NBME 15 mix

60yo F with 6-month history of pain in her hips and knees. Osteoarthritis, recommends ibuprofen. Patient refuses and asks about using glucosaine. Which responses is most appropriate?

"What have you heard about using glucosamine to treat arthritis?"

During normal skeletal muscle twitches, the ATP concentration does not fall appreciably because of which?

ATP is quickly regenerated from creatine phosphate

Physical shows course facial features and contractures of large joints. Xrays show dysostosis multiplex. Lysosomal enzymes analysis shows increased beta-hexosaminidase, beta-glucuronidase, beta-galactosidase, and alpha-fucosidase activities. Cause of lysosomal enzymes findings?

Abnormal targeting into lysosomes

Male newborn has multiple congenital anomalies resulting from failure of migration of neural crest cells during embryonic development. Dies 3 weeks later. Autopsy of organs will show?

Absence of the adrenal medulla

18yo F with 3-day history of pain with urination and urinary frequency and urgency. Mild tenderness over the suprapubic region. Urine culture grows an organism that is lactose fermenting and spot-indole test positive. Resistant to ampicillin but sensitive to ceftriaxone. Mechanism of antimicrobial resistance exhibited?

B-lactamase production

52yo F with no history of major illness. Vitals are normal. Physical is normal. Labs: hemoglobin 10.2, hematocrit 31%, mean corpuscular volume 65, leukocyte count 5900, platelet count 350,000. Dx?

B-thalessemia minor

72yo F with acute myocardial infarction and gets cardiac catheterization. Angiography shows left dominant circulation, 90% narrowing of artery going to diaphragmatic surface and AV node. Stent going to be placed, and catheter must be passed through which vessels to reach narrowed vessel?

Left coronary--> circumflex--> posterior interventricular

25yo primigravid F 25 weeks' gestation uses cocaine one to two times weekly. Vitals normal. Physical: uterus consistent with 25-week gestation. Ultrasound shows no abnormalities. Fetus increased risk of what because of her cocaine use?

Prematurity

31yo F treated for Plasmodium vivax malaria with primaquine and chloroquine to prevent relapses. Which explains why primaquine is used with chloroquine in this patient?

Primaquine kills hypnozoites

27yo M with 3-hour hx of nausea, cramping abdominal pain and diarrhea. Sx started 24 hours after he ate at a wedding reception and other people have similar sx. Culture of stool grows Salmonella enterica. Able to maintain oral hydration. Sx resolve after 36 hours but persist in milder form for several days. Which occurs if pt is treated with antibiotics?

Prolonged fecal excretion of the organism

3-year-old man has a 3-month history of mildly depressed mood, decreased energy, and dry skin. His thyroid gland is not palpably enlarged. Thyroxine (T4) and thyroid-stimulating hormone concentrations are decreased. Diagnosis?

Secondary hypothyroidism

Renal failure after hospitalization

See dirty brown casts

51yo F gets dilation and curettage for dysfunctional uterine bleeding. During anesthesia, she gets isoflurane and another compound. T 105 F and muscle rigidity is present. Which compound caused adverse effect?

Succinylcholine

71yo F with 30-year hx of type 2 diabetes treated with insulin. She has BMI 23. Her bp is 116/78. The patient most likely has endogenous fasting serum insulin concentration (N=5-20 uU/mL) closest to which?

1 uU/mL Beta-cells have atrophied

20yo F with menstrual period 1 week late. Menses were normal and had unprotected sex 20 days ago. Urine pregnancy test positive. Stage of development of embyro now?

The neural plate is present, but the neural tube is not yet complete

Muscles of mastication

1st pharyngeal arch

45yo M with chronic renal failure admitted. Unable to convert which to its active form?

25-hydroxycholecalciferol

Muscles of facial expression

2nd pharyngeal arch

Male newborn is delivered at term with a right-sided aortic arch. Physical shows full cheeks, low-set ears, and a small chin. Decreased calcium concentration. Site of the malformations?

3rd and 4th brachial pouches DiGeorge

Muscles to swallow and speak

4-6 pharyngeal arches

Where does erythromycin bind?

50s subunit

A paper says, "We chose the sample size to have an 80% power of detecting a 15% mean difference with a significant level (two-sided) of 5%." If there is really no difference between the groups overall, what is the chance the study will find a statistically significant difference, and what is this error called?

5%; type I error

45 yo M has a 2-day history of severe abdominal pain. Patient admits to consuming large amounts of alcohol over the past few days. Serum amylase activity of 700, lipase of 850, and serum calcium concentration of 7. Appropriate therapy is initiated; however, the patient dies after 48 hours. Photomicrograph shows the mesenteric fat as seen at autopsy. Which explains the appearance of the fat?

Action of pancreatic enzymes on adipose tissue

Drug that has no effect on nitocitic R's?

Bethanechol

26yo F with flank pain, palpitations, sweating and recurrent headaches past 2 weeks. BP is 180/95. Urine shows increased concentrations of metanephrine. CT abdomen shows retroperitoneal mass. Where is the mass?

Adrenal medulla

67yo M with 2-day hx double vision and drooping of left eyelid. He has no trauma to that eye. Vitals normal. Physical shows ptosis of left eyelid, eye fixed in the out position and pupil is dilated. Cause?

Aneurysm of Pcomm

21yo M with self-inflicted laceration to his right arm after he was arrested for trying to rob a convenience store. He has hx of arrests for substance abuse, robbery and assault. Was in juvenile detention center as teen. Threatened mother with knife. Fired from jobs for not complying with employer's policies. Said that jobs were beneath his ability. Personality disorder?

