NBME 17

Physician sad to inform patient of progression of carcinoma to the terminal phase. Physician's face makes patient cry and ask, "It's bad news, isn't it?" Which is best response?

"Yes, it is."

43yo woman for health maintenance exam. Physician 30 minutes late for appointment because of emergency, when enters, patients checks watch. Which is best initial response?

"I'm sorry I got delayed. I hope I haven't made you late somewhere else."

50yo M with increasing cough for 6 month and hemoptysis for 1 week. Smoked 1 pack per day for 32 years. Plays squash, swims. CXR shows a 3 x 4-cm hilar mass. Cytologic examination of sputum shows a non-small cell carcinoma. Tells patient he has lung cancer. The patient responds, "How can this be happening to m? I eat right and exercise." Appropriate response?

"It must be difficult for you to accept this diagnosis when you feel healthy."

65yo F with widely metastatic breast cancer unresponsive to chemo. No family. "close friend," at all her visits and now she is moved to inpatient hospice after she decides she wants no further curative therapy. Says, "We can't bear to be apart. It would be cruel to separate us now.". Which response is appropriate?

"The two of you seem to have a very important relationship. Of course you may stay together." Hospice care is about providing comfort

17yo boy with 8-kg weight gain during the past year. No medical illness. BMI is 32. He asks, "Do you think that my weight gain is inherited from my father?" Appropriate response?

"Yes, your weight gain can be caused by genes and environment combined."

47yo F with psoriasis for follow-up. Was given several topical creams, to be used in specified sequence twice daily. No improvements apparent at this appointment. How to begin discussion of compliance?

"most people find it difficult to adhere to a routine, how did you do"

55yo M with sepsis. Appears anxious and confused. Rx with vancomycin and ceftriaxone initiated in ED. T 39.8, P 132/min, BP 85/48. PE shows warm, flushed skin. No edema. Administrer which solutions?

0.9% saline

40yo African American woman 2-week hx fever, malaise, dyspnea. Temperature 36.7 C (98 F), respirations 20. Physical exam: erythema nodosum, parotid enlargement, hepatosplenomegaly. Calcium 16. CT chest bilateral hilar adenopathy. Increased in which in serum?

1,25-Dihydroxycholecalciferol

Female newborn is delivered at 38 weeks' gestation. Apgar 8 and 8 at 1/5 min. PE shows a bulging, fluod0filled mass approximately 5 cm in diameter in the midline over the lumbosacral region. No spontaneous movements of the lower extremities. Abnormality most likely occurred because of abnormal development during which periods of postconception (in days)?

15-40; neutral tube closes at about 4 weeks

15yo girl 1-day hx redness and painful skin following sunbathing. She used sunblock. No medications. Physical exam: severe erythema of back and extremities, no blisters. Dx?

1st-degree burn

25yo F with 3-year hx of irregular menses. Menarche was at age of 14 years. BP 116/62. PE shows increased hair growth on the face and chest. Pelvic exam shows clitoromegaly and a normal-appearing uterus. Serum shows increased 17-hydroxyprogesterone and androstenedione. Deficiency of ?

21-hydroxylase

45yo woman follow-up exam after 8 weeks tamoxifen therapy for estrogen- and progesterone-positive invasive ductal carcinoma of breast. 50yo sister also hormone-sensitive breast cancer. Physical exam normal. Serum decreased concentrations of endoxifen, active metabolite of prodrug tamoxifen. Genetic analysis shows homozygous cytochrome P450 2D6*4 alleles. Likelihood patient's sisters has same alleles?

25%

In a survey of 100 households (average three residents per household), 45 with asthma are detected. Prevalence?

45/ (100*3)= 15%

Exam scaled so scores are normally distributed with mean of 500 and SD of 100. Which % are between 400 and 600?

67%

Girl for well-child exam. Normal development includes pincer grasp, finger feeding, standing while holding onto a table, and playing peekaboo. Age (in months)?

9 months

24yo M with hx of IVDA could not be aroused. Friend reports that the patient injected himself with a drug 6 hours ago. Labs show drug concentration of 0.3. Assuming first-order one-compartment kinetics, has a half-life of 2 hours, and a volume of distribution of 200 L in this patient. What is quantity of drug (in mg) injected?

= 200 (0.3) =60 3 half-lives = 120, 240, 480

62yo M dies suddenly while playing tennis. No cardiac risk factors, no hx of CAD. Autopsy, cardiac valve defect and concentric LVH. Which valve abrnomalities is most likely involved?

AS

68yo F with T2DM and hypertension that has been poorly controlled despite hydrochlorothiazide treatment. BP 150/96, Labs show serum glucose concentration of 130 and proteinuria. In addition to current Rx, which is most appropriate pharmacotherapy?

ACE I (Lisinopril)

20yo F has multiple neurofibromas. Mom, uncle, and brothers with similar lesions. Mode of inheritance?

AD

20M with 3-month hx of progressive thirst (drinking a lot of fluids) and urinary frequency during past 3 days. U/A shows specific gravity less than 1.006. Most likely has dysfunction of which endocrine structure?

ADH--> posterior pituitary

12yo boy immersed up to his neck in 60F water for 20 minutes. Physiological changes? ADH: Central Blood volume: ANP:

ADH: decreased (VC leads to decreased ADH) ANP: increased Central blood volume: increased

18yo M with yellow nodules on achilles tendons of his feet and extensor tendons of his hands. Exam shows collection of foamy histiocytes within the dermis. Serum cholesterol is 980, and lipoprotein electrophoresis shows a selective increase in LDL. Underlying disorder?

Absence of functional LDL R's in hepatocytes

42yo farmer has a 7-mm red scaly plaque on helical rim of left ear. Photomicrograph shown. Dx?

Actinic keratosis

32yo M with 3-month hx of swelling and breast tenderness. Receiving thyroid hormone and steroid replacements since removal of pituitary adenoma 2 years ago. Began hCG injections 4 months ago. Most likely binding site of hCG causing gynecomastia?

Acts on testes and leads to increased estrogen

35yo M uses crack cocaine daily, with 2-hour Hx of substernal chest pain. T 37C, P 110/min, BP 160/100. Most appropriate next step?

Admit the patient for possible myocardial ischemia

60yo man progressive shortness of breath past 3 months. Worked in shipyard. Respirations 25. Bilateral basilar crepitant crackles. Xray chest reticulonodular pulmonary infiltrates consistent with interstitial fibrosis. Picture: sputum sample of elongate structures (ferruginous body). Fibrosis initiated by interaction of structures with which cell?

