Rx Questions
A 5-year-old boy is brought to the physician because of a 1-month history of increased bedwetting. His mother states that he had not wet the bed at night in over 2 years and was toilet trained by the age of 2. She states that a few weeks ago he had a viral illness with a sore throat, cough, and fever, which she believes he may have gotten at his daycare center. He has been eating more than usual, but his pants have become loose. Both parents are healthy and have no history of significant illness. The patient's serum analysis shows sodium of 134 mEq/L, potassium of 5.8 mEq/L, and a fasting blood glucose of 275 mg/dL. Which of the following is the most likely pathophysiology of this patient's condition?
An autoimmune process associated with HLA-DR4 Type I diabetes Also involved with: SLE, Graves disease, Hashimoto thyroiditis, Addison disease
A 32-year-old woman presents to the clinic with sore throat, low-grade fever, fatigue, and malaise for the past month. Other than occasional treatment for bacterial trichomonas vaginosis, she does not have any notable medical history. Her social history is significant for occasional alcohol use, no illicit drug use, and multiple sexual partners. On examination she is found to have generalized lymphadenopathy and the non-tender lesions seen in the image. The patient denies any generalized joint pain. If left untreated, which of the following is a possible sequela of the most likely cause of her symptoms?
Aortic infarction Secondary syphillis
Antibiotics are widely used in clinical practice to fight infection. Antibiotics work in many different ways to inhibit bacterial growth, including blocking cell wall synthesis, disrupting cell membranes, and blocking protein synthesis. Which of the following antibiotics inhibits bacterial 50S peptidyltransferase, an enzyme used in protein synthesis?
Chloramphenicol
A 16-year-old girl in a rural community has swollen, painful lymph nodes in her right axilla. Medical history is significant for untreated HIV infection. Physical examination reveals multiple healed scratches on her right arm with a papule associated with one of the scratch marks. She states that the scratches occurred about 5 weeks ago. What organism is the most likely cause of this patient's infection?
Bartonella henselae Gram-negative bacterium; visualized with Warthin-Starry stain
A young girl is brought to her pediatrician with fever, cough, and fatigue for the past 2 weeks. The coughing episodes are spontaneous and nonproductive, occasionally terminating with the child vomiting. The physician notices that her parents have declined all immunizations. Vital signs are temperature 38.0°C (100.4°F), blood pressure 100/70 mm Hg, pulse 75/min, respiratory rate 16/min, and SpO2 98% on room air. Lungs are clear bilaterally to auscultation. A swab of the posterior nasopharynx is performed and sent for culture. The most likely causative organism of this child's condition will grow best on which of the following culture media?
Bordet-Gengou agar Bordetella pertussis--2nd stage (paroxysomal stage)
A 27-year-old man presents to his family practice physician with a painful and swollen right knee. He asks if this problem might be related to a new skin rash on the soles of his feet. The patient states that he has been healthy except for a bout of gastroenteritis that he and his wife both had 3 weeks earlier. His family history is notable for his father having psoriatic arthritis. On examination, the knee appears erythematous, and a mild effusion is appreciated. Skin exam reveals scaly plaque-like lesions on an erythematous base on the soles of the feet. Synovial fluid analysis from his right knee reveals: Volume: 5 mL (normal: <3.5 mL) Viscosity: low (normal: high) WBC count: 10,000/mm3 with 65% polymorphonuclear leukocytes Glucose: 89 mg/dL (normal: nearly equal to that in blood) Gram stain: negative Culture: pending Which of the following findings is the patient most likely to have in addition to the signs and symptoms described?
Conjunctivitis Reactive arthritis: can't pee, can't see, can't bend my knee, no anti-IgG Reactive arthritis is associated with human leukocyte antigen B27
Anemia
Decreased affinity for oxygen: right shift sigmoidal curve
A 65-year-old man with hypertension and type 2 diabetes mellitus presents to his primary care physician for a routine check-up. He reports that he has had worsening shortness of breath when climbing stairs, and physical examination reveals crackles at the bases of the lungs. Results of a chest x-ray are shown. Laboratory tests show the creatinine level has increased to 2 mg/dL from a baseline level of 1.7 mg/dL 1 year ago, and the B-type natriuretic peptide level has increased to 250 pg/mL from a baseline level of 75 pg/mL. The physician decides to increase the patient's dosage of lisinopril. How will the increased dosage of lisinopril affect this patient's efferent renal arteriole smooth muscle cells?
