MCQs

A 55-year old man fractures his ankle attempting to replicate the latest dance fad he has seen his children do. He is otherwise fit and well and is haemodynamically stable. The fracture requires open reduction and internal fixation. The trauma registrar has said that he needs to be nil-by- mouth from midnight, however the operating list is always changing and new emergencies may come in. There are at least three cases that are likely to get done before him. Your request that he have breakfast as he is likely to be done later in the day is met with derision. He will need physiological fluid replacement when he is nil-by-mouth. He weighs 70 kg. Which of the following regimens is closest to physiological needs? ជ្រើសមួយ៖ 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose with 20 mmol potassium in 24 hours 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose with 20 mmol potassium in 24 hours 1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose in 24 hours 3 L Hartmann's in 24 hours 2 × 1 L 0.9% normal saline with 20 mmol potassium and 1 L 5% dextrose in 24 hours

1 L 0.9% normal saline with 20 mmol potassium and 2 × 1 L 5% dextrose with 20 mmol potassium in 24 hours

At which of the following ages does separation anxiety usually first manifest?

8-9 months

The father of a 13-year-old boy asks if his son's adult height can be predicted. The peak veloc- ity of growth during adolescence averages which of the following?

9-10cm

The most common congenital infection is infection with cytomegalovirus, affecting 3/1000-4/1000 livebirths. Of those babies infected, approximately what percent are normal at birth and develop normally?

90%

What five-year survival rate does a Breslow thickness of <1 mm melanoma correspond to? ជ្រើសមួយ៖ 60-75 per cent 95-100 per cent 80-96 per cent 75-80 per cent 50 per cent

95-100%

Which of the following is characteristic of Hirschsprung's disease? A. Constipation is the most frequent presenting feature. B. Severity of the symptoms corresponds with the extent of bowel involvement. C. Acetylcholinesterase activity is decreased in the aganglionic segment. D. The proximal colon is most commonly affected. E. It presents most commonly in young adults.

A. Constipation is the most frequent presenting feature.

Apatient with a known family history of multiple endocrine neoplasia (MEN) I, now presents with intractable ulcer disease. Which of the following statements about his condition is most accurate? A. Diarrhea is a frequent complaint. B. Tumors are rarely multiple. C. Tumors are rarely malignant. D. An elevated fasting gastrin level is diagnostic for the Zollinger-Ellison syndrome. E. CT is useful in localizing the tumor in greater than 75% of patients.

A. Diarrhea is a frequent complaint.

A 59-year-old White male with a 40 pack-year history of smoking presents to your clinic complaining of three prior episodes of a "shade passing over his left eye" over the last 2 months. He reports that last week he experienced some weakness in his right arm, which resolved after 5 minutes. Appropriate management and counseling for this patient includes which of the following? A. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography. B. Explanation to him that he has had a stroke and will be referred to a neurologist for management. C. The most common cause of strokes in these patients is related to decreased blood flow. D. Presence of a carotid bruit confirms the diagnosis and may lead to operative intervention without the need for imaging studies. E. The presence of a 50% stenosis in the right carotid artery should lead to bilateral surgical repair.

A. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography.

A60-year-old woman presents with an abnormal cluster of microcalcifications on a routine mammogram, and undergoes a needle-localized excisional biopsy. The pathology is shown in Figure. When counseling the patient regarding her surgical options, which of the following statements would be correct? A. Modified radical mastectomy differs from a Halsted mastectomy in that the pectoralis major is spared in the modified radical approach. B. Modified radical mastectomy differs from Halsted mastectomy in that an axillary lymphadenectomy is not performed in the modified radical approach. C. The anatomic limits of the modified radical mastectomy include the sternum medially and the anterior border of the serratus anterior muscle laterally. D. Injury to the thoracodorsal nerve during mastectomy results in a "winged scapula." E. Lymphedema occurs mainly as a complication of the Halsted radical mastectomy and should not be seen after modified radical mastectomy.

A. Modified radical mastectomy differs from a Halsted mastectomy in that the pectoralis major is spared in the modified radical approach.

A 60-year-old Asian male presents with early satiety and 40-lb weight loss over 3 months.Upper endoscopy shows an irregular mass in the antrum of the stomach. He follows up in the clinic a few days later, and you see that the results of the endoscopic biopsies are suggestive of a gastric lymphoma. Which of the following is true regarding this condition? A. The incidence of gastric lymphoma is increasing. B. Obstruction, perforation, and bleeding are common presenting symptoms. C. Upper endoscopy with biopsy is highly accurate for diagnosis. D. Gastric involvement of systemic lymphoma is best treated with gastric resection. E. Survival rates are dismal with overall prognosis similar to that seen in gastric adenocarcinoma.

A. The incidence of gastric lymphoma is increasing.

A 26-year-old man is brought into the emergency room via ambulance, minimally responsive to questioning or examination. According to his girlfriend, he has a history of major depressive disorder as well as alcohol dependence. He was found unconscious with a suicide note and many empty beer bottles. She also believes that he had taken "some other drug" that he purchased from a local drug dealer. Which of the following substances found in urine toxicology would be the most dangerous in this patient? A. barbiturate B. cannabis C. cocaine D. opiate E. PCP

A. barbiturate

After being informed of the various choices, she decides to proceed with medication. Which of the following medications is most useful for tobacco cessation? A. bupropion (Wellbutrin) B. fluoxetine (Prozac) C. mirtazepine (Remeron) D. trazodone (Desyrel) E. venlafaxine (Effexor)

A. bupropion (Wellbutrin)

A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SICU). There is concern for primary nonfunction of the allograft. Which of the following is a sign of this? A. coagulopathy with an INR of 2 B. normalizing albumin level C. hyperglycemia requiring an insulin drip D. initial rise of transaminases E. high urine output

A. coagulopathy with an INR of 2 (sign of liver dysfunction (': hypoglycemia, coagulooathy, acid-base, hyperkalemia, elevated ammonia ..)

Which of the following is a commonly used mechanism for reducing medical errors in hospitals? A. confidential peer review B. national hospital accreditation C. departmental grand rounds D. longer work shifts for employees to promote continuity of patient care E. random drug testing

A. confidential peer review

Which of the following structures can be found outside of the spermatic cord during a hernia repair? A. direct hernia sac B. indirect hernia sac C. vas deferens D. testicular artery E. ovary

A. direct hernia sac

Bupivacaine is a local anesthetic agent that is much more potent and the duration of action of which is considerably longer than procaine. Possible reasons for this difference include which of the following? A. higher partition coefficient for bupivacaine than for procaine B. covalent binding to the receptor site C. lower protein binding of bupivacaine than procaine D. decreased rate of metabolism of procaine compared to bupivacaine E. bupivacaine constricts blood vessels

A. higher partition coefficient for bupivacaine than for procaine

A patient presents with a new neck mass. On examination, she has a palpable thyroid nodule and a palpable cervical lymph node on the same side. Needle biopsy of the thyroid nodule shows amyloid in the stroma. The treatment for this patient is which of the following? A. total thyroidectomy and modified neck dissection B. resection of the involved thyroid lobe, isthmusectomy, and removal of the palpable lymph node C. total thyroidectomy and radiation therapy D. resection of the involved lobe and part of the contralateral lobe, isthmusectomy, and removal of the palpable lymph node E. radioactive iodine administration

A. total thyroidectomy and modified neck dissection

A 43-year-old man presents with sudden right arm and leg weakness. He is normotensive. CT demonstrates a substantial haematoma in the left frontoparietal region. What is the most likely diagnosis of this patient? ជ្រើសមួយ៖ Dural AV fistula rupture Pituitary apoplexy Arteriovenous malformation rupture Hypertensive intracerebral haemorrhage Berry aneurysm rupture

AV malformation rupture

Eight days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a patient begins to leak 2-3 L of greenish fluid per day through the right corner of his bilateral subcostal surgical incision. He is afebrile and has no clinical signs of an acute abdomen. At surgery, a feeding catheter jejunostomy was placed, through which the patient has been receiving 3 L/day of elemental diet with a caloric content of 1 cal per mL, and 1 g nitrogen per 100 cal. The nursing staffs have rigged a very effective collection device for the fluid that is leaking through the wound, and the skin around the site is well protected. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ Surgical reconstruction of die gastroduodenostomy No changes in the present therapeutic plan Immediate discontinuation of the jejunal feeding, and replacement by 5 L/day of IV 5% dextrose-half normal saline Surgical drainage of the operative area Addition of 2-3 L per day of IV Ringer's lactate

Addition of 2-3 L per day of IV Ringer's lactate (The patient obviously has developed a fistula at the operative site, but there are no signs that the gastrointestinal contents are spilling into the abdomen (no signs of an acute abdomen) or colecting inside a pocket (no fever). Thus, we can provide general support and wait for the fistula to close.)

A mother calls you frantic because she has just been diagnosed with chicken pox. She delivered 7 days ago a term infant that appears to be eating, stooling, and urinating well. The child has been afebrile and seems to be doing well. Which of the following is the most appropriate step in management? ជ្រើសមួយ៖ . Advise the mother to continue regular well-baby care for the infant . Isolate the infant from the mother . Administer varicella-zoster immunoglobulin to the infant . Hospitalize the infant in the isolation ward . Administer acyclovir to the infant

Advise the mother to continue regular well-baby care for the infant

A6-month-old who is failing to thrive is brought to your clinic. Tests reveal hepatosplenomegaly, muscle weakness and atrophy, hypotonia, and decreased deep tendon reflexes. Blood tests reveal that the infant has normal glucose levels. Biopsy of the liver reveals initial stages of cirrhosis due to the accumulation of an abnormal glycogen with few branch points, whose structure resembles amylopectin. The clinical and laboratory results presented are indicative of which glycogen storage disease? . von Gierke disease (type I glycogen storage disease) . McArdle disease (type V glycogen storage disease) . Tarui disease (type VII glycogen storage disease) . Cori or Forbes disease (type III glycogen storage disease) . Andersen disease (type IV glycogen storage disease)

Andersen disease (type IV glycogen storage disease)

A 16-year-old nulligravid high school student is on your afternoon office schedule for a "talk visit." She was seen last year by one of your colleagues for an initial GYN evaluation. She is healthy and has no medical problems. Today she tells you that she and her new boyfriend had intercourse the night before, and the condom they were using broke She tells you that earlier in the day she had called her family doctor, who wouldn't call in a prescription because it was "against his personal beliefs." Your response should be which of the following? A. Prescribing health care providers must always prescribe it upon patient demand. B. It is within his right to decline giving treatments he deems outside his belief system, but he is ethically obliged to help her find a provider who does dispensePlan B. C. Plan B is available over the counter for all patients. D. You will report him to the state medical board. E. In situations regarding pregnancy, the physician is entitled to follow his personal ethical beliefs and has no obligation to assist a patient in seeking care that is outside of these beliefs.

B. It is within his right to decline giving treatments he deems outside his belief system, but he is ethically obliged to help her find a provider who does dispensePlan B.

1. A22-year-old male presents to the emergency department (ED) with complaints of right-sided chest pain and dyspnea. He has no other significant medical history. There is no history of trauma. On examination, he has a pulse of 95, BP of 110/70, and SpO2 of 95% on 2 L. A chest x-ray reveals a large right pneumothorax. Which of the following statements is true? A. Since the patient is hemodynamically stable, he can be observed with oxygen supplementation, pain control, and serial chest x-rays. B. The patient is likely to have a tall, thin habitus. C. This condition is probably due to small lacerations in the apex of the right lung. D. His risk of recurrence is 10%. E. Recurrences are usually on the contralateral side since adhesions prevent recurrence on the ipsilateral side.

B. The patient is likely to have a tall, thin habitus.

You are seeing a 48-year-old female in followup in your clinic. She originally presented for evaluation of a suspicious nonpalpable lesion in her right breast that was seen on her annual mammogram. A stereotactic core biopsy was done. She now returns to your office to review the results of the pathology report that confirms the presence of lobular carcinoma in situ (LCIS). How do you counsel her at this time? A. Tamoxifen can prevent this cancer from spreading but may increase your risk of developing cancer in the other breast. B. You can consider nonoperative treatment with close observation, annual mammograms, and semiannual clinical examinations. C. The recommended treatment is a right breast mastectomy. D. Further staging workup at this time will include a chest x-ray and bone scan. E. Because you are at such high risk for future cancers, bilateral mastectomies should be performed to prevent this from happening.

B. You can consider nonoperative treatment with close observation, annual mammograms, and semiannual clinical examinations.

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following would lead to the classification of this patient's infection as "complicated?" A. a history of recurrent UTIs B. a diagnosis of type II DM C. the patient's gender D. a history of undergoing a laparoscopic appendectomy 1 month ago E. a postvoid residual volume of 25 cc

B. a diagnosis of type II DM

A30-year-old separated female with borderline personality disorder is brought in by her roommate after she admitted to feeling suicidal and taking several handfuls of "an old prescription" some hours ago. Her vitals demonstrate a slight fever, elevated BP, and tachycardia. On physical examination, her pupils are dilated, she has a tremor, and she complains of "seeing scary faces." She also has noticeably dry mucous membranes. Which of the following medications did this patient most likely ingest? A. alprazolam B. amitryptyline C. oxycodone D. risperidone E. tranylcypromine

B. amitryptyline

Which additional of the following would best help in the determination of the etiology of this patient's nephrotic syndrome? A. fractional excretion of sodium B. anion gap C. estimation of glomerular filtration rate D. fractional excretion of urea E. split 24-hour urine for protein

B. anion gap

A74 year-old widowed man presents for evaluation to his physician. He has a history of several episodes of major depression, with one prior hospitalization many years ago although he cannot remember the medication he was prescribed. He complains of 3 months of depression, crying spells, terminal insomnia, poor appetite with weight loss, anhedonia, and passive suicidal ideation without plan. His medical history is significant for hypertension, peripheral vascular disease, hypercholesterolemia, and unstable angina. He is currently prescribed diltiazem, aspirin, metoprolol, and simvastatin. Which of the following antidepressants would be the most appropriate treatment option? A. amitriptyline (Elavil) B. citalopram (Celexa) C. fluoxetine (Prozac) D. paroxetine (Paxil) E. phenelzine (Parnate)

B. citalopram (Celexa)

A74 year-old widowed man presents for evaluation to his physician. He has a history of several episodes of major depression, with one prior hospitalization many years ago although he cannot remember the medication he was prescribed. He complains of 3 months of depression, crying spells, terminal insomnia, poor appetite with weight loss, anhedonia, and passive suicidal ideation without plan. His medical history is significant for hypertension, peripheral vascular disease, hypercholesterolemia, and unstable angina. He is currently prescribed diltiazem, aspirin, metoprolol, and simvastatin. Which of the following antidepressants would be the most appropriate treatment option? A. amitriptyline (Elavil) B. citalopram (Celexa) C. fluoxetine (Prozac) D. paroxetine (Paxil) E. phenelzine (Parnate)

B. citalopram (Celexa) Citalopram and sertraline are not believed to considerably inhibit P450 enzymes, so in this patient with polypharmacy, either would be appropriate first choices

The modern history of the protection of human research subjects began in the twentieth century in response to human experimentation which occurred during World War II. The Nuremberg Military Tribunal set forth initial basic standards for the conduct of research which ultimately became known as the Nuremberg Code (1947/1948). In subsequent years, these recommendations have been modified and expanded to reflect various aspects of medical ethics in biomedical and behavioral research. These international ethical guidelines include the Declaration of Helsinki (1964), the Belmont Report (1979), CIOMS (1982), and the Common Rule (1991). The concept of beneficence in the Belmont Report emphasizes the importance of which of the following? A. establishing institutional research boards (IRBs) B. maximizing benefits and minimizing harms to research subjects C. ensuring independent ethical review of research D. ensuring scientific validity of research E. including patient advocates on scientific advisory boards

B. maximizing benefits and minimizing harms to research subjects

Which of the following is a contraindication to sentinel lymph node biopsy in breast cancer? A. clinically negative axillary examination B. multicentric disease C. lesion under the nipple D. history of previous breast biopsy E. patient preference for breast conservation

B. multicentric disease

Polyarteritis nodosa (PAN) typically involves which of the following? A. large elastic arteries B. small- or medium-sized muscular arteries C. arterioles D. capillaries E. venules

B. small- or medium-sized muscular arteries

Which of the following is characteristic of damage to the corticospinal (pyramidal) system? . loss of deep tendon reflexes . Babinski's sign . intention tremor . immediate muscle degeneration and atrophy . flaccid paralysis and hypotonia

Babinski's sign

You see a 5-year-old child in your office with a palpable lymph node in her right axilla that is progressing in size over the last 3 days. It has become erythematous and warm. On examination, the node is indurated. You also note many scratches on the child's arms. On further questioning, you discover that the family has recently adopted a new kitten. What is the most likely etiology of the child's adenopathy?

Bartonella henselae (cat )

35week gestation infant with omphalocele, large tongue. Dx?

Beckwith-Wiedemann syndrome

Eye drop cap is yellow

Beta blocker

Which of the following statements regarding possible complications of acute MI is true? ជ្រើសមួយ៖ Beta blockers may reduce the early occurrence of ventricular fibrillation Severe mitral regurgitation is 10 times more likely to occur with anterior MI than with inferior MI The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial showed that rhythm-control strategies provided a significant survival advantage when compared with rate-control strategies None of the above When patients have right ventricular infarction, the left ventricle is

Beta blockers may reduce the early occurrence of ventricular fibrillation

A 30-year-old Hispanic male presents to the office with complaints of palpitations, tremor, nervousness and headache. His past history is insignificant. His mother has type 2 diabetes, which is well-controlled with medications. His temperature is 37.0°C (98.6°F), pulse is 100/min, blood pressure is 150/80 mmHg, and respirations are 16/min. He appears anxious, sweaty and shaky. His neurological examination is non-focal, and examination of other systems is unremarkable. His fingerstick blood glucose level is 38 mg/dL. Intravenous administration of a bolus of 50% dextrose leads to the improvement of his symptoms. He is then subjected to supervise prolonged fasting. After an overnight fast, laboratory studies reveal: Blood glucose 40 mg/dl, Serum insulin 15 microU/L (normal value is < 6 microU/L with hypoglycemia), Serum pro-insulin 9 microU/L (normal value is < 20% of total immunoreactive insulin), C-peptide level 0.8 nmol/L (normal value is less than 0.2 nmol/L), Sulfonylurea Negative, IGF-II Negative. Based on the above information, what is the most likely cause of this patient's hypoglycemia? ជ្រើសមួយ៖ . Glucagonoma . Non-beta cell tumor . Sulfonylurea agents . Exogenous insulin . Beta cell tumor

Beta cell tumor (whipple triad=> insulinoma)

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization. His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient? ជ្រើសមួយ៖ . Nasogastric tube placement . Femoral line placement . Bladder catheterization . Intravenous lorazepam . Intravenous atropine

Bladder catheterization (Patients with traumatic spinal cord injuries should first be hemodynamically stabilized and have proper airway management. An important next step is urinary catheter placement to assess for urinary retention and prevent bladder distention and damage.)

A 50-year-old male presents to your office after reading an article on the Internet stating that a recent study showed that the drug finasteride can prevent prostate cancer. He asks you to prescribe this medication for him. You review the article and find the following information: a randomizedcontrolled trial of men over the age of 55 with normal prostate-specific antigen (PSA) readings was performed comparing finasteride and a placebo. At the end of the study, 18% of the men in the finasteride group and 24% of the men in the placebo group had developed prostate cancer. How many men need to be treated with finasteride to prevent one case of prostate cancer (NNT)? A. 6 B. 10 C. 17 D. 24 E. 32

C. 17

A recent study compared two drugs--exemestane and tamoxifen--for the treatment of estrogenreceptor positive breast cancer in postmenopausal women. At the end of the study, 91.5% of the women treated with the drug exemestane and 86.8% of the women treated with tamoxifen were disease free (P < 0.001). What is the relative risk of developing recurrent breast cancer in a woman treated with exemestane compared to a woman treated with tamoxifen? A. 90% B. 72% C. 64% D. 36% E. 4.7%

C. 64%

One of your responsibilities at the community health center is to serve as director of the tuberculosis (TB) screening and prevention program. You see a 2-week-old child for a routine wellbaby check-up. The mother is feeding him formula that she prepares by mixing powdered formula with her home tap water that comes from a well. The local health department considers the water to be nonfluoridated. Which of the following suggestions would be appropriate? A. She should start giving her baby a fluoride supplement now. B. Powdered infant formula contains an adequate amount of fluoride, so a supplement will not be required as long as she continues formula feeding. C. A fluoride supplement would be recommended starting at age 6 months. D. She should take a fluoride supplement during subsequent pregnancies for the benefit of the fetus. E. There is no risk to fluoride supplementation, so any dosage may be used.

C. A fluoride supplement would be recommended starting at age 6 months.

While in the emergency department you see a 3-week-old infant. The mother says that the child felt warm earlier in the day and has not been eating very well. The infant has a temperature of 100.9°F and has mildly decreased tone. What is the most appropriate initial management? A. Give acetaminophen and reassess in a few hours. B. Draw a blood culture, recommend increased fluid intake, and follow-up for re-examination in 24 hours in the primary pediatrician's office. C. Admit to the hospital and perform a full "sepsis workup." D. Draw a blood culture, give a shot of ceftriaxone (Rocephin) to cover for any infections and follow- up in 2448 hours. E. Get a urine culture and begin trimethoprim/sulfamethoxazole (Septra).

C. Admit to the hospital and perform a full "sepsis workup."

Apatient undergoes a gastrectomy following a gunshot injury. How would you counsel him about postgastrectomy syndromes? A. Most patients tolerate gastrectomy without a change in their digestive habits. B. Dumping syndromes can be treated with high carbohydrate liquid diets. C. Cholestyramine is a treatment for postvagotomy diarrhea. D. Most patients with these syndromes require surgical intervention. E. Proton pump inhibitors are effective against alkaline reflux syndrome.

C. Cholestyramine is a treatment for postvagotomy diarrhea

Which of the following is the correct statement regarding the treatment of hyponatremia? A. Desmopressin acetate (DDAVP), used in conjunction with intravenous saline, will help correct the serum sodium. B. Correction of sodium slowly by 3 meq/day will prevent any subsequent neurologic injury. C. Correction of serum sodium by 15 meq over 24 hours could lead to permanentneurologic injury. D. Diuretics should be avoided in the treatment of hyponatremia. E. Potassium should always be added to IV saline solutions when treating both hyponatremia and hypokalemia.

C. Correction of serum sodium by 15 meq over 24 hours could lead to permanentneurologic injury.

Which of the following is true regarding melanoma? A. Chest radiographs are not recommended as a part of a patient's follow-up surveillance. B. Timely treatment of metastatic melanoma has been shown to have an effect on mean survival. C. Elevated serum LDH suggests metastatic melanoma. D. Patients without clinical lymphadenopathy are not at risk for metastatic involvement. E. High mitotic rate and a lower Clark level are poor prognostic signs.

C. Elevated serum LDH suggests metastatic melanoma.

Which of the following is a true statement regarding puberty delay? A. The onset of puberty in males is earlier than that in females. B. A puberty delay is not considered pathologic unless accompanied by short stature. C. Hypothyroidism can be a cause of pubertal delay. D. Males do not have a true adrenarche as females do. E. The most common cause for pubertal delay is pan-hypopituitarism.

C. Hypothyroidism can be a cause of pubertal delay.

Which of the following is the most common characteristic of a serous cystadenocarcinoma of the ovary? A. It causes pseudomyxoma peritonei. B. It is composed of transitional epithelial cells. C. It is frequently bilateral. D. It is most common in children and young adults. E. It often metastasizes to the brain.

C. It is frequently bilateral.

A 13-year-old boy is brought into the emergency room with a laceration of his right arm. According to his parents, he received the injury when he fell on the ground while playing at the family farm about 1 hour ago. He has no known history of any medical problems. His parents say that they haven't brought him to the doctor in years. On questioning, they report that he only received one of his "baby shots" and they are not sure which one that was. On examination, he is healthy appearing. He is appropriately apprehensive but calm and consolable. His right arm has a 5 cm linear laceration with visible soil particles in and about the wound. The remainder of his examination is unremarkable. You carefully clean and irrigate the wound and then primarily repair the laceration with sutures. After the treatment given above, what would be the recommended "catch-up" immunization schedule to protect against tetanus? A. Td every 5 years B. Td in 6 months then booster every 10 years C. Td in 4 weeks and 612 months then booster every 10 years D. Td in 2 months, 4 months, 1518 months, and 5 years and then booster every 10 years E. TIG IM every 510 years

C. Td in 4 weeks and 612 months then booster every 10 years

OCD, Which of the following would be the most appropriate pharmacotherapy for his condition? A. alprazolam (Xanax) B. bupropion (Wellbutrin) C. citalopram (Celexa) D. desipramine (Norpramin) E. olanzapine (Zyprexa)

C. citalopram (Celexa)

A 21-year-old male presents to the ED after sustaining a gunshot wound to the neck. After evaluation, it is determined that he has C6 quadriplegia. Which of the following activities will be limited by this injury? A. wrist extension B. elbow extension C. elbow flexion D. shoulder flexion E. raising his arms above his shoulders

C. elbow flexion

"You suspect the diagnosis of Werdnig-Hoffman disease in an infant with severe hypotonia. Which other finding will support this diagnosis? A. normal deep tendon reflexes B. seizures C. fasciculations of the tongue D. recurrent fevers E. atrophy of the optic nerve"

C. fasciculations of the tongue

What is the most common malignancy of childhood? A. medulloblastoma B. Wilms' tumor C. leukemia D. neuroblastoma E. rhabdomyosarcoma

C. leukemia

citalopram (Celexa), which he is taking for his depression, but he complains of "problems with sex." Consideration is given to switching the patient to another antidepressant in order to minimize his side effects. Which of the following would be the most appropriate medication to choose? A. desipramine (Norpramin) B. fluoxetine (Prozac) C. mirtazepine (Remeron) D. phenelzine (Nardil) E. venlafaxine (Effexor)

C. mirtazepine (Remeron)

A 26-year-old HIV-positive man is admitted to the hospital for treatment of a varicella-zoster infection. On the fourth day of treatment, he develops an acute renal insufficiency. What is the most likely treatmentrelated mechanism accounting for the patient's acute renal insufficiency? A. the formation of toxic metabolites B. decreased glomerular filtration rate C. the precipitation of acyclovir in renal tubules D. direct tubular cytotoxic injury E. hypersensitivity interstitial nephritis

C. the precipitation of acyclovir in renal tubules

A 26-year-old G2P1 female comes to your office for her initial obstetric visit. The first day of her last menstrual period was 6 weeks ago. Other than some mild morning sickness, she is feeling fine. Her first pregnancy was 40 weeks in gestation and uncomplicated. She has no significant medical history. Which of the following tests is recommended for the initial obstetric visit? A. TSH B. blood glucose measurement 1 hour after a 50 g glucose load C. urine culture D. vaginal culture for group B Streptococcus E. basic metabolic panel (Chem-7)

C. urine culture

5-year-old girl suffers from a second episode with meningococcal meningitis. What is the best next laboratory study?

CH50

The infant has club foot. Associated with?

CNS involvement

HIV + ulceration throughout the oesophagus. causative organism?

Candida albicans

A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. Which of the following are the most likely diagnosis and most appropriate next step in management? ជ្រើសមួយ៖ . Ligamentous injury; Ace bandage and analgesics . No fracture; reassurance . De Quervain tenosynovitis; steroid injections . Carpal navicular fracture; thumb spica cast

Carpal navicular fracture; thumb spica cast

A 34-year-old male is brought to the emergency department by his neighbor. The neighbor found the man lying on the floor beside an empty bottle of unknown substance. At the hospital, the patient is conscious and alert, but in severe pain. His temperature is 36.8°C (98.2°F), blood pressure is 130/70 mmHg, pulse is 90/min and respirations are 20/min. Abdomen is benign, with normal bowel sounds. Pupils are 5 mm, bilaterally. His tongue is white, heavy drooling of saliva is noted and he is unable to swallow. Which of the following is the most likely explanation for this patient's symptoms? ជ្រើសមួយ៖ . Anticholinergic poisoning . Cyanide poisoning . Tricyclic antidepressant poisoning . Alcohol intoxication . Caustic poisoning

Caustic poisoning (Caustic poisoning does not cause alteration in consciousness)

An 81-year-old retired farmer presents with a 1.5 cm raised lesion on his left temple that has slowly grown over the past year and occasionally bleeds. He has had a basal cell carcinoma removed from his right temple previously, and he has had cryotherapy for actinic keratoses on his temples and head several times at his GP surgery. On examination, the lesion has a rolled edge and is translucent with telangiectasia. Which of the following treatment options is NOT recommended for this lesion? ជ្រើសមួយ៖ Mohs micrographic surgery Excision Radiotherapy Chemotherapy Topical 5-fluorouracil

Chemotherapy

Which of the following are not associated with Crohn's disease? ជ្រើសមួយ៖ Abscess formation Fistulae formation Non-caseating granuloma formation Cigarette smoking reduces incidence Associated with transmural inflammation

Cigarette smoking reduces incidence

When cells acquire sufficient energy such that the rate of flux through the tricarboxylic acid (TCA) cycle declines, excess acetyl-CoA that cannot be oxidized is predominantly converted into fat. In order for the carbons in mitochondrial acetyl-CoA to serve as a precursor for fat synthesis, they must be delivered to the cytosol. Which of the following represents the molecule used to transport acetyl-CoA to the cytosol? . beta-hydroxybutyrate . carnitine . citrate . pyruvate . acetyl-CoA

Citrate

A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Open intramedullary nailing of the femur . External fixation of the fracture . Closed intramedullary fixation of the femoral shaft . Internal fixation of the fracture with plates and screw . Place a plaster cast

Closed intramedullary fixation of the femoral shaft

A 3-year-old girl has a mild febrile illness with mild URI symptoms. She has an erythematous rash on both cheeks. Her pregnant mother had arthralgias of the hands wrists, knees, and ankles a week ago. What should be the next action?

Closely monitor the child's sibling who has spherocytosis.

A 41-year-old man complains of terrible headache. It started an hour ago, without warning, while stressed at work. It affects the right side of his head. He scores it '11/10' in severity. When asked, he agrees that light does bother him a little. He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, he looks quite distressed and prefers to pace up and down, unable to sit still. What is the diagnosis? ជ្រើសមួយ៖ Intracerebral haemorrhage Tension headache Subarachnoid haemorrhage Migraine Cluster headache

Cluster headache (is more common in men and is classically excruciating, unilateral headache associated with autonomic features such as miosis, ptosis, conjunctival injection, tearing, sensation of nasal congestion and facial flushing. Timing is important, headaches occur in clusters of multiple episodes over a couple of weeks, then resolve spontaneously only to reoccur months to years later. Timing & autonomic symptoms point to cluster headache)

A 33-year-old woman who is 10 weeks' pregnant develops increased frequency of urination and dysuria. Urine dip is positive for nitrites. Which of the following antibiotics could be used to empirically treat the urinary tract infection? ជ្រើសមួយ៖ Doxycycline Vancomycin Co-amoxiclav Ciprofloxacin Trimethoprim

Co-amoxiclav

You see a 70-year-old man diagnosed with hypersensitivity pneumonitis following a four-month history of shortness of breath at rest and cyanosis. Which of the following does not fall under the category of hypersensitivity pneumonitis? ជ្រើសមួយ៖ Coal worker's lung Mushroom picker's lung Farmer's lung Malt worker's lung Pigeon fancier's lung

Coal worker's lung

A 51-year-old man with a recent diagnosis of pancreatic carcinoma with metastases to the liver and omentum is about to commence gemcitabine chemotherapy. Prior to his first cycle he mentions that he is getting increasing severe abdominal pains. He is currently taking paracetemol for this, which eases the pain but is now becoming less effective. The most appropriate analgesia for this patient is: ជ្រើសមួយ៖ Fentanyl patch Oral morphine sulphate solution as required Morphine sulphate tablets Codeine phosphate Codeine phosphate plus paracetamol

Codeine phosphate plus paracetamol

A 46-year-old woman with atrial fibrillation is seen in clinic following an episode of syncope while shopping. She has a family history of epilepsy and a past medical history of breast cancer. She remembers feeling dizzy for a couple of seconds then waking up on the floor. What is the most useful step in management? ជ្រើសមួយ៖ A collateral history Lying-standing blood pressure An MRI brain A CT head An ECG

Collateral history from a witness is key in determining the duration of the event, any colour changes or movements

An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a dinner fork. X-ray films show a dorsally displaced, dorsally angulated fracture of the distal radius. There is also an associated fracture of the ulnar styloid. A neurologic examination is normal. Which of the following is the most appropriate management? ជ្រើសមួយ៖ . Open reduction and internal fixation . Skeletal traction . Closed reduction and short arm cast . Intramedullary rod . Closed reduction and long arm cast

Colles fracture => closed réduction and long arm cast

Which of the following is the most common cause of thyroid nodules? ជ្រើសមួយ៖ . Papillary carcinoma . Follicular carcinoma . Colloid nodule . Follicular adenoma . Anaplastic carcinoma

Colloid nodule

The patient in Question 15 was hospitalized for 2 weeks, treated with phototherapy for 12 days, and required a red cell transfusion during the hospitalization. Which of the following is the most common serious late clinical manifestation of ABO disease?

Congestive heart failure

A 35-year-old Caucasian male presents with weakness, fatigue, and weight loss over the past year. He is anorexic and has lost interest in all his activities. His temperature is 37.1°C (99°F), pulse is 84/min, blood pressure is 101/72 mmHg, and respirations are 14/min. On physical examination, he does not appear to be in acute distress. Dark brown pigmentation is present on his skin creases and oral cavity mucous membranes. Laboratory studies show: Hemoglobin 10.3 g/dL, WBC count 3,000/micro-L, Neutrophils 60%, Monocytes 5%,Eosinophils 10%, Basophils 1%, Lymphocytes 24%, Serum sodium 130 meq/L, Serum potassium 5.5 meq/L. Chest x-ray and PPD tests are normal. What is the most appropriate next step in the management of this patient? ជ្រើសមួយ៖ . Measure plasma ACTH level . 24-hour urinary free cortisol . Begin intravenous hydrocortisone . Low-dose overnight dexamethasone suppression test . Cosyntropin stimulation test

Cosyntropin stimulation test

A recent study compared two drugs--exemestane and tamoxifen--for the treatment of estrogenreceptor positive breast cancer in postmenopausal women. At the end of the study, 91.5% of the women treated with the drug exemestane and 86.8% of the women treated with tamoxifen were disease free (P < 0.001). What is the number needed to treat (NNT) with exemestane compared to tamoxifen to prevent one breast cancer recurrence? A. 79 B. 50 C. 36 D. 21

D. 21

The background of major congenital anomalies in a general obstetric population is closest to which of the following numbers? A. 0.1% (1 in 1000) B. 0.5% (5 in 1000) C. 1% (10 in 1000) D. 3% (30 in 1000) E. 7% (70 in 1000)

D. 3% (30 in 1000)

A recent study compared two drugs--exemestane and tamoxifen--for the treatment of estrogenreceptor positive breast cancer in postmenopausal women. At the end of the study, 91.5% of the women treated with the drug exemestane and 86.8% of the women treated with tamoxifen were disease free (P < 0.001). What is the relative risk reduction for the development of recurrent breast cancer for women taking exemestane compared to women taking tamoxifen? A. 95.3% B. 72% C. 64% D. 36% E. 4.7%

D. 36%

A 60-year-old Asian male presents with early satiety and 40-lb weight loss over 3 months.Upper endoscopy shows an irregular mass in the antrum of the stomach. What can you tell him and his family about his situation? A. Weight loss indicates distant metastases, and surgical resection is not indicated. B. Antral tumors have a worse prognosis than tumors at other sites in the stomach. C. CT is the most effective imaging modality for determining TNM (tumor, nodes, and metastases) stage. D. 5-year survival for patients with gastric adenocarcinoma confined to the mucosa with no nodal metastasis approaches 90%. E. Chemotherapy is an effective treatment modality in stage IV gastric adenocarcinoma, with significant benefit in overall survival.

D. 5-year survival for patients with gastric adenocarcinoma confined to the mucosa with no nodal metastasis approaches 90%.

A 50-year-old male presents to your office after reading an article on the Internet stating that a recent study showed that the drug finasteride can prevent prostate cancer. He asks you to prescribe this medication for him. You review the article and find the following information: a randomizedcontrolled trial of men over the age of 55 with normal prostate-specific antigen (PSA) readings was performed comparing finasteride and a placebo. At the end of the study, 18% of the men in the finasteride group and 24% of the men in the placebo group had developed prostate cancer. Further review of the article reveals that 6.4% of the men in the finasteride group and 5.1% in the placebo group developed high-grade prostate cancers. How many men need to take finasteride in order to have one excess case of high-grade prostate cancer (number needed to harm [NNH])? A. 1.3 B. 12 C. 37 D. 77 E. 94

D. 77

The results of your study in question 43 find two risk factors associated with the development of the disease that you are studying. Risk factor "X" was found to have an odds ratio for the development of the disease of 2.5 (95% CI: 1.34.0). Risk factor "Y" had an odds ratio of 1.9 (95% CI: 1.13.3). Which of the following statements is true? A. Both risk factors X and Y are now proven to cause the disease. B. Persons with risk factor X will have a worse prognosis than those with risk factor Y. C. Risk factor X was more common in your study population than risk factor Y. D. Both risk factors occurred more commonly in persons with the disease than in persons who did not have the disease. E. For every 100 people with the disease, 25 will have risk factor X and 19 will have risk factor Y.

D. Both risk factors occurred more commonly in persons with the disease than in persons who did not have the disease.

A 49-year-old male presents with crushing substernal pain and rules out for a myocardial infarction. He is noted to have subcutaneous emphysema of the chest and neck and precordial crackles that correlate to his heartbeat but not his respirations Which of the following approaches to management is most appropriate? A. This condition should always be managed operatively. B. The best diagnostic test is thoracic CT. C. Early endoscopy is contraindicated. D. Primary surgical repair is the first approach to treatment if the diagnosis is made within 24 hours. E. Anticoagulation should be started while the diagnostic workup proceeds.

D. Primary surgical repair is the first approach to treatment if the diagnosis is made within 24 hours.

A 45-year-old man presents with suprapubic tenderness, fevers, and nausea. After a thorough evaluation, he is found to have acute cystitis and bladder stones. Which of the following bacteria is most likely responsible for this infection? A. Staphylococcus aureus B. Pseudomonas C. Escherichia coli D. Proteus mirabilis E. Klebsiella species

D. Proteus mirabilis

An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies. Which of the following information is required to make this diagnosis? A. The child must currently have a fever. B. The child must have arthritis. C. The presence of a group A streptococcal (GAS) infection must be documented. D. The child may have chorea alone E. Aspiration of fluid from the swollen knee is required to confirm the diagnosis.

D. The child may have chorea alone

A 65-year-old woman complains that she has become increasingly light-headed after playing golf. She also has had some cramping type pain in her left arm, which coincides with the episodes. She undergoes arteriogram and is found to have a stenotic lesion of her subclavian artery. Which of the following is true? A. The stenotic lesion is distal to the take off of the vertebral artery. B. It is unusual for these patients to have coronary artery disease as well. C. The patient's light-headedness is caused by an incomplete Circle of Willis. D. The operation of choice for this patient is a carotid-subclavian bypass. E. Radial pulses in this patient will be equal bilaterally.

D. The operation of choice for this patient is a carotid-subclavian bypass.

On your surgery rotation you are assisting in a gastric surgical procedure. The attending surgeon asks you to describe the vascular supply to the stomach. You reply with which of the following? A. The right gastric artery arises from the celiac axis. B. The left gastric artery arises from the common hepatic artery. C. The right gastroepiploic arises from the right hepatic artery. D. The short gastric arteries arise from the splenic artery. E. The left gastroepiploic arises from the left gastric artery.