Alveolar macrophages

60yo M from china to USA with 1-month hx of confusion and swelling of abdomen and legs. Peanut farmer in china. Smoked 1 pack per day for 40 years. No alcohol. PE shows ascites and ankle edema. Liver palpable, spleen isn't. Serum: Albumin 4, total bili 2.5, Alk Phos 200, AST 45, ALT 60, IgG anti Hep A positive; Anti hep B negative, anti hep C negative. U/S shows 10 cm lesion. Biopsy shows dysplastic hepatocytes in small clusters and rows with no normal architecture. Exposure to which?

Aflatoxin

41yo man with asthma and allergy to grass pollen wheezes and difficulty breathing 10 min after mowing lawn. Drug for immediate relief of acute symptoms?

Albuterol

45yo F intubated, mechanically ventilated with fungemia with Candida albicans. Rx with caspofungin is started. Feature of causal organism targeted by this drug?

B-glucan carbohydrates in the cell wall

RCT to compare wound healing and cosmetic differences between two surgical procedures for closing skin after C section. Surgical specialists cannot be blinded to the procedure. Results show procedure A has a lower rate of wound infection compared with B (relative risk 0.66, 95% CI 0.3 - 1.45). Which accurately represents comparison bewtween A and B?

CI crosses 1--> neither procedure is superior

62yo F in ED for 2-day hx of fever, abdominal tenderness, and painful urination. Agitated. T 38.8C, Labs show WBC 14k. Admitted to hospital, nurses note she has torn up four breakfast menus because she is confused. Cause?

Delirium

65yo woman surgical repair of aneurysm right internal carotid artery in cavernous sinus. Three days later, physical exam right pupil larger than left pupil. Weakness of eye movement. Diagram of coronal section through middle cranial fossa shown. Which nerve is damaged?

CN III (first nerve on the lateral side) III-->IV-->V1-->V2; VI in the middle

Ten years after total gastrectomy, 60yo man difficulty walking. Diffuse spasticity in arms and legs, impaired proprioception in his feet, increased muscle stretch reflexes in arms and knees, absence of muscle stretch reflexes in ankles, bilateral extensor plantar responses. Which vitamin is deficient?

B12

56yo woman with restrictive cardiomyopathy, proteinuria, renal failure. 35-year history of rheumatoid arthritis. Renal biopsy shows glomerular deposition of eosinophilic hyaline material. Congo red statin: birefringent pattern under polarized light. Structure of material?

Beta-pleated sheet structure

10yo girl well-child examination. No menstrual period. 50th percentile height and weight. Physical exam absence of breast bud development and no pubic or axillary hair. It is most appropriate to tell mother that first objective sign of puberty will be which?

Breast bud development

63yo M with 6-month hx of exertional chest pain relieved by rest. smoked for 45 years. Mild HTN, no meds. Which lesion in LAD is most likely cause?

Calcified 80% stenosis

45yo F has thyroidectomy because of asymmetric enlargement of thyroid noticed 6 weeks ago. Underwent adrenalectomy for pheochromocytoma 3 years ago. Bilateral thyroid lesions with spindle cells arranged in small clusters. Amyloid deposits b/w neoplastic cells. C-cell hyperplasia, malignant. Which marker to monitor?

Calcitonin (MEN 2A)

Compound is taken up by bacterial cells. No energy is necessary for uptake, and the compound is not concentrated in the cell. Which describes this mechanism of transport?

Carrier-mediated diffusion

59yo F with gradual onset of lack of muscle control in her left arm and leg. Sx 1 mo ago after dx with metastatic breast cancer. PE shows ataxia of left upper and lower extremities. Muscle strength, DTR, sensation, proprioception normal. Metastatic tumor in which location?

Cerebellum

42yo F with 1-mo Hx of abdominal pain, after eating fatty meals. BMI 31. PE shows jaundice and tenderness of RUQ. Increase of which liver function?

Cholesterol synthesis

50yo M smoked 2 packs per day for 34 years, with SOB on exertion, chronic cough, and wheezing. Increased AP diameter, diminished breath sounds, scattered rhonchi. Which Lab abnormalities is expected?

Chronic bronchitis--> increased PaCO2--> to compensate, increase HCO3-

Study of breast cancer in women. Hundred healthy women observed for 10 years. Goal is to determine if number of family members who previously received dx of breast cancer correlates with incidence of future development of cancer. Best design?

Cohort

Male newborn has macrocephaly with poor skull mineralization, shortened extremities with misshaped long bones, and several fx. Defect in which?

Collagen

Newborn delivered at 38 weeks' gestation weighs 1800 g. PE shows petechial rash, microcephaly, and hepatosplenomegaly. Serologic test for CMV: IgG + in mother, + in newborn; IGM - in mother, + in newborn. Explanation?

Congenital CMV infection

4yo boy two bacterial urinary tract infections past year. Physical exam normal. Radiologic studies show dilation of left ureter and renal pelvis, minimal left-sided renal function. Left nephrectomy done. Photo: dilated renal pelvis and ureter. Which is cause of renal disease?

Congenital urethral obstruction

38yo M with 3-year hx of T2DM. Taking an oral antihyperglycemic agent, he has tried diet and exercise. BMI 32. PE normal. Hb A1c is 10%. Physician recommends initiation of insulin injections. Responds, "I know that insulin would help control my blood sugar. But a lot of people in my family have diabetes, and insulin made them really sick at times. Patient is at which stage of change?

Contemplation

40yo M with interstitial pulmonary fibrosis has greater maximal expiratory flow rate than predicted. Which best explains this?

Increased radial traction on airways

8yo boy with disruptive behavior, interrupts, always moving, trouble completing tasks. Drug with which mechanism is appropriate?

Increased release of DA and NE

6-week-old girl with 6-day hx of vomiting small amount of milk 2 to 3 times daily. 50 %ile for length and weight. Cause?

Immature LES

9yo girl with poor growth during the past year. < 3rd %ile for height and at 10th percentile for weight. PE normal. Visual field testing shows bitemporal hemianoia. Labs show GH deficiency. MRI shows calcified cystic mass in suprasellar region. Tumor derived from?

Craniopharyngeoma--> diverticulum of the rood of the embryonic oral cavity

27yo F in ED 30 min after ejected through windshield during MVC. Unrestrained front-seat passenger. PE shws marked edema and tenderness of the jaw. Panorex x-ray of mouth shown. Which is injured?

Inferior alveolar nerve (branch of mandibular n)

21yo M in ED with excruciating anal pain for 4 hours. Exam shows 15-mm, blue tinged rounded mass at anal margin. Represents thrombus in a tributary of which blood vessel?

Inferior rectal vein

79yoM 30 minutes after LOC for 30 seconds. Alert, but dizzy. No urinary or fecal incontinence. Pulse 40/min, BP 92/56. PE shows no tongue biting. Lungs clear, Variable intensity S1. Oriented X3. ECG shows a third-degree atrioventricular block. Next step?