Decreased phospholipase C activity Lisinopril is an ACE inhibitor (Angiotensinogen II binds to Gq receptor that activates phospholipase C) Phospholipase C cleaves PIP2 to form IP3 and DAG
A 2-year-old boy is brought to his pediatrician by his mother, who states that he has had watery diarrhea and abdominal pain for 3 days. The patient attends daycare, and recently, many children have had similar symptoms. The boy has not received a complete set of vaccinations. His heart rate is 160/min and his blood pressure is 90/65 mm Hg. Findings on physical examination are unremarkable except for dry mucous membranes and increased capillary refill time. His serum osmolality is 300 mOsm/kg. Which of the following best describes the pathogen most likely responsible for this patient's symptoms?
Double-stranded, nonenveloped, linear-segmented RNA virus Rotavirus--family of reovirus Cause of viral gastroenteritis and diarrhea in unvaccinated children
A 17-year-old girl is brought to an endocrinologist by her mother because she has never had a period. The patient's blood pressure is 165/92 mm Hg in both upper extremities and 160/95 mm Hg in both lower extremities. Physical examination shows sparse pubic hair and Tanner stage 2 breasts. Pelvic ultrasound demonstrates the presence of both a uterus and normal ovaries. Which of the following laboratory abnormalities might one expect to see in this patient?
Hypokalemia Turner Syndrome: decreased progesterone with amenorrhea
A 12-year-old girl presents to the emergency department after experiencing difficulty remembering things and displaying bizarre behavior over the past 2 days, according to her mother. Routine immunizations are up to date. After evaluating the patient, the pediatrician orders a lumbar puncture. The lab results show: Opening pressure: 195 mm H2O White blood cells: 240/μL Red blood cells: 435/μL Protein: 90 mg/dL Glucose: 40 mg/dL The patient is also sent for magnetic resonance imaging of the brain, shown in the image.
Encephalitis due to HSV-1 Gingivostomatitis
A 5-year-old boy is brought to the pediatrician by his mother after having a fever and cough for the past 2 days. He has not been eating very well and has not been playing with his siblings as he usually does. The mother is concerned because she declined all vaccinations for her children after her oldest child was diagnosed with autism. Physical examination reveals increased redness in the conjunctiva bilaterally and a stuffy, runny nose. Lesions in the buccal mucosa are detected and shown in the image below. Which of the following describes the organism most likely causing these symptoms?
Enveloped, single-stranded, negative-sense, and linear RNA virus Koplik spots appeared--measles (rubeola) virus
Immediately after birth, a preterm male infant delivered by cesarean section seems ill. He has an elevated respiratory rate, appears uncomfortable, and has a blue tinge to his skin. He is making grunting noises, and his nostrils are flaring. His mother had appropriate prenatal care, and his cardiac examination is normal. Vital signs are: temperature 37.2°C (98.9°F), blood pressure 60/35 mm Hg, pulse 122/min, respiratory rate 60/min. After another 2 hours, his chest begins to retract and breathing continues to worsen. Which of the following treatments seeks to correct the underlying deficit in lung physiology in this patient?
Exogenous phosphatidylcholine Neonatal respiratory distress syndrome--inadequate surfactant production
A 28-year-old man presents to his physician complaining of worsening arthritis in his left knee. He has a history of spontaneous bleeding episodes (which have led to his osteoarthritis) and easy bruising. Previous testing has shown a normal platelet count and bleeding time but a prolonged activated partial thromboplastin time. This patient is most likely deficient in which of the following factors?
Factor 8
A 29-year-old man who has just returned from camping in Arkansas visits his physician after developing a fever and experiencing generalized fatigue. He is worried because he discovered a tick behind his right knee after the trip and estimates that it may have been in place for as long as 48 hours. The patient recalls that shortly after discovering the tick, a small itchy bump emerged at the site of the lesion. He denies nausea, vomiting, or diarrhea. Physical exam reveals a temperature of 38°C (100°F), blood pressure of 128/70 mm Hg, pulse of 78, and respiratory rate of 14. He has a well-demarcated, tender skin lesion with a black base behind his right knee. Right inguinal lymphadenopathy is appreciated. Microscopy obtained from a sample of the ulcer reveals the presence of gram-negative coccobacilli, which are predominantly intracellular. Which of the following organisms is most likely responsible for this patient's disease?
