dad." Patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI 23. Sex development is Tanner stage 4. After reassurance, Most appropriate next statement to mother
Tell me more about your concerns about your son's height
67-year-old woman with atrial fibrillation with sudden onset severe abdominal pain. Ex-lap shows embolus in superior mesenteric artery with complete occlusion of middle colic artery. Ischemic changes where?
Small intestine, ascending colon, and part of the transverse colon Midgut = major duodenal papilla (of the duodenum) to the proximal 2/3 of the transverse colon.
35-year-old woman with infertile, receive injection of contrast material into cervix. On hysterosalpingogram (shown), contrast material (indicated by arrows) also seen in peritoneal cavity, which explain this finding?
Spillage of contrast which normal fallopian tubes - leak contrast - a gap between fallopian tubes and ovary. no spillage, that means there is a blockage = infertility
32-year-old woman brought in after 10-foot fall from ladder. PE suggests severe hemorrhage and shock. Xray shows fracture of left ninth and tenth ribs. Organ injured?
Spleen
28-year-old woman comes to the physician because of a 4-day history of palpitations, severe neck pain, fatigue, and malaise. Her pulse is 120/min and regular. Physical examination shows a diffusely tender, mildly enlarged thyroid gland. There is no exophthalmos. Serum studies show a thyroid-stimulating hormone concentration of 0.01 μU/mL. Which of the following is the most likely diagnosis?
Subacute granulomatous thyroiditis de quervain's = pain
47-year-old woman with irregular, raised, multicolored dark lesion on left forearm with frequent sunlight exposure. Biopsy shows malignant pigmented cells. Worst prognosis with involvement of which layer?
Subcutaneous tissue highly vascularized and has larger blood vessels than the dermis, leading to a higher risk of metastasis and worse prognosis (TNM staging system) Deeper than basement membrane - no longer carcinoma in situ
30. 35-year-old woman with 2-day history of blistering lesions on sun-exposed face, arms and hands. Recurrent episodes of skin lesions over several years. Taking oral contraceptives for 15y. PE shows fluid-filled vesicles and bullae. Labs: AST increased, ALT increased, total porphyrin increased, urine uroporphyrin III increased. Precursor to uroporphyrin?
Succinyl CoA
28-year-old man infertility, weight lifter and takes anabolic steroids. Mechanism of infertility?
Suppression of Gonadotropins Anabolic steroid use suppresses the Hypothalamic-Pituitary-Gonadal axis which will down regulate GnRH. FA 2020 p636
62-year-old woman with 3-day hx of fever, shaking chills, and left flank pain. Dx acute pyelonephritis and treated with ciprofloxacin. Five days after, sudden onset watery diarrhea and lower abdominal cramps. T 100.9 F, pulse 80, rr 18, bp 124/88. PE moderate tenderness to palpation in lower quadrants especially on right and increased bowel sounds. Stool is brown and occult blood negative. Next step?
Test of the stool for Clostridium difficile toxin b. Pseudomembranous colitis c. Couple days after Ciprofloxin
An investigator conducts a meta-analysis of three genome-wide association studies of Crohn Disease. The studies encompassed 3200 cases and 4800 controls, all of European descent. The initial studies identified 11 significant loci with odds ratios above 1.3 and 1.5; the combined meta-analysis identified an additional 21 loci with odd ratio of 1.1 to 1.3. It is estimated that the 32 loci identified explain about 10% of the variance in disease risk with 2 loci accounting for 2% of the variance. Previous studies of twins indicated a 50% heritability rate for Crohn's disease. Which of the following best explains these results?
The identified loci account for a relatively small part of the variance
14-year-old girl with 4 months of heavy menstrual flow. Menarche at 13 with regular intervals. History of frequent nosebleeds and easy bruisability. Father has problems with nosebleeds and clotting. PE shows mild gum bleeding and ecchymoses. Labs: hb 8.2, hct 24.6, platelet 250,000, bleeding time 10, PT 14 (INR 1.5), PTT 60. Dx?
von Willebrand disease prolonged bleeding time + prolonged PTT =
20-year-old woman with 2-week fever, shaking chills, headaches, fatigue, and joint and muscle pain. Spent summer workin as lifeguard in Long Island, New York. Has splenectomy for motor vehicle collision 6 years ago. T 102.4 F. Peripheral blood smear shows small intraerythrocytic rings. Polymerase chain reaction for Plasmodium is negative. Causal organism from bite of?