Insertion of transvenous pacemaker

68yo M with difficulty swallowing solids for 2 months. Hx of dilated cardiomyopathy. X-rays of esophagus w/ barium contrast show indentation and posterior displacement of the esophagus. Enlargement of what caused dysphagia?

LA

45yo M with intermittent bloody diarrhea and abd pain. Sigmoidoscopy and rectal biopsy show IBD. Monoclonal antibody is begun, which is directed against what components?

Crohn's disease--> TNF inhibitor

18mo girl. Separation of the umbilical cord was delayed after birth. Has had four severe skin infections Staphylococcus aureus; No pus formation at infection sites. Persistent leukocytosis in absence of infection. Mechanisms impaired?

LAD

16yo girl with 2-year hx of fainting; increased in frequency during past 6 months. BP 110/80 supine and 60/40 standing. Neuro exam normal. Plasma shows undetectable noreipinephrine and marked increase in dopamine concentration when standing. Deficiency of which?

DA-B-hydroxylase

16yo boy with no signs of puberty. Sex development Tanner stage 2. Physical exam: circumcised penis, soft small tests 5 mL, prostate firm, nontender, no discharge or lesions. Testosterone low. Which hormone is cause of decreased serum testosterone and lack of pituitary hormone stimulus?

LH

18-yo F with sepsis after an abortion. Within 24 hours she becomes dyspneic, oliguric, and develops petechiae, ecchymoses, and bleeding from venipuncture sites. Which lab finding?

DIC--> decreased fibrinogen

65yo F with ovarian cancer treated with cyclophosphamide and other chemotherapeutic agents. Cyclophosphamide affects which target?

DNA replication

36yo M undergoes elective liposuction under general anesthesia. Operation is terminated when patient develops hyperthermia, tachycardia, and marked muscle rigidity. MOA of drug that should be administered?

Dantrolene Decreases release of Ca from the sarcoplasmic reticulum

48yo F with 2-month hx of fatigue and intermittent headaches. BP 180/110, PE normal. Serum show a decreased potassium concentration and increased aldosterone. CT abdomen shows tumor on adrenal gland. Which additional findings supports aldosterone-secreting adrenal adenoma?

Decreased plasma renin

66yo M with stage IV colon cancer with 3-day hx of severe diarrhea after receiving chemotherapy with flourouracil, leucovorin, and irinotecan. Prescribed opioid antidiarrheal agent with no CNS effects. Which med?

Loperamide

38yo M truck driver with 1-week hx of watery, itchy eyes and a runny nose. Physical shows inflamed nasal mucosa. No congestion in lower lung. Pharmacotherapy?

Loratadine--> less sedating antihistamine

Sequence surrounding the first two exons of the human beta-globin gene shown, with exons in bold. Translation start codon is underlined. A mutation from G-->A at position 355 is most likely to lead to beta-thalassemia by which mechanism?

Disruption of normal splicing by creation of a new 3' splice site

28yo M in ED 30 minutes after SOB. 3-year hx of cocaine abuse. T 38.1, P 100/min, BP 150/45. PE: diminished pulses in left upper extremity. Crackles heard over all lung fields. 2/6 diastolic murmur at left sternal border. CXr shows a widened aortic arch. Dx?

Dissecting aneurysm

45yo F farmer in ED for 2-day hx of confusion, lethargy, fever, headache, muscle pain, vomiting, and a rash on her wrists and ankles. Bitten by a tick a few days ago. T 38.5 C, Red-purple papules on distal extremities progress to trunk. Rx?

Doxycycline

46yo M treated with oral cyclosporine after cardiac transplant. Cyclosporine decreases likelihood of rejected by which actions?

Suppressing the early response of T-lymphocyte activation

32yo F G2P1 at 7 weeks' gestation with vaginal bleeding for 3 days and increasingly severe left abdominal pain for 18 hours. Direct and rebound tenderness with guarding in left lower quadrant. Cervical os is closed. serum beta-hCG is 6000. U/S shows empty uterus. Dx?

Ectopic pregnancy

70yo M from china with poorly differentiated monoclonal carcinoma of the nasopharynx. DNA probes of neoplastic cells are most likely to detect genome of which virus?

EBV

80yo F with suspected temporal arteritis (TA). ESR is 100, Pretest probability for TA is 50% in this patient. In the evaluation of TA, ESR has a sensitivity of 99% and specificity of 60%. Based on the results of the ESR testing, most appropriate next step?

ESR is not sensitive; need additional testing like a biopsy to confirm the diagnosis

83yo M brought to ED after being found at home bedridden and confused. No meds. P 100/min, BP 85/50. BP unchanged after 1L IV saline. Pulmonary artery catheter shows: Cardiac output high, PCWP low, systemic vascular resistance low. Cause of hypotension?

Early septic shock (only form with decreased SVR)

48yo nulligravid woman with excessive uterine bleeding for 3 months. Bleeding during menses and at irregular intervals. Menses were regular before. BMI 27. Pelvic exam: adnexae are nonpalpable. Endometrial curettage shows abundant tissue. Which is cause of symptoms?

Endometrial hyperplasia

38yo F with 2-year hx of pain and heavy flow with menses causes her to miss work. Ibuprofen not effective. One 6yo daughter; unable to conceive another child. PE shows mildly enlarged left ovary and retroflexed uterus. U/S shows substantial evidence of ovarian cysts and one peritoneal cyst. Bx of cyst will show?

Endometriosis--> proliferative endometrial tissue

45yo man poorly controlled type 2 diabetes 1-month low-grade fever. Getting hemodialysis for end-stage renal disease. T 37 C (98.6 F), pulse 72, bp 144/92. Physical subclavian catheter below right clavicle. Lungs clear. Cardiac exam no murmurs. Blood cultures grow nonhemolytic, catalase-negative, gram-positive cocci in pairs and chains. Which organism?

Enterococcus faecalis

20yo man with 6-hour difficulty breathing and vomiting. 10-year history of type 1 diabetes on insulin. Pulse 90, respirations 30 and deep, bp 90/60. Physical shows dehydration. Labs: Na+ 130, K+ 6.5, HCO3 5, glucose 500, pH 7.2, pCO2 25 mm Hg. Which compound stimulated hormone-sensitive lipase in adipocytes causing accumulation of metabolites causing acidosis?

Epinephrine/ glucagon--> triggers FA breakdown to create glucose

60yo F with 3-year Hx of hyperlipidemia. Low-cholesterol diet and exercise program ineffective after 1 year. Lovastatin initiated, but unable to tolerate greater than 20 mg daily. Additional drug is added that inhibits transport of cholesterol through intestinal wall. Which drug?