Francisella tularensis
A 3-week-old boy is brought by his mother to the physician because he has been vomiting since birth. The mother is concerned because she thinks her son is "shrinking," and she describes how he seems to be unable to keep his bottled milk feedings down. The infant was born at home and did not undergo newborn screening. Vital signs are: temperature, 37°C (98.6°F); blood pressure, 70/50 mm Hg; heart rate, 150; and respiratory rate, 35. He is at the 50th percentile for height and the 30th percentile for weight. On physical examination, the patient is found to have yellow discoloration of the skin, clouding of both eyes, a distended abdomen, and palpable liver margins. Which of the following enzymes is likely to be present at an abnormal level in this patient?
Galactose-1-phosphate uridyltransferase Classic galactosemia The enzyme allows phosophorylated galactose to be converted to UDP-galactose. Without the enzyme galactose-1-phosphate and galactitol accumulate in various organs in the body. Long-term consequences of continued feeding with milk include cataracts and intellectual disability.
A 58-year-old man with a history of alcohol abuse presents to the hospital with a protuberant abdomen, slurring of speech, and confusion. On physical examination there are multiple spider angiomata on his chest, and a fluid wave is elicited on abdominal examination. When his hands are extended outward, a flapping tremor appears. He is promptly treated with medications to reduce the level of toxic metabolite responsible for his symptoms. Normally, where do the initial steps for detoxification of this metabolite take place?
Hepatocyte mitochondria
A type B blood group, Rh-positive recipient mistakenly receives a kidney from a type A blood group, Rh-negative donor. Which of the following best describes the mechanism of transplant rejection that is most likely to ensue in this recipient?
Hyperacute rejection Recipient preformed antidonor antibody mediated
The mother of a 3-year-old boy is referred to genetic counseling after her son is diagnosed with an enzyme deficiency. Recently, the mother noticed that her son has been developing an abnormal facial appearance and is hyperactive compared with other children of the same age. Examination reveals pearly papular skin lesions over the scapulae and on the lateral upper arms and thighs. Funduscopic examination findings are unremarkable, and his corneas are clear bilaterally. This patient is likely deficient in which enzyme?
Iduronate sulfatase Hunter Syndrome: lack of corneal clouding, whereas Hurler syndrome has corneal clouding
A 20-year-old college student presents to the student health center with a 1-week history of malaise, headaches, fever, chills, and a nonproductive cough. He has been staying up late every night preparing for his MCAT and appears very anxious because this illness has affected his ability to study. The patient is currently taking methylphenidate for attention deficit/hyperactivity disorder and albuterol as needed for exercise-induced asthma. Vital signs are: temperature, 38.3°C (101°F); blood pressure, 102/76 mm Hg; heart rate, 96; respiratory rate, 20; and oxygen saturation, 92% on room air. Rales and diffuse wheezes are auscultated bilaterally on lung examination. A chest x-ray reveals fluffy bilateral infiltrates. An antibiotic is prescribed. Which of the following is the mechanism of action of the antibiotic used to treat this patient's infection?
Inhibiting protein synthesis by blocking the translocation of the peptide chain Patient has atypical pneumonia which is most likely caused by Mycoplasma pneumoniae Treatment requires macrolide antibiotics: azithromycin
A 79-year-old man presents to his physician and says that he has been coughing up rust-colored mucus for the past week. He also reports shortness of breath and sharp chest pain that worsens when he breathes or coughs. He has a 25-year history of hypertension that is managed with lisinopril. He also takes daily vitamin supplements. He appears malnourished. He does not smoke cigarettes but drinks a couple of beers every weekend. His temperature is 38.2°C (100.7°F), blood pressure is 132/84 mm Hg, and heart rate is 108/min. On physical examination, the patient's breathing appears labored and he is using his accessory muscles to breathe. There are diffuse wheezes on auscultation. No dullness or hyperresonance are noted on percussion. No edema, jugular vein distention, or hepatomegaly are present. Blood tests show a left shift with increased numbers of neutrophils. Results of a sputum culture are shown below and an x-ray of the chest shows a lobar effusion. Which of the following is characteristic of this patient's type of pneumonia?