Antisocial

After both cell types are treated with transforming growth factor-beta, the number of normal cells decreases, whereas the number of tumor cells remains unchanged. The tumor cells most likely express a mutation that inhibits which?

Apoptosis

2yo girl brought in 20 minutes after ingesting insecticide. She is in moderate respiratory distress. Respirations are 18/min and shallow. Pulse oximetry on room air shows oxygen saturation of 82%. Physical shows copious oral secretions. In addition to securing airway, best next step is giving which medication?

Atropine

48yo F 2-month hx pain and stiffness in hands, elbows, knees, hips when she gets out of bed in morning. Physical shows multiple swollen, tender joints. Presence of which would best support dx of rheumatoid arthritis?

Autoantibody IgM reactive with IgG

4yo boy with respiratory tract colonization with pseudomonas. Sweat chloride is 120 (N<60). Mode of inheritance?

Autosomal recessive

15-year-old boy with right wrist pain that began when he landed on his hands after falling backward while skateboarding 4 hours ago. No bone deformities of the wrist. Point tenderness to palpation of the radial aspect of the wrist between the abductor pollicis longus and extensor pollicis brevis tendons. Increased risk for which sequelae?

Avascular necrosis of the proximal aspect of the scaphoid bone

69yo M with benign prostatic hyperplasia develops urinary retension 1 day after undergoing removal of a melanoma. After cath, drug is given that increases phophoionositide turnover in the smooth muscle cells of the bladder fundus but has no effect on nicotinic synapses. Which drug?

Bethanechol

4 yo boy with asthma, 4-hour history of difficulty breathing. No improvement with inhaled beta-adrenergic agonist. Exam shows tachypnea and intercostal and subcostal retractions. Expiratory wheezing is heard bilaterally. Following IV methylprednosolone, there is marked clinical improvement. Which molecular pathways of methylprednisolone best explains this improvement?

Binds to its cytoplasmic R, translocation to the nucleus, and activation of transcription of target genes

53yo M with fever and hypotension treated at hospital for crush injury to right lower extremity. Leg infected. During surgical debridement, myonecrosis found. Gram stain shows large gram positive rods with few neutrophils. Organism?

C. perfringens

Which endogenous chemoattractants primarily caused recruitment of leukocytes to site of acute inflammation?

C5a

21-year-old-woman at 30 weeks' gestation is admitted to the hospital because of contractions for 1 hour. Fetal ultrasonography shows that the ductus arteriosus has closed. Inhibition of which enzymes is the cause of this finding?

COX

Hormones that use GPCRs

Cacitonin GnRH TRH Oxytocin Somatostatin TSH, ACTH, FSH, LH

60yo F develops a secreting adenoma of the parathyroid gland. Which is increased?

Calcium loss in the feces

Blunting of microvilli is seen in?

Celiac's

37yo F found unconscious. Temp 36 C (96.8 F), pulse 128, bp 70/40. Physical shows cool, pale extremities, JVD, faint peripheral pulses, crackles bottom 2/3 of lung fields. Heart sounds normal with no murmurs. Withdraws to painful stimuli. Which type of shock?

Cardiogenic shock

7-month-old girl with HR 110, RR 22, BP 95/50. Cardiac exam shows 3/6 systolic murmur best heard at interscapular region. Femoral pulses are decreased bilaterally. Dx?

CofA

Study began in 1950s to research causes of lung cancer. 40,000 physicians asked if they smoked cigarettes. The frequency of lung cancer was then assessed 10 years later, and the group of smokers and nonsmokers were compared. Study design?

Cohort

32 yo F with a 6-month history of increased urinary frequency, especially at night, and increased thirst. She tells the physician that she is always thirsty despite frequent water intake. Has bipolar disorder treated with lithium carbonate. Physical normal. Serum sodium concentration is 154 meq/L, and urine osmolality is 180 mosm/kg. Abnormal function of which is the most likely explanation?

Collecting duct

43yo F with 6-month hx of altered consciousness. During hx, she stops talking mid-sentence turns her head to right, and extends and stiffens right upper extremity. Has blank look and doesn't respond to questions. Then has repetitive lip smacking and picking movements of hands. 30 seconds long. Returns to normal state in 4 to 5 minutes. Type of seizure?

Complex partial

18yo M with 1-year hx of progressive headaches. Xray of head shows cystic tumor above the sella turcica. Serum concentration of which hormone is increased?

Craniopharyngoma Prolactin

4yo boy with 2-month progressive weakness and loss of muscle function. Difficulty running, climbing stairs, rising from sitting position. Hypertrophy of calf muscles on physical. Markedly increased creatine kinase activity. Cause of defective or absent protein in which areas of muscle?

Cytoskeleton

32yo M 3-month hx episodic epigastric cramping that awakens him at night and is relieved by eating. Smoker 1 pack per day and 3 cups of coffee daily. Serological testing shows helicobacter pylori for which he gets antibiotics. Which lifestyle change will decrease recurrence of symptoms?

Decrease smoking

22 yo M with an 8-year history of epsidoes of yellow-tinged eyes. He is a medical student, and says that he has noticed that the symptom occurs during studying for final exams and other periods of stress. No pain. Serum show: Bilirubin, total: 3.2; Bilirubin direct 0.4; Alkaline phosphatase 35, AST 16, ALT 15. Which explains signs?

Decreased conjugation of BR

72yo M with hypertension with severe abdominal pain for 2 hours. Pale and lethargic. P 124/min rr 16, BP 95/60. S4. Abdominal guarding, rigidity, and a pulsatile periumbilical mass. Additional findings?