Ezetimibe

28yo F at 18 weeks' gestation has palpitations. Labs show increased serum total thyroxine (T4) concentration. Best test to confirm hyperthyroidism?

Free T4 In pregnancy, total T4 is falsely increased

3yo boy and his 5yo brother with recurrent hemarthroses. Both parents healthy, but mother with two younger brothers with same sx and maternal uncle who died at 8 of mild head trauma. Partial thromboplastin time is prolonged. Defect?

Factor VIII

Randomized controlled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from both the control and treatment groups do not complete the study are are not included in the analysis. Treatment group able to fall asleep 5 minutes faster than control (p=0.001). Neither group report an improvement in quality of life. Conclude that new med is efficacious in treating insomnia. Type of error?

Failure to distinguish between statistical significant and clinical significance

35yo man increasingly depressed, impulsive and difficult over past year. Grimaces intermittently with rapid, jerking, purposeless movements of fingers. Historical factor relevant in dx?

Family history

62yo M with pericardial friction rub 3 days after acute myocardial infarction. Cause of rub?

Fibrinous pericarditis

41yo F with increasingly severe headaches for 6 weeks. BP 160/100. bruit over left costovertebral angle. U/A norma. Angiogram of left renal artery shows alternating areas of stenosis and aneurysmal dilatation ("string of beads" sign). Dx?

Fibromuscular dysplasia

72yo M with weakness and fatigue. Hemoglobin concentration is 9.2, WBC 5400, platelets 350k. Peripheral blood smear is shown--> hypochromic cells. Cause?

GI blood loss--> iron deficiency anemia

40yo woman hx of 6 month episodic sinusitis with 2-week intermittent headaches, fatigue, and generalized joint pain, worsening cough productive of blood-tinged sputum. Failed antibiotics, decongestants and nasal corticosteroids. Physical exam: erythema nasal mucosa, two small ulceration. Lungs scattered crackles. Xray patchy bilateral opacicites. Labs: Hemoglobin 13, ESR 70, leukocyte 10,500, antineutrophil cytoplasmic antibody increased. Dx?

GPA

34yo woman with pyelonephritis treated with bactericidal antibiotic 4 days no improvement. Antibiotic added that inhibits binding to 30S ribosome, blocking protein synthesis intracellularly. Antibiotic?

Gentamicin

6-Mercaptopurine (6-MP) used to treat acute lymphoblastic leukemia (ALL). 6-MP acted on by enzymes to make 6-thioguanine nucleotides (6-TGN). Efficacy and toxicity of 6-MP correlated with 6-TGN. 6-MP acted on by xanthine oxidase (XO), thiopurine methyltransferase (TPMT), leading to inactive metabolites. Which are clinical consequences of ALL patients homozygous for low-activity alleles of TPMT?

Give decreased doses of 6-MP--> slow metabolizer

27yo F with fever, malaise, abdominal pain, and vaginal d/c for 4 days. LMP 5 days ago. Had ectopic 1 year ago. T 38.3 C, bilateral lower quadrant tenderness with rebound and guarding. Pelvic exam with cervical motion tenderness and bilateral adnexal tenderness WBC 18k. Pregnancy test neg. Dx?

Gonorhhea

57yo M with alcoholism has distended abdomen with shifting dullness, fluid wave, caput medusae, palmar erythema, spider angiomata. Additional finding?

Gynecomastia

80yo F in ED for 2-day hx of "feeling funny." "Lost my pep." Hx of poorly controlled hypertension. Just started medication 2 weeks ago. BP 130/85. Pe normal. Serum potassium is 3. Which drug?

HCTZ

24yo M with small tender blisters on his penis 3 days after unprotected sex. Photograph shown. Causal agent?

HSV-2

40yo M skin extremely sensitive to sunlight, which causes formation of vessicles and blisters on the skin which take weeks to heal. Diagnosed with disorder caused by increased synthesis of compounds in the skin that are subject to excitation by visible light. Which biochemical pathway is defective?

Heme synthesis

48yo M with bronzing of his skin, weakness, and fatigue during the past 3 months. PE shows hepatomegaly, and small testes. Serum: AST INCREASED, ALT INCREASED, iron INCREASED, transferrrin sat INCREASED, ferritin INCREASED, testosterone DECREASED, LH DECREASED, FSH DECREASED. Explaination?

Hemochromatosis--> increased intestinal iron absorption

10yo boy has had anemia since birth. Spleen is five times normal. Splenectomy is indicated if anemia is caused by which?

Hereditary spherocytosis

2mo boy given vaccine to convert T-independent antigens to T-dependent forms to enhance protection in young children. Which vaccine given?

Hib type B

50yo M 3 days after his first generalized tonic-clonic seizure. 1-month hx of frequent episodes of pins-and-needles sensation around the mouth, hands, and feet, involuntary contraction of muscles. Neuro exam shows mild, diffuse hyperreflexia. Which serum electrolyte is abnormal?

Hypocalcemia

62yo F with recurrent pulmonary emboli comes for follow-up. PE normal. Labs show PT of 12 seconds. Warfarin begun. Which clotting factors is first to be decreased by 50% after initiation of Rx?

II, VII, IX, X

3yo boy with bacterial colitis caused by Salmonella enterica serovar arizonae. Which factor accounts for recruitment of PMNS to inflammatory site by intestinal epithelial cells?

IL-8

16yo girl with 3-day hx of fever, nonproductive cough, and fatigue. T 38.3, P 88/min, BP 102-70. PE shows pale conjunctivae. CXR shows bilateral interstitial infiltrates. Blood spontaenously agglutinates while awaiting transport to the laboratory. Antibody isotypes causing agglutination?

IgM (mono and mycoplasma)

Mouse embryos are produced with two pronuclei, both of same parental origin. When the pronuclei are maternal, produces have poorly developed extraembryonic structures. When both pronuclei are paternal, produces have poorly developed embryonic tissue. Which genetic mechnanisms?

Imprinting

Female newborn at 36 weeks gestation has respiratory distress. Apgar 3 and 5 at 1 and 5 minutes. Physical shows cyanosis. Endotracheal and NG tubes placed. Xray shows nasogastric tube in left hemithorax, mediastinum displacement to right, absence bowel gas in abdomen. Which embryological event led to these findings?

Incomplete formation of pleuroperitoneal membrane (diaphragmatic hernia)

34yo man lightheaded after running 12 miles of marathon hot day. Pulse 130 bp 80/60. Which changes to autonomic nervous system occurred?

Increased SNS, decreased PNS--> orthostatic hypotension

63yo man 3-month hx difficulty sleeping. Sleeps better upright. HR 90, bp 110/60. Physical exam: increased jugular venous pressure, mild ankle edema. Cause of edema?