It is the most frequent cause of lobar pneumonia Streptococcus pneumonia
A 22-year-old man visits his college medical center complaining of flu-like symptoms that have been present for about 1 week. He reports low-grade fevers, night sweats, a painful sore throat, headaches, and increasing fatigue. He used to exercise 5 days a week but is no longer able to do so because of "lack of energy." Vital signs reveal a temperature of 100.8°F (38.2°C), blood pressure of 114/62 mm Hg, pulse of 95, and respiratory rate of 12. His heart has a regular rate and rhythm with no audible murmurs. His lungs are clear to auscultation bilaterally. The rest of the examination reveals erythematous tonsils without exudates, enlarged cervical lymph nodes, and a palpable spleen tip. What is the structure of the virus that has most likely infected this patient?
Linear double-stranded DNA virus with an envelope Epstein-Barr virus--infectious mononucleosis
Giemsa stain
Lyme disease Malaria African sleeping sickness Chagas disease Chlamydia
A Salvadoran woman brings her 9-year-old son to the pediatrician. She states her son had been very energetic and well liked by all of his teachers and had received excellent grades in school. Over the past 6 months, however, he has become withdrawn and lethargic, and his performance in school has deteriorated. Physical examination reveals occasional myoclonic jerking motions and some sensory deficits. The mother has the child's medical chart with her, and a nurse's note from a clinic in El Salvador describes that the patient had a peculiar rash when he was 11 months old. The pediatrician orders a brain biopsy that is positive for a hemagglutinin-containing RNA virus. Which of the following is the most likely cause of this child's symptoms?
Measles virus
A 54-year-old woman has had longstanding rheumatoid arthritis. Her rheumatologist recently started her on methotrexate, a reversible, competitive inhibitor of dihydrofolate reductase (DHFR). What effect does methotrexate have on DHFR?
Methotrexate acts on DHFR by increasing its Michaelis-Menten constant
A 40-year-old woman without significant medical history presents to her physician with a 2-week history of right upper quadrant pain and malaise. The pain is not relieved by antacids or ibuprofen and is not associated with meals. She denies any nausea or vomiting. She does not currently have diarrhea or constipation, although she notes that she experienced bloody diarrhea 4 months ago after returning from a mission trip to a small Mexican village. Current temperature is 100.1°F (37.8°C). Physical examination reveals right upper quadrant tenderness. Murphy sign is negative. Her serum laboratory studies have the following results: Stool microscopy is negative. Ultrasound shows a large, well-circumscribed, hypoechoic mass in the liver. Which of the following is the best treatment for this patient?
Metronidazole Amebic abscess caused by infection with Entamoeba histolytica
A 70-year-old man comes for evaluation because of a 3-week history of coughing and night sweats. His medical records indicate a positive PPD test for tuberculosis 50 years ago for which he received isoniazid therapy. He has unintentionally lost 6.8 kg (15 lb) since his last visit 3 months ago, at which time the liver edge was palpated 2 cm below the costal margin. A current x-ray of the chest is shown, and a tissue biopsy is scheduled. Which of the following findings is most likely?
Multiple fine granulomas Miliary TB demonstrates widespread seeding of the lungs with mycobacteria in a pattern that resembles millet seed. Mycobacterium tuberculosis
A 35-year-old woman presents to the physician with a 1-week history of mild fever, malaise, headache, and a nonproductive cough. She works as a cashier at the local grocery store and has smoked 2 packs of cigarettes every day for the last 5 years. She is sexually active with multiple male partners and uses condoms consistently. Her vital signs are: Heart rate: 77 Temperature: 102°F (38.9°C) Respiratory rate: 17 Blood pressure: 128/76 mm Hg Physical examination was only significant for late inspiratory crackles. Gram staining of a sputum samples does not reveal any organism. A chest x-ray is shown in the image.
Mycoplasma pneumonia Measurement of cold agglutinin titer in serum
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder that can take numerous forms depending on the gene involved. It occurs when one of the numerous enzymes required to convert cholesterol to cortisol is deficient or defective. Which of the following compounds is the primary reducing equivalent used in the synthesis of steroids?