Decreased femoral pulses Ruptured abdominal aortic aneurysm

43yo M with 10-year history alcoholism comes for changes in skin color. Patient taking acetaminophen for 3 days for severe headache. Physical: jaundice. Labs show increased prothrombin time and increased serum AST activity. Alternation in which metabolite in hepatocytes is a/w his illness?

Decreased glutathione

45yo M follow-up after treatment with hydrochlorothiazide for hypertension. Feels faint, light-headed, and dizze when he gets out of bed. P 75/min, rr 12/min, BP 130/85 supine. Changes in the cardiovascular system when going supine to standing?

Decreased venous tone Decreased carotid sinus baroR activity Decreased cerebral blood flow

22yo M in ED 30 minutes after he was hit by an automobile while crossing the street. Struck him on the lateral side of his leg. Unable to dorsiflex the left foot. Inversion and eversion are normal. Which nerve is damaged?

Deep fibular (peroneal)

48yo M with 1-hour history of nausea and chest pain radiates to left arm. ECG and cardiac enzyme confirm myocardial infarction of anterior wall. 14 hours after he is in cardiac arrest. Resuscitation efforts are successful after 30 minutes. Immediately develops severe oliguria. Studies show increased urea nitrogen and creatinine. Patient's urine microscopically shows?

Degenerating epithelial cells and dirty brown casts

Which best explains why deoxygenated blood can carry more carbon dioxide for a given Pco2 than oxygenated blood?

Deoxyhemoglobin is a better buffer of H+ ions than oxyhemoglobin

45yo M with ulcer in anterior superior portion of fundus of stomach comes with acute pain in left upper quadrant and left shoulder for 4 hours. Physical shows rigid abdomen. Perforation of ulcer suspected. Irritation of which explains the left shoulder pain?

Diaphragm

27yo F with 1mo hx of shortness of breath with exertion and swelling of her legs. P 90/min, rr 22/min, BP 120/80. S3, and a displaced apical pulse. Chest x-ray shows marked cardiomegaly and Kerley B lines. Echocardiography shows ejection fraction of 29%. Dx?

Dilated CM

19-year-old F for a follow-up examination. Has scarring acne vulgaris not been responsive to topical medication. A bacteriostatic drug that acts by inhibiting the binding of aminoacyl-tRNA to the 30S subunit of bacterial ribosomes is prescribed. This drug is which?

Doxycycline

30yo W seasonal rhinitis on chlorpheniramine for 4 weeks. Adverse effect most likely?

Drowsiness

EF equation

EDV-ESV/EDV

Newborn undergoes surgical repair of esophageal atresia. Pathological exam shows esophagus that's fibrotic and has no lumen. Which of the following embryonic germ layers is the origin of the cells that fill the lumen?

Endoderm

50yo F with progressive shortness of breath during past 2 years. RR 20/min. Physical shows cyanosis and ankle edema. Pulmonary artery pressure, pulmonary vascular resistance, and right atrial pressure all increased; pulmonary capillary wedge pressure 9.3 (N=8-16). Ventilation improves with nitric oxide administration. Treatment with bosentan. Drug antagonizes which mediator of pulmonary resistance?

Endothelin

5-year-old boy 15 minutes after developing hives and shortness of breath and then collapsing. He had been eating peanuts 4 minutes before the onset of symptoms. On arrival, his pulse is 220/min, rr 10/min, and palpable BP is 40. After establishing a patent airway, the most appropriate next step is administration of which?

Epi

Patient's oligomenorrhea is due to increased production of which hormone?

Estrogen in the adipose tissue

Strongest predisposing risk factor for sarcoidosis

Ethnicity

4yo boy with a karytotype of 47,XY+21 develops pancytopenia, lethargy, numerous bruises, pallor, and fever. Subsequent examination of bone marrow will show?

Excess lymphoblasts

3yo girl with abdominal pain, constipation, and irritability for 1 month. Lives in 50-year-old house being renovated. Pallor, normocytic, hypochromic anemia and increased 5-aminolevulinic acid (d-ALA). Lead concentration is 50. Decreased activity of which enzyme?

Ferrochetalase Lead poisoning

3yo girl 1-month hx of lump on upper neck. Physical shows 2-cm mass midline. Mass moves upward with swallowing and protrusion of tongue. Radionucleotide imaging with technetium 99m pertechnetate shows uptake in mass. Biopsy of mass shows?

Follicular cells (thyroglossal cyst)

22yo college student with 1-year history of anxiety, irritability, and difficulty sleeping. Feels keyed up and on edge all the time. Worries about school, relationship with her boyfriend. Drinks two cups of coffee each morning and drinks alcohol occasionally. Does not smoke. P 84/min, rr 12/min, BP 110/80. TSH 3, T4 6, cbc wnl. Dx?

GAD

6-year-old girl develops edema, hypertension, hematuria, and proteinuria 2 weeks after an episode of pharyngitis. Diagnosis of acute glomerulonephritis is made. Throat cultures grow catalase-negative, gram-positive cocci. Causal organism?

GAS

Hormones that use tyrosine kinases

GH, IGF-1, PRL

Hormones that use JAK-STAT pathway

GH, PRL, leptin

5yo boy stung by bee. 30 minutes there is local edematous area. Extravascular accumulation of fluid is directly related to which?

Gap formation between endothelial cells

A couple has two children with osteogenesis imperfecta type II (OI). Genetic analysis of the father shows that 1 in 10 of his sperm carry mutations of the type 1 procollagen genes associates with OI. Explanation?

Germline mosaicism

How to diagnose surreptitious insulin use?