Increased capillary hydrostatic pressure

75yo man 2-year history of decreased force of urinary stream, urinate several times throughout night. BUN 55, Cr 5.0. Ultrasound shows bilateral hydronephrosis and dilated ureter. Mechanism of renal failure?

Increased hydrostatic pressure in Bowman's space

42yo M in ED because of a 10-day history of progressive fever, SOB, and nonproductive cough. 20-kg weight loss. Immigrated to USA from the Ivory Coast 4 years ago. T 38C. Lungs clear, CXr shows diffuse interstitial infiltrate. Silver stain obtained via bronchoscopy shows Pneumocystis jiroveci (formerly P. carinii). High dose prednisone and trimethoprim-sulfamethoxazole is initiated, and workup for HIV infection is done. HIV ELISA positive, HIV western blot positive, CD4 22; HIV viral load <50. Explanation?

Infection with HIV-2--> progresses more slowly and is only seen in a few West African countries

35yo M with 4-day Hx of high-grade fever, sever muscle aches, malaise, loss of appetite, and a nonproductive cough. wife and kids had similar illness. Temp 39.2, PE normal. CBC and CXR normal. Causal virus replicates its genome within the cell's nucleus. Organism?

Influenza

68yo M in for a hemiorrhaphy. Surgeon gives info of risks and benefits. Patient says that he understands what he has been told, and his family will be able to discuss later. In this patient, which combination of components fulfill the criteria for fully informed consent?

Information, competence, voluntariness

14yo boy daily headaches for 2 months. Headaches are bilateral aching in temples. "Has not been himself" for months. Confused, forgetting names, dates, places, clumsy, frequent falls. School performance declined. Physical exam: broad-based ataxic gait. Slow to answer questions. Chronic abuse of which substance?

Inhaled glue

50yo woman 1-year hx of hot flashes and irregular menses. Decreased bone mineral density. Alendronate prescribed. Mechanism of drug?

Inhibits osteoclasts

22yo woman, g1p1, 2-day hx of fever, severe vaginal bleeding. four days ago delivered healthy male newborn. Temp 38.1 C (100.6 F). Pelvic exam: open cervix, heavy vaginal bleeding. US shows uterus with no placental tissue or thrombi. If operation required to control bleeding, ligation of branch of which artery required?

Internal iliac --> supplies the pelvic

65yo women progressive vulvar itching past 2 months; miconazole for yeast infections ineffective. Exam: atrophy of labia minora and thin, parchment-like skin over vulva and anus. Dx?

Lichen sclerosis

35yo M with recurrent sinusitis and bronchitis. Cardiac examination shows PMI at fourth intercostal space within the midclavicular line on the right. Hepatic margin is palpable on the left. Endoscopy shows nasal polyps. Biopsy shows thickened, ciliated, pseudostratified epithelium with small patches of squamous metaplasia and mild lymphoid infiltration. Which structure most likely to be absent on electron microscopic exam of epithelium?

Kartageners Dynein arms

30yo F training for a marathon, running 20 mild/day. Fasting glucose is 60. After her glucose stores have been depleted, which organ, in addition to liver, releases glucose?

Kidney

65yo F with 20-year hx of osteoarthritis of the hands now has pain radiating down the distal anterior thigh, knee, medial leg, and food. Bony outgrowth of vertebrae compressing one of the spinal nerves is suspected. Nerve root in which intervertebral foramina is effected?

L3 to L4

Corresponded to penis shaft?

Labia minora

52yo F with hot flashes. Menses have been irregular for the past 6 months. Physiologic cause?

Lack of ovaries to secrete 17B-estradiol

19yo M in MVC. Penetrating wound to right cerebral cortex with paralysis of the left lower extremity, fracture of right mid humerus with severing of the radial nerve, and a fracture of right tibia. After 10 weeks, DTR strongest in which locations?

Left achilles tendon Lesion to the right cerebral cortex will lead to UMN loss of motor function to the left lower extremity (UMN lesion--> hyperreflexia)

Pharm co trying to develop a long-acting weight-loss agent that mimics activity of a naturally occurring peptide originates in adipose tissue, signals brain about stored fat, and suppresses appetite by its action in the CNS. Which chemical mediator?

Leptin

30yo primi at 22 weeks' gestation with 1-day hx of fever, chills, and muscle aches. T 39.4, P 114/min, resp 15/min, BP 104/72. PE shows uterus consistent with 22-week gestation. Fetahl heart sounds are heard. WBC 12K, Blood cultures grow gram-positive rods. Causal organism?

Listeria

59yo man has total thyroidectomy for 4-cm follicular carcinoma of thyroid. Twelve hours after procedure, has paresthesias of hands and feet. Vitals stable, carpal spasm on inflamation of bp cuff. Lab findings?

Low PTH and calcium; accidentally remove parathyroid

0yo M in ED 15 minutes after found unconscious. Comatose, pupils 4 mm in diameter, not reactive to light. CT head shown. Cause of coma is bleeding from which structures?

MMA

34yo AIDS patient with pulmonary tuberculosis. No CD4+ T lymphocytes in peripheral blood. Which cellular components most likely to have deficient function in tuberculous lesions in lungs?

Macrophages

56yo F follow-up 8 weeks after recovering from pneumococcal pneumonia. Chest X-rays normal. Which allowed this resolution to occur?

Maintenance of the BM integrity

55yo woman 6-week history low energy, irritability, crying spells, difficulty falling asleep, wakes up during night, cannot focus. Taking lorazepam for 15y for generalized anxiety disorder. Taking estrogen replacement therapy for postmenopausal symptoms. Vital signs normal. Physical exam normal. Mental status shows constricted affect. Mood is "testy." Speech is slowed. No psychosis. Wishes she wouldn't wake up but doesn't plan to harm herself. Cause of symptoms?

Major depressive disorder

53yo M returned from Africa, has fever, headache, and abdominal discomfort. Received appropriate vaccinations prior to the trip. T 39.4C. A wright-stained peripheral smear shown (ring forms in RBCs). Dx?

Malaria

45yo M with yellow skin. Drinks eight to ten 12-ounce cans of beers daily for 10 days. Liver is tender. Serum: total bili 5.9, Alk Phos 210, AST 110, ALT 69, gamma-glutamyltransferase 25 (n = 0-30). Liver biopsy will show?

Mallory hyaline--> alcoholic hepatitis

20yo F with 1-day hx of increasing urinary frequency and a burning sensation with urination. One sexual partner, uses condoms. VSS. PE shows mild suprapubic tenderness to deep palpation. Urine shows rare epithelial cells and 10 WBC/hpf. Urine grows E. coli > 100k. This bacterial strain has which virulence factors?