D. The short gastric arteries arise from the splenic artery.

You are contacted by the regional Federal Bureau of Investigations (FBI) field office to evaluate a prisoner in custody. The prisoner has confessed to crimes for which he could receive the death penalty. The FBI believes that he has information that could lead to the arrest of multiple co-conspirators and end an ongoing criminal enterprise. For which of the following actions is physician participation ethical? A. providing medical clearance for verbal interrogation B. providing medical treatment for sustained physical interrogation C. starting intravenous access and administering medications to sedate a prisoner prior to execution D. certifying the death of an executed prisoner E. continuing medical treatment based only on medical record documentation

D. certifying the death of an executed prisoner

Patients with septic arthritis of the hip joint usually present with which position? A. internal rotation and flexion B. internal rotation and extension C. internal rotation and abduction D. external rotation and flexion E. external rotation and abduction

D. external rotation and flexion

The patient is a 70-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia). Which of the following characteristics on MSE is most consistent with pseudodementia? A. appears unconcerned during examination B. attends poorly to questions on MSE C. displays poor insight into symptoms D. gives "don't know" answers to questions E. consistently performs poorly to tasks

D. gives "don't know" answers to questions

You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. Which of the following signs is associated with Down syndrome? A. café au lait spots B. high arched palate C. ambiguous genitalia D. hypotonia E. club feet

D. hypotonia

What should she be told is the most likely side effect from ECT? A. broken teeth B. fractures C. hypertension D. memory loss E. vomiting

D. memory loss

The most common site of aortic transection in deceleration injuries is which of the following? A. the root of the aorta B. at the level of the right innominate artery C. at the level of the left innominate artery D. near the origin of the left subclavian artery E. in the middle portion of the descending thoracic aorta

D. near the origin of the left subclavian artery

A 37-year-old female presented to your office with an ultrasound report suggestive of bilateral ovarian masses. You take her to the operating room for an exploratory laparotomy and note the left ovary to be replaced by an 8 9 cm neoplastic process. The right ovary appears to have a small 2 x 2 cm cystic process, similar in appearance to the left ovary, involving only a small portion of the right ovary. After obtaining pelvic and upper abdominal washings, you remove the left ovary and then perform a cystectomy on the right ovary, removing all visible disease without rupture. The frozen section on both resected specimens reveals a serous tumor of low malignant potential (LMP). The best procedure for the patient at this point is which of the following? A. termination of the procedure; await final pathology report on the resected specimens B. total abdominal hysterectomy and right salpingo-oophorectomy C. omentectomy and peritoneal biopsies D. omentectomy, peritoneal biopsies, selected pelvic and peritoneal lymph node sampling E. terminate procedure and prescribe postoperative chemotherapy

D. omentectomy, peritoneal biopsies, selected pelvic and peritoneal lymph node sampling

A 72-year-old male presented with nonspecific symptoms of easy fatigability, weight loss, and anorexia. On physical examination, generalized lymphadenopathy and hepatosplenomegaly were present. On the peripheral blood, he was found to have a marked lymphocytosis and in the serum, a small monoclonal spike was present. This disease is most prevalent in which age group? A. teenagers B. 2030 age group C. 3040 age group D. over 50 years E. it may appear at any age

D. over 50 years

A 67-year-old man is seen in the clinic for a scheduled visit. He complains of walking difficulties that have progressively worsened over many months. He also has noticed "shaking" of his hands, resulting in his dropping objects occasionally. He is greatly upset by these problems and admits to frequent crying spells. His only chronic medical illnesses are gastroesophageal reflux disease and hyperlipidemia. He is currently prescribed a proton pump inhibitor and cholesterol-lowering agent. His MSE is notable for little expression or range of affect. His vitals signs are within normal limits. On physical examination, there is a noticeable coarse tremor of his hands, left greater than right. His gait is slow moving and broad-based. Some time after initiation of treatment with the proper medication, he becomes agitated and is noted to be hallucinating. Which of the following medications would be the most appropriate to treat these new symptoms? A. clozapine (Clozaril) B. haloperidol (Haldol) C. risperidone (Risperdal) D. quetiapine (Seroquel) E. thioridazine (Mellaril)

D. quetiapine (Seroquel)

A 64-year-old White female presents to your office with complaints of vulvar pruritis and pain. You examine her and find an ulcerated lesion in the medial aspect of the left labia majora, 3.0 1.5 cm, that is thickened and indurated. You biopsy this lesion and the findings confirm a squamous cell carcinoma of the vulva. The groin nodes are palpably normal bilaterally. The next step in the patient's management would be which of the following? A. wide local excision of the lesion B. chemotherapy C. radiation therapy D. radical vulvectomy with ipsilateral inguinofemoral lymphadenectomy

D. radical vulvectomy with ipsilateral inguinofemoral lymphadenectomy

Which of the following produces the greatest increase in bone mineral density (BMD) in patients with osteoporosis? A. estrogen B. calcitonin C. alendronate D. teriparatide E. raloxifene

D. teriparatide

A 72-year-old male presented with nonspecific symptoms of easy fatigability, weight loss, and anorexia. On physical examination, generalized lymphadenopathy and hepatosplenomegaly were present. On the peripheral blood, he was found to have a marked lymphocytosis and in the serum, a small monoclonal spike was present. The clinical behavior of this disease can best be described by which of the following? A. rapidly progressive B. never relapses C. can be completely eradicated by chemotherapy D. the median survival is 46 years E. never responds to chemotherapeutic agents

D. the median survival is 46 years

A43-year-old Black female (gravida 3, para 3) with a previous tubal ligation, presents to your office complaining of increasing menorrhagia, dysmenorrhea, and fatique over the past 6 months. On examination, her vital signs are normal, and on abdominal examination you palpate a firm, mobile mass just below the umbilicus. On pelvic examination, there is a moderate amount of old blood coming from the Cervical os. A urine pregnancy test is negative, her last pap smear was normal and her spun HCT today is 28%. Which pharmacologic agent would potentially result in an improvement in her HT and help to decrease uterine size? A. oral contraceptive pills (OCPs) B. medroxyprogesterone C. nonsteroidal anti-inflammatory agents D.GnRH agonist

D.GnRH agonist

Triad in chronic pancreatitis

DM, steatorrhea, calcification

What is the best test to diagnose HIV infection in this infant?

DNA PCR

A 45-year-old man shows up in the emergency department with a pale, pulseless, paresthetic, painful, and paralytic right lower extremity. The process began suddenly 2 hours ago. On examination, no pulses are apparent in the right lower extremity. Pulse at the wrist is 95/min and grossly irregular. Treatment would likely be based on which of the following? ជ្រើសមួយ៖ Dacron prosthetic vascular conduits Fogarty balloon tipped catheters Saphenous vein bypasses Heparin and dicumarol Selective sympathetic blocks medical

Dacron prosthetic vascular conduits (He needs an emergency embolectomy, which is done with the balloon tipped catheters invented by Fogarty.)

A 57-year-old man is undergoing a femoral-popliteal bypass of his right lower extremity because of severe peripheral vascular disease. This patient has a longstanding history of claudication and shortness of breath. He had a myocardial infarction 3 years ago and has had progressive limitation of his exercise capacity because of his peripheral vascular disease. He has not had any risk stratification after his infarction. Two weeks ago, he underwent a lower extremity arterial study that showed severe diffuse disease of his right leg arterial system. The patient is brought to the operating room, and, during the procedure, his right lower extremity is made bloodless by application of a thigh tourniquet for 1.5 hours. The surgeons complete their bypass and are preparing to restore blood flow. Which of the following is an expected consequence of this maneuver? ជ្រើសមួយ៖ Increase in venous return Increase in cardiac output Increase in preload Sinus bradycardia Decrease in blood pressure

Decrease in blood pressure (the use of cross-clamping and tourniquets produces localized or regional ischemia. The consequences of ischemia include the accumulation of metabolic waste products and acid load (so-called evil humors), which are freely available to wreak havoc on the systemic circulation once they gain access to it)

A 46-year-old male presents with swelling of his face that is especially prominent in the periorbital area. He also complains of bilateral ankle swelling. He denies shortness of breath, fever and discoloration of urine. He is a non-smoker and non-alcoholic. His past medical history is not significant. He is currently not taking any medication. His pulse is 78/min, blood pressure is 130/70mmHg, respirations are 14/min and temperature is 37.1°C (99.0°F). Examination shows bilateral pitting ankle edema. Auscultation reveals clear lungs, normal heart sounds, and no murmurs. Dipstick urinalysis is positive for protein. 24-hour urine collection shows proteinuria of 4.6 g/day. Lab studies show: Total serum calcium 7.5 mg/dL, Albumin 2.2 g/dL, Phosphorus 3.5 mg/dL, Magnesium 2.2 mg/dL, Creatinine 0.8 mg/dL. Which of the following is the most likely cause of his low serum calcium level? ជ្រើសមួយ៖ . Decreased 25-hydroxylation of vitamin D . Decreased 1-alpha-hydroxlation of 25-OH vitamin D . Decreased levels of parathyroid hormone . Increase 25-hydroxylation of vitamin D . Decreased serum albumin

Decreased serum albumin (This patient has normal creatinine levels, making it unlikely that his low calcium level was caused by impaired 1-alpha-hydroxylation)

A 32-year-old man presents to the clinic with shortness of breath, which is particularly bad when he goes jogging. He has recently increased his exercise to try and reduce his weight. On a couple of occasions he has also noticed some chest discomfort which has caused him to stop exercising. On examination his BP is 150/88 mmHg, and he has a double apical impulse. On auscultation there is a harsh mid systolic murmur which is loudest between the apex and the left sternal border. Investigations; Hb 13.0 g/dl, WCC 4.8 x109/l, PLT 199 x109/l, Na+ 140 mmol/l, K+ 5.0 mmol/l, Creatinine 100 μmol/l. ECG LVH and widespread Q waves. Which of the following is most directly correlated with increased risk of sudden death? ជ្រើសមួយ៖ Systolic anterior motion Asymmetrical septal hypertrophy Degree of left ventricular hypertrophy Increased left ventricular outflow tract gradient Presence of mitral regurgitation

Degree of left ventricular hypertrophy

The parents of an 8-year-old boy are concerned about their son's short stature. What should be the most important next step?

Determination of height velocity

A 55-year-old male presents with complaints of an ulcer over the sole of his right great toe for one week. His medical problems include a ten year history of hypertension, diabetes and hypercholesterolemia. His current medications are ramipril, aspirin, metformin, glibenclamide and pravastatin. He has a 20-pack year history of smoking and occasionally drinks alcohol. He denies illegal drug use or multiple sexual partners. Which of the following is most likely contributing to the development of his foot ulcer? ជ្រើសមួយ៖ . History of smoking . Poor glycemic control . Peripheral vascular disease . Bony abnormality of the foot . Diabetic neuropathy

Diabetic neuropathy (present in approximately 80% of diabetics who develop foot ulcers)

A 17-year-old adolescent boy is stabbed in the left seventh intercostal space, midaxillary line. He presents to the ER with a heart rate of 86 beats per minute, blood pressure of 125/74 mm Hg, and oxygen saturation of 98%. Breath sounds are equal bilaterally. Which of the following is the most appropriate next step in his workup? ជ្រើសមួយ៖ . Echocardiography . Local exploration of the wound . CT scan of the abdomen . Diagnostic laparoscopy . Left tube thoracostomy

Diagnostic laparoscopy

A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor image quality. Which of the following is the most appropriate next step in management of this patient? ជ្រើសមួយ៖ . CT scan of the abdomen . Immediate laparotomy . Plain X-ray films of the abdomen . X-ray of the chest . Diagnostic peritoneal lavage

Diagnostic peritoneal lavage

A 7 -year-old boy is brought to your office with a mild fever and neck swelling. His mother says that the boy has been complaining of neck pain for a couple of days and she noticed a tender neck lump yesterday. All of his vaccinations are up-to-date. He has no known allergies. Physical examination reveals a tender and fluctuant anterior cervical mass. Which of the following is the best medication for this patient? ជ្រើសមួយ៖ . Penicillin . Amoxicillin . Erythromycin . Dicloxacillin . Acyclovir

Dicloxacillin (Rapidly enlarging, fluctuant cervical lymph nodes typically represent streptococcal or staphylococcal infections, especially in children. The treatment is incision and drainage of the mass plus an antibiotic active against these two types of organisms. Of the antibiotics listed, dicloxacillin covers streptococci and has the best anti-staphylococcal coverage)

A previously healthy 2-year-old male is brought to the emergency department after experiencing a seizure-like episode. His parents report that he has been healthy with the exception of mild upper respiratory symptoms for the past 24 hours. During the episode, his parents state that he fell down and had rhythmic, jerking movements of his arms and legs. The episode lasted about three minutes. The patient was sleepy when the emergency personnel arrived. Vital signs are temperature 39.2 c (102.5 F), pulse 120/min, and respiratory rate 25/min. The patient is alert and oriented in the emergency department. On examination, there is mild rhinorrhea and the left tympanic membrane is erythematous, bulging, and poorly mobile. The neck is supple. A complete neurological exam is unremarkable. After treating this patient's fever, which of the following is the next best step in the management of this patient? ជ្រើសមួយ៖ Admit for further observation Discharge home with education Lumbar puncture Electroencephalogram Magnetic resonance imaging of the brain

Discharge home with education (Simple febrile seizures do not typically require an extensive work-up, and these patients can usually be discharged home from the emergency department.)

A 16-year-old male is brought to the emergency department after falling off a bicycle and hitting the ground with his head. He briefly lost consciousness, but had no seizures. He has a mild headache but has no nausea or vomiting. Vital signs are stable. Examination shows no neurological deficit or any signs of fracture. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Admit the patient; do the imaging study; serial neurological exams every 2 hours. . Discharge the patient home if CT scan of head is normal and ask him to return if he develops any unusual symptoms. . Admit the patient and observe for neurological signs every 4 hours. . Discharge the patient home if a skull radiograph is normal and ask him to return if he develops any unusual symptoms. . Discharge the patient home and ask him to return if he develops any unusual symptoms

Discharge the patient home if CT scan of head is normal and ask him to return if he develops any unusual symptoms.

A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient? Digital disimpaction of fecal mass in the rectum . Urgent colostomy or cecostomy . Diagnostic and therapeutic colonoscopy . Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders . Detorsion of volvulus and colopexy or resection

Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders

A neonate does not pass any meconium during the first day of life. On day 2 he is brought for evaluation because of repeated green vomiting and progressive abdominal distention. X-ray films of the abdomen show multiple dilated loops of small bowel and no gas in the colon. A contrast enema shows a normally positioned microcolon, and the contrast material refluxes freely into the small bowel, filling some of the more distal distended loops. Exploratory laparotomy is done. There is no malrotation, the small bowel does not have any atretic or obstructed segments, and there is no inspissated meconium in it. Which of the following is most appropriate next step in management? ជ្រើសមួយ៖ Diverting ileostomy Diverting ileostomy and appendectomy Total colectomy Transverse loop colostomy Total proctocolectomy and permanent ileostomy

Diverting ileostomy and appendectomy

A 24-year-old woman presents with increasing breathlessness on exertion, which has been developing over several months. There are no abnormal physical signs on examination. On the ECG, there is right axis deviation and an R wave in V1, with peaked P waves. Chest x-ray showed prominent hilar vessels with sparse vasculature peripherally in the lungs. Doppler echocardiography revealed a pulmonary artery pressure of 60 mmHg and primary pulmonary hypertension was diagnosed. Which of the following medications would not be appropriate in managing this patient? ជ្រើសមួយ៖ Doxazosin Sildenafil Bosentan Warfarin Prostacyclin

Doxazosin is a selective α1-receptor blocker which is used in systemic but not pulmonary hypertension

For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice? ជ្រើសមួយ៖ . A Whipple procedure . Duodenostomy . Partial resection of the annular pancreas . Gastrojejunostomy . Vagotomy and gastrojejunostomy

Duodenostomy

Plummer-Vinson syndrome

Dysphagia, esophageal web (in cervical region), iron deficiency anemia

A recent study compared two drugs--exemestane and tamoxifen--for the treatment of estrogenreceptor positive breast cancer in postmenopausal women. At the end of the study, 91.5% of the women treated with the drug exemestane and 86.8% of the women treated with tamoxifen were disease free (P < 0.001). What is the absolute risk reduction (ARR) for the development of recurrent breast cancer for women taking exemestane compared to women taking tamoxifen? A. 95.3% B. 72% C. 64% D. 36% E. 4.7%

E. 4.7%

For each clinical setting described below, select the set of ABG determinations with which it is most likely to be associated. A 60-year-old man with morbid obesity pH Pa02 PaC02 A. 7.23 64 80 B. 7.39 88 40 C. 7.22 74 33 D. 754 75 24 E. 7.37 67 52

E. 7.37 67 52 (obesity => hypoventilation => chronic respiratory acidosis)

Which of the following is true regarding anorectal abscess and fistula? A. The most common cause is a subepithelial extension of a genital infection. B. Conservative management should always be considered for fistula-in-ano as many heal spontaneously. C. Most acute anorectal abscesses require a course of antibiotics. D. The treatment protocol is not altered for patients with valvular heart disease. E. Anal fistula is classified as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric.

E. Anal fistula is classified as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric.

Which of the following conditions usually causes hypoglycemia at birth? A. Sturge-Weber syndrome B. neurofibromatosis, type 1 (von Recklinghausen disease) C. tuberous sclerosis D. CHARGE association E. Beckwith-Wiedemann syndrome

E. Beckwith-Wiedemann syndrome

A 74-year-old female with a history of hypertension and hypothyroidism is admitted with easy bruising, guaiac positive stools, and anemia (Hgb 8.1 g/dL). Screening coagulation tests reveal a prolonged activated partial thromboplastin time (aPTT) with a normal prothrombin time (PT) and platelet count. What is the next step in the diagnosis of this woman's problem? A. Perform upper and lower endoscopy with biopsies. B. Check factors II, VII, IX, and X levels. C. Check factor VII level. D. Check factors XI, VII, IX, and VIII levels E. Check an aPTT 1:1 mix with normal plasma and 1-hour incubation.

E. Check an aPTT 1:1 mix with normal plasma and 1-hour incubation.

A 19-year-old female presents to the ED complaining of swelling in her left lower extremity. She reports that she had arthroscopy of the right knee about a week ago for a torn meniscus. The swelling started last night and is uncomfortable. Which of the following statements most accurately describes the situation? A. This condition is less likely to occur in women than men. B. The patient should be put on strict bed rest with leg elevation until her swelling resolves. C. Her surgically treated knee should be aspirated immediately to rule out a septic joint. D. Prophylaxis to prevent this complication includes subcutaneous heparin or daily coumadin. E. Directed lytic therapy is indicated for this patient if her lower extremity becomes bluish and has evidence of vascular compromise.

E. Directed lytic therapy is indicated for this patient if her lower extremity becomes bluish and has evidence of vascular compromise.

A40-year-old woman presents with epigastric pain and is diagnosed with peptic-ulcer disease. A duodenal ulcer is seen on upper endoscopy. How would you counsel her regarding surgical management options? A. The ulcer is most likely secondary to a malignancy. Further workup is needed to rule out distant metastases before considering surgery. B. Surgery is the most effective first-line therapy. C. Recurrence rate of a duodenal ulcer 15 years after vagotomy and a drainage procedure is less than 5% . D. Patients operated on for intractability are more prone to developing postgastrectomy symptoms. E. Incidence of dumping syndrome is lower after highly selective vagotomy than after truncal vagotomy.

E. Incidence of dumping syndrome is lower after highly selective vagotomy than after truncal vagotomy.

A6-month-old boy is brought to the office for a routine check-up by his mother. They have recently moved to the area and are new to your practice. He is the product of an uncomplicated term pregnancy, has grown and developed appropriately for his age, and is up-to-date on his immunizations. He has had two cases of otitis media in his life. Neither of his parents has been diagnosed with any chronic medical conditions. Both of his parents smoke cigarettes, but "not in the same room" as the child. Which of the following statements is true? A. Children of parents who smoke become smokers less often than children of nonsmokers. B. Chemicals from cigarette smoke do not get into breast milk. C. More than 95% of the smoke from a cigarette is out of a room within 30 minutes of smoking cessation. D. The United States Environmental Protection Agency (EPA) does not consider secondhand smoke to be a carcinogen. E. Parental smoking may be considered as a factor in assessing the "best interest" of a child in child custody hearings.

E. Parental smoking may be considered as a factor in assessing the "best interest" of a child in child custody hearings. Exposure to smoke => otitis media => hearing problems

One of your responsibilities at the community health center is to serve as director of the tuberculosis (TB) screening and prevention program. Which of the following statements about testing for TB is true? A. Multiple puncture (Tine) testing is recommended for children. B. Previous recipients of the BCG (Bacille Calmette-Guérin) vaccine should not receive TB skin testing because they almost always will test positive for the rest of their lives. C. If a patient has a positive skin test, the next test is collection of sputum for acid-fast bacilli (AFB). D. Any patient with 10 mm induration at the site of injection 72 hours after skin test placement should have a chest x-ray. E. Repeat skin testing 2 weeks after a negative purified protein derivative (PPD) can increase the sensitivity of the test.

E. Repeat skin testing 2 weeks after a negative purified protein derivative (PPD) can increase the sensitivity of the test.

A 14-month-old girl is brought into the primary care clinic by her parents. Her prior wellbaby checks have been normal, but her parents have noticed that while she used to be "outgoing," she has now become shyer and less responsive. Whereas she had been beginning to walk, she has recently been falling more and unable to even stand up. Her mother noticed that she has been flapping her hands and that her sun hats have become too big for her. Which of the following is the most likely diagnosis for this patient? A. Asperger disorder B. autistic disorder C. childhood disintegrative disorder D. fragile X syndrome E. Rett's disorder

E. Rett's disorder

An 8-year-old boy is brought in for evaluation by his parents, who are worried about his behavior in school. Recently, he has become increasingly upset about attending school. Whereas he had always enjoyed being read to as a small child, he has appeared easily frustrated when reading or being asked to write. During those times, he will often disrupt the class, and this has led to his parents being asked to remove him from the school. Which of the following tests would be the most useful in the evaluation of this child? A. Bender Visual Motor Gestalt Test B. Children's Apperception Test C. Reitan-Indiana Neuropsychological Test D. Rorschach Inkblots Test E. Wechsler Intelligence Scale for Children

E. Wechsler Intelligence Scale for Children

Patient was admitted to the ICU with a diagnosis of sepsis and respiratory failure secondary to suspected pneumonia. After obtaining blood and sputum cultures, the initial empiric antibiotic coverage should be which of the following? A. gatifloxacin alone B. vancomycin and metronidazole C. ceftriaxone and azithromycin D. ceftriaxone, gatifloxacin, and azithromycin E. ampicillin/sulbactam and gatifloxacin

E. ampicillin/sulbactam and gatifloxacin

The concept of justice as described in the Belmont Report means which of the following? A. ensuring that risks to research subjects are minimized B. ensuring the protection of privacy C. maintaining confidentiality D. ensuring informed consent E. ensuring the equitable distribution of research burdens and benefits

E. ensuring the equitable distribution of research burdens and benefits

Of the following conditions, which results in the most deaths each year in the United States? A. acquired immunodeficiency syndrome (AIDS) B. breast cancer C. motor vehicle accidents D. occupational injuries E. medical errors

E. medical errors

A mother brings her baby girl for a 9-month wellchild visit. You have been following her since birth. Her growth chart is shown in Figure. Her vital signs and examination are otherwise normal. The growth pattern is most consistent with which of the following? A. congenital growth hormone (GH) deficiency B. constitutional short stature C. constitutional growth delay D. familial short stature E. nutritional failure to thrive (FTT)

E. nutritional failure to thrive (FTT)

Which of the following patients is most likely to have symptoms of the carcinoid syndrome? A. patient with carcinoid tumor localized to the appendix B. patient with carcinoid tumor of the small intestine and a 3-cm nodule in the liver seen on CT scan C. patient with an apple core lesion seen on barium enema D. patient with adrenal mass and elevated levels of urinary vanillylmandelic acid(VMA) E. patient with a retroperitoneal carcinoid tumor

E. patient with a retroperitoneal carcinoid tumor

Which of the following maternal cardiac conditions is associated with the highest mortality rate during pregnancy? A. mitral stenosis, New York Heart Association class 12 B. corrected tetralogy of Fallot C. porcine prosthetic heart valve D. mechanical prosthetic heart valve E. pulmonary hypertension

E. pulmonary hypertension

A65-year-old female presents with ascites, multiple peritoneal implants, and a large abdominopelvic mass. At laparotomy, she is found to have omental disease, splenic metastases, retroperitoneal lymphadenopathy, and bilateral pelvic masses with rectosigmoid involvement posteriorly and bladder involvement anteriorly. The appropriate surgical management for this patient would be which of the following? A. bilateral salpingo-oophorectomy, followed by postoperative chemotherapy B. total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by postoperative chemotherapy C. complete omentectomy, retroperitoneal lymphadenectomy, total abdominal hysterectomy, and bilateral salpingooophorectomy, followed by postoperative chemotherapy D. peritoneal stripping, splenectomy, complete omentectomy, retroperitoneal lymphadenectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy, followed by postoperative chemotherapy E. rectosigmoid resection with reanastomosis, peritoneal stripping, splenectomy, complete omentectomy, retroperitoneal lymphadenectomy, total abdominal hysterectomy, and bilateral salpingooophorectomy, followed by postoperative chemotherapy

E. rectosigmoid resection with reanastomosis, peritoneal stripping, splenectomy, complete omentectomy, retroperitoneal lymphadenectomy, total abdominal hysterectomy, and bilateral salpingooophorectomy, followed by postoperative chemotherapy

A patient has broad-complex tachycardia features resembling ventricular tachycardia rather than supraventricular tachycardia with a bundle-branch conduction defect. Which of the following makes Wolff-Parkinson-White the most likely underlying diagnosis? ជ្រើសមួយ៖ V-lead polarity is discordant Absence of capture or fusion beat QRS duration less than 140 ms P wave preceding wide QRS complex ECG in sinus rhythm reveals right bundle-branch block with left axis deviation

ECG in sinus rhythm reveals right bundle-branch block with left axis deviation

A 70-year-old man with a history of congestive heart failure (CHF) secondary to nonischemic cardiomyopathy presents to the office for preoperative evaluation for total hip replacement. The previous echocardiogram revealed an ejection fration (EF) of 30%, and he occasionally has shortness of breath with exertion. His vital signs: BP 185/60 mm Hg, HR 95 beats/min, R 20 breaths/min, T0 98,60F. Which of the following factors in this patient's history and physical examination puts him most at a high risk for perioperative mortality? ជ្រើសមួយ៖ EF < 35% Current smoker Chronic alcohol use JVD History of cirrhosis

EF < 35%

A 65-year-old black female presents for an annual examination. Physical examination is unremarkable for her age. In completing the appropriate screening tests, you order a dual x-ray absorptiometry (DXA) to evaluate whether the patient has osteoporosis. DXA results reveal a T-score of -3.0 at the total hip and −2.7 at the spine, consistent with a diagnosis of osteoporosis. Since her Z-score is -2.0, you proceed with an initial evaluation of secondary osteoporosis. Laboratory evaluation reveals: Calcium: 9.7 mg/dL, Cr: 1.0 mg/dL, Bun: 19 mg/d, Glucose: 98 mg/dL, 25, OH vitamin D: 12 ng/mL (optimal > 25), WBC: 7700/μL, Hg: 12 g/dL, HCT: 38 g/dL, PLT: 255,000/μL. Based on the above information, additional laboratory would most likely reveal which of the following? ជ្រើសមួយ៖ . Normal iPTH, low ionized calcium, elevated alkaline phosphatase . Elevated iPTH (intact parathormone), low ionized calcium, normal alkaline phosphatase . Elevated iPTH, normal ionized calcium, elevated alkaline phosphatase . Normal iPTH, normal ionized calcium, elevated alkaline phosphatase . Elevated iPTH, low ionized calcium, normal alkaline phosphatase

Elevated iPTH, normal ionized calcium, elevated alkaline phosphatase (osteoporosis secondary to vitamin D deficiency)

A 72-year-old man with end stage renal disease secondary to hypertension presents with several months of back pain. He denies fever, weight loss, difficulty walking, altered sensation in his legs, or incontinence. He was diagnosed with renal disease 20 years ago and was managed medically for many years. However, 2 years ago he began hemodialysis because of a progressive decline in renal function. There is no family history of renal disease or malignancy. Physical examination is unremarkable. X-ray of the chest shows ill-defined bands of increased bone density adjacent to the vertebral endplates. What laboratory abnormalities is most likely in this patient? ជ្រើសមួយ៖ Elevated parathyroid hormone Bence-Jones protein in urine Decreased phosphate Decreased parathyroid hormone Elevated bone-specific alkaline phosphatase

Elevated parathyroid hormone ( secondary hyperparathyroidism due to renal failure)

A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91% on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity? ជ្រើសមួយ៖ . Decreasing the dose of her postoperative opioids . Sequential compression devices to her lower extremities . Postoperative benzodiazepines . Elevation of the head of the bed . Inhaled albuterol

Elevation of the head of the bed (Moving from supine to sitting can increase the FRC by 20% to 35%. ln normal adults, this can amount to several hundred cubic centimeters of lung volume. lncreasing the FRC can help prevent postoperative atelectasis.)

A 46-year-old male was admitted with epigastric pain radiating to the back. He has a previous history of endocarditis from intravenous drug use and cellulitis of the arm. Serum lipase is elevated. He was admitted and treated conservatively. Two days later he started to have a fever. He is awake but slightly disoriented. His temperature is 38.7C (101.6F), blood pressure is 120/76 mm Hg, pulse is 110/min and respirations are 16/min. He is tremulous and says bugs are crawling on him. His blood cultures are positive for gram negative rods. Empiric antibiotic therapy is started. CT scan of the abdomen shows a new 6 x 6 cm cystic lesion attached to the pancreatic head. Laboratory results show: Hematocrit 44.0 g/L, MCV 105fl, Leukocyte count 18,500/mm3, Amylase 255 U/L. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Perform lumbar puncture to rule out meningitis . Continue conservative management . External drainage of the cystic lesion . Obtain Ca 19-9 level for pancreatic cancer . Obtain echocardiogram to evaluate for endocarditis

External drainage of the cystic lesion (Pseudocysts may uncommonly become infected resulting in a pancreatic abscess. Pancreatic abscess is typically accompanied by fever and leukocytosis and may result in bacteremia, as described in this patient. Treatment includes antibiotics and drainage of the abscess.)

A 36-year-old man presents to the emergency room with renal colic. His vital signs are normal and a urinalysis shows microscopic hematuria. A radiograph reveals a 1.5-cm stone. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Percutaneous nephrostomy tube . Open surgery to remove the stone . Extracorporeal lithotripsy . α-Adrenergic blocker . Hydration and analgesics

Extracorporeal lithotripsy

A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case? ជ្រើសមួយ៖ . Endoscopic retrograde laser vaporization of the stone . Open surgical removal . Plenty of fluids and analgesics and await spontaneous passage . Extracorporeal shock wave lithotripsy (ESWL) . Endoscopic retrograde basket extraction

Extracorporeal shock wave lithotripsy (ESWL) A 7-mm stone way up at the ureteropelvic junction has a very small chance of spontaneous passage

An adult man suffered from stable angina pectoris for 15 years, during which time there was progressive heart failure and repeated pulmonary thromboembolism. On his death at age 63, autopsy disclosed enormous cardiomyopathy (1100 g), cardiac storage of globotriaosylceramide (11 mg lipid/g wet weight), and restricted cardiocytes. Which of the following lipid storage diseases would result in these clinical findings? . Niemann-Pick disease (NPD) type I A . Fabry disease . Tay-Sachs disease . Gaucher disease . Krabbe disease

Fabry disease

5-year-old female presents with intoeing. Her mother states the child is very umber and has no complaints of pain. On examination, with the child in prone position and knees flexed 90 degrees the child can easily place her lateral malleoli on the table. What is the most likely condition described here?

Femoral anteversion

Which type of hernia is more commonly seen in female patients vs male?

Femoral hernia (Femoral =female)

A 58-year-old man is found to have a small mass in the right neck on a yearly physical examination. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative review of systems. On examination there is a hard, mobile 2 cm mass along the mid-portion of the right sternocleidomastoid muscle. Which of the following is the most appropriate initial step in the workup of the neck mass? ជ្រើសមួយ៖ . Fine-needle aspiration (FNA). . Excisional biopsy. . Core needle biopsy. . Incisional biopsy. . No further workup is needed. Reevaluate the mass after a course of antibiotics for 2 weeks.

Fine-needle aspiration (FNA).

A 32-year-old woman who is known to be 17 weeks' pregnant presents for review. She has periods of paroxysmal supraventricular tachycardia (SVT) and on this occasion has a ventricular rate of 165/min and a blood pressure of 90/50 mmHg, feeling faint and unwell. Which of the following anti-arrhythmics would be the most appropriate prophylaxis for her? ជ្រើសមួយ៖ Phenytoin Propafenone Amiodarone Digoxin Flecainide

Flecainide

A 32-year-old woman presents for evaluation of a sensitive tongue, which she has been experiencing for 2 weeks. She describes loss of appetite, weight loss of 15 lb over 3 months, and frequent (four or five times a day) loose stools. She denies having bloody stools, risk factors for HIV infection, or a personal or family history of gastrointestinal disease. She does recall briefly taking ciprofloxacin for traveler's diarrhea while in Indonesia 18 months ago, which resolved with therapy. Review of systems is otherwise negative. Examination reveals normal conjunctiva; a swollen, tender tongue; a normal abdomen; and trace pedal edema. Laboratory tests show a hematocrit of 27, mild hypokalemia, and hypomagnesemia. Which of the following pairs of interventions is most likely to help with this patient's condition? ជ្រើសមួយ៖ Gluten-free diet and prednisone Azathioprine and prednisone Iron sulfate and tetracycline Folate and tetracycline Folate and niacin

Folate and tetracycline (tropical sprue)

A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). On examination both breasts are dense without palpable masses. The neck and bilateral axilla are negative for lymphadenopathy. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Right total mastectomy with sentinel lymph node biopsy . Radiation . Bilateral modified radical mastectomy . Frequent self-breast examinations and yearly screening mammograms . Chemotherapy

Frequent self-breast examinations and yearly screening mammograms

A 69-year-old man is taken to his GP by his concerned wife. She complains that he has not been himself for the last year. He has slowly become withdrawn and stopped working on his hobbies. Now she is concerned that he often forgets to brush his teeth. She has noticed he sometimes struggles to find the right word and this has gradually become more noticeable over the last couple of months. She presented today because she was surprised to come home to find him naked and urinating in the living room last week. He has a history of hypertension and is an ex-smoker. The most likely diagnosis is: ជ្រើសមួយ៖ Lewy Body disease Depression Vascular dementia Alzheimer's disease Frontotemporal dementia

Frontotemporal dementia

A 45-year-old man presents to your office complaining of nausea, early satiety, anorexia, and abdominal discomfort. His medical history is remarkable for a Roux-en-Y partial gastrectomy a few months ago. You suspect that the surgery has resulted in disruption of gastric motility. Which of the following is most likely to relieve this patient's symptoms? ជ្រើសមួយ៖ Erythromycin lactobionate, 3 to 6 mg/kg every 8 hours Omeprazole, 20 mg two times a day Further resection of the gastric remnant Metoclopramide, 10 to 20 mg up to four times a day None of the above

Further resection of the gastric remnants

A 37-year-old male is brought to the emergency department immediately after being smashed in a hydraulic press at a local factory. He is alert and oriented. Despite 10mg of IV morphine given by the paramedics, he is crying with pain. His blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 18/min. apparently, his left humeral shaft is fractured and the left arm is severely deformed being bent medially 90 degrees. Left radial artery pulse sensation and muscle strength in the left forearm are decreased compared to the right side. His right leg is shortened and externally rotated. Deformity of the right thigh is noted. Pedal pulses are symmetric. He has pain in the left anterior chest on antero-posterior sternal compression, but breath sounds are normal. Physical examination otherwise shows no abnormalities. The paramedics have placed 2 peripheral intravenous lines and immobilized the fractured limbs. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Repeat 10 mg morphine . Gentle traction of the right leg to attempt alignment of the fragments of the femur . X-ray of the left arm, right leg and chest . Gentle traction of the left forearm to attempt alignment of the fragments of the humerus . Induction of general anesthesia for operative reduction of the fractures

Gentle traction of the left forearm to attempt alignment of the fragments of the humerus

A 35-year-old man presents to his GP with diarrhoea, abdominal pain and nausea. He says he his stools have been pale and he has felt persistently bloated. His symptoms started 6 weeks ago while on a surfing holiday in Peru. What is the most likely diagnosis? ជ្រើសមួយ៖ Giardia Enterotoxigenic E. coli gastroenteritis Salmonella Cryptosporidiosis Coeliac disease

Giardia

The occurrence of Type II diabetes (NIDDM) in adolescent females can lead to the development of polycystic ovarian syndrome (PCOS). PCOS is the result of follicular atresis and ovulatory dysfunction brought about by a hyperandrogenic microenvironment in the ovary. Which of the following statements reflects the underlying cause of the hyperandrogenic state in females with NIDDM? . Hyperinsulinemia, associated with NIDDM, reduces the level of sex hormone-binding globulin leading to increased free testosterone. . The increased level of circulating lipid in NIDDM patients competes for steroid binding to sex hormone-binding globulin, resulting in a reduced transport of estrogen within the ovary. . The persistent hyperglycemia associated with NIDDM causes increased levels of glycosylated hemoglobin, which interferes with the need for increased ovarian vascularization at puberty. . NIDDM in adolescents is primarily the result of obesity and the associated disruption in fatty acid metabolism negatively affects adrenal estrogen production.

Hyperinsulinemia, associated with NIDDM, reduces the level of sex hormone-binding globulin leading to increased free testosterone.

Which of the following general statements about hypertension is false? ជ្រើសមួយ៖ Hypertension is the third most common reason adults visit the doctor's office; it is surpassed only by visits for upper respiratory complaints and low back pain Hypertension is the most common chronic disorder in the United States, affecting 24% of the adult population For a normotensive middle-aged person in the United States, the lifetime risk of developing hypertension approaches 90% None of the above Hypertension is a major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, progressive atherosclerosis, and dementia

Hypertension is the third most common reason adults visit the doctor's office; it is surpassed only by visits for upper respiratory complaints and low back pain

A 69-year-old man presents to the emergency department with ongoing chest pain. He has a past medical history of intermittent claudication and hypertension. He is an overweight smoker and heavy drinker of alcohol. On analysing the electrocardiogram (ECG), you notice broad S-waves in the right-hand chest leads, two R-waves per complex in the left-hand chest leads and ST-segment elevation. He asks if he has had a heart attack. What is the best answer to this question? ជ្រើសមួយ៖ Yes No - but we need to do more tests to find the true cause No - it's just right bundle branch block No - it's just angina I'm not sure; we need to do more tests

I'm not sure ; we need to de more tests

A 68-year-old man is diagnosed with right forearm cellulitis. You are asked to start the patient on treatment and he has no known drug allergies. Which one of the following antibiotics would be the most appropriate choice in this scenario? ជ្រើសមួយ៖ Oral erythromycin IV flucloxacillin Oral clindamycin IV clindamycin Oral flucloxacillin

IV flucloxacillin

A 17-year-old man comes to the physician because a one-week history of fever and abdominal pain. This began with mid-abdominal pain and nausea one week ago, but he was able to continue his usual activities. However, during the past two days, the pain has become worse. It is now localized to the right iliac fossa and impairs walking. He has had two episodes of vomiting during the past several hours. His temperature is 39.4C (103F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows a tender iliac fossa mass palpated on the right side; remaining abdominal examination shows no rigidity or guarding. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Immediate surgery . IV hydration, tetracycline and metronidazole . IV hydration, erythromycin and metronidazole . Ciprofloxacin and vancomycin . IV hydration and cefotetan

IV hydration and cefotetan (Patients who present more than five days after the onset of symptoms, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotics and bowel rest.)

A 42-year-old woman presents to her physician with complaints of fever (38.2°C [100.8°F]) and mild-to-moderate anterior neck pain. On examination the physician finds her to be tachycardic and sweating, and to have an exquisitely tender thyroid gland. Her blood work shows a depressed thyroid-stimulating hormone level and increased free thyroxine. Which of the following is the most appropriate treatment at this time? ជ្រើសមួយ៖ Levothyroxine Prednisone Acetaminophen Radioactive iodine Ibuprofen

Ibuprofen (subacute (de Quervain's) thyroiditis, fever, neck pain)

Which of the following statements about biological disease-modifying anti-rheumatic drugs (DMARDs) is NOT true? ជ្រើសមួយ៖ Injection site reactions for subcutaneously injected agents are common If the patient's disease gets worse whilst on biological therapy, switching from one biological DMARD to another is unlikely to produce an improvement A chest X-ray should be taken before starting to rule out latent tuberculosis (which could be reactivated) The more commonly used agents target and inhibit tumour necrosis factor alpha (TNF-alpha) They can be used in combination with methotrexate

If the patient's disease gets worse whilst on biological therapy, switching from one biological DMARD to another is unlikely to produce an improvement

True complication of intussusception

Ileoileal involvement

positive for the Philadelphia chromosome and the patient is diagnosed with chronic myeloid leukaemia. The most appropriate treatment is: ជ្រើសមួយ៖ Venesection Imatinib Stem cell transplant Hydroxycarbamide Dasatinib

Imatinib

A 65-year-old woman has a life-threatening pulmonary embolus 5 days following removal of a uterine malignancy. She is immediately heparinized and maintained in good therapeutic range for the next 3 days, then passes gross blood from her vagina and develops tachycardia, hypotension, and oliguria. Following resuscitation, an abdominal CT scan reveals a major retroperitoneal hematoma. Which of the following is the best next step in management? ជ្រើសមួយ៖ . Immediately reverse heparin by a calculated dose of protamine and place a vena caval filter (eg, a Greenfield filter). . Stop heparin and observe closely. . Reverse heparin with protamine, explore and evacuate the hematoma, and ligate the vena cava below the renal veins. . Stop heparin, give fresh-frozen plasma (FFP), and begin warfarin therapy. . Switch to low-dose heparin.

Immediately reverse heparin by a calculated dose of protamine and place a vena caval filter (eg, a Greenfield filter).

While playing football, a college student injures his shoulder. He comes in with his arm held close to his body, complaining of pain over the clavicle, rather than the shoulder joint. Physical examination shows a normal shoulder, but there is point tenderness at the junction of the middle and distal thirds of the clavicle. Gentle pressure elicits a gritty feeling of bone crunching on bone. He has normal pulses on that arm. After appropriate x-ray studies are performed, which of the following is the most appropriate initial step in management? ជ្រើសមួយ៖ Arteriogram of the subclavian vessels Immobilization by hanging cast Immobilization by a figure-eight device Open reduction and internal fixation Analgesics only

Immobilization by a figure-eight device

A 5-year-old child presents with a small mass near the anterior border of the sternocleidomastoid muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem? ជ្រើសមួយ៖ . Immediate excision followed by postoperative antibiotic therapy for 1 week . Incision and drainage . Incision and drainage followed by complete excision after resolution of the inflammation and infection . Partial excision followed by clinical observation . Antibiotic therapy

Incision and drainage followed by complete excision after resolution of the inflammation and infection (branchial cleft cysts, sinuses, and fistulas).