Get c-peptide level Will see decreased c-peptide level

Serum studies show a glucose concentration of 330, 2+ ketones, and a pH of 7.2. Following intravenous fluids and insulin, there is marked improvement. Activity of which enzymes has most likely increased in this patient's hepatocytes?

Glucokinase

51yo M with a 5-year history of Wegener granulomatosis. Has general malaise, fatigue, myalgia, and arthralgia. Which additional findings is most likely to indicate exacerbation?

Hematuria

6yo girl has been receiving treatment with potassium citrate monohydrate since dx with renal tubular acidosis at age 2yo. Physical exam is within normal limits. Na 142, K 3.5, Cl 115, HCO3 18, BUN 9, Creatinine 0.9. A defect in renal ammoniagenesis suspected. Which substrate is source of ammonia production?

Glutamine (acts as NH3 donor)

2-month old M infant with 2-day hx of generalized tonic-clonic seizures, myoclonus and hiccuping. Fed poorly and floppy. Physical shows decreased deep tendon reflexes and hypotonia. A signally defect in an inhibitory neurotransmitter suspected. Which neurotransmitter?

Glycine

45yo F with pneumococcal pneumonia and bacteremia. Intubated and mechanically ventilated. Temp 39.4 C (102.9 F), pulse 120, bp 90/50. Bilateral crackles heard. Labs: Hemoglobin 13, hct 40%, leukocyte count 500, platelet 250,000. Which protein is necessary for leukocyte count to increase?

Granulocyte colony-stimulating factor

56yo F has a 3-week hx of progressive difficulty swallowing. Felt large pieces of food wouldn't pass, but now having difficulty with all food and some liquids. pHysical is normal. X-ray after barium swallow shows irregular mass at gastroesophageal junction. Photo shown of biopsy of specimen from esophagogastroduodenoscopy. Chronic infection with which pathogen caused histo findings?

H. pylori

6yo boy with 3-month hx of pubic and axillary hair growth. Tanner stage 2. Mild enlargement of the testes. If left untreated, which of the following combinations is course of growth in this patient?

Height percentile one year from now: 75% Height percentile as an adult: 25%

23yo F brought by her roommate abecause she was found unresponsive on the living room floor. Constricted pupils and stupor. Substance responsible?

Heroin

43yo F 40 minutes after a transient hypoxic-ischemic event caused by ventricular fibrillation. Stabilized after using an automated external defibrillator. 2 days later she is unable to remember new events in her life. No other neuro issues. Which part of brain was injured?

Hippocampus

18yo is a defensive end on football team and wrestler. Patient is embarrassed because of enlarged breasts. He is muscular with no obesity. BMI 29. Sexual development is Tanner stage 5. Physical shows 2-cm soft mounds of breast tissue under areola. Best next step?

History of anabolic steroid use

7yo boy with chronic renal insufficiency undergoes unilateral nephrectomy. Kidney is shown--> largely dilated

Hydronephrosis

70yo F found dead in her bed in a skilled nursing care facility. Had a 12-year history of poorly controlled hypertension. Photograph of her heart at autopsy shown; it weighs 650 g. Which describes the changes?

Hypertrophy

If pregnancy were to proceed, what is the mechanism would most likely increase the amount of aortic regurgitation in this patient?

Hypervolemia--> increase preload

An investigator wishes to test the hypothesis that a number of CD44 splice variants correlate with aggressive disease progression and risk of relapse in patients with Hodgkin disease, especially if the variant protein CD44v10 is expressed. The investigator plans to retrospectively screen archives of fresh frozen tissue and paraffin-embedded biopsy specimens from documented Hodgkin disease patients. Assuming the necessary reagents are available, which of the following methods would be the most effective in screening the archives for the variant protein?

IHC

Deficiency of what predisposes a patient to disseminated Mycobacterial infections?

INF-gamma--> decreased TH1 response

Patient with SOB, fatigue, and cough. Leukocytosis with left shift. High platelet count. Pharmacotherapy?

Imatinib for CML

45yo F (lll,7). Several people in her family, including her son (lV,3), have hereditary telangiectasia. Pedigree shown. Physical exam normal. Which explains the reason for this patient's health?

Incomplete Penetrance

18yo F 2-hours after she ingested approximately 100 aspirin tablets in a suicide attempt. Physical shows tachypnea. Two days after admission, her hemoglobin concentration is 12. Test of the stool for occult blood is positive. Which additional hematologic findings is most likely abnormal?

Increased bleeding time

A study is conducted of patients with restrictive airway disease who have BMIs above normal. Significant correlation (r = -0.25) between body fat and lung capacity. Most accurate conclusion?

Increased body fat is associated with lower lung capacity

48-year-old woman with palpitations. P 180/min BP 104/68. ECG shows atrioventricular (AV) nodal re-entrant tachycardia. Carotid sinus massage is performed and sinus rhythm is restored. Which of the following is the most likely mechanism of the termination of the tachycardia in this patient?

Increased cardiac parasympathetic activity

64yo M with 2-month history of progressive shortness of breath with minimal activity. Temp 37 C (98.6 F), RR 30, BP 125/80. Physical shows clubbing of fingers. Total lung capacity is decreased. Chest Xray: coarse reticular pattern. Underlying cause of findings?

Increased fibrosis in interstitum

47yo M with myocardial infarction. Pulse oximetry on 30% oxygen shows saturation greater than 95%. Three hours later patient gets shortness of breath. Pulse oximetry shows oxygen saturation of 90%. Crackles heard at lung bases with grade 2/6 systolic murmur. ABG on 30% O2: pH 7.41, pCO2 36, pO2 60. What is the cause of patient's hypoxemia?