Tick
63-year-old man with abnormal blood pressure. 6 months ago, bp was 135/85. Today bp 170/98. Bruit heard over left renal artery. CT angios hows left arterial stenosis. Labs?
Total peripheral resistance increased, Plasma renin activity increased, Serum aldosterone concentration increased renal artery stenosis.
45-year-old man with hypertension not compliant with medications. bp 160/100. Cardiac exam shows apical impulse displaced laterally, loud S2 and S4 gallop. Echo shows thickening of left ventricular wall. Mechanism of change in cardiac muscle?
Transcription factor c-Jun: increased beta-myosin heave chain: increased endothelin: increased
69-year-old woman with 3-week history of muscle cramps, weakness, abdominal pain, and constipation. Hypertension treated with metoprolol and hydrochlorothiazide for past 4 months. Labs show hypokalemia. Which drug should be added?
Triamterene (potassium-sparing) = Keep your SEAT Spirolactone, Eplenone Amiloride, Triametrene Work in Distal Tubule Collecting Duct
63-year-old woman with 2-week history of daily episodes of severe, lancinating, left-sided facial pain. Pain lasts 30 to 60 seconds and shoots down ear along jawline. Precipitated by chewing or brushing teeth. Dx?
Trigeminal neuralgia
4-year-old male with recurrent UTIs, left kidney found small and non functional; right is normal. Nephrectomy is done, and the picture shown (dilated ureter and renal calyx). Microscopic exam of kidney will show which?
Tubular atrophy tubulointerstitial fibrosis of the kidney
Study designed to test the effectiveness of a new drug in the treatment of endometriosis, 100 women randomly assigned to one of two groups. 48 of women receive new drug, 52 receive standard therapy. The primary purpose of this method of assigning patients to different groups is to create which of the following?
Two groups with similar underlying characteristics
39-year-old man with 1-week of red spots on shins, joint pain and fatigue. PE shows purpura over lower extremities. Liver palpated 4 cm below costal margin. Labs: WBC 10,000, AST 142, ALT 154, hepatitis C virus RNA positive, anti-hepatitis C virus antibody positive, cryoglobulins positive, C4 120 (N=350-600), urine protein 4+, urine RBC numerous. Hypersensitivity reaction?
Type III (immune complex-mediated)
32-year-old man with X-linked recessive disease has deafness, hematuria and progressive renal failure. Protein abnormality?
Type IV collagen Alport Syndrome Can't See, Can't pee, Can't hear a Bee
2-month-old boy well child exam, mother with no concerns. 25th percentile for length and 30th percentile for weight. Cardiac exam shows blowing holosystolic murmur best heard at lower left sternal border. Cause?
Ventricular septal defect Blowing Holosystolic Murmur at Lower left sternal border
60-year-old man 1 day of fever, chills, confusion and memory loss. Returned from Gulf coast where he walked barefoot. Hx of severe cirrhosis and portal hypertension. T 39C (102.2 F), RR 22, bp 90/48. Physical shows early blister formation on right lower extremity. Blood culture: gram-negative, lactose-fermenting organism. Bug?
Vibrio vulnificus
35-year-old woman with fever and sharp chest pain for 3 days. T 101.3F. Friction rub heard. All causes of secondary pericarditis ruled out. Cause of primary pericarditis?
Virus
65-year-old woman comes to the physician because of a 1-week history of a swollen, painful left knee. Her temperature is 38°C (100.4°F), and blood pressure is 110/65 mm Hg. Examination of the left knee shows erythema and swelling of the joint and decreased range of motion. A photomicrograph of synovial fluid obtained by arthrocentesis is shown. This patient's synovial fluid most likely contains which of the following?