A 37-year-old woman has developed a 6-cm mass on her anterior thigh over the past 10 months. The mass appears to be fixed to the underlying muscle, but the overlying skin is movable. Which of the following is the most appropriate next step in her management? ជ្រើសមួយ៖ . Above-knee amputation . Abdominal CT scan . Bone scan . Incisional biopsy . Excisional biopsy

Incisional biopsy

Side effects of hydralazine

Increased angina, tachycardia, SLE

Continued consumption of calories in excess of energy expenditure will eventually lead to obesity, a current major health problem in the United States. A major contributing factor in obesity is a disorder in fuel partitioning, as evidenced by a lower rate of fat oxidation in obese individuals. Which of the following situations would best explain a reduction in overall fat metabolism in these individuals? . An increase in the hepatic ATP/ adenosine diphosphate (ADP) ratio increases incorporation of carbon into fatty acids by causing an inhibition in acetyl-CoA oxidation in the TCA cycle. . Insulin-induced decrease in the activity of acetyl-CoA carboxylase (ACC) causing reduction in fatty acid synthesis. . Insulin-induced repression of fatty acid synthase (FAS) activity. . Increased levels of malonyl-CoA occur in these individuals leading to inhibition of carnitine palmitoyltransferase I. . Decreased hepatic gluconeogenesis which requires acetyl-CoA from fatty acid oxidation, thus fat oxidation is secondarily inhibited.

Increased levels of malonyl-CoA occur in these individuals leading to inhibition of carnitine palmitoyltransferase I.

A 59-year-old man is found to have a 6-cm thoracoabdominal aortic aneurysm which extends to above the renal arteries for which he desires repair, but he is concerned about the risk of paralysis postoperatively. Which of the following maneuvers should be employed to decrease the risk of paraplegia after repair? ជ្រើសមួយ៖ . Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours . Maintenance of intraoperative normothermia . Clamping of the aorta proximal to the left subclavian artery . Extracorporeal membrane oxygenation . Cerebrospinal fluid (CSF) drainage

Infusion of a bolus of steroids immediately postoperatively with a continuous infusion for 24 hours

A 62-year-old woman undergoes a pancreaticoduodenectomy for a pancreatic head cancer. A jejunostomy is placed to facilitate nutritional repletion as she is expected to have a prolonged recovery. What is the best method for delivering postoperative nutrition? ជ្រើសមួយ៖ . Institution of supplemental enteral feeding via the jejunostomy tube only if oral intake is inadequate after return of bowel function . Complete nutritional support with total parenteral nutrition . Institution of a combination of immediate trophic (15 mL/h) enteral feeds via the jejunostomy tube and parenteral nutrition to provide total nutritional support . Institution of enteral feeding via the jejunostomy tube within 24 hours postoperatively . Institution of enteral feeding via the jejunostomy tube after return of bowel function as evidenced by passage of flatus or a bowel movement

Institution of enteral feeding via the jejunostomy tube within 24 hours postoperatively (The small bowel functions normally within hours of surgery and is able to accept nutrients promptly, either by nasoduodenal or percutaneous jejunal feeding catheters or, after 24 hours, by gastric emptying)

A 39-year-old man presents with an isolated fracture of the tibia after being hit on the leg with a car. The patient is stable and a radiograph of the leg shows a tibial shaft fracture with severe dislocation. Which of the following is the most appropriate management of the fracture? ជ្រើសមួយ៖ . Surgical fixation with unreamed nailing . External fixation . Plate fixation . Closed reduction and application of a long leg cast . Intramedullary nailing

Intramedullary nailing

. You suspect that this patient is suffering from aspiration pneumonia. From the list below, which is the most appropriate antibiotic regimen for this patient? ជ្រើសមួយ៖ Oral amoxillicin and metronidazole Intravenous cefuroxime and metronidazole Intravenous clarithromycin Oral co-amoxiclav Intravenous cefuroxime

Intravenous cefuroxime and metronidazole

A 17-year-old girl presents to the clinic because she has not yet menstruated and does not have significant breast development. Family history is significant only for some cousins who are color blind. The patient denies ethanol, tobacco, and illicit drug use and sexual activity. Physical examination reveals a normal-appearing girl in no acute distress with minimal breast development and a lack of pubic hair. She is 168 cm (5'6") tall and weighs 61.2 kg (135 lb). Cardiac examination reveals no murmurs, rubs, or gallops, with point of maximal impulse at the left mid-clavicular line between the third and fourth intercostal space. Gynecologic examination reveals a vagina without rugae and a cervix that is easily visualized. There is no discharge. A urine test is negative for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis? ជ្រើសមួយ៖ Pregnancy Kartagener's syndrome Kallmann's syndrome Gonadal dysgenesis Androgen insensitivity syndrome

Kallmann's syndrome is a disorder of gonadotropin-releasing hormone (GnRH) synthesis and is associated with primary amenorrhea without secondary sexual characteristics due to the lack of pulsatile GnRH release, which is the initiating event of puberty. It is associated with anosmia or hyposmia due to olfactory bulb agenesis or hypoplasia. It is also associated with color blindness, optic atrophy, nerve deafness, cleft palate, renal abnormalities, cryptorchidism, and neurologic abnormalities such as mirror movements. Multiple mechanisms of inheritance have been observed, including autosomal recessive, autosomal dominant, and X-linked. Treatment is with oral contraceptives. To become pregnant, patients with Kallmann's syndrome require further treatment with a GnRH pump. This syndrome would account for this patient's symptoms of amenorrhea and lack of secondary sexual characteristics.

During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. Which of the following is the most important criterion to determine the patient's need for rabies prophylaxis? ជ្រើសមួយ៖ . The events that took place have already established the need to proceed with rabies immunization . Killing the animal and examining the brain . The patient's clinical course over the next few weeks . Observing the animal's behavior over the next few days . The patient's history of previous immunization

Killing the animal and examining the brain

Your patient reports that several days earlier he "threw his back out" when he bent from the waist and picked up a very heavy package. The pain was immediate and extended from his hip, down the back of the thigh, and into his leg and foot. As he lies on the examining table, you raise his leg by the foot keeping the knee extended and elicit intense pain over the distribution of the sciatic nerve. An MRI scan confirms your conclusion that your patient has a herniated intervertebral disk between the fourth and fifth lumbar vertebrae. Herniation of the intervertebral disk between the fourth and fifth lumbar vertebrae most likely impinges on the roots of which spinal nerve? . L5 . S1 . S2 . L3 . L4

L5

A 45-year-old woman presents with dysphagia, regurgitation of undigested food, and weight loss. She had x-rays shown here as part of her workup. Upper endoscopy reveals no evidence of malignancy and esophageal motility studies show incomplete lower esophageal sphincter relaxation. Which of the following is the next best step in the treatment of this patient? ជ្រើសមួយ៖ . Laparoscopic anterior 180 (Dor) fundoplication . Laparoscopic 360 (Nissen) fundoplication . Transhiatal esophagectomy . Laparoscopic myotomy of the lower esophageal sphincter (Heller) . Laparoscopic posterior 180 (Toupet) fundoplication

Laparoscopic posterior 180 (Toupet) fundoplication

During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Thoracotomy with chest tube drainage and esophageal exclusion . Placement of a nasogastric tube to the level of perforation, antibiotics, and close observation . Left thoracotomy, pleural patch oversewing of the perforation, and drainage of the mediastinum . Left thoracotomy with esophagectomy . Spit fistula (cervical pharyngostomy) and gastrostomy

Left thoracotomy with esophagectomy

A 22-year-old Caucasian man presents to the ENT clinic complaining that he is unable to hear properly in the right ear. A week earlier, he received a blow to the right ear while playing rugby. Rinne's test is negative on the right (bone conduction greater than air conduction). On Weber's test, sound is heard best on the right side. Which one of the following is the most appropriate, regarding the likely cause? ជ្រើសមួយ៖ Right-sided sensorineural deafness Left-sided conductive deafness Left-sided sensorineural deafness None of the above Right-sided conductive deafness

Left-sided sensorineural deafness (school choice)

A 56-year-old man presents to the emergency department with complaint of chest pain of 20 minutes' duration. The pain is severe, crushing, substernal, and without radiation. He has associated nausea and diaphoresis without vomiting. He has had no previous episodes of chest discomfort. He has not seen a doctor for over 20 years and takes no medications. He has smoked two packs of cigarettes a day for the past 35 years and has lived a sedentary lifestyle. His family history is remarkable for an MI in his father at 49 years of age. Physical examination reveals a thin man, sitting upright, breathing rapidly on 2 L of oxygen. His vital signs include the following: temperature, 98.8° F (37.1° C); pulse, 98 beats/min; respiratory rate, 22 breaths/min; blood pressure, 150/95 mm Hg. Cardiac examination reveals normal rate and rhythm without murmur, and neck veins are not elevated. Lungs are clear to auscultation. ECG shows normal sinus rhythm with occasional premature ventricular contractions and ST segment elevations of 0.2 mV in leads II, III, and aVF. Which of the following ជ្រើសមួយ៖ Metoprolol Morphine sulfate I.V. Aspirin Lidocaine Streptokinase

Lidocaine

During a bar brawl, a 19-year-old man sustains a 4-in laceration on his left arm from glass and presents to the emergency room the following morning, 10 hours later. He is neurovascularly intact and the wound is deep, extending down to fascia. Which of the following is the most appropriate management of the wound? ជ្រើសមួយ៖ . Closure of the skin and subcutaneous tissue and administration of oral antibiotics for 1 week . Closure of the skin only and administration of oral antibiotics for 1 week . A single dose of intravenous antibiotics and closure of the skin only . Local wound care without wound closure or antibiotics . A single dose of intravenous antibiotics and closure of the skin and subcutaneous tissue

Local wound care without wound closure or antibiotics (The wound should not be closed because the elapsed time to presentation was greater than 6 hours. Wounds that are dirty or contaminated (eg, animal bites), that are traumatically induced by a puncture, gunshot, or crush injury, or that are older than 6 hours should be left open. Prophylactic antibiotics have not been demonstrated to prevent wound infections.)

A 48-year-old white male complains of generalized bone pain after undergoing bowel surgery for inflammatory bowel disease. His pain is more severe at the lower spine, pelvis, and lower extremities. Examination shows tenderness over the lower spine, pelvis, and lower extremities. Proximal muscle weakness is noted. X-rays of the lumbar spine show decreased bone density with blurring of the spine. X-rays of the femoral neck show pseudofractures, bilaterally. Which of the following lab abnormalities is consistent with this patient's diagnosis? ជ្រើសមួយ៖ . Normal serum calcium, normal serum phosphate, normal serum parathyroid hormone . Low serum calcium, increased serum phosphate, low serum parathyroid hormone . Increased serum calcium, increased serum phosphate, low serum parathyroid hormone . Increased serum calcium, low serum phosphate, increased serum parathyroid hormone . Low serum calcium, low serum phosphate, increased serum parathyroid hormone

Low serum calcium, low serum phosphate, increased serum parathyroid hormone (radiologic features (i.e., symmetrical 'looser zones' or pseudofractures, blurring of the spine) are classic for osteomalacia)

A 27-year-old woman, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C. Cardiorespiratory and gastrointestinal examinations are unremarkable. What is the most likely differential diagnosis? ជ្រើសមួយ៖ Typhoid Malaria Influenza Dengue fever Tuberculosis

Malaria

Which of the following statements is true regarding infants of comparable weight and gestational age (> 1500 g) in the United States regarding mortality rate?

Males have a higher mortality rate than females, and African Americans have a lower mortality rate than Caucasians. (Male> female, African-Américain < Caucasian )

During development, the upper limb buds appear by day 27 and the lower limb buds by day 29. An apical ectodermal ridge at the tip of each limb bud promotes growth. This multilayered epithelial structure interacts with which of the following to direct the growth of the limb? . sclerotome . mesenchyme . notochord . ectoderm . endoderm

Mesenchyme

A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure? ជ្រើសមួយ៖ . Mitral valve annuloplasty . Mitral valve replacement . Mitral commissurotomy . Both aortic and mitral valve replacement . Aortic valve replacement

Mitral valve annuloplasty (The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another)

A 57-year-old woman develops bony metastases 1 year after right modified radical mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic disease? ជ្រើសមួយ៖ . Antiestrogen (Tamoxifen) . Aromatase inhibitor (Anastrozole) . Monoclonal antibody (Trastuzumab) . 5-fluorouracil . Selective estrogen receptor modulator (Raloxifene)

Monoclonal antibody (Trastuzumab)

A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient? ជ្រើសមួយ៖ . Monoclonal antibody against epidermal growth factor receptor (Cetuximab) . Monoclonal antibody against interleukin-2 receptor (Daclizumab) . Tyrosine kinase inhibitor (Imatinib) . Monoclonal antibody against vascular endothelial growth factor A (Bevacizumab) . Monoclonal antibody against tumor necrosis factor α (Infliximab)

Monoclonal antibody against tumor necrosis factor α (Infliximab)

A 17-year-old girl shuffles awkwardly into clinic with her mother, who explains that her daughter has suffered from severe acne for the last few years and nothing that the GP has tried has shifted it. On examination, as well as several large pustules on her face and comedones, some scarring is beginning to develop. You would like to start oral isotretinoin (roaccutane). When counselling about side effects, which of the following would you NOT advise the patient? ជ្រើសមួយ៖ Most people feel depressed on isotretinoin Parts of the skin and lips often get very dry Pregnancy should be avoided as teratogenicity is a risk Blood tests should be taken to monitor for hyperlipidaemia Blood tests should be taken to monitor for raised liver function tests

Most people feel depressed on isotretinoin

A stockbroker in his mid-40s presents with complaints of episodes of severe, often incapacitating chest pain on swallowing. Diagnostic studies on the esophagus yield the following results: endoscopic examination and biopsy mild inflammation distally; manometry—prolonged high-amplitude contractions from the arch of the aorta distally, lower esophageal sphincter (LES) pressure 20 mm Hg with relaxation on swallowing; barium swallow 2 cm epiphrenic diverticulum. Which of the following is the best management option for this patient? ជ្រើសមួយ៖ . A trial of calcium-channel blockers . Diverticulectomy, cardiomyotomy of the distal 3 cm of esophagus and proximal 2 cm of stomach with antireflux fundoplication . Diverticulectomy, myotomy from the level of the aortic arch to the fundus, fundoplication . Myotomy along the length of the manometric abnormality . Pneumatic dilatation of the LES

Myotomy along the length of the manometric abnormality

An infant admitted to the emergency room has been found to be suffering from ammonia intoxication, which was verified by measurement of an elevation of N + in the serum. Treatment of this infant with arginine results in a reduction serum N + and a lessening of the effects of the ammonia toxicity. The ability of arginine to render this effect stems from its role in the synthesis of an allosteric activator of the the urea cycle enzyme, carbamoylphosphate synthetase-I (CPS-I). Which of the following represents this potent allosteric effector of CPS-I? . fumarate . bicarbonate ion . argininosuccinate . N-acetylcysteine . N-acetylglutamate

N-acetylglutamate

The test to evaluate potential ADHD in a 7-year-old

NICHQ Vanderbilt assessment scale

A 23-year-old man is brought to the emergency department after being hit in the neck with a dull instrument. He has neck pain and stiffness. Vital signs are stable. Neurological examination shows no abnormalities. An astute medicine resident decides to order an angiogram of the neck vessels to rule out carotid artery injury. Diagnostic angiography shows an intimal flap in the left internal carotid artery just above the carotid bifurcation. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Observation . Neck exploration and repair . Aspirin . Heparin . Ligation of carotid artery

Neck exploration and repair (When there is an intimal flap of the carotid artery, surgery is recommended to repair the vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia. Today, with the availability of stenting, this may be an alternative option to surgery)

A 45-year-old Asian man is diagnosed with Cushing's disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK one year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases of both hands. The most likely diagnosis is: ជ្រើសមួយ៖ Ectopic ACTH secreting tumour Side effects from iatrogenic steroid intake Prolactinoma Nelson syndrome Addison's disease

Nelson syndrome (occurs in patients who undergo bilateral adrenalectomies, the loss of negative feedback over time causes a macroadenoma to form in the pituitary which secretes adrenocorticotropin (ACTH)

A 2-year-old toddler has a large abdominal mass and pancytopenia. Which of the following diagnoses would most likely be established by bone marrow aspiration?

Neuroblastoma

A 72-year-old male patient has long-standing IHD. He has significant angina that is stable but causes him considerable distress and limits his activities of daily living. You hope to improve his anginal symptoms. For this patient, which of the following statements regarding the management of the symptoms of chronic stable angina is true? ជ្រើសមួយ៖ Nitrates should not be used as treatment for anginal symptoms within 24 hours of taking sildenafil for erectile dysfunction Although both beta blockers and calcium channel blockers are effective in the treatment of angina, the combination of these two medicines offers little additional benefit Because of bronchospasm, beta blockers are usually not well tolerated in patients with chronic obstructive pulmonary disease Patients with left ventricular systolic dysfunction should never be started on calcium channel blockers because of their negative inotropic effects None of the above

Nitrates should not be used as treatment for anginal symptoms within 24 hours of taking sildenafil for erectile dysfunction

A 22-year-old woman requests birth control pills. She has just moved to the United States from Poland with her new husband. She has no history of illness or current illness and has not seen a doctor in a long time. On examination, multiple flat, brown, uniformly pigmented 1 to 3 cm macules, as well as several fleshy, almost pedunculated, nodules are seen on her left leg, hip, and buttock. These lesions stop abruptly at midline on her back. None of these lesions are seen elsewhere on her body. She recalls having these all her life. Which of the following steps will be useful in the management of this patient's skin lesions? ជ្រើសមួយ៖ Topical steroid therapy Referral for genetic counseling Diagnostic skin biopsy No further interventions are required Ophthalmologic screening

No further interventions are required (neurofibromatisis type 5)

After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained carcinoma in situ. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . No further therapy . External radiation therapy to the rectum . Anterior resection of the rectum . Abdominoperineal rectosigmoid resection . Reexcision of the biopsy site with wider margins

No further therapy

A 72-year-old man presents for an extraction of three teeth under local anaesthesia. He has a past history of rheumatic heart disease. Mitral stenosis has been identified but the rotten teeth are being removed before valve replacement. He is allergic to penicillin. Which of the following would be the most appropriate antibiotic regime for him? ជ្រើសមួយ៖ Augmentin 1 g po before procedure Vancomycin 1 g po 1 hour before procedure Amoxicillin 3 g po 1 hour before procedure Ciprofloxacin 1 g po 1 hour before procedure No prophylaxis necessary

No prophylaxis necessary

A 72-year-old retired banker is brought to the ED by his daughter for increasing confusion, lethargy, cough, and fever. You remember the patient because he was discharged just 3 days earlier after being treated for urinary retention secondary to benign prostatic hypertrophy (BPH). The patient's cough has been present since discharge and is accompanied by dark green sputum. He has not returned to work, and he has not been able to ambulate. His vital signs: BP 86/40 mm Hg, R 32 beats/min, P 121 beats/min, T0 101.90F (39.190F). What is the best next step in the management of this patient? ជ្រើសមួយ៖ Start anti-biotherapy Consult pulmonary Dextrose 5% water colloid bolus Await blood culture results Normal saline (NS) bolus

Normal saline (NS) bolus ( because he's hypotensive)

What is the most common cause of viral gastroenteritis worldwide?

Norovirus

Following significant head trauma, a 34-year-old woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial management of this patient? ជ្រើសមួយ៖ . Intubation and hyperventilation . Placement of an intracranial pressure monitor . Observation and administration of anticonvulsive medication for 1 week . Observation alone . Administration of 25 g of mannitol

Observation and administration of anticonvulsive medication for 1 week

A 28-year-old medical student seeks your attention because of a testicular mass. Biopsy is consistent with pure seminoma. There is no evidence of enlarged retroperitoneal lymph nodes on CT scan. Which of the following is the best treatment strategy for this patient? ជ្រើសមួយ៖ . Orchiectomy followed by chemotherapy . Orchiectomy alone . Orchiectomy followed by external beam radiation to the retroperitoneal lymph nodes . Orchiectomy with retroperitoneal lymph node dissection followed by external beam radiation . Orchiectomy with retroperitoneal lymph node dissection

Orchiectomy followed by external beam radiation to the retroperitoneal lymph nodes (Seminoma is extremely radiosensitive; therefore retroperitoneal lymph node dissection is unnecessary.)

A 29-year-old G1P0 presents to the obstetrician's office at 41 weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at -3 sta- tion. Which of the following is the best next step in the management of this patient?

Order BPP testing for the same or next day.

A young motorcycle driver is thrown against a concrete bridge abutment and sustains severe trauma about the face, with marked periorbital edema and ecchymosis as well as epistaxis. He is obtunded with rapid, shallow breathing. Which of the following is the next appropriate step in his workup and management? ជ្រើសមួយ៖ . Oropharyngeal intubation with cervical in-line stabilization. . Emergency tracheostomy. . Evaluation of the cervical spine. . Emergency cricothyroidotomy. . Blind nasopharyngeal intubation with cervical in-line stabilization.

Oropharyngeal intubation with cervical in-line stabilization.

A 59-year-old man sustains blunt trauma in an automobile accident, resulting in multiple intra-abdominal injuries. Surgery for the repair of these injuries takes several hours and requires multiple blood transfusions and infusions of Ringer's lactate. Before all the operative steps are completed, the patient develops a significant coagulopathy, a core body temperature less than 34 C (93.2 F), and refractory acidosis. The anesthesiologists are administering fresh frozen plasma and platelet packs. Which of the following is the most appropriate next step in management for the surgeon? ជ្រើសមួយ៖ . Abort the operation and leave the abdomen open, covering the bowel with mesh . Provide hemostasis by liberal use of electrocoagulation . Wash the abdomen with warm saline and continue to operate . Complete the operation as soon as possible and do a formal abdominal closure . Pack the bleeding surfaces and close the abdomen temporarily with towel clips

Pack the bleeding surfaces and close the abdomen temporarily with towel clips

A 31-year-old man is brought to the ER following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initial management of this patient? ជ្រើសមួយ៖ . Immediate operative stabilization . Pain control, chest physiotherapy, and close observation . Stabilization with towel clips . Stabilization of the chest wall with sandbags . Intubation, mechanical ventilation, and positive end-expiratory pressure

Pain control, chest physiotherapy, and close observation

A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6 week trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management? ជ្រើសមួយ៖ . Local excision of the ulcer . Repeat trial of medical therapy . Vagotomy and pyloroplasty . Highly selective vagotomy . Partial gastrectomy with vagotomy and Billroth I reconstruction

Partial gastrectomy with vagotomy and Billroth I reconstruction

A 38-year-old woman with a history of classical migraine is admitted with a right hemisphere ischaemic stroke. She has optimal blood pressure and a very favourable lipid profile, and duplex scanning of the carotids shows total absence of atheromatous plaque. Echocardiography, however, reveals an abnormality which may be relevant. Which of the following is it likely to be? ជ្រើសមួយ៖ Dilate left atrium Ventricular septal defect Left ventricular hypertrophy Patent foramen ovale (PFO) Tricuspid incompetence

Patent foramen ovale (PFO)

A subsequent biopsy of a bulla shows splitting at the dermoepidermal junction. What is the diagnosis? ជ្រើសមួយ៖ Toxic epidermal necrolysis Pemphigus Stevens-Johnson syndrome Pemphigoid Insect bites

Pemphigoid

Which of the following is the drug of choice for the treatment of meningococcal meningitis?

Penicillin

A 15-month-old boy is brought to the ER because of fever and a rash. Six hours earlier he was fine, except for tugging on his ears; another physician diagnosed otitis media and prescribed amoxicillin. During the interim period, the child has developed an erythematous rash on his face, trunk, and extremities. Some of the lesions, which are of variable size, do not blanch on pressure. The child is now very irritable, and he does not interact well with the examiner. Temperature is 39.5C (103.1F). He continues to have injected, immobile tympanic membranes, but you are concerned about his change in mental status. Which of the following is the most appropriate next step in the management of this infant? ជ្រើសមួយ៖ . Perform bilateral myringotomies . Discontinue administration of ampicillin and begin trimethoprim with sulfamethoxazole . Perform a lumbar puncture . Begin administration of IV ampicillin . Begin diphenhydramine

Perform a lumbar puncture

A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, genitourinary, or musculoskeletal anomalies. Which of the following is the best next step in the management of this patient? ជ្រើសមួយ៖ . Perineal operation only . Posterior sagittal anorectoplasty only . Perineal operation with diverting colostomy . Diverting colostomy only . Posterior sagittal anorectoplasty with diverting colostomy

Perineal operation only

The term "genomic imprinting" refers to the phenomenon of gene expression dependence on the mode of inheritence. A typical example of this phenomenon is the control of the expression of the growth factor IGF-II. Genomic imprinting, termed "epigenesis," is defined by which of the following? . Gene expression that is restricted to a specific cell lineage. . Gene regulation is exerted by sex-type specifc factors. . Gene expression results from regulated levels of DNA methylation. . Phenotype differences are independent of genotype variation. . Genotype differences are not reflected by phenotype differences.

Phenotype differences are independent of genotype variation.

Distributive shock due to spinal cord injury

Phenylephrine

Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?

Phosphatidylglycerol is present

A 35-year-old male presents with complaints of weakness and fatigue of one year's duration. He is anorexic and has lost interest in all his activities. He also complains of cold intolerance and constipation. His blood pressure is 98/72 mmHg, temperature is 37.1°C (99°F), respirations are 14/min, and pulse is 50/min. His skin is dry and rough, nails are brittle, and hair is thin. There is no hyperpigmentation of the skin. Delayed deep tendon reflexes are noted on neurological examination. Lab studies show: Hemoglobin 10.2 g/dL, WBC count 5,000/micro-L, Neutrophils 45%, Monocytes 5%, Eosinophils 10%, Basophils 1%, Lymphocytes 40%, Serum sodium 135 mEq/L, Serum potassium 4.0 mEq/L. Which of the following is most consistent with this patient's findings? ជ្រើសមួយ៖ . Adrenal tuberculosis . Adrenal CMV infection . Autoimmune destruction of adrenal glands . Adrenoleukodystrophy . Pituitary tumor

Pituitary tumor (Hyperpigmentation of the skin and mucous membranes is characteristic of primary adrenocortical deficiency, and is due to the increased levels of ACTH. This clinical feature is not seen in patients with secondary adrenal insufficiency, which is due to hypothalamo-pituitary failure.)

Factor associated with teen pregnancy

Poor academic performance

A 25-year-old man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. At laparotomy, it is discovered that the left transverse colon has incurred a through-and-through injury with minimal fecal soilage of the peritoneum. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Primary repair should be performed, but only in the absence of hemodynamic instability. . Primary repair should be performed with placement of an intra-abdominal drain next to the repair. . The patient should undergo a 2-stage procedure with resection of the injured portion and reanastomosis 48 hours later when clinically stabilized. . A colostomy should be performed regardless of the patient's hemodynamic status to decrease the risk of an intraabdominal infection. . Primary repair should be performed and intravenous antibiotics administered for 14 days.

Primary repair should be performed, but only in the absence of hemodynamic instability.

An 82-year-old man develops severe abdominal distention, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stools for the past 12 hours. His vital signs are normal, and his pulse is regular. He has a distended, tympanitic abdomen, with hyperactive, highpitched bowel sounds. There are no signs of peritoneal irritation. Rectal examination is negative for masses or occult blood, and trie rectal vault is empty. Abdominal xray films show distended loops of small and large bowel, as well as a very large round gas shadow that is located in the right upper quadrant and tapers toward the left lower quadrant in the shape of a parrot's beak. The patient has never had any abdominal surgery, and he does not have any palpable hernias. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ Emergency exploratory laparotomy Repeated enemas and laxatives Emergency celiac and mesenteric arteriogram Proctosigmoidoscopy Nasogastric suction, IV fluids, and observation

Proctosigmoidoscopy

A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. He is being considered for surgical intervention. Laboratory studies done at the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk? ជ្រើសមួយ៖ . Prohibitive unless he is dialyzed to normalize his bilirubin . Amenable to improvement if he receives vitamin K . Amenable to improvement if he is given albumin . Prohibitive regardless of attempts to improve his condition . Acceptable as he now is

Prohibitive regardless of attempts to improve his condition (The studies show extremely marginal liver function, which would be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate)

A 32-year-old G2P1 woman at 16 weeks gestation presents to her obstetrician complaining of fatigue, anxiety, and palpitations. She says she has been feeling warm, even in her air-conditioned home, and has been having three or four loose stools per day, as compared to one or two prior to her pregnancy. She has a temperature of 37.1°C (98.9°F), heart rate of 105/min, and blood pressure of 128/76 mmHg. Neck examination reveals mild diffuse enlargement of the thyroid gland with no lymphadenopathy. Relevant laboratory findings include a total triiodothyronine level of 400 ng/dL, free thyroxine of 6.8 ng/dL, and thyroid-stimulating hormone of 0.01 μU/mL (normal: 0.4-4 μU/L). Results of a thyroid- stimulating hormone-receptor antibody test are positive. Which of the following is the most appropriate therapy for this patient? ជ្រើសមួយ៖ Propylthiouracil Surgical resection Methimazole High-dose iodine therapy Radioiodine ablation

Propylthiouracil (Although both cross the placenta and can cause fetal goiter and hypothyroidism, propylthiouracil is the preferred drug because it has a lower risk of severe congenital anomalies.)

A 5-year-old girl is brought to medical attention by her parents 12 hours after the onset of generalized tonicoclonic seizures. She never had similar episodes in the past. The girl is otherwise healthy. Her temperature is 37 C (98.6 F). Physical examination is unremarkable. There is no evidence that the girl had a fever at the onset of the convulsive episode. The parents fear that seizures may damage the child's brain and may eventually recur. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ Admit patient to the hospital for further evaluation Perform electroencephalographic studies Perform CT/MW studies of the brain Provide reassurance to child and family Start antiepileptic medication

Provide reassurance to child and family

Which part of the ECG is most closely associated with the first heart sound? ជ្រើសមួយ៖ S Wave T Wave U wave P Wave R Wave

R wave

Classic Quincke triad of hemobilia

RUP pain, GI bleeding , jaundice

A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Tamoxifen therapy . Palliative mastectomy . Radiation and chemotherapy . Radical mastectomy with extended lymph node dissection . Local wound care, but no specific antineoplastic therapy

Radiation and chemotherapy (very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy)

A 45-year-old woman presents with a 7-cm renal cell carcinoma with radiologic evidence of abdominal lymph node involvement with no distant metastases. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Radiation followed by nephrectomy . Radical nephrectomy . Chemotherapy followed by nephrectomy . Chemotherapy . Radiation

Radical nephrectomy

A 63-year-old woman notices lumps on both sides of her neck. A fine-needle aspirate is nondiagnostic, and she undergoes total thyroidectomy. Final pathology reveals a 2-cm Hürthle cell carcinoma. Which of the following is the most appropriate postsurgical management of this patient? ជ្រើសមួយ៖ . Chemotherapy, external beam radiotherapy, and radioiodine ablation. . External beam radiotherapy. . Chemotherapy. . Radioiodine ablation. . No further therapy is indicated

Radioiodine ablation.

A male infant is born to a primigravid woman whose pregnancy was uneventful. The delivery was uncomplicated. Physical examination of the newborn reveals deformity of the feet, specifically adduction of the anterior aspect of the foot with a convex lateral border and concave medial border. The ankle movements are normal, and passive and active movement of the foot overcorrects the deformity into abduction. AP radiographs reveal mild adduction of the metatarsals at the tarsometatarsal articulation, and an increased angle between the 1st and 2nd metatarsals. What is the best next step in the management of this patient? ជ្រើសមួយ៖ Surgical correction at age two Orthosis Reassurance Immediate casting Surgical correction within the first month of life

Reassurance

A 1-month-old infant is brought to the office for a routine neonatal visit. His prenatal and birth histories are unremarkable. His vital signs are normal. Examination reveals a harsh, loud holosystolic murmur over the left, lower sternal border. Palpation reveals a thrill over the precordial region. There is no cyanosis, and pulmonary auscultation reveals no rales. Chest radiograph reveals a heart of normal size and a slight increase in pulmonary vascularity. EKG is normal. Which of the following is the most appropriate course of action? ជ្រើសមួយ៖ . Digoxin and diuretic therapy . Reassurance . Surgical repair . Oxygen administration . PGE 1 administration

Reassurance (Most small ventricular septal defects close spontaneously and require no treatment, as long as there are no signs of pulmonary vascular disease. Reassurance, surveillance (via EKG and echocardiography), and infective endocarditis prophylaxis are all that are needed for management)

A 35-year-old woman presents with a lump in the left breast. Her family history is negative for breast cancer. On examination the mass is rubbery, mobile, and nontender to palpation. There are no overlying skin changes and the axilla is negative for lymphadenopathy. An ultrasound demonstrates a simple 1-cm cyst in the area of the palpable mass in the left breast. Which of the following represents the most appropriate management of this patient? ជ្រើសមួយ៖ . Fluoroscopically guided needle localization biopsy . Mammography and reevaluation of options with new information . Aspiration of the cyst with cytologic analysis . Reassurance and re-examination . Immediate excisional biopsy

Reassurance and re-examination

A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step? ជ្រើសមួយ៖ Reassure and discharge Repeat ECG exercise testing on anti-anginal medication Dobutamine stress echocardiography Coronary angiography Radionuclide myocardial perfusion scanning

Reassure and discharge

A toddler is brought to the emergency department with burns on both of his buttocks. The areas are moist, have blisters, and are exquisitely painful to touch. The parents explain that the child accidentally pulled a pot of boiling water over himself. Which of the following is the most important step in management? ជ្រើសមួយ៖ . Early excision and grafting of the burned areas . Application of mafenide acetate to the burned areas . Education of the parents on accident prevention . Prompt administration of fluid resuscitation . Referral to the proper authorities for suspected child abuse

Referral to the proper authorities for suspected child abuse

A 15-year-old boy has been diagnosed with retinitis pigmentosa, peripheral polyneuropathy, and cerebellar ataxia. Analysis of his cerebrospinal fluid indicated a high protein content but no elevation of cell number. A telling clinical finding was a high level of serum phytanic acid. These findings are indicative of which of the following disorders? . fragile X syndrome . Refsum disease . MCAD deficiency . rhizomelic chondrodysplasia punctata . carnitine palmitoyltransferase I deficiency

Refsum disease

A light is shone into a patient's right eye and it constricts. When moved to the left eye, the left eye constricts. When moved back to the right eye, the right eye dilates. What is the diagnosis? ជ្រើសមួយ៖ Efferent lesion Relative efferent lesion Relative afferent lesion Afferent lesion Normal

Relative afferent lesion

Glucagon binding to liver cells induces an increase in intracellular cAMP concentration. The rate- limiting step in cholseterol biosynthesis is regulated as a consequence of this glucagon-mediated rise in cAMP. The effect of increased cAMP on the rate of cholesterol biosynthesis occurs because of which of the following? . AMP-activated protein kinase (AMPK) is activated and directly phosphorylates human menopausal gonadotropin (HMG)-CoA reductase, leading to an increase in the activity of the latter enzyme. . Removal of phosphate from HMG-CoA reductase increases its activity. Activated PKA results in a reduced level of phosphate removal from HMG-CoA reductase so that the latter enzyme is kept less active. . The increased cAMP directly inhibits HMG-CoA reductase. . PKA is activated and phosphorylates AMP-regulated kinase, which then phosphorylates and activates HMGCoA reductase. . Cyclic AMP-dependent protein kinase (PKA) is activated and directly phosphorylates HMG- CoA reductase, reducing the activity of the latter enzyme.

Removal of phosphate from HMG-CoA reductase increases its activity. Activated PKA results in a reduced level of phosphate removal from HMG-CoA reductase so that the latter enzyme is kept less active.

After being injured by a bull on his mother's farm, a young man is placed in a cast for a supracondylar fracture of his humerus. A few hours later he begins to experience intense pain, swelling, and weakness in the ipsilateral hand. Pulses are normal in bilateral upper extremities. Which of the following is the most appropriate initial management of this patient? ជ្រើសមួយ៖ . Removal of the cast . Surgical decompression (fasciotomy) . Elevation of the extremity . Repeat imaging of the humerus . Observation

Removal of the cast (The cast needs to be immediately removed and the upper extremity needs to be thoroughly assessed)

A 30-year-old postman with hypertension but normally in good health presents to the emergency department with sudden severe breathlessness and sweating. Chest examination reveals bilateral basal crackles. He improves with diamorphine and frusemide (furosemide). Electrocardiograms (ECGs) and cardiac enzymes are normal. He develops two further episodes of pulmonary oedema which respond well to diuretics. The most likely cause of pulmonary oedema is? ជ្រើសមួយ៖ Myocarditis Ischaemic heart disease Phaeochromocytoma Dilated cardiomyopathy Renal artery stenosis

Renal artery stenosis

A 60-year-old male is admitted to the hospital because of right lower lobe pneumonia. His medical history is significant for hypertension, diabetes mellitus, severe degenerative disease of the spine, and longstanding lower back pain. He is a chronic smoker with a 40-pack year smoking history. During his hospitalization, the laboratory report shows decreased serum calcium levels and increased phosphate levels. Further evaluation reveals increased serum intact parathyroid hormone levels. Which of the following medical conditions is most likely responsible for this patient's abnormal lab findings? ជ្រើសមួយ៖ . Primary hyperparathyroidism . Thyroidectomy . Lung cancer . Renal failure . Plasma cells in marrow

Renal failure (secondary hyperparathyroidism due to renal failure)

A 45-year-old G2P2 female presents for annual examination. She reports regular menstrual cycles lasting 3 to 5 days. She exercises 5 times per week and reports no difficulty sleeping. Her weight is stable 140 lbs and she is 5 ft 8 in tall. Physical examination is unremarkable. Laboratory studies are normal with the exception of a TSH value of 6.6 mU/L (normal 0.4-4.0 mU/L). Which of the following represents the best option for management of this patient's elevated TSH? ជ្រើសមួយ៖ . Order thyroid uptake scan . Repeat TSH in 3 months and reassess for signs of hypothyroidism . Begin low dose levothyroxine (25-50 μg/d) . Measure thyroid peroxidase antibodies (TPOAb) . Recommend dietary iodide supplementation

Repeat TSH in 3 months and reassess for signs of hypothyroidism (subclinical hypothyroidism with no risk => surveillance) -Thyroxine therapy is not currently recommended for asymptomatic patients in whom the TSH level is below 10 mU/L.

A 25-year-old man was found by his family at home having suffered a cardiac arrest. He was previously well, apart from well controlled Type 1 diabetes controlled with a basal bolus insulin regime. His family followed the ambulance and ask if they can be in the resuscitation room. After 20 mins of repeated resuscitation cycles he has remained in asystole. Blood gases; pH= 7.01, PO2= 8.4 kPa, PCO2= 3.9 kPa, Bicarb= 10 mmol/l. Which person is the most appropriate person to make the decision to discontinue resuscitation? ជ្រើសមួយ៖ Parents of the patient Patient's fianceé AE consultant On call medical consultant Resuscitation team leader

Resuscitation team leader

A 34-year-old man comes to the emergency department because of severe pain in his penis. He was having sex with his wife on top when he had sudden onset severe pain in the penis at the height of orgasm. Swelling of the penis and deviation of the penile shaft to the right followed the pain. Examination shows a man in severe distress. The penis is uncircumcised, grossly swollen and deviated to the right. There is no blood at the urethral meatus. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Retrograde urethrogram followed by surgical exploration of penis . Surgical exploration of penis . Do a circumcision . Foley's catheterization . Antibiotics, analgesics and anti-inflammatory and follow up in 24 hours

Retrograde urethrogram followed by surgical exploration of penis

A septuagenarian woman undergoes an uncomplicated resection of an abdominal aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean-shaped structure in the left upper quadrant. Which of the following is the most appropriate management at this time? ជ្រើសមួយ៖ . Administration of a gentle saline enema and encouragement of ambulation . Placement of the NG tube and administration of low-dose cholinergic drugs . Operative decompression with transverse colostomy . Right hemicolectomy . Decompression of the large bowel via colonoscopy

Right hemicolectomy (cecal volvulus)

A 45-year-old unconscious male is brought to the emergency room. His airway is secured, oxygen is administered, and his vitals are as follows Temperature 36.4°C (97.8°F); PR 102/min; BP 90/65 mmHg; RR 27/min. An IV line is secured and blood and urine samples are drawn. Lab results are as follows: Blood urea nitrogen 40 mg/dl, Calcium 9.1 mg/dl, ALT 50 U/L, AST 60 U/L, Ammonia 15 micro-mol/1 (Normal is 9-33 micro-mol/1), PT 13 sec, APTT 30 sec, Amylase 100 U/L, Glucose 400 mg/dl, Sodium 134 meq/L, Potassium 5.2 meq/L, Chloride 97 meq/L, Bicarbonate 12 meq/L. Arterial Blood Gases: PH 7.19, PaCO2 25 mm Hg, PaO2 80 mm Hg. Blood and urine are positive for ketones. A diagnosis of diabetic ketoacidosis (DKA) is made and IV infusion of normal saline and regular insulin are started. What will be a most reliable index for monitoring the response to treatment? ជ្រើសមួយ៖ . Serum anion gap . Serum ketones . Serum osmolality . Urine ketones . Urine glucose

Serum anion gap (Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis.)