Increased pulmonary capillary pressure

3 year-old boy with chronic otitis media is scheduled to undergo bilateral myringotomies with placement of polyethylene tubes under general anesthesia. Asleep after only three to five breaths. Which properties of the anesthetic is the most likely explanation for the rapid onset of action?

Low blood solubility

66yo F with ovarian cancer in ED for inability to urinate for 2 days and bilateral flank pain for 8 hours. Has not had suprapubic pain. Bilateral costovertebral angle tenderness. Insertion of a Foley catheter yields no urine. Renal ultrasonography shows bilateral hydronephrosis. Which is present?

Increased tubular hydrostatic pressure

20yo cyclist taking recombinant human erythropoietin has polycythemia. Cause?

Increases erythroid precursors

19yo F with painful swelling of the external genitalia for 5 days. Not sexually active. Palpable, tender 3-cm mass in the posterior aspect of the labium majus. Blood and urine cultures are negative. Case?

Infection of the Bartholin gland

Diffuse wheezing is heard on auscultation of the chest. Abdominal examination shows mild hepatomegaly. Pulmonary function tests show a decreased FEV1 and decreased diffusing capacity. A chest x-ray shows hyperinflation consistent with air trapping mostly in the lung bases. A CT scan of the chest is shown. Which of the following is the most likely cause of these findings?

Inherited protease def

MOA for antidote of ethylene glycol poisoning

Inhibits alcohol DH, blocking the conversion of methanol to formaldehyde

Vision screening is performed on 4000 people who are older than 65 years. Cataracts are found in 200. Which best describes the annual incidence of cataracts in this population?

Insufficient data

32yo F comes for follow-up for atypical cells on Pap smear. Physical shows 1X1-cm leukoplakia on cervix. Biopsy shows invasive squamous cell carcinoma. Malignant cell from site will drain to which lymph nodes first?

Internal iliac

18mo boy with severe combined immunodeficiency syndrome requires a blood transfusion for severe anemia. Which blood product is most appropriate?

Irradiated packed RBCs

Km=

Km= [substrate] at 1/2 Vmax

Loading dose caculation

LD= Vd x weigh x peak serum concentration / F For IV: F= 100%

36-year-old man who is heterozygous for an LDL-receptor deficiency has a total serum cholesterol concentration of 330 mg/dL. After taking a drug that inhibits cholesterol synthesis, total serum cholesterol concentration decreases to 200. Which proteins would be upregulated as a result of drug therapy?

LDL R

56yo F with fever and shortness of breath for 2 hours. She has had urinary frequency and dysuria for 2 days. In respiratory distress, T 101.7 F, HR 120, RR 30, bp 80/50. Which causes hypotension?

LPS

2mo male with a ventricular septal defect with poor weight gain and a 5-day hx of rapid breathing and difficulty feeding. CHF, and an operation to place a synthetic patch across the septal defect planned. Compared to prior to operation, which heart pressures are most likely 1 month after a successful operation?

LV pressure: increased RV pressure: decreased LA pressure: decreased

Study to evaluate effectiveness of cough medication in children. 120 patients under 12 years with URI receive dextromethorphan or no treatment. Parents rate children. Significant improvement in cough scores for patients receiving dextromethorphan. Limitation to internal validity?

Lack of blinding--> parents know if they are or are not getting the medication

75yo F with 3-month hx of enlarging lesion on her face. Physical shows 1.5-cm, brown-black, mottled, scaly lesion with irregular borders. Microscopic exam of biopsy shows atypical melanocytes along basilar layer of epidermis. Cause?

Lentigo maligna

75yo M with cerebral infarction. Dies 1 week later. Exam of brain shows which type of necrosis?

Liquefactive

23yo primigravid woman develops fever and chills 2 days after eating unpaseurized cheese. A gram-positive, coccobacillary bacterium is isolated from her blood. Organism?

Listeria

Newborn at 28 weeks' gestation in severe respiratory distress. Immature alveoli have a diminished ability to serve as sites of effective gas exchange. Increase in which explains this?

Lung elastic recoil

Eyes converge normally, but decreased adduction in both eyes during lateral conjugate gaze. Where is demyelinating plaque that's causing the diplopia?

MLF

45yo M has not been to physician in 30 years because he hasn't felt ill. Cardiac exam shows grade 2/6, holosystolic murmur best heard at left axillary line. Which is cause of findings?

MR

62yo M with productive cough, night sweats, and T to 37.8 during the past 2 weeks. PPD skin test is positive, but culture of the sputum shows only normal flora after 2 days. Biopsy of enlarged lymph node is done. Organisms are most likely present in which cells?

Macrophages

54 M with increasing abdominal pain for the past 2 months and a 9-kg weight loss over the past 3 months. He is jaundiced. CT scan of abdomen shows a mass in the head of the pancreas with considerable extension to the stomach and biliary system. Greatest risk for developing which?

Major depressive disorder

Unable to ABduct left thumb. Sensation decreased over palmar aspect of thumb and index and middle fingers. Injured nerve?

Median

50yo M with firm thyroid nodule. Neoplasm is resected and histology shows sheets of granular cells embedded in hyaline stroma. Stain shows cytoplasmic calcitonin. Carcinoma type?

Medullary

65yo M with hypertension volunteers for new loop diuretic therapy trial. Acid-base/volume status monitored. After 3 days of tx, which sets of findings is likely?

Metabolic alkalosis and volume contraction

During an experiment of muscle contraction, intracellular calcium is decreased after a substance is administered to a muscle preparation obtained from an experiment animal. Which best explains why contraction is inhibited in this case?