Mannose-binding fimbria

14yo boy come to ER 1 hour after colliding with teammate playing soccer. Physical exam: edematous tissues of left eye, mild depression of left zygomatic bone. Skin between eye and upper lip numb. Double vision look upward. Nerve damaged causing sensory loss?

Maxillary division of the trigeminal nerve

1-week-old girl. screening showed a possible defect in fatty acid oxidation. PE normal. Next step?

Measurement of serum acylcarnitine concentrations

40yo F with mole on her back that has increased in size during past 4 months. PE shows raised irregular lesion with variegated black-tan pigmentation and ill-defiined margins. Pleomorphic, hyperchromatic cells within clear islands that tend to collapse. Extend from epidermis into papillary dermis. Dx?

Melanoma

60yo M in ED for sudden onset of acute abdominal pain and tenderness, nausea, vomiting, and bloody diarrhea 2 hours ago. He has a Hx of cirrhosis and hepatocellular carcinoma. BP 99/50. Loss of bowel sounds. Surgery shows small intestine with dark purple-red hemorrhagic appearance. Cause?

Mesenteric venous thrombosis

17yo girl 1-day shortness of breath, weakness and muscle tenderness. Did triathlon previous day. BMI 19. Temperature 38 C (100.4 F), respirations 20, bp 150/90. Physical bilateral crackles lower lobes, muscle tenderness. Creatinine 4. Urinalysis 3+ protein, 4+ hemoglobin. Patient's condition is from increased release of which substance?

Myoglobin--> rhabdo

54yo F 1 week after sudden loss of vision in left eye, returned within 1 day. 3-month hx of progressive SOB with exertion. Echocardiography shows mass in the left atrium of the heart. Lesion is resected, photomicrograph of it is shown. Which describes the lesion?

Myxoma (most commonly appear in the LA)

25yo woman 6-month history of joint pain poorly responsive to aspirin. Physical exam: bilateral swelling of proximal interphalangeal joints, metacarpophalangeal joints, and wrists; weakness of grasp. Small nodules palpated beneath skin around joints of fingers. Dx?

RA

55yo M with chronic bronchitis in ED after being unresponsive. Found bottles of albuterol, ampicillin, codeine, and theophylline bedside. T 37.2 C, p 112/min, respirations are 6/min, BP 95/60. Acute Rx should include?

Naloxone

35yo woman abnormal Pap smear. Cervical biopsy shows microinvasive cervical carcinoma. Which microscopic features led to dx?

Neoplastic cells in the sub-basement membrane CT

60yo F 3 hours after sudden onset ankle pain. 4-year Hx of increasing serum creatinine concentrations. Began furosemide 1 month ago, also takes glipizide. P 120/min, resp 25/min, BP 150/100. Joint fluid shows negatively birefringent crystals. Increased risk of which complications of underlying process causing joint findings?

Nephrolithiasis

Study designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in patients with CHF. Sixty patients with CHF are recruited. Each assigned by coin toss to one of tw groups. Design?

RCT

50yo man has persistent cough for 2 months. He has had a 5 kg (11 lb) weight loss. He is a farmer and on itraconazole 4 weeks for histoplasmosis from chicken coops. Medications: hydrochlorothiazide, enalapril, atenolol, omeprazole, and metoclopramide for hypertension and gastroesophageal reflux. Thin. Physical exam otherwise normal. Itraconazole interacts with which drug and account for lack of effect of itraconazole?

Omeprazole (CYP P450 inhibitor)

3yo boy sickle cell disease with fever and pain over left foot 3 weeks. Hematocrit stable. Leukocyte count 15,000 predominance of neutrophils. Which is most likely explanation for findings?

Osteomyelitis

42yo M with multiple lesions over his body. PE shows flaccid bullous erosions involving upper and lower extremities and torso. Biopsy shows extensive epidermal acantholysis resulting in the formation of intraepidermal blister. Intact basal layer of keratinocytes adherent to basement membrane is identified. Which is related to pathogenesis?

Pemphigus; antibodies against desmosomal proteins

68yo M with 6-month hx of erectile dysfunction. PE and labs normal. If pharmacotherapy is indicated, drug with which MOA?

PDE inhibitor

28yo woman wants to lose weight. She binges on high-carbohydrate foods 2 to 3 times a week, forcing herself to vomit after. BMI 23. Which physical finding is likely?

Parotid gland enlargement

80yo man type 2 diabetes 2-month history severe constipation. Laxatives haven't relieved symptoms. Abdominal exam shows distention. Colonoscopy shows no abnormalities. Patient has dysfunction of which nerve?

Pelvic splanchnic

52yo M neighbors have reported that he has been confused and not taking care of himself. 4-mo Hx of diarrhea. PE shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. Diagnosis?

Pellagra

60yo M with 6-month hx of fatigue. Four years ago, had subtotal gastrectomy after gunshot wound. Drinks 6-8 beers daily. PE shows paresthesias of both hands. Labs show: Hb 8, HCT 24%, MCV 115, WBC 5k, Platelets 165k, RBC Folic acid 500 (N = 125-600), B12 10 (N = 160-195). Cause is absence of?

Pernicious anemia--> loss of parietal cells

58yo F in ED for 2-hour hx of SOB and chest pain radiates to her back between the shoulder blades. Resp 28/min, PE shows diaphoresis. ECG normal. Coronary angiography shows occlusion of marginal branch of LAD coronary artery. Revascularization done with stent placement. CK-MB and troponin I increased. Mechanism of these lab findings?

Peroxidase-mediated membrane damage

A study conducted to assess effectiveness of injections of lidocaine into "trigger points" of pain symptoms in patients with fibromyalgia. Fifty patients randomly assigned - 0.9% saline only or saline plus lidocaine. Graph shows self-reported pain scores. Explanation?

Placebo effect

60yo M 1-month Hx of progressive SOB with exertion. Breath sounds: Dec on right lung base, normal on left lung base Percussion note dull on right lung base, nml on left lung base Tactile fremitus decreased on right lung base, nml on left lung base Adventitious sounds none on right lung base, crackles on left lung base Dx?

Pleural effusion

81yo woman massive pulmonary embolism from deep venous thrombosis. Platelet count 160,000. Appropriate pharmacotherapy is started. One week later, platelets 55,000. Thrombocytopenia most likely caused by a drug with which of the following mechanism of action?

Potentiates the action of AT III

6yo girl with 4-day hx of round shiny bumps in areas where she has eczema. Her mother saw similar bumps on a playmate at pool party 3 weeks ago. No other Sx. PE shows firm, smooth, umbilicated papules 2 to 4 mm diameter in clusters. Causal organism?