A 3010-g (6.6-lb) boy was born to a 37-year-old primagravida by spontaneous vaginal delivery after an uncomplicated pregnancy. On examination he has cyanotic extremities and a significant right precordial heave, a single S2, and a harsh systolic ejection murmur along the sternal border. He also has a prominent squared nose and cleft palate. An echocardiogram is subsequently performed and demonstrates tetralogy of Fallot. Corrective surgery is performed without complications. At 2 months of age the infant is diagnosed with Pneumocystis jiroveci pneumonia, and at 3 months he is diagnosed with fungal septicemia. Additional work-up of this child should include which of the following tests? ជ្រើសមួយ៖ Serum calcium Hemoglobin electrophoresis Nitroblue tetrazolium Quantitative immunoglobulin levels Renal ultrasound

Serum calcium (Di- George's syndrome, with deletion of chromosome 22q11. Patients are identified by physical examination, tetany in the neonatal period, and frequent infections, especially with fungus and/or P. jiroveci. )

A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient's management? ជ្រើសមួយ៖ . Sigmoid resection with end colostomy and rectal pouch (Hartmann procedure) . Cystoscopy to evaluate for a fistula . Long-term suppressive antibiotic therapy . Expectant management with sigmoid resection if symptoms recur . Sigmoid resection with primary anastomosis

Sigmoid resection with primary anastomosis

Which of the following statements is true about systemic sclerosis? ជ្រើសមួយ៖ Oesophageal dysmotility is only seen in limited cutaneous systemic sclerosis Microstomia is only seen in diffuse cutaneous systemic sclerosis Skin involvement is limited to face, hands and feet in limited cutaneous systemic sclerosis Raynaud's phenomenon occurs as a result of skin fibrosis (scleroderma) Anti-double stranded DNA antibodies are normally detected in patients with systemic sclerosis

Skin involvement is limited to face, hands and feet in limited cutaneous systemic sclerosis

16-month-old girl presents with acute onset of truncal ataxia with vomiting, nystagmus, and dysarthria. She is afebrile and has no nuchal rigidity. Which of the following historical items would help you to identify a cause for these symptoms?

Sore throat with blisters on palate 3 weeks ago

Which of the following best describes the temperament?

Stable, individual modes of responding to the environment

A 56-year-old man with a history of coronary artery disease and a documented ejection fraction of 40% by echocardiography presents for further management. At this visit, the patient denies having shortness of breath, dyspnea on exertion, orthopnea, or lower extremity edema. He has never been admitted to the hospital for congestive heart failure (CHF). According to the new American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the evaluation and management of heart failure, in what stage of heart failure does this patient belong? ជ្រើសមួយ៖ Stage C This is a patient normal condition Stage B Stage A Stage D

Stage B Stage A identifies patients who are at high risk for developing heart failure but who have no apparent structural abnormality of the heart. Stage B denotes patients with a structural abnormality of the heart but in whom symptoms of heart failure have not yet developed. Stage C refers to patients with a structural abnormality of the heart and symptoms of heart failure. Stage D includes the patient with end-stage heart failure that is refractory to standard treatment. This patient has stage B heart failure. The goal of therapy is aimed at preventing progression to stage C or D.

A full-term, ill appearing, infant presents with vesicles and large bullae shortly at birth. Which of the following is most likely?

Staphylococcus aureus

A 55-year-old woman is seen in clinic, she has a ten-year history of type 2 diabetes treated with glibenclamide. Her blood pressure is 148/93 with new onset proteinuria, her serum results show elevated lipid levels, glycated haemoglobin of 5.5 per cent and fasting glucose of 6.0 mmol/L. A renal biopsy shows the presence of Kimmelstiel-Wilson lesions. The most appropriate management is: ជ្រើសមួយ៖ ACE II antagonists Start ACE inhibitors Increase oral hypoglycaemic dosage Start cholesterol lowering therapy Start renal dialysis

Start ACE inhibitors

A 55-year-old overweight pub landlord presents with a several-year history of episodic acute painful joint swelling that started in his left big toe and now affects his knees. Symptoms improve with use of diclofenac. Gout was diagnosed on his first hospital visit, however this now appears recurrent. He developed an acute attack in his left knee 2 days ago. Which of the following represents the best plan for prophylaxis? ជ្រើសមួយ៖ Keep on long-term diclofenac with gastric protection Start allopurinol at least 2 weeks after the acute attack has settled with NSAID cover and increase until his urate level is below 300 mmol/L Switch to long-term colchicine Switch to use of depot steroid injections Start allopurinol now with non-steroidal anti-inflammatory drugs (NSAIDs) cover and increase until his urate is below 300 mmol/L

Start allopurinol at least 2 weeks after the acute attack has settled with NSAID cover and increase until his urate level is below 300 mmol/L

A 59-year-old man is planning to undergo a coronary artery bypass. He has osteoarthritis and consumes nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain. Which of the following is the most appropriate treatment prior to surgery to minimize his risk of bleeding from his NSAID use? ជ្រើសមួយ៖ . Stop the NSAIDs 3 to 4 days prior to surgery. . Give FFP few hours before surgery. . Begin vitamin K 1 week prior to surgery. . Stop the NSAIDs 1 week prior to surgery. . Stop the NSAIDs the day before surgery.

Stop the NSAIDs 3 to 4 days prior to surgery.

A 62-year-old white woman with a history of coronary artery disease presents to the emergency department with substernal, squeezing chest tightness of 2 hours' duration. The pain is identical to the pain she experienced with her first MI. On physical examination, the patient's heart rate is found to be 105 beats/min; a tachycardic regular rhythm without gallop is noted. The patient's lung fields are clear. A chest radiograph is normal, but ECG reveals ST segment elevation in leads I, aVL, V5, and V6. Which of the following statements regarding the management of this patient is true? ជ្រើសមួយ៖ Current recommendations are that the time between a patient's presentation to the emergency department and the administration of thrombolytic therapy not exceed 2 hours Thrombolytic therapy has been studied in patients with ECG findings other than ST segment elevation or bundle branch block and has been found to be superior to conventional therapy Streptokinase therapy is contraindicated in patients who have recently received a dose of streptokinase because of antibodies that form against the drug None of the above Coronary angiography is recommended

Streptokinase therapy is contraindicated in patients who have recently received a dose of streptokinase because of antibodies that form against the drug

A 47-year-old woman patient presents with a facial, macular 'butterfly rash'. Rheumatological investigations do not reveal that the patient has SLE. You suspect drug-induced SLE-like syndrome and assess her medication history. Which one of the following drugs is most likely to be responsible for this condition? ជ្រើសមួយ៖ Trimethoprim Diclofenac Atenolol Lansoprazole Aspirin

Sulphonamides are one of the many drugs that are known to cause druginduced SLE-like syndrome. The other drugs responsible for this condition include: • hydralazine; • methyldopa; • griseofulvin; • oral contraceptives; • penicillins; • minocycline; • phenylbutazone; • procaine amide; • diphenylhydantoin. ចម្លើយត្រឹមត្រូវគឺ Trimethoprim

An 18-year-old high school senior develops peripheral vision abnormalities. A CT scan of the brain reveals a cystic suprasellar mass with some calcification noted. Clinically, this is compatible with a craniopharyngioma. What is the best next step in treatment? ជ្រើសមួយ៖ . Surgical resection . Radiotherapy . Transsphenoidal decompression of the optic nerve and optic chiasm . Cerebral angiography with tumor embolization . Growth hormone therapy

Surgical resection

A 55-year-old diabetic woman presents with altered sensations in her hands and feet. She finds it difficult to turn pages of books and discriminating between different coins. When walking, the floor feels different and she likens the sensation to walking on cotton wool. The most likely diagnosis is: ជ្រើសមួយ៖ Diabetic mononeuropathy Diabetic amyotrophy Symmetrical sensory neuropathy Autonomic neuropathy Acute painful neuropathy

Symmetrical sensory neuropathy

Which investigation would help differentiate between acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL)? ជ្រើសមួយ៖ Auramine O stain Sudan black B Leukocyte alkaline phosphatase Myeloperoxidase stain Tartrate-resistant acid phosphatase stain

Tartrate-resistant acid phosphatase stain

Which of the following statements regarding FAP and the APC gene mutation is true? ជ្រើសមួយ៖ Testing of the APC gene has been shown to be cost-effective when used to identify carriers of the APC gene mutation among at-risk relatives of individuals with FAP None of the above Presymptomatic testing has never been shown to reduce morbidity or increase life expectancy Persons with the APC gene mutation develop colorectal adenomas starting at around age 30 FAP is an autosomal dominant disorder with 50% to 70% penetrance of the disease-causing gene mutation

Testing of the APC gene has been shown to be cost-effective when used to identify carriers of the APC gene mutation among at-risk relatives of individuals with FAP

The ability of the liver to regulate the level of blood glucose is critical for survival. Anumber of sources of carbon atoms of nonhepatic origin are used by the liver for gluconeogenesis. However, the net conversion of carbons from fat into carbons of glucose cannot occur in humans because of which of the following? . The carbons of acetyl-CoA from fat oxidation inhibit conversion of pyruvate to oxaloacetate. . Storage of fats occurs in adipose tissue and gluconeogenesis occurs in liver and kidney. . States of catabolism and anabolism are never concurrently active. . Fat oxidation occurs in the mitochondria and gluconeogenesis occurs in the cytosol. . The carbons of acetyl-CoA from fat oxidation are lost as C in the TCA cycle.

The carbons of acetyl-CoA from fat oxidation are lost as C in the TCA cycle.

The mother of a 2-year-old male child states that she has noticed white, cheeselike material arising from his foreskin and also that he cannot fully retract the foreskin behind the glans penis. Which of the following is the correct advice for this parent? ជ្រើសមួយ៖ . The child has paraphimosis, and in addition to a circumcision, likely has an infection requiring topical antibiotics . The child has phimosis and requires a circumcision . Ultrasound of kidneys, bladder, and ureters is indicated to check for unidentified associated defects . The child likely has a previously undiagnosed hypospadias . The child is normal

The child is normal

A 35-year-old woman presents with a right breast mass. You perform a thorough history and physical examination as well as a core biopsy of the right breast mass. In which of the following circumstances would a sentinel lymph node biopsy be indicated? ជ្រើសមួយ៖ . The core biopsy is consistent with ductal carcinoma and the patient has a positive pregnancy test. . The core biopsy is consistent with ductal carcinoma in situ without comedo necrosis for which the patient desires partial mastectomy only. . The core biopsy is consistent with ductal carcinoma and the patient has a bone scan suspicious for metastasis. . The core biopsy is consistent with ductal carcinoma and the patient has palpable axillary lymph nodes. . The core biopsy is consistent with ductal carcinoma and the patient desires partial mastectomy.

The core biopsy is consistent with ductal carcinoma and the patient desires partial mastectomy.

Reticulocytes control the rate of globin synthesis as a consequence of the level of heme in the cell. This prevents globin protein from being made when there are insufficient amounts of heme. Which of the following best explains the effects of heme on protein synthesis in these cells? . RNA polymerase activity is decreased in reticulocytes by low heme. . A tRNA-degrading enzyme is active in the absence of heme. . Heme normally activates peptidyltransfersase in reticulocytes. . A heme-controlled phosphatase dephosphorylates cap-binding factor, which prevents recognition of globin mRNA by the ribosomes. . The initiation factor eIF-2 becomes phosphorylated, reducing its level of activity.

The initiation factor eIF-2 becomes phosphorylated, reducing its level of activity.

A 34-year-old banker has just finished 6 months of warfarin therapy after a pulmonary embolus resulting from deep vein thrombosis. During her hospital stay, she was told she has a factor V Leiden mutation, which makes her prone to clotting. Her husband and two children have now all been tested as well; those test results are as follows: Patient: Arg 506 Gln; increased activated protein C (APC) resistance Husband: Normal, Daughter 1: Arg 506 Gln; increased APC resistance, Son 1: Normal. On the basis of these test results, what steps should be taken now? ជ្រើសមួយ៖ The daughter with a factor V Leiden mutation should be counseled not to take oral contraceptives The proband should be counseled about her need for anticoagulant therapy if she should choose to become pregnant again The family should be tested for other thrombophilic disorders as well, such as lupus anticoagulant The patient and her family should be advised that heterozygosity for factor V Leiden is associated with neither an increase in mortality nor a reduction in normal life expectancy The proband and the daughter carrying her mutant allele will require anticoagulation for a minimum of 6 months to 2 years

The patient and her family should be advised that heterozygosity for factor V Leiden is associated with neither an increase in mortality nor a reduction in normal life expectancy

A patient comes to your office for a new-patient visit. He has moved recently to your city due to a job promotion. His last annual examination was 1 month prior to his move. He received a letter from his primary physician stating that laboratory workup had revealed an elevated alkaline phosphatase and that he needed to have this evaluated by a physician in his new location. On questioning, his only complaint is pain below the knee that has not improved with over-the-counter medications. The pain increases with standing. He denies trauma to the area. On examination you note slight warmth just below the knee, no deformity or effusion of the knee joint, and full ROM of the knee without pain. You order an x-ray, which shows cortical thickening of the superior fibula and sclerotic changes. Laboratory evaluation shows an elevated alkaline phosphatase of 297 mg/dL with an otherwise normal metabolic panel. Which of the following is the treatment of choice for this patient? ជ្រើសមួយ៖ . Observation . Melphalan and prednisone . A bisphosphonate . Nonsteroidal anti-inflammatory . Ursodeoxycholic acid (UDCA)

The radiographs and elevated alkaline phosphatase suggest Paget disease of the bone.

A 5-year-old boy is involved in traffic accident and is complaining of neck pain. Which of the following statements is true regarding the cervical spine radiograph? Select one: • The distance between the anterior arch of C1 and the dens can be up to 5mm Subluxation of up to 7mm of C2 anteriorly on C3 is normal The soft tissues anterior to C2 must be no wider than 1/4 of the width of the C2 vertebral body • Subluxation of up to 3mm of C2 posteriorly On C3 is normal • The soft tissues anterior to C2 must be no wider than 1/2 of the width of the C2 vertebral body

The soft tissues anterior to C2 must be no wider than 1/4 of the width of the C2 vertebral body

Which of the following features in this case would be an absolute contraindication to thrombolytic therapy? ជ្រើសមួយ៖ Age greater than 75 years Failure to meet ECG criteria Elevated blood pressure History of stroke There are no absolute contraindications

There are no absolute contraindications

Which of the following is true of mitochondrial inheritance?

These disorders commonly follow a maternal line of inheritance. (Pass from mother to child)

You are examining a 12-year-old male patient who has a slowly enlarging, painless swelling in the left inferior region of the neck. After careful palpation and consideration of the results of the radioimaging studies, you diagnose a branchial cyst in the left inferior parathyroid gland. This gland arose in development from which of the following pharyngeal pouches? . fourth . second . first . third . fifth

Third

A 31-year-old male immigrant from India is found on a routine physical examination to have a single, 2-cm nodule in the right lobe of his thyroid gland. The mass is firm, moves up and down with swallowing, and is not tender. The skin of his face and neck is pitted with multiple scars, which suggest smallpox; however, he explains that the scars are due to very severe acne that he had as a youngster, for which he eventually received external beam radiation therapy at the age of 14. His thyroid function tests are normal, and fine needle aspiration (FNA) cytology of the mass is read by the pathologist as "indeterminate." Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . FNA should be repeated until it can be read as benign or malignant . No further care is needed . Thyroid scan and sonogram are needed . Thyroid function tests should be repeated yearly . Thyroid lobectomy

Thyroid lobectomy

A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient? ជ្រើសមួយ៖ . External beam radiation to the neck. . Thyroid lobectomy. . Prophylactic neck dissection is indicated along with a total thyroidectomy. . Multidrug chemotherapy. . TSH suppression by thyroid hormone.

Thyroid lobectomy.

Which of the following is an indication to start dopamine? ជ្រើសមួយ៖ . To decrease heart rate . To lower peripheral vascular resistance . To increase coronary flow . To inhibit catecholamine release . To increase splanchnic flow

To increase coronary flow

A 45-year-old man presents with right upper quadrant abdominal pain and fever. CT scan shows a large, calcified cystic mass in the right lobe of the liver. Echinococcus is suggested by the CT findings. Which of the following is the most appropriate management of echinococcal liver cysts? ជ្រើសមួយ៖ . Medical treatment with metronidazole. . Medical treatment with steroids. . Medical treatment with albendazole. . Percutaneous catheter drainage. . Total pericystectomy.

Total pericystectomy.(at the time of surgery, and efforts are made to avoid spillage and contamination of the peritoneal cavity.)

A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for discussion for surgical intervention. The patient is otherwise healthy and does not have evidence of rectal dysplasia. Which of the following is the most appropriate elective operation for this patient? ជ្រើសមួយ៖ . Total proctocolectomy with end ileostomy . Total abdominal colectomy with ileal-rectal anastomosis . Total abdominal colectomy with end ileostomy and very low Hartmann . Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and diverting ileostomy . Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy

Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy

A 33-year-old woman is found to have a palpable thyroid nodule during a routine medical checkup. A sonogram confirms the presence of a solid, 1.5-cm nodule in the right lobe of the thyroid gland. Fine needle aspirate cytology (FNA) is reported as "follicular tumor, otherwise unspecified." At surgery, a frozen section is read as follicular carcinoma. With the neck open, the surgeon can feel for enlarged jugular and peritracheal lymph nodes, and finds none. Which of the following is the most appropriate treatment? ជ្រើសមួយ៖ . Enucleation of the tumor . Total thyroidectomy, radical neck dissection, and postoperative radioactive iodine . Right thyroid lobectomy . Total thyroidectomy . Total thyroidectomy plus postoperative radioactive iodine

Total thyroidectomy plus postoperative radioactive iodine

A 50-year-old man complains of loss of libido and impotence after starting treatment with leuprolide for prostatic hyperplasia. An alpha-blocker and finasteride have also been tried, but with similar adverse effects. So far, the patient has not experienced any episodes of urinary tract infection or hematuria, but he is excessively bothered by his symptoms without any medication. Digital rectal examination shows mild prostatic enlargement. At this time, his prostate-specific antigen (PSA) is 4.5 ng/mL, and his creatinine is 0.7 mg/dL. Dipstick examination shows no hematuria. Which of the following is the most appropriate alternative to his current pharmacologic treatment? ជ្រើសមួយ៖ Watchful waiting Open prostatectomy Transurethral resection of the prostate (TURP) Transurethral incision of the prostate (TUIP) Megestrol acetate

Transurethral incision of the prostate (TUIP) involves incision of the periurethral prostate without resection of any tissue

A 60-year-old man seeks m edical attention because of recurrent urinary tract infections. The patient also reports a history of increasing difficulty in urination (decreased flow, straining, and hesitancy) over the last several months. A prostate-specific antigen (PSA) level is mildly elevated and a prostate biopsy proves benign. Which of the following is the most appropriate initial management of this patient with benign prostatic hyperplasia (BPH)? ជ្រើសមួយ៖ . α-Adrenergic blocker . α-Adrenergic blocker and 5-alpha reductase inhibitor . 5-alpha reductase inhibitor . Open prostatectomy . Transurethral resection of the prostate (TURP)

Transurethral resection of the prostate (TURP)

A 17-year-old boy living at home with his parents presents with an intensely pruritic papulovesicular eruption involving the hands and wrists. Skin scrapings identify eggs and waste products of Sarcoptes scabiei. Which of the following management options is most appropriate? ជ្រើសមួយ៖ Treat the patient and all household members with permethrin 5% cream, and tell them to wash all clothing and linens with which they have come in contact over the past 10 days Treat the patient and all household members with permethrin 5% cream, and tell them to wash all clothing and linens with which they have come in contact over the past 2 days Treat the patient and symptomatic household members with permethrin 5% cream, and tell them to wash all clothing and linens with which they have come in contact over the past 2 days Treat the patient and symptomatic household members with permethrin 5% cream, and tell them to wash all clothing and linens with which they have come in contact over the past 10 days

Treat the patient and all household members with permethrin 5% cream, and tell them to wash all clothing and linens with which they have come in contact over the past 2 days (2days because S.scabeii can live 48h away from the host)

An 18-year-old cricketer develops pain and swelling around the MTPJ of his big toe after a long period of fast bowling. He now has difficulty pushing off on that foot. What is the most likely diagnosis? ជ្រើសមួយ៖ Ulcer Turf toe Morton's neuroma Osteomyelitis Stress fracture

Turf toe

Which of the following is NOT an indication for implantation of a cardiac pacemaker? ជ្រើសមួយ៖ Complete AV block Resynchronization in the treatment of heart failure Neurocardiogenic syncope with significant bradycardia Type I second-degree atrioventricular (AV) block in an asymptomatic athlete Temporary pacing in the setting of acute myocardial infarction complicated by conduction abnormalities and hemodynamic instability

Type I second-degree atrioventricular (AV) block in an asymptomatic athlete

Desmin is a 53-kDa protein found in skeletal and smooth muscle cells. It plays a role in coordinating muscle cell contraction. Desmin belongs to which type of intermediate filaments?

Type III

Which of the following statements concerning muscle spindles is correct? . Alpha motoneurons synapse directly with intrafusal muscle fibers. . Type Ia sensory fibers from a spindle form direct synaptic contact with alpha motoneurons in the spinal cord. . Activation of type Ia sensory fibers from a given spindle leads to inhibition of the muscle in which that spindle is located. . Each intrafusal fiber is innervated by two different gamma motoneurons. . Only one type of intrafusal muscle fiber (cell) is present in most muscle spindles.

Type Ia sensory fibers from a spindle form direct synaptic contact with alpha motoneurons in the spinal cord.

A 25-year-old medical student noticed that he had a murmur when he tested his new stethoscope. On assessment in the cardiology clinic, he was found to have a harsh systolic murmur over his precordium, which did not change with inspiration. ECG showed features of biventricular hypertrophy. What is the most likely diagnosis? ជ្រើសមួយ៖ Tricuspid regurgitation Mitral regurgitation Aortic stenosis Ventricular septal defect Hypertrophic cardiomyopathy

VSD ( Right-sided murmurs increase with inspiration (eg tricuspid regurgitation, TR), whereas left-sided murmurs show no change. The clue to diagnosis is in the ECG finding. Aortic stenosis and mitral regurgitation produce left ventricular hypertrophy, TR produces right ventricular hypertrophy and a ventricular septal defect produces biventricular hypertrophy.)

Shellfish poisoning, which is caused by eating shellfish that have ingested toxic dinoflagellates (red tide), is characterized by which of the following?

Weakness and paralysis

A2-month-old infant suffering from increased vomiting and diarrhea is seen in the hospital and observed to have significant abdominal distention due to hepatosplenomegaly. Unfortunately, the infant does not survive. Autopsy reveals calcification of the adrenals and massive accumulation of cholesteryl esters and triglycerides in most tissues. Analysis of enzyme activity in fibroblasts and lymphocytes demonstrates a significant acid lipase (cholesteryl ester hydrolase) deficiency. These clinical findings are indicative of which of the following disorders? . Sanfilippo syndrome . Wolman disease . Maroteaux-Lamy syndrome . I-cell disease (mucolipidosis type II) . hyperlipoproteinemia, type I (familial liproprotein lipase deficiency)

Wolman disease

A 3-month-old infant exhibits profound neurologic deficit in addition to being blind and deaf. Pathologic examination indicates renal cysts, hepatomegaly, and facial dysmorphism. Biochemical analysis reveals plasma accumulations of very long-chain fatty acids, abnormal intermediates of bile acid synthesis, and a marked deficiency of plasmalogens. These physical and biochemical features are characteristic of which of the following disorders? . infantile Refsum disease . hyperpipecolic acidemia . Zellweger syndrome . neonatal adrenoleukodystrophy . rhizomelic chondrodysplasia punctata (RCDP)

Zellweger syndrome

Heparin is a rapidly acting, potent anticoagulant that has many important clinical uses. Which of the following is an action of heparin? . acts with antithrombin to inhibit thrombin activity . inhibits calcium action . decreases prothrombin time . promotes vitamin K activity . activates prothrombin

acts with antithrombin to inhibit thrombin activity

In which of the following conditions would the gas composition of both end pulmonary capillary blood and alveolar air approximate that of mixed venous blood? . airway obstruction . pulmonary capillary embolus . normal breathing . breathing 100% oxygen . hyperventilation

airway obstruction

A 14-year-old female patient complains of a severe sore throat and you use a cotton swab to obtain specimens for a culture. As you lightly touch the pharyngeal wall with the cotton swab, the patient gags. What is the location of neuronal cell bodies innervating pharyngeal constrictor muscles involved in the gag reflex? Select one: a. hypoglossal nucleus b. ambiguus nucleus c. facial nucleus d. abducens nucleus e. dorsal motor nucleus of the vagus

ambiguus nucleus

You see a 67-year-old man who has presented with a four-month history of progressive shortness of breath, initially on exertion but now also at rest. Associated symptoms include a dry cough. His past medical history includes atrial fibrillation, hypertension and hypercholesterolaemia. On examination, oxygen saturations are 92 per cent on room air, respiratory rate is 19 and the patient is apyrexial. On auscultation of the chest you hear bibasal fine inspiratory crackles. You review the patient's medication history. Which of the following drugs from the patient's list is most likely to cause the symptoms experienced by the patient? ជ្រើសមួយ៖ Amiodarone Amlodipine Aspirin Alendronate Simvastatin

amiodarone (=> pulmonary fibrosis :dry cough, low O2 at, bbasal fine crackle)

Which of the following drugs below is likely to have caused the derangement in the patient's liver function? ជ្រើសមួយ៖ Amlodipine Aspirin Amiodarone Ramipril Bendroflumethiazide

amiodarone (drug-induced liver cirrhosis secondary to chronic amiodarone therapy)

When the body becomes acidotic, the liver and the kidneys play central roles in reactions designed to reduce the proton level (i.e., increase the pH) of the circulation. Which of the following constitutes the hepatic reaction occuring during periods of acidosis? . increased production of urea to dispose of ammonia . glutamine conversion to glutamatereleasing ammonia . glutamine conversion to alphaketoglutarate-releasing ammonia . ammonia incorporation into glutamateforming glutamine . ammonia incorporation into alphaketoglutarate-forming glutamate

ammonia incorporation into glutamateforming glutamine

Synthesis of glycogen is inhibited in hepatocytes in response to glucagon stimulation primarily as a result of which of the following? . a decrease in the level of phosphorylated phosphorylase kinase . an increase in the level of the dephosphorylated form of glycogen synthase . a decrease in the levels of phosphorylated phosphoprotein phosphatase inhibitor-1 . a decrease in the level of phosphoprotein phosphatase . an increase in the level of the phosphorylated form of glycogen synthase

an INCREASE in the level of the PHOSPHORYLATED form of glycogen synthase

Osteitis fibrosa cystica is caused by:

an increase in the parathyroid hormone, x-ray of the chest may show a classic "rugby jersey" (striped like a rugby jersey) spine due to ill-defined bands of increased bone density adjacent to the vertebral endplates.

A newborn infant suffers from epidermolysis bullosa simplex, characterized by skin blistering soon after birth. The blisters appear at sites of pressure or rubbing such as the fingers. You explain to the distressed parents that this condition is a disease of intermediate filaments and results from mutant genes for keratins K5 and K14. Which cells of the skin normally produce keratins K5 and K14? . melanocytes of the epidermis . adipose cells in the hypodermis . basal cells of the epidermis . fibrocytes of the dermis . upper differentiating cells of the epidermis

basal cells of the epidermis

Multiple sclerosis is a relatively common nervous system demyelinating disease. It is autoimmune and restricted to the central nervous system. Nerve conduction velocity is depressed in almost all affected individuals. Manipulations which prolong action potential duration seem to mitigate symptoms, possibly by facilitating conduction through sections of membrane which are no longer myelinated. Application of which type of drug might be expected to prolong action potential duration and thus be a potential therapeutic tool? . blocks potassium channels . activates potassium channels . blocks sodium channels . blocks L-type calcium channels . increases sodium channel inactivation

blocks potassium channels

Normal metabolism by the body generates large quantities of acid. In spite of this, normal blood pH is a slightly alkaline 7.4. This extracellular fluid alkalinity is maintained primarily by the body's removal of which of these? . carbon dioxide . keto acids such a acetoacetic acid . titratable acids such as phosphoric acid . ammonia . lactic acid

carbon dioxide

In the central auditory pathways, second-order neurons are located in which of the following? . inferior colliculi . cochlear (spiral) ganglion . superior olivary nuclei . nuclei of lateral lemniscus . cochlear nuclei

cochlear nuclei

Which of the following statements about keloids is false? ជ្រើសមួយ៖ Cryotherapy is ineffective They are more common in African Americans, Hispanics, and those with a family history of keloids None of the above Intralesional steroids can flatten the keloids Risk factors for the development of keloids include wound tension, ear piercing, healing by second intention, young age, and deep laceration

cryotherapy is ineffective

A term infant has respiratory distress and a blood count reveals a hematocrit of 65%. Your resident states that fetal hemoglobin has an increased affinity for oxygen as compared with adult hemoglobin. What effect might this result in?

decreased binding with 2,3-diphospho- glycerate (2,3-DPG)

A 25-year-old woman is admitted to accident and emergency with a severe exacerbation of asthma. On examination, her respiratory rate is 30, oxygen saturations are 95 per cent on 15 L O2 and temperature is 37.2°C. As you feel the peripheral pulse, the volume falls as the patient inspires. Which of the following explains this clinical sign? ជ្រើសមួយ៖ Decreased right ventricular filling pressures on inspiration Increased left atrial filling pressures on inspiration Decreased left atrial filling pressures on inspiration Decreased right atrial filling pressures on inspiration Peripheral vasodilation

decreased left atrial filling pressure on inspiration.

You are the designated driver on Saturday night and are soberly walking to your car with your friends. You spot an elderly man lying on the ground. He is not breathing and has no pulse although he is warm. You ask a friend to call 999. His airway is clear. Your praecordial thump fails. The most likely way for his heart to resume beating is: ជ្រើសមួយ៖ Recovery position Adrenaline Cerebral reoxygenation Defibrillation Chest compressions

deefibrillator A praecordial thump upon the chest is only likely to cardiovert if given within seconds of a cardiac arrest. Chest compressions will move blood from the lungs to the cerebrum. This will prevent tissue hypoxia, leading to infarction and therefore reduce morbidity should the patient become successfully resuscitated, however they are unlikely to restore a pulse. Only defibrillation will start the heart beating again, although his airway should always be checked first as per the ABC protocol.

A 15-year-old high school football player is brought to the emergency room. On examination, his right lower limb is deformed and swollen around the knee. At full extension, there is valgus instability, suggestive of knee dislocation. The patient is in great pain and there is a concern for concomitant vascular and nervous injuries. Palpation of the dorsalis pedis artery reveals a normal pulse. However, neurological examination reveals impaired dorsiflexion of the foot with decreased sensation in the space between digits 1 and 2. Which of the following nerves is affected? . saphenous nerve . femoral nerve . superficial peroneal (fibular) nerve . deep peroneal (fibular) nerve . tibial nerve

deep peroneal (fibular) nerve

Which of the following is most appropriate for the treatment of Mycoplasma pneumoniae infection?

erythromycin

A 16-year-old boy presents to accident and emergency in a confused state. He appears pale, sweaty and has a heart rate of 110 bpm and temperature of 37°C. Respiratory examination reveals good air entry and a respiratory rate of 12. He is accompanied by a group of friends who admit they had been drinking alcohol earlier and smoking marijuana. They deny he has any medical problems apart from mild asthma and deny ingesting any other recreational substances. Urine dipstick is negative for any significant findings. His blood glucose is 2.1 mmol/L. The most likely cause of the patient's symptoms is: ជ្រើសមួយ៖ Cannabis toxicity Diabetic ketoacidosis Asthma attack Ethanol toxicity Ecstasy ingestion

ethanol toxicity

A 59-year-old Caucasian female is self-donating blood in preparation for a hip replacement surgery in the near future. Shortly after her third session of donating a unit (pint) of whole blood, her mean arterial pressure remains unchanged, even though the venous return of blood to her heart is diminished. Which of the following is the most likely reason for the preservation of arterial pressure? . cardiac output rises to compensate for the reduced venous return . fall in venous return is offset by an increase in total peripheral resistance . heart rate rises to compensate for a reduced venous return . venous return and blood pressure are unrelated . end-diastolic ventricular filling pressure rises during hemorrhage

fall in venous return is offset by an increase in total peripheral resistance

A newborn infant displays wheezing respiration, which is aggravated when she feeds, flexes her neck, and/or cries. Radioimaging studies of her chest reveal a double aortic arch compressing her trachea and esophagus. This rare developmental defect results from persistence of the right dorsal aorta, which normally disappears. The arch of the aorta arises from which of the following structures? . fifth pair of aortic arches . fourth pair of aortic arches . second pair of aortic arches . sixth pair of aortic arches . third pair of aortic arches

fourth pair of aortic arches

Vitamin K serves as a coenzyme in reactions that result in the modified activity of several enzymes of the blood coagulation cascade. Which of the following amino acid modifications requires the activity of vitamin K? . lysine to hydroxylysine . glutamate to gamma-carboxyglutamate . proline to hydroxyproline . lysine to beta-methyllysine . aspartate to beta-carboxyaspartate

glutamate to gamma-carboxyglutamate

A 60-year-old woman recently diagnosed with type 2 DM complains of daily headaches and double vision that have gradually worsened over the previous month. An MRI shows a large pituitary adenoma. Which of the following is most likely being secreted by this tumor? ជ្រើសមួយ៖ Luteinizing hormone Thyroid-stimulating hormone Prolactin Growth hormone ACTH

growth hormone

The patient with uncomplicated postmenopausal osteoporosis (ie, primary osteoporosis)

has normal iPTH, ionized calcium, and alkaline phosphatase levels.

First-time parents of a 1-month-old are anxious to hear what they can expect in the next few months. Which of the following best describes the usual sequence for attainment of gross motor milestones in a young infant?

head control, hands together in midline, rolling over, pulls to stand

A 4-month-old female infant has generalized hypotonia, small ears, inner epicanthal folds, clinodactyly, and wide-spaced first and second toes. For which of the following problems is she most at risk?

hearing loss

There is but a single enzyme-catalyzed reaction in the human body known to generate carbon monoxide (CO) as one of its products. Which of the following enzymes represents the one that catalyzes this CO-producing reaction? . uroporphyrinogen decarboxylase . coproporphyrinogen oxidase . heme oxygenase . biliverdin reductase . protoporphyrinogen oxidase

heme oxygenase

A 70-year-old man presents with back pain and increasing difficulty with initiating a urinary stream. On rectal examination, he is found to have a hard, irregularly enlarged prostate. He has an elevated prostate-specific antigen (PSA), and osteoblastic lesions in the vertebral column and bones of the pelvis. A needle biopsy of the prostate shows well-differentiated adenocarcinoma. Which of the following is the treatment of choice? ជ្រើសមួយ៖ . radical prostatectomy . hormonal manipulation . transurethral prostatectomy . radiotherapy . cytotoxic chemotherapy

hormonal manipulation

A patient with chronic renal insufficiency due to renal vascular disease has a net functional loss of nephrons. If we assume that production of urea and creatinine is constant and that the patient is in a steady state, a 50% decrease in the normal GFR will cause which of the following to occur? . greatly increase plasma . not affect plasma creatinine . decrease plasma urea concentration . significantly decrease plasma . increase the percent of filtered Na+ excreted

increase the percent of filtered Na+ excreted

A patient presents with long-standing emphysema. Which of the following would you expect to see in this individual? Select one: a. increased FRC b. increased FVC c. increased FEV1/FVC d. increased lung elastic recoil e. decreased physiological dead space

increased FRC

Apatient presents with long-standing emphysema. Which of the following would you expect to see in this individual? . increased lung elastic recoil . decreased physiological dead space . increased FEV1/FVC . increased FVC . increased FRC

increased FRC

A healthy 27-year-old male is given a treadmill stress test. His cardiovascular values at rest and during exercise were: When compared to rest, what was the change in his estimated mean arterial pressure? . decreased by 10 mm Hg . increased by 140 mm Hg . increased by 5 mm Hg . increased by 25 mm Hg . increased by 35 mm Hg

increased by 5 mm Hg

Muscle membrane will depolarize in response to acetylcholine binding its receptors at the neuromuscular junction. Associated with this depolarization are changes in glycogen metabolism in skeletal muscle cells. Which of the following represents the correct changes in enzyme activity seen in response to acetylcholine binding? . decreased phosphorylation of, and inhibited activity of glycogen phosphorylase kinase . increased phosphorylation of, and inhibited activity of glycogen phosphorylase kinase . increased glycogen phosphorylase kinase activity due to an activation of phosphoprotein phosphatase . increased glycogen phosphorylase kinase activity due to an increase in calcium binding to its calmodulin subunit . decreased glycogen phosphorylase kinase activity due to an increase in calcium binding to its calmodulin subunit

increased glycogen phosphorylase kinase activity due to an increase in calcium binding to its calmodulin subunit

A 1-year-old infant presents with cardiomegaly and congestive heart failure. She has increased intracranial pressure with hydrocephaly and cranial bruit. A vein of Galen aneurysm, revealed by MRI, is shown to compress the aqueduct of Sylvius, the posterior part of the third ventricle, and the splenium of the corpus callosum. Normally, the cerebral vein of Galen joins with which dural venous sinus? . inferior sagittal sinus . sigmoid sinus . superior petrosal sinus . superior sagittal sinus . transverse sinus

inferior sagittal sinus

A newborn female infant cannot swallow, exhibits persistent drooling, and aspiration or regurgitation of food after attempted feedings. When the infant strains, coughs, or cries, the stomach inflates, elevating the diaphragm and making respiration more difficult. The patient is diagnosed with congenital esophageal atresia at the cervical levels, necessitating surgical repair. During the surgery, the blood supply of the esophagus must be carefully isolated to protect from injury. Which of the following arteries supplies the esophagus at cervical levels? . left inferior gastric artery . inferior thyroid artery . internal thoracic artery . bronchial artery . left inferior phrenic artery

inferior thyroid artery

A 19-year-old man was in a barroom brawl and was punched squarely in the right eye. He comes to the emergency room the next day and complains of diplopia. An X-ray reveals fracture of the orbital floor. Neurological examination shows loss of sensation of the skin of the right face below the right eye and the upper gums. Which of the following nerves may be injured? . nasociliary nerve . supraorbital nerve . frontal nerve . infraorbital nerve . trochlear nerve

infraorbital nerve

The statin class of drugs that are currently used to control hypercholesterolemia function to lower circulating levels of cholesterol by which of the following mechanisms? . inhibiting the interaction of LDLs with the hepatic LDL receptor . increasing the elimination of bile acids, leading to increased diversion of cholesterol into bile acid production . decreasing the absorption of dietary cholesterol from the intestines . increasing the synthesis of apolipoprotein B-100 (apo ), resulting in increased elimination of cholesterol through the action of low-density lipoprotein (LDL) uptake by the liver . inhibiting the rate-limiting step in cholesterol biosynthesis

inhibiting the rate-limiting step in cholesterol biosynthesis

A 6-year-old male with a known history of asthma presents to the emergency department with the most severe asthma attack of his life. When you listen, you hear very little air movement and your patient has a declining level of consciousness. After your initial measures, you see very little improvement and a decision is made to intubate the patient's trachea. Which combination of drugs is most appropriate in this situation to prevent worsening bronchospasm?

ketamine, lidocaine, and rocuronium

A 75-year-old male presented with a 6-month history of early satiety and with upper abdominal discomfort for many years. Physical examination revealed mild epigastric tenderness. Esophago-gastro- duodenoscopy showed a large, ulcerated mass in the upper stomach, which was found to be cancerous. Surgery resulting in the removal of the gastric fundus was performed. After successful surgery, the patient was advised to eat small portions and to drink small volumes because of which of the following? . lack of receptive relaxation in the stomach . weaker and slower propulsion of food toward the pylorus . inadequate mixing of large food boluses . distorted emptying of liquids . almost complete absence of gastric motility

lack of receptive relaxation in the stomach

A 3-month-old infant has persistent stridor. What is the most likely cause?