Myosin binding sites on actin remain covered by troponin C

The lymphoproliferative properties of the gammaherpesviruses result in malignant transformation of cells. Epstein-Barr virus is associated with which disease?

Nasopharyngeal carcinoma Burkitt's lymphoma

5yo F with palpitations and insomnia for 5 months; she also had 5-kg weight loss. P 125/min. Exopthalmos, thyromegaly, and hand tremors. Thyroid-stimulating hormone concentration less than 0.1, thyroxine (T4) 18, triiodothyronine (T3) 250. Symptoms cause by hormones acting on which receptors?

Nuclear/retinoid X binding to DNA

35yo G1P1, 2-month history of generalized weakness and fatigability exacerbated by exercise. Sx began during pregnancy. Physical shows diplopia. Reduction in muscle strength with repetitive movement, but preservation of deep tendon reflexes. Pyridostigmine provides relief. Antibodies to which protein?

Nicotinic Ach R

52yo M 3 days after sudden onset of blindness of the left eye. No eye pain. Funduscopy shows a pale, opaque fundus and a bright red fovea centralis. Visual field shows dense scotoma of the entire visual field of the left eye; right eye normal. 6 months later, patient remains blind in the left eye. If left eye is illuminated, which reaction in the right pupil?

No constriction because the retinal ganglion cells of the left eye have been destroyed

8yo boy for a well-child examination. His sister died of leukemia 4 months ago. Parents state thta he is sad at times, but he has had only minor performance difficulty at school since his sister died. Patient talks about his sister's death and cries. He then says he has a headache. Which best describes patient's condition?

Normal emotional response

1mo male newborn for well-child examination. Uncomplicated pregnancy. Pale skin, fine white hair on the scalp, and blue eyes. Biopsy specimen of the skin will show which findings?

Normal melanocytes Decreased melanin

40yo F with breast cancer with 1-week history of progressive loss of peripheral vision to the left in both eyes. Unable to count fingers or detect finger movements on the left. MRI will show a metastatic tumor in which locations?

Occipital lobe--> Left hemianopia with macular sparing

23-year-old F with 3-day hx of a drooping right eyelid. Also has a 2-week history of visual discomfort when in a room with bright lights. On examination, the right pupil is larger than the left, it also seems like the right eye is looking somewhat down and to the right. These suggest dysfunction to which structures?

Oculomotor nerve (CN III)

38yo M with progressive heartburn for 6 months. Liquid antacids, at least twice daily, no longer relieve the pain. Modified his diet, decreased his coffee and citrus intake, and has raised the head of his bead. Upper endoscopy shows marked erythema of the distal 6 cm of the esophagus. Three linear erosions are noted. Biopsy show marked inflammation of squamous epithelium. Pharmacotherapy?

Omeprazole Ulcers not caused by increased GA

6yo F with vaginal irritation and discharge for 5 days. Sexually active with same partner for 6 months. Uses a diaphragm for contraception and partner sometimes uses condom. Frothy, yellow-green discharge in vagina. Vaginal wall is markedly erythematous and two red macular lesions on cervix. pH is 4. No foul or fishy odor. Micro exam shows motile organisms with flagella. Tx?

Oral metronidazole

65yo F follow-up after DEXA scan showed a decrease in bone density. Physical normal. Which sets of findings in the bone most likely?

Osteoblasts: decreased Osteoclasts: increased RANKL: increased

72yo F with diffuse muscle pain and weakness for 6 months. Exacerbated by activity. Proximal muscle weakness and tenderness over the surface of both shins. PTH is high, Ca2+ is low.

Osteomalacia (vitamin D def is causing lack of Ca2+)

One-half hour after an uncomplicated vaginal delivery, a 30-year-old woman delivers the placenta but has continued heavy blood loss from the vagina. Pulse 120/min, BP 90/60. No cervical or perineal lacerations. Uterus is soft, and contractions have stopped. Medical treatment with which is likely to be most helpful?

Oxytocin

30yo M 1-day hx irrational behavior and severe abdominal pain. 3 days ago started tx for UTI with trimethoprim-sulfamethoxazole. Urine light burgundy color during similar time 1 yr ago. Mother and maternal grandfather have sx. Anxious and restless, pulse 96. Physical shows diaphoresis. Serum shows increased 5-aminolevulinic acid (gamma-ALA) and porphobilinogen. Decreased activity which enzyme?

PBG deaminase

28 year-old woman has hirsutism and irregular menstrual periods. Which is the most likely underlying abnormality?

PCOS

70yo M 4-month history of weight loss, abdominal pain, and diarrhea. Stool shows increased excretion of neutral fat and muscle fiber. D-xylose test for carbs shows no abnormalities. Tissue exam of intestinal biopsy is normal. Patient will respond favorably to which agent?

Pancreatic enzymes

55yo M with 2-month hx of increasing difficulty swallowing and regurgitation of undigested food. Also has noticed unusual rumbling sounds in his voice that originate in his neck. Physical: halitosis. Videofluoroscopic swallowing study shows 4-cm, posterior midline pouch protruding between the thyropharyngeus and cricopharyngeus portions of the inferior pharyngeal constrictor muscle. These muscles are innervated by which nerves?

Parasympathetic fibers from the vagus nerve

8yo boywith moderate mental retardation. Parents say son has recently become more stubborn and has begun to have temper tantrums. Episodes involve fighting about food. Parents concerned he will hurt himself because he picks his skin and pulls his hair when he is frustrated. Father says " He spends his day looking for more things to eat." 10th percentile for height and 90th percentile for weight. Diagnosis?