NADPH Involved in pentose phosphate pathway
A 31-year-old man presents to his physician's office with pain on urination for the past day. The patient also reports yellow-white discharge from the urethra. He is sexually active, occasionally uses condoms, and endorses three sexual partners in the last month. He denies fevers, chills, changes in weight, new rashes, and tingling/numbness in the extremities. The patient has a temperature of 99.5°F (37.5°C), blood pressure is 135/70 mm/Hg, pulse is 88/min, and respiratory rate is 14/min. Physical examination does not reveal any tender lymph nodes, rashes, or skin lesions. The patient has full range of motion of his joints, and normal strength and reflexes in all extremities. Which of the following describes a component of the most likely causative organism?
Neisseria gonorrhea Antigenically variable pili
A 3-year-old boy is being seen by his pediatrician because of recurrent bacterial and fungal infections, specifically abscesses. Many of these abscesses have been found to be positive for Staphylococcus aureus. On physical examination, lymphadenopathy is detected, and flaky plaques are present on his arms and legs. A diagnosis is confirmed with a test in which nitroblue tetrazolium dye is used. Which of the following substrates is used by the enzyme that is deficient in this patient?
Oxygen Patient has CGD which is caused by NADPH oxidase deficiency NADPH oxidase uses oxygen as a substrate
A 15-year-old girl comes to the clinic with lower abdominal pain that worsens during vaginal intercourse. She also reports a yellowish vaginal discharge. The patient uses oral contraception but does not use barrier protection; she has had three sexual partners in the past year. Vital signs are: temperature, 100.9°F (38.3°C); blood pressure, 110/80 mm Hg; heart rate, 68; and respiratory rate, 17. Pelvic examination reveals a normal appearing vulva and introitus; her cervix is friable, and there is purulent discharge coming from the cervical os. Cervical cells grown on culture are shown in the image below. Which of the following is a long-term complication of this patient's condition?
PID: Extrauterine embryo implantation Chlamydia trachomatis
A previously healthy 12-year-old boy presents to the emergency department with abdominal pain. Three days after eating in a fast-food hamburger restaurant, he developed diffuse abdominal pain and bloody diarrhea. He is up to date on all of his vaccinations. He is admitted to the hospital. His stool smear shows many gram-negative organisms in the absence of fecal leukocytes. Stool culture reveals a gram-negative oxidase-negative bacterial species that does not ferment sorbitol. What findings are consistent with this patient's condition?
Patient has E. coli--enterohemorrhagic O157:H7 Hemolytic uremia syndrome: Thrombocytopenia and elevated creatinine
A 27-year-old woman with a past medical history significant for type 1 diabetes mellitus, systemic lupus erythematosus, and depression presents with shortness of breath, fatigue, and dark urine for the past week. Lab tests reveal the following: Hematocrit: 28% Hemoglobin: 10 g/dL RBC count: 2.8 million/mm3 WBC count: 7500/mm3 Hemoglobin A1c: 5% Indirect bilirubin: 2.8 mg/dL Direct bilirubin: 0.2 mg/dL She subsequently undergoes testing to confirm a suspected diagnosis. Which of the following test results would be expected in this patient?
Positive direct Coombs test for IgG autoantibodies that react with the patient's RBCs
A 40-year-old woman is hospitalized and treated for aspiration pneumonia. She is given ceftriaxone and clindamycin. On day 4 of hospitalization, her breathing has improved, but she develops crampy abdominal pain and multiple loose stools. Her temperature is 103.8°F (39.8° C), blood pressure is 118/78 mm Hg, pulse is 106/min, and respiratory rate is 12/min. On physical examination, the patient's lungs are clear to auscultation bilaterally; however, the patient's abdomen is distended. Auscultation of the abdomen discloses hyperactive bowel sounds. A complete blood count with differential and basic metabolic panel are ordered and results show: Leukocytes: 34,900 Neutrophils: 82% Lymphocytes: 10% Monocytes: 6% Basophils: 1% Eosinophils: 1% Hgb: 13.4 Platelets: 250,000 Which of the following best describes the mechanism of action of the toxin most likely causing the patient's symptoms?
Pseudomembrane colitis due to clostridium dificile Apoptosis
A 36-year-old nurse comes to the physician at an urgent-care center with a 3-day history of runny nose, headache, sneezing, sore throat, and postnasal drip. He denies any history of fever, myalgia, or dysphonia. The patient says that every year he suffers similar symptoms during the late fall, and notes that the doctor he works for has complained of "the same symptoms." The patient states that he has not had a chance to get his flu shot this year. Which of the following is the most likely cause of this patient's illness?