laryngomalacia

A 45-year-old man attends for review. He has been suffering increasing shortness of breath over the past few years. He is a non-smoker who drinks 20 units per week of alcohol and has no significant past cardiovascular history. Now he presents with what seems to have been a transient ischaemic attack (TIA), with weakness and co-ordination problems affecting his left side, which have resolved over the past 24 hours. On examination blood pressure is 142/95 mmHg and he is in sinus rhythm. There is no opening snap, but a diastolic murmur is heard which changes in character according to posture. Bloods are unremarkable, including C-reactive protein (CRP), which is in the normal range. Which of the following diagnoses fit best with this clinical picture? ជ្រើសមួយ៖ Mitral regurgitation Aortic stenosis Left atrial myxoma Right atrial myxoma Mitral stenosis

left atrial myxoma

During surgical resection of the gastrointestinal tract for treatment of long-standing irritable bowel syndrome, a surgery resident is asked to select a surgical site coinciding with the termination of the vagal innervation. Which of the following does she select? . junction of the second part and third part of the duodenum . ileocolic junction . left colic (splenic) flexure . right colic (hepatic) flexure . duodenojejunal junction

left colic (splenic) flexure

A 19-year-old camper fell asleep with the right side of her face against the cold earth on an autumn night. In the morning, she woke up and found that she could not move the right side of the face. She went to the local emergency room in a nearby town and was diagnosed with Bell's palsy. Which of the following muscles is not affected in her condition? . orbicularis oculi . levator labii superioris alaeque nasi . levator labii superioris . buccinators . levator palpebrae superioris

levator palpebrae superioris

Arrow 2 in following figure points to which of the following structures? . lacis cells . glomerulus . juxtaglomerular cells . macula densa . vascular pole of the renal corpuscle

macula densa

which one of the following medications can act as an acute bronchodilator? Select one: sodium phosphate calcium chloride sodium bicarbonate potassium chloride magnesium sulfate

magnesium sulfate

Infants exhibiting profound metabolic ketoacidosis, muscular hypotonia, developmental retardation, and who have very large accumulations of methylmalonic acid in their blood and urine suffer from a disorder known as methylmalonic acidemia. This disorder results from a defect in which of the following enzymes? . tyrosine aminotransferase . methylmalonyl-CoA mutase . alpha-keto acid dehydrogenase . phenylalanine hydroxylase . homogentisic acid oxidase

methylmalonyl-CoA mutase

You are examining the biochemical characteristics of the liver dysfunction in your patient, who is exhibiting signs of a glycogen storage disease. You have isolated the microsomal fraction (contains the endoplasmic reticulum) of a liver biopsy homogenate from your patient and a control individual for your studies. Incubation with radioactive phosphate-labeled glucose-6-phosphate results in an increase in isotope associated with the microsomes from your control sample but no increase in association with the microsomes from your patient. These results are best explained by a defect in which of the following? . microsomal glucose transport . cytosolic glucose-6-phosphatase . microsomal phosphate transporter . microsomal glucose-6-phosphate transporter . glucose-6-phosphatase activity in the microsomes

microsomal glucose-6-phosphate transporter

The structure indicated by arrow 1 in following figure is innervated by which of the following? . lesser palatine nerve . nasopalatine nerve . greater palatine nerve . middle superior alveolar nerve

middle superior alveolar nerve

A 10-month-old male infant with a history of umbilical hernia repair is noted to have coarse facial features and is diagnosed with Hurler disease. This condition is the most severe of which of the following groups of inherited diseases? Select one: glycogen storage diseases glycoproteinoses sphingolipidoses mucopolysaccharidoses mucolipidoses

mucopolysaccharidoses

A 7-year-old boy is examined by his pediatrician because of complaints of severe cramping pain in his legs whenever he rides his bike. He also expriences nausea and vomiting during these attacks. The child has noted that the severity of the cramps is most intense after dinners that include baked potatoes or pasta, and sometimes bread. Clinical studies undertaken following a treadmill test demonstrate myoglobinuria, hyperuricemia, and increased serum bilirubin. Which of the following enzyme deficiencies is associated with these clinical findings? . glucose-6-phosphatase . glycogen synthase . muscle phosphorylase . liver glycogen debranching enzyme . muscle phosphofructokinase

muscle phosphofructokinase

Analysis of a tumor cell line indicates that there is a dramatically increased level in the activity of the transcription factor E2F. Which of the following is the most likely explanation for this observation? . hypophosphorylation of pRB so that it can no longer interact with E2F . an increase in the expression of pRB resulting in increased binding of pRB to E2F . loss of expression of pRB which normally activates E2F . mutation in the domain of pRB to which E2F binds, the consequences of which lead to constitutive E2F activity . mutation in pRB that prevents its phosphorylation so that it cannot interact with the gene to which it normally binds and coactivates with E2F

mutation in the domain of pRB to which E2F binds, the consequences of which lead to constitutive E2F activity

In a comparative study of two related cell lines, you find that one responds normally to insulin while the other has an impaired response. You discover that both cell lines bind insulin with equal affinity but that the impaired response is manifest in an inability to recruit the insulin response substrate- 1 (IRS-1) protein to the receptor. This would most likely be due to which of the following? . mutation in the tyrosine phosphorylation site of IRS . serine phosphorylation of the insulin receptor preventing IRS binding . loss of activation of phospholipase C-gamma (PLC-g) . tyrosine phosphorylation of the insulin receptor leading to the loss of the IRS binding site . inability of the receptor to phosphorylate the RAS G-protein

mutation in the tyrosine phosphorylation site of IRS

Production of specific granules occurs mainly during which stage of granulocyte development? . promyelocyte . metamyelocyte . myelocyte . myeloblast . granulocyte colony-forming unit

myelocyte

Which of the following compounds directly functions in excitation contraction coupling in smooth but not skeletal muscle? . troponin . calcium . myosin . myosin light chain kinase . actin

myosin light chain kinase

In coordinating pediatric residents to perform head start (early childhood development) physicals and developmental screenings on a group of preschool children, it is mentioned that a child who can walk downstairs alternating his or her feet, do a broad jump, and throw a ball overhand, also would be expected to do which of the following?

name two or three colors

A 29-year-old nonhelmeted motorcycle driver is involved in a single vehicular crash, resulting in a significant closed-head injury. He is intubated in the field and transported to a level 1 trauma center. On arrival, he is oxygenating well with assisted ventilation and has a normal blood pressure and moderate tachycardia. His Glasgow Coma Score is 7, and his pupils are equal and sluggishly reactive. After stabilization in the emergency department, the patient undergoes a CT scan of the head that demonstrates a small amount of subarachnoid blood and a right frontal lobe contusion with edema with no midline shift. CT scan of the abdomen is normal. The patient is transferred to the ICU. The optimal initial management of this patient's intracranial pressure (ICP) would be which of the following? ជ្រើសមួយ៖ . hyperventilation and IV steroids . fluid restriction, hyperventilation, and ventriculostomy . craniotomy . fluid restriction, hyperventilation, and osmotic diuresis . normovolemia, normocarbia, sedation, and ventriculostomy

normovolemia, normocarbia, sedation, and ventriculostomy

Apatient has been severely injured in the back of the head during a mugging attempt and imaging studies reveal possible fracture of the skull along with the C1 (atlas) vertebra. The patient is also hemorrhaging from the vertebral artery in this location, and the attending surgeon will attempt to stop the bleeding by access through the suboccipital triangle. Which of the following muscles attaches from the transverse process of C1 to the occipital bone and forms the lateral border of the suboccipital triangle? . semispinalis cervicis . obliquus capitis superior . rectus capitis posterior major . rectus capitis posterior minor . obliquus capitis inferior

obliquus capitis superior

After removal of cancerous lymph nodes from the lateral pelvic wall, a patient develops painful spasms of the adductor muscles and sensory deficits in the medial thigh region. The adductor muscles are innervated by which of the following nerves? . femoral . inferior gluteal . pudendal . sciatic . obturator

obturator

An 8-year-old girl presents with a 3-month history of intermittent joint swelling and stiffness and is subsequently diagnosed with juvenile idiopathic arthritis (JIA). Which of the following types of JIA is most commonly associated with development of severe arthritis?

polyarticular rheumatoid factor positive JIA

A 40-year-old Indian man presents to accident and emergency with a one-month history of haemoptysis. He is a non-smoker. On further questioning, he mentions that he has also been having fevers and night sweats. Chest x-ray shows nodular shadowing in the right upper zone. What is the most likely diagnosis? ជ្រើសមួយ៖ Small cell carcinoma of the lung Primary tuberculosis Pneumocystis pneumonia Sarcoidosis Post-primary tuberculosis

post-primary tuberculosis

Your patient presents in your office complaining of hoarseness. During your examination, you find that one vocal fold has deviated toward the midline and does not abduct during deep inspiration or vocalization. You also observe that touch sensation in the vestibule of the larynx appears to be intact. Which laryngeal muscle is most important in abduction of the vocal folds? . transverse arytenoid . cricothyroid . posterior cricoarytenoid . thyroarytenoid . lateral cricoarytenoid

posterior cricoarytenoid

Which of the following is a true statement regarding renal clearance of a substance? . is measured in milligram per minute . insulin is zero . glucose is greater than that of insulin in the normal kidney . potassium clearance will increase after an injection of aldosterone . PAH remains constant regardless of the plasma level

potassium clearance will increase after an injection of aldosterone

A 36-year-old woman presents to clinic with neurological symptoms. On examination, she is able to stand with her feet together. Upon closing her eyes, however, she is unable to keep her balance. What is the diagnosis? ជ្រើសមួយ៖ Diabetes Cerebellar problem Visual problem Proprioceptive problem Alcohol abuse

proprioceptive problem (Romberg's test. It is positive in patients with proprioceptive loss)

A term newborn infant has a normal weight but height below the 5th percentile. A large posterior fontanelle is the only other finding. A delayed bone age is noted on skeletal survey based on the appearance of ossification centers and further testing reveals the diagnosis of con- genital hypothyroidism. In normal neonates, ossification centers are usually radiographically visible at birth in which of the following sites?

proximal tibia

Noonan syndrome Choose the cardiovascular anomaly most closely associated with the condition below: Select one: coarctation of the aorta atrioventricular septal defect mitral valve prolapse supravalvular aortic stenosis pulmonary stenosis

pulmonary stenosis

Acetyl-CoA enhances the rate of gluconeogenesis by acting as an allosteric activator of which of the following enzymes? . ACC . pyruvate carboxylase . PEP-carboxykinase . PDH . pyruvate kinase

pyruvate carboxylase

A patient with benzodiazepine overdose presents with

slurred speech, unsteady gait, and drowsiness. Benzodiazepines are used for the treatment of anxiety, insomnia, seizures and alcohol withdrawal. During benzodiazepine intoxication, pupil size tends to be normal, with only mild respiratory depression.

A 53-year-old male patient has developed an abnormal hypersensitivity in the face area. He complains that he feels pain when he drives with the window down and from the wind blowing on his face. The pain is exacerbated by direct touch to the left side of his lower jaw. The patient is diagnosed with trigeminal neuralgia (tic douloureux). Where do pain fibers from the left side of his mandible project to? Select one: a. trigeminal (gasserian) ganglion b. mesencephalic trigeminal nucleus c. motor trigeminal nucleus d. spinal (descending) trigeminal nucleus e. principal sensory trigeminal nucleus

spinal (descending) trigeminal nucleus

A patient was thrown from a tractor, which partially ran over him and caused injury to the base of the skull. The origin of the internal jugular vein at the jugular foramen was compromised. Which of the following cranial nerves courses through the jugular foramen? . spinal accessory nerve (eleventh cranial) nerve . abducens (sixth cranial) nerve . facial (seventh cranial) nerve . hypoglossal (twelfth cranial) nerve . vestibulocochlear (eighth cranial) nerve

spinal accessory nerve (eleventh cranial) nerve

On examination, observations are stable, she is apyrexial, her Glasgow Coma Score (GCS) is 12, and on neurological examination, she appears to have some mild left arm and leg weakness with normal or brisk reflexes. There is no hemianopia or other neurological deficit. Which of the following is most likely to explain the changes? ជ្រើសមួយ៖ Bacterial meningitis Lacunar infarct Subdural haematoma Intracerebral haemorrhage Subarachnoid haemorrhage

subdural hematoma

Hepatocytes deliver ketone bodies to the circulation because they lack which of the following enzymes? . the form of the beta-ketothiolase necessary to hydrolyze acetoacetyl-CoA . succinyl-CoA-acetoacetate-CoAtransferase . hydroxymethylglutaryl-CoA-lyase . beta-hydroxybutyrate dehydrogenase . hydroxymethylglutaryl-CoA-synthetase

succinyl-CoA-acetoacetate-CoAtransferase

An obese 18-year-old woman is brought to the emergency department by her mother, who noted that she had been lethargic all day, and suffered a brief, seizure-like episode. One month earlier, the patient had been started on medication for type 2 DM. Lactic acid levels are normal. Which of the following medications most likely played a role in the patient's current presentation? ជ្រើសមួយ៖ An α-glucosidase inhibitor A sulfonylurea A statin A thiazolidinedione Metformin

sulfonylurea (glipizide, glyburide) treat type 2 DM by increasing the amount of insulin secretion. The obvious potential adverse effect of this is hypoglycemia. Weight gain is another adverse effect

The efferent limb of the pupillary light reflex is interrupted along with corticospinal and orticobulbar fibers in which of the following clinical entities? . inferior alternating hemiplegia . superior alternating hemiplegia . Broca's aphasia . middle alternating hemiplegia . Wallenberg syndrome

superior alternating hemiplegia

In the skull, a network of thick-walled vessels named dural venous sinuses drains the cerebrospinal fluid and the venous blood from the brain. These vessels are formed by reflections of the dura mater, which also form partitions between major parts of the brain. Which of the following dural venous sinuses is associated with the falx cerebri? . cavernous sinus . superior sagittal sinus . transverse sinus . sigmoid sinus . inferior petrosal sinus

superior sagittal sinus

A 60-year-old diabetic patient presents with an 8-hour history of being unable to pass urine. On taking his history, he reports a 3-day history of pyrexia and throbbing pain around the back passage. He is also concerned as he has also noticed he has been passing urine increasingly frequently and worries that his diabetes is getting worse since increased urinary frequency was how his condition was initially diagnosed. On examination of his abdomen there is no evidence of peritonism. On digital rectal examination there are no abnormalities visible in the perianal area; the procedure is extremely painful. However, the prostate feels normal and is in the normal position. The diagnosis is? ជ្រើសមួយ៖ Acute prostatitis Invasive pelvic malignancy Ischiorectal abscess Supralevator abscess Urinary tract infection

supralevator abscess (unique)

A 51-year-old woman presents to the physician's office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown in picture. Which of the following is the most appropriate next step in management? collection of discharge for repeat cytologic analysis . modified radical mastectomy . terminal duct excision (microdochectomy) . observation, with repeat examination and imaging studies in 3-6 months . central lumpectomy (including removal of the nipple/areolar complex

terminal duct excision (microdochectomy). (Intraductal papilloma )

A 30-year-old woman presents with a three month history of chest pain. On auscultation, there is a midsystolic click and a late systolic murmur. Her electrocardiogram shows T-wave inversions in leads II, III, and aVF. Which of the following statements concerning her condition is true? ជ្រើសមួយ៖ An exercise stress test would most likely be positive Prophylactic measures to prevent subacute bacterial endocarditis are not warranted Asymmetrical hypertrophy of the interventricular septum is revealed on echocardiography The click and murmur is likely to occur earlier in systole when the patient stands The woman's chest pain could be due to associated coronary artery disease

the click and murmur is likely to occur earlier in systole when patient stands

Which of the following statements is false? ជ្រើសមួយ៖ None of the above Treatment of ichthyosis includes emollients and keratolytics The most common form of ichthyosis is acquired ichthyosis Ichthyosis can be an acquired condition associated with endocrinopathies, autoimmune diseases, HIV infection, lymphomas, and carcinomas The ichthyoses are a group of diseases characterized by abnormal cornification of the skin leading to excessive scaling

the most common form of ichthyosis is acquired ichthyosis

Serous cells are glandular acinar cells that produce a watery, proteinaceous fluid. This cell type is most predominant in which of the following glands? . the sublingual gland . esophageal glands . intestinal glands (of Lieberkün) . the parotid gland . the submandibular gland

the parotid gland

One of your diabetic patients has a blood glucose level of 200 mg/dL. Surprisingly, a dipstick test is negative for urinary glucose. How could this finding be explained? . the patient is in a state of antidiuresis . the patient has significantly reduced GFR . the patient has diabetes insipidus . dipstick tests are more sensitive for reducing sugars other than glucose . the patient has defective tubular glucose transporters

the patient has significantly reduced GFR

A 55-year-old male diabetic has an accommodative power of the lens of 10 dioptres. His near point is located 5 cm (2 in), his far point 10 cm (3.9 in) in front of the eye. Which of the following statements are correct? . the patient is capable of driving a car without corrective glasses . his corrective lenses have a positive dioptric value . the patient is functionally blind . his corrective lenses are convex . the patient has hyperopia

the patient is functionally blind

The forensic analytical technique identified as DNA fingerprinting refers to which of the following processes? . the identification of sequences of DNA to which specific proteins bind, thereby rendering them resistant to digestion by DNAdegrading nucleases . the specific association of complimentary strands of DNA to one another . the synthetic oligonucleotide-directed enzymatic amplification of specific sequences of DNA . the use of repeat sequences to establish a unique pattern of fragments for any given individual . the establishment of a complete collection of cloned fragments of DNA

the use of repeat sequences to establish a unique pattern of fragments for any given individual

A 45-year-old female patient develops Parinauds syndrome (vertical gaze palsy) and an MRI shows a large tumor of her pineal gland. The tumor is not only compressing her tectum, causing the vertical gaze palsy, but also obstructing the underlying cerebrospinal fluid pathway causing progressive noncommunicating hydrocephalus. The obstruction causes immediate accumulation of cerebrospinal fluid in which of the following? . cerebral aqueduct of Sylvius . lateral ventricle . subarachnoid space . third ventricle . fourth ventricle

third ventricle

A 65-year-old man presents to the emergency department with sudden onset of pain and weakness of the left lower extremity of 2-hour duration. Past history reveals chronic atrial fibrillation following a myocardial infarction 12 months ago. On examination, he is found to have a cool, pale left lower extremity with decreased strength and absent popliteal and pedal pulses. The opposite leg has a normal appearance with palpable pulses. Which of the following is the treatment of choice for this patient? ជ្រើសមួយ៖ . r-TPA (tissue plasminogen activator) infusion following anticoagulation . thromboembolectomy . anticoagulation and close observation . four-compartment fasciotomy . administration of vasodilators

thromboembolectomy (Thrombolytic therapy is reserved for treatment of irretrievable clots in small vessels)

Which of the following statements regarding thrombolytic therapy is true? ជ្រើសមួយ៖ Thrombolytic therapy is contraindicated because of the presence of cardiogenic shock Thrombolytic therapy is contraindicated because of the risks of bleeding associated with it Thrombolytic therapy will establish antegrade coronary artery perfusion in 75% of cases Thrombolytic therapy is contraindicated because of her age Thrombolytic therapy is indicated, but direct revascularization is preferable if it can be obtained quickly

thrombolytic therapy is indicated , but direct revascularization is preferable if it can be obtained quickly.

Afailure of the truncoconal septum to follow a spiral course results in which of the following conditions? . transposition of the great vessels . common atrium . persistent truncus arteriosus . persistent atrioventricular canal . Tetralogy of Fallot

transposition of the great vessels

A 23-year-old man sees his physician to ask about the recent appearance of several large closely spaced bumps on his elbows. Suspecting that these are fatty eruptions, the physician tests the man's blood for lipid, cholesterol, and lipoprotein levels. Results show elevated cholesterol and triglycerides and the presence of a variant form of very low-density lipoprotein (VLDL) identified as betamigrating VLDL (-VLDL). Amore careful analysis of the biochemical properties of the apoproteins associated with the beta-VLDL particles identifies a form of apo E that has a more negative charge than apo E from normal individuals. These results indicate the individual is afflicted with which of the following hyperlipoproteinemias? . type II (FH) . type III (dysbetalipoproteinemia) . type I (familial LPL deficiency) . Wolman disease . type IV (familial hypertriglycerolemia)

type III (dysbetalipoproteinemia)

A 26-year-old Bangladeshi man presents to accident and emergency with a 1-week history of fever, headache, malaise and dry cough. He returned to the UK 2 weeks ago, having spent his summer in Bangladesh. On examination, his temperature is 39°C and a patchy maculopapular rash is seen over his trunk. On examination of the abdomen, there is splenomegaly. Blood tests reveal a low white cell count. What is the most likely diagnosis? ជ្រើសមួយ៖ Cholera Typhoid Tetanus Primary syphilis Malaria

typhoid

A 45-year-old female patient presents to the emergency room with a headache and complains of abnormal sensations on the left side of her body. She claims that the sensory changes came on rapidly in the last few hours. Her laboratory reports come back normal, a spinal tap reveals normal cerebrospinal fluid (CSF), and her mental ability seems good. You perform a neurological examination and find she has greatly reduced sensation on the entire left side of her body, including her face. The sensory loss includes all modalities. The motor examination is normal, as is her visual examination and hearing examination. Based on the neurological findings, which of the following thalamic nuclei would be involved? . lateral and medial geniculate nuclei . ventral anterior and ventral lateral nuclei . pulvinar . lateral dorsal and lateral posterior nuclei . ventral posterior lateral and ventral posterior medial nuclei

ventral posterior lateral and ventral posterior medial nuclei

Which of the following statements regarding adjuvant medical therapy for acute MI is false? ជ្រើសមួយ៖ Prophylactic therapy with lidocaine does not reduce and may actually increase mortality because of an increase in the occurrence of fatal bradyarrhythmia and asystole Early administration of beta blockers reduces the mortality and the reinfarction rate Unless contraindicated, angiotensin-converting enzyme (ACE) inhibitors are indicated in patients with significant ventricular dysfunction after acute MI When given within 6 hours after presentation to the hospital, I.V. nitroglycerin reduces mortality in patients with MI None of the above មូលវិចារណ៍

when given within 6h after presentation to the hospital, IV nitroglycerin reduces mortality in patient with MI

The four main sites where the ureters are constricted are

(1) the pelvicureteric junction, (2) as the ureter crosses the pelvic brim, (3) as the gonadal artery crosses the ureter (4) as the ureter enters the bladder obliquely at the vesiculo-ureteric junction.

Which of the following has a carrier state that is not considered contagious? A. E. coli B. HSV C. Chlamydia trachomatis D. GAS E. RSV

GAS

A 29-year-old man sustained a gunshot wound to the right upper quadrant. He is taken to the operating room and, after management of a liver injury, is found to have a complete transection of the common bile duct with significant tissue loss. Which of the following is the optimal surgical management of this patient's injury? ជ្រើសមួយ៖ . Roux-en-Y choledochojejunostomy . Bridging of the injury with a T tube . Loop choledochojejunostomy . Primary end-to-end anastomosis of the transected bile duct . Choledochoduodenostomy

. Roux-en-Y choledochojejunostomy

A febrile infant with poor feeding and moderate respiratory distress due to pneumonia is being admitted to your inpatient service. With regard to sodium content, which of the following intra- venous fluids would be the maintenance fluid of choice of a 12 kg infant?

0.2 %NaCl

The management of diabetic gastroparesis includes:

1 . Improved glycemic control 2. Small, frequent meals 3. A dopamine antagonist (e.g., metoclopramide, domperidone) before meals 4. Bethanechol 5. Erythromycin: This drug interacts with motilin receptors and can promote gastric emptying. 6. Cisapride is effective in diabetic gastroparesis, but it is currently available only through the manufacturer. It is issued only after providing adequate documentation of the need for the drug, and after a thorough assessment of the individual's risk factors for cardiac arrhythmias

The three major treatment options of patients with Graves' disease are:

1 . Radioactive iodine ablation: This is the preferred modality of treatment in the United States. 2. Antithyroid drug (ATD) therapy 3. Thyroidectomy

manifestations of vitamin D toxicity

- including constipation, abdominal pain, polyuria and polydipsia - are similar to symptoms of hypercalcemia.

The indication for surgery in asymptomatic patients is the presence of at least one of the following features:

1 . Serum calcium level at least 1 mg/dl above the upper limit of normal 2. Urinary calcium excretion greater than 400mg/24hr 3. Young age ( < 50 years old) 4. Bone mineral density (BMD) lower than T-2.5 at any site 5. Reduced renal function ( eGFR < 60 ml/min)

The indications for treatment of Paget's disease include:

1. Bone pain 2. Hypercalcemia of immobilization 3. Neurological deficit 4. High output cardiac failure 5. Preparation for orthopedic surgery 6. Involvement of weight-bearing bones (to prevent deformities)

Impetigo treatment

1. mild: mupirocin or retapamulin 2. severe: ox, clox, diclox, nafi, if rash, 1st cephalosporin

you mention the calcium requirement for a school-age child is which of the following?

1.3g/day

A 5-month-old child is admitted with severe hypoxia and respiratory failure to the pediatric intensive care unit. A diagnosis of P jiroveci pneumonia (PCP) is made on silver staining of bronchoalveolar lavage fluid. You suspect immunodeficiency in this patient, and HIV testing is negative. What is the most likely immunodeficiency? Select one: O adenosine deaminase deficiency • Job syndrome O common variable immunodeficiency • asplenia • Bruton agammaglobulinemia • Job syndrome O common variable immunodeficiency • asplenia • Bruton agammaglobulinemia

1/1000

Rate of bilateral hearing loss in infant in US

1/1000

What is the likelihood that a patient with asymptomatic diverticulosis will go on to develop diverticulitis? ជ្រើសមួយ៖ 40% to 50% > 90% < 5% 10% to 25% 70% to 80%

10-25%

At what age should the palmar grasp reflex disappear?

12-16 months

Hands together at midline

12weeks /3 months

Which of the following best describes the average birth weight of a 30-week gestation infant?

1500g

Treatment of chylothorax

1st-line: tube thoracostomy + low-fat diet Chyle drainage >500ml/day: right thoracotomy + ligation of duct from diaphragm to T6 Injury is recognized intraoperatively: ligation of duct

Smiles responsively, follows a moving object or face with turning of the head:

2 months

Viral shedding due to maternal HSV reactivation is associated with transmission to the fetus in approximately what proportion of cases?

2%-5%

Askydiver landing forcefully on his right lower limb suffered a central fracture of the acetabulum with dislocation of the femoral head into the pelvis. The acetabulum is formed by the joining of the ilium, ischium, and pubis. These three bones are completely fused by which of the following periods? . 6 years . 23 years . puberty . 16 years . birth

23 years

In your discussion with the patient regarding the risks and benefits of the different management options listed above, which of the following values should you quote regarding the expected 5-year survival rate following curative surgical resection? ជ្រើសមួយ៖ . 5-10% . 60-70% . 15-20% . 25-35% . 40-50%

25-35%

The father of a 2-month-old boy wonders why his son's head looks so big. Which of the following best describes the head growth during the first month of life?

2cm

Fixation and tracking through the visual field are well developed by which of the following ages?

2months

peak height velocity for girl occurs around which sexual maturity rating (SMR)

3

analyzing a sample of double-stranded DNA, it has been determined that the molar ratio of adenosine is 20%. Given this information, what is the content of cytidine? . 40 . 30 . 20 . 10 . 60

30

What percentages of infected children less than 6-years-old are symptomatic hepatitis A?

30%

Infants typically double their birth weight by what age?

4 months

Percentage of all child deaths related to mal- nutrition in developing countries:

40%

Children stop taking day time naps at which age?

48 months

At what age can a child first receive influenza vaccine?

6months

The pharynx extends from the level of the skull base to which vertebrae?

6th cervical vertebrae

Gentamicin and piperacilin-tazobactam is initiated in an 8 year old with acute myeloblastic leukemia for dual coverage of Pseudomonas aeruginosa bacteremia. Gentamicin levels will be checked to ensure that the peaks are high enough to kill the bacteria relative to the MIC (peak concentration to MIC or peak/MIC ratio). For the above patient, the appropriate time to check serum gentamicin levels at steady state would be after how many half-lives?

5

Draws a triangle, uses past and future tense in language:

5 years

Among 18-year-old males, approximately what percent have used anabolic steroids as performance enhancers?

5%-10%

At what age does a Babinski reflex disappear?

6-8

A 7-month-old infant presents for well-child care and the physician notes a well-developed Moro reflex, palmar grasp reflex, and tonic neck reflexes on examination. The persistence of neonatal reflexes is an indicator of develop- mental delay, he tells the mother of the infant. At which age should the Moro reflex typically disappear?

6-8 months

At what age should the tonic neck reflex disappear?

6-8 months

The rate-limiting step in glycolysis occurs at the step catalyzed by which of the following enzymes? . pyruvate kinase . phosphoglycerate kinase 6-PFK-2 . 6-phosphofructo-1 kinase, PFK-1 . glyceraldehyde-3-phosphate dehydrogenase

6-phosphofructo-1 kinase, PFK-1

Concerns about childrens' TV watching are being discussed with a group of parents. The age at which a child can reliably distinguish fantasy from reality occurs at which of the following ages?

7

Thumb-finger grasp:

8 months

Which of the following statements reflects the process by which the telomeric ends of chromosomes are replicated? . Telomeres are replicated as short tandem-repeated stretches of ribonucleotides instead of deoxyribonucleotides. . Short template-independent block of DNA are ligated to the ends using a 5'-5' bond. . A unique RNA molecule serves as the primer for synthesis. . Telomeres are replicated in a templeindependent process. . A unique RNA molecule serves as the template for synthesis.

A unique RNA molecule serves as the TEMPLATE for synthesis.

A39-year-old obese female presents with irregular menstrual periods, mild acne and hirsutism, and acanthosis nigricans on the nuchal fold, axilla, and intertriginous areas (inner upper thighs). You suspect PCOS Which of the following laboratory tests would be most important to perform to rule out a likely confounding diagnosis? A. 2-hour oral glucose tolerance test B. testosterone C. prolactin D. dehydroepiandrosterone sulfate (DHEAS) E. LH and FSH

A. 2-hour oral glucose tolerance test

Given the patient's history of postpartum depression as well as her family history of depression, her risk of postpartum depression after this pregnancy is approximately what percentage? A. 50% or greater B. 5% C. 10% D. 20% E. less than 1%

A. 50% or greater

You are evaluating a journal article describing a test for the diagnosis of congestive heart failure (CHF). In the study described, 250 consecutive patients were given the test. Of the 250 subjects, 106 tested positive for CHF and 144 tested negative. All 250 subjects were then evaluated by expert cardiologists who were blinded to the results of the experimental test. These cardiologists determined that of the 106 persons who tested positive, 95 actually had CHF. Further, the cardiologists found that of the 144 who tested negative, 2 truly had CHF. What is the sensitivity of this test for the diagnosis of CHF? A. 98% B. 93% C. 75% D. 61% E. 39%

A. 98%

Gastrin secretion is enhanced by which of the following? A. antral distention B. antral acidification C. presence of fat in the antrum D. sympathetic nerve stimulation E. duodenal acidification

A. antral distention

Which of the following is not an obstructive cause of dysphagia? ជ្រើសមួយ៖ Pharyngeal carcinoma Peptic stricture Retrosternal goitre Oesophageal web Achalasia

Achalasia

After Heart surgery + widening mediastinum

Acute mediastinitis => surgical débridement and antiobiotic

A 13-year-old boy is brought to the pediatrician by his mother because of increasing body hair. Several months earlier he had been diagnosed with 17α-hydroxylase deficiency and treated with hydrocortisone. Physical examination reveals an overweight boy with a moderate amount of both chest and genital hair, and some facial hair growth. His physical examination is otherwise unremarkable. Which of the following is the best treatment for this patient? ជ្រើសមួយ៖ Add cosyntropin Add spironolactone Keep the current dose of hydrocortisone Increase hydrocortisone Add dexamethasone

Add dexamethasone (In individuals with 17α-hydroxylase deficiency, ACTH secretion is elevated secondary to decreased cortisol levels. The goal of treatment with hydrocortisone is not only to replenish cortisol, but also to suppress ACTH secretion. The reason for this is that if ACTH remains high, it will stimulate androgen production and lead to premature virilization and growth plate ossification. Nightly dexamethasone treatments may be necessary to more completely suppress ACTH secretion in adolescents.)

severe heart failure, increasing shortness of breath. Her current pharmacological treatment consists of an angiotensin-converting enzyme (ACE) inhibitor, loop diuretic and b-blocker. What is the most appropriate management? ជ្រើសមួយ៖ Add simvastatin Add spironolactone Stop ACE inhibitor Add digoxin Stop b-blocker

Add spironolactone

A 5-month-old child is admitted with severe hypoxia and respiratory failure to the pediatric intensive care unit. A diagnosis of P jiroveci pneumonia (PCP) is made on silver staining of bronchoalveolar lavage fluid. You suspect immunodeficiency in this patient, and HIV testing is negative. What is the most likely immunodeficiency? Select one: adenosine deaminase deficiency • Job syndrome common variable immunodeficiency • asplenia • Bruton agammaglobulinemia • Job syndrome common variable immunodeficiency • asplenia • Bruton agammaglobulinemia

Adenosine deaminase deficiency

Your patient had an ultrasound examination today at 39 weeks gesta- tion for size less than dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient's cervix is unfavor- able. Which of the following is the best next step in the management of this patient?

Admit her to the hospital for cervical ripening then induction of labor.

A 26-year-old man is brought to the emergency room after being extricated from the driver's seat of a car involved in a head-on collision. He has a sternal fracture and is complaining of chest pain. He is hemodynamically stable and his electrocardiogram (ECG) is normal. Which of the following is the most appropriate management strategy for this patient? ជ្រើសមួយ៖ . Admit to telemetry for 24-hour monitoring . Immediate operative plating of the sternal fracture . Admit to the regular ward with serial ECGs for 24 hours . Emergent cardiac catheterization . Discharge to home with nonsteroidal anti-inflammatory agents for the sternal fracture

Admit to telemetry for 24-hour monitoring

A 15-year-old has exudative tonsillitis, cervical adenitis, and splenomegaly. His monospot test is positive. Which of the following is the most common complication encountered?

Airway obstruction

A 45-year-old asthmatic patient presents with palpitations. An ECG shows supraventricular tachycardia, with narrow QRS complexes. Carotid sinus massage is not successful. What would you do next? ជ្រើសមួយ៖ Administer intravenous digoxin Administer intravenous sotolol Administer intravenous verapamil DC cardioversion Administer intravenous adenosine

Although adenosine is the drug of choice for terminating paroxysmal supraventricular tachycardia, it can cause bronchospasm and is thus contraindicated in patients with asthma, sotolol should be avoided for the same reason. Verapamil would therefore be the drug of choice in this case. However, verapamil should not be used for tachyarrhythmias where the QRS complex is wide. It is also contraindicated in patients with the Wolff-Parkinson-White syndrome. ចម្លើយត្រឹមត្រូវគឺ Administer intravenous verapamil

The next part of the modified BPP is which of the following?

Amniotic fluid index evaluation

A 32-year-old man is brought to the ED by paramedics after a diving accident. The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not resurface. On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. He is able to feel light touch and position of his four extremities. A cervical spine radiograph does not reveal a fracture. Which of the following is the most likely diagnosis? ជ្រើសមួយ៖ . Brown-Sequard syndrome . Spinal cord injury without radiographic abnormality (SCIWORA) . Anterior cord syndrome . Central cord syndrome . Cauda equina syndrome

Anterior cord syndrome (results from cervical flexion injuries (eg, diving in shallow water) that cause cord contusion or protrusion of a bony fragment or herniated intervertebral disk into the spinal canal.)

A 46-year-old man develops sudden severe central chest pain after lifting heavy cases while moving house. The pain radiates to the back and both shoulders but not to either arm. His BP is 155/90 mmHg, pulse rate is 92 beats per minute and the ECG is normal. He is distressed and sweaty, but not nauseated. What would you consider the most likely diagnosis? ជ្រើសមួយ៖ MI Aortic dissection Pulmonary embolism Pneumothorax Musculoskeletal pain

Aortic dissection

A 22-year-old graduate student recently returned from a trip to central Mexico. She subsequently developed several nontender nodules on her lower back that intermittently drain brown fluid. She received treatment with dicloxacillin, without improvement. On examination, she has five purple, firm nodules that measure approximately 2 cm; the nodules have tiny central openings that intermittently drain serosanguineous fluid. What would you do next for this patient? ជ្រើសមួយ៖ Give her a 10-day course of oral levofloxacin Apply fatty bacon over the nodules Excise a nodule for pathologic evaluation Give her a 10-day course of oral cephalexin Give her a 10-day course of I.V. gentamicin

Apply fatty bacon over the nodules (This patient has just returned from an area endemic for the botfly. The nodules with a central punctum that intermittently drain are a characteristic of infestation with larvae of that insect. Not infrequently, patients with myiasis are misdiagnosed as having bacterial furunculosis and are managed with a variety of antibiotics that have no effect. It is important to consider the diagnosis of myiasis because occluding the punctum with fatty bacon causes the larvae to protrude. The larvae can then be removed with forceps. Other occlusive substances, such as petroleum jelly and nail polish, have also been effective. Excising the nodule for pathologic evaluation is not needed.)

A young man is shot in the upper part of the neck with a .22 caliber revolver. Inspection of the entrance and exit wounds indicates that the trajectory of the bullet is all above die level of the angle of the mandible, but below the skull. He is fully conscious and neurologically intact. A steady trickle of blood flows from both wounds, and it does not seem to respond to local pressure. He is hemodynamically stable. Which of the following is the most appropriate next step in diagnosis? ជ្រើសមួយ៖ Barium swallow Arteriogram Endoscopy Continued clinical observation Surgical exploration

Arteriogram

In an enzyme with a critical Glu residue in the active site, which of the following amino acid substitutions would be expected to have the least effect on enzyme activity? . Asp . Ser . Lys . Arg . Tyr

Asp

A 32-year-old female professional gardener complains of increasing muscle weakness and fatigue during the day, requiring her to take frequent rests. She also reports that she cannot enjoy her meals any more because her muscles of mastication quickly weaken and she has to stop chewing. When she watches television at night for a long period of time, her vision becomes blurry and she sees double. Her neurologist makes a preliminary diagnosis of myasthenia gravis. Which of the following is the cause of myasthenia gravis? . Neurotransmitter release is impaired at the presynaptic membrane of the neuromuscular junction. . Signal transduction within the muscle is impaired. . Acetylcholine synthesis in motor neurons is impaired. . Acetylcholinesterase synthesis is inhibited. . Autoantibodies destroy cholinergic receptors at the postsynaptic membrane preventing binding of acetylcholine.

Autoantibodies destroy cholinergic receptors at the postsynaptic membrane preventing binding of acetylcholine.

Neurofibromatosis II

Autosomal dominant Bilateral acoustic neuromas => deafness

Neurofibromatosis I

Autosomal dominant Cafe au lait spots, neurofibromas, axillary/inguinal freckles, optic glioma in toddlers, cortical thinning of long bones, Lisch nodules (iris hamartomas)

What is the approximate prevalence of cystic fibrosis carrier state in White individuals? A. 1 in 10 B. 1 in 25 C. 1 in 50 D. 1 in 100 E. 1 in 200

B. 1 in 25

A 25-year-old nulligravid woman presents as a new patient to your gynecology practice. She has recently moved to the area. She is a healthy woman with no medical problems and is currently using oral contraceptives without problems. She informs you that she and her husband are planning to start a family within the next year. On review, you find her family history is unremarkable, but she informs you that her husband's sister has cystic fibrosis. Given that the husband's sister has cystic fibrosis, what is the likelihood that he is a carrier? A. 100% chance of being a carrier B. 67% (2 in 3) chance of being a carrier C. 50% (1 in 2) chance of being a carrier D. 25% (1 in 4) chance of being a carrier E. his chance of being a carrier is no greater than the general population

B. 67% (2 in 3) chance of being a carrier

The family of a patient recently diagnosed with esophageal cancer requests more information regarding the disease. You tell them which of the following? A. The incidence of SCC of the esophagus is rising more rapidly than adenocarcinoma. B. Premalignant conditions include caustic esophageal burns, Plummer-Vinson syndrome, and tylosis. C. It is more common in women than men. D. Smoking is not a risk factor for esophageal cancer. E. Barrett's esophagus increases the risk for esophageal SCC.

B. Premalignant conditions include caustic esophageal burns, Plummer-Vinson syndrome, and tylosis.

A 6-year-old previously well African American child presents with new-onset jaundice, dark urine, and pallor. There is a history of a recent mild upper respiratory tract infection. Vital signs are normal. Physical examination is remarkable for icterus and pallor. Laboratory examination reveals hemoglobin of 7 g/dL with a normal platelet and white blood cell count. The total bilirubin is 4 mg/dL. Which of the following historical findings is most likely to indicate the diagnosis?

Baby aspirin given to him last year was associated with dark urine.

A 33-year-old woman with multiple sclerosis (MS) is having problems with painful spasms and disabling spasticity in her left leg. Which of the following medications is most likely to help? ជ្រើសមួយ៖ Propanolol Lactulose Modafinil Baclofen Oxybutinin

Baclofen is a gamma-amino-butyric acid (GABA)-derived drug commonly used as an antispasmodic. Oxybutinin is an anticholinergic used in detrusor instability and urinary continence issues in MS. MS sufferers can become constipated so lactulose (an osmotic laxative) can help. Modafinil is a stimulant drug sometimes used in MS to combat fatigue. Beta-blockers such as propranolol can help tremor.

You read a report which was handwritten in a patient's medical notes who you suspect has inflammatory bowel disease. The report reads, '... there is cobblestoning of the terminal ileum with the appearance of rose thorn ulcers. These findings are suggestive of Crohn's disease'. Select the most likely investigation that this report was derived from: ជ្រើសមួយ៖ Colonoscopy Abdominal ultrasound Abdominal CT Sigmoidoscopy Barium follow through

Barium follow through

A 6-year-old girl presents with unilateral non- painful, nonsuppurative conjunctivitis and preauricular lymphadenitis. What is the most likely causative organism?