Prader-Wili

25yo primigravid at 12 weeks' gestation 1 hour after passing small amount tissue vaginally. Gross tissue exam shows fetus. D&C shows chorionic villi with focal edema and trophoblastic proliferation. Dx

Partial hydatidiform mole

2-month-old boy with hypotonia and poor feeding since birth. Physical shows large fontanels, midface hypoplasia, hepatomegaly and cryptorchidism. Serum show increased very-long-chain fatty acids, phytanic acid, and pipecolic acid. If hepatocytes were analyzed, which organelle absence?

Peroxisomes

22 basketball player who uses cocaine recreationally suddenly develops severe shortness of breath after a routine scrimmage. Respirations of 25/min. Left lung field is hyperresonant and breath sounds are diminished. Dx?

Pnemothorax

Four days after a hike in forest, 40yo M develops multiple intensely pruritic areas on skin (photograph). The involved skin was not covered by clothing. 1% hydrocortisone obtains relief. Lesions subside in 1 to 2 weeks. Findings consistent with which condition?

Poison ivy Type IV hypersenitivity

34 year-old woman who is a scientist brought to ED after being exposed to aerosolized 123-I while synthesizing a radiolabeled compound. Reports no symptoms other than anxiety. No allergies. Most appropriate initial treatment is?

Potassium iodide

Investigator conducts study of von Hippel-Lindau (VHL) disease. The protein forms part of the ubiquitin-ligase complex (E3) that targets hypoxia-inducible factor-1. Diagram shown. Step IV involves which organelle?

Proteasome

22yo F HIV positive after sexual contact. Combination therapy with lamivudine (3TC), ritonavir/lopinavir, and zidovudine (AZT) started. Three months later, HIV strain resistant to ritonavir/lopinavir. Resistance came from mutation in a gene critical for which viral processes?

Protein processing

72yo M with 3-month history of progressive burning chest discomfort after meals. X-ray of the chest and abdomen show a paraesophageal hernia. Barium swallow shown. Findings present?

Protrusion of the fundus into the chest above the level of T10

1yo boy with 4-week hx of progressive generalized tonic-clonic seizures and a strange odor in urine. Hx of delayed development. Physical shows fair skin and blond hair. Phenylalanine hydroxylase is homozygous for point mutation in intron 12 of affected gene causes skipping of exon 12. Reason for exon skipping in this patient's affected gene?

RNA spice error

60yo M generalized weakness for 6 hours. Onset occurred 2 hours after taking 4 (rather than one) of a medication that prevents angina pectoris. HR 36, bp 100/50. After isoproterenol, HR increases to 60. Mechanism of patient's usual chronic medication?

Reversible; dose-dependent

32yo man has no hobbies. He works as a computer programmer because he can live at home with 15 cats. He says, "I like to be with my cats because they are my best friends. I don't have to waste any time talking to anyone." Supervisor says, "We could use him on some team projects, but he refuses." Dx?

Schizoid personality disorder

Which of the following best describes the role of IκB in the nuclear factor-kappa B (NF-κB) signal transduction pathway from IL-1 binding to IL-6 induction in this patient?

Releases NF-kB after undergoing phosphorylation NF-KB then translocates to the nucleus where it binds to DNA response elements to alter transcription

Previously healthy 35-year-old woman develops hypoxemia 35 minutes after ingesting a near-lethal dose of barbiturates. Has not aspirated. Which sets of arterial blood gas values is most likely in this patient?

Respiratory acidosis pH: low PO2: low PCo2: high A-a gradient: normal

50yo M with progressive left-sided vision loss during past 6 months. On visual field testing, patient cannot see to the left with either eye. Lesion is where?

Right optic tract

24yo M with recurrent vesicular lesion on left upper lip. Causal virus maintains latency in which cell?

Sensory neurons

30yo F with 6-month history of intermittent cutaneous flushing and diarrhea. X-ray of the chest shows a solitary pulmonary nodule in the left lower lobe. Increased synthesis of which caused symptoms?

Serotonin

55yo F comes for routine exam. Last menstrual period 8 years ago. No medications and physical is normal. Serum lipid studies ordered to screen for cardiovascular disease. Compared with 25yo F, which is likely to be decreased in patient?

Serum HDL concentration

Sequencing of the gene encoding the protein from the original and subsequent isolates is done It is found that subsequent isolates have nine consecutive cytidine residues, whereas the original isolate has eight.

Slipped-strand mispairing

72yo M with COPD with progressive shortness of breath during the past 3 months. Smoked 1.5 packs of cigarettes daily. BMI 34. P 80min, rr 22, BP 130/80. Pulse oximetry on room air shows oxygen saturation of 94%. Rhonchi heard. Breath sounds decreased bilaterally. Which intervention to slow the rate of decline in pulmonary function?

Smoking cessation

50yo M with 2-week hx of progressive shortness of breath while climbing stairs. Father had major myocardial infarction at 52y. HR 110 and regular, RR 16, bp 135/95. Lungs clear. Heart sounds normal with physiologic split S2. Stress echocardiography shows hypokinesis of posterior left ventricle with increasing activity levels. Cause?

Stenosis of RCA

Hormones with nuclear R's

Steroid hormones Thyroid hormones Vitamin D3

An investigator is designing a study to compare a new behavioral program for attention-deficit/hyperactivity disorder (ADHD) with the standard behavioral modification program for this disorder. Because ADHD is more common among boys, girls and boys are randomized into the two treatment groups separately. Which treatment allocation used?