Poxvirus

37yo M with 4-day hx of diarrhea and abdominal pain, worse in past 24h, with watery-brown stools. Completed a 10-day course of amoxicillin for a sinus infection 5 days ago. Stool shows: Fecal fat negative; ova and parasites negative; Cx for infx negative; C. Diff toxin positive. Which pathologic findings present in intestinal tract?

Pseudomembranes of fibrin and inflammatory debris

70yo M with recent loss of mental function. Hx of weight loss. No drugs. VSS, not dehydrates. Mild anemia. Labs show Na 110, Cl 85, K 4.4, BUN 15, Cr 15; Plasma osmolality 250; Urine osmolality 750. Dx?

Pulmonary neoplasm (SIADH--> Small cell)

70yo F in longitudinal study of effects of aging on pulmonary function tests. Which represents woman now compared with results at age of 20 years?

RV: increases PaO2: decreases A-a ratio: increases

55yo F with left flank pain and gross hematuria. Mass is palpable in LUQ of abdomen. Ultrasonography shows a 12-cm solid mass on lower pole of left kidney. Angiograms show hypervascular mass. Dx?

Renal cell adenocarcinoma

75yo man 2-day ear ringing, nausea, fatigue. Temp 37 C (98.6 F), pulse 100, respirations 24, bp 140/85. Physical: mild epigastic tenderness. ABG pH 7.42 pCO2 30 pO2 95 HCO3 19. Dx?

Respiratory alkalosis; salicylate poisoning

28yo F with 3-week hx of double vision. Episode of blurry vision in left eye that improved during next 2 months w/o Rx. Neuro exam shows right eye does not adduct past the midline on horizontal gaze when looking to the left. When convergence is tested, the right eye is able to adduct past the midline. Rightward horizontal gaze is normal. Lesion is where?

Right MLF Ipsilateral lesions leads to failed adduction

56yo M 4 hours after sudden onset of uncontrollable irregular movements of the left side of the body. PE shows flailing movements of the proximal appendicular muscles on the left. Nuclei damaged?

Right subthalamic (contralateral lesion)

42yo F with 3-year hx of an intermittent facial rash, including the forehead, eyelids, nose, and cheeks. Rash seems to be getting worse since she moved from New York to Florida last year. Spicy foods precipitate a flushing reaction that seems to exacerbate the rash. PE shows erythema over the nose and cheeks, with scattered telangiectasias and a few papules. Dx?

Rosacea

28yo F G1P1 with 2-day history of a painful mass in her right breast. Delivered healthy female newborn 3 weeks ago, and been breast0-feeding since. T 37C, PE shows 3-cm tender mass surrounded by an area of erythema beneath the right areola. Causal org?

S. aureus

21yo M in ED 45 minutes after sustaining multiple injuries in a MVC. His BP is 90/50, PE shows diffuse abdominal tenderness. Dx with laceration of the spleen and undergoes splenectomy. Predisposed to infection with?

S. pneumo

26yo F 5 weeks after birth of first child. Worries constantly that the infant is ill and wakes up to make sure he is well. Washes her hands 30 times per day. Worried about people braking into her house, checks lock 3-4 times a night. Not breast feeding. Rx?

SSRI (sertraline)

27yo M for employment exam. No Hx of major illness. Never been sexually active. Minimal contact with parents and siblings, no hobbies. Doesn't feel depressed. Shrugs in response to congratulations about his new job. Flat affect. Personality disorder?

Schizoid

27yo primigravid woman at 34 weeks' with nausea and vomiting, and abdominal pain for 12 hours. Everything's been normal. BP is now 164/102, and right upper quadrant tenderness. Labs show Hb 7.4, HCT 24%, Platelets 72k, Cr 1.2, total bili 2.3, AST 112, ALT 126. Peripheral blood smear will show?

Schistocytes

Newborn has male genital ducts but female external genitalia. Cytogenetic analysis shows a 46,XY karyotype, and genetic testing shows a mutation of the gene encoding 5alpha-reductase. In absence of this mutation, labia majora would have been?

Scrotum

42yo M in ED for 5-hour hx of fever, chills, and severe pain and swelling of his left arm. Scratched his arm on a nail yesterday. Appears confused, T 40C, BP 71/38. Labs show Hb 14, HCt 42%, WBC 15K (35% PMNs, 40% bands, 25% lymphos), Platelets 50K, Serum BUN 28, Cr 2.8. Symptoms due to systematic release of which cytokines?

Septic shock--> IL-1 and TNF-alpha

62yo M with alcohol-induced liver disease develops ascites. Infection ruled out. Most appropriate diuretic, in addition to loops, is which?

Spironolactone Many times, patients with cirrhosis will have hyperaldosteronism. Spironolactone is an aldosterone antagonist

32yo M with 6-month hx of low back pain and stiffness, worse in morning and improve during the day; the pain radiates to his buttocks but not down his legs. Back stiffness if he sits for prolonged periods. Which to confirm diagnosis?

X-ray of SI joints

While lifting weights, 24yo M swelling in right inguinal region. Photograph shown of small intestine resected. Dx?

Strangulated

60yo M exam prior to employment. PE normal. Labs show Hb 14, HCT 42%, WBC 12k (PMN 45%, lymphos 50%, Monos 5%), platelets 250k Flow cytometry analysis of peripheral lymphocytes shows: CD3 50%, CD4 40%, CD8 10%, Kappa 47%, lambda 3% Which is most predictive of a clonal lymphoid proliferation?

Suface kappa:lambda ration

27yo woman 12-hour history of fever and abdominal pain. History of recurrent urinary tract infections. Temperature is 39 C (102.2 F). Physical exam tenderness of right flank. Abdominal xrays bilateral staghorn renal calculi. Urinalysis pH 8, many RBCs, WBC, bacteria. Calculi composed of?

Struvite

40yo F with 1-year hx of episodes of crampy abdominal pain, intermittent diarrhea, and rectal bleeding with passage of mucus. BMI 18. Abdomal exam: diffuse tenderness with no rebound. Sigmoidoscopy shows diffuse ulcers. Initial Rx?

Sulfasalazine

18yo man Crohn disease 1-day hx severe abdominal pain and intermittent bloody diarrhea. Temperature 38 C (100.4 F), pulse 98, respirations 18. Physical exam: draining anal fisutla. Treatment with antibiotics and prednisone over next 3 weeks recovers. Mechanism of pharmacotherapy is suppression of which?

T-lymphocytes

24yo M with 2-day history of an itchy rash on his arms and legs. Returned from a camping trip in the woods 5 days ago. PE shows edematous, erythematous rash with linear vesicles. Cause is activation of which cell types?