Bartonella henselae

A 55-year-old patient of yours presents for routine follow-up of CHF. An echocardiogram done 6 months ago showed a left ventricular ejection fraction of 20%. He feels quite well, has unlimited exercise tolerance while exercising on flat ground, and has dyspnea only with climbing more than two flights of stairs. His current regimen is enalapril, 40 mg/day, and furosemide, 40 mg b.i.d. On physical examination, his blood pressure is 135/80 mm Hg, his pulse is 88 beats/min, and his respirations are normal. The rest of his examination is remarkable only for moderate obesity and 1+ pretibial edema. He has heard that medications called beta blockers could be helpful for people with heart trouble and wonders if he should be taking them. Which of the following statements regarding beta-blocker use is true? ជ្រើសមួយ៖ Beta blockers are contraindicated in patients with CHF Beta blockers are not indicated in this patient because his blood pressure is already well controlled Beta blockers are indicated in this patient Beta blockers are contraindicated in this patient because his ejection Beta blockers are not indicated in this patient because his CHF is well controlled by his current therapy

Beta blockers are indicated in this patient

Which of the following statements regarding this patient's pacemaker VVI program code is false? ជ្រើសមួយ៖ Both the atria and ventricles are programmed to be paced The sensing lead is in the ventricle When the intrinsic heart rate falls below 60 beats/min, pacing will occur After a paced beat, the pacemaker clock resets and senses the next ventricular contraction VVI is also referred to as ventricular demand pacing or ventricular inhibited pacing

Both the atria and ventricles are programmed to be paced (VVI, V - Ventricle paced, V - Ventricle sensedI - Pacing is inhibited if beat is sensed)

Which of the signs and symptoms is not commonly associated with parkinsonism? ជ្រើសមួយ៖ Autonomic instability Hypomimia Postural instability Rapid eye movement (REM) sleep disturbance Broad-based gait

Broad-based gait

You suspect pneumocystis pneumonia. Which of the following tests is the best way to confirm the diagnosis? ជ្រើសមួយ៖ Cytology of sputum induced by nebulised hypertonic saline Bronchoalveolar lavage Chest X-ray Computed tomography (CT) of the chest Hypoxaemia on arterial blood gas

Bronchoalveolar lavage (dry cough, fever, shortness of breath, weight loss and night sweats, Radiological changes can be conspicuously absent early on, but a perihilar ground-glass pattern of change can be found) Treatment is with co-trimoxazole (trimethoprim and sulphamethoxazole). Patients with HIV who have a low CD4 count (<200/μl) receive prophylaxis for pneumocystis (e.g. co-trimoxazole or dapsone).

A 29-year-old diabetic with blood glucose of 280 mg/dL pH Pa02 PaC02 A. 7.23 64 80 B. 7.39 88 40 C. 7.22 74 33 D. 7.54 75 24 E. 7.37 67 52

C

C1 deficiency has three subcomponents, of which the most common is deficiency of C1q. Most of those patients will have clinical and serologic findings typical of which of these? A. polymyositis B. RA C. SLE D. recurrent Streptococcus pneumoniae infections E. recurrent H. influenzae type B infections.

C

The practice of confidentiality has roots in the Hippocratic Oath. However, the increasing use of health information technology has increased the efficiency of acquisition, manipulation, and dissemination of this potentially sensitive data. Federal laws have been adopted to safeguard health information privacy. Under the Health Insurance Portability and Accountability Act (HIPAA), which of the following is allowed? A. conducting teaching rounds at a table in the hospital cafeteria, as long as patient names are not used B. sharing a patient's diagnosis with any family member who requests the information C. discussing patient information with a consulting physician D. leaving an electronic medical record page with patient information open on a computer in the hallway of the ICU, to allow the nurse to have more rapid access to information E. sharing health information about a patient with his or her employer if the employer is paying for the patient's health insurance

C. discussing patient information with a consulting physician

A 31-year-old woman with a known psychiatric history presents to the ED after ingesting an unknown quantity of pills from her medication vial. In the ED, she complains of nausea, abdominal cramping, and feels unsteady on her feet. On physical examination, you observe that she is tachycardic and ataxic. Which of the following substances will best be treated by activated charcoal that could present like this? ជ្រើសមួយ៖ . Lithium . Acetaminophen . Carbamazepine . Lye (sodium hydroxide) . Phenobarbital

Carbamazepine

A 28-year-old woman patient who is 13 weeks pregnant presents for an antenatal clinic appointment. The patient feels embarrassed when asked to provide a urine sample and produces enough for a urine dipstick test only which is positive for leukocytes and nitrites. The patient denies any symptoms. The most appropriate treatment is: ជ្រើសមួយ៖ Ampicillin Trimethoprim Tetracycline Cephalexin Quinolone

Cephalexin ( Penicillins and cephalosporins, such as cephalexin are safe for use during pregnancy.)

Your patient is a 48-year-old Hispanic male with a 4-year history of diabetes mellitus type 2. He is currently utilizing NPH insulin/Regular insulin 40/20 units prior to breakfast and 20/10 units prior to supper. His supper time has become variable due to a new job and ranges from 5 to 8 PM. In reviewing his glucose diary, you note some very low readings (40-60 mg/dL) during the past few weeks at 3 AM. When he awakens to urinate, he feels sweaty or jittery so has been checking a fingerstick blood glucose. Morning glucose levels following these episodes are always higher (200-250) than his average fasting glucose level (120-150). Which change in his insulin regimen is most likely to resolve this patient's early AM hypoglycemic episodes? ជ្រើសមួយ៖ . Increase morning NPH and decrease evening NPH . Discontinue both NPH and regular insulin; implement sliding scale regular insulin with meals . Change regimen to glargine at bedtime with lispro prior to each meal . Decrease morning NPH and decrease evening regular insulin . Change regimen to glargine at bedtime and continue morning and evening regular insulin

Change regimen to glargine at bedtime with lispro prior to each meal

A 14-year-old boy is brought to medical attention because of nasal fullness and bleeding. Inspection reveals enlarged cervical lymph nodes as well. Biopsy of a lymphnode confirms nasopharyngeal carcinoma. What is the best management strategy for this patient? ជ្រើសមួយ៖ . External beam radiation therapy . Surgical resection followed by adjuvant chemoradiation . Surgical resection . Intracavitary radiation therapy . Chemoradiation

Chemoradiation is standard therapy for nasopharyngeal carcinoma

A 22-year-old man with testicular cancer has undergone an inguinal orchidectomy. Histology has confirmed teratoma. A preoperative CT staging scan has shown involvement of the para-aortic lymph nodes. Which of the following treatments is the best post-operative option? ជ្រើសមួយ៖ Radiotherapy to affected lymph nodes Chemotherapy (bleomycin, etoposide, cisplatin) Lymph node dissection Surveillance using tumour markers. Chemo-radiotherapy

Chemotherapy (bleomycin, etoposide, cisplatin)

A deficiency of argininosuccinate synthetase (ASD) can be suspected in a 2448-hour-old neonate with elevated serum ammonia. To discriminate the fact that the hyperammonemia is indeed due to ASD and not due to a deficiency in other urea cycle enzymes, one can assay for the serum concentration of citrulline and urinary orotic acid concentration. Which of the following would best describe the expected findings? . Citrulline levels will be absent but orotate will be elevated. . Citrulline levels will be > 1000 M, orotate will be near normal. . Citrulline levels will be between 100300 M and orotate levels will be elevated. . Both citrulline and orotate levels will be low.

Citrulline levels will be > 1000 M, orotate will be near normal.

Minor hemobilia

Conservative, monitor

A 29-year-old woman presents with a 6-month history of erythema and edema of the right breast with palpable axillary lymphadenopathy. A punch biopsy of the skin reveals neoplastic cells in the dermal lymphatics. Which of the following is the best next step in her management? ជ្រើសមួយ៖ . Modified radical mastectomy followed by hormonal therapy . Combined modality chemotherapy and radiation therapy to the right breast with surgery reserved for residual disease . Combined modality therapy with chemotherapy, surgery, and radiation . Modified radical mastectomy followed by adjuvant chemotherapy .

Combined modality therapy with chemotherapy, surgery, and radiation

The parents of a 2-year-old boy report he is about to be thrown out of daycare due to biting other children. For the primary care provider, which of the following facts are important to inquire about regarding biting behavior?

Concerns about the child's developmen- tal progress

enterocolitis

Congenital aganglionic megacolon

A 23-year-old woman presents to the GP complaining of palpitations. She says these are rapid and when she gets them she feels light headed and sick. They tend to come on without warning, but have occurred when she has been out dancing with friends, and after a game of squash. On examination she looks well; her BMI is 21, pulse 70/min regular, BP 122/70 mmHg. Bloods; Hb 13.1 g/dl, WCC 5.4 x109/l, PLT 251 x109/l, Na+ 139 mmol/l, K+ 4.0 mmol/l, Creatinine 75 μmol/l. Which of the following investigations is most likely to help with the diagnosis? ជ្រើសមួយ៖ 24hr holter monitor 12 lead ECG Continuous loop recorder 3 day holter monitor Tilt table test

Continuous loop recorder

A newborn presents with signs and symptoms of distal intestinal obstruction. Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the right side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial management of the patient? ជ្រើសមួយ៖ . Contrast enema . Bowel rest with nasogastric tube decompression and broad-spectrum intravenous antibiotics . Administration of oral polyethylene glycol . Surgical evacuation of the luminal meconium . Resection of the dilated terminal ileum

Contrast enema

What's the best screening test for ADDISON ?

Cosyntropin test

Side effects of lisinopril

Cough, hyperkalemia, angioedema

What nerve does not supply sensation to external ear?

Cranial nerve 8

8-month-old female presents with failure to thrive, constipation, fevers, and polydipsia. On evaluation, you find hypokalemia and hyperchloremic metabolic acidosis and suspect Fanconi syndrome. Which of the following would be the most likely inherited cause?

Cystinosis

A30-year-old woman with salicylate intoxication pH Pa02 PaC02 A. 7.23 64 80 B. 7.39 88 40 C. 7.22 74 33 D. 7.54 75 24 E. 7.37 67 52

D

A 27-year-old Caucasian male is diagnosed with medullary thyroid carcinoma that is non-resectable. His past medical history is insignificant. He does not smoke or consume alcohol. His family history is significant for thyroid cancer and pheochromocytoma in his father. Which of the following tests could have been most effective in preventing this patient's non-resectable cancer? ជ្រើសមួយ៖ . Annual physical examination . DNA testing . Frequent self-examination of the neck . Periodic serum calcium measurement . Periodic stimulated serum calcitonin measurement

DNA testing

Clue to the diagnosis of Legionella pneumonia?

Diarrhea , abdominal pain, azotémie , hématurie

A patient with newly diagnosed schizophrenia is given chlorpromazine. It is a drug that has amongst other effects moderate anticholinergic activity. As a consequence, which of the following is an expected side effect of this medication? . increased GI motility . bradycardia . dry mouth . emptying of urinary bladder . decreased GI sphincter tone

Dry mouth

A39-year-old woman with a long-standing history of normal pap smears undergoes a total albeiminal hysterectomy for a large uterine fibroid and menorrhagia. Six months after her hysterectomy site hat a negative vaginal pap smear from the vaginal apex. She presents to your clinic today for a routine sin sica examination. Based on the American College of Obstetricians and Gynecolagists recommendation, whet should this patient have pap smears? A yearly B every 3 years C.every 5 years D. never again E. only it she develops risk factors

E. only it she develops risk factors (the patient who had a hysterectomy for benign conditions, no longer need Pap smear screening as long as she is monogamous and does not develop risk factors for cervical dysplasia

75 year olds , An x-ray of the hip shows a markedly displaced fracture of the neck of the right femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate step in management? ជ្រើសមួយ៖ . Closed reduction and external fixation . Internal fixation of the fracture . Perform a primary arthroplasty . Lower limb skeletal traction . Closed treatment in a spica cast

Elderly patients with displaced femoral neck fractures should be treated with primary arthroplasty. ចម្លើយត្រឹមត្រូវគឺ . Perform a primary arthroplasty

The best screening test for virilizing neoplasm is the measurement of serum testosterone and DHEAS levels.

Elevated testosterone levels with normal DHEAS levels indicate an ovarian source, whereas elevated DHEAS levels with relatively normal testosterone levels indicate an adrenal source.

3-day-old infant with PDA, now develop overt cardiac failure. Next step? Incomethacin Emergency closure of VSD Emergency surgical division of PDA Digitalis & diuretic

Emergency surgical division of PDA

A 6-month-old boy is found to have very low levels of IgG, IgM, and IgA. Which of the following organisms is most likely to cause problems in this patient?

Enterovirus

A 3-year-old girl is seen in the emergency department for bruising. Her family denies fever or weight loss but states she had a "cold" 3 weeks ago. She is afebrile and the remaining vital signs are normal. She is happy and playful and has generalized ecchymoses and petechiae. The laboratory results return and the platelets are 10,000/mm3. A bone marrow aspirate demonstrates increased megakaryocytes but is other- wise normal. Which of the following is an indication for WinRho (anti-RhoD antibodies)?

Epistaxis

What is the term used to describe the exanthem in the patient in the above question?

Erythema migran

The most common serious bacterial infection encountered in a febrile 1-month- old infant is

Escherichia coli urinary tract infection

A healthy adolescent is found to have elevated blood pressure on several occasions. Which statement is correct?

Essential hypertension is the most common cause of hypertension among adolescents.

Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with sampling of central cervical lymph nodes . Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue . Excision of the cyst and the central portion of the hyoid bone . Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with biopsy of the thyroid gland . Excision of the cyst

Excision of the cyst and the central portion of the hyoid bone

A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, which of the following will this patient most likely need? ជ្រើសមួយ៖ . Extraction of the bullet via local back exploration . Exploratory laparotomy . Barium swallow . Extraction of the bullet via left thoracotomy . Bronchoscopy

Exploratory laparotomy

A 36-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . CT of the abdomen . Exploratory laparotomy . Diagnostic peritoneal lavage . Diagnostic laparoscopy . Chest x-ray

Exploratory laparotomy

You are asked to review an electrocardiogram (ECG) in the emergency department. Helpfully, a summary of details is printed at the top as follows: rate 88/min, regular rhythm, axis -20°, PR duration 0.26 seconds (constant), QRS complex 0.08 seconds, QT interval 0.2 seconds. You note that P-waves are only present before each QRS and that the rhythm is regular. Which of the following would be the best summary? ជ្រើសមួយ៖ Refuse to summarise until it can be compared with an old ECG Left axis deviation Left bundle branch block Ventricular tachycardia First-degree heart block

First-degree heart block

A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal examination and proctoscopic examination are negative, but he has gross hematuria. He is hemodynamically stable. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Retrograde cystogram . CT scan of the abdomen . Exploratory laparotomy . Intravenous pyelogram . Diagnostic peritoneal lavage

Exploratory laparotomy (gun shot wound => surgery)

After confirming the diagnosis of slipped capital femoral epiphysis, which of the following is the most appropriate management? ជ្រើសមួយ៖ . Immediate osteotomy of the femoral neck . Closed reduction of the hip joint . External fixation of the hip joint with pins . Aspiration and microscopic examination of the hip joint synovial fluid . Conservative management with rest and analgesics

External fixation of the hip joint with pins

A 4-month-old boy presents with painful progressive joint deformity (particularly the ankles, knees, elbows, and wrists), hoarse crying, and granulomatous lesions of the epiglottis and larynx leading to feeding and breathing difficulty. Biopsy of the liver indicates an accumulation of ceramides. The observed symptoms and the results of the liver biopsy are indicative of which disease? . Gaucher disease . metachromic leukodystrophy . Sandhoff-Jatzkewitz disease . Farber lipogranulomatosis . fucosidosis

Farber lipogranulomatosis

A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. Which additional procedure should be performed along with the embolectomy? ជ្រើសមួយ៖ . Application of a posterior splint to the leg . Fasciotomy of the anterior compartment in the leg . Electromyography (EMG) of the leg . Measurement of anterior compartment pressure in the leg . Fasciotomy of all the compartments in the leg

Fasciotomy of all the compartments in the leg

The greatest percentage of calories in human breast milk:

Fat

An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient's estimated date of delivery?

February 14 of the next year

A 30-year-old woman presents to accident and emergency with worsening stiffness in the hands, wrists and feet. She mentions that the pain has been particularly bad in the mornings. On examination, there is a palpable spleen. Initial blood tests reveal a low neutrophil count and a raised C-reactive protein. The most likely diagnosis is: ជ្រើសមួយ៖ Reactive arthritis Still's disease Felty's syndrome Serum sickness Infectious mononucleosis Clear my choice

Felty's syndrome (triad of RA, neutropenia, splenomegaly)

A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . immediate laparotomy . administration of H2 blockers . placement of a central venous line . nonoperative management with NG decompression and antibiotics . fluid resuscitation

Fluid resuscitation

The inability to rapidly synthesize DNA during the process of erythrocyte maturation leads to abnormally enlarged erythrocytes. This disorder is referred to as macrocytic anemia and is caused by a deficiency in which of the following vitamins? . biotin . thiamine . ascorbate . niacin . folate

Folate

A 45-year-old man presents with a 5-day history of progressive tingling and numbness of his hands and feet. He insists that he has never had this problem before and that he was perfectly fine a week ago. Over the last 2 days he has had some difficulty walking but mostly he complains about difficulty rolling up cigarettes. On examination, there is mild symmetrical distal weakness, mild gait ataxia and dysdiadochokinesia. He smokes 30 cigarettes a day and drinks 1-2 bottles of wine. He has a family history of hypertension and his 63-year-old mother has type 2 diabetes, whom over the last year has complained of numbness and burning in her feet. He self-discharges. A week later, his symptoms have peaked. He displays moderate distal weakness and numbness to his knees, after which he turns a corner and his symptoms start to slowly resolve. What is the diagnosis? ជ្រើសមួយ៖ GBS Charcot Marie Tooth disease Chronic idiopathic demyelinating polyneuropathy Alcoholic neuropathy Miller Fisher syndrome

GBS (Guillian-Barre syndrome)

The most common used "date-rape drugs"

Gamma-hydroxybutyrate and flunitrazepam

Which of the following occurs in the lipidosis known as Tay-Sachs disease? . Phosphoglycerides accumulate in the brain. . Synthesis of a specific ganglioside is excessive. . Ganglioside GM2 is not catabolized by lysosomal enzymes. . Xanthomas, due to cholesterol deposition, are observed. . Synthesis of a specific ganglioside is decreased.

Ganglioside GM2 is not catabolized by lysosomal enzymes.

A 42-year-old man presents with hepatomegaly, jaundice, refractory ascites, and renal insufficiency. Peripheral leukocytes exhibit only 20% of normal glucocerebrosidase activity. Which of the following would explain his symptoms? . Niemann-Pick disease type II C . Tay-Sachs disease . Gaucher disease . Krabbe disease . Fabry disease

Gaucher disease

Which of the following statements regarding giant cell arteritis is true? ជ្រើសមួយ៖ Giant cell arteritis commonly occurs in patients 50 years of age or younger None of the above Giant cell arteritis often affects the branches of the proximal aorta Giant cell arteritis never results in complete blindness despite the high frequency of visual complaints Standard therapy for this arteritis is prednisone, 5 to 15 mg/day

Giant cell arteritis often affects the branches of the proximal aorta

The Fanconi syndrome is characterized by which of the following?

Glycosuria, aminoaciduria, phosphaturia

Resistance to Type I diabetes has been shown to be associated with a specific polymorphic allele. Which of the following loci represents this allele? . glutamic acid decarboxylase (GAD) . a VNTR in the 5' region of the insulin gene . HLA-B27 . HLA-DQ . HLA-DR3

HLA-DQ

A 4-year-old boy is brought to the pediatrician by his worried mother. She notes that he urinates 10 times a day and is always drinking water. She also reports that despite eating more than either of his brothers did at the same age, he is not gaining any weight. Which of the following human leukocyte antigen (HLA) types is associated with the most likely diagnosis for this child? ជ្រើសមួយ៖ HLA-DR3 HLA-B51 HLA-B27 HLA-DR2 HLA-D11

HLA-DR3 type 1 DM

Ingestion of LSD will result in

Hallucinations

A patient has a fracture, which is effectively a spondylolisthesis of C2 on C3. What is the most likely diagnosis of this patient? ជ្រើសមួយ៖ Facet dislocation Anterior cranio-cervical dislocation Hangman's fracture Teardrop fracture Atlanto-axial instability

Hangman's fracture

episode of cerebellar ataxia seen in

Hartnup disease

The mother of a kindergartner is concerned that her child may have a learning disability. Which of the following would be consistent with a learning disability?

Has a discrepancy between intelligence and achievements in one or more areas

A 9-year-old African-American child presents with anemia and stroke. What is the most likely finding with hemoglobin electrophoresis?

HbF 15%

The most common manifestation of alpha1 anti trypsin deficiency in infancy?

Hepatic cirrhosis

Chromatin remodeling is associated with alterations in the transcriptional activity of genes in the region of the remodeling. Which of the following statements is most correct concerning the events of chromatin remodeling? . Histone acetylation tends to destabilize chromatin structure. . Remodeling is necessary to induce the property of genomic imprinting. . Chromatin remodeling occurs predominantly in regions enriched in CpG dinucleotides. . Methylation of cytosine residues induces the remodeling event. . Methylation of histone H1 is sufficient to stimulate remodeling.

Histone acetylation tends to destabilize chromatin structure.

Which of the following statements regarding our current knowledge of Kaposi sarcoma (KS) is false? ជ្រើសមួយ៖ Total CD4+ T cell count is the most important factor predictive of survival in the form of this disease associated with HIV Male sex is a significant risk factor for the condition, especially in the classic form of the disease If HIV infection is confirmed, initiation of highly active antiretroviral therapy (HAART) in this patient would likely lead to dramatic improvements in the lesions during the first few months of therapy Human herpesvirus 8 (HHV-8) plays an etiologic role exclusively in HIV-associated KS Visceral organ (i.e., lung and GI tract) involvement is relatively common in HIV-associated KS

Human herpesvirus 8 (HHV-8) plays an etiologic role exclusively in HIV-associated KS

Numerous inherited disorders are the result of the expansion of trinucleotide (triplet) repeats either within the coding regions of genes or the untranslated regions of the resultant RNAs. Which of the following diseases has been shown to be caused by triplet expansion? . FH . Menkes disease . Huntington disease (HD) . Duchenne muscular dystrophy (DMD) . cystic fibrosis (CF)

Huntington disease (HD)

A 45-year-old sheep farmer complains about a gradually enlarging painful lump in the right upper abdomen for 3 months. He is otherwise healthy. Physical examination reveals firm tender hepatomegaly. He has a total leucocyte count (TLC) of 8600 with a differential leucocyte count (DLC) showing 12% eosinophils. What is the diagnosis of this patient? ជ្រើសមួយ៖ Filariasis Hydatid disease Amoebic liver abscess Actinomycetoma Ascariasis

Hydatid disease

Approximately 2 weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum. A long, thin mass is palpable in the right upper quadrant of the abdomen. No peritoneal signs are present. Intussusception is suspected. Which of the following is the most appropriate next step? ជ្រើសមួយ៖ . Diagnostic air enema with subsequent observation and serial abdominal examinations . Exploratory laparotomy with bowel resection . Diagnostic laparoscopy with laparoscopic reduction . Decompressive colonoscopy with placement of a rectal tube . Hydrostatic reduction with air enema

Hydrostatic reduction with air enema

the patient has a history of low transverse C-section. she desires bilateral tubal ligation during her next C-section. your opinion?

If the patient desires a bilateral tubal ligation, it is safer for her to undergo a vaginal delivery followed by a postpartum tubal ligation rather than an elective repeat cesarean section with intrapartum bilateral tubal ligation.

A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused. She also complains of hemoptysis and weight loss of 10 lbs (4.5kg) over a period of 2 months. She has smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 16/min. Her mucus membranes are moist. There is no jugular venous distention. Her neurological examination is non-focal, and cardiovascular examination is unrevealing. There is no ankle edema or ascites. Serum studies show: Sodium 115 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 100 mg/dL, BUN 10.0 mg/dL. Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40 mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the management of this patient? ជ្រើសមួយ៖ . Demeclocycline . Hypertonic saline . Loop diuretics . Normal saline . Water restriction

Hypertonic saline (SIADH secondary to lung cancer. Severe hyponatremia (plasma sodium < 120 meq/L with central nervous system symptoms (e.g., seizures or change in mental status) requires aggressive management with intravenous 3% saline)

Which of the following electrolyte abnormalities may result from the use of thiazide-type diuretics?

Hyperurecemia

Most death related to Ecstasy

Hyponatremia or hypernatremia

10 month olds baby with 24h symptoms of intussusception. Next step?

IV fluid rehydration and the management is hydrostatic reduction, either by contrast enema or air enema

15-year-old male presents with a 2-day history of fever, chills, and cough. He complains of aching muscles. Today he noticed his urine was red. Examination revealed a tired-appearing adolescent with fever, pharyngitis, nasal congestion, and tender calf muscles. Of the following infectious agents, which is most likely to cause this condition?

Influenza

53-year-old male is brought to the emergency department after being involved in a motor vehicle accident (MVA) as an unrestrained driver. He was found unresponsive at the scene and was intubated by paramedics. He has received 1L of normal saline over the last 20 minutes. His blood pressure in the emergency department is 70/30 mmHg, and his heart rate is 100/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. On exam, there are multiple bruises over the anterior chest and upper abdomen. The trachea is midline. A Swan-Ganz catheter reveals a pulmonary capillary wedge pressure of 12 mmHg. Rapid infusion of 1L of normal saline increases the pulmonary capillary wedge pressure to 17 mmHg, with a blood pressure of 75/30 mmHg and heart rate of 103/min. Which of the following is the best treatment for this patient? ជ្រើសមួយ៖ . Inotropic agents . Chest tube . Anticoagulation . High-rate IV fluids . Pericardiocentesis

Inotropic agents (cardiac contusion)

To alter the course of this patient's diabeticnephropathy, what is the most appropriate next step in management? ជ្រើសមួយ៖ . Intensive glycemic control . Intensive blood pressure control . Very low protein diet . Aspirin therapy . Aggressive lipid management

Intensive blood pressure control (goal <130/80)

mental retardation, a boy is tall has long face with prominent jaw and large ears. True statement?

It is the most common form of inherited mental retardation (fragile X)

During surgery at the root of the neck, an attending surgeon cautions her resident to locate important structures which need to be protected. One of these is the phrenic nerve, responsible for the innervation of the diaphragm and thus, respiration. The phrenic nerve can be positively identified by which of the following anatomical relationships? . It lies immediately between the esophagus and the trachea. . It wraps around the right subclavian artery. . It is found immediately between the common carotid artery and the internal jugular vein. . It lies on the scalenus medius muscle.

It wraps around the right subclavian artery.

A 24-year-old Jehovah's Witness who was in a high-speed motorcycle collision undergoes emergent splenectomy. His estimated blood loss was 1500 mL. Which of the following strategy should be employed for his resuscitation? ជ្រើសមួយ៖ . 0.45% normal saline should be administered in a 3:1 ratio to replace the volume of blood lost. . Synthetic colloids should be administered as the primary resuscitation fluid in a 3:1 ratio to replace the volume of blood lost. . Lactated Ringer solution should be administered in a ratio of 3:1 to replace the blood lost. . Vasopressors should be primarily utilized for maintenance of his blood pressure. . 0.9% normal saline should be administered in a 1:1 ratio to replace the volume of blood lost

Lactated Ringer solution should be administered in a ratio of 3:1 to replace the blood lost.

Congenital varicella

Limb abnormalities

A 60-year-old man sees a urologist for what he describes as bloody urine. A urine sample is positive for cytologic evidence of malignancy. Cystoscopy confirms the presence of superficial transitional cell carcinoma. Which of the following is the recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder? ជ្រើសមួយ៖ . Radical cystectomy . Systemic chemotherapy . Topical (intravesicular) chemotherapy . Radiation therapy . Local excision and topical (intravesicular) chemotherapy

Local excision and topical (intravesicular) chemotherapy

What is the characteristically heard on auscultation in atrial myxoma?

Loud third heart sounds

A 55-year-old woman complains of double vision. She finds that she is tired all the time and has difficulty climbing stairs. She has difficulty getting items off high shelves at work. Reflexes are absent but elicited after exercise. Shoulder abduction is initially 4-5 but on repeated testing is 4 +/5. What pathology is associated with this female's diagnosis? ជ្រើសមួយ៖ Stroke Thyrotoxicosis Diabetes Lung cancer Peptic ulcer

Lung cancer (Lambert-Eaton myasthenia syndrome experienced increased strength upon repetition. LEMS is a rare disease caused by autoantibodies against the voltage-gated calcium channels on the presynaptic motor nerve terminal. It is a paraneoplastic disorder, most often associated with small-cell lung cancer)

A patient is found to be deficient in folate. This patient is anemic, and a complete blood count indicates that the MCV is 105 fL (normal range: 8096) and the MCHC is 34 g/dL (normal range: 3236). The anemia is thus macrocytic, normochromic. In this patient how would you predict that the MCH (mean corpuscular hemoglobin) would compare with the normal range? Select one: a. MCH would be within the normal range b. MCH would be depressed with respect to the normal range c. MCH would be elevated with respect to the normal range d. this cannot be determined based on the information provided

MCH would be elevated with respect to the normal range

Apatient is found to be deficient in folate. This patient is anemic, and a complete blood count indicates that the MCV is 105 fL (normal range: 8096) and the MCHC is 34 g/dL (normal range: 3236). The anemia is thus macrocytic, normochromic. In this patient how would you predict that the MCH (mean corpuscular hemoglobin) would compare with the normal range? . MCH would be depressed with respect to the normal range . MCH would be elevated with respect to the normal range . this cannot be determined based on the information provided . MCH would be within the normal range

MCH would be elevated with respect to the normal range

HTN, DM, intermittent claudication , ABI 0.7 .adverse health outcomes in the next 5 years?

MI

Injuries remain the leading cause of death among all children of age 1-19 years. For those 15-19 years of age, which of the following lists the categories of injuries from most common to least common?

MVA-homicide-suicide

Toxic shock syndrome (TSS) skin finding?

Macular erythroderma

TSS (toxic shock syndrome) skin finding?

Macular erythroderma (sunburn-like rash )

Antibiotic tx for campylobacter enteritis in severe patient

Marcolide( Azithromycin)

A 7-year-old girl presents with red striae which her mother noticed around her abdomen. The girl also has plethoric cheeks and, on her back, several faint, irregular brown macules are observed. The mother is particularly concerned about the early breast development that seems apparent on her daughter. Serum phosphate is decreased. The most likely diagnosis is: ជ្រើសមួយ៖ McCune-Albright syndrome Paget's disease of the bone Cushing's disease Neurofibromatosis Hypopituitarism

McCune-Albright syndrome (genetic disorder that causes the uncontrolled secretion of a number of endocrine glands causing abnormalities of the skin, bones and hormonal disturbances. It is usually suspected when the following pathologies occur: precocious puberty, cushingoid features, hyperpituitarism (acromegaly, gigantism), café-au-lait spots and hypophasphataemia.)

A 22-year-old man is examined following a motor vehicle accident. He has a right knee dislocation which is reduced in the emergency room. He has palpable pedal pulses and is neurologically intact. Which of the following is an appropriate next step in his workup and management? ជ្រើសមួយ៖ . Angiography of the right lower extremity . Surgical exploration of the right popliteal artery . Prophylactic below-knee 4-compartment fasciotomies . Observation with serial pulse checks . Measurement of ankle-brachial indices

Measurement of ankle-brachial indices

Mc Murray's test

Meniscal injury (perform this test when a person has a history of trauma followed by locking, giving away, or local pain in the knee.)

A3-month-old infant who otherwise appeared normal during the first 2 months of life except for a bout of hyperbilirubinemia is now clearly exhibiting developmental delay. In addition, the infant's hair has become grayish and dull and there is a stubble of broken hair over the occiput and temporal regions. The facial appearance has also changed such that the infant has very pudgy cheeks, abnormal eyebrows, and sagging jowls. The occurrence of frequent convulsions was the stimulus for the parents to bring their child to the emergency room. These rapidly deteriorating symptoms are indicative of which of the following disorders? . Refsum disease . Menkes disease . Gilbert syndrome . hemochromatosis . Crigler-Najjar syndrome type I

Menkes disease

Cardiac contusion treatment

Monitor for dysrhythmia, check cardiac enzymes, give inotropic agents.

A 46-year-old man comes to the emergency department because of abrupt onset of epigastric pain radiating to the back and associated vomiting. He has had these symptoms for the past 1 day. The symptoms are progressively getting worse. He has no other medical problems or previous surgeries. He does not use tobacco, alcohol, or illicit drugs. His temperature is 36.5°C (97.6°F), blood pressure is 100/70 mm Hg, pulse is 100/min, and respirations are 20/min. Abdomen is mildly distended and very tender to palpation in the epigastric region; bowel sounds have decreased. There is no rebound tenderness or organomegaly. Rectal examination shows no abnormalities. Laboratory findings reveal: CBC: Hb 15.0 g/dL, Platelet count 223,000/mm3, Leukocyte count 14,500/mm3, Serum Chemistry: Serum Na 134 mEq/L, Serum K 3.6 mEq/L, Chloride 93 mEq/L, Bicarbonates 29 mEq/L, BUN 30 mg/dL, Serum creatinine 0.8 mg/dL, Calcium 10.3 mg/dL, Blood glucose 168 mg/dL, LFT 1.4 mg/dL. Total bilirubin: Alkaline phosphatase 220 U/L, Aspartate aminotransferase 88 U/L, Alanine aminotransferase 155 U/L, Lipase 523 U/L. Abdominal x-ray shows gaseous distention of the small bowel in the upper abdomen. Computed tomography (CT) scan with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics, and antibiotics are started. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Add intravenous sodium bicarbonate . Administer intramuscular carbachol to treat ileus . Add intravenous pancreatic protease inhibitor . Obtain a right upper quadrant ultrasound . Perform colonoscopic decompression

Obtain a right upper quadrant ultrasound (The most common causes of acute pancreatitis are gallstones (biliary pancreatitis) => RUQ US is needed

Which of the following statements incorrectly characterizes attributes of the medications to be considered for this patient? ជ្រើសមួយ៖ Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause diuretic unresponsiveness Oral bioavailability of loop diuretics varies little from drug to drug Without a loading dose, the blood level of digoxin will plateau in 7 days Spironolactone has been associated with gynecomastia Hydrochlorothiazide may exacerbate hyperglycemia

Oral bioavailability of loop diuretics varies little from drug to drug

An 11-month-old African American boy has a hematocrit of 24% on a screening laboratory done at his well-child checkup. Further testing demonstrates: hemoglobin 7.8 g/dL; hematocrit 22.9%; leukocyte count 12,200/μL with 39% neutrophils, 6% bands, 55% lymphocytes; hypochromia on smear; free erythrocyte protoporphyrin (FEP) 114 μg/dL; lead level 6 μg/dL whole blood; platelet count 175,000/μL; reticulocyte count 0.2%; sickle-cell preparation negative; stool guaiac-negative; and mean corpuscular volume (MCV) 64 fL. Which of the following is the most appropriate recommendation? ជ្រើសមួយ៖ . Intramuscular iron dextran . An iron-fortified cereal . CalciumEDTA . Blood transfusion . Oral ferrous sulfate

Oral ferrous sulfate

A 12-year-old boy presents with an intensely pruritic rash for 3 days. He just went on a camping trip, during which he wore only short-sleeve shirts and short pants. His temperature is 37.6 C (99.7 F), blood pressure is 96/62 mm Hg, pulse is 65/min, and respirations are 12/min. There are numerous erythematous papules and vesicles on both arms and legs. Most of them are in a linear array. Which of the following is the most appropriate pharmacotherapy? ជ្រើសមួយ៖ Topical diphenhydramine Oral cephalexin Topical mupirocin Oral prednisone Topical 1% hydrocortisone

Oral prednisone

A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has opened her bowels nine times since the onset of her symptoms. You diagnose gastroenteritis after learning that the patient and her family all ate at a new restaurant and the rest of her family have had similar problems. The most appropriate management is: ជ្រើសមួយ៖ Admission for intravenous fluid rehydration Oral rehydration advice, anti-emetics and discharge home Oral antibiotic therapy and discharge home Admission for intravenous antibiotic therapy No treatment required

Oral rehydration advice, anti-emetics and discharge home

During maturation of the oocytes, which of the following structures retain almost all of the cytoplasm after the first meiotic division? Select one: a. second polar body b. zygote c. first polar body d. ovum e. primary oocyte

Ovum

An 81-year-old woman is referred to cardiology out-patients with a history of dizzy episodes and one episode of syncope. She is known to have long-standing atrial fibrillation. A 24-hour tape confirms atrial fibrillation, with rates varying from 30 to 140 bpm. There are several daytime pauses of over 3 seconds. She is listed for a permanent pacemaker. Which of the following would be the most appropriate device? ជ្រើសមួយ៖ VVI VOO DDI DDD VDD

Pacemaker types are defined by an international code, which uses three or more letters in a set sequence. The first letter is related to the chamber that is to be paced: A = atrium, V = ventricle, D = both. The second letter refers to the chamber that is sensed (A, V or D). The third letter refers to the response to a sensed beat by the pacemaker: I = inhibits, T = trigger or D = both (ie either inhibits or triggers). VOO is a fixed output setting (eg pacing at 60 beats per minute irrespective of intrinsic activity); the 'O' as second and third symbol implies that the chamber is not sensed and therefore there is no response to a sensed beat. A fourth letter refers to whether or not the pacemaker has rate-adaptive properties (R). This woman has atrial fibrillation and as such there is no need for an atrial lead. VVI means there is one lead in the ventricle (pacing and sensing the ventricle). If the pacemaker senses an intrinsic QRS complex then pacing is inhibited (I). This means the pacemaker will only deliver a stimulus when there is a significant pause. ចម្លើយត្រឹមត្រូវគឺ VVI

hearing loss, increased hat size, and occasional headaches

Paget's disease

During development, the uterus develops from which of the following? . yolk sac . paramesonephric ducts . mesonephric ducts . nephrogenic ridge . urogenital sinus

Paramesonephric ducts

Side effects of amlodipine

Peripheral edema, flushing, constipation

Which of the following would be an indication for splenectomy in patient with ITP?

Persistence of thrombocytopenia for more than 1-2 years

Drug that can decrease the recurrence of febrile seizures

Phenobarbital

Which of the following statements is true regarding children of divorce?

Preschool-aged children may demonstrate regressive behavior.

A 36-year-old male comes to the office for the evaluation of fatigue and weakness for the last several weeks. He denies any change in appetite, change in weight, heat or cold intolerance, nausea, vomiting and constipation. He cannot recall any recent stressful events. His past medical and family histories are unremarkable. He does not have any medications. His pulse is 76/min, blood pressure is 120/70 mmHg, respirations are 14/min, and temperature is 36.7°C (98°F). He is well-oriented to time, place and person. His neurological examination is nonfocal; the deep tendon reflexes are normal. Lab tests show: Hematocrit 43%, WBC count 6,000/microl, Platelet count 200,000/microl, Serum calcium 11 mg/dL, Serum albumin 4.5 g/dL, 24-hour urinary calcium 200 mg. Which of the following is the most likely cause of his symptoms? ជ្រើសមួយ៖ . Milk alkali syndrome Familial hypocalciuric hypercalcemia . Primary hyperparathyroidism . Malignancy . Increased calcium intake

Primary hyperparathyroidism

A 56-year-old female is admitted with a diagnosis of chronic renal failure from systemic lupus erythematosus and non-steroidal anti-inflammatory drug use. She has a history of recurrent kidney stones. Laboratory studies show the following: Serum calcium 10.6 mg/dL, Serum albumin 3.9 g/L, PTH 140 pg/mL, Serum phosphorus 3.0 mg/dL. Her baseline serum creatinine level ranges from 1.6 to 1.8 mg/dL. Her bone mineral density is measured by DXA scan, revealing a T score of-2.5 at the lumbar spine, which is consistent with osteoporosis. What is the most likely cause of this patient's hypercalcemia? ជ្រើសមួយ៖ . Milk-alkali syndrome . Primary hyperparathyroidism . Sarcoidosis . Chronic renal failure . Hypercalcemia of malignancy

Primary hyperparathyroidism

Which of the following cardiovascular conditions is an absolute contra-indication to pregnancy? ជ្រើសមួយ៖ Mitral valve prolapse Primary pulmonary hypertension Previous repaired patent ductus arteriosus Bicuspid aortic valve Atrial septal defect

Primary pulmonary hypertension

Fractured scaphoid with highest incidence of avascular necrosis

Proximal scaphoid

The mother of a 9-month-old girl reports that she is now waking up at night, after sleeping all night for several months. Nighttime awakening at this age can be treated by which of the following?

Put the infant to sleep while drowsy but still awake

Risk for high altitude pulmonary edema?