Stratification

25yo F with hx of rheumatic fever and mitral valve dysfunction has 2-week hx of fever and fatigue. Had a root canal 1 month ago, before which she took single dose amoxicillin. Temp 38.4 C (101.2 F). 4/6 blowing murmur heard at left axilla. Gram stain from blood culture shown. Blood agar plates shows alpha hemolysis. Organism?

Strep mitis

Cause of sepsis with staph. Mechanism of causal organism?

Superantigen activation of T lymphocytes

55yo F with 3-day history of persistent right shoulder pain. Began weight-training program 6 weeks ago. Point tenderness lateral to acromion, over the humeral head. Pain with resisted abduction of the shoulder when the shoulder is abducted 90 degrees and the arm is giving the "thumbs down" sign. Tendon injured?

Supraspinatus

13yo boy is going to get chemotherapy for leukemia with histological findings of malignant lymphocytes. The neoplastic cells do not express: CD4, CD8, surface IgM, surface IgG, cytoplasmic IgM and u-heavy chain, cytoplasmic IgG, and gamma-heavy chain. The cells express class I MHC and show rearrangement of the T-lymphocyte receptor beta-chain gene D and J segments. What is the normal counterpart of these lymphocytes?

T-lymphocytes thymocytes localized to the thymic cortex (undergoing positive selection--> CD4+ and CD8+)

17yo boy with 4-month history of low back pain and night sweats. 4-kg weight loss. Immigrated to USA from southern India 9 months ago. BMI 18. Tenderness over the L1 spinous process. Dx?

TB abscess of the spine

54yo F with 2-week history of heavy vaginal bleeding. Menopause 5 years ago. Mastectomy 3 years ago for estrogen receptor-positive breast carcinoma with axillary lymph node involvement. Taking tamoxifen for 3 years. Biopsy of endometrial tissue shows hyperplasia. Explanation?

Tamoxifen has an agonist effect on endometrial estrogen R's

71yo F with sudden onset double vision. 4-day hx of progressive fever, fatigue, headache, left-sided facial pain, periodic episodes of blurred vision. T 101 F. Physical shows swelling and tenderness of left side of face. Labs show mild normochromic anemia and ESR 60. Dx?

Temporal arteritis

30yo F with Hodgkin disease dx 10 years ago and treated with radiation and chemo for 6-month period. Remained in remission for 10 years. Now feels weak and has petechiae and ecchymoses. Dx with acute myelogenous leukemia. Course of events?

Therapy for Hodgkin disease causes mutations in hematopoietic stem cells, and one mutant cell progresses to leukemia

25yo F with general malaise and a facial rash for 1 week. 10-year history of episodes of pleurisy and arthritic pain in peripheral joints. Malar rash that does not involve the nasolabial folds. Cardiolipin antibody, anti-dsDNA, and anti-Sm antibody assays are positive. Which hematologic abnormalities is most likely?

Thrombocytopenia

13yo girl with 5-month history of behavioral problems. Mother states that daughter alternates from being sad and socially withdrawn to being extremely angry and aggressive. Diagnosis of bipolar disorder is made. Treatment with valproic acid, which inhibits histone deacetylase, is started. Drug is most likely to affect which?

Transcription

9 yo with mental retardation, seizures, papules on nose, LVH with narrowing of the aortic valvular outflow tract due to a subvalvular mass arising from the septum

Tuberous sclerosis

62-year-old man undergoes cystoscopy for investigation and removal of a suspected renal calculus. During the procedure, a cystoscope is inserted through the penis and into the bladder. Slit-like openings are then visualized near the lateral ends of the top of the trigone region of the bladder Which of the following best describes these structures?

Ureteric orifices

7-year-old boy is brought to the physician because of a 1-day history of fever, headache, nonproductive cough, and muscle aches. T 39.4. Physical shows a mildly erythematous pharynx. Rapid antigen test of nasal secretions is positive for influenza A virus. Treatment with zanamivir is initiated. Which viral activities will be directly inhibited?

Viron release

82yo F with alcohol dependence is admitted to the hospital after sustaining multiple injuries in a fall. Has a recent history of right hip fracture and multiple old and new ecchymoses, abrasions, and superficial lacerations. 3-cm laceration on her forehead, sutured after a fall 6 weeks ago, has dehisced. Has few teeth, hemorrhagic macules around hair follicles on upper/lower extremities. Cause?

Vit C def--> inadequate hydroxylation of collagen polypeptides

14 boy has had fatigue, intermittent right lower quadrant abdominal pain, diarrhea, and a 5-kg weight loss over the past 6 months. A diagnosis of inflammatory bowel disease limited ot the terminal ileum is made. Absorption of which is impaired?

Vitamin B12 def

Food handler has a fresh furuncle on his face. Prepares meat loaf and lets it sit for 12 hours at room temperature before it is cooked at 350 F for 1 hour. Eight of the 10 people who eat the meat become ill in 4 hours. Symptom most likely?

Vomiting

After a stoke, 68yo M has language problem. Speech is fluent but has many grammatical errors, word substitutions, and neologisms. Unable to repeat words and unable to comprehend verbal requests. Which site labeled in picture of brain is damaged?

Wernicke's area Posterior temporal lobe

Baby born with very low neutrophil count

congenital neutropenia

Pain type in peripheral neuropathy

burning

Which electrophysiologic characteristsics is expected in a muscle biopsy specimen from a patient with acute botulism?

epp Amplitude: decreased mepp amplitude: normal Response to Ach: normal

Micrognathia, glossoptosis, cleft palate, and airway obstruction. Altered development of which pharyngeal arch?

first

Healthy 3yo boy has a cleft lip and palate. No other birth defects. Which modes of inheritance is the best explanation?

multifactorial