T-lymphocytes (type IV HS)

20yo M with suspected appendicitis has periumbilical burning and discomfort, localizes to RLQ 5 cm superomedial to anterosuperior ilica spine. This is because periumbilical region and appendix are both supplied by afferent fibers in dorsal root ganglia of which levels?

T10

30yo woman 20 weeks gestation, uncomplicated pregnancy. Fundal height is greater than expected for gestational age. Ultrasound shows increased amniotic fluid. Which abnormality is cause?

TEF

24yo with second-degre burn. Two weeks after, tissue shows increased fibroblast migration and proliferatoin, increased collagen and fibronectin, and decreased metalloproteinases. Caused by production of which?

TGF-B

29yo F with 5-week hx of fatigue and 4-day hx of heart palpitations and anxiety. Has primary hypothyroidism Rx with triiodothyronine, but she has doubled the dose because of fatigue. TFT will show which?

TSH: decreased Free thyroxine: decreased (measure of T4--> decreases when T3 increase) Free triidothyronine: increased (T3)

15yo girl emigrated from India and with several lesions on neck for 2 weeks. Physical exam shows hypopigmented, hypoesthetic area on left side of forehead and 4-cm lesions on neck. Biopsy shows acid-fast bacilli. Best explanation why the organism results in dermal rather than visceral infections?

Temperature sensitivity

54yo F with hypertension and bilateral renal artery stenosis starts taking NSAIDS for back pain. Her Cr concentration increases from 1.0 to 5.0. Cause is due to inhibiting which?

Vasodilation of the afferent arteriole

58yo man supraventricular tachyarrhythmia refractory to pharmacotherapy gets ablation of accessory excitatory pathway in atrial endocardium. Which area should be avoided to leave sinoatrial (pacemaker) node intact?

The junction of t he SVC and RA

30yo F has ptosis, ophthalmoplegia, and diplopia. Serum shows autoantibody with affinity for acetylcholine receptor at the postsynaptic neuromuscular junction. Which neoplasm?

Thymoma

64yo M in ED 3 hours after SOB with exertion and extreme fatigue. Has ischemic heart disease. P 125/min, BP 105/60. ECG shows atrial fibrillation. Intravenous ibutilide is administered. Ten minutes later, ECG shows normal sinus rhythm. Risk for which drug effect in the next 6 hours?

Torsades de pointes

6yo boy with 3 systemic infections with Neisseria meningitidis over the past 2 years. Healthy otherwise. Which lab test is most likely abnormal?

Total hemolytic complement concentration

13yo girl 2/6, holosystolic murmur heard best over left fifth intercostal space adjacent to the sternum; it increases with inspiration. Abnormality of which valves?

Tricuspid

27yo F with vaginal bleeding for 3 weeks. First pregnancy ended with a spontaneous abortion 8 months ago. No Rx since dilatation and curettage at that time. PE shows enlarged uterus, beta-hCG markedly increased. Ultrasonagraphy of pelvis shows material within the endometrial cavity and no intrauterine pregnancy. CT scan shows a necrotic intrauterine mass and metastatic nodules in the lungs. Site of Origin?

Trophoblastic tissue

65yo M emigrated from Brazil with 8-month history of shortness of breath and fatigue, edema of lower ext. CXR shows cardiomegaly. endomyocardial biopsy specimen shows myofiber necrosis with a mixed inflammatory infiltrate of PMNs, T lymphos, m.phages, and eosinophils. Causal org?

Trypanosoma cruzi

70yo M dies in a motor vehicle collision. Was undergoing evaluation for occult blood in the stool. Photo of transverse colon shown. Dx?

Tubular adenoma or villous polyp. GI blood loss suggests a risk for malignancy

44yo woman follow-up after two Pap smears showing atypical squamous cells of undetermined significant. Test shows viral E6 protein of human papillomavirus. This protein promotes cell growth and malignancy by causing cellular p53 protein degradation. This degradation beings when p53 protein targeted to which type of cell enzymes?

Ubiquitin ligase

Ten human subjects given new oral drug to monitor drug effect and toxicity. Blood analyzed for human pharmacokinetics of drug for first time. Which trial type?

Type I

Male newborn at 28 weeks'. Given ventilatory support with up to 80% oxygen for the next 72 hours, but dies of resp. failure. Cause is inadequate secretion from which labeled cell types?

Type II pneumocytes (large cell with round shape in the airways)

69yo F with weakness of left leg since awakening. PE shows weakness. Babinski present on left. Decreased somatic sensation in left foot, agraphesthesia on plantar surfaces of the toes, and decreased position sense in the toes. MRI shows edematous area in cerebral cortex of right hemisphere. Lesion?

UMN lesion--> motor cortex

Protein found in brown adipose tissue of mice causes leak of H ions inward across inner mitochondrial membrane. Effect of this protein on oxidative phosphorylation and energy metabolism?

Uncoupler--> leads to increased O2 consumption and decreased ATP production

67yo M has urinary urgency after placement of urinary bladder catheter during transurethral resection of the prostate. Most appropriate Rx has which MOA?

Urinary urge incontinence--> Oxybutinin--> M3 R antagonist

15yo girl health maintenance exam. Mother dx squamous cell carcinoma face, maternal grandfather died of metastatic melanoma. In patient this age, which factor most predicts compliance with photoprotection?

Use of sunscreen by peers

35yo M in ED with 2-hour hx of sever fatigue and dizziness. Had profuse, watery diarrhea for 8 hours despite a lack of oral intake. Recently returned from a medical relief trip to a remove village in Honduras. T 36.7 C, P 122/min, BP 90/50. PE shows dry skin and decreased capillary refill. Stool for occult blood is negative; stool is gray and turbid. Gram stain shows gram-negative, comma-shaped bacteria; no erythrocytes of leukocytes. MOA of toxin?

V. Cholerae--> activates AC

38yo F with 3-day hx of sore throat. Photo shown of throat. Which nerves is tested by saying "ah," elevating uvula at tip of the arrow?

Vagus

6yo boy from Russia with unstable gait and incoordination for 2 weeks. Pale, bulky stools for 4 years and two episodes of bacterial pneumonia and chronic cough since age 1 year. 3%ile for height/weight. Neuro exam shows ataxia, no DTRs, loss of proprioception. Stool shows inc fat concentration. Vitamin deficient?

Vitamin E

38yo M in ED 30 min after unable to stand upright. Lethargic, pulse 110/min, BP 90/62. PE shows dry mucosa and poor skin turgor. Midepigastric tenderness. Labs show: Serum: Na 143, K 3.2, Cl 101, HCO3 11 ABG: pH 7.28, Pco2 23, Po2 98 Acid-base status in this patient?

pH: decreased pCO2: decreased HCO3: decreased Metabolic acidosis