Rate of ascent

Which of the following should be included in the differential diagnosis of infant who is not thriving? Select one: Recurrent otitis media Small atrial septal defect Acute bacterial meningitis Cystic fibrosis Mild intermittent asthma

Recurrent otitis media

A 60-kg, 53-year-old man with no significant medical problems undergoes lysis of adhesions for a small-bowel obstruction. Postoperatively, he has high nasogastric output and low urine output. What is the most appropriate management of his fluids? ជ្រើសមួយ៖ . Infusion of D5 lactated Ringer at 100 mL/h . Replacement of nasogastric tube losses with 0.45% normal saline with 20 mEq/L of potassium chloride in addition to maintenance fluids . Replacement of nasogastric tube losses with lactated Ringer in addition to maintenance fluids . Infusion of D5 0.45% normal saline at 100 mL/h . Infusion of D5 0.9% normal saline at 100 mL/h

Replacement of nasogastric tube losses with lactated Ringer in addition to maintenance fluids

Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 125 mEq/L. Which of the following is the most appropriate management strategy for this patient? ជ្រើសមួយ៖ . Administration of hypertonic saline solution . Plasma ultrafiltration . Hemodialysis . Aggressive diuresis with furosemide . Restriction of free water

Restriction of free water

A 42-year-old woman presents with ataxia. Gadolinium-enhanced MRI reveals multiple subcortical white matter lesions as well as enhancing lesions in the cerrebellum and spinal cord. She is diagnosed with MS. Two months later she develops optic neuritis. What feature is associated with a milder disease course? ជ្រើសមួយ៖ Her MRI scan appearance The interval between the two episodes of two months Her age of 42 Her female gender Her initial presentation of ataxia

her female gender

32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan? ជ្រើសមួយ៖ . Right lower lobectomy and mediastinal lymph node dissection . Neoadjuvant chemoradiation followed by right lower lobectomy and mediastinal lymph node dissection . Chemoradiation . Neoadjuvant chemotherapy followed by right lower lobectomy and mediastinal lymph node dissection . Right lower lobectomy and mediastinal lymph node dissection followed by adjuvant chemotherapy

Right lower lobectomy and mediastinal lymph node dissection

Which of the following is NOT associated with aortic regurgitation? ជ្រើសមួយ៖ Aortic dissection Marfan syndrome Systemic lupus erythematosus (SLE) Ankylosing spondylosis Rheumatic fever

SLE

Carpal navicular fracture aka

Scaphoid fracture

Protein zero (P0) is the predominant protein in myelin in the peripheral nervous system and its function is to stabilize adjacent plasma membranes by interaction with similar P0 molecules. Which of the following cells manufacture P0? . oligodendrocytes . fibrous astrocytes . microglia . protoplasmic astrocytes . Schwann cells

Schwann cells

The ability of rod cells in the eye to respond to light and transmit that response to the optic nerve requires that the 11-cis form of vitamin A be attached to which of the following proteins? . transducin . cGMP phosphodiesterase . scotopsin . Na+ channel . rhodopsin

Scotopsin

PEDS questionnaire is the best screening test for ?

Screens for development in children less than 8 years

Cell adhesion molecules enable intercellular contacts in epithelial as well as nonepithelial cells. Which of the following cell adhesion molecules are calcium-dependent molecules? . integrins . selectins . intercellular adhesion molecules (I-CAM) . disintegrins . neural cell adhesion molecules (N-CAM)

Selectins

Chemoprophylaxis for adult household of a child with meningococcal meningitis

Single-dose ciprofloxacin

A 2-year-old girl has persistent seborrheic dermatitis in the diaper area. In addition she has chronically draining infected ears. In which location do bony lesions most often occur in patients with this disorder?

Skull

what are the tumors that cause SIADH?

Small cell carcinoma of the lung, prostate cancer, cancers of the thymus, pancreatic cancers and lymphomas may cause SIADH (

A 57-year-old previously alcoholic man with a history of chronic pancreatitis presents with hematemesis. Endoscopy reveals isolated gastric varices in the absence of esophageal varices. His liver function tests are normal and he has no stigmata of end-stage liver disease. Ultrasound examination demonstrates normal portal flow but a thrombosed splenic vein. He undergoes banding, which is initially successful, but he subsequently rebleeds during the same hospitalization. Attempts tocontrol the bleeding endoscopically are unsuccessful. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . Splenectomy . Placement of a Sengstaken-Blakemore tube . Surgical mesocaval shunt . Transjugular intrahepatic portosystemic shunt . Surgical portocaval shunt

Splenectomy (thromboses splenic vein and recurrent bleeding, refractionated to therapy => splenectomy)

A 17-year-old primipara at 41 weeks wants an immediate cesarean section. She is being followed with biophysical profile (BPP) testing. Which of the following is correct information to share with the patient?

Spontaneous decelerations during BPP testing are associated with significant fetal morbidity.

A previously healthy 3-year-old boy brought in by his parents for help with potty training. The boy refuses to use the toilet. If his parents try to place him on the toilet, he becomes upset and cries. He has regular urination in his diaper. He has 1-2 soft bowel movements a day. In the office, you note that the child speaks in short sentences that are mostly understandable. He runs well and can climb up on the examination table without help. His physical examination is unremarkable. Which of the following is the next best step in the management of this patient? ជ្រើសមួយ៖ Perform a urinalysis Stop potty training attempts for several months Put him on the toilet at regularly scheduled times Increase fiber in his diet Use a positive reward system

Stop potty training attempts for several months

Where does the facial nerve exists the temporal bone?

Stylomastoid foramen

A 48-year-old woman presents to her primary care physician because of 2 weeks of neck pain. The pain is constant and sharp (rated at 10 of 10) and is felt in the anterior portion of her neck. She also notes several weeks of loose stools and fatigue. Past medical history is significant for a viral upper respiratory infection about 1 month ago. She has a temperature of 37.9°C (100.2°F), heart rate of 96/min, and blood pressure of 136/82 mmHg. On neck examination there is diffuse enlargement of the thyroid and it is exquisitely tender to even mild palpation. Laboratory tests show a total tri-iodothyronine level of 280 ng/dL, total thyroxine of 25 μg/dL, and thyroid-stimulating hormone of 2 μU/mL (normal: 0.4-4 μU/L).Which of the following is the most likely diagnosis? ជ្រើសមួយ៖ Hashimoto's thyroiditis Subacute granulomatous thyroiditis Acute infectious thyroiditis Drug-induced thyroiditis Riedel's thyroiditis

Subacute granulomatous thyroiditis (de Quervain's thyroiditis, which typically follows an acute viral illness, typically an upper respiratory infection.)

A 74-year-old woman is brought to the emergency department by her daughter. The daughter states that her mother lives alone and has no significant medical problems. She says that she last saw her mother a month prior, before she left on an extended business trip. When she returned, she found her mother appeared restless and very nervous. She also appeared to have lost a noticeable amount of weight. The patient told her daughter that she had been having increased frequency of bowel movements, and felt like her heart was beating fast and funny, and that she felt like she might be coming down with a cold. Initial evaluation in the emergency department reveals sinus tachycardia and a painful, enlarged thyroid. Which of the following is the most likely etiology of her symptoms? ជ្រើសមួយ៖ Graves' disease Subacute granulomatous thyroiditis Medication-induced hyperthyroidism Toxic multinodular goiter Autoimmune thyroiditis

Subacute granulomatous thyroiditis (painful, enlarged thyroid.)

A term infant is now 10 hours of age and has a seizure. Which of the following diagnoses is more common among term rather than premature infants?

Subdural hemorrhage

Williams syndrome:

Supravalvular aortic stenosis

A 19-year-old female university student presents with problems in both arms and difficulty walking. Since starting her course she has had difficulty writing, typing, and other such activities, and thus has struggled to keep up with the workload. She says the arms have "felt unusual" for around 6 months. She describes finding small burns and blisters on her arms that she can't remember getting in the first place. In the last few weeks she has also fallen twice when walking up the stairs. The only other thing she describes is some mild occipital headaches that have increased in frequency lately. She is otherwise fit and well. On examination, there is a loss of pinprick sensation found throughout the arms and on the back to around T3 level. Her hands appear to have some element of small muscle wasting and there is some loss of power throughout the arms. Reflexes are hard to elicit or possibly absent. In the legs, there is some mild symmetrical weakness, and the knee reflexes appear brisk. Plantars appear equivocal. What is the most likely diagnosis? ជ្រើសមួយ៖ Psychogenic neurological symptoms Cervical spondylosis Multiple sclerosis Syringomyelia Viral transverse myelitis

Syringomyelia

A 45-year-old man presents after a high-speed motor vehicle collision. He has a seatbelt sign across his neck and chest with an ecchymosis over his left neck. He is hemodynamically stable and neurologically intact. A CT angiogram shows a left carotid dissection. In the absence of other significant injuries, what is the next step in his management? ជ្រើសមួយ៖ . Antiplatelet therapy . Systemic anticoagulation with heparin . Neck exploration and left intra-extracranial bypass . Neck exploration and left carotid artery repair . Angiography and left carotid artery stenting

Systemic anticoagulation with heparin

cherry red macular spots: Select one: Tay-Sachs disease Menkes syndrome Wilson disease familial hypercholesterolemia

Tay-Sachs disease

A 12-month-old baby is brought in for a well-baby visit, during which the baby is noted to have leukokoria (a white pupillary reflex). On further evaluation, it is determined that the child has an ablatable, unifocal retinoblastoma, with an RB1 cancer-predisposing mutation in a tumor and no evidence of a germline RB1 in white cell DNA. The parents are concerned about the risk of retinoblastoma if they have other children. Regarding these parents' concern, which of the following statements is true? ជ្រើសមួយ៖ Both parents should be screened; if a germline mutation is not identified, the risk to future siblings is not increased The patient's future siblings may be at increased risk and should have aggressive surveillance and genetic screening Absence of a germline RB1 mutation on the patient's DNA screening reduces the risk in the rest of the family to chance; there is no need for further family testing The patient's future siblings would not be at increased risk, but the patient's offspring would be and should be screened for RB1 mutations prenatally Testing for RB1 is presymptomatic, and the patient—but not future siblings—will need continued aggressive surveillance to ensure that another retinoblastoma does not arise de novo

The patient's future siblings would not be at increased risk, but the patient's offspring would be and should be screened for RB1 mutations prenatally

A 24-year-old man with a history of increasing muscle cramps, myalgias, and calf muscle hypertrophy was recently diagnosed with Becker muscular dystrophy (BMD) through muscle biopsy. The lab report of the patient's leukocyte DNA analysis, however, states, "no mutation known to be associated with BMD found." On further questioning, you discover that the patient has a reportedly healthy 2-year-old daughter; a 16-year-old maternal cousin who recently began suffering from muscle cramps similar to those of the patient; a sister in her teens who is reportedly healthy; a mother with a "big heart"; and a maternal grandfather who died of an unspecified heart problem 20 years ago. You suggest further genetic linkage analysis and counseling for this patient and his extended family. Which of the following facts would serve as the basis of your recommendation? ជ្រើសមួយ៖ Even though the patient cannot pass on the gene for BMD, his apparently healthy sister might be a carrier You should not suggest further counseling or testing because the lack of a specific gene mutation in the proband means you will not be able to determine the degree to which the patient's asymptomatic relatives are at risk The mother's mutation probably represents germline mosaicism; link-age analysis would help determine both her risk and her other children's risk Analysis of family members might help define the mutation in this patient and therefore help guide his therapies This patient's offspring and other relatives are at risk for BMD, and a genetic linkage analysis would help define their genotypic risk status

This patient's offspring and other relatives are at risk for BMD, and a genetic linkage analysis would help define their genotypic risk status

A 42-year-old homeless man presents with a 3-week history of shortness of breath, fevers, and pleuritic chest pain. Chest x-ray (CXR) reveals a large left pleural effusion. Thoracentesis reveals thick, purulent-appearing fluid, which is found to have glucose less than 40 mg/dL and a pH of 6.5. A chest tube is placed, but the pleural effusion persists. Which of the following is the most appropriate management of this patient? ជ្រើសមួយ៖ . Thoracotomy with decortication and antibiotic therapy . Thoracotomy with instillation of antibiotics into the pleural space . Infusion of antibiotics via the chest tube . Intravenous antibiotics for 6 weeks . Placement of a second chest tube at the bedside and antibiotic therapy

Thoracotomy with decortication and antibiotic therapy

A previously well 12-year-old présent with painful swelling on the shin 3days duration. Test to confirm the diagnosis?

Throat culture

No improving despite being prescribed conventional therapy. On examination, you note the presence of erythematous scaly plaques on the extensor surfaces of the knee and elbows. There is no evidence of flexural involvement. The most appropriate treatment is: ជ្រើសមួយ៖ Topical vitamin D analogue preparations Topical steroid preparations Topical retinoid therapy Topical tar preparations Antibiotics

Topical retinoid therapy (The question states that the patient is unresponsive to conventional therapy. Therefore, the next step would be to consider topical retinoid therapy.)

A 41-year-old man underwent successful living-related kidney transplantation 1 year ago with good results. Preoperatively, he was noted to have an elevated calcium level; post-transplantation, he continues to have elevated calcium levels and associated symptoms. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . CT scan of the neck and mediastinum . 99mTc sestamibi scanning . Total parathyroidectomy with autotransplantation of a portion of a gland into the forearm . Measurement of urinary calcium levels . Ultrasound of the neck

Total parathyroidectomy with autotransplantation of a portion of a gland into the forearm

What should be suspected in patient with systemic toxicity (fever, hypotension, tachycardia) and colonic dilation visualized on abdominal radiograph > 6cm

Toxic mégacôlon

A 42-year-old man presents to accident and emergency with a 1-day history of headache and fevers. He presents with his partner who says he has been becoming increasingly confused and disorientated. On examination, his temperature is 38.5°C. On cranial nerve examination there is a right-sided superior quadrantanopia. An urgent CT scan of the head is organized which shows multiple ring enhancing lesions. What is the most likely diagnosis? ជ្រើសមួយ៖ Meningitis Cryptosporidiosis CMV encephalitis Toxoplasmosis Histoplasmosis

Toxoplasmosis

A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Endoscopy shows blood coming from the ampulla of Vater. Which of the following is the most appropriate first line of therapy for major hemobilia? ជ្រើសមួយ៖ . Hepatic resection . Transarterial embolization (TAE) . Correction of coagulopathy, adequate biliary drainage, and close monitoring . Ligation of bleeding vessels . Percutaneous transhepatic biliary drainage (PTBD)

Transarterial embolization (TAE) for major hemobilia

The level of iron in the body must be tightly regulated due to the severe toxicity associated with elevated levels in the circulation and within cells. Which of the following proteins is primarily responsible for iron homeostasis? . transferrin . haptoglobin . ferritin . ceruloplasmin . metallothionein

Transferrin

The presumptive diagnosis is constrictive pericarditis. Which of the following physical signs would be consistent with this? ជ្រើសមួយ៖ Fourth heart sound Third heart sound Increased jugular distention on inspiration Rales at both lung bases Loud first and second heart sounds

increased jugular distention on inspiration (Kussmaul's sign)

A 25-year-old man presents to the emergency department wth a 1-week history of fever and myalgia. He had travelled to Chile 8 weeks ago. On examination there are no positive findings, although the patient recollects that his right eyelid was swollen for a few weeks after he left Chile. ECG reveals non-specific, T-wave changes in all leads. What is the most likely diagnosis? ជ្រើសមួយ៖ Echinococcosis Trypanosomiasis Toxoplasmosis Schistosomiasis Falciparum malaria

Trypanosomiasis (In acute trypanosomiasis, the patient presents with fever, myalgia, hepatosplenomegaly and myocarditis. Unilateral periorbital oedema and swelling of the eyelid can result from a bug bite around the eyes. This is called Romana's sign. The other conditions listed can cause myocarditis, but the best choice is trypanosomiasis.)

An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. His family wants "everything done." Which of the following is the best management option in this patient? ជ្រើសមួយ៖ . Intravenous antibiotics followed by elective cholecystectomy . Lithotripsy followed by long-term bile acid therapy . Open cholecystectomy . Laparoscopic cholecystectomy . Tube cholecystostomy

Tube cholecystostomy (High-risk, critically ill patients with multisystem disease and cholecystitis experience a significant increase in morbidity and mortality following operative intervention. Tube cholecystostomy can be performed under local anesthesia in the operating room or via a percutaneous approach in the radiology suite.)

A 60-year-old woman is found to have a systolic murmur at a routine medical. When you see her she is asymptomatic. Electrocardiography (ECG) shows marked left ventricular hypertrophy with strain. Echocardiography shows a peak aortic valve gradient of 90 mmHg, and decreased LV systolic function. What is the correct management? ជ្រើសមួយ៖ Aortic valvuloplasty Routine aortic valve replacement Regular out-patient review Anticoagulation Urgent aortic valve replacement

Urgent aortic valve replacement ( Surgery for aortic valve replacement is indicated in symptomatic patients (angina, exertional breathlessness, syncope) as the risk of sudden death increases dramatically with the onset of symptoms, or, in those with severe asymptomatic disease (peak outflow gradient greater than around 50 mmHg). Patients with a gradient of less than 25 mmHg have a 20% chance of needing surgical intervention within 15 years. Valvuloplasty is used only in patients with critical aortic stenosis who are unfit for surgery as the benefits are usually short-lived.)

Following a relatively normal early developmental period, a 6-month-old boy becomes pale and lethargic and begins to show signs of deteriorating motor skills. The infant has severe megaloblastic anemia; however, serum measurements of iron, folate, vitamins and demonstrate they are within normal range. Urine samples were clear when fresh, but when left to stand for several hours showed an abundant white precipitate that was composed of fine needle-shaped crystals. Analysis of the crystals identified them as orotic acid. Significant improvement is observed in the infant following oral administration of a nucleoside. Which of the following is most likely the nucleoside used? . cytidine . uridine . thymidine . guanosine . adenosine

Uridine

A 63-year-old male was admitted to accident and emergency 2 days after discharge following an apparently uncomplicated MI. He complained of rapidly worsening shortness of breath over the previous 48 hours but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. Which of the following is the most likely diagnosis? ជ្រើសមួយ៖ Further myocardial infarction Aortic stenosis Mitral incompetence Dressler's syndrome Ventricular septal defect

VSD

A 62-year-old woman is admitted having collapsed at her local supermarket complaining of palpitations. On examination she is very unwell with a BP of 90/50 mmHg and very rapid palpitations. Investigations; ECG - Ventricular tachycardia with moving axis - torsade de pointes. Which of the following drugs is not associated with this arrhythmia? ជ្រើសមួយ៖ Flecainide Sotalol Risperidone Verapamil Digoxin

Verapamil

What type of colonic polyp has the highest risk of becoming cancerou?

Villous adenoma

A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Endoscopic modalities fail to stop the bleeding. Which of the following is the most appropriate surgical management of this patient? ជ្រើសមួយ៖ . Wedge resection of the lesion with truncal vagotomy and antrectomy . Wedge resection of the lesion with highly selective vagotomy . Wedge resection of the lesion . Wedge resection of the lesion with truncal vagotomy

Wedge resection of the lesion

Incisional biopsy of a breast mass in a 35-year-old woman demonstrates cystosarcoma phyllodes at the time of frozen section. Which of the following is the most appropriate management strategy for this lesion? ជ្រើសមួយ៖ . Wide local excision with a rim of normal tissue . Excision and postoperative radiotherapy . Lumpectomy and axillary lymphadenectomy . Modified radical mastectomy . Excision, postoperative radiotherapy, and systemic chemotherapy

Wide local excision with a rim of normal tissue

A 2-month-old infant suffering from increased vomiting and diarrhea is seen in the hospital and observed to have significant abdominal distention due to hepatosplenomegaly. Unfortunately, the infant does not survive. Autopsy reveals calcification of the adrenals and massive accumulation of cholesteryl esters and triglycerides in most tissues. Analysis of enzyme activity in fibroblasts and lymphocytes demonstrates a significant acid lipase (cholesteryl ester hydrolase) deficiency. These clinical findings are indicative of which of the following disorders? Select one: a. Wolman disease b. Maroteaux-Lamy syndrome c. I-cell disease (mucolipidosis type II) d. Sanfilippo syndrome e. hyperlipoproteinemia, type I (familial liproprotein lipase deficiency)

Wolman disease

Has greatest effect on increasing heart rate:

isoproterenol

A 3-month-old infant exhibits profound neurologic deficit in addition to being blind and deaf. Pathologic examination indicates renal cysts, hepatomegaly, and facial dysmorphism. Biochemical analysis reveals plasma accumulations of very long-chain fatty acids, abnormal intermediates of bile acid synthesis, and a marked deficiency of plasmalogens. These physical and biochemical features are characteristic of which of the following disorders? Select one: a. Zellweger syndrome b. hyperpipecolic acidemia c. neonatal adrenoleukodystrophy d. rhizomelic chondrodysplasia punctata (RCDP) e. infantile Refsum disease

Zellweger syndrome

appendiceal adenocarcinoma

a rare neoplasm accounting for less than 0.5% of GI tumors, should undergo formal right hemicolectomy.

In Type I diabetes, the increased production of ketone bodies is primarily a result of which of the following? . decreased cyclic adenosine monophosphate (cAMP) levels in adipocytes . elevated acetyl-CoA levels in skeletal muscle . a substantially increased rate of fatty acid oxidation by hepatocytes . increased gluconeogenesis . an increase in the rate of the citric acid cycle

a substantially increased rate of fatty acid oxidation by hepatocytes

A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. A complete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. We inject high-dose IV steroids and broad-spectrum antibiotics. After 48 hours, there is no clinical improvement. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . abdominal colectomy with ileorectal anastomosis . proctocolectomy with ileal pouch-anal anastomosis . abdominal colectomy and ileostomy and Hartmann's procedure . cyclosporine . colonoscopic decompression

abdominal colectomy and ileostomy and Hartmann's procedure

Unilateral multicystic dysplastic kidney in an infant usually presents with which of the following?

abdominal mass

A 13-month-old female in day care presents to the outpatient clinic with 3 days of rhinorrhea, cough, and fever to 101°F. Her examination is significant for clear nasal congestion and red tympanic membranes that are mobile with insufflation. The mother asks for antibiotics. What is the most appropriate therapy at this time?

acetaminophen and fluids

Exogenous peripherally injected insulin differs from endogenously secreted insulin in a number of aspects, including which of the following? . achieves a higher concentration in the periphery than in the liver, contrary to endogenous insulin . is able to bypass insulin resistance observed with endogenous insulin . is in the form of proinsulin, whereas endogenous insulin has had C-peptide removed . contains C-peptide, which is missing from secreted endogenous insulin . is always extracted from animal sources and, therefore, is less effective due to sequence differences and anti-insulin antibodies

achieves a higher concentration in the periphery than in the liver, contrary to endogenous insulin

A healthy 17-year-old male tells his doctor during a normal check-up visit that "his muscles gave out" when he recently attempted to lift a heavy load. On questioning, he answers that he did not experience any other neuromuscular problems after this experience. What is the most likely mechanism responsible for the abrupt cessation of skeletal muscle contraction? . activation of gamma motor neurons . activation of alpha motor neurons . activation of Golgi tendon organs . skeletal muscle ischemia . activation of muscle spindles

activation of Golgi tendon organs

Which of the following statements concerning skeletal muscle is correct? . active tension depends on the extent of overlap between thick and thin filaments . significant passive tension is generated at normal rest fiber length . tension generation depends on myosin attachment to the z line . velocity of shortening is independent of fiber load . during contraction, thin filaments shorten and thick filaments maintain constant length

active tension depends on the extent of overlap between thick and thin filaments

triad of Bud-chiarie syndrome

acute abdominal pain, ascites, hepatomegaly.

Severe combined immunodeficiency disease (SCID) is characterized by a complete lack of cell- mediated and humoral immunity. This disorder results from a deficiency in which of the following enzymes? . adenosine deaminase . orotic acid decarboxylase . purine nucleotide phosphorylase . asparatate transcarbamoylase . HGPRT

adenosine deaminase

Adrenal calcification is a typical feature of

adrenal tuberculosis

A 14-year-old female patient complains of a severe sore throat and you use a cotton swab to obtain specimens for a culture. As you lightly touch the pharyngeal wall with the cotton swab, the patient gags. What is the location of neuronal cell bodies innervating pharyngeal constrictor muscles involved in the gag reflex? . facial nucleus . hypoglossal nucleus . ambiguus nucleus . abducens nucleus . dorsal motor nucleus of the vagus

ambiguus nucleus

the attending surgeon decides on an end-to-side portocaval shunt. Which of the following describes the chosen procedure? . anastomosis by suturing the inferior end of the portal vein to the inferior vena cava . anastomosis of the splenic vein to the left renal vein . anastomosis by prosthetic vascular graft between the inferior vena cava and the superior mesenteric vein . placement of an expandable stent between a hepatic vein and the portal vein . anastomosis by communication between the portal vein and the inferior vena cava

anastomosis by suturing the inferior end of the portal vein to the inferior vena cava

A well-appearing, 10-year-old presents to the emergency department with a red rash on his trunk, ankles, elbows, and red lesions on his tongue. You suspect that these look like petechiae and order some laboratory tests including a complete blood count. When the laboratory values come back, you see that the platelet count is read as 5,000/µL. The patient's blood type is A and he is Rh positive. You diag- nose the patient with idiopathic thrombocy- topenia purpura. What is the next step in your management?

anti-D immunoglobulin

During development, which of the following structures act as a temporary set of kidneys in the fetus? . pronephroi . paramesonephric ducts . ureteric bud . metanephroi . mesonephroi

mesonephroi

Which of the following apoproteins is found exclusively associated with chylomicrons? . apoE . apo CII . apo B48 . apoA . apoD

apo B48

Lipoprotein lipase (LPL) is the endothelial cellassociated enzyme necessary for release of fatty acids from circulating lipoproteins. Which of the following apolipoproteins is required to activate LPL- mediated release of fatty acids from chylomicrons? . apo CII . apoE . apoA . apo

apo CII

A 72-year-old male patient has suffered a cerebral infarct affecting the left cerebral hemisphere. On examination of the patient, it is noticed that his verbal output is fluent and paraphasic. His comprehension of speech is normal but repetition is severely impaired. Naming is also impaired, although when given a list, the patient is able to select the correct name. Special consultation with a neurologist results in a diagnosis of conduction aphasia. Which of the following brain structures is affected? . red nucleus . arcuate fasciculus . Wernicke's area . Broca's area . nucleus ambiguous

arcuate fasciculus

One important function of nitric oxide (NO) is the induction of vascular smooth muscle relaxation in response to acetylcholine. The production of NO requires which amino acid? . arginine . lysine . cysteine . asparagines . glutamine

arginine

Regarding the axon of the second-order neuron in the pathway for conscious awareness of fine, discriminative touch and vibratory sensation from the upper limb, which of the following is correct? . terminates in the nucleus cuneatus . ascends the brainstem in the medial lemniscus . decussates in the ventral white commissure of the spinal cord . has its cell body in the nucleus gracilis . is found in the dorsal funiculus of the spinal cord

ascends the brainstem in the medial lemniscus

The initial reaction of the de novo synthesis pathway for pyrimidine nucleotides begins with glutamine and C and is complete with the formation of uridine monophosphate. Which of the following represents the ratelimiting enzyme in this pathway? . PRPP synthetase . ribonucleotide reductase . aspartate transcarbamoylase . orotate monophosphate decarboxylase . phosphoribosylpyrophosphate (PRPP) amido transferase

aspartate transcarbamoylase

The electrocardiogram of a 66-year-old male with a history of atherosclerotic heart disease reveals an irregular, but rapid heart rate. The QRS complexes are normal but no P-waves can be seen. What is the most likely reason for these findings? . Sinus tachycardia . atrial fibrillation . Right bundle branch block . Paroxysmal ventricular tachycardia . Wolff-Parkinson-White syndrome

atrial fibrillation

Correct targeting of newly synthesized hydrolytic enzymes to the lysosomes requires which of the following modifications? . attachment of mannose-6-phosphate to the enzymes . prenylation of the enzymes . gamma-carboxylation of glutamate residues in the enzymes . O-linkage of carbohydrate to the enzymes . proteolytic activation following transport to the lysosome

attachment of mannose-6-phosphate to the enzymes

An 8-year-old boy is referred for new-onset seizures. Which of the following would mostly support a diagnosis of complex partial (psychomotor) seizures?

automatisms

mode of inheritance of Peutz-Jeghers syndrome:

autosomal dominant

Tuberous sclerosis

autosomal dominant condition characterized by a triad of cutaneous abnormalities, mental retardation and seizures.

A 72-year-old woman with severe COPD who requires home oxygen is unable to ambulate inside her home without experiencing severe left hip pain. She was hospitalized 1 year ago for a viral pneumonia and was ventilator-dependent at that time for 6 weeks. On examination, her blood pressure is 165/80 mm Hg. She has weakly palpable bilateral femoral pulses. An angiogram demonstrates severe aortoiliac disease involving bilateral iliac vessels. Which of the following is the most appropriate vascular procedure for this patient? ជ្រើសមួយ៖ . Axillofemoral bypass . Femorofemoral bypass . Common femoral and profunda femoral endarterectomise . Femoropopliteal bypass . Aortobifemoral bypass

axillofemoral bypass

Most patients with XYY constitution are which of the following?

behaviorally normal

A 38-year-old female patient suffers from pleurisy and requires pleural fluid sampling (thoracentesis). The attending physician asks you to perform the procedure at the midaxillary line on the right side. Which of the following would be the appropriate level to perform the procedure? . at the level of the 5th rib . above the level of the 7th rib . at the level of the 10th rib . between the level of the 8th and 10th ribs . below the level of the 10th rib

between the level of the 8th and 10th ribs

A 24-year-old student is brought to the emergency room after being found in a ditch where he had lain overnight after being hit by a car. He complains of severe pain in the left arm and examination reveals a broken humerus. Neurological examination reveals that the patient can extend the elbow but displays inability to supinate the elbow when it is extended. The patient also has wrist drop and very weak hand grasp. The neurological lesion is likely localized at which of the following locations? In the above patient, when the elbow is partially flexed, the patient can supinate the left forearm. This is due to the function of which of the following? . brachioradialis . anconeus . brachialis muscle . biceps brachii . pronator teres

biceps brachii

Turner syndrome

bicuspide aortic valve

mechanism of action of Taxol?

binds to microtubules, which stabilizes them preventing their shortening and interfering with cell division

In counselling a family regarding the diagnosis of alcaptonuria, you state that is a metabolic disease caused by a defect in or lack of homogentisic acid oxidase. The excess homogentisic acid leads to which clinical finding?

black urine and darkly pigmented sclera, cornea, and ears

In comparison to cow milk, human milk contains more of what substance?

calories

An infant has been diagnosed with congenital hypoparathyroidism. What are you most likely to find on evaluation? Select one: hyponatremia goiter candidiasis microcephaly hyperkalemia

candidiasis

Amother has brought her 3-month-old baby to the pediatrician and indicates that the infant is lethargic and has poor suckling and seems uninterested in eating. In addition, the mother notes that the baby's diapers often smell like burnt sugar. This infant likely has a defect in which of the following enzymes? . phenylalanine hydroxylase . glycine cleavage complex (GCC) . cystathionine synthase . branched-chain alpha-keto acid dehydrogenase . homogentisate oxidase

branched-chain alpha-keto acid dehydrogenase

In renal insufficiency, calcium absorption is reduced and leads to increased bone resorption, a condition referred to as renal osteodystrophy. Treatment with which of the following can assist in the amelioration of the symptoms of this condition? . growth hormone . calcitriol . antidiuretic hormone . calcitonin . parathyroid hormone

calcitriol

Amember of a college fraternity, who had consumed a large amount of alcohol on a dare, is brought to the emergency room with vomiting and severe abdominal pain. Blood tests reveal that he has elevated serum levels of amylase and lipase. Atentative diagnosis of acute hemorrhagic pancreatitis is formulated. Which cells of the pancreas are directly involved in this condition? . delta cells . beta cells . alpha cells . F cells . centroacinar cells

centroacinar cells

A 44-year-old woman with a history of GSE is evaluated for refractory disease. She was diagnosed with GSE 8 years ago. Her disease was initially well controlled with a gluten-free diet. Over the past few months, she has had persistent diarrhea and malabsorption that has not responded to her usual diet. Findings on physical examination are consistent with chronic malnutrition. An abdominal CT scan shows no masses or anatomic abnormalities that would account for her symptoms. An endoscopy is obtained, and small bowel biopsy shows villous atrophy and a layer of collagen underneath the enterocytes. Which of the following is the most likely explanation for this patient's symptoms? ជ្រើសមួយ៖ None of the above Small bowel lymphoma Collagenous sprue Tropical sprue Poor adherence to gluten-exclusion diet

collagenous sprue (Collagenous sprue is a rare, devastating disease in which there is a layer of collagen underneath the enterocytes of the small bowel. The origin of collagenous colitis is unknown, but it develops in approximately half the patients who have refractory celiac disease. The symptoms are severe and include obvious malabsorption. The diagnosis is made on the basis of the classic histologic picture of villous atrophy and subepithelial collagen deposition. Therapy for collagenous sprue is uncertain; some patients respond to steroids. Poor adherence to gluten-exclusion diet is common; however, it would not explain the histologic changes seen in this patient. Small bowel lymphoma can be a complication of GSE; however, there is no evidence of this disorder on the imaging studies and biopsy. Tropical sprue is a malabsorptive disorder that appears in certain areas of the world. The diagnosis is based on the history of travel to endemic areas and a biopsy showing villous atrophy and inflammatory cells.)

A patient suffering from Charcot-Marie-Tooth disease displays progressive degeneration of peripheral nerves, distal muscle weakness and atrophy, and defects in deep tendon reflexes. This condition is associated with an abnormal mutation in the gene encoding connexin-32. Connexins are normally found in which type of cell junctions? . zonula adherens (belt desmosome) . hemidesmosome . occluding (tight) junction . communicating (gap) junction . macula adherens (spot desmosome)

communicating (gap) junction

A 23-month-old female is hospitalized for severe malnutrition. Which of the following problems is most likely to be the result of inappropriately rapid treatment of the severely mal- nourished child? Select one: hyperglycemia renal failure hyperkalemia hyponatremia congestive heart failure

congestive heart failure

Your young female patient has a large bulge on the anterior thigh below the inguinal ligament. You suspect an abdominal hernia that has passed through the femoral ring into the femoral sheath and then through the saphenous hiatus into the subcutaneous layer of the upper thigh. In addition to the hernia sac, you would expect the femoral canal to contain which of the following? . femoral artery . femoral vein . femoral nerve . great saphenous vein . connective tissue and lymph nodes

connective tissue and lymph nodes

For the bithermal caloric test, a measure of vestibular sensitivity, warm or cold water is introduced into the ear. This often causes vertigo and nausea as a side effect as a result of which of the following? . temporary immobilization of otolith organs . temporary immobilization of cristae ampullares . convection currents in endolymph . especially fast flow of endolymph . temporary inhibition of cochlear hair cells

convection currents in endolymph

A 19-year-old previously healthy man is an unbelted driver of a motor vehicle involved in a front-end collision. On arrival in the emergency department, the patient is noted to have stridor, with marked respiratory distress, and an oxygen saturation of 88% despite 100% oxygen by mask. He has obvious extensive facial injuries, a flail chest, and poor chest expansion. Bag-mask-valve ventilation is ineffective. Which of the following is the most appropriate next step in management? ជ្រើសមួយ៖ . cricothyroidotomy . tracheostomy . nasotracheal intubation . placement of bilateral chest tubes . orotracheal intubation

cricothyroidotomy (maxillofacial trauma)

A 39-year-old woman with a known history of von Willebrand disease has a ventral hernia after a previous cesarean section and desires to undergo elective repair. Which of the following should be administered preoperatively? ជ្រើសមួយ៖ . Fresh-frozen plasma (FFP) . Low-molecular-weight dextran . Whole blood . High-purity factor VIII: C concentrates . Cryoprecipitate

cryoprecipitate

Achild born and raised in Chicago planned to spend the summer on a relative's fruit farm and help with the harvest. The summer passed uneventfully, but several days after the harvest began the child became jaundiced and very sick. On admission to the hospital the following clinical findings were recorded: in addition to the expected hyperbilirubinemia, the patient was hypoglycemic, had a markedly elevated rise in blood fructose concentration, and was hyperlactic acidemic. Further history taking revealed that during the harvest it was customary for the family to indulge in fruit-filled meals and to snack freely on fruit while carrying out the harvest. The following conclusions were reached. The elevated blood fructose was due to which of the following? . defective hepatic glucokinase . defective hepatic fructose-1-phosphate aldolase (aldolase B) . defective hepatic fructose-1,6-bisphosphate aldolase (aldolase A) . an allergic reaction to constituents in the fruit diet . defective hepatic fructokinase

defective hepatic fructose-1-phosphate aldolase (aldolase B)

AIP is the major autosomal-dominant acute hepatic porphyria. This disease is caused by a deficiency in porphobilinogen (PBG) deaminase, an enzyme of heme biosynthesis. Patients afflicted with this disease would be expected to excrete excess amounts of which of the following? . delta-aminolevulinic acid (ALA) . protoporphyrin IX . type III uroporphyrinogen . coproporphyrinogen III . hydroxymethylbilane

delta-aminolevulinic acid (ALA)

PDH is a complex multisubunit enzyme. Which of the following exerts a positive influence on the activity of PDH? . NADH . ATP . dephosphorylation . phosphorylation . acetyl-CoA

dephosphorylation

Patients with acromegaly may be at increased risk for

developing colonic polyps and colonic malignancy. Patients with acromegaly are also at increased risk for coronary artery disease, cardiomyopathy, hypertension, DM, and sleep apnea.

A 6-year-old boy has multiple, honey-colored, crusted lesions on his face, periungual areas, and forearms. The first lesion appeared 2 weeks ago on his philtrum. Since then the lesions have spread to his hands and arms. Each began as a small pustule on an erythematous base and eventually ruptured to form the crusted lesions now present. His temperature is 100.6 F, pulse is 100/min, and respirations are 14/min. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate treatment? ជ្រើសមួយ៖ Penicillin G dicloxacillin Penicillin V Clarithromycin Vancomycin

dicloxacillin

Delirium on EEG

diffuse slowing

You are studying the effects of a compound on the respiratory activity of isolated mitochondria. Your experiments demonstrate that oxygen consumption is normal when pyruvate and malate are added. Oxygen consumption is also seen to be normal when succinate is added. However, you find that the production of ATP is severely impaired in the presence of pyruvate/malate or succinate when the compound is added to the reaction. These results most closely resemble the effects that would be seen by the addition of which of the following inhibitors of oxidative phosphorylation? . azide . antimycin .A . dinitrophenol . rotenone . oligomycin

dinitrophenol

Asymptomatic patients with Paget's disease

do not require treatment

Exhibit: *missing* A healthy 27-year-old male is given a treadmill stress test. His cardiovascular values at rest and during exercise were: When compared to rest, what was the change in his arterial pulse pressure? . increased from 30 to 75 . increased from 115 to 140 . remained unchanged since heart rate and systolic pressure both increased . increased from 68 to 140 . decreased from 140 to 65

increased from 30 to 75

A 45-year-old man presents with thunderclap headache. He gives a history of longstanding right-side headaches and a rushing sound in the right ear in time with his pulse. What is the most likely diagnosis of this patient? ជ្រើសមួយ៖ Arteriovenous malformation rupture Dural AV fistula rupture Hypertensive intracerebral haemorrhage Berry aneurysm rupture Pituitary apoplexy

dural AV fistula rupture ( Pulsatile tinnitus is pathonomic of dural arteriovenous fistula. Rupture of these lesions can manifest with subdural, subarachnoid, or intracerebral haemorrhage.)

Dicrotic notch

during dystolie , aortic valve closure.