Rhinovirus
A 73-year-old woman is admitted to the hospital because of an acute exacerbation of congestive heart failure. A central venous catheter is inserted on the second hospital day. On hospital day 6, the nurse notes that the patient can no longer recall her name and is confused about where she is. The patient's temperature is 38.9°C (102°F), pulse is 95 beats/min, respirations are 24 breaths/min, and blood pressure is 130/90 mm Hg. Blood culture reveals a gram-negative rod that produces a red pigment. Which of the following organisms is the most likely cause of this patient's infection?
Serratia marcescens
A 35-year-old man comes to the clinic because of acute chest pain that began 3 days ago and is exacerbated by deep inspiration. He has also had a persistent dry cough of the same duration. His other symptoms include fatigue, malaise, and occasional chills. He has no history of serious illness. The patient is currently sexually active, and reports 35 pack-years of tobacco use, social drinking, and occasional marijuana and heroin use. His temperature is 38.9°C (102°F), blood pressure is 130/86 mm Hg, pulse is 94/min, and respiratory rate is 20/min. Physical examination reveals a diaphoretic man with a slight build, tachypnea, scar tissue in the antecubital fossa of his arms, and jugular venous distention synchronous with pulse. Auscultation of the heart reveals a systolic murmur. Which of the following culture findings is characteristic of the most likely cause for this patient's symptoms?
Staph aureus induced tricuspid endocarditis Catalase-positive, coagulase-positive cocci
A particular hormone is synthesized and secreted by the gastrointestinal mucosa and pancreatic D cells. It has an overall inhibitory function, suppressing gastric secretion and pancreatic exocrine function. Which other hormone acts on the same class of receptor?
The hormone described is somatostatin--GPCR Calcitonin is also GPCR
A 50-year-old man presents to his clinician because of bilateral itching, burning, and redness of the lower extremities. He states that he wore shorts while gardening outside his house one day ago and could have come in contact with poison ivy. Which of the following statements regarding this patient's immune response is most correct?
The pathogenesis requires differentiation of CD4+ T lymphocytes Type IV hypersensitivity--requires secondary exposure to an antigen
A nucleic acid fragment is added to a tube along with a polymerase, a primer, and deoxynucleotides. The tube also contains the four bases as fluorescently labeled dideoxynucleotides. The products in the tube are then run through a capillary, and a laser detects the fluorescence of the products that come out of the capillary. For which of the following purposes would the described laboratory technique be utilized?
To decipher the order of nitrogenous bases in a strand of DNA Sequencing uses capillaries
A previously healthy 23-year-old man comes to the urgent care center with a headache that started 2 hours ago. He rates the pain of the headache as a 10 of 10 and says that it started abruptly. His blood pressure is 138/95 mm Hg, and his heart rate is 56. The physician notes highly stretchable skin and bruising over his bony prominences. Other findings of the examination are unremarkable. Which of the following genetic defects is associated with this patient's most likely disease?
Type III collagen gene mutation
A 46-year-old man with a history of intravenous drug use visits the clinic with a cough of several months′ duration accompanied by occasional production of blood-tinged sputum. The patient has dry skin and reports marked fatigue and a 20-lb weight loss over a period of 3 months. Vital signs are as follows: temperature, 102.2°F (39°C); blood pressure, 130/85 mm Hg; heart rate, 85; respiratory rate, 19; and oxygen saturation, 95% on room air. Physical examination reveals crackles on auscultation of the right lung after the patient coughs. PPD and Candida antigen test results are negative (0 mm of induration for both). A chest x-ray shows findings suggestive of disease, prompting the physician to order a CT scan of the chest. Which of the following stains can be used to identify the etiology of this patient's lung lesions?
Ziehl-Neelsen stain Suspected pulmonary TB even though PPD test is negative because negative candida antigen test suggest immunosuppression and IV drug user suggests untreated HIV
A 6-month-old girl is brought to her pediatrician because of respiratory and feeding difficulties. On examination the infant is weak and hypotonic; cardiac evaluation reveals left ventricular enlargement with outflow tract obstruction and early cardiac failure. What is the most likely etiology of the patient's condition?
α-1,4-Glucosidase deficiency Pompe disease