Uric acid needle shape right in the middle was a uric acid crystal
Physiologic dead space
portion of the tracheobronchial tree that does not participate in gas exchange
25-year-old woman with fatigue for 3 wks and intermittent fever for 7 days, had teeth cleaned a month ago, no abx for prophylaxis, and had rheumatic fever as child and endocarditis 4 y ago. PE shows 2/6 murmur, ultrasound shows abnormal mitral valve. Photo of growth from blood cultures shown (GP cocci in chains). Characteristic of causal organism?
]Greening reaction on blood agar alpha hemolysis (green)
45-year-old man comes to physician for follow up after appendectomy. There is mild scleral icterus and well healing surgical incision. Lab values show Total bilirubin 3.2 Direct: 0.2 Indirect 3 mg/dL Dx?
a. Gilbert Stress related - Mild jaundice with increased unconjugated in an older fellow is decreased UDP-glucuronyltransferase activity.
1. 36-year-old F with 2 week history of fatigue, bleeding of the gums, and bone pain. Physical examination shows pallor, hepatosplenomegaly, and ecchymotic lesions over extremities. Labs:Hb 8g/dlHt 25%Leukocytes: 36,000segm neutr 4%eosinophils 4%lymph 6%mono 6% promyelo 80%platelets 25,000Polymerase chain reaction test shows an mRNA corresponding to the retinoic acid receptor- alfa/promyelocytic leukemia fusion gene resulting from a reciprocal translocation of chromosomes 15 and 17. Treatment w/ all-trans retinoic acid is started. In response to the therapy, the fusion protein will most likely attract which of the following proteins to form a pre-transcriptional complex?
a. Histone acetylase b. Histone acetylation allows for relaxation of the DNA e. Histone Acetylation makes DNA Active f. Histone Methylation Mostly Makes DNA Mute.
33-year-old woman who three weeks ago, underwent oophorectomy for epithelial ovarian cancer. Recommends adjuvant chemotherapy with paclitaxel. Mechanism?
a. Inhibits microtubule disassembly "taxes STABILIZE the economy"
4-month-old boy with 1-day respiratory distress. Has progressive weakness and difficulty feeding for a month. RR 50/min. PE shows enlarged tongue and generalized hypotonia. Increased lactate, pyruvate, glucose, and uric acid. CXR shows cardiomegaly. Biopsy of skeletal muscle shows increased glycogen. Enzyme impaired?
alpha-1,4-Glucosidase Pompe Disease (Type 2) Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase)
17-year-old boy in septic shock unresponsive to ADH (vasopressin). Treat is discontinued, and high-dose dopamine in started. Which receptors are stimulated?
alpha1-adrenoreceptors low doses d1 = dilates renal vessels medium b1 agonist = ionotropic and chonotropic high doses a1 agonist = vasoconstriction
39-year-old man with polycystic kidney disease has 6-month history intermittent blood in urine. T 98.6 F HR 100 RR 24 BP 160/90. Urea nitrogen 100, creatinine 8. UA shows blood. Arterial blood gas shows?
pH 7.22 pCO2. 28 HCO3- 11 Uremia: part of MUDPILES Bad kidneys = Can't reabsorb HCO3 "base" > Metabolic Acidic with respiratory compensation
18-year-old woman comes 12 hours after ingesting 100 aspirin tablets in suicide attempt. PE shows tachypnea. Labs?pH/pCO2/HCO3-
pH 7.32 pCO2 15 HCO3 8 aspirin overdose (early) = Resp Alkalosis aspirin overdose (Later) = Metabolic acidosis HCO3- should also be less than normal (22-28) 12 hours = Late Stages
4-year-old boy (pedigree shown) has clumsy gait for past year. Exam calf hypertrophy and proximal muscle weakness. Creatine kinase increased. Muscle biopsy shows loss of muscle tissue, regenerating muscles fibers and fibrosis. Maternal uncle had similar findings and died at 15 years. Patient's sister is pregnant. Ultrasound identifies male fetus. Probability fetus has disorder?
¼ boy you only look at half, so the chance of him having it is 1/2.so 1/2 * 1/2= 1/4