Aortic regurgitation murmur

early diastolic murmur-high pitched "blowing", wide pulse pressure

An individual harboring a mutation in ornithine transcarbamoylase (OTC) would be expected to exhibit which of the following measurable abnormalities? . uric acid deposition in the joints . citrullinemia . elevation in blood orotic acid . elevated urinary excretion of argininosuccinic acid . excess production of foam cells

elevation in blood orotic acid

A 30-year-old-man presents to the outpatient clinic with a 2-month history of progressive effort intolerance. Some three weeks ago he experienced an episode of shortness of breath at rest, suggestive of paroxysmal nocturnal dyspnoea. Examination reveals a JVP raised up to his earlobes, a soft tender hepatomegaly and a bilateral pitting oedema up to his knees. Chest examination reveals bibasal crepitations, and an audible S3 on auscultation of the heart. The chest X-ray shows cardiomegaly with interstitial infiltrates. Echocardiography shows global left ventricular hypokinesia with an ejection fraction of 25-30%. Which of the following is the LEAST likely aetiological factor? ជ្រើសមួយ៖ Alcohol abuse Genetic factor Adenovirus Eosinophilic states HIV infection

eosinophilic states (this patient has dilated cardiomyopathy)

As part of a neurological examination, a patient is placed in a chair that rotates to the right under the control of a computer so that the patient's head and body move in unison with the chair. How would a healthy person react immediately upon getting off the chair that turned for 1 minute? . fall to the left when asked to walk on a straight line . behave the same as before the rotation . experience a vertigo that would be diminished if he immediately got back in the rotating chair . experience "past pointing" to the left when asked to reach a target . display post-rotational eye nystagmus to the right

experience a vertigo that would be diminished if he immediately got back in the rotating chair

After recovery from the surgical removal of the thyroid gland, the quality of the voice in a patient changed to a monotone. It was discovered that the cricothyroid muscle in this patient was paralyzed. The cricothyroid muscle is innervated by which of the following? . accessory nerve . internal laryngeal nerve . external laryngeal nerve . ansa cervicalis . hypoglossal nerve

external laryngeal nerve

A 34-year-old male is brought into the emergency room, having been found unconscious in his apartment. Apparently, he has been in this state for 2 days. The laboratory values for the patient's blood and urine are consistent with elevated circulating antidiuretic hormone (ADH). Which one of the following will directly stimulate ADH in this patient? . thyroid hormone . angiotensinogen . extracellular fluid osmolality increase . temperature decrease . volume increase

extracellular fluid osmolality increase

You follow a patient with craniosynostosis and congenital malformations of the head and face in your clinic. What other congenital malformations will you most likely find in this patient?

extremity malformations

A healthy term infant is circumcised and experiences excessive blood loss eventually requir- ing transfusion. The most likely diagnosis is which of the following?

factor VIII deficiency

Which of the following is appropriate in the management of the patient with hemolytic transfusion reaction? ជ្រើសមួយ៖ . Removal of nonessential foreign body irritants, for example, Foley catheter . 0.1 M HCl infusion . Steroids . Fluid restriction . Fluids and mannitol

fluid and mannitol

A 3-day-old infant with severe jaundice, hypoglycemia, and anemia is further noted to have liver nodules and cirrhosis. Serum tyrosine and methionine levels are markedly elevated. What enzyme defect is causing this child's liver failure?

fumarylacetoacetate hydrolase

A 2-week-old female is admitted to the hospital for jaundice, hypoglycemia, and acidosis. She has also recently been febrile and blood cultures are positive for Escherichia coli. The patient is most likely deficient in which enzyme?

galactose-1-phosphate uridyl transferase

The anterior two-thirds of the tongue differ from the posterior one-third of the tongue by its special visceral afferent (SVA; taste) innervation. The perikarya of neurons providing the sensation of taste in the anterior two-thirds of the tongue are found in which of the following? . pterygopalatine (sphenopalatine) ganglion . submandibular ganglion . geniculate ganglion . trigeminal (gasserian) ganglion . otic ganglion

geniculate ganglion

An investigational diabetes treatment involving a hypoglycemia-inducing drug has been developed. This drug is designed to inhibit dipeptidylpeptidase IV (DPP IV) activity and has been shown to decrease plasma glucose concentration and pancreatic glucagon secretion. DPP IV hydrolyzes which of the following hormones such that its inhibition results in the observed effects? . insulin . glucagon-like peptide-1 (GLP-1) . pancreatic polypeptide . glucagon . insulin-like growth factor-I (IGF-I)

glucagon-like peptide-1 (GLP-1)

A 4-month-old Caucasian male infant with a temperature of 38.4°C is examined by his pediatrician. His mother indicates that he has had the fever for the past 4 days, been listless, vomiting, and has watery stools. Blood work indicates the infant is hypoglycemic but this condition does not respond to either epinephrine or glucose administration. In addition, his blood pH is slightly acidic and shows reduced bicarbonate. Other untoward blood chemistry includes elevated triglycerides, cholesterol, and liver enzymes. The child has a protruberant abdomen, thin extremities, and a doll-like face. The pediatrician suspects a specific condition and orders a liver biopsy to test for the activity of which of the following enzyme activities? . glucose-6-phosphatase . muscle phosphorylase . muscle phosphofructokinase . glycogen synthase . pyruvate kinase

glucose-6-phosphatase

The abdominal aorta provides for the major blood supply in this region and its branches are organized into paired or unpaired and visceral or parietal branches. Which of the following are paired visceral branches of the abdominal aorta? . superior mesenteric artery . inferior phrenic arteries . celiac trunk . lumbar arteries . gonadal arteries

gonadal arteries

Which of the following is not a recognized cause of multiple myeloma? ជ្រើសមួយ៖ Human herpes virus-8 (HHV-8) Herbecides and insecticides Hereditary HIV High-dose radiation

hereditary

Gluconeogenesis is an extremely important reaction carried out in hepatocytes allowing for glucose homeostasis in the blood. The primary positive control of hepatic gluconeogenesis is exerted by which of the following? . high adenosine triphosphate (ATP) levels . low citrate levels . high citrate levels . low ATP levels . high acetylcoenzyme A (acetyl-CoA) levels

high acetylcoenzyme A (acetyl-CoA) levels

Lymph nodes are populated by lymphocytes that exit the vascular compartment to gain access to the parenchyma of the node by passing through the walls of which of the following? . medullary sinuses . arterioles . high endothelial postcapillary venules . afferent lymphatic vessels . efferent lymphatic vessels

high endothelial postcapillary venules

A 54-year-old insulin-dependent diabetic notes that her insulin requirements have gone up dramatically in the past year (from 50 U to nearly 200 U of recombinant human insulin) and her blood glucose is still poorly controlled. A possible explanation for the worsening of her diabetes includes which of the following? . an improved exercise program . an improved diet . a high titer of anti-insulin antibodies . progression of macrovascular disease . weight loss

high titer of anti-insulin antibodies

A child with mental retardation is also noted to have severe myopia. On examination, subluxation of the ocular lens (ectopia lentis) is found. This generally occurs after 3 years of age in children with which of the following?

homocystinuria

You have followed a 7-month-old infant who has failed to gain weight. Birth weight was 3250 g; the child currently weighs 5.5 kg. In your office, the baby takes an 8 - oz bottle with ease and does not vomit. What is the next best step?

hospitalization of the child with unlimited feedings

Hemochromatosis, a disorder that is the result of excess iron accumulation, is caused by deficiencies in which of the following proteins? . human leukcocyte antigen (HLA) complex iron protein (HFE) . transferrin . ferritin . divalent metal transporter-1 (DMT1) . ferroportin

human leukcocyte antigen (HLA) complex iron protein (HFE)

A significant number of children with recurrent gross or microscopic hematuria, normal renal ultrasound, and normal tests of renal function have which of the following?

hypercalciuria

A 54-year-old woman presents to her GP complaining of a change in her breathing sound. She first noticed numbness, particularly in her fingers and toes, three months ago but attributed this to the cold weather. Her partner now reports hearing a high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring blood pressure, you notice the patient's wrist flexing. The most likely diagnosis is: ជ្រើសមួយ៖ Raynaud's syndrome Hypocalcaemia DiGeorge syndrome Obstructive sleep apnoea Guillain-Barré syndrome

hypocalcemia

Which of the following symptoms can occur frequently in infants suffering from mediumchain acyl-CoA dehydrogenase (MCAD) deficiency if periods between meals are protracted? . bone and joint pain and thrombocytopenia . hypoglycemia and metabolic acidosis with normal levels of ketones . hyperammonemia with decreased ketones . metabolic alkalosis with decreased bicarbonate . hyperuricemia and darkening of the urine

hypoglycemia and metabolic acidosis with normal levels of ketones

side effects of hydrochlorothiazide

hypokalemia, hyperglycemia, hyperurecemia,

3rd degre burn tx

immediate excision and grafting

Panceatic insufficiency, He has an elevated HgbA1C and fasting hyperglycemia. The patient is sent for diabetic teaching sessions and begun on insulin therapy, but is unable to achieve euglycemia. He experiences frequent bouts of symptomatic hypoglycemia requiring ER visits. What is the most likely cause for these episodes? A. insulin overdose B. impaired glucagon production C. inadequate oral intake D. vitamin K deficiency E. vitamin B12 deficiency

impaired glucagon production

Which of the following statements regarding the epidemiology of psoriasis is accurate? ជ្រើសមួយ៖ In persons with earlier age of onset, psoriasis is more likely to be severe None of the above In northern latitudes, exacerbations of psoriasis commonly occur during the spring and summer Psoriasis occurs more commonly in women than in men On average, onset of psoriasis occurs during the fifth decade

in person with earlier age of onset , psoriasis is more likely to be severe.

Some of the complications of splanchnic venous thrombosis

include gastrointestinal bleeding, esophageal or gastric varices, intestinal ischemia, anemia, thrombocytopenia, and infection.

Presentation of the platelet membrane protein complex, GPIIb-GPIIIa, which binds with von Willebrand factor, is necessary for which of the following? . release of thrombin from platelet granules . inducing platelet crosslinking . activation of PKC leading to phosphorylation of myosin light chain and platelet morphology changes . stimulation of endothelial and smooth muscle cell interaction resulting in vasoconstriction . cleavage and activation of high molecular weight kininogen

inducing platelet crosslinking

An 18-year-old school student of East African origin presents with a 2-week history of lethargy, myalgia, rigours with hot flushes and intermittent pyrexia. Neither she nor any close contacts have been travelling recently. Examination reveals enlarged anterior and posterior chain lymph nodes in the neck. A blood film reveals the presence of Downey bodies, thrombocytosis and an increase in the lymphocyte count to 50% of total leucocytes. This girl is likely to have? ជ្រើសមួយ៖ Infectious mononucleosis Toxoplasmosis Human immunodeficiency virus (HIV) infection Lymphoma Tuberculosis

infectious mononucleosis

Your patient presents in your office complaining of hoarseness. During your examination, you find that one vocal fold has deviated toward the midline and does not abduct during deep inspiration or vocalization. You also observe that touch sensation in the vestibule of the larynx appears to be intact. You suspect that a nerve has been damaged, but which nerve is most likely involved? . glossopharyngeal . inferior laryngeal . superior laryngeal . external laryngeal . internal laryngeal

inferior laryngeal

A 13-year-old girl presents with lethargy, fever, severe headache, and a stiff neck. On examination, a unilateral fixed, dilated pupil and papilledema are noted. Which of the following is the most appropriate initial step in managing this patient? ជ្រើសមួយ៖ CT of the head administration of IV cefotaxime performance of a lumbar puncture administration of IV mannitol intubation and hyperventilation

intubation and hyperventilation

What are the blood requirements for transfusion of a patient with hypocalcemia, heart defect, and recurrent infections?

irradiated

A 55-year-old male with a history of smoking presents with a chronic cough with expectoration. He exhibits dyspnea on exertion, has a stocky build, and shows some cyanosis. Which of the following receptors is involved in the cough reflex? . muscle spindles . irritant receptors . carotid body chemoreceptors . lung stretch receptors . central chemoreceptors

irritant receptors

A 32-year-old-woman was cross-country skiing when she fell down a water-filled gully and became trapped beneath an ice-sheet. Frantic efforts were made to extract her, but after 40 minutes all movements ceased. Which of the following statements is true? ជ្រើសមួយ៖ Defibrillation at the scene is likely to succeed Metabolic alkalosis will quickly set in Her pulseless state is, in all likelihood, due to ventricular fibrillation It is important to lift her out of water in the prone position Aspirated seawater is more likely to produce pulmonary oedema than fresh water

it is important to lift her out of water in the prone position

Which of the following best describes an inguinal hernia in a 2-month-old girl?

it may contain an ovary

sedation, miosis

k kappa

Under conditions of anaerobic glycolysis, the NAD+ required by glyceraldehyde-3-phosphate dehydrogenase is supplied by a reaction catalyzed by which of the following enzymes? . glycerol-3-phosphate dehydrogenase . alpha-ketoglutarate dehydrogenase . malate dehydrogenase . PDH . lactate dehydrogenase

lactate dehydrogenase

The bacterial lac operon is controlled by both glucose and lactose levels. Which of the following conditions would result in the greatest level of transcription from the lac operon? . lactose present but no glucose . glucose present but no lactose . both glucose and lactose present . no glucose or lactose present

lactose present but no glucose

A patient has been admitted for hematemesis (vomiting of blood). Endoscopic examination reveals bleeding esophageal varices resulting from portal obstruction. These varices represent anastomoses between branches of which of the following? . inferior vena cava with a patent ductus venosus . left gastric, azygos, and hemiazygos veins . superior, middle, and inferior rectal veins . veins running on the ligamentum teres and the epigastric veins . right gastric vein and the inferior vena cava

left gastric, azygos, and hemiazygos veins

A 65-year-old woman presents to the physician's office for a second opinion on the management options for recently diagnosed breast cancer. She presents with a 2.5-cm mass in the upper outer quadrant of the left breast associated with a palpable axillary node suspicious for metastatic disease. The remainder of her examination is normal. Mammography demonstrates the cancer and shows no other suspicious lesions in either breast. Chest x-ray, bone scan, and blood test panel, including liver function tests, are normal. Family history is positive for breast cancer diagnosed in her sister at age 65. Past history is unremarkable. The first physician recommended modified radical mastectomy. Which of the following is the most appropriate management option for locoregional control yielding results equally effective as mastectomy? ជ្រើសមួយ៖ . irradiation of the breast and axilla . quadrantectomy, irradiation, and axillary node dissection . lumpectomy, irradiation, and axillary node dissection . radical mastectomy . lumpectomy and axillary node dissection

lumpectomy, irradiation, and axillary node dissection

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder in which autoantibodies attack voltage-gated calcium channels in the presynaptic nerve terminal. A characteristic manifestation of LEMS is limb muscle weakness. A decrease in which of the following would you expect to see in LEMS? . amplitude of the miniature end-plate potential (MEPP) . quantal content . activation threshold for the action potential . amplitude of the action potential . magnitude of the end-plate potential (EPP)

magnitude of the end-plate potential (EPP)

Papez circuit provides the anatomic substrate for the integration of cognitive, emotional, and expressive brain activities. Which of the following brain structures participates in Papez circuit? . mammilary nuclei . ventrolateral thalamic nucleus . suprachiasmatic nucleus . amygdale . caudate nucleus

mammilary nuclei

In elderly patients (over 60 years of age), fractures of the neck of the femur following a fall are common. Arterial branches supplying the femoral head and neck are vulnerable to injury during these fractures, and the resulting posttraumatic avascular necrosis affects the head of the femur. In the adult, the most important direct vascular source to the femoral head and neck is which of the following? . superior gluteal artery . lateral circumflex femoral artery . medial circumflex femoral artery . artery to the head of the femur . femoral artery

medial circumflex femoral artery

Apatient with a developing astroglioma in the primary auditory cortex (Brodmann's area 41) complains of hearing unusual noises. What is the main source of subcortical input to the primary auditory cortex? . medial geniculate nucleus . superior olivary nucleus . lateral geniculate nucleus . inferior colliculus . superior colliculus

medial geniculate nucleus

In examining a 30-year-old male patient with multiple sclerosis, you notice that when you ask the patient to look to the left, the right eye fails to adduct and when the patient looks to the right, the left eye fails to adduct. However, both eyes in the patient can adduct during convergence. There is no noticeable strabismus when the eyes are focused on a far point. During abduction, both eyes display nystagmus. You record on the patient's chart a diagnosis of bilateral internuclear opthalmoplegia. Which of the following neural structures is affected? . second cranial (optic) nerve . medial longitudinal fasciculus (MLF) . third cranial (oculomotor) nerve . fourth cranial (trochlear) nerve . sixth cranial (abducens) nerve

medial longitudinal fasciculus (MLF)

A neurology resident is testing the jaw-jerk reflex in a patient by tapping gently on the right masseter muscle and observing elevation of the mandible. What is the location of the neuronal cell bodies of the proprioceptive fibers mediating the jaw-jerk reflex? . trigeminal (gasserian) ganglion . motor trigeminal nucleus . spinal trigeminal nucleus . mesencephalic trigeminal nucleus . principal (main) trigeminal nucleus

mesencephalic trigeminal nucleus

During development, the upper limb buds appear by day 27 and the lower limb buds by day 29. An apical ectodermal ridge at the tip of each limb bud promotes growth. This multilayered epithelial structure interacts with which of the following to direct the growth of the limb? Select one: a. mesenchyme b. notochord c. sclerotome d. endoderm e. ectoderm

mesenchyme

A renal calculus (kidney stone) passing from the renal pelvis into the ureter causes excessive distention and severe ureteric colic. During development in the embryo, the ureter arose from which of the following? . metanephric mass of intermediate mesoderm . paramesonephric duct . mesonephric duct . metanephric diverticulum . pronephric duct

metanephric diverticulum

A 52-year-old woman has terminal cervical cancer with extensive pelvic invasion, and requires strong opiate analgesia to control severe pain. Intermittent nausea and vomiting have precluded the use of oral agents. She was on fentanyl patches but she developed allergic skin reactions to the adhesive and now requests to be switched to parenteral medication. Because of prior chemotherapy treatments she has no available venous access, but she is willing to have her family administer intramuscular injections. Assuming equianalgesic dosages, which of the following would be the most appropriate pharmacotherapy? ជ្រើសមួយ៖ . Hydromorphone (Dilaudid) . Codeine . Methadone . Meperidine (Demerol) . Morphine sulfate

methadone (the longest acting agent would be the best choice. Methadone lasts about 12 hours, compared with around 4 hours for all the others opiates listed)

Cilia are anchored to the apical portion of certain types of epithelial cells and they are mobile. Which of the following form the motile cytoskeletal component of the cilia? . microtubule . microfilament . neurofilament . tonofilaments . intermediate filaments

microtubule

To establish the aetiology of pulmonary hypertension, a cardiac catheter study was performed. The wedge pressure was normal and the mean mitral valve diastolic pressure gradient was > 3 mmHg at rest, both of which increased with exercise. From this data, what is the probable diagnosis? ជ្រើសមួយ៖ Congenital heart disease Mitral regurgitation Left ventricular diastolic dysfunction Mitral stenosis Major pulmonary artery occlusion

mitral stenosis

Which of the following is not included in the cardiovascular criteria for Marfans? ជ្រើសមួយ៖ Mitral valve calcification Mitral valve prolapse Mitral valve regurgitation Aortic dissection Aortic dilatation

mitral valve regurgitation

Which of the following is characteristic of a night terror?

most often occur during the first one- third of the night

You suspect cor pulmonale. Which of the following is not a cause of cor pulmonale? ជ្រើសមួយ៖ COPD Myasthenia gravis Pulmonary fibrosis Multiple sclerosis Primary pulmonary hypertension មូលវិចារណ៍

multiple sclerosis

A 68-year-old woman presents with sleep disturbances and memory loss. After careful analysis, she is diagnosed with early stages of Alzheimer's disease. Her pharmacological treatment plan includes acetylcholine esterase inhibitors. One week after starting treatment, the woman's daughter calls in, reporting that her mom has developed new symptoms that might be related to her new medicine. Which of the following is a likely side effect of the drug? . vertigo . dry mouth . forgetting to urinate . nausea and diarrhea . muscle weakness

nausea and diarrhea

A 3-year-old male presents with random eye movements, ataxia, and developmental delay. Of the following, which is most likely the diagnosis?

neuroblastoma

In this same patient, the pectineus muscle is also badly bruised. This muscle is innervated by which of the following? . genitofemoral nerve . saphenous nerve . tibial division of the sciatic nerve . peroneal division of the sciatic nerve . obturator nerve

obturator nerve

A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Several hours after this intervention a bolus of IV crystalloid, the patient is reassessed. The blood pressure is 150/85 mmHg, heart rate is 90/min, neck veins are distended, and the pulmonary arterial wedge pressure is 17 mmHg. Urine output is still low in volume. At this point, management should be which of the following? ជ្រើសមួយ៖ . a dopamine infusion . IV furosemide . a nitroprusside infusion . a bolus of IV crystalloid . IV digoxin administration

nitroprusside

Which of the following is directly involved with the descending modulation of pain transmission? . dopamine . rubrospinal fibers . ventral lateral thalamic nucleus . MLF . nucleus raphe magnus

nucleus raphe magnus

Which of the following persons will have a negative free-water clearance? . one with neurogenic diabetes insipidus . one who drinks 2 L of distilled water in 30 minutes . one with an oat cell carcinoma of the lung, who excretes urine with an osmolality of 1000 mosm/kg H2O . one who is receiving lithium treatment for depression, and who develops polyuria that is unresponsive to administration ADH . one who begins excreting large volumes of urine with an osmolality of 100 mosm/kg H2O after severe head injury

one with an oat cell carcinoma of the lung, who excretes urine with an osmolality of 1000 mosm/kg H2O

A 42-year-old woman returns to the clinic following an uneventful biopsy for a well-defined, mobile mass. The pathology report describes the mass as a fibro adenoma, but LCIS is identified in the breast parenchyma adjacent to the fibro adenoma and extending to the margin of resection. She has no current illnesses, is on no medications, and her family history is negative for breast cancer. Breast imaging studies show fatty breasts with no abnormal findings except for the fibro adenoma. Which of the following is the most appropriate management option? ជ្រើសមួយ៖ . contralateral breast biopsy . observation including examinations and mammography . ipsilateral mastectomy . re-excision of the biopsy cavity to gain negative margins of resection . bilateral total mastectomies

observation including examinations and mammography

The shortest distance between the sacral promontory and the symphysis pubis is called

obstetric (OB) conjugate

A 6-year-old boy presents to the emergency department with a painful, markedly swollen elbow. While ice-skating, he fell with his arm outstretched. Radiographs of the elbow demonstrate a displaced, supracondylar fracture of the humerus. On examination, there is pain on passive flexion at the wrist and a decreased radial pulse, with diminished capillary refill in the hand. Which of the following is the most appropriate management of this injury? ជ្រើសមួយ៖ open reduction with pinning, exploration of the brachial artery, and decompression fasciotomy of the forearm fascial compartments closed reduction with percutaneous pinning under general anesthesia admission to hospital for close observation, with immobilization of the elbow at 90 of flexion open reduction with pinning, and exploration of the brachial artery open reduction and pinning under general anesthesia

open reduction with pinning, exploration of the brachial artery, and decompression fasciotomy of the forearm fascial compartments (Decreased perfusion below the fracture in conjunction with pain on passive wrist flexion are signs of a developing forearm compartment syndrome.)

Which of the following normally occupy the dark spaces indicated by the arrows in following figure? . osteocytes . osteoclasts . osteoblasts . blood vessels . differentiating blood cell precursors

osteocytes

During maturation of the oocytes, which of the following structures retain almost all of the cytoplasm after the first meiotic division? . first polar body . primary oocyte . zygote . second polar body . ovum

ovum

When dividing cells are progressing through the cell cycle, many checks are imposed to ensure that the process is occuring with fidelity. A critical checkpoint in the cell cycle occurs in response to DNA damage, such as that induced by ultraviolet light. Which of the following cellcycle proteins is involved in DNA damagemediated cell-cycle arrest? . cyclin D . p53 . CDK2 . cyclin A . E2F

p53

Which of the following correctly defines the term: p ? . pH at which an equivalent distribution of acid and conjugate base exist in solution . ion constant of water . negative log of the concentration of . equilibrium constant for the dissociation of HA to and . pH at which a molecule is neutrally charged

pH at which an equivalent distribution of acid and conjugate base exist in solution

A mother brings her 11-month-old infant along with her 3- and 9-year-old children into your office for a several day history of pruritic rash. You note the rash is similar in the two older children with burrows characteristic of scabies in between the fingers, and on the flexor surfaces of the wrists. Which of the following rep- resents the typical manifestation in infants?

papulovesicular rash

Patient who uses carbamazepine present with signs of hypocalcemia

patient's hypocalcemia is vitamin D deficiency due to therapy with carbamazepine. Carbamazepine and other medications including phenytoin, rifampin, and theophylline increase the activity of cytochrome P450 enzymes in the liver that inactivate vitamin D. Deficient vitamin D leads to decreased absorption of calcium from the gut.

defense mechanisms is defective and the cause for recurrent infections in chronic granulomatous disease?

phagocyte oxidative burst

Intrauterine growth retardation (IUGR) is a common adverse effect of which drug if taken by the mother during pregnancy? Select one: lithium phenytoin lisinopril warfarin acetaminophen

phenytoin

sudden onset of headache, visual problem, ophthalmoplegia. Dx?

pituitary apoplexia

A 23-year-old Caucasian male is admitted to the hospital following a motorcycle accident. On examination, no bones appear to be broken, but there is extensive muscle bruising resulting in tissue swelling from increased capillary permeability. His arterial blood pressure is 80/40. He is awake and able to walk with assistance. Based on this information, it is likely that which of the following will be decreased from normal? . plasma aldosterone concentration . plasma lactate concentration . circulating levels of catecholamines . plasma renin activity . left atrial pressure

plasma lactate concentration

Pseudohypoparathyroidism is associated with which of the following?

short stature

Your patient reports that several days earlier he "threw his back out" when he bent from the waist and picked up a very heavy package. The pain was immediate and extended from his hip, down the back of the thigh, and into his leg and foot. As he lies on the examining table, you raise his leg by the foot keeping the knee extended and elicit intense pain over the distribution of the sciatic nerve. An MRI scan confirms your conclusion that your patient has a herniated intervertebral disk between the fourth and fifth lumbar vertebrae. Intervertebral disks may protrude or rupture in any direction, but they most commonly protrude in which direction? . posteriorly . posterolaterally . anteriorly . laterally . anterolaterally

posterolaterally

An 18-year-old male patient was thrown from a horse and suffered extensive damage to the back and pelvic region. After 2 weeks of recovery, it is noted that the patient has a spastic neurogenic urinary bladder. Although the patient is unable to initiate micturition, the bladder periodically empties itself. Where is the lesion affecting control of the bladder in this patient located? . cauda equine . spinal cord, at the level of S2 . spinal cord, above the level of S2 . spinal cord, at the level of S3 . spinal cord, at the level of S4

spinal cord, ABOVE the level of S2

A 45-year-old woman presents to the rheumatology clinic with a three-month history of itchy, dry eyes and a persistently dry mouth. She also mentions that her fingers have been extremely cold, occasionally turning blue after going outside in the morning. Shirmer's test is positive. What is the most likely diagnosis? ជ្រើសមួយ៖ Secondary Sjögren's syndrome Primary Sjögren's syndrome Raynaud's disease Systemic sclerosis SLE

primary sjogren syndrome

I-cell disease (also identified as mucolipidosis type II) is characterized by the presence of inclusion bodies in fibroblasts (hence the derivation of the term I-cell), severe psychomotor retardation, corneal clouding, and dystosis multiplex. These symptoms arise from a defect in the targeting of lysosomal enzymes due to an inability to carry out which of the following processes? . synthesize the mannose-6-phosphate receptor found in lysosomes . produce mannose-6-phosphate modifications in lysosomal enzymes . transport mannose-6-phosphate receptors to lysosomes . remove mannose-6-phosphates from lysosomal enzymes prior to their transport to the lysosomes . recycle the lysosomal receptor for mannose-6-phosphate present on lysosomal enzymes

produce mannose-6-phosphate modifications in lysosomal enzymes

Hormone-secreting chromophils in the pars distalis of the adenohypophysis are classified into acidophils and basophils. Which of the following hormones is secreted by the acidophils? . luteinizing hormone . adrenocorticotropin . thryrotropin (thyroid-stimulating hormone) . follicle-stimulating hormone . prolactin

prolactin

During diagnostic evaluation, a 14-year-old girl with menorrhagia, frequent nosebleeds, and irondeficiency anemia is found to have a low platelet count with a normal coagulation profile. Bone marrow biopsy reveals abundant megakaryocytes. On abdominal examination, no organomegaly is noted. The patient has a satisfactory response to the initial therapeutic intervention, but over 6-12 months' time, the response is less dramatic and shorter in duration. There are signs and symptoms of increasing side effects from therapy. The next step in management should be to recommend which of the following? ជ្រើសមួយ៖ . plasmapheresis . bone marrow transplant . increase in steroid dose and frequency . splenectomy . partial splenectomy

splenectomy

Horner syndrome is sometimes seen in patients diagnosed with the lateral medullary syndrome. Which of the following is a characteristic feature of Horner syndrome? . atrophy of tongue musculature . profuse sweating . paralysis of muscles of facial expression . mydriasis . red blushing of the skin in the affected area

red blushing of the skin in the affected area

A 55-year-old male diabetic has an accommodative power of the lens of 10 dioptres. His near point is located 5 cm (2 in), his far point 10 cm (3.9 in) in front of the eye. Which of the following statements are correct? . the patient is capable of driving a car without corrective glasses . his corrective lenses have a positive dioptric value . the patient is functionally blind . his corrective lenses are convex . the patient has hyperopia

the patient is functionally blind

A 1-week-old term newborn is in your office for a well-child assessment, physical examination findings are consistent with oral candidiasis (thrush). Which of the following is a correct statement regarding thrush in a term newborn?

responds well to topical therapy with nystatin

On the second day of treatment for pneumococcal meningitis, a 10-month-old child who had been alert is noted to be lethargic. Serum electrolytes reveal: Na 120 meq/L; Cl 82 meq/L; K 3.1 meq/L; BUN 2 mg/dL. The most appropriate management of this problem would be which of the following?

restriction of fluid intake to 70% of maintenance requirements

The sinoatrial (SA) node initiates the heartbeat by giving off an impulse about 80 times per minute. It is located at the junction of the superior vena cava and right atrium. In about 60% of the cases, the SA node derives its vascular supply from which of the following? . right marginal branch . right coronary artery . anterior interventricular artery . left circumflex artery . posterior interventricular artery

right coronary artery

On observation, a patient has a left facial droop. On closer examination his nasolabial fold is flattened. When asked to smile, the left corner of his mouth droops. He is unable to keep his cheeks puffed out. Eye closure is only slightly weaker compared to the right and his forehead wrinkles when he is asked to look up high. What is the diagnosis? ជ្រើសមួយ៖ Bell's palsy Parotid gland tumour Left internal capsule stroke Right middle cerebral artery stroke Cerebellar pontine angle tumour

right middle cerebral artery stroke ( forehead sparing which implies an upper motor neuron lesion)

The finding of a low serum concentration of C3 component of complement in a child with nephrotic syndrome indicates which of the following?

the presence of membranoproliferative glomerulonephritis

Overdose of which of the following is most likely to be complicated by hypoglycemia?

salicylates

With increasing age, it is quite common for adults to have very low sensitivity for highpitch sounds. Which of the following physiologic responses occur as the pitch of a sound is increased at constant sound pressure? . the frequency of action potentials in auditory nerve fibers increases . the location of maximal basilar membrane displacement moves toward the cochlear base . the amplitude of maximal basilar membrane displacement increases . a greater number of hair cells become activated . units in the auditory nerve become responsive to a wider range of sound frequencies

the location of maximal basilar membrane displacement moves toward the cochlear base

A 35-year-old male patient suffering from pulmonary hypertension has been diagnosed with ostium secundum atrial septal defect. Abnormal development of which of the following structures is responsible for this developmental defect? . endocardial cushion . interventricular septum . septum primum . aorticopulmonary septum . sinus venosus

septum primum

Which study is the most important to obtain in a 2-year-old child with Beckwith-Wiedemann syndrome and an abdominal mass?

serum alpha-fetoprotein level

Which of the following vessels participate in the arterial circulation of the spleen? . efferent arteriole . afferent arteriole . sheathed arteriole . interlobar arteries . interlobular arteries

sheathed arteriole

Below figure is a high magnification photomicrograph of the gall bladder. The arrow points to the internal lining that is formed by which of the following? . stratified cuboidal epithelium . transitional epithelium . stratified squamous epithelium . pseudostratified columnar epithelium . simple columnar epithelium

simple columnar epithelium

A 53-year-old man is being treated for hypertension and diabetes. His medications include insulin and propranolol. He presents at his physician's office complaining of muscle weakness. Blood tests reveal hyperkalemia (elevated serum potassium) as well as elevated BUN (blood urea nitrogen). Propranolol is gradually eliminated and his insulin dosage is adjusted. His serum potassium normalizes and his muscle weakness is alleviated. What probably caused his muscle weakness? . skeletal muscle depolarization with resultant Na-channel inactivation . motor neuron hyperpolarization . high potassium-mediated block of acetylcholine receptors . high potassium-mediated block of skeletal muscle calcium channels . skeletal muscle hyperpolarization with resultant Na-channel blockade

skeletal muscle depolarization with resultant Na-channel inactivation

A 53-year-old man is being treated for hypertension and diabetes. His medications include insulin and propranolol. He presents at his physician's office complaining of muscle weakness. Blood tests reveal hyperkalemia (elevated serum potassium) as well as elevated BUN (blood urea nitrogen). Propranolol is gradually eliminated and his insulin dosage is adjusted. His serum potassium normalizes and his muscle weakness is alleviated. What probably caused his muscle weakness? Select one: a. high potassium-mediated block of skeletal muscle calcium channels b. high potassium-mediated block of acetylcholine receptors c. skeletal muscle hyperpolarization with resultant Na-channel blockade d. skeletal muscle depolarization with resultant Na-channel inactivation e. motor neuron hyperpolarization

skeletal muscle depolarization with resultant Nachannel inactivation

Cyanide poisoning

sodium nitrite/sodium thiosulfate or hydroxocobalamin

Cyanide is produced in the metabolism of which of the following?

sodium nitroprusside

Sensations from the thoracic and abdominal organs are usually difficult to localize. They are conveyed by general visceral afferent (GVA) fibers, which synapse in which of the following nuclei? . dorsal motor nucleus of the vagus . ambiguus nucleus . hypoglossal nucleus . spinal (descending) trigeminal nucleus . solitary nucleus

solitary nucleus

A 53-year-old male patient has developed an abnormal hypersensitivity in the face area. He complains that he feels pain when he drives with the window down and from the wind blowing on his face. The pain is exacerbated by direct touch to the left side of his lower jaw. The patient is diagnosed with trigeminal neuralgia (tic douloureux). Where do pain fibers from the left side of his mandible project to? . motor trigeminal nucleus . spinal (descending) trigeminal nucleus . trigeminal (gasserian) ganglion . mesencephalic trigeminal nucleus . principal sensory trigeminal nucleus

spinal (descending) trigeminal nucleus

A 32-year-old man is diagnosed with Hodgkin's lymphoma following a recent history of weight loss and night sweats. Computed tomography (CT) staging scan shows disease in the mediastinum bilaterally and some abdominal lymphadenopathy, including the spleen, but no evidence of disease in extranodal sites. What is his stage of disease? ជ្រើសមួយ៖ Stage IIIB Stage IIB Stage IIIA Stage IVB Stage IIA

stage IIIB (CT scanning is used to assess spread, and staging is by the Ann Arbor system (I=one node region involved, II=2+ ipsilateral regions, III=bilateral node involvement, IV=extranodal disease). The presence or absence of B symptoms is indicated in the staging by the suffix "A" (B symptoms absent) or "B" (B symptoms present). Early-stage disease is usually managed with radiotherapy alone. In advanced and bulky disease the combination of radiotherapy and chemotherapy is often employed. The prognosis of Hodgkin's lymphoma is usually good, with a 70% chance of cure even in late-stage disease. Increasing age indicates a poorer prognosis.)

Infiltrating or invasive ductal cancer is the most common breast cancer histological type, comprising 7080% of all cases. Invasive breast cancers usually are epithelial tumors of ductal or lobular origin. Which of the following epithelia line the lactiferous ducts? . pseudostratified . stratified cuboidal . transitional . simple squamous . stratified squamous

stratified cuboidal

popliteal artery aneurysm

surgery

A 20-year-old female tennis player has just won a tennis match on a warm summer day. Her blood pressure at this time is 135/70 with a heart rate of 140 beats per minute and a respiratory rate of 25 per minute. She is flushed and sweating profusely. Compared to the resting state, what can be said about the level of activity of sympathetic nerves to her heart and to her cutaneous vasculature? . both are decreased . neither is different from at rest . sympathetic activity to the heart is decreased while that to the cutaneous vasculature is increased . both are increased . sympathetic activity to the heart is increased while that to the cutaneous vasculature is decreased

sympathetic activity to the heart is INCREASED while that to the cutaneous vasculature is DECREASED

Many proteins undergo modifications during and/or following translation. The ATPdependent polyubiquitination of proteins is a signal for which of the following events? . recycling of the protein back to the endoplasmic reticulum (ER) from the cis-Golgi to allow proper folding . translocation of the protein into the nucleus . addition of the oligosaccharide core to the N-linkage site adjacent to the ubiquitin . targeting the protein for degradation in the proteasome . recognition by the toxin of diphtheria

targeting the protein for degradation in the proteasome

A patient has a hyperextension injury. X-ray shows a small chip of bone off the front of a vertebral body next to the disc space. What is the most likely diagnosis of this patient? ជ្រើសមួយ៖ Wedge fracture Teardrop fracture Jefferson's fracture Facet dislocation Hangman's fracture

teardrop fracture

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

telangiectasia, epistaxis, vascular abnormality.

the osteoid is found along which of the following locations? . the interface between the fibroblasts in the periosteum . the interface between the osteoblast and bone . the ruffled border of osteoclasts . the interface between osteocytes and bones . the interface between osteoprogenitor cells and bone marrow

the interface between the osteoblast and bone

A gang member is rushed to the emergency room suffering from multiple stab wounds made by an ice pick. Athird-year medical student rotating through emergency medicine is puzzled by the sight of a milky white substance exuding from a stab wound just superior to the right sternoclavicular joint. Which of the following structures is possibly injured at this location? . the common carotid artery . the internal jugular vein . the cupola of the right lung . the right lymphatic trunk . the thoracic duct

the right lymphatic trunk

The sensory innervation of the posterior onethird of the tongue is performed by cranial nerve IX (glossopharyngeal). During development, this region of the tongue develops from which of the following pharyngeal arches? . second . fourth . first . third . sixth

third

Which of the following is characterized by an absence of lymphoid follicles and germinal centers? . spleen . axillary lymph node . pharyngeal tonsil . thymus . Peyer's patches

thymus

Opioid peptides are an important physiological mechanism of the body for relief from painful stimuli. Used as pharmacologic agents, they are highly valuable tools for pain management, although side effects are usually inevitable. Which of the following problems are most likely during opiate treatments? . tolerance (need for higher dosage to achieve the same therapeutic effect) . difficulty sleeping . respiratory alkalosis . hypermotility of the GI tract . placebo effects

tolerance (need for higher dosage to achieve the same therapeutic effect)

Steroid hormones interact with specific receptors within target cells. The steroid-receptor complexes then regulate the rate of which of the following intracellular processes? . translation of specific mRNAs . posttranscriptional processing of specific mRNAs . transcription of specific genes . posttranslational processing of specific proteins . replication of DNA

transcription of specific genes

During the process of protein synthesis, the factor eEF-2 induces the hydrolysis of GTP. The energy of this hydrolysis is coupled to which of the following? . translocation of the ribosome . amino acid activation by attachment to a tRNA . formation of the peptide bond . formation of the 80S initiation complex . correct alignment of the mRNA on the 40S ribosome

translocation of the ribosome

symtomatic paget's disease

treated with oral or intravenous bisphosphonates.

A premature female infant is born about 24 weeks after fertilization and develops rapid, labored breathing shortly after birth. She is immediately transferred to intensive care where she is diagnosed with hyaline membrane disease (HMD). Which of the following is most likely deficient in the infant? . type II alveolar cells . terminal saccules . type I alveolar cells . alveolar ducts . lung surfactant

type I alveolar cells

Riboflavin deficiency

typically mild and nonspecific in presentation, but symptoms may include sore throat, hyperemic and edematous oropharyngeal mucous membranes, cheilitis, stomatitis, glossitis, normocytic-normochromic anemia, seborrheic dermatitis, and photophobia

In which of the following situations is BNP most likely to be normal? ជ្រើសមួយ៖ Acute mitral valve rupture Pulmonary embolus Pericarditis Acute myocardial infarction Unstable angina

unstable angina BNP is secreted in response to raised intra-cardiac pressures. thus, acute MI, constrictive pericarditis, acute mitral valve prolapse can cause increased BNP.

A group of first-year residents is examining the National Center for Health Statistics growth curves for girls and boys. Typically, infants and children stay within one or two growth chart channels. A normal exception to this rule exists for which of the following?

up to age 2 years

A 5-day-old infant boy is jaundiced. The total bilirubin level is 14 mg/dL and the direct bilirubin is 4 mg/dL. Which of the following tests is the most appropriate?

urine analysis and culture

You are told that a 45-year-old woman, who presented to the vascular surgery clinic, has a positive tourniquet test in the left leg. On the basis of the information conveyed to you, choose the most likely diagnosis that is associated with a positive tourniquet test? ជ្រើសមួយ៖ Acute leg ischaemia Varicose veins Chronic leg ischaemia Deep vein thrombosis Arterial ulcer

varicose vein

Which of the following thalamic nuclei subserves a motor function? . medical geniculate nucleus . dorsomedial nucleus . ventral posterior medial nucleus . lateral geniculate nucleus . ventral lateral nucleus

ventral lateral nucleus

What side effects should you monitor for that would indicate high levels of theophylline? Select one: vomiting rash polyuria myopathy nystagmus

vomiting

You are tending to a patient with a high tendency to bleed. He bruises easily and has bleeding from his gums. Analysis of coagulation factors in his blood shows normal levels of factor V but low levels of factor VIII. Injection of factor VIII provides only minimal benefit and you find that the injected protein is rapidly degraded. Using a platelet aggregation test, you find that combination of your patient's serum with normal platelets results in only 20% of the platelet aggregation seen with both samples from a normal individual. Based on these findings, you determine that your patient is deficient in which of the following factors of coagulation? . factor X . fibrinogen . thrombin . factor XII . von Willebrand factor

von Willebrand factor

Which one of the following drugs could be responsible for causing generalized alopecia? ជ្រើសមួយ៖ Bendroflumethiazide Simvastatin Warfarin Ramipril Aspirin

warfarin

Which of the following is likely to cause a negative free-water clearance by the kidney? . nephrogenic diabetes insipidus . water deprivation . central diabetes insipidus . water drinking . demeclocycline, an inhibitor of the renal tubular actions of ADH

water deprivation

A very thin 15-year-old female presents with headache, polyuria, and grand mal seizures. She answers the question, if she has had to vomit recently, with "frequently" but that these symptoms "are under control now." Her body mass index is 14.1. Serum glucose, calcium, and potassium are normal. Serum sodium, chloride, and osmolarity are low. As a working diagnosis, which of the following is most likely? . water intoxication . nephrogenic diabetes insipidus . diabetes mellitus . central diabetes insipidus . Addison disease

water intoxication

A 6-month-old infant is found to be lethargic and cyanotic. Blood obtained by venipuncture appears chocolate brown and does not become bright red when shaken in the presence of air. It is especially important to seek a history of exposure to which of the following?

well water

physical dependence

δ (